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W[i0 EKPr."k2'T' COMMITM REPOkT' 021 SMOKING CONTROLy, "CONTftOLLIP:G TF.Ft SMbKING' EFIDE;IC" . 1'Jorld, Health Organisation, Geneva, 197i9): RECOMMATION'S The Committee has produced some new recommendations which address themselves to changes in the situation, particularly in the area of smoking control in developing countries. These recommendations are forthe,advice of'WHO, governments (not merely their heglith departments), and official organisations; they are also for the information of people throughout the rrorld whose lives may be affected by this problem. ~ The recommendations of the 1974 Expert Committee are reprinted as knnex I' to this report. In general, they reflect the basic opiaions of the Committee and,are again endbrsed. Recommendations addressed to alli cou.ntries t The Comoittee recommends :hat non-smoking should be rega_dedi as the normal social behaviour and that all action which can promote the development of this attitude be taken. There shoull be a total grohibition of all!farns of tobacco promotion. Promotion of the export of tobacco and tobacco products shou:d be disco•.:raged. Tbbacco*-g-,owing a.-idi manufacturing, indtrstries; should be p.-ogressive3y reduced in size as rapidly as possible. - Governments should recognise the serious danr-rs for smokers in certain indus+.rial' occuations and devel'op speciali programmes to eradicate smoking from these industries, introducing legislation - where necessary, The synergism observed between smoking and certain occupations implies the need for careful monitoring in industries where toxic inhalation is a problem and indicates the netd for research in.this area.- ! Upper limits should be established for appropriate emission,products of cigarettes. These limits (currentl~ for tar, nicotine, and carbonn monoxide)should be progressively lowered as rapidly as possible. Every tobacco packet should contain a health warning and inforraticnn on emission levels. ~~

2,. - Recommendations addressed!to developed countries Exports of tobacco containing higher l!evels of toxic substanees, than those marketed under the same brand designat'ion in the country of origin should cease inmediately. All packaged tobacco that is exported should carry the health warnings and emission level's required in the country of'origin printed in such a way as to be intelligible to the recipients. Recommendations addressed to develoain4 countries b . Countries that have a recognisable smcking,problem ehould attempt to control: it by the means elaborated in this report and countries so far without such a problem should!give high priority to policies directed at the prevention of smoking. This implies the development of data collection systems to deTineate the problem, the adoption of the necessary legislaati!on, and the use of educational techniques suitable to the socio-cultural sit•.zat3on„ particularly those where communication is 2. No country should allow a tobacco growing or manufacturing industry to be develol,ed- Where such an indsstry exists, priority should be given to the development of substitute crops,, with international co-operation.. Recommerdations addressed to the United Pfations system 1. The Camml:ttee reco=iends that collaboration in this area be emphasised and s--le:ted as actively as possiblie by WHO. Indications of new responses from FAO,_ILO and IITiCT.3D,, were encouraging. The Conflittee, however,, expressed conee'rn,that the,United Nations system and World Bank have as a v,rhole not yet accepted the inportance of'their involvement ih a world smoking control programe. 2. wL0'has speci'a1! respor,sibility to facilitate the,develiopment of data collectionisys±'ems inistandard form. The Committee recommends that appropriate actionibe taken as soon as possibTe. 4~

8vmma~ry o:f' WHO Expert, Com^ittee 8eport "Controlling the Smoking Epidemic" Chapter 1i, Introduction In the introdizction the 1410 Expert Com.:.ittee on Smoking Control stresses that : ,"There can no longer be any doubt among informed people that in any country where smoking; is...... a common practice, it is a major and certainly removable cause of ill-health and prema-ture death. Moreover the introduction and'extension of' the smoking habit in countries where it is not yet establisned will certainly be folilowed"by similar effects there. The threat to many developing co•unt'ries is immediate and serious.. Governcents of developed'countries have failed to face their responsibilities either to their o:ai people or to those of developing countri'es". "Eirery effort should be made to reduce smoking to the status of a private activity of a minority of adults who are unzble to give up the habit". "Ia the absence of strong and resolute go:rernmer.t action, we face the serious probability that the smoking,epid'emic will have affected the developing world within a decade and' thatt a major avoidablie public health problem will have been inflioted upon countries least able to withstand it far the twin reasons ,.of commercial enterprise and governsent inactivity. ......Smo'king diseases will appear iax, developing countries before corrunicable diseases ar.d malnutrition have been controlled"'. "It-cust be recog,nised that the tobacco industry has presented, and will . continue to pres2nt, a formidable barrier to smo::i:ng control. An example of` this is its studious avoidance of aclmowledgement of the risls of smoking. The common view of' all those seriously concerned to reduce smokL.g is that no worthwhile progress can be achieved unless gov_rnvents are prepareed to put the interests of public health before those of' private tobacco enterprise,,and to secure appropriate action by sta.te-okzted: I-idustry.: 7"heinternationaY tobacco iizdustry's irresponsi3le behaviour, and its mrssive advertising and pro- motional,caapaigns are, in,the opinion of the Coamit:tee„ direct causes of a substantial number of unnecessary d'eaths"'. Chapter 2. The I?armful realth Consequences of Spoking. This chapterr s::m=arises the hars:y°u3 health consequences of s_o:<ina, w'r.ich. have been reported previously, and indicates some of the more recent developments, It,includes evidence on the effect of smoking on the shorteni:.g of life, the increase of il'lness,, the role of smoking in relation,to lung cancer,, coronary heart disease;, chronic bronchitis ar.d emphysemay and its effect on the deveiiopment of the fetus and the outcome of pregnzncy. Of apeciafi interest / ~

interest to women is the evidence that the risk of a heart attack under the age of 50 is greatlyy increased by scoking, and even more if oral contraceptives are taken in addition. Also women who smoke are likely to experience an earlier menopause. There is discussion of the risk to young children if the parents smoke and the harmful effects on the respiratory system which, deveiiop very soon after children or yo:ng people begin to smoke. The combined'effeets of smoking and other environmental hazards such. ,, as might occur in certain occup..:tions are outlinedi. These could leadito cancer and chronic lung disease. It is suggested that this interaction should be taken into account when occupational safety and health regulations "'are set up. The report oonsiders certain other occupational hazards of smoking such, as the risk to passengers if an--air line pilot is a smoker and thereby atl greater risk of a heart attacic. -The risk of accidents as a result of aa high level of carbon monoxide in the blood of smokers may be a factor of considerable importance. - Involuntary smoking (exposure to smoking by other people) may resit in distressing symptoms and impaired efficiency at work. In addition involur.tary smoidng maq be directly haraful to those suffering from cardiac, respiratory or allergic illness and to young c'r-ildren., Chanter, 3. Soci'o-ecanoni'c Z~pl'icatior.s of Tobacco This ehapter considers losses caused by smoking, the role of'taxation,, the_ role of the tobacco industry,, ,:.-,d problems in tobacco produc tior.,. "The smoker- induces costs that affect his family, other taxpayers, a.ndl socie tj at Zarg--"'. Smoking leads to loss of Gross National Product beeaus2 of:eariy deaths, disability, and absenteeism from work: increased'tob_.eo taxes canr-ot compensate for such liosses, while income from toba«co production goes largely to transnationsL companies,, often at the expense of reduced Sbod'production. The Report sets out procedures for..calculating costs (lost productivitf~ t lth i t ) d serv ces, e ea o csuse by smoking, and the likeli t ..-y economic ganso be derived from a reduction in smoking. s;a.,;~ In the chapter it is noted that: - economic losses because of smoking are huge and constitute a siseable burden toinational eeonomiesr, - while saokin,r, control measures should primarily be undertaken because of'the deleterious health consequences of'smoking„ the economic losses also lend support to the,desirabili!ty of smoking controL; - - collection,of tobacco revenue offers noijustificztion for ~ delaying implementation of measures to reduce smokir•g;, - taxation can be used as a tool for curtailing or modifyir.g, tobacco consumption; - tobacco production is seldam genuinely profitable for the countries concerned and can lead to economically important negative consequences for food production and environmental protection;, - and substitution of other crops for tobacco is a vital factor in implementing smoking control in tobacco-growing countries. A

3. Chavter 4. The D.s a..^aics of the Smo.ding Lpidemie. 'Phis chapter describes how the smoking habit has spread from one country to;another and between different popu,l'ation groups and has been followed by an increase inismoking-related disease. This phenomenon or in the lower socio-eeonemic groups. It appears that a siyilar pattern is emerging,ia c"anyy developing couatri_~s. ku&ner soeic-econqmse groups.. Littye decrease has yet been seen in women where consumption is declining this~also occurs first in men and' i^n the Smoking-related disease hcd followed a similar pattern. In those eountries "2`g- groups and been follawed'by women andthe lower socio-econom'ic groups. Smoking has typically begun~ i;n men~ a.nd in the higher socio-ecor.omic ; consumpti'on".1 they have not yet experienced the "grim increase in smoking-related . 'mortality"' they "must expect itunless they halt and then reverse their cigarettes per head are now'smoked as ir.i:orway 30 years ago, and'taoughd similar to that which occurred in the U.K. 30 years esrlier., The l'ung cancer death rate in Norway is now approximately that which occurred 30'years ago in the U.K. In a number of developing countries asimany is illustrated by a"comparison of't'he United Iiingdomiand Norway which, shows that the cons,uiption of cigarettes in Norway followed a gradient This chapter sets out general objectives, presents the case for international co-opera+w.fon, and considers strategy at the national level, economic pla^ri^g,, the use of key groups,, and the role of Goverr.ment. The following poiicy objectives are,recam.**.ended (they have aYsa been accepted by the other,main internatienal health agencies active in the Chapter 5. Strategies for SmokinR Control' field): "11. `dchieve^ent of lower smoking rates in all age groups of the pablicity, and education programnes, smoker,, as i,rel.7l as neasures such is are involved in, poiiitical,, on smoking opportunites, encoura'gement of the rights of the non- health warnings on packets,, t<.:xation'manipulation, restrictions pressures onismoking rates are practicable. These might ir.clh.de population. This implies the application of whatever downward 2. The e,~ncouragement of non-smokers to remain non-smokers. The WHO/ mental factors which contribute to smoking-associated diseases. The extra hazards of smoking in certainlindust'rial situation3 are now known to be such that alcombinati'on of'restriqtions and'anti-smoking educationiprogpaLes should be developed." empnasis of tn=s programme is oniyouth. . at high risk, should be'encouraged to reduce, as far as possible,, their exposure to harc:ful compor.er.ts of tobacco smoke. To mai'ntairn liaison with other health organisatior.s and authorities to ensure:c.axim:m effectiveness and avoid conflict of activitles. The cessation of alI forms of to5acco protaotion. Those who have not yet stopped smoking, and therefore renain '' 6. To achieve public health control of relevant industrial and environ-

« WHO should promote iaternational'smoking control by strengthening collaboration within the UN system, and mobilising non-government'al agencies„ colIecting and distributing international smoking control information, supporting and co-ordinati'.ng,basic applied epidemiological research, eapeciaTly in developing countries, supporting suitable pilot' projects, assembling expert groups as appropi.late„ running regional serainars for key person.nel, and providing assistance wherevrer, possibie, particularly to dpveloping countries. At the national level suitable ir_formation should be gathered, before the design of'a comprehensive and balanced snoleing eontroi programme comprising legislative controls, educational activities, and therapeutic facilities. Action in, deveiopea,countrYesd nas, so.Iar aeen snaaequate:,, ana resuitis~ correspondingly modest. In developing countries different approaches may be appropri:ate: the concernihere should be "tIo1PREYn;T the social plague of' smoking from spreading, rather than trying to eradicate the habit when it has become deeply ingrained4inithe society and has begun to produce disease."' Tobacco producing countries should consider seeking substitute crops, and export of surpluss tobacco should be discouraged. There must be better collaboration betwecn health and economic planners, so that tobar;co production is not =cstered, for short'-term gain,, and plans for progressive reduction in tobacco commerce should safeguard all whose live- lihoods are involved', Support of key groups (opinion lt:ad'ers, doctors, health professionals,, et..,)', should be mobilized, and major education programmes directed at exemplar groups. "7n view of'the importance of the exemplar role of health, proftssior.alG and!health bodies,, it is desirable that smoking, shou2d'not be permitted in WHO, in government heal'th-oriented buildings, in hospitals, or in re:1 th centres except in specially desigrtazed smoiQSig, areas." Goverr-e.n.ts should play a leading role in, recognition of: needs, policy directiony and provision of funds, ?;ationa2 activities should be the responsibility o£'a specific central smoking and health agency. Chanter 6. the ?;ational SnoKing Problem ar.r? Evaluating Control nctivitie:s. " This chapt'er: points out that beforz deciding on an, overalli prog+a.:r.e of smoking control and the specific measures to be used, it is importa.^.t to analyse the extent of the problem and ta monitor it regularly. This wil!I,enabl2 the effectiveness of the pro g--a..e to be assessed, Measurements should focus on changes in the level of',public informatibn,, of:public attitudes and~of saoking behaviour. Information and',attit'udes can be measured by survey techniques.: Per eapita consnmpticn can measure long-term treno.a of snoking behaviour, but it is more valua'ule to obtain information on the prevalence of smoking and daily consumption in varilc;:s demographic clti,3soups. This agai'n.requizes survey techniques and exp;ert advice can be cotained through WFD'. In addition it is important t'o mcnitor the types of cigarettes sa.okPd and the way they are smoked. Mortality statistics for lung cancer and coronary heart disease can indicate the consequencesiof changing sroking behaviour.

5. Qhapter 7 Pubii'c Information and Educatior.,Pro3s+armes Despite some overlap, "Experience has shown thati public information and public education programmes are two separate and essential component's of smoking control that are mutually complementary and re-inforeing:" 4 public information progr?`r:e generalTy uses the mass-cozc.vr.ications approach, creating,an atmosphere in which ed'ucation programmes eaniflouri'sh,, while a public education programme is conc--rned ti:ith reaching specific targmet groups', The chapter, o•utl'::es the need for analysis, design, and implementation of public information and education programnes, which are considered in terms of Objectives, Targets, Design (using the traditional modeli of ,i"senders, messages!, media, receiver")„ and'evaluation. Chanter 8. Legislation of Res'~rictive Measures to Control SmokinQ, This chapter sets out the case for legislation and restrictive in general,, and discusses specific measures in the areas of : - control of' sales promotion - health warnings on cigarette pac!'sets and'alvertisements - product description - imposition of upper limits of harmful substances - taxation. - sales.restrictions - restrictions on saoking,in public places - restrictions on.saoking-in places of work "Restrictive aation_is a part of prevention at all stages - before exposure,,aftler exposure, and to limilt hzrm, to those already affected." Such actinn is considered in,terms,of need, purpose of legislation, evidence,of effectiveness, protection of'the young and non-smokers, the economy, freedom of the individual, legislation as one part of an ovsralli' smoking control strategy,,cost-benefit, different phases of effectiveness,,' the in_ade(ruacy of voluntary control.s,, ensuring compliance, international , . aspects,,_ ar_ evaluation. Ztt is fu12y accepted.that "total prohibition,of'tobaceo sales is impracticable in a free scciety...." Smoking control legislation has the following s.a.jar, purpases : •1) To help reduce smoking, or ensure that it does not iz:crease. 2) To complement educational activities 3) To demonstrate Governmental concern 4)I To influence:public attitudes to smoking, 5) To help, reduce the hazards to health for those who continue 6) To limit the exposure of'non-smekers to cigarette scoke , . The Report strFsses tnat : "Fllowir_;_r t;;bacco promotion to_ continue is permitt9:ng, an experime _-. Waich,, irn the view of t'lis Co¢!.,^.ittak:,, has already had the serious health consequences, and will maintain i'f' not incre:*:M those ill, effects„ The experiment of banni_~ng such promoti*.i cannot be tia_-afui' to health. The only serious objections arise from the vested interests of manufe.cturers and advertisers."

6, Specific measures are recorv=nded (bannfng tobacco promotion,, enforcing effective health wesnings,; etc.), but it' is emphasised that : "No single measure can be expected of, itselif'to soLvve the smoking. .problen. The measures reco:ended must always be seen as part of a.n overall strategy, of' which, legislation forms only a singl'ee though an essential component". Chanter,9. flelving the Individual to Stop Sooking This section points out that in a number cf countries there is evidence that people are being increasingly successful in g_ving,up smoking ar.d are doing this-without professional help. R7iis,; along with the,decreasing social acceptibility of smoking and the incr~asing restrictions on smoking,ir, public plaees may make it easier for otiiers to make the attempt and to succeed.. Smoking cessationiclLnics use a varietyy of techniques including group therapy end counselling, and specific treatments such as drugs, hyFnosis,, nicotine substitutes, aversion~therapy, etc. Motivation, co:,mitment, effort and continuing support appear to be more important than the specific ;F; technique selected., Whatever technique is used the result's indicate that about 15-25i,: of those attending are abstinent one year Tater., This nay appear to be a low success rate until it is reoembered that clinics attract many who are higL:ly depend'ent, on smoking,, Owing, to their high cost the report suggests that clinics might be reserved for high-risk groups and for .opir.ion 1oa:ers. It,poir:ts oat also that the existence of a clinic in a conn=ity focuses attention on the seriousness of the problem and n;:y have a"spin-off"' t'ending to increase the "spontasieous` cessation, rate. other less expensive methods which canireach large numbers of people r:ig}:t, even_with a lower success rate, result in a much greater number of, ex-s=olsars. These methods may involve the use of radio, television, news- papers, magazinesy direct mail and the telephone.. All methods require the individual to understand his or her own sWo'k3r3"', and to participate in devising a pla^i that is suitable for his or her owz ~ needs. A system of continuing support is recomnen-led to avoid relapse, ana! Wlierevver,possible a system which,wilil enable the factors leading to relapse to be identified. This is an area where further researeh is required'. •,t,; Straight forward personalised advice from, a doctor to his patient has been shown to be a cheap and highly effective technique. Volunteers in organisations and individually can make a valuable contribution to smoking cessation. Keai'th Authorities are advised to encourage and support this activity. Standards for evaluating cessation progr:cses have been developed ar.d are,available through WHO. Their use wiTli prevent exaggerated cl3i:.s being made. L' , Chapter 10. F•ecoamen~_Tatio^s. See separate sheets. The Report also incTudec as!annexes recommendations of the 1974 k^0 Sxpert Committee on Smoking and its Effects on Health, and!statements by the representatives of FAO and ILO. -r no