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2.3 Ischaemic heart disease The evidence that cigarette smoking is probably the major modifiable risk factor in ischaemic heart disease is now very strong and is supportcd by numerous large-scale studies of various kinds--clinical, e:perimental, epidemiological, retrospective, and prospective-which have been carried out in several countries. There is evidence that the influence of smoking is independent of, but also synergistic with, other risk factors such as hypertension and high blood cholcsterot. This means that the effects are more than additive (Fig. 3). . EI®. 9. Ten-year Incidence of first major coronary event In relation to . cigarette smoking, serum cholesterol, and diastolic blood pressure In white males In the USA aged 30-59 years 20 None of the three 171 l ~yr.~(. - 8- amoklna of cloanlles, any number C - cholesterolIneerum>2.5a11 ~MI4t.t.lreo R - pressure, dlastollc > 12.0 kP Nole t flrat melor coronary event Includn fatal and non-tslsl myeprdlal IntVOtlon and sudden death due to toronery heart dlseese. Relda are epe-edJuatedt source: /PtaaBocLM Commisslen for Heart Dlseesa Resourns, CktuhWa, a(a)) Aa4 (1a70). Because the incidence of other risk factors for ischaemic heart disease varies in different countries, the relative importance of cigarette' smoking also varies. It has been shown (10) that the relative risk is greater at younger ages and that the risk for r the smoker increases with the amount smoked. As with lung cancer, the risk of death from ischacmic heart disease decreases on cessation of smoking. The risk declines quite substan- tially within one year of stopping smoking and more gradually thereafter until, after 10-20 years, it is the same as that of the non-smo~er (6). For those who have had a myocardial infarction the risk of a fatal recurrence may be halved (24) after giving up smoking (Fig. 4). Flg. 4. Rate of second Infarctlon In smokers and non-smokers 20 Months 1. 8weden, 405 patients who wera smokerg at the Ilme of arst myoeerdlal Infarction were lullowed up 1m 24 menlhs, Thou who stopped smoking had e much lower non-letel r.lap.e rate than hadlhoae who continued smok/np. Source p Wllhelmnan. C. st d. L+acN, 1 p 415 (1p75). _ A study on British mak doctors (10) showed a decrease in_ death rates from coronary heart disease concurrent with a decrease in the number of doctors who smoked. ]n contrast, the death rate increased for all other men in the study who, as a group, did not markedly decrease their amoking habits (Fig. 5)- - Atherosclerosis of the myocardial arterioles is more common in smokers than in non-smokers of a corresponding age (2S).1t is also more common in the aorta and other arteries. PyripLeral vascular disease is highly eorrelated with cigarette smoking (26). [ i

Flg. 7. Annual cigarette consumption per adult (>15 years) In Norway and In the United Kingdom 8000 40W -. .- ~ - ~- ~ ~ ~ UN` IGDWl1 : i1 - -~ _ _AY 900 -I'" -_ - 600 ~ - . - . - - - 499 _ _ _- ~~ 200 100 -- - 1920 1950 1900 1970 1940 1930 Nole: The velues for both countdes Include estlmatas ol hend-roRad cigarettes because in Nrtrwey such cigarettes constitute e suhstsntlal proportion or all clgaretles smaked. Source: Blarlvslt, K. Rqklna oa helse-sllueelonen I deu [Smoldny and h..ilh- tM situation loday]. In t t.ersen. . ad. fusbyoYends med/srn (Preventlve medlclne]. 0910, UnF •arslty Prass, 1979, p.9l. ~~L'~'P/ [*O - Fig. 9. Annual lung cancer moRallty In males aged SO-89 years In England and - Wales and In Norway, 1931-70 400 200 . ~ ENOLAND AND WALES -- ~ ,00 90 -- - - - - _ i 60 40 20 NORWAY - ' 10 - - 9 8 ' - 4 2 ---- ' , --- -------- ~ - 1930 1940 1950 - . _- ----1960 1970 Soumal 91erlrNt, K. RqLnu ep hslss.-situeelonen I deo [SmoUnp and health.-the situation todq]. In: Larsen, ®., ad. faebrypeude mrdlsln IPreventlve medicine]. Oslo, UnF reral Press, tYT6, a, eS

Table I (continued) 1e50 1955 1960 1965 1070 19115 Iceland .. . M - - - 9.9 10.4 19.5 Ireland F M 9.8 - 18 0 - 25.3 6.0 30.1 4.0 39.6 11.8 44.2 F sA . 5.4 5.6 7.5 9.9 13.8 j Italy M . F - 14.3 . 3.8 20.9 4.0 26,6 aA 35.9 4.6 (I1.8) ~ (5.1) Nethedanda Norway M F M p4.a 2.9 - 30.0 2.8 7.8 e0A -8.2 12.4 51.4 3.4 1a.1 63.2 3.6 18.0 713 4.2 - 22.3 F - 2.7 2.5 . 9.2 -3.4 4.5 Poland -- M - 17.0 27.1 35.1 44.2 Portugal F M - 7.6 33 !.! 4.4 1e.5 4.7 13.1 ' 6.7 15.1 F - 2.0 2.1 2.0 28 3.3 Spain M - - 16.6 16.6 ' 21.9 (26A) F - - 3.8 36 a.0 (4.2) Sweden M - 10.8 14.1 16.5 19.4 !3-0 F - 5.1 5.1 6.6 4.7 6.0 Swlteedend M - 26.9 31.1 34.6 - 40.3 47.6 F - 2.9 3.0 3.2 1 314 4.4 United KtnOdom England & Wales M 37.5 61.7 61.8 68.5 72.8 71.8 -- -- F 5.6 e.6 7.9 10.0 12.1 14.6 ' Northern Ireland ~ S M 20.7 30.1 34.4 40.7 41.9 52.6 --~ F 3:/ 4.0 5:8 5.9 8.6 11.7 Scotland M 38.1 50.0 65.7 75.8 92.6 82.7 - F 8.1 7.1 8.5 11.0 14.1 15.8 Yu9osla.le M - - -- 21.7 27.3 32.6 F - - - 4.0 4.7 5.5 Dceanla Australia M 13.4 20.2 26.3 34.9 12.2 46.0 - F 2.6 2.9 3.4 4.2 6.6 7.0 Nsw Zealand M 16.1 25.5 27.1 35.9 46.2 48.7 F 2.5 3.0 4.5 6.6 8.7 10.0 Source; World Health Oroenha8on. Values In hrackels ara lor Me year 1971. The evidence for a causal relationship is now very strong. It is based on a large number of retrospective studies in several countries, and on large prospective studies in Great Britain, the USA, and Canada (12-13). These show a consistent and close relationship between lung cancer and cigarette consumption (Fig. 1), The risk of developing lung cancer is strongly related to the number of cigarettes smoked, the age of starting to smoke (13), and smoking habits that inerease the exposure of the lung to the constituents of tobacco smoke. These include the frequent puffing of the cigarette, the retention of the cigarette in the mouth between puffs, and the degree of inhalation (3). The evidence from epidemiological studies is consistent with that from clinical, experimental, and patho- logical studies. Utzax0 flp.1. Mortatlty ratios ot deaths from lung caneer In men h_o_ m -. . . four large prospective studies 10 20 30 CRrmi number 91 cigarettes smoked p:r day 40 50 Brlllsh doclora r poll. R. i Hill, A. B. Brtllsh medical lownal, t: 119Y,1a5o (19e1). Canadian rNerane: Best, 8. W. R. A CmWMn study of smn6/n9 ud health. Oltawa. Depertment of NetlonM Health and Wellare, /68s. US rNernns : Kehn, H. A. In: Heenaee4 W„ ad. Eptdamblo9ka/ ey- poachea to the study of cancer and other chronk d/seas...-aenhesdn, Nehond CancH Institute, 1986 (idono0reph No. 19). US men In 25 States: Hammond, E. C. In: Haenazel, W., ed., op. cR. I

Internartonar Unlon for Health €Aueur7on Professor E. "Berthet, $ecretary.General, Inlernational Union for Health Edu- - cation, Paris, France - Initrnatlonal Assocfatlon of 6nviranmental Mafagen Soeletfes De H. Greim, Department ofToxico_lo_gy, Environmental Research Ltd. Munich, .' Federal Republic of Germany - International Union Agalnrt Tuberculosis ~ ~ Dr R, van der Lende, Research Unit for Epidemiology, University Hospital, Groningen, Netherlands - tYcr/d Federation of United Nations Assoerartonr . . - Dr A. Bonapace. Rome, Italy .' Senetariaf ' Dr B. As, Research Director, Ethnographic Museum, University of Oslo, Norway . (Tesnpufary Adviser) Mr M. Daube, Director, Action on Smoking and Health, London, England (Tenrporary Advhre) Professor W. F. Forbes, Professor of Statistics and Dean of the Faculty of Math- emalia. University of Waterloo, Ontario, Canada (Temporary Adviser) Professor P. Macuch, Director, Postgraduate Medical and Pharmaceutical Insti• rute, Prague, Czechoslovakia (Temporary Adviser) P%fessor M. M. Mahfouz, Chairman, Kaar EI-Einy Centre for Radiation On- cology and Nuclear Medicine, University or Cairo, and Vice-President of the Egyptian Cancer Patient Welfare Society, Cairo, Egypt (Temporary Adviser) Dr R. Masironi, Scientist, Cardiovascular Diseases, WHO, Geneva, Switzerland (Secretary) Professor B. Paccagnella, Institute of Hygiene, University orPadua, Italy (Tempor- ary Adviser) - -- - GONTROLLING THE SMOKING EPIDEMIC Report of the WHO Expert Committee on Smoking Conhol - - ...,.. , . . , The WHO Expert Committee on Smoking Control met in Geneva from 23 to 28 October 1978. Dr Ch'en Wen-chieh, Assistant Director- General, opening the meeting on behalf of the Director-General, said that the aims of the meeting were to review the latest evidence on the harmful effects of tobacco smoking, to review the world situation in regard to smoking control (legislation, educational approaches, etc.), and to suggest ways of helping Member States to prevent the spread of the smoking habit. The harmful effects of tobacco smoking were now well established and the medical evidence had been presented by a previous WHO expert committee (1). The present task was the more difficult one of proposing control activities that would doubtless be of a complex nature based on education, information, and legislation and involving political and economic considerations of the greatest import- ance. ance. Governments should be made aware that the revenue from tobacco is usually offset by the great expense of caring for the millions who are made sick and by the loss in output of those people--and of those who die prematurely. 1. INTRODUCI7ON The recommendations made by the WHO Expert Committee on Smoking and its Effects on Health (I), which met in Geneva in 1974, are still valid. They have been implemented in varying degrees in some. countries but fully in none. For convenience these recommendations are reprinted in Annex 1. The present Committee decided that the asscss- ment made by the earlier Committee needed no abatement and need not be repeated. It therefore elaborated the earlier assessment and recom- mendations, where such elaboration was justified by new knowledge and by the further extension of the smoking hazard _in countries previously less affected. The Committee felt that the time had come for WHO and national health agencies to make a fresh and realistic assessment of their objectives. There can no longer be any doubt among informed people that in any country where smoking is (and has for a considerable period been) a common practice, it is a major and certainly removable cause of

them to maintain their non-smoking habits, to change their smoking habits, and to participate in the smoking and health campaign. Health education, when directed at smoking, should be multidisciplinary and have a wide variety of practitioners. All aspects of the promotion and protection of health are complemen- tary and interdependent and require the coordination of work in different areas suc as health, education, and agriculture. The International Union for Health Education plays a valuable part in this work by establishing links between organizations and individuals, facilitating the interchange of information, promoting scientific research, improving professional training, and contributing to increased public awareness of all aspects of health education. Some governments have found it useful to establish a national smoking and health agency to devise and implement smoking control programmes. Where this is not feasible, governments themselves have the responsibility of coordinating smoking control activities or must delegate the responsibility to an appropriate organization and provide support where necessary. Where a number of governmental or voluntary bodies are involved in the national programme, steps should be taken to develop an integrated approach, and to ensure accuracy in the content of all informational and educational activities. Analysis of the problem should always precede design and implemen- tation of any aspect of public information and education programmes, which must themselves be fully integrated with other components of the national smoking control programme. Legislation is needed to sustain the impetus imparted by education activities, and some kind of help may have to be provided for the hard core of smokers who find serious difficulty in giving up the practice unaided. 7.1 Public information programmes It is essential that the public in any country should be well informed on smoking and health. This will not necessarily of itself alter smoking rates but is a prerequisite for further action. The techniques employed will vary widely depending on local circumstances and objectives. 7.1.1 Objectives In planning any programme, the objectives must be stated. These might be inter alia: - to increase public awareness of the smoking problem and its magnitude, OSLZf:4C() - to increase awareness among decision•makers of the need for smoking control and the possibilities for action, - to counteract the effects of inaccurate information. 7.1.2 Target groups Although public information is essentially a mass approach, certain targel groups within the population can be singled out for specific treatment by the choice of the message or the medium employed to convey it. L Clearly, the population can be divided into smokers and non- smokers and subdivided by sex and age group, hcalth circumstances ^ (e.g., pregnant women), socioeconomic status, and importance to the progress of the smoking and health campaign (decision-makers, edu- cators, health professionals, etc.). It is both inevitable and desirable that messages directed at some groups will be perceived by olhers. 7.1. 3 Design of the programme When designing a public information programme, it is necessary to bear in mind the traditional communications model of "senders, mess-, ages, media, receivers'. Each of these elements must be carefully con- sidered to ensure proper communication and feedback, leading to increased efficiency with repetition. Each element must be adapted to the local culture. The techniques of programme design are described fully in the litera- ture (94, 97). Where a number of organizations are involved in the programme, eoordination of activities is vital in order to avoid confusion among^ target audiences. Senders. The sender of any message must be appropriate to the target group, the objective of the communication, and the message itself. Thus, consideration should be given to the credibility and acceptability of those appearing in the mass media. Messages. In information work as in education programmes, it is essential that messages be accurate, carefully considered, and appropriate to the target audience. If there is a succession of messages, each should complement and reinforce the others. Choice of the wrong message can be counterproductive, and, if possible, messages (or other aspects of the programme) should, before emission, be tested for comprehensibility and acceptability. Messages should be apposite to the objective, aimed

(b) by adopting regulations to protect non-smokers from exposure, without their consent, to tobacco smoke in the working environment; (c) by the provision or extension of non-smoking areas in public transport and other public places where smoking is not totally prohi- bited; (d) by clearly defining non-smoking areas and publicizing prohib- itions of smoking so that all users are aware that smoking is pro- hibited; (e) by giving special attention to the protection of infants from contact with persons who are smoking. 6. In activities to assist the individual to cease_ smoking, it is essential that: (a) the national smoking and health body should provide material to help members of the health professions who have opportunities in the course of their daily work to advise on how to stop smoking; (b) smoking withdrawal clinics should be established. 7. Research should be carried out: (a) to define more precisely the social, psychological, and pharmaco- logical determinants of the smoking habit; (b) to understand better the mechanisms by which the various consti- tuents of tobacco smoke, particularly nicotine and carbon monoxide, cause their pathological effects; (c) to establish methods for planning and periodically evaluating the educational and informational activities related to smoking and health; (d) to determine the magnitude and nature of the problem of smok- ing, and to assess the smoking behaviour and the attitudes towards smoking of the general public, of the health and education professions, and of other opinion leaders; SOZ'2'C(aCO (e) to determine, if possible, the cost to the country of smoking by calculating the excess of work-days lost by smokers, both from absence due to sickness and from premature death, and the cost of caring for those made ill by smoking, as well as the decrease in mor- bidity and mortality that could be expected to follow a reduction in smoking.'Phese figures would provide a basis for the planning, evalu- - ation, and budgeting of programmes for the control of smoking. 82 i i I I i B. Recommendations for implementatlon by WHO WHO should be prepared to: - collate information on the smoking habits of the populations of Member States and on their smoking and health problems; - adopt standard definitions and ways of measuring smoking behaviour so that cross-cultural comparisons may }+e facilitated; -- collate information on smoking control activities and methods from Member States and also on developments in tobacco sales promotion, especially in areas where smoking has not yet widely /, been accepted; - recruit experts so that the health authorities of countries in which smoking has not yet reached serious proportions or the health hazards have not yet been identified could, upon request, be given assistance in analysing the situation and in initiating preventive programmes in accordance with the relevant parts of the foregoing recommendations; - give assistance and encouragement to research on smoking and health; - facilitate the exchange of technical information and of health education materials on smoking available in different countries; - encourage multidisciplinary seminars for those working in this field; - consider applying the recommendations of this Committee to its - nWvi w of the multidimensional nature of the problem of smoking ~ and health, try to involve other members of the United Nations family, such as UNESCO and UNICEF, and appropriate nongovernmental organizations in its antismoking campaign; , - try to establish collaboration with FAO and ILO in studying, on a lon_g-term basis, the problem of agricultural and economic changes possibly occurring in some countries as a consequence of the anticipated reduction in tobacco use; - consider the advisability of convening another Expert Committee to review the position at an appropriate time as further develop- ments occur.

3.5 Summary (I) Smoking entails huge economic losses, which constitute a s_izeable_ burden to national economies. (2) Smoking control measures should primarily be undertaken because of the deleterious health consequences of smoking. However, the economic losses lend support to the desirability or smoking control.. (3) The collection of tobacco revenues offers no justification for delaying the implementation of measures to reduce smoking. (4) There are indications that taxation could be used as a tool for curtailing or modifying tobacco consumption. (5) The world tobacco economy is dominated by a few large companies whose combined advertising budgets total about 2000 million dollars. (6) Tobacco production is seldom genuinely profitable for the country concerned or for individual farmeis and workers and can lead to economically important negative consequences for food production. (7) The`substitution of other crops for tobacco is a vital factor in implementing smoking control in tobacco-growing countries. _ 4. THE DYNAMICS OF THE SMOKING EPIDEMIC The spread of the smoking habit has occurred like an epidemic. The habit has spread from_ country to country, from continent to conti- nent, and even between different population groups within the same country.. Some examples may illustrate this point. Fig. 6 demonstrates the burden of two health problems that have moved in opposite directions during the past 25 years. While tuberculosis has been decreasing in most countries, there has been a rapid increase in smoking-related diseases, of which lung cancer is the most striking example, These trends vary from country to country, the cross-over of curves taking place at differ- ent times. YBLZEJ'~Q The increasing trend in smoking-related diseases, as exemplified by lung cancer, parallels the trend in smoking. As an example, Fig. 7 shows the per capita cigarette consumption for Norway and the United Kingdom. In both countries there has been an increase during recent decades but the curve for Norway has been 30-40 years behind that fnr the United Kingdom throughout the period, Cigarette consumption in Norway is still no more than half that in the United Kingdom. Fig. 8 shows that the increases in lung cancer mortality in these same countries' have similar gradients and are also 30 years apart, the level in Norway having so far reached only one quarter that in England and Wales. In some developing countries there has been a similar increase in cigarette consumption but again the curves are many years behind these for tlte developed countries. In 1973 cigarette consumption was 230 per adult per year in Indonesia, 43_0_ in Sierra Leone, 480 in Ghana, and 760 in Pakistan (see Annex 4). Ftg. 6, Crude death rates for males of all ages In selected eountrlers and areas lrom lung cancer and tuberculosls, 1950-75 enNOEO OF LUNO, TNI0NE/1, AND anONeNU.II ~oo eo Eo 40 4 2 r, . 11 rs . so as a , ee rese ss a es ~u Fs w rs Developing countries have not yet had_ time to experience the same grim increase in smoking-related mortality as has taken place in the industri- alized countries, but they must expect it unless they halt and_ reverse the increase in cigarette consumption, The United Kingdom is today suffering the heaviest penalty and is only beginning to contain it. Norway has the great benefit of being able to learn from that experience and check the increase in mortality at a level well short of that in the United Kingdom. The developing countries have the still greater advantage of being able to prevent an increase in mortality, which is otherwise inevitable, by reversing the increase in ^

is a luxury, radio programmes are often of much greater value, particu- larly when broadcast in the local language in rural areas. Visual forms of presentation can also be effective, particularly when related to some form of traditional activity. Mobilization of support from village heads, leaders of thought, religious and voluntary groups, and workers in schools, hospitals, etc., c_an be of great value in prevention, 5.3.3 Toboecoprodueing countries The approach to the problem in countries (both developed and delop- ing) that possess a tobacco industry should include: - a search for a substitute crop, - the phasing-out of tobacco subsidies, - the introduction of appropriate subsidies to encourage the plant- ing of substitute crops, - consideration of a global agreement on tariffs on tobacco and quotas of tobacco production to help current tobacco exporting countries to convert to substitute crops, - the discouragement of the export of surplus tobacco, and - the cessation of duty-free sales of tobacco. In many countries lack of collaboration between health and economic planners has had deleterious effects. Opposition to smoking control programmes by those responsible for agriculture presumably represents dominance of monetary considerations over those of health, poor understanding of the problem, or poor communication between govem- 5.4 Strategy for key groups To achieve smoking control objectives it is of great value to mobilize the support of key groups within a country, which include political and religious leaders, relevant voluntary organizations, doctors, other health professionals, and teachers. These groups should apply social pressures wherever appropriate, including support for the rights of the non- smoker and activities directed at estahlishing non-smoking as the norm. The skills possessed by the members of key groups should be coordinated in a multidisciplinary programme, because no one group has a monopoly of expertise. In view of the importance of the exemplar role of health professionals and health bodies, it is desirable that smoking should not be permitted in WHO, in government hcalth-oriented buildings, in hospitals, or in health centres except in special ly designated smoking areas. Major education programmes should be directed at exemplar groups. 5.5 Thc role of government In developing countries the government should generally play a leading role in smoking control owing to the need for overall policy direction and for funds. Where government is not ready to recognize a potential smoking problem, interested private groups should try to convince the leaders of public opinion of the need for action. It is desirable that national activities should be the responsibility of a competent central body dealing with problems of smoking and health. There are many ways of organizing such a body, which (whether govern- mental or not) should have clear objectives, the capacity to pursue them, and sufficient operational independence. ment departments, 6. MONITORING TNE NATIONAL SMOKING PROBLEM Economic plans should not foster tobacco production for short-term AND EVALUATING CONTROL ACTIVITIES gains. Long-term planning must accept the need for a progressive reduc- tion of tobacco commerce, and this should be accomplished in such a Smoking control activities should not be undertaken in a vacuum. way as to safeguard the livelihood of those involved. Decisions on appropriate activities should, as far as possible, be preceded Around the world, almost 4.5 million hectares of arable land are by an analysis of the problem, and the extent of the problem should be used to grow tobacco (95), yet developing countries must try to achieve regularly monitored. Many well-intentioned measures aimed at reducing high rates of increase in food production to avoid dependence on imports smoking have in the past failed to reach their full potential because no and to meet the needs of growing populations (96). The Committee mechanism was created to monitor trends or to evaluate the effectiveness ~ considered that the use of so much arable land to produce tobaeca, of overatl programmes and spec'fic measures. Evaluation and moniter- which not only has no nutritional value but also damages health, is not ing should be seen as essential components in the design and develop- m nt f Il ' - c k ' o n smo mg wntrol acttvittes. E44EO an economically sound practice. BElt2 e~)

At least 13 countries, to the Committee's knowledge, already imple- ment total bans on tobacco promotion. It may be desirable for legislation to ensure that information on possible less harmful forms of smoking can still be made available (by publicity through government agencies) and to provide for some statutory body with the power to determine what constitutes, for example, a tobacco advertisement. Where restrictions apply only to cigarette adverli=ing or promotion, tobacco cco manufacturers have frequently promoted other forms of smok- ing (cigars, cigarillos, pipe tobacco) with brand names similar to those of cigarettes. No restriction of sales promotion will be fully effective unless it applies to all tobacco goods. Evidence on the specific effectiveness of a tobacco advertising ban is not easy to obtain, as those in operation have generally been partial, unaccompanied by health education, or imposed in societies where all advertising is restricted. In Norway, however, the 1975_ ban on tobacco advertising, together with a comprehensive education programme, has, already been followed by a substantial and rapid fall in smoking rates among males (101). These observations are promising evidence and might indicate that a comprehensive programme including an advertising ban will be followed by more rapid results than health authorities have anticipated in the past. Advertising bans may, of course, have completely different objectives. They may be a means, for example, of protecting a national tobacco monopoly from international competition. A ban for such a purpose, unsupported by education programmes, cannot be expected to affect tobacco consumption. 8.2 Health warnings It is now widely accepted that many consumer products-including cigarettes-should carry information about their contents (section 8.3) and dangers. Although voluntary agreements would in normal circumstances be preferable to legislation, experience has shown-as with tobacco promotion-that tobacco manufacturers will not, in general, voluntarily agree to warnings that re_tlect accurately the views of health authorities and that they will make every effort to minimize the impact of such warnings. Health warnings have now been introduced on cigarette packets and advertisements in many countries. A sophisticated system of warnings is that implemented under the provisions of the Swedish Tobacco Act: GEZZUEO 56 cigarette packets carry any one of 16 different messages. All 16 warnings are required to appear at approximately equal frequencies-i.e., a particular manufacturer cannot confine himself to a given warning notice. This ensurss that the smoker does not become accustomed to the same message. Introduction of a mandatory system of warnings provides yet further evidence of government concern about smoking and health. It is vital to ensure that exact specifications for the warning are carefully set out so that its effect is not minimized by careful pack design qr any other device. Care should be taken that any warnings used are bAth accurate and comprehensible to the public at large, and the government should retain the right to vary the warning at will. ^ It has been argued that the introduction of a health warning may permit tobacco manufacturers to evade legal responsibility for the consequences of using their products. This is unlikely to be true and is not a sufficient reason for abandoning the health warning. 8.3 Product description It is widely accepted that many consumer products should carry information about their potentially hazardous constituents. In several countries information is now given on packets and/or advertisements about the constituents of cigarette emissions such as tar, nicotine, and carbon monoxide. Although it is not yet possible to determine precisely the nature of the association between the constituents of cigarettes and the various smoking-related diseases, there is good evidence that certain components of cigarettes do contribute to specific smoking-related diseases and that cigarettes with lower yields of such substances are less hazardous to i s health, although still harmful. Since the exact interrelation of etfects not known, the desirable objective is to reduce all the harmful emission of cigarettes. The purpose of providing information about these sub- tances is partly to alert smokers to their existence, and partly to help smokers to choose potentially less harmful brands. In providing information about the constituents of tobacco smoke, care must be taken that: (1) the public is not so confused by information on different sub- stances that it is unable to make a rational choice-for example, reference values must be published before tar yield printed on a packet becomes intelligible p ^

Paaa 9. Helping the individual to stop smoking . . . . . . . . . . . . . 66 9.1 Ex-smokers in the community . . . . , . . , . . . . . . . . . 66 9.2 Process of smoking cessation . . . . . . . . . . . . . . . . . 67 9.3 Smokingceasationmethuds . . . . . . . . . . . . 68 9.4 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 70 10. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . 71 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Annex 1. Recommendations of the 1974 W I IO Expert Committee on Smoking and its ERccls on Health . 78 ......... . ....... . _.______ _..__. . . . . . . . . . . , . . . . . Annex 2. Statement by representative of the Food and Agrkulture Organivation of the United Nations 84 Annex 3. Stntement by representative of the International Labour Organisation SS Annex 4. Summary data on tobaoco consumption , . . , . , . . . . . . . 85 .WHO FXP&RT COMMiTTF.6 ON SMOKING CONfI(OL Professor 0. 0. Akinkugbe, Vice-Chancellor, Ahmadu Bello University, Zada, Nigeria - '~ Dr K. Bjarlveit, Chairman, National Council on Smoking and Health, Oslo, Norway (Rnpporteur) Dr H. Coudreau, Director-Generat, National Committee on Tube~suiosis and Respiratory Diseases, Paris, France Dr E. Crofton. Medical Director, Scottish Committee, Action on Smoking and Health, Edinburgh, Scotland Sir George Godber, Cambridge, England (Chafrman) Dr N. Oray, Director, Anti-Cancer Council of Victoria, Melbourne, Australia (Rappnreeur) • - - - Dr D. Hem, Frenehtown, NJ, USA Dr D. Loransky, Director, Central Institute for Sdenti8c Research in Health Education, Ministry of Health of ihe USSR, Moscow, USSR Dr L. Ramstr;Vm, Director-General, National Smoking and Health Association, Stockholm, Sweden Dr J. Sulianli Saroso, Adviser to the Minister of Health, Jakarta, Indonesia ( f'1ecChatramn) Reprerenratlaa of other organl3 arionr United Nations Conference on Trade and Development Dr F. Clairmnnte, Commodities Division, UNCTAD, Geneva, Swilurland InrernarionafLabour Orgoniaotion Or D. Djordjevic. Occupational Safety and Health Brench, 1LO, Geneva, Switzerland - - Food and AgrienGure Organization of the Unlted Nations Mrs P. Marongiu, Commodities and Trade Division, FAO, Rome, Italy international Council on Afcohof and Addictlaonr Mr Archer Tongue, Director, International Council on Alcohol and Addictions, Lausanne, Switzerland Jntnnarlonaf Union Against Cancer . Mr D. Reed, Assistant to the Director, UICC, Geneva, Switzerland e Attended also as a rcprcuntative of the Internationd Union Against Cancer.