Behind the Cigarette Curtain

Millions to keep them smoking/how much to help them stop?

Last January when the Surgeon General's Advisory Com-mittee on Smoking and Health laid down the decisive judg-ment that "CIGARETTE SMOKING IS A HEALTHHAZARD OF SUFFICIENT IMPORTANCE IN THEUNITED STATES TO WARRANT APPROPRIATEREMEDIAL ACTION," it also pointed out the majorfuture direction for that action:

The overwhelming evidence points to the conclusionthat smoking-its beginning, habituation, and occasionaldiscontinuance-is to a large extent psychologically andsocially determined.

On the first anniversary, Surgeon General Luther 1.Terry himself declared: "Millions of adult cigarette smok-ers are ready to be fully convinced that the time has cometo change their smoking habits. And, therefore, the oppor-tunity to convince them in 1965 and the years ahead isgreat."Wh~t has happened in the intervening year?

• About 43,000 more Americans have died of lung cancer-the smokers outnumbered non-smokers by more than tento one.• About twice as many smokers as non-smokers have diedof heart and circulatory disorders. Emerson Foote, chairmanof the National Interagency Council, which is a body ofpublic and private health organizations concerned with themenace of cigarettes, states that at least 125,000 people diedas a result of smoking cigarettes.

• Dr. Terry reports that adult male smokers declined from59 percent to 52 percent between 1962 and July, 1964.Women fell 3 percent. Nonetheless, cigarette sales (whichfelI as much as 30 percent in some states immediately afterthe 1964 Report) had nearly climbed back by November.• The cigarette companies spent another $250,000,000 foradvertising.• The Congress of the United States did not directly ap-propriate a single dollar for research and education concern-ing the psychological and social reasons why people smokeand how to help them to stop or never start.• When the Public Health Service requested $1,900,000in supplementary funds for this purpose, the request wasrejected and will have to wait at least until the new budgetof Fiscal 1966 for an appropriation, if it comes at all.

These were the major findings of the Surgeon General'sreport a year ago:

• The more you smoke the sooner you die. Those smokingless than ten cigarettes per day have a 40 percent higherdeath rate than non-smokers from all causes; those smokingmore than two packs a day have a 120 percent higher deathrate. Men who smoke half a pack a day will die of lungcancer at seven times the rate of non-smokers; those whosmoke two or more packs a day die of lung cancer at morethan 20 times the rate of non-smokers.• The earlier you start the sooner you die. This is especial-ly true of those starting before age 20. An estimated 4500

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between 12 and 17 start every day; many others start before12. They died soonest of all.• The more you inhale the sooner you die. This probablyexplains much of the greater mortality among cigarettesmokers-who generally inhale-than among cigar andpipe smokers, who generally do not. The average smokerinhales a cup of tar into the tissues of his lungs annually-the same tar that causes cancer on laboratory animals andis considered one of the factors causing lung cancer inhumans.

Spurred by these appalling facts the Public Health Servicehas been trying to finance research and education withfunds, totalling between $350,000 and $400,000, scrapedfrom other budget items. Dr. Daniel Horn of the CancerControl Branch of the Division of Chronic Diseases of thePublic Health Service states flatly that the possibilities andneeds for research are so great that if Congress had madethe $1,900,000 available, the money could have beentotally committed in one month.

The original sum requested was minimal at best, but theamount scraped together (and the way it had to be done)suggests penurious disregard of the health of the nation.

With the release of the Report medicine had completedthe major task of identifying the criminal, accumulating thedamning evidence, and pronouncing guilt. Whether thekillings stop depends largely on whether or not the victimscan be persuaded to quit embracing their killer. The onlyknown effective way to limit the ravages of cigarettes is tostop smoking; the only way to eliminate them altogetheris never to have started. Either the supply or the demandmust be curtailed. The behavioral sciences can make theirspecial contribution in research aimed at cutting the de-mand, learning more about why people smoke, and thensuggesting "remedial action."

ROUTES FOR GOVERNMENT ACTION

The government could, in theory, take other approaches-limiting the availability of cigarettes (especially for theyoung) and prohibiting the worst abuses of advertising andsalesmanship. But strong built-in inhibitors hobble the abil-ity of any government agency to dry up the source ofcigarettes, or their distribution. Twenty-four states, repre·sented by almost half the members of the Senate (and aneven greater percentage of chairmen of important Congres-sional committees), grow tobacco. Over 700,000 peopleearn livelihoods through tobacco production, the great ma-jority from cigarettes. Federal and state cigarette taxes (notcounting employment taxes) account for almost 3 percentof alI federal and state tax colIections. Congressmen fromthe major tobacco states, like the tobacco industry itself,have trouble believing that all those hard words about cig-arettes could be true. They do not feel that they wereelected to preside over the liquidation of home stateempires.

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The Federal Trade Commission, under its broad mandate"to prevent ... unfair methods of competition in corn-rnerce," has defined "unfair methods" to include whateveroperates against the public good-especially for childrenand teen-agers, who are considered relatively helpless againststrong social pressures and Madison Avenue. (Studies indi-cate that adults are seldom a match for Madison Avenueeither. For instance, much cigarette advertising gains au-thority simply by frequent repetition, because many fondlybelieve that if cigarette claims were untrue or cigaretteswere really dangerous, "the government would do some-thing about it.") Thus claims, or even implications, thatfilters will really protect, that success in athletics, life, orsex will be helped by smoking can be considered "unfairor deceptive advertising or labeling." It is unfair competi-tion if children hear a star athlete earnestly describe howcigarettes relax him so that he can play better. At the ex-treme, since there is no clear and effective way to keepchildren from being exposed to adult advertising, espe-daIly on television, all advertising might legitimately besubject to tighter regulation.

On June 22, 1964, the FTC issued a "Trade RegulationRuIe for the Prevention of Unfair or Deceptive Advertis-ing and Labeling of Cigarettes in Relation to the HealthHazards of Smoking." It provides that all advertising andall cigarette containers must bear, clearly and prominently,a warning of the danger to health. The briefer of twooptional statements reads:

"CAUTION: Cigarette smoking is dangerous to health.It may cause death from cancer and other diseases."

This rule might provide an effective warning for somepeople, at least; more important, it might make advertis-ing less attractive both to advertiser and consumer. At therequest of Congress, enforcement of this rule has been de-layed until July 1, 1965, with the standard provision that"cause" might delay it further.

The tobacco industry has set up its own code, under itsown "czar" (former Governor Robert Meyner of NewJersey), and promises to eliminate some of the worst abusesfrom its advertising.

Many experts believe that the menace to health is seriousenough for more drastic action. Thalidomide, which af-

A MODEST PROPOSAL TO CONGRESS:

Let Congress enact legislation which would providethat 1 percent of federal cigarette tax revenue be setaside for behavioral science research into smoking toaid in discouraging new smokers and helping oldones quit. This would amount to something over$20,000,OOO-less than 10 percent of what is spentfor cigarette advertising.

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fected far fewer people, was outlawed. If direct regulationis difficult, perhaps economic pressures could be used. To-bacco supports could be eliminated and cigarette taxesraised greatly. Tobacco companies and their employeescould be given liberal subsidies to diversify to other fieldsso that they could stop identifying cigarette profits with theeternal verities of American free enterprise. There is prac-tically no chance, however, that any of these measures willbe put through. There is no present practical governmentalmechanism for limiting production. And how much wouldit help if the supply was cut, but the demand remainedhigh? No one believes that bootleg cigarettes would be anyimprovement.

Nor can there be much hope that a "safe" cigarette willautomatically solve everyone's problems. The cancer caus-ing and toxic factors in cigarettes are apparently many innumber and not all known. No filter will take them allout. Moreover, they seem closely associated with preciselythose things that give the major satisfaction in smoking.Neither smokers nor manufacturers seem interested in anon-tobacco cigarette. Dr. Horn does not believe we willsee a really safe cigarette for a very long time, if ever.

Therefore, since only a small percentage of smokers willchange their suicidal habits unaided, the burden must shiftto persuasion and education, to the psychological and socialfactors.

About 70,000,000 Americans smoke. Probably no otherhabit not dictated by our physical nature is so widespread.Purely as an aspect of human behavior, apart from thehealth hazard, smoking should long ago have inspired atremendous amount of research.

Nevertheless on September 8, 1964, Dr. Godfrey M.Hochbaum, chief of the Behavioral Science Section of thePublic Health Service, delivered this indictment before asymposium of the American Psychological Association:

A compulsive habit by which that many people are en-slaved, most of them urgently wishing but unable tostop, should be of intense interest to psychologists, evenwithout its momentous medical and social importance.. . . (We) have a social obligation which can be dis-charged only if at least some of us feel challenged tohelp find practical solutions to smoking. . . . Unfortu-nately, psychologists have made virtually no contributionsto ... the development of psychologically sound methodsto strengthen campaigns trying to prevent teenagers fromtaking up smoking or of techniques to help smokersbreak the habit. This failure . . . to make needed con-tributions . . . is particularly disheartening in view ofthe fact that responsible government and private agenciesand organizations increasingly turn to us for help andadvice....

Of course research difficulties do exist. The very numberof smokers makes analysis difficult. It is not possible to iso-

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late one distinct "smoker's profile" from such a major seg-ment of the total population. Few character or behavior"types" could be defined which would not be contradictedby the characteristics or behavior of other tens of millions.But research does show some trends which, though notapplicable to all, do apply to significant numbers.

Only in very extreme cases does smoking approach apharmacological addiction. It does however become a deeplyingrained habit-closely involved and associated with thelife, feelings, and gratifications of the user. It is not im-portant for what it is but what it means to the smoker-and this makes it a major problem of behavior. "Cessa-tion," Hochbaum says, is not "a single, isolated change ina person's life, but a rather radical and extensive disrup-tion of a complicated interwoven pattern of habits, ofneeds gratified, of pleasures derived, and of tensions re-leased." Horn reports that in studies of smokers' attitudesmost say they are opposed to smoking: it is expensive,dirty, harmful, not worth the cost, and they wish theyhadn't started. They wish they could stop-but few say thatthey will stop or intend to try very hard. Hochbaum addsthat we cannot assume that even those who seek treatmentseriously expect to stop. Smoking clinics and counselorscan be convenient devices for shifting responsibility. If theexperts can't help the smoker how can he help himself?

But if he can't always help himself, he can at least makesure that his children find starting less attractive or in-evitable. He can quit being such a prominent example. Hecan relate what he has suffered, the risks he is running, andhis desire to stop if he could. The same applies to otheradults working with-and who set examples for-children.

The children of smokers are more apt to be smokers.They start in revolt against adult authority-and also inorder to establish their own adult authority. They gen-erally start because of example, convenience, propinquity,social pressure, and status. They want to be "mature," tobe one of the gang, to be important. These motives seldomlast long; but they last long enough to create smokers whoare more apt to keep at it, smoke more, inhale more deeply,and die more quickly.

HOW ARE CIGARETTES USED?

Older smokers have other motives, many of them appar-ently contradictory, but all associated in the smokers' mindsand therefore often inseparable. First, smoking becomes ahabit-lighting up and smoking a cigarette 7000 times ayear, which a one-pack-a-day smoker does, is not a passingwhim. Further, Hochbaurn reports that "smokers haveclaimed variously that cigarettes help them to relax, toconcentrate, to sleep, to stay awake, to get over difficultsituations, to feel self-assured, or to accomplish a varietyof other things." In each case the smoker is convinced thecigarettes really do help him. "Abrupt cessation is com.monly followed by acute nervous tensions, irritability, and

CIGARETTE CURTAIN. , .

even anxieties, The , , . unaccustomed deprivation ... mayhaunt the ex-smoker's thoughts, making it often difficult, .. to concentrate on any tasks, It is exactly these condi-tions which he may have learned over many years to allevi.ate by smoking." To the non-smoker, a scale which has acigarette on one side and death on the other is awesomelyunbalanced in one direction; to the smoker in desperateneed of just one more, with lung cancer a distant and unrealspectre, the scale tilts in the other direction. How muchharm can one smoke do?

To children and teen-agers death and disorder in a re-mote and half-legendary condition called middle age areparticularly unreal. How can it compare with impressingyour friends right now? M. Powell Lawton, psychologist atthe Philadelphia Geriatric Center, ascribes his almost com-plete failure to get high school students to stop smoking tothis factor, plus the related one that the young are not re-strained by worry about financial dependents,

Two ghosts haunt any analysis of smokers: one, alreadymentioned, is that any conclusion has millions of "excep-tions"; the other is that it is difficult to decide what iscausal and what is accidental.

Unmarried people smoke less than married, and marriedsmoke less than widowed or divorced. But there is overlap.And different kinds of people remain single for differentkinds of reasons. And if smoking, as is sometimes implied,is useful in relieving sexual frustration ("They satisfy!")then why only for those who have lost spouses and notthose who never had any?

Psychologist Charles C. McArthur and associates foundthat, for a sample of Harvard undergraduates, "non-smok-ers tend to be lower-middle class in origin, upwardly mo-bile, earnest young men. . . ." A study by PsychologistR. M. Lynn, then at the University of North Carolina,showed that adolescent boys who did not smoke madehigher grades in school, failed less often, caused less dis-ciplinary trouble, and had better health, and made betterscores on psychological tests. But advance in schooling, intograduate work, is accompanied by more, not less smoking;and if more smokers fail, is it because of smoking, or didthey take up smoking because they were failing? The moreeducated tend to smoke less than others-especially sincethe Surgeon General's report.

On the other hand, no significant relationship was foundbetween intelligence and smoking by a number of investi-gators. Most agree with the conclusion of a group headedby E. J. Salber, M.D., of Boston that "the difference insmoking habits results from differences in academic achieve-ment rather than intelligence."

The children of the poor and uneducated, like their par-ents, smoke more and start earlier, though by the senioryear in high school most differences are wiped out. Smok-ing increases with age regardless of parental example, butwithin each group the children of smokers smoke more.

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The very religious-a-except for Catholics-tend to smokeless. Catholics generally smoke more than other religiousgroups, parochial students more than public school students.

Farmers smoke less-but small rural townsmen do notsmoke appreciably less than city slickers.

The lower classes smoke more and start earlier. Theunemployed-and the frequent job-changers and othersshowing signs of economic insecurity and restlessness-smoke more,

H. J. Eysenck, professor of psychology at the Universityof london Institute of Psychiatry, found a definite posi-tive relationship between smoking and extroversion. Severalother investigators, using other samples and testing methodsreport similar findings.

The Surgeon General's Report states: "The general pic-ture ... is one of smokers tending to live faster and moreintensely, and to be more socially outgoing." Also, "Smok-ers show greater interest in TV and movies, non-smokersin reading books." (Perhaps, therefore, non-smokers donot see as many cigarette commercials.) McArthur, nowstudying the connection between smoking and "orality,"reports that "every investigator finds smoking significantly

related to drinking, to coffee consumption, to gum chew-ing. . . ," But once more does this show a relationship toorality in the Freudian sense or simply to people who "livefaster and more intensely"? Or is it all just coincidental?

If smokers are generally more extroverted and sociallyoutgoing, can they also be more maladjusted? Accordingto the Report they can, even if this seems to contradict aprevalent stereotype. Emotional stress, anxiety, and tensionare closely related to the amount of smoking; and "... therelative consistency of findings lends support to the exist-ence of a relationship between the smoking habit and a per-sonality configuration that is vaguely described as 'neu-rotic.' "

Women smoke less than men (though they smoke cigar-ettes almost exclusively), and they have lower death ratesfrom lung cancer both absolutely and comparatively.

TRhNS-AcnON

Among people smoking more than one pack a day, thedeath rate for women is one-fourth that of men.

In summary, smoking seems to have some relation tofrustration, tension, inadequacy and failure; it seems to beconnected somehow with the growing complexities of oururban civilization. The Report states:

. . . the experience of stress together with social situa-tions favorable to smoking can (plausibly) provide thetrigger ... as well as a mechanism to reinforce the habitonce established.... Nervous traits, anxiety, and over-reaction to environmental stimuli have been found tobe very prevalent among smokers as compared to non-smokers. Underachievement ... can produce stress.

Yet, as Joseph D. Matarazzo and George Saslow of theUniversity of Oregon Medical School emphasize in theirbroad review of smoking research:

None of the studies has shown a single variable whichis found exclusively in one group and is completely ab-sent in the other.... A clear-cut smoker's personalityhas not emerged from the results published so far in theliterature ... none of the studies ... provides an answerto the "cause and effect" question. . . .

Does this mean that there is no hope to help greaternumbers of people stop? Not at all. It merely means that

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r d:nlrcaseWIIAT~

{add a!l£/

the answers aren't easy or straightforward; and that the paceand quality of research must be greatly stepped up.

No one method will work with all smokers, and whatworks with a given smoker this month may prove inffec-tive the next time; but the research does show that greatnumbers do have similar psychodynamics.

Discontinuance is related to beginning. Those whostarted latest stop most easily; they have smoked the fewestyears and the fewest cigarettes. They are therefore the bestprospects for a program designed to help smokers stop.

Children who quit generally say that they never didreally enjoy smoking-didn't even like the taste. Thosewho never started hardly mention enjoyment, but speakof morals and health. Adults who want to quit speak ofhealth (in general), morality, and "will power." The Re-port notes that few people mention any of the tobacco-linked diseases as a reason for wanting to quit.

The "high-scare" technique worked for a short whilein early 1964 but may not be effective over the long runand can even boomerang. It can bring on symptoms ofdenial and refusal to face facts-such as avoiding medicalexamination-lest the nightmare be proven true. Apathy,depression, and fatalism can follow ("I've smoked so long,nothing can help me now"). At times it has resulted inmore, not less, smoking. It is a basic psychological principlethat an act will tend to be repeated if it gives pleasure.Thinking of lung cancer does not give pleasure; having acigarette to settle your nerves after such thought does. Horn,

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in a large-scale study on high school children found that afactual, straight-forward presentation worked best. Other reosearch and experience supports this finding, and such or-ganizations as the American Cancer Society and the PublicHealth Service are modifying their educational programsaccordingly.

Medical men tend to take a "cold turkey" approach tocessation: the only way to stop is to stop, and not to trans-fer to pipes or cigars because they are harmful too. Butsocial psychologists know that man will work much morereadily for the near goal whose rewards he feels he canreach. If he cannot put off the next cigarette forever, hemay be able to put it off for a few hours-knowing it willtaste better then-and a few more hours the day after.Pipes and cigars are less dangerous and may help in theweaning. So may lobeline and nicotine injections. Habitswill have to be changed: women, for instance, considercigars and pipes unfeminine; but so did they once considercigarettes-and slacks.

Work with withdrawal techniques is going on now atthe Roswell Park Institute at Buffalo. It is too early toevaluate success or failure. The Seventh Day Adventistswho have been conducting dinics since 1960 claim somesuccess; but little of the data has had rigorous analysis orbeen subjected to long term followup. Those who volunteerfor such clinics do not represent a typical smoking popu-lation.

A "smoke-weaning" technique developed by Dr. BorjeEjrup at Stockholm's Karolinska Institute has been usedat six Swedish clinics with some success since 1956. It isnow being tried in New York, where Dr. Ejrup is super-vising the program at the Cornell University Medical Cen-ter. The technique involves nicotine or lobeline injectionsto lessen the craving, daily conferences between doctor andpatient, and other drugs such as tranquilizers and appetite-suppressants when needed. The Karolinska Clinic special-izes in patients ordered under treatment by their doctors.What about the average smoker who feels, vaguely, thathe would like to quit, or who would really rather not thinkabout it?

Obviously, progress must wait on research. That moreis not being done is a major public scandal. The AmericanMedical Association is dispensing $10,000,000, donatedby the tobacco industry, for twenty-eight research grants-only one for behavioral research.

At the meeting of the National Interagency Council onJanuary 11, 1965 at which the Surgeon General urged "atruly national effort that will convince people of the dangersof cigarette smoking," other speakers called on Congress tosupport the campaign with strong legislation and withmoney.

But the NIC is only a coordinating agency, and it cannotitself initiate new projects. Important and fundamentalquestions remain to be answered:

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• Why has the government hesitated so long and done solittle about attacking this menace?• Why, since the Report stated clearly that smoking "is toa large extent psychologically and socially determined," hasno money been given to the Public Health Service specifi-cally to research these areas?• Why did not significant numbers of psychologists andsociologists concentrate more intensely on this problemlong ago---even without government sponsorship? Whydoes social science so often follow the research moneyrather than the research needs?

The reasons for the insufficiency of behavioral scienceresearch on cigarette smoking are surely complex. Still,certain basic elements can be seen in any answer;

• Above all, research designed to prevent smoking or tohelp people stop is threatening to the economic interests ofkey Southern states. Southern Congressmen are bound totake these into account when considering appropriations.• The various governmental funding agencies themselves-for example, the National Institutes of Health and theU.S. Public Health Service-are and must be sensitive tocongressional opinion and pressures. They wish to protecttheir own position with Congress; they seek to insure thatthe great variety of other programs which they support arenot endangered by any aid they may give to research designedto curtail smoking. Consequently, as one informant stated,researchers interested in studies that might curtail smokingare asked to submit their funding proposals under theheading of "Studies in Bad Habits."• Studies on cigarette smoking find insufficient supportfrom the scientific and academic community itself. In part,this is because they encounter reactions such as those citedabove. In part, because senior researchers are usually heavilyfunded and do not wish to embarrass their funding agen-cies, they fear that this may generate difficulties when theyseek to re-fund ongoing research in other areas to whichthey are committed.

With or without government aid, more social scientistsmust cross over into Marlboro country.

See:

]. D. Matarazzo and G. Saslow, "Psychological and RelatedCharacteristics of Smokers and Non-smokers." PsychologicalBulletin, No. 57, 1960.

Smoking and Health: Report of the Advisory Committee to theSurgeon General of the Public Health Service: Public HealthService Publication No. 1103, Washington, D. c., 1964. (Seeespecially Chapter 14, pp. 359-379.)

Federal Trade Commission, Washington: "Trade Regulation Rulefor the Prevention of Unfair or Deceptive Advertising and Labelingof Cigarettes in Relation to the Health Hazards of Smoking" and"Accompanying Statement of Basis and Purpose of Rule."

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