Tobacco Documents Online

BRITISH MEDICAL JOURNAL LONDON SATURDAY MARCH 10 1962 A DEADLY HABIT Smoking cigarettes is a dangerous-and for many a deadly-habit. In' 1960, some 22,000 persons died of cancer of the lung, and d'iedl a most unpleasant death. The causative link between cigarettes and Jung cancer is undeniable, and no amount of statistical casuistry, has been able to undermine the case presented in the Bhitish Medical Journal more than 11 years ago' by Dr. Richard Doll and Professor (now Sir Austin) Bradford Hill.' Further work in both Britain and t!he U.S.A. has confirmed and extended their observations, and the ill-effects of cigarette smoking' on bronchitis, coronary disease, peptic ulcer are added to blacken the picture. Yet patients in N.H.S. hospitalfi are, at permittedl times; allowed to smoke in the wards, and cigarettes are on sale in the same hospitals, slot machines often convenient'ly, being' provided for the purpose. If typhoid bacillil got into the water-supply of these hospitals there would be a public outcry, in spite off the fact that we have an efficient antibiotic against'the bacillus and no remedy except the knife against lung cancer. No remedy, that is, except preventioni If the medical profession-and the Ministry of Health, -took the dangers of smoking seriously, they couldl at least convince the public of their concern and stopp the sale of'cigarettes in hospitals: It is the long latent periodl between the applicationi of the carcinoron and the ap pearance of, cancer that remuves the sense of' urgency. Although profession and public have'lpng been ativare'of't'he deadlydangers of smoking cigarettes there has been an extreme reluctanee to press home the lesson of prevention. The publication this week by the Royal College of Physicians of London of the report2 entitled Smoking a,;d Health oug'ht therefore to mark a turning-point in t IDoII. R., and Hill, A. B.. R•it, med. J:,,1950, 2, 739. ! =Smnkingmr l. iJrrr!rh. A. R`na•r of the Rbv7l. Coilrae of Phvsiaiana on, SrnnkiR.p in R•&nton to Cancer of the Lunq and Orher Disrasrs; 1962. Pitman Medicat',PublixhinAC.o:. Ltd , London. Price. Ss: net.. a T) 11, R., and Hilli A. D., R-ir. mr'd, J:, 195!4; 1, 145'I Ii,195b, 2; 107iU 4 Dean, G ibid.,,19G1„2;,1599. ' Haensal„W,, J, nrnaanrr• Inxt„ 196'11 20, 37. * Koulumes;,M.,,Arta. •ndinl. (.Crorkh.), 1953; 31, 258: t Rouin+ P. J. E:. and Onie, N. G. M.. Ned. T. Graersk., 1960 : 1C4, 709. a Cartwristht.,A., Mf,rtin, F. M.. and Thomson, JJ G:, Lenan, 1959; !, 725. ~ Pyke, D. A., 8'ir, mrd. J:, 1955;1, 11115'. '~Ibid., 1959,.2, 1249:. ~t ibid., 1951, 2. 1625. ~a C x~per, C. 1., ibid.. 1962. 1„ 643. ta Jahnston: L. M., L.urre/+ 1942, 2, 742. the approachi to " one of the most challenging,oppor- tunities for preventive medicine to-day." The committee responsible for the report, a summary of which appears at p. 703, was set up in 1959, andd it should be well satisfied with the results of its labours. The report does not present any new, unpublished facts on the relationship between smoking and disease, but provides a valuable and impressive review' of' evidence that has accumulated in the past 10 years. The risk of cigarette smoking is now widelyy known, but how great is it ? An important section of the College's report provides so>me indication of the magnitude of the risks based on new figures from Doll and Bradford Hill's inquiry among' doctors.' These show that the chance of a man aged 35 dying in the next ten years is 1 in 23 if' he smokes 25 or more cigarettes a day, but only 1 in' 90 if he is a non-smoker. His chance of dying before the age of retirement is only 15% if he is a non-smoker but 33% if' he smokes 25~ or more cigarettes a day. These figures„ being derived from men in Social Class I, may underestimate the hazard' in the general population. But the disparity cannot all be attributed to cigarette smoking itself, for constitutional differ= ences between the habits and nature of smokers and non«smokers may also be involved. A minimum estimate' of the risk is given by the figures for lung cancer. For a smoker of' 25 or more' cigarettes a day the chance of dying', of lung, cancer is I in 14' between the ages of 35 and 74 and 1 in 9 between the ages of 35 and' 84. The risks for non-smokers could not be calculated, from Doll and Hill's figures since the mortality among non-smokers was too „ small to show in the size of'population'they studied. Some 3'8;000 deaths in men and nearly, 9;000' in women between the ages of 30' and 64' occurred in, 1959' in E'nglandi and. Wales from diseases " °associ- ated with smoking." If only a small proportion of these deaths (amounting to 450110, of all males and. 7% of all female deaths at these ages)' could be saved, by redtncing, the eonsuniptioni of cigarettes a vast amount of suffering and unhappiness could be avoided. Recent evidence` s has shown that those nurtured in the British Isles carry throughout, their lives a greater risk from smoking' than do, those born in less sooty climates. But the report' denies that the risk of smoking could be countered in our generation by reducing pollution of the atmosphere. Thus iff young people are to avoidi the risk they must not start smoking. It, would be convenient if preventive measures couldl be confined'' to those individuals whom smoking, is actually going to injure, but

'° to smoke a cigarette at such a time will in due course also be deemed a social impropr4ety." * Secondly,, there are fiscal measures, aimediat the pocket; and!here the College recommenLUincreasing the tax on cigarettes while " perhaps " reducing that on pipe and cigar tobaccos. The second part of this recommendation seems to be almost as important as the first. As a matter of practical politics, no really big tax increase is going to be accept- able unless accompanied by a countervailing tax reduction, and we agree with our correspondent on p. 530 ~ that the cigarette habit is now so much part of the national life that the main hope of changing it lies in definitely encouraging the public and the manufacturers to substitute a less harmfull variant. Though perhaps the greatest effect would be obtained from a big and dramatic alteration of taxes, it is even more important that & beginning should be made att once. Why not in the coming, Budget?

(continued from previous pa;ge)'. good evidence that most' people have heard of the hazards in general terms,' and yet, apart from a small decline after the last budget, tobacco consumption, unfortunately they cannot be identified-apart' from~ the possibility that the_ risk may be greater in those with a smoker's cough ° '. But what are these measures to be ? There is chiefly of cigarettes, has continued steadily to increase in Bri,tain: in fact expenditure on tobacco products reached a new high level in 1961-probably about £1,210m., of which cigarettes accountedi for nearly 90%. Even if people know of the risks they do not seem to care. Ten years ago this seemed to be the attitude of, doctors too,' but the College's report produces evidence, based on a special' survey carried out by Doll and Hill last year, that doctors are now taking heed. Since 1951 one in every three doctors who used to smoke has given up the habit : 54i°;, are now non-smokers compared with 24% of all men, and' only 29% smoke cigarettes compared with 54% of' all men. Presumably this change has occurred because doctors, " in their daily practice, witness the tragic consequences of the habit."' The College of'Physicians urges that some decisive steps should now be taken by the Government to g bring home to the public that this is a matter of lifee and death. Powerful means are now available in the press and on radio and television for general education, and; in particular, for the education of children and adolescents. Sch,uolchildren themselves have asked for more information, finding the existing publicity material not enough.'= The College's report contrasts the paltry £5;000 , or less spent by local health authorities on anti-smoking education during the past five years with the £38m. spent by tobacco manufacturers on advertising. In a recent annotation" we said't;hat there was a strong case for curtailing tobacco advertising, mentioning that in Sweden these advertisements were forbidden. This was misleading, for though the Swedish tobaccoo monopoly stopped advertising for six moatWs the foreign firms continued to adw•ertise and the monopoly startedi again because it was losing trade. The College's report' admits that advertising may not be a major reason for the onset of smoking in adolescence, and the tobacco manufacturers naively claim (in an appendix to the report) that the effect of their advertising on total consumption " is likely to have been smallC" Direct advertising of a toxic product to the public: however, is hard' to justify, especially when, as Dr. C. J. Cooper" pointedd outt in last, week's kourra!: stiff'l enalrties are meted out p to food manufacturers who include potential carcinogens in their products. The College's report rightly recommends wider restrictions on smoking in public places and also suggests " an increase of tax on cigarettes, perhaps with an adjustment of' the tax on pipe and cigar tobaccos:"' This might indeed' persuade some people to change to safer forms of smoking. The suggestion advocatedI by E. L. Wynder in the U.S.A. that people should be encouraged to use cigarettes whose smoke has a reduced tar and nicotine content is perhaps more qttestionable. Not enough is known yet about the nature of the carcinogen in cigarette smoke, nor how smoke produces bronchitis or encourages coronary disease, to be sure that the risk would be reduced in this way. It is; however, to be hoped that such cigarettes will be produced and used; so that ini the course of time their effect on those who cannot forsake the habit of smoking may be gauged. The most important problem to which an answer is still needed is why people want, to smoke cigarettes and why do so many become addiated'to them. The report's discussion on the psychological aspect of smoking concludes that " social factors play a, bigger part, in, determining smoking, habits than internal drives or needs;" though addiction to nicotine may also be importanta", If this is so the problem, should, not be insuperable. The social effect of opinionn within the profession has probably been as effective in reducing cigarette smoking among doctors as has any fear of the consequences. But the inveterate addict to smoking remains, and we know very little about how his addiction can be overcome other than by self-control. The report suggests " anti:smoking clinics." These might' well' be valuable, and provide guidance for a policy of health education. So far as doctors are concernerii the report is quitee outspoken. Those who continue to smoke "inevitablv lessen the effect of any campaign of' public education concerning the consequences of the habit, and will findi it harder to help their patients who need to stop smoking." Some would say that no doctor who cares for the public health should be seen smoking a cigarette in public view, and' certainly not, in the presence of' ycung people. But the duty of inftuencing public opinion does not rest solely with doctors. The Minister of Health should take steps too keep himself andl Parliament fully informed about the epidemic of diseases associated with the smoking of cigarettes. B1at, to be effect2ve propaganda, andl health education should be local, and throughout thee country as a, whole there are opportunities for locall health authorities to observe, to advsse, and to act. They were charged under the National Healthi Service Act with the prevention of illness, and the illnesses caused by smoking can be prevented.