ION
L. c. F. e.
2 8 JAc. 1990
Draft Paper for 1980 Tobacco Division C. A. C. ACK ......
FILE .......
CURRENT ISSUES IN SMOKING AND HEALTH
Undoubtedly, the most encouraging recent development in
the controversy over smoking and health has been the
recognition by scientific and medical authorities that
modern developments in low tar delivery products imply that
smokers may be exposed to a greatly reduced risk compared
with that Incurred by smokers tiventy years ago. The
original statements in 1976 by Dr. Gio Gori, with the
endorsement he gave to sDecif ied low delivery U.S. brands,
has been followed this year by a publication by Wynder and
co-workers in which & brand specification for a less
hazardous @roduct was listed, which went beyond Gori by
giving a limit for the delivery of nitrosamines. There is
also the recent press report of a statement by Prof. SchmXhl
in Germany, to the effect that modern low delivery products
may be smoked in moderation without any risk. The
forthcoming Cold Spring Harbour Symposium (October 1979)
may well be the occasion for further statements of this
nature.
2. That such a development would occur became plausible
when it was first shown that male mortalities from lung
cancer had stabilised and were subsequently turning downwards,
particularly in the younger age groups, who had been exposed
to filtered products for a longer fraction of their smoking
years. This was first apparent from U.K. mortality statistics.
It has subsequently been noticed in the results from a large
U. S. prospective survey by Hammond. Earlier, there had been
indications that smokers of filter cigarettes appeared to
incur less risk than smokers of plain cigarettes (Bross and
Gibson; Wynder, Mabuchi and Beattie: T. R. C. North East
England study); but these had been relatively small-scale
surveys, subject to sizable error. In the early days of the
controversy, importance had been attached by many experts to
the claim by Auerbach that-, he could recognise the
precancerous state of "carcinoma in situ" in the lungs of
most smokers at autopsy; ea ual importance, therefore, should
be attributed to a recent paper br Auerbach in which he
notes the fact that this state now only occurs im a very
small proportion of smokers' lungs. He suggests -that this is C=>
largely because the products smoked in recent years have been 1-.0
filter cigarettes. (It is prcbAbiv too soon for the co
increased consumption of lcw-delivery products to be reflected
in a further change of di-cezse rate or cell state).
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These encouraging signs are seen in male mortality
rates and it must not be expected to be found in female
mortality rates yet, apart from the U.S.A. As a result
of the increase In cigarette consumption by females
elswhere In recent years, it is probable that female
death rates from smoking associated diseases will continue
to increase, although, because women tend to smoke lower
delivery products, these rates are unlikely to reach the
levels attained by male mortality statistics in the past.
3. Paradoxically, the encouraging developments outlined
above have thrown up the greatest weakness in the controversy.
For legal reasons, which are easy to appreciate, the industry
s unable to claim credit for these developments or to use
the results directly In any campaign to popularise the
smoking of low delivery products. Indeed, while adopting
an aggressive stance with the intention of offering consumer
assurance, the Industry is running the danger of sharpening
the controversy and thereby being forced more on the defence,
just at the time that some of its long term opponents are
prepared to indicate the relative safety of certain products
for those smokers who are unwilling to forgo the habit.
Polarisatioa of the situation has the potential of
antagonising would-be allies, who have given clear
indications of their willingness to say things that the
industry dare not.
A crucial task for the future would, therefore, seem
to be finding some way out of the legal impasse.
4. In the past two years, the threat posed by carbon
monoxide in scientific terms has abated. Following the
public recantation by Astrup, there are no valid scientific
reasons for the belief that carbon monoxide may initiate
cardiovascular disease. Smoking still persists as a risk
factor epidemiologically, but there are no adecuare models
for testing theories of the courses of these diseases.
Public authorities remain somewhat equivocal about the
possible significance of carbon monoxide in smoke. it
remains something of a hazard for people already suffering
from the disease.
Equally, measurements have shown that there is little
strength to attacks based on carbon monoxide contents in
ambient air. The thrust of the debate on passive smoking
has turned to the arguments based on social acceptability,
indicating that the anti-smoking lobby recognises the
weakness of their case in scientific terms.
5. Other weaknesses in the controversy con to be
the already-recognised problems associated with nitrosamines
and potential allergens in smoke. Nitrosamines formation Cr_
is dependent upon the tobacco blend and is, theoretically, cc
su@5ceptible to control by tobacco selection. U-4
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They are selectively removed from smoke by cellulose
acetate filters and, consequently, the levels suggested
by Wynder as non-hazardous are potentially attainable.
The U.S. Surgeon General's Report stated unequivocally
that tobacco smoke allergy remained unproven. Nevertheless,
some workers suspect that bronchitis and/or emphysema
associated with smoking may be a manifestation of an
allergic response by the lung. This is a comnlex area In
which there is genuine disagreement among experts, but It
remains a threat.
Both nitrosam nes and allergens are more important
threats to the industry's position on passive smoking.
The social implications of potential hazard to non-smokers
are well recogntsed. The establishment of safe exposure
levels to nitrosamines on the part of medical authorities
would greatly clarify the position.
6. There are two smoke constituents which, in the past,
have been considered relatively hazard-free, but about
which new suspicions have arisen. One is the radioactive
element polonium-210 (a radium-like material), which is
believed to be present in the insoluble residue of smoke
particulate matter. Its deposition in the lung is
suspected of causing radioactive "hotspots", leading to
cell mutation of malignant type. Potential risk associated
with polonium has been raised at least twice in the past,
latterly by Radford, but the subject has died away, because
of lack of positive experimental evidence. T.-.e matter has
been re-opened in the U.S.A.
(I hope to learn the latest position during my visit to
the U.S. in October)
The other suspected constituent is nicotine, for which
evidence of carcinogenic (or more probably co-carcinogenic)
activity has been revealed In studies under the auspices of
the National Cancer Institute and has been partly confirmed
in our own extramural programme. The potential importance
of this suspicion cannot be overemphasised.
(Again, I hope to learn more about the latest thinking
during the U.S. visit).
There is, as yet, no other substance with the same
pharmacological activities (both beneficial a@:d undesirable)
as nicotine. It underlines the need to understand as much
as possible of the ways whereby nicotine exerzs its action
on the central nervous system. A theory that nicotine may C::1
mimic the wav in which a natural substance ma-- act on
brain processes is attractive and it is very significant C=
that Philip Morris are working with a group i-vesiigating C=
this, originally under a C. T. R. grant, but ncw exclusively
with Philip Morris.
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7. Despite the threat around nicotine, it is still
recogntsed as being one reason, but not the only reason,
for people smoking. The danger that it would be labelled
a drug of addiction, differing little from heroin or
cocaine, appears to be receding; although zealous
anti-smokers may still pursue this idea pole=ically,
authorities on addiction do not substantiate the charge.
If advantage is to be won by marketing low delivery
cigarettes, there will be a need to understand fully the
motivations for smoking and the factors which govern the
way in which cigarettes are smoked. We are well placed
as a Group, in that we are in the forefront of the
technique at present.
S. A potential danger is that smoking by males may be
incriminated as causing a genetic mutation, thereby
affecting progeny. There have been one or two isolated
papers alleging evidence for this recently, without any
aztempt to define the alleged cause. They have passed
by without being noticed. Were this allegation to be
picked up by the press, particularly in counties with a
strcngly-masculine outlook, it could have an effect on
sales out of proportion to its significance for health.
THE FUTURE
There can, of course, be no guarantee t-_: an issue,
hit'.-.erto unsuspected, will not be discovered and used to
fashion a new weapon, to attack the industry. There seems
no medico-scientifIc area, which has not a I re a been
discussed; politico-economic issues lie outside this brief.
The nature of the problems and opportunities foreseen
in the foregoing review will undoubtedly differ in extent
cr applicability, depending upon the current szate of the
i For simplicity's sake,
smoking and health controversy.
three stages are considered:-
(a) Developed countries, with a recogni-sed pattern
of mortality in the smoking associated diseases.
League tables of brands are most probably already
published and a sophisticated public are aware of the
major issues. This group covers Al. Amer Europe,
Australasia.
Here, there are clear incen:ives fc7 the
oroduction of low-delivery cigarettes a the
specifications published by Gori and Tv- .4m - accc-uanied,
perhaps, by the publication of " ar@:icles
:!I-a%vi ng attention to these cri teri a.
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This may well be accompanied by demands for syste=s
of graduated taxation, based on tar yields. The
motivation behind such demands may not be the
encouragement of these brands, so much as the
progressive reduction of yields to zero, with the
intention of extinguishing the smoking habit.
Consequently, such systems should be resisted and,
for this purpose, aspects of the work on smoking
behaviour may be useful.
While there will continue to be demands for
a simplification of multi-component leiguetables,
these should be resisted. They cannot be justified
scientifically and they are fraught with undesirable
legal implications.
There is a school of thought, to which we have
subscribed in the past, advocating a progressive
change in the ratio of tar to nicotine, enabling
smokers to satisfy their need for nicotine, while
reducing their tar intake. While this procedure
is plausible in changing from high to medium deliveries,
there is evidence from smoking behaviour that it may
not hold for the switch from medium to low delivery
products and, while there exists a question mark
about nicotine, it would clearly be imvolitic to
stress nicotine deliveries in this context.
In order to demonstrate that the change in product
deliveries has led to an amelioration in health
statistics, there will be a need for prospective
epidemiological studies. Where possible, the national
health authorities should be involved in these,
partly to gain their commitment to the policy, but
also to avoid awkward legal predicaments, which could
arise, if the industry were too closely identified
with the findings of the surveys.
As mentioned earlier, a resolution of the legal
imoasse in the U.S.A. would greatly assist these
approaches.
If we assume the policy to be successful and to
result in reduced mortalities, the anti-smoking forces.
are likely to intensify their attacks on social
acceptability of smoking. In this case, reliance
will have to be placed on concepts of individuals'
freedcm and the demonstration of absence of harm in <=)
smoky environments. 1_-0
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(b) Developing countries with stable political
environments, in which the daily per capita
consumption of cigarettes by smokers Is around
10-20 and where standards of medical care are
becoming available to all the population with
reliable mortality statistics. This would cover
the Far East and parts of Latin America.
The products available here are predominantly
higt tar, but with an increasing proportion of
filter tip cigarettes. It must be expected that,
wirn increased medical care leading to longer life
and 'with an improving economic climate resulting
in higher disposable income, there is likely to be
a rise in mortality rates from smoking-associated
diseases, just as in the case of women in Developed
Countries. There will be advantages If the major
products can be moved into, at least, the middle
tar category and, for this purpose, changes in the
ra of@ tar to nicotine would enable the change
to be msde without undue loss of consumers (a replay
of the U.K. situation in the late 1960' If
possible, agreement through ICOSI with major
in competitors might ensure that most
brands were moved at about the same time.
Shculd there be demands from Governments,
prodded by WHU, for publication of league tables,
there will be an acceleration in the demand for low
delivery products and this may well occur before the
publication of adverse health statistics. It would
be prudent to maintain at least one brand in the low
delivery category, even although it may not be
sumcorted in the market.
Restrictions on smoking for anti-social reasons
mar be expected. more on the basis of "me -too ism"
rather than because of a legitimate campaign.
(C) Underdeveloped or politically unstable countries,
or :hose with a large uneducated peasantry. here the
daily per-capita cigarette consumption is generally
so low tnat mortality statistics, if available, would
not show much connection with smoking. It must be
rems--bered that smoking two pre-1960 U.S. cigarettes,
equivalent to 20 low delivery 1979 cigarettes, was
noz associated with any increased health risk.
The problems here are infant mortality, infection
it a ting tropical diseases.
an d deb The attack on the
ind,_,strv in these circumstances has been rade on -tile
basis o.C ..double standards", but this can be refuted
if covering the range of deliveries are
a V P. j :- 7
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Governments of these countries are likely
to be more interested in the raising of agricultural
standards and the revenue to be gained by taxing
tobacco products- rather than In eradicating non-
existent tobacco-associated diseases.
DGF/AIB/1.1.1.5
24th September, 1979
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