sample="quota" bates="501772729" isource="rjr" decade="1960" class="ui" date="19620000" NOT FOR PUBLICATION d 1481 CONFIDENTIAL COMMENTS ON THE REPORT ON SMOKING AND HEALTH BY A COMMITTEE of THE ROYAL COLLEGE OF PHYSICIANS by G. F. TODD DIRECTOR, TOBACCO MANUFACTURERS' STANDING COMMITTEE FOR RESEARCH INTO THE EFFECTS OF SMOKING ON HEALTH 1962 Addendum to A. 317 In January 1964, the Report of the Surgeon General's Advisory Committee on Smoking and Health was published in the United States. This was a much more detailed report than that of the Royal College of Physicians. It concluded that "cigarette smoking contributes substantially to mortality from certain specific disease and to the overall death rate"; and that it "is a health hazard of sufficient importance in the U.S. to warrant appropriate remedial action." (It was outside the Committee's terms of reference to recommend the nature of such action). Apart from reference to minor diseases, the report stated that cigarette smoking was causally related to lung cancer; related to chronic bronchitis and emphysema, but not necessarily causally, and related to coronary heart disease to a degree which made it prudent to assume that the association had "causative meaning". This report attracted little attention in Britain, but it and the R.C. P. report remain the two most important general documents. A second R.C.P. report, dealing primarily with air pollution but bringing the previous report on smoking and health up to date, is being prepared but its publication is not imminent. In Britain, the most important published research during the last three years has been Doll and Hill's final report (1964) on their survey of British doctors, which showed, in particular, a diminished risk of lung cancer in those who had stopped smoking. Political pressure here has been largely concentrated on cigarette advertising. In consequence it was banned on television from August 1965; a voluntary limitation in other media was adopted, at the instigation of the Minister of Health, for six months from June 1966; and a permanent formula, which is likely also to cover coupon promotion, is now under discussion. There have been no new major pronouncements on health hazards, though the Chief Medical Officer of the Ministry of Health, in his report for 1965 (published on 30th September 1966) used unusually strong language in referring to "the melancholy toll of cigarette smoking" and to "undoubted causes of death and illness sold to a gullible public", and in expressing the hope that cigarette smoking "will come to an end in Britain." He also stated as a fact that cigars and pipes "are certainly less harmful to the user." In scientific circles smoking and health has for the most part ceased to be a controversial issue, since the association at least of cigarette smoking with lung cancer and bronchitis is taken for granted. By comparison with America, there has been little discussion of the possible role of smoking in heart disease. The Prime Minister had stated in the House of Commons on 30th January 1963 that "I do not think that there is any excuse for anyone not to know the connection between cigarette smoking and cancer". A paper by Dr. A. C. McKennal, of the Government's Social Survey, delivered at the International Cancer Conference at Tokyo in October 1966, reporting the results of two surveys covering a total of 4,200 people, stated "It should be stressed that there is no lack of information about lung cancer and smoking among the public. All but three per cent of informants said they had heard or read about the connection. This level is near the limit that can be expected among the public on any topic." In America, there have been other developments, some of which may have a persuasive effect in this country. A systematic and large-scale public education campaign, launched after the Surgeon General's report, has concentrated increasingly on overall mortality among cigarette smokers rather than on particular diseases. From the beginning of 1966, all cigarette packets must bear the notice: "Warning: cigarette smoking may be hazardous to your health", though this seems to have had little effect on consumption. The industry successfully resisted the incorporation of a similar notice in advertisements. The Federal Trade Commission, which since 1960 had refused to permit statements of tar and nicotine yields on packets or in advertising, on the ground that the information would be misleading, has since March 1966 not only allowed but encouraged such statements and is setting up its own testing laboratories. A Bill (S.365) was introduced in July by Senator Magnuson to make such statements mandatory. Actions for damages against cigarette companies by smokers who have contracted lung cancer and some other diseases (or by their widows) continue to be brought, though not in such numbers as in previous years, since no case has yet been finally decided in a plaintiff's favour. In the annual report of the Chief Medical Officer of the Ministry of Health for 1954, published in December 1955, it was stated, "Despite the fact that research into the causes of cancer of the lung has been intensified not only in this country but also abroad such further evidence as has been published , while generally strenthened the presumption of a causal connection between cancer of the lung and smoking does not yet permit of any more definite conclusion than that contained in the statement made in 12th February, 1954 by the Minister in the House of Commons." The Minister of Health made a further announcement in the House of Commons in March 1956, on the advice of the Standing Medical Advisory Committee and the Central Health Services Council that action should be taken to inform the public about the connection between smoking and cancer of the lungs and of the risks involved in heavy smoking. The Minster said he would consider what action would be appropriate. On 7th May he made a further statement and said: "Since my predecessor made a statement in February 1954, investigations into the possible connection of smoking and cancer of the lung have been proceeding in this and other countries. Two know cancer-producing agents have been identified in tobacco smoke, but whether they have a direct role in producing lung cancer, and if so what, has been proved…The Chairman of the Committee of the Medical Research Council which has been investigating the subject considers that the fact that a causal agent has not yet been recognised should not be allowed to obscure the fact that there is, statistically, an incontrovertible association between cigarette smoking and the incidence of lung cancer. The statistical evidence from this and other countries to which he refers tends to show that mortality from cancer of the lung is twenty times greater amongst heavy smokers than amongst non-smokers. The Government will take such steps as are necessary to ensure that the public are kept informed of all the relevant information as and when it becomes available." On the same day in reply to this, the tobacco industry made a statement "with a full sense of our duty to the public." In this statement they stated that " the evidence on the possible relationship of lung cancer and smoking is conflicting and very incomplete; much more research is necessary before firm conclusions can be drawn." The Tobacco Manufacturers' Standing Committee was set up in June 1956. All the U.K. home and export tobacco manufacturers were directly or indirectly represented on the Committee. Its function was to assist research in smoking and health questions, to keep in touch with scientists and other working on this subject in the U.K. and abroad, and to make information available to scientific workers and the public. In January 1963, because of the greatly increased scale of its activities, the Committee changed its name to the Tobacco Research Council. Its objectives and constitutions were unaffected. In July 1956, the Postmaster General declined to prohibit tobacco advertisements near children's programmes on Commercial Television,. He added, however, that the programme companies themselves had decided not to include tobacco advertisements in children's programmes. A second report by Doll and Hill on their enquiry into the mortality of British doctors was published in the British Medical Journal in November 1956. The analysis showed that "there has been a marked and steady increase in the death rate from lung cancer as the amount smoked increased." "The death rate of the heavy smokers is approximately twenty times the death rate of the non-smokers." The mortality from lung cancer was "substantially and significantly greater in cigarette smokers than in pipe smokers"at each level of consumption. There was "a progressive and significant reduction in mortality" amongst ex-smokers with the increase in time over which smoking had been given up. Study of deaths from cancer in sites other than the lung revealed no association with smoking. Mortality from coronary thrombosis revealed a "slight but significant relationship with smoking" and three other causes of death showed a "steady increase in mortality from non-smokers to heavy smokers - chronic bronchitis, peptic ulcer, and pulmonary tuberculosis." Only with chronic bronchitis was the gradient statistically significant. In his annual report for 1955, published in December 1956, the Chief Medical Officer of the Ministry of Health again referred to the increase in lung cancer. "Two conditions seem to be associated with its occurence; air pollution and excessive cigarette smoking, though other factors at present unknown may also be operative." Within a week of publication of the R.C.P. Report, the Minister of Health announced: "The Government certainly accept that the Report demonstrates authoritatively and crushingly the connection between smoking and lung cancer and the more general hazards to health of smoking." The Government immediately increased educational anti-smoking measures and said it was looking at the recommendations of the Report. On 5th April, the manufacturers announced that they were taking steps to remind traders that the law prohibited the sale of cigarettes to those under 16 and that they would not advertise on television before 9.00 p.m. The Ministry of Health prepared a new series of anti-smoking posters which were made available free of charge to local authorities for use in public places, schools, technical colleges and youth clubs, etc. The Ministry also encouraged the establishment of a small number of clinics to help people give up smoking, and two mobile vans toured the country giving lectures and advising the public on the dangers of smoking. In the House of Commons on 17th May, the Prime Minister said , in answer to questions about what further action the Government would take to restrict the sale of tobacco, "I think we must accept the broad view of the medical report, but I do not think anyone would doubt that in a free country like this it is a very big question how far it can be implemented by legislative or any other action." In June 1962, after discussions with the Advertising Advisory Committee of the Independent Television Authority, the tobacco manufacturers agreed to nodify certain of their advertising themes. The types of advertisements which were considered by I.T.A. to be objectionable were those which appealed to manliness, those which associated smoking with young people's pleasures and those suggesting that smoking was a pleasure associated with modern living. In October 1962, the Annual Report for 1961 of the Chief Medical Officer of the Ministry of Health was published. It said, "Lung cancer is so closely associated with tobacco smoking, and especially cigarette smoking, that the conclusion that cigarette smoking is a principal cause in inevitable. It is clearly not the only cause but it is certainly the most important." In January 1963, T.M.S.C. changed its name to the Tobacco Research Council and the Council published a review of its past and present activities. This review contained no expression of opinion about the nature of the association between smoking and various diseases, but summarised the research that was being carried out by the industry the beneficial effects that had been attributed to smoking. In regard to the adverse effects on health attributed to smoking, two main lines of research were being carried out - namely, investigation of the possible carcinogenic and irritating effects of tobacco smoke, and identification of the characteristics of minorities susceptible to heart and respiratory disease. The bulk of the research that T.R.C. was caring out in the first of these fields was being done at their own laboratories at Harrogate, under the direction of Dr. T.D. Day. In the second of these two lines of research, the most important project was the Cardio-repiratory Disease Research Project of the London School of Hygiene and Tropical Medicine, to which T.R.C had agreed to contribute up to £500,000 over the next ten years. September, 1963.