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.. . Rrprietrd f rom thr A. W iA. Archivri of 1Ktrnrof Mrditinr Frbrvo ry 1 DS8, Vo1.101, pp. 377-381 Coplriyhr IDSd, by Ar,rriroe Xrdiro/ Arlociariow _ I. ;; ' and Nonsmokers Differences Between Smokers / n s & ~ . ,,, AR C tA 0 M / d ' ~' I K W, H TH. b1 ., .~ .. , Msw .~ Why some men smoke and others do not' I. The Collection of Data on Smoldng `,%:-• sf has never been adequately explatned.L..The. ~ original group of participants arm-.,= , ' question has some medial ydevance_now prised 268 men. Ten of these left the study" ;~• ;.~r~.::.~ . . . . ,. . ~xcr_. .. • 1 . .. . .. •. .c ? elft s... .. .. :v, ~. .':~ .~,. ~ r, .. ~•. . .. : . ~y!. . • . .. • _ ..r.f,;C•,•..r ., .~• . t. .. . T. t .. .•:r ,. ® that heavy smoking has been shown to have . relationship to lung cancer and possibly to coronary disease and since there have been • certain therapeutic indications for the con-trol of smoking. It is at least~theoretieally ~ ' is. .often_ a symptom possible that unoking . or sign of physiologic.•~or personality' characteristics which themselves may in-,• fiuence disease.,. Tbe opportuntty. . has recently come to explore some data already, collected in respect to differences of phy-• sique, physiology, and personality bexween smokers and nonsmokers. This is a part of, a larger study of smoking habits. Charles C. McArthur, Ph.D., is preparing material from the same source on the psychody-. namics of smoking,' and Carl C. Seltzer,. Ph.D., on physique of s^tokers :~ ~y-~ yt'.}'.: The g:oup under study comprises 252. college graduates, now in the age range of 33 to 37 years, most of them married and settled in a wide variety of occupations throughout the country. They are members of the Study of Adult Development (Grant Study),2 which is a long-term study of selected "normal" college men, who were first seen in 1938 to 1942 and have been pursued by interview and questionnaire to the present. During the gathering of the. data, inquiry into smoking habits x•as givezt the same degree of attention as other•aspecu . of information obtained about these partid- pants...~. y' .- . Submitted for publicatior Sept. 30, 1957• `.. This inveui&7aCOn was supported in part by the Tobacco Industry Research Corrunittec, ICew York From the Study of Adult Development (Grant Study). 1-Iealth Scrviocs, Harvard University, CambridQe, Mass. ~ . = 4 'j . •.~ during the initial years, and six were killed ` - during the war, leaving two hundred fifty-.•;.- • two men Three additional men had not re-j,-•' • plied to questionnaires sufficiently to be 1`}-t included, and one more was exduded f roai~~, the group by the nature of his sdection and by 'personality difficulties. However, four ~ • referred cases were included. These were men who had been studied in precisely ~; similar ways, whose subicquent careers ~ have shown good accomplishment, and who • have been faithful in follow-up question- naires. For this total group of 252 men the annual questiotuuires have been returned by 80% on the avenge for eac^n year. Ninety per cent of the men have returned at '' least one questionnaire every two years. • During the initial medical examination i.n 1938-1942 the smoking habits, among other : habits, were recorded by the following tabu-' lar scheme: Tobacco-none, daily, .aries; ' eigarettes---0, 1-5, 6-10, 11-19, 1 pack, 2+ packs pu day; pipes-4-1-2-3-4-5-F pcr-. day; eigars--0-1-2-3-4-5 per day. In ad- : dition, the psychiatrists and othcrs recorded.=;; for many cases the participants' comments ~." about their smoking habits. Each full ques-. ` tionnaire in years subsequent to World Vti'ar~.; : 1:I has contained the above tabular scheme under a section on health and habiu..: :' Table 1 shows the number of men answer- ' ing the tobacco question each year and the per cent of men under each category of smoking. The year 1945 is omitted because of too few responses. This was the last year of the war and was preceded by a question- naire and immediately followed by a thorough qucstionltaire concerned with activ- ities during the .var. ~~~;0 ; ~1"4 4 ~" C ®~ ~ti N ~`° ~`.~ 0 .~'~ E~ ` c

.•.1'. A. H. A. ARCHIVES OF INTERNAL MEDICINE Twit[ 1-Sammary of Data ft Ssnokap HabitJ . ~..i..rrr) a r.- :;~'RxJ9 ,r•r. . ~.. b o. li11,.~.+~:. ~y~~[~ r:V « •i .. . .s: ", 1'I . ~ i i a ~ i7 ~ w ttY w M.7 • K7 •slt . IfRJ s• _ fif KJ IW.^~'.' ~--. ~ -. LW • Naa.b.n tadsats ha e.nl N aa ' . . ~ . . .•; nJ '_. The nonsmokers varied between 44.2% daily, either continuously or for a majority and 51.4%, the largest numbers falling dur- of the yca.rs during which they were fol-: it ing college and in reccnt years. When one lowed. considers the history of smoking over the";-.'•`w tvhole period of some 15 years, the numbers' II. Personality Differenccs of nonsmokers are considerably reduced be-' O+fe Descriptioas cause of those who took up smoking tcnta-' ~ The records of the Study of Adult Dt_,':.' . tively or intermittently. Only 51 men have ' velopment are a rich source for ca_se descrip-`:: never smoked (20%). The table shows an tion. Verbal descriptions of pr.sons can increase of heavier smokers (one package or supply ample evidence of personality dif--:' morc daily) to a peak of 357o in 1948 and ferences without lending themselvu to any then a diminution of numbers to 29cf'o in psy statistical handling or proof. A read : recent years. Smoking during collcge in ing of records showed marked differences . 1938 to 1942 was, for nuny men, merely between some of the smokers and the non- ' an intermittent experimmt, and the 6gures smokers. The following brief case desuip- at this time should be discounted. Relatively tions, somewhat disguised, i.Ilust:-ate this. few men smoked two or more packages of The first five cases are the men who smoked cigarcttes a day, not more than four men most heavily (two or more packages of prior to 1950. Eleven men smoked two or cigarettes a day for a prolonged period of more packages a day in 1952. r time).- Pipe or cigar smoking was less frequent Fivr Haaviut( SmokrrJ TrnY''R-: . ~' . - .:. .1EY1 .1 'Zrtu u ) A- _,~ ...~-4..': . '~ud1 b^. . !~1 .. . :iV . ~c:. . . .. . . a -~Y V 3. . i 0 t?un cigarette smoking. Cigar and pipe ' C.cst t-A product of a poor facaily, with smoking will be essentially disregarded in the present study:a ; ~ -4::. A threefold classification of smoking has been constructed, based upon long=term ob- servation of each subject. The men who never smoked are grouped with 10 men who smoked rzrely and intermittentlyonly, bbefore 1947, and they are considered nonsmokers: Thcy total 61 men, or 24.2%. A group of moderate smokers, 95 men, or 37.7%, in- wounds. Psychosocn.uic symDtoms on rcturnina to cludes all of those smoking up to 19 cigaret- - civilian lile. A uor,ny courtship• but evcntually a tes daily and also 30 men who were chiefly cigar or pipe smokers. The remainder, called heavier smokers, totalling 96 men, or 38.1 ofo, smoked one or more packages of cigarettcs 378 l •L4 . 1-ifa « 'sd ~ , « 3l~nDa•C7 •. ii.x s~ a i. i~'i w~" A7T. . it.! fl].~. ~ 323 3fJ lJ 4R ` IfJ ~ .. . _ ~ . .. U a~~LOfl~rl, af1J . - 11 . . . 11l t-_. .•. %+.:. .. ... '[ 'n.L. . • ~. S - doaunating cridcal yarcou, be had to work his way through co(k-Pe. He chose a dan`crau branch of the arase•d service durine the wa.r, one for w•hich he had admitted same fear, and ful6lled his duties well. Active physical work for a large 5rm which sets ttarviards for emploYtts but yro- vidct housing, prnsior% and insurance ytans. $orne ; uwita] dif6culties. Somewhat auspioosa of othcn, t: CG.s[ 2-Hard-drivins and atrivins worker. , s. Remarkable combat record during the war, indud- ; inY long periods of danPerous 6tfitiesy and aeveral succcssful marriagc and successful career. Ag- g-ressive worker in a highly cocnpctitivc businesi held . • . Gsc 3-This rnan v+as cast o(i by a broken ' family at an early age to make his own way. Vol. 101, P.b.,193d 1441' ..a CTR' NH 0034'66

:, ! in orxnbat His work requires tnvel in foreign• between basic rrseuc} and applied sdrn« but at eaurtries and eoruiderabk initiative and physinl' knKth lus found a good comDrocnise. Happily '„~ { y ~:,•, .. activity. Marriage resulted in divoroti''-1 •"•-: married and devoted to both his own and his wife's . t ., jak, • . , tnC, pz-ts. A quiet kader. .5 ve , There is no ., qucstion that these have something in eomm~xt• Thcy shaw~ 1 Gse 10-This young man came 'from an agri- . enltural eorrununity in the Middle West, of upright energy, seeking for danger, restlessness, and and striu parents. Since childhood be thowed a kind of independence which keeps them' evidence of wcnpleang every job with grat de- .~~ actively engaged in some enterprise whieh termination. Has •'mental alertness in excess of appeals. They are interesting men who per-'' cultural atninments" Language offi«r during the . form useful work r. Steady promotions in his work, which is a They seem to be K'eu w•a r beld of btuineu. Happily aurried Friendly, ,- sexed, but they have had difl•iculties wtith ` s_ energetic, dependable. ; ~~T marriage, perhaps stemming from their in= dependent natures. Their smoking to excess"t It happcu L4at each of the five non smokers, chosen at random, comes from the seems to be a symptom of their great rest ,t, •, •,,.W4 r; biiddle Vi'est, whereas all of the heavy lessness ~~r:, Lo "• -s,. ~ smokers are from the Fastern Seaboard. Of ,:,, A random um t„~ ple of S5 of the 51 non-~ the whole group of SI men who neva . - smokers was taken; and their brief nse smoked, 19 came from the Middle West; • summaries are as follows:' ' "'' "" ~Xa:t 26 from the Eastern States, S from the Fivr Nonsmokerr;',.:r:n West, and 1 from the South. The geo '~ CAst: 6.-Obtiined perhaps the highest Arrny graphieal factor may be partly an artifact a grades of the study. Public uhool and Middle because of college admission policies and '. West background Parents both died when he was other factors, and .it may contribute a . ~rtF~t young, and he was raised by an older sister who ltunl influence towards nonsmoking, pvc him good security under the eircumstaru-es ~ lt u nlB' ` He rracu quickly to threats but rcturns to normal as stricter codes of eonduct quickly. Specialized noncornbat duties during the It is evident that the brief case descrip• k ,,,, war. His intellectual qualities ave recogniied by tions of the five nonsmokers are in quite business, in which he is incrcasingly successful z~.xz marked contrast to those of the five heavy Devoted, careful, and intcllectual in all his aRairs; has a broad gTasp of events arlou,d hirn smokers. The nonsmokers are steady, de- '-1t Cwse 7-This young rrun came from a famity pendable, and hard workers, with stable 11t ,. of very modest mcans and high standards in the marriages, histories of specialized, non- 1::~.• 7 Ncnfk 379 j- eulties CAn 9.-Tall, impressive, and oompetent man Cwst S- Io ooiJege dexnbed as a`tood-look-~ ot acieace f rnm a borrx in the ASiddle West i.•t ing. auive, e:xrgetic, athktic bay ` Ooe of the fevr which aame of the patriarchal customs of Europe handed doxa He has bem thorough d ' have been v i r attoo taar k Hi s a,o } ,e sa id `Fi c t t t w i h s t ,, . CTR-'® M. .14 4 5 V ~\y i -ti \ { N \..,` C)•.,up 4\..F ,'' SMOKERS AND NONSMOKERS Highly intdligcnt, bitter, criticat, be bas srnt one Middle West He put himself through college on aetback alter arwthier, tuually of hia o+ra malanY.. scbolarships and by workinr. His 6eld ia physinl Di6iculty fitting into oonventiooal aocut life; maay seiaroe w•as chosen in youth aad pursued without '' lovt aHaira. Dilfiadty oootroilint drinkins. Has . quesdon to the praent and in a very atisfutorj ' e hi h bc' • N • c matmv Iast foussd ssfuf esrecr at w ot athlcti ke bad oab aodaliun a s actory , , c, tr ka m t : i. works with almost deaperate elerp'.'~: wben in sc3tooL He is a taan of reYular habits e. f kix and devoeed to his wofk wltb rather 1Lm,ted Cw.t:a 4.-A robast enertctc , ' I+eadstrong d who broke from Iw oon.crntive family whik io iaterats oasside of this work Tbcre Fuve been a college, got into brawls, pe.rformed impulrive act,.-• . few minor psychowmatic episodes oooaected with and in gtaeral .ras a problem to f amily and eollerc- biterpersoca.l rclatioas at his job. He has been C ~ The ' prychiatrut r_•!kd Km an 'Snegular and ~ shrevrd in dcveloping his eareer. He is eomfortably unsystematic boy." In his junior ytar be had a tnamed "rearnngemeat of idns` and benme 'i' good ~' CASL b-A brilliant young taan from the Middle student. He was eoavnander of a combat imit of West who is pursuing a scientibc eareer. He has 250 men during the war. Since then be has beci found it d'Jficult to loeate himselt in a suitable branch of his field of work More than the usual - . ve i voate o soc i a l re f ortns an d u d J y an merget c a d t number of ilinessrs. A succcssful family maa f9t?,'' =• : - s '• •' pnu Lis idus into effecL 1slodentc marriate diffi- ~~ I s• _ ,, and systematic in ptannin the highest rade of g t . ove w a new i rt to a new ea an a s i n l t id ll h i b h d f ~, girl every day." During the war was a naval offiar,: traiaing in his fiel(L Has bad trouble deciding

, A. Jd. A. ARCHIVES OF INTERNAL MEDICINE combat war dutia, and leading rather quiet TAns J-NownKokerf, Hodrrotr S.akeri, oR d Nrovin Swaktrr CAo.acterirrd . ~'lao.tk.dar progressive lives. The nonsmokers have the rnore steady dependabte sea-going qualitics'" ' = tT~.:~, ttbA- • ~i: o.vweeq'rTax `•::' - a~fr" the srookers are the more dashing, energtti ci •.::rx .,.~tc }t • ` • impulsive, and volatile. A study of N:: N!, might reveal tnarked differcaces. HYpv.r: ~+. u yo«..,~ w t,.n u w t• a r s ot _ =T»r•t' %-.3r ..~•r: .. . `• thetically, it may be assumed that an ethical tva motive of "keeping healthy" would vary in arked degree between the two groups. t' : • - rn , . .L, .i../ ::~ ~:: . •. . • ;. ~.. •. .. . .. .,,./_: . 025), kis well-integrated (P=O.Od), lack , _ Outsundin= TrnIts. . of purpose and values (P=021), cultural In the first years of the Study, while the P=0.56 and men were yet in college, the psychiatrists de- ( )' practical organiimg (P= t•- +?='' -= ^ 0.51). The five traits which had the greatest t.. :.. velo , as a first attem t at rsonali classification, a list of 26 "oustandpng tniu" d~1p~C1es of HS representatives were as ', t ~ f ollows : sel f-conscious and introspective 't which were assigned to persons whenever ' (P=0.20), well-integrated (P=0.13), in••:- pnctiuble.e Only two of these traits, when articulate (P=0.01), shy (P=026), and ~,a,~= compared K-ith smoking habiu, showed bland affect (P=0.01). The terms used to ' relationships which ruch statistical confr designate traits are self-explanatory. Terms dcnce. The method of comparison is shown such as "less well-integnted" and "lack of ~ .. ; •. in Tables 2 and 3.': purpose and values" should not be con• ~' „ t. Bland affect is defined as "Tendency to be sidercd evidence of s thol The ~ ^ colorless and neutral ; plain, undistinguished, p~'~ ~' subjects were all well within rtorrrul , uncomplicated and conventivnaL" Inarucv• psychologic limits of personality, if we de- . late is defined as "Inability to express one- fine normal broadly as those who function tJ t~ "v :'. J•-' self in language; inability to descrit?e their . well and usefull who ar lth d h y, y an e ea :. .. .: ~ "'. feelings and experiences." The nonsmokers .•good•• in a number of scnsu: good fathers, . .-T1.. ....st:. •-. : . . L _ -J nave DCen aSSlgiKU Ulcx ,..v ualis iu . . good businessmen, good sc~rntists, teachers, d l. K . ' .. mo eratc excess. . , - - , -•.- _ .1" .. . •_: .. and professional pevple. .::. , Although there were only these two out- ' . A /1[• L_ -L_ •:~•C . l1111vtt~ ~ItC VJ UIC cJ[CC]~CS a7e V1 U1c ~ standing traits which, when compared in { ll i i i o ow ng tn ts: well• ntegntcd, inarticulate, smokers ~ and nonsmokers, reached sig- bl d ff d h i l i Th an a ect, an p ys ca sc ences. e nificance, certain of the remaining traits whcn arranged according to excesses or deficiencie:s are of the following traits: ~~ verbal richness, dominance of mood, lack of ~ t deficiencies of the nonsmokers (OS) and d values, and less well-int = heavier smokers (HS) groups showed pat- purpose an cgntcd' terns of traits which suggest differences of This suggests that the smokers, in contnst personality. Thus the five traits which to the nonsmokers, may be men who have ~ shax•ed the greatest excesses of HS repre- more difficulties of adjustment but also may °='= = sentatives were as follows: least sound (P= be men who are more expressive, perhaps more irnaginative, and variable. :•~ ~.. .. ~ Twsu 2-NoR,.aok.+r, Nod.rotr Smokr.r, o.,d ' For the moderate smokers (MS) grovp Nrov;n S,+,okrrr CAa.,act,rris.d by the notable excesses in numbers of men are ^Blowd Ag.cr'• • . .-.. ;• found for the traits: sclf-conscious and D+•iae,t,r t introspective, shy, atal affect, humanistic, owua0tnt 7T+h'.' ewotmt H.bw' •' ... " oe• tKe, se• and pragmatic; the notable deficiencies are No. t~.. N.. found for the trait, bland affect (practically e,.nd.a.a 30 tu u t:-ar atnnr with the nossible addition of the tn;tc Nat -tn. tAe tr>,ft .e a. x n cnm r.,.t. w .e n inarticulate and sensitive aftcct). All of the •Os-noormeten:~is-roo7<ntt.mot.n:Re-fw.l.rt•oot• five traits having notable eXcesses of I,SS _ •n. P u oetermtnW Dr ttr CNl.C1u.n ua. _ ~ have deficiencies of OS and I i S. They all 3Rp 1 4 ... •. Yol. J01, Ftb., 1958 1446 , CTRZ Ntq 003-466

_• . SMOKERS AND NONSMOKERS %:!. ie.n rd • - ~'e' . ~. .. • ~ : ~ -- Y. suggest traits not without value for the TAnz 4.-,Arro of Co!!rDr~ MoJo. Rr!°trd ro if '; S1ROk"fta Nobie. t}ut it handlin of human situations g , ; one'an imagine one person possessed of aU~,~e!bc;.-;r ; . of these outstanding traits (perhaps a con~iy1,~;,Y~~ ~' .: roNe' N.6.' fusing concept) one can conceive of t3e' t"'W ,e,,,,;;' person utilizing one against the other to as.ruM a advantaqe in dealing with other human bo~•i ;pti°°'°~tirow, ings. There is no case in the series which-.r.;, . .. 31 b fD • • 77 a1 40 N-17o u ae u P <oai IJ M /~i was assigned all five traits: There is only'• 'sess *the more stable qualities of depend- one assigned four of them (without the tnit,•' ability 'and good direction of aims in life, vital affect) ; he is a very sucee.ssful " although they are somewhat on the bland, businessman, classified, however, among' colorless side, whereas the smokers appear- the I-IS ! Twenty-one others were assigned to contain more of the men who are , three of these outstanding traits apiece. The energetic, searching for aims and purposes, 21 men distribute themselves as follows: •and perhaps, although less stable, more OS 4, MS 11 , HS 6: Cs •.-AlQ interesting.-' Crrtain of the outstanding ' tnits " ," t.• 1. and show~=?~k~+f~' Choice of M ive rl lu or ne so t ll j ll i C y , , mu ua y exc s a a or eee n o contrasting trends which strongly suggest ~5 W differences in personality among the three. h.'. what a man actually chooses for major types of smokers and nonsmokers. Thus •m college and what carcer he goes into are the well-integrated group contains an e.xcas • more tangible criteria than are traits which are subjertively assigned Table 4 shows a . of OS, whereas the less well integnted relation between general area of major in group contains an excess of HS. The in-` eollege and smoking habits I articulate are represented by an excess of ~e OS group shoHS an excess of inen OS, whereas a group called "verbal rich-= '' ~ a ness" contains a slight excess of MS and ~'oosing the natural sciences, the ?.i~ an.. HS. 7lx group characterized as shy cor, HS groups excesses of men choosing social studies and arts or letters. More specifically, tains an excess of ?~iS, but that characterized th e OS group chose particularly chemistry as sociablc contains an excess of HS. The and physics and the HS group, fine arts, group with the trait, bland affect, contains foreign languages, and social sciences. an excess of OS, but that with the trait, vital affect (colorful, rich in expression), an ex-r Ctreer Choice cess of MS. It is interesting that a grovp ' , , of 3-4 men assigned "unstable autonomic': ' ~'lY one career aru reveals a relation perspiring, palpitation, and other functional symptoms) had a normal distribution of smol:ing habits (P=0.71). . ~' A later classification of the men according to "personality stability" based ori years of follow-up after college, when compared to , , Fl~ • ••l (periodic anxiety, tremulousness, blushing, ship reaching stgnifiance. Of the 31 men in science and engineering there is a signifi- cant excess of nonsmokers. This is il- lustrated in Table 5. Excesses of H S were present for social relations (P=0.25), education (P=0.40), and writing (P=0.33). Excesses of MS Twsit S.--C°.rrr Choirr Related ro Srnuki,,p N°birJ In summary, a study of a comparison be- ' cO+Mt': t..•een personality traits and smoking habits NoaKkTeLLU suggests that nonsmokers, as a.group, pos- (A'=206, P=0.09). the OS, DiS, and HS categories, shows an excess of OS and MS for the most stable, and an excess of HS for the lust stable 06. No M6, No. 86, No. 75 yt 1 N-H7 p H~ ~ P <°-0I 1447 ~~.. •. ~ 6~ ~~ ~~"~ ~``~ ~~ ~~ ~4169

t i U 5tt tVT'= .•^ : w. + A. !!. A. .lRCHIVES OF INTERh'.!L MEDICINE were present for business (P=0.40) and men were among the nonsmokers and medicine (P=0.36). The distributions of- moderate smokers. In a small grovp of 19 ,, OS, MS, and HS were approxitrLately cval , men poorly'adjusted to the armed services for Law (P=0.94) and for a misocllaneous _ there was a small exoess of nonsrnoken: group of ozrupa.tions.-I'-w;:oriQ-,-r.r, wY-t: •Havier smokers tended to be in exce.ss. In the 1953 questionnaire selected ques-_. among the men who had oombat duty as tions taken from the Strong Vocational opposed to those who had noncombat duty: _ _ nk w r erted (Th e Stron t t Bl i ' I . g ;L n eres a e t ns tA Tcst has been found to be a good predlctcr, .~ ~,~ ._,i Pr~cbot~pe - . n..( of career, particularly for a middle class-&i " S°tr'a' - ' culture.4) Of the 25 carea questions com- totonia, ccrebrotooia, and viscero- • pared to smoking habits, 2 showed relation-. tonia, according to the Sheldon Tcmpen ships to the cxtent that P was less than the ment Scale, were compared to smoking habits grade, and for 2 others P was 0.04. biu but revealed very little (R -243, P= The OS group tended to dislike the careu•-• 0.09). The OS group was in slight excess _: on th b t' 1' 'd am g e ccre ro onlcs (va urng t tas) ,;. of sales manager, the MS group to like it h MS h i irx, -5; ~. . . • . _. ~,.:. . •r. .t. :rr•....... • ., - -- ~'e-' - (P<0.01). The OS group liked the carecr, of scientific research worker, and the HS group disliked it (P<0.01). The careers of farmer and also statistician were liked by MS, disliked by HS (P=0.04). Other y, g g trends were for OS to like chemistr} but of an excess of HS here can be discounted. '' to dislike the caretrs of farmer, corporation lawyer, advertiser, judge, manufacturer, and Ans..erint tbe Questionnaire ,iffice manager and for HS to like the carerr ~ .of judge. The trends bear similarity to The OS group answered the 1955 ques- those for choice of major in college and tionnaire more promptly than did the MS nrcu. ~ ` ` ; . • _ ,, or HS groups (N=251 P=0 03) 2 :~ . . . . 1_.).1. wrrDtd $er7icef'.:~~.% ':~''•-I•. '. WnSclcnnCRlsncss, as a tran oI Ule lJJ , ,.. group, goes very well with some of their The tendency in respect to branch of other traits: bland, well-integratcd, sciences. sen'ice during World War II was for I-IS •p}~e MS group was intr.:nediate, and the to choose the Army and for OS to choose HS group was the slowest in aruwering. the Navy or to remain in civilian life Out of 62 men not answmng in four (usually in a specialized scientific area allied Ast iJ. to the .vu effort). This tendency is shokn months s no rel there ation were ct 33 of wecn the the f HS ull mcnness. of There the in Table 6. .,. _, _. answers in the returned questionnaires and -l/ .r•' , t,, ;. A carefully drawn scale of adlustment ~~ng habits. . to the armcd services showed suggrstive* .•-., ,• ...~M. ., . relationships to smoking habits (N=214,. ' III. Physiologic a.nd Medical Factors ro:;L,~.; P=0.09).. Excesses of the best adjuste~d':•. Physiology, viewed in a broad way, in- - TAILL 6.-BroRrk oJ Arwrid Sr+virt R.Ioitd 'Fo dudes personality, for human behavior is '• ~ SMOk~g Habirr +' ~.' the functioning of body in its environment. BnntL.r.rm.d i.IVIot 06• No. K6. . 8s. No. Na. t e group, among t e sornatoton cs (liking for. action) ; the HS group, among the viscerotonics (seeking comfort and pleasure). Since smoking, as a so-called "oral pleasure,'• influenced the assignment of cases to the viscerotonia cate or the findin Even with our relatively crude methods of measuring and recording physiology we should not be surpriscd to find physiologic b 40 p h :IDi uwAodmr c°•A differences between smokers and non- •. • ~ Owrd god Nu,n.~) L K ~ O <oat • c~wr`°,,or,y W b a smokers. Out of many comparrsons in this area, including some of the medlcal findrngs ,t• .' • Vo/. 101, Frb., 19Sd 0 CTR.i 14~5 C `~`R '. I-AU', 0 ( ~--l"N

- _4 , . t SMOKERS AND NONSMOKERS Twtru 7-RrfPirafory Ratr at Time oj Mrdica! Erurninatlow Relaud to SawkiRy Habifr several weeks or months may have lapsed •- •tii:._. s pneurnograph respiratory rate, although a..vu.Wr x.up~ ura.r~r a- 1:. between the two (r=0.69): `=',i'l~1~: .. if .: uTtmo.fifodlat Ot. Kt, HD, . samm.uoa No. N.. xw ~ Smoidng during college. cornpared .vith " • ~Wth.w e r: ;1 u respiratory rates shows iunilar trcnds to x x 23 those given in the tables for respiratory rate . Pam t x ss so«~. ~- r . : 't`.WO M M during medical examination (P=0.03). r ~. Thus there is a tendency for nonsmokers to be slow breathers and f or heavier smokers recorded by the physician, are two positlve findings which raise important questions: to be rapid breathers. The habit of smok- respiratory rate'and reflexes. ing is,' of course, partially a respiratory Respiratory Rate.-Nonsmokers tend to function. Whrn one is a rapid breather, . TW. :T._L.,. .J. , !' . .,.• _.,~ -.. ,. ..~•. . :; : .. , . ~;. . 0 have slower respiratory rates than do his tidal air is small and the dead spaces of •. smokers. Respiratory rates were taken on the lungs are less apt to be filled. There 1 two occasions: •(1)' during the medial even may be at times an uncomfortable ac-; examination, with the subjcct in the sitting' cumulation of carbon dioxide in the blood. position, after the pulse was taken, and (2) Smoking perhaps gratifies these shallower ' at the time of the basal metabolism, the breathers by increasing oxygen intake and subject having fasted and being recumbent blowing off carbon dioxide at times, ir- and resting. The latter was recorded byY respective of other satisfactions. kymograph, allowing for the simultaneous If rapid breathers (and, therefore, shal- recording of other respiratory functionsi' low breathers) tend to smoke more, we tidal air, variation of breathing, number of should find a relationship between smoking sighs and swallows. Tables 7 and 8 give the and tidal air, the amount of air inspired relationships of respiratory rate and the with each breath. This is the case when OS, MS, and HS classifications.:,; tidal air is compared in the groups OS, MS, Table 7 shows excesses of OS men with and HS, although P(0.13) is not in the ; slow respiratory rates and excesses of HS rangc of confidence. Ventilation per minute' . men with rapid respiratory rates. (The (the amount of air inhaled every minute) difference between the respintory means is'' does not show a relationship (P=0.50). If greater than 3X P. E. for OS, hiS, and anything, the smokers have greater -vYntila- for OS, I-IS differences, but not for MS,,. tion than the nonsmokers. NS difierences).., ., t, ;,.. ; Heavier smokers also were found to Table 8 shows the same trends as Table sigh more frequently during the pneumo- 7, although P is not as low. Numerous • graph than nonsmokers or moderate smokers observations have shown that persons have: (P=022). Chi-square is not in the range •:. to Smokiep Habir, moderate smokers (P=0 04) . . Swallows respiratory rates under standard conditions of corrfidence, but the finding is consistent which are characteristically low or high or with the thesis that smokers, as shallower average. Thus, for our subjects the respira- breathers, may need to fill and empty their tory rate at the time of the medical exam- lungs, at times, more fully. ination is rather closely related to the . The heavier smokers swallow more Tw.Lr 8-Rr,oiraroTy Ratr at Ba.ra! State Rc(atrd frequently than do the nonsmokers or the RafDlntory R.tape r ASIODU (Puumor*+ph. Hua etat.) -. oe, N.. '' xe. Na. Ee. No. taoJ n ' U ls 10.611J ' U i6 p N-1a 1/.4i 1 III 1• P OAd Toul, • u • 74 1. - are recorded on the pneumograph as little notches where respiration was suspended while the subject swallowed. Presumably such swallowing is due to excess salivation from the effects of the rubber mouthpiece, ..•psychological or not. The possibility of a llrafh JAS 1449 0~'..~ 34 . :'' I

3 r . .• , A. lf. A. ARCHIVES OF 1NTERNAL MEDICINE different mouth physiology, that is, a dif-: Tasu 9.-,rl6dan;,a1 Re~leref o, Relatrd to id salivary ' '~`` S"ak'*g Ffab;u ferent flow of saliva and more ra p r A e cx o f th e smo k ers i s a po nt w hi i c h wot il be well worth investigating. :` '.. r A"~ea1 01, N.. u s, N.. Comparisons of OS, MS, and HS with the y- 1....4 n ~ coefficirnt of variation of the tidal air (P= ~ ND.°~ e n 1 Y N 0.20) and with the standard deviation of a b the tidal air (P=0.37) are not consistent- •T,e,.be,WJCW r,a,r.,,,tx.ra.e er,Q,uh~ sn, a,,, fo.dnaq aftD lrw atrrD potnl.ft weo6an aD lstor. te snt The trndrn~y is for heavier smokers to have .t a.Q.P.~.e t,n.,.a oD~ .,a ro.,r ,,,, ,a „w,~, ~. ~sa r.aad.d. Aeu.e abdeminal nMw a(w eoca,.d tn tb4 more variability in the depth of respirations. sb,o rrurn nl,br„m.r,t Respiratory rate and tidal air are also b.°am u»ID ..l r'n""L related to outstanding traits. Thus, slow' r' "; Th bl h h breathers are in excess among the follow=• ing trait groups: pragmatic, humanistic, cultural, and practical organizing. Rapid breathers are in excess among the following trait groups: shy, ideational, less w•ell-inte- grataf, and asocial. Again we may be dealing with constellations of traits and physiological functions, with smoking habits . a part of the constellations. Frequent sighs and swallows also tend to relate themselves to certain traits in the expected fashion. "_" There seems to be no relationship between respiratory rate and pipe smoking. The above differences occur between nonsmokers and cigarette smokers. Pipe smokers, as a rule, do not inhale, such smoking being more a mouth, lips, and tongue activity than one in.•ohing the lungs. rc Refle:a Reflexes w•erc recorded during the physical examination on a threefold scale (normal, increased, decreased) for four loations: knee, ankle, biceps, and ab- domen. When a man had active knee jerks he usually had active reflexes elsewhere, but this was not always true. Each of the four reflexes showed similar relationships to smoking habits, but the relationship w~s most pronounced for the abdominal re- flexes (Table 9).' • The abdominal rc8ex was obtained by scr•atch- ing the four auadrants with the sharp point of•a wooden applicator. In cases of diurepandes be- t.xcn upper and lowtr ref~exu an average was rccorded. Active abdominal reflexes oftcn occurred in the more ticklish subjects Rcflexes which re- Quircd reinforcement to obtain them were inclu•kd u "decrcascd•" reflexcs. - - e ta e s ows t at abdominal reflexes tend to be increased for nonsmokers, de- creased or normal for the smokers. The same tendency exists for the biceps jerk (P=0.05), ankle jerk (P=0.07), and knee jerk (P=0.19). It seems unlikely that nico tine ingestion or other effects of smoking could cause reduction of reflexes, which were tested during college when smoking habits had not been fully established_ There are also some interesting differences in outstanding traits for men showing the various types of reflexes. Men a-ith in- creased reflexes tend to have traits such as s'e11-i.ntegnted (P=0.02), shy (P=0.08), inarticulate (P=0.10), bland affect (P= 0.17), physical science (P=0.35), which are mostly those common for nonsmokers. If we group normal and diminished reflexes together, excesses are present for the traits vital affect (P=0.11), lack of purpose and values (P=0.12), and less well-integrated (P=0.07). There is also a moderate relationship demonstrable between abdominal reflexes and respiratory rates (P=0.05), those with increased reflexes tending to be slower breathers, those with normal or decreased reflexes tending to be more rapid breathers. No clear relationship of a like kind was observed, however, between the other re. flexes and respiratory rates. • ; , Eating and Drinking Habiu When the participants were in college, a careful dietary history was obtained. Measurements of the servings were made in college dormitories so that the relative 3&4 t.. ••' ' Yol. 101, PiD., 19Sd CTRA ,. i..4~0 M.' 19'{"'h [~N ~~.J* S ../f~3{••.~~.,..

SMOKERS AND NONSMOKERS I s1g~r _~:rrrr~~aer:., . .a~... . . • environment has to offer. gorics, with their P values. values of food intake for each man could be care was taken to obtain information about observed. No definite relationships between• the kinds and qualities of symptoms which smoking ' habits and daily ingestion - of ` yoting men show under stress. (Tbe corn-• calories (P=0.68), fat (P=0.08) ' protein'- inon stresses experienced we.re particularly (P=0.36), or carbohydrate (P=0.51)wereM exaininations, athletic games, oral recita- found. However, for each of these facttir`s"tions, and social ooca.sions, and symptoms the heavier smokers tended to consume the were especially anticipatory ones.) The larger amounts: _~ symptoms experienced were the common The heavier smokers consumed more functional ones of palpitation, easy perspir- sugar (P<0.05) during college. This is ing, and gastrointesti.nal or urinary syrnp- partly associated with a larger cof3'ee in- tarns. Insomnia, headaches, nail biting, dulgence (P=020). Coffee drinking after frequent colds, hemorrhoids, and other college is positively related to smoking (P<',symptoms that tnight be associated atith 0.01). Alcohol indulgence is rather dosely `' nervousness under tension were also con- related, after college, to smoking habits sidered. Note was made of the degree of (P<0.01). Candy eating was about equal apprehension wb3ch was shown when blood for the three kinds of smokers. Such find-' was taken from the arm by vcztiptmcturc. ings suggest common habit formations which The following list is of factors wh;ch were might depend for their nature upon what the compared with the OS, MS and HS cate- A;nt•3a r-. One might expect that the heavier smokers would be the ones who would gain more weight because of the evidertce' of earlier consumption of more culories. Over the years, however, it is the heavier smokers who tended to lose weight. The moderate smokers had among them the most weight gainers, and the nonsmokers had an excess of those whose weight stayed about the same (P=0.05). We have no reliable figures for food consumption after college, and so no conclusions as to a relationship between calorie intake and smoking at this time can be made. The gain of weight of men who stop smoking has been studied by Brozek and Keys T . .... .•~ ..,.. • . .. Symptoms During Streu Although smoking is commonly consid- ered to be a "nervous habit," •certain data do not confirm that impression.t During the initial medical examinatiori considerable t A breakdown of the concept of "nervous" or •'nervousnus" is needed Although the degrce of symptoms tsnder stress does not here show relations to smoking, it was shown in the previous section that hcavy smokers tend to ha.•e continuous drivc, energy, restlessness, etc., which might be considered a difierent kind of "nervousnas." /-lentk , Wagbt ,....._ . P Frequency of urination <0.01 D'urrbea • 028 Regularify of bo.rel movement 0.32 Frequency of bowel movement 0.64 Constipation 0_39 Loss of appetite or nausea 075 Hemorrhoids 0.70 Gastrointestitu7 tract irritability 024 Circulatory syrnDtocs 0.94 Degree of sinus arrhythm a 0.97 Ikrmatographia 0.75 Nail biting 040 Rcaction to vcnipuncturc 0.40 Insomnia . 060 Frequency of headachu 0.76 History of hay fever or asthma 0.53 Ovcr-all judgmau of stability of autonomic nervous systcm 0.31 Only one of the items showed a relation- ship which could reasonably occur other than by chance. That item is frequency of urina- tion under stress. The figure of P<0.01 is mostly due, however, to only one cell in a 3X3 table. Out of an expected number of 10 nonsmokers only I had moderate to marked frequency under stress. The re- mainder of the table is not suggestive; in fact, the heavier smokers had about the expected distribution among the three factors of frequency of urination which were tested, . . . .. • C ~I } ~ ~"1 ~"~ ~ ~.~ ~'~ .'~ ~

• A. M. A. ARCH/vES OF /NTERNAL MEDICINE Other Medical and Physiologic F.cton 1•. . Summary and Conclusions ':' Two hundrrd fifh'two selected Trial comparisons with other factors .vere . ool}egt :; run but have not revealed consistent relation- men, 5rst studied in 1938 to 1942 and fol- ;. . ships with smoking. 'Some of these are lowed by interview and questioarsaire since '-• 4. :l ., :I•.. A. . ., I , :. 0 I listed as follows: ~ r , i: . - . . 1.. t. yr;,.A Height :I Weight . : Acne vul9arit ~ : Poaure nting Number and severity of past illnesses Number of inedinl visiu during college . Frequency of comrnon colds . Basal axtabolitm , Hemoglobin _ Physical 5tnesa: duration of run' Physicnl fitness : recovery index ••. Physical 6tness: lactic aad after run •-- -' Pulse rate (OS, MS, HS) , ` Pulse rate (smoking in college) Systolic blood pressure Diastolic blood pressure Tlumbcr of tetth SIIed -: Crowding or spacing of tecth OcOnsion Naturc of bite '. t H andedms Blood ¢rrcwp . .~ , A rating of the number of skin ~P. 0.76 . 020 0.43 0.45 0.79 020 0.57 0.80 0.82 0.64 020 027 0.32 0.1/ 0.84 0.98 08•' 0.1A 0.45 0.72 0.96 0.69 moles, made during the medical exuninatic,n, cor- related surprisingly with the OS, hiS, HS categories (P=0.01) (Table 10). An excess of nonsmokers had only rare b,)dy moles. Table 10, however, is not consistent, and it is felt that this may be ar, instance of chance. (Since there is I (lance in 100 of P equalling 0.01, it is to be expected that chance alone will acc•x,nt for such a relationship when many comparisons are made.) However, it i~, conceivable that skin moles may be related to tumors of the respiratory epithelium, which is also derived from cctoderm. TAu.c 10-NMoMbfr oJ SkM blela:' Rdacd to - Sr+w'nwp Hcbitr NumEer o,bodr ldaW 0s. No. Xs. No. S.. No. i++ wd 4-+ 7 14 , + ,o ao 43 k,M aDat~ow~ u ~ ~ 3Bb . ~ ' _ N-t1+ P-ont that time, h:sve served as subjects for aa iavestigation of possible differences in personality and physiology between smokeri ; and notumokcrs. The collection of data on smoking was a part of a much lnrges ml- lection of inf,xaution from the subjects and was n•.•ver stressed. After obscrvation of individual smoking habits over the ycars;' :• a di vision of men according to smoking - habits was as follows: 61 nonsznoktrs i- (2,*2rf'o), 95 moderate smokers (37J%), ; : a•id 96 heavier smokers (38.1%). A comparison of the case records of the five heaviest smokers (two or more packages of cigarettes daily) with those of five non- smokers chosen at random showed marked contrasts in personalities. Tbe smokers showed great energy, restlessness, seeking for danger, and a kind of independence which keeps them actively engaged in some ' enterprise which appeals, and they had ditl•iatlties with marriage. The nonsmokers were steady, dependable, and hard workers; with stable marriages and histories of specialized, noncombat war duties, and they led rather quiet progressive lives. Such differences were statistiaIl}• borne out for the whole group when comparsions were made with certain personality tnits t4at had already been categorized and with uther data which distinguish persons from •-lne another. The nonsmokers, as a group, possess the more stable qualities of depend- ability and good direction of aims in life, although they are sornewhat on the bland uncommunicative side. The group of smokers appears to contain more of the men who are energetic, scarching for aims ar.d purposes, verbal, variable, and perhaps, al- though less stable, more interestinp. The nonsmokers tended to major in natural, sciences, particularly physics and chemistry, while in college ; the smoker; tended to choose majors in social studi•.s and arts and letters. The nonsmokers tended to enter Yol. ,ol, 6' ~ PT R. ~ i4. M°PNH