Tobacco Documents Online

An Evaluation of the PHS CLEARINGHOUSE Basic purpose of the National Clearinghouse on Smoking and Health is to inform people about cigarette smoking and encourage them to quit, however ... Clearinghouse spokesman describes the Clearinghouse program as the "first effort for mass behavior change on a national level." Results could also be applied to control of liquor or narcotics con- ` t sumption, say Clearinghouse spokesmen or even politics. • Clearinghouse is on an accelerating budget apparently cleared by PHS that would boost the current $2.7 million to an annual $12.5 million 'by 1972 - and the program is to expand by communities as budget ~ grows . : .~:.,~-~ ,. : . .... . . . _ .,.. , . . . _.~: . , - _g,r~. . . .~.:. ~ ... . . .. Application of a new cost-benefit ratio for comparing disease control ,'programs could result in further expansion of the program, including wider use of mass media, and a budget of some $31.5 million annually ' house on Smoking and Health is National Clearin g spending some $2.7 million in federal funds to "change behavior" of U. S: cigarette smokers this year - that is, to get them to stop smoking. Interestingly, the Public Health Service has approved a budget that would accelerate this to an annual $12.5 million by 1972 - and if estimates of effectiveness of propaganda campaigns prove accurate, federal supportof the anti-smoking program may increase to an annual $31.5 million by 1972, under application of a new cost-benefit formula being used to compare effectiveness of various Health, Education and Welfare programs. ~ • • .1 . . On Changing Behavior - About a year ago the President's Commission on Heart Disease, Cancer and Stroke recommended a$500;000 Public Health Service project to set up a Center for Research in Health Motivation. It was described as follows: •'In addition to specific behavioral studies directed at the individual decision making process in changing patterns of living, the Center would' analyze the contents of public campaign ma- terials with reference to their effectiveness and influence ^ upon behavior, and it would hopefully concentrate particular attention upon hard-to-reach population groups which reject existing educational campaigns emphasizing individual initi- arive and changes in living patterns." Although this particular recommendation has not yet been acted'upon, the National'Clearinghouse on Smoking and Health, an agency of the Public Health Service set up in September, 1965, seems to be operating along very similar lines. "A better name for the Clearinghouse would be National Center for Behavior Change," com- ments a member of the Clearinghouse staff, who points out that the Clearinghouse is involved in the first nation-wide program devoted to chang- ing behavior on a national level. -- ---- •' He adds that the staff is quite excited about 'athe project, noting that no real advances have been ..«r~;,t,~;made in this area since the rash of "'subliminal" messages several years ago that supposedly sent consumers dashing out for products as a result of ~' '-- :~ .March / 19( 7 3~ii~~ ~.4 ~~ ... ~ messages flashed onto movie and television screens too rapidly to be consciously noticed by the viewer. ~'-` -~ And he observes, "If a 'safe' cigarette is de- veloped it won't put us out of business . . . " since the same basic program can also be applied to liquor and narcotics control, used in other national education programs and even politics. Dr. Daniel Horn, head of the Clearinghouse, tells Tobacco Reporter that he is leary about describing his goal as "behavior change." He says, "Use of that term makes it awfully easy for people to look at us and think we re trying to get people to do things they don't want to do." He points out that studies indicate that a large percentage of current cigarette smokers have tried to give up cigarettes -- thus, „' he believes, they want to change. ~ Nevertheless the term "behavior change" is one that has ~~ been repeatedly used by Dr. Horn, and the current Clearing- house program is built around a theoretical model drawn up by Dr. Horn and Selwyn Waingrow, his special assistant, and presented at the American Public Health Association under the title, "Some Dimensions of' a Model for Smoking Behavior Change." Dr. Horn has commented to the American Association of School' Administrators, "We are in rather a new area in smoking ed'ucation, Unlike trying to motivate people to do something once, like getting a chest x-ray or a tetanus shot, and unlike trying to teach children to do something always such as "brush your teeth after every meal," we are trying to persuade people to, NOT do something f orever. So old techniques, while not necessarily invalid, must be studied carefully before we place too much faith in them." (Along these lines Dr. Horn has suggested: "When the Mathematics teacher discusses graphs could he use lung cancer death rates? Could the English teacher discuss adver- tising copy? Might the Civics or History teacher discuss the _role of Congress and the Federal Trade Commission in developing consumer safeguards in the effects of industry +; -lobbies?„) Dr. Horn sees his project as development of a pcogram for controlling "gratificacion behavior." "mk ~ _ Continued on following page ,

CLEARINGHOUSE Continued from preceding page He notes, "What we are doing here could also be applied to weight control or used to reduce alcoholism or even promote use of 'less hazardous' cigarettes." He points out, however, that smoking is not like other forms of gratification behavior. "When you drink too much you get drunk. When you eat too much you get fat- But when you exceed an acceptable level of cigarette smoking you can't see the damage." Thus, he explains, the Clearing- house's job is to warn~ smokers. He says that the Clearinghouse wants to intro- duce "moderation" into smoking habits of those smokers who refuse to quit by encouraging them to "take smaller dosages" by smoking fewer ciga- rettes, lower nicotine and "tar" cigarettes, leaving longer butts and taking fewer puffs. .In a pgper recently presented at the American Public Health Association, Dr. Horn introduccd some findings about individual' smoking dosage. He notes that in some cases a smoker may smoke two packs a day and get a relative. ly low dose, while smokers of 5 to l0 cigarettes a day may get a high dose - depending on hotu and what they smoke. He also commented, "Although the prospect of a 'less hazardous' cigarette that would solve the health problem does not appear imminent, the possibility remains that changes in the cigarette combined with changes in the ways in which people smoke might produce a level of exposure which is tolerable' for many people. It would remain for research. of course, to determine what would be the 'tolerable' level for how many, of which people, under, what conditions. How- ever, until such levels of 'toleration' are determined the control task must remain basically oriented' to persuading as many people as possible to stop their cigarette smoking coni- pleteiy or not to start in the first place." What does Dr. Horm think might be an acceptable Ievelc He says, "Figures for women who smokeless than 5 cigarettes Here is how HEW cost-6enefit formufa .` -,; Last spring the Secretary of Health, Education an& ~` '*Welfare set up task groups to try to apply a new formula of cost-benefit analysis to several HEW programs. One of these task groups was Disease Control, which included sub-task groups, one of which was Cancer Con• trol. These sub-task groups completed their analyses and the over-all analysis became a program memorandum which was submitted to the Bureau of the Budget in to the economy by lives saved per dollar spent by HEW for each, program. These ratios for the various programs "` `: The cost-benefit formula projects ratio of dollars saved December 1966 by the Secretary of HEW. Health Service - did participate in the committee.) Dr. Horn an& his staff also prepared alternatives that would include the current Clearinghouse program plttw increased' efforts in two areas emphasized in his model, of' behavior change - intensified use of health pro- fessionals and greater use of mass communications. The four alternatives proposed included the curren: program (Alternative A),' the current program plus in- creased involvement of health professionals (Alternative B), the current program plus increased use of mass com- munication (Alternative C) and a program that involves all three (Alternative D). Here are comparative figtores for five-year program under each alternative: can be compare& and may be used as a tool by HEW to compare effectiveness of' various programs and alternative programs for controlling various diseases. - f i f d f F gures or each program inclu e a ive-year cost o Cast (aiillians d. dal lan) -fal.nti.1 Cast Nr Tasal sa.injs Sarinp a.iMsinIlfa (williansal prd+ Aarr li.as ddilan/ spanr the program to HEW, nu mber of li ves th at the pr ogram ALTERNATIVE A Current program __f46.9 7,000 $6,700 S268 5.7 is estimated to save, conve income potential that wou were to die, and expression rsion of t ld be los of the c hose l t if th ost of ives into ose indiv the progr dollar iduals am as ALTERNATIVE'8 Current plus more professionals _-__ 84.9 16,000, 5,300 635 7.3 a ratio to the over-all dolla Here is how the cancer r savings. control p rogram s fared i nclud- ALTERNATIVE C Current plus more mass media ----- 76.9 13,500 5,700 531 6.9. ing the anti-smoking cam Smoking and Health in lun paign of g cancer c the Cl ontrol earingho : use on ALTERNATIVE D Current plus Cess Pat.efinl Cast'yar Tetal sarings Sarings professionals and 114.9 di 22 000 5 200 875 7 6 CANCER. (willient a1f sa.ings in lifa (nillians af, Par dallAr mass me a ------ , , . dallanl lins. dallon) spanr Cervical-uterine Under alternative Program A percent of' adult popu- cancer -------- .5118.1i 34,200 $3,470 $1,071 9 lation who are smokers drops from 40 per cent in 196' (screening program). Head and neck to 36 per cent in 1972. Alternative B' it drops to 29 per cent in, 1972. Alternative C has it dropping to 31 per cancer 7.8 268 29 100 9 1 1 --------- (detection research) , . cent in 1972,,and Alternative D has percent of adults who 24 i b Breast cancer 22:4' 2,396' 7,663 101 4.5 per cent ng to are smokers dropp y 1972. These pro- (screening program) Lung cancer -------- 47 7,000 6,400 268 5.7 jections were also estimated by Dr. Horn. Comments a footnote about the estimate for effect of (anti-smoking education program) The $47 million investment is the 5-year planned "current ' program, which was only one of four alternative Dr. Horn's office, according to Gerald Sparer, of the Secretary's Office, who prepared the over-all report from the various analyses. The estimates of potential lives saved used in project- ing effects of the lung cancer program were supplied by increased' mass communication, "this is based on assump- tion that as in 1964' Clearinghouse sample, some 83 per cent of current smokers are concerned about the health hazards of' cigarettes and may be considered 'potential former smokers,' and of the potential former smokers, 15 per cent will actually become former smokers as in smok- ing withdrawal clinics " According to Mr. Sparer and Dr. Horn no actual figures are available to show how many people will stop smoking when exposed' to increased mass programs considered for lung cancer controf through anti- -- communication "education." However, Dr. Horn says the smoking campaigns. (None included a program for de- -- _=fact that doctors are smoking less now than 15 years ago veloping a"safe" cigarette, although a member of the indicates people will stop smoking when "educated." National Cancer Institute - research arm of the Public _ ; This mass communication alternative would involve. ,r _.- -:r`,~ bacco Reporter - - - _ - _ . ---,---. ~,.

0 a day are about the same as for non-smokers" (The paper presented'to the APHA also noted that women tend to smoke lower "'tai " and nicotine cigarettes, according to Dr. Horn.), He adds that the best level of dosage is none ar all. Dr. Horns smoking behavior change model being used by the Clearinghouse includes four basic target populations: youth in school (elementary, intermediate, secondary, college and' in organized gcoups)~ adults (industry, clubs and as parents), professionals (physicians, dentists, nurses, pharma- cists) and'general public (mass communications). A look an the current program gives some idea of how Dr. Horn intends to "change behavioi ° of each of these populations. CURRENT PROGRAM The atrrenr program for the Clearinghouse is financed by a little more than $2 million in federal funds„plus some $500,000 which the Clearinghouse awards in grants - the Presidenes budget for 1968 includes a similar level of expenditure. Bur this is far less than was cleared at the Public Health Service ldwell for the Clearinghouse under an increasing S•year program for the anti-smoking campaign. A spokesman for the Clearinghouse notes that expendi- tures for Viet Nam will probably mean it will be at least 1969 before the Clearinghouse can even get started on its accelerating 5-year program. Under this program approved at the PHS level the Clear- inghouse will spend some 346.9 million over the five-year period - increasing from =5:2 million the firsr year to some E12:5 million in the fifth year. According to HEW (which apparently got the infor- mation from Dr Horn) "a reasonable expectation for re- ducing cigarette smoking at this level of expenditure over, the next tive years is 1) Reduction in the number of adult male smokers by about 10 per eenr 2)i Reduction in the number of adult female smokers by about 3 per cent; 3) Re- duction in the number of young people (ages 13-20) who rake up cigarette smoking by about 15 per cent and' 4) Continued on following page ® G according to the report, development during 1968 of appropriate materials adapted for mass communications media, primarily, television. This would' be coupled with and followed through a series of trials and demonstrations. Widespread promotion through grants to states and com- munities would be carried out in 1970, 1971 and 1972. (According to Dr. Horn use of' mass communication in no way means use of paid advertisements in these media - the current NCSH project with educational television probably is a moresubstantiallclue.) _ Projection B, which is based on increased use of health professionals, is based on the assumption that physicians will discuss smoking and'health with 70'per cent of'their patients rather than 17 per cent as is currently done. (Dr. Horn apparently has a study that shows this.) And that patients assisted by physicians using improved techniques are successful 50 per cent of the time quitting smoking, rather than the cvrrenr 30 per cent• Io also assumes that dentists will~have as much effect on smoking,habits as physicians. Since the more extensive Alternative D seems to offer, a better cost-benefit ratio than the others, why was " Alternative A selected as the program submitted in the Secretary's memorandum to the Budget Department? Largely, according to Mr. Sparer, because these alternatives are all based on "professional judgement•" He says the formulas will all be"worked over, reconsidered' and evaluated in terms of results of this coming years pro- . gram." Several "uncertainties" were also mentioned in the report One was the efforts of other agencies in the area of smoking and health, which according to the report "are not known-" - , . . The report also notes the "effect upon the tobacco industry and upon tax receipts of the estimated reduction in smoking- We do not know whether this would be a cosror a benefit„but we assume analysis would show it to V be a mixed blessing." ;r r, , . . . . .. . . :. . . (Editoi s Note: Since about $3.5 billion is collected annually in federal and'snte cigarette taxes, a reduction by 10 per cent, as under Alternative A, would represent a eur in tax revenue alone of some $350 million - more than the $268 million alternative A is said'to represent in ~y}; 3 dollar saving, if one wants to get cotnmercial'about this.) ~`~i The report also notes that savings accrued from re- ~~ ductroa of "death and' disability from causes other than Lf~~, a„r.,: - . ,.r- -.. .. .. .. . .. .. .. .. . ,. t was applied to anti-smoking Marcb/1967 campaigns lung cancer; are not reflected in the current figures. The report; based on information supplied by Dr. Horn, comments, "It should be emphasized that death and disability associaced' with smoking gpes much beyond the problem of lung cancer, which accounts for only approxi- mately 10-15 per cent of the mortality and 5 per cent of the disability associated with cigarette smoking."' "We are looking at this possibility with interest," explains Mr. Sparer. Two Other Programs In analyzing the lung cancer programs in the over-all memorandum two additional programs were induded, Alternative E, professional education alone (an expendi- ttue of $38 million over a five year period) and Alter- native F, mass media alone (an expenditure of $30 mil+ lion over a five year period• ) The report comments, "These two programs (E and' F) alone have anticipated benefit cost ratios of 9.6 and' 8.8. While a basis for a critical analysis of program effectiveness for each component does not exist, the pri- mary preventionpmgram presented ranks with the middle range of productive programs analyzed in this paper on a- par with the breast cancer program. Additional support - appears warranted. Support of' the basic program would provide data on which to make judgments concerning further program emphasis. We will be looking txitically at the basic program to determine if it is possible to trade . off components of that program against the apparentl~' more productive components of' Ptograms E aad F." The report also notea„'There has been little actual experience for these estimates except a study, which indi- , rrtes that patients advised to stop smoking by health pro- .. fessionals are more likely to. If the estimates of program effectiveness were overstated by 30 per cent or more, and • this ispossible, the pmgram would still warrant suppoa- . at ftmding levels concemplated, Shtut of severe legd restrictions on smoking we-have no other weapons to make significant progress in curtailing lung cancer deatha." It concludes, "In many respects the lung cancer pre- vencion program oriented toward smoking curbs is similar to a number of the motor vehicle programs. Additional ', emphasis on these educational programs is warranted because of the reasonably high productivity of these pro- grams and also in order to test and validate some of the key assumptions made in estimating benefits and lives saved• If these estimates are not confirmed, shift of emphasis to other programs would be in otdee , ti`? 4, , M r 11 t r e1 { i. z lW m [ .~ t'J~'~`~1 11

CLEARINGHOUSE Continued from preceding page Encouragement of significant numbers of those who continue to smoke to use forms of tobacco and techniques oP smoking which are less hazardbus." The report confidently notes, "Attainment of this level of'success among adult smokers could result in the reduction of' smoking related~ litng cancer deaths by about 4,000 in 1972." ( The charts accompanying this show total percentage of the population who are adult smokers would be reduced' from 40 per cenr in 1967 to 36 per cent in 1972 - or a drop of 10 per cent in number of adult smokers.) How Horn Plans to Do This Dr. Horn, a psychologist, has been interested for some time in changing smoking behavior. His early work included cooperation with Dr. E. Cuyler Hammond at the American Cancer Society'on studies of smoking habits and lung cancer - which formed the background for much of the Surgeon General's Report. One of~ his first projects was adaptation of a projective test to discover why people smoke. He explains that some time ago he adapted a test similar to the Thematic Apper- ception Test ("But that was before the TAT even had' a name;` he notes) for use in studying attitudes toward'smok- ing. (The TAT makes use of pictures of people in un- structured situarions: The subject is told to make up a story to go with the picture or "tell what is going on;" thus sup- posedly revealing subconscious feelings. To study cigarette smoking attitudes subjects are asked to respond to pictures in which the people are holding or smoking cigarettes.) He says that a test he designed along these lines is now being used by the Council' for Tobacco Research in Btitain, and he has given sets of' the pictures to workers in the U., S., although no projects of this nature are now being financed! by the Clearinghouse, "largely because they are too costly in terms of results." Also, Dr., Horn explains, the responses were too stereotyped. Dr. Horn also used some projective testing when he made a study of youngsters in the Portland school svstem back in 1959. This study in the Porti9nd schools has been the basis for much of the Clearinghouse approach to anti+smoking propaganda campaigns. In Portland Dr. Horn used word association rests along with a battery of' other tests and questionnaires to discover exactly what approaches could be most effecrivelr employed to change smoking behavior. Basically five experimental approaches to changing smok- ing behavior were tried - long term effects (health), short term effects (cigarette smell on breath), combined long and short term effects, authoritarian approach and adult role- taking. The authoritarian and adult role-taking approaches were found totally ineffective; shorrterm effects were effeaive only with gii•ls; the combined approach was apparentlyy effective to some degree with all of the students;, but the approach that centered' on the long-term health ; hazard was most effective with both groups. However. Dr. Horn,oow describes the people in Pordind as "unusual,' and interestingly some recent propaganda efforts of the Clearinghouse have leaned toward short term effects -"boys don't like to kiss girls wfio smoke, husbands doa't like wives who smoke - thus non-smokers are more marriageable, more 'A"students are non-smokers, more 'pooi people smoke" (Dr. Horn says that a recent study, of college men in :.fasuchusem shows college men are smoking less.) A NCSH project now' in progress at the University of Illinois is"designed to determine whether Horn's Portland study findings continue to be valid in the light of recent develbpmeno." : Horn's ModeliProgram £ ~\ The bulk of' the current Clearinghouse budj;qt is going Horn's theoretical model of smoking'behavior changt;. This model involves application of a four-step process to each of four populations - studd:nts, adults, professionals and general public. According to Dn Horn's model a smoker must be arot't- vated to stop (for example by health, issues or to set an example for his child or student). Hto must then perceite the threat, realize it is significant, applies specifically to him and than he can do something about ii,, (Dr. Horn repeatedly puints out that by quitting, smoking a smoker can reverse statistical correlations with disease.) Finalltwo steps involve alternative ptycholbgica!'mechart- iimr, (these are based on _ paper, Psychologicai Model for Smoking,Behavior, by Dr. Silvan Tomkins, who says peopl6 smoke for different specific reasons, thus some can give it up more easily than others. Both Dr. Tomkins' paper and Dt. Horn's Model tor Smoking Behavior Change appear in tht American Journal' of Public Health supplement issued last month by the American Public Health Association ), and other factors that must facilitate continrting reinforeenoent. These would include "social forces (including action by official I and voluntary agencies, whether in the health field or, not, and legislative bodies at various levels of govern- ment); interpersonal influences ..., and activity by and exposure to the matt media, particularly television .., as facilitating or inhibiting,the change process . . ' Comments the paper, "It is further suggested that other facilitators or inhibitors in this model of change are the behavior and' attitudes of certain key groups, such as health workert in general and phyticisnt in particrdar."' "Another facilitating or inhibiting factor that warrants consideration for the change model is the general level of acceptability of'the behavior tharexists at a given time. The current general I climate of acceptability of smoking is prob- ably one of the strong counter-infllrences to those factors which would otherwise facilitate the cessation of~ smoking.. Restrictionr on the placet and condiiionl tn uhich tmokiAg ii pennitted, and reduction in the influence of, cigarette advertiring migh'••t be tu^o mechanirmt for changing thit climate. "However, acceptability, being,a sociall phenomenon, is subject to social change. With the sharp reduction in physician smoking that has taken place in the past 15 years, the acceptability of smoking in physician groups diminished along with the shrinking clbuds of smoke. A similar re- duaion in the general population might lead to the same kind of self-generating reinforcement or 'band-wagon effect " Dr, Horn seetns to feel chat a certain percentage (ap- parently, about 83 per cent): of smokers if "educared"' will be- come non,smoken-an assumption hrseems to base largely on performance of doctors. He cites the example of doctors and says that 15 years ago about 60 per cent of doctors smoked and today4ess than 30 per cent do (or at least say they do): Dr, Horn is just completing a study on level of doctor smok- ing and says that less than 30 per cent now say, they are smokers. As to why anti-smoking dinics, which supposedly "edu- cate" smokers, have proved'. ineffective with great regularity (less than 15 per cent generally give up smoking for more than a year, according-to Dr, Horn ), he comments, "An odd selection of people go to antikmoking clinics, most average people who want to give up smoking try to do it on their '" own. - _ Some Clearinghouse Projects ' A look at some of'the more than 50 project grants and contract projects now sponsored by the Clearinghouse should give some idea of'w how an expanding 5-year program migbt operate. At present the Clearinghouse is financing a number of research studies on attitude change and development of "educational" programs and materials. These materials sre 12 f .u.f. . sy- ~_

4. ! 13 of state and l'ocali Interagency Councils on Smoking and Health - which are partly sponsored by the Clearinghouse grants - through school programs, and through organi- zational activities also coordinated by the Interagency Coun- cils using materials partly supplied by the Clearinghouse. At the present_the program is described as "develop- mental." As the budget increases efforts will be expanded to more states and more communities. Here are some examples of' current Clearinghouse pro- jects: The County Health Department in Bakersfield, Calif., is studying ways of' correlating with~ their school curricvlum what junior an& senior high school students know about smoking and health and is exploring techniques for possible development for use in regular secondary school curriculum. Two of the largest projects sponsored by the Clearing- house are five-year project with the San Diego (California) County Council on Smoking and Health and another with the Onondaga County (New York): Interagency Committee on Smoking and' Health. These are community projects designed to test methods by which organized community action can change cigarette smoking habits. The San Diego project has been underway for about a year and Dr. Horn's office describes results as "encouraging," the New York project is only just beginning. In a sense these are both test markets for the "full" Clearinghouse pro- gram. They may include, according to a contract desuiption, everything from "psycho-social studies and research related to the motivational and behavioral aspects of cigarette smok- ing" through "educational programs for health professionals" and "community-wide participation of agencies, organizations, young people's groups, entertainers and professional organi- zations most able to exert an influence on the community ..:" The government has budgeted about $1 million for each of the,e projects over the next five years. A Clearinghouse grant under the current pro- gram of particular interest is a re-interview of about 3,000 adults 22 and over who were identified as current smokers and former smokers in a 1964 national survey of smoking attitudes and behavior. Dr. Horn says among the results of this survey - which are still not completely tabulated - is evidence that when a smoker switches -to a lower "tar" and nicotine cigarette he does not increase the number of cigarettes that he consumes. Ac- cording to Dr. Horn some of the smokers increased, some decreased, but the over-all effect was a slight decrease in consumption, following a switch to lower "tar" and nicotine brands. (This information could well crop up again in hearings over the bill on nicotine and "tar" label- ing Senator Magnuson promises to introduce soon.. Incidentally, Dr. Horn says he would not be sur- prised if hydrogen cyanide and acrolein labels - both part of the gas phase - were also suggested as part of that legislation.) Another Clearinghouse project involves development of educational television programs on smoking and health: On the basis of proposals from educational television stations, support has been provided by the Clearinghouse and National Association of Educational Broadcasters for production of programs by some 20 local ETV stations. March / 1967 ,.;, ..