- Email: [email protected]
SMOKING: SUCCESSES AND FAILURES
759
by the courts, as the State had not shown any real need for introducing it, but now the State claims its financial situation does constitute an emergency, and so the case is up before the courts again. But other experience in New York is interesting. Previously cheques were mailed to recipients, and often stolen and then replaced with little question. But now recipients have to pick the cheques up at employment centres, and may therefore be required to work. It seems that between 15 % and 25 % of the cheques are not claimed. Just why this is so is as yet uncertain, but inquiries are on foot. However, the news has been greeted by conservatives with the words, " we told you so "; the liberals are dismayed and seeking explanations. In any event, it seems that the welfare services were being cheated on a big scale. Some of the alleged chisellers are now
being prosecuted.
Conference SMOKING: SUCCESSES AND FAILURES THE Royal College of Physicians of London and the World Health Organisation have this year produced plans for attack on the smoking habit, and in many important items the two lists are as one (see table). In the main, working-groups at the Second World Conference on Smoking and Health, organised by the Health Education Council in London last week, agreed. There is no shortage of ideas. However, if funds, which must always seem insufficient in the face of this ever-increasing spectrum of man-made disease, are to be used wisely, dilution of resources might have to be avoided. The London conference did not try to draw up a formal list of priorities : from the platform came enthusiastic yet often self-critical reviews of experiences with anti-smoking projects in many countries and exhortations to its committed, militant audience to be patient. One promising note was struck, but even this was in an area that is bound to be controversial. Some say that it is foolish to talk of a safer (or, even, a less dangerous) cigarette because such a limited objective could be self-
defeating.
It
undermine the work of school prochild taught that smoking is dangerous
might
grammes where
a
home to parents smoking a product carefully chosen to be " safe ". Dr. M. A. H. RUSSELL (London) raised an important practical objection which needs
returns
more fully: by lowering the tar and nicotine content of cigarettes we cannot be sure that the smoker will not puff the more vigorously to compensate for the nicotine loss and so inhale more tar products. Nevertheless,
exploring
the review by Dr. E. L. WYNDER and Dr. D. HOFFMAN (American Health Foundation) was hopeful. In the United States and Germany nicotine and tar levels of cigarettes have fallen dramatically in the past decade. In the U.S.A. between 1956 and 1968 the average nicotine content of the best-selling brands almost halved to around 13 mg., and the tar content fell by a similar proportion to 20-25 mg. In Britain, Dr. Wynder said, the change has been less spectacular. (Figures published in the September Which? gave nicotine levels ranging from 0,8 to 1.8 mg. per cigarette for 25 British brands; the range for tar was 15-27 mg.) Dr. Wynder thought we had gone a long way towards identifying the harmful products in tobacco smoke-at least as far as lung cancer is concerned. The solid (particulate) phase of smoke contains twelve known carcinogenic polycyclic aromatic hydrocarbons, and tumour promoters and accelerators have been identified. The gas phase contains three nitroso derivatives, but these are not thought to be significant. The addition of sodium nitrate seems to reduce the carcinogenicity of tobacco smoke; nitrates were once thought to increase carcinogenicity by participating in the formation of nitroso compounds, but this is no longer accepted. Dr. Wynder believes that the precursors of the polycyclic hydrocarbons are terpenes and phytosterols in the wax surfaces of tobacco leaves. Using more stem tobacco might be a step towards a less dangerous cigarette. Smoke from reconstituted tobacco with high cellulose content also has a lower tumorigenic capacity. These studies have been done in animals: the American Health Foundation is now planning epidemiological research based on the brand smoked (i.e., taking into account the composition of the tobacco). The position is less clear for smoking and heart-disease and respiratory conditions. In atherosclerosis nicotine is a likely culprit, but carbon monoxide might also play a part. Chemical research has identified in tobacco smoke substances (phenols, aldehydes, and hydrogen cyanide) which can destroy the defence characteristics of the respiratory system. In many countries the longest experience with smoking control has been in smokers’ clinics and school publicity programmes: on the whole, results have not been all that encouraging. Prof. W. W. HOLLAND’S working-group was told that in many countries smoking among children is on the increase. In Scotland the emphasis- in youth-oriented health education is not so much on far-distant hazards but
MAIN RECOMMENDATIONS FOR ACTION AGAINST
SMOKING PUBLICISED
IN
1971
Summary ofRoyal College of Physicians’ report Smoking and Health Now. W.H.O. = Resolution passed at World Health Assembly. R.C.P.
=
2nd World Conf.
=
Recommendations of working-groups
at
Second World Conference
on
Smoking and Health.
760
fitness, notably in athletic success, which many highly. The simplest explanation of smoking among schoolchildren is that it is a way of attaining peer respect: also, and paradoxically, the child who smokes is copying an adult habit yet at the same time defying adult authority. Several speakers thought that we should turn to the children themselves for help, and Prof. W. E. P. FRITSCM (Germany) described some of the as yet unon
present
boys
rate
evaluated work which the Federal Centre for Health Education has been doing with direct participation of the young (e.g., in magazines and clubs for leisure-time activities). Smoking-clinics get abstention-rates of the order of 30%-a considerable success in many ways, but a drop in the ocean of less highly motivated smokers all the
legislate for this publicity and proceed towards a ban on all advertising of tobacco products. Voluntary organisations need and deserve this support; for their own part they should proceed with enthusiasm and imagination tempered with tolerance and patience. proceedings of which are to be published exhibition of publicity techniques used in many countries and by film shows. Among the material was a useful factual booklet The Deadly Cloud, written by Mr. Ronald Bedford; obtainable from the Health Education Council, Middlesex House, Ealing Road, Wembley, Middlesex HAO 1HH. The conference, the
was
same.
With seemed
some success with adults, especially in the middle classes, but campaigns aimed at children have not yet had much measurable effect. By reducing the tar and nicotine content of cigarettes and by giving continuous publicity to these levels those who cannot stop smoking will, at least as far as lung cancer is concerned, run
less of
a
risk.
Governments
must now
step in and
an
In
varying degrees of
confidence some delegates to feel that in the middle social classes the battle against smoking may be being won, albeit slowly. Among poorer groups (and in poorer nations) the habit may prove more recalcitrant. Dr. BERIT AAs (Norway) warned that cigarette manufacturers, faced by discouraging home markets, might seek to increase sales in developing countries where populations might still be vulnerable. Unfortunately, among the 400 delegates no-one from Asia and Africa was able to comment on this disturbing allegation: indeed, for a world conference, the attendance was heavily European and North American. Dr. Aas and others were also unhappy about the use of increased taxation of tobacco products. If the lower-income groups are the ones who find it hardest to give up smoking, increasing prices could have negative social and economic effects. Governments would also be in the position of being responsible for the health of citizens yet raising money from the sale of products known to harm health. (The United Kingdom has been in this position for some time without-until the setting-up of the interdepartmental committee this summer-seeming even to be aware of the incongruity.) Dr. C. M. FLETCHER (London) underlined the importance of getting the health message through to legislators, and provided support for one of Dr. Aas’ points: he quoted from a letter sent by a Treasury Minister in response to a suggestion that differential taxation be used to encourage a shift away from cigarettes to less dangerous tobacco products. The Minister’s revenue-entrenched refusal avoided the health issue, and ended with the bald admission that " the capacity of tobacco duty to produce revenue would be eroded ". In research there are many gaps, but one of the greatest is that we do not even know why people smoke. The working-group on psychopharmacological aspects of habituation asked many more questions than it answered, and even if the projects they suggested were taken up immediately it is difficult to see how results useful to those designing anti-smoking programmes could be available for many Dr. Fletcher thought that clinical research on years. smoking was held by the research community to be unglamorous and somehow not suitable for serious science. The Medical Research Council, which had backed the epidemiological research on lung cancer and smoking, today provided no support at all for research into why people smoke-apparently because no-one applies for grants for work of this kind. In summary, anti-smoking persuasion is having
accompanied by
England
Now
On the crowded flight back an Ancient Mariner stopped of three from reading the paper by announcing that he hadn’t much enjoyed the Congress. " Felt too damned ill ", he said. " Abdominal colic, diarrhoea, cramp in both feet, frightful palpitations with D.A.H., sweating," and absolute lethargy. Now what’s your diagnosis ? " Can’t think." " But if you’d been a paediatrician you’d have said gastroenteritis with hypoelectrolytsemia, wouldn’t you ? " " Yes, I suppose I should." " Well let me put it another way. Let’s suppose this old character was all the time on prostigmine, for reasons of his own. Might the whole thing not have been caused by intolerance or " overdosage ? " " Never thought of that." But what of course will happen will be that I shall tell my wife I must have caught a bug and, as we were brought up in the microbial era, we shall accept it. Of course my son would say I must have had a Bad Thought, or have suppressed a Bad Thought." " That’s an idea." " But his son will say I got a whiff from a disintegrating Neutron. You know-what they used to call a Touch of the Sun." one
*
*
*
strength for the wedding which kindly timed so as to interfere least with normal diurnal rhythms. The organist was playing the sort of music that reminds bridegrooms that life is not all honey, and the minutes ticked away and away. Eventually an usher informed us that the Vicar was delayed. The hands of our watches wound slowly round. Before the hour had passed the music changed, the bride on her father’s arm passed radiantly down the aisle, and a stranger Vicar announced his special permission from the Rural Dean to proceed with the marriage. The rest of the arrangements were as planned. It is not true that future brides are to be asked to sign a consent which states " No assurance has been given to me that the marriage will be performed by any particular Vicar ". We had turned up in
was
*
*
*
THE IMPORTUNATE DOG
Whose hairy tail beats tattoo on the floor Reminds me of a time-honoured adage: That sedentary man should not ignore His daily walk on meeting middle-age. Pup !Peering at mine eyes, thou hast appraised The arcus senilis there evident, Xanthelasmata, too, reflecting raised Serum-triglycerides-their dire portent Of growing atheromatous disease, Systemic arteries shortly to sclerose; And so thou would’st disturb mine evening ease, Approving not a post-prandial doze. Thine importunity is meet, sage hound: Retrieve thy lead! We’ll walk the block around.
by the courts, as the State had not shown any real need for introducing it, but now the State claims its financial situation does constitute an emergency, and so the case is up before the courts again. But other experience in New York is interesting. Previously cheques were mailed to recipients, and often stolen and then replaced with little question. But now recipients have to pick the cheques up at employment centres, and may therefore be required to work. It seems that between 15 % and 25 % of the cheques are not claimed. Just why this is so is as yet uncertain, but inquiries are on foot. However, the news has been greeted by conservatives with the words, " we told you so "; the liberals are dismayed and seeking explanations. In any event, it seems that the welfare services were being cheated on a big scale. Some of the alleged chisellers are now
being prosecuted.
Conference SMOKING: SUCCESSES AND FAILURES THE Royal College of Physicians of London and the World Health Organisation have this year produced plans for attack on the smoking habit, and in many important items the two lists are as one (see table). In the main, working-groups at the Second World Conference on Smoking and Health, organised by the Health Education Council in London last week, agreed. There is no shortage of ideas. However, if funds, which must always seem insufficient in the face of this ever-increasing spectrum of man-made disease, are to be used wisely, dilution of resources might have to be avoided. The London conference did not try to draw up a formal list of priorities : from the platform came enthusiastic yet often self-critical reviews of experiences with anti-smoking projects in many countries and exhortations to its committed, militant audience to be patient. One promising note was struck, but even this was in an area that is bound to be controversial. Some say that it is foolish to talk of a safer (or, even, a less dangerous) cigarette because such a limited objective could be self-
defeating.
It
undermine the work of school prochild taught that smoking is dangerous
might
grammes where
a
home to parents smoking a product carefully chosen to be " safe ". Dr. M. A. H. RUSSELL (London) raised an important practical objection which needs
returns
more fully: by lowering the tar and nicotine content of cigarettes we cannot be sure that the smoker will not puff the more vigorously to compensate for the nicotine loss and so inhale more tar products. Nevertheless,
exploring
the review by Dr. E. L. WYNDER and Dr. D. HOFFMAN (American Health Foundation) was hopeful. In the United States and Germany nicotine and tar levels of cigarettes have fallen dramatically in the past decade. In the U.S.A. between 1956 and 1968 the average nicotine content of the best-selling brands almost halved to around 13 mg., and the tar content fell by a similar proportion to 20-25 mg. In Britain, Dr. Wynder said, the change has been less spectacular. (Figures published in the September Which? gave nicotine levels ranging from 0,8 to 1.8 mg. per cigarette for 25 British brands; the range for tar was 15-27 mg.) Dr. Wynder thought we had gone a long way towards identifying the harmful products in tobacco smoke-at least as far as lung cancer is concerned. The solid (particulate) phase of smoke contains twelve known carcinogenic polycyclic aromatic hydrocarbons, and tumour promoters and accelerators have been identified. The gas phase contains three nitroso derivatives, but these are not thought to be significant. The addition of sodium nitrate seems to reduce the carcinogenicity of tobacco smoke; nitrates were once thought to increase carcinogenicity by participating in the formation of nitroso compounds, but this is no longer accepted. Dr. Wynder believes that the precursors of the polycyclic hydrocarbons are terpenes and phytosterols in the wax surfaces of tobacco leaves. Using more stem tobacco might be a step towards a less dangerous cigarette. Smoke from reconstituted tobacco with high cellulose content also has a lower tumorigenic capacity. These studies have been done in animals: the American Health Foundation is now planning epidemiological research based on the brand smoked (i.e., taking into account the composition of the tobacco). The position is less clear for smoking and heart-disease and respiratory conditions. In atherosclerosis nicotine is a likely culprit, but carbon monoxide might also play a part. Chemical research has identified in tobacco smoke substances (phenols, aldehydes, and hydrogen cyanide) which can destroy the defence characteristics of the respiratory system. In many countries the longest experience with smoking control has been in smokers’ clinics and school publicity programmes: on the whole, results have not been all that encouraging. Prof. W. W. HOLLAND’S working-group was told that in many countries smoking among children is on the increase. In Scotland the emphasis- in youth-oriented health education is not so much on far-distant hazards but
MAIN RECOMMENDATIONS FOR ACTION AGAINST
SMOKING PUBLICISED
IN
1971
Summary ofRoyal College of Physicians’ report Smoking and Health Now. W.H.O. = Resolution passed at World Health Assembly. R.C.P.
=
2nd World Conf.
=
Recommendations of working-groups
at
Second World Conference
on
Smoking and Health.
760
fitness, notably in athletic success, which many highly. The simplest explanation of smoking among schoolchildren is that it is a way of attaining peer respect: also, and paradoxically, the child who smokes is copying an adult habit yet at the same time defying adult authority. Several speakers thought that we should turn to the children themselves for help, and Prof. W. E. P. FRITSCM (Germany) described some of the as yet unon
present
boys
rate
evaluated work which the Federal Centre for Health Education has been doing with direct participation of the young (e.g., in magazines and clubs for leisure-time activities). Smoking-clinics get abstention-rates of the order of 30%-a considerable success in many ways, but a drop in the ocean of less highly motivated smokers all the
legislate for this publicity and proceed towards a ban on all advertising of tobacco products. Voluntary organisations need and deserve this support; for their own part they should proceed with enthusiasm and imagination tempered with tolerance and patience. proceedings of which are to be published exhibition of publicity techniques used in many countries and by film shows. Among the material was a useful factual booklet The Deadly Cloud, written by Mr. Ronald Bedford; obtainable from the Health Education Council, Middlesex House, Ealing Road, Wembley, Middlesex HAO 1HH. The conference, the
was
same.
With seemed
some success with adults, especially in the middle classes, but campaigns aimed at children have not yet had much measurable effect. By reducing the tar and nicotine content of cigarettes and by giving continuous publicity to these levels those who cannot stop smoking will, at least as far as lung cancer is concerned, run
less of
a
risk.
Governments
must now
step in and
an
In
varying degrees of
confidence some delegates to feel that in the middle social classes the battle against smoking may be being won, albeit slowly. Among poorer groups (and in poorer nations) the habit may prove more recalcitrant. Dr. BERIT AAs (Norway) warned that cigarette manufacturers, faced by discouraging home markets, might seek to increase sales in developing countries where populations might still be vulnerable. Unfortunately, among the 400 delegates no-one from Asia and Africa was able to comment on this disturbing allegation: indeed, for a world conference, the attendance was heavily European and North American. Dr. Aas and others were also unhappy about the use of increased taxation of tobacco products. If the lower-income groups are the ones who find it hardest to give up smoking, increasing prices could have negative social and economic effects. Governments would also be in the position of being responsible for the health of citizens yet raising money from the sale of products known to harm health. (The United Kingdom has been in this position for some time without-until the setting-up of the interdepartmental committee this summer-seeming even to be aware of the incongruity.) Dr. C. M. FLETCHER (London) underlined the importance of getting the health message through to legislators, and provided support for one of Dr. Aas’ points: he quoted from a letter sent by a Treasury Minister in response to a suggestion that differential taxation be used to encourage a shift away from cigarettes to less dangerous tobacco products. The Minister’s revenue-entrenched refusal avoided the health issue, and ended with the bald admission that " the capacity of tobacco duty to produce revenue would be eroded ". In research there are many gaps, but one of the greatest is that we do not even know why people smoke. The working-group on psychopharmacological aspects of habituation asked many more questions than it answered, and even if the projects they suggested were taken up immediately it is difficult to see how results useful to those designing anti-smoking programmes could be available for many Dr. Fletcher thought that clinical research on years. smoking was held by the research community to be unglamorous and somehow not suitable for serious science. The Medical Research Council, which had backed the epidemiological research on lung cancer and smoking, today provided no support at all for research into why people smoke-apparently because no-one applies for grants for work of this kind. In summary, anti-smoking persuasion is having
accompanied by
England
Now
On the crowded flight back an Ancient Mariner stopped of three from reading the paper by announcing that he hadn’t much enjoyed the Congress. " Felt too damned ill ", he said. " Abdominal colic, diarrhoea, cramp in both feet, frightful palpitations with D.A.H., sweating," and absolute lethargy. Now what’s your diagnosis ? " Can’t think." " But if you’d been a paediatrician you’d have said gastroenteritis with hypoelectrolytsemia, wouldn’t you ? " " Yes, I suppose I should." " Well let me put it another way. Let’s suppose this old character was all the time on prostigmine, for reasons of his own. Might the whole thing not have been caused by intolerance or " overdosage ? " " Never thought of that." But what of course will happen will be that I shall tell my wife I must have caught a bug and, as we were brought up in the microbial era, we shall accept it. Of course my son would say I must have had a Bad Thought, or have suppressed a Bad Thought." " That’s an idea." " But his son will say I got a whiff from a disintegrating Neutron. You know-what they used to call a Touch of the Sun." one
*
*
*
strength for the wedding which kindly timed so as to interfere least with normal diurnal rhythms. The organist was playing the sort of music that reminds bridegrooms that life is not all honey, and the minutes ticked away and away. Eventually an usher informed us that the Vicar was delayed. The hands of our watches wound slowly round. Before the hour had passed the music changed, the bride on her father’s arm passed radiantly down the aisle, and a stranger Vicar announced his special permission from the Rural Dean to proceed with the marriage. The rest of the arrangements were as planned. It is not true that future brides are to be asked to sign a consent which states " No assurance has been given to me that the marriage will be performed by any particular Vicar ". We had turned up in
was
*
*
*
THE IMPORTUNATE DOG
Whose hairy tail beats tattoo on the floor Reminds me of a time-honoured adage: That sedentary man should not ignore His daily walk on meeting middle-age. Pup !Peering at mine eyes, thou hast appraised The arcus senilis there evident, Xanthelasmata, too, reflecting raised Serum-triglycerides-their dire portent Of growing atheromatous disease, Systemic arteries shortly to sclerose; And so thou would’st disturb mine evening ease, Approving not a post-prandial doze. Thine importunity is meet, sage hound: Retrieve thy lead! We’ll walk the block around.