Most people are unaware of how widespread smoking is and of the pattern it takes among the American people. From the most comprehensive survey of the U.S. Public Health Service, it is estimated that of the approximately 50 million men in our civilian population, about 39 million, or 78 percent, have a history of tobacco use. While the percentage of men smokers has in recent years been relatively stable, the proportion of women smokers has been showing a steady increase.
From 1880 to 1955 the annual total consumption of tobacco per person over fourteen years of age more than doubled, from 5.41 pounds a year to 11.92 pounds, but during the same period cigarette consumption multiplied about 204 times, from .047 to 9.57 pounds per person.
Although there is some variation in the different studies on when North Americans begin to smoke, a consensus of the findings indicates that by age thirteen about one out of six youngsters has begun to experiment with smoking, by fourteen one out of four, and by eighteen virtually one out of two has the smoking habit. Girls do not lag far behind boys in early adoption of smoking, but the boys appear to be consistently heavier smokers. Adolescent smoking is by no means a recent phenomenon, yet the last decade has seen a highly accelerated shift to an earlier age for beginning smoking, and young teen-agers characteristically smoke cigarettes only.
A great many investigators have discussed the reasons for starting to smoke. However, no common agreement has been reached. For the most part, the various explanations fall into the psychological realm. They range from such motivating factors as the desire to appear more grown-up or the wish for adult status, adolescent rebelliousness, striving for proper group status, reduction of tension, novel experience, curiosity, peer orientation, personality inferiority, imitative-sociability element, all the way to the suggestion of a "phallic significance of the cigarette, cigar, and pipe."
What is striking in the bulk of the material on smoking motivation is the emergence of a profile of the nonsmoker. Some characteristics of the nonsmoker crystallized more definitively from these studies than those of the smoker, the original subject of investigation. This is not to say that the nonsmokers share a single personality type or display an exclusive set of identifying characteristics. Rather, the profile is to be viewed as a group tendency on the part of the nonsmokers to exhibit particular traits more frequently.
The consensus of various studies indicates the nonsmoker to be of middle-class origin rather than in either the upper or lower classes, reflecting the mark of middle-class respectability and the persistence of the Puritanical trait. Seemingly, he considers smoking one of the small vices to which the flesh is heir, is often pious and a devout churchgoer, and is frequently an abstainer from alcohol. While the nonsmoker tends to be dependable, purposeful, hard-working, stable in marriage, and quietly progressive in general outlook, he is less gregarious and sociable than the smoker. He is described as being more often inner-directed or an introvert, and is, accordingly, immoderately preoccupied with his own thought processes and other internal states. More rigid in personality than the smoker, the nonsmoker is attracted to scientific rather than business studies, and during his adolescence he tends to be more seriously absorbed in his studies and academic achievements.
We have already noted that smokers are differentiated in our population with respect to some aspects of age and sex. But in addition to these factors, smokers are differentiated from nonsmokers in other criteria. Smokers as a group are more frequent among urban dwellers than in rural farm populations, and considerably more prevalent among the lower and upper social classes than in the middle classes. Smokers marry more often, display a tendency toward divorce and widowhood, move their residences more frequently, change their jobs more often, and are hospitalized more than nonsmokers.
Addiction to smoking is found to be consistently greater among men in military service than in civilian life, irrespective of peace or war, and greater in veterans than in nonveterans. Smokers participate more frequently and in more sports than do nonsmokers, and come from families in which there is a greater history of hypertension or coronary disease and in which the practice of smoking is more prevalent. In families in which both parents are smokers, the chance that their children will smoke is several times greater than in nonsmoking households.
With respect to occupation, smokers are proportionately more heavily represented in the mining, construction, manufacturing, and transportation industries, and in the fields of business contacts (promoters, salesmen, retail and wholesale dealers, and buyers). They also predominate among business executives of all ranks, cultural administrators (editors, educational administrators, museum curators), and in the entertainment and recreational services. Among farmers, engineers, surgeons, elementary and high school teachers, and clergymen there is a notably small proportion of smokers. It is interesting to note that, in consonance with the public image, pipe smokers are more frequently found among research scientists, cultural administrators, lawyers, college professors, and schoolteachers. Cigar smokers, on the other hand, are especially prevalent among business executives, bankers, editors, attorneys, and those in the technological field.
Notable distinctions between smokers and nonsmokers apparently exist in the realm of psychological and personality features. Several studies stress the greater degree of extroversion of the smokers. They are described as being more energetic, restless, and more externally oriented than the nonsmokers. Possessing more "neurotic" traits, smokers tend to show more signs of psychological tension and psychosomatic symptoms than do the nonsmokers. In the words of one researcher, "the group of smokers appears to contain more of the men who are energetic, searching for aims and purposes, verbal, and perhaps, although less stable, more interesting."
What is the significance of these findings? What are their wider implications? It is clear that smokers as a group do differ from nonsmokers as a group in a variety of characteristics. Yet, in no instance are these differential features found to be present exclusively in one group and completely absent in the other. There is no manifestation of a clear-cut smoker's personality. That this is so is not surprising. With about sixty million or more adults smoking in one form or another, it would strain credulity to expect that such a large segment of the total population, with its infinite varieties of temperament, would share in common a single personality type. Ultimately, the answer may lie in the existence of a number of more or less discrete types.
Whether or not there are smoker personality types, there may be important underlying processes which are in part responsible for the differences between smokers and nonsmokers. It is conceivable that such processes may play a role in determining whether a person becomes a smoker, and even the form of smoking adopted.
The eminent biometrician, Sir Ronald Fisher, reported on a study of the smoking habits of a series of male twins based on data gathered in Germany. His data showed about twice as many identical twins to be alike in their smoking habits as nonidentical twins—65 percent against 33 percent. In another group, of female twins from England, 83 percent of the identical pairs were alike in their smoking habits, as compared with 50 percent of the nonidentical pairs.
Further analysis of the female-twin data, in order to eliminate the possible mutual influence between twins living together, revealed greater concordance of smoking habits in identical twins brought up separately from shortly after birth than in nonidentical twins. Similar results were also obtained, independently, from data gathered in Scandinavia. This evidence suggests that there is a genetic factor in the formation of patterns of smoking behavior. In a study just completed but as yet unpublished, I investigated the relationship between characteristics of physical structure and the smoking habits of the members of the Harvard class of 1946; Certain aspects of this study are noteworthy. The class of college undergraduates examined anthropometrically was surveyed sixteen years later for its past and present smoking histories. The availability of anthropometric data at the college age gave the special advantage of representing the "pristine" physical status of the individuals, unaffected by habit, diet, physical activity, health, and disease of the subsequent adult years.
Moreover, the period covered by their smoking histories was closely related to the age span of maximum smoking experience. At the time of their reply to the smoking questionnaire, the Harvard alumni were thirteen years out of college and averaged thirty-five years of age. And the number of individuals composing the study—more than 900—was large enough to permit the breakdown of the smoker series into exclusive groupings of "pure" cigarette, "pure" cigar, and "pure" pipe smokers. All "mixed" smokers—those who regularly used more than one form of tobacco—were omitted from these classifications. Thus, many of the criticisms leveled against other studies were obviated in this investigation.
Briefly, this study revealed that substantial differences in body build exist between smokers and nonsmokers. Smokers are consistently larger than the nonsmokers. They are taller, heavier, broader in the shoulders and hips, bigger in the size of the chest, leg, and hand. But even more significant, there is a consistent graded arrangement of physical differentiation among the smoker types. The pure cigarette smokers are the least differentiated from the nonsmokers in physical structure, followed by the pure pipe smokers, while the pure cigar smokers differ most from the nonsmoker group. For example, in the case of body weight, the pure cigarette smokers are on the average more than four pounds heavier than the nonsmokers, the pure pipe smokers more than six pounds heavier, with the pure cigar smokers averaging an amazing ten pounds more in body weight than the abstainers. Similar patterns are observed for a number of other body measurements, all indicative of the same trends of deviation.
Despite the inherent limitations in the research done thus far, it has become increasingly clear that smoking, the form of smoking adopted, and abstention from smoking are structured reflections of very complex forces, innate and environmental, in constant counterplay. Rather than a superficial habit overlaid indiscriminately upon various persons, smoking appears to be a response to a wide variety of personality and behavioral characteristics which have their origin, in part, in the biological or genetic makeup of the individual.
This opens up important and far-reaching implications for the highly controversial subject of the association of smoking and lung cancer.
If smoking has a constitutional basis, then there is a possibility that persons of a certain makeup are peculiarly liable to both smoking and lung cancer, as well as other diseases. This is not as large a speculative step as appears on the surface. That there is a relationship between constitution and disease is generally accepted in medical circles. Such a relationship has been indicated for an extensive variety of diseases, including coronary artery disease, diabetes, arthritis, duodenal ulcer, rheumatic fever, tuberculosis, and hypertension. Even with respect to cancer, the evidence favors a biological substrate for cancer of the breast, cervix, and uterus, and it is not beyond the realm of possibility that a similar situation pertains to cancer of the lung.
There is as yet no published evidence to this effect, but the possibility cannot be dismissed lightly. Further investigation remains to be done, and a comparative study of the constitutional aspects of lung-cancer patients will shed some light on the problem, one way or another.
An analogous supposition may have an even stronger basis in the case of the nonsmoker minority. Nonsmokers may be of a constitutional type that is, generally speaking, biologically disposed to rigid, inhibiting, self-protective habits, correlated with constitutional forces which resist disease.
This is not to imply that a determination of a constitutional lung-cancer factor will automatically solve the problem of the relationship of smoking to disease. Not at all. For it is highly unlikely by itself to account for the whole of the tenfold excess of lung-cancer mortality for cigarette smokers as compared with nonsmokers. In no sense would it overthrow the known statistical association between heavy cigarette smoking and cancer mortality, but it might serve to moderate the role of smoking as a lung-cancer risk. It would, moreover, establish the fact that the individual's constitution is an element to be reckoned with in the predisposition to lung cancer. We do not need to be persuaded of the concomitant rise in the mortality ratios for lung cancer and other diseases with increased amounts of cigarette consumption. This is a verified and accepted finding. No one is ruling out cigarette smoking as a prime suspect in the causation of lung cancer. But, for the present, we do have to consider the existence of accessories to the fact as well as possible accomplices. Pending the complete evidence, the problem of smoking and disease is still not fully settled.