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The purpose of this letter, then, is to thank you for your elo-quent support for those of us opposed to the exercise by phys-icians of "industrial action", and to stress that there must bedramatic changes made in the N.H.S. if patients are to receivethe services they deserve.

Willis Eye Hospital and Jefferson Medical College,1601 Spring Garden Street,Philadelphia 19130, U.S.A. GEORGE L. SPAETH

TAXES, SMOKING, AND HEALTH

SIR,-Since public education and health warnings on

cigarette packets and advertisements have had only marginalimpact, the most effective means of reducing consumption isprobably simply to increase the price of cigarettes. A U.S. con-gressional enquiry on cigarette prices and advertising controlis due to start soon and the Chancellor of the Exchequer isplanning his next budget, so this seems a good time to suggesta specific strategy for smoking control. The table shows theprojected effects of increasing the real price by 10% per annum

EFFECTS OF INCREASING THE REAL PRICE OF CIGARETTES BY 10% PERANNUM FOR 10 YEARS, THEN HOLDING IT CONSTANT

for 10 years then maintaining it at that level, which by 1985would be 1-30 for 20 plain cigarettes at current values. Theresulting fall in consumption and mortality and the increase inrevenue are calculated on the assumption that a 10% price in-crease reduces consumption by 5%. This estimate, based onchanges in price and consumption in Britain since 1951,’ maybe too low. A Canadian study2 suggests that consumptionmight fall by more than this, and price increases are likely tobe more effective over a period when real incomes are falling.The fall in consumption might thus be considerably greaterthan these figures suggest, particularly if all forms of promo-tion were banned at the same time.The likely long-term effect of such a policy would be a sav-

ing of at least 12 000 premature deaths a year among theworking population and a substantial increase in revenue.Since alternative steps to reduce smoking are unlikely to be aseffective and can only reduce revenue, the Government seemsboth morally and economically obliged to act immediately.D.H.S.S. Cancer Epidemiology andClinical Tnals Unit,Department of the Regius Professor of Medicine,9 Keble Road, Oxford. JULIAN PETO

CARBON-MONOXIDE YIELD OF FILTER-TIPPEDCIGARETTES

SIR,-Dr Wald (Jan. 17, p. 136) presented evidence to sug-gest that carbon monoxide (CO) rather than nicotine may bethe factor in tobacco smoke responsible for the higher cor-onary-heart-disease (C.H.D.) mortality among cigarettesmokers. His argument is based upon his finding that, onaverage, the CO yields of a sample of nine brands of filter-tipped cigarettes were a little higher than a similar sample ofplain cigarettes. His sample of filter-tipped cigarettes over-re-presented king-sized brands (five out of nine brands tested). I

1. Peto, J Br. J. prev. soc. Med. 1974, 28, 241.2. Thompson, M. E., McLeod, I. Personal communication.

do not disagree with Dr Wald’s findings or his conclusions butwould comment on a matter of emphasis.Dr Wald’s concluding remark, which was picked up by the

lay Press, is easy to misinterpret. He states: "The possibilitythat smoking filter-tipped cigarettes might be more harmful inrelation to c.H.D. than smoking plain cigarettes is of consider-able importance in view of the large number of filter cigaretteswhich are now smoked". Many people reading this, and es-pecially second-hand reports of it, might gain the false impres-sion that filter-tipped cigarettes are not a great deal safer thanplain ones.The truth is, and Dr Wald discussed it, that the risk of lung

cancer and bronchitis is greatly reduced by smoking filter-

tipped rather than plain cigarettes. CO yield, and presumablythe risk of C.H.D. is also greatly reduced in those filter-tippedcigarettes which have ventilated filters. We have shown thatthe CO yields of cigarettes with ventilated filters are as low asa quarter the yield of plain cigarettes.’ Thus while brands withconventional filter-tips might have slightly higher CO yieldsthan plain cigarettes, the brands with ventilated filters havelower CO yields as well as lower tar and nicotine yields.Although Dr Wald does mention this in the body of his paper,his main conclusion does not make it clear that cigarettes withventilated filters are the safest cigarettes.

This confusion would be rapidly dispelled if the Governmentwere to publish CO yields along with the tar and nicotineyields of cigarettes. When we suggested this in 1973,z Dr Waldstated that such action then was premature.3 In view of hisexcellent paper it would seem now to be urgent.

Addiction Research Unit,Institute of Psychiatry,Maudsley Hospital,London SE5 8AF. M. A. H. RUSSELL

ETHICS OF FLUORIDATION

SIR,-While I will not cast a stone against John Locke, I amprepared to do so metaphorically against Professor Sinclair(Jan. 17, p. 142). Surely, as a member of the International In-stitute of Human Nutrition, he must see a parallel betweenfluoridation of water supplies and the compulsory fortificationof foods with vitamins, to which his institute cannot takeexception. Whereas he and I and you, Sir, are prepared to re-spect individual freedom, others are not. If they are willing toeat too much sugar, and prepared to forego brushing theirteeth, that is personal freedom. It ceases to be when theirchildren are encouraged, if only by example, to do the same.It also impinges on my freedom when they take up more thantheir fair share of my dentist’s time, when he is called upon tomend the errors of their ways; it impinges again when thisextra treatment is paid for out of their Exchequer and in-surance contributions and mine. I wholeheartedly supportfluoridation of water supplies, not only as a technique of pre-ventive medicine, but also as one that, in the best traditions ofethics, prevents the (dental) sins of the fathers being visited onthe children. In conclusion, I would draw a parallel betweenchlorination and fluoridation of water supplies in place of acontrast. The object of both is to ensure that the consumer isnot subjected to attack by pathogens; that the two elements actin different ways to bring this about is immaterial.International Institute of Cellular andMolecular Pathology,Catholic University of Louvain,B-1200 Brussels, Belgium. A. E. LEEK

SIR,-Dr Long (Jan. 17, p. 142) believes that professionalorganisations should take a lead on all diet-induced diseases-

1. Russell, M. A. H., Cole, P. V., Idle, M. S., Adams, L. Br. med. J. 1975, iii,71.

2. Russell, M. A. H., Wilson, C., Cole, P. V., Idle, M. S., Feyerabend, C.Lancet, 1973, ii, 687.

3. Wald, N., Smith, P. G. ibid. p. 907.