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Tt~E 'LANCET, NOVEMBER 16, 1985 1111 Occasional Survey IS THERE A FUTURE FOR LOWER-TAR-YIELD CIGARETTES? Participants of the Fourth Scarborough Conference on Preventive Medicine* Summary An international workshop was held to consider whether the policy adopted in many countries to encourage the decline in cigarette tar yields was beneficial. The consensus was that the policy had been beneficial and that tar yields should be further reduced. In addition the yield of other smoke components should be reduced even in the absence of conclusive evidence of their specific toxicity. The lower-tar policy should be monitored to ensure that the concentration of smoke components (or their metabolites) in smokers declines as the yields decline. The public need to be made aware ofthe uncertainties of the policy with respect to its effects on the risk of diseases other than lung cancer and that the benefits from smoking lower-yield cigarettes are smaller than those derived from avoiding cigarettes altogether. INTRODUCTION CIGARETTE smoking is the most pressing health issue in economically developed countries. Public health policy has been directed at discouraging non-smokers from starting to smoke and encouraging smokers to stop. By the early 1980s in both the US and the UK, cigarette consumption per head had decreased. In the UK it had decreased by about 35% in men iom a fairly steady maximum spanning the period 1940-75 end decreased by about 25% in women from a peak value in 1976. In the US it decreased, in both sexes combined, by about 20% from a peak in 1963. The trends are shown in fig 1~,2 (and Tobacco Advisory Council, unpublished). Since the early 1970s, the US and UK authorities have also recommended that people who are unwilling or unable to give up smoking switch to cigarettes of lower tar and nicotine yield, in the expectation that the adverse health effects of smoking could be reduced.la The policy was never intended to be an alternative to encouraging smokers to give up smoking; nor was it expected that the benefits of smoking lower delivery cigarettes would be as great as those to be derived from stopping smoking altogether. Despite the decline in sales-weighted tar yields in the US and UK (fig 2),l't doubt has been expressed about "whether "l)articipams: N. Benowitz, M. Eeinlcib, C. Feyerabend, L. Garfinkel, R. Grcenberg, T. Guarino, J. tladdow (Co-chairman), V. Hawthorne, S. Jones, \V. Kanncl, D. Kauliuam G. Knight, L Kozlowski, M. Kunze, J. Luoto, G. Palomaki, N. Pride, G. Rose, M. Russell, R. Stepney (Rapporteur), H. van Vunakis, N. Wald (Co-chairman), J. Wilkenfield, E. Wynder. No. Gi~aret tes¢ Adult/Year ,ooo 4000 2g~ 1500 --- US men & women 500 ]- ..'* ...... UK women 0 20 25 30 35 40 45 50 55 60 65 70 75 8085 Fig 1--Annual consumption of manufactured cigarettes per adult in the USA and UK from 1920 to 1985. (Data for men and women separately are not available for the USA.) the lower-yield policy has been beneficial.%6 In this paper, which arose from discussions at a meeting in Maine, USA, in 1984, we consider the issues surrounding the advisability of a lower-tar policy. The conclusion expressed in this paper represents the general view of the group involved but on some issues there were one or two dissensions. HAVE I.OWER-YIEI.D CIGARETTES BEEN OF HELP SO FAR? Lung Cancer The carcinogenic activity of tobacco smoke seems to reside in the tar,7 so it is reasonable to expect that cigarettes yielding less tar will be less likely to cause lung cancer. However, the relation may not be straightforward. One cause of uncertainty involves "compensatory" smoking--the tendency of smokers to increase the amount of smoke inhaled from a cigarette of lower tar yield and, to a lesser extent, to increase the number of cigarettes smoked. Several studies in which the intake of carbon monoxide or nicotine have been used as an indirect measure of tar exposure have found that'the estimated reduction in tar intake is only about half of what might be expected from the difference in cigarette tar yields.8Jl Prospective epidemiological studies1~14 of lung cancer show, on average, an approximate 20% reduction in risk associated with lower-tar (or filter) cigarettes compared with higher tar (or plain)--a difference that is very much what would be expected from the intake studies. Most lung cancers still occur in filter cigarette smokers who have switched from plain cigarettes, so the full effects of falter cigarettes have not yet been seen. One case-control study that has looked at IifeiongTiiier smokers Suggests that the reduction in risk may be between 30 and 40%.15 Secular trends in lung cancer mortality and cigarette consumption in Britain indicate that the lower risk of lung cancer in smokers of lower tar compared with high-tar I. lh~pe.Simpson RE. The nature of herpes zoster: A long term study and a new hypothes~s, Pre¢ R Sac Med 1965; 58: 9-20. 2. Thomas 3,t, Robertson W], Dermal transmission of virus as a cause of shingler. Lancet 1971; it: 1149-50. 3. Berlin BS, CampbellT. Hospltal-acquired herpeszoster following exposuretochicken- pox, J,-/3L~/1970~ 2:11: 183,1-3,3,, 4. Morens DM. Bregman D J, West M, et al. An outbreak of varicella-zo*ter viru~ three- lion among cancer pat ienl~. Ann Intern Med 1980; 98." 414-19. 5. Ederer F, 3tyer~ MH, Mantel N. A statistical problem in space and time: Do leukemia ¢as~ come in clusters? Bwmetrlcs 1964; 20: 626-36. Weller TH. Varicella and herpe~ zoster, N EnglJ Med 1983; 30~: 1362-68. S. R, PALMER AND OTHERS: REFERENCES 7. Ross CAC, B ro,,~-n WK, Clarke A~ et al. Herpes zoster an general practice,.7 R Coll Pratt 1975; 25: 29-32. 8. Cradock-Wat~.on IE, Ridehalgh blKS, Bourne MS. Specific immunoglobulin res- ponses after varicella and herpes zoster. J H)~ (Camb) 1979; 82: 319-36. 9. Weller TH. Varicella and herpes zoster. N EnglJ 3led 1983; 30~: 1434-40. 10. Arvin AM, Koropchak CM, Witter AE. tmmunologtc evidence of reinfection with varicella zoster virus. J Infect Dis 1983; 148: 200-05. 11. Gershon KA, Steinberg SF, Gelb L. Clinical reinfection witi~ varicella-zoster virus. Infect Dis. 1984; 149:13,7-42. 12. Gersbon APt, Steinberg SP, Ceil.mediated immunity to varicella-zoster virus measured by virus inactivation: Mechanism and blocking of the reaction by specific antibody. Infect Immun I979; 25: 164-69. 0 O

mt3/ci£t 30 25 20 15 ]0 5 0 2.00 1.80 1.60 1.40 1.20 1.00 0.80 0.60 0.40 0.20 0.00 T~r u~ USA ~ I i I I I 68 70 72 74 76 78 80 - Nicotine I 82 84 UK USA I I I I I I I I 68 70 72 74 76 78 80 82 84 Year Fig 2--Sales-weighted tar and nicotine yields in the UK and USA from 1968 to 1984. cigarettes observed in epidemiological studies is not the result of self-selection. Male per head cigarette consumption changed only slightly between 1946 and 1975 (fig 1), but tar levels per cigarette decreased substantially, beginning in 1965 (fig 2). In the next few years the incidence of lung cancer began to decrease in younger men.16 Since then, a similar trend has become apparent for oIder men as well. During the same period, while tar yields decreased, cigarette consumption per head increased among women, and no reduction in female lung cancer mortality occurred. Coronary lIeart Disease The component of cigarette smoke that is responsible for the excess risk of coronary heart disease is not known, though nicotine and carbon monoxide are suspect. The nicotine and carbon monoxide yields of lower yielding cigarettes have, on average, been reduced by less than their tar yields.; Therefore, compensatory smoking results in an intake of nicotine and carbon monoxide which is not much less than that of smokers of higher yielding brands. On the assumption that coronary heart disease is due to nicotine, carbon monoxide, or a smoke constituent closely related to either, the disease is thus unlikely to be materially reduced by smoking currently available cigarettes with lower nicotine or carbon monoxide yields. Recent epidemiological observations indicate that the risk ofcoronary heart disease is not greatly affected by the yield of the cigarette. The American Cancer Society Study suggested a small decrease in coronary heart disease mortality among smokers of relatively low tar or nicotine cigarettes compared with smokers of higher yields,tz In the Framingham study, however, filter cigarette smokers had a greater risk of coronary heart disease than smokers ofnon-filter cigarettes.17 Data from the Whitehall Studyt4 were inconclusive, and the West of Scotland Study~3 found no significant difference in coronary heart disease mortality between smokers of plain and filter cigarettes. A recent study from BostonIs showed clearly that the risk of non-fatal myocardial infarction, while THE LANCET, NOVEMBER 16, 1985 increased threefold in cigarette smokers, was unrelated to nicotine or carbon monoxide yield. Therefore, apart from one study (the largest),~2 reductions in tar and nicotine yields have been found to have essentially no effect on the risk of coronary heart disease. Chronic Obstructive Lung Disease Chronic obstructive lung disease has not been extensively studied in relation to tar yields and, though the smoke components responsible for it are unknown, interest has extended to oxides of nitrogen as a possible cause. Several cigarette brands yielding lower amounts of tar and nicotine have relatively high deliveries of nitric oxide and other gases (unpublished results, UK Laboratory of Government Chemist). The evidence that lower-tar cigarettes confer a health advantage rests mainly on results from only two prospective studies. The American Cancer Society Study~9 found an association between lower-tar-yield cigarettes and a (non-significant) reduction in deaths due to emphysema. The Whitehall Study reported that lower-tar smokers produced less phlegm2° and had a slightly higher FEV, 2~ than smokers of the same number of high-tar cigarettes. DOUBTS ON TIlE FUTURE OF THE I.OWER-YIE1.D POLICY The wisdom of advocating further reductions in cigarette yield has been challenged on three main grounds. We present the argument and the response in each case. Diminishing Returns and Possibility of Encouragh~g Smoking The reductions in male lung cancer risk observed so far in the UK and US are largely attributable to the switch from non-filter to filter cigarettes during the 1950s and 1960s. There is no direct evidence that the beneficial effects which accompanied thc reduction in yield from around 35 mg to around 18 mg tar will also bc found when yields fall from the present average of 15 mg to 10 mg or below. More research on the effects of smoking modern lower-tar cigarettes is needed. Compensation might increase with further reductions in yield, leading to diminishing returns in disease prevention. If this were true and if the lower-tar policy were to encourage people to start smoking or discourage smokers from giving up the habit, the balance could be tipped against the lower-tar policy. On a larger scale, by appearing to legitimise the habit, the lower-tar policy may also militate against government efforts to encourage the avoidance of smoking. The importance of compensatory smoking should not be overemphasised. Even if further reductions in tar yields produce proportionately less benefit, any benefit would be worthwhile. Concerns that a lower-tar policy will encourage smoking do not seem to be well grounded and tar-reduction programmes may actually help people to give up smoking. In both the US and the UK, which have active tar-reduction programmes, there have been notable reductions in general smoking rates and cigarette consumption. In the American Cancer Society Survey, people who had switched to lower-tar cigarettes at the start of the study were more likely to have become ex-smokers by the end, irrespective of the number of cigarettes originally smoked. Possibility that Cigarette Enghzeering Might Increase Risk of Disease Changes in cigarette design might increase the risk of chronic obstructive lung disease or cardiovascular disease by increasing the concentration of harmful smoke components 0 O~ C~ O~ 0 THE LANCE" other than t" by increasin However, component~ lower yield~ lower-tar cardiovascu comparison Possibility t. It has bee purpose of~ on a standar may misleat tar strategy. "cheat the ~ (the US br represents a the ventilat These cigar allow smol~ 'Barclay' is is approprk typically ct smoking b3 machine sm these cham rather than Canadian unpublishc. counter tht Altering tht affect the ra are therefo~ do not retie, attempts sh having an machine sc cigarettes a' more closel gripping d~ efforts hart Continue t/ Other Nox, Despite ~ tar yield fi policy alto emphasis t mono~de i of tar yield Governme: the UK, a~ specified s; encourager This polic~ withdrawn cigarettes ~ The rob policy in tl exports of industry, 1 controls or the groum .t

, THE LANCE~T, NOVEMBER 16, 1985 other than those specifically being reduced and possibly also by increasing the extent of inhalation. However, although it is possible that certain toxic smoke components may be increased in. cigarettes with otherwise I~'lower yields, there is at present no satisfactory evidence that lower-tar cigarettes materially increase the risk of cardiovascular or chronic obstructive lung disease in comparison with current higher tar brands. Possibi]#y that Tar-tables May Mislead S~nokers It has been argued that compensatory smoking defeats the purpose of Government tables of tar yields, based as they are on a standard set of machine-smoking variables.22 Tar-tables may mislead smokers and reduce the credibility ofthe lower- tar strategy. Furthermore, it is possible for manufacturers to "cheat the machine". One brand of cigarette, in particular (the US brand 'Barclay', which uses the 'Actron' filter) represents a special case of a general problem of blockage of the ventilation holes of cigarettes with ventilated filters. These cigarettes have holes in the side of the filter tip which allow smoke drawn through the cigarette to be diluted. 'Barclay' is alleged to occupy a lower rank in the tar-table than is appropriateJ~ Its filter has ventilation channels which are typically crushed and blocked in the normal course of smoking by lips and fingers, but are not obstructed during machine smoking. With ventilated cigarettes that do not have these channels, hole blocking is thought to be a sporadic rather than a systematic consequence of normal smoking. Canadian and British data-'~'-~5 and the results of unpublished studies by the UK Government Chemist largely counter the argument that the tar-tables mislead smokers. Altering the machine-smoking conditions does not materially affect the ranking of different brands. As intended, the figures are therefore fair indications of relative yields, although they do not reflect the absolute yields to the smoker. Undoubtedly,. attempts should be made to prevent particular brands from having an unreasonable advantage under conditions of machine smoking. For example, the grip with which the cigarettes are held in the machine could be made to simulate more closely that produced by human lips--for instance, the gripping device could be elliptical instead of circular, but efforts have to be made to ensure that there is no leak. T t I E \VAY FORWARD Continue the Lower-tar Approach while Reducing Yield of Other Noxious Agents Despite uncertainties about the medical effects of reducing tar yield further, there is insufficient reason to abandon the policy altogether. It needs to be modified, though. More emphasis needs to be given to the reduction of carbon monoxide yields and those of other noxious agents. Control of tar yields, albeit by "voluntary agreements" between the Government and the tobacco industry, are already in force in the UK, and similar controls could be instituted for other specified smoke components. Yield reductions could also be encouraged by taxing higher-yielding brands more heavily. This policy was followed in the UK-~6 but was unfortunately withdrawn, despite successful reductions in the sale of cigarettes with tar yields over 20 rag. The tobacco industry has complied with the lower-tar policy in the US and the UK. It has recently also curtailed exports of high-tar cigarettes to developing countries. The industry, however, may be less enthusiastic about price controls or the control ofthe yield of other noxious agents, on the grounds that evidence of toxicity for a specific smoke 1113 Fig 3~Diagram by which smokers can gauge their intensity of smoking. Middle circle indicates the staining of a cigarette butt with standard smoking procedure; left circle represents relative "under-smoking" and right circle relative "over-smoking". (Supplied by L. Kozlowski.) component should be provided before the yield of that component is restricted. At first sight, this seems reasonable. However, the chances of showing that any single component of tobacco smoke is responsible for a particular disease is small, not because the component is harmless, but because the studies required are difficult, if not impossible, to carry out. Cigarette smoke inhaled into the lungs is one of the most toxic environmental hazards in general life, but the exact chemicals responsible and their modes of action remain largely unknown. In the face of these difficulties it is unreasonable to demand evidence of toxicity for individual • chemicals before preventive action is taken. To do so would be like resisting demands for clean drinking water until the precise microorganisms responsible for disease were known. it is sensible public health policy to focus attention on broad components of tobacco smoke for which there is general evidence of toxicity, such as tar, while at the same time ensuring that the concentration of other components likely to be harmful are reduced as well. A gradual reduction in the concentration of components such as carbon monoxide and oxides of nitrogen, based on knowledge of their biological effects, is more likely to change mortality and morbidity for the better than for the worse. Publicising the reduction in yields other than tar (preferably on the packet as ffell as in separate tables) will draw attention to the risk of diseases other than lung cancer, such as coronary heart disease, which are caused by cigarette smoking. Implement Biochemical Epidemiological Monitoring The continuation of the lower:tar policy and its possible extension to other noxious agents in cigarette smoke needs to be monitored. There are practical difficulties in doing this with disease or death as end-points. An alternative and more manageable approach is to measure exposure to smoke components directly, by the use of biochemical markers such as cotinine and carbon monoxide in blood. The application of such "biochemical epidemiological" techniques may help predict changes in mortality and morbidity without having to wait for the full pathological effects. Investigate Contpensatory Smoking A medium-nicotine low-tar cigarette has been proposed as one which might reduce the extent to which smoke from a cigarette is inhaled.-'7 The effect ofnicotine yield (and other features of a cigarette, such as i~g draw resistance) on the extent of compensation in the general population needs further investigation. The public health position on whether nicotine yields should be maintained can then be clarified. Increase Awareness of Possible Dangers of Compensatory Smoking At the same time as the lower yield approach is pursued, governments should make smokers more aware of the reality and potential risks of compensatory smoking. Kozlowskie.~

, • '•° , , 1,114 has suggested that cigarette p~ckets might contain a simple illustration (fig 3) showing the extent to which the end of a filter is stained by smoking. Darker staining would suggest oversmoking relative to the machine and so provide a guide to the absolute yield being obtained, and how it can be reduced. CONCLUSION There is a future for lower-tar yield cigarettes, but the aim should be to reduce the yield of other smoke components as well as of tar. Biochemical monitoring of the concentration of smoke components (or their metabolites) in smokers can ensure that exposure is on average reduced even if this reduction is less than would be expected from the reduction in machine-smoked yields on account of human compensatory smoking. The public needs to be made aware of the uncertainties of the policy, particularly those arising from compensatory smoking, and also that the benefits of smoking lower-yield cigarettes can only be small compared with those of avoiding the smoking habit altogether. The lower-yield approach is but one facet of a general strategy aimed at reducing the extent of disease caused by smoking in societies in which some people will continue to smoke regardless of the adverse long-term consequences to their health. This paper arose from papers and discussion at the Fourth Scarborough Conference on Preventive Medicine held in September, 1984, in Scarborough, Maine, USA. The meeting was sponsored and supported financially by the American Cancer Society, Maine Division, Esther G. Dachslager Fund, and the American Heart Association, Maine Affiliate Inc. We thank the Tobacco Advisory CounCil, the Laboratory of the Govern- ment Chemist, the US Office of Smoking and tleatth, and Stephanle Kiry|uk for helping to providc certain data referred to in thc paper. Correspondence should be addressed to N. J. W., Department of Environmental and Preventive Medicine, Medical College of St Bartholomew's ttospitat, Charterhouse Square, London ECIM. 6BQ. REFERENCES 1. The health consequences of smoking: A report of the surgeon general. US Department of 11eahh and tluman Serwccs, l'ubhc Ilealth Service, Oll'tce of Smoking and Ileahh, 198l. 2. Lee PN, ed. Statistics of smoking m the Umtcd Kingdom, research paper 1.7th ed. I.ondon: Tobacco Research Gounod, 1976. "L Third Report of the Independent SctcnUfic Committee on Smoking and health. Chairman: Peter F~ogg~tt. London: tim Stauonery office, 198~: 11. 4. Wold N J, Doll R, Copeland G. "Fronds in tar, nicotine, ~nd carbon monoxide yields of UK cigarettes manufactured since 1934. BrMedff 1982; 28~." 76]-65. 5. Prevention of coronary heart disease: report of a WHO expert committee. 1~'I10 Tech Rip Set, 678. Geneva; World tlcalth Organisatinn, 19~2: 27. 6. Gersteln DR, 1.evison PK, eds. Reduced tar and nicoune cigarettes: smoking behavior and health. Washington DC: National Academy Press, 1982: 5. 7. Wynder EL, Hoffmaa D. Tobacco and tobacco smoke: studies m experimental carcinogenesis. New York: Academic Press, 1967: 529. 8. Wold NJ, Idle M, Boreham l, Bailey A. Inhaling habits among smokers of dilTerent types of cigarette, Thorax 1980; 35: 925-28. 9. Ashton tt, Stepney R, Thompson JW. Self.titration by cigarette smokers. Br Med] 1979; it: 357-60. 10. Russell MAH, Sutton SR, lyer R, Feyerabend C, Vesey CJ. Long term switching to tow-tar low nicotine cigarettes. BrffAddict 1982; 77: 145-48. I 1. Stepney R. Would a medium-nicotine, low-tar cigarette be less hazardous to bealth? Br .44edff 198t; 283:1292-96. t2. Hammond EC, Garfiokel L, Seidman H, Lew EA. "Tar" and nicotine coatem of cigarette ~moke ha relation to death rates. Env Res 1976; 12: 263-74. IL Hawthorne VM, Fry JS. Smoking and health: the association between smoking behaviour, total mortality, and cardiorespiratory disease in W est Central Scotland.ff Epidemiol Comm tllth 1978; 32: 260-66. 14. l-liggenbmtam T, Shipley MS, Rose G. Cigarettes, lung cancer, and coronary heart disease: the effect~ of inhalation and tar yield. J Epidemiol Comm Hlth 1982; 36: 113-17. 15. Lubin JH, Blot WJ, tlertino F, et at. Panerna of lung cancer according to type of cigarette smoked, lot ~ Cancer 1984; 33: 569-76. 16. Wold N'J. Smoking. In: Vessey MP, Gray MJA, eds. Cancer risks and prevention. Oxford: Oxford University Press, 1985: 44-67. 17. Castelli WP, Dawbet TR, Feinleib M, Garrison R J, McNamara PM~ Kannel WB. The filter cigarette and coronary bean disease; the Framingham study. Lancet 1981; it: 109-1J. 18. Kaufmzn DW, Helmrlch SP, Rosenberg L, Miettinea OS~ Shapiro S. N.icotine and carbotx m~noxide ¢~ntent of cigarette smoke and the risk ~f myocardial irffarct iota in young men. NEngl.~Med 198J; 1108: 410-1~. References conthnted at foot of next column THE LANCET, NOVEMBER 16, 1985 Point of View COMMUNITY GENERAL PRACTITIONER DAVID MANT PETER ANDERSON Oxfordshire Health Authority, Manor House, Headley l~ay, Oxford OX3 9DZ Summary The attainment of quality in general practice entails explicit recognition of the public-health content of primary care. General practitioners should accept responsibility for auditing the state of the practice health, monitoring and controlling environmental disease, planning local services, auditing the effectiveness of preventive programmes, and evaluating the population effects of medical intervention. This requires specific training in the skills of population medicine, reallocation of scarce resources, and cooperation with existing public-health doctors. Eventual integration of community medicine and general practice is desirable. INTRODUCTION "The world needs a new kind ofdoctor, one who combines clinical skills with the skills of population medicine." This exhortation by Hart~ applies not only to general practice but to all areas of medicine. It is ironic that this dichotomy exists in the United Kingdom, which boasts a population-based system of primary care, an expertise in population medicine which is unrivalled in Europe, and a National "Health" Service. The divisions in the structure of the health service which have led to a community-medicine specialty without access to the community and a primary-health-care system without responsibility for the community's health is not an evolutionary accident. Some of the political forces that led to a tripartite structure in 1946 have not weakened. However, a growing number of doctors working within the constraints imposed by these damaging divisions are eager for change. The Royal College of General Practitioners has set the lead with its recent emphasis on prevention, and in practical terms the involvement of general practitioners in this field is increasing: for example, the proportion of cervical smears taken by general practitioners in Oxfordshire has increased from 40% to over 70% in the past decade. SimiLarly the number of community physicians who wish to see community medicine live up to its name is also growing. It was therefore disappointing to read the two recent papers on quality of care published by the Royal College~'3 which fail to include the integration of the skills of popu)ation N. WAI.D AND OTIfERS: REFERENCES--COtIti?Iu¢d 19. Lee PN, Garfinkel L. btor tality and type of¢igarene smoked, ff Epidemlol Gomm tilth 1981;85: 16-22. 20. nlgenbonam T, Sbapley MJ, Clark TJtt, Rose G. Lung function and symptoms of cigarette smokers related to tar yield and number of cigarettes smoked. Lancet 1980; i: 409-12. 21. Lee PN. Low tar ctgarene smoking. Lancet 1980; i: 1365-66. 22. Hatriman E. Turning the tables. The Guardian, May 2, t984: p 11. 23. Harriman E. Tar table 'chca~' are sued. NewSciemist July 21, 1983: 175. 24. Rickert WS, Robinson JC~ Young JC, Collishaw NE, Bray DF. A comparison of the )fields of tat, nicotine, and carbon monoxide of ~6 brands of Canadian cigarettes tested under three conditions. Preheat Afed 198,3; 12: 682-94. 25. Rawbone RG. Switching to low tar cigarettes: are the t~ league tables relevant? Thorax 1984; 39: 657-62. 26. Editorial. Silent prevention. Lancet 1979; i: 705-06. 27. Russell MAH. Low-tar medium-nicothae cigarettes: A new approach to ~afer smoking. Br3ledff 1976; i: 1430-33. 28. Kozlowski LT, gickert WS, Pope MA, Robinson JC. A color-matching technique for monitoring tat/nicodna yields to smokers. Am ff Publ Hlth 1982; 7~: 597-99. THE LANCI medicine a be argued commitme However, to make o debate we of"qualit3 The "co is a revol democrac~ define the care team achieved communit achieved i practice a~ same agail | The State It is per public-he: general p health of~ for the Ct The State documenl primary c main det~ the publk on health accident ~ drinking ~ local high the punk be taken. informin~ communi to his ad' from his The "Dr, The in sewers ir There is reLating t better do is prima~ collected and bact Health I extra di~ perhaps of sentil establish There tasks wh disease t controllt exclusio disease ~ prophyk neither t is the environ1 areas an l