Special report: Eight years after

Puhl. II/zh. L~:mt. i' 1971 ). 85, 133-136

Special Report: Eight Years After .,%~Y~Ni interested in tile h~ahh of the people x~ill welcome the appearance of the new report of thc Royal College of Physicians on Smoking and Health. Eight years :tftcr the appearance of tile ('ollege's lirst Report it is a logical and intclligcm ~,equcl which lakes full account of ~shat has h a p p e n e d - a n d what has failed Io h a p p c n - during the interim. It i~ nalural to feel disappointed that so little has been done to improve the situation during lhosc eight years, but only the starryeyed and the unrealistic could have expected :~ubstantially rmwe. Addiction generally carries ~ith it a built-in resistance to reason. The ,;l;Atl,-,llca[ presentation of information and argument tends to bore or balttc the ordinary man and ~ o m a n with no scientific training and to lea~e them with a suspicion thai someone may be deliberately trying to "'blind them ,.~ith science". To counter the procigarette propaganda of the manufacturers with the resources available for health education was almost c o m p a r a b l e to engaging tanks with air rifles. The history of preventive medicine in this country has proved abundantly that no British gw, ernnaent will take steps for the promotion of heahh which would be likely to cost it a substantial a m o u n t of votes or revenue unless there is a state of national crisis bordering upon panic: cholera pandemics and three major wars have been ',he most important public health reforming agents of the last 150 years. Obviousl~y the R.C.P. was not so naive as to believe that in 1962 to beat the public over the head with masses of statistics would do much more than stun the majority. Presumably it deliberately decided to take the ri:.k and one can see two very good reasons for doing so. In the short term the presentation of a reasoned factual case would appeal to the people who ask for facts and reason and whose help and sympathy was well worth enlisting. In the long term, if argument was going to have to be sustained and developed over a period of years that argument could survive only if the facts underlying its premises were made available to all.

The new report is shorter, blunter and simpler. It may well have disappointed some interested people who had expected it to contain a substantial addition to the body of scientific knowledge on the effects of smoking. In fact, detail of new research work has been largely relegated to references and this is not unreasonable in view of tile way in which virtually all such work supports pre-1962 investigations and findings and the basic arguments of the 1962 document. The case was proven beyond reasonable doubt i n / 9 6 2 and the need was essentially to deal with the less reasonable doubts and the sophisticated shufflings of interested parties. A m o n g other useful points there is discussion of probable reasons for the comparative immunity of pipe and cigar smokers, not only in regard to lung cancer but also in regard to cardiovascular disabilities and chronic bronchitis and emphysema, and a glance through a range of other conditions which have at various times been attributed to smoking, in some of which the evidence against tobacco is substantial though in others smoki~g is probably innocent. It is precisely this careful avoidance of o~,er-statement of the case which should make the report the more effective. Why has so little effect flowed from the 1962 report'? it is bluntly suggested that the G o v e r n m e n t action which would be necessary for the m~iking of real progress has been withheld because the revenue from taxation on cigarettes is regarded as economically necessary. One would be reluctant to regard this as really critical, .but reluctance is shaken by a couple of telling quotations from politicians of standing in both the tl~ain ,parties. It is certainly true that revenue loss which would follow a substanilal reduction in the cigarette habit could be made good only by a substantial increase in other taxation. The cynical might say that at present the smokers themselves are paying a good deal of the cost which they impose on the N.H.S. and that it would be unfair to shift the burden of this on to the shoulders of non-smokers until such time as the smokers whose health is already ruined have died off, but the report

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makes it quite clear that the cost to the nation of smokers" illnesses is much more than the cost of medical treatment and bears heavily on non-smokers as well as smokers already. Pro-cigarette p r o p a g a n d a has continued. True, the adxertising of cigaretles on television was stopped in 1965 and the manutacturers have voluntarily adopted a code which restricts certain other kinds of advertisement. but the fall of 25~'i, in expenditure on direct advertising vdaich occurred between 1965 and 1968 has been far more than offset by an increase of something like 150",, in expenditure on gift coupon s,:hemes. Incidentally, the manufacturers" ingenuous claim that since advertising was merely brand-versus-brand p r o p a g a n d a it did not encourage the public to s m o k e more can hardly be made in respect of coupon schemes, which in addition to pressing the smoker to change from brand "A'" to brand " ' B " offer him a "reward'" in direct proportion to the n u m b e r of Brand "'B'" cigarettes which he smokes. Was the approach to the public in anticigarette education made on the wrong lines? The fact that it has had little impact suggests that this was so, but probably expectations were too high. It is easy to say that the campaign was foredoomed to failure because of lack o f resources, but there is no certai~,ty that spending ten times the m o n e y would ha~,e produced even double the effect. The College is certainly right in saying that more research into both the causes o f cigarette addiction and the educational methods used to c o m b a t it is necessary but it may well be that the mounting of a campaign which has been a comparative failure has in itself been a worthwhile experiment which can, if it is critically studied, provide sorne invaluable research material. W h a t o f the steps which should now be taken? The College's recommendations are characterized by reasonableness and this is surely right. It is quite possible that some o f the i m m o d e r a t e approaches which have been made in certain quarters have done more harm than good. To stigmatize all smoking as a filthy and antisocial habit cart too easily rouse emotions to a point at which the smoker is not willing to listen to the voice of reason; it is to express a point of view which, however legitimate, is held by only a minority. Basically, the attitude o f the College is that

the case oll health grounds against the cigaretlc is incontrovertibly established v, hile thal against the pipe al~d the cigar is not. It follows that a campaign based on reason must make the cigarette its main poinl of attack. There is a very good case l\~r a total ban on cigarette adverti,qng and gif', coupon schclllC~,. Certainly rio harm at all can c o m e from the proposal to print a danger s~:arning on all cigarette packets, though its deterrent effect may not be great. Differential taxation rates on cigarctte~, ;lnd on cigars and pipe tobacco ha~e t~-cn suggested befl:~re. Such a policy has much to commend it in theory. If the differel~tial i,, rcall.v ~,uhstanti:d it could reasonably be expected to promote a change fl'om the more dangerous to the comt)arati,,ely innocuou,~ forms of tobacco and at the same time take much of the substance out of the argument that the Exchequer could not attbrd !.o lose the revenue which comes from Laxation of tobacco products. Whether it would be clfective in practice can be discovered only by experience. There are some countries in which such a differential already operates but they are countries in which the cigar and the pipe have long been the preferred forms of smoking. The report advocates the strengthening of regulations forbidding the sale of cigarettes to children, one of those " o b v i o u s " steps which clearly must be recommended but will probably m a k e little difference in itself. It will have virtually no effect at all unless the parallel recommendation is implemented that cigarette vending machines should be removed from public places. Health education of the public in this field must continue, with special concern for the school child and the adolescent but without forgetting those older people who are already " h o o k e d " . One likes the frankness o f one paragraph in the s u m m a r y of the r e p o r t ~ ~More effective techniques for helping unwilling smokers to stop must be developed in special research clinics, and when this has been done smoking-control clinics should be established in hospitals, health departments, factories and offices.*" It seems certain that smoking-control clinics will not be cheap to establish and maintain and that, entirely apart from the cost in money, they make considerable demands on the faith and patience of the people who conduct them, who must in

EIGHT YEARS AFTI-R any event be people of u n c o m m o n and rather special quality. It would be unfortunate to discontinue existing clinics if those in charge of Ihem tire ready to keep them going, but large-scale expansion, however desirable, should best await the purposeful collection of much more reformation by a well-designed research i"~rogra n l m e .

In a lesser degree, the same principle applies to health education in general, There is a case tor doing more of what is being done already, if only to make it clear that the concern behind tile report is really felt by all those who are intere.~ted in the health of the public and to emphasize theft the matter is and shall continue "'li~e". But the comparative failure of health cdueaiion :~cti~ itie.~ to get rid of smoking cannot t~e shrugged away on tile grounds that pro~moking propaganda ha.~ more money behind it than anti-cigarette education. We are still a long way from discovering the springs which have to be touched to get people to accept pre.~enl knowledge and take the obvious action and there needs to be more investigation of tiae things which make people start smoking and continue in the habit. Here is a field in which both background rcsearch and evaluation of whatever educational measures may be tried are absolutely imperative and money put into such research will be well invested. The institution and enforcement of more restrictions on smoking in "public places" is a sensible recommenda,',ion. It will effect some slight overall decrease in smoking but this is hardly its main purposes; its chief value will be that it will make it easier for those who are trying to give up smoking to do so and that it will help to get rid of the feeling that smoking is the "'in". thing. What must be avoided is the kind of approach which can be labelled "kill-joy"; there is in practice no difficulty in finding a reasonable a p p r o a c h based on what the public is already prepared to accept. in Britain already the public acquiesces in the prohibition of smoking in concert halls, m a n y theatres and other places like museums and libraries. In other countries no less addicted than Britain the prohibition has been extended to such places as cinemas and underground railways without causing revolutions. It is doubtful whether addicts would riot here if they were totally deprived o f their solace for the 45 minutes or so which is the m a x i m u m time that most people spend continuously on

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short-distance public transport and it would not be unreasonable to prohibit smoking altogether on, say, underground railways and local buses. For the rest the approach could well be to prohibit smoking in enclosed "'places o f public resort" and in long-distance public transport "except in sections of those places and vehicles specifically reserved for smoking". This could well cover cinemas and sundry other places for public entertainment, aircraft ---where there is at present a positive incitement to smoke cigarettes and active discouragement of the smoking of pipes and c i g a r s - - a n d the public rooms of hotels, it could be applied also to m a n y cafes and restatirants, though those physically too small to make separate provision might be in difficulties. (These Litter might take a leaf out of British Rail's dining car book and ban smoking at certain times during the service and consumption o f meals.) Could this be started on a voluntary basis? Probably "'yes" in some degree, though some proprietors would be hesitant because of the risk of losing custom to rivals. This really appears to be a field in which G o v e r n m e n t action (or action by m o n o p o l y bodies such as London Transport) would offer the best prospect of success. And, finally, to the force o f example. It is all to the good that public bodies should adopt self-denTing ordinances which ban smoking at their committee meetings and so forth, but self-denial in private cannot by its very nature greatly influence the public. While people of eminence and influence have the same inalienable individual right as anyone else to dig their graves in their own way, they have, because of their public position, a responsibility not to do anything which would carry the risk of influencing others in a dangerous direction. The doctor who enjoys his pipe in his study or drawing-room is exercising a simple right. The doctor who smokes a cigarette in his s u r g e r y - - o r elsewhere in the presence of his patients and their relations--is abusing his responsibility. (The prudent doctor would be aware that if he indulges in cigarette smoking even in private the news might leak out and undermine whatever advice he was giving in public !) The same principle applies to the teacher in his relation to his pupils and to a good many other people, not excluding in these days the participants in

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television discussion or documentary progra mnles. Is there any case against the r e c o m m e n d a tions made in the report ? Certainly there is no substantial one. Some people appear to get some benefit from smoking and the report concedes as much. it might be better to say that some people believe that they get some benefit but this comes down in the end to m~iters o f emotional satisfaction in which there is no material distinction between the two methods of expression, if one must have an addiction it i~ more desirable to be addicted to cigarettes than to be an alcoholic or a heroin addict, but there are plenty of far less harmful addictions available. The ethical question of infringement of personal liberty is c o m m o n l y raised. In answering this it is perhaps injudicious to imply analogies between respiratory disorders and epidemics of infectious disease. To curb the freedom o f a smallpox patient or a carrier of typhoid or diphtheria is clearly j~stified in the public interest. True, the s m o k e r of cigarettes may encourage others by his example to maintain o r acquire the habit but, unlike people exposed to risks of infection, those others have a free choice as to whether they do or do not pick up the contagion. The

basic principle behind all the report's ~ecommendations is that of strong discouragement and restriction rather than total prohi~-;~ion and this cannot'be regarded as an infringement of liberty which goes beyond what the facts justify. Finally. one must c()mmend the way in which the report has very little to say about the need for further research into the mechanism of the relationship between cigarette smoking and respiratory cancer. T o emphasize this would be to eiacourage the addict to defer personal action until more delailed evidence is avai!able, an excuse which too many addicts ha'~e used too often in the past. The value of such research could be to find ways of smoking which might well be less harmful than using cigarettes and from this point of view it is fully justified. But there is no need whatever to seek further evidence that cigarettes are dangerous: the case against them is proved beyond any reasonable doubt and the certainty of that danger is the basis upon which urgent action must be taken.

"Smoking and Health Now". A Reporl of It~c Royal College of Physicians. 1971. pp. 148. Price £0.50 net.