NYSA TI Single-Page 4
610 Im transient situations, the approach can be more direct. _nere is often no time.to _eek the d_e
Abstract
Im transient situations, the approach can be more direct. ~nere is often no time.to ~eek the d~e process o~ law~ and usually a s~oker when potitely co~£~o~t~' ,~ill cease ~lluti~ the air in your space. ~er~ng ~a~ the ~k~r is a~saili~ innocen~ bystanders with a docu~n~ ~oxlc substance, ~he ~g~ker can ~ £orceEul £n the request (£~ ~acc does ~t work) and ¢~ to ~ successful.
Fields
- Named Organization
- Advertising Association
- American Cancer Society
- American Health Foundation (Health Research)
Plaintiff- American Lung Association
Voluntary health organization concerned with fighting lung disease, promoting lung health and advocating clean air, indoors and out.- 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- Avon (Makeup)
- Benson and Hedges (Benson & Hedges (elite cigarettes, 1948))
A small, elite cigarette company in NY, NY in 1948.- Biometric Society
- British Broadcasting Company (BBC) (British Broadcasting Company)
The British Broadcasting Company did "Panorama" show (British "60 Minutes"), an expose' of the tobacco industry called "A Pack of Lies" circa 1993.- British Medical Journal (BMJ) (scientific periodical)
scientific periodical- British-American Tobacco Co Ltd (British-American Tobacco Co. Ltd.)
British-American Tobacco Company Limited was a operating group under B.A.T. Industries P.L.C. in 1985.- Canadian Council on Smoking and Health
- *Department of Health and Human Services
- *Department of Health, Education, and Welfare (HEW) (use United States Departmen (use @hew_dept)
- EEC (European Economic Community)
European Economic Community- 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.- Government Printing Office (GPO)
- Health and Welfare Canada
- International Agency for Research on Cancer (IARC) (WHO cancer research arm)
International Agency for Research on Cancer - The cancer research arm of the WHO. Conducted a multi-center epidemiology study on ETS, initiated in 1988, data collection completed in 1994 and results were published in 1998- International Society and Federation of Cardiology
- International Union Against Cancer
- John Wiley & Sons (Publisher)
- London School of Hygiene and Tropical Medicine
- Metra
- Ministry of Health (Located in Singapore)
- National Institute of Child Health and Human Development
- National Institute of Education
- National Institutes of Health
- Office on Smoking and Health
Responsible for creating reports on the health effects of smoking. Created by the Public Health Service.- Preventive Medicine (periodical)
- Research Council
- Salvation Army
- Seventh Day Adventists (religion that prohibits smoking. runs smoking cessation prog)
- Singer
- Statistics Canada (Federal Statistics Canada)
- The Shield (anti-tobacco and alcohol publication of the 1920s)
- 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).- Tobacco Institute of Australia
- Trinity College
- University of California Press
- University of Manitoba
- University of Minnesota
- University of Newcastle
- University of Southern California
- Washington University in St. Louis
- World Conference on Smoking and Health
- World Health Organization (Concerned with global public health)
International organization concered with public health worldwide - American Cancer Society
- Named Person
- Alexander, H.M. (Researcher on Youth Smoking, Newcastle, New South Whales)
- Ary, Dennis V.
- Ashley, Mary Jane
- Ball, Keith
- Best, Allan
- Best, J. Allan
- Big, Anthony
- Brown, K. Stephen
- Caceres, Eduardo
- Chapman, Simon ("Tobacco Control" Editor for British Medical Journal)
- Collishaw, Neil E. (Canada Nat. Health & Welfare Ministry, Tobacco Products Dir.)
- Dobson, Annette J.
- Europe, Phillip Morris
- Flay, Brian R., Ph. D. (professor, University of Illinois at Chicago)
Plaintiff- Fletcher, Charles (Chest Physician)
Colleague of Sir Richard Doll, did research on why doctors who continued to smoke did so and what effect they'd found giving up smoking was when they gave it up. 8 smoking.- Glantz, Stanton
- Gray, Nigel
- Heart, Stanford
- Hill, David
- Jones, R.T. (BATCO GR&DC)
R. T. Jones was with BATCO-GR&DC. (Source: NM Tobacco Companies Personnel List)- Kunze, Michael
- Lee, John F.
- Legge, David A.
- Lewis, Ian C.
- Lynch, Cornelius J.
- Marcus, Lola
- Mulligan, Linda
- Ochsner, Alton, M.D. (President, Ochsner Foundation, Early Anti-Tobacco Expert)
Plaintiff- Overholt, Richard
- Pechacek, Terry (Office of Smoking and Health Associate Director for Science)
- Rahman, Abdul
- Range, Brooks
- Rayner, Kent J.
- Reek, Van
- Ryan, Katherine B.
- Sawatzky, Vern
- Severson, Herbert H. Ph.D.
Plaintiff- Simpson, David
- Stanwick, Richard S.
- Thomson, Margaret P.
- *Todd, G.F. (use Geoffrey Todd)
- Trudeau, Pierre
- Weissman, Wendy
- Wood, Michael
- Woodward, Stephen D.
- Wynder, Ernst L., M.D. (Epidemiologist, Sloan Kettering, Anti-Tobacco Expert)
1993 First scientist to report in 1950 on the carginocencity of cigarettes in rats painted with tar. Assistant at Sloan-Kettering Institute for Cancer Research Directed the American Health Foundation (AHF) from 1984 to his death in 1998. - Ary, Dennis V.
- Master ID
- TI08350674-1466
Related Documents: - Date Loaded
- 18 Jul 2005
- Box
- 1618
Document Images
610
Im transient situations, the approach can be more direct. ~nere is often no
time.to ~eek the d~e process o~ law~ and usually a s~oker when potitely
co~£~o~t~' ,~ill cease ~lluti~ the air in your space. ~er~ng ~a~ the
~k~r is a~saili~ innocen~ bystanders with a docu~n~ ~oxlc substance,
~he ~g~ker can ~ £orceEul £n the request (£~ ~acc does ~t work) and
¢~ to ~ successful. Ve~ £~ ~opte I£~ to ~ publicly e~arrassed
~ad~.~y.~9¢ g~kers know ~ha~ the tide o~ public opinion bzs Cured
~ ~t~cte~ ~ing in sbar~ air spaces.
BeECh"addressing specific actions, let m leave this point o~ con£rontation
with a clear ££nai ~hought. Positive action is called ~or in a11 cases
e~posure to second-hand smoke when a non-smoker ~eels £~ represents a threat
tp.~th; hesitation bel~es the imd~acy o~ the ~hrea~; and an apparent
willingness. ~o su~er chronic exposure wichou~ proces~ undermines
e~£ecti~eness o~ pro~ess£onal eE~orts to improve the envlron~nt. The
o~ a~u and response to s~kers must ~ dictated by the circnmsCances, the
.p~p~gy~o£ the actors involved, and the ~d£cal needs, but some action
£s~ndato~ i~ non-smoking £s ~o beco~ ~he norm.
:'~tld~'-~ ~n-s~k£ng worker can cake a~£ect other sectors o~ public I££e as
"well-when we cons£de~ that almos~ every public place £s also so,one's work-
.site.'.~ile the bulk o~ actions have been £n private work locations,
£n industry or £n government~ waitresses, airline ground and ~light person-
" nel~ bank tellers, and re~a~1 clerks seeking protection have created s~ke-
£ree environments for the public entering ~he£r work area. There are non-
a~k£ng health care ~ac£1£ty empZoyees who have played an active role in the
passage o£ ordinances and legislation req~irlng such ~acil£cies to have a
s~king control policy.
~he two important common law actions mentioned earlier also had great impact
on every other facet of the smoking or health question, with broad language
supporting preventive measures to protect health:
'~he evidence is clear and overwhelming. Ci@arette smoke
contaminates and pollutes the ~ir ereatin~ a health hazard not
merely to the smoker but to all those around the smoker who
.m~st.rely ~pon the s~me air supply. The right of the indivi-
dual to risk his or her own health does not include the right
td'j&opardiee the health of those w~o must remain around him or
her in order to properly perform the duties of their jobs. The
o~inion chat tobacco smoke should be e1~minated from ~he work
e=viror~me~t is sh~red by a11er~ists, immunologists an~ special-
ists in ~he ~ield o~ industrial medicine." (I)
~ew Jersey Superior Court
Released 12/20/76
T108351271
" .... tobacco smoke of co-workers smoking in the ~ork area is
hazardous to the health of employees in general and plaintiff
in particular...plaintiff should not be required to await the
harms fruition before he is entitled to seek an inadequate
remedy .... "(2)
Missouri Appellate Court
Unanimous Opinion - 1982
These reasoned opinions say that no longer should an employee wait until
sickeued by smoke before acting; no longer is the payment of workmen's
compensation, after the full-blown disease or injury, considered an adequate
remedy. The legal definition of tobacco smoke as a toxic substance in the
workplace, not only in New Jersey (where the courts are known to be innova-
tive), but in Missouri where the climate is extremely conservative, gives
every non-smoker a mandate to action, although legal action should certain-
ly be a last resort.
Employees seeking relief under the common law have been few in number, as
employers have made adequate accommodation for their needs without having to
be sued. Three cases are in the courts now seeking smoke-free work environ-
ments and, in two cases, reinstatement with back pay. Smith vs Blue Cross
and Blue Shield of New Jersey is being tried August 15, 1983, the defendant
having failed to develop a smoking control policy to protect the plaintiff
as originally requested by the Court in the preliminary stages and having
terminated the employee. Cooper and Cooper vs Hewlitt Packard was filed in
April 1983 in the Law Division of Morris County, N.J., also seeking rein-
statement for a couple with well documented sensitivities to tobacco smoke
who were ultimately discharged as a direct result of their inability to work
in the presence of tobacco smoke. In the case of Lee vs State of
Massachusetts, a smoker was permitted to intervene as an addicted person,
unable to perform her job without smoking. She freely admitted when ques-
tioned by the press that she was being represented without charge by legal
firms retained by the tobacco industry. Other non-smoking employees have
joined Ms. Lee as plaintiffs in this suit which will be tried later in 1983.
Handicapped Acts
Another course of action for non-smoklng workers is filing a complaint of
discrimination as a handicapped person under state and/or federal laws. The
U.$. ~ehabilitation Act of 1973, ar~ most state laws, require that "reason-
able accommodation" be ~iven pars~ns whose physical impairment substantially
limits one or more of life's major activities, such as breathing and work-
ing. This premise has been tested and persons with respiratory disease or
impairment have been declared handicapped; the question lies in defining
"reasonable accommodation" and the administrative law decisions have varied
greatly in adjudication of the few cases pursued to completion.
Unemployment/Disability/Damges
~ compensated to employees who are forced to quit
their jobs because of management's refusal to restrict smoking or provide
accommodation. Substantial workmen's compensation awards have been made to
T1083~51272
non-s~okers sustainlr~ illness from occupatioual exposure to tobacco s~oke.
Other employees have been granted disability retirement pensiorm because
employers wo~ld ~t provide ~hem with s~ke-free ~rk enviro~nts.
e~loyees have been fired because of their requests for a s~kinz control
policy, a~ ~til ~cen~ly ~ ~e has challenged =he action ~ccessfully.
In an interesting California case (Hentzel vs Singer Corp.) (3)~ an appel-
l~e c~r~ ~eld ~he ~ of ~s~kinE ~en~ a~to~ey ~ntzel ~o sue
for reinstate~nt. The court stated that he could not be fired "at will"
with no remedy at law, and further indicated he could sue Singer for ~,e-
~..ds~es as a result of "intentional inflic~i~ of emotional distress"
(caused by harassment during his employment and the trs~ of dismissal).
A similar case in S=. Louis involves an engineer fired by Washington Univer-
sity for an infraction of rules historically codified by all employees, but
the protesting non-s~ker was the only one discipllned. After administra-
tive remedies are exhausted, a similar suit will be filed
the employee is not reinstated.
II~DIVIDUAL ~lOl~S IN A UI~II~D
Employees are subliminally influenced by what happens in the workplace and
the non-smoking worker has a responsibility to be a continual reminder of
the'health threat posed by smoke in the ambient air. In every instance each
non-smoker must speak up in whatever setting second-hand smoke is encoun-
tered .... restaurants, schools, union meetings~ public meetings, private
honms, social functions. Legislators should be educated and constantly
pressured to protect non-smokers in public places and places of work. The
non-smoker should not sit back and let someone else work to protect his or
her health. Only by sheer numbers, banded together in a c~operative spirit,
can the non-smoking forces hope to overcome the billions of dollars spent by
the tobacco interests to advertise their deadly wares and to misinform
readers.
The International Non-smokers' Network formed at the Fifth World Conference
is an important first step in welding these individual and organizational
efforts into a cohesive, driving force to eliminate this most serious health
problem.
If anyone still doubts the seriousness of the forced or involuntary smoking
health threat, let me invite him or her to '~alk a mile in my moccasins", as
the utlve ~riean saying goes. Spend your days as a non-s~oker with
special sensltivies, eudeavorir~ to live without encountering tobacco smoke
in public places, to work productively without career limitations. Counsel
the thou.~ands of non-smoking employees we work with each year, hear their
stories o.f harassment and indifference, suffer with them the pain of head-
ache~ vision impairment, chest p~in, bleeding nasal passages, and nausea.
The problem is real, it is serious, it demands the individual concern and
the action of every delegate to this conference to achieve the social chan~e
eh=r w~]| m~ ~¢~-~$ ~ norm around the world.
T108351273
613
I. Shlmp vs ~ew Jersey Bell, 368 Atlantic Reporter 2rid 408. (1976 Dec).
2. ~mith vs Western Electric, 643 S.W. 2d10 (Ho. App. 1982).
3. Hentzel vs Sin~er ~0,~, 188 Cal. Rptr. 159 (Apr. 1982).
B IBLIO~R~[I~
American Lung Association. Smoking at the workplace: the changing legal
situation. American Lung Association, 1740 Broadway, N.Y,, N.Y. 10019. 1983.
Environmental Improvement Associates. Improving the work
Environmental Improvement Associates, 109 Chestnut Street,
08079. Original publication date 1983; Rev 1984.
environment.
Salem, N.J.
Epstein S. The politics of cancer. New York: Anchor Press, Doubleday & Co.,
1979.
Brody A, Brody B.
1977.
The legal rights of nonsmokers. New York: Avon Books,
T1083,51274
615
David Simpson
Director, Action on Smoking and Health
27-35 ~ortimer Street
London
U.K. WIN 7PJ
The very fact that there is opposition to those who seek to reduce the harm
caused by smoking; the fact that more than 20 years after the acceptance by
medical opinion around the world of the overwhelming, scientific evidence
linking smoking and i11-health; the fact that since that time, and now more
than ever, the tobacco industry has tried not only to deny, pervert and
otherwise impair the transmission of that evidence to the general public,
but also to undermine the initiatives of those whose interest is the better
health and welfare of mankind; these facts amount, quite simply, to the big-
gest public health scandal of our time.
The object of this and other papers presented at the Conference is to
provide ideas on how to counter the opposition to smoking control measures
from tobacco and advertising industries, and from others with financial
interests in smoking. The object of this paper is to give a brief, overall
guide to the main areas of opposition and to present some hints on how best
to deal with them. Although most of the examples, like the experience on
which the paper is based, are from the UK, they are still relevant to the
international scene. Here is the first important point about the
opposition, together with the first hint about how to counter it: the
tobacco industry, although colossal in size and financial and political
power, is very compact in its identity. Apart from the People's Republic of
China and the Soviet bloc countries, just half a dozen companies dominate
the world's tobacco trade. Three of them, including the biggest of all, are
British, while the others are American. Thus the tactics used by the
tobacco industry around the world are not only very similar - they are often
identical to one another, having sprung from the same source. Close liaison
between smoking and health activists around the world, therefore~ can
greatly facilitate the opposition to anti-health initiatives.
Some insights into ~he way the tobacco industry thinks and the lengths to
which it will go in its attempts to push its wretched pro~ttcts ~im~t the
e~orts of the health lobby, were revealed in a British Broadcasting
Corporation film in 1980. The 'Panorama' programme was given two internal
documents by people in tobacco companles~ who presumably still had some sort
of conscience about their employers' work. Such insights are important to
those trying to counter the opposition and the most interesting examples
were as follows:
T108351275
616
S~OU
I) A document from the 'Task Force' monitoring the Fourth World COnfe~
ence, set out the following objectives:
- We must try to stop the development towards a Third World commitment
against tobacco;
- we must try to ~et all or at least a substantial part of Third Wor:
countries committed to our cause;
- we must try to influence official FAO and UNCTAD policy to take a
.... pro-tobacco stand ;
- we must try to mitigate the impact of WHO by pushing them into a
more objective and neutral position;
2) A document from British American Tobacco included the following
=: i..Statement s:
:.;,~":'-A~.ad~rtising bans tend to fall unevenly on countries, within
regions, companies should explore the opportunities to co-operate
~.. one with another by beaming TV and radio advertising, into, for
.. example, a "ban" country. Obviously the political risks of this
....... action must be weighed up and treated with prudence,
"~'~-: .The company, its position and prestige in society assumes greater
"'~,~:~ .: importance as the cigarette industry comes under attack. The com-
. . ..... -puny image must be enhanced by whatever publicity resources are
- ... it has been found most successful in arguing the industry's case
to government ministers (particularly Economic Ministers) that
marketing departments should assist in compiling and presenting a
dossier proving the contribution of the industry to the economic
well-being of the country. "Opportunities" to establish and
nurture friendly relations with media writers and presenters should
be sought.
These extracts give an indication of the nature of the opposition to our
work. NeXt~ some of the different types of opposition and how to deal with
Chum are examlm~i in a little ~re ~tail.
It is suggested that the opposition from the tobacco industry can be divided
into four broad areas:
1) anti-health propaganda
2) promotio~
3) ecouomic propaganda
4) 'social ac~ptah~]~y,
These subjects do, of course, appear in different arenas - for example with-
in the press, in political lobbying or in direct approaches to the public.
This should be borne in mind while examining each subject in turn.
T108351276
617
All s~okin~ a~d health activists will be fssdliar with the sorts of things
the industry says to try and resist our efforts: they talk of the '~dical
controversy" or the "alleged" hazards o~ a~ktns; so~i~a ~h~ s~ak of
"e~essive" s~king or oE "safer" s~kin8 and worse still, ~o~eti~s "safe"
s~k~. ~ey say Chat ~ causal relationship ~eeu s~i~ s~ ill-
health has been proved, ~owing full well that ~st people
a causal relationship is and will assume, from such a state~ut, that the
case a~ainst s~kln~ has ~ot been proved. They talk about a "balanced view"
being ~cessary, ~ich really means they want people to reject ~he over-
whelm{~ scientific evidence about s~kin~. They refer ~o ~s as do-gooders
or fanatics and accuse us of "nannylng" people.
Further examples of the industry's style in promoting anti-health propaganda
can be seen in two booklets prepared for the employees of tobacco compa-
nles. In '%4hat about Smoking and Health?", sub-titled "Some Questions and
Answers about Smoking and Health for the Information of the Employees of
Phillip Morris Europe/Middle East/Africa", the first question begins thus:
"Has it been established that smoking causes cancer and other
diseases? No. The numerous reports and studies on smoking
and health fail to establish a cause-and-effect relationship
between cigarette smoking and cancer and other diseases .... "
"Smoking Issues", a British American Tobacco Employee Information Booklet,
is a rather longer document but no less disgraceful in content. Counter
arguments will not be presented here, not only because most readers will be
quite familiar with them, but also because the tactics to adopt are laid out
so competently in publications such as '~he Lung Good-bye" produced by Simon
Chapman (I) and the UICC Manual "Guidelines for Smoking Control" (2).
The one thing which we have on our side which is not available to the
tobacco industry is, quite simply: TRUTH. Our job is to ensure that the
scientific evidence about smoking reaches as wide an audience as possible.
Reassuringly, the amount of anti-health propaganda and the number of avenues
used for its dlssemiuatlon by the tobacco industry, are usually fonnd to be
iu inverse proportion to the strength of expression of medical opinion about
smokin~ and the amount of pro-health activity going ou in any one co~ntryo
In other words, an active medical lobby is essential. All the medical and
health professions ~a~st be involved and we must tall them our needs so that
they can summarise their opinions and make clear, in a way which we can use
best, the ~nanimlty and strength of feeling within their ranks about the
smokin~ issue.
It is not intended to cover this topic in detail since it was the
..... . e. us ea , a ew key points will be
presented which may be of assistance in counterir~ opposition in this area.
T108351277
Firstly~ it is entirely possible to counter the arguments which the tobacco
industry uses to preserve its promotion of its products. On close examina-
tion,, most of the arguments are worthless and frequently include sophistry
which can be exposed easily. In the UK some years ago, the industry pub-
fished the ~etra Report 'The relationship between total cigarette advertis-
ing m~ total cigarette consumption"(3). Since then, this same report has
surfaced i~ the USA, Australia a~d many other countries around the world.
All that is really necessary to deal with such ~onsense is to read reports
llke this, then expose the errors and omissions, sophistries and false
arguments. Good journalists will be quite prepared to publicise the truth
about s~ch material. In the UK, even the respected financial newspaper 'The
Financial Times", which is frequently supportive of, or at least not hostile
to~ "kh~"-tobacco industry, headlined its report of the Metra document
'~obacco: How Not To Play A Hand"(4). Furthermore, the leading British
advertising journal "Campaign" ran a leader which was highly crltical of the
doc~ment~(5);.
Another hint on the subject of promotion is to turn once again to our
medical-~rofessioRs. In December 1981, the Presidents of no less than eight
"~d~i~-ai-Royal Colleges in Britain signed a letter to the Sports Minister
urging him not to renew an agreement allowing tobacco sponsorship of sport
or, if he dld~ to at least plan to phase it out. That such a strong letter
wasslgned by so many eminent medical men led the British Medical Journal to
describe the letter in a leading article as "an event unprecedented in the
his~0ry of public health in Britain"(6). Although it did not,
unfortunately, achieve its objective at the time, it did receive widespread
publicity and without doubt advanced the anti-tobacco cause.
The thir~ point to remember is that there are always some advertising indus-
try o£f~clals who are prepared to stand up and be counted on the smoking and
health question and who, on principle, do not accept tobacco advertising
business. It is the job of health activists to identify these people and
use them in their work.
Lastly, the general public can be recruited against tobacco advertising,
particularly when made to realize the effect of advertising in presenting
cigarettes to children as a socially acceptable product. The public can be
e~couraged, also~ to protest when, as is frequently the case, the cigarette
advertisers grossly overstep the bounds of public decency.
~C PROPA~A}~A
The tobacco industry talks of the benefit of tobacco to the economy and the
unfairness o£ taxation to the smoker. It ma, kes much of tobacco as a provid-
er of jobs and a source of revenue to government.
On the question of benefits, we can do no better than refer to the plenary
paper delivered by Dr Nigel Gray, in which the enormous costs to the
econo~ry, as opposed to the '*benefits" quoted by the tobacco industry, were
co~uterim4g t~is form of opposition is to ensure that health economists carry
out appropriate work to evaluate the costs of tobacco and to ensure that
the results o£ s~ch ~ork are publicised and presented to governments.
T108351278
Turning to the question of jobs, ~e need only ask, publicly, who would dare
to propose that we should stop trying to prevent road accidents, because of
the ~obs they provide for neurosurgeons, nurses, undertakers, florists and
garage repair mechanics? ~hls is simply a question of seizing such anti-
health propaganda every time it arises and setting it in the context of the
colossal da~ge to l~ealth caused by smoking which, of course, is never
mentioned by the tobacco inclustry.
Regarding revenue, we must always point out that tobacco is such an
~nelastic commodity, that virtually every government around the world can
make more revenue every time it increases its tax on cigarettes, even
th.ough, at the same time, consumption is forced down. In other words, the
total tax paid on a smaller volume of sales after a tax increase is still
larger than the total revenue gained from a lower rate of tax on a larger
volume of sales before the increase. This point is not often understood by
the public at large and our job is to explain it as carefully as possible
every time this topic of tobacco propaganda is produced.
Also~ public opinion is often found, sometimes unexpectedly, to be on the
side of health and in favour of further increases. In the UK, at the end of
1981, a majority of the population was found, in a public attitude survey,
to be either in favour of, or indifferent to, a further increase in
cigarette taxation, although it was only about nine months after the biggest
rise in cigarette tax in almost two decades. Health professionals must
connnission such surveys in every country where economic propaganda is
produced by the industry. Support is often there waiting to be harnessed to
the cause of health - it simply has to he collected and pressed into
service.
"SOCIAL A~CEP~BILI~" ISSUE
This covers three main areas: non-smokers' rights, including smoking in
public places; the so-called "freedom" issue; and a wide range of activities
by which the companies try to ingratiate themselves with governments and
other important target groups.
The issue of non-smokers' rights has been dealt with admirably by Professor
Stanton Glantz (8) and thus will not be examined here except to record, once
again, the importance of sou~din~ out public attitudes. In the UK, for
exa~aple, it is not only ~ou-smokers who are found by opinion polls to be in
favour of increased provision of smoke-free sp~ce in public places, but also
smokers themselves. Such f~ndlngs are important to counter the tobacco
industry's frequent contention that smokers are being victimised.
The "freedom' issue is, of course, without foundation, because on examina-
tion, it is obvious that smokers, far from exercising freedom of choice, are
the victims of loss of freedom. We ~ow from surveys among ~mokers in the
IlK and elsewhere, that the majority of smokers started smoking when they
were children, rather than making a free, adult choice
i ,-- _ r~e a east once to give up smoking; and do not
understand the nature or amount of risk which they run by smoking.
T108351279
62~
Thus any argtm~ent about freedom can be turned against the opposition.
among those who are not prepared to accept reasoned arguments about fr~
and **bose main interest is the fzeedom to promote and sell cigarettes,
often found that arguments involving children a~d their need for
are irrefutable. '~i
Dealing wich those ac~ivitles by which the companies try to e~hance
names is clearly a matter of weighing up the relevant facts of each part
ular case, Once sgaln, public opinion can be harnessed so expose wha~
tobacco co~panles do to try to gain undeserved respectability or
priate infh~ence. In the OK, ~he British ~ericsn Tobacco Co~ny's
tire of eatert~ining Civi1 Servants from various sovernment depart~nts
the Wi~ledon Tennis Cha~ionships c~eated substantial publicity
apparently helped to counter the effectiveness of this operation.
There are obviously o~hec areas in which the opposition has to ~ countered
by health authori~ies~ but which have not ~en deal~ with here ~cause
are covered in other papers presented at this conference. O~ these, the~
~s~ important example is probably that of lower emission cigarettes, ~ich.~
tend to assu~ greater importance as health campaigns achieve ~re and ~re
success. ~hls is because a trend to lower emission cigarettes is the one
item.ln health policy about smoking which envisages continued cigarette
sales, rather ~han ~£ng designed to reduce consumption. In ~his and other
areas which have not been dea1~ wi~h, health workers must be no less.
vigorous in their efforts to counter the opposition. Clearly, the war
against s~king is bein~ won and the greater the international co-operation
and' e~ch~nge of experiences between heal~h workers, the sooner the final
victory will be achieved.
Chapman S. The lung goodbye.
author, 28 Queen street, 1983.
Chippendale, NSW, Australia: By the
Gray N, Baube M, eds. Guidelines for smoking control.
International Union Against Cancer, 1980.
Me=ra Consulting Group Ltd. The relationship between total cigarette
advertising and total cigarette consumption in the UK. London: Metre
Consultlug Croup Ltd., 1979.
~ompson-NoeI M.
1980 Jan 17.
Tobacco: how not to play a hand. Financial Times
E~tozial. Cigarette ads: Why this latest report can only be harmful.
CmapaiEn 1~80 Jan 25.
Leader. Tobacco sponsorship of sport: think again.
2~:
Br Med J t982;
T108351280
Gray l~. The social and economic implications of tobacco use. In:
Forbes WF, Frecker RC, l~ostbakken D, eds. Proceedings of the Fifth
World Coaference on Smoking au~ ttealch, Winnipeg, Canada, 1983.
Ottawa: Canadian Council on Smoking and Health, 1985.
Glantz SA. The tobacco industry's response to scientific evidence on
i~voluntary mklng. In: Forbes WI~, Frecker RC, l~stbakken D, eds.
Proceedings of the Fifth World Conference on Smoking and Health,
Winnipeg, Canada, 1983. Ottawa: Canadian Council on Smoking and
Health, 1985.
T108351281
623
TO~CO C~LTIVATION
Since its introduction as a cash crop by the Malaysian Tobacco Company (a
aubsidiary of the B.A.T.) in 1959, flue-cured Virginia tobacco has increased
steadily in hectarage and production. By 1982, 12,000 hectares were culti-
vated, mainly in two rural states, and it is expected to increase to 15,800
hectares by 1985. The output had increased from 1.82 million kilograms in
1970 to the peak of 9.4 million kg in 1982 - worth US$38 million. In 1972,
the National Tobacco Board was formed to control production and marketing,
to prevent outbreak of tobacco disease and to encourage growth of the indus-
try. In the 4th Malaysia Plan (1980-85) US$8 million was a11ocated for
research and subsidies.
The tobacco industry is unusual in Malaysia as the functions of growing,
curing and manufacturing are performed by three separate groups. Because of
this separation of functions, the farmers are more interested in quantity
than in quality. The yield is still low at about 700 kg/hectare as compared
to the ideal of 1500 kg/hectare.
Malaysia's population is about 14 million. About 62,000 families (120,000
people) are involved in tobacco farming, and the 360 independent curets
employ about 25,000 workers. Most of the farmers have small farms, about
I/2 to i hectare each, resulting in about US$I00-$140 income per month for
each farmer.
The Minister for Primary Industries has declared '~igher tobacco prices have
raised the socioeconomic standards of people in the rural areas" and the
Deputy Agriculture Minister pointed out "the success of tobacco growing
promises to raise rural living standards of the East Coast States". In
~dition, these two states have been economically backward with strong
opposition political parties. The irony is that these parties are conserva-
tive and Huslim parties. The extent of influence by Islam on tobacco is
still not clear. Alcohol is considered "haram" (sinful) while tobacco smok-
ing is only 'tmakroh" (discouraged).
TO~ I@~OFACI~R~RB
are seven companies manufacturing cigarettes, of which the three
T108351282
largest are ~jltiamtio~al: Malaysian Tobacco Co~pany (HTC), Roth~ans and R J
~olds. ~ t~sel~ holds 70Z of the ~rke~ and t~s turnover has risen
fro~ US$73 milIion ~n 1974 ~o US$27~ Billion in 1982, a
ni~ years, an average of 30~ per year. The profits have also increased
consistently fr~ ~S$22 m[ll~on in ~978 Co US$~2 m~llion in 1982, an
increase of 90~. ~C is the 19~h largest co,any in the ~laysian cor~rate
sector. ~h~ns also ~ncreased i~s turnover from US$I16 million
U~145 m~li~ in 1982 (ri~ of 2~%) a~ its pre~ax profits rose from ~8.3m
to $II.3m (increase of 37%). The total turnover for all cigarettes sold
1982 was nearly US$460 million.
This figure can be compared to the US$273 m£11£on allocated to the Health
Ministry for a period of five years. The government derived about 47Z of
the total turnover £n various forms of taxes. This large amount could
easily influence the government in its dealings with the issue of cigarette
smoking.
The tobacco manufacturers have a direct interest in the tobacco growing as
the. industry, unable to deny the harmful effects of cigarette smoking, is
now exploltlng the economy of the tobacco farmers to justify their business
and to~nfluence the government from taking any action against smoking.
They still provide technical expertise, guarantee purchase of tobacco and
provide almost 75% of the fertilisers used. Since 1959, it has spent US$4.2
milli6n in helping the tobacco farmers. At present 60Z of the tobacco
required for cigarette manufacture £s locally produced and is expected to
increase to 65-70Z by 1985.
Cigarettes were the leading form of product advertised in 1981, when USa9
million was spent, the only product to exceed the US$8 million mark. Until
cigarette advertisements were banned from radio and television (both govern-
ment owned), US$0.68 million was spent on radio advertisements and US$2.3
million on television in 1978.
In 1978~ the Minister of Information declared that cigarette advertisements
~ould not be banned, as he believed that banning is futile in reducing smok-
ing and would only reoult in greater unemployment! But by 1979~ several
restrictions had been made on different occasions. Firstly, advertisements
c~id not im~1ve ~eople. They were then restricted in number. Later
advertlsem~nt$ were not allowed before 9 p.m. It was then decided to add
the health warning notice which was silent but later was to be voiced over.
The frequent changes in rules led to complaints by the manufacturers.
"Since ~he begimn~r~ of this year, almost every three months, there have
been addlt~onal guidelines on advertising. This disrupts marketin~ and
~rom~t~onsl strategies. W~ny not 5~n all cigarettes advertisements~" In
!982, all cigarette advertisements on television, radio and all government
publications were prohibited B then the new Minister said
advertxsementa for~
and could be replaced
o . er ze~e~t~eo. This action had far reaching implications as both radio
and televisi.on are entirely government o~ned. Wearly half of the adults
regularly listened to the radio and there are 2.5 million television sets
(each with a~ average of four viewers) in a population of 14 million.
TlO83512t
Of course, the cigarette companies continued their promotional campaigns as
they said nThe ban is definitely making our advertising task difficult - new
ways out of this dilemma have to be found". The newspapers offered them a
suitable channel, with over 50 newspapers in eight languages and a total
circulation of over four million published in the country. Full page multi-
coloured advertisements appeared regularly in the papers. Although the
warning sign is compulsory, it is small and placed inconspicuously in one
corner.
Cigarette companies often camouflaged their advertisements by using brand
names to sponsor certain events, especially in sports. It could be '~Benson
and Hedges" Golf, "Football sponsored by Dunhill" or Rothman's "Grand Prix"
but not only are the warning signs not included in such advertisements~
these events could be advertised on radio and television. An insidious
campaign by I~TC, in launching their new brand 'heritage", is the holding of
an exhibition '~leritage in Gold" at different towns over the last two years~
each time with numerous announcements and the logo of 'heritage" and "Benson
and Hedges" displayed over radio and television. Winston had a campaign to
associate their flying eagle symbol with the sale of prints of the eagle for
the World Wildlife Fund. Live football telecasts were sponsored by Dunhill
of London showing non-tobacco products. The Malaysian Press Awards are
sponsored by the Malaysian Tobacco Company.
CIGARETTE SI~OKII~ 11~ HALAYSIA
The number of cigarette smokers has increased by about 5-7% over the last I0
years. In 1975, a study by a leading newspaper showed that 1.25 million or
20% of the total adult population smoked. Most of them (91%) were males.
Nearly three-quarters of them (74%) were in the lower socioeconomic class
earning less than US$125 a month. The average cigarette consumption per
adult aged 15 years and above has risen from 1440 cigarettes/year in 1965 to
over 2000 cigarettes/year in 1978, an increase of 44%. In 1977, over I0
million cigarettes were consumed.
Recent studies on secondary schoolchildren showed that the incidence of
smoking is about 20%. About half of the children were habitual smokers and
about 20% of them had smoked for over three years. Concern has been shown
about student smokers, not so much because of the health dangers of ciga-
rettes but due to a close association with drug addiction. The Education
Ministry issued a circular ~ha~ no smoking is allowed on the school premises
except in the teachers common room. Students caught smoking could be
~nished by- warning, caning or even suspension. This did not apply to
college students.
Except for elderly village women, smoking is still uncommon in women. A
recent study of women attending an Obstetrics & Gynaecology Clinic showed
only 3% were smoking, in contrast to 41% of their husbands who smoke. Even
those who did were mainly light smokers.
Be£ore 1980, action against smoking was slow and sporadic. The ban on smok-
ing in air-conditloned cinemas in the larger towns was surprisingly
effective.
T108351284
The medical profession was ohe first to raise the issue of the ill-effects
of smoking. The MMA, together with the Ministry of Health, formed a joint
Antl-smokin~ Committee in 1970. After nearly five years of lobbying against
strong opposition the breakthrough was achieved. In 1977, the Cabinet
approved the proposed legislation that all cigarette packets should incl~e
the health warning: "Smoking is hazardous to health" (or in Malay, merokok
membahayakan kesihatan). Although the effects of the health warning are
debatable, this is the most definitive sign that the government acknowledges
the dangers of smoking, thus making subsequent demands easier to justify.
Progress was slow partly beca~,se many of the political leaders were
s~6kers. The first Prime Minister, Tunku Abdul Rahman, even declared he
anjOU's~ "smoking. The first Speaker of the Federal Parliament was made Chair-
man of Rothmans (Malaysia) when he retired. Packets of Rothmans cigarettes
were especially prepared and distributed free to all Members of Parliament.
In ~980 the World Health Theme on smoking proved to be a catalyst in focus-
~ng~att'entlon on the issues of smoking. The Ministry of Health, in
r~tlonLwith the Medical Associations and consumer bodies, led a State-to-
~t~_af~-'~.~pa-ign featuring government personalities.
It.~ was also opportune that the new Prime Minister, Dr Mahathir, was a
medical doctor and a non-smoker. New ant i-smoking measures were taken,
cul{ninating in the 19-polnt Federal Government circular prohibiting govern-
ment off,cars from smoking in the office and at meetings and restricting
¢igsrette advertisements. The circular is however not law but only an
adm~n%strat~ve directive. No mention was made of action for defaulters and
impl~me~tstion has not been uniformly achieved, much depending on the head
of-dep~rtment. At the start, "no-smoking" notices were not even available
and ~he Malaysian Medical Association had to supply our posters to many
gov~rn'ment departments. Several town councils took action to prohibit
advertising in public places including the feder~l capital and the state
cap~l of Kelantan~ the largest tobacco growing state. There were,
however, several loopholes. The act mainly covered roads and public
buildings. Private buildings including such public places as restaurants,
cinemas and even stadiums could continue advertising even though these are
obviously accessible to the public.
Smoki~tg on p~blic transport, especially buses, became a burning is~ue with
numerous letters appearln~ in the press. Although ~he Ro~d Transport
Ordinance of 195~ prohibits smoking by bus drivers ~nd conductors wh~le at
work '~nd~ve~ prohibits amokiu~ by passengers in buse~ which h~ve No-Smoklng
s~gns~ implementation was not ef~e¢~ive a~ ~¢ ~ left to ~he bus opera-
tots. N(~-$m~k~ areas were provided in trains and ferries. The national
airline ~n early 1983 took an unprecedented step of converting the seating
to Ehe vertical div~slon on the grounds that smokers had complained that
they always had to sit at the rear. Protests made by ASH of the MMA were
imstrumem, tal in persuadlng MAS to change thls decision back to fore-aft
division.
The I~82 budget increase for excise duties on local tobacco and import
duties o~ imported ~o~¢e ~=i ~= ~e flrs~ slgn~/~cant increase ~n the
price of cigarettes. For many years, the price increase of a packet of 20
clgarettes~was lo~er than the rate of inflation, being only 60 cents US in
T1083,51285
627
1980. The increase in duties led to an increase of 15 cents US per packet.
The sudden rise in price did lead to a drop in the sales - as admitted by
MTC "fewer cigarettes w~re sold as a result of the increase in prices".
Since then, the manufacturers have had to increase prices again by another 5
cents due to higher production costs. Just last week the Finance Minister
announced a further increase in duties on imported cigarettes and cut rags
tobacco so as to cut down imports which had reduced demand for local tobacco
leaves from 94.7% in 1979 to 83.4% in 1982. Nith the increase, the cost of
imported cigarettes is likely to go up by 15-20 cents per 20s packets.
Forthcoming action should be targeted along the following lines:
(I) Banning all cigarette advertisements, or at least plugging the loopholes
on cigarette advertisements, such as increasing the size of the warning
sign~ preventing pseudo adverts with the use of cigarette brand names on
non-tobacco products.
(2) Stopping all cigarette sponsorhip of sports events.
(3) Publication of tar/nicotlne/carbon monoxide contents. As was revealed
by the Health Ministry's study of twelve brands of locally manufactured
cigarettes, the tar/nlcotine levels were much higher. The tar content
ranges from 18-61 mg, with nine brands at 22-29 mg and only two brands
at 18-19 mg. The nicotine levels were at or above 2 mg in three brands,
and 1.5-1.9 mg in six brands.
(4) Stricter implementation of non-smoking areas in public places.
(5) Greater efforts in health education especially in the non-English
language media and to the youth.
T108351286
PAPUA
Hartin ToVadek
Minister for Health
P.O. Box84, Kooedobu
Papua New Guinea
Konrad Jamrozik
Lecturer in Community Medicine
University of Papua New Guinea
P.O. Box 5623, Boroko
Papua New Guinea
INTRODUCTION
Papua New Guinea consists of the eastern half of the island of New Guinea, lying
just north of Australla, and a number of nearby Pacific islands. It is both
new nation, having gained independence in 1975, and a young nation, with 43Z of
the population being under fifteen years of age. There are 3.5 m£11ion
people speaking at least seven hundred different languages and spread over
terrain varying from tropical atolls to rugged mountains of m~re than
metres. Currently, the major health priorities are those of any developing
country, namely, control of infectious disease, provision of clean water and
adequate sanitation, and extension of maternal and child health services to all
Chose who require chem. Nevertheless, we are aware that the developed coun-
tries, having overcome these problems, now face an epidemic of chronic diseases,
many of which are related in some way to lifestyle, and in particular to
smoking.
HISTORY OF ~4DKIN~ IN PAPUA NEW CUINEA
The origin of tobacco in Papua New Guinea (PNG) is unknown. It appears to have
been introduced into the Phillppines and Java at the e~ of the sixteenth
century, and possibly it was from these areas that it found its way via Malay
traders through Irlan Jaya (West New Guinea) to the Seplk area in the eastern
half of the island. Yrom the $eplk it gradually spread to other areas along
traditional tr~e and exchar~e routes. T~e ~u~b~-efter ahells from the coastal
areas were traded from one gro,p to ~nother until they reached the Highlands
where they were bartered for ~obacco. There is even a legend which tells
to~cco being given to the Kiva£ people by the sacred figure who taught them
to cultlvate food crops. This suggests that native tobacco, known as brus,
been cultivated and s~ked ~ the ~ople o~ PNG since long before t~ sixteenth
century.
T108351287
At t.he time o£ first contact with Europeans in the late nineteenth century,
smoking of home-groom leaf was prevalent amongst a widely scattered popula-
tion throughout the length and breadth of the country, and even in remote
and iuaccesaible areas, as well as in the Islands region. When the peo~le
of r~e Cencral Highlands were discovered in the 1950's, they too were grow-
ing and imoklng tobacco.
Ho~ever~ it would appear that the smoking habits of those who used tobacco
were not excessive. Oniy small amounts were grown, and, as it is very
strong~ only small amounts were used. It was mostly smoked in a bamboo pipe
or wrapped in a green leaf.
The Europeans brought with them loose twist tobacco which they used to trade
for food and labour. The Papua New Gulnean people were attracted to the new
tobacco because it was milder to smoke and easier to carry. It also became
a status symbol. The white man was obviously a 'big man' with his wealth of
axes, guns and other tools, his clothing, and later his aeroplanes - and he
smoked..¢his new tobacco. Therefore it followed quite naturally that PNG
people thought that they looked better or bigger in the eyes of their fellow
_ men if they too smoked this tobacco. It became a fashion and a symbol of a
supposed position within the society. From this example of the "smart thing
to do"~ others, who never smoked even local tobacco before, began to smoke
twist . tobacco. As the supply increased - it was a cheap method of payment
" ""~'0~~ h~rd labour- so did consumption by local people. In the early 1940's
PNG Was'' importing 70,000 kina* worth of twist tobacco, and, despite increas-
• ing iinterest by Europeans in the growing of tobacco for commercial use, it
was ~1958 before twist tobacco was being produced locally in a regular
st~pply.
In the 1960's, cigarettes began to take over and the international tobacco
companies moved into PNG in order to produce twist tobacco and cigarettes.
In 14 years, between 1959 and 1973, the annual consumption of manufactured
tobacco in PNG rose by an incredible 161% - that is, by almost one million
kilograms. Of this 161%, three-quarters was cigarettes, and 90% of the in-
crease took place between 1964 and 1974 after cigarettes began to be manu-
factured in the country. By 1982, total tobacco sales had grown to
K50,310,000 per annum.
The l~ealth Department of PNG spends many =housaztds of kina per year treating
tob~¢~o~~elated illnesses. Both lung cancer and coronary heart disease,
previously al~st unknown, are now being seen ~re frequently. Chronic
resPirato~~ disease is already a problem in the ~ighlands, ~rhaps due to
s~ke f~om.do~stic fires, and acute resplrato~ infecti~ is still a~ng
the top three c~uses of death ~io.nwide. The cost to the country in
absenteeism ~nd loss of productivity due to s~king-related illness has yet
to ~ ~asured,
1 Zina is approximately equal to US$1.15.
T108351288
lvO~CCO ~'~F~rlS/.~ IN PAPUA ~ G~I~EA
Tobacco imports, including prepared tobacco ready for manufacturing in P~G,
as well as some fully-imported brands of cigarettes, are taxed at the rate
of K53.50 per kilogram. In the first eleven months of 1982, the Government
of PI~G earr~ed a total of K20.14 million from excise duty levied on the sales
of locally made cigarettes, which works out at about 30 to 40 toea (or 35 to
45 cents U.S.) per packet of twenty. On top of this, some provinces add
another local tax on the sales of consumer goods iucluding cigarettes.
From excise duty charged on sales of trade (twist) tobacco, the government
made an estimated K3.5 million. To that we must add import duty of K2.5
million on cigarettes made o~zerseas, this tax being designed to protect the
local industry which employs around 700 people in a total non-village work
force of approximately 400,000.
The final total of government revenue from import duty on tobacco and ciga-
rettes during this eleven-month period was approximately K27 million.
Compare this w~th our population of about 3.5 million, and it is seen that
the government benefits by about Kg.00 for every man, woman, and child in
the country.
In 1981, the tobacco farmers in PNG earned a total of K824,000. This
amounts to only 2% of the value of tobacco imports into the country, despite
the fact that a high proportion of their crops was exported to Australia for
processing and then re-exported from there back to PNG. The tobacco
industry, as such, therefore does not contribute anything of significance to
the benefit of the people of our country apart from the employment of 700
people and a mere K824,000 per year in tobacco purchases from local growers.
PROMOTION OF TOBACCO
To summarize the present situation, in the 1940's K70,000 worth of tobacco
products were imported into PNG; in 1982 government revenue alone, from
sales tax and import duty on tobacco products, exceeded K27 million. The
first considerable increase took place within two years of the first ciga-
rette being manufactured in the country, and consumption has escalated
alarmingly since then because of vigorous advertising and sport and cultural
promotions by the major cigarette manufacturers. It has long been the
concern not only of the Healt~ Department of PNG, but of many of our people,
that cigarette smoking is increasing at such a rapid rate. In many of the
poorer househol~s as m~ch ar~ often ore money is spent on cigarettes and
tobacco as on food, with the exception of rice.
More and more younger people are beginning to smoke, with the example being
set by the 'big men', the leaders in business, academic life, government,
sport[ng and social groups, in whose footsteps our yo~r~ people would like
to follow. This example is being actively encouraged by the advertising and
promotion of cigarettes and tobacco by the major companies manufacturing
these products in our country. In the remotest villa~e~ on moun~aln top,
island or valley, one is able to identify the small villa e st e b
s promoting o~e or other o~ the popular
brands of cigarettes or tobacco sold to our people. In 90% of these stores,
this is the only form of advertising to be seen. Cigarette signboards
T108351289
632
similarly dominate roadaide advertising in the larger urban areas. T-shirts
are almost a uniform in our country and probably are one of the most
effective ways of getting a message across. Again, throughout the country,
T-shlrts may ~e seen advertising and extolling the virtues of cigarettes and .
tO~>aCCO.
We are ~.fortunate so far, inasmuch as we do not yet have television and .
tkerefore our people are not exposed to the pernicious advertisir~ seen in
some of those countries which do have this medium. However, we do have
extensive advertising of cigarettes and tobacco in both the newspapers which
are published in PNG, and, of course, in the great majority of those news-
papers .and periodicals that are imported from other countries. Pull-page
a4~vertisements for cigarettes appear a~ least weekly in the local papers,
and cost at least K200 each. We also have radio advertising in several
languages which is extremly effective in a country where many of the people
~a~'no reading skills.
Perhaps' the form of advertising with the greatest impact of all is the
promotion by cigarette companies of major sporting and cultural events in
PNG, For example, the headquarters of the major football club in Port
Mo~esbf-displays a large hoarding announcing that it is also the '%ome" of
a leading cigarette brand. In our newly-developing country we have few
large'business houses or other private enterprise concerns upon whom we can
depend ,for the financial support necessary to sponsor our sporting and
cultural affairs. Most of our people are subsistence farmers living in
~iii~ge& ~and obviously they are not able to fund our nation's love of
s~ort. ~-Therefore the cigarette companies (and formerly the breweries) have
a ready-made audience waiting to receive and applaud their donations and
sponsorship and to defend the advertising of their noxious products.
M ~OVERNMENT'S ~ESPONSE
A few years ago the government was successful in banning the general adver-
tising of alcohol. Today these products are advertised only in so far as
the outlets which sell them may put up a sign advising the public of this.
There is the occasional dispensation when the brewery may sponsor a major
sporting event, usually an internatlon~l one requiring a lot of funding.
Although the Minister of Health does not agree with this personal~y, this
concession had to be made in order £o obtain agreement to the general ban.
The Health Department, in consultation with the PNG Institute of Medical
ReseatS.an4 the Ant~-Smoking Council of PNG, has drawn up legislation which
will effectively ban all advertising and promotion of cigarettes, tobacco
and related products. It also aims to:
- create non-smoking areas in public places,
- establish health education programmes,
- provide clinics and counsellors for those who want to give up
s~oking,
- collect c~rrent informetio~ on trends and attitudes of smokers,
- measure the health consequences of smoking in the co,unity.
T108351290
633
Legislative measures will include:
- regulations controlling advercislng of tobacco products
- the prohibitio~ of cigarette packets which do not carry a health
warning and hazard symbol,
- prohibition of the sake or giving of tobacco products to people
under the age of eighteen years,
- increased import duty on tobacco products.
A policy submission has been drawn up and is ready now for presentation to
Cabinet together with the draft legislation. We are merely waiting for it
to appear on the agenda. We do expect a great deal of opposition particu-
larly, of course, from the tobacco companies and those sporting and cultural
groups whom they support. Doubtless, too, there will be pressure from the
smoking public whose addiction we propose to tax heavily. Although it is
not going to be an easy piece of legislation, we are determined to prevent
an epidemic of smoking-related diseases in our country before the situaton
gets out of hand, as it has in so many developed and other developing
countries.
We will not allow these companies to exploit the health of our people in
order to gain the enormous profits they collect when they off-load their
dangerous products on to the public. We will not allow the health of our
people co deteriorate because we failed to take preventive measures in time.
T108351291
635
Stephen D. Woodward
ASH (Australia)
214 Drummond Street, Carlton
Victoria 3053, Australia
This paper will describe the preparation, introduction and passage of a
parliamentary Bill to end tobacco advertising in Western Australia (W.A.),
one of the seven states of the Commonwealth of Australia. The Bill was a
project of the Australian Council on Smoking and Health (ACOSH), a volun-
tary, charitable council with nominees from the major medical and health
professional organizations concerned with reducing the health consequences
of smoking, and the numbers of children starting to smoke. Nominees to
ACOSH were heavily committed to their own occupational spheres and could
devote only a little time to Council activities. ACOSH had no full time
staff until the appointment of a Research Officer, in July 1981. The objec-
tives of ACOSH are in accord with the objectives of the U.I.C.C.'s Compre-
hensive Smoking Control Programme (I). Whilst ACOSH believes that all
objectives should be pursued, this paper will deal with an attempt to stop
all forms of tobacco promotion in W.A.
PREPARATION OF THE BELL
At its inaugural meeting in 1971, ACOSH had resolved to take action to
restrict advertising of cigarettes and tobacco products. In 1976~ the
Federal Broadcasting and Television Act was amended to prevent direct adver-
tising of cigarettes on Australian radio and television. The amendments
allowed however for 'indirect or incidental' advertising and it is now
common to see many billboards or perimeter adverClsements for cigarettes
during the telecasts of sporting or cultural events. This was the only
significant legislative measure undertaken in Australia to prevent tobacco
promotion. The purposes of ~his new Bill, described in this paper, were to
extend the restrictions ~o all areas where the W.A. Government had constitu-
tional control, including billboards, newspapers, magazines ~nd other publi-
cations prinfed in W.A., on public transport and by the distribution of free
samples of cigarettes.
A legal-political sub-commlttee of ACOSH was formed in 1979 to investigate
and recommend the necessary legislative initiatives. The sub-committee met
with Federal and State parliamentarians, undertook correspondence and issued
questionnaires before resolvlng that a parliamentary Bill should be draft-
ed. They were assisted in this regard by expert legal counsel. A draft Bill
modelled on similar legislation in Singapore (2) and Norway (3) was avail-
able in ~ay, .......
standing colleague of the med{cal doctors on ACOSH and the o~]y ~edlcally
TIO835'I~D2
quallfled ~ember of the g.X. Parliament, Dr. C.T. (Tom) Dadour. Regarding
introduction of the Bill into parliament, Dr. Dadour recou~ended that the
Minister for Health be encouraged to do it. The chances of success of the
leglslatio~t would be considerably enhanced. To introduce it as a Private
Member's Bill would be placlng successful passage in doubt and to introduce
it as an Opposition Bill, beyond hope.
Appointments to discuss the propositio~n were made with the Minister, but
because of ill health on his part, discussions were held with the Deputy
Premier (soon to become Premier) in September and December 1981. The Deputy
Premier expressed his "personal sentiment against tobacco smoking and his
government!s commitment to do all it could to lessen the magnitude of tobac-
co _i.nd~ced disease" (it had in fact done little and had no specific pro-
gra~mnes of its own in this area). He said that "there would be a lot of
sympathy within the Liberal Party (his government party) to a Bill prohibit-
ing the advertising of tobacco products, but felt it should be a Private
Members Bill". He advised us to continue discussions with the Minister for
He.a.l.~.h. :..We recommenced negotiations with the Minister and he took the Bill
to Cabinets which would not support it. Dr. Dadour offered immediately to
.introduce..the Bill and he did so on 13 October, 1982. It was titled the
Smoklng and Tobacco Products Advertisements Bill (STAB).
Lobbying of parliamentarians by the tobacco industry is a continuous
process. It is increased in tempo and intensity when a Bill such as STAB is
introduced. In February 1982, prior to the introduction of STAB, Members of
the W.A. Parliament had received a document entitled "Don't Sit On The Side-
li~es,.,The Case for (Tobacco) Sponsorship of Sport". This consisted of an
appalling collection of sol~cited letters from sporting administrators show-
ing their indebtedness to tobacco companies for providing sponsorship money
to their particular sport. Co{ncldentally, shortly after ACOSH had met with
the Deputy Premier and the Minister, and provided the latter with a draft
copy of the proposed Bill, the Tobacco Institute of Australia, the indus-
try's lobby, sent a proposal to 'Selected Cabinet Ministers of the Parlia-
ment of Western Australia' concerning 'the Retention of the Right to Display
Cigarette Advertising on Sites Under the Jurisdiction of the Government'.
Whe~ Dr. Dadour had tabled STAB, the Tobacco Institute responded immediate-
ly, sending propaganda material to every parliamentarian the next day.
I~¢l~de4 ~m t~Is propaganda p~ckage was "Advertising and C~garette Consumma-
tion" by M.J. Waterson (4). This document ~nd its author have been promoted
by the tobacco industry as definitive authorities on this subject. @¢ert
ge,eralisations and glaring omissions make a rebuttal of the publication
simple. S,eh a critique is available from ACOSH. The industry did not
spare fln.sneial or manpower resources. According to one journalist assigned
to cover the Bill, a specialist team of seven lobbyists was flown to Western
Australia to co-ordinate their campaign. The campaign included:
Details of these interviews are for obvious reasons unavailable. It became
clear, however, after speeches by some members in the House, that parliamen-
tarians h~d bee, liberally supplied with misleading information.
T108351293
CAI~AIGaIilG ~ 1.~GI ~SLATI0~I
637
2. Imtez~ie~s o~ talk l~ck radio m~d television
There was no bias apparent in reporting by any of the three local television
stations. The tobacco lobbyists had a disproportionately large share of
radio air time and showed no conscience about giving misinformation and
telling outright lies a~out the effectiveness of the advertisin~ bans in
Singapore end ~orway. Some anno%m~ers and journalists uncrit~cally contin-
ued to repeat the industry propaganda, despite receiving briefing notes to
the contrary, referenced to authoritative sources.
3. Telexe$ sad letters to 1~rliameutaria~s
Despite the previous assurances given by the Deputy Premier (now Premier) of
"his personal sentiment against tobacco smoking ...", it became obvious that
his office was co-operatlng fully with the tobacco lobby. Over 270 telexes
from various advertising groups, addressed to members of parliament, urging
them to vote against the Bill, were received on the Premier's telex machine
and dispatched on his office stationery. The Premier was later rebuked for
this in Parliament.
4. Newspaper ~dvertise~ents
During the reading of the Bill in the Legislative Assembly, the debate was
adjourned on the call of the government, to be resumed at the wish of the
Premier. Despite requests from government members, other parliamentarians
and representatives from the health lobby, the Premier refused to divulge
when the debate would resume. The tobacco industry lodged nmny full page
advertisements in every daily newspaper for nearly a week preceding the
resumption of the debate on the Bill. Was it an apparent coincidence that
the industry was able to lodge these advertisements at precisely the right
time or were they privy to inside information? The advertisements claimed
that the Bill would be ineffective in controlling smoking and would have a
number of unintended adverse effects. Although the Minister for Health and
his other Cabinet colleagues later confirmed, in the Parliament and in
private correspondence, the untruthfulness of the industry's criticisms,
they did not make any press statements whilst the advertisements were
published. Another series of industry sponsored full pa~e newspaper adver-
tlsements encourage4 m~mbers of the public to write to the Premier if they
opposed the Bill and provided a coupon to facilitate reply.
5. ]~le of newspapers
The newspapers gave preferential treatment to the point of view being
expressed ~y the tobacco lobby, both in editorial and news columns. Whether
this reflected the publishers vested interests in the income generated by
cigarette a~vert[sem~nts or their proclaimed 'freedom of the press' argument
was mot known. What was known was that articles written 5y journalists
sympathetic to the objectives of the health lobby were not published. The
management of the paper with the largest Sunday circulation in Western
influence to get the M.P.'s in their circulation districts to vote against
the Bill.
More detail on specific arguments raised by the industry has been given
elsewhere (5).
T108351294
Althou~h much smaller a~d much less co-ordinated than the tobacco lobby, the
health interests were influential. The role played by medical doctors can-
not be u~derrated. Three government members voting against Cabinet, but for
the" Bill, recorded in their speeches that the position expressed by doctors
ha~d strongly i~flu.enced their decisions to support the ~ill.
I. Propaganda to parllameutarlans
Submlsslons and briefs provided to parliamentarians were always endorsed by
tb~"Australian Medical Assoclatlon~ the Cancer or Heart Foundation or the
University Medical School and focused on the number of deaths caused by
smoking and the numbers of children starting to smoke. In these areas the
i~d~~'ry is defenceless. Although less lavish than the industry's submis-
sions~ parllamentarians had more confidence in their credibility. Special
sh0r.t~pap.e.rs were prepared whenever the industry was providing misinforma-
demonstrate the inconsistency of industry arguments. Brevity and
.~..c¢,u,r.~.cy.. were important here. Parliamentarians do not get time to read
wordy and long winded submissions. It is more effective to issue five
separate two page submissions than to issue one ten page paper.
2.,.. Person~l interviews with parliamentarians
Interviews were not undertaken with the same frequency as performed by the
industry. The medlcal-health lobby need to be more acquainted with parlia-
mentarians on a face-to-face basis.
.Petitions
Junior medical staff at the major teaching hospitals organized petitions
signed exclusively by doctors. They were presented to parliament and
received wide press publicity,
4. Doctors rally at Parliament House
A nmrch and rally at Parliament House was also composed exclusively of
medicsl doctors. One hundred and fifty doctors ~arbed in long white co~ts
with obvious stethoscopes carried placards in the only public demonstration
by medical doctors in W.A.
Although these two strategies were undertaken exclusively by the medical
element of the health lobby and could be criticized as professional snob-
bery, they were very powerful. The prestige and cre~ibillty offered by the
medical profession cannot be bought by the industry and should be used to
the maximum.
5. Pz~ss statements
cancer socle¢ies a~d leading personalities such as the medical officer to
the Australian Olympic Team. ~arely were they publish~ in full and often
not at all, ~is contrasted with the exposure given to the industry ~£nt
of view. ~e health lobby issued ~st press state~nts £n typed for~t; the
T108351295
639
industry was kno~-n to have issued only one typed press statement, all others
were communicated personally or by telephone. This difference may reflect
greater assistance given to the industry by the publishing houses.
6. Ory~n~zatio~l m~pport
Only a few sympathetic organizations were co-ordinated to voice their
support for the Bill. A request from the local branch of the Australian
Hedical Association to its members that they contact their parliamentarians
(preferably in person or by telephone) drew excellent response• Many other
organizations made unsolicited submissions to parliamentarians. Organiza-
tional support should be co-ordinated in future campaigns to maximise its
effectiveness.
VOTING IN ~ PARLIAMENT
To become law, the Bill had to be passed by a majority of votes in both
Houses of the Parliament, the Legislative Assembly and the Legislative
Council. The Government parties had a majority of 9 in the Assembly and a
majority of 13 in the Council. With declared Cabinet opposition to the Bill,
government backbenchers were under pressure similarly to oppose it.
Certainly any aspiring Minister would have committed political suicide by
voting for it. In the Legislative Assembly, the Bill was passed, 30 votes
for and 24 against, with 6 Government party members voting for the Bill. In
the Legislative Council it was lost 13 votes to 18, with 3 Government
members voting for the Bill.
Gray N, Daube M. Guidellnes for smoking control. UICC Technical Report
Series - Volume 52, Geneva, 1980.
Rajah KS. Legislation on tobacco smoking in Singapore. UICC Regional
Workshop on smoking and health, !98~.
L~chsen PM, Sjartveit K, Haukness A, Aar@ LE. Trends in tobacco
consumption and smokin~ habits in Norway. Oslo, Norway: National
Council on Smoking and Health. 1983.
Waterson HJ. Advertising and cigarette consumption. London, England:
The Advertising Association. 1981.
Woodward S. The 1982 Western Australlan smoking and tobacco products
advertisements bill. ~ed J Aust 1983; I: 210-212.
TI08351~
---
LOWGIT~DEWAL PREDICTION OF ~E O~SET AND CHARGE OF ADOLESCENT S~K)KIR~
Dennis V. Ary, Ph.D.
Anthony Big|an, Ph.D.
Cheri L. Gallison
Wendy Weissman, M.S.
Herbert H. Severson, Ph.D.
Oregon Research Institute
195 West 12th Avenue
Eugene, Oregon 97401, U.S.A.
This paper presents a longitudinal study of the onset of adolescent ciga-
rette smoking and changes in smoking rate. The onset of smoking is distln-
guished from change in rate, since the factors that affect these two facets
of the transition to regular smoking may be different.
Despite the large number of studies of the correlates of adolescent smoking,
few have been longitudinal. The available longitudinal studies have identi-
fied three main sets of variables that predict later smoking, although
results are not entirely consistent. Intentions to smoke have predicted
later smoking in three studies (1,2,3). Adolescent smoking has been shown
to be predictable from peer and sibling smoking (2-5). Parental smoking
behavior has also been found to predict later adolescent smoking (1,2,4,5).
All but one of these studies (2) sampled subjects from the 6th, ~th, or 8th
grades. This may be problematic in that smoking is more likely to occur in
higher grade levels (2), and the factors that influence smoking may be
different in higher grades. To date, there have been no studies which
systematically examined whether the predictors of smoking differ by grade
level. Similarly, differences in smoking predictors for males and females
have not been analyzed. The present study does so.
The use o£ alcohol and marijuana as predictors of smoking is also examined
in the present study. Johnson, Grsham, and Hansen (7)studied the relation-
ships among the use of these three substances over time in a sample of 1,105
lOth grade students. ~hey found that the use of m~rijuana predicted
cigarette ~ki~t~ over a six-month period, although drinking of alcoholic
beverages did not. Differences in these relationships at higher and lower
grades and between males and females shovld also be examined.
Most of the available longitudinal research has focused on pred£ctlng later
smoking for samples of subjects who had never smoked or were not smoking at
the time of the first assessment (1,2,3). The variables that influence onset
Send requests for reprints to: Dennis V. Ary.
T1083512'98
642
of smokin~ may not be the same as those that influence current adolescent
smokers to increase or decrease smoking. This latter group has not been
studied. T~erefore, the present study examines the correlates of char~es in
the rate of smokin~ at follow-up among subjects who report smoking at the
~nitial assessment.
The questionnaire assessments employed in this study were accompanied by
collection of two physiological measures of smoking - expired air carbon
monoxide and saliva thiocyanate. These procedures have been shown to
increase the reported rate and the accuracy of self-reports of smoking
(8,9), The absence of such a procedure could particularly jeopardize the
findings of lon~itudinal studies of smoking.
Eleven hundred elghty-one teenage students participating as controls in a
long-range smoking prevention project provided initial questionnaire and
physiological data regarding their smoking. Eight hundred eighty-four, or
75%,'of these subjects also responded to a slx-month follow-up questionnaire
regarding their current smoking behavior. Subjects came from two school
districts in Lane County, Oregon, U.S.A. Two high schools and five middle
schgols participated. Five hundred sixty-two middle school subjects were
assessed in 7th grade health and science classes. There were 322 high
school students in three lOth grade health classes and seven 9th grade
health classes.
Measures
A questionnaire regarding smoking experience was administered to all sub-
jects. Items explored the respondent's socioeconomic status, smoking
history, attitudes toward cigarettes, and the smoking behavior of parents,
siblings, and friends. Current self-reported smoking rate, knowledge of
health risks, and use of alcohol, chewing tobacco, and marijuana were also
probed. Table I list6 the specific variables that were i~cl~ded in the
present study. They are grouped accordin~ to the type of factor they
assessed.
A composite measure of smoking was developed which was a weighted average of
the ~epo~ted numbe~ of cigarettes smoked in the last week and the reported
number of cigarettes smoked yesterday. It was weiEhted to provide an index
of smoking over the last week:
[cigarettes last week + (7 x cigarettes yesterday)I/2
Procedures
Two weeks prior to
the students in the classroom setting. Sub~ects ~ere told that the assess-
ment would consist of filling out a questionnaire regarding their smokin~
experiences a~i providing a breath and saliva sample. Simultaneously, a
letter was mailed to parents explaining the project and the nature of the
T108351299
classroo~ assessments. A passive coosent procedure was used, in which a
parent returned a postcard only if they did not want their child to
participate. The initial data collection occurred in classrooms tw~ weeks
after the consent presentation. Anyone wishing to decline was allowed to do
T~-~LE 1
INITIAL ASSESSMENT VARIABLES A~D T~EIR
ORDER OF EIZTRY IR REGRESSION EQUATIONS
Order of
Entry for
Variable
CateKory
Variable Category
Description of Specific Variables
Pretest Smoking Rate
Initial smoking rate - number of
cigarettes in last week.
Socioeconomic Status
Mother's education level.
Father's education level.
Number of people per bedroom.
Parent Variables
Mother's smoking status.
Father's smoking status.
Anticipated parental response to
subject smoking.
Peers and Sibling
Variables
Number of smoking friends.
Number of brothers who smoke.
Number of sisters who smoke.
"Put down" if you don't smoke.
Smoking is "Showing off".
Other Substance Use
Number of times smoked marijuana
in last week.
Number of times drank alcohol
in last week.
D
Cigarette Offers
Number of times cigarettes offered
to subject.
l~tention to Smoke
Composite of intention to smoke
bo~h in a year from now and when
older.
Participants filled out an Id.entlf~cation Sheet, then gave expired air
carbon ~onoxide (CO) samples. Prior to collection of this b~eath sample,
subjects were informed that analyzing expired air ~or carbon moaoxide (CO)
content would allow identification of smokers. Subjects held their breath
for 15 seconds, then inflated a 1 or 2-1iter polyethylene bag, sealing it
sa~le us[~ a procedu~ delineat~ by Pech~cek, Murray, a~d i~ep~r
Students ~re told ~hat the saliw ~hiocya~te could ~ ~asured to de£er-
mine ~he a~unt they s~ked.
TI0835130O
Follow-up assessment occurred six ~onths after the initial assessment.
procedures ar~i measures were identical to the initial assessment.
The data were analyzed uslv~ hierarchical ~ultiple regression. Table
presents the variables that were entered into the equations and the initial
order of their entry.
Di££erences in Prediction by Ssoking Status, Grade Level, and Sex
The first analysis was designed to test whether the prediction of smoking
rate at follow-up differed depending on subject sex, grade level (i.e.,
middle or high school), and/or smoking status (i.e., smoker/non-smoker).
These relationships were examined using multiple regression in which the
predictors were entered first, followed by multiplicative interaction terms
between each predictor and grade level, between each predictor and smokin~
status at initial assessment, and between each predictor and sex (6). The Rz
for this analysis was .58. The shrunken R2 was .56. Over half of the inter-
action terms were significant, however, requiring that subset analyses be
carried out. Consequently, separate analyses were done for pretest non-
smokers and for pretest smokers. Subjects who reported smoking in the last
week were defined as smokers.
Prediction of Smoking Onset Among Non-s~okers
Differences between ~rade levels. The first analysis of non-smokers (N =
801) tested for the presence of significant interactions between grade
level and the predictor variables for first assessment. Again, over half of
these interaction terms were significant, making it appropriate to derive
separate regression equations for non-smoking high schoolers and middle
schoolers. There were no sex differences in the prediction of smoking
onset at any grade level. The predictors of later smoking differed for the
middle school and high school samples of non-smokers in a number of
interesting respects. As shown in Table 2, there was greater predictability
at the middle school level than at the high school level (R2 = .250 vs. R2 =
• 120). Number of cigarette offers, alcohol use, merljuana use, and in~en-
tion to smoke were more highly related to later smoking for middle school
subjects than for high school subjects.
Of the high s~hool subjects who did not report smoking at initial assess-
merit, 5% were smoking at the six-month follow-up. For high schoolers the
number Of smoking friends accounted for 4.8% of the variance in smoking
onset. Marijuana use in last week explained an additional 1.7% of the
variance, while alcohol use in last week was the only other variable to
account for a significant amount of the remaining variance. Alcohol intake
functioned as a suppressor variable (6). That is, when number of smoking
friends and marijuana use were partialled from both alcohol use and follow-
up smoking, the remaining variance in alcohol use was negatively and signl-
ficantly related tO the partialled follow-up ~oKing variable. Y,K=,,
together, marijuana and alcohol use accounted for 3.0% of the variance when
entered after friends who smoke.
T108351301
TABLE 2
MULTIPLE REGRESSION PREDICTING SMOKING RATE AT
FOLLOW-UP FROM INITIAL ASSESSMENT VARIABLES
NON-SMOKERS ONLY
Description of Specific Variables
Simple
Change in R2 Correlation
Pae~ ~/Sibllngs
r Substances
Othqr Substances
.~igh School - 9th and lOth Graders - R2 = .12
Number of Smoking Friends .048
Nu~nber o,f Times Smoked Marijuana Last Week .017
~mber of Times Used Alcohol Last Week .013
.220
.219
-.005
Pee~ s/Sibllngs
Oth~ r Substances
Oth~ r Substances
Int~ ntlon
Cig~|rette Offer
Middle School - 7th Graders - R2 = .25
Number of Smoking Friends .018
Number of Times Smoked Marijuana Last Week .129
Number of Times Used Alcohol Last Week ,019
Intention to Smoke .018
Number of Cigarette O~fers Last Week .037
.120
,393
.297
.194
-.303
Not : Only variables accounting for a significant increment in R2 are included•
Beta
.210
.171
-.I17
-.084
-.317
.092
• 108
-. 209
For m~ddle ~ch~olers, alcohol use ,.,as positively correlated with follo-~-up
smoking, lu additiou, the number of offers to smoke was negatively corre-
lated with smoking six months later, accouuting for 3.7Z of the variance
after the other four variables had been entered in the equation. Thus, sub-
jects ~ho h~i received offers to smoke in the last week but did not mmoke
were less likely to be smokers at follow-up.
Prediction o£ Chan~es in Smok£ag Rate
These analyses included only those subjects who were smoking at initial
assessment (N = 83). Sex and grade interactions were not included iu the
model because the sample size was not adequate to evaluate reliably the
significance of the additional interaction terms. Consequently, a single
m~Itiple regression was used for all initial assessment smokers regardless
of grade level. The ~erall R2 was .48, and the shrunken R2 was .35. The
two best predictors were pretest smoking rate and number of smoking
friends. Two additional variables predicted foll0w-up smoking. Subjects
who expected their parents to be angry if they were found smoking were less
likely to be smoking at follow-up. The number of brothers who smoke was
negatively related to subjec~ smoking rate ac six-month follow-up. That is,
pretest smokers with brothers who smoked were smoking less at follow-up.
DISCUSSION
A couple of cautionary points should be made here. First, the study
utilizes six-month follow-up data. The resulting predictors may not fully
replicate with longer range follow-up data. Secondly, the regression equa-
tion derived in this study to predict later smoking rate for pretest smokers
is based on a relatively small sample of smokers (N = 83). Thirdly, some of
the v&riables (e.go, cigarette, marijuana, end alcohol use) represent low
rate behaviors that are not normally distributed (i.e., highly skewed).
The results of this study underscore the need to study adolescent smoking
onset separately from the processes involved in changes in smoking rate.
The factors that predict whether a currently non-smoking adolescent will be
smoking six m~nths later are not the same as those that account for changes
in the rate of smoking for adolescents who are already smoking. Specific-
ally, the number of friends who smoke is more important in accounting for
changes in smoking rate than it is for predicting onset. Similarly, the
likelihood of parental disapproval of smoking is more highly correlated with
chasges in smoking rate than it is with the onset of smoking.
The fi~di~SS of the present study suggest that already smoking adolescents
will be m~re likely to quit on their own or decrease their smoking if (a)
they are not yet smoking at a high rate, (b) few of their friends smoke, and
(c) their parents disapprove of smoking. Thus, school-wide prevention
programs and programs designed to get parents to intervene actively when
their childrem are smoking may be of value in de~err£ng continued smoking.
T108351303
~47
It appears that the factors associated with the onset of smoking depend on
the grade level of the adolescent. While marijuana use and number of smok-
ing friends are significant predictors for both groups, marijuana use
predicts better for middle schoolers and number of smoking friends predicts
better for high schoolers. It may be that both marijuana use and cigarette
smoking at the middle school level are more "deviant" behaviors, and are
highly related for a relatively small number of students. This hypothesis
is also consistent with the high positive relationship between alcohol use
and smoking onset with this grade level. Thus, there may be a relatively
small number of middle schoolers engaging in a good deal of "deviant"
behavior, of which smoking is only an example.
The high negative correlation between cigarette offers and follow-up smoking
rate for non-smoking 7th graders implies that, if a student has been receiv-
ing offers to smoke but has successfully refused them, then he or she is
more likely to remain a non-smoker at follow-up. In fact, when "offers" is
entered as the first predictor, it accounts for 9.2% of the variance in
later smoking rate for these subjects. This finding for 7th graders, should
it replicate, adds support for the value of prevention curricula that stress
refusal skills.
ACKNOWLEDGEMENTS
The preparation of this paper was supported in part by two grants from the
National Institute of Child Health and Human Development (#1R01 HD15825-01
and #5 R01 HD13409-02).
Allegrante JP, O'Rourke TW, Tuncalp S. A multivariate analysis of
selected psychological variables on the development of subsequent youth
smoking behavior. J Drug Educ 1977-78; 7(3); 237-247.
National Institute of Education. Teenage smoking: immediate and long
term patterns. Washington, D.C.: U.S. Government Printing Office,
1979. (D~EW publication)
McCaul KD, Glasgow R, O'Neill HK, Freeborn V, Rump ~S.
adolescent smoking. J Schl Health 1982; ~; 342-346.
Predicting
Bewley BR. Smoking in childhood. Postgrad Med J [978; 54; 197-198.
Pederson LL, Baskerville JC, Lefcoe NM. Multivariate prediction of
cigarette smoking amon~ children in grades six, seven and eight. J
Drug Educ 1981; 11(3); 191-203.
Cohen J, Cohen P. Applied ~Itiple regression/correlation analysis for
the behavioral sciences. New York: Halstead Press, Division of John
Wiley & Sons, 1975.
T108351304
I0.
3ohnso~ CA, Graham J, Bansen W. Interaction effects of multiple
risk-taking behaviors: cigarette smoking, alcohol use and marijuana use
in adolescents, Paper presented at American Public Health Association
An~al Meeting 1981.
Baumsn KE, Dent CW. Influence of an objective measure on self-reports
of l~eh~vior. J Appl Psych 1982; 67(5); 623-628.
Eva~ RI, Hansen WB, Mittelmark MB. Increasing the validity of
self-reports of smoking behavior in children. J Appl Psych 1977;
62(4); 521-523.
Pechacek TF, Murray DM, Luepker RV. Saliva sample collection m~nual:
Health Behaviors Measurement Laboratory. Laboratory of Physiological
Hygiene, School of Publ~c Health, University of Minnesota. July 1980;
Version II.
T108351305
649
METHODOLOGICAL ADVA~CKS, ~ESD-~TS, A~*~D EMPIRICAL GI~II)F-LI~S
FO~ DISSKMIMATIO~ TO T~K S~O0~S
J. Allan Best, Ph.D.
Katherine B. Ryan, B.A.
K. Stephen Brown, Ph.D.
Shelagh M.J. Towson, M.A.
Department of Health Studies
University of Waterloo, Ontario, Canada
Brian R. Flay, Ph.D.
Health Behavior Research Institute
University of Southern California
Los Angeles, California
U.S.A.
The Waterloo Smoking Prevention Project is designed to conduct program
development research aimed, ultimately, at the dissemination of a social
influences curriculum for smoking prevention throughout the schools in the
Province of Ontario. This paper reports on the first study conducted, a
formatlve/process evaluation intended to provide an initial indication of
how effective this type of program is when introduced in Canadian Grade 6
classrooms. We also wanted to collect data on the variety of variables
which presumably underlle the smoking onset process and mediate program
effects, so as to be in a better position to understand how these programs
work and to refine the curriculum. A third objective was to address some of
the methodological limitations in previous work.
Over the pas~ five years, several research teams have reported promising
results from smoking prevention programs for preadolescents which focus on
the social influences presumed to affect smoking onse[- peers, parents, and
the media. Results are remarkably consistent, suggesting that these pro-
~rams keep new experimentation to a minimum, during a time when smoking
prevalence otherwise roughly doubles. However, while consistency of results
does argue for the efficacy of this approach, research in the area, at the
time we designed this study, had a variety of methodological limitations.
Many studies had only one or two schools per experimental condition, and
random assiEnmen= had ~t always bee= achieved. Also, since the curriculum
typically is provided to entire classes, and the school milieu is presuma-
bly an important context for the operation of social influences, it makes
sense to use the school as the unit of statistical analysis, but none of the
research had done so. Some of the previous studies had been plagued by pro-
blems of high subject attrition, so that at follow-up many o~ the original
subjects were not available. In part due to this limitation, previous
studies had not tracked individuals over the course of the study to see what
Address for correspondence: J. Allan Best, Dept. of ~ealth Studies, Faculty
of Human Kinetics and Leisure Studies, University of Waterloo, Waterloo,
Ontario, C~nada N2L 3GI.
happened to different students. In general, longitudinal aaalyses are
superior to cross-sectional w~en the process being studied is an ongoing
one. Finally, since it is important to examine the effects of social
infl~ences prograum on children who are at different levels of risk to
start smoking if a program is not available, w~ wanted, in this study, to
have at least an initial look at the concept of risk.
Ne conceptualized two kinds of risk. Smokiug experience risk refers to the
experience ~he individual student has with smoking before the program
begins, in this case at the beginning of Grade 6. Some of our students
already had experience with smoking, others did not; those who had experi-
ence varied in the amount and nature of that experience. Researchers have
shown that previous experience with smoking is one of the best predictors of
future smoking. Social models risk refers to the prevalence of smoking
models (peers, parents, and sibllngs) present in the student's environment.
At pretest, we classified students as low risk if they reported no smoking
models in their environment, as moderate risk if they reported one of these
smoking models, and as high risk if they reported two or more.
The core curriculum was delivered to students during the fall of Grade 6,
when they were I0 or II years old. The first two sessions comprised an
information component, covering negative consequences of smoking, population
smoking rates, situations in which smoking influences occur, and ways of
resisting these influences. We emphasized three major sources of social
influence: peers, parents and media. The next three sessions were devoted
to s akills development component, designed to give children actual experi-
ence in resisting influences. Videotapes and popular peers modelled the
strategies and the class then worked in small groups to develop skits which
were preDented to the class and discussed. Children also worked with media
adverti|ing and made posters countering these arguments. The sixth, and
final core session was devoted ~0 decision making. Children filled out a
sheet listing the advantages and disadvantages of smoking, made decisions
about their future smoking behaviour and ~hen announced these decisions to
the ~est of the class. These six core sessions were followed with two main-
tenance sessions spread over the remainder of Grade 6, designed to maintain
contact with the children and to review social influences. The program also
incl~ed two, one-hour booster sessions in Grade 7 and one in Grade 8,
designed to review and update content so that i~ remained salient and
relevant to the ~ow-maturing students.
Twenty-two schools from one separate and one public school board were rough-
ly matched, within board~ for size, geographical location, and socio-
economic • ~atus, and then randomized to experimental or control condi=ons.
Three pairs of schools from one board were not randomly assigned because of
school board concerns with the principals' cooperation, but these schools
did not differ aiEnificantly from others in the study. The initial partici-
pation rate, incl~ding all students with parental consent, was 93%. ~oth
experimental and control stu~= f~]lo~ n,,~ ~v~on~.M~ o~o]~,o~n~ ~tt~r~es
before ~e program began (Tl), immediately following the program (T2), at
the end of Grade ~ (T3), st the beginning and end of Grade 7 {T4 and TS),
and at t~e end of Grade 8 (T6). At each data point, before reporting on
T108351307
651
their s~oking hehavlour, students were given a description of how cigarette
s~oking can be objectively verified by measuring saliva thiocyanate, and
students provided saliva samples. In addition to self-reported smoking
behaviour, the questionnaire tapped demographic infor~mtion, reports of
smoking habits of parents, siblings, friends, and teachers, and ~ediating
variables such as knowledge, beliefs and values, attitudes, perceptions of
social norms, behavioural intentions and personality measures.
The longitudinal data analyses are restricted to the 67% of the initial
subject pool who provided complete data at all six points. All major con-
clusions of our research are checked with the parallel cross-sectional
analyses, and in each case a similar although not identical pattern of
results is seen. The primary outcome measure is smoking status. We define
five categories for this purpose. Never smokers are those who have never
smoked, not "even one puff of one cigarette". Tried once includes those
students who have smoked, but "not again since the first time". Quitters
are those who have smoked more ~han once, but report that they have "quit
smoking for good". Experimenters are those who report that they are
currently smoking, but "usually not every week". Finally, regular smokers
are those who report that they currently smoke "usually every week".
At the beginning of the study, three-quarters of the students had never
smoked or tried it only once. Twelve per cent reported themselves to be
quitters, 9% experimenters, and only 3% regular smokers.
TABLE i.
SMOKING AT THE END OF GRADE 8 (30 MONTH FOLLOW-UP)
BY EXPERIMENTAL CONDITION
Smokin~ Behaviour Category
Never Tried Regular
Condition n Smoked Once Quitter Experimenter Smoker
Experimental Group 248 27.0% 18.6% 31.8%
Control Group" 191 19.9% 18.3% 27.2%
12.5% i0. ~,o"
~ 12.6%
Two and a half years later, at the end of Grade 8, students who had received
the program were s~oking significantly less than those who had not, X2 (~
= 9.51, p < .05 (see Table !). There were somewhat more never smokers in
the treatment condition than in the control group. However, the greatest
difference is with respect to experimental smoking. Experimentation did not
the major period of smoking ~set and thus is the Best tiu~e to provide a
prevention program. By the Beginning of Grade 7~ a program effect starts to
emerge; it is significant by the end of Grade 7. At the end of Grade 8,
T108351308
there ~ere 1.8 tt~s ~ ~ny ex~ri~tal s~kers i~ the control condition
as ~here ~ere ~n the treat~nt condition. ~
~l~s crosl-lectional view indicates a si&,nificant overall program impact.
The ~ext que|tion to lsk is, "for whom does the program work?" or ~ow does
initi|l level o£ risk mediate program effects?**. First, let us consider the
effect| of previous experience with smokin8, as shown in Figure 1.
FIGURE I. SMOKING BEHAVIOUR AT T6 AS A FUNCTION OF T1 SMOKING EXPERIENCE
RISK STATUS
TI Tried
(TN • 86 ; CN
TI
(TN,;'6 ; CN, Z4)
(TN,5 ; CN,9}
At the end of Grade 8, 53% of the control group never smokers, but only 40%
of ~he treatmen~ ~ro~p never smokers, had tried smokin~ at least once, a
difference which approaches stacisLical significance, XZ(1) : 3.16, p <
.08.
Thlrty-three per cent of the children had cried cnly one cigarette ac the
!~gi.m~%~ Of ~ program. There iS ~o difference at the end of Grade 8 bet-
ween Ereatmemt a~d control students ~n ~e~s of how ~ny of £hese cried once
s~kers subseq~n¢ly tr~ed a£ least one ~re c~gare~Ze. Nowever, experi-
+reZZe l~ lel'l likely Zo Eo on to regular s~kin~, X 2(2) = 7.83, p < .02.
T108351309
,@
653
There is little sustained difference between treatment and control
conditions for those who were quitters at the beginning of the program.
Cross-sectionally~ the program had its greatest effect in the experimental
smoking category, especially with those who were experimenters at the begin-
ni~g of the program. Immediately following the program, 68% of the treat-
merit group quit as compared to 222 of the control group X2(1) = 7.94, p <
.005. At the end of Grade 7, the treatment group was still clearly
superior, although the difference was no longer statistically significant by
the end of Grade 8. This is due in large part to the large number of con-
trol group pretest experimenters who quit. Program impact on pretest
experimenters is sustained, since 42% of the pretest experimenters who
reported quitting immediately following the program did not smoke through
the entire follow-up period, In contrast, only 20% of the initially much
smaller group of control quitters achieved this level of success.
There were too few pretest regular smokers - five in the treatment condition
and eight in the control condition - to analyze impact statistically.
Inspection of the data suggests a somewhat greater rate of quitting follow-
ing the treatment program. At the end of Grade 8, differences appear
minimal.
In sunmmry, the program has several effects. It seems to produce a sustain-
ed level of quitting for experimenters, and significant effects for children
with limited smoking experience before the program (never smokers and tried
once). However, program impact for pretest quitters or regular smokers is
limited.
How about the effect of smoking models in the environment? At pretest, 17%
of the sample were classified as low risk because they reported no smokin~
friends, parents or siblings. The treatment program did not have a 3ignfi-
cant preventive effect on these low risk children, primarily due to the low
rate of smoking among both treatment and con=roi low risk children. This
outcome is not unexpected since this group is least likely =o star~ smoking
with or without a treatment program.
At pretest, 42% of the children reported one source of smoking influence and
were classified as intermediate risk. Although the overall difference bet-
ween treatment and control groups approaches significance at the end cf
Grade 8, it is not statistically reliable. The treatment ~roup seems ~c
include more quitters and fewer experimenters.
The program effect is clear among high social model risk children, ";2~A~ =
9.61, p < .05. At the end of Grade 8, roughly twice as m~ny contrel
treatment group children are experimenting wi~h cigarettes and only one-
third as many still have never smoked. There is also a small but noticeable
difference in regular smoking rates. In sum, the program seems to have bee~
most beneficial for children who were at high risk initially due tc the
s~pport to the presumed processes by which these programs operate and
indicates that the program works best for the children who need it m~st.
All the analyses reported thus far consider the individual child. We wanted
to look at the school as the unit of analysis, in order to determine whether
T108351:~10
pro~"aB ~.~pac¢- may vary from one school to another. Schools ~ere entered in
a b£~i~l regression analysis, using ~he Likelihood Ra~io S~a~ist£c to test
the mll hyp~hesis tha~ school variability could be accounted ~or by trea~-
m~t cor~it£~ ~ school ~ard. At T6, ~he sign£fican~ degree of variabi-
I£¢y ~tween schools e£~h£n trea~n~ x board conditions X2(18) - 71.7~ p ~
.~I, indicates thaC ~h~ do vary tre~ndously wi~h respect bo~h to a~unt
of ~ing and program impact.
FZGURE 2. SH4~KING RATES FOR SCHOOLS AT THE END OF GRADE 8 (30 HONTH FOLLON-
UP) ~ RANKING SCHOOL BY EXPERZHENTAL CONDITION
Percent
Current 30
/// /~
./ • / Ex~rlmentol Group
// f Control Groul)
t~#est Rote
Rare
T108351311
655
We have just completed the final year of the second Waterloo Smoking Preven-
tion Project study. The study design controls for possible intensive test-
ing effects. It also provides a comparison between our program snd what is
currently available in the schools. Most important for the present discus-
sion, we plan to study the influence of school environment on smoking onset.
The conceptual framework we are developing to guide our study of the various
personal and environmental factors which influence smoking onset includes
three dimensions - agents of influence on the smoking onset process, the
nature of the influence, and the relative objectivity of the influence.
Primary Interpersonal Influence a~ents include parents, siblings, favourite
teachers, same and opposite sex best friends, and Secondary Interpersonal
Influence agents include extended family members, the larger circle of
friends, peer acquaintances, other teachers, and other students and adults.
School System Influences include physical and social aspects of the school,
curriculum, social norms, and rules about smoking.
The nature of the influence can vary for each of these agents. Explicit
influences include factors such as actual smoking behaviours, explicit
school rules, and anti-smoking posters in the hall. An example of implicit
influences is the case in which the child's best friend has never expressed
an opinion about smoking but the child has observed the friend not smokin~
in a group of smokers and therefore inferred that the friend is against
smoking. At the School System level, non-enforcement of smoking rules prc-
rides implicit evidence that the school is not really opposed to smoking.
Finally, each influence can be characterized according to its degree cf
objectivity. For example, one could objectively determine the number of the
child's peers who smoke, but it is the child's perception of the number in
the peer group which -~y influence his or her smoking behaviour.
Within this working framework, we have identified six types of influence
which may have an effect on the smoking onset process. First, there is
modelling. Significant agents do or do not smoke. They make positive or
negative statements about smoking. Second, there is persuasion in which the
agent actively engages in persuasive interaction with the child. Thiri,
there is instruction. Teachers and others work to give the child factual
information about smoking and smokin~ onset. Fourth, we need to think in
terms of rewards and punishments. Clearly, contingent consequences of smok-
in~ are likely to affect children's future smoking behaviour. Fifth, oppor-
tunity play~ a role, for example whether cigarettes are r~adily available,
and the size of the child's allowance. Finally, the nature of the rela~ion-
ship between the child and various influence agents plays a role. For exam-
ple, a negative school-child relationship may foster rebellion and increase
the likelihood of smoking. A positive parent-child relationship may have a
protective effect.
Our exploration of environmental influences is just beginning, but we are
hopeful that this line of research will extend our understanding of the
smoking o~set process, provt . ~u-
ence programs work better in some schools than in others, and enable us co
develop guidelines for improving programs in situations where they are less
effective.
T108351312
~57
P~IO~ITIES l~Ol SOCIAL S~IF~CE ~SEA~CH O~ ~
~eport of the F~f~h ~orld C~fereoce ~rk~ Group on Social
Sci~ce ~ ~o~r~Rela~ed ResearchI
The International Liaison Group on Smoking and Health formed an ad hoc Work-
inE Group on Social Science and Program Related Research to ~eet in conjunc-
tion with the Fifth World Conference on Smoking and Health and to prepare a
report for the International Liaison Group and its member organizations. The
International Liaison Group identified social science and program related
research as an area of particular importance. Views and recommendations of
the Working Group will provide guidance both ~o the planning committee for
the Sixth World Conference on Smoking and Health, and to member organiza-
tions of the International Liaison Group.
The aims of the Working Group were (i) to reach consensus on research and
development objectives of highest priori=y over the nex~ two to five years,
(2) to suggest specific issues and methods appropriate to such research and
development, and (3) to recommend to the International Liaison Group further
planning initiatives. The Working Group met for a full day before the Fifth
World Conference on Smoking and Health. The Workin~ Group was able to
address each of its aims, as described in this Report. At the same time,
the Working Group recognized that a one day meeting could not fully develop
central issues and recommendations, and that various follow-up activities
should be implemented by the International Liaison Group.
The Working Group was chaired by Allan Best (Canada). The membership
included Mary Jane Ashley (Canada), Keith Ball (UK), Nell Collishaw
(Canada), Brian Flay (USA), David Hill (Australia), Michael Kunze (Austria),
Sergei Oleynikov (USSR), Deborah Ossip-Kiein (USA), Terry Pechacek (USA),
Lars Ramstr~m (Sweden), and Michael Wood
The basic components of comprehensive smoking prevention and control
programs have been defined in numerous exuer= committee documents (e.g.,
"Controlling the Smoking Epidemic", WHO, i979; "Guidelines for Smokin~
Control", UICC 1980; "Smoking and Healt~ in Ontario: A Need for Balance"~
Ontario Council of Health, 1982). Briefly, such comprehensive programs
include (I) ~egislative and restrictive measures, (2) public education, (3)
smokin~ prevention programs, (A) smokin$ cessation and change programs, and
(5) research and evaluation. The Workin~ Group saw its deliberabions within
~h~s context~ and it focused on the role for social science and program
research in relation to comprehensive smokin~ ~nd health programs. The
I Submitted to the International Liaison Group. World Conference on Smokin~
and Health.
Address correspondence to: J. Allan Best, Ph.D., Working Group Chairman,
Department of Health Studies, University of Uaterloo, Waterloo, Ontario,
Canada N2L 3Gl.
T108351313
Working Grocp began the day by brainstorming a large number of possible
research and development 9bjectives- A remarkable degree of consensus
emerged, and the Working Group organized priority objectives around five
research areas: (1) methods for effecting political and system change, (2)
health, ~ocial, and economic consequences of smoking and benefits o£ smoking
cessation, (3) smoking cessation and change, (6) smoking prevention, and (5)
regional development of comprehensive smoking and health programs.
For over two decades, it has been recognized that the implementation of
comprehensive programs is dependent on effective political action. In
particular, zestrictlve measures dealing with all phases of tobacco
productlo~, marketing, and distribution now are recognized as having federal
importance. Also, political controls of some aspects of tobacco usage, such
as restric~ion on smoking in public places and other designated areas, and
political support of public education are critical. Based on this recogni-
tions many proposals about how government can take effective steps have been
made, but the instances of actual implementation are rare indeed. ~nis
suggests that we do not know enough about how to influence government to
take the action required. Research and informed advice are needed about the
political process itself to identify and ~ocument how effective political
action regarding smoking and health can be achieved. This is a top priority
area for study since, without this knowledge, the realization of comprehen-
sive program is exceedingly unlikely.
Broadly, we are recommending collaborative research between social scien-
tlsts concerned with smoking and health, and political scientists. In some
cases, controlled research will be feasible. However, in other cases, it
will be recognized that the political arena does not lend itself to tightly
controlled experiments and that historical, comparative, and case-study
techniques provide useful alternatives. Historical research would be help-
ful in fully documenting the evolution of smoking and health policies, and
implications for present day action. International and within country
comparative research on policy development also would be valuable, along
with specific case-studies which attempt to tease out factors bearing on
political declsion-making under certain conditions. Specific areas for
research include:
(I) Factors" influencing political decision-making.
(2) Survey and other epidemiolog~cal techniques to describe and analyze
attitudes and other relevant populstion attributes. Surveys should
follow, Where possible, the Guidelines for Smoking Surveys, published
by WHO, Geneva, 1983. A politician's stock-in-trade is popular
sopporZ and politicians will take action if they perceive that appro-
priate • c~ion is, if not demanded, at least accepted by a clear major-
~ty of eo~$titcents. Public attitude research is needed so that the
favo~zable ;,~bli¢ opinion which (we believe) already exists in many
juriz4ic~ions can be documented.
(3) Research on how public attitudes can be most effectively and efficient-
ly comm~u~cated to politicians, including use of the media, letter
T108351314
PliO~i'ri.~ l~OR SOCIAL
writing, and other public displays.
(4)
659
(5)
In general, data are needed on what fac~or~ influence the political
process a~d decision-making with respect to smoking and health, and how
these factors can be created, mobilized, or neutralized so as to effect
implementation of various measures.
(6)
In addition to research on the political process, we need data on the
politicians themselves, how they perceive smoking and health problems,
to what pressures they are most sensitive and in which context, and how
they are led to make particular decisions.
Research is also needed on the impact of misinformation, such as that
regularly distributed by the tobacco industry. How pervasive are its
effects and how can it be countered?
A greater understanding of factors affecting public attitudes, politicians,
and the political process now is required if comprehensive smoking and
health programs, which are well described and urgently needed to combat the
smoking epidemic, are to be realized.
Sl~)Klli~ CONSEQUENCES AND CESSATIO~ ~ENEFITS
The Working Group concerned itself equally with the broad area of health,
economic, and social consequences of smoking, as well as with the parallel
benefits Go smokers of smoking cessation. In general, the Working Group
felt that existing data document well the pathophysiological consequences of
smoking. The Working Group particularly focused on research on the effects
of smoking re~arding: (I) the effects of passive smoking, (2) hazards of
"low" yield cigarettes, (3) short term consequences of smoking and benefits
of cessation, (4) effects of smoking changes on passive smoking, and (5)
health information for special groups.
(I) Passive smoking
There is increasing concern about potential health hazards of second-hand
smoke. Both exposed adults and children seem affected. Increased morbidity
and mortality have been reported, but findings are not always consistent.
The Working Group recommends further examination of the health impact of
passive smoking, for example through epidemiological examination of spouses,
children and co-workers of smokers. The Working Group further recom~enCs
research to identify early indicators of morbidity which may be influenced
by passive smoking (e.g., COa/COHb, small airways dysfunction, cholesterol
change, respiratory chan~e, alterations in measures of i~m~une function,
etc.). Research should evaluate risks, not only for the general population,
but also for special ~roups who may be at particular risk (e.~., pregnant
women, the elderly, children, groups with existing ~isease). Researchers
also need to evaluate health impact of passive smoking on occupational
• " " nt vels e. . those workin
in public bars). Las~, but certainly not least, .there is a r~ed for surveys
of public attitudes concernin~ passive smokin~ and both current and poten-
tial control methods, so that these attitudes can inform decisions of local
T108351315
politicians, restauranteurs; businesses and others considering the implemen-
tation of no smoking or restrictive smoking policies.
(2) Easards of "i~" yield cigarettes
Recent years have seen major shifts in developed countries of sales patterns
with respect to nominal tar and nicotine yields of cigarettes. In general,
an increasing proportion of smokers in i~dustrialized nations are buying
cigarettes with "low" tar and nicotine deliveries. Presumably, the smokers
see "low" yield cigarettes as safer, and believe brand changes may provide
an acceptable alternative to cessation.
Recent research findings do not unequivocably support the contention that
current "low" yield brands reduce health risks or exposure to smoking
constituents, notably carbon monoxide and nicotine. Possible factors
accounting for this lack of risk reduction include increased smoking rates
and puff pattern changes associated with brand switching, physiological
compensation, inaccuracies in measurement of cigarette yields, and use of
flavour-enhancing additives, with undetermined health effects. The net
result is that these "low" yield cigarettes may be no safer than others.
There is a need for controlled outcome studies of the effects of "low" yield
brands on exposure and disease. It must be recognized that it is not suffi-
cient that research document decreased exposure; rather, the magnitude of
the decrease must be empirically related to health risk. There is also a
need for prospective studies to determine relationships between current
brand "yields" and morbidity and mortality outcomes.
(3) Short-term consequences of smoking and benefits of cessation
There is a need to document further health, social, and economic consequen-
ces of smoking and benefits of cessation. For example, if discrete
physical~physiological indicators of health risk, which reliably change on
cessation, can be identified, such information might be fed back to the
smoker/ex-smoker on an ongoing basis through the health care provider. As
another example, better calculation of economic consequences of smoking
(e.g., lost work days, use of medical facilities and cost benefits of quit-
ting) might be used to persuade political and industrial decision makers to
implement smoking control programs, and as dependent measures for interven-
tion trials.
(4) Effects of smoki.g cha~es on ~assive smokers
Programs designed to reduce passive smoking effects must be empirically
tested to ensure that cigarette smoke exposure is, in fact, reduced for non-
smokers. It is also important that research investigate the effects of
switching to "low" yield brands on passive smokers.
(5) Health information for special groups
Information on the consequences of smoking and the benefits of cessation
commonly is provided throush ~ublic education programs. In addition, there
is a need for research to investigate the effects o~ specific consequence
and benefit information on different target groups of smokers, including
children, adolescents, pregnant women, and others.
T108351316
The Working Group strongly encouraged continuing research emphasis on the
development of co-ordinated, multi-intervention approaches to cessation.
This "networking" concept was elaborated later by the smoking cessation rap-
porteurs for the Fifth World Conference on Smoking and ~ealth. The Working
Group specified several priority areas for development of program compo-
nents, including: primary care, the work place, use of the mass media, use
of family and friends, use of existing social structures for mutual support
groups, self or u~tural help, high risk groups, print materials, financial
incentives such as those possible with health and life insurance, and
development of methods for ~mproving long term ~aintenance of smoking
cessation. These recommendations consider priority settings for cessation
programs (i.e., primary care, the work place, the natural environment),
methods of program delivery which show particular promise (i.e., the mass
media, print materials), particularly important cr understudied ~echanisms
for improving smoking cessation (i.e., family and friends, existing social
structures, incentives), and key aspects of the smoking cessation process
(i.e., long term maintenance).
The Working Group addressed critical issues in the development of co-
ordinated networks of smoking cessation services. I~ was clearly recognized
that the various services must be integrated at a community level, to ensure
comprehensive coverage of smoker needs, to avoid redundancy and duplication
of efforcs, and to provide the individuai smokers with a range and hierarchy
of services from which they can choose and through which they can progress
as necessary. It was recognized that the concept of integrated networks of
services is extraordinarily complex and still under developed. Current
research projects studying comprehensive smoking cessation services a~ a
population level are beginning to elaborate the concept. We underlined two
particular research requirements. First, there is a need for systematic
development of dissemination ~0dels. Briefly, i~ is not enough to demon-
snrate that a complex array of smoking cessation services can produce signi-
ficant cessation at a population level. Researchers also must develop
methods bv which a comprehensive network of cessation services can be
effectively implemented in other communities. Second, "network research"
requires population evaluation. Researchers need ~o identify program wan~s
and needs (e.g., current smoking problems, readiness for chan~e, preference
for program alternatives), as well as moniaor Fopu[ation chances in smoking
behaviour and related risks. The WHO Guidelines for Smoking Surveys a~ain
should be used, as far as possible, in th~s context. The Working Group also
recognized-the importance of developin~ standardized evaluation ~uidelines,
buildinB on work that has already been Cote. We noted the central impor-
tance of demons~ratin~ cost benefits of program elemenc~.
In the context of network research, the Working Group identified =
particular research needs. There is a nee./ ~o develo~ cessation programs
for children. There is a need to stud': w~ich proBrams suit which smokers.
Research is required to understand "self change" and how =his can best be
f~z~!i~te4 ~-~ ;-~o~=,=~ ~h a n~twer~ approach. There i~ a continuin~
need for process research which studies the individual, and the various
stages and problems associated with cessation. Examples ~nc!ude the
abstinence syndrome" (development of readiness for change), typical stages
in cessation and program needs aL e~ch 9oint, beliefs and motivations
T108351317
662
surrounding quitting (for example those related to "low yield" cigarettes),
and factors involved in the ~intenance of cessation. ~inally, the Working
Group nosed that it would be important to compare the effectiveness of a
network designed to increase smoking cessation, with networks more broadly
deaigned for health promotion.
The Working Group agreed that recent research on smoking prevention has
produced promising results which indicate that smoking onset rates can be
significantly reduced by school-based smoking prevention programs delivered
during early ~dolescent years. At the same time, the Working Group noted
two major caveats. First, there remain a variety of research and develop-
meat issues which need to be resolved in preparing promising programs for
dissemination. Second, much of the recent advance may be of only indirect
value in developing countries. The Working Group addressed only research
and development in developed countries in this section, reserving considera-
tion of issues for developing countries until the following section.
The Working Group identified nine specific areas for research and develop-
ment. The listing does not denote an order of priority.
(1) Tailoring of programs to target audiences
There remain serious questions as to how effective the promising smoking
prevention technology will be with diverse populations, since it has been
primarily applied in white middle class, and relatively low risk environ-
meats/populations. Therefore, the Working Group recommends that continuing
research define which types of program strategies are most appropriate for
multiple target populations, including: high risk environments, low socio-
economic groups, multiple ethnic groups, and individual students with a
variety of social and psychological characteristics which place them at
higher risk for smoking onset.
(2) Broader ~del$ for smoking onset
The basic smoking technology shown to be promising in recent years empha-
sizes primarily social influences on smoking. The approach needs to be
broadened to consider multiple cognitive, behavioural, emotional, and econo-
mic consequences of smoking onset and benefits of non-smoklng. It is recog-
nized that the basic technology may be significantly enhanced, especially
for some target populations, by the additional inclusion of more traditional
health information (especially that which would induce a degree of emotional
arousal), various forms of skill training, including individual coping
skills, and a variety of other information regarding smoking consequences
and the benefits of non-smoking.
(3) The role of t.ke f~mily
Existing amking prevention technolo~[ has almost exclusively involved
s~b~|-~=~d ~u~. ~e Working Croup recognized Chat the efficacy o~
~hese programs .my be enhanced by greater involvement of the co~Iete family
unit. l~novative efforts to involve parenEs and siblings in the s~king
T108351318
663
prevention process~ as ~+ell as the target adolescents in smoking cessation
activities for adults, is suggested for £uture research.
(4) I~creased use of the m~sa ~mdia
It is generally recognized that the mass media, particularly tobacco adver-
tisements, play a role in the smoking onset process. However, the Working
Group suggested that additional research be focused on innovative uses of
multiple media channels for smoking prevention. Film and video classroom
media have been widely used; however, the use of mass media outside the
school-based programs needs to be explored with additional innovative
research.
(5) Reduction of social influences
As noted, most of the emerging smoking preventive technologies place a major
emphasis on social influence processes. They largely attempt to instill
within treated individuals social skills necessary to resist these pressures
and influences that encourage smoking onset. However, the Working Group
notes that addi=ional research should focus on mechanisms for changing
social influence at the broader societal level (including legislation,
restricting access to smoking, and broad-based changes in societal norms and
attitudes), so that there would be lessened pressures and influence and thus
lessened risk for adolescents and need for individual resistance skills.
(6) Standardized evaluation
Significant progress has been made in recent years in the development of
more standardized evaluation techniques for smoking prevention curricula.
Nevertheless, the Working Group noted the need for additional evaluation
mechanisms and standardization of cri=eria. Particular emphasis needs te be
placed on delineation and validation of intermediate and short term indica-
tors of treatment effects. For example, while the rate of change within a
treated population from non-smoking ~o smoking s~a~us remains the ul~imate
end point, it may be possible ~o use some indicaEors of treatment effect
such as enhanced skills in the resistance of smoking pressure as a suffi-
cient intermediate outcome f=r initial evaluations of smoking prevention
programs. The need is to identify early indicators which reliably preiict
the desired end point.
(7) Process research
The previous six objectives have indica=ed the need for continuing research
upon the smoking prevention technologies. However, this process of revi3ion
and enhancement requires continuing research emphasis on definition and
elaboration of factors and processes related to the smoking onset. In
particular, while i~ now is widely recognized that an adolescent's friends
play a major role in influencln~ the o~see or maintenance of smoking benav-
lout, the mechanisms by which peer influence operates remain largely un-
defined. As a consequence, our ability to refine or enhance existing smok-
ing prevention programs is limited. Therefore, the Working Group feels that
it has long been recognized that exemplars (e.g., health professionals,
teachers, and high status individuals) pl~y a r~!e in the onset ~roces~o we
T108351319
need research to define the exact mechanisms by ~hich exemplars exert
influence, snd to explore use of these individuals for innovative prevention
programs.
(8) Disseaim~tio~ research
Wide-spread acceptance of social influence approaches to smoking prevention
seems to be emerging. However, the efficacy of this approach has been
demonstrated only in reasonably controlled, experimental contexts. Few
studies have specifically addressed the question of how these programs can
be disseminated and implemented as part of ongoing services. Careful demon-
stration research needs to be conducted to develop alternative dissemination
models and to assess both the efficiency and effectiveness of the distribu-
tion of existing technologies to established educational systems.
(9) Comprehensive programaing
Existing smoking prevention technologies are almost exclusively school-
based. This ~,~del of dissemination is eminently practical; however, the
Working Group felt that additional research could be conducted to explore
the potential of combining school-based programs with multiple other forms
of intervention including use of the mass media, smoking cessation efforts,
youth organizations, community-organized leisure time activities, and multi-
ple other education efforts directed at adolescents.
REGIOnaL ~D~ING ~ ~LT~ PROGRAMS
The Working Group recognized the need for region-specific statements of the
smoking and health problem and priority actions. Each region can build on
data and experience from other parts of the world to interpret the situation
in their own region, thus avoiding the necessity for repetition of some
research and some experience. At the same time, countries in which smoking
and health problems now are escalating can anticipate the "epidemic" nature
of the problem as it has developed in other countries and avoid pitfalls.
There is a pressing need to develop model smoking and health programs for
regions with common problems, so that these can serve as a general framework
and "cookbook" for development of national and regional programs. The Work-
ing Group discussed the reality that all aspects of smoking control programs
must'be tailored to the political and cultural realities of the region in
which they are to be applied. The Working Group specifically discussed the
need for development of prevention and cessation strategies for developing
countries. Several Working Group members have considerable international
experience. However, the Working Group did not include a representative
from a developing country, and therefore continuing development of the
following recommendations is essential. The Working Group identified four
priorities for research in this area: (1) collection of region-specific
data on tobacco use and related diseases, (2) parallel data on tobacco-
related k~wledge, attitudes, and beliefs in Third World populations, (3)
critical evaluation of the generalizabi[ity of experiences from industrial-
ized countries, and (4) research in developed countries necessary to affect
TI08351320
665
(1) Collection of reg£on-specific data
Epidemiological study of various forms of tobacco use, d~seases, and related
factors must be conducted when initiating national/regional smoking control
programs and ~onitoring subsequent development. The 1983 WHO guidelines
should be followed, paying particular attention to important local forms of
tobacco use.
(2) Kmowledge, attitudes, and beliefs
Design and evaluation of intervention programs requires specific information
about tobacco knowledge (or lack of knowledge), attitudes, and beliefs.
Incentives to use or not to use tobacco probably d~ffer a great deal in
developing countries from those in the Western World. Measurement of know-
ledge, attitude and belief changes, as well as changes in smoking behaviour,
is essential to provide sensitive measurement of program effects, particu-
larly when the objective is prevention of smoking onset.
(3) Generalizability of industrialized countries' experien=es.
Specific conditions in developing countries influence programs. For
example, perceived economic factors affect smoking policy. Often the econo-
mic benefits of tobacco production are overestimated and negative side-
effects (e.g., deforestation, reduction in food production) are unrecog-
nized; economic costs of consumption (especially loss of productivity) are
underestimated. Research to establish realistic estimates of costs and
benefits is essential to prevent misconceptions. As another example, high
rates of illiteracy will influence program design. Feasibility studies are
needed to develop and test ways of reaching illiterate groups.
(4) Tobacco marketing in developing countries
Transnational corporations based in the Western World strongly influence
tobacco business in developing countries. T.~ influence effectivei[; zhese
corporations "at home", we need research such as the Eesting of ex~or=ed
cigarettes, to make possible disclosure of "dumuin~" hi,h-yield products in
developing countries.
CORCLUSIONS AND ~E(~CjMME~ATIONS
In sum, the Working Group considered five major areaa of future social
science and program-related research and development, in each area, speci-
fic suggestions are made fo~ needed research. The Working Group sees two
outstanding prerequisites f~r effective action. First. there need~ tc be
further development o£ research strategy to meet these needs. "- ~any
cases, research methodology needs to be develope~. For example, there i~ a
real need for methodoleg~cal development in the area of political
influence. We also need focused effort to develop models for dissemination
r~searcn in the evaluation o~ smoking contro~ "'networks". Continuing work-
ing groups could do much to develop methodology in these areas. Related to
issues of research methodology ~s the question" of research funding. Appro-
priate funding mechanisms need to bu identified or developed. Second,
priority research areas need to be further elaborated. I~ this brief report,
T108351321
the Working Group could do no more than identify ~jor areas of interest.
These need to be further delineated and developed before effective research
is likely to occur.
For these reasons, the Working Group recommends tha~ the International Liai-
son ~ittee consider ad hoc task force or expert co~ittee ~echanisms for
continuing development of social science and progra~-related research prior-
~t~es. ~ever~l n~lon~) and international agencies already are involved in
planning of this kind. The remarkable consensus a~ngst the Working Group
~Bbers suggests that the issues and priorities ~re co~n across jurisdic-
tions, ~nd that ~ch can be gained from an international and co-ordinat~
approach. At the sa~ time, the WorklnR Group recognized thac special
efforts are ~ecessary Co achieve effective international co-ordination.
Cherefore we specifically reco~end two additional key actions:
(I) The organizing committee for the Sixth World Conference on Smoking and
Health should be explicitly encouraged by the Liaison Group to use this
report in developing a framework to h~ghlight these social science and
program-related research priorities at the Sixth World Conference.
(2) ~he Liaison Group secretariat should ask ~ember group secretariats to
forward this report and its recommendations to national counterparts
and contacts. At a national level, recommended research activity
should be strongly encouraged and fac~litated. The Liaison Group
itself should serve a co-ordination function, making every effort to
ensure international collaboration where indicated.
In su~ry, the Working Group noted many ways in which the social sciences
are playing a significant role in the development of comprehensive smoking
and health programs. There are still many issues outstanding, but the sense
of the Working Group was that concerted and sustained efforts will lead to
si~nifican~ further advances by the ti~e of the Sixth World Conference on
Smoking and Health.
T108351322
667
Neil E. Collishaw, M.A.
Chief, Policy Analysis
Bureau of Tobacco Control and Biometrics
Room 202, Laboratory Centre for Disease Control
Health and Welfare Canada
Ottawa, Canada KIA 0L2
I NT~/)I)U6"~ION
To monitor progress in tobacco control, we need to know whether cigarette
consumption is increasing or decreasing. On the surface, this looks like a
simple problem. One need only look at the trends over time in the number
and proportion of smokers in the population as shown by survey data (I), and
the consumption of cigarettes as shown by sales data (2). The survey data
show that the number of cigarette smokers in the adult Canadian population
declined slightly from 6.9 million in 1975 to 6.7 million in 1981, and that
the proportion of smokers declined from 42% to 35% over the same period.
While the proportion of smokers was declining, however, the consumption of
cigarettes by adults, as measured by sales data (adjusted to measure adult-
only consumption) (3) advanced from 64 billion cigarettes in 1975 to 71
billion in 1981, an average annual rate of increase of nearly 2% per year.
Since by one measure it would appear that cigarette use is declining and~ by
another, it appears to be increasing, the apparently s~mple problem of
determining whether cigarette use is growing or receding is no ionger
simple. Can the apparently contradictory trends be explained by factors of
population growth and shifts in population structure? Or are proportionate-
ly fewer smokers smoking more cigarettes? Are there sources of underestima-
tion in our trend data that lead to improper conclusions about trends in
cigarette use?
The hypothesis of this paper is that all three factors contribute to the
observed trends. Sources of underestimation are identified and adjustments
applied. Controls are introduced for population growth and population
structural changes. With these modifications, trends in cigarette use can
be more fully unders~oodo
SOURCES OF [fN~RKSTIMATIO~
Information on smoking behaviour has been collected at regular intervals
since 1965 in the Smoking Habits of Canadians Survey (4), a supplement to
the Labour Force Survey. Populations in institutions, Indian reserves and
the northern territories are excluded from the la ~ " _
Reprint requests and correspondence may be addressed to the author at ~he
above address.
T108351323
quently is representative of only 97% of the Canadian POpulati~
adjustment is introduced for this undercoverage, assuming that s~oke
distributed in the excluded population in the same manner as the
population, within each age an~ sex group.
There is evidence of further underestimation in the S~oking
Canadians Survey. The Canada Health Survey, conducted from July
M~reh 19Y9, produced higher estimates of the number of s~okers than
the December 1977 or December 1979 Smoking Habits of Canadians
The Canada Health Survey, which relied on self-completed questionnaire~
thought to have produced a more accurate count of smokers than the
Habits of Canadians Survey, which relied to a large extent on
responses (5). The ratios of the proportion of s~okers reported by
Canada Health Survey (1978-79) to the proportion of smokers reported by
Smoking Habits of Canadians Survey (1977-79 average) are given in Table
(6). Assuming that similar underreporting existed for at least one surw
cycle either side of the base period, an adjusted estimate can be obtained
for the period 1975-1981.
TABLE i. RATIO OF THE PROPORTION OF SMOKERS REPORTED BY THE
CANADA HEALTH SURVEY (1978-79) TO THE PROPORTION
REPORTED BY THE SMOKING HABITS OF CANADIANS SURVEY
(1977-79 AVERAGE), BY AGE AND SEX.
Age Group Me___Sn Wome~n
15-24 l.IA 1.22
25-34 1.01 1.00
35-44 1.02 1.15
45-54 1.08 1.14
55-64 0.94 1.06
65+ 1.09 1.24
Total 1.05 1.13
Total consumption of cigarettes, classified by age and sex, can be estimated
from the Smoking Habits of Canadians Survey data. Unfortunately, the survey
estimate~ represent lass than two-thirds of consumption as measured by
reported cigarette sales. Moreover, the percentage of total consumption
estimated by the survey declined from 67~ in 1975 to 63% in 1981, as shown
in Figure ~. It may, ~harefore, be argue4 ~hat estimates of cigarette
cons~mptlon obtained from survey data, by age and sex should be adjusted
~pwar4 t~ a~eo~odate this discrepancy as well.
Cigarette consumption varies widely by a~e and is therefore affected by
chan~s ~n the population age structure. The Smoking Habits of Canadians
~ata have ~herafore been standardized by abe and sex to the Canadian popula-
tion in |9&6, a census year (7). W%ile s~andardi=a~on to 1976 or 1981
populations may have been more desirable, a 1966 standardized data ser~es
was readily available. The latter is certainly adequate for controlling for
the effect of changin a e st ..... ~o" ~=~ ~o~,~!"
T108351324
FIGURE 1. PERCEMTAGE OF CIGARETTE SALES ACCOUNTED FOR
BY SURVEY ESTIMATES OF CONSUMPTION, 1975-81
PERCENTAGE
67
66.
64
63
6~
YEAR
The "effect of these adjustments and standardization procedures on the ate-
sex distribution of the number of s~kers in 1981 is shown in Figure 2. The
1981 Smoking Habits of Canadians Survey reported 6.66 million cigarette
smokers. The adjustment for survey undercoverage increased this estimate to
6.82 million smokers. The further adjustment for survey underreportin~
increased the estimate to 7.37 millicn cigarette smokers, for a ~o=ai
increase of II%, or 710,000 smokers, over the original sur~ey estimate.
Both the number of cigarettes consumed and the number of smokers i~ the
population are accounted for by daily consumption of cigarettes per smoker,
n~ ........,~ ~;~,~= ~ ~y age an= sex ~or 19~I. Adjustment and a~e.
standardization procedures increased the total estimate of daily consumption
of cigarettes per smoker in 1981 ~rom 18 to 27. This 50Z increase
statistically significant for both men (p<.01) and ~omen (p<.05).
T108351325
670
FIGURE 3.
27
24
1-"
35-44 45-54
DALLY CIGARETTE CONSUMPTION PER SMOKER, BY AGE AND SEX,
ORIGINAL AND ADJUSTED DATA, 1981
T108351326
671
Figure 4 shows that the number of m~n who smoke has been generally decreas-
ing since 1975 while the number of women who smoke has been increasing.
Both original and adjusted, standardized data series show little change in
the number of smokers over the period in question, although the number of
smokers estimated by the latter series is significantly higher than the
number estimated by the former series (p<.O01) over the whole period in
question. The adjusted data series reveals that the total number 0[
cigarette smokers declined very little over the 1975-1981 period.
FIGURE 4. NUHBER OF MEN AND WOMEN ~O SMOKE, ORIGINAL
~DJUSTED ESTIMATES, CANADA, 1975-1981
4.5¸
L~- -0.034
4,0¸
Smokers
(millions)
bm -0.0~4
I
A~juste~ estlm~tes
0.015
b= 0,0037
4.5
4.0
~kers
(mlll:ons'
3.5
3.0
However, the proportion of smokers in the population has declined consider-
ably for both sexes, as revealed by Figure 5. The percentage decline has
e ~, the
adjusted, standardized estimates are significantly higher than the estimates
t .ken directly from the Smoking Habits of Canadians Survey (p<.00[). For
both sexes combined, the 1981 survey estimate of the proportion of cigarette
sL:okers was 35Z, the adjusted estimate for the same year was 39Z.
T108351327
672
FIGURE 5.
PERCENTAGE OF CIGARETTE SHOKERS BY SEX, ORIGINAL AND
ADJUSTED, STANDARDIZED ESTIHATES, CANADA, 1975-I~8~
3S
3O
Adjusted estimates
Original e~t:mates
75 77 79 ~; 7~ 77 ?9 6~
YL~c
4O
35
T108351328
673
FIGURE 6.
25
15
10
DALLY CONSUMPTION OF CIGARETTES PER S~OKER, ORIGINAL
AND ADJUSTED, STANDARDIZED ESTIMATES, CANADA, 1975-1981
0,57
I0
FIGURE 7.
33
DALLY CONSUMPTION OF CIGARETTES PER CAPITA AND PER SMOKER FOR .MEN
AND WOMEN, ADJUSTED, STANDARDIZED ESTIMATES, CANADA, 1975-1981
C.:~U~'~O',
From the results examined so far, it would be tempting to conclude that~
tobacco consumption has increased. While smokers have declined as a
proportion og the population, cigarette consumption per smoker has
increased. However, other factors further complicate the issue. ].ike
consumption p~tterns, cigarettes have changed since 1975. The average
weight of tobacco used in a cigarette has declined from 0.91 grams in 1975.
to D.Sb grams in 19~I ($)- The saLes-weighted average tar yield has also
declined from 17 milligrams of tar per cigarette in 1975 to 13.5 milligrams
iR 1981, a 2L% decline in 6 years (9). It is possible to examine the effect
of these product changes on consumption by examin£ng ~he weight of tobacco
consumed daily per smoker and the average daily consumption of tar per
s~ker~ based on sales-weighted average tar yields. ~ese ~rends are
p~esenced in Figure 8.
FIGURE 8. DAILY CONSUMPTION OF TOBACCO AND TOBACCO TAR PER SMOKER FOR MEN
AND WOMEN~ ADJUSTED, STANDARDIZED ESTIMATES, CANADA, 1975-81
TAR I~
~ ll... 0.34
TOCACt.O
15
T108351330
675
DISL~SSIO~ ~ CO~CLUSIO~S
From studying Figure 8, one might conclude that tobacco consumption has
decreased because cigarette tar yields have decreased more than enough to
offset observed increases in the number of cigarettes consumed per s~oker.
But this conclusion must be tempered by the knowledge that an, as yet,
undetermined proportio~ of smokers change their smoking behaviour in an
attempt to compensate for lower average tar and nicotine yields of
cigarettes. There is now evidence from several investigators that, in
laboratory experiments, smokers change their smoking behaviour by smoking
more cigarettes, leaving shorter butts, taking larger puffs, taking longer
puffs, leaving a shorter time between puffs, blocking some of the air dilu-
tion holes in filters, or some combination of these compensatory techniques
(10-17). The results of these investigations show that there are no signi-
ficant decreases in biochemical measures of cigarette smoke exposure upon
switching to low-yield cigarettes (18,19). If compensatory mechanisms
operated widely in the smoking population, then average tar yields, deter-
mined by machine smoking under constant conditions, could not be used to
measure trends in exposure to tar from cigarette smoke. The downward trend
in average daily exposure to tar per smoker shown in Figure 8 would there-
fore be suspect. Unfortunately, our knowledge of compensatory mechanisms
comes from brand-switching experiments in laboratory settings with unrepre-
sentative populations and, to date, no information is available on the
extent to which compensatory mechanisms operate among the general population
of smokers. Until such information becomes available, it cannot be conclud-
ed that observed declines in average tar yields per smoker represent real
decreases in consumption of cigarette tar. No conclusion can be drawn about
the significance of these trends at this time.
The results of this investigation suggest that the Smoking Habits of
Canadians Survey underestimates both the number of cigarette smokers and
total consumption of cigarettes, and that underestimaticn of these latter
data became more serious from 1975 to 1981.
The adjusted trend data revealed that the number of men who smoke has been
decreasing while the number of women smokers has been increasing. As a
proportion of the total population, however, smokers represent a declining
fraction of the adult population.
Per capita consumption remained constant at about 10.5 cigarettes per day.
Cigarette sales increase4 at a rate of nearly 2% per year and daily per
smoker consumption increased from 24 cigarettes per day in 1975 to 27 ciga-
rettes per day in 1981. It smst, therefore, be concluded that cigare=te
consumption increased over the period studied.
Weight of tobacco consumed each day per smoker increased modestly and there
were declines in average daily consumption of tar per smoker, as derived
from trends in sales-weighted averages of dec~ds. H~owever
" " avlour of the smoking
~'~pulation is
needed to interpret this latter trend.
Ti08351331
The technical assistance of Linda Mulligan in the preparation of this report
is gratefully ~c~n~ledged.
I. Millar WJ. Smoking behaviour of Canadians - 1981. Health Promotion
Directorate. Health and Welfare Canada. Ottawa, 1983.
Statistics Canada. Production and disposition of tobacco products.
Ottawa: Statistics Canada, 1966-1981 {monthly). Catalogue No. 32-022.
3. Morrison JB. Smoking habits of Winnipeg school students, 1960-80. Can
Med Assoc J 1982; 126: 153-154.
4. Health and Welfare Canada. Smoking Habits of Canadians Surveys, 1966-
81. Unpublished data. Ottawa: Health and Welfare Canada, 1983.
Statistics Canada, The health of Canadians: Report of the Canada Health
Survey. Ottawa: Statistics Canada, 1981. Statistics Canada Catalogue
No. 82-538.
6. Health and Welfare Canada. Canada Health Survey.
Ottawa: Health and Welfare Canada, 1983.
Unpublished data.
Statistics Canada. Postcensal estimate of the population by sex and
age, Canada and provinces. Ottawa: Statistics Canada, Demography
Division, 1966-81 (annually).
8. Agriculture Canada. Trends in weights of tobacco in cigarettes. Unpub-
lished data. Ottawa: Agriculture Canada, 1982.
Canadian Tobacco Manufacturers Council.
average tar deliveries. Unpublished data.
Manufacturers Council, 1982.
Trends in sales-weighted
Montreal: Canadian Tobacco
I0. Chair LD, Griffiths RR. Smoking behaviour and tobacco intake: Response
of smokers to shortened cigarettes. Clin Pharmacol Ther 1982; 32:
90-97.
ii. Gust SW, Pickens RW. Does cigarette nicotine yield affect puff volume?
|982. Manuscript submitted for publ~catlon.
12. Gust SW, Pickens RW, Pechacek TF.
topographical measures of smoking.
licat[on,
Relation of puff volume to other
1982. Manuscript submitted for pub-
13. Herning RI, Jones RT, Bachman J, Mines AH. Puff volume increases when
low-nicotine cigarettes are smoked. Br Med J 19SI; 283: 1-7.
14. ~erning RI, Jones RT, Benowitz NL, Mines AB. Ho~ a cigarette is smoked
determines blood nicotine levels. C|in Pharmacol Ther 1983; 33: 84-90.
T108351332
~77
15.
Henningfield JE, Grif~iths P~R.
response: Effects of d-Amphetamine.
497-505.
Cigarette smoking and subjective
Clin Pharmacol Ther 1981; 30:
16.
Russell HAH, Sutton SR, lyer R, Feyerabend C, Vesey CJ. Long term
switching to low-tar, low-nicotine cigarettes. Br J Addict 1982; 77:
145-158.
17. Kozlowski LT et al. Estimatimg the yield to smokers of tar, nicotine
and carbon monoxide from the 'lowest yield' ventilated filter ciga-
rettes. Br J A~dict 1982; 77: 159-165.
18.
Robinson JC, Young JC, Rickert WS. A comparative study of the amount
of smoke absorbed from low yield (less hazardous) cigarettes. Part
One: Non-invasive measures. Br J Addict 1982; 77: 383-398.
Robinson JC et al. A comparative study of the amount of smoke absorbed
from low yield (less hazardous) cigarettes - Part Two: Invasive
measures. Br J Addict 1983; 78: 79-87.
T108351333
679
G~O~ ~I~CTS II~ S~KKII~G ~SEA~CII: STAIISTIC~EL CORSIDERATIORS
Annette J. Dobson
Dept. of Mathematics, Statis=ics and Computer Science
University of Newcastle, Australia
Gregory R. Hardes
Hunter Region, New South Wales Department of Health
Australia
I~fRODgCTION
Research on smoking frequently involves the study of groups. For example:
(1)
(il)
(iii)
Smoking prevalence rates and patterns are known to differ among
different groups in any society, such as socio-economic classes or
occupational groups;
Peer group influences have been shown to be strong determinants of
smoking behaviour, especially among children and adolescents;
Controlled trials of lifestyle interventions are often directed at
groups of people rather than individuals; for example, the
populations of different towns in the Stanford Heart Disease
Prevention Program, or different school classes in the Hunter Region
Childhood Smoking Prevention Study which is used to illustrate this
paper.
A consequence of the similarity of smoking behaviour of people within the
same social group is that the individuals in a study population should not
be assumed to be a simple random sample of people acting independently. A
more appropriate model is to reEard the study subjects as a cluster sample.
AS a result the effective sample size of a study is not the number of
individuals in the sample but some smaller number related to the number of
subgroups or clusters and the ~egree of homogeneity of smoking behaviour
within these clusters. For controlled trials this group or ¢lu~ter effect
Address for correspondence and reprints: Associate Professor A.J. Dobson,
Dept. of Mathematics, Statistics and Computer Science, University of
Newcastle, New South Wales, 2308, Australia.
T108351334
reduces the power o£ a trial to detect real differences in outcom ~hich
be associated with the interventions.
We begin by considering the theory of these sampling ~odels and then
discuss the consequences in relation to our study of childhood smoking.
I~ql~'DOMIZATION 1~ (~JSTKRS
Suppose there are m clusters of sizes nl,n2,...,nm ~n the sample so thac the'~'
total sample size ~s N = Zni. Let X I,X2,...,Xm denote the numbers of
smokers in the clusters.
If the data are regarded as a simple random sample from a single binomial
distribution with parameters N and ~, this is equivalent to assuming the N
study subjects act independently and all have the same probability of
smoking. In this case, an unbiased estimator of the probability of smok-
ing, ~, is
~ = Z X./Nz = £ niPi/N
where Pi = Xi/ni is the proportion of smokers in the ith cluster.
estimated variance of ~ is
The
a = ;(~-;)ICN-~)
SSRS
which has as its expected value the binomial variance E(~ = ~(I-~)/N.
Now consider the cluster sample model in which the X i's are independent
and each Xi has the binomial distribution with parameters ni
and ~i; that is, the proportions of smokers differ between clusters. In
this case the ~b~ased estimator of the average proportion ~ = I ni~i/N for
the sampled clusters is
~ = Z niPi/N
(which is the same as for simple random sampling), and the estimated
variance of ~ is
2 _ m l 2 - 2
Scluster (m_l)N2 ni(Pi-P)
T108351335
(for example, see p. 137 of Mendenhall, Oft and Scheaffer (I)). In the case
when the clusters are all of the same size ~ = N/m,
- 1 i p. and 2 _ i E (Pi - ~)2
P = ~ ~ Scluster m(m-l)
as discussed by Cornfield (2).
E(S luster) = m m
It can be shown that
2
2 (l~i) ~
~i(l-~i) I {E ~. } I
- + m---'--~ ~ m
n
The first term in the large brackets represents the average of the binomial
variances for each cluster and the second term is the variance between the
cluster proportions si" If the ~i's are equal then
E(S~luster) =
2
E(sSRS) •
(A somewhat different model for group or cluster effects, described by
Altham (3), Brier (4) and Donner, Birkett and Buck (5), gives similar
results.)
In general s2 has two components: one corresponding to the binomial
cluster
variance for a simple random sample and the other reflecting the variation
between clusters. The relative efficiency of cluster sampling is defined
as s2 /s2 . This represents the loss of power due =o cluster effects
SRS cluster
Its reciprocal is the factor by which the sample size needs to be increased
to attain comparable power to the simple random sample case.
The magnitude of these differences in sample models is illustrated using
some data about childhood smoking patterns.
~R IIBGIOI~ CHILI)HOOD
This was a rgndomised con~rolled trial of a smoking prevention program
designed for 10-12 year old school children; details are given in (6).
Thirty-four pairs of schools were matched by geographic area, =he State or
Catholic school system, class sizes and socio-economic status of parents.
By random allocation one school in each pair was assigned to the £reatment
category and the other to the control category. All children were
questioned about their smoking behaviour, attitudes and knowledge in July/
AugusE 1979. The, the smoking prevention program was conducted in the
treatment school~
There were four strata which were analysed separately. These were defined
by sex and school class, Year 5 being mainly lO-~l year olds and Year 6
mainly 11-12 year olds.
T108351336
We wanted to be able tO detect a difference of 5% in smoking prevalence
between children in the treatment an~ control categories using a 2-tailed
test at the 5% significance level with power of 80% - 90%. Sample size
calculations based on simple random sampling showed that we needed about n ffi
800 children in each of the treatment and control categories for each of the
four sex x school class strata. Therefore the study involved about 6,500
ch [ Idren.
The smoking prevalence rates at the baseline survey differed considerably
between schools. The consequences of this variation, in terms of loss of
efficiency, are shown in Table I. Overall the relative efficiency was about
67% of that intended, suggesting that we should have had around 1200 per
group or, alternatively, representing a loss of power of 10% - 20%.
TABLE I. SUMI~LARY OF BASELINE SMOKING PREVALENCE RATES
(T denotes treatment group and C denotes control group)
p x 102 S~RS × 104 S~luster × I04 tel. elf.
Year 5 boys T 9.4 1.18 2.26
0.52
Year 5 boys C I0.0 1.25 1.93
0.65
Year 6 boys T 17.1 2.08 2.73
0.76
Year 6 boys C 14.2 1.79 2.61
0.69
Year 5 girls T 4.7 0.62 0.71
0.88
Year 5 girls C 5.6 0.81 1.86
0.43
Year 6 girls T 10.7 1.46 2.41
0.61
Year 6 girls C 5.7 0.83 0.96
0.86
The results of the study are sumarized in Table 2 which shows s=oking
for those children who completed questionnaires at both the baseline and
follo,~-'up surveys. Despite ~he matching, ~here were differences ~n baseline
smoking rates between schools assigned to the treatment and control
categories. In view of these initial differences and the large increase in
smoking among all the children over the study period, the adoption rate was
considered a more appropriate outcome measure than the prevalence rates;
this was defined as the proportion of non-smokers at the baseline survey who
were classified as smokers at the follow-up survey.
T108351337
GB(NP ~q~CTS: ST~ETISTICkL C[I~SI1)~TIO~S
TABLE 2. COMPARISONS OF SMOKIMG RATES BETWEEN TREATMEN'r AND
OONTROL GROUPS (Rates as percentages)
Year 5 Year 6 Year 5 Year 6
boys boys girls girls
Treatment
Control
Treatment
Control
Treatment
Control
Smoking Prevalence at Baseline
9.4 17.i 4.7 10.7
i0.0 14.2 5.6 5.7
Smoking Prevalence at Follow-up
14.2 28.8 9.2 22.4
ii.I 25.7 9.7 26.7
Adoption Rates
II .4 22.3 7.7 17.6
8.0 19.2 7.1 23.9
d x 102 3.02
S2 x 104 5.44
d,cluster
d/s2d~,~luster 1.30
Comparison of Adoption Rates
2.94 1.02 -5.52
6.46 4.52 7.45
* p < 0.05
To assess the statistical si~niflcance of the differences in the adoption
rates between the matched pairs of schools, we used the measure
m (nit + nic)
d = Z N (PiT- PiC)
~=I
T108351338
where PiT ~s the ~doption rate in the treatment school of the ith matched
pair of schools, nit is the number of non-smokers in this school at the
baseline survey, PIC and nic are the corresponding variables for ~he control
school in the pair and N = ~(nlT+ niC)is the total sample size. Thus d is
the average difference in adoption rates weighted by the initial numbers of
non-smokers. The corresponding variance estimate, based on the cluster
aample model, is
2 m Z(niT + niC)2(PiT PiC - d)2
Sd,cluster = (m_l)N2 -
(In the case where all the clusters have the same size ~ and the numbers of
smokers in each school are assumed to be independent, it can be shown that
2 ~iT(l-~iT) Wic(l-~iC)
E(Sd,cluster)= I-W~ { E - +
+ re(m-l) Z {(WIT - ~T)2 + (WiC - ~C) - 2(~iT - ~T)(~iC" =C)}')
The significance test results are shown at the bottom of Table 2. For boys
the apparent increase in the adoption of smoking in the treatment schools
was not statistically significant, whilst for the older girls, the adoption
rate was significantly lower (at the 5% significance level) in the treatment
schools than in the control schools.
The peer group or clustering effect in smoking behaviour has substantial
s~atist~=al implicac~oos for research. The variance in smoking prevalence
in a study population is likely to be larger than the crude binomial
estimate would suggest because of variation between subgroups within the
population as well as variation within each subgroup. This results in a
loss of atatistical power to detect real differences or, equivalently, a
need for larger samples.
T108351339
685
I. Mendenhall W, Oct L, Sheaffer RL.
Belmont: Duxbury, 1971.
Elementary survey sampling.
Cornfield J. Randomization by group: a formal analysis.
Epidemiol 1978; 108:100-102.
Am J
Altham PME. Discrete variable analysis for individuals grouped into
families. Biometrika 1976; 63:263-269.
Brier SS. Analysis of contingency tables under cluster sampling.
Biometrika 1980; 67:591-596.
Donner A, Birkett N, Buck C. Randomization by cluster: sample size
requirements and analysis. Am J Epidemiol 1981; I14:906-914.
Lloyd DM, Alexander HM, Callcott R, et al. Cigarette smoking and drug
use in school children: III - evaluation of a smoking prevention
education program. Int J Epidemiol 1983; 12:51-58.
T108351340
687
SM~KI~ A~D WO~.~'S EMARCIPATIO~; THE DEVELOPED
Ingrld Eide
~nivers~ty of Oslo
Institute of Sociology
Box 1096, Blindern
Oslo 3, Norway
We are by now well acquainted with the general picture of women and smoking
in the so-called developed world.
women smoke
their smoking rates and smoking behaviour were lagging behind men's by
about one quarter century
more young women than men now start smoking, or start smoking earlier
women have greater problems than men in quitting
women more frequently than men smoke to cope with emotions and stress
women are targeted by the tobacco industry
women who smoke are now aware of the health risks of smoking
crossnatlonally there are differences in the level of smoking by women
internationally there are, obviously, differences.
If we look at the trends of women daily smokers from the United Kingdom and
the four Scandinavian countries over the last ten year period, the picture
is largely one of stability. Percentage point variations are 4 or 5 in
Scandinavia, 4 also for England, but perhaps 8 if a recently rumoured daily
smoking rate of 33% is correct. Before this period, trends had been
climbing slowly and steadily.
TABLE I. CROSSNATIONAL COMPARISON, WOMEN'S DAILY SMOKING, 1973-1982
Years: 73 74 75 76 77 78 79 80 81 82
United Kingdom: 41 38 37 37
(33)
Denmark: 46 &'2 43 42 44 45
Finland: 20 15 17 18 17 16 16 16 17
Norway: 32 32 32 32 30 31 33 30
31 34
Sweden: (34 34 3~) 34 31 34 32 26 3~ 30
Note: The UK data are from the Governmental Statistical Service, the
Danish from Observa, the Finnish from the Central Bureau of Statistics
and Gallup, the Norwegian from the National Council on Smoking and
Health, the Swedish from NTS. All figures percent.
This paper asks how these facts relate to the emancipation Q~ Momen. If:
-~- . ~-~6~rn~ng, %,e interpret this as a question of whether emancipated
women smoke, we shall have to look for indicators of emancipation to
reach an answer.
T108351341
In regular, ~tional studies, we can only fir~i age, education, ecou~ic
activity and place of iiving. Our rationale for using them is that the
younger women, those who have more than compulsory education, those who
for money, and those exposed to the wider range of options an4 activities of
urban |iving can be termed emancipated. We then suppose they have a Profile
of participation, or a potential for it, that distinguishes them from the
traditional roles of housewives.
Making a five point additive index of these variables, applied
Norwegian national sample of December 1982, we obtain this table.
SMOKING ~D WOMEN'S EMANCIPATION. PERCENT
NORWAY, NATIONAL SAMPLE, DECEMBER 1982 (N=1241)
Emancipation index
Low High
1 2 3 4 5 Total
TABLE 2.
Smokes daily 22 30 34 44 30 35
Sometimes 3 4 5 7 9 5
(less now)
Not any longer 4 12 14 12 22 13
Sometimes 1 4 4 6 5 4
(never daily)
Never 70 50 43 32 34 43
Sum I00 I00 I00 I00 i00 I00
N 107 331 317 370 116 1241
In this table the most emancipated, by our definition, appear in column 5.
We can first no=e ~hat there are fewer daily s~okers in t~is group than in
the total~ bu~ definitely more than in the least emancipated category.
Secondly, we observe, on ~he ~hird line, tha~ many (22%) have been able to
q~i~. They have been daily smokers. Fin~lly, on ~he last li~e, we have a
demonstration of a well known fact: the old housewife with only compulsory
e~=a~ie~ ~s very unlikely to smoke. 70% of them say: never, The propor-
Zion of '~ever-smokers" drops to 34% among the most emancipated.
Consequently, we can say that the most emancipated women are not over-
represe~Zed among daily smokers, ap~ that, apparently, they are more
successf~ ~n giving it up ~han any other category. A word a~$o about
highest proportion of daily smokers: category 4. A possible explanation may
be ~hat women in this category, more frequently than those in category
are under some par,
~at might open up a better life. We can almost hear them
sighing, .. arm lighting a cigarette.
T108351342
689
This index may be considered unsatisfactory because it overlooks more recent
developments in the women's movement. The modern, feminist woman is
concerned with the interplay between private and public life. She is
concerned w~th women's rights as such and not only getting access to men's.
A sample of 206 women, aged 16-40 years, were interviewed in June 1983 in
Ro~way (NOI, natl. sample) on smoking habits and feminist issues and
attitudes. On two questions they could indlcare identity: would they call
~bemselves a "woman ' s rights person" (kvlnnesakskvinne) and had they
participated in organized activities on Woman's Day, March 8? On two
questions they could indicate ideology: should mothers of small children
work outside the home and should fathers of small children work less (than
normal) outside the home and spend more time at home? On smoking we asked
the standard questions.
Table 3 shows how smoking habits relate to feminist opinion.
TABLE 3.
FEMINISM AND SMOKING HABITS. PERCENT
NORWAY, NATIONAL SAMPLE, JUNE 1983, (N=206)
Feminist
identity
March 8 Mothers Fathers Total
participants work work less
outside outside
the home the home,
more at
home
Smokes: Yes No Yes No Yes No
Yes No
daily 33 44 28 45 47 39
41 45 43
sometimes 15 13 28 II 16 13
15 Ii 13
never 52 43 44 44 37 48
44 44 44
Sum I00 I00 i00 I00 I00 I00
I00 i00 100
N 27 176 25 181 98 102 96 105
206
% 13 85 12 88 47 50 47 51
First we no~e that there are fewer daily smokers among those who identify
themselves as feminist, than among non-feminists. The proportion who smoke
"now and then", particularly among March 8 participants, may indicate that
some kind of prolonged cessation activity is occurring. Thirdly - and most
important - we must not overlook how few of the women see themselves as
feminists, according to this definition: the feminist is one ~. But
~ " " " e
~r-6~rtlon gr~s to
almos~ half. And here we find more smokers among those sympathetic to
feminist views (about job sharing at home, an& mother's right to work for
pay).
T108351343
69~
Human beings tend to be '~omosocial". If we believe this is true for sel
identifying feminists, (and we have good historical reasons to believe that)~
it will be of interest to know if they report socializing mostly with
who smoke, with non-smoking women or equally with both. Table 4 shows tha~
a slim ~ajority of feminists as well as non-feminists claim mostly to meet
wo~en-smokers. But we also see that many more feminists than non-feminists
socialize with mostly non-smokers. In other words, the feminist milieu more
frequently is perceived as having a non-smoking majority.
TABLE 4.
SELF-IDENTIFIED AS FEMINIST; AND SMOKERS IN GROUP. PERCENT
NORWAY, NATIONAL SAMPLE, JUNE 1983. (N=206).
Feminist identity March 8 participant
Yes No Yes No
Socializes with
women who:
mostly smoke
52 60 52 60
mostly do not smoke 44
equal number smokers,
non-smokers 4
36 48 36
4 0 4
Sum i00 I00 i00
i00
N 27 174 25 179
Summing up, and remembering that we have squeezed a very small sample, it
must be said that feminists are not smoking to an extent that can support
the idea of the new woman's movement being responsible for the spread of the
smoking epidemic among wo~en.
But are th6re effects of emancipation among those not identified with the
women's movement, those not themselves emancipated? The diversification of
roles women can enter and mould has definitely changed the ideas of what
is proper female 5ehaviour among humans. Smoking is now unwise, but not
unladylike. Women buy more, including tobacco. The expanded number of
roles which women hold integrate women in society. But new insecurity,
~ncompatible and overburdening role-requirements may follow in many cases
resulting in stress and strain.
Equal participation by an increasing number of women in contexts formerly
dominated by men or monopolized by men has, in many countrlesI e~posed those
w~9~en to mit,,~r~ee~ -_~.&~ ~,~ki~g ~S the norm. They have tolerated i~, and
perhaps eo~|~ed with it. Smoking is a kind of behaviour quickly learnt
compared to ~ome of the other intricacies of adequate role behaviour. This
may apply to ~he newcomer in genera|, and of e~ther sex. Only we are still
in a phase %~here the female newcomer may be a newcomer in a double sense as
the first, or one of the first, women. The new man is another man.
T108351344
691
Actually, it is not unlikely, and we know this from interviews and observa-
tions, that the cigarette "protects" in situations like this.
I have had a long conversation with a young man about smoking in his age
group. In his opinion~ the girls appear to smoke more frequently and more
heavily than the boys. It is as if the girls are present and part of the
group, but the boys run it. The ~oys have the ideas, the [irls join. The
boys discuss, the girls listen. The boys have projects and save money, the
girls have fewer plans of their own and spend what they earn. The boys
stick to their declsions~ the girls are ambivalent, have less self-control.
So the girls sit there occupied w~th their s~oking. These are girls 18 to
20, with more ~-han 12 years of education.
Watching young mothers with children and housework, managing the criss-
crossing demands of being totally "at service", or in salaried jobs of a
similar nature, one gets the impression that smoking "permits" withdrawal.
A time for yourself, or with other participants in what appears as a
ritual. A ritual, by definition, has its own way, it is sinful to inter-
fere, and unthinkable to abandon. Observed socially, in private or private
surroundings, some women apparently interact by smoking, quiet as conversa-
tion develops, but sending up a smoke-signal that indicates participation or
rather some kind of detached presence.
These modern modes of behaviour are rather different from emancipation. And
modern feminism can be seen as an attempt to analyze, and act on them. It
is also noteworthy that countries with high frequencies of debate and action
by the women's movement have no parallel increase in s~king among women -
stability is the overall tendency in Table i.
On the other hand, smoking has never been a major issue in the new women's
movement. It ~y be fruitful, briefly, to compare smoking with another
health issue successfully promoted by women and the women's movement:
breastfeeding.
Breastfeeding
Non-smoking/Smokin~
"act" is the message
nature
relational (mother-child)
private and intimate
lay-issue
free of cost
contributes to health r~pidly
applies to women only
commercial interests against
~le~islstion involved
"abstain" is the message
culture
individual (but pregnancy, etc.)
private and public
expert-issue
money involved
affects health less visibly
applies to men and women
commercial interests involved
iegisletion involved
This listing of some differences between ~he issues umy explain why ic was
so much easier for the women's movement to catch on to the breastfee~ing
issue. But these wo~en were up against strong and familiar forces: multi-
" " " uS
~nternat~o'-~'~ advertisin~ and
market~ng~ a male professional mo.opoly for a long time ~nable to understand
human lactation. It took years of systematic work at the grass roots and at
T1083513,45
the level of governments and WHO to turn the trend. The struggle
contiuues. ~othing is won forever. We may be wise to ask what we can learn
from this lesson.
The data collection for the study on feminism and smoking was made possible
by funding from the Norwegian Information Service and the National Council
on Smoking and Health. In preparing the present paper I have benefitted
from the cooperation with fellow members and staff of the National Council
on Smoking and Health.
BIBLIOGRAPHY
Jacobson B. The ladykillers, why smoking is a feminist issue.
Pluto Press, 1981.
London:
U.S. Dept. of Health and Human Services. The health consequences of smoking
for women. A report of the Surgeon General. Rockville, Md.: USDHHS, Office
on Smoking and Health, 1980.
Berlin S. Smoking and the women's movement. Paper prepared for Health and
Welfare, Canada, 1977.
Whelan E et al. Analysis of coverage of tobacco hazards in women's
magazines. J of Public Health Policy 1981; 2.
Brantenberg G. Ja vi slutter... Pax, Oslo 1978.
World Health Organization. Controlling the smoking epidemic. Geneva,
Switzerland: WHO, 1979. WHO Technical Report Series 636.
T108351346
6~3
SteiP~r ¥olger4, can4. mag.
Ingerma 3rofoss, cand. aociol.
Fer Morten L@chsen, canal, polit.
Kjell Bjartveit, M.D., dr. reed.
National Council on Smoking and Health
Trondheimsveien 15TM , 3ox 8025 Dep.,
Oslo i, Norway
II~'ROD~ CTIOl~
The Central Bureau of Statistics of Norway has carried out studies on
smoking habits in the population (16-74 years) since 1975. Throughout this
period the smoking habits of women (all ages) have remained stable.
The Norwegian National Council on Smoking and Health have studied smoking
habits among doctors (1974) and among teachers (1977).
In 1979 the Council conducted a study on smoking habits among three groups
of health personnel in the nursing aec~or (registered nurses, auxiliary
nurses and nurse aides). A questionnaire was sent to a representative
sample of 2300 individuals selected at random from the lists of members of
the respective professional organizations. Two groups were excluded from
those who returned the questionnaire, duly filled in. These were male
nursing staff, because they were too few in number, and women who had not
answered the questions on smoking habits or profession.
The following report relates to the almost 1900 female nursing staff who
participated in the analysis. These included 1129 registered nurses, 529
auxiliary nurses and 200 nurse aides, comprising altogether 84% of the total
female sample.
Smokiag h~bit s
There were distinct differences in the smoking habits of the three groups
(Table I).
Address for reprints:
Steinar Folger~, National Council on Smoking and
Health Tro h " " IV .
Oslo l, Norway.
T108351347
TABLE I. SI'~)KING H~J~ITS
Daily Occasional Non-
smokers smoke~s smokers
Total
~ (N)
Registered nurses 22 13 66 I01
(1129)
Auxiliary nurses 31 ii 58 I00 (529)
Nurse aides 39 ~ 57 i00 (200)
(X2 = 41.755, df = 4, p<O.O01)
The average daily cigarette consumption was the same for auxiliary nurses
and nurse aides, and somewhat lower for registered nurses. For all three
groups, however, the consumption was h~gher than for women in the population
as a whole.
There were differences between the groups in respect of daily smoking at
work. About 7 out of i0 of the registered and auxiliary nurses who smoked
daily did so at work, while this applied to 9 out of 10 of the nurse aides
who smoked daily. However, the nurse aides had more opportunity to smoke
while at work than did the other groups.
There were few nurse aides who worked at places with full restrictions
(i.e.smoking is prohibited in all rooms) (Table 2). The percentage of
registered and auxiliary nurses working at such places was about twice as
high. The percentage of nurse aides who worked at places with no restric-
tions (i.e. no rooms where smoking is prohibited) was high compared with the
other two groups.
TABLE 2. RESTRICTIONS ON SMOKING FOR NURSING PERSONNEL AT WORK
No Some Full
restric- restric- restric-
tions* tions** tions**~ Total
Registered nurses 19 55 26
I00 (996)
Auxiliary nurses 27 49 24 I00 (479)
Nurse aides 39 49 12 I00 (187)
(~)
* Percent who work at places with no restrictions.
** Percent who work at places where smoking is prohibited in one or
several rooms.
*** Percent who work at pl~Ge~ ybere smok~n~ £~ prnh~h~r~a ~e 9I]
roo~s.
T108351348
~Tbereforethe low percentage of occasional _ --~:_=
~c~
. (and the high percent-
~a~e of daily smokers), among nurse aides ce~3~ ~e
because ~his group has
~- ~-.~,,~" v to s~ke ~ work It is
.~sonable ~o assu~ tha~
the f~er the restrictions ac the place of
~ ...... ~evc. ~-.~ ~re will persons, who
~re b~sically occasional s~kers in company, ~ s:~a~ed ~o s~ke dally at
Ferce~t~ge ~ke~ ~ ~ge and ~neral level of ~iou.
A~n~ auxiliary nurses and nurse aides, ~e ~r:~r.:aBe of daily smokers
decreased with increasin~ a~e (Table 3). W .... :-.e ~=eption of the youngest
age ~roups, the sa~ pattern was found a~nB re~:ered nurses.
Age
TABLE 3 PERCENT DALLY $~C_~_='~Z =-Y AGE
Registered Auxilia~= Nurse
nurses nurses aides
% (N) % ,~ : (N)
16-24 22 (186) 40 ~-~ .. (13)
25-34 26 (412) 36 k=~- 55 (33)
35-44 22 (216) 28 ,~ 42 (53)
45-54 19 (167) 22 .-- 32 (53)
55-64 13 (127) 9 ~ 22 (45)
65-74 ,. (17) ..... (i)
No answer .. (4) ....... (2)
(1129) [bZ~ (200)
The next question is whether the differences L~ ~=~king habits in the dif-
ferent groups are due to age-composltion, A_~.-e--z.~us=ment showed that ~his
was not the case; the difference between regist~re~ nurses and nurse aides
was much grea~er after adjustment for age, N~ ~tall re~urn to =his point
later.
There was no difference between auxiliary nur~e~ and nurse aides as re~ards
the percentage of daily smokers ~ccordi~ :: ~neral level of education
(Table 4). (li these groups, there were veq: ~ wi~h the highest ~eneral
education).
Among registered nurses the proportion of /a=i= smokers was lowest among
~hose with the lowest level of education, This ~s in
contrast to the find-
~ngs amon% woman in the population as a whc l~. in ~his case, however, the
a~e-variable may have had a diszinc£ effec:. Le~istered nurses wi~h the
lowest ~eneral e~ucation were in the main o!=er, an/ here there were few who
smoke.
T108351349
TABLE 4 PERCENT DAILY SMOKERS BY GENERAL LEVEL OF EDUCATION
Registered Auxiliary Nurse
nurses nurses aides
Lowest* 17 (i18) 32 (219) 39 (160)
Middle* 22 (633) 30 (196) 40 (30)
Highest* 22 (361) .. (9) .. (2)
No answer .. (t7) .. (33) ,:. (8)
(1129) (529) (200)
Level of education
Neither the age-composition, nor the general level of education explain the
differences in smoking habits between these groups of nursing personnel. We
also tried to find out whether differences in smoking habits between the
three groups of nursing staff could be connected in any way with the actual
profession (e.g. type of work place, hours of work, and shift arrangements),
but found nothing to indicate this. It is ~herefore reasonable to assume
that the differences in smoking habits are more likely to be due to some
kind of group identification.
Previous daily s~okers
The percentage of previous daily smokers was about the same for registered
and auxiliary nurses, but somewhat lower among the nursing aides. (Table 5).
TABLE 5
Daily Ex-daily Never
smokers smokers smoked
daily
Total
% % % %
(N)
Registered nurses 22 23 56 101
(1120)
Auxiliary nurses 31 22 47 100 (527)
Nurse aides 39 15 46 i00 (198)
(1845)
PREVIOUS DAILY SMOKERS
About half the registered nurses tcho smoked daily said that they will not do
so in five years time. The corresponding proportion was somewhat less among
auxiliary nurses. Among nurse aides there were few who were of this opinion
- only 2 out of 10. Nevertheless, in the course of the last twelve months,
g~most half of rh~ .~!!7 c~ in t.e taree groups had tried to stop smok-
ing daily.
T108351350
On the basis of the above information it is possible to calculate the stop-
ping rates for the three groups of personnel. In this connection it is
important to note that the stopping rate in this report is defined and
calculated differently fro~ in, for example, the IlK and USA. To avoid too
many figures, the stopping rates will be discussed in connection with age-
adjusted comparisons between the three different groups.
SMOKING HABITS OF REGISTERED NIIRSES AS COMPARED WITH OTHER GROUPS
In ~he follow~ng paragraphs, the results for registered nurses are used as a
basis for comparison with other vocational and population groups in Norway.
Figure 1 shows the percentage of daily smokers for registered nurses (in
1979) compared with other groups.
FIGURE
PERCENT DAILY SMOKERS AMONG REGISTERED NURSES COMPARED WITH
OTHER FEMALE GROUPS IN NORWAY. (Figures are age-adjusted to
registered nurses.)
i 2 3 4 5
6
Registered Auxiliary Nurse General Doctors
Teachers
nurses nurses aides population { 1974)
(1977)
The percentage of daily smokers was lower among registered nurses th~
pop~ a~1o~ as a w-~, but higher than among doctors and
teachers.
"1-108351351
The relationship to auxiliary nurses and nurse aides has been discus$~
earlier.
The stopping rate was higher for registered nurses ~han ~or worn
~e~era~ ~ for the other ~vo nurs~n~ groups, bu~ ]o~r than for doc~or~
and teachers (Figure 2).
STOPPING PATE AMONG REGISTERED I~CRSES COMPARED WITH OTHER FEM~LE
G~O~JP~ I~ ~K),RWAY. (Figures are age-adjusted to registered
l"~.lrs es • )
I 2 3 4
5 6
Registered Auxiliary Nurse General
Doctors Teachers
nurses . nurses aides popular &on (1974)
(1977)
There is little difference between the stopping rate ~or doctors in 197~ an4
~hat for registered ~u~ses in I~?~. I~ is probable, however, tha~ more
Studies of medicel stodents in their last semester indicate a clear change
in smok!n~ habits among doctors since the study on thi~ group was carried
OUt i~ ~974. ~ere has been a similar cha~ge a~ong registere~ nurses.
About half of the registered uurses who had stopped smokin4~ had done so in
1976 or later. The curve for the stopping rate for the populatioa as m
whole a]~o ~hows ~ i.crease ~n ~he percentage who have stopped s~kin~ in
recenZ ~ars.
T10,~.'.'3513~
It is hoped that the question as to whether doctors have changed their
smoking habits will be answered more conclusively in 1984, when the National
Council on Smoking and Health is to carry out a new study, among this group.
Investigations from the USA in the period 1959-1975 (1,2,3) sh~ that the
percentage of "present smokers" was larger or the same among registered
nurses as amongst women in general. The studies also show that the smoking
habits of the nurses did not change in step with those of other professional
groups (doctors, dentists and pharmacists). Although many nurses stopped
smoking, this was counterbalanced by new younger nurses who smoked.
A study from the United Kingdom in 1974/75 (4) showed that there was n~re
smoking among registered nurses than among other professional groups in the
health and education sectors. It also showed that the percentage who
stopped smoking was smaller among nurses than among other professional
groups.
As mentioned above, the present study has shown that among Norwegian
registered nurses the percentage of daily smokers is lower, and the stopping
rate higher, than among the female population as a whole. Therefore
Norwegian nurses and their American colleagues differ in this respect.
On the other hand, the percentage of daily smokers is higher and the
stopping rate lower for registered nurses than for doctors and teachers,
thus confirming on this point the pa=tern demonstrated in USA and the United
Kingdom.
I. Green DE. Nurses are kicking the habit.
1936-1938.
Am J Nursing 1970; 70(9):
U.S. Dept. of Health, Education, and Welfare/Publlc Health Service.
S~king behavior ~nd Jttit~des Of physicians, dentists, nurses, and
pharmacists, '1975. Morbidity and Mortality Weekly Report. 1977 June i0;
26 (23),
Garfinkel L. Cigarette smoking among physicians
professionals, 1959-1972. CA - Cancer J for
Nove~er/December; 26 (6): 373-375.
and other health
Clinicians 1976
people. U.K. Dept. of Health ~nd Social Security, Office of Population
Censuses and Surveys, Social Survey Division, London 1977.
T108351353
QUART~TATIVE N~)ELS OF ~ CA~C~E ~ALITY PO~ THE
U~'ITKD ~ll~oD0~l, CANADA ~qD AUSTRALIA
R.W. Gibberd, Ph.D.
E. Doyle, ~.Sc.
University of Newcastle
Shortland~ N.S.W. 2308, Australia
K.S. Brown, Ph.D.
W.F. Forbes, Ph.D., D.Sc.
University of Waterloo
Waterloo, Ontario, Canada N2L 3GI
701
II¢Iq~ODUCTION
Lung cancer mortality is strongly associated with tobacco consumption.
Quantitative relationships between lung cancer mortality and tobacco
consumption will provide a tool for predicting future mortality rates and a
means for evaluating strategies a~med at reducing lung cancer mortality.
Reviews of quantitative models of cancer have been given by Whittemore and
Keller (i) and by Forbes and Gibberd (2). In this paper, one such model is
used to relate lung cancer mortality to a~e and cumulative tobacco consump-
tion in three countries; Australia, Canada and the U.K.
DATA SOURCES
Tobacco consumption
The Tobacco Research Council has tabulated annual tobacco consumption for
many countries. Estimates of cousumption by age and sex are also available
for the U.Ko (3), Canada (4) and Australia (5). Cumulative tobacco consump-
tion was calculated by a~e and sex for three cohorts with central year of
birth 1901, 1906 and 1911. The cumulative consumption allowed for the
different mortality rates between smokers and non-smokers.
Lung Cancer Mortality
Data giving the number of lung cancer deaths in 5-year age-groups for aCes
3~6~ Yere obtained. The standards of d~a~nosis of lun~ cancer have
improved during the period of interest (1930-1980) and the number of deaths
were adjusted as described by Todd (4).
METHODS
The Go~oertz, Weibull and Brown-Forbes models have been used to describe ~he
T108351354
702 ~.~, DOYLE, ~ AM} ~
age-dependence of mortality. These models were generalized to include
cumulative consumption D(x) at age, x as foll~s:
re(x) = exp (a+ ~x + Y D(x))
re(x) = x5 exp (a÷'Y D(x))
re(x) = 1 -~(a+Sx + ~' Z~(x))
Gompertz
Weibull
Brown-Forbes
where m(x) is the age-specific mortality rate, and ~ is the standard normal
cumulative distribution function. All models contain three parameters ~,
and Y which were estimated using maximum likelihood techniques.
RESOLTS
Table I presents the estimated values of the parameters obtained for the
cohorts separately and combined for each country, for the Brown-Forbes
model. The models were able to describe male-female differences in lung
cancer mortality rates in terms of their differing consumption patterns. The
values of the goodness of fit statistic (Pearson chi-square, X2) are highest
for the Gompertz model, while the Brown-Forbes model was generally lower
than the Weibull model. However, using X2 values as a measure of fit can be
misleading with large numbers of deaths, and other statistics such as R2 may
be more appropriate. R2 values greater than .98 were obtained for all three
models, and residual plots revealed no systematic departures from the model.
The Brown-Forbes model was also used to predict lung cancer mortality rates
for non-smokers (Table 2). This was done by setting D(x) = 0 and using the
parameters given in Table 1 for all cohorts. The results are in good agree-
ment with the experimental studies (6). Further analysis is suggested, in
enon caused by other factors such as the environment.
With the Brown-Forbes model, the relative risk ~epends on age and cumulative
consumption, increasing approximately exponentially in each case. For some-
o~e smoking 20 cigarettes a ~ay since a~e 20, the relative risk at age 40-44
is ~.3.
The model was also used to predict Australian lung cancer mortality for the
~ext 15 years. It was assumed that consumption rates would remain the same
as those in 1971-75, and the model predicted that male cancer rates have
nearly stabilized while female rates continue to i~crease (a more detailed
report on such predictions is ~eing prepared).
T108351355
70~
The models used in this study have described the increasing lung cancer
mortality rates in three countries using two variables, age and cu~alative
tobacco consumption. The data requirements for the m~delling of the
influence of smoking on lung cancer mortality are relatively modest
national lung cancer mortality rates, corrected for under-diagnosis, and
national tobacco consumption figures, with recent surveys to disaggregate
consumption into age/sex categories. It should not be too difficult to
obtain these data for other countries and determine whether cumulative
cigarette consumption could explain the changes in lung cancer mortality.
TABLE 1 PAI~AMETERS OBTAINED, AND y2 FOR BROWN-FORBES MODEL
Australia
1901 1906 1911
All Cohorts
~ 5.036 5.131 5.033 5.047
8 -.0212 -.0227 -.0212 -.0218
7 -.0853 -.00888 -.00899 -.00886
X2 i0 21 14 61
d.f. 13 13 13 45
Canada
1901 1906 l~Cll
All Cohorts
~ 4.559 4.674 4.911 4.733
8 -.01A9 -.0£65 -.0213 -.OlB6
Y -.00739 -.00689 -.00611 -.00648
X2 31 18 15 196
d.f. 13 13 1~ 45
1901
United Kingdom
1906 1911
All Cohorts
~ 4.678 4.710 4.760
~ -.0185 -.0196 -.0204
~2 ~0~5 89[ A67
d.f 13 13 ]5
~.729
-.0199
- .-~0~Y0-
5470
45
T108351356
TABLE 2
LUMG CANCER I~KTALITY RATES FOR NON-SMOKERS,
USII~ COEFFICIEWfS IN TABLE I (ALL COHORTS)
AUSTRALIA CANADA U .K . U . S . ~LES*
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
.7 1.8 2.1 J
2.8
1.1 2.6 3.3
1.8 3.9 5.0 1 5
2.9 5.7 7.4
4.5 8.3 ll.l I 13,9
7.0 12.0 16.3
10.9 17.2 23.7 I 25.6
16,6 24.4 34.3
25.1 34.5 49.1 ] 49.4
37.4 48.1 69.7
From Doll (6).
I. Nhittemore A, Keller Jr. Quantitative ~heories of carcinogenesis. SIAM
Rev 1977; 20: 1-20.
2. Forbes ~F, Gibberd RN. Mathematical models of carcinogenesis;
review. Math, Scientist. ~984 (In press),
3. Lee P~. Statistics of smoking in the United Kingdom, Research Paper I,
7th ed. London: Tobacco Research Council 1976.
T10835135~
Todd, GF. An estimate of ~anufactured cigarette consumption in Canada
by sex, age and cohort, 1921-75. Waterloo, O~tario: Univ. of Waterloo.
1979.
5. Doyle E.
1982.
Unpublished manuscript, University of Newcastle, Australia.
6. Doll R. The age distribution of cancer: Implications for ~odels of
carcinogenesis. J.R. Star. Boc. 1971; 134: 133-166.
T108351358
707
P~__.DICTIO~ OF ~ CAIqCER I~CIDE~CE I~
A.PI~ISAL ~ DIFFE~EM'I' APPB0~.CKES
Timo R. Hakulinen, Sc.Do
Esa M. Laara, M.$c.
Finnish Cancer Registry
Helsinki,-Finland
II~DUCTION
Prediction of the occurrence of a disease is essential for decision-making
~n public health issues related to that disease. Predictions are used in
large-scale planning of preventive, diagnostic and therapeutic measures. A
clear and true picture of the cancer situation in the country can be best
achieved with a complete nationwide or otherwise representative cancer
registration system. There are about 70 population-based cancer registries
in the world. One of the tasks of these registries is to investigate time-
series in cancer incidence and to make predictions. In this paper several
methods of making predictions for lung cancer incidence are reviewed and
evaluated by using data collected by the Finnish Cancer Registry. In
Finland, cancer registration is an integral part of the health and vital
statistics registration system and can be considered prac~ically complete
(~).
EXTRAPOLATION OF TI~NDS
The easiest strategy in forecasting is to make extrapolations (2). For lung
cancer in males the extrapolation of trends as a means of forecasting has
failed: the observed age-adjusted incidence rates in Finland have been lower
than those predicted (Figure I). The prediction for 1980 has been made on
the basis of the observed trend from 1957 to 1968. An apparent explanation
for this failure is found in changes of ~moking habits among males in
Finland.
When forecasting, smokin~ can be accounted for by usin~ a variety of
methods. Hakama and Pukkila (cf. 3) constructed a forecast for lun~ cancer
usin~ a dynamic linear model, lagged time series and forecasts of cigarette
consumption as independent variables (Figure 2).
Correspondence and reprint requests should be addressed to Dr. Timo R.
Hakulinen, Finnish Cancer ReKistry, Liisankatu 21 B, SF-O0170 Helsinki,
Fiu~
T108351359
FIGURE 1
~'E-~JUS'rED ~¢IVE~ S~TZ oF c~c~z oF TRE ~ IN ~LES ~
FI}U_,Ai4D ~957-1976 AI~ A PREDICTION (90% CONFIDENCE INTERVAL)
(~).
'.'.'.'.'-'.'-'.'-'-'"-'-":':':'T'.'.'.,,T~ :
1968 1980
YEAR
FIGURE 2
AGE-ADJUSTED INCIDENCE RATE OF CANCEE OF THE LUNG IN FINLAND
1955-1975, AND THE PREDICTED RATES FOE 1976-2000 BASED ON A
DYNAMIC LINEAR MODEL, LAGGED TIME SERIES AND FORECASTS OF
CIGARETTE CONSUMPTION AS INDEPENDENT VARIABLES
LUNG,, males
T10,~351360
COHOrt ~t.~D PEILIOD SPECIFIC I~DELI~G
In reality, not everybody in the population smokes the average m~ber of
cigarettes and started smoking a fixed number of years ago. The popuIatlon
at a given ~ consists of several b~r~h-ye~r cohorts a~ it is possible
~ha~ dif~eren~ cohorts also have differen~ caucer risks. S~klng hab~s are
adopt~ early in life and ~y determine the general level for lung c~,cer
incidence in the cohort. Depending on ~he economic situation, an~i-smoking
pol~cy e~c., the general level for cancer incidence may differ bergen
cohorts.
These levels may be estimated with log-linear models by usir~ the rather
well-known mathematical relationship between age and risk of lung cancer
(4). The results are the cohort-speclflc relative risks (Figure 3). The
risk for the cohort born in 1874-1875 has been denoted as one. Each
birth-year cohort experienced increasing cohort-specific risks of lung
cancer up to cohorts born in about 1920. For later cohorts, the
cohort-specific risks decreased rapidly. It is possible that this would not
actually be the case since the estimation for later-born cohorts is based
upon observations in age groups below 55 years in which the effect of age is
far from maximal.
FIGURE 3
COHORT-SPECIFIC RELATIVE RISKS OF LUNG CANCER IN MALES IN FINLAND
AND FIVE HYPOTHETICAL TRENDS (i-5) IN RELATIVE RISK FOR THE MOST
RECENT COHORTS (the relative risk for cohorts born in 1874-1875
equal to one) (2).
T108351361
Five alternative predictions for later-born birth-year cohorts were
constructed (Figure 3). In assumption ], for cohorts born in ~he mid 1960s,
the cohor~-sFeci£ic risk continues to decrease smoothly to ~pprox~mately
o~e-£ourth of izs cop value. I, assumptions 2-5, ~h~s value is 40, 60, 80
and I00 per cent approxi~tely.
~e foCecas~s ~de by using these five alternative predlc~ions for ~he
later-born cohorts' lung c~ncer risks sh~ ~hat even the ~s~ rapid decrease
in the cobor¢-speciflc risk o£ lung cancer does no~ promise a ve~ rapid
~ecrease in ~he period-specific a~e-a~jusced incidence race for cancer o~
Cbe lu~ (Figure ~). ~e 1953 level in ~he risk of lung cancer will noc be
reached earlier than around the year 2000. The cases to be diagnose~ in ~he
l~80s and also £n the 1990s are mostly persons belonging ¢o the present
h~gh-rlsk cohorts. The ra~es £n Figure 4 concern ages of ~5 years ~nd over
and are thus noC, as absolute numbers, comparable wi~h ~hose £u the other
figures of ~his paper.
FIGURE 4
AGE-ADJUSTED INCIDF~C~ RATES OF LUNG CANCEE ~l~ ~A%LES ~G~ 35-79
~ARS IN FI~D 1953-1976 ~ ~CASTS ~ ~ ~E YE~ 2000
~SULTING FROM T~ FIVE DIF~ ~TE~ATIVES OF ~ COHORT-
SPECIFIC ~LATIVE RISKS ~R ~E ~ST ~CENT ~HORTS (c£. Figure
3) (2).
LUNG, males
II
T10835136;
711
It is interesting to study, by calendar time, the residuals of the leg-
linear model used in the prediction. For every calendar year the ra:=c
between the observed lung cancer incidence rate and the expected rate given
by the model was calculated (Figure 5). The period-specific ratios were
aystematically below one in the early 1950s and m~d 1970s. This may ~eil
hand, other explanations are also possible. First of all, there ~y have
been underd~aKnosis of lung cancer ~n the early 195Os. Secondly, in any
case, the kmowled~e abou= the etiology of funk cancer suggests that the lung
cancer risk would not be attributable to smoking habits adopted by d~fferen~
bir~h-year cohorts ~n their early life, a~d a~ing alone. Stopping of s~king
reduces the risk of lung cancer rather rapidly. There are t~mes when, fer
example, due ~o a rise ~n the prices or campaigns in the ~ss ~dia, people
tend to stop s~k~ng more often than on average. These specific times may
be reflected in ~he ratios between the observed annual lung cancer incidence
rates and the values ~iven by the ~del. Introduction to less-harmful
cigarettes ~y also produce such effects.
FIGURE 5
PERIOD-SPECIFIC RISK RATIOS BETWEEN THE OBSERVED AGE-ADJUSTED
INCIDENCE RATES OF LUNG CANCER IN MALES AGED 35-79 YEARS IN
FINLAND 1953-1976 AND FITTED RATES DERIVED FROM AN AGE-COHCRT
LOG-LINEAR MODEL (2).
RISK RATIO
1.3
1,0
0.7
LUNG, males
T108351363
712
IndeedI the proportion of- smokers among the male population in Finland has
reduced since the early 1960s (6). During the twenty years this proportion
has diminished from almost 60% to roughly 30% (Figure 6). On the other hand,
the consumption figures have not decreased in such a drastic way but the tar
and nicotine content of the cigarettes has strongly decreased (7). Bo big
changes have occurred since the late I960s in the proportion of smoking
females.
For females, there has been an increasing trend in the cohort-specific
relative risks (Figure 7). This corresponds well to the increase in the
proportion of female smokers up to the late 19.60s (9). There was no system-
atlc variation in the period-specific residuals and the three alternative
extrapolations shown in this figure were used for predictions.
The lung cancer incidence forecasts resulting from the models and extrapola-
tions show, in females, a steady increase with every alternative (Figure
8). In males, the three alternatives are from a model in which parameters
related to age, cohort and period were estimated simultaneously (8). The
alternatives 1-3 correspond to three extrapolatlon combinations. According
to all of these alternatives a slight decrease in lung cancer incidence for
males is to be expected.
ACCOIYRTING FOR SMOKIRG Iff SI~YLATION
Hitherto the cohorts have been assumed to be homogeneous. In reality, not
everybody in the cohort smokes the average amount of cigarettes and has
started smoking a given number of years ago. However, data exist to
decompose the cohorts into various categories with respect to smoking.
These data can be combined with the existing knowledge on the risk of lung
cancer of persons in the subcategories.
A simulation model was constructed on the basis of which hypothetical
effects of different public health programs in the area of lung cancer could
be directly quantified (10). A fictitious population, comparable to the
entire male population with respect to smoking habits, was simulated by the
computer to experience selective general mortality and different lung cancer
risks caused by different smoking habits and changes in them.
In the forecasts, it has been assumed that 30% of the non-smokers aged
I0-14, 15% of those aged 15-19, and 5% of those aged 20-24 years will start
smoking in each consecutive 5-year period in the future. Three alternatives
were considered for cessation of smoking (Figure 9). If in each consecutive
5-year period 20% of the smokers in all smoking categories stop, the
incidence of lung cancer in the year 2000 will be 46/105, which is clearly
lower than the rate for 19751 71/I05. If the proportion stoppi~ were only
10% the rate in 200.0 would be 64/105, which again is somewhat Jess than the
observed rate in 1975. If r~obody stopped smoking, the incidence in the year
2000, $8/105, would clearly exceed that of 1975. The forecasts for 2050 are
lower than those for 2000. The temporary ~ise in the e~.r1= 3~ ~ d'~e ~
t~= |~r~e proportion o~ those wi~o started smokin~ in cohorts born in 1951-
19~0. This coincides with a temporary change to a more liberal attitude of
the society at large and especially of school authorities towards smoking in
schools.
T108351364
FIGURE 6.
TRE~D II~I THE PERCEI~TAGE OF CUKRENT S~OKERS AI~ONG THE ADULT
POPULATION ~I FTNLAND, BY SEX. Arrow: ~e~ tobacco le~isla~ion
(6).
50-
40-
20-
10-
PROPORTION OF SMOKERS
19',60 1965 1, 970
1980
TI08351365
~9-096 t ~t'-O~6 !
kE-OESI 1~-O06t I'8-088 ~
8"0
O'l
0"~
O'OI
O'~t
• :-(g) (auo 03 Ienb~ 6LIII-~LgI
e.I u2(x[ s~=oqoo "~o~ ~S.LI aATaela~ aqa) S£~IOI{OO LX3D~I~ ISOW 3~
~I~ XAILY'I~RI NI (g-I) SQI4T~-T. qYDI£3I~OcI_~14 33~H.T. (~W (ItIY~dilcI
FIGURE 9.
A~E-ADJUSTED INCIDENCE RATES (/105 PERSON-YEARS) FOR LU~ CANCER
IN MALES IN FINLAND 1953-1975 ~ THREE FORECASTS FOR THE RATES
IN 1980-2050 DERIVED BY A SI~JLATIOK MODEL WITH THE FOLLOWING
~SUMPTIONS :
In each consecutive five-year period in 1976-2050, 30% of non-
smokers aged 10-14, 15% of those aged 15-19, and 5% of those aged
20-24 years will start smoking. 0%, 10% or 20% respectively, of
the smokers in each category will stop smoking in each consecu-
tive 5-year period. The distribution of amount of adopted
smoking by age is the same as for smokers in 1975 who were 5
years older (i0).
The introduction of different alternatives for starting to smoke does not
"~ one0-reeas s y t e year - . en t e requeney o~
cessation is held constant (Figure I0), tha= is I0% in all smoking
categories during each 5-year period, which is the middle algernative in
Figure 9. The latenZ period of clinical lung cancer is too long and the
year 2000 too close for these assumptions to yield forecasts diverging very
~uch from each other. Bowever, after 2000 the effect is material. With the
716
starting freq~encies presedted in Figure 9, the incidence in 2050 would be
58/105. for ~Icernative 2. In alternative I, She starting frequencies
have been doubled, and the incidence in 2050 is 94/I05. If the starting
frequencies are, instead, reduced by one half the lun~ cancer incidence in
205.0 will ~ ~/I05 as in alternative 3. Alterna~ive 4 is an exa~le of a
gradual decrease ~n s~artlng frequency towards zero in She 2000s.
FIGURE I0. AGE-ADJUSTED INCIDENCE RATES (/105 PERSON-YEARS) FOR LUh~ CANCER
IN MALES IN FINLAND ~953-1975 AND FO~CASTS FOR THE RATES IN
|980-2050 DERIVED BY A SIMULATION MODEL WITH THE FOLLOWING
ASSUMPTIONS:
In each consecutive 5-year period in 1976-2050, 10% of the
smokers in each smoking category will s~op, and one of the
following alternatives holds true:
l: a% of non-smokers aged 10-14 years, ~% of ~hose aged
~nd 7% of those aged 20-24 years will start smoking, a= 60,
~" 30, Y" I0,
same as I but a- 30, 8" 15, Y" 5,
3: same as I but ~" 15, 8- 7.5 Y- 2.5,
sa~ as I but the values of ~ for consecutive 5-year periods
starting from 1976-1980 are: 30, 2~,18, 12, 6 and 0 remain-
ing intervals), those for ~ : 15, 12, 9, 6, 3 and 0 (remain-
in8 in~erwsls), and those for 7 : 5, 4, 3, 2, 1 and 0
(remaining intervals) (.|0).
T108351368
71.7
The amount of ~moking adopted by the new smokers hs a great impact upon
the lung cancer incidence in the beginning of the 2000s (F~gure II). With
the previous ~ddle assumptions ("]0%" ~n Figure 9, "2" in F~gure I0) and
with a ~dification that all n~ s~kers start to s~ke 40 cigarettes a
day, the incidence of lung cancer in 2050 will be very high, I161105, ~ in
a1~ernative H. If the n~ sm~ke~s all s~ked only 5 cigarettes pe~ day ~he
figure ~uld be only 27/I05, ~ha~ £s al~erna~ive L.
FIGURE II. AGE-ADJUSTED INCIDENCE RATES (/105 PERSON-YEARS) FOR LUnG CANCER
IN MALES IN FI~ 1953-1975 AND FOI~ECASTS FOR THE RATES IN
1980-2050 DERIVED BY A SII~JLATION MDDEL WITH THE FOLLOWING
ASSUMPTIONS:
The starting frequencies as in Figure 9, stopping frequencies as
in Figure I0, with the following alternative modifications:
H: All new smokers start to smoke 40 cigarettes/day.
M: The smoking habits of all new smokers are a mixture of all
possibilities (alternative 2 in Figure I0).
L: All new smokers start to smoke 5 cigarettes/day.
MS: As in alternative M, but starting postponed by 5 years.
MI0: As in alternative M, but starting postponed by i0 years.
M20: As in alternative M, but starting postponed by 20 years.
(io).
110"
17o ~
T108351369
718
The lung cancer incidence in the future can also be affected by changing the
age at starting (Figure 11). With the previous basic assumptions ("10%" in
Figure 9, "2" in Figure lO) but with all the events of starting postponed by
5 years, the lung cancer morbidity forecast is as given by the alternative
HS. If this postponement could not be m~de, the forecast is higher,
alternative M. If all scar~ing events could be postponed by I0 years, the
result is a|terna~ive H10 whereas with a 20 years~ postponement the much
lower forecast is M20. A comparison of Figure 11 with Figure 10 ~eveals
that a postponement of the startiug age by I0 years roughly corresponds to
reducing the proportion of those s~ar~ing ~o s~ke by one half. A
poscpoae~nt of star~£ng age by 20 years would elimina~e ~s~ of the lung
cancer cases caused by s~king.
If every smoker in Finland would stop smoking immediately, the result would
be the curve denoted by "min", that is the minimum, in Figure 12. The
maximum curve is related to a situation in which every non-smoker over I0
years of age at once would start to smoke 40 cigarettes a day.
FIGURE 12. AGE-ADJUSTED INCIDENCE RATES FOR LUNG CANCER IN MALES IN FINLAND
1953-1975 AND TWO FORECASTS FOR THE RATES IN 1980-2000 DERIVED BY
A SYMULATION MODEL WITH ASSUMPTIONS:
All non-smokers become heavy smokers (40 cigarettes/day) either
in 1976-1980 or a~ the age of 10-14 years, and nobody in the
population will stop (m~x), and every smoker will stop in
1976-1980 and none of the non-smokers will start smoking (min)
(2).
LUNG, mates
T108351370
719
DISCU$SIO~
When thinking of predictions one should first know how long the prediction
period should be. In practice the shortest period will be roughly 5-10
years because the cancer registries usually are about 2-3 years behind the
current year with their statisgics. Contrary to most other cancer sites, an
extrapolation of the current trend does not work with lung cancer, even for
such a relatively short-term prediction.
If the whole variation in the incidence rates can be attributed to age and
cohort effects~ much more reliable predictions can be made than in a
situation in which there also exists significant variation by calendar
time. This is true if the risk estimates for the present cohorts will not
have any unpredictable variation - or no variation at all - in the future.
According to the experience in Finland (8), lung cancer in males is an
exception. With most cancer sites there is no significant variation by
calendar time after allowance for the effects of age and cohort has been
made.
The usual advantage of cohort analysis of this type - it is not necessary to
identify the real causal factors behind the cohort and period effects - is
of no use with cancer of the lung. Identifying the model is a serious
question with lung cancer, especially for males, because of the inclusion of
period-speclfic risks in the age-cohort model. Since a certain cohort can
be at a certain age only at a given time, a model like this is likely to
become over identified or badly multi-colinear. With age-cohort-period
models it is always necessary to use prior opinions and the analysis may
never become a pure technical routine.
Lung cancer is an exceptional cancer for having one major causal factor with
well-known dose-response relationships. For this kind of situation a
simulation model is well-sulted. There are, of course, several limitations
for using models like this in forecasting. Continuous phenomena have to be
categorized, assumptions of independence have to be made, and risk ratios
derived from a certain population, have to be generalized for another
population.
On ~he other hand, the results become very concrete but must not be accepted
as absolute figures but rather as a background for the design of preventive
pr~rammes, gven though preventing the onset of smoking ~y, in the long
attempting to affect those ~ho already s~ke, the effect of such progra~es
up~ cancer incidence is likely to take several decades, whereas the effects
o.f stopping s~king are relatively i~diate. In Finland, the large
proportion of the populati~ ~ho started s~king in their youth in the early
1970s will cause a new rise in lung cancer incidence unless the proportion
sgopping in this group or o~erall is u~usually large. A similar situation
may also be expected in other ~veloped countries ~ere s~king has ~co~
~re prevalent a~ng youth.
T108351371
720
The study has been supported by the anti-smoking funds of the
of Bealth, Finland.
1. Sax6n E, Teppo L. Finnish Cancer Registry. Twenty-five years
nationwide cancer registry. Helsinki: Finnish Cancer Reglstry~
2. Rakulinen T, Pukkala E. Prediction of cancer incidence by utiligati
of risk factors and the effect of intervention. ~n: Magnus KD
Trends in cancer incidence. Causes and practical impllcationa.
York: Hemisphere, 1982: 111-123.
3. Hakama M. Projection of cancer incidence: experience and some
in Finland. Wo~Id ~ealth Statistics Quarterly 1980; 33: 228-240.
4. Hakama Me Epidemiologlc evidence for multi-stage theory:.~
carcinogenesis. Int J Cancer 1971; 7: 557-564.
5. Van der Hof~ NH. Cohort analysis of lung cancer in the
In~ J Epidemiol 1979; 8: 41-47.
6. Teppo L. Lung cancer in Scandlnav£a: tim trends and
In: Mizell M, Cortes P, eds. Lung cancer: causes and preventio'n~'
Deerfield Besch: Chemie International, 1984: 21-31.
7. Putkonen C. Total consumption of tobacco products in Finland in
1960-1978 (in Finnish and Swedish). Helsinki: Central
O~£ice, 1980 (Studies no. 55).
L~r~ E. Development of cancer morbidity in F£n1~nd up to the
2002. Predictions on incidence rates av~ numbers of ne~ eases for ~0me
• common cancers in Finland based on analysis by age~ period and cohort
(in Finnish). Helsinki: National Board of Realth in Finland~ I~$2.
(Series Original Reports
Rimpel~ M. Trends in the smoking habits in Finland in 194~ and
1960-1967 (in Finnish). J Social Medicine (Tampers)1978; 15: 112-123.
I0. Hakulinen T, Pukkala E. Future incidence of lung cancer: forecasts
based on hypothetical changes in the s~oking habits o~ mles, I~t J
Epidemiol 1981; i0: 223-240.
T108351372
A. Hauknes, Head of Division
P.M. L~chseu, Info.r~mtio~ Officer
L.E. Aar~, Research Officer
National Council on Smoking and Health
P.O. Box 8025 Dep., 0030
Oslo I, Norway
Attitudes towards and ideas concerning health-habits and the mode of living
exist in what may be called the culture of the society. As far as smoking
is concerned, it can be said that a culture with a negative attitude towards
smoking produces few smokers who make a late debut, and a culture with a
positive attitude towards the habit produces a large number of smokers who
start smoking early. We now recognize the important fact that the habit
shows a social-psychologlcal pattern of existence, with its foundation in
the growing-up environment. Therefore anti-smoking programmes must be
directed at the whole environment at once; that is to say, the home~ the
immediate environment and the society in general. The measures employed
must be varied and should include education, restrictions, and help to
quit. The different measures must be coordinated, and balanced.
THE BACKGRDUND OF A SPECIAL SMOKII~G AND HEALTH PROGRAMME FOI~ SCHOOLS
In 1975 the National Council on Smoking and Health began an extensive
follow-up study in order to clarify the extent of smoking in the Norwegian
basic school (1,2).
The trend in smoking habits rose from about 2% daily smokers for both sexes
at age 12, to 22% for boys and 28% for girls at age 15. The average
consumption was 7.1 cigarettes a day for boys, and 6.5 a day for girls. A
similar study in 1980 showed that the proportion of daily smokers among
girls had dropped to 21%.
An important question to be solved before starting the work on an
anti-smoking campaign is at what age smoking can be opposed most
effectively. To prevent children from takin~ up the smoking habit,
antl-s~oking efforts must reach them before the habit is established.
T108351373
722
TABLE I. SMOKING HABITS BY AGE AND SEX, 1975
Per cent Per cent Per cent
daily occasional nonsmokers
smokers smokers who have tr:
to smoke
Age Boys Girls Boys Girls Boys
Gir~s
12 2.3 1.5 25.6 22.0 44.3
36.~
13 6.6 7.0 28.7 28.9 44.7
38.6
14 16.4 16.5 29.2 34.2 39.8
32.3
15 22.5 28.3 24.0 30.3 40.0
29.2
Results from the project described above suggest that, in Norway~
critical age is 12-13 years. A strong increase in the percentage of
smokers is observed among both boys and .girls across the age-group
years.
FAL~ORS W~ICH INFLOENCE ~ (~ILDREN'S SMOKING
Studies from several countries confirm that the probability of
smoker increases markedly when father smokes, mother smokes, older
smoke, best friend smokes, and when the child is permitted by the parents.~
smoke (as opposed to parental restrictiveness towards children's
The Norwegian 1975 study showed that when both parents smoke~ and
permit the children to smoke, 67% of the boys and 78% of the girls aged
are daily smokers. When neither of the parents smoke, and the children
not permitted to smoke, the figures drop to 9% among boys and 11%
girls. The results from the 1980 study were almost identical (2).
THE ST~I~CTU~ OF THE PACKAGE FOR ANTI-SMOKING PRO~RAMMES IN SCHOOLS
The objectives for the programme and the pedagogic principles on which this
programme was based, put great emphasis on the immediate effects of smoking
on t~e organism, and on the modern de,ate on pollution and waste
resources. One important part of the programme was intervention in the
social network of the pupils through their parents, another w~s active
involvement of the pupils in tobacco and health education by asking them
write an essay on smoking and health.
The first edition of the "package" contained a folder for the pupils~
describing the imm~ediate effects of smoking on the omganlsm, smoking as •
co growing as ~ waste
agrzcu
resources. Amotber folder was directed at the parents, telling them ~hat mm
anti-smoking cmmpaign at school would probably have no effect w~thout their
active partlc~pation and support. The "package" also included a teacher's .'~
guide emphasizing experiments showing that the pupils' active participation
in a programme increases the probability for attitude changes.
T108351~4
723
~'I~.,D ~I~S A~D ~ALUATION
Two field experiments were carried out to test the effects of the material
and the total school campaign. The first of the experiments was designed
especially to test the short-term effect of the campaign on the smoking
behaviour of the ~Jpils. ~enty-two schools in a rural district were divid-
ed into four groups.
In the first group of schools the pupils were only given the folder prepared
for use in the classroom. In the second group of schools, the pupils were
given the folder and asked to write an essay on smoking and health. In the
third group, the pupils read the folder but did not write an essay. Instead
the parents were involved. In the fourth group, the pupils were the object
of a complete integrated programme (folder, essay, parents).
In group no.4 the reduction in total cigarette consumption (21%)
immediately after the campaign was more than three times that achieved in
group no.l (6%). In the two other groups the reduction in use of
cigarettes lay somewhere in between that achieved in groups 1 and 4 (3).
OUR CONCLUSIONS ARE ~,~ FOLLOWS:
(ii)
It is possible to achieve a reduction - at least on a short-term basis
- in the use of cigarettes among school children.
The design of the campaign is of vital importance, and even "small"
improvements may lead to increased effec; on the children's smoking
habits.
After the evaluation of the first field experiment, which also included
interviews with parents and teachers, the material was changed and
"improved" considerably.
The long-term effect of the revised material and campaign has been tested
out in a second field experiment conducted in an urban-rural area. I: was
concluded that the c~=p~ign h~d a certain lon8 term effect on children who
smoked occasionally. In t~e first half year after ~he campaign, smoking
rates in fact decreased, thou~n an increase would have been expected at ;his
level. In the next six months ~he total percentage of smokers ~ncreased a~
a lower rate than expected (3).
1~ INAL CONCLUSI01~S
In Norway, a hopeful trend has appeared in recent years in the development
of smoking habits of children and youth. The nation-wide studies in 1975
and |980 confirmed a substantial reduction in the percentage of both daily
and occasional smokers. Girls have reduced smoking even more than boys
Soce possible explanations of this new trend are an increase in general
health information in Norway, and a more active involvement by schools,
teachers and parents in anti-smokin~ education. It should also be noted as
T108351375
an i~ortant factor that a Tobacco Act (including a ban on advertisin$)
entered into force in 1975 and took away the opportunity to glamourlze
smoking (4).
A partial explanation may be that the more negative attitude towards smoking
which has developecl in recent years looks more positively upon anti-smoking
measures. It is also possible that the e~ucatio~ campaigns amt progra~es
have improved in content. In our opinion the key to further improvement
lies in learning from empirical evaluation studies, and from theories on how
to influence attitudes and behaviour, based on principles of social
psycho fogy.
Aar~ LE, Hauknes A, Berglund EL. Smoking among Norwegian
schoolchildren 1975-1980: I. Extent of smoking in the age group 12-15
years 1975. Stand J of Psychology 1981; 22:161-169.
Aar~ LE, Hauknes A, Berglund EL. Smoking among Norwegisn
schoolchildren 1975-1980: II. The ihfluence of the social environment.
Scand J of Psychology 1981; 22:297-309.
Aar~ LE, Bruland E, Hauknes A, L~chsen PH. Smoking among Norwegian
schoolchildren 1975-1980: III. The effect of anti-smoking campaigns.
Stand J of Psycholgy 1983; 24:277-284.
Hauknes A: The role of legislation in a comprehensive programme of
smoking control. Abstracts and Lectures. Institut d'estudis de
salut, Catalunya, Barcelona, Spain 1984; IIi-I17.
T108351376
725
C]~/~GES IN ~OKI~ E~BITS
1976 ~ 19~I
D.R. Hay, M.D., F.R.C.P., F.R.A.C.P.
National Heart Foundation of New Zealand
Christchurch, New ZeaIand
INTR~UCT~ON
New Zealand was the first country to include a question on smoking habits in
its 5 yearly population census (I). This has provided information about the
smoking behaviour of over 2 million persons of European origin as well as
160,000 New Zealand Maoris and more than 50,000 Pacific Island Polynesians,
most of whom have migrated to New Zealand in the past thirty years. The
census smoking question was introduced in 1976 and repeated in 1981, a
period of moderate heal~h education activity by governmeut and voluntary
agencies.
METHODS
Information was sought about cigarette smoking only. All persons 15 years
and over were asked whether they had never smoked, used to smoke or if they
were regular smokers, defined as one or more cigarettes a day. Smokers were
asked to state the number of cigarettes they had smoked the previous day.
Percentages have been rounded and were not adjusted to add to 100.
RESULTS
Response rate
The response rate was high, 96.7% in 1976 and 98.8% in 1981, indicatin8 that
very few people objected tO providing th~s information a~d that the ques-
tion was easily understood. Approximately 2.2 million persons responded in
1976 and 2.3 mill~on in 198].
The percentage of male smokers has fallen from 40% in 1976 to just under 35%
in 1981, and in women from 32% to under 30%. The chan~e in women has
resulted from a small increase in the number giving up smokin~ rather than
from an increase in those who have never smoked. In
men, both ex-smokers
and those who had never smoked, increased in 1981.
T108351377
TABLE Io C~GAR~TTE SMOKING IN N.Z.
Never smoked
Used to smoke
Smoke regularly
PERCENTAGE DISTR]
Males Females
1976 1981 1976 1981
39 42 56 56
22 24 12 14
40 35 32 29
In men there has been a reduction in smoking in every age group
and 1981, the biggest changes being in those aged 40 years onward0~
changes in women are similar but less marked, with the important
that the number of smokers has increased and remained highest in tho
20-24 years, where 40% were regular smokers in 1981, and is unchanged
15-19 year olds. Young men aged 20-24 also comprised the age grou
most regular smokers (40%) but there has been a reduction in those
15-19 years.
TABLE 2.
PERCENTAGE OF REGULAR SMOKERS:
TOTAL N.Z. POPULATION
Males Females
Age 1976 1981 1976 1981
15-19 30 27 30 30
20-24 42 40 39 40
25-29 42 38 38 35
30-34 4A 37 38 33
35-39 43 38 35 33
40-44 44 37 35 31
45-49 45 38 36 31
50-54 44 38 34 31
55-59 41 36 31 28
60-64 38 32 26 24
65-69 35 29 20 20
70-74 31 25 14 15
75+ 24 20 8 8
TOTAL 40 35 32 29
Smoking and ethnic groups
Maoris smoke very heavily. Twice as many Maori women smoke compared with
Europeans and in all ages under 55 years smoking is more common in Maorl
~omen tna~ ~ori ~on. ~mo~ing by young M~ori ~o~en
proportions with 70% of those aged 20-24 years being regu|ar smokers. In
this age group and in those aged 15-19 years the figures have increased~
T108351378
727
since 1976. In contrast, the number of smokers among Maori men has fallen
slightly in all ages and to some degree among Maori women over 25 years.
pacific Island women smoke m~ch less than Maori women but their level cf
smoking has increased since 1976. Pacific Island men are heavier smokers
than their women but they have reduced their level of smoking since 1976.
Chinese and India~ co.rise relatively s~all groups in flew Zealand, name!v
approximately 13,000 and 7,000 respectively, and it is of interest to note
their low rates of smoking.
TABLE 3.
!981N.Z. CENSUS:
CIGARETTE SMOKING BY MAIN ETHNIC GROUPS
MALE
Never Used to Smoke
Smoked Smoke Regularly
European ~2 25 33
Maori 31 16 53
Pacific Island
Polynesian A6 12 42
Chinese 67 12 22
Indian 69 10 21
TOTAL N.Z.
POPULATION A2 24 35
FEMALE
Never Used to Smoke
Smoked Smoke Regularly
58 IA 28
28 13 58
67 8 25
88 4 8
92 2 6
56 IA 29
Smoking consumption
On average, European men smoked 18 cigarettes and Maoris 16 cigarettes a
day, while =he figure for women averaged 14 per day. The average
consumption has dropped slightly since 1976 as has the proportion of heavv
smokers of :~cre than 20 cigarettes a day, except for women among whom there
has been ii=:ie change. It is disturbing to note that half of the men who
smoke, censume~ more than 20 cigarettes a day, and these comprise a
substantial reservoir of high-risk candidates for smoking-rela~e~ diseases.
T~LE g. DALLY COHSUMPTION OF CIGARETTES (% OF SMOKERS) ALL A~ES
Males Females
Total popula:ien 1976 17 32 51 26
40 34
Total popula:ien 1981 18 33 4~ 26
39 35
Maoris 1976 20 35 &6 28
38 35
Maoris 1981 23 37 40 28
40 32
T1~1~79
7~
Smokin~ a~d o¢cup~tlon
In 1976, the census data showed a clear social class gradient iu
behaviour according to income, education and occupation. Similar Patti
are apparent in 1981 and again it has been those in the higher
economic groups who have moved most strongly away from smokir~.
Several occupations have been selected to illustrate the trends in
over the five year period. Zn some of the professions the number of
is now below 20%, but among labourers and female shop asslstanta,
has increased. Employers of labour tend to smoke less than average,
the unemployed smoke heavily (56% in men and 52% in women). The heav
cigarette consumption rates in both men and women were in managers, le
latlve officials and government administrators (60% of these men exceeded
cigarettes/day and 50% of women). Smoking rates in male doctors
dropped from 37% in 1963 to 15% in 1981 and in women from 29% to under
(2).
TABLE 5.
CHANGE IN PERCENTAGE OF REGULAR SMOKERS IN SELECTED OCCUPATION
Males Females
1976 1981 1976 1981
Teachers 23 19
Accountants 25 18
Authors, journalists 38 32
Composers, performing artists45 42
Farmers 31 26
Labourers 56 54
Typists, etc. 40 31
Shop assistants 41 38
Transport equipment operators55 49
Food and beverage processors 53 47
23 20
29 21
36 31
21 29
21 19
49 50
31 30
37 37
~9 47
50 48
The prevalence of smoking is high among those receiving a sickness benefit|
i.e. for short term illnesses. Possibly this reflects a lower socio-
economic group who receive such benefits. On the other hand, the love| o~.
smoking among those on invalid benefits - a permanent benefit for chro,i@
illnesses or disabilities - is about the same as the population average."
Smoking is very high among those on unemployment or domestic p~rpose~
benefits. The latter tend to be people such as solo mothers or younger.
persons of less privileged social groups. As in 1976, smoking was less J~
- " n ,Igner than average
level.
T108351380
729
TABLE 6. 1981 N.Z. CENSUS: PERCENTAJE OF REGULAR SMOKERS
ACGORJ)ING TO SOCIAL SECURITY BENEFITS
Male Female
Family -$ 34
National Superannuation 2- 17
Sickness 53 50
Invalids 3S 23
Domestic Purposes 57 56
Unemployment 5~ 53
War Pensions 32 22
Widows - 35
No Benefits 35 30
S~okin~ and education
There is a gradient of smoking according to level of education with the
lowest rates among those who have been to University. Those with a combined
Teachers Training College and University background were unlikely to be
smokers and this was also reflected in the low rates of smoking among
teachers (19% men and 20% women). It may seem anomalous that those who had
received no secondary education had average instead of high levels of
smoking. The explanation is that this category consists largely of older
people and the usual trend is for smoking rates to decrease with age.
TABLE 7. PERCENTAGE OF REGULAR SMOKERS ACCORDING TO
HIGHEST EDUCATION LEVEL 1981 N.Z. CENSUS
Male Female
Still at school q ii
No secondary education37 24
3rd, 4th or 5th Forms 43 37
7th Form 23 20
University 21 19
Teachers Training College 28 19
University and T.T.C. 19 16
Polytech., Tech. Inst.,
Community College 32 27
Univ., Tech. Inst.,
Other ~ertiary 29 26
T108351381
TABLE 8. PERCENTAGE OF REGULAR SMOKERS ACCORDING TO MARITAL
Males Females
1976 1981 1976 1981
Never Married 37 32 52 30
Married 41 33 33 28
Separated 61 55 54 51
Divorced 57 52 45 43
Widowed 39 34 21 20
I
Smoking and religion L
When smoking was correlated with stated religion, the highest levels
those of the Ratana Church, most of whom are Maoris. As in 1976,
Catholics smoked more than those in other denominations, although nearly al|
showed some reduction since 1976. It is perhaps surprising that there
not even fewer smokers among the Seventh Day Adventists. Again, rates of
smoking were noted to be high among those who objected to stating ~heir
religion.
TABLE 9. PERCENTAGE OF REGULAR SMOKERS ACCORDING TO STATED RELIGION
Males Females
1976 1981 1976 1981
Aeglican 40 33 33 29
Presbyterian 37 32 28 25
Roman Catholic 45 39 37 34
Methodist 38 32 27 25
Baptist 26 21 16 !4
Ratsna 60 58 65 65
Latter Day Saints 36 34 33 33
~re~hren 12 i0 8 7
Salvation Army 33 27 21 19
Jehovah's Witness 6 5 5 S
lkbrew - 27 - 23
~o religion 38 34 33 31
Object to stating religion 45 41 40 39
T108351382
731
A significant change in smoking behaviour has occurred in N~ Zealand during
a relatively short period and without a major effort by government or health
authorities. The fall in smoking has, to a large degree, resulted from
increased nu~ers who have given up smoking, although there are encouraging
signs that f~wer ~oys ma~ be taking up the habit. The problem areas remain
young women, Maoris, and those of lower socio-economic status. Heavv
smoking by Maoris reflects the cultural changes which this ethnic group has
undergone in the last 50 years and the insecurity that many young Maoris
feel in the modern urban world. Until they can regain their self-esteem and
c~Itural pride, they are unl~kely to regard non-smoking as very important or
relevant. The solution may have little to do with health education but
depend on political issues such as the reduction of unemployment or housing
shortages. Similar trends are appearing among some of the Pacific
Islanders, which may provide lessons for all who hope to control the smoking
epidemic in developing countries.
Although smoking has fallen in most educational and occupational groups,
there remains a strong social class gradient in smoking behavlour and there
is a need to develop better strategies for reaching those who are less
privileged and less well educated. We can be encouraged by what has
happened in the professions and may even look forward to a time when smoking
will be negligible in this group. But perhaps we as professionals have
focused our educational efforts too much on our own middle classes, using
middle class methods when what we should be doing is to move out among the
masses where the smoking problem really exists.
Hay DR. Cigarette smoking in New Zealand: results from the 1976
population census. NZ Med J 1978; 88: 135-138.
Hay DR. Intercensal trends in cigarette smoking by New Zealand doc=ors
and nurses. NZ Med J 1984; 97: 253-255.
T108351383
733
A ~ m~ ~S ASPECTS
M. Khellaf, M.D.
B. Bensmail, M.D.
Clinic of Pneumo-phithisiology "A"
Universit4 de Constantine
66, Bouelevard Pasteur
Constantine, Alg~rie
Le tabagisme, fl~au mondial n'a pas ~pargn~ l'Alg~rie o~ l'extension des
habitudes tabagiques est impressionnante, si l'on consid~re l'augmentation
annuelle des quantit~s de tabac consomme; une ~tude men~e recemment, fair,
~tat d'une augmentation de 75% entre 1964 et 1982. En effet la consommation
per capita est pass~e de 0.7 kg ~ 1.2 kg.
Pour comprendre ce phenomena social qui s'est developp~ au tours des 20
derni~res armies qui ont suivi la guerre d'ind&pendance, nous avons men~ de
diff~rentes enqu~tes ~pid6miologiques sur: le tabagisme, ses implications
sur la sant@ et ~galement sur ses facteurs socio-culturels. L'extension de
ce fl~au est d'autant plus inqui~tante qua rien ne permet de prevoir son
ralentissement ~ court terme.
Comme dans beaucoup de pays les jeunes fument de plus en plus pr~cocement -
31% des adolescents interrog~s ont commenc~ ~ fumer avant 15 ans. On
assiste ~galement ~ un d~but de tabagisme chez les filles: 3-4% des filles
scolaris~es fument alors qu'elles 4talent ~pargn~es de ce fl~au dans un
pass~ tr~s recent.
Le tabagisme testa l'apanage de la population masculine. 53% des hommes
fument~ 13% ont cess6 de fumer, 34% n' ont jamais fum@, alors qua parmi les
~emmes les 10% qui fument et les 4% qui on~ =ess~ de fumer laissent augurer,
a l'ima~e des pays europeans, une augmentation des habitudes ~abagiques.
Parmi les diff~rentes varifies de ~abac, c'est la cigarette qui es~ la plus
consomm6e; 96% des fumeurs fument la cigarette et la consommation quoti-
4ieune exc~de I0 cigarettes pour 80% d~s fumeurs. Le 4~but du tabagisme est
le plus fr4quent entre ~5 et 24 ans, l'~ge moyen de l'arr~t do tabac
relativement pr~coce: 56% des ex-fumeurs d~clarent avoir cess~ de fumer
avant 29 ~ns, 20% entre 30 et 39 ans. La fum~e est inhal~e par 75% des
fumeurs.
rues la gravit~ et l'importance de ce phenomena social, il nous a paru
int~ressant d'analyser quelques aspects psycho-soc~aux et culturels de
tabagisme en Al~rie.
LF~ MOTIVATIONS
A la question "Pourquoi fumez-vous ou pourquo~ avez-vous fum6?", les fumeurs
T108351384
73,~
et les anciens fumeurs fournissent des ~ponses o~ sont men~ionn~s
successivement: l'habitude (21%), le plaisir (14Z), la d~tente (I0%), le
besoin (12%), la recherche d'assurance (2%), et enfin ~outes los raisons
pr@cddentes r~unies (13%).
Dans un autre ordre d'id~e, los ps~chanalystes metten~ l'accent sur
l'oraliZ~ 4u fumeur. Cos ~endances regresslves a L~ sta~e pr~coce du
developpement libidi.al domin6 par le plaisir buccal de la "t~t~e", sont
effec£ivement re~rouv~es chez los grands fumeurs.
Cetce or~lit~ se manifesto par del'avidit6 affective et une intol~rance aux
frustrations, permettant de comprendre l'absence de volo~t6 habituellement
reproch~e au fumeur invet~r~. Or, des psychiatres Maghrebins ont soulign~
pr~cis6ment la fr~quence des traits oraux de personnalit~, qu'ils reliant
aux conditions d' 4ducation de l'enfant en milieu traditionnel ~allaitement
prolong~ et sur demande, sevrage tardif, contact corporal constant avec la
m~re).
LES INFLUENCES SOCIO-CULTURELLES
En Alg~r£e la religion musulmane demeure le ciment social et communautaire
de base. L'Islam est un facteur de cohesion fondamental, car cos pr~ceptes
ne rdsument pas seulement l'essentiel de la philosophic de la vie, ils
constituent aussi un cadre moral, @ducatif et socio-juridique de grande
valour dont los r~gles sont applicables ~ tousles cas concrets.
Carte importance de l'Islam dans la vie socio-culturelle et sa quotidiennet~
amine ~ s'interroger sur son attitude envers le tabagisme. Si aucun texte
coranique ne fair explicitement r~f~rence aux "habitudes de rumor" en usa@e
~ l'~poque, deux citations du Livre Sacr~ condamment indirectement le
tabagisme.
Par contre chez los Mozabites appartenant ~ la secte religieuse des
Ibadites, le tabac est formellement prohib~. Ii s'agit de Musulmans
h~t~rodoxes impr6gn~s de rigorisme et d'aust~rit~, pour qui tout acre nocif
pour la san~ est proscrit; l'interdi~ remonte probaSlement au si~cle
dernier lorsque le tabag~sme s'est r~p~du en Alg~rie.
On co.state ai~si qua contrairement ~ ce qui se passe pour la consommation
d'alcool, et ~ l'exce~Zion de la petite m~norit6 Mo~abite, il n'existe au~un
tabou religieux vis-a-vis du tabac. Bien au contraire, le tabagisme est le
plus souven~ b~en ace.apt&, larEement diffusE, volt
On assiste ~ une v~ritable contagiosit6 tabagiq~e,
r~sul~at 4e
solli¢itations sociales permanentes, confinanc parfois au
pros~lytisme,
aliment~e par ~uel~ues mythes archa~ques inscrits dans
l'inconscient
collectif. Le £abac est ainsi associ6 au module de la"virili~" £r~s
g!orifi~ ~ass |a culture arabo-musulmane. "Souls los ho~es fument", eL ~
cat ~gard, la cigarette repr~sente un symbole phallique de puissance e~
d'autorlt~. Ceci fair com~rendre l'amDleur, sans cease cro~=.~ ~,,
t.~,~i~-.~ ~= ~es ~eunes e£ los adolescents (sur 848 lyc~ens de Constantine
29% sont ~u~eurs), qui sont, on le salt, soumis ~ un profond ddsir
d'identif~=atio~ aux adultes.
T108351385
Par a~lleurs en Alg~rie, com~e dans tout le Maghreb, le champ psychosocial
est caract~ris~ par un intense processus d'acculturation. Les mutations
sociales, les inevitab[es distorsions engendr~es par un d~veloppement
rapide, l'~moussement des valeurs traditionnelles, la mobi[it~ des p61es de
r~f~rence, la moltiplicit@ des modules, ont entralne in~luctablement des
tensions et des conflits sur le plan individuel, familial et social; les
reto~es psycho--pa~hog~nes vont se m~nifester par une augmentation
spectaculalre des nevroses, des ~tats d~pressifs, et surtout chez les
jeunes, de comportements deviants ~ type suicidaire, de d~l~nquance,
d'alcoolisme et de toxicomanie. Dans un tel contexte, il est slots permis
~e supposer ~ue face au stress, ~ la maladaptation et aux d[~ficult~s
exi~tentlelles~ le pa~uet de cigarette constitue un exutoire honn~te et
licite, pratique et commode, puisque imm~diatement disponible h tout moment
et en tout lieu.
Quant au tabagisme f~minin, il reste un ph~nom~ne hab[tuellement trSs
dans notre soci@t~ bu le tabac est toujours l'apanage de l'homme. L'image
sociale tradit[onnelle de la fumeuse est mauvaise, car elle ~voque une femme
marg[nale,"affranchie" et de r~putation plus ou moins douteuse.
CONCLUSION
Cette approche psycho-sociale montre que le tabagisme, ph~nom~ne de soc[gt@,
est devenu un mode d'existence, une fa~o~ d'etre et de para~tre". On
con~oit donc que la lutte antl-tabac a promouvoir, dans notre pays,
s'annonce slnguli~rement ardue, car elle exlge une prise de conscience
collective. Ce travail, grfce ~ l'~clairage descriptif qu'il apporte,
pourra peut-~tre, malgr~ tout, contribuer, nous osons l'esp~rer, ~ cerner et
~ lever les "r~sistances", ~ affiner l'action ~ducative san[taire, en
l'adaptant aux r@alit~s socio-culturelles du pays.
BIBLIOCRAPHIE
Rapport Congr~$ H~dical Maghrebin. Aspects 4conomiques, ~pldSmiologiques
et pa~hologiques du tabac en Alg~rie. Travail co[[ectif des Un~versit~s
Alg~rie~nes. C~s~blanca, mai 1953.
Bensmail B. Aculturation et adaptation psycho-social.
recherche, CURER Constantine, septembre 1980; I0.
Les cahiers de ia
Bensmail B. Soci~t~ traditionnelle psychiatric et culture. Les cah£ers de
la recherche, CURER Constantine, septembre 1980; I0.
Boutin C, Viallat J. Aspects psycho-soeialogiques de la consommation du
tabac. Revue du praticien 1978; 28:19.
Freour P, Courdray P, Serise N. Le tmbagisme, phenom~ne sociml. Appreches,
~pid@mio|ogiques et prophylact~ques. Revue de [a tuberculose et de Pneumc-
logie 1972; 30 (2).
TI08351386
737
A profile of the ~moking Patterns in f~ve ~ort~st ~ct~c Comities, ~
Su~eys Done for the Pur~se of De~lopi~ a~ gval~ti~ a S~king ~
Preventi~ Program for Alaska Youth
John F. Lee, M.D., M.P.H.
Health Services and Consultation
3214 Wesleyan Drive
Anchorage, Alaska 99508
U.S.A.
Smoking, a serious health hazard in other parts of the United States,
appears to be a common habit among Alaska Natives. The extent of this
habit, its characteristics, and the method of prevention and intervention
applied to reduce it are not well known. On the other hand, lung cancer,
virtually non-existent earlier in the Native people, has increased sharply
from 1960 to the present, rising in males from 9 to 39 per i00,000, and in
females from about 2 to 13 per I00,000, four and six fold increases respec-
t ire ly.
Concerned about the problem of smoking in youth and its effects, the Alaska
Native Health Board, a consumer advocacy organization representing the 12
Native Regions on health matters, selected smoking prevention as its fore-
most priority in 1980. As a result, the Smoking Prevention Project was
formed with the goal to "Contribute to the long-term health and quality of
life of Alaska children and youth by helping them successfully avoid acquir-
ing the smoking habit."
The main initial Project task was to determine the extent and pattern of
smoking habits in a representative region, as a basis for designing and then
evaluating, the effectiveness of a smoking prevention program aimed at
youth. The survey findings and conclusions are presented here.
TH~ NORII'HWKST ARCTIC ~GION K~D PEOPL~
The ~niilaq Association, a non-profit health and social development and
services organization of the Northwest Alaska Native Association (NANA)
Region joined with the Alaska Native Health Board to conduct the project in
that region, with the cooperation of the Northwest Arctic School District.
The NANA Region lies just south of the Brooks Range, abuts the Chukchi Sea
and Kotzebue Sound, and is traversed by the Arctic Circle. There are Ii
villages inhabited by the 5300 Eskimo residents. English is commonly spoken
the same time they are assuring that culture and language are being taught
and preserved. Satellite 74 is now available in a~l co~munities; travel is
TI08351387
comm~n and frequent within the area, and to other parts of the State.
Tobacco products are readily available in any comunlty. Hunting and fish-
ing are vital to subsistence; they are a way of life, and a source of pride.
Five of the ii co~nitles were selected for inclusiou in the project. Two
small villages, Ambler and Shungnak were chosen for study and matched with
• uckland awl Noatak as controls for a future smoking prevention program.
Kotzebue, the largest city in the Region, served as both a study and control
community, with two equal groups (grades 7-12 only). All school children in
all five communities took part in the survey initially, and as many adults
contactable during the survey period. Standard smoking questionnaires,
modified, were used.
TABLE I.
INITIAL SURVEY PARTICIPANTS (1981)
Grade Group Number
% of Regional Group
Population
Children K-3 216 52
Children 4-6 161 40
Youths 7-12 319 61
Total
school children
Adults
Grand Total
696 52
435 14
1131 21
A PROFILE OF SMOKING C~RACTERISTICS
Adult Smokers
Of the 435 adults surveyed, 56.% smoked, 46% daily, and 24% smoked a pack a
day or more. In addition, 8.3% of the adults surveyed chewed tobacco. The
percentage of smokers in each of the five communities ranged between 50% and
74%. Smokin$ prevalence was highest in the 40-49 year old groups (69%);
next highest in those 19-29 (60%); lowest among persons 60 and over. Fifty-
five percent of the women and 59% of the men smoked.
Most smokers did not know why they smoke; 16% did it for pleasure, 16% said
it relaxed them. ~owever, 93% said it was harmful; 73% wanted to quit but
only 64% would take part in a no-smoking program.
K-3
~ve comuntty sc GO s, ~ere was
age group. Among these children, 8.4~ had smoked~ 3.3% many times. Attitude
~oward not smoking was very favorable, but 38% believed a person can smoke
without harm. They experienced strong negative and positive pressure from
parents, moderate from friends and slight impact from the media. Sixty-one
percent of the students lived with a smoker, but 91% of parents would be
angry if their child was found smoking.
T108351388
gradea 4-6
Of the 161 students, 9.6% smoked and 8.8% smoked ofteu. The number of boy
smokers equalled the girl smokers. In addition, 20.6% of them chewed
tobacco or used snuff; o~e-third of these were girls. Eighty percent of the
students lived with a smoker; 13 of the 15 child smokers lived with a
smoker! Knowledge o~ smoking effects was high - 98% scored correctly; atti-
tude toward not smoking was highly favorable.
Grades 7-12
There was a total of 319 students for the five schools in each grade group.
Kotzebue contained 203 students; the four village schools numbered from 25
to 35 students. Fifty-four percent were boys and 46% were girls.
I. Smoking Behavior
The communities of Ambler and Shungnak had smoking rates of 79% and 69%
respectively, while Buckland and Noatak had rates of 32% and 21%. Kotsebue
had a rate of 37%.
The onset of smoking began at age 6 in this group by some members, zooming
from 4% at age I0 to a peak of 12% at ages 12 and 13 (grade levels 6 and 7),
but the number of new smokers fell rapidly to 1% at age 18, indicating the
choice to smoke is made very early by many students.
Of those who smoked, girls outnumbered the boys 59% to 41%. The percentage
of smokers by grade (and concomitantly by age) increases strikingly from a
level of 16% in grade 7 to 42% in grade 8, progressing steadily and surely
to 63% in the 12th grade. One hundred twenty-four were current smokers.
2. Tobacco Use
One hundred twenty-four or 41.4% were cigarette smokers; 79% of these smoke
daily. Fifty-eight percent of the daily smokers were girls. Twenty-eight
percent of the students chewed tobacco or took snuff; almost all of these
were boys, Forty-nine percent of the girls smoked whereas 29% of the boys
smoked.
3. Knowledge, Attitude and Social Pressures
Over 95% knew that smoking can cause heart attacks and lung cancer, but
awareness of the lesser known and immediate effects was in the 60%-70%
range. Ninety-three percent of the students believed that most teenagers
smoke (true in this group). Other attlt~de responses were mixed, but
generally favorable toward not smoking in the 60%-75% range. Press,re to
smoke from friends and family was indicated because of the high prevalence
of smokers in these associates. There was moderate favorable pressure ~mt
to ~moke from p~r~n~: h~,t 85% of the stud~t~ 1~,,ed ~ith = hzzzch=l~
smoker.
T108351389
740 I~Z
CO]~(ILUSIO~S lrROH THE ~d~TI~ SUKVKY
Prevalence
Tobacco use, especially cigarette smoking, among adults and school age chil-
dren in the HAHA ~gion is much higher than in the ~eneral U.S. population.
A comparison of these rates is shown in Table 2.
TABLE 2. COMPARISON OF NANA AND U.S. SMOKING PREVALENCE
Group_ NA/~A U. S .____* Rat i o
Adults 56.4% 33.2% 1.7
Women 54.8 29.6 1.9
Men 59.0 37.5 1.6
Youth 12-18 41.4 11.7 3.5
Girls 12-18 49.3 12.7 3.9
Boys 12-18 28.8 10.7 2.7
* Source: (1,2)
Smoking rates parallel each other, as far as sex and age are concerned, but
the percentage of Alaskans smoking is 1.6 to 3.9 times that in the lower 48
States.
Smoking patterns are essentially the same in each of the five communities;
however, there is a difference in the prevalence of smoking among them in
the school age population which is not explained by the data but is probably
due to local influences, such as religious, traditional and unique community
values.
Influences ~u $~oki~g Behavior
Correlation analysis indicated that smoking behavior is shaped by various
influences, internal and external, as shown by several observations. It
appears that the most significant factor influencing youth to smoke or not
to smoke is related to pressure from family, friends or environment. ~ow
friends behave, one's attitudes to sports and beliefs about what others say
are important. Students' knowledge about the effects of smoking is high,
hut its influence on smoking behavior is not readily detectable. Bowever,
the level of medical knowledge shows a favorable relationship to sports and
what their parents say, which could have an indirect benefit.
l-u--~riez, the smoking characteristics and Intluencing factors s~ow the same
patterns in the ~orthwest Alaska population and the ~.S. general population
for adults and for students grades 7-12, except that prevalence rates are
m~ch h~her in the former population.
T108351390
I. US B~pt. of Health, Education and Welfare. Smoking and health. A report
of the Surgeon General. WashinEton, D.C.: US Dept. of Health, Education
and Welfare, Public Health Service, 1979.
2. US Dept. of Health and Human Services. Smoking programs for youth.
Bethesda, Md.: US Dept. of Health and Human Services, Public Health
Service, National Institutes of Health, 1980.
T108351391
Ian C. Lewis, M.D., F.R.C.P, F.R.A.C.P, D.P.H, D.C.H
Professor of Child Health
Kent J. Rayner, B.Sc.
Research Assistant
Klaus M. Schwarzenholz, B.A., Dip. Psych.
Industrial Counsellor
Department of Child Health
University of Tasmania
INTRDDUCTION
Hobart is the capital city of Tasmania, the island state of Australia, and
has a population of approximately 160,000 people. The State has well
developed health education and welfare services. Education is compulsory
from 6-16 years. Most children go to kindergarten at about 4 years of age
and, when they leave school at 16 years, about 30% go on to matriculation
colleges for one or two more years. As well as the state school system,
there are Catholic schools and independent or private schools, to which
about 20% of children go.
In 1971, 1977 (i) and 1982, nineteen secondary schools in Hobart were
surveyed by questionnaires for aspects of student behaviour such as the use
of special diets, vitamin intake, analgesic intake and alcohol consumption
as well as tobacco usage. This paper will examine attitudes to, and the use
of, tobacco only. In the first two surveys factual information was collect-
ed, but in the 1982 survey attitudes to smoking were also examined. In
three high schools, representing different socio-economlc areas, parent
smoking habits and attitudes were included. So~e of these results have been
reported by Lewis and Rayner (2) and Schwarzenholz (3).
At about the same time as the 1982 survey, an assessment was made of the
health education programmes used in the 19 schools.
METHOD
The 1982 questionnaire was the same ms that used in the 1977 survey, but
with the addition of questions related to attitudes towards analgesics,
~Idress for Repriu:ts: Professor I.C. Lewis, Department of Child Health,
University of Tasmania, Clinical School, 43 Collins Street, Hobart,
Tasmania, Australia.
T108351392
744
cigarettes and alcohol as health hazsrds. The smoking question asked '%~hen
do you think smoking becomes bad for your health?", followed by six choices:
(a) smoking 20 or more cigarettes daily
(b) smoking I0 - 20 cigarettes daily
(c) smoking 5-10 cigarettes daily
(d) smoking 3-5 cigarettes daily
(e) smoking 1-2 cigarettes daily
(f) smoking any cigarettes at all
The questionnaire was administered to students in Grades 8, 9 and I0 in 19
secondary schools in the ~obart metropolitan area. These included four
Catholic and four independent schools and were the same ones surveyed in
1977, comprising a11 but two of the secondary schools in the area at that
time. The questionnaires were administered by the class teachers in mid-
March at a time well clear of examinations.
The difference in attitude between parents and children was investigated in
o~e of the State high schools by asking these students and their parents
whether they agreed with the statement '~oderate smoking is not harmful".
These parents, as well as parents in two other high schools, were also asked
the same question as the students relating to how much smoking they
considered was harmful.
Smoking trends within different school systems were examined to locate any
differences which existed, and for the 1982 figures the ii State high
schools were subdivided according to their socio-economic class ranking.
The rankings were determined on the basis of both fathers' occupation (1971
data) and the social characteristics of the feeder suburbs (1976 Census
data).
RESULTS
The total numbers of students and the breakdown by age and sex are shown in
Table I.
TABLE I. hUMBER OF RESPONDENTS IN 1971, 1977 AND 1982
SURVEYS, BY AGE AND SEX.
SURVEY AGE TOTAL
13 !4 15 16
1971 Males 411 752 724 380 2267
Females 614 903 887 391 2795
Total 1025 1655 1611 771 5062
1977 Males 781 I173 1066 368 3388
Females 939 1249 1085 376 3649
1982 Males I006 1061 882 77 3026
Females 1178 1044 787 47 3056
Total 218& 2105 1669 124 6082
T108351393
A reduction in the number of boys ~no reported smoking cigarettes in the
7 days prior to the surveys was observed between 1971 and 1977 and again
in the 1982 survey; 23.6% of the 13-16 year-olds reported s~oklng in 1982
compared with 29.8% in 1977 and 33.5% in 1971. The girls showed a similar
pattern, with the trend to increased smoking between 1971 and 1977 being
reversed, but with the reduction of smoking being less than for boys. Of
the girls, 27.4% smoked, the 1977 figure being 32.2%. As in 1977, more girls
than boys reported smoking.
Nben the numbers of cigarettes that the students admit to smoking were
analysed, the 'heavy smoking" group (I0 or more cigarettes daily) among the
males was fouud to remain statistically constant over the three surveys,
representing about 30% of the male smokers at the age of 16 years.
The percentage of '~eavy smokers" among the girls fell to the 1971 levels
and was II.2% of the 16 year-old smokers. It was in the I-I0 cigarettes
daily group that the girls outstrlped the boys: at 16 years of age, 33% of
the boys who smoke and 51.2% of the girls who smoke have l-|O cigarettes
daily.
FIGURE I. PERCENTAGE RESPONSES FOR 13 YEARS AND 15 YEARS-AND-OVER AGE
GROUPS, DIVIDING SMOKERS AND NON-SMOKERS, TO THE QUESTION,
"WHEN DO YOU THINK SMOKING BECOMES BAD FOR YOUR HEALTH?"
70.
~.o
30.
T108351394
Out of a total of 1401 smokers answering the "attitude to smoking" question,
612 (43.7Z) believed that smoking less than 20 cigarettes a day was not
harmful, whereas of the non-smokers only 19.3% opted for this response;
28.7% o£ smokers believed "any smoking st all" was harmful, compared with
57.3% of the non-smokers, this difference being significant in both male and
female groups. Figure 1 graphs the percentage responses to the question for
smokers and non-smokers and for 13-years and 15-years-and-over age groups.
The differences between smokers and non-smokers at the extremes of the
response scale are clear, and although the differences between the age
groups are not statistically significant, the trends are consistent in
showing that for both smoking and non-smoklng groups, older students
responded "over 20 per day" less often than the 13 year olds, and "any
amount" more often. There was no significant difference between the sexes
in the pattern of responses to the attitude question.
The comparison between the replies of parents and children to the statement
"moderate smoking is not harmful" is shown in Table 2. About 69% of the
parents disagreed with the statement, compared with 63% of their children.
The students were more often undecided.
TABLE 2. RESPONSE TO THE STATEMENT, "MODERATE SMOKING IS NOT HARMFUL" (1982)
Response category
Parents Students
% % (N=312)
Agree, Strongly Agree 17.9
Undecided 9.6
Disagree, Strongly Disagree 68.9
No response 3.5
19.9
16.7
63.1
0.3
Nhen these parents were asked the same question given to their children
relating to how much smoking was harmful, they were again shown to be more
convinced of the damage caused by smoking. Parents from two other State
high schools were also asked this question, and the results are summarised
in Table 3. While the number of parents Who believed that any amount of
smoking was harmful ranged from about 74% to 80%, only about 44% to 57% of
students thought so. The proportion Who thought it necessary to smoke over
20 cigarettes per day ¢o cause harm to beatth ~enged from 7.5Z to 17.7g in
the parents, and from 12.1Z to 31.7Z in the students.
Table 4 shows, for the three types of school~ surveyed in 1971, 1977,
1982, the percentages of male and female students in the four main age
groups who claimed to have smoked cigarettes in the previous 7 days. In
each group the consumption trends appear to be similar to those observed in
the to~al sample, although the changes observed in the independent school
students appear to be more drama "
T108351395
747
TABLE 3.
PERCEI~TACES OF STUDENTS F~OM THREE STATE HIGH SCHOOLS, AKD THEIR
PARENTS, ~ ~ESPOI~DED IN VARIOUS CATECORIES TO THE QUESTION
'~HER DO YOU ~II~ SHOKII~C BECOMES BAD FOR YOUR HEALTH?"
N~mbe r o~
cigarettes
considered
unhealthy
Any amount
I-5 daily
6-20 daily
20+ daily
School 1
Parents Children
t % (N-312)
School Z
Parents Children
79,6 S7.1
3.0 9.6
8,7 18.4
7.S 12.1
75.3 48.7
0.8 13.2
12.0 12.8
11.2 22.3
$chooi 3
Parents Childre
t t (N-44
73.8 43.9
3.7 6.1
4.8 15.8
17.7 31.7
TABLE
SMOKING RATES FOR DIFFERENT TYPES OF SCHOOLS IN THE
THREE SURVEYS, BY AGE AND SEX.
NUMBER
AGE 13 14 15 16 TOTAL
SUBJECTS
Independent
1971 12.7 24.1 31.7 21.3 23.9 318
1977 11.9 38.7 32.5 30.0 29.1 485
1982 4.8 10.5 17.6 nil 9.2 273
FEV~LE
State
197I 22.0 25.4 33.0 36.2 28.4 1923
1977 24.9 33.5 40.5 46.8 34.3 2494
1982 19.7 29.1 33.3 39.5 26.9 2136
Catholic
1971 24,0 24,4 29,4 20,4 25.0 619
1977 19,1 23,0 32,0 35.8 27,0 649
1982 13.5 29.2 26.6 50.0 22.5 626
ln~tepe~ent
State
Catholic
1971 30,8 31,6 45,3 56,6 43,3 187
1977 20,7 23.1 34,5 31,9 27,4 398
1982 15.3 25.7 18.8 42.9 20.3 325
1971 21.8 30,5 37,5 39.9 32,5 1969
1977 24,5 27.1 34.4 40.1 30.1 2785
1982 12.2 23.2 25.9 33.3 20.7 2512
1971 22.9 26,5 41,3 46.2 ~.? !56
1972 18,7 25,8 34.4 46.2 30,4 180
1982 21.1 21.6 19.0 50,1 21.4 154
T108351396
For the 1982 survey, the II State high schools were divided into three
groups~ A, ]~, and C, with A being chose with the highest socio-economic
scale score a~d C the lowest. As can be seen from Table 5, the group G
schools have higher rates of smoking, and although groups B and C are
s~m~lar £u the f~les, and groups A ~nd B are si~lar ~n ~he ~les, the
inverse relaCionship between the rsce o~ s~ki~ and socisl cl~ss is stsCis-
tically highly significant.
TABLE 5. PERCENTAGE S~ERS IN THKEE GROUPS OF STATE HIGH SCHOOLS,
GROUPED ACCORDING TO SOCIO-ECONOMIC STATUS, BY AGE AND SEX.
Scare A
SCats A
C
AGES No.o£
students
10.4 20.2 24.9 54.5 18.6
26.7 32.$ 37.2 41.2 32.8
20.4 31.0 40.7 20.0 28.8
8.7 22.7 26.1 42.9 19.2
13.5 20.2 25.4 32.0 19.9
37.7 48.4 58.8 51.9 48.3
737
870
1018
619
DISCUSSION
Over recent years, the hazards of smoking have been given considerable
publicity in the news media and in health education programmes for all
ages. Some countries have banned advertising of tobacco and others have
curbed amoking in public in certain locations. Australia cannot be regarded
as very progressive in these areas.
The trends that have emerged from these surveys show Chat whiIe fewer boys
are ~kin8 overa|l, the heavy st~okin8 ~oup, representing nearly 30% of the
smokers, has.remained constant over the eleven year period. The number of
girls smoking has fallen since 1977, but not to the same extent as the boys,
and more girls smoke than boys. While not so many glrls smoke heavily,
large numbers are smoking at least one cigarette daily which must be a cause
for concern.
S~udent attitudes to smoking reveal that health education needs to be
reviewed. Over ~OZ o~ ~r~e~t~ ~h~ "~?k=d ~=~ C~,,C ~ chin 20
cigarettes daily is not harmful and only 29Z of them agreed that any amount
of smoking was injur~ou$o Even amon~ the non-smokin~ students, r~early 20%
thought that less than 20 c~garettes daily was harmless. There were no
s~gni~icant differences in views between the sexes. One trend is worth a
comment: as the students ~et older~ more felt that any amount of smoking was
T108,351397
potentially harmful. This probably reflects the effect of health education
which tended to be concentrated in the 15 year-old age groups, and, as
stated by Schwarze~nolz (3), "If a degree of association according to age
was really an indication of the growing influence of the peer group, the
results ... are clearly contradictory. This could mean that .. the
influence of the peer group on drug-taking behaviour is over-rated ..."
Parents were more convinced of the harmful effects of tobacco than their
children, in the one school surveyed.
There was little difference between the smoking behaviour of students in the
three educational aystems, namely government, independent (or private), and
Catholic schools, but when the government schools were grouped according to
the socio-economic status of the area they drain, students of both sexes
from the lowest socio-economic schools were more likely to be smokers than
those from the better-off environments.
When the results of a survey of health education progra~es were examined,
it was found to be impossible to draw comparisons. All students appeared to
receive some health education, but the quality of the sessions or even the
methods of education attempted were not assessable. It can be said that no
school had a comprehensive programme covering all grades and a11 students.
The results of the survey would indicate that there is a very real need for
a review of health education methods in Hobart schools.
ACKNOWLEDGEMENTS
We wish to thank the staff members and students of participating schools for
their co-operation.
Lewis IC, Rayner KJ. The changing acene: dieting, vitamins, analgesics,
alcohol, smoking and Hobart Secondary School students. Med J Aust 1978;
2: 632-635.
Lewis ZC, Ray~r KJ. The contiuu£~ saga: a further review of some
aspects of behaviour of Hobart Secondary School students. In: Proceed-
ings of the Xlth International Conference on Health Education, Hobart,
Tasmania, Australia, August 1982.
Schwarzenholz I~. Parental modelling of drug-taklng behaviour. Unpub-
lished Diploma Psychology thesis, Department of Psychology, University
of Tasmania.
T108351398
751
Cornelius J. Lynch, Ph.D.
The Franklin Institute
Policy Analysis Center
4701Willard Avenue, Suite 310
Chevy Chase, Maryland 20815
U.S.A.
Beginning in the early 1970s, the National Cancer Institute's Smoking and
Health Program, under the direction of Gio B. Gori, ScD, MPH, sponsored a
case-control study of the health effects of smoking and other lifestyle
factors in the United States (I). The study was designed by Ernst L.
Wynder, MD (American Health Foundation).
As the study progressed, it became necessary to increase and substantiate
its findings by investigating incidence rates, smoking practices, and relat-
ed factors ~n other countries. Western Europe provided a promising epidem-
iologic setting for comparisons with the U.S. experience. Consequently, a
similar study, under Prime Contract, was started in 1976 in five Western
European countries, with seven research centers: Vienna, Austria; Paris,
France; Hamburg and Heidelberg, West Germany; Milan and Rome, Italy; and
Glasgow, Scotland.
SCOPE OF WESTERH E~ROPE STUDY
Subjects for personal interviews were recruited by each center from hospi-
tals in several cities. The results that follow are identified by center;
it is not implied that they represent the more general smoking populations
of the host countries.
The study addressed 36 diseases for which respondents were hospitalized, and
covers a variety of ~emographic an~ socioeconomic characteristics: age, sex,
education, occupation, marital status, alcohol consumption, dietary and
other factors. This paper concentrates on a limited component of the study,
namely: smoking practices and funs cancer as the variables of interest. The
data were obtained during approximately three-and-a-half years of field
intervlewin~.
8MOKIRG PRA~IqCES OF RESPO~ENTS
There were over 60 questions on smoking practices alone, covering ciga-
rettes, cigars, and pipes. A smoking practice of particular interest in the
study was the frequency of inhalation, since smokers who inhale all the time
~"~ .... : high~ ~I~~-~.~ ~" ' ~ ,=,~p~,~' " " i~ c~ncer ~nan smokers who r~ver
inhale, or who rarely inhale. Table [ summarizes the responses by frequency
T108351399
7 5 2 LY-m~
of inhalation for cigarette smokers. These are m~le respondents only;
female respondents, have similar distributions.
Each column of the table gives the percentages of respondents by "their
frequency of inhalation. For example, 69.2% of the Viennese mmle cigarette
smokers reported that they ir~aled all the time, 17.5% moat of the
so forth. The bottom row lists the total number of respondents. For the
center in Vienna, there were 2,562 male cigarette smokers.
For each center, most of the smokers inhaled all the time or most of the
time. Very few respondents never inhaled - except for Paris, w~ere 34%
reported that they never inhaled. This issue will be addressed later.
It was found that the following six smoking practices, individually or in
combination, provide valuable information for discerning differences and
identifying similarities in smoking practices between the U.S. and Western
Europe.
Current Smoking Status:
smoked.
present smoker, ex-smoker, never
- Age Started Smoking: age at which the respondent started to
smoke regularly, as contrasted to a teenager or pre-teen
experimenting with cigarettes.
- Number of Years Smoking: total number of years as a regular
smoker, adjusted for intermittent periods of abstinence.
- Number of Cigarettes per Day:
smoked each day.
number of cigarettes usually
- Amount of the Individual Cigarette that is Smoked: how much of
each cigarette is usually smoked (all of it, half of it, or
whatever).
Frequency of Inhalation: all of the t~me, most of the time,
part of the time, rarely, never.
Because of the importance of these smoking practices, each center was ranked
in term~ of the corresponding level of hazard, as shown in Table 2. These
resulLs were ~s~d on ~espoa~es from mle lung cancer cases.
For each smoking practice, Rank 1 is the most hazardous level and Rank 8 the
least hazardous, For example, with respect to current smoking status, Milan
ranks most hasardous and Vienna least hazardous, with the U.S. falling
slightly below the midpoint.
The plus and minus signs denote statistically significant differences, at
the 5Z level, between the respective centers a h ~
In-'~cate s~ly more hazardous smoking practices ~nd minus s~ns
~ndicate significantly less hazardous smoking practices ~han the U.S. For
current smoking status, the first four centers rank significantly more
hazardous than the U.S. (note the plus signs). The remaining three centers
rank less hazardous than the U.S., but not significantly lower.
T108351400
Parl
Rat!
Naw
Ran
1
2
3
4
5
6
7
8
TABLE I. PERCENTAGES OF ~SPONDENTS BY INIL6LATION FI~QUENCY
nhalatlon
'requency
Vienna Paris Hamburg Heidelberg Htlan Rome Glasgow U.S.
of the Time
of the Time
of the Tima
:r
69.2 45.1 63.4 88.6 78.6 66.2 79.8
73.9
17.5 10.4 8.8 2.5 15.7 23.6 6.1
18,4
8.8 5.I 11.7 3,4 3.3 6.[ 4.8
2.8
2.8 5.4 5.3 1.7 1.1 2.1 3.6
--
1.8 34.0 I0.7 3.9 1.3 2.1 5.7
4.9
Current
Smoking
Status
2,562 2,014 717 900 1,710 728 1,294
515
TABLE 2.
RANKINGS BY LEVELS OF HAZARD FOR SELECTED
CIGARETTE SMOKING PRACTICES - CASES
A~e Number Number Amount of
Frequency
Started of Years of Cig. Individual of
Smoking Smoking per Day Clg.Smoked Inhalation
Milan (+)
Paris (+)
Glasgow (+)
Ro~e (+)
UoS.
Hamburg
Heidel.
V i e nna
Milan Glasgow (+) U.S. Milan (+)
Heldel.
~nme Vienna (+) Vienna (-) Paris (+) Milan
U.S. Rome (+) Milan (-) Heidel. (+) U.S.
Glas-'----~ow (-) Hamburg (+) Glasgow (-) Rome (+)
Glasgow
Paris (-) Milan (+) Paris (-) Vienna (+) Rome
Heidel. (-) Paris Rome (-) Glasgow (+) Vienna
Hamburg (-) U.S. Hamburg (-) Hamburg (+)
Hamburg
Vienna (-) He[----del. Heidel. (-) U.S. Paris
(-)
(-)
!I
An interesting feature of this table is the consistency within each smoking
practice in the sense that each smoking practice contains only plus signs
(and blanks) or contains only minus signs (and blanks). There is no
instance where one European center reports a significantly more hazardous
level than the U.$. while another center reports a significantly less
hazardous level for the same smoking practice.
Overall, the European centers report more hazardous smoking practices than
the U.S. with respect to current smoking status, number of years smokinE,
and the amount of the individual cigarette that is smoked. The European
centers report less hazardous smoking practices than the U.S. with respect
to the age at which smoking started, the number of cigarettes smoked each
day, and the frequency of inhalation.
As mentioned above, Table 2 is based on responses from male lung cancer
cases. There are similar results for the other subjects who were inter-
viewed, including the consistency of plus and minus signs for individual
smoking practices (3).
The reasons why individual centers rank higher or lower than the U.S. is not
part of this paper, but some of the contributing factors are of interest.
For example, social customs in Italy traditionally have been, and still are,
more tolerant of cigarette smoking among teenagers than has been the case in
the U.S. and elsewhere. So it is not surprising that Milan and Rome are the
most hazardous among centers in starting to smoke at early ages. Economics
is also a factor in smoking practices. Cigarettes are much less expensive
in the U.S. than in Europe and the average smoker in the U.S. has more
disposable income to spend on cigarettes. Consequently, those who do smoke
in the U.$. smoke significantly more cigarettes each day than do the
Europeans. Note that the U.S. ranks number I in hazard with respect to daily
cigarette consumption. On the other hand, the more expensive cigarettes in
Europe are often smoked right down to the last possible puff~ to get the
most out of the price paid. Every European center smokes significantly more
of the individual cigarette than do Americans.
With respect to inhalation, Paris ranks the least hazardous. The French
macho movie star was occasionally ~ortrayed with a cigarette dangling from
his llps, without puffing. It was found that this was more than simply a
cinematic caricature - it was common practice in France. The result is that
some French smokers were smoking at a level less hazardous than would other-
wise be the case.
SI~EI~ PBACTICES ~ I~RTALITY RATES
These and other results (2,3,4) demonstrate that there are significant
differences in smoking practices among the various centers. The importance
of such findings depends upon whether differences in smoking practices are
associated with differences in disea " " "
t ~-~ssue, a step-up multiple regression analysis was performed, usir~ lung
cancer mortality rates as the dependent variable and measures of the six
smoking practices for each center as independent variables.
T108351402
The resulting regression e%press]on had an adjusted multiple R of greater
than 0.95, indicating that the smoking practices used, even though they
represent only six out of more than ~0 variables that were ~easured, are
associated with over 90% of the variation in mortality ratios. The smoking
practice variables entered the step-up regression expression in the follow-
ing sequence:
I. Number of years as a s~oker.
2. Number of cigarettes smoked each day.
3. Frequency of inhalation.
4. Age at which cigarette smokir~ started.
5. A~>unt of each individual cigarette that is smoked.
6. Current cigarette smoking status.
The number of years as a smoker was the most significant smoking
practice in accounting for the variation in lung cancer mortality rates bet-
ween the European centers and the U.S. This factor was closely followed by
the number of cigarettes smoked each day and the frequency of inhalation.
The least important factor was found to be current smoking status. The low
ranking of this last factor may be due to some case respondents ceasing to
smoke prior to diagnosis, influenced by the symptoms of disease. That is,
they were ex-smokers for at least six months when the disease was first
diagnosed. Another possibility is that, since the etiology of lung cancer
involves a long latency period, smoking status at the tin of diagnosis is
relatively less significant. Both of these hypotheses are consistent with
other analyses that were performed
PRACTICAL USE O¥ T~ RESULTS
The value of results such as these, from the public health viewpoint, lies
in identifying those smokers who are at a particularly h~gh risk of disease,
to assist in curbing the prevalence of smoking in the host countries. For
example, the smoking population as a whole has high relative risks of devel-
oping emphysema, arteriosclerosis, cancer, and heart disease. Within this
population of smokers, there are subpopulations which have even higher rela-
tive risks of disease. If an individual can be shown that his or her per-
sonal smoking practices are especially hazardous, then there is a better
chance of encouraging that person to quit smoking. The intent is to avoid
generalities and be ~pe=ific, as a ~eans of improving the effectiveness o~
smoking cessation programs.
T108351403
i. Gori GB. Smoking and health - A program to reduce the risk of disease in
smokers, National Cancer Institute. Status report, 1979 December.
2. Lynch CJ. Case-control epidemiologic study in Western Europe. Smoki~
and ~ealth Program, National Cancer Institute. 1979 December.
3. Lynch CJ. An epidemlologic investigation of lifestyle factors and
disease incidence, Proceedings of the Biometric Society/American
Statistical Association Joint Meeting. Richmond, Virginia, 1981 March.
4. Lynch CJ, Yu WW. Smoking practices of case-control respondents in
selected Western European countries. World Tobacco and Health 1981
March.
T108351404
757
R£chael ~rray
Department of Community Medicine
St. Thomas~a Hospltal l~edicaI School
London, U,K. SEI 7EH
Previous research into the reasons for the development of smoking among
children and adolescents has largely been based upon cross-sectional surveys
of the social and psychological correlates of the phenomenon. The
underlying assumption in this approach was the conception of the smoker as a
passive individual who responded by smoking when exposed to such stimuli as
peer pressures. The intervention strategy which followed from this approach
was to try to "innoculate" with health warnings particularly vulnerable
groups of children who were likely to be exposed to these stimuli. The
limited success of this strategy suggests the ~eed for an alternative to
this rather mechanistic model of the development of smoking.
An alternative social psychological approach would be to consider human
behaviour as socially meaningful action rather than passive responses to
various stimuli. This approach would view smoking as a social act which has
a variety of meanings to different people in different situations. To
understand why children and adolescents adopt smoking would thus require an
understanding of the dlf~erent meanings attributed to smoking by them and an
understanding of the situations in which smoking occurs.
This paper, using peripheral data from a large-scale survey of smoking,
attempts to sketch out some aspects of the meaning of smoking to adolescents
by placing it within its social context. But first it is important to be
aware of the widespread nature of smoking among adolescents.
PR~VALEN~ OF ~l~0Kl~ A~Ol~g C~ILDRRN ~
Despite the plethora of anti-smoking campaigns over the past ten year,
smoking remains popular amor~ a large number of adolescents in the
Even before ~hey re~ch a4oles¢~nce m~y childre~ have tried smokln~. In
survey of almost 1000 9-10 year olds, conducted in Sheffield in 1978, we
found that as many as 50% of boys and 30% of girls had had at least a few
puffs of a cigarette (I).
On entering adolescence smokin~ increases rapidly in popularity. A
lo~itudinal survey of adolescents conducted in Derbyshire between 1974 and
1981 found that the prevalence of regular smoking rose from 6% of 11-12 year
old boys and 3Z of II-12 year old girls to 33Z and 30% of 18-19 year old
........ ~I~ ~p~c~vely {~). i~ addition, the proportion of teenagers
T108351405
smoking occasionally or experimenting with cigarettes increased steadily
throughout adolescence, such that by 18-19 years less than a quarter had
never tried a cigarette.
The quantity of cigarettes smoked by regular smokers also increased during
adolescence. In the Derbyshire study the average number of cigarettes
smoked per week by regular smokers rose from 15 at 11-12 years to 120 at
18-19 years among boys and, within the same age ranges, from 9 to 90 among
girls.
Throughout adolescence more boys than girls in Derbyshire smoked cigarettes
and they also smoked more heavily. In addition, we found a sex difference
in the brand of cigarettes preferred by the teenagers. Although over 90% of
them smoked the middle tar, non-mentholated brands, among the remainder more
girls than boys smoked low tar or mentholated brands.
Finally, similar to the social class difference in the prevalence of smoking
among ad~its, we found that, in Derbyshire, smoking was more prevalent among
teenagers from manual households, irrespective of their parents' smoking
practices.
To understand the reasons for the different form which smoking takes among
different groups of adolescents requires a consideration of the different
meanings attributed to smoking within the changing social and psychological
context of adolescence. Subsequent sections will attempt to do this using
anecdotal evidence collected in the Derbyshire study. The anecdotes were
obtained from the free comments on smoking which many adolescents added to
the structured questionnaire used in the Derbyshire survey. All the
comments considered below were made by 13-14 year olds.
PSY~OLOGICAL DEVK~OPM]~NT$ D~ING ADOLESCENCE
Adolescence is a period of transition between childhood and adulthood.
During this period the teenager undergoes rapid physical and mental growth.
The adolescent must not only come to terms with these changes but also has
to develop a new adult identity. The adolescent experiments with a range of
new identities. The actual character of the identity preferred will be
conditioned by the ideal adult model available to his or her sex and social
class.
The adolescent can use various props to indicate this new identity. These
props include clothing, hairstyle, cosmetics and, for some adolescents,
smoking. Not only the adoption of smoking but also the style of smoking and
the brand of cigarettes preferred can all be used to accentuate a particular
image. Thus, some boys would smoke high tar cigarettes to emphasise their
manliness whereas some girls would prefer low tar, mentholated brands to
emphasise their femininity.
"_ " .~ . e young s~------k~? can
misinterpreted by his or her peers. For example, the image of the adult
sophisticate presented by the teenage girl smoker may be interpreted by her
peers as an indication of promiscuity. A comment by a non-smoking girl
illustrated this:
T108351406
759
"One girl I know (not a friend) she smokes over 30
a day (...) She is a flirt and goes out every
night and amokes with her boyfriend as well as
having sexual intercourse".
The youn~ smokers themselves were aware of this danger as was apparent in
the following comment from a glrl" smoker:
"Just because I smoke doesn't mean I am a tart as
most people think".
In an attempt to prevent this misinterpretation, girls are often more
circumspect about when and where they smoke.
Part and parcel of identity formation is the negotiation of independence by
the adolescent. This means acquiring the freedom to make day-to-day
decisions and to take responsibility for one's actions. For some
adolescents, the adoption of behavlour practices condemned by authority,
e.g. smoking, is part of that independence negotiation. Such an attitude
would also involve rejection of the advice given by adult authority. This
rejection of health warnings was evident in the following comments by a girl
smoker:
"I think that parents and teachers shouldn't have a
say whether you smoke or not. You go into the
streets, breathe in polluted air and affect your
lung. The difference is you are polluting
yourself, normally everybody else is polluting
yOU".
and a boy smoker:
"If you want to smoke then you can if you llke.
What you do with your private life is your own
concern, it should not be controlled by others but
left to the individual (...) If you want to smoke
then you should be allowed to. Life is what you
make of it, not what is made for you".
Several non-smokers also asserted the right of the individual to smoke. For
example one girl wrote:
"So what if people do smoke~ There's hardly
anything you can do aSout it! I want to start
smokin8 in the future and I wouldn't thank you for
interfering or getting smoking 5armed."
while a boy added:
"Its nothing to do with you if we smoke, it's our
Since the r, egotiation of independence is part of the process of achieving
adulthood, the use of smoking as an aid in this process would be of less
concern if later the adolescent could have the opportunity to reassess the
T108351407
decision. Unfortunately the promise of independence which smoking initially
offers soon turns on itself as the adolescent discovers the strength of
cigarette dependence. This problem was £11ustrated in the comment of one
young girl:
"I smoke a lot recently and would like to give up
but I can't. I never thought I would ever get to
the stage tha~ I can't give up but I just can't. I
would really like to stop it before I get older".
Several other adolescents added pleas for advice on smoking cessation.
SOCIAL CRANGES IX~EING AIX)LESCENCE
On entering adolescence the teenager becomes increasingly involved in social
activities outside the home and school. This is especially so for working
class boys. Many of these boys spend much of their social time on the
street. Their social environment offers little excitement so they hang
about waiting for something to happen.
It is in this context that smoking acquires a valuable meaning for working
class boys. The exchange of cigarettes provides a means of strengthening
group solidarity - an important aspect of street life. The activity of
smoking disrupts the boredom and also provides a means of structuring time.
The social connotations of smoking provide a simple means for the boys to
~isplay their musculinity. Ex-smokers seemed most aware of~ or at least
most prepared to admit, the strength of the social norms within working
class male groups which encourage smoking. For example one boy wrote:
"I used to smoke one cigarette every two days or so
because everyone else did (or so I thought) but now
I have given up (...) This is because my real
friends made me realise it was bad for my health and
also didn't make me look big".
While another commented on the difficulties of cessation:
"I have tried to stop but my friends keep smoking
and offer m~ one I can't refuse. I do not come out
at weekends because of them offering them to me".
Social activity outside the home for girls often involves relationships with
boys. Such relationships start at an earlier age for girls from working
class homes. To these girls smoking may appear particularly valuable as a
means of appearing adult and sophisticated or of attaining equality with
boyfriends. One young girl mentioned the pressure to smoke from her
boyfriend:
"It was my brother who started me smoking. The
trouble is I can't stop. All of my boyfriends have
smoked or do and it is terribly hard to stop the
habit".
T108351408
On the other hand, some boys may assert their dominance over their girl-
friends by restricting their smoking. For example, one girl wrote:
"I stopped smoking because my boyfriend made me. I
stopped for at least a year. But ~,~hen my boyfriend
finished with me I started again".
While another girl added:
"I don't smoke now because my boyfriend and parents
don't allow me to".
Related to these restrictions are boyfriends' expectations of the "proper"
behaviour for women. Such expectations may reduce the attractiveness of
smoking to some girls. For example one girl wrote:
"My boyfriend is 17 and is trying to give up smok-
ing. ~e never offers me a cigarette as he says a
girl looks 'common' with one hanging in her mouth. I
agree with him. I don't mind a cigarette once in a
while but as a rule I don't smoke".
Teenagers from middle class homes are not as actively involved in social
activities. They remain more attached to the more formal activities
organised by their families and by their school. In this context smoking is
of less value.
Smoking is popular among certain groups of adolescents because of its valua-
ble meaning as an activity within certain social contexts. This suggests a
two-fold intervention strategy. First, to reduce directly the positive
social connotations of smoking and, second, to alter the social environment
such that the value of smoking is reduced.
The former requires widespread national action to reduce the public accept-
ability of cigarette smoking. This could involve restrictions on promotion-
al campaigns, on availability of cigarettes and on smoking in public
places. It would also require health education programmes which were based
upo~ an understanding of the different value of smoking to different groups
of smokers. For young people its message should not be presented in a moral-
istic fashion which could only repel those adolescents who are using smoking
as a means of asserting their independence. Instead the contradictory
nature of smoking which leads from ~ssertion of independence to cigarette
dependence should be emphasized.
The second prong of the intervention strategy would involve social changes
.............................. =p~nce s~oothly without
the need to use s~klng as a prop. One of the c~aracteristics o~ adoles-
cents, especially those from working class homes, is the lack of control
which they have over their lives. Until this situation is changed the
value of smoking as a symbol for their desire ~or such control will remain.
T108351409
I wish to thank the young people who participated in this study for their
comments and the various me~bers of the MRC/Derbyshire Smoking Study team
for their advice. Financial assistance for this study was provided by the
Medical Research Council and the Department of Health and Social Security.
Murray M, Swan AV, Enock G, et al. The effectiveness of the 'My Body'
health education project. Health Education J 1982; 41 : 126-130.
Murray M, Swan AV, Bewley BR, Johnson MR/3. The development of smoking
during adolescence. Int J Epidemlology 1983; 12 : ]85-192.
T108351410
763
Desmond J. O'Byrne
Health Education Bureau
34 Upper Mount Street
Dublin 2, Ireland
INtROdUCtION
In line with trends in other western nations, smoking in Ireland declined
during the 1970's. In 1982, 35% of Irish adults (16 years and over) were
regular smokers, a figure which shows a constant decline of approximately 8%
during the 1973-82 period (I). Comprehensive baseline research has provided
much useful information about Irish adult smokers (2). The prevalence of
smoking among adolescents in Ireland has also received attention. In 1980 a
survey of tobacco smoking habits was carried out on a stratified random
sample of post-primary schools in Dublin City and County - a part of the
Irish Republic with a population of one million people - just less than a
third of the population of the State. This was the second stage of a
similar study carried out ten years previously among five thousand 12-18
year olds in the same region (3).*
METBOD
Sixteen schools were randomly selected in the sample area. Every student in
each class/form of the school was asked to complete a questionnaire by a
member of the survey team, who was in attendance when the questionnaires
were being completed. Students were permitted to ask for clarification of
any points not immediately clear (Table I).
TABLE I.
SURVEY POPULATION: SEX AND AGE DISTRIBUTION OF RESPONDENTS
,~$e 12 13 14 15 16 17
18+ Total Number
Boys % I0 21 24 21 15 7 2
i00 3086
Girls % 10 18 21 20 18 I0 3
I00 2092
Total % !0 20 23 21 -16 8 2
I00
Number** 529 1024 1189 1067 840 427 102
5178
The study was made possible by funding by the Health Education Bureau,
the Medlco-Social Research Board a~d the Irish Cancer Society. Both
sta~es were or~anlsed and implemented by Dr Aen~us O'Rourke, Dept. of
Comunlty Health, Trinity College, Dublin.
Tfte total number of answered questionnaires was 5189 but II question-
naires had either sex or age unstated.
TI08351411
764
DEFIRITIG~ O~ TEEMS
For the purpose of this study, the following definitions were used as a
means of classifying smokers and non-smokers:-
(i) A regular smoker is a student smoking at least one cigarette per week
every week.
(il) An occasional smoker is one who states that he does not smoke
regularly but smokes on holiday, at parties, etc. The students in
this group have also completed the questions on the questionnaire
applying to smokers.
(iii) Ex-smokers are those who state that they have smoked, but do not do
SO now,
RESULTS
Table 2 shows the number of current smokers. In response to the question,
"Do you smoke now?", over 33% of the boys and 25% of the girls declared
themselves current smokers. Twenty-five per cent of both boys and
girls said they were occasional smokers. It may be reasonably assumed that
some at least will become regular smokers. By including the ex-smokers, it
can be seen that nearly three-quarters of the boys and almost two-thlrds of
the girls had tried smoking at some time.
TABLE 2. RESPONSE TO THE QUESTION, "DO YOU SMOKE NOW?"
B o_9.~[ Girls
Total
Smoke Now:
Occasionally:
Ex-Smokers:
Never
Smoked:
1033 (34%) 536 (26%) 1569
736 (24%) 548 (26%) 1284
494 (16%) 234 (II%) 728
807 (26%) 767 (37%) 1574
Total:
3070 (100%) 2085 (I00%)
5155
T108351412
765
Table 3 gives the prevalence of smoking by age and sex, while Table
provides a comparison between the percentage of regular smokers at each age
group in the 1967, 1970 and 1980 surveys.
TABLE 3 SMOKII~ HABIT BY AGE
12 13 14 15 16 17 18+ Total
BOYS
Percentage of:
Regular Smokers 21
Occasional Smokers 22
Ex-Smokers 16
Never Smoked 41
31 39 37 32 31 46 34
24 22 21 30 29 23 24
17 14 18 16 14 17 16
28 25 24 22 26 14 26
Number (=I00%)
309 644 744 650 458 215 48 3068
GIRLS
Percentage of:
R~gular Smokers
Occasional Smokers
Ex-Smokers
Never Smoked
I0 18 29 27 32 34 29 26
19 22 24 30 31 31 30 26
9 I0 12 12 i0 12 15 II
62 50 35 31 27 23 26 37
Number (=100%)
218 376 438 414 378 207 54 2085
TOTAL
Percentage of:
Regular Smokers
Occasional Smokers
Ex-Smokers
Never Smoke~
17 26 35 33 32 32 36 30
20 23 23 24 30 30 26 25
13 15 13 16 14 13 17 14
50 36 29 27 24 25 21 31
Number (=100%)
527 1020 1182 1064 836 422 102 5153
T108351413
TABLE 4 COMPARISON B~TWEEN REGULAR SMOKERS, 1967, 1970 ABD 1980
12 13 14 15 16 17 18+ Totals Sample Size
BOYS
Percentage of:
Regular Smokers (1967) 13 19 31 36 42 43 55
32 2,710
Regular Smokers (1970) 25 24 33 38 45 44 47
35 3,015
Regular Smokers (1980) 21 31 39 37 32 31 46
34 3,068
GIRLS
Percentage of:
Regular Smokers (1967) 1 6 II
Regular Smokers (1970) 3 9 18
Regular Smokers (1980) i0 18 29
13 15 22 20 II 1,792
25 28 29 28 18 2,468
27 32 34 29 26 2,085
Variations in the totals in the various tables are accounted for by students
not filling in particular questions.
It appears that girls will shortly be approaching the smoking levels of
boys. In 1970, nearly twice as many boys as girls were regular smokers, 35%
versus 18%. Whereas, in 1980 the difference had dropped to 34% versus 26%.
While more girls of all ages were smoking in 1980, the increase is parti-
cularly remarkable in the younger age groups. More than three times the
number of twelve year old girls were smoking in 1980 as compared to 1970; a
tenfold increase on 1967. A~ain in the thirteen year olds, the number of
smokers had doubled in the decade and in all other age groups there had been
an increase so that by the age of 17, over 30% of girls were regular
smokers,
One third of the smokers used 50 or more cigarettes each week, one ~n ten
smoking more than 90 cigarettes a week. This last group spent IR £4.00
or more each week on their smoking habit. (In spring 198|, a packet of
twenty cigarettes cost 80p-90p). Twenty percent of the sample smoked I0 or
more cigarettes per day on average.
It is important to note that the boys in the survey smoked more heavil_!y_~
".. " eo per wee~.an t e glr s of all ages and that in both
boys and girls heavier smoking increased by age as one would expect (Table
5). In a recent study of cigarette consumption in the Common Market,
Ireland was shown to have the highest per capita consumption of cigarettes
of any member state (4).
T108351414
767
TABL~ 5.
AVERA~q~ ~FI~BER OF CIGARETTES SMOKED PER ~EEK IN EACH AGE GROUP
BOYS
GIRLS
Average Number Per Average Number
Per
A~e Week in A~e Group Number Week in A..~e Group
Number
15 b under 39 731 29
305
16 54 136 41 118
17 61 663 42 67
18+ 70 23 67 115
In answer to the question: "Do your parents know you smoke?", half of the
boys under sixteen years of age smoking regularly, reported that their
parents knew of their smoking habit and two-thirds of the parents knew in
the older age group, Fewer parents knew of their daughters' smoking habit,
although their knowledge was correlated with the age of the girls.
Parental attitudes to their children's smoking habits are shown in Table 6.
They are, of course, the students' interpretation of their parents'
attitudes.
Nearly a quarter of regular smokers did not know whether their parents
approved of their smoking habits or not. While parental approval increased
with the age of the child, the vast majority of the parents did not approve
of their children's smoking habit.
TABLE 6.
DO PARENTS APPROVE OF YOUR SMOKING? - BY AGE GROUP AND SEX
BOYS GIRLS
Age Group Age Group
under 16 & under 16 &
|6 over 16 over
% % % %
Yes 9 16 Yes 3 I0
No 68 63 No 71 66
Don~t Know 23 21 Don't Know 26 24
Total Number 792 231 328
204
T108351415
Nearly three times more parents of boys in the under sixteen year age group
(9%) approved of their sons smoking than parents of girls in the same age
group (3Z). In the sixteen year plus age group, the respective figures are
16% and 10%.
It is interesting to note that although parents disapproved more strongly of
their daughters ~moking than of their sons smokin$, ~a~ongst girls smoking
is increasing. This may indicate a weakeni~ of parental influence and of
changing attitudes, espec~ally of young girls.
The students were also asked whether their parents would punish them if they
knew of their smoking habit. Four out of ten of the younger girls thought
that their parents would, but this decreased as they grew older. However,
at all age groups, the girls seemed more afraid of their parents' attitudes
than the boys. For instance, in the over sixteen year age group, twice as
many girls as boys - 22% versus 11% - thought that their parents would
punish them if they knew they smoked.
As can be seen in Table 7~ the students' smoking habits were influenced to
some extent by their parents' smoking habits but less than was anticipated.
TABLE 7. SMOKING EXPERIENCE BY PARENTAL SMOKING HABIT CLASSIFIED BY SEX
BOYS
Percentage of:
Both Father Mother Neither Number
Parents Only Only Smoke
Regular Smokers % 31 27 17
24 1024
Occasional Smokers % 23 24 17 36
729
Ex-Smokers % 28 27 17 28 491
Never Smoked % 31 26 15 27
8'02
ALL BOYS
Total Number of Boys
Parental Habits
878 799 5'05 863 3046
29 26 17 -2~
GIRLS
Percentage of:
Regular Smokers % 30
Occasional Smokers % 19
Ex-Smokers % 23
24 16 30 534
25 14 42 548
26 15 36 233
ALL GII~LS
Total Number of G~rls
Parental Habits
507. 509 314 745 2075
% 24 25 15 36
T108351416
769
Six out of ten of those who had ever smoked indicated that they obtained
their first cigarette from a friend.
The question: '~ow many of your friends smoke?" was posed ou the
questionnaire. A choice of five answers was provided. Table 8 gives a
cross-tabulation of rahe respondentst smoking habits by that of their
friends.
TABLE 8. RKSPOD~DENTS' SMOKING KABIT BY FRIEI~DS' SMOKING HABIT
All Most Half Some None Total
Smoke Smoke Smoke Smoke Smoke
Respondents'
Smoking Habits
Number
BOYS
Never Smoked 2 9 II 44 34
I00 729
Occasional Smokers 2 14 15 43 26 I00
657
Ex-Smokers 4 17 13 45 21 I00 447
Regular Smokers 20 37 18 23 2 I00 1024
Number 253 619 414 1037 534
i00 2857
GIRLS
Never Smoked 1 5 7 37 50
i00 703
Occasional Smokers 2 9 I0 52 27 I00
494
Ex-Smokers 2 ii 15 49 23 I00 210
Regular Smokers 17 39 21 22 i i00
533
"Number 107 308 249 741 535
I00 1940
Peer group influence is vitally important in the adolescent sta~e of
• 4evelopment. Smokers and non-smokers appear to congregate in separate
groups. Almost all of the friends of regular smokers also smoked to some
degree. This holds true for boys and girls. Whereas in the case of boys,
one third of the friends of non-smokers were also non-smokers, 50% of the
friends of female non-smokers were also non-smokers. It iS debatable
whether smoking is itself an important factor in choosing one's friends or
whether it is merely one of several traits which influence a sense of group
~dentity.
T108351417
770
O' ~'~
DES~I~ TO STOP
There was a small difference in the percentage of girls and boys who report-
ed that they wanted to stop smoking. Among regular smokers, 62% of boys,
but only 55% of girls wanted to give up smoking. We have already shown
above that the percentage of girls who smoked cigarettes was on the increase
when compared with the 1970 survey. However, it must be borne in mind that
boys smoked more cigarettes per week in each age group than girls.
With increasing age, a declining percentage of smokers wanted to stop smok-
ing. At the age of seventeen years those who wished to stop and those who
wished to continue were of equal proportions. One can see that those who
smoke in late adolescence are in a minority, but are more confirmed in t~e
habit and more likely to continue.
CONCLUSIONS
The study indicates that a high percentage of boys begin smoking at an early
age, though compared with the 1970 study, there is a slight decrease in the
percentage of boys who smoke in the 15-17 year age group.
However, the situation with regard to girls gives cause for some concern.
The study shows a continual increase in the percentage of girls of all age
groups who smoke. Three times more twelve year old girls smoked in 1980/81
than ten years previously. In 1970, 17% more boys than girls in the
12-18 year age group smoked; in 1980 the gap had narrowed to 8%.
In 1970, only 18% of girls smoked more than forty cigarettes per week. In
1980/81 this had risen by 20% to 38% of girls .who smoked more than forty
cigarettes per week.
Fewer parents approved of their children smoking in 1980/81 than in 1970.
Parental influence on smoking "appears" to be declining. Peer pressure is
very important - six out of ten of all those who said they had ever smoked
o.btsi~ed their first cigarette from a friend. This is a major factor in the
decision to smoke. In addition, there is the contemporary ethos which
promotes equality and liberation and which may confirm smokin~ as part of
this !ibera~io~ process of youth, in psrtlcular of young women.
The study findings reiterate the need for preventive measures directed at
younger school-going children. In addition, there is a need for new strate-
gies and approaches which are more closely attuned to the values of a youth
culture. Girls in particular should be a special target group for prevent-
ive measures with a strong emphasis being placed on the antl-social, person-
al hygiene, impairment of sporting performance and financial aspects of the
smoking habit.
T108351418
77!
Joint National Media Research Survey Irish Marketing Surveys Limited,
1973-1982. Health Education Board Fact Sheets On Smoking, 1984.
O'Connor J. A national study of smoking and drinking behaviour and
attitudes: social and cultural influences.
Health Educat{on
Bureau/Gill and Macmillan, [984 (to be published).
O'Rourke A, Wilson-Davis K, Gough C. Smoking, drugs and alcohol.
Irish J Medical Sociology 1971: 140(5):230.
Merzdorf J, Reuter U, Welsh G. First comparative study on smoking
trends in the E.E.C. between 1960 and 1980. Report EUR. 7907 DE, 1982.
T108351419
773
IN BIGBE~ I~I~II~IO~S OF L~I~ IN RIGEEIA
B.O. Onadeko, M.D. (D.ublin)~ F.R.C.P.(Lond.), F.R.C.P.(Edin.)
A.A. Awotedu, M.B.B.S.(Ibadan), F.M.C.P.(NIE.)
Dept. of ~dicine
M.O. Onadeko, M.B.B.S. (Ibadan), M.P.B. (Boward), F.M.CoP. (Nig.)
Dept. of Preventive Medicine and Social Medicine
University College llospital
Ibadan, Nigeria
INTRODUCTION
Smoking, the 'man made epidemic' exists in almost every country in the world
today, and wherever it does, it is accompanied sooner or later by a host of
diseases and conditions that threaten health and shorten life.
In the last two decades, scientists, (i-5), health workers, legislators and
interested members of the general public have increasingly taken steps to
curb this plague that humanity has brought upon itself.
Cigarette smoking is increasing in the developing countries. The Third
World is a particular target of unscrupulous advertising since there are no
restrictions on content or media. In most of the developing countries,
smoking is associated with prestige and sophistication.
Few reports on smoking habits of students in institutions in Africa have
appeared in the literature (6,7,8). Arya and Bennett (6) reported that
31.5% and 7% respectively of male and female African students in Uganda
smoked. Elegbeleye and Femi-Pearse (8) observed in their own survey that
72% of Nigerian male students and 22% o~ female students were smokers. How-
ever, in an earlier survey carried out in 1973 by Femi-Pearse, Adeniyi and
Oke (7), an incidence of 2.4% was given for Nigerian female students.
In Nigeria, £n the last decade, the significant increase in income and
affluence due to the sudden oil boom, coupled with increased efforts in
advertising by tobacco companies, has resulted in an increase in the smoking
habits of young people, especially post-secondary students.
The survey carried out by Elegbeleye and Femi-Pearse (8) focussed attention
mainly on secondary school children and a small number of medical students.
That study, as they stated, was meant only to provide guidelines for further
studies.
The aim of this survey is to determine the present status of cigarette
smoking among post-secondary school students and to make suggestions for
smoking control in Nigeria.
T108351420
774
Questionnaires were distributed to male and female students in two Universi-
ties, two Polytechnics, two Colleges of Education and two Schools of Nurs-
ing. The contents were explained personally to the students. In order to
obtain their cooperation, and to stress the confidentiality of the study, no
name was inserted in the forms. The assistance of lecturers in the i~stit~r-
tlons selected was sought in distributing the questionnaires. Students were
instructed to return completed questionnaires to the lecturers concerned.
In the case of medical students, questionnaires were distributed directly at
the end of lectures and collected on the spot. The questionnaires were then
collated and analysed.
RESIIL~S
Three thousand questionnaires were distributed. A total of 2,317 (1,480
male and 837 female) students returned completed questionnaires:
Unlversities - 1,068 males and 450 females; Polytechnics - 240 males and 40
females; Schools of Nursing - 8 males and 283 females; and Colleges of
Education - 164 males and 64 females.
Incidence o£ Smoking
Table 1 shows the summary of overall incidence of smoking among the
students. Four hundred and thirty six (29.5%) of male students and 174
(20.7%) of female students were smokers. The result is statistically
significant (×2 = 20.8; P < 0.001). A further analysis reveals that 24.7%
and 23.5% of male and female students respectively in the university smoked,
while 21.2% and 30% of males and females respectively smoked in the
polytechnics. The highest incidence of smoking was observed among students
from Colleges of Education, i.e. 75% and 51.6% of males and females
respectively. (Table 2)
TABLE 1. OVERALL PREVALENCE OF SMOKING AMONG
POST SECONDARY STUDENTS IN NIGERIA
Ma I e
No. %
Smokers 436 29.5
Non-smokers 1044 70.5
Total 1480 I00.0
Female
l~o. %
174 20.7
663 79.3
837 100.0
20.8 P < O.OOl
T108.351421
TABLE 2. PREVALEI~CE OF SHOKI~ IN KELAT~ON TO INSTITUTIONS
Smokers Non-smokers Total
No. Z l~o. ~ No.
University:
Male 254 (24.7) 814 (75,3)
1068 (I00)
Female 106 (23.5) 344 (76.5)
450 (I00)
Polytechn£c:
Male 51 (21.2) 189 (78.8)
240 (lO0)
Female 12 (30.0) 28 (70.0)
40 (i00)
Nursing School:
Male 8 (i00.0) - - 8
(I00)
Female 23 ( 8.1) 260 (91.9)
283 (100)
College of Education:
Male 123 (75.0) 41 (25.0)
164 (I00)
Female 33 (51.6) 31 (48.4) 64
(100)
775
TABLE 3. NUMBER AND % OF SMOKERS PER AGE GROUP
Age Group Hale Female
(years) No. % No. %
15 - 20 58 13.2 76 43.6
21 - 30 360 82.5 96 55.2
31 - 40 16 3.6 2 1.2
41+ 2 0.7 - -
Total 436 I00.0 174 100.0
• ~e group of makers
Table 3 shows the number and percentage of smokers in relation to age
groups. Eighty-three percent and 55% of male and female smokers respective-
ly belonged to the 21-30 age group.
T108351422
776
TABLE 4. QUANTITY OF CIGARETTES SMOKED
Quantity Male Female
Per Day Ho. % ~o.
Under 5 134 30.7 99 50.8
5 - I0 220 50.5 47 27.0
II - 20 38 8.7 18 10.3
20+ 44 10.l I0 5.9
Total 436 i00.0 174 I00.0
×2 = 40.92 P < 0.001
(3)
Quantity of cigarettes
Table 4 reveals that 81,2% and 57.8% of male and female students smoked not
more than I0 cigarettes per day. Fifty percent of male students smoked 5-10
cigarettes per day, while 50% of females smoked under 5 cigarettes per day.
This is found to be statistically significant (X2 = 40.92, P < 0.001).
TABLE 5. DURATION OF SMOKING
Duration Male
(years) No. %
Female
No. %
Under 1 37 8.5 49
I - 5 173 39.7 84
6 - I0 132 30.3 24
Over I0 94 21.5 17
28.4
48.2
13.7
9.7
Total 436 100.0
174 i00.0
X 2 = 59.039 P < 0o001
(3)
Duratlo~ of smoki~
Seventy-nine point five percent and 9.0% of male and female students respec-
tively had been smoking for a period of one to ten years (Table 5). Forty-
eight percent and 76% of male and female students had been smoking for a
• " ys~s is statlst~ca y
cant (X2 = 59.039; P < O.OOl). Further analysis of the questionnaires from
the students in the Universlt[es revealed that 33% and 9% of male and female
students started smoking in high school.
T108351423
777
Reasoo for
Table 6 illustrates the reasons given by students for s~oking. It is
relevant to point out that the influence of parents has been mlni~ml a~ong
Nigerians. The largest group of smokers was influenced to start smoking by
friends and by nervousness. The role of teachers is of no significance in
this survey.
TABLE 6. REASON FOR SMOKING
Reason Given Males Female
No. % No. %
One or both parents smoked 32 7.3 7 4,0
Friends 77 17.7 37 21.3
To be sociable 65 14.9 21 12.0
Nervousness 127 29.1 36 20.7
To forget problems 52 11,9 33 19.0
Teachers smoke ....
No reason 83 19,1 40 23.0
Total 436 I00.0 174 I00.0
X2 = 12.412
(5)
significant P e 0.05
Unpleasant effect of s~oking
It is of interest that 78% and 75% of male and female smokers were aware of
the dangers of smoking. Forty-seven percent of male and 32% of female
smokers had experienced some form of symptoms. These included cough~ short-
ness of breath, chest pain and abdominal discomfort, Despite the awareness
of complications, 58% and 72% of male and female smokers would not be
deterred from smoking,
TABLE 7.
Methods
METHODS OF DISSUADING SCHOOL CHILDREN FROM SMOKING
Males Females
Smokers Non-Smokers
No. No.
Bealth Education 276 714
Mass Media 191 141
Parents (by example) 113 q4
Legislation 109 2&
Total 689 1073
Smokers
No.
90
10
4
I10
Non-Smokers
No.
500
44
17
593
Most students gave ~ore than one reply.
T108351424
778
S~ok~mg control
~hirty-slx percent of male and female smokers were in favour of legislation,
while 63% and 60% of male and female non-s~okers favour legislation.
Fifty-four percent and 70% of male and female smokers would support banning
s~okin~ from ~ubllc places. Similarly, 75% amd 74% of male and female
smokers agreed with the suggestion that a warning should be written on
cigarette packets.
Seventy-two percent of male and female smokers, surprisingly, would support
dissuading school children from smoking. The methods advocated are shown in
Table 7.
DISCUSSION
This survey reveals that cigarette smoking among post-secondary students in
Nigeria is increasing. It is the largest survey carried out so far in
Nigeria, and perhaps in Africa, judging by the number of students that
participated. The prevalence of 72% and 22% for male and female students
respectively in the survey of 196 male and 36 female medical students
carried out by Elegbeleye and Femi-Pearse (8) cannot be representative,
because of the small sampling involved. Conversely, the figure of 30% and
21% for male and female students respectively in this survey is more realis-
tic as it is derived from a much larger sample and from a cross-section of
post-secondary institutions in Nigeria. In an earlier survey by Arya and
Bennett (6), a prevalence of 31.5% and 7% was obtained for African male and
female students in Uganda. The result shows some similarity to our own
study. Furthermore, it is the general view from the World Health Organiza-
tion Survey on Smoking that it is rare to find, in Asia, Africa and Oceania,
more than 40% regular smokers among males and more than 30% among females
(9). The results from the present survey confirm the fact that the preva-
lence of smoking is still lower than that recorded for most European and
North American countries.
It is observed from this survey that the majority of smokers are light
smokers, with less than 25% exceeding I0 cigarettes per day and with only
about 50% smokin8 for more than 5 years. This is encouraging, in a way,
because it m~y still be feasible to convince a good proportion of these
students to stop ~moking or to cut ~o~n on the number of cigarettes.
The reason given for smoking is, in general, similar to what is obtained in
other surveys, except for a few slgnifica~t departures. In most parts of
Europe and America (10), parental example is an important factor. In
contrast, in this survey and two other surveys from Africa (6,8), parental
inf|uence is not significanc. The influence of friends and the environment
play a major role. This difference is understandable, because many of these
students are first " ". . •
t-~ca~me many did not smoke. This revelation will support the assump-
tion that smoking increases with education income, and edoptlon of western
culture. '
The findings in this survey reveal that a significant proportion of smokers
will approve of some measures to control smoking, espec~ally among high
T108351425
779
school children. However, it is rather unfortunate that no impact has been
made on s~oking control in ~any countries in Africa. This might be due
either to the financial gains some of the countries get, or to apathy and
lack of interest on the part of health personnel. This state of affairs has
further encouraged the tobacco industries to shift their emphasis on adver-
tising to the developing world. Wickstrom (ii) found heavy tobacco adver-
tlsimg and an efficient distribution network in Kenya and Ghana, more often
with the connivance of the government. It is also known that the tar and
nicotine yields of most brands of cigarettes in these countries are higher
than ~hose marketed by the parent companies in Europe and America. A
recent study by Awotedu et al. (12) on tar, nicotine and carbon monoxide
yields of some Nigerian cigarettes, revealed that the contents of all the 14
brands of cigarettes marketed in Nigeria had a tar content above 19 mg. A
similar observation was made on the nicotine content. This was also the
experience of Wickstrom (II) in Kenya.
In conclusion, this survey has shown an upward trend in the smoking habits
of Nigerian students in post-secondary institutions. It will now be neces-
sary for the government to introduce a smoking control policy in order to
guard the present and future generations from this potential epidemic. The
short term economic benefits will no doubt prove to be long term health dis-
advantages. Control measures, which should follow WHO smoking guidelines
(13), should include restrictions on advertising, banning of cigarette smok-
ing from all public places, a warning notice on cigarette packets, and
vigorous health education of its citizens, especially school children, on
the dangers to health from smoking.
ACKNOWLEDGEHENT
The authors wish to express their gratitude to the authorities of the
Universities of Ibadan and Ire; Oyo State and Ogun State Polytechnics;
Colleges of Education at llesha and ljebu-Ode; and the Schools of Nursing,
University College Hospital, Ibadan and Eleiyele, for their cooperation. The
assistance of Miss Lola Marcus of the Department of Medicine throughout the
period of the survey is sincerely acknowledged.
Doll R, Hill AB. A study of the aetiology of carcinoma of the lung.
Br Mad J 1952; II: 1271.
Doll R, Hill AB. Hortality in relation to smoking. I0 years observa-
tion of British doctors. Br Mad J 1964; I: 1399.
related social class and parental smoking habits. A~ J Public Health
1961; 51: 1780.
Hausner JS. Smoking in medical students. A survey of attitudes,
information and smok[ng habits. Arch Environ Health 1966; 13: 51.
T108351426
5. Forest DN. Attitudes of undergraduate women to smoking. Psychol ~ep
1966; 19: 83.
6. Acya OP, Bennett FJ. Smoking among university students in Uganda. East
Air l~ed J 1969; 47:
7. Femi-Fearse D~ A~en£yi A, Oke AB. Respiratory syml=toms and their
relatlonship to cigarette smoking, dusty occupations and domestic air
pollution; studies in a random sample of an urban African population.
Nest Aft Ned J 1973; 22: 57.
8. Elegbeleye OO, Femi-Pearse D. Incidence and variables contibuting to
the onset of cigarette smoking among secondary school and medical
students in Lagos. Brit J Prey Soc Med 1976; 30: 66.
9. World Health Organization. Tobacco smoking in She world. WHO Chronlcle
1979; 33(3): 94.
I0. Bewley BR, Bland JM, Harris R. Factors associated with starting of
cigarette smoking by primary school children. Brit J Prey Soc Med 1974;
28: 37.
II. Wickstrom BO. Cigarette marketing and the Third World.
Sweden: University of Gottenburg, 1979.
Gottenburg~
12. Awotedu AA, Higenbottam TW, Onadeko BO. Tar, nicotine and carbon
monoxide yields of some Nigerian cigarettes. J Epidemlol Community
Health 1983; 37: 218.
13. World Health Organization. Controlling the smoking epidemic. Geneva,
Switzerland: WHO, 1979. WHO Technical Report Series No 636.
TI08351427
S~3KL~IG TI~RDS I~ I~BR~E~ BAY, (R~fARIO wrc~ SCHOOL ~
Richard S. Stanwick, M.D.
Vern Sawatzky, M.D.
David A. Legge, M.D.
Depts. of Social and Preventive Medicine and Pediatrics
University of Manitoba
Winnipeg, Manitoba, Canada R3T 2N2
781
Ih~E~ODUCTION
In Canada, surveys from the early to mid-seventles (1,2) indicated that
cigarette smoking among young Canadians was increasing, especially for
females. In Winnipeg, the prevalence of smoking among high school boys was
44% in 1960, reaching 46% in 1968 and dropping to 25% by 1980 (3). For high
school girls, the prevalence rate was 28% in 1960, also peaking in 1968 at
41%, and declining to 34% by 1980 (3).
A major limitation of Morlson's study, as acknowledged by the author, was a
diminution of the response rate from 91.5% in 1960 to only 63.4% in 1980.
That non-respondents might represent a disproportionate number of cigarette
smokers is supported by other figures published for Canada (4) citing a
smoking frequency for mid-teenage girls of 41% and for mid-teenage boys 35%
(regular smoking was defined as more than one cigarette per week).
The present study was performed to determine more current prevalence rates
of teenage smoking among high school students and to obtain a better
response rate than those achieved in other recent studies.
METHODS
A possible reason for a reduced response rate in the Winnipeg based studies
has been the repeated use of the students for many different surveys. The
present study was conducted in an area which has not been subjected to such
intensive academic scrutiny - the Thunder B=y School Division. An addition-
al attraction of this locale is that Ontario students have a curriculum
which goes to grade XlII, so students will range in age from 14 to 19 years
of a~e. With the approval of the superintendent and principal, the teachers
at the institution were introduced to the study and the questionnaire during
an in-service meeting.
T108351428
The questionnaire was administered to all classes on the morning of February
17th, 1982. Anonymity was guaranteed and the students were advised that
tl~ey had the right to refuse to answer any or al| of the questions posed.
Tl~e students were asked to identify their sex, age, age at which they smoked
tl~eir first cigarette, whether they had smoked in the last four weeks, the
quantity they smoked in the last week if they dld, the age at ~hich they
beca~ regular smokers, and finally whether their parents smoked (5).
Statistical analysis was performed using the Chi-square test
with
significance set at the p < .05 level.
R~OLTS
Of the 973 students in class at the time of the study, 947 completed the
questionnaire for a response rate of 97.7%. However, given an average
absenteeism rate of 5% for any given day in February, the response rate for
the population at risk was adjusted downward to 92.7%. The mean age of the
population under study was 15.9 years of age. Fifty-three percent of the
population was male. Aggregate socio-demographic characteristics provided
by .the school indicated that the students came from all social classes.
In considering smoking frequencies, the trends were differentiated on the
basis of sex. For males, 19% of 14 year olds, 27% of 15 year olds, 35% of
16 year olds, 30% of 17 year olds, 28% of 18 year olds and 20% of 19 year
olds smoked more than one cigarette per week. For high school females, 31%
of 14 year olds, 34% of 15 year olds, 47% of 16 year olds, 48% of 17 year
olds, 45% of 18 year olds and 44% of 19 year olds smoked more than one
cigarette a week.
When the number of cigarettes smoked was compared for males and females,
females tended to be smoking more cigarettes, however this trend did not
reach statistical significance (p = .44). It is of note that over 40% of
smoking h~gh school males and females consumed more than two packs of
cigarettes per week.
While boys tended to experiment with cigarettes at a slightly earlier age,
the proportion of males and females who had experimented with cigarettes was
the sa~e by Ii years of age. A significant finding was that 37.8% of males
had never tried smoking, while only 25.!% of fe~les had not (p < .001).
The effects of parental smoking on high school students' smoking patterns
were examined.. No significant differences between the proportion of male
and female h~gh school s~udents who smoked were noted when neither parent
smoked or if the father smoked. However,when the mother smoked, 51.7% of
their female offspring d~d also, while only 21.2X of boys did so.
Similarly, when both parents smoked, 48.5% of glr[$ fro~ these families
smoked whi|e only 32.0% of boys dld so (approximating the rate in families
where the father only smoked). For both sexes, parental smoking was signi-
15th years (r = .46; p < .00}). After the age of 15, parental effects
rapidly diminished.
T108351429
783
DISCUSSION
The frequency of regular cigarette smoking amon~ males was slightly greater,
at 28.2%, than Morison's 1980 figure of 25%, but significantly lower than
the 35% cited by the WHO International Clearing House on Smoking and
Health. However, the proportion of female high school students smoking in
Thunder Bay was identical to the figure cited for Canada by the World Health
Organization - 41%, and was the same as the figure Horison found in the
Winnipeg school system in 1968. On examining the trends, cigarette smoking
appears to peak at 16 years of age for males, with 35% smoking, followed by
a drop off by age 19 to a level similar to that recorded for 14 year old
boys - 20%. This rise and fall phenomenon is not noted for females. More
young women were smoking at age 14 (12% more than boys), and attained a much
higher level by age 16 - 47%, and the rate, rather than dropping off,
maintained a plateau. Forty-four percent of 19 year old girls smoked.
The survey reaffirms the disturbingly high frequency with which teenage
girls smoke. One possible explanation for more females smoking is their
higher rate of experimentation with smoking.
The persistence of high rates of female smoking in the later teens could be
due to a form of non-random attrition from the sample. That is, male
smokers who are lower academic achievers drop out of school to pursue
careers as non-skilled laborers. As a result, one could have an artificial
drop in the rate of smoking among boys. However, given the recessionary
times in 1982, the need for such individuals in the job market was negligi-
ble. School records did not show a greater proportion of males dropping out
when it became possible to do so.
A limitation of the study was the failure to address an important factor in
students~ decision to smoke - scholastic sttalnment. As well, the study was
a cross-sectional survey and the smoking patterns reported should be
interpreted cautiously.
If the results are indicative of actual trends, Canada is facing a major
public health problem. Over a third of Canadian infants, when smoking
histories are bein~ recorded,will have to be considered to have been regular
smokers even before they were born.
ACK~O~F-.DGEHEtCI'S
The superintendent, principal, teachers and students of Thunder Bay High
School are thanked for their cooperation and enthusiastic participation in
the study.
T108351430
Health and Welfare Canada. Smoking habits of Canadians, 1965-1974.
Technical Report Series, No. l, 1976.
Hanley JA, Robinson JC. Cigarette smoking and the young: a national
survey. Can Med Assoc J 1976; 114:511-17.
Morison JB. Smoking habits of Winnipeg school students, 1960-80. Can
Med Assoc J 19B2; 126:153-154.
Masironi R, Roy L. (International Clearing Rouse on Smoking and Health,
World Health Organization, Geneva): Cigarette smoking in young age
groups: geographic prevalence. Heart Beat 1982 June; 2:3. Published
by The International Society and Federation of Cardiology, Geneva,
Switzerland.
London School of Hygiene and Tropical Medicine. The smoking habits of
school children. Br J Prey Soc Med 1959; 13:1-4.
T108351431
785
~ S~OKIIWI B~BITS OF NATIVE CANADIABS
Mmrgaret P. Thomson, R.N.
Manitoba Lung Association
Winnipeg, Manitoba R3A IP6
Canada
II~TRODUCTION
Tobacco is a native American plant which, since time immemorial, has been
widely used by Natives for medicinal and ceremonial purposes, as well as
being smoked for pleasure. This article reviews recent data on the smoking
habits of Canadian Indians, Inuit and Metis, who together comprise about 5%
of the Canadian population.
REVIEW OF PUBLISHED DATA
The main source of information about smoking in Canada is the Smoking Habits
of Canadians Survey, published every two years. Analyses are by sex, age
group and regions, not by ethnic groups. This means that the only way to
estimate Natives' smoking habits is to look at the regions where they form a
high percentage of the population, such as the Yukon and Northwest Territo-
ries. Unfortunately the Yukon and Northwest Territories and persons living
on Indian Reserves are excluded from this survey.
The Nutrition Canada survey in 1970-72 (I) is more informative. Fifty-nine
point five percent of Indian men and 56.4% of Indian women smoked at a time
when 43% of non-Indian men and 34.0% of non-Indian women smoked.
A community survey in 1973-74 of 1,055 Indian residents of remote and
isolated settlements near Sioux Lookout in Northern Ontario (2), found that
48.% of those over 15 were smokers, compared with 38% in the Canadian popula-
tion. The same trends were present in both sexes and all age groups. A
lower level of education was associated with a higher level of smoking, and
this association persisted after age adjusting. The highest prevalence,
found in 15-19 year olds, was 59.2%.
Another way to look at smoking habits is to analyze the type of cigarettes
sold. Based on 1980 sales records of the Hudson's Bay Company in the
Central Attic (personal communication - J.B. Clarke, Hudson's Bay Co.,
Correspondence to: Margaret P. Thomson, R.N., Manitoba Lung Association,
629 McDermot Avenue, Winnipeg, Manitoba, Canada R3A IP6.
Ti08351432
Winnipeg), 45% of cigarettes sold had over 17 mg of tar and 44% were in the
14-17 mg range. The Smoking Habits of Canadians Survey (3) reported that
22% of Canadians smoked cigarettes with more than 17 mg of tar, and 44% were
within the 14-17 m~ range. This suggests that the smoking habits of Central
Arctic residents, who are predominantly Inuit, differ substant~ally from
Canadians in general, at least with respect to exposure to tar.
DISCUSSION
The health of Canadian Natives is, by all measures, poorer than that of
Canadians generally. In the Province of Mmnitoba the death rates for
Indians from age 1-4 and 20-24 years are four times higher than for the
general population, and infant mortality is double the Canadian average (4).
Smoking is only one of the many causes of this situation, which include
inadequate housing, water and sewage systems, lack of potential for economic
development and the isolation of small communities, which lack immediate
access to comprehensive health services (5).
There is no doubt that health was highly valued by the Indians who signed
the treaties. During the negotiations prior to the signing of Treaty Number
6, the Indians' amendments included "a free supply of medicines" (6). If
the promises made in the treaties are interpreted today in the spirit in
which they were written, this is a promise to provide the best available
health care, which today implies a comprehensive education program on
smoking.
The data on Natives' smoking habits is sparse but it all points in the same
direction. Natives are heavy smokers and more detailed information is
urgently needed if health care planners are to intervene effectively.
The Northwest Territories Department of Health is now completing a study of
tobacco use by school age children (7). The questionnaire, distributed to
grades 3-12. covers smoking prevalence and age of onset, source of
cigarettes, parental, sibling and peer group smoking behaviour and use of
smokeless tobacco. Two questions measure knowledge of the health effects of
smoking. This survey is the first large scale study in Canada to produce
data on the smoking habits of Indians, Inuit and Metis, and the results will
be used to guide curriculum planners.
CONCLUSION
Among the priorities of Native people themselves, smoking is unlikely to be
seen as important compared with the need for better housing and clean water,
but in the light of present knowledge about ~ts adverse health effects, it
can no longer be ignored. The direct effect on the individual smoker is
only a part of the
aggravates respiratory d~sease. Cigarette-caused fires are commonplace.
Smoking in pregnancy deserves special attention, because of its contribution
to infant mortality and because the number of ~atives entering their
child-bearing years is growing rapidly. Between 1976 and 1986 the Native
young adult population (age 14 to 29) is expected to increase by 35% from
T108351433
787
86,000 to 116,500 (5). These are the people who will be passing on their
health habits to the next generation, which is unlikely to be a generation
of non-smokers.
The Canadian Government has spent at least half a m~llion dollars so far on
'Time to Quit", a mass media self-help smoking cessation program, for which
the pilot program was conducted in l~anitoba in 1982, st a time when smoking
rates in Canada were already declining steadily. As far as I am able to
ascertain there are no special smoking education programs for Native people
even though they smoke much more heavily than urban whites, the target group
for Time to Quit.
The Government has already stated, when listing the causes of poor health
among Natives, that this complexity of factors generates unique needs which
can only be met by multiple inter-disciplinary approaches along with active
native participation (4).
Perhaps it is "Time to Start".
I. Information Canada. Nutrition, a national priority.
Information Canada, 1973.
Ottawa, Ontario:
2. Kue Young T. Self-perceived and clinically assessed health status of
Indians in Northwestern Ontario: analysis of a health survey. Can J
Public Health 1982; 73: 272-277.
3. Health and Welfare Canada. Smoking Habits of Canadians 1965 to 1979.
Ottawa, Ontario: Health and Welfare Canada, Health Promotion Director-
ate, Health Services and Promotion Branch, 1980 Dec. (Technical Report
Series No. 9).
Department o~ Indian and Inuit Affairs. An overview of demographic,
social and economic conditions among Manitoba's registered Indian popu-
lation. Ottawa, Ontario: Dept. of Indian and Inui~ Affairs, Research
Branch, 1980.
Department of Indian and Northern Development and Statistics Canada.
Indian demographic workshop: implications for policy and planning.
Ottawa, Ontario: 1980 June 20.
Taylor JL. The spirit of Alberta Indian treaties. In: Price R, ed. Two
views on the meaning of Treaties Six and Seven. Montreal: Institute for
Reearch on Public Policy, 1979.
~ealth and Welfare Canada and Government of the Northwest Territories.
Tobacco use among students in the Northwest Territories, 1983. Ottawa,
Ontario: Health and Welfare Canada, 1983.
T108351434
SI,~II~ mzHAVIOq~ IN ~ It~'H~RLA~ S ~ 1958-1982
Jan van Reek
Department of Medical Sociology
University of Limberg
P.O. Box 616, 6200 MD Maastricht
The Netherlands
I~TI~ODUCTION
In the Netherlands anti-smoking information has been distributed and the
smoking behaviour of adults investigated since the late fifties. In 1957,
the Minister of Social Affairs and Public Health drew attention to the
dangers of smoking in connection with lung cancer. Distribution of anti-
smoking information via mass media and schools started at the end of 1963.
At first feelings of anxiety were played upon in the anti-smoking
campaigns. Later on other methods were applied too (I). In 1958, a survey
of adult smoking behaviour was conducted by Gadourek (2). After that a
survey tradition came into being. Nowadays large surveys are conducted
every year. The surveys give no direct information about the effect
anti-smoking information. Hypotheses about this can be formulated, indeed,
referring to changes in smoking behaviour and the attitude towards smoking.
A problem, when interpreting time-trends, is that other socio-cultural
influences, different from anti-smoking information, also affect smoking
behaviour, of which female emancipation is the most important.
MATERIAL AND I~THODS
Twenty-three representative surveys, giving a total of 322,295 respondents,
were used for this paper. From these surveys "Risky Habits" (1958) and
SWOAD (1976) were governmental projects; "Products and People" (1963), TON
(1967 and 1970) and NOP (1972-1979) were conducted for the press media and
NIPO (1970-1982) for the Netherlands Foundation on Public Health and
Smoking. Polling and interviewing techniques were of suff[cient quality.
Owing to differences ~n questioning, pollinK techniques and interview refus-
als, the validity of the observed trends in the percem~age of smokers seems
to be problematic. Why the information is still valid, will be published
elsewhe=e (3). In the period 1947-I750 RIPO conducted some representative
surveys of smoking. Unfortunately short reports remained only. One result
from a survey among males of 23 years and over will be used in this paper.
The consumption of cigarettes could be 6alculated for 1958, 1972 and 1981.
A vslidation of the consumption of cigarettes to the pro4uction figures
sho~ed an underreporting of respectively O, 23 and 32 per cent. Under-
reporting was roughly corrected, assuming an equal underreporting per
category.
T108351435
The percentage of former smokers could be calculated for 1958, 1972 and
1982. In a cohort analysis of the percentage of present, former and uon-
smokers in the period of 1958-1982, the percentage of r~n-smokers appeared
to increase enormously regarding some cohorts from 1972 to 1982. The lower
mortality of non-smokers can hardly explain this. Also the percentage of
former smokers, who have stopped more than ten years ago, was low in 1982.
Many might have forgotten their former smoking behaviour. For 1982, the
percentage of non-smokers was calculated by means of the percentage of non-
smokers among persons of 15-34 years of age in 1982 and the percentage of
non-smokers among persons of 25 years and over in 1972. The percentage of
former smokers in 1982 was I00 minus the percentage of present smokers minus
the percentage of non-smokers in 1982.
RESULTS
Percentage o£ smokers
The trends in the period 1958-1982 are shown by means of eight selected
surveys in Table i. Among males there is a decrease in the percentage of
smokers from 90% in 1958 to 41% in 1982. The decrease is exponential. In
the period of 1958-1970, the decrease is 1% per year and, later on, 2% per
year. Among females an increase from 29% in 1958 to 42% in 1970 was
followed by a decrease to 33% in 1982.
TABLE I.
PERCENTAGE OF SMOKERS BY AGE AND SEX
IN THE NETHERLANDS FROM 1958-1982.
1958" 1963 1967 1970 1975 1979 1982
males:
15-19 - - 58 55 46 29 18
20-34 91 78 79 77 68 56 45
35-49 91 85 80 77 69 58 44
50-64 89 81 82 78 68 61 45
65+ 88 76 83 74 66 57 43
all a~es 90 82 78 75 66 52 41
females:
15-19 - - 57 57 48 39 27
20-34 46 45 5.8 57 58 52 45
35-49 32 38 46 48 47 40 36
50-64 18 20 26 27 29 30 27
65+ 5 3 13 13 12 13 13
all ages 29 32 42 42 40 38 33
age groups for 1958: 21-40, 41-50, 51-70, 71+
T108351436
Percenta[~es of fo~mer s~okers ~nd nou-s~okers
The trends in the period of 1958-1982 are calculated by means of the results
of three surveys and presented in Table 2. Among males, the percentages of
former smokers and non-smokers increased markedly. The large increase in
the percentage of former smokers among females is remarkable.
TABLE 2.
PERCENTAGES OF SMOKERS, FOP~MER
SMOKERS AND NON-SMOKEP~ BY SEX
AMONG ADULTS.
1958 1972 1982
males:
smoker
former smoker
non-smoker
90 68 41
6 18 31"
4 14 28*
females:
smoker
former smoker
non-smoker
29 40 33
6 14 22*
65 46 45*
corrected percentages
Consumption of tobacco
According to an estimation based on the tobacco excise-duty registration,
the yearly consumption of tobacco increased from 2.3 kg in 1958 to 2.8 kg in
1981 per head of the population. There was a similar increase for the
consumption of cigarettes. This trend differed according to sex. The
consumption of cigarettes slightly ~ncreased among males and strongly
increased among females (Table 3).
TABLE 3. DALLY CONSUMPTION OF CIGARETTES,
PER ADULT SMOKER OF CIG~TTES,
IN GRAMMES OF TOBACCO.
1958 1972 1981
males 18 20* 23*
females 8 12" 19"
corrected for underreporting.
T108351437
Socio-cultural influences on smoking behavlour
The decrease in the percentage of smokers among males and the increase in
the percentage of former smokers a~ong raales and females from the late
fifties onwards may have been influenced strongly by antl-smoking informa-
tion. In support of this hypothesis, half the former s:okers in the survey
SWOAD-1976 declared that they had stopped smoking for reasons of health.
The decreased differences in the percentage of smokers and the level of con-
sumption by sex is a way of female emancipation. This influence has an
opposite effect to the anti-smoking information, resulting in the fluctua-
tion in the percentage of smokers among females.
Analysis by social class, education, urbanisation and religion
In 1958, there was no significant difference by level of education among
males (Table 4). In 1967, a gradient by social class and education
originated that continued to be relatively stable. Among females of 35-49
and 50+ years of age a reverse gradient was found by education in 1958:
females of higher education smoked more in 1958. A reversal of this
gradient took place among those of 35-49 years of age in the period of
1958-1979.
It is understandable that the decrease in the percentage of smokers started
earlier among higher educated than among lower educated males, considering
the differences in knowledge about the harmful effects of smoking. Later on
the percentage of smokers also decreased strongly among males of lower
education. Then new norms in smoking may have developed, in which the
mechanism of normative control (4) lead to a general trend of anti-smoking.
Mimicking males in the labour situation is mentioned as a reason for the
high percentage of smokers among females of higher education in cities (5).
This effect has decreased, which the reversal of the gradient by education
among females of 35-49 years of age shows most distinctly.
The lower percentage of smokers among Protestants indicates a third socio-
cultural influence on the smoking beh~viour: puritan norms. There ~ay be a
stronger rejection of smoking as "worldly behaviour" for females.
The rank of importance of the factors related to the percentage of smokers
can be estimated by ~eans of logistic regression (6). The high rank
orders of sex and age are a result of the high prevalence of smokers among
males and young females compared to older females, which indicates the
traditional sex-role among smokers. The change by the year of survey is
next in the rank order. Religion, social class and urbanisation are
significantly related to the percentage of smokers, but remove considerably
less chi-square. The low rank number of social class is remarkable.
T108351438
SMO~ I~_~UAVIO~R IN THE h-ETHERLANDS
793
TABLE 4. DIFFERENCES IN THE PERCENTAGES OF SMOKEP~B BY SFL( AND AGE FOR
SOCIAL CLASS~ EDUCATION, URBANISATION A~D RELIGION.
males females
20-34 35-49 50+ 20-34 35-49 50+
*social class (lower minus higher)
1967 6 9 5 -4 0 -8
1972 4 8 6 5 3 -4
1977 6 ii 7 12 8 -7
1982 8 8 3 9 6 0
education (only primary school minus further education)
~1958 -I I -7 6 -8 -8
1967 13 9 4 -i -I0 -17
1970 5 7 7 2 -6 -12
1975 12 7 7 12 -2 -9
1977 12 i0 0 9 5 -8
1979 14 14 4 6 8 -9
urbanlsation (urban minus rural)
~1958 -5 0 -i -2 22 II
1967 -4 -7 0 12 18 13
1972 0 -3 0 6 7 8
1977 9 0 0 6 i0 6
1982 3 3 -I 2 4 4
religion (Protestant minus rest)
~1958 -13 -I -5 -7 -9 4
1967 3 1 -5 -9 -17 -15
1972 1 -4 -I0 -I0 -22 -9
1977 -2 -8 -l -14 -13 -14
1982 -2 -8 -6 -5 -3 -6
* social class: higher = well-to-do .and middle class
lower = lower and lowest income
age-groups for 1958: 21-40, 41-50, 51+
the reliability interval is usually 4 or 5%.
TI0835t439
794
TABLE 5.
ORDER OF IMPORTANCE OF FACTORS RELATED TO THE PERCENTAGE OF
SMOKERS IN THE PERIOD OF 1979-1981 (STEPWISE LOGISTIC REGRESSION)
estimated chi-square
remove dF
sex (male/female)
age(20-34/35-49/50+)
year (1967/1970/1977/1979/1981)
religion (Protestant/rest)
social class (well-to-do and middle class/
~ower and lowest incomes)
urbanisation (urban and rural)
4091 1
1286 2
758 1
317 1
89 1
41 1
(N = 52,310)
An analysis of time-trends in smoking behaviour based on secondary data has
considerable drawbacks. A follow-up on the individual level is impossible,
and the influence of short-term effects, such as specific antl-smoklng
campaigns or changes in tobacco excise-duties, cannot be estimated. It
would not be correct, however, to complain of the quality of data available,
as better material over a period of 25 years would have been very expensive.
Formulating hypotheses about the influence on smoking behav~our should be
done carefully. It cannot be suggested that the "true-blue" smokers will
always remain, as there is a growing rate of decrease among males 35 years
and over.
It is reasonable to conclude that anti-smoking information has caused a
decrease in smoking behaviour. Besides campaigns, it is the result of
adults advising youngsters, general practitioners advising patients, changed
norms about smoking behaviour, etc. Anti-smoking campaigns have an
initiating and sustaining role. Indication for this can be found in the
nearly constant level in the percentage of smoking males before the
campaigns (89% in 1950 and 90% in 1958) and the decrease in the percentage
of smoking males since the first campaign. Other soclo-cultural influences
on smoking behaviour (7) turn out to be female emancipation and puritan
norms.
~C~e present trends, it may be possible to form an impression about
future trends. In all age-groups the decrease is still lower among females
than among males, but the influence of female emancipation on smoking
behaviour has been achieved for the greater part. A continuing decrease in
the percentage of smokers among males and females is very likely. An
TI08351440
S~K.~ EEHAVIOUR IN TEE NET~S
795
accurate prediction is impossible owing to the changing rate o~ decrease and
the uncertainties about the different influences on smoking behaviour. A
favourable effect of the decrease in the percentage of s~okers is, in the
short run, an improve=ant in physical performance (8). In the long run, a
favourable influence on ~ortality can he e~pected, and especially in lung
cancer mortality (9).
Van Reek J. Pays Bas. 1907-1982: 75 ans de lutte anti-tabac. Int J
Health Educ 1982; News Section: 11-12.
Gadourek I. Riskante gewoonten en zorg voor eigen welzljn. Gronlngen:
Wolters-Noordhoff, 1963.
Van Reek J. Smoking behaviour in the Netherlands and the United
Kingdom: 1958-1982. Ray Epidemiol Santa Publlque (in press).
U.S. Dept. of Health and Numan Services. The health consequences of
smoking for women. A report of the Surgeon General. Rockville, Md.:
USDHHS, 1980: 327.
Gadourek I. Evaluatie voorlichting token.
827-830 and 836.
T Soc Geneesk 1965; 43:
BMDP, Statistical Software.
330-344.
LA: University of California Press, 1981:
Reeder LG. Sociocultural factors in the etiology of smoking behaviour:
an assessment. In: National Institute of Drug Abuse. Research on
smoking behavior. Washington: USDHEW, 1976: 186-200.
Hill D, Lacombe J, Refshauge JG. Smoking and impairment
performance. World Smoking and Health 1979; 4: 30-34.
Hakulinen T, Pukkula E. Future incidence of lung cancer: forecasts
based on hypothetical changes ~n the smoking habits of males. Int J
Epidemlol 1981; I0: 233-240.
TI08351441
CLOSING ADDRESS
T10,2.,351 ~,~1.2
797
SMOKING OR HEALTH ACTIVITIES: LESSOHS FROM TKE PAST~ ~MPL$CATIONS OF PRESENT
EXPERIENCE~ CHALLENGES FOR THE FUTURE
Look At The Future Through A Look At The Past)
N.C. Delarue~ M.D.
25 Donlea Drive
Toronto
Ontario M4G 2MI
Canada
As the papers presented at this conference have shown, there have been many
real successes in the campaign against cigarette smoking. Unfortunately,
warnings abound that things are not entirely as we might wish.
For example, a 1981 report by the U.S. Federal Trade Commission indicated
that 50% of Americans were unaware of the risks of smoking. In that report,
20% did not know about the risk of lung cancer and 30% did not appreciate
the fact that smoking was related to heart disease. In addition, millions
did not believe the quoted statistics or chose to ignore the risk. These
findings alone would be enough to shock us out of any sense of satisfac-
tion. The similarity to the situation concerning the current use of mari-
juana is a sobering consideration.
Indeed, when one considers the potential impending additional load of
marijuana-induced disease - as well as the problems anticipated in the
developing countries - mobilisation of resources can be considered to be
only beginning, as our activities are expanded more aggressively into the
required program areas.
The requirements have been recognised for ~ore than 20 years. The fact that
we have had little success in implementing the entire gamut of proposed
programs on a world-wide basis brings little credit to our ability to pursue
the necessary co-ordinated program.
HISTORICAL PERSPECTIVE
It was in 1962 that a handful of us met to plan a First World Congress on
Smoking and Health. Some of the key figures ~n those early days were Alton
Ochsner as President, and Richard Overholt, Charles Fletcher and Johannes
Clemmesen as early Vice-Presldents. Subsequently, McFarlane Burner of
Australia and Eduardo Caceres of Peru joined the group of Vice-Presidents as
international interests evolved. Many other important-people joined after-
wards in the planning process. ~en funding proved unequal to the task, the
American Cancer Society came to the rescue and ~ounted the First World
CJ~ence In New York in 1967.
TI08351443
798
As the Canadian representative in that group, I took the following tables
with me_ as a guide to the areas which should be covered in such a Congress.
They w~uld seem to be as relevant today as they were then.
Figure 1 emphasises the importance of the knowledge-attltude-behaviour
triad, adding an element of personal cormmitment to the simple information
transfer of traditional education.
FIGURE i. SMOKING OR HEALTH
FormallZ 'learned' behaviour*
Knowledge - no longer the educational end-point
Attitude - requires relevant information
Behaviour - based on exemplary re-enforcement
(* personal decision required)
Figure 2, depicting the facilitation-discussion equation, views the problems
faced by the smoker and is intended to emphasise the fact that one must deal
with all these factors s~multaneously if the desired result is to be
achieved.
FIGURE 2. INFLUENCES AFFECTING THE CIGARETTE SMOKING HABIT
A. Dissuasive Influences
The Social Environment
Behavioural Modification
Social unacceptability
Non-smoking exemplars
Institutional example
Counter - advertising
Government role
(legislation)
Voluntary agencies
(lobby)
Risk of passive smoking
(non-smoking behavioural
norm)
Public Education
Factual - risks of smoking
Relevance-specific target groups
Re-enforcement - exemplars
(community & inter-personal)
Personal (individualised)
assistance
The Smoking Withdrawal Clinic
Group support
Instruction in withdrawal
Bo
The Social Environment
Social acceptability
Smoklng exemplars
Advertising impact
Facilitating Influences
The Smokin$ Environment
Pleasure of smokin~
Relief from tension
Automatic smoking
("habi t uat ion")
"Addict ire" smoking
(ps>'¢hologlcal habituation)
T108351444
SF~KIN~ O~ ~F~L~: ~ISTORICAL PERSPEL~TI~E
799
The number of necessary programs seemed overwhelming, were all these
determining influences to he given the attention they deserved.
A. Programs Designed to Strengthen Dissuasive Influences
I. Provision of relevant information for selected target Groups
a) Disadvantages of smoking (or advantages of non-smoking) - children
b) Risks of smoking - adults
c) Expansion of exemplary influence - exemplars of note
2. Reinforcement techniques
a) Continuing reiteration of relevant information
b) Demonstration of non-smoking behavioural norm
- establishment of smoking areas: • buses, trains, planes
• restaurants, theatres, meeting places
• offices, factories, retail outlets
3. ProGrams for smokers who wish help in ~ivlng up their smoking habit
a) Smoking Withdrawal Centres - personalised assistance
b) Kits for personal use - individualised information
B. Programs Designed to Minimize Facilitating Influences
i. .~obb~in~ for legislative ban on advertising and promotion
a) Preleglslative influence at the community level
b) Legislative lobby at Provincial and Federal levels
2. Counter-Advertising Programs
a) Programs to stress the social acceptability (advantages) of non-
smoking.
b) Programs to emphasise the social unacceptability of smoking in
enclosed spaces (risk to others)
Obviously such a complicated approach would be feasible only if duplication
of effort could be avoided and wastage of resources terminated.
The experience that we have gained allows us to state with confidence that
antl-smoking programs can be mounted for children and adults alike; and that
these can be successfully implemented in the schools and in the media. The
carefully conceived and centrally co-ordinated Norwegian National Campaign
has involved legislative and educational measures. The disjointed North
American effort, largely without over-all direction or leadership, has
attempted to harness all components involved in behavioural change - all
have successes to report. From these studies certain reco==endations can be
unequivocally supported:
TI08351445
SO0
I) A total ban on co.~-ercial advertising and pro=orion.
A co-ordinated increase in public education in view of the
significant proportion of the population still ignorant of
the risks.
Widespread and on-going school programs.
4) Utilisation of prime-time television and radio coverage.
5) Provision at the community level of cessation programs on a
continuing repetitive basis. Adults who are aware of the
risk want to stop and need help in accomplishing their aim,
Those who do not succeed at first need the opportunity to
practise their new skills.
6) Social action programs which are effective in defining other
legislative needs and in pursuing them to a logical
conclusion.
The feasibility of a successful broad public attack on the problem is there
for all to see. The process must now go forward with something more than
the present lukewarm support a 'total' program is all too frequently given.
Popularlsation of the interagency movement then became the challenge of the
1970's. Co-operatlon in co-ordinated activities was offered but grudgingly
in the early days, but the urgency in accepting the principle behind this
movement became m~re and more apparent and there is now a far more harmoni-
ous and dedicated participation by all concerned. Governmental agencies
work in close liaison with the voluntary agencies, the school system is more
intelligently served by the pedagogical community in association with public
health and nursing specialists. Community groups are playing their role
frequently in a total community commitment involving the media, social
services, the medical profession, volunteers of all persuasions and church
groups. Not only communities but in some areas entire countries have become
enthusiastic proponents of the co-operative and co-ordinated approach.
The argument between those who have supported an approach based on behav-
ioural education, emphaslsing the social acceptability of the non-smoking
posture, and those who have emphasised the need for legislative restrictions
is being slowly resolved by a 'meeting of the minds'.
We have come to appreciate the fact that behavioural change in general
occurs primarily in generational interludes. It has been re¢ognised that
decisions cannot be imposed prior to public acceptance of the need, and it
is true that public decisions are best made on the_~&~s_~ consen-
sus and not as the result of confrontation. However - and this is the major
issue - when a need is recognised and accepted (i.e. public attitudes are
defined) action must be taken. The action may still be based on co-
operation but polarisation may have to become one of the principal vehicles
for change, once public recognition of the need brings with it public
support.
TI0835144.6
SHOEING OR EFALTit: HISTORICAL PERSFECTIVE
891
Those who favour legislative action contend that the two most effective
=easures designed to achieve changes of this type are:
I) Peer group pressure
2) Lobbying to stimulate necessary action.
Nowhere is this more clearly apparent than in the improve=ent in indoor
environmental quality, including the work place.
Emphasis is placed on the fact that resistance to change is a basic fact of
life on the social scene and in some instances this resistance has to be
overwhelmed if change is to result. Those of us who were initially con-
vinced that an educational approach, based on behavioural modification, was
the more attractive and potentially more effective avenue to pursue - on the
premise that a personal decision, voluntarily made, is far more effective
than one imposed by restrictive legislation - have been made 'believers' on
several scores:
I) Pressure on individuals in positions of power has been effect-
ire.
2) Taking the issue to the public has been productive.
3) Enlisting the help of the committed in demonstrating firm
support at the time of the decision-making process has produced
spectacular results.
Prevention through social action is feasible and practical and, even more
importantly, the process now has public approval. Municipal by-laws, for
example, are becoming effective deterrents as well as a constant reminder
that smoking is no longer a socially acceptable habit. In general, approxi-
mately 95% of the publ~c will uphold the law without finding out whether it
is legally enforcible or not. The fact that the industry reacts so bitterly
to the imposition of bans on advertisement and promotion merely reflects the
enormous value of removing this facilitating influence.
CHALLENGES FORT HE 1980'S
In posing challenges for the rest of the 1980's, a warning about the present
situation must be interjected.
The example of our own country point~ out the problem very clearly.
Undoubtedly progress is being made in Canada, albeit far more slowly than
desired. Some have become smug, demonstrating a tendency to think that they
are on the right track and that they can therefore concentrate on current
programs. As a result there is a lack of the initiative which might lead to
the creation or development of new ideas. We are still not covering all the
facets of that complex facilitatlon-dissuaslon equation and still not taking
advantage of the potential contributions of all members of interagency
councils.
We continue to pursue traditional activities or programs in which we feel
comfortable, despite the fact that we are about to be overwhelmed by the
TI0835144.7
802
Eq~KRtFE
potential impending spectre of marijuana-induced diseases and by the
predictable epidemic of disease in the Third World. Far from gaining
ground, we may find in the very near future that we are actually losing
ground, even if a few skirmishes have been won.
We cannot let our energies flag. Mobilisation of resources is just begin-
ning. An enormous resource of personnel is required, as well as a nmjor
increase in available funding, before these energies can be directed into
the sphere of programming where major new initiatives are required.
In the 1980's the interagency movement desperately needs bolstering. The
full implications of its possible failure have not been generally recognised
and certainly not universally accepted.
Personalities have threatened to turn our efforts into a 'political' storm.
Strong personalities do~ of course, demonstrate leadership abilities, and
innovative ideas tend to flow from them in a seemingly unending stream,
coupled with the energy and determination to pursue them diligently and
effectively. We simply cannot perform to our potential without this very
special type of personality, but unfortunately it is all too common to find
these important people mired in the quicksands of inactivity as they spar
with - and against - each other. This politic of 'greatness' must be
harnessed to our advantage and no longer allowed to hinder our progress.
Fortunately, every successful politician eventually learns the fundamental
lesson of leadership - patience while an 'idea' he/she may be promoting, is
germinating in the public mind, followed by dramatically conceived activism
when the time is right.
In the smoking or health scene the time is now right. Leadership is readily
available. It remains for us to make it abundantly clear to this developing
leadership cadre that it would be politically - and socially - astute for
them to dramatise the potential dividends of co-operation in co-ordinated
activities, since public support will no longer sustain the internecine
rivalry and bickering which has coloured efforts of common aim to date.
There is much therefore yet to do. The challenge of the 70's relating to
the interagency concept of co-operative, co-ordinated programming must be
met more clearly.
Once co-operatlve involvement in co-ordlnated activities has become the
accepted norm, think too of the future dividends of nationwide programs of
this type:
I) Possible assistance, at the request of developing countries,
in producing co-ordinated co-operative efforts of their own.
2) Possible expansion of these efforts, perfected in the crucible
of the trial and error process, into other destructive llfe
style challenges such as those posed by alcoholism and
indolence and obesity.
3) We must not ignore the needs of current smokers who are un-
successful in their efforts to stop. As we know m~re and
~re about the value of early diagnosis of disease,
consclousness-raising activities designed to lead to the
T10835144.~
SMOKING O~ -~:2~L~H: HISTORICAL PERSPECTIVE 803
discovery of diseases in their biologically and potentially
curative stages, are begging to be pursued.
As one who has closely followed the smoking or health controversy for almost
40 years I have increasingly high hopes for future success. However it is
essential that we do not let doom our guard at this critical stage. A great
effort must now be expanded if that hope is to come to fruition.
Bioethical considerations must forge a basis for these activities. Factual
scientific data must be disseminated in an understandable way to the general
public. The public, once educated, must bring to bear that combination of
advocacy and political power which represents the only truly effective way
to alter unacceptable social behaviour.
Bioethical creeds have been formulated, as have biological 'bills of rights'
for mankind. Relevant components of these guidelines should influence our
own activities. Mankind has a 'right' to a physiologically healthful
environment free from iatrogenic pollutants. The health-oriented profes-
sionals (educators, social scientists, researchers) must accept the need for
prompt remedial action in a world still beset by one crisis after another.
These concepts are based on acceptance of the thesis that the future surviv-
al and development of mankind, both culturally and biologically, is depend-
ent on present activities and effective planning for the future.
Fortunately, the aim is not merely 'Utopian' since commitment to these
objectives comes naturally to all human beings, possessed as they are by the
instinctive need to contribute to the betterment of some larger social
grouping.
FUTURE {~IALLENGES
In looking forward to the next World Conference, what new programs can we
anticipate? As we begin to see the epidemic of smoking-induced disease come
under control in countries in which it first appeared, we must not allow it
to develop in other areas of the world. The scene is now set for interna-
tional co-operation in co-ordlnated world-wlde efforts to bring together
national governmental agencies or national councils under overall guidance,
such as that which might be provided by agencies llke the World Health
Organization - already so heavily committed in this field.
The 'one world¢ concept, which has met with such unbridled resistance since
it was first seriously considered in the aftermath of World War II, when the
co~unicatlon revolution created instant information transfer, seems at long
last to be rebounding with a deafening crescendo as the interdependence of
the world's financial structure, as well as its food-delivery, systems
becomes more and more apparent.
As Pierre Trudeau, Prime Minister of Canada, has said "We cannot escape from
~ee-~.'o~-l-d ~u~ ~an w~'i~g~b~u~ a ~o~aily independent National recovery".
He has always emphas~sed that the temptation to turn inward upon ourselves
must be resisted.
TI083514.-49
Appreciation of this interdependence between rich and poor nations, the
industriallsed North and the developing Third World, ~anufacturers and
consumers alike, particularly in the wake of great population =ovec~nts~
poses similar challenges in the propagation of health care delivery
systems. Not only is disease control involved but, of almost equal impor-
tance, the control of destructive life styles in general. Economic viabil-
ity cannot be completely expressed in the presence of uncontrolled disease,
no matter whether it is environmentally induced or the result of behaviour~l
custom.
Transfer of information that has been generated by those in 'advantaged'
positions to the 'disadvantaged' becomes an international imperative for the
1980's. The smoking or health problem is part of this imperative and
warrants our attention. As we struggle to manage the problem successfully
ourselves, we must make available to others the techniques that are evolv-
ing, so that they will not have to face the epidemic catastrophe with which
we have been plagued. A simple example: advertising is the key to the
introduction of the cigarette into these countries. If we do not effective-
ly ban advertising and promotion ourselves, and prove the value of such a
step, it is unlikely that they will be able to do so.
The evidence is clear; the decisions have been rendered. We know what needs
to be done and we have developed a host of proven techniques by which to
achieve our goals. To this end our efforts must be more successfully
co-ordinated, not only in the narrow community context, not only in the
broader national picture, but surely on the international scene as well.
It has been demonstrated clearly that governments and the public can work
together effectively and in concert. The enormous resource of volunteers
makes it possible to mount programs which could not be financed otherwise.
Indeed it has become apparent that this combination which brings the profes-
sional and the volunteer into close association, takes advantage of the
skills which are needed to complement each other ~ore effectively than any
other techniques. The stage is set for the progress we have been seeking
for far too long.
The message of the Fifth World Conference is the one we have all been
awaiting. A different atmosphere has been made abundantly clear. Great
things are about to happen. I would confidently predict that, in the
interval until the next Congress, more progress will be made in achieving
our world-wide objectives than has been made in the last 15 years of
Congresses. The sessions at the next Congress will assuredly prove exciting
and rewarding.
T108351450
CONFE~-NC~ m~.CONNENDATIONS
TI08351451
RECOMMENDATIONS THROUGH RAPPORTEURS
TI08351452
8O5
RECOMMENDATION 1
There should be a significant increase in the activities of women's health
groups; and investigative networks should be established in each hemisphere
to evaluate the effectiveness of programs for women.
Background: The Fifth World Conference on S~oking and Health has recognized
the emerging problem of s~oking among women. The scientific evidence clear-
ly shows the increasing prevalence of smoking by females. Further, the
effects on maternal and fetal health have been well established.
RECOmmENDATION 2
Research efforts should be intensified on the role of low tar and nicotine
cigarettes to assess their harmful effects.
Background: Since the tar and nicotine levels of cigarettes are continually
being reduced, a better knowledge of the harmful consequences of these
products is required. Similarly, more needs to be known about the smoking
behaviour, rate of consumption, depth of inhalation, etc. of the consumers
of such cigarettes.
RECOMMENDATION 3
Based on the demonstrated interest and enthusiasm at this Conference,
non-smokers' rights issues should be given appropriate weight in the
planning of the Sixth World Conference program.
EECOMMENDATION 4
The availability of routine data - consumption and vital statistics - for as
many countries as possible should be increased.
Background: Vital statistics and cigarette consumption data can be used to
estimate smoking and non-smoking rates, provide projections, and help to
identify changes in risk, e.g., effects of changes in the environment, use
of low tar cigarettes, etc. This will be especially useful during the next
twenty years since there may be large changes in consumption during this
period. One body is also needed to oversee the development of standard
instruments and data collection procedures.
TI08351453
~06
Research in the area of passive smoking and its effects on health should be
increased.
Background: More research on the health effects of passive smoking is need-
ed. The amount of literature on the subject is negligible compared with
that on other aspects of the smoking and health problem. Evidence from
several studies suggests that lung cancer ~ortality is increased in passive
smokers exposed at home, at the workplace, or in society generally. How-
ever, other studies have not shown this relationship; therefore, more
definitive research is needed to clarify the question.
RECOMMENDATION 6
The Third World should be supported in its research on the harmful conse-
quences of smoking so that developing countries can establish their own data
base.
Background: In many Third World nations the harmful effects of cigarettes
are still not generally known and consumption is rising. Further, high tar
and nicotine tobacco is being dumped in developing countries.
TI03351454
807
PUBLIC ~DUCATION AND INFORMATIO~
To support the development of a knowledge base for interventions aimed at
high priority target population groups. These include women in general, and
nurses and pregnant women in particular, as well as individuals at lower
educational levels.
RECOMMENDATION 2
To develop liaisons between regional agencies that have defined responsi-
bilities for promotion of health. These are agencies at a community or
higher level.
RECOMMENDATION 3
To establish channels of communication for the exchange of information on
service and action programs. This would include the dissemination of
supporting materials.
RECOMMENDATION 4
To develop and support youth non-smoking activities that involve the young
themselves. These are activities that explicitly utilize the talents of
young people in influencing their own age peers.
Background: This Conference, unlike earlier Conferences, has provided a
world perspective. The enormity of the need to protect people from the
harmful consequences of smoking has linked the developing and developed
countries in a common mission.
Reports on community and regional programs have included descriptions of
sophisticated approaches to the development of these activities. Program
development appears to be grounded in theory, but far too few programs have
been developed with reference to the work of others and past evaluations.
The content of the messages, campaigns, materials, and programs described or
shown during the Conference indicates a shift away from negative communica-
tions to a more positive approach.
A varzety of studies conducted in different countries have identified the
priority of similar groups of smokers. Specifically pinpointed have been
women smokers, especially nurses and pregnant women. It has also been in-
dicated that future smokers are likely to be those with the least amount
of formal schooling.
TI08351455
8O9
CESSATION
EECOMMENDATION I
Promising approaches to cessation - physician treatment, behavioural
clinics, and the electronic media - should be further developed and evaluat-
ed in community demonstration projects to examine the effectiveness of an
integrated network of cessation services.
Background: Recent promising results for several approaches to cessation
combined with (a) encouraging signs of effectiveness for comprehensive
community programs, (b) a consensus that a diversity of coordinated services
are required to be maximally effective, and (c) evidence that repeated
efforts with individual smokers and services aimed at relapse-prevention
maintenance of non-smoking increase success, all argue for development and
testing of cessation service networks. Following demonstration of efficacy
of these programs, effective means of dissemination need to be developed.
To maximize efforts and avoid duplication, service providers and researchers
must collaborate throughout development and coordinate efforts with
comprehensive smoking and health programs on community, national, and
international levels.
RECO~qENDATION 2
Research should continue in the development of nicotine-bearlng chewing gum
as a new cessation tool showing clear evidence of potential effectiveness
and wide-spread utility.
Background: Research since the Fourth World Conference demonstrates the
efficacy of nicotine-bearing chewing gum in at least some circumstances when
used in conjunction with other cessation methods. Continuing study is
encouraged to pinpoint necessary and sufficient conditions for its efficacy,
to specify optimal dosage and duration parameters, and to identify for whom
and under what circumstances the gum is to be recommended.
R~OI~ATION 3
Program development must cont{nue to be balanced with research to (a) refine
our understanding of processes underlying smoking cessation, and thus
provide a basis for more effective cessation programs in the future, and (b)
provide careful, accurate evaluation of current cessation programs.
Backgound: Future development of ~ore effective programs will depend on
increased understanding of smoking processes. For example, the process by
which smokers stop by themselves, and the nature and role of nicotine
dependence in cessation, are not well enough understood to design maxi=~lly
effective cessation =ethods. Process research sometimes will have direct
TI08351456
implications for cessation =ethods, but the long-term value of process
research with less i===ediate utility also zust be recognized.
Evaluation of cessation ~.ethods should include (a) validation of reported
cessation, (b) follow-up of effectiveness beyond one year, and (c) calcula-
tion of abstinence rates both in terms of percent of participants continual-
ly abstinent since program termination (continuous abstinence) and total
percent abstinent at follow-up evaluatlon (abstinence prevalence),--
~OMMENDATION 4
Development of cessation programs sensitive to socio-cultural realities in
developing countries should begin; and these methods evaluated and imple-
mented as appropriate in the context of comprehensive smoking and health
programs.
Background: Over the past two decades, effective cessation programs have
evolved slowly in developed countries. If parallel programs are to be
"ready when required in developing countries, efforts must begin to specify
the requirements for effective methods in these cultures, Such efforts may
5e facilitated by joint working sessions of representatives from developing
and developed countries.
T[07.,351457
811
ECONOMICS
RECOMMENDATION 1
All countries should collect regularly, in a standardized way, and report
accurately data on tobacco use.
Background: Accurate information is essential in order to monitor progress
toward the goal of eliminating tobacco use; to compare trends in diffePent
countries and between sub-groups within countries; to predict future health
consequences of past and present tobacco use; to develop and share appro-
priate scientific methods to assess the effects of smoking on health.
RECOMMENDATION 2
To help reduce economic dependence on tobacco, countries should request WHO
and FAO to encourage alternatives to tobacco production to ensure employment
and cash income, export earninBs and foreign exchange, and productive land
use equivalent to that currently provided by the growth and manufacture of
tobacco products.
Background: Objectives of the above would be to facilitate agricultural
diversification in tobacco growing areas, to change land use, particularly
toward food production, to reduce government dependence on tax revenue, and
to encourage corporate diversification by tobacco companies.
RECOMMKNI)ATION 3
Governments should use appropriate taxation measures, in conjunction with
other measures, i.e., educational and legal, to reduce tobacco consumption
patterns.
Background: There is evidence that such actions may be especially effective
among young smokers. Other objectives are to encourage changes to lower
risk cigarettes, and to ensure that real tax levels are maintained or
increased, and that they are targeted appropriately.
T108351458
813
LEGISLATION
RECOMMENDATION 1
An international initiative to influence politicians, including a survey on
attitudes of political decision makers, should be launched. A special
information system for politicians is also proposed.
Background: A common concern experienced in all sessions dealing with
smoking-related political issues centered on how to influence politicians to
take appropriate action. It was felt that, with a few exceptions, politi-
cians do not yet react in accordance with the magnitude of the said
problems.
RECOMMENDATION 2
Smoking control should be achieved by implementing comprehensive programs
which include public information, health education, cessation, and legis-
lation.
Background: Several political issues received special attention. They in-
clude a ban on advertising and sales promotion, and price policy and taxa-
tion. Smoking control represents a multi-faceted opportunity requiring
comprehensive action.
RECOMMENDATION 3
Developing countries should be provided wi~h the necessary support to over-
come the growing threat of the tobacco industry.
Background: While some progress is being observed in developed countries,
tobacco industry initiatives in the developing nations is going unabated.
By doing the above, international solidarity should again focus on political
decision-makers, reminding them of what was possible in other fields, e.g.
the breastfeeding issue.
TI08351459
RECOMMENDATIONS FROM DELEGATES
TI08351460
815
The following is a llst of priority reeor~ne_ndations to be carried out inter-
nationally as swiftly as possible. These reco=mendations are based on a
synthesis of responses to the special input form completed by Conference
participants, as well as other suggestions contributed.
The International Liaison Committee on S~oking and Health has considered and
endorsed the recommendations as set forth below:
I. That the primary objective of international and national smoking control
programs should be to establish NON-SMOKING AND THE RIGHT TO A SMOKE-FREE
ATMOSPHERE AS THE NORM.
2. That the Ministries of Health of all countries be asked to report to the
1987 World Conference on Smoking and Health on progress made toward each
of the goals set out in the WHO Expert Committee on Smoking Control
recommendations of 1978, particularly in relation to advertising, health
warnings~ sales to minors, and health education programs.
Action to he taken by Conference Chairman.
3. That all countries be asked to measure the prevalence of local tobacco
usage and to report findings to the Sixth World Conference on Smoking and
Health. The standardized measuring system developed by WHO and UICC is
recommended for this purpose.
Action to be taken by Conference Chairman via WHO and UICC.
4. That all countries be urged to form a National Smoking Control Coordinat-
ing Body, representing governments and non-government agencies, by 1987.
Action to .be taken by Conference Chairman via WHO and international
agencies.
5o That world religious leaders and groups be asked to support actively the
international program on smoking control.
Action to be taken by Conference Chairman.
TI08351461
816
EECOPIH~CDATIONS FF~)M DELEGATES
That this Fifth World Conference on Smoking and Health urge all
governments to heed the Honourable Monique B~gin's call for regular
increases in taxation as part of a comprehensive program to reduce
smoking and improve health.
Action to be taken by Conference Chairman.
That production and export of cigarettes with a tar yield of more than
20 milligrams cease worldwide. This upper limit should be reviewed in
1987 and progressively reduced. Yields of nicotine and other hazardous
substances should be similarly reduced.
Action to be taken by Conference Chairman via WHO international
agencies.
That all cigarettes and tobacco products sold worldwide should carry a
health warning and precise labelling of tar, nicotine and carbon
monoxide - this is to include duty-free cigarettes.
That all international agencies, including WHO, be urged to demonstrate
their commitment to smoking control by substantially increasing the
resources made available for this purpose.
Action to be taken by Conference Chairman to WHO and international
agencies.
10. That the Director General of WHO be asked to open the Sixth World
Conference on Smoking and Health and to report progress on the develop-
ment of WHO's smoking control program at that time.
Action to be taken by Conference Chairman and International Liaison
Committee on Smoking and Health.
11.
That WHO, possibly in cooperation with the International Agency on
Research and Cancer (IARC), be requested to organize an assessment of
the size of the global tobacco problem in terms of mortality, morbid-
ity, tobacco production and sales; and to report this to the 1987 World
Conference on Smoking and Health along with long-term projections.
Action to be taken by Conference Chairman to WHO and IARC.
12. That regular international planning meetings be held of selected
Action to be taken by Conference Chairman to international agencies.
TI08351462
817
13. That UN agencies be urged to cease supporting tobacco growing and to
initiate programs to develop alternative crops. These agencies are
requested also to examine the deforestation which occurs as a
consequence of tobacco production.
Action to be taken by Conference Chairm~n to UN agencies.
14. That a world NON-SMOKING DAY be held each year, co~=r~encing in 1984.
Action to be taken by Conference Chairman via WHO and international
agencies. Date to be set by International Liaison Committee on Smoking
and Health.
15. That national research institutes be requested to intensify their
research activities in the area of smoking and health.
Action to be taken by Conference Chairman to WHO and international
agencies.
T108351463
T108351464
819
RECOM/~ENDATIONS
At an especially convened meeting, about 40 of the Third World delegates to
the Conference recorded their appreciation of the opportunities it had
afforded to broaden their knowledge of smoking control but regretted the
absence of opportunities to focus in more detail on certain areas peculiar
to their countries. They noted also the need to enlist the aid of non-
governmental organizations (NGOs) to support the efforts of Health Minis-
tries in the field of smoking control.
The meeting made the following specific proposals:
Future conferences should be organized in a manner which allows time for
the discussion of subjects specific to certain regions, economic group-
ings or political organization without conflicting with other agenda
items - for instance traditional forms of tobacco use; control of
smoking in developing countries with state monopolies, etc.
A coordinator should be nominated to coordinate those parts of the
program relevant to the Third World participants.
Support should be given to the establishment of an international network
of NGOs in the field of smoking control in the developing countries.
The representative of the Consumer Association of Penang, Malaysia
offered to provide initial coordination for this purpose. In support of
this it was noted that for future smoking control workshops in develop-
ing countries, funds should be sought to permit the participation of
representatives of such organizations and that suppor~ should also he
sought for the establishment and operation of such a network.
Tl08351465
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