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CIGARETTE SMOKING AND PUBLIC POLICY In the United States, efforts to influence cigarette smoking have not been as successful as public health interests had hoped. While an estimated 30 million smokers' have quit cigarettes since the Surgeon General's 1964 report Smoking and Health, and millions more have tried to quit, total consumption has climbed to 600 billion units in 1974 from 511 billion in 1964.2 Furthermore, women and teenagers are smoking more. Cigarette smoking, which has been called the greatest single public health problem this nation has ever faced,3 continues to be a profitable business to tobacco farmers and cigarette manufacturers while at the same time costing the nation an estimated $11.5 billion annually in health care costs.4 The formulation and implementation of public policy relating to cigarette smoking and tobacco has been parceled out among competing federal agencies and fragmented within local, state, and federal levels of government. Considering the public costs of cigarette smoking and the size of the tobacco economy, relatively little has been done to tackle the problem. Nevertheless, some efforts have been made and some changes in the components of the problem have occurred. Social controls have been promoted through educational activities and by manipulation of economic incentives through advertising regulation. In addition, government has supported research. Long before the relationship of smoking and health had been scientifically explored, laws prohibiting the purchase and smoking of cigarettes by minors were in effect in many states, although rarely enforced. These laws, like those relating to alcohol consumption, were promoted on moral rather than public health grounds. Whether statewide or schoolwide only, such direct controls of behavior must now contend with the concept of rights of minors. The promulgation of laws prohibiting smoking in public places in order to protect the nonsmoker are a growing focus of anti-smoking activists. However, such laws or regulation are not new. Quite apart from fire protection regulations, the restrictions of smoking to certain public places (rooms, railroad cars, etc.) were common in the previous century. Educational efforts to influence the behavior of school children likewise date from the previous century. There is little evidence that such efforts have been successful even though more recent knowledge has greatly strengthened their message. The law has also been used to mandate the inclusion of educational messages (warnings of hazard) on cigarette packages and in cigarette advertisements. Regulations mandating equal time on radio and television to counteract smoking advertisements with anti-smoking messages may have had some impact on smoking behavior but were vitiated when the promotion of smoking through these media was prohibited.
The use of economic incentives might be expected to exert stronger effects upon behavior, but this approach has not been fully exercised. Although federal and state tax revenues from cigarettes now amount to over $5.6 billion annually,5 the rates have not increased significantly since the early 1950s. Even the most recent actions, such as the New York City tax based on tar content or increases in state taxes, are relatively small and enacted as much for their revenue production as for their effects upon the health of the public. Tobacco export subsidies and the export development program for tobacco have been phased out or eliminated. Tobacco supported under the U.S. Department of Agriculture's farm price support program has been reduced. However, tobacco exports now amount to over a billion dollars annually, and the price support mechanism still remains available if needed. Really significant tax increases-on the order of 100 to 200 per cent-could have an effect on cigarette consumption. as well as on the production of revenues for government. At the present rate of cigarette consumption, an increase of 1 cent per pack in federal taxes could produce well over $275 million annually in revenue. On the other hand, higher taxes might prove detrimental to health by causing smokers to maximize their cigarettes, smoking closer to the butt and inhaling more deeply. Further research could help to elucidate this issue. The federal government has promoted research efforts to delineate and clarify the relationship of cigarette smoking to disease. However, its support has been minor considering the magnitude of the problem. The National Clearinghouse for Smoking and Health, in recent years, has suffered from increasing neglect. Two very definite changes in the manufacture and consumption of cigarettes have occurred over the past 15 to 20 years-a reduction in tar and nicotine content, and the introduction of filtered brands. One tobacco manufacturer reported that tar in cigarettes had declined 46 per cent from 1956 to 1972.6 Filtered brands now comprise over 86 per cent of total consumption7 and the low tar and nicotine brands are heavily promoted relative to their market shares. These changes doubtless reflect the impact of educational efforts. Further reductions in tar and nicotine content, voluntarily or involuntarily, may be anticipated. In addition, public policy may soon have to deal with tobacco substitutes such as "Cytrel" and "New Smoking Material,"8 already being produced and blended with tobacco in Europe. Unfortunately, it remains unclear as to whether filters and/or reduced tar and nicotine content will result in a less hazardous cigarette. More importantly, the resources to thoroughly evaluate the potential health hazards of tobacco substitutes do not appear to be available. Unless EDITORIAL
979
there are changes in public policy, the smoking-health controversy, to which there are no simple solutions, is likely to haunt us for many years to come. The failure of U.S. public policy to confront the smoking health problem in all its dimensions can be viewed in concert with analogous failures of public policy to deal with such health problems as automobile accidents, alcoholism, occupational disease, and pollution of the environment. Within a social action framework these failures can be viewed as reflections of: govemmental fragmentation, the power of vested economic interests, or the price which a society must pay for individual freedom. The price becomes higher and the problems multiply as technology advances, and society becomes more interdependent. It is only at the point where insightful understanding is widespread enough to produce citizen pressure for change that significant changes in public policy can be expected. This goal, surely, is one of the primary missions of public health.
References 1. Carr, D. T. Introductory remarks. Third World Conference on Smoking and Health, New York City, June 2,
1975.
ON BCG CONTROVERSY There has been a controversy about BCG vaccine and vaccination between Dr. George Comstock of Baltimore and Dr. Sol Rosenthal of Chicago and California in your journal. BCG has had more than enough needless obstacles to its use over the years (incomplete early statistics, dissociation of a culture, the Lubeck disaster, the distractions of "atypical" infections, etc.), all of which were proved to be unimportant. It doesn't need misinterpretations, obstinacy, or publications which delete the most important references. Dr. Comstock has been involved in the follow-up of vaccinations in 980
Kenneth M. Friedman, PhD The Journal is grateful to Professor Friedman for the above editorial. An Assistant Professor of Political Science at Purdue University, Professor Friedman is the author of Public Policy and the Smoking-Health Controversy, published by Lexington Books, Lexington, MA, 1975, which examines the strategies of health interest groups, government health administrators, and tobacco corporations; government policy in this and other countries; and the impact of public policy and private economic health interest groups on cigarette consumption.
a*
I LETTERS Letters are welcomed and will be published, if found suitable, as space permits. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references) and generally should not exceed 400 words.
2. U.S. Department of Agriculture. Tobacco Situation, p. 5. June,1975. 3. Diehl, H. S. Tobacco and Your Health: The Smoking Controversy, p. 2. McGraw-Hill, New York, 1969. 4. Walker, W. J. Government Subsidized Death and Disability. J. A. M. A. 230:1530, 1974. 5. U.S. Department of Agriculture. Tobacco Situation, p. 29. Mar., 1975. 6. Morris, J. D. Tar in Cigarettes Is Reported Down 46% Since '56. New York Times, Feb. 11, 1973. 7. U.S. Department of Agriculture. Tobacco Situation, p. 6. Mar., 1975. 8. Cytrel, NSM, et al. Form Basis for Stampede to Synthetic Cig. Tobacco Reporter 101:5, 1974.
Georgia-Alabama and in Puerto Rico from the era of 20 to 25 years ago, and in the more recent work in India. Sadly, the first two series had the obstacle of a high incidence of "atypical" mycobacterial infections in the populace; Dr. Palmer, his predecessor, felt that the atypicals confused the issue, and many workers feel that arguments about those series are futile and should be set aside. Sadly also, Dr. Comstock will not listen to other, better, and favorable reports-and there are quite a few. He cannot be convinced, though Dr. Rosenthal and others have tried for years. His recent semi-Shakespearean ridicule of Dr. Rosenthal in your journal is not justified, or dignified, especially since Dr. Rosenthal has developed the stable and standard vaccine (the only one manufactured in the U.S.) and the equipment to give it; has produced the largest controlled series (123,000 by 1972); and has consulted in the use of BCG throughout most of the world. The orderly way to describe the
AJPH SEPTEMBER, 1975, Vol. 65, No. 9
status of BCG would be to ask and answer a series of questions: 1. Is BCG vaccine stable and standardized? (Yes. It has been for more than a dozen years, by reason of freeze-drying and seed-lots, with recurrent testing of samples.) 2. Can it be given by a simple and satisfactory vaccination method? (Yes. It should be given by the transcutaneous multiple-puncture method, using a disc with tines through a vaccine supension on the skin, or vaccine dried on the tines. Injection can thus be avoided.) 3. Is there a local or systemic hazard from use of BCG? (Almost none of either, using the methods just mentioned. Local or regional lesions, often quoted, are due to the single intradermal or subdermal injection, and almost entirely in foreign series.) 4. Has BCG been effective in protecting large series against TB? (There is no question that protection occurs, in a 3 or 4 to 1 ratio, in many series where proper vaccine, technique, selection, and a lack of interfering
_
_,
CIGARETTE SMOKING AND PUBLIC POLICY In the United States, efforts to influence cigarette smoking have not been as successful as public health interests had hoped. While an estimated 30 million smokers' have quit cigarettes since the Surgeon General's 1964 report Smoking and Health, and millions more have tried to quit, total consumption has climbed to 600 billion units in 1974 from 511 billion in 1964.2 Furthermore, women and teenagers are smoking more. Cigarette smoking, which has been called the greatest single public health problem this nation has ever faced,3 continues to be a profitable business to tobacco farmers and cigarette manufacturers while at the same time costing the nation an estimated $11.5 billion annually in health care costs.4 The formulation and implementation of public policy relating to cigarette smoking and tobacco has been parceled out among competing federal agencies and fragmented within local, state, and federal levels of government. Considering the public costs of cigarette smoking and the size of the tobacco economy, relatively little has been done to tackle the problem. Nevertheless, some efforts have been made and some changes in the components of the problem have occurred. Social controls have been promoted through educational activities and by manipulation of economic incentives through advertising regulation. In addition, government has supported research. Long before the relationship of smoking and health had been scientifically explored, laws prohibiting the purchase and smoking of cigarettes by minors were in effect in many states, although rarely enforced. These laws, like those relating to alcohol consumption, were promoted on moral rather than public health grounds. Whether statewide or schoolwide only, such direct controls of behavior must now contend with the concept of rights of minors. The promulgation of laws prohibiting smoking in public places in order to protect the nonsmoker are a growing focus of anti-smoking activists. However, such laws or regulation are not new. Quite apart from fire protection regulations, the restrictions of smoking to certain public places (rooms, railroad cars, etc.) were common in the previous century. Educational efforts to influence the behavior of school children likewise date from the previous century. There is little evidence that such efforts have been successful even though more recent knowledge has greatly strengthened their message. The law has also been used to mandate the inclusion of educational messages (warnings of hazard) on cigarette packages and in cigarette advertisements. Regulations mandating equal time on radio and television to counteract smoking advertisements with anti-smoking messages may have had some impact on smoking behavior but were vitiated when the promotion of smoking through these media was prohibited.
The use of economic incentives might be expected to exert stronger effects upon behavior, but this approach has not been fully exercised. Although federal and state tax revenues from cigarettes now amount to over $5.6 billion annually,5 the rates have not increased significantly since the early 1950s. Even the most recent actions, such as the New York City tax based on tar content or increases in state taxes, are relatively small and enacted as much for their revenue production as for their effects upon the health of the public. Tobacco export subsidies and the export development program for tobacco have been phased out or eliminated. Tobacco supported under the U.S. Department of Agriculture's farm price support program has been reduced. However, tobacco exports now amount to over a billion dollars annually, and the price support mechanism still remains available if needed. Really significant tax increases-on the order of 100 to 200 per cent-could have an effect on cigarette consumption. as well as on the production of revenues for government. At the present rate of cigarette consumption, an increase of 1 cent per pack in federal taxes could produce well over $275 million annually in revenue. On the other hand, higher taxes might prove detrimental to health by causing smokers to maximize their cigarettes, smoking closer to the butt and inhaling more deeply. Further research could help to elucidate this issue. The federal government has promoted research efforts to delineate and clarify the relationship of cigarette smoking to disease. However, its support has been minor considering the magnitude of the problem. The National Clearinghouse for Smoking and Health, in recent years, has suffered from increasing neglect. Two very definite changes in the manufacture and consumption of cigarettes have occurred over the past 15 to 20 years-a reduction in tar and nicotine content, and the introduction of filtered brands. One tobacco manufacturer reported that tar in cigarettes had declined 46 per cent from 1956 to 1972.6 Filtered brands now comprise over 86 per cent of total consumption7 and the low tar and nicotine brands are heavily promoted relative to their market shares. These changes doubtless reflect the impact of educational efforts. Further reductions in tar and nicotine content, voluntarily or involuntarily, may be anticipated. In addition, public policy may soon have to deal with tobacco substitutes such as "Cytrel" and "New Smoking Material,"8 already being produced and blended with tobacco in Europe. Unfortunately, it remains unclear as to whether filters and/or reduced tar and nicotine content will result in a less hazardous cigarette. More importantly, the resources to thoroughly evaluate the potential health hazards of tobacco substitutes do not appear to be available. Unless EDITORIAL
979
there are changes in public policy, the smoking-health controversy, to which there are no simple solutions, is likely to haunt us for many years to come. The failure of U.S. public policy to confront the smoking health problem in all its dimensions can be viewed in concert with analogous failures of public policy to deal with such health problems as automobile accidents, alcoholism, occupational disease, and pollution of the environment. Within a social action framework these failures can be viewed as reflections of: govemmental fragmentation, the power of vested economic interests, or the price which a society must pay for individual freedom. The price becomes higher and the problems multiply as technology advances, and society becomes more interdependent. It is only at the point where insightful understanding is widespread enough to produce citizen pressure for change that significant changes in public policy can be expected. This goal, surely, is one of the primary missions of public health.
References 1. Carr, D. T. Introductory remarks. Third World Conference on Smoking and Health, New York City, June 2,
1975.
ON BCG CONTROVERSY There has been a controversy about BCG vaccine and vaccination between Dr. George Comstock of Baltimore and Dr. Sol Rosenthal of Chicago and California in your journal. BCG has had more than enough needless obstacles to its use over the years (incomplete early statistics, dissociation of a culture, the Lubeck disaster, the distractions of "atypical" infections, etc.), all of which were proved to be unimportant. It doesn't need misinterpretations, obstinacy, or publications which delete the most important references. Dr. Comstock has been involved in the follow-up of vaccinations in 980
Kenneth M. Friedman, PhD The Journal is grateful to Professor Friedman for the above editorial. An Assistant Professor of Political Science at Purdue University, Professor Friedman is the author of Public Policy and the Smoking-Health Controversy, published by Lexington Books, Lexington, MA, 1975, which examines the strategies of health interest groups, government health administrators, and tobacco corporations; government policy in this and other countries; and the impact of public policy and private economic health interest groups on cigarette consumption.
a*
I LETTERS Letters are welcomed and will be published, if found suitable, as space permits. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references) and generally should not exceed 400 words.
2. U.S. Department of Agriculture. Tobacco Situation, p. 5. June,1975. 3. Diehl, H. S. Tobacco and Your Health: The Smoking Controversy, p. 2. McGraw-Hill, New York, 1969. 4. Walker, W. J. Government Subsidized Death and Disability. J. A. M. A. 230:1530, 1974. 5. U.S. Department of Agriculture. Tobacco Situation, p. 29. Mar., 1975. 6. Morris, J. D. Tar in Cigarettes Is Reported Down 46% Since '56. New York Times, Feb. 11, 1973. 7. U.S. Department of Agriculture. Tobacco Situation, p. 6. Mar., 1975. 8. Cytrel, NSM, et al. Form Basis for Stampede to Synthetic Cig. Tobacco Reporter 101:5, 1974.
Georgia-Alabama and in Puerto Rico from the era of 20 to 25 years ago, and in the more recent work in India. Sadly, the first two series had the obstacle of a high incidence of "atypical" mycobacterial infections in the populace; Dr. Palmer, his predecessor, felt that the atypicals confused the issue, and many workers feel that arguments about those series are futile and should be set aside. Sadly also, Dr. Comstock will not listen to other, better, and favorable reports-and there are quite a few. He cannot be convinced, though Dr. Rosenthal and others have tried for years. His recent semi-Shakespearean ridicule of Dr. Rosenthal in your journal is not justified, or dignified, especially since Dr. Rosenthal has developed the stable and standard vaccine (the only one manufactured in the U.S.) and the equipment to give it; has produced the largest controlled series (123,000 by 1972); and has consulted in the use of BCG throughout most of the world. The orderly way to describe the
AJPH SEPTEMBER, 1975, Vol. 65, No. 9
status of BCG would be to ask and answer a series of questions: 1. Is BCG vaccine stable and standardized? (Yes. It has been for more than a dozen years, by reason of freeze-drying and seed-lots, with recurrent testing of samples.) 2. Can it be given by a simple and satisfactory vaccination method? (Yes. It should be given by the transcutaneous multiple-puncture method, using a disc with tines through a vaccine supension on the skin, or vaccine dried on the tines. Injection can thus be avoided.) 3. Is there a local or systemic hazard from use of BCG? (Almost none of either, using the methods just mentioned. Local or regional lesions, often quoted, are due to the single intradermal or subdermal injection, and almost entirely in foreign series.) 4. Has BCG been effective in protecting large series against TB? (There is no question that protection occurs, in a 3 or 4 to 1 ratio, in many series where proper vaccine, technique, selection, and a lack of interfering
