Tobacco Documents Online

wORLD~OSiF1REL*I~JON SMOKINCLAND H Ar'rw ~ lammng Committee mnuttee on Invntations PREFACE ............................................ CHAPTER I--SETTIhTG THE THEME.................. A TIME FOR ACTION-Luther L. Terry, M.D., Chair- man, World Conference on Smoking and Health, and Vice President for Medical'Affairs, University of Pennsylvania.. Objectives: Exchange information-Stimulate action / Public awareness at peak ADDRESS by The Honorable Robert F. Kennedy ...... Advertising industry self-regulation / Legislation re tar and nicotine / Strong warning in all advertising /"Fair- ness" doctrine /'Local monitoring /'Sliding tax scale. aFTR.R n m 14 ©RLD C DIS- 6,-- bAJL, U1JAliJ1.11. Y ANU UEA1'ri-L?. C hyter tiam- -' mond,, Sc.D., Vice President for EpidemioTogy and Sta- tistics, American Cancer Society...................... 15 Increased illness and disability / Cessation of smoking effect / Statistics on lung cancer internationally / Chronic respiratory disease in children / Higher cancer death rates other sites / Recommendations. CIGARETTES AND CARDIOVASCULAR DISEASE- Jeremiah Stamler, M.D., Associate Professor of Medicine,. Northwestern University Medical School'.............. 44 One million cardiovascular deaths Ui S. 1965 / Cig- arettes major factor-cor pulmonale deaths / Mortality ratios higher for younger age groups / Cigarette smoking problem of 20th century--can be changed. CIGARETTES AND CANCER-George E. Moore, M.D., Director, Public Health Research, New York State Health Department........................................ 74 Clinical research needed re specific sites /Government's task force for lung cancer / Development less harmful cigarette / Need large-scale cooperative clinical trials. CIGARETTES AND RESPIRATORY DISEASE-C. M.__ '" Fletcher, C.B.E., M.D., Reader in Clinical Epidemiology, Kdysl'Postgraduate Medical School, London, Eng. .. 78 England's Respiratory Mortality Rate World's Highest Bronchitis-emphysema syndrome / Smokers chief air pollution victims / Cessation only preventive for ventila- tory incapacity. PROBLEMS IN' CONDUCTING SMOKING RE- SEARCH-Sir Austin Bradford Hill, M.D., Professor Emeritus of Medical Statistics,, University of London.... 92 V THE S IC BACKGROUND

vi Contents Ethics of smoking research dominant problems I Con- ~ sideration of whole population / Profile of smoker un- likely to be answer / Randomization of clinics. CHAPTER III THE BRITISH AND NORWEGIAN EX- PERIENCES .......................................... 97 THE BRITISH EXPERIENCE--Sir George E: Godber, IC.C.B., M.D:, D.P.H., F.R.C.P., Chief Medical Officer, British Ministry of Health, London.................... 97 Differences between cigarette and other preventive medi- cal problems / Three notable reports since 1950 /'British restrictions on advertising / Government Social Survey on habits and attitudes / Suggestions for reaching uncon- vinced. INFLUENCING SMOKING HABITS: A NORWEGIAN CONTRIBUTION-Kar1 Evang, M.D., F:R.SM., F.R.S.L, Director-General, The Health Services of Norway ....... 108 Anti-cigarette campaign based on Committee analysis by multi-disciplinary scientific approach / Smoking levels of various age groups / Choice of media / Restrictive and therapeutic measures / Economic aspect. CHAPTER 1V-II*TFLUENCING SMOKING BEHAVIOR..118 KEYNOTE ADDRESS-William H. Stewart, M.D., Sur- geon General, United States Public Health Service...... 118 People want knowledge transformed into action / Con- cept of reduced tar-nicotine / Specific groups vulnerable to smoking risks / Total abolition impracticable / Future guidelines. HOW DID SOCIETY GET INT'O THE CIGARETTE MESS? WHY IS 1T SO HARD TO FIND A WAY OUT? -Daniel Horn, Ph.D., Director, National, Clearinghouse for Smoking and Health, U. S. Public Health Service ...... 126 60,000 puffs annually for pack-a-day smoker / Resolu- tion of earlier forms of gratification behavior / Factors involved in initiation and cessation / Solution through behavioral approach. PANEL DISCUSSION OF PSYCHOLOGICAL AS- PECTS OF SMOKING-A. C. MeKennell, Ph.D., Pro- fessor of Psychology, The University of Southampton, Southampton, England .............................. 133 Smoker vs. non-smoker pattern set by age 20 / One-half smokers want to stop / Light smokers best target Richard L. Foster, Ph.D., District Superintendent, San R'amon Valley Unified School District, Calif. ..........135 Programs require strong public relations pitch / Lesson learned best by teaching people what they have to teach, Silvan S. Tomkins, Ph.D., Director, Center for Research in Cognition and Affect, City Univeisity of New York, N. Y.. 136 The habitual smoker / The positive affect smoker / The negative affect smoker / The addict. Godfrey M. Hochbaum, Ph.D., Chief, Behavioral Science Section, Bureau of Health Services, USPHS ............ 1Ci8 Smoking has values for most smokers / Reduction may be only effective approach to certain smoketa

Contents vii CHAPTER V-WORK GROUPS: POSTTTON PAPERS ....140 Work Group 1 Addiction, Habituation, Pharmacology Work Group 2A Behavioral Problems and Progress Work Group 2B Behavioral Problems andpro ess Work Group 8 Role of Physician and Other Exemplars Work Group 10 Commuuicstions-The Media TOBACCO-HABIT AND ADDICTION-William A. Hunt, Ph.D., Chairman, Department of Psychology, Loy- ola University, Chicago, Illinois and Joseph D. Matarazzo, • Ph.D., Professor and Chairman, Department of Medical Psychology, University of Oregon Medical School, Port- land .............................................. 140 Paradigm of tobacco habittiation / Need A.A, type of supportive therapy / Smoking over-learned behavior. THE PHARMACOLOGICAL BASIS OF ADDICTION TO TOBACCO: NICOTTNE--Murray E. Jarvik, M.D., Ph.D., Albert Einstein College of Medicine, New York.... 142 Chemical cause underlies addiction / Effect of nicotine on brain not fully known / Drug to mimic or antagonize nicotine action / Research needed' to help addicted. A. C. McKennell, Ph.D. The University of Southampton, England (see Chapter I~, p. 133) Silvan S. Tomkins, Ph.D., City University of New York..143 Smoking's function control of affective information / Face primary site of human feelings / Smoking a tech- nique to help relieve suppressed emotions I Important toxic consequences of smoking. Work Group 3 Towards A Less Harmful Cigarette (Proceed- ings published separately by the National Cancer Instttute, Monograph No. 28, FVashington, D. C., June 1968) Work Groups 4A & 4B School Programs: Program Content, Materials, Ages to Reach Work Group 6 Teacher Edncation SMOKING EDUCATION: WHEN, WHERE, AND HOW-Ira Gordon, Ph.D., Institute of Human Develop- ment, University of Florida, Gainesville ...... .145 Problem is teaching non-behavior / Strong self-value concept important l' Child should see non-smoker re- warded' / Teacher behavior persuasive. THE SCHOOL AND SMOKING-AN EXERCISE IN FRUSTRATION (?)-Louise E: Hock, Ph.D., New York University, New York, N. Y. ........................ 161 Modifying habits of an entire people / Guiding principles / / Specific suggestions / Methodology and materials Greater promise lies with models. CIGAREfiI'E SMOKING, RESPIRATORY SYMPTOMS AND ANTI-SMOKING PROPAGANDA, AN EXPERI- MENT-W. W. Holland, M.D., B.Sc., Reader in Clinical Epidemiology and Social Medicine, St. Thomas's Hospital Medical School, London and A. ELLIOTT, MD., D.P.H. County Medical Officer, Kent County Council, England.. 169 Smoking habits children under age 13, over 14. Work Group 5 College Programs THE PRESENT SITUATION IN COLLEGES AND UNIVERSITIES AND A LOOK AT THE FUTURE-

viii Contents W. T. Robbins, M.D., Director, Student Health Service, University of California, Santa Barbara, Calif.......... 171 Behavior-changing activities / Projected study among 50,000 students / Survey of college policies re campus smoking. Work Groups 7A & 7B Giving Up Cigarette Smoking NEW YORK CITY SMOKING WITHDRAWAL CLINIC -Donald T. Fredrickson, M.D., Director, Smoking Con- trol Program, New York City Department of I3eaith..... 187 Purpose and design / Staff of volunteer ex-smokers / Orientation / Withdrawal / Reinforcement / Results. REPORT ON WITHDRAWAL CLINICS-Borje E. V. Ejrup, M.D., Clinical Associate Professor of Medicine, New York Hospital, Cornell Medical Center........... 198 Program for hard core smokers / Approach for use by general practitioner / Lobeline hydrochloride injection / Preventing relapses. SMOKING WITHD RAWAL IN MEDICAL PRACTICE -SOME EPIDEMIOLOGICAL ATTRIBUTES OF SMOKING-George Christakis, M.D., Assistant Dean and Associate Professor, Community Medicine, Mt. Sinai School of Medicine, New York........................ 207 Results of study of smoking on Island of Crete. RESULTS OF AN ANTI-SMOKIPIG CLII+lIiG-Keith P. Ball, MD., F.R.C.P„ and Miller Mair, M.A., Dip. Psych., Ph.D., Central Middlesex Hospital, London ............ 208 Method of' operation / Four implications for treatmentl AN' ATTEMPT TO DISCUSS' THE COST-BENEFIT PROBLEM RELATED TO SMOKING WIITFIDRAWAL CLINICS AND COURSES-Kje11 Bjartveit, M.D., Senior Medicai'OfEoer, National Mass Radiography Service, Oslo. 210 Death rates of 100,000 smokers vs. 100,000 non-smokers. THE ROLE OF THE PFIYSICIAN IN THE CONTROL OF SMOKING-Judith S. Mausner, M.D., Assistant Pro- fessor of Epidemiology, Woman's Medical College, Phila- delphia, Pennsylvania and Bernard Mausner, Ph.D., Pro- fessor of Psychology, Beaver College, Glenside, Pennsyl- vania .............................................211 Physician influence potentially greater than mass media or clinics / How to increase physic~an participstion. IMPLICATIONS FOR FUTURE TREATMENT PRO- GRAMS:-Jerome L. Schwartz, D:P.H~., Project Director, and Mildred Dubitzky, Ph.D., Research Psychologist, Smoking Control Research Project, Berkeley, California..216 Control methods / Selecting ants / Evaluating k Gro~ap / Fo Role of PhysiWhat dan ~a d«Othf ~~ efit7 Wor THE PHYSICIAN AS EXEMPLAR-Richard H. Over- holt, M.D., Director, Overholt Thoracic Clinic, Boston..226 Four constructive steps for physicians. CIGARETTE SMOKING: MAGNTITJDE OF THE PROBLEM-R. T. Ravenholt, M.D., M.P.H., Director, Population Service, Office of the War on Hunger, Agency for International Development ....................... 227 Smoking by medical;: dental, and nursing faculty.

Contents AN ANTISMOKING PROGRAM FOR TEACHERS- Eva J. Salber, M.D. and Theodore Abelin, M.D., Depart- ment of Epidemiology, School of' Public Health, Harvard University ........................................ 228 Clinic attendance by high school teachers related to su- perior knowled~e re smok~ng nsks. Work Group 9 Government Actioo and LegiShBon RESULTS OF GOVERNMENT ACITON AND LEGIS- - LATION-Leo Noro, M.D., Director, Institute of Occu- pational Health, Helsinki ............................ 230 No advertising / Eight governmental activities. REMARKS-David '1~ Carr, M.D., Professor of Clinical Medicine, Mayo Clinic, Rochester, Minnesota.......... 231 Smoking by sports figures and TV actors possibly more inflnentialthan commercial advertising. THE PRESENT STT4JATION IN ITALY-Professor Carlo Vetere, Director, Division of Health Education, National Ministry of Health, Rome................... 232 No advertising / General increase in sales / Ban on cigarette smoking m movie theatres opposed. WHAT OTHER CiOVERNMENT ACTION IS NEED- ED? Lester Breslow, M.D., Director, California State Department of Public H'ealth, Berkeley................. 232 Problem intensified by availability of cigarettes and longevity / Must solve economic problems of industry. REMARKS ON F.C.C. "FAIRNESS DOCTRINE" RUIr ING-John F. Banzhaf; III, Attorney, New York, N. Y.. .236 Attack on health agencies /'Request for support of Con- ference delegates in enforcement of ruling. RESULTS OF GOVERNMENT ACTION' AND LEGIS- LATION-Gyorgy Karpatf, M.D., Leader of Fight Against Cancer, Minister of Health, Budapest, Hungary.......... 237 Anti-alcoholism program strengthens anti-smoking cam- aign / Influence of tobaozo on male genital organs. T OTHER GOVERNMENT ACTION IS NEED- ED?: Vsevolod Bilyk, M.D., Inspector General, Minis- try of Health and Social Welfare, Bucharest, Ronmania..237 Smokers compnlsory checkup / Nicotinelesa cigarettes. Work Group 10 Comm~katlons-The Malla CHANGES IN ADVERTISING EXPENDITURE AND SMOKING BEHAVIOR AFTER THE BAN ON' TELE- VISION ADVERTISING IN THE UNTTED KINGDOM -John Wakefield, Head, Department of Social Research, Christie Hospital & Holt Radium Institute, England.....238 Increased cigar, pipe advertising /'TV revenue loss made up by other products / Coupon schemes popular / 3%'o increased smoking in 16-19 year-old agegrou TALK TO THEM IN THEIR OWN LANGUAG~Tony Schwartz, New Sounds, Inc., New York, N. Y............ 239 Special techniques to reach young people. THE NORWEGLAN EXPERIENCFf-Ottar S. Jacobsen, Secretary-General, Norwegian Cancer Society.......... 240 No radio and TV advertising / Restrictions on cigarette advertising in other media. WHAT TO DO ABOUT CIGARETTE ADVERTISING

a Contents -Emerson Foote, New York, former Chairman, National Interagency Council on Smoking and Health...........242 $300 million annual advertising expenditure /' F.C.C. Fairness Doctrine / Advertising Council sponsorship ant9=smoking campaign? CHAPTER VI-WHAT SHOULD SOCIETY DO TO CON- TROL CIGARBTI'E SMOKING? PANEL DISCUSSION OF WORK GROUP RECOMMENDATIONS The Honorable Frank E. Moss, U. S. Senator from Uteh.250 Education, not prohibition / Pending legislation. Sir George E. Godber, K.C.B., M.D., D.P.H., F.R.C.P.....251 Conference results in new and definite message for public. Karl Evang, M.D., F.R.S.M., F:R.S.L,, F.A.P.FLA....... 252 "Our platformm is strong" / In Norway, fear not a deter- rent to youth not moved by statistical evidence / Involve WHO, UNESCO, etc. William H. Stewart, M.D., U. S. Surgeon Generai....... 254 Recommendations point to three-part program. Ashbel C. Williams, M.D., President, American Cancer Society (1967) .................................... ,255 Establish research institute to get new answers. Arthur T. Roth, Board Chairmani Franklin National Bank.255 Employees smoking forbidden on basis of profits. Ernest L. Wynder„M.D., Memorial Sloan-Kettering Cancer Center .......................................... 256 Impractical to remove all. tar and' nicotine. Luther L. Terry, M.D., Conference Chairman........... 256 The challenge-to save worldwide loss of life. CHAPTER VII-WORK GROUP RECOMMENDATIONS,.258 Work Group 1 Addktlon, Habituation, Pharmacology of Tobacco Work Group 2A Behavioral Problems and Progress Work Group 2B Behavioral Problems and Progress Work Group 3 Towards A Less Harmful Cigarette Work Group 4A School Programs: Program Content; Materi'- a1s, Ages to Reach Work Group 4B School Programs: Program Content, MaterL als, Work Groap 5 College Work Group 6 Teacher Education Work Group 7A Giving Up Cigarette Smoking Work Group 7B Giving Up Cigarette Smoking Work Group 8 Role of Physician and Other Exemplars Work Group 9 Government Action and Legislation Work Group 10 Commmntcations-Tbe Media LIST OF PARTI'CIPANTS AND ADDRESSES............285 l

Robert F. Kennedy 13 enacted right away. For the industry we seek to reg- ulate is powerfuli and resourceful. Each new effort to regulate will bring new ways to evade, just as the television advertising ban in Britain brought forth an intensified coupon war to promote smoking. Still, we must be equal to the task. For the stakes involved are nothing less than the lives an& health of millions all over the world. But this is a battle which can be won-and with the commitment that is dem- onstrated by this conference; with the commitment that all of you show in being here and in your work at home-I know it is a battle which will be won.

CHAPTER II The Scientific Background The first session of the Conference then heard a sum- mary of the most recent research findings in a number of fields: epidemiology, cardiovascular disease, cancer, res- piratory disease, and problems of conducting smoking re- search. The first of these scientific talks, by E. Cuyler Hammond, SC.D., Vice President f or Epidemiology and Statistics of the American Cancer Society, was delivered on behalf of the following international Committee on Epidemiology: Johannnes Clemmesen, D.M.Sc., Director, Danish Cancer Registry, Copenhagen, Denmark H. N. Colburn, M.D., M.P.H., Medical Consultant, Smoking and Health Program, Department of National Health and Welfare, Ottawa, Canada Charles M. Fletcher, C.B.E., M.D., F.R.C.P., Postgrad- uate Medical School, London, England William M. Haenszel, M.A.,, Chief, Biometry Branch, National Cancer Institute, Bethesda, Maryland E. Cuyler Hammond, Sc.D., Vice President for Epide- miology and Statistics, American Cancer Society, New York, N.Y. Takeshi Hirayama, M.D., Chief, Epidemiology Divi sion, National Cancer Center, Tokyo, Japan W. W. Holland, M.D., B.Sc., Department of Clinical Epidemiology & Social Medicine, St. Thomas' Hos- pital Medical School, London, England S. Koller, M.D., Ph.D., Johannes Gutenberg Univer- sity, Mainz, Germany Naum Marchevsky, M.D., Office of Secretary of Public 14

E. Cuyler Hammond 15 Health, flipolito Irigoyen 370, Buenos Aires, Argen- tina,, South America Torbjorn Mork, M.D., Ph.D., Deputy Director, Cancer Registry of Norway, Oslo, Norway Jerzy Staszewski, M.D., Institute of Oncology, Gliwice, Poland C. B. Walker, Principal Research Officer, Bio-Statistics Division, Department of National Health & Welfare,, Ottawa, Canada. Dr. Hammond's paper, on worl& costs of cigarette smoking in disease, disability and death, follows: Since early this summer our Committee has been working on the preparation of material for this ses- sion. During July, small preliminary meetings were held in Oslo, Copenhagen, London and Mainz. Members of the Committee have worked diligently in reviewing a tremendous volume of material pub- lished in many different languages. In addition, sev- eral of the members analyzed original data from new studies as well as more extensive data resulting from several more years of follow-up of subjects in large prospective epidemiological studies. Some of this new material will be presented this morning. This last Saturday and Sunday all but two of us met in New York, discussed our joint' findings and prepared this report. We will first present findings on totali mortality and total morbidity and then present findings in relation to three important diseases: coronary heart disease, lung cancer and other lung diseases. We will men- tion other diseases more briefly, discuss the problem of extrapolation to countries where studies have not been made and end by presenting several reeommen- dationsforfuture research. Total Mortality In the past, the effects of smoking have usually been expressed in terms of mortality ratios. For example, it has been said that the death rate of heavy cigarette

16 The Scientific Background 1 smokers is two to three times as high as the death rate of non-smokers. Now we have data covering a sufficiently wide age range to be able to construct life tables in relation to smoking habits. We have chosen to use this form of presentation today. It will be noticed that slightly different groupings by age and by amount' of smoking have been used in dif- ferent countries. This prevents direct comparison. Life Table for 35 year old Men Estimate from British Doctor Study Non Current No. Cig.A Day Age Smokers 1-14 15-24 25+ $ ~ $ $ 00. 100.0 100.0 100.0 40 99.5 99.2 99.2 97.8 45 98.6 98.]. 97.9 95.1 50 96.3 '95.4 94.4 90.4 55 94.3 91.6 89.9 84.5 60 88.7 83.8 81.1 74.3 65 81.9 74.3 71.5 62.9 70 69.7 58.4 57.7 46.2 Slide 1 From Doll and Hill's study of British doctors. This slide (#1) shows life tables for 35-year-old men constructed' from findings during 12 years of' follow-up of 34,000 British physicians in the study carried out by Doll and Hill. 69.7% of male British physicians who never smoked regularly may be ex- pected to live to the age of 70. In contrast, only 58.4% of those who smoke 1 to 14 cigarettes a day, 57.71o of those who smoke 15 to 24 cigarettes a day, and 46.2 jo of those who smoke 25 or more cigarettes a day may be expected to live to that age. The next slide (#2) shows life tables for male Canadian war veterans. It is based upon findings among 78,000 men traced for six years in a study undertaken by Best, Walker and others of the Cana- dian Department of National Health and Welfare.