unifrib oktttrs ocnMir - Legacy Tobacco Documents Library
unifrib oktttrs ocnMir - Legacy Tobacco Documents Library
unifrib oktttrs ocnMir - Legacy Tobacco Documents Library
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['1IiP <strong>unifrib</strong> <strong>oktttrs</strong> <strong>ocnMir</strong><br />
R eport of Proceed i n gs<br />
Ilearin g held before<br />
Connnitice on Conuncrcc<br />
S . 569 and S, 549<br />
.<br />
l3IId,S TO It1iGU1,ATLl I .AttE1,IWG OF CIGARI{TTk)B<br />
A1411 PGlt CPPISi'sR PUkPOSBS<br />
39 April 1965<br />
AD1)SHDU7d<br />
tlatvrlal submittotl for tlso record<br />
Washingmn, D . C .<br />
MONICK-SULLIVAN<br />
OfficialReporters<br />
415 Second Street, N . C .<br />
VOLUME<br />
Washington, D . C ., 20002 ioiovho-<br />
54i-L4Y1<br />
NATION-WIDE COVERAGE
a=1 ] 77.7<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
u . (il'1(i ia . iY((7 .<br />
fs%Ya,R 'i•O 1!tL,GUXh'PL• Y4EL IM •dtlC. Oti' CSChf:PO•a:iCS, hNPa P'09. C'i"i6FI1s P iIA',ML .YtS<br />
t.l7k~k4n117Y~t3<br />
Ur. :IR.eF 06cAe,e. Sere.to,<br />
Ca :unittUts on Co¢nme,re,o,<br />
~Y[a~lika~;ton, IY . C .<br />
tfntorS .eS sttLmi4.ttr.tA for th.e rooor0<br />
'xYiur§Gay, $ 6.pri1 7wG8
•<br />
c'o N m°ii ~a 7-~<br />
slvre]SMEaaB o;^, PAG$<br />
GoorEc V . Gllen, 1712<br />
]SrGEr£ii0nt.,<br />
The 2obaeco 1nc;ti.tute, Inc ,<br />
fV9 3.] e.rQ 11a .lryuiplcv, P& .ly„ 1735<br />
Ilfx•c+etor, University IloaAth 8orvi.coei,<br />
PrS.ncotoiz Unive^rc:i .t,v ; .<br />
Colun!hia tPn£vorsity ;<br />
Aweri.cen Co1i.cIs+ ]4ca]th Ar)r.auintion .<br />
poNi .tt C . DituRBtry, Gi .b . ]737<br />
050 Wo,^thwes,•t Tcent.h Avenue,<br />
IDiami , hl .ortiria, 53130,<br />
1lmmenuel . 1°erber•, 1.1 .U„ (telog .ara) ]780<br />
)acprcrtmemt of Pntho)r,Ey,<br />
University a£ I'7 .ttai)ur(r,h .<br />
Jac:k AS . )rzz•r, is, A9 .1.Y,, 1740<br />
1127 8'i.iFh£xo 6oulevaxU,<br />
1•oF. F.ne'e1e6, Cali :forr$n,<br />
3lOllsEII' V . 11RCtk.e19„ ]u,J1 ., 1748<br />
36C 8tincon a;u4lding,<br />
SiDatt .ie, ICF,shin[Cton, 06101 ;<br />
AmorA .enl Co1.lege of Radi.olo69 .<br />
1'oz'Gin;4aQ C .. XeHM, N .D .,<br />
St . Lu4re'c: ]!ocspAtal,<br />
Y ;tua€:pr, C:i.t,v 11, I?ir, ::onrfi .<br />
1, t?.:nry Gnrlailti, H .b .<br />
8 . R . Groemro, EOJ,<br />
1'ele University ;r,hoo7l of IdoUi .oi.ne .<br />
1
0<br />
•<br />
c2 1719<br />
STANlf60?N1' 01P :<br />
MNTNNTB (contAnued)<br />
lAuAe. A . l.eovio, 61 .ll .,<br />
Rhode Ivlnnd Noel :•i .tn3,<br />
Provi.dence, ithoda is).and .<br />
Son . Jetnoes ll . Cuifllon, N.C .,<br />
1'irat Vii.htrict, 'A'onncar.oe .<br />
1COnry Easton Lfcbinhou, 67 .D .,<br />
NGW YtlXh, NU w York .<br />
rnn ttmcdc.nald, DI .D„<br />
Yhaivor+.+i.ty o7 Sont.hern (:nXiforni .n .<br />
)r.rnel Rappnhort, Hi .D .,<br />
)eP1).cvuo Horl~dtn7, New York,<br />
it . N . l,i .gdwa, F1 .D .,<br />
Cin).vG6to0, T6y.R s ,<br />
Nrrcodcric V? . )3i .p7qv, Jr ., Si.D„<br />
Proei.dor,t., ithodo XGlnnd Division,<br />
Ameri.c:nn Cnnccr Soei.oty,<br />
333 Grotto AVOntlc,<br />
Providenr,o, N .) ., 0'L906 .<br />
Ano .,<br />
PAGE<br />
1.603<br />
1807<br />
1606<br />
1616<br />
1632<br />
).86).<br />
1662<br />
Milton 1; . Ro:aonb)ntt, hi,D ., 1664<br />
).040 P`ifth Avoouo,<br />
Now Yoa•Y. 28, Ncu Yorlc .<br />
ShoHdcrn C . Bumtr,ora, M,D ., 1927<br />
llr7 .lefi.cld NoripAtral ., New York,<br />
'Cheodor 1? . Storlini;, Pt, .D .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Johu 'lrurnor, lY, d7 .D .,<br />
Chn£rr.nn., YRibli.c X:uucxtion Ccmmittr.o,<br />
ltlwcio l,e,lond DAvis£on, %nc .,<br />
Amc+rAc:an Cefic¢r Boeiety,<br />
333 Grotto Av enue,<br />
ProvSdG•tieo, R,) ., 02000 .<br />
1033<br />
A009<br />
Chn.rlcs : F . 5`et< :, Jr ., N .U ., (2 t.clcgrnnic) ) .071<br />
lYniverci.ty of Nzemf. School of Afc:ctic.i .ne,<br />
JxcAaon 1Aru,oriul . kloci,i.tnl,<br />
F')ori.du CownStteo mn :rookine nnd.IHoul .th,<br />
A7Aatai, Yloridn .
CON ;NTS (oont4.nvod)<br />
STATI!:rAS1YC OF: PAGE<br />
S41Yinund L . N'ilens, 18 .D. 1973<br />
ORCANSZATIONS ;<br />
Advertisiuir hoderat9on of America, ]977<br />
Mark 1' . Cooper, %'resident & Gcmoral MannBOr .<br />
American Astociati.on of School Admini.strators 3,983<br />
1Forrert E . Corener, Sxocutive K cretary .<br />
American Cn uoer Society, 117.inoie Division, Ync .,<br />
RoOer A . Harvey, M .D ., ProBideut .<br />
American Co]]eCe Hoal.th Asoociation,<br />
Worea D . YoaOer, M .D ., Pr®nidcnt .<br />
American Dental. AnEoe3.ation,<br />
Howard J . Niedhnmor, D .D .S .<br />
Auwrican Newspapor £'uhlishors AESooiation, 1992<br />
• }d . W . Arinisteu.d, 13I,<br />
Chai .rmrn, t`oc?era1 . L .nv/e Com€ni .tteo .<br />
•<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
American 8cdnool Heulth Association,<br />
Perry J . Sandell, Prenidant,<br />
As:uoci.ation of Nati .onal Advoatisers, Inc .,<br />
].6G Suet 44th Street, Nov 3tor1 ;, N„Y .<br />
13crgen County Phar.iyaccutical Society,<br />
Walto,r 1" . Nrowninly, Sr ., Prosident,<br />
36 N . V7e.ehinaton Avonmo,<br />
Dergenf9.o].d, New Jersey .<br />
Cancer Coordinating Caiunitteo<br />
of thc, State of 4lawhington,<br />
David 19othony, 1d .D ., Chni .rraan .<br />
Co].orado Departwent of Public Heal .th,<br />
Roy 1 . . Cleoro, M .D ., Ff .P.H .,<br />
Director oR Publi.c Hcalth,<br />
1985<br />
3987<br />
1990<br />
1998<br />
2000<br />
2007<br />
2011<br />
2014<br />
Col.orac3o 'yuboreodosiea Aosoc:iwti .on, 2017<br />
rioneld A . ltiller, 8xecuti .ve Diroctor,<br />
1033 Vino Streot, Donvor, Colorado, 80206 .
•<br />
.<br />
e4 3721<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
CONTIutiT'S (contAnued)<br />
07Y17.'E;Oftr,Nl, 0'C: MAGF<br />
Cotinect}cnt. Ile2lth Lwr,OUO, 7010<br />
Iff.ltor. Geyor, pacsAdent,<br />
%de,ho Del)nutrac:nt of Hen.Yth, 202.1<br />
Aon ii, knyf.)on, ChfeB,<br />
Honlth Educuti .on & TrxAni.n(: Sectlon,<br />
Rntnrag:ency Coanci.X an F4modcd.ng, 2024<br />
.7ohn 'Bur•ner, X}, ris,fi„ ProvAdenne, 6'c .I .<br />
77op,r Cattti.< County Junr.or HABh ConYCrm7co on firaokin6 2026<br />
Wnuk V . Pinrr.ar~, Jr ., ChnArmr+n,<br />
b11iC1Y11_nQ 1'Uh1k9nUrfY A6/~Yoe$fit$On, YnC ., 2036<br />
Q)hnrlah U . AbScirJ, V :l .c:o Fh•osfdr.n9:,<br />
Linx;vA 0 n6 Dep PrtMon t of Henlth, 2042<br />
f;,ay K, Pldvmrde, ff .U„ fS,B,H,<br />
L1us.rtma•.husei'te Dogm3.rtmont of Yuhlic fXOtalth, 2044<br />
k'M•unb. W, Hopnaldn, Ft .D„ lli.rec:t.or,<br />
b1:InnbHotE1 f)4`pkl'tE10nt o$' PS($IcntSon, 20Q6<br />
har7 .p,y n, ha^AS.ht, Av:nletent Co.uialv;.r&nnor,<br />
mi .se:oo.ri BxotadeRCtorm AoeooeRhtAon, 2047<br />
tlonuo4.h W . }Eandy, X+xcoi.dont .<br />
fiutiaaiaY F.d4tornn5 Asrmcil.ntfon, 2050<br />
'Cheodoro A . SernrAXl ., klxec . Vice Prosi.dent. '<br />
mnnsylvanir . I,cyexrt)xe:a)t of Hoalth, 2054<br />
C: . 1., 1V?J.hav, dr„ 6i,11„ Secx•ethry of Health .<br />
'Phe knb7.i.c blrna7.th Csncer Ascvoc9.tetAon of AmerAon, 2058<br />
John F9 . E.+?n, Jr ., p4,D ., Pa^eeldant .<br />
Sottth Cnrol9 .nu 1)eg,aztanc.nt cy AgrACu7tnro, 2061<br />
Uillknrr, C . Hcrrole:on, Coiniuis[s4oncsr .<br />
'tobraaco Y?orkoa•c Xntcrnat4.ona1 Uuion, !a'),•430, 2003<br />
J'ohn 0'Hrzre, Pron.afont .<br />
Univcasaty oS 5'oronto, Cantrdn. 2068<br />
UraF9 :9.nTton BCnto Ficpr
•<br />
•<br />
•<br />
ty 1<br />
6'J'A'1'14hILt1Q'C OF GI90HG1S V . ALbRN<br />
I+7C7t6YD&>t'/', ~`t[ii tOiiACCO IWSy' ;(Atl'CF., YhC,<br />
My nnm2 in Goorf.'o V, A15on . ?aui ]hro&idexat and<br />
Iixcentive Dircctor of The <strong>Tobacco</strong> Ynstituto, Inc„ whose<br />
weraberc;lrip Aecomposcd 01 S'irons which mFUiufucture and 0013<br />
tobacco products, i .ncLuding the nui:ion's c.iga.rotte manu--<br />
TaetllrerF. .<br />
The Ynst3 .t.ute tvac: formed in 1958, cwith hr.adryuarters<br />
in 19ashfu(:ton., D . C . Its 5:irst presldeeht was Mr . James<br />
R . lti.ohards, a d4.stiuguAdcd momber of the Congress and,<br />
Cha-irmRn of the COGIDtitte2 Gh I''oreign A fQaS .rs, I had the<br />
pr4vi .l .cl;c of succeoding hz,a on rny rotirerunrt from Govern-<br />
Llent sGTVice four yeftr[: U.(;O<br />
tobacco ind.ur;try .<br />
. 7 11on1<br />
.Q l i.ke to d .'Yl.cnft[s tt+day varieu s aC
•<br />
i<br />
ty 2<br />
cxistence .<br />
In the report by the Surgeon General's Advfsory Cow-<br />
ttec, there is an important questA .on posed which should<br />
be of i.ntoresf: to this Cor.miittee . The report asks : "What<br />
would satisfy the psychological need s of the 70,000,000<br />
Americnns t To rsmokeiw in 1!9H3 i£ they woxo suddenly deprivcd<br />
of tob a cco4"<br />
The Report €foes on to say that '7dedical porspeoti .vc<br />
requires recognition of r :i€!nificar.t bonoPicial O effects of<br />
cmokS .np, primaril.y in the areaa of inental health . These<br />
benefits origina.tr. Sn a psychogenic search for contentment<br />
and are moasurable only i.n terms of individual behavior .<br />
Since no means of quantf .tating these bonefits is apparent,<br />
the Cobuaittce finds no basis for a,judgownt which would<br />
weigh bone ;.its versus hazarde of smokin€: as St may apply<br />
to the general popu]ation,•'<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
As thit : quotation su ggests, the que sti.on of whethor<br />
to F391OA:R or nO t re{Yiai.nfJ an individual dPGisiAn, And, as<br />
1 hixve said, the cSP;arette industry cmi.st.s to meet the<br />
desir.e:s oY those indi .vi.dualc who choer,e to emokc .<br />
In doing so, the: industry also p rovides a livelihood<br />
for imSllions of Mneric:ans . While thiei Sr> significant,<br />
we arc 01 aw2re thatt eauch consadormtionr, ennnot be al .lo wed<br />
to outweigh questions of public health . However, job~s<br />
1723
•<br />
•<br />
•<br />
ty 3<br />
nnii S.ne:o;ne e :ro ha?^dl.y ir.•releva.ut . They axe a necertsary<br />
hae.c+ for a1l the othcr l :;oals oi' our nstionall l .i£e, i.uolu-<br />
di .pE• heal.th, educat:ion, and, ul .t9eiaat.oly, the F.reodom of<br />
the, Sndi .vidua7l to rna'r.e c.ertai.n choic.os i .u lif.o .<br />
The ConGrosr S.s charged with the rc:sponsihiYity for<br />
determ+ .nin(; what 7 .eiSislatxon rnoelc thr ovoraYA public<br />
i.nteref.lt . TG deterat?.ne 1l'hat the Ovf.l`al .l public i.ntereUt<br />
is, 1 cifn sure the C:on[prcrs v,A .ll riant to consider al.A the<br />
factcf, and to try to est.ima.ta : the Sm,pac t of any propoerod<br />
new pol .i .c.i .rr .<br />
In thS.s: convfoctAon, the trobveco industry has y,ivon<br />
long and care'Yu1 6onCiderat.P.on to the i36port On SH :'&ola .ng<br />
and 1[cal .th by the 5urgoon C.onorn.l.'e Advisor.y Commflttoe .<br />
A'ho andustry Se c.onv :i.uced that mnch more needs to be know<br />
about the poss'ihl.o relat:i.onuhip hetweuu sruols9ug ; and<br />
hea.lth . Coneedu .ntly, V/e hel .ieve that any haflicy or i .lla<br />
CoOceiWed action V/oul .d be unwarranted at. thin time .<br />
$flnce nufEProuF f,i1G` :iti_ons re(¢3 .rh'in[; f ;td0$i .n(( and health<br />
rcmmazu to bc : reso7.red by the &ofenticta, St follows i :hat<br />
any P.'overnrr:cnstal ac.f :9.on In this field fnust be er.arnincd<br />
with the greatest care lost it he prefnx6urc or Sai .l to<br />
In in the oi ,cralA publ.ic, iuterest .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
What arc the faote: about the tohacr..o Anductry that<br />
e?hould be trlcen into accour,t In fornnelatiuic Roverhmentaa<br />
pol9.cice? 1viot+,l .ci like to s troso three aspec:ts of the<br />
1724
ini~!ur.try .<br />
First, it i .U a ].n.rC .e Wuntry, sorvin£; rnore than<br />
70,000,000 Nb.ericanEi who uoo the indur,tr,y'r products .<br />
Second, St is Qne C?f t4bi : IOor.t S .InpUrtant to America's<br />
i.ntc r nntion al trade .<br />
Third, it is one of i :bc a?ost productive i.ndustries<br />
f.rom the tnn: standpoint in ite contri.butAou to s t ate and<br />
o:edcra7 revem.+on .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
'Phe ab rolute siee of the kndufrtlry cnn be conveyed In<br />
round nwnberr; by a fow fii;uros, In 1964, coneumerE; spent<br />
ovor $8 billi .on for tobecco producto . This expenditure<br />
providod yobs for 1,300,000 poreons,<br />
<strong>Tobacco</strong> Aso this country's fifth 1ar£,est cash crop .<br />
Around 700,000 fara;, Saeni.A .i.es grow tubacco, giving ompl.oy-•<br />
msnt to r>omE: 900,000 peoplo, %n rsix mtates ••- Worth<br />
Caroliira, Itentucky, Bouth Carolina, V 9 .rgi.nia, Goorgia, and<br />
R'enncse,ee -- tobac:co farnwing io a taa,yor producer of income,<br />
a pxi.neipaA eaeh crop, and the ovet^a] .1 frr .rm ecbnomy is<br />
hmavil.y dependent on the rovonuos brought In by tobacco<br />
1.caR Ealo e , <strong>Tobacco</strong> i .s ; also grown i.n 70 other states .<br />
Any eiubctant.i.al reduction in the demand for leaf<br />
tobacco viould rayui.re a drantic roor€:ani.r,a.tion in the<br />
oeonowies of these fmn5.ly farmE : ; .md no ;farro econor.aist with<br />
wiw[a I have talked Iio-u3 bE+en able to eW.(;gest a substitute<br />
ParfA Ck'(Yp prOducitl(t, anythint9' li .ke tl2e rSn}pe revenue pe%'<br />
1 .725
ty 5<br />
ar,re an that generated by leaf tobacco ,<br />
In ]= , tobacco farmers rocolve6 more than $l,?<br />
hi7.7ion for their crop„<br />
a'ohacco farma.n([ offore the oppcrrtnnity f.tmore man- .<br />
pcnror per acrc thn.tv any other fcxm crul - .. .ttA.li . r. intr; over<br />
2 80 maarhoiSY n per caro, ownpared to ten Imr
•<br />
•<br />
k ,v 6<br />
orop=, in 1964 .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
•Lo4rrzcco toanufactur, .ug, includi.nd ; ]ca;.f handlina and<br />
procce.i;•,;fng opera.tions, previded di .rec :t enploynient for co:no<br />
115,000 porconr: i.n 1 .062 . Thoso tobacce mor.3cer[< earned<br />
$ 500 ini 1P .i.oat 9.n w(t6ar and salaries in 1>i62 . Theee opera-t<br />
:ionE;, 3ilco tobacco EavmA .nE, are of pei ratnount 4mportance<br />
to the Ccono :ny of co ertaf.n (ste.t.ee„ EAnco the facilities<br />
and c quipmont ueed fn nianufacturfnt; tahac:co products,<br />
incaud)n(; e£I'.'eretteE :, a1Rt highly Apeei,al`A8®d, any enh• .<br />
fDtantinYl redUOtion in th3 d4nand a'()r C:f garett'.es would<br />
render thiN hi .(t'31•-coflt CG,nili mcnt vallkEi .e6n, ab Y/ell aE<br />
cauEte.n(; G[1hStftntY .al Unel~lYO1tt5n1E3Lt in the areaB in question .<br />
In the li4r,trS .UutS.on of toUacco producte, both vihole-<br />
sal.e and ret.ai.3 ., i.t ics etit :iv:atod that naore than 300,0110<br />
pc+re',ons aro omployed vth.ono jobs n:ea d'xreotl.y att:aihuted<br />
to the calc or^ tobacco nrod .uctr. . Y'here a.re over 7.,500,000<br />
outlets Yor tobacco productr, c.rn(t countless etnployeoH,<br />
ot:hcn than those direc'k.l.y anvolvoci, recei .ve pa.+.•t of their<br />
i.ncorao f'rotn thc sale off tobacco products .<br />
To bAcco n .7 so contributes signi.fi.a:antly to solving<br />
Aarter9.ct .' s dif'ficu?.t balance of payotentia problem . <strong>Tobacco</strong><br />
3.eaf i .rn AmorS .ceJ(; f'ourth Rnrgest com mod'xt,v export . ]n<br />
1064, about O10 million pounds of loaf, valued at $4 l ;.'<br />
mtJ . :lAon, cva4 exportcd, 77he Un9.ted Sta.E:ecu ie zloo the<br />
rrorJd' s Aeadi .n, expor'ter of o2t5arettes ; theso oxporte.<br />
3721
•<br />
.<br />
ty 7<br />
last year w.':D'c valilo(7 F .f. ]aoro th?n $).$4 wil7 .ion .<br />
A'bur;, throtrr .h Fsh .'rparoonts abroad o'll lunoricac.l Ionf<br />
tobacco tln(4d tebaeeo Pre't7llctF', the tobacco SI1G7u0try accounts<br />
for moro theu $554 cv .i7.5.on annually In the in+p>ortant ei:'forts<br />
of pri.v[tt.e infue,try to ai .
•<br />
ty 8<br />
In a.dd4 .ta.on, tobaee,o fa:~mcus and Andustry empl .oyees<br />
spent alrproxknrato7 .y $1 .6 bf1 .) .fon f:or E;oods and E:ervfeeo .<br />
A].so, there are more than 300,000 holders of sheree<br />
in toba00o Inanuf.aetuk' i.n£ Cellpan106' . Thefie shareholders<br />
l.ive fn cach o f the 60 state a and the Bist:rict c.f Colulnbla,<br />
a.n wol.l as abroad . 7'hey rr.psesent raany different econonlS .c<br />
grORpE, $.ilelUdin6C 61OT, and WORI311 EroO FtIJ3 wallfs of Yffe,<br />
and al6o boF
•<br />
•<br />
•<br />
ty 9<br />
generated by the induntry, inc).uding indi•r•idual and corpor•-<br />
ate in .ame taxo£: nard inz£:ce7l .aneom£: buaA .noss txxen . In<br />
3962 these actdi .ti .ona.l tar:es v'ero aPBror:ima.tcly $650 mill.i .on,<br />
M nhi-n[; a totx7l of c.lor:o to $4 billion In federnl., state<br />
and locnl revoantes dori .ved from the tobacco industry In<br />
1962, 'i'his e,.luount£ : to about $45 D,000 s.n hour .<br />
Xou may be 5 .n9:cror>ted 9n knowing jucr'c• what that $2<br />
bi1.J.ton in fedOral CY.l:i.£.e tflxeE} would f :n]> p ort, by way of<br />
govcrnmont activAtfcs . Veu.ng i'i.ncn.1 1900 budget requeste ;,<br />
the ci.Carettc tnx would [ :ui,gort. :<br />
Blie entire co st of rumvlu(f the Nntional l:nstitutec<br />
of Health, in.e9 .udiuf: their rosea.rch proftr.ams, which 16<br />
just iunder $73 bil.lion a year - •• with enough money left<br />
over to covc :r the $1. .06 billion approved by the Senate<br />
for tho AgYa7.achian recovery ProE:rant<br />
for the h'ar on Povcrty pr•o,Mra m .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1730<br />
. Or, it woulfl mara thim cover the $1 .3 Ui).1ion roqueF,te.ti<br />
Or, it would mox'c than eove r the eost ofR oper•ating<br />
al.l vetoranE ; honpri .tal.es and a17l veterans nGodical care, some<br />
$1 .3 billion •- - with about $700 mi .lli .oai 7 .efft over, enough<br />
to eupport• both llousesi of Con(gress t .luoe and a half yoars .<br />
The industry contributf.on to state rovenueo desorven<br />
part:icaO.ar not.e . Cvor 30 of th e ntates got more than<br />
5 pcrcont : of their total rovonuc :a; from tobacco excises .<br />
State nceds 9.or revenuer> have bc*on tyrowing in recent years,
0<br />
•<br />
ty 10<br />
and t
•<br />
•<br />
•<br />
ty 11<br />
T am not a scienti ..t, and do aiott intend to discuss<br />
thin puostion at longth, hfodica7l witne:rsers appeering<br />
boforo thi.o Committoe c :an provide oxpert opinions, and<br />
can evaluato the result:s of sci.entifi.e rerearch, both<br />
E;ovexmnwri:al and private, during the pant ton Yoa .rs .<br />
x do believe, however, that the need to eneourage<br />
wt.do . ..ranE!in6t, basic rer.earch to dotornii .no the facts --<br />
t.he nncts about nrnoki .nf: and health, an d the facts about<br />
thocse disacaese s with lNt? .eh 60-iOhS .ng han been assoniated --<br />
i.c g !rea.t.er today than ever Uef.ore .<br />
Lr . itovm Nn Gray, in hS.G: appearnnc.e beforo this<br />
ConunS.tt.ae, mentionod the act4vities of' the induntry dn the<br />
area oi' hoa7 .th re+acarch and told you oV the cigarette<br />
c:ompan3e .;' pLSdge of $10 mil.lion to help rupport the<br />
ro searc:h program on scoRinR nnd health bo :ing coonducted<br />
by the Tmerf.can Medical Associ.at :ion hduc.ation and Re search<br />
Si'eundat. i en .<br />
'fho tobrecco industry has cooperat e d with other<br />
c:cient.ikic an d medical organi.Yations , aud with the Rovern-<br />
ment, on pro9octs which offered po :asi.b9.lities for pro-<br />
vidiag nocdod knowledge .<br />
ponsAble research art every levol .<br />
We recognizetho need for roe . •<br />
'A71is has boon t;hc industry'Er con£a'.ant position since<br />
iiutustry loadorr first decided to provide funds for<br />
9.udopendeut uczonia .ctsi to i.nvestflfqatc: tobacco products,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
779'L
0<br />
zy :.2<br />
In ef :fect., the i.ndu stry, e:turting in 1£+ 54, placed itself<br />
in the hands of the soi.ontists . And thn,t is where the<br />
Inntter is today .<br />
Why did the industry tako this approt,ch7 Because<br />
i.ndustcy l.eaders worr.+ and are convi.nced that the answors<br />
to questi.ons about s,lohinG and hoalth will coyne only through<br />
scientifi.c roscarch . Xt was, and is, the only responei.blo<br />
path to talce .<br />
The people I know in the tobacco indncifcry have a<br />
vital intorer,tin the public health aspects of this<br />
queEltion . lri.r[1t of all, they are huNRn beings, with a<br />
nkturnl intoror.t in their own health and in the health of<br />
theirSoll.ow r.an . Becond, they obviously want to find the<br />
2.n .:1'fc3'E; toqueEiti .onfi' about their products .<br />
If there is solnethitl(; in tobacco that is causally<br />
Rel.[tted to ealleer or any other dii"seaBe, the tobacco<br />
ittdustry wantr> to find out ©hat it is, and the sooner the<br />
het£er . EY it is sorr:et.hinE in tobf:cco or in the e:nmice ,<br />
T. aw sorc thio can be remedA.ed by esoi.ontists . If it is<br />
e:omo'i;hi nt; elac:, such an eemoC, virunes, horedi.ty, or a<br />
comtAe.t.i.on of ttdngs, 1 annl suro the seionti.sts will find<br />
the uo7.ution .<br />
1:n addition to i.t.Ra strong support of indopendent<br />
ycr.o arch, with no stri.ng's attached, the tobacc+o industry<br />
has also tnlec;t erihor action in an oFfort to fnlfill Its<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1733
•<br />
•<br />
ty 13<br />
public: responnibil3tiem .<br />
You are a1 .1l awaro of the CSCarotto AdvertininC Code,<br />
which govorns al l cigaretto advertisinE; . 1'orwer Governor<br />
Moyner, the Ad!ui.nkctrAtor of the Code, f.s a ma.n in whom<br />
the MioricAn people: cAn have full confii .dmnce . He has full<br />
and fi.ual aut hority to enforce the L'ode .<br />
AdvorticinG mattcr.ep arc not within the sphere of the<br />
l:nsti .tu9:o'n nctiviia .oc ; they arc properly the activities<br />
of the i.ndividUal companies, IloVfevor, I ean ABJUre yeU<br />
that the adontion of thi n Code by the cigarette companies<br />
themnel . vca represent :n a ElerfoUEt effort to respond to<br />
critic£nra ci ci gasotto a.dvortisinf ; .<br />
X hope you will vici:' tlz9e Code as 1 do : A[s a conrmond- -<br />
abl.e cwd camprohoneavo effort by private industry to meet<br />
its rospcrosibilities .<br />
Iloreover, I hope you wi.ill agree with me that in a<br />
nation such as ours, voluntary a,ction by industry ie far<br />
preferable to C•ovornmont action . When au induetry denon -<br />
f:trates the responsoib5 .lity and fortitude to regulate<br />
i.tcolt, tihero bocomes lene and losae need f'or govornmental<br />
reCulatf.on .<br />
i'hEmk you .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1.734
.<br />
•<br />
•<br />
ty I<br />
Univor.'sit,v hos]'ih Scrvi.cos<br />
PRMNCP:71oN UNYVFI+2SrdTY<br />
Ia'incoton, Now ,Iersey - 08540<br />
BtcCosh IInTA.reunry ,Apri1 6, 1965<br />
NonoPnb7.e Warrnn (i . D4ag'nuson<br />
ChAiritlatl, COWrid]<br />
.ttee on (RffinierCo United Fi'tatoJ rSelih4q<br />
PJasohin€".'i.on, II, C . 20515<br />
llear. 5enator b1agnuson :<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
I vrvite to you to put on rocord nry hearty support<br />
i'or the attcnapt whi .ch you are ulakci .nC' to :insure labo1111 .nQ<br />
oP c :.Onretto kin.chpgen ard IilaE :e lloo.fii.hl.e the La .bodlkng'<br />
c,f e9.grrrette ac?vort ;a:ang n£: a pos:eibl.o health haeard .<br />
hikc thc: ovcrn4zo7m :inc; ruayority of my co]leaguefl both with-<br />
in ar,y o1:m sqler.*nLty ot' co7L7.eco health wor•h a .nd within<br />
the tlled?ca.l . I1ro1'E6)£i.en at l .argo, I atl) GOnv$.nced that the<br />
ElOiontM . :Ei .c evidence incYi0linatin g ciE'i1.h'e.tte s111aki116 as a11<br />
importa}zt £actor in lung cancer and a1.so :ln causing deaths<br />
from resa:y other disea.e:es is ovcrwholmtnC . One of the<br />
Croatc+ut oppartun9 .t.i .e:, that 1r[, have today to save lives i .s<br />
to c7ieu.nich the t!mount of aif.nrett.o saaokinC .<br />
H:ore at Wincotou we have as.eembled statie :tics showing<br />
a nrark¢ettl c?ocran£io in esaok :i.nC a .monG entering stud®nts from<br />
I.020 p:voC,roce,aveAy to the 11r'o£:ent . l:n my opinion thi.e :<br />
gr,n(tuaL deorcase 4,r+ due to the eonstsnt publ.icity given to<br />
]1736
•<br />
•<br />
0<br />
ty 2<br />
the trnc factC about this hcalt.h hae,ard, Adding wnrni .ngs<br />
to c9.gnrotte lnhols and to c9.dnrotte advc:rtisin[; offers a<br />
faost s:Sfecti.ve nonns avn .i.lable of koepaarg tho Maori .can<br />
puhi.ic, pvrtS.cularly yoang pcaople, awturc of this hasard,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
S9.nccaely youre .,<br />
r„/ 1'dill.nrd Dalrytupl .e, SS,b,<br />
I)i.rcetor, Univcrei.ty Health Sorviees<br />
I'i'S.ncoton UnivcreRi :y<br />
l.nstx•netor in IdcdicF .ne,<br />
Columbia UnAver¢,ity<br />
1736<br />
Chafrman, Eection on Clinical Tfedic4ne<br />
Amoricnn Col .lef;o Hoalth Association
•<br />
•<br />
ty .i<br />
DI .S . D7:IYXT'A' C . AAUGY{i`fSYI JOHN G . CSS/35N1iY,<br />
fiARGCd) C . SpEI R, '!'ffOMkf"i 0 . GENTSCfZ<br />
7'bormoP.c, Cnrd7.ac 1's 1550 SCorthwest 4"ent.h Avenue<br />
C:roa.t Verse7. I"surgory b74am£, F't .ori.da 331$G<br />
FRenlcfin 9-3441<br />
lharch 25, 1965<br />
The Mfonornb7,e 7Cnrron G . ri1ngnuSon, Cha'r_rmxn<br />
C:onmi :ittec on Conwtcrce<br />
fln9.ted Statee Sennte<br />
VlaehinCton, U, C .<br />
1Krnr Henntor A°+4gnU9on :<br />
A prent nuribcr o8 ue arc concer.ncu nlrout the &erioun<br />
i;tr.eeut of c3gnrette c,volc£nG upon hea7 .t8i . Uncfnes'8ionnbly,<br />
thore i.e: a ciiroei : cauc:al roleitf.cnrshS.p between cancer of<br />
thc 1un[t, pu).rnonnr.y en:plrysoRUa, cflrona.c^c bronch3.t£rr and<br />
e,evornll other d9uenoes und the habit oi : ci.Cnretto smoking .<br />
X wic+h to urUe pas:SaUe of tbo Roo.borper f3i7.1 (9-54Y)<br />
orr tlne f,1agnuson 13i)1 ( :9-55fl) . I thirdi: it ie very £inpor-<br />
tnnt thn,t:)vc pugs coPae+ rneaemre rc6utnt'r.ng the nclvertisinU<br />
of tcb:ecco px'oductE and properr lubef,f .ing of pncha6efl of<br />
e£((nrett'.ob or tobacco ao that thero woufQ be no question<br />
?'.rl the R19.iZQtd ci: Con6Ubler'N nC to $h6A .r lc7Tect6 upon he0.lth .<br />
Thank yovu so ver3- mnc1: 2or your atternti.on to this<br />
matt er whR .ch 4.e: co very vit :nfl to the health of our nation .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
I rsflght add, that here £n F 7.oria a. we sct up a proIXram of<br />
1737
•<br />
•<br />
CdUCHtfon g32 thl'- Fchoo1P, Go that the yoLLthoP. our E7ti\to<br />
wdll hzVer tha PactEa nF'it 1:huEi cboose lleone wise7 .y ar; to<br />
whothoxor not thcy E
•<br />
•<br />
0<br />
ty I<br />
WESA'Iik2 .N 1NIO;d<br />
TBLE( kAM<br />
1965 MAR 30 PM 7 . :1).<br />
14110,056. (56) PC033 .<br />
P PGA 360 UiNG PD 10 R] ;TttA XrA): PY7T51)'UCCGO PI:NN 30 120SP EST<br />
SSNAT6R IYAtt1C2~.N MAGNUSON, SENATF3 COMI10 :iitC1: COLRdITTIFIE<br />
NE1V SP:NA'CE OfiPX.CEI DLl)0 PIASFII)C<br />
7/1'sAR SWi/'.`ROit, PAAONUSOiV . TYSTXMON :f P42ESI;SiT1<br />
.SFO THA'1' I YfAD Rh6FtOVA'AXCNS :OD YES'TdC3tDAY APPARDNTLY FMN'Y AliQU'T TNY+<br />
COitCLUtiION 0'.Y: SA90IKINGANU YANG CANCEYt XN OUR XCLiPORT TO<br />
TNI~'. SURO7:Clld OY3N .V:YtAL IN 1ANUARY 1Cnu liNTITLED "SBSOKING<br />
AND E£6AILCII" . I IDS ;NIVItX i'!1SN TO EMPI{ASY.'GE Tt3AT I HAVE NO<br />
R);Si';$VAT%ONS AL'OUT :i'dIIT CONCLUSIONS IN TII%S REPORT . TGIB<br />
FVEDnnCp4 lr(u,. CIGA5[F.Te'E SMOKIING A6 A 1 ;V:JOI4 CAUSE OY' IANO<br />
CANCEtt XN NUMANS AS fi0 OVY:Yt1sUAiLMXNG Al:> TO LEAVE 110 DOUSYI .'<br />
IN Ml' MSRD AS TO TI7k; VAXXDITY' OS' TNIIS COFiCLUSION .<br />
1SMMANUEL, PAhI9ER 1 :"D PIID YROI?ES£9Oii ANI) CNAXgMAN DEPT OF<br />
PAx1f0Y,0GY U1dIV ON PI2"fSfiUP¢OfT SCHOOL f)X' MISDICINY: ANI)<br />
6YX:Ml3k:l. 01' TBtXi SURG15O2d GP ;NSKAL~; C.OMMIT'Xti1S ON "SMOKING A1ID<br />
NDAF,!'Sl"<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1739
•<br />
•<br />
•<br />
ty I<br />
S9`A'fSMFNkd'f OF JACK I1, FAUNIS, Ii .U .<br />
).72'8 1VXL.HNXIUS O;OUL,P:VANII, LOS ANCiRLfS, CALIGOhNIA<br />
My namo in Jack M . Farrio . I am a general surgeon<br />
and a EubStanti .a7 portion of my life haE : boon spent in the<br />
care oi' patYelt9:s suRfering from cancer of all parts of the<br />
body .<br />
R,v the aL`e of te•onty-•four, X had received an A .IS .,<br />
U .F . and M .]) . degree frola the Univer s ity of Nebraska,<br />
buring the iioXlor/i .ng ton years (1cS5'7 - 7.9Qt7), I cvas asGoci .-<br />
atod with the Uni.ver® :i ty of Mic :higan both in participation<br />
and diroction o£f poGLESradun¢o activitioe : in the Medical<br />
SCheoA, I becaIDe AGaiECGant I°rofensor of SUCQCry there,<br />
whor Y di.rected reuonrch, participated in the teachinQ<br />
aetivlti .eG ol both graduate and URCICrETaduate levels and<br />
anntmied i.ndepe;ndont responsi.bility for the surgi.ceal care<br />
of nppvoxira ;ctoly 50 percent of the total Univorr;ity UoGpi . -<br />
ta l popu2ation in general . GurGCry . During the War, Y<br />
c:orvod a pproxi.cle,te7y txranty-four .montho ovorcxoa n ae: a<br />
nurgeon in the Univorsi:ty of Michigan Unit and for a time<br />
t'/a61 attaehed to Golleral Fatton ' G Third Army during the<br />
canlpaiun th ;'ouCh Germany and durl.ng thie time received<br />
tho D roli v.c ditnr .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
At the pl'Cf.ent tilne, nly chief activities are eoneerned<br />
eiith the susgioai tl°oatmont of pationte at the Good<br />
SamarAtan ht;cii.enX Center in Loe : AnEe)eo, I am AGe:ocJ.ato<br />
17QG
0<br />
0<br />
0<br />
t ;; 2<br />
('S.inicnY Proxc :ssor of Surgery at the University of Cfll .i•-<br />
£ornia :1.n W ftnge7.oe+ nnd a C(n1 .ftUltan'L in 8urgery for tho<br />
Vetc vaus AwmAu.e .E:t.r.ation, for whom T¢lirect the surgieal<br />
acti .viti .es of thcar i.ntatit.utionrs at LonC )3each, Cal.ii'orni.a,<br />
Tuccsou, Arirona, Phoeni .r., Arizona, Prescott, Arizona anc7<br />
othe.re,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1 nAl GGrti.£y.e(1 by the /IDlerican Y3Uar/) of Surgery,<br />
hoYC,inL Cerf.i£i .cnte IIumbon• 7.83cJ• 1 arp a menbos o£ the<br />
O[.ncoz ComriAt:teo a,', the American Colle>I;e o£ SurEecnao and<br />
f>oct9.on Chie£ in cha .rgo oF cancer ac t i.viti .es for the<br />
Ce17.ego of E'.uxg•cone : 2or Ar•en X1, whir.h fincluQOr, Cn.liSornP.a,<br />
ArS.eons+., Novad a r.uct )7awn4 .i, I have publiclaod a nu abcr ot.<br />
aciontiYic v.rticies and YNnve written srovoraPl chapters £or<br />
GurGf .ca1 te x .f•s . D: bclong to a nvmber oTf surgical societies,<br />
the c?etn5.ds a£' whi.ch are in the attachecl curricul<br />
.<br />
I have follovod wi.iAa intoreet t1u•oulthout the past tc,u<br />
yeRrS the SY'S .dS'IIC6 : for alld against the thefl3F that cigarette<br />
smodcing har, a oaueal reA .ationehip wit h cancer of the luug .<br />
Yt is only natural, thea•e£oro, that k havo read with<br />
interest SMOS.Yh(6 A)d!) W Y•fR{Y, the repo r t nf the Advisory<br />
Comedtteo to the Ehu.°{:ewr Gencr•aa of the Public Ronlth<br />
Service . I do ro t bWUvc that ].unE; ceuwcr bn s boon showm<br />
to b r.i eaused by c!(;arotte suioNa.nC . In my opinion, any<br />
acnaaXnHicm to the eontarasy 9.s'not Just.i.iieu - -par•tA .cubea•1y<br />
.urn vitao<br />
170
I ty 3<br />
.<br />
9<br />
f'rom the evt.dence at hand thus f ar . The report of the<br />
Surgeon Gancra]l does not resolve but onl .y adds to this<br />
controvorey, in my opinion, and lende : further evidence to<br />
support, tho froryuent obr,orvatio n that statistics are mis -<br />
loading .<br />
!!any of the data presanted are c :ont::rad'xctory and,<br />
to say the least, confusing .<br />
Vor examplo, on Page X12, it stutes ; "Uoath rates<br />
for current pipe smokors were little if at all higher<br />
than for non-smokers . ., . ktx-pi} o smokers, on the<br />
other hand, showec2 hi .Shor death rates thnn both non-<br />
aGtokere, and current snokors in four out of (the) five<br />
studies (report:od) ." !t possible conc:7ue,iqn to be drawn<br />
hcre ist that if on e once accluiros tho pi .pe smoking habit,<br />
he mur;t never quit for fcar of actual .ly increasing his<br />
liability to cancer of the lung, Heu .rond and Norn, on<br />
the other hand, 6uj,roF.1C that a possi .b7.o explanation may<br />
bG that a sub:3tetlltial number of pipe smokers stop Clmokin( ;<br />
becauso of ill .ness . But no one has data to show which ex-<br />
planation is correct, if, i .ndeed, oi .t .her one is . We can<br />
onYy speculate .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
On PaCe 133, in a discussion on the sex ratio of<br />
cancer of the lung, the report state s : The lung cancor<br />
sex ra.tio of 7 .6 to 7 in 1930 has gt.eadiAy increased during<br />
the interver.in0 per.iod to the current value of over 6 to L,<br />
1~az
0<br />
•<br />
ty 4<br />
that is, foaevery one fcmalo who develops cancer of<br />
the lung there ar.e six males . This su[;ESo[ts thnt cancer<br />
of the lun g has little or no roiationship to cigarette<br />
smohing boceuso, in np3 .to of thafact tiri,t moi'o and rnoro<br />
females have acquired the hab .it in tho j ast thirty years,<br />
the disparity between tY,e incidence in cralos and fomales<br />
Rs increasinE .<br />
Xu thin connect5,on, I direct your attention to<br />
Table XX1 on Page 156, whore Mills aui parter in 1057<br />
report on 04 cases of' cr .ncer of the lturl; occurrin g or.<br />
cius'svoiy :tn fema9es . Xt clearly st o t.ee: that £13 por••<br />
eont oii these canc:er• victimo wero no l ••sm:rhers and o :.riy<br />
73 .3 porcent of the fomal .es in this ut:udy without J.ung<br />
CarreeT YlUPe non•-fimolGJrGr, A possible coiAL'lnnion 9rom<br />
thor;e otatietics is that it is saSOr A'or fomales to<br />
ruuolco than not to smoho .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
T^urthormor.•o, cancer of the larg i.s more common<br />
amon3 the poor than the rich m•• al. Lws t twice no much .<br />
ahero fs no evidence to show, however, i:hat cone,umption<br />
ofR tobacco is high in th .o low income Mroup and it may<br />
be even lerrG . Arlothfr point of inter'ent . Caneer of the<br />
lttn g i :+ uwre com non 9s, Britain, perhaps twice as much<br />
no in this country, whoro, on the other hand, significantly<br />
l .ess tobacco is consurned . Won Uriti .r.h rnales who ax•o<br />
trnxicplmitoQ to 97e w lenland and Austx•n .li.a, whoro they<br />
1743
•<br />
•<br />
ty 5<br />
reside for many years, have a higher incidence of cancer<br />
of the lung t.heuo the nativos of thoso countries .<br />
I quotefrom pago 1.66 : "Mostexperiments in which<br />
tobacco tars (theso are condensates of tobacco combustion)<br />
are brought into direct contact with the lung and wind<br />
pipo or: oxporirnental animals have yielded negative rosu .its ."<br />
It han always intorested mo that in humm ns that the<br />
deepl.y e.i:ai.nod £inGOirn of the habitual nmekcr never dovo -<br />
lop cancer o'i the skin . It han also interested me that<br />
the wind pipe of nan, which 7recoives the initial impact<br />
of the inha10d smoke, is rarely the site of cancet ." . The<br />
comruon locatfone are out In tho fi.ne branchos of the wind<br />
pipe -, r.reacs which have little or no oont .act with the<br />
inha).od smokc .<br />
An X havc di .s:cussed this problem with Physici .an<br />
friends throulhout the c:ountry, it has beca%o apparent<br />
that there aro three groups of i .ndividua.l .r-o in our pro-<br />
fession .<br />
Thorc as c those, first of all, who have a firm<br />
conviction that there iE: a definite reXationshi .p between<br />
cancer of Lho lung and ci . gnretto e,moki.nG and a second<br />
group who feol just as t:tronF'l.y that there is little<br />
or nlo rel,ationGhi.p .<br />
There ir a thi rd group of physicians, howovor, Who<br />
a.re undccider,l . I fal .l In th.is group . In other words,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1744
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X@ral .iovo that A'(t i .es pr(nna+ture to mn,ke any far rencLi.nO<br />
Coilel.Uf15_onF : :[b.'o,t the evi .d,Cnee at I10.ndd thl(n i'nr and that<br />
510 nh013Yd COntYflU6 to make OOrei'ull obf.ervntions bAE£ed<br />
upon 7 .0(;•i .c R!1(i care'.tt17 niln .l.yEiE( O)"9 tiiOre £/t75ti£Jt3.cE) and<br />
infinStc:ly mnre expa::rrim.^.ntal nnd cl.Snicah evidence thnn<br />
nrc avr:Alah].e nt the lrresent timo .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Aoc.ordS . at : to the ltr£vttniond-}:orn c.al .cuAati.ohs ac pub. .<br />
lishcd in the Surgeon Geireral's Report, the highest<br />
rAn)c P:""oup r.oraper,ad oi henvy smolcorr) sufi'orcd e rate oA<br />
239 lung ennecr ctcaths p©r 100,000 poPUlnt :ion nc opposed<br />
to 2'1 rie'-' 7.00,000 amon(t nom-smo$crs . Although this ratio<br />
is high v,nd avp3'o£3Sivo, 4S olte nppISO v roVe.1'se 1e11glish,<br />
it `xs apParont thot niore 'ihan 90-1 ./l percent of heavy<br />
rsiaoF :erc: nro not vflotilrs ; of lung cancer .<br />
$f ci garettes<br />
nro onncer oau(si.n0, M y doen this larG'e number of honvy<br />
s :eokc :r( : enc :=l,m . Uo thoy hnvo a buiJ W S .n protection or<br />
9.nsnnity . We do not lnsom, but the con:parativcl.y vory<br />
san£+.7.7 munbor of.' heavy e~enoxore a4Teetad makes me wondor<br />
t•rhothor the more lihedy cupl .anation fe; that cigarettos nre<br />
not the Clll.p,t^it . G Ui1G7.l.nr pr.'ob1eG1 eNi .stE: i.ll 8ttemptS to<br />
pinpaoint the p o :;ei.Llo cnuccr; ei' canc( r of the stomach, for<br />
c>:e.n:p2e, . 8 wo yctar ;, at{o, 77 visited five m^dien l schools<br />
in .Feriaw, hoping to uuoover i .nfornation concerning cancer<br />
ofr the Stomaoh . Ae, you nlr*.y ]cuow, the incidence in Japan<br />
. . ., ianenty to i:hirty timoL. €:ronter thssv in this eountry .<br />
1725
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http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
(:f3 a filattOr o% ]'.aet, 60 percent of all mial.06 and 30 per-•<br />
ccnt oaP all ficneale .; who die from cauoer in Japan cUO f'rota<br />
e(Illcer Of the 53toma .cll . (ianceS(' of th0 lung is extremely<br />
rnre . rrom the s:tati.otica l poznt of vi .e.w , thi .n high ine.S.-<br />
dencw of cancor of the stomach can eat'
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tobaoc:o -- following the pati:orn oi' cnmc.er of the stomach,<br />
Therofora, in suMiuaary, I believe that all thoughtih l<br />
phyiai.ciano are concerned ovnr the p .roblem of cancor.,<br />
regardless of what px.rt of the body i n involved . As far<br />
ns thc cancor of tho lung problem is concerned, there<br />
are those wh o t:hink that smoking i-t; important and those<br />
who think it ic not . I am not cortain . I simply nny<br />
that i.t is too early to make any far reachi.n$ conclusions<br />
Yroro the evidence at hand and that n defi,nito possibility<br />
oxists that smokin g has little or nothing to do wi.th the<br />
i.ncidencc of cancer o2 the lund,. I hope to keep an .<br />
opon mind,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1747
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DRO . IIAR'NBLL, CNl•SLEDON •ANU ItOSNNDRRG<br />
RADY9IAGY<br />
8omor V . Narttell, M .D . 306 Stinuson Building<br />
iVayne A . CheeYOdou, 1,4D. Seattlo, Washington 9&101<br />
Robert H .<br />
Itor.onbor6, R1 .D. MAin 2_ 6730<br />
15ichaol . S . I.ewinhi, M .D . k`obruary 26, 1965<br />
Tho 1lonosable Senator Warren Nagr,uson<br />
Itoone 127 Senato Offi.ce Rldg .<br />
tVashingt.on, D . C .<br />
Doar Senator Magnuson :<br />
I am indood ploae:ed that you are introducing Senate<br />
Di11 559 ^To regulate the labo]ing of ci.garettes, and<br />
for other purposos" .<br />
As a radi.ologi .st I have boen sooing from two to three<br />
nevr cascrs of cancer oS the lung each weol : . In practically<br />
every caso thero has beon a history of hcnvy cigarette<br />
smokinFi• 'I'his piti .ablo si .tuation can certainly be im-<br />
proved if tho public i.s educated and constantly alort.ed<br />
to the daugers of thi .c habit . The youngor generation is<br />
the imlrortant one to be informod . Reliable studios have<br />
ShoC.7n that if a ehil.d of ten staxts smoking and averages<br />
n consumption of two packages a day he will have a ninety<br />
porc.ent chanco to have Sung cancer by the tirno ho is<br />
forty .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Again I want to congratulate you on your determilled
•<br />
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http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Etnnd on this movt Anpcu•tantt and vita :l dnsuo,<br />
Sincoroly,<br />
s/ Nomor V . F[artzoll, M .D .<br />
Chancollor,<br />
Amorican Colloro of Radiology<br />
1749
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http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
P7ilU]xNAND C.tIk15TIAli 1'1A'sY :9fIG, AI .D .<br />
rATxai,a:xsa ,<br />
sT . LUKIs''s A'G£PiTAr,<br />
44th and ,S .C . ISicP.ois parkway<br />
Kausas City 11, Missonri .<br />
0A'P.'17;MIiR7.' CF H16RAXYVAND C . MhL1YYG, M .1Y .<br />
hF,SH'P-TY:h`G SMSHCYFIG A12D itL'J:SfxFT<br />
f.fy nane als k'ordineund C . Hclwig, of Kansas City,<br />
Mi_ssonri . ~C am a Uoc:tor oi Fdedic:ino specialiv.ing in<br />
k'athol.nFry . 1 eras eoxt :iSAcd by the Amsri .can hoard of<br />
Yriholoa:;y 9n 7,6(iG and am a Fell.oc; i.n the Amorican Collol ;e<br />
oY Yfiyeiciaue . . In ad.dif;fon to e7camining- tissae Yrwnm<br />
pa6i.e,ni:r; £rum the Y,ansrs : City ntatropollitan area, aet weli<br />
ac pxti .onts comt .u(, to IP.enn[tr: City fox trcat(stent, I also<br />
CXatliine (epE+ci.menE sellt t.o 0?C i.'rom other F.YCas, principally<br />
ci t f .c :: i.u 7Gauons a,nd fd9,c„r,our.•i . 1 ata C15.nicaY Professor<br />
of pa.thology and VucoioC;y at the Univoxc:i.ty of Kansas<br />
Fchooll of 6+.edic9.ne ahore X have been on t.he faculty since<br />
l.atc 1 0? . 1`ol.YowrnCe an i.ntcrnohip, E etatdi .od with the<br />
l .ato pro£ossor 74rwA.n Ghri.atollcr, at tSw 1'tudolf, Virchow<br />
Kospital in igorii.n . G3rman pathology haa ICOneraliy boon<br />
o.^c a hv'gh ordosr and this hospital had one of the i'i.neat<br />
pa.thalogy doNnrtrtents irl klaropo at tha .t, ti.nle .<br />
L:,tc .r, In 1025, 1f+7.Ci and 1fe79, 1 dif, rosoarch in an<br />
nttempt to produce canecr by the ETpl5 .cation of tobacco<br />
17140
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ty 2<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
tar to tho sd :in of nice . One of the subjects taught by<br />
me at the Univers5.ty of Kansas School of Medicine is<br />
Oncol .o ;iy, which iss the s;cionco of tumors . In 1935,<br />
1 published a book for ms :di.cal students on cancer and<br />
allied diseae:cs entitled "An Introdur.tf .on to Oncology" ,<br />
I havc devoted my major interest to the sub,ject of cancer<br />
during al7l of nry profosmional careor and have studied<br />
porhaps as niany as 30,000 cases of caneer of all types<br />
anci eatos over the last 4 2 years, I have been very much<br />
intorested in cancer of the lung . A list of my gualifi--<br />
cations and publications fs attached .<br />
I do not bo].ievc that cancer ir, eauued by smoking<br />
cigarettes . Those who do boliove it are forced to rely<br />
principally on sta t irsti.cs . Statisticn, f .n my judgment,<br />
r:how only an association between ciUarett :o smoking and<br />
cancer ; they certainl.y do not prove cewsation . Even the<br />
Sur geon General's Report, which really prosents only one<br />
side of the controversy, pdults that "Statistical mothods<br />
cannot ostabRish proof of a co .usal rele,tf .onship in an<br />
aosociation" (page 20) . As a matter of fact, even many<br />
of tho available stat.ir.t.ice soem inconsi.eatont with a<br />
theory thnt cigarette amoking causes lung cancer . flhy,<br />
for in stance, is c.nnc:er of the iung in m en twice as common<br />
in k}ritai.n as in the Unitod States when British mon smoke<br />
only hal£ nri many cip,aretteo as do men i.n the United
•<br />
•<br />
Stntes? 19hy is there a higher incidence of cancer ofthe<br />
lung amonff mon in lovvor economic brackots than a .mong those<br />
in hi.gher economic bracke.ts when the lal :tor are repn•.•ted<br />
to emoke rnorc ciGaiettcr? Why has there boon ne iic'reaae<br />
in the oc:curronco of lung cancer in women at all c>mparable<br />
to the zncroarc in men when there has boon a trom i ndour,<br />
iucrcare ovor the pact forty years in the number of<br />
woraon who smokc (it would seem t.hat ifF :moki .nC vere a<br />
cause of cancer, the :ro should have boon an equnaYy tre•-<br />
mendous f .ncrea ee in feraaA.e lung cancer)?<br />
A11l sorts of snrokinf. experirnentr and eve l painting<br />
of the 1S.hinG of the bronchiall tubes with concentrated<br />
tobacco c;anol:e cxtrac :ts: have boon totally negative in<br />
peroducinE' a siugl.e lung cancer in experimentr .S animals,<br />
Yn ],925, 1026 and 3927, fn studying cancer of the lip,<br />
Y perronnlly treated a small area on the E.Ian of a rerios<br />
o :f mice with concentrated tobacco tars wiS:hout producing<br />
a sinnle cancer . h9any yaa.rrs aft:ar my negative results,<br />
rome succecs ceaus obtained by 1Punder and Graham in the<br />
production of e:mall, slccn cancorta in the area of appYi--<br />
cation on the r;hin of r,usc.eptibl.o mice . Immediately this<br />
wa.m hai7.od by some as evidence of the c.aus:e of cancer of<br />
the lung . This ela4.m woul .d coem to have boon rendored<br />
rather untenab 7.e by (1) the basic problem of extrapolating<br />
or applying such findi.nge, to man, (2) the further problem<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1752
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of extrapolati .ng findings £ro;n one aito to another site<br />
eveu in the rstwio sipecies, (3) the total failure to pro-<br />
duce cancer in expL'riLlenta]l animals by inhalation of<br />
cigarette s:moke, and (4) the failure of tobacco tar to<br />
produee eaneer of the skin in man .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
]9ith regnrd to reasons (1) and (2), the danger in-<br />
horent in reaehing conclusions applying experimental data<br />
either to a d9.fPcrent location or site In tho samo ani .mal<br />
spocioc:, or to the eame location or site In another<br />
speci.Us, is universa7.] .y reUOgniSed . 'Eo BeOh to apply<br />
dat:e.f'rom the s3kin oSf a mouso to the lurng of a man i.s not<br />
sci..enti,ficaAly sound . 1 f any mouso date , were applicable<br />
to tho lunG'f ; of man 9.t would be the datsa rclating to the<br />
IuCrgf; of mice, all of which haG been neF ;'ative as to<br />
ei Vnretto E:mb :e, ac, mentioned In reason (3) . With regard<br />
to renson ( d), a human cignrotte cmoko c :xperiment involving<br />
milA.flons of casos ha s boon going on for ,vears . That 18,<br />
the intonsc bro wn dir.iuoA.orati.on of tho . shin oR the fingerc<br />
whcrc, over ,nany decade w , the smoke fra;ei cigarottes has<br />
depoti.ted tobaor,o t:ar . In all of my oxporience I have<br />
novor seen a s]ein oancer on a cigarette emohei^ s fingers<br />
in the smoko s+tninec] areao . O n the othe r band, skin<br />
cancor on the back of the hand, nn area not involved by<br />
ciGt re t~te sa~olco, In nn extrc:mely common typo of los£on .<br />
i: Pg :eco with Y47 . lan ffiaodoria .ld who conc7 .nded that the<br />
1703
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http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
c+onccutrati .on of tobacco tar applied to the backs of<br />
oxi,rer3.montaA mfco could be ogualod only by smoking 1U0,ODo<br />
cigarettes a day . Ono reason for suoh conclusion is that<br />
the exposed area of the lungs in many thousands of times<br />
greater than t.ho exposed area of the mouse's skin .<br />
Certa£nly the concontrat£on of tobacco tar over the small<br />
area on the fingers must be literally thousands and t :hou-<br />
sands of tfmoes gr.ent.cr than that spread over the much<br />
]arE,'er area of the bronchial tubes of the lungs .<br />
With regard to the amount of smoke reaching the<br />
lungs, and the dist.ri.but.fon of such smoko, it is fntero[:ting<br />
to note the site of cancers occurring in the respiratory<br />
system . Xn the l .ast three docnd.es the provalenco of<br />
cancer of the mout.h and pharynx has csi .Eni.ficantly decreased<br />
in spii:e of the fact that the concentration of smoko ist<br />
higher in these, aroas thtue in the lurtge : . Why? Tho ma,tor<br />
viindp3.po or trachea earries air to the ].ungs . Exposure<br />
to nil of the S.nha,led c£gnrette sruoke fs groatost in this<br />
7.ocat:£on, ann the 1£nfng of this iarge tube is the same<br />
as that in the smaller branches of the brcntchial troo .<br />
Yet the trr.choa, before i .t branches into the bronchial<br />
tuboe :, is the site of cancer in only extremely rare<br />
c£rcumstancos . Why? Furthermore, it is now generally .<br />
recogn£zod that a h£gb p¢rccntage of canc :er& of the l.uttg<br />
oa•£t;i .nrstee i.n siurl].or taranehcs of the two ma£n di .vi.sions<br />
1754
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of the bronchial tree, whore tho concent r atien of oigarette<br />
smoho is not nearly so „roat as in t :b.c trachea and /.argor<br />
branchos, Why?<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1 do not bol.ieve that there has been nearly so great<br />
an incroa .se in cancer off thc lung us may at fi>st e.ppoar .<br />
For oxample, some of the roaeonh Ror the inorI aso in veportod<br />
caeos of cancer of the lung aro as follows : (1) a greater<br />
interest in the subject after Ar . Oraham :.ured the first<br />
case by removal of a lung (previously dt was always fatal) ;<br />
(2) grcater sNCill l in Girect examinatirnb of the bronchi by<br />
the uso of the bronchoscope ; (3) groxtly refined x-ray<br />
techniques ; (4) the u>o of the pap[ .nicolnou smoar, which<br />
is the atiero8copi.e study of cells i.n washings and sputum<br />
from the bronchial tree ; (5) the creat refinements in<br />
anesthesia wihich mahe opon oxposurb of the lunge and<br />
exploring of the chest a relative : .y innocuous procedcn e ;<br />
(6) mor.e wi .dosproad facilities foc carefully and thoroughly<br />
investigated post-mortem examin .aticns, such as wore common<br />
in 13eri.in at a much on .rlier tLio ; and (7) the increasing<br />
ago span oP the populati .on in ; lcinnra.l, bringing more<br />
patients into the cancer ago . YncrenEed awareness of the<br />
die,caso and the Improved mothods : of diaguosi.s, when coupled<br />
with the inereasing ago span of the population, may account<br />
for most, if not all, of the increase in cad;es reported<br />
dnai.nG recent years . In Germany, where careful post-mortem<br />
1755
.<br />
ty 7<br />
examinati.ons have long boen the rule, the increased<br />
i .ncr".dence of lung cancer was reported. about the turn of<br />
the ccmtury, long before cigaretto snaking became popular .<br />
The hi.g9nestt incidence of lung cancer is at approxi-<br />
rnato] .y 57 ycars of ago i.n smokers an d non-smokers aliko .<br />
Thio poak incidence irs maintained very strictly regard-<br />
loss of omoking habits . If cigarette smoking wore a factor,<br />
one would expect hoervy and prolonged smokers to develop<br />
cauccr at an oarlier age than others . One would also<br />
expect that :Lun e: cancer incidence in smokers would eon-<br />
t9.uue to iue?roase with advancing age, yet lung cancer<br />
shows a sharp decYSUe after 65, rogardloss of cigarette<br />
consumpti.on .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
In rospoct to the tissue changes reportedly observod<br />
in post -mortom exoan9.nationn of the lungs of heavy smokers,<br />
it should be pointed out that sirni .lar changos are not<br />
uncommon in the 7.rmgs of non-smokers, have boon produced<br />
oxpr.r.imontally in animals by a variety of agents completely<br />
unrelated to tobacco smoke, and have been demonstrated<br />
to bo reversible so that the bronchial tubes may return<br />
to normal and no cancer develops . If these changes wore<br />
always premaaiEonant, they should not be reversible .<br />
During my years an a practicing doctor I have soon<br />
many changes in the general population of this country .<br />
btedi .cal advenccs have certainly not boon limited to<br />
1 .7b6
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diagnostie faci .).i.tios, but have also included the<br />
dis-oovcr,y of the so<br />
- ea7LX.od "mirac1o1/ drugs that aro so<br />
effccti.vo in combating many respiratery diseases . Thia<br />
very advancc, howcvor, may be contributing to the increase<br />
in the numbor of ).unr cancer cases that we soo . Thirty<br />
yours ago pneu monia was a highly fatal di .sease, influena<br />
opidemi .cs were not nnusual, and tuborcu).osi.s, or consumption,<br />
was sti .1.1 x•iunpnnt . tty curing such rospi.ratory disoases<br />
as thcse, raodi,cine hns undoubtea9).y saved the lives of<br />
mQny per6enE who would not otherwise ha.vC survived to<br />
tho canoer ago . It ln .ey alco have saved the livos of<br />
personss who wero susceptible to ar.spi ratory diseases .<br />
In othor words, that porson who, in enr).ior ti.mos, may<br />
ita.ve contracted and diAd of eonl3umptioll in his youth,<br />
now Jnrvi .ves to contract lung calteel.` in his fifties or<br />
f:i#t'.f.es .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Yt. is my f9.rm ccnlviction that a virus agent causes<br />
the majori'sy of cancers in the human . fitanloy, the Nobe)<br />
pri ;me winnor in tdedicf.no for 1938, vrho was the first to<br />
crysta).li.zo a virus and has done much wo ;rk oh cancer,<br />
Tools thar`t most, if rot a) .)., cancers are caused by a<br />
vi.rus . Canacre lmomn to have beon ceused in lower animn .)s<br />
by a vfruw aro often indistiugnishnble from the same<br />
l,ror>s and microscopic lesions in man, Well documolltod .<br />
n.nd ceuwfuXly contro] .lod c}.perimontaX ov :idence has<br />
1767
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i.r,di.cated not only that cancer may be causod by a vi .rus<br />
in rwi mals, bu9: that an imiiunity to the virus may also<br />
be so t up . This extromoly si gni.ficant area should be<br />
fully oxplored . I would dsoply regret any action that<br />
would sti.fle research !n this and other Pields of en-<br />
dea.ver .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
I have secn many chanCos in wedi .ci .no . I have hoard<br />
many theories that were supposed to account for certain<br />
observed ofi'eetn which turned out to be quite incorrect<br />
in the long rUn . 1 have honestly and earnestly reviewed<br />
a groat deal of the literature rel.atfng to smoking and<br />
lung caucor and have c:onsidered it in the light of my<br />
own experienae o£ over 42 years . P7hi .7.e I am aZways roa.dy<br />
to ent.ortain further ovi .donco, i .t i .s nry opinion that the<br />
aarsi:, agai.nnt cigarottcs has not been pravod .<br />
175Ft
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S'fA19moke lesr . What causes t.his two to one<br />
dlfferenco? In At a nutritional factor?<br />
3 . In many of the studios intorprotod as implicating<br />
cigarette smokAn g an aa health hazard, the death ratos in<br />
the cigarette smokers actually turn out to be lower<br />
than the death rvates in United States malas as a whole .<br />
For oxa,npa.e, the age adjurstod death rateEl per thousand<br />
n:an yoars fo+r cf .i;arotto smokers of one pack or more<br />
dail.y, i .n North fueerfcau (ages 35 aud over) average 2X .5,<br />
1759
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•<br />
•<br />
ty i i<br />
whi :le for United Stater> mal.os as a whole for a comparable<br />
year (1960) thoy aver® .6o 22 .9 . Either it i.s a fact that<br />
the cigarette smoking ma.les havo a slight :ly lower death<br />
rate than U . S, white malos as a whole, or it is a, fact<br />
that the sample of the malo population used in many o W<br />
those st.udios is not >.•epresentat :ive oP: U . S, males as a<br />
whole .<br />
The above figures are tnkon from tt;e 1964 Rv.port to<br />
the Surgeon (ionernl . On pagos 94-96 of i :ha.t .Report<br />
those pc,rtinent factr: appear :<br />
"None of the populai :fans was desi6roed, in<br />
parti.cular, to be representative of 2ho U . S . male<br />
populati.oh, Any answer to the question 'to what<br />
general populations of inen can the xesults be<br />
applied?', must involve an element of unverifiable<br />
,jud6ment. ."<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
"(h.oports) suffer from the diffioulti .os that<br />
the populations studied are had to dofine, that the<br />
smokers and nwi-smokers were rccrui.tod by a large<br />
number of volunteer workers, and that oomplotoness<br />
in the reportinU of deaths was hnrd to achieve, since<br />
this depends on reports from the volunteers ." (P .<br />
96) .<br />
"Scr far as £nterpr.etation of rec:ults is concerned,<br />
the discrepancy raises two points, l,t is clear that<br />
thc seveh pro5ipect£ve studies involve populations<br />
1761)
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•<br />
ty 12<br />
whi.ch are heals:hzer than U . S . m¢1es as a whole .<br />
Sc :c:ondl.y, tho low death rates for non-f;mekers sug7est<br />
tho pos•nihil9.ty that the studies recruited unusua.lly<br />
he[=,1thy groups of non•emo'.ceree ." (P . 96)<br />
ke).i.ah7 .c genoralieation cannot safely be based or ,<br />
sttu7ies of such unrepresentative popul.ations: .<br />
r . Yn connection w9.th bi.adder canccr : somo writers<br />
boli.eve that thi.s 9.r casually related to heavy cigarette<br />
sn:oL:ing . X t im noteworthy therefore that at the 1963<br />
luacr9.can l3fblic: Health Associ.at9 .on mo otina, a distin6'ui .shod<br />
proponent of this hypothosis obsorvod that "there are in••<br />
sui'i'ici.ent dnt.a to warr•a nt conolvsione;, an® the avai.lnble<br />
data are often contradictory ." 7t eioe.ns to mo pcrsonalZy<br />
that tlwre f.1`O compar0ble levol0 of ineo]ApletenCEs or<br />
contra,cti.ctorinesv in the lung cancer and chronic bronchitis<br />
datffi .<br />
5 . Tn connection with coronary axtory diseae.e, the<br />
Roporf : atresres that the causativo role of cigarette nmok-<br />
ing in death :a from this disease iei not proven, and that<br />
whi.l.e male c :i6aroti:e a:mokers do have higher reported<br />
death rates :trom coronary astery disease than do non-<br />
smoACCrn "it is not ol .ear that the associ.ati.on hae caur .al<br />
siCni.1'icance ." (kp . 38-39) .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
At the A+.le)ricnn {6oaP.•t AE:Soeinti.onr annual meet$.ng in<br />
1963 31fF.ny F;j~enkers opined thht toh9Aco probably haa a<br />
1701
•<br />
•<br />
•<br />
del.etorious oSfoct on the heart, butthnt this effect is<br />
not easy to pinpoint . But in a sttldy' ON GOme 6,000 .<br />
£rooklyn men, Spa .in £otmd that inriking habits could not<br />
be related to heart disoaso ; Tr.lbott reported that ci gar-<br />
otto r,inok9 .ng aetuall,v spoodod the clear :ing of lipids from<br />
the blood after a high-fat moaX ; Cnnnon coucludod that<br />
the evidence does not indicate that cigarette smoking<br />
coaftri.butos to the underlying pathology of coronary<br />
heart disealie (although he beli .o .•es it may be a serious<br />
complicatinf ; factor under certaitispcu ;ifiod couditi .onn) :<br />
Cmumt the datn from which those di.scordani : statements<br />
arise Be subinittod to i .udopenden t biostatistical review<br />
fow apparent siSnS,ficanc-o?<br />
6, S9.uce most o .4 the ovid.enco i.noxdminatiuC cigar-<br />
ettos is stati .stt.cal, all sorious studonte of the problem<br />
should, I boli.eve, read and re-read the cnrofull qualifying<br />
comments in the Report to the Surgoon General, notably<br />
the words AtttiSticn.7.ltothodtl cannot or>tabli .sh proof of<br />
a causal rol .nti.onf :h)p i.n an aSf.oUi .at"fon . The causal<br />
fii(i,'f'1 .9.ficallce of an association ifi a mattOr of judgment<br />
which goes beyond any st.atement of statistical proba-<br />
bi.lity .° (1'p . ®9-£7?) .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
7 . Thero are mnny other unanswered questions :<br />
(a) 19hy has the prevalenco of oral cavity<br />
caucer and phearynx cancer doclinod i.n the last three<br />
1?62
•<br />
•<br />
ty 34<br />
decades, despite the hiGher inteneity of exposuro<br />
to these areas to ci.garette smoge?<br />
(b) Would a larCe study onployi .nt; trkilted and<br />
tested i .nVest'.i . getolCs yield the f3nme data aa that<br />
co I 9vnonly quoted from many of the volunteor--holper<br />
e9i :udi.os in this country?<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
(c) Is the increase i.n pri.uiary bronehi.al cancer<br />
really as great ac commonly quc.tod? The study by<br />
Gi,l .li.a9n quoted on page 140 of the Report to the<br />
S u.rECeon Gcnoral ficnnonctrates how the increase In<br />
repnrted Ct . S . bronchial. oancor nay be much loss than<br />
cla9 .nmd . This study shows that i.f in 1914, two por -<br />
eeilt oi' the deathF certified to t:uberculesffi were<br />
really due to lung cancer, then the ineroase In<br />
pri,mary bL"onchial cancer botween that year and the<br />
yoar 1950 would 1)e about eQht-fold for maleF and<br />
only 1 .8 fold for females . ., fiGcrees vastly lower<br />
than the connonly quoted increace .<br />
A suUsequont study by Gi1lia.m noted a declining<br />
rnte o£ i .ncreese In reported bronchi.a l cancor, which<br />
is not oons4 .r,tont with roportod increased cigarette<br />
consun:pti.on if ci.Cnratto smoking is regarded as<br />
causinC lung cancer . (Gi1l .iam, etc . Cancer 14 (S),<br />
G22••2f3, May-•.YCnro 1f)G1) . Similar decline is reported<br />
In xnC]and and Wr1es, (Locs, Lnncot, June 20, 1f9G4,<br />
7703
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page 1393) .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
(6) My own studies on the ] .oe.us of origin of<br />
primary bronchial canoor indi .cal:e that almost tao-<br />
thirds of them arise in portiona of tho bronchial<br />
troe removed from the main bronchi. (where the con-<br />
oontratione of cigarette smoke are presumably lowost :) .<br />
(e) 'Phe peak incidence oipriira.ry bronchial<br />
cancer in U . S . males is close to 60 years of age,<br />
both in anokors and non-smokera, arad this peak tends<br />
to bo maintained irrespective oi' the amount smokod<br />
or when the cigarette srnoking alEe),nsdly commeneed .<br />
These are extraordinary findings which S.n my opinion<br />
re:riously c)uestl.on the eigurotte hypothesis .<br />
(f) Brit:ish scientists report that "in men wRo<br />
have given up cigarette smoking, mortality rates<br />
fr.om luag cancer decline immediat:ol,y", (Doll & Hill,<br />
Hrit, 69ed . J„ ]069, pp, 1.300) . Ef lung cancer is<br />
a response to a hypothetical carcinogen in cigarette<br />
sinoke, and this carcinogen hnn boon applied for 30<br />
or 40 years, how could cossatio n of application be<br />
followod by an immodiate decline? My ntudics on<br />
the natural duration of untreated human bronchial<br />
cancer, and my )niomledge of oxperl.menta7)<br />
tumor respons<br />
;c to proved carcinogens, lead me to the con-<br />
c.Yusion that Do1X Pc H11),'s observat9wn 9 .s compAOkely<br />
1764 :
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•<br />
•<br />
ty 36<br />
paradoxi .cai .<br />
Wel.ll dosignod rosoF rch prograrns should hol .p to provide the answers<br />
to many of these 4uoations, and should, I<br />
bolievo, be pursued . In thee moantimo, the established<br />
facts in my api .nion aro7<br />
(a.) That rnedical science does not yet know the<br />
cause oi' cancer, or emlrhysema, or atherosclerosis,<br />
and<br />
(b) That it is unlikely that a single exogenous<br />
factor r uCh afl cigarette nmoke should be a prime cause<br />
o.i thoss three diverse disorders .<br />
It is my imdorete,ndin4' that those heaxi .ngs pertain<br />
to l .abcling . If I may be permitted to or.press some<br />
G'olNn4nte, I Bhonld like to do 50 .<br />
1 . Cirarottos are said by somo to bo potentially<br />
l.ethal when u.scd to oxces :s . There is ] .ittl.e doubt that<br />
automobilos, liquor, wine and, indeed, some say even<br />
certain dairy products, are lethal when used negligently<br />
or to oxeess . To be consictent, should we not so label<br />
all these products? 1Phere does it ondP<br />
2 . In the light of the know perversity of human<br />
nature, is such laboli ..ng apt to be more of' a source of<br />
attraoti .on than deterrence? Ic it any sulestitute for<br />
education or cormnon sonse moderation?<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
3 . 1 bold no br.i.ef for the tobncco companies nor<br />
1765
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•<br />
0<br />
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their n,dvertisinC, but X notice no uatiaieal organization<br />
campaigninL' to curb tho .:ra1e or advertiE:ana of alcohol,<br />
cars, Etunf: or other lotlra]3 products, ench of v;hioh has<br />
t.he ovil) that victimr.: of i .to nac or misu :-;o nre frequently<br />
innocent bye•tienders . ):f smoh3.ng huri -s, "At hurts only<br />
t.he smoL•er ; it shou)d bo at the bottanc o :P the list of<br />
dangere i. Prcw whl.ch ei , free people rnust be protected, When<br />
I nm snSe frum druntcer•, d :rAvors, enz•eless heuvters, and<br />
sprayhnppy fnrmor.s, thero may be somo 7ogic in savinG nic<br />
ffl^om mysolf ." (Dorothy Samuel, Eati rday hovf .cw, February<br />
!2, ].PGa),<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1766
•<br />
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ty 16<br />
. b . NE'NRY GARLAND, 61,ID .<br />
References for first five nrunbere,d paragraphs,<br />
l . . Dean, G, Complex otiology of lun g eanoer . Acta Un•<br />
lnt, Canoer . 19, 7?l ., 1963 .<br />
2a . Dorn & Cutler . U . S . Public Health Service Monograph<br />
No . 5(i, 1959 .<br />
2b, fAarlcchiug l:esoarch ltoriort No . 189 , U . S . Department<br />
of Agricultur•o, Jul .y, 1957, page (t3 .<br />
3 . Rcport to the Surgeon General of the United States,<br />
19G4,pa6e 95 . Table 18 .<br />
4 . L4.licnfold, A . M . Medical 'Cribune, 12, 2, 63, page 1 .<br />
5 . Amorican Heart A•ssociati .on Conver .tiar Report .<br />
Modern tdedicine, 11 ., 25, 03 .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1•rG7
0<br />
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ty 1 .<br />
SA'i'G41F.'h'l.' 01T 11A1tRY S . N . GVtBiiNS„ 61 .D .<br />
My name ic: Harry S . N . Groon o . I was gradnal:ed fY'om<br />
61cGi11 University, School of itodieine, in 1930 .vii.th a<br />
degreo of B1 .D ., C .61 . At the present time, I am the<br />
Anthony N . Brady Pro£essor of £'a .thol.ogy and Chairman of the<br />
Depa,rtment o£ pat.ho7ogy at Yale University Sr.hooll of<br />
6fodi .ciue . b am an cxporirnental pathologist and have boen<br />
act9voYy engaged in cancer swoea .rcb for the past 30 years .<br />
Y am al.so a smohor, and the etiology of lung ctulcor is<br />
a matter of persOLa7. GonCOrn as welll as of seielitific<br />
interefit .<br />
IIt aptronrs to me that the priwary issuc at this stago<br />
of the lung ccuwer probtcem concerns an in .torprotation of<br />
statfstica.l cIrsoeiations . A sta .tisti.aal association<br />
betwoen two tiappenings ma.y be th.e cause of the other .<br />
All of those various possibi .litios mur>t bo considered in<br />
assess9 .ng tho Ed.gnificauco of a statistical association .<br />
Tt must be omphaE :§.zed that the j udgmeint i .s not made by<br />
gathor3 .ng moro statistics but rather by subyocting the<br />
difforont poe,sl .bil.itics to experimontation . In the preeeat<br />
instance, this moans subjecting the asscuood association<br />
between smoking and lung cancer to laboratory invosti-<br />
gation .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Lnhoratory investigation, to date, has not borne out<br />
the su[;gostion of a cause and effect relationship . A<br />
1766
•<br />
ty 2<br />
groat cdca]l of tvor]c has been done, but not . in a single<br />
instance has lung cancer boon induced by tobacco products .<br />
It is true that cancer has been proc3uced in the slci .n<br />
of rnico by long-continued painting with tobacco conden-<br />
sates . It should bo emphacized, howevor, that cancer hass<br />
also boon produced in mico by a varioty of common<br />
innocuous substances such as salt, sut :ar, egg white, and<br />
cellophane . i''Imther, our concern is with the lung rathor<br />
than with the s]cin and despite many oxperimentall attempts,<br />
no tumors have boon f'ou.nd to follow lont€^term exposuro<br />
of this orge n to i .nhalat.i.on of tobacco nmoko .<br />
5.`ho reported production of cancer of the lung in a<br />
dog in an i.n.terval o£ ].]1 days after the application of<br />
smoke condensate to its bronchial mueosa must• be dis-<br />
counted . Cencor induct.i.on is a slow process and materials<br />
of the greatest known potency in this direction require<br />
months for their action, I"urther, many other experiments<br />
utilizing this samo mat,erial and ani.mals of the same<br />
species have yielded completely nogativo results . It must<br />
be concludeN in the case in question that oi.thor the cancer<br />
was present before the experiment was begun or that the<br />
lesion was i .ncorrectl.y diagnosed .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
I:xperimonts utilicing lung tissue in i.nti .mate and<br />
prolonged contact with tobacco products have boon carried<br />
out in my ] .aboratory . It had boon found that embryonic<br />
2769,
ty s<br />
tf .sl .u9ff were mUCh b1Ore fiusCeptibl0 to CU1ICe1'•-indUCS .n[;<br />
substnnces than wcre t,helr adult counterparts . When<br />
embryonic or•ganc were infil .trai:od wii:h a canccr-•inducing<br />
substanco .and transpl ented to the body of an adult ani-•<br />
mal., cancer occurred with twice the fneidence and in ]oss<br />
than ha.1f thet titno that charar,tex•iaod tLe reaction of the<br />
aame organ i .n its adult r,tate . F'or this reason, embryonic<br />
tiseme transplants Wore used to test the possible cancor••<br />
Auducing propert.ies of va,riouo s.ubstancos, includ'xng<br />
condousoteo f.rom diTferent ciraret :to and pzpe m i .r.turet<br />
:,cake from my<br />
pipe, and ash from ci .garetto papers . R nbryonic<br />
moune ] .ung was used as a test organ, and a very 1arGe<br />
rnmbor of animals was e hprloyed, but no t in a single<br />
i.natance was: anytlting romoto],v resowblinrg a cancor ob•-<br />
tainod .<br />
The point to bG emphasized is that despito long-<br />
continued ex pmrimentation, no evidence has boon forth••<br />
coming to author.iz.e an interpretation of the purported<br />
association between tobacco smokinC and lung caneer .<br />
Cortai .nly a t a comparable stage of pro€;ross in the invosti-<br />
getion of an assooi .ati.on observod to occur in a researcU<br />
laboratory, the absence of evidence to support a causal<br />
connection would cast considerable dout: t on its relevance,<br />
and high priority would be accorded to a soearch for other<br />
oxplanati.ons to account for the coinoideneo of the two<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
7770
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happenings . %n rey or.pcr3ence as a rof::oarch workor,<br />
the usual answer has turned out to Le the .t the two<br />
happeua.nCs wore relatedd not because mre bausud the other<br />
but because both ropresonted different responses to a<br />
common canne, 1n thee prosent context, e, promising ponoi-bility n,lonEr this 99<br />
.ue 9n that a conyon factor may oporate<br />
to produce an 3ncreased suscopt :Lbilif:y to lung cancer<br />
on the ono hand and a heavy srnolcerr on the other .<br />
The snwkinl; population is a solc :ctciR population<br />
difforS.ng in other ha.hits not related to the use of tobacco .<br />
in i;'eneral, smoY.erE1 ar'e 1CsC concerv E t.ively inclined and<br />
havo rnoro noad for the support of€erod by tobacco . It is<br />
quite po£e.ibl.e that they represent N, d'Y fferont con9ti'Lu -<br />
tionnl type and that the gonetic doter.mAuers of this type<br />
also operate to produce an incroared suscoptibility to<br />
lung cancor .<br />
Genetic combinations of this vu.r4 .ety are not uncommon,<br />
and one mani :Pesta t ion may appear comp7,otoly unrelated<br />
to nnothor . For example, there in a earai.n of rabbit<br />
collntitutio11n11 .y charFwt.orired by a high incidence of<br />
OanCer of the nteY.'uEi and a pugnacious disposition . The<br />
latter is often extreMe, and the animal1 paces back and<br />
'ior5:h in its ea(je, snarls at pa5:oors-by, and attacks<br />
hanARers like a bulldog .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
This behavior is present from<br />
ear.].y l .i .fc and is so oonsintontl .y asrsociatcd with eventual<br />
1771
•<br />
•<br />
ty s<br />
death from a uterine cancer that it nffords a uniformly<br />
accurate moans of prognosis .<br />
diffbrent in their manifcstatione+, may bc mediated by a sin(<br />
In any caso, characteristics of behrcvior, highly<br />
;le horod'xtablo Eenet9 .c el.ement, nud it i .s entirely<br />
possible that, in man, an noed for tobauco smoke and an<br />
increascd suscept9.bil.ity to lung cancc r represent mani-<br />
festations of a common genetic factor rather than a cause<br />
and effect seguenco . Thre st:atistlcax observation that<br />
smokcrs are more suscc:ptible than non-eomobers to a multi<br />
.y ai7.ments 9n addition to l.ung cancer i.s more<br />
.-tudo of bodil<br />
in l.ine with a[;eneral, eonstitlltiena l differefnCe than with<br />
the expressed assumption that tobacco Eamolce is tho diroet<br />
causativo agent o f such a diversity of di.r>or.dors .<br />
. Th e possibility of a variation i.n the constituion of<br />
pipo and cigarette smokers al.so offers a xationall expla-<br />
nation of the observed differoncos in c:usceptibi.lity to<br />
di.sease . The incidonce of disease in pipe smokers is<br />
reported as not greater or oven less t :b.an that in non-<br />
smokers . This observed difference in diseaso i .ncidenco<br />
botween eiGarotto and pipe smokers con stitues a fundamental<br />
discropancy in the arduments favoring aR causo and effect<br />
r•cl .atioh,ship between cigaretto smohiug and disease . The<br />
evidence does not establish inhalation as a factor in the<br />
dif.ferenco, and the content of nicotine amd bene:apyrono<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
~<br />
1772
•<br />
•<br />
•<br />
r:c<br />
fs a.c.tual.ly gareater i.n pipe smoko .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
%n view o ;: a coruvun oxposure to tobacco srnoke, the<br />
dt.f:ference in the i .nr.i.denco of dA .soa se between cigarette<br />
and' W pipe srwkers probably re7.ates to a difference in<br />
susecpt9bil.ity . rii?'foronces i n susoeptibility to in- ,<br />
featious a godts and cauc.or -producing substn.ncos are known<br />
to occur in man an d in l .nborctor,y animals and have been<br />
the subject of i.nten s ivQ study . Faetor5 nuch &Ff ago, sex,<br />
an d race pl .ay a hi ghl .y sf.L'nifi .cant role and other loss<br />
obviours variat:iwis in oonrti.tuti.oa are of equal importance .<br />
Cancer of the lung in man is, iteo7.f, an excellent example<br />
of a constitut9 .onal.ly affll5.ated disorder . Yt occurs<br />
prodominnntl.y betwc :en the ages of 45 and 60, in six t.imos<br />
as common i .ci n+ales ar; in females, and the frequency varies<br />
widely in different rac.ca; and ethnic groups, The influence<br />
of othcr constitut9.oual) fac,tors on its occurrence has not<br />
boon investi .gated, but it i.s suggested that the inborn<br />
traits that rnake a pipc: smoker or non•-s moker out of one<br />
individual 2.ncd a ci.raroi :te smoker out of another may also<br />
be oporativc in determining suseepti .bility to lung caneer .<br />
ln any case, the inf.oronce that tobacco smoking ie a<br />
cause of lu nG cancer is not based on experimental evidence<br />
but on stati .stical judnnront, and my primru•y object in pro -<br />
parinD this statement has lwon to omphasize that causation<br />
cannot bo 9rnforred from statistical associatic .n . The<br />
1773
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ty 7<br />
.:tatict.ical . relationship betwoen sinoking and lung cancer<br />
is subject to any nurnber of imssiblo S.utarprotations .<br />
Vor example, while it can he intel'preted eauBal7.y, it<br />
also can be interpreted as a con>>tittrt:lonnl d'xathesis<br />
asEloeiated with a need for tobacco BmeI:e. I;Xperimental<br />
conf :lrmr..tionn is csscnt.ial. to oi.thea^ 9.r~t;or°7>roRati.on, but<br />
to date this hnr, not been forthcoraing, and the nature o4<br />
the roal t ionF/hij'1 of tobacco P3mok :lng to lung cP.neer re-<br />
mains, an unresolved question .<br />
The roported discovery of collul .mx modi.fioati.ons<br />
in various cu^eas of. the lungs of smolce.re has led to the<br />
suGECOsti.on that such modi.fications represent precancerous<br />
changes . It should he noted, howevor, that ilmg cance<br />
is a single losion, whereas the so- call.ed, pro-<br />
cancorons chaingcs are found in multiple pulmonary locations .<br />
i'arthor, i.dentical chaufes in the appcaranoe of the colls<br />
are present in the lungs of adults with pneumonia, influenza,<br />
and other pulmonary diseases and are also couimon i n<br />
diseace of young children . Mi.ce also reaet similarly<br />
to infecti.on with ini'luonza virus and respond with a<br />
rapid growth of bronchial coils so an.apl.astic in appearance<br />
as to lead to an erroneous diagnosis of cnnoer . Such<br />
lesions, howover, completely di.sapiwar when the animal<br />
recovors from the disease . It in apparent, therefore, that<br />
the changes in Wnolcors aro not preoancerous and that<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
r itself<br />
1%7 A
0<br />
0<br />
i!<br />
their Urodence in the lung dooe not rcr7.ato the habit oR<br />
smoking to canoer .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
177 b
•<br />
•<br />
y I<br />
SA'PBM E N'f OF LS6 KAT'L, PH .D .<br />
I am h oe Katz oi :' East Lansing, Michi((an, currently<br />
Professor of' Statie.ti.es and Director of the Statistical<br />
Laboratory at Michigan State Univorsity and Visiting<br />
Professor of Niostatistics in the Nedica.l School at the<br />
Univors5 .ty of Cinci.nnati . Since 1951, I h.avo beon<br />
ha•incipal . lnvest:igator on r.esearch sponsored by the Gffice<br />
of Naval NCfIOG.reh and the NationRl Scienee Bonndati.On . I<br />
have hold VisitinQ P2rofessorships at tho . University of<br />
North Caro].ina and at Stanford Univerrity and have servod<br />
one year as Lhmopean Scientif5 .o Linson Gfficer for Prob-<br />
abil9.ty and Statistics in the London branch office of'<br />
the Gfi'ie0 of N&val. Research .<br />
I ali1 a PG11oW of the lnstitut0 of M.athematical Sta-<br />
t9 .st9.cs, the American Statf.st:i .cal Association, tho Royal<br />
Stat:i.stical Society, and the Amorican Aesociation for the<br />
Advancet:cont of Science . I am a mombr, .r of the American<br />
MathCMilatieni . SOO£!lty, the Mathematical AsflOeiatiOn of<br />
AmOriCa, the IAndon Mathemati0al Society, the DiOmetric<br />
Scoi.ety and othors . My teaching, rosoarch and consulting<br />
activities aro all. in t.he fields of Mathematical Statistics<br />
and Probability Theory . My vitae in (,reat.er detail are<br />
attached hexowith .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
The report of the advisory committee to the Surgeon<br />
Gonornl of the Vid .tod St.ates Public llealth Service has<br />
]7'IG
•<br />
0<br />
0<br />
ty2.<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
two prime objectives ; firstly, to esttrblash that thore<br />
exi.sts a clear and significant association botwoon pat-<br />
torns of smoking hnbi.ts and risks of death, and secondly,<br />
if associ.ation in established, to verify that the form<br />
of this associatfon is betweon smokinN' as cause and<br />
111croased ri.sk of death as offer,t . 9a partieu7.ar, the<br />
argument is in sharpest focus in consi.dering the relation-<br />
1777<br />
ship between the ama.utt of ciiiarettc smoking and the risk .<br />
of doath from cancer of the lung . I d.irect my initial<br />
remarks toward clarification and ovaluataon of the extent<br />
to which these two objectives are attained in the report .<br />
ASSOCIATION<br />
On the first objective, the do9:ermination of asso-<br />
ciation coul
ty 3<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
in a population are Sndood associated, it is o]omentAry<br />
and os::ntial stati.sticn] prftctiee that' . the investigator<br />
seloc+t his samplo so as to represent ndoquately the popu-<br />
lation he studios and that he neither permits individua] .s<br />
to nomi.nato themselves for i.nclusion in the study nor<br />
user some readily avilablo but possibly non-reprosentative<br />
group of individuals . Yurther, the fact some do and some<br />
do not respond to hi s queries invites the immediate eae-<br />
picion that theso t wo groups may differ In respect to the<br />
very attribtltos being studied ; a further investigation<br />
into the similarity or dissimilarity of mon-rospondents<br />
to rospondonts is necessary to allay We suspicion . The<br />
fact that the vari.ous computations mnde from the sample<br />
e.urvoys reported by the advisory col:mlittoo to the Surgeon<br />
Goneral consistently underestimate the knonM general and<br />
spcoific death rates of the population In an indication<br />
that such biasos did i.ndeod occur In thor.e studios .<br />
IVh11o one can sympathize with the committee in its<br />
i.nabil.ity to go beyond existing studies to conduct In-<br />
dependent investigation of Its own, It is unfortunately<br />
true as matters stand that there is no way to ovaluato<br />
accurately the extent of the biases In the osti.mates .<br />
At the very least, the committeo has established that<br />
there might be an ascociation between cigarette smoking<br />
and lung cancer ; at n,ost, it has established that the<br />
1778
•<br />
•<br />
0<br />
ty 4<br />
ar..&ociatiou is oP the maLnitude c.l.aimed in the report .<br />
The truth of the matter is probably somewhere between<br />
these two cIItreSti08 and ,7Ufit.ifi0s leeltinQ : into the s'econd<br />
ic:nnee, name'ty, whether the assee£.at£on mit;ht be one of<br />
caiNSe and oi:fect .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1 should like to om7ahasi?e that there is a f'unchanantal<br />
difforenco betwocn argumcnts which serve to establish as-<br />
sociation and thoser required to dete.rrein,u that one phencnnenon<br />
is ctur•al and ano•ther is an effect ascribablo to the<br />
P,i.rst as cause . Ar.socS .ati.on i s a purely statistical<br />
prepcrty of colloctions of observations on two attributes<br />
of thc same ind5 .viduals . The occurrence of association,<br />
in wh :atovor degree, cannot of iteolf ind icate whether or<br />
not the re9ationrhi.p between the attributes is or is not<br />
one of causo•anci-r,ffcct . %n particul .ar (s;ee pp . 182 ff .<br />
of the report to the Surgeon General), evidence as to<br />
",, .consistoncy of the assooiation,,,•strenEd :h of the<br />
association . . . . spocificfty of the asli0ciation, .,,temporal<br />
rol.ation of the assoc:i&tion, (and/or) . . .coheronce of the<br />
assocf.ation" can ouly serve to buttress the claim that<br />
thore- in association bu t cannot cast any light whatever<br />
of the guestion of causa7l relationship .<br />
CAUSAI,I'!Y<br />
l..ogically, onco posi .ti.vo association has been es-<br />
tabliEhed bbtw
•<br />
ty 5<br />
statistical £ilferOncO, there are only four posS£bil£ties<br />
nlD regards the nature of th9 rel .al:ion ship . These ar
.<br />
•<br />
committeao could have boon so eontaminated that the asso-<br />
ciatione : observed muOt bo $udged to be mostly spur.ious .<br />
],et us assume, in order to continue discunaion in the<br />
present line, that the fourth posuibi :lity listed above has boon<br />
ruled out ; we still have before us the problem<br />
of deci.dl.ng which of the r.emaining th roe r.ases describes<br />
tho causal nature of £he relationship botwoen the two<br />
factora . The insue now in clear : DUeft A cause B, does<br />
B cause A, or are both A and B ef'fects due to an under-<br />
lying system of causes which produces tho observed ae-<br />
sociation9 Uero we come to the heart of the matter . Up<br />
to this point, statistt.cal mothods to evaluate the dogroe<br />
Af assoc:iation are valid and, indeed, aro the only valid<br />
method of proceeding in the ftace of individual variability<br />
and uncertainty . However, from this ppint onward, sta-<br />
stiti.ca l mothods alone are of no further avail and our<br />
only recourno it to definitive exporimoni;s . Specifically,<br />
the question of cadsality can only be resolved by an ox-•<br />
porimon t so designed that two clearly diatinguishable re-<br />
sults of the exporimenta .ti.on will be observed depending<br />
on which of the two competf .ng hypotheses in correct :<br />
(1) increased cigarette smoking does cuasc increased risk<br />
of lung cancer or (2) increased cigaret.te smoking does<br />
not caaise increased ri8k of lung canecur . Since no such<br />
oxpo:rimcnt han boen dono, no positive statement regarding<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1781
'<br />
•<br />
0<br />
.y 7<br />
causality is ,ju ::ti.fieu,<br />
The argument ) have just presented ie entirely in•-<br />
depencient, may I stresr., of the question of association .<br />
1Yoti.co that I st.ipttl .a.ted, for oontinuat3.on of that dis-<br />
cussion, that association did exist . INt us turn now<br />
t.o the claim euade by the advisory coaunltteo to the 6nrgoon<br />
Gonera9l thnt the resu]tsr of oxpori.monts which convoy in--<br />
f'ormation rogarding associati .on can somehow be made to<br />
impui:o the ex7.stence oi a cause-offect relationshi.p if<br />
the nssociation is consi.stent, strong, specific, of<br />
propor order in tempora l relationship, and coherent .<br />
psychologists are agreed that poople differ in their<br />
i.ndivi .dua7l noods for oral gratificatiore and that one of<br />
the mai.n sources of this gratifi.cation is the smoking<br />
habit . Another pri.ncipal source of sa5'.isfaction of oral<br />
needs is the habi .t of thumb-suaking, practicod largely<br />
by infants and usually abandoned in early childhood . It<br />
is not at all tnn likely that carefully-oellducted oxpori-<br />
nients would i ndicate significant associations among oach<br />
pair of the factors :<br />
cigarette smoking, deaths from lung<br />
eancor, and thumb-sucking in infancy . Focussing on the<br />
association batwoon thumb-sueking and deaths from lung<br />
c,ancer, we seo that the tomporal relationship is even<br />
more pronouncud than betweon smoking a .nd<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
:h.at 20 :lcmg cancer,k'urther,it is reconable to suppose t retrospective<br />
778'L
•<br />
•<br />
' :v £:<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
studic[: could consist.onfa .y uhcro stronE, association as<br />
spec:if't.c as that soen In lung cancer vor,us nmolccing .<br />
Mally, this whole ool.lection of phenomona is coherent<br />
In a theory which holds that those indivi.duals who develop<br />
thc tknusb-+:uch ;nk; habit and erc l.ater fe» •ced by social pre s•-<br />
sures to adopt other foxms: of oral g ratificati .ou tend to<br />
introduce in.to thei .r iuouths and r.ir-passnCes carcinogenic<br />
and other 9oa!]l suh ste.nees which nay pirodtwe lung cancer<br />
(aud 9.ncroaaed risyk of cleath from a long ].ist of causes) .<br />
'a'he hypothet5 .c:a.ll c»:.ampl.e we have just oxamined is<br />
not entirely trivie.l . Although you may object to a claitn<br />
made on the evidence ou9D .iamd thet lung crnn c:or is caused by<br />
thumb - s•uoleix,C, X, ras,i.nte.i.n that this ia ; precisely the nature<br />
of the supPW inE ovi.demco for the claiscm that lung cancer<br />
is c:auued by ci{tarette smo]cinC• Y'he stnti .stica] arguments<br />
presey :tod In the report of the advisor .•y cosmnit.tee to the<br />
Surgeon Gentral cannot, in and of themselves, be used to<br />
go beyond demwnst.r.at4on of a .ssociatf.on in an attempt to<br />
support a cnsc• for a causo••offoct relationship .<br />
PDSSIDLF: AC4'IONS AND C.ONS1iQUl:NCRS<br />
My remO.ninC ro wnrhs are directed toward discussinG<br />
brief]•y the posnS .bl .co actions ava.ilablo to the Conrree :s<br />
of the Unitod States, on which rccovamvndations may be<br />
macle by thfs comm :k.tteo . My ow• n opinion is that the<br />
questi.on of whether cigarette smoking cavses lung cancer<br />
19613
i<br />
•<br />
0<br />
ty 1)<br />
has notheen settled, nud that oonsetguonily no fina.ll<br />
dooision ehou]c2 be und.ertalcsn on the+ s :tronsEh of the<br />
prosont evidcnoo . ti'hor.efor,e, itt c,oemw: to aic that the only<br />
possShlc action which shouAd bye conside .ed by this conmzit••<br />
tGC 1F A, dec@t#ion to Po .9,S .hholrA jufig]Oent and to cA.l1 fox' a<br />
jud;aaont and to cu .1.7. £or a maximmH effort to produce<br />
ono or more i+.efieoStiye oxp ov i,monts which would provido<br />
cmra]oai.vo ewidcnoe on the matters st :iA1 under dispute .<br />
$ feo l mo,+t cEa7osE{I.y the dGsirab il .S.t,v of Qoei .Bn9.ng<br />
r.nd poar2orm2ng euch a>qlcrimrmte as oxpodAtious7 .y u .s pos . .<br />
ei .bl.c . Y ercpeet that wc &ha .11, encountc!r ciifficul .tio€, in<br />
enrx•yiatt out th3s proPram, but a£ter aBbl n peopl.e who<br />
eNh flchY.eva 8uch diverF.e la9rlLcle6 as ?IDterplaliotary travel<br />
OmGi ttho inV(riltion of a pl .€lEtiA ha(( to wrap sandwiches<br />
should h[cvo no tnsur•aiowe9 :€€h1 .e difficult :y s.n ma .rshal.l.ing<br />
enouGb. i-n¢earu4t.y to o€unry oast saeh a pxogran of er,per-<br />
z€aentu .ti .on .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
aiJ<br />
9fAT E M7;NT Or UR . SHHRMAN IfAVLAN<br />
My narne i.s Pr . Sherman ICaplan . 7 am Ch< :i .rman of the<br />
Ucpartment of Medici .ne, Mt . Si .nai. Hospital, t1i .arni Heaeh,<br />
Flori.da, end Assistant Clinical Professor of Medicine az<br />
the llni.verslty of Miami. Medical School .<br />
I am a specia.7i .a:t, certi.fi.ed by the fvaer:ican Board of<br />
]:nirrnal Mcndi.ci.ne and a Fellow of the Ameri.can Co].lege of<br />
Nhysici .ans .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
] 76 -b<br />
I att.ondcd medica l school at the University of F,ouisv9 .] .7 .c .<br />
After completing internship and residency training at Michael<br />
Reese Ilospi tal and Cook County Hospital i.n Chicago, l : taught<br />
at the Cook County Post Graduate Sehool of Medicine, the<br />
Ch9.ca.P.o Med :i.cal Sc.t,ool., and parti .ci.psted in the running of<br />
a tcachi.ng dopartment of the Cook County Hospital . .<br />
Por the past thirteen and a half years T have practi .ced<br />
in Miami Beaeh and at the present time 3 am engaged both i .n<br />
teaching house staff c,ffieers at the intern and resident leve7<br />
and in the private practicc of mcdir.i .ne .<br />
My training and practicc havc beon devoted principally<br />
to the treatment of diseases of' the heart and vascular systern .<br />
Practici.ng in Miami Beach, I have had a unique opportunity to<br />
obsorvc and treat a groat number of people corning from a71<br />
par•ts of the Uui .tod States and many foreign eou.ntrnies sinq>] .y<br />
hecreiuse : of the fnct that I am in an arca where the temperature<br />
:is warm emd the c0.i mate eongemia] for people with thi.s type of
•<br />
•<br />
jon?<br />
diseaGe .<br />
During the past thirtcen and a half years there have<br />
passed throu Rh my practice not less than 2,500 individual .s<br />
with condi .tione• ro].atinf; to acute coronary occlusion and<br />
coronary artery i.neufficiency,<br />
These peop7 .e have come fr•om various and diverse bttek•<br />
gro umds and they ane as varied a group as can be found in<br />
any usual human popu7 .ation .<br />
1766<br />
From obscrving these pati.ents and col7ectinF information<br />
about a7 .1 aspects of their histories and life pat:terne: I have<br />
reached some conclusi.ons rc7 .ative to the background and de-<br />
vc7.oprnent of coronary artery disease which I wou l.d like to<br />
coromunicate to you .<br />
I would like to approach from a cli .ni.r.a7l viewpoint the<br />
question whether cigarette smoking results in deleteri .ous<br />
effects on t.hee cardiovascular system ].eadiny, to coronary<br />
artery diseare and to review critically the notion that<br />
smoking may bc responsible for some large number of deaths<br />
resulting from the effects of this di .sease .<br />
I would al .so I.i.ke to review briefly established causative<br />
factors of vascular disease .<br />
I should like to emphasize at the start, that to this<br />
date, there i .s no known proven cause of hardeni :nP, of the<br />
arteries (arteri.osclerosi,s) .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
First, aet: me point outt that a gr
•<br />
jon'i<br />
coronary disese ar e traceable to certain definite disease<br />
cirCum5tanCe& . .<br />
Diabetes, wh :ich to most people simply means a di .sorder<br />
in the body's handling of sugar, is knoan by physicians to<br />
be an important contributing factor in various types of<br />
vascular di .sorders .<br />
The circ:ulatory di.ffi.culties which arise from this<br />
disorder may ]ead to a group of comp :l.i.cai:ions, includinF<br />
marked dec :rease of blood flow in the coronary artery . Thus<br />
we find that the incidence of coronary occlusion in the<br />
1787<br />
di.abetic is considerably in excess of that in the non-diabetic .<br />
A second disease c•i.rcumstance ]vr.die:posi.ng to vasmrlar<br />
disease is one invol .vinp• the abnormal hu'ndling of ingestcd<br />
fats . It is called "hyperli.perni .a" ar,d is characterized by<br />
ea fatty or m i .]ky appearance to the blood serum .<br />
This condition is hereditary and results i.n marked<br />
deposi.ts of fat arrd calcium materi .all in the arteries with<br />
premnture death due to vascular di .sease :i.nvol.vi.ng, in the<br />
wain, the coronary e.rtery .<br />
To these recoGni.zed disease circumstances we can add<br />
the effect of the ap p arent inheritance pattern in heart<br />
ciisoase .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
When one i .nterrogates a patient with coronary artery<br />
di.sease about his family history, he is impressed by the<br />
faci: that the patient ur,ua] .]y re.veals in his genealop•y an
0<br />
•<br />
unc:ommonly high incidence of vascular disease not only<br />
among his e.i .bl .i.ngs but i .n his parents and grandparents on<br />
dne or both sides of the family .<br />
The fre quency with which this type of history occurs<br />
presents the unavoi .dab].e conc] .usion that there is some<br />
1769<br />
hereditary abnormality involved in the production of vascular<br />
disease, which i.ncludcs not only corornary artery disease, but<br />
hypertension and stroke as well .<br />
This abnormality i.s present at the very moment of<br />
conception and its presentation as some form of vascular<br />
disease depends only on the passage of the proper interval<br />
of time .<br />
l :ven mo :re intri.guing is the contribution of the factor<br />
of sex ;io rnones to the i.ntegrity of the vascular system . Tt<br />
is a we] .L-estab] .i.shed fact that the menstruati.ng female is<br />
uniquely protected aCainst coronary oeclusi .on<br />
. ln<br />
contrast, in the post-me :nopausal female in whom<br />
ovarian funetion has decreased or ceased, there is now a<br />
sha .rp ri.se i .n the inci.dence of coronary occlusion, so that<br />
the i .nc:idcnce among these women approa.ches that of their male<br />
counterparts . .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Another i .nte :rr.st.i.ng fact is that when the ovari.es of a<br />
young menstruating female arc removed, the incidence of<br />
coronary artery disease in such females abruptly rises to a<br />
ratc paral.l .e :l.ing that in the male or the post-menopausal
•<br />
femed .e .<br />
The importance of e:ex hormones if f urther borne out<br />
ty the observation that males in whome certain types of<br />
liver damage occurs -- such as in the chronic alcoho]ic<br />
with cirrhosis of the ] .i .ver --- the deactivation of female<br />
hormone accompl .i.shed by the normall liver is absen t and he<br />
exhi.bits certain feminizing changes .<br />
Such men are found to have a surprising freedom from<br />
coronary artery disease similar to that in the menstruating<br />
young female .<br />
A particular0.y nertinent subject for the purpose of<br />
this discussion is the wel l known effects of stress upon<br />
the cardiovascular system .<br />
It has been wel l documented for some time from<br />
observations in l .aborat.ory ani.mals that in circumstances<br />
of increasing t-neiions orsudden stressfu]l stimuli there is<br />
a response in the function of varous endocrine glands, .whi .ch<br />
results in isar•ked alterations in cardiac output, heart rate,<br />
serumcholenterol ]evel and vari .ations from the norma]l blood<br />
pressure .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
C :Linica] studios have extended these observations to<br />
human beings in si .tuati.ons of stress .<br />
Some yenrs ago observati.c,ns were made on a group of<br />
accountantc i .n Sar, Yranci .sco . The group was evaluated first<br />
in the month of Septembor with respect to serum cholesterol<br />
1769
.<br />
•<br />
'lon6<br />
]evcls, and blood clotti-n{; acti .vity . The sarne group was<br />
7790<br />
then re-eval .ucted during F1arch and Apri .l. . Under the stresses<br />
of the tax r :eason a striking change was found to havee occurred<br />
in al] of the fa ctors studi.ed .<br />
'1'hi.s group which in Septe mber had appeared to be<br />
essentia7.ly norma] in ra:sper.t to cardiovascular function<br />
showod under stress th e disturbances which are thought to<br />
favor the deve.loprnent of coronary artery di .ser.se and coronary<br />
occlusi .on .<br />
These studies have bcan extended and si .rnilar results<br />
found by owuparinfi eo]le .F;e Ftudents during the mi.d-semestcr<br />
and during final exam weck .<br />
Striking di.fYercnccs are seen in the rate of coronary<br />
occlusion in the overworked and pr e saurcd gener&. practiti .oner<br />
of medicine as compared to the pathologist of der mAtolofi i e.t .<br />
llow docs cigarette smoking fit into t.his patternl Tn<br />
my opini.on, it ie• simpl.y nn easily visualized or discqve rable<br />
trai .t whi.ch is very l .iknly to bo part of the behavior pattern<br />
of an indi-vidual rcaction to etress .<br />
St does not cause or exacerbate the cardiovascular<br />
scbnornnalit-ies which appear to contribute to the development<br />
of heumt disease and heart attacks .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
In thi.es connection , ci(;aretto smoking in ana]ogous to<br />
nail bi_tiny, or hair p :lucking which sorae individuals resort<br />
to under 5i'itt8tio11F.' of SnCr•ca5ed tens :ion or sb^ess .
•<br />
•<br />
0<br />
It is i .uteresti .nPg that very often the so-called chain<br />
smoker may actually consume very ]ittle tobacco . Like the<br />
nail biter, who i.s unaware of biting hi .s nails, the chain<br />
smoke.r is not awe:re that he has reached for and lighted a<br />
ciga»ette and he may snuff it out after one or two puffs .<br />
]:n norma] . humans, smoking p ro duces no change i.n blood<br />
flow in the coronzry arter . X-ray studies of the coronary<br />
1791<br />
art:eri.cs bofore and after smoking show r,o change in the vessel<br />
cali.ber .<br />
With cmriinucd smoking there is no change from the<br />
resti .ng ].eve] of coronary flow in both norma7l persons and<br />
those with eoronary artery di .sease .<br />
The elec2rocaz•diogram in both normal and heart patients<br />
shows no sign :tficant change and frequently none at all in<br />
the presence of smoking .<br />
Studies relating to the clotting of the blood show no<br />
effect from tobacco or nicotine .<br />
'1'o c:onc]ude those ra:marks, I wish to comment briefly<br />
on t.he idea which has been advanced that steps taken to<br />
discourane cigarctte smoking may reduce the number of deaths<br />
from cerdi.ovascular di-sease .<br />
]: have tried to point out that evidence to estahl .i.sh a<br />
eonnection between smoking and coronary artery di .sease -- the<br />
most common forvn of he.z.rt disoase --is ].acking .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
'1'he rcce:nic popu]ari.ty of the theory ihat cho] .esterol i .n
•<br />
•<br />
]eno,<br />
the di.et was a factor favoring the development of coronary<br />
diseaee yve rri.so to a big business in safflower oil and<br />
other forun& of unsatm•ated fats. ' '<br />
The emphasis on obesity as a factor has led many people<br />
to undertake crash diets .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Theories concerning the type of behavior which is best<br />
calculated to afford an individual protection from heart<br />
disease have been advanced from decade to decade and have<br />
en j oyed varying degrs.e.s of popularitiy .<br />
Just as the Public Ilealth Service has wisely refrained<br />
1792<br />
from endorsinPg any of these theoriees in the past, so it would<br />
a]so seem wise to avoi .d any expressi.ons which appear to endorse<br />
the theory that cip,arette smoking is i .mp :licated in coronary<br />
artery disease in the present state of our knowledge .<br />
k'ar moro pertinent woul .d be an undaunted pursuit of<br />
the missi .np, 7.ink;s in the fawi]i.al transrni.ssion of vascular<br />
disease and Ca.t metabolismy and a carefualy p7 .anned educatior,a7<br />
program desi .gnod to champion an even and moderate way of life .<br />
/s/ Shemnan R . Kaplan, M .ll .
•<br />
•<br />
STAftliP111NT OF SENATOR R01tSRT F', KllNNEDY<br />
The testimony at these heari.ngs leaves no doubt that<br />
cigarette smoking i .s a pub]ic hcalth problem of great and<br />
Frowin g seri.ousness . The ovcrwhel.ming consensus of medical<br />
opinion holds that smoki.nP is the pri.nci.pal cause of lung<br />
cancerwhi.ch ki .l].s more than 40,000 American s every year ;<br />
that it is a major cause of chronic bronchitis : and that it<br />
1793<br />
is associated with, and may well be a cause of, heart disease,<br />
emphysema, and other serious diseases whi .ch each year bring<br />
des.th to a large number of Americans .<br />
In New York Ci.ty there were 2761 deaths from lung cancer<br />
a]one ] .ast year, to say nothing of the other diseases, and<br />
Dr . George James, The City's Co mmissioner of Health, estimates<br />
that, viewed conservative] .y, at ]east 70 percent of these<br />
deaths were attributed to cigarette smoking .<br />
A pub].i .c health problem as grave as cigarette smoking<br />
demands prompt and effective action in the public interest .<br />
But what doe :s t.he record show has been done to protect the<br />
publi.c7<br />
7'he ans .wer is not nearly enough . The eir;arette companies<br />
themselves, who cer~ta.i.nly bear the brunt of the responsibi .lity<br />
havc not undertaken c.i,gnificant action . Not only do they con .-<br />
ti.nue to deny that ci.gzurotte smoking is an estab] .i.shed health<br />
harard, but they have tried to dampen pub] .i.c awareness of tlris<br />
hazard through rr,aseive ac]vertisi.ng .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
jon%<br />
These campaigns seek to impress the American people<br />
with the untenable notion that ci.i;arette smoking i.s con-<br />
sistent wi.th hea].th and vigor, and that i .t is a mark of<br />
sophista cai :ion and maturity and a gateway to glamor and<br />
rornance .<br />
Si.nee evidence of the hea] .th risks of cigarette smokin g<br />
began to appear, the cigarette companiee have spent rni .l] .i.ons<br />
2794<br />
ofdo]].ars to advertise their product --mainly to tc].evisi.on<br />
and radio audi .ences including large numbers of children and<br />
teenagers .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Too often youngsters are swayed by advertising that<br />
conveys the idea that if they want to act like grown - ups they<br />
should ]i ght up a cigarette . They are too young to reali .ze<br />
t:he scriousness of the dangers to their health when they<br />
srnMeo these dan gers seem too remote and distant .<br />
They cn•e not, however, too young to obtain cigarettes<br />
and thus acquire a habit very difficult, if not impossible,<br />
to break in later life . Once aa youngster becomes a confirmed<br />
smoker, he may never be able to break the habit, even after he<br />
grows up and gai.ns an insight into the health dangers .<br />
In the absence- of any significant effort by the cigarette<br />
companies to face the problem -- and current cigarette<br />
com-mercia7<br />
.s demonstrate that the much-publicized Cigarette<br />
Adverti.si.ng Code adopted by the manufacturers has made no<br />
meani .ngfu7l c:hanRF In cigarette advertising -- private groups
•<br />
•<br />
jou"s<br />
like the American Cemoer Soci .ety have tried to educate the<br />
7795<br />
public in the dangers of cigarette srnokinR . But their efforts<br />
have been modest and have been mostly lost in the tide of<br />
advertising by the ci.garette companies .<br />
Government -- federa] ., state or local -- also has not<br />
done enough to cope wi .th this groat public health probl .em .<br />
In c:ontrc:st to other potentially harmfu]l products, cigarettes<br />
are promoted and distributed wit.hou t restr•i.cti .on .<br />
N thoueh drugs whi .ch may have harmfu l side effects are<br />
labeled to al.ert the purchaser, cigarettes are not . Hard<br />
liquor is not advertised on tclevisiom eiParettes arc .<br />
AAcoholic beverages are.not sol.d to minors ; it is not uncommon<br />
to see children in the seventh grade smoking ci.garettes . No<br />
one can driv e an autcnnobi.le without being li.eensed : anyone<br />
con smoke cif;arettas .<br />
The fact that cigarettes are sold and promoted without<br />
rostr .i .oti .on (either self--i .mposed by the oiga m tte manufacturers<br />
or i.mposed by government) helps explain why many Amcri .cans do<br />
not yet, despite the evidence, fu] .l.y understand and accept<br />
that cigarette smoking may ki]]l them .<br />
7M only agency that has made a serious effort to cope<br />
with this problem is the Federal Trade Comnission, whose duty<br />
is to prevent unfair or deceptive advertisin g of produeta<br />
sold in interstate commeroe .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
On the basi.s of hearings in which the views and opinions
•<br />
•<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
of' all i.nte.rceted parti.es, i.ne] .udi.ng thee cigaret:te manu-<br />
factm~ers, wcre considcred, the (:omrniseion determined that<br />
1796<br />
it i .s unfvi.r and dccepti .ve to sel .l cigarettes without •<br />
di.so]osi-rrg on the nackage and i .r, al) advertiscments thet<br />
cigare
•<br />
•<br />
•<br />
jrn0<br />
lt is deceptive for oigar,ette cornpaoies to advertise<br />
and promote their products without a hint of the dangers of<br />
cigarette smoking . Our children should not be exposed to<br />
such advertisi .ng .<br />
7'ho Commission's Rule would not prevent cigarette<br />
rnanufactur.;rs from advert :i.si.nR their product to young people,<br />
but it would at loast: prevent them from giving a one-si.dc.d<br />
view of cigarette smoking in their adver•Ci.cing .<br />
It would make them give the whole p :ic:ture -- whi .ch is<br />
that whil .e cigarette smoki.ng may he enjoyable to some, it<br />
is at the stnue time a cause of disease and premature death .<br />
1997<br />
What are the re.e;ponsi.biliti.es of the Congress in respect<br />
to the publir health problern of cigarette smoking?<br />
Phcre are many thin g s we can do - there ien very clearly<br />
one thing that we should do first, and that : is strengthen<br />
the Pcderal Trade Commission's s.uthority to enforce its Rule<br />
requiring r cautiona.ry statemcn t i.n u1l cigarett e labeling :<br />
and advertisiny, .<br />
]sefore the ci.Farotte manufacturers could be compelled<br />
by ]aw to coiip] .y with the Commissi .on's Rule, it io almost<br />
certain that there would be protraoted litigation to test<br />
the Conmiission's authority to make such a rule . Such l .iti-<br />
Cati.on could delay the effective ctate of the Rule for some<br />
years, and i .n this period the public would be without pro-<br />
teeti.on .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
.<br />
.<br />
jcn6<br />
1798<br />
Congrv'ss, however, can elimi.nate al.ll question of the .<br />
Cor:rrnission's authority to r :oke its Ku :l .e by expressly<br />
enacting the requiremer,ts of the Rule into a law . This,<br />
in effect, i.e: the aunrorrch taken by Scmat.or Heuber{;er's<br />
bi1l . S . 547, whieh thi.s Committee han under consideration .<br />
9'he other [,i.7.]l under consi.deration by this Committee,<br />
Senator Magnuson's bil] . (S . ;t59), takes essentially the<br />
samc; apt,r~ach, but it is limited to labo :lirrg .<br />
Chai.rrnan Aixon oft.he Federal Trade Commission has<br />
testifi .ed -- and I think any ] .aryer considering, the quest9 .on<br />
ohjectively mou7d agree -- that the Mapnuson bill would<br />
].eave uudist .urbed the Cornn•.ission's uuthori.ty to enforce<br />
that part of i .ts Trade Regulation Rule which requi.res a<br />
caut.ionary stat'ement in all cigarette advertising .<br />
7 favor the auProach taken in S . 547 . But if Congress<br />
acts only on the labeling proftrant, then it shou] .d use S . 659<br />
to do so .<br />
One point requi.r•en special emphasis : Legis] .ation<br />
proventinF tlro F'edoral Trade Conmrission from reMulati .ng<br />
eigar•ette adverti .s :ing would be directly contrary to the<br />
pub]ic welfain in view of the grave health hazards of ciga .<br />
rettc: smoki .ng .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
There ir; no justi.fi.c :ati .on for puni .shing the Commission<br />
for promptly applying ge.nere. l consumer-prot.cetion ] .eptislation<br />
to ciFcrette advert :ising . The result of such punitive
•<br />
•<br />
ion7<br />
legisl.ation woulA he comple.t:el.y anamalous . It would di6--<br />
courap;e the C.ornmission from taking needed steps in con-<br />
troversia] areas in the future<br />
.ssion would remain . The Commi free to enforce its Fenerall<br />
consurner--protecti.on legi.sl .nt :ion by requiri .ng in a advertising<br />
an affi.rma.ti.ve statement whenever, for exaimple, a sell .er's<br />
motor oi .l was reprocessed rather than new, or that the<br />
1199<br />
advertised product was of foreign rather than domestic origin .<br />
Ru t the Commission would no l.onger have the power to<br />
prevent consumer deception regardirrg c :i .gare t:tes . It would<br />
not require disclosure in cigarette advertising that cigaret.te<br />
smoking is hazardous, despite the consensus of medical opinion<br />
that cigarette smoking i.s dangerous to health .<br />
The CornmS.ssion would be powerless to act, even though<br />
in its Trade Regulation Rule nroceedi .nt; it made painstakiuf;<br />
findings - whi.ch have rrot been controverted --- that the<br />
tx:quirement of a cauti .onary stat
•<br />
•<br />
Jun<br />
involved danr;erous to health .<br />
Legislation dea]ing wi .th the rnarketing of cigarettes<br />
in ]i.Cht of the heal .th hazards of smoking has its origin,<br />
of course, in the mounting public concern and the now<br />
overwhe] .ming evidence that those dangers are real and not<br />
me rea.y conjectured .<br />
Por such ]egfs].ation to include any provision that<br />
would prevent the Commission from exercising its authority<br />
to prevent deceptive cigarette advertising would be a<br />
regressive step .<br />
]t would mean that Congress was curtailing the<br />
Commi.ssion's authority with respect to the adverti.si.np, of<br />
this commodity, and this commodity alone, despite public<br />
concern and medical evidence that : cigarette smoking is<br />
lsoo<br />
dangerous . That, surely, would be a paradoxiea l and untenable<br />
resu7t .<br />
T, therefore, urge thi.s Committee and the Congress not<br />
to accede to the powerfu7l pressures being applied by those<br />
who have a P take in ihe unrestricted sale and promotion of<br />
cip;ar•ettes .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
ConP,ress should not adopt le g islation that would curtail<br />
the Pedera] . Trade Commission's authori.ty to require truthful<br />
cigarette adverti .s:ing . I would urge this Committee and the<br />
Congress to support leF.islation that strengthens the Corn-<br />
rsission's authority i :o protect the public against unfair and
•<br />
•<br />
•<br />
on9<br />
misl .ceiding cigarette advertising .<br />
I do na t me an to ].eavc the impressi.on t.hat I regard<br />
a warning statement in cigarette adverti .si.ng and l.abeling<br />
as a completc answer to the proh] .om of cigarette smoking<br />
and he.alth . The Dri.tish, for example, have banned a11<br />
cigarcti.e : advertising nn television, and ar•e studying<br />
l.initati_ons on advertising in other media at the present<br />
ti.me . Ras: :icaJly, horaevmr , the problem is one of education,<br />
and this wil7 be a difficult task .<br />
Ci garetto smokinC is attracti .ve to young people as a<br />
]&ox<br />
sign of matur.ity and sophisti.cation, and the cigarette habi .t,<br />
once aoqui .red, is very difficult to M e ak .<br />
if there ir, to he any hope of c :hanging the smoking<br />
hnbi.ta of Ameri.can youth, it is assentia .]. That some restric-<br />
tion be pl.accd on cigarette advertising . Just as ci.garette<br />
adver t isinR nv,ny years ago mado cigarette snioking by women<br />
soci .al .l.y ac:eeptable, .^.o contemporary ci.garette advertising<br />
hcis e.ouf(ht and secks to make cigarette advertising the symbol<br />
of adult and sophi.sticated life, and as such an ir re sistihlc<br />
attrar.ti.on to many young poop] .e .<br />
Thc: minimum restrietion on sueh adve,rni .si .nt; is to requir•e<br />
the inclusi.on of a wnr•n :i.ng statement in alll cigarette adver-<br />
ti.sinq, euc.h a restri.crt :ion holds out €ome hope, at l .east, of<br />
re.duci .ng the effecti.veness of rui .sleuding cigarette adverti .sing .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
But it is en].y a srall fir!xt step in the campaign of
•<br />
•<br />
JOnJII<br />
pnb7 .i.c education that i.s nececsarY i .f we are to dea]l<br />
effec7:i.ve7y with the probaem of ci .g-r..rette eanoki.ng and hca7th .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
c-1 1803<br />
itHODN'. ISI .AND f1OSPITAL<br />
PROVIDENCE, RHODE<br />
March 26, 1965<br />
Sonator John 0 . Pastore<br />
201 po[ :t Office Annex<br />
Provtdenco, R . 1 . 02003<br />
Uear Senator pnstore :<br />
ISLAND Lloyd L . Hughes, Executive Director<br />
My conti.nui.ng experience with the tragic problem of<br />
advanced, untroatable lung cancer has prompted this urgent<br />
letter . Your positiou as a raomber of the U .S . Senate Commerce<br />
Committee afforc?s you an unucually good opportunity to pre-<br />
• servo the lives of many thousands of people who now smoke or<br />
are about to ini.tiate this habit .<br />
I would ur€YO your strong support of Senate Bill 0547,<br />
Introduced by Senator Ma.urine Neuborger of Oregon, with<br />
Scnator Clark of Pennsylvania, "TC confer upon the Noderal<br />
Trado Coamnission the power and duty to regulate the advHr-<br />
tiuiuC andlaboli.ng of' r,ig[±rettoc ." It is vital to the<br />
itnproverae~at of the hoalth of .all Ame•ricans that this bill<br />
bccomo law for the following reasons :<br />
• 1) 'fhe causative rol .ationshi.p between cigarette<br />
rmol:ing and lutng cancer is a raattor of established sciontific<br />
Sact .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
i) '1•ho cli.nfcltll courso of chronic pulinanary dtseaso,
•<br />
•<br />
•<br />
c2<br />
spocifically chronic bronchitis, brouchioctasis and<br />
emphysema, is greatly exacerbated by cigarette smoking .<br />
3) besides the inoe,tirnable econornic: loss through<br />
i.l.lno&s from ehronic pul .amnary disaas e and cancer, the<br />
combined death rato of these diseases, including cancer,<br />
oxceedr. 300,000 persons por year . Many such deaths are<br />
premature because of inc:reased early pulmonary damage<br />
resul.ti.nLt from excessive smoko inhala.ti .on .<br />
4) In spite of the excellont educational programs of<br />
the American Canccr Society many people havo failed to<br />
1804<br />
gra.sp tho significance of the rolationship between cigarette<br />
cmoki .ng and pul .monary impairment, including bronchiogenic<br />
carcinoma . A law which would influence cigarette consump-<br />
tion by specfe .l labelling of the product as woll as its:<br />
advertising, supplies authori.tY through our government<br />
organization which so often has assisted people in health<br />
matters 1n tho past . There should be no greater hesitancy<br />
for defining and label .ling the toxicity off a tobacco product<br />
than for informing the purchaser of many proprietary<br />
medi.cinos that excessive use is dangerous .<br />
5) The potential harm from cigarette smoking lios<br />
primarily among the very young . Cigaret.to advertfsing !s<br />
obviously directed toward the young and lmprossionablo among<br />
our peoplc . It in the advertising that is scrutinized by<br />
the viewer rat.her than aa almost il7.egil :.le label on a<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
cS 1R05<br />
cigarette package . Thereforo, it is essential that proper<br />
warning be attached to all advertising with special concern<br />
for the potently effective television mcthods . Failure to<br />
regulate the often misl.oading television advertising of<br />
cigarettes renders a specific disservice to our young people .<br />
Al.though it is clear that Senator Neuberger's bill<br />
would properl .y embrace the entire problem, a second bill,<br />
introduced by Senator 6^.agnuson (5 .559) a.lno merits support .<br />
This bi .l l reryuiroe a w[:rniug label on cigarette packages<br />
but nmits reference to advertising regul .ation . It is my<br />
opinion t:hnt Congrets aatst ultiraately pn.ss laws to regulate,<br />
through every channel, the distribution of a noxious product ;<br />
hovover, it is possible that package labe).).ing will precede<br />
broader regulatory measures . Thoroforo, I urge your full<br />
support of Senator 6lagnuson's bi11, 8 .559 .<br />
During the pas t yoar an oxporimental Smoking Deterrent<br />
Clinic has operated at Rhode Island Noni:,ital under a grant<br />
from the Rhode Island :;tate Health Department . It has bonn<br />
siuocessful in assieting 50% of our candidates to give up<br />
smoking . Tho reviarkablo i .mprovement in physical well-being,<br />
with speoial emphasi .s on improved pulmonary function has<br />
boon very impressive . We have gained the distinct impres-•<br />
siou that among the maJority of people, both from within<br />
our clinics and from among their many Exi.ends who have not<br />
applied Ror aeeis.tance, there is an incr.•easing conv iction<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
0<br />
c4<br />
of the harmfulness of cigarette smoking and the need for<br />
discontinuation of this habit . There is; especial conoern<br />
by adults for the welfare of their children and they plead<br />
for assistance in preventing the initia t ion of the smoking<br />
habit f .n teenagers or in discontinuing this rocently-formed<br />
tcmage habit . Therefore, it seems a17l the more Important<br />
that the atachf.nox•y of government be placed at the full<br />
disposal of the people through proper laws to regulate the<br />
advertising and labelling of cigarette products .<br />
Yt is my opinion that it is the du .ty of science and<br />
government to inform our people, and to assist thom in<br />
every possibYe way towarde the practice of good health<br />
ha.bits .<br />
Sincerely yours,<br />
n/ Louis A . Leone, M .D .<br />
t/ Louis A . Leone, M,O .<br />
Director<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
liept . of Oncology<br />
1806
•<br />
•<br />
c••1 1807<br />
CONORRSS OF THE UNXT817 STATRS<br />
House of Representatives Washington, D<br />
Doar Mr . Chairman :<br />
. C .<br />
March 26, 1965<br />
James H . Quillen<br />
First District, Tennessee<br />
Thirn is with reference to 6 .597 by Senator Neuberger,<br />
which would impose special restrictions on the advertising<br />
of cigarettos .<br />
I hove boen advised of the position of the American<br />
Newspapor Publishers Association on th1 .n measure, and I<br />
agroe with their views wholeheartedly .<br />
Since cigarettes o .re legitimate articles of commerce<br />
and tho tobacco industry is an important segment of our<br />
economy, the fundamentall questions of constitutional lavi<br />
as well ae of public policy are raised when the Government<br />
sochs to regulate the right to publish advertising eon-<br />
oorning legitimate articlos of commerce .<br />
Fach publisher has the right to deterllline individually<br />
the content of his newspaper ; and, if this legisl.ation uow<br />
proposod ehould bo onacted, the precedent would be ostab-<br />
. .. c.L. . . . ., .a . ., . .,. . .. . .. .. .. . . . . ..o .., .. . .,. ., .. . . . . ., .., right ., f<br />
nowspnpers und other media to decide their policies as to<br />
the content of advortie,omonts which they wf.ll accept for<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
c2<br />
Oub7.ication .<br />
I would deoply npEneci.ate your sorious consideration<br />
of thi .r.. matte:r, e.nd I vrill be grateful for your advice .<br />
SinCe}'OY .y,<br />
s/ Jnmos R . Quillen<br />
fton.orablc Pde.rrcn G . Magnuson<br />
Chr:i.rmn.n<br />
Senate Co minerce Committee<br />
Room G202 6oneto Office f3uiYding<br />
Wanbington !5, it . C .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1808
•<br />
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S9'AJ91M71MP OF DI : . IIttWRy T:AB'1'0`J McMAilOI!<br />
] mm Dr . Ilerry f :ar;ton McMahon, a practiein8 special .ist<br />
in heart di.seasc in Now York City . I was Pormerly chi.ef of<br />
t:ho card.i.ec cli .ni .c of St . C1are's Posp :ital, New York and have<br />
boon af :soci.ated with cardi .ac ciini .cs in Bellevue, St . Luke's<br />
and New York Fo7yclinio liospitals .<br />
1809<br />
Por the past 26 years I have served as cardiac consulta n t<br />
for a nurabcr of business firms and industrial unions which<br />
has piven rnc the op p ortuni .t.y to examine, and treat people<br />
from a wide range of oceupations from sand hogs and miners<br />
to Me:disr»i Avenue mrocutives .<br />
During WorJd War ):T 7 served i .n the United States Navy<br />
and was in charp,e of the cardiae servic< : at the (1 .9 . Naval<br />
Ilospital, BroNc7yn, How York, the U .S . Naval Hospi .ta l and<br />
U .S . Marine Corps Rase, San Diego, California and aboard the<br />
U .S . 'rlaval llospi.tal Ship "ConsoZati .on" (now the "Ilope") .<br />
]b] .lowi.ng vry re]eose from duty with the Navy I became<br />
i :hr, fir: :i: me.cti .e.al direction of the United 1Jations .<br />
I on : a P'c71ow of the American Co7 .Yege of Chest Physiei.ans<br />
and Amcri .can Co17et;e of Cardiology ; past president and prrsent<br />
Chairmau of the Ilaw York Cardi.olohieaa Soci .ety, charter member+<br />
of' th e t/orl.d Unalth Orp,init.ation, Vi.ce -dlhairman of the Counci .]l<br />
on Cardi.ovascular Diseases of the American Col] .ege of Chest<br />
Physiciaos and Chai .rn .an of the Commi.tte e on Aehabilitation in<br />
Cardiovosculam hiseases .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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]el0<br />
7 have Lecn Associ . a.ite Cl .i.nical Professor of Cardiology<br />
at the ?7ew Yordc Medi.cal Col]eF;c and am present] .y l.ecturer in<br />
Cardiology at the qew York E'o7 .yelini .c Pfed :ical. School, one of<br />
the ol.dest post-gradu-r,te medical school^. in the country .<br />
As a physie.i.an with more than 30 years of experience,<br />
7 hrive deve].oped some opi.ni.wns concerning the importance of<br />
vari.oues factors i .n a patient's life hi .story in relation to<br />
cardSovascular di.sease and, particularly, coronary sclerosis .<br />
I think it i.s well agreed among physicians in my<br />
specialty that the cause of arteri.osc:lerotic heart discase<br />
i.s unknown .<br />
6a.sed on my cl.inica7l e:xpericnce ar,d my i.nterpretation<br />
of the medical literat.ure, I would also say that there is<br />
no ar.eep'table evidence that a causa7l re] .ati.enship exists<br />
between cigarette smoking and coronary heart disease . I do<br />
not Le] .i.eve that by di.scouraginp; cigarette srnoking we shall<br />
reduce the incidence of this disease .<br />
lt is my further opinion that it is misleading to i<br />
.nfornn the puU] .i .c that they may avoid or minimize their<br />
chances of deve].opi-ng heart disease by avoiding or discon-<br />
ti .nui .nr smokir,g .<br />
Those who contend that smold ng is an important factor in<br />
the devel .opment of cardiovascular disease, relate its effects<br />
princi .pal .l.y to coronary artery disease, the most frequently<br />
fatal form of heart disease .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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Ilowever, it nmst be remembered that thi .s c]isease has<br />
]onPg been considered a part of aging and that there is_a<br />
recoFni .zed age group in which arteriosclerosis and coronary<br />
sclerosi.s are prone to occur•<br />
1831<br />
Arteriosclerosis is a genera]l arteri .al conditi .on usual] .y<br />
mard fested throughout the system of the subject, but more<br />
advanced or marked in some parts of the body than in others .<br />
Thus, in some peopl e arteri.osclerosi.s is manifested by<br />
symptoms refcr•ab]e to th e brain, in others by symptoms of<br />
the 7et;s and in stil] othe rs by i .nvolve,c•ient of the kidneys .<br />
Coronary e,olerosis, t :herefore, is only an anatomically<br />
srna] .] p :nrt of the over•a]], generalized arteriosclerotic<br />
picturc .<br />
Now I do not think we have any evidence that cigarette<br />
srnoki .ng ccrose•a hardening of the arteries throughout the<br />
entire body . Unless it is estab] .ished that cigarettes have<br />
this effect, it is di.fficult to understand the basis for any<br />
assertion that smoki .nE is responsible for coronary sclerosis .<br />
There cire a nurnber of condi .tions or factors which ar< :<br />
statisti .cril .].y associ .ated with the development of coronary<br />
sclerosis . Among thes e it seems to me that a family history<br />
of heart disease appeea•s to he the most outstanding .<br />
It does seem ylausi.ble that a person's future health<br />
pattern, as regards constitutional disease.s, may be "built : i .n"<br />
on his arr.iva]l into this wor7d because of his inherited<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
c:onstitution, body structure, familial tendencies to<br />
certain diseases and so forth<br />
.i_nical. research has confirmed .Cl that high blood<br />
pressure, high bl.ood cholesterol and various other dis-<br />
orders of the blood and circulatory system tend to run in<br />
families .<br />
]81 . 2<br />
].ac:k of exercise has also been statisticall associated<br />
with coronary sc]erosiec . Studies of inen in particular<br />
occupation grouna indicate that those who are sedentary<br />
develop coronary disease more fr oquent]y than those who are<br />
physi.cally active .<br />
Another characteristic which is statistically associate d<br />
with coronary disease is overweight or obe:stiy . l find that<br />
when hypcrtencion is present, weight reduction is usually<br />
followed by a]owerinE of the bl.ood pressure .<br />
A great deal of rd:tention has been called to the<br />
statisticr,] assocmation between cholesterol in the diet<br />
dorived from eatinp, meat fats and dairy products and coronary<br />
sc]erosis .<br />
I am uncertain of the relationship between hyper-<br />
chol.estero]emi.a and arteri.osclerotic heart disease, but I<br />
have found that patients with high cho]este rol level.s feel<br />
bett¢r when their cholesterol is brought back to norma] .<br />
Based on experience, stress seems to be the most<br />
important preci.pilat.in8 or triggering factor in the<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
jonS<br />
development of a coronary heart attack . This would<br />
i.nc7.ude the str•ess of hard physiea]l labor as well as<br />
stress of the mind, nervous system and emotions .<br />
In my<br />
practi .cc, stress has been the common factor in nearly all<br />
cases of coronary thrombosis that I can re :call .<br />
P]hi.le the use of tobacco may be a symptom of stress,<br />
in my judpmen't smoking is not causal.ly related to coronary<br />
throrebosi .s .<br />
I have not observed any difference in the clinical<br />
course of a patient with myocardi:a]l infarcti.on which I can<br />
relate to previous smoking habits .<br />
One of the principal di.fficulti.e& in attempting to<br />
study coronary sc]erosi .s is that its manifestations are not<br />
a.l.ways apparent .<br />
]0]3<br />
It has been referred to as an "iceberg disease" because<br />
its cl .i.nical signs are often only minor evidence of the under-<br />
lying condi-tion which may be oir ;reat magnitude .<br />
Some people are hardly aware of the pain and other<br />
sympt:oms of' coronary insuff'iciency ; indeed, some peop]e may<br />
even have a marked myocerrdi .al infarctiLn and be unaware of it .<br />
3 can reca].] half a dozen of such cases in laborers picked up<br />
by e?ect.rocardi .ographic study on the occa[ :i.on of a periodic<br />
heaith examination .<br />
Decause of the di.ffi.cu]ty in di.agnosi-ng coronary disease,<br />
findings basod on surveys of the incidence of coronary disease<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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among various segments of' the population are of questionable<br />
signi.fi.cance<br />
think . I that many worthwhile efforts have been made i n<br />
searching for the cause or causes of arteriosclerotic heart<br />
disease by clinici.ans, rese :arch physiologists and chemists ,<br />
A81 .4<br />
natho]oP:ists, roentt;enologi.sts and statisticians, but we have<br />
yet to find the cause or causes of this disease .<br />
I find no reason from the evi.dence at hand why we should<br />
at thi.s parti.cu]ar point in time act to discourage cigarette<br />
smoking on the presumption that this one factor has been<br />
discovered to bc of importance in respect to heart disease .<br />
The evicknce to date does not furnish any sound basis<br />
for such a conclusion, but rather i .ndi.cates a need for<br />
continuing theresearch effort with the best resources<br />
availabl .c<br />
. /s/ Dr . II . g . McMahon .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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STA'1'liMtiN'1' OP IAN MACDONALD, i1 .ll .<br />
My name is Yan Macdonald . I am a surgeon, with the<br />
del;rce of M .D ., C,M ., fbotn McGi .11 University, received in<br />
3928 .<br />
Fnr 24 yc.ars I have been associ.ated with the School<br />
of Medicine of the Uni.versity of Southern California, where<br />
]: am C].i .nS.cal Professor of Surgery, and for 10 years I wac<br />
Coordi.nator of Cancer '1'eactri .ng .<br />
Since 1955 my cli .nical work has been limited to the<br />
1615<br />
treatnient of cancer and allied diseases, both by surCery .<br />
and radiation therany, with certi .fi.cataon as a specialist<br />
i.n racliotherapy by the American 13oard of Radiology in 1938 .<br />
cancer rescarah, 13 have beon the re.sponsibl .e<br />
inve. .^.ti.gator in various pro-jccts at our Schooll of Medicine,<br />
Chairunan of two nati .onzl, oooperati .ve research groups, a<br />
rnrrnber of the American Association for Cancer Research and<br />
of the Cormnittee on Cancer of the Amerioan College of Surgeone. .<br />
I arn a member of other sur•gi .cal, ractiologi.c and medi.eal<br />
soc :ielie :;, a former Officer and Di.re etor of the Ameri .e
0<br />
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of cancer<br />
. 7n Ju].y 3957, as an invited witness before the<br />
Subcomrnittee on Legal and Monetary Affai.rs, Comrnitteeon<br />
16)G<br />
Covermncrrtal Operations, House of Representatives, I expressed<br />
nry conviction that "the totall evidence fails to provide a<br />
cause and effect relati .onshi.p between . . .the smoking of<br />
ci .F,arettc:e and the development of lunft cancer in humans ."<br />
flow, near] .y eight years later, I have examined the<br />
published record of my testimony and f:ind uo significant<br />
detail which req ui .res moc]i .fi.cation<br />
.though the causati.on of lung . A] cancer remai .ns as<br />
eni.gnatic and aes complex as ever, i .n the past several years<br />
a nurriber of pnb] .i.shed reports have emphasized the variety<br />
of factors in the background of individuals who develop this<br />
form of cancer .<br />
This expz,ndin n evidence of a constellation of factors<br />
associ.ated with lung cancer )ends no comfort to the advocates<br />
of a si.ngle i .n.Pluence -- that of cigarette smoking -- as the<br />
"principal ca vse" of the disease .<br />
In fact the inconsi.stenci.es surrounding this cause-and--<br />
effect thesis have becorne rven more numerous than i .n 1957 .<br />
Some of the mere notable, recent contr :i-buti.ons on the subject<br />
will be cited shortly .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
"CONTRT.[sUTORY" pACTORS IN CANCER
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7817<br />
certain Types of cancer may indicate a morr. frequent assoei .a-<br />
ti.on with some factor, or factors, than in control, non-<br />
cancerous F,roupF .<br />
If such an associ.ation is i .mpressi.ve as determined by<br />
statisti .ca]l anal .ye.i.s, the background fac.tor may be referred<br />
to as a"contr:i.butory" influence in the development of the<br />
specific cancer .<br />
The propriety of such a concept is questionable, and<br />
for the fo]lowinfC rcasons :<br />
present .<br />
- In no forn of cancer is the associated factor always<br />
-'1'he camcen• can and does develop in its absence .<br />
-The factor may be present in l.arge numbers of persons,<br />
only a very few of whom develop the cancer in question .<br />
6uch is thc "relationship" between the smoking of<br />
cigarcttee and lung cancer .<br />
1'rans]ation of "Contri .bution" to "Cause"<br />
As rK.petiti.ous statistical studies in this and other<br />
countri .es becane pyrami.dect in an i .nternational., hi.gh-rise<br />
statistical unani.mity, the associati .on of cigarette smoking<br />
and lutg caneer became t.ranslatcd into a cl.aim of cause and<br />
effect . .<br />
When, in i:he laboratory, cancer appeax e d, albeit rr.l.uctantly<br />
in the skin of nice g,enetical]y prone to skin cancer, after the<br />
app] .i.c:ati .on of unrea].ist.i.c concentrations of tobacco tar, some<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
propegcmdi.sto abandoned a7.1 reserve to describe ei.garette<br />
srnokinF, as the "pri .naipal cause of' lpnp, caneer ."<br />
Pcne Dubos recently has commented on the unsolved and<br />
cornp]cx problems which concern man and his envi .ronment, by<br />
sayi .ng : "A]]3 pr•oblems o f the ]iving organism, in health<br />
and di.r,case, are prob) .em^s of or• ganized complexity . The<br />
r•educti.w~i.st aporoach (is the) ana].ysis of oversimplified<br />
systems .invo]vinp only one variab] .o ."<br />
Ilo more dreunatic il.lustration of these words can be<br />
offerr.d 'i:han the attempt to explain lun g cancer in terms of<br />
a single variab]e, created bp statisti.cal il] .usion .<br />
PEC)]H9' PtipOPi'S OtJ LUNG CANC] ;P .<br />
1818<br />
'1'he past severa7l years have been marked by the pub].i.cation<br />
of some careful studi .e.s with conclusions which are in direct<br />
conf]ict with the notion of a tobaceogenic causation of ] .unr<br />
cancer .<br />
keference to sonie of the morr i.mportant of these i .nves--<br />
tigati.ons is approyrie0.e here .<br />
rrom Merc:y tlospi .ta]l in Pittsburgh, Joseph A . Perrone<br />
has reported on 7.,000 cases of lung cancer . He emphasizes<br />
the variety of background factors, concludes that : .<br />
. .,srnoking cannot be implicated as<br />
the rna`ior cause of Jung cancer ."<br />
Of these 1,000 cases, 42 percent were nonsmokers ; of<br />
')BU male pati .ents:, 26 were nonsmokers, and 77 percentt of'<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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41.6 women with ).uh£g cancer had never smoked .<br />
Dr . Perrone concl.udes that three fnctors are of<br />
paramount impor=tance in contributing toward the probability<br />
of lung cancer :<br />
OCCUPATION .<br />
AIR POLLUTION<br />
liCONOMIe 8TATUS<br />
Of the seven occupations most frequently pursued by<br />
these patients with lung cancer, five involved exposure to<br />
petroaeum products and their combustion in automotive equip-<br />
ment, both of internal combustion and Diesel types .<br />
Of the 300 men involved in the seven most frequent<br />
1819<br />
occupations, which included coal miners and painters, 59 per-<br />
cent were nonsmokers .<br />
n r,<br />
An i.mportant contribution in the German literature is<br />
the report of a meticulous study by two pathologists at the<br />
Pathologi.cal Institute in Dusseldorf (POche and Kneller),<br />
with the aid of a biostati .stician (17ittman) .<br />
The study was based on 1 .,229 patients with lung cancer<br />
proved by mi.eroscopie examination . The questionnaires which<br />
produced the i .nformation were completed by physicians only .<br />
Factors found to be of significant influence, statistically<br />
tested by correlation coeffi.cients were :<br />
URBAN R}<br />
;SIDIINCE OCCUPATI OiJ<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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BackFrouud factors of no .^,ip•ni .fi.cance included the<br />
smoking of cigarettes . In fact, the heaviest cigarette<br />
smoki .nR was in the occupational group with the lowest<br />
i .nci.dence of lunft cancer (office workers, teachers and<br />
other professions, clerks) .<br />
A di.fferent approach was used at the University of<br />
Gror,i.nP.en, i.n which the interest of the investigator<br />
(Aona M . Der Wal) was focused on the association of prior<br />
chronic disear.es of the lunP:s with the devel.opment of pul-<br />
monary cancer in ]ater ]i .fe .<br />
smoking .<br />
She otrta lned infonmation from three se0aratc groups :<br />
1 . 150 patients with lung cancer .<br />
1620<br />
2 . 150 control persons, no t matohed for ci .garette<br />
3 . 100 controls carefully m.atched with the lung<br />
cancer nati .errts for smoki .nr habits .<br />
This, too, was a sophisticated, st.atistica]ly controlled<br />
study . Some of the pertinent conclusions were :<br />
- therc is a highly significant re:lationehip (P(0 .001)<br />
between chronic )unp, diseas e and lung cancer :<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
- this ra] .ati.onshi .p is independen i of smoking :<br />
- the number of ci garettes smoked (10-20 and > 20)<br />
n ,: n<br />
From the Ori.e:nta] medi .cal literature, a report by a<br />
:
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Japanese chest surgeon (K . Kaiho) concerns 1.,659 cases of<br />
1827<br />
lung cancer . About 80 percent of these pati .ents were smokers,<br />
but 83 percent of a control group of non-canoer patients were<br />
devotees of the weed .<br />
llc found nodiffererwe in the proportion of heavy smokers<br />
among the patients with lung cancer and patients without<br />
cancer .<br />
There was a high fami .lial predisposition to cancer in<br />
general in the relatives of lung cancer patients .<br />
'1'hi.s author believes that the low oat .i.o of male-femal .e<br />
lung cancer (4 :1., compared to about 6 :13 in the U .S .), is<br />
evidence that external factors such as smoking are of little<br />
importance .<br />
One of his definite conclusions : there is no relation-<br />
ship between smoking and lung cancer .<br />
i: S. 1 G<br />
A Chinese Clinician (J . -S . '1'sai) has reported from<br />
Pekin on 252 patients with lung cancer . The most unusual<br />
feature of his group of patients makes them, to our knowledge,<br />
uniquc : There was "no great difference" in sex incidence .<br />
Only 62 .5 percent ofthese Chinese patients were smokers .<br />
In the southeastern area of South Dakota, during a<br />
t:el.vc year period (1949 - 1 .961.) only thir•ty-three cases of<br />
lung cancer were recorded in the Tumor Reg:istry of the Sacred<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
jon7<br />
llcart IlnsPita] in Yanki:on, rnakinp, it tenth in order of<br />
frequency in this non-industria] i v.ec] area .<br />
This part of South Dakota thus registers annuall y<br />
]62 2<br />
less than 5 new 7ung cancer patients per 3 00,000 population,<br />
comparcd to less than 3 5per 100,000 for the U .S . at laree .<br />
i'his di"sparity cemnot be credited to a lescer proportio n<br />
of s mokers in this agriculturr.l area, as will be evident in<br />
a comparison with the Pittsburgh seri.es rn"ported aUove :<br />
Smokerc 571,<br />
ton 51JOke r6<br />
IAIIG CAIICCR CASI'S<br />
_ . . .<br />
VSatsi~urph, _Pe S .L Soufti llakot a<br />
52 8<br />
42% 48 %<br />
Pre viou :: comparisons of this sort have demonstrated the<br />
some laCk of any correlation 6ei:ween fnokinl5 and the prevalence<br />
of lmr7; cancer .<br />
Some yearc aTO a oompar.ison of the State of New York<br />
and Tdaho showed equal Was of oi garet te :; per oapita, with<br />
a rnortal.ity from lunP, ca.nccr four times greater in the more<br />
dcnsr.ly populated, hi.ghly industriali7.ect Ftate .<br />
n . . . .<br />
The Canadian I'u61 :i.c.Iloalth Service is concerned with<br />
an aborip;ina] popu7at'i.on far removed from our "civi].i.zed"<br />
w.rys of 1ifc .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
In rcccut yeare, X-rny survey taans have eombed the
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Canadian Arctic:, mainly in a search for pulmonary di.seases .<br />
Hot a si<br />
.nglc case of lunE cancer has b¢cn found in the Fskimo or lndian popu]ations, yet nearly a]Jl of them are<br />
heavy smokers, usually of cigarettes in recent decades .<br />
4 tr<br />
A feraale popu]ation with no signi.i'i_c,r,nt experiencein<br />
smokinp, ., but with a lung cmncer i .nci .dence which rnay be hi .P,Ler<br />
than in U .S . women in i;enera7., has besm t:he subject of a<br />
report by J . T . Nix .<br />
At the '1'ulana 6io-Medica] Center, with sponsorship by<br />
the 1Jational ].nstitutes of Meelth, Doctor Nix has set up a<br />
corrCinuirrg study of mortali.ty in ] .16,173 nuns, as collected<br />
from Catholic Ilospitals in the U .S . and Carrada .<br />
In his pre] .iminary report, 1 .04 percent of 575 deaths<br />
were duo to verified lung cancer . Shou3d this rate be main-<br />
tai.nod in a signi.fieant sample, the lung cancer mortality<br />
rates for nmis would approximately 10 per 100,000, compared<br />
to 4 .9 per 300,000 f-emales in Upstate New York .<br />
'J'he mystery deepends if one recoSnizes that the majority<br />
of these re]iF.ious do not have the same e xposure to environ-<br />
mental influences as does the average woman .<br />
Si gn,ific:anee of "Rccen t ReporCS"<br />
Seven of the rec:errt: reports just cited provide i .nforrna- ti<br />
.on on samp]es of experi.ence with lung cancer, numbering in<br />
ell . 4 .377 pa'i.Ser,ts with this disease . .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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I :ach of these rcports includec the resul ..t of anincluiry<br />
i.nto a possible relationship of smoki.ng with lung ca.ncer,<br />
i.n sovcral i.nctancps with sophist.icated techniques in<br />
biemetrio control of the data .<br />
In none of these studies was a cr•edib].e or signifioant<br />
rolct.ionstd .p established between smoking and ]un g cancer .<br />
dy corrtrast, the conc]usi .ons made in "Snoking and ilealth,"<br />
the Reportt of thc Advisory Committee to the Surgeon Genera7l<br />
of the Pub]i_c Ilealth Service (Pub]ication ao . 1103) was based<br />
]argely on seven prospectivc studi .es, w h ich provided data on<br />
a tota]l of on]y ],984 cases of lung cancer (page 164) .<br />
] :ar1y in 1864 an l :di .tori.all in the Journal GRO'.J'17i, in<br />
stating the need for extensive basio r'seareh in ]ung cancer,<br />
oonunerrled on the farnous Aeport :<br />
"As with 03. one-sided statis'fi.cal surveys, the Report<br />
fai.ls tc, take into consideration the complexity of' the factors<br />
invo]ved, and thus invites criticis m to its cmiclusions : ."<br />
Other 01017520.00] lnconsastcncics<br />
When eomparisons are made oftotal populatf .ons, by smoki .ng<br />
and death rates from lunl; cancer, usually no correlation with<br />
cip,arette smoki .ng is evident .<br />
In some i-nstances the relationshin of ciquretie eonsump-<br />
t .i.on and ] .unp, carrccr i .s an inverse ratio : for men, th e uce<br />
of cigarettes in the United Kingdom is about one-half of that<br />
in the United States, but iort .rl.ily from ]ung, cancer is morc<br />
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than twiCe a& p•reat in ] :n{;land arx] Wa1es .<br />
].R?5<br />
blithi.n the U .S ., many compari .sons of States and cities<br />
show cquivalent consumution of tobacco as cigarettes, but<br />
m.orta]ity ratios frocr ]rmg cancer which di .ffer great]y .<br />
Sex Difference in ]ne :dence of _LUnp_ Caneer<br />
I•ew U .S . women smokcd cmti .] . ].930, w}ri .]e recent surveys<br />
indi.cate that 40 ne :rcerri or more of wonaen are smokers . The<br />
major• share in the increased use of ci g arottes since 3930 is<br />
attri.but.ed to wemen .<br />
In spito of these facts, the male-fenale ratio of<br />
mortality from lung cancer has increased from 2 :1 in 1930,<br />
to as: much as 7 :1 in recent years .<br />
Thi.s incrensitlr excess of lun g canCe :C in males is<br />
interpreted by some investiUators as cvidence of an impor-<br />
i .ant hormonal influence - it is surely inconsistent with<br />
patterns of cigarette consWmotion .<br />
TinB?-iJOse hactOr<br />
/1sGur_ll]R that a F-1.Ven sLlbstanCC has Fome carcinogenic<br />
i.nflucnce in an i u a ls, the tine at which a cancer will appear<br />
in a suscepti .b].e individua] wi]] be determined by the tin e of<br />
exposure and the dose used .<br />
Although the factor of susceptibi .]i.ty, as determined by<br />
genel.ic i.nher:its,nee, is by far the most irnoortant inf]uonce,<br />
and a]ihoup,h such 6i .oi .osic i.nteractions are not measurab]e<br />
with rsther°atical3 exaet .itudc, if am adequate samp]e of<br />
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ion]]<br />
i.ndi .vi.duals is exposed there wi17l be a tough conformance<br />
to the ]aw of time and dose .<br />
cancer :<br />
Consider these cri .t.eri.a i .n termi: of tobacco and lung<br />
-"Dose" in m a les since 3920 has increased from<br />
1 .6 to 6 .3 pounds ner capita, 1920 to 1950 :<br />
- Me of exposure has lengthened, due to use<br />
1126<br />
of tobacco earlier in life in the last several decades .<br />
By the ]aw of ti .nm-dose relationship, Yung cancer shou] .d<br />
have shown a distinet t .rend toward peak incidence at an<br />
e.ar] :i.er age i .f cip,arette smoking had any causative influence .<br />
IJo suggestion of any such chanp,e is evident : peak years<br />
of inci.dence of ma]e ]ung cancer remain fixed at 55 to 59<br />
years of age since the first decade of th :is century .<br />
In the broader persnec :ti.ve of general mortality ratio<br />
of cip,arette smokers versus nonsmokers therre a a paradoxica]<br />
time-dose rel .ationship in data found in the Report of "Smoking<br />
and Ilealth" (paRe 87, Pable 6) .<br />
here the mortality rate for all causes, for currentsmokerc t<br />
of cin,6rt:ttes on]y, is expressed in terms of that of<br />
nnnsmokarrs as unity, from the fifth throu g h the ninth decades<br />
of' ]i.fe, and 'ny the n ur iher of cip,arettes per day .<br />
ReP.ardloss of the aruount of smoking, there is a pro-<br />
p,ressi_ve i .mprovement in mortali .ty ratio in each succeeding<br />
deaee of ]if
•<br />
.<br />
jon]i:<br />
of won who are exoessive smokers of 40+ cigarettes dail .y :<br />
Mortali.ty Ratio for Smokers<br />
AC7 : . of 40t C :igcu.ettes _ per _Day<br />
h0 - 49 3 .06<br />
50 - 59 2 .37<br />
- 60 - 69 . 1 .68<br />
70 - 79 3 .28<br />
80 - 69 0 .58<br />
Thi.s natterrn defies the larw of ti ne-dose relationshi .p,<br />
wilh the octoEenartan smoker of 40+ ci .f;rret.tes daily hsvinf;<br />
a NO nercent hetter chance of surviva] t:han hin nonsmoking<br />
fe]loms .<br />
'Phese data sug{;est that the less fesvorable mortality<br />
1827<br />
rerli .os of' cigarette smokers in earlier yea rs are not rel .ated<br />
di re.c.'t7 .y to smok.i.ng .<br />
Perhaps smoking is a beha.vior•a l c.he.ract.eri.stic ef the<br />
younger man who has a]eEiser prob ability of survival than<br />
the noneumoker . dut fcr reasons unrelal:ed to sreokin,v, .<br />
Ttiese ne$at".iVe corrElations with the duration end amount<br />
of nigarctle s6rokinp, provide the basis for two st.atements :<br />
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- the evidence indi.cates the absence of any contribution<br />
of cignrette smoki .n{; in the causution of ]unp cancer .<br />
- the dat.r6 cit'ec] arc ineonsi .stent w ith an inf] .uenee of<br />
C]AarCttL eonfllmiptien pCr so on WoYtallty rateE .
•<br />
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•<br />
1 :XPCR7 .i;lCC F11TII IA :uG CA:ICI:R I ;d '1'lIL COIIi7TY 0}'<br />
LOS NdO1:L}IS<br />
Ai.r polluti .on --- in -----------<br />
tne I .os Angeles 13asi n has evoked an<br />
i.nereasi.ng interest in respiratory diseas :es, and especi.ally<br />
].n lunF<br />
= canoer .<br />
The I,os Angeles County Ilospital has one of the ] .ar/•;esC<br />
]018<br />
autopsy seri .e^, in th v United States, and the niost variegated<br />
f-roiz a racial-ethnSc standpoint .<br />
As now and i.mproved techniques iu di .apnosi .s devel .oped,<br />
1un/; canccr showed an upward trencl at L .A .C .H . for eoma years<br />
unti.l 1958 . Si n ce then, and throu gh 3962, the proportion of<br />
] .un/; cancer in total autopsies has reached a relative p]ateau .<br />
. .9'hr._1 a +-c^st . ._ .+:lahle . . . d .~t. .,for , 19G 3 t„^p .h., . ., . .a^;z,.<br />
. the fixeC . 6.<br />
inci.denee of the disease .<br />
Ltmy, Caneer as Per Cent<br />
Year Ilo Autnp{.?e Lcm~..C~ncer _,of A7 .1 AutopsJ,e_s<br />
1 .950<br />
]969<br />
]960<br />
]96]<br />
1962<br />
7963<br />
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811<br />
69<br />
'13<br />
86<br />
79<br />
67<br />
9'his large scri.es of' autopsies on 7 .ung cancer pati .eits<br />
has made possi .Lle a spcci .al study of microsoopic typos o :C<br />
3 .0<br />
2 .9<br />
3 .3<br />
3 .8<br />
3 .8<br />
3 .0
•<br />
•<br />
turnor, the results of whi .ch are perti.nent to the allegect<br />
cause-andeffect relationshi .p with ci.f;aret.te smoking .<br />
it has becorne an article of faith, among those who<br />
a.dvocat .e this thesis, that the influence of smoking is<br />
roco gnizable in terms of miscropseopi.c studies .<br />
1`pi ;dortant was a more aceurate deteetion of a substancc
•<br />
•<br />
•<br />
jon]5<br />
Oouein) },roduced on)y by glandular tissue : when identif :i.ed<br />
in lung cancer, the tumor must be an adenocarcinoma .<br />
Id3ren t}iis research method was used in the re-study<br />
of the 956 cases, so many of the supposed "epidermoid"<br />
cancers had to bee rn•.olassi.fi.ed as adenooarcinoma that a<br />
now orientation was evident : the proportion of adeno-<br />
caroi.nornas was increasing, espeei50 ly in recent years,<br />
whi.le those of epi.dermoid nature were stationary .<br />
Su this Lar1 ;e . representative group o1' lung cancers,<br />
on the Unsi .s o f improved accuracy in i.denti .f'ic :ation of the<br />
1830<br />
two main types of tuper, the distribution i.s thus completely<br />
i.ncons.istent with the tobaccogenic thesis .<br />
Tho other unusual feature of lung cancer in Los Angeles<br />
deserves comment here . The incidence of the disease in<br />
women of Ilexic am ancestry and birth is almost as great as<br />
in Mexican males, who, in turn, have a slip,htly greater<br />
incidonoc of lung cancer than white males of United States<br />
origin .<br />
Yet, avai).ahle information i.ndicates that the smoki .ng<br />
of ci .p,arettes by Mexic:an -born women is at a much .lower level<br />
than in iho Fenora)l female population .<br />
Por women of 11exi ..can origin, hut born in California,<br />
there is no such excess of lung cancer, althou gh cigarette<br />
smoki .rrf: is rr:orc : prevalc :nt among the U .S . - born than in native-born I<<br />
:exican f¢.ma.les .<br />
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Thi.s synopt :ic di.soussion han, touchect unon only some<br />
of the faoets whf .ch indfcatn the coronlexity of the problem<br />
aihich is 1unPg cancor,<br />
A hmre are other data of si p ni.fi.cance on the relation . -<br />
].83]<br />
shi.p of the discasc to socio-econornic and nutritional factors,<br />
to residcance in Sown and country and the almost unexplored<br />
arca of intrincic influences - horcional, saexual, cnzymatic,<br />
vira] and hercditar,, .<br />
The currrnt, popul.ar eenphasi.s on a s :ingle environmental .<br />
factor, i . .c ., the smokf.n{; of cigarettes, has been shown to<br />
be ineonsistent with the cvi .denee Provided bl' a number of<br />
recent clinice.7, inves'tip,ati.ve renorts .<br />
Cancer of i:he lunA s.canes to be a highly eomplex biolo(;i .c<br />
enigr ,a, thc ba.sio causes of whi.ch, in oomnion wi .th other forms<br />
of cancer, arc as yet unknown .<br />
] :mryhasis on a sinCle environme.ntal factor as a"pri .ncipal<br />
cauee" roduces the prob]em to a narrow concent of causalit .y,<br />
whcn the diseaoe with whi .eh it i.s thus i .dentifi .ed becomes<br />
estah].ishcd in its absenca, and occurs infrequently in its<br />
nresence .<br />
Such substitutions of shadoia for scientific substance<br />
Iany lead to a dcereasect effort in cancer research .<br />
/s/ San !'acdonald, 17 .I1 .<br />
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SH'ATI :MCIIT OP ISRAI :L RAPPAPORT, 19 .D .<br />
7 e m Israel Rappauorl (M .D ., University of Uudapest,<br />
Hungary, 1979, flew York State 13oard, 1921), a practicing<br />
physi.cian specializai.ng in diseases of the chest since 1928 .<br />
Ilaviny served as a visiting physieaan to the Chest<br />
Service of Rellevue Ilospit .a7l from 1930 to 1958, I am now<br />
consulii.ng physician there .<br />
S also serrved on the Facul.ty of Col.umbia University<br />
Atedi.cal Schoo l as Aseoci.at.e Clinical Professor of Medicine<br />
up to nry re tirernent in 1958 .<br />
1 am a].so Consultant to the Chest Service ofGrasslanc7s<br />
ilospita], Westchester County, ^leui York, for many years past .<br />
1: have nublished numerous articles and several chapters<br />
in textbooks on various aspocts of pulmonary diseases,<br />
i.neludi.n g more than 20 artic]es on or related to pulmonary<br />
emuhysema .<br />
These have appeared between ].936 and 1960 in issues of<br />
Annals of Internal Medicine, Diseases of the Chest, Journal<br />
of the American Ncdi .cal Association, and the. Lancet of London .<br />
L'ecause of new concepts which I evaaved on chronic<br />
pulmonary di.sease, the l.ate Dr . J . A . 11i.llor invited me to<br />
jotu his staff at the Chest Service of Oe]].evue Hospital in<br />
3928 .<br />
Uere, on my initiative, Dr . "'iller aaunched the pulmonary<br />
f-unetion rescarch nroject which was carried on by Dr . Richards<br />
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] 832
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•<br />
and Dr . Cournand to world - wide fame, honored by the 7obe1<br />
Prize in 1958 .<br />
'I'he novel concepts about pulmonary emphysema which<br />
]833<br />
i.nspirec7 launching this research were announced (by Dr . J . A .<br />
Iti]lcr) in a uub]ication "Pulmonary Fibros :i.s and L'mphysema"<br />
in Ann . ]nt . Med . in SeUt.ember 1935 and "Chronic Lung Disease"<br />
in November ]938 .<br />
In r, series of subsequent articles, I was perhaps first<br />
i.n drawinPA repeated attent .i.on to the risini; incidcnce of<br />
nuhnonary emphyse pa and chronic bronchi.tis, and in 1957 in<br />
an artic]e in the Journa]& of the Ameri .can Hedical Association,<br />
October ]9G7, 1 drew attention to "ChanP,inC Forms and Causes<br />
of Pulmonary ]nsuffi.ciency in the Present Era of NeAicine,"<br />
exp]aininP, the recent changes in chro nic bronchitis and<br />
emnhysema .<br />
'[n ]9G8 7 proposed the troatmont of acute pulmonary<br />
i.nstfficiency by tracheostomy, which is now a widespread<br />
urocedure used to tide over patients c]anp.erously i11 from<br />
acute comp] .i.cati.ons of chronic respiratory disease .<br />
I fee] that I have a right to speak out on the subject<br />
hcre involved because chronic lunq disease has been a subject<br />
of prime interest to me for over 35 vears .<br />
I am onposed to acceptance of the concept that "ciKarette<br />
smoki.nR is the most important of the ca .uses of chronic<br />
bronchitis in the United States which increases the risk of<br />
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dyinC from chrwn ic bronchiti .s ."<br />
]I am al .so opposed to acceptance of the concept that<br />
a relationsl,i,p exists bet .wecm pulmonary emphysema and<br />
ciFarette smoki.ng "whic•.h a.lthouph not oaus-r.1 leads to<br />
i.nm•eased risk of dying from pulmonary emplrysema ."<br />
My opposi .ti.on is based on the followi.ng two reasons :<br />
(1) It is a fact that the theory of the ]ink assumed<br />
to exist between cigarette smoki .np, and chronic lung disease<br />
2834<br />
refers to the tradit.i .ona l entities of chronic bronchitis and<br />
of pulmonary emphysema .<br />
Protaeonists of this theory acLnit t.ha t we cannot define<br />
and cannot r::corni.ze: these concti.tions olini .cal .]y with any<br />
degree of certainty . The nature and oriCins of these con-<br />
ditions are sti .ll open problems .<br />
The fact that we are now in the process of establishi .nF;<br />
definitions and are now e.eekinF i .nformati .on regarding the<br />
nature and oriP.ins c+f the.se diseases should in itself pre-clude<br />
our maki . n R de•.ci .si.ons regardin g such et.i.ologieal concepts<br />
as that i.mpli.cd in the cigarette smokin£'g theory at least untill<br />
we know what pulmonary, condition we are act.ua7 .ly referrinfi to .<br />
In the foll.owi.n£„ I wi .l]l endeavor to prove with<br />
:i.sts of the cigarette smoke theory<br />
state-ments made by protagon<br />
that they are uncertain about what ] .ung disease smoking should<br />
be ]inked to and that in the final nnaay.^,is, their claims<br />
imply a link on]y with minor symptoms of little clinical<br />
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c-i[`.Yd ;Ficcno.cl rathor than mith any disensc eni :itv .<br />
!?) C7iWa] rgoerience in hospita]s and i .n uri .vatc<br />
prae'ii .oc ove.r ihe : pae.t 40 yeare, const.ant7y oonsidered in<br />
ihe 11£;ht of ihe pasR, mcent and current aitarature, has<br />
laught mc 9hni ohronic ]uny, di .soaso as now observcd ic not<br />
to hc i .Clcntif :iad wi.th the trac7itiona] crtities of chronic<br />
Lronohitis awd e:mUhVSCna .<br />
Tn The. ,fo'q .ooiin«, 7 05 .]]l ene]eavor to show that we are<br />
now conecroed rei .th a discase miti .'ty which has been evo] .ving<br />
durinF the nast hrJf ccntury, bec{'i .nnin n before ciRarette<br />
srrokin0 hccamo wictcsprcad , that emokinr ;rvas not a factor in<br />
this mvo]ut i on - and t.'het recent and current obscrvations<br />
n .fford no drfinite evidence Provinpg tha t<br />
c:ip,arette smokin p<br />
p]ays a c]ceidi.np, or indc
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•<br />
•<br />
Jo:,<br />
I Lzrt ci_garefto ;;rrokinp, ie the chi .efc•nuvre or the only caueo<br />
of chc ct.ie;eu e and l .i t aunple evi.Jenm> i "plicati .nP, other<br />
faetor9 .<br />
Pointing to 1 :hc fact thet death rrrtes Prom chr•oni .c :<br />
2836<br />
blvnchit ;i.s in 'i :he Unitod IGng:dom cro mmny 'Ci .mes F,vexi:or-thnu<br />
in thn U .S .A ., ihcy eoncludc- cu follows. :<br />
' .`:Jric.a ciP.a'rctic conGuim & i .on is va.m'iJar in i .ho two<br />
counU•ios, fectora othcr thnn .^-mo'.< :inR must he i .mpli .cateJ .<br />
Pe,'i of 14 nc > p l,,n[,t5t'm tany bo i .hc diffQrr.lls:es in ,h,giroeP.io<br />
-icr m s: used in thn iwo co :nri'riee, hut 'ihe uxpcrience of phy-<br />
sic . .ns vho T a ve e,ox T cd in hoth coun'ir :ie b lcaver+ no doubt<br />
that e.hr:,rd c hronchi.tit i¢e wuch u:orc prevulent in the Uni .ier7<br />
Alup,bom than in the U,S,q,"<br />
Alihmu.gh 1:nF7.ieh yhyeieinu ; s4d1J spe.~~Y,'v,^nrli.ti.onal .l.y<br />
of eT.ronic bronchiti .s, they ar•o reforrr5 .nf, to a cii .sabling<br />
and foiaa forr of i1: .<br />
1L 7 :n87cmJ the di_racrose in qucsti .on is a very serious<br />
pub]ic heD]RH problem .. :;ince it: cr.u ::re neorJV 10 percent of<br />
i1nc nation8l tunTa7i'iy .<br />
).n a most roomrC nee'?i.nP of the fore,n= ] .unp, sVeci.al-<br />
ie.is: in the Ilnticd Kingdo®, it w•aF inads, c7car thnt this gr•ave<br />
6iseassc ia noi : t .o bc : ideut-lticd with eithcr chr•onic : bronchitis<br />
nor u,ith Du] .monnry emphv"ema, ..n is cus'Ccaiiary in the U .S .A .<br />
in thi.s Svnuok:3.mm it a:ees t,her,°forc proposec7 to des%ate<br />
i9 n cnndit'cD . . 'bhr,n7.o non--le.cifi .c Icrg c .iscoec .°<br />
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1837<br />
Dr . P . ltcid, in a recen4t disc.use;ion of the opidemiolop,y<br />
ofchroni.c non-s~,>eciFic ]ung cliseaoe, attUdbutes it chiefly<br />
to i.hc combincd effec'Cs of recurrou{ resnirat .ory infection,<br />
foP., coJd mrd air nol.]ution, resi :rictinfi the effects of<br />
sn:okinr to "coulih and phl .et,w ."<br />
AlthouPh thei'e are definitcly moro heavy smokers i n<br />
the U .S .A . than in the Unitad KinAr1ow, ya1 : mcrrb :i_di.ty and<br />
morti a lii.y frao chronse ]rmq di .ceasc i.re hero inconnanably<br />
J c9$ ,<br />
A , cvil.] he shcan Lolors, in the U .S ., too, the sYati .s-<br />
r :ies on the n sociati ou with s mokinp; mostly r¢+fer to persons<br />
with "coui¢ and vlReGm" rather than to {lalicn t s with the<br />
dise s :;c wildch causnd the hiAh morhi .di t y and mortality and<br />
p,i.ver: so nmch ooncern to public health o .ffi.c.ials .<br />
'1'im ltoyal Co :I7cge of I'hysi .ci.ans of London must be p,iven<br />
cr::dit for hot omi_t5:inl; frow its reVort tTie ]ist offactua]<br />
dnta which arn :i.n opposi-Li_on to the presunied ] .ink between<br />
smokinf :<br />
a nd eSronic br onchi.ri .s .<br />
Thcy rLached Cha ooneluniocr thai . "Cigarette smokiig<br />
should I n regz.rGed ns: an :i.emnrtant conditionin( ; factor ren-<br />
dcxJnP, m Any mcn nnd womcn li .aLJa t.o a disablinR diFCasc which<br />
thcy M iryht Lzive oscai,ed had they not snroked ."<br />
'This oarrl:3ous ssiatcrnent is, oPcoursc, a far cry from<br />
the ooncc:pt ¢~ smo]cinF oa the mcost ircportant eausc of the<br />
di so<<br />
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'lon<br />
38311<br />
What is moro important is that it br :inF.s down the i.ssuc<br />
over tlre effects of smok.inp, to the dub :i .ou2 : a.nd tenuous zresump--<br />
t:ion that i.n every onse of ehrord c lung dise4se caused by<br />
the factors r~enrioned above, cough tmd phl .egrn due to smoki.ng<br />
musi havo procedeci, whi.ch, of com>se, omnmot be ascert®i.ncd .<br />
1'hc ascrarption thatt ther,e patients mi .f;ht hmve escapcd<br />
development of dioab7ing di .ceas.e had they not 8isoked before<br />
:iu ahocy ;;hccuJati .on .<br />
Piosst imPOrlant of al:ll is the fact that in the report<br />
oS the Royal College of Physici .ana a c,iusarf lirdc to sniok :i .ng<br />
i: ela :irna;cl only for soccilYed s :irnnle bronet, .itis, but not for<br />
disob7luny- chron .ic Lrenchitis .<br />
Thc tcrv si.inple bronohi'ti_s rafcrs nicrc7y to "cough arrd<br />
phlcrpr,r," trivial symp-toms an compare.d wi'ih chroni .c bronchitis<br />
wh :ich .in llngannd is a rcthcr• oom'mon cause of daath .<br />
9'hc 'terv bronehi.t . :is applied to 6oth ofthese conditions<br />
hrs ]ed to the euro' w nt a.onfusi .on pxr•ti.col a r]y in the ]ite.rn-<br />
t ura ].ink :in, em cl:ino with chron_ic bronc•.hiti .s .<br />
I 'he ca r or ;rd .siny f xrom this confusi .on is perhaps beet<br />
M usfratcd by the ]or.g z:.nd firrnly he] .d belief expressed in<br />
the Coiwnon 'I)hraEe °aobody di(iS froin ChroniA brollehltis° which<br />
ies found repcatedly in the "li.teratnre in Iingland as wel] as in<br />
Wc United Sl .e:.ies .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
7n the. !
•<br />
•<br />
the evidenoe upon whioh is baeed the ecnipl .usion thet<br />
ciP,arctto smokin& is the most :importontt cause of chronio<br />
bronchi.ri.s, cmd that a reJati_onship, whi .ch is nott aausal,<br />
existF b¢tvc.en ,mok5nr au
•<br />
.<br />
The survcys scrve to ovcJ .oate "whether smoking is<br />
associ.ated With certain :;i.gns or eymptorns to a greater<br />
er.icn1, thmr wit-h other .findi-ngs ."<br />
St. is Yepenicdl .y emphElsi .zcd that the di .eignosi .s of<br />
ehr•oni .c br unch.itis c;an bc achi .evod on]y by exclusion of<br />
many other• cli-ecases of the ] .miYS and thlri' a c] .i-nioal diag-<br />
nO51 .8 of ell)physeilla J .E even ]esF OxF ct .<br />
Tnl', re4117.tE of a feb/ syl9ptom-preValenee su.rveys (r'6-<br />
ferri.ng to cough, expectoratiou and br eathlessness) are pre -<br />
s¢nted as epidcciiologi .c uvid ence . The claim i.s mado for<br />
oxis.t'.,rnen of a re)ationship between selobd.ng snd thosc<br />
syiirptom•s .<br />
3 840<br />
This pmrt of thec report i .no7.udcs a mmmber of statenleuts<br />
whi.ch clearly indicate that this eviclenoe i.s quite i .nadequcate<br />
to cs~ablish cven ihis c7 .aini of a ]i.nlc to these sylsptoms .<br />
For exard,) .c, it is conceded that "7 :n oeveral of these<br />
sur•veye, fomcles show n higher preva7ence of breathl .essnese<br />
in non-sh .okors than in smokers, particua.arly in the older age<br />
group .<br />
"7he reasons for ihi .s sex difference have not been<br />
explainod ."<br />
9he- importance of this admission aies in the fact that<br />
brcathlcr,snese is, of c :om•se, the most ao.i.hnificant symptwn of<br />
chronie lung niseasB .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Another important ad m i .ssi.on ie; this statmnent : 'R4orhidi.ty
•<br />
•<br />
•<br />
dtrta are insufficient ait prosent to bc of value in the<br />
cstimation of the nossible health haaards of smok3 .nf• ."<br />
Smomation of the clini .cal ev3donco includes this<br />
statemmnt : "Such evidenco can do ]iti'ie more than Pro .<br />
vide a hasSs for hypothc :si.s and i .ndicate the effect of<br />
continued snoking on estab7ished diseasc<br />
.sh or nxc]ude eawsal reAati.onship : it docs not, ofcour•sc, estahli<br />
."<br />
]Sy]<br />
heferring to the P atholo Rie, chan gas i.n Vulmonary p¢rrem<br />
clrymr~ whi.ch orc assumed to 3ndicate a re7ationshi .v between<br />
s m olci nG and crnphyscma, the report conecdes : "'1'hese chanp,es<br />
cannot he ro]ated with certai.nty t o ernphysema or other<br />
reco(wized dir;ease at the orescrrt ti me ."<br />
Lcek of spaac doas not permni.t here inelusion from thi .s<br />
Itcnort of rnacy more such quotntions mhich detract from the<br />
assomed valuc of the cvida :nec presented .<br />
Ohvious] .y the sum tot a l of t'hin evidcnce is far frorn<br />
adequate nrocrf of a. li .nk bei .veen srnokiny, and the changes and<br />
r,ywptoioa di.scu&sed i.n t}d.s report .<br />
iurthermnrc, whi7e it i .ss<br />
freely adnritted that these<br />
chanIIes are non-epeci.5ic and it i.s not posei .bJ.e to idnntify<br />
thcm as thoso of cl ronic brvmchitis and emphysema proPer, yet<br />
in this repow the Conmdttoc did not refr&i,n from doi.ng just<br />
lh o t .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
I3eforr coud~udiny, the^n Urief re rnark:s on statcments made<br />
by the two p;roups of protap:onir,te of the cigaretie smoke ihoory,
•<br />
•<br />
jon<br />
Gomc corcmant . .; requirad on the m,cst s ;i.qnifinan't difPerenca<br />
Dotwccn thom miti ; rega^d to their v:i_ows: on the effectss of<br />
smokiug here znd ahr•oac7 .<br />
ln 7 :np,]anct t.hoy hold the view thaC xmoking is not<br />
the chi e ` ocul :;c of ch'roni .o bronchiti-s and that its di .s .<br />
c,l ling fatal icnm in e.tusect by the combinofl effects of fo( ;,<br />
air po]]uticm ar ;d Tcctn'mbnt infoc,tionc .<br />
]L Tho lteport of the Surgcou General's P.dvi.sorV Com-<br />
m :ii-'ice, it ic conc? .udad thr :t "Cip.nrcttc smbking is the most<br />
impm•teusk cem R o of hrwte:lliti.s in the U .S ." and that "For<br />
ihc Lu11c of thc populz,iioac of the U .S . the i.mportanec of<br />
ci . g iirci .tC BYilokl] .rl({ £,R 0 G a U46 ei bronChoOll7NOnary d]Sen£C :In<br />
much grc•rcter 4.han t.hr,t of atmospheric po77 .utl .on, or occupa-ti<br />
.onn7 cxposns,c °<br />
'J'hG dl :ffGr@11C'O 2F, of eO11P50y of iundDp1611tNl £11(,n]fleLnCe<br />
fhois th n slt-onch,,oi .rrt af the iSSVe ovmr the effeets c,f sruokinp ; .<br />
This ro rv.;sdcablc differenec c:c:rtain)y rv:qu .iros a eonsidcrableY<br />
ai ;ouni ofi>qrJ f .ai .nin,• by the prota,P.ordetu of the smolci .nYg theory<br />
hf:PN . .IDG
•<br />
•<br />
protaftou5sts of t he c:i.prrettc srroko theory) vrere forced to<br />
c:onc]udo, corrtrary, to thei_r• f oriier]y repeatect)y expr•ecsed<br />
helicf . thai ::moki .ng haLits al .one do not determir :e the<br />
prevrOence of respiratory sy :npt-enns :in a connnunity .<br />
Thcy concede that their fir:diags now point i.n the<br />
di.rection of r,ir po]]uCic:n as a factor and they also spco .-<br />
i0atc on thc ro7e of ethnic diffeirunces in the populat :ion<br />
as a eauso ofpredicposStion to chr•on :i.c resni .ratory discase .<br />
IJith widenint: epic7cni.o).o8ic sturlies, the li .nk betrooen<br />
smoking and cainioal]y si .pni.ficant lung disease is bound to<br />
beconc incroa :;intyly tenuous .<br />
77<br />
3843<br />
Ny second reason f.or oppoai .nf6 the ciF.arottc srooko theory<br />
ie : har : :eal on the concept tha2 the ]ung disease nour in ascen .<br />
c]ancy is ncither hronchitis nor emphyseme, but i .s a new<br />
puLronzmy dise.ase ent'i.ty which has cvo]vod during the past<br />
hal.f century beRinninpg before cigarette smokinY, hceame wi .de-<br />
s ncud .<br />
7'his ucw f-ore : of' chronic :lunt; diseasev i .s nosr wideAy<br />
rccognizcd ns such t.s indicated by the apt deslGnation of<br />
"ehronie nonr ;pecifis 7 .ar:e di.sorrse" now used in the ] .itcnrature<br />
wnrc .:nd moro frcauQntly .<br />
Thi.r, new form hus evolved as a result of prvfound changes<br />
in wcrlic :n) se5.ence, chzurGes in the l .ives of the people, aud<br />
chenp{ec i.n ihe c.nvironcim :i rahich have nffected the respi .ratory<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
ion<br />
o>r;nns iu particulmr, dttrinf: the p ..st halP of the present<br />
cen'tury .<br />
The i.nci denc e of the preseM form of chronic laug<br />
discnsc is known to have inoreased parallel with the Al .<br />
.ni: chanP,cr> :<br />
) 1'hera hac occurred a very sharp decl .ine in the<br />
.1owi<br />
iII4 h<br />
mortality from pulwonrmy i.nfections (pneumonias, tuberculosi .s,<br />
at ectcra) . llorec:ver, mxny reurvivore of thosc formerly fatal<br />
nff]iciions urv now lcf't with pcrn¢menY ] ung dN ma{;e, an d<br />
thcy rmuai.n mor v prone to furt4ie r lunt; damap,e by subscquent<br />
affections involv .ing this organ .<br />
2 . [Phere has ocomr:re d e: ticmkoci increaee in r espiratory<br />
snfec:tion b by ,? vardoty of vir al agontn, inc:ludinft many only<br />
most rocently idenYificd, rahich though rv:latively mild jr,<br />
W 'nis of mwrtA?Sy, hnve ;i verY hiY.h incidence of morbidity .<br />
14 have n o antib:Co-l .ics ap;uinst thase respiratory infecti.ons<br />
which 'Lend to recur frocluentay durintt 1ii'o .<br />
3 . ateree has occurze:d a striking increase in the<br />
incdAnon of ;;1)ergie and r.n'rhmatio rrspirstory affeesic,ns .<br />
4 . Vnstay incrc:ased iuduatrializatiun has br ouf;ht about<br />
chanf.es in olp envi.ronmant 2:ffoetiuq partioular ly our YesPirmtory<br />
or;;ans by pourinq a nwnher of po]lutants into the air we breathe<br />
hzrmrul Si araumrt and n»turc .<br />
u . The lcngth of :I :ifa of peoylc has inoreasad, the ratio<br />
as mon and wo"en ]ivink to advnneed and old age is much p,reeter .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
•<br />
jon<br />
'1'he factors 7 .i.sted above now have arnple ti .cie to exert their<br />
corabi.ned untoward effects and aggravate the effects of the<br />
aging process particularly i.n the respi .ratory tract . Ilence<br />
the increasing prevalence of chrorri .c lunC disease in our<br />
dj;ing popul .ation .<br />
1845<br />
The chronic ltmA disease which we now observe represents<br />
the resu] t s of a 1iSC-iirne of wear and tear on the re+spi-ratory<br />
system .<br />
Its development and rate of progress in any particular<br />
case is uri.rrenily clc:terrrrined by the i .ni.t.inl pulrnonary endow-<br />
ment the i.ndi .viAua7 is born wi.th, the lunr capaci .ty he developrs<br />
duri .nlt the groeri.ng pcri.od of li.fe and by the pulnonary afflio--<br />
tl.ons and dainar;os he suffered during his l :i.fetime .<br />
We soem to be dea7i .np; with eun exceedin g ly com ;q .ex<br />
disease entity whieh we now observe with apparently increasi .n g,<br />
frequcncy i .n man und women of advanced and advaneinA a ge . It<br />
hr.s a s7.ow and vory i.ncidi.ous evolution be ninning quite earl .y<br />
in l .i.fe, and ]eads to ovs,r'i pulmonary di.sabi :li.ty only many<br />
years ]ater .<br />
fn e :.ll1 popu3ati.on s:urveys, age pr'nvect to be the factor<br />
of hi.p,hcst corrclation wi.th the symptoms said to be indicative<br />
of chronic lunP, dieease .<br />
'fhi.s insidious change in the prevalent forms of chronic<br />
lunp; disoaa:o began lonF Lofore cip,arette smoking became wide-<br />
spreacl . 31 became notiecahle soon after the turn of the century<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
j on<br />
unc), by a]] ir,di.cat :i.cros, it afflict:s non-smokers as well<br />
a.^s emokers<br />
:ngr7ond . Ju l whora this ssrious form of chroni .c )ung<br />
di .seac :e is by far the most oonnnon as eom p aireci, for example,<br />
wi.th thi.s country, and re) .i .abi.e str:tis1 :ics of its incidence<br />
nnrc< availablc:, the hihh rate of i .ts occur renee in non-srnokar•s<br />
has bcen c coD spicuous i-eaevxY : .<br />
31 tiso uPpecrs t o be far more fre:quernt in men than in<br />
wome.n, e:7thovnh c7urinF, t ho past few docades womcn have hcen<br />
scicki.nL in increasinp• ncmibere: .<br />
7he naturo and or•igins of the chanf;ed form of chroni.c<br />
] .un); d'isease presont]y evo,) .ving under• the effects of recent<br />
and current chanpos in mc :dical science nnd in medica] prr,ctice,<br />
xwd rmder the offe.cts of changes in the cnviroronent we are<br />
]?v5ng i .n, is .far inorc, proh]emati .o thian is genera])y appre-<br />
ci.ated, parta culnr]y Dy t :hosee who cti :lll insist on speaking<br />
of chr onic bronohi.tis and pulmonary emphysetna, di .seaso<br />
entitieu whi .ch they c,an no 7 .onger def:ine or understand .<br />
in spirCe of numexmus cympos :Ia held re:cently on ths problem<br />
of p«linondry emphysema, wee have, madc+ 1i .ttle pr•ogress, so far,<br />
in so)v :i .ug, th.i.s prob)cm . Current studi .es cmphasi .r.e ]oss of<br />
)un}•, subr;tuuce (depart .iti .oni.ug) as the ece :entia] criterion of<br />
i'his condi.tion .<br />
]n the proce.ss of a9trition oi' lung suLstauee thr•ough-oui ]if-e, a]<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
.ar);e ntuchcr of faetors continuc to operate, and
•<br />
•<br />
jon<br />
the r•o).c of mosi of thcee factors sti.1 .7, remtrins to he<br />
doter•mined .<br />
C]inS .er,lW er.pe.ri.earce does not aff~orti any indi_cations<br />
of posuibYo harm to the lur,ee f9^oin smoking, end certa :inly<br />
th¢r.• arc no rnparen4 si.gns or symptows of c7 .i .ni.cal s .ig-n5f<br />
:i.cancc which dciir,'itely impAieatc smolci .ng i.n the ori .gi .n<br />
imd dcveJopmevt of ehxon :ic 1tmf; diseasc in generW .<br />
77:decd .. i.n rny own cli .ni.cnJl eryeri .oncr .. I have had under+<br />
lonFt ol :sc,rvati .on many men and cuomen wi .th obvi .ous7y poor•<br />
puJis:onary andoyrnent (poor chce :'t ctevclopmcnt and 7_ow pul-<br />
rnonnry c,apz :c,ity) rino hrcd smokcd hro.v .i.1-y i'ov many years and<br />
rumaSn.d compMe7.y f3ee frolu rmy sSl6ns of harmfu]l ef'fecis<br />
oS'thief hab{'i' :in the J .rwgs .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
)n the lurge nwourrt of iilteratu re rr•oent? .y aceurnulute C<br />
on poc : :SbJe- effects of srnoking, no evi .cience hae been produced<br />
of eic.-iueJ harmful ofJ'ecris in humans, e :nd oert ..inl.y there is no<br />
def5 .nit.c evidenc
•<br />
)C<br />
]_n contrast, ]arn not suro :ris¢ci by t he fact that thc<br />
over'^r.theluinA Pl•nq,ortion af omok
•<br />
•<br />
I o n<br />
-ius t ifl' s uch netion, ht my opinion, the answer to this<br />
au
•<br />
•<br />
jon<br />
5'he fz:c-f thct we cto nott yet po&seser the know)ec]F ;e<br />
which Iaou]d o.naLlo ue to seleet t'hose to whom syoking may<br />
pos ::ib)y be harndaa dc>es not P.ive us ihc right t.o advoeate<br />
thZlt CvcryOLO rCfr(iin fIRHm flIDokin) ; .<br />
Un'li.l wo havc ;:olved thi .s problem, physiei .ans 03)1<br />
mroLnbly coni .i.nuc to do what: they hnve boon Aoin&, nawely,<br />
a (IviBln(; n :/ti.eht6 wi'ih Sy1 :Into19S suggesting VG&5ih) .C ohse t<br />
of ch ronic lmlg disease that smoki,ng inny ap,gr
'<br />
•<br />
0<br />
•<br />
srnrla+crrr or R . u . xlcJlo ;r, M .n .<br />
I am H . 11 . Rip,don of Galveston, '1'cxas, I am a uhysic :ian .<br />
7 rocci .ved r:y M .b, deP.roe of Hrnory University, Atlanttj,<br />
Ocorgin, in :19'31 . . 7 took ny int :ern and resident trai-ni .nr;<br />
in patho]op,y at Duke llniversi .ty in North Carolina .<br />
7]iave boon a tc;ncher of P
•<br />
•<br />
•<br />
jon<br />
sponsor•ed by the U .S . P:rmy .<br />
For the last 15 year•e. ]: have been interested in lung<br />
IR52<br />
canecr . lhave )-,uhliahed three revi .ew arti.cles on lung cancer .<br />
Thc first diiscuss®d ttmg c.cnn cer• as : it wa& known Lefore 190D,<br />
the second f :wm 1900 .to 1930, and the t .hi.r•d from 1930 to 7.960 .<br />
1 an now gathe :rin(; nmaterial for a fourth review from 1960 to<br />
1970,<br />
.7 have •xl .&o been interested in the frequency of lung<br />
eancer in caues that we have stuclied at autopsy (Preguenc :y<br />
of eancer of the 1tInP& in P111 mdlignancie3 studied at<br />
atrtopsy . Southern Mc.d .i.ce ) Journal 44 : 506, 3953) and the<br />
cor .u:lntion of the diognosis of caneer as made on the death<br />
oor•T.i .fi .catcr: with that ohserved a t the autopsy (Vita l stati.s-<br />
t .i.c.s tnd the feeyuenc:y of dise:ace . Tcxas State Journa l of<br />
Mczdicinc: 59 : 317, 1963) .<br />
I have: Lcen interested in oLtaining the history of<br />
cijttlrettC smokinCg in hos p ita1 und cl .i.nic patients and cOr--<br />
r•clating these data with the el .i.ni.c s t diagnosis (Smok :ing<br />
hahi .ts oi 21 .,61 .2 :i .ndivi.duals in 'Pexss . Journal of the<br />
Nnti.ouc] Ccnccr•]nsti.tute 16 : 1287, 1966) .<br />
)3 havce obtained the smoking hi.stories of college students<br />
to estnblish the frequency they smoke (Smoki .ng habits of<br />
cc)]egc stud entc in 3'exas . '1•exas Ite p orts on Biology and<br />
Medi .c.ine 12 : 292, ]954) .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
In the field of research 3 have been i.nterested in
•<br />
•<br />
•<br />
18G3<br />
studying the effect of chcmi.cals that produc:e cancer . Somc,<br />
of these chenricals are put di .rect :]y iuto the ] .unrs of ducks<br />
and dop;s through the mouth and wi .ndpi.pe .<br />
One of thce.e cherni.cals, methychoanthrene, has produced<br />
many t.umors in the ] .ung . lienzpyrene is a chemical frequently<br />
su8kested as a si.gni_ficant carcinogen in cigarette smoke . It<br />
has bomi Gcrnonstrated that large amouits of benzpyrone are<br />
present in charcoal bro i.lcd steaks . It is a] .so i.n the air we<br />
bre athe . Y have placed larpe amounts ir, the lunp;s of ducks<br />
..nd have rat obsorved nny cc,nce.rs . .<br />
As far a:, I know, lung cancer has not been produced i .n<br />
aery ruiima] that inhaled cigarette cnnoke : . ]di.d not obtain<br />
t.umors when tobacco tars weft: put di .rK:ct]y into the ].ungs of<br />
duCkP .<br />
) t i .a interesting tc, know that tobacco tar when put on<br />
the slci.n of micc will producc a skin cancer .<br />
I put a oancer-producing aP,ent, methyloholanthrene, on<br />
the F:ki.n of et duck and got rnany different typos of tumors, but :<br />
when the samee agent was put on the ski.n of the turkey one<br />
typo of tumor rasultod .<br />
Noa thor :: is not much di .ffe.rence in the skin of the<br />
duck and turkey, but there is l.ots of difference in the skin<br />
of a mouse a.nd the respiratory tract oi' man .<br />
] cmi unahlc to transfer dctn about cnncer, as obtained<br />
from ev.pcrimenta] ani.rnr.7., to man . RecentYy, that ie withi .n<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
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the pc:st thr'c:e y ears , cantoers have been found to deveYop<br />
i .n the l .i.ve:r of rvts fed pcanut meerJ. (Nembc rne, P .M . ,<br />
19m . Id . Car )1on and G .N . WoAUnn• 13epatornas in rrits a r,d<br />
he pn torenal3 i.nJury in duck7 .inF,s fed peanut mca.l or<br />
FlepergiJ.lue. :ftirvus er.tract . Path . Vet . 1 : 105, 1 .96rs) .<br />
1 have heen sturryi n g some of thee:c: Yet: J .i.vers . fn<br />
vi.Rw oflny OJ p eri .ehce 4!i .th ei.glrett'e.s Flnd eF.nC:Crn lI capnot<br />
he).p but tF'nk of the proLlems i :hat cou)d ari.se in rei .Mt .i .on<br />
t.o raLS ceai .ng peanute: . .<br />
Th en, too, we hr,ve the probJ.om ofli.ver cancer in fi .sh<br />
fed OOitbnFfCf1 productH ( Wolf and .reCltPOn . 116ptitolnfls in<br />
rainbow trov'c, dosenipi9 .ae nnd exper•i.mentall epidemino] .opy .<br />
scicttcs A7 : H'I6, 1863) .<br />
It is my opini .on 1hat moro researoh is needed in the<br />
i'i_ci .d nf c
•<br />
.<br />
•<br />
of1unOrF b @ing pro 9e.nt in 8 liiotltf'.r 'c'an(1 daughter .<br />
i'he o a usc: of' cancer is not known . by th1e, cae mean<br />
t hat o-ie : d o not kn ow wby a cei .a in the body of one prnreon<br />
W l l :ecome a canecr nnc7 the rorrceponding ce11 in c,nother<br />
prrson vi .l'1 no t hocoice a cencer .<br />
P, canccm .:n5.ees frorn ce7JS withi_ri t'he body . A norma :l<br />
cc:U p.rrown rud rsq,roWcs itcei .f in a tud .forrm manner, whS.'.c :<br />
n canoa,,rr cre11 grrovrs and wulti .pSi .ess r>t an abnorna] rate ; i .t<br />
).NS .<br />
spres;ds into par4cs of the body iaherv a norvnal cel] would not<br />
96is ahnm u a ) act :ivi4y of e cel .a in what w e c :all a<br />
crnocr . Lt is a known r a ct, and so fe .r• a.s ) : kno w it- is not<br />
denicd by anyono, thct a
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•<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
racor•ded t'hic eas
•<br />
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infOrina9:].OII to SerVe aF the bLFi.6 for dLrterl0inlnFg the caqFE:<br />
ofcanc:er, In my opinicm, more worlc i.s i.ndieat:ed on this<br />
prob]eui .<br />
In 3934 Swe-r.ny sni.d, "If there in any merit in thi .s<br />
theory (cigmY;tte srnokinp, and lung c :aricex), it should be<br />
msnifest in the femaJe nex, where thee inr.rease in the ueee<br />
of ciEaretY .es has been greater than in me.n .<br />
"7f, for exarnple, the ratio of men to women 20 years<br />
o$o wfle 3 to l, and now in 193$ it is 1 .5 to 1, the case is<br />
wel.l n ;gh proved,<br />
"So far, no such inerease in ratios has appeared, for<br />
the se.r, rotio wns and st :i]Jl in around 3 males to 1 female,<br />
ei .m:itur to other ma5ignant aond'xtions other than those of<br />
sex differences,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
'bn the other hrnd, there are uv,iny patSents with lung<br />
3 067<br />
ccaicer who do not f;ive a history of cigarettce smokiurf; at a71 ."<br />
(Priniary hronchi .o{,e:nio carci .nonia ; i .ncide.nce, pathogc:nesi .e.,<br />
and diagnoe;is . Annaln Otolopy, Rhinol .ogy 43 ; 501, ).934) .<br />
lir- . Joseph perrone in Flpril of 1964 reported a group of<br />
1,000 eases of ]wig ee,ncer in Yittsburgh and pointed out that<br />
474 ofthosc reere precent in nonsmokere .<br />
Dr . Ycrrone aJ .so poiuted out ihat in his group of 1,000<br />
cases of lung eancer there were 754 whites and 246 nonwhites .<br />
lie t:hen asked, "thy should the Negro not develop lung cancer<br />
Irorc frcquently than the whito, for he in ee-r•t ain]y exposed
•<br />
•<br />
•<br />
tc, irritatinf ; f;ases, e,nd furthermore, many co) .orcd men<br />
smokc cigar•att'e.s they ro173 thern:elvice" (One thousand cr.ses<br />
195D<br />
of ]ung eanccr . Fcnsylvvu .a Medi.cal Journal 67 : 31, 19F4) .<br />
3.t is ny opini.on that ectucttt.ion has boon an i .nryortant<br />
factorS .n the inm•eei8e :Iu l.ung oancor . ti'ith pulmonary<br />
tuberoulosi-e d
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the cormectness of the di.aguosi .s on t-he: death certificate-,<br />
bui: I do .<br />
Ccnt]omon, I hope that i .t is obvious from my remarks<br />
why l3 was c]r,ssi .fi.ed in the Surgeon C;eneral's Report on<br />
Ci.i;arc:tte Stnoki .ng on page 7 .79 as "thoul ;h accepting the<br />
1EL9<br />
er.ie;tenc:c of an aesociafi.on, have quecti.oned its signifieance<br />
in torvis ofa oaut:al hypothesis ."<br />
]h regard to the Surgeon GeneraJ's Report on Smoking<br />
mul Ilaalth, ]thi.nk it is an exce7lent suwnary of one side<br />
of th :i .s controversy .<br />
.lf oqus0l timrre anci e ffort had bee.n given to the opposil :e<br />
view by thi&: Ce mmit:tee, 1 think the report would heve beon<br />
twice t he We and would have been a xk;port that scienti .sts<br />
in the future could review to see really what the state of<br />
kno,a] .edt;e was i.n :19G3 .<br />
l,-r.r.t yez,r the Federa) Tra.de Comm :i.ssion e,olici .ted my<br />
cominentS on '[hei.r propo8ed °11 .Y•NdC kegU7 .atiOn 12Oles .° In my<br />
re:ply 1 diea p med with th e ir l.abel prv>posa]l and pointed out<br />
that 1 do not think the atatewent. "Cigarette smokinp i .s<br />
danY,erour, to he n ).th . laM may cause death from cancer and<br />
other di9eeseH° i6 OOrreCt .<br />
1: wou7d cons .ider the statement "Caution - Cigarotto<br />
smoki.ng may be dangerous to hea)1h" to he more consistent<br />
with the fuct5 as we know tllem today .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
31 we 1JW - Ci .gPrette5, then we F.honl.d lahel peanutH
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since we know that ca.neer occc rr> in the ]i .vers of rats<br />
fed peanuts .<br />
- Chareoal broiled steaks should also be laDeled since<br />
benzpyreno has been demonstrntcd in thern . An i.ndefini.te<br />
number of i .teme wi7 .1 fa71 into this ] .abe]i.ng category .<br />
1860<br />
To c.wnmarizee my vi.ews ., may I say that, first, I be]ieve<br />
that there is no sati .sfactory experimental evidence to<br />
estab]ish a connoction between cigm•ettc srnuki .nY and ].ung<br />
canccaV .<br />
Cenc:er of the 1un€: has not been produced experimentally<br />
i.n any cmirn
•<br />
.<br />
0<br />
dcfoct responsib7 .c: for stea•il .i.ty and the development of<br />
tomors . 4ui.rnc~.1 . rase :er¢:h n7.so e:urgests the :ittyrortanee of<br />
onxS.s :i.n fac'tors cta~h as vi .roses, i .rrndiation and others .<br />
Second, 7 c;ue&•ti.on some of the ci.rcmnsstanti .a7, evidence<br />
concerning smoking and c.r.uccr . Y pointed out that my exper--<br />
i.ence 3.n the gorfornemoe of autopsS .ec :Le:euls me to question<br />
whether lunPg cunoor oocurs m& frv±quently ass it i.s racordcd<br />
on ds:ath cer4i.fi.c
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w] xear<br />
AI3MRICAI3 CAnCBR SOCIETY<br />
Rhodo Y:s7.nnd FHvi.eSon, Xno .<br />
3133 GroC4o Av©l1nc<br />
Providcnco, R . t ., Ok!fS06<br />
6'nrch 1G, )0C5<br />
The ltonox•ab3c John P . p o store.<br />
307 Pur.i Offiacc: 4.nncnv<br />
ProVYdGllC3, {2'i,Oi1p AN7P15C1<br />
llenr 8nnetor :<br />
An a pri .vato yrhycici.r.n :and P)° .dont of the Amori.cesn<br />
Qnc,or Pxeci.oty, lihode )ca)and llivdrsion, Tnc ., I am vAtnlYy<br />
csoneorued nbou4 thn znoroae ;e)d SncS.denoe of lung enncox• end<br />
the 1'S'o1r(tn YC+7 .N$Soneh'n)) VA Oigflr[ettb EfGokin(; to tl)16i dSPOR9G .<br />
Va.rt.our e:turiiers in thne' aountry and nLrond bavo Aivun ovox° .. .<br />
lYheRmPnR nupporYt to Uhis theciFe .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
In RhUdO )C+).knd F(f+ ltkv0 fl C6[e/1POhOl1E3vC cIYS .)dl•CIl'O<br />
and Hdut4's jJxo(+,rno1 on cS .f :nrotto HalokSn([ Ql1d hRa14h . This<br />
1nC7lndOa fi .IJln'.), 3$.20PAtuTG, a.nd ©OC'M1.4YB, CRYPCntly we Fax'O<br />
a)anmhcr o£the Ithodo ) .F;Sand 'SUte+rxgc;ncy C:ounci .]l on SlnokSUp<br />
Ylhich ( :On(.SE .LE; Oi RCvCYa.7 Vo)nn9lnFy P>Pnd official agencies<br />
LhpC hr6 Wi((kh'4d in a coopC+ra8i .vC PYbI'ranr to di.HConl'NF,'4e<br />
cSfY.RrUbtC tiNO$ .S,.fl(; Fzf9ong n(7u1t6 and ch93-dYGn .<br />
Ac$Svi.tiffi kUld inS:GYC€3l in each o f th(i8C nrCPB con••<br />
eSnltce to $.n9rens6, but we do not foul that thi.s is enough .<br />
11 Ci . Va 'PCY,tC` J9i61cinfo in t o (iCCx'flanf* n ppYCCi.AIA)y 3i.IGi.YO(7
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SoveP6lrQfitnl fiGti.on }n IleCadE+d . I fOGl t-h6t federPl 1hwE<br />
voqni.rS.nEC ths^ laheli .uh oR eS .grcrottot; n.ud the reC•ul .ntfng<br />
of oi.(rl:r.ottc; advcrtEri.ng iro needod .<br />
'19snreSoro I ur€±c you to G9vc your f ul.l support to<br />
Bp:hA'I'1? BS1 .1, 8@7 which lrou5d reFCql.nte. oi.gorotte labeling nnci<br />
ndverf7e.i-ng. A bcalAevo tnut th&e would mnr4 the beg9 .nnfng<br />
bt f.
i<br />
mc :r.<br />
tiR'ATL3P 91sK' OF 11IY.7`ON D. pN)SP:NNI ATT, M, :D., ASSOCIATE<br />
C 13NTCAL, YA6h BfSSUR OF Mt 01CSNPI, NEW YORK M13llICA L<br />
CC7:d:MC1 S<br />
186h<br />
Dr . }tosenbiatt : The i.nc:rease In lunG cancer in the past.<br />
few decafes has fostered the concept that this is a modern dS : -<br />
case produced by exposure to recent7.y 4ntroduced caroinogen3c<br />
substances . In the Intensifi.ed search for causa l agents many<br />
Sundeqnental facts have been d :isre@;arded . The proper di.€€er-<br />
entiat i.on between apparent and abso7 .ute iru:rease requires a<br />
porspcc:t7.ve that encotnpasses for more than a more asseesment of<br />
epidcrd.oiotri.c&3. e:teitisti..cr, . The rapi.d rise of a di.sease co<br />
.th i.rnprovernent in d9.agnostic techniques has occurrect<br />
-incldcritr ii<br />
many timos in the eourse Of rnedlca,J history . At the turn of<br />
the century, when the marked :tncrease In cancer deaths In<br />
L,[7and was attrP.buted varAously to parasitic infestation ,<br />
meat eonecanpt3.on and excessive ralnfa7.1, King' and Nowsholme (1)<br />
observod propheti.ealfly In 1 $93 that whenevar a cancer became<br />
dSagnor,ti.oai.ly accesr,ib7.e the Irroidenee automatioa7ly Sn —<br />
c*rcased . The Ecport of the Advisory Coam:nAttee has based its<br />
,iudgmcnts of caueality almost enti.reJy on epidemiologi.oal data,<br />
has invoked hy p otheti.oal considerattons to substantlate the<br />
ctatist.5.oal oorrcaations, and has not suf€lciontJ.y consi.dor od<br />
pertinent refutatory evidenco .<br />
tc~tor7.ca7 Gonsi.dw atPOns : The Report of the Advisory<br />
Ccnnmattec d9 .scuesos the hi.story of 7.unp, oancer only finso€ar<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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as it rei.ates to the stucties on emok4 ..ng and completely<br />
9.gnoros the fact that the disease hs.s been prevalent for<br />
a hundred yoars befo re o :tgarette emok:Sng heoame widespread .<br />
Nowhere S.n the Report :to 5.t even ; .nti.mated that the baai .o<br />
1865<br />
know7 .odt;e of' the patholog;y of lung cancer was developed in the<br />
19th centu.ry, that a17. the oharaciterist9.c symptoms and physi-<br />
caA s9.gns were d3soovered 1n the 19th century, and that astute<br />
c15.ni.ctnns, bi>th hero and abroad, wero omphasizin6d, In the<br />
19th century, that lung cancer oc :cu.rred far more frequently<br />
than was gencra4 .7.y realized .<br />
Yn 3815,<br />
Laennaro (?) d9fferent .iated 7ung cancer Yrom<br />
tuberou7 .osi.s a.nd other pulmonary diseases '1n an article In<br />
the ll~cS .l.onnaSre dee sc,ences mod~cales . 1?our years later<br />
he pubi.S.ehed a t r eat9.se on physioa7l df.aCnosie, lio_1!ausrouAta-<br />
t ion roed:tats, which we,s trans7.ated by Horbes (3) and evoked<br />
considorable 5ntcrest 9.n the diseaae In h`n gIand .<br />
Andra7. (h), In 1821, irrvostigated the possibility of<br />
diuFSnas l s by sputunr exami .natl.on and in ?.837, edited the fourth<br />
edS .tS.on of Laennee's e1.ae.s :t.o work contributing a profusion of'<br />
footnotes on lung ccincer .<br />
houillard (5), ln 1826, discussed the possible relation-<br />
shi.p between anteeedont pu.lmonary infection and lung oanoer .<br />
Sbyfelder (6) won a oitati .on for h :is studies on the<br />
sub,7ect in 7 .83y and, 1,11 .Bay1o's 1939, `as_a te des maladies<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
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3 5.866<br />
oanoereuocs 7.3.stcd c`oanccr du poumon" os ar, established<br />
prlmary ma7.5p ra ncy .<br />
Uiher'Br•enr.h a .rt4 .c+i .os were published by Uorar•d (7) in<br />
1821, nrna7 . ( 6 ) in 044, Lebert (9) In 5.8dG>, charoe7ay (10)<br />
In 1837 . and N'.ormerot and F3oury (1 L) In :t£StF6, the latter<br />
au.thorw oontrPhutS.ng a sB.Yab1o bf.b7. ;.ograph,v .<br />
Lung oanc e r has been a subJeot of eonsiderabie intereat<br />
In Pu•itai.n sS.nce the pub5.icat5on of Stokes' textboak,<br />
S~1c•easc+s of, ths Chys4, In ] .837 . ti'ho desorS .pti.ons of tho marh-<br />
foat5 .ationo of the cin .se•r,sc+ and the Kmob7 .en,s of differential<br />
diagnoss5.s were Y.ndicat3.ve of a w5 .de clirf, .c:al experience .<br />
Stimu'iated by Stolmei te:achings many other fsrit :ish phyeio4ar,a<br />
mude important contrtbuti.ons .<br />
A report by fu+ro (S .A) In 1838 deaor4bed a neuro3.og9.oo1 .<br />
complication whd .oh was re-discovered (1 ;3) a hundred yeara later<br />
1.n thf.s countrN . Signif'icant observations In pathology and<br />
cl5nicaJl medielno were cwade durlnfS this era by £tughes (14),<br />
£Qao&ach2an (15), k,urrowa (7 .6), and (craves (7q) .<br />
In Apri3., 7 .8t :3, the PrAtiS j~h cnd I~or~elf7n Medical Review<br />
rev5 .ewec. f5.ve ar•t5cies on lung canccr with an editoria7 ,<br />
ccanmont on the 5-ncreas7 .ng lnterest S.n the diaease and its<br />
greater• prevalcwoe th[m previoualy euepocted . In the seeond<br />
hs].f of the 19th oontatry, Z.Mg7ish reports showed an inoreas•-<br />
inB interent In the microsoopic studf.es of lung oancer S .n<br />
order to bettor d9.fforentiato it Prom metaatatS .e tv.rnors of<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
the S.ung . Histologi.oal finGings estab7lshod In 1857 by<br />
Ouai .n (7 .8), Cockle (19), Mayne (20), Pitman (21), F3udd (22),<br />
Page (2,), and others aro ,iust aa valid today as they<br />
werc a century ago .<br />
The gr•eatcst advances In the patholof ;y of lung oancor•<br />
were no& In Rerroany in the latter decadee : of the 19th<br />
century . U:aideyor's (2$) stud3.es of the origin of oanoero<br />
1867<br />
stimu3 .at•ed i.nvest9 .F,at:,.ve roaoarch culminat•inp, in the establ3sh-<br />
mout of t•he origin of 7•unE' canoor from br.onohiai opi.theliu.m .<br />
9'bo rnamber of case reports, ar•tiolos, and inaugurai disserta-<br />
tlonee on "lungenkrebs" contributed by oerrnan physl .olanF: in the<br />
19th century is renuarkebYe .<br />
The authors whoce works provided the groundwork for our<br />
cunrent pathoJ .of;ioal concepts 3 .nc7•u.de Per9.s (25), Qeor£ ;3 (26),<br />
Hc3.nhar•Gt (27), Mirch-H7.rsohfo7 .d (P8), Heeee and Hartung (29),<br />
Sioge9. (30), Si .Oert (31), Wolf (,S2), Yasslor (33), Franke7 .<br />
(gt;), gcht^!albe (35), Har•traann (36), and a grcat many others .<br />
The varf .ous ce7 .7l t,vpes and archltoetural struotures<br />
found 3 . n lunf; cancer were wcll desor3bed In those publf .cations .<br />
Tho Gernun pathologS .sts noted that lung cauoor eases usually<br />
came to autopr;y In a far advanced stago of the disease but that<br />
few hod bcen 6i.agno[:ed during r.ife . qio o f the most valuable<br />
contri .butionr, i•+as the d0.£ferentd.ation of primary lung canoor<br />
from secondary pu7.monary growth and ben3 .gn tumors . It is<br />
noteworthy that the patho7.og5cai techut@uusand stal .ns<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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N ;tscervered by the German pathologAote : In the 19th century<br />
arc: sti7.5l very rnuch i.n use at present .<br />
Cenera7 . S.nterest in an.nES c:ahcer dove5oped ooneSdswably<br />
i.ater 9.n the 17rr.'itod Staten than It did 1n Ru.rope but ecafie ::<br />
nere desorSbed (37) at the Massaclmsetts (+onerat . Hospitat In<br />
18rB<br />
7.8&P anG ] .850 . Ar•tic:i.oo eontrlbuted by Le :h7.bnoh (38) in 18%C<br />
eand by J,ooml .s (39) S.n i.87G showed considerab1.e Earcf.llarSty vlth<br />
the tAscaee . llcF.&f :tcld (4Q), the pathoJ.og18t at Roosevelt<br />
Nospatai, wae wo? .1 .2oqua9.nted wf.th pri .rnary tun(; cancer as<br />
car].y as 1858 ae erv idoneed by h1 .s e:uto psy records .<br />
tn the i.ettor dens,dos of the 39th century the number of<br />
AverAc :an arti.cJcs S.nc:reasod 3 .nea .ud3 .ng oontri .buti .ons by<br />
r'ctTer (1•1), vi:n (;Sc ::en (42) , Ripley (d1) ), t:omper (kU),<br />
Janeuay (115), Yo2 :iand (116), Rodenpy) . ( 47), and LeCount (48) .<br />
On lA^.oembor 7.8, 3.680, the Nr.dlca9, Y;ecord canmentefi cdAtorS.a97.y<br />
that 1tun t; canoe,r wouid corB :tnuo to 3 .ntorost patho3o(;1.ats des .<br />
p9to the i .ack of spoo7f9c tr•eatment,<br />
9'he most important .P.n;orf.oan artfic7 .e on lung oaneer 1.n the<br />
5.9t:h ce,r,tm,y a ppearod 5_n the NEw,Ygxlt M17E ;~7,oa.A Jour7iai on<br />
tbbruary 8, 7 .896 . The author was Adler (!!{;) whose monoSraph<br />
on the sub,jec :t i .n 7.912 ha ;s since boeone a med i oai c7ass7 .c . In<br />
the 3896 art9 .c:le, Adlor repeatedly emPhs,el sod that lung<br />
caancmr Yeos not a raro GtGSearo In the United 3tates but was<br />
rare7 .y dial;nosed . PIe urged phyaie£.anrrs to beoome more farnl] .R&r<br />
rr.tth i .tF. c7zni.oc;7, rrnni .See.tati.ons ar,d pathol.o(y3str, to do rnoxs,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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motieulous work to as to bet,tmr reoognize the disease at<br />
aatopr,y .<br />
As the 190h century oame to a close, artieles on 1un g<br />
canoer also appeare6 In rue8l.oaJ. ,9ournal& In Xtaiy, Fo}.and,<br />
1669<br />
and Nor•u.ay, and aava.nces v:ere being made in c15.nioal dia gno-<br />
si .e . ;it Au not genorva7.7y rea2izod that the X - ray (50), and<br />
the bronchoscope (51) i• .oae bcF:irm].n(; to be usod to dotect<br />
?ung oanaer b o Pore the 20th century . Ono of the most in-<br />
fornr
411<br />
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pathoLogiat to reeogni.ze eases fcmmori.y obscured by late<br />
comp5 .7.eations . It i.s very evident : froin the many published<br />
reports that the rise 1n autopsy i .ncidence In Oar•rnany wa.s<br />
1870<br />
due to gmeater awa.reneas of the di.seae,o and bettor patholog .f.•<br />
ca1 d :i.a6'.nosis .<br />
1UN(a CAhCBft t+OFNPAYA;9'Y<br />
Pr•oponeutm of the oausa7 . reiat ;.onehi.p between smolcAng<br />
and 7.cmE•, oancer have poi-nted to the ri.so In lung cancer• deaths<br />
during the past three decades aa oorrobatlvo eviderioe e .i.nae<br />
thi.a pori .od wan a].so ohrcraotori2ed by a rAse In o2garet :te<br />
consunption . On the bas:As of natSona7 .l mor4s7.9 .ty fi.guros it<br />
would appoar that a tremendous inercase in lung cancer had<br />
ooourred in the UnAted Stntes since 7.930 . There 1e, howover,<br />
much ovi.dence ava5.3.ab1o to chal.7.oage the accuracy of the morta-<br />
7.Aty t:t:atSati .efi . It in not gonertd3 y reaSi .zod that even i .f<br />
i.t had bc:en ponei.b7.e to dS.agnose lung cancer In the early<br />
decades q F this century there was no speoif9.o oategory In the<br />
vital stetAsti .cs 9.n whi eb to record the lung cancer deaths .<br />
7:t wa n not untiJ . 1919, after rev0.ni.on of the International<br />
Cod o , th[A: o].ae.si.Yioabi.on of lung caneer beeacne a statl.stioal<br />
reality .<br />
Xn 1912, A.ctl.er (5Y) In hLs famous text on lung cancer<br />
ori.tioai.ly ques9si.oned the accuracy of the eonsus reports<br />
amphasi.rSng thet thc incidenoe of S .ung cancer xas far greator<br />
thnn rca9 . :Laed . a'he tntaA nurnber of r•ocordcd lung cancer deaths<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
0<br />
•<br />
in tho tini .ted Scntes in 1914 wao 7.oen than 400 resuh5 .ng<br />
at?prm:i.m ateiy 3,000 by 1920 .<br />
On hebru2,ry )3, 1916, . the<br />
1871<br />
.TOUrnal oz'. Lhe Amerioan Medloai<br />
RosooZatjon cdmrnented od3.tor9 .a5.iy that the nunber of oases<br />
In the preeodi .ng 15 year taorSod wao so great an to al:most<br />
def.'v onumeratJ on but the ourrent nationai . figure for lung<br />
cancer doaths wau st9 .Si 5000c than 'r,o00 .<br />
X n 1930, .when the nurabor of lung oanoer deaths In the<br />
United States wae recorded as 2,837 Chova7 .i .er J'aokson (58),<br />
the pi.onoer in bnwiohoa:oopic di.agnoa7.a, htut records of almost<br />
500 casec;, . .<br />
.r.t i.s very apparent that the increase 5 .n 7.ung cancer<br />
cince 1930 waes baaod on greater patho9 .og :lca?l knowlodge and the<br />
devel.opment of toohnic ;us s wStir which to di.agnoao lung oanoer .<br />
tiowov or , the Report of the Advisory CanmS.t•tee states that a<br />
true :tncreaae Su luntg cancor hau ooourred and bases ito<br />
contention on evidence furn :?.ahod by otate cancer registries<br />
smd nocrapny recordo from 9.arge genera5l hoopitaSa .<br />
A'he pepori oitec the statistics in upstate Now York<br />
ahowf.ng an o.ve :ra(;c armua2 rato of inorease of 7 percent for<br />
m^lcrs and 3- 3 .5 perc:ont for females dur9 .ng the period 1g47-<br />
19b0 .<br />
LCho pn•ecentation of the data 91n this nvanner is most<br />
mi.s l oading . Rov3.ow of the total lung oa.ncer deaths In Now<br />
Ycurk Stato du rlngtho per i od wnder discussion ohowa that the<br />
rate oi' i .noroaaeo of lunp; cancer had 6ccl7 .ned from 42 percent<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
.<br />
•<br />
9 18 Y2<br />
botwec.n 7.940 anct 7.945 to a low of 18 percent betwoen 1955 and<br />
1950, 71n5scould not have oceurred in the presence of a true<br />
i.nor•ease of the dlseaee .<br />
The Yepcn•i ; a7.so cS.tes autopsy data from large hospi-tu7 .s<br />
where "diagnoet3 .c: acetn•ac,y has been uniforrn and exooilent for<br />
rnany yes re ." A ri,se In autopsy Snoi .denee In hospitals is not<br />
an index of au absoAute i.norease of the dieeaoo . It is well<br />
known that n€any factors nontrf .bute to autopsy inc9.donce amonfg<br />
which ar•e (1) increased patholo88.ca5 knowledge, (8) change In<br />
autopsy materl.a3l with respect to seX and ag;e (lung oancer 3 .a a<br />
dieeaso of oldor aC.e groups), (3) gr.•oater percentage of autop-<br />
s7.os of . "9.nteresti.nE>" cases, (4) chanKe ,in nature of oanos<br />
tmspita3.5.•r.ed, ennd (5) w9.der sel.ectf.on of population (clinics<br />
7.n medical centers uttract pat7 .onts frcuu 7 .arge areas .)<br />
The 1.nten sa f,nteroe.•t In i.unts eanoer primed by the ftrr.t<br />
sueocs sfu ) aurglnr.9l traatment by Graham (61) in 1933 arid sus--<br />
t•ainod by greater aw :orene€:vi of the dxsease has resulted in the<br />
hospitz.l r ;;Serra7 of nr3.ny more iung cancer cases with subse-<br />
cfuent Snr,r.•o&.ae i.n autopui-es .<br />
'a'he WpM r,cwipares the autopsy records at the Massaohusotth<br />
Genoral Ilospitai bntweer, the periods 189P•S RP9 and 195G-1963 .<br />
showing an inorease from 1'7 lung oancers to 172 In the later<br />
period• Fran the,se flgures it would appear that a true f<br />
.se had recently ocourred but an ear]t,er report from the<br />
.n•crea<br />
same ho Up3tar by IK9.ng (37) showed that the Lncreae.e had begun<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
10 1673<br />
as earl,y as 1920 and that by 1938 there wc :re 475 oases<br />
d9.agnosed of rl i ch IL5B had been confirmed by autopsy, bi .opsy,<br />
• or expioratory thoraototorn,y . King, who had porsonally<br />
9<br />
•<br />
observed the i.neroase An lung cancer hospita7 l adnrissions<br />
attributod it to @:reater interest in diagnosis and surgical<br />
therapy .<br />
Autopsy exporience in 7.rmg cancer in the United States<br />
7.aG€ ::ed eonsl.de.rably behind that of the Corman pathologl .o<br />
inetitut.es, In the 1931 edition of Uenke and Lubarsoh ' s<br />
tl,andbuoh der `pcw7e]l.cn Satholsohon 1lnatomlo cmd Histop,Ae, ol<br />
Nlecher's date on lung cancer inoluded roports of almost<br />
4 ,000 cnsos of whioh only a very sma11 percentage were derived<br />
from American souroes . The paucity of lung cancer autopsy<br />
reports !n the United States !.n the early decades of this<br />
century was not due to absence of the di.scase but to absence<br />
of knowledge .<br />
ThS.e is well i13ue :trated ! .n a ropnrt by Jaffe (59), in<br />
1935, rhowl.ng that lung oancer oomprised more than 113 peroent<br />
of all the cancers ot th e Cook County Hospi .tal in Chicago . Thie<br />
figure 9 .r.oomparable to the incidence during the present era .<br />
During the eame per•iod that Jaf'fe, a I'suropean trained patho7 .o-<br />
g7.et In 7.ung canc,er diagnoeis, found t•he proportion of lunp,<br />
oanoer to a15l cancers to be ] .R percent, tho: inoidence at the<br />
Vancouver Concmal IfospAtol was lees than two percent and was<br />
less than one percent at the University of Oregon (110) .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
•<br />
1)<br />
1874<br />
There has Leen oonstant prograss in the pathologfca3l d1,af,-<br />
nos5.a of. 1unF; cancer in a7 .7l e.reas ok' thc: world . A revS .ou: by<br />
Harvey (60) of the auLop(:y materlal s ,t the Royal YrAnoc GS .frc :d<br />
Hosp7 .ta7l in AustralS.a revealed an error of aimoat 20 pcrcemt<br />
in the d5 .agnoa4e of lung cance :r . Ther e are a7.so marked<br />
dS.Sferenoes In pathotogi.cai int'erpretati.ons during the present<br />
era s^.hen, accor2tAng to the Re p ort pa .t.ho :l.oglca}l diagnosis has<br />
been M .fox w .<br />
Spain (S .S .h.) In 3959 reported an 3r,crease In eqaamous<br />
ooi5l carc5.noma and a Goc3 .:xno 2n adenoearoinoma and presented<br />
th, .s ev7 .dence of the caroinoE'.en?.c effe.ct of cS .Garettes . In<br />
contrast, Y .ee and Ts'o (7.15) In 1963 found the autop&y i.ncS . .-<br />
denee of adC.P~GCAr63 .nGiGa to be AJ .meat throe ti .me s tha t of'<br />
sguamouu eerro?.noms . Onv factor reapons5 .b7.e for a eonsider-<br />
Ah1o portion o;, the lung oancer autopcy increase waa the<br />
obeorvatlon by Ya rnard (62) 3n Lktglar,d, and Karanor and<br />
Saphir (63) In the Uni.ted Statee, that oertain tumora formeriy<br />
dS.a:E;nor,ed ns sarccenas were, S.ncatuai5.ty, cancers of the iunn .<br />
The trensiem of thece oa t ceil tutnors from one oategory to<br />
Another automatically roau lted In P.n autopsy lncrease of lung<br />
canoor wh5.c+h wat; only appar•ent . The frequency of incidence<br />
of oo.t ce .l3l tumox• s v•r,r5.es r:9.th d5ffe:rcnt pathol .ogfata3 ldhft•weS1<br />
(116) :'oun(i that oat cell eancers cornpr :caed as high as<br />
S41 pe :vicent of n.].5 iun3; cs noe p s while many others found the<br />
i.nolderwe much lower .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
0<br />
0<br />
12 5'E?5<br />
7:t is Interesting to observe the di .sdain with whioh the<br />
proponents of the smokfcng-eancer theory reject improvernont In<br />
diagnosis as a ma jor factor In the increase of lung cancer .<br />
Neverthe ;.osa, every d9 .agnostio faoi.9 .i..ty used at present to<br />
deteot 7unt^ c:ancer wa,s either dlscovcmeR or perfected within<br />
tho past three deoader. - the perlod of the great inc reaso of<br />
:cung cancer .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Bronchosoopy, one of the most a .niportant diagnostic pro-<br />
aeduros, had boen aval.lab7.e f'cm many ,year•s but was scarcely<br />
used prior to 1930 because of unwarrantod anxiety as to<br />
possible hasa :ods . It is of hi .stori.oa7 . 9.ntorest that at the<br />
isrompton Hmapi.tc4 in X•ondon, renowned for speoi.al4.zation 1n<br />
pu3.monary d7 .scases, only one bronohoe.eopie oxamination had<br />
boon performcd prlor to 1925 . Wi.thin three decades the number<br />
of bronohosoopior, exceeded 800 pc:r year, .<br />
Nor more than a oentw^y physicians had been attcmpting<br />
to fiiagnosa lung cancer by exam9.nati .on of the sputum for<br />
frat;ments cotital.ning rna),i.P.nant tissue . Although suoeess was<br />
aohs.eve@ sporadi .cal7 .y, the prooedure was tedS .ous and hampered<br />
by technica7, dlfficaiti.cs . In the 1930's staintng teohniques<br />
mere deve9 .oped wh7.oh fe;ci .7.itated sputum exami .nation but the<br />
pr•ocess remerined ossontial7y a resoarch procedure . In 1943,<br />
Papani.colaou described a staining teohm :i.que which within a<br />
f.'ew yoars became app7 .7.cab7 .e: to the r•out5.ne examination of the<br />
spubum . 'the "Pap" smoar for cancer ce7 .1s In the sputum and
•<br />
•<br />
•<br />
13 1876<br />
broneh5al aspiratc has 00606 sign5 .ficantl .y to the dia€5nostic<br />
e.pproacb duri .np: the two dtlocados 1n which it has been ut5 .l .9.tied .<br />
SurgS.cail exp7.orat9 .on oPthe cheE:t is anothor procodure<br />
whAch has added to the no.rsbor oR cases dAagnesed, grS .ar to thr ::<br />
7 ;'h0's, exp7.oratory th.oraootomy was o4'ten oona5<br />
:.eat9.ona wcre .dexod e0 pro•oedure of laO resort and the indvery<br />
limited,<br />
SS .nc:o then rc-f3neinentr. In suxg; ;.ea3l t€ohniqtte and anesthesia<br />
have tuztio thin a :;a:Pe Fro< :edure with oY.•.dc dia€;nostio l.nd9.oa-<br />
t) .oilE .<br />
7.n 5.9k9, aP r.pori. %rout the Mayo (ri5 .n5.c by Johnson (f!`)<br />
showed that 50 percent of the lcmg canoers had beon diagnosed<br />
only after a urg3 .oa7 exploration . ArSng the past two doead e s<br />
Anto~eost In thoracic v urf.ery has S.ncre a sed tromendous3y and<br />
thonacotomy ts a rout7no procodu :re In ( :.xactical7.y all hosp5.ta3 :,<br />
dt .sc7 .esj .ng casec of 5.unp; cancer wh :i.oh wouad other•wise rema] .n<br />
undi.agnoocd . SurE7ery has E ;].so been of d5,agnost9.o value i .n<br />
the anoreasnd rutmber ot' biopsy oxami_nat7.ens utilizing now<br />
techniou e s .<br />
The C;A•ce;teet contribution to i,unE cancer diagnosis ttas<br />
bean the va :t znc:rease 4n Y,-ray
•<br />
•<br />
e.h 1&'l7<br />
a fa r crcater• reoogniti .on of lung canca r than was pr•eviourly<br />
poscd.b7.e . ClAn :tca! M expcrS.enoe has show n how easily lung<br />
cancer may be mistaken for 1',ncumoni.a, tuboroulosS.s, lung<br />
absoess, brain tunior or even abdom3.na7l dAseaso In the absenoe<br />
oP apprapri-ate di .apa',ostio invcstigat9.on . Plow much relaab :114.t .y<br />
can bc placed on lung cancer• mortai.ity stati.[sticrs duri .nE ; an<br />
era nhcn the disease sais not clinically di .at,nosab].e4<br />
ACCURACY :rN ])7:AON09l:£S<br />
Thc vast improvemontz 9.n diagnoct7e 4 .eehnAdueo have mado<br />
9.t possible to detoot £ :reater nu.mbers of lung cancers but have<br />
elso revoa7 .ed th a t there arc rnany pi.tfa?.ls An diagnosis not<br />
sunpeoted previ .ous"c,y . Autopsy studi.cs have shown that cases<br />
cP3.at?nor>od o2l.nica] .1,y ar, lung canoer, even with biopsy c:on-<br />
ftirmation, may actually be seeondary canoer.» . It is now ws:i.A<br />
established that thc lung has a great affinity for metastatic<br />
tumors and ths.t 30° 1b0 percent (a7.2,i .3.3) of a7 .7l cancers produoe<br />
secondary pulmonary gronths, some of wh5 .ch may simulate<br />
br.•onchacen:te carcd.ncana . Llhen non-pulmonary cancers spread to<br />
the bronch :ca l tubes a9 .il the rnani9os;tations of primary lunf ;<br />
cancer may bc reproduced recultinf; in erroneous diaf5noses .<br />
In apite of all the progress m'.de in d9 .ai;nostic techni..yues, a<br />
ponitive di.fsorent9.ation between prRmary arrtl secondary lung<br />
cancer m^.y not be pocs, .ble t:i.thou.t autopsy exclusion of other•<br />
pri.rma :ry sltes .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Tho present oJ.essi .fi.cation ttf lung e.encer dc
15 ] f>'78 a<br />
two cate€:orles : ( :c) xungg eancer, r,pocffied as prinkary ; and (2)<br />
lung eanoor, unspocfficd as to primary or secondary, ISxami .na-<br />
tion of lung cancer rnortalAty ntati .stS.c ;s fo1' 1961 and 1962, the<br />
7.atest years for whi.ch dtat have been completed, reveai .e some<br />
interos'c9 .nQ factE+ .<br />
k'er the year 1961,.out of a tota7l of 38,929 lung oancer<br />
deaths, on7y 7 .9,1s6? (50 percent) were spec5.ff.ed as primary<br />
lnny, canr,er. . For the year 1962, out of a tota7l of 41,176 lung<br />
canc+er deaths only i.G,866 ( 0 6 percent) were spooffY.ed ae<br />
prima r ,y . The renvalndess raere unspecif4od which means that the<br />
lung canc:ers rnay have been primary tn thc+ lung, or, may have<br />
sproad to the lung fr.om tumors origA .nat:i .ng 7.n other organs .<br />
Phc stati .sti.cAan amd epAdemiolog?.et, 7aokt.nr experience<br />
i .n o3 . :i,nioa5 M d2a gnoe:tic probl.ems, are o,t,•ten totally unaraare of'<br />
the dfifYLcu9.ties 1n d if£'orord;iat7.ng beto:eeh primary and<br />
seoondar,y7 .un(; cancer• . Even when oaset: are specified ao prA .<br />
m?nry S.ung oancor thS.s docs not neooesariJ .y mean that the<br />
diagnosis waa correct Sn a17. oason .<br />
Xt has bcccane zncreasinf59 .y apparent to olRnlofans and<br />
patho3og S.sta mork9 .nt: 7.ti the S9e1d of ].urn; cancer that sputum<br />
eY.ami .nati.ena for cancer OelLs and even biopsy exanlAnations may<br />
yie) .ct ni; .u7.cad9.ng lydormat, .oa . Ureat reli .aneo i.s pS.aced en the<br />
h? .E;tolog9 .ca1 f? .ncif .nfs obte,5.ned by examfn ation of t, 1ynmph node<br />
or of' bronchial tissue but, posStAve di .fferonti.atlon butrreon<br />
pr).Iiler.Y and secondary ea.neer's is not a .LWaya possf.Il7 .e .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
•<br />
)6 1879<br />
ln a recent aUtOpGy 6tudy (65) of cancer of the pancreas,<br />
it was Pound that ] .9 porcent of the caE46f: bad been di.agnoE .ed<br />
dmd,nE, Wb ac primary lung oancer . Other reports of<br />
crroneoousl .y diaCnosed lung canoera on the basis of biopsy<br />
examination have ineZu.doc canoers of thr, k3dnoy, adrena :e,ovary,<br />
thyro?.d, st.omaeh, and reetu .m, anas muoh as the cases apeoY .f9-ed<br />
as pr :i .ma•ry lung cancer were not aA1 autops] .ed, there is a<br />
si.p;nificant potent?.aR nouaroe of error to be conoiderod .<br />
The Adv9.cor3 Conmittee to the Surgeon (leneral pleoed the<br />
(,reatost reliance on atr..tSatf.cal oomputati .ons in arr9 .ving; at<br />
i4.e conc7-usions o.rf a eausai rolationshtp botween smoking and<br />
Aan" canoer . The Repm•t atstos, "In reoent years, about two-<br />
th3.rdn og the cortiiacation of' lung cancer deatha have boen<br />
basod on m:e.oroscopS,o extmeinat5.on eS' tisuue from the primary<br />
e9.te and the porcentage As oven higher for deaths under 75<br />
yeurs ." The two rePerencea cited to vaJ .f.date the above state-<br />
eaont appear as vory tenuous endorsements .<br />
Onc report (66) te an evaiuat9.on of ac:curaoy 7.n a sor.ies<br />
of 1,L}S7 death certiPS .oates 7.n Pennsylvania . The oonclusion<br />
with respect to prl.mary lung oanaer was ba ted on a tota3l of 21<br />
c:ases wp.th no raention m,vde of the number of d9.a4nosos based<br />
on autoto ;y .<br />
The soconii rcY.orence (67) dp.scusses the general aupoots<br />
of ca.nccr citagiwsi.s but prersonts no partieufi.ar data on primary<br />
lung caneer• . A etudy brse+d on 27. lung aaneer cases without<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
0<br />
0<br />
17<br />
i88o<br />
autopsy c onfirmat7.on is 9.nade0uato authority for a bronG state-<br />
ment i.mp3ying that over two - thir ds of all the lung cancer<br />
deaths were confirmed patho3.og9.ca11.y .<br />
IinPl.i 01+ 1NCRFIASE<br />
The so - caJ.lod sbpidemic" r9se In oortS.f7ed lung cancer<br />
dcaths In the United States has followed a pattern that, when<br />
serutinSZed ob,9eoti.vely, is more indicatS .ve of progrese in<br />
dlagnos5e: than of a true i.norease of the diseese . This<br />
pattern shoces a proGresef.ve deeline in the rate of increase<br />
of lung cancer and was fully elaborated upon by Gillian (66)<br />
In his stndi.cs at the NatSona1 Cancer ansti.tute, It is<br />
regrettable that the Ac3visory Commlttoe ciis:reaarded this signi-<br />
f i cant eontrfibution to 9t o epidemiolog,7.oa1 consi.derations .<br />
The earlS.cat statistAes avaAlab:ce (Pab:!e I) show that the<br />
number of cort.7.fS.ed Lung eancer deaths in the United States was<br />
373 in 1 9 14 , and 956 in 1920 . A3.thoup,b these figures are rd.d3.c-<br />
ulously low when corepared to the 7,ar(,e numbr.rs of oases re-<br />
ported In hluropean Anstitutions during this era they represented<br />
an l.ncrcase of more than 1 50 peraent, A comparable trend was<br />
noted In the reco-rdc of the Nuatropoli.tan liife Insurance Company<br />
which uhowod an increaee of 3 00 percent In the standardized<br />
annuel dcath rate from 3ung canccr among its po3.iey holders<br />
betwcen 191 7 and 1926. It is to be emphasis:ed that this tre<br />
mendous inorcase ocourr& before the era of widesprea d<br />
ci.C r,rctte emolc4ng . In the succeed :t.nF; yc'ars the total numbor of<br />
lung ccncer oascs incr. ca.::od but the rate of inerease decl.ined .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
_18-<br />
TABLE I<br />
MORTALITY OF LUNG CANCER IN THE UNITED STATES .<br />
r>~~ Yea Ni i mbe' x of De a t~is " Percnt e I nc rease<br />
~<br />
1914 371 (No comparative data)<br />
1920 956 158<br />
1930 2,357 146<br />
1935 4,237 '/9<br />
1940 7,127 . 68<br />
1945 1.0,922. 53<br />
1950 . 18,313 67<br />
1955 26,827 46<br />
].960 37,500 39<br />
w Data for 1925 not available<br />
YearF<br />
1931<br />
1935<br />
1940<br />
1945<br />
1950<br />
1955<br />
1960<br />
MORTALITY OF LUNG CANCER IN NEW YORK STATE Number<br />
Data for 1930 not available<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
TABLE JI<br />
. of Uestha Percent Increase<br />
i;Sl
•<br />
0<br />
18<br />
Setween 1930 and 1935 .the tncrease was 79 percent ; be-<br />
tween 1940 and 1945 it was 53 percent ; and between 1955 and<br />
1960 3.t was only 39 peroent . A comparative study (Tab1e 11)<br />
180<br />
of the lung cancer mortality statlsti.cs of New York State (no<br />
fi gures avai7 .ab7 .e before 1937 .) ohowod the greatest- rate of'<br />
increase, 64 percent, between 1931 and 1935, Sinae then the<br />
ra.te pro greeci.vely declined and botweon 1955 and 1960 it was<br />
only 18 percent .<br />
FJow As it possible to reconcile the declining rate of<br />
increase of lung cancer with the 200-PoJ.d 9 .ncrease In oigarette<br />
consumption during the same period? 7Y tobacco is a cancer<br />
producing agent there should have oecurr•ed a progres0ive rise<br />
in the rate of I ncrcase . A logical exp7anahion for tho pro-<br />
Rressi.vo dcoxi .ne In the rate of i.ncroaae In that 1t is a<br />
ref7.eotion of the increasing ability to diagnose lung cancer<br />
durinf: the past three decades .<br />
In the early 1930 ' s the mortality attributed to lung<br />
cancer was 9.ncr.eas ing among the white male population at the<br />
rate of epproxi.mate9.y 10 peroent per year . Phereafter, this<br />
purcentage declined regalarly and by 1958 the lung cancer<br />
deaths were increasing only at the rate of 5 percent annually .<br />
Among tho whito female population, the rat e of lnerease de-<br />
clinod fr•om approximately 6 percent per year in the earlier<br />
per] .od to about. a. Perc:ent in 1958 . mThe recorded ] .ung cancer<br />
deaths amung the non-whitc popu2ation, ai .thougk much smalter<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
411<br />
f~ 9 1883<br />
in number, showed the same downward trend in the rate of in-<br />
crease . The hSk:her rate of lncrease in the norrwhi.te popula-<br />
t5.on wes consistent with the acee3.crated i .mprovement in<br />
rned9.oa 2 £aoii .ities In rcccnt ycars for thi .s group .<br />
The progmeosive dce] .ine in the rate of increase is a very<br />
cigni.ficant factor in eva7.uating the earoinogenie effect of<br />
tobacco . If smoklnpg produced lung eancer„ directly or i.n-<br />
direc:t3.y, the incroascd consumption of eigarettes would have<br />
resui .tcct in a sustai.nect or greater rate of inorease . The faet<br />
that the oppor,ite has occur•red implies that there is a rela-<br />
tivciy fi .xed preva7,enee of lung ceneer in the population and<br />
that w i .th each succood9.ng decade the 9.mprovement In df.agnostic :<br />
tochrri.gucs resulted In the recognition of a greater numbor of<br />
casee. . .Nentua79.y, the incidence of lung oanoor wi11 bo<br />
stabi7 .i.•r•ed as it has boen for many other canoers in which the<br />
i.nvesti.gative procedures have boen standardi.wed for long periods<br />
of ti.rne .<br />
The expa:ri.enee in the dec2ining rates of i.ncrease of the<br />
certified cases of lung cancer i.s very ¢ind .lar to that which<br />
or.curr.ed in the Qerman pstho7.og4c institutes in the late 19th<br />
and ear] .y 20th centuries . This was the era when the diagnosis<br />
of 1o.ng cancer cou.ld onRy be definito7y established at autopsy .<br />
In aa.mo.a e11 of 4ie major hospitals the rate of increase<br />
fo3.lowcd a definite trend conr,isti .ng of a suddon rise, oorres-<br />
poind7 .n,rc, to the period in whioh pathologie diganoatic eriteri.a<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
•<br />
20 188 1s<br />
iuere estebi.ishod, £o1l .uwed by a decAine in the rate of in-<br />
crcaso as the diseaso beoame better knortn .<br />
At the Moabi .t Hosp :tta7. In Bor19 .n, Wah1 . (69) £ouna a 300<br />
percent inorease in the percc:ntaC;e of Aung cc:noers to all<br />
cancera between 1917 and 1 .92, . The £o1.1ow).ng year the rate u2<br />
i.nereaee had Boclinod to 17 percent .<br />
Schonheri• (70) reportcd simfi-1ar £indi .ngs at the Pathoio-<br />
gTc Hyg9.eni-o :Inst9.tute of ChomnS .trl cotnpari .ng the periods<br />
1Sy8 .4 .9i.6 and ] .9i9-7.92fr there was a 110 percent increase in<br />
P.ung cancer autopai .cs wh3.ch S.'e11, to 24 percent in the next :<br />
Sou.r years .<br />
Comparab7 .c ohscrvntf.ons (seo Table 71:T) wore made by<br />
Matorisa (71) in 7S^oppau, by SohSesingerr ('(2) in SsRpef .g, by<br />
I .M€;enu) .f (73) in Gotti ..ngon, and by t,olxcr. (7ib) in Prague .<br />
At St . FtarthoRome w 's Ftosp',•tal in hondon, MitaxweA l and Niohol--<br />
son (75) fovnd that the qrcat increase in the autopsy In-<br />
ot..dence of xun;; cancer had occurred betwoen the periods of<br />
1884-3.888 and 7.89h - 1.898 .<br />
Tn u rapli, i .ncrease 5 .n the inci.de:nce of a disease when<br />
now c7.i .n5.ea1 or patho l ogi.ca7, d7 .agnosti.o teehniques are Antr o•-<br />
dncod has beon obazervod repeatedly . An exoe3 .5 .ent example is<br />
endobronchf.a5l toberoul .oci.s, a very common eomp7.icat9.on of<br />
pro€:x" o asive pulmona ry tubercul .osi .s . The condition has been<br />
undetreted by pathoi.ot;4sts in thoucands OP aatOpsios pe.r£ormod<br />
in L'hie e.ountry and alrroaci . 1n the early 1.y30's elinical and<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
III<br />
•<br />
.<br />
21 18 5<br />
bronctmsoop :i.o stud.i.es establ5.shed the ex1stermo oR' endobroru+hIai<br />
tuborcul .as4s 2nct th3s wass ref3.eoW immediately In a tremc,ndou .e;<br />
>•?.eu In ncepopsy i .r,bi.dence .<br />
Tho Re P ort .of the Advi .sory Oommi .tteo states (page 135)<br />
that 'lung Cancer rnortal;cty amon g males has ri .sen at a fai.rly<br />
cormtant rate o,.nce 7 .9;,0" end ctt.e ;. rordon, et a1 . (76) of the<br />
1'ationaa l ( :enc:er :[nst.i.tutc as refe :venom . hovtever, there seoros<br />
to be anmc dlsdarAty betrreen the i2eCior t' e :intprprotatior, a .nd<br />
OordoW art.i.c2c: xxhich statos, "hor, wh3te males a.nd fomales<br />
cun d for nom uhi.to met2es the 'inorease In Mort.a5.ity for cancer<br />
oi' tho }.ung: and bronahu.s ttas greatost between 1950 and 1935 and<br />
hae s :inoc tenQod to decezerato ." '.!'ho a.rt',.ole a3r;o noted that<br />
the 7 .norense i .n lung cancer mortality began xf.multanoouel.y for<br />
•r,17l ailu5.t uge 1;:rouC,s suf;gereti.nE i.t was c :aucied by i.noreared<br />
diaCnos,t ; .c c,warones,e .<br />
3NrC U%;TR7EtpV7073<br />
Canaer c,f.' the ].ung oecu,rs gredor;tinantSy among males .<br />
]n the Un7.ted 9tatea in 9 . g30 there s¢ora 1,Li ;18 lung cancer<br />
deat.he In maie s r.nd 1,039 in fema :ces (rati .o - 1 .$ :1 .) . 7n<br />
7 .9 h 0 thore were 6,0 5 ( mcilos anfi 2,029 femalo 7.ung caneor,<br />
deat.hs (ratio = 3 :1) . fA deocdc la,ts:r• the :re meme 14,922<br />
rncito and 3, :i97 1 fem,9.o doaths (ratp.o =1l .11 :3.) . For 3$60 the<br />
.il,ure& worc 30,800 m :e2ee and 5,000 fen a les (rati.o , 6 .2 :1) .<br />
9'hm h,nof;rossa .ve w i.dening; of the eox rat3 .o QurAn g recent<br />
[iecauc :: h„s baan :i.nterprcted by many 06 an O.ndloat .ion of<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
-23_<br />
TAELE III<br />
LUNG CANCER IN EUROPEAN HOSPITAI .S IN . .,<br />
LATE 19TH AND EARL~TH CNTUR ESI- .<br />
. _._._~.~<br />
Percent<br />
Total Percent<br />
City Institution Author Years Cancers Increase<br />
. MOABIT Moabit<br />
, Hospital<br />
Wahl . 1917-1918 3 .53 ' .<br />
1923-1924<br />
. 14,08 300 1924-1925 16 .45 17<br />
1925-1926 12,35 . ' 0<br />
1926-1927 13 .10 ,' 6<br />
.<br />
. CHEMNIT7.PathologicBriese 1898-1916 4 .51<br />
Hygienic<br />
Schonherr 1919-1922 9 .50 ,1 .10<br />
Institute<br />
1923-1927 11.80 24<br />
TROPPAU Pathologic Materna<br />
. Institute<br />
.<br />
ZURICH Pathologic<br />
Institute<br />
. .<br />
LEIPZIG Pathologic<br />
Institute<br />
' .<br />
:<br />
'<br />
Probst<br />
Seyfarth<br />
Schlesinger<br />
GOTTINGENPathologic Feldnea<br />
. Institute<br />
. Simrosa<br />
Engenolf<br />
DRESDEN<br />
PRAGUE<br />
.<br />
.<br />
L`riedrichstadt, Reinhard 1852-1876 0 .92<br />
Hospital<br />
Wolf<br />
. Junghanns<br />
1877-1894<br />
1893-1912 6.46 600 .<br />
. . 1913-1927 10 .73 24<br />
Pathologic<br />
Institute<br />
Holzer 1895-1 .899<br />
. . 1905-1909<br />
. 1915-1919<br />
1920-1924<br />
1912-1914 2 .08 .<br />
1915-1917 7 .14 :240 .<br />
1921-1923 8 .00 12<br />
1906-1910 1 .13<br />
1911-1915 3 .34 190<br />
1916-1920 6 .12 83 .<br />
1921-1925 7,17 .17 .<br />
~ 1900-1906 5.01 '<br />
1907-1913 --<br />
1914-1918 11 .23 120<br />
1924-1929 13 .20 .18 ,<br />
1852-1879 0 .62 . ' .<br />
1880-1908 0 .90 , 61<br />
1906-1912 2 .59 190<br />
1921-1927 4 .43 70<br />
0 .78<br />
2 .24<br />
4,81<br />
7 .98<br />
. IANDON St, Bartholomew's Maxwell 1884-1888 3 .91<br />
. Hospital , , and 1694-1898 7 .83 100<br />
Nicholson 1904-1908 7 .1.7 . 0<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
190<br />
110<br />
66
0<br />
•<br />
27<br />
f;E'cater diF.C'.noGt'J.e acCur2cy 7.naGmUAh FiBfl lunf( cancer has been<br />
found to be: p.°ti:cinNAn :ant :i.y a d5sea :>e of ineQr,c . In 1c)i:7,<br />
C7.enmtonsee and l:usk (77) obr+erved that• the Sung cancer sex<br />
rat4.o 9.n ]knrna :r•k between 1936 and 1945 vas 0 .4 :}1 urhereae the<br />
ratio in a spocSta7l diagnostic c].3nie S .n Copenhagen rcae 7 .2 :1 .<br />
( I'hie wc17l iurown cstudy tc v s ornitted in the Fceport) . Lou sex<br />
r.ctioa wcrc foo.nd In many of the iung cance+r stud2ec £n the<br />
ifsG7<br />
19th century and reflooted the d, .Rlf.'4.cultieu in diffcrenGAttt4ng<br />
beto:eon primary and metaetatic irnrolvement .<br />
The dAsparity<br />
In eerx d i stribut5.on han led to assurnptiona by those unfrarniiiar<br />
v:?.th f:ho b9-ologloal cha raetesn9 .sties of tho d4 .xe:ase that<br />
grredomi .nsance In the male 3.si the rosu7.t o f heavicr smokLnC<br />
habitu . Tho validity of this inter•pret-ntion ie readily<br />
cha) .icn['.ed by (3 .) sox fi :iatribut9.on of lung cancer before the<br />
cra o t cif;arotte smokir,f; and (2) th¢: 1.ack of any effect of the<br />
i.neree,csed oonsumpti.on of cigarettes by females on the sox ratio .<br />
7t in epparent from Tabie IV that 7.ung cancer was predan-<br />
inant5.y a dS.senso of ma7.ec during an cra in whteh o9 .garette<br />
eruck ;.ng ncs vi rtua5.iy non - e:a.lstenL . YLot?t nf the studies shota<br />
a fie>: ratio of at lea[tt ,jt1, and eome rAre co0lparabl .e to<br />
rati .os roported ya5.thin the p, ;ct de.oado . I0 S.n of considerabie<br />
interce:t thet as car7 .y as 1895, Wo1f'a c:asen of "prirnre 1unGOn-<br />
krehe" from the Areodmn municf.pal hosp5_tals shotued a d9,utrS-<br />
but9.on of 6 :73 favorF.n{6 thn rnnle, and Passler, 9 .n 1896, found<br />
a ratio oli 3 :1 in h eeJ`J.ected Se1.^i.ea of 68 eases .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
Aut tl'-or A _ .Years_<br />
-25-<br />
. TABLE. IV .<br />
1866<br />
SEX DISTRIBUTI.ON OF LUNG CANOER ,<br />
BEFORE CIGARETTE SMOKING ERA . . .<br />
Place<br />
as `-~ -~es<br />
Fema R_aCio<br />
Hare, H . 1630-1880 Collected Series 90 33 3 :1<br />
Buday 1870-1888 Kolozsv6r 9 ! 1 9 :1<br />
Harris, V . 1882-1891 London . . 52 17 9 :1~<br />
Passler, H . 1878-1894 Collected Series 50 18 . ~ ~ 3 :1<br />
Wolf, K . . ~ . 1885-1894 Dresden 27 ~ 4~ 6t1<br />
West, S . 1897 London . 47 14 3 :1<br />
Lenhart:z 1893-1899 Leipzig . 13 1' 13 :3<br />
Feilchenfeld, J . 1894 -1900 Berl in 20 ' 2 ~ . ~ 10 : 1<br />
Riechelmann, W . 1895-1901 Berlin ' 21 ~ ~.6~ 3 :1<br />
Watsuji., S . 1904 Berlin 4 1 4 :1<br />
Redlich, W . . 1900-1905 Berlin 26 5 5 :1<br />
Haberfeld, W . 1887-1906 Vi .enna' 48 . 20 . 2 .4~:1<br />
Karrenstein 1908 Berlin . . 24 8 ; 301<br />
Feldner, 0 . 1908 GBttingen . ~ 6 1 . 6 :1<br />
Seydel 1900-1909 Munich 16 4 4 :1<br />
Adler, I . 1842-1911 Collected Series 269 ~93 . 2 .9 :1<br />
Dormanna, E . 1901-1911 Munich 7 . ~~ 1~~ ' ~ 7t1<br />
Weller, C . 1878-1912 Collected Series . . 70 17 4 :1<br />
King, I> . 1875-1914 Boston 36 9,'~ ~ 4 :1<br />
Rau , W . 1909-1914 Dresden-<br />
. Friedrichstadb ~ 2 . . ~ 6 .5 :1<br />
Briese 1898-1916 Chemite 44 : 16 . 3 :1<br />
Lavrinovitch 1915 Petrograd 42 . 19 ~ 271~ .<br />
.Jeff6, R,' 1915-1918 Vienna ~ .~ 92 ~ 8~ - ~ 11 1 1<br />
Passey, R .'~ ~ ,1894-1918 Great Britain 579 . 182 . . ~ 3 .2 :1<br />
~ Rau,-W.~ ~ . 1914-1919 Dresden-<br />
Friedrichstadt 22 5 . . 4 .4 :1<br />
Eichengrun, W.' 1902-1919 Cologne ~ ~ ~ 32 ~ 5 . 6t4<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
0<br />
•<br />
•<br />
, :Cn t,'arG'F YathoJ .ofy, 11SnAcyt }tiRtory Entd ll4.oCnoaf,c of<br />
Af'SOCiS,onc, o,. vhe t+ledAaciinura, puhliahed In 1889, the ratio<br />
was a].ao ;Sr1 In a eox•Aes Gf 122 oaeoa . Narr1[:((8) S.n<br />
1892, made a comhf .ned Etudy of St , Hsrtholomewrs Hospltal. and<br />
at tho Of.ty o. London HotepAtal f.c¢• llircaeeu of the ChosC and<br />
found a ratio exceediuF+, 3 ;1 . Lonhartz (79), 9.n Leipzig, ro-<br />
ported a ratio o5' A :1 In 1699, and P'ef.iohenk'eAd ( 52), in<br />
1901, a ratio oS 7.Of1 In Berlin .<br />
Yredanf.nauoe ox lung cancer In the male in the 19th<br />
century waa ev :Lder,t In both the J.ndf.v2dual necrop[+y atud9.ee and<br />
In the oo3loctCd sor7.Os of cases . Ad) .orra ( 5 () oollected<br />
B!].`P .CO apsnncd more tt,an seven deeadee and included caaee Procn<br />
London, i'raruo, l3oriin, Jetia, Heme, kar3.a, li7 .aaS;ow, St . Petero-<br />
burK, Zur :ich eud evcn Hrookiyn .<br />
ISOOp :ite the varlet.y oY rxoux•ooa the overal]l tO.oCure of male<br />
predilee0 :eon was v3.md1ar to Roichoiraanr5 (!30) report In 1901,<br />
f.'rem the J+rof .dr5.chohn.6.n klo ;rpital in Hor1in, Karrenetef .nre<br />
(56) 7 .n 1908, from the Un:rverr,ity oP Se r7.in, and Hriesera (E31)<br />
report, in 7.916, from the Patfiologic - HyOi .enP .c+ xnP;tit'ute of<br />
Oh 9mo7 .tz . Weller (£Sf.), who wae among the first Amer4can pathoi-<br />
ofrgr;tr; to bcuome 5 .nt-nrestod In bronoha5onf.o earcfaioma,<br />
reported, in 3913, a uorf.ecs of B7 eol9 .eetect oaees with a sex<br />
ratio of.' 1y ;}„<br />
]:n eoorno 9.octanoor; S .t wae: possible to £'o11ow the sex ratio<br />
of !.unfr, cancer thr-euf;h aevera7M per9.od ;:s 1.n the sarne Snetitations .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
lip<br />
•<br />
III<br />
21E iF590<br />
In 1.925, L%orbl.inger (83) completed a noorospy st•ady previouely<br />
arif;f.natcd by Laesohka at the Pathoi.ogio 1nst3.tUte of Jena .<br />
Lung cancer prorian9 .natod In tho male for ear :h 1.uatrum beginning<br />
with 1910, and the ratio £or the 15-year poriod was 4 :1 .<br />
Poterc (8 0 ) found .a rati.o of 3 : 1 between 1905-1908 at the<br />
P7oabit and Urban Hospitals of Seriln and a ratio of 5 :1 be--<br />
twcon 1 .917--1922 . At tho Dresden and B7rdodrS .chctadt hospital.s<br />
and nursing liornee, Junghanns (85) found a ratio of $ :1 in the<br />
per5.od 7.893-1897 and again In the period 1898-1902 .<br />
Dormanne (8f,) found a sox rat9 .o of almOSt 7 :1 at the<br />
Un ;.voruity o£ Munich in 1901-1911 and agair, in 1922a.931 .<br />
In ColoBnc, L•'ichengruni and Essor (87) found a ratio of approxC-matel<br />
1919 .<br />
y 6 :1 In the period 7 .902 -1914 and a 9 :1 ratio In 1914-<br />
We of therroet aignif'ioant studiec+ wa .s that of Passey and<br />
ltolmes (BG) £ro :u a group of teaehing hospite .ls in England and<br />
SeOtiand cOver9 .n[( a periRd of move than ;i0 years and inolUd.ing<br />
the cree boforo and after the anset of hoavy cigarette smoking .<br />
T;r*y found a se.n rata.o of 3 :1 for each of the periods 1894-1898,<br />
1.899-190z, and :i909-1913 . 7letween 191lI-3918 the ratio wae<br />
4 :1, and betwoen 1919-1923 it was again 1 :9. . The highest ratio<br />
was 4 .5 :7. wh9.ch occurred in the period 1924•-1928 .<br />
Thc offd.nA.Oy of lung cancer for the male was present before<br />
and after the onset of the a ;.f;arette smoking era . Some of the<br />
pex ratios in the 19th century reports were actually higher<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
411<br />
41,<br />
25 1895<br />
than those obtained ! .n recent studles . The alleged oorrols-<br />
ti.on betwoon smok? .pE, and male predominanoe of lung oancerr is<br />
based on a statistic.al aasooiat-ion which S.Cnores the faot<br />
that t•he disease favor.ed the male whon cif;Arette smokine was<br />
soarcely known .<br />
T h?.o point was emphaeized in a report: by Tbrahim (89)<br />
from the Dacca Medical Co9 .lego Hospital In Ea st Pakistan where<br />
he found a sex ratio of 9 :1 in a group af 20 lung cancer<br />
oaaes whioh 4 .no :Luded 1f : non•-smokexre, 4 occasional smokers and<br />
2 heavy smokcrn . Cigaretto smok3.nC is a rrarity 1 .n l ast<br />
Yuk :latani the popular method of smoking is the hukka pipe<br />
w).th the water filter .<br />
LUNC CANCER I1V NLM0.LES<br />
T.here has boon a progrowa9 .ve increaoe In oigaretto<br />
coneumpt-S.on by mo:nen for moro than four decades . A survey<br />
of smoking patternr, by the U . S . Bureau c£ the Census In 1955<br />
stated that 7.8,000,000 women, 18 years of age and over, had<br />
reported uae of tobacco, and that 15,000,000 had at one time<br />
or anothor been reKUlar cigarette smokers . The corresponding<br />
figuroa for rnon were 38,000,000 and 31,000,000 respectively .<br />
The survey aoknow7.edCe>d that 9 .t had underost'irnated cigarette<br />
oonou.mpts.on by 15 peroent on the basis of comparable tax<br />
data, and common observatP.on sul;gosts even a greater margin of<br />
oxror .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Ae.cord9 .n€r, to the varA.ous prospeotive and retrospective
ill<br />
•<br />
•<br />
26 18,10<br />
studioc<br />
cigarette emoking is a1lefSed to be a potent oaroino-<br />
genie agent . 1t ls difficult to reoonoile this conclusion with<br />
the oontinued predominance of the diaeaae in rnales despite<br />
the prodf_gious rise 1 .n cigarette eonstun.Xkion by femalea . Ucr-<br />
Ang all the years of incroase female smoking there has not<br />
boon the si7.ghtest narrowi .ng of the ae x ratio indioative of<br />
a rolative ine :cease of 1u.ng cancer amon .g women . Xt has already<br />
been omphaoASed that the sox ratio han actually widened, . Inas-<br />
mo.ch aa di.agnoatic faeilitiea are equal7y avail.able to both<br />
seY.e6y it S.a mora logiea7l to a6ablme that the predominance in<br />
rnales is the result of sex predileotfonc of the disease<br />
rather than of srnoking .<br />
Data from the U . S . National Offiuc of Vita1 Statistics<br />
ahom that lung cancer death rate bet.woen 1930 and 1958 i.n-<br />
cmeaeed twclve ti .mes fcr men and three times for women . The<br />
greate.at inoreaae among women occurred betvreen 1930 and 1 .950<br />
du.ring whloh t?.me the rato rose from 1 .5 per 100,000 to 4 .0<br />
por 100,000 . Sinco 1950 .the rate showed little increase . The<br />
maieafema7 .e r•at i o w9.th reepect to mortality rates was 1 .7e1<br />
i.n 1930 apd 6 , 6e1 in 1958 emphasiaing the relative decrease<br />
among woman dur ;.ng an era of heavy cigarotte emoking .<br />
[4orta9.ity statistica in suoeeedi .ng years show no indioa-<br />
tion of changing trende, The total. inoreaae of male lung<br />
cancer deaths between 1959 and 1962 was 4 ,665 ." The increase<br />
'Mortaltt,v c:tatist7 .co for 1962 estimated by Arner},ean Cancer<br />
soc9.ety .<br />
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•<br />
.<br />
•<br />
2( 1893<br />
of femaie lung oancer deaths for the fnur••year period was<br />
333 casen, averaging iose than 85 caser., p er year .<br />
It is evident from the foregoing that the tremendous in-<br />
crease in cigarette smoking by women di,d not result In any<br />
comparable rise in lung cancer deaths w' In redu.ction of the<br />
sex ratio of the d7.sease, llaring the past few years the female<br />
lung cancer death rate has remained virtually stationary . It<br />
is soAentlficali.y Incongruous to attribute the etiology of<br />
iung cancer to cigarettes when niore than 15,000,000 regular<br />
womon smokers show an annual lnerease of loss than 85 cases .<br />
The rapld edoption of smoking habits by women about 40 yeara<br />
ag,o wouid have rosulted in a continuing epidemic of lung cancer<br />
Sf toba.cco woro the oausative a .gent .<br />
AOR DXSTRXflU'1`ION OIr TANO CANCRR<br />
Observatf.ona for oonsiderabiy more than a century have<br />
shown that lung canoer 1.s primarily a disease of older age<br />
groups with most caseo occurring In the 5th, 6th, and 7th<br />
decades . Simons (9.11) 1.n a co7.lected series of more than<br />
5,000 caaes found that $0 percent had occurred between 40 and<br />
70 years of ap,o . Lung cancer is uncommon below the age of<br />
40 and rate during the first three deoados of life . It is<br />
seen, In irable V, that the predi7 .oetion for older age groups<br />
was noted cons9 .stentiy 4.n all the statistical reports before<br />
and after the onsot of heavy cigarette smoking .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
Walehe, W. 1846+<br />
Reinhard, W. 1876 +<br />
Hare, H . . 1880 + +<br />
Buday<br />
. Before Onset of Heavy Cigarette Bmoking<br />
. 1888 +<br />
Harris, V. - .1891 + +<br />
Pessler,'H, . 1894 +<br />
Wolf, R. 1894<br />
West, S,-r 1897 +<br />
. Lenharte 1899 1- +<br />
Fellchenfeld, J . .19D0 + + +<br />
• Riechelmenn, W .<br />
Sehrq E .<br />
: Watsuji, S .<br />
Redlich, W .<br />
HaberEeld, W,<br />
%errenstein<br />
Seydel<br />
Adler, I .<br />
Dormenns, E .<br />
'Weller, C .<br />
Ring, D .<br />
Rau ._ W .<br />
Brlese<br />
Deced~~<br />
AuthorYeen .4th• 5tn~ 6thy7th•_Bth .<br />
+<br />
1914 +<br />
-31-<br />
TABLE V<br />
F.GE DISTRIBUTIOM OF )JJNG CAWCER . , . '. .<br />
+<br />
+ +<br />
1914 + + +<br />
1916 +<br />
~~. •*Decedes in which meJority 0<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Fronccy, K .<br />
Henf, 0 .<br />
'Fiehberg, M<br />
After Onset of Heavy Cig¢rette Smoking<br />
___.~..sea 'I=f--_ . .<br />
AuthorYen[ 4th, 5th 6th, 7th1 8th i<br />
. Shennen, T, .<br />
Schonherr, E . '<br />
Wahl, S .<br />
;Mazwell,J,~<br />
Ruhn, C .<br />
Freemont-Smith, M . 1929<br />
Schlesinger, M, 1929<br />
Funk , E . . 1930<br />
Buschbeck, H . r 1930<br />
Sitson, A. '<br />
Jaffe, R.,<br />
Harvey, C .~<br />
' Halpert, B .<br />
ASng, A,<br />
Frled, B<br />
. Rosenblatt, M .~<br />
Ibrahim, M . ; 1953 .<br />
Sebour, M .,<br />
. 1915 +<br />
. 1960 MeoFarlene, l. 1960<br />
+
•<br />
•<br />
•<br />
2e 1695<br />
The age distribut9.on of lung cancer has a definite rele-<br />
vancy to the etiolo gAca7l consS.derations . It has been alloged<br />
that cigarette smoking produces a omnui,ati .ve careinogenic<br />
effect over a period of approximatoly two docades . If this<br />
concept 7 .s va].id, the sogrnent of the ei6;arr.tte srnoking popula-<br />
tion wh ;.ch began smoking in thecar.ly teen ages should develop<br />
lung cancer before 40 yetu>s of age . No indication of this<br />
has occurred in over 40 years o£ heavy c9.@:mrette smoking . Aata<br />
frona the Hori :d Ii;aJth Orf:anization shew a sirnilar curve of age<br />
dl.etri.buti.on in the United Statea, the IInit:ed Kirrgdom, Oor-<br />
many, and 'Staly with the greatest ncmrber of oases between 55<br />
and 6 4 years of ago and only a small proportion before 44<br />
years of age .<br />
The agc at tahioh the t.ung cancer patiemt started to smoke<br />
hao no relation to the age Sn which the di sease was aoryui .red .<br />
Patients whe began amokS.ng 9.n the early teen ages and those<br />
who began 20 or more years later developed lung cancer during<br />
the later periods of life, namely, in the 5th, 6th, or 7th<br />
decacie,<br />
kurthermore, there is no evidence that the lung cancer<br />
patg.ent who wae a heavy smoker developed the disease at an<br />
earlier period of 7i£e than the pat .tent who was a light smoker .<br />
If t.obscoo is a potent oarcinogen the arnount consumed and the<br />
duration of smoking should have some re7 .a.ti.onship to the onset<br />
of the ciisease . Yar,acy (90) studied the srookinA' histories of'<br />
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0<br />
•<br />
29<br />
115 men rrS .th lung cancer and f.'ound that they had acquired<br />
tho disease at appro x i.mateiy the samc age roCardless of'<br />
whcthcr e:mokinp, had becan started at six years or at 41 years<br />
of eige . :Ct waes also fov.nd that the number of e9 .garottes<br />
1696<br />
oonswned daily dS .d not 1nfluence the age of onset of disease ;<br />
the light smokcr wae. aPfoc ted with lung ctqioer at the same<br />
a ge as the heavy emo}cer. ,<br />
htfAi7AN OIT, tUNO ChNC} :}t PU 70).fL CPNCERS<br />
llu.r•S.nE; recent years lung cancers have comprised roughly<br />
1015 per•oent of a7)l eancers diagnosed at nocropsy and<br />
nat5.onail morta7.8ty statist5 .cs have followed a sflm5.lar pattern<br />
of di .etribut :Lon . It i.s of conside rablo i nterest, therefore,<br />
to obscrve that t•he same relat5 .onehip was present before the<br />
era of eigarette s+noking 1n certain }suropean institutions<br />
with a long hP.story o f experienoe in lung otnwor,<br />
M1uau:e?.1 and NAcho:i.son (75) found that between 1894 and<br />
1E98, the percentage of 1u.nt;' canooro to total cancers at the<br />
St . }artho5,omew's Hospital tsas 7 .83 . Bonaor (91)<br />
found the peroentage oi' 1.unf, cancers at the Leeds General In•.<br />
fP.rmary to be 13 .6 in 7.895, 8,1 i.n 1899, and 10 .9 S.n 1910 .<br />
Hampeln (92) frou :ui a :t2 .5 percenta &c betweon 1894 and 1899 at<br />
the IU . ga Nospito.l . In Dresden, a'unghanns (8Ji) found the por•-<br />
cont.age to be 1 .7 .6 between 1893 and 1897, and 9 .3 between 1898<br />
anf 1902 . Seyfarth (g3) famd a percentage of 11 .23 in Loip-<br />
e.i.(i betwcen 1 €inc3 3914 1938 .Jaff`o . and Ste.rnberQ: (9}+) foo.nd a<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
30 1 697<br />
] .0 .73 percentaEe in Vienna between the years 1915 and 1918 .<br />
Lipsch ;.tz (95) found 11 .3 peneent between 1919 and 1923 at<br />
the Nat:iona7 . Rouearch insti-tute in Zwiclrau . The large pro-<br />
• portion of Sun(; cz,ncern amc+nG tota7l cancurs in these reports<br />
is compar•r,ble to current reiationshipr. . In institutiona un-<br />
fand.liar with lung cancer the ratios were lower in the pre-<br />
cigarette ora and r•osc stcadiYy mith increaoinp, knowledge of<br />
the dise:ase .<br />
'i7iN• Rl~7'X107,WSCf~E . LiV1A$NCR<br />
'1'he I'ceport of the LuivYSm,y Committee oited certain patho-<br />
logical 9.nvestigations (96, 99, 125) as corroborative evi .dOnoe<br />
of a rela4.f.oneh9.p between smoking and lung cancer . The results<br />
• of theso investi .gatl.ons rhowed that patholog ;iea9l chances<br />
occurri .ng in the epitho5 .9.al . ].ining of the traohea and large<br />
bronchial tubce wero much more cornmon in smokers and in lung<br />
cancer pa t ients than in non - nmokors . 'fhere were three types of<br />
changes obucrve6 and each was found to increase with the number<br />
of oi.Earetten smoked ; among thc ex-ciGarette smokers, the<br />
changes wcuro far 'd.ess noF.loablo .<br />
The opeoi .fi.c patho7.oGi.ca1 changee were : (J.) loss of<br />
cilia of the surface cells, (2) hyperplaa9 .a of the basa7l oells,<br />
• and (3) the presexme of atypical ce11s . 73eoauee the changes<br />
vwre found 'xn smokera and in lung cance r patients the Report<br />
deduced that thcs.o chanCe,s, eepec1a11y the advanced stages, pro-<br />
bably represented prc-canoe r otts eondi-tionc . . In the 3udgment<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
31 1896<br />
of the Report, the missing link between smoking and lung<br />
cancer had been estabiishe:d .<br />
• There is, however, a major fallaoy in the assumption that<br />
these pathological changes lead to lung eanoer . The ehanges that<br />
wero found In smokors wore looated in those parts of the brom -<br />
chia7l tube:s In which lung cancer seldorn devolops : There were<br />
other significant inoorir,istencieE: . The advanoed pathological<br />
changes (oarcinoma-in-situ) were found equally distributed<br />
arnong the largo and sma17l bronchial tubes whereas it is now<br />
we11 established (126, 127, 128) that 7.ung cancer predomi.nantly<br />
originates In the smaaler bronchi, or, more peripherally .<br />
In a recent pathologi.ca7 W study of lung canoer oases<br />
• oporated at the Dootors ffospi.tsl during the past 15 years it<br />
wa :s found that almost 90 percent of the cases had originated<br />
in tho smallor bronchi or In the dista7l brcnohioles .<br />
The tendency for the alleged pr•ootu,aerous changes to occur<br />
in parts of the bronchiaA tubes seldom Involved by lung eanoer<br />
was aloo noted In a study (129) similar in coope to those<br />
cited In the Report . Yt was found that the most advanced<br />
changes ocourrod at the carina, the si.te of the largest<br />
broneh I , and that the chtmges were least evident In the smaller<br />
bronchial tubes whore )un g cancer develops most frequently . It<br />
was also noted that "bronehi.al epithc :Siu.ra may be perfectly<br />
norrnal In heavy smokers, even In men who have smoked from<br />
adoa.oocenoe and reached a oonoumption of 40 cigarettes daily .a<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
.<br />
•<br />
.<br />
r 7.8yy<br />
An interee.t£ng £.nadvertent eomtrSbut :ion to this subject<br />
S.s a study (130) of the df.utr£but£on of cigarette smoke In<br />
the bronch9 .a7l tubes . 7.t• waa dernonstratod that the greatest<br />
concentration of smoke oceurred In the 1 .argu bronchi just<br />
bea.ow the trachea, where lung cancer is n eldorn found, and the<br />
least concentration of emoko In the por7 .pher.all parts of the<br />
lung, where lung oancer Aa eommon . This inverse relation-<br />
ship bc+twoen the concontratlon of the i.nhaled smoke and the<br />
site of origin of lung canoer does not support a causal<br />
asson£atSon . The concentration of smoke was greatest in the<br />
parta of the bronchi associated with the most "precanoerous"<br />
ohangee• and the f'owest lung caneers .<br />
There were otherr paradoxScal results in the patholofS£-<br />
cal stud9.ea cited Sn the Report . The moderate and 7.ess advanced<br />
"prooanceroua" condit7.ons were found with groatest frequenoy<br />
in the iargo bronchia7l tubes whcre lung cancer seldo.m<br />
occurs, and wero found with least frey.uency in the small tubes<br />
Y'.here lung cancer coimnonty oeours . Tho findings of so many<br />
instancos of carcinoma-Sn-s£tu among the smokers was a most<br />
unusual observatr7.on .<br />
This 1eeSon 4 .s generally considered a rar•ity in non-•<br />
cancer patients and a su mrrViry (].00) of eleven other studies<br />
compr£o£n g almost: a thousarid non-canoer patients showed that<br />
caroinornn-9 .n--a5 .tu had occurred In only one Snatance . The<br />
Report savr fit to i.nc7.ude in its evidence a study of certain<br />
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w<br />
•<br />
33 19ua<br />
ce7.S.s in bronehial epithei .ium which wore presumed to typl.fy<br />
the ex-smoker . The a1leRed specifioity of these oe11s ia<br />
extremely douht :fui . . T.hey are de8enerated oe11s of the<br />
op ; .theJ.2a1 lini.ng in which the nuoleus has contracted to<br />
aaaume an eccentr3e position beeause of aeeUmulation of mucus,<br />
These oo].la have boon observod in many inflammatory conditions<br />
of the respiratory traot . They may also be found in the<br />
natal sooretiona of smokers, and non-smokors, alike, who<br />
happen to have coavnon colds .<br />
7t must be emphaaised that th e allc[;ed preeanoerous '<br />
ohangesv observed in the bronchia7l lining of smokers are the<br />
same c+hanges that have bcen observed in patients with inflamma-<br />
tory dlseases of the lunt for many deoades before cigarette<br />
smok9 .ng became wAdospr.ead . In early 1876, it was noted (97)<br />
that one of the oomp7 .S.catione of pneumonia waa an atypioal<br />
grovrth of the celt.s of the bronehial lining . 'Phese changes<br />
trere also found in eases of chronic pulmonary tuberculosis<br />
and were weSl dcxorihod 9.n 1895 (32) .<br />
Similar cha.ngos were notcd (98) in bronohopneumonia and<br />
in ini'luenza . The pathological alterations described in the<br />
Roport as identifiable wi.th cigarette smoking occur oommonly<br />
in a variety of pulmonary condi .tions inoludi.ru; bronohiectase,<br />
bronohopneumonia, tuberculosie, and lung abscwas . They repre-<br />
sent the natural protect9.vo response of the bronchial<br />
epithelial co17 .s to i.njury and oocur, a11,ko, in smokers and ! .n<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
34 1901<br />
. non-smokors . The pro5 .i.feration oP cells from the germinal<br />
layer of the epf .t•hel7.um to form a new type of tissue,<br />
squaroos mctap7 .aeda, is a natural process whAOh attempts to<br />
recreate the typo of epithcllum which oxir>ted in the embryonic<br />
state . These changes are very common and if they led to lung<br />
cancer, tho i.noi.denoe of the disoase would bc many times<br />
greater . There have been studies (117,118) which showed a<br />
relationship betv.een post-d.nflammatory changes and lung cancer<br />
but the latter changes were not observed 9 .n the studies<br />
aseociatin g smoking and lung cancer .<br />
1n spite of all the evi .dence that negates the etiologicall<br />
si.gnificance of the pathologioa]l changes found in smokers, the<br />
• Rcpork concluded that these changes help to establish a<br />
causal relationship between smoking and lung oanoer . R`he pro-<br />
c4.se wording of the oonclusion ia most interesting t "It may<br />
be cone].uded . . . that pome aC tite advanced opithelial hyper-<br />
plastio lesions with many atypical eo11s, soen in the bronchi<br />
of some clgarette smokers, are probably premal4.gnant ." One<br />
may speculate as to why a conclusion couched in such equivo-<br />
ca3l terms should be used to scientifically evaluate such an<br />
lmportant relationshf .p as amoki.ng and lung cancer . A baef .o<br />
• knowledge oP the comnion inflammatory reactions of the<br />
bronchi does not ,jueti .fy such extrapolative predictions .<br />
it i.a also impii . ed in the heport that thnro are two oato-<br />
gorf .es of 3.ung cancer and corroborative studies (131,132)<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
35<br />
are cited . The f7.rst, ep3,dermoid and anaplastic, ) .s assooia-ted<br />
1902<br />
with sraok ;,nF• but the second, adenocarci.noma, is assoolate.d<br />
with non-smokS,n g . The arguments agai.nrt such a oonoept are<br />
dect .s3ve . The oategories ar•e, in fact, determined by the<br />
si.tc• o1' orS(+rin from the br•onchAa]l tract . The epadermoid tumors<br />
originute in the brronchi and the adenocarcinomas in the ternr7 .nail<br />
bronchl .oles . 7:f smoking has a car•ci.noCer,lo effect and pro-<br />
duces epA .dormoid car•cinoma then this ef!'eat must stop abruptly<br />
at the ,junctioal bet ween bronch9l and bronchW .o7.ea .<br />
8'urthormore, Snasmuch as 1unG canoer has a predilection<br />
for only certaS.n segments o% the lung f.t• must aiso be assumed<br />
that oi.C:arctte smoke has a preternatural affinity for these<br />
partA.culsr seUmonts .<br />
'1'tili lr:Xl'I :FSP-0t3N'PAL~ 1iJI1)IfldCNI<br />
One o f the ma j or obstacles In ootablSr>hing a oausal<br />
relationship tetween srnok9.ng and lung oa,ncer• has boon the in-<br />
ability to obta4n b1o).ot;9 .ca7l oonf7 .:rmation of'the statistical<br />
association . Mpite the many attempts to produce bronohoCnic<br />
carci.rmm?. In the expcrarnental anAma]l by exposure to cigarette<br />
emoko, the results have beon dismal fai•iures . Mioe have been<br />
fr•equent] .yy used 5.n those experimonts because of the tendency<br />
of cer•tai.n strai3ne to develop sporloaneous lung tumors . Uni-<br />
forml .y net;ati .ve resu7.ts wore obtained by Campbell (12k) In<br />
1936, by Lorenz (119) In 19 0 3, by Fssenbert5 (120) In 1952,<br />
and Leuehtenborger (a .0P) 9.n 1960 . In not a single tnstanoe<br />
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0<br />
•<br />
•<br />
3b 1903<br />
has bronehogeni.o carc£noma boon produced experimentally by<br />
exposure to tobacco smoke . The other• forms of experimentation<br />
1nvo7.ved d5.raot application of fobacc:e extracts or smoke<br />
condOnAates .<br />
Again, 4.t was Cunnd impossible (129 .) to produce broncho-<br />
gen9.c earc9 .noraa with one glaring exception . itockey (101)<br />
Inf.nted tobacco tar on the left ma5.n bronahu.s of dogs three<br />
to f9.ve tirnos weekly through a fistu7 .a . Out of 130 dogs<br />
used in the exper :tnient thero wae : one s,hich obligingly respond-<br />
ed w5.th the production of invas4 .vo carroin oma . The Report<br />
acknow! .edges that thi .s work has not boon conPirrnnd and there<br />
are aspects of the experi.ment which ovokc skepticism r.ogard-<br />
S.ng the S .mpJ.?.catS .ons .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
It would seem roasonably that such overwhelrninf ; evidenee<br />
of the lack of lung cancerr producing properties of tobacco or<br />
its Products should he an S.rnportant consideration i.n the<br />
ova7.u.ation of a eausa7l relationship between cigarettes and<br />
lung caneer . However, in the Report, these ttogat5.ve results<br />
aro treateG ae Sncxdonta93 flnctings and an extended effort S.s<br />
rne;do to reconci? .o the failure to produce bronahogenic OareSn-<br />
oma er.parimenta lly with the smoking-ounoor theory,<br />
Yrcooding the disouasion on the carcinogen5oity of<br />
tobacco, the Report subtly vitiated the negative findings by<br />
emphas5 .•r,7 .ng that "faii.uro to produce cancer in a given test,<br />
by a@:fven m?teriaA, does not rule out the carcinogenic
•<br />
37<br />
capacity oP the same niaterial in another• spacies . . . u In<br />
another sects .ou, the Report stated that certain poiyoyoiic<br />
aromabio hydrooarbons In cigaretto smoko have been denignated<br />
as ceroinoBeni .o on the bae.i.a of tests In rodents and that<br />
thoreforo onc can "rea.sonabiy postulate" that the same sub-<br />
etancea may a.i.so be caroi.not;en:io 5n oue or rnor•e tiusuos of man .<br />
The faia.uro of some invoati.gatore to produce akin canoer 9 .n<br />
niioe by applyi.ntt vurioue : tobacco pro2uots 5 .c rationaSized<br />
by oxp7 .tmations cri.tioizing thc technAque of the expex4 .ments .<br />
The: ]ieport efuotos ev9 ..dence that okin oanoer can be<br />
inducoG in mah by indus'tr'sal e> :posu.re to Ftoots, eoai tar ar,d<br />
pitch, and mi.neral. o :i .ls . Tt then statos that lussmuch as eome<br />
of the hyipooarborre• are also present In tobaooo smoke "It ie<br />
reasoi,ob7 .e to asisume that these oan be eaxwirrogenic for niau<br />
al.eo ." Th$.a type of ey) .1o(;fati0 rCaaon :lnE; impl :LOatin(/'g tCiba00o<br />
an a caroi .nogen o'vems a very weak argumer,t when oonfronte@ by<br />
thc many mi7.7.i.on-years of exposure af the fingers of the smok-<br />
ing popuaation to tubaoco without produoing oancer of the akin .<br />
The oxpo rimcntai . ovAdenco sngt;est•1ng that certain hydro-<br />
oarbono in oSfiarotto smoke, are ea.roSnogeni .o for man Is not<br />
substantiated by the low prevai.onoe of lung cancer In smokers .<br />
Tho statASCioal ri.eh of srxpo¢ure to 1un g cancer is generalAy<br />
prasen8ed 1n terms of oomparlson between smokors and non- .<br />
srnokers . The most recently pubiielzod :report of Nammond found<br />
110 Yuhg canccrs In 36,c)y 5 smokers and only 12 lung canoors in<br />
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904
0<br />
•<br />
0<br />
3B z9o5<br />
a"raztched" group of an equal number of rmn-bmokers . The risk<br />
S.n the smoking group was 171 times that of the non-smokers<br />
but the prevalence rate of lung cancer among tho smokerswas<br />
only 0,3 per•c.cnt, or, one 5 .ung cancer in every 333 smoker•s . Sf<br />
c:i.garotte omoki.ng 9 .o a potent oancer produoing agent, it 9 .s<br />
difficuit to explain why 36,865 smokere in the study group of<br />
36,975 v:ore not affected .<br />
CHI?ONSC S3HONCNX.'fYS AND TdMPHX55T1N<br />
Phe maniYeot•at5.ons of chronic Tronoh7.tis have been<br />
deecribod for a3.most P00 yearolut~ the ReporC of the Advisory<br />
CommS.ttee concluded that cigarot•te emokin€, vras the most irnport-<br />
ant oause . The d}.aeaGe was desor0.bed by Coato (122) In 1767,<br />
by Euuihara (103) in 1808, by baennoo (104) 1xr 187.9, by<br />
Fberlo (123) S.n 1830, and by many others vthose oboorvatl .ons<br />
antedated the era of o9 .garette emokin(5 by many decades . It is<br />
daffS .cuJ.t to unde.ratand how cigarette smoking can be impli-<br />
oatod ao the "4nost lmportant cause" of bronohitis when the<br />
di.seane was so prevalent before cigarette consumption became<br />
wP.desprea.d . %t is al.so difficult to understand how a causal<br />
ro9 .ati .oneht .p can be oatablisbed between smoking and chronic<br />
bronchitis when tho ].a.ttcr has boon defined 7 .n an arbitrary<br />
manner, unre7.e:eed to specS .fie pathologl.oal, biochemioal, or<br />
physiological criteria .<br />
C:hr•oni.c tsonoh5 .tis has been defined as a disorder<br />
characterized by productSve cough on most days for at loast<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
39 ] .gCCi<br />
three monthe of the year for not ].oss than two suooeasive<br />
years . The Report acknow].edp,es that the di.agriosis of chronic<br />
bronchi.tis requ.iros thcoxolusion of other bronohopulmonary<br />
diseasos which produce identi.oal symptorns .<br />
The crux of the problem is that the conolusions of the<br />
kdvinery Cosimi.ttee wore bascd on epidemi.oloKioal studios from<br />
whieh other di.seanos had apparontly not been exeluded by<br />
appropriate d iagnosti.o examinations . In most of the studies<br />
the di.af;nosis was estab9.ished solely on the basis of porsonal<br />
recol7.eotion . Chronic or recurrent productive cough may re-<br />
su7.t from a variot ,y of pulmonary conditions ranging from<br />
tumor to a7.3orgi.o rhiniti.s . Recurrent seasonal oough it a<br />
cornmcn syrnptom of many diseases . Resid= inflammatory<br />
changes rasulti.ng from bronohopulmonary i.nfoctions in ohi.].d-<br />
hood frequont].y produce cough and other respiratory symptoms<br />
in adu7t life . Symptoms interp:reted a s chronic bronohiti . s<br />
by the i.nguiring epidemio]ogiet may trttvo an entirely di.ff'erent<br />
rneani.nF: in ciinica7. ruodi.cine .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
The history (1 05) of ernphyseraa a .].so antedates the era of<br />
oi.garette smoktng but the Report found that smoking was<br />
assfiei.ated with an increased r iak of dying from the dieease .<br />
71hi.s correlation as very tenuous because emphysema is not a<br />
speci.Ric ent9.Ly . It is an anatorei.cal and pathologioal oondi-<br />
t5.on of the ai.r spases which occurs in a varioty of disease s<br />
ineiu.ding baotorial pulmonary infectlon involving the smaller
•<br />
•<br />
iLO 1JO7<br />
bronchi, tuberculcais, silicos9.a, and non-apeoifio pulmonary<br />
fibrosie . J•,lnphysema rmay be found at autopsy In patients who<br />
presonted no pulmonary s,yrnptoms during life and, oonversely,<br />
nay be entirely aboent at autopsy In pati.ents presenting a11<br />
the typieal rrvmptrnns, st gns, and X-ray features of the dieease .<br />
The fi.ndl .nt;rr In pulrnonary function tests are not specific<br />
for the d?.agnoc :irr of emphysema . Yn sonie i .nstanoes the di .seasu<br />
is a7.ready fer advanecd in ear7.y adult iifei in others the<br />
symptom e beoorne• apparent; oni.y with advraneing age . The ehanCes<br />
found In the lungs at autopny ran go frorn local sub-pleural S .n••<br />
voiverocnt to estonsi.vo b9.latera7l alveolur destruction with the<br />
formation of gi.ant air vesicles . The fact that a clinical<br />
diagnoeia of.emphysema ba snd on eymptoron rnay bave absolutely<br />
no relationship to the actual ctisease deatroys the validity<br />
of any etatisti .oa7 O oorrf:lati-0lts .<br />
1iY :cllFNYAY~6pSCAT, FVlA1iNC Pt<br />
A7.though the epidem .ologica3 surveys purport to investi .-<br />
gate the prevalence of chronic bronohYti.a and emphysema, the<br />
a.bsonco of e,tandardi.red di,aGnouti .c criterl .e mi3itatos against<br />
any accnrate evaluation . The atatiati.c :a)l studios have oon-<br />
centratcd on eymptoms which are supponrad to be t•ypioal of the<br />
di.seacee, under i .nvesti.Eation . The oonclusl.ons ooneerning<br />
chroni .c: bronehitiu and c:mphysema conta9 .ned In the Report• of<br />
the Rdvisory Committee are therefore based on the asooci .ati .on<br />
betwecro smold .rrp; and eerfain symptone rather than on a<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
0<br />
0<br />
relat5onahS.U botvwon f;mohi,ng :i.nd spec4Sic d1nP .ascs .<br />
The x•c•HuAts of a acr :wo 04' studiea rovea7 .ed th+at i .n tcwc-rfl)<br />
. [rWokGi'6 CoRi :hF :d rtlLiPO t :ha.il T"(ltl-3rfi01F.et"6 . f{OY:flvHr, the k".I,dp<br />
varS.€tionF in the inoldmnec± of couf;h =uEF :oate; that this sryn?p-<br />
torn, reg•a.rd7.cr..psotora.t5.en of sputunl m, .e a0 . .o eauatoci wi .th c:moklnE,<br />
V1t.h no4t oi' tho atu6i .ozr eriranat :i.ng frorcr" the samc eouroes as<br />
the erarveys on cou8h . 'i'hm isYe3 .dencs" of spu.tum productioh f.n<br />
the nmokcrc : rz.ngert frcnr 71A pa ;:reelnt, to 6H„7 poro©ut . ; 5.n tho<br />
non . .r.rrolccrs thn ran[!c wa frcen 0 to £'ll .0 pe :r•oent . T'ho S;opar-t<br />
found ;t 5.ntorecR,ing t•h .t 9n moctt oi' tR"ee studlos the non-umok
•<br />
•<br />
42 1909<br />
irrocone5 .lable . Unl.ess coughing is a ncrvous habit it £s<br />
tho reoui,t of a physioloAoa1 r•ofRer.to ol£m£nate the sputum<br />
whf.oh has aecumulated £n tho traoheobronchAall tree . The<br />
sputum cannot enter the pharyr,x under ita oran power ; £t<br />
must be eou(,ned up . The dtseropaney between the inc£danoo<br />
of• c+putumpr•oduct.i.on and coup;h exemplifies the type of<br />
irr•esponc£hlu tabu3 .ati.on that has been u1 i.lAZod in the eatabli .e,h-<br />
rnent of Lopor•tiant concl .u.s7.ons .<br />
In 2'ab].c• 3, page P8lI, of the Rcport e.rr 7.£ated a summary<br />
of utud£ees on the prevalcnco of both cough and sputum in re1 .a- .<br />
tfon t:o smoki.n7;. 1'he rsm€ie was from 7 .2 peroent to 51 .0 per-<br />
cent In the srnekors and from 0 to 8 .9 percent in the non-emokers<br />
. Not iistod in tho table £e e report by Oswald and<br />
h]edvoi. (iC6) whkch included oeea67.ona1) cough or eputum :un<br />
addition to the more fropuent and persistont symptoms . This<br />
e.tudy of mor•e than 5,000 poreonn found 63 .7 percent of t he<br />
rca 1.e eanokora and 47 .7 pemcont of the niale non-smokers w5.th<br />
cough or eputun ; among the femalea, 63,2 percent of the smoicers<br />
sputurn .<br />
s and !!7 .'( percent of the non -amokeres had cough and/or<br />
Again, it rnmy be pointed out that popu .lntion prevalence<br />
stud7.cs of sputum or cough., no matter how paf.nstakinCly done,<br />
cannot contribute sufficiently accurate data for valiA eon-<br />
clus£on ::, . )a n u y- be further emphasi .wed that even i.f cigarette<br />
smokers have morc cou@Sh and moro sputum than non-smokers : this<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
43 1910<br />
does not neoessarily indicate that these a,ymptoms are rc-<br />
8lsotod Sn per•wanent pat•holoK+-ca5l ehanges in the traoheo-<br />
~ b;aonchial tree .<br />
The prevalence of' breathlesanoss among smokera wae also<br />
stud9 .ed . The resuits showed variations of 1 .nc±dnnco simiSar<br />
to the surveycs cou@;h and sputum . In one st :udy (107) approxi-<br />
mateiy 25 percent of the male smokers and 1.7 percent of the<br />
non-smokors adm9.tted to breathiessnoss .<br />
. In anothor study (1 .0£4) the female non -nmokers were moro<br />
breathless than tho srnokers . Ifowever, the i'enale amokers over<br />
!!5 years eoughed and expectorated more than the non-smokers<br />
• even though they wore iosn short of breath .<br />
i<br />
Still another study (7.0g) found mor e shortness of breath<br />
In both maie and fernale non•smokers than In the smokers .<br />
Experience In his'r•ory taki,ng has made it very apparent that<br />
sub,tootive evaluation of breat-hlesaness ds fraught with<br />
potential error . There are any nutnber of phyalologloal oondf.-<br />
tiona oapabl .e of produeS .ng sensations of breathlessness<br />
9aic?.ud :tnC anxiety ayndromea . Latent oarGiovasouiar disease,<br />
thyroid ctisorder•s, anemAa, and other org ;€mic diseases may<br />
aiso be mahifc:sted In cxertional shortnoss of breath .<br />
A correiati.ve study botween smok3 .n@: and breath}.ossness<br />
mu&t exoludo all other causes by oomplete examination Snolud-<br />
i .nC. laboratory stud9.os . The ftepor•1 : of.tes seve.rai studias<br />
correla.tin€;<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
smoking wi.th a heterogeneous asnortment of
•<br />
44 1911<br />
rospiratory conditions ranginp ; from "chest illnoss" to<br />
"0.rrevere4blo obutruct] .ve lung di.soaso ." Among males the<br />
prevalence of theso cond5.tions were found higher in smokers ;<br />
among femai.eo the differences were loss marked and in some<br />
aurvoys there rvero no differencos found between smokera and<br />
non-amokors .<br />
SUMMARY<br />
i. . Historica7l studies ahow that lunf: oanoer had been<br />
prevalent for a century before the era of widespread smokf .ng .<br />
2 . Progress in the diagnoois of lung oancor during the<br />
past three deoades has resulted 9.n the recognition of far more<br />
cases than was prev3.ousAy possible .<br />
g . The rate of incrwase of lung cancer has progressively<br />
declined in the past 40 years despite the 200-fold inorease in<br />
cigarette consumption .<br />
) L. i,unt; eanoe .r hae occurred predorninantly in males in<br />
the 19th century and in the ora of cigarette smoking; the sex<br />
predilection ir, a biolofgicnl characteristic and not a resutt<br />
of urnok?.ng .<br />
5 . 1'hore has boen no oanparab7 .e S.ncreaso of lung cancer<br />
1 .n forc a lcs despite the prodigl.ous oonsu!npti .on of cigarettes ;<br />
the rate in incroase has already been stabi9.ieed In females .<br />
6 . Lung ccn,oer has ooourred prodanP .nantly in the 5th,<br />
6th, and 7th decade0 during the 9.9th oentury and In the era of<br />
cigarette smokdng ; the age distribution has not been influenced<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
ill<br />
0<br />
0<br />
45 1912<br />
by duration of srnoking ov by smoking habits .<br />
7 . Sn institutions with long expsrience In lung oancer<br />
the peroontaGe relatlonshi .p of lung cancer to total cancer Sn<br />
the 19th century was similar to peroentagos prevailing at<br />
pl''eElent .<br />
fi . Tho pathologAcal evidence presentod In support of the<br />
smokinF;- J ung cancer theory is eauivooal antl the conclusions<br />
are unwarranted . The greatest number of alleged pro-canoerous<br />
oonditions in smokers v+ero f ound In bronchial tubes that are<br />
7c:aat Involved by lung canoor .<br />
9 . There is nc+ valid experimental evidence confir.ming<br />
the smoking-7.ung cancer theory ; bronohogonic carei.noma has never<br />
boon produced by exposure of experimental anima7.s to tobaooo<br />
smoko .<br />
10, The a5.legations that bronchitis and emphysema are<br />
related to smoking are based on the most tenuous assumptions ;<br />
the d5seaseo are defi .nod arbitrarily and the conclusions are<br />
thereforc meanYngiess .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
!46<br />
(3)<br />
HI~'LHNNCFvS<br />
7.913<br />
K1.np, 0 ., and Newsholme, A . : On the a1 .leyed i.noroase of<br />
OaneOP, Pryg,, R~yal,Soo., hondon 14 : 209, 1893 .<br />
(2) Laennec, lt . : Traite__Ae_1.!AUSeultttion Med3 .ate~et de,s Mala:<br />
dS.es dee Poumons et du Coeur, Paris : J, S . Chaude,<br />
181 .9 ; 4th od ., 1937<br />
(3) Porbcs, J . : Treatise on Disea .ses of th.e Chest, Londona<br />
T . & C . Underwood, 7.521 .<br />
(4) Andral, 0 . : Hecherchos su .r liexpoctorat7.on dans 1es<br />
. d3fforcntes maladies de poitrine, Paris : USdat,Jr .,<br />
1821 .<br />
(5) Douillaud, 3 . : Observations sur le cancer des poumons . . .<br />
J ._ .Oonipl,_,dq .,Dica,._des_SC ._med . 289,1826<br />
(6) HeyS'older : llu. oancer des poumons, ArcYdves Gen, de,_Mod .<br />
1837 .<br />
(7) lterard : Tumeurs oncephaloldes d l une fo rme sAnguliero a<br />
ia surface des p oumones, Pu1A ._Soc ._anati._de_F'ar1_s_<br />
3.: 13, 3898 .<br />
(8) firnal : Cancer epitheloiAo du thora .x :, ete . . .., Oaz•, de iiopO<br />
l'!_ : 78, 1Fhts .<br />
(9) Lebert, H . : Du cancer des orCanes de la respd .ration,<br />
Yh~!s :(o)_ogie Faa.holoEliquc, Parir ; : J . fl . issi111er,<br />
Vo1 . 2, p . .',90, 18!!5 .<br />
(10) Charcelay, M . : Massa enoaphaloi .de volumineuso dans 1e<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
plevre droite, 12, 7837 .
•<br />
47 19111<br />
(11) Nionneret, E ., & Fleury, L . : Cancer oP the lung, Congrna-<br />
ium de Med . YrFit . 1 : 167, 18146 .<br />
O.`r) Harc, Ia . : Carnours f.nvoAving certain nerves, London Me :,d .<br />
Oaz . 1 : 16, 7.838 .<br />
(13) rancoast, N . : Superior pulmonary r.u7c.us tumur, J .A~M _A. .<br />
29: 1391, 1932<br />
(31:) Hughes, H .P7 . : Oaees of malignant disease oP the lung,<br />
q_uy!s Hosu : he~. 6 : 330, 1841 .<br />
(7.5) Idacbachian ; On prS .mary cancerous degeneration and ulcer•a-<br />
t:ton of the lung, T.ondon I~7od . ._Oa~r . Y2 : 23, 1842 .<br />
(16) Hurrowe, G . : Caso of extensive oare9noma of the lungs,<br />
Medlco_Ch1r ..,frdns . j: 119, lERW .<br />
(17) Graves, R . J . : C33n3oa1_LOC1:uroe, ., Brit ._ Mea .__J ., P . 902, 1857 .<br />
(22) Uudd, 0 . : On soree of the effects of primary cancerous<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
tumours withYn the chest, MedS .co-Chir . Trans . 2fL :
•<br />
•<br />
•<br />
48<br />
2).5, 1859 .<br />
Wi:.a.ignant dis:easc: o;f the lung, Lr}nqot . ]. : 489, 1852 .<br />
(24) a ldaldeyer, H . : ]i ;i.e e.ntv;?.ekelung der oaro9.nome, Aroh .. _f .<br />
~p¢h• .__Anat . ?.Id : 140, 7 .868 .<br />
b ; Uher• don Yrobe Sannn9 . . k7 .in . Vortr .<br />
.. . . . . ._ ._._. . . .. . . ., . . . ... , _, . .._ ._.,~._ . . . .._. . ._ . ..~ .._~ .<br />
No . 33 ., ChArm :Se No . 10, 18'72 .<br />
(25) Per7 .s, Wl . : Zur CeiouistAk des Lungenoaroinoms, Archb,y._f .<br />
patk, .. . Anat . 56e 437, 78'72<br />
(26) peor•gi, 19 . : Tt3 .n Fai.7l von prS.maron Lungenoareinom ohne<br />
t•k:tastosen, k:crL . ]Ci .in .,,ldchne:chr ., No . 28-29, p . 413,<br />
7879 .<br />
(27) Ro4.nhardt, W . : Iier pr).maro Lungerdcrebs, Arah4v~ S . Ka7.gk .<br />
? 9 : 369, a•878 .<br />
(28) 19irch-N9.r•tschfeid, P . : Das primare Caroinom der Lungen,<br />
i,ohrhuoh cter,poUh . Finat ., Leip2ig : F . C . Vogel, Vol .<br />
2, p . 462, 1.6Ei2 .<br />
(29) gesse, H ., and Hartung, F . : Der Lungenkrebs die Serg-<br />
kraukk:rAt in don Sohneoborger brugen, Vl .ertol,aahreohr .<br />
f .,, [c:r?,uh5...,_trgd, 30 : 296, 18'79 .<br />
(30) Si.egel, J . : Luz__Pcnnt?.~ica.
0<br />
0<br />
49 195 .6<br />
(33) Passler, SL : Uober d.ae primaro Caroi .nom der Lunge,<br />
Arohi .v Y, ._ paCh : Anat_. 145 : 191, 1896 .<br />
(314) Yrankel, A . : Zur Dia6Snootik der Brunthohlengesohwu3 ..ato,<br />
btsch .__med ._4IC_hns~chx• . 7.'_l,: 1345, 1891 .<br />
(35) 3chwulbc, J, : Zur Lebr•e von den primaron Lungen-und<br />
BrueCi'e) .l~cschsvuieten, DEsoh mcd ., .Wohnsohr . 171<br />
1235, 097 . .<br />
(36) N .artmann, N . : Uper 3Fung_cultz~ebs vorn 13rnnohus aus_gehen,<br />
K9.e1 : P . Peters, 1896 .<br />
(37) KinS2, U . : Pri.msr•y cancer of the lung, N,R,J .M, 2i_ :<br />
828, 7.9g8 .<br />
(38) Lehlhach, C . : Cono of primary encephalod.d cancer of right<br />
7.ung, S_oo,_NilsF Jer6ey, p . 150, 1870 .<br />
(39) Loomis, /: .7 LeeS.qreEj,en Atseue Ee p~_the,kaeofrato~ftans~<br />
New York ;<br />
Wi7.liam Wood & Co„ ).876 .<br />
(i!0) llelafield, S . : Yrimary cancer of the lung, in Ca_so<br />
Siof,ortc_Of._'i'um~rg_of' the Lung;,_,18E~8-1888, unpublishod<br />
notobook, Neei York City .<br />
(iL"i) Pepper, W . : 71wo cli .nloal ] .ectur•es o n primary intra-thoracio<br />
oarcinoma, ra1] a, ,i?ed Ttmen, 9 :97, 1878 .<br />
(h2) Van O,.oson : Cancer of tho lung, Me@,,,Reoor,_d_16s 495, 1880 .<br />
(43) Ri.pley : Pri.mary i.nf'iltrating meduJ .7.ary caroinorna of the<br />
7.un(;, Mcd_ Heuurd. 7_8 : 691, 7.880,<br />
(44) Hompor, 0 . : Pr .trnary cancer of the lung, 7`rfa_ns~,_~:nd,A_agn<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
State Mod, Soc ., p, 170 1880
411<br />
•<br />
•<br />
50 1917<br />
(N5) Janenay, 7ii . : Primary carcinoma of the lung, MeQ._ReoorQ .<br />
230 215, JB63<br />
(46) Hoilanxi : A specimen of oncophalo7Q eanoor of tho lung,<br />
172, 1.884 .<br />
(47) }{odcnpy1, li . : tAUitipie nom growthu of the lung, PrT,<br />
p . 19,<br />
3895 .<br />
(!!(S) rie Count, B, g . : Primary carcinoma of the lung, Trt~ns,<br />
ChSCS: p. f;&th,, Svc . !!.: 67, 1899 .<br />
(49) Ad1cr, X . : 9'he df .agnor7.s of malignant tumors of thc.<br />
aung U , tu .x,fa . i. . E> 5 : 173, 1896 .<br />
(50) Wcinbarger: fl¢S.t'rage zur K1S.nik der rnalignen Lungen-<br />
gosoh :•luJ .ate, 2.teohr ._ f, .-_KCfEk . 2t 78, 1901 .<br />
.17 .i .an 0 . : iur X>S.agnos.tiaohen Ve .rwertung der .(51) KS oboren<br />
Sronchoskopie b,.e hungenoaro9.norn, Tiex`^l,-_kiAn ;,<br />
1Vohnc.chr . i.(. : 4y7, 1900 .<br />
(52) b'eSJ .c:henf.eld, J . : He£troy;q .,_PUr, Stcxt;tst!,k, ~d, KaauiatS .o<br />
dori_Cax~cincnn~, l .elps9 .g : P1, Rbering, 1901 .<br />
(53) Rioc:k, H . : itrcbs-, :itatistS,.k, 1!tunohc,ne Kastner & Caliway,<br />
1904 .<br />
(511) Y'eidner, 0 . s]trellot•at :xs ;t11: ,nnoh don eektlons-protokollen<br />
dea 3athoi ..of,lech_l+natomio~hen Snst .iLute zu Ootting ;on,<br />
vo:n Jahr
0<br />
51<br />
1918<br />
Kasu3.otichoc zur F'rago dos prA .maren Bronchial und<br />
Lungondrobe..es, (-horS ..to_A.un . 315, 1906 .<br />
(57) Adler, T, : I'rE;maYsV Mali~nant Cirowl.hs, .o!` the_LUnZ and<br />
Sr•onchi, Mew Rork : Longmanc, Green & Co ., 1912,<br />
(58) Jackson, C . : Moehan2.sm of phyeieal signs in nooplastlc<br />
diseases, J~._A .)h_A. Q 639, 1930,<br />
(59) Jaffe, R . : 9'ho prS.mar•y carcinoma of the lang, J .Lab ., &<br />
Ciiq,.. ..Med ..,20, : 1227, 1934 .<br />
(60) Harve:,y, C . : Cancer of the 1u.ng : A clinical survey of 100<br />
caees, Ned . J . of_,AUetralf .a 2 ! : 565, 1936 .<br />
(61) Graham, B ., and S9.nger, J . : Suceessful removal of ontire<br />
7.ung for carcinora a of the bronchus, J.A,M.A . 101%<br />
;37a, 1923 .<br />
(62) Da ;rnard, W . : The nature of the 'bat••ce7 .7.od sareemao of<br />
the medAastinum, J . Pabh, and 1k!p t_, 2 ;? : 241, 1926 .<br />
(63) Karancr, H ., and Saphir, 0 . : Sma3.2l ee3 . :l carcinoma of the<br />
lung, E: 553, 1930 .<br />
(64 ) Johnson, C . Fl ., C1aCott, 0 . T ., and Good, C .A . : The<br />
importance of exploratory thoracotomy 1n the diagno-<br />
efa; of certain pulmonary 7 .osS,onc, ,3u_r,go Ky 21 :<br />
21e, 194,<br />
(65) Lisa, J ., 71r5.n i dad, S ., and Roeienblatt, bi . : Pu7 .monar.y<br />
rnanA .fe[;tatione of carcinoma of the pancreas, Canoer<br />
7.7 : 395, 190 .<br />
(66) Mor@.yama, 1•&, ?3au.rn, 41, S ., Haensze7., 41 . M ., and<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
!<br />
0<br />
•<br />
52<br />
Matt7 .so.n, Lt . V : 1ngulry Into d1aR . .nootio evidenoe<br />
1919<br />
I<br />
supportinf;rnod9 .oa1 c:ert5.ficuti.on of death, Amer . 3 .<br />
of Pub7.io floalth 48 : 1376, 1958 .<br />
(67) Haenazol, W . : Mortallty and morbidity statlstios on a17l<br />
forms of cancer, A_ote ._Un . ZnL .,_CEmoer 17 : 837, 1961 .<br />
(68) G9 .119 .am, A . 0 ., M, .lmoro, Li . ff., and Lloyd, J . W . : Trends<br />
of mortality at.trlbutod to carc:inoma of the lung,<br />
Canow, lh : 622, 1961 .<br />
(69) Weha., S . : Uber die 2unahrne dea Lungenoaroinoms, 2tachr .<br />
f ._ Kret+n . 25-: 302, 1927 .<br />
(70) Sohonorr, 3i . : floitrar zur Stat3 .stik und KtinS.k der Lungen-<br />
tumorcm, ztsuYu• . f,,_Krory.27 : 436, 1928,<br />
('(7.) Materna, A . : Gur K1S.ni.k und Pathologie dea prlmaren<br />
LunC;or:krobses, Seri .tra~e, .e___,k1L?~Chir . 132: 708, 19z
0<br />
0<br />
53 1920<br />
mortality trends in the United States, 1930-1955 .<br />
Part 3:}: : Hnd rebu3.ts and mortality tronds in<br />
canoor, Nat l 1 . C[+noer Inet . Monopnr . 6 : 131, 1961 .<br />
('t'I) Clemrnonsen, J ., and riusk, T . : On the apparent increase<br />
In the incidence of lung oancer in Denmark, 1931 -<br />
2!i3, 1 947 .<br />
(78) ttarmi.s : IntrathoraoAc groiaths, Sta_Wmtholomew!s Nosp .<br />
lto. 28 : '73, 5.892 .<br />
(79) Lenhorbz : D?.c boaart5.gen Neublldungan der Lungon, in<br />
Isbatoin, kJ ., and SchWalbe, J . : Itar/dbuoh dor<br />
Praltc5sohon_fAeda,zin, Stuttsart : P . Enke, Vol . 1,<br />
P . 490, 1899 .<br />
(80) Roichclrnan, W . : Ri.nc Krebstat9.otik vom patho1o81eohe-<br />
anatomloohen Standpunkt, Bor7 . ._k17._yWOhnschr . 321<br />
728, 1902 .<br />
(Si) TirAeac : Znr Kenntni.sa des prlmaren X;ungenkarzinoms mit<br />
statlalsohon 6+ngabon, Frankfurt . E_tschrri' . Path.23 :<br />
48, 3920.<br />
(8'r.) 19e71er, 0 . : Yrlrrar y caro7.noma of the 1ar2:er bronchi,<br />
nrchiv f . 7:nL .,MeQ . 51. : 314 , 193.3 .<br />
(83) 13erb7.i.ngor, W . : ilber Ole Lunahmo des primaren Lungen-<br />
) rebsas In uen 7ahron 1920 bis i924 , K11n . Wohnsohr.<br />
4 : 9?.3, 7925<br />
(84) Poters, 41 . : Ubor das Lunt;enearcinom, 2t $ohr . F . Krebs 3 7 :<br />
56l, 3932 .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
.<br />
0<br />
51! 1921<br />
(85) J"un[!hEmna, H . : Der K.robs der Lungon, Hronchlen und<br />
oberon Luftvoel;o, GCSChr .f, KrobFl,A : 572, 1929 .<br />
(86) Uormanns, It, : 13o7 .traG zur Frage der 2unahme der ftroUs-<br />
kr•ankhe4 .t, Zt_e_cYU .^, f, _ Krek~s . :9 : 40, 7 .933,<br />
(87) Ki.chenGrrm, W ., and Esser, A . : Statistik ubor die tn<br />
don wmen J .902-1926 S .m Path . :[nstitut Augusts<br />
Hospital Itoln obdua9.orton CarcAnornfal) .o m5.t bceon-<br />
dcrer fieruchsS.ohtigung der Frago der hrebszunahme<br />
naoh dern Rr ; .et;o, Ztschr . % . Krebs 'r.14 : 63, 192'(,<br />
(88) Passey, H„ and Ho7 .rnea . J, : The Snr,S .dence of intra-<br />
thoraolc neotiiao5,a 3 .n the teaohdng hosp5 .tals of<br />
Grcat ]iritaSn, 1.894-1928, Ruarti_. J'. Mod . 4 : 321,1935 .<br />
(89) lbrahim, A7 . : }Sronchoy,cn3 .o caroinorna in Fast Pak4stan,<br />
nss . vr. . chect„ 26 : 266, 1954 .<br />
(90) passey, H . : Some pr5.blomc of lung oanoer, IrvanoeL .2 :<br />
3.G7, 1962 .<br />
(91) Sonser, G . : The S.nc7.Aenoe of tumours of the respiratory<br />
tract 7.n Loods, 3..._Ftyl;z. 28 : 340, 1929,<br />
(92) HampcS .n, P . : HauP9 .gkoi.t und Ursachn des primaren Lungen-<br />
carz7xwms, t79 .t1., a,d . Gren~tteb .., d,, med, u,_Ohir, ;i_6 :<br />
1t45, 1923 .<br />
(93) 8ayfcuPoh, C . : Lugonlcaru4 .namo 9.n Le4.lrzif;, Ptsch ._med,<br />
47chnr~chr . L .k : '1 .1197, 192l4<br />
(9!t) Ja .TXe, P, . J ., and SternberC, H, : Y,rS.ogrpathologPsohe<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
iiriahrang:en, Ar . titv F;_~o?ch. ..,l1n2L . 2 ;fi, : 346, 1927,
•<br />
•<br />
•<br />
55 1922<br />
(95) lilpsoh9 .tz, M . : Ubor die 7,unahme dos £ronohusoarinoma Sn<br />
1otGcen Jahraehnt und die dSa(,nosti.sohe Sierwertung<br />
der i3ronohoCraphic, Dtsoh. med G)jnnahr . 5 5_.: 1708,<br />
5929 .<br />
(96) Auerbaoh, 0 ., oL._7. . : Caro :,,noma-4.n-sAtu tmd early Anvau7 .vo<br />
carcinoma ooeurr9.ng i.n the traehcobronohiai trees<br />
in casos of bronehial carc+inoma, J . of 2'hor, 4urU .<br />
;4 : 29 8 , 1957 .<br />
(97) 1ir5.odlandc :r, C . : l~kperimental Untcrsuchungen uobor<br />
oh:c•onischo Pneumonp .e und Lungensehwindsuoht, Arahlv_<br />
f . path . Auat . 61 : 325, 1876 .<br />
(98) a McKenzi.c, W Iip7.thei.motapJ.as?.a bei l .ronahopnomonAe,<br />
7,9Q : 350, 1907 .<br />
b l:'internitz, M• C ., et• e.7_ . : The Y?a3t;ho o~„of.' . Xnfluon•r,a,<br />
Now tiaven : YaSO University Prer.+s, 1920 .<br />
(99) Auerbach, 0., yt .ai .,. : Changea in the br.onohia)l ep9.tho19.um<br />
1n relation to smoking and oar•cinoma of the 1ung,<br />
97, 1957 .<br />
(100) Abrd, 1) ., et a?, . : ]iyspiastS.c 1es9.ons of the bronchial<br />
tr•ee, Canecx 7.4 : 1226, 1963 . .<br />
((101) Rookey, I? . ]?., et al . : Facperimerhal s :tudy of effeota of<br />
cigarette sii+oke oondensato on bronohial mueosa,<br />
J„A .M Jy . 7,82 : 1904, 1962 .<br />
(1D2) Mohtonbcmger, C ., ct- Q . : A corre7.ated historogi .oaA<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
oyto7.oEacai-, and oytoohernxoa3l stud•y of the
0<br />
tasiehoobronoh9a7M tree and 7.unbe of rnioe exposed to<br />
cif-,'a:rettc smokv,Canoox, 1"~ : 7'rl., 1960,<br />
(].03) a riadham, C . : Obscrvat9 .ons on the SnfAammatory AtSeotiats<br />
of the Kucous AYemb ranoa of the Eironehiae, London :<br />
Ca?2ow, 3808 „<br />
Kokes, id . : n,aro~. Rco oer LhEDia,gncsi&,tnG, ireat ;men+• of<br />
Ma ecs_ oS' Lhc Clrost, Yhilado :Lphi .a, A . 17aldie, 3 .637,<br />
(SON) Mennoo, 1 . 4`raite dc• L"AU6onJtatl .Dn h7edtate, 4tli ed .<br />
VoI . Y, Yar1.s, J . 5 . Chau.do, 1837,<br />
(105) I,ou9s, F7 1•r,•~c ;archcs on F7nphycema. uf the Lun~c, trans .<br />
by `l' . flteetttrdsoh, Jr ., Phi7adoiph4a : I1unp;7.isox,<br />
Ameriec.n P6odioal Y .9.brary, 1838<<br />
(J06) O : w a:.id, h . C ., anti Gledve i , V . C, : Chrorcl.o bronohl .tis :<br />
The cffec:t of o9 .tarc:ttc smok2nEb ?qJLoeb 2 : 843, 1955 .<br />
(A07) lu•nsem, P .Pd„ et aS. .. : New York City ltea3.th Dapartment<br />
ohronic respiratcry dlsease snu•ve ;p, May, 1963,<br />
3Mr1m Repart to Advisory Cnnm9ttee .<br />
(1U(i) Ri .ggS .ns, _( .`i' .T . : 17esp1rnf.ory symph.oms, bronchSt§ .s and<br />
vent2.latory cah;cc5 .ty 1n a ranGOm uampie of an agri-ou3<br />
.tnra3, popu3 .:,tion, Srft : Me~, ..J. 2 : 1198, 3957 .<br />
(3 .09) J .i.g(ans
•<br />
c17<br />
J,A .M.A . i . : P2t.(i, 1947 . .<br />
(].i]_) Stmons, 1 . : Yz-7mary Caroinoma of tho l,un g , ChAcago :<br />
Yenrbook Pub]i-shers, 1937 .<br />
9.9?11<br />
(11P) Wi.7afla, R . Fl . : Yathqlog;y_of!i'umnrF+,, 3rd od ., WashLngton,<br />
D . C . : }3utterKor•th & Co ., Ltd ., 1960 .<br />
(5 .7.3) 7'ri.nidad,, S ., IJ.sa, J . P. ., and Rosenbiatt, N .H . :<br />
]3ronr.hof;eni-c camoi.noma stimulatoa by motastati .c<br />
tumors, Clance3• ? .,6 : 15P1, 1963 .<br />
(7.:U!) Spai .n, D . : Recent ohunges in re l atti .vo frequency of<br />
vcu,.ous hSAoloEr,lc types of bronohogenS.c carcinoma,<br />
8;i . : 477, 1957 .<br />
(11"i) i:,co, S ., and 2' w o, T . : N9.stoAo6riea7i t;ypin); of lung<br />
eance rs in Hong Kong, Eri.tQ. Oanoer.1f. : 37, 1963 .<br />
(if.6) Whi.twcl1, F . : 2'h e hAstopathology of ].ung cancer i.n<br />
zdv[:rpool : The spoc7.fici.ty of the hAStologl .oa3. oell<br />
types of 7 .wig cancer, llrlti .._ J..._Canoor q : $A-0, 1950 .<br />
(17.'7) k3cavcr, ]) . L ., and Scha.piro, J . L . : A consAder•ati.on of<br />
chron9.c pulmonary parenchymal inflammation and<br />
alveo]ar rcSat3onshdp, A 0 J . . M . B1 : 879, 1956 .<br />
(318) Raeburn, C ., and Spencer, H, : hung sear cancers, Br1t . J .<br />
Tqberc . 51 : 237, .1,957 .<br />
(119) a Lorene h„ Stervart, H . Q, ].k,ntel, J . N„ and Nelson,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
C, V . : T3,^ effects of br•c:mth3.ng 9:o&aeco smoke on<br />
rt.rain A mf .oe, C~ :ricoi~_lipr ., 3 : 123, 3943 .<br />
h] : srcnz., lt . : );xp3rTmontal etudies on tobacco smoke,
•<br />
•<br />
0<br />
5K<br />
f~rc-c . }daLs7. . Cancer Conforcnoe, p . 203, 19!•9 .<br />
(320) l ;e:eonberf .t, :~ . h9 . : Cagaawtte e:aolce ar,d the inoldence of<br />
priitlFq'V n001i1,aEBlin Of' thN lu,n[{ a.n albSno I11ic:C,<br />
SOACYICE:. 1,).(i : 5h?., 1952 .<br />
(12i ) a Poaooek :, p .R . : CfF:arette oniok3.ng by laboratory an9 .mwle•,<br />
Sevelth _ . lntox .r (on~resn, 7, ondon, ondon,Cauar p . 153, .<br />
. Y. c .' .`, $ .<br />
b . . . : CS.gareate smokMo or:perS .rnents, }?.•rf.L,<br />
)~n~ . . Catfoar C : , . . . :t.e??, ~ .<br />
h_Ann :~ai Repo.rt,Fart 2, 1957 .<br />
(la2) Coyteo ?r Eto_dc P : ~[,~iki,[; du Youraon, Paris : HorS .t+c^art<br />
fi.1 :,, 17hY .<br />
(1?3) )'^boOe, Y lee,rSt1Eq ge{_Lhc l :act$,oe, oP P1ehYC~ .ne, YhS1ade^3<br />
.phaa : John CrS.gg, 1830 .<br />
(7.28) Campbell, w : 'l.'he effeot of exhaust gasee from Anterna5<br />
oombunt5 .on cnYginc:¢a eand o!' tobsooo owo)ce upon mf .ee,<br />
YMt 5 Llxpex )r.th .a ..Q 1)+6, ) .93G<<br />
(1P5) Auerbaoh, 0 ., Stouf,, P, . Y ., Hammond, )3 . C ., and CarCAn).c3 .,<br />
W Ohanges in bronohial epAthelS.um In relation to<br />
c.q .fwr•e:tte smol ,.ng and 1n ro7 .at?.nn to 7 .un(; oanoer,<br />
ICeq~ )ric,tun~_ .1,)ICC). . 2G5 : 253, 19b7 . .<br />
(i'lC) C¢mj .anc7„ ): : . H ., f+oaor, R . L ., Coui.aoiY, ld ., }Seald, 3 . Pi .,<br />
anu Wi.n, 8 . L . : Tho a.pparont sites of orfg4n of o<br />
c:uroixianas of the 7.un(;, k:ad :tglo(';y . fLS.: 1, 1962 .<br />
(12%) ) ;9.chowi, A . F . : Cited S.n (larland, ot n7, . : The apparen6<br />
s:ttos o£ ortg5n Of care? .nomas of tho lung, ii2dtology .<br />
'(f, : ?, i952 .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
59 1926<br />
(128) WaJ.Lor, J, B ., and Fryoe, A, Pfl, : Tho nit•e of orig9 .n<br />
of J.un cancer anG AtiH relation to h i stoioGloa3 .<br />
Lype, 9lhorax J.,O : 117, 1955,<br />
(J.9y) C :enn,.ngham, 0•J„ and 4JAnotan :iey, P: . P . : F.yperplacSa<br />
anGW mot•aplasd .a i .n the 1»ronchi .a3l opStihel7.um, Fnnaic .<br />
c; Lh FtoV i7 CoJ icg;e,_cF SnAg;ecm : .. ?~ : 323, 1959 .<br />
(130) G7 i cld :in, 0 . 0 . ; lnrauetion or bronchy.a3l cancer by 2oea1 .<br />
rnaes :.ng of carcanogon ConeentraLe 3n outdrAft0.ng<br />
rnucus, ~„2horaclo sur€ . 3J . : 238, 1958 .<br />
(3 .33 .) 33rc :e•1ov, ):, ., Hoagai.n, L ., &;,Fmuaeen, 0 ., P,nd ltbrares,<br />
B . R, : OGOu[1at3.Ons and (l :lgarBtte 91llok'1nE; B.6 Me$ers<br />
In 1unp; canoer, J, Am, Pub11e Hoat ~ . ._,<br />
J._ . ... h, uU : 17x, 1954 .<br />
(3.32) Do11, Y.,, tlS7 .7 ., A .}3 ., and Kroyberg, 7. . : The s9.gnifloance<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
of cc5.1 type S-n Io1a0A.on to the actio]ogy of lung<br />
cancer, }ir7,t, J, COnO(:r 3.J. t~I(i, 1957 .
c-! 19'l.9<br />
Si.`A'1'kMIiNT OP IxN . Stlidb)Kt)V C: . Sf,Atk'YSItO<br />
A esl i+hciBon C . .osunex•t~, ea physr .c.ittn, gener[al pntholoCisrt :<br />
anteY'ested i)1 t9.bJSue CIiN(¢lo[91k? fl .nti an eXp6ri1¢Fnta)l patllo)o( ;l'.st<br />
• onF;agecad for ovex• 7[i yearF: in dnvc,r :tip:nting tnechunistnsc of<br />
C1AnG(Itln . }.1V co2k(3QjG and (pfld4(tRJI scho4l . G3uCn0io6 t9@?'H at<br />
hrsrvcu^d, and I pa°acx•i.cofl and taught ptxtholog:y in Y ostcma 3'or<br />
?F year,i . Fn 'JL'EM A UFUS Pz•esident : of the Aoa i?nNlond L
.<br />
•<br />
•<br />
e`L<br />
hawtun boErq ;s : tha,t Ietly M aet tt eir sace.cptibzl4ty f:a<br />
davo7c p c: corEaSn kin d of clio:ri .es Q e.oric,u s Mar
•<br />
•<br />
C?1EEaHPP;, EelCohol9.Eq11 flnn @ev@rC trAupLa . 9)hey ilKllilde[i E<br />
nltU1h@Y of IBCVp tith Cvj.O61Ybo o£ e8Cee6Gitrp Ilorvoid9 Citbl'Qy<br />
eeXprGGIIC(1 by ot'CrPtl'f,in,r .11Q; tho3r ph,WEACH7 CPpBCitieC In<br />
vurS.oue trays, PhcArthur, a i5arvarc+ psycho},ogir .•.t, from h4 .e.<br />
v9-et'ry0int htae E'oupd the emmo i'eaturor> In S .ung ec=.ncer<br />
})atientr+, eon:e of tvhcm h.e+ dusorihce am "l.f.vinn In overcSr4 .vc" .<br />
fxil 0Y;C651JAltt Q@GOF£pti .bn o1' EEGGh P p01'Fbn, naNOly TtoS6,<br />
the fatnous oditor oY the 18etv Yorker wnga.a;S.nc, aho clied o%'<br />
]ang Cauoer, In In tha lnook "Tho Yostiru tvt th Ross" by Janlsxa<br />
'F.'iturbcr . 6tnl ;t of the ausu had cviCence of ]onA continued<br />
].nk'I1/1!Hp Y:t9on Vl1.th AnSOC£Seeli of thCY bi)OYIChSi a116 lunt`; .<br />
iho ot.be.r ar .ndi.lep: In the sen w7th nguelxousl ]wtg cnneer<br />
that cU .r.tit .VuSeho d thcavn f.'roln ot .her g rout,el uae h pere iotence<br />
ok noxc,eil tes;ticul.a.x auc4 prot;tftt9.c structure into late c1iA8Se<br />
L',g0, v/hCn 15(/rt IDPn C.Ito1Y So111(> te3E+tj.6ula1; nt'rojihy atiti rYYOHtFSU .C<br />
0n7SrC`o m oilt . A"InH .lB" £F.ctAr l .on(Y, rdCOQp1SZ.Fp in llln g 6a_ntler<br />
Nnencc+d to Z .nvo7.vo pV r,ont5nued aetf,vo production of malo sea<br />
hormo [eG :. 1JCyoilCi t110 Eltrpr(i g0 .<br />
'%Oo £'O1Y 5NUll18b \Y%th th'06 051nRer tyl4' vere nvn71 .ah1C<br />
2or afoc,tnnto an•r.YysBc .<br />
En tvoracm anc; eomm naen ndenoactrci4nomp.s of the luug<br />
ul,loaxed to e±rtse 1roo-l abnorwel intornlal proceseon thut<br />
:inv0l.vCf7 feldnGrYikR7 eFtro[BCfniC hoY'HWn[tl 6tLYllnlatieel'1 . ThiE1<br />
:ICaQ 9c. prcr4cmtly being £olloWot) by h£'urtiu+r s4 ;utiy of Sp<br />
a.rCol.fi :xoa c+n :.eH ol' wmaon trith lan(c eteut+er frrna Ylolafiold<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
I 0<br />
•<br />
•<br />
kospital, llec' York .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1930<br />
8ubscqucntly, Dr . Mar,}oric J . Williams, then pathologist<br />
at Tomple 1'A. Oenter and now Chief of the Pathology Section<br />
at VA CentrF.l Offico, and I niado a similar study of 100<br />
mcn with lung cancer autops= from Temple, Texas . Their<br />
e:nvironmontnl exposurc v cvero not analyaed . As was proviousl .y<br />
found, mo rt shoerv>ci evidence of underlying chronic inflamura-<br />
tory 7ung ilzsea se . 'i'he men with squamous lung cancers again<br />
sheWed thu greateF,:t tendenoy to preservnti .on of the norma l<br />
t.eE:tf.enlnr Ftructere in Into middle nge . Ilest factors wore<br />
thus found to be 4raportant in respect to the development of<br />
th.e typo of lung oaneer.• r>scribed by son :o to cigarett :e smokin!- .<br />
19ore recontl.y in a c:tudy of tho d:egenerative lung<br />
disenso omphysecna, which according to J . P . Wyatt, a leading<br />
authori.ty, predorninates markodly In mon, host fact. or ® were<br />
faund . Thore tvoro endocrine chaugon in men with emphysema<br />
nC:Boef.ate[i eithor with overgrowth of br'eAFt tifr8u4 micro^<br />
ahopinnlly or with i,t:n prosorvat:9.on In a normal state . In<br />
contract maniy other rfen had hreant atrophy .<br />
7fioee host factoa• studies aro rel .evant to tho i .nveati.t ;a-ti<br />
.fanv of rm7.utionshi,pr botwoen cigarette smoking and lung<br />
cr.ncer in the fol.lovring way¢ . Icven if one accepts n heavy<br />
inhnleiticn er.posure= at the r•at.e off two paoks per day for<br />
20 yenrs, only a ermnll minority of mnle cigarette sr,kokers<br />
(soracrvbnt Ace.© than 3 per 100 men-yeare) developod tnta] .
c6 )JS1<br />
lung ca.ncor . As with nl.l factors nu:pectod of being weak<br />
c:arci.noLons, a vari.oty of significant contributing factors<br />
aro ) .il .•oly . itost factor studied previously described hnve<br />
• i.ndfeated at l.east two : (1) chronic inflnmmatory lung<br />
0<br />
diseaso ; probably bactori.nl, viral or both ; (2) Lormonal<br />
faOtore, particui .Nrly evidence Of persi .Ctent mal.0 sex<br />
hor,'mene productioel into lato middie a6e . The maj or point<br />
i.s that the dungor of cancer is not apparently spread ovonly<br />
nr.aoni{ heavy smokers . It affects particularly men, some with<br />
oxconsivo nervous energy, often with ehroui.cal.ly inflamed<br />
bronchi and luugs, and coeae with evidont nbundant male<br />
horwonn ) production . ]Vouen, men with decreasing male nox<br />
hormoucs nnd certnin othor groups are 1esEs affectod .<br />
ln summury, thero 1s evidonce for mu] .ti.ple factors<br />
An lcuig cancor dovclopraent, and extonsive scientific investi .ga -<br />
tian suhould cwn tinue to determine what role, if any, al l the<br />
factore i .ncluding cigarette smoki .ni; may pl .oy . The subject<br />
of the enuew of the lung cancer ir;cw t c)osed but just barely<br />
O]renQld .<br />
s/ Sheldon C . $omers, N .1) .<br />
tYr21'IaNSHO)i8 :<br />
nesoci.ate Pathologist<br />
peh ., s, 190s<br />
]idi.tori.nl Rcvicwt "Tho ]3ndocrino ared Genetic Fnctors<br />
in Cancer of thc Y.nmg" . GrowtL, 1064, 28, 1••1U .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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•<br />
0<br />
c6<br />
McArthur, C .C . The Personal and Social Psychology of<br />
]93fl<br />
Smoking . In '"fobacco and Hea7.th", C .C . Thomas, Springfield,<br />
Ill ., if^61, pp . 7.01-,0 . "SmokinG and Ilo£dth", U,S . Dept . of<br />
Health, Mduaation and Welfare, Washi .ngton D .C ., 1964, 387 pp .<br />
Sommose, S .C ., "Host Factors in Fetal Human Lung<br />
Cancor", A .M .A . Ar•ch . Path„ IOSS, G5, 104 .<br />
Somwers, S .C ., "Pulmonary Hmphysem a, Healed Myocradia7.<br />
1nS:arCts and other Disease Correlations with Male Bree,st<br />
Structure" . Ana .J .HOd . S¢a ., 1964, 245, 341-44 .<br />
Thurber, J, "The Years with IM£ :a"„ Little, Brown f+<br />
Co ., Bostoas, 1957 . 310 pp .<br />
Willinms, M .D ., and Sommers, S .C ., "Endocrine and<br />
Certain other t:haliRC9 in Men with Carcinoma of the Lung" .<br />
Cancer, 1962, 15, 109 .-17 .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Wyatt, J .P ., V .W . Fin:chor and B . .C, Sweet, ^Rmphysoma" .<br />
Ani . Rov . Re£ip . Dis ., 1964, 09, 533 -60, 721-35 .
•<br />
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ra I<br />
S'f`A'CFIMRNT OP Tfik:Ol1OS U . STLiKL1NGp Yh .U .<br />
lntroduction And Summary Of Concl .u ::ions<br />
lnformation collectod so fkr on the link betweon smoLi .ng<br />
1833<br />
and various dieeYatiF.f ha^ rHS .Eed a CQrtnill amollnt of di.sa(;reCmeni :<br />
In the sci .ontific comm umi.tp . Off hand, dirsagroements among<br />
seionti.ents have al.ways, bcen holpfu l in elucidat .ing solution<br />
to problems .<br />
'cGic useiull function of .r,ientifi .c disagreomr,nt .<br />
is somewhat di.minislred when it becomes a meltf.er of public<br />
. However, the fact that thi.s disagreeuwnt exists is in<br />
con-corn<br />
no way elimi .nn.ted by reports of committees or of organi .zations<br />
who study cerl.ain health prohlemm in a professional mannor .<br />
'171e conr.ensus of tho sci.ontific communi .ty i.s nei.ther<br />
measured OaEil.y nor In this consensus decisive In e.Cientific<br />
hattorc . Scfent.is:ts have too often viff.nessod that the correct<br />
i.nterpretation about the state ofnatnre was advanced by the<br />
rnf .nori.ty rathor than by the via j orit.y . In faet, the opi.nions<br />
of sc.ientistc: or of the scientific commani .ty are of no con-<br />
e.oqucmce to facts: ofnature, If emoki.ngdoes caus+e dfsease<br />
then the body viil.l respond to it, if it does not then the body<br />
v,ill not, irre gn rdLer;s of wli6t Opinions we, the Surgcon-Gen-<br />
cral, or comrlittce o appoi .nted by anydody raay hold .<br />
1, for one, am convinced that the anCwer to the problem<br />
ofwhCther or not Emohillfg of tobacco causRs disease is not<br />
y4t NI1hNt.alltiated sufficiently so tflat a firm poEitfve or<br />
I1P.Gative 1'erClfCt eall be rCndered, 1 vi .ph to C/fiplaeiLe thnt I<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
a 2 ]£r3 4<br />
ar0 teSW yin(, lyith P cHvPct to tbE : adE!Quacy of the evidCnFC for<br />
saPport .ing ff .,a.ll verdicts rather thcn advancinf: one myself-<br />
The reason n on whioh 7 baso my own eoncluaions may h e svmmar--<br />
i.aod an fol.loltis=<br />
1., A mmmher of nntmall stod3 .es have nttcmpted to producol<br />
.un .^- caucr,r by mea.ncu of c.igarot .tn snnlm . The r.oe.ults<br />
of r,]l thess f>t .udies have boon ue ;r.atlve,<br />
2, A'pidemAoio ;;i .c:a7l wi.donce+, Gae,ed rior..tly on st .atioti .c.Al<br />
m+.ni .cml ;at .ions, is nac.lsar, confli .ctinG , and in mau y<br />
ways .tmpoz.eiDlc• to interpret .<br />
It in a rai.mp7e fact the.t the public suid ropeatable produc-<br />
tion of n phenomcnon is the prer.o[duisiEC for proof of c.ausa -<br />
•tiDn in al l zcioncees and curta.i.nly In bio .loCy . Al l er.pori-.<br />
wcautc that hav v a?.termpted to prodncc lunYg cancer by tho cm_• o .f<br />
cilro .rot'
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ra 3<br />
rnakes up sciemtd.fic procrf . on the who] .e though, whf.le there<br />
are no pre,cise rules, there is genera] . agreement among inves-tiB<br />
.ators on the major aspects and methods of a work that make<br />
it scientific, Floxevcr, not all docisions, oven those made<br />
by soivnti .stc, are noc:arssari.ly sci.ontiRic:, This has beoorne<br />
9.ncreaeingiy clear in the l .nst few years when scientists<br />
have bcen asked to make deci.sions which have public import<br />
183&<br />
either i.n war or In the nrcn of publi c health . In dealing with<br />
our I>resont problem it i.e very importn .nt to koop In mind when<br />
s+uch deci.sioaes are motivated by purposes of science and when<br />
they nre motivoted by public health or other oocessitios and<br />
cims .<br />
The scientific decisio n proces6 seeks to dorive solf corr ,<br />
t.ainod statemmts of fact about the existence of phonomena or<br />
essociat9.one : . The sci.ent .ist has learned that correct stat<br />
.e-meuts of faot<br />
l bestow upon man immonse 1>owors to manipuYato<br />
and modi .fy natcu•e to his benefit and sat.isfaction . He hns<br />
loaruod also that to bo offective scienti.l'ic deoisions must<br />
be rcachcd by str7 .ngent and hard -headed ru7es . frimary among<br />
these is that the soismtist c.annot be i.nfl.uenced by extraneous<br />
motivue . It does not matter whether these motives arise<br />
from the noblcst rnost selflees aeipi .rations : or from the basest<br />
drive for self aggrandi> .ation . Any possible influoncos on<br />
sci .ent .if9 .c decisions t.hat are not relcvant to the problem it.-<br />
sel .f are direct or implicit sourco h of bi.as, Incl.udod In sucT<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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sources of biasos nro considerations of tho social or Holiti-<br />
cal consequences of the scientific decision itself . The<br />
cnro with which extraneous motives are eliml.nated from the<br />
scientific process is reflected in the manner in which<br />
. aro usually documented<br />
. The conclusion is documented : 1, to have a more than<br />
reassonably hi.l;h probabil :lty of being correct> The<br />
preferred demonstration is to specify the conditions<br />
by v:hi.ch tho phenomena can be produced publicly and<br />
at will .<br />
'L . Iti-s shovm that alternativo conclusions either have<br />
a high probability of being i.nc:orroot or have a much<br />
lower probabili .f.y of being cora•ect than the prefer-<br />
red stntemont .<br />
3 , It is dernonstrated that sourcos of bias which are<br />
its con-clusione<br />
3936<br />
extraneous to the evidence itself have been elirninat -<br />
od from any influcnce on the decir>fon process .<br />
It is gemerally recogni .zed that spccial care must be tak-<br />
e.n if dccisionc on medic.al or biological fact are based pre-dcnid<br />
.nant.ly on cv .tidcnce of Etati .st.ical assoc,iations botween<br />
agent and dieoae :c, Such ar, aosocietion does not reach the<br />
status of z scientific fact until3 the di.eense itself can be<br />
czlJ.ed forth or prevented undor controll.ed conditions either<br />
Li man or in noinin].s, Correct conclusions es to cause and<br />
effect havo trmero drawn purely from epidsi®i.ologieal coincidence<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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in the past . Those occasions have boen more than counter-<br />
balanced by the many ins :t.r,nces in which exclusive reliance on<br />
statistica l association has provcn to be mislonding,. Woll<br />
aceepted epidomiolo6i.ca1l findings have been confirmed by ex-<br />
poxd.mr.ntc that tested the suC.f:este.d asscroiationa under labor-<br />
ator,V conditions .<br />
It in at the point of scientafic versus action oriented<br />
attituden that interpreters of the data On smoking and health<br />
hnve failed to reach a common understanding and appreciation<br />
of their respecti.ve points of vierv . For the proponents of<br />
)p?7<br />
public action the demonstrated statistioal association between<br />
smoking and increased incidenc:e of mortality is conclusive .<br />
For the proponents of hnrd-headed scientific judgment, the<br />
statie,tical association does: not representadeniuate evidence<br />
on which to base conclusions, Thereforc : action orientation<br />
hn& led to the repetition of basically the<br />
.i.n st.atisticn snme study, demon-strating over and over ngain that cortn<br />
l coin-<br />
cidences do indeed exist and the scientific orientation has<br />
kc:pt on be Jng di .sturbed. hy the constant occurring anomalies<br />
within the statistical evidence, the laek o]' adoo,uato method-<br />
ol.ogy, and above all, by the failure of laboratory exporimonts<br />
to produce posi.tive ovidence of a presumed offect of smoking .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Eixperi.meutnl ftvi .deuce on Attempts to Induce Lung<br />
(:wtlC-0r with <strong>Tobacco</strong> and <strong>Tobacco</strong> Fmeke '<br />
'Pho report by the Snrt;eon-Genoral's (:ommittee on Smoking
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s<br />
ra6<br />
and Heaith point.e out most ndoquat.ely thn9t while broncho6:enic<br />
carcinomas can be produced In a variety uf animal„=s by many<br />
r ast,<br />
euhe.tancon, such ttinmr€. cannott bo producod by tobacco extractr„<br />
F,moke, or condensat :es .<br />
"9'he lunl ;s of mi .cc, rate, hamstors und primates Lave<br />
bocm found to bo susce.pti.ble to the induction of<br />
bronchogeni.c carci.noma by the admird.stration of poly -<br />
cycJi.c aromv.ti.(: hydrocarbonu, ourtcrln niet.al .~., radio-<br />
Acti .ve S:nbEtSncen, and Oncopt,elliC Vir'uSeF. . the hiF,to• ,<br />
patlwlogic: c:he.ractort .stcF: of the tumors prodrroe(1 arc<br />
Si.ndlar to those obCOrved in nlan a11d are fFeqllent .l y<br />
of 1,he squamous variat.y . (Bl.IohinF[ and 11ea1 .1.h, p,<br />
167)<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
"f.romicho(toniec carcinoma has not boen produced by the<br />
appllcat5on of tobacco extracts, sniokc, or conden•€<br />
.atos to thn 1.unE( or the traeheobronchial t .roo of<br />
oxporamoutal . ani.male with the possiblc exception of<br />
doF'F+•" (Snmki.ngand }lealth, p, 165)<br />
As thc firstt quote points out, it has been well . estab -<br />
1Lshed t.bst hroewLo((emi.e car•c.inoma s can ho produeed in ani-<br />
n:a1s . A n(nibor of studlos publie;hed in the litoraturo havc<br />
t:o i'ar fai.lcd to dernon5arate the same for ci .lraret,te smoke as<br />
a cauv:ati.vc agont . One shonl.d be atvaro P.t this point that.<br />
ihe Fmmber of etudics appoari .ng in the 7 .i.terat.urc may be nds-<br />
1 e Bdinft . 'rh.ere YF ; a d0(ttnnented tendency of :lciAnt.l.fi.c reportFe
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to publish only pocitive: results and avoid the publicatdon<br />
of neRativo rosults ns much as possible (95) . Whatever• thc<br />
ea6e might be, expcrimelltal facts appear to be as follow's .<br />
Bssonborg (13), Muehlhock (29), and Louchtenber(;er (26)<br />
exposed mico to cigarette smoke wit.h no reecQts on the forma--<br />
t.ion of canccrs . Aoren z et al (3l .) and Leuchtcnberger et al .<br />
(27) di .d not obs,erve an i .ncrease in pulmonary ndenomas in<br />
rni.ce that i.nhaled ciCarette smoke , beuchtcnborger ot al (25)<br />
doe[:: describe a series of microscopic chan[;'es in the lungs of<br />
mic:c exposed to ci .l:arette smoke resembii ng somewhat those<br />
found by Aucrbach e t al (2) (3) (4) (5), . However tro dose<br />
responeo ef .Peot was reported, The norpholoF:ica1 findings<br />
couavi .e:tod of bronc.ld.tie with prol.iferation of the opithel .ium .<br />
Sorne areas of bypcrplasia showed atypical changes . iiowever<br />
1 939<br />
the change s wore reversible when exposure to smolce War, stopped,<br />
Such pathol .o R i.ca1 changes are uanally not considered ceir-t<br />
.ain enough are i.ntli .cators of actual damage to tisstte . In<br />
di.scussi.n(i Lhi . ;: ovi.Gcnce, the Sur6:eon - Gencral's report con-<br />
elude6 :<br />
"'fhe production of bronchogenlc carc.inomas<br />
has: not been reported by any investigut.or oxpos-<br />
in4'n experim u nta1 anlmals to tobacco smoke," (page<br />
165)<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Most e xperimenl .c in which tobacco tars were brought i.n ,<br />
to Gireot contuct with the LunG ?nd the tracheobronchia] tree .
•<br />
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ra 8 3940<br />
of espori .mental a.ni .mais have yielded neRa .ti.ve result (41,<br />
42, 43)~ it should he pointed out that producin6'g carcinomaa<br />
by painting ekin epithc:lium with or without additional addd-<br />
tives such as olive oil or killed tuborculo bacillus i .s real-<br />
ly not ovidenco that such carcinomas c :au be produced by to•hacco smoke,<br />
It cannot be denied that one of the most significant piocec;<br />
of clomontn on the rclntionuhip botwomn smokin[r and heal .i:h,<br />
ecpecially on the rol.ationchip betwoon smoking and the causa-<br />
tion of tumors is tho fact, that . it hac not bocn possiblo to<br />
prodUcO such tumors i.n Pnimay5 w1W ordinarily respond to other<br />
i.rritent, by formi.ng the eamo type of tumors found in man,<br />
This ie not j ust lnck ofer.perimontal evidence . It is nmLative<br />
evidence to the hypothecis that smoking causes bronchogenic<br />
t.umors .<br />
'fhere are howevor, certain dangm•s in gmioralizing from<br />
animal oxporimcnts . These dangers should a,lways be kept in<br />
mind . Snmetiuce nE;oute+ which are not hnrmfu l to man may be<br />
so for animnls and sometimes agents vihich are harmful to ani-male<br />
may fail to result in simi.lar afEoct.s on m a n . 9herc+ aro<br />
di.fforoncoo in the rosponses of different, animal speci_os of<br />
which, of cource, man ie one .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
0ne of three pocsAbillties e,xistea with the interpretation<br />
of datna on animal s . The fi.rst one in that e,mekin{; per se<br />
docs not cauro bmonchoconic tomoro . The second one is that
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with respect to smol
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ra 10<br />
pnthwnyse and c.ould be the effect of the acctimulation of rneny<br />
events acting over u long period of time, the applicnti.ou of<br />
epidemiological tools and methods have led to li.ttie more<br />
than confusion< There arc many (iangors nssociated w i.th the<br />
unquestioning nccoptanee of epidr,mioloe7 .ea1 evidence, I<br />
poi.nt here to l.engthy disnusoi .ons which 7 end othorc have<br />
undertuken in such areus as the associat .ion between load or<br />
between l.ow doso radiation and ecrtai .n diseases (22) (45)<br />
( ;i0) (51) (56)e It i .s vi .th tho sxucrPi .c9.on that cnidomfolo(ti-<br />
cal and e:tntissti.ca3. evi.donce ie: oftc.n anrbi.,guoues and, unless<br />
collcctad tri.th the greatest of care, br, n rclativcly J.ittle<br />
vr4tw that we mnst approach existinC evi .dencc on smoki.ns<br />
a,nd ItnaES cancw• or other health aff setc .<br />
J would summarizco the views of others as weJ1 as of my<br />
own with re a poct to exi .eti .nr epidomioJogac :al evidence by<br />
mnint .ai .nin6' t:hmt it iu unclear- insufficient, and hopalers ,-<br />
ly confounded wi.th many cxtraneous factore< Specifically I<br />
wouXd cmphn.e ;i .ze the followirq; :<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
J, 'fhe aEr•OCSAtion hetween ci.t;areti :e consumpti.on aud<br />
fno:coasos of aay disonrm over tt.ne f5 not menpi"p-<br />
fuJ., (In contrast, t .h0 laclc of such an assoniat9on<br />
J94?<br />
would be a Gignifi-0ant il'idicetlon that no cFw sai . fe-<br />
J . .^.S . :IonS6i .p hetween s;moicznRg n.nd heaJ .th oxi .F.t .ed),<br />
8, 9'hc riepWntfenG which have boon sampled show so<br />
n:?nY RnolrlnlieS when Cempared to cen9J5 (iata that
•<br />
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rn 11<br />
.:ono,'me ; o n a nc,;cd on thei .r atudy rs•em less then<br />
RNftF.i .n .<br />
., 'PUahni .gues used to measunc the effect of smolcing cm<br />
diennr,e are often un5uitablo, .<br />
1943<br />
4, it . W uuclmar 4ror pre•soot date whi.th if any disease<br />
i.l= or S .r net cuut:cd by Smok>_n8 :,<br />
5 . 611pa1'Mit 4`fiWG11D on htHlth CB :.n In4 teeonnted for by<br />
fSCt4V' :v othOR thF ;n E :ni'vning .<br />
A2;ociatiou 7: ;:t:enea C'igarette Consumpt .fon and Lung C'ancer Over<br />
9'imc<br />
TII'JAe has Loon & OUnFrF&erahlo Ancrea6e in the repart.ed<br />
AP3n]t 0c lAql UanJ9r ]n tho last few dQCbdei . Ther0 hne also<br />
lman an inc,a&ero in ti,& e : :noimt smolaled during the sarne time,<br />
(12) (1.ri)(1,7) i2ta) ( :I?7 (?•W .. 7.t As oot 't .un hov:ovcr that<br />
one crn : :cnoA'ad,- r,,,q'ti,i .ng Lrom thin oBSVPVed covarintion . Tho<br />
uprocni o f dln=:ctiW t hA t n•r.u baon rused durint; tho uame time<br />
hra inc .rent:cl) j1, ::4 as rcuch as Lss ihe c wowh of gaeolino, al-<br />
coho"f, or r :,rett ni,li Ilairy proc;uctes couo U me6 . Over any hhort<br />
perind of time thl,re [ : oro rea] trm :ds a_, wo13l us apparent fluc-<br />
tre'.t.i.ans an0 myclc& tvhi.ch, by thei.r eheer number anu by the<br />
fact t that LhiitG ;s c-11bcr ;('o up or down, aiWayU mnflt give the<br />
apr-nWxr,nce of ev m o sorL of sn aseiociation 11 thir,i typo of<br />
ovi drucm v,e r ,x ,:ve v a.cc.eptod at al.l us pointing toward r.n<br />
asr:nai-sa4on . 3'iie truth c,f the mati .e n i s t :hntt an i-ncreace in<br />
cmoiisg and lins incrcaso :lr, f.ung can ier de : 60 m are ovl.dence<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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of cau_:ali.ty than t.he increase In the co D sumption of meat<br />
and dai .ry producte :: and the i.ncrease in lung cancer or the in-<br />
creaso in smoking and tha t of either nati .onal inc .omo or the<br />
national deht .,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
The cusious aspect about the ti .mo-xerd.al rolation he-<br />
9 .v;oon inr,i.rlcuce of srnoking and disease i» the foot that while<br />
the rol.ativel.y short t .1nw cofluctuations between these i nci .-<br />
dents, by thcroselvcs, are not proof of cr .usality, the failure<br />
of such aacoincidence svould be f .mporta.nt negative datao Thexe<br />
is a 1?oSf•i .bi.3ity that euch negative evidellce fE apDearin€[ now .<br />
Gilli.am etf al . (15) detected a decl.i.ne In the rate of fnc.rease<br />
In the i .nci .demc :e of 3.cm g carwor wLi .ch can not be related to<br />
rny deeline In the ra.tc of increase of smoking . . If those<br />
ubr:ervat .tourw ahoul.d t ur n out to be true and if a doclinin€ ;<br />
trend In lung cancer r,lwul.d develop in the next few yeare :<br />
such a ta•e:nd woul .d ho ntrong cvidence against a causal ae :socie .,<br />
tion hot.wo on smoking and lung cancer,<br />
Samplin€. cnd Suit .ahi .l .i .ty of the Sanqp led Populations<br />
The fol.low-up of populati.on i .s s.n extromel.y difficult<br />
Y,nd e>'.ponC•i.ve upde.rte_]dn€ ; . It is conYenient therefore to<br />
t;cleclt popu7ttions whi.ah a.rc easy to follow . Those might be<br />
groups of i_rldividuale readily avai .lahi.v for study and willing<br />
to pe r tici.pa.te or groups of i .ndividne .7e: 1.hatcan he used to<br />
Relcct SaNplA& within their own Cnvi .rehmont . Under ei.ther<br />
eOndif.i.on thC 5am{)l.in(' Eitu3tion 1s far 1°rom l .dLal ., Specially
•<br />
•<br />
•<br />
ra 13<br />
OBkNli .i .ed gCoupn di .ffer alnloF.t by (lefinitiOn from the (;eheral<br />
popnl .af .i.ou, This differenco may er.erft itsel f In many waye,<br />
a) .1 or ;omo of w hich rnay bear iniportantl,y on hoaltho Yor in-<br />
s tFnee 3.f bU wOTO to SLu(iy a//o pu)at1Dn Uf poGl6men beeaUFO<br />
postmcn are readily ovailabl.e vre would also st<br />
.ttdy a populn-timn thcrt does agroat<br />
: deall of walking as well as other phy . .<br />
:;i.cal. e:xcrci .ses .. P.nother r,spcct of eca .r:rpli.nFg for populations<br />
whi.ch furni.e:hh the Prec:cntt evidence on the r :moki.ng-hoalth<br />
li,nk W wort:hy ofl not•e . 79ce tondeno,V haei been to select amocig<br />
ro) .a.f .i .ve) .y ol.der nre P:roups .. The roason for the celoction<br />
In t.hat l.cm(g cancer, the }n•imary health problem of Lrterest.,<br />
occ ur s: rith e(
•<br />
•<br />
roc.rui.f.ed by n) .ur.P.e numher of vol.wrteer wor9cers of the<br />
Aiaori .r,an Cr.necar 3oe.iot.y . Vcc),unt.eer wor9eers of the Arnw•i .cr,n<br />
Canc.er Soc.icf.y may con :;i . N t lerhely of relat7 .vc S of cnnuer<br />
vi.ct.i.M r-. or of indd.vfdtte:ls with strong convici .i.ons on cruicer<br />
and ais Fuch cun not be conFi6erod unbfas,od wi .th respeet, to<br />
t.he effe .c.te, oi : :rnnhi .nY~ on c ..noer . 'fhu fa( :t t.hat, a lzreo nuru-<br />
hor of sqe,h tvoxRCr . wa r involved % e $ i n rw wmy eli.mirnclla<br />
1946<br />
po'LC,i)i) .e hJ.NFRFM in4ro/iUCOd bS' this pTrt:icnlar lil4tho(i of selee-<br />
tion, ltccausca of this source of bias the populat.ion studiod<br />
hy l .rn» : :a nd ;_s: L mposr,ib1e to define . .<br />
Anot,her pro4J .e,ra r+ith all prtscnt rctud4eer wau that w5thout<br />
e)CCelnti.(RI the pCr cent of ryRP, blO rCt)1.1efJ to qt1e51.1Onna4reE1<br />
or to f01).Crl9--00s hKVe boon GAtrO[dcl .y t.T4@11., The p(Gr eent<br />
ofur.aFJ.o rmter?zf in fo) .).ow~ups ru•o Civen in the taliln bclow<br />
v:hich hrs boen £atcon frrna Smokinr: r :nd t.on).th (paF[e pf),<br />
9'el0.e 16 .Wbt•nent.alqes of usable ropl,iem in five studiec<br />
lirit4r:h U,S . C :all.forni.a Cal.ifornir. Canad'aan<br />
eloctors vetoruns occupatAontal f.npion voterane,<br />
cih Fi8,F.S 83 56 G7<br />
F:hat eFfect i.he lec) : nf respoue.es has had on the observed<br />
rocnk9e, :it oxtremely hszrd to deYi .noa Certninly , whnt.evor<br />
none)ar:kocre can be baseti on such iucompl .etn surveys are depend-<br />
-<br />
ont on ex /tirc':at nueibor of as6unLpt.i.onv, which one has Lo be vri.19 . .<br />
iqt ; t0 tlni .:C .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
4notlmr mosYt di.&turbinl ; A©ai= s: .bou.t the vnriouss s a w ple
•<br />
•<br />
0<br />
1'll 1 `u ~n•1%<br />
pocz~l.nt .i~pe is the Prcct Saet ihsT da ceb rtt;'re?013 ~uh<br />
oiher orad5`~ thc- V . : . G•>fu~utca 7.ti tesm.~. oA their Gisensc<br />
pa!SrsCt,e1RV~ low<br />
th :<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
:S :.nce, ihc^ 'tat•lo bo :kw ha :+ kDun teic•sn Imr. S :nolc1np: ruld
~ur.Y ~s. rR
•<br />
•<br />
ra lE<br />
Lic :pect.inn of thic tnblc &hows the following :<br />
1 . . There rrc lar ge diYferences amon@ : the study populatfous:<br />
with recpectt to dcach r'ato,<br />
2, ivith corae excoption, the Qenth r.ato of null thcrse popu- .<br />
latiou s (i.ne]udL1g heavy smokor,s) is wny below ttat fo :r<br />
white U„ S . pi9).© n . '1'here are a nreat ntlhlher ef PRpl.anf ..<br />
Lions that (6ay be aciVEnCed to eIIplni.n Lhi5 .<br />
I :UV/eVGT,<br />
1.t it1 one t.hin([ to advRllCe CknA.anntlons to Ecfotlllt for<br />
dir,crepanc:ioe i .o datn in mhiekr no die.crepancy ohould<br />
e%iR t and tllbth&r One to noe t,he4e (IatH plus the eY. . -<br />
plmuationa as : a baois i'or fi .rin conclugions about a<br />
phenomena such as &mokintq and hoalth,<br />
ln b[onoral, we mny surr,mari.zc that n7though a numher of<br />
oCridoudul.ogicel. ntudiv :: have aiade available nomo informat:ion<br />
on the dk.PfCYCnc'GS ill death r'atefs hEtV/OQ/rl 6GIoI9Cr5 a1HI nUn .FlplolaPrE,<br />
it xe genorally true that t .hoso populntionl eeom to bc hirh5y<br />
:rol.ect .ed, di_1'for i'ram each ot.lrer rmd from the E<br />
:enrral populra-tion in thely doath<br />
.ra,te¢, eu,d hnvc a very loAV Sbllow-up ros-<br />
pouz;c rntsi . 'fhe cxt.elNto rvhich suc.h c:a .mp].ing pucul.iarfitios<br />
can di.stor8 the ob:crved pattern of' dicqase for a populnt .ion<br />
hnvo b .^.cn deeionr :truted and ceil,aussqod (6) (44) (5]) 02) (5G) .<br />
Unti.l adequate and roae.ouuhly unbiasod e,nmplec are obtai .r,ed,<br />
the memits oS thc obs:ervnt.flonF on aise= patterns exhibited<br />
t,y t .hev;o popu7 .etionc ate difficult to ,jttdgo .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
ln'on i .f' S .hnep gyokinlntiAt1m aA'e acccapte : as providing the
•<br />
•<br />
0<br />
ra 1 .7 19b6<br />
be :.~t data availahic a .t the momr,iit, the compar'i.son of smokorce<br />
nnd non-er :okoe•s mortrlity mnde possiblc by them raises more<br />
qneetion .: than Pt providOe: a.nswers for . lbremost among thec ;o<br />
arv :<br />
1, Row to ntoa :,ure the effectt of sool:ing ; and<br />
? . 'the paohlem of the overrl .l vorrusthe r:pocif4c effect<br />
of ۥmoLing,<br />
tde,asuron,ent: of tLe Y:ffect of Gmoking Or, D3 .sanso<br />
The covnperisons of raortali.ly inei.dance betvc,en smoh:ers<br />
and non•-e .inoieer :; has been b[,sed predominantiy ori mortalll .y<br />
xati.os, 'Phis mortnl4.ty ratio i-e obt .afned by dfv9.ding tho<br />
ag:c specffic doat.h rat.o for d"xeoase of smok .ors by that of<br />
nom-smoLars . 'A`be rat.i.o should be in the approxzmate reCzon<br />
of unity Sf no di.ffcrence cr.ACts hef.vcan amokers wnd non-smokers<br />
with respoc :t to thH deat:Y rato of the e.pceffio dfss+asoo Table<br />
).9 (pa9e 102 froie 5mokinfg and 1lealth) abi .ch is rolev&nt to the<br />
onsui.uk (ASCUSrSi,on is rapx•oducod helov)o<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
~_~ l~_ ~<br />
VnNOrlrymux~I~[[N ,<br />
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wn . . . . . . . . . . .. . . . . . . . . .<br />
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.<br />
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Y~IIrc.v4}1 . . . .. . . . . . . . . .<br />
r nil~rt i . . . L ° I ° v<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
~~<br />
MaEinn<br />
NrltlblY<br />
°af .. . . .. . . . . . : .<br />
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L` 1 3<br />
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AaIJe ' ~f. rv~[I x~~blaom~~/1/..: : . I~WI ;<br />
i ee.~d Loo. B i<br />
44<br />
n~ya~<br />
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. . .. . . .. . . . .. . . rya<br />
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10. . yyta<br />
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. I
a 18<br />
P.052<br />
We find i.h i t cancer of the lung hn, the highest mor4ality<br />
ratio, bronchitis and emphysema the next highes:t, followo d<br />
by cancer of the larynx, and so on . From this ranking the<br />
conc}usi.on i s reached by some that the most important effect<br />
of emoki.n¢ is on cancer of the lung, etc . But does the mor-<br />
tnlity ratio really fndicatc what weight e,hould be given to the<br />
associai.ton botween smo€ci.n€; and various diseases? Yhore are<br />
altogether 15,653,E: expect:ed deaths from all oauses . Of<br />
these, 6,430 .7 woulei be expected to be due to coronary artery<br />
di.seaeo alone, It stands to reason that it non-cmokers have<br />
roughly 45 percent of al .l deaths due to coronary artery di<br />
-soase, eanokorsr even if<br />
all 26,2 23 deaths had been duo to this<br />
cause could not have had a mortality rat.io higher than 4 .<br />
There Is a limi.tation here to the maximum size of the mortsl.ity<br />
rati.o .. Yet the mortality ratio increase to 1 .7 for coronary<br />
artery dincano actually reprerent.r, a very large numbor of ex .<br />
cess deathe„ on the othcr hand, the expected ntnnber of deaths<br />
due to cancer ofthe lung among smoker s turns out to be 170,3 .<br />
This rcpreecnts rouChly one percent of the total number of<br />
expoct.ed deaths. Thcrefore, a relaidvely small increase i n<br />
the lunH canccur deathc amo ng the smokers could possibly yield<br />
a lar€;o inc:rea ue in the mortality ratio . The mortality ratio<br />
Is thereforo dependent on the actual proportion of deaths<br />
irom spccific oauces within the popui.ation ,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
The c;ucst .+.on whie,li now rc:maicie unanewered is if the
•<br />
0<br />
ra 19 1953<br />
incrcasc in the percentage of death due to coronary artory<br />
discase obeerved in thi.n popul .ati.on Indicates a greater or a<br />
l .ec:e,cr effect of smoki .n{; than daathr, due to cancer of the lung<br />
or hronchll.is or emphyscma or cancer of t .he larynx? 6ven if<br />
rmokinfg had the effec t ascri.bed to it, is this effect mcasured<br />
aecuratoly by the mort,ality ratio? This is by im means a<br />
monor point . Yn tcruas of possihle confounding hypotheses it<br />
woul.d bc very suggestivu i f one would say thatt the major effect<br />
of E¢ilokin(; i(; On eorona'!.'y artery disease since soniC of the<br />
di .ffc:rences between smokers and non -smokers are procie0ly in<br />
those mcdieaA O regions which are u[-:ually r,ssociated with coro<br />
.y artery disease, It should Ure pointed out here that<br />
nccordi.nE; to Borksoo'e published calculai :ions the effect<br />
of i.un9 canc,]r is actually minioaal as compared to that of<br />
certain circulatory diseases (f3)o<br />
The menz.urem©nt of the effect of smoking is important ,<br />
The us,o of mo•talit.,v ratio to define the specific effeet of<br />
sar,old_n2, i .f such a dofinition is possiblo (and there is good<br />
rea :,on to ma i.ntai.n 'ihat . it is not) 1s of 9uestimiahlo va] .i.di .-<br />
ty,<br />
R'hat ViscaEro Is Ca.used Py Smoking?<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
bnc very eerioue& ryuesti.on raiesd by the ava@ .].able epidemio-<br />
logi.cal data concorns the increaso fn deat .h for all causes<br />
for .mohors as cornparnd to uon-rvmokore„ Whether or not one<br />
aeeC[t.F the NPPtality ratio af: valid, it is obvious that<br />
.nar
•<br />
•<br />
•<br />
ra 20 ) fe52<br />
smokorr: in tho e:aral7) .ee died at a fk , tor rnte iban oon- . mokers<br />
fro(n p!"aCtioal)y a).) 111ESOaGese Ytiere ie enly one diECaso,<br />
cancer of the i.ntestine, for which smolcersv c71.e at a losser<br />
rate than do non - e,nwkere:, nnd one di .senee, cancer of the roW<br />
tum, fo y which th e rni .ce: for both smokers and norn•smoP;err, are<br />
a)ilce . The conolus;ion t.hat hae boon i9rn.wni.n the pav t from<br />
euch data vinrz that emokxore diffor from non--e :mokers in thoi.r<br />
Lot :x1 PPtttcr u oi' mori:R1ity . This haE Q,iven riFe t .o the cc'r-<br />
i.oun gucstion if one c.an ascribe an effect of s:woking to zi1)l<br />
dirreasr,tz'I !be- cone)u :;ion that a11 excoena ryrorte.lity i6: c.ouced<br />
by r .rnoki.ng hae proven very rmgoNu)a.r In the Past> l t rfoet i<br />
seern unrozs:onable thr.t one part'xcu)ar egent would cause a)Jl<br />
those damnf;os . On the othcar hand it 1 n not too un) .ikclv to<br />
come up with coneir:tent difter'encos in a11.) meacuros or in the<br />
6'ho).e (>mttePn of i .) .1nCF54': iF f,erioll& biflceF are i,ntrodueed<br />
tbllou(;h inadCrlnEtte sa v )111ng procedures, For inEltanee my<br />
&Edb`oci .at.cE and I 6howed thflt Llndor OOYtai .b conditions a heilth)'<br />
popoa.at.ion rnny he mado to n py,ear to have erither a higher or<br />
:r )owar donth rate thau the c:omgarnblqi 1„e.neral poUulation<br />
dePending upon how ono ari•nngee the data (52) .<br />
Mopr, the bohrcd d,iffcrencee bei :weeo smokerc and non--sewlo-,<br />
era havc: to be recogni_ze>d as one of the mo.Jor diffi .cultie ::<br />
iJ, nmkf.ng the oxistting: eCiiderniologica)l da't8 palatable . Seme<br />
n rr6hor ;- (A.ncluti .u g thoqc, rospuneib ) e i'or Lamohing and Hsa11 .h)<br />
have cPur:.on to bypasn th'r :,~ proS :J .em by W inkg a tiseate by<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
ra Z1<br />
l9hs<br />
discnsa ceaapcrison betwc=e,n shokers and non-esmokers and letting<br />
eome outridc eriterion (e.ur,h os aatnti.ECti.aal signif.icnnce)<br />
decSdo on whether or not the obeerved difforonce indicates tho<br />
caxist.oncc of a real effeet duo to cmoking . ]t. is ei®plo to<br />
denlonFtrate that stleh n(rroeedure i .lJ f:tatflstiCFJ.Iy aE weli as<br />
lo€4lcnlly unatonnd,<br />
L.et us* t,seurnc we test whothor or not differonoos in denth<br />
ratcvil rclate to polit.ioa.l percuaraion . A 1ErrGe samplo of whi .to<br />
mel .c*s i.r-n divifle:d xe; to Hepuhl .ican or Ire:rwcrati .c regic,.tration<br />
E:nd fnilowcd for s,ome t .i.me es in the smok :ing e:tudies . A<br />
disoae;e by df .sc2 ::e oompsrie,on of doat .h rates in both pupula•t<br />
.iAn4: iFmade next . Where e, ]Lir(;e di.filerence as CICflsUred by<br />
L;tetastienll t .er't appeNP'H in the /JiiPeA6:C IHte it is a6eribed<br />
to d :lfYorenc.es in pol9ticnl belie€p<br />
Quite obviously no one would accept r..onclueionn based<br />
on tiueh a Oo m pn .S'i5bn, Me Vlould rea3Gn that even though 110<br />
di.ffrnrenecn in the rato of dmnisr, of Uornocrnts and ]tepublicans<br />
u:cy r,>;0. ::t, randor.i eeleet3on vould nl.ros t ae.•eure that for some<br />
di .seaa.e: : :, i r:o vc Por•mm s t.s: nnd for otheres ruose ]tepuhli.can, dted .<br />
P:c tvould bo eoncarued in ler
•<br />
•<br />
ra 2!,<br />
1956<br />
nlTenr i .o exiet f:or a l.rxge number of dieerr;e n,ortalily rva.tlos ..<br />
Lot St: bo cs :vumed thatt t,here docs er.fet- e difaorence in mor-<br />
1 .aJi.ty pvat.tern botwcon r=nmktire nod non-,n;rm;rkors, one would<br />
calx.ct that, by ehaoce e,lono, for some diseasos this df .rfnr-<br />
once would be Yargor anG for otbors i .tt would be ttmallcr . Oh--<br />
sorvinP: viithin the da.i.n thai, raoirb of the rniooases are differ-<br />
ernt a.nd few of them Rre arlEke one wou2d be i'orcod to the con•-<br />
7.usGon that the p:oncral i,attern of mortallty >s difforcnt --not th2t on?<br />
.y Forae o4t .hosc diseasec diffrar nud othory do not,<br />
Y'o do any othnr viay ks to ignorae soneo data and e :eloct othcrs<br />
for onc'r• purpoyov . Tbe reason thA .o 1'oi.nt has becomo such a<br />
bone, of eont .emti .on ic t,hatt obviounly two hi .nds of conc'lur ;i.on<br />
can be dravm horc+ . One con assurne t:hat ciP:arotte smokini;<br />
eaunoe Just. W-ncticaily every disoasm known to man or ono<br />
could n,orc: re:me+onably aesmne that tlve differences exhAbitod<br />
in the various srs:~(!Le Go6,ul .atione bct t cc:n smokors and non-emok-.<br />
el'C. ArN duo to r:o111e faOteY s other than f:Ipoki.n(r' .<br />
Other Foe-norc 'i'hat Could Account For t,he Observed lli.fforenee<br />
Hntv:ecm Smokc :rs en
•<br />
•<br />
that amo)cinE is oncs of the chexractafi$ticH of this atyi .e of<br />
lii'o, On the other hand, other individua)s live n :tyle of<br />
) .i .fc vfiicli is ccanerk) .1y consxi.dcred hea).thy of which non---smol :-<br />
S.nK iF one of the S,n(;FOdiCntf:o Thus the B.€59ciAtion one<br />
obsorvc : ; mary not bo hctwvon cigarotte emo4 :ing nnd dir.osse<br />
but it mny be be.tween n cort a in stylo of life nnd di .noNe,o,<br />
('Pho fbYlowicq, cioscriptlons of study findinfSs have boen taken<br />
ulurc .et: vorbni . :(m from t.he Sm-goon- .Gcnerni's rohor t on 6wokinC<br />
nnd Hoa)th .)<br />
Scvcrnl Stud9es reported thrat : heavy Smokers el-eo driN (<br />
P l.cohor'LC bcvoro.gcv cr.ees:rivoly p.6), (33), (h5) , Kricdman's<br />
t.ylrc A rnon (t.ho coronnry typo) tend to be heavy eamudcors ( .R.) .<br />
Smokers nI'e Fliid to be IaDre oR®il .y fln(;CI'ed and to Dat Ino1'C<br />
whnn under c=txe^;n (55), . They have Uosn roported to marry of-<br />
tcniel•, to changc ,iob o nio rc frequontly and to be morc ofton<br />
hospi.t:Eil.iaed d S t')- The concent.ration of e.ercmi cho7.ne.toro3<br />
trea becn found to bc Sl.ightly hi .hhes in Smokers than in nmrvsr<br />
.rolrcre : (8 ) , (t), (1)), ((+6), (5 6 ) , alt.hou g h aome stud :iee+<br />
hnve found no rolntions:hip (J.)p (23) . (ane invosti gat.owr found<br />
m1€:o not only that c?o rom cholestc;rol wnu higher in srno)cors<br />
p.hrur in nou-emoker :; but r,ls,o thmt. it, rcniaf .ned highcr in thoe e<br />
19h0 Nto p 11ed EBWkinl! ( :1) . Smokers 81 ;40 ilRv e higher heSirt<br />
rnter; thfun non-erensors (e)„ One ntudy Round an cxcoss of<br />
f0qo)Celrp Who WCrC 30 )SellCfJnT<br />
m oveYtVei ght flnd the Eub,j'eets who<br />
leorc 40 (+crcernt or moro ovcrweflght nrnre a)I reBcOnr smo) :ere,,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
ln&%
•<br />
0<br />
rn 2 4 )fltiN<br />
blr.o 1,hu non-sfilokCrF hr+a a 1'.rrater frocjuency of indi .v,i.(lu£:}.x,<br />
aAth ]0 ga ::reaut or morc uudervmif ;ht thrsu did the e-mokcr& (5G),<br />
Sisokcrs not o a)y havo certaio yrhyGfnal ohnrnctor5.st6,ola thrt<br />
would malco t .hcit,El .y Of tl:,cci .rualntory syr .t .cnt, bu9 : thoi.r fxsychcrlogica7'<br />
ch£(r£ar.tor9.eotics : nro i .n Y,ine viith the hyPothe£+ia aUvonc(Alhcrc .<br />
Y'hL t ;e nCr411 n :icture) CPtFrC:knC1 fronl 5],2 tbtn(ii.C'3 if. One (rS E16ok-<br />
vrs t(intii.nEt to live 1.'tn(,tc,r rne more i.nSen :ooly an(? to b(i more ;<br />
£-ocAnlly cmtf[od .n6 . Studios, usk.u¢ bch£,vforr,.l rnt.her t .lr£aa<br />
ys ; ;e,choAof ;kcr+l toet :; supuortthfle pi.eture (10) (35) . Mosa,<br />
c:tu0ior; euGPomf, the contention thntt neuroi .icinm oefine(i,<br />
arnonG othors, by th(t ex9e.touce of r-:nxfiety si.atec, nervousnoss,<br />
e.oYrnLic symPtoinu, nnue.un7 res4lesfineris Su terms of ,)ohs and<br />
roci .ctencc, ie: Meed £(sf,oci£rted wit .h £anekf.ng hrbits (24) (3U)<br />
(S•5) (S! :) . Other re7.cvunt evEeencc f.nclud,a ::; the lnrg,o<br />
8iffcrcncev; hottaotm the moriulity of emoke .r& and rrou-s(nokor :s<br />
toheo comp .arcd by mnrStrl stuto2, oduc.ot.ionnl levels, uuo of<br />
t.rwaetr.d]ivors, and doriree of cxerc.Ke (Pet@e 10U, Tahi.e 78,<br />
Sr.iok3ne anG 14o2) .th),<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
($e.(' Table 16 ou th6 followi .n({ (mp{e)
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
]9C0<br />
f.l.Y the roferences cited above are includod in the report<br />
ou SraoNing and kloai.t.h E!re woll as othern thflt would indi .eatc<br />
that E:moltin(; nlny lie a response to fru5trntion and failure to<br />
nchievo ctatuE: (20) Eand may be eecomE>an£cd by impulsivr, and<br />
robo1.17ous bchavi.or (R2) ( .`, ;.) ( 4 7) . In short, s pScture qui .to<br />
in harinony with our hyFrothesin of differences in style oC life<br />
cm,.rgoE ; both In phye,ic(al and In psychob,oEtica l tox'nrs,<br />
C1onC) . u&i onED<br />
I have P .tlCm pted to su01m(iri!(i FSomC of the rGabonF why E3<br />
numher of invoetd .certor,, feel that the E'+roh7 .em of the rolati .on<br />
hct .ween sreol(intr and healtiE is far from olosed . To the cont.rary,<br />
thc ovidcnco a[°&vea rr, to pcrin t to a number of studies which ought<br />
to be done rtightt now .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
SnVIDtari'r :inip the di . f ferOGCeEa nUtonlg investiratoRs 9nd<br />
c6;Hec:in2lg tr v tween nw own iE,te r 6vretation of the da9 .a and thvt<br />
of oMr2 I wovld strcas again the fo11ov7inl= hoints :<br />
l . Labaretory i .rrvestigat£oEis us i ug ci.harett.o smoko as<br />
a11 i .ndeP(pndeAY4t variahl0 have net heon Rh7e to L/ro-d(ICe<br />
=nChOC[enie Ca.rCinorOa : ?n ArIl01n7 .6 which or .'<br />
d£nRrily re4[aoOd wil.h t11iE d£Ferdf§e to a vElriety et<br />
trrl .tEStits . 'Yhire may be the e;trougest and nrost con•-<br />
V£ n cinL: fie(fC o f evldenC4l warning iElve(lttgators fPerh<br />
thC coPclUtifpe that s nIo1V .tl^ CIqU .^,eEi 1 .(Ent; CanC9r .<br />
l . k11JidPDlio) .oP.i('.a7, Stttfi].JR hffvG Co17CCtr`.d datrf with an<br />
C)c to cost, to vuch Eh (-!2odi ! :hNt thCi.r xcs;ultN are
•<br />
•<br />
too u,nhS&uoue Eor claar-out ! .3n:rrpretat.i.ans .<br />
'PhL• riNaEt9 of the exiSting Ovidetlce compels rne to t4)0<br />
major conclursioas . The first ono is that oxistin(r evidenc e<br />
does not o r trab3.feh any Sirm causa] rolati .onship between smok-<br />
in g and di.aer.se, The second is that existing evi,dence does<br />
indicate a numhor of Smport.ant problem areas which should ro-<br />
ccivo thorough study,<br />
hIh;L1oGHApnr<br />
396)<br />
1 . Achooon, 6 . M„ Jorr.soP, t7 . J . M, <strong>Tobacco</strong> smbking nnd servrn<br />
lipids :in ol .d mc:n, y)ri.t Mod J 2 : 1 .102;-1171,1961 .,<br />
2, P.uerbnch, O„ Gorc, J . H., Norcoann, J, B., Petrick, T, G .,<br />
Smnlin, H . J ., FScuhs;nru, G, t. ., Kasseuny, A, 1' ., Stout,<br />
A J' . Cbtuil ;es in the bronctriall epi,thelium in rolatioa to<br />
crotolrinf; nnd caneer of tlre lun5 . Ntiw F.nR J b4ed 256 :<br />
07-104, 7 .057 .<br />
3, Anorbach, O„ Petri .cd;, 'f, 6„ Stout, A . . P ., Statsinger, A . L„<br />
Y
•<br />
•<br />
•<br />
C:hanl:ecs in hronchi.ai opithcliwu in rolation to cigxrot.tc<br />
smokinC and in rcil .ation to lu~th r-encor,. Now ltng J Mod<br />
265 : 2[i3-.'r267, 1961, .<br />
19G'l<br />
6 . Gorkson, Jo, and lilvehack, L, Competing exponential riuk a ,<br />
v:ith partic,ular roi'ereuco to the f.tudp of smoking n .nd l .un.{ ;<br />
czocer . JoAoS>Ae CrS : 415, SePt,,, 1960,<br />
. {tlaekburn, 11 ., Rroo-.ek, J ., Taylor, kk .% . h . (<br />
7!s 1-11e- .1.1?R, 1960 .<br />
.n enioke.r& and nonernokcres :onrtaon cireula-y tory tncanm•cmonte i<br />
.. Circulation<br />
E . ksronto--Stovr rt, R . Cigarette smoking and iechaoroic: hear t<br />
di.nuase . ISri.t Mcd J . 1= 37f1 ;aEiG, 1961,<br />
S . Damon, A . Const9.tution anc4 [mioki .nF . Science 1.94 : 339 .-341.,<br />
19G1 .<br />
10, Lavis, R . CiCorette smoking mot9vation ntiWy .. Research<br />
Sc'vi-ceNp London, 19560<br />
1.1 . Anwber, T' . R .,, h.nnnel, tN . 13 ., Rovot&kie, No, Stokes, J .,<br />
r(ugan, A ., Gordon, T . Sonso factorn atssociatod with the<br />
dovelopment of coromrn.ry henrt d-xeaoauo . Six years' foilov-uP osspcr<br />
.4euoc in the k'raminP-ham ntudy . Amer .Ja Yublic<br />
lhtalth s!a : 1349-1.s68, 19590<br />
12„ l+bl1, R . Etiology of lung cancer . Advsncos Cancer Ros W<br />
1 . - 'u0, 3955 .<br />
13 . Rc,nenherg, Jo M, Cigarette smoke and the incidenec of<br />
pnAiua.ry nooplcenas of the 7 .nng in aYhino rni.eeo Science 1 ..6 ;<br />
;,6a-A, 1Rp,2 .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
a 2ft 1963<br />
79, PT1cdmHnn, M ., Itoscn[dnrl, P,. R. Association oispecyfAc<br />
ovcrt Lohnvior p•r,ttorn vrith blood and cardiovescular find . .<br />
~ ine.s, JkMA 169 : 1286=1286, 1069 .<br />
15, Gi .J.li.am, A . G .,. Rilruoro, B, K .., and tdoyd, J, P7, Trcnd s<br />
of rt,ort ul i .t .y attributed to cF'rc5.nomsa of the 1ung . Tho<br />
dccli.ning rate oP incrcase . Cancor 147 628--G28, 1963 .<br />
. Gordon, 1„ Crit.tonden, M,., t ;aensze] ., w, Canccr nox•Lality<br />
.116<br />
t.rendr- fin the United States, 193U-1955 . Part il : k:nd<br />
rcrall.s nnd mortali.ty trends in cancer . Nat, Cancer ]nst<br />
Monogr No, 6 : 131•REi5, 1961 .<br />
17 . llacnr;zol, {Y„ 6hirnkin, M, lA ., Millor, H . 1>, 7bbc;cco<br />
. s ;r„okin6; pat.torns in the Un3ted States . Pub Uoalth Monogr<br />
No . 45 : 7.•-111 ., 18,56 .<br />
18, With, (1 . P7 . UiYference bCtV.'een snlokerfi and non-smohQYF..,<br />
AMA Arch lnt Med 101 : 377, 2050<br />
19 . llolland, J . J, ni.ssertatio innugur . mod, chir, sist,ons<br />
carcinomar lnhii i,nferrior7s abstluc coctfone persnuatum .<br />
]n : Wolff, J, lli.e Lohro von der lirobskrrwhhei .t Jena,<br />
]AII . Co : . A, p . 52-4R,<br />
AG, ]BOrn, li, Rehavd.oraf aspectc of ciFaretto smokfng,<br />
~ J, Chr•or~i .c. Dis 16 : 3E3 .95, 1963 .<br />
7;7 . B n rvoncr„ M„ Keys, A„ Ormn, 1% ., V idanzN, F„ Rrozoh . J,<br />
. Ci_gnrotte smoking, serwn-cho W sterol, blood-pressuro, nnd<br />
body fatnces . Ohscrvaa.imic in linland . ].mucot 1 :<br />
4EY_ ;! ; d , 1 : :5£~<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
ra 29<br />
]ta64<br />
22 . Y.ehoo, Ro A ., Parbon L.eckurec, J Roy lost I1abli.c Reelth 24 :<br />
177, 1061,<br />
13 . Nont.tinen, A . Cigarette sa oking auid serum lipidu in young<br />
men . i r i,t. Aiec? J 1 : 1115 - 1)17, 1962 .<br />
24, Laut.on, Yd ., Phillips, R . Tho relutionshi<br />
Mec7 b'ci 112 : 3C7-.h0'1., 1956 .<br />
.ogical .p betvocn excos-sive cillarette smokin0 and psycholtensAon<br />
. Amer J<br />
2 :;, hcaichtontrer{•,er, C ., Leucbtenbergor, R ., lkrol.i.n, P, F .<br />
A corre].ated hie:t.okoUi.cal, cytological, and cytocb,emicul<br />
eotudy ofl the traehoobronchiai trec &nd lungs of mice<br />
ox(o sod to eigarette smoke . 1 . Alronchit3.s w ith atypt .-<br />
cal e p theli.ai changes in mice expoaed to cigarette smoko .<br />
Canoor 7 .1. : 4 DO-.606, 1058 .<br />
2(; . Lcl+chtenbcrger, C ., Imtlchtonbcr ger, R ., 2ebram, W„ Shr. .fi'cr,<br />
P . A correlated hi¢;tologi_cnl , cytologien7 . , a nd cytochnmi .-<br />
cal. study o :f the troacheobronchial tree enad lungz : of rui .ca<br />
exposed to cigarette srookeo 1Y . Verying respone :es of<br />
ana,jos bronchfi to cigarette snmke . Absence of broncho-<br />
gc:rde o o rci.nonua aftcsr prolonged exposure, and dic,apper:r .-<br />
ance of bronchial lesions aftor eossation of exposure,<br />
Cancer 1 .3e lfsi•32, 1960 .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
27 . Lnawld :oubery;er, R ., bouchtenberl;er, C ., Zobrun, A' .,<br />
Sh[affor, P . PA cor'relatAd hi.stolop,ical, cy0ological and<br />
cyt .ochowi .eal study of the traeheobronchial tree and lungs<br />
ef ,rSc:o ezpmeed to ci .garet.te smoke . 11Y . Unaltorecl
•<br />
•<br />
•<br />
ra $) ) f>GE<br />
iutorvi .ctr inP.e,rraction patterne,, . J Ahnorm Soc Pe.yehol. 56 ;<br />
3TY•-3H . )flSS .<br />
3 :: . A?cArthwq C ., rcldron, Po, t>.tckiuson, J . 9'hc pcyc.holoCip<br />
of smokinG= J P,bnox•rn Soc Psychol 56 : 28l-75, 1cJ5® .<br />
RG . 61iS .1os, V . C . 7rulEOn, M . k' ., AicCeinn, A9, B„ Nhit .o, P . U .,<br />
6taro, 1' .. J, Piot L1ood )-iCdde and health of ltaJ.inn men<br />
4n Ibnt .on . Ann Intm•n Mod 98 : 117G•1900, 1358„<br />
37 . Milmore, G . Y ., Conovcr, A . C . <strong>Tobacco</strong> e.onsunrption fln<br />
t.he Unitctl St .nCO :r., ) .RfiCr0 fs5`s . Ihal .,li.c Uonlth 6ion g r h'o .<br />
F6 : 3 .313,, )17bC+ .<br />
38 . kuaniie, V . Smof,inC;, dr.inMng, and nervouenc+r.c;, l .n.ncot 2 :<br />
1F,8-8 . 1H59 .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
SF . l/uhlboG'V :, Oe C..nroAnugooo WericinCf va11 Signrott .onYooL" LfJ<br />
h4uFr.on . :VOOer1 T . Gonoo ::k . E9 : ?.87P,-H, Lp56 .<br />
40,. Ni.ol ::en, t,,, laenudcanemi, J . Uronehirtl cnrci.nonia - .._ A<br />
pandomic . 13,- Inci.denc.o and t .obacco conr :nmption in<br />
var7onc countri.es . Dru,Ssh Mod £:u11 1 : I9h-D, 1055 .<br />
41 . Pczcock, P . Yt, Ctp,nrolae smoki .nC; by Yeborut.org rundmuls .<br />
Ss:venth Internnt :F.onal Cnncer Conkrcc':s, Londmn , Jnl .y G-12,<br />
108 . Ahataacte : of papcrs . p . 153,<br />
4p . PerrcocS, P . H . Cin s+rertto ennoY.Lu{ ; os:porimonte . ]trit. 8mp<br />
Cancsr CamgmiSn, Slith Axm Rep, Paro 2, 1957 . P . 303<br />
d :. . Vr acwoL., P . R . l: :xperi .rnentall cigc retts+ emol :S.ng by dnmes-<br />
t .ic: So V Cfo . 0.:ri.t J, Cnncer 9 : 461, 1y5P„<br />
Ra . riavcn9os,, Antoliu, Yn . ll . Rnd4olokiiat5 Und Fpi .derdol .oF.y,
•<br />
•<br />
ra sl<br />
45 .<br />
Ru :di .ol.ogy, VoA, 74, No . 6, pp, 873-975, Juno, ) .060,<br />
(9 d :i tor i. o ). )<br />
)nci<br />
Sanugo r , R„ SY.lvarma n , 8„ Turner , IR, Neoplaraa fol.low-<br />
in[r thOrn peqtie Ar'radi .ation for honi g n conditions ill<br />
ch4ldhood . Rad9o) .o(Cy 74 ; 860-804, 1960,<br />
G6, Snednvisk.y, D, A ., Gi).)i.o-rn, P., G,., Corufiel.d, J, 9'he e :tatis : . .<br />
t'rca)I ausoci .ati .on bet.ween suroo)einR and careinoma of the lunr,<br />
J Nst Cancer )nst : 7.9 : 77,37- .5K, 1953 .<br />
47 . SchonPOlci, J, Spnc4al rePortt to the Selrpeon Gonornl's Ad .. .<br />
'Vi.FOry l.efutlittee on SnYO3CinQ and RCf.).tH,<br />
6F. . SrriakSng aud F,oalth, Beport of the Advisory Comdlit:tee to<br />
ther Snrd;con-Gonerat of the f'uhlic liealth Service .<br />
49 . Storl9 .ng, "1' .U, FRIL).icP.t7An deefr :) .OnP and their possible<br />
CfTFOtS ob irlf0l"erlOe9 drawn lrCRll teEttS ef siinnifieMnep --<br />
or vi.ce versn . Jourv'ial of Tho Ar„ev£ean Statisti .cal As&oc4e-<br />
'Lion Vol . SQt 30-3!, Af :rrcal 1859,<br />
60 . 3teri.inp;, '1'-ll, Spzdetaiology of di .sea.ae aesooi .atect wi.ih<br />
Iead, 4rchive#: of Suvi-rolvueK'itnl lloalth, Vol . 8 :<br />
(333-3 .8, Ccb . lt?G5 .<br />
5) . Btorlin4f, 'f .)i ., Sacnyer, 1 : . L„ r=xad 7>hair, J . J, Radiation<br />
epidcomi.olof,y, Cnncer 10 ; 489, ) .GF?,<br />
LR . Stor:).inG, W,U ., T'hei .r, J . J ., and Rustag ;i, J, New develop_<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
roonts in chrontc dSsoano ep£.dem£ol .o£r,y : corapet.ing T9.skp<br />
ruld e) .igltriiit:y, Arncric:an lndusi.r'i .fil. Hygienc Aseooiation<br />
Jolrz•ne.), Su : O3 ..679G, Nov .- .Pr.:c ., )J.GR,
•<br />
•<br />
0<br />
53, Socrnnicrring, S„ Th, Do Morbi.e Vacorum Absorbetlti .wu<br />
C
•<br />
•<br />
ty l .<br />
The ilonoratrle John 0 . Yn a tore<br />
307 Post Office Annex<br />
vrovideace, Rhode le.l.nnd<br />
War Senator :<br />
AMCiRICAN CANCEVt SOCIETY<br />
Rhodc Island Aivinion, Inc .<br />
333 Grotto Avenue<br />
Provi .dencc, ii .I, 02006<br />
March 26, 1965<br />
TRmple 3-69'70<br />
The Yabli.c 8ducntion ComnAittee of the American<br />
Cancer Sgeietyr Ehode Island llivi6i.on, Ino, on MP.rch<br />
15, 1965 enctorsod S1'iNATE IIII .J. 547 which in currently<br />
troinl; considered by the Senate Commerce Committee,<br />
Thi.s: bSl.l would regala.te cigarette labol .ing and adver-<br />
tising .<br />
i`he overwhelming evidence to support the relation-<br />
ship botw[:eb cignrett:e suoking and lung cancer gives<br />
us a i•e€qonsi.bi3ity to support effeot :ive measuree that<br />
r ii7 lead to a do wnward trendi.n cigarette smoking .<br />
Therefore vro xrc urgi.ng you to support SE:NA'SE BILL 547<br />
introduced by Senat.or Maarine Neu.ber6er of Oregon .<br />
If thiF aep,i.E:Aation ia enact .od into law, I believe<br />
that cQarette smoking will docreasre and the incidence<br />
of l.ung cancer r;77.1 rt.leo sho w a downward trend, If' you<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1(066
•<br />
•<br />
0<br />
ty '1,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
hnvo rmy quoeti.ons coneornin(, the position of the Amorican<br />
Cancor Society, p].ease fool free to contnet me .<br />
Sincerely,<br />
s/ John 7vrner, 11, M . D .<br />
Chairman<br />
Public Education Committee<br />
1970
•<br />
•<br />
•<br />
N YB02h (32)A/:1.IF.<br />
WESTERN UNION<br />
TXLEGRAM<br />
1965 MAR 2 0 PM 1.2 53<br />
A M7.Y021 M'7.22 Mt72 DL PD 22 EXTHA MIAMI FIA 29 NFT<br />
UON 1t'ARREN C MP:GNUSON , CHAIRMAN COMMI7"1l-.k ON COMMERCE<br />
US SIF.NF.'I'N WASH00<br />
I'LEASE DD ALL YOU CAN TO GET PASSAGE OF I :ITHICN THIE NEUHNItGBF[<br />
ItILL (,5',5.7) OH MAGNUSON HILL (S,55U) Nk:GAHAING LAUBLLING<br />
AND AUVL:flTISING OP TOEsACC :O . TIIN FUTURE O7? UNTOLD THOUSANpS<br />
WIId. I117!E,NO ON THI:S, 'I'HOUSANIIS WHO 1YIId, AIF: OR BR TOTALLY<br />
I11SA61LFG) PHYSICALLY FItOM TOBACCO USAGE - IF THE PRESENT<br />
IiATA OF SMOKING CONTINIEES LNTTP:It W1LL FOLLON<br />
C.HANhF',S F'Y'A'A'C JR MU ASSOCIATE YROFP; :;SOti OF MEDICINE<br />
UNIVHItSMTY OF MIAF7I SCHOOL OF MEPJICINS CHIEF CREST DISEASE<br />
SIICI'ION JACKSON MWN.ORIAL 11OSPITAL , CHAIEtMAN , NLONIpA<br />
COMMI'["IEE; ON SMOICING AND HIIAi.'PN MIAM H'LA,<br />
NFD030 (39)AAIIii<br />
1565 MAIt 10 PM 12 55<br />
A M2Y0'l.3 M7.Z'h MC22 11 Pll 22 EXTRA MIAMI k'IO 29 NFT .<br />
]10N GkIO A SMATHERS<br />
US S'FNATIC WASNOC<br />
PLEASE UO ALL YOU CAN 1,10 Gb:f PASSAGE OF EITHIffi TN6 NBUHEHGEEE<br />
I11LL (S .G67) ON MAGN'USON BILL (5,55G) REGAHDINO LABEILLING<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1977
i TY 2<br />
0<br />
AND ATNK}t'fTSIND OF AYIAACICO . 'L'H3Y FU'fURI: OF UN9'OLA THOUSIIN ➢S<br />
IPILL DLiPRNll ON T13IS , TUOUSANbS WHO NTLL UTN OR HE T(0'ALLY<br />
ItISl:JtldtY! Y'UYSTCALLY ~'Y,Oht 4'013AQC'0 USAGE - TI' THE YkTiS&NT<br />
ItA9ri; OF EibIONIN(i COPvgTNUEtS T,ti'f'L'Iilt WILL FOLLOW<br />
CHALLR5 P'A'ATJ+ JR MU ABADCIA'!9f YROY'HBSOR OF E".6iUJCTNJi<br />
UNIVT,1tSXTY OF }1TA1,11C SCUDDY. OF MIiDICINI: C ➢{IEF CHEST UISEASE<br />
SFIC9'TON 3AC:I(SON 6UiMORJAP, IiOSY%'CAL~ CJiAIiiMACo, FIAItIDA<br />
CCh;t,7IY'T.'P4; ON f M067NG AND Iff;AJH'N MIA51I I'LA ,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
I'3%2
•<br />
•<br />
•<br />
S'fATY,MENi` f1k' SIGM17UND L . V41GENS, N .D .<br />
Ni:Ali'1' !ii"l`ACH$ ANU C7GAIt7iTTS SMOKING<br />
At the outset 1 should like to make i .t clear that I<br />
will roee9ve no remuneration for this otatonvont, that. I<br />
have no connect :ion w3.th any tobaeco c:ornpar,y and that I<br />
have never emukod coigarottee, if FI have any perr,onal<br />
feclSnge about tobacco coar.pani .ec, 9.t Is one of annoyance .<br />
1 do rwt care for their televieion cornrcaorci .n.ls .<br />
bty rear ;ons for mat;f .ng this statf:wcnn t are twofold .<br />
I beliove that the ovidonco l .inkin6f hoart attacks with<br />
ciCarettce tmuokinr Is far from eoncl.usri .ve and that such<br />
a rclati .ont ;hi.p r>hould not be presented to the ltubl .ic ac<br />
an e ;:tablished faot . Secondly, I believe there Is a<br />
growing trndency to accept without question medioa l judg-<br />
rnant.e if t.hey are actvanced by por :one : of omi .nenco, i .f they<br />
aro publiehed in leadin g medical. ,journal s and if they<br />
aro sttpported by a number of invest.i€„ators . This ought<br />
not to be E;o, A71C valAtiS.ty of a Medi.Cal conCluGiAn should<br />
Uo judged entirely on the noundnees s of the evidencc devo .,<br />
loped to cup poxt it . P do not believe that the evidence<br />
tbat has: beon prenwrted to as,socia .te heart attacks with<br />
ci(;arret.te tnnoki .e g Is incti.sputablo .<br />
a'bi s evirlenoe is based alrnot,t entirely on the fact<br />
that n high pe rcentage of raen who arc treate.d for heart<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1973
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ty<br />
r ;ttachs rre+ heavy cigauette srr,okers . This hrat been found<br />
) ;. Aa nPmbcr of i.n4ependent i.nve5lti[(a.tion9 nl .L of whiCh<br />
ur nd essentinlAy the samle mothod of ctudy . It may woll<br />
bc true that . reo n whor o caroore: Snvol .vo more than an<br />
nvnrajro dc :6rec: of ra€qious'rbi7lity ond who nre s :ub,ject to<br />
tennSOnr .:, nnxieties aud worrics develop syliipto®s of heart<br />
ntt aChIS n1K1 S .rtdulho iri }denvy cAC{arette Fil'6oN:inG more often<br />
thnli the c,vcra go Porr :on . 9`his does not prove that cigar-<br />
otto Faro3cinG cnurror< hc.nrt r.t4:rtckr: . They rnay both be the<br />
resu :.t oi' the snrme so t of cond9tions . !a : aa+n grow older<br />
t.heir h..ir tulrns € ;ray rued thei.r arteries hnr.den . ThiF :<br />
doen no't prove that gray hair oaucoe hardening of arteries<br />
or vicci ve .rsa .<br />
'i'ho truth of the matter is that these studies examine<br />
only a ]iroStod seGment of the lta•ge number of people who<br />
have rerl7 heart nttac . .ks aometimo during their lives and<br />
nccswr.c that th,.t, celect e.l;t;7aent is ful.l .y rre}:resontative<br />
oi' tho ent.ir'e g.roup . A 6rrorat mnny persoins have real hottrt<br />
nttrtelCL nnd never F.eek ntedi.cnJl help . When a mnn hns a<br />
(5enl12ne itE:urt &ttac7S a}' .:ortion of hiE heart muF.el .e Is<br />
de/?r$ .t'ed ofnollrishment nn(j degenerates . In faet it<br />
bccomer d nad ti-sr:uo . Yf he survivee, ns he very often<br />
@eon, the deatd muscle S . 6 replaced by soar tissuc very<br />
aUtailnr to thet wAi.ch C,rown 7,nto any healin g wound .<br />
W oss' d.csth ooours on t.he nr+me day as the f3 .rst attack,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
797h
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a patholo€:ist who oxami.nos such heat•to can easily identify<br />
the dnraa€;cct area, which is culled an infarct . At least<br />
one -half of the i.nfa.rcte: thr.t patholoCtatF: find at<br />
antop s ie& are onos who5e prCF:ence was £tOt fiuspCcted during<br />
]ifo . Thi.n is a widely rcco€'niv,ed fact although there may<br />
bu somc d'zfference of opi .ni.on as to how frequent)y it<br />
occurs .<br />
In adGition, p3oplo can have typl.ca] eymptoms of a<br />
hcart attack without any real in jury to heart museie .<br />
SYi.th iuerehci .ng d9a.gnos:ti.c .skill it has become possiblo<br />
for the heart specialist, to di.ot4nRVi ch between genuine<br />
and fn]ec heart at.t:acks: i .n most i.nstanccs . Sometimes,<br />
howovor, the hcart at nut.opsy fa9 . :ls to show evidence of<br />
a hen v t at.t.nclc even though cl .i .ni.cal tcsi :s during life<br />
indi.cated tdrxt euch in ;lury was present . From my own<br />
arperaonco I ectinrate thn.t some IJi porccnt of cases<br />
di.agnoned £es havi .ng renl3 heart at.tncks durin6 life are<br />
not confirmed by post--mortem osami .nation . It is thus<br />
npparent, tha t tho c.ii .ni .col studies which show a relaticm-<br />
ship between cigarette ranoking and hca.rt attacks arc based<br />
on an inco mq>lete, highly solective and not enti .rely<br />
acCUTate EnmplO .<br />
In order to coxifirui their results it is necessary to<br />
prove that evidenco of heart attack£a is found morc comnionly<br />
at autops y Sn heavy ci .€;arette smo@:eu& than in non -smokers .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
0<br />
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Yo my ksowlo6tyre there is no report that wnlces thas claim .<br />
In my study based on findinCs in 989 autopuies in men<br />
performad at the New York Votcrans Adminisi :rati .on Itospi-<br />
tal3 and reported in Bcfence (Vol, 1 .35, pp, 975-97'), 1962)<br />
no si6nificantt rcl.ati .oushi .p between ciE,arot :te smoking and<br />
dnmvge of the heart could be demonstrnted . Admittedly<br />
thAs study is olEto based on a hi .((hly aoleetod group of<br />
hospitalfned veterana and t :he sample in not larGe compared<br />
to E;omo of the otatietfoni e.tudi.es lraned on persons<br />
under medical ob:IUrt•tttion but a11l ki.ndE/ ef heart infaretF<br />
aro dncluded, the eilent ones as woll arrc t.he symptom .•<br />
pr.oduci.ng onos, Purf.hc:zro'ore, the 8puriAUEs ones are<br />
exc:luded . It i.s obvious that further studi .es of this<br />
naturo on autopey findiuE ;s i.s nocenaary .<br />
Clinicians baae their clain',s on only c fraction of<br />
the toal number of heart. attacks . It may be that this<br />
fractior, is reprosentati .vo of al l hoar t at.tacke . My<br />
findinlCs would lndlcs.te that It i.C not . You can not alwayF<br />
ee t iveate the Wa and ehape of.' an iceberg from tho portion<br />
that protrudes above the water l .ovel .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
? 9 %6
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AfrV1iRT1SiNG FA7DENA1'I:ON Ok A61BR1CA<br />
655 FVrdison Avenue, Now Vork<br />
Y7ae:hington 13ereFm : 1725 K 8trcot, N .W .<br />
'!'ho tIC=norabl.e 19arren 6lnpnuson, Cha.irmnn 1Narch 12, 1965<br />
Ecma.te Commerce Committee<br />
Senate Ilf f iee lln f id i hQ<br />
N'ae:biugton, tD . C .<br />
Doar Mr . Chafru:an :<br />
In antici.pation of the henrings beginning Afarch 22 by<br />
your Cosmri.ttee on bilas : rclnti.ng to exf,nret:tes and smoking<br />
productn and contaAni.ng rostriotions nlld requirements re -<br />
in.ting to the packaging nnd advertislnf, of such products,<br />
the Advertising Yoderation of Amnricn, on behalf of its<br />
memberstdp, wishes to renffirlu the staud It took when this<br />
.1ogSsleti .on wa n f'i.rst introduced In 1964 and to again to go<br />
on r ocord as beiin g oppoaod to certain provisi.ons oi' the pro-<br />
posod logisluL`ion .<br />
The Advc r i:ini.ng BederntAon of Anxmfon is thc oldosti ;nd<br />
lnrg o st e,dver•t5sing orgnnir.at:i.on in tho worid . It is the<br />
only horie.ontal ussoc9 .at.ion in the advertising field and<br />
reprus.cnts every facetnnd ctratum of the advert.isi .ng ; bus-i<br />
.nosrs . Al'A hae tr.cuty-fivo other irahc r ta.r.t advertising<br />
nse:ocintions auG related organizntions directly affiliated<br />
vith it and reprosontcd on its Board of biroctors . Our<br />
Koderati .on a :lao pon'sornserN a very tun iquc and effective publi.c<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
ls7r
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•<br />
opint-on Sorso •at tbe gzz,gr„ raot> ; lovel in i .ts 7NQ v.9£i.i.iated<br />
advortis :iaig cY.ubc tb y on€Cbout tbo country with a tota l mmob :a^•=<br />
: : :hi .p o f nforo thfln 25,000<br />
bin¢;e Siz: Soum3in(; an 1905, the AVfi Isar, becn dodi.aa.tc=d<br />
to art
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67 9<br />
7 . Vio arc. compJatcly in rtcc :ord wit.h tho though4t that<br />
t,he pubY .d.c hnrs uvery ri@:Lt to be ini'o rhod, t.h9'oug;h tt proh'r aei<br />
oi pilhl,iA An£orbYati .olln i4n d eCitleN$ i on, co1lCEirnfltl(; produ(:tS<br />
thono cxoes :c=ivz une mery i .nvol .ve eoriouc hessl.th irRZardn„ D.n<br />
the aRrc of ciNtes
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hl F<br />
the forc:e of ) .acv , r.uQ 2nvolci.ng the pc+nQ'4t.iec .<br />
! . We bolLovc t:ha.t our econior.i.c•c ryt;tcnn can opcr2te<br />
Alt4cc5n9Sd17 .y ofi).y Sf t0o regard (,OVCrn1!,e11t YO[nI1B .tfionE Bk<br />
a 7as ;t >_•aE;or4: vlhen nY.i othcnr mon.nrs hnve bean given a feAr<br />
tx'&al anr,3 fai .le6 .<br />
. . tk:e8uvo of the Svalsort:an•t ecwn,omEc, inq+licn .ti .one<br />
invoivod, too, vr : do not Lwl.ieve this erztremeYy con9:roversinR<br />
unf, Nr•cus,Gont=*roQ,tirrg :6og1sl .atzori s:hou'id br, rt!nhod through<br />
tco r•n&ntmont i.ocau :;e of Po3 .flt.i .cral mac!rocli.oncy or fln ancxor<br />
to k UlXaNr§ (.tatCit&•ntH, fRatl Ca!Hjra$tUlff [7eE19.gnflft tO eatl6b<br />
105'Ffs hyt%tQr4 .a or otheP n(YIJG :a7,F to public OG!Ot9.01ffi1.3.6rit On<br />
the lanr-L of 14.es r,ropononte regarcilc*ce : of hotr r'Anooro they<br />
taxy ht: in tho .x• te)ke.fr . . :'aW N:atOrlttl5 SUn(1 the pta.nUfacttRre of th09e pL`Oduc :tfc,<br />
a.nd vlonl.d have e:ezi.ouE conwoe;uonoen for thc~ econoa!i .e well~<br />
]£kQ<br />
i:airrg oir otu^ n ;'r.i.on'0 r,N,xrSCUlturra axld niv.nafa.cturAul„ iuterest :e .<br />
Grl a7se2dy di .t:turbing uncmYloyraont probSenl 9n our country<br />
c:ou7.d raoCdt c:or4.ai-ni.y ba3 Snt,crntd4.find and tvcnrt3oned if the<br />
toh.-.oco iuch!tatry was• toprylod from fte Noyi .tiwt an ono of<br />
the inx°e;cet cmip3oyors An the nat.ion and one : of the mos:t<br />
S.nq;ort.ant contn•AhutosF: to ot!r natSon'sc thrivSng eoonovy .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
d, 'Lire cipi .rc*t .t•c, colr,Ntua£ers have recontly adoptod a .<br />
:n•rna
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•<br />
•<br />
volunt ary ndvcu•t :i .eznf; code for the industry upon which the<br />
i.nk 3s he?:rdly dry . AS.rvady, holvevor, thiu code has made<br />
itf,r,).f tcit and has clxGhkod the rnothod of aFrpea.l and tone<br />
of CiQlHretto kdvertiF^, :IA(I, Climinat .llt(,° to a considerable<br />
eat.cnrt v:hat p*ropone n t:u of the pr•o posed 7.eCiGlatf.on most<br />
strcnuou€;ly ohiec2ed to - - nennely, tneesed.as aimed at our<br />
youth A 4 .ch might inctuce, them to b e t;f.n stnoking . . It 1G<br />
ecPta9n that Pr~, thi n vo).rnntary oodo i .5 put Anto greater<br />
uce tvnd given uw re tide to worh, thexo will be other 1m•-<br />
por t.ant hc:ne£+.t.a ..<br />
7 . Y7o he).flove that 1::o tnahe advcrtisinE : the "whS.ppi .ng<br />
hoy" in thfs controv< :rrey over the harmful effects of smokin g<br />
cij{Ilr."ettefi in nn effort to cure the x@S111t and not the cauEe .<br />
11,, afte .r lonE: Ftnd er;ceflrl study and seseaxc :h, the etnoking<br />
of ci,@.arettos is dofinf.toAy and irrefut.alriy determined to<br />
be an ar4tyorooly danrerous hoaN .th hhzetrd nnd drestflc action<br />
9 .e: deemcd tiw on]y solution, then the p .rohibi.tion of the<br />
mknufacanro of oif,arotteu; x+hould ho considoro@ as the Xogica)l<br />
nolutiAn to the prob7em . 1£, howCvex•, the right to menu-<br />
fticturc thoro con2inuoci to be en ;loyed, theet most certainly<br />
the right to a6.vortia:e cl .laarotaoa dn tr,uc, eornpet9.tivo fnshion<br />
vme.t t,1e.o be enyoyed without unfo.t.r or disariminetory<br />
r cstr+ctf.ons axr ref;uletionG .<br />
Tn r.:mmaary of our pos :i.tSOn, it in our ntrong recomr end-<br />
rtti.on n ithtaU tdro com;o i itoo :<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
738)
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0<br />
f,9 C<br />
F . StrAko from t.hose hills ne dangerouE:, disorimintt-<br />
tary nnd prf,cePiont .. ::otti .ng: aeny imovi s ion reduit•A n (; tho<br />
auivortiF,cr to carry in cach aclvortieecu•nt th e warning that<br />
"hsbltua.t cii;a vc'tte asc,tcin(c is i .n;uriour to hcep .th", or<br />
s:nc+h othc r intormktAorv n
•<br />
•<br />
k11<br />
Al.9P;R .7ClAN AE .SOC'Y.ATION OW SCRO61 .. AUN7N1S2'gA'!'OBS<br />
3101 l6th Sta•cet:, N .W ., V/arzhi.ngton, Cr . C .<br />
B9arch ;, 1901,<br />
'1$6 NonGN£Lle W5.8'Ten (i, Idlfn g nUEtoli.<br />
'CNe Unl .tr,d Stnt :es Senate<br />
S7ara6Angton 25, D . C .<br />
U"salP S(inator Yd@(;nRGOn ;<br />
'd$p AN(+£ie .nU kEi9pC .'lfl'Cflon o f SVhoo1 kd miU}.69q'A.toY6, L6W<br />
1n lt& A(/(Ith ypf:(e o$' FNPViCCti, i.k a pYi\pktN, pTo feLWiAll£ l<br />
£csoc:i .rlt.i .on o f cahooF . udnsinistratore, w9 .th b monborchip oS<br />
1L,OOD . Mo have boon ::nfortnod that 9.n the near future yoh<br />
vd :Ctl ho cottdracti,ug op;n heari.naR on S . 669 and S . 547,<br />
concexvu,d c;lth the 301,0109g and/or advorti.ci,nN of cigaretter; .<br />
The krnerracan Aasoci.ktion of School Aelmieli[rtratorc+ 16<br />
vitally c:oncernnd with 9 :ho roAationehip Uotisoon arnoki.ng<br />
and h4fl)th, and i.t liYiN thi6 COLCOrn thOLt ph`olnpteG our<br />
AlaooAat.i.on to hcmcnue n consti.tuent ruomhor of the N£tiona7<br />
Yutorrtttaanoy CounoAA. orn Stwoking anli }toelt.h .<br />
WLUt; tho Strr:oon Ci:nnoraa.'e Iteportt mxfo raleased, we,<br />
pnrhapu n2ong Wh uril7Aoas of others, hocr2nte v1ta11y con-<br />
cerned on rohdi.n ;; eaitch ratntowentn as :<br />
1 . "Oigzir•ettr, r :crok5ng Ar £eos+oc,9.atod with a 70<br />
px :vcont amoraew o 4n the . . . death Wot+ of tnaloe . . .<br />
2 . "C4g£rotte f:raokahg ih+ cauca,R7.p s•elnted to<br />
.LnnE: C£bCOP in<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
L1GlG . . , °<br />
39153
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n, "Cigeevotto smoking is tho mnst iv}portant of<br />
th , cnac: cs of chron9.c bronchi .tir, in the United states,<br />
and Ancrcaroe, the r isk of dying firom ohronic bronchi9:As<br />
and em7ihysoma. ."<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
d . "Et is crdtahllshod that malo cigarette smoke,rs<br />
htavo a hi.Ch Genth ra.to from coro»avy hoart dieoaso ;<br />
hS.Ghor 4hnn that 0 .1' non-smoki.ng ioalen ."<br />
i4o carneetly hopz •r.nd rospoctfula.y roquost that the :<br />
Congroee3 give opocial at4.ontion to tho 1»rohhlem of amaL^ing<br />
an a hexlth h.nm-6, wid that it do all Within its poWCr to<br />
prooludo snmk.S.ng tsy chilcbrmn . We hc]ar,vo that e.peciffo nnd<br />
htandRtory WBA'ning r1~La(.:a(,os (+n all cignrottO packages and<br />
ativorti.~4ng vould ha n Ci.ant step 9.n thio diroction .<br />
Sincerely yourc,<br />
/r:/ ['orrost B . Conaor<br />
)te.®out ivo Fecxetnuy<br />
]AKd
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AM1sRTCAN CANCER SOCTk:T1<br />
1).ai .noiF: DiviFion, .inc ..<br />
3i S . Wnba.:h Avenue, Chicago, Illinois<br />
The llonorablP warron f : . Ddagnuson<br />
(.`haiPlBan, (7oPIDittce on (:eMlOerce<br />
United States Senet.e<br />
Washington 25, D. C .<br />
Uoar Seuator f]a6"nue :on :<br />
D9hrch 24, 1965<br />
Nonrly two qenrc: aC9o the ]:111nois Divisi.on of the<br />
Americen Cancer Society i.nitiated efforts to obtain warnf .ng<br />
)abo7.c: on ci. p arette pacha .ge, in the State of lllinois . Vle<br />
havo sue :pondod our action ih this rugard ponding the outcome<br />
of offorts to ohtain such l .a.boLing on nia nrtional level and<br />
]9S5<br />
hav® expreqwod our suppoxt of the ponition taken by the Federa7 .<br />
'trade Commicci-on An this regierd .<br />
Accordingly, in the reatter of vari .oue bills now before<br />
the Fennte in roL;a*'d to cigax•etto labo7 .i.ng, the Illinois<br />
Div£e=iwi of the Amerfcau Canoor Society wirrhe[ ; to exproSs<br />
its support for the Sieuborgor Bill (Fi . Sd9) because it would<br />
c;treargthen the posi .tion of the 1'edora] . Trade Conunission and<br />
sot, out now nuthori,ty for federal regu7 .ati .on of cigarett .e<br />
adverti .ring .<br />
We boll.ove the adoption of this mnarrure wil.l help to<br />
rr,duae the sterndA9.W nvounti.ng number of prernsturo deathes cnu&od<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
.<br />
•<br />
0<br />
h]. 2<br />
by cigaa•ette emoldug, a hr.b9.t which poroa; the greatest<br />
publ .ic hoalth, m:ontce of our t3ertcs .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
S1.neerei,v,<br />
Aog;er A . 3Carvoy, M .D .<br />
X>rce• Adant .
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47 1<br />
AIA(4t¢1CAYV CO1.LpOS NEAIlCN APS(M:IA4'ION<br />
Nono:eablo Warren 0 . Ma{r,nuson<br />
Chairman, Corvmittee on Commerco<br />
United Stater. &enate<br />
IYaphi.nY,t.on, b . C, 2051 .1 ;<br />
hiy Aear Sir :<br />
March 5, 10g5<br />
Uecauso of my bohoorn for tho health of four million<br />
e.ollege studcnts, I ask you to snpportt thc Nouberger. (5 .567)<br />
fietllin(r with cigarette advortieing and ].abeling . In my<br />
opinion, cigarette fanoki .ng ix one of the chief health<br />
problemu facinf: collegc r•tudents today because 1.t wi7l1<br />
interfcre with the uti .li.zation of col.lcgo education by<br />
i,ncrensing respiratory ills, such as bronchitis, emphysema,<br />
a.nd by producing early dcathe from lung cancer . If we as<br />
a nati.onn arc concerned about hi .gher education, we should also<br />
be ooncerned about hoal .t.h matteren which limit the utilization<br />
of such an education .<br />
8ucaur.o of our concerns, the Amcri .can College Nealth<br />
lwsor.i.ation, on April 28, 1961, adopted the following reso-<br />
7vtions :<br />
NHI{NBAB, n. preponderance of scientific evidence (with<br />
c:cant counter evidence) indicates an ar;sooiati.on relationc,hip<br />
and suggest.s a causal relationship between cigarotto smoking<br />
and ewmo diseases, nnd<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1967
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•<br />
b1 2<br />
WllERAAS, the cigxret.to smoking habit often is acquired<br />
now by young peoplc : ei.tlxer not long boforo they commence<br />
col.lege, or v:hile they are a.ttending college, and<br />
{'lltPtlttiAS, collego s c.nd universities aro i.n a particularly<br />
advnutngoouss position to undertake an effective educationa l<br />
effort to stop a nd to provent Cigarotto smoking by collego<br />
e.tudents:,<br />
THh'R&N'OFE, BE IT k19SO7 .VN','ll, that tho fanerican Colloge<br />
tlealt.h Assoei .ation, roeogni.eing tho above mentioned relai .ion-•<br />
shf .p. betwoon cigaret4:o smoking and some diseases, urges i .ts<br />
cnti .rc mmabarship - - both i.nstituti.onnl and individual -• - to<br />
nttempt, in whatever wayc+ considered most suitable, to dis•,<br />
courage cigarette smoking by college students and future<br />
aimnni .<br />
The eorwerns felt by our organiu.ati.on i.n 1962 have<br />
been we1.1 conf'irme:d by the Surgeon Gonoral's report and other<br />
roports since that time .<br />
k1 though the tragic morbidity and mo rtality occurs later<br />
i.n 1340, c:oll.ege r,tudcnt.s who smoke report a significantly<br />
1 g&Ei<br />
€;retrta:r nnmber of physical complaints t.han non-SmokerS . This,<br />
of course, intorfcres with their woll-boing while in colloge .<br />
Studontc: arC iucl9.rmd to feel that: l.awmakers who are<br />
sesponsihle for such regulation by failing to approve this<br />
a.ct li .torally give tac:it approval to ci.garotto smoking .<br />
'iherofoyo, the studentr-s feel.rnore eomfort .nblo about smoking<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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cigarettes . 9he lavnnakors should indicate that they are<br />
concorned about this problern, that they ronl .i.zo it ie a<br />
GOrioU6 hapnrd, and give proof of their concern by taking<br />
appropriuto action .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Respectfully enbml .tted,<br />
/cl/ l.oona Fi . Yea"r, M . D,<br />
]rroe,idont .<br />
7969
AP6f3?:ICAN DENTAI ASS0CIA27.ON<br />
IVashi.u(,t.on O:£ficc<br />
$ui.to 1200, 1750 peunGylvania A .vonuo, V . W ~<br />
The Nonore.bAC VYat:'r.'en G . Muhvurson<br />
Chairnan, Sonato Conmrorco Cormnfttco<br />
Son:at:c= OffAc:e l;ui.3.ding<br />
4dashir,gton ::F, D.C .<br />
llen v Senator t.tagn118o 11 7<br />
Uaroh 31, 198 5<br />
I am wrAtinC you on hohalf of thi American TAVntu.l<br />
Anfioz:i.ati.on concerning S. 559 and S. 547, bi.lls rclat.ing<br />
to the labe3.in(c and c.dvertiei.ng of ci.garotter : ,<br />
'Pho Amcn acan 1lentsr7. Aosoci.atfon Is rnost. oyrapathstle<br />
to the purposos consraon to both hA7.le:, bel8evem these pur -<br />
proses to be prope» and dceirablc, and u :e(;oc the Senate<br />
Cmnncroo Co ; mittce to take favoreblo actAon consonant with<br />
tI1C111 .<br />
h cm1.iG'rci of the dontftl profensdon have been doeply<br />
e:oncorvmd its mo.no tiam about the heaa.th hnc,erdu oie :mol:fng .<br />
24iPC, concern has becn ertrengthonec] and deopened during our<br />
activitiee to a ioendln(; mewbor of the Nntional I:nteragoncy<br />
Counci.l on 5Yno1:91tp, and fYctn3.th<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
At its 105th mwu r.7 ec:€aion, hold November 9- 12, 1964<br />
in San hranoi.coo, the, Apu r Scmn Aonta.l Ar+n ocfat.i.on'c hour:o of<br />
1K,le€;ate.r. ptarse:ed the follonin(C rev;o3utfon :<br />
3990
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°ROS;ol.vod, that 4 :he nembers of the Amorican Ibnta7<br />
As;+oc2atiooi b ;: oa7.7csd upon und encourhE;ad to tuidertnko<br />
an culucatiatnl efi'ox•t to i.nf'orm thoir pni:i.ents of thc<br />
iu :n .7.th havaards of the nso of CobftCbo aand, ee,pecf .a).1y<br />
wit.h young proE.lc, to warn sgeS .nnt ncx;u3.r9ng the habi.t<br />
of cigpro'ii:o suwlefnR: .n<br />
a'hc kind of ri'edere.l activities tBn t ciould be aarthorized<br />
by 6 . :i ;,h and S . 5.( V9on7d hC*o o3mNtoriRl i:eEistAlWe to<br />
tho dontxl profc.eion in thc oduontionhll off'ort 8t is<br />
undortnkzng to a,.Aort puticnts of the holsYth Ihazax•ds of smelcd<br />
inC and vre sur,port thciv cnanctment .<br />
Tho Ao B ocint9 .on vrouP.P, approciEatc hatvi .ng this letter<br />
an odo n pa v t of the record oY tlm Senhto Cck Amezwo Comsiittoe<br />
heari.r, on S, u&9 •r,nd S . M7 .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Sincorely yourc,<br />
/[;/ Iioarnx•d J . Ffis,dhnmor, DOS<br />
Ho®ber, CcruncJ .l on Logislntion<br />
l~hl
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N.tIskYCAN X)a1PSPAl7ER P1Ig) :,1S1/BR,S ASfiOClAT10N<br />
Nonorab7c t'darreap 0 . tfat;;nuson<br />
750 Third Avcnue<br />
Now York, New York<br />
ChaArraan, Soncto Connnorcc, Committee<br />
Psnate Or:Pice 15ui1ding<br />
IYaehAnt;ton, D . C .<br />
Doar Pnr . Chairro:nr ;<br />
lSerch 17, 19C5<br />
1'h e Amuri .can Nowspag e r publi .shors Anrociation subm .its<br />
f.ts vicrrrn in this letter for tho ror,o:rd of leoari.nrs: to be<br />
hold by your committee boainu9.ng March 22 on two biil.s, onn<br />
of tvhich, E317. S, 547 by Senator Neuborgou (Oro .), would<br />
i.mposc spccfa l restri.c:tions on tho advertini.nt; of ci.[;ecrotte :, .<br />
Th e ANPA isn a trade ac s ociati.on of daily nctrsPapors<br />
©it:h more than 900 mombarr havi nN moro than 90 percent of<br />
tote) U .S, daily ncwr,paper e9 .rcuiation .<br />
)992<br />
!D'xil. S, hx7 would authoriac tho Federal T.•ado Comnaisnion<br />
to c?i.rt:ct thet 01) . c9{ ;rtx•ctbc advertirin„ -i .uelude a statemont<br />
to the effect t:hnt snoki.ng ir, in$urtious to lheaith . It would<br />
afloo nuthorAee the FTC to "Provide for the elimination of<br />
aill advcrtis5 .iqg mat:ter vihich tends to make cigarette anooking<br />
attractive to chiidren,"<br />
Ni,snt anc7 foremost, thic: Asswciation wishes to ompLasiro<br />
that it taNO n no positiou acn to thn merfts or ctomerits of<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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1993<br />
ciliarettc amokin€; . Tho Acesoc:iation recognizes and appreciates<br />
tho legititnate interee:t of the 1'odera l roven•nment in matters<br />
which ma,y be found to affoct tho henlth of citisons .<br />
Yf cignrctto smoLing is found to Ua a nati .onal health<br />
hazard, we thi .nk thntt thc problem should bo attaeked diroct7 .y .<br />
P7e rmte that your Coumtf .tteo will alno considor Bill<br />
S . 559, introduced by you, calling for the i.nclusion of<br />
warnf,nt; e.taten:etnt,s in cigarette labelint ; . I'he latter bill<br />
docrs not rair.c the sorzous conntitutional and public policy<br />
QUGGtiCnlE: that are rait :ocl by propc.sed reE:tPietions on ei[;ar-<br />
ett.e adve :rtf .r,3.ng .<br />
It ?& difficult to follow the logi c ox the precise<br />
roanon& for the proposed advertising roe.ttdetions . Tho<br />
Governlilcrht would be plaeedin a etrenge position . It 5nb-<br />
sidi7er. t.he farnwrs who grou tobacco, t .hen it taxos not<br />
on].y the Groroore but al .ro the tobacco mn .nufac,turers, whole-se<br />
:7.orr and rotailern, then imposes additional taxes on the<br />
swolsern t.homrolvea. 'lb f'ollcrvr that with a Governmont ro-<br />
qu.ireutcnnt thut every advertfnoment r,te.te affirmatively that<br />
smoki .ng iE; inyuricns to hoaP.th puts the Governm©nt in the<br />
untoaablo positt.on of sinmltaneouetly subsidixing and taxing<br />
an itom which the Govermnont says wf.l] dosicroy its citizens'<br />
heaY,ih .<br />
When the Y1 .S . Sur6oon Genoral early in 1064 issued his<br />
roport on snmlc9 .nC and health, newspaporu and other media gave<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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that report the West possi .blo disee m inn .ti.on, No claim<br />
can be niado that there hae: boon an inforrW on failure, The<br />
general eonelueions of the burgeon Gancral'r report were .<br />
wide:).y dx.f:sominated to the public by nomspr,pors and other<br />
mcdin .<br />
Sincc then a nationa3l cft;arotto ncivertising code<br />
eponE:orod by thee nation's ma,jor c :iry,arettc: manufact.urers<br />
haa boon adopted . 9.`ho codo provides that adverticing may<br />
not be usod in any media, i.ncluding nowsha.pers, unless it<br />
hao: been subruittcrci to the adufinietratcm a .nd determined by<br />
him to be in c :o:upliaraoo with the c:ode . The code also barA<br />
the use of to :,timouials ox• ondorsemente: from athletes or<br />
cclcbri.tAer., 4.f such u=.e vould havo a spor,ial appear to<br />
young people, and catogoricel .7.y prohibf .ts a :ll advortising<br />
dorignod to appcar to pereone under 21 .<br />
This Acsocia.tion bci .ieves that the code is praiseworthy<br />
in that it providos seif-policing by an i.mportant tax-paying<br />
€:e unaent oa: American inductry . The code should be givon an<br />
opportunity to prove its vrorth .<br />
Now an to the o,ueastions of Constitutional law,<br />
Yt .ts a ftmdamcntall bclief of our Association that it<br />
]nf;d<br />
should be logai to advertise S :ruthfully any product or sorvi .co<br />
it is l.cg;a7, to seAl, No instrnmonta .lity of government should<br />
adcpt any law ow ru1.e to prohibit or c:urtail dissomination<br />
of i.nfo•rrnatien through truthful advertiei .ng .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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Cigarettes are logitimhto articles of commerce . The<br />
tobacco i.ndnsary is an important segment of our economy . We<br />
respectful.ly submit that fundamental auestions of consti .••<br />
tational law es me1 .Y1 as of public policy are raised when<br />
Covornment ecehs to rc :ru9.nte the right to publish truthful<br />
advertising concerninA legitimate articles of commerce .<br />
1995<br />
We be].ievo eaoh publi .shor has not only the right but the duty<br />
to determine individua7.ly the content of his newspaper .<br />
This appl .ies es much to the advertising content as to the<br />
news cont.ont .<br />
Tho ANC~A tukes r,o posi .tion on 1:i .11 S,. 569 introduoed<br />
by you rcY.atfng to iab .,li.ug reQuiromentc : . But we do believe<br />
thnt restrieti.enC on adverrti.sing such IIFe nre proposed in<br />
1}Y17. S . £iA7 invndo areas of individual choice of expression<br />
which are protocted unctov the Constitut ;i.on . That Bill offers<br />
a dan geroues precedent .<br />
We csre living i.n n conlplex society arrA all of us are<br />
subject to many risl ::s evory day .<br />
poople di.e in automobi .lo accidontei . Should the auto<br />
muker s be required to Sne,ert warnings in their s.dvortisements?<br />
.Airplrules crar.h . Should we force the airlines to<br />
include wnrning statennnte in their ads to that effect?<br />
lt is snS.d to be he rmful to eat too much rich food .<br />
Should wo require food producerc and scl .le ru to mention this<br />
Ract in thoir ndvertisements?<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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II any doctors F:ay that it is hazardous to Kome adultH to<br />
dz'ilik milk or to ent eggs . peri.le ere ase.ociat.ed with liquor<br />
and beor, electric light sockots, gasoi.ino, engaging in ath-<br />
letic activitioai, using products in aerosol containers,<br />
]D96<br />
Al.l t.hose nay be daxigaroux, y'ei : it can hardly be reryuircd<br />
that advertisemontc for those products mui ;t contain warning<br />
Htatement s .<br />
11 t.hc advori:ising l.et;is:latS.on now proponed should he<br />
enaeted, the procedent wouAdbe established that could lead<br />
to totelitarian restrfcti .ons on the right of businessmen to<br />
advertise their In`oducte : and the right of nowepapers and<br />
other uwedia to dooide independently their policies as to the<br />
content of advortir,emeti'ts which they will accept for publ .icati.on,<br />
plense l.et ue omphaf;iw.o the obvious, Our Association<br />
does not condone mir:) .oadi.ng or untruthful advertising . The<br />
memUers of our Rss:ooiation have a long and pnaiseworth record<br />
of rejecting ndvortisemonte which are not truthful and re-<br />
sponea.bl.e or which miea•eprcisent the product advertised . Many<br />
publi .ehere: profc r not to advertise partioulfx products . But<br />
wo cannot ap, .ree that Congress or any govozauuental agency should<br />
dotermine the ccmtents of advertisoments of legitimate artic :les<br />
of commcrce .<br />
If there ia any fUrthez• information tlzit : Association<br />
can supply, ploaee let uh k.noe/ .<br />
k'S.tU high esteem .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
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http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Siuoorely yoars,<br />
/e,/ b9 . B', Arumist ead, III<br />
11 .<br />
1087<br />
Y!, Ar inistoad, III, Chairwlaa<br />
Foderal Laws Committee
e x x»s!e<br />
t.nshl:xcarl S cxloar, N n:AVTts Asuv
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rlurn4ng i cecr, J .;O.: or . c I .(;et~ e,i;f-c pn, cicsGcx; 0e• aieax rar~ ur, aEl,<br />
oigue~ t:+tCa reei.Ral).v,<br />
cJ kwr.y .Y, .5'nadcra.3 .<br />
8/ k!o€F`q ~f . Scfl,dclY, ArocACIBUS:<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
AlAbiC$.OBY , :io,31GOY. YGi'A Eh ASf:4c9,£dS.U11
0<br />
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a•7 2000<br />
A.1'iGFr?Sl'%SING .. . ., Afi AN'1'Y-.R3+3NbktdY,kfn3 .actf,an<br />
c:hS
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cr aooa<br />
?S;G oi 4 . .N .A, m oiaborF : i.nveat over $1,000,000 in advortfsi .ng<br />
annSSS7 .Ay, Wost 100 member oomy.anfoc : kpmnd lesa than<br />
$F00,000 each year .<br />
G. .N .A . mu,eibe:rs u[,a ovory adveWni .nti medfum in t.he9r<br />
advc :r25t:+fn£; proF.ruNs . a'hoy repxor>entt the bulk of the<br />
nataonul nuppo ;rt for t.olevAsion as 87 of the 100 lead4ng<br />
usera of the,C modfurs carer A .N .A . mr3enbore . Nowever, tho<br />
mctw;rt :is:i,n€t f .nvc:eainee.t :[: of
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A .)7 .4, nnbwS .trs th9 .e r.tateines,t fn the cauar> of two<br />
f'uhdeaP.c:nte) princ;5plec Wcb ar© ir,l}?ortnht to the public<br />
a9 a lVhole, not n;HrCAy to adv9rti6e8N . They ar0 :<br />
19hcre the luw pex•mitu5 a product to bc Oold to<br />
the (yer=il public, 4.t >fhould allow t.hrt product to bo<br />
n6.vertie,.ed to the ponvral pubY.i.c .<br />
Nlhc:re m•rndat:e,ry instruct4.onez or cautfonn uro<br />
cour.:P.dor oc?. nce;e s c,,u.ry to the pub)i.c goou , thnir propo :° placo<br />
i.n wAth the pacha6•:i`!ty of the yr roduct ., not An itH adve!•-tir<br />
;5.nh .<br />
1'he f' :Lre.t prfll'iciple fo) .lowts dtrect :ly frote the lvrolaEeo<br />
tbftt £.(1v6rt1iF.in[f P.P4 bene7ldoi.ay, if nott indicpenEabl.e, to thb<br />
(f:LOhnkdS.R fltlucturG: of our nNtf.Gn . AdvBrti.8i11g 'J.6 d l,1ne<br />
(SU a non bo t)te rnass d9.c+Cri.bution which I n turn supportkt reasc;<br />
productioa und mak.a s poeecibl .e macs coueu mption, the totalS .ty<br />
o8 whS .ch is: the ve ry b ..oe of our oconomy . Furt6ormoro,<br />
wi-t.hout advan°i :i(+iu(g rovonueG to e:upljon•t them, our proat sls,dia<br />
of infOrlnGt :iAIA, newc4 rL nfi OhtortaSlnlnCut could no 1(ynQJGP 00rvCe<br />
thc bY•OHOd p'.Ibl.ic . Pk .Nt would go oUt of HfrliPtencR . fhphe<br />
Vhi.ch RN'vi.ve(4 wOll] .d6 hhave to chaFQ(() pr1C06a too hi gh foY<br />
moclt peopA .c to prxy .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
lYE YCcofitlA%e, of COUrbe, that ecorlolniR ar(;unlent6, and<br />
(>Ven the BtRbi.l .ity Of thH nat1G11 ' cf preFN atld eohlMUnil:atiollC<br />
ICadi.r+a lauraat t(llco (accond place whorc a produe :t ie cancArne+d<br />
LOat tLreK.ti,ne public sai'ety . Ltu t the public 4F3 e.ustomnri .Xy
a~ 2003<br />
denAod free r..cooce: to products o£ thr.t cntot:ory . Xf n<br />
3r.roduct tn not so dnni:e.rous, thnt its purohueeabilit .y should<br />
• bo rostr£ctor3 or prohS.hi.ted, theu thc puh7i.c good vrhich<br />
flotnG from ndverti.r:inf'r+hould not be mecrifi .ced,<br />
ri'urthermore, me, long es cfgnrett .es fony be sold to<br />
the pubAf .c, :1t i .rs hAgh3y icapoa .°tant - for rat le a et two mu ;ior<br />
ronsons7 - that thero bce vAf;orouP intE rba.°nnd compctition .<br />
V: :thout cuch cenpotitfon there woukd be the inexornble<br />
avoY.ution tocrnrd monopoly which ico t+bteorrent to our baeic<br />
canc:cptn .<br />
Furth¢ ;rmoro r.oaapetition in the vdto3 stimulus toward<br />
product improvemont . 4ihnt cou3d b® a shrmper spur to over•<br />
• coaai.ng e.uch drnwbuclcs as ci.gairottus may he suenpoctad of<br />
bnv i ng than the r.ompetit.ive ndvccnt.a geo va mnnufacturer cmald<br />
nnti.c.i.pnt.e from c,ueoef,efu3.3.y o3.Aminnti .rep such dnngers fram<br />
hAC.: p roduct •• - prov5.dcd he c:an lot the public know about it<br />
in lei .c rcitvor tirsing2<br />
ttut A.nter-brcurd compotition subsls9 :e on radvertis•i.ng .<br />
FY9thont: the r.c.pahf.9ity of radvcrtimi.ug thau°e is little ronson<br />
to believe the,t ranr,ufr .cturert; could commi,t themsolvos to the<br />
larF[e^ .nAe` A.nvoetmcnt of cnpitrtl, the dovotion of mnn•-hours,<br />
• the cxen•e:ise of znFtenuity that mucrt be inspired iR whatever<br />
honStb prob3emer mny atte+nd ci.gnrette snmk.i ng are to be<br />
c3.i.19i .u v toci .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
AcrcorGangly, i f ei gwxrttes are to bo publicly sold,
ch 2004<br />
thGiP 0lAnnfabCUPOrF' shbuld have the freedom to adverti6E .<br />
And t hir enhnuxd be r; freaiowr In fact not in theory .<br />
Vor It to be Rreeoorn In Yact advertising uhould not.<br />
be Idf3nQntor :U.y cJ.V,tt(er6P7 wSt19, forE)bodi.n(ZE of a dil'b $ate to<br />
thotier vAeo ]ook upon or Pfaton to the advertfsomont . Such<br />
adven tAS9.ng would e:in+p7y not be vered (ttn7osc It Is determAnod<br />
that the advortit:ca3 eavoatcs have no aff'oet.l.ve dmtcrrmtey ;<br />
which wouYd harASy he a sonnd basis for proscribinA thon:)<br />
and (;onttrcs s; tai(„Irt juet as woll forbid It forthrightYy ns<br />
rec9niaro thnt It be r..o pat4.ornoN .<br />
17c hs.vo the an:n. mp7.o of many e.rtic9.oe, vihosc danger 9.s<br />
Por more dePinit.o7.y c:stahlAOhedl than th it of ciQarett:eo .<br />
'l.'raditiona3Ry, whmtcvcv^ e,froci.a.l. vrarninli s, or i.nstruotiono<br />
have been de0 mcd neceElinlPy for thCIG have been consi(i,'ned to<br />
pY.C'1^.'.R.ti.n1{, and not to advertiFlinE'. ( Wg ., foo£in, drugs<br />
EtndfKrE:pi Stfib6, haM.nr@OtES £SubiJtnncb6, economic poisons, etc . )<br />
There are a nwdbc:v of valid roar,ottes for this .<br />
Ono<br />
the A .M .A . f'0c).6 part:icuPerRy 4nn)ificd to speak to is the<br />
fect that r.dvortisf.ng In a corMrcnnfcatA.on forta all of Its own ,<br />
It u:u s t opnx ute within cxtronwRy rostxi.cted litnits oftivie<br />
or e:pace , It in not t9oriCncd or nble totransmit oompro .-<br />
hona:hvo trce.tf.r:oc: ut,aon, or oncyc4op&dio hnowledge of, a<br />
proct£mt .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
'i'hc, purpose of adverti.f:f.ng In to croate a favorabie<br />
Fuii'a nhont 00 itc M that will be conducfvo to its purchase .
•<br />
•<br />
0<br />
c0 800f .<br />
Yts: f:oc.hniquor, necer :varAll .y are morre EynboAi.c, ni] .ucavo,<br />
ursoeintAve +bhem eapoUikAaxr.tAmxas_, A.c}vor9 :£ei .hg in eaore<br />
oloe.cly e.ki.b to the ?i.tore,ry the',te to the 7i.te+xal, to : :r't<br />
$or1AE: oR C3YpF'CF'Ri.b)1 'LIIPJe to eIt(;fl}te6t'iii[,t plR4il!@l .CZ pUd FiYUe--<br />
pri.n5a7 . 4"o ,Porco 'npron a:e;.vortAe:i.et(p the job of c.ntn).ogfng<br />
dE>tuA]G tEDYI)-Q vlol :etEr i.b(t bPt(uY.Cv nF;tA9r6 Nf,d 1Hake N WRp'Le<br />
o," taie, e .eone+y that €roc;r.. £nto it .<br />
G,FVo rI"euta)_ di .v;trBi .on oY' tvttt:.t rcuat Uppramr tn adver-<br />
tECi11(r, g VO1Y)SS IH`, ttllrt(3llR>L1Pnt to j ;.rohY .bhiCi011, '$hp 6otOj/oUi .tfloH<br />
oi u r ad.voxiAeeis~ealt i.r: a hi(;h1y SRi .73.efe tA.nl9 er,ec£kY9sad<br />
p)kt.GPf3F ; . We hi1CrW tl'IN.t 90FPFRbgly' £IaFJi[411i,S'3 .4allt C:hfltaQ' e B AA<br />
H}1!'SrAtnCl •--or evhnl o f F,& k7ord --•- Ata.y HSri .o4fi:ly aptOr At.6<br />
C>£$,'UUtiVPSriRS:.d . 11dvC+S'G'Jb'C rG D.rG+ not Mf))y to ri .ph the LnCrSlk .GE<br />
P.ho.t rrc hoeQOd t.o rnn o oarqrsiCen whi.ob Ania.ttcrog ce,py t.hey<br />
{cxs). et,lfl f,e°c:r,t thm vory p;urprosao o f t.hcir 2uvea.ntment .<br />
Wtc:vrer dctexi .l.ad An..orTn•.ti-on Ctonyrd+cs be).ioaars s+houRd<br />
hC GOIn:nMptG+tC, to CeS.Iiar6fttca f14W1CG+rG by Ci .(ga}•Citte IGCtlil£a( :LL1TQ;r :r<br />
oan 4?e+ raorri oosnpx7 .crEG:%,y ttesd n>ore. anpprroq,r5.lctohy feaoorporatcei<br />
7.nta ps;Ahti .np•: the.iet advort.i.nf-eeg . Hvax•yome v:ho ueos tho<br />
pn^oclnct vou7d i:huc: be oxproG;ed to the nnxersap;o at the very<br />
untrmt oPs s:ver~•y ucie .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
V'c, r¢aogixi .tse, Exr+d do not ; chur-x'roPl with, the prroposi .tion<br />
thrit svp edvc r tfeom oerb cannot colhte+axt AtOC1R tvAth a ha7 .i'a<br />
trelis b , r.erd thx35., to thce extent iurthcar S.n .Porn R ti.on 9rs roquired<br />
t ci>vi-t, .N ela,Vptivcrtrc in what un rcdvoxti .r:cr has ele :atnd
•<br />
•<br />
•<br />
C'I<br />
to hhy, hC tkh4YVl(t not b0 R)108 .r.t the uso en(i r•a2e oS th e<br />
cuaareocaS.ty 9 .i:ce7£ . .r;P, howc+vor, S .t S .t, w117ing that tho 3tom<br />
kto £'roo]y trvt•iYEahS .o to the pub7 .9 .o, i .t ehou7(i not 6rc3dc the<br />
i3kSb$iF11 OWSt Hn(i Y .IVrjvoy'ttdqt CfOOnotfiS .c £uP]Ct£On, flCCvBrS]£01Irt; .<br />
'PR(" ]JY'OGQ'lOFIt 14oll1.Q bC !in AIYEJflC3,£041k1 UY/© $nd, OrecF3 £Ubclll .LitOCi,<br />
hflrCi tl0 cOEit;(1}.n,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
C :®nsPt ;tearF : :ey vi .th tho.t eatsco}+t, the AecocAati .on of<br />
79otzorinl . Cuv(rxt4n(ar>r• rc
•<br />
•<br />
•<br />
isY~lES+FRN COYRdPY" TBSAAISAC)s•07`1CA L SOC8Y11X<br />
2YG N . Wozshiotk4.an Avontte<br />
Se.a•( ;dri.Itt :.tore, b . C .<br />
lyas;r vouacor MgmtFYO+ :<br />
2001,<br />
Wra}ter Ci . C!ormvttd.ng, .Xx• ., 7>rersS.ec:rst<br />
Lfe.xch ).G, 19016<br />
fi3czx: :, tre o .Qvfe;crd that the ktca•l;en Corn:rty (Yd .J" .)<br />
E^I~asS^nc° usse on arigm.x•et lanbo7Ang . This vrott) .d he<br />
c+ous :S .r:C(:bt wi .kh xp°ccsr,nt requix•omeu,te o9 thc k•e(ierEi2 1•'oo3o a :nd<br />
1?sa(s lac9m :4nkntx•t,tAon tlsr,t 7pe .tcerl :drol/.y :afax•xosu3l non•.nrcrecr9l>tSor.,<br />
re!:E•aeaGEesf;Eng lyroe3ue5 :cr eerrrry mr ;.x•rrflngs, eeutfon not :3.ces nud<br />
6osraq ;c T.oxP :O orr 'dr.bOy axtd f,naavrte: . Sone of those Pae<br />
rnoMrr•s:9.e7ncrsu d.,•vt•.k, anbAhPatnrvuixror.+, :;7ecpittg y>9.7.yra,
•<br />
0<br />
0<br />
hea W he rno:9r. .•l .uor: rwt2 tabllot s , llnxatpvcrr, nnd nas:c+ end<br />
eye dF'e})C<br />
. Our cmacern Sn thts vr.ttor, f9rst made ytublio si,any<br />
monthe: t+.p;o furAng thc Ykr'cuidcnati .pi term of rey predc,ceuz;or,<br />
.t . Ituuson Mrmwhnn, ropxc,r:eattc e ee .nt4nueA 9.nteroct in<br />
cduc:ot'acut an tho rnu(,n5tudo of thSe ; y,ublic : heea]th probll.em .<br />
We, the,roforc, do lvish youx vct7ued le(;iolati.on n 2,g,eeciy<br />
voy ::Te throu( ;h r,Xl the tr.ect,ani .cr: of the Ship of Ste.te on<br />
the hotemm Oon you tmvo P.ird.shoc7 with your committoc,<br />
hc:nxl.nf;a, which staa't t?arch 22 .<br />
Si.neeF6rl.y y'en2'6,<br />
Saii .tor R' . F;rotvnin(;, ,Ytr .<br />
Pre+6S.dc :nt.,<br />
(COpi.eF, oS Xottex• eont to 6enntore Ce?so mad WS7.l .imna .?<br />
H}'ItG?ai COU10'CY PEA/JIACPS'u'CYCfIY, BOC%P'kY<br />
G . .T, Vx Denv., R .k' ., fio¢nrotnry<br />
`f:$ IJ, Ruby rnVC ., PlE .l2.pinde3 ltRrh, N©W J(7YHC1V .<br />
2008<br />
hlalY : - r"or raloare llednesdny, N,taroh YY and thorca&te r -•-<br />
h'RehehTaCh, 1'1„Y ., t$:TCh }7 -<br />
YionYth hav,hrd c ;apn9,ngr. a.nd edotlunto d9rections for<br />
ureo oh c.£EVarct peelang< ; Xx.boAca vns urgod &,dr,y by the t§vr(am<br />
Cotmty Phr.rt:n :eouti .m). Socfety .<br />
I7aXtox 6P, Hrcamin(„ dY• ., pharmaolat of Ber•trenfieid, YremRoont oP the Gocfoty, ea<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
.id, "Ovoa•vnceJ.pr)nC ecfentA2i,c
•<br />
•<br />
e3 2009<br />
evidenco reportod by Surgoon (foneral lrather L . Terry's<br />
Advir;ory Cot,nmittec on Smokfng and Health has ,justified the<br />
ronAi :;tic ncod Sor count:orwonsures : to protoot the well-•<br />
bci.nA' of the Amorioan poople ."<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
lu•owninrr, snid the v£ows of the LIerE ;en county<br />
phaa;aane.caticaR Soc:iety h ad boon sont f.n a, lottor yestorday<br />
to Yi . f? . Sanzitor S . nn r ron T=taenuson (li„ Washington),<br />
chai.rnrtnn of the Eonate Comraerce CommAtt.oe, which plans ci.x<br />
Gaye of Irenri.ngci, r,turti .ng on 1A;crch 2r, on tohacoo-hoaAth<br />
lotriF3lntion . H
•<br />
•<br />
0<br />
'1.010<br />
6f9~, li"A q 1P jr~•C':/:Oii~ !)I ^vl£ Pt,f, .C.C[4jJj f~ (i~AF; ((i'Pp V(r :4L1aYiQ:F:<br />
/o (bA$3C n w[,Q .j.GD£ SYf7 45 ::E4(G {VrF, l of, 3@c:7 .0 iilFa 'CJVUPrrF•°<br />
, . .a4r etp tY c . . l .e.i;.>.cM./1 vx•trti(tetrt, Pk t1e .i e .ar,:;<br />
li[Si.4iPC•).(11 ''~S liYt!!, :,, F :XC :oXrj .i .( . Fi%]),Fy fecfi4"2c11@ 1Cdwc :Tt1o`s,<br />
7 .FY ;Lr{W&', hit(n 4(rm kOG1 f3y6 C%5`(it .(u DoCuJl'L<br />
o7a 'tl .e lla 1 u9. 8r.tk6cc .'i [, i:er:7.s4-lp r,i .g(rrt,L [ .n'sierf :, hnr; bcx :rr<br />
t 1(e( . .V).C •p1 .OCt 4¢• £ 4va&Y . da malN"c~ . E[IC11 tV1iC*, Id_ flRi.(ip<br />
At4 IC9iv f rb5 .1'eC1 . Vh''Lh afiCl[P(e(a o.f.5,eI/ i :foi9 11 .0(( C(IIwCr"<br />
6te(1 6i=I1ON ll (Ci . .S6b, y i :hbLp( c2COPfY.k,V flk'LCF'y di.F,CC! :O, L•ltiftnll% .4 ;<br />
tt -,ruc.SrMr r t t c .=,.-?s\c .t-, :p . 4h j( A.cuHr E awil (f oag&"vtt<br />
r'•h31)E', Ie ( ;Y, i [ C' :e'i: 19 :UPt1( ;b tiltf. ((t_r.cJV.fi+el' fti"C; br!y)C.P<br />
GJaImCy 4rS` 4ibaYli i ;p .C3 L; LOS
•<br />
•<br />
.<br />
ty ?.<br />
CANCRIt COOItpINA'fINO COD7MIT'PkE<br />
01" TIfP S7"ATli OE WASHING^xON<br />
e/e<br />
1:`T.&hiiE(;t011 State MOdiCal. AEneCial.iOn<br />
3309 SevontU Avenue<br />
77tre NoeleraUle 19arren O . 47aCUU ::on<br />
Sonate Of.fice bui.].dfitA<br />
Wachi.ni:ton, D . C . 805 :c0<br />
Uon• Sc :uator MaGnuE;on :<br />
8eattl .e, Washingtal OPl .01 .<br />
k'ehruary l0, 7 .005<br />
It has cotr.e to t.hc n.ttention oF the (:ancer Coord£na-•<br />
tin(; Coimnitteo of the Stato oF 14huh9n};ton that you have<br />
introduced Sonnte D3i11 560 to rerulato £ho lo .bel.Sng of<br />
ci(;nrottou, nnd for other pu7•posos .<br />
590 •r.re eoEpiizant of ,vour i .nterest In the controll<br />
of cancer In the pa .ffont as ov.preacod i .u the IIoone -<br />
Afa„mrvvn Itil .) . . The Coranti.ttee voted unrulimeusl .y to cao-•<br />
mc*,nd you for your• offol•t In the past and f.he present,<br />
nand hope to seo it oxtcrnded £n the futtu^e i'at^ this good<br />
pL+rpe se .<br />
I EaI ene7osinC a copy of the fleso .luti.on paesod by<br />
the Wnuhington St.ate Modical AsE :ooiati.cnl rcgardlng<br />
ci .gax°ett.es 01 Ats l .ast. Annuasl Meetin[; . I hone it hiill<br />
he of velue to you .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
`L071
0<br />
•<br />
ty 2<br />
RBSOIAI9'lO1i<br />
(Smolcing)<br />
Most E .3.nGerely yours,<br />
2012<br />
s/ Aav?,d Iietheny, M .D ., Cha}rmf a<br />
Canccr Cloordinating Commd .ttoo<br />
State of Washington<br />
54111 .R1iAS,thcre i& overw:holming evi .denn,~e of a defini .te<br />
c:mFlative rol.ationstd .p between the smoking of cigarots<br />
nnd the over .dLicroa.si.ng inc:idonco of lung cancer, and<br />
WKF,RhAS, there i.s also good ovidenoo that illness and<br />
deatfi from other common dSr,rasoe such r .c emphysema and<br />
coronary artery heart dAsoase i .s much fd .gher in ci .garet .<br />
6GIokR1'f: tltan in other persons, now theref(.re<br />
RK YT kB.OLVI&D, thn.t the Washington State Afodical .<br />
Associataon regards smoking aes a si.gni.Ai.cant health<br />
harard and goes on rocord as strongly dicacouraGing smoki .ng,<br />
and be i.t furthoi><br />
R13SOLVli6t, that i:liie AFSocintion oppo ;nes all adver-<br />
tieinS and other i .ndar.r.nonts that mi .ghtt t:empt young poople<br />
to start smotcing, and be it further<br />
RP,SOLVR:R, thatthe Wa,chinFton State NSedical AssoeAat.ion<br />
will e.ontinuo to endorso, encourage and cooporato with<br />
efforts of itf ; mombere Fuid other health e.Gencies, to<br />
di.NBCntli .nflte inforliYati .V11 0oncerGing the po.itive relationship<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
~<br />
Ly 3<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
b6$N!een $hc? fC mokin[ ; ei /:i . gNf'Ris R nd d580NCi0 ; to urge FUYd<br />
nc:eA.st ciCero t e,mokcrf: to c! i sc:on.trnue thc : habit ; and to<br />
dr.scourage t.hrou(!4e ctdneN$ion, young poop7o from smoki .ng .<br />
(+ilhcrt G . P:ndo, AolegaLe<br />
K9ng County Medical Society<br />
2013
•<br />
•<br />
•<br />
ty .3<br />
STAA2' OF 6Yri.RtFtA1Xr DR;hIAFtRtfr;LT1' OF I*UBYdC 111'iAhTH<br />
4230 lioe3t ll.th Avr-.nuo, Uvnver, Colora,do 80220<br />
H, L . Cleere, h1 .17„ M . P ,H ., Diroctor Phone 356-56U7 .<br />
'1'he klonorahlcr Warren 0 . Magnucon<br />
C}nearmpn<br />
Senate Conme rco Comm 9tteo<br />
U, ii, : enntc<br />
iva .shinnton, A, . C,<br />
My doar 8ena'i.oY 61aCrmFson :<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
lfarc:h 23, 3965<br />
A,f.tcr carefu l c+tuQy of Bills propoafing f'ederal action<br />
on Yahc, :ci.n(c a,nd advortisin g of cir;arott :on whieh hnve<br />
boon ini:roduoed in the 80th Confiro&s, we support oi.ther<br />
S . 547 or S, SticJ . in view of the oxtcnsive study and<br />
ev7ua'Giet/ of 01 avai.Iable evidence, the Colorado State<br />
nc:akth Delrar truont concurs with the findin gr> of tho<br />
Advisory Cotard.t0eo to the Surgeon Genera7l of the U, S,<br />
Inrtal.ic 1Hea].th Scmvice that. : ^( :i{;arett.e EunukinG ir a<br />
hea].th haxos•d of r.ufficiont importance in the United<br />
Stat.o :: to wa»rant al yropa•ia.te remedial ac.ti.on ."<br />
1't in o!' vita7. AnTortanco thrt the public receive<br />
ndaduate finfos•mation reGarct9n6 the posaiGle hea7 .th<br />
hFW,ardH of ci .i aTett{! E,'dllo16in6' andl tPe t'h1n1 :r that the h'l1t :<br />
Rholl . .ld have :folne res'jKrnf:i .h]l.ity fOr snJ7e1'vif,5of1 of<br />
eiQAXettC IabF.lfn(g and advCrti9J. .nC . PoP thib rOaFon, we<br />
2014
•<br />
•<br />
•<br />
t y a<br />
would favor eithe,r S . 547 or S . 559 over Ff .lt . 885 or<br />
R .R . 3014 .<br />
Sinceroly yours,<br />
2015<br />
s/ Roy L . Cloore, 11 .L ., }d .P .H .<br />
Director of Public Health<br />
ADOI°PF.p Dy a'Rt ; COLOItAt7O STATS HOAR11 OF HEA6TH<br />
January 13, 7.954<br />
SIR)3RPIAS, the 9 .EUxoas :f.ng frequency oP lung cancer ica<br />
of Crca .t pub7,ic•c health concern, and<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
t9lltsRNAS, thore is mounting evidence, based on Enedi .cal,<br />
publio healtlh and zstE,tiE:tioal fi.lldings, of the association<br />
o f the umountt and Den g th of cigarette smolci.hG history<br />
and tho incic+ence of diE :eane fncludinE ; lung cancer, other<br />
lung co7lditLons aild corona.ry heart dif3enEie, and<br />
WIPERFAS, thore As an growing tendopmy for porsons to<br />
begin Eawottfnf, at an earl.y age, which in turn incroases<br />
the potontial of lung eara :er and othor diE:easos in their<br />
adul t ycE rs v9wn they should be inatcing t.hoi.r greatest<br />
caNltrAbution toa.•onomic nnd family life, and<br />
MREA6, no present method of treat9.ng tobacco or<br />
f9.ltcrin€; sauo] :e har•: beon proven effecti .ve in roduoine; the<br />
hsrmfu.ll effects of ci .Caret :te suaoRing, therefore<br />
D)r IT R3sSOI•VStD, the the Colorado State fioard of<br />
1:oaYth urge parents, eachoulE:, college^., uni .vorsitics,
•<br />
•<br />
0<br />
ty 6<br />
voluntary and public health agencies and tho various<br />
public Anformation modi.a to conti .nue or i .ni.ti.atc intoa-<br />
si.vc cducationall progrnms to i.nform the public, parents,<br />
and young poople i.u parti.cu7.ar of the modicaY and health<br />
haGaNd9 ef Bfu4kSng, and b3 it<br />
PqR'fYlF,ft H16SO1NS :p, that all schools An Colorado be<br />
urged to prov9.de c,ontiuui.ng opportunity throu6hout the<br />
echooll curriculum to help ear.h student come to a sound<br />
pereonal doci.siou whethw• he viSlll or wi] .7l not smoke, to<br />
dolay the timc ho may begin smolcinG , and to stop or<br />
mo6orn.to the amount if he is uov, smokin[t .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
7.0Y6
•<br />
.<br />
ty 'r<br />
COIpkAlq T9FIENCOIASIIS ASSOCIATION<br />
163$ Vi .no Street, Uonver, Coiorfldo 80206<br />
Phone (303) 3SY.- .4827 March 29, 7 .965<br />
NollorablA Warren 0, NaQ7%U son<br />
Seirate Office Ctuilding<br />
Washington 26, U, C,<br />
Doar Senator bingnueon :<br />
]t i.s our undcrFltandi .ng that henri .ngs are taking place<br />
regardi.ng Senate bi .ll.[+ 559 and 547 proposing federal govern-<br />
tnent action on th® laboling and/or advcstising of cigarettee : .<br />
A'hrough the Nati .onal %nteragoncy Council on Smoking and<br />
Noalth and the Colorado Itnt.eragoney Counc:i.l on Smoking<br />
and NCn1.th, ithn£; beon called to onr att:ention that the<br />
proposed Seao.te bAl,1, Af enaetod, will ensure that a1.1<br />
persons wi.l.l know that oi.gxrotto smokl .nC i.s potentially<br />
harmful to their health . Af: a volunteu•y health agency<br />
concerned with the many respiratory di seas :es affecting<br />
the Aia.rican public today, we believo that 1t ie necess- ,<br />
ary that overythi .ng be done to cal l their attention to the<br />
probloms caused by cigarette emoking a n they relate to<br />
these di.soa9es .<br />
We are especially concerned that the Senate bills<br />
arc 1 i.von favorabl.e cenflideration over I :bUGe bills 885<br />
twd 30)4 whioh spocificail .y exclude the hcdornl 'Cmado<br />
Cornm6stei,on from responsi .b ility for supcrv .i.oion over<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
2017
•<br />
•<br />
ty 8<br />
cigarctto advertfei .ng .<br />
It is our sfncoro hope that you wi .11 consider these<br />
aspocts in further dfscucsS .on of Sonnto bf17s 559 and<br />
547 .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Respoet.fu5ly yours,<br />
s/ Rona .lti A . M11).er<br />
Execul :S.ve Dlrector<br />
2016
•<br />
•<br />
ty 8<br />
CCh7141iCTYCUT HYiAVPN DRAGUI:<br />
c/o Connecticut Heart Associ .ation<br />
65 A'othoxsfi.old Avenue<br />
Hartford, Connecticut 06314<br />
Etarc:L 2D, 1965<br />
'fho ltonorablc Warren C, ri4a,r7•nuson, Chairman<br />
Committee on Camnorce<br />
United Statos Senate<br />
IVashington 25,D . C .<br />
ilear 8enator 69aUnuson :<br />
IIn .llumary 1964, the Connecticut Health Lea6ue, a<br />
confedoration of Connecticut aGenciea+ i.nterested in health<br />
problems; adopted at its membership meeting a resolution<br />
concorning tbe dangors o f cSt;arette smolcin6 and the<br />
dic5omiuation of kno wlodgo about such dnnk,ers to the<br />
public . H'he broad type of mcmbershi.p In the Connecticut<br />
Health Lea gue 3.s il.luetrated by the lis :ting of the momber<br />
aGonc9.es on this letterhead .<br />
Yt is out undorstandi .n ;, that the Senate Commerce<br />
Committ:oe of which you aflre Chairman is currently conducting<br />
hearSnge on two bills, S 559 and fi 547 . Both of those<br />
bills provide for labolin g and di.ssominati,on of informa-<br />
tion i.n a marrnor which i.s in keeping wi .t.h a rosol.ution<br />
ndoptod by the Connecticut lleal.th hoaguo . PassaCe of<br />
c:ithcr piece of proposcrd leg4slat,ion would reproccnt a<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
209
0<br />
ty ®<br />
conctroctS.ve nhPraaoh . 5 E97 nppoars to ho ei73glrt]y more<br />
el>oox83e i.n etrenGtheu ..nG the por:Atf.on of t.h¢: I'cderal<br />
'dknda Co.+~m ;ic~~i.on and, thorerforo, perhnpn prefornhle<br />
1eg451aLSon .<br />
The tioard of CN.reetarF: of the ConnoctAcut Health<br />
Yn.n gue hno authoaYred this c:tatoment to be fS.)ed w1 .th<br />
your commfttoc .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
SS .ncc :re].y yonre.,<br />
B/ ni11 .t6n Geyer<br />
pre&f.dent<br />
2020
.<br />
•<br />
•<br />
ty 10<br />
IDAHO bI1PARTR9EN'P Ol' HRAIIfH<br />
6tatehOnsO<br />
Boise, Idaho C3707.<br />
Thc Horwrable Warren O . AiaGnuson<br />
Chairrrean, Comiafttee on Consmerne .<br />
U . S . E:enate<br />
WcBhingt.on, n . C .<br />
Uoar Senator 61a.gnuson :<br />
March 1 .9, 1965<br />
The %dalro State nalu+rtrnent of Hcalth woul.d like to<br />
comp]i.rdent the ConmuStt.ee on Cornmorce oftho United St.atos<br />
Senate for Hivi.ng such thorough r,onsicieraai .on and<br />
deli.b3ra.4:i.on ar: well as holding publt.c: hcarings on variour;<br />
bi11 .s prolro .si.nC federn,l government actSOn on the labeling<br />
and/or ftdvertisfng of oAgarett :es .<br />
Inasmuch as it will he imgossiblc, for any of our<br />
sta .f t of the Uepart.ment of Health to be px•esont at the<br />
hearings on the bi.11s (S .8`u9 by !0'aSnusan and 9 .fiAO by<br />
NeuberE,er) eie redur.st this letter he x•cad into the records<br />
afr e'Catinle Onr pOsi.ti011 O» the lab0li .ng and/or advert.is-<br />
i.ng of the hc:nl .th lxnzards on cit;arettes .<br />
1'ha Irepax•tment of Health believes the Heuberger,<br />
b9.i1 (5 .627) wfllD provide for sgecific aud rnandatory<br />
vax•nt .n0 mesr+eTes on eflCesrrette paekal';eo and mil .ll also<br />
b®lp iu €9.v5.h:5 this warninK on aY .l advortzsing conducted .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
2021
•<br />
•<br />
•<br />
We support the Neuberger ltill<br />
2.022<br />
United Statee Public. Tbe lYea .lth S'er.vice, the phyxici.ans,<br />
the v.edi.cal societies, tho state dep®rtmonts of health,<br />
the vo).ontary hen]th aIXencios and other rrotqpn too numer-<br />
ouo to l .9st all reaogniao that cigarette smolcing is a<br />
health hr.zard . The dAagnuson bill (S .55f1) is a clear<br />
roognition by the Qohgress o8 our country thnt ci .garett .e<br />
smoking Yf.n a danGeron .^<br />
s and serions threat to health .<br />
While this bil.l) does not reior to ndvertieinG and l .enves<br />
the l•bderal 4'radc Com ni.ssion free to sot up advertising<br />
controls and re gnelations this bill is moving in the<br />
propi:r direction and the ldaho Department of Health<br />
supports this bil.) .,<br />
Nc believe two bill.s by the Honorable Walter Rogers<br />
of Texas (R .R . 68`5 nnd i .tem succossor H,R, 3014) do not<br />
provide for the Vedoral Trade Co mmission and other federal<br />
aQenci .eFw to interpret their existing authority to cover<br />
act.ivi.ty in t.ho fic)d of cigarette smoking advortisin g .<br />
Yn ll .R . fiS5 we noLiced the rorulation of advertising<br />
i.h given in tho title and purpono portions of the bill<br />
but tna],oc: no tnontion of ndvcrtisinG in the reain body of<br />
tho bi)1 .<br />
We in tho field oi' public honl.th have Or$anized state<br />
intor•-agr.ney committees on sraoleA.ng and hc:nXth ; conducted<br />
educationai pro6ram°Np written vo2unros of peunph)ots ;<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
0<br />
produced many good fl.lms a11d aUdio••vistial aids ; have<br />
lVitnefi3ed the 6'Lnte )3oaYd13 of Health adopt resoLutions<br />
Ag a i nGt 6IDo)4in g ; al.l of those netiv).tief7 are necessary .<br />
Ibwevcr, if the npproach nsed by the ifagnunon bill (8 .559)<br />
and thu NbuborGOi' bil] . (5 .557) arc pas xed with defeat of<br />
the Rogers Bi11r. 11 .H,880 and 13 .)t .301.d a big t:tep A .ll<br />
have heen t:elccn to r.ave through proper wa.rning nnd edu-<br />
CatS.oi tilRJly American WeE .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Your aonnidoi•ation to those pxoposal s is appreciated,<br />
Since re) .y,<br />
co/ ))on It . lByboo, Chief<br />
2023<br />
Health };duontimi & Traini .ng Section
•<br />
•<br />
ty 13<br />
IN7`X:RAGRNCY COUNCIL ON SMGICING<br />
333 Grotto Avenue<br />
Providence, II . 1 ., 02900<br />
Thc Nonorable Warren C . Ma€{nuson<br />
Chairman<br />
Committoo on Commerco<br />
United States Senate<br />
Washington 25, A . C .<br />
Doax Senator Magnuson :<br />
7ilmhurst 3-2950<br />
6"arch 22, 1005<br />
At a meet.i.ng of the Rhode Is9.and Interagoncy Council<br />
on Smokiug he).d on March 1'u, 1961 a motion was made to<br />
support Sonatc hi11 S . 5 2 '/ placed bofore the Senate by<br />
Sonatror idoubargcr . Tho n otion was adopted by a unanimous<br />
voto .<br />
Our Council fools, that it is quite important not<br />
only to provA .do for speci.9lic and mandatory viarning<br />
,a,^sea€ce r on every cigarotte package but that such spociffc<br />
and mandatory warning mossages should appear in all<br />
cigarette advcrti .sing . We feol that the effort to dis-<br />
courage sraok9rng nood» ovory moopon possiblo to combat the<br />
groat appeal to smoke ca Carottos . Of the three bills<br />
before the Senate Conhna.tt.e.o on Conmorce, the bill S, 547<br />
by Senator Neu,borger 3 .s: the stron gest and would, thorefore,<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
2024
•<br />
0<br />
0<br />
ty 14<br />
be i:ho nrost oxibctive .<br />
IVO hopc thvtt you will rcGisl :or our support of<br />
Smintor lioubargor'® bi .ll. with tho Sonnto COWneroo<br />
CormuP.ttac .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
65ucerel,y yours,<br />
e/ John Turner, 11, M .D .<br />
Chairman<br />
2025
411<br />
•<br />
ty 1s<br />
NEW CAS79,1:: COUN'1"M' JUNIOR HIGH CONt7IIUSNCF ON SMOKING<br />
Sponsored by<br />
iblaware Heart AF6ociati .on<br />
Dclawaro Tuberculosis & HcnLi:h Society<br />
Awori.can Cancor Society, Uolawaro Division, Inc .<br />
Dolaware L:ter -Agoncy Counc9l on Smoking & Health<br />
IVarren G . hiagnuson<br />
Chairman, Coswittoo on Commerce<br />
U . S . Sonato<br />
IBnshingten, D . C .<br />
My dear Sir :<br />
1305 Delaware Avonuc<br />
{qi.imington 6, Delaware.<br />
March 26, 1 .865<br />
i'ho Delaware Inter-Agoncy Counc4.1l tm Smoking and<br />
Health supporta: the proposed Iegislati .on as writt:en in<br />
the two bi.lls 8 .547 and 5 .550 . We definitoly opposo<br />
H .R .30).d .<br />
Our Ynter-A;oncy Council has boon workin(, with stu•-<br />
donts sSnce ].06'h on the various aDpocts involved with<br />
this E3e1'iouE hOalth pllehleID . We have hold four conferenceC<br />
conducted and plnnnod by student londers on a statewide<br />
bnsi.s . Ln the discusfsions, the quoc.tion of warning and<br />
advort:i .si.hg wan a!ways a maJor topi .e . The oonsensus of the<br />
group Icaderc: was that n warning on tUe packages and<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
202G
•<br />
•<br />
0<br />
ty W<br />
advertisin[; ,:tcor9.ntt an^ay youth ru,ulcN hrtvo aa dec9 .ded<br />
c:?fec(: toward thoir henA.th .<br />
'A'he attacheci rogartt i.ndSOatoe the covora€e for ono<br />
yotur as i .t p Drvains to youth .<br />
Ovor 30,000 studonts have<br />
p,artYeipatod Sn the6:e. ProCr :ure, St is frorn their reactions<br />
end si:atwnont.c: that tvo feo :l that somc form oR warning ehould<br />
bo placed on the packages .<br />
%n conclus:ion, the E1eYasiare %nf.cr-AGoncy Couvo4l3 on<br />
6moki.ng and Heal.th endorset: the recobwwnda.tion made by<br />
the hational . liater-•AL;ency Council as S.t relates to the<br />
7,oU :i€ :2at9.on now hef .n(`g caircur;sod .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Sincorely yours,<br />
2079<br />
e/ 7?rtmk F . Pierson, J ., Cha irnni,<br />
Ik,lnw'nro Yntor- -egency on Smuld.ng<br />
and iYeea7th<br />
8secutivo Secrotary<br />
Uc+davve ro 7utercu7.osics and goaXth<br />
Society
•<br />
.<br />
ty 17<br />
LNTLRAGP;NCY R.1iYtklT<br />
an<br />
SMOKING AND ItEAL'd11 P)IOORAAf<br />
foa' 3'A'ATIi Or b)31 .ANARFI<br />
Fohtunry 1., ] .9fi4 -.. FeUnpsury 1, 1965<br />
AMtaRYCAN CANCRac EoOC%FTY, Do).mmnre Division<br />
D]G) .AIYAIYIi HEART ASS(CSAT'YCN<br />
D1:LAIVARP: 'CpY:SkCIfIASIS ANU HEA .ITIU SOC1riYfY<br />
2026<br />
hoe[ttion Tyln of. AnUaeneo No , of FstSmated<br />
Pi1rn Aud9 .ence<br />
b'1?)3RUAILY<br />
Mt . P 7.oasant Sr . DiEt9r Yanol . Students<br />
BPaakor -- A . 1Proljch<br />
$'R J .OS /,RnUBI<br />
FpoNce r - Dr . )nnn5han<br />
Arbwn 'i°cch trp fn Stnolco<br />
:;poolmr -Dr.• . Gronf<br />
Epalkar -- Dr . Iannihatx<br />
.eld d'uvmsund BTA Yr^,aial . St.tedont>5<br />
Showings<br />
3330<br />
ColwyC)c Ie: Smolainn Worth I4`r 1 700<br />
Spealeer - Dz• . Wz)h<br />
0 ;;Ectovm Jr . High Ie. Smolcinn Worth It? 4 250<br />
J?• . lfigh Conforenao Up Yn SmoYce 1 275<br />
Spc ;A ;ex• - D,•, ]t . S a !np<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
550<br />
90
ty 1.6<br />
RranQyw$ne Hoa.lth Is Smoking Worth It? 6 200<br />
Claese:<br />
; Spoakar - Ur, tYhAt:ney Tape<br />
Boyn CP.uh In Smoking Worth it? 1. 50<br />
P,randywine Slvriu60. Is Smoking Worth It? 8 200<br />
Jr . ll9.{;h<br />
Chrietiahn.lligh fichoo7 Is Smoking Worth It? 4 400<br />
Howard Il :+gh Sohool Is Smoking Worth It? 1 4 00<br />
Spnakos Dr, IonnihEnn<br />
MARC H<br />
SuloF~ittrium Up in Shuoke<br />
I:avor Corp Is Smoking Worth It?<br />
0glotovvn Sr . ]iiSh Up in 6moke<br />
2029<br />
1336<br />
ciulront CO . hxpor5.- IIc: Smoking Worth It? 1 60<br />
mentul. 5t ,<br />
lYm, 1Conry Comh . Up In Smoko<br />
Sc:hool.<br />
P .A . ciuPont };S .E;h Is Smoking Worth it? 1 1300<br />
SponkeY ^ Dr, {9h5tnoy<br />
Cin .ygoni.lii.gh Is Smoking Worth It? 3 1200<br />
Spoakoa's - llr, AaF.'\YItF.<br />
l . A . J . Morris<br />
No . 80 7 0hHat:<br />
L . L, Iteuci9.n(; IIiOh In Smoking Worth It? 1. 200<br />
School<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
250
•<br />
•<br />
•<br />
Corpuis Christi Is SmokhaS Worth It? 1 525<br />
Spe aker . .. Ur . Vaudorvort<br />
Vctora.n'e llospitn .l •Pi.mo YOFYS The Y'rSOCOr l .<br />
6p0e9cor - br . Meflalc<br />
]4evr Castle County Is Smo]ciuVl;• Worth Yt? 3 350<br />
Workhour:o<br />
Speakor - ]ar . VancEorvort<br />
Forri s School )'].l. Choose the High ] ]25<br />
F.peRicfS` -4oC S loboj iftn ]Cont]<br />
Sussox Couni .y - 13 Is Smoking Worth It? 17 2587<br />
]CSgh Schooln<br />
(Spons:orod by Student Council)<br />
APRIL<br />
GoorOr.towu ]tigla IYp Yn Smolao<br />
Iurd Ita7.t.iaaoro High Up Ln Srmlce 3 &]0<br />
i>a.dun Floadrnuy Ya; Smohing Worth It? 1 400<br />
Spenkc:v - Dr . F . 0'3Ar4cn<br />
Oa2
•<br />
•<br />
•<br />
ty `1. .0<br />
L'aynsrd Jr . YiAgh Up In Smwlee<br />
hfnnUl - ))k, .AOllny<br />
Irr- SholLenberger<br />
DSSl :e Tfrown<br />
Conra6 kl .gh tksUool .<br />
Iorcd b olaPYxrr<br />
Oglcto wo Sr . llAg h<br />
P owC s Srroos.al 5cbooa .<br />
nsetrlo2 ;<br />
Yotortu}'s Y€os .pi:fn7 .<br />
CAaymoni. 8cbool<br />
A} .exf .0 L, t3uPor7ti IYS<br />
Up In Smoko<br />
SmokAng ou6 You<br />
T .2 : . S1i .@os<br />
Up In Smoko<br />
(iy'ieRker - llY` . .I'[dAHeE $OPfAJ ."2+<br />
19m . Henry C:omEprc:hon-.Acoeromb5 .y<br />
er.vo School<br />
INf .I.n.i .n(,Eon pc3>if.c Up lo Smoke<br />
ScYmo)s<br />
Iaurcl High ;:cHool. T .R. S15dos<br />
YF1CA<br />
Spoalccr •• ]ar, Ortwz Fmokf .tkC & You<br />
SyYGaker - Ib.' . IfG1'i'o).'o<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Rlvs, Y, E . Crorf:on<br />
JUI,Y<br />
2051<br />
850<br />
G00<br />
G 140<br />
20
•<br />
•<br />
ty ^•1<br />
XM1!C.A - V Mon's Club Up In Smoke 1 25<br />
Spenlcer - NAar7.in Time Pulls Tt,o R9.gger 1 25<br />
Yfowory<br />
!Do] .nc,r,rc Conferc,nc:c %fi S!noking Worth It? 1 110<br />
of Youth AEo©11biy<br />
19m . Mme, High :chool. Smoking &%ou 5 180<br />
CK:TOhY:U<br />
Hed C`] .e,y Pron . Church Up In Smoh.o 1 125<br />
Spc+rcke+r -Dr, k[offord<br />
Wn . Porna Iligh School Up fn Smoko ]G 640<br />
Win . 1'enn High Sohoo] Ti1m Fnllln The TrigGer IF 560<br />
Conrs.d HSgh Sr .haol. Uy; In Srnoke 3. 050<br />
Spenkor -Im . 7bi,xrda<br />
DSLT state Convont9 .on •.S7seaker -• Dr . Charles F1nmRey, 225<br />
Health lSdtlcatore: konn . State, Display and<br />
3.A terpturr.<br />
1'rosr: Ccnifersncc for Kent & SuFsex Cocnoty Fchoo3 it<br />
Editors eoo-shonsoreca by Nr.vrs••Journral)<br />
Sg,vak.ex° - Dx• . Hofford<br />
NOVR MDLR<br />
C1zEymont Ye Smoking Worth Xt? 1G 000<br />
ll:.ae,C70,•x• Up In Smokc:<br />
Governor Hxec,n Up In Smoke 2 135<br />
Hot!Yth Ck:nter<br />
Covexd5r kx,acou Ys Saoking Worth lt7 2 135<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
2032
•<br />
•<br />
ty 29,<br />
Ilea].th Ceuter<br />
11eUilfarr Time 1V 11s R`ho 4'rigger<br />
St . 1FhS.] 1ip's lath . Smotanl, and You 1 35<br />
Church<br />
St . Aiban's Atpis . Up in Smoko 1 25<br />
C:huxch<br />
St . All.inn'e 1?g.i .n . Sn;oking ated You 1. 25<br />
Churc.h<br />
Caosrzr' k6duey, ls fimokSnS Vlorth It? 5 ]fi0<br />
lyi d(:ovl J.le is Sraokin(t Wc+rth Yti' 2 160<br />
Mf lton Sraokin(; and You 5 9) .<br />
Soai'oxd, 9••lf Club Smokinl; and You 1 30<br />
Coni'erezce<br />
p"i'A INealtlr Conrai .tteo F7moking end . You 1 20<br />
met e.t h.cadomy of Mod.f.c3.uc<br />
St.udent Nurses, Up In Smoke 1 9<br />
Hi.lYord }losp .<br />
Delslea.rn<br />
Dayn.rd Jr . High<br />
D1iCRMR7)<br />
S mokS .ng and You<br />
]rs Smoking Worth It? 5 150<br />
fiayard J'r . kii .(;h Smoki .nC and You 5 150<br />
Mfddl .etown Hil;h Smoking and You 2 tao0<br />
Uni .tul. Club<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
3 in '1,0,000<br />
(borrowed f rom 7th Day Adve=nti .©t)<br />
7'imo Yhtlls 1'he Cx•i .CE;nr 1 75<br />
2033
•<br />
•<br />
•<br />
ISridgeviZlo i:chool Fimei dru] .Y.o 'l'ho fr•S.Y,Qer<br />
$r={
0<br />
•<br />
9:y 24<br />
SPJi1''Ly k1CAdQ'Ufi?ItOrS 1t'IYY .031 N(:tt': N0 . OUntiftY (liF•trAbUt :in(;<br />
point . A Y'Ga^31i.ng+ Ckt>41o \YaF CiFVCl.opte(7 $L lf3SC COop6T'Ut'2CC]y<br />
uitit tltc Sttao i)apartment of PoW.Sc 7us,tx°uct4on, Statu<br />
ECc :[ni tG .,Y,t3 )^Lye9.r,al }kioaat9on AsmaAati.on and the State<br />
172arr1 oi Hoa) .`ch . GUadoc+ aa•v stoc&od Sn the Ststo bepn'rt-<br />
)aut of Pnb]H Yn&-trnr.t.f.on, ldocclth n o ei physScal Ih.lwsti .on<br />
EHtd. ISA,VO ),^oA 4q;gnod to £ .Ll Fofin(14R in tb? St .'e,4G .<br />
rar:xr: ast:r -. ati.strtnstc e<br />
7Si:udout ;titoM= i'rom 2 .-L.W - 9 . . .A ...C4 26),tJ7.G<br />
F>tucterrl : Xk£crmi:vro 8trow B .-l ..f:4 . .. g . .l .-C;i 10, 21B<br />
9'oaehn,r's RcSoroncc 2-7- .C4 ~ fn .x ..M<br />
9 ..1-{in -. 2 . .1. .6:4 236<br />
Yne?rvs
•<br />
•<br />
bl 1<br />
LIAGAGIWP 1'UI3):,]ISIII;RS ASSOCIATION, INC .<br />
F2agnzAne Cemter, 575 l .oxingi :cn Avenue<br />
Wocr York, W, 1' .<br />
9 bs Honorable 19nsren G. Uagnusen<br />
Clttstrman, Couonittce on Cow;roroo<br />
Un .4to21 Statos Sonate<br />
SYRRh4nI{t4n, 17. C. 26$1G<br />
tly Clear Spnator tlal;'nUSCnI :<br />
E9nrNl 28, 1065<br />
The lla2nv.ine 1=r.ehern Ac
•<br />
•<br />
bl 2<br />
a'Oa' t1IP prodll0t . ThiF. &hprOAch in the bost way to roach<br />
the r.onrsunv,r, and i.t raRi.ntalne tho traditional dietinction<br />
betcm,en the functions of product labol.ing and advertising .<br />
Thank you for cc.nuf.doring our vicrrs,<br />
S :Lncorel.y,<br />
/a./ Claarloe U . Ablard<br />
Vice Prc&idont<br />
FA`ATEtAL;NT ON PROYOSED<br />
CYOARh"1'M`E: AbVERTYSING AND<br />
LAI}gy,ING LROISLA ;f1ON<br />
Ibfore<br />
CO:Spo l'fTBF: ON COblh9h'l:CE<br />
UNITIOFJ STAT7:dS SENATE<br />
k:y John lC . MYOrUert, Presido nt<br />
hfagar,ine riub] .Arhorr Association, Inc .<br />
March 23, 1965<br />
A'hc Rtaga o f .nc Pcil?lishort'i Aeroocf.ation in mr a 8sooiat.ion<br />
of =c hundred and nine magav;ino publf.ehorn of the United<br />
:tatcs Publi.rshinr over thrue hundred dif€or.ent nlagazines of<br />
general intoreret, laost of which accept adv'ertisillg, The<br />
1dal ;a,ii.no Pnbi.f.nhcrc Asr:oca.ation appreciaten the opPostunit.y<br />
to testi . :Py bec :auso among the quustions be4orc this Com m ittoe<br />
is thaf: of thc propor xroY.e of advertieing in our natior n and<br />
tha a pyropriet .c relatlonshit> which Edaould oxist betwoon<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
2037
•<br />
0<br />
b1.3<br />
Gcrvcrmnont and advert.isis,g .<br />
As carriers: oS advertieihp•, magarinon are f .ntorested<br />
in 9.er;l.olatic,n which afiectr advertising . I hope to convoy<br />
to you our vi .ows on thr role of advertising 1n the bueiners<br />
coumuiity, tho oxtont of industry eolf-rogulntion which now<br />
prevaale;, and the need for rertraint 1n legislating advor• .<br />
tifiing requirementF : .<br />
In our v iew the role of advertisi .ng in our nation is<br />
that at promc.ter the occnromlc goals of Our free enterprise<br />
by :<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
1 . Stinm lntin g product compotition and improvourent ;<br />
2 . Reducing oonr:umer prices through competition ovor<br />
a nc.tiorewide meu^ket ;<br />
8 . tlel.pinl, tho gz^owth of the oconomy, in terms of more<br />
3ob r and 6 :zroator national productivity, keep paco<br />
with the f ;rowth ef population ; and<br />
1 . Provf.ding the eoonomic ionndation for essential<br />
comn :unicntl .onr., media .<br />
2038<br />
F,dvortieint; ie a vital ine,trument in our whole competi .t-<br />
ivo prcceue, ti`tw rop,uUt.ion o£ advertising to require it<br />
tco rnont ito ahligfntionr to the public ie a legitimate aim<br />
of Govw^nmont• Tha : advortieing 1.nduetry recognfzed this need<br />
nnd p].nyed a raignif.icnnt role in the os,tablishmbnt of the<br />
Fc:dw'cl 9•wado CowmiE.rion which, in aocordanoo with trnditional<br />
,pudici.a.2 typo proccdurcr, her the authority and renponeibility
.<br />
•<br />
•<br />
bA 4<br />
to pwevont fc .lruro avd faAnloaciS.ng oAeoxt2nAng .<br />
2039<br />
Tlre 7r:ocSS.[r whSch dcpc,nd in varyin;x c3ol:roee: on advertisP .ng<br />
for sulypart or,nrr.2wo th :7i.r ,jndbsueart aac to tho propriety<br />
oa eau.y Nvort ieaom
0<br />
•<br />
•<br />
k• 1 5<br />
corrc :ctf.on of utmoen . it. hrsF, alreaNy rcuu .ltod. In chaugee<br />
£u poc7raSfng ilenign and aGvertl .cing, hoth nn to contont, snd<br />
n ;.l,ocl .<br />
The code hcia+ born In effect lor•e t.hun a yea .r . We<br />
ti0ievc that thc, tohocoo dndtlr::try shnul4 be given an oppot'••<br />
tunity to provo that rc7.4P-•ro€Nlut9on c:en be effoctive . Lnst<br />
yer:r na R.dvort .£ .o9u,. t:dvinory C
•<br />
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b? G<br />
the flSoGt CareflLY aE6cN9glOntt of ocionti).'ic 6vit#CnCO,<br />
r:tnt9ntica9t pro,yeotflons, p€ :ycho2og:y nul, judgment . This<br />
i .€< the vrif+c type ofaction that Qangrorf ; has• taken regardin(;<br />
SS.al01T(tb2.6 pro[1VCtE, V!(rox e llC, and drll({Et„<br />
A raryulveluont the
•<br />
•<br />
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R Y . Y .<br />
11FdY'F~'A'1':k;HA' o}' 6YAY7 .1'Pl .<br />
Statr, ngM1?tr,VSnnci<br />
402 W . PridxtoP£ F:trCmt,r lA . S.t .Susol^o, McF .<br />
7,'iar: piouoraFiYa tias•aRn tF . IdHt"nueron, ChaArr*,aa<br />
Ccm+.wl .t:too oea Co mn:¢ya.o<br />
i.i• ., . .¢:m ;,.to<br />
L9c n L_ington 5 s , 1% C .<br />
li ; ; ;c r S i?r :<br />
p.lnzch 11, 7.SSi:<br />
'a'k.C R#xrpY.crm9 C:otr
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http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Vcvy frnSy yours,<br />
/h/ ISay K, Lawa),•c6c<br />
[CHy R . L "" wktrtt«, 6M1 .Tl ., M .P .H .<br />
Cic9.eS', llfv3r:Aon of Adult<br />
}y; I e,YCL fio xvAqcrs;<br />
Chias.emar l , ;dtarvler,d Committoo<br />
OFl s 1 u 01AAS g~ ftlil 1 liAfi~ .~a1
•<br />
•<br />
'A'A~i Ck~tlr4d(YNVY~AI'd4i Ol~ lUAC6ACFiUSk ;CTB<br />
27spftrttncnt of Public henkth<br />
U9v4c . W of Adult fioulth<br />
170 hloston Gtrcot<br />
dnmn9ec4 ffiT1cAn, tFasnaclwse4.tc,<br />
Bonetor N[t yso n G . Ffia,gnu o on, Chni ra rui<br />
('o1Alf4:3'c'e c fnt!Ildttoo<br />
Seneric 0'2ico ]?eiildin(:<br />
Yrur,h kng4 .on, 14 C .<br />
]}eut• Honn6os 18nFP~usotr ;<br />
March 8,<br />
An 'sho govorn mont oS'Fi.cSnfl in tho Com monwenlth of<br />
Mar1n a cbee
•<br />
•<br />
hlx<br />
SG'.nfltoF 17kd'%'GR C : . p:11tr(;nloon<br />
Cio:dnK+r'cC COL1ttLl't.tlee frhEYir9ntln<br />
Dnited etctee. ::3nato<br />
Wnarh9,nEton 7G, I) . O .<br />
IK+flr F;tenL'.tor }IAf;nuGot! ;<br />
S't'A'8'P: Clx' k91Nt71SSOTA<br />
Y1,t.r,rtnrrouf. of i;duoat9.on<br />
CttrrtonninY Offico Yaul 3, 6!innrE+otn<br />
t.lflrch ].7, 1955<br />
F'o ra.ro g.aoac.od to RoF.rn thatyou nro npon£aorinr fl bi31 .,<br />
S . 6u9, for tho purtaooe of 1aboYlnf; cigarette y,nckngon . The<br />
E~eppGrt: t'.hat SGn[ttox IdE!ubP.rger la f•;iving to thi.s: 6orioun<br />
pnU1S.c henlth pxoblom 5.4 nYeo mont OratiSyiug<br />
204&<br />
.nce tho Surgeon B.nn,rnl's Pu,port un . 6lnokingnnd . Si<br />
Health<br />
ovcu• aa yc+c.r ef!o, ts tatai:e i.nt,erngency comtni .ttoo on r,moking<br />
nedd honlth 0t±s: bcon orfarni.zed . The Statc I1Myrartmont oY<br />
L;ducn.t9.on, Steltc S1oEalt.t, llopnrtmont:, 1linnomotn R7adictel Society,<br />
P :.i11nuHOtks, Qancetp SoeiCty, PinneEtotH . IIL-art A£tEto[a.ntioll, bind<br />
tho E!iruxosott! 'r'uhercu7 .o:;3r: nnd Hefl3.th Rs?nocintion nre<br />
Yef1rGHPlttpd . A'hC t41nn©Eiottl (1hapt:Qr of the P'tltnr'G 1''6MnIPrc<br />
e .¢ A)iiCF`)G(L hn.F. Ql£:e . (;'J.verl E :utYFioY't to thiFi intUr'Af?:ency e:On,<br />
€ya .ttNE: .<br />
fVAtsiAy, n ser£cs oi:' iois;crvi.cc oducationnl cli.nics ou<br />
7nbnoea )ideeorstion havo Beon cemciuutod ios•• c.lcmontF.ry and<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf
•<br />
•<br />
0<br />
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oocondary schooll todchcrr• . Tho attond,aneo at those onc-day<br />
clinios Peas bcmp exco21 .on9 :, which i .r.t%icates : the intorest of<br />
oducatovs in tho prok .lesuv: of smoki.ng and health . Other<br />
ednotitionnl proj,A'nmq ti'411 bco developed for the future .<br />
Hb b*9.ievc that odncatF .on can make e significant contrA<br />
bntion to tixie : publi .c hoalth problosn, bat i<br />
'1.048<br />
:d by other rzoane, or r~etbodse .t must be snpplo-lnontod nreR r,'upporte The propo ::al<br />
to labc 1 eitrur,atte paol:aees c:oncernint: the hoalth huzards<br />
of sutokk .ng wronlc; be a vory vaYi!a,ble adsunc5t to a continuour :<br />
public heult.h aducnti.oh prograxa . Tho kodoral Trado Commiseion<br />
should bc RA .ven the nutdaor8t.y to cont.roll the tuivcrtising of<br />
ciy;nrufaev u.e rnee inon.ns, of hnvi.nt; a continuoue program .<br />
You cc.nco+^n ubout su!okin(; and ho&itb is very nn!ch<br />
upprociabc+d .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Sir,corely,<br />
/s/ Fnriey u . r3ripbt<br />
A^S1SIANT CO19M1SS1ONI+.N
•<br />
•<br />
•<br />
k~l 1<br />
Senator A;Cwauvl V . LonA;<br />
lhr} .tr.d 8tntos Ss:nator<br />
Hsnntc Of'f'ice 1:n9.Y.dinr<br />
IYnehanl .,ton, U . C . 50024<br />
Isas S ;oiator S;ong :<br />
6SXSS(IURI LIROAUCA8T1:YaFz ASSOCIATION<br />
15%1 hast Nigh. Btroet, J'offorson City, A9ir,courA<br />
lNdreh 15, 1965<br />
P'ik'st, Y.icaeo accept tho aratitudo oR the Nirtsouri<br />
Ccroadcnatorr: Aeaocf .ntf.ou for the fnvore you have r:hown us<br />
In tho l,nst n!.lf, the i.nterast you contf.nue to display in our<br />
incluntry . 7`hcy Yrs vcry much npprociatod .<br />
Now ngn9.n, tvc cn17l on your holp . We ca11 your attontion<br />
to thc rrcont B"i`t: r.•u).nug concerninF, the wasnint; uiernsngoc to<br />
be oaasiod on cigaretto adveri:isi.nE ; . As you know, unloss<br />
further rsctlon In teLC:n by the Cc.ngrocn, by the courts or<br />
1•y the Noderal 'Prrade Comm insioa, an YTC rule wil .)l go f.nto<br />
offoct on ,Yulv 1 of th9.n yenn• which willI roquira emcrng other<br />
th.`,a4;O tlra.t a lahol bc pltaced on onoh pacL : of cigarettes<br />
r',nd Lha.t a r:tntoment. Lc Inecn^pora .ted In oig'aretto n[7vor tise -<br />
he,ntF: Aa nll undi.e including radlo nnd to)ovision .<br />
Un7.c a :: ths W 3ng Ps; ae.e+cindod, ft will require that<br />
onr^ of the Yo?L10%ill[; r[ta..t(:NUnt s apl.E+nY In each cigarette<br />
commarct .nl on r [:.dio and, tolovisi on : (a) "CAY/'P10N-••CIOAhHT'Pk :<br />
F.MO1qNG 1R A 1lF,AYA Ft: }iAlAkli : 'Phs Snrgt+on Goncral'e Ar1viF:ory<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
ZO@
•<br />
.<br />
Connafttoo oxti aaolcYaE• on } 4 r,itb har• ec.:,uC . -h.aA nig :arc:tto<br />
Evnoktiag contr ;hutcs strsh^Rffiv!aall to Gio!ri2d co1 . :(.'k9 .'ic+7r 4~Y wUdgiriq ;:<br />
fbe cyu„"•.A2a OT tdhe pacti:.ttct . TauiiYloDitY .iyr a baroadoa,nto•ei'<br />
x•or}.toasR.h ;.Z99;y c,Ucs+Pn u, cftct,xtiSowOni :r: M F1eeu *ii^.t t.7aQr<br />
fa'aa2 £$ ~.CCtahPr :ei u'A F.ouocaty, S'a'rz°taci6'G {tT?A PppB t^uYte . {`2 ..e2 .: ..g<br />
.lud . vs>st on tLr =t . :. .v r .f ^,fi;v :'.9rod ri^c , fr: i'or Bnyoalt7<br />
4Jor °r^, .Irc o° xhe brai : .a :aeSs3sntil 1'axORrM .cnzi .<br />
Yn ndc73j:i"oA, 4k;e*<br />
r+c:op, r :IO o .nsirrraea.s.y bAra:ar,` i . : : cE007rdncl iry '<br />
rciavs ^I_sm t t, a;e ry of Phe . arormcenrt .<br />
;a ups5'n'br tr, iltcr ptthlf.o 6 .n that<br />
fhcra r,.rcriiiSC:r ;.apr vntlioa.7l vAevv on % : r:ubtcrot, Alro . 11<br />
(1fEiCS'?llt7mC'r.er,d tgc9atc .c the], :v-c.fl:r,ltet Ir[3d'i .a., 7Tieatrei a(IVer-<br />
tir,otv,trts : eM ;YCi c,s>;iry tho L•.li,A In ruc+h an«;8 . .'l tyym m .o to<br />
h e _:navcie.iri a , •rt¢:xn ; N * . car4oec5tsr .g orvalf K 4 M ff; Per . ' r<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
.i ov t1_r , te 001 7 6 .,_ •~nqsccedon9 .ra K c:ua, o£ aman<br />
4 arnr S~u .~@ M in roza ~.£^9aeg tF, r r tc. :a' x .r} siaus=l . ab 5a %r'C "~<br />
2048
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•<br />
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%ri.Y? hs Pro•r.C (;rc,et7y Gnd, mc. wflx<br />
FAj?jnt/'4 :AGC; pQlaP' tlil•?&ti.U,: vu q5' YtlLlI £OE+) . :P.L[;d". 1J1 Gt2S 1 :92LC$BY`„<br />
29YPaPk y0u .<br />
G£m::oso7l~~<br />
/r,/<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
Os'9
•<br />
•<br />
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bA 5 .<br />
Eiotrox•4th7r: Fieam ot . (d . A1r< gnu ::o n<br />
Cp m ir•m~<br />
(,`QidYdYttE:e On UGL^iNFY•CG<br />
Ylug.to
•<br />
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.<br />
of tbe Eo :cintcf: enf the k7i.s:'trict of Co7.umb£a, hxgeniserd<br />
i14 lfif@i, t}AQt MFI/1 tOlrft.y y'o(,voUCkntE 6ioro fban (",('(IC/ ncVl :)¢$ .iX3r[3'<br />
of thnf ;ct f+os•o Wn SyfaQpl eFro UoektAcis, mcwt oi' the ret
•<br />
.<br />
•<br />
b) 3 2052<br />
hut- svonlct po :=e a ca}r,+cACi :t thrcat to ottx• nntion'e : froc (Aroni,<br />
rn af.gaa7Afj .cfrnt r :ogaaont of Lvhich i,a roprarented by the mornbcrc<br />
of our A.ec:a :9 .nt.flon, Pnvoductt ndvortis+ing is our mombcvrrs'<br />
ceox,oanAc: :aifebinoci, and nP snhstdnt .f.x7 vednct :ion In tatch<br />
advorticinlt e:ou :ki obvioue;P.y ilnkxarik our nAawboa•c' contS.uucd<br />
er.iotc:nccr and lu.do}xndonce .<br />
In ondorcS.nF[ the rtgsht of Antsinofl sutefn to ru,vortisa<br />
oAf,ec.Uvco?.y any AgaA product, thr : )',trstion,al Fdf .tor :.a7.<br />
IA^fioe2lltACRa, G$ e(NBYf :R, doOfi 11ot a[iVo0t1tA3 dOCC+}It1.vC a•dVQI .'-•<br />
t+avin4 cre e ;uy6o ut that ar, risCht, to au9vesrtfine doccptf .vei.y<br />
eNP.iltf :, . Our I:Bf:OLY.ht4An htiE' COO :B4bit(Ant[SV fought Cihcp}tti.vEl<br />
ndvor t r.rsfini; . Selood, lwo hexvo c .ften nct:od a n s kind of "ftottor<br />
L$uCni{Iflflr ; fIl1P0a11 " ]ln hP.tpinl : Oltr P4onthOkFi to @NAkd aQainHt i,nftd•°<br />
v¢>.°tonCl.y acoopting daace pt :ivic edvortzsangiri their advortfsr .ng<br />
ofS'11n1Afi,<br />
YBoct cortnan).y, &owovor, ssn; do not r;ubcicribc to tho<br />
notion tha:t advcrticiug rrhich feils to r.ot forth poncihl .o<br />
nrr;aercaat:a tcpyaier.•t ueo of thc ndvcrt.3ocd parolluct in ftil.ec or<br />
}naulceclAniE= %t,tiood, r:houZd p,overmneuit prelxcym3 to dictate<br />
to nGvc:rt.P-nors tho c:otltont o :f their f9dvertf6inf;, 1t wou7.d<br />
trond upon rAnks,c thatt nzao axot or ;Zy 7,oaa};.noooYit.od hut, In<br />
ovr• vr.en, canxtitataoaarxl .]ly•ganotoe.COCi . We bolfevo that the<br />
rr :iyart to advortzaa Sct,Atirnrztc 7*rtS .cal.c:n of ooinm2rca, in ae ;<br />
pcseunn :ivc tortou ts poc,nnhlo, In a necer.nax•,y A.uoident to<br />
thc x1ftM to s(e :L9 . Mg8'r.fxaato ra•ti[:1o :, oS ctonovo
•<br />
•<br />
•<br />
bl 4<br />
08 cour.se we app l.aud tho efS'orts of any trusl .noan group<br />
to reNt'Llxto ite own aCrvvxt,fier .t,ry, . In thifn coxubectl.on, we<br />
uotr, tha :.tt ci!tarcrtto taanufstcturern 7.ant yoar adopted a CitCe.r••<br />
otte A@ves•ti.gi.ng Coctce, v^hieh bec+u}7e offiaially effective<br />
on .aU1nRk'y 1, M : . In otxr HOCiety anG Hef»loliy, Ftllf-<br />
ro(ntils.tf.on hae trndi.ti.onn.l.l.y treon preYerrreci to (;overne,u¢t<br />
:(ntorvent9.on . Xt wca+16 be particulerly rogrettable for<br />
cotnpul.sory u&nePt3einlq wnrni.nige to be iiapos :od at a time<br />
wLnn the c:i.,;arctte i-nGus,try has t.akan eotcspEV to ref ;uln-te<br />
i .i:ec lf .<br />
In cxpresr,ing. our eppot ;ition to the advortiaang pro-•<br />
vicvionu oir 10, fr9V and the ffi4'C'ti "'i.'raCee Relaulntion 1Sul.e", we<br />
wSsAi to Inaho Mar that our Ar,ecrrir .t4.on hns no viea on the<br />
barsie eo9ontR.isc ie. ::uoc it?vc .Lvca9 -•» i .e ., whethor cfgrsetto<br />
amols2nE flc, or is r,ott a asip;uffi.cnnt, hoAlth pr•oblem . We &lso<br />
7DG3<br />
wish to F)'GntC ihilt: t"e take no po£+'iti .oll Whntn
.<br />
III<br />
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q9,c L„narrb)r We*'Yon Pnocu_ou<br />
CYic.oa~r,m", Owr-nt.ua• o) G(r, .crne .<br />
1&iLr, :(i }=i.(ttat- liohk .ia<br />
I+er,ldngi .cw, P . 0 .<br />
)r( w . , Vcmn6:oP Aia y nnenn :<br />
COLViC,iPltir,A ;l/'It (l' )T?VRti17NlIRTR<br />
!uxK1c99ONS' (0i+ p ;t:T)8't7<br />
l :n,ri ^l wrP.<br />
7?] :+0 b".a"cH 22, )gli6<br />
!n s pfti lro :-i:)±rttt:p : the olsi .niotr e•e out i?rce:oc5at .iero<br />
oor .ccrn5nt" V WD W 8 . bW 7Lesc lulln new oosmer-noG<br />
u:it.& Fa ;te:r1 :1 ;crye,ircmmtl4s ; S'uyp elt :raz :i .f.s, i.nhc:7Sn(: r ;n6<br />
D.F\T1'tiPipr FEtr(; FSE bL1G :Cl : )+MiY` t'bm:9 .t£00 q)1 (_:CMpABFCO 1CG1'<br />
f:9l j4F QW t--bUP1 , S .'i .Spr; (t f l;,bihi':iOn, Oodp(,BO :i<br />
oi the W?£pa (J'lfe:ox~ (i or.oi, e.io.be- tmcl onoh torr9tox•y o£<br />
1 .he 7qiii .oa Fa Ic•, p ;+< :.ob r, t.o tJio cffcet<br />
'ibflr t-tt .,c cnt Wc r,a S,rX,(t i :: ; plovoit bc- Oidi hkysr•d<br />
ilrr t, .t^£" W F11] ( 10, .; I ,'i n 6H( ['fc_ tIP's'i .
•<br />
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A e(=py c.; { .LC Ar :c .ao5tiion a'obol,r,rav .nJn$ :ic,r<br />
h, vi(n oi' t),0 :C(tai . t .hrci onr n •'. tnlarli-wrsnsoiv<br />
F-. . - i:(i tlt( d RGi.o11t£i')(, Ol`itiL)'.rC{ '. :h61YF: Ih L Cl.gE3`Ot .LNF: L1'O<br />
i./e tr(ri',li a W581, 6vsaar•F ., tre, v'api)d r .i1 ::o 4o bo on rr•acrrd<br />
(i -,ippOSK'f((, t :1+.0 t,Vi a O) {'C(i(Fhl . )O( ;M . :.3 :Ii .iWl CIRhD(ii .Of4 31,<br />
6 . .r .O (r ` : . .If'( . 5( See) t)r t ti.( : itvtj( .iR1V:P2 leFl6at'(1.S<br />
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http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
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tadjacwnt to onro anothox on the bcnPo Ho ri.ng .<br />
http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
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http://legacy.library.ucsf.edu/tid/hly24f00/pdf<br />
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