WORLD HEALTH ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

ВСЕМИРНАЯ ОРГАНИЗАЦИЯ

ЗДРАВООХРАНЕНИЯ

R E G I O N A L C O M M I T T E E F O R E U R O P E C O M I T E R E G I O N A L DE L’ E U ROPE

ЕВРОПЕЙСКИЙ РЕГИОНАЛЬНЫЙ КОМИТЕТ

At its nineteenth session, the Regional Committee requested the Regional Director to report to the present session on measures which have been taken to control cigarette advertising and to discourage cigarette smoking (resolution EUR/RC19/R20 .

With this in view, the Regional Director in February this year wrote to Member States in the Region (circular C2/76/2), asking them the following three questions:

(1) What measures have been taken to control the advertising of cigarettes or to include in promotional material appropriate warnings?(2) What measures have been taken to restrict cigarette smoking in places of work or in public gatherings?

(3) What other methods have been used to warn the public about the dangers of smoking?Up to now, 16 Member States have replied. In an annex to this document ex­

tracts are given from each of these replies. These extracts have been selected, not so much to show the position of any country with regard to cigarette smoking, as to illustrate, through the range of outlooks expressed, the diversity and extent of the problem faced in the European Region. The Secretariat have available a copy of the full text of the replies received in the original languages which can be consulted by representatives if they wish to do so.

The Director-General submitted to the Twenty-third World Health Assembly a report on "The Limitation of Smoking” (A23/P&B/6) presenting the facts about the relationship between smoking and disease, examining the possibilities of prevention

Twentieth SessionMalta, 22-26 September 1970Provisional agenda item 8.2

EUR/RC20/8 3 August 1970ORIGINAL: ENGLISH

CONTROL OF CIGARETTE SMOKING

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and making a series of recommendations. On 2Л June 1970 the Director-General sent Member States and Associate Members a circular (C.L.2l) referring to the resolu­tion adopted by the Twenty-third World Health Assembly (WHA2j5.p2) on the effects of smoking on health and drawing the attention of all Member States and Associate Members to the recommendations included at the end of the report referred to above and enclosing them with a copy of the resolution.

The report in itself is a remarkable document rounding off the material col­lected by the Regional Director and extending its range still further, particularly in the chapters on "Approaches to prevention" (paragraphs 4, 5 and 6) and "Experience in one Member State". In the same way, the replies by Member States to the Regional Director’s questions (particularly the extracts given in the Annex) underline and confirm almost point by point some of the considerations expressed in tne Director- General's report and make virtually the same recommendations.

In the field oi publicity, where legislation on advertising varies from country to country from total absence of regulations to complete pronibition under penalty of heavy fines, it would appear that the recommendations made by the Director- General are both flexible and realistic, since they would, in the long run, tend to curtail smoking and for the immediate future would restrict cigarette advertising.

In most countries of the Region, such steps are tending to be consolidated by fresh legislation and by realization of the seriousness of the problem, on the one

hand by responsible opinion (teachers, doctors, legal experts) and, on the other, by the public itself, which is becoming ever better alerted to the dangers of cigarette smoking.

The effectiveness of any campaign against smoking must depend directly on the publicity given to the dangers it involves. However, whereas restriction or pro­hibition of cigarette advertising is essentially a political, economic and social decision, involving new legislation affecting an immense source of revenue and the employment of large numbers of workers in production and distribution, counter­publicity on the dangers of smoking is mainly a matter for the health and other relevant authorities. It is in discouraging smoking that WHO's work, based on a scientific knowledge of the dangers, can be most effective. In this connexion, it should be pointed out that many countries have already taken steps to combat smoking in places of public gathering and public transport, and to prohibit it in workplaces.

lù ü A /iiC c ïO / 8 page 3

The Regional Committee at its nineteenth session recognized "on the basis of the facts, now well established, that cigarette smoking is an important cause of, or a substantial factor contributing to, premature deaths from broncho-pulmonary cancer, coronary disease, chronic bronchitis and other chronic lung diseases".While the medical profession and, no doubt, a large part of public opinion concedes that cigarette smoking leads to cancer, Its role in causing other conditions, particularly coronary diseases, is less known and less accepted. For this reason, it vrould seem worthwhile to attach a copy of the study by Professor D.D. Reid of London (Annex 2) "Smoking and the heart". At the same time it should be pointed out that the Regional Office is still conducting investigations in this field with the assistance of countries of the Region.

ANNEX 1

Austria1 April 197°

Manufacturers have agreed to abstain, at least from advertising specifically addressed to young people. However, general advertising by Austrian manufacturers could not be curtailed as long as at the same time the public is exposed to adver­tising by numerous foreign newspapers and weekly magazines sold in Austria.

Furthermore, the attention of Austria's broadcasting and TV services has been drawn to the health hazards of cigarette smoking. It was suggested that advertising be restricted and given up in the long run altogether.

Belgium24 March 197O

No steps have been taken to control cigarette advertising and no restrictions placed on the insertion of advertisements in advertising media.

Czechoslovakia 9 April I97O

At present no regulation exists in Chechoslovakia, whicn would prohibit puolicity for cigarettes. The Ministry of Health has advised the producers of these goods, however, not to advertise. Although this advice is not binding, publicity for cigarettes and tobacco products may be considered as limited.

Denmark 13 April 197O

In agreement witn the Minister of the Interior the cigarette manufacturers have, since I.963j voluntarily desisted from advertising in cinemas and in those weeklies particularly read by young people.

Furthermore, the cigarette manufacturers promised some limitation of the size of cigarette advertisements in the daily papers.

EUR/RC20/8page 4

page 5 Annex 1

EUR/RC20/8

Federal Republic of Germany 26 May 197O

Problems concerning the advertising of cigarettes and the inclusion of appro­priate warnings on cigarette packages are, at present, being considered in the frame­work of the reform of food legislation.

Finland h April 197O

It is understandable that neasures taken by the Government against smoking tend to be inefficient and slack in & country like Finland, where the State (tax) on tobacco products is high, particularly as no figures on the economic losses caused by smoking in the form of increased health expenditure can be snown in comparison with the State income from the tax on tobacco products.

Greece2 March 197O

No steps have been taken so far.

Iceland7 April 197O

Printed warnings on all cigarette packages. Education and propaganda in schools, especially primary and secondary schools.

Ireland 25 March 197O

The National Radio and Television Authority has decided to phase out cigarette advertising on television. At present, cigarette advertising is not shown before8 p.m. on Irish Television and as from 1 April next it will not be shown before 9 P.m. The phasing-out policy will be fully implemented by 3-1 March 1971*

EUR/RC20/8page бAnnex 1

ItalyЮ June I97O

Cigarette advertising is forbidden in Italy.

A bill has recently been drafted that cigarette packets should bear a clear warning against the danger of smoking. However, the bill has not been passed so far.

Monaco12 March 197O

No steps have been taken in the Principality to control cigarette smoking.

Netherlands13 March 197O

Since 1964 the Ministry of Social Affairs and Public Health has made an annual grant of 55О 000 florins ... to finance a No-Smoking Campaign.

The Campaign ... consists of ... medical information and advice for school­children ... parents and other educators ... the pursuit of restrictions on the sale and use of cigarettes. In the Netherlands, there are no restrictions on the ad­vertising of tobacco products in daily or woekly papers.

... Attempts to help people break the tobacco habit: possibilities in this respect are limited, on the one hand because there are no universally applicable methods for breaking the habit and on the other because of the lack of sufficient manpower.

Norwayl8 March 197O

A white paper on cigarette smoking was tabled in the Parlia.ment last year.No doubt various restrictive proposals will be put forward.

Poland25 May 197O

In Poland, there is no advertising of tobacco products. On the contrary, the public is informed about the harmful effects of smoking.

page 7 Annex 1

EUR/RC20/8

A Social Committee for the Control of Smoking has just been set up with the purpose of propagating information on the harmful effects of smoking in different environments, using different forms of mass propaganda.

Portugal 24 March 197О

So far no legal measures have been taken to prevent cigarette advertising. However, such advertising is not on a large scale. Attempts have been made to warn the public of the danger of smoking, and particularly of cigarette smoking, by means of health education.

Romania 23 April I97O

No special measures have been taken in Romania to control cigarette advertising or the placing of advertisements for cigarettes, since it is not the practice in our country to advertise cigarettes.

Sustained propaganda is carried on in the population to warn the public of the dangers of smoking to health in general, and to the health of women and young people in particular.

SwedenЮ April 197O

There is a working group of members of the National Board of Health and Welfare and the Tobacco and Importing Association to find ways and means of restricting advertising and to change its content.

Switzerland 11 March 197O

The clauses on smoking in the regulations governing trade in foodstuffs are being revised. They envisage in particular prohibition of advertising addressed specifically to young people.

EUR/RC20/8 page 8 Annex 1

All advertising and publicity is prohibited on the radio. As regards televi­sion, where advertising is allowed, advertisements for drugs, alcohol and tobacco are forbidden.

United Kingdom7 April 197O

In 1965, the Postmaster General ... issued a direction banning the advertising of cigarettes on the Independent Television network. There is no advertising on the British Broadcasting Corporation's radio and television programmes. The ban does not extend to advertisements for cigars and pipe tobacco. Mo restriction on cigarette advertising in any other media are at present in force.

USSR2k March 197O

In the USSR, advertisements for tobacco and articles containing tobacco ceased in 1955.

Smoking is not allowed in medical establisnments, in schools, and in the work­places of many offices and industrial establishments. In these premises special places for smoking are set aside, but teachers and doctors can smoke in teachers' colleges and postgraduate medical schools.

Yugoslavia 6 April I97O

Measures have been taken to restrict smoking on public premises ... and to prohibit advertising through mass information media.

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ANNEX 2

byProfessor D.D. Reid

Professor of Epidemiology London School of Hygiene and Tropical Medicine

No reasonable doubt now exists about the importance of cigarette smoking as the major cause of lung cancer. The effect of smoking on oardiovascular health is less clear cut.; but there is an increasing realization of the extra risk of death from heart disease that is associated with this habit. Middle-aged men smoking more than 20 cigarettes each day are about 20 times as likely to die from lung cancer as their non-smoking contemporaries- and about twice as likely to die from coronary heart disease. On the other hand, in middle-aged men in developed coun­tries this form of heart disease is the commonest cause of death (depending on the country, several times more common than lung cancer). For this reason, even a relatively small increase in hazard from heart disease means that cigarette smoking can be held responsible for far more deaths from this cause them from lung cancer. From the individual middle-aged man's point of view, smoking more than 20 cigarettes a day doubles his chance of death over the levels for non-smokers; and half of this excess risk is due to the two-fold increase in the risk of death from ischaemic heart disease. In other words, of 100 excess deaths from all causes observed among heavy smokers about lb may be due to lung cancer but 5^ might result from heart disease.

It could be argued, of course, that if the psychological stress of life is a major cause of coronary heart disease, then both the disease and the habit of smoking may be simply different expressions of reaction to mental tension. On this basis, the more tense the individual the more he smokes and the greater is his risk of heart disease; but the cigarette smoking would not, if this argument held, be the cause of the heart disorder. In other words, the fact that heavy cigarette smokers have high death rates from coronary heart disease is merely a coincidence rather than an example of cause and effect. There is, however, no very good evidence that temperamental qualities and the stresses of life are important causes of coronary heart disease. Moreover, there is much evidence to suggest that cigarette smoking has a quite independent influence on the course of the disease.

SMOKING AND THE HEART

EUR/RC20/3page 10 Annex 2

The rise in the death rate from arteriosclerotic heart disease that has taken place since the First World War began earlier and has since been most rapid among men in all the countries of Europe where cigarette consumption was rising at the same time. Yet there is no reason to suppose that, for the first time in history, men were suddenly becoming more nervous than women. In fact, the death rate, par­ticularly among men, from arteriosclerotic heart disease is highest in those coun­tries in Europe where the predominatingly masculine habit of cigarette consumption is commonest; and the rise, especially in the death rate for younger men, has been broadly in step with increasing cigarette consumption.

Studies of the frequency of symptoms of heart disease in identical and non­identical twins have certainly shown that some individuals are, for familial or genetic reasons, more likely to have such symptoms than others. Nevertheless, in other large-scale studies where the subjects have been matched for all sorts of constitutional characteristics such as height, weight, blood pressure and level of fat in the blood, those who smoke more are more likely to die from arteriosclerotic heart disease. Non-smokers, particularly where there is a strong family history of the disease, are not of course immune to it, but long-term follow-up surveys in many countries have repeatedly shorn,e.g. in British doctors or American veterans, a consistent increase in the death rate fron coronary heart disease in step with the number of cigarettes smoked daily. Of perhaps greater significance from the view­point of prevention is the finding in a major American study that the risk falls when the habit is given up. A recent survey of the frequency of heart symptoms shows that they also eventually fall to near the level found in non-smokers. On the other hand, the practice of inhaling the smoke seems to raise the frequency of both symptoms and death.

In all these studies, the apparent effect of cigarette smoking is most clearly seen among men under the age of 50 years. In general, the effect among women is less obvious. Another common feature of the surveys done thus far is the appreciably lower frequency of heart disease among those who habitually smoke either pipes or cigars. It is likely that deep inhalation is less common when tobacco is smoked in this way.

page il Annex 2

The epidemiological evidence accumulated in recent years thus strongly indicates that smoking, especially of cigarettes, does increase the risk of suffering and dying from coronary heart disease. It does not, however, explain how smoking acts on the circulatory system to produce the interference with the blood supply to the heart muscle which is the cardinal feature of the disease. Cigarette smoke is a complex substance, but nicotine is one of its important constituents. Studies on patients suffering from coronary heart disease have shown that smoking a cigarette has an effect similar to the injection of nicotine in that it produces an immediate increase in the blood pressure and the output of the heart.

Other clinical investigations have shown that smoking cigarettes causes changes in the blood which increase the risk of the process of thrombosis in the arteries supplying the heart muscle. Cigarette smoke also contains carbon monoxide - the lethal component of coal gas. Carbon monoxide combines readily with the haemoglobin in the blood corpuscles which carries oxygen from the lungs to the tissues of the body. This reduces the ability of the blood corpuscles to carry oxygen to vital organs such as the heart. In fit young people, this is usually of little practical importance; but, especially when nicotine is increasing its pumping action, this other effect of smoking may impose a great burden on an already damaged and failing heart. Examination after death of the bio i vessels supplying the heart have re­vealed in their walls degenerative changes which slow up tne blood flow and increase the risk of blockage of the arteries. These changes are much commoner in smokers than in non-smokers.

All these investigations, whether epidemiological, clinical or pathological, thus seem to point firmly at the cigarette as one of the factor's which favour the onset and seriously aggravate arteriosclerotic heart disease. As already noted, this is a main cause of death among men in middle life and, although cigarette smoking is only one of the factors in its causation, any public healtn action to limit smoking would effect a worthwhile reduction in mortality from this disease. Unfortunately, general propaganda against smoking based on its risk to health appears to have little in­fluence on the trend of consumption of cigarettes. Raising taxation on tobacco in general and cigarettes in particular to punitive levels might have an immediately beneficial result but the political and financial objections appear to be insurmount­able in the present climate of public opinion. There is thus a need for leadership from the profession and the laity who are concerned about public health.

EUR/RC20/8page 12 Annex 2

The influence of the profession can be exerted by example as well as by precept. The cliange in smoking habit recorded by the profession in e.g. Britain and the USA, is bound to have an effect on the mortality of the doctors themselves and on the habits of their patients. For patients already suffering from ischaemic heart disease the sensible advice is to give up cigarette smoking; and where giving up smoking proves to be beyond the patient’s capacity, there is the alternative of the lesser danger to the heart presented by pipes or cigars. Recent developments in the detection of either the early stages of heart disorder or of those physical characteristics such as high blood pressure which indicate an undue personal liability to coronary heart disease may be important in this context. Screening of popula­tions, particularly of middle-aged men, may detect those for whom coronary heart disease presents a major hazard to health and life. It seems reasonable to suppose that it is on these men that persuasion to stop smoking should be concentrated; and field trials are now in progress to assess the value of such methods.

Through the co-ordination and stimulation of this kind of trial WHO is making an important contribution to the prevention of coronary heart disease in Europe.