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Cigarette smoking
194
PUBLIC
HEALTH
CIGARETTE
VOL.
LXXVI
NO.
4
SMOKING
AT the opening of the Symposiurr: ~hose present were asked not to smoke cigarettes but to confine their smoking to pipes and cigars. Thus the Society fired an anticipatory shot in the campaign which was formally opened five days later by the publication of the Royal College of Physicians' Report on Smoking and Health, a modest contribution, perhaps, but an eminently proper one. For the Society has been concerning itself with this particular aspect of preventive medicine for a number of years and has been learning in hard the way just what practical difficulties have to be faced. It may be that there are still a few medical officers of health who are not finally satisfied that there is a causal relationship between heavy cigarette smoking and lung cancer, but the growing weight of evidence has certainly convinced the vast majority as one alternative explanation after another has been shown to have no substance. There is no need to wait until the precise mechanism of carcinogenesis is demonstrated before accepting the fact for the individual that if he refrains from developing the cigarette habit or rids himself of that habit he fivoids a substantial risk of lung cancer or the fact for the community that the elimination of cigarette smoking would reduce lung cancer deaths to a small fraction of the present figure. These facts accepted, the need for action is obvious. It is temptingly easy to say "Here is an obvious problem in preventive medicine; it is the business of the M.O.H.--let him go ahead and solve it". This argument is based on incontrovertible fact but it overlooks one vital point. In his activities in preventive medicine the M.O.H. is to a great extent an adviser to elected bodies and his own executive powers are strictly limited. It follows that though there is much he can do and though there is a duty upon him to do it he can achieve comparatively little unless he has positive and active help from outside. In some respects there is a parallel between the lung cancer problem and the problems of epidemiology--notably cholera--in the 19th century. A statistical causal relationship between faulty sewage disposal and polluted water supplies on the one hand and the incidence of cholera on the other had been demonstrated. Sanitary reforms presented a financial threat to certain strongly vested interests. The precise causal linkage between polluted water and cholera had not yet been demonstrated (nor could it be till Pasteur came on the scene) and the interests concerned had no lack of ingenious alternative explanations of observed phenomena. Cholera was, however, a manifest and immediate threat to the individual ; lung cancer is a rather more remote one. Even more important, there was no substantial section of the general public which derived positive pleasure from the lack of sanitation or the drinking of dirty water!
EDITORI
AL
195
In the present case preventive medicine is compelled to deal with an addiction which is widespread and which, unlike certain other drag addictions, carries little or no social disapproval in most circles. This addiction is being assiduously encouraged by all the resources of modern advertising. The cigarette manufacturers show a singular naivety in their public pronouncements on this subject. They are in business to make money. Out of their income they spend £11,000,000 a year on advertisement. We find it hard to believe that they would do this unless they were satisfied that in the long run it would bring some tangible return either by making more people smoke or by making people smoke more. They count it to themselves for righteousness that they have never tried to secure advertising space for tobacco goods in boys' and girls' papers or to advertise cigarettes in the breaks in children's television programmes. Yet only the blind or the deaf could imagine that cigarette advertising is not being "angled" to youth in a way which is likely to encourage young people to smoke and only the simplest of souls would believe that this emphasis is innocent. Against this flood of propaganda the modest expenditures of prevention look ridiculously small and, even so, Goliath is not ready to allow David full freedom. There have been several cases in which advertising contractors have sought, not without success, to prevent the health educators from having the freedom of the TV. screen and the hoardings. When The Times editorially deprecates the censorship of tobacco advertisements it should not ignore the fact that censorship of anti-tobacco advertising is already in existence! The public health service must, however, be aware of ethical considerations. It accepts and insists upon the principle that in certain circumstances it is sound and proper to limit individual freedom in the interests of the well-being of the community. The heavy cigarette smoker injures principally himself. He may, if he persists in smoking in a confined space, do some slight injury to asthmatics and other "chesty" people who are compelled to share that space with him, but such sufferers are few. He may annoy or disgust the minority of the population who do not smoke if, again, they must share confinexl space with him. But the main lethal risk lies within the 20 ~ or so of smoking men who consume more than 20 cigarettes a day. It may be sound medicine to protect those people from themselves but is it sound sociology to coerce all for the sake of a foolish minority? Even if it is sound, can it be made to seem reasonable to the mass of the people ? This last is the critical question, because coercion is impracticable unless it has majority consent. So far as the individual adult is concerned, it would seem that persuasion must be given a greater role than coercion. But a substantial part of the task lies in preventing the young and immature from contracting the cigarette habit and it is legitimate to curb both the nature and the degree of the temptations which are either accidentally or deliberately placed before them. It is with these principles in mind that the General Purposes Committee of the Society of
196
PUBLIC
HEALTH
VOL.
LXXV1
NO.
4
Medical Officers of Health has made certain suggestions which are set out on page 250 of this issue and will, we hope, be carefully considered both within and without the Society. Suggestions (a) and (b), covering the control of smoking in places of entertainment and on public transport, merely extend an existing practice. Most concert halls, many theatres and some cinemas in this country already forbid smoking in the auditoria and many transport undertakings confine smoking to the upper floor of double-deck buses and the rear seats of singledeckers ; there is no logical reason against making these restrictions general. The consequences may include some reduction in the cigarette consumption of individuals but this is not the major benefit. Those who find other people's smoke intolerable will benefit and, probably more important, there will be a diminution of the encouragement to smoke which present conditions offer to the young who are not yet confirmed in the habit. Suggestions (c), (d), (e) and ( f ) stress the vital importance of a vigorous national effort as distinct from purely local schemes. This is not to decry the importance of local action; indeed, the bulk of field effort must be in the hands of local executive officers, who can adjust it to meet local needs and who, as the known and trusted advisers of their communities, can often make a much greater impact than strangers. The importance of national effort is that it can make better material resources available, whether locally or through national mass media of communication; it also enhances the prestige of the general campaign and makes it possible for local authorities which drag their feet to be encouraged or persuaded, by financial or other means, to accelerate their work. And though the word "national" implies action by government departments it connotes also, in this context, action by professional bodies, of which the Society itself and the teachers' organisations are specifically mentioned. We are interested to find among the measures suggested the banning of slot machines for the sale of cigarettes. The significance of this is not easy to estimate. Existing legislation prohibits the sale of cigarettes and tobacco to children for their own use. It is circmrivented by children who buy ostensibly for their parents and there is a case for forbidding sales in any circumstances to children apparently below a certain age. Such a prohibition would be completely useless in the widespread presence of slot machines. Smokers of the less dangerous pipes and cigars appear to exercise sufficient forethought to purchase stocks in advance of need and do not require this mechanical aid, no bona fide adult cigarette addict need complain if he, too, is required to look ahead ! The anti-cigarette campaign will not be a short one and will not bring swift and spectacular results. But it need not be without hope. Such work as has hitherto been done has been sporadic and unco-ordinated and has been hindered not merely by lack of resources but by apparent lack of conviction. The force of example is potent and the thinking smoker cannot but be impressed
EDITORIAL
197
by the substantial number of doctors who have given up cigarettes in the last I0 years. Unfortunately the unthinking smoker can still find enough doctoraddicts to rationalise his own infirmity of purpose. The basic information contained in the Royal College of Physicians' report has been publicly available for something like 10 years; the undeniable impact of the Report comes not from its novelty but from the fact that it is the first full public statement on this subject to be made by a major responsible medical body in this country. If the whole weight of organised medical opinion in Britain were firmly and openly thrown into the scales we believe that the prospects of the campaign would be enormously improved and we should fike to see the Society active in mobilising that opinion.
PUBLIC
HEALTH
CIGARETTE
VOL.
LXXVI
NO.
4
SMOKING
AT the opening of the Symposiurr: ~hose present were asked not to smoke cigarettes but to confine their smoking to pipes and cigars. Thus the Society fired an anticipatory shot in the campaign which was formally opened five days later by the publication of the Royal College of Physicians' Report on Smoking and Health, a modest contribution, perhaps, but an eminently proper one. For the Society has been concerning itself with this particular aspect of preventive medicine for a number of years and has been learning in hard the way just what practical difficulties have to be faced. It may be that there are still a few medical officers of health who are not finally satisfied that there is a causal relationship between heavy cigarette smoking and lung cancer, but the growing weight of evidence has certainly convinced the vast majority as one alternative explanation after another has been shown to have no substance. There is no need to wait until the precise mechanism of carcinogenesis is demonstrated before accepting the fact for the individual that if he refrains from developing the cigarette habit or rids himself of that habit he fivoids a substantial risk of lung cancer or the fact for the community that the elimination of cigarette smoking would reduce lung cancer deaths to a small fraction of the present figure. These facts accepted, the need for action is obvious. It is temptingly easy to say "Here is an obvious problem in preventive medicine; it is the business of the M.O.H.--let him go ahead and solve it". This argument is based on incontrovertible fact but it overlooks one vital point. In his activities in preventive medicine the M.O.H. is to a great extent an adviser to elected bodies and his own executive powers are strictly limited. It follows that though there is much he can do and though there is a duty upon him to do it he can achieve comparatively little unless he has positive and active help from outside. In some respects there is a parallel between the lung cancer problem and the problems of epidemiology--notably cholera--in the 19th century. A statistical causal relationship between faulty sewage disposal and polluted water supplies on the one hand and the incidence of cholera on the other had been demonstrated. Sanitary reforms presented a financial threat to certain strongly vested interests. The precise causal linkage between polluted water and cholera had not yet been demonstrated (nor could it be till Pasteur came on the scene) and the interests concerned had no lack of ingenious alternative explanations of observed phenomena. Cholera was, however, a manifest and immediate threat to the individual ; lung cancer is a rather more remote one. Even more important, there was no substantial section of the general public which derived positive pleasure from the lack of sanitation or the drinking of dirty water!
EDITORI
AL
195
In the present case preventive medicine is compelled to deal with an addiction which is widespread and which, unlike certain other drag addictions, carries little or no social disapproval in most circles. This addiction is being assiduously encouraged by all the resources of modern advertising. The cigarette manufacturers show a singular naivety in their public pronouncements on this subject. They are in business to make money. Out of their income they spend £11,000,000 a year on advertisement. We find it hard to believe that they would do this unless they were satisfied that in the long run it would bring some tangible return either by making more people smoke or by making people smoke more. They count it to themselves for righteousness that they have never tried to secure advertising space for tobacco goods in boys' and girls' papers or to advertise cigarettes in the breaks in children's television programmes. Yet only the blind or the deaf could imagine that cigarette advertising is not being "angled" to youth in a way which is likely to encourage young people to smoke and only the simplest of souls would believe that this emphasis is innocent. Against this flood of propaganda the modest expenditures of prevention look ridiculously small and, even so, Goliath is not ready to allow David full freedom. There have been several cases in which advertising contractors have sought, not without success, to prevent the health educators from having the freedom of the TV. screen and the hoardings. When The Times editorially deprecates the censorship of tobacco advertisements it should not ignore the fact that censorship of anti-tobacco advertising is already in existence! The public health service must, however, be aware of ethical considerations. It accepts and insists upon the principle that in certain circumstances it is sound and proper to limit individual freedom in the interests of the well-being of the community. The heavy cigarette smoker injures principally himself. He may, if he persists in smoking in a confined space, do some slight injury to asthmatics and other "chesty" people who are compelled to share that space with him, but such sufferers are few. He may annoy or disgust the minority of the population who do not smoke if, again, they must share confinexl space with him. But the main lethal risk lies within the 20 ~ or so of smoking men who consume more than 20 cigarettes a day. It may be sound medicine to protect those people from themselves but is it sound sociology to coerce all for the sake of a foolish minority? Even if it is sound, can it be made to seem reasonable to the mass of the people ? This last is the critical question, because coercion is impracticable unless it has majority consent. So far as the individual adult is concerned, it would seem that persuasion must be given a greater role than coercion. But a substantial part of the task lies in preventing the young and immature from contracting the cigarette habit and it is legitimate to curb both the nature and the degree of the temptations which are either accidentally or deliberately placed before them. It is with these principles in mind that the General Purposes Committee of the Society of
196
PUBLIC
HEALTH
VOL.
LXXV1
NO.
4
Medical Officers of Health has made certain suggestions which are set out on page 250 of this issue and will, we hope, be carefully considered both within and without the Society. Suggestions (a) and (b), covering the control of smoking in places of entertainment and on public transport, merely extend an existing practice. Most concert halls, many theatres and some cinemas in this country already forbid smoking in the auditoria and many transport undertakings confine smoking to the upper floor of double-deck buses and the rear seats of singledeckers ; there is no logical reason against making these restrictions general. The consequences may include some reduction in the cigarette consumption of individuals but this is not the major benefit. Those who find other people's smoke intolerable will benefit and, probably more important, there will be a diminution of the encouragement to smoke which present conditions offer to the young who are not yet confirmed in the habit. Suggestions (c), (d), (e) and ( f ) stress the vital importance of a vigorous national effort as distinct from purely local schemes. This is not to decry the importance of local action; indeed, the bulk of field effort must be in the hands of local executive officers, who can adjust it to meet local needs and who, as the known and trusted advisers of their communities, can often make a much greater impact than strangers. The importance of national effort is that it can make better material resources available, whether locally or through national mass media of communication; it also enhances the prestige of the general campaign and makes it possible for local authorities which drag their feet to be encouraged or persuaded, by financial or other means, to accelerate their work. And though the word "national" implies action by government departments it connotes also, in this context, action by professional bodies, of which the Society itself and the teachers' organisations are specifically mentioned. We are interested to find among the measures suggested the banning of slot machines for the sale of cigarettes. The significance of this is not easy to estimate. Existing legislation prohibits the sale of cigarettes and tobacco to children for their own use. It is circmrivented by children who buy ostensibly for their parents and there is a case for forbidding sales in any circumstances to children apparently below a certain age. Such a prohibition would be completely useless in the widespread presence of slot machines. Smokers of the less dangerous pipes and cigars appear to exercise sufficient forethought to purchase stocks in advance of need and do not require this mechanical aid, no bona fide adult cigarette addict need complain if he, too, is required to look ahead ! The anti-cigarette campaign will not be a short one and will not bring swift and spectacular results. But it need not be without hope. Such work as has hitherto been done has been sporadic and unco-ordinated and has been hindered not merely by lack of resources but by apparent lack of conviction. The force of example is potent and the thinking smoker cannot but be impressed
EDITORIAL
197
by the substantial number of doctors who have given up cigarettes in the last I0 years. Unfortunately the unthinking smoker can still find enough doctoraddicts to rationalise his own infirmity of purpose. The basic information contained in the Royal College of Physicians' report has been publicly available for something like 10 years; the undeniable impact of the Report comes not from its novelty but from the fact that it is the first full public statement on this subject to be made by a major responsible medical body in this country. If the whole weight of organised medical opinion in Britain were firmly and openly thrown into the scales we believe that the prospects of the campaign would be enormously improved and we should fike to see the Society active in mobilising that opinion.