NYSA TI Single-Page 4
1959. J Nat Cancer Instit 1964; 32: 115
Abstract
Ham~-ond EC. Smoking in relation to ~ortality and =orbidity. Findings in first 34 ~onths of follow-up in a prospective study started in 1959. J Nat Cancer Instit 1964; 32: 115.
Fields
- Named Organization
- Addiction Research Foundation of Toronto
- Agricultural Research Service
- Agriculture Department (USDA)
- Alcohol, Drug Abuse and Mental Health Administration
- American Association of Advertising Agencies
- American Cancer Society
- American Health Foundation (Health Research)
Plaintiff- American Heart Association (Voluntary health organization that focuses on cardiac health)
Voluntary health organization that focuses on cardiac health and stroke. AHA occasionally teams with tobacco retailers to engage in promotions/fund-raisers (see http://www.smokefree.net/doc-alert/messages/247136.html and http://www.rawbw.com/~jpk/stand/Pictures.html).- American Public Health Association (Public health organization)
Professional organization for people working in public health- ASH (Action on Smoking and Health)
Action on Smoking and Health- ASHRAE (Am Society of Heating, Refrig and AC)
American Society of Heating, Refrigeration and Air Conditioning- Association of National Advertisers (Ad group)
Group of advertising entities nationwide.- Avon (Makeup)
- British Medical Journal (BMJ) (scientific periodical)
scientific periodical- Californians for Nonsmokers' Rights (Americans for Nonsmokers rights precursor)
Precursor organization to Americans for Nonsmokers Rights- Canadian Council on Smoking and Health
- Chilton Research Services
- CPD (Curriculum and Professional Development Dept., TX Ed Agency)
Curriculum and Professional Development Department of the Texas Education Agency- Dell
- Department of Commerce (DOC)
- *Department of Health and Human Services
- *Department of Health, Education, and Welfare (HEW) (use United States Departmen (use @hew_dept)
- *Department of Transportation (use United States Department of Transportation)
- Doctors Ought to Care (Activist physician group on tobacco)
Founded by Alan Blum M.D- Education Department (ED)
- Environmental Protection Agency (EPA)
- Federal Aviation Administration (Ruled on smoking on U.S. flights)
- Federal Communications Commission (FCC)
- Federal Highway Administration
- Federal Trade Commission (Enforcement agency for laws against deceptive advertising)
Enforces laws against false and deceptive advertising, including ads for tobacco products. Ensures proper display of health warnings in ads and on tobacco products;collects and reports to Congress information concerning cigarette and smokeless tobacco advertising, sales expenditures, and the tar, nicotine, and carbon monoxide content of cigarettes.- Federal Trade Commission (FTC)
- Gastroenterology (scientific periodical)
- Harvard Medical School
- *Health and Human Services (HHS) (use United States Department of Health and Hum (US)
- Institute of Psychiatry (London)
- ITC (India Tobacco Company)
India Tobacco Company- Journal of Preventive Medicine (scientific periodical)
- Kaiser-Permanente
- Lakartidningen (Swedish medical journal)
- Lancet
- Ministry of Health (Located in Singapore)
- MRD
- National Academy Press
- National Center for Health Statistics (Keeps statistics on health-related matters)
Plaintiff- National Institute of Education
- National Institute on Drug Abuse (An addiction research center in Baltimore, MD)
An addiction research center located in Baltimore, MD- National Institutes of Health (NIH)
- National Research Council
- Naylor Dana Institute for Disease Prevention (unit of AHF)
- New England Journal of Medicine
- New Scientist (scientific periodical)
- New York State Department of Health
- Newsweek (Weekly News Magazine (U.S.A.))
- Office on Smoking and Health
Responsible for creating reports on the health effects of smoking. Created by the Public Health Service.- Preventive Medicine (periodical)
- Reader's Digest
- Red Cross
- Research Council
- Roper Organization (Consumer Research/Public Relations Org.)
Interested in finding out what drives consumer behavior; surveys consumers on their prime areas of concern; assists corporations with reputation-building and public image based on its findings.- Royal College of Physicians (Monitors the quality of Canadian/U.K. medical education)
- Smokers Clinic
- Tobacco Institute (Industry Trade Association)
The purpose of the Institute was to defeat legislation unfavorable to the industry, put a positive spin on the tobacco industry, bolster the industry's credibility with legislators and the public, and help maintain the controversy over "the primary issue" (the health issue).- U.S. Department of Agriculture
- University of California Los Angeles (UCLA)
- University of California San Francisco
- University of Edinburgh (Located in Scotland)
- University of Houston
- University of London
- University of Manchester
- University of Minnesota
- University of New Mexico
- University of Nottingham
- University of Toronto
- University of Vienna
- University of Western Australia
- University of Western Ontario
- Veterans Administration
- World Conference on Smoking and Health
- World Health Organization (Concerned with global public health)
International organization concered with public health worldwide- Yale University
- Agricultural Research Service
- Named Person
- Armstrong, Bruce K.
- Bailey, Jeffry
- Bishop, Jr., Mike A. (RJR Corp. Public Relations)
Manager Smoking- *Bock, F.G. (Fred)
Associate Cancer- Bray, Jeremy
- Brown, Ron
- Dekker, Marcel
- Elizabeth, Queen, II
- Evans, Richard (smoking in teenagers)
- Fisher, Deborah A.
- Glantz, Stanton A.
- Gritz, Ellen R., Ph.D.
Plaintiff- Hall, Russell
- Harris, John (District Supervisor in Florida Police)
- Heart, Stanford
- Hill, J. Stanley
- Howe, Holly L.
- Jacob, Micheal
- Johnson, Anderson
- Jones, R.T. (BATCO GR&DC)
R. T. Jones was with BATCO-GR&DC. (Source: NM Tobacco Companies Personnel List)- Leathar, D.S.
- Lee, J.D. (ATLA Tobacco Litigation Gp Chair, Knoxville, TC attorney)
J.D. Lee is an attorney in Knoxville, TN and chairman of the ATLA Tobacco Litigation Group in 1994. The telephone number is (615) 544-0101.- Loeb, Barbara Keely
- Mah, Russell
- Mantel, Nathan (Biostatistician, American U., Industry Expert)
PM witness- Parker, Gillian
- Pederson, Linda
- Pellegrino, Ed
- Pindborg, J.J., M.D. (Studied the effects of smoking on Leukoplakia)
- Randell, Jane
- Rawson, Nigel
- Reid, Donald
- Samet, Jonathan M.
- Schwartz, Tony
Plaintiff- Shephard, Roy J.
- Stephens, Thomas
- *Todd, G.F. (use Geoffrey Todd)
- Tso, T.C., Ph.D. (PM Tobacco Working Group)
Defense - Bailey, Jeffry
- Master ID
- TI08350674-1466
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189
Ham~-ond EC. Smoking in relation to ~ortality and =orbidity. Findings
in first 34 ~onths of follow-up in a prospective study started in
1959. J Nat Cancer Instit 1964; 32: 115.
Ravenholt RT. Addiction ~0rtallty in the United States, 1980: tobacco,
alcohol, and other subtances. Population and Development Review 1984;
I0: 697-724.
Radford EP~ Hunt YR. Polonium 210: a volatile radloelement in
cigarettes. Science 1964; 143: 247-249.
I0. Ravenholt RT. Malignant cellular evolution: an analysis of the
causation and prevention of cancer. Lancet 1966; I: 523-526.
II. Ravenholt RT. Circulating mutagens from smoking. (Letter), New Engl J
Med 1982; 307: 312.
TI03350873
191
James L. Repace, M.S.
Office of Air and Radiation
U.S. Environmental Protection Agencyt
Washington, D.C. 20460
U.S.A.
INTRDDUCTION
The major prospective studies on smoking and disease show that the risk of
the diseases of smoking are related to the total dose delivered, regardless
of the time pattern of exposure, that the disease risk increases with
increasing depth of inhalation, and that there is no discernible threshold
for any of the risks (i).
Moreover, there is now evidence, some of it conflicting, that indirect
exposure to tobacco smoke, so-called passive or involuntary smok{ng, the
breathing of indoor a{r polluted with tobacco smoke, may cause cancer and
respiratory impairment (2,3,4). In these epidemiologic studies, the
exposure variable used has typically been the number of c{garettes smoked by
a spouse; relatively little attention has been focused on factors affecting
a non-smoker's exposures or on total doses received. The purpose of this
paper is to discuss these factors.
STUDIES DESIGNED TO QUANTIFY U.S. NON-SMOKERS' EXPOSURE TO ~OBACCO SMOKE
Exposure of non-smokers to tobacco smoke might be expected to be common in
the U.S., because one out of three UoS. adults smokes cigarettes at the
estimated rate of 32 per day (5), while an additional one out of six smokes
cigars or pipes, and because indoor air pollution from tobacco smoke
persists in indoor environments long after smoking ceases (5,6,7).
Repace and Lowrey (5) presented a model of non-smokers' exposure to the
particulate phase of ambient smoke that was supported by controlled experi-
ments and a field survey of the levels of respirable particles indoors and
out, in both smoke-free and smcky environments; this phase contains 60
proven or suspect carcinogens (2,8). This work, which established that
ambient tobacco smoke imposed significant air pollution burdens on
non-smokers, was extended by later work (7) which further demonstrated the
predictive power of this model. The model predicts a range of exposure of
from 0 to 14 mg of cigarette aerosol per day, depending upon the non-
~DISCLAIMER: The op{nions in this article are those of the~_~uthor-~_ t~
crff~ci~l--6~dor~em~nt-q~-th~E~vironmental Protection Agency is intended or
should be inferred.
T[08350874
192
smoker's lifestyle. Exposures of prototyplcal non-smokers were modeled, but
no attempt was made to estimate the average population exposure. It was
shown that the concentrations of ambient tobacco s~oke encountered by U.S.
non-smokers in a variety of microenvironments can, to a good approximation,
be estimated by knowledge of two factors: the average smoker density and the
ventilation rate (5). On the average, a characteristic value of the ratio
of these factors can be assigned to a particular microenvironmental class,
e.g., homes, offices~ restaurants, etc. (9). Therefore, the average daily
REPACE ~" i
exposure of individuals can be estimated from the time-weighted sum of -:-"
concentrations encountered in various microenvironments (9,10) containing
smoke.
It is important to realize that most persons' lifestyles are such that they
spend nearly 90% of their time in just two microenvironmental classes, thus
affording a great simplification of exposure modeling (6,9). Szalai, as
part of The Multinational Comparative Time Budget Research Project, which '-"-"
studied the habits of nearly 30,000 persons in 12 countries (1964-1966), has
compiled data reporting the average time spent in various locations or
.--"-
microenvironments. Szalai's data for 44 cities in the U.S. were reorganized ..~
by Oft (11) who showed that U.S. urban dwellers spend an average of 88% of
their time in just two microenvironments: in homes and in workplaces; more- ""
over, employed persons in the U.S. cities were estimated to spend only 3% of
the day outdoors while housewives spent only 2% outdoors. Repace and Lowrey
(6) used these data to model the average exposures typical non-smokers might
receive in the two most frequented microenvironments.
Exposure of the population to the particulate phase of cigarette smoke can
be modeled to determine both range of concentration and exposure, which is
the concentration multiplied by the average respiration rate (12) of the
exposed persons.
Repace and Lowrey (5,7) have shown that the ambient concentration of tobacco
smoke particles, Q, from cigarette smoking can be usefully represented by an
equilibrium model based upon occupancy of a space by habitual smokers who
smoke 32 cigarettes per day (for every three habitual smokers, there is one
cigarette burning constantly),
Q = 217 Dhs/Cv (~g/m3)
[1],
where Dhs is the habitual smoker density in units of smokers per i00 m3, and
Cv is the ventilatory air change in units of air changes per hour (ach).
The model accurately predicts ambient concentrations of cigarette smoke over
a wide range of smoking rates and ventilation rates (5,6,7).
Ventilation rates given by the American Society of Heating, Refrigerating,
and Ventilating Engineers (ASHRAE) (13) were useful in this model to predict
observed concentrations of tobacco smoke in indoor microenvironments
(5,6,7). ASHRAE Standards are national concensus standards for ventilation
rates in the U.S., and are tied to expected building occupancy. Thus, Eq.
[I] offers the ~osslbility of modeling the range of non-smDkers' exposures
T108350975
193
to ambient tobacco smoke by inserting the ranges of occupancy and air change
rate. Using this method, Repace and Lowrey (6) estimated that the typical
U.S. ~orkplace exposures range from 1.35 to 3.38 mg/8 hrs. for an estimated
average exposure of 2.37 mg/8 hrs. This value is consistent with that
estimated from the concentrations ~easured in a field survey of 23
commercial buildings in the Washington, D.C. and New York City metropolitan
areas, which reported a mean concentration of 242 ± 238 ~g/m3, averaged over
all of the buildings. Assuming an average inhalation rate of 1.47 m3/hr (a
rate corresponding to light work) (12) for those exposed, yields an
estimated exposure of 2.85 mg/8 hrs, or at an inhalation rate of 0.99 m3/hr
(a rate corresponding to alternate sitting and light work) (12), an
estimated exposure of 1.92 mg/8 hrs. Thus, the exposure estimates are
consistent with the limited observations available. Based upon the ratio of
white-collar to blue-collar workers, and upon surveys of smoking policies of
about I000 U.S. corporations, large, medium, and small, Repace and Lowrey
(6) estimated that the exposure probability of U.$. workers to on-the-job
smoking was 63%, and that the average on-the-job exposure to passive smoking
was 1.82 mg/day, when weighted for average hours per day worked.
For comparison, we now examine the estimated average exposure modeled for
the domestic microenvironment.
HODELINC EXPOSDRE OF NON-SNOKERS AT HOME
Similarly, by using data from time budget and census studies, Repace and
Lowrey (6) estimated the average length of time a person spends in the home
microenvironment. This time differs by gender and employment status.
Taking into account the different amounts of time spent in the home by
employed men, employed women, and homemakers, they estimated that the
occupancy-weighted average number of cigarettes smoked in a typical U.S.
home of 340 ms volume during a 16-hr waking day was equal to 22 cigarettes
per day (CPD). Using this figure, Eq. [I] predicts, using an air exchange
rate typical of that expected for U.S. dwellings, a concentration value in
good agreement with measurements of respirable particles obtained in homes
containing one smoker from the Harvard Six City Study by Dockery and
Spengler (14,15). By multiplying by a respiration rate corresponding to
that of alternate sitting and light work, Repace and Lowrey (6) estimated
that a typical U.S. non-smoker is exposed to an average inhaled exposure of
0.45 mg/day, with an exposure probabil~ty of 62%, assuming that occupancy of
the home by smokers and non-smokers is coincident.
NEAN ESTIHATED EXPOSURE FOR A TYPICAL ADOLT FROH TI~ HDST-FREQUENTED
NICROENVIRONMENTS
Repace and Lowrey (6) estimated a probability-weighted average exposure for
a typical U.S. adult by combining the estimated exposure to U.S. adults
ex~osed~i~_~he~wo_~kpi~ce_and_~__h~.~e~_by
each microenvironment by the probability of receivinB it, assuming that the
probabilities are independent, i.e., tha~ exposure at work i~ not correlated
wit~ exposure at home. The results are su~arized in Table I.
TI0~o50,..,76
TABLE I. ESTIMATED PROBABILITIES OF NON-SMOKERS BElOnG ~XPOSED TO
TOBACCO SMOKE AT HOME AND AT WORK (6)
Probability of being exposed at work: 63%;
Probability of not being exposed : 37%.
Probability of being exposed at home: 62%;
Probability of not being exposed : 38%.
Estimated
Daily Annual Average
Probability of being exposed
(Rounded Values)
Estimated Estimated
Daily Daily
Average Probability-
Exposure Weighted
ReceivedExposure
At work and at home:
Neither at work nor at home:
At home only:
At work only:
63% x 62% = 39% 2.27 mg .89 mg
37% x 38% = 14% 0.00 mg .00 mg
37% x 62% = 23% 0.45 mg .lO mg
38% x 63% = 24% 1.82 mg .44 m~
Total: 100% 1.43 mg/day
Table 1 suggests that the typical U.S. non-smoker is in fact a passive
smoker who receives an average exposure of 1.43 mg/day, and that very few
(~15%) persons in the general population appear to escape daily exposure to
tobacco smoke. Table 1 further suggests that indlvlduals having exposure
both at home and at work constitute high exposure groups, with the workplace
likely contributing more exposure than the home by a ratio of 4 to i. These
calculations imply that epidemiological studies of passive smoking should
control for exposures both at home and in the workplace. Further, if
passive smoking does create a risk of smoking-related disease, there may be
disparities in incidence observable by comparing the more-exposed and less-
exposed categories, but if these categories are not separated, as they were
not in the American Cancer Society Study of passive smoking and lung cancer
(16), a potentially large confounding factor has not been taken into
account, particularly since more than one third of U.S. women have been in
the labor force since 1950 (17). Although the Japanese and Greek studies
also did not take working into account, as Hammond and Selikoff (18) have
suggested, this factor may not be as important in such relatively tradition-
al societies (26,27).
TRANSLATING EXPOSURE INTO DOSE
At this point, the estimated range of exposure has been established for
typica~U_.S_._non=s~ok.~s_as_0~t~ 14 ~g~.ay~__t~__ty~_i~.al ~l~qk~lace exposure
has been estimated at 1.82 mg/day, the typical home exposure at 0.45 mg/day,
and the typical exposure at 1.43 mg/day. These may be directly compared
with the 1981 sales-weighted average tar level for U.S. cigarettes of 14
mg/day, or with the level of the lowest tar cigarettes on the market, 0.55
mg or with pre-1960 cigarettes of tar level greater than 30 mg, according to
T108350877
one's preference (191. However, none of these comparisons ~xpress the dose
of tobacco tar to the non-s=oker's bronchial epithelium, rather, they
express the a=ount inhaled daily. It is of interest to calculate the dose
received by a typical non-smoker's lung in each of three cases: the worst
case, the workplace, and the home.
Close association with smokers at work and at home may lead to repeated
daily inhalation of tobacco smoke by non-smokers. This is significant
because repeated daily ezposure of non-smokers to indoor air pollution from
tobacco smoke may lead to a buildup of tar in the lungs to an equilibrium
amount which may far exceed the daily exposure. This is a direct conse-
quence of the very long clearance times for fine-particle aerosols deposited
in the lungs (201. On a single-compartment ra~del (i0) for lung-clearance,
the equilibrium level of tobacco tar in a non-smoker's lungs is given (5,10)
by De~. = ~ ~ D_,,, where D~, is the daily nominal dose, r is the mean life for
pulmonary clearance (1.44 times the half-life), and ~ is the fraction of
inhaled aerosol deposited. We assume the values r = i01 days (20) and ~ =
11%, although a value as high as 20% has been reported (21). In terms of
our modeled Dn (al of 1.82 mg/day for a typical non-smoking worker, (bl of
.45 rag/day for a typical non-smoker at home, (c) 1.43 mg/day for a typical
non-smoker overall, and finally, (d) our worst case, 14.4 mg/day (5) for a
non-smoker working in a piano bar with a chain-smoking spouse, we calculate
respectively, in units of mg of tobacco tar, an equilibrium dose to the
bronchial epithelium of (a) 20 mg, (b) 5 mg, (ci 16 mg, and (d) 160 mg.
On this single-compartment equilibrium model, the estimated doses to the
bronchial epithelium of regularly exposed passive smokers are equivalent to
smoking between a third of a 1981 sales-weighted average tar cigarette per
day and a half-pack per day. In view of the U.S. Surgeon General's
assertions that there is no safe level of consumption of cigarettes, that
there does not appear to be any threshold effect for any of the diseases of
smoking, that risk is closely related to total dosage, regardless of the
time pattern of exposure, and that even the lowest yield of cigarettes
presents significant risks, dosages of this magnitude cannot be dismissed as
inconsequential, being well within the range of observed effects in smokers.
Is there any evidence to support this concept? Earlier work (5) discussed
anecdotal evidence, based on elevated aryl-hydrocarbon hydroxylase and
pigmented alveolar macrophages, that this buildup appears to have been
observed in two non-smokers. Moreover, serum thiocyanate (22) and benzpyrene
(23) levels in some non-smokers have been found to be comparable to the
elevated levels typically found in smokers. However, the most persuasive
evidence has recently been provided by Matsukura (24), who found that
urinary cotinine levels in 472 Japanese passive smokers who lived with
smokers of >40 cigarettes per day or worked with >6 smokers, were virtually
indistinguisable from urinary cotinine of smokers of less than 3 cigarettes
per day. Such a buildup phenomenon appears to offer a plausible explanation
for the findings by White and Froeb (25), Trichopoulos et al. (26), and
Hirayama (27), that the risks of passive smoking were considerable fractions
T108350878
196
REPACE
CONCLUSIONS
Non-smokers' exposures to ambient tobacco smoke can be estimated using an
equilibrium m~del. Estimates of such exposures appear to be consistent with
measurements of concentrations in various indoor microenvironments.
Estimates of exposure probabilities indicate that passive smoking appears to
be a widespread daily phenomenon which only 15% of non-smokers of working
age escape. The results also indicate that estimated average U.S.
workplace-related exposures are about four times higher than estimated
average U.S. domestic exposures.
A single-compartment model for the equilibrium dose of respirable aerosol to
non-smokers' lungs, resulting from regular passive smoking, indicates that
tobacco tar may accumulate to levels reaching an order of magnitude higher
than nominal daily exposures. This phenomenon offers a possible explanation
for the results of epidemiological studies of diseases caused by passive
smoking which indicates risks which are substantial fractions of those of
active smoking. Estimates of the average doses to non-smokers from passive
smoking at home and at work suggest that typical equilibrium doses from
these two most-frequented microenvironments are 20 mg and 5 mg, respective-
ly, and the overall probability-weighted dose to the typical non-smoker
appear to be about 16 mg. The worst-case equilibrium dose is estimated to
be 160 mg of tobacco tar on the bronchial epithelium. The magnitude of
these doses is equivalent in value to the exposure obtained in smoking from
i/3 to ii sales-weighted average tar (14 mg) cigarettes (1981 value) per
day.
Cigarette smoking has been judged by the Surgeon General to be a major cause
of cancers of the lung, larynx, oral cavity, and esophagus~ and a
contributory factor for the development of cancers of the bladder, pancreas~
and kidney, to be causally related to coronary heart disease, and to be the
leading contributory cause of death from chronic bronchitis and other lung
disorders. The U.S. Surgeon General has also stated that there is no safe
cigarette nor safe level of consumption.
Because non-smokers' doses of tobacco smoke from involuntary smoking appear
to be, even on average, well within the range of exposure of active smokers,
there is good reason to believe that indoor air polluted with tobacco smoke
poses a significant threat to the health of non-smokers (28).
US Dept of Health & Human Services. The health consequences of smoking:
the changing cigarette. A report of the Surgeon General. Washington,
D.C.: U.S Dept. of Health & Human Services,. 1981.
US Dept of Health & Human Services. The health consequences of smoking:
Smoking and cancer. A report of the Surgeon General. Washington, D.C.:
U.S. Dept. of Health & Hum_an Services, 1982. (DHHS publication no.
82-50179).
TI08350879
197
3. Kauffman F, Tessier JF, Oriol P. Adult passive smoking in the home
environment: a risk factor for chronic airflow limitation. Am J
Epidemlol 1983; 117: 269-280.
4. Repace JL. The problem of passive smoking. Bull N¥ Acad Med 1981; 57:
936-946.
5. Repace JL, Lowrey AH. Indoor air pollution, tobacco smoke, and public
health. Science 1980; 208: 464-472.
6. Repace JL, Lowrey AH. Modeling exposures of non-smokers to ambient
tobacco smoke. Paper presented at the 76th Annual Meeting of the Air
Pollution Control Association, Atlanta, 1983 June 20-25.
7. Repace JL, Lowrey AH. Tobacco smoke, ventilation, and indoor air
quality. ASHRAE Transactions 1982; 88: 894-914.
8. US Dept of Health, Education and Welfare. Smoking and health. A report
of the Surgeon General. Washington, D.C.: U.S. Dept. of Health
Education and Welfare, 1979. (DHEW publication no. (PHS) 79-50066).
9. Repace JL, Oft WR, Wallace LA. Total human exposure to air pollution.
Presented at the 73rd Annual Meeting of the Air Pollution Control
Association, Montreal 1980 June 22-27.
10. National Research Council. Indoor pollutants. Washington, D.C.:
National Academy Press. 1981.
Ii. Oft, WR. Human activity patterns: a review of the literature for
estimation of exposure to air pollution. Washington, D.C.: U.S.
Environmental Protection Agency, (in press).
12. Altman PL, Ditmer DS. Respiration and circulation. Bethesda, MD:
Federation of American Society for Experimental Biology, 1971.
13. American Society of Heating, Refrigerating, and Ventilating Engineers,
Atlanta. ASHRAE Standards for Natural and Mechanical Ventilation.
1973: 62-73.
14. Dockery D, Spengler JD. Indoor-outdoor relationships of respirable
sulfates and particles. Atmospheric Environ 1981; 15: 335-343.
15. Dockery D, Spengler JD. Personal exposure to respirable particulates
and sulfates. J Air Pollut Control Assoc 1981; 31: 153-159.
16. Garfinkel L. Time trends in lung cancer mortality among non-smokers and
a note on passive smoking. J Nat Cancer Instit 1981; 66: 1061-1066.
17. US_Dept of Comme~ce_. S~9~j~!_i~9~_Ab_%~acts of the United States~ 1980.
Washington, D.C.: U.S. Dept. of Cor~erce, 1980.
18. Ha~_~ond EC, Seliko~f IJ. Passive smoking and lung cancer with co~ents
on two new papers. Environ Res 1981; 24: 444-452.
T108350880
19 8
REP~C'~
19. Bock FG, Repace JL, Lowrey AH. Non-smokers and cigarette smoke: a
=odified perception of risk. Science 1982; 215: 197.
20. Cohen D, Arai SF, Brain JD. Science 1979, 204: 514.
21. Hiller FC, McCusker KT~ Mazunder M~[, Wilson JD, Bone RC.
Respiratory Dis 1982; 125: 406.
Am J
22.
Cohen JD, Bartsch GE. A comparison between carboxyhemoglobin and serum
thiocyanate as indicators of cigarette smoking. Am J Public Health
1980; 70: 284-286.
23. Repetto M, Martinez D. Benzopyrene de cigarettes et son excretion
urinaire. J Europ6en de Toxicologie 1974; 7: 234-237.
24. Matuskura S, et al. Effects of environmental tobacco smoke on urinary
cotinine excretion in non-smokers. New Eng J Med 1984; 311: 828-832.
25. White JR, Froeb HF. Small airways
chronically exposed to tobacco smoke.
720-723.
dysfunction in non-smokers
New Eng J Med 1980; 302:
26. Trichopoulos D, Kalandidi A, Sparros L. Lung cancer and passive
smoking: conclusion of Greek study. Lancet 1983; 2: 677-678.
27. Hirayama T. Non-smoking wives of heavy smokers have a higher risk of
lung cancer: a study from Japan. Br Med J 1981; 282: 183-185.
28. Repace JL, Lowrey AH. A quantitative estimate of non-smokers' lung
cancer risk from passive smoking. Environment International 1985;
ii: 3-22.
NOTE ADDED IN PROOF:
Dr. Hirayama, in a presentation at The Fifth World Conference on Smoking and
Health, suggested that passive smoking in Japan contained an additional
component, innate to the Japanese lifestyle, which he called "direct passive
smoking" to connote the exposure received hy Japanese spouses who associate
with one another in closer proximity than is common in Occidental cultures.
A crude estimate of the magnitude of this effect based on limited data (7)
suggests that exposures received in this manner are of the order of 40%
higher than those received by general mixing from room air circulation.
This may tend to offset the effect of higher infiltration rates in Japanese
dwellings relative to the U.S.
Tl0,3350681
PASSIVE S~OKIRG ARD I~E LUNGS:
A ~EVIEW OF EFFECES OTHER ~ MALIGRANCY
Jonathan M. Samet, M.D.
The Department of Medicine
University of New Mexico Medical Center
Albuquerque, New Mexico 87131
U.S.A.
Frank E. Speizer, M.D.
The Channing Laboratory~ Department of Medicine
Brigham and Women's Hospital, Harvard Medical School
180 Longwood Ave., Boston, Massachusetts 02115
U.S.A.
Passive smoking refers to the involuntary exposure of non-smokers, both
children and adults~ to tobacco combustion products. This review examines
the epidemiologlcal evidence for effects of passive smoking on the lungs,
other than lung cancer and upper airway irritation.
PASSIVE SMOKING A~D (~IILDREN
For children, smoking by parents or other household members is the principal
source of exposure. In the United States, approximately 54 million adults
are current smokers and the majority of homes have at least one smoker
(I,2). Because of this high prevalence of passive smoking, even small
adverse effects have important implications for public health.
Six investigations of varying design have demonstrated an increased risk of
lower respiratory tract infection in infants with smoking parents (Table
|). Four longitudinal studies evaluated the respiratory illness experience
of infants; each showed a significantly increased frequency of bronchitis
and pneumonia during the first year of life when parents smoked (3-6).
Dose-response relationships with ~xtent of parental smoking were demonstra-
ble in three (3,4,6). An effect of passive smoking was not readily identi-
fied after the first year of life. Two controlled follow-up investigations
of children with respiratory syncytial (RS) virus infections during infancy
also demonstrated an effect of passive smoking (7,8).
Studies of older children have demonstrated similar adverse effects of
passive smoking on respirato~/ illness experience. In two large studies in
the United States, parent smoking was associated with a history of serious
Address correspondence to: Jonathan M. Samet, M.D.
TI08350882
TABLE 1.
EARLY C~ILDDOOD I~ESPIRATORY I~CTIO~ ~ PASSIVE
O
C~
CO
C~1
CO
CO
STUDY POPULATI(M
10,672 blrlths in
Israel, 1907-1968
(3) births
2,205 in
England, 1963-196§
(~)
12,068 blzths in
Y[nlandp )66
(5)
1,265 blr is in
New Zealar , 1977
(~).
3~ chEldr~n
hospital i~ ed with
ItS virus t~ronch|tls
in infanc~,
England (~).
130 childlen with
RS virus Infection
in infancy, England
(8).
• RR e reative risk.
STUDY DESIGN EFFEC~ OF PASSlV~ S~OKING
COld~NTS
Antenatal m~ternal smoking
history, monitoring of
hospital adsisslons in
first year of Ills.
Prospective cohort with
annual questionnaire.
Prospective cohort with
follow-up of hospttallza-
tions, physician v/slts,
and mortality.
Prospecti~ cohort with
diaries, physician and
hospital record review.
Significant increase in
hospitalization for
pneumonia and bronchitis,
8R* - 1.38.
81gniflcant increase in
bronchitis or pneumonia in
first 7ear of life, I~R- 1.73
if one parent smoked,
RR = 2.60 if both smoked.
Significant increase of
hospitalization for resplra-
tory diseases during first
5 years, RR - 1.7~.
Significant increase in
bronchitis or p~eumonia during
the first 7ear of l~fe,
~= 2.0~p if m~ther smoked.
Case-control with 35
matched controls performed
g years after index
illness.
Borderline slsniflcant effect
of materna! sm0klns during
first year of life~
Case-control with III
controls performed I0
years after index illness.
Significant effect of maternal
smokinS st time of illness,
Calculated from published data if not provided by the authors.
Dose-response relationship
present. Maternal amokin~
only.
Sex of mokin~ parent not
examined.
Effect largest durin8
first year. Naternal
smoklns only and measured
during pregnancy.
No effect of paternal
smokinS. Effect of mater-
nal smoking equivocal in
second year, absent in
~hird. Dose-response
present in first,
Significant increase in
daily numbers of cigs-
reties smoked during the
first year of life by
parents of cases.
Effect of paternal smoking
also present.
respiratory illness 1>~fore age t~o and with respiratory illness in the last
year (9,10). In data from the 1979 National Health Interview Survey, parent
smoking was associated with significantly more days of restricted activity
from acute respiratory illness (2).
TABLE 2. RESPIRATORY SYMPTOMS ZN CHILDHOOD AND PASSIVE SMOKING
STUDY POPULATION
EFFECT OF PASSIVE SMOKING
COMMENTS
2,426 children, ages
4-14 yr, in England
(n).
~ prevalence of cough with
number of smoking parents.
Effect re~ved ~heu
parents' symptom
status controlled.
626 children under
age 15
United States (12).
Non-significant ÷ in preva-
lence of cough and phle~n
if smoking household.
Effect reduced by con-
trolling symptom status
of adults.
816 children, age 7
yr and above,
United States (13).
No effect on symptom
prevalence.
Small numbers in
specific subgroups.
5,835 children,
first year of
secondary school,
England (14).
÷ prevalence of cough and
breathlessness.
Child's smoking
controlled.
1,937 children, age
6-Ii yr, Japan (15).
÷ prevalence of lower air-
way symptoms.
Composite symptom
index. Effect varied
with residence location
650 children, age
5-9 yr,
United States (16).
676 elementary
school children,
United States (17).
4,071 children, age
5-14 yr,
United States (I0)
+ prevalence of persistent
wheeze.
~ prevalence of wheeze,
sputum, and cough.
No effect on prevalence of
symptoms or asthma.
Effect not significant
for chronic cough and
phlegm.
Effect not significant
for asthma.
Multivariate analysis
with maternal smoking
as the exposure
variable.
For respiratory symptoms, the evidence for effects of passive smoking is
less convincing (Table 2). The differing results may reflect tmcharacter-
iz~d v~riation--b~rween--wradie~--i~h~--~v~--6mb~d£~g exposure Yt~T.f~--In
each, the level of passive s~king has ~eu assessed with simple questions
about smoking by parents or household ~mbers. Variation in residence
construction and ventilation ~y result in differing concentrations of
tobacco smoke components at equivalent levels of passive smmking, as assess-
TI03350584
202
SAMET ARD ~PEIZE£
ed by questionnaire. Additionally, differing symptom questionnaires have
been used in these studies.
The evidence concerning effects of passive smoking on children's lung func-
tion is also conflicting. Most investigations have been cross-sectlonal and
preliminary data from longitudinal evaluations have only become available
recently. In general, studies with positive results have examined the
effects of passive smoking on flows at low lung volumes; those with negative
results have utilized lung function parameters less sensitive to smut1 air-
ways function or have involved relatively small populatlon samples.
Cross-sectional analyses involving a sample of five to nine year-old chil-
dren in East Boston, Massachusetts, provided an important early demonstra-
tion of passive smoking effects (16,18). In subjects with data available
for both parents, a dose-response relationship was demonstrated between the
level of FEF25_75 (forced expiratory flow from 25% to 75% of the forced
vital capacity) and the number of smoking parents. By multiple regression
analysis, the effects of passive smoking were prinmrily attributable to
maternal and not paternal smoking. Other cross-sectional investigations
have confirmed these results. Yarns11 and St. Leger (19) described
reductions of lung function consistent with a passive smoking effect, but
did not statistically assess the association. In a very large U.S. investi-
gation, statistically significant, but very small reductions of FEVo.75
(forced expiratory volume in 0.75 seconds) were associated with maternal
smoking (20). Vedal et al. (21) found significant reductions of several
spirometric measures in children with smoking parents. The effect primarily
reflected maternal smoking and was larger in girls.
Methodological limitations may explain the negative findings of other
studies. The population studied in England by Leeder e~ al. (22) was
relatively small and the PEFR (peak expiratory flow rate) is an insensitive
index of subtle changes in lung function. The methods of analysis may have
resulted in overadjustment for passive smoking in this study and that
conducted by Schilling et al. (13). Speizer et al. (9) did not find effects
of parental smoking in a large investigation of children from six U.S.
co~nlties. With expansion of the study group and the use of a more robust
adjustment for lung size, however, small effects were present in a preliml-
nary longitudinal analysis (24). Several investigations in Arizona were
limited by relatively small samples (17,23).
In summary, during the past ten years, the health effects of passive smoking
on children have been investigated with increasing intensity. The available
data are most convincing for an increased incidence of lower respiratory
tract infection during pregnancy. The evidence meets conventional epidem-
iological criteria for a causal relationship. Although associated with only
modest elevations of relative risk, passive smoking could be an important
source of morbidity in infancy. Assuming a 30% prevalence of
maternal smoking and a relative risk of 2.0, then 23% of lower
re~pira~orS'--rra~cr-~i-~f~c-vi~ffs--dfi-rTng EnTa~y ar~-~att~fa~q~ to th~s
exposure.
For s)nnpto=s and lung function level, the data on passive s~king effects
are conflicting. Because of the low prevalence of symptoms and the large
variance of function measurements, large study samples are needed. Some
TI08350885
pAS$1VE S]40KIRC AMD THE LUNGS
203
published investigations have not met this requirement and others have used
insensitive measures of function. Crude assessment of exposure also limit
their findings. The investigations least affected by the limitations of
sample size and insensitive lung function measurements suggest that passive
smoking does impair lung function in children. The effects are small and
their biological importance is uncertain. Longitudinal investigations may
clarify this issue.
PASSIVE SMOKIRG ARD ADULTS
Although less well characterized, the health effects of passive smoking on
adults are equally controversial. As with children, exposure is widespread
and involuntary when sustained in public areas or the workplace. For
respiratory symptoms, the available data do not demonstrate a consistent
pattern of passive smoking effects. Symptoms have generally not been
increased in non-smokers exposed to cigarette smoking by other household
members and sources of exposure outside of the home have not been evaluat-
ed. With regard to pulmonary function, exposure to passive smoking has been
associated with reduction of the FEF25_75 in two cross-sectional investiga-
tions, though others have been negative. White and Froeb (25) compared
spirometric test results in middle-aged non-smokers, with at least 20 years
of passive smoking exposure in the workplace, to values of controls. Flow
rates in the exposed group were significantly reduced. Criticism of this
investigation has focused on the test procedures, the determination and
classification of exposures, and the handling of former smokers. Bias may
have been introduced by uncontrolled correlates of social class. ~owever,
the findings of a populatlon-based French investigation of over 7800 adults
were similar and not subject to these limitations (26), Above age 60, the
FEF25-75 was reduced in non-smoking men and women with a smoking spouse.
The small reductions of FEF25_75 found in these studies would not be asso-
ciated with clinically important impairment and their long-term implications
must be established.
CONCLUSIONS
While clarification of the effects of passive smoking is an important
scientific objective, sufficient data for the development of preventive
strategies are already available. Prevention of active smoking will remain
the best approach for reducing the effects of smoking, regardless of the
results of additional research.
National Research_Counc_i_l_.~!~doo_r__poilR~aruLs~__WaahingtQn,_D.C:: Nation-
hal Academy Press, 1981.
Bonham GS, Wilson RW. Children's health in families with cigarette
s~okers. Am J. Public Health 1981; 71: 290-293.
TI08350886
204
SAMET ARD SPEIZER
o
8.
9.
10.
ii.
12.
13.
14.
15.
16.
Harlap S, Davies AM. Infant admissions to hospital and =internal s~ok-
ing. Lancet 1974; 1: 529-532.
Leeder SR, Corkhill R, Irwig ]hi, Holland ~q#, Coley JRT. ~nfluence of
family factors on the incidence of lower respiratory illness during the
first year of life. Br J Prey Soc Hed 1976; 30: 203-212.
Rantakallio P. Relationship of maternal smoking to morbidity and
mortality of the child up to the age of flve. Acta Paediatr Stand
1978; 67: 621-631.
Fergusson DM, Horwood LJ, Shannon l~r, Taylor B. Parental smoking and
lower respiratory illness in the first three years of life. J
Epidemiol Community Health 1981; 35: 180-184.
Sims DG, Downham MAPS, Gardner PS, Webb JKG, Weightman D. Study of
8-year-old children with a history of respiratory syncytial virus
bronchiolitis in infancy. Br Med J 1978; I: 11-14.
Pullan CR, Hey EN. Wheezing, asthma, and pulmonary dysfunction 10
years after infection with respiratory syncytial virus in infancy. Br
Med J 1982; 284: 1665-1669.
Speizer FE, Ferris B Jr, Bishop YHM, Spengler J. Respiratory disease
rates and pulmonary function in children associated with NO2 exposure.
Am Rev Respir Dis 1980; 121: 3-I0.
Schenker KB, Samet JM, Speizer FE. Risk factors for childhood respira-
tory disease: the effect of host factors and home environmental expo-
sures. Am Rev Respir Dis 1983; 128: 1038-1043.
Colley JRT. Respiratory symptoms in children and parental smoking and
phlegm production. Br Med J 1974; 2:201-204.
Lebowitz HD, Burrows B. Respiratory symptoms related to smoking habits
of family adults. Chest 1976; 69: 48-50.
Schilling RSF, Letal AD, Hui SL, Beck GJ, Schoenberg JB, Bouhuys A.
Lung function, respiratory disease, and smoking in families. Am J
Epidemiol 1977; 106: 274-283.
Bland M, Bewley BR, Pollard V, Banks
parents' smoking on respiratory symptoms.
If0-115.
Effect of children's and
Arch Dis Child 1978; 53:
Kasuga H, Hasebe A, Osaka F, Matsuki H. Respiratory symptoms in =choo]
children and the role of passive smoking. Tokai J Exp C1in Med 1979;
4: 101-114.
Weiss ST, Tager IB, Speizer FE, Rosner B. Persistent wheeze. Its
relation to respiratory illness, cigarette smoking, and level of pul-
monary function in a population sample of children. Am Rev Respir Dis
1980; 122: 697-707.
TI08350887
PASSIVE ~)~ING ~[D ~HE LU~S
17. Dodge R. The effects of indoor pollution on Arizona children. Arch
Environ Health 1982; 37: 151-155.
18.
Tager IB, Weiss ST, Rosner B, Speizer FE: Effect of parental cigarette
smoking on the pulmonary function of children. Am J Epidemiol 1979;
110: 15-26.
19. Yarnell JWG, St. Leger AS. Respiratory illness, maternal smoking habit
and lung function in children. Br J Dis Chest 1979; 73: 230-236.
20.
Hasselblad V, Humble CG, Graham MG, Anderson HS. Indoor environmental
determinants of lung function in children. Am Rev Respir Dis 1981;
123: 479-485.
21. Vedal S, Schenker MB, Samet JM, Speizer FE. Risk factors for childhood
respiratory disease: analysis of pulmonary function. Am Rev Respir
Dis 1984; 130: 187-192.
22. Leeder SR, Corkhill RT, Wysocki MJ, Holland WW. Influence of personal
and £amily factors on ventilatory function in children. Br J Prey Soc
Med 1976; 30; 219-224.
23. Lebowitz MD, Armet DB, Knudson R.
pulmonary function in children.
8:371-373.
The effect of passive smoking on
Environment International 1982;
24. Dockery DW, Ware JH, Speizer FE, Ferris BG Jr. Preliminary longitudi-
nal analyses of pulmonary function in school children in the slx-cities
study (Abstract). Am Rev Respir Dis 1982; 125:145 (Part 2).
25. White JR, Froeb HF. Small-airways dysfunction in non-smokers chronic-
ally exposed to tobacco smoke. N Eng J Med 1980; 302: 720-723.
26.
Kauffmsnn F, Tessier JF, Oriol P. Adult passive smoking in the home
environment: a risk factor for chronic airflow limitation. Am J
Epidemiol 1983; 117: 269-280.
T108350888
207
EFEECT OF SMOKING ON GASTROINTESTINAL ~RM01qE SECRETION
Yutaka Seino
Kinsuke Tsuda
Kozaburo Mori
Shozo Li
Jiro Takemura
Shigeru Matsukura
Hiroo Imura
Second Division, Department of Medicine
and Division of Metabolism and Clinical Nutrition*
Faculty of Medicine, Kyoto University
Kyoto 606, Japan
INTRODUCTION
Recent studies have reported the frequent occurrence of peptic ulcer and
chronic pancreatitis in smokers. Previously, it has been demonstrated also
that smoking reduces exocrine gastric (i) and pancreatic secretions (2) and
gastrointestinal contractile activity (3).
Several gut and pancreatic hormones have a close relationship with gastric
and pancreatic secretions and gastrointestinal motor activity: gastrin is
secreted from the gastric antrum; most pancreatic pol~peptide (PP) is found
to be distributed in the pancreas; and motilin and gastric inhibitory poly-
peptide (GIP) are located in the upper part of the small intestine. The
biological activities of these hormones are well known: gastrin stimulates
gastric acid secretion; motilin produces gastrointestinal motor activity
(4); and PP is related to pancreatic and biliary secretions (5). On the
other hand, GIP suppresses gastric secretions. In addition, the main GIP
action is thought to be the enhancement of insulin secretion.
The effect of smoking on endocrine gastrointestinal hormone secretions has
remained unclear, however. The present study was undertaken, therefore, to
elucidate the effect of smoking on the release of gut hormones such as gas-
trin, motilin, PP, and GIP.
SUBJECTS AND ~THODS
For each hormone, two experiments were performed. In experiment I, in order
to compare the effects of smoking 2 mg. nicotine cigarettes with non-
Address - .'_, ,___._
.~_Seco~d_D~ri-s~u~--Dep~rt~__nt
correspondence.~o'~_in~ ~ ~
of Medicine, Faculty of Medicine, Kyoto University, Shogoin Kawahara-cho,
Sakyo-ku, Kyoto 606, Japan.
T10~350889
smoking, six males aged 20-42 yrs were given a 280 Real. meal to stimulate
hormone release after an overnight fast. In experiment 2, six males aged
20-40 yrs smoked 1.2 mg D-nicotine (an isome_r of L-nicotlne) cigarettes to
compare the effects with those of 1.2 mg L-nicotine cigarette smoking on
200 Kcal. meal-induced motilin and PP release. Blood was withdrawn at
intervals of 5-15 mln. for two hours before and after the meal. The volun-
teers smoked one cigarette every 15 minutes for a total of 16 cigarettes in
four hours. Gastrin, GIP~ motilin, and PP were measured by specific radio-
immunoassay.
RESULTS
No significant difference in gastrin or GIP release was observed with or
without smoking, as shown in Figures I and 2. Motilin has an intermittent
secretory behavior which causes hunger gastrointestinal contractile activi-
ty. Smoking reduced the intermittent fluctuation of motilin release in the
fasting state, although the interval of fluctuation was different in each
subject, and also blunted the significant rise after meal ingestion, as
indicated in Figure 3.
FIGURE I. EFFECT OF SMOKING ON GASTRIN SECRETION
BEFORE AND AFTER MEAL INGESTION
~/ml
I~0
5O
'T~n':| { Mrn)
Tl08350890
FIC[TRE 2. EFFECT OF SMOKI~G ON GIP SECRETION
BEFORE AND AFTER MEAL INGESTION
FIGURE 3. EFFECT OF SMOKING ON MOTILIN SECRETION
BEFORE AND AFTER MEAL INGESTION
TI08350891
210
~IBO L~ AL.
Figure 4 shows the effect of smoking on PP release. In the non-smoking
controls, PP showed a biphasic secretory pattern after meal ingestion.
Smoking suppressed the significant rise in PP secretion after the ~eal,
especially the second phase of meal-induced PP secretion found with non-
smoking. When we calculated the total amount of meal-induced second phase
PP secretion, Z pP was significantly reduced by smoking (P < 0.05).
FIGURE 4. EFFECT OF SMOKING ON PP SECRETION
BEFORE A~ AFTER MEAL INGESTION
10oo
500
T~me (M~n)
Figure 5 shows the comparison of D- and L-nicotine cigarette smoking on
motilin release. The intermittent fluctuation in the fasting state and the
peak_mor_ilin_lev.~af~- ~ndd__to~e ~educe& by-J~nico~zJme_ciga-
rette smoking when compared to D-nicotine cigarette smoking. We found also
that the suppressive effect of L-nicotine cigarette s~oking on PP release
after meals is much stronger than D-nicotine cigarette smoking, as shown in
Figure 6.
TI08350892
211
FIGURE 5. COMPARATIVE EFFECT OF D- AND L-NICOTINE CIGARETTE SEOKING
ON MOTILIN SECKETION BEFOKE b/~D AFTER M~AL INfiEST~ON
2O0
~00
FIGURE 6. COMPARATIVE EFFECT OF D- AND L-NICOTINE CIGARETTE SMOKING
ON PP SECRETION BEFORE AND AFTER MEAL INGESTION
hPP
T108350893
DISC-t]SSION
In the present study, we have found that motilln and PP secretions are
impaired by s~oking, but that the augmented gastrin and GIP secretions after
meal ingestion are not affected by smoking. Since we have reported in a
previous study (4) that the intermittent m~tilin secretion, measured in the
plasma in the fasting state, has a close relationshlp with gastrointestinal
contractile activity, smoking may reduce gastrointestinal motor activity.
In addition, we have found previously that plasma PP levels induced by
secretagogues reflect pancreatic exocrine function (6). It seems likely,
therefore, that smoking suppresses pancreatic exocrine function.
We have demonstrated also a lesser effect of D-nicotine cigarette smoking on
motilin and PP secretions, compared with L-nicotine cigarette smoking (7).
This observation agrees with our previous findings (7) that D-nicotine ciga-
rette smoking has a lesser effect on changes in blood flow, heart rate,
blood pressure, and plasma catecholamines than L-nlcotine cigarette smok-
ing. The lesser effect of the D-nicotine cigarette may result from less
action on the autonomic nervous system or from a direct action on the hor-
mone producing cells.
Our present findings show that smoking L-nicotine cigarettes, but not
D-nicotine cigarettes, suppresses motilin and PP secretion and suggest that
it might be related to decreased pancreatic exocrine secretion and gastro-
intestinal motor activity.
i. Wilkinson AR, Johnston D. Effect of cigarette smoking on gastric secre-
tion. Lancet 1971; 2: 628.
2. Konturek ST, Solomon TE, McCreight WG, et al. Effects of nicotine on
gastrointestinal secretions. Gastroenterology 1971; 60: 1098.
3. Hug CC Jr, Bass P. Effects of nicotine on gastrointestinal contractile
activity. Univ Michigan Med Center J 1970; 36: 246.
Itoh Z, Takeuchi S, Aizawa K, et al. Changes in plasma motilin concen-
tration and gastrointestinal contractile activity in conscious dogs. Am
J Dig Dis 1978; 23: 929.
5. Greenberg GR, McCloy RG, Adrian TE, et al. Inhibition of pancreatic and
gall bladder functions by pancreatic polypeptlde in man. Lancet 1978;
2: 1280.
o
Yamamura T, Mori K, Tatsumi M, et al. Availability of plasma pancreatic
polypeptlde measurement in diagnosis of chronic pancreatitis. Stand J
Gastroenterol 1981; 16: 757.
Li S, Seino Y, Nakano R, et al. Effect of smoking on autonomic nervous
system and peripheral vessel. Folia Endocrinol Japan 1982; 58 (Suppl.):
342.
T108350894
213
IRRITATI~G AND ANNOYING EFFECTS OF CIGARETTE SFEKE
Roy J. Shephard, M.D., Ph.D.
Department of Preventive Medicine & Biostatistics
and School of Physical & Health Education
University of Toronto
Ontario, Canada
Arguments to limit smoking in public places may ultimately be based upon
such concerns as respiratory disease in children, an increased risk of bron-
chial carcinoma, and the danger of fire (I). But for the moment, the most
readily justified complaints of the non-smoker are annoyance and irritation.
SUBJECTIVE (X)NPL~NTS
Complaints after two hours of experimental exposure to cigarette smoke are
very similar to those found in random questioning of the adult population.
In allergic patients, cough and nasal irritation are ranked more highly than
eye irritation. With non-allergic subjects, 69% complain of eye irritation,
32% of headache, 29% of nasal symptoms and 25% of cough (2). The relative
importance of the various symptoms depends also on humidity [irritation
being greatest with warm and dry air (3)] and smoking habits [smokers being
more vulnerable to eye irritation, and non-smokers to nasal irritation
(I)]. The smoke of a person's own cigarette is less annoying than the smoke
from someone else's cigarette. Part of this is situational, and part
reflects the lower combustion temperature and lesser filtration of both
irritant gases and particulates from sidestream smoke. The gas phase of the
smoke seems largely responsible for annoyance, while the particulate phase
is to blame for irritation (4).
ESTIMATING EXPOSURE
Exposure to cigarette smoke can be estimated from the accumulation of carbon
monoxide in the room, the accumulation of carbon monoxide in the subject's
blood, and the urinary excretion of substances such as nicotine.
AVOIDANCE OF P/~SIVE SMOKI~
Possible tactics include segregation of smokers, increased room ventilation,
and prohibition of smoking. In 1971, the U.S. Federal Aviation Admlnistra-
Address correspondence to: Roy J. She9~ Director,_Sghoo_l_of Phys~ical_&
Heal~h-EH~-6~flo-~, 32~-Huron Street, Toronto, MbS IAI, Ontario, Canada.
TI08350895
i
214
~P~k~
tion (5) found that 84% of non-smoking aircraf~ passengers would have been
content with a segregated seating arrangement. Selff (6) found that when
smoking was restricted to the back one-fifth of an interclty bus, none of
the other passengers complained of eye irritation.
The particulate level for eye irritation in different reports has varied
from 2-5 mg/m3 (7,8,9). While smokers are satisfied with a room ventilation
of 15 m3/hr, non-smokers demand 30 m3/hr to avoid eye irritation (9). A
figure of 60 m3/hr/clgarette is necessary to hold carbon monoxide levels
below 5 ppm.
Differences of threshold between studies are related in part to aging of the
smoke - although the initial particle size is about 0.2 ~, there is a rapid
coalescence to fewer and larger particles. A fur=her variable is whether
smoking is merely allowed, or is actively encouraged for experimental
purposes.
POPULATION RESPONSE
In general, the ex-smoker is annoyed to at least the same extent as the
non-smoker. Figures for annoyance are underestatements, since they are
coloured by the subject's range of experience. Thus, 51% of a professional
and managerial group [who use aeroplanes frequently] complained of smoke on
aircraft, but only 36.2% of other occupational groups made a similar
protest. Likewise, annoyance in buses was reported by 63.2% of those still
at school, compared with 47.4% of the remainder of the sample. Some 64.4%
of clerical workers reported annoyance in offices, compared with 48.7% of
remaining subjects. Finally, 40.3% of the "housewife" group stated that
they were annoyed by smoke in shops, compared with 26.7% of the remainder of
the sample (Ii).
Our studies of eye irritation have been conducted in a 15 m3 exposure cham-
ber, with smoke generated by a standard smoking machine (I0). The three
items of concern to the non-smoker are irritation, suffusion and lachryma-
tion, with the associated disturbance of vision. Vision is disturbed less
in subjects who complain of lachrymation than in those who report irrita-
tion, and we may hypothesize that lachrymatlon helps to wash away irritant
particles from the eyes. In our study, older subjects lachrymated more than
those who were younger (12).
Both ex-smokers and continuing smokers report more lachrymation with passive
than with active smoking (12). More than half of non-smokers and ex-
smok~j and~40%_of_con~i~uing_smo-~~m~!ain--of--lachryz~tion-.---The~l-a~
period for build-up of irritants and penetration of the cornea is 5-~0
minutes (12,13). Itching, tear flow, eye-closing and eye rubbing all
develop roughly in parallel. Attempts to pin-point the irritant chemical
have not been particularly successful. Both acrolein and formaldehyde seem
less irritant than cigarette smoke (14), although these compounds - with
acrylonitriles - are plainly in quite high concentrations in crude cigarette
smoke.
O0 O0~
T10,_,o50~ o
215
Basu and associates (I0) noted further that I0 minutes in the s~_oke exposure
eha~.ber was sufficient to halve the time to break-up of the tear film. It
is unlikely that bl~nking and rubbing of the eyes influence either the
volume or the chemical composition of the tears over the first i0 minutes.
The time also seems insufficient for aldehydes and oxidants to cause peroxl-
dation of the lipid film. The most likely explanation is that the irritant
chemicals =x)dlfy tear composition, either increasing the output of the
watery phase, or decreasing the output of the stabilizing liplds.
About 14% of subjects stated that vision was adversely affected. The pro-
blem was corrected quickly on leaving the smoke-filled room - we suspect
there was some conjunctival suffusion, but that tears quickly washed the
irritant away.
NASAL DISORDERS
Nasal complaints include odour, nasal discharge, nasal obstruction, itching,
dryness and frequent rubbing of the nose (8,13,15). The acrid sensation
dominates, with receptors adapting over the course of a few minutes. We
have not been particularly impressed with changes in nasal resistance, but
Cockcroft et al. (16) also found some increase of nasal resistance.
PSYCHOLOGICAL RF..ACT J.ON S
Cameron (17) commented that symptoms were twice as frequent in children who
disliked smoke. Our female subjects also showed an appreciable tachycardia
during smoke exposure.
REMEDIAL A~'~ION
Segregation is only a partially effective remedy. What about engineering
smoke out of a room? The main objection is one of cost, both for installa-
tion and operation. Let us imagine a room occupied by six smokers and one
non-smoker. To keep the non-smoker's exposure to the equivalent of one
cigarette per day, ventilation must be three times that needed to dispel
body odours. In winter, with a temperature differential between indoors and
outdoors of 40°C, 4 kilowatts of extra energy must be supplied, a major
consideration with escalating fuel costs (I). Given that symptoms arise in
almost every public space where smoking is presently permitted, and that
surveys show 75% of smokers willing to accept further regulation (If), the
remedy seems rather to enact further legislation that will assure clean air
to the non-smoker by the prohibition of smoking in public places.
I. Shephard RJ. The risks of passive s~oking. London: Croom Helm, 1982.
2. Speer F. Passenger smoking effects on bus drivers. Arch Environ Health
1971; 22: 512.
TI08350.897
216
Johansson CR. Tobacco smoke in room air - an experi=ental investiga-
tion of odour perception and irritating effects. Building Services Eng
1976; 43: 254-262.
4. Weber-Tschoop A, Fischer T, Grandjean E.
loglschen Wirkungen des Passlvrauchens.
1976; 37: 277-288.
Objectiv und subjectiv physio-
Int Arch Occup Environ Health
U.S. Federal Aviation Administration. Health aspects of smoking in
transport aircraft. Washington, D.C.: U.S. Dept. of Health~ Education
and Welfare. Public Health Service Safety and Health. 1971 Dec: 1-85.
Seiff HE. Carbon monoxide as an indicator of cigarette-caused pollution
levels in intercity buses. Washington, D.C.: U.S. Dept. of Transporta-
tion, Federal Highway Administration, Bureau of Motor Carrier Safety,
1973: I-ii.
7. Anderson G, Dalhamn T. Halsoriskerna vid passiv rokning. Lakartidnin-
gen 1973; 70: 2833-2836.
8. Pimm P, Shephard RJ, Silverman F. Physiological effects of acute
exposure to cigarette smoke. Arch Environ Health 1978; 33: 201-213.
Johansson CR, Ronge H. Klimatinverkan p~ lukt och irritationseffeki av
tobaksrok. Prelimlnart meddelande. Nord Hyg Tidskr 1966; 47; 33-39.
I0. Basu PK, Pimm PE, Shephard RJ, Silverman F. The effect of cigarette
smoke on the human tear film. Can J Ophthalmol 1978; 13: 22-26.
11. Shephard RJ, Ponsford E, Basu PK, LaBarre R. Reactions to passive ciga-
rette smoke exposure. The 1977 Toronto Survey. Willowdale, Ontario:
York-Toronto Respiratory Disease Association, 1978.
12. Shephard P~J, Ponsford E, Basu PK, LaBarre R. Effects of cigarette smoke
on the eyes and airway. Int Arch Occup Environ Health 1979; 43: 135-
144.
13. Weber A, Jermini C, Grandjean E.
pollution due to cigarette smoke.
672-676.
Irritating effects on man of air
Am J Public Health 1976b; 66:
14. Weber-Tschoop A, Fischer T, Cierer R, Grandjean E. Experimentelle Reiz-
wlrkungen yon Akrolein auf den Menschen. Int Arch Occup Environ Health
1977; 40: 117-130.
15. Weber A, Fischer T, Sancin E, Grandjean E. La pollution de l'air par la
fum~e de cigarettes; effets phys~ologiques et irritations. Soz Praev
Med 1976a; 21: 130-132.
16. Cockcroft DW, MacCormack DW, Tarlo SM, Hargreave FE, Pengelly LD. Nasal
airway inspiratory resistance. Am Rev Respir Dis 1979; 119: 921-926.
17. Cameron P. Second-hand tobacco smoke - children's reactions.
Health 1972; 42: 280-284.
J Sch
T108350898
217
SMD~II~G, PHYSICAL ACTIVITY AND HEALTH:
FINDIRGS FEOM TFr~ CANADA FITNESS SURVEY
Thomas Stephens, Ph.D.
Canada Fitness Survey
Ottawa, Ontario, Canada
Linda Pederson, Ph.D.
J. Stanley Hill, Ph.D.
University of Western Ontario
London, Ontario, Canada
IMTEODUCTION
This paper reports so=e preliminary findings from the 1981 Canada Fitness
Survey on the relationships between and among cigarette smoking, leisure-
time physical recreation, fitness and health. The principal objective of
the study is to investigate the relationship between smoking and fitness,
about which relatively little has been written.
The key questions asked at the outset of this study were: What are the fit-
ness levels of heavy, light, ex-, and non-smokers, and what role do physical
recreation habits play in the formation of these fitness levels? Some
surprising answers are provided here, although the analysis is still in
progress and it is too soon to be definite about the effect of smoking.
METHODS
The analysis made use of data collected between February and July 1981
during the course of the Canada Fitness Survey (CFS). The CFS was a
Canada-wlde household survey of physical recreation habits and fitness
levels, funded by Fitness Canada, the Canadian government's fitness agency.
The objective of the survey was to describe the population as of 1981,
providing statistics for planning purposes and a baseline for future
comparisons.
Data on lifestyles, includlnB physical recreation, smoking, alcohol consump-
tion, and dietary habits, were collected from 21,733 persons age I0 and over
by means of a self-completed questionnaire. These were filled out during
household visits, at which time fitness testing and anthropometry was also
completed. The protocol for the latter was the Standardized Test of Fitness
(I), ~ich included cardiorespiratory fitness, muscular strength and endur-
ance, trunk flexibility, and body weight. The cardiorespiratory test was
the advanced version (three sessions of three minutes) of the Canadian Home
_Fi~ness~esL_~_~_which~i~oi~ea_c/imbing__t~o__ZO=c~.~ep~_to__a_muslc~1
cadence adjusted to age and sex. The tests were completed by 15,518 persons
Address for correspondence: Thomas Stephens, Distinguished Visiting
Scientist, National Center for Health Statistics, 3700 East-West H~ghway,
Hyattsville, MD 20782, U.S.A.
T[08350899
218 S~P~:NS~
P~EP,~SO~ ~[1) HILL
age 7-69 yrs. Analyses reported in this paper are confined to the sample of
9,626 people age 20-59 yrs who completed both questionnaire and fitness
test.
The sample for the CFS was a multi-stage probability design with 13,350
households, located in urban and rural areas of each province of the coun-
try. Sample data were weighted by appropriate factors to represent the
Canadian population as described by the 1981 Census. (See Appendix B of
reference #5.) All figures reported in this paper are weighted means or
proportions.
The key variable, smoking behaviour, was based on responses to a single
question of the type commonly used to describe general practices (3).
Categories are defined as follows:
"heavy" - I to 2 or more packs daily
"light" - occasional to I/2 pack daily
"ex" - stopped cigarettes over one year ago
"never" - no history of smoking.
Table 1 shows the results on several parameters of fitness for the different
categories of smoker.
Flexibility results (trunk flexion in centimeters where 25.0 is equivalent
to touching the toes) are clearly related to sex (females are better),
secondarily to age (young are better), and not at all systematically to
smoking, except that the heavy smokers are not as flexible as other groups.
Grip strength was measured with a handgrip dynamometer, reported scores
being the sum of right and left hands. Males outperform females; there is
little deterioration in strength with age, and no relationship exists with
smoking.
Muscular endurance was tested with speed sit-ups (maximum in 60 seconds) and
push-ups (maximum number from the toes for males and from the knees for
females). Scores were added to produce an index of endurance. These
results show better performance by men, a deterioration for both sexes as
the years advance, and no systematic differences for types of smoker.
The cardiorespiraory test results in Table 1 show the percentage achieving a
recommended level of fitness, that is, completing all three stepping
sessions. Since heart rate is measured at intervals, those who reached the
recommended level had heart rates below pre-established standards at the end
of three minutes and again at six minutes.
~ re-lationsh-i.?--ca-n--be--em~-ted~--b~t~,-een--to-pe--of~m~ker~,~d--anD~a~mam~_~tem
of fitness, it should be cardiorespiratory fitness. As Table 1 shows, there
is a decrease of cardiorespiratory fitness with increasing levels of smok-
ing, but there is a major anomaly as well.
First, the anticipated findings: in each age-sex group, the heavy smokers
perform worst. In three groups, there is an apparent dose-response rela-
TI08350~00
o
0
Sex
Male
Female
20- 39
41)-59
2 1-39
41 ~-59
TABLE 1. FITNESS RESULTS AND BODY WEIGHT BY TYPE OF SMOKER
Canada, 1981
Type of
Smoker
FLEXIBILITY GRIP STRENGTH ENDURANCE STEP-TEST
mean, cm. R + L, kg. total push-ups percent
+ sit-ups "recommended"
BODY WEIGHT
mean, kg.
Heavy 28.3 106 30
20 74.4
Light 30.5 104 30 23
72.3
Ex-smoker 29.4 109 30 23
75.8
Never smoked 30.3 107 33 24
75.8
Total 29.6 107 31 22
-
Heavy 23.8 I00 23
12 75.7
Light 24.8 I01 20 14
78.4
Ex-smoker 24.8 102 21 14
79.2
Never smoked 24.3 I00 22 14
78.5
Total 24.4 i00 22 14
-
Heavy 31.8 63 22
15 59.5
Light 32.2 62 24 17
58.2
Ex-smoker 32.8 63 23 17
59.5
Never smoked 32.4 61 24 17
58.9
Total 32.2 62 23 17
-
HEAVY 28.8 60 13
12 62.9
LIGHT 29.2 59 II II
62.4
EX-SMOKER 30.8 60 13 12
64.2
NEVER SMOKED 29.7 58 12 12
65.0
TOTAL 29.7 59 12 12
-
220
tionship for the smoker types, excluding light s=okers, that is, the "never"
do better than the "ex" who do hetter than the "heavy".
The light smokers are the anomaly: they show the best cardiorespiratory fit-
ness in each age-sex group. There are at least three p~ssible explanations
for this unexpected result:
l)
Light smokers may he more active than average, and this compensates for
the effect of their smoking on their cardiorespiratory systems.
2)
Light smokers may weigh less than other smokers, a fact which would
g~ve them an advantage in the test results, since the test procedure
tends to penalize body weight (2).
3)
A moderate amount of smoking, bike a moderate amount of alcohol
consumption (4), may provide a protective or beneficial effect on
certain parameters of health and fitness, of which cardiorespiratory
fitness may be one.
TABLE 2. ACTIVITY LEVELS BY TYPE OF SMOKER.
Canada, 1981
Sex Age
Male 20-39
40-59
Type of Smoker
% "Active"
Heavy
Light 59
Ex 60
Never 63
Total 59
Female 20-39
Heavy 37%
Light 42
Ex 53
Never 60
Total 49
Heavy 53%
Light 55
Ex 61
Never 57
Total 56
40-59
Heavy 47%
Light 46
Ex 5~
Never 53
Total 51
Table 2 shows the proportion of each type of smoker classified as "active",
that is, people who spend a m~nimum of three hours of leisure tire each week
in physically active pursuits, over at least nine months of the year. Ouite
clearly, the light smokers are less active than average, while the "ex" and
TI08350902
221
"never" smokers are ~x~re active in all age-sex groups. Thus the superior
cardiorespirato~y performance of the light smokers cannot be attributed to
their activity levels, at least as described by this index of activity.
However, these figures do indicate that activity may explain the limited
dose-response relationship shown in Table I.
Mean body weight values for types of smoker are shown in Table I. These
suggest that weigh= may explain at least some of the superior performance of
light smokers, since they record lower weights than the "ex" and "never"
smokers in all age-sex groups and have the lowest weights in three age-sex
groups.
There are no data in the CFS to test adequately the possibility that light
smoking may have a beneficial effect. ~owever, neither are there findings
from other sources to suggest that this is a very plausible hypothesis.
DISCUSSION
These results show no clear relationship between smoking and flexibility,
muscular strength or muscular endurance. As these are anaerobic activities,
there is no reason to expect a relationship when other variables are
adequately con~rolled. Age and se~ are the two variables most strongly
associated with these parameters (5), and for this reason have been used
here as controls. Activity level~ however, is also related positively to
performance on these parameters (6), and to smoking level (Table 2), and has
not been controlled. This will be done in future analysis.
The relationship between smoking and cardiorespiratory fitness is much as
expected, except for the suprislngly good performance of the light smokers.
This seems to be at least partly attributable to the lower body weight of
these individuals. While the weight differences are not large, this variable
is as important as heart rate in the regression equation which is used to
predict oxygen uptake from the test results (2).
The most important variable in the equation is the energy requirement or
average oxygen cost of the last stage completed. Whether this stage is the
second session or the third ("recommended" level) for the test subject
depends on his or her heart rate after the second stage. This, in turn,
will reflect not only cardiorespiratg~ry endurance but also such extraneous
variables as the effect of prior tobacco, caffeine or alcohol consumption.
While all test subjects were instructed not to smoke or dr~nk for at least
two hours prior to the test, it is difficult to know with certainty if these
instructions were followed. It is reasonable to assume that light smokers
were more likely to comply than heavy smokers. If this is true and, as a
result of this, the heart rates of light smokers were temporarily lowered
below their normal levels, their test performance may have benefitted.
It is instructive to note that when smokers are tested for fitness with a
in a 2&00-metre run (7), s~okers do worse than non-s~Dkers.
Further analysis of the CFS data will be carried out in order to resolve
so~e of the outstanding questions. In particular, multivariate methods will
TI08350£03
222
STEPHENS, PEDERSOR ~ HILL
be used to examine t ~- ~ r~ ~ between smoker type and cardiorespirato-
ry fitness when age, ~ ~ ~ , v level and body weight are simultaneously
controlled. Ever ~r~ ~ --rL , of these analyses, it is clear that heavy
smokers are at a dis~dv--:~. ,~, ex- and never-smokers are at an advantage
in testing for ca~2, :~: :e , :y fitness, while flexibility, =ascular
endurance and streng[;- ..:.. , e e~dent of smoker type.
One final thought on th- ma:. e= :~f body weight, test performance and smok-
ing. Even though the l,~'Lt ~mo. cr's good test results may be an artifact of
the test protocol, W~a~ ~:ig]~' t',is do to the self-image of the smoker? Add
to this positive impact, tt:e :act that the light smoker is lighter, on
average, than other type- o[ smcker. In a society which values slimness,
the resulting self-[mage m~ ~, positive. Hardly conducive to a reduction
or cessation of smok[ng
TABLE 3.
WEIGHT CONTROL VERY IMPORTANT
REGULAR ACTIVITY VERY IMPORTANT
ACTIVE IN LEISURE TIME (TO AGE 18)
CURRENTLY SMOKE
OTHER PERTINEN~ RESULTS
Male Female
48% 67%
49% 44%
77% 71%
17% 23%
The importance of weight control as a motive for continuing or even begin-
ning to smoke demands further study: only two papers at the Fifth World
Conference on Smoking and Health dealt, even tangentially, with this topic.
Other CFS data (Table 3) suggest that women, in particular, may look to
smoking as a means of weight control. Perhaps the cigarette manufacturers
have already co~e to this conclusion, for their advertising only shows slim
women smoking. Since western culture in its every expression glorlf~es
slimness, this tends to reinforce any belief that smoking is acceptable if
weight control is the result. This issue demands attention, including
further research. Secondary analys~s of the CFS data is l~mited in the
answers it can provide.
This research, llke the Canada Fitness Survey itself, was ~de possible by a
contribution from Fitness Canada.
T108350904
EEFERF~CES
Govern=ent of Canada. Standardized Test of Fitness; Operations Mauual
(Second Edition). Ottawa, Ont: Govern=ent of Canada, Fitness and
Amateur Sport, 1981.
Jett~ M, Campbell J, Mongeon J, Routhier R. The Canadian Home Fitness
Test as a predictor of aerobic capacity. Can Med Assoc J 1976; 114:
680-682.
Johnson CA, Graham JG. Standard measures in smoking prevention
research. Presentation to the Fifth World Conference on Smoking and
Health, Winnipeg, Canada, 1983 July 12.
Belloc NB, Breslow L. Relationship of physical health status and health
practices. Prey Med 1972; I: 409-451.
Government of Canada. Fitness and lifestyle in Canada.
Canada Fitness Survey~ 1983: 24-26.
Ottawa:
Op. cir., p. 32.
Ong TC, Tan PY. The effect of cigarette-smoking on the 2.4 Km run of
155 adult males in S~ngapore. In: Forbes WF, Frecker RC, Nostbakken D,
eds. Proceedings of the Fifth World Conference on Smoking and Health,
Winnipeg, Canada, 1983. Ottawa: Canadian Council on Smoking and
Health, 1985.
T[08350905
225
SMOKI~ A~D SUBARACHHOID HAEMORRHAGE
A. Taha, MRCP
K.P. Ball, MD, FRCP
R.D. lllingworth, FRCS
Central Middlesex Hospital
London NWI0, England
INTRODIJCTION
It has recently been shown that cigarette smoking is associated with
increased risk of subarachnold haemorrhage (SAN) due to ruptured cerebral
aneurysm (i). A report from the USA suggested that the risk is particularly
high in women on oral contraceptives (0C) who also smoke (2). In order to
refute or confirm whether cigarette smoking is associated with SAN, patients
admitted to the Neurosurglcal Department of the Central Middlesex Hospital
were investigated.
METHOD
A questionnaire on smoking habits was sent to all 199 patients admitted bet-
ween 1972 and 1980 with SAH who had survived long enough to undergo angio-
graphy and who had left hospital alive. Women were also asked about the use
of oral contraceptives.
,!
RESULTS
Questionnaires were completed by I78 patients (60 men, 118 women). Informa-
tion was also obtained from the relatives of Ii patients (5 men and 6 women)
who had died since leaving hospital (9 with cerebral aneurysm, 2 with
arteriovenous malformations (AVM)), giving a response rate of 95%. Ten
patients could not be traced.
The angiographic findings and the smoking habits of patients with cerebral
aneurysm, AVM and those with normal angiographlc findings (NAF) are shown ~n
Table i. Both men and women with SAH due to cerebral aneurysm had a higher
prevalence of cigarette smoking compared with the other two groups com-
bined. They had also smoked more cigarettes daily (Table 2). Men with cere-
bral aneurysm, but not women, had started to smoke at a significantly
earlier age.
Comparison of smoking habits of patients with those in the UK population (3)
i_s shown__in Table ~,~the~_ear 1975 in the mi~d~ of_s!~dy ~i_nE_ch~s_e_n_fgr
control. UK age-specific smoking rates were applied to the age distribution
of the SAH patients. It show5 that a~.on~st patients with aneury~m (but not
T108350g06
TABLE 1.
SMOKING HABITS ON ADMISSION (WITH PERCENTAGE) AND MEAN AGES OF 189 PATIENTS
Cerebral
Aneuryem
AVM
AVM & NAF
Ex- Non- Hesn age
Ex- Non- Mean
Smokers Smokers Smokers Total (RanRe) Smokers
S~okere Smokers Total (Range)
31 4 2 37 47.7 68
l0 24 [02 48.5
(83.8) (]0.8) (5.4) (100) (20-69) (66.7)
(9.8) (23.5) ¢100) (19-65)
5 1 I 7 37.5 1
1 2 4 40.7
(20-70)
(16-70)
13 2 6 21 43.4 9
[ 8 X8
(20-65)
(33-65)
18 3 7 28 61.9 ]0
2 10 22 47,9
(~4.3) (I0.7) (25) (100) (20-70) (65.5) (9)
(45.5) (100) (16-70)
Aneuryem
AVM & NAF
TABLE 2. MEAN DALLY CIGARETTE CONSUMPTION OF SMOKERS AT THE TIME OF SAH
At~ HEAN AGE OF ONSET OF SMOKING IN EACH CATEGORY
Mean
Hean age Age of onset c~8arettes Mean age
(years) of smoking per day (years)
46.8 16 27.4 48
45.7 19.4 13.5 45.4
(P<0.05) CP<0.001 )
Mean
Age of onset clgare~tes
oE ~mok~ng per day
19 21.9
IB.L 9.7
(NS) (P<O.OOt)
Ani?urysm
AVM & NAF
TABLE 3.
Smokers
0 E
31 23.3* 4
18 17.0 3
X2 = .8; 2 d.f.: P<0.05.
X2 = [7.9; 2 d.f.: P<O.001.
}UMBER OF SMOKERS, EX-SMOKERS AND NON-SMOKERS OBSERVED (O) IN EACH CATEGORY
AND EXPECTED (E) NUMBERS IN GENERAL POPULATION OF I~
WO~EN
E~-smokers Non-Smokers Smokers
0 E O E O
6.7 2 7.0 68
4.5 7 6.5 I0
Relative risk for smokers = 4.7
Re]ative risk for smokers = 2.6
Ex-smokers Non-smokers
E O E O E
47.4** I0 11.8 24 43.0
I0.0 2 2.7 I0 9.3
O~
228
TAHA, BALL A~D ILLINGWORTH
those with AVM or NAF) the number of smokers was significantly higher than
the number expected by comparison with the UK population. There was no sig-
nificant difference in the social class distribution between patients with
aneurysm and those with AVM and NAF. Seventeen of 102 women w~th aneurysm
reported that at some time they had been taking OC compared with 5 out of 22
patients with AVM and NAF. Of the 127 smokers, 24 reported that they had
stopped since leaving hospital and 103 that they were still smoking.
DISCUSSION
These results support the findings of Bell & Symon (I) who carried out a
similar retrospective study. They found that smoking was associated with an
increased risk of SAH due to cerebral aneurysm by factors of 3.9 for men and
3.7 for women. In a large cohort of women, Petitti & Wingerd (2) found that
SAH was significantly associated with cigarette smoking and with OCs. The
risk of cigarette smokers was 5.7 times that of non-smokers, but in women
who both smoked and used OCs it was 22 times that of women who neither
smoked nor used OCso
Although it was previously thought that cerebral aneurysms were primarily
congenital in origin~ it is now generally accepted that there is also an
acquired atheromatous lesion (4).
The findings of this study show that there is a greater proportion of smok-
ers among patients with SAH due to aneurysm than among those with AVM or
NAF, or than the expected proportion in the general popular{on. The aneu-
rysm patients had on average smoked more cigarettes and, in the case of men,
had started earlier. The accuracy of the smoking histories can, of course,
be queried, but any fallacies would be expected to have affected all groups
to a similar extent.
SAH due to cerebral aneurysm should be considered another smoking-related
disease, but unlike others it is much more common in women, showing that
there must be other causative factors. Patients wlth SAH should be advised
to stop smoking.
ACKNOWLEDGEHENT
We would llke to thank Mr. Nigel Rawson, MSc, FSS, for his help with the
statistics.
I. Bell BA, Symon L. Smoking and subarachnoid haemorhage. Brit Med J 1979;
I: 577-578.
2. Petitti DB, Wingerd J. Use of oral contraceptives, cigarette smoking,
3. Lee PN, ed. Statistics of smoking in the United Kingdom. London: Tobac-
co Research Council 1976. Research Paper I, 7th ed, Table 9m: 30-31.
4. Walton JN, ed. Brain's Diseases of the Nervous System. Oxford: Oxford
University Press, 1977: 352.
T[08350909
THE SMOKERS' DEPENDENCE ON ~ICOTINE AHD TRE FATE OF I~qCOTINE
DURINg; TOBACCO CgRII~G AND ~OKING ARiD ITS EED[~CTIOH
T.C. Tso
Tobacco Laboratory, Beltsville Agricultural Research Center
Agricultural Research Service
U.S. Department of Agriculture
Beltsville, Maryland 20705, U.S.A.
J.D. Adams
N.J. Haley
D. Hoffmann
Naylor Dana Institute for Disease Prevention
American Health Foundation
Valhalla, New York 10595, U.S.A.
INTRODUCTION
Nicotine, the major tobacco alkaloid, continues to challenge investigators
in health research sciences because of its direct pharmacologic effects in
man and because of its role as a precursor for a variety of toxic and car-
cinogenic compounds in tobacco and tobacco smoke and in in vivo systems
(I-5). Epidemiological studies have established a direct dose response
relationship between consumption of tobacco products, respectively quantity
of inhaled tobacco smoke, and the risk of related diseases. Consequently,
reduction of the amount of tobacco consumed would be expected to lead to a
reduction of risks of those diseases that are associated with smoking or
chewing of tobacco (1,3).
These considerations formed the basis for studies on the reduction of tar
yields in tobacco products, and especially in cigarettes, through agricul-
tural practices and through modifications of cigarette engineering, suggest-
ed by us and other investigators at the Third World Conference on Smoking
and Health (6,7). The effectiveness of these methods is well summarized in
the 1981 Report of the U.S. Surgeon General (I). In the present study we
examined the fate of nicotine during curing and smoking of tobacco in order
to elucidate means of reducing the alkaloid levels as well.
In the course of the past two decades, nicotine levels in the smoke of the
sales-weighted average cigarette in the U.S.A. have declined from 2.7 mg to
1.0 mg. This comparison is based on FTC-measurements of nicotine in machine
generated mainstream smoke. Indices of nicotine uptake by smokers of low-
yield cigarettes, however, have revealed that such smokers often compensate
for the lower nicotine delivery by more frequent puff-drawing and/or deeper
and longer inhalation of the smoke (8-11). Since this smoking behavior
__mi_Kh~__nega_~e__~he__i_n~nd~d__bene~_it_s ~f__~a_r__a~d n.i~.o~_i~e ~educ~_io.n_in_c~ga-
rett~ o ...... =, it was importan~ to d~termin~ the degree of compensation occ~-
TI08350910
230
ring and also to evaluate ~he consequences of such changes in smoking
behavior in respect to the uptake of nicotine, carbon monoxide, and other
toxic and carcinogenic agents.
PART I. BIOCHEMICAL I~.J~SUREMENTS OF NICOTINE UPTAKE
As part of a cross-sectional study of smokers, biochemical measurements of
the absorption of smoke constituents have been carried out on blood samples
from 450 volunteers at a community blood center who smoked different brands
of cigarettes.
Methods
After giving informed consent, each smoker filled out a detailed question-
naire on smoking history and o=her lifestyle ~nformation, such as drug use,
as well as a personal health history. A venous blood sample was collected
from each smoker by the nurse interviewer. All samples were collected into
vacutainers containing EDTA as an anti-coagulant and were kept in an ice-
bath until delivery to the laboratory.
Since plasma nicotine and carboxyhemog]obin have half-lives of 15-60 min and
2-4 hr respectively, extrapolation of obtained carboxyhemoglobin and plasma
nicotine levels depends on the time elapsed since the last cigarette
smoked. All subjects had smoked a cigarette at some time within 90 min
before the study, but none had smoked during the 30 min prior to venipunc-
ture.
Carboxyhemoglobin in blood was assayed spectrophotometrically, using an
IL-182 CO-oximeter (Instrumentation Labs) calibrated with certified stand-
ards to guarantee a reproducibility of ± I%. Aliquots of blood were centri-
fuged and the plasma was frozes at -20°C until assayed for nicotine,
cotinine and thiocyanate.
Plasma nicotine and cotlnine were quantitated by radioimmunoassay (12) using
specific antisera produced by injection of trans-cotinine carboxyamide and
trans-3-succinylmethylnlcotine, bound to albumin, into rabbits. The ~nter-
assay and intra-assay variations are 6% with a sensitivity of 500 pg/ml for
nicotine and cotinine. Plasma values obtained by this method are comparable
to those obtained by gas-liquid chromatography (12).
Plasma thiocyanate was quantitated by an automated (Autoanalyser) procedure
(13).
Data from questionnaires and biochemical measurements were analyzed by
linear regression of the Student 't' test.
Results and Discuss£ou
The population studied had a normal distribution in regard to age (36.3
years), sex (235 men, 215 women), cigarettes s~mked per day (=22), years of
~in).
TI08350911
IPL~ORT~NCE OF NICOTINE REDUCTION IN SMOKE
231
There was a linear relationship of cotinine and carboxyhemoglobin but the
relationship between thiocyanate and self-reported daily consumption was
poor. The relationship of tar yield with inhalation based on carboxyhemo-
globin or thiocyanate was insignificant; however, increasing daily cigarette
usage was reflected in progressively higher carboxyhemoglobin and plasma
nicotine in both men and women. Plasma cotinine and nicotine levels approxi-
mated a plateau when more than 21 cigarettes per day were smoked. Plasma
thiocyanate was higher in women than in men smoking more than 21 cigarettes
per day. This could be related to diet or to differences in metabolism.
Carboxyhemoglobin continued to rise with increased consumption of cigarettes
to average levels of 6-7% carbon m~noxide bound hemoglobin when 30 or more
cigarettes per day were smoked.
Comparisons of cotinine and carboxyhemoglobin levels showed that
younger men and women have similar patterns of smoke absorption and metabo-
lism, but older men seem to inhale more deeply or metabolize nicotine to
cotinlne more effectively than do women of the same age. The number of
cigarettes consumed per day was similar for men and women at these age
intervals.
We compared ind~viduals smoking c~garettes y~eldlng e I mg nicotine (n=250)
with those smoking cigarettes yielding <i mg nicotine (n=130) and found that
the former absorb more nicotine per cigarette and exhibit higher plasma
cotinine than the latter. Smoking about 21 or more of the low-yield ciga-
rettes per day produced a plateau for plasma nicotine and cotinine levels
while these levels continued to increase for those who smoked products with
higher nicotine yields.
Trend analysis showed similar patterns for smokers of more than 10 ciga-
rettes per day. COHb increased with greater consumption while nicotine and
cotinine appeared to plateau.
To investigate this phenomenon in detail, we determined within the test
population the most popular brand of cigarette in the high-yield and the
low-yield categories and analyzed the biochemical parameters in the smokers
as a function of daily dosage. This revealed that smoking of the most
popular high-yleld brand (nicotine, I.I mE, carbon monoxide, 21 mg) and of
the most popular low-yield brand (nicotine, 0.4 mg, carbon monoxide, 7.0 mg)
caused comparable levels of carboxyhemoglobin, thlocyanate and cotinine,
except for those smokers who consumed less than 15 cigarettes per day.
These measurements substantiate observations of other ~nvestigators (8,9,10)
that most smokers are able to maintain an optimum nicotine level even when
smoking Iow-yleld cigarettes by modifying their smoking behavior. The
degree of exposure to nicotine thus remains substantial, even for smokers of
low-yield cigarettes (I|).
PART 2. ~ FATE OF NICOTINE DUR/NG (~JRING AND SMOKING
Because sf the pharmacological effects of nicotine and its role as a precur-
sor of tobacco-specific N-nitrosamines (TSNA), its reduction or m~dification
is mandatory. This task can be undertaken only upon elucidation of the fate
of nicotine during curing, smoking and human m-:_tabolism (4,5,14-17).
TI08350912
232
Nicotine can be N-nitrosated to form three major alkaloid-N-nitrosamlnes all
of which are carcinogenic in laboratory ani=als (5). These compounds are
not present in freshly harvested leaves but are formed during aging and
curing due to the presence of nicotine, nornicot]ne and nitrite in the
leaves (16). During smoking, additional quantities of N-nitrosamines are
formed by reaction of nicotine and other alkaloids with nitrogen oxides
(Figure I; 15,17).
FIGURE I, FORMATION OF N-NITROSONOP~ICOTINE (NNN) IN TOBACCO AND IN
TOBACCO SMOKE BY N-NITROSATION REACTIONS
The formation of alkaloid-derived N-nitrosamines could conceivably be
inhibited or controlled by precursor modification or by addition of chemical
N-nitrosation inhibitors to the tobacco. This requires studies on the
mechanisms of formation of cyclic N-nltrosamines with defined precursors.
Therefore, we utilized tartrates of radiolabelled nicotine isomers to stem-
feed mature leaves of nitrate-rich Burley-21 plants. These were air-cured
for 12 weeks and analyzed for TSNA aimed at delineating specific pathways of
TSNA formation from nicotine which was 14C-labelled either at the 2'-
position, or at the methyl group, or randomly.
Methods
The nitrate-rich Burley 21 tobacco plants originated from the Tobacco
Laboratory of the U.S. Department of Agriculture in Beltsville, MI).
14C-Labelled nicotine isomers were obtained commercially and dua1-1abe]led
nicotine was isolated from plants, fertilized with 15N-nitrate and grown in
a 14C02._atmosphe!~_. ~qrt_he i~lg_~ig.n o_f ~he dUall~labelled__nic_o_t_i_ne_~__the
mature plants were harvested and extracted with ethanol. Nicotine-U-14C and
15N-labelled compounds were enriched by several solvent distribution steps
A dried nicotine concentrate so obtained was dissolved in methanol and
analyzed by HPLC on a Whatman Partisil PXS 10/25 ODS-2 column with a linear
TI08350913
IMPORTANCE OF NICOTINE REDUCTION IN SMOKE
233
solvent gradient of 100% A to 40% A / 60%B over 30 mln at a flow of 1.5
ml/min. Solvent A was a triethylamine phosphate buffer (pH 7.20), solvent B
was acetonitrile. The peaks corresponding to the retention time- of nicotine
were collected separately from more than 80 runs, combined and steam-
distilled from a basic me_dium. The organic phase of the distillate was
gas-chromatographed on a 12 ft x 2 mm i.d. glass column packed with 10%
Carbowax 20M - 2% KOH. (The nicotine isolated from this system was >99%
pure; specific activity: 14.6 ~ Ci/~M). The 14N/15N ratio, determined in
another aliquot of the ~solated nicotine by mass-spectrometry, was found to
be i0:I.
Leaf Feeding and Analysis of TSNA
Mature leaves from the Burley 21 plants were individually stem-fed with
solutions containing labelled nicotine tartrate (pH 6) as shown in the
protocol, summarized in Table i. The leaves were then cured for 12 weeks
and analyzed with 3H-NNN as an internal standard for the quantitative deter-
mination of TSNA. 3H-NNN was prepared by tritiation of myosmine. The cured
leaves were ground in a blender and st~rred overnight in a citrate-phosphate
buffer at pH 4.5 with 20 mM ascorbic acid and 3H-NNN (2 x 106 dpm). The aqu-
eous extract was adjusted to pH 5 and extracted with chloroform. The
concentrate of the organic phase ( = 70 ml) was extracted with 0.I N HCI.
The aqueous phase was again adjusted to pH 5 and extracted three times with
chloroform. This organic extract was dried (Na2S04), concentrated and
chromatographed on alumina (Woelm, basic, activity II-III). Fractions
containing TSNA were combined; aliquots were analyzed by GC-TEA, other
aliquots were subjected to HPLC and the individual N-nitrosamines were
collected for liquid scintillation counting. A flow chart of this method is
presented in Figure 2.
TABLE Io LEAF FEEDING PROTOCOL
Nicotine
DPM per
No. of Leaves mg/leaf Type of label leaf
30 5.5
30 2.5
30 5.5
30 2.5
30 5.5
30 2.5
30 5.5
30 2.5
30 -
Nicotine-2'-iAc
Nicotine-l'-14C
Nicotlne-14C-15N
Nicotine-14C-15N
Nicotine-methyl-14C
Nicotine-methyl-14C
Unlabelled
Unlabelled
Tartrate Buffer Control
=8.7 x 105
= 9.0 x 105
-~ 1.0 x 106
-" 5.0 x 105
-~ 1.6 x 106
= I .6 x 106
T/0~o_914
FIGURE 2. FLOW CHART OF ~;ALYTICAL PROCEDURES FOR QUANTITATIVE
DETERMINATIONS OF TEtrA
Results and Discussion
Table 2 summarizes findings of this study. Stem-fed nlcotine-2'-14C and
random-labelled nicotine-16C give rise to l'4C-labelled N'-nitrosonornicotine
(NNN) and N'-nitrosoanabasine (NAB); slgn[ficant amounts of labelled NNK
were not detected. The yields of NNN (6 x 10-3% and I0 x 10-3%) from the
labelled nicotine compared well with an earlier curing study in which the
stem-feeding of Burley-21 leaves with n]cotlne-2'-14C ~ave a yield of 9 x
did not lead ~o measurable amount s of any of the tobacco-specific
N-nitrosamines.
TI08350915
TABLE 2.
FORMATION OF TOBACCO-SPECIFIC N-NITROS.~MINES
DURING CURING[
Tobacco-Specific % Transformation
from
N-Nitrosamines
14C-Nicotine
(ppm)
Leaf Material ~N NAT NNK NNN NAB2 ~K
Nicotine-2'-14C i.i 0.2 0.! I0 x 10-3
0.7 :< 10-3 ND3
Nicotine-U-14C 1.2 0.2 0.I 6 x 10-3 0.4 :.: 10-3 ND3
Nicotine-methyl-14C 1.2 0.3 0.I ND3 ND3
ND3
Nicotine I .0 0.2 0.I - - -
Control I .0 0.i 0.09 - - -
1 Values are based on leaf weight after curing.
2 NAB and NAT coelute in the analytical system used in this part of the
study.
-3~,
3 ND = not detected (>0.05 x 10 ~).
On the basis of work with nicotine-2'-14C as a precursor, we hypothesize
that nicotine undergoes oxidative N-nitrosation to NEN w~th loss of the
methyl group during curing. Earlier in the curing process we determined the
levels of both labelled and unlabelled alkaloids in an aliquot of leaves.
This revealed that 2% of the nicotine was converted to anabaslne which could
then be n~trosated to y~eld the l~C-label|ed N'-n~trosoanabasine (NAB)
identified in this experiment (Figure 3).
N~trosoanatabine (NAT) also could possibly be formed during curing by
oxidative N-nitrosation of the nicotine under ring opening between C-5' and
the pyrrol~dlne nitrogen (Figure A). The resulting N-nltrosaminoaldehyde
(NNA) reacts either with other tobacco components or undergoes ring closure
to iso-NAT and by rearrangement, to NAT. The follo~ng earlier observations
support this concept. F~rst, although not detected ~n smoke~ NNA is formed
from nicotine treated w~th nitrite at acidic or neutral pH in model
studies. The lack of identification of NNA ~n tobacco or in tobacco smoke
is likely due to its highly reactive aldehyde group. Secondly, although
anatabine concentrations ~n cured Bright and Burley tobaccos and in
cigarette tobacco blends range only 0.05-0,1% and constitute no more than
3-5% of the concentration of nicotine, NNN and NAT levels in processed
tobaccos are comparable (5). ~n~s phenomenon ~s currently being explored.
The absence of detectable amounts o~ NNK in cured tobacco leaves which were
stem-fed w~th 14C-labelled nicot~ne may be explained by transmethylation
which is known to occur during curing.4 Th~s hypothesis~ ~s also supported by
the observation that nicotine'-methyl-I C did n~ ~i~e rise to any measurable
amounts of NNK.
Tl08350916
236
TSO~ ADAMS, HALEY A~D ~OFFMA~-~
FIGURE 3. HYPOTHESIS OF ~;N AND .~AB FORMATION BY OXIDATIVE
N-NITROSATICN OF NICOTINE
II
FIGURE 4. HYPOTHESIS OF NNN AND NAT FORMATION BY OXIDATIVE
N-NITROSATION OF NICOTINE
T107.,350917
II~ORTAHCE OF HICOTIh~ RF_/)~JCTIOH EH SMOKE
237
The study of the mechanism of formation of tobacco-speclfic N-nitrosamines
from nicotine is not merely of academic interest. N~ and N~I are
biologically much more active than NAT or NAB. Since nicotine is an
essential factor in tobacco products, control over the N-nltrosation process
during curing, aging and smoking from NNN and NNK to NAB and NAT would lead
to a significant detoxification of tobacco products which is an important
aspect of tobacco research for the reasons outlined during this report.
ACKNOWLEDGEMENTS
The biochemical studies reported here were supported by institutional funds
of the American Health Foundation. The tobacco studies were funded by USDA
contract No. U.S.D.A. 53-32U4-I-210.
o
US Department of Health and Human Services. The health consequences of
smoking: Cancer. A report of the Surgeon General. Rockville, Md: Office
on Smoking and Health, 1982:322 (DHHS Publ. No. (PHS) 82-5179).
US Department of Health, Education and Welfare. Cigarette smoking as a
dependence process. Krasnegor NA, ed. 1979: 194. (DHEW Publ. No. (ADM)
79-800).
US Department of Health, Education and Welfare. Smoking and health. A
report of the Surgeon General. Washington, DC: 1979: 1136. (DHEW Publ.
No. (PHS) 79-50066).
Hoffmann D, Brunnemann KD. Endogenous formation of N-nitrosoproline in
cigarette smokers. Cancer Res 1983; 43: 5570-5574.
Hecht SS, Castonguay A, Rivenson A, Mu B, Hoffmann D. Tobacco-specific
nitrosamines: carcinogenicity, metabolism, and possible role in human
cancer. J Environ Sci Health 1983; CI: 1-54.
Tso TC, Gorl GB, Hoffmann D. Reduction of nicotine and tar in tobacco
and in cigarettes through agricultural techniques. 1976: 35-48. (DHEW
Publ. No. (NIH) 76-1221).
Hoffmann D, Wynder EL. Selective reduction of tumorigenicity of tobacco
smoke III. 1976: 495-504. (DHEW Publ. No. (NIH) 76-1221).
Russell MAH. The case of medlum-nicotine, low-tar, low-carbon monoxide
cigarettes. Banbury Rept 1980; 3: 297-325.
9. Hill P, Marquardt H. Plasma and urine changes after smoking different
brands of cigarettes. Clin Pharmacol Ther 1980; 27: 652-659.
I0. Herning RI, Jones RT, Bachman J, Mines A~:. Puff volume.
l~w-nicotine cigarette~ are smoked. Br Med J 19$I; 253: 187-189.
TI08350918
23S
II. Sepkovic DW, Haley NJ, Wynder EL. Cigarette smoking as a risk for
cardiovascular disease III. Nicotine regulation and compensation with
increasing nicotine yield cigarettes. Addict Behav 1983; 8: 59-66.
12. Langone jJ, Gjika HB, Van Vunakis H. Radioi~unoassay for nicotine and
cotinlne. Biochemistry 1973; 12: 5025-5030.
13. Butts WC, Kuehneman M, Widdowson GM. An automated method for
determining serum thiocyanate to dis=inguish smokers from nonsmokers.
Clin Chem 1974; 20: 1344-1348.
14. Klus H, Kuhn H. Untersuchungen uber die nichtfluchtigen N-nitrosamine
der Tabakalkaloide. Fachl. Mittlg. Austria Tabakwerke 1975; 16:
307-318.
15. Hoffmann D, Dong H, Hecht SS. Origin in tobacco smoke of
N'-nitrosonornicotine~ a tobacco-specific carcinogen. J Nat Cancer
Instit 1977; 58: 1841-1844.
16. Hecht SS, Chen CB, Hirota N, Ornaf RM, Hoffmann D, Tso TC.
Tobacco-specific nitrosamines: for~atlon from nicotine in vitro and
during tobacco curing and carcinogeniclty in strain A mice. J Nat
Cancer Instlt 1979; 60: 819-824.
17. Adams JD, Lee SJ, Vinchkoski N, Castonguay A, Hoffmann D. On the
formation of the tobacco-speclflc carcinogen,
4-(methylnitrosamino)-l-(3-pyridyl)-l-butanone during smoking. Cancer
Lett. 1983; 17: 339-346.
18. Adams JD, Brunnemann KD, Hoffmann D, Tso TC. Biogenesis and chemistry
of alkaloid derived N-nitrosamines. Presented at the 184th National
ACS meeting, Kansas City, MO, 1982 Sept 12-17. Abstract #66.
TI08350919
239
LUNG CANCER RISK AND TAR YIELDS OF CIGARETTES SF~OKED
Christian Vutuc, M.D.
Brigitte Gredler, Ph.D.
Institute of Social Medicine
University of Vienna
Kinderspitalgasse 15
A-I095 Vienna, Austria
II~IqIODUCT ION
In Austria, the market shares of filter cigarettes increased from 8% in 1960
to 94% in 1980. During the same period, the average tar yield decreased
from 33.7 mg to 12.9 mg per cigarette; the average nicotine yield from 1.9
mg to 0.7 mg per cigarette. This paper deals w{th the lung cancer risk of
female and male cigarette smokers in relation to the tar yields of ciga-
rettes smoked (1,2).
MATERIAL AND I~THODS
The data were collected in a nationwide case control study described in
detail elsewhere (1,2,3). In the period from 1976 to 1980~ data from 1580
male lung cancer cases and 3160 controls and 297 female lung cancer cases
and 580 controls have been collected. From the male sample only persons
having no occupational exposure were used for analysis, comprising a total
of 252 patients and 839 controls.
The analysis of smoking habits referred to duration and daily number of
cigarettes of all brands ever smoked. The brands were allocated to one of
three groups according to their tar yields: group I < 15mg/cig., group II
15-25mg/cig., group III > 24mg/cig.
The lung cancer risk, adjusted by age, total duration of smoking and daily
consumption, compared to non-smokers was calculated for smokers who only
smoked brands of'groups I, II or III and for smokers who consumed mainly -
at least 2/3 of their smoking career - brands of group I, II or III.
Furthermore, for men the adjusted (age and duration of smoking) lung cancer
risks were calculated for group II consumers and compared with those of
group III consumers, with different daily consumption being taken into
account.
RESULTS
In females and males, significantly (P<0.OI) =ore lung cancer patients than
controls were cigarette s~3ker~ (e~-s~kers included). Ar~3ng females, 188
TI08350920
240
out of 297 cases (63%) and 119 out of 580 controls (21%) were cigarette
sr~nkers. For males, the figures were 248 out of 252 cases (98%) and 536 out
of 839 controls
Table 1 shows the adjusted lung cancer risk in relation to tar yields for
women. Table 2 shows the same data for men and Table 3 for men who consumed
predominantly group II brands compared to lung cancer risk of group III
smokers~ taking into account the variety of daily consumption.
TABLE i.
FEMALE CIGARETTE SMOKERS, LUNG CANCER RISK ADJUSTED
FOR AGE AND YEARS OF SMOKING HABIT AND AVERAGE NUMBER
OF CIGARETTES SMOKED PER DAY.
(NEVER SMOKED: R = 1.0) (i).
Cigarettes smoked belonging exclusively to:
group I
(<lSmg tar/rig.)
group II
(15-2Amg tar/rig.)
group III
(>24mg tar/clg.)
R 1.6
95% Cl 0.i - 34.5
Risk reduction 76%
2.6* 6.3*
1.4-4.5 3,5-11.3
57% 0
R
95% Cl
Risk reduction
Dominating brands of cigarettes smoked belonging to:
group I group II group III
1.7 4.5" 8.9*
0.9 - 3.2 3.0 - 6.6 6.5 - 12.3
71% 54% 0
* P < 0.01
DISCUSSION
The study confirms the dose-response relationship of lung cancer risk and
tar yields of cigarettes (4,5,6). Compared to the smokers consuming group
III cigarettes, smokers consuming group II and group I cigarettes experi-
enced a reduced lung cancer risk. The risk reduction is the same in males
and females. Results referring to group I cigarettes are based on small
samples; their interpretation, therefore, is rather difficult. Relatively
low-tar cigarettes were not available in Austria before the mid-1960's.
Daily consumption is somewhat more important than tar yields as far as the
- lung cancer risk :s ~erned.
We could demonstrate in a cohort analysis of lung cancer mortality in men
and women (7) a decreasing trend in younger birth cohorts which can be
T108350921
LDI~G CA_~CER R~SK ~ TAR Y~ELDS
2~
related to the declining tar exposure of smokers caused by the decreasing
tar yields of c£garettes. Although not s=oking is the only really safe way
to avoid lung cancer, the reduction of tar yields seems to be a feasible way
to influence the risk of all people who will not or can not stop this habit.
MALE CIGARETTE SMOKERS, LUNG CANCER RISK ADJUSTED FOR AGE, YEARS
OF SMOKING HABIT A~ AVERAGE ~JMBER OF CIGARETTES SMOKED PER DAY.
(NEVER SMOKED: R = 1.0) (2).
R
95% Cl
Risk reduction
Cigarettes smoked belonging exclusively to:
group I group II group III
(<15mg tar/cig.) (15-24mg tar/cig.) (>24mg tar/cig.)
- 10.4" 25.1"
- 5.3 - 20.4 17.6 - 35.7
- 59% 0
Dominating brands of cigarettes smoked belonging to:
group I group II group III
R I0.9* 20.6*
36.7*
95% Cl 3.8 - 30.7 12.3 - 34.8 27.0 - 49.9
Risk reduction 70% 44% 0
* P < 0.01
TABLE 3.
MALE CIGARETTE SMOKERS, LUNG CANCER RISK ADJUSTED FOR AGE AND
YEARS OF SMOKING HABIT, TAKING INTO ACCOUNT DIFFERENT DAILY
CONSUMPTIONS (CIGARETTES BELONGING TO GROUPS SMOKED AS DOMINAT-
ING BRANDS) (2).
R 95% CL
group II > 20cig./day : group III ll-20cig./day
1.3"
group II > 20cig./day : group III < lOcig./day
7.8*
group II ll-20cig./day : group III < 10cig./day
2.5*
1.2 - 1.4
5.9 - 10.2
2.1 - 3.0
* P < 0.01
TI0~350922
2~2
t
V~EUCANDG~D~R
Vutuc C, Kunze M. Lung cancer risk in women in relation to tar yields
of cigarettes stroked. Prey Med 1982; II: 713-716.
Vutuc C, Kunze M. Tar yields of cigarettes and male lung cancer risk.
Nat Cancer Instit 1983; 71: 435-437.
Vutuc C. Epidemiologische Untersuchung zur Atiologie des Bronchuskar-
zinoms in Osterrelsch. In: Kunze M, Vutuc C, eds. Sozialmedizln des
Bronchuskarzinoms. Wien: Facultas Verlag, 1980: 77-132.
Dean G~ Lee PN, Todd GF, Wicken AT. Report on a second retrospective
mortality study in North-East England. Part I. Factors related to
mortality from lung cancer, bronchitis, heart disease and stroke in
Cleveland County, with particular emphasis on the relative risks asso-
ciated with smoking filter and plain cigarettes. London: Tobacco
Research Council, 1977. Tobacco Research Council research paper no. 14.
Hammond EC, Garfinkel L, Seidman M, Lew EA.
cigarette smoke in relation to death rates.
274.
Tar and nicotine content of
Environ Res 1976; 12: 263-
Wynder EL~ Stellman SD. Impact of long-term filter cigarette usage in
lung and larynx cancer risk: a case-control study. J Nat Cancer Instit
1979; 62: 471-477.
Vutuc C, Gredler B. Lung cancer in Austria: present and future trends.
Lung, ~n press.
TI08350923
0
CO
C~
243
SMOKING ~NG (~II2DKEN
Theodor Abelin, H.D., M.P.H.
Professor and Head
Department of Social and Preveut~ve Medicine
University of Berne
Finkenhubelweg ii, CH-3012 Berne
Switzerland
The purpose of this paper is to give an overview of the activities aimed at
the prevention of smoking in children, and to illustrate the different
approaches with examples from all over the world.
One of the very first experiments in school smoking education was started in
1960 in Winnipeg (I). Various didactically attractive teaching techniques
such as movies, slides, class projects, designing posters, writing newspaper
articles and parent-teacher meetings, were used to influence the smoking
behavior in two Winnipeg schools. In one of the schools, teachers, students
and parents became qu~te enthusiastic about the smoking issue, whereas ~n
the other school, there was no such positive reaction. In the enthusiastic
school, smoking rates decreased considerably, whereas in the other school,
there was no measurable success. The reason for the difference in response
by these two schools was not obvious, but it became clear that success in
smoking education does not depend just on the communication of knowledge
about the ill-effects of smoking, but also on psychological and social
factors. Since those days, much additional research has been done on the
factors affecting the beginning of the habit, and it w~ll be tried here to
draw some practical conclusions from the results.
THE EXTENT OF THE I'~BLEM
When the 1960 smoking education program was started in the two Winnipeg
schools, smoking in children, as well as in adults, was largely a problem of
the industrial~zed countries. As Figure I shows, many of the less developed
countries have caught up with Lheir rich northern .counterparts. For example,
boys in Montevideo, Uruguay, seem to smoke almost as much as boys in
Australia, and those in Ethiopia almost as much as those in Canada. In spite
of cultural influences, even girls in many developing countries start
smoking at progressively earlier ages.
FACTORS FACILITATIN(~ 7~II~ ~ ~KI~
T6e~epidemi~l~[~[ model of host, agent and environment in disease causa-
tion will be used to examine the factors facilitating a child's taking up
TI0,..,,:,50925
smoking [Figure 2). In the epidemiology of infectious diseases, ~%ere the
m~del was first applied, host factors refer to the susceptibility to
disease, agents are specific microorgan{s~s or parasites, and an environ-
=ental factor ~ight he sanitary conditions.
FIGURE I. SMOKING RATES AMONG CHILDREN: INTERNATIONAL COMPARISON (2)
~- _Is" ,~"
I z?'
~ ~/t AUSTRAUA
! .
.~.':.~" .~. " •
9 1011 121314 "151617181g ~=0 91011 l~1314151617 w1g :~)
FIGURE 2. THE EPIDEMIOLOGICAL MODEL OF DISEASE CAUSATION BY HOST,
ENVIRONMENT AND AGENT FACTORS
A~nt
TI0,..,...,s092o
~40KII~ AMOI~ (~IILD~EN
In Figure 3, the same_ model, involving interaction of host, agent and
environment, is applied to the problem of smoking onset among children. The
host's susceptibility to smoking is expressed by how well he is prepared to
start or not to start smoking. The agent is the cigarette or other tobacco
product, and examples of environmental factors of concern are the smoking
habits of parents, teachers, doctors and peers, and more generally, the
social acceptance of smoking. All three elements are needed for a child or
an adolescent to start smoking, and each element leads directly to certain
possibilities for preventive action. In the past few years, much progress
has been made in this field (3),
FIGURE 3. TE EPIDEMIOLOGICAL MODEL AS APPLIED TO TBE
ONSET OF SMOKING IN CHILDREN
EPIDEMIOLOGICAL MODEL OF SMOKING
I
I
Iteadlness
lSMOKING
I
!
L--
Env I torment
DEVELOPMENT
lobacco "products
lWARNING : ,1
APPROACHES TO SMOKII~G PEEVENTION
I. ~he agent
To start-with--the agent (Ta~-I-~--iD~ the first question is whetber ciga-
rettes are available to children. Availability is facilitated when the
sale of cigarettes to children is not prohibited, when vending machines
are accessible to children, when single cigarettes are being sold, thus
reducing the amount of money needed to buy cigarettes, and when the
distribution of free cigarette samples is permitted. Another factor is
TI0~'50927
246
ABELIN
whether cigarettes appear attractive to the child. Cigarettes are less
attractive when they are expensive, and when the child is reminded of the
health hazards associated with the smoking habits, such as by government-
al health warnings and by the declaration of harmful substances. Legis-
lative action is needed to limit the accessibility of cigarettes to
children and to make cigarettes unattractive.
TABLE 1.
Category
Availability
Attractiveness
FACTORS IN SMOKING PREVENTION AFFECTING TI{E AGENT
Tobacco Products
not conducive to smokin$ conducive to smokin$
legally prohibited
legally prohibited
legally prohibited
legally prohibited
sale to children
vending m~chlnes
sale of single cigarettes
free samples
expensive
health warning
tar/nicotine content
declaration
inexpensive
no warning
no tar/nicotine content
declaration
2. ~ne envirou~nt
As shown in Table 2, the predominant environmental factor is the example
given by important persons in the life of the child, such as the parents
and, later in life, siblings and peers. The influence of parents in
inducing children to smoke may be especially strong when ignorance about
the harmful effects of smoking is still widespread, as in many developing
countries (3). In this situation, educating the parents about the
problems associated with smoking may be a very important element of any
campaign aiming at the prevention of smoking in children.
Another environmental factor determining whether children will develop a
willingness to smoke, is the image of smokers advanced by advertisements,
movies and television. A ban on cigarette advertising is the most
effective means against this important influence.
Finally, there is the role of the physical environment, in which children
and adolescents first start to smoke. If smoking is banned from the home
and the school, and if attractive non-smoklng cafeterias, discos and
other leisure-time places are made available, the chance is certainly
greater that young people will remain non-smokers than in an environment
with_ plenty of a%htrays~_th.e__smell_of_cigam~_tte-smoke and peers-tryin~ to
pressure others into smoking.
3. The host
The aim of any preventive intervention at this level is to stimulate the
child or adolescent into wanting to remain a non-smoker, and to teach him
to develop the skills needed to resist the pressure to smoke. The
different approaches are su~arized in Table 3.
Tl08350928
~7
TABLE 2. FACTORS IN SMOKING PREVENTION AFFECTING THE Et~FIRONY~NT
.Category
Personal mode
General models2
Environment
not conducive to smokin$
don't smoke
quit
warn
express concern
forbid smoking
don't smoke
quit
conducive to smokin$
smoke
don't try to quit
don't warn
are unconcerned
allow smoking
smoke
don'~ quit
Home, school
Leisure time
environment3
smoke free
smoke free
ashtrays, smoking zones
associated with smoking
I parents, teachers, doctors, etc.
2 persons in advertisements, movies, TV, etc.
3 discos, cafeterias, sporting grounds, etc.
TABLE 3. FACTORS IN SMOKING PREVENTION AFFECTING THE HOST
Category
Readiness
not to smoke to smoke
Involvement
(younger children)
Self image
Image of non-smoker as
for non-smoking
fairy-tale heroes
as part of the non-
smoking trend
athletic
healthy
popular
independent
oriented toward role
~dels being smokers
as suggested by ciga-
rette advertisement
weak
immature
socially isolated
over-cautious
Involvement (older children)
Knowledge
for non-smokers' rights
perception of organ
functions
knowledge of effects
of smoking
de~'~limg-of--ci-g~re=te
advertisements
assertion training
peer pressure resistance
smoking cessation
Tl08350929
248
It is now believed chat this influence should start in preschool or
school age, before actual contacts with cigarettes are likely to
The principal aim is to involve children, to give them an opportunlt,
identify wish non-smoking heroes, and to make them aware of the val~
breathing clean natural air.
In several countries, teaching materials for young children have been
available where non-smoking is embedded in situations stimulating
child's imagination. For example, in Sweden, p~cture books, posters
badges are available with visual themes involving animals (4), and
Switzerland, a set of teaching materials has been prepared around a fai
tale with a non-smoking hero (5). It is important to note that, in all
these materials aimed at young children, care is taken to avoid
reference to the smoking and disease issue.
The next step is to associate non-smoking in the child's mind with be~
~thletic, healthy, popular and independent. Examples of this approach..
available from a11 over the world. In Ethiopia, beautiful line drawlr
were used in posters to demonstrate the assoclaton of non-smoking
sports, health and pleasure (6). In Sweden, beautiful multl-color stamp
were made from children's drawings on the same subject, showing a lot
colors, nature and happiness as symbols of non-smoking (4). In Switze~
land, a poster showing two well known soccer players of the natloual
confirming that they are non-smokers, was offered last year to the sehooi
children of parts of the country. Pupils and teachers responded by
for another poster, showing women athletes, and as a consequence,
posters are being prepared. An important experience in this context
that distribution of the tens of thousands of posters only worked in
regions with organizations able either to conduct major postal mailln
campaigns, or to provide volunteers who could take the posters to
hundreds of schools in the region.
It has to be noted that not all young people respond equally to the
model presented by sportsmen, and for thls reason, other role models, such~
as musicians and singers should also be involved in non-smoking campalgns. :~~
The purpose of such advertising is to develop ~n the young person a self-
image £n which non-smoklng - or smoking as the case may be - plays a
determining role for future behavior. An interesting example of i~tensive~
promotion of no,-smoking is the Swedish campaign calling itself "A non-
smoking generation" (7). Its aim is not simply to promote the idea of
non-smoklng as something superimposed on today's lifestyle, but to
stimulate children and youth to identify with a modern, healthy, dynamic
new generation, the trademark of which is non-smoking. The Swedish
campaign, like others, makes use of the fact that the most popular
athletes of the country and some of the popular personalities in enter-
tainment are non-smokers. These persona]itles wear the same sweaters
with the non-smoking trademarks, tha~ anybody can buy in local stores -
further facilitating identification with non-smoking•
Smoking education programs for children may begin by allowing them to
pate in experiments with cigarette smoke. Of course, teachers have to he
offered the opportunity of learning how to conduct these experiments, and
practical courses should be offered for this purpose.
T10~350930
For a long time, smoking education was limited to the association between
stroking and the development of disease, but its effect on s~oking habits
retained questionable. More recently s~oking education programs have been
expanded. An example is to ~each not only about the effects of tobacco
smoking on the hu~n body, but also the implications of tobacco growing on
world econo~'. A picture used as a basis for discussion in Noway seems
to sti~late ~ Io~ of interest a~ng students. It shows a tobacco growing
field on one side a~d a ~eat gro~ing field on the other, and points ou~
that if ~obacco were replaced by food crops throughout the world, this
would provide enough fo~ ~or 45 million persons (8).
A very important development in smoking education has been to teach not
only knowledge, but also skills enabling the young person to resist the
pressures acting on him in favor of smoking. Such skills include the
decoding of advertisements, assertion training, peer pressure resistance,
end for those who have already started to smoke, smoking cessation skills.
The UICC publication '% Manual on Smoking and Children" (3) gives useful
details about methods that have been successfully applied. For example,
it presents a detailed methodology for the decoding of advertising
messages (Table 4) and discusses methods for teaching peer pressure
resistance.
TABLE 4. STEPS IN DECODING ADVERTISEMENT MESSAGES (3)
I. Establish a list of partial elements
2. Interpret meaning of elements
3. Classify into referent systems
4. Decode promises made by advertiser
5. Analyze reasons for promises
6. Formulate contrary messages
7. Compare student smokers' own behavior with
their brands' suggested heroes.
Table 5 shows the elements included in a comprehensive life skills train-
ing program developed by Botvin and co-workers at the American Health
Foundation (9). It uses methods in which students are actively involved
in group discussion and special skills training. The program proved to
keep grade 8 to 10 students from smoking, when directed by an outside
specialist. For large numbers of schools such programs, teaching llfe
skills techniques, must use regular teachers or peers. Thi~, for example,
was the case in an experiment conducted in connection with the Stanford
Heart Disease Prevention Program, where peer leaders were trained to
practice peer pressure resistance skills with seventh grade students. In
the experimental school, the number of smokers could be kept very low
DDnths after the start of the study (10).
Peer-pressure resistance techniques have recently been applied in many
=~re programs, including a co~--~nity oriented coronary disease risk factor
T108350931
2.5O
intervention program in Switzerland. A~ng the teaching =aterlals avail-
able to the regular school teachers in this project, were drawings showing
a group of children confronted with one of the peers offering cigarettes.
Based on these drawings, the students were challenged in role playing
situations to think of answers helping them to cope with smoking pressures
(11). In the two experimental towns, s~oking rates went down during the
3-year experimental period, whereas a similar trend was not apparent in
the rest of the country (12).
TABLE 5. ELEMENTS OF A COMPREHENSIVE LIFE SKILL TRAINING PROGRAM (9)
Self image
Decision making
Advertising techniques
Coping with anxiety
Communication skills
Social skills
Assertion training
DISCUSSION
There is no single action able to solve the problem of smoking among
children. One is legislation: legislation to make the cigarette less
available and less attractive; legislation to allow children to grow up in
an environment where the smoking habit is unlikely to develop; and last but
not least, legislation to provide sufficient financial support for
educational action and publicity for non-smoking. The second and most
important approach is education. Here it will be important that the
accumulated experience in how to influence children's smoking behavior will
be wldely applied. The concepts and methods that have proven successful
should not have to be rein~ented over and over again, although they will
have to be adapted according to the cultural background and educational
traditions of any given country or region.
Countrywide success in preventing children from starting to smoke can only
be reached if ambitious, t~ough realistic quantitative goals are being
stated for future developments. Thus the Swedish government is conducting
its long-term anti-smoking campaign with the goal in mind, that the next
generation of children should remain smoke-free (7). And the American
government's goal for the year 1990 is to have reduced smoking rates in the
12-18 year age group to below 6% (13).
Actually, the future has already begun. As Figure 4 shows, Sweden has
already achieved a considerable reduction of smoking rates, both among boys
and among girls. The same can be said for Canada (Figure 5), the United
States (Figure 6) and a few other countries.
The ~ha4-1enge--new--is--f<~r---each--coun~ny__to__set~i~s_own__goals_ and to_work .......
intensively toward reaching them. Success will he certain if the same
enthusiasm can be produced all over the world, as was the case in one of the
two Winnipeg schools when smoking education work started in this pioneer
city =ore than 20 years ago.
L
T108350932
FIGURE 4. SMOKII~ TI~.ENDS AMOI~S SCHOOLCHILDREN IN SWEDEN (2)
~ 2O
I0
FIGURE 5.
16 ye,r~
~~~" 13 y~ars
I ! !
1971 1974 1977 1980
SMOKING TRENDS AMON~ BCHOOL CF~ILDREN AND YOUTH IN CANADA (2)
Tl08350933
ARELIN
FIGURE 6. SMOKING TRENDS AMONG SCHOOLCHILDP~N AND YOUTH
IN THE UNITED STATES (2)
~ BOYS
__ ,,,,,,,,-,,-, ,-,,,, GIRLS
~~'~ ~~17-18 year~
=" -" "- -"%'~"%/~//~'~'"- ~ 15-16 years
,- ,--. .....
12-14 yeus
,,,o ,,,, ,,,,
I w~sh to thank all those who made ~nformation and materials from their
countries available for the purpose of this presentation. They deserve the
credit for the achievements reached in the area of smoking prevention and
presented in this paper.
Horison JB, Medovy H, MacDonell GT. Heal~h education and cigarette
smoking: a report of a three-Fear program in Winnipeg School Division,
1960-1963. Can Med Assoc J 1964; 91: 49-56.
Masironi R, Roy L.
prevalence. Gcnuva:
WHO/SMO/82.3.
Cigarette smok~n~ {n :'eu~g a~e groups. Geographic
World Health Organization, 1982. Document No.
3. Wake R, McAlister AL, Nostbakken D. A manual on smoking and children.
4. Ra=strSm LM. Personal co==nunication.
5,. Lehmann-Gugolz U. Der Rat des WurzelkSni~s. Eine Unterrichtseinheit
"X f~r die Unterstufe. Arbeitsgemeinschaft ~esunde Jugend, Bern, 1981.
TI08350934
253
6. ~agdu T. Personal co~-~unlcation.
7. Nordgren P. Preventing the onset of smoking. In: S~oklng control in
Sweden. S~ockholm: Swedish National Smoking and Health Association NTS,
1983.
8. Bjartveit K. Personal communication.
9. Botvln GJ, Eng A, Willia~s CL. Preventing the onset of cigarette
smoking through life skills training. Prey Med 1980; 9: 135-143.
I0. Telch MJ, Killen JD, McAllster AL, Perry CL, Maccoby N. Long-term
follow-up of a pilot project on smoking prevention with adolescents. J
Behav Med 1982; 5: I-8.
ii~ Bar=sob N, Bartsch B. Rauchen bringt keinen Gewinn. A teaching aid in
German. Swiss adaptation of a publication of the Klett Verlag. Aarau
eusl gsund Stadt, Aarau, 1977.
12. Programme national suisse de recherche No. IA. Groupe d'~tude. Change-
ments de la consommatlon de tabac induit par un programme de prevention
primaire dana la collectivlt~. Poster, 5th World Conference on Smoking
and Health, Winnipeg, July ]0-15, 1983.
13. Luoto J. Reducing the health consequences of smoking - a progress
report. Public Health Rep 1983; 98: 34-39.
-I
T108350935
255
Mira B. Aghl, Ph.D.
Behavioural Scientist and Media Expert
Oral Cancer Project
Tara Institute of Fundamental Research
Bombay, India
A casual study of the consumption figures for tobacco in India may lead one
to suppose that smoking in this part of the world does not qualify as a
public health problem. For instance, the consumption of cigarettes per
adult per year in India works out to just 190. The corresponding figure for
the United States of America is about 4000, for the United Kingdom 3050, and
for Japan 2810. But these figures must be viewed in light of the fact that
the majority of the Indian population dwell in villages where tobacco is
consumed not in the form of smoking cigarettes but in the form of smoking
bidis and chewing tobacco by itself or along with betel leaf, llme and areca
nut. Cigarette smoking is common mainly in urban India.
Indian women by and large do not smoke as yet. A number of surveys
conducted among University students have indicated that no more than 2 to 5%
of the women in the sample ever smoked. No figures are available in the
total urban population, but it will be less than 5%, if that much. Today's
trend in cigarette smoking is seen among girls who either work for multi-
national companies or airlines or work in mass media like television and
films.This is because these young ladies identify themselves with their
counter parts in the western world. Fortunately, this number is negligibly
small. It is not yet acceptable, in the Indian life style, for daughters
and daughters-in-law to smoke, though the men folk may smoke.
Row does the rural scene compare with the urban? There are well-defined
tobacco pockets spread all over India where men, women, and children all use
tobacco. The tobacco profile of a woman in rural India is indeed very
colourful. In Kerala she chews pan (betal leaf) with tobacco and llme. She
smokes bldls - small indigenous cigars - and hookah in B~har and parts of
Punjab and Haryana. She smokes dhumti in Goa. She rubs and plugs burnt,
powdered tobacco inside the cheek or under the lip in Maharashtra, Gujrat
and Bihar. Mos~ remarkably, in Andhra, she smokes chutta, something llke a
cigar or cheroot in the reverse style, i.e., when the cheroot is well lit,
she puts the lighted end inside her mouth. It should be noted that,
wherever a woman in rural India is seen to indulge in tobacco habits, she is
an equal partner with the men, that is there is usually a nearly equal
distribution of male and female habitues.
How do they take "to these habits and what do they know about these habits?
They
Andhra asks the little daughter (4-5 years onwards) to light her chutta. Of
T108350936
',"cessity, many times the daughter will have a puff to examine if it is well
~it. This develops into a habit - "There can't be anything wrong with the
h"bit since ~. =other has it"- is the g~rl's reasoning. If childhood pass-
without the habit being adopted, she starts during her adolescence. She
"~'es all her friends do it. Many times she is advised to take to this
}~bit as a cure for many minor ailments (constipation, gas) and some major
lments such as anaemia and rheumatism. The dynamics are the same for
°~her modes of smoking, whether it ~s bidi, hookah or dhumti. The woman
'~arts chewing pan with tobacco, for it is the way of life in the part of
country where she dwells. The same applies to rubbing and plugging
u~,acco.
the areas of tobacco consumption, rural Indians' attitude to smoking~ in
'~[~,ost all cases, ie; one of benign tolerance, verging on acceptance and very
'~[en incllning towards recommendation and prescription of it. They are
h~issfully unaware of any ill effects of tobacco. Unlike cigarettes, bidis
}~,ve no warning on them and even if they did, only a few could read. As if
~hls was not enough, the women have attributed many magical and medicinal
i"~,perties to tobacco. If it cures the toothache for the woman in Kerala,
helps the woman in Maharashtra to keep her mouth clean. The woman in
^"dhra is able to get rid of the foul smell in her mouth in the morning,
~",trol morning sickness when pregnant and bear the labour pains during
d"~ivery. And of course, it always helps you to have a llttle fun, relax,
"'"'[alize and enjoy the dull existence.
t~h~t has research to say on these tobacco habits? Oral cancer is one of the
~""~ frequently encountered cancers in India. It is almost invariably and
"h| [rely to be found where the tobacco habit exists. In our work, where we
"~"mined almost I00,000 people, there was not a single case where we found
:~,I cancer but no tobacco habit. We found the overall crude annual inci-
'I"~"~e rate of oral cancer to be 16 per I00,000 in Kerala and 14 per i00,000
~'~ Andhra (1). The incidence ~n the h~her age group was s~x t~mes the
~"' }dence in the middle age group. In Andhra, the higher age group had an
t~"idence of oral cancer of 93 per 100,000. Also, the tobacco habits
"~m~erated ~n th~s paper have been shown to be h~gh r{sk factors for ~ny
'~*,,r types of cancers such as cancer of the phary~, larynx, esophagus and
l~b~s. It has also been sho~ that, just like cigarette smoking, b~di
'~'~1,~ng causes chronic bronchitis. The overall health effects of different
*'q~cco habJts~ however, ~ave ,or been studied so far. A study on ~rtallty
"~"rience in relation to tobacco chewing and smoking habits from a I0 year
~]low-up study at our Institute (2) revealed that the crude relative r~sk
3.4 for the female tobacco user and 2-3 for the male tobacco user.
~ntervention programme was launched to persuade these people to give up
tobacco habits (3,4). The intervention strategies combined several
~*ts such as personal interaction, films, folk drama, radio slogans and
~%~Vlets, newspaper articles, posters and projection of slides in movie
~""a[res. The pertinent findings to date are [I] Personal interaction is
to be producing_the most imp99~ [2J_In~ervention is more successful
females than males (e.g. in Kerala: 13% females as opposed to 5% males
given up the habit).
Tl0~350937
Why is this? ~en one looks at the data in the West, one is struck by the
fact that the findings are contrary to what we have found. Jacobson in her
book "Ladykillers" demonstrates that it is indeed very hard for the woman
to give up smoking (5). The pressures and burden of life are as hard on the
woman in India. What is the difference then? I conducted I0 case studies
on the women who had given up their habits. There were a few co~monalities
in their reporting. One glaring similarity was that "you talked to me_,
convinced me, I tried, found truth in what you say, I determined and so I
gave up". It seems from their reports that it is very important to interact
with the habitu~ on a personal basis, to convince her, to support and to
show her how to quit. It is not enough to advise. Women are found to be
more open in a one to one situation than men. They reveal their weaknesses
and have less ego problems. The second thing which came out on probing is
that, despite all the miseries, pressures and discomforts of life, the women
in India on the whole are emotionally very secure. There is hardly any
threat to her wifehood. She has the comfort and peace of mind that her
husband will always be hers - whatever he has belongs to her. Also she has
security and support in her children, especially if they are in their early
teens and are school-going. They can influence her through their knowledge
and tender love for her. I have no scientific data to support this except
to disclose to you the llfe style of the rural Indian woman.
Gupta PC, Mehta FS, Daftary DK, et al. Incidence rates of oral cancer
and natural history of oral precancerous lesions in a 10-year follow-up
study of Indian villagers. Community Dept Oral Epidemiol 1980; 8, 287.
Gupta PC, Bhonsale RB, Mehta FS, Pindborg JJ. Mortality experience in
relation to tobacco chewing and smoking habits from a 10-year follow-up
in Ernakulam district, Kerala. Int J Epidemiol 1984; 13.
Mehta FS, Aghi MB, Gupta PC~ et al. An intervention study of oral
cancer and precancer in rural Indian populations: a preliminary report.
Bull WHO 1982; 60: 441-446.
4. Aghi MB, Gupta PC, Mehta FS. Intervention in the tobacco habits of
rural Indian women. World Health and ~moking 1984; 9(I) Spring: 10-14.
5. Jacobson, B. The ladyk~llers; why smoking is a feminist issue. London:
Pluto Press, 1981.
TI0-O350938
259
MORTALITY AND H)RBIDIT~ FEDM SMOKING-RELATED DISEASES IN PARLIAMENTARY
CONSTITUENCIES IN SCOTLAND - A HEW METHOD OF PRESENTATION OF DATA
K.G. Brotherston, M.B., Ch.B., M.Sc.
Information Services Division
Common Services Agency for the Scottish Health Service
Edinburgh, Scotland
E. Crofton, B.M., B.Ch.
Medical Director
Scottish Committee Action on Smoking and Health
Edinburgh, Scotland
The Scottish people suffer from some of the highest rates in the world for
death and disease from the three main smoklng-related diseases. Successive
British Governments have done little to combat the effects of smoking,
although all have recognized that it is, in the words of the present Prime
Minister "The largest single preventable cause of death and disease in this
country." Action on Smoking and Health (ASH) is a campaigning body with the
specific aim of reducing the toll of death and disease from smoking. One of
the activities undertaken by ASH is to inform those in positions of influ-
ence of the effects of smoking, and among the most influential are Members
of Parliament.
Hitherto the figures for the estimated number of deaths and hospital admis-
slons due to smoking have been given on a national basis. We felt that the
impact on a Member of Parliament would be increased if he could see how many
of his own constituents died or were admitted to hospital on account of
smoking, and also have some indication of the financial cost to the Health
Service. A first attempt at this was made by the ASH branch in the North-
West of England but only rough approximations of the figures could be
produced. We decided to develop the idea further and to produce a similar
publication for Scotland. We have the advantage of a highly developed
system of information collection on all deaths and 100% of discharges from
hospital. We also have complete population data and information on the cost
of hospital care. Throughout, great care was taken with the methodology and
the accuracy of the calculations.
For the maximum impact, the published volume would have to be attractive to
look at and to read, and the information in it would have to be easy to
understand at only one reading, since it would have to compete with many
other demands on the time of MPs. It was also essential that MPs would be
able to pick out information for their own constituencies easily. Such a
publication would be expensive, but our production costs were fully covered
by-~he-~a~tt_is~ Health~du~a~i~n_~.~up~_to_who.m_w~_are_ve_ry grateful._ We
decided to call the book THE SCOTTISH EPIDEMIC.
T108350939
260
EOW "I"EE ~IGURES ~ERE CA~CULA.T]~
We were able to obtain numbers and rates of deaths and hospital admissions
for the three main smoklng-related diseases (ischaemic heart disease, lung
cancer, bronchitis and emphysema) in each Health Board Area. All the
seventy-one parlia=entary constituencies in Scotland were allocated to
Health Board Areas using official government maps. This was a difficult
task, especially i~ the heavily populated central belt of Scotland where ~he
constituencies are very close together and many cross Health Board bound-
aries.
All the calculations for the book were carried out manually. As there are
seventeen separate figures to be calculated for each page and in the
ninety-nine pages there are a total of nearly 20,000 figures, it will be
readily appreciated why it is hoped to carry out the calculations for subse-
quent editions by computer.
The calculations for deaths and hospital admissions were carried out by the
formula:
NUMBER OF
DEATHS OR = POPULATION X RATE X RCP FACTOR
ADMISSIONS
(RCP FACTOR: Percentage of deaths or hospital admissions dlrectly
attributable to smoking.)
By combining the population data for a constituency with the death and
admission rates for the appropriate Health Board, we calculated the numbers
of smoking-related deaths and discharges in each constituency. In the
second report of the Royal College of Physicians on smoking, "Smoking and
Health Now" (I), estimates are given of the percentage of deaths from the
smoking-related diseases which could be directly attributed to smoking.
Using these percentages, we calculated the figures printed in section I of
each page. For comparison the number of deaths from all causes was also
included. A similar calculation for hospital admissions gave us the figure
in section 2. Our figures are undoubtedly underestimated because only the
three main smoking-related diseases are included.
By multiplying the number of admissions by ~he mean stay in hospital for a
particular disease we obtained the total number of days spe~t in hospital
due to that disease, this figure divided by 365 gave us the number of
patients in hospital every day because of that disease. When this calcula-
tion was carried out for each disease and both sexes, we obtained the total
number of patients in hospital every day as a result of their smoking. The
bed-day gave the figure for part of the cost of hospital care of patients
with smoking-related diseases. This information is printed in section 3 of
each page. For each constituency the three sections are printed on one page
and each page is printed on only one side of the paper.
Similar calculations were carried out for the fifteen Health Boards and
twelve Local Government Regions and the results are printed in a similar
ford_at. The results for each of these areas are printed on a different
colour of paper and the whole book is bound in an attractive cover. The
volume is of such a size that MPs would be unlikely to throw it away but
would keep it on their shelves.
T108350940
MORTALITY A~D ~RBIDIT~ IN SCOTLAHD
261
PUBLICISII~ T~E IqG~I%ES
The production of THE SCOTTISH EPIDEMIC took eight months and the finished
copies of the book were ready in November 1982. We decided, however, to
hold over publication so that ~t would coincide with the return of MPs to
Parliament after their Christmas recess. A copy was sent to every Scottish
MP with a personal letter from the Chairman of the Scottish Committee of
ASH, Sir John Brotherston, a former Chief Medical Officer for Scotland. The
letter quoted the figures for the MP's own constituency, emphasised that
these deaths and hospital admissions were preventable and invited MPs to
support measures designed to reduce them. Copies were also sent with appro-
priately tailored letters to the chairmen of the health boards and regional
councils, as well as to many other individuals and organisations whom we
knew to be supportive or interested.
Copies of the book, with a press release describing the aims of the exer-
cise, were sent under an embargo two weeks before publication to the Scot-
tish and UK press and media as well as to medical and certain other special-
ist journals. The main office of AS}{ in London distributed copies with a
similar press release to its press list, includ~ng national newspapers and
the national broadcasting media. The few instances of embargo breaking did
not affect the publicity on the official publication day.
THE RESPONSE
Radio and television coverage nationally and locally on publication day was
excellent. The book was even publ[cised in the first broadcast of breakfast
television in Britain. There were several other mentions in news and
current affairs programmes on national and local radio and television
channels.
The Scottish press carried extensive reports and there was coverage of the
book in several of the national newspapers. Many Scottish weekly newspapers
carried long reports of the data for their own areas as did several special-
ist journals and magazines. The reports were all very supportiue of ASH's
alms and there were several resultant calls for Government action.
The response from the main target group of Members of Parliament was also
very encouraging. Many wrote to ASH expressing concern and offering help
and support and several wrote to Government Ministers drawing attention to
the study. It is known that MPs used material from the report for speeches
in their own constituencies; their com~nents on the data for their own
constituencies were quoted in the local and national media. Several MPs
commented favourably on this method of drawing attention to the magnitude of
the smoking problem. Recently we have had a general election and we took
this opportunity to send copies with a covering letter to all the candidates
standing for Scottish constituencies.
The book has not turned out to be a nine days wonder and continues to be
quoted by MPs and others. It is interesting that there has been no response
from the tobacco industry although there have been several intriguing tele-
phone calls from public relations companies.
T108350941
262
SUGGESTIONS FOR ~IPROVEI~NY
THE SCOTTISH EPIDEMIC is the first real attempt to produce figures for
smoking-related death and disease, broken down by parllamentary constituen-
cy, from official statistics, and with hindsight we can see that both the
production and launch could have been done better.
The calculations were based on all-ages data and it would have been better
to have calculated age specific figures. With the help of a computer these
more extensive calculations will become possible. Several MPs have asked
for death and admission rates so that comparisons could be made between
constituencies. It was not our intention to draw comparisons, only to draw
attention to the magnitude of the problem. We shall, however~ include rates
in future editions.
It is our intention to publish updated editions of THE SCOTTISH EPIDEMIC
regularly. The first edition is already out of date, only six months after
publication, because of boundary changes to the constituencies. In addi-
tlon, more recent population, mortality and morbidity data have become
available. In the long term we hope that calculations will become unneces-
sary and the actual numbers of smoking-related deaths and hospital admis-
sions in each parliamentary constituency will be made available by the offl-
cial bodies responsible for collecting the data.
It is encouraging to note that politicians have reacted more positively to
this initiative than to many others in the past. To quote only two of the
letters received from Members of Parliament:
"I am shocked at the level of smoking-related diseases
affecting Leith people". Ron Brown, MP for Leith.
"I commend this admirable exercise". Dr. Jeremy Bray, MP.
We would recommend this exercise to other countries who might find it a
valuable means of influencing their decision makers in parliament and else-
where and make them take firm action to control their own smoking epidemic.
We are grateful to the following for their help and encouragment: Miss
R.G. Findlay, Mr. M.M. Dauhe, Dr. S.K. Cole, Dr. M.A. Heasman, North-West
ASH, The Scottish Health Education Group, General Register Office (Scot-
land), Information Services Division, (Common Services Agency), Map Library
(Scottish Development Department), and the Scottish Office Finance Division.
I. Royal College of Physicians. Smoking and health now. London: Pitm~n
Medical, 1971.
Tl08350942
263
A RANDOMISED-CONTF.OLLED TRIAL OF EDUCATION FOR PREVENTION OF
SI~K~NG IN 12 YEAR OLD CIllLDREN
Deborah A. Fisher, B.Ed.
Bruce K. Armstrong, D.Phil., F.R.A.C.P.
Nicholas H. de Klerk, M.Sc.
National Heart Foundation of Australia (WA Division) and
NH & MRC Research Unit in Epidemiology and Preventive Medicine
Department of Medicine
University of Western Australia
II~.ODUC~ION
In 1979 the West Australian Division of the National Heart Foundation of
Australia undertook to develop and evaluate a Smoking Prevention Program for
use in Year 7 (the last year of Primary School) in West Australian schools.
Research undertaken by the University of Minnesota indicated that their
program, the "Social Consequences Curriculum", using same age peer leaders,
videotape materials and elicitation of a commitment by students to remain
non-smokers, had been successful in reducing smoking rates (i). It was
decided to replicate the Minnesota program in the West Australian environ-
ment.
T~E ADAP~I'ED PROGRAM
Materials from the "Social Consequences Curriculum" were adapted in the
following ways.
Videotape Films
I)
Minnesota materials were pilot tested in two West Australian Primary
Schools. The programs were well received, but feedback indicated that
Australian videotapes should be made (s£tuatlons covered in the film
were not realistlc to West Australian children).
2)
The Minnesota scripts were adapted by a script writer. Their content
and presentation remained the same as the US program; changes were
made only in the scene loc~tlons (eg. beach, school toilets, etc.).
The Minnesota dialogue was translated into Australian idiom to increase
credibility of the situations.
3)
School children (with no previous acting experience) were selected for
the video production. The films were professionally produced and
directed.
Address for correspondence: Dr. B.K. Armstrong, University Department of
Medicine, Queen Elizabeth II Medical Centre, Nedlands, Western Australia,
6009.
TI08350943
264
Written l~aterials
i) Written materials were pilot-tested by I0 teachers in three Primary
Schools.
2) Only minor modifications were made:
(a) The format was altered to suit the teachers (eg. objectives identi-
fied and specified at the beginning of each program and specified at
the beginning of each program write-up).
(b) In pilot testing, students found the concept of non-smokers' rights
(in Session 3) particularly difficult. To assist in conveying the
concept, cartoons were drawn showing scenes in which a smoker is with
a non-smoker who is not enjoying the smoky atmosphere. Students
were asked to write a comment on the scene, to discuss the comments
and to act out the scene of their choice.
(c) It was not possible for us to film students making a public commit-
ment not to smoke in Session 5. We did ask the children, however, to
write an essay giving the positive reasons why they were not going to
smoke. These essays were read to the class if students wished to do
so.
(d) A poster outlining the program was included with the written
materials.
Peer Leaders
I) The training program for peer leaders was pilot tested at three Primary
Schools. Training was conducted on two half days by staff of the
National Heart Foundation. A film was made for use in training.
2) The peer leaders' scripts were re-written in accordance with the program
changes outlined above.
3) Teachers acted as facilitators for the peer-led program and were trained
at a half-day workshop.
4) A special folder of program materials was presented to each peer leader.
The program, therefore, consisted of five intervention sessions, three
sessions were introduced by a video cassette film with same-age peer
actors. In Session 1 the students estimated the number of Year 7 students
who smoked, listed and categorised the negative consequences of smoking and
identified reasons why Year 7 students start to smoke. The immediate phy-
siological effects of smoking on heart rate and carbon monoxide levels were
also introduced.
In Session 2 the students were given information on the actual number of
Year 7 smokers in their school. This strategy was intended to counteract
the inaccurate beliefs of children, ~e. that rr~st of their peers smoke.
This matter was discussed in the classroom setting. They then listed
Tl0835094-4
YEIAL OF EDUCATION PROGRAM FOE CHILDREN
265
several situations in which they had personally experienced social pressure
to smoke and practised their refusal techniques to simulated offers of ciga-
rettes. In the third session, the students prepared and discussed arguments
in support of non-smokers' rights and developed arguments that counter the
excuses smokers often give for their smoking. The family and its role in
influencing smoking behaviour was discussed in Sesssion 4. Advertising
techniques used to promote cigarettes were also identified.
In the final session students identified the reasons for remaining non-
smokers through a short essay and made a public commitment to non-smoking,
if they wished, by reading the essay to the class.
Sessions were conducted at monthly intervals over the last five months of
the 1981 school year (August to December). The median age of children in
the program was 12 years. Peer opinion leaders were used to lead the
program in the classroom in one version of the program; they were selected
by their class and trained in the manner already outlined. The peer leaders
assumed responsibility for each classroom session with the classroom teacher
acting as facilitator. In the other version of the program the classroom
teachers implemented the program. They were trained at a full-day in-
service course and each received a detailed curriculum manual. Apart from
the training programs and curriculum manual, no assistance was provided with
conduct of the course.
EVALUATION 0P THE PROGRAM
The aim of evaluation was to determine whether implementation of the program
in the last year of Primary School reduced the uptake of smoking dur{ng the
ensuing year in Secondary School.
The South Eastern Metropolitan Education Region of Perth was chosen for the
study. There were seventy-five Primary Schools in the Region, feeding six-
teen Secondary Schools. Ten of the sixteen High Schools were randomly
selected for the project. Their feeder Primary Schools (45) formed the
study population of 2,500 students. These Primary Schools were randomly
assigned to three groups:
I) Control group (no planned intervention);
2) Peer-led program;
3) Teacher-led program.
Randomisatlon was stratified by size of Year 7 class and sub-region to
ensure, as far as possible, equal numbers of children and uniformity of
socio-economlc status across the three treatment groups.
In June or July 1981, all students were surveyed by questionnaire, adminis-
tered in class, which dealt with their smcking haDit~, smoking hab{ts of
parents, siblings and friends, knowledge of and attitudes to smoking__~In
addition, saliva was collected after the students viewed a video film which
showed how recent cigarette use can he detected from samples of saliva. The
questionnaire was completed after collection of saliva. At the time of the
survey, the children, their teachers and those conducting the survey did not
know the treatment group to which the school had been assigned.
TI08350945
Training of the teachers and peer leaders took place in July and the educa-
tion program ran from August to December.
About 16 months after the initial survey (ie in November, 1982) these
students were re-surveyed in the first year of Secondary School by use of
the same procedure as in 1981. Students were located by review of enrolment
records of all Secondary Schools (both public and private) in the State.
All schools in the Perth area with I0 or more students from the 1981 survey
were visited by the survey team. All students in the relevant class were
surveyed regardless of whether they had been surveyed in 1981. No reference
was made to the previous survey or education program and those who conduct-
ed the survey were unaware of the "treatment" group to which any particular
child belonged. Schools were visited a second time if there was a substan-
tial number of absentees at the first visit.
Th~ results of tracing and response to the second survey are shown in Table
i. In a11, 87.7% of the children were located in High School records; of
those located 93.2% were re-surveyed.
TABLE I. RESULTS OF TRACING IN 1982 OF ALL CHILDREN SURVEYED IN 1981
Total surveyed in 1981 2404
Total surveyed in 1982 1964
Not surveyed in 1982
Reasons for non-survey in 1982:
Not located in high school records
Schools not v~sited by survey team
Dead, moved away or absent from school
on day of survey
440 (18.3%)
296
53
91
RESULTS OF EVALUATION
The questionnaire data and salivary thiocysnate leve|s collected from each
child ~n 1981 and 1982 were linked by computer. Editing of data and
preparation of files for analysis were undertaken without knowledge of the
"treatment" group to which any child belonged. Eleven children were excluded
from analysis because of missing data on smoking habits (usually because one
page of the questionnaire had been missed); this left 1,953 children on
whom these results are based. Results of the analyses involving salivary
thiocyanate levels have not been included in this report.
To simplify the analysis, each child was classified to one of two arbitrari-
ly defined ~o~Lin~ s~at,as-_g=~p~81 an& 1982. Non-s~okez_-_bad voL~___
s~gked a c~garette, not even a few puffs, in the 12 months before the
survey; Smoker - had smoked a cigarette, even just a few puffs, in the 12
manths before the survey. The for~er ~ncluded children ~no had never smoked
(45.2% of all girls and 30.2% of all boys in 1981) as well as some who had
experimented last more than 12 months before. The latter ~ncluded a small
T108350946
267
proportion (3.0% of ali girls and 4.7% of all boys in 1981) who appeared to
be established smokers (ie. said that they had smoked in the past week and
intended to smoke again in the next week). Conveniently, the 12 month
period used in the defin~tion of a non-smoker was about the interval from
the end of the education program in Primary School to the survey in High
School.
Table 2 shows the prevalence of non-smoking in 1982 according to sex,
"treatment" group and smoking status in 1981. It was significantly higher
in the teacher-led group in boys who were non-smokers in 1981 than in the
control group. In girls the prevalence of non-smoking in 1982, for previous
non-smokers, in both the teacher-led and peer-led groups was higher than in
the control group but not significantly. There was little difference
between treatment groups in the prevalence of non-smoking in 1982 for those
who were smokers in 1981.
TABLE 2. PREVALENCE OF NON-SMOKING IN 1982 BY "TREATMENT" GROUP
AND SMOKING STATUS IN 1981
Sex and "treatment" gr.ou.p
Girls:
Boys:
Smoking Status in 1981
Non-smoker Smoker
Control 65.5% (203)I 17.2% (93)
Teacher-led 73.8%2 (229) 18.6% (113)
Peer-led 74.1%2 (205) 16.1% (87)
Control 69.3% (212) 27.5% (138)
Teacher-led 81.4%3 (199) 25.4% (142)
Peer-led 64.4% (208) 26.6% (124)
1 Numbers in parentheses refer to the number of children in each
sex, "treatment" and smoking status group.
2 X~ = 3.12 and 3.20 respectively for difference of teacher-led and
peer-led programs from control; 0.10 > P > 0.05.
2
3 Xi = 7.36 for difference of teacher-led program from control;
p < 0.01.
Multiple variable analysis was undertaken to determine whether differences
between the three treatment groups could be explained by differences among
them in the distribution of confounding variables in 1981. An initial least
squares multiple linear regression identified the following as likely con-
founders; smoking habit in 1981; smoking habits of mother, brothers and
........... ~riends, attitudes of p~rents to-
with respect to his/her future smoking; knowledge of health and social
effects of smoking; attitudes to smoking; frequency of pressure to smoke
from friends; susceptibility to peer pressure; and perceived response to
cigarette advertisements. The following did not appear to be confounding
variables: age; country of birth; smoking habits of father and sisters; and
TI08350947
268 PISHER,
AEMSTEOI~G ARD DE KLERK
proportion of children in Year 8 (1982) who were from the sa~e treatment
group.
A forward stepping multiple logistic regression analysis was undertaken in
which the log odds of a non-smoker in 1981 being a non-smoker in 1982 were
regressed on treatment group and the likely confounders listed above. The
"treatraent" conditions were forced in at the first step; thereafter the next
"most significant" variable was selected at each step until the value of the
score test for entry fell below 3.84. The results are shown in Tables 3 and
4.
TABLE 3. RESULTS OF REGRESSION OF LOG ODDS OF A NON-SMOKING BOY IN 1981
BEING A NON-SMOKER IN 1982 ON TREATMENT AND OTHER VARIABLES1
Step
Variables entered
Adjusted
Exposure B p4
Odds Ratlo2 SEB 3
I) Teacher-led group 2.07
2.93 0.002
Peer-led group 0.87
-0.63 0.528
2) Will never smoke or 3.56
4.27 <0.001
never smoke again
3) Most/all good friends smoke 0.15
-2,17 0.030
4) Mild/moderate response 0.54
-2.58 0.010
to cigarette advertisements5
5) Hardly ever/never do things 1.77
2.29 0.022
that other kids want me to
do even if I don't want to
6) Strong response to cigarette 0.43
-2.05 0.040
advertlsements5
Constant 0.53
1 Based on 619 non-smokers in 1981.
2 Natural antilogarithms of the regression co-efficients and constant with
all significant variables in the model.
3 Ratio of each regression co-efficlent to its standard error.
Significance of contribution of variables to the model assuming a normal
distribution for B.
Elicited by question "How much do cigarette advertisements make you
think you would like to smoke a cigarette?" with responses: not at all;
not much; a l~ttle; a lot. Mild/m~derate = not much or a little;
strong = a lot.
TI08350948
TEIAL OF ZDUC.~TIOH PROGRAM FOR CHILDREN
269
TABLE 4. RESULTS OF REGRESSION OF LOG ODDS OF A NON-SMOKING GIRL IN 1981
BEI~;G A NON-SMOKER IN 1982 ON TREATMENT AND OTHER VARIABLES!
Step
Variables entered
Adjusted
Exposure B p4
Odds Ratio2 ~
I) Teacher-led group 1.54
1.99 0.046
Peer-led group 1.49
1.76 0.078
2)
3)
4)
Will not smoke cigarettes 1.99
when grown up
Friends have never tried 2.14
to make her smoke cigarettes
Will never smoke or never 2.12
smoke again
Constant 0.31
3.20 O.OOI
3.40 <0.001
2.11 0.035
I Based on 637 non-smokers in 1981.
2 Natural antilogarithm of the regression co-efficients and constant with
all s~gniflcant variables in the model.
3 Ratio of each regression co-efficlent to its standard error.
4 Significance of contribution of variables to the model assuming a normal
distribution for B.
In boys a significant positive effect of the teacher-led program persisted
after adjusting for the confounding effects of expectation with respect to
future smoking, friends' smoking habits, response to cigarette
advertisements and susceptibility to peer pressure. The peer-led program,
on the other hand, had a small but statistically insignificant negative,
i.e. adverse, effect. In practical terms the expected prevalence of
non-smoking in 1982 in boys who were non-smokers in 1981 and at low risk of
becoming smokers (ie. said they would never smoke, or never smoke again, had
none or some good friends who were smokers, claimed no response to cigarette
advertisements and hardly ever or never did things that other kids want them
to do even if they don't want to) was 77.0% in the control group, 87.4% in
the teacher-led group and 74.4% in the peer-led group.
In girls, both teacher-led and peer-led programs had positive effects
although the latter was _got statisticall~__s~nificant at the_conventlonal
level after adjustment for the effects of the confounding variables. The
expected prevalence of non-smoking in 1982 in girls who were non-smDkers in
1981 and at low risk of becoming smokers (ie. with the characteristics list-
ed in Table 4) was 73.7% in the control group, 81.2% in the teacher-led
group and 80.7% in the peer-led group.
T[08350949
270
The status in 1982 of smokers in 1981 has been addressed in similar
analyses. There was no evidence to suggest that, after adjustment for
confounders, either the teacher-led or the peer-led program had any effect
on the probability that a smoker in 1981 would be a s=oker (or non-smoker)
in 1982. The beneficial effects of the program, therefore, appear to have
been limited to those who were non-smokers at the time the program began.
CONCLUSIONS
I) A teacher-led "Social Consequences Curriculum" type s~oking education
program reduced uptake of s~oking by non-s~okers of both sexes during the
first year of High School.
A peer-led program of identical design probably had a similar effect in
girls but appeared to be ineffective in boys.
3) Neither program increased the frequency with which smokers became
non-smokers in the succeeding twelve ~onths.
4) Apart from the program effects, intention with respect to future smoking,
friends' smoking habits, perceived susceptibility to peer pressure and
strength of response to cigarette advertisements were significant
predictors of uptake of smoking by boys. Intention with respect to
future s~oking and peer-pressure to smoke were significant predictors of
uptake of smoking by girls.
This research was supported by grants from the National Heart Foundation of
Australia, The Cancer Foundation of Western Australia and The Australian
Schools Co~mission.
The project would not have been possible without the co-operation and
assistance of the Education Department of Western Australia and teachers and
students of the Bnuth-East Metropolitan Education Region of Perth.
I. Leupker RV, Murray DM, Anderson-Johnson C, Pechacek F. Prevention of
cigarette smek~ng in youth. University of Minnesota. Paper presented at
the 52rid Scientific Session of the American Heart Association, No. 12-15,
1979.
T[08350950
271
THE SB~LIEFS' ~ 'ACTIVITIES' OF CPs AND HF_NkLTH VISZTORS ABOUT
AMTI-SMOKI_WG EDUCATION
Godfrey Fowler, B.M,, F.R.C.G.P.
General Practitioner and Clinical Reader in General Practice
Konrad Jamrozik, M.B., D.Phi[.
Research Fellow
Department of Community Medicine and General Practice
University of Oxford
Oxford, England
Ilq;I'R~DOCTION
The potential of a primary care consultation as an opportunity for health
education, health promotion and preventive medicine is being increasingly
recognised and has been well described by Scott and Davis (Figure l). More-
over, the credibility of the general practitioner (GP) as a source of health
advice is confirmed by the survey finding of McCron and Budd (2) that in
health advice "it is the GP who is m~st trusted and whose advice has most
impact".
FIGURE 1. THE POTENTIAL IN EACH PRIMARY CARE CONSULTATION (I)
A B
Management of Modification of
presenting problems help-seeking
behaviour
C
Management of
conLiuuinB problems
D
Opportunistic
health promotion
In repeated surveys (3), about 70% of smokers say they want to stop smoking
and claim they would do so if advised to stop by their doctors, and it has
been suggested that the medical consultation is a situation in which advice
against the habit can be given to individual smokers by a person in a post-
~i~n o~ a~thorit~~ (4,5).
Tl08350951
272
H~.~ER ~ID JA~OZIK
Evidence of the effectiveness of GP anti-smoking advice has been provided by
two large controlled trlals (6,7) and it has been argued that if all GPs in
Britain gave antl-smoklng advice at least on one occasion when consulted by
their patients, half a million patients would stop smoking as a direct
result.
Each GP in Britain has, on average, on his or her list about 600 patients
who smoke and the average group practice of four doctors includes more than
2,000 smokers. About three-quarters of them consult their GP about some
medical problem at least once a year, so what does the physician think about
giving anti-smoking advice? In a suz~ey of primary care physicians in
Massachusetts (8), 93% of doctors rated "to eliminate cigarette smoking" as
"very important" and 90% claimed they routinely asked patients about
smoking.
As a preliminary to a smoking cessation study in Oxford, a postal question-
naire survey of all Oxfordshire general practitioners and their health
visitors (public health nurses) was conducted in 1980. Health visitors were
included in the sample because, like GPs, they have repeated contact with a
large number of patients and even less is known about their views on
smoking.
AIMS OF STUDY
The aims of the study were:
i)
2)
3)
To elicit candid self-reports of 'activities' and 'beliefs'
about
anti-smoking education.
To compare 'activities' with 'beliefs'
To compare the 'activities' and 'beliefs' of health visitors with those
of general practitioners.
METSOD
Eligible practices were randomly divided into two groups, a 'beliefs' group
and an 'activities' group, after being ranked by number of partners and in
alphabetical order according to the senior partner's name. In the 'beliefs'
group, all the doctors and health visitors were sent a questionnaire asking
about their 'beliefs' about anti-smoklng education. They were also asked to
define the role of their own and other professional groups in anti-smoking
education, what internal factors (such as expense, aesthetic distaste,
health and so on) motivates smokers to give up, and what external influences
(such as advice from health professionals, hypnosis and nicotine chewing
gum) were thought to be effective.
In the 'activities' group, all the doctors and health visitors were sent a
questionnaire asking them to report their 'activities' in anti-smoking
education. They were asked how, and in what way, they attempted to help
apparently healthy smokers to give up smoking and how often they discussed
the subject with patients for whom a personal or family history or an inter-
T108350952
current condition increased the potential risks of s~oking.
Respondents in both groups were asked about their stoking history and
professional background, and about the policy towards smoking in the
practices in which they worked.
A reminder letter ~nd a second questionnaire (identical to the first) were
posted to non-respondents a month later. All questionnaires were reply-
paid.
RESULTS
A total of 360 individuals, all 238 GPs and their 122 health visitors, were
surveyed. Completed questionnaires were returned by 314, an overall
response rate of over 87% (Table I).
Apart from an excess of women doctors in the 'beliefs' group, there were no
significant differences between the two groups for either profession, in
terms of their year of qual~fication, years spent working in general
practice, size of practice, smoking status of respondents or cigarette
consumption of smokers. Of the 208 GPs who replied, 22% were current
smokers, 39% ex-smokers and 39% lifelong non-smokers. Of the 106 health
visitors who replied, 7% were current smokers, 30% ex-smokers and 63% llfe-
long non-smokers.
Since the allocation to survey groups was random and the groups were
balanced, it may be inferred that the replies of one group to a given ques-
tion should be representative of those that would have been received had the
whole study sample been asked all the questions. Moreover, since each group
was unaware of the other questionnaire, anti-smoking 'activities' may be
compared with 'beliefs'
The Role of t_he ~eneral Practitioner
In response to the question "To what extent should the general practitioner
be involved in efforts to curb smoking?", 74% of GPs and 70% of health
visitors considered the GP should have a major involvement (Table 2). This
view did not vary with the respondents' own smoking status, year of gradua-
tion, time spent working in general practice or number o£ partners in the
practice.
When asked about their 'beliefs' (Table 3), 84% of GPs agreed they should
set a non-smoking example, 44% that they should make public stater~nts
against smoking, 28% that they should exert pressure on their Member of
Parliament and 64% pressure on Government via professional organisations.
GPs who were smokers were less in favour of a role-setting example, or of
exerting pressure on Government, and, despite almost 30% of the 'beliefs'
groups expressing agree~enb tha-~--GP-s--she,~!~--exert--pre-~s~re--~n~their Me~ber
of Parliament, only one doctor in the 'activities' group reported ever
hawing written to his MP on the subject of smoking.
Tl08350953
-I
TABLE I. BREAKDOWN OF RESPONSES
i"Ac t iv i t ies" "Belie fs"
Total
GPs
HVs
TOTAL
Completed Completed
Completed
Number and Number and Number and
posted returned % posted returned % posted returned
%
127 115 90,6 111 93 83.8 238
208 87,4
65 55 84.6 57 51 89.5 122
106 86.9
192 170 88.5 168 144 85,7 360
314 87.2
TABLE 2. INVOLVEMENT OF THE GENERAL PRACTITIONER
Major Minor Involvement
involvement involvement not appropriate
N % N % S %
General pr~ctitloners
n = 92
68 73.9 22 23.9 2 2,2
Health visitors
n = 50
35 70.0 15 30.0
TOTAL
X2 = I .161 2 df
103 72.5 37 26.1 2 1.4
p<0.5
Not answered 2
N
TABLE 3. POSSIBLE ACTIVITIES FOR GPs OUTSIDE THE PRACTICE
Anti-smokin~ activity
Setting a non-smokiug
example
Agree that Disagree that
GP has a role GP has a role Total
77 83.7 I5 16.3 92
Addressing community
groups/making public
St&te~nts, etc.
Exerting pressure on own
Member of Parliament
Exerting pressure on
Parliament via their
professional organisations
38 43.7 49 56.3 87
25 28.4 63 71.6 88
58 64.4 32 35.6 90
In the 'activities' group, 74% of GPs reported that they "usually initiate a
discussion of smoking with basically healthy adults who smoke". Asked
whether they "usually record the smoking status of patients", 62% claimed
that they did. Responses to questions about smoking policies in their
practices are illustrated in Table 4.
TABLE 4. POSSIBLE ACTIVITIES FOR GPs WITHIN THEIR PRACTICE
Question Yes
Total
Do you usually record the
smoking status of your patients?
124 62.3 75 37,7 199
Does your practice have a policy
of no smoking on the practice
premises by:
- patients?
181 88.7 23 11.3 204
189 91.7 17 8,3 206
76 37.6 126 62.4 202
practice personnel of all types
when dealing with patients?
- practice personnel of all types
when not dealing with patients?
TI08350955
276
The Role of the Health Visitor
Both GPs and health visitors felt that doctors should he ~ore involved in
efforts to curb smoking than health visitors. As indicated in Table 5, only
56% of respondents assigned a major role to health visitors compared with
70% assigning a =a jot role to doctors. Moreover, although health visitors
appeared to view anti-s~king activities outside their day-to-day practice
more favourably than doctors, less than 10% reported that they usually
record patients' smoking status and none had written to an MP about any
aspect of smoking.
TABLE 5. INVOLVEMENT OF HEALTH VISITORS
Major Minor
involvement involvement
Involvement
not appropriate
N % N % N
General practitioners 48 52,7 40 44.0
3 3.3
n = 91
Health visitors 31 63.3 17 34.7
I 2.0
n = 49
TOTAL 79 56.4 57 40.7
4 2.9
X2 = 147 2 df p < 0.05 Not answered 4
Health Education Officers
The views of GPs and health visitors about the role of health education
officers differed significantly.
Ninety-two per cent of health visitors b,t only 72% of GPs considered that
major involvement of health education officers in efforts to curb smoking
was appropriate; five GPs, but no health visitors, considered involvement of
~EOs inappropriate (Table 6).
A further very significant difference between doctors and health visitors
was highlighted by the question: "With regard to basically healthy adults
who smoke, how often do you uti]ise literature prepared by such agencies as
the Heal~n Eouca~ion Council?~. As inozca~e= zn Table 7, over 50% of GPs,
co=pared~w~h -5~d~'~-6aTth v~sz~ors, repor~ed~thar ~hey -never--u~ed
literature.
TI08350956
277
TABLE 6. INVOLVEI~NT OF HEALTH EDUCATION OFFICER
Major Minor Involvec~nt
~nvolvement involve~nt not appropriate
General practitioners 65 72.2 20 22.2
5 5.6
n = 90
Health visitors 47 92.2 4 7.8
0 0.0
n = 51
X2- 8.41 2 df p <0.05
Missing observations 3
TABLE 7.
GP s
n- 114
UTILISATION OF LITERATURE IN DEALING WITH HEALTHY ADULTS WHO SMOKE
Never Sometimes Often
Always
N % N % N % N
61 53.5 45 39.5 8 7.0 0 0.0
HVs 3 5.5 27 49.1 22 40.0
3 5.5
n = 55
TOTAL 64 37.9 72 42.6 30 17.8
3 1.8
X2 ffi 52.38 3 df p < 0.0001 Not answered 1
The Mass Media
~%ile the 'activities' group were asked about their use of literature, the
'beliefs' group were asked whether mass media campaigns in general were
thought to be effective in causing patients to stop smoking. Only four
respondents ~3%) thought ~at ~uc~ cam~-i~n~ ~e~ the ~ost effe~t~ive of nine
possible 'external' =ethods of influencing people, while most thought they
were not (40%) or were undecided (4&%) (Table 8).
TI08350957
278
TABLE 8.
GPs
n=93
HVs
n=47
TOTAL
EFFECTIVENESS OF MASS MEDIA CAMPAIGNS IN SMOKING CESSATION
Effective
N %
Available
Not evidence
effective inconclusive
N Z N %
18.3 41 44.1 35 37.6
8 12.8 15 31.9 28 55.3
23 16.4 56 40.0 61 43.6
X2 = 3.98 2 df
p < 0.05 Not answered 4
IRFORMATION ABOI~T SMOKIN~ IN PRACTICE RECORDS
A separate study, concerned with review of recorded information about
preventive measures, was conducted by GPs from 38 Oxfordshire practices,
using a Practice Activity Analysis data sheet (9). As part of this study, a
randomly selected sample of 1845 records of men and women aged 40-59 years
was reviewed and any mention of smoking behaviour was scored.
Some information about smoking habit was present in about 23% of records,
with more information on record about men than women (Table 9).
In one-fifth of the practices, such information was present in 28% or more
of the records, and in one practice this was as high as 61%.
TABLE 9. SMOKING HABITS RECORDED
Random sample of records from 38 practices (Oxford) n = 1845 (9)
Smoking behaviour
Se_.~x Age (yrs) Number recorded (%)
M~les
Females
Males & Females
Mai~s &
Males & Females
40 - 59 919 26.8
40 - 59 926 18.6
40 - 49 961 22.4
50---59 -88~ - 23-I
40 - 59 1845 22.7
TI0835095°u
Interpretation of the data from the questionnaire survey depends on the
reliability attributed to self-reports.
Three-quarters of ~hose GPs surveyed thought that GPs should have a major
involvement in anti-smokinE education and almost two-thirds claimed that
they usually record the smoking status of their patients.
The acknowledgement that the GP has a ~jor role to play in efforts to curb
smoking is en=ouraglng. But the finding that few GPs regularly use health
education literature as an adjunct to counselling smokers is disappointing,
particularly in the light of the finding that literature potentiates advice
C6).
It is encouraging, however, that the majority of GPs appear in favour of
continued pressure on Government in relation to smoking.
CONCLUSION
If Primary ~ealth Care is to help to reduce smoking and its associated
morbidity and mortal~ty, many CPs w~ll need to bridge the gap between the
positive attitudes demonstrated in this study and effective activity in
their day to day work. (Figure 2)
FIGURE 2. INVOLVEMENT OF g.P.s IN ANTI-SMOKING
9O
~0
3O
10
Claim
smoking
Sr~eklng
yr.
T[08350959
280
FOWLER AND JAMRDZIK
I. Stott NCH, Davis KH. The exceptional potential of each primary care
consultation. J R Co|l Gen Pratt 1979; 29: 201-205.
McCron R, Bu~d J. Communication and health education. Prepared for
Health Education Council, University of Leicester Centre for Mass
Co~unication Research. 1979 October. Chapter 8. (Unpublished).
National Opinion Programme. (1977-1979) N.O.P. Market Research Ltd.
Surveys carried out for the Office of Population Censuses and Surveys on
behalf of the DHSS.
4. Leventhal H. Changing attitudes and habits to risk factors in chronic
disease. Am J Cardiol 1973; 31: 571-580.
Ball KP, Turner R. Smoking and the heart: the basis for action. Lancet
1974; 2: 822-826.
6. Russell l~, Wilson C, Taylor C, Baker CD. Effect of general
practitioners' advice against smoking. Br Med J 1979; 2: 231-235.
7. Jamrozik KD, Vessey MP, Wald N, Fowler GH, Parker G, Dimmock E.
Controlled trial of three different anti-smoking interventions in
general practice, 1983. Br Med J 1984; 288, 1499-1503.
Wechsle~ H, Levene S, Idelson RK, Rohman M, Taylor JO. The physician's
role in health promotion - a survey of primary care practitioners. New
Eng J Med 1983; 308: 97-100.
o
Fleming DM, Lawrence MST. An evaluation of recorded information about
preventive m~asures in 38 practices. J R Coll Gen Pratt 1981; 31:
615-620.
Tl0,8350960
28I
HONIGO
PROGRAHHE D' Ih-TERVElqTION SUR LE TABA~ISHE
POOR LES ENFANTS DE 5 A 12 ANS
Jocelyne Gauthier, animatrice
Association pulmonaire du Quebec
264, rue ChOrtler
Quebec (Quebec)
Canada GIK IR2
Monigo est un programme de sensibilisation sur les effets du tabac ~
l'intention des enfants de l'6cole primaire. Monlgo est un personage sorti
de l'imagination d'enfants de I0 et II ans d'une classe de 5e ann4e du cours
primaire. II tire son nom des trois princlpales composantes de la fum4e de
tabac "monoxyde de carbone, nicotine, goudron". Depuis longtemps,
l'Association pulmonaire du Quebec dont le mandat est la pr6vention des
maladies respiratoires 4tait pr4occup~e par la monroe du tabagisme chez les
jeunes. Si aux Etats-Unis, une 4rude a permis d'@tablir que 4,000 enfants
commencent ~ fumer chaque jour, plus pros de nous les r6sultats d'une Etude
de sp~cialistes de l'Universit~ Laval aupr~s d'enfants de 4e, 5e et 6e
ann~es au cours primaire (~tude faite dans la r~gion de Quebec, en ]978-79)
6tabllssent que 32% des gargons et 24% des filles avaient d~j~ experiment4
la cigarette avant l'~ge de 9 ans, soit de la maternelle ~ la 4e ann6e (I).
C'est donc dire qu'attendre que les enfants soient rendus au secondaire pour
les informer sur le tabagisme semble une erreur.
Pr~sentement, peu de personnes, fumeurs ou non-fumeurs, peuvent affirmer ne
rien savoir sur les m6faits du tabac. Depuis plusieurs ann6es les campagnes
de sensibilisation se sont multipli6es et de plus en plus de fumeurs aban-
4onnent leur habitude tabagique et viennent grossir les tangs de la
majorit6. Si les adultes ont ~t~ touches par les campagnes d'information,
chez les jeunes la probl~matique est diff@rente. Pour les enfants, fumer
semble ~tre une action de grandes personnes, et s'ils se sentent concern4s
c'est presque toujours en relation avec leurs parents, qu'ils soient fumeurs
ou non-fumeurs! Si vous demandez & des enfants quels sont les dangers de la
cigarette, ils ~ous r~pondront: le cancer, en ajoutant "moi" mes parents
fument ou "moi" mes parents ne fument pa$. lls ~dent{f~ent au
monde adulte,
les probl~mes causes par l'usage du tabac.
Les enfants avec le mim4tis~e qui les caract6rise im~tent de modules et
sou~ent dans leur environnement les_mod~les ~ "~L~i~er~s~nt --de~-adulte~
fumeurs. Offrez une cigarette en bonbon ~ un enfant, il la fumera avant de
la gr~gnoter apprenant ainsi le gestuel du fumeur. La publicit~ qui ne
T108350981
282
discri~ine pas les groupes d'~ge attaint l'enfant d~s son plus jeune ~ge
(2-4). Ainsi .~i l'usage du taba¢ est consid~re" par les enfan~s cozzze un
geste d'adulte, comment les atteindre, les sensibiliser et les ~mpliquer en
rant qu'enfants dans la lutte anti-tabac? La question est importante.
Aussi je l'ai posse ~ ceux qui pouvaient le mieux me r~pondre, des
personnes-ressources de premier ordre: aux enfants eux-m~mes.
La r~ponse:
par des enfants du m~me ~ge et ce par la parole et par l'image.
~T~ODE
I. Conception du programme
C'est ainsi qua des ~l~ves d'une classe de 5e annie dens le cadre d'un tours
de franGais ont d~cid@ de faire un diaporama pour expliquer aux @l~ves des
autres classes les m@faits du tabac, lls ont ~crit l'histoire salon leurs
preoccupations et leurs intdr~ts. Etant positifs par nature, ils ont ignor~
les ~nonc@s de maladies futures et ont pr~f@r~ valoriser leur condition de
non-fumeur, lls ont fair les diapositives et enregistr~ leur voix.
Un fair ~ rioter, l'enseignante qui a partlcip~ au programme Monigo ~tai~
fumeuse (s.v.p.) comma quoi une fois qua le paquet de cigarettes est
honn@tement assume, il est possible pour les personnes qu~ fument de
travailler ~ l'apparition d'une premiere g~n~ration de non-fumeurs.
Nous avions un diaporama original calqu~ sur les int~r~ts des enfants,
rdalis~ par de jeunes pout les ~eunes mais commen~ le rendre utilisable par
le milieu?
Encore I~ ce sont mas jeunes personnes-ressources qui m'ont ouvert la voie.
En observant les di~f@rentes demarches qu'ils ont d~ faire lots de la prepa-
ration du diaporama j'ai r~alisd qu'un programme sur le tabagisme devrait
s'inscrire dens le v@cu scolaire o~ se d~veloppment les m~canismes d'appren-
tissage. Ce n'est pas un film, un d~pliant, un diaporama vu ~ la sauvette
une lois par annie qui va pouvoir conifer la publicit@, les pressions socia-
les et souvent familiales venues d'adultes fumeurs. Par le btais du
quotidian scolaire les enfa~ts sont amends ~ explorer de facon organis~e le
concept de la communication et en particuller dans le cadre du cours de
fran~ais.
En se servant des m~canismes d'apprentissage de l'~coute: le savoir-
~couter, la parole, le savoir-parler, l'~criture, le savoir-~crire, la
lecture, le savoir-lire, il deviant possible de faciliter l'acquisition de
connaissances pour l'enfant et de favoriser le renforcement de sa condition
de non-fumeur.
A la suite de rencontres avec des enseignants, des directeurs d'~cole, des
conseillers pedagogiques et des infirmi~res, nous avons b~ti un programme
ax@ sur le cours de fran~ais,~i to~_en__respec~_l~p=ojet p~dagog~q~e-- -
du M~nis=~re de--l~Education permet ~ l'Associatton pulmona~re du Quebec de
rencontrer ses objectifs de sant~. C'est-~-dire qua des objectifs de sant~
sont int~gr~s a~x objectifs p~dagogiques du progra~-~e en fran~ais.
2. Les intervenants
Dens les ~coles le directeur et les enseignants sont les responsables des
TI08350962
prograrm~es, des p~dagogues form's et reconnus pour enseigner. Pour ce
est du volet sant@ il est la responsabilitd de l'inf~rni~re en sant~
scolaire. Elle est pr~par@e et poss~de la competence n@cessaire pour trans-
mettre les ~l~ments du concept de sant~. Comme le program~e_ vise une
meilleure sant~, le crdneau le mieum adapt@ nous a sembl~ @tre celul des
infirmi~res qui sont dans les dcoles. C'est done par elles que le programme
devralt ~tre transmis aux enseignants. C'est ainsi que l'Association
pulmonaire du Qu@bec a donn~ 16 journ~es d'information ~ 817 infirmi~res et
directeurs d'~cole du mois d'octobre 1979 jusqu'en juin 1982. Le programme
Monigo n'est pas obligatoire dans les dcoles. Ce sont des infirmi~res et
des enseignants qui sont convaincus de la n~cessit@ de la prevention qui
int~grent Honigo ~ leurs act~vit~s p~dagogiques. Cette libert~ d'acc~s au
prograrmae est importante puisque des intervenants aussi motivds deviennent
des multiplicateurs de premiere force.
3. Les objectors
L'objectif global du programme est: "D'informer et de sensibiliser les
enfants de 5 ~ 12 ans sur le tabagisme". Afin de former une prem~@re
g@n~ratlon de non-fumeurs les objectifs spdciflques sont gradu~s selon les
degr~s.
Pour la maternelle et ]a l~re annie: Permettre ~ l'enfant de connaltre la
lutte anti-tabac.
En 2e et 3e annie: Inciter l'enfant ~ se reconna~tre comme non-fumeur.
En 4e ann@e: Permettre ~ l'enfant de s'impliquer entant que non-fumeur.
En 5e annie: Inciter l'enfant ~ former des groupes de non-fumeurs.
En 6e annie: Inciter l'enfant ~ faire respecter ses droits de non-fumeur.
4. Implantation du progra~e
Le programme Monlgo se compose d'un dlaporama de 40 diapositives d'une duroc
de 8 minutes~ II secondes avec une cassette synchronis~e. Un cahier
d'exercices pour chaque enseignant. Le programme se devise en 7 ~tapes de
la maternelle ~ la sixi~me annie. Chacun des m~can~smes d'apprentissage
savoir ~couter, savolr parler, savoir life, savoir @crire sert de sujet ~ la
r~alisatlon d'actlvit~s dans le cadre d'objectifs precis. II est un outll
p~dagogique au service de l'enseignant. Chaque inf~rmi~re re~oit un guide
pour lui faciliter la t~che aupr~s des dlrecteurs d'~coles et des
enseignants. L'~valuation se fair de faGon ponctuelle ~ la fin de chaque
activitY. Le materiel n~cessa~re ~ l'@v~luation et ~ la relance est fourni
aussi dans le programme: cartes de membres, dessin ~ compl~ter, affiches,
ballons, auto-collants.
La fa~on de proc~der est la m~-~me pour chacun des degr~s soit: l'~laboration
de l'objectif, le moment sugg~re pour la tenue des activit~s et la d~marche
possible apr@s le v~sionnement. Viennent ensu~te les activit~s reli~es aux
quatre savoir.
Pour vous faciliter la comprehension du program~re j'ai cho~si de vous
presenter les activit~ possibles pour des ~l~ves de 5e annie. Deux types
d'activit~s peuvent se d~rouler.
T10~350963
i. Des activit~s ponctuelles
2. Des activit@s ~ plus long terme.
Voici des activlt6s ponctuelles:
L'objectif 6rant d~termin4, le moment du visionne=ent choisi, voyons quelles
activit6s peuvent convenir aux besoins de 1'enseignant.
D'abord le savoir dcouter:
Apr~s avolr vislonn~ le diaporama, les eq@ves se divisent par groupes et p~@pa-
rent un mime sur les fa~ons de combattre Monigo. Ensuite, chaque groupe presen-
te son mime aU reste de la classe. (La meilleure fa~on de savoir si les enfants
ont bien @court.)
Savoir-parler:
Preparer des rimes sur Monigo et les r@citer. Jeu: Une moiti6 de la classe
pr6pare un questionnaire sur le tabagisme et interroge l'autre ~oiti@ de la
classe dans un style d'interview. Ce jeu n'est pas un questionnaire sur les
connalsssances mals bien une mise en situation de style entrevue t61@vis6e,
exemples: Que pensez-vous de Monigo? Les jeunes ont-ils raison de fumer?
etc... Donnez-leur quelques pistes et leur imagination fera le reste! Cela
peut se faire avec un magn~tophone et servir au "savoir ~couter". Apprendre le
serment de la r@sistance anti-tabac par coeur et le m~moriser. (Ceci est conte-
nu dans l'annexe du cahier d'exercices de l'enseignant.)
Savoir lire:
I. Former des equ~pes
2. Chaque 61~ve trouve un mot nouveau (revoir le diaporama si n~cessaire).
lls cherchent les d@finitions dans les dictionnaires et encyclop~dies.
lls 6crivent ces mots et leurs d6finitions sur ac6tates et les projettent
avec un r~tro. Ce moyen en plus de servir aux apprentissages de la lecture
et de l'~criture d@veloppe de habilet6s manuelles (se servlr d'apparei~s
audio-visuels).
Savoir ~crire:
Les ~l~ves pr~parent des textes sur les non-fumeurs ou Monigo, avec recher-
che des mots plus dlfficiles, lls ~changent leurs textes afin de les
corriger.
2. Diviser les ~l~ves par @quipes.
caches. __
Chaque ~quipe prepare un jeu de ~ots
3. Echanger des jeux entre les @quipes.
Les @quipes adverses doivent trouver les r6ponses dans un laps de temps fix~
~ l'avance.
Preparation des devlnettes-charades.
I I0.~,.,50~o4
285
Voil~ pour les activit~s plus quotidiennes. Pour ce qui est d'une d~marche ~
plus long ter=e, cela pent ~tre r6alis@ avec des enfants de plus de 10 ans
car les plus jeunes seraient rite d~=otiv~s devant l'ampleur de la t~ehe et
la fin tardive de l'activit~.
D~arche s'~chelonnant sur quelques mois
I. Fondation d'un club de non-fumeurs
i.i Election d'un comit6 administratlf
i.I.I Mise en candidature aux postes de presldent, v~ce-pres~dent
et secr~taire
1.1.2 Cabale: d~scours, preparation de slogan, chanson th@me
1.1.3 Election
1.20r~anisatio~ de comit@s
Comit~ du journal: Pr4paration de textes jeux-devinettes Cueillette
d' information aupr~s d'organismes de sant~.
Comitd de la bande dessiude: Les enfants int~ressds font une bande
dessin@e qui sera publi~e dans le journal. Ce
m~me comit~ pourra fournir d'autres dessins sus-
ceptibles d'int~resser le lecteur.
Comitg de la publicitg, etc.: Le comlt~ de la publicit~ se charge
de la vente du journal, de pr@parer un klosque
d'~nformations daus le hall d~entr~e de l'gcole,
etc.
Une relanee avant les vacances semble indiqu~e.
Pr~voir une discussion au sujet des activit~s qui ont eu lieu. Leur demander
leurs impressions et leurs suggestions. Un ~l~ve prend en note et les fair
parvenir ~ l'infirmi~re.
Exercice de "cl~sure" (adaptS) serv~ra ~ la fois de relance et d~valuation.
5. Evaluation
Plusieurs types d'~valuation out ~t@ r@alis~es dans differentes ~coles ainsl
qu'un prO-test par l'Association pulmonaire du Quebec mais comme tout
changement, modification ou renforcement de comportement ce sera l'avenir
qul nous indiquera via les statistiques sl nous avons atteint nos objectifs.
La meilleure dvaluation est l'int~r~t grandissant des enselgnants pour le
progra~an.e Monigoo Pr~sentement 1278 ~coles ont particip~ au programme
Monigo avec un total de 252,614 enfants et 966,900 d~pliants et affiches ont
dtC distribuds et cela de novembre 1979 au 31 mars 1983.
Si le programme Monlgo favorlse la valorisation de l'enfant en tant que
non-fumeur et lui permet d'agir pour cottager une situation qu'il juge mena-
~ante pour sa condition d'enfant on peut vraiment esp~rer voir appara2tre
une premiere g~n~ratlon de non-fumeurs.
T[08350985
C'est vers quol tend l'Association pul~onaire du Quebec. Le progra~e est
en marche depuis l'auto~ne 1979, une @valuation au niveau provincial pourra
&tre indiqu4e ~ l'automne 1986. -:
BIBLIOGRAPHIE
:~
I. Minist~re des Affaires sociales, Gouvernement du QuEbec: Usage du ~abac
en milieu scolaire. Juin 1979.
2. Ministate de 1'Education: Programr~e de fran~ais, principes g~n@raux
directives, r~sum~. Quebec 1979.
3. Lagneau G. La Soclologie de la publicitY.
num~ro 1678, Paris 1977.
Collection "Que saisje"
4. Victoroff David.
1978.
La publicit~ et l'image.
Editions Dauoel/Gonthier
~,;
5. Cossette Claude. Communication de ~asse et consolation de masse.-.'
Editions du BorEal-Express, 1975.
Le prograr~me est disponlble ~ L'Association pulmonaire du Quebec
264 rue Ch@nier, Quebec GIK IR2.
TI08350966
287
THE TOBACCO INDUSTRT~S a~.SPONSE TO SCIENTIFIC EVIDENCE
ON INVOLUNTARY SMOKING
Stanton A. Glantz, Ph.D.
Associate Professor of Medicine
Member, Cardiovascular Research Institute
University of California
San Francisco, CA 94143, U.SoA.
President, Californians for Nonsmokers Rights
Berkeley, CA 94704, U.S.A.
There are 30,000-40,000 scientific publications on the harm smokers do to
theemelves; this number contrasts with 500-600 publications on the effects
of involuntary smoking on non-smokers. Yet this relatively new area of
investigation, the effects of involuntary smoking on the non-smokers,
probably holds the key to controlling and reducing primary smoking.
Every two years, the Tobacco Institute commissions a national poll of
attitudes towards cigarette smoking, smokers, and the industry. The results
of these polls are closely held within the industry, but one, conducted i~
1978 by the Roper Organization (1), was obtained by the Federal Trade
Co~ission and subsequently made public. This poll is probably the most
important piece of research available to guide people concerned w~th
developing effective strategies for dealing with smoking. It says:
The original Surgeon General's report, followed by the first
"hazard" warning on cigarette packages, the subsequent "danger"
warning on cigarette packages, the removal of cigarette advertis-
ing from television and the inclusion of the danger warning in
cigarette advertising were all "blows" of sorts for the tobacco
industry. They were, however, blows that the cigarette industry
could successfully weather because they were all directed against
the smoker himself .... [and have] not persuaded many smokers to
give up smoking.
The anti-smoking forces' lates~ tack, however - on the passive
smoking issue - is another matter. What the smoker does to him-
self may be his business, but what the smoker does to the non-
smoker is quite a different matter .... Nearly six out of ten
believe that smoking is hazardous to the non-smoker's health, up
sharply over the last four years. More than two-thirds of non-
smokers believe it; nearly half of all smokers believe it.
This we see as the moat dangerous development yet to the viabil-
ity of the__tobacco~dua~ry_~yet---eccor=ed~--~eml~ha~i~
added] (1)
TI08350967
i
Another poll conducted by Roper for the Federal Trade Commission in 1980 (2)
confirms that the trend is eont~muing. Seventy-two percent knew or thought
the statement, "Cigarette smoke poses a health hazard to non-smokers exposed
to it," was true, compared with only 12% who knew or thought it was not true
(Table I). This widespread belief that involuntary smoking harms non-
smokers underscores the demands for separate areas for smokers.
TABLE i.
IS SMOKING HAZAP.DOUS TO NON-SMOKERS' HEALTH?
1974 1976 1978
Probably is hazardous 46% 52% 58%
Probably doesn't have any real effect 48% 40% 33%
Don't know/no answer 6% 8% 9%
1980
72%
12%
16%
Sources: 1974-1978
1980
1978 Roper PolI-Q.21 (I)
1980 Roper PolI-Q.30 (2)
Note: 1980 poll asked about the statement, "Cigarette smoke poses a
health hazard to non-smokers exposed to it." People who respond-
ed '~now it's true" or "Think it's true" were tabulated as
"Probably is hazardous." People who responded "Think it's not
true or 'Know it's not true" were tabulated as 'Probably doesn't
have any real effect."
Ironically, relatively few non-smokers are aware of how many people agree
with them. A 1975 survey conducted by the U.S. Department of Health, Educa-
tion and Welfare found that 70% of adults surveyed agreed with the state-
ment, "The smoking of cigarettes should be allowed in fewer places than it
is now." (3). Another survey, conducted by Chilton Research Services for
the Federal Trade Commission in 1980 (4), found that only 17% of adults knew
that the percentage was this high. Seventy-three percent underestimated the
percentage agreeing with the statement.
The industry has dealt with growing public awareness and interest in the
health effects of involuntary smoking, much as it has dealt with the effects
of primary smoking - by attacking the evailable evidence and trying to
create a controversy about the validity of scientific studies linking
involuntary smoking with harm to non-smokers. This strategy is well estab-
lished within the industry. The Federal Trade Commission obtained (under
subpoena) documents from the cigarette manufacturer Brown and Williamson
which established that, as early as 1969, the company had a plan to confuse
the public about the evidence linking smok{ng to disease and death. One of
their planning documents says:
the "body of fact" that exists in the mind of the general pub-
lic. It is also the v~ans of establishing a controversy. If we
[Brown and Williamson] are successful at establishing a contro-
versy at the publ~c level, then there is an opportunity to put
across the real facts about smoking and health (5).
TI0835096,3
In other words, by playing up areas where there is a genuine scientific
controversy about the particular effects of smoking, Brown and Williamson
proposed to cast doubt on the validity of the =zuch larger body of uncontro-
vetted ~edical evidence.
This strategy took an unpre=ede~ted torn in 1981 when Hirayama (6) publighed
a study linking involuntary smoking with cancer. This study received exten-
sive coverage in the popular press. The Tobacco Institute's initial
response was typical; they hired a consultant, biostatisticlan Nathan
Mantel, to critique the paper. Mantel raised a few technical questions
about the paper, then the Tobacco Institute published a press release stat-
ing that Mantel had found an arithmetic error that "invalidates" Hirayama's
study. This release also received wide coverage in the press.
At the time, more of the specific criticisms were available to the scienti-
fir community; the entire interchange was based on press releases by the
Tobacco Institute. (Some months later, the British Medical Journal reopened
correspondence on the Hirayama paper and published both Mante1's criticisms
and Hirayama's reply, ~hlch effectively dealt with those criticisms (7). The
interchange received virtually no public attention.)
The industry, however~ went even further in its attempts to discredit Hira-
yama's study. During the late summer and early fall of 1981, the Tobacco
Institute ran full-page advertisements in major newspapers and news maga-
zines throughout the United States specifically attacking the Hirayama study
(Figure I). This is probably the first time a nationwide advertising cam-
paign has been conducted to attack a specific scientific paper. The Tobacco
Institute stressed a study (8) that differed with Hirayama's work by report-
ing no significant increase in lung cancer among non-smoking wives of
smoking husbands in the U.S. (There was an increase in risk, but it did not
reach statistical significance.) The Tobacco Institute conveniently ignored
a third study (9) that supported Hirayama's conclusions.
This approach is consistent with one of the recommendations in the 1978
Roper Poll conducted for the Tobacco Institute:
The strategic and long run antidote to the passive smoking issue
is...developing and widely publicizing clear-cut, credible
medical evidence that passive smoking is not harmful to the
non-smoker's health. (I)
The Tobacco Institute subsequently launched a year-long advertising program
to sell the public their perspective on issues surrounding smoking. The
series of two-page color advertisements, running in major U.S. magazines,
including TIME, NEWSWEEK, US NEWS and WORLD REPORT, PEOPLE, SPORTS ILLUS-
TRATED, and TV GUIDE, has reached 80% of the adult population (i0). The
advertisements urge the public to '~eigh both sides before you take sides."
(Figure 2). The advertisements routinely make liberal use of context quota-
tions or outright misrepresentation. For example, the advertisement in
Figure 2 says:
In his most recent report, the Surgeon General said that the
available evidence is not sufficient to conclude that other
people's s~oke causes disease in non-s~kers.
TI08350969
29O
GLAMTZ
The actual statement made in the Surgeon General's report (II) is
Although the currently available evidence is not sufficient to
conclude ~hat passive or involuntary smoking causes lung cancer
in non-smokers, the evidence does raise concern about a possible
serious public health problem.
Significantly, half the advertisements deal with the health effects of
involuntary smoking and attempts to secure legislation to protect non-
smokers. The industry is clearly very concerned about public perceptions of
the effects of involuntary smoking and the growing pressure to protect non-
smokers' rights. People and agencies who want to do something about smoking
should recognize this fact and focus their energies on non-smokers' rights,
just as the Tobacco Institute has.
FIGURE I. ADVERTISEMENT ATTACKING HIRAYAMA'S PAPER
TI08350970
THE L~DUSTRY ~ INVOLUNTARY SM~KIN~
291
FIGUKE 2. ONE OF THE "WEIGH BOTH SIDES" ADVERTISEMENTS BY
THE TOBACCO INSTITUTE
questions about cigarettes.
DOES
CIGARETTE
SMOKE
ENDANGER
NONSMOKERS?
WEIGH BOTH SIDES
BEFORE YOU TAKE SIDES.
I. The Roper Organization. A study of public attitudes toward cigarette
smoking and the tobacco industry in 1978, Volume I. 1978 May.
2. The Roper Organization. Study 726. 1980 November.
3. Center for Disease Control and National Cancer Institute. Adult use
of tobacco~l-9~5.~B~th~d-a-~--~MdT:---CdrfC~-£--[~---D~h~e---Control ~nd
National Cancer Institute, 1976.
~. Chiffon Research Services. A survey of adolescent and adult attitudes,
values, behavior, intentions and knowledEe related to c~arette s=okin~:
Final report. 1980 June.
TI08350971
292
~
5. Myers l~L, Iscoe C, 3ennings C~ Lenox W, Minsky E, Sacks A. Staff report
of the Cigarette Advertising Investigation. Federal Trade Commission
1981 May.
6. Hirayama T. Non-smoking wives of heavy s~okers have a higher risk of
lung cancer. A study from Japan. Br Med J 1981; 282: 183-185.
7. Hirayama T.
1393-1394.
Pass£we smoking and lung cancer.
Br Med J 1981; 282:
8. Garfinkel L. Time trends in lung cancer ~rtality among non-smokers and
a note on passsive smoking. J Nat Cancer Instit 1981; 66: 1061-1066.
9. Trlchopoulos D, Kalandidi A, Sparros L, MacMahon B. Lung cancer and
passive smoking. Int J Cancer 1981; 27: I-4.
I0 Anonymous. Chilcote cities growing need for unified action. United
States Tobacco Journal 1983 May 8.
I1. US Dept of Health and Human Services. The health consequences of
smoking: cancer. A Report of the Surgeon General. Rockville, Md.:
Office on Smoking and Health, 1982. (DHHS Publ No (PHS) 82-5179).
TI08350972
293
SMOK'~NG EDUCATION FOR TEENAGERS
E.M. Gray, M.Ed., University of Bristol
P. Gammage, Ph.D., University of Nottingham
M.J. Morgan, Ph.D., ~.W.I.S.T.
J.R. Eiser, Ph.D., University of Exeter
BACKGRO~I~D TO M PROJE~T
This project, set up in October 1981, was funded for a period of three years
by the Health Education Council.
Th~ initial project was to examine and apply techniques derived from certain
American work on teenage smoking based on a 'resisting social pressures'
approach.
Much previous health education in this field, concentrating principally upon
long-term health consequences, has proved to have limited success in reduc-
ing the number of adolescent smokers. Recent American work, initiated by
Richard Evans (i,~) at the University of Houston has, however, apparently
demonstrated some promising results with evidence of fairly substantial
reductions in the incidence of smoking, in addition to changes in attitudes
and behavioural intention. Evans initially concentrated on what he refers
to as a 'behavioural' version of McGuire's (3) concept of inoculation to
persuasion, in which it is supposed that, by exposing adolescents to a
preliminary version of typical social pressures to smoke (mainly using
audio-visual materials), it is possible to increase their defences against
such pressures by providing them with counter-arguments and behavioural
coping strategies.
One of the prime functions of the Smoking Education for Teenagers (SET)
project was to evaluate this American work, not only in terms of its
generalisability to England, but also as to whether there was a specific
treatment effect attributable to the 'resisting social pressures' films
themselves or whether any reasonable method that succeeded in generating
similar levels of activity and interest over a comparable period of time
would have more or less than the same effect.
The preliminary investigation (4) began with a set of interviews with teen-
agers in order to find out the pattern of their smoking behaviour. It con-
sisted of semi-structured interviews with a sample of eighty 14 year olds in
South West England. Ten girls and ten boys were chosen from each of four
co-educational schools. Using the criterion that the subject had tried at
least one cigarette, first experiences and current smoking status were
discussed.
Address for correspondence: Miss E.M. Gray, Research Fellow, University of
Bristol Research Unit, 22 Berkeley Square, Bristol, Avon, England, BS8 IHP.
T108350973
294
GRAY~ GAM~AGE, I~R/~AN~ ~ EISER
THE P~F.VALENCE STUDY
Bearing in mind that the prime function of the research undertaken by the
project was to develop currlcular materials appropriate to the British
context for use in secondary schools, it became clear from this preliminary
investigation, in which several important issues were highlighted, that
there was a need for an extensive, though locally based, study of prevalence
rates in the types of schools in which interventions would later be under-
taken. Such a study would also aim to establish whether particular psycho-
social variables differentiate between those children who would never smoke
a cigarette, those who would merely experiment and those who would be likely
to become addicted smokers.
Subsequently, work was begun on the preparation for such a prevalence study,
which involved approximately 10,000 11-16 year old children from ten co-
ed.ucational secondary schools randomly selected from the Bristol conurba-
tion, Avon, South West England. All children in the first five years of
each of the ten schools took part in the study, which involved the
completion of a self-report questionnaire and, for some of the children, the
giving of a saliva sample.
The undertaking of such a large and detailed study involved a considerable
amount of preparation and organlsation prior to its being carried out in the
last three weeks of April 1983. Much careful planning went into the prepa-
ration of the questionnaire and close attention was given to the type and
nature of the information sought. As well as the need to know the percent-
ages of children smoking at different ages, for example, it was planned to
collect data on other variables - certain indices of actual and perceived
soclal pressures, such as a putative llnk between smoking and friendship
patterns, the use of alcohol and the extent to which children saw themselves
as in control of their own health, were included. Also included was a modi-
fied Locus of Control Scale (5). However, while it was desirable to collect
as much important relevant information as possible, 'relevant' had to be
strictly interpreted within the theoretical framework in which the study was
planned. In addition, the questionnaire was designed both to be read out to
the children along standardised procedures and to fit into a slngle lesson
time of approximately 50 minutes. This would cause the minimum interruption
possible to the schools. It had to be borne in mind too that time would be
needed within this limit to collect the necessary saliva samples. The ques-
tionnaire underwent several revisions before being pilot tested with 90
children. Following this pilot test, minor amendments, largely in respect
of phraseology, were made.
The questionnaires were not anonymous but were confidential and it was
clearly explained to the children that neither teachers nor parents would
know their responses. Named questionnaires were considered important for
two reasons, apart from the fact that there is some evidence to indicate
that anonymous self reports are less reliable than named ones (6). The_
putat~ve--l~n~ 5~w~n s~oklng ~-d~fFi~ds~ip patterns expl-~red in some of
the questions required children to name close friends. Names would be
necessary too for initial ident{fication purposes for any sample that might
be selected for a future follow-up.
The Governors of one school raised objections to names helng required; as
T[0~50974
SMOKIHG EDUCATIOH FOR TEEHAGERS
295
soon as this was made known, the Headmaster of a nearby school felt that he
could no longer ask his pupils to put their names to the questionnaires.
Fortunately this 'knock on' effect proceeded no further and, as both schools
were relatively small, this still left the project with a sample size of
approximately 8,500 with names, and a potentially interesting comparison
group of 1,500 anonymous questionnaires.
In terms of organisation, too, this was a considerable enterprise involving
much preliminary public relations work with Headteachers and Advisers prior
to gaining official permission from the Director of Education to approach
the schools. Following a letter to each of the schools requesting their
co-operation, a personal visit was made to meet the Headteachers and their
Deputies to discuss the details of the exercise, so that the purpose of the
prevalence study would be clearly understood.
Wi~h such a large scale survey, it was very important that the procedure for
the actual administration of the questionnaires was standardised and accord-
ingly 26 Research Assistants, employed for the purpose, attended three
training sessions prior to going into the schools. According to the
preference of the individual schools, the questionnaire was administered
either to a year group at a time who were assembled in the school hall for
the purpose, or to a year group at a time divided in their classrooms.
Prior to the questionnaire being administered, the children were told that
some of them would be asked to give a saliva sample after the questionnaire
had been completed. This would be done by selecting the children at random.
Overall, 20% of the total cohort were asked to give a sample; this number
was obtained on a sliding scale with the largest sample being coll6cted from
the youngest age group to ensure approximately the same number of smokers'
and non-smokers' samples in each of the five age groups.
Originally, the purpose of the cotinine test was purely to validate the
questionnaires but it was later decided to use the results to examine the
cotinine levels in comparison with the reported type of smoking, and also
the perceived levels of addiction, in order to learn more about the nature
of dependence. Additionally, subsequent intervention could be assessed and
evaluated against rellable biochemical evidence. The latter could help
also to determine when the development of adult smoking patterns occur.
One thousand of these samples have been randomly selected for analysis.
Should any of the smoking groups not be represented adequately, then further
samples can be analysed at a later stage.
During the period of this data collection, the Research Assistants received
instructions in coding procedures; coding began as soon as each school's
data had been collected.
Ceding haz--~.keen-i-o-mp-let-ed--and--t,,~e--dat~--ar~-a-Fy-shh- using the-SPSS-computer
package.
TI08350975
296
GRAY, GK~AGE, I~)RSAN, AND EISER
T]IE O]RRIOILDM GUIDE 'SAM'
During the course of the first year, the project team was invited to examine
one of the existing American curricula on smgking prevention, based largely
on the 'resisting social pressures' model, with a view to considering its
acceptability in a British context. The particular curriculum so identified
was the Minnesota Peer-Led Social Consequences Curriculum, a programme
designed for 12-13 year olds, one of three curricula developed in the
Minnesota Smoking Prevention Program.
It was clear, from the start, that this exercise involved much more than a
'straight translation' into the British idiom and cultural context. It was
clear too that as this was in essence an exercise in curriculum development,
~n which several of the strategies to be undertaken were largely pre-
determined, the context and approach through which the Minnesota version was
introduced to schools would not be replicated in this particular instance.
By the time that the team had been asked to take on this brief, there was
already a list of potential 'customers', as it were. Some twenty Health
Education Officers from different parts of Britain had responded to an
earlier information item in the Health Education Council Newsletter seeking
interest in this particular curriculum material. They in turn indicated
that they would pass on information about the curriculum to interested
teachers with whom they had professional contact.
At this point some explanation of the role of Health Education Officers vis
~ vis the Education Service would seem to be appropriate.
Health Education Officers themselves do not have a direct responsibility for
what is taught in Health Education in schools; their responsibility is to
promote Health Education in the community at large; but, depending on their
relationship with the Local Education Authority, they act in an advisory
capacity to teachers by running courses and providing information on new
Health Education material. Health Education is not a compulsory subject in
the school curriculum and there is no common pattern for teaching it in
schools. It may be taught within a variety of subject contexts: Social
Education, Science, Physical Education or Home Economics for example, by
teachers with a variety of subject backgrounds. Such diversity has, of
course, implications for the introduction of any new curricula concerning
Health Education.
The actual adaptation of the Minnesota Manual was done by a process of revi-
sion and consultation with Health Education Officers and teachers, through
holding workshops and issuing questionnaires. One workshop was held
initially for the interested Health Education Officers and subsequently two
workshops were held for teachers who had been contacted by their local
Health Education Officers. The first partially revised version of the
manual was to serve to introduce the Health Education Officers to the notion
of peer-led _ac~i_vitie~4~pr-ior te---tbe-~r w~r~-~hop,-~ea~h He.ll,h---Education
Officer had been provided with the original Minnesota Manual, for discussion
and comparison with the newly revised version. The second revision for the
two teachers' workshops incorporated suggestions made by the Health
Education Officers and was based closely on the format of the original
Minnesota Manual with as ~uch background material as passible from the
TI08350976
, SI~KIHG E]~E;C.~TOZ; FO;~ ~-,E~t~'~RS
297
British context replacing similar A=erican material. (Data from the Avon
prevalence study will he included in later revisions as it beco=es avail-
able.) Altogether the na~es of 84 interested teachers were sent to us; of
these, 41 were able to get leave from school to attend a workshop.
After the second teachers' workshop, a third revision was prepared and given
the title "SMOKING AND ME" (SAM). This version incorporated the comments
and suggestions received from Lbe questionnaires and workshop discussion and
is, of course, substantially different from the original Minnesota Manual.
This third version was sent out to a mailing list of some 200 teachers,
Health Education Officers and Local Education Authority Advisers with an
accompanying questionnaire requesting further comments and seeking an indi-
cation of interest in trying out the programme in school. Using suggestions
from this latter questionnaire, a fourth version was prepared; again this
was sent out to an increased number of interested teachers and another work-
shop was held to prepare a version that was planned for a pilot evaluation
in the next phase of the project.
PEER TEAL"RING AND PEER LEADERS
The process of adaptation and revision of this teachers' guide initially
proved to be a complex one which posed some interesting problems, especially
in respect of the nature of the teaching strategies involved in this parti-
cular curricular context. The label'Peer Teaching' is relatively unknown
within the British school system, so clarification of what exactly was meant
by 'peer-led' was essential, for the concepts are not clear-cut and the
terms 'peer-leader', 'peer teaching' and 'peer tutoring' are sometimes
referred to in the literature without sufficient distinction. Similarly,
the term 'group work' in this context needed explanation. In Britain, group
work has been incorporated into a variety of activities in schools, and
diverse curricular developments over the past two decades have interpreted
the term in widely differing ways. The term 'group work' has thus come to
have specialised meanings to teachers. It now tends to signal specific
psycho-dynamic concerns of group relations rather than solely organisational
ones.
However, close examination of the concept of peer-led groups in the Minne-
sota teachers' guide suggested that initial difficulties were largely those
of semantics; the concept was much simpler than its explanations. Such
strategies were not unfamiliar to British teachers or children -certainly
most of the latter would have had experience of this type of group work in
their primary schools and in many instances too, discussion-based work in
certain subject areas was already taking place in secondary schools.
Nevertheless, these particular issues were embedded in the context of the
development of a teachers' guide that had to be seen to be 'free standing'
as a piece of curriculum material for the potential users - self selected
teachers with diverse subject 5ac~kgr~unds and int~_~ests..__Co~vincinB~uch
t~achers £bat there is no mystlque about the discussion-based group work
involved in this programme is crucial. To feel confident and at ease with
what they are doing is of pri~e importance; teachers are not likely to be
successful if they are anxious and uncertain. Because of possible ambigui-
ties surrounding the phrase 'peer led', this has not now been used except in
TI08350977
298
GRAY, CAI~GZ, MOF.EAN, AND E~SEE
referring to the original Minnesota guide.
leader' replaces 'peer leader'.
Similarly, the term 'group
The pilot version of 'SMOKI~ A~ ME' is now undergoing formative evaluation
in a selection of schools in England and Wales. This forms part of the work
of the second phase of the project which commenced in October 1984.
The prevalence study has y~elded much valuable data for several potentially
important investigations; as the first report shows (7), in im~edlate terms
the project team is looking to the data to provide a framework in which the
videotapes and accompanying curricula materials can ~e developed, as well as
providing important factual information for the teachers' guide 'SMOKING AND
RETROSPECT ~ PROSPECT
The setting up and development of this project has been particularly
interesting, both in terms of the structure of the project itself and in the
programme of activities that have ensued. In respect of the latter, the
investigations for the theoretical and social context of the videotapes and
the work on the adaptation of the American curriculum guide have sought
common ground in the Avon prevalence study, itself a thoroughly researched
and carefully planned exercise. Both of these aspects of the work concerned
with the development of curricular materials are firmly rooted in a broadly
based theoretical background.
An examination of the structure of the project reveals several unusual
features. The work of the project is directed towards both research and
development in the curriculum - an area of enquiry that has had much atten-
tion focussed on it in research years in respect of development of materials
and teaching strategies. However, it is also necessary to ensure that
critical appraisal of relevant research is accorded to such developments and
the project team have placed strong emphasis on the necessity for carefully
evaluated judgments forming the basis of the development of materials.
A joint project between two universities means that expertise is shared and
this enhances the collaborative nature of the work in which universities,
schools and health authorities are brought together w~th a common purpose to
their mutual advantage. In the recent fieldwork particularly, the project
team has been accorded the greatest co-operation and support; such qualitles
augur well for the future research and development of the project.
ACKNO~EMENT
A~o~ect--f~udeu~by--th-e~a-l-th Education t~6~h~i-l-~-~8--N~-Oxf~r~ Street~--
London WCIA IAH.
TI08350978
SMDKING EDUCATIO~ FOR TEENAGERS
299
I. Evans RI. Smoking in children: developing a social psychological
strategy of deterrence. Journal of Preventive Medicine 1976; 5:
122-127.
2. Evans RI, Rozelle RM, Maxwell SE, et el. Social modell~ng films to
deter smoking {n adolescents: results of a
three year field
investigation. J Appl Psychol 1981; 66: 399-414.
3. McGuire WJ. Communication-persuasion models for drug education:
experimental findings. In: Goodstadt M, ed. Research on methods and
programs of drug education. Toronto: Addiction Research Foundation,
1974.
4. Morgan MJ, Eiser JR, Gammage P. Initiation into cigarette smoking: an
interview study. Institute of Health Education (in press).
5. Wallston BS, Wallston KA, Kaplan D, Maides S.
validation of the health locus o~ control (HLC) scale.
Psychol 1976; 44: 580-585.
Development and
J Consult Clin
Evans RI, Hansen WB, Mittelmark MB. Increasing the validity of
self-reports of smoking behaviour in children. J Appl Psychol 1977; 62:
521-523.
Nelson SC, Budd RJ, Eiser JR et al. The Avon Prevalence Study: a survey
of cigarette smoking in secondary school children. Health Education J
1985; 44(I): 12-15.
T[08350979
301
THE ~tALLEHGE ~0 PUBLIC EDUCATION: A HTLTI-HATIOHAL PERSPECTIVE
Ellen R. Gritz, Ph.D.
Division of Cancer Co,trol, Jonsson Comprehensive Cancer Center
and Department of Psychiatry and Behavioral Sciences
University of California, Los Angeles
U.S.A.
TNTRDDUCTION
There is no question of the importance of reducing smoking prevalence by
facilitating cessation among all smokers and discouraging initiation
yoang people. I% has been widely publicized that lung cancer mortality
women will surpass breast cancer mortality some time in this decade in the
United States (I).* In fact in 1980~ lung cancer had already replaced
breast cancer as the leading cause of cancer deaths amonE women in
Washington State; and a check in 10 other states revealed that in over half
of them the lung cancer death rate either had or shortly would surpass that
of breast cancer (2).
The acceleration of lung cancer mortality among females in the U.S. is
striking. &Ke-adjusted death rates of white females increased by an average
of 1.0% per year between 1950 and 1957, 5.5% per year between 1958 and 1967,
and 6.7% per year between 1968 and 1977 (i). (Rates were only slightly
different for nonwhite females). The rise in female lung cancer mortality
rates observed in the late 1950s and early 1960s appears to be replicating
the pattern noted among males 20 to 30 years earlier. Bubtractlng 25 years
from female lung cancer death rates shows the rates for women to be only
slightly below those for men, thus supporting the statement that there is no
substantial di£ference in the risk of developing lung cancer between the
sexes. Age-speci£ic mortality is similar in the youngest cohorts of men and
women, where smoking prevalence is most comparable (I,3).
Taking just one more example, from an international perspective, Junge and
Hoffmeister (&) compared causes of early death among men and women 55 to 64
years of age in 26 countries in Europe, the U.S., Canada, Japan and Austra-
lia between 1958 and 1976. For |ung cancer, the m~r~al~ty sex ratio (males
to females) Was 7:1, but the relative increase among women was twice as h~gh
as that among men. The death rates for lung cancer in women varied between
approximately 10 per 100,O00 in Portugal, Spain and France and 60 per
* The American Cancer Society has predicted that in 1985 lung cancer will be
the cause of death of more women in the United States than breast cancer,
38,600 vs. 38,400 (A~erican Cancer Society, Cancer Facts and Figures, 1985).
__Responsible_Authoz--and--Reque~--for---Rep~'~rni~.Dlq-en~Grltz, Jons~0n
Comprehensive Cancer Center, Division of Cancer Control, 10920 Wilsh[re
Boulevard, Suite 1106, Los Angeles, California 90024, U.S.A.
TI083509g0
302
GB/TZ
I00,000 in the U.S. and England & Wales. The upper value for women just
touches the lowest value for men ~n Portugal, Japan and Sweden. Since 1958,
female mortality increased in all countries except Bulgaria and Spain.
These frightening trends in lung cancer mortality are, of course, intimmtely
related to changes in women's smoking prevalence. Adult male smoking in
the U.S. has falle~ from a prevalence rate of 51.5% in 1965 to 36.7% in
1980, while adult female smoking has only declined from 33.3% in 1965 to
28.9% in 1980 (5,6). Recent data do provide optimism regarding women's
smoking cessation patterns. An analysis of estimated rates of attempted and
successful quitting among adult cigarette smokers in 1980 showed that '~ith
respect to the probability of attempting to quit and the success rate, adult
men and women cigarette smokers are now indistinguishable" (6, p.26).
Between 1978 and 1980, 1.8 million adults quit smoking, 60% of whom were
female (5). Adolescent smoking patterns in the U.S., however, show a
digturbing trend for females; between 1968 and 1979, prevalence increased in
each age group surveyed at each of four temporal points, such that female
smoking now exceeds male smoking, with only slight evidence of downturn (7).
Space does not permit discussion of prevalence trends in other countries,
except to say briefly that North American smoking patterns are relatively
similar; in Europe, female smoking shows increases in some countries and
decreases in others; the Scandinavian countries show rather consistent
declines in smoking; smoking rates in Japan, Central and South America are
still quite low among women (8).
THE SOCIOC[ILT~RAE COI~TEXT OF SMOKING
These data illustrate the importance of continuing the public education
campaign against smoking for women. We have not won the battle and, in
fact, face tremendous challenges in both developed and developing nations.
The principal thesis of this paper is that public education must increase
its scope and content to include the sociocultural context of smoking
behavior as well as its disease consequences. In our desire to tell women
how dangerous smoking is to their health, their pregnancies and their
infants, we often overlook the behavioral, cultural, and economic factors
that simultaneously influence their decision whether or not to smoke. I
will expand this thesis with regard to both developed and developing
countries.
People make decisions about changes in their behavior according to their
conception of "the good life". What that means to the public health expert
may be far from the interpretation of any given individual in society and
certainly varies among societies. We feel that the harm caused by tobacco
use is of such magnitude and established causality that steps should be
taken in every society to eliminate its use on a voluntary basis. That is a
moral and ethical decision of some magnitude and bears implications for what
p~ople--consider-~a~rt---of~h~--good--l~Te~9~ But count~ng--rlsk-tak~ng
behaviors as part of the good life is also learned, and people can learn to
enjoy a life style that is more healthful (I0). To accomplish this, we can
no longer ignore the social and behavioral embedding of smoking in our
public education programs. We must move away from the context of purely
individual focus. It is "...important to identify those forces in the
T108350981
EDUCATION: A I~JLTI-NAT~OHAL P'~RSPECTIVE
social environment that influence smoking behavior so that social and
cultural interventions may be devised" (Ii, p.185).
HIGELIGBTS OF PROGRESS TO DATE
There is quite a difference of opinion about the effectiveness of smoking
control programs. James (12) has estimated that antl-c~garette smoking
education accounts for approximately 90% of primary cancer prevention
programs. Yet it is dlff~cu]t to show that behavioral change actually
results from educatlonal intervention, and we know that the formal transfer
of information about health is usually insufficient to achieve the same goal
(9). The relatively poor (25%) long-=erm success rates of smoking cessation
treatment programs make one dubious to recommend their widespread use. The
fact that 50 ~o 60 million people st~ll smoke in the U.S. after almost 20
years of public education efforts, and that s~oking in developing countries
promises to follow the patterns of the developed nations is further evidence
for our lack of power in education.
However, reality has a Rashomon-like quality - truth takes many forms. We
can interpret the same 20 years of public education effort in the U.S. from
a mech more positive viewpo{nt. I would llke to use the work of Warner and
Mutt to illustrate this point graphically (13). Instead of comparing recent
smoking rates with those which immediately preceded the anti-smoking cam-
paign in order to measure its effectiveness, they compared current smoking
rates with those that would have been expected today, had the campaign not
occurred. The usual observation is that the rate of smoking has fallen
consistently among men since 1964 but that the campaign has had a minimal
impact on women, whose lowest smoking prevalence rate was less than four
percentage points below the highest. Warner and Murt point out that age-
specific data show decreasing smoking rates among men of all ages, but a
variable pattern among women: a marked increase in women's rates from 1955
to 1964 in all age groups, unewen downward trends in the four youngest age
categories (21-5~) after 1964~ and increasinK rates in the two oldest age
groups (55-64+). The fact that women's smok{n~ rates were climb{ng rapidly
prior to 1964 in a pattern similar to that of men in earlier decades leads
these authors to argue that "the anti-smoking campaign interrupted the
diffusion of the habit among women, causing smoking participation rates to
'stall' rather abruptly, or to stabilize at levels well below those that
might have been e~pec~ed. ~ contrast, smoking rates among men appear to
have peaked prior to ~be first Surgeon General's Report. Thus, both the
decreasing rates among men and the relatively stable rates among women
represent positive impacts of the anti-smoking campa{gn" (13, pp.377-378).
To calculate the smoking rates that would have occurred in the absence of
the campaign~ Warner and Mutt used the assumption that firmly established
smokinB patterns would have continued ~nto the 19~O's: for men, an extension
of the smoking frequencies of earlier cohorts, and for wo~en~ a continuation
of the post-World War II growth trends. Smoking rates are estimated between
1964 and 19__7~__u~ing._thes~e_as~su=ptio~s---F~gu~r~--f~r-~h~ 1921-30 ~nI~41-50
male cohorts are taken from their paper, and Dr. Warner kindly supplied me.
with the data necessary to plot the parallel cohor~ figures for women and
the two youngest cohorts of smokers. Estimated prevalence rates were
calculated by Warner and Murk; age specific (actual) smoking rates by year
TI08350982
were derived by Harris from the 1978 Health Interview Survey (6,14).
Figures 1,2 and 3 depict actual and estimated smoking prevalence histories
for the 1921-30, 1941-50, and 1951-60 female cohorts. The following
conclusions can be drawn:
(I) Through 1975, the public education effort influenced a greater percent-
age of men than women to give up smoking or not begin, with the most
pronounced difference appearing in the youngest cohort. Males ~n this
group would have had an expected smoking prevalence of 61%, yet there
was only a reported smoking rate of 39% in 197B. In this same youngest
cohort of women, 37% reported smoking, the only group in which the
gender rates are approximately equal.
(2) All female cohorts show a substantial impact of the campaign, possibly
with the exception of the 1901-1910 cohort, among whom smoking was never
common. The influence on men's rates is greater.
(3) For both genders, the difference in percentage points between reported
and estimated rates in 1978 grows larger from older to younger cohorts,
suggesting a greater effect on initiation than cessation, For the
youngest cohort of women, there is a decrease in the difference from the
previous cohorts; along with the smoking prevalence data of teenage
girls this suggests somewhat less of an effect of the campaign on this
group.
(4) Estimated smoking rates among men in all but the two oldest cohorts
would have been over 60Z in 1978, yet no cohort even reached 50%. For
women, estimated rates in the four youngest cohorts would have been near
half, but actual rates never even reached 40%.
(5) The youngest male cohort could be the first born in this century for
whom more than 50% never smoked, if the downturn reported in 1978 really
represents that group's peak smoking rate.
Warner and Mutt (13) observe that the campaign generally dampened tendencies
for smoking prevalence to rise and speeded tendencies for it to fall. The
current trend in all cohorts will produce the overall smoking rate of 25% in
1990, set as a goal by the Surgeon General in 1979 (15). While over 200,000
premature smoking-related deaths were avoided between 1964 and 1978 because
of these changes, a %o%a1 of four =dl|ion deaths were attributed to smoking
in this period (]6). They conclude that the success achieved depends on
continual reinforcement of these changes with aggressive education and
publicity. In their words, "there is always the danger of complacency and
therefore the loss of progress that has been realized. And while we argue
that health professionals can derive satisfaction from the accomplishments
experienced to date, we share the frustration that so much of the public
health problem remains. The latter cries out for new and imaginative ways
to shape the antismoking campaign in the 1980s" (13, p.3BS).
TI08350983
EDUC~TION: A I~LTI-RATIONAL PERSPECTIVE
3O5
FIGURE I.
ACTUAL SHOKING PREVALENCE HISTORY (SOLID LINE) AND ESTII%~TED
PKEVALENCE FOR 1965-1978 IF; TH~ ABSEq~CE OF THE ANTI-SMOKING
CAMPAIGN (DOTTED LINE)
53"
40-
30-
20-
10-
"32 35 "40 44 "48 "52 "55 "60 64 68"?2 q'6 80
FIGURE 2.
ACTUAL SMOKING PREVALENCE HISTORY (SOLID LINE) AND ESTIMATED
PREVALENCE FOR 1965-1978 IN THE ABSENCE OF THE ANTI-SMOKING
CAMPAIGN (DOTTED LINE)
50'
30'
20"
,r \
\
I
TI08350984
306
FIGURE 3. ACTUAL SMOKING PREVALENCE HISTORY (SOLID LINE) AND ESTIMATED
PREVALENCE FOR 1965-1978 IN THE ABSENCE OF THE A~TI-SMOKIES
CAMPAIGN (DOTTED LINE)
FEMALE COHGRT
20-
10-
YEAR
CULTU~R.-SPECIFIC DKRECTIONS FOR PUBLIC EDUCATION P~RAM~
The final part of this paper is devoted to some ideas on how to direct
public education programs on smoking for women both in developed and in
developing countries, given the need to work within the important cultural
framework of each society.
In the case of the developing countries, individual consideration must be
given to women's smoking trends. Is smoking control even an issue in a
given country compared to other health problems? What place does women's
smoking have in the culture, and on what grounds might it be discouraged?
If it has reward walue, with what should one replace it? In the case of
Japan, where smoking rates among women have been very low for many years
(about 10-15%) but now threaten to take a dramatic upswing, what reinterpre-
tation of western gender equality can replace the cigarette (17,18)? In
what countries can one implement a primary prevention campaign to spare
women as a whole the dangers of tobacco-related diseases, and in what coun-
tries can we only hope to slow and then reverse an otherwise inevitable
trend? In each country or region of the world, what part c~n L he governmen~ ..........
real~st/¢ally he--eKp-~-gte-~-~--to play in smoking control; is there a tobacco
monopoly; what external economic forces are mitigating against public educa-
tion efforts (such as an aggressive western tobacco sales drive or a
tobacco-growing economy)? Aghl (19) has shed much light on how effectively
TI0~,.,50~u5
EDUCATIOH: A I~LTI-NATIOH~L PERSPECTIVE
307
a rural population can be approached in its own social context, and Hosten-
Craig has shown us the force of the opposition in a developing area
(19,20). We need to be creative together to provide effective responses in
individual situations.
For the developed countries, we have a great deal of experience to direct
our planning. In terms of pure health information, we have learned that the
general message regarding smoking has reached the teen and adult populace,
but that more personalization of risk is necessary. We also know that
smokers show a markedly lower level of conviction or knowledge than non-
smokers on many specific health questions. Teenage smokers are also woe-
fully unconvinced of the addictive properties of smoking. So we know what
kind of information needs to be dispensed (21).
What about sociocultural specificity? We have dramatic examples of
school-based programs that are working in smoking prevention because they
are dealing with the psychosocial context for taking up the behavior - peer
pressure, adult role models, and media pressure (I). These programs have
reduced smoking initiation by 50% compared to controls, and yet this
research is still only in its infancy.
We also have some excellent guesses for campaigns directed at adult women.
First, provide specific program modules for those concerns which prevent
women from quitting, such as weight gain and modulation of negative affect.
While the dependence-producing properties of nicotine do not seem to vary by
gender, withdrawal effects (e.g., craving for food, irritability) may have
different significance for women than men and may call for different
preparation (6,22). (See ref. 23 for the importance of negative affect and
suppression of opinion among subgroups of women smokers in relation to
coronary heart disease). Second, develop adult-oriented programmatic
material paralleling the teen media-influence modules, showing women how
they are being exploited by male advertising and tobacco corporate
executives who equate their femininity, modern role status, and buying power
with a cigarette in the hand. Howe has traced such a historical trend in
U.S. cigarette advertising (24). A recent article in a trade journal
commented that the rise in the proportion of women smokers in Europe, their
increased social and economic power, and longer llfespan than men make them
"...a prime target as far as any alert European marketing man is concerned.
So, despite previous hesitancy, might we now expect to see a more defined
attack on the important market segment represented by female smokers?" (25,
p.6). Third, pick out important target groups, women at high risk for
smoking-related diseases. It may be necessary to practice allocation of
scarce resources in terms of public education efforts. I suggest pregnant
women, women with carcinogen-related occupational exposures, women with
family histories of cardiovascular and respiratory diseases, women ~n set-
tings where a large proportion of their male colleagues or significant
others still smoke. What are the special needs of such groups, and what
particular information or aids in the form of tailored materials might they
benefit from? The developed countries might do well to take a lesson from__
the a~proach--u~d by~-i----- ~-ratlng motlvati~n-~nd-int~v-~ntion into
people's lifestyles using culturally relevant and popular formats, such as
art or drama (19). We can do this for ethnic and cultural minorities, and
it may apply as well to "subcultures" of certain women professionals, such
as the corporate executive or middle manager. These are new avenues to
TI08350986
~RITZ
explore. Because of the predilection of most smokers to quit on their own,
I could see developing a whole series of ~Ddules to be tacked onto a good
basic self-help cessation program. How do we involve women in ~utual social
support for quitting, and is there a need for this (6,26)?
Finally, permit me to plead for well-designed evaluations of whatever new
public education programs we devise. Effects of specific programs may be
difficult to sort out from effects of general societal trends, but with
sophisticated methodological design and statistical analyses we should be
able to measure the impact of our efforts.
AC~OWLEDCK~EI~
Th~s work was supported by the following sources: USPHS Grant CA 23974,
USPHS Grant CA 36~09 and the Research Service of the United States Veterans
Administration.
I. US Department of Health and Human Services. The health consequences of
smoking: cancer. A report of the Surgeon General. Rockville, Md.:
Department of Health and Human Services, Public Health Service, Office
on Smoking and Health, 1982. (DHHS publication no. (PHS) 82-50179.
2. Starzyk PA. Lung-cancer deaths: equality by 2000? (Letter) New Eng J
Med 1983; 308(21): 1289-1290.
3. Doll R. The smoklng-induced epidemic. Can J Public Health 1981 Nov/Dec;
72: 372-381.
Junge B, Hoffmeister H. Civilization associated diseases in Europe and
industrialized countries outside of Europe: regional differences and
trends in mortality. Prev Med 1982; II: 117-130.
US Department of Health and Human Services. National Realth Interview
Survey. In: Smoking and Health Bulletin, Department of Health and Human
Services, Public Health Service, Office on Smoking and Health, 1981
Sept-Oct.
6. US Department of Health and Human Services. The health consequences of
smoking for women. A report of the Surgeon General. Rockville, Md.:
Department of Health and Human Services, Public Health Service, Office
on Smoking and Health, 1980.
7. National Institute of Education. Teenage smoking, i~ediate and long-
term patterns. Rockville, Md.: Department of Health, Education, and
Welfare, National Institute of Education, 1979.
8. Gritz ER. Women and smoking. Paper presented at the 13th International
Cancer Congress (UICC), Seattle, Washing[on, September 15, 1982.
T103350987
EDUCATIOH: A kELTI-HATIONAL PERSPECTIVE
309
9. Pellegrino ED. Health promotion as public policy: the need for =oral
grounding. Prey Mad 1981| I0: 371-378.
I0. Stachnik TJ. Priorities for psychology in medical education and health
care delivery. Am Psychol 1980; 35(I): 8-15.
ii. Syme SL, Alcalay R. Control of cigarette smoking from a social
perspective. Annu Rev Public ~ealth 1982; 3: 179-199.
12. James WG. Health education for adults. Prey Mad 1980; 9: 281-286.
13.
Warner KE, Mutt HA. Impact of the anti-smoking campaign on smoking
prevalence: a cohort analysis. J Public Health Policy 1982; 3(4):
374-390.
Harris JE. Cigarette smoking among successive birth cohorts of men and
women in the United States, 1900-1980. J Nat Cancer Instit 1983;
71(3): 473-479.
15.
US Department of Health, Education and Welfare. Preventing disease/
promoting health: objectives for the Nation. Washington, D.C.: Depart-
ment of Health, Education, and Welfare, 1979.
16. Warner KE, Mutt HA. Premature deaths avoided by the anti-smoking
campaign. Am J Public Health 1983; 73(6): 672-677.
17. Smoking in Japan. Canadian Tobacco Grower. 1981 April: 75-77.
18. Hirayama T. Smoking and chewing in the developing world: the epidem-
iological approach. Paper presented at the 13th International Cancer
Congress (UICC), Seattle, Washington, September 15, 1982.
19. Aghi MB. Intervention in the tobacco habits of rural Indian women.
Paper presented at the Fifth World Conference on Smoking and Health,
Winnipeg, Canada, July 10-15, 1983.
20. Hosten-Cra£g J. Tobacco use among Caribbean women. Paper presented at
the Fifth World Conference on Smoking and Health, W~nnipeg, July 10-15,
1983.
21. Federal Trade Co-~ission. Start Report on the Cigarette Advertising
Investigation. Washington, D.C., 1981.
22.
Shiffman SM. The tobacco withdrawal syndrome. In: Krasnegor HA, ed.
Cigarette smoking as a dependence process. NIDA Research Monograph 23.
US Department of Health, Education and Welfare, Public Health Service,
Alcohol, Drug Abuse, and Mental Health Administration, National
Institute on Drug Abuse, 1979: 158-184.
Haynes SG, Feinlelb M. Women, work and coronary heart disease:
prospective findings from the Framingham Heart Study. Am J Public
Health 1980; 70(2): 133-141.
TI08350938
310 ¢RITZ
24,
Howe ~L. Advertising and women's changing s~oking habits: a historical
perspective. In: Forbes WF~ Frecker RC~ Nostbakken D, eds. Proceedings
of the Fifth World Conference on Smoking and Health, Winnipeg, Canada,
1983. Ottawa: Canadian Council on Smoking and Health~ 1985.
25, Targetting Nomen. Tobacco Reporter. 1982 February: 6.
26. Wright FE, Drake E, Poole S. Wo~en, a~oking cessatlon~ and cessation
maintenance. Canadian Council on Smoking and Health, Ontario, 1980.
TI0 ~o50...,~9
311
THE N&SS )~DIA LN HEALTtl EDUCATION
The Need for Audience Involvement
G.B. Hastings, B.Sc.
Research Fellow
D.S. Leathar, M.A., Ph.D.
Director
Advertising Research Unit
Department of Marketing
University of Strathclyde
Stenhouse Building
173 Cathedral Street
Glasgow G4 0RQ, Scotland
In recent years health education has made considerable use of the mass
media. However, spiralling costs and an apparent lack of effectiveness in
some cases have given rise to uncertainty and some disillusionment with the
media. As a result, there has been a tendency towards a polarisation of
thinking, with 'pro' and 'anti' media lobbies forming. This has encouraged
a view of the media and other health education activities as alternatives or
even rivals. A more constructive view, however, is to see the mass media as
one of many approaches that can be adopted in health education, each of
which has a function to perform. These can operate in an integrated way, in
conjunction with one another rather than as alternatives.
This viewpoint accords with thinking in the commercial world, where the use
of the mass media in the form of advertising is seen as only one of several
elements that can contribute to the whole umrketlng effort or 'mix'. From
this perspective, the mass media should at least be given consideration in
any health education campaign. Its strengths and weaknesses should be
analysed dispassionately with a view to determining whether it can make a
suitable contribution to the overall effort.
The most obvious and fundamental strength of the mass media is that it
provides, at least potentially, the opportunity of communicating with a
large audience. Counterbalancing this are two major weaknesses. The first
is the unidirectional flow of mass communications. Communication is being
seen increasingly as an exchange process involving audience feedback rather
than a simple one-way transference of information. Media such as television
obviously do not provide any potential for this two-way process. As a
result, there is considerable risk of miscommunication and miscomprehension
of mass communicated messages.
The second major weakness of the m~ss media is that messages transmitted
through them often lack individual or personal relevance. Because they are
T108350o~£0
~P~P~A~ O~E~I~S
The appropriateness of objectives will obviously be influenced by the nature
of the indlvidual campaign, but nonetheless it is possible to draw some
general conclusions by looking more closely at the nature of advertising.
Many models have been posited as to how advertising works. The most popular
of. these are subsumed under the title 'hierarchy of effects' models (1). As
the name suggests these assume the existence of a series of sequential and
related steps in the operation of advertising, starting with awareness,
leading to learning, attitude change and eventually to the desired action.
The number and precise nature of the steps vary between models but the basic
assumption remains the same.
Many criticisms of this genre of model have been made (2), and the hierarchy
of effects remains empirically unproven. However, most of the criticisms
concern the relationship between the stages and their direction of flow,
rather than the stages themselves. A closer examination of these stages
reveals at least four levels at which advertising might operate:
Awarene s s :
making people aware of, for example,
the product;
Communication:
the transmission of factual messages
about the product;
Empathy:
the transmission of emotional messages
about the product;
Persuasion/
conviction:
the generation of appropriate action.
This list is not intended to be exhaustive; it could, for example, be great-
ly extended by using a more complex model. However, even in this perhaps
over-simpllfied form, it demonstrates two points. First, that a variety of
possible objectives exist for advertising, and second, that advertising may
be better suited to fulfilling some of these objectives than others. It
may, for example, have more potential at the first three levels mentioned
above (equivalent to the agenda setting role sometimes attributed to the
_ma§s media by health_e~cg~_~onis_t~sO~Se--less--su-~t~d--to persuasion, ~h~ch - --
may require a more individual input.
These points about advertising in general also apply to the use of the mass
media in health education. Thus, in deciding whether it can contribute to a
particular campaign all these potential objectives should be considered.
Furthermore, if the mass m.edia is to be used, care should be taken to select
those health education objectives that best suit its characteristics.
TI08350991
~Ih~f.N'f.ZI--NG M ~EC~ OF ~..SSES
313
Two techniques can he used to help minimise the weaknesses of the mass media
- consumer research and targeting. Consumer research can help overcome some
of the problem~ that result from the lack of feedback in the mass media, by
providing what is al=~ost an artificial level of feedback. Mass media ~aterial
can be developed in conjunction with its intended audience and, as a result,
problems of communication and comprehension can be overcome.
Targeting involves the grouping of the total population according to relevant
criteria, and the subsequent selection of a 'target group' for particular
attention. The criterium may be demographic (eg, people of a certain age) or
more closely related to the subject concerned (eg, heavy smokers). In this
way targeting represents a compromise between the acceptance that each indi-
vidual is unique and hence requires a different approach, and the indis-
criminate assumption that one message will do for everyone. Consumer
research makes it possible not only to determine relevant target groups, but
also to design material that will cater specifically for their needs. There-
fore, targeting and consumer research can, between them, offer a means of
increasing the personal relevance of mass media material.
This process of increasing the personal relevance of material will now be
looked at in greater detail.
At a fundamental level, personal relevance must be present in the core
message. This implies that the message contained in the material
should match the perceptions of the target group. For example, research done
by the ARU1 among working class groups has revealed a tendency for their
lives to be much more influenced by short-term than long-term considerations
(3). For these groups, therefore, messages about the long-term ill effects
of smoking are less powerful than might be expected and messages about the
short-term drawbacks are more readily accepted.
In using the mass media, this acceptance of the message is of vital impor-
tance, and therefore considerable attention needs to be paid to getting the
message right. In this sense 'right' means a clearly communicated and
comprehensible message that is relevant to campaign objectives and has a
degree of personal relevance.
However, with the mass media the acceptance of any message is generally
dependent on at least two preliminary steps: getting the audience's atten-
tion, and then generating and maintaining their involvement with the
material. Without these, the message is unlikely to be communicated, and
therefore no matter how relevant and clear, will not gain acceptance.
Attention and involvement can be influenced by the content of the message.
However, they can be generated more d~rectly by manipulating the style in
I The ARU (Advertising Research UniL) is based in the Marketing Department of
Strathclyde University and is sponsored by the Scottish Health Education
Group (SHEG), the government body responsible for health education in
Scotland.
TI03350992
314
~TII~S AND LEATtIAR
which the message is presented. The style can be used to increase impact
and hence gain the audience's attention. It can also be used to make the
material raore interesting and thereby encourage audience involve=ent. Both
these aspects will be enhanced if the style matches the preferences and
perceptions of the target audience. In other words, as with the core
message of the material, the optimum style, at least in terms of impact and
involvement,is the one with greatest personal relevance for the audience.
The manipulation of style in this way can, however, cause problems. It can
interfere with the most basic requirement of mass media material - the clear
communication of a comprehensible message. These aspects of style, both
positive and negative, are illustrated by SHEG's recent experiences in the
field of antl-smoklng.
CASE H~STORY
Introduction
During 1982, the SHEG considered developing a health education film, or
films, suitable for adolescents. Neither the exact format of the finished
film(s) nor the channels through which it would be promoted were finalised.
However, initial scripts were produced for about 20-30 minutes of film.
The material was developed in conjunction with a highly popular group of
British comediaqs, members of the 'Monty Python' and 'Not The Nine O'Clock
News' teams. They are well known for their satirical and zany style of
humour and were particularly popular among young people. It was thus felt
that health education material based on their style of humour would have
increased relevance for this group.
The ARU was asked to assess response to the material among the target
audience. For the purpose of this research, four sections of the scripts
were made into animatic films, which, although thematically related, also
made sense individually and could be shown in isolation. Three of these
'sketches' were concerned with antl-smoklng.
Method
The research took the form of qualitative group discussions with members of
the target audience. This technique [which is discussed in more detail
elsewhere (4)] was chosen because it gave respondents the freedom to esta-
blish their own priorities for discussion, using their own language. As a
result, there was full opportunity to explore spontaneous response to the
material as well as to analyse specific issues.
The interviewing of respondents in groups had two advantages. First, it
provided an efficient means of inte~ier~i~g__a__numbes--~f r~-~pendent~--in .....
depth. Second, the group setting mmde it possible for respondents not only
to express their o,~ thoughts, but also to react to each other's ideas.
A total of 56 target group members were selected for interview by means of a
quota sample, which applied demographic controls to ensure the inclusion of
both sexes, a range of ages (from 10 to 18 years), and socio-economic groups
in the research.
TI0,~.~50~9o
THE HASS I~_~DIA IN HEALI~I ED~JCATION
315
Findings
The research revealed that overall response to the material depended on the
sophistication of the respondent and this in turn related, at least approxi-
mately, to their age. The findings can therefore be divided into two
sections according to age.
1. The Younger Respondents (up to 14 years old)
Among this group, immediate reaction to the material was usually of one of
two kinds: amusement or confusion.
Amusement resulted from both the cast and the content of the film. The cast
were amusing because respondents recognised them as some of their favourite
comedians, whom they had often enjoyed watching on television. However,
this does not mean that they understood the satirical components in their
humour - on the contrary its appeal seemed to stem mainly from its zany
quality. This is reflected in respondents' enjoyment of the content of the
test material, which related to less sophisticated aspects such as the
silliness of certain expressions and events rather than the satire. This
often led to their accepting the material at face value, and missing any
serious message.
The confusion caused by the material was most in evidence among the minority
of respondents who were not followers of the comedians. For these
respondents, the b~zarre happenings were not seen as silly things being done
or said for comic effect by people who would be expected to behave in such a
manner, but simply as senseless. The resulting uncertainty did provide the
necessary stimulation to try and make sense of the films, but, as with the
other young respondents, they usually lacked the sophistication to manage
this successfully.
Thus among all the younger respondents, attempts to extract a serious
message from the material, either as a means o~ resolving uncertainty or as
a result of prompting, were usually unsuccessful. Their attempts could lead
to their extracting a message on the wrong subject, or the wrong message on
the right subject, but most typically they just remained uncertain.
When the true nature of the message was explained to them, the response was
generally unfavourable. Because they did not appreciate the more sophisti-
cated elements of humour in the material, they could not understand why the
messages were being promoted in what they saw as excessively indirect ways.
They would have been much happier if the anti-smoking messages had been
spelt out simply and directly.
2. The Older Respondents (16 to 18 years old)
The response to the test material was more positive and confident among this
group. They usually recognised not only the actors ~q!t_ra~e~ in_~h_e__fil~__ .....
but ~lso thei~ ~ty~e-o~---humour. As mentioned above, this style had two
important elements: it was amusingly bizarre and it usually included a
degree of satire. This latter aspect led them to expect and look for a
serious component within the humour, and, because of their greater maturity
when compared with the younger respondents, they were usually successful in
extracting the r~essage.
TI03350994
316
EAST~I~S ~ ~
For this group then, the ~aterial seemed to have greater potential (although
there were still problems with it, as will he discussed below). Furthermore,
the style of the ~aterial, with its satirical humour, did seem to invest it
with a number of strengths, especially when compared with =ore tradlt~onal
anti-smoking material. It gave the films impact ~n that it provided a ~tark
contrast with what respondents felt was the usual depressing anti-smoking
material. It ~ade the films interesting, stimulating and enjoyable to
watch, in that the indirect approach adopted required some mental effort on
the part of the audience. Most important of all, however, two aspects of
the films' style were felt by the respondents to be particularly relevant to
their age group. First, both the actors and humour had strong associations
with the younger generation. Second, the films were non-directive - they
did not order the audience how to behave. Therefore, the style of the films
was successfully used to produce material that had impacts interest ands
above alls personal relevance.
Despite these strengths, howevers there was evidence that the material would
need to be used with caution beeause~ even with this age group~ there were
problems in understanding some of the specific content. Most of these
problems were attributable to the style. The fact that this made the film
enjoyable to watch increased the risk of their being seen as purely enter-
tainment~ and the need for mental effort to understand the message could
lead to misinterpretation~ especially if that mental effort were not forth-
coming. Furthermore, the humour could be appreciated but misinterpreted, in
that it could be seen as making fun of anti-smoking rather than smoking
publicity. Finallys the possibility of putting more than one interpretation
on the serious health education message in at least one of the films (for
example, seeing it as about drug addiction in general rather than smoking
addiction in particular) led to some confusion. This problem was confirmed
by respondents expressing reservations about their own ability to understand
the correct ~essage, particularly when viewing the films in less controlled
circumstances than existed during the interviews.
For the older respondents, therefore, the unusual style of the material had
a beneficial effect in terms of impact, interest and relevance. At the same
time, however, it caused some problems in terms of communication and compre-
hension. Respondents felt that these could be overcome by using the
material in 'controlled circumstances', where the serious message could be
given suitable prominence and clarity. This control might be achieved on
television by careful introduction ~nd detailed discussions but most
respondents felt that more control than this was required and suggested
using the material in a more personal setting, such as in schools.
Paradoxically therefore, success in minimising one of the major weaknesses
of the mass media - lack of personal relevance - seemed to undermine its
great strength - the facility to reach a mass audience.
COHCLUSION
This paper has argued that the mass media should be seen by health educa-
tionists as operating in conjunction with, rather than as an alternative tos
other health education activities. In this context the mass media's
strengths and weaknesses should be recognised in order to ensure firstly,
that appropriate objectives have been set for it, and secondly, that steps
T108,350995
THE MASS I~DI_A IH HEALTH
317
are taken to maximise ~ts potential. This latter process depends on the use
of consumer research and targeting.
More specifically, the paper examined one attempt to use these two tech-
niques of consumer research and targeting to develop an innovative style
which would overcome one of the potential weaknesses of the mass media: lack
of relevance to the ~ndividual. This at=empt met w~th some success but it
also proved problematic as the novel style undermined basic communication
objectives.
I. Colley RH. Defining advertising goals for measured advertising
results. New York: Association of National Advertisers, 1961.
2. Palda K. The hypothesis of a hierarchy of effects: a partial evalua-
tion. J Marketing Research 1966 February; III(i): 12-3A.
3. Leathar DS, Davies JK. The role of images in health communication. .In:
Baker MJ, Saren MA, eds. Marketing into the eighties. Proceedings of
joint MEG/EAARM semimar, Edinburgh, 1980 March: 410-417.
Blinkhorn AS, ~astings GB, Leathar DS. Attitudes towards dental care
among young people: implications for dental health education. Br Dental
J 1983 November, 311-314.
TI083509,96
319
Holly L. Howe, Ph,D.
Bureau of Cancer Epldemiology
New York State Department of Health
Albany, New York 12237
U.S.A.
Decreasing cigarette sales and decreasing rates of per capita cigarette con-
sumption could lead one to believe that the smoking problem is declining in
the United States. These general statistics, however, are not sensitive to
the smoking behavior of smaller subgroups of the population. Similar
statistics for teenage women show that more younger women are smoking at
earlier ages and at higher rates than ever before.
Female lung cancer mortality is increasing at a steady rate as shown in
Figure I. Soon it will equal the mortality of female breast cancer. These
data were drawn from the New York State Cancer Registry.
FIGURE I. DEATHS FROM BREAST AND LUNG CANCER AMONG WOMEN
(Adjusted according to age to 1970 United States census)
BREAST
1970 1175
~1 OF DE~TH
1,114
TI08350997
320
ROWE
Young women smokers will accumulate a longer and heavier smaklng history
than any other female age cohort. In fact~ wo~en'~ smoking behavior is
becoming similar to men's. Thus we can ezpect that in 20 to 30 years~ these
young women w[~l bare a lung cancer mortality rate that will approximate the
lung cancer mortality rate among men, as shown in Figure 2, also using New
York State data. lu addition, the May 26, 1983 issue of the New England
Journal of Medicine had an article which stated that Washington State shows
equal rates occurring even sooner than the New York State data. The article
went on to say that many other states are showing the same trend of
converging data.
FIGURE 2. DEATHS FROM LUNG CANCER AMONG MEN AND WOMEN
(Adjusted according to age to 1970 United States census)
$
=2 2~0S
YF.AR OF OEATH
• THE DATA FOR NEW YORK STATE. E-'XCLL~tNG NEW YORK CtTY. FOR THE PERIOD 1960 TO 1977,
• THE DASHED LINES SHOW PROJECTED TRENDS
The challenge this presents is overwhelming. It is not easy to answer why
anti-smoking efforts and health education have been, apparently, less
effective among this young age group of women than any other age group of
women or among any age group of men. Perhaps the most difficult task facing
us is how to help reverse this trend.
This paper su==narizes historical events in the United States that have had
an impact on women's smoking behavior. A focus was taken on cigarette
advertising targetted toward women, because of the implications any such
association ~ay have on the continued recruitment of non-smokers to the
smoking habit.
TI0835099g
It was of interest to look at the extent to which women were used in ciga-
rette advertisements during the period 1935-1979. To obtain these data,
magazines were selected that were closest to regular production from 1935 to
1979, that accepted cigarette advertisements throughout the entire time_
period, and also that appealed to both men and women in the general
population.
The magazine that came closest to continuous publication from 1935 to 1979
was LIFE magazine. LIFE began publication in November 1937 and ran as a
weekly periodical until December 1972. It resumed publication as a monthly
periodical in October 1978 and since then it has appeared continuously.
The data were collected by taking a random sample of months and reviewing
every issue occurring during that month. This included counting the total
number of cigarette advertisements which showed women smoking. The monthly
frequencies were m~itiplied 5y 4.3 to make them comparable to the frequen-
cies obtained when it was a weekly periodical.
To remove some of the random variations in yearly frequencies, three-year
moving averages were calculated and graphed for analysis and for interpreta-
tion of potential relationships between advertising and smoking prevalence.
The two measurements most often used to describe smoking behavior are per
capita cigarette consumption and the level of cigarette sales. The sales
figures are not available by sex, and neither measurement reflects the
proportion of people smoking.
Data on a third possible measure, the prevalence of female smokers, are
limited. Independent national surveys were conducted infrequently prior to
1975. Since 1975, independent national surveys have occurred almost yearly
(1976, 1978, 1979). These surveys were too sporadic to undertake a meaning-
ful historical analysis of smoking behavior.
Since 1924, however, a yearly survey of the prevalence of cigarette smokers
has been conducted in the Greater Milwaukee Area. For the first ten years,
only data for males were collected-and then female smoking data were added
in 1935. These data were used for analyzing the relationships between ciga-
rette advertising changes and the prevalence of women smokers.
Prevalence figures for both men and women for the period, 1935-1979, are
shown in Figure 3 from bomb ~he Greater Milwaukee area and from the less
frequently occurring national surveys. The absolute prevalence levels in
the Greater Milwaukee data are different from what would have been found in
the general population. However, one would probably expect higher rates in
urban areas. When compared to the combined data from the national surveys,
the relative changes in prcvalcnce are =imi!~r unt;] ~he year 1965. Since
1965, all the surveys show decreasing prevalence but the rate of change is
greater in the Milwaukee data than in the national data.
TI08350999
322 BO~,
FIGURE 3. PERCENTAGE OF ADULT CURP.KNT CIGAI~ETTE SMOKERS IN 1"rlE
GREATER MILWAUKEE AREA AND IN THE GENERAL POPULATION,
1935-1979, BY SEX.
1 Milwaukee Journal. Consu=er Analysis of ~he Greater Milwaukee
Market, 1924-1979. See also, Surgeon General's Report 1980, The
~ealth Consequences of Smoking for Women.
2 Source: Surgeon General's Report 1980. The Bealth Consequences
Smoking for Women.
3 New York Ti~e.s, May 6, 1981.
A review of the history behind smoking and advertising shows that cigarettes
became a popular smoke for men during WWIo Prior to this time, male smokers
preferred pipes and cigars. Society held a strong belief that women should
not smoke. Moralists, largely made up of women, paraded against the evils
beliefs, in 1901, twelve grates ~ade it i11egal to sell or use cigarettes.
Cigarette advertising experienced tremendous growth during the early
1920's. Women were still noticeably missing from these advertisements. The
tobacco industry feared a backlash against wo=en portrayed as s~okers and
that this ~ould generally hurt their sales more than the direct appeal to
w~:en would help ~hem.
TI0 -,8,351000
323
Tobacco co=panles~ however, began testing the public's reaction to wa:en in
cigarette advertisements by the late 1920's. In a 1926 Chesterfield adver-
tisement, a non-smoking woman implored her male companion to 'blow some my
way". The question, does he or doesn't he, seems to linger in your memory.
In a 1927 Marlboro advertisement, a woman's hand was shown holding a
cigarette, but not her entire body.
In the same year, Camel put women into their advertisements, but did not
show them smoking until 1933.
The public responded favorably to these promotions and the tobacco industry
expanded their target audience permanently to include women. One of the
most successful advertising campaigns was launched in 1929 with the slogan,
"Reach for a Lucky instead of a Sweet." It was later changed to "Reach for
a ~ucky Instead" with connotations of sllm figures being a result. This
campaign, targetted primarily at women, catapula~ed Lucky Strikes into the
number one spot in cigarette sales.
This historical perspective continues with the data on the frequency of
cigarette advertisements showing women smoking in LIFE magazine. (Figure
4). In 1935 and 1936~ there were no advertisements. Thereafter the data
show (I) Two early periods of increasing frequencies: 1937 to 1942 and 1947
to 1950, (2) A slight decline during ~x~st of the 1950's, (3) A recovery
to previous levels of frequencies from 1958 to 1964, (4) A dramatic drop
during 1965-1968, (5) A sharp rise during 1968-1971, and (6) The lone
point for 1979 returns to a lower frequency.
FIGURE 4. THREE YEAR MOVING AVERAGES OF THE FREQUENCY OF CIGARETTE
~, 24
ADVERTISEMENTS WITH WOMEN SMOKING
LIFE, 1936 - 1972, 1978-1980
/
/
1~35 1~4~ 1~45 1953 1~'55 I~0 1~E5
1~'~0 1975 1960
Tl0,8351001
/
L,Zt11800'=
FIGURE 5. ~
A~EETISING ~-~D ~]~N'S S~0KING ~ITS
325
Taking the advertising data and considering them with the changing
prevalence data of women stokers from the Greater Milwaukee area, there are
several notable relationships between the change in the proportion of women
smokers and the amount o~ direct appeal by cigarette advertisers.
A causal sequence cannot be established. Twenty percent of all women had
begun s~oking before advertisers began their direct mass appeal. It is
possible, of course, that the more subtle early advertising efforts, not
measured by this research, may have contributed to this prevalence figure -
most notably the Lucky Strike slogan, "For a slender figure, reach for a
lucky instead of a sweet."
Following the initiation of direct appeal, the increase in women smokers did
grow at a faster rate. By 1940, five years later, the prevalence was about
26%, an increase of 30%. During the next ten years, the proportion climbed
too. nearly 40%, reflecting a 100% increase since 1935. The large growth in
direct appeal advertisements coincided with these years.
Figure 5 is a time line to show the effect that other events may have had
on the relationships noted. Before 1950, the trends were similar~ but after
1950, it is difficult to note any similarities between magazine
advertisements and prevalence data of women smokers. Several reasons for
this change are possible.
Back in the 1930's, for example, the health hazards of smoking were not
prominent issues and other anti-smoklng activities were of little practical
impact or import. During 1941-1945, the two data series diverge. Prevalence
continues to rise, but advertising drops off. During this WWII era, 18% of
all cigarettes were sent to servicemen overseas. One might hypothesize that
the divergence occurred because there was little need to advertise when, on
the homefront, the commodity was in short supply and overseas it was in
great demand. As many cigarettes as could be produced were being sold
easily.
The earliest discussion of the health hazards of smoking appeared in the
READER'S DIGEST in 1941. This article began a long history of anti-smoking
pieces in the DIGEST. Because many magazines found these articles threaten-
ing to advertising revenues from tobacco companies, anti-smoking literature
has been virtually non-existant in the public media.
Professional reports of these hazards began in 1949 with Hammond's report on
the association of cigarette smoking and lung cancer. The early 1950's
brought a watershed of published research on this association.
By the mid 1950's, discussion on the hazards of smoking had expanded from
the professional media into discussions among the general public. The
government began a series of regulations and restrictions on the content and
layout of cigarette advertisements. In 1955, the FTC barred stated or
implied__medical_app~oy_a_l ~r ~e~_~i_t
1959, this ruling was expanded to include any mention of reduced tar and
nicotine levels achieved by filters.
The 1950's were also a period of great penetration into the TV medium.
Since the Milwaukee data continue to show an increase in the proportion of
T108351003
women s~oking, it appears that either the scientific data did not reach much
of the public, that the data were not convincing, or that the cigarette
advertisers were very effective in counteracting the health scares, perhaps
by advertisement content or by the use of the new powerful medium,
television.
Anti-smoking sentiments continued to grow through the next decade of the
60's. The advisory committee to the US Surgeon General prepared a massive
report on smoking and health in 1964. Ibis report became the basis for the
health warnings that first appeared on cigarette packs in 1965. The report
has been hailed as the cause for a large decrease in cigarette sales and per
capita cigarette consumption. While these statistics may suggest that
smokers decreased their level of smoking, the Milwaukee data did not show
that the proportion of women smokers decreased.
One of the most dramatic effects in the mid 1960's grew from the
anti-smoking lobby, Action on Smoking and Health (ASH). They strongly
promoted the idea that =he FCC's fairness doctrine~ that of guaranteed equal
air time for opposing views, should be applied to cigarette advertisements
on television in the interest of public service. In 1968~ the FCC ruled
that the fairness doctrine did apply. From this point on, television
stations had to air free public service anti-smoking messages for an equal
amount of time as that purchased by the tobacco industry. The tobacco
companies used television as their primary source of promotion. The equal
t~me ruling thus provided a large amount of free media exposure for
anti-smoking messages. As the data indicate, the most dramatic decline in
the proportion of women smokers occurred during this period.
Lobbying efforts continued and by 1971 a total ban on television cigarette
advertising was imposed. Unfortunately, a side-effect of this ban was that
the amount of air time given to antE-smoking messages was drastically
reduced. The declining rate of women smokers since the 1971 ban has slowed
down considerably.
Throughout the 1970's, the United States government continued to i~pose
restrictions on cigarette advertising. The Surgeon General's health warn-
ing, that was previously required only on clgsrette packs, was, in 1975,
also required, in all newspaper and magazine advertisements and in 1976,
expanded to include billboard advertisements.
Several other interpretations of these data need to be considered. First,
today's women are experiencing transitions in their social roles. The
early 1940's were similar in that women were also experiencing great role
changes. During the WWII era, more women went to work outside the home than
ever before. These times of role transition and expansion into traditional-
ly male areas have occurred simultaneously with an increase in the adoption
of another traditionally musculine behavior - cigarette smoking. One
wonders if it should be surprising that the young women of today, who are
1ook~ng at themselves on an equal basis with ~hp~r~loung_~a~e~ou~te~pa~Ls~
~r~-ioo~ing-~mi-l~ly a~ cigarette s~oking.
Second, in addition to these cultural forces, some research has suggested
that women's biological tolerance to cigarette smoke is lower than men's.
It is plausible that, before the introduction of filters and low tar and
T108351994
nicotine cigarettes, cigarettes were too tox{c and too noxious for women to
become accustomed easily. These two product changes may have =ade it easier
for women to adopt the cigarette hab{t. The fact that most of the smokers
of filtered cigarettes are women, lends even =ore support to this hypo-
thesis. Similarly, these product changes, especially the recent promotional
emphasis on extremely low levels of tar and nicotine, may have facilitated
the adoption of the c{garette habit among young teenage women.
In closing~ I want to make several general comments. The United States
female population aged 16 and over g~ew from about 62 million in 1930 to
over 91 million in 1980. Therefore, stable proportions reflect an increase
in the actual numbers of smokers, and increasing proportions reflect an even
greater increase in the actual numbers of smokers.
Cigarette smoking is habit forming, thus we assume that advertising is most
important in acquiring new smokers and not so much in persuading old smokers
to continue smoking. Categories of non-smokers are targetted until a
break-even point of cost to benefit is reached. The data would support this
line of reasoning. The large untapped population of women were targetted in
the early years~ the 1940's. Once a substantial proportion were "addicted",
brand-choice persuasions could be carried on without continuing to increase
advertisement frequency. This finding may suggest that the untapped teenage
market has been a similarly large one for the tobacco industry to target.
To determine that penetration levels of women smoking in cigarette
advertisements were not unique to LIFE, another long standing publication,
EBONY, was similarly reviewed. Figure 6 shows the three-year moving
averages of the frequencies of women smoking in cigarette advertisements in
LIFE and EBONY.
One would not expect that the absolute frequencies of women smokers in
cigarette advertisements to be the same for both publications. It is
interesting to note~ however, that the trends are similar. Large increases
in women smoking appear in both magazines in the late 1940's; in the early
1950's frequencies stabilized somewhat, the late 1950's to 1964 saw another
increase, 1964 to 1968 were years of large declines, and 1968 to 1971 was a
final period of great increases. Another period of note is the dramatic
decrease from 1972 to 1978 in the EBONY data. These data may suggest
another example of increasing recruitment by the tobacco industry of a large
relatively untouched market, black females, during 1960 to ]971.
Finally, the advertising industry as a whole is masterful in the art of
product promotion. Cigarette advertisements generally take one of three
promotional strategies. First, for the health-conscious consumer, low tar
and nicotine cigarettes. If tar and nicotine have a greater noxious effect
on women, then availability and promotion of these cigarettes might make it
easier for women to adopt the habit.
The second strategy emphasizes taste and flavor. Traditionally, this
strategy has been aimed at men, but recently advertisements using this
technique have moved into the female arena.
T[08351005
328
l~Ok~
~ 15
I~J
• 10
FIGURE 6.
THREE YEAR MOVING AVERAGE OF THE FREQUENCY OF
CIGARETTE ADVERTISEMENTS WITH WOMEN SMOKING
LIFE, 1956-1972, 1978-1980 and EBONY, 1945-1980.
The third tactic is building a brand image that will promote sales.
Positive and desirable attributes are associated with the people who smoke a
particular cigarette. Producing this imagery has been very successful in
promoting "female" cigarettes like Lucky Strike, Virginia Slims, and Mores.
In the 1940's and 1950's, cigarette smoking was promoted by glamorous women.
Cigarettes were used in motion pictures to convey romance and intimacy.
These images created a positive, socially acceptable association with smok-
ing. No doubt they affected sales favorably.
Similarly, in the late 1960's, Virginia Slims was introduced with a market-
ing concept that was one of the most successful. "You've come a long way
baby" was an image that appealed to many women who were moving into more
assertive, independent roles. The cigarette captured one percent of the
market in less than one year - the yardstick of a very successful promotion-
al effort. Again image played an important part.
Role models for today's women seem to be female athletes. Advertisements
show-w~me~-jog~i~a-g~--,~ki~-g~--b-a~a-cki.~, a~d-q~1~I/~g--t~rmisr-a~l-~hile--s~k,
ing a cigarette, ~oo. It would be difficult to argue that these positive
images are not influential on young, i~age-conscious people.
Adolescents want to look and feel like adults. They also want to look and
act in ways that will gain peer approval. The image of cigarette smokers as
portrayed by the tobacco companies are people in enviable life styles.
T108351006
329
Even though health professionals recognize the invalidity of the tobacco
industry's images of cigarette smokers, this imagery has not been
successfully counteracted in any effective way. Anti-smoking messages, like
the one, "I smoke for smell", prepared by DOC, an organization called
Doctors Ought to Care, have not been used to dispel the mythical attributes
given to the smoker by the tobacco industry. Nor have they been used to
create a desirable image of the non-smoker. The antl-smoking perspective
needed to educate consumers, and especially young consumers, is that
not-smoking is glamorous, desirable, mature and even an enviable attribute.
Without an energetic effort to promote the image of the non-smoker, we
cannot expect that consumers will have been w~ll-enough educated to make an
informed choice about smoking.
BIBLIOCRAPHY
Alpert H. Smoking no longer sexy in films, TV. Cancer News 1981; 35:4.
Blum A. Medicine vs Madison Ave. JAMA 1980; 243: 739-740.
Bonnet L. Why cigarette makers don't advertise to women. Advertising and
Selling 1926: 21.
Christoffel T, Stein S. Using the law to protect health: the frustrating
case of smoking. Medicolegal News 1979; 7: 5-9.
Fallows J.
29-31.
The cigarette scandal.
Columbia Journalism Review 1978; 16:
Greenwald PG. Letter to the editor. New Eng J Med 1979; 301: 274.
Jacobson B. Women: smoking's new victims. New Scientist 1981: 506-508.
Marlboro makes a direct appeal. Advertising and Selling 1927; 8: 25.
Reeder LG. Sociocultural factors in the etiology of smoking behavior: an
assessment. In: Jarvlk ME, Cullen JW, Grltz ER, Vogt TM, West LJ, eds.
Research on smoking behav~=r. Rockville, M~: ~S Dept Health, Education and
Welfare, Public Hea~th Service, National Institute on Drug Abuse, 1977:
186-201. NIDA Research Monogr 17, Pub. No. 75-581.
Silverste~n B, Fold S, Kozlowski L. The availability of low-nicotine ciga-
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Behav 1980; 21: 383-388.
Smith--~C~--The--magaz~n~s--~=ok~-n~--h~-~£. Columbia Journalism Review 1978;
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Smoking alarm: women in danger. Science News 19S0 Jan 19: 37.
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330 lll~
Sobel R. They satisfy: the cigarette in A=erican life. Garden City: Anchor
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Study Group on Smoking and Health. Smoking and health. Science 1957; 125:
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Tennant RB. The American cigarette industry. New Haven: Yale University
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U.S. Dept Health, Education and Welfare. Smoking and health. Report of the
Advisory Committee of the Surgeon General of the Public Health Service~
1964. (DHEW Pub. No. 1103).
US Dept Health and Human Services. The health consequences of smoking for
women: A report of the Surgeon General. Rockville, Md.: US Dept Health and
Human Services, Public Hea1~h Service, Office on Smoking and Health, 1980.
(USDHHS Pub. No. 80-0-326-003).
Wagner S. Cigarette Country. New York: Praeger Pub, 1971.
Wakefield J. Advertising and smoking. Int J Health Educ 1970; 13: 118-122.
Weinstein H, Sow an agency builds s brand - the Virginia Slims story.
Presentation to American Association of Advertising Agencies: 1970.
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magazines. Presentation at the American Public Health Association Annual
Meeting, Detroit, MI: 1980.
TI08351008
Office o~ ~he Commissioner
U.S.A.~ashingt°n' D.C. 20580
331
To gain access to the public co~nunications media, to disseminate the truth
about smoking, and to contravene the reassuring propaganda of the cigarette
industry must be a prime goal of smoking control advocates. Yet in many
countries our colleagues have come to view the communications media as an
inhospitable battleground upon which the public health forces are ill-
equipped and outnumbered.
Indeed, if we look only at the economics of the public media in most of our
countries, we would expect never to see bold or unbiased stories about the
health hazards of smoking.
As we know, cigarette advertising has become a major source of revenue for
both broadcast and print media. The cigarette industry spends mere than two
billion dollars a year worldwide on advertising in both print and broadcast
media. Even without overt pressure by the cigarette advertisers, the
publishers' and broadcasters' instinct for self-preservation counsels self-
censorship on stories which may be d~scomforting for cigarette advertisers
to read.
There are very few countries in which public health organizations have
access to significant funds for paid antl-smoking messages. They are not a
significant source of advertising revenue.
We know also that the cigarette industry employs the services of skillful
public relations spec~allsts who not only seek to shape news coverage of the
"smoking controversy" but also work to maintain close and cordial relations
with broadcasters and publishers.
It is no wonder tha~ an American researcher has recently found that there is
a direct inverse relationship between the amount of cigarette advertising
carried in magazines and the space reserved by those magazines for stories
relating to the hazards of smoking.
Therefore, the tltle of this paper, "The Creative Uses of the Communica-
tions Media", might appear to be a cruel irony. Nevertheless, there is
great potential for skilled, imaginative and strategically planned public
health media campaign~. And success does
elegant public relations experts and advertising agencies.
TI08351009
332
PEETSCHUK
casters who are Lnte~:ested in being heard, have Iearned that the public is
deeply fascinated by almos~ all aspects of the cigarette smoking story
because their own lives and the lives of their loved ones are intertwined
with smoking and its consequences. It is a national "natural disaster".
In country after country, public health advocates, frustrated with the lack
of public or government response to the evidence of smoking hazards, have
found that they can generate widespread public outcry for action by skill-
fully carrying their story to the mass media.
Of course, cigarette companies and those economically allied with them can
afford great sums of money for advertising and propaganda and lobbying. But
over many cultures and political systems, other symbols are stronger, more
persistent, deeper and more appealing than theirs: the defense of children
from commercial exploitation; the defense of family from the premature loss
of father or mother; the relief of overburdened health care systems; the
preservation of labor productivity; the human right of the non-smoker to be
free from smoking-caused pollution.
The challenge for public health advocates is to help shape this raw material
of news about cigarette smoking into a coherent and imaginative public
information campaign. We know that no single story or series of stories in
the media will succeed in convincing government that it must act. But we
also know that a sustained and aggressive public information program can
greatly increase public awareness of the hazards of smoking; a skillful
media campaign can reinforce and complement health education programs, and
can also build a foundation o[ public support for substantial and effective
smoking control programs.
Each time a new report illuminating the hazards of smoking is published;
each time a prominent citizen, a sports or theatrical celebrity, or a great
teacher or scientist speaks out on smoking; each time a public figure is
disabled or dies from a smoking-~elated disease; each time a representative
of the tobacco industry overreaches or lies about the hazards of smoking;
each time a cigarette company sponsors a sporting or cultural event; each
time they have targeted advertising at children; each time a courageous
political leader has taken a stand in support of cigarette legislation,
public health advocates must be alert to the possibility of important
stories in the mass media that will multiply the social impact of the
action. A quiet but forceful interview of a national sports hero who
• ~er~r~--~m~ki~g hoTds--~ potenti-~l--for savlng more lives lost to smoking
than any combination of medicines.
As the UICC manual "Guidelines for Smoking Control" says, smoking control
programs must ~e both comprehensive and long term. We know that no single
story or series of stories in the media can dramatically affect public
attitudes or behavior. And we know that public information programs are
Tl08351010
USES OF COMM~HICATIONS MEDIA
333
only part of an overall smoking control program; not a substitute for, hut a
supplement to public education programs, especially in the schools. But we
also know that a sustained and aggressive public information program can
make a difference.
Within public information programs we need to relate each sto~y or press
release to our overall objectives. Let us ask, ~at are these objectives?
Why do we use communications media? Our overall objective, of course, is to
assist in reducing smoking or preventing its increase. We aim to increase
general awareness of the hazards of smoking and of the benefits of not smok-
ing, to reinforce and complement education programs and also to build a
foundation of public support for substantial and effective government smok-
ing control programs. There are other interrelated objectives, and any
given story can serve multiple purposes:
I. To increase public awareness of the dangers of smoking.
2. To inform community leaders, health authorities, govern-
ment officials and politicians of the need for smoking
control programs.
3. To reach young people, and especially to counter the
culture of tobacco use cultivated by advertising and peer
pressure.
4. To persuade the adult smoker of the benefits of giving up
smoking.
5. To analyze and criticize the activities and propaganda of
the cigarette industry.
6. To raise the consciousness of the non-smoker to his or her
rights to breathe unpolluted air.
7. To contribute to public attitudes in which not smoking is
viewed as normal social behavior.
To inform the public about critical facts concerning ciga-
rettes themselves, such as the benefits (and the risks)
of lower tar and nicotine cigarettes.
To put forth a national agenda for smoking control, legis-
lation, and regulation and to build public support for
such legislation.
i0.
To publicize success stories of individuals and population
groups ~no have successfully given up smoking and the
health benefits which they have enjoyed.
To provide encouragement and assistance to those smokers
wishing to give up smoking.
In designing r~_dia programs, it is useful to analyze four separate compo-
nents: the senders, the messages, the media channels and the target
audience.
TI08351011
334
Doctors and health authorities are the most obvious senders of ~essages but
they" =ay not be the most effective. Sports heroes and other national
celebrities, especially those who have themselves suffered or had close
friends or relatives suffer from s=oklng-caused diseases, can he enormously
effective, as cJn .school, community and church leaders. Recently, in the
United States, groups of mothers whose children have been injured in auto~o-
bile accidents and groups of high school students whose friends have been
killed or maimed in automobile accidents, have become powerful spokespersons
for legislation to control the sale of alcoholic beverages to young people.
Very often, ,~_he_m~.~t effective spokesman on a local radio show or in a
regi~a[-~wspaper will be respected local community educators or other
le~ders~ In-small communities, the most effective speakers may be public
health field ~orker~.
Just "as ~the~ spokesmen, the senders of messages, can and must be diverse, so
must the mes6~ges.themselves. Because cigarette smoking is so ubiquitous,
there is aconstant stream of studies, epldemiological or clinical, which
continue-to be solid news. These are studies not only on the proof of the
hazard~ 6~-[~.m0_~ing.but on such related issues as the significance of reduced
tar ~nd'~n~cot~ne, and evidence that giving up smoking reduces morbidity and
even mortality from smoking. Anti-smoking programs and campaigns organized
by publlc:health officials or school officials are themselves newsworthy.
The consta~t~[monlt0ring of new cigarette commercials and advertising cam-
palgn~ wil.l produce ample grounds for attacking the subversion of health in
cigarette advertising. Those attacks will also be effective in gaining
access to'themedia because they generate the kind of conflict and contro-
versy to which the media are addicted.
The medi~ ch~nels are also many and varied. Newspapers and nmgazines are
often most effective in reaching community and political leaders and
families, who are themselves standards-setters for styles and social
trends. The broadcast media, especially radio, have enormous potential for
reaching, emotionally and effectively, even the least literate and most
geographically remote people. To the extent that even modest resources are
available for paid advertising and publicity, these resources can be used in
innovative and imaginative ways to reach target audiences, especially young
people. From food shops to schools, clever, lively and artistically imagi-
native campaigns, featuring puppet shows, theater and marvelous posters, not
only generate lively interest among young people, but themselves become
newsworthy. Stories about them can augment tenfold their ~odest cost.
There are, of course, different targets for media messages. The broadcast
targets are young people who may be on the threshold of taking up smoking
and the smoker who is on the threshold of throwing his cigarettes away. But
there are intermediate targets, and reaching and convincing them may be
vital to effective smoking control programs. These are the physicians them-
selves, and specialized p~blicatlons which reach doctors are a primary
medi~n to convince them that their own habits and their own leadership in
the co-'~unity can have enormous i.mp.~c-L-u~-o,->--t~h~--~e-~t-cmc~d--~-d- fo~
~mok-i-~-cont~ol--'ia-the larger population.
When it comes to campaigns for the development of strong government anti-
s=oklng measures, we can learn from the work done in the United States by
=edla experts such as Dr. Tony Schwartz who created many of the ~ost effect-
T108351012
USES OF COM/4UNIC~ATIONS MEDIA
335
ive anti-stroking television commercials during the late 1960's. Dr.
Schwartz has become increasingly involved in targeting public information
campaigns directly at the key decision makers in society. Whether it be a
governor, a prime minister, a president, or members of a critical legisla-
tive committee, public health groups can use the very powerful sanction of
shame against decision makers who are shirking their responsibility for
their nation's health.
These objectives and techniques suggest that we must become as expert and
competent as we possibly can in the technology as well as the folkways of
the communications media. Of course we will rarely have access to the
professional media consultants, public relations experts and advertising
agencies that the cigarette companies can buy, although the more enlightened
of these professionals will be willing to share their services with us in
the public interest. Gradually we have to develop our own expertise in the
media. How the media work, how to seek out the key journalists, how to
provide them with the material they need. We must be sensitive to journal-
ists' own special requirements, such as deadlines, to make ourselves avail-
able to meet their needs, not our own.
We need to learn such basic techniques as how reporters and editors like
press releases to be written, and what basic information must be included in
them. Like skilled politicians, we need to be sensitive to the press'
desire for "photo opportunities" to accompany stories. We need to package
our stories for editors and programmers in an easy and convenient way, in
order to gain quickly the attention of those who decide what will go over
the air and what will be thrown away.
Still, we must not expect too much from the media in the short term. They
have their own needs, their own biases, their own conflicts. The stories
will not always suit us. Too often they will insist upon portraying the
medical evidence against smoking as "scientific controversy", when we will
be insisting that no serious controversy over the proof or extent of the
hazards of smoking exists any longer. They will never provide as much time,
space or clarity to the issues as we think they merit. They will give voice
to tobacco industry spokesmen as if these economically self-serving state-
ments were entitled to as much authority as those of objective scientists.
Even the most dramatic stories will not have dramatic short term effects.
The smokers will not throw away their cigarettes.
Over the long term, however, the ~edia can perform certain tasks well. They
will reinforce trends toward the cessation of smoking. They will reinforce
knowledge. They will serve to counter cultural acceptance and passivity
about smoking. They will inform people about programs and facilities avail-
able to help them combat smoking. They will keep the public alert to the
continued existence of the smoking problem. And they w~ll help lay the
foundations for public attitudes in which education programs and political
and legislative progress can occur.
TI08351013
337
Uma Ram Nath, M.A.
35 Cardozo Road
London N7 9RJ
England
One of the ironies of the multinational 20th century is that India's "pan-
wallah", sitting on his ~obile bicycle trolley or in his hole in the wall
has become Kingmaker to the great tobacco names - playing them off one
against the other, and the government into the bargain.
Because of the intense war between the tobacco companies and the brands~ he
has been able to solicit goodies in terms of advertising and promotional
materials. He can strip his shelves overnight and re-stock with another
brand. He changes allegiance and promotes the brand that gives him a better
deal under and over the counter. If his margins are cut he will slap a
few paise on the printed price and no one else, least of all the government,
is going to gain from that.
So, while the tax man works out ways of realising all the monies due to him,
the promotion of cigarettes actually picks up pace as each manufacturer
finds ways of selling more cigarettes, promoting its brands and recruiting
more unsuspecting victims.
It is because smoking is socially acceptable, because images of smoking
confer status and style, and because there is no one to dispute it, that
smoking continues to grow as a habit in India. Consumption may be low sis ~
vi._~s the West, but it is high enough already. It is not just a brand war in
India, but the industry is seeking to expand each share and since the only
real restriction is a minuscule health warning, intended for those who can
read, there is little to stDp them. But let us look at the spider's web of
Indian production and sales.
WHAT PRICE ~OBACCO?
"Tobacco growers, like cigarette butts, are throwaways" said a 72-year-old
farmer, who has been growing the leaf for over fifty years, in the state of
Andhra Pradesh, one of India's most lucrative tobacco growing areas. It is
a lucrative business, that is, for the national exchequer and the industry.
The farmers do not do so well. They have been protesting, with bloody and
sometimes fatal results, for about three years at the low price being paid
to them for their crop. One reliable estimate holds that, though land under
tobacco represents one percent of total cultivated land, it fetches raore
tha~n
million (US$300 million) in much prized foreign exchange. Figures for
TI08351014
338
~ ~
central excise receipts for 1980-81 showed that cigarettes topped the list
of 27 commodities, while the hand-rolled bidi came 17th and the cup of tea,
24th.
'~What price tobacco, cancer apart?", asks ~ newspaper headline on the tobac-
co farmers~ agitation. At least the caption writer is aware of Lhe health
consequences of using tobacco. This is not at all evident in a self-
congratulator~ piece by the managing director of Molins India in the S~a~es-
man newspaper in April 1982. Molins of India Ltd., he says, was established
over 20 yearsago when the country was still dependent on imported ~chinery
for ~ts--"f~st-growing" cigarette industry. He ~ntions with pride the
achlevemea~s of the company ~n building up a "reservoir of design and
development,.of S0p~isticated ~chines for the cigarette and other indus-
tries." ~ese, he says, "have placed ~t in an excellent pos£=ion today not
only ~o ~ake on development of newer ~chines but also to absorb sophisti-
ca=ed te~hqplog~ crans~erred from abroad."
Le~ ~ q~o.~..jus~ o~e more headline - "B~and ~ars" - "~he roadside hoardings
~el~ ~h.e .~ho~ s~o~y~ ~sking you ~o smoke A-ls Royal ~pers~ Pe~sonal
Preference and'every o~he~ kind of preference These gnd ouher ue~ brands
sz~nal ~.~.L~jor assaul~ by ~he lesse~ cigarette compau~es ou a ~rke~
dom~uat'~d:b~TC' L~d."~ (~he ~ndian associate o~ BA~). ~C has over ha~ ~he
ma~ke~ ~or~over.90.bil~ion c~a~e~es sold annually. I~s supremacy is be~u~
challenged, by o~he~, smaller produce~ such as Goldeu Tobacco, ~odfre
Phillips a~d N~oual ~obacco. ~ is s~gn~ic~ ~h~ ~11 ~hese ~e
ogned by "~a~"Iudi~u iudus~r~l conglomerates - Godfrey Phillips was
~ormerly a Philip ~orris compau~ - ~ho have obviously seeu ~he possibilities
o~ exploiting a n~scen~ c~arec~e smokers~ marke~.
Adver~is~n~ is ~heir ~eapou. Added to ~his is
and d~s~eSbut~o~ s~s~em to which ~ wil~ come back ~a~er. Buk ~ is adver-
t~s~ns, ~he care~u~ creation o~ ~mages and perceptions o[ ~mokin~ aud
smoking ~X endo~ ~he smoker w~h, ~ha~ rei~us supreme iu ~ud~a. The
are rusged and v~r~le. The gomen expensive a~d seductive. Occas~oually
they are seductively sporty. All o~ ~hem h~ve what one could naively
describe as "class". They are plan~ed ~n situations the ordinary Indian
would shrink from ~n reality, but aspires to in his dreams. Escape £s a
potent e1~nt ~i~ che Indian co~un~cat~ons formula, witness the success of
the Indian film industry.
It is adver¢.!sing ~f.a kind generally no longer allowed in the West. But in
India.there are few controls and most consumer products are sold on the
"gla~ur" a~peal.
So what is the health legislation which cigarette manufacturers have to
observe? The "Cigarettes (regulation of production, supply and distribu-
tion) Act, 1975", in essence concerns itself with the health warning that
should appear on each packet of cigarettes and on any form of advertising
T[08351015
T~E EXPERTS MW_~ET T~E ~DIA
339
including '~isible" representation made by any means of light, sound, smoke
or gas. It also determines the languages in which the warning, which at the
moment reads "Statutory warning: cigarette smoking is injurious to health"
is to be expressed. This can be printed in English and/or Indian and
foreign languages. It also states that "No warning shall be deemed to be in
accordance with the provisions of this Act if the height of each letter used
in such warning is less than three millimetres." The Act does not pertain
to the bidi, cheroot or cigar.
There are also regulations governing the placing of advertising hoardings -
these may not be placed near schools for example, or hospitals and other
public institutions. Cigarette advertising does not occur on radio or
television, but it is allowed in the cinema and in newspapers and
magazines. And there is no control whatsoever on the sponsorship of sports
events, cultural jamborees or beauty contests, to name a few standard
activities.
It is true that some developing countries do not even have this hint of
legislative control on the advertising of cigarettes. In Sri Lanka, tobacco
advertising on television has just been banished because, says one report,
the minister of information had a heart attack and was told to give up smok-
ing. In Malaysia, where regulations on the nature of advertising prohibit
the portrayal of human beings but advertising is allowed on television, the
Consumers" Society has been agitating for a total ban of advertising in the
print media and the cinema and pressing for control of tar and nicotine
content and the labelling of these on packages.
A CIGARETTE IN EVERY VILLAGE VE~SUS ~IALT~ EDUCATION
It is really by default that cigarettes are being promoted in India. It is
a cynical disregard for the health of the consumer, a trading on the lack of
knowledge and informed opinion, that allows cigarettes to be sold and
promoted. The biggest markets are in the rural area where 70% of
the population lives. The marketing and population organisation of the
cigarette manufacturers is impeccable. Some k~nd of cigarette can be found
in every village store, along with all the products of the multinational
corporation - soap, cooking oil, matches, analgesics and cough mixtures.
Promotional gimmicks and giveaways penetrate the most remote areas, wh~e
standard government food distribution networks are floundering.
Tobacco consumption is increasing in the developing countries at about 5%
per year. The increase in the incidence of disease is already becoming
evident. In India, research on smoking and health is still embryonic; yet
several small scale surveys have shown that the ~ncidence of chronic bron-
chitis amongst smokers was definitely higher and statistically more signifi-
cant than among non-smokers. Thus, says one health expert, when
tuberculosis is brought under control, the importance of chronic bronchitis
There are too many interests muffling the proper control of the advertising
of cigarettes. %~en I first looked more closely at initiatives by the
government to ban cigarette advertising two years ago, I went to see an
official in the Ministry of Health. He told me_ that ~ore funds had been
TI08351016
alloted to the state ministries of health and for making public education
films. But the ~ost significant content was that, if the government decided
to ban all advertising, the industry would retaliate by demanding similar
sanctions be imposed on the hand rolled bidi industry. This would be
politicallyunthinkable for the government, because bidl production is a
cottage industry, and as such supported by special grants and rebates from
the government. It is labour intensive and employs a large number of women.
Negotiations have. also been in hand for the health warning to be printed in
sixteen' different regional languages, rather than just English and Nindi as
the# are" at -~h~ moment. It is believed that the industry claims this would
be unmanageable logistically since cigarettes manufactured in one part of
the country:are not necessarily sold in the same area. What use is a warn-
ing prlnt~d in English when only a small section of the population is liter-
ate in certain languages? It is a patently false observance of the letter .K~
of the l~w,': Cigarettes in India, as in m~ny developing countries, are often
sold-"by the" stick" anyway, so what use is this minimal genuflection to
heal~h .legislation when most smokers do not even see the packet?
For the first time this year I saw a health education film on smoking on
Indian .tele~islon (again there are hundreds of millions who do not see
television)~ ~ It was made in Germany, and was obviously intended for western
audiences. Its portrayal of the "pleasures" of smoking and its damaging
consequences, was so far removed from the Indian context that it might as
well not have been shown at all. Such is the mismanagement and lack of
coordination and planning between various executive arms of the government.
Nowever, ~ubllc knowledge about the health effects of smoking is growing. A
newspaper advertisement for a spice mixture to be eaten with "Pan"
(pronounced "parn"~, or the betel leaf, exhorts the reader to switch to pan
because s~oking is ~njurious to health. The smoker "knows" his habit is
doing him no good. ~ut the advertising pressure is all in favour of the
cigarette and not the smoker's health. There is little public information
or education to show him the long term effects of the use of cigarettes.
S~KIN~ AND TAX - W~OSE ~ENEFIT~
It is well known ~hat legislation for the compulsory health warning is the
first and ~0st~tentative step towards a smoking control programme. Fiscal
measures are not always philanthropic. Tobacco and manufactured cigarettes
are among the ~ountry's most heavily taxed products and a valuable source of
revenue.inIndia. ~ Because of this, cigarette production remained somewhat
stagnant in the 'late seventies at about 58 billion pieces. In the budget of
1981 no new taxes-were imposed and sales rose by 6%. The next year there
was a tax on packaging, but, says an industry spokesman~ the government had
probably realised that, from a ~--angle~th~dus.~y h_~s ~eached
saturation point. So in 1983 the government decided to claw back possible
lost revenue and plug a loophole in the taxation system for tobacco. Under
a highly complex system, tax had been calculated on the ad valorem cost of
the cigarettes. Under the 1983 budget, manufacturers will pay tax on the
specific retail price which has to be printed on the cigarette packet at the
factory.
TI08351017
This has thrown the industry into disarray, as there is now little room for
=anoeuvre in the price cutting war. Someone, somewhere in the selling chain
is going to suffer a slash in profit margins. The obvious victim is the
retailer, the 500,000 bidi and cigarette "panwallahs" who sit in their
booths or on patches of pavement in the bazaar. They have already organised
themselves into an association and they hold the real selling power at
street and village level.
Cigarettes are a curious product - their use is an abuse of the human body.
The only product which can be used as a parallel is infant formula, but here
India is legislating to safeguard health and prevent potentially dangerous
use. India, among the developing countries, has taken a very progressive
stance on advertising and promotion of breast milk substitutes and included,
within that, infant foods as well. Though doubts are still being cast on
the efficacy of the restrictions on advertising, the fact is that there is
so.me public debate, and informed consumer opinion and doctors are involved
in setting the record straight. But cigarettes are a threat and an abuse o~
health, and yet there is too little public debate or comment or consumer
movement in this field.
SONE ANSWERS
There must therefore be a twofold attack on the situation. Although it is
.greatly to be desired, the government has not shown it is ready to fight the
power of the tobacco interests and ban all advertising. But it should be
possible to legislate the nature and contents of the cigarette advertisement
and prohihit depiction of people and situations which create a false glamour
for the product. If, as the industry claims, they are only seeking to
increase brand share, and not promote the idea of smoking, then a reproduc-
tion of the brand packet should suffice. One could go a step further and
restrict such advertising to point of sale only. That should reduce the
appeal and visibility of the product. Secondly, promotional activities
should come under scrutiny - schemes such as sending in tops of cigarette
packets to get a free pack of cards should be banned. Sponsorship should
also be examined. ITC, for example, has a reputation for sponsoring cultur-
al and sports events and thus perpetuating the image of a supporter of the
good things of life. But who are the Indians to protest when, less than a
fortnight ago, Martlna Navratilova was seen on telev~slon wearing a sports
shirt bearing the name of a cigarette. This happens on Indian television
too - names of cigarettes loom familiarly in broadcasts of national and
sporting events - no doubt the advertisers choose their sites with care.
The visual element is exceedingly ~mportant, given that not all the popula-
tion is literate and instant messages of this kind are very powerful.
The ubiquitousness of the cigarette must be countered with other messages
about its harmful effects. There have been only the most feeble attempts at
health education. Four years ago I saw the rough drafts for a series of
on any public hoarding. With our fast growing population, the tobacco
industry is looking fo~dard to a reservoir of advertising-indoctrinated
youngsters. Experts in education are trying to formulate syllabuses that
will teach children about population and nutrition. It is ti~e now to take
one of the West's useful habits and find a Superman versus Nick O'Teen
TI08351018
RAM ~
equivalent which has been so successful in mobil~slng youngsters against
their parent's ~=oking habit.
Of course one would llke to see stater-ents of tar, nicotine and carbon mono-
xide levels on cigarette packets. The industry itself has become aware of
the threat to their business - ITC has tried to corner a new slice of the
market, as one magazine put it, ~'the health conscious smoker with W£11s
Lights~ India's first mild cigarette". That is the new twist in the origin-
al marketing ploy of shifting high-tar cigarettes from uncooperative North
to ill informed South. But the possibillty for such legislation seems light
years ~w~y..- wha~ we have to do is to prevent ~re people ~ro~ smoking and
more pe~p.~ ~fr@~ s~k~ng more.
This should be. supported by wigorous p~blic health education progra~es of
~ich s~klng Ca~ be one component. After all it was posslble, with the
help o~ the Wo~Id Health Organization and the cooperation of the Indian
people, to exterminate the dreaded sm~llpox. The anti-smallpox poster~
offer~ng'~.'rewardfor ~ny report of suspected cases, was we~ effective.
The i~ge ~kers ~st ~ ~b£1ised to do the same for smoking.
The budget for health is severely strained - how do we assign priorities?
Surely san~tatlonland supply of clean drinking water, immunization, maternal
and child health schemes rank above smoking control? The only answer is to
make health professionals and workers aware that smoking is fast becoming s
cause of visible disease and that the hideous costs and consequences of the
futu~e.smoking'epidemlc can be avoided by doing something about it now.
Information is the key and as Halfdan Mahler, Director Oeneral of the World
Health O~gan£zation has said, health education information must be carried
out £earlessly. Nowhere is that more true than on the issue of smoking,
with so many vested financial and government interests at stake around the
world.
T[0835101c~
PUBLIC EDUCATION PROGRAI4S
Lars M. Ramstrbm, Ph.D.
Director General of NTS, National Smoking and Health Association
and
Head and Principal Investigator of the WHO Collaborating Centre for
Reference on Smoking and Health
Wenner-Gren Center, 22nd Floor
S-I13 46 Stockholm, Sweden
~43
Smoking and health problems come from the fact that a large number of people
use a product that impairs their health, namely tobacco. This use involves
many aspects ranging from pharmacological dependence to personal beliefs and
social norms. Among the possible means of intervening in the use of tobacco
we might find, for example, medical treatment for smoking cessation and
certain legislative action. However, there is probably no other kind of
intervention that could influence so many aspects of tobacco use as educa-
tional activities. This paper will therefore try to delineate some general
principles for public education seen as part of a comprehensive smoking
control program.
Educational action can be described as a process containing a number of
basic elements. The process begins by identifying tasks and establishing
pertinent baseline data. Then it is necessary to define the operational
objectives, and methodology for the evaluation that has to be done in a
later s~age. Next comes determining the program design, and then implemen-
tation, which should include both intervention and evaluation. This is
followed by program revision and so the activities go on in a continuous
manner. The whole process can be represented in principle by the "educa-
tional spiral" shown in Figure I.
FIGURE I. THE EDUCATIONAL SPIRAL (Adapted from Guilbert)
Identification of TASKS and
establishment of BASELINE DATA
I Methodology for EVALUATION
Program REVISION I Program DESIGN
Program I MPLEMENTATI,ON
(intervention and evaluation
020
Each of the five elements in the educational spiral w{ll now be examined
=ore closely. .
IDENT~¥1~ATION OF TASKS
First o£"all we have to identify and to observe the nature of the tasks. In
the case of smoking control, the tasks would be to influence knowledge,
attitudes.and behaviour of people i~ such a way as to achieve a reduction of
smok!~g%related-[ms~tallty, morbidity and loss of production. Consequently
we need ~o'~tbblish baseline data regarding all these factors. In prac-
tlce,;~thi~a~ "that the educator has to review the results of biomedical,
epidem~ol0g~cal and other studies as well as smoking surveys. Or, if good
enough--studies have not been carried out in thaC country, he or she would
have ~o.ini~ia~e chose kind of activities.
It is. generally agreed that smoking control programs in general are meant to
attain..~hese~four major objectives:
I. Recognition of the need to combat smoking-related d~seases.
Preve6£{b6 of the onset of smoking.
3. Lowerlngof existing smoking rates.
4. Creation of a social cl~mate where non-smoking would be the norm.
~nless decision-makers have recognized the need to combat smoking-related
diseases, "the~e wil] probably be very little action and, ~f the public at
large does not recognize this need, there will be very limited acceptance of
the program, making the implementation difficult. Obviously, the long-term
solution of the smoking problem would consist in 100% prevention of
the onset of smoking in young people, and this is therefore a very important
objective. However, we must accept as a fact that smoking-related diseases
would, in most countries, continue to rise for a number of decades, unless
there is a lowering of existing smoking rates. In addition, a lowering of
existing smoking rates would reduce the incentives for young people to take
up the smoking habit. None of these objectives could be attained easily i£
the prevailing social climate were too favourable towards smoking. There-
fore, a separate objective would be the creation of a social climate where
non-smoking would be the norm. In such a society, there would be less risk
of renewed smoking habits, after having been reduced in an initial period of
smoking control action.
Each of the above four major objectives could, to a great extent, be attain-
ed by educational action. More specific educational objectives can be
derived from a b~eakdown of these broad, ma~r objec~i~es.~_Two-impor~ant
area-~l-l--no~be-~:x~di-ed--~n more detail.
Prevention of the onset of saoking
Educational objectives in this area naturally relate to factors that
influence young people with regard to smoking. Some of these factors are
indicated in Figure 2.
T108351021
PUBLIC EDIICATION PRD~P~S
FIGURE 2. FACTORS INFLUENCING THE ONSET OF SMOKING
EXILES OF FACTORS THAT INFLUENCE YOUNG PEOPLE
PRO- SMOKING :
PRO-NON-SMOKING :
PEER PRESSURE~ I'PEER PRESSURE
(from smoking | I ( from non-smoking
peers) ! Ipeers)
ATTRACTIVE IMAGEi IATTRACTIVE IMAGE
345
The face in the middle is meant to symbolize any young person. He or she
will be under the influence of pro-smoking factors, as illustrated in the
left column, as well as by pro-non-smoking factors, as listed on the right
side. Peer pressure is a very strong influence which could be either pro-
smoking or pro-non-smoking, depending upon what peers the individual has.
Among pro-smoking influences, there might be age status, which is often
attributed to smoking, and some common false beliefs, as, for example,
that virtually everybody smokes, which is not the case in most countries.
Or, the young person might falsely believe that quite safe cigarettes are
just around the corner, so why not smoke? Many young people also perceive
an attractive i~age of smokers, which is heavily supported by traditional
tobacco advertising. On the other hand, there might be forces to suggest an
attractive image of non-smokers. This would serve as a pro-non-smoking
influence in addition to the awareness that non-smoking is related to better
fitness and better health.
With this p~cture as a background, some more operational objectives can be
stated, for example:
Weakening of pro-smoking influences.
Strengthening of pro-non-smoking influences.
Bt-rengthen~ng
pro-smoking influences.
The first of these objectives primarily require teaching that improves
knowledge and changes attitudes. The third objective requires the teaching
of skills, such as how to cope with pro-smoking peer pressure.
TI08351022
346
RA~STR~M
The adoption of this kind of objective makes it necessary that the method-
ology for evaluation meets some specific requirements. These objectives do
not, as is often the case, deal with some change of personal behaviour.
Rather they de'elwith the preservation of (non-smoklng) behaviour but the
change of attitudes, beliefs and perceptions. The evaluation methodology
must, therefore", be laid down so as to include measurements of such
variables. ..
Lowering of existing s~oking rates
To break thi=..objective down into smaller, more specific parts, we have to
look at the--p~ro~ess of stopping smoking, which is illustrated schematically
in Figure 3;:.-"
".~ FIGURE 3. ~E PROCESS OF STOPPING SMOKING
WANT 1 sToPPING BUT I TO TRY TO AVOID OFF
RELAPSES
SMOKING
At first sight, stopping smoking might appear to be as easy as indicated in
Figure 3 above the horizontal arrow, which serves as a time axis; somebody
smokes, he gets off and so he does not smoke. The process is, however, a
good deal more complicated, as is indicated below the time axis of this
figure. In many eases, the smoker initially does not want to stop. There-
fore, the first intermediate objective in smoking cessation would be
Motivation. This requires educational action to improve the smoker's
knowledge about the reasons to stop smoking. This might make him contemplate
stopping, but he may still not try to stop, for example because of certain
false beliefs about the difficulties of stopping. Consequently, a second
intermediate objective in smoking cessation would be Encouragement, which
helps the smoker decide to try to stop. Finally, he or she stops smoking.
But in most cases, he or she must struggle to avoid relapses, and this
constitutes a third educational objective, Support, so as to win this
struggle, and stay off smoking. In these last phases there is, of course,
a case for medical and]or psychological treatment as well, but it is very
important to remember that first of all there are these three educational
ob j.ec~A:~e~
It is striking that very much of what has been done traditionally in most
countries, has been a rather one-sided concentration on motivation, which
has made education deal with little else than smoklng-related diseases and
related matters. The next objective, encouragement, requires certain less
traditional messages, first of all about the feasibility and the usefulness
T10~351023
PI~LIC EDUCATIOt~ P~OCRA~-~
347
of stopping smoking. With the third objective, support in smoking
cessation, ~essages must be introduced about the s=oklng habit itself and
what happens ~n physiological, psychological and sociological terms when the
habit is broken. This is again a matter of teaching skills in addition to
teaching knowledge.
The composite nature of the cessation concept and the multitude of
cessation-related objectives mentioned above have important implications for
education. Since the various objectives represent successive steps in a
multi-step process, evaluation must include such procedures that can detect
not only the final steps in terms of change in behaviour, but also the
previous steps in terms of changes in knowledge, attitudes and beliefs that
determine the individual's degree of Readiness to Stop Smoking.
The next box in the educational spiral deals with program design. As a
background to the discussion on this topic we should look at the elements of
the communication process itself.
FIGURE 4 THE COMMUNICATION PROCESS IN PUBLIC EDUCATION
E E E
N S D :
E A U
R G H
E {
E ! F {
i C { ~ F {
~ E ~E{~
FEEDBACK
As illustrated in Figure ~, there is a sender who sends some message through
some medium to a group of receivers in order to produce some effect. The
process should not be a one-way process, but should include some system for
feedback to the sender, so as to allow for adjustments according to whether
the actual effect was the intended one or not. Program design could then be
described as determining_the characteriEt_i.¢.~_of_eack_one__of~these--ele~ent-~.-
Let us look at some_ e~amples of such program design viewpoints.
Speaking of the sender, it is necessary to choose one with maximum
credibility for the actual situation. In a situation where the purpose is
to co~Jnicate to young people the idea that non-smoking is actually what
T10 351024
|I
=akes you attractive, a popular young celebrity would he ~uch ~ore credible
than any =iddle-aged professor as sender of this message.
Both content and s~ape of the =essage are important. It is striking that
much earlier work has been restricted to quite limited kinds of contents.
It has~ ~for example, been pointed out very often, that smoking causes
diseases and deaths. But it would be important in ~ny cases to add state-
ments that indicate the magnitude of the risk. Looking at the shape of the
message~ at is desirable to use, as far as possible, a positive approach by
emphasizing the benefits of non-smoklng rather than the horrors of smoking.
When choos'in~.~he best ~edium, it ~s first of all important that the medium
does reach,"~"a physical sense~ most of the individuals in the intended
receiver group. Whenever possible, it would be best to use selective
media, for example professional journals to reach members of certain profes-
sions. The choice of medium has also to be related to the nature and the
shape of the mess@ge. For example, television ~s very good medium for
catching attention and teaching some basic facts. On the other hand,
televis~i'.~y~eu~suitable when it comes to a mere detailed kind of teach-
ing, sxnce the viewer can never guide the ~V-presentation so as to make it
proceed at a suitable pace and he or she will not have the chance of
stopping, it to think over something or to go back to something that was
lost.
If we Io~ at the chronological order of program design activities, we will
find tha~ the identification of the receiver group should be the very first
step. Without a clear-cut indication of the receiver identity, the program
would probably be too vague to be meaningful and evaluation would be
virtually impossible. Further, the characteristics o~ the receiver and the
desired effect constitute the major determining factors for the program
design with respect to sender, message and ~edia, as illustrated above. As
a general rule, the program design should be such as to le~ all the elements
in the communication process be well adapted to each other.
IMPL~4~NTAI'ION
Program.lmplem~ntatlon should be, as far as possible, an integrated entity
comprising not only intervention in terms of actual educational activities,
but also evaluation. ~he following discussion of the implementation box of
the educational spiral will be centred around the kind o~ national infra-
structures ~ha~ will ~e needed to allow implementation to take place on a
really large scale. A structure that is rather widely applicable is out-
lined in Figure
TI08351025
PUELIC EDUCATION
FIGURE 5. NATIONAL STRUCTURES FOR IMPLEMENTATION OF PUBLIC
EDUCATION PROGP_AY~ FOR SMOKING CONTROL
AUTHORITIES, RESEARCH INST. ETC )
CENTRAL AGENCY
FOR SMOKING AND HEALTH
KEY ESTABLISHMENTS I
TARGET POPULATIONS
When reading the chart in Figure 5 it would be best to begin at the bottom.
The target populations could, to some extent, be reached by activities
directly organized by authorities, research institutes, etc., as indicated
by the arrow to the right. However, this kind of direct contact could not
be very comprehensive. The major way hy which it would be possible to reach
most target individuals would be by using what are called here, "key-
establishments" in the society, present in the everyday neighbourhood of the
people of the country such, as for example:
Mass media
Primary health care units
Other health services
Schools at all levels
Community centres
Sports and other organizations
All these key-establishments are staffed by various professionals who, in
their daily work, are in touch with target individuals so that they have
good opportunities to Bive some smoking and health education. Consequently,
the most efficient way to introduce smoking and health education would be to
have such professionals, for example teachers at schools or health workers
at primary health care units, incorporate in their daily work, elements of
smoking and health education along with other tasks that they perform.
Such an approach would be beneficial from a number of viewpoints. First of
all, there would be enough of these professionals to represent a reasonable
chance of actually reaching most people in a country within a reasonable
period of time. Further, these professionals all represent an authority in
`their-fie~,-wh~c`h-w~-be-~-very--~F~rt~a~t-~-~a-~re-[-r~m-r~-~re~bi~y
and acceptance point of view. In each case, incorporating the material
would allow the elements of smoking and health education to arise in a
natural context. As a typical example, let us take the patient with
respiratory symptoms visiting the doctor, who would then be in a good
TI08351026
position to teach the patient both how smoking can influence his actual
health situation and how he could most easily stop smoking.
There might seem to be one difficulty with this philosophy; namely how could
a large number of various professionals be expected to find the time and
other resources needed to incorporate any substantial portion of educational
activity in their primary work. In order to overcome this difficulty, it is
necessary that all these key-establlshments and the professionals working
there are g~[en'.a~rv~ces containing the following components:
Specifictraining programs:
Smoking-related facts (medical, psychological, sociological,
economic, etc.)
Educational methodology
Teachisg aids:
$11d~s~ other AV-material, model speeches, wall charts,
posters, pamphlets, etc,
Looking back at the chart of implementation structures (Figure 5) it can be
seen that th~ above-mentioned services to the key-establishment would come
mainly from a central agency for smoking and health. The central agency
would be able~ to give such services, since it has input from research
institutes,au~horitles, etc.
As pointed, out above, the program evaluation will have to be carried out
within this same implementation structure. Evaluation could basically be
described as a cheek-up of the extent to which the d~fferent objectives have
been attained or not, Some evaluation aspects have already been discussed
in connection with the analysis of objectives. It was, for example, pointed
out that all objective-related aspects have to be covered - not just smoking
rates but also a number of variables representing knowledge, attitudes and
beliefs. But evaluation should not be restricted to registering the actual
outcome ~S just indicated. There should also be a specific "technical"
assessment of the various procedures that have been part of the program.
Then it-would.:be necessary tO assess the efficiency of a procedure under the
conditions where ~t is actually meant to be used. Some procedures m~ght well
appear efficient if carried out under certain ideal conditions, but they may
be useless when it comes to large-scale implemen~ation. Further, it is
important not only that each procedure by itself would be a good one, but
also that the composition of procedures i~ such that the program as a whole
will serve its purpose efficiently.
PEOGRAM REVISIOR
Before beginning another round in the educational spiral, the program should
be checked for possible improvement. At such a program revision a number of
aspe~a~eould-be-consi~er~d~--F6~ example, certain basic conditions may have
changed ~o as to require a redefining of priorities. If certain activities
have turned out to he effective, it could be worthwhile strengthening these,
while other activities, that have proved unfeasible for large-scale i=ple-
mentation, would he dropped. It would also he essential to identify any new
TI08351027
P~BLIC ED~]CATIOH PRDGEAMS
351
needs. If, for example, so~e new~ m~sleading =essages have appeared in
tobacco industry advertising, there would be a need to counteract that. It
might also be possible that new educational techniques had been developed,
opening the possibility of introducing new approaches in continued activi-
ties. These and other aspects might lead to a revision of the program so as
to ~ake the next program period better adapted to the actual current s~tua-
tion than it would otherwise have been.
ACTUAL EXPERIENCES
Since the above presentation suggests quite a complex system of educational
action, questions might be asked whether there is any evidence that action
of this kind does actually work. In order to have at least some indication
of that kind it would be useful to look at some very basic data on the
development in one country, Sweden, where smoking and health programs were
officially instituted in ]964, and where action has largely been carried out
along such lines as pointed out here.
TABLE I.
PREVALENCE OF SMOKING IN SWEDISH ADULTS
(18-70 YEARS)
Percent of adults
who are daily smokers
Males Females
1970 52 34
1981 30 31
A first indication o~ the development is given by Table i= which shows
the percentage of daily smokers among adults in 1970 and 1981. Quite
obviously, during this decade there has been a quite substantial reduction
in the percentage of male smokers. The reduction in females is much less,
but the previously upward trend has very definitely been broken.
As pointed out above, it would be interesting and important not only to look
at smoking rates, but some other variables as well.
TABLE 2. WISH TO CONTINUE SMOKING AMONG SWEDISH ADULT
(18-70 YEARS) DALLY SMOKERS
Percent of daily smokers (adults) who indicate
that they wish to continue to smoke
Males Females
1976 27 29
1980 20 16
TI08351028
352
Some years there have been measurements in Sweden of certain attitude varia-
bles, as for example how smokers feel about their smoking. The percentage
o£ daily smokers who indicate that they want to continue to sm=ke, could be
regarded as a measure of the stability of their smoking habit. Such figures
are shown in Table 2. They indicate that the stability of the smoking habit
is on the decrease, both in males and females. This table suggests good
possibillties for a continued downward trend in smoking rates.
All these figures relate to adults. We must also look at young people.
International statistics suggest that, although the contrary is often
believed, preventing the onset of smoking is much more difficult than
influencing adult smokers to stop.
TABLE 3. PREVALENCE OF SMOKING IN SWEDISH
ADOLESCENTS (AGE 16)
Percent of 16-~ear olds who smoke
Girls
1971 ~I 47
1981 23 35
As shown in Table 3, Sweden has been able to register a very striking
decrease in smoking in 16 year olds, and figures for 13 year olds are
similar,.al~hough on a lower level. These data indicate that it is possible
to reduce the number of children who take up smoking, if appropriate educa-
tional pr&Brams are implemented on a large scale.
SUMMARY
In smoking control there are four major objectives: (i) that both decision-
makers and the public have a clear understanding of the urgency of a reduc-
tion in smoking, (2) that young people do not start smoking, (3) that smok-
ers stop smoking, and (4) that the social climate is such that it promotes
non-smoking as the norm. For each of these objectives, educational efforts
are fundamental, while at the same time legislation or medical treatment may
be a necessary supplement. There has to be a multitude of educational
activities, each one tailored to serve a specific objective with respect to
a certain target population. It is essential to have the specific objec-
tives carefully defined and the evaluation methodology determined at the
planning stage.
The educational methodology has to take into account that the current educa-
tional goals do not relate only to knowledge, but first of all_~o_attitudes
and_behaviou~*-l~s-means-tha~-~-a~-ts about smo~in~nd-~isease are far from
enough. There is an urgent need for expand~n~ the content of the education
to inciu~e facts zegarding the smoking habit, its initiation, maintenance
and discontinuation as well as social, economic and other aspects of smok-
ing. It is also desirable, whenever possible, to adopt a "positive
approach" by emphasizing the favourable aspects of non-smoking rather than
the unfavoursble aspects of smoking.
T[08351029
PD~LIC EDUCATION PEOGRAMS
353
In the implementation of educational programs for s=oking control, it is
essential to utilize existing infrastructures such as the school system, the
health care system, the network of health-oriented voluntary organizations,
etc. A key role should be given to professionals within these structures
who stay in touch with target individuals and who can incorporate certain
educational tasks in their daily routines. Providing encouragement and
assistance to these key professionals in terms of both specific training and
supply of pertinent teaching aids, is necessary in order to make these
professionals form a dense and effective network by which virtually every-
body can be reached. The provision of these services to key professionals
is a major task for a central agency specialized in smoking and health.
Evaluation should be comprehensive enough to cover not only smoking rates
but also intervention effects in terms of changes of attitudes and beliefs.
It should also cover the technical construction of the program. Based on
the evaluation and a reassessment of certain basic conditions there should
be'appropriate revision of the program.
GENERAL REFERENCES
Delarue NC. Educational requirements for smoking and health programs. In:
Nieburgs H, ed. Prevention and detection of cancer. New York: Marcel Dekker
Inc., 1977.
Gastrzn G. Public education for smoking cessation - some operational view-
points. In: Proceedings of the 3rd World Conference on Smoking and Health,
Volume II. Washington, DC: 1977. US Department of Health, Education and
Welfare Publication No. (NIH) 77-1413.
G~strin G, Ramstrbm L. How to reach and convince pregnant women to give up
smoking. In: Progress in smoking cessation. Proceedings of the
International Conference on Smoking Cessation. New York: American Cancer
Society, 1979.
Guilbert J-J. Educational handbook for health personnel. Geneva, Switzer-
land: World Health Organization, 1981. WHO Offset Publication No. 35.
Nordgren P. Preventing the onset of smoking. In: Smoking control
Sweden. Stockholm: NTS, National Smoking and Health Association, 1983.
RamstrBm LM. Public education - its role in smoking cessation. In: Proceed-
ings of the 3rd World Conference on Smoking and Health, Volume II.
Washington, DC: 1977. US Depar~men~ of Health, Education and Welfare
Publication No. (NIH) 77-1413.
Ramstrbm LM. Effekt6itning av samh~llsinsatser ~ot tobaksbruket - n~gra-
exempel p~ svar~gheter och ~jligheter. (Evaluat.ion_oi_n~iom3! ef.fert~--t~
combat smoking - examples of difficulties and possibilities). In:
Behavioural research on smoking. Stockhol=: H-rapport ]6, National Board of
Health and Welfare, 19~I (Swedish).
T108351030
35~
Rau~tr~m LM. Designing =ulti-media programs for the prevention of
s~oking. In: Leathar DS et al, eds. Health education and the =edla.
Oxford, England: Pergamon Press, 1981.
Ra~trBm LM. Ways to reach the educational goals. In: Fontana F, ed.
Tobacco land youth. University of Padova, Institute of Hygiene, Padova,
1982.
Ramstr~m LM. ~National action ~n Sweden. In: Fontana F, ed. Tobacco and
youth~~Usilversit~ of Padova~ Institute of Hygiene, Padova, 1982.
Ramstr~m LM.- • Sweden's programme to eliminate smoking - activities and
success to date. In: Smoking Control in Sweden. Stockholm: NTS, National
Smoking and Health Association, 1983.
Wo~Id Health Organization. Controlling the smoking epidemic. Report of a
WHO Expert Committee 1978. Geneva, Switzerland: World Health Organization,
1979. WHO Technical Report Series, No. 636.
World Health Organization. Smoking control strategies in developing
countries. Report of a WHO Expert Committee 1982. Geneva, Switzerland:
World Health Organization, 1983. WHO Technical Report Series, No. 695.
World Health Organization. WHO action programme on smoking and health.
Geneva, S~itzerland: World Health Organization, 1982. WHO/SMO/82.5.
World Health Organization. Guidelines for the conduct of tobacco smoking
surveys~ of the.general population. Report of a WHO Meeting in Helsinki,
November 29-December 4, 1982. Geneva, Switzerland: World Health
Organization,1983 WH0/SMO/83.4.
World Health Organization. Guidelines for the conduct of tobacco smoking
surveys among health professionals. Report of a WHO, UICC and ACS Meeting
in Winnipeg, July 7-9, 1983. Geneva, Switzerland: World Health
Organization, 1983. WHO/SMO/83.5.
TI08351031
355
SMOKING EDUCATION IN THE ~NITED KINGDOM
WITH SPECIAL REFERENCE TO ENGLAND, WALES, AND NORTHERN IRELAND
Donald Reid
John Harris
Micheal Jacob
Alan Maryon Davis
Jane Randell
The Health Education Council
78 New Oxford Street
London, U.K. WCIA IAA
OVERVIEW
The purpose of this paper is:
(a) to summarise the development of smoking education in the United Kingdom,
chiefly in relation to England, Wales and Northern Ireland;
(b) to comment on its effectiveness; and,
(c) to review in detail the current programme of the Health Education
Council in this field.
PREVALENCE IN THE U.K.
The prevalence of adult smoking in Britain has declined by about 1% per year
since 1962, with a markedly sharper fall since 1980 (see Table i). This
decline has occurred especially among male, middle class, light smokers.
Female smoking remained relatively static until recently, but has also
declined sharply since 1980. Annual sales (Table 2) have declined since
1973, with a sharp 15% decline since 1980.
TABLE i. PREVALENCE OF SMOKING BY SEX AND AGE IN THE U.K., 1972-1982
% SMOKING CIGARETTES
AGE 1972 1974 1976 1978 1980 1982
MEN Aged 16 52 51 46 45 42 38
and over
WOMEq~--Ag~d~6 41 4~ 3-8 37 37 33
and over
Source: General Household Sur~,ey (i).
7108351032
356
REID, BARRIS, JACOB, DAVIS AND RAN-DELL
TABLE 2.
Source:
ANNUAL SALES OF ~i~I~UFACTURED CIGARETTES IN THE U.K.
YEAR
t~IBER (millions)
1970 127,900
1973 134,400
1976 I30,600
1979 124,300
1980 121,500
1981 110,300
~982 102,000
H.M. Customs and Excise
HAS PREVALENCE DECLINED IN THE O.K.?
The long term decline in cigarette smoking between 1962 and 1980 was largely
due to ~health~education~ in the broadest sense. Economic factors had little
effect before 1980, as cigarettes were cheaper in real terms in 1980 than
they were in 1960.
In 1981, however, a sharp increase in cigarette tax occurred. This, combined
with a fall in real disposable income and the increasing health education
campaign, led to a sharp fall in prevalence and consumption.
Legislation has had little effect, since the only relevant laws (a ban on TV
advertising and sales to children under 16) are either circumvented or
ignored.
SMOKING I~UCATION IN ~ U.K.
The health education movement against smoking is spearheaded by the govern-
ment funded voluntary body, Action on Smoking and Health (ASH), supported by
the government's Health Education Council (HEC), the Scottish Health Educa-
tion Group, and by health and education professionals throughout the coun-
try. Increasing support is now being given also by major health charities,
e.g. the Cancer Research Campaign and the British Heart Foundation.
With allied organisations, the HEC and ASH aim to:
Cii)
reduce adult prevalence to less than 20% by 1993 (1983: 36%)
reduce cigarette sales to less than 66,000 million (1983: 102,000
million)
reduce prevalence among 16 year old school leavers to 15% (1983: 25%)
THE HEC'S SMOKING EDUCATION PROGRAMME - OVERALL AIM
The HEC's overall aim, following Leventhal (2), is to give chief priority to
discrediting the image of smoking. Promotion of the health message by
TI08351033
S~OKI~(~ EBUCATION IN ~ U.K.
357
itself or of cessation techniques is given lower priority. For this reason,
the Council does not encourage so-called "less hazardous" smoking, since
this implies support for s=oking as a habit.
Since 1980, the HEC program~.e has been greatly expanded and focussed mainly
on childrens' s~gk~ng, at the request of the Council's sponsor, the British
Government's Department of Health. This paper will consider in detail the
childrens' and adult programmes, with specla] reference to their evaluation.
~EC P~OGRAMME ON C~IILDRENS' SI~OKING
Rationale The childrens' programme is based on the PRECEDE model of Green
(3). This involves:
(a) listing those influences which predispose, enable and reinforce
childrens' smoking
(5) identifying those influences upon which health education can make an
impact, and
(c) devising appropriate strategies to address each identified influence.
Key influences addressed by the programme include:
Parents' ~nfluence
Resource materials for use by health visitors (community nurses) have been
developed to support their efforts in persuading parents not to smoke in
front of young children. This follows the work of Baric (4) who has shown
that childrens' attitudes to smoking are formed from the moment they first
see a cigarette smoked.
Evaluation suggests that smoking parents do not believe that they are
"teaching their children to smoke", but they are concerned at the effects of
smoke on their children.
Leaflets for use by parents of teenagers, especially in conjunction with
school projects, are also under trial.
Evaluation in Norway by Aar~ (5) suggests that this approach may have a
marked effect on childrens' prevalence.
2. Ignorance of the hazards
Curriculum projects for schools have been designed to provide accurate
information in a lively manner. These include the HEC "My Body" project,
and the HEC "Phase" project (on immediate physiological effects of smoking).
Evaluation of the HEC '~y Body' project for 10-12 year olds (adapted from he
U.S. School Health Curriculum or "Berkeley" project) reveals that it may
halve the risk of children experi~entlng with smoking (6). There is also a
possible influence on parents' smoking (7).
TI08351034
358
REED, HARRIS, JACOB, DAVIS ~-ND RANDELL
3. Influence of schools
School influence may operate through teacher s=oking, provision of
designated smoking areas, etc. A policy guide for schools, supported by
research;will be drawn up during 1983.
Schools are~also being encouraged to undertake regular prevalence studies,
with• a ~iew to •encouraging teachers to accept prevention as their goal,
rather than gains in knowledge or changes in attitude alone.
Evaluations.in Derbyshire (8) and in France (9) suggest that teacher smoking
and prov~slon of designated areas, are both associated with higher
prevalence...
4. Influence of peers
To helpl ~ei~s~is,ti.~ocial pressures, short films are being designed following :':~..
careful research into British teenagers' smoking habits. Same age peer ._i~
lea.de.rship:)mgnuals.are also under trial.
Evaluati6nTof'films in Houston (i0) suggests that these may offer a simple
and easily disseminated means of educating the young against peer pressure.
Luepker's (II) evaluation of peer leadership manuals in Minneapolis suggests
that these may have a powerful long term effect.
5. Com~nity image of smoking
To raise-awareness and to continue the denigration of smoking as a habit,
mass campaigns for children have been carried out. These include the HEC's
well-known Superman campaign for 7-11 year old children between 1980 and
1983.
Evaluation revealed that 850,000 children wrote for free materials; and a
high level of.awareness was created, with massive spin-off coverage in the
British press.
The campaign also caused as many as 1 in 4 schools to give additional time
to smoking education (12) so helping to integrate the different elements of
the progra-,-e.
Other mass campaigns in 1983 intended to denigrate smoking included brief
TV advertisements sh~wing a group of socially mixed, "typical" teenagers
making derogatory comments about smoking. Two "advertisements" for a hair
spray ("Ashtr~") and an aftershave ("Stub"), both made from cigarette stubs,
were also ahown.
The advertisements showing teenagers achieved high levels of awareness and
recall, while "Stub" and "Ashtr6" stimulated considerable comment.
ADULT SMOKING
Rationale. In recent years, the HEC has concentrated on providin~ advice to
sr_okers who wish to give up, especially with the support of health profes-
TI08351035
I
sionals. Other opportunities to support cessation have been taken as they
occurred.
Specific activities have included:
I. Kits for F~ly Doctors
Give Up Smoking (GUS) kits ~ere distributed by the HEC to at least one in
three British family doctor partnerships in 1982-3, following work by
Russell (13).
~.91iminar~ Evaluation suggests that GUS kits by themselves may not necessa-
rily be any more effective than doctor's advice unsupported by any kind of
literature. However, their distribution may well have increased the number
of doctors who give advice to smoking patients.
2. Resource Packs for Nurses
Following extensive research, a resource pack for nurses, supported by a
training and dissemination programme, has recently been produced.
Evaluation is not yet available.
3. Smoking in Pregnancy
Mass campaigns, with supporting literature, were carried out during 1982-3.
These emphasised available sources of help and advice, and were accompanied
by literature for men to encourage them to support their partners.
Evaluation of the 1981-2 campaign suggests that campaigns of this kind are
no longer as effective as ten years ago - partly because of the major
decline in female smoking which has occurred since 1980.
4. Smoking in the Workplace
A sample survey of 100 major British companies carried out in 1982-3,
revealed that only 6% of those replying had drawn up a formal policy state-
ment on smoking, although over half believed that smoking was a legitimate
concern of employers.
More optimistically," the British Trades Union Congress has invited the Coun-
cil to collaborate in the production of materials on smoking in the work-
place (despite objections by the Tobacco Workers' Union). A major develop-
ment project is therefore about to commence.
5. Health education in general
Many of the HEC's other activities contribute indirectly to the smoking
education programme. These include the growing movements for a healthy,
active lifestyl~ based on exercise and
ties of this kind are currently undergoing rapid expansion.
In all of these ways, the Council, with its allies, looks forward to an
acceleration of the current highly favourable trend towards the elimination
of Britain's greatest public health hazard.
TI08351n"-'
360 R~ID, RARRIS, JAGOB, DAVIS ~
RAN~ELL
p~FE~N~S
OPCS Monitor. Cigarette s=~king: 1972 to 1982. General Household
Survey: GRS 83/3, London 1983. Office of Population, Censuses and
Surveys.
Leventhal H, Cleary PD. The s=oking problem: a review of the research
and theory in behavloural risk modification. Psychol Bull 1980; 88
C2): 370-405.
Green LW, Kreuter MW, Deeds SG, Partridge KB. Health Education Plan-
ning: a diagnostic approach. Palo Alto: Mayfield Publishing Co., 1980.
Baric L, Fisher C. Acquisition of the smoking habit. Health Education 3
1979; 38(3): 71.
5. Aar6 LE, Bruland E, Hauknes A, L6chsen PM. Smoking among Norwegian
schqolchildren, 1975-1980: the effect of anti-smoking campaigns.
Scand J Psycho] 1982; 23.
Gillies PA, Wilcox B. Reducing the risk of smoking in the young.
Public Health 1984; 98: 49-54.
Wilcox B, Gillies P, Wilcox S, Reid DJ. Do children influence their
parents' smoking? Health Education J 1981; 40(I): 5.
8. Bewley BR, Johnson MRD, Banks MH. Teachers' smoking. J Epidemiol
Community Health 1979; 33: 219.
Burghard Get al. The tobacco habit and respiratory symptoms among the
adolescents of a French Department. Bull Int Union Tuberc 1979; 54(1):
83-86.
I0. Evans RI et al. Social modelling films to deter smoking in adoles-
cents. J AppI Psychol 1981; 66(4): 399-414.
II. Luepker RV~ Johnson CA, Murray DM, Pechacek TF. Prevention of clga-
rette smoking: Three year follow-up of an education program for
youth. J Behav Med 1983; 6(I): 53-62.
12. Wilcox JS. Evaluation of the HEC Superman campaign in Sheffield
primary and middle schools. Report to HEC, 1981.
13. Russell MA~ Wilson C, Taylor C, Baker CD. Effect of general practi-
tioners' advice against smoking. Br Med J 1979 July 28; 2: 231-235.
TI08351037
361
THE ROLE OF LEGISLATION, HEALTH EDI]CATIOH AND SOCIAL ORGANIZATIONS
OF A SOCIALIST COUNTRY IN ~E BATTLE AGAINST SMOKING
Adam Tahy, M.D.
Head, Cardiopulmonary Department
Institute for Pulmonology
Mosdos, 7257
Hungary
In this study the current situation regarding smoking in Hungary will be
discussed. The role of legislation, health education and social organiza-
tions in the context of smoking will be described.
The trend in per capita cigarette consumption of the whole population and
the "active" population in Hungary shows quite a substantial increase in the
last 20 years (Figure i). The highest rate of smoking is in factories
and industrial plants, where three-quarters of factory employees are
smokers. More blue collar than white collar men (80% and 71%, respectively)
and more white collar than blue collar women (70% and 63%, respectively)
smoke.
The next figure shows the smoking rates of doctors in Hungary and other
countries. Not knowing the data for 1981 in other countries, but only the
trend, it is presumed that the percentage of smoking doctors in developed
countries may now be below that in Hungary (Figure 2). Figure 3 shows the
smoking habits of teachers and their pupils in different Hungarian secondary
schools. In schools, where the proportion of smoking teachers is high, the
proportion of smoking pupils is high as well.
What can be done about the spread of smoking? Some suggest the prohibition
of cigarette advertisements, and legislation to restrict time and places
where smoking is permitted (Table I). Legislative action could help, but it
is insufficient, if there is no health education. The administrative
measures, laws and health education will give no results if we cannot create
a social atmosphere, in which smoking is not accepted.
SOCIAL ORGANIZATIONS INVOLVED IN THE ANTI-S~0KING CAMPAIGN
Hungary's Institute of Health Education has published in the last 20 years a
number of periodicalsp pamphlets, posters, etc., to convince people of the
harmful effects of smoking. The Society of Opponents to Smoking is a
voluntary organization, a grass roots movement, which started in 1975, in
response to a broad demand. Among the founders were doctors and educators,
-thos~ who most ~'~-I-~ the necesslty. ~n--~b~dy can be a member whether smoker
or not, "because it is not against the smoker, but against smoking". The
Society arranges conferences, su~aries of which are published. In fact,
TI08351038
362
FIGURE 1. CIGARETTE CONSUMPTION IN HUNGARY
3O00
O
_~)
2565
- t~PTION
I I , I 1 ,,,t,
1~0 ~ t~70 1975 4980
YEAR
FIGURE 2. DOCTORS' SMOKING RATES
SMOKERS
[ ~ EX-SMOKERS
SMOKERS IN
PREVK)tJS YEARS
447%
.... I;:,I:1:1
HUNGARY J~AN" ~s A~ U~KY ~ S'~ED
D~TOR$ IN LEADIN3
~T~ IN ~ CAPITAL
~CT~S NOT IN T~ CAPITAL
74%
40% ~ : ~5~
NOR~Y N[W
TI08351039
FIGURE 3. SMOKING HABITS OF TEACHERS ~I~D THEIR PUPILS
PUPILS
38%
TEACHERS
GRAMMAR-SCHOOL
58~ 58%
53% ~51%
PUPILS TEACHERS
"SPECIAL"
SECONDARY SCHOOL
1980
57%
APPRENTICES TEACHERS
SKILLED WORKER
TRAINING SCHOOL
~A~LE l
LEGISLATIVE ACTION TO COHBAT THE
SMOKING EPIDEMIC IN HUNGARY
Advertising:
Package Information:
Total Ban
Health Warning, No Indication
of Tar, Nicotine and CO Level
Smoking in Public Places: Wide Range of Restrictions
Mandm~cor)~He~q~h-Educabien-:--Bread-~e~l-t',~Ed~-~t~on~P~i-cy
Smoking by Minors: No Restriction.
363
T108351040
the Society ~s the only one ~n the country which published a book on the
harmful effects of smoking. The Society, in co.on with other social
organizations, ¢o~ducts studies on s~king. The members try to take part in
educational work, and to =aintaln a constant flow of information. The
Soc~etyts d~rect, or ~ndlrect influence is shown by numerous regulations
restricting s~oking. The organization has two sources of income: (I) Every
member pays for his or her own activity in the organization. (2) A local
conference, or a publication is supported by the Hungarian Red Cross, the
official health education system, or other official bodies.
The Hungarian Red Cross also shoulders a large part in the battle against
smoking. A good example is a children's movement called "The Enemy Is Among
Us" to di~9.~urage children and teenagers from smoking. It is like a game.
It lasts fo~ months. According to the game, tobacco is a very dangerous
enemy in.~d~sgu~se. "He" is a criminal. '~e" walks among us in nice
costumes (nice~ackages). The children have to detect him. Their task is
to investigate, to collect evidence to make a "record of his crimes". The
months spent on this search give them a good opportunity to collect data
for argum~q~s ..against smoking. For example, results of biological experi-
ments, biometrical measurements, measurements of lung capacity and hand
tremor, a. 6ollection'of superstitions, interviews with doctors and sport
stars, participation in drawing and photo competitions. At the end of the
investiga~ibn~'-a: "criminal court trial" takes place where tobacco is
"accused"'of-'guilt. In the last few years more than I00,000 primary school
children.and.~econdary school students have participated in this ~x~vement.
I shall now discuss the results obtained in studies made in two Hungarian
counties. The effects of two and a half years activity of the Society of
Opponents to S~oking and the Red Cross were evaluated by use of self-
administered questionnaires. Certain key groups (health care providers,
educators) and special target groups (youth, industrial workers) were inves-
tigated in a county of 360,000 inhabitants (county '~"). As controls,
similar groups were studied in another county of comparable size where such
activity was not carried out (reference area). The activity in county '~"
was made up of seminars in schools, hospitals, scientific conferences for
health workers, lectures for youth leaders, competitions for children,
simple smoking cessation courses, special pamphlets, brochures against
smoking, and anti-smoklng articles in the local paper. However, there has
been no specific TV or radio program for county "M". The survey was
administered in schools, high schools, factories, hospitals, etc.
Results
According to the results of surveys in county '~" there was no significant
difference in the smoking behaviour of the investigated demographic sub-
groups between the beginning (1980) and
a_non-&ignificant-d~'r~ge--fn th-~s~ok~n~ rate of doctors and school boys,
and a non-slgn~ficant ~ncrease a=ong school girls and factory employees.
There were, with a single exception, no significant differences between the
T108351041
365
two counties in the stoking behaviour at the end of the study. The excep-
tion was the stoking rate of doctors which was significantly higher in the
reference area than in county '~". In the reference area 58% of ~ale
doctors and 39% of female doctors stoked, while in county "M" the rates were
40% and 33%, respectively.
Change~ in knowledge and attitude in county ~M"
On the other hand, there was a significant change in the information level
and public attitude between 1980 and 1982 in county '~". In this respect
there was a difference between the two counties in 1982, at the end of the
study. The information level and attitude of health workers and children in
county '~" at the beginning of the study was roughly the same as that in the
reference area at the end of the study.
At the end of the control activity, significantly more teachers were con-
vinced of the harmful effects of smoking than two and a half years earlier.
Before the study it was 43% of those who smoked and 57% of those who did not
smoke; after the study the percentage was 75% and 78%, respectively. Even
so, at the end of the study more smoking teachers held the opinion that the
propaganda against smoking was not necessary (before: 59%, after: 70%). The
opinion of the non-smokers was the opposite (before: 35%, after: 21%).
More children wanted to stop ~moking than before the intervention (before:
69%, after: 91% of the respondents). According to the children the teachers
should not smoke. Before the study, 28% of the smoking children and 14% of
the non-smoking children thought that teachers should not smoke. After the
campaign, the figures were 58% of smoking and 20% of non-smoklng children.
Nearly all of the children thought that smoking was harmful to health
(before: 93% of the smokers, 88% of the non-smokers, after: 95% and 95%,
respectively). In spite of this, after the control activity even more
children thought that the harmful effects of smoking were exaggerated
(before: 20% of the smokers, 40% of the non-smokers, after: 42% and 52%,
respectively).
A symptom of the total contradiction between knowledge, behaviour and atti-
tude is that, at the end of the study, 99% of doctors believed in the harm-
ful health effects of smoking, yet 30% of them smoked in front of patients.
Most (93%) of the health care providers, including the doctors, have the
opinion that they should not smoke in front of patients.
According to the surveys, the 5ealth workers, both smokers and non-smokers,
"became" much more "liberal" with smoking patients. At the end of the study
fewer health workers (35% of smokers, 25% of non-smokers) wanted to reduce
sickness allowances because it felt like "punishing" "resisting" smoking
patients. Previously, 46% of smokers and 60% of non-smokers felt this way.
In contrast to teachers, the health workers' opinion was that ~uch ~ore
effective~ropaganda__~gain~_~oking_wa~--neede~/~90%--of--~oker~9~ o~
non-smokers).
TI08351042
365
DISCUSSION
This paper shows the current s~oklng situation in Hungary. Up to now much
has be~n donel.against s~oklng in our country, but the efforts have failed.
The battle against smoking is fought with the help of leg~slatlon, the
official health education, and the Red Cross, hut this does not seem to be
enough.
Comparing the results of our efforts in county '~" with the results of the
North. Karella.project (I) the role of health professionals and especially
the role of_public health nurses has to be emphasized. It is to be regret-
ted th~t__~he smoking rate of this group in our country is especially high.
We have to find the proper approach to school teachers in order to have less
contradictory results (70% of the smoking teachers said: "The propaganda
against smoking was unnecessary").
A mistake_in our work at the beginning of the control activity in county '~"
was a psychological one. The negative effects of smoking were emphasized,
i.e. d~seases and death, instead of stressing the positive consequences of
stopping ~smoklng. We could see the aftermath of this on the drawings made
by children'at an "antl-smoking competition". The drawings were full of
skeletons, skulls and caskets.
The smokers are quite unfortunate. Their nicotine addiction causes extra
expenses and a lot of trouble. They need help. One of our results was that
at~ the end of the study in county "M" fewer health workers wanted to
"punish" the smokers. Finally I would llke to stress that the significance
of the mass media, especially television and radio broadcasts, can not be
overemphasized. My firm conviction is that health professionals, influenced
by their own knowledge, experience and conscience, and the mass media,
influenced by the health professionals, have a major and determining respon-
sibility for the future of society.
ACKNOWLEDGEMENTS
I am grateful to Dr. L. Juh~sz, Head~ Dept. of Oncology, for providing data
and advice and to E. Korom for her secretarial assistance.
Puska P, Neittaanm~kl L. Health professionals as educators -
experiences from the North KaKe_l_ia_P~roject.--~Rams~-r~m-LM,~.--The
s~king--upi-dvmi~c, a ~atter of worldwide concern. Proceedings of the
Fourth World Conference on S~oklng and Health, Stockholm, 1979.
Stockholm, Sweden: Almqvist and Wiksell International, 1980: 263-266.
TI08351043
367
AlCl"I-TOB~CCO EDUCATIOHAL FILM IN THE LIGHT OF RECEIVERS' OPIMION:
13-15 YEAR OLD YO~I"HS
Stanislaw Wijatkowski
National Anti-Smoklng Center
90-368 L~d~, Piotrkowska 194, Str.
Poland
In investigations carried out among 13-15 year old youths of L6d~ schools,
we examined the decrease of cigarette smoking ~n comparison with 1979.
This phenomenon and its present character have probably been influenced by
the socio-economic situation of the country, the rapid change in the tobacco
market, i.e. regulation and increases in the price of tobacco products, and
more intensive health education.
In order to estimate the influence of antl-tobacco health education on ciga-
rette smoking among the young, we are investigating, among other things, the
reception of an anti-tobacco film.
The first stage of the investigations into the anti-tobacco film which are
now being carried out ~n the National Anti-Smoklng Centre in L6d~, involves
examination of existing films. Though it is still too early to understand
fully how such anti-tobacco films function and the best structure, certain
remarks can be made, which can arouse health education practitioners'
interest.
The present information is a part of the anti-tobacco film study and it con-
centrates on the questions connected with the reception of anti-tobacco
films by the young.
Anonymous surveys, the results of which are presented below~ were carried
out in February 1983 among 378 13-15 year old pup{Is, chosen at random from
L6d~ prin~ary schools.
The age of persons studied were the adolescent years - the stage of develop-
ment which is characterized by the onset of regular, daily smoking. In this
period the=e are the following phenomena: the need to excite admiration,
peer group pressure, protest against rules and restrictions from adults.
Cigarette smoking often coincides with these phenomena.
The investigation of attitudes a~ong youths towards s=oking, ~ich have been
carried out for several years by us, make it possible for us to notice
changes, which have taken place in cigarette smoking among the young.
T1083510'44.
368
WI2AI~KOWSKI
Comparison of results obtained recently by us with the results of investiga-
tions in 19?9, makes it possible for us to state that the spread of smoking
ar~ong the young is now somewhat less. In 1979 we found that among 13-15
year olds, as ~any as 86.8% of boys and 70.9% of girls had already tried
smoking; 29.0% of boys and 13.0% of girls were smoking cigarettes regular-
ly. Thus, of those who had tried s~oking, 33.5% of boys and 18.4% of girls
were smoking regularly.
The present data show that there are 73.1% of boys and 62.0% of girls who
have experimented with tobacco. Altogether, 19.3% of boys and 8.4% of girls
admit to smoking regularly, which constitutes 26.5% of boys and 13.5% of
girls after initiation.
Thus one. can state that, at present, fewer young people reached for the
first cigarette in their lives and fewer than in 1979 decided to continue
smoking~--This is encouraging. It is the result, however, not of a radical
change in-young peoples' attitudes towards smoking, but probably of the
situation of the tobacco market in Poland. It has been influenced surely
by a two-year regulation of tobacco products, a temporary shortage of ciga-
rettes on the market, and a large increase in cigarette prices. Undoubted-
ly, as already mentioned at the beginning, a part was played by more
intensive antl-tobacco health education carried out in recent years.
The encouraging fact of the decreased extent of smoking among 13-15 year old
youths can be supported by examination of the percentage of persons who
have never smoked.
In 1979 - never smoked: 13.2% of boys; 29.1% of girls.
In 1983 - never smoked: 24.1% of boys; 34.9% of girls.
Data obtained by us show that intensity of cigarette smoking underwent
greater changes among girls than among boys. At present, fewer girls smoke
cigarettes permanently than in 1979, and those who smoke, smoke fewer ciga-
rettes per day.
The ~ain issue I would like to present against the background shown above,
concerns our. interest in the reception of information about the harmfulness
of tobacco smoking in an educational film.
At present, there are several films about tobacco problems in Poland. How-
ever, their dissemination is insufficient. This is shown, among other
things, by the results of our investigations.
The data obtained by us show that only 43.4% of boys and 40.0% of girls have
seen an anti-tobacco film once. The films which have been seen are, as a
rul6,-vlewed--P°Sit~vel-Y--a~--re~a-¢ds--their plots and~to'~£ - -7275% of boys
and 83.6% of girls said that they had enjoyed the film. Moreover, 75.0% of
boys and 86.6% of girls think that they have learned something interesting
from th~s film.
Among the boys who have seen an anti-tobacco film, there were 76.1% of non-
TI08351045
ANTI-TOBACCO IrILHS
369
s=okers and a=ong the girls - 88.0%. There were 79.2% of non-smoking boys
and 88.9% of non-smoking girls who had seen our film. This comparison
de=.onstrates the lack of concurrence between experiences with the film and
current cigarette smoking and confirms indirectly the thesis about the
complexity of motivation of smoking initiation in the young.
Earlier experiences of L6d~ youth with an anti-tobacco film can be estimated
indirectly on the basis of postulates addressed towards the film by the
young under investigation. We were, first of all, anxious to determine whom
the young under investigation suggest to be a target group, for which enti-
tobacco films should be prepared. The results of the investigations show
that prior film watching does not influence the views regarding a possible
addressee. Both groups of persons under investigation: a group of those who
have seen anti-tobacco films and a group of those who have not seen them
say, in the same percentages, that such a film should be addressed, first of
all, to the young (64.3% of those questioned) and to children (on the aver-
age 16.7%). Only a small percentage of those studied say that antl-tobacco
films should he produced also for teachers (1.6%) and parents (2.1%).
Other questions of interest concentrated on the format of a suggested anti-
tobacco film.
We found that 79.6% of respondents were in favour of taking tobacco smoking
problems, touched upon in a film, seriously. This was said by 77.1% of boys
who have seen the film and 79.1% of g~rls. In the group without experience
of the film, the percentages of boys and girls who preferred seriousness
in films on such problems were: 78.3% and 83°8%, respectively. Only 6.1% of
those studied thought that an anti-tobacco film should be lighter in its
form, and for 11.9% of persons the style of a film did not matter.
Being interested in the format of a suggested anti-tobacco film, we also
asked in our study how long such a film should be. Again, the earlier expe-
riences were of little importance because both groups suggested, with slm~-
lar proportions, that an anti-tobacco film should last about half an hour
(48.7%) or about 15 minutes (42.8% of persons studied). More girls than
boys were in favour of a shorter film (15 minutes).
The last feature of a model anti-tobacco film, suggested by the young, were
suggestions referring to the character plot of such a film. We analyzed the
suggestions of the youngsters who had already seen an anti-tobacco film
sometime in the past, treating this group as a more reliable source of
investigation.
The data show that half the boys who had smoked but who do not smoke at pre-
sent and who had already seen an anti-tobacco film, thought that such a film
should give, first of all, scienti[ic information on the harmfulness and
consequences of smoking (50.0%). On the average, a quarter of this group
said that such a film should explain how to stop smoking (25.0%); 16.6% of
~e_~e--b~y~ ~.~.id--th~t--an--ant-~t~b:w~-~o--f-i-l~--~-Fd--~hb,~ p~s~t~ve examples of
non-smokers and publicize the advantages of non-smoking. Among girls who
did not smoke at present, 52.8% were in favour of an anti-tobacco film with
scientific evidence as a source of knowledge; 18.4% of girls from this
group, that is almost every fifth girl, would like to see anti-tobacco films
TI08351046
370
~LI~~
promoting positive examples of individuals without a c~garette; and 15.8% of
them thought that such a film should emphasize that smoking is harmful and
that it should condemn the behaviour of those persons who say that smoking
is harmful but smoke themselves.
The study on attitudes and motivation of smoking initiation by the young,
carried out by us, convinced us that 13-15 year old young people, deciding
to smoke cigarettes, depend, to much higher degree than it is generally
assumed, on knowledge of the advantages and disadvantages of smoking. That
is why,~n developing an anti-tobacco film, cognitive values are stressed.
In summary, results of the study suggest that new anti-tobacco films:
- should be addressed, first of all, to the young,
- should give scientific information about the harmfulness and
consequences of smoking,
- should have a serious story and style,
- should last about half an hour and should not be shorter than
15 minutes.
Practical' activity of the National Antl-Smoking Centre in the field of
antl-tobacco educational film production will take the above points into
account in future.
T108351047
IV. CESSATION
T108351046
371
A RANDOHISED TRIAL OF ~REE DIFFERENT ANTI-SI~0KING INTERFEHTIONS
IN GENERAL PRACTICE
K.D. Jamrozik
M.P. Vessey
Department of Community Medicine and General Practice
Radcliffe Infirmary, Oxford OX2 6HE, England
N.J. Wald
G.H. Fowler
ICRF Cancer Epidemiology and Clinical Trials Unit
Radcliffe Infirmary, Oxford OX2 6HE, England
INTRODUCTION
The value of anti-smoking advice given routinely during general practice
consultations is uncertain. The seven studies of this approach that appear
in the literature have produced conflicting results, and each of them
suffers from at least one of the following shortcomings - small sample size,
lack of a control group or of randomised allocation of "treatments", or
presentation of results limited to those traced at follow-up. Nevertheless,
the largest of these studies, which involved over 2000 general practice
patients seen in London, England, showed that a combination of verbal advice
from the doctor with written advice in the form of a booklet and a warning
from the doctor that the patient's progress would be ~onltored, significant-
ly increased the rate of self-reported cessation of smoking one year later.
Of patients who replied to follow-up, 19.1% of those who had received the
antl-smoking advice claimed to have given up smoking, compared with 10.3%
of patients in a non-lntervention control group (I).
As anti-smoking advice given during the course of routine general practice
consultations is potentially a cheap and practical way of influencing a
large proportion of smokers, we decided to conduct a further large
controlled trial to confirm that such intervention is effective, and to
determine whether the ~ost effective "advic~ package" used in the London
study could be improved.
ME~HOD
Eligibility of patients
Six general practices in Oxfordsh~re, in which the majority of doctors and
health visitors (community nurses) had expressed an interest "in participat-
ing_in_fu~ther~es_ea~ch~ov__s=~vk~ag"
patients for the study. Eligible patients were identified by ~eans of a
questionnaire entitled "Updating of practice records", which was distributed
T10,..,o 1049
372 JAMKOZIK, VEHE?, WALD
~.~U) FOWI~R
by the reception staff to all adults over 16 years of age who were
attending to see a doctor for the first time during the 4 week recruitment
period in that practice.
Recrult~ent and treat~en~ allocation
The recruitment phase of the study began in October 1980 and continued until
February 1981. Eligible cigarette smokers were allocated to a Trial group
according to their day of attendance by reference to a scheme which provided
for a -balanced treatment sequence over a 4-week cycle. Each doctor was
provided with a desk-top card reminding him of the "treatment" to be given
to smokers seen on that day, but at all times the doctors were free to with-
hold advice from "treated" patients or to give advice to patients allocated
to the non-interventlon control group if they felt this to be necessary.
If. the patient was a non-smoker, or smoked a pipe or cigars only, or the
allocated trial group was "Control", nothing further was done after the
first questionnaire was completed. On days when smokers were to receive
advice they were asked to complete e second questionnaire that sought more
details of their smoking habits and were told that the doctor would want to
discuss their answers during the consultation. For their part, the doctors
were asked to give verbal advice of the kind they thought appropriate, but
each was given a copy of some suggestions as to what "best advice" might
constitute.
The three "active treatments" studied were:
I) Staudard.'~dvice group - verbal advice from the doctor plus written advice
in the form of the "Give up smoking" booklet developed by Action on Smok-
ing and Health and the Health Education Council, with a warning from the
doctor that the patient's progress would be reviewed.
2) Exhaled CO group -as in I, with the addition of a demonstration to the
patient of his or her own exhaled carbon monoxide (CO) level using a
portable CO-oximeter (Ecolyser, Energetics Science Inc., New York). This
demonstration was conducted in a corner of the walting-room by a member
of the Trial staff who gave a simple explanation of how the patient's CO
level compared with levels seen in non-smokers.
3) Health Visitor group - as in I, but a card describing how and when to
contact a health visitor attached to the practice for further help and
information about how to stop smoking was attached to the advice booklet.
Follov-up procedure
All cigarette smokers and a one-in-eight sample of the non-smokers original-
ly recruited to the survey were sent a reply-paid questionnaire one year
after the index consultation. Non-respo~n~_s ~e_sen~_up~o_~wo~emiv~der_s
~t--interva~s--of~/-~ee~s.
For each smoker, information was sought as to the number of attempts, if
any, to stop or reduce smoking over the year, and the timing of the first
attempt. Non-smokers were asked whether they had begun s~oking over the
year. Any patient who admitted smoking at the time of the follow-up enquiry
TI08351050
373
was asked to give further details as to the type, quantity and brand of
cigarettes, and depth of inhalation of the sr.oke.
RESULTS
Prevalence of s~oklng
Two thousand one hundred and ten (820 men and 1200 women) of the 6052 eligi-
ble patients (2225 men and 3827 women) seen, admitted to smoking at the time
of the index consultation. The overall smoking prevalence of 35% was simi-
lar to the rate of 39% found in a national sample of over 22,500 people sur-
veyed in 1980 (3).
~alance of study groups
The four study groups were balanced with respect to the age and sex dlstri-
butions of the patients, but, despite randomisation, there was a significant
social class imbalance whereby the Advice group was weighted towards higher
soclo-economic groups, and the Health Visitor group towards lower ones,
compared with the Control and Exhaled CO groups (p < 0.01). There were no
differences in cigarette consumption, type of cigarette smoked, depth of
inhalation, perceived danger of smoking, or desire or intent to stop smoking
among patients allocated to the three "active treatment" groups.
The 487 patients originally identified as non-smokers who were selected for
follow-up after one year did not differ significantly from the remainder of
this group in terms of age, sex, social class, practice of origin, or preva-
lence of pipe or cigar smoking.
Response to follow-up
A one-year questionnaire was returned by 72% of the smokers and the response
rate did not differ significantly between the four study groups. Ninety-one
per cent of the sample of non-smokers returned a questionnaire.
Atten~ts to stop smoking
Of the Control patients who returned a questionnaire, 64% reported that they
had attempted to stop or reduce their smoking since the index consultation.
This did not differ significantly from the corresponding figures in the
other three groups of 70% (Advice), 72% (Exhaled CO), and 68% (Health
Visitor).
Cessation of smoking
The numbers of patients who reported that they were no longer smoking at the
time of the one-year follow-up are given in Table I. Non-respondents are
assumed not to have stopped s=oking, hut, in spite of this conservative
a~sumpti<rn~~ca~t~di-f'f~°'r~ce--5~w~en ~h-~"~reatment" groups
apparent (X2 = 8.53, 3 dr, p < 0.05). Pooling of the results for the three
groups which received "active treatment" shows a clear increase in cessation
of smoking compared with the non-intervention control (X2 = 5.8, I dr, p <
0.02).
Tl08351051
374
TABLE l. NUMBER (AND PERCENTAGE) OF PATIENTS ~qO REPORTED THAT
THEY HAD STOPPED SMOKI~ AT ONE YEAR FOLLOW-UP
Study Group
Total
No. (%) Who Reported
Not Smoking
Intervention: Advice 512 77 (15.0)
Exhaled CO 528 91
(17.2)
Health Visitor 521 69
(13.2)
All intervention groups: 1561 237 (15.2)
Control: 549 58 (10.6)
TOTAL:
2110 295 (14.0)
Comparison.of all four groups X2 = 8.5, 3 df, p < 0.05
Comparison of pooled intervention groups with control group
X2 = 5.8, 1 df, p < 0.02
Both values adjusted for effect of social class.
Results for non-smokers
Eight per cent of the former non-smokers who replied to follow-up admitted
to smoking at some time during the year, and 5.4% were still smoking at the
time of the follow-up survey. Ex-smokers made up 31% of the original non-
smokers who returned a questionnaire, and were five times as likely as
never-smokers both to have begun and to have continued to smoke (p < 0.001).
Effect on the prevalence of smoking
Since the sample of former non-smokers seemed to be a representative one, it
is valid to assume that 5.4% of all of the non-smokers, (i.e., 212 indivi-
duals), would be smoking one year after the index consultation. At the same
time, had" ~ll of the cigarette smokers been allocated to the non-
intervention Control group, then 10.6% of them (224 individuals) would have
been expected to stop smoking over the year. Thus the net decline in
numbers smoking in th~ total population of 6052 patients would have been 12
individuals or 0.2%.
Table 2 gives the results of similar calculations for each of the "active
treatments" individually and a pooled result when they are combined. The
standard advice package is predicted__to~c=ea~e~he r~-te~f~ec~ne--in
smo~ing~y--a--~a~for of-nine times, from 0.2% to 1.8% per year, and the
Exhaled CO "treatment" to increase it by a factor of thirteen times.
TI08351052
TABLE 2. EFFECT OF ADVICE 0N THE PREVALE~CE OF SMOKING
"Treatment" Cessation Number Non-smokers
rate % stopping
startln~
Nett change
Number Per cent
Control 10.6 -224
+212 - 12 -0.2
Advice 15.0 -317
+212 -105 -1.8
Exhaled Co 17.2 -363 +212 -151
-2.6
Health Visitor 13.2 -279 +212 - 67
-1.2
Pooled Advice 15.2 -321 +212 -109
-1.8
DISCUSSION
This study confirms that anti-smoking advice given during the course of
routine general practice consultations has a useful effect. While a
previous study in London indicated that the main effect was to increase the
number of attempts made to stop smoking (i), our results show a difference
specifically in the proportion of attempts that were successful. However,
our generous definition of an "attempt" as any effort made "to stop or
reduce smoking" may have clouded the issue. It seems unlikely that two-
thirds of the smokers made a serious attempt to reduce their smoking over
the year, and this figure may partly reflect changing social attitudes
obliging smokers to be seen at least to be trying to stop.
Intensive follow-up, including home visits by health visitors, was associat-
ed with a very high rate of cessation of smoking (62%) in a study of myocar-
dial infarction patients (4). In the current trial, however, only six out
of 521 patients took up the suggestion that they might contact a health
visitor for extra advice. One possible explanation is that few patients
were acquainted with health visitors or their role and therefore the impact
of the anti-smoking intervention was diminished by the confusion caused by
the mention of this extra person. Alternatively, there is the possibility
that the doctors saw their own anti-smoking role being eroded through shar-
ing it with a health visitor and gave less effective advice themselves.
Whatever the explanation, this modification of the standard "advice package"
must be regarded as a failure.
This study is the first to incorporate follow-up of a sample of non-smokers
so as to allow estimates to be made of changes in the prevalence of smoking
in the whole of the population consulting the general practices. The
response rate from this group was remarkably high, and the trend for ex-
smokers~ as compared with never-smokers, to be at much greater risk of
beginning to smoke was very signlficant. We had not asked the doctors to
give any form of advice to this group and cannot comment as to how effective
such an intervention might prove to be.
In summary, our findings confirm the value of simple anti-smoking advice
given in general practice and show that the demonstration to patients of the
level of carbon monoxide in their breath has an added impact. Although the
strategies investigated~ was modest, they were all simple, cheap, and safe.
Widespread implementation co~Id have a mmjor effect on prevention of
diseases associated with cigarette smoking.
T[ 0 ,.., ~510 a,..,
I
376
JA~tOZIK~ VESSEY, WALD ~ I~OW~R
This study was funded by the Realth Education Council. Gillian Parker
helped wi~h the recruitment of patients and with the initial stages of data
processing. Dr. Jamrozik was supported by the Nuffield Dominions Trust.
The study would not have been possible without the cooperation of the
doctors, staff and patients of the "study practices".
Russell MAH, Wilson C, Taylor C, Baker CD. Effect of general practi-
tioners' advice against smoking. Br Med J 1979; 2: 231-235.
Jamrozik K~ Fowler G. Anti-smoking education in Oxfordshire general
practices. J R Coll Gen Pract 19B2; 32: i~9-153.
3. OPCS Monitor General Household Survey GHS 81/i, 1981: 13-15.
4. Burr A, lllingworth D, Shaw T, Thornley P, White P, Turner R. Stopping
smoking after myocardial infarction. Lancet 1974; i: 1306-1308.
TI08351054
THE USE OF NICOTINE CHEWIRC GUM IN A S:~DKERS' CLINIC
M.J. Jarvis, M.Phil.
Addiction Research Unit
Institute of Psychiatry
University of London
London SES, England
NICOTINE ~ SNDKIN~: ~ ~ATIONALE FOE NICOTINE
377
The role of pharmacological factors in the maintenance of cigarette smoking
is receiving increasing attention. It has been shown that smokers compen-
sate for changes in cigarette deliveries of nicotine, both in short-term
experimental studies and iu more natural studies of smokers who have them-
selves chosen to smoke brands with widely differing deliveries (1,2). The
natural history of different forms of tobacco use also points to nicotine as
the addictive factor. Snuff taking can lead to strong dependence just as
does cigarette smoking. The only factor in common is nicotine, since snuff
is free of combustion products such as tars and carbon monoxide (3).
The existence of a tobacco withdrawal syndrome is also widely recognized.
This comprises a number of phenomena, both physiological and psychological.
3ubjects experience a decline in heart rate, changes in the excretion of
• ~ormones and a rise in skin temperature. They also complain of irritabil-
ity, difficulty in concentrating, increased hunger and a variety of changes
for the worse in mood state. This acute withdrawal syndrome may be~ at
least partly, responsible for the failure of many attempts to give up
smoking.
To the extent that elements of the withdrawal syndrome are due to nicotine
deprivations, ra~her than to the loss of beha~ioural components of the
smoking habit, nicotine replacement may provide a rational therapy. The
would-be quitter can break down giving up cigarettes into two stages. In
the first, behevioural aspects of the habit can be addressed while nicotine
intake is to some extent maintained. The subject can then be weaned off
dependence on nicotine itself. Nicotine chewing gum was developed to meet
this need.
USII~ NICOTINE O/EWIN~ CUM: A CAVEAT
The foregoing should not be taken to imply that nicotine chewing gum could
ever be a complete treatment for smoking cessation in itself. Civing up
smoking involves many psychological and social factors in addition to
dependence on nicotine. No smoker is going to give up smoking without
making a positive decision to do so, and without being prepared to face the
whole variety of problems involved. At best, nicotine replacement via the
T108351055
378
JARVIS
gu~ can only ~ake coping just a little easier, rather than making it no
problem st all. It should therefore be seen as a treat=ent adjunct rather
than as a complete treat=ent, and it in no way replaces accounts of smoking
cessation in ter~,s of psychosocial factors. Rather it supplements them.
PRE~IO~S STUDIES WITH RICOTI~E
There is reason to suppose that smoking clinic attenders are a group of
smokers who are.particularly likely to benefit from this approach. Compared
with the general smoking population, they contain disproportionate numbers
of very heavy smokers whose dependence is likely to reflect pharmacological
factors. Our experience with nicotine chewing gum at the Maudsley Smokers'
Clinic began .nearly 10 years ago. Early studies showed that the gum was
more effective-than placebo in inhibiting sd libitum smoking, and absorption
studies showed that, with repeated use, the 4mg strength produced nicotine
levels slmilar:to those from cigarettes, while a single piece chewed over
half._an, hour. gave_ rise to a nicotine concentration intermediate between a
cigarette and~noninhaled smoking of a large cigar. The gum does not provide
the transient high peak in plasma nicotine seen after a cigarette, but a
similar blood'level is achieved after 20 to 30 minutes chewing. This
suggests"th&t"itis unlikely to mimic the positive pleasure of cigarettes,
but may allay some of the effects of nicotine depletion.
In the early days, we did not find clear increases in abstinence rates with
use of the gum, but with improvements in its formulation and increased expe-
rience with its clinical use, we reported in 1980 a one-year abstinence rate
of 38% "ih-subj~cts treated with the gum which was ~re than double the
success rate of 14% achieved in a similar group of smokers with intensive
psychological intervention techniques (4).
We were encouraged by these results to mount a controlled trial of the gum
to see how much our results were due to placebo factors and how much to the
effect of nicotine replacement per se. This trial has been reported in
detail elsewhere. (5). The following summarises the main features of the
design. A to~al of 58 subjects were treated with active gum and 58 with a
placebo. The active ~um was the commercial 2mg preparation and the placebo
contained Img of ni©otine~ but unbuffered, the intention being to maximize
the taste similarity while minimizing biological availability. The subjects
were treated in groups of approximately I0, and each group was allocated
randomly_;~' receive either the active or the placebo gum. Two therapists,
who were blind to gum allocation, each treated 3 active and 3 placebo
groups. Treatment was in the context of standard smoking clinic group
therapy over a 6 week period. Thereafter subjects attended as necessary to
collect gum and for follow-up. Claims of abstlnen~L~ooe~_yeaz--we~e
v~l~i~ated-by--measur~ment--of--ekp~red air carbo~--~i~e (6).
All subjects were given the sa~e_ instructions about the gum. They were told
that it contained nicotine which would be absorbed through the lining of the
=outh as it was chewed. They were warned that since absorption was not as
efficient as from cigarettes, the gum would not give the sate positive
Tl08351056
CLXNIC UgE OF N~COTINE
379
satisfaction, but it would allay craving and might reduce the severity of
withdrawal so=ewhat. It was stressed that they would still have to stop
stoking themselves, and that the gum would only ~ake things a little
easier. They were urged to persist with the gum for several days to get
used to it and they were recommended to use it for at least 3 months before
attempting to go without.
OUTCOHE AND PROCESS I~.ASURES
The main results are given in Figure I, which shows the percentage of smok-
ers in each group who stopped and survived lapse-free up to each follow-up
point. An advantage for the active gum was already evident at 2 weeks after
the start of treatment when 67% on the active gum had stopped compared with
45% on the placebo. At one month the corresponding figures were 60% and
29%, and the twofold advantage of the active gum was maintained throughout
the rest of the year. At one year follow-up, 31% of those treated with the
active gum had not smoked since the beginning of treatment compared with
only 14% of those treated with placebo. Figure 2 shows the proportion
abstinent at each follow-up point. It will be seen that more were abstinent
in the active group at one year than at s~x months. This was due to re-
lapsers returning for further treatment.
FIGURE I. PERCENTAGE OF SMOKERS IN TKE ACTIVE AND PLACEBO GROUPS
WHO STOPPED SMOKING AND SURVIVED LAPSE-FREE.
8O
,~ 6O
0
: 40
2O
placebo "'-.
2 1 3 6 9 12
weeks months
Time from start of treatment
T[03351057
38O
FIGURE 2.
80
PERCENTAGES IN E~E ACTIVE AND PLACEBO GROUPS
ABSTINENT AT EACH FOLLOW-UP POINT
Placebo
0 I I, I I I
1 2 1 3 6 9 12
Weeks Months
Time from start of treatment
JARVIS
The two groups also differed in their gum use. Similar proportions used it
in the first month, but thereafter the pattern diverged. Forty percent were
using the active gum at 3 months compared with only 14% of those on place-
bo. Four subjects in the active group used it throughout the year and can
therefore be regarded as showing some degree of dependence. This was not
true of any subjects in the placebo group.
As well as,outcome and gum use pointing to a role of nicotine, subjects'
ratings of the gum and of withdrawal over the first six weeks also favoured
the active gum. They rated it as stronger and more helpful. They found it
more unpleasant tasting on week I~ but not thereafter. Table 1 shows that a
number of withdrawal symptoms were rated as signflcantly less severe on
active gum. Other ratings were in the same direction but did not reach
s_tat_isti~a~_slgnlflcance.,
Finally, among those who were abstinent at one month, gum consumption corre-
lated with the b~ood nicotine concentration from normal smoking measured be-
fore the start o£ treat=ent in the active group, but not in the placebo, and
with pretreatment cigarette consumption in the placebo, but not the active,
group (Table 2).
TI03351053
CLINIC UFE OF NICOTINE GUlq
TABLE 1. RATINGS OF ~rlTHDRANAL SYMPTOMS
OVER FIRST 6 WEEKS OF TREATMENT
Active Placebo
Irritable 38.8* 47.1
Sleepy 28.1"* 38.4
Tense 41.8 47.5
Alert 44.0 47.7
Hungry 47.3* 55.0
Miserable 34.1 42.1
No~e: Ratings were made on a 0-90 scale
TABLE 2. CORRELATION BETWEEN GUM CONSUMPTION AND PRETREATMENT
BLOOD NICOTINE AND CIGARETTE CONSUMPTION.
Active Placebo
(n=31) (n=lg)
Correlatlon of number of gums
used daily at one month with:-
Pretreatment blood nicotine
Pretreatment cigarette consumption
.48"* .17
.II .47"
Base: All not smoking at one month.
DISCUSSION
What do the results of this trial show? They certainly do not show that
nicotine chewing gum is a panacea for smoking cessation. Only 31% of sub-
jects sustained lapse-free abstinence over one year of follow-up among those
treated with the active gum, but there was nevertheless a significant advan-
tage over the placebo. The role of support and encouragement in achieving
these results should not be underestimated. In ~y view, the results show
that partial nicotine replacement, in conjunction with the intensive support
and encouragement
~fican-~ly enhances the ability of these subjects to give up smoking success-
fully. In showing this, they point to a specific role of nicotine in ciga-
rette withdrawal.
Tl08351059
382
The results do not necessarilY suggest that the gum will he equally success-
ful in other sett~t~gs and with other kinds of sr-okers. Given that the gum
is best seen ms a treatment aid rather than as a complete treatment, careful
instructions on ho~ to use it and what to expect are necessary in order to
benefit fully frum it. Smokers who casually try a piece with the naive
expectation that it will somehow stop them smoking are bound to be dis-
appointed.
Nicotine chewing gum is a therapeutic aid particularly well suited to use in
a smokers' clinic. This is not only because heavy, pharmacologically
dependent smokers predominate in this setting, but also because the
intensive "contact gives much better opportunity for instructions~ for
creating appropriate expectations, and for encouragement to persist through
initial .mdaptat~on. The gum also helps by prolonging treatment. While a
person continues to use the gum~ in a real sense their treatment and
involvement:with the clinic also continues, although formal group sessions
only last for the initial six weeks. This extended involvement with the
clinic g~y.~ opportunities for continuing support and for coaching on
relapse avoidance. Finally it helps by inducing clients to return for
further ~e~p following relapse. Having experienced what most of them viewed
as real help wlth~ staying off cigarettes, clients are more likely to return
for further help if they relapse to smoking. This is in contrast to our
previous experience, when those who relapsed showed a marked disinclination
for further clinic contact.
i. Herning RI, Jones RT, Bachman J, Mines All. Puff volume increases when
low-nicotine cigarettes are smoked. Br Med J 1981; 283: 187-189.
2. Russell HAH, Jarvis l~J, lyer R, Feyerabend C. Relation of nicotine
yield of cigarettes to blood nicotine concen~ratlons in smokers. Br Med
J 1980; 280: 972-9~5.
3. Russell HAll, Jarvis MJ, Devitt C, Feyerabend C.
snuff users. Br Ned J 1981; 283: 81A-817.
Nicotine intake by
Raw M~ Jarvis HJ, Russell MAN. Comparison of nicotine chewing-gum and
psychol0g~cal treatments for dependent smokers. Br Med J 1980; 281:
481-~82.
Jarvis HJ, Raw M, Russell MAlt, Feyerabend C. Randomised controlled
~ri a I_ _o ~--n i c 0 ~e-chewin g - g um.-- Br-M~--j--1-~8~I;--~fS-5-:--5-yf~40.
Jarvis M3, Russell MAH, Saloojee y. Expired air carbon m~noxide: a
simple breath test of tobacco smoke intake. Br Med J 1980; 281: 484-
485.
T108351060
YMHEDIATE AND DELAYED EFFECTS OF POSTAL ADVICE ON STOPPYNG SMOKING
383
Frank Ledwlth
Department of Community Medicine
University of Edinburgh
Old College, South Bridge
Edinburgh
Scotland EH8 9YL
II~fRODUCTION
The main emphasis in the literature evaluating methods of smoking cessation
(1,2) continues to be on individual or small-group approaches, in spite of
the preponderant weight of evidence which suggests that, no matter what
method is used, no more than 20-25% of smokers are likely to be still
abstinent one year after treatment. The cost in scarce resources of money
and expert help of each "success" is too large to have a major impact in
reducing smoking prevalence. There is a need to establish a variety of
highly cost-effective, rather than merely highly effective, methods of
smoking cessation.
Leaflets on how to stop smoking, provided routinely by health education
authorities, are the most widely used "treatment" for stopping smoking,
yet there seems to be no information on their effectiveness. A controlled
trial was therefore carried out to evaluate one such leaflet produced by the
Scottish Health Education Group and to test whether relatively standardised
advice, which can now be given on an indlv~duallsed basis with the advent of
word processors, would be worth ~h~ ~x~ra ~ffoL~. i~ ~as calculated ~haL,
compared to sending a leaflet, interactive individual advice involving seven
letters and replies would cost ten times as much and a smoking clinic twenty
times as much per individual advised. It was decided that the criterion of
success would be smoking cessation at 12 month follow-up since shorter-term
cessation or reduction in consumption were felt to be less reliable predic-
tors of long-term health gains.
~ET~OD
Smokers who wanted advice on stopping smoking were recruited (N=1839) by
advertisements in mass-circulation (working class) newspapers in Scotland
between June and September 1980 and were assigned at random to one of three
conditions, with the restriction Lhat there were as many in group 3 as in
groups I and 2 combined:
Groul~-l~-No--~d¢~ite--(-c-oarro-~nwy were ~- that "The Advice Centre" had
been overwhelmed with replies and could not help.
Group 2 - Leaflet with standard letter.
Group 3 - Advice group offered individual help. They were sent the leaflet,
Tl08351061
a questionnaire to be filled in, on which individual advice would be based,
and two weekly smoking diaries which were to be sent in as they were
completed. The questionnaire dealt with preferred method of smoking,
critical times for smoking and social support available. It had been
pre-tested against a glossy questionnaire used by the Addiction Research
Unit in their clinics and found to produce double the response rate.
There were ethical problems in the trial since the control group were not
given the basic advice which was available. It was therefore decided to
offer help to the control group at the one year follow-up, though they were
not initially told this. Such deception was thought to be justified since,
without a control group, it would have been impossible to evaluate the leaf-
let, on which a good deal of money had been spent, and it would not have
been possible to estimate any adverse effects of advice, which are known
to have occurred in some interventions (3).
Of'..thos~::@ssigned to Group 3 only 26.5% sent in the questionnaire to
initiate the advice-giving interaction. With two reminders this response
rate was raised to 33.9%. Only 9% sent in at least one smoking diary and 2%
sent in.more than one. Three months after first contact, all of those in
Group 3 were sent a short questionnaire on their smoking, to which the reply
rate was only 23%.
Twelve months after initial contact, all clients were sent a brief question-
naire, attractively printed on a card with a cartoon on the front. Those
not replying were sent two reminders. Non-respondents were contacted by
=elephone or home visit. All those who claimed to be not smoking were asked
uo provide (usually by post) a saliva sample for chemical validation by
thiocyanate determination using Pettigrew's (4) method. The major purpose
of this validation was to check whether there was a tendency for some treat-
ment groups to prevaricate relatively more than others.
Statistical analysis of treatment differences in the proportion not smoking
(p) was carried out using the GLIM statistical package with conversion of
probabilities to logistic p=log(p/l-p). The 2 degrees of freedom for the
treatment differences were partitioned by comparing: i) Group 2 with Group
1 to test if there was any effect of the leaflet and 2) Group 3 with Group
2 (or with Groups 1 and 2 combined if they were similar in outcome) to test
if there had been any extra benefit from individual advice.
RESULTS
Age, Sex and Initial S~oking Rates
Compared to the population at large there was an over-representatlon in the
Rates of Cessation
At 12 month follow-up the non-response rate was 4.6% with a further 11% Gone
Away or Dead. Over 40% of all clients reported having quit smoking but two-
thirds of these relapsed. The control group showed a much higher proportion
who never attempted to quit in comparison with the two treatment groups
(i2=49.5, 2 df, p<.0Ol).
T[08351062
EFI~ECTS OF POSTAL ADVICE ON CESSATION
Treatment Effects
It would be too crude to use smoking status at one year as the criterion by
which to compare groups since this assumes that cl~ents either stopped or
not after receiving advice and that there would be no further cessation
during the year. In fact those not smoking at one year follow-up had
stopped at various times during the year with a minor peak of 19% stopping
between September and November 1980 (i~mediately after the advice giving)
and a major peak of 26% between February and April 1981 during which there
was a large Budget increase in the price of cigarettes.
The proper comparison of treatments is the proportions who stopped smoking
and remained stopped within a short time of the treatment. Given that
smokers typically take no more than one month in any attempt to stop smoking
and that the time of cessation was ascertained by retrospective recall to
the nearest month it seems reasonable to compare the groups for maintained
cessation within two months of initial contact. Table 1 shows that there
was an effect of treatments (p<.025), due mostly to the effect of the
individual advice since Groups 1 and 2 were similar, and that males showed a
greater gain from individual advice than females (p<.025).
TABLE I.
INTERVAL BETWEEN FIRST CONTACT AND CESSATION
MAINTAINED UNTIL 12 MONTH FOLLOW-UP
Interval from first contact
2 months or less 6 months or less
M+F M F M+F M F
% % % % % % BASE
Group 1 1.2 1.7 2.7 2.6 2.3 2.7
459
Group 2 1.9 1.2 2.8 5.2 5.2 5.5
481
Group 3 3.9 4.9 2.8 6.9 8.6 5.0
899
It should be noted that the success rates quoted are on the total number of
clients and thus assumes that non-responders were all still smoking. There
was no sign[ficant difference in the extent of the advice effect when
analysed by age or initial smoking rate.
However if a more lax criterion of treatment effects is adopted of maintain-
ed cessation within 6 months of first contact (and thus maintained for a~
least 6 months) a different conclusion can be drawn of the relative efficacy
of leaflet and individual advice. Table 1 shows that, on this less
restrictive criterion, the leaflet group did better than the control group
(p<.05) but there was no significant gain from ~ndividual advice (E2=1.58, ]
dr.). There was no indication that this leaflet effect was more__p!~nounced
when--ana!-y~ed ~%F--ag~-or--i~i~-i~-l--~o~f~ng rate.
Clients' Confidence in the Future
A measure of the potential damage done by the advice given can be found from
TI08351063
386
LEDWITH
unsuccessful clients' ratings of their confidence in stopping smoking in the
future. Among those who relapsed, there was no indication of a lower
confidenceS, in those who had advice. However, a=ong those who never stopped
at alithe~ew~s.a marked harmful consequence of the advice since, in Group
3, the ~e~centage who thought it likely that they would ever give up smoking
was 35% as ~ompared with 57% in the control group (p<.O01) and 48% in Group
2 (p<.l).,~ Hore~detailed analysis of these data showed no difference by sex,
age or initial rate in the degree of confidence nor of any differential
interaction with the treatment effects.
Val~dity o~ ~est~o~y
To the request for a saliva sample from all those who claimed not to be
smok~ng:the _non-response and refusal rate was 25% with a further 8% admit-
ting re~@~=~_Q~.43.4% of the samples returned were analysed due to tech-
nical!~d{££~l¢]~s" and insufficiency of sample. There is certainly no
in~icatio~ ;that_.the Groups 2 and 3, which had the higher reported rates of
cessation, had-more, clients with suspiciously high levels of thlocyanate.
As'not~ ~'ve~:if~iS" not easy to estimate the absolute levels of deceptions
in testimony. However 20 clients with thlocyanate levels above 60 ~g/ml who
had telephones were contacted and gently told that their level was a little
higher than~expected. From the conversation and circumstantial evidence
such as comments of spouses w~thin earshot it seemed clear that 12 of the 20
were probably not smoking. Of the eight probable smokers, two had smoked
nothing but cigars once or twice a week. It would seem an oversimplifica-
tion to .classify as liers all those with a thiocyanate level greater than
the suggested value ol I00 ~g/ml.
DISCUSSION
It seems that a firm conclusion can be drawn that individualised advice to
Group 3 did produce a statistically significant increase of 3.9% in the rate
of maintained cessation of smoking within 2 months of contact as compared
with 1.7-~.9% in control and leaflet groups. Whether such individualised
advice effects are of practical as opposed to statistical significance is
another matter. Since no more than a third of Group 3 actually received any
more advice than that given to Group 2 (with the leaflet) it is not obvious
what it was.which made the difference between Groups 2 and 3 within 2 months
of initial contact. The main difference in overall treatment between the
two groups within this time period was a) the offer of individual help and
b) the volume of mail since all those in Group 3 received 2 reminders if
they did not .reply to the initial offer of help. Thus it would seem that
the number of letters sent~ possibly with the addition of the offer of per-
sonal adv~ce~ made the difference in the short run between Groups 2 and 3.
The effect of the leaflet would appear to be a genuine latent or "sleeper"
effect, of a kind which is often suggested in health education but seldom
demonstrated. There was a diffe~enc~_be~weem_t.he_co~t-r~l--and-l~afler-g~oups
wh~ch--wae--mam[fem-ted~ot ~ed~ately after the advice but up to 6 months
later. Due to the randomised nature of the trial there seems no reason to
doubt that the d~fference was a result of the leaflet. This result seems
truly serendipitous in that it ~ght not have been shown w~thout the power-
ful, subsequent persuasion exerted by the Chancellor of the Exchequer,
T108351064
a persuasion which seemed to have been more powerful (and certainly more
wide-spread) than the advice offered. Where such powerful extra persuasion
is absent, then such delayed effects may be difficult to demonstrate by
controlled trials but may nevertheless be occurring. Over the last I0 years
in the United Kingdom, total cigarette consumption has declined by some 26%
(6), although ~ost evaluations of individual campaigns to reduce smoking
have been found to have little |ong-term effect. It seetm that ~he
criterion of how many smokers maintained cessation for at least one year
itmaediately following some specific intervention may be too strict and
narrow to show the cumulative effects of many different interventions.
There is always a possibility in trials on methods of smoking cessation tha~
clients will conceal their smoking, especially among those who have been
given the most help. The evidence in the present investigation gives no
ground for believing that such prevarication has produced spurious superior-
ity of treatment effects. In the first place there is no indication that
Groups 2 and 3 were any less ready to admit that they had relapsed and,
though incomplete, the saliva analysis shows no signs that Group 3 were any
less truthful. The simple equation of high saliva thiocyanate with "lying"
seems to be inaccurate.
There was worrying evidence that the treatments offered did some harm to
some clients in reducing the subjective hopefulness of eventual cessation.
It may be that the harm is small in relation to the gains for others but the
finding is an important reminder that interventions designed to help smokers
may have unsuspected damaging effects.
The research reported was funded jointly by The Scottish Health Education
Group and The Chief Scientist's Office of the Scottish Home and Health
Department.
Evans RI, Henderson AI~, Hill PC, Haines BE. Current psychological,
s,ocial and educational program~ in the control and prevention of smok-
ing: a critical methodological review. Atherosclerosis Review 1979; 6:
203-243.
Leventhal H, Cle~ry PD. The smoking problem: a review of the research
a~d ~heory in behavioral risk modification. Psychol Bull 1980;
88:370-405.
3. Lehrer T. Cessation from smoking in groups: the quasi-slck role arm the
problem of relapse. PhD Thesis, University of Manchester 1978.
4. Pettigrew AR, Fell GS. Simplified colorimetric determination of thio-
cyanate in biological fluids. Clin Chem 1972; 18: 996.
Burd PD, 3ohnson C~, Pechacek TF, ]Last LP, Jacobs DR, Luepker RV.
Prevention of smoking in seventh grade students. 3 Behav Med 1980; 3:
15-28.
6. World Tobacco, 1982: 45.
T108351065
Barbara Keely Loeb, Ph.D.
Gunnar Waage, M.D.
Jeffry Bailey, B.A.
~eslth Services Research Center
Kaiser Foundation Hospitals
~610 S.E. Belmont, Portland
Oregon 97215, U.S.A.
IRTRODI~CTIOR
• Although innumerable
investigators have shown increased morbidity and
mortality in infants born to smoking mothers, and pregnancy has been viewed
by many health educators as a highly susceptible period in which to influ-
ence health behavior, there are remarkably few studies of smoking interven-
tion in pregnancy.
A number of studies have looked at the rate of spontaneous smoking cessation
during pregnancy. The largest one, a retrospective survey at the time of
delivery of 16,994 British women (I) found that the smoking rate dropped
from 38.5% in early pregnancy to 31.5% by four months; an 18% decline. A
smaller Australian study showed a 14% spontaneous cessation rate (though
one-fourth of these women resumed smoking later on in pregnancy) (2). Baric
(3) found a 21% spontaneous cessation rate among the women he surveyed.
Only two studies, however, have tried to see whether the cessation rate can
be increased by health professional counselling or whether women who do give
up smoking in pregnancy have a decreased morbidity and mortality rate.
Donovan's study (4) tenatively answered "no" to both questions. Two hundred
sixty three pregnant women were given anti-smoking advice by their physician
at each pre-natal visit. This group was compared to smokers who were not
given such regular advice. The test group mean number of cigarettes smoked
decreased from 15.2 per day to 9.2 ~er ~ay ~ry 28 weeks, c~a~ed to no
significant change in the number of cigarettes smoked in the control ~roup.
This ~ecrease in smoki~E in the test group had ~o appreciable effect on the
mean birthweight or mortality of the Kro~p as a whole. Dowov~n concluded
~hat even with intervention the proportion who change is small.
Two small studies did suggest that smoking cessation was feasible by inter-
vention. Danaher (5) found in his study group of Ii pregnant women that,
~fter seven weeks of intensive couuselling in the second trimester of
pregnancy,33% discontinued smokin~ ar~ maintained this until delivery while
2~% significantly cut down the amount smoked. These women were volunteer
subjects, all over the age of 25, and there was no control group.
Baric in
aon
T1~1066
program with 63 pregnant t~omen of less than 20 weeks gestation ~ho were
mostly working class and long term, as well as heavy smokers. His interven-
tion consisted of one lengthy discussion with a senior medical student after
the first prenatal visit and instructions on the use of a free smoking
diary. In the intervention group, 16X discontinued smoking versus 6X in the
control group. The endpoint interview, however, was only i1 weeks later,
not at delivery.
One review of the smoking behavior literature (7) is quite critical of most
studies because of the lack of long-term maintenance data. Pregnancy smok-
ing intervention studies may be different in concept from these as generally
they are primarily interested in changing fetal morbidity and mortality and
four tosixm~nths maintenance, not years, wouId then be the goal. Although
more modest goals of short-term smoking cessation are easier to obtain, the
short period of time involved in pregnancy makes any program dlfficult stra-
tegically,..both in recruiting participants and getting them through a cessa-
tion program; Our study deals in depth with these particular problems of
smoking intd~v~tion in pregnancy.
STUDY SETTING
T~e setting~ ~or this study was the Kaiser-Permanente Medical Care Program
(KPMCP) of Oregon, a federally qualified health maintenance organization.
The program currently enrolls about 20% (26,000 members) of the Portland
SMSA (Standard Metropolitan Statistical Area) population. The characteris-
tics of enrollees are highly similar to census data on the Portland SMSA.
Five basic .principles shape the organization of the KPMCP: voluntary enroll-
ment, prepayment for comprehensive benefits on a service basis; preventive
medical car6," integrated, hospltal-based health care facilities; and provi-
sion of physician services through group medical practice.
The system maintains two hospitals with a total capacity of 495 beds,
although at the time of the study only one hospital had maternity facili-
ties. There are I0 ambulatory care facilities located in various neighbor-
hoods throughout the metropolitan area, four of these offering pre-natal
care. Physician services are provided by an independent professional
co.rporatlono£ over 250 board-certified or board-ellgible physicians. These
physicians, who practice full time in all the major specialities of medicine
and surgery, compose the active staffs of the two hospitals.
A single, comprehensive ~edi.csl record for every member of the health plan
is stored in a central location. Every medical care contact an individual
makes is recorded on the unit chart. Whenever a patient has an appointment
at a clinic, the record is delivered to the attending physician to be avail-
able at the t~Ime of appointment.
At the time of this study approximately 3,900 infants per year were deliv-
ered at our hospital. More than 95% of the mothers were members of the
Kaiser-Permanente,_.__, Medical Care Program ~f._ Orz~n. ~L_~ ,==~.~,~y ~,~
~amking
gtm;y xr.oo~ ..= designed as a randomiged controlled trial of smoking inter-
vention during pregnancy. It was hypothesized that early pregnancy s~ould be
a time mhen smoking intervention would be more effective than the anti-
smoking emphasis given in the usual prenatal care. It was also hypothesized
I I
T108351067
391
that quitting smoking in early pregnancy would have a positive influence on
pregnancy outcole and neonatal health status.
Women appearing for their first pre-natal visit between July 1979 and
September 1980 were given a questionnaire requesting information on their
current and past smoking behavior including age began smoking, current
number of cigarettes per day, previous quitting history and whether or not
the father of the baby was a smoker. During the study period, 3,856 women
completed the questionnaire with 25.0% (963) answering "yes" to the question
of whether they now smoked. These women comprised the smoking group.
The smokers were randomly assigned to either the control group (486) which
would continue to receive normal medical care for the duration of their
pregnancy or the intervention group (477). All women in the intervention
group were invited to take part in a treatment plan consisting of individual
and group counselling using a multimedia approach adapted from the Multiple
Risk Factor Intervention Trial (MRFIT). Various methods were used to
contact the intervention group and solicit participation. Thus, this was a
non-volunteer population at the time of randomization.
Women randomly assigned to the intervention group were sent a letter
explaining the study and inviting them to participate. This letter included
a self-addressed, stamped post card to return, indicating interest or dis-
interest. Those who did not respond were followed up by a second letter.
Women returning the card who indicated a willingness to be involved in the
program, were invited to attend a group information meeting where the
program would be detailed and a physician would make a short presentation.
The plan called for an individual session w~th a trained smoking counselor
in the week following the orientation meeting. Participants would then begin
a series of six 1½ hour group sessions meeting once a week. The general
approach was to introduce various techniques, provide information and
support and develop a plan for a quit date on the 3rd session, with support
for the following three sessions. A number of films was selected as appro-
priate and various literature was available for the taking. Subsequent to
the six scheduled groups, women were to be followed to delivery by on-going
support groups, individual sessions and phone calls according to the
expressed needs of the ~articlpant.
The actual course of intervention is an interesting and revealing picture of
the problems of attempting smoking intervention with this identified group,
pregnant women. Eight weeks after we had begun placing the smoking ques-
tionnalres in the clinics and had sent out a number of letters we calculated
that only 60X of the questionnaires were being completed and the response
rate to the number of invitations sent was 25%, with a refusal rate of 37%.
xncreasxng ~terest and awareness of
the staff in obtaining completed questionnaires. The low response rate was
explored by a telephone survey of those from whom we had not heard. We were
unable to locate or contact 27% of the women and those spoken to indicated
the letter was too threatening or confusing. In addition, 14% of those con-
T108351068
tatted said they had already quit smoking since filling out the intake form.
We then revise~ the letter to present the program in simpler and non-
threateni~ lar~ua~e. Tb~ acceptance rate increased slightly but was still
in the unacceptable range. At the end of four months our response rate was
77.2_% ~¢! ~r re~ r~te ~as 43.7%. ~ ~ga~n revised our sCra=e~ and
sent a s~le le~er followed by a phone call. With th~s approach our
response rate, now measured by ~he number spoken to, increased ~o 83.6% and
~he refusal ra~e ~ropped to 30.6%.
Btill not sa.t~sf~e~ wi~h our accession rate and d~sapppointed by our
~aab~iity ~o re~eh--a large number by either phone or letter, we decided to
s~ation our counselors in the clinics during the ~imes pre-natal examina-
tlons were scheduled, so face to face contact could be establlshed. Unfor-
tunately we ~d not have the personnel to cover all four clinics at all
scheduled pre-nata1 times but the data show =~at w~en the ~rst contact was
made at t~e clinic visit the refusal rate dropped to 24.4% and the contact
rate~*~5~%'~s--the nurse would refer ~he patient to the counselor's
off~=e;~ t~e ~ues~onna~re indicated a s~ker with a chart nu~er b~longing
to ~he interventio~ group. An occasional patient either did ~ot return ~
ques~ionnaire or was not ident~fled as belonging to the intervention group.
In addition to the program of establishing initial contact with the women
and presenting the program in an easily understood and inviting manner, we
had the .problem of reorganizing our intervention plan to fit the reduced
rate of'accession attributable to the decreased number of expected smokers
and the' high refusal rate, Women were offered whatever method they pre-
ferred to help them quit smoking but groups were few and small in size,
often ~umber~g no more than two or three participants. The proposed topic
sequence was abandoned as women came in and out of what group meetings there
were at different stages of quitting.
The majority of the women received individual counselling. Patients were
often met at the time of clinic appointments or were invited to come to an
office. After one or two visits, continued contact was primarily by phone.
~omen were contacted regularly until they delivered or unless they indicated
they no longer waste8 contact from us. Those w~th w~om we were able to
co.~ti~e tm~ ~el~very were considered active cases. Women ~o requested
no further conta¢~ (usually because they had been unsuccessful in quitting)
were considere~ ~ropouts. Women who were ~ble to be reached by phone or
l~tter ov ~ ~ul~ ~ot be located after being seen in the clinic on the
initial visit were ~esi~at.e~ unable to be located.
End point data were collected on all groups including the non-smokers (2893)
at the ~ime o~ ~e~l~ery and consisted of another questionnaire as well as
data on the mother and baby obtained from the i~patienC ~ecords of both.
Of the 3,856 mothers in the study, 963 (25%) admitted to smoking at the time
of intake. An earlier questionnaire given routinely by the obszetrician
T10835106~
indicated 37% had recently been smoking. The majority of the women (76.6%)
were in the age range of 20-29 years. T~ average age was 25.5 years but
that of the smoking group alone was 23.3 years; somewhat younger. Fewer of
the smokers (66.2X) were married as compared to non-smokers (88.6Z). Forty-
four percent of mothers aged 19 years or less smoked but only 13% of mothers
over age 30 smoked. While 50.4% of single mothers smoked, omly 19.8% of
marrie~i mothers mmoked. In addition, the father of the baby smoked in 74.1%
of the cases of sm~klng women, in contrast to 26.7% where the mother did not
smoke. The rate of heavy smoking (more than I0 cigarettes per day) increas-
ed directly with age from 45% at age 19 or less to 67.6% in the group over
age 30. The married smoker is generally a heavier smoker (63.2% married
vs. 42.)% single),
Finally, it should be noted that among the smokers, 21.5% were covered under
public assistance vs. 7% for non-smokers.
Intervention
It was clear as the study progressed that we did not have the impact we had
wanted. In the intervention group 18% were active participants throughout
pregnancy, 25.2% dropped out of the program, 38.4% refused to participate
and 18.2% were unable to be located. Fully 56.4% had no exposure to the
intervention program.
Intervention group data were cross-tabulated by type of contact and partici-
pation with demographic data. The older mothers tended to be more active in
the program: 28.3% of the mothers over 30 years of age versus 11.6% of
mothers less than 20 years of age. The m~rital status made a significant
difference. Married women participated actively at the rate of 20.7% vs.
11.8% for single mothers. The fathers' smoking habit made little difference
in participation.
Outco~
The smoking intervention results of thls study are based on all available
data, including information on dropouts and those who refused to partici-
pate. Thus we present a picture of the [ntervention group as a whole, not
simply those ~o were sctlvely participating, in comparison with a control
group.
Consistently the study s~l control ~roups were similar in outcome. Of the
477 in the intervention program, 271 (56.8%) ~swered the e~ipoint qttestio~t-
naire, with a comparable rate in the control group. This contrasts with the
72.8% of non-smokers w~o completed the questionnaire. On the ~uestion '~o
you ~ow smoke?" 15,4X indicated "no" vs. 14,2% in the con=rol group.
~enty-four percent stopped o~ reduced smoking by I0 or ~re cigarettes.
Age, h~ever, was ~ot a significan~ predictor in q~itting. Also, the
father's s~king ~de no statistically significant difference. ~ether
the ~ther was sln~le or m~rried did ~ke a difference. Only 12.5Z of the
single ~thers stopped or decreased s~kin~ vs. ~7.F% of those ~rried.
~ile th~ r~- ~f ~ti~1 .... t_-~ ~ ~f~ce i~ ~ re~uc~l~ or
q~ittia~, ~he ~rticip~n~s ~o ~re active i~ ~he program stopped or reduced
s~klng significantly ~re frequently than those who drop~d ou~ or re~sed:
~.gZ vs. 9.1~ and 18.3%, respectively.
T108351070
Also, the number of active participants was significantly higher in the
group ~.~o~h~rs contacted directly in the clinic, 35.9% compared with 25.9%
where cow,arced by letter and phone, and ~ly 16.7% ~en contacted by letter
~I~. ~Of thoae com~act~ ~n the cl~nic who then partic~pat~ actively in
~he ~=£e~w~Z~, Zhere were 66% who later stopped or red~ced s~kimg by I0
or ~_~
~e ver~cx~y of ~ep0r~ed s~k£ng status at delivery was investiga=ed ~ a
random .s~le of cord blood thlocyanate levels in 282 deliveries, 29 of
~ich~re"from =he intervention Stoup ~nd 24 from the control group.
Alth~g~...~._~S...~@t~. feasible fin~ncially or logistically to obtain s~ch
i~~ all our s~kers, ~he resslts showed that ~hiocy~nate levels
wet4 ~Oq4S~s6~ w~£h the reported s~king status. In every case ~ere the
£h~oey~ma~e .leve~ was grea~er than i00 micro~les per litre the individual
was a _e~ker.-. In every case where the result was less than i00 micromoles
per l~tre the {nd~v~dual was either a non-smoker or a smoker who reported
qu~tt ~ng,'
The cost .?~..Su.c.h...an ~ntervention program must be evaluated against the cost
ifi'&U~.i.~byi~%4 smoking mother. We found that there was no difference in
length~of'st~y o£ smokers vs. non-s~kers, and no difference in the rate of
spontaneous abortion or Apgar scores. There was a direct effect on birth
weight"of[~h~ infant: the birth weight was less than 2500 gm for 3.6% of
non-smokers, 5.8% of light smokers, and 7.8% of heavy smokers.
D S SS,6
Our stud~'~did not verify our hypothesis that pregnant worn are ~re a~na-
ble to.~s~king £nterventlon than the non-pregnant smoker. In fact pregnancy
may" b~"~p~rti'cularly stressful situation where smoking becomes an integral
part of the coping ~chanism. This is supported by the profile of the
smoker as younger, unmarried and more often on pubic assistance than her
non-s~klng, counterparc. Anecdotally, often the refusal to part£cipate was
ada~nt in worn who were continuing to smoke. The reasons frequently given
were those of prior satisfactory pregnancy outcomes while s~k[ng or reluc-
tance to t~ to .quit at this ~i~ because of o~her pressures.
Co~ta=~!~ the worn in the clinic directly was more effective in ensuring
p~rticipatlon. If t~ey participated in intervention ~here was a si~nifi-
ca~tly~i@be= ~ber ~ ~thers who quit smoking. Our program was expensive
~nd not ~st effective. Th~ n~er of s~k~ng ~hers contacted directly in
t~e clinic was often only one or two per day, For such a program to be cost
effective the counselor ~st either participate in a lar~er p=e-natal clinic
or the ~bstetrician and his nurse will have to be trained to deal ~re
effectively wit~ t~is very difficult ~pulation and intervention ~st become
a ~rt of the routine pre-nata] care.
Obviously, smoking intervention with a non-volunteer population is quite
different from volunteer programs and ~ns~@r~hly m~re d!ff!cul=.
T108351071
