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©^:. caia I I I ( ~ 1 I I DOCTORS AND SMOKING (III) Their Smoking Habits, Their Advice to Patients on Smoking, and Their Views on the Correlation Between Cigarette Smoking and Lung Cancer and on Research Conducted Thereon A Study of TFM NATIONAL PhYSICIANS :-l.DVISG,3 Y PA!•lEL Ccnduc`.ed by T ;J-E JdEDIb:ETrtIC INSTITUTc Prescnted Exclusively to Hill & Knowlton, Inc. for the T'JEtiCCC INDI.rSTi3Y RESER,RCH MAUI:TEI 1 4 Date of Study: Date of Aeoc:t: April 1958 May 1956 Do~Q.. ,  . 0 y9 RQGERS C 1 R0021831 C TR ~ tN 02 B E5 5 E5

i i 1 1 I i I I I THIS DOCUMENT SUBJECT T0 AUG. 20, 1985 NON-DISSEMINATION ORDER IN R GER AND UKE CaSES. INTRGDUC'rIUN The present study is the third of its kind conducted by The Vedir..etric Institute for The Tobacco Industry Research Cor.unittee. The stuJy, es those before, is based upon the National Yhysicians' Advisory Panel, a probability sample of all general practitioners and part-tir..e specialists under sixty-five in private practice in the United States. 7he present study vras incorForateu as part of the monthly "Trend in General Practice" survey fc: the month of -'%pril, 195S. The find- inv,s ore based on the retL:ns of 334 physicians which have been statistica:ly %-seighted so es to zeprEser,t as closely as possible the distributions that would have been obtzined had a censL: been taken. Comrerative data from March 1957, have been included vjherever appro- priate. ROGERS C 1 R0021532 CTR HN 02-8556

MAXIMl1M TOLERANCES 90% Confidence Level THIS DOCUMENT SUBJECT TO AUG. 20, 1985 NON•DISSEtAiNATiDN ORDER IN 0 ERS AND UKE CASES. ;+:rmber of Tolerance* Physicians Responding Percentages of the Physicians Responding to the Question th t e o Question 10 or 90 20 or 80 30 40 or 0 1,000 ±1.6 ±2.1 ±2.4 ±2.5 ~ ±2.6 800 1.7 2.3 2.7 2.6 2.9 .750 1.6 2.4 2.7 2.9 3.0 700 1.9 2.5 2.8 3.0 3.1 ! 600 2.0 2.7 3.1 3.3 3.4 550 2.1 2.8 3.2 3.z 3.5 500 2.2 2.9 3.4 3.6 3.7 450 2.3 3.1 3.6 3.8 3.9 400 2.5 3.3 3.6 4.1 4.3 350 2.6 3.5 4.1 4.3 4.6 300 2.8 3.8 4.4 4.6 4.9 250 :.1 4.3 4.6 5.1 5.2 200 3.5 4.7 5.3 5.7 5.7 150 4.0 5.4 6.2 6.6 6.7 125 4.4 5.9 6.7 7.2 7.4 100 4.9 6.6 7.5 8.1 8.2 75 5.7 7.6 6.7 9.3 9.4 50 7.0 9.3 10.7 11.4 11.6 25 1C.0 13.2 15.1 16.1 16.5 it equal to the absolute errcr in percentace units. ROGERS C 1 R0C21833 CTR HN 0285E5'7

1 1 1 ! 1 ?H~S DOCUMENT SUBIECT TO AUG. 20, 5 U A N A R Y 1985 NON•DISSEMIhATION ORDER !N D ER NNp UK CASLS. The ratio between smokers and non-smokers approximates 1:1 as Smokin9 Habits of Physicians (Tables 1 - 9) compa:ed with a ratio of 3;2 in favor of smokers a year ago (Table 1). This in conjunction with the "Gave up smoking" response in Table [, is evidence of t change in physicians' smoking habits. Since the present penel is substantially the same as it was in 1957, "never smoked" can be used as a control. Taking into consideration small differences in "no ans%+e:" end in the number of zespondents, the figures :or never smoked can be regarded as not having changed. How- ever, 27 per cent of physicians nov: say they have given up smoking as compared with 19 per cent last year. Furthermore, Table 8 reveals thct 16 per cent of physicians have given up smoking sometime within the past year. The pe:centage of physiciens who smoke cigarettes dis- plays the largest drop in comparison with last year. There is also a decrease in the percentage who smoke a pipe and either ciga:ettes or cigars. Overall, pipe smokers have decreased, while the percent- age v.-ho smoke cigars has remained unchanged. Although the percentage of cigarette smokers has decreased, the amount smoked by the remainder has not exhibited, on the ave:ege, any change; it zemains at a little over a pack a day (Table 5). Un the other hand, cigar and pipe smokers evince changes as co,mpared to last year (Tables 3 and 4). tilhile tr.oze than 40 per cent of the pipe sc,okers smoked more then five pipefuls e day last year, only 12 per cent do so noci. The percentai~e who smoke only one pipefv.l has doubled. ROGERS CTR002a834 CTR HN 0265SB

ii The decrease is not due to the fact that pipe smokers now smoke othe: things besides pipes since that figure has also decreased, so evident- ly pipe smokers are smoking less now than a year ago. Cigar smokers have increased their consumption of cigars, with large increases in the number who smoke three rather than two a day, and in the number smoking over six a day. Of the physicians who smoke, one-fifth have cut down on smokin; within the past year (Table 6). This includes thcse who have cut down for the first ti.ae and those who cut down further since the last z:port. !'rhile the exact proportion is indeterminate, it is clea: that overall, physicians continue to cut down on their smoking. Riore striking is the percentage who have changed to filter-tips during the interi,a period: 32 per cent. All of these must be in addition to the 41 per cent who changed in the previous year. There may be some ove:- lap here in recall of date of change. Comparison of physicians who do not p=esently smoke reveals that most non-smokers have smoked at some time in the past (Table 7), anc ialf of those riho have given up smoking have done so within the past five years (Table 8). Of those who have given up smoking, moderate r,mokers again comprise the largest group; almost two-fifths. Heavy and light smokers are almost equal (Table 9). In this question c:efinitions were left up to the respondents, but for other purposes in this report we have again defined "heavy smokers" as those who say they daily smoke more than one pack of cigarettes, more than four cigars, or more than six pipes; "moderate smokers": more than one-hal THIS DOCUMENT SUBJECT TO AUB, ?p, 1985 NDN-DISSEMINATIDN ORDER "' /N RDGERS AND UKE CASES, ROGERS iC.T R0021835 CTR ~N 0~~~~'~

1 I 1 1 1 I , I iii to one pack of cigarettes a day, three to four ciga:s, or five to six pipes; "light smokers": half a pack of cigarettes o: less a day, one to two cigars, or four pipes or less. Advice on Sroki-; (Tables 10 - 22) Advice on smoking to patients with various conditions is gener- ally similar to that found in the last survey. Shifts of a few per- centage points are noticeable here and there, as tre shifts in ever- ages from a fey: tenths to a few patients. (The lower percentages in the "0" pat_e::ts line and the higher percentages in the "No ansv.er" line is due to a change in coding procedures.) Patients with cardio- vascular or respiratory conditions are given advice on smoking more often thao patients with G.I. conditions. Fev, physiciens advise patients to change to filter-tip cigarettes or to cigzrs or pipe (T3bles 10 - 13). I .:hen acJvice given is correlated with type of scoker•the physician is, we find that physicians who have given up smoking are more apt to advise their patients to do the same (people aay that "misery loves cocr.pzny"). As a group, heavy smokers advise fewe: patients to give up smoking than any other group. Moderate smokers pursue a moderate course; they advise their patients to "cut dow•n on =moking" (Tables 14 - 17). Fevi physicians (nine per cent) ever re- commend smoking to their patients, but of those who do, heavy sr•.ok:rs account for forty pe_ cent (Table 16). ;:ost physicians hav,!~ not changed the frequency of their adv_c2 on s.:,oking c:ur:nr t}-e pas= year, but ;icnificant pc-rcentages cf ph;,si- ciens have chanoec:. Gf those %rhose ac:vice h3S chana^: a nE71i;:b:: THIS DOCUMENT SUBJECT TO AUG. 20, 1985 NON•DISSEMINATION ORDER IN RO_ GERS AND UK CASES RQGERS C T R0021836 [.y t R HIN 0265-560

iv amount now tend to curtail smoking less often. h:oderate smokers account for a substantial portion of this group, but it is a very small minority of the moderate srrokers. Large proportions now tend to curtail smoking more often. With the exception of heavy smokers, no group is disproportionate here. The heavy smokezs do not come up to the other groups for the percentage of their group tyho now curtail smoking more often. The heavy smokers dominate the group whose fre- quency of advice on smoking has not changed (Tables 19 - 22). Opinion of Snoking and ;tesea-ch (Tables 23 - 16) The majority of physicians (62 per cent) feel that in the present :tate of knowledge cigarette smoking can be considered only one of •several factors associated in the etiology of lung cancer. These p hysicians split about fifty=fifty betviee,n smokers and non-smokers. Thirteen pe= cent feel that the case for cigarette snoking as the major ceuse of lung cancer is conclusively proven -- three-quarters of these are non-smokers, and the majority of these have given ..noking. At the other end of the scale, h=avy smokers account up for more than half of the physicians who say that the case against cigar- Ytte smoking has not yet been conclusively proven, with smokers, in toto, comprising more than eighty per cent of this group. Heavy smokers also dominate the small group who say there is no evidence that cigazette smoking is a causative factor in lung car.cer (T2ble 23). Vith the exception of research sponsored by the U. S. Government, physicians on the whole, do not rate the various sou:ces of inforna- tion on smoking and disease as highly as they did a year ego. That :s, in all cases (except for the U.S. Gove=tuner.t) the rercentage of THIS DOCUMENT SUBJECT TO AUG. 20, R O G E R 5 1985 NON-DISSEMINATION ORDER C T R 0 0 218 3 7 IN ROGERS AND UK CASE.S. C T R I H N 0 ~B556 1

1 ; t 1 i I I v physicians %Nho rate any source "good" is less than it was a year ago, . ; and the percentage who rate each source "poor" is higher than a year ago. Even with the increased respect shown towards research spon- sored by the Government however, The Amaz:can Cancer Society again rates highest. More than half the physicians still place no reliance in research conducted in laboratories of tobacco companies, and ze- search supported by funds from the Tobacco Industry Research Committee dDes not faze much better (Table 24). ~ A new c,-jestion not heretofore included asks physicians to rate various environmental factors in importance for increased research attention as possibly contributing to lung cancer. Many doctors feel research is needed on most of these factors. Fumes, smoke and dust rate highest for increased research attention (Table 25). Two-thirds of ph-ysicians believe a comb:.natioh of both exogenous and endogenous factors are most important in lung cancer causation (T.aDle 26!. Conclusion Generally, the findings from this study concur with those founc previously, especially so for physicians' advice to their patients 3bout smoking, and their attitude towarc's smoking and lung cancer. J.Iiore physicians, Ebout half of them, do not now smoke, and 20 per cent _`. those who do have cut down during the past year. The prestige of research on smokin3 and disease sponsored by t;:e U. S. Government has increased during the past year, but the 1~,roericzn C:.ncer Society stil; cor..:.:n::s the highest respect. Research dene b) tne :cL:cco cor.rar.ies re::._ins in lot: estr~er. THIS DOCUMENT SUBJECT T0 AUG. ?0, . 1985 N 0N•DISSEMINATION ORDER JN ROGERS AND UKE CASES. ROGE 8S~ C1R0021 CTR HIIN 0228ZIG2

vi ':e may conclude that the trend in physician opinion and practice regarding scaoking is negative, and indicates a poorer prognosis frc.-.) the point of view of the tobacco industry than a year ago. There xemain, however, substantial bodies of physician smokers,- physicians who are moderate in their professional advice to others, and physi- cians whose advice has not changed. The distribution of physician advice for the specified conditions has remained remarkably stable in the face of all the other changes. THIS DDCUMEh1T SUBJECT T0 AUG. 20, 1985 NDN•DISSEAIINATION ORDER IN ROGERS AND DUKE CASES. ROGERS CTE002183J C T R_ H N O~'6 15 6' -

1 Trends in Gtneral Practice. April. 1958 Docter, do you now smoke? 1F rES Page 2 Pire: Appro:. ntsnber of pipeluls smoked ptr day: Page 3 te I i Cilars: Appros. number of trjars amoked ptr day Page 4 „ l Citarettes: Appros. number ol packs e(er (raction) per ray. ta~e 5 . tt Have you, .ithin the past year: Page 6 Csr doud on smokinj', Yes ~t,.., No ry, Chanjed to filter lips t Yes D,..t No Qr I . . Yes 00., Noos Page 1 (F NO Page 7 Never snaked .... Qrt•r Gave up smoking 0 s ' about ._1 years ago Page 8 Be(ore giving up smokinj, I .as s heavy 0,s., moderate n s Page 9 smok er. 1. During the past year there has been pubLicrty, bort professional and lay, linking lung cancer tn crAaretce smoking. rnat do you think (Please check the ttste• tnent most nearly correspond+nj to your .,e.s.) Pa6e 32 The' case (or cigarette smoking as the major cause oflunj cancetis conclasivtl) provr. ..... _... In the present state of knorledje, citarette smoking can be considered only oat of several factors ssao• ciued in the etiology of Iteta cancer .... ._ .. - t The case against cigarette smoking Aes .or yet been conclusively proven .......__. . . There is so evidece that cigarette smokinj is a causatiee factor in lunj cancer. ......... _........ .. No opinion . .. . . .. . . . = t 5. Please rate (I :sood; 2 = fair; 3= poor) the folloe,in/ sources of ea!orwarroe on awolinj and disease by t4• dejrte of rtlta+ce you place in them. i.eports in the lav prtas based on: 1 2. Dsrinj the past .o.t1 about how rnany of your patients with the (ollovinj conditions have you sdeistd to (1f uone, vrite "0"): I page 10 Give up smoking .... Page 11 Cutdovnon ar++okinj ........ _..... Page 12 Change to filter tip Fa ~e ~ Chanje o pip ~ I I or etsar Conditions Cardto• Resprra• vascul_ar tory G/ OtAtr Flge ' ~age Pi6e ~e 4 6 8 20 16.116 e+.to 1111.114, ....6 a - ar ss so 83,84 ai a] sr so .o a. ....o .7..8 as es at .. .,.a .e.a. Do you ever recommend sn,okinjl Yet+ po,.. NoOr Page 22 THIS DOCUtdENT SUBJECT TO AUG. 20, 1985 NON•DISSEMINA110N ORDER JN ROGERS AND UKE CASfS 3• O+er the pasr year, how have your reconunendations to patients concerning smoking cAaovjtd. if at all? Ca.dio• Rtspi.a• vascYlar to, y a tend tn curtail Page smoking worr ofren ^u ~ 1'rins tend to curtail 21+ anaktnp less oHee _ e Mk aJ.rce on smoking haa 14,4 c0a"/rd ~ s . Independent research sypported by funds from: Pa g e 31+ 1Research in the L:.S ...... ... - t• Research abroad .................. _ sr U. S. G9eerronent ................ - t . American Cancer Society - - Tobacco Industry Research C,ornmi ttee .......................... - . American Heart Association - e: Damon Runyon Fund ........... _a Research conducted in l,boratories of tobacco .. companies .................................... ........................... 6a.In addition to steokinS, aumtrous ethn tatno.we.ro factors are suspect as possibly contribLtinj to lun, cancee. Ho..ould you rate the (ollo.inj in iwporta.cr /o, iecreased researcl attearioe: (Very ImponLnt = I. Important = 2. Little letportant = 3, Not Importa-.t =4. No Opinion = 0) Page 36 Oprnro" Gasoline engine and diesel eihauet fumea ............ . _ ........... Specific occupational esposures © (such as ehemicals and metals) .. Genersl orban sir pollution (including steoS) ..... ................ ...._ .• ..-- ... . .~ lndustrial smokes and fumes Radioani.e eases and dusts ............ Combustion of coal . ..................._. • Combustion of pruole.us ........... .. . . Asphalt road and rubber panicle. pther: ++ b. Thich du you believe ue most important in causatiun: Page 38 lung eL^.ce f ,oleeors factors + E~dotreors factors T R 0~ E~Y~ A combinatron of both No opinioo =•r ~ VTiO t i i i 02B5V--i