- Email: [email protected]
WHY PEOPLE SMOKE
250
patient when derived from his peers instead of from authority. Many will differ from Dr. Schmideberg’s views and methods, but their particular virtues seem to be their It is to people with her realism and common sense. and that we look for new ideas positive approach energy and methods-the trouble is that methods already in use remain somewhat unknown quantities. Apart from the work at Belmont,2Simpson has an interesting unit at Wormwood Scrubs,3 and elsewhere different types of formal psychotherapy and psychoanalysis have been used. Everyone working in or observing these endeavours must agree that " things happen " (treating psychopaths may be trying but it is certainly not uneventful), and the dynamic situations that arise are of much scientific interest. But the ultimate results are hard to judge, and comparison of one kind of management with another is impossible. WHY
PEOPLE SMOKE
TEMPERAMENTAL differences between smokers and nonsmokers have been described by Heath 4; and now McArthur et al. have published further observations on the same group of men. Their subjects were 252 Harvard graduates who, while at the university in 1938-42, were selected for a study of adult development because of their apparent normality. They were examined by psychological and various other techniques, and their progress was checked by annual questionaries, tests, and visits. Smoking habits were among the extensive data collected about these men, and information accumulated over a fifteen-year period was available for analysis. Believing with Bales6 that the social and cultural environment is the most potent influence on habit formation, McArthur et al. considered that non-smoking was likely to be commonest in the lower middle class of the U.S.A., since there is evidence7that people of this rank, more than those above or below them in the social scale, still cleave to values derived from what has been called the Protestant Ethic 9-religious doctrine according to which it is sinful to waste time and substance on unprofitable activities. Children reared in this tradition- are taught to eschew frivolity, and to be upright, industrious, and ambitious.8 10 11 It seemed probable, therefore, that members of the middle class would be less likely to indulge in a pleasure of the flesh, such as smoking, than members of other less ascetic sections of the population. In order to test this hypothesis they compared the smoking habits of men who had prepared for Harvard at public high schools with those of men who had prepared for Harvard at private preparatory schools, as the high-school graduates were mainly of middle-class and the preparatoryschool graduates of upper-class origin. They found, in fact, that there was a highly significant correlation between smoking and exclusiveness of school. 20% of the graduates of very exclusive private schools, 30% of the graduates of less exclusive private schools, and 40% of the graduates of public schools did not smoke. At first sight it might appear that a public-school education is less 2. 3. 4. 5. 6. 7. 8. 9.
10. 11.
Jones, M., et al. Social Psychiatry. Tavistock Publ. London, 1952. Landers, J. J., McPhail, D. S., Simpson, R. C. J. ment. Sci. 1954, 100, 953. Heath, C. W. Arch. intern. Med. 1958, 101, 377. See Lancet, 1958, i, 680. McArthur, C., Waldron, E., Dickinson, J. J. abnorm. soc. Psychol. 1958, 56, 267. Bales, R. F. Quart. J. Stud. Alcohol, 1946, 6, 480. McArthur, C. Harvard educ. Rev. 1954, 24, 256. McArthur, C. J. abnorm. soc. Psychol. 1955, 50, 247. Weber, M. The Protestant Ethic (Translated by Talcott Parsons). New York, 1930. McClelland, D., Rindlisbacher, A., De Charms, R. Studies in Motivation; p. 389. New York, 1955. Miller, D. C., Form, W. H. Industrial Sociology. New York, 1951.
conducive to smoking than a private-school one; but this is not so, for it has been estimated 12 that only 9% of boys at American public schools do not smoke It must therefore have been from this select minority that the Harvard public-school non-smokers were recruited. They were predominantly earnest young men of the middle class, the pride of their families, heavily indoctrinated with " work morality ", and bent on achieving the status of a technical or professional career. The upper-class privateschool boys, on the other hand, aimed rather at conformity with an accepted code of behaviour than at advancement through self-denial, and most of them went into business. A significantly high proportion of nonsmokers had pious parents, and the sons were often more pious than the fathers. In short, it would appear from the findings of this investigation that a comparatively poor but very honest Protestant, keen to " improve himself", is more likely than most in America to remain a nonsmoker ; and McArthur et al. quote a market survey carried out in England 13 which suggests that here also non-smoking is associated with middle class respectability ". Whatever the reason for starting to smoke, it may be assumed that the degree of addiction will be determined by the extent to which the habit satisfies the personal needs of the smoker. It is generally believed that smoking is indulged in to allay anxiety, but McArthur et al. found no convincing evidence of a general tendency in their subjects to smoke more heavily in times of stress, although they admit that their experiment was not ideally designed to test this point. However, as 70% of heavy smokers and only 30% of light smokers said they smoked more when under pressure, it seemed possible that smoking may become a suitable tension reducer only when it has become a deeply ingrained habit. Heavy smoking in their study was found to be most significantly correlated with a " coartated " performance of a special Rorschach test-that is, a record indicative of a lack of emotional resources. Coartated men were " inarticulate, pragmatic, and bland ... hard to get to know ... compulsive fiddlers, desk-arrangers, people who allayed their tension through fussy activities ". Once a coartated person started to smoke he tended to smoke heavily, no matter what his social background had been. Moreover, he tended to smoke increasingly, so that if he started late he was soon smoking more than men who had started early. Among the heavy smokers who were not coartated there was, as Heath.4 has already observed, a significantly high proportion of impulsive men with poorly integrated personalities. As regards ability to stop smoking, the amount of tobacco previously consumed was found to be the most significant factor. It was estimated that men who have smoked a mean number of 9 cigarettes a day can stop, men who have smoked 18 do not try, and men who have smoked 20 cannot. (Presumably it is assumed that some 18-a-day men can stop if they try.) The ability of the subjects of the study to stop smoking was also significantly related to the length of time they had been breast-fed. Light smokers who could stop had been weaned at 8 months; heavy smokers who could stop had been weaned at 6-8 months; smokers, mostly heavy, who did not try to stop had been weaned at 5 months; and smokers, mostly heavy, who tried to stop but could not had been weaned at 4-7 months. McArthur et al. do not suggest that there is an immediate connection between early 12. Hollingshead, A. Elmtown’s Youth. New 13. Davis, F. Unpublished.
York,
1949.
251
weaning and inability to stop smoking-the time of weaning may reflect only a certain pattern of infant training-but they point out that smoking is associated with a liking for other oral gratifications: smokers tend drink more alcohol and coffee than non-smokers,4and if they stop smoking they are apt to substitute food for tobacco.14 Also, a lower than average proportion of men who could stop smoking had been bottle-fed babies, and a higher than average proportion of men who could not were reported to have sucked their thumbs in childhood. McArthur et al. therefore conclude that, although the amount of tobacco previously consumed is of prime importance in determining whether or not a person can stop smoking, an orality " factor may also be influential. Perhaps the most interesting finding of this study is that in the past some parents, on general principles, have persuaded their children not to smoke. Now that the perils of cigarette smoking are so widely known, it would be even more interesting to learn what parents are managing to persuade their children to avoid the habit on the specific ground that it is dangerous to life.
to
"
ANTIBODY TO PENICILLIN
Ley a1.15 have reported a new and interesting observation-that specific antibody to penicillin may be demonstrated in some human sera. The discovery was made accidentally. Penicillin was added as a routine to preserve red-cell suspensions used in a blood bank. The serum of one prospective recipient of a transfusion was found to agglutinate all red cells against which it was tested, but the agglutination did not appear when the same serum was tested against red cells which had not been mixed with penicillin. When the patient’s red cells were treated with penicillin, they also were agglutinated by his own serum. Investigation showed that red cells of all human bloodgroups could be made agglutinable to antibody-containing sera in this way, but so far only with the penicillins G, 0, and K, and the penicillin derivative synnematin B. Results were negative in tests with streptomycin, dihydroet
streptomycin, polymyxin B, bacitracin, neomycin B, ristocetin, viomycin, and oleandomycin; but it is not stated whether cells sensitised with these agents were put against sera likely to contain antibody to them or only against sera known to contain antibody to penicillin. Penicillin inactivated by penicillinase did not sensitise the red cells; but red cells once sensitised could not be desensitised by subsequent treatment with penicillinase, papain, or ficin. Sensitisation of red cells with penicillin proceeded in proportion to the concentration of the drug and time of exposure, reaching a maximum in about twenty-four hours and persisting for as long as the cells remained useful for testing-that is, for some two to three weeks. To carry out tests for serum antibody, Ley et al. prepared penicillinised red cells by adding 8 ml. of a mixture of equal parts of whole blood and Alsever’s solution to 200,000 units of powdered penicillin G. After incubation at 37°C for an hour the red cells were washed thrice in physiological saline solution and made up to a suitable suspension (4-10%) in physiological saline. The incubation temperature was not critical, since sensitisation could be accomplished at any point in the range 6-37°C. Antibody was eluted from sensitised cells by heating them at 54°C for fifteen minutes; the antibody was stable at 14. Brozek, J., Keys, A. Science, 1957, 125, 1203. 15. Ley, A. B., Harris, J. P., Brinkley, M., Liles, B., ibid., 1958, 127, 1118.
Jack, J. A., Cahan, A.
refrigerator temperatures and resisted 56°C for two hours. Its possession of many of the known attributes of a true antibody, and its specificity, thus appear to be well established; further, it may be completely adsorbed from sera by their exposure to concentrations of penicillin of the order of 12,000 units per ml. or greater. A positive reaction between antibody-containing serum and sensitised red cells may be easily demonstrated by conventional or tube agglutination methods if there is enough antibody, and by anti-globulin methods if there is not. So far, Ley et al. have detected 25 positive sera among about 2000 tested. All who yielded positively reacting sera had received penicillin treatment at some time, but only a minority had been known on clinical grounds to be sensitive to penicillin.
slide
This report is of great interest both because it offers
a
possible method of studying the sensitisation of patients to penicillin-an important problem in its own rightand because, despite the negative results with other antibiotics so far tested, this report raises the hope that the valuable method of red-cell agglutination may perhaps, with appropriate technique, be yet found adaptable to the study of other hypersensitivity phenomena, which cause so an
much distress to their victims and appear of medical practice.
to
be
increasing feature
EXPERIMENTAL MONILIASIS
MONILIASIS is attracting attention because overgrowth of the causal agent, Candida (formerly Monilia) albicans, is commonly observed in patients treated with antibiotics-particularly, it seems, with broad-spectrum antibiotics such as chloramphenicol and the tetracyclines. Usually this overgrowth is without clinical significance; but exceptions are common enough to maintain our interest in the influences that may favour or counteract invasion of tissue by C. albicans. Studies of these problems are reviewed by O’Grady and Thompson,! who describe their own experimental approach, which has novel and notable features. To begin with, they chose to work with a lesion produced by inoculating C. albicans into the left thigh of mice. This was done to eliminate the uncontrollable and unmeasurable effects that might arise in experiments where a local bacterial flora was normally present. It is suspected that, in actual practice, monilial overgrowth may be due partly to suppression of normal flora; but the unresolved question which was studied was whether an antibiotic might have a more direct effect either on the growth of the candida or on the defences of the host. The closed lesion in the thigh of the mouse met this point. Furthermore, objective, accurate, rapid, and frequent measurements of the progress of the experimental infection could be made by measuring daily with sliding callipers the mediolateral diameters of the thighs and thence calculating the average increase compared with the normal thigh. O’Grady and Thompson examined 2 Seligmann’s postulate that chlortetracycline (aureomycin) exerts on the response of the host to candida infection an effect analogous to that of cortisone.’ In the effects of cortisone and chlortetracycline they discovered, by their approach, two similarities and two differences. Both drugs caused a decrease in size of the experimental lesions, which was followed by a rapid increase when treatment was stopped. In addition, if the dose of chlortetracycline was high enough, the diameter of the thigh on the side 1. 2.
O’Grady, F., Thompson, R. E. M. Brit. J. Pharmacol. 1958, 13, 1. Seligmann, E. Proc. Soc. exp. Biol., N.Y. 1952, 79, 481 1953, 83, 778.
patient when derived from his peers instead of from authority. Many will differ from Dr. Schmideberg’s views and methods, but their particular virtues seem to be their It is to people with her realism and common sense. and that we look for new ideas positive approach energy and methods-the trouble is that methods already in use remain somewhat unknown quantities. Apart from the work at Belmont,2Simpson has an interesting unit at Wormwood Scrubs,3 and elsewhere different types of formal psychotherapy and psychoanalysis have been used. Everyone working in or observing these endeavours must agree that " things happen " (treating psychopaths may be trying but it is certainly not uneventful), and the dynamic situations that arise are of much scientific interest. But the ultimate results are hard to judge, and comparison of one kind of management with another is impossible. WHY
PEOPLE SMOKE
TEMPERAMENTAL differences between smokers and nonsmokers have been described by Heath 4; and now McArthur et al. have published further observations on the same group of men. Their subjects were 252 Harvard graduates who, while at the university in 1938-42, were selected for a study of adult development because of their apparent normality. They were examined by psychological and various other techniques, and their progress was checked by annual questionaries, tests, and visits. Smoking habits were among the extensive data collected about these men, and information accumulated over a fifteen-year period was available for analysis. Believing with Bales6 that the social and cultural environment is the most potent influence on habit formation, McArthur et al. considered that non-smoking was likely to be commonest in the lower middle class of the U.S.A., since there is evidence7that people of this rank, more than those above or below them in the social scale, still cleave to values derived from what has been called the Protestant Ethic 9-religious doctrine according to which it is sinful to waste time and substance on unprofitable activities. Children reared in this tradition- are taught to eschew frivolity, and to be upright, industrious, and ambitious.8 10 11 It seemed probable, therefore, that members of the middle class would be less likely to indulge in a pleasure of the flesh, such as smoking, than members of other less ascetic sections of the population. In order to test this hypothesis they compared the smoking habits of men who had prepared for Harvard at public high schools with those of men who had prepared for Harvard at private preparatory schools, as the high-school graduates were mainly of middle-class and the preparatoryschool graduates of upper-class origin. They found, in fact, that there was a highly significant correlation between smoking and exclusiveness of school. 20% of the graduates of very exclusive private schools, 30% of the graduates of less exclusive private schools, and 40% of the graduates of public schools did not smoke. At first sight it might appear that a public-school education is less 2. 3. 4. 5. 6. 7. 8. 9.
10. 11.
Jones, M., et al. Social Psychiatry. Tavistock Publ. London, 1952. Landers, J. J., McPhail, D. S., Simpson, R. C. J. ment. Sci. 1954, 100, 953. Heath, C. W. Arch. intern. Med. 1958, 101, 377. See Lancet, 1958, i, 680. McArthur, C., Waldron, E., Dickinson, J. J. abnorm. soc. Psychol. 1958, 56, 267. Bales, R. F. Quart. J. Stud. Alcohol, 1946, 6, 480. McArthur, C. Harvard educ. Rev. 1954, 24, 256. McArthur, C. J. abnorm. soc. Psychol. 1955, 50, 247. Weber, M. The Protestant Ethic (Translated by Talcott Parsons). New York, 1930. McClelland, D., Rindlisbacher, A., De Charms, R. Studies in Motivation; p. 389. New York, 1955. Miller, D. C., Form, W. H. Industrial Sociology. New York, 1951.
conducive to smoking than a private-school one; but this is not so, for it has been estimated 12 that only 9% of boys at American public schools do not smoke It must therefore have been from this select minority that the Harvard public-school non-smokers were recruited. They were predominantly earnest young men of the middle class, the pride of their families, heavily indoctrinated with " work morality ", and bent on achieving the status of a technical or professional career. The upper-class privateschool boys, on the other hand, aimed rather at conformity with an accepted code of behaviour than at advancement through self-denial, and most of them went into business. A significantly high proportion of nonsmokers had pious parents, and the sons were often more pious than the fathers. In short, it would appear from the findings of this investigation that a comparatively poor but very honest Protestant, keen to " improve himself", is more likely than most in America to remain a nonsmoker ; and McArthur et al. quote a market survey carried out in England 13 which suggests that here also non-smoking is associated with middle class respectability ". Whatever the reason for starting to smoke, it may be assumed that the degree of addiction will be determined by the extent to which the habit satisfies the personal needs of the smoker. It is generally believed that smoking is indulged in to allay anxiety, but McArthur et al. found no convincing evidence of a general tendency in their subjects to smoke more heavily in times of stress, although they admit that their experiment was not ideally designed to test this point. However, as 70% of heavy smokers and only 30% of light smokers said they smoked more when under pressure, it seemed possible that smoking may become a suitable tension reducer only when it has become a deeply ingrained habit. Heavy smoking in their study was found to be most significantly correlated with a " coartated " performance of a special Rorschach test-that is, a record indicative of a lack of emotional resources. Coartated men were " inarticulate, pragmatic, and bland ... hard to get to know ... compulsive fiddlers, desk-arrangers, people who allayed their tension through fussy activities ". Once a coartated person started to smoke he tended to smoke heavily, no matter what his social background had been. Moreover, he tended to smoke increasingly, so that if he started late he was soon smoking more than men who had started early. Among the heavy smokers who were not coartated there was, as Heath.4 has already observed, a significantly high proportion of impulsive men with poorly integrated personalities. As regards ability to stop smoking, the amount of tobacco previously consumed was found to be the most significant factor. It was estimated that men who have smoked a mean number of 9 cigarettes a day can stop, men who have smoked 18 do not try, and men who have smoked 20 cannot. (Presumably it is assumed that some 18-a-day men can stop if they try.) The ability of the subjects of the study to stop smoking was also significantly related to the length of time they had been breast-fed. Light smokers who could stop had been weaned at 8 months; heavy smokers who could stop had been weaned at 6-8 months; smokers, mostly heavy, who did not try to stop had been weaned at 5 months; and smokers, mostly heavy, who tried to stop but could not had been weaned at 4-7 months. McArthur et al. do not suggest that there is an immediate connection between early 12. Hollingshead, A. Elmtown’s Youth. New 13. Davis, F. Unpublished.
York,
1949.
251
weaning and inability to stop smoking-the time of weaning may reflect only a certain pattern of infant training-but they point out that smoking is associated with a liking for other oral gratifications: smokers tend drink more alcohol and coffee than non-smokers,4and if they stop smoking they are apt to substitute food for tobacco.14 Also, a lower than average proportion of men who could stop smoking had been bottle-fed babies, and a higher than average proportion of men who could not were reported to have sucked their thumbs in childhood. McArthur et al. therefore conclude that, although the amount of tobacco previously consumed is of prime importance in determining whether or not a person can stop smoking, an orality " factor may also be influential. Perhaps the most interesting finding of this study is that in the past some parents, on general principles, have persuaded their children not to smoke. Now that the perils of cigarette smoking are so widely known, it would be even more interesting to learn what parents are managing to persuade their children to avoid the habit on the specific ground that it is dangerous to life.
to
"
ANTIBODY TO PENICILLIN
Ley a1.15 have reported a new and interesting observation-that specific antibody to penicillin may be demonstrated in some human sera. The discovery was made accidentally. Penicillin was added as a routine to preserve red-cell suspensions used in a blood bank. The serum of one prospective recipient of a transfusion was found to agglutinate all red cells against which it was tested, but the agglutination did not appear when the same serum was tested against red cells which had not been mixed with penicillin. When the patient’s red cells were treated with penicillin, they also were agglutinated by his own serum. Investigation showed that red cells of all human bloodgroups could be made agglutinable to antibody-containing sera in this way, but so far only with the penicillins G, 0, and K, and the penicillin derivative synnematin B. Results were negative in tests with streptomycin, dihydroet
streptomycin, polymyxin B, bacitracin, neomycin B, ristocetin, viomycin, and oleandomycin; but it is not stated whether cells sensitised with these agents were put against sera likely to contain antibody to them or only against sera known to contain antibody to penicillin. Penicillin inactivated by penicillinase did not sensitise the red cells; but red cells once sensitised could not be desensitised by subsequent treatment with penicillinase, papain, or ficin. Sensitisation of red cells with penicillin proceeded in proportion to the concentration of the drug and time of exposure, reaching a maximum in about twenty-four hours and persisting for as long as the cells remained useful for testing-that is, for some two to three weeks. To carry out tests for serum antibody, Ley et al. prepared penicillinised red cells by adding 8 ml. of a mixture of equal parts of whole blood and Alsever’s solution to 200,000 units of powdered penicillin G. After incubation at 37°C for an hour the red cells were washed thrice in physiological saline solution and made up to a suitable suspension (4-10%) in physiological saline. The incubation temperature was not critical, since sensitisation could be accomplished at any point in the range 6-37°C. Antibody was eluted from sensitised cells by heating them at 54°C for fifteen minutes; the antibody was stable at 14. Brozek, J., Keys, A. Science, 1957, 125, 1203. 15. Ley, A. B., Harris, J. P., Brinkley, M., Liles, B., ibid., 1958, 127, 1118.
Jack, J. A., Cahan, A.
refrigerator temperatures and resisted 56°C for two hours. Its possession of many of the known attributes of a true antibody, and its specificity, thus appear to be well established; further, it may be completely adsorbed from sera by their exposure to concentrations of penicillin of the order of 12,000 units per ml. or greater. A positive reaction between antibody-containing serum and sensitised red cells may be easily demonstrated by conventional or tube agglutination methods if there is enough antibody, and by anti-globulin methods if there is not. So far, Ley et al. have detected 25 positive sera among about 2000 tested. All who yielded positively reacting sera had received penicillin treatment at some time, but only a minority had been known on clinical grounds to be sensitive to penicillin.
slide
This report is of great interest both because it offers
a
possible method of studying the sensitisation of patients to penicillin-an important problem in its own rightand because, despite the negative results with other antibiotics so far tested, this report raises the hope that the valuable method of red-cell agglutination may perhaps, with appropriate technique, be yet found adaptable to the study of other hypersensitivity phenomena, which cause so an
much distress to their victims and appear of medical practice.
to
be
increasing feature
EXPERIMENTAL MONILIASIS
MONILIASIS is attracting attention because overgrowth of the causal agent, Candida (formerly Monilia) albicans, is commonly observed in patients treated with antibiotics-particularly, it seems, with broad-spectrum antibiotics such as chloramphenicol and the tetracyclines. Usually this overgrowth is without clinical significance; but exceptions are common enough to maintain our interest in the influences that may favour or counteract invasion of tissue by C. albicans. Studies of these problems are reviewed by O’Grady and Thompson,! who describe their own experimental approach, which has novel and notable features. To begin with, they chose to work with a lesion produced by inoculating C. albicans into the left thigh of mice. This was done to eliminate the uncontrollable and unmeasurable effects that might arise in experiments where a local bacterial flora was normally present. It is suspected that, in actual practice, monilial overgrowth may be due partly to suppression of normal flora; but the unresolved question which was studied was whether an antibiotic might have a more direct effect either on the growth of the candida or on the defences of the host. The closed lesion in the thigh of the mouse met this point. Furthermore, objective, accurate, rapid, and frequent measurements of the progress of the experimental infection could be made by measuring daily with sliding callipers the mediolateral diameters of the thighs and thence calculating the average increase compared with the normal thigh. O’Grady and Thompson examined 2 Seligmann’s postulate that chlortetracycline (aureomycin) exerts on the response of the host to candida infection an effect analogous to that of cortisone.’ In the effects of cortisone and chlortetracycline they discovered, by their approach, two similarities and two differences. Both drugs caused a decrease in size of the experimental lesions, which was followed by a rapid increase when treatment was stopped. In addition, if the dose of chlortetracycline was high enough, the diameter of the thigh on the side 1. 2.
O’Grady, F., Thompson, R. E. M. Brit. J. Pharmacol. 1958, 13, 1. Seligmann, E. Proc. Soc. exp. Biol., N.Y. 1952, 79, 481 1953, 83, 778.