Tobacco Documents Online

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T_ABLE_OF CONTENTS Members of Task Force on Tobacco and Cancer Charge to the Task Force The Problem Recpmmendations for Five-Year Smoking Control Program - Professional Education - Public Education - Public Information - Legislative and Governmental Affairs Appendix Summary of Findings: Study on Smoking Among Teen-Age Girls and Young Women 3O A Supplemental-Study - Smoking Among Teen-Age Boys "Adult tlse Of Tobacco - 1975" Study Report of Anti-Smoking Activities in ACS Divisions and Units Federal Laws and Regulations Relative to Cigarettes 38 43 68 77 -!-107581575

',MEMBERSO~;,TASK IFORCE • , ;: ." . : ~ .' .;~. TI07581576

-1- N~TIONAL TASK FORCE ON TOBACCO AND CANCER Chairman: ~llan K. Jonas, Los Angeles, California Robert L. Brown~ M.Dr~ Clinical Programs Coordinator, Georgia Cancer Management Network, Inc., Atlanta, Georgia ~muel ~..,..Fisher, Managing Partner, S.M. Fisher Company, Philadelphia, Pennsylvania Donald T. Fredrickson: M.~b~, Director, Inter-Society Con~ission for FF~art-D~seas~ Resources, New York, New York Gio Gori, Ph.D., Deputy Director, Division of Cancer Cause and Preve6-tion, National Cancer Institute, Bethesda, Maryland .. Paula Green, President, Green bolmatch, Inc., New York, New York Will~am GTiffiths. Ph.D., Professor, School of Public Health, Cal~fornla, Berkeley, California University of ' ~ -~ Jerome H. Jaf~e~ M.D., Chief of Department of Biological Psychiatry, New York State Psychiatric Institute, New York, New York Murray E. Jarvik~ M~D., Professor of Psychiatry and Pharmacology, University of California, Los Angeles, California Edw#~d J. Kletter, Chairman of the Board of Directors, Parkson Advertising Agency, New York, New York Jes~ Steinfeld~ M.D., Dean, Medical College of Virginia, Richmond, Virginia ...... Philip Terman, D.D.S., New York, New York E~n~ Wvnder~ M.D., President, American Health Foundation, Inc., New York, New York T1075815-77

TI07581578

CHARGE TQTHE TASK FORCE In June of 1975, the Bo~d of Direeto~ of the American Cancer So~Lety appointed a N~Lional T~k Force on Tobacco and Cancer. St~sing the importa~ ga~ ~h~ch have been made to date by the A~ and ~ aLU~ in comb~g smo~ng, ~e Bo~d of D~e~o~ noted, nev~- ~e of smo~ng ~ begin~g to ~e ag~, ~ ~ ~e of smo~ng ~ong wom~ and ~ong te~-ag~ w~ ~ing ~ an ~g degree, and ~, in g~, ~ny of ~ advan~ of ~ p~t 20 y~ w~e in ~n9~ of b~ng ~ped o~. The T~k Force w~s th~efore given th~ ehaxge: [a) r~aken ~e ~on to ~e ~g~ of s~o~g: (b) s~~ gov~ (~ ~ lev~) to d~ ~ ~ probl~; (e) ~s~de many more p~ople, ~pe~ yo~k, from smo~ng; (d) p~d~ ~ny more smok~ to stop and provide ~ ~k ~s~t- ~ee to do so; [~) ~volue in ~ ~ffo~, mu~ mor~ ~ b~fore, ~e ~d ~ed ~of~sio~, ~bor and ma~e~, ~e i~~o~ of edue~on, a~ ~e ~s The T~k Force wa~ aZso .~ged to e~u~ne e~Lti~y all of the work of the Am~ean Cancer So~y, du~ing ~he ~t several de~ad~ in the figk~ a~ain~t ~moking, to ~ropose the ~imina~i~n of a~Liv~ti~ that ~ere not adequately productive and to recommend more effective program~ in th~Lr place. Th~ appointm~n~ and eha~ge wa~ accepted, and ~c T~k Force h~d f~t toeing on O~ob~ I, 1975. S~seque~, subcom~e~ w~ appoi~ed to d~ ~ dep~ ~ sev~ sep~e ~: Pu~c E~c~on, C~s~on Prog~, Prof~sio~ ~on, Pubic Info~on, L~g~v~ and Gov~n- m~ AfrO. Me~ng and wo~n9 ~dep~de~y, ~e s~eo~e~ broug~ in i~ repo~, ~ seu~ s~g~, for reui~ of ~e T~k Force ~ a whole. Th~ ~t me~ of ~e T~k Farce w~ h~d on Sept~b~ 7, 1976 ~d adopt a fi~ s~ of ~eeommen~o~. Thee ~ s~ fo~ in t~ docu- In the course of i~ work, the T~k Force had avallabl~ ~ number of studies and special repo~ w~ch proved to be of in~timable value for ~se~Aa£ info~on and exp~rt g~idance. Thee included the fol~wing: I. eon~lu~£ons of 3rd World Confero~ce on Smoking and H ~z~th. ~. ReporL of WHO Exp~r~ Committee. TI07581579

-3- Findings of Study - "Adult U~e of Tobacco - 1975"- done b~ Na~onal Clea~inghou$e on Smoking and Health. ~. ACS studi~ of Cigarette Smoking A~on~ Teen-Ag~ and You.~3 Women. 5. A Revi~ of the Li~are on Educational Prog~z~ to Change Smo~ng Behavior (ACS) : I%0-1976. 6. SITUATION ANALVSIS of A~L-Smoking Activiti~ in ACS Div~Zz~ and U~b~.. Thro~hou~ a£Z of it~ work, the T~k Force on Tobacco and Cancer has be~n ~ndf~ of ~e g~v~ of ~ ~d~ng. We ~ sp~ng, aft~ ~, not ~o~ so~ a~c m~, b~ abo~ ~e n~e~s ~ss of te~ of ~o~an~ of ~v~ ~ y~, and ~ ~~g~ of dlv~ing a ~og~ to prew~ ~ t~bl~ loss.. Y~, ~ b~nc~ ~ cancan, w~ ~v~ be~ ~f~ ~o of ~ co~ ~ s~g~ of ~ ~~n Canc~ So~y, ~e de~on of ~ ~d in r~, ~ give l~d~p and ~e~on ~ the ~g~ ag~2 smo~ng. We a~e confiden~ th~ when thee recommendations have b~er~ reviewed and adopted, they ~ be put into effect ~ith the c~tomary vigor and dispatch w~ah the public has co~e to ~xpeat from the American Cancer Society. And, that ~ a r~Lt, ~o~ of Am~Lca~ mill be saved f~om d~ase and de~h due to smo~ng. A~n K. Jo~ Chairman Natio~ Task Force on Tobacco and Cance]~ T107581580

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THE P~OBLEM_. Cigarette smoke is responsible for more deaths from cancer than any other single agent. This year, 85,000 Americans will die of lung cancer; 80 percent of these deaths will be due to smoking. Cigarette smoke is implicated not only in cancer of the lung, but in other types of cancer as well. This one agent is responsible for nearly 70,000 cancer deaths a year, practically one in every five deaths from this disease. Cigarette smoke is a causal agent also in diseases of the lung other than cancer, and diseases of the circulatory system, including heart disease and high blood pressure. In all, smoking is responsible for more than 250,000 premature deaths each year. In addition, we must note that heavy cigarette smoking is costing this nation some $17 billion a year in unnecessary expenditures -- $4 billion for medical care to treat the illnesses it causes, and a loss of $13 billion sus- tained as a result of accidents, absenteeism, lost output, etc. If smoking were eliminated completely, all these lives and all o7 this money would be saved. Yet, we know that smoking has.not stopped, that. more than 50 million Americans are still smoking cigarettes, even though the tragic con- sequences of smoking have been known for many years; even though the American Cancer Society and its allies, including the American Heart Association and the American Lung Association, have been carrying on energetic campaigns against smoking during the past two decades. Yet, to think that there has been no progress in this effort would grossly misrepresent the truth. The progress has, in fact, been remarkable considering that the nationwide fight against smoking has been going on for only two decades; and considering that the anti-smoking forces have had aligned against them a multi-billion dollar cigarette industry spending more than $300 million a year on advertising; and considering also that they have been able to count on only lukewarm support from the executive and legislative branches of government.. Even though 50 million Americans are still smoking, 30 million have stop- ped since the anti-smoking campaigns began. In 1964, 42 percent of the adult population in the United States was smoki6g. Today, that figure is between 33 and 34 percent. The average cigarette today has 60 percent less tar and nicotine than it had 20 years ago, and levels are continuing to drop.* But, more importantly, there is a definite sign that public attitudes toward smoking and the public image of smoking are significantly changing from positive to negative. Twenty years ago the popular question was: "Aren't you smoking?" Today, it is: "Are you still smoking?" *To date, the toxic agents in cigarette smoke identified as the causal factors responsible for cancer, cardiovascular and pulmonary illness are tar, nicotine and carbon monoxide. Knowledge in this area is still incom- plete and several other factors are under suspicion. As these are made known and their culpability confirmed, measures must be taken to safeguard the smoker. With at least several hundred components under consideration, this is an extremely complex task. T107581582

This Task Force believes, in other words, that the decisive breakthrough has been made; that the challenge now is to exploit it to the fullest. Hence, the problem is today, as this Task Force sees it: How can we expand the gains we have made? How can we improve our methodology? Where should we be putting our greatest focus for future advances? Which audiences require special concentration? The answers of this Task Force to these questions are contained in the recommendations set forth later in this report. To arrive at these proposals, the Task Force reviewed the campaign against smoking from its inception, noti the successes and the failures, and taking account of the factors responsible for both. T.h.e Scientific .Evide.~ce Is Amassed The first warning note of any significance regarding the hazards of smoking was sounded in 1939 by Dr. Alton Ochsner, a surgeon (later to become President of the American Cancer Society), at the Internatibnal Congress Against Cancer. Noting a sharp rise in the incidence of lung cancer, Dr. Ochs found that the curve ran parallel, to a remarkable degree, to a curve showing the year-by-year increase in cigarette smoking. He concluded that cigarette smoking was causally related to lung cancer. These startling findings created hardly a ripple in medical circles and even less in public circles. The voluntary health organizations recognized the significance of the disclosure, but were not yet fully cdnvinced. Subse- quently, several other pieces of vital research confirmed Dr. Ochsner's conclusions. In the late 1940's, Dr. Ernst Wynder, in research supported by t! American Cancer Society, found among a large group of men who had died from lung cancer a very great majority were heavy smokers. Then, in the middle 195. Dr. Cuyler Hammond and Dr. Dan Horn of the ACS reported from a very large epi, emiological study that the.lung cancer death rate for cigarette smokers was ten times as great as for non-smokers; also that the death rate among cigaret' smokers from all causes was much higher than among non-smokers. In England, Dr. Richard Doll and Dr. A. B. Hill followed 40,000 physicia~ starting in 1951 and found that death from lung cancer among these individual: was definitely and directly related to the number of cigarettes smoked, a fin, ing confirmed later in the massive Cancer Prevention Study conducted by the American Cancer Society. This study also disclosed a much higher death .rate from heart disease for smokers as compared with non-smokers, and implicated smoking in emphysema, cancer of the mouth, pharynx, larynx, esophagus and pancreas. T107"581583

-6- hrough i ences the :.sals, .. noting " sible The Health Organizations Act. As this alarming data began to accumulate, it became clear to the American Cancer Society and to other national organizations that the time had passed for accumulating evidence -- now was the time for action. On June I, 1961, a joint letter was dispatched to President John F. Kennedy over the signatures of the Presidents of the American Cancer Society, American Heart Association, National Tuberculosis Association (now the American Lung Association), and the American Public Health Association, asking that appropriate action be taken. The voluntary agenci~e, the letter pointed out, had used £heir resources to uncover the health risks of smoking. Now, it was up to the government to take a stand and to respond accordingly. icome Ochsner wing ~e and :bse- I .~y the ~ 1950's, ~ epid- ~ S ]~rette >icians iduals a find- the ate ted The Sur~eo~ General's Report On June 7, 1961, Dr. Luther L. Terry, Surgeon General of the ~nited States Public Health Service, announced that by direction of the President, he was establishing an expert Advisory Committee to undertake a comprehensive review of all data on smoking and health. On January II, 1964, the Committee made its report titled "Smoking and Health", the famed document which became known throughout the world by the title "The Surgeon General's Report". The two most significant conclusions were: "Cigarette smoking is a health hazard Of sufficient importance in the United States to warrant remedial action. Cigarette smoking is causally related to lung cancer in men; the magnitude of the effect of cigarette smoking far outweighs other factors. The data for women, although less extensive, point in the same direction". The report produced shock waves. There was an immediate public reaction, and a sharp, albeit short-lived, drop in cigarette sales. But there were other more long-lasting results. With this ammunition in hand, the American Cancer Society and its allies launched intensive programs of Public Education, through the schools and community groups of all types. For the Society, this constituted an expansion and intensification of a program which had been going on for at least ten years, and which had already reached most high schools throughout the country. The Surgeon General's Report provided incentive and ammunition also for a nationwide campaign by the American Cancer Scciety and its allies via the press, radio and television. T107581584,

-7- Conqressional Action Congress reacted to the Surgeon General's Report by enacting the first national law regulating the labeling of cigarettes and requiring specificall. that all cigarette packages carry the warning label: "Caution - Cigarette Smoking May Be Hazardous To Your Health". Simultaneously, the Government established, under the Public Health Service, the National Clearinghouse on Smoking and Health to conduct research, provide scientific reports, and give education and information to the public on trends in smoking and on the health hazards involved. The voluntary agencies were mightily disappointed with the outcome. No restrictions had been placed on promotion and advertising of cigarettes. Instead of undertaking a massive government program of public education to warn the American people about smoking, Congress had sidestepped the issue by appointing a Clearinghouse on Smoking and Health; instead of a strong, effective warning of the kind that is placed on bottles o~ poison, Congress had required only a very weak, innocuous warning. Nevertheless, a vital breakthrough had been made. Th~ government had finally committed itself to an official position declaring smoking to be harmful to health, and had at least undertaken some measures, however limite consistent with this position. However, the task of carrying on the battle through Public Education and the mass media was left to the voluntary health organizations, a respon- sibility they discharged with great faithfulness and vigor. pe~capita consumption Drops The cumulative impact of all these factors proved to be great. The per capita consumption of cigarettes, which had reached an all time high in 1963, began to fall immediately after the issuance of the Surgeon General's Report in 1964. The following year, this figure rose slightly and remained on a plateau for 1966 and 1967, but at a level considerably under the 1963 mark. While there was disappointment that the per capita consumption curve did not continue to fall, there was still considerable satisfaction that it had not resumed its rise. This was proof that the anti-smoking activity of the health organizations was proving powerful enough to counteract the advertising of the cigarette companies. Had this not been the case, the consumption curve would have, without a doubt, continued to rise in sharp ascent after 1963. T107581585

=irst :ically .~ tte ;e and ~.. NO ;. ~ to ;sue I ess The "~ai~ness Dpctrine" Then, in 1967, an event of great importance took place. The Federal Communications Co~ission ruled that the "Fairness Doctrine", hitherto applied only to political campaigns, should apply also to cigarette adver- tising on television and radio. Broadcasters who used "spots" advertising cigarettes were required to give a "significant amount" of free time for anti-smoking messages. This was the signal for launching a massive, intensive campaign on television and radio warning about the dangers of smoking, an effort in which the American Cancer Society and other large voluntary health organ- izations joined. Simultaneous with this saturation campaign, per capita consumption of cigarettes began to drop. It ~ontinued to decline sharp.ly through 1969, 1970 and part of 1971. Midway in 1971, it began suddenly to point upward again .... l.~.d mi ted, ,: pon- ,. per :.ed _3 'it of CiBarette Ads Banned On Radio And TV In 1969, .the Federal Trade Co~ission, supported by the voluntary health organizations, called upon Congress to ban all cigarette advertising from television and radio as had been done in eleven other countries including Great Britain, Norway, Sweden, Italy, Switzerland, the Soviet Union and Poland. Congress responded by passing, in 1970, a "Public Health Smoking Act" banning cigarette advertising on radio and television after January 1971. The act also ordered a stronger warning label reading: "Warning - The Surgeon General Has Determined That Cigarette Smoking Is Dangerous To Health". While this law was .hailed as a victory for the anti-smoking forces, it could not be foreseen that it would also produce a serious drawback. Since the broadcasters could no longer advertise cigarettes, they no longer were required to carry anti-cigarette messages. How powerful these messages had really been was demonstrated by what happened when they were no longer there. By the end of 1971, the per capita consumption curve for cigarettes had begun to point upward again; then it continued to move up gradually through 1972, 1973 and 1974. But, in 1975, the upward trend was halted, and that year, the figure remained about level with that of 1974. Whether this slowdown was temporary, or whether it will continue, no one knows. There is also a question as to what this really means. Does it mean that inflation and unemployment are cutting into the purchase of cigarettes? Or is the anti-smoking idea beginning to take hold, resulting in a growing taboo against cigarettes? T107581586

Smg~.n~.Restricted in Public Places While the former is a reasonable explanation, there is strong evi- dence in support of the latter. After the enactment in 1973 by the Arizona legislature of a statewide law to restrict smoking in public places, many other states have followed suit. In 1975 alone, 15 states passed legislation regulating smoking areas In addition, there are federal regulations in effect restricting smoking i~ airplanes, inter-state buses and trains. A number of organizations have come into existence making 9uite vocal their antagonism tosmoking. The psychological effect of these measures and activities has been to place smokers in the position of being different or an unpopular minor- ity. This, we believe, has worked synergisticBlly with the continuing campaigns of Public Education and. Public Information to cause many more smokers to give up cigarettes. While some television programs still feature stars with cigarettes in their mouths, the overwhelming trend, reflected in "family type" programs and in educational and news broadcasts, is in the other direction. This is certainly also true in the newspapers and magazine: Smoking is becoming more and more unpopular, Con~inue~ .DeGline~IE_Eercentafle~ Of Smokers This is borne out by the report "Adult Use Of Tobacco - 1975" issued by tBe U.S. Department of Health, Education and Welfare and based on the study of the National Clearinghouse on Smoking and Health. Some dramatic changes have occurred between 1970 and 1975. Namely: - the proportion of male smokers 21 and over dropped from 42.2 percent to 39.3 percent - the proportion of women smokers dropped from 30.5 percent to 28.9 percent the proportion of male and female smokers was down in every age category with the exception of a slight increase in women 21-24, women over 55, and men over 65 - the most impressive decline was recorded for men 21-24, a drop from 49.8 percent in 1970, to 41.3 percent in 1975 Going back to 1964, the year of the Surgeon General's Report, and com- paring the figures then with the figures today, the gains stand out even more dramatically. In 1964, 52.2 percent of all adult males ~ere smoking. In ]975, the figure was 39.3 percent; In 1964, 31.5 percent of all adult women were smoking; in ]975, 28.9 percent. T107581587

-n Fes. -1 O- ~ttitudes Unfavorable To Smo~nq Corresponding to these actual reductions in cigarette smoking are some very significant indications of future declines, based on present attitudes and assuming these are properly exploited by the health agencies. Fifty-six percent of those surveyed believed that cigarette advertising should be banned completely. Those voting this way included two out of every five smokers. Seventy-eight percent, including two out of every three smokers, felt that teachers, doctors and other health professionals should set a good example by not smoking. Most current smokers, th~ report also disclosed, have made at least one serious attempt to stop smoking. Overall, nine out of every ten say they have either tried to stop smoking or would probably do so if there was an easy way. The message from this survey, so far as the American Cancer S~ciety is concerned, is sharp and clear. Whatever the Society and its allies have been doing to persuade people to stop smoking, or not to take up the habit, has had a deep, long-range impact. The anti-smoking campaigns have produced substantial, impressive results. A_ Numb_er~O_f G~n.eral. P~r.~_p__o_sals The Task Force on Tobacco and Cancer would, therefore: make these general observations: - educational efforts -- through Public Education, Public Infor- mation and Professional Education -- should be intensified and expanded. - since most smokers want to stop, a greater proportion of the Society's anti-smoking resources ~hould go into measures which will help them quit. - since anti-smoking efforts have had greatest impact among educated white males resulting in decreased rates of cancer of the lung and larynx, these disorders are now becoming increasingly diseases of the poor. Special efforts must, therefore, be directed toward these susceptible segments of the population. - since it is evident from educational research that firm attitudes on health are formed in the early years of childhood, a larger proportion of the total effort should be devoted to influencing children starting at the age of 5 or 6. There should be, however, no reduction in efforts directed to teen-agers, nor of the efforts directed to adults. T!07581588

- young women contemplating pregnancy are an especially important target. The life and health of a child is a very powerful incentive to stop smoking. - the importance of involving the medical, dental and allied prof- essions as exemplars and as activists is paramount. - encouragement should be given to popular efforts aimed at bring- ing reasonable restrictions on smoking in public places for the benefit of both the smoker and the non-smoker. Since most smokers want to stop smoking, the majority would welcome regulations which restrict the times and places where they can smoke, and help to support a wavering resolution. Th.e Low Tar-Nicotine _Ciq~re~tt_e A point which has not yet been fully discussed is the "low tar" and "low nicotine" cigarette. Considerable scientific evidence has been amassed demonstrating the "dose-response" relationship between cigarette smoking and cancer, respiratory and heart disease. Tar, nicotine and carbon monoxide have been identified as the causative factors. While pretending to ignore this evidence, the cigarette companies have been reducing the tar and nicotine content of their products steadily, year after year. In 1954, 95 percent of all cigarettes sold in the U. S. fell in the range between 35 milligrams and 53 milligrams of tar per cigarette. By 1960, a decided shift had taken place across the board with 90 percent of all cigarettes sold fall~ng between 19 and 35 milligrams of tar. The downward trend had gone much further, and in 1975, 90 percent of all cigarettes sold fell between 12 and 25 milligrams. Beyond this general downward shift in tar for the regular cigarette brands, there has been an eruption of "low tar" brands. In 1967, cigarettes with 15 milligrams of tar or lower (these are classified as "low tar") constituted only 2 percent of the market. Today, this figure is between lO and 15 percent. The movement, in the industry, is definitely toward the production of less hazardous cigarettes, by reducing tar and nicotine content, and even- tually, by reducing carbon monoxide as well. While this trend to reduce the noxious elements in cigarette smoke should be encouraged, the issue should remain quite clear. While some cigarettes may be less hazardous than others, no cigarette is safe. The efforts of the American Cancer Society should continue to be "d~oted to bringing about total abstention from smoking for as many people as possi61e. T107581589

-12- Importance Of Keep.in~ Tb~ Public Informed Another question which has been raised in the course of the deliberations of the Task Force has to do with the necessity of continuing to "convince" the public with evidence. Some have felt that "all the evidence is in" and "everyone is convinced". "Therefore, our efforts should not be dissipated in telling the same old story to people who know it". Since the time of the Surgeon General's Report, many important epidemi- ological studies have been made with respect to the relationship between smoking and heart disease. Foremost among the researchers have been Dr. William B. Kannel of Framingham, Massachusetts, and Dr. Jeremiah Stamler at North- western University in Chicago. These studies have not only reconfirmed the disastrous effect smoking has on heart disease and other circulatory ailments, but have produced evidence also that .those who stop smoking reduce their risk of suffering a heart attack. Similar results have been produced by Dr. Ernst Wynder. Furthermore, a significant new area of research -- the relatiofi~hip between smoking and pregnancy -- in which area Dr. Neville Butler of Bristol, England, has made o'utstanding contributions -- has established that the rates of miscarriage, stillbirth and infant mortality are higher for mothers who smoke during pregnancy than for mothers who do not. It has also been estab- lished that infants born to mothers who smoke have lower weight at birth, on the average, than do the infants of mothers who de not smoke. This factor is significant since it has been further demonstrated that low weight at birth is related to the later development of physical and emotional disability. In the area of noxious substances in cigarette smoke, recent research has disclosed that the carbon monoxide in cigarette smoke is a very important causal factor in circulatory ailments, and that its presence in the atmosphere where many cigarettes are being smoked is much higher than is acceptable under safety standards. This new evidence should be brought to public attention with as much force as was used to publicize findings of the Surgeon General's Report..Nor should there be any slackening of effort in publicizing the old evidence. A new smoke-vulnerable generation has emerged since the time of the 1964 Report. They must be given the facts, the old and the new. Furthermore, memory ha~ a way of fading, especially when the memory stands in the way of something the individual would like to do. Therefore, even those who know the facts quite well, should have them reinforced through repeated exposure. Now, to conclude this section of the Task Force report. T107581590

S!Decific Five-Year Goals The gains which have been made in the fight to combat smoking are many and they are impressive. The outlook for further and much greater gains is extremely favorable. We believe that it is entirely feasible, based on what has been achieved to date, and based on our evaluation of the strength and determination of the American Cancer Society, its Divisions, its Units and its two million volunteers, to set specific five-year goals. In order to reduce tobacco-related disease and death, we propose the following goals to be achieved by 1982: To reducEthe number of~du!ts who smoke by at least. 25 percent ~.cgd~ s~okinq amo~nq younq oeople b_~ at least 50 ~ercen$ (In quantitative terms, this means reducing the total number of smokers by approximately 16 million persons as follows: 4.5 million teenTagers; 22.5 million adults -- of the 50 million who now 'smdke)' (3) To encourage ~overnmen~a~dindu~trv to reduce the toxic ~.l.e~.~q.t@ in ci~acettE.sm@kEbY a~ 16ast 50 Percent by com~a~i~dn-t6~ ~'he averaRe leve]s~of today, as a step toward the'it ~'l eli~at~X And finally, to reiterate a principle enunciated over a~d over by the /knerican Cancer Society. It is our belief that effectiw implementation of these proposals and achievement of the five-year goals depends on each of the 68 ACS Divisions and more than 3,000 local Units. Unless the Society, at all levels of organization, takes this program to heart, these r~co~nendations will remain just recommendations. We add our voices to those of national leadership in the American Cancer Society in a plea for the speediest, fullest, and most wholehearted action to bring this new anti-smoking program to life, and thus to preserve life for millions of our fellow-Americans. T107581591

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PROFESSIONAL EDUCATION More than 75 percent of ~I respondents to the recent National Clearinghouse Study - "Adult Use Of Tobacco - 1975" - said they believe that physicians should set a good example by not smoking cigarettes. The ACS Cancer Prevention Study shows that physicians have changed their personal smoking habits. The percent- age of male physicians in a group of approximately 5,000 who were interviewed concerning their smoking habits dropped from 38.6 percent smokers in 1959 to 28.3 percent in 1965 and to 19.5 percent in 1972. Unfortunately, this decrease in smoking does not apply to the general population. It is apparent, then, that physicians can and must play a major role in the five-year American Cancer Society effort. An additional report on the smoking habits of professional groups in the health fields is presently being prepared as partof a second National Clearing- house Study (1976) and this may suggest modifications in planning effective programs to enlist their active support. "" In the past, the importance of the physician as a health educator has not received sufficient attention from the American Cancer Society. The President's Committee on Health Education pointed out the potential role the physician can play in helping patients stop smoking because he has contact with them at a "teachable moment" in their lives and they would be more prone to listen then not. While individual physicians and some medical organizations have taken impressive steps to strengthen this activity, in recent years the evidence is clear that much more remains to be done. The target "audience" for physicians and other health professionals should be ALL SMOKERS who come to their attention. Special attention should, however, be given to the "high risk" populations, including the heavy smoker, teen- agers, women of childbearing age and small children (through the influence of their parents). Our recommendations for Professional Education, therefore, are designed to reach the entire population of smokers, with special attention to several "high risk" audiences through the channels which appear to have the most influ- ence in helping them to modify their health habits. R_ECOMMENDATIO,~S~ I. All Physicians and Dentists The nation's 300,000 practicing physicians and 125,000 dentists can and must assume a more active part in this anti-smoking campaign. Recognizing the pressures under which they work, it is the Society's role to provide them with the resources they need to do their job more effectively and efficiently. It is reco~ended, therefore, that the following program be authorized: T107581594

~ppo~. An essential element in this resolution should be a request for co~ttment by every p~sician and dentist to confront every patient who smokes, every consultation, on the dangers ot smoking, and to encourage him to stop. These materials should include: - Self-Help Kits - A smoke-cessation curriculum that the doctors can use to assist patients - A list of community resources where patients needing various types of intervention can be referred to get help in giving up cigarettes $oc~t~ meeX~g~. This film will motivate physicians and dentists to become active in helping their patients to stop smoking, and provide them with specific advice on measures to take with patients who smoke. F. A key element in all approaches to doctors is the goal of persuading the doctor to commit himself to confront ALL PATIENTS who smoke and encourage the~ to stop. 2. O)Fte~rlcians_an~ Gyn~coloq!sts The dangers to unborn children of cigarette smoking by their mothers is clear and present. The physician who comes in closest contact with the mother during that period is the OB-GYN speclalist. He a]so has contact with tRen-age girls and with young women. In both of these groups, smoking is increasing and counter measures are needed. O~e~ ~,~ZGy~ecotog, i.,s~ ~n~~ a majo~ ~mo~ng e~mp~n ~o~e~membe~h~p. This group has already expressed interest, in working with the American Cancer Society. /| T!07581595

-16- The Society's role should be to h~p prepare whateue~ materia~ deemed appropri~e for th~ effort and i~ Divisio~ and Units should o~co~raged to ac~ coop~tiv~ly ~ local OB-GYN Chapters to ass~r~ cooperation and d~rib~tion of thee materials. Appropriate anti~smo~ng mat~ s~o~d ~ added to Pap ~m~ar and BSE progr~ cu~re~y underway. A simi~ l~t of eommun~y r~oure~ to h~/p patients stop smoking should a~o be made av~LZable. 3. Pediatricians Smoking is increasing sharply among very young people. Current and new findings indicate that smoking at age II and 12 is no longer unusual, but is, indeed, increasing. The role of the Pediatrician in dealing with the health hazard, therefore, becomes increasingly important. ... It is recommended that the Society work with the Am~Lean Academy of Pedia~ in launc~ng a simila~anti-smo~n~ ~paign for i~s m~mb~ip. H~r~, too, ~e So~cty's role sho~Zd be to prepare special mat~tia~ needed for this age group; to see th~ t~ey ~e provided to Pediatri~ia~ a~ the lo~ lev~; and to ~si~t in gat~ring co~m~C~y r~o~c~ so th~ referrals ~an be made for more int~iv~ co, cling and ~sistance, as .needed. Since attitudes on health and illness are known to be formed as early as ages four to six, ~pee~ m~te~s and g~Ld~ sAou~ 6e deu~ZopEd ~y m~a~ of which the P~dia~ri~Lan ~n influence the child poY~en.t directly w~th r~pect to smo~ng and healS; or if not di~e~tly, then through the child's pare~ . Inasmuch as nurses are assuming an increasingly important role in the health care field, they should be encouraged to participate in the anti-smoking programs of the Society. Dev~op a mod~ ~olution to be adopted by the memb~p of ~t~n~l, state and local n~rsing so~eti~, aff~n~ tE~ a~ue suppo~ of ~ smo~ng cobol ~n. Th~ Society should encourage ALL NURSES to adopt an ex~pl~y role and quit smoking and to use their influenc~ to r~trict th~ sale and use of ~gar~tt~ in hosp~ and aZl kea~th-care faeit~ties. T107581596

-17- 5. Social Workers O¢v~p a mod~ ~o~on to b¢ adopted by the mmb~h~p of of ~h¢ among cobol ~n. Th¢ So~ty sho~&~ eneo~age all so~al wor~s to adopt an ~plary ~ole and quit smoking and to u~e their ~nfluence ~n p~on-to-pe~on co~ta~ to dee~as¢ the ¢ons~mption of cig~ among th~b~ client. 6, Pharmacists Dcv~Zop a mod~ ~olu~on to 6~ adopted by the memb~hip of the ~tate and ~atioRal chap£~ of th~ American Pharmaceutical A~sociatlo~ affirm- ~g th~b~ active ~ppo~ of the smoking control campaign. 7. Students I~ X~ r¢co~e~ed tha~ majo~ ~mph~X~ aSou~ smokin9 and h~th be £nc~dcd in th¢ t~achin9 of ~edical, dental, nursing, pharmacy, and oth~ aZlicd h~h stud~ by: could be Z~tegr~ed into their c~r~Zum - c~u~atln~ stud~ at Divis£on-spo~orcd ¢onfer~nc~ We believe that increasing the awareness, understanding and par- ticipation in the anti-smoking campaign by students is of great importance. It iS fw~h~rrecomm~dedthatth¢ new Prof~sio~Ed~t~o~ film,. "Cancer of the tun~", be give~idep~omo~on and showing among th~ s~d~ntgrou~. 8. EVALUATION IT IS RECOMMENDED THAT A SPEOIAL FUnD BE SET ASIDE TO EVALUATE THE EFFECTIVENESS OF THE PROPOSED MEASURES INVOLVING THE PERSON-TO-PERSON ROLE OF THE PHYSICIAN, THE DENTIST, AN~ THE NURSE IN INFLUENCING SMOKING BE- HAVIOR. T!07581597

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-18- ~UBLIC EDUCATION The Society's Public Education program has been of major importance in the effort to date which has helped to induce more than 30 million people to stop smoking. We believe that past and current Public Education activities which have proved effective should be continued. However, in view of the five- year task ahead of convincing an additional 16 million persons to either stop or never start, we recommend embarking on several new programs as well. In the ADULT area, the thrust of these new programs will be: ~e " to assist people who want to stop smoking to find the appropriate vel of assistance for their situation ~. to ensure that people who once stop smoking stay quit ~.. to reach those smoking segments our programs do not now re~ch well In the YOUTH area, the thrust of our recommendations are for new programs targeted at younger populations and designed to instill early in youth, a strong commitment against smoking. ADULT REC.O .MMENDAT~O_NS_: The recent study "Adult Use Of Tobacco - 1975" found that 90 percent of the current smoking population agree smoking is harmful to health; two out of three smokers are concerned about the possible effect of smoking on their own health; and more than half would like to quit. Surveys of ex-smokers show that many of them start and stop smoking several times before finally quitting for good. The Society's own expe~ience shows that of those who successfully complete a Quit S6oking Clinic, only 25 percent to 30 percent are still off cigarettes one year later. Reachlnfi Those~fiQ Want To..Quit It~ r~aomm~ndedthat eack ACS Unit ~tabl2~h a "Smoke~s Hot L~n~" w~ich ~ald ~nabl~ anyone~ho woa!d like to ~i~smoking to obtain inform~on about ACS e~ation activi~i~ or oth~r~o~r~es in the ~ommu~ity, and to 6~ directed ~alntaini~q A ~ntinuunl ~f intervention MethodoloQies Many smokers who want to quit can do so only through some form of Quit Clinic involving maximal intervention. Others can do with less intensive intervention. The~e.~(o~, ~eu~r~l ot~ ~nt~uention mcthodologi~, ~ho~ of ~ ~c fo~, ~ho~ be deu~opEd to me~ ~e u~qu~ nee~ of T107581599

(I) Self-Help_Kits It~ recomm~ndedthatthe AOS develop and pre-t~t ~elf-he~p ~ for the majority of smok~t~ requ~Lng o~Zymi~Lm~int~rven~ion. Where these have been tried, 23 percent have been able to maintain abstinence up to 12 months without outside support. The primary i~al foIZow-u~ from a "hot .t~ne" call should be dY~tribution of a s~f-h~p ~t. ~t ~ recommended that the ki~ also be dis- ~buted mid~@ at club and industrial p~ograms, adult eduea~on cl~s~, in doctors' offices, in supermarkets and drugstores, door-to-door, in r~po~e to m~-in requ~.~, and in eonfunctlon w~th s pea~al ~adio and TV programs. (2) Deve!opin~ a volunteer follow-up ~ff~r~t~ Experience has shown that many smokers relapse after responding successful ly to intervention. It ~ therefore ~ecommended .that the disX~ib- ~tion of th~ .~f-h~p kit be fo~owed ~y p~on-to-p~on co~a~. ~ fo~ow-u~ (or fo~ow ~ough) prog~ shoed ~z~ ~ned vo~u~t~ n~, ~sing fo.~ smok~ wh~eu~ possible, a. find o~ if the s~f-h~p kit has been u~eful b. h~p q~tcrs over the ~iffiault period when mang go ba~k to smo~in~ -- thee first six mon~ are crltica~ guide those who need it to more .~ensive fo~ of int~ven~ion (3) Utilizatiqn~ of Former Smokers The 30 million people who have stopped smoking are a potential source of enormous strength to the Society in helping others quit. Ex-smoke~ shoed be recr~ted, trained and involved in self-help and ~ (4) quit Smokinfl Clinics The Society has had good success with its sponsorship of "Helping Smokers Quit" Clinics. In 1975, it conducted 1,660 such clinics for adults. These clinics, like those carried out by others, achieved an average success rate of 25-30 ~ercent one year after intervention. However, research suggests this figure can be increased to as high as 60 percent where maintenance programs are utilized for continued intervention. an inv~tmentb~ made Zn s~ver~d~mo~t~tlo~roje~ts d~igned.to t~thc v~Zue and f~ibil~y of ma~n~enance-i~t~ve~t~on for smoking e~sation. T1075816OO

It is f~th~r recommended that: (a) by 1982, at ~east ~a ACS Quit Smoking ~£i~ be conducted p~ year far every 50,000 p~a~ in those U~Lt~ ~pr~ent~ng the 719 caunt~ m¢eting.th~ pop~Zation ~iteria. These clinics would guarantee each participant IB hours of quality content, a we11- structured methodology, and the most advanced over-all techniques to help in quitting (including utilization of the new trigger film series); (b) onc ~Lt Smo~n~ Cli~c FAOILITATOR should be recruited and trained for each 50,000 population. .Evaluation of Ces.sa~ipD Clinics~ (ACS and Non-ACS) To implement a recommendation of the Third World Conference on Smoking and Health "that a system be established to evaluate private and commercial cessation activities", /~tis proposed that the ACS p~ovid~ financlal~uppo~ for a f~ibiZ~study to d~t~mine to wh~t e~e~the u~riaus ~ajar U.S. ~roups invo£uedin h~ping smokers q~itwo~Zd pa~cicip~ute in such a~ endeavor. Once ~ocumented evidence of their willingness to cooperate has b~e~received, a larger grant would be required from the ACS and/or outside sources for implementation and on-going operation of the evaluation system. Reaching_New T#rg~t Populations Of the 7,200 hospitals in the United States, ACS Divisions report that less than five percent are actively involved in the anti-smoking effort. Yet, hospitals provide an opportunity to reach huge numbers of individuals at one of the most "teachable moments" in their lives. In 1974, for example, there were more than 35 million in-patient admissions and 250 million out-patient visits to hospitals in this country. These are impressive numbers. The Society, through its physician me~bers and volunteers, many of whom serve on local hospital boards, is in a unique position to influence the role hospitals can play in reaching new target populations as part of the five-yeBr effort to control smoking. I~is, therefore, recomm~ndedthatthe ACS conduct a major ~p~n in th~ ~ion's hosp~ ~o: a. educate pa,~en,~ (in-p~tient and ou~-patie~t) and ~ir fami~, ~s well as ~ploye~, about the dang~ of smoh~ng and the bcnefit~ of quittin~ provide assistance to those persons wanting help in givln~ c. ~tabtish on-going hospital-based Q~it Smoking Cl~i~ for p~¢~s and ~ommunity resident. Thee elini~ sho~Zd be mod~cd ai(=ter ot~er hos~ p~t~e~ ~ttending thee ~ T107581601

Industry Absenteeism due to cigarette smoking and related illness now costs American industry $700 million a year. This is regarded as a low estimate. Because of new OSHA requirements, industry has even a greater incentive to work cooperatively with the Society, its Divisions and Units, to reduce cigarette smoking among employees. In addition, studies show that the heaviest incidence of smoking is among blue collar workers (male) and clerical person- nel. It ~ recommended the: a. a major educ~onal program be developed ~ cooperation with ~ocal ind~trial physicians and n~, u~ion leaders, and other i~G~ted parties w~ich wo~Id seek to reac~ thes¢ heavy smoke~ at th~ pla~e of work and h~p th~ to q~it b. appropriat~ supporting materials be developed for ~his target ~op~%ion group, including a film on the benef~ of q~ng ~g~t~ the ACS make every effort to prepare appropriate p~onn~ with- major ~ompanies to condu~ their own in-ho~e cessatio~ a~tivi~ d. spe~Lal attention be giv~ to the dev~opment of c~sation a~- ~viti~ in those companies whose work~ are exposed to known occupational ~a~inoge~ Evaluative Comparison of. ACS Cessation Activities Since the Task Force has proposed the development of several NEW forms of cessation intervention to be carried out in different settings, X~t~s • recommended that demo~t~ation proje~ be s~ up £n va~io~ locations around ~e country to ev~uate their ~ative effectiveness in h~ping smokers quit. YOUTH RECOMMENDATIONS: One of the findings of the President's Committee on Health Education was that lifestyles are almost always formed in the early years. Health behavior experts agree that good health habits form early in life and tend to persist throughout life. Programs directed toward children in school would, therefore, appear to be an appropriate setting for the Society to devote substantially more energy and resources than in the past. This can be done by working more closely with school health nurses, school health educators, specially trained in- structors and others within the school system responsible for various component~ of a youngster's health. T107581602

oo -22- ate. e to _~ "~eaviest ;erson- In the YOUTH area, we believe two age groups deserve special Public Education attention: students in Kindergarten Through Grade Three The following is recommended: a. that an "E~y Sta~tTo Good Health" program be developed ~ocusing on the systems and fun~o~ of the body, good he~th habit~, and the adverse ~ffect~ of smoking b. that eac~ ACS U~Ct e~u~t one educator for ev~j five elem- entary schools who will i~oduce the program and r~ted mat~Is to othP_Pt elementary teachers c. that a Conference of Exper~ on E~ey C~dhood Educat~o~ be ~onvened to propose n~r~earek needed, n~approaeh~ and materials designed for ,t~ age lev@Z to help instill in th~mth.~ concept of ~ood healt~ habit~ Other Pre-Adolescents Recent studies sponsored by the Society and confirmed by the Clearinghouse on Smoking and Health indicate that youngsters are starting to smoke heavily at the age of II and 12, and that girls particularly in this age group are becoming heavy smokers. It is apparent that the Society must direct much of its efforts to this pre-adolescent group, Because the Divisions and Units are strategically situated and can have influence and impact on school boards and school systems, we recommend an expa~ion of e~t~ng Public Education progr#m~ d~ected specifically at th~ ~~ age g~up. Because it is generally agreed that youngsters in this age group present complex motivational and behavioral problems where health is concerned, ~o re~o~endedth~t: a_. the Society conuene a Specia~ Co'nf~rence of Exp~.tts on ~s a~e g~up to advl~e on the preparation of n~ approach~ and the deuelopmen~ of spe~Lal ,~ri~ b. experimentation ~,~th peer group s~ssions for +~ age level be ~t~ied ou~ to determine how ~zose ~#~o do not smoke can h~Zp avoid the pr~sur~s from those who do T107581603

Teen-Agers ACS studies indicate that very young people act as deterrents to parents who smoke, but they start to smoke themselves upon reaching their teens. The reasons for this are varied. The Task Force recommends that he probl~ of ~ age group be thoroughlg r~e~ched and~the So~i~yproduce n~ prog.~ and materials spe~ia~ gelid ~o ~ audience ~ the e~li~t possible t~. In the interim~tiod, e~Cst~ng films such as "~e~h of Air" d~igned for Ju~or-Senior High Schoo~ students should be brought up-to-date and ~ircul~%¢dwidely. Teacher Training, It ~s r~commended th~ the ACS spo~or a me~ting of appropriate edua- a~:ona~ authoritie~ to dev~op ~h~ s~egy-c~~-teac~ng m~~ fo~ incorpo~ng ~e heath h~ of smo~ng ~ p~t of h~h educ~Lon pro~ in tea~ ~ng i~~o~, ~v~i~ ~ and other educ~o~ ~ ~b~ hme~ . INNOVATIVE PROGRAMS THE TASK FORCE RECOMMENDS THAT THE ACS ENCOURAGE THE DEVELOPMENT OF INNOVATIVE PUBLIC EDUCATION PROGRAMS ON SMOKING AT THE COMMUNITY LEVEL BY PROVIDING S,~IALL GRANTS TO RELIABLE GROUPS AND INDIVIDUAl. T107581604

.~rents • tCt" PUBLIC INFORMATION T1075816O5

PUBLIC INFORMATION The study "Adult Use of Tobacco - 1975" shows that public awareness of the dangers of cigarette smoking has increased greatly over the past decade. It is an axiom of effective Public Information activities, however, that one cannot rely on past successes. New audiences are constantly coming into the market and new media people have to be educated and convinced that the ACS deserves a fair amount of time and free space for its messages. The issues surrounding Eigarette smoking command the maximum interest of the mass media. The Society must create events and happenings which will continue to generate full exposure and discussion of the key issues. As part of the new five..year plan, we recommend thc Pub//c Infor~CEon effo~tinvo£ue several n~nde~ta~ngs: ~ECOMME~DATIDN~: I. P.r_odu¢~ New_S~ries of Proqram~..fpr PBS That a ne~s~rie.~ of programs be produced fort he Pub~Lc ~oadc~Ln9 Sy~t~ma~med ~thel~n~ people q~i~ smo~Lng. This series might be patterned after the one produced in the ~arly 1970's, affecting the smoking habits of over 250,000 men and women. Or it might be patterned after a two-hour special such as "VD Blues", "Drink, Drank, Drunk" and "Why Me?", aimed at a specific healt~ problem. By involving community facilities as an adjunct, such programs affected the behavior and attitudes of millions toward venereal disease, alcoholism and breast cancer. The resulting publicity in the press reinforced the message i~easurably in those co~unities which carried these programs. 2. )£d_ ve]c_ti s i nq and Prom_%ti onal....Camoa i qn A_i.m~d.. at Women Based on findings of the National Study on Women and Smoking, d~u~p a ~peci~ad~ing e~paign ~medatwomen. This skould co~ist of ~viSion ~dradio spots, ad~, n~wspap~r feature, c~ip sheets for p~6Z~o~utLo~. The study itself should continue to be a newsworthy event and continue to serve as a resource for writers and magazine~. To implement findings of the study, propo~ a. a ~pe~i~ publication b~ed on .d~e study shc~Zd b~ pr~c~zd ~nd d~tribut~d to opi~on mak~ at mat~.o~, state and local lev~ T107581606

c. a film for teleui6ion sho~d be produced " ac,_ ~bu~an to local commercial s.~o)~ accamp~ed by a ~romo~on~ ~ w~ch ~e h~p Div~io~ and U~ b~ au~ence~ fc~ spe~E~ show- ings of the 3. Other Television and Radio bpOL~ The Society .~ho~ a~o ),~roduce a s~..L~ of t~evi~ion and ra~o spo~.~, ads and o~e.~ m~te,~a&.~ ~med ~ the gen~l popu~tion of ~mok~.s and non- smoke~. The vast number of male smokers must be encouraged to quit~ The Society needs to be on record with messages which can affect the behavior of 50 million smokers and more than 25 million who would like to quit. 4. Creation of Blue Ribbon Commission on Smokin~ A Blue ~Lbbon ~ommi6sian sho~d be ~zbl~hed to condu~ pubZic forums t~raughoutt}~e LI~Lted Stat~ and develop a public man~e about smo~ng, This Commission would be composed of some of the key leaders in the Society as well as other men and women representing science, public health, education, communication, youth and civic as well as governmental sectors. The Commission would conduct public forums in key cities and take testimony on possible future courses in social action which will be submitted to the ACS National B~ard of Directors for its approval. The Board will be responsible for determining what to do with the Commission's findings, such as presenting them in Washington to the Congress, regulatory agencies, etc. 5. Mass Med~a - BroadcastinE A new ef~o,a.~ sho~d be mad~ to coi~v.Lnce too e:c.~c~L,.:c~ of major n~t- work~ of the u~emL~n~ dang~ of c~g~tte smoking a~ %]~ ~ing~ mo.st se~ou~ ~,-~ <~'-~ . ',.lh~ I e there c~e of preventable dL~e. and dc~ab~..c~,j i~ ~ "" :~"~ is no longer any legal requirement for them to donate public ~ervice time for television spots, we believe an appeal to their 9ood ci~izenshi~ and corpe'rate ~esponsibility migh~ open u~ more time than is currently available. It should be borne in mind tha~ almost without exception: %hese ~p~roacbing t~e b~oadcasters will be dealing with new ~ndividuals ~.~h~ were :~ previeus~y involved in ~his effort. T107581607

of n~ ~-n 6. ,Local ,Med~a, N~ effo~t~ ~hould be made lo~, as w~l, to p~uade broadcasting ~a~ion~ to ea~y.a~i-smokin~, m~sag~ and to integrate a~-smoking f~a~u~cS in on-gorng programming. 7. Local Proqramming There have been a number of successful attempts by local television and radio personalities using their own program formats to encourage listeners to quit smoking. Thee me ezampl~ shoed be d~cri6ed in a g~idebook and circulated to AOS DiuZ~io~ and Un/~, ~ exp~enc~ an~ to ~oi~ up ~ys t~ ~ enco~ge loc~ s~o~ to ~ply th.~ ~fo~ t~o~Eo~ the co~. It is obvious that TV and radio through this type ~f progra~ing can influence the smoking habits of millions of ~ericans, B. S~e~a~."Do~'t_S~oke".Dax All Divislons of th~ American Canc~t Soe_~.P.Y3g should seck to ~ougho~ ~ r~pe~ve ~e~, cov~in9 ~ many co~~ ~ possibl~, on~ spE~ ~y ~ ye~ in w~eh no ~g~ ~ so~ and no ~g~ ~e smoked. Since "D-Day" has already proved so successful ~n M~nnesota, this is suggested as a model. Based on the experience of Divisions, co~id~on should 5~ ~ivEn to holding a Nationa~ "~on'~ Smoke" ~a~ ~t an approprLat~ ~ime in the f~t~re. 9. ~ampai~n Amon~ HiQh School-Colle~e Media Since adult smoking habits are known to be initiated in the teen years a~d since peer pressure is a very influential factor in the formation of these habits, /~ /~ recommended ~at a spe~L~ campaign ~e d~ec~ed to ~g~ ac~oo~and co//~g~ publiccC/o~. Since these publications do not accept cig- arette advertising, it is likely they will be receptive to ACS materials. It is al~o .~commended th~ t;~ Public R~a~ions Soci~tu of ~ica invited to ppv~t/e./pate in ~ campaign since t~~ e~ga~izat.'Lon h~ l~cal chapt~ on 60 co~E~ge c~npuses. Spc~al tap~, plat~e~s and script~ ~ho~Zd be p~epared for coll~e ~dlo S,~o~,~ d~a~in9 wi~ th~ smoking problem and community ,%~ow'ce.~,~ h~p in q~tting. TI07581608

I0. Compan~y_House Orqans Because 85 million people are employed and can be reached at their place of work through company publications, and because of the high incidence of smoking among blue collar workers, me ~ecommendth~ .tJ~e Pu6li¢ Imfo~m~o~ Pep~tmentmake a studied ~ffo~tto provide ma]o~ co~po,tat~ ho~e organa with ~eful and dramatic materi~ on the dang~ o~ smoh~ng and oppo,~tuni~ for h~l~in q~tting. In addition, such activities wou]d supplement Public Educ- ation efforts in working with corporate medical departments to help employees quit smoking. II. Newslette~ We recommend the Public Information Department publish and d~t~ib~te a c(uz~ct~.ru~g n~wsletter which would reflect the progress b~ng made in the new five-year anti-smoking effort and ~hat this pubtica~on receive wide dis- tribu~on. In addltion~ we recommend that the ACS-spo~5ored WORLD SMOKING AND HEALTH Publication ~eceive wide c~rc~tion in t~ cou~try and ,that it be continued on a p~rmane~t basis. EVALUATION iT IS RECOMMENDED THAT A SPECIAL FUND BE S~T ASIDE TO EVALUATE THE EEFECTIVENESS OF THE VARIOUS MEASURES PROPOSED UNDER PUBLIC INFO~{ATiON IN INFLUENCING SMOKING BEHAVIOR. T107581609

o 00 0

LEGISLATIVE AND GOVERNMENTAL AFFAIRS Action to safeguard the health of the public is a basic responsibility of government. This responsibility has been historically discharged through one Public Health Service in the Federal government, and in the health departments of state and local governments. Since the United States government has already declared it to be official policy that smoking is dangerous to health, /tshou/d be prodded to ~u~a~on to poZicy and ta~e the n~ces~ary tnea~ to reduce smoking and safeguard ~e h~alt~ of the pubtic a~the exe~uZ~ve, leg~s~tive and ju~L- ~ial l~ve~. StaZe and local governments should be encouraged to do likewise. Therefore, .it Z~ recammended that the American Canc~ Society: ~RECOMMENDATI ON.S,: I. Formulate guidzlin~ for .~tate and municipal leg'i-~l~tion an~ ordin- anc~ to r~.~i~t smoking in public places and regulate sal~.~ and promotion of 2. Prepare model legislation for state and local governmem~, ~eong .the lines of legislation recently enacted in severaZ s~tes to be ~L~ized, ~ appropriate, by ACS DivL~iow~ and Units. 3. Begin imme~:~ately to develop an an%i-smoking caucu.~ .~n t~e Ho~.~e and Senat~ to i~oduce and support l~gisl~tion and regulations eo~.s.~.st~,~t with th~ gov~r~e'.~'s de~red position that ai~a~e ~moking .~ dangerous .to 4, Sub~t, sab~ect ~o Bo~d approval, finding.~ and .~ecommend~%.zio~s of th~ Blu~ ~bbon CommLs~ion on Smo~n~ to a~propriaZe officiaZa of the tory age~es, Se,n~te and Hou~.~e subcommi~te~, and the Pr~ident of the United T!0758I 611

-29- 7. Ij~tiat~, immediately, a~tiv~y to brin~ about Congressional action to ban adv~ing of ~igar~es in tl~e nez~ five yea~s, except ad~ertise~ men~ for bran~ 'with a ~ar and ~co~ne co~%ent ~ least 50 p~.~c~t b~ow s~ w~ighted av~age~ for the ~revio~ year. Meanwhile, sup~o~ FTC effo~ to end th~ deducZion of ~igaratte adve~ing as a b~i~s expense. 8. Work with legi~.~tive forc~ and ot~er h~a£th orga~Lzation~ for the phasing out, ovG~ a p~od of five ye~-~, of approxim~y $60 mi£~on annua~J b~ing spe~.~ by the fed~al govG~e~ to support the produG~ion of tobacco and ~e m~k~t~n~ of tobacco produ~s. 9. Work for bo.th legislative and ,~egu~tory (executive. agencies) a~tion s6~ting maztmam acceptab£e levels for tar, ~L~otine and other noxiota age~ in tobacco smoke, subject to gradua£ succ~sive redu~on yew~ by yea~. A much s£~ong~r ini~tat~ve is required from ,th~ Am~riaan Cancer So~iG~y than h~ been ~'~e ca~e to date. 10. Seek pub£Lc hearing by a Senate Committee to focus a£~e~ion on go~nme~t r~p.onsZbility and failur~ of vario~ b,~ancha3 of governme~ to d£~ch~e th£~ r~po~ibi~y. I ~ Tnv~,~g~te the fe~ib.b~3 of fede.~ regu~%ion_~ .to pro!.~tb.~t the sale oi ~gc~tes where they ~e e~ily accessible to mino.~.~. T107581612

0 O0

STUDY OF TEEN-AGE GIRLS AND YOUNG WOMEN T!07581614

-30- SUMMARY OF THE FINDINGS From a Studu~ About Cigarette Smoking Among Teen-age Girls and Young Women Conducted for The American Cancer Societ', Yanke!ovich, Skelly and White, Inc. February, 1976 T107581615

SUMMARY OF THE FINDINGS Four major trends dominate this study of cigarette smoking among teen-age girls (ages 13 to 17) and young women (18 to 35 years of age). The results are based on in-depth interviews with a total of 826 teen-agers and young women, screened on the basis of their smoking patterns from a national probability sample of 3,000 house- h ol ds. i. The Increase in Smokin.q: There is a dramatic increase in th~ number of young teen-age girls smoking cigarettes compared to just a few years ago. An American Cancer Society study conducted in 1969 indicated that 22% of all teen-age girls smoked cigarettes. Now the percentage is 27%° Translated into people, this 5% increase means that half a million more teen-age girls are smoking currently-- some occasionally, many others more regularly. The increase in heavy smokers among teen-age girls is equally significant. The 1969 study showed that 10~,~ of all teen-aged girl smokers smoked a pack or more a day. Now, four out of ten teen-age girl smokers are smoking at least one pack of cigarettes daily. The scene among young women is somewhat different - but also alarming. For while smoking in- cidence has shown only a slight shift (34% in 1965; 36% now~, the proportion of heavy smokers -- rc_-~ii~" heavy smokers -- has accele- rated sharply• According to the U.S. Health Survey conducted in 1965, one out of two young women smokers (51%) were smoking a pack or more of cigarettes a day. Now the figure is 61%, with the sharpest increase among the percentage of smokers smoking more t~an a pack a day (9~.~ in 1965; 25.~ now). 2. The Anti-smokin~ Message Has 3een Heard: This i.ncrease in the numbers and intensity of cigarette smoking has occurred an a ti~Te when teen-age girls and young women at least inte!iectuall!~ continue co be fullu aware of the hazards of smokinc. For a majori~ .... f the group, the message has come through !cud and clear: • ..Smoking is as harmful for women as f.yr men ~7~_~ teen-age c~irls; 80% young women). .. ,Smoking is harmful for young people as well as :.or older people (71% ~een-a.ce girls; 71~ ~3oung :¢om~:~.,', . it is not safe to smoke low tar (56.% teen-age girls; 5~ you~g women). • ..Smoking during pregnancy can harm the fetus (56% teen-age girls; 62~ young :¢omen). Amcng 9oung smokers, 56% of the teen-age girls and 62~ of the young women believe wholly or in part tha~ smokz'ng is as addictive as illegal drugs. Yet, they still smoke and start to smoke in greater numbers and with more frequency than in the past. The question is why? Two trends help to explain the reasons: T!075816t6

:'ng :.; of tal ~eir ~ouse- ust 1969 :ntly-- • 969 ~ "k or }.ing " hen arpest ~ a hue he and :~ ds -32- ' 9. .T_he~_A~il Pervasive Smokin9 Environment: On the one hand, teen-age ~. g~rls and young Women smokers continue to be awale of the anti-smoking g~" ~essage-~but tke situation all around them and their own perceptions '" of who and how many people smoke more than counterbalances the impact [ of what they have seen, heard or read about the dangers of smoking. [" For example, among teen-age girl smokers: ~ ,. o82g of all teen-age girls think of teen-agers as smokers rather than non-smokers. ...TWO out of three believe that more women are smoking now than a few gears ago. ...72~ of the girls with boyfriends report ~hat their fellows are smokers. ...66~ say that half of their friends or more smoke. ...87% smoke with their parents' knowledge; 34% with their parents' approval. .°.84% have fathers who smoke or smoked; 64%, mothers. Add to this the fact that: ...49% of the teen-age girls who smoke report that their schools have special "smoker" rooms where it is permitted to light up during the school day. ...And 68% of the teen-age girl smokers indicate that their own doctors have not warned them against smoking. operating against this all pervasive smoking environment, the one most dominant countervailing force -- awareness of anti-smoking television commercials, has been cut drastically as a resul~ of the retrenchment of free matching time following the barring of c~garette adve2tising on television. In 1969, 87% reported that they had seen or heard an anti-smoking television commercial in the past four weeks. Currently, only 48% are exposed to zhis type of television spot. On the other hand, the kinds of people identified with cigarette advertising include the fo!!owlng: attracti;,~., enjo~'ing themselves, well dressed, sexy, young and healthy. 4. Chan~in~ Values: Further bolstering the impressions c--" the all Pervasive smoking environment and the increase in smokinc ~-tsei$, is the growth and acceptance of the "New values" generated by --cl!ege YOuth in the sixties, and now permeating the majority of all yo~ng People. The "New Values" represent the breakdown of prev!oas moral norms and are characterized by the rejection of authority, emphasis on the emotional rather than the rational, freer sexual morality, Strong accent on self and self-fulfillment, the acceptability of illegal drugs and a more informal life style. The new youth values do not necessarily cause more young people to Smoke -- but theg make it easier to do what one wants to do and to resist arguments against doing, it. Both ~he prevailing smoking environment and the changed value structure of young people raise major challenges for the American Cancer Society: T107581617

To ~reak through the mythology of how everybody smokes with the real facts -- that cigarette smoking is a minority phenomena. To utilize the more positive elements of the "New values .... the importance of self and self-fulfillment, the need to be an independent thinker, the importance of physical wellbeing -- as strong barriers to smoking. Using young people's own immediate interests and satisfactions as the main leverage against smoking rather tl~an the threat of future problems. in analyzing the results of the study, we have paid special attention to those findings which appear to have the most direct bearing on curbing and preventing teen-age girls from smoking and encouraging young women to qu.".t. These have in- cluded studying the psycho-social environment of the smokers and non-stackers, the implications of the Women's Liberation Movement, the impact of anti-smoking education, pressures to smoke, motivations not to smoke, and the problems "and potentials for quitting. All of this information is covered in detail in the full report. Here in capsulated form are some of t].~e major highlights of the study: The Profile of the Teen-ag9 Giml Smoker: The profile of the teen-age girl smoker counters the image of a socially ill-at-ease youngster turning to cigarettes as a means of being thought of as more sophisticated or as a needed .Drop for handling social situations. Instead, it is the teen-age 5~irl smoker who is at ease social!u.', very put together, and wi~h full Confidence in herself. Parties and social gatherings are her metier. One measure of both. her sophistication and her value structure is the fact that 31% have already had sexual relations. it is instead the non-smoker who tends ~o be ~uietel', .far Zess self-assured, more involved with a.zhletics, school activities and clubs -- but more likely in he-," spar.9 z-'me to be reading or watching television. Rebelliousness and Smoking:~ Cigarette smoking among teenage girls, ho~¢ever, does appear to be highly identified with an anti-authority rebellious ~yndrome. Among tee:~.-age girls who smoke, 25~ use marijuana regularly corn;areal to 3% of the non-smokers; 81% of the smokers drink and 32~/. drink at times to get drunk compared to 42~ of the non- smokers who drink or 4~ who drink to get drunk. One out of four teen-age girl smokers have run away from home compared to 10~ of the non-smokers, Despite the widespread acceptance of cigarettes, and the acknowledgement of smoking bu. parents and school author- ities, the old "wood shed" image of cigarette smoking lingers on-- while the concept of not smoking as a symbol of non-conformity or rebellion against advertising, big business, societ'_~, has not ~'et caught on. T10758I 618

Teen-age Girl Smokers and Peer Relationships: Peer relationships, long ~dentified as a major factor in teen-age smoking, continue to operate as a dominant in- fluence. Teen-age girl smokers flock together and have more respect for the opinions of their own peers than for authorities. There is, however, an opposite side to the story as well. For the current study indicates that all teen-age girl non-smokers are not homogenous but rather divide into two almost equal groups. It is easy to explain why over half of the non-smokers (55%) do not smoke -- for they are not influenced by the new values, but are very traditional in their views and outlook. They are strongly religious and respectful of authority -- and they shy away from their peers who smoke, use marijuana and are part of the new values. The other group of non-smoking teen-agers aze very different -- for they share many of the same values as the smokers -- and are highly exposed to uhe total smoking environment. We call them the "Vulnerables" for, on the surface, they appear to be ready candidates for the next wave of new smokers. One out of two of the "VulnerablesTM report that half or more of their male friends smoke; a third indicate that most of the girl friends smoke. A major- ity have one or more parents who smoke, They see more ~¢omen smoking now than in the past. Yet tAey do not smoke. In- stead they have found, consciously or unconsciously, some strong barriers to smoking. These are - the importance of being in control of one's own life; and emphasis on physical fitness and well-being; concern about the addictive nature of cigarettes, and perhaps most of all, by becoming militant anti-smokers - people who are angered by other smokers, upset by smoke filled rooms and ready for increased regulation of smoking. In other words, they are finding a cause -- and a ~ew 9ear identification. T~een-age Girls and Anti-..s.m.ok.in..g Education: One out of two teen-age girls have attended an.~i-smokin~_~ programs -- 48~ of the smokers; 49% of the non-smokers. A large majority of the girls (84%) have fo.lnd them meaningful -- 'ncluding, however, 6~,% of the smokers. The ~roblem is one cf timing. Six out of ten smokers have started to smoke before the9 are thirtee~ years of age...but have attended smoking education classes oz programs in the seventh, eighth; ninth or tenth grades of school, when it is already too late. Only 4~ of all teen-age smokers attended an anti-smoking class, for example, by the time they were in the sixth grade (ages 12 and 13). The lateness of the educational effozts is exacerbated by the fact that the te~n-age girl who is likely to smoke can also be turned off by school -- especially once she reaches Junior high. A third of all teen-age girl smokerx report that they hate school -- compared to 16% of the non-smokers. Almost an equal number (29%) have been suspended or expelled from school - compared to 4% of the non-smokers. The teen-age girl s, moker ~s apt to be a "C" or "D" student; the non-smoker, an A'" or "B" student. The results of the studu, thu~, emphasize Ltwo major directions for anti-smoking education= T!07581619

Give it ea_~lier -- and concentrate more on peer sponsor=-d anti smoking campaigns in the higher gra4es. Y. oung Women Smokers: Many of the same qualities which distinguish teen-age girl smokers from non-smokers are also apparent -- but to a lesser degree -- between young women smokers and non-smokers. The women smokers also tend to be more social and outgoing, anti-authority and strongly subjected to the to~al smoking env!'ronment a.6d "peer" pressure. Over two thirds of all u. oung women smokers (68~;) have boy friends or husbands who smoke compared to less than half (41~) of the non-smokers. Their friends also smoke -- and they are some~zhat more !ikelp" to have come from homes in which one or both of their parents smoked. Compared with their own non-smok'-'n9~ peers, ~he young wcmen smokers are readier to: ...Have fun now and forget about the future (46~,~ smokers; 36~ non smokers). ...~ationalize that everything 9oU do these days seems to give you cancer (46% smokers; 3~o non-smokers). ...Feel that there is too much regulation of people'9 lives (41% smokers; 32Z non-smokers) . Yet they also have one strong characteristic which could be used as an integral part of any anti-smoking effort -- of the young women smokers express a strong need to be independent compared to 52f~ of their non-smoking contempo- raries. Contrary to the theory tha~ the increase .".n keav? smoking among u_cung :./omen is correlated with the greater numbers of women who are now employed, the findings of tile study show that it is t:~-e hou--ewives -- not the workin,~. women more likely to ~.e the heavy smokers. Among young women smokers, 39:~ are emp!oped full or p~.r: time -- and 51~ are housewives (or unemployed or-~tudents). The pattern for non-smokers is parallel (37?; are em91o[:ed; 6.3~ are ".'lousewiTes). Leek, however, at the incidence of heavy" smoking -- and the myth about cigarettes and working women is refuted. Among housewives who smoke, 66% are heavy smokers; among working women, 5.3<~ are heav,] smokers. Interestingly, it is also the working women who afford the best mpportunit!~ for converting smokers into non- stackers, accentuating the des{-rabilih9• oS anti-smoking campaigns di_~ected at t:~.e workplace. The myth about the Women's Liberation movement encouraging cigarette smoking is also not substantiated by the findings of the study for e~ua! numbers of _uoung women smokers and non-smokers (69~) identify strongly" or partially with Women's Liberation movement. T107581620

-36- Smo_~kkin~ and .P.r.e. gnan~y : A critical period to reach young women smokers is not only during pregnancy but in the months after the woman has given b_~rth. A majority of young women smokers (62.%) believe that smoking can harm the fetus. Even more important, during pregnancy, 67% of the smokers have either cut back (323;) or stopped smoking (35%). Unfortunately, however/ the ,~bsti- nence does not hold up - for here they are back smoking once again. SmO__~kin~ and Children: Several years ago, when anti-smoking commercials were far more widely available on television, young children ;.,,ere reported to be among the main crusaders against their mother's smoking habits. Today, over half of the young women smokers with children (56%) report that their children are bothered by their smoking -- but there is little evidence that the children are as militant in their efforts as in the past. Among former smokers, for example, very few mention that their children were a major influence in getting them to quit. The Former Smokers: While progress has been made in getting some young women to quit smoking -- the main success has been among the light rather than the committed smoker. Among the young women/ 13% report that they have quit smoking. Most of these former smokers (63%) smoked less than a pack a day. There are, however, important !ess~ns to be learned from :he former young ~¢omen smokers : ~ rn ','9S) . -: One out o~ k'~',."~ u:~.c~ ".;~iiyower rathe2 =han substitutes such as candy or gul~; almost none of this 6~L;~" of young women smokers 2eported that they gained weight; and most found immediaEe gl-atificaticn frog: quitting. The feeling of being in control of l£fe, an improved sense of physical wellbeini, zhe of cigarette bad breath and smell, and :non:~,~; p~oved to be stronger reinforcements than even insurance tf:ey are buying against future disease il~ heal th. The Pctentia! for Quittinc: A careful ana!i~sis of the data suggests that there is a huf:e POtential for getting both teen-age gin! and young women smo.'-:ers to quit. App!ying a scale made v~p of five items, 70% of the young women smokers and 58% of the smokers qualified as "potentials for quitting" TI07581621

-37- Among the young women, the potential quitters ~n comparison with the "committed smokers" are younger, more interested in sports and physical e.~ercise, more active in clubs, especially the PTA, and more likely to be employed. Over half of them are smoking a pack or more of cigarettes a day. Among the potential quitters in the teen-age girls group, there is a particular interest in phys~cial exercise, jogging, tennis, golf and team sports. They think of themselves being more popular than most and leaders. They are active in clubs and organizations inside and outside of the schools. Qui~ting is on the minds of most young teen-age girls and young women smokers. Six out of ten current teen-age girl smokers (59~) have tried to quit smoking in the recent past; 72% of the women have made similar efforts. The ~esire is there;- buc not the will. Undermining this desire is the belief that: ...Smoking is addictive • . . Once you start you can' t sto9 ...air pollution is even more likely than cigarettes to give you cancer. Anti-smoking efforts have nearer communicated that cigarettes are addictive -- but clearly not enough stress has been placed on their non-addictive qualities. Today's teen-age girls and young women need to be sold on the fact that: •..There is immediate g~atification in not s,~..okiny; independence; and expression of their own values; physical well-being and attractiveness, as well as ~nsurance for future health. ...;.Ion-smokers are in t,Te majority an~ have to b..9 : ~ " ' m_._ltant about c~he'_" peoples smoking. • •.Smoking ~'-'- no~ addictive - but that 3here=_-,'~.. other far more powerful reasons for no~ smoking. TI0758I 622

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-38- T~EN-AGE BOYS A.'.¢D GIRLS AND C'IGA~,ETTE SMOi~I:.'~G A SUPPLE~ENTAL R~.'UDY The Education 1~ep=_~men~ February, 1976 Yankelo~ich~ Skelly and Wh~e, Inc. T!07581624

SECTION I INTRODUCTIO~ In conjunction with the study of cigarette smoking among teen-age girl& and young women, the Education Department of The American Cancer Societ decided to also include a sampling of teen-age boys (13 to 17 years of age) to answer three major guestions. i. [.lhat had happened to smoking among teen-age boys since the last study conducted in 19697 2. Were the {nfluences and incentives to smoke the same for teen-age boys as for girls? 3. Would teen-age boys respond to the same kinds of anti-smoking appeals and messages as girls? With these purposes in mind, a sample of 250 teen-age boys were included in the sample. The boy respondents were interviewed in the same sampling clusters as the girls, and a similar screening pattern was used. Thus, the two samples of teen-age boys and girls are parallel.i The final sample included the following: Total Teen-Aqers Boys 246 Girls 267 Teen-Aye. Smokers Boys 127 Girls 127 Nonsmokers Boys !!9 Girls i40 The Report This report is written as a supplement to the "Study on Smoking Among Teen-Age Girls and ~oung Women" and should be used in conjunction with ~t. The purpose of this special xeport is to highlight the similarities and differences among teen-age boys and girls which The American Cancer Societ'.o faces in trying to get young teen-agars not to smoke. T107581625

~40~ SECTION II THE OVERVIEW AND HIGHLIGHTS OF THE FINDINGS -age gir1~The single most salient factor emerging from the study of teen-age car Socie£~sm~..<ing patterns is that the girls have all but Caught up with the gears o_~ . • .smoking h~s/zncreased by 5 per cen~ among the teen-age girls ~- last !i~s'ince 1969 .~"~ and ~s. now at the 27 percent level. During this saree I period of tree, smoEing among the teenage bou_s remained at the same level (30%). • ..The girls previously were lighter smokers; now they are heavier smokers than the boys. While gains in curbing smoking have not been chalked up among the boyS, it is clear that the first priority today must be the girls-- for this is where the increase is occurring. Factors Contributing to Teen-Age Smoking een -age ing n the t tern parallel. Many of the same conditions are responsible for both the continued smoking rate among the teen-age boys and the increase among the teen-age girls. These include the following: Fewer Television Spots Fewer teen-agars of either sex are now exposed to television commercials than s.='z years ago. With the banning of cigarette advertising on television, free anti-smoking spots were serious!V cut back. The ._results te.Zl the sto.--L,'. About one-half as many teen-agers now see anti-smoking commercials in a single month as did then and in addition they find the anti-smoking commercials less effective. A ,'-fore Relaxed Anti-Smokinq..C..iimate The main authority fi~,u~-~ in a teen-ace,"s 11"~,~'9-- L~a~en2s sc:noois teachers, doctors appear to be taking a laissgz-fa~re atcitu,:2-e ioward teen-age smoking. Schools have set up s~mcklng areas--whicf~ ha'..,e had special impact among teen-age girls. ?arents kno~o/ their teen-age chi ~ - ~dren smoke even if they don't approve of ~t. Teen-agers buy Cigarettes freely although in many states it is illegal. Doctors do not warn the teen-agars about the dangers of smoking. Pervasive Smokinq Environment Teen-agars, bogs and girls overstate the total smoking environment and think that almost everybody is a smoker, especiaiTy their own Peers and their teachers. Amonc teen-agers, there is a definite reeling that smoking in ceneral is on the increase esDeci-" ; among women• ~anCancer Societu~ Stud9 of ~een-Age Smoking, 1969. T107581626

Cigarettes Are Bad--but the Dangers Are Exa~c. erated for My Zge Group Teen-agers have no illusions about cigarettes. On the one hand, the9 even tend to overstate their dangers, but still and all they think the dangers are exaggerated for their age group. The boy smokers, in particular, resist the health hazard story for their peer group. Advertisinq Cigarette advertising helps to reinforce and enhance the image of the teen-age smoker as young, attractive, healthy and sexy. Anti - -~mo~.in~ Education Anti-smoking education in the schools is valuable if it is given early enough. The problem is that most teen-agers--boys and girls-- now start to smoke before they are in junior high. These trends tell part of the story of what is happening among teen-avers as far as smoking is concerned. There is, however, an even more interesting part. which in turn explains why smoking is on the increase among the girls, and leveling off among the boys. It is simply this: The Teen-Age Boys Compared to the teen-age girls, teen-age boy smokers have changed less than the girls in their attitudes, needs and feelings about themselves as far as these relate to smoking. With teen-age boys, cigarette smoking goes together with social uneasiness, the need to be popular wit); the opposite sex, the urge to prove one's masculinity, it is an intrinsic part of adolescent bou_, rebelliousness--as it has a~wa~s been. "-he Teen-Ace Gf r!s The oicture which emerges regarding the teen-age girls, however, is ver'.4 different. For in this instan'ce, .a real change has occurred in the .~revaiiing social norms and the differential between boys and girls has been blurred. The teen-age girls, tee, have been mot.= influenced by the new youth values than "the boys-- with their emphasis on greater sexual freedom, more stress cn self, :-no i.:ngorcance cf the emotional rather than the rational. The ceen-a~.'e girl smokers are socially far more .at ease, more "~'cphisticated" than their male peers, less in need of social props but on che other hand, even more inveived ~-ith the concept of the ne'.~ sexual freedom. The rebelliousness--once far more the province ef the bovs--is now very much a part of the girls' environment as well. Girls are joining in with the ~.~oys--and smoking pot, drinking a!cohci, and getting in trouble with the authorities. It is not just in cigarette smoking that the teen-age girls are catching up with the T!07581627

~d , they think • ersI of the • as n g part-. • ~ ge d 'ops king .~ the ~cat!ons for Anti-smoking Education what are the :fmplications for anti-smoking education in this environment? new The job is harder and more urgent than ever before-- for there is a trend toward smoking among the girls that could be contagious. Unless the tide is reversed, the boys may begin to smoke in larger numbers too, to catch up with the girls. 2 o In some ways, though, the job is easier for groups perhaps more than in the past, many of t~e same appeals will work equally well for both groups of young teen-agers. The importance of physical fitness (important to both boys and girls) . ... The importance of physical appearance (slightly more important to the girls but a majority phenomena for both boys and girls). ... The emphasis on being in control of one's own life. ... The stress on sports and the credibility of athletes as "nonsmokers." ... The need for greater visibility of the nonsmokers, the real majority. ... The mobilization of new forms of peer pressure, i.e., the militant nonsmoker. All of these are covered in the recommendations in the present "Study on Smoking Among Teen-Age Girls and Young Women" We would, however, like to stress two major considerations ~hat must be kept in mind in dealing with the teen-age constituency: The boys are less likely to listen than the girls. They are less secure in this adolescent period, and l..~9s convinced about the hazards of smoking. Fewer of them have tried to quit to cut back than the girls. Sports, physical fitness, are their big motives not to smoke--or to quit smoking. On z~'.e c~hec hand, one big advantage is that the boys don't get the same pressure from girl friends to take up smoking as the girls boys. The girls are looking ~o be in the vanguard--even in an anti- smoking crusade. Teen-age girl smokers are more concerned than the boys about smoking. Two out of three (64~,~) have made an attempt to cut back compared to 48 per cent of the teen-aqe hops. A majority (59~) have tried to quit compared to onl~" 39 per cent of the boy smokers. They are somewhat more apprehensive about the health hazards of smoking--and also worry more than the boys about bad breath, cigarette odor, and what it might do to their children later on. TheV are also more convinced hhat cigar- ettes are addictive (believe smoking is as addictive as illegal drugs; teen-age girl smokers, 52%; teen-age boy smokers, 38%). Most important, perhaps, the teen-age girl smokers don't think that smoking is a social asset, the bo~s do. T107581628

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-43 - The survey, "Adult Use of Tobacco - 1975", was conducted under the auspices of the National Clearinghouse for Smoking and Health, Bureau of Health Education, Center for Disease Control, Public BealthServlce, Department of Health, EDucation, and Welfare. This report is issued Jointly by the Prevention Branch, Division of Cancer Control and Rehabilitation, National Cancer Institute, which assumed a major responsibility in the preparati6n of the report, and the Center for Disease Control. The study was conducted by Chilton Research Services under Con- tract CDC 21-74-520. TI07581630

iNTRODUCTION -44- In 1964, 1966 and 1970, studies were conducted among the adult (21 and over) population of the United States in order to determine attitudes, knowledge, and behavior related to use of tobacco--especially cigarette smoking. The 1964 study was the first n~tional study in this area and established baseline data. The 1966 and 1970 studies included reinterviews with respondents who had participated in previous studies. All interviews were conducted with adults 21 years of age and over, both cigarette smokers and nonci~arette smokers. Since the study of cigarette smoking among adults in the United States in 1970, federal and private agencies have exerted considerable efforts to educate smokers about the kno~ adverse effects of smoking on health. Legislation has been enacted to . warn current smokers, to discourage new smokers and to protect " nonsmokers. Ergo.t= ~-o discourage smoking, such as placing restric- tions on cigarette advertising, mandatory warning labels on cigarette packs, and increasing taxes on cigarettes, have been made. With a lapse of five years since the last national study, it is necessary to determine what changes in behavior and attitudes have taken place since 1970; therefore, this 1975 study was under- taken. Detailed information is available on respondents who partici- pated in the 1964, 1966 and i970 studies. By comparing changes in 1975 behavior and attitudes with previous years, these continuing studies provide valuable information about trends on progress of altering smoking behavior. Also, information about attempts to cease or change cigarette smoking practices is useful in determining the factors related to stopping cigarette smoking. Finaiiy, the attitudes and perceptions of both s~okers and non-~moker~ p~ov~de a description of the national environment in which anti-smoking forces must operate. T!07581631

BACKGROLrND Cigarette smoking continues to pose a major public health problem in the United States, in spite of more than ten years of effort on the pare of concerned organizations and individuals to counteract it. The extent and nature of the problem are the subject of continued study 5y the Federal Government, The first national survey was conducted in 1964 and was followed by surveys in 1966, 1970, and the one repgrted on here, in 1975. Results 1 from the 1964 and 1966 surveys are described in Us_~eo__fTobacc____~o, those of the 1970 survey are contained in Adult Use of Tobacco 1970,2 Purpose. The purpose of the 1975 survey was twofold: (i) to evaluate possible changes in knowledge, attitudes~ beliefs, and behavior concerning smoking that have taken place since 1970, and (2) to provide in-depth information to all who have a continuing and concerted interest in the problem, so that all smoking programs can be maximally effective. Samm!e. The majority of the interviews were conducted by tele- phone, the remainder in face-to-face interviews in non-telephone households. The data are based on approximately 12,000 interviews of adults 21 and over, all of which were conducted by Chilton Re- search Services of Philadelphia. The telephone samples were randomly selected by a computer from a bank of all possible combinations of area codes, telephone exchanges, and subscriber numbers with a sufficient surplus of selections to allow for the elimina~ion of nonresidence telephones. Standardized questionnaires were administered by trained professional interviewers. The non-televhone samples were designed to a!lew greater representation in geographic areas kno~a~ to hnve a hizh prevalence of non-telephone households. Definitions. The respondents were classified by smoking status into one of the fo!!owin~ categories: Never Smoker - A person who has never smoked as man7 a~ as !gO cigarettes (5 Fac:<ages7 in h±s ..... War arettes during his lifetime. IU.S. Deparnmen." of Iiealth, Education, and Welfare, Use of Tobacco: Practices. Attitudes, Knowledge, and Beliefs. Public Health Service, July, 1969. 2U.S. Department of Health, Education, and ~elfare, Adult Use of Tobacco 1970 Public Hea!.th ~ ~ - . Se_v~ce, June, 1973. T!07581632

-46- Deflni~ions. (contlnu~d) • Current Smoker - An ever smoker who now smokes cigarettes. • Former Smoker - An ever smoker who does not now smoke cigarettes, but who once did. OrKanization of the Rap.9_~. The salient results of interest to a wide audience ~re outlined in the section titled Discussion of FinHings. Those wi~h special interests should examine appro- priate tables in more detail. In some cases, comparisons are made with earlier findings; readers concerned with other compari- sons should refer to previous publications. T107581633

:47- - DISCUSSION OF FINDINGS I. Demographic Data A. A_~9_and Sex Between 1970 and 1975, there was a slight decrease in =he proportion of adult cigarette smokers in the United States. In 1970, 42.2 percen~ of adult males reported that they were cigarette smokers while in 1975, 39.3 percent were smokers. The corresponding percentages for females were 30.5 percent in 1970 and 28.9 percent in !975. Among men, decreases in the proportion of smokers were observed in every age group except the oldest. There was prac- tically no change in the proportion of men aged 65 and over who are cigarette smokefs. Among women, there was a small increase in the number of smokers in the youngest age group 21-24 years of age, and a slight increase in the 55 to 64 year old age group. There was no change in smoking behavior of women who were 65 years of age or older. There was a decrease in the proportion of cigarette smokers in all other age groups. In every age group, in both sexes, the proportion of smokers was smaller than would have been predicted from previous data obtained in 1970. Chart i shows the proportion of current smokers in each age and sex category for each of the four surveys. B. Marital Status The maJorit'y of the respondents (78 percent of the ~:en ~nd 71 percent of the women) replied that they were married. Since they comprise such a large part of ~he ~otal Dopulation, their smoking rates parallel those of the total population, in the married group there is a slight drcp in the proportion cf curre~ smokers since i970--from aO percent to ~ percent fcr males, anl from 32 percent to 28 percent for f~ma!eso About the same percentage of males who have never be~n married~and males who are married are current smokers. Single females have a slightly higher rate than those who are married (31 percent and 28 percent respective!y). Both males and femaie~ show a substantially lower smoking rate than in 1970 (56 percent ef single males and 36 percent of sin~ie females were curren~ smokers in 1970). Ti07581634

-48~ The highest smoking rates are among ~hose who are divorced or separated. ~hi!e only one-third of the respondents who are married and living with spouse are smokers, 60 percent of the men and 50 percent of the women who are divorced or separated are smokers. This represents a substantial decrease from the 1970 data showing that 76 percent of the men who were divorced or separated were smokers, but at the same time, it represents an increase from the 44 percent r=te for women reported in that year. Men who are widowed have a slightly lower smoking rane (36 percent) than those who are married (38 percent). Widowed women, however, have a much lower rate (19 percent) of cigarette smoking than do married women (28 percent). This probably re- flects the lower smoking rate among older women. The proportion of smokers among both m~les and females in this marital category (widowed) is little different from that observed in 1970. To summarize the marital status category, the data show that men and women who are divorced or separated are more likely to be cigarette smokers than are persons who are married, widowed, or single, in all marital categories, a greater proportion of men than of women are smokers, C. Socioeconomic Status i. Educational Level. The smoking rates are lowest for those who never went to high school--37 percent for men and 18 percent for women. Because educational level is related to income, there may be a corollary between income and the cost of cigarettes for persons in this education group. At all other educational levels there is a decided relation- ship between the amount of education and smoking behavior, with a decrease in the proportion of smokers at higher educational levels. ~ong males, those who attended high school but not college showed 46 percent current smokers, those with some co!le~e, 36 percent, and those who graduated from college, 28 percent. Comparable proportions for women are 32 percent, 32 percent, and 21 percent. An examination of quit rates shows that half of the college graduates who ever smoked cigarettes are no~ former smokers. 2. Occupation. Among males, white collar workers (including sales personnel) are much less likely to be current smokers (36 percent) than are those in all other ocnupations (~7 percent). This finding is consistent with the relationship between educa- tional level and smoking behavior. T107581635

Two-fifths of the women in the sample reported that they are employed outside the home. Of these employed women, one- third are current smokers, while only 27 percent of those who classify themselves as housewives are smokers. This finding tallies with previous evidence of greater prevalence of smoking among working women. Among the employed women, white collar workers are more likely to smoke than are those in other occupations (34 percent and 32 percent,respectively) - a relationship opposite to that found among men. 3. Income. Family income is related to smoking rates with both males and females, but in different ways. Men in relatively affluent families are less likely to smoke while women in this group are more likely to be current smokers. Only 35 percent of the men who reported an annual family income of $20,000 or more are cigarette smokers, while 46 percen= of the men in the $7,500-$10,000 range are smokers. Among women, however, there is an increase in smoking from 24 percent for those in families earning under $3,000 to 34 percent for those with incomes of $20,000 or more. Ii. Attitudes In this part of the survey, respondents were asked the extent of their agreement with each of 19 attitude statements. For each statement, they indicated their preferences by choosing one of the following categories that best represented their attitudes: "strongly agree", "mildly agree", "no opinion", (or "don't kncw"), "mildly disagree", "strongly disagree". To facilitate interpretation of the data, results are reported here by only three categories: "agree" (the sum of ';strongiy agree", and "nildly agree") "no opinion", and "disagree" sum of "mi!diy disagree" and "strongly disagree"). It. addition, unless other~,lise noted, all results in this section are reported for males and females combined, as there are few sex differences in responses to these questions. A. Smokina and Health A very large majority of respondents believe that cigarette smoking is detrimental to health, as evidenced by the fact ehat 90 Fercent ngree that smokin~ is ha~..fui, 84 percent think it is enough of a health hazard for something to be done about it, and 82 percent believe it frequently causes disease and death. Although the agreement with each of these statements ~as extremely high in 1970 (87 percent, 86 percent, and 76 percent,respectively), it was even higher in 1975 on two of tke three items. A~reemenz T107581636

they one- ~- who ! ing chat both is :t of ~e rose from 87 percent to 90 percent on the statement about smoking being harmful to health, and from 76 percent to 82 per- cent on the one ccncerning disease and death. The slight decrease from 86 percent to 84 percent on the statement concerning the importance of doing something about the hazard of cigarette smoking reflects a change among current smokers only, but not for former smokers or those who hsve never smoked. Even those who are current smokers show a high rate of agree- ment with these three statements. ~he agreement rate is around 70 percent for the statements on h~inh hazard and disease and death, and 80 percent on the general statement about harmfulness to health. In sunun~ry, awareness of the definite relationship between smoking and health has increased greatly over the past decade, B. Remedial Actlo______~n- General Most people acknowledge that smoking has harmful effects on health. However= there are still a substantial number who feel thac the status quo should aot be disturbed. In fact, 42 percent believe that nothing more should be done about cigarettes until the cigarette manufacturers are given a reasonable amount of time to come up with a safer cigarette. While this is a decrease from the 46 percent holding this point of view in I970, it is surprising that such a large proportion still agree with this. Approximately the same proportion, 40 percent, agree that the general public knows all it needs to know about the effects of smoking on health. In 1970, 43 percent of the public agreed with this statement. This seems to indicate a willingness of more people in havin~ information about the hazards of cigare=te smoking disseminated to the public. Only about one in five view cigarette smoking as ~ minor problem, ~he same as in 1970. C. Remedial Action - ExemD].ar~ ~[ore then three out of every four respondents feel that teachers, doctors and other health ~rofessionals should set a good example by not smoking cigarettes. For each of the three groups, there is an increase over that found in 1970. l~nile it is under- standable that fewer smokers than non-smokers agree, it is signifi- cant that almost two out of three smokers feel thmt members of these groups should set an example. D. Remedial Action - Settin~ Limits There has been a growing feeling that non-smokers have a right to be allowed to breathe air free from the contaminants in cigarette smoke. The most dramatic change in attitude over the T107581637

years is toward the statement, "The smoking of cigarettes should be allowed in fewer places than it is now". Only 52 percent agreed with this szatemen~ in 1964 and 1966, but 57 percent agreed in 1970, and 70 percent in 1975. Between 1970 and 1975, this increase took place among current smokers (from 42 percent to 51 percenn), among former smokers (from 61 percent to 77 percent), and among those who have never smoked (68 percent to 82 percent). This means that more than half the smokers at the present time would like to see smoking allowed in fewer places than it is now, despite the fact that there are more and more restrictions on places where people are allowed to smoke. Since so many people would like to see smoking allowed in fewer places, it is not surprising to find that nearly two-thirds .(63 percent) of the respondents say that it is annoying to be near a person who is smoking cigarettes. Ten years ago less than half of the total number of respondents (46 percenn) agreed with this, and now even more than a third of the smokers (35 percent) do so. A ban on cigarette advertising was advocated by a little over one- third (36 percent) of the 1964 respondents. By 1970, this had in- creased to 60 percent. Since then, television and radio commercials advertising cigarettes have been banned. Because these two media were the most widely used for advertising cigarettes, it might be presumed that such a ban would satisfy the public. This is not sc. In 1975, 56 percent believed that cigarette advertising should be stopped completely. This view is subszribed to by 51 percent of the men and 60 percent of the women. Two out of five smokers would like to see cigarette advertising stopped, perhaps because some smokers who are trying to quit find that the advertisements make it more difficult. A second possibility is tha~, while they continua to smoke, they are loath to see the younger generation take Because of the grc;..,inc feeling [hat s.-..cking should be regulate:| more stringent!v questions were added ~o the 1975 survey to "'o the matter of regulation more fully. First, [he question, "De you favcr stronger Federal regulations concerning cigarette smoking?" elicited 52 percent "yes" res2onses from men and 60 percent fro~omen. >[ore than i~ percent o~ curren~ smokers even favor such regu].atiens. Another area explored was whether management does or does no~ the right to prohibit smoking in its place of business. Only 1"% percent of the respondents felt that management should ne~__q i~ve ,~he right, while 78 percent though~ they should have the right; the eti~er 6 percent were undecided. ~:~ ,~~ghty percent o~ the women and 75 percent of the men thought that management should have the rich to prohibit smoking. Of those who felt this :~ay, "IB percent lieved that they should be able to do this eniv when smokinB is a T!07581638

should ~t agreed -' in ncrease :.tong .~ s means "~- to the ' Rear .~ne- in- : ials ~o. it ~re safety hazard, while 7"1 percent said they should have this privilege whether in is a safe~y hazard or not. Respondents were asked if they found it annoying to be near a person smoking cigarettes. Those who said "yes" were asked whether they found cigarette smoking more annoying than several other things that might be bothersome. The majority of these respondents expressed the be!Jar Ehat ciBarettes are more annoying than smoking a pipe, cracking knuckles, chewing gum, and hum~ing or whistling. At =ne same time, a greater number of people said that smoking cigars is more unpleasant than cigarettes, and about the same number found cizarette smokin~ ~ore annoying than drink- ing alcoholi~ beverages as found drinkin~ alcoholic b~zerages more irritating chat smoking. E. Present vers~:-; '.:u~-'a:-e Orlent:~a.!on Two gr~:~ps of .s::ace~nen=s w.~re included in the 1975 survey that do not mead!on elga:e~ce ~mokinT~, bun ~:ere hyFothesized as being related to smok~_n~ behavior, One group of statements explores a~titudes t~:ward p!.an:-.ing ahead as opposed to enjoying the present, Three cut cf f'::~r z'esecndents agree tha'~ having money puz aside for a rainy day :na~e:~ "hem happier than ~pending it now. More non-smokers than smokers agree with this statement (77 percent and 73 percent,respectively). Three out of four respondents also agree that one of the things they enjoy most is planning ahezd. More non-smokers (79 percent) than smokers (72 percent) express agreement with this, and a larger proportion cf men (7~ percent) than women (74 percent) agree. better to ~,':::+ take ~hLn-..s -n.~ g[.e., come "" ... ~_n~_. £0 try ........... e--- nabs;an zn the future. Azain, mc.r~ ~mokers than no~--m,,:'_. =.,,..,=.~= ~end _.,~ be orion{led to t~]e present Fatalistic. var3u~ C,)ntrol 3~-i~an~ation to believe ahat ~'he,: "av= !iu:_'ie c-~- no con,-rel over wha" hamDens to them, statemen~:s were included n3 test this hypothesis. More smokers than non-smokers believe ~hat what happens co people depends !ar~ely on luck or f%te (44 percent of smokers and 37 ~ercent of net-smokers a~ree). There is no difference between former sm;~ker~ and those who have never smoke~. T107581639

There was practically no difference between smokers and non-smokers in a~reement with the statement that working hard is no guarantee of success if fate is against you (42 percent and 40 percent,respectlvely). Approximately one in three (32 percent) of the respondents think that the best way no get ahead in life is to have good luck. There was no difference between smokers and non-smokers, but former smokers agreed to a lesser extent. FACTOR SCORES Table A shows mean and standard deviation of scores on six factors, hypothesized and tasted through factor analysis techniques of the 18 attitude statements. These scores were obtained by assigning values of 1 to 5 according to the re- spondent's answer on the Strongly Agree-Strongly Disagree continuum. In most cases, Strongly Agree was assigned a score of 5, Mildly Agree a score of 4, No opinion a score of 3, Mildly Disagree a score of 2, and Strongly DisaEree a score of 1. There were three statements per factor, and scores on these three- item factors had a range of from 3 to 15. Factor I, called Smoking and Health, measures the extent to which the respondent agrees that there is a causal relationship between smoking and disease. The higher tile score, the greater the acceptance of such a relationship. The items in this factor are : a. Cigarette smoking frequently causes disease and death. g. Cigaretee smoking is harmful to health. Cigarette smoking is enough of a health hazard for somethin7 to be done ~beut it. Factor 2, lakeied ~amedia! Action - &enerel. ~ests the atti- tude for or. against "disturbing the s~amus quo." A high score means tha~ the re~>cndent feels that the problem isn't very important: nothin~ more sh3u!d be done ~bout it. Items are: d. The genzr~i public knows all it zeeds te know about the effects cf smoking and health. j. Nothing mare should ba done about ci~aretEes until nile cigerette manufacturers ar~ given a reasonable amount of time to come up with a safer cigarette. p. The whe!e Frobi.~:m of ,~i~xrett:~ smokinZ ~nd health ia a very miner one. T107581640

.: ts ~rS, !y -54- Factor 3, Remedial Action - Exemplars, is a measure of the respondent's attlt~de toward the responsibility for setting a good example by certain authority flgures--doctors, persons in various other health professions, and teachers. A high score reflects the feeling that these groups should set a good example by ~ot smoking. Items in this cluster are: b. Teachers should set a good example by not smoking cigarettes. h. People in the health professions should set a good example by not smoking cigarettes. n. Doctors should set a good example by not smoking cigarettes. Factor 4, Remedial Action - Setting Limits, concerns attitudes toward "doing something about" the cigarette smoking problem. A high score indicates that the respondent is in favor of remedial action- The items making up this cluster are: e. Cigarette advertising should be stopped completely. k. The smoking of cigarettes should be allowed in fewer places than it is now. q. It is annoying to he near a person who is smoking ciga- rettes. Factor 5, Present versus Future Orientation, determines the extent to which a person is willing to delay present gratification for future satisfaction. A high score is indicative of this will- ingness. The first statement in this cluster (f) states the opposite view--a preference for taking things as they are rather than preparing for the future. Therefore, this item is scored i~ reverse. That is, Strongly Agree was assigned a score of 1 and Strongly Disagree was given a score of 5. The items are: f. It is better to just take things as they come than to try to prepare for something that might happen in the future. i. Having money put aside for a rainy day makes me happier than spending it now. r. One of the things I enjoy most is planning ahead. Factor 6, Fatalistic versus Control Orientation, is a b~polar measure with "destiny control" at one end and "luck" or "fate" at the other end. Because of the way in which the items are worded, a high score describes a strong feeling of dependence on "luck". Items are: c. What happens to people depends largely upon luck or fate, i. Working hard is no guarantee of success if fate is against you. o. About the best way to get ahead in life is to ],ave goo6 good luck. T10758164-1

-55- The average score on Factor I, Smoking and Health, was higher for non-smokers than for smokers, as might be expected. Even current smokers, however, show a high acceptance of the causal relationship between smoking and disease, with a mean score of i!.73 out of a possible maximum score of 15. Women obtained slightly higher scores than men. on Factor 2, Remedial Action - General, e high score indi- cates agreement with the attitude that no further action should be taken with regard to cigarette smoking. Current smokers are most inclined to subscribe to this opinion, those who have never smoked next, and former smokers are least likely to agree. Non-smokers have higher average scores on Factor 3, Remedial Action - Exemplars, than do smokers. ~Smokers are much less likely to agree that people in an exemplar role should refrain from smoking than are non-smokers, perhaps because of smokers' awareness of the difficulties encountered in not smoking. Those who have never smoked are most likely to want these people to set an example. Overall, women have higher scores than men on this factor. On Factor 4, Remedial Action - Setting Limits, higher scores are found among the non-smokers than among the smokers, as would he expected. Women are more likely than men to want to set limits on cigarette smoking. The measure of present versus future orientation~ Factor 5, does not relate to attitudes toward cigarette smoking. However~ non-smokers are slightly more likely to be future-oriented than are smokers. If we postulate that smokers are reluctant to delay present gratification for future gains and, at the same time, tend to minimize the health hazards of cigareL~e smoking, =he findings =~ ~cm Factors 1 and 5 substantiate the hypothesis. On Factor 6, it was found that former smokers are more in- clined than either current smokers or those who have never smoked to Believe that they have control over what happens to them. The fact that they have overcome a difficult habit which current smokers have not done an& that never smokers have not had to face lends credence to this finding. To summarize the results of the data, a current smoker is more apt to discount the heal~h hazards of cigarette smoking, to agree that no further action should be taken about smoking, tc disagree with statements that certain groups should Be exemplary by re- fraining from smoking, to express reluctance with the idea of setting more prohibitive limits on future gratification, and to believe that what happens to them mostly depends on luck or fate. T107581642

G. There is a widespread belief that being afraid of gaining a lot of weight keeps people from quitting cigarettes, In fact, 50 percent of the men and 60 percent of the women agree wi=h this statement. Surprisingly enough, more non-smokers than smokers subscribe to this belief (57 percent and 53 percent, respectively). Values In order to ob=a±n some measure of the value the respondent places on "being healthy" compared to other desirable goals in life, a series of forced choices were presented. For example, the respondent was asked, "Which is more important to you, having a good family life or being healthy?" In six of the statements presented, "being heal~hy" was compared with some other value. There were five "flilerI' pairs that did not present a choice with "being healthy". In every case, being "healthy" was chosen more often than the other alternative. In order to get an estimate of how much value each respondent places on health, a score was developed by counting the number of times he chose health over the other alternatives. These scores range from zero to six with six representing the greatest concern about health. Among men, form.er smokers were more likely than never smokers to obtain a score of six, and they. (never smokers) were more likely than current smokers to obtain a score of six. Among women, the same proportion of never and current smokers obtained a score of six, with more former smokers obtaining this score. Women in every smoking category were more likely to obtain a score of six than men in the same category. This finding could be expected since ~omen, traditionally, have responsibility for the health and well bein~ of the family. I. Attitudes To___ward Effect o__~n.One'_~s_Own Health I. ~o cu~ of three smokers are concerned abouu the poss~'~ effects of cigarette smoking on ~heir health. In fact, one in four smokers is ver____~ concerned. There is practically no difference between men and women in response to this question. 2. When asked their opinion about the relative hazards of different kinds of cigarettes, 40 percent of the respondents say that some kinds of cigarettes are probably more hazardous to health than other, 52 percent agree that all cigarettes are probably about equally hazardous, while less than 3 percent (mostly smokers) think that cigarettes are probably not hazardous TI07581643

III. at all. Smokers are more likely than non-smokers to believe that some cigarettes are more hazardous than others (51 percent of the smokers and 34 percent of the non-smokers). Half of the smokers who think there are differences among kinds of cigarettes believe that the kind they smoke is probably less hazardous to health than others. More women than men (56 percent and 47 per- cent, respectively) subscribe to this. It is true that women tend to smoke cigarettes lower in tar and nicotine than do men. 3. Two-thlrds of those with a history of smoking say that they have never been advised by a doctor to quit smoking or to cut down. Among current smokers, a few more women than men (38 percent and 35 percent) report that a doctor has advised them to do something about their smoking. Perception of Environment A. 20 "Adults You Know" Respondents have a tendency to overestimate the pr&valence of smoking in the adult population. Although fewer than 7 in 20 adults are smokers, nearly half (48 percent) of the respon- dents think that Ii or more of 20 adults they know are smokers. More males than females (53 percent and 43 percent) perceive this number of smokers am6ng 20 adults they know, and more smokers than non-smokers (63 percent and 40 percent) have this perception. The latter might be attributed to two phenomena: (i) Smokers may actually be acquainted with more smokers than non-smokers~ and (2) smokers may tend to perceive others as being like themselves, and so overestimate the actual number of smokers among their friends and acquaintances. it is significant to learn than in the five-year period from 1970 to 1975, when there was a slight decrease in smoking prevalence, there was also a corresponding decrease in the ception of prevalence. Using the arbitrary cutoff of knowing ii or more smokers out of 20, the proportion perceiving this smoking rate dropped from 57 percent to 53 percenn among men, and from 46 percent to A3 percent a~ong women. B. Smoking Behavior of Family Doctor Of those who reported having a family doctor, 22 percent cf the men and 18 percent of the women report that their doctor smokes; 52 percent of the men and 54 percent of the women say he doesn't smoke, and 26 percent of the men and 29 percent of the women really don't know whether their doctor does or doesn't smoke. (Only about i0 percent of the men and 6 percent of the women in the sample re- ported that they do not have a family doctor.) T107581644

eve Percent of the [gate ttes • '~ tO 7 Per- ".an tend : (38 -58- For both sexes: :_he it. r5 da-'a slow a decre:~s~, in -'he propor- tion who thin_____~k thai': u~zr-ar :s a &moher. Ib.e decrease is from p~_=u_nu ~monr_~ men and from 2° percent to 18 24 percent ~o 22 "-'~ - . - • percent among women. ±rim= may tel!eat a decrease in the preval- ence of smoking among physlcian~, or it may s=a.m, f=~'om a chan~e ~n what the general pcpul.'."-ien he!laves. Smokers are more iikaiy .=c ".-aport aha.= their doc"-crs smoke than are non-smokers. Thep=-~...,~a-~ ...... ..... o_=~ ........ =..-= 9=. [.:e~cent and 20 per- -.. .,.o e:" c ,=.::..: ,,-'he tner cent for men, and the doctor actual.-"--:. .~:,,,k=~_ o:- nor, 3mo:.4.z.v~s a:.'.~. ..,~.:=_ iikely to perceiv__e the= the'.'.; i. H~e_'al_/%n ='." gene,_'~:..i. .~.. _i..:tle o-:z~=" half the respondents ~:~7 ::h .... • .... ~---e~,'--....-..~.~,u=.,~ ha~ .:ffm::%.~.d th'e health of someone ,'"~-'," .:,:.'.':}e ',~: "' ~.,'.n~'.~--.<.'::,':h ~.=, a friend, chem~=ei r.:-~ :--.~," .... :..,=-.'.:e z: qc_'k., ,.~r :'=.;me ..;'~ue'" ...... .-.-:c:]ua'. ntance" . greater knowledge c.f ,:ha i}~.-m,f'41 effeacs of smoking. As in 1970, smokers are ~:~.uch less likely than non-smokers to report that they know someone, including the'mse!ves~ whose health has been affected by smokin_e. Cnly 35 ~e:¢cent of the smokers say that they know someone vhose health has been affected by smoking, while 61 percenu af non-:~moke£s claim kn.~wla~a ~ someone with a health condition inluce~ hy :~mokin~. ~t is {.c~.~i:-.].e tn~.t smex~!rs suppress this knowledge i= cf:iac no: uo feel t.:~ ~uch con=con cr guilt about their ~mckin~. T107581645

IV. -b9- For each of the three diseases, as with the general health question, smokers are much less likely to give a positive re- sponse than are non-smokers. For example, 47 percent of smokers say they have known someone with coronary heart disease, while 56 percent of non-smokers say they have. Comparable propor- tions for lung cancer are 27 percent of smokers and 39 percent of non-smokers; for emphysema and chronic bronchitis, 51 percent and 58 percent. At first glance, we might think that smokers who have known someone with one of these diseases have quit smoking. This explanation is not tenable, however, in view of the fact that there is little difference in the way former smokers answer these questions in Gomparison with those who have never smoked. Smokers are slightly younger than non-smokers, so that older non-smokers may be more likely to observe these diseases in themselves and in their friends. It is also possible that there is some element of denial and rejection in the smokers' responses. Smoking History The questions on smoking history were asked only of former smokers and current smokers. One-half the males and one-third of the females with a history of smoking were regular smokers at age 17 or younger. Only 6 percent of the males and 18 percent of the females became regular smokers at age 25 or older. Among males, there was a tendency for current smokers to report they started smoking earlier than did former smokers. For example, 53 percent of current smokers reported age 17 or younger as the time they became regular smokers compared with 48 percent of former smokers. Such differences were not observed among females. The majority of current smokers (61 percent) have, at least once, made a serious attempt to stop smoking cigarettes entirely. Of those who have not, about one-half say that if there were an easy way they would try it, about one-fourth say "probably" or "it depends$" and only one-fourth say "no," they would not try it. So, overall, 9 out of i0 smokers have either tried to quit smoking or would probably do so if there were an easy way to do :~ Two-thirds of the men and three-fourths of the women who are current smokers have tried to Just cut down the number of cigarettes they allowed themselves without trying to stoDsmoking entirely. The proportion of former smokers who have tried this is much smaller--50 percent of the men and 46 percent of the women. T107581646

~60Z ~ent s ~.:kers :ory Although a maj0rity of smokers apparently would like to quit, 57 percent say they will either definitely or probably be smoking 5 years from now. Very few of the non-smokers (1.5 percent) ex- pect to be doing so. Current smokers are, in general, smoking fewer cigarettes a day now than they were during that period of life when they were smoking their heaviest. Among men, 36 percent now smoke 25 or more cigarettes a day, but at their heaviest, 42 percent were smoking 25 or more a day. Corresponding percentages for female current smokers are 23 percent and 26 percent. On the average~ men have smoked cigarettes for more years than have women. Men current smokers have smoked an average of 2A years compared with 21 years for women. Male former smokers smoked an average of 19 years before they quit; females, an average of 15 years. Most former smokers (70 percent) have not smoked in more than 4 years. Fewer than I0 percent had quit within the year before they were interviewed. Dosage A. Ho__~_wth__eCigarette .is Smoked. Many current smokers smoke their cigarettes in such a way as ~o maximize the hazards. For example, more than half say that they draw the smoke into the chest (54 percent), and an almost equal number say that they inhale almost every puff of each cigarette (55 percent). ~nen asked how much of each cigarette they smoke, 64 percent report that they smoke more than half. As a rule, most smokers say that non much of their cigarettes burn without being smoked; fewer then 15 percent say that "a great deal" of the cigarette burns in this way. In general, men smoke in a more hazardous way than do women, and former smokers reported that they did so more than do current smokers. B. Averame Number of Cigarettes Smoked Per Day A_n important measure of dosage is the number of cigarettes smoked each day. Men smoke more cigarettes a day than do women, with the average for men being 23 cigarettes a day, and for women 19. This represents no change for the men, but an increase from an average of 17 cigarettes a day for women who were smokers in 1970. ~%ile 36 percent of the men smoke 25 or more cigarettes a day, only 23 percent of the women smo.ke this many cigarettes. Former male smokers are more likely to say they smoked this many cigarettes than do current men smokers. T107581647

-6]- C. Tvn__~_~eo__fCiKarette Most current smokers use filter-tipped king-size cigarettes (61 percent of the men and 54 percent of the women). More women than men tend to smoke i00 mm cigarettes (35 percent and 17 percent, respectively), and also menthol cigarettes (32 percent of the women; 23 percent of the men). Women are more likely than men to buy cigarettes by the carton than by the pack (60 percent and 51 percent,respectively). VI. Other Forms of Tobacco Snuff and Chewing Tobacco 0nly 3 percent of the men and i percent of women use snuff, and not many more use £newing tobacco--5 percent of the men and less than i percent of the women. A larger proportion of the men, 16 percent, have chewed tobacco in the past but no longer do so. There is very little change since 1970 in the use of either of these forms of tobacco. Bo Cigars and Pi_p~_~ Both of these forms of tobacco are used almost exclusively by men, with only about one-half of one percent of women using either. About 18 percent of the men smoke cigars, and another 25 per- cent used to smoke them. More current cigarette smokers than non-smokers are cigar smokers (26 percent and !3 percent,respec- tively), while the largest preponderance of ex-cigar smokers (41 percent) is among the former cigarette smokers. More than 35 percent of the ex-cigar smokers quit smoking cigars ten or more years ago, and another 19 percent quit between 4 and i0 years ago. Almost half the men (&7 percenn) have a hisnory of pipe use. with only about one-fourth of these current pipe smokers. Therm was a decrease in pipe smoking since 1970, from 18 percent to 12 percent. As in 1970, current cigarette smokers are more likely to be pipe smokers than are former smokers or those who have never smoked. Of those who smoked a pipe at one time and no longer do so, aimost half (46 percent) quit i0 or more~ ....... ~-~_ ago. T107581648

~arettes Dre women 17 Percent, the ~he carton 2 • ~62~ - _Cha~nEes lu SmokiuE Behavior During the years that a person smokes cigarettes, he is likely to change his smoking behavior in some way. For example, 12 percent of the male current smokers have at some time changed to or smoked more cigars, and 18 percent changed to pipe or smoked a pipe more often. Thirteen percent of current smokers increased the amount of each cigarette smoked while i0 percent smoked less of each cigarette. Ten percent of the males and 61 percent of the females changed completely, at least once, to ~ different Brand of cigarettes. • huff, : n and -.he -'nger "ere D TI07581649

CIGARETTE SMOKERS ~- -- ----"I'1 -:-1~~- ~'-~=.. : i ~- DECLINING MINORITY / I I ......... i .......... " 1964-1966 1970 1975 32.5% 28.9% I I o ~4 O~ Oo I~] fVIALES 21 AND OLDER [---] FEMALES 21 AND OLDER iPERCEI"JTAGE IN EACH CATEGORY WHO ARE SMOKERS}

i WHO ARE SMOKERS) MALE ..... ~.,:.:o.~.*.'.sx- .....;',',' .,'.',','.°,','.'.':'.°.'.'.'.'.'.'.'.','.','~'.- 21-24 FEMALE 25-34 | I 37.4%1 - , .... '~, ".-" ............. ~ 7~/~u ~.:,....:.:.:.:.:.:.: ....:.-.:...:.:...:.:.:.: .......... ...:.:-: ............ 3 - % :'" .!:::"':?i':--'."i: ===================================== 55-64

CHARACTERISTICS OF ADULT SMOKERS -- 1975 MALE FEMALE MARRIED SINGLE DIVORCED/SEPARATED WIDOWED 50.0% WHITE COLt.AR BLUE COLLAR HOUSEWIFE I ! t4tGH SCHOOL GRAD. SOME COLtEG[~ COLLEGE GRAD. (PERCENTAGE IN EACH CATEGORY WHO ARE SMOKERS}

PUBLIC SUPPORT IS INCREASING FOR SOCIAL ACTION AGAINST SMOKING SMOKING SHOULD BE ALLOWED IN FEWER PLACES THAN tT IS NOW SMOKING IS ENOUGH OF A HEALTH HAZARD FOR SOMETHING TO BE OONE CIGARETTE ADVERTISING SHOULD BE STOPPED COMPLETELY THE PUBLIC KNOWS ALL IT NEEDS TO KNOW ABOUT THE EFFECTS OF SMOKING TEACHERS SHOULD SET AN EXAMPLE BY NOT SMOKING IT IS ANNOYING TO BE NEAR A PERSON SMOKIt~JG CIGARETTES 90.2% AGREED ~1975 72.5% J • , ... .... .- :.~; ..... . o/I ;:~iii:~':;: ~.'-." ~: i~;''6:':u::::"'::' ''';';~:''~::;:::::::::::'::: ................................... 0%

THE TROUBLED WORLD OF AMERICAN THEY KNOW THE CONSEQUENCES SMOKERS • ABOUT 70% BELIEVE CIGAFIETTE SMOKING FREQUENTLY CAUSES DISEASE AND DEATH • OVER 80% AGREE THAT SMOKING CIGARE-I-~ES IS HARMFUL TO HEALTH • OVER 70% SAY CIGARETTE SMOKING iS ENOUGH OF A HEALTH HAZAR.D FOR SOMETHING TO BE DONE ABOUT ABOUT IT 2 OUT OF 3 SMOKERS ARE CONCERNED AtJQUT EFFECTS OF CfGAREI-FE SMOKING ON THEIR HEALTI-I. THEY REALLY WOULD LiKE TO CHANGE • 6 OIJT OF 10 SMOKERS HAVE MADE A SERIOUS ATTEMPT TO STOP. ANOTHER 3 OF THEM SAY THEY WOULD TRY TO STOP IF THERE WERE AN EASY WAY. o 2/3 OF MALE SMOKERS AN{) 3/4 OF FEMALE SMOKERS 14AVE TRIED TO REDUCE THEIR SMOKING. BUT MAI.E SMOKERS, ON AVERAGE: • CONSUME 23 CIGARETTES A I~)AY (NO CHANGE FROM 1970) HAVE SMOKED ABOUT 24 YEARS 36% SMOKE 25 OR MORE CIGARE~'~'E£ A i')AY FEMALE SMOKERS, ON AVERAGE: CONSUME 19 CIGARETTES A DAY IUP I:FIf)M ]7 I1',1 1970) =. HAVE SMOKED ABOUT 21 YEARS ,,, 23% SMOKE 25 OR MORE CIGARETTE£ A DAY

I I I I Z Z I I I I

-68- ACS ANTI-SMOKING ACTIVITIES REPORT HIGHLIGHTS Prepared For ACS TAS~ FORCE ON TOBACCO AND ?ebruary I0 , 1975 T107581656

Introduction This report summarizes findings of a study of anti-smoking activities engaged in by ACS Divisions. The study findings are based on questio~ naires filled out and returned by 55 of the 58 ACS Divisions. The study was commissioned by the ACS Task Force on Tobacco and Cance; It was intended to provide information on the status of current activ~ ties and to provide guidance about areas for. future directions and activities for the ACS's anti-smoking efforts. The present report presents highlights of the results obtained. scale report of findings of the study will soon be issue~. A ful Legislative Action About 4 out of 5 Divisions report that there has been legislative or executive action on smoking in their Divisions (at the state, county or municipal levels) in the past ~ years. In some instanoes bills have been enacted.; in others bills are pending but have not yet been enacted. Efforts should be made to determine the sources of barriers to bill enactment. Professional Education The Divisions report that, on the average, about one-quarter of the doctors and about one-quarter of the dentists smoke in their Divisions. This is significantly below the level of s;P.oking in the general adult population. At the same time, the Divisions report that, cn the average, about two-f_,ths of the nurses smoke in their Divlsicns. Thla is no lower than the level of smoking in the general population (and is actuall9 higher than the level of smoking in the adult female population). These findings suggest that _~ast efforts directed aT J.cc~-ors and dentists have succeeded. More efforts directed at nurses are required. Less than half of the Divisions report that professional organi- zations have adopted official positions against smoking by members of their organizations. Formal anti-smoking stances have been adopted more by doctors' organizations (47%) and dentists" organizations (35%) than by nurses" organizations (18~,~) Less than half of the Divisions report that professional organi- zations have taken action to persuade their patients not to smoke. Formal action urging patients not to smoke is more co.-:.mon among doctors" organizations (38%) and dentists" organizations ~31%) than among nurses' organizations (16%). T107581657

n cer. ti vi- ful i- ve 7o -70- Only a minority of the Divisions report that special anti-smoking efforts have been conducted among professionals who deal wfth women of child-b'earing age. The incidence of Divisions reporting such efforts: OB-GYN specialists, 16~ pediatricians, !6~ pediatric nurses, 5~. About one-third of the Divisions report that they have conducted educational programs on smoking and health aimed at health pro- fession als. They report that they have reached 27,315 physicians, 14,085 dentists and 48,050 nurses with such programs in the past 5 9ears. Almost half of the Divisions report that the.~ have made special efforts to get educational units on smoking included in the curri- cula of schools for health professionals. Public Education The Divisions report that they conduct.~-d 25,509 adult programs on lung cancer, reaching 715,728 people, last year. The Divisions repol't that they conducted 1,660 ACS Quit smoking Clinics, reaching 19,883 smokers last 9ear. The Divisions also supported 516 non-ACS Quit Smoking Clinics, reaching 12,755 smokers, last year. .:. 10. Of various high-risk and potential smoking groups, the DivisiOns re~ort greater efforts expended against teenagers and adult heavy smokers than against women in child-bearing ages and pregnant women. While 75~ direc~.ed programs at teenagers and 552; at adult heav~ smokers, on!9, 24.~ directed programs at women in child-bearing ages and 26Z at pregnant women. (These latter findings reinforce Zhe findZng that on!~ a of Divisions have directed special efforts at gvnecologisrs and obs tetri cians. ) II. The Divisions report that 177 hos-~itais provide on-going Quit Smoking Clinics. This represents less than 5".~ of hcs.D~tals having such on-going facilities available. 12. The non-ACS organizations which Divisions most commonly report are involved ~_n anti-smoking activities are the Seventh Adventists (mentioned by 84~,~ of the Divisions); the American Lung Association (mentioned by 40~) ; and Smoke-E~ders (mentioned by 29%). T107581658

Youth~School Education 13. The Divisions report that they conducted 105,387 youth programs on lung cancer, reaching 3,159,!87 youngsters, last year. (2his is about four times the number of adult programs conducted and about four times the number of adults reached by such programs.) 14. The Divisions report that they conducted 501 ACS Quit Smoking Clinics among 11,470 youthful smokers last year. (This is about one-third of the adul~ 9uit Smoking Clinics that the ACS conducted last year). 15. The Divisions report that about half of the schools have incor- porated smoking education in the curriculum. This level holds about e~_ually well for elementary schools, junior high schools and senior high schools. 16. The Divisions report that abou~ one-sixth of the colleges and universities have smoking education programs. (This is considerably lower than the incidence of smoking edu- cation programs in elementary, junior high and senior hig,h schools) . 17. A little less tha~ half of the Divisions have taken official positions on designated smoking areas in schools. Of those Divisions who have taken a stand on this issue, most (20 Divisions) oppose designated smoking areas, but a few (4 Divisions) favor them. 18. Less than one-third of the Divisions report that State School Boards have taken official positions on designated smoking areas in schools. of those State School Boards who have taken official positions, ~ favored designated smoking areas in schools and 7 opposed 19. The Divisions report that they are aware of designated smoking areas in 1,098 junior and senior high schools. (Most of these are in senior high schools). (This zepresents only a small fraction of schools having desig- nated smoking areas for their students). Community Action 20. The Divisions report that 472 hospitals have taken action to prohibit smoking on their premises and 491 hospitals have banned the sale of cigarettes in their institutions. (These figures each represent less than one-tenth of the number of hospitals covered by the Divisionsl. T107581659

26. 21. The Divisions report that about 5~ of pharmacies no longer sell cigarettes. 22. About one-fifth of the Divisions have taken a formal stand on non-smokers' rights. These include 6 Divisions who favor non-smokers rights, 2 who are opposed, and 2 whose positions were not ascertained. 23. Almost two-thirds of the Divisions report that there are state- level Interagency Councils on Smoking and Health in their Divi- sions. In most but not all instances (32 out of 35 Divisions), ACS is a member of these Interagency Councils. A majority of Divisions feel that this membership is a worth- while expenditure of money and effort. 24. About two-thirds of the Divisions report that they have laws prohibiting the sale of cigarettes to minors. However, about one-third report that they do not have such laws or they do not know whether or not there are such laws. 25. A majority of the Divisions report that 18 is the age at which cigarettes can be legally sold. However, about one-quarter of the Divisions report that cigarettes can be legally sold to 16 year o!ds. About th_-ee-quarters of the Divisions repo-~± that they have taken action to restrict smoking in their institutions -- in offices, at meetings, at workshops, etc. Public Information 27. The following are the incidence:; of D:~visions reporting engag:ng in various tu_'pes of public information 9rograms and ,2fforts: Distributed anti-smoking s_~ozs in pas: !3 monEhs 95~4 Urged szations to use anti-smoking Publicized Quit Smoking Clinics S2 Distributed press releases about smoking S~ Distributed TV film, "Let's Call It Quits" 78 Distr~_buted ant~-smoking ads to daily and weekly press 76 Arranged for special TV smoking progra~--~ 60 TI07581660

Arranged for feature stories about smoking in press Promoted IQ campaign Distributed anti-smoking ads in industrial publications Interested radio disc jockeys in anti smoking programs Promoted anti-smoking campaigns in high school and college newspapers Distributed editorials about smoking Promotional tie-ins with "Feeling Good" special on smoking Arranged for "~ Day" type promotions 58 55 55 46 42 38 29 T107581661

-74- Division Recommendations The following is a summary of recommendations offered by the Divisions for future anti-smoking efforts. (As can be seen, there were some areas where consensus was expressed but other areas where Divisions made opposing recommendations). Legislation * Local legislation to restrict smoking in public places * Greater emphases on legislation Work to ban all cigarette advertising * National legislation to restrict smoking in public places * Stop cigarette advertising in print media * Legislation to prohibit smoking in schools * Outlaw cigarette vending machines * Get government to stop subsidizing tobacco industry Promote hospital enforcement of restricted areas Non-Smokers Rights * Stress non-smoker rights * Develop materials on the effect o.f tobacco smoke on non-smokers Media Materials Use educational TV for Quit Smoking Clinics * Editorial copy for local newspapers * -~ilms for specific age groups -- adults, sen~or high, junior hight elementary schools Make more ~se of the m-~teriaTs that are available * Shorter films, shorter radio spots * 5-day Quit Smoking Plan (pamphl~t) * .Deve!o~ more effzctive TV, radio and print mate2ials * Prepare multi-faceted media bits * Develop catchy lapel butt;~ns * Develop "Group action" pamphlet T107581662

Media and Materials (Continued) * No on-camera smoking on TV * Get more anti-smoking information into school newspapers * Release syndicated feature articles to news services Appeals * Use fear tactics and hard-hitting messages rather than humorous approach * Oppose fear tactics in smoking communications Use positive benefit approach rathan than negative benefit approach * Stress immediate benefits rather than delayed benefits * Emphasize socially undesirable aspects of smoking (bad breath, * Stress gap between money spent by pro-and anti-smoking segments Progra ms * Promote educational programs for health professionals ~ ~:[ationally s_Donsored Quit Smokin~i DaF * S~.~ck~nc_ .. .programs aimed at ~:vic-_ and service o__~a~.-zat'-ons~ ~4 ' .~ iurthe- behavioral studies of smoking habits ~ "-~ -~ ~ d involvement _ t .... .q~nc More effect, ire Quit Smoking Ciin,_cs Eff..c~s of smoking b:.., sex and by age groups * Dangers of smoking to women~pregnant women * Yocus on cigarette smoking among women T!07581663

FEDERAL LAWS AND REGULATIONS Tl07581664

Yo un ~s te rs "~ Need for protecting young people (and/or sick people) with respiratory diseases and ailments * Stress programs aimed at youngsters -- pa~t!cularly pre-teens Cstop before you start) Orcani zati ons * National area conferences on smoking and health * Division level task force on tobacco and cancer * Encourage ACS staff and volunteers not to smoke * More statistics on tobacco and cancer * Guidelines for strengthening Interagency Councils * Maintain data banks of ACS antE-smoking activities as benchmarks for comparisons * Saturation effort at one and same time yearly * System for sharing successful ideas among Divisions * Lung cancer should be topic for Crusade education program * Develop staff and volunteer training programs T107581665

Federal Laws and Regulations Relative to Cigarettes Existing Laws and Regulations I. Public Health Cigarette Smokin~ Act of !969 (Public Law 91-222~ April i, 1970) Extends and amends the cigarette labeling law of 1965 as follows: Requires health warning to state "Warning: The Surgeon General has determined that cigarette smoking is dangerous to your health", such warning must appear on all packages, and in printed cigarette advertising for distribution in the States and to the Armed Forces of the UoS. Overseas. Prohibits the advertising of cigaretnes on the broadcast media (radio and television) after January I, 1971. Prohibits the Federal Trade Commission from making any trade regulation rule before July 1971. After that date the FTC in making any trade regulation rule must notify the Con~=ress and that such a rule could not take effect until 6 months after FTC has notified Congress. Requires that the Secretary of HEW repo~-t Co the Congress annually concerning (i) current information in the health con:~equences of smoking and (o) such rec~mmenuation:,~ legislation as he may deem approp:.-ia-__ [[equires the FTC to report to the Cen,lre:]:~ annually on (I) the effectiveness ,,~f cigare:-'te labeling (2) current practices and me.~hods of cigarette advertising and promotien, and (3) such recommendation for legislation as i~ may deem appropriate T107581666

ll. III. F. Provides for criminal penalty for violation of the provisions of this act. Invests inforcement responsibility to the Attorney General of the U.S. and the Federal Courts. The Little Cigar Act of 1973 (Public Law 93-I09~ September 2.1,. 1973) Since all of the manufacturers of "little cigars" would not voluntarily consent to the inclusion of "little cigars" under the Public Health Cigarette Smoking Act of 1969, the Cong2ess enacted this law which extended the basic legislation to include "little cigars" by changing the definition 'of "little cigars". It was intended specifically to prevent the advertising of "little cigars" on radio and television. The Federal Trade Commission 1972 consent order requires cigarette manufacturers to disclose health warning on all advertisements. Voluntary agreement that cigarette manufacturers will display tar and nicotine information in their advertising. IV. The Federal Communication Commission VI. Has no specific regulations relative to cigarettes since the "Fairness Doctrine" is no longer applicab]e to advertising of cigarettes on radio and television. V. The Interstate Commerce Commis~ion Interstate buses may either permit or prohibit smoking on the buses. If smoking is permitted it must be confined to the area 20% of the hus's sesting capa~clty. The Civil Aeronautics Board i. Airlines must >rovide separate seating areas for smokers and non-smokers. T107581667

The number of seats reserved for non-smoking passengers is at the discretion of the airline but must provide adequate s~ace for passengers desiring non-smoking areas. (In practice, the airlines usually designate from 1/3 to 1/2 of the seats to non-smokers, and the non-smoking areas are in the for,~ard position of each compartment). Proposed Laws and Regulations I. S-2248 - Sponsor Ms. Moss introduced July 31, 1975 Proposed to amend the existing Federal laws to require within 6 months after enactment to promulgate standards establishing maximum acceptable levels of tar, nicotine and other incriminating agents in cigarette smoke. Such maximum standards may be reduced annually but no more often than once in a calendar year. II. S-2896 -.Sponsor Mr. Brooke, introduced January 29, 1976 Proposes an additional Federal tax on cigarettes of $2.50 per thousand. Such funds will be assigned to "~ trust fund for heart and lung disease and other purposes" I!I. S-2902 Sponsor Mr. Gary W. Hart (With Mr. Kennedy), introduced January 29, 1976 Proposed to ammend Title %' of the Public Health Service A~t to establish a National Health Research and Development Commission and a National ]le::!th Resea~"ch and Developmen~ Fund. Bill opens with a snatemenn :~-" findings and decl~ration of purpose ~,:ith regards to serious ~hreats to health o~ preventable environmenEal factors ~nd with special reference to the health hazards of cigarette smoking. The Commission would be ,!dvisory [e the ?resident and the Congress and would consist o~ 15 members, !0 to be appointed by the President a:ld five to be the Chairman of 5 expert advisory panel es=ablished by the Commission. There would be an additional escalating tax on cigarette~ based upon tar and nicotine conte~t and thac this Fund wou].d be applied to appropriate medical research and to the advancement of health by research in the fields of preventive medicine and public health. T!07581668

IV. S-2906 - Sponsor Mr. Hanfield, introduced January 30, 1976 Proposes to: I. Strengthen the warning label to state: "Warning: cigarette smoking is danBerous to your health and may cause death from cancer, coronary heart disease, chronic bronchitis, pulmonary emphysema and other diseases," require statement of tar and nicotine content on package and on all advertising. Such labeling would be required on all cigarettes exported and would be in the dominant language of the receiving country. Prohibit smoking in any enclosed area in any Federal facility and a provision for the separation of smokers and non-smokers in the work area and other locations. o Require tile prohibition of smoking in certain general public areas and the effective separation of smokers and non-smokers in other areas of any interstate passenger carrier facility. Provides for an increased Federal tax on all cigarettes but a very high tax on cigarettes . weighing more than 3 pounds per thousand. Authorize ~.a..': appropriation of $475 million and • tile increa.~e ~rom the additional tax to be -.:.~ reserved for programs "respecting disease which .... are caused in whole or in part b}' cigarette smoking." !{.R. 491 -M~-. Hechler~ introduced January 14, 1975 "'~'f}] i. Amend In~craal Revenue Code Co increase tax on ~J'., cigarettes weighinB more than 3 pounds per thousand -:~'/'~ or more than (~-i/2 "[nche.~ in length. Establish a Nati,~na]. Cancer :{esearch Fund trust with certain funds From the genera[ [und of the treasury (].976-77 - $830 million, July 1977 - September .~ ~0, 1977 - ~246.25 million, FY 1978 $985 mi12ion). ~~ HR 596, Mr. Lekman, introdnced 3anuac7 14, 1975 ~~} Revise the health warning on cigarette p .... ~. to read: "Warning: Cigarette smoking dangerous to health and may cause death from cancer, coronary heart disen:~e, chronic bronchitis, pulmonary emphysema and other di>;eases." TI07581669

VII. Vll!. IX. HR 1227~ Mr. Young (Fla.), introduced January 14, 1975 To require the Secretary of Transportation to prescribe rules and regulations to require seating space for non-smokers on (i) air carriers certified by CAB, (2) railroads subject to Part I of the Interstate Commerce Act, and Motor Vehicle Common Carriers subject to Part II of the Interstate Commerce Act. HR 1605, Mr. Drinan, introduced January 17, 1975 I. To amend the Internal Revenue Code of 1954 to increase the excise tax in a manner equal to that proposed by HR 584, Mr. Koch. To amend the Public Health Service Act to $475 million per year plus the funds denied from the increased excise tax, to be resumed for programs respecting diseases of the lungs and diseases of the blood. 2792 }Jr Broomfield~ introduced February 5, a~ To terminate all price-support programs for tobacco beginning with the 1976 crop. HR I0748, Mr. Drinan, introduced November 13, 1975 I. To strengthen the warning label on packages and in advertisement with 4 explinit reference to cancer, coronary heart disease, chronic bronc~hi~_is, pulmonary emphysema and other diseases. 2. To require a statement o~ tar and nicotine content on packages and advertisi.-g by stating actual FTC test results and to show the percentage by which the tar and nicoti:~e ieveJ.~ vary fro~ the average of all c!g:~rottes tested. Both of above requirements apply manufactured, imported or -,~.~'-~,,~. the U.S. = ' ° Federal ~:acilities by p~-<':~ibiting Regulate ,.mommng in .... smoking in certain areas and te ~rovide f~r the separation of smokers and non-smokers in orher areas (dining areas and work areas - requires anginal report to GSA). T!07581670

Increase Federal excise tax similar to several other bills ($475 million plus amount derived from this tax) which are to "be used for program.~: respecting diseases caused in ~Thole or in Dart by cigarette smoking. State Legislation on Smoking and Health Information on State legislation de~iin~ with tobacco, tobacco products, smoking and health has been summarized ~n a report by the National Clearinghouse on Smoking and Health (HEW) through the calendar year of 1975. In summary the report gives the following information: "This has been an active legislative ,year with 49 State legislatures convening. Only Kentucky did not meet in 1975. Of the 49 States meeting between January ~ =no October 31, ~75, 48 introduced a total of 423 bills relating to smoking and tobacco products. A total of 31 States enacted 60 bills into law. Of the States, 15 passed legislation regulating smoking areas. These States were Alaska, Deleware, Georgia, Idaho, Kansas, Maryland, Massachusetts, Minnesota, Nebraska, Nevada, New York, North Dakota, Oklahoma, Oregon, and Texas. ~hese laws limited or restricted smoking in such areas as ~ublic buildings, elevators, theaters, sports arenas, hosTit~[.s, and buses. Also included are requirements to pcst "n.? a~ekin~" notices and to provide smoking and non-smoking a~ea~ in rest:zurants . Taxation of ci:garettes was a toeic of much ie-_.isl-~.-ive activity along with regulation of licensin~ of v=nd~-s~ distributors, and wholesaler's. A ;-oral of 22 Staaes passed 35 such "~obacco comm@rc~" laWS . Legislation concerning smo~i,:~:.~ and :-'~-~ols .... ".;a:-~ a aub!~.c= cf 17 bills in eight States; laws were passed hi" C.~].iferoln and New York. Other areas o~ legislative c:ct iris'. :.;ere ~a~,-~ ;~:~ ~_ ors, advertising, and insurance. We hope ~his report will be a helpful reference. .',/ditional single copies of the report are available on request from the Natien~l Clearinghouse for Smoking :~ud Health. Any co:nments or suggestions for J.mproving this report will L'o welcome." T107581671