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Parliament

Beyond Reasonable DoubtON March 22, in opening a debate in the House of Lords

on smoking and health, the EARL OF ARRAN said that in face ofthe evidence presented in the report of the Royal College ofPhysicians only a blind or prejudiced person would dare to saythat the case against cigarette-smoking was not proved beyondreasonable doubt. We must not burke this simple issue, becausetobacco was bound up with vast vested interests. Nor were

they by any means evil interests. The most benevolent andhumane of administrations would find it hard to do without therevenue that smoking brought in. In 1960 it was E825 million,which in an ironic paradox was almost the exact cost of theNational Health Service. Shareholders and workers in the

industry would be hard hit if cigarette-smoking were suddenlyto become taboo.

He congratulated the Government on having so forthrightlyaccepted the report, but was that all that they, and we, weregoing to do about it ? Surely we needed a major campaignagainst cigarettes, especially in schools. A circular and a fewpamphlets would have about as much effect as a wet sponge.Something was needed to impress, to jolt, and even to frighten.Because the thought of cancer was so appalling we tended notto mention it. He believed that we should say it and print it tillevery man, woman, and child was aware what it meant.

He was not sure that it would be wise to make cigarettes illegalor to raise the tax on them. Prohibition had introduced worseevils into the United States than alcohol, but he did ask theGovernment to prohibit the sale of cigarettes in slot machineswhich were easily accessible to children.

Baroness SUMMERSKILL thought that the public were waitingfor a strong lead from the Government. Failure to take actionnow would be interpreted as lack of confidence in the report.Our primary object should be to help young people not toacquire this dangerous habit. Yet in 1960 local authorities

spent E200 on material from the Central Council for Health

Education, while the tobacco interests spent Ell million onadvertising. She was glad that some authorities were nowconsidering how to restrict smoking in public places.Lord AMULREE pointed out that education persuaded people

not only to drink less but also to drink at the right time. Hewould like to see people who wanted to smoke do so at certaintimes of the day and not regularly from the time they got uptill they went to bed.Lord SINCLAIR OF CLEEVE, speaking both as a smoker and as

one concerned with the manufacture and sale of tobacco, foundthe case still not proven. The manufacturers considered thatthe report left too many important questions unanswered.There was no lack of publicity about the possible risks. Whatwas needed was more research, especially into the chemistryand biological effects of tobacco smoke, individual susceptibilityto cancer, and air pollution. Many people felt that they derivedbenefit as well as pleasure from smoking. It could ease tensionand aid concentration. Since medical authorities had begun toaccept the probability that statistical association pointed to acausal connection, manufacturers had done everything in theirpower to help to establish scientific proof one way or the other.So far no substance had been found in tobacco in quantitiessufficient to cause cancer of the lung and the statistical evidencewas questioned by many authoritative and disinterested people.Lord COHEN OF BIRKENHEAD conceded that no specific

carcinogen had yet been isolated from tobacco smoke, butpointed out that we should not have controlled many diseases,including cholera and typhoid, if we had waited until the

specific xtiological factor had been unmasked. He agreed thatthere was need for further research, but in any more orthodoxpublic-health problem we should have taken action on half theevidence that had already been accumulated. The tobaccomanufacturers were threatened by the advance of medicalknowledge. They were not meeting a normal necessary need of

mankind. They were offering for sale a potentially dangerous,habit-forming drug, which though it might give pleasure tohundreds of thousands, yet killed tens of thousands. In thecircumstances the giving of money for research was not asufficient answer to a problem which needed action.Lord BRAIN reminded the House that the report had

shown that heavy cigarette-smoking had a serious general effecton health apart from lung cancer. He, like other speakers, wasdoubtful whether attempts to restrict smoking should be madeby increased taxation or control of advertisements. He pre-ferred education and example as a means of influencingchildren and adolescents.Lord AMPTHILL, who is a director of a tobacco company,

defended the industry’s advertising policy. The suggestionthat smoke analysis should be printed on every packet ofcigarettes was not in his view practicable. He did not thinkthat the public were short of information on the dangers ofsmoking nor did he think the tobacco manufacturers’ expendi-ture on advertising was excessive.Lord TAYLOR said that in the last 30 years cancer of the

lung had become forty times more common. It was unheardof in public health for a disease of this severity to appear in amatter of a few years. Each year we spent millions on cancerresearch, yet we knew the commonest cause of cancer and didnot do much about it. He was not optimistic about propagandaand he doubted if we were right to attack tobacco advertising,though we could attack its slant towards young people. In hisview, to stop deaths from lung cancer, we must cut tobaccoconsumption by half. Rationing and prohibition would beuseless, and he believed that the only way to do it would be toincrease the price, so that tobacco became a luxury insteadof a necessity.

Viscount HAILSHAM, winding up the debate for the Govern-ment, said that during the lifetime of most of us, there hadbeen a great change in the attitude towards smoking. He

suggested that a social habit might easily be changed in theother direction in a similar period. But in the course of thissocial revolution a great industry had arisen and our publicrevenue rested largely on smoking. If we admitted the facts,we could not shrug off responsibility. We could not yield tothe interest of the revenue. We could not afford to feareconomic consequences to business interests.He believed that the case was proved beyond any reasonable

doubt whatever that cigarette-smoking was a cause of lungcancer. The departments of health in our own and othercountries had accepted this. He admitted that we did notknow the exact mechanism and he agreed that research wasneeded. But we must not delude ourselves that research wouldbuy us out of action now. He believed that the tobacco com-panies would do well to plan their future policy in the soberrecognition of the true facts. Nor could the public afford tobury their heads in the sand. If they had children they couldnot afford to leave it to the schools. It was no good asking theGovernment to take action unless the public was prepared totake action themselves. In their homes they were the govern-ment. Could they afford to let their children know that theysmoked ? As individuals we could not continue to act as ifthe facts stated in the report were incorrect.

If the facts were conceded, what was the Government to doabout it ? Whatever their duty to adults they could not shrinkfrom their responsibility to children, though if parents did notcooperate much of the effort would be wasted. The Ministersof Health and of Education had already sent circulars to alllocal authorities. The Minister of Health had also announcedthat he had in mind experiments with anti-smoking clinics.The report had also suggested differential taxation: this

was obviously a matter for the Budget, but he would pointout that though the present tobacco duty on most other thingswould have been considered crippling, it did not seem to act asa deterrent. Other recommendations in the report would haveto be considered in the light of their likely effectiveness. Hethought that the debate had done a great deal to help the publicto form its own conclusions, and his own impression was that

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this report had succeeded where others had failed, and that thepublic had at last begun to take an interest in this importantmatter.

Children’s Teeth

On the adjournment, on March 26, Mr. JOHN HOWARD saidthat children beginning school had an average of 5 decayedteeth. This meant that 5 million fillings were needed. Wellover 1000 dentists, roughly the whole of the school dental ser-vice, would thus be needed to deal with the decayed teeth ofthe new school intake each year. He knew that efforts were

being made to increase the number of dentists and train

auxiliaries but these were necessarily slow. As possible imme-diate solutions to the problem he suggested rearranging thescale of fees to induce dentists to treat children and adolescents,and requiring students on qualifying to serve for a time in theschool dental service. An experiment on this line could beapplied to a test area. Such a service would need continuousdental health education, an adequately staffed school dentalservice with complete autonomy, fluoridation, and supportfrom general dental practitioners.Unless something on these lines was introduced, the only

alternative would be to abandon the school dental service as atreatment agency. In its place, if it were abandoned, the familydentist, using, preferably, every form of ancillary help, couldtake care of all children from birth to adulthood. If such a

policy decision could be made, a public-health dental staffwould have to be created at local-authority level whose taskwould be similar to that of the local medical officers of healthwith whom they would work in parallel, not in the departmentof the medical officer of health as at present. Treatment wouldbecome the responsibility of the dental practitioner and all

aspects of dental health, such as fluoridation or dental healthcampaigns, would be the concern of the public dental healthofficer. It would also be his task to maintain a close liaison withthe schools by using the dentists on his staff to examine thechildren and refer them for treatment to one of the generaldental practitioners in the area.Mr. KENNETH THOMPSON, the parliamentary secretary to the

Ministry of Education, agreed that dental caries among school-children had spread at an alarming rate. The Minister of Educa-tion was responsible for the school dental service, but he workedin close collaboration with the Minister of Health. In dischargeof their duties, the local education authorities were up againstan overall shortage of dentists, and no amount of shifting ofthese duties would produce more dental officers. The trainingand supply of dentists was a matter for the Minister of Healthand plans were in operation to increase the number of placesin the dental training schools. From 1963 it was expected thatthe dental schools would be able to accommodate an additional300 students, which represents an increase of about 50% on thepresent position. The position in the school dental serviceitself, though difficult and in many ways still serious, was notdeteriorating. There were now 1069 full-time equivalentdental officers in the service, a little more than enough to keeppace with the rapid rise in the number of children in ourschools. Slightly more than half the children in our schoolshad their teeth examined annually and a little more of half ofthose who were examined and recommended for treatmentreceived it through the school dental service. He admitted thatthese were very unsatisfactory figures. But the parents hadtheir responsibility and the general dental service was availablefor the care of the teeth of these children. Mr. Howard’sproposal to rearrange the service so that all the treatment forchildren’s teeth was carried out by dentists in the general dentalservice, or in some new local authority dental service, wouldbring many complications. It would not attract recruits to set

up a service which consisted of nothing more than the examina-tion of children’s teeth. Dentists would find little satisfactionif their entire professional life were to be spent doing nothingmore than examining children’s teeth and passing them tosomebody else for treatment. Nor would local-authority clinicswhich did nothing but treat children’s teeth offer the dentistsufficient variety in his work.

QUESTION TIMEHospital Visitors

Since July, 1960, the Minister of Health has visited 52 hospi-tals outside Greater London, and since October, 1959, theParliamentary Secretary has visited 55.

Agency NursesAt June 30, 1961, hospitals were authorised to employ up to

388 agency nurses, but some did not employ as many asauthorised.

Public Health

SequelaeNINE days are past, and the wonder is still with us: the

report of the Royal College of Physicians on the dangersof cigarette-smoking 1 has made no ordinary impact. Theappearance on television of Sir Robert Platt, P.R.C.P.,brought home the dangers of cigarettes in just the sort ofway the college had recommended, and was very largelyresponsible for the present public concern. Tobaccoretailers say that their sales have fallen since the report(in the experience of some, by 25%) and cigars, pipes, andpipe-tobaccos are in demand.

Television, then, is influential. In the Commons, the Post-master-General was asked whether he would be taking any stepsto restrict the advertising of cigarettes on television.2 He repliedthat the matter was being considered and I.T.A. had consultedhim about the implications of the report; but such restrictionwould raise the question of similarly controlling the advertisingof many other commodities.The Ministries of Health and Education reacted to the report

by drawing the attention of local authorities to it-and byplacing on them most of the onus of doing anything about it.3They demanded a positive effort to publicise the facts, and todiscourage children from smoking; they emphasised theimportance of health education and of adult example. TheL.C.C. has already been showing films in welfare centres andschools, and distributing pamphlets; it admits that the diffi-culties lie, not so much in publicising the facts, as in persuadingpeople to respond to these facts.

Although it is illegal to sell cigarettes to children under 16,there is nothing to stop the children from buying them fromslot-machines. Romford borough council 4 is trying to put anend to the practice of some ice-cream vendors of sellingcigarettes with the ice-cream.The banning of smoking in places of public congregation has

been widely canvassed. The health committees of the L.C.C.,and of Bristol and Manchester,5 are looking into the possibilityof prohibiting smoking in cinemas and theatres. Manchesteris also contemplating a smoking ban in buses. In the Commonsit was said that the decision to ban smoking in trains would liewith the British Transport Commission, and not with theGovernment.On Thursday of last week, the report was debated in the

Lords. Lord Hailsham said that the case against cigaretteshad been proved " beyond all reasonable doubt." He spoke"

as a converted smoker ", but many must have thought that hespoke for the Government and that increased taxation oncigarettes, or even a tax on cigarette-advertising, might be inthe offing. Until Lord Hailsham spoke, the prices of tobaccoshares had withstood the effects of the report, investors nodoubt recalling that earlier reports had had only a transienteffect on cigarette sales; but after his speech the share pricesfell sharply.The manufacturers say that the case against cigarettes is not

proven. At the annual general meeting of Imperial Tobacco1. Smoking and Health: a report of the Royal College of Physicians of

London, 1962. See Lancet, March 10, 1962, p. 519.2. Hansard, March 20, col. 195.3. See Lancet, March 17, 1962, p. 598.4. Evening Standard, March 21.5. Guardian, March 26.6. See this issue, p. 696.