SW. Ser. Mrll Vol. 17. No. 8. pp. 517-5’2. 19X3 Pergamon Press Ltd. Printed in Great Britain

Social Work and General Medical Practice. by JUNE HUNT- oped for helping social work and medicine understand INGTON. Foreword by MARGOT JEFFERYS. George Allen & themselves better as a means of putting their respective Unwin. London. 1981. 196 pp. E12.50 (paper) f5.95 houses in order.

Huntin@ton’s effort to subject the relationship between what she terms the “occupations” of social work and gen- eral medical practice to disciplined sociological scrutiny and analysis makes for lively, informative, and provocative reading. Her study derives from the opportunity she was given to serve as a participant observer to the introduction of social work into a general medical practice in Sydney, Australia. She is thus able to provide first-hand evidence of “the social construction of inter-occupational reality, the development of meanings and rules in situ. and attempts by practitioners to articulate their own occupation’s back- ground meanings to members of another occupation”.

Departmenr of Community Medicine Mourn Sinai School uf Medicine of The City U&wrsiry o/’ New York New York, NY, U.S.A.

BESS DANA

Smoking: Psychology and Pharmacology, by HEATHER ASH- TON and ROR STEPNEY. Tavistock, London, 1982. 222 pp. $19.95

As a correction for the limitations of a case study of one particular practice organization and one social worker,.Dr Huntington -turned to the literature of seven countries to provide a more comprehensive base for the identification and analysis of the factors affecting inter-occupational col- laboration. The reach of her inquiry into the literature extends beyond those writings that deal specifically with the relationship between social work and general medicine. It encompasses both the antecedents of that relationship as reflected in the. earlier literature of medical social work and, of particular significance to her findings and rec- ommendations. an insightful review of what the author terms the “identity literature of each occupation”, i.e. those tasks and articles that “address the questions what is social work and what is general practice”.

Reduced Tar and Nicotine Cigarettes: Smoking Behavior and Health. edited bv DEAN R. GERSTEIN and PETER I. LEVIKIN for the Committee on Substance Abuse and Ha- bitual Behavior, Commission on Behavioral and Social Sciences and Education, National Research Council. National Academy Press, Washington, DC. 1982. 52 pp. No price given

Coffin Nails and Corporate Strategies, by ROBERT H. MILES in collaboration with KIM S. CAMERON. Prentice-Hall, Englewood Cliffs, NJ. 298 pp. $18.95 (paper) $1 I.50

Relevant data from both the literature and real life as observed by the author are skillfully interwoven in the five chapters (parts) that constitute the book as a whole. Part One introduces the reader to the sociological perspective which provides the conceptual frame of references for the work. Part Two places social work and general medicine within their respective occupational structures, comparing and contrasting the demographic variables, conditions of work. income levels and the sources from which they are derived and types of clientele that influence the behavior of each “occupation” and the relationship of one to another. Parts Three and Four deal with the similarities and differ- ences between the cultures of the two occupations. In con- trast to Part Two, which is more descriptive than dynamic, both the language and the content of these two com- ponents of the work speak tellingly to social work’s re- lationship to medicine. (In fact Dr Huntington might well have been an eavesdropper on many a social worker-phy- sician encounter. U.S.A. style.) Part Five provides the reader aith a well organized and clearly stated tabular summary of the analysis of the data and a brief but telling consideration of the significance of the findings for future collaboration between social workers and general medi- cine.

It is now just 30 years since the American public, thanks to The Reader’s Digest, began to worry about cigarettes. In the interval. those early puffs of anxious speculation have merged into a harsh stream of facts: 6 or 7 years are knocked off the cigarette smoker’s life expectancy. and not only the smoker but his or her family and co-workers suffer measurably increased morbidity from the habit. Yet the manufacture of cigarettes remains one of the most pro- fitable enterprises in America. because a third of adults continue to smoke and the average smoker now consumes half again as many cigarettes as in 1953.

There are, it seems, two major reasons for the paradoxi- cal durability of the cigarette habit. First, nicotine de- livered in this dosage form is highly addicting; as long as a healthy percentage of teenagers (who tend to discount the remote consequences of cigarette smoking) can be recruited to the habit, a fairly stable market for cigarettes can be maintained. Second, the net effect of regulatory efforts has been, presumably by inadvertence, to protect the cigarette industry and not the consumer.

As Margot Jefferys points out in the foreword, itself a contribution of no mean significance to the overall quality of the book. Dr Hungington is not the first to recognize that conflict is an inborn characteristic of the social wor- ker-physician relationship, deriving both its particular form and substance from factors in the social, cultural. intellectual and political environment. .Nor is she alone in her recognition that both social work and general medicine must deal \vith their own identity conflicts if they are to be able to tiork effective]! w,ith each other. What is unique is the analytical framework which Dr Huntington has devel-

Ashton and Stepney. two productive and painstaking British investigators, have written a thorough and readable book on smoking behavior. Their approach is even- handed, and they give full weight to alternative hypotheses that might account for the natural history of cigarette use. the smoker’s pattern of motivations and the phenomenon of compensation for lowered nicotine content of cigarettes. They offer a responsible and comprehensive review of the literature and their very cautiod in evaluating the addiction hypothesis underscores, for me, the credibility of nicotine dependence as the paramount influence on cigarette con- sumption. Indeed. the book’s most useful contribution may be its elegant chapter discussing smoking as a psychologi- cal tool-i.e. a means of controlling states of arousal and focusing attention. By showing how nicotine serves not only to shift the user along the spectrum from pain toward pleasure but also under certain circumstances to improve performance. Ashton and Stepney make it clear that nico-

BOOK REVIEWS

517

51s Book Reviews

tine ma\ have an e\en more insidious hold on the smoker

than :I Simple addiction model reflects. The virtue of .S,tr&irly-its measured and impartial

stance-is also its defect. The book never quite develops a

point of view. and the two chapters in which a book tra-

ditionally does so. the first and the last. are in many ways the least adequate. The first chapter. unfortunately titled

“The Indian’s Revenge”. is a superficial rehash of the his- tory of tobacco use: it makes no convincing effort to relate

what is known of the history of smoking behavior to the

nature of that behavior. as analyzed in subsequent chapters. The last chapter, ‘-Less Hazardous Smoking”. reviews the arguments that low-tar. low-nicotine cigarettes are “safer” than the older. stronger cigarettes and. for my money, rather too uncritically accepts as valid the reports

(chiefly from a small group of American advocates of low- tar cigarettes). that switching has appreciably benefitted the

health of smokers. And they ignore the important question of whether the availability of low-tars favors recruitment of new smokers-a far from trivial issue.

Rrduced Tur ad !Vicofine Ciyurerres. a brief report

issued by the National Research Council. was virtually ignored upon its release (in part because the media were

distracted by the death of Princess Grace of Monaco). The pamphlet briefly reviews and questions previous studies

purporting to show that switching to lower-yielding cigar- ettes has improved smokers’ life expectancy. It then offers a

new analysis, undertaken for the NRC’s committee. which indicates that there may have been no benefit whatever. It

explains this startling result with a summary of the nicoti- ne-addiction hypothesis and evidence that smokers of low-

tars do compensate for the lower delivery of nicotine (and therefore do not much reduce their intake of anything). Finally. it proposes a sensible research program to resolve the large questions that remain.

The crux of the report is its inference that the steady

reduction. over three decades. of cigarettes’ tar and nico- tine delivery has not led to a measurable reduction in smokers’ risk of respiratory cancer. The investigators

reached this conclusion by calculating death rates from

respiratory cancer in 5-year age groups of American males.

These were plotted against an estimate of each group’s lifetime consumption of cigarettes. The resulting table shows that there has been no reduction of respiratory cancer deaths per cigarette smoked for any group between

the ;~gcs of 35 and 64. This is an utterly remarkable stat- istic. but it depends on the validity of Daniel Horn‘s esti-

mates of total clgarctte consumption. by age. in the 1977 edition of S/noki~~/ tr~tl !fecr/r/l (DHEW 77-141 3). and, un-

fortunately. the method by which these tigures were de- rived is not altogether clear. It is regrettable that the NRC committee did not publish Its tindings in a refereed journal, which might have stimulated the investigators to sharpen

their methodology and improve their presentation. As it stands, the report. though provocative. cannot be read as firm evidence that low-tars have failed to benefit their

smokers. On the other hand. It is quite clear that low-tar cigar-

ettes have benetitted their manufacturers. The technical innovations that have reduced delivery of tar and nicotine to the smoking machines at the Federal Trade Commission

(whatever the real delivery to live smokers may be). have also made cigarettes chcapcr to manufacture And because the typical smoker consumes more of them, unit sales of cigarettes have been fairly well mamtaincd in the face of a decline in the pcrccntagc of smokers In the American population. This is just one aspect of the turbulent history of the American clgarcttc Industry over the past 30 years.

In Co//l~r .V<~il,\ (rrrcl C‘r~rp~~rrt/c .S/nrrqics. Robert H. Milca of the Harvard Wusincss School analy/es the cigar- ctte cornpanics‘ rcsponsc to the threat that their product would come to hc rccognijcd ;I a dwdly poison. Much of the hook I\ addrcsscd 10 thcorcllcal questions of interest to

management science and organizational behavior. but

along the uay Miles offers some good stories about the tobacco companies. and in a telling epilogue he summar- izes the evidence that most efforts to regulate or contain

the cigarette menace have. perversely. bolstered the industry’s position. The requirement (as of 1965) that ever!

package carr) a health warning, appears to have protected

the manufacturers in perpettnty from product liabilit! suits. Meanwhile. export cigarettes have been esempt from the labeling requirement: thus. this policy has also encour- aged the industry to develop lucrative foreign markets. The broadcast advertising ban (as of 1970). rel7eved radio and television stations of the obligation to carry free antismok- ing spots. These spots were. in retrospect. much more effec- tive than the industry’s commercials. and the ban led to an immediate increase in per capita consumption. Finally. as Miles does not point out. the requirement that tar and nicotine delivery be listed on packages (with its dubious implication of benefit to the consumer from purchasing low-tar cigarettes), has encouraged the smoking public to buy more of a product that is cheaper to make than the older. “standard” brands.

From the standpoint of public health. some progress has undeniably been made. There is a hint of decline in the mortality rates from respiratory cancer in men below the age of 45. No doubt the falling death rate from heart dis- ease and stroke, and the apparently lowered incidence of peptic ulcers. at least partly reflect the diminished propor- tion of cigarette smokers in the population. But Miles’s

book shows that the cigarette industry has been. and remains, both durable and resourceful. The recent trend to diversification (into such products as soft drinks and beer. aluminum and shipping), far from providing an incentive to leave the cigarette business, has proved opportunities for growth that the highly profitable. but mature. cigarette market does not. Far from devaluing the companies’ investment in cigarettes. diversification has confirmed the importance of that traditional activity. One could argue that the cigarette industry is stronger now than it was 30

years ago.

WILLIAU BENUETT

Policy Options in Long-term Care. edited by JUDITH MLLTZEK. FRANK FAKKOW and HAKOLI) RI(XIA&. The University of Chicago Press. Chicago. IL. 19X I. 213 pp. No price given

On the face of it. policy options in long term care include: who receives care. where. who provides that kind of care and who pays. These, in turn. are all affected by issues of: organization. regulation and incentives: patients’ rights and equity; allocation of resources including goals and priorities. At best a two-way matrix is needed as the out- line for a discussion of policy options. Few. if any. reviews in the field have resolved this organizational dilemma. This report of a conference sponsored by the Administration on Aging in 1980 suffers from the lack of such a resolution. It

addresses most crucial issues in long-term care. but with the exceptions noted below. it is confusing. disorganized. rcpetltlous and fails to provide a lucid statement of policy options.

After an introductory chapter h? the edilors. which might have laid out a clarifying structure for the whole report hut doesn’t. there is a chapter on health status and demographic charactcr7stics of the long term cart patient by Lewis Butler and Paul Newachek. Most of the quanti- GI~IVC material in the book is in this chapter and is