Memorandum by the Health Education Authority
THE TOBACCO INDUSTRY AND THE HEALTH RISKS
OF SMOKING (TB20)
CONTENTS
1. Introduction to the HEA
2. Background to the smoking problem
3. The evidence of harm
4. Responsibility to warn
5. Level of knowledge
6. Children and smoking
7. Recommendations and conclusion
8. References and appendices
1. INTRODUCTION
TO THE
HEA
The Health Education Authority (HEA) is a special
health authority within the NHS which has a statutory responsibility
to advise Government on health education issues. It is a national
centre of excellence for health education research and expertise
and, through its campaigns, publications and work with health
professionals and others, encourages the public to adopt healthier
lifestyles. We use national advertising campaigns, unpaid publicity,
leaflets and other resources to reach a wide range of audiences
and disseminate our research.
The HEA, and its predecessor the Health Education
Council (HEC), provide the public and health professionals with
information on the dangers of smoking. The predominant message
of this work over the years has been to encourage smokers to stop
smoking. However, from the early 1970s until the mid-1980s, the
HEC was advising people to switch to smoking lower tar cigarettes,
if they could not give up. At the same time, tobacco companies
were actively marketing low tar products using names like "light"
and "mild" and many consumers switched.
But the advice to switch to low tar products—which
was based on the best available scientific evidence1—was
wrong. And our recent research shows that many smokers still believe,
mistakenly, that smoking a "light" cigarette is better
for their health than smoking a higher tar cigarette.
The HEA would like to draw the Committee's attention
to the background to the problem, to some important points about
consumers' understanding of "light" cigarettes, and
to make some recommendations concerning the regulation of tobacco.
2. BACKGROUND
TO THE
SMOKING PROBLEM
Tobacco smoking, as we now know it, is a relatively
recent phenomenon, more recent than the motor car, the aeroplane
and telephone.2 Although tobacco has been smoked, chiefly in pipes
and cigars, or sucked and chewed by a number of different societies,
some for many centuries, the development of the manufactured cigarette
in the late nineteenth century substantially changed smoking habits
forever.
Manufactured cigarettes, made by a combination of
hand and machine, and later machine alone, were first marketed
in England in the 1850s. Although at first regarded as a hooligan's
alternative to pipes or cigars, they were convenient to use and
widely available, allowing consumption levels to increase. Their
convenience in the trenches during the First World War did much
to extend their popularity and more than 60 per cent of tobacco
donated to the Allies on the Western Front was in the form of
cigarettes.3
Cigarettes encouraged different patterns of
inhalation compared to other tobacco products. People primarily
use tobacco for the effects gained from nicotine, the addictive
drug it contains. Pipes, cigars and chewing tobacco produce nicotine
in an alkaline environment, enabling absorption through the lining
of the mouth. The more acidic smoke of cigarettes, however, necessitates
inhalation into the lungs for effective uptake of nicotine.4
While the other forms of tobacco use certainly
carry a burden of disease for their users, cigarettes, because
of their frequency of use and depth of inhalation, produce far
more disease.
3. THE EVIDENCE
OF HARM
Sir Richard Doll has comprehensively documented
the history of the evidence of harm caused by tobacco in his Green
College lecture (Appendix 1).
The major health problems caused by tobacco
are due to the manufactured cigarette and the marketing, advertising
and promotion of it.
All forms of tobacco are dangerous when smoked,
chewed or sucked. However, in British society the overwhelming
proportion of tobacco consumed is smoked in the form of the manufactured
cigarette.
Although the practice of cigarette smoking was
notionally regarded as harmful as far back as 1506, when James
I issued his "Counterblast to Tobacco", sound scientific
evidence of the harm it caused did not emerge until the 1950s
with the first case control studies of smoking and lung cancer
conducted in Britain by Sir Richard Doll and Sir Austin Bradford-Hill,
and in the USA by Dr Ewarts Graham and Ernest Wynder.
The evidence accumulated so decisively through
the 1950s that the Royal College of Physicians issued its first
report summarising the ill effects of smoking in 1962. The College
has since published five more reports on smoking and its effect
on adults, children and pregnant smokers.
The US Surgeon General has similarly published
15 comprehensive reports, the first in 1964.
Doll and Bradford-Hill began their follow-up
study of British doctors in 1952. Although there have been larger
studies, no other study has tracked the course of smoking and
ill health as comprehensively as the follow-up study of British
doctors (Appendix 2).[1]
. RESPONSIBILITY
TO WARN
Any manufacturer of any product which is dangerous
to health has a responsibility to warn those who may be affected
by that product. The principle of responsibility in common law
negligence ("the duty of care") was established in the
House of Lords in 1932, in the matter of Donaghue v Stevenson.
Thus tobacco companies had a moral and legal
responsibility to warn consumers and others who would be affected
of the dangers of smoking.
A second level of responsibility to warn and
protect the public from dangers to its health lies with the Government.
At no stage does the fact that the Government has acted or failed
to act to warn the public excuse any manufacturer from their primary
responsibility.
We have come to appreciate that there is a third
tier of organisations which have developed over time to warn and
educate the public about various health dangers. These are local
authorities, health authorities and non-Government organisations,
including charities.
All of these organisations above have played
a role, to a greater or lesser degree, in informing the public
of the health dangers of smoking.
The health warnings which have appeared on advertisements
and tobacco packages are warnings from Government. The tobacco
industry has never voluntarily warned its customers about the
dangers of smoking, and only recently has done so in the United
States, having been coerced by the threat of legal action from
the states' Attorneys General.
5. LEVEL OF
KNOWLEDGE
Documents which have come to light in the United
States over the past five or six years, as a consequence of litigation,
reveal for the first time the extent of the knowledge held by
tobacco companies on the dangers of smoking.
Documents from one US company, Brown and Williamson,
a subsidiary of BAT, reveal that tobacco companies have known
in specific and general detail the impact of smoking on humans.
They have had this information many years ahead of the general
scientific community.
Although the Brown & Williamson documents
provide an insight to one company, it is clear from other documents
filed in the Minnesota litigation, that the level and depth of
knowledge held by this one company was relatively common throughout
the industry. Several examples are available which show the extent
to which the failure of the tobacco industry to share what it
knew, either confidentially with governments, or universally with
the public health community, has led to errors in public policy
which have had far reaching effects.
Possibly the most obvious of these now appears
to be the advice on low tar cigarettes.
Switch to low-tar-lower health risk?
During the early 1970s, up until the mid-80s,
the HEC (a Government quango), was advising smokers to give up
smoking or, if that was not possible, to switch to a lower tar
brand. Examples of some of their advertisements are attached (Appendix
3).
In 1972, an HEC poster listed the tar and nicotine
content of various brands of cigarettes and carried the warning,
"Although it is important to switch to a brand containing
less tar and nicotine, remember that smoking any cigarette is
dangerous."
A television advertisement broadcast in the
early 1970s showed the tar from a cigarette being poured into
a petri dish while a voice-over said, "all cigarettes damage
your lungs but high tar cigarettes do the most damage."
In 1975 a press advertisement asked, "Which
cigarettes kill you the quickest? Last year alone, cigarettes
killed at least 50,000 smokers. But some cigarettes kill you quicker
than others. If you can't stop smoking choose those brands with
the least tar and nicotine .
.
. Remember the quicker you change to a low
tar cigarette, the better your chances."
Similarly, an HEC poster published in 1981 says,
"Remember—all cigarettes are lethal! If you must smoke,
change to a low tar yield cigarette."
This advice was based on the best scientific
knowledge available outside the tobacco industry. But it turned
out to be wrong. Certainly, smoking a "low tar" cigarette
today is not better for your health.
Smokers' behaviour is determined largely by
their need to consume nicotine. People smoking low tar, low nicotine
cigarettes engage in "compensatory smoking". They take
more puffs, inhale more deeply and block the vent holes in the
filter, either consciously or unconsciously. Just three or four
extra puffs on a cigarette can transform a low tar cigarette into
a regular strength cigarette, particularly as manufactured cigarettes
now span a fairly narrow tar range (1-12 mg) so there is less
difference between the two.
In fact, smoking "low tar" cigarettes
may carry specific health risks and be related to dramatic increases
in a previously rare form of lung cancer, adenocarcinoma.5 Whereas
the cigarette smoke from the high tar cigarettes smoked in earlier
decades was too irritating to inhale very deeply, smokers of low
tar cigarettes puff more intensely, delivering more carcinogens
and toxins to the peripheral lung area where adenocarcinoma develops.
Additives are used to make cigarettes that provide
high levels of "free" nicotine which increases the addictive
"kick" of the nicotine. Additives are also used to enhance
the taste of tobacco smoke and to dilate the airways, allowing
the smoke an easier and deeper passage to the lungs.6
What do consumers know about their cigarettes
and how do they perceive low tar or "light" cigarettes?
In 1999, the HEA published a report entitled
"Consumers and the Changing Cigarette" based on research
which looked at what smokers in England know about the cigarettes
they smoke and how they perceive low tar or light cigarettes.
The research had two components: a small-scale
qualitative study to help develop the questionnaire and a survey
in which face-to-face interviews were conducted with 3,448 adults
(1,036 of them smokers) aged 16 and over.
Who smokes light cigarettes?
Over a third (34 per cent) of all smokers in
England reported that they smoked cigarettes described as "light",
"mild" or "ultra light". Light cigarettes
were more popular amongst women, smokers from non-manual social
groups, and smokers aged 35 or over. Almost half (46 per cent)
of the women smokers in non-manual social groups reported smoking
light cigarettes (see Table 1).
Why do smokers switch to light cigarettes?
Most light smokers (over 77 per cent) have switched
from regular cigarettes largely because they see "light"
cigarettes as being less harmful than regular cigarettes.
A third (34 per cent) of the smokers who currently
smoked light cigarettes said that a main reason for switching
to a light brand was because they were worried about their health.
Almost three out of 10 (28 per cent) of smokers also said that
a main reason for switching was as a step towards quitting (see
Table 2).
Do smokers see "light" cigarettes as less
harmful?
The research shows that some smokers, particularly
smokers who already smoke light cigarettes are persuaded that
light cigarettes are less harmful.
Over a quarter (28 per cent) of smokers thought
that light cigarettes were less harmful than regular cigarettes.
More than a third (36 per cent) of the smokers currently smoking
light cigarettes thought them to be less harmful than regular
brands.
Young smokers (those aged 16-24) were the most
likely (33 per cent) to think that light cigarettes were less
harmful than regular cigarettes.
These young smokers were also the most likely
to think that their risk of serious illness would halve if they
switched from a cigarette with 8mg of tar to one with 4mg of tar.
Over a quarter of smokers (26 per cent) thought
a pregnant woman could lower the risks to her unborn child by
smoking lights, and a further 8 per cent were unsure.
In fact, a quarter (25 per cent) of all smokers
thought that switching to light cigarettes would be a step towards
giving up altogether.
Do smokers know about the different substances in
cigarettes?
Smokers know relatively little about what is
in their cigarette.
Although most (94 per cent) smokers identified
nicotine as the main addictive element in cigarettes, only two-thirds
(66 per cent) identified tar as the main cancer causing substance.
More than two-fifths (43 per cent) thought that nicotine was also
a cancer-causing component of cigarettes (see Table 3).
Do smokers understand tar and nicotine yields?
This research indicates strongly that consumers
really do not understand the product information given on their
cigarette pack.
Smokers find it difficult to interpret what
particular tar numbers mean. Almost half (46 per cent) of all
smokers thought that a cigarette with 3mg of tar (defined as a
"very low tar" under the current classification system)
was about average or higher than average compared with most other
brands on the market.
Over two-thirds (69 per cent) of smokers correctly
thought that the tar level referred to the tar yield from each
cigarette. However, just under a third of smokers either thought
it referred to the whole packet (17 per cent) or were not sure
(14 per cent) what the number on the packet meant.
Over six out of 10 (62 per cent) smokers knew
that the amount of tar they got from a cigarette was affected
by how deeply they inhaled. However, only one in five (20 per
cent) smokers knew that tar levels could also be affected by the
size of ventilation holes in the cigarette (see Table 4).
About half of all smokers were unable to estimate
the tar and nicotine levels of the cigarette they themselves were
currently smoking.
The Brown & Williamson documents featured
in a special section of the Journal of the American Medical Association.
In particular Nicotine and Addiction, by Slade et al,
details the knowledge that the tobacco industry has had about
nicotine and the importance it has placed on it (Appendix 4).
6. CHILDREN AND
SMOKING
The tobacco industry has long claimed that it
has no interest in children smoking cigarettes. This assertion
is curious given the industry's stated belief that smoking does
not cause any illness. If cigarettes were as harmless as other
commercial items highly sought by children, such as CDs or ice
cream, why is it not legitimate to market to them?
However, the Minnesota documents from the Internet
reveal a very strong industry interest in under 16s smoking, as
the confidential report of a Philip Morris researcher, Myron Johnstone
show. Although Johnstone wrote the report attached (Appendix 5)
in 1984, he was still in the employ of Philip Morris in the 1990s.
Johnstone wrote:
"It is important to know as much as possible
about teenage smoking patterns and attitudes. Today's teenager
is tomorrow's potential regular customer, and the overwhelming
majority of smokers first begin to smoke while still in their
teens. In addition, the ten years following the teenage years
is the period during which average daily consumption per smoker
increases to the adult average level. The smoking patterns of
teenagers are particularly important to Philip Morris. Of the
11 packings of which the median age of smokers is under age 30,
seven are Philip Morris packings, and the share index is the highest
in the youngest age group for all Marlboro and Virginia Slims
packings and for B&H Lights and Menthol.
Furthermore, it is during the teenage years
that the initial brand choice is made. At least part of the success
of Marlboro Red during its most rapid growth period was because
it became the brand of choice among teenagers who then
stuck with it as they grew older" (emphasis in original).
7. RECOMMENDATIONS
& CONCLUSION
THE HEA WOULD URGE THE COMMITTEE TO MAKE
THE FOLLOWING RECOMMENDATIONS:
1. Remove unproven health claims on the packaging
of tobacco products by preventing the use of undefined terms such
as light, ultra, mild, low nicotine and low tar. This should include
preventing the use of such words in the brand name of cigarettes.
As our survey shows, smokers are clearly very
confused about the difference between light and regular cigarettes.
The use of the term "light" in other contexts, connotes
"low in fat" or "low in sugar", and therefore
healthier. A proposed EU Directive on tobacco content regulation,
shortly to be released for internal consultation within the Commission,
may curtail the use of these terms. The proposed Directive is
expected to be discussed at the next Health Council meeting.
2. Push for a review the International Standards
Organisation (ISO) standards that measure the tar and nicotine
yield in cigarettes.
The current European Directive on the labelling
of tobacco products stipulates that tar and nicotine yields must
be shown on cigarette packets and should be measured on the basis
of two ISO methods. However, the current ISO test results do not
provide consumers with meaningful measures of what they can expect
to ingest from cigarettes since people do not smoke like machines.
Generally, the ISO standard methods underestimate the tar and
nicotine level of cigarettes and provide smokers with misleading
information.
3. Require full disclosure by brand and by
regulation of additives
Tobacco products have escaped meaningful regulation
partly because of a lack of technical knowledge about them outside
the industry. It is essential to know more about the product in
order to regulate it correctly. Greater information is needed
about the role of constituents, chemicals, flavourings and other
additives and their effect on smoking behaviour. Moreover, their
safety when burned needs to be established.
Tobacco companies should be required to disclose
all ingredients and additives for all brands of cigarette and
other tobacco products.
4. Regular public access to tobacco industry
documents
The documents from the US tobacco companies
involved in the Minnesota litigation, Philip Morris, Brown &
Williamson, Lorillard and the US Tobacco Institute, have all been
posted on the Internet, accessible at http://tobaccoresolutions.com.
The British public should have an equal opportunity to the Americans'
right to know about British tobacco companies. This information,
such as at BAT's Guildford document depositary, should be scanned
and available on the Internet.
5. Provide more useful, meaningful information
for consumers.
There is room for public education to counteract
the marketing of light cigarettes by highlighting to smokers how
the ideas of "healthier" or "safer" or "less
risky" cigarettes contradicts information they already have
about cigarettes.
Smokers also seem confused, not surprisingly,
about the health risks of different ingredients in cigarettes.
Even after four decades of public education on smoking, a third
of smokers were not aware that tar is the main cancer causing
substance in cigarettes. The HEA survey found that four out of
10 smokers thought nicotine was cancer causing, while over a third
of smokers judged nicotine to be more harmful than tar. This may
be one explanation why more smokers who want to quit have not
yet tried nicotine replacement therapies (NRT). Given the potential
public health benefits offered by nicotine replacement therapies,
providing smokers with more information about nicotine and tar
is crucial.
It is a paradox that the most dangerous form
of nicotine delivery, the cigarette, is virtually unregulated
whereas, its safest form, NRT, is strictly regulated by the Medicines
Control Agency.
Smokers are also entitled to information about
compensatory smoking. The HEA research found that smokers were
aware that they could increase their tar yield by inhaling more
deeply but few knew about vent holes in cigarettes. The research
suggests that smokers do not realise how the ability to vary tar
yields through compensatory smoking can undermine the information
that appears on the packet. Information on compensatory smoking
will help to give smokers greater understanding of the product
they are smoking.
CONCLUSION
Cigarettes are by far the most dangerous consumer
product on the market. It is shocking that consumers have less
information about cigarettes than they have about any other product.
Government should require tobacco companies to give more accurate
and more appropriate information about tobacco products to consumers.
September 1999
8. REFERENCES
AND APPENDICESREFERENCES
1. The Changing Cigarette—a
report of the Surgeon General, US Department of Health and Human
Services, 1981.
2. US Department of Health and Human Services,
Public Health Service, Office on Smoking and Health, Smoking,
tobacco and health: a fact book. Washington DC: US Government
Printing Office, 1980.
3. Walker R, Under Fire. A History of
Tobacco Smoking in Australia. Melbourne: Melbourne University
Press, 1984.
4. Benowitz NL, Pharmacologic aspects
of cigarette smoking and nicotine addiction. New Engl J Med
1988; 319: 1318-1330.
5. Stellman SD, Muscat JE, Hoffman D, et
al. Impact of filter cigarette smoking on lung cancer histology.
Preventive Medicine 1997; 26:451-6.
Hoffman D, Djordjevic MV, Hoffman I. The changing
cigarette. Preventive Medicine 1997; 26:427-34.
Thun MJ, Lally CA, Flannery JT, et al. Cigarette
smoking and changes in histopathology of lung cancer. J National
Cancer Institute 1997; 89:1580-6.
6. Bates C, Connolly G, Jarvis M. Tobacco
additives: cigarette engineering and nicotine addictions, 1999.
London. Action on Smoking and Health and Imperial Cancer Research
fund 1999.
APPENDICES
Appendix 1 Green College Lecture, Sir
Richard Doll
Appendix 2 Follow up study of British
doctors, Doll and Bradford-Hill[2]
Appendix 3 Health Education Council
advertisements*
Appendix 4 JAMA special section on Brown
and Williamson documents*
Appendix 5 Myron Johnstone report for
Philip Morris*
1 Appendices 2-4 not printed.4. Back
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