BORJE EJRUP SWEDISH-AMERICAN PIONEER IN SMOKING CESSATION
by Hans Gilljam MD, PhD.
Head of the Centre for Smoking Cessation,
Karolinska Institute,
Samhällsmedicin Syd NOVUM,
Huddinge, Sweden.
It has become increasingly obvious that the health consequences of tobacco use are unacceptable. The habit of smoking tobacco is a dead-end street in the history of mankind. Backed by overpowering advertising resources and aided by addicted allies, the tobacco companies introduce their products to adolescents and enslave many of them for life. The public has been slow to react to this and even the medical profession has been surprisingly inactive in this, the most important single health issue in the western world. Over the years however, there have been some memorable attempts to conquer the habit of smoking. This is the story of Borje Ejrup - the Swedish-American doctor who first implemented large scale smoking cessation clinics.
Today, Borje Ejrup is 85, a retired MD who still plays a good game of tennis. Having graduated from medical school at the Karolinska Institute in Stockholm in 1941 Borje Ejrup took an early interest in diseases of the peripheral arteries. In collaboration with his tutor Gustaf Nylin he developed an oscillographic instrument to record blood pressure and peripheral pulsations under various conditions. These studies were presented in his 1948 thesis: "Tonoscillography after exercise - a method for early diagnosis of arteriosclerosis in the leg arteries".
By that time i.v. doses of Lobeline sulfate was used as a respiratory stimulant in asphyctic newborns. Lobeline is a derivative of Lobelia, a close relative to the tobacco plant. In 1936, Dorsey had used the drug in a few patients to reduce the craving for tobacco (1). Unaware of this, Nylin and Ejrup introduced Lobeline as a diagnostic aid in detecting hypertrophy of the heart. The effects of Lobeline on the central nervous system could be seen and heard as a deep breath about 12 s. after the injection in a healthy individual whereas a dilated heart delayed the response to 18-25 s. The method was simple and convenient at a time when rheumatic heart conditions were common and no simple method to measure dilated hearts was available.
The elimination time of Lobeline was approximately 24 hours, and one of the patients who was a heavy smoker reported to have lost his craving for cigarettes after the injection. This clinical observation inspired Borje Ejrup to conduct a pilot study on 10 smoking volunteers. They were given 10 days consecutive treatment with Lobeline and advice as how to break the habit, and eight out of ten patients quit smoking! One of the quitters wrote an enthusiastic letter to the largest evening newspaper in praise of the method and on the 30th of November 1955 Borje Ejrups portrait was all over the front page.
In the mid-fifties the first cautious reports of a connection between smoking and lung cancer had appeared but had not yet gained recognition. The link between emphysema and tobacco was relatively well established, but apart from Buerger´s disease not very much was known about the vascular effects of smoking. In spite of this ignorance, the reports of the press encouraged many smokers to seek help. The first preliminary smoking cessation clinic opened early in 1956 at the Nortull Hospital in Stockholm using much the same method as described above. Later that year the clinic could expand as it moved to a new location, next to Ejrups new vascular laboratory. After the first follow-up the Swedish National Union Against Tobacco was encouraged to finance new clinics and by 1959 six clinics were operating (2). The cost of running these clinics was covered by patient fees - 125 SKr (approximately 25$). Borje Ejrup was the unpaid supervisor of the six clinics.
Every clinic was run by two nurses working full time. The nurses were responsible for patient records, they gave injections and advised patients. More than 10,000 patients were treated. The clinics were open from 8.00 a.m. to 7.00 p.m. five days a week, thus allowing patients to visit after working hours. Each clinic was visited weekly by Dr Ejrup. Reports were published which indicated 65% favourable results after 3 months, and after 6 months 44% had quit smoking (3, 4). The results are compatible with those achieved today. "How to stop smoking" was published in 1959, with the help of a well-known journalist (Borje Heed). In popular form it described the method and the reactions of a heavy smoker (Heed). The method spread very fast and by 1959 about 50 doctors all over Sweden were using it.
The Stockholm clinics soon became internationally famous. The American, British and Canadian press had articles about the method and the BBC filmed on location. But, all was not well. At that time, about 50% of Swedish doctors smoked and some of them failed to separate their own smoking from smoking as a health issue. The press exposure evoked unexpected reactions and Borje Ejrup made powerful enemies among his collegues. The tobacco industry was very active, cultivated their contacts with the press and were always welcome to comment whenever anti-smoking news were published. Borje Ejrup had been working very hard and wanted to devote more time to his vascular research. Therefore, in 1960 he welcomed the opportunity to go to the USA. A one-year scholarship in the laboratory of Irving S. Wright at the Bellevue Hospital, Cornell University, New York was an offer he couldn't refuse. A psychiatrist (Ture Arvidsson) agreed to supervise the clinics in Stockholm and Borje Ejrup moved to New York.
Shortly after the arrival in New York he was contacted by the American Cancer Society and invited to La Jolla where he gave a much appreciated lecture which sparked the interest in smoking cessation in the US. Somewhat later he was encouraged, again by the American Cancer Society, to establish smoking cessation in New York. By now, Borje Ejrup had received another scholarship, his research had developed quite well and he decided to stay in the US.
However, in spite of all the financial support and positive reports (5) the conditions in New York were not as good as in Stockholm. Restricted visiting hours and staffing problems were some of the factors that made the New York clinic less successful. It was closed a few years later. After a career in vascular research Borje Ejrup was offered a partnership in a practice on Long Island. He was able to retain his affiliation to Cornell University and it's North Shore Hospital branch. Borje Ejrup thus left the field of smoking cessation but continued to lecture about his Swedish experiences (6). In 1987, Borje Ejrup retired from a long and successful career.
After 30 years in the USA Borje Ejrup has seen the view on smoking change dramatically (7). Smoking in public places, restaurants and aeroplanes has been restricted. Unfortunately, smoking in the younger generation has increased in recent years. Borje Ejrup finds the same basic trends in Sweden when he returns on his yearly summer visit. The six clinics which he pioneered in the 50's were slowly reduced to one which was engulfed by the Stockholm County Health Service and starved to death in 1985. Since 1987, there has been a revived interest in smoking cessation in Stockholm but we have reason to regret that the initiative of 1955 was not allowed to prosper and develop into an even better preventive service than the one we have today.
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