BOSTON — Dr. Julius Richmond, the U.S. surgeon general in the Carter administration who issued a massive report labeling cigarette smoking "slow-motion suicide," has died. He was 91.

Richmond, who also was the first director of the federal Head Start program, died Sunday at his Boston-area home, said Alyssa Kneller, a spokeswoman for Harvard University, where Richmond was professor emeritus.

In 1979, Richmond formally presented his Surgeon's General's Report on smoking, a follow-up to the historic 1964 report by an earlier surgeon general that led to warnings on cigarette packs.

The 1,200-page report provided greater detail, saying that smoking causes a variety of diseases and smoking by pregnant women harms their fetuses.

"Today there can be no doubt that smoking is truly slow-motion suicide," it said. It said the about a third of adults smoked, down from 1964, but there had been a sharp increase in smoking by teenage girls.

"It really put the tobacco companies on the defensive," Allan Brandt, dean of Harvard's Graduate School of Arts & Sciences. "That was really case closed in terms of the science."

In another report in December 1980, Richmond documented Americans' efforts to live healthier lives, citing increases in the number of adults who exercise regularly and a greater awareness of the dangers of high blood pressure and heart disease.

According to his Harvard biography, Richmond's work on poverty and early childhood development led to an appointment as the first director of the national Head Start program.

Part of the Johnson administration's war on poverty, it was launched as a summer program in 1965 aimed at helping poor children be better prepared for school.

Critics later said the enrolled children rarely made lasting educational gains, but Richmond said participants also received other benefits, such as dental checkups and medical care.

Former first lady Rosalynn Carter said in a statement that Richmond was "a wonderful and compassionate champion in the fight to improve health, mental health and educational opportunities for our nation's children."