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177


CHAPTER 4

Other Conditions and Areas of Research

Smoking and PepticUlcer-.--..i---.--- __.____.___.__ -._-
Smoking and Disturbances ofVision------- _____ --_._--_.--
SmokingandCirrhosisof theLiver-.--------.----.--------
EffectsofSmokingDuringPregnancy ____ --.---___---___-__
Smoking and Accidents---- .__. -___----_-___---__--______
Psychosocial Aspects of Smoking----.-----.--------.---.--
References _____ --._-_.- _.___ - _.____ -.--_._---._--.._-__

P8W
181
183
184
185
187
188
193

179


SMOKING AND PEPTIC ULCER

Since the publication of the Surgeon General's 1964 Report, three of
the continuing prospective mortality * studies (&2?, 6',7) have provided
additional information which confirms the association between ciga-
rette smoking and mortality from peptic ulcer, especially gastric ulcer.
The mortality ratios increase with increases in amounts smoked. The
tables presented below illustrate the relationships involved. Although
Hammond's (6) study contained a large number of females, insutllcient
deaths from. peptic ulcer have occurred in cigarette smoking females
to provide statistically reliable data. A trend is observable among cigar
and/or pipe smokers with regard to increased mortality from gastric
ulcer, but the number of deaths is too small for significant conclusions
to be drawn.

TABLE 1 .-De&h ratea and m&a&y ratios for gastric and dum%naJ
  ULcers by specifi age group8 of ??lak l?igar& 8rnokem

                           Age 44-64           aessa-?o

           Site             Death mte  "%F  De8th ml43 ?sE'

Gastric ulcer . . . . . . . . . . . . . . ._..  `(2) 7     2.95   (7) 26      4.06
Duodenal ulcer ._.... . . .._.._..   (3) 7     2.86 --r
                              (21) 31      1.50

1 Number In parantheses indlcat8e death rate for psmor~ who never smoked cf&&y.
Sour.08: Hammond, E. C. [table U(s)].

TABLE 2.-M& death. rates and molzality ratio8 for gastric and duooTem.zl
ulcers by spec@ age groups for cuw& and ex-moker8 of cigarette8
&Y

                     Current olg8mtte allohm OnlJr       EX-dglUOtt.3
                                            wlokem only

        Site                  Death rate     2atP  "OmTtY

                                     76-84     m8n     (total)
                     sH4      44-74

Gastric ulcer ._.. . . . . . . . . 1 (2) 7   (5) 17   t-133    4.13      2.74
Duodenal ulcer .._.. . . . . .  (4) 8   (10) 29 (37) 122   2.98      2.13

1 Number In pamnthswa India&a death rata for pemona who have never amolted.
SOUBCI: U.S. veterana study [app. table A (7)).
o AU death rati thron@oUt tbln chapta IUO PcE lO&CiOD PoPulation, ~CSIl otherafae ftldia@d.

181


TABLE %-Peptic ulcer death rates by type and amount smoked, in ma.h 1

                 cige,rcttc cmokcn

Nonsmokers AU anoken                      - OZtlfe -
                                              COlOkraS
                 All                p1%rm
                       I-14
               SmOllllts      lb-24 2s+   smokiag

        P-----P--

0      13     13     2     18 19     12     12     10

' Includea &astric and/or duodenal ulmm
Sounm: Btudy of British physiclan8 (tabled 23 and 7.4 (a)].

A recent survey (I$), based on a national sample of 42,000 house-
hold interviews, shows that the prevalence of peptic ulcer is almost 100
percent greater in male cigarette smokers and over 50 percent higher
in females who smoke cigarettes as compared to those males and females
who ,had never smoked. Hammond's data (5) shows twice the number
of cigarette smokers reporting the occurrence of peptic ulcer over a
2-year follow-up period as contrasted to nonsmokers. This also in-
creases with increases in the amount smoked.

Several small retrospective clinical studies (4, 8, 59) have shown
significantly more smokers and less nonsmokers in their peptic ulcer
patients as compared to control groups. Doll (I) reviewed various pro-
spective studies on gastric ulcer therapy regimes, such as : die&bland,
normal, high and low fat; milk drips with alkali ; drugs; and advice
to stop smoking. The best results were obtained in patients who stop-
ped or cut down on their smoking habits. The Surgeon General's 1964
Report (14) points out the conflicting literature concerning the effects
of smoking on gastric secretion and motility. Lee (IO), in a small
series of peptic ulcer patients and controls, showed that after smoking,
74 percent of patients and 58 percent of controls had a significant rise
in free gastric acidit.y. Those subjects with initially normal or hyper-
acidity had the greatest response, whereas, of those with initial hypo-
acidity only 28 percent had an increase in gastric acidity. Five of nine
controls, smoking a non-nicotine cigarette preparation, also had a rise
in gastric acidity, perhaps due to factors in smoke other than nicotine
or to oral stimulation.

Cigarette smoking is shown to be associated with peptic ulcer.
This relationship is greater for gastric than duodenal ulcer and is
proportional to the amount smoked. The etiology of the peptic ulcer
diathesis is still unknown. Smoking is a definite risk factor in peptic
ulcer mortality. It may also be a factor in the delay in healing of a
gastric ulcer. More research is needed on the physiological effect of
smoking on the gastrointestinal tract.

182


SMOKING AND DISTURBANCES OF VISION

TOBACCO hBLYOPIA

Recent evidence points to the tobacco and/or alcohol amblyopias as
being manifestations of nutritional amblyopia (4, 7, 8, 17, %, $6).
Various deficiencies in factors of the vitamin B complex have been
implicated (4,6,7,10,17, %, 2%).

A new theory that chronic low vitamin B12 levels potentiate the
toxic effects of cyanide in tobacco has recently been expounded
(8,10, %,%9) .
The anatomical lesion in amblyopia seems to be a demyelinization
of the optic pathways, particularly in the papillomacular bundle
(10,17,%5).
In view of the fact that cyanide is neurotoxic, more research is needed
in this area to further elucidate its association with this disease entity.

OTHER DISEBSES

Several studies have hypothesized that Leber's optic atrophy, which
also is attributed to a demyelinization process in optic pathways, may
be associated with a defect in cyanide detoxification, which is aggra-
vated by the cyanide in tobacco smoke (I, 27).

VISUAL ACUXTY

The Surgeon General's 1964 Report, and others, cite evidence of
increased levels of carboxyhemoglobin in smokers (20, $244)) due to the
carbon monoxide content in tobacco smoke. It has been suggested that
a decrease in nighttime visual discrimination in smokers is related to
this increase in carboxyhemoglobin levels (9,15,16', 29). It may also
possibly be due to the relative anoxia produced by the carbon monoxide
inhalation from tobacco smoke. A value of only 5 percent carboxyhemo-
globin saturation, not uncommon in smokers, creates a physiological
state of anoxia equivalent to being at an elevation of 8,000 feet, with an
arterial 0, saturation of only 91 percent (X,16).

It is suggested that tobacco amblyopia is but a manifestation of
nutritional amblyopia, which is aggravated by tobacco smoking. More
research is needed on the toxicity of tobacco smoke, with special con-
cern for the cyanide component. Experiments have shown a visual
discrimination deficit, possibly related to the carbon monoxide content
of tobacco smoke. Burther work is needed in t.his area in order to
ascertain any clinical consequences.


SMOKING AND CIRRHOSIS OF THE LIVER

Increased mortality of smokers from cirrhosis of the liver is found
in the prospective studies. This has generally been thought to be largely
secondary to an association between smoking and heavy alcohol con-
sumption. Published data are inadequate to test this interpretation.
The three prospective studies (I, $7, 8, 4) ail show increased death
rates and mortality ratios from cirrhosis of the liver in cigarette
smokers.

TABLE l.-ikiortaiity ratios and d+m% rades for liver cirrhosis by sex
          and S$WC$C age gIVUp8

Mortality ratio-- _ ___ ___ ___ __ __     2.16
Death rate-- __________ _______   `(5) 10

' Calculated from ap . table 10 8.
' Numbers in parent ii esa Indicate death mtea for penom~ who have never amoked regalarly.
8OUECE: Hammond, E. C. [tables 2428, and apt. tabla 19 @I.

TABLE 2.-M&e morta&ity ratios and death rates for liver cirrhosis by
      age and amount smoked, in U.S. vetiana

I-

I O

Mortality ratio (total) __ _______   1.00
Death rate:
  Age45to54 ______________     9
  Age55to64 ______________     15
  Age65to74 ______________     16
  Age 75 to84 ______________     53

BOWCE: U.S. vetarms ahtdy [app. table A (d)].

Current emoken of cigarettes only

  2.72    3. 15

---- ----     7
   12     35
   74     57
---------------_

-

--

. -

21-29

3.61

   7
  44
  57
-------

ro+

5.50

162
46
87

__-____

Doll and Hill present their data with respect to cirrhosis of the
liver and alcoholism combined. See table 3.

TABLE 3.-M&e d&h rat+x for l&r cirrhosis by type and amount
         smoked, in B&h physicians

I I i
Non- AU C&I
smokera mnokexa mtt
           smok

           Number of cig.areti    Qlwn
        a
       ela 1-14 u-24 2Sf All wzk-
                      amolmta
---------

Clrrboein of liver and
alcnholfJm - - -_ - ---_ 1 0 11 12 S 842 IS 6 11 S
8OVIiCE: Study of British ph~lciam. [tablm 21 and 22 (I)].

184


The Surgeon General's 1964 Report points out the association be-
tmeen heavy smoking and excessive alcohol intake. In view of the
fact that "The increased death rate from cirrhosis among smokers
may reflect the consumption of alcohol and associated nutritional
deficiencies rather than the effect of cigarette smoking" (6), further
research is needed to elucidate the association between smoking and
cirrhosis of the liver.

EFFECTS OF SMOKING DURING PREGNANCY

The current new literature on pregnancy and smoking supports the
Surgeon General's findings that there are a greater number of "low
birth weight" babies and premature babies as defined by weight alone
(2,500 g.) in those women who smoke during their pregnancy (6,9,
18, $?0, 22, 94-96, $28, 3&B, 36). Furthermore, this decreased weight
has been shown to be consistent in each trimester (%!2,31,3g, 34,36)
and is proportional to the amount smoked during pregnancy (5,34-
@6,30--3~, 34,36).

There are many factors which affect the outcome of pregnancy.
These include con&itutional, pathobiological and psychological fac-
tors. Multiple-regression analyses of these various factors have shown
smoking to be a significant negative independent variable with respect
tobirthweight (1,5,l7).

Smoking has been linked to increased incidence of abortions and/or
stillbirths (6, 25, 26, 28? 30, 36), premature rupture of membrances
(30-32) and decreased male/female birth ratios (If, $25, M) ; however,
other studies do not support these findings (7, 9,24,3&B).

The significance of low birth weight and prematurity in regard to
increased fetal and infant mortality, has not been clearly demon-
strated. Most studies show no increased mortality (9, 31, 3B). How-
ever, Yerushalmy (34) and Underwood (32)) point out *hat although
the overa,ll mortality is the same between infants of smoking versus
nonsmoking mothers, premature babies (as defined by birth weight of
less than 2,500 g.) of smoking mothers have decreased mortality.
Other studies show a slight but significant increase in fetal mortality
for mothers who smoke (6, 8). MacMahon (19) shows that rather
than increasing the proportion of low birth weight babies, smoking
actually causes a shift t.o the left in the entire weight distribution
(fig. 1).
\Jansson (15) in his study states : "Thus, in the absence of other com-
plications, smoking mothers seem to make a proportionally greater
contrsbution to infants in *he weight group just below 2,500 g. where
the prognosis is Ibetter."

185


10

8

0

Non-smokers
Smokers

4 5 6 7 8 9   10 11

Fxomm l.-Percentage distribution by birth weight ' of infants of mothers who
did not smoke during pregnancy and of those who smoked one pack or more
per dw.

8ource : MacMahon, B., et al. [tlg. 1 (.I9) 1.

Steele (29) suggests that smoking is associated with sudden unex-
pected deaths in infancy. The relationship of smoking in mothers to
increased fetal morbidity, either perinatally or after long-term follow-
up, has not been adequately probed and is a major area for future
research.

Some studies show a relationship between smoking and decreased
gestational age (6, 8, 39) ; others do not (I, H).
Gestational age probably is a better indicator of fetal prematurity
than birth weight. Therefore, it may better reflect perinatal risk. Yet
even in the studies showing a correlation to smoking, this relationship
is less marked than that to birth weight (6,8, $$,3$). This may he
due to the relative di5culty in determining the last menstrual period
accurately and therefore the true gestational age.
The mechanisms by which smoking affects pregnancy have not been
elucidated. Events influencing decreased fetal ,birth weight have been
attributed to several factors :

1. Placental vasoconstriction due to nicotine. No direct evidence of
this exists at the present time. The e&&s of smoking on uterine blood
flow are being conducted in animal experimentation (S).

1 Birth weight (scale in pounds ; intervals of 4 ozs. )

186


2. Increased carbon monoxide in cord blood (Zle).
3. Decreased carbonic anhydrase activity due to increase in cord
carbon monoxide (m) .

4. A postulated direct effect on the fetus of some toxic agent in
cigarette smoke.

5. Decreased caloric intake due to decrease in appetite of smokers
(10). Several studies have shown t,hat there is no difference in weight
gain during pregnancy between smokers and nonsmokers (&?, 30,36).
Since smoking in general, does decrease appetite, it-might be well to
consider a difference in the type and/or distribution of caloric intake
between smokers and nonsmokers.

Kumar (17) has shown an increase in human uterine activity after
smoking, both in frequency and magnitude of contractions. However,
these findings were not observable in every patient. There was no
significant effect of nicotine on myometrial strips in WitTo from preg-
nant human uteri.

King and Becker (4,16) have done experimental work with nico-
t,ine on pregnant rats. High concentrations of nicotine had greater
toxic effects on pregnant rats than controls. The offspring were lighter
in weight and survived less well than controls.

Clearly, more research is needed to elucidate the significance of the
relationship of smoking in pregnancy and low birth weight. Addi-
tional long-range morbidity studies are needed, as well as studies on
the effect of smoking on uterine activity and placental blood flow.
Smoking does have an effect on the outcome of pregnancy. How-
ever, it is not known whether this effect is deleterious or not.
Until such evidence is presented so as to clearly define the role of
smoking in pregnancy, it is more prudent at this time to advise
pregnant women to stop or decrease their cigarette-smoking practices.

SMOKING AND ACCIDENTS

The most obvious contribution of smoking to accidents is as a cause
of fires. Estimates of the proportion of fire loss due to "smoking and
matches" (includes fires attributed to careless smoking and the care-
less use of matches and lighters by smokers ; does not include misuse
of matches by children) vary from 19 percent to 25 percent. The

187


National Fire Protection Association gives "smoking and matches" as
a reported cause of fire in various buildings for 1965 as follows (3) :

A~rtmente----_--__--------___-------------------------------------- 26
Boarding and rooming houses __________: ______________________________   30
Dormitories, etc----------_--____-___,_-__---__--___,----------------- 24
Dwellings (l- and S-family) __________-___--________________________--   19
Hospitals------_----_----_-______________________-------------------- 21
Hotels, seasonal-----_---__--___,____,-________,---------------------- 24
Hotels, year round---,----,--__---__,---_,-___,----------------------------- 35
Motels---------------,---_---__,--__--------------------------------------- 20
Nursing ________c_-_____________________________--------------------- 25

In 1965 there were 163,900 fires linked to smoking or the matches
used in smoking with a concomitant property loss of $80,400,000-in
1964, there were 159,460 fires and a property loss of $79,500,000 (6).
The statistics on the number of deaths attributed to those fires are
not available, but it is estimated that 1,800 people per year will die due
to fires caused by smoking and matches (7).

Smoking has been shown to cause decreased visual discrimination
especially under conditions of low illumination (4). This could have
serious implications with respect to night-time driving.
Several studies (I, 2, 6) have indicated an association between
smoking and traffic and industrial accidents, but the evidence is insuffi-
cient at this time to draw any significant conclusions. More research
is needed in this area.

PSYCHOSOCIAL ASPECTS OF SMOKING

There has been a sharp increase in the attention devoted to behav-
ioral research since the Surgeon General's 1964 Report. A number of
new concepts have been developed and more sophisticated multi-
variate approaches are being used. However, because of the recency
of these studies, very little in the way of findings has been published
on which firm conclusions may be based.

One of the byproducts of the Surgeon General's 1964 Report has
been its stimulation of more research in all areas of smoking, includ-
ing the psychosocial. Much research will soon be completed but has
not yet been reported in the literature.

Three behavioral science conferences have heen held since the Sur-
geon General's 1964 Report. The content of these conferences are either
in print (9) or mill shortly he published (11,21) . These conferences
dealt with many different studies and research findings, theories,
methodological criticisms, and discussions on a number of important
issues. Among the primary purposes was the development and speed-
ing up of communications among those doing work in the field, pre-

188


venting duplication and wasted effort, developing bettor measuring
instruments, and providing assistance in conceptualizing new theo-
retical models or further developing approaches already proposed.
Much prior research in the psychosocial aspects related to smoking,
while yielding valuable data and suggestive theory, has been concerned
largely with discrete variables or attributes and has looked for gross
differences between smokers and nonsmokers. Since it, is unlikely that
such research will discover that either group possesses an attribute
that is unique to it other than the behavior of smoking, the ability
of any single attribute to differentiate between these two populations
is bound to be limited. It is because of this that a number of investi-
gators have turned toward trying to distinguish subgroups of smokers,
as well as toward developing more unifying concepts. These efforts
are part of the attempt to obtain greater insight into the dynamics of
smoking and develop more powerful predictive instruments.

One area that shows conceptual and methodological maturation is
that of the study of smoking and personality. Much prior research
studied smoking in relation to such concepts as extroversion, intro-
version, neuroticism, emotional stability, orality, femininity, mascu-
linity, hypochondriasis, psychosomatic symptoms, risk taking and
chance orientation, psychopathic tendencies, achievement needs, social
approval, relationships to authority, independence, aggression, and
the like.

At the 1966 behavior research conference, it was pointed out that
a better understanding of the total personality structure must be
achieved in order to increase understanding of some of the psycho-
logical correlates of smoking. Factor and hierarchical models have
much to contribute to this approach (1). At the 1967 conference this
and other points pertinent to personality research related to smoking
were discussed, and a reminder of the utility of multivariate tech-
niques was repeated (20). Toward this end these investigators are now
studying university students, seeking factors in the realm of person-
ality integration such as experience of control, scope of awareness,
reality contact, self-insight, temporal perspective, independence, anxi-
ety, and the like. After these factors have been identified they can be
used as independent variables in testing hypotheses suggested by other
developments, such as the recently developed typology of smokers,
illustrating the potential yield from a cross-fertilization of unifying
concepts.

Theories which emphasize the role of anxiety in the development of
personality and in the understanding of personality dynamics (7) pro-
vide a unifying frame of reference which, when combined with an
understanding of the gratifications derived from smoking, may lead to
useful explanations and investigations into smoking behavior. They
may also provide some cohesiveness to research on such concepts as

189


guilt, self-punishment, need to fail, and risk-taking behavior as they
relate to the initiation, continuation, or inability to discontinue smok-
ing. Concepts from depth psychology, and ego psychology in par-
ticular may additionally illuminate the source and function of some
of the apparent inconsistencies among attitudes, beliefs, and behavior
noted by various investigators beyond that provided by dissonance
theory (6).

Another area showing some growth is represented by attempt to dis-
tinguish between the different levels of dosage to which smokers expose
themselves beyond that indicated by the average number of cigarettes
smoked daily. More sophisticated dosage measurements (18) obviously
have application in epidemiological research. They may also prove use-
ful in psychosocial research There is the possibility that an interplay
exists between the degree and kind of exposure, physiological and
psychological processes, and the dynamics, mechanisms, or degree of
difficulty involved in achieving long-term cessation of smoking.
Another conceptual development was contained in the proposal, re-
ported at the first of the national behavioral conferences (16) and later
refined (lb), of a new way to define smokers-in terms of the smoker's
use of cigarettes to help manage affect, i.e., emotions. From the types
of smoking identified (habitual smoking, smoking to increase positive
affect, to reduce negative affect, and psychologically addictive smok-
ing) and from a theoretical discussion of the dynamics involved in
their formation, possibilities'exist for the development, testing, and
application of t.heories and techniques for producing cessation either
in a clinic or a natural setting. By identifying differences between
smokers in the psychological use of cigarettes, the typology makes it
possible to develop theories and techniques to reinforce behavior
change and to expand knowledge of the dynamics of smoking behavior.
These concepts are undergoing empirical identification and veriflca-
tion at both the national level and in a variety of clinical settings
studying behavior change.

In one study (13)) for example, which compared three methods of
aid to people who were trying to give up smoking, efforts were made to
assess the subjects' progress, the nature of the change process, and the
social-psychological factors which influence the ability to give up
smoking and resist resuming. The investigators are analyzing their
data from the conceptual base of smoking types as well as from other
points of view in an examination of cessation processes.

The smoking typology is also being applied in an analysis of a survey
of adults' and adolescents' smoking habits and attitudes in the United
Kingdom (10). At the recent 1967 behavioral conference results were
presented showing the relation between these smoker types and nervous
irritation and relaxation smoking scales, wishing and trying to give Up
smoking, and addiction indicators for both adolescents and adults.

190


There were other kinds of analyses described in this research which
provide the stimulus for further development and testing of theory.
In this country, a parallel set of surveys has been going on which
utilized many questions from the above-mentioned survey just as that
survey also borrowed from it. Cross-cultural comparisons are thus
possible.
The national surveys of adult smoking behavior, beliefs, and at-
titudes in this country stimulated, and were also based upon, an
organizing framework which discussed some dimensions of a model
for behavior change (6). This framework incorporated the concepts
related to the typology of smokers previously mentioned and also
leaned heavily on a behavior model developed originally to provide
a theoretical base underlying participation in a mass X-ray screening
program (3,.& 16). Four dimensions of the framework are discussed
and postulated as being essential in considering whether smoking be-
havior change will or will not take place. They are : The motivations
for change (e.g., the exemplar role, economics, esthetics, mastery, and
others beside the health threat) ; the perception of the threat (e.g., the
awareness of the threat, the acceptance of the importance of the threat,
the personal relevance of the threat, and beliefs about the susceptibility
of the threat to intervention) ; the reasons for smoking in terms of
affect management, and the potential development and use of alterna-
tive psychological mechanisms ; and factors supporting or inhibiting
continuing reinforcement (e.g., the role of social forces, interpersonal
influences, the mass media, the behavior and attitudes of certain key
groups, and the general level of acceptability of the behavior).
Backed by the longitudinal data at the national level and subject
to multivariate analysis, this conceptual framework can potentially
be developed to the point whereby the parts may be related quan-
titatively and qualitatively to each other and thus afford a more
dynamic interpretation of the behavior change under consideration.
The possibility also exists for the development of an instrument for
the prediction of change, as well as an opportunity for the verification
of some prospective findings reported earlier (I.$). These constructs
have also since been extended to considerations of the process of either
taking up smoking or remaining a nonsmoker (5).
In another area of investigation, one project (19) is concerned not so
much with individual differences but with cultural differences in val-
ues, attitudes, and behavior related to smoking among various ethnic
groups in the Southwest and has as its main assumption the probable
existence of a common core of psychosocial factors operating to pro-
duce different motivation patterns among young people socialized in
a particular cultural environment.
Another kind of research-that of the controlled experiment
manipulating one variable at a time with a number of small sample


has advantages which were discussed at the 1967 behavior research
conference (8). The use of such laboratory methods and controls has
been shown to be particularly useful in communications research,
including the study of factors that affect a person's acceptance and use
of health information. More systematic efforts are needed which will
.relate the content of the message, the form of the message, the kind of
medium used, and the characteristics of the communicator to changes
in smoking behavior which are also related to the psychosocial nature
of the target audience. In particular, emotion-provoking communica-
tions need to be studied in relation to various factors that are known
to maintain actions, such as public commitment and conformity to
group norms
As in the case with epidemiological investigations, however, it is
probable that more prospective research studies combining social-
psychological, sociological, and anthropological concepts must be car-
ried out before a better understanding of smoking behavior initiation
(or non-initiation), continuation, or change can be achieved.

192


                     PEPTIC uLc!EB

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us. swmNbml PmNllNs omcr: la87  o-m-s84