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r educed3'arand lea~ine C1ga~~es: Smoking Behavior and Health

Redaaced 7arand Nicatine Cigarettes: Smoking Behavior and Health Dean R. Gerstein and Peter K. Levison, Editors Committee on Substance Abuse and Habitual Behavior Corrmmission on Behavioral and Social Sciences and Education National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1982

C NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The National Research Council was established by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and of _ advising the federal government. The Council operates* in accordance with general policies determined by the Academy under the authority of its congressional charter of 1863, which establishes the Academy as a private, nonprofit, self-governing membership corporation. The Council has become the principal operating agency of both the National Academy of . Sciences and the National Academy of Engineering in the conduct of their services to the government, the public, and the scientific and engineering communities. It is administered jointly by both Academies and the Institute of Medicine. The National Academy of Engineering and the Institute of Medicine were established in 1964 and 1970, respectively, under the charter of the National Academy of Sciences. Library of Congress Catalog Card Number 82-81147 International Standard Book Number 0-309-03246-0 Available from NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Printed in the United States of America

c . COMMITTEE ON SUBSTANCE ABUSE AND HABITUAL BEHAVIOR LOUIS C. LASAGNA (Chair), Department of Pharmacology and Toxicology, University of Rochester HOWARD S. BECKER, Department of Sociology, Northwestern University PETER DEWS, Department of Psychiatry and Laboratory of Psychobiology, Harvard Medical School JOHN L. FALK, Department of Psychology, Rutgers University DANIEL X. FREEDMAN, Department of Psychiatry,.. University of Chicago JEROME H. JAFFE, University of Connecticut School of Medicine and Veterans Administration Hospital, Newington, Connecticut DENISE B. KANDEL, Department of Psychiatry,- Columbia University, and New York State Psychiatric Institute, New York JOHN KAPLAN, School of Law, Stanford University GARDNER LIND2EY, Center for Advanced Study in the Behavioral Sciences, Stanford, California GERALD McCLEARN, College of Human Development, Pennsylvania State.University CHARLES P. 0'BRIEN, Drug Dependence Treatment Service, Veterans Administration Hospital, Philadelphia, Pennsylvania JUDITH RODIN, Department of Psychology, Yale University STANLEY SCHACHTER, Department of Psychology, Columbia University THOMAS C. SCHELLING, John F. Kennedy School of Government, Harvard University RICHARD L. SOLOMON, Department of Psychology, University of Pennsylvania FRANK STANTON, New York, New York ALBERT M. STUNKARD, Department of Psychiatry, University of Pennsylvania Hospital RICHARD F. THOMPSON, Department of Psychology, Stanford University PETER K. LEVISON, Study Director DEAN R. GERSTEIN, Senior Research Associate DEBORAH R. MALOFF, Research Associate MARIE A. CLARK, Administrative Secretary iii

c CONTENTS PREFACE INTRODUCTION AND CONCLUSIONS V 1 THE HEALTH EFFECTS OF CIGARETTE SMOKING 7 Earlier Studies, 7 Changes in Death Rates from Respiratory System Cancer in the United States Since 1940, 10 Summary, 16 SMOKING BEHAVIOR The Nicotine Compensation Hypothesis, 21 A Note on Cutting Down and New Smokers, 26 18 TOWARD A RESEARCH PROGRAM ON ALTERNATIVES- 28 Introduction, 28 Cigarette Research and Development, 29 Delivery and Absorption of Tobacco Products, 30 Standardized Measures of Smoking Behavior, 31 Studies of Alternatives, 33 Smokers' Responses to Existing Alternatives, 34 Health Effects, 36 - SPECIFIC RESEARCH RECOMMENDATIONS 38 Cigarette Research and Development, 38 Delivery and Absorption of Tobacco Products, 38 Standardized Measures of Smoking Behavior, 39 Testing the Addiction Model, 39 Smokers' Responses to Existing Alternatives, 40 Health Effects, 41 APPENDIX 42 REFERENCES 45 iv

I PREFACE Since the early 1900s, cigarette smoking has increased in popularity with relatively muted concern over its health effects or-habituating properties. Reports of cancer risk based on hospital studies in the early 1950s and the landmark Surgeon General's report in 1964 induced many cigarette smokers to quit smoking entirely-but many others who tried to stop discovered the habit to be one not so easily broken. The persistence of smoking habits in those who wanted to quit and the great difficulties experienced by many others who finally stopped smoking only after repeato~d cycles, bf withdrawal, abstinence, and relapse led to the recognition of cigarette smoking as an addiction, at least for a substantial proportion of smokers. The Committee on Substance Abuse and Habitual Behavior was formed within the National Research Council to examine similarities and differences among many kinds of firmly established habitual behavior patterns, princi- pally but not exclusively involving~chemical substances, and to see what common processes might be found to underlie compulsive, resistant habits that can endanger health and well-being. The committee's work has been sponsored by the National Institute on Drug Abuse (NIDA), which, in conjunction with its charter mission of research on and treatment and prevention of problems associated with narcotic drugs, was persuaded by the commonalities between habitual cigarette smoking and classical drug addictions to propose this major public health concern as an addictive process. In 1978, the committee and NIDA cosponsored a symposium entitled Cigarette Smoking as a Dependence Process, the V

P C proceedings of which were published in 1979 as NIDA Research Monograph No. 23. The committee members who participated in the symposium were especially interested in the hypothesis that habitual smoking reflects an addictive process involving the bio- logical and behavioral effects of nicotine. Experimental studies of the quantity of smoking in relation to the nicotine content of cigarettes form a growing body of evidence suggesting that smokers who are given cigarettes yielding less nicotine (in standard mechanized assays that simulate smoking) than their usual ones smoke more of them. Such experimental findings might be especially important for persistent smokers in light of some major changes in the cigarette marketplace. First, measures of the average tar and nicotine yields of commercial cigar- ettes have declined dramatically since 1955. Second, some investigators have argued, with considerable support in public health circles and attendant publicity, that these lower yields represent a lessening of the health hazards of cigarette smoking (in short, that they amount to "less hazardous cigarettes"). Third, 'light' and 'low"-yield brands have been heavily promoted by cigarette manufacturers. This confluence of factors led the committee to form a subgroup to study the question of how tobacco products with reduced yields of nicotine, tar, or other components affect the health of those smokers who continue to use tobacco products. The first draft of this study was discussed by the full committee and a number of consultants in a small conference in 1979. Initially the study sought to place equal emphasis on a range of alternatives to cessation of cigarette smoking, including pipes, cigars, "smokeless" tobacco for chewing or snuffing, and nicotine-bearing gum. However, the scarcity of useful epidemiological data on these alternatives to cigarettes and the com- mercial growth in demand for decreased-yield cigarettes, persuaded us to place the major emphasis of the study on cigarette smoking. The committee ended up synthesizing and drawing inferences from evidence on nicotine as the key addictive component of cigarette smoke, on the behavioral and health effects of reducing the standard yields of tar and nicotine in cigarettes, and on the consequences likely to result from the interaction between these two factors (addiction and yield reduction). In its survey of epidemiological studies, the committee was struck by the growth in death rates vi

P C from respiratory system cancer in the same period when tar and nicotine yields were falling, leading us to undertake a new analysis of these data. The committee is grateful to a number of individuals and institutions for help given during the preparation of this report. The comments of our consultants Lynn Kozlowski, Lee Fredericksen, and Dan Beauchamp on an early draft were very helpful in setting its final direction. Unpublished and prepublication materials supplied to us by Lawrence Garfinkel, Frank Godley, G. H. Miller, Carl Pieper, and Eugene Rogot were most useful. The biblio- graphic services of the library of the National Academy of Sciences and the Technical Information Service of the Office on Smoking and Health, U.S. Department of Health and Human Services, were very valuable. I would also like to acknowledge the advice of John Bailar, Robert Enstrom, E. Cuyler Hammond, Daniel Horn, Zdenek Hrubec, Morton Levin, Abraham Lilienfeld, and Marvin Schneiderman. The committee subgroup, comprised of Louis Lasagna (chairman), Jerome Jaffe, Stanley Schachter, Thomas Schelling, and Albert Stunkard, was responsible for overseeing this report through many rounds of criticism and redrafting; they deserve a large share of the credit for its completion. This report was also the beneficiary of constructive criticism by individual reviewers of the Assembly of Behavioral and Social Sciences and the Report Review Committee of the National Academy of Sciences. Gardner Lindzey chaired the Committee on Substance Abuse and Habitual Behavior during the larger part of the study. I would also like to acknowledge the role of Christine L. McShane, editor of the Commission on Behavioral and Social Sciences and Education, who polished the report and prepared it for publication, and of Deborah Maloff, research associate for the committee, who tracked down and organized much of the data used in the epidemio- logical analysis. Finally, the committee has relied on Dean Gerstein and Peter Levison, the committee's senior research associate and study director, respectively, who designed and executed the analysis of respiratory system cancer data, organized the research recommendations, and in general shared primary staff responsibility for the report. Louis Lasagna, Chair Committee on Substance Abuse and Habitual Behavior vii

c INTRODUCTION AND CONCLUSIONS Habitual cigarette smoking is hazardous to health. This is not only a scientific finding widely accepted by the biomedical research community; it has also become accepted as fact by a large majority of cigarette smokers. Mainly for this reason, more than 30 million of the 60 million habitual smokers in this country report having made serious but unsuccessful attempts to quit smoking. And more than 30 million others have in f act quit smoking since 1964 (U.S. Department of Health, Education, and Welfare, 1980; U.S. Department of Health and Human Services, 1981). Nonsmokers, especially young ones, are also aware of the hazards of cigarettes, and since 1975 fewer young people have started smoking them (U.S. Department of Health, Education,- and Welfare, 1980). Nevertheless, many people do not want to give up smoking cigarettes, and many people who want,to quit still do not. Further complicating matters, tobacco has been an economic staple of a large region of the country for more than 250 years. Finally, cigarettes have acquired -firm cultural associations, at times with social sophistication, individuality, or maturity, and such associations remain attractive to many people. From this mixture of motives has come a movement for "reducing the risk" for those who continue to use ~ tobacco. People can attempt such reductions in three principal ways. The first is by reducing the number of cigarettes smoked. The second is by taking tobacco in a different way than cigarettes--such as pipes, cigars, chewing tobacco, or snuff. The third is by smoking 'less hazardous cigarettes." Although we comment on the first two methods, the focus of this report is on the third: first, because there are adequate scientific 1

2 reports to evaluate this method as a health strategy for smokers; second, because it has unquestionably been the major direction of consumer interest, commercial development, and governmental activity in this country in the past 25 years; and finally, because experiments with different types of cigarettes have provided the opportunity to assess the role of nicotine in the motivation to continue smoking. The assumptions that have guided development of the less hazardous cigarette were outlined by Hammond et al. (1977:105) : (1) Death rates from lung cancer, cancer of several other sites, coronary heart disease, and several other diseases increase with degree of exposure to cigarette smoke. (2) Many experi- mental studies have shown that material condensed from cigarette smoke (usually called "tar") is carcinogenic when applied to animals. (3) The known acute effects of nicotine upon the heart and circulatory system suggest that the nicotine content of cigarette smoke is partly, if not entirely, responsible for the fact that age- specific death rates are higher among cigarette smokers than among nonsmokers. (4) Therefore, it seems reasonable to suppose that if the tar and nicotine content of cigarette smoke were reduced, then the harm done per cigarette smoked would be correspondingly reduced. Due in part to this kind of reasoning, the tar and nicotine (T/N) yields of commercially available cigar- ettes in the United States have declined markedly over the past 25 years. In 1955 the average cigarette sold in the United States yielded 43 mg. of tar and 2.8 mg. of nicotine (43/2.8) in standard tests. Almost no cigarettes yielded less than 30/2.0; the highest-yield brands were considerably higher; and virtually all cigarettes were unfiltered. In 1979 the average cigarette yielded about 15 mg. of tar and 1.0 mg. of nicotine; almost no cigarette yielded more than 30/1.8; and the tar and nicotine yields of readily available cigarettes ranged down to 0.5/0.01. The overall reduction has been achieved both by smokers' choosing the new; lower T/N brands and the steady reduction by cigarette companies of the T/N ratings of already