Tobacco Documents Online

i 0 s , that 34 percent of the patients who recalled the advice had stopped smoking at the time of the survey. Mausner (34): compared respiratory-disease patients' recollection of being advised against smoking with their physicians' notation of advice in medical records. At least 1 year after they had been cautioned not to smoke, almost all remembered the advice and more than half had stopped smoking. Pincherle and Wright (53) studied the effectivenessof advice against smoking,given to business executives during routine physical examina- tions. They reported that at the next routine examination about one- fourth of the executives had stopped smoking cigarettes or had reduced their cigarette smoking by 30 percent. They compared the effectiveness of the physicians' advice with the smoking habits of the physicians and found that, of 10 doctors, the 3 who had never smoked or who had smoked no more than five cigarettes a day tended to have more patients who gave up or cut down on smoking (24 to 37 percent of their patients did so) than did doctors who had previousliy been heavy cigarette smokers (~17 to 23 percent of their patients stopped or cut down on smoking). Apparently, these findings are not a product of individual differences in persuasiveness among the doctors, because those doctors who were most successful in influencing patients against smoking were least successful! in dealing with~ patients' weight problems. The study by Stamler, et al. (64)' of industriall workers who were referred to their physicians in a coronary heart disease detection project found that 20 percent of the workers who had' been advised to quit smoking by their doctors had stopped 6 months later. In summary, these studies tend to show that, if doctb" advise their patients not to smoke, about 10 to 25 percent may quit or reduce the amount they smoke. Health Care Providers as Managers in the Control of Smoking in Health Care Settings Smoking in health care facilities is being increasingly limited by law, and health care providers in administrative positions will be involved in this implementation. This trend toward limiting smoking im public places and medical care facilities is evident in several recent state legislative reports from the National Clearinghouse for Stnoking and Health (4,43-45). Some health care providers in administrative positions have acted to controli smoking in health care facilities, regardless of legal require- ments, for a variety of reasons other than fire prevention: insuring that employees set a nonsmoking example, protecting nonsmokers from tobacco smoke, reinforcing advice not to smoke, and providing an opportunity for smokers to stop smoking. 22-19 0 I U

Attitudes Toward Controlling Smoking ;E In 1967, Schnitzer reported on an informal survey he had made of health professionals concerning the question of controlling smoking in'' hospitals. The consensus of this group of health professionals was that~ "absolute nonsmoking hospitals would' be ideal, but it is not possible at ;: this time" (60). Since 1970, health ca.re providers have begun to move toward greaterY, control of smoking in health care settings, as indicated by resolutions '' calling for the control of smoking in these facilities by various " professional groups. In 1975, for example, the Canadian Hospital Association passed a resolution requesting the prohibition of smoking ' in patient areas and for the establishment of nonsmoking sections in ' public and general' use areas of hospitals (11). The resolution also : recommended that hospitals ban, the sale of cigarettes on their premises. In 1976, the same group resolved to adopt a policy of actively discouraging the sale and use of tobacco products in Canadian, health facilities as an example for the public and't'o emphasize the hazards of smoking. Even earlier than these resolutions, the American Cancer Society was conducting, a nationwide campaign against the sale of cigarettes in hospitals (18). And in Britains in 1977, the Social Services. Secretary announced a new antismoking drive which, included guidelines to hospitals on restricting smoking (66). Actions to Cbntrol Smoking Willingness on the part of health care providers to act to control, smoking in health care settings has developed more slowly than their willingness to assume the roles of exemplars and health educators. In a 19631etter to The New England Journal of Medicine, Gage (23) reported that the general staff of the Cooley Dickenson Hospital, Northampton, Massachusetts, had passed a resolution recommending that the sale of cigarettes in the hospital be stopped. The hospital trustees voted to deny their request, however, and agreed only to place signs which indicated the hazards of smoking. Nevertheless, there were hospit'alss even at that early date that were willing to ban the sale of cigarettes. Another 1963 letter (28) to The New England Journal of Medicine reported that the Emerson Hospital in Concord, Massachusetts, had banne& the sale of cigarettes in December 1962 and had banned smoking by visitors earlier in the same year. In 1973 the Connecticut Lung Association (17) carried' out a state- wide survey of hospital' smoking, policies. The findings are showni in Table 7. A survey in 1972 of 222 nursing homes (38) reported' that 2 percent had no restrictions on smoking by patients, 4 percent did not permit patients : to smoke, and the remainder had some restrictions. Of those permitting smoking by patients, 68 percent did not permit smoking in 22-20 T1 Wr No via Err off e s. t t r F . 1

TABLE 7.-Smoking regulations reported by Connecticut hospitals in 1973 Type of regulation 1973 survey' (Percent! of 41 hospitals) Written smoking policies 78 No tobacco products sold on premises 71 Visitor smoking regulated 71 Employee smoking at duty stations, 36.5 offices, desks, prohibited SOURCE. Davis, K.M. (17), patients' rooms. The most frequent reason given for restricting patients' smoking was' the danger of fire, and 2 percent of those that permitted smoking, issued fire-resistant clothing to patients who smoked. Also, 18 percent of the institutions reported they had had firess caused by smoking. Finally, this survey reported that 7 percent did not permit visitors' to smoke, and in 33 percent, employees were not allowed to smoke in front of the public. A study of Canadian hospitals (11); reported in 1976, found that 66 percent had some form of smoking policy. Smoking was prohibited on 47 percent of psychiatric wards, 45 percent of maternity wards, 37 percent of general wards, and 60 percent of out-patient departments. Depending on the type of hospital, 85 to 90 percent of heart and chest wards prohibited smoking. hl 63 percent of the hospitals, physicians' and nurses on the wards were responsible for enforcing the smoking regulations; in 25 percent this was the fire marshal's r-eZponsibility: Fifty-six percent of the hospitals said the regulations were partially enforced. Forty-nine percent of the hospitals did not sell cigarettes. In 1977, Crofton~ (15) reported that 36 percent of Scottish hospitals sold' cigarettes in some way; 28 percent sold them on the wards through the ward trolley service, and; in some cases the trolley service to maternity wards sold cigarettes. Another study of Scottish hospitals (16) in 1977 found that they were more likely to ban smoking by visitors (67 percent) than~by patients (12 percent)~or nursing staff (44 percent). In a 1976 survey of 37 hospitals in the Washington, D.C., metropolitan~ area to determine smoking policies of hospitals (21), 21 (57 percent) returned completed' questionnaires. Nine of the twenty- one (43 percent) hospitals consistently provided for a nonsmoker's preference for a nonsmoking room; 10 hospitals'did not sell cigarettes; and 17 hospitals did not permit staff to smoke in patients' rooms. Sangster in 1967' (59) had' reported that a no-smoking ward in an Australian repatriation generaT' hospital was met with enthusiasm by patients and with cooperation by the staff. Of the first 100 patients' 22-21 0

discharged from the ward, one-fourth sai& they had stopped smoking permanently and two staff members also stopped smoking, Efforts to control smoking in health care settings are not always met with enthusiasm. A hospital that removed vending machines and prohibited the: sale of cigarettes in the hospital gift shop shortly after publication of the 1964 Surgeon General's Report on the effects of smoking found that the work of hospital employees was interrupted by trips away from the hospital to buy cigarettes, for themselves and for patients (60). Some employees were also charging patients highly inflated prices for cigarettes. As a result, the hospital staff reconsid- ered their decision not to sell cigarettes. A more recent study reports on a Massachusetts hospital ('74) that attempted to influence established smokers to change to low "tar," low nicotine cigarettes by selling only those types. The hypothesis was that smoking behavior could be modified in a limited supply situation. Some employees did try the low "tar", low nicotine cigarettes, but there was no indication of any permanent change in their smoking habits. Many employees expressed resentment at this controll of their smoking habits, although there was no indication that employees were leaving the hospital to purchase other types of cigarettes. A number of specific recommendations have been made by health~ care providers for the control of smoking in health care settings. The National Forum on Office Management of Smoking Problems recommended~ formally in 1968' (54) that physicians in their offices should: inquire about the smoking, habits of all patients; inform~ each patient about the risks involved in continued smoking and't'he benefits to be derived from stopping smoking; and advise strongly against smoking. It was also recommended that, to be maximally effective, physicians should actively assist smokers in efforts to stop smoking, create an office environment conducive to cessation, generally prohibit smoking in the office, and provide signs and literature on the subject to emphasize the medical concern. The same report recommended restricting smoking to certain areas of hospitals and prohibiting the sale of cigarettes. More encompassing recommendations were made by Fishman in connection with a survey of Metropolitan hospitals in W'ashingtons D.C. (21). Two lists of recommendations for the control of smoking by health care providers were presented in the 1978 report of the National Commission on Smoking and Public Policy to the Board of Directors of the American Cancer Society. One was prepared by the Veterans Administration (VA) and'the second was t'he Commission's recommen- d'ations (47). The following are the VA guidelines: (1) Forbid the distribution of free cigarettes to patients. (2) Restrict cigarette sales in hospitals, clinics, and other direct care facilities to canteens or similar areas where other products are sold. 22-22

1 (3) Discourage smoking by professional personnel and staff in the presence of patients. (4) Rest'rict smoking to specifically designated~ waiting areas, patients' day rooms, staff lounges, and private offices. (5) Eliminate smoking, among patients with high-risk diseases through aggressive and ongoing patient education. (6) Encourage all personnel involved in~ public appearances not to smoke while in the public eye. (7) Cooperate with community groups in the development and implementation of community-wide programs concerned with the hazards of smoking. The Commission itself recommended that: (1) Similar guidelines should be adopted by all government and private hospitals and clinics. (2) The promotion of healthful lifestyles should be the core of preventive programs offered by physicians, health~ departments, health! plans, and voluntary health associations. (3) Physicians should counsel patients on the risks of smoking and how to quit smoking or make referrals to various types of smoking cessation programs offered in the community. (4) Obstetricians, in particular, should take advantage of the "teachable moments" that arise when counseling pregnant patients; expectant mothers are eager to produce healthy infants, and smoking jeopardizes the chance of normal uncomplicated delivery and a normal healthy infant. (5) State Medicaid programs, prepaid health plans, and insurancee companies should either sponsor or pay the cost-of smoking withdrawal methods of beneficiaries. Conclusions Most studies of health care providers have focused on health professionals (physicians, nurses, dentists, and pharmacists); Therefore, conclusions cannot be drawn regarding the role of others in health care occupations in influencing the smoking behavior of the public. Even for health professionals, there are no studies that quantify and evaluate their impact on smoking practices of the public. However, studies do indicate that the example set by health care.providers plays some role in influencing the public, a role recognized by both health care providers and the public. Health professionals as a group have preceded the general public in improving their smoking habits-they have stopped smoking, reduced health risks by smoking less hazardous forms of tobacco, or reduced the amount smoked. In addition, many who continue to smoke act as exemplars by not smoking when~ functioning as health care providers. I I d 22-23

k- Health~ professionals, as a group, by and large recognize their responsibilities as health educators. Perhaps the most important need at this time is to educate students in the health professions on the health hazards of smoking and their own responsibility to act as exemplars and health educators. As members of the medical hierarchy, their actions will continue to have an, influence on others in the health field, as well as on the general public. 22-24 ..x £t.

The Role of Health Care Providers: References (1) AMERICAN PUBLIC HEALTH ASSOCIATION: Sixth Report on the Ptojectt to Develop a Program on the Smoking Exemplar Role of Public Health Professionals. January, 1, 1973. Washington, D.C., American Public Health Association, 1973, 179 pp. (2) ANDERSON; J. Medical'student's and smaking: British Medical Journal 4(5727): 120, October 10, 1970: (Letter) (3) ATWATER, J.B., HEIL, K. A study of cigarette smoking among the American Public Health Association. Summary of Health Administration Section ~ results. In: American PublicHealth Association, Sixth Report on the Project to Develop a Program on the Smoking Exemplar Role of Public Health Professionals. January 1, 1973. Attachment E. Washington, D.C., American Public Health Association, 1973,3 pp. (4) AXEL-LUTE„P. Legislation Regulating Smoking Areas: A Selective, Annotat- ed Bibliography-June 1976. U.S. Department of Health,, Education, and Welfare, Public Health Service, Center for Disease Control, Bureau of Health Education, National Clearinghouse for Smoking an& Health, December 1976, 23 pp. (5) BALL, K. Medical students and smoking, British Medical Journal 4(731);: 367, November 7; 1970. (Letter) (6) BARIC, L., MACARTHUR, C., FISHER, C. Norms, attitudes and smoking behaviour amongst Manchester students: Health ~ Education Journal 35(1): 142- 150,1976. (7) BARIC, L., MACARTHUR, C., SHERWOOD, M. A study of healthi education (8) a (9) (10) (11) (12) (13) (14) (15) (16) (17) DAVIS, K.M. Connecticut works with health professionals. American Lung Association Bulletin 61(4): 14, May 1975. (18) DOWDELL, W. Nonsmokers' revolt accelerates. Cancer News 27(2):2-4, Fall/ Winter, 1973/74. (19) EISINGER, R.A. Cigarette,smoking and the pediatrician. Findings based oma national survey. Clinical'Pediatrics 11(11): 645-647, November 1972. (20) EYRES;, S.J. Public health nursing section report of! the 1972 APHA smoking survey. American Journal of Public Health 63(10): 846-852, October 1973. aspects of smoking in pregnancy. Internatfional Journal of Health Education 19(2, Supplement) 1-17, April-June 1976. BOURKE, G.J., WILSONLDAVIS, K., THORNES, R.D: Smoking,habits of the medical profession in the Republic of Ireland. American Journal' of Public Health 62(4): 575-580, April 1972: BURGESSa A.M., JR., TIERNEY„J.T. Bias due to nonresponse in a mailisurvey of Rhode Island physicians" smoking habits-1968. New England Journal of Medicine 282(16): 908, April 16;,1970. BURGESS, A.M., JR., TIERNEY, J.T. Rhode Island physicians"smoking habits revisited 1963-1968. Rhode Island Medical Journal 52(8): 437-440, August 1969. CAMPBELL, D. Smoking policies in hospitals. Dimensions in Health Service 53(12):20-23, December 1976. CHRISTEN, A.G. The dentist's role in helping patients to stop smoking: Journal of the American Dental Association 81(5): 1146-1152, November 1970. COE, R.M.,, BREHM, H,P. Smoking habits of physicians and preventive care practices: HSMHA Health Reports 86(3): 217-221, March 1971'. COMMITTEE ON YOUTH. A new approach to teen-age smoking. Pediatrics 57(4): 465-466, April 1976. CROFTON, E:C: The sale of cigarettes in Scottish hospitals. An ASH enquiry,. Health Bulletin (Edinburgh) 35(1)' 36-39, January 1977. CROFTON; E.C., HAWTHORNE, V.M., HEDLEY, A.J. Smoking in Scottish hospitals. An~ASH survey. Health Bulletin (Edinburgh) 35(1): 29-36; January 1977. 22-25

;j (21) FISHMAN, L. More rights for airplane passengers than for hospital patients: A report on smoking policies in metropolitan Washington, D.C. hospitals: Washington; D.C., Public Citizen's Health Research Group, April 4,1976; 21 pp:. (22) FULGHUM, J.E~, GROOVER, M.E., JR., WILLIAMS, A.C., BRAATZ, W. Smoking habits of Florida physicians revisited. Journal Florida Medical Association 59(10); 23-28, October 1972. (23) GAGE, R.W. Letter to the editor. New England'Journal of Medicine 269(7): 378, August' 15, 1963: (24) GARFINKEL, L. Changes in cigarette smoking habits among physicians. 1959- 1965. CA-A Cancer Journal for Clinicians 17: 193-195, 1967. (R5), GARFINKEL, L. Cigarette smoking among physicians and other health professionals, 1959-1972. CA-A Cancer Journal, for Clinicians 26(6): 373-375, November/December 1976. (26) GREENWALD, P., NELSON, D., GREENE, D. Smoking habits of physicians and their wives. New York State Journal of Medicine 71(17): 2096-2098, September 1, 1971. (27) HERITY, B.A., BOURKE, G:J., WILSON-DAVIS, K. A study of the smoking habits of medical and non-medical university staff. Irish Medical Journal 69(7): 163-16fi, April i 10, 1976. (28) HOLMES, J'. K. Smokeless hospitals. New England'Journal of Medicine 269(7); 377-878, August 15; 1963. (Letter), (29) KNOPF, A. The medicali schooll and smoking; British Journal of Medical Education 9(1): 17-21, March 1975. (30) KNOPF, A., WAKEFIELD, J. Effect of medical education on smoking behaviour. British Journal of Preventive and Social Medicine 28(4): 246-251, November 1974. (s1) LEVITT, E.E., DEWITT„ K.N. A survey offl smoking behavior and attitudes of Indiana physiciana: Journal of the Indiana State Medical Association 63(4): 336-339, April 1970. (32) LIPP, M.R., BENSON, S.G. Physician use of mariju4ga, alcohol, and tobaoco. American Journal of Psychiatry 129(5): 612-616,,November 1972. (33) MATTHEWS, V.L., BOLARIA, R., FEATHER, J. Smoking behavior and attitudes among members of the Canadian Public Health Associatiom Saskatoon, Canada, University of Saskatchewan, College of Medicine, Department of Social and Preventive Medicine, April 1975,70 pp. (34) MAUSNER, J.S: Cigarette smoking among patients with respiratory disease. American Review of Respiratory Disease 102(5): 704-713, November 1970. (85) MODERN MEDICINE. 1966 Survey results: Fewer doctors now smoke; patients often ignore advice. Modern Medicine 34(6): 14,18, March 14; 1966. (36) MODERN MEDICINE. Sixty thousand answer MM smoking survey. Modern Medicine 32(5): 18,22,26,30, March 2, 1964. ($7) MODERN MEDICINE. 34,627' Physicians take part in smoking survey. Modern Medicine 38(26): 47,49, December 28, 1970: (88) MODERN NURSING HOME. Administrators dislike smoking but permit it, survey shows. Modern Nursing Home 28(4): 15-16,20, April 1972. (39) MONSON, R.R. Cigarette smoking by Massachusetts physicians-1968. New England Journal iof Medicine 282(16): 906-908, April 16,1970. (40) MURPHY, T:H., TIERNEY, JIT. Current status of cigarette smoking among Rhode Island physicians. Rhode Island Medical Journal 46: 655-657, December 1963. (41) NATIONAL CLEARINGHOUSE FOR SMOKING AND HEALTH. Adult Use of Tobacco, 1970. U.S. Department of Health, Education, and Welfare, Public Health Service, DHEW Publication No. (HSM)73-8727, June 1973',129 pp. 22-26

,: (.1,2)~ NATIONAL CLEARINGHOUSE FOR SMOKING AND HEALTH. Adult, Use of Tobacco, 1975. U.S. Department'of Health~ Education, and Welfare; Public Health Service, June 1976, 23'pp. (43) NATIONAL CLEARINGHOUSE FOR SMOKING AND HEALTH. State Legislation on Smoking an& Health-1975. U.S: Department of Healthi Education, and Welfare, Public Health Service, Center for Disease Control,. December 1975,84 pp. (/,4) NATIONAL CLEARINGHOUSE FOR SMOKING AND HEALTH. State Legislation on Smoking an& Hoalth-1976. U.S: Department of Health,. Education, and Welfare, Public Health Service, Center for Disease Control,. Bureau of: Health Education, December 1976, 73 pp. (45) NATIONAL CLEARINGHOUSE FOR SMOKING AND HEALTH. State Legislation on Smoking and Health-1977. U.S. Department of Health,, Education, and Welfare, Public Healthi Service, Center for Disease Control,. Bureau of! Health Education, National!Clearinghouse for Srnoking and Health, HEW Publication No. (CDC) 78-8331, January 1978,79 pp. (:G~~6) NATIONAL CLEARINGHOUSE FOR SMOKING'. AND HEALTH. Survey of Health Professionals: Smoking and~ Health, 1975. U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control. Bureau of Health Education, National Clearinghouse for Smoking and Health, June 1976,42 pp: (47) NATIONAL COMMISSION ON SMOKING AND PUBLIC POLICY. A National Dilemma: Cigarette Smoking or the Health ofl Americans. New York, American Cancer Society, Inc., January 31,1978, pp. 61-6Z (48) NOLL, C.& Health professionals and the problems of smoking and health. Report' 2. Dentists' behavior, beliefs, and4ttit'udes toward smoking and health. Report on NORC Survey 4001. Chicago, University of Chicago, National Opinion Research~Center, November 1969, 11 pp. (49) NOLL, C.E. Health professionals and the problems of smoking and health. Report'3. Physicians' behavior,, beliefs, and attitudes toward smoking and health. Report on NORC Survey 4001. Chicago, University of Chicago, National Opinion Research Center, November 1969,105 pp. (50) NOLL, C.E. Health professionals and the problems of smoking and health. Report 4. Pharmacists' behavior, beliefs, and attitudes toward smoking and health. Report on NORC Survey 4001. Chicago, University of Chicago, National Opinion Research Center, November 1969, 105 pp. (51) NOLL, C.E. Health professionals and the problems of smoking and health. Report 5. Nurses' behavior, beliefs, and attitudes toward smoking and health. Report on NORC! Survey 40011 Chicago,, University of Chicago, National Opinion Research Center, November 1969,99 pp. (52) PHILLIPS„A.J. The smoking habits of professional groups in~Canada. In: UICC Technical' Report Series; Volume 6. Public Education About Cancer. Recent' Research and, Current Programmes, 1969. Geneva, Union I~nternationale Contre le Cancer, 1970, pp. 34-37. (58) PINCHERLE, G;, WRIGHT, HIB. Smoking habits of business executives. Doctor variation in reducing cigarette consumption. PraAfitioner 205(12a6): 209-212, August 1970. (54) PROCEEDINGS OF THE NATIONAL FORUM ON OFFICE MANAGEMENT OF SMOKING PROBLEMS. Diseases of the Chest 54(3): 169-220; September 1968. (55) PURVIS,, J.M., SMITH, D.L. Smoking among medical students. Southern Medical Journa169(4); 413-416, April 1976. (56) RAVENHOLT, R:T. Work Group 8-Role of physiciawand other exemplars. In: First World Conference,on Smoking and Health, September 11-13, 1967. New York, NationaliInteragency Council on Smoking and Healtha 1967, pp. 226-228. N I 0 I R M IfU E 22-27

(57) READ, C.R The teenager looks at cigarette smoking.. In: UICC~ Technical Report'Series, Volume 6. Public Education About Cancer,,Recent Research and Current Programmes, 1969. Geneva, Uniom International Contre le Cancer, 1970, PP. 97-104. (58) ROSE, G., UDECHUKU, JIC. Cigarette smoking by hospital patients. British Journal of Preventive and Social Medicine 25(3): 160-161, August 1971. (59) SANGSTER, J.F. A no-smoking ward. Lancet 2(519): 765-766, October 7, 1967: (60) SCHNITZER„K. No smoking in the hospitall Surgeon's Management 2(4)r 18-24, April 1967. (61) SCHROEDER, S.A., SHOWSTACK, J.A. Merchandising cigarettes in pharma- cies: A San Francisco survey. American Journal of Public Health 68(5): 494 495, May 1978. (62) SNEGIREFF, L.S., LOMBARD, O.M. Survey of smoking habits of Massachu- setts physicians. New England Journal of Medicine 250(24): 1042-1045, June 17, 1954. (68) SNEGIREFF, L.S.,, LOMBARD, O.M. Smoking habits of Massachusetts physicians. Five-year follow-up study (1954-1959). New England Journal of Medicine 261(12): 603-604, September 17,1959. (64) STAMLER, J., SCHOENBERGER, J.A., LINDBERG, H.A.,, SHEKELLE, R, STOKER, J.M., EPSTEIN„M.B:, DEBOER, L.,,STAMLER, R, RESTIVO, R., GRAY, D., CAIN, W. Detection of susceptibility to coronary, disease. Bulletin of the New York Academy of Medicine 45(12): 1306-1325, December 1969. (65), TATE; C.I., FULGHUM, J.E. Seventy percent of Florida physicians are nonsmokers. Journal of the Florida Medical Association 52(1): 47-48, January 1965. (66) TOBACCO INTERNATIONAL. 8-point anti-smoking drive launched in UK. Tobacco International 129(9): 19-20, April 29, 1977. (67) U.S. DEPARTMENT OF LABOR. Bureau of Labor Statistics, Occupational Outlook Handbook, 1978-79 Edition. Bureau of Labor Statistics; 1978, p. 447. (68) VAILLANT, G.E., BRIGHTON, J! R., MCARTHUR, C. Physicians' use of mood altering drugs: A 20-year follow-up report. New England Journal of Medicine 282(7): 365-370, February 12, 1970. (69) VLASSIS, T. Should pharmacists sell cigarettes? Iowa Pharmacist 24(9): 10,15, September 1969. (70) WEITMAN, M., MEIGHAN, S:S. Smoking, patterns and specialty training of' Oregon physicians. Cancer 20(6): 974-982,,June 1967. (71) WESTLING-WIKSTRAND, H., MONK, M.A., THOMAS, C.B. Some character- istics related to the career status of women physicians. Johns Hopkins Medical Journal 127(5): 273-286, November 1970. (72) WILHELMSEN, L., FAITH-ELL, P. New study on the smoking habits of Swedish physicians. UICC Technical Report Series. Volume 11. Public Education About Cancer, 1974. Geneva, Union Internationale Contre le Cancer, 1974, pp. 66-67: (78) WILLIAMS, H.O. Routine advice against smoking. A chest clinic pilot study. Practitioner 202(211): 672-676, May 1969. (74)' WITTE, L.M. "I'd rather switch~ than quit." Mount Auburn Hospital, Cam- bridge, MA. Anti-smoking project final report. Hospital Topics 54: 28-32, May/June 1976. (75) WORLD HEALTH ORGANIZATION. Survey on Smoking, and Health in the European Region, 1974-75: Data as of 11 September 1975. Copenhagen; World Health Organization„Regional Office for Europe, Document H3/76/4,1975; 72 PP• 22-28