unifrib oktttrs ocnMir - Legacy Tobacco Documents Library

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['1IiP unifrib oktttrs ocnMir 

R eport of Proceed i n gs 

Ilearin g held before 

Connnitice on Conuncrcc 

S . 569 and S, 549 

. 

l3IId,S TO It1iGU1,ATLl I .AttE1,IWG OF CIGARI{TTk)B 

A1411 PGlt CPPISi'sR PUkPOSBS 

39 April 1965 

AD1)SHDU7d 

tlatvrlal submittotl for tlso record 

Washingmn, D . C . 

MONICK-SULLIVAN 

OfficialReporters 

415 Second Street, N . C . 

VOLUME 

Washington, D . C ., 20002 ioiovho- 

54i-L4Y1 

NATION-WIDE COVERAGE

a=1 ] 77.7 


u . (il'1(i ia . iY((7 . 

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 

t.l7k~k4n117Y~t3 

Ur. :IR.eF 06cAe,e. Sere.to, 

Ca :unittUts on Co¢nme,re,o, 

~Y[a~lika~;ton, IY . C . 

tfntorS .eS sttLmi4.ttr.tA for th.e rooor0 

'xYiur§Gay, $ 6.pri1 7wG8

• 

c'o N m°ii ~a 7-~ 

slvre]SMEaaB o;^, PAG$ 

GoorEc V . Gllen, 1712 

]SrGEr£ii0nt., 

The 2obaeco 1nc;ti.tute, Inc , 

fV9 3.] e.rQ 11a .lryuiplcv, P& .ly„ 1735 

Ilfx•c+etor, University IloaAth 8orvi.coei, 

PrS.ncotoiz Unive^rc:i .t,v ; . 

Colun!hia tPn£vorsity ; 

Aweri.cen Co1i.cIs+ ]4ca]th Ar)r.auintion . 

poNi .tt C . DituRBtry, Gi .b . ]737 

050 Wo,^thwes,•t Tcent.h Avenue, 

IDiami , hl .ortiria, 53130, 

1lmmenuel . 1°erber•, 1.1 .U„ (telog .ara) ]780 

)acprcrtmemt of Pntho)r,Ey, 

University a£ I'7 .ttai)ur(r,h . 

Jac:k AS . )rzz•r, is, A9 .1.Y,, 1740 

1127 8'i.iFh£xo 6oulevaxU, 

1•oF. F.ne'e1e6, Cali :forr$n, 

3lOllsEII' V . 11RCtk.e19„ ]u,J1 ., 1748 

36C 8tincon a;u4lding, 

SiDatt .ie, ICF,shin[Cton, 06101 ; 

AmorA .enl Co1.lege of Radi.olo69 . 

1'oz'Gin;4aQ C .. XeHM, N .D ., 

St . Lu4re'c: ]!ocspAtal, 

Y ;tua€:pr, C:i.t,v 11, I?ir, ::onrfi . 

1, t?.:nry Gnrlailti, H .b . 

8 . R . Groemro, EOJ, 

1'ele University ;r,hoo7l of IdoUi .oi.ne . 

1

0 

• 

c2 1719 

STANlf60?N1' 01P : 

MNTNNTB (contAnued) 

lAuAe. A . l.eovio, 61 .ll ., 

Rhode Ivlnnd Noel :•i .tn3, 

Provi.dence, ithoda is).and . 

Son . Jetnoes ll . Cuifllon, N.C ., 

1'irat Vii.htrict, 'A'onncar.oe . 

1COnry Easton Lfcbinhou, 67 .D ., 

NGW YtlXh, NU w York . 

rnn ttmcdc.nald, DI .D„ 

Yhaivor+.+i.ty o7 Sont.hern (:nXiforni .n . 

)r.rnel Rappnhort, Hi .D ., 

)eP1).cvuo Horl~dtn7, New York, 

it . N . l,i .gdwa, F1 .D ., 

Cin).vG6to0, T6y.R s , 

Nrrcodcric V? . )3i .p7qv, Jr ., Si.D„ 

Proei.dor,t., ithodo XGlnnd Division, 

Ameri.c:nn Cnnccr Soei.oty, 

333 Grotto AVOntlc, 

Providenr,o, N .) ., 0'L906 . 

Ano ., 

PAGE 

1.603 

1807 

1606 

1616 

1632 

).86). 

1662 

Milton 1; . Ro:aonb)ntt, hi,D ., 1664 

).040 Pìfth Avoouo, 

Now Yoa•Y. 28, Ncu Yorlc . 

ShoHdcrn C . Bumtr,ora, M,D ., 1927 

llr7 .lefi.cld NoripAtral ., New York, 

'Cheodor 1? . Storlini;, Pt, .D . 


Johu 'lrurnor, lY, d7 .D ., 

Chn£rr.nn., YRibli.c X:uucxtion Ccmmittr.o, 

ltlwcio l,e,lond DAvis£on, %nc ., 

Amc+rAc:an Cefic¢r Boeiety, 

333 Grotto Av enue, 

ProvSdG•tieo, R,) ., 02000 . 

1033 

A009 

Chn.rlcs : F . 5èt< :, Jr ., N .U ., (2 t.clcgrnnic) ) .071 

lYniverci.ty of Nzemf. School of Afc:ctic.i .ne, 

JxcAaon 1Aru,oriul . kloci,i.tnl, 

F')ori.du CownStteo mn :rookine nnd.IHoul .th, 

A7Aatai, Yloridn .

CON ;NTS (oont4.nvod) 

STATI!:rAS1YC OF: PAGE 

S41Yinund L . N'ilens, 18 .D. 1973 

ORCANSZATIONS ; 

Advertisiuir hoderat9on of America, ]977 

Mark 1' . Cooper, %'resident & Gcmoral MannBOr . 

American Astociati.on of School Admini.strators 3,983 

1Forrert E . Corener, Sxocutive K cretary . 

American Cn uoer Society, 117.inoie Division, Ync ., 

RoOer A . Harvey, M .D ., ProBideut . 

American Co]]eCe Hoal.th Asoociation, 

Worea D . YoaOer, M .D ., Pr®nidcnt . 

American Dental. AnEoe3.ation, 

Howard J . Niedhnmor, D .D .S . 

Auwrican Newspapor £'uhlishors AESooiation, 1992 

• }d . W . Arinisteu.d, 13I, 

Chai .rmrn, tòc?era1 . L .nv/e Com€ni .tteo . 

• 


American 8cdnool Heulth Association, 

Perry J . Sandell, Prenidant, 

As:uoci.ation of Nati .onal Advoatisers, Inc ., 

].6G Suet 44th Street, Nov 3tor1 ;, N„Y . 

13crgen County Phar.iyaccutical Society, 

Walto,r 1" . Nrowninly, Sr ., Prosident, 

36 N . V7e.ehinaton Avonmo, 

Dergenf9.o].d, New Jersey . 

Cancer Coordinating Caiunitteo 

of thc, State of 4lawhington, 

David 19othony, 1d .D ., Chni .rraan . 

Co].orado Departwent of Public Heal .th, 

Roy 1 . . Cleoro, M .D ., Ff .P.H ., 

Director oR Publi.c Hcalth, 

1985 

3987 

1990 

1998 

2000 

2007 

2011 

2014 

Col.orac3o 'yuboreodosiea Aosoc:iwti .on, 2017 

rioneld A . ltiller, 8xecuti .ve Diroctor, 

1033 Vino Streot, Donvor, Colorado, 80206 .

• 

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e4 3721 


CONTIutiT'S (contAnued) 

07Y17.'E;Oftr,Nl, 0'C: MAGF 

Cotinect}cnt. Ile2lth Lwr,OUO, 7010 

Iff.ltor. Geyor, pacsAdent, 

%de,ho Del)nutrac:nt of Hen.Yth, 202.1 

Aon ii, knyf.)on, ChfeB, 

Honlth Educuti .on & TrxAni.n(: Sectlon, 

Rntnrag:ency Coanci.X an F4modcd.ng, 2024 

.7ohn 'Bur•ner, X}, ris,fi„ ProvAdenne, 6'c .I . 

77op,r Cattti.< County Junr.or HABh ConYCrm7co on firaokin6 2026 

Wnuk V . Pinrr.ar~, Jr ., ChnArmr+n, 

b11iC1Y11_nQ 1'Uh1k9nUrfY A6/~Yoe$fit$On, YnC ., 2036 

Q)hnrlah U . AbScirJ, V :l .c:o Fh•osfdr.n9:, 

Linx;vA 0 n6 Dep PrtMon t of Henlth, 2042 

f;,ay K, Pldvmrde, ff .U„ fS,B,H, 

L1us.rtma•.husei'te Dogm3.rtmont of Yuhlic fXOtalth, 2044 

k'M•unb. W, Hopnaldn, Ft .D„ lli.rec:t.or, 

b1:InnbHotE1 f)4`pkl'tE10nt o$' PS($IcntSon, 20Q6 

har7 .p,y n, haÂS.ht, Av:nletent Co.uialv;.r&nnor, 

mi .se:oo.ri BxotadeRCtorm AoeooeRhtAon, 2047 

tlonuo4.h W . }Eandy, X+xcoi.dont . 

fiutiaaiaY F.d4tornn5 Asrmcil.ntfon, 2050 

'Cheodoro A . SernrAXl ., klxec . Vice Prosi.dent. ' 

mnnsylvanir . I,cyexrt)xe:a)t of Hoalth, 2054 

C: . 1., 1V?J.hav, dr„ 6i,11„ Secx•ethry of Health . 

'Phe knb7.i.c blrna7.th Csncer Ascvoc9.tetAon of AmerAon, 2058 

John F9 . E.+?n, Jr ., p4,D ., Paêeldant . 

Sottth Cnrol9 .nu 1)eg,aztanc.nt cy AgrACu7tnro, 2061 

Uillknrr, C . Hcrrole:on, Coiniuis[s4oncsr . 

'tobraaco Y?orkoa•c Xntcrnat4.ona1 Uuion, !a'),•430, 2003 

J'ohn 0'Hrzre, Pron.afont . 

Univcasaty oS 5'oronto, Cantrdn. 2068 

UraF9 :9.nTton BCnto Ficpr

• 

• 

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ty 1 

6'J'A'1'14hILt1Q'C OF GI90HG1S V . ALbRN 

I+7C7t6YD&>t'/', ~`t[ii tOiiACCO IWSy' ;(Atl'CF., YhC, 

My nnm2 in Goorf.'o V, A15on . ?aui ]hro&idexat and 

Iixcentive Dircctor of The Tobacco Ynstituto, Inc„ whose 

weraberc;lrip Aecomposcd 01 S'irons which mFUiufucture and 0013 

tobacco products, i .ncLuding the nui:ion's c.iga.rotte manu-- 

TaetllrerF. . 

The Ynst3 .t.ute tvac: formed in 1958, cwith hr.adryuarters 

in 19ashfu(:ton., D . C . Its 5:irst presldeeht was Mr . James 

R . lti.ohards, a d4.stiuguAdcd momber of the Congress and, 

Cha-irmRn of the COGIDtitte2 Gh I''oreign A fQaS .rs, I had the 

pr4vi .l .cl;c of succeoding hz,a on rny rotirerunrt from Govern- 

Llent sGTVice four yeftr[: U.(;O 

tobacco ind.ur;try . 

. 7 11on1 

.Q l i.ke to d .'Yl.cnft[s tt+day varieu s aC

• 

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ty 2 

cxistence . 

In the report by the Surgeon General's Advfsory Cow- 

ttec, there is an important questA .on posed which should 

be of i.ntoresf: to this Cor.miittee . The report asks : "What 

would satisfy the psychological need s of the 70,000,000 

Americnns t To rsmokeiw in 1!9H3 i£ they woxo suddenly deprivcd 

of tob a cco4" 

The Report €foes on to say that '7dedical porspeoti .vc 

requires recognition of r :i€!nificar.t bonoPicial O effects of 

cmokS .np, primaril.y in the areaa of inental health . These 

benefits origina.tr. Sn a psychogenic search for contentment 

and are moasurable only i.n terms of individual behavior . 

Since no means of quantf .tating these bonefits is apparent, 

the Cobuaittce finds no basis for a,judgownt which would 

weigh bone ;.its versus hazarde of smokin€: as St may apply 

to the general popu]ation,•' 


As thit : quotation su ggests, the que sti.on of whethor 

to F391OA:R or nO t re{Yiai.nfJ an individual dPGisiAn, And, as 

1 hixve said, the cSP;arette industry cmi.st.s to meet the 

desir.e:s oY those indi .vi.dualc who choer,e to emokc . 

In doing so, the: industry also p rovides a livelihood 

for imSllions of Mneric:ans . While thiei Sr> significant, 

we arc 01 aw2re thatt eauch consadormtionr, ennnot be al .lo wed 

to outweigh questions of public health . However, job~s 

1723

• 

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ty 3 

nnii S.ne:o;ne e :ro ha?^dl.y ir.•releva.ut . They axe a necertsary 

hae.c+ for a1l the othcr l :;oals oi' our nstionall l .i£e, i.uolu- 

di .pE• heal.th, educat:ion, and, ul .t9eiaat.oly, the F.reodom of 

the, Sndi .vidua7l to rna'r.e c.ertai.n choic.os i .u lif.o . 

The ConGrosr S.s charged with the rc:sponsihiYity for 

determ+ .nin(; what 7 .eiSislatxon rnoelc thr ovoraYA public 

i.nteref.lt . TG deterat?.ne 1l'hat the Ovf.làl .l public i.ntereUt 

is, 1 cifn sure the C:on[prcrs v,A .ll riant to consider al.A the 

factcf, and to try to est.ima.ta : the Sm,pac t of any propoerod 

new pol .i .c.i .rr . 

In thS.s: convfoctAon, the trobveco industry has y,ivon 

long and care'Yu1 6onCiderat.P.on to the i36port On SH :'&ola .ng 

and 1[cal .th by the 5urgoon C.onorn.l.'e Advisor.y Commflttoe . 

A'ho andustry Se c.onv :i.uced that mnch more needs to be know 

about the poss'ihl.o relat:i.onuhip hetweuu sruols9ug ; and 

hea.lth . Coneedu .ntly, V/e hel .ieve that any haflicy or i .lla 

CoOceiWed action V/oul .d be unwarranted at. thin time . 

$flnce nufEProuF f,i1G` :iti_ons re(¢3 .rh'in[; f ;td0$i .n(( and health 

rcmmazu to bc : reso7.red by the &ofenticta, St follows i :hat 

any P.'overnrr:cnstal ac.f :9.on In this field fnust be er.arnincd 

with the greatest care lost it he prefnx6urc or Sai .l to 

In in the oi ,cralA publ.ic, iuterest . 


What arc the faote: about the tohacr..o Anductry that 

e?hould be trlcen into accour,t In fornnelatiuic Roverhmentaa 

pol9.cice? 1viot+,l .ci like to s troso three aspec:ts of the 

1724

ini~!ur.try . 

First, it i .U a ].n.rC .e Wuntry, sorvin£; rnore than 

70,000,000 Nb.ericanEi who uoo the indur,tr,y'r products . 

Second, St is Qne C?f t4bi : IOor.t S .InpUrtant to America's 

i.ntc r nntion al trade . 

Third, it is one of i :bc a?ost productive i.ndustries 

f.rom the tnn: standpoint in ite contri.butAou to s t ate and 

o:edcra7 revem.+on . 


'Phe ab rolute siee of the kndufrtlry cnn be conveyed In 

round nwnberr; by a fow fii;uros, In 1964, coneumerE; spent 

ovor $8 billi .on for tobecco producto . This expenditure 

providod yobs for 1,300,000 poreons, 

Tobacco Aso this country's fifth 1ar£,est cash crop . 

Around 700,000 fara;, Saeni.A .i.es grow tubacco, giving ompl.oy-• 

msnt to r>omE: 900,000 peoplo, %n rsix mtates ••- Worth 

Caroliira, Itentucky, Bouth Carolina, V 9 .rgi.nia, Goorgia, and 

R'enncse,ee -- tobac:co farnwing io a taa,yor producer of income, 

a pxi.neipaA eaeh crop, and the ovetâ] .1 frr .rm ecbnomy is 

hmavil.y dependent on the rovonuos brought In by tobacco 

1.caR Ealo e , Tobacco i .s ; also grown i.n 70 other states . 

Any eiubctant.i.al reduction in the demand for leaf 

tobacco viould rayui.re a drantic roor€:ani.r,a.tion in the 

oeonowies of these fmn5.ly farmE : ; .md no ;farro econor.aist with 

wiw[a I have talked Iio-u3 bE+en able to eW.(;gest a substitute 

ParfA Ck'(Yp prOducitl(t, anythint9' li .ke tl2e rSn}pe revenue pe%' 

1 .725

ty 5 

ar,re an that generated by leaf tobacco , 

In ]= , tobacco farmers rocolve6 more than $l,? 

hi7.7ion for their crop„ 

a'ohacco farma.n([ offore the oppcrrtnnity f.tmore man- . 

pcnror per acrc thn.tv any other fcxm crul - .. .ttA.li . r. intr; over 

2 80 maarhoiSY n per caro, ownpared to ten Imr

• 

• 

k ,v 6 

orop=, in 1964 . 


•Lo4rrzcco toanufactur, .ug, includi.nd ; ]ca;.f handlina and 

procce.i;•,;fng opera.tions, previded di .rec :t enploynient for co:no 

115,000 porconr: i.n 1 .062 . Thoso tobacce mor.3cer[< earned 

$ 500 ini 1P .i.oat 9.n w(t6ar and salaries in 1>i62 . Theee opera-t 

:ionE;, 3ilco tobacco EavmA .nE, are of pei ratnount 4mportance 

to the Ccono :ny of co ertaf.n (ste.t.ee„ EAnco the facilities 

and c quipmont ueed fn nianufacturfnt; tahac:co products, 

incaud)n(; e£I'.'eretteE :, a1Rt highly Apeei,alÀ8®d, any enh• . 

fDtantinYl redUOtion in th3 d4nand a'()r C:f garett'.es would 

render thiN hi .(t'31•-coflt CG,nili mcnt vallkEi .e6n, ab Y/ell aE 

cauEte.n(; G[1hStftntY .al Unel~lYO1tt5n1E3Lt in the areaB in question . 

In the li4r,trS .UutS.on of toUacco producte, both vihole- 

sal.e and ret.ai.3 ., i.t ics etit :iv:atod that naore than 300,0110 

pc+re',ons aro omployed vth.ono jobs n:ea d'xreotl.y att:aihuted 

to the calc or^ tobacco nrod .uctr. . Y'here a.re over 7.,500,000 

outlets Yor tobacco productr, c.rn(t countless etnployeoH, 

ot:hcn than those direc'k.l.y anvolvoci, recei .ve pa.+.•t of their 

i.ncorao f'rotn thc sale off tobacco products . 

To bAcco n .7 so contributes signi.fi.a:antly to solving 

Aarter9.ct .' s dif'ficu?.t balance of payotentia problem . Tobacco 

3.eaf i .rn AmorS .ceJ(; f'ourth Rnrgest com mod'xt,v export . ]n 

1064, about O10 million pounds of loaf, valued at $4 l ;.' 

mtJ . :lAon, cva4 exportcd, 77he Un9.ted Sta.E:ecu ie zloo the 

rrorJd' s Aeadi .n, expor'ter of o2t5arettes ; theso oxporte. 

3721

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ty 7 

last year w.':D'c valilo(7 F .f. ]aoro th?n $).$4 wil7 .ion . 

A'bur;, throtrr .h Fsh .'rparoonts abroad o'll lunoricac.l Ionf 

tobacco tln(4d tebaeeo Pre't7llctF', the tobacco SI1G7u0try accounts 

for moro theu $554 cv .i7.5.on annually In the in+p>ortant ei:'forts 

of pri.v[tt.e infue,try to ai .

• 

ty 8 

In a.dd4 .ta.on, tobaee,o fa:~mcus and Andustry empl .oyees 

spent alrproxknrato7 .y $1 .6 bf1 .) .fon f:or E;oods and E:ervfeeo . 

A].so, there are more than 300,000 holders of sheree 

in toba00o Inanuf.aetuk' i.n£ Cellpan106' . Thefie shareholders 

l.ive fn cach o f the 60 state a and the Bist:rict c.f Colulnbla, 

a.n wol.l as abroad . 7'hey rr.psesent raany different econonlS .c 

grORpE, $.ilelUdin6C 61OT, and WORI311 EroO FtIJ3 wallfs of Yffe, 

and al6o boF

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ty 9 

generated by the induntry, inc).uding indi•r•idual and corpor•- 

ate in .ame taxo£: nard inz£:ce7l .aneom£: buaA .noss txxen . In 

3962 these actdi .ti .ona.l tar:es v'ero aPBror:ima.tcly $650 mill.i .on, 

M nhi-n[; a totx7l of c.lor:o to $4 billion In federnl., state 

and locnl revoantes dori .ved from the tobacco industry In 

1962, 'i'his e,.luount£ : to about $45 D,000 s.n hour . 

Xou may be 5 .n9:cror>ted 9n knowing jucr'c• what that $2 

bi1.J.ton in fedOral CY.l:i.£.e tflxeE} would f :n]> p ort, by way of 

govcrnmont activAtfcs . Veu.ng i'i.ncn.1 1900 budget requeste ;, 

the ci.Carettc tnx would [ :ui,gort. : 

Blie entire co st of rumvlu(f the Nntional l:nstitutec 

of Health, in.e9 .udiuf: their rosea.rch proftr.ams, which 16 

just iunder $73 bil.lion a year - •• with enough money left 

over to covc :r the $1. .06 billion approved by the Senate 

for tho AgYa7.achian recovery ProE:rant 

for the h'ar on Povcrty pr•o,Mra m . 


1730 

. Or, it woulfl mara thim cover the $1 .3 Ui).1ion roqueF,te.ti 

Or, it would mox'c than eove r the eost ofR oper•ating 

al.l vetoranE ; honpri .tal.es and a17l veterans nGodical care, some 

$1 .3 billion •- - with about $700 mi .lli .oai 7 .efft over, enough 

to eupport• both llousesi of Con(gress t .luoe and a half yoars . 

The industry contributf.on to state rovenueo desorven 

part:icaO.ar not.e . Cvor 30 of th e ntates got more than 

5 pcrcont : of their total rovonuc :a; from tobacco excises . 

State nceds 9.or revenuer> have bc*on tyrowing in recent years,

0 

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and t

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ty 11 

T am not a scienti ..t, and do aiott intend to discuss 

thin puostion at longth, hfodica7l witne:rsers appeering 

boforo thi.o Committoe c :an provide oxpert opinions, and 

can evaluato the result:s of sci.entifi.e rerearch, both 

E;ovexmnwri:al and private, during the pant ton Yoa .rs . 

x do believe, however, that the need to eneourage 

wt.do . ..ranE!in6t, basic rer.earch to dotornii .no the facts -- 

t.he nncts about nrnoki .nf: and health, an d the facts about 

thocse disacaese s with lNt? .eh 60-iOhS .ng han been assoniated -- 

i.c g !rea.t.er today than ever Uef.ore . 

Lr . itovm Nn Gray, in hS.G: appearnnc.e beforo this 

ConunS.tt.ae, mentionod the act4vities of' the induntry dn the 

area oi' hoa7 .th re+acarch and told you oV the cigarette 

c:ompan3e .;' pLSdge of $10 mil.lion to help rupport the 

ro searc:h program on scoRinR nnd health bo :ing coonducted 

by the Tmerf.can Medical Associ.at :ion hduc.ation and Re search 

Si'eundat. i en . 

'fho tobrecco industry has cooperat e d with other 

c:cient.ikic an d medical organi.Yations , aud with the Rovern- 

ment, on pro9octs which offered po :asi.b9.lities for pro- 

vidiag nocdod knowledge . 

ponsAble research art every levol . 

We recognizetho need for roe . • 

'A71is has boon t;hc industry'Er con£a'.ant position since 

iiutustry loadorr first decided to provide funds for 

9.udopendeut uczonia .ctsi to i.nvestflfqatc: tobacco products, 


779'L

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In ef :fect., the i.ndu stry, e:turting in 1£+ 54, placed itself 

in the hands of the soi.ontists . And thn,t is where the 

Inntter is today . 

Why did the industry tako this approt,ch7 Because 

i.ndustcy l.eaders worr.+ and are convi.nced that the answors 

to questi.ons about s,lohinG and hoalth will coyne only through 

scientifi.c roscarch . Xt was, and is, the only responei.blo 

path to talce . 

The people I know in the tobacco indncifcry have a 

vital intorer,tin the public health aspects of this 

queEltion . lri.r[1t of all, they are huNRn beings, with a 

nkturnl intoror.t in their own health and in the health of 

theirSoll.ow r.an . Becond, they obviously want to find the 

2.n .:1'fc3'E; toqueEiti .onfi' about their products . 

If there is solnethitl(; in tobacco that is causally 

Rel.[tted to ealleer or any other dii"seaBe, the tobacco 

ittdustry wantr> to find out ©hat it is, and the sooner the 

het£er . EY it is sorr:et.hinE in tobf:cco or in the e:nmice , 

T. aw sorc thio can be remedA.ed by esoi.ontists . If it is 

e:omo'i;hi nt; elac:, such an eemoC, virunes, horedi.ty, or a 

comtAe.t.i.on of ttdngs, 1 annl suro the seionti.sts will find 

the uo7.ution . 

1:n addition to i.t.Ra strong support of indopendent 

ycr.o arch, with no stri.ng's attached, the tobacc+o industry 

has also tnlec;t erihor action in an oFfort to fnlfill Its 


1733

• 

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ty 13 

public: responnibil3tiem . 

You are a1 .1l awaro of the CSCarotto AdvertininC Code, 

which govorns al l cigaretto advertisinE; . 1'orwer Governor 

Moyner, the Ad!ui.nkctrAtor of the Code, f.s a ma.n in whom 

the MioricAn people: cAn have full confii .dmnce . He has full 

and fi.ual aut hority to enforce the L'ode . 

AdvorticinG mattcr.ep arc not within the sphere of the 

l:nsti .tu9:o'n nctiviia .oc ; they arc properly the activities 

of the i.ndividUal companies, IloVfevor, I ean ABJUre yeU 

that the adontion of thi n Code by the cigarette companies 

themnel . vca represent :n a ElerfoUEt effort to respond to 

critic£nra ci ci gasotto a.dvortisinf ; . 

X hope you will vici:' tlz9e Code as 1 do : A[s a conrmond- - 

abl.e cwd camprohoneavo effort by private industry to meet 

its rospcrosibilities . 

Iloreover, I hope you wi.ill agree with me that in a 

nation such as ours, voluntary a,ction by industry ie far 

preferable to C•ovornmont action . When au induetry denon - 

f:trates the responsoib5 .lity and fortitude to regulate 

i.tcolt, tihero bocomes lene and losae need f'or govornmental 

reCulatf.on . 

i'hEmk you . 


1.734

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ty I 

Univor.'sit,v hos]'ih Scrvi.cos 

PRMNCP:71oN UNYVFI+2SrdTY 

Ia'incoton, Now ,Iersey - 08540 

BtcCosh IInTA.reunry ,Apri1 6, 1965 

NonoPnb7.e Warrnn (i . D4ag'nuson 

ChAiritlatl, COWrid] 

.ttee on (RffinierCo United Fi'tatoJ rSelih4q 

PJasohin€".'i.on, II, C . 20515 

llear. 5enator b1agnuson : 


I vrvite to you to put on rocord nry hearty support 

i'or the attcnapt whi .ch you are ulakci .nC' to :insure labo1111 .nQ 

oP c :.Onretto kin.chpgen ard IilaE :e lloo.fii.hl.e the La .bodlkng' 

c,f e9.grrrette ac?vort ;a:ang n£: a pos:eibl.o health haeard . 

hikc thc: ovcrn4zo7m :inc; ruayority of my co]leaguefl both with- 

in ar,y o1:m sqler.*nLty ot' co7L7.eco health wor•h a .nd within 

the tlled?ca.l . I1ro1'E6)£i.en at l .argo, I atl) GOnv$.nced that the 

ElOiontM . :Ei .c evidence incYi0linatin g ciE'i1.h'e.tte s111aki116 as a11 

importa}zt £actor in lung cancer and a1.so :ln causing deaths 

from resa:y other disea.e:es is ovcrwholmtnC . One of the 

Croatc+ut oppartun9 .t.i .e:, that 1r[, have today to save lives i .s 

to c7ieu.nich the t!mount of aif.nrett.o saaokinC . 

H:ore at Wincotou we have as.eembled statie :tics showing 

a nrark¢ettl c?ocran£io in esaok :i.nC a .monG entering stud®nts from 

I.020 p:voC,roce,aveAy to the 11r'o£:ent . l:n my opinion thi.e : 

gr,n(tuaL deorcase 4,r+ due to the eonstsnt publ.icity given to 

]1736

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ty 2 

the trnc factC about this hcalt.h hae,ard, Adding wnrni .ngs 

to c9.gnrotte lnhols and to c9.dnrotte advc:rtisin[; offers a 

faost s:Sfecti.ve nonns avn .i.lable of koepaarg tho Maori .can 

puhi.ic, pvrtS.cularly yoang pcaople, awturc of this hasard, 


S9.nccaely youre ., 

r„/ 1'dill.nrd Dalrytupl .e, SS,b, 

I)i.rcetor, Univcrei.ty Health Sorviees 

I'i'S.ncoton UnivcreRi :y 

l.nstx•netor in IdcdicF .ne, 

Columbia UnAver¢,ity 

1736 

Chafrman, Eection on Clinical Tfedic4ne 

Amoricnn Col .lef;o Hoalth Association

• 

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ty .i 

DI .S . D7:IYXT'A' C . AAUGY{i`fSYI JOHN G . CSS/35N1iY, 

fiARGCd) C . SpEI R, '!'ffOMkf"i 0 . GENTSCfZ 

7'bormoP.c, Cnrd7.ac 1's 1550 SCorthwest 4"ent.h Avenue 

C:roa.t Verse7. I"surgory b74am£, F't .ori.da 331$G 

FRenlcfin 9-3441 

lharch 25, 1965 

The Mfonornb7,e 7Cnrron G . ri1ngnuSon, Cha'r_rmxn 

C:onmi :ittec on Conwtcrce 

fln9.ted Statee Sennte 

VlaehinCton, U, C . 

1Krnr Henntor A°+4gnU9on : 

A prent nuribcr o8 ue arc concer.ncu nlrout the &erioun 

i;tr.eeut of c3gnrette c,volc£nG upon hea7 .t8i . Uncfnes'8ionnbly, 

thore i.e: a ciiroei : cauc:al roleitf.cnrshS.p between cancer of 

thc 1un[t, pu).rnonnr.y en:plrysoRUa, cflrona.c^c bronch3.t£rr and 

e,evornll other d9uenoes und the habit oi : ci.Cnretto smoking . 

X wic+h to urUe pas:SaUe of tbo Roo.borper f3i7.1 (9-54Y) 

orr tlne f,1agnuson 13i)1 ( :9-55fl) . I thirdi: it ie very £inpor- 

tnnt thn,t:)vc pugs coPae+ rneaemre rc6utnt'r.ng the nclvertisinU 

of tcb:ecco px'oductE and properr lubef,f .ing of pncha6efl of 

e£((nrett'.ob or tobacco ao that thero woufQ be no question 

?'.rl the R19.iZQtd ci: Con6Ubler'N nC to $h6A .r lc7Tect6 upon he0.lth . 

Thank yovu so ver3- mnc1: 2or your atternti.on to this 

matt er whR .ch 4.e: co very vit :nfl to the health of our nation . 


I rsflght add, that here £n F 7.oria a. we sct up a proIXram of 

1737

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CdUCHtfon g32 thl'- Fchoo1P, Go that the yoLLthoP. our E7ti\to 

wdll hzVer tha PactEa nF'it 1:huEi cboose lleone wise7 .y ar; to 

whothoxor not thcy E

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ty I 

WESA'Iik2 .N 1NIO;d 

TBLE( kAM 

1965 MAR 30 PM 7 . :1). 

14110,056. (56) PC033 . 

P PGA 360 UiNG PD 10 R] ;TttA XrA): PY7T51)'UCCGO PI:NN 30 120SP EST 

SSNAT6R IYAtt1C2~.N MAGNUSON, SENATF3 COMI10 :iitC1: COLRdITTIFIE 

NE1V SP:NA'CE OfiPX.CEI DLl)0 PIASFII)C 

7/1'sAR SWi/'.`ROit, PAAONUSOiV . TYSTXMON :f P42ESI;SiT1 

.SFO THA'1' I YfAD Rh6FtOVA'AXCNS :OD YES'TdC3tDAY APPARDNTLY FMN'Y AliQU'T TNY+ 

COitCLUtiION 0'.Y: SA90IKINGANU YANG CANCEYt XN OUR XCLiPORT TO 

TNI~'. SURO7:Clld OY3N .V:YtAL IN 1ANUARY 1Cnu liNTITLED "SBSOKING 

AND E£6AILCII" . I IDS ;NIVItX i'!1SN TO EMPI{ASY.'GE Tt3AT I HAVE NO 

R);Si';$VAT%ONS AL'OUT :i'dIIT CONCLUSIONS IN TII%S REPORT . TGIB 

FVEDnnCp4 lr(u,. CIGA5[F.Te'E SMOKIING A6 A 1 ;V:JOI4 CAUSE OY' IANO 

CANCEtt XN NUMANS AS fi0 OVY:Yt1sUAiLMXNG Al:> TO LEAVE 110 DOUSYI .' 

IN Ml' MSRD AS TO TI7k; VAXXDITY' OS' TNIIS COFiCLUSION . 

1SMMANUEL, PAhI9ER 1 :"D PIID YROI?ES£9Oii ANI) CNAXgMAN DEPT OF 

PAx1f0Y,0GY U1dIV ON PI2"fSfiUP¢OfT SCHOOL f)X' MISDICINY: ANI) 

6YX:Ml3k:l. 01' TBtXi SURG15O2d GP ;NSKAL~; C.OMMIT'Xti1S ON "SMOKING A1ID 

NDAF,!'Sl" 


1739

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S9À'fSMFNkd'f OF JACK I1, FAUNIS, Ii .U . 

).72'8 1VXL.HNXIUS O;OUL,P:VANII, LOS ANCiRLfS, CALIGOhNIA 

My namo in Jack M . Farrio . I am a general surgeon 

and a EubStanti .a7 portion of my life haE : boon spent in the 

care oi' patYelt9:s suRfering from cancer of all parts of the 

body . 

R,v the aLè of te•onty-•four, X had received an A .IS ., 

U .F . and M .]) . degree frola the Univer s ity of Nebraska, 

buring the iioXlor/i .ng ton years (1cS5'7 - 7.9Qt7), I cvas asGoci .- 

atod with the Uni.ver® :i ty of Mic :higan both in participation 

and diroction o£f poGLESradun¢o activitioe : in the Medical 

SCheoA, I becaIDe AGaiECGant I°rofensor of SUCQCry there, 

whor Y di.rected reuonrch, participated in the teachinQ 

aetivlti .eG ol both graduate and URCICrETaduate levels and 

anntmied i.ndepe;ndont responsi.bility for the surgi.ceal care 

of nppvoxira ;ctoly 50 percent of the total Univorr;ity UoGpi . - 

ta l popu2ation in general . GurGCry . During the War, Y 

c:orvod a pproxi.cle,te7y txranty-four .montho ovorcxoa n ae: a 

nurgeon in the Univorsi:ty of Michigan Unit and for a time 

t'/a61 attaehed to Golleral Fatton ' G Third Army during the 

canlpaiun th ;'ouCh Germany and durl.ng thie time received 

tho D roli v.c ditnr . 


At the pl'Cf.ent tilne, nly chief activities are eoneerned 

eiith the susgioai tl°oatmont of pationte at the Good 

SamarAtan ht;cii.enX Center in Loe : AnEe)eo, I am AGe:ocJ.ato 

17QG

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('S.inicnY Proxc :ssor of Surgery at the University of Cfll .i•- 

£ornia :1.n W ftnge7.oe+ nnd a C(n1 .ftUltan'L in 8urgery for tho 

Vetc vaus AwmAu.e .E:t.r.ation, for whom T¢lirect the surgieal 

acti .viti .es of thcar i.ntatit.utionrs at LonC )3each, Cal.ii'orni.a, 

Tuccsou, Arirona, Phoeni .r., Arizona, Prescott, Arizona anc7 

othe.re, 


1 nAl GGrti.£y.e(1 by the /IDlerican Y3Uar/) of Surgery, 

hoYC,inL Cerf.i£i .cnte IIumbon• 7.83cJ• 1 arp a menbos o£ the 

O[.ncoz ComriAt:teo a,', the American Colle>I;e o£ SurEecnao and 

f>oct9.on Chie£ in cha .rgo oF cancer ac t i.viti .es for the 

Ce17.ego of E'.uxg•cone : 2or Ar•en X1, whir.h fincluQOr, Cn.liSornP.a, 

ArS.eons+., Novad a r.uct )7awn4 .i, I have publiclaod a nu abcr ot. 

aciontiYic v.rticies and YNnve written srovoraPl chapters £or 

GurGf .ca1 te x .f•s . D: bclong to a nvmber oTf surgical societies, 

the c?etn5.ds a£' whi.ch are in the attachecl curricul 

. 

I have follovod wi.iAa intoreet t1u•oulthout the past tc,u 

yeRrS the SY'S .dS'IIC6 : for alld against the thefl3F that cigarette 

smodcing har, a oaueal reA .ationehip wit h cancer of the luug . 

Yt is only natural, thea•e£oro, that k havo read with 

interest SMOS.Yh(6 A)d!) W Y•fR{Y, the repo r t nf the Advisory 

Comedtteo to the Ehu.°{:ewr Gencr•aa of the Public Ronlth 

Service . I do ro t bWUvc that ].unE; ceuwcr bn s boon showm 

to b r.i eaused by c!(;arotte suioNa.nC . In my opinion, any 

acnaaXnHicm to the eontarasy 9.s'not Just.i.iieu - -par•tA .cubea•1y 

.urn vitao 

170

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9 

f'rom the evt.dence at hand thus f ar . The report of the 

Surgeon Gancra]l does not resolve but onl .y adds to this 

controvorey, in my opinion, and lende : further evidence to 

support, tho froryuent obr,orvatio n that statistics are mis - 

loading . 

!!any of the data presanted are c :ont::rad'xctory and, 

to say the least, confusing . 

Vor examplo, on Page X12, it stutes ; "Uoath rates 

for current pipe smokors were little if at all higher 

than for non-smokers . ., . ktx-pi} o smokers, on the 

other hand, showec2 hi .Shor death rates thnn both non- 

aGtokere, and current snokors in four out of (the) five 

studies (report:od) ." !t possible conc:7ue,iqn to be drawn 

hcre ist that if on e once accluiros tho pi .pe smoking habit, 

he mur;t never quit for fcar of actual .ly increasing his 

liability to cancer of the lung, Heu .rond and Norn, on 

the other hand, 6uj,roF.1C that a possi .b7.o explanation may 

bG that a sub:3tetlltial number of pipe smokers stop Clmokin( ; 

becauso of ill .ness . But no one has data to show which ex- 

planation is correct, if, i .ndeed, oi .t .her one is . We can 

onYy speculate . 


On PaCe 133, in a discussion on the sex ratio of 

cancer of the lung, the report state s : The lung cancor 

sex ra.tio of 7 .6 to 7 in 1930 has gt.eadiAy increased during 

the interver.in0 per.iod to the current value of over 6 to L, 

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that is, foaevery one fcmalo who develops cancer of 

the lung there ar.e six males . This su[;ESo[ts thnt cancer 

of the lun g has little or no roiationship to cigarette 

smohing boceuso, in np3 .to of thafact tiri,t moi'o and rnoro 

females have acquired the hab .it in tho j ast thirty years, 

the disparity between tY,e incidence in cralos and fomales 

Rs increasinE . 

Xu thin connect5,on, I direct your attention to 

Table XX1 on Page 156, whore Mills aui parter in 1057 

report on 04 cases of' cr .ncer of the lturl; occurrin g or. 

cius'svoiy :tn fema9es . Xt clearly st o t.ee: that £13 por•• 

eont oii these canc:er• victimo wero no l ••sm:rhers and o :.riy 

73 .3 porcent of the fomal .es in this ut:udy without J.ung 

CarreeT YlUPe non•-fimolGJrGr, A possible coiAL'lnnion 9rom 

thor;e otatietics is that it is saSOr A'or fomales to 

ruuolco than not to smoho . 


Tûrthormor.•o, cancer of the larg i.s more common 

amon3 the poor than the rich m•• al. Lws t twice no much . 

ahero fs no evidence to show, however, i:hat cone,umption 

ofR tobacco is high in th .o low income Mroup and it may 

be even lerrG . Arlothfr point of inter'ent . Caneer of the 

lttn g i :+ uwre com non 9s, Britain, perhaps twice as much 

no in this country, whoro, on the other hand, significantly 

l .ess tobacco is consurned . Won Uriti .r.h rnales who ax•o 

trnxicplmitoQ to 97e w lenland and Austx•n .li.a, whoro they 

1743

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reside for many years, have a higher incidence of cancer 

of the lung t.heuo the nativos of thoso countries . 

I quotefrom pago 1.66 : "Mostexperiments in which 

tobacco tars (theso are condensates of tobacco combustion) 

are brought into direct contact with the lung and wind 

pipo or: oxporirnental animals have yielded negative rosu .its ." 

It han always intorested mo that in humm ns that the 

deepl.y e.i:ai.nod £inGOirn of the habitual nmekcr never dovo - 

lop cancer o'i the skin . It han also interested me that 

the wind pipe of nan, which 7recoives the initial impact 

of the inha10d smoke, is rarely the site of cancet ." . The 

comruon locatfone are out In tho fi.ne branchos of the wind 

pipe -, r.reacs which have little or no oont .act with the 

inha).od smokc . 

An X havc di .s:cussed this problem with Physici .an 

friends throulhout the c:ountry, it has beca%o apparent 

that there aro three groups of i .ndividua.l .r-o in our pro- 

fession . 

Thorc as c those, first of all, who have a firm 

conviction that there iE: a definite reXationshi .p between 

cancer of Lho lung and ci . gnretto e,moki.nG and a second 

group who feol just as t:tronF'l.y that there is little 

or nlo rel,ationGhi.p . 

There ir a thi rd group of physicians, howovor, Who 

a.re undccider,l . I fal .l In th.is group . In other words, 


1744

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X@ral .iovo that A'(t i .es pr(nna+ture to mn,ke any far rencLi.nO 

Coilel.Uf15_onF : :[b.'o,t the evi .d,Cnee at I10.ndd thl(n i'nr and that 

510 nh013Yd COntYflU6 to make OOrei'ull obf.ervntions bAE£ed 

upon 7 .0(;•i .c R!1(i care'.tt17 niln .l.yEiE( O)"9 tiiOre £/t75ti£Jt3.cE) and 

infinStc:ly mnre expa::rrim.^.ntal nnd cl.Snicah evidence thnn 

nrc avr:Alah].e nt the lrresent timo . 


Aoc.ordS . at : to the ltr£vttniond-}:orn c.al .cuAati.ohs ac pub. . 

lishcd in the Surgeon Geireral's Report, the highest 

rAn)c P:""oup r.oraper,ad oi henvy smolcorr) sufi'orcd e rate oA 

239 lung ennecr ctcaths p©r 100,000 poPUlnt :ion nc opposed 

to 2'1 rie'-' 7.00,000 amon(t nom-smo$crs . Although this ratio 

is high v,nd avp3'o£3Sivo, 4S olte nppISO v roVe.1'se 1e11glish, 

it `xs apParont thot niore 'ihan 90-1 ./l percent of heavy 

rsiaoF :erc: nro not vflotilrs ; of lung cancer . 

$f ci garettes 

nro onncer oau(si.n0, M y doen this larG'e number of honvy 

s :eokc :r( : enc :=l,m . Uo thoy hnvo a buiJ W S .n protection or 

9.nsnnity . We do not lnsom, but the con:parativcl.y vory 

san£+.7.7 munbor of.' heavy e~enoxore a4Teetad makes me wondor 

t•rhothor the more lihedy cupl .anation fe; that cigarettos nre 

not the Clll.p,tît . G Ui1G7.l.nr pr.'ob1eG1 eNi .stE: i.ll 8ttemptS to 

pinpaoint the p o :;ei.Llo cnuccr; ei' canc( r of the stomach, for 

c>:e.n:p2e, . 8 wo yctar ;, at{o, 77 visited five m^dien l schools 

in .Feriaw, hoping to uuoover i .nfornation concerning cancer 

ofr the Stomaoh . Ae, you nlr*.y ]cuow, the incidence in Japan 

. . ., ianenty to i:hirty timoL. €:ronter thssv in this eountry . 

1725

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(:f3 a filattOr o% ]'.aet, 60 percent of all mial.06 and 30 per-• 

ccnt oaP all ficneale .; who die from cauoer in Japan cUO f'rota 

e(Illcer Of the 53toma .cll . (ianceS(' of th0 lung is extremely 

rnre . rrom the s:tati.otica l poznt of vi .e.w , thi .n high ine.S.- 

dencw of cancor of the stomach can eat'

0 

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tobaoc:o -- following the pati:orn oi' cnmc.er of the stomach, 

Therofora, in suMiuaary, I believe that all thoughtih l 

phyiai.ciano are concerned ovnr the p .roblem of cancor., 

regardless of what px.rt of the body i n involved . As far 

ns thc cancor of tho lung problem is concerned, there 

are those wh o t:hink that smoking i-t; important and those 

who think it ic not . I am not cortain . I simply nny 

that i.t is too early to make any far reachi.n$ conclusions 

Yroro the evidence at hand and that n defi,nito possibility 

oxists that smokin g has little or nothing to do wi.th the 

i.ncidencc of cancer o2 the lund,. I hope to keep an . 

opon mind, 


1747

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DRO . IIAR'NBLL, CNl•SLEDON •ANU ItOSNNDRRG 

RADY9IAGY 

8omor V . Narttell, M .D . 306 Stinuson Building 

iVayne A . CheeYOdou, 1,4D. Seattlo, Washington 9&101 

Robert H . 

Itor.onbor6, R1 .D. MAin 2_ 6730 

15ichaol . S . I.ewinhi, M .D . kòbruary 26, 1965 

Tho 1lonosable Senator Warren Nagr,uson 

Itoone 127 Senato Offi.ce Rldg . 

tVashingt.on, D . C . 

Doar Senator Magnuson : 

I am indood ploae:ed that you are introducing Senate 

Di11 559 ^To regulate the labo]ing of ci.garettes, and 

for other purposos" . 

As a radi.ologi .st I have boen sooing from two to three 

nevr cascrs of cancer oS the lung each weol : . In practically 

every caso thero has beon a history of hcnvy cigarette 

smokinFi• 'I'his piti .ablo si .tuation can certainly be im- 

proved if tho public i.s educated and constantly alort.ed 

to the daugers of thi .c habit . The youngor generation is 

the imlrortant one to be informod . Reliable studios have 

ShoC.7n that if a ehil.d of ten staxts smoking and averages 

n consumption of two packages a day he will have a ninety 

porc.ent chanco to have Sung cancer by the tirno ho is 

forty . 


Again I want to congratulate you on your determilled

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Etnnd on this movt Anpcu•tantt and vita :l dnsuo, 

Sincoroly, 

s/ Nomor V . F[artzoll, M .D . 

Chancollor, 

Amorican Colloro of Radiology 

1749

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P7ilU]xNAND C.tIk15TIAli 1'1A'sY :9fIG, AI .D . 

rATxai,a:xsa , 

sT . LUKIs''s A'G£PiTAr, 

44th and ,S .C . ISicP.ois parkway 

Kausas City 11, Missonri . 

0A'P.'17;MIiR7.' CF H16RAXYVAND C . MhL1YYG, M .1Y . 

hF,SH'P-TY:h`G SMSHCYFIG A12D itL'J:SfxFT 

f.fy nane als k'ordineund C . Hclwig, of Kansas City, 

Mi_ssonri . ~C am a Uoc:tor oi Fdedic:ino specialiv.ing in 

k'athol.nFry . 1 eras eoxt :iSAcd by the Amsri .can hoard of 

Yriholoa:;y 9n 7,6(iG and am a Fell.oc; i.n the Amorican Collol ;e 

oY Yfiyeiciaue . . In ad.dif;fon to e7camining- tissae Yrwnm 

pa6i.e,ni:r; £rum the Y,ansrs : City ntatropollitan area, aet weli 

ac pxti .onts comt .u(, to IP.enn[tr: City fox trcat(stent, I also 

CXatliine (epE+ci.menE sellt t.o 0?C i.'rom other F.YCas, principally 

ci t f .c :: i.u 7Gauons a,nd fd9,c„r,our.•i . 1 ata C15.nicaY Professor 

of pa.thology and VucoioC;y at the Univoxc:i.ty of Kansas 

Fchooll of 6+.edic9.ne ahore X have been on t.he faculty since 

l.atc 1 0? . 1òl.YowrnCe an i.ntcrnohip, E etatdi .od with the 

l .ato pro£ossor 74rwA.n Ghri.atollcr, at tSw 1'tudolf, Virchow 

Kospital in igorii.n . G3rman pathology haa ICOneraliy boon 

o.^c a hv'gh ordosr and this hospital had one of the i'i.neat 

pa.thalogy doNnrtrtents irl klaropo at tha .t, ti.nle . 

L:,tc .r, In 1025, 1f+7.Ci and 1fe79, 1 dif, rosoarch in an 

nttempt to produce canecr by the ETpl5 .cation of tobacco 

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tar to tho sd :in of nice . One of the subjects taught by 

me at the Univers5.ty of Kansas School of Medicine is 

Oncol .o ;iy, which iss the s;cionco of tumors . In 1935, 

1 published a book for ms :di.cal students on cancer and 

allied diseae:cs entitled "An Introdur.tf .on to Oncology" , 

I havc devoted my major interest to the sub,ject of cancer 

during al7l of nry profosmional careor and have studied 

porhaps as niany as 30,000 cases of caneer of all types 

anci eatos over the last 4 2 years, I have been very much 

intorested in cancer of the lung . A list of my gualifi-- 

cations and publications fs attached . 

I do not bo].ievc that cancer ir, eauued by smoking 

cigarettes . Those who do boliove it are forced to rely 

principally on sta t irsti.cs . Statisticn, f .n my judgment, 

r:how only an association between ciUarett :o smoking and 

cancer ; they certainl.y do not prove cewsation . Even the 

Sur geon General's Report, which really prosents only one 

side of the controversy, pdults that "Statistical mothods 

cannot ostabRish proof of a co .usal rele,tf .onship in an 

aosociation" (page 20) . As a matter of fact, even many 

of tho available stat.ir.t.ice soem inconsi.eatont with a 

theory thnt cigarette amoking causes lung cancer . flhy, 

for in stance, is c.nnc:er of the iung in m en twice as common 

in k}ritai.n as in the Unitod States when British mon smoke 

only hal£ nri many cip,aretteo as do men i.n the United

• 

• 

Stntes? 19hy is there a higher incidence of cancer ofthe 

lung amonff mon in lovvor economic brackots than a .mong those 

in hi.gher economic bracke.ts when the lal :tor are repn•.•ted 

to emoke rnorc ciGaiettcr? Why has there boon ne iic'reaae 

in the oc:curronco of lung cancer in women at all c>mparable 

to the zncroarc in men when there has boon a trom i ndour, 

iucrcare ovor the pact forty years in the number of 

woraon who smokc (it would seem t.hat ifF :moki .nC vere a 

cause of cancer, the :ro should have boon an equnaYy tre•- 

mendous f .ncrea ee in feraaA.e lung cancer)? 

A11l sorts of snrokinf. experirnentr and eve l painting 

of the 1S.hinG of the bronchiall tubes with concentrated 

tobacco c;anol:e cxtrac :ts: have boon totally negative in 

peroducinE' a siugl.e lung cancer in experimentr .S animals, 

Yn ],925, 1026 and 3927, fn studying cancer of the lip, 

Y perronnlly treated a small area on the E.Ian of a rerios 

o :f mice with concentrated tobacco tars wiS:hout producing 

a sinnle cancer . h9any yaa.rrs aft:ar my negative results, 

rome succecs ceaus obtained by 1Punder and Graham in the 

production of e:mall, slccn cancorta in the area of appYi-- 

cation on the r;hin of r,usc.eptibl.o mice . Immediately this 

wa.m hai7.od by some as evidence of the c.aus:e of cancer of 

the lung . This ela4.m woul .d coem to have boon rendored 

rather untenab 7.e by (1) the basic problem of extrapolating 

or applying such findi.nge, to man, (2) the further problem 


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of extrapolati .ng findings £ro;n one aito to another site 

eveu in the rstwio sipecies, (3) the total failure to pro- 

duce cancer in expL'riLlenta]l animals by inhalation of 

cigarette s:moke, and (4) the failure of tobacco tar to 

produee eaneer of the skin in man . 


]9ith regnrd to reasons (1) and (2), the danger in- 

horent in reaehing conclusions applying experimental data 

either to a d9.fPcrent location or site In tho samo ani .mal 

spocioc:, or to the eame location or site In another 

speci.Us, is universa7.] .y reUOgniSed . 'Eo BeOh to apply 

dat:e.f'rom the s3kin oSf a mouso to the lurng of a man i.s not 

sci..enti,ficaAly sound . 1 f any mouso date , were applicable 

to tho lunG'f ; of man 9.t would be the datsa rclating to the 

IuCrgf; of mice, all of which haG been neF ;'ative as to 

ei Vnretto E:mb :e, ac, mentioned In reason (3) . With regard 

to renson ( d), a human cignrotte cmoko c :xperiment involving 

milA.flons of casos ha s boon going on for ,vears . That 18, 

the intonsc bro wn dir.iuoA.orati.on of tho . shin oR the fingerc 

whcrc, over ,nany decade w , the smoke fra;ei cigarottes has 

depoti.ted tobaor,o t:ar . In all of my oxporience I have 

novor seen a s]ein oancer on a cigarette emohei^ s fingers 

in the smoko s+tninec] areao . O n the othe r band, skin 

cancor on the back of the hand, nn area not involved by 

ciGt re t~te sa~olco, In nn extrc:mely common typo of los£on . 

i: Pg :eco with Y47 . lan ffiaodoria .ld who conc7 .nded that the 

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c+onccutrati .on of tobacco tar applied to the backs of 

oxi,rer3.montaA mfco could be ogualod only by smoking 1U0,ODo 

cigarettes a day . Ono reason for suoh conclusion is that 

the exposed area of the lungs in many thousands of times 

greater than t.ho exposed area of the mouse's skin . 

Certa£nly the concontrat£on of tobacco tar over the small 

area on the fingers must be literally thousands and t :hou- 

sands of tfmoes gr.ent.cr than that spread over the much 

]arE,'er area of the bronchial tubes of the lungs . 

With regard to the amount of smoke reaching the 

lungs, and the dist.ri.but.fon of such smoko, it is fntero[:ting 

to note the site of cancers occurring in the respiratory 

system . Xn the l .ast three docnd.es the provalenco of 

cancer of the mout.h and pharynx has csi .Eni.ficantly decreased 

in spii:e of the fact that the concentration of smoko ist 

higher in these, aroas thtue in the lurtge : . Why? Tho ma,tor 

viindp3.po or trachea earries air to the ].ungs . Exposure 

to nil of the S.nha,led c£gnrette sruoke fs groatost in this 

7.ocat:£on, ann the 1£nfng of this iarge tube is the same 

as that in the smaller branches of the brcntchial troo . 

Yet the trr.choa, before i .t branches into the bronchial 

tuboe :, is the site of cancer in only extremely rare 

c£rcumstancos . Why? Furthermore, it is now generally . 

recogn£zod that a h£gb p¢rccntage of canc :er& of the l.uttg 

oa•£t;i .nrstee i.n siurl].or taranehcs of the two ma£n di .vi.sions 

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of the bronchial tree, whore tho concent r atien of oigarette 

smoho is not nearly so „roat as in t :b.c trachea and /.argor 

branchos, Why? 


1 do not bol.ieve that there has been nearly so great 

an incroa .se in cancer off thc lung us may at fi>st e.ppoar . 

For oxample, some of the roaeonh Ror the inorI aso in veportod 

caeos of cancer of the lung aro as follows : (1) a greater 

interest in the subject after Ar . Oraham :.ured the first 

case by removal of a lung (previously dt was always fatal) ; 

(2) grcater sNCill l in Girect examinatirnb of the bronchi by 

the uso of the bronchoscope ; (3) groxtly refined x-ray 

techniques ; (4) the u>o of the pap[ .nicolnou smoar, which 

is the atiero8copi.e study of cells i.n washings and sputum 

from the bronchial tree ; (5) the creat refinements in 

anesthesia wihich mahe opon oxposurb of the lunge and 

exploring of the chest a relative : .y innocuous procedcn e ; 

(6) mor.e wi .dosproad facilities foc carefully and thoroughly 

investigated post-mortem examin .aticns, such as wore common 

in 13eri.in at a much on .rlier tLio ; and (7) the increasing 

ago span oP the populati .on in ; lcinnra.l, bringing more 

patients into the cancer ago . YncrenEed awareness of the 

die,caso and the Improved mothods : of diaguosi.s, when coupled 

with the inereasing ago span of the population, may account 

for most, if not all, of the increase in cad;es reported 

dnai.nG recent years . In Germany, where careful post-mortem 

1755

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examinati.ons have long boen the rule, the increased 

i .ncr".dence of lung cancer was reported. about the turn of 

the ccmtury, long before cigaretto snaking became popular . 

The hi.g9nestt incidence of lung cancer is at approxi- 

rnato] .y 57 ycars of ago i.n smokers an d non-smokers aliko . 

Thio poak incidence irs maintained very strictly regard- 

loss of omoking habits . If cigarette smoking wore a factor, 

one would expect hoervy and prolonged smokers to develop 

cauccr at an oarlier age than others . One would also 

expect that :Lun e: cancer incidence in smokers would eon- 

t9.uue to iue?roase with advancing age, yet lung cancer 

shows a sharp decYSUe after 65, rogardloss of cigarette 

consumpti.on . 


In rospoct to the tissue changes reportedly observod 

in post -mortom exoan9.nationn of the lungs of heavy smokers, 

it should be pointed out that sirni .lar changos are not 

uncommon in the 7.rmgs of non-smokers, have boon produced 

oxpr.r.imontally in animals by a variety of agents completely 

unrelated to tobacco smoke, and have been demonstrated 

to bo reversible so that the bronchial tubes may return 

to normal and no cancer develops . If these changes wore 

always premaaiEonant, they should not be reversible . 

During my years an a practicing doctor I have soon 

many changes in the general population of this country . 

btedi .cal advenccs have certainly not boon limited to 

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diagnostie faci .).i.tios, but have also included the 

dis-oovcr,y of the so 

- ea7LX.od "mirac1o1/ drugs that aro so 

effccti.vo in combating many respiratery diseases . Thia 

very advancc, howcvor, may be contributing to the increase 

in the numbor of ).unr cancer cases that we soo . Thirty 

yours ago pneu monia was a highly fatal di .sease, influena 

opidemi .cs were not nnusual, and tuborcu).osi.s, or consumption, 

was sti .1.1 x•iunpnnt . tty curing such rospi.ratory disoases 

as thcse, raodi,cine hns undoubtea9).y saved the lives of 

mQny per6enE who would not otherwise ha.vC survived to 

tho canoer ago . It ln .ey alco have saved the livos of 

personss who wero susceptible to ar.spi ratory diseases . 

In othor words, that porson who, in enr).ior ti.mos, may 

ita.ve contracted and diAd of eonl3umptioll in his youth, 

now Jnrvi .ves to contract lung calteel.` in his fifties or 

f:i#t'.f.es . 


Yt. is my f9.rm ccnlviction that a virus agent causes 

the majori'sy of cancers in the human . fitanloy, the Nobe) 

pri ;me winnor in tdedicf.no for 1938, vrho was the first to 

crysta).li.zo a virus and has done much wo ;rk oh cancer, 

Tools thar`t most, if rot a) .)., cancers are caused by a 

vi.rus . Canacre lmomn to have beon ceused in lower animn .)s 

by a vfruw aro often indistiugnishnble from the same 

l,ror>s and microscopic lesions in man, Well documolltod . 

n.nd ceuwfuXly contro] .lod c}.perimontaX ov :idence has 

1767

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i.r,di.cated not only that cancer may be causod by a vi .rus 

in rwi mals, bu9: that an imiiunity to the virus may also 

be so t up . This extromoly si gni.ficant area should be 

fully oxplored . I would dsoply regret any action that 

would sti.fle research !n this and other Pields of en- 

dea.ver . 


I have secn many chanCos in wedi .ci .no . I have hoard 

many theories that were supposed to account for certain 

observed ofi'eetn which turned out to be quite incorrect 

in the long rUn . 1 have honestly and earnestly reviewed 

a groat deal of the literature rel.atfng to smoking and 

lung caucor and have c:onsidered it in the light of my 

own experienae o£ over 42 years . P7hi .7.e I am aZways roa.dy 

to ent.ortain further ovi .donco, i .t i .s nry opinion that the 

aarsi:, agai.nnt cigarottcs has not been pravod . 

175Ft

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S'fA19moke lesr . What causes t.his two to one 

dlfferenco? In At a nutritional factor? 

3 . In many of the studios intorprotod as implicating 

cigarette smokAn g an aa health hazard, the death ratos in 

the cigarette smokers actually turn out to be lower 

than the death rvates in United States malas as a whole . 

For oxa,npa.e, the age adjurstod death rateEl per thousand 

n:an yoars fo+r cf .i;arotto smokers of one pack or more 

dail.y, i .n North fueerfcau (ages 35 aud over) average 2X .5, 

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whi :le for United Stater> mal.os as a whole for a comparable 

year (1960) thoy aver® .6o 22 .9 . Either it i.s a fact that 

the cigarette smoking ma.les havo a slight :ly lower death 

rate than U . S, white malos as a whole, or it is a, fact 

that the sample of the malo population used in many o W 

those st.udios is not >.•epresentat :ive oP: U . S, males as a 

whole . 

The above figures are tnkon from tt;e 1964 Rv.port to 

the Surgeon (ionernl . On pagos 94-96 of i :ha.t .Report 

those pc,rtinent factr: appear : 

"None of the populai :fans was desi6roed, in 

parti.cular, to be representative of 2ho U . S . male 

populati.oh, Any answer to the question 'to what 

general populations of inen can the xesults be 

applied?', must involve an element of unverifiable 

,jud6ment. ." 


"(h.oports) suffer from the diffioulti .os that 

the populations studied are had to dofine, that the 

smokers and nwi-smokers were rccrui.tod by a large 

number of volunteer workers, and that oomplotoness 

in the reportinU of deaths was hnrd to achieve, since 

this depends on reports from the volunteers ." (P . 

96) . 

"Scr far as £nterpr.etation of rec:ults is concerned, 

the discrepancy raises two points, l,t is clear that 

thc seveh pro5ipect£ve studies involve populations 

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whi.ch are heals:hzer than U . S . m¢1es as a whole . 

Sc :c:ondl.y, tho low death rates for non-f;mekers sug7est 

tho pos•nihil9.ty that the studies recruited unusua.lly 

he[=,1thy groups of non•emo'.ceree ." (P . 96) 

ke).i.ah7 .c genoralieation cannot safely be based or , 

sttu7ies of such unrepresentative popul.ations: . 

r . Yn connection w9.th bi.adder canccr : somo writers 

boli.eve that thi.s 9.r casually related to heavy cigarette 

sn:oL:ing . X t im noteworthy therefore that at the 1963 

luacr9.can l3fblic: Health Associ.at9 .on mo otina, a distin6'ui .shod 

proponent of this hypothosis obsorvod that "there are in•• 

sui'i'ici.ent dnt.a to warr•a nt conolvsione;, an® the avai.lnble 

data are often contradictory ." 7t eioe.ns to mo pcrsonalZy 

that tlwre f.1Ò compar0ble levol0 of ineo]ApletenCEs or 

contra,cti.ctorinesv in the lung cancer and chronic bronchitis 

datffi . 

5 . Tn connection with coronary axtory diseae.e, the 

Roporf : atresres that the causativo role of cigarette nmok- 

ing in death :a from this disease iei not proven, and that 

whi.l.e male c :i6aroti:e a:mokers do have higher reported 

death rates :trom coronary astery disease than do non- 

smoACCrn "it is not ol .ear that the associ.ati.on hae caur .al 

siCni.1'icance ." (kp . 38-39) . 


At the A+.le)ricnn {6oaP.•t AE:Soeinti.onr annual meet$.ng in 

1963 31fF.ny F;j~enkers opined thht toh9Aco probably haa a 

1701

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del.etorious oSfoct on the heart, butthnt this effect is 

not easy to pinpoint . But in a sttldy' ON GOme 6,000 . 

£rooklyn men, Spa .in £otmd that inriking habits could not 

be related to heart disoaso ; Tr.lbott reported that ci gar- 

otto r,inok9 .ng aetuall,v spoodod the clear :ing of lipids from 

the blood after a high-fat moaX ; Cnnnon coucludod that 

the evidence does not indicate that cigarette smoking 

coaftri.butos to the underlying pathology of coronary 

heart disealie (although he beli .o .•es it may be a serious 

complicatinf ; factor under certaitispcu ;ifiod couditi .onn) : 

Cmumt the datn from which those di.scordani : statements 

arise Be subinittod to i .udopenden t biostatistical review 

fow apparent siSnS,ficanc-o? 

6, S9.uce most o .4 the ovid.enco i.noxdminatiuC cigar- 

ettos is stati .stt.cal, all sorious studonte of the problem 

should, I boli.eve, read and re-read the cnrofull qualifying 

comments in the Report to the Surgoon General, notably 

the words AtttiSticn.7.ltothodtl cannot or>tabli .sh proof of 

a causal rol .nti.onf :h)p i.n an aSf.oUi .at"fon . The causal 

fii(i,'f'1 .9.ficallce of an association ifi a mattOr of judgment 

which goes beyond any st.atement of statistical proba- 

bi.lity .° (1'p . ®9-£7?) . 


7 . Thero are mnny other unanswered questions : 

(a) 19hy has the prevalenco of oral cavity 

caucer and phearynx cancer doclinod i.n the last three 

1?62

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decades, despite the hiGher inteneity of exposuro 

to these areas to ci.garette smoge? 

(b) Would a larCe study onployi .nt; trkilted and 

tested i .nVest'.i . getolCs yield the f3nme data aa that 

co I 9vnonly quoted from many of the volunteor--holper 

e9i :udi.os in this country? 


(c) Is the increase i.n pri.uiary bronehi.al cancer 

really as great ac commonly quc.tod? The study by 

Gi,l .li.a9n quoted on page 140 of the Report to the 

S u.rECeon Gcnoral ficnnonctrates how the increase In 

repnrted Ct . S . bronchial. oancor nay be much loss than 

cla9 .nmd . This study shows that i.f in 1914, two por - 

eeilt oi' the deathF certified to t:uberculesffi were 

really due to lung cancer, then the ineroase In 

pri,mary bL"onchial cancer botween that year and the 

yoar 1950 would 1)e about eQht-fold for maleF and 

only 1 .8 fold for females . ., fiGcrees vastly lower 

than the connonly quoted increace . 

A suUsequont study by Gi1lia.m noted a declining 

rnte o£ i .ncreese In reported bronchi.a l cancor, which 

is not oons4 .r,tont with roportod increased cigarette 

consun:pti.on if ci.Cnratto smoking is regarded as 

causinC lung cancer . (Gi1l .iam, etc . Cancer 14 (S), 

G22••2f3, May-•.YCnro 1f)G1) . Similar decline is reported 

In xnC]and and Wr1es, (Locs, Lnncot, June 20, 1f9G4, 

7703

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page 1393) . 


(6) My own studies on the ] .oe.us of origin of 

primary bronchial canoor indi .cal:e that almost tao- 

thirds of them arise in portiona of tho bronchial 

troe removed from the main bronchi. (where the con- 

oontratione of cigarette smoke are presumably lowost :) . 

(e) 'Phe peak incidence oipriira.ry bronchial 

cancer in U . S . males is close to 60 years of age, 

both in anokors and non-smokera, arad this peak tends 

to bo maintained irrespective oi' the amount smokod 

or when the cigarette srnoking alEe),nsdly commeneed . 

These are extraordinary findings which S.n my opinion 

re:riously c)uestl.on the eigurotte hypothesis . 

(f) Brit:ish scientists report that "in men wRo 

have given up cigarette smoking, mortality rates 

fr.om luag cancer decline immediat:ol,y", (Doll & Hill, 

Hrit, 69ed . J„ ]069, pp, 1.300) . Ef lung cancer is 

a response to a hypothetical carcinogen in cigarette 

sinoke, and this carcinogen hnn boon applied for 30 

or 40 years, how could cossatio n of application be 

followod by an immodiate decline? My ntudics on 

the natural duration of untreated human bronchial 

cancer, and my )niomledge of oxperl.menta7) 

tumor respons 

;c to proved carcinogens, lead me to the con- 

c.Yusion that Do1X Pc H11),'s observat9wn 9 .s compAOkely 

1764 :

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paradoxi .cai . 

Wel.ll dosignod rosoF rch prograrns should hol .p to provide the answers 

to many of these 4uoations, and should, I 

bolievo, be pursued . In thee moantimo, the established 

facts in my api .nion aro7 

(a.) That rnedical science does not yet know the 

cause oi' cancer, or emlrhysema, or atherosclerosis, 

and 

(b) That it is unlikely that a single exogenous 

factor r uCh afl cigarette nmoke should be a prime cause 

o.i thoss three diverse disorders . 

It is my imdorete,ndin4' that those heaxi .ngs pertain 

to l .abcling . If I may be permitted to or.press some 

G'olNn4nte, I Bhonld like to do 50 . 

1 . Cirarottos are said by somo to bo potentially 

l.ethal when u.scd to oxces :s . There is ] .ittl.e doubt that 

automobilos, liquor, wine and, indeed, some say even 

certain dairy products, are lethal when used negligently 

or to oxeess . To be consictent, should we not so label 

all these products? 1Phere does it ondP 

2 . In the light of the know perversity of human 

nature, is such laboli ..ng apt to be more of' a source of 

attraoti .on than deterrence? Ic it any sulestitute for 

education or cormnon sonse moderation? 


3 . 1 bold no br.i.ef for the tobncco companies nor 

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their n,dvertisinC, but X notice no uatiaieal organization 

campaigninL' to curb tho .:ra1e or advertiE:ana of alcohol, 

cars, Etunf: or other lotlra]3 products, ench of v;hioh has 

t.he ovil) that victimr.: of i .to nac or misu :-;o nre frequently 

innocent bye•tienders . ):f smoh3.ng huri -s, "At hurts only 

t.he smoL•er ; it shou)d bo at the bottanc o :P the list of 

dangere i. Prcw whl.ch ei , free people rnust be protected, When 

I nm snSe frum druntcer•, d :rAvors, enz•eless heuvters, and 

sprayhnppy fnrmor.s, thero may be somo 7ogic in savinG nic 

fflôm mysolf ." (Dorothy Samuel, Eati rday hovf .cw, February 

!2, ].PGa), 


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. b . NE'NRY GARLAND, 61,ID . 

References for first five nrunbere,d paragraphs, 

l . . Dean, G, Complex otiology of lun g eanoer . Acta Un• 

lnt, Canoer . 19, 7?l ., 1963 . 

2a . Dorn & Cutler . U . S . Public Health Service Monograph 

No . 5(i, 1959 . 

2b, fAarlcchiug l:esoarch ltoriort No . 189 , U . S . Department 

of Agricultur•o, Jul .y, 1957, page (t3 . 

3 . Rcport to the Surgeon General of the United States, 

19G4,pa6e 95 . Table 18 . 

4 . L4.licnfold, A . M . Medical 'Cribune, 12, 2, 63, page 1 . 

5 . Amorican Heart A•ssociati .on Conver .tiar Report . 

Modern tdedicine, 11 ., 25, 03 . 


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SA'i'G41F.'h'l.' 01T 11A1tRY S . N . GVtBiiNS„ 61 .D . 

My name ic: Harry S . N . Groon o . I was gradnal:ed fY'om 

61cGi11 University, School of itodieine, in 1930 .vii.th a 

degreo of B1 .D ., C .61 . At the present time, I am the 

Anthony N . Brady Pro£essor of £'a .thol.ogy and Chairman of the 

Depa,rtment o£ pat.ho7ogy at Yale University Sr.hooll of 

6fodi .ciue . b am an cxporirnental pathologist and have boen 

act9voYy engaged in cancer swoea .rcb for the past 30 years . 

Y am al.so a smohor, and the etiology of lung ctulcor is 

a matter of persOLa7. GonCOrn as welll as of seielitific 

interefit . 

IIt aptronrs to me that the priwary issuc at this stago 

of the lung ccuwer probtcem concerns an in .torprotation of 

statfstica.l cIrsoeiations . A sta .tisti.aal association 

betwoen two tiappenings ma.y be th.e cause of the other . 

All of those various possibi .litios mur>t bo considered in 

assess9 .ng tho Ed.gnificauco of a statistical association . 

Tt must be omphaE :§.zed that the j udgmeint i .s not made by 

gathor3 .ng moro statistics but rather by subyocting the 

difforont poe,sl .bil.itics to experimontation . In the preeeat 

instance, this moans subjecting the asscuood association 

between smoking and lung cancer to laboratory invosti- 

gation . 


Lnhoratory investigation, to date, has not borne out 

the su[;gostion of a cause and effect relationship . A 

1766

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groat cdca]l of tvor]c has been done, but not . in a single 

instance has lung cancer boon induced by tobacco products . 

It is true that cancer has been proc3uced in the slci .n 

of rnico by long-continued painting with tobacco conden- 

sates . It should bo emphacized, howevor, that cancer hass 

also boon produced in mico by a varioty of common 

innocuous substances such as salt, sut :ar, egg white, and 

cellophane . i''Imther, our concern is with the lung rathor 

than with the s]cin and despite many oxperimentall attempts, 

no tumors have boon f'ou.nd to follow lont€^term exposuro 

of this orge n to i .nhalat.i.on of tobacco nmoko . 

5.`ho reported production of cancer of the lung in a 

dog in an i.n.terval o£ ].]1 days after the application of 

smoke condensate to its bronchial mueosa must• be dis- 

counted . Cencor induct.i.on is a slow process and materials 

of the greatest known potency in this direction require 

months for their action, I"urther, many other experiments 

utilizing this samo mat,erial and ani.mals of the same 

species have yielded completely nogativo results . It must 

be concludeN in the case in question that oi.thor the cancer 

was present before the experiment was begun or that the 

lesion was i .ncorrectl.y diagnosed . 


I:xperimonts utilicing lung tissue in i.nti .mate and 

prolonged contact with tobacco products have boon carried 

out in my ] .aboratory . It had boon found that embryonic 

2769,

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tf .sl .u9ff were mUCh b1Ore fiusCeptibl0 to CU1ICe1'•-indUCS .n[; 

substnnces than wcre t,helr adult counterparts . When 

embryonic or•ganc were infil .trai:od wii:h a canccr-•inducing 

substanco .and transpl ented to the body of an adult ani-• 

mal., cancer occurred with twice the fneidence and in ]oss 

than ha.1f thet titno that charar,tex•iaod tLe reaction of the 

aame organ i .n its adult r,tate . F'or this reason, embryonic 

tiseme transplants Wore used to test the possible cancor•• 

Auducing propert.ies of va,riouo s.ubstancos, includ'xng 

condousoteo f.rom diTferent ciraret :to and pzpe m i .r.turet 

:,cake from my 

pipe, and ash from ci .garetto papers . R nbryonic 

moune ] .ung was used as a test organ, and a very 1arGe 

rnmbor of animals was e hprloyed, but no t in a single 

i.natance was: anytlting romoto],v resowblinrg a cancor ob•- 

tainod . 

The point to bG emphasized is that despito long- 

continued ex pmrimentation, no evidence has boon forth•• 

coming to author.iz.e an interpretation of the purported 

association between tobacco smokinC and lung caneer . 

Cortai .nly a t a comparable stage of pro€;ross in the invosti- 

getion of an assooi .ati.on observod to occur in a researcU 

laboratory, the absence of evidence to support a causal 

connection would cast considerable dout: t on its relevance, 

and high priority would be accorded to a soearch for other 

oxplanati.ons to account for the coinoideneo of the two 


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happenings . %n rey or.pcr3ence as a rof::oarch workor, 

the usual answer has turned out to Le the .t the two 

happeua.nCs wore relatedd not because mre bausud the other 

but because both ropresonted different responses to a 

common canne, 1n thee prosent context, e, promising ponoi-bility n,lonEr this 99 

.ue 9n that a conyon factor may oporate 

to produce an 3ncreased suscopt :Lbilif:y to lung cancer 

on the ono hand and a heavy srnolcerr on the other . 

The snwkinl; population is a solc :ctciR population 

difforS.ng in other ha.hits not related to the use of tobacco . 

in i;'eneral, smoY.erE1 ar'e 1CsC concerv E t.ively inclined and 

havo rnoro noad for the support of€erod by tobacco . It is 

quite po£e.ibl.e that they represent N, d'Y fferont con9ti'Lu - 

tionnl type and that the gonetic doter.mAuers of this type 

also operate to produce an incroared suscoptibility to 

lung cancor . 

Genetic combinations of this vu.r4 .ety are not uncommon, 

and one mani :Pesta t ion may appear comp7,otoly unrelated 

to nnothor . For example, there in a earai.n of rabbit 

collntitutio11n11 .y charFwt.orired by a high incidence of 

OanCer of the nteY.'uEi and a pugnacious disposition . The 

latter is often extreMe, and the animal1 paces back and 

'ior5:h in its ea(je, snarls at pa5:oors-by, and attacks 

hanARers like a bulldog . 


This behavior is present from 

ear.].y l .i .fc and is so oonsintontl .y asrsociatcd with eventual 

1771

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death from a uterine cancer that it nffords a uniformly 

accurate moans of prognosis . 

diffbrent in their manifcstatione+, may bc mediated by a sin( 

In any caso, characteristics of behrcvior, highly 

;le horod'xtablo Eenet9 .c el.ement, nud it i .s entirely 

possible that, in man, an noed for tobauco smoke and an 

increascd suscept9.bil.ity to lung cancc r represent mani- 

festations of a common genetic factor rather than a cause 

and effect seguenco . Thre st:atistlcax observation that 

smokcrs are more suscc:ptible than non-eomobers to a multi 

.y ai7.ments 9n addition to l.ung cancer i.s more 

.-tudo of bodil 

in l.ine with a[;eneral, eonstitlltiena l differefnCe than with 

the expressed assumption that tobacco Eamolce is tho diroet 

causativo agent o f such a diversity of di.r>or.dors . 

. Th e possibility of a variation i.n the constituion of 

pipo and cigarette smokers al.so offers a xationall expla- 

nation of the observed differoncos in c:usceptibi.lity to 

di.sease . The incidonce of disease in pipe smokers is 

reported as not greater or oven less t :b.an that in non- 

smokers . This observed difference in diseaso i .ncidenco 

botween eiGarotto and pipe smokers con stitues a fundamental 

discropancy in the arduments favoring aR causo and effect 

r•cl .atioh,ship between cigaretto smohiug and disease . The 

evidence does not establish inhalation as a factor in the 

dif.ferenco, and the content of nicotine amd bene:apyrono 


~ 

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r:c 

fs a.c.tual.ly gareater i.n pipe smoko . 


%n view o ;: a coruvun oxposure to tobacco srnoke, the 

dt.f:ference in the i .nr.i.denco of dA .soa se between cigarette 

and' W pipe srwkers probably re7.ates to a difference in 

susecpt9bil.ity . rii?'foronces i n susoeptibility to in- , 

featious a godts and cauc.or -producing substn.ncos are known 

to occur in man an d in l .nborctor,y animals and have been 

the subject of i.nten s ivQ study . Faetor5 nuch &Ff ago, sex, 

an d race pl .ay a hi ghl .y sf.L'nifi .cant role and other loss 

obviours variat:iwis in oonrti.tuti.oa are of equal importance . 

Cancer of the lung in man is, iteo7.f, an excellent example 

of a constitut9 .onal.ly affll5.ated disorder . Yt occurs 

prodominnntl.y betwc :en the ages of 45 and 60, in six t.imos 

as common i .ci n+ales ar; in females, and the frequency varies 

widely in different rac.ca; and ethnic groups, The influence 

of othcr constitut9.oual) fac,tors on its occurrence has not 

boon investi .gated, but it i.s suggested that the inborn 

traits that rnake a pipc: smoker or non•-s moker out of one 

individual 2.ncd a ci.raroi :te smoker out of another may also 

be oporativc in determining suseepti .bility to lung caneer . 

ln any case, the inf.oronce that tobacco smoking ie a 

cause of lu nG cancer is not based on experimental evidence 

but on stati .stical judnnront, and my primru•y object in pro - 

parinD this statement has lwon to omphasize that causation 

cannot bo 9rnforred from statistical associatic .n . The 

1773

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.:tatict.ical . relationship betwoen sinoking and lung cancer 

is subject to any nurnber of imssiblo S.utarprotations . 

Vor example, while it can he intel'preted eauBal7.y, it 

also can be interpreted as a con>>tittrt:lonnl d'xathesis 

asEloeiated with a need for tobacco BmeI:e. I;Xperimental 

conf :lrmr..tionn is csscnt.ial. to oi.thea^ 9.r~t;or°7>roRati.on, but 

to date this hnr, not been forthcoraing, and the nature o4 

the roal t ionF/hij'1 of tobacco P3mok :lng to lung cP.neer re- 

mains, an unresolved question . 

The roported discovery of collul .mx modi.fioati.ons 

in various cuêas of. the lungs of smolce.re has led to the 

suGECOsti.on that such modi.fications represent precancerous 

changes . It should he noted, howevor, that ilmg cance 

is a single losion, whereas the so- call.ed, pro- 

cancorons chaingcs are found in multiple pulmonary locations . 

i'arthor, i.dentical chaufes in the appcaranoe of the colls 

are present in the lungs of adults with pneumonia, influenza, 

and other pulmonary diseases and are also couimon i n 

diseace of young children . Mi.ce also reaet similarly 

to infecti.on with ini'luonza virus and respond with a 

rapid growth of bronchial coils so an.apl.astic in appearance 

as to lead to an erroneous diagnosis of cnnoer . Such 

lesions, howover, completely di.sapiwar when the animal 

recovors from the disease . It in apparent, therefore, that 

the changes in Wnolcors aro not preoancerous and that 


r itself 

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their Urodence in the lung dooe not rcr7.ato the habit oR 

smoking to canoer . 


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SA'PBM E N'f OF LS6 KAT'L, PH .D . 

I am h oe Katz oi :' East Lansing, Michi((an, currently 

Professor of' Statie.ti.es and Director of the Statistical 

Laboratory at Michigan State Univorsity and Visiting 

Professor of Niostatistics in the Nedica.l School at the 

Univors5 .ty of Cinci.nnati . Since 1951, I h.avo beon 

ha•incipal . lnvest:igator on r.esearch sponsored by the Gffice 

of Naval NCfIOG.reh and the NationRl Scienee Bonndati.On . I 

have hold VisitinQ P2rofessorships at tho . University of 

North Caro].ina and at Stanford Univerrity and have servod 

one year as Lhmopean Scientif5 .o Linson Gfficer for Prob- 

abil9.ty and Statistics in the London branch office of' 

the Gfi'ie0 of N&val. Research . 

I ali1 a PG11oW of the lnstitut0 of M.athematical Sta- 

t9 .st9.cs, the American Statf.st:i .cal Association, tho Royal 

Stat:i.stical Society, and the Amorican Aesociation for the 

Advancet:cont of Science . I am a mombr, .r of the American 

MathCMilatieni . SOO£!lty, the Mathematical AsflOeiatiOn of 

AmOriCa, the IAndon Mathemati0al Society, the DiOmetric 

Scoi.ety and othors . My teaching, rosoarch and consulting 

activities aro all. in t.he fields of Mathematical Statistics 

and Probability Theory . My vitae in (,reat.er detail are 

attached hexowith . 


The report of the advisory committee to the Surgeon 

Gonornl of the Vid .tod St.ates Public llealth Service has 

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two prime objectives ; firstly, to esttrblash that thore 

exi.sts a clear and significant association botwoon pat- 

torns of smoking hnbi.ts and risks of death, and secondly, 

if associ.ation in established, to verify that the form 

of this associatfon is betweon smokinN' as cause and 

111croased ri.sk of death as offer,t . 9a partieu7.ar, the 

argument is in sharpest focus in consi.dering the relation- 

1777 

ship between the ama.utt of ciiiarettc smoking and the risk . 

of doath from cancer of the lung . I d.irect my initial 

remarks toward clarification and ovaluataon of the extent 

to which these two objectives are attained in the report . 

ASSOCIATION 

On the first objective, the do9:ermination of asso- 

ciation coul

ty 3 


in a population are Sndood associated, it is o]omentAry 

and os::ntial stati.sticn] prftctiee that' . the investigator 

seloc+t his samplo so as to represent ndoquately the popu- 

lation he studios and that he neither permits individua] .s 

to nomi.nato themselves for i.nclusion in the study nor 

user some readily avilablo but possibly non-reprosentative 

group of individuals . Yurther, the fact some do and some 

do not respond to hi s queries invites the immediate eae- 

picion that theso t wo groups may differ In respect to the 

very attribtltos being studied ; a further investigation 

into the similarity or dissimilarity of mon-rospondents 

to rospondonts is necessary to allay We suspicion . The 

fact that the vari.ous computations mnde from the sample 

e.urvoys reported by the advisory col:mlittoo to the Surgeon 

Goneral consistently underestimate the knonM general and 

spcoific death rates of the population In an indication 

that such biasos did i.ndeod occur In thor.e studios . 

IVh11o one can sympathize with the committee in its 

i.nabil.ity to go beyond existing studies to conduct In- 

dependent investigation of Its own, It is unfortunately 

true as matters stand that there is no way to ovaluato 

accurately the extent of the biases In the osti.mates . 

At the very least, the committeo has established that 

there might be an ascociation between cigarette smoking 

and lung cancer ; at n,ost, it has established that the 

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ar..&ociatiou is oP the maLnitude c.l.aimed in the report . 

The truth of the matter is probably somewhere between 

these two cIItreSti08 and ,7Ufit.ifi0s leeltinQ : into the s'econd 

ic:nnee, name'ty, whether the assee£.at£on mit;ht be one of 

caiNSe and oi:fect . 


1 should like to om7ahasi?e that there is a f'unchanantal 

difforenco betwocn argumcnts which serve to establish as- 

sociation and thoser required to dete.rrein,u that one phencnnenon 

is ctur•al and ano•ther is an effect ascribablo to the 

P,i.rst as cause . Ar.socS .ati.on i s a purely statistical 

prepcrty of colloctions of observations on two attributes 

of thc same ind5 .viduals . The occurrence of association, 

in wh :atovor degree, cannot of iteolf ind icate whether or 

not the re9ationrhi.p between the attributes is or is not 

one of causo•anci-r,ffcct . %n particul .ar (s;ee pp . 182 ff . 

of the report to the Surgeon General), evidence as to 

",, .consistoncy of the assooiation,,,•strenEd :h of the 

association . . . . spocificfty of the asli0ciation, .,,temporal 

rol.ation of the assoc:i&tion, (and/or) . . .coheronce of the 

assocf.ation" can ouly serve to buttress the claim that 

thore- in association bu t cannot cast any light whatever 

of the guestion of causa7l relationship . 

CAUSAI,I'!Y 

l..ogically, onco posi .ti.vo association has been es- 

tabliEhed bbtw

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statistical £ilferOncO, there are only four posS£bil£ties 

nlD regards the nature of th9 rel .al:ion ship . These ar

. 

• 

committeao could have boon so eontaminated that the asso- 

ciatione : observed muOt bo $udged to be mostly spur.ious . 

],et us assume, in order to continue discunaion in the 

present line, that the fourth posuibi :lity listed above has boon 

ruled out ; we still have before us the problem 

of deci.dl.ng which of the r.emaining th roe r.ases describes 

tho causal nature of £he relationship botwoen the two 

factora . The insue now in clear : DUeft A cause B, does 

B cause A, or are both A and B ef'fects due to an under- 

lying system of causes which produces tho observed ae- 

sociation9 Uero we come to the heart of the matter . Up 

to this point, statistt.cal mothods to evaluate the dogroe 

Af assoc:iation are valid and, indeed, aro the only valid 

method of proceeding in the ftace of individual variability 

and uncertainty . However, from this ppint onward, sta- 

stiti.ca l mothods alone are of no further avail and our 

only recourno it to definitive exporimoni;s . Specifically, 

the question of cadsality can only be resolved by an ox-• 

porimon t so designed that two clearly diatinguishable re- 

sults of the exporimenta .ti.on will be observed depending 

on which of the two competf .ng hypotheses in correct : 

(1) increased cigarette smoking does cuasc increased risk 

of lung cancer or (2) increased cigaret.te smoking does 

not caaise increased ri8k of lung canecur . Since no such 

oxpo:rimcnt han boen dono, no positive statement regarding 


1781

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causality is ,ju ::ti.fieu, 

The argument ) have just presented ie entirely in•- 

depencient, may I stresr., of the question of association . 

1Yoti.co that I st.ipttl .a.ted, for oontinuat3.on of that dis- 

cussion, that association did exist . INt us turn now 

t.o the claim euade by the advisory coaunltteo to the 6nrgoon 

Gonera9l thnt the resu]tsr of oxpori.monts which convoy in-- 

f'ormation rogarding associati .on can somehow be made to 

impui:o the ex7.stence oi a cause-offect relationshi.p if 

the nssociation is consi.stent, strong, specific, of 

propor order in tempora l relationship, and coherent . 

psychologists are agreed that poople differ in their 

i.ndivi .dua7l noods for oral gratificatiore and that one of 

the mai.n sources of this gratifi.cation is the smoking 

habit . Another pri.ncipal source of sa5'.isfaction of oral 

needs is the habi .t of thumb-suaking, practicod largely 

by infants and usually abandoned in early childhood . It 

is not at all tnn likely that carefully-oellducted oxpori- 

nients would i ndicate significant associations among oach 

pair of the factors : 

cigarette smoking, deaths from lung 

eancor, and thumb-sucking in infancy . Focussing on the 

association batwoon thumb-sueking and deaths from lung 

c,ancer, we seo that the tomporal relationship is even 

more pronouncud than betweon smoking a .nd 


:h.at 20 :lcmg cancer,k'urther,it is reconable to suppose t retrospective 

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studic[: could consist.onfa .y uhcro stronE, association as 

spec:if't.c as that soen In lung cancer vor,us nmolccing . 

Mally, this whole ool.lection of phenomona is coherent 

In a theory which holds that those indivi.duals who develop 

thc tknusb-+:uch ;nk; habit and erc l.ater fe» •ced by social pre s•- 

sures to adopt other foxms: of oral g ratificati .ou tend to 

introduce in.to thei .r iuouths and r.ir-passnCes carcinogenic 

and other 9oa!]l suh ste.nees which nay pirodtwe lung cancer 

(aud 9.ncroaaed risyk of cleath from a long ].ist of causes) . 

'a'he hypothet5 .c:a.ll c»:.ampl.e we have just oxamined is 

not entirely trivie.l . Although you may object to a claitn 

made on the evidence ou9D .iamd thet lung crnn c:or is caused by 

thumb - s•uoleix,C, X, ras,i.nte.i.n that this ia ; precisely the nature 

of the supPW inE ovi.demco for the claiscm that lung cancer 

is c:auued by ci{tarette smo]cinC• Y'he stnti .stica] arguments 

presey :tod In the report of the advisor .•y cosmnit.tee to the 

Surgeon Gentral cannot, in and of themselves, be used to 

go beyond demwnst.r.at4on of a .ssociatf.on in an attempt to 

support a cnsc• for a causo••offoct relationship . 

PDSSIDLF: AC4'IONS AND C.ONS1iQUl:NCRS 

My remO.ninC ro wnrhs are directed toward discussinG 

brief]•y the posnS .bl .co actions ava.ilablo to the Conrree :s 

of the Unitod States, on which rccovamvndations may be 

macle by thfs comm :k.tteo . My ow• n opinion is that the 

questi.on of whether cigarette smoking cavses lung cancer 

19613

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ty 1) 

has notheen settled, nud that oonsetguonily no fina.ll 

dooision ehou]c2 be und.ertalcsn on the+ s :tronsEh of the 

prosont evidcnoo . ti'hor.efor,e, itt c,oemw: to aic that the only 

possShlc action which shouAd bye conside .ed by this conmzit•• 

tGC 1F A, dec@t#ion to Po .9,S .hholrA jufig]Oent and to cA.l1 fox' a 

jud;aaont and to cu .1.7. £or a maximmH effort to produce 

ono or more i+.efieoStiye oxp ov i,monts which would provido 

cmra]oai.vo ewidcnoe on the matters st :iA1 under dispute . 

$ feo l mo,+t cEa7osE{I.y the dGsirab il .S.t,v of Qoei .Bn9.ng 

r.nd poar2orm2ng euch a>qlcrimrmte as oxpodAtious7 .y u .s pos . . 

ei .bl.c . Y ercpeet that wc &ha .11, encountc!r ciifficul .tio€, in 

enrx•yiatt out th3s proPram, but a£ter aBbl n peopl.e who 

eNh flchY.eva 8uch diverF.e la9rlLcle6 as ?IDterplaliotary travel 

OmGi ttho inV(riltion of a pl .€lEtiA ha(( to wrap sandwiches 

should h[cvo no tnsur•aiowe9 :€€h1 .e difficult :y s.n ma .rshal.l.ing 

enouGb. i-n¢earu4t.y to o€unry oast saeh a pxogran of er,per- 

z€aentu .ti .on . 

http://legacy.library.ucsf.edu/tid/hly24f00/pdf

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aiJ 

9fAT E M7;NT Or UR . SHHRMAN IfAVLAN 

My narne i.s Pr . Sherman ICaplan . 7 am Ch< :i .rman of the 

Ucpartment of Medici .ne, Mt . Si .nai. Hospital, t1i .arni Heaeh, 

Flori.da, end Assistant Clinical Professor of Medicine az 

the llni.verslty of Miami. Medical School . 

I am a specia.7i .a:t, certi.fi.ed by the fvaer:ican Board of 

]:nirrnal Mcndi.ci.ne and a Fellow of the Ameri.can Co].lege of 

Nhysici .ans . 


] 76 -b 

I att.ondcd medica l school at the University of F,ouisv9 .] .7 .c . 

After completing internship and residency training at Michael 

Reese Ilospi tal and Cook County Hospital i.n Chicago, l : taught 

at the Cook County Post Graduate Sehool of Medicine, the 

Ch9.ca.P.o Med :i.cal Sc.t,ool., and parti .ci.psted in the running of 

a tcachi.ng dopartment of the Cook County Hospital . . 

Por the past thirteen and a half years T have practi .ced 

in Miami Beaeh and at the present time 3 am engaged both i .n 

teaching house staff c,ffieers at the intern and resident leve7 

and in the private practicc of mcdir.i .ne . 

My training and practicc havc beon devoted principally 

to the treatment of diseases of' the heart and vascular systern . 

Practici.ng in Miami Beach, I have had a unique opportunity to 

obsorvc and treat a groat number of people corning from a71 

par•ts of the Uui .tod States and many foreign eou.ntrnies sinq>] .y 

hecreiuse : of the fnct that I am in an arca where the temperature 

:is warm emd the c0.i mate eongemia] for people with thi.s type of

• 

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jon? 

diseaGe . 

During the past thirtcen and a half years there have 

passed throu Rh my practice not less than 2,500 individual .s 

with condi .tione• ro].atinf; to acute coronary occlusion and 

coronary artery i.neufficiency, 

These peop7 .e have come fr•om various and diverse bttek• 

gro umds and they ane as varied a group as can be found in 

any usual human popu7 .ation . 

1766 

From obscrving these pati.ents and col7ectinF information 

about a7 .1 aspects of their histories and life pat:terne: I have 

reached some conclusi.ons rc7 .ative to the background and de- 

vc7.oprnent of coronary artery disease which I wou l.d like to 

coromunicate to you . 

I would like to approach from a cli .ni.r.a7l viewpoint the 

question whether cigarette smoking results in deleteri .ous 

effects on t.hee cardiovascular system ].eadiny, to coronary 

artery diseare and to review critically the notion that 

smoking may bc responsible for some large number of deaths 

resulting from the effects of this di .sease . 

I would al .so I.i.ke to review briefly established causative 

factors of vascular disease . 

I should like to emphasize at the start, that to this 

date, there i .s no known proven cause of hardeni :nP, of the 

arteries (arteri.osclerosi,s) . 


First, aet: me point outt that a gr

• 

jon'i 

coronary disese ar e traceable to certain definite disease 

cirCum5tanCe& . . 

Diabetes, wh :ich to most people simply means a di .sorder 

in the body's handling of sugar, is knoan by physicians to 

be an important contributing factor in various types of 

vascular di .sorders . 

The circ:ulatory di.ffi.culties which arise from this 

disorder may ]ead to a group of comp :l.i.cai:ions, includinF 

marked dec :rease of blood flow in the coronary artery . Thus 

we find that the incidence of coronary occlusion in the 

1787 

di.abetic is considerably in excess of that in the non-diabetic . 

A second disease c•i.rcumstance ]vr.die:posi.ng to vasmrlar 

disease is one invol .vinp• the abnormal hu'ndling of ingestcd 

fats . It is called "hyperli.perni .a" ar,d is characterized by 

ea fatty or m i .]ky appearance to the blood serum . 

This condition is hereditary and results i.n marked 

deposi.ts of fat arrd calcium materi .all in the arteries with 

premnture death due to vascular di .sease :i.nvol.vi.ng, in the 

wain, the coronary e.rtery . 

To these recoGni.zed disease circumstances we can add 

the effect of the ap p arent inheritance pattern in heart 

ciisoase . 


When one i .nterrogates a patient with coronary artery 

di.sease about his family history, he is impressed by the 

faci: that the patient ur,ua] .]y re.veals in his genealop•y an

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unc:ommonly high incidence of vascular disease not only 

among his e.i .bl .i.ngs but i .n his parents and grandparents on 

dne or both sides of the family . 

The fre quency with which this type of history occurs 

presents the unavoi .dab].e conc] .usion that there is some 

1769 

hereditary abnormality involved in the production of vascular 

disease, which i.ncludcs not only corornary artery disease, but 

hypertension and stroke as well . 

This abnormality i.s present at the very moment of 

conception and its presentation as some form of vascular 

disease depends only on the passage of the proper interval 

of time . 

l :ven mo :re intri.guing is the contribution of the factor 

of sex ;io rnones to the i.ntegrity of the vascular system . Tt 

is a we] .L-estab] .i.shed fact that the menstruati.ng female is 

uniquely protected aCainst coronary oeclusi .on 

. ln 

contrast, in the post-me :nopausal female in whom 

ovarian funetion has decreased or ceased, there is now a 

sha .rp ri.se i .n the inci.dence of coronary occlusion, so that 

the i .nc:idcnce among these women approa.ches that of their male 

counterparts . . 


Another i .nte :rr.st.i.ng fact is that when the ovari.es of a 

young menstruating female arc removed, the incidence of 

coronary artery disease in such females abruptly rises to a 

ratc paral.l .e :l.ing that in the male or the post-menopausal

• 

femed .e . 

The importance of e:ex hormones if f urther borne out 

ty the observation that males in whome certain types of 

liver damage occurs -- such as in the chronic alcoho]ic 

with cirrhosis of the ] .i .ver --- the deactivation of female 

hormone accompl .i.shed by the normall liver is absen t and he 

exhi.bits certain feminizing changes . 

Such men are found to have a surprising freedom from 

coronary artery disease similar to that in the menstruating 

young female . 

A particular0.y nertinent subject for the purpose of 

this discussion is the wel l known effects of stress upon 

the cardiovascular system . 

It has been wel l documented for some time from 

observations in l .aborat.ory ani.mals that in circumstances 

of increasing t-neiions orsudden stressfu]l stimuli there is 

a response in the function of varous endocrine glands, .whi .ch 

results in isar•ked alterations in cardiac output, heart rate, 

serumcholenterol ]evel and vari .ations from the norma]l blood 

pressure . 


C :Linica] studios have extended these observations to 

human beings in si .tuati.ons of stress . 

Some yenrs ago observati.c,ns were made on a group of 

accountantc i .n Sar, Yranci .sco . The group was evaluated first 

in the month of Septembor with respect to serum cholesterol 

1769

. 

• 

'lon6 

]evcls, and blood clotti-n{; acti .vity . The sarne group was 

7790 

then re-eval .ucted during F1arch and Apri .l. . Under the stresses 

of the tax r :eason a striking change was found to havee occurred 

in al] of the fa ctors studi.ed . 

'1'hi.s group which in Septe mber had appeared to be 

essentia7.ly norma] in ra:sper.t to cardiovascular function 

showod under stress th e disturbances which are thought to 

favor the deve.loprnent of coronary artery di .ser.se and coronary 

occlusi .on . 

These studies have bcan extended and si .rnilar results 

found by owuparinfi eo]le .F;e Ftudents during the mi.d-semestcr 

and during final exam weck . 

Striking di.fYercnccs are seen in the rate of coronary 

occlusion in the overworked and pr e saurcd gener&. practiti .oner 

of medicine as compared to the pathologist of der mAtolofi i e.t . 

llow docs cigarette smoking fit into t.his patternl Tn 

my opini.on, it ie• simpl.y nn easily visualized or discqve rable 

trai .t whi.ch is very l .iknly to bo part of the behavior pattern 

of an indi-vidual rcaction to etress . 

St does not cause or exacerbate the cardiovascular 

scbnornnalit-ies which appear to contribute to the development 

of heumt disease and heart attacks . 


In thi.es connection , ci(;aretto smoking in ana]ogous to 

nail bi_tiny, or hair p :lucking which sorae individuals resort 

to under 5i'itt8tio11F.' of SnCr•ca5ed tens :ion or sbêss .

• 

• 

0 

It is i .uteresti .nPg that very often the so-called chain 

smoker may actually consume very ]ittle tobacco . Like the 

nail biter, who i.s unaware of biting hi .s nails, the chain 

smoke.r is not awe:re that he has reached for and lighted a 

ciga»ette and he may snuff it out after one or two puffs . 

]:n norma] . humans, smoking p ro duces no change i.n blood 

flow in the coronzry arter . X-ray studies of the coronary 

1791 

art:eri.cs bofore and after smoking show r,o change in the vessel 

cali.ber . 

With cmriinucd smoking there is no change from the 

resti .ng ].eve] of coronary flow in both norma7l persons and 

those with eoronary artery di .sease . 

The elec2rocaz•diogram in both normal and heart patients 

shows no sign :tficant change and frequently none at all in 

the presence of smoking . 

Studies relating to the clotting of the blood show no 

effect from tobacco or nicotine . 

'1'o c:onc]ude those ra:marks, I wish to comment briefly 

on t.he idea which has been advanced that steps taken to 

discourane cigarctte smoking may reduce the number of deaths 

from cerdi.ovascular di-sease . 

]: have tried to point out that evidence to estahl .i.sh a 

eonnection between smoking and coronary artery di .sease -- the 

most common forvn of he.z.rt disoase --is ].acking . 


'1'he rcce:nic popu]ari.ty of the theory ihat cho] .esterol i .n

• 

• 

]eno, 

the di.et was a factor favoring the development of coronary 

diseaee yve rri.so to a big business in safflower oil and 

other forun& of unsatm•ated fats. ' ' 

The emphasis on obesity as a factor has led many people 

to undertake crash diets . 


Theories concerning the type of behavior which is best 

calculated to afford an individual protection from heart 

disease have been advanced from decade to decade and have 

en j oyed varying degrs.e.s of popularitiy . 

Just as the Public Ilealth Service has wisely refrained 

1792 

from endorsinPg any of these theoriees in the past, so it would 

a]so seem wise to avoi .d any expressi.ons which appear to endorse 

the theory that cip,arette smoking is i .mp :licated in coronary 

artery disease in the present state of our knowledge . 

k'ar moro pertinent woul .d be an undaunted pursuit of 

the missi .np, 7.ink;s in the fawi]i.al transrni.ssion of vascular 

disease and Ca.t metabolismy and a carefualy p7 .anned educatior,a7 

program desi .gnod to champion an even and moderate way of life . 

/s/ Shemnan R . Kaplan, M .ll .

• 

• 

STAftliP111NT OF SENATOR R01tSRT F', KllNNEDY 

The testimony at these heari.ngs leaves no doubt that 

cigarette smoking i .s a pub]ic hcalth problem of great and 

Frowin g seri.ousness . The ovcrwhel.ming consensus of medical 

opinion holds that smoki.nP is the pri.nci.pal cause of lung 

cancerwhi.ch ki .l].s more than 40,000 American s every year ; 

that it is a major cause of chronic bronchitis : and that it 

1793 

is associated with, and may well be a cause of, heart disease, 

emphysema, and other serious diseases whi .ch each year bring 

des.th to a large number of Americans . 

In New York Ci.ty there were 2761 deaths from lung cancer 

a]one ] .ast year, to say nothing of the other diseases, and 

Dr . George James, The City's Co mmissioner of Health, estimates 

that, viewed conservative] .y, at ]east 70 percent of these 

deaths were attributed to cigarette smoking . 

A pub].i .c health problem as grave as cigarette smoking 

demands prompt and effective action in the public interest . 

But what doe :s t.he record show has been done to protect the 

publi.c7 

7'he ans .wer is not nearly enough . The eir;arette companies 

themselves, who cer~ta.i.nly bear the brunt of the responsibi .lity 

havc not undertaken c.i,gnificant action . Not only do they con .- 

ti.nue to deny that ci.gzurotte smoking is an estab] .i.shed health 

harard, but they have tried to dampen pub] .i.c awareness of tlris 

hazard through rr,aseive ac]vertisi.ng . 


• 

• 

jon% 

These campaigns seek to impress the American people 

with the untenable notion that ci.i;arette smoking i.s con- 

sistent wi.th hea].th and vigor, and that i .t is a mark of 

sophista cai :ion and maturity and a gateway to glamor and 

rornance . 

Si.nee evidence of the hea] .th risks of cigarette smokin g 

began to appear, the cigarette companiee have spent rni .l] .i.ons 

2794 

ofdo]].ars to advertise their product --mainly to tc].evisi.on 

and radio audi .ences including large numbers of children and 

teenagers . 


Too often youngsters are swayed by advertising that 

conveys the idea that if they want to act like grown - ups they 

should ]i ght up a cigarette . They are too young to reali .ze 

t:he scriousness of the dangers to their health when they 

srnMeo these dan gers seem too remote and distant . 

They cn•e not, however, too young to obtain cigarettes 

and thus acquire a habit very difficult, if not impossible, 

to break in later life . Once aa youngster becomes a confirmed 

smoker, he may never be able to break the habit, even after he 

grows up and gai.ns an insight into the health dangers . 

In the absence- of any significant effort by the cigarette 

companies to face the problem -- and current cigarette 

com-mercia7 

.s demonstrate that the much-publicized Cigarette 

Adverti.si.ng Code adopted by the manufacturers has made no 

meani .ngfu7l c:hanRF In cigarette advertising -- private groups

• 

• 

jou"s 

like the American Cemoer Soci .ety have tried to educate the 

7795 

public in the dangers of cigarette srnokinR . But their efforts 

have been modest and have been mostly lost in the tide of 

advertising by the ci.garette companies . 

Government -- federa] ., state or local -- also has not 

done enough to cope wi .th this groat public health probl .em . 

In c:ontrc:st to other potentially harmfu]l products, cigarettes 

are promoted and distributed wit.hou t restr•i.cti .on . 

N thoueh drugs whi .ch may have harmfu l side effects are 

labeled to al.ert the purchaser, cigarettes are not . Hard 

liquor is not advertised on tclevisiom eiParettes arc . 

AAcoholic beverages are.not sol.d to minors ; it is not uncommon 

to see children in the seventh grade smoking ci.garettes . No 

one can driv e an autcnnobi.le without being li.eensed : anyone 

con smoke cif;arettas . 

The fact that cigarettes are sold and promoted without 

rostr .i .oti .on (either self--i .mposed by the oiga m tte manufacturers 

or i.mposed by government) helps explain why many Amcri .cans do 

not yet, despite the evidence, fu] .l.y understand and accept 

that cigarette smoking may ki]]l them . 

7M only agency that has made a serious effort to cope 

with this problem is the Federal Trade Comnission, whose duty 

is to prevent unfair or deceptive advertisin g of produeta 

sold in interstate commeroe . 


On the basi.s of hearings in which the views and opinions

• 

• 


of' all i.nte.rceted parti.es, i.ne] .udi.ng thee cigaret:te manu- 

factm~ers, wcre considcred, the (:omrniseion determined that 

1796 

it i .s unfvi.r and dccepti .ve to sel .l cigarettes without • 

di.so]osi-rrg on the nackage and i .r, al) advertiscments thet 

cigare

• 

• 

• 

jrn0 

lt is deceptive for oigar,ette cornpaoies to advertise 

and promote their products without a hint of the dangers of 

cigarette smoking . Our children should not be exposed to 

such advertisi .ng . 

7'ho Commission's Rule would not prevent cigarette 

rnanufactur.;rs from advert :i.si.nR their product to young people, 

but it would at loast: prevent them from giving a one-si.dc.d 

view of cigarette smoking in their adver•Ci.cing . 

It would make them give the whole p :ic:ture -- whi .ch is 

that whil .e cigarette smoki.ng may he enjoyable to some, it 

is at the stnue time a cause of disease and premature death . 

1997 

What are the re.e;ponsi.biliti.es of the Congress in respect 

to the publir health problern of cigarette smoking? 

Phcre are many thin g s we can do - there ien very clearly 

one thing that we should do first, and that : is strengthen 

the Pcderal Trade Commission's s.uthority to enforce its Rule 

requiring r cautiona.ry statemcn t i.n u1l cigarett e labeling : 

and advertisiny, . 

]sefore the ci.Farotte manufacturers could be compelled 

by ]aw to coiip] .y with the Commissi .on's Rule, it io almost 

certain that there would be protraoted litigation to test 

the Conmiission's authority to make such a rule . Such l .iti- 

Cati.on could delay the effective ctate of the Rule for some 

years, and i .n this period the public would be without pro- 

teeti.on . 


. 

. 

jcn6 

1798 

Congrv'ss, however, can elimi.nate al.ll question of the . 

Cor:rrnission's authority to r :oke its Ku :l .e by expressly 

enacting the requiremer,ts of the Rule into a law . This, 

in effect, i.e: the aunrorrch taken by Scmat.or Heuber{;er's 

bi1l . S . 547, whieh thi.s Committee han under consideration . 

9'he other [,i.7.]l under consi.deration by this Committee, 

Senator Magnuson's bil] . (S . ;t59), takes essentially the 

samc; apt,r~ach, but it is limited to labo :lirrg . 

Chai.rrnan Aixon oft.he Federal Trade Commission has 

testifi .ed -- and I think any ] .aryer considering, the quest9 .on 

ohjectively mou7d agree -- that the Mapnuson bill would 

].eave uudist .urbed the Cornn•.ission's uuthori.ty to enforce 

that part of i .ts Trade Regulation Rule which requi.res a 

caut.ionary stat'ement in all cigarette advertising . 

7 favor the auProach taken in S . 547 . But if Congress 

acts only on the labeling proftrant, then it shou] .d use S . 659 

to do so . 

One point requi.r•en special emphasis : Legis] .ation 

proventinF tlro F'edoral Trade Conmrission from reMulati .ng 

eigar•ette adverti .s :ing would be directly contrary to the 

pub]ic welfain in view of the grave health hazards of ciga . 

rettc: smoki .ng . 


There ir; no justi.fi.c :ati .on for puni .shing the Commission 

for promptly applying ge.nere. l consumer-prot.cetion ] .eptislation 

to ciFcrette advert :ising . The result of such punitive

• 

• 

ion7 

legisl.ation woulA he comple.t:el.y anamalous . It would di6-- 

courap;e the C.ornmission from taking needed steps in con- 

troversia] areas in the future 

.ssion would remain . The Commi free to enforce its Fenerall 

consurner--protecti.on legi.sl .nt :ion by requiri .ng in a advertising 

an affi.rma.ti.ve statement whenever, for exaimple, a sell .er's 

motor oi .l was reprocessed rather than new, or that the 

1199 

advertised product was of foreign rather than domestic origin . 

Ru t the Commission would no l.onger have the power to 

prevent consumer deception regardirrg c :i .gare t:tes . It would 

not require disclosure in cigarette advertising that cigaret.te 

smoking is hazardous, despite the consensus of medical opinion 

that cigarette smoking i.s dangerous to health . 

The CornmS.ssion would be powerless to act, even though 

in its Trade Regulation Rule nroceedi .nt; it made painstakiuf; 

findings - whi.ch have rrot been controverted --- that the 

tx:quirement of a cauti .onary stat

• 

• 

Jun 

involved danr;erous to health . 

Legislation dea]ing wi .th the rnarketing of cigarettes 

in ]i.Cht of the heal .th hazards of smoking has its origin, 

of course, in the mounting public concern and the now 

overwhe] .ming evidence that those dangers are real and not 

me rea.y conjectured . 

Por such ]egfs].ation to include any provision that 

would prevent the Commission from exercising its authority 

to prevent deceptive cigarette advertising would be a 

regressive step . 

]t would mean that Congress was curtailing the 

Commi.ssion's authority with respect to the adverti.si.np, of 

this commodity, and this commodity alone, despite public 

concern and medical evidence that : cigarette smoking is 

lsoo 

dangerous . That, surely, would be a paradoxiea l and untenable 

resu7t . 

T, therefore, urge thi.s Committee and the Congress not 

to accede to the powerfu7l pressures being applied by those 

who have a P take in ihe unrestricted sale and promotion of 

cip;ar•ettes . 


ConP,ress should not adopt le g islation that would curtail 

the Pedera] . Trade Commission's authori.ty to require truthful 

cigarette adverti .s:ing . I would urge this Committee and the 

Congress to support leF.islation that strengthens the Corn- 

rsission's authority i :o protect the public against unfair and

• 

• 

• 

on9 

misl .ceiding cigarette advertising . 

I do na t me an to ].eavc the impressi.on t.hat I regard 

a warning statement in cigarette adverti .si.ng and l.abeling 

as a completc answer to the proh] .om of cigarette smoking 

and he.alth . The Dri.tish, for example, have banned a11 

cigarcti.e : advertising nn television, and ar•e studying 

l.initati_ons on advertising in other media at the present 

ti.me . Ras: :icaJly, horaevmr , the problem is one of education, 

and this wil7 be a difficult task . 

Ci garetto smokinC is attracti .ve to young people as a 

]&ox 

sign of matur.ity and sophisti.cation, and the cigarette habi .t, 

once aoqui .red, is very difficult to M e ak . 

if there ir, to he any hope of c :hanging the smoking 

hnbi.ta of Ameri.can youth, it is assentia .]. That some restric- 

tion be pl.accd on cigarette advertising . Just as ci.garette 

adver t isinR nv,ny years ago mado cigarette snioking by women 

soci .al .l.y ac:eeptable, .^.o contemporary ci.garette advertising 

hcis e.ouf(ht and secks to make cigarette advertising the symbol 

of adult and sophi.sticated life, and as such an ir re sistihlc 

attrar.ti.on to many young poop] .e . 

Thc: minimum restrietion on sueh adve,rni .si .nt; is to requir•e 

the inclusi.on of a wnr•n :i.ng statement in alll cigarette adver- 

ti.sinq, euc.h a restri.crt :ion holds out €ome hope, at l .east, of 

re.duci .ng the effecti.veness of rui .sleuding cigarette adverti .sing . 


But it is en].y a srall fir!xt step in the campaign of

• 

• 

JOnJII 

pnb7 .i.c education that i.s nececsarY i .f we are to dea]l 

effec7:i.ve7y with the probaem of ci .g-r..rette eanoki.ng and hca7th . 


c-1 1803 

itHODN'. ISI .AND f1OSPITAL 

PROVIDENCE, RHODE 

March 26, 1965 

Sonator John 0 . Pastore 

201 po[ :t Office Annex 

Provtdenco, R . 1 . 02003 

Uear Senator pnstore : 

ISLAND Lloyd L . Hughes, Executive Director 

My conti.nui.ng experience with the tragic problem of 

advanced, untroatable lung cancer has prompted this urgent 

letter . Your positiou as a raomber of the U .S . Senate Commerce 

Committee afforc?s you an unucually good opportunity to pre- 

• servo the lives of many thousands of people who now smoke or 

are about to ini.tiate this habit . 

I would ur€YO your strong support of Senate Bill 0547, 

Introduced by Senator Ma.urine Neuborger of Oregon, with 

Scnator Clark of Pennsylvania, "TC confer upon the Noderal 

Trado Coamnission the power and duty to regulate the advHr- 

tiuiuC andlaboli.ng of' r,ig[±rettoc ." It is vital to the 

itnproverae~at of the hoalth of .all Ame•ricans that this bill 

bccomo law for the following reasons : 

• 1) 'fhe causative rol .ationshi.p between cigarette 

rmol:ing and lutng cancer is a raattor of established sciontific 

Sact . 


i) '1•ho cli.nfcltll courso of chronic pulinanary dtseaso,

• 

• 

• 

c2 

spocifically chronic bronchitis, brouchioctasis and 

emphysema, is greatly exacerbated by cigarette smoking . 

3) besides the inoe,tirnable econornic: loss through 

i.l.lno&s from ehronic pul .amnary disaas e and cancer, the 

combined death rato of these diseases, including cancer, 

oxceedr. 300,000 persons por year . Many such deaths are 

premature because of inc:reased early pulmonary damage 

resul.ti.nLt from excessive smoko inhala.ti .on . 

4) In spite of the excellont educational programs of 

the American Canccr Society many people havo failed to 

1804 

gra.sp tho significance of the rolationship between cigarette 

cmoki .ng and pul .monary impairment, including bronchiogenic 

carcinoma . A law which would influence cigarette consump- 

tion by specfe .l labelling of the product as woll as its: 

advertising, supplies authori.tY through our government 

organization which so often has assisted people in health 

matters 1n tho past . There should be no greater hesitancy 

for defining and label .ling the toxicity off a tobacco product 

than for informing the purchaser of many proprietary 

medi.cinos that excessive use is dangerous . 

5) The potential harm from cigarette smoking lios 

primarily among the very young . Cigaret.to advertfsing !s 

obviously directed toward the young and lmprossionablo among 

our peoplc . It in the advertising that is scrutinized by 

the viewer rat.her than aa almost il7.egil :.le label on a 


• 

• 

cS 1R05 

cigarette package . Thereforo, it is essential that proper 

warning be attached to all advertising with special concern 

for the potently effective television mcthods . Failure to 

regulate the often misl.oading television advertising of 

cigarettes renders a specific disservice to our young people . 

Al.though it is clear that Senator Neuberger's bill 

would properl .y embrace the entire problem, a second bill, 

introduced by Senator 6^.agnuson (5 .559) a.lno merits support . 

This bi .l l reryuiroe a w[:rniug label on cigarette packages 

but nmits reference to advertising regul .ation . It is my 

opinion t:hnt Congrets aatst ultiraately pn.ss laws to regulate, 

through every channel, the distribution of a noxious product ; 

hovover, it is possible that package labe).).ing will precede 

broader regulatory measures . Thoroforo, I urge your full 

support of Senator 6lagnuson's bi11, 8 .559 . 

During the pas t yoar an oxporimental Smoking Deterrent 

Clinic has operated at Rhode Island Noni:,ital under a grant 

from the Rhode Island :;tate Health Department . It has bonn 

siuocessful in assieting 50% of our candidates to give up 

smoking . Tho reviarkablo i .mprovement in physical well-being, 

with speoial emphasi .s on improved pulmonary function has 

boon very impressive . We have gained the distinct impres-• 

siou that among the maJority of people, both from within 

our clinics and from among their many Exi.ends who have not 

applied Ror aeeis.tance, there is an incr.•easing conv iction 


• 

• 

0 

c4 

of the harmfulness of cigarette smoking and the need for 

discontinuation of this habit . There is; especial conoern 

by adults for the welfare of their children and they plead 

for assistance in preventing the initia t ion of the smoking 

habit f .n teenagers or in discontinuing this rocently-formed 

tcmage habit . Therefore, it seems a17l the more Important 

that the atachf.nox•y of government be placed at the full 

disposal of the people through proper laws to regulate the 

advertising and labelling of cigarette products . 

Yt is my opinion that it is the du .ty of science and 

government to inform our people, and to assist thom in 

every possibYe way towarde the practice of good health 

ha.bits . 

Sincerely yours, 

n/ Louis A . Leone, M .D . 

t/ Louis A . Leone, M,O . 

Director 


liept . of Oncology 

1806

• 

• 

c••1 1807 

CONORRSS OF THE UNXT817 STATRS 

House of Representatives Washington, D 

Doar Mr . Chairman : 

. C . 

March 26, 1965 

James H . Quillen 

First District, Tennessee 

Thirn is with reference to 6 .597 by Senator Neuberger, 

which would impose special restrictions on the advertising 

of cigarettos . 

I hove boen advised of the position of the American 

Newspapor Publishers Association on th1 .n measure, and I 

agroe with their views wholeheartedly . 

Since cigarettes o .re legitimate articles of commerce 

and tho tobacco industry is an important segment of our 

economy, the fundamentall questions of constitutional lavi 

as well ae of public policy are raised when the Government 

sochs to regulate the right to publish advertising eon- 

oorning legitimate articlos of commerce . 

Fach publisher has the right to deterllline individually 

the content of his newspaper ; and, if this legisl.ation uow 

proposod ehould bo onacted, the precedent would be ostab- 

. .. c.L. . . . ., .a . ., . .,. . .. . .. .. .. . . . . ..o .., .. . .,. ., .. . . . . ., .., right ., f 

nowspnpers und other media to decide their policies as to 

the content of advortie,omonts which they wf.ll accept for 


• 

• 

c2 

Oub7.ication . 

I would deoply npEneci.ate your sorious consideration 

of thi .r.. matte:r, e.nd I vrill be grateful for your advice . 

SinCe}'OY .y, 

s/ Jnmos R . Quillen 

fton.orablc Pde.rrcn G . Magnuson 

Chr:i.rmn.n 

Senate Co minerce Committee 

Room G202 6oneto Office f3uiYding 

Wanbington !5, it . C . 


1808

• 

0 

j on] 

S9'AJ91M71MP OF DI : . IIttWRy T:AB'1'0`J McMAilOI! 

] mm Dr . Ilerry f :ar;ton McMahon, a practiein8 special .ist 

in heart di.seasc in Now York City . I was Pormerly chi.ef of 

t:ho card.i.ec cli .ni .c of St . C1are's Posp :ital, New York and have 

boon af :soci.ated with cardi .ac ciini .cs in Bellevue, St . Luke's 

and New York Fo7yclinio liospitals . 

1809 

Por the past 26 years I have served as cardiac consulta n t 

for a nurabcr of business firms and industrial unions which 

has piven rnc the op p ortuni .t.y to examine, and treat people 

from a wide range of oceupations from sand hogs and miners 

to Me:disr»i Avenue mrocutives . 

During WorJd War ):T 7 served i .n the United States Navy 

and was in charp,e of the cardiae servic< : at the (1 .9 . Naval 

Ilospital, BroNc7yn, How York, the U .S . Naval Hospi .ta l and 

U .S . Marine Corps Rase, San Diego, California and aboard the 

U .S . 'rlaval llospi.tal Ship "ConsoZati .on" (now the "Ilope") . 

]b] .lowi.ng vry re]eose from duty with the Navy I became 

i :hr, fir: :i: me.cti .e.al direction of the United 1Jations . 

I on : a P'c71ow of the American Co7 .Yege of Chest Physiei.ans 

and Amcri .can Co17et;e of Cardiology ; past president and prrsent 

Chairmau of the Ilaw York Cardi.olohieaa Soci .ety, charter member+ 

of' th e t/orl.d Unalth Orp,init.ation, Vi.ce -dlhairman of the Counci .]l 

on Cardi.ovascular Diseases of the American Col] .ege of Chest 

Physiciaos and Chai .rn .an of the Commi.tte e on Aehabilitation in 

Cardiovosculam hiseases . 


• 

• 

ion2 

]el0 

7 have Lecn Associ . a.ite Cl .i.nical Professor of Cardiology 

at the ?7ew Yordc Medi.cal Col]eF;c and am present] .y l.ecturer in 

Cardiology at the qew York E'o7 .yelini .c Pfed :ical. School, one of 

the ol.dest post-gradu-r,te medical school^. in the country . 

As a physie.i.an with more than 30 years of experience, 

7 hrive deve].oped some opi.ni.wns concerning the importance of 

vari.oues factors i .n a patient's life hi .story in relation to 

cardSovascular di.sease and, particularly, coronary sclerosis . 

I think it i.s well agreed among physicians in my 

specialty that the cause of arteri.osc:lerotic heart discase 

i.s unknown . 

6a.sed on my cl.inica7l e:xpericnce ar,d my i.nterpretation 

of the medical literat.ure, I would also say that there is 

no ar.eep'table evidence that a causa7l re] .ati.enship exists 

between cigarette smoking and coronary heart disease . I do 

not Le] .i.eve that by di.scouraginp; cigarette srnoking we shall 

reduce the incidence of this disease . 

lt is my further opinion that it is misleading to i 

.nfornn the puU] .i .c that they may avoid or minimize their 

chances of deve].opi-ng heart disease by avoiding or discon- 

ti .nui .nr smokir,g . 

Those who contend that smold ng is an important factor in 

the devel .opment of cardiovascular disease, relate its effects 

princi .pal .l.y to coronary artery disease, the most frequently 

fatal form of heart disease . 


• 

• 

]On3 

Ilowever, it nmst be remembered that thi .s c]isease has 

]onPg been considered a part of aging and that there is_a 

recoFni .zed age group in which arteriosclerosis and coronary 

sclerosi.s are prone to occur• 

1831 

Arteriosclerosis is a genera]l arteri .al conditi .on usual] .y 

mard fested throughout the system of the subject, but more 

advanced or marked in some parts of the body than in others . 

Thus, in some peopl e arteri.osclerosi.s is manifested by 

symptoms refcr•ab]e to th e brain, in others by symptoms of 

the 7et;s and in stil] othe rs by i .nvolve,c•ient of the kidneys . 

Coronary e,olerosis, t :herefore, is only an anatomically 

srna] .] p :nrt of the over•a]], generalized arteriosclerotic 

picturc . 

Now I do not think we have any evidence that cigarette 

srnoki .ng ccrose•a hardening of the arteries throughout the 

entire body . Unless it is estab] .ished that cigarettes have 

this effect, it is di.fficult to understand the basis for any 

assertion that smoki .nE is responsible for coronary sclerosis . 

There cire a nurnber of condi .tions or factors which ar< : 

statisti .cril .].y associ .ated with the development of coronary 

sclerosis . Among thes e it seems to me that a family history 

of heart disease appeea•s to he the most outstanding . 

It does seem ylausi.ble that a person's future health 

pattern, as regards constitutional disease.s, may be "built : i .n" 

on his arr.iva]l into this wor7d because of his inherited 


c:onstitution, body structure, familial tendencies to 

certain diseases and so forth 

.i_nical. research has confirmed .Cl that high blood 

pressure, high bl.ood cholesterol and various other dis- 

orders of the blood and circulatory system tend to run in 

families . 

]81 . 2 

].ac:k of exercise has also been statisticall associated 

with coronary sc]erosiec . Studies of inen in particular 

occupation grouna indicate that those who are sedentary 

develop coronary disease more fr oquent]y than those who are 

physi.cally active . 

Another characteristic which is statistically associate d 

with coronary disease is overweight or obe:stiy . l find that 

when hypcrtencion is present, weight reduction is usually 

followed by a]owerinE of the bl.ood pressure . 

A great deal of rd:tention has been called to the 

statisticr,] assocmation between cholesterol in the diet 

dorived from eatinp, meat fats and dairy products and coronary 

sc]erosis . 

I am uncertain of the relationship between hyper- 

chol.estero]emi.a and arteri.osclerotic heart disease, but I 

have found that patients with high cho]este rol level.s feel 

bett¢r when their cholesterol is brought back to norma] . 

Based on experience, stress seems to be the most 

important preci.pilat.in8 or triggering factor in the 


• 

jonS 

development of a coronary heart attack . This would 

i.nc7.ude the str•ess of hard physiea]l labor as well as 

stress of the mind, nervous system and emotions . 

In my 

practi .cc, stress has been the common factor in nearly all 

cases of coronary thrombosis that I can re :call . 

P]hi.le the use of tobacco may be a symptom of stress, 

in my judpmen't smoking is not causal.ly related to coronary 

throrebosi .s . 

I have not observed any difference in the clinical 

course of a patient with myocardi:a]l infarcti.on which I can 

relate to previous smoking habits . 

One of the principal di.fficulti.e& in attempting to 

study coronary sc]erosi .s is that its manifestations are not 

a.l.ways apparent . 

]0]3 

It has been referred to as an "iceberg disease" because 

its cl .i.nical signs are often only minor evidence of the under- 

lying condi-tion which may be oir ;reat magnitude . 

Some people are hardly aware of the pain and other 

sympt:oms of' coronary insuff'iciency ; indeed, some peop]e may 

even have a marked myocerrdi .al infarctiLn and be unaware of it . 

3 can reca].] half a dozen of such cases in laborers picked up 

by e?ect.rocardi .ographic study on the occa[ :i.on of a periodic 

heaith examination . 

Decause of the di.ffi.cu]ty in di.agnosi-ng coronary disease, 

findings basod on surveys of the incidence of coronary disease 


• 

• 

0 

among various segments of' the population are of questionable 

signi.fi.cance 

think . I that many worthwhile efforts have been made i n 

searching for the cause or causes of arteriosclerotic heart 

disease by clinici.ans, rese :arch physiologists and chemists , 

A81 .4 

natho]oP:ists, roentt;enologi.sts and statisticians, but we have 

yet to find the cause or causes of this disease . 

I find no reason from the evi.dence at hand why we should 

at thi.s parti.cu]ar point in time act to discourage cigarette 

smoking on the presumption that this one factor has been 

discovered to bc of importance in respect to heart disease . 

The evicknce to date does not furnish any sound basis 

for such a conclusion, but rather i .ndi.cates a need for 

continuing theresearch effort with the best resources 

availabl .c 

. /s/ Dr . II . g . McMahon . 


• 

• 

jonl 

STA'1'liMtiN'1' OP IAN MACDONALD, i1 .ll . 

My name is Yan Macdonald . I am a surgeon, with the 

del;rce of M .D ., C,M ., fbotn McGi .11 University, received in 

3928 . 

Fnr 24 yc.ars I have been associ.ated with the School 

of Medicine of the Uni.versity of Southern California, where 

]: am C].i .nS.cal Professor of Surgery, and for 10 years I wac 

Coordi.nator of Cancer '1'eactri .ng . 

Since 1955 my cli .nical work has been limited to the 

1615 

treatnient of cancer and allied diseases, both by surCery . 

and radiation therany, with certi .fi.cataon as a specialist 

i.n racliotherapy by the American 13oard of Radiology in 1938 . 

cancer rescarah, 13 have beon the re.sponsibl .e 

inve. .^.ti.gator in various pro-jccts at our Schooll of Medicine, 

Chairunan of two nati .onzl, oooperati .ve research groups, a 

rnrrnber of the American Association for Cancer Research and 

of the Cormnittee on Cancer of the Amerioan College of Surgeone. . 

I arn a member of other sur•gi .cal, ractiologi.c and medi.eal 

soc :ielie :;, a former Officer and Di.re etor of the Ameri .e

0 

• 

of cancer 

. 7n Ju].y 3957, as an invited witness before the 

Subcomrnittee on Legal and Monetary Affai.rs, Comrnitteeon 

16)G 

Covermncrrtal Operations, House of Representatives, I expressed 

nry conviction that "the totall evidence fails to provide a 

cause and effect relati .onshi.p between . . .the smoking of 

ci .F,arettc:e and the development of lunft cancer in humans ." 

flow, near] .y eight years later, I have examined the 

published record of my testimony and f:ind uo significant 

detail which req ui .res moc]i .fi.cation 

.though the causati.on of lung . A] cancer remai .ns as 

eni.gnatic and aes complex as ever, i .n the past several years 

a nurriber of pnb] .i.shed reports have emphasized the variety 

of factors in the background of individuals who develop this 

form of cancer . 

This expz,ndin n evidence of a constellation of factors 

associ.ated with lung cancer )ends no comfort to the advocates 

of a si.ngle i .n.Pluence -- that of cigarette smoking -- as the 

"principal ca vse" of the disease . 

In fact the inconsi.stenci.es surrounding this cause-and-- 

effect thesis have becorne rven more numerous than i .n 1957 . 

Some of the mere notable, recent contr :i-buti.ons on the subject 

will be cited shortly . 


"CONTRT.[sUTORY" pACTORS IN CANCER

• 

• 

• 

jon3 

7817 

certain Types of cancer may indicate a morr. frequent assoei .a- 

ti.on with some factor, or factors, than in control, non- 

cancerous F,roupF . 

If such an associ.ation is i .mpressi.ve as determined by 

statisti .ca]l anal .ye.i.s, the background fac.tor may be referred 

to as a"contr:i.butory" influence in the development of the 

specific cancer . 

The propriety of such a concept is questionable, and 

for the fo]lowinfC rcasons : 

present . 

- In no forn of cancer is the associated factor always 

-'1'he camcen• can and does develop in its absence . 

-The factor may be present in l.arge numbers of persons, 

only a very few of whom develop the cancer in question . 

6uch is thc "relationship" between the smoking of 

cigarcttee and lung cancer . 

1'rans]ation of "Contri .bution" to "Cause" 

As rK.petiti.ous statistical studies in this and other 

countri .es becane pyrami.dect in an i .nternational., hi.gh-rise 

statistical unani.mity, the associati .on of cigarette smoking 

and lutg caneer became t.ranslatcd into a cl.aim of cause and 

effect . . 

When, in i:he laboratory, cancer appeax e d, albeit rr.l.uctantly 

in the skin of nice g,enetical]y prone to skin cancer, after the 

app] .i.c:ati .on of unrea].ist.i.c concentrations of tobacco tar, some 


• 

• 

propegcmdi.sto abandoned a7.1 reserve to describe ei.garette 

srnokinF, as the "pri .naipal cause of' lpnp, caneer ." 

Pcne Dubos recently has commented on the unsolved and 

cornp]cx problems which concern man and his envi .ronment, by 

sayi .ng : "A]]3 pr•oblems o f the ]iving organism, in health 

and di.r,case, are prob) .em^s of or• ganized complexity . The 

r•educti.w~i.st aporoach (is the) ana].ysis of oversimplified 

systems .invo]vinp only one variab] .o ." 

Ilo more dreunatic il.lustration of these words can be 

offerr.d 'i:han the attempt to explain lun g cancer in terms of 

a single variab]e, created bp statisti.cal il] .usion . 

PEC)]H9' PtipOPi'S OtJ LUNG CANC] ;P . 

1818 

'1'he past severa7l years have been marked by the pub].i.cation 

of some careful studi .e.s with conclusions which are in direct 

conf]ict with the notion of a tobaceogenic causation of ] .unr 

cancer . 

keference to sonie of the morr i.mportant of these i .nves-- 

tigati.ons is approyrie0.e here . 

rrom Merc:y tlospi .ta]l in Pittsburgh, Joseph A . Perrone 

has reported on 7.,000 cases of lung cancer . He emphasizes 

the variety of background factors, concludes that : . 

. .,srnoking cannot be implicated as 

the rnaìor cause of Jung cancer ." 

Of these 1,000 cases, 42 percent were nonsmokers ; of 

')BU male pati .ents:, 26 were nonsmokers, and 77 percentt of' 


• 

• 

jon5 

41.6 women with ).uh£g cancer had never smoked . 

Dr . Perrone concl.udes that three fnctors are of 

paramount impor=tance in contributing toward the probability 

of lung cancer : 

OCCUPATION . 

AIR POLLUTION 

liCONOMIe 8TATUS 

Of the seven occupations most frequently pursued by 

these patients with lung cancer, five involved exposure to 

petroaeum products and their combustion in automotive equip- 

ment, both of internal combustion and Diesel types . 

Of the 300 men involved in the seven most frequent 

1819 

occupations, which included coal miners and painters, 59 per- 

cent were nonsmokers . 

n r, 

An i.mportant contribution in the German literature is 

the report of a meticulous study by two pathologists at the 

Pathologi.cal Institute in Dusseldorf (POche and Kneller), 

with the aid of a biostati .stician (17ittman) . 

The study was based on 1 .,229 patients with lung cancer 

proved by mi.eroscopie examination . The questionnaires which 

produced the i .nformation were completed by physicians only . 

Factors found to be of significant influence, statistically 

tested by correlation coeffi.cients were : 

URBAN R} 

;SIDIINCE OCCUPATI OiJ 


• 

• 

jonG 

BackFrouud factors of no .^,ip•ni .fi.cance included the 

smoking of cigarettes . In fact, the heaviest cigarette 

smoki .nR was in the occupational group with the lowest 

i .nci.dence of lunft cancer (office workers, teachers and 

other professions, clerks) . 

A di.fferent approach was used at the University of 

Gror,i.nP.en, i.n which the interest of the investigator 

(Aona M . Der Wal) was focused on the association of prior 

chronic disear.es of the lunP:s with the devel.opment of pul- 

monary cancer in ]ater ]i .fe . 

smoking . 

She otrta lned infonmation from three se0aratc groups : 

1 . 150 patients with lung cancer . 

1620 

2 . 150 control persons, no t matohed for ci .garette 

3 . 100 controls carefully m.atched with the lung 

cancer nati .errts for smoki .nr habits . 

This, too, was a sophisticated, st.atistica]ly controlled 

study . Some of the pertinent conclusions were : 

- therc is a highly significant re:lationehip (P(0 .001) 

between chronic )unp, diseas e and lung cancer : 


- this ra] .ati.onshi .p is independen i of smoking : 

- the number of ci garettes smoked (10-20 and > 20) 

n ,: n 

From the Ori.e:nta] medi .cal literature, a report by a 

:

0 

• 

jon6 

Japanese chest surgeon (K . Kaiho) concerns 1.,659 cases of 

1827 

lung cancer . About 80 percent of these pati .ents were smokers, 

but 83 percent of a control group of non-canoer patients were 

devotees of the weed . 

llc found nodiffererwe in the proportion of heavy smokers 

among the patients with lung cancer and patients without 

cancer . 

There was a high fami .lial predisposition to cancer in 

general in the relatives of lung cancer patients . 

'1'hi.s author believes that the low oat .i.o of male-femal .e 

lung cancer (4 :1., compared to about 6 :13 in the U .S .), is 

evidence that external factors such as smoking are of little 

importance . 

One of his definite conclusions : there is no relation- 

ship between smoking and lung cancer . 

i: S. 1 G 

A Chinese Clinician (J . -S . '1'sai) has reported from 

Pekin on 252 patients with lung cancer . The most unusual 

feature of his group of patients makes them, to our knowledge, 

uniquc : There was "no great difference" in sex incidence . 

Only 62 .5 percent ofthese Chinese patients were smokers . 

In the southeastern area of South Dakota, during a 

t:el.vc year period (1949 - 1 .961.) only thir•ty-three cases of 

lung cancer were recorded in the Tumor Reg:istry of the Sacred 


jon7 

llcart IlnsPita] in Yanki:on, rnakinp, it tenth in order of 

frequency in this non-industria] i v.ec] area . 

This part of South Dakota thus registers annuall y 

]62 2 

less than 5 new 7ung cancer patients per 3 00,000 population, 

comparcd to less than 3 5per 100,000 for the U .S . at laree . 

i'his di"sparity cemnot be credited to a lescer proportio n 

of s mokers in this agriculturr.l area, as will be evident in 

a comparison with the Pittsburgh seri.es rn"ported aUove : 

Smokerc 571, 

ton 51JOke r6 

IAIIG CAIICCR CASI'S 

_ . . . 

VSatsi~urph, _Pe S .L Soufti llakot a 

52 8 

42% 48 % 

Pre viou :: comparisons of this sort have demonstrated the 

some laCk of any correlation 6ei:ween fnokinl5 and the prevalence 

of lmr7; cancer . 

Some yearc aTO a oompar.ison of the State of New York 

and Tdaho showed equal Was of oi garet te :; per oapita, with 

a rnortal.ity from lunP, ca.nccr four times greater in the more 

dcnsr.ly populated, hi.ghly industriali7.ect Ftate . 

n . . . . 

The Canadian I'u61 :i.c.Iloalth Service is concerned with 

an aborip;ina] popu7at'i.on far removed from our "civi].i.zed" 

w.rys of 1ifc . 


In rcccut yeare, X-rny survey taans have eombed the

• 

• 

• 

1123 

Canadian Arctic:, mainly in a search for pulmonary di.seases . 

Hot a si 

.nglc case of lunE cancer has b¢cn found in the Fskimo or lndian popu]ations, yet nearly a]Jl of them are 

heavy smokers, usually of cigarettes in recent decades . 

4 tr 

A feraale popu]ation with no signi.i'i_c,r,nt experiencein 

smokinp, ., but with a lung cmncer i .nci .dence which rnay be hi .P,Ler 

than in U .S . women in i;enera7., has besm t:he subject of a 

report by J . T . Nix . 

At the '1'ulana 6io-Medica] Center, with sponsorship by 

the 1Jational ].nstitutes of Meelth, Doctor Nix has set up a 

corrCinuirrg study of mortali.ty in ] .16,173 nuns, as collected 

from Catholic Ilospitals in the U .S . and Carrada . 

In his pre] .iminary report, 1 .04 percent of 575 deaths 

were duo to verified lung cancer . Shou3d this rate be main- 

tai.nod in a signi.fieant sample, the lung cancer mortality 

rates for nmis would approximately 10 per 100,000, compared 

to 4 .9 per 300,000 f-emales in Upstate New York . 

'J'he mystery deepends if one recoSnizes that the majority 

of these re]iF.ious do not have the same e xposure to environ- 

mental influences as does the average woman . 

Si gn,ific:anee of "Rccen t ReporCS" 

Seven of the rec:errt: reports just cited provide i .nforrna- ti 

.on on samp]es of experi.ence with lung cancer, numbering in 

ell . 4 .377 pa'i.Ser,ts with this disease . . 


• 

• 

• 

ìon9 

1824 

I :ach of these rcports includec the resul ..t of anincluiry 

i.nto a possible relationship of smoki.ng with lung ca.ncer, 

i.n sovcral i.nctancps with sophist.icated techniques in 

biemetrio control of the data . 

In none of these studies was a cr•edib].e or signifioant 

rolct.ionstd .p established between smoking and ]un g cancer . 

dy corrtrast, the conc]usi .ons made in "Snoking and ilealth," 

the Reportt of thc Advisory Committee to the Surgeon Genera7l 

of the Pub]i_c Ilealth Service (Pub]ication ao . 1103) was based 

]argely on seven prospectivc studi .es, w h ich provided data on 

a tota]l of on]y ],984 cases of lung cancer (page 164) . 

] :ar1y in 1864 an l :di .tori.all in the Journal GRO'.J'17i, in 

stating the need for extensive basio r'seareh in ]ung cancer, 

oonunerrled on the farnous Aeport : 

"As with 03. one-sided statis'fi.cal surveys, the Report 

fai.ls tc, take into consideration the complexity of' the factors 

invo]ved, and thus invites criticis m to its cmiclusions : ." 

Other 01017520.00] lnconsastcncics 

When eomparisons are made oftotal populatf .ons, by smoki .ng 

and death rates from lunl; cancer, usually no correlation with 

cip,arette smoki .ng is evident . 

In some i-nstances the relationshin of ciquretie eonsump- 

t .i.on and ] .unp, carrccr i .s an inverse ratio : for men, th e uce 

of cigarettes in the United Kingdom is about one-half of that 

in the United States, but iort .rl.ily from ]ung, cancer is morc 


• 

• 

• 

than twiCe a& p•reat in ] :n{;land arx] Wa1es . 

].R?5 

blithi.n the U .S ., many compari .sons of States and cities 

show cquivalent consumution of tobacco as cigarettes, but 

m.orta]ity ratios frocr ]rmg cancer which di .ffer great]y . 

Sex Difference in ]ne :dence of _LUnp_ Caneer 

I•ew U .S . women smokcd cmti .] . ].930, w}ri .]e recent surveys 

indi.cate that 40 ne :rcerri or more of wonaen are smokers . The 

major• share in the increased use of ci g arottes since 3930 is 

attri.but.ed to wemen . 

In spito of these facts, the male-fenale ratio of 

mortality from lung cancer has increased from 2 :1 in 1930, 

to as: much as 7 :1 in recent years . 

Thi.s incrensitlr excess of lun g canCe :C in males is 

interpreted by some investiUators as cvidence of an impor- 

i .ant hormonal influence - it is surely inconsistent with 

patterns of cigarette consWmotion . 

TinB?-iJOse hactOr 

/1sGur_ll]R that a F-1.Ven sLlbstanCC has Fome carcinogenic 

i.nflucnce in an i u a ls, the tine at which a cancer will appear 

in a suscepti .b].e individua] wi]] be determined by the tin e of 

exposure and the dose used . 

Although the factor of susceptibi .]i.ty, as determined by 

genel.ic i.nher:its,nee, is by far the most irnoortant inf]uonce, 

and a]ihoup,h such 6i .oi .osic i.nteractions are not measurab]e 

with rsther°atical3 exaet .itudc, if am adequate samp]e of 


• 

• 

• 

ion]] 

i.ndi .vi.duals is exposed there wi17l be a tough conformance 

to the ]aw of time and dose . 

cancer : 

Consider these cri .t.eri.a i .n termi: of tobacco and lung 

-"Dose" in m a les since 3920 has increased from 

1 .6 to 6 .3 pounds ner capita, 1920 to 1950 : 

- Me of exposure has lengthened, due to use 

1126 

of tobacco earlier in life in the last several decades . 

By the ]aw of ti .nm-dose relationship, Yung cancer shou] .d 

have shown a distinet t .rend toward peak incidence at an 

e.ar] :i.er age i .f cip,arette smoking had any causative influence . 

IJo suggestion of any such chanp,e is evident : peak years 

of inci.dence of ma]e ]ung cancer remain fixed at 55 to 59 

years of age since the first decade of th :is century . 

In the broader persnec :ti.ve of general mortality ratio 

of cip,arette smokers versus nonsmokers therre a a paradoxica] 

time-dose rel .ationship in data found in the Report of "Smoking 

and Ilealth" (paRe 87, Pable 6) . 

here the mortality rate for all causes, for currentsmokerc t 

of cin,6rt:ttes on]y, is expressed in terms of that of 

nnnsmokarrs as unity, from the fifth throu g h the ninth decades 

of' ]i.fe, and 'ny the n ur iher of cip,arettes per day . 

ReP.ardloss of the aruount of smoking, there is a pro- 

p,ressi_ve i .mprovement in mortali .ty ratio in each succeeding 

deaee of ]if

• 

. 

jon]i: 

of won who are exoessive smokers of 40+ cigarettes dail .y : 

Mortali.ty Ratio for Smokers 

AC7 : . of 40t C :igcu.ettes _ per _Day 

h0 - 49 3 .06 

50 - 59 2 .37 

- 60 - 69 . 1 .68 

70 - 79 3 .28 

80 - 69 0 .58 

Thi.s natterrn defies the larw of ti ne-dose relationshi .p, 

wilh the octoEenartan smoker of 40+ ci .f;rret.tes daily hsvinf; 

a NO nercent hetter chance of surviva] t:han hin nonsmoking 

fe]loms . 

'Phese data sug{;est that the less fesvorable mortality 

1827 

rerli .os of' cigarette smokers in earlier yea rs are not rel .ated 

di re.c.'t7 .y to smok.i.ng . 

Perhaps smoking is a beha.vior•a l c.he.ract.eri.stic ef the 

younger man who has a]eEiser prob ability of survival than 

the noneumoker . dut fcr reasons unrelal:ed to sreokin,v, . 

Ttiese ne$at".iVe corrElations with the duration end amount 

of nigarctle s6rokinp, provide the basis for two st.atements : 


- the evidence indi.cates the absence of any contribution 

of cignrette smoki .n{; in the causution of ]unp cancer . 

- the dat.r6 cit'ec] arc ineonsi .stent w ith an inf] .uenee of 

C]AarCttL eonfllmiptien pCr so on WoYtallty rateE .

• 

• 

• 

1 :XPCR7 .i;lCC F11TII IA :uG CA:ICI:R I ;d '1'lIL COIIi7TY 0}' 

LOS NdO1:L}IS 

Ai.r polluti .on --- in ----------- 

tne I .os Angeles 13asi n has evoked an 

i.nereasi.ng interest in respiratory diseas :es, and especi.ally 

].n lunF 

= canoer . 

The I,os Angeles County Ilospital has one of the ] .ar/•;esC 

]018 

autopsy seri .e^, in th v United States, and the niost variegated 

f-roiz a racial-ethnSc standpoint . 

As now and i.mproved techniques iu di .apnosi .s devel .oped, 

1un/; canccr showed an upward trencl at L .A .C .H . for eoma years 

unti.l 1958 . Si n ce then, and throu gh 3962, the proportion of 

] .un/; cancer in total autopsies has reached a relative p]ateau . 

. .9'hr._1 a +-c^st . ._ .+:lahle . . . d .~t. .,for , 19G 3 t„^p .h., . ., . .a^;z,. 

. the fixeC . 6. 

inci.denee of the disease . 

Ltmy, Caneer as Per Cent 

Year Ilo Autnp{.?e Lcm~..C~ncer _,of A7 .1 AutopsJ,e_s 

1 .950 

]969 

]960 

]96] 

1962 

7963 


811 

69 

'13 

86 

79 

67 

9'his large scri.es of' autopsies on 7 .ung cancer pati .eits 

has made possi .Lle a spcci .al study of microsoopic typos o :C 

3 .0 

2 .9 

3 .3 

3 .8 

3 .8 

3 .0

• 

• 

turnor, the results of whi .ch are perti.nent to the allegect 

cause-andeffect relationshi .p with ci.f;aret.te smoking . 

it has becorne an article of faith, among those who 

a.dvocat .e this thesis, that the influence of smoking is 

roco gnizable in terms of miscropseopi.c studies . 

1`pi ;dortant was a more aceurate deteetion of a substancc

• 

• 

• 

jon]5 

Oouein) },roduced on)y by glandular tissue : when identif :i.ed 

in lung cancer, the tumor must be an adenocarcinoma . 

Id3ren t}iis research method was used in the re-study 

of the 956 cases, so many of the supposed "epidermoid" 

cancers had to bee rn•.olassi.fi.ed as adenooarcinoma that a 

now orientation was evident : the proportion of adeno- 

caroi.nornas was increasing, espeei50 ly in recent years, 

whi.le those of epi.dermoid nature were stationary . 

Su this Lar1 ;e . representative group o1' lung cancers, 

on the Unsi .s o f improved accuracy in i.denti .f'ic :ation of the 

1830 

two main types of tuper, the distribution i.s thus completely 

i.ncons.istent with the tobaccogenic thesis . 

Tho other unusual feature of lung cancer in Los Angeles 

deserves comment here . The incidence of the disease in 

women of Ilexic am ancestry and birth is almost as great as 

in Mexican males, who, in turn, have a slip,htly greater 

incidonoc of lung cancer than white males of United States 

origin . 

Yet, avai).ahle information i.ndicates that the smoki .ng 

of ci .p,arettes by Mexic:an -born women is at a much .lower level 

than in iho Fenora)l female population . 

Por women of 11exi ..can origin, hut born in California, 

there is no such excess of lung cancer, althou gh cigarette 

smoki .rrf: is rr:orc : prevalc :nt among the U .S . - born than in native-born I< 

:exican f¢.ma.les . 


• 

• 

• 

;lC1qA1tY 

Thi.s synopt :ic di.soussion han, touchect unon only some 

of the faoets whf .ch indfcatn the coronlexity of the problem 

aihich is 1unPg cancor, 

A hmre are other data of si p ni.fi.cance on the relation . - 

].83] 

shi.p of the discasc to socio-econornic and nutritional factors, 

to residcance in Sown and country and the almost unexplored 

arca of intrincic influences - horcional, saexual, cnzymatic, 

vira] and hercditar,, . 

The currrnt, popul.ar eenphasi.s on a s :ingle environmental . 

factor, i . .c ., the smokf.n{; of cigarettes, has been shown to 

be ineonsistent with the cvi .denee Provided bl' a number of 

recent clinice.7, inves'tip,ati.ve renorts . 

Cancer of i:he lunA s.canes to be a highly eomplex biolo(;i .c 

enigr ,a, thc ba.sio causes of whi.ch, in oomnion wi .th other forms 

of cancer, arc as yet unknown . 

] :mryhasis on a sinCle environme.ntal factor as a"pri .ncipal 

cauee" roduces the prob]em to a narrow concent of causalit .y, 

whcn the diseaoe with whi .eh it i.s thus i .dentifi .ed becomes 

estah].ishcd in its absenca, and occurs infrequently in its 

nresence . 

Such substitutions of shadoia for scientific substance 

Iany lead to a dcereasect effort in cancer research . 

/s/ San !'acdonald, 17 .I1 . 


• 

• 

• 

jon 

SH'ATI :MCIIT OP ISRAI :L RAPPAPORT, 19 .D . 

7 e m Israel Rappauorl (M .D ., University of Uudapest, 

Hungary, 1979, flew York State 13oard, 1921), a practicing 

physi.cian specializai.ng in diseases of the chest since 1928 . 

Ilaviny served as a visiting physieaan to the Chest 

Service of Rellevue Ilospit .a7l from 1930 to 1958, I am now 

consulii.ng physician there . 

S also serrved on the Facul.ty of Col.umbia University 

Atedi.cal Schoo l as Aseoci.at.e Clinical Professor of Medicine 

up to nry re tirernent in 1958 . 

1 am a].so Consultant to the Chest Service ofGrasslanc7s 

ilospita], Westchester County, ^leui York, for many years past . 

1: have nublished numerous articles and several chapters 

in textbooks on various aspocts of pulmonary diseases, 

i.neludi.n g more than 20 artic]es on or related to pulmonary 

emuhysema . 

These have appeared between ].936 and 1960 in issues of 

Annals of Internal Medicine, Diseases of the Chest, Journal 

of the American Ncdi .cal Association, and the. Lancet of London . 

L'ecause of new concepts which I evaaved on chronic 

pulmonary di.sease, the l.ate Dr . J . A . 11i.llor invited me to 

jotu his staff at the Chest Service of Oe]].evue Hospital in 

3928 . 

Uere, on my initiative, Dr . "'iller aaunched the pulmonary 

f-unetion rescarch nroject which was carried on by Dr . Richards 


] 832

• 

• 

• 

and Dr . Cournand to world - wide fame, honored by the 7obe1 

Prize in 1958 . 

'I'he novel concepts about pulmonary emphysema which 

]833 

i.nspirec7 launching this research were announced (by Dr . J . A . 

Iti]lcr) in a uub]ication "Pulmonary Fibros :i.s and L'mphysema" 

in Ann . ]nt . Med . in SeUt.ember 1935 and "Chronic Lung Disease" 

in November ]938 . 

In r, series of subsequent articles, I was perhaps first 

i.n drawinPA repeated attent .i.on to the risini; incidcnce of 

nuhnonary emphyse pa and chronic bronchi.tis, and in 1957 in 

an artic]e in the Journa]& of the Ameri .can Hedical Association, 

October ]9G7, 1 drew attention to "ChanP,inC Forms and Causes 

of Pulmonary ]nsuffi.ciency in the Present Era of NeAicine," 

exp]aininP, the recent changes in chro nic bronchitis and 

emnhysema . 

'[n ]9G8 7 proposed the troatmont of acute pulmonary 

i.nstfficiency by tracheostomy, which is now a widespread 

urocedure used to tide over patients c]anp.erously i11 from 

acute comp] .i.cati.ons of chronic respiratory disease . 

I fee] that I have a right to speak out on the subject 

hcre involved because chronic lunq disease has been a subject 

of prime interest to me for over 35 vears . 

I am onposed to acceptance of the concept that "ciKarette 

smoki.nR is the most important of the ca .uses of chronic 

bronchitis in the United States which increases the risk of 


• 

• 

• 

dyinC from chrwn ic bronchiti .s ." 

]I am al .so opposed to acceptance of the concept that 

a relationsl,i,p exists bet .wecm pulmonary emphysema and 

ciFarette smoki.ng "whic•.h a.lthouph not oaus-r.1 leads to 

i.nm•eased risk of dying from pulmonary emplrysema ." 

My opposi .ti.on is based on the followi.ng two reasons : 

(1) It is a fact that the theory of the ]ink assumed 

to exist between cigarette smoki .np, and chronic lung disease 

2834 

refers to the tradit.i .ona l entities of chronic bronchitis and 

of pulmonary emphysema . 

Protaeonists of this theory acLnit t.ha t we cannot define 

and cannot r::corni.ze: these concti.tions olini .cal .]y with any 

degree of certainty . The nature and oriCins of these con- 

ditions are sti .ll open problems . 

The fact that we are now in the process of establishi .nF; 

definitions and are now e.eekinF i .nformati .on regarding the 

nature and oriP.ins c+f the.se diseases should in itself pre-clude 

our maki . n R de•.ci .si.ons regardin g such et.i.ologieal concepts 

as that i.mpli.cd in the cigarette smokin£'g theory at least untill 

we know what pulmonary, condition we are act.ua7 .ly referrinfi to . 

In the foll.owi.n£„ I wi .l]l endeavor to prove with 

:i.sts of the cigarette smoke theory 

state-ments made by protagon 

that they are uncertain about what ] .ung disease smoking should 

be ]inked to and that in the final nnaay.^,is, their claims 

imply a link on]y with minor symptoms of little clinical 


• 

• 

c-i[`.Yd ;Ficcno.cl rathor than mith any disensc eni :itv . 

!?) C7iWa] rgoerience in hospita]s and i .n uri .vatc 

prae'ii .oc ove.r ihe : pae.t 40 yeare, const.ant7y oonsidered in 

ihe 11£;ht of ihe pasR, mcent and current aitarature, has 

laught mc 9hni ohronic ]uny, di .soaso as now observcd ic not 

to hc i .Clcntif :iad wi.th the trac7itiona] crtities of chronic 

Lronohitis awd e:mUhVSCna . 

Tn The. ,fo'q .ooiin«, 7 05 .]]l ene]eavor to show that we are 

now conecroed rei .th a discase miti .'ty which has been evo] .ving 

durinF the nast hrJf ccntury, bec{'i .nnin n before ciRarette 

srrokin0 hccamo wictcsprcad , that emokinr ;rvas not a factor in 

this mvo]ut i on - and t.'het recent and current obscrvations 

n .fford no drfinite evidence Provinpg tha t 

c:ip,arette smokin p 

p]ays a c]ceidi.np, or indc

• 

• 

• 

Jo:, 

I Lzrt ci_garefto ;;rrokinp, ie the chi .efc•nuvre or the only caueo 

of chc ct.ie;eu e and l .i t aunple evi.Jenm> i "plicati .nP, other 

faetor9 . 

Pointing to 1 :hc fact thet death rrrtes Prom chr•oni .c : 

2836 

blvnchit ;i.s in 'i :he Unitod IGng:dom cro mmny 'Ci .mes F,vexi:or-thnu 

in thn U .S .A ., ihcy eoncludc- cu follows. : 

' .`:Jric.a ciP.a'rctic conGuim & i .on is va.m'iJar in i .ho two 

counU•ios, fectora othcr thnn .^-mo'.< :inR must he i .mpli .cateJ . 

Pe,'i of 14 nc > p l,,n[,t5t'm tany bo i .hc diffQrr.lls:es in ,h,giroeP.io 

-icr m s: used in thn iwo co :nri'riee, hut 'ihe uxpcrience of phy- 

sic . .ns vho T a ve e,ox T cd in hoth coun'ir :ie b lcaver+ no doubt 

that e.hr:,rd c hronchi.tit i¢e wuch u:orc prevulent in the Uni .ier7 

Alup,bom than in the U,S,q," 

Alihmu.gh 1:nF7.ieh yhyeieinu ; s4d1J spe.~~Y,'v,^nrli.ti.onal .l.y 

of eT.ronic bronchiti .s, they ar•o reforrr5 .nf, to a cii .sabling 

and foiaa forr of i1: . 

1L 7 :n87cmJ the di_racrose in qucsti .on is a very serious 

pub]ic heD]RH problem .. :;ince it: cr.u ::re neorJV 10 percent of 

i1nc nation8l tunTa7i'iy . 

).n a most roomrC nee'?i.nP of the fore,n= ] .unp, sVeci.al- 

ie.is: in the Ilnticd Kingdo®, it w•aF inads, c7car thnt this gr•ave 

6iseassc ia noi : t .o bc : ideut-lticd with eithcr chr•onic : bronchitis 

nor u,ith Du] .monnry emphv"ema, ..n is cus'Ccaiiary in the U .S .A . 

in thi.s Svnuok:3.mm it a:ees t,her,°forc proposec7 to des%ate 

i9 n cnndit'cD . . 'bhr,n7.o non--le.cifi .c Icrg c .iscoec .° 


• 

• 

1837 

Dr . P . ltcid, in a recen4t disc.use;ion of the opidemiolop,y 

ofchroni.c non-s~,>eciFic ]ung cliseaoe, attUdbutes it chiefly 

to i.hc combincd effec'Cs of recurrou{ resnirat .ory infection, 

foP., coJd mrd air nol.]ution, resi :rictinfi the effects of 

sn:okinr to "coulih and phl .et,w ." 

AlthouPh thei'e are definitcly moro heavy smokers i n 

the U .S .A . than in the Unitad KinAr1ow, ya1 : mcrrb :i_di.ty and 

morti a lii.y frao chronse ]rmq di .ceasc i.re hero inconnanably 

J c9$ , 

A , cvil.] he shcan Lolors, in the U .S ., too, the sYati .s- 

r :ies on the n sociati ou with s mokinp; mostly r¢+fer to persons 

with "coui¢ and vlReGm" rather than to {lalicn t s with the 

dise s :;c wildch causnd the hiAh morhi .di t y and mortality and 

p,i.ver: so nmch ooncern to public health o .ffi.c.ials . 

'1'im ltoyal Co :I7cge of I'hysi .ci.ans of London must be p,iven 

cr::dit for hot omi_t5:inl; frow its reVort tTie ]ist offactua] 

dnta which arn :i.n opposi-Li_on to the presunied ] .ink between 

smokinf : 

a nd eSronic br onchi.ri .s . 

Thcy rLached Cha ooneluniocr thai . "Cigarette smokiig 

should I n regz.rGed ns: an :i.emnrtant conditionin( ; factor ren- 

dcxJnP, m Any mcn nnd womcn li .aLJa t.o a disablinR diFCasc which 

thcy M iryht Lzive oscai,ed had they not snroked ." 

'This oarrl:3ous ssiatcrnent is, oPcoursc, a far cry from 

the ooncc:pt ¢~ smo]cinF oa the mcost ircportant eausc of the 

di so< 


• 

• 

• 

'lon 

38311 

What is moro important is that it br :inF.s down the i.ssuc 

over tlre effects of smok.inp, to the dub :i .ou2 : a.nd tenuous zresump-- 

t:ion that i.n every onse of ehrord c lung dise4se caused by 

the factors r~enrioned above, cough tmd phl .egrn due to smoki.ng 

musi havo procedeci, whi.ch, of com>se, omnmot be ascert®i.ncd . 

1'hc ascrarption thatt ther,e patients mi .f;ht hmve escapcd 

development of dioab7ing di .ceas.e had they not 8isoked before 

:iu ahocy ;;hccuJati .on . 

Piosst imPOrlant of al:ll is the fact that in the report 

oS the Royal College of Physici .ana a c,iusarf lirdc to sniok :i .ng 

i: ela :irna;cl only for soccilYed s :irnnle bronet, .itis, but not for 

disob7luny- chron .ic Lrenchitis . 

Thc tcrv si.inple bronohi'ti_s rafcrs nicrc7y to "cough arrd 

phlcrpr,r," trivial symp-toms an compare.d wi'ih chroni .c bronchitis 

wh :ich .in llngannd is a rcthcr• oom'mon cause of daath . 

9'hc 'terv bronehi.t . :is applied to 6oth ofthese conditions 

hrs ]ed to the euro' w nt a.onfusi .on pxr•ti.col a r]y in the ]ite.rn- 

t ura ].ink :in, em cl:ino with chron_ic bronc•.hiti .s . 

I 'he ca r or ;rd .siny f xrom this confusi .on is perhaps beet 

M usfratcd by the ]or.g z:.nd firrnly he] .d belief expressed in 

the Coiwnon 'I)hraEe °aobody di(iS froin ChroniA brollehltis° which 

ies found repcatedly in the "li.teratnre in Iingland as wel] as in 

Wc United Sl .e:.ies . 


7n the. !

• 

• 

the evidenoe upon whioh is baeed the ecnipl .usion thet 

ciP,arctto smokin& is the most :importontt cause of chronio 

bronchi.ri.s, cmd that a reJati_onship, whi .ch is nott aausal, 

existF b¢tvc.en ,mok5nr au

• 

. 

The survcys scrve to ovcJ .oate "whether smoking is 

associ.ated With certain :;i.gns or eymptorns to a greater 

er.icn1, thmr wit-h other .findi-ngs ." 

St. is Yepenicdl .y emphElsi .zcd that the di .eignosi .s of 

ehr•oni .c br unch.itis c;an bc achi .evod on]y by exclusion of 

many other• cli-ecases of the ] .miYS and thlri' a c] .i-nioal diag- 

nO51 .8 of ell)physeilla J .E even ]esF OxF ct . 

Tnl', re4117.tE of a feb/ syl9ptom-preValenee su.rveys (r'6- 

ferri.ng to cough, expectoratiou and br eathlessness) are pre - 

s¢nted as epidcciiologi .c uvid ence . The claim i.s mado for 

oxis.t'.,rnen of a re)ationship between selobd.ng snd thosc 

syiirptom•s . 

3 840 

This pmrt of thec report i .no7.udcs a mmmber of statenleuts 

whi.ch clearly indicate that this eviclenoe i.s quite i .nadequcate 

to cs~ablish cven ihis c7 .aini of a ]i.nlc to these sylsptoms . 

For exard,) .c, it is conceded that "7 :n oeveral of these 

sur•veye, fomcles show n higher preva7ence of breathl .essnese 

in non-sh .okors than in smokers, particua.arly in the older age 

group . 

"7he reasons for ihi .s sex difference have not been 

explainod ." 

9he- importance of this admission aies in the fact that 

brcathlcr,snese is, of c :om•se, the most ao.i.hnificant symptwn of 

chronie lung niseasB . 


Another important ad m i .ssi.on ie; this statmnent : 'R4orhidi.ty

• 

• 

• 

dtrta are insufficient ait prosent to bc of value in the 

cstimation of the nossible health haaards of smok3 .nf• ." 

Smomation of the clini .cal ev3donco includes this 

statemmnt : "Such evidenco can do ]iti'ie more than Pro . 

vide a hasSs for hypothc :si.s and i .ndicate the effect of 

continued snoking on estab7ished diseasc 

.sh or nxc]ude eawsal reAati.onship : it docs not, ofcour•sc, estahli 

." 

]Sy] 

heferring to the P atholo Rie, chan gas i.n Vulmonary p¢rrem 

clrymr~ whi.ch orc assumed to 3ndicate a re7ationshi .v between 

s m olci nG and crnphyscma, the report conecdes : "'1'hese chanp,es 

cannot he ro]ated with certai.nty t o ernphysema or other 

reco(wized dir;ease at the orescrrt ti me ." 

Lcek of spaac doas not permni.t here inelusion from thi .s 

Itcnort of rnacy more such quotntions mhich detract from the 

assomed valuc of the cvida :nec presented . 

Ohvious] .y the sum tot a l of t'hin evidcnce is far frorn 

adequate nrocrf of a. li .nk bei .veen srnokiny, and the changes and 

r,ywptoioa di.scu&sed i.n t}d.s report . 

iurthermnrc, whi7e it i .ss 

freely adnritted that these 

chanIIes are non-epeci.5ic and it i.s not posei .bJ.e to idnntify 

thcm as thoso of cl ronic brvmchitis and emphysema proPer, yet 

in this repow the Conmdttoc did not refr&i,n from doi.ng just 

lh o t . 


I3eforr coud~udiny, the^n Urief re rnark:s on statcments made 

by the two p;roups of protap:onir,te of the cigaretie smoke ihoory,

• 

• 

jon 

Gomc corcmant . .; requirad on the m,cst s ;i.qnifinan't difPerenca 

Dotwccn thom miti ; rega^d to their v:i_ows: on the effectss of 

smokiug here znd ahr•oac7 . 

ln 7 :np,]anct t.hoy hold the view thaC xmoking is not 

the chi e ` ocul :;c of ch'roni .o bronchiti-s and that its di .s . 

c,l ling fatal icnm in e.tusect by the combinofl effects of fo( ;, 

air po]]uticm ar ;d Tcctn'mbnt infoc,tionc . 

]L Tho lteport of the Surgcou General's P.dvi.sorV Com- 

m :ii-'ice, it ic conc? .udad thr :t "Cip.nrcttc smbking is the most 

impm•teusk cem R o of hrwte:lliti.s in the U .S ." and that "For 

ihc Lu11c of thc populz,iioac of the U .S . the i.mportanec of 

ci . g iirci .tC BYilokl] .rl({ £,R 0 G a U46 ei bronChoOll7NOnary d]Sen£C :In 

much grc•rcter 4.han t.hr,t of atmospheric po77 .utl .on, or occupa-ti 

.onn7 cxposns,c ° 

'J'hG dl :ffGr@11C'O 2F, of eO11P50y of iundDp1611tNl £11(,n]fleLnCe 

fhois th n slt-onch,,oi .rrt af the iSSVe ovmr the effeets c,f sruokinp ; . 

This ro rv.;sdcablc differenec c:c:rtain)y rv:qu .iros a eonsidcrableY 

ai ;ouni ofi>qrJ f .ai .nin,• by the prota,P.ordetu of the smolci .nYg theory 

hf:PN . .IDG

• 

• 

protaftou5sts of t he c:i.prrettc srroko theory) vrere forced to 

c:onc]udo, corrtrary, to thei_r• f oriier]y repeatect)y expr•ecsed 

helicf . thai ::moki .ng haLits al .one do not determir :e the 

prevrOence of respiratory sy :npt-enns :in a connnunity . 

Thcy concede that their fir:diags now point i.n the 

di.rection of r,ir po]]uCic:n as a factor and they also spco .- 

i0atc on thc ro7e of ethnic diffeirunces in the populat :ion 

as a eauso ofpredicposStion to chr•on :i.c resni .ratory discase . 

IJith widenint: epic7cni.o).o8ic sturlies, the li .nk betrooen 

smoking and cainioal]y si .pni.ficant lung disease is bound to 

beconc incroa :;intyly tenuous . 

77 

3843 

Ny second reason f.or oppoai .nf6 the ciF.arottc srooko theory 

ie : har : :eal on the concept tha2 the ]ung disease nour in ascen . 

c]ancy is ncither hronchitis nor emphyseme, but i .s a new 

puLronzmy dise.ase ent'i.ty which has cvo]vod during the past 

hal.f century beRinninpg before cigarette smokinY, hceame wi .de- 

s ncud . 

7'his ucw f-ore : of' chronic :lunt; diseasev i .s nosr wideAy 

rccognizcd ns such t.s indicated by the apt deslGnation of 

"ehronie nonr ;pecifis 7 .ar:e di.sorrse" now used in the ] .itcnrature 

wnrc .:nd moro frcauQntly . 

Thi.r, new form hus evolved as a result of prvfound changes 

in wcrlic :n) se5.ence, chzurGes in the l .ives of the people, aud 

chenp{ec i.n ihe c.nvironcim :i rahich have nffected the respi .ratory 


ion 

o>r;nns iu particulmr, dttrinf: the p ..st halP of the present 

cen'tury . 

The i.nci denc e of the preseM form of chronic laug 

discnsc is known to have inoreased parallel with the Al . 

.ni: chanP,cr> : 

) 1'hera hac occurred a very sharp decl .ine in the 

.1owi 

iII4 h 

mortality from pulwonrmy i.nfections (pneumonias, tuberculosi .s, 

at ectcra) . llorec:ver, mxny reurvivore of thosc formerly fatal 

nff]iciions urv now lcf't with pcrn¢menY ] ung dN ma{;e, an d 

thcy rmuai.n mor v prone to furt4ie r lunt; damap,e by subscquent 

affections involv .ing this organ . 

2 . [Phere has ocomr:re d e: ticmkoci increaee in r espiratory 

snfec:tion b by ,? vardoty of vir al agontn, inc:ludinft many only 

most rocently idenYificd, rahich though rv:latively mild jr, 

W 'nis of mwrtA?Sy, hnve ;i verY hiY.h incidence of morbidity . 

14 have n o antib:Co-l .ics ap;uinst thase respiratory infecti.ons 

which 'Lend to recur frocluentay durintt 1ii'o . 

3 . ateree has occurze:d a striking increase in the 

incdAnon of ;;1)ergie and r.n'rhmatio rrspirstory affeesic,ns . 

4 . Vnstay incrc:ased iuduatrializatiun has br ouf;ht about 

chanf.es in olp envi.ronmant 2:ffoetiuq partioular ly our YesPirmtory 

or;;ans by pourinq a nwnher of po]lutants into the air we breathe 

hzrmrul Si araumrt and n»turc . 

u . The lcngth of :I :ifa of peoylc has inoreasad, the ratio 

as mon and wo"en ]ivink to advnneed and old age is much p,reeter . 


• 

• 

• 

jon 

'1'he factors 7 .i.sted above now have arnple ti .cie to exert their 

corabi.ned untoward effects and aggravate the effects of the 

aging process particularly i.n the respi .ratory tract . Ilence 

the increasing prevalence of chrorri .c lunC disease in our 

dj;ing popul .ation . 

1845 

The chronic ltmA disease which we now observe represents 

the resu] t s of a 1iSC-iirne of wear and tear on the re+spi-ratory 

system . 

Its development and rate of progress in any particular 

case is uri.rrenily clc:terrrrined by the i .ni.t.inl pulrnonary endow- 

ment the i.ndi .viAua7 is born wi.th, the lunr capaci .ty he developrs 

duri .nlt the groeri.ng pcri.od of li.fe and by the pulnonary afflio-- 

tl.ons and dainar;os he suffered during his l :i.fetime . 

We soem to be dea7i .np; with eun exceedin g ly com ;q .ex 

disease entity whieh we now observe with apparently increasi .n g, 

frequcncy i .n man und women of advanced and advaneinA a ge . It 

hr.s a s7.ow and vory i.ncidi.ous evolution be ninning quite earl .y 

in l .i.fe, and ]eads to ovs,r'i pulmonary di.sabi :li.ty only many 

years ]ater . 

fn e :.ll1 popu3ati.on s:urveys, age pr'nvect to be the factor 

of hi.p,hcst corrclation wi.th the symptoms said to be indicative 

of chronic lunP, dieease . 

'fhi.s insidious change in the prevalent forms of chronic 

lunp; disoaa:o began lonF Lofore cip,arette smoking became wide- 

spreacl . 31 became notiecahle soon after the turn of the century 


• 

• 

j on 

unc), by a]] ir,di.cat :i.cros, it afflict:s non-smokers as well 

a.^s emokers 

:ngr7ond . Ju l whora this ssrious form of chroni .c )ung 

di .seac :e is by far the most oonnnon as eom p aireci, for example, 

wi.th thi.s country, and re) .i .abi.e str:tis1 :ics of its incidence 

nnrc< availablc:, the hihh rate of i .ts occur renee in non-srnokar•s 

has bcen c coD spicuous i-eaevxY : . 

31 tiso uPpecrs t o be far more fre:quernt in men than in 

wome.n, e:7thovnh c7urinF, t ho past few docades womcn have hcen 

scicki.nL in increasinp• ncmibere: . 

7he naturo and or•igins of the chanf;ed form of chroni.c 

] .un); d'isease presont]y evo,) .ving under• the effects of recent 

and current chanpos in mc :dical science nnd in medica] prr,ctice, 

xwd rmder the offe.cts of changes in the cnviroronent we are 

]?v5ng i .n, is .far inorc, proh]emati .o thian is genera])y appre- 

ci.ated, parta culnr]y Dy t :hosee who cti :lll insist on speaking 

of chr onic bronohi.tis and pulmonary emphysetna, di .seaso 

entitieu whi .ch they c,an no 7 .onger def:ine or understand . 

in spirCe of numexmus cympos :Ia held re:cently on ths problem 

of p«linondry emphysema, wee have, madc+ 1i .ttle pr•ogress, so far, 

in so)v :i .ug, th.i.s prob)cm . Current studi .es cmphasi .r.e ]oss of 

)un}•, subr;tuuce (depart .iti .oni.ug) as the ece :entia] criterion of 

i'his condi.tion . 

]n the proce.ss of a9trition oi' lung suLstauee thr•ough-oui ]if-e, a] 


.ar);e ntuchcr of faetors continuc to operate, and

• 

• 

jon 

the r•o).c of mosi of thcee factors sti.1 .7, remtrins to he 

doter•mined . 

C]inS .er,lW er.pe.ri.earce does not aff~orti any indi_cations 

of posuibYo harm to the lur,ee f9ôin smoking, end certa :inly 

th¢r.• arc no rnparen4 si.gns or symptows of c7 .i .ni.cal s .ig-n5f 

:i.cancc which dciir,'itely impAieatc smolci .ng i.n the ori .gi .n 

imd dcveJopmevt of ehxon :ic 1tmf; diseasc in generW . 

77:decd .. i.n rny own cli .ni.cnJl eryeri .oncr .. I have had under+ 

lonFt ol :sc,rvati .on many men and cuomen wi .th obvi .ous7y poor• 

puJis:onary andoyrnent (poor chce :'t ctevclopmcnt and 7_ow pul- 

rnonnry c,apz :c,ity) rino hrcd smokcd hro.v .i.1-y i'ov many years and 

rumaSn.d compMe7.y f3ee frolu rmy sSl6ns of harmfu]l ef'fecis 

oS'thief hab{'i' :in the J .rwgs . 


)n the lurge nwourrt of iilteratu re rr•oent? .y aceurnulute C 

on poc : :SbJe- effects of srnoking, no evi .cience hae been produced 

of eic.-iueJ harmful ofJ'ecris in humans, e :nd oert ..inl.y there is no 

def5 .nit.c evidenc

• 

)C 

]_n contrast, ]arn not suro :ris¢ci by t he fact that thc 

over'^r.theluinA Pl•nq,ortion af omok

• 

• 

I o n 

-ius t ifl' s uch netion, ht my opinion, the answer to this 

au

• 

• 

jon 

5'he fz:c-f thct we cto nott yet po&seser the know)ec]F ;e 

which Iaou]d o.naLlo ue to seleet t'hose to whom syoking may 

pos ::ib)y be harndaa dc>es not P.ive us ihc right t.o advoeate 

thZlt CvcryOLO rCfr(iin fIRHm flIDokin) ; . 

Un'li.l wo havc ;:olved thi .s problem, physiei .ans 03)1 

mroLnbly coni .i.nuc to do what: they hnve boon Aoin&, nawely, 

a (IviBln(; n :/ti.eht6 wi'ih Sy1 :Into19S suggesting VG&5ih) .C ohse t 

of ch ronic lmlg disease that smoki,ng inny ap,gr

' 

• 

0 

• 

srnrla+crrr or R . u . xlcJlo ;r, M .n . 

I am H . 11 . Rip,don of Galveston, '1'cxas, I am a uhysic :ian . 

7 rocci .ved r:y M .b, deP.roe of Hrnory University, Atlanttj, 

Ocorgin, in :19'31 . . 7 took ny int :ern and resident trai-ni .nr; 

in patho]op,y at Duke llniversi .ty in North Carolina . 

7]iave boon a tc;ncher of P

• 

• 

• 

jon 

sponsor•ed by the U .S . P:rmy . 

For the last 15 year•e. ]: have been interested in lung 

IR52 

canecr . lhave )-,uhliahed three revi .ew arti.cles on lung cancer . 

Thc first diiscuss®d ttmg c.cnn cer• as : it wa& known Lefore 190D, 

the second f :wm 1900 .to 1930, and the t .hi.r•d from 1930 to 7.960 . 

1 an now gathe :rin(; nmaterial for a fourth review from 1960 to 

1970, 

.7 have •xl .&o been interested in the frequency of lung 

eancer in caues that we have stuclied at autopsy (Preguenc :y 

of eancer of the 1tInP& in P111 mdlignancie3 studied at 

atrtopsy . Southern Mc.d .i.ce ) Journal 44 : 506, 3953) and the 

cor .u:lntion of the diognosis of caneer as made on the death 

oor•T.i .fi .catcr: with that ohserved a t the autopsy (Vita l stati.s- 

t .i.c.s tnd the feeyuenc:y of dise:ace . Tcxas State Journa l of 

Mczdicinc: 59 : 317, 1963) . 

I have: Lcen interested in oLtaining the history of 

cijttlrettC smokinCg in hos p ita1 und cl .i.nic patients and cOr-- 

r•clating these data with the el .i.ni.c s t diagnosis (Smok :ing 

hahi .ts oi 21 .,61 .2 :i .ndivi.duals in 'Pexss . Journal of the 

Nnti.ouc] Ccnccr•]nsti.tute 16 : 1287, 1966) . 

)3 havce obtained the smoking hi.stories of college students 

to estnblish the frequency they smoke (Smoki .ng habits of 

cc)]egc stud entc in 3'exas . '1•exas Ite p orts on Biology and 

Medi .c.ine 12 : 292, ]954) . 


In the field of research 3 have been i.nterested in

• 

• 

• 

18G3 

studying the effect of chcmi.cals that produc:e cancer . Somc, 

of these chenricals are put di .rect :]y iuto the ] .unrs of ducks 

and dop;s through the mouth and wi .ndpi.pe . 

One of thce.e cherni.cals, methychoanthrene, has produced 

many t.umors in the ] .ung . lienzpyrene is a chemical frequently 

su8kested as a si.gni_ficant carcinogen in cigarette smoke . It 

has bomi Gcrnonstrated that large amouits of benzpyrone are 

present in charcoal bro i.lcd steaks . It is a] .so i.n the air we 

bre athe . Y have placed larpe amounts ir, the lunp;s of ducks 

..nd have rat obsorved nny cc,nce.rs . . 

As far a:, I know, lung cancer has not been produced i .n 

aery ruiima] that inhaled cigarette cnnoke : . ]di.d not obtain 

t.umors when tobacco tars weft: put di .rK:ct]y into the ].ungs of 

duCkP . 

) t i .a interesting tc, know that tobacco tar when put on 

the slci.n of micc will producc a skin cancer . 

I put a oancer-producing aP,ent, methyloholanthrene, on 

the F:ki.n of et duck and got rnany different typos of tumors, but : 

when the samee agent was put on the ski.n of the turkey one 

typo of tumor rasultod . 

Noa thor :: is not much di .ffe.rence in the skin of the 

duck and turkey, but there is l.ots of difference in the skin 

of a mouse a.nd the respiratory tract oi' man . 

] cmi unahlc to transfer dctn about cnncer, as obtained 

from ev.pcrimenta] ani.rnr.7., to man . RecentYy, that ie withi .n 


• 

• 

• 

the pc:st thr'c:e y ears , cantoers have been found to deveYop 

i .n the l .i.ve:r of rvts fed pcanut meerJ. (Nembc rne, P .M . , 

19m . Id . Car )1on and G .N . WoAUnn• 13epatornas in rrits a r,d 

he pn torenal3 i.nJury in duck7 .inF,s fed peanut mca.l or 

FlepergiJ.lue. :ftirvus er.tract . Path . Vet . 1 : 105, 1 .96rs) . 

1 have heen sturryi n g some of thee:c: Yet: J .i.vers . fn 

vi.Rw oflny OJ p eri .ehce 4!i .th ei.glrett'e.s Flnd eF.nC:Crn lI capnot 

he).p but tF'nk of the proLlems i :hat cou)d ari.se in rei .Mt .i .on 

t.o raLS ceai .ng peanute: . . 

Th en, too, we hr,ve the probJ.om ofli.ver cancer in fi .sh 

fed OOitbnFfCf1 productH ( Wolf and .reCltPOn . 116ptitolnfls in 

rainbow trov'c, dosenipi9 .ae nnd exper•i.mentall epidemino] .opy . 

scicttcs A7 : H'I6, 1863) . 

It is my opini .on 1hat moro researoh is needed in the 

i'i_ci .d nf c

• 

. 

• 

of1unOrF b @ing pro 9e.nt in 8 liiotltf'.r 'c'an(1 daughter . 

i'he o a usc: of' cancer is not known . by th1e, cae mean 

t hat o-ie : d o not kn ow wby a cei .a in the body of one prnreon 

W l l :ecome a canecr nnc7 the rorrceponding ce11 in c,nother 

prrson vi .l'1 no t hocoice a cencer . 

P, canccm .:n5.ees frorn ce7JS withi_ri t'he body . A norma :l 

cc:U p.rrown rud rsq,roWcs itcei .f in a tud .forrm manner, whS.'.c : 

n canoa,,rr cre11 grrovrs and wulti .pSi .ess r>t an abnorna] rate ; i .t 

).NS . 

spres;ds into par4cs of the body iaherv a norvnal cel] would not 

96is ahnm u a ) act :ivi4y of e cel .a in what w e c :all a 

crnocr . Lt is a known r a ct, and so fe .r• a.s ) : kno w itis not 

denicd by anyono, thct a

• 

• 

• 


racor•ded t'hic eas

• 

• 

• 

infOrina9:].OII to SerVe aF the bLFi.6 for dLrterl0inlnFg the caqFE: 

ofcanc:er, In my opinicm, more worlc i.s i.ndieat:ed on this 

prob]eui . 

In 3934 Swe-r.ny sni.d, "If there in any merit in thi .s 

theory (cigmY;tte srnokinp, and lung c :aricex), it should be 

msnifest in the femaJe nex, where thee inr.rease in the ueee 

of ciEaretY .es has been greater than in me.n . 

"7f, for exarnple, the ratio of men to women 20 years 

o$o wfle 3 to l, and now in 193$ it is 1 .5 to 1, the case is 

wel.l n ;gh proved, 

"So far, no such inerease in ratios has appeared, for 

the se.r, rotio wns and st :i]Jl in around 3 males to 1 female, 

ei .m:itur to other ma5ignant aond'xtions other than those of 

sex differences, 


'bn the other hrnd, there are uv,iny patSents with lung 

3 067 

ccaicer who do not f;ive a history of cigarettce smokiurf; at a71 ." 

(Priniary hronchi .o{,e:nio carci .nonia ; i .ncide.nce, pathogc:nesi .e., 

and diagnoe;is . Annaln Otolopy, Rhinol .ogy 43 ; 501, ).934) . 

lir- . Joseph perrone in Flpril of 1964 reported a group of 

1,000 eases of ]wig ee,ncer in Yittsburgh and pointed out that 

474 ofthosc reere precent in nonsmokere . 

Dr . Ycrrone aJ .so poiuted out ihat in his group of 1,000 

cases of lung eancer there were 754 whites and 246 nonwhites . 

lie t:hen asked, "thy should the Negro not develop lung cancer 

Irorc frcquently than the whito, for he in ee-r•t ain]y exposed

• 

• 

• 

tc, irritatinf ; f;ases, e,nd furthermore, many co) .orcd men 

smokc cigar•att'e.s they ro173 thern:elvice" (One thousand cr.ses 

195D 

of ]ung eanccr . Fcnsylvvu .a Medi.cal Journal 67 : 31, 19F4) . 

3.t is ny opini.on that ectucttt.ion has boon an i .nryortant 

factorS .n the inm•eei8e :Iu l.ung oancor . ti'ith pulmonary 

tuberoulosi-e d

• 

• 

• 

the cormectness of the di.aguosi .s on t-he: death certificate-, 

bui: I do . 

Ccnt]omon, I hope that i .t is obvious from my remarks 

why l3 was c]r,ssi .fi.ed in the Surgeon C;eneral's Report on 

Ci.i;arc:tte Stnoki .ng on page 7 .79 as "thoul ;h accepting the 

1EL9 

er.ie;tenc:c of an aesociafi.on, have quecti.oned its signifieance 

in torvis ofa oaut:al hypothesis ." 

]h regard to the Surgeon GeneraJ's Report on Smoking 

mul Ilaalth, ]thi.nk it is an exce7lent suwnary of one side 

of th :i .s controversy . 

.lf oqus0l timrre anci e ffort had bee.n given to the opposil :e 

view by thi&: Ce mmit:tee, 1 think the report would heve beon 

twice t he We and would have been a xk;port that scienti .sts 

in the future could review to see really what the state of 

kno,a] .edt;e was i.n :19G3 . 

l,-r.r.t yez,r the Federa) Tra.de Comm :i.ssion e,olici .ted my 

cominentS on '[hei.r propo8ed °11 .Y•NdC kegU7 .atiOn 12Oles .° In my 

re:ply 1 diea p med with th e ir l.abel prv>posa]l and pointed out 

that 1 do not think the atatewent. "Cigarette smokinp i .s 

danY,erour, to he n ).th . laM may cause death from cancer and 

other di9eeseH° i6 OOrreCt . 

1: wou7d cons .ider the statement "Caution - Cigarotto 

smoki.ng may be dangerous to hea)1h" to he more consistent 

with the fuct5 as we know tllem today . 


31 we 1JW - Ci .gPrette5, then we F.honl.d lahel peanutH

• 

• 

• 

since we know that ca.neer occc rr> in the ]i .vers of rats 

fed peanuts . 

- Chareoal broiled steaks should also be laDeled since 

benzpyreno has been demonstrntcd in thern . An i.ndefini.te 

number of i .teme wi7 .1 fa71 into this ] .abe]i.ng category . 

1860 

To c.wnmarizee my vi.ews ., may I say that, first, I be]ieve 

that there is no sati .sfactory experimental evidence to 

estab]ish a connoction between cigm•ettc srnuki .nY and ].ung 

canccaV . 

Cenc:er of the 1un€: has not been produced experimentally 

i.n any cmirn

• 

. 

0 

dcfoct responsib7 .c: for stea•il .i.ty and the development of 

tomors . 4ui.rnc~.1 . rase :er¢:h n7.so e:urgests the :ittyrortanee of 

onxS.s :i.n fac'tors cta~h as vi .roses, i .rrndiation and others . 

Second, 7 c;ue&•ti.on some of the ci.rcmnsstanti .a7, evidence 

concerning smoking and c.r.uccr . Y pointed out that my exper-- 

i.ence 3.n the gorfornemoe of autopsS .ec :Le:euls me to question 

whether lunPg cunoor oocurs m& frv±quently ass it i.s racordcd 

on ds:ath cer4i.fi.c

• 

• 

• 

w] xear 

AI3MRICAI3 CAnCBR SOCIETY 

Rhodo Y:s7.nnd FHvi.eSon, Xno . 

3133 GroC4o Av©l1nc 

Providcnco, R . t ., Ok!fS06 

6'nrch 1G, )0C5 

The ltonox•ab3c John P . p o store. 

307 Pur.i Offiacc: 4.nncnv 

ProVYdGllC3, {2'i,Oi1p AN7P15C1 

llenr 8nnetor : 

An a pri .vato yrhycici.r.n :and P)° .dont of the Amori.cesn 

Qnc,or Pxeci.oty, lihode )ca)and llivdrsion, Tnc ., I am vAtnlYy 

csoneorued nbou4 thn znoroae ;e)d SncS.denoe of lung enncox• end 

the 1'S'o1r(tn YC+7 .N$Soneh'n)) VA Oigflr[ettb EfGokin(; to tl)16i dSPOR9G . 

Va.rt.our e:turiiers in thne' aountry and nLrond bavo Aivun ovox° .. . 

lYheRmPnR nupporYt to Uhis theciFe . 


In RhUdO )C+).knd F(f+ ltkv0 fl C6[e/1POhOl1E3vC cIYS .)dl•CIl'O 

and Hdut4's jJxo(+,rno1 on cS .f :nrotto HalokSn([ Ql1d hRa14h . This 

1nC7lndOa fi .IJln'.), 3$.20PAtuTG, a.nd ©OC'M1.4YB, CRYPCntly we Fax'O 

a)anmhcr o£the Ithodo ) .F;Sand 'SUte+rxgc;ncy C:ounci .]l on SlnokSUp 

Ylhich ( :On(.SE .LE; Oi RCvCYa.7 Vo)nn9lnFy P>Pnd official agencies 

LhpC hr6 Wi((kh'4d in a coopC+ra8i .vC PYbI'ranr to di.HConl'NF,'4e 

cSfY.RrUbtC tiNO$ .S,.fl(; Fzf9ong n(7u1t6 and ch93-dYGn . 

Ac$Svi.tiffi kUld inS:GYC€3l in each o f th(i8C nrCPB con•• 

eSnltce to $.n9rens6, but we do not foul that thi.s is enough . 

11 Ci . Va 'PCY,tC` J9i61cinfo in t o (iCCx'flanf* n ppYCCi.AIA)y 3i.IGi.YO(7

. 

• 

• 

SoveP6lrQfitnl fiGti.on }n IleCadE+d . I fOGl t-h6t federPl 1hwE 

voqni.rS.nEC ths^ laheli .uh oR eS .grcrottot; n.ud the reC•ul .ntfng 

of oi.(rl:r.ottc; advcrtEri.ng iro needod . 

'19snreSoro I ur€±c you to G9vc your f ul.l support to 

Bp:hA'I'1? BS1 .1, 8@7 which lrou5d reFCql.nte. oi.gorotte labeling nnci 

ndverf7e.i-ng. A bcalAevo tnut th&e would mnr4 the beg9 .nnfng 

bt f.

i 

mc :r. 

tiR'ATL3P 91sK' OF 11IY.7ÒN D. pN)SP:NNI ATT, M, :D., ASSOCIATE 

C 13NTCAL, YA6h BfSSUR OF Mt 01CSNPI, NEW YORK M13llICA L 

CC7:d:MC1 S 

186h 

Dr . }tosenbiatt : The i.nc:rease In lunG cancer in the past. 

few decafes has fostered the concept that this is a modern dS : - 

case produced by exposure to recent7.y 4ntroduced caroinogen3c 

substances . In the Intensifi.ed search for causa l agents many 

Sundeqnental facts have been d :isre@;arded . The proper di.€€er- 

entiat i.on between apparent and abso7 .ute iru:rease requires a 

porspcc:t7.ve that encotnpasses for more than a more asseesment of 

epidcrd.oiotri.c&3. e:teitisti..cr, . The rapi.d rise of a di.sease co 

.th i.rnprovernent in d9.agnostic techniques has occurrect 

-incldcritr ii 

many timos in the eourse Of rnedlca,J history . At the turn of 

the century, when the marked :tncrease In cancer deaths In 

L,[7and was attrP.buted varAously to parasitic infestation , 

meat eonecanpt3.on and excessive ralnfa7.1, King' and Nowsholme (1) 

observod propheti.ealfly In 1 $93 that whenevar a cancer became 

dSagnor,ti.oai.ly accesr,ib7.e the Irroidenee automatioa7ly Sn — 

c*rcased . The Ecport of the Advisory Coam:nAttee has based its 

,iudgmcnts of caueality almost enti.reJy on epidemiologi.oal data, 

has invoked hy p otheti.oal considerattons to substantlate the 

ctatist.5.oal oorrcaations, and has not suf€lciontJ.y consi.dor od 

pertinent refutatory evidenco . 

tc~tor7.ca7 Gonsi.dw atPOns : The Report of the Advisory 

Ccnnmattec d9 .scuesos the hi.story of 7.unp, oancer only finso€ar 


0 

• 

• 

mc2 

as it rei.ates to the stucties on emok4 ..ng and completely 

9.gnoros the fact that the disease hs.s been prevalent for 

a hundred yoars befo re o :tgarette emok:Sng heoame widespread . 

Nowhere S.n the Report :to 5.t even ; .nti.mated that the baai .o 

1865 

know7 .odt;e of' the patholog;y of lung cancer was developed in the 

19th centu.ry, that a17. the oharaciterist9.c symptoms and physi- 

caA s9.gns were d3soovered 1n the 19th century, and that astute 

c15.ni.ctnns, bi>th hero and abroad, wero omphasizin6d, In the 

19th century, that lung cancer oc :cu.rred far more frequently 

than was gencra4 .7.y realized . 

Yn 3815, 

Laennaro (?) d9fferent .iated 7ung cancer Yrom 

tuberou7 .osi.s a.nd other pulmonary diseases '1n an article In 

the ll~cS .l.onnaSre dee sc,ences mod~cales . 1?our years later 

he pubi.S.ehed a t r eat9.se on physioa7l df.aCnosie, lio_1!ausrouAta- 

t ion roed:tats, which we,s trans7.ated by Horbes (3) and evoked 

considorable 5ntcrest 9.n the diseaae In h`n gIand . 

Andra7. (h), In 1821, irrvostigated the possibility of 

diuFSnas l s by sputunr exami .natl.on and in ?.837, edited the fourth 

edS .tS.on of Laennee's e1.ae.s :t.o work contributing a profusion of' 

footnotes on lung ccincer . 

houillard (5), ln 1826, discussed the possible relation- 

shi.p between anteeedont pu.lmonary infection and lung oanoer . 

Sbyfelder (6) won a oitati .on for h :is studies on the 

sub,7ect in 7 .83y and, 1,11 .Bay1o's 1939, às_a te des maladies 


• 

• 

• 

3 5.866 

oanoereuocs 7.3.stcd còanccr du poumon" os ar, established 

prlmary ma7.5p ra ncy . 

Uiher'Br•enr.h a .rt4 .c+i .os were published by Uorar•d (7) in 

1821, nrna7 . ( 6 ) in 044, Lebert (9) In 5.8dG>, charoe7ay (10) 

In 1837 . and N'.ormerot and F3oury (1 L) In :t£StF6, the latter 

au.thorw oontrPhutS.ng a sB.Yab1o bf.b7. ;.ograph,v . 

Lung oanc e r has been a subJeot of eonsiderabie intereat 

In Pu•itai.n sS.nce the pub5.icat5on of Stokes' textboak, 

S~1c•easc+s of, ths Chys4, In ] .837 . ti'ho desorS .pti.ons of tho marh- 

foat5 .ationo of the cin .se•r,sc+ and the Kmob7 .en,s of differential 

diagnoss5.s were Y.ndicat3.ve of a w5 .de clirf, .c:al experience . 

Stimu'iated by Stolmei te:achings many other fsrit :ish phyeio4ar,a 

mude important contrtbuti.ons . 

A report by fu+ro (S .A) In 1838 deaor4bed a neuro3.og9.oo1 . 

complication whd .oh was re-discovered (1 ;3) a hundred yeara later 

1.n thf.s countrN . Signif'icant observations In pathology and 

cl5nicaJl medielno were cwade durlnfS this era by £tughes (14), 

£Qao&ach2an (15), k,urrowa (7 .6), and (craves (7q) . 

In Apri3., 7 .8t :3, the PrAtiS j~h cnd I~or~elf7n Medical Review 

rev5 .ewec. f5.ve ar•t5cies on lung canccr with an editoria7 , 

ccanmont on the 5-ncreas7 .ng lnterest S.n the diaease and its 

greater• prevalcwoe th[m previoualy euepocted . In the seeond 

hs].f of the 19th oontatry, Z.Mg7ish reports showed an inoreas•- 

inB interent In the microsoopic studf.es of lung oancer S .n 

order to bettor d9.fforentiato it Prom metaatatS .e tv.rnors of 


• 

the S.ung . Histologi.oal finGings estab7lshod In 1857 by 

Ouai .n (7 .8), Cockle (19), Mayne (20), Pitman (21), F3udd (22), 

Page (2,), and others aro ,iust aa valid today as they 

werc a century ago . 

The gr•eatcst advances In the patholof ;y of lung oancor• 

were no& In Rerroany in the latter decadee : of the 19th 

century . U:aideyor's (2$) stud3.es of the origin of oanoero 

1867 

stimu3 .at•ed i.nvest9 .F,at:,.ve roaoarch culminat•inp, in the establ3sh- 

mout of t•he origin of 7•unE' canoor from br.onohiai opi.theliu.m . 

9'bo rnamber of case reports, ar•tiolos, and inaugurai disserta- 

tlonee on "lungenkrebs" contributed by oerrnan physl .olanF: in the 

19th century is renuarkebYe . 

The authors whoce works provided the groundwork for our 

cunrent pathoJ .of;ioal concepts 3 .nc7•u.de Per9.s (25), Qeor£ ;3 (26), 

Hc3.nhar•Gt (27), Mirch-H7.rsohfo7 .d (P8), Heeee and Hartung (29), 

Sioge9. (30), Si .Oert (31), Wolf (,S2), Yasslor (33), Franke7 . 

(gt;), gcht^!albe (35), Har•traann (36), and a grcat many others . 

The varf .ous ce7 .7l t,vpes and archltoetural struotures 

found 3 . n lunf; cancer were wcll desor3bed In those publf .cations . 

Tho Gernun pathologS .sts noted that lung cauoor eases usually 

came to autopr;y In a far advanced stago of the disease but that 

few hod bcen 6i.agno[:ed during r.ife . qio o f the most valuable 

contri .butionr, i•+as the d0.£ferentd.ation of primary lung canoor 

from secondary pu7.monary growth and ben3 .gn tumors . It is 

noteworthy that the patho7.og5cai techut@uusand stal .ns 


• 

0 

• 

N ;tscervered by the German pathologAote : In the 19th century 

arc: sti7.5l very rnuch i.n use at present . 

Cenera7 . S.nterest in an.nES c:ahcer dove5oped ooneSdswably 

i.ater 9.n the 17rr.'itod Staten than It did 1n Ru.rope but ecafie :: 

nere desorSbed (37) at the Massaclmsetts (+onerat . Hospitat In 

18rB 

7.8&P anG ] .850 . Ar•tic:i.oo eontrlbuted by Le :h7.bnoh (38) in 18%C 

eand by J,ooml .s (39) S.n i.87G showed considerab1.e Earcf.llarSty vlth 

the tAscaee . llcF.&f :tcld (4Q), the pathoJ.og18t at Roosevelt 

Nospatai, wae wo? .1 .2oqua9.nted wf.th pri .rnary tun(; cancer as 

car].y as 1858 ae erv idoneed by h1 .s e:uto psy records . 

tn the i.ettor dens,dos of the 39th century the number of 

AverAc :an arti.cJcs S.nc:reasod 3 .nea .ud3 .ng oontri .buti .ons by 

r'ctTer (1•1), vi:n (;Sc ::en (42) , Ripley (d1) ), t:omper (kU), 

Janeuay (115), Yo2 :iand (116), Rodenpy) . ( 47), and LeCount (48) . 

On lA^.oembor 7.8, 3.680, the Nr.dlca9, Y;ecord canmentefi cdAtorS.a97.y 

that 1tun t; canoe,r wouid corB :tnuo to 3 .ntorost patho3o(;1.ats des . 

p9to the i .ack of spoo7f9c tr•eatment, 

9'he most important .P.n;orf.oan artfic7 .e on lung oaneer 1.n the 

5.9t:h ce,r,tm,y a ppearod 5_n the NEw,Ygxlt M17E ;~7,oa.A Jour7iai on 

tbbruary 8, 7 .896 . The author was Adler (!!{;) whose monoSraph 

on the sub,jec :t i .n 7.912 ha ;s since boeone a med i oai c7ass7 .c . In 

the 3896 art9 .c:le, Adlor repeatedly emPhs,el sod that lung 

caancmr Yeos not a raro GtGSearo In the United 3tates but was 

rare7 .y dial;nosed . PIe urged phyaie£.anrrs to beoome more farnl] .R&r 

rr.tth i .tF. c7zni.oc;7, rrnni .See.tati.ons ar,d pathol.o(y3str, to do rnoxs, 


0 

• 

• 

6 

motieulous work to as to bet,tmr reoognize the disease at 

aatopr,y . 

As the 190h century oame to a close, artieles on 1un g 

canoer also appeare6 In rue8l.oaJ. ,9ournal& In Xtaiy, Fo}.and, 

1669 

and Nor•u.ay, and aava.nces v:ere being made in c15.nioal dia gno- 

si .e . ;it Au not genorva7.7y rea2izod that the X - ray (50), and 

the bronchoscope (51) i• .oae bcF:irm].n(; to be usod to dotect 

?ung oanaer b o Pore the 20th century . Ono of the most in- 

fornr

411 

• 

. 

pathoLogiat to reeogni.ze eases fcmmori.y obscured by late 

comp5 .7.eations . It i.s very evident : froin the many published 

reports that the rise 1n autopsy i .ncidence In Oar•rnany wa.s 

1870 

due to gmeater awa.reneas of the di.seae,o and bettor patholog .f.• 

ca1 d :i.a6'.nosis . 

1UN(a CAhCBft t+OFNPAYA;9'Y 

Pr•oponeutm of the oausa7 . reiat ;.onehi.p between smolcAng 

and 7.cmE•, oancer have poi-nted to the ri.so In lung cancer• deaths 

during the past three decades aa oorrobatlvo eviderioe e .i.nae 

thi.a pori .od wan a].so ohrcraotori2ed by a rAse In o2garet :te 

consunption . On the bas:As of natSona7 .l mor4s7.9 .ty fi.guros it 

would appoar that a tremendous inercase in lung cancer had 

ooourred in the UnAted Stntes since 7.930 . There 1e, howover, 

much ovi.dence ava5.3.ab1o to chal.7.oage the accuracy of the morta- 

7.Aty t:t:atSati .efi . It in not gonertd3 y reaSi .zod that even i .f 

i.t had bc:en ponei.b7.e to dS.agnose lung cancer In the early 

decades q F this century there was no speoif9.o oategory In the 

vital stetAsti .cs 9.n whi eb to record the lung cancer deaths . 

7:t wa n not untiJ . 1919, after rev0.ni.on of the International 

Cod o , th[A: o].ae.si.Yioabi.on of lung caneer beeacne a statl.stioal 

reality . 

Xn 1912, A.ctl.er (5Y) In hLs famous text on lung cancer 

ori.tioai.ly ques9si.oned the accuracy of the eonsus reports 

amphasi.rSng thet thc incidenoe of S .ung cancer xas far greator 

thnn rca9 . :Laed . a'he tntaA nurnber of r•ocordcd lung cancer deaths 


0 

• 

in tho tini .ted Scntes in 1914 wao 7.oen than 400 resuh5 .ng 

at?prm:i.m ateiy 3,000 by 1920 . 

On hebru2,ry )3, 1916, . the 

1871 

.TOUrnal oz'. Lhe Amerioan Medloai 

RosooZatjon cdmrnented od3.tor9 .a5.iy that the nunber of oases 

In the preeodi .ng 15 year taorSod wao so great an to al:most 

def.'v onumeratJ on but the ourrent nationai . figure for lung 

cancer doaths wau st9 .Si 5000c than 'r,o00 . 

X n 1930, .when the nurabor of lung oanoer deaths In the 

United States wae recorded as 2,837 Chova7 .i .er J'aokson (58), 

the pi.onoer in bnwiohoa:oopic di.agnoa7.a, htut records of almost 

500 casec;, . . 

.r.t i.s very apparent that the increase 5 .n 7.ung cancer 

cince 1930 waes baaod on greater patho9 .og :lca?l knowlodge and the 

devel.opment of toohnic ;us s wStir which to di.agnoao lung oanoer . 

tiowov or , the Report of the Advisory CanmS.t•tee states that a 

true :tncreaae Su luntg cancor hau ooourred and bases ito 

contention on evidence furn :?.ahod by otate cancer registries 

smd nocrapny recordo from 9.arge genera5l hoopitaSa . 

A'he pepori oitec the statistics in upstate Now York 

ahowf.ng an o.ve :ra(;c armua2 rato of inorease of 7 percent for 

m^lcrs and 3- 3 .5 perc:ont for females dur9 .ng the period 1g47- 

19b0 . 

LCho pn•ecentation of the data 91n this nvanner is most 

mi.s l oading . Rov3.ow of the total lung oa.ncer deaths In Now 

Ycurk Stato du rlngtho per i od wnder discussion ohowa that the 

rate oi' i .noroaaeo of lunp; cancer had 6ccl7 .ned from 42 percent 


• 

. 

• 

9 18 Y2 

botwec.n 7.940 anct 7.945 to a low of 18 percent betwoen 1955 and 

1950, 71n5scould not have oceurred in the presence of a true 

i.nor•ease of the dlseaee . 

The Yepcn•i ; a7.so cS.tes autopsy data from large hospi-tu7 .s 

where "diagnoet3 .c: acetn•ac,y has been uniforrn and exooilent for 

rnany yes re ." A ri,se In autopsy Snoi .denee In hospitals is not 

an index of au absoAute i.norease of the dieeaoo . It is well 

known that n€any factors nontrf .bute to autopsy inc9.donce amonfg 

which ar•e (1) increased patholo88.ca5 knowledge, (8) change In 

autopsy materl.a3l with respect to seX and ag;e (lung oancer 3 .a a 

dieeaso of oldor aC.e groups), (3) gr.•oater percentage of autop- 

s7.os of . "9.nteresti.nE>" cases, (4) chanKe ,in nature of oanos 

tmspita3.5.•r.ed, ennd (5) w9.der sel.ectf.on of population (clinics 

7.n medical centers uttract pat7 .onts frcuu 7 .arge areas .) 

The 1.nten sa f,nteroe.•t In i.unts eanoer primed by the ftrr.t 

sueocs sfu ) aurglnr.9l traatment by Graham (61) in 1933 arid sus-- 

t•ainod by greater aw :orene€:vi of the dxsease has resulted in the 

hospitz.l r ;;Serra7 of nr3.ny more iung cancer cases with subse- 

cfuent Snr,r.•o&.ae i.n autopui-es . 

'a'he WpM r,cwipares the autopsy records at the Massaohusotth 

Genoral Ilospitai bntweer, the periods 189P•S RP9 and 195G-1963 . 

showing an inorease from 1'7 lung oancers to 172 In the later 

period• Fran the,se flgures it would appear that a true f 

.se had recently ocourred but an ear]t,er report from the 

.n•crea 

same ho Up3tar by IK9.ng (37) showed that the Lncreae.e had begun 


10 1673 

as earl,y as 1920 and that by 1938 there wc :re 475 oases 

d9.agnosed of rl i ch IL5B had been confirmed by autopsy, bi .opsy, 

• or expioratory thoraototorn,y . King, who had porsonally 

9 

• 

observed the i.neroase An lung cancer hospita7 l adnrissions 

attributod it to @:reater interest in diagnosis and surgical 

therapy . 

Autopsy exporience in 7.rmg cancer in the United States 

7.aG€ ::ed eonsl.de.rably behind that of the Corman pathologl .o 

inetitut.es, In the 1931 edition of Uenke and Lubarsoh ' s 

tl,andbuoh der `pcw7e]l.cn Satholsohon 1lnatomlo cmd Histop,Ae, ol 

Nlecher's date on lung cancer inoluded roports of almost 

4 ,000 cnsos of whioh only a very sma11 percentage were derived 

from American souroes . The paucity of lung cancer autopsy 

reports !n the United States !.n the early decades of this 

century was not due to absence of the di.scase but to absence 

of knowledge . 

ThS.e is well i13ue :trated ! .n a ropnrt by Jaffe (59), in 

1935, rhowl.ng that lung oancer oomprised more than 113 peroent 

of all the cancers ot th e Cook County Hospi .tal in Chicago . Thie 

figure 9 .r.oomparable to the incidence during the present era . 

During the eame per•iod that Jaf'fe, a I'suropean trained patho7 .o- 

g7.et In 7.ung canc,er diagnoeis, found t•he proportion of lunp, 

oanoer to a15l cancers to be ] .R percent, tho: inoidence at the 

Vancouver Concmal IfospAtol was lees than two percent and was 

less than one percent at the University of Oregon (110) . 


• 

• 

• 

1) 

1874 

There has Leen oonstant prograss in the pathologfca3l d1,af,- 

nos5.a of. 1unF; cancer in a7 .7l e.reas ok' thc: world . A revS .ou: by 

Harvey (60) of the auLop(:y materlal s ,t the Royal YrAnoc GS .frc :d 

Hosp7 .ta7l in AustralS.a revealed an error of aimoat 20 pcrcemt 

in the d5 .agnoa4e of lung cance :r . Ther e are a7.so marked 

dS.Sferenoes In pathotogi.cai int'erpretati.ons during the present 

era s^.hen, accor2tAng to the Re p ort pa .t.ho :l.oglca}l diagnosis has 

been M .fox w . 

Spain (S .S .h.) In 3959 reported an 3r,crease In eqaamous 

ooi5l carc5.noma and a Goc3 .:xno 2n adenoearoinoma and presented 

th, .s ev7 .dence of the caroinoE'.en?.c effe.ct of cS .Garettes . In 

contrast, Y .ee and Ts'o (7.15) In 1963 found the autop&y i.ncS . .- 

denee of adC.P~GCAr63 .nGiGa to be AJ .meat throe ti .me s tha t of' 

sguamouu eerro?.noms . Onv factor reapons5 .b7.e for a eonsider- 

Ah1o portion o;, the lung oancer autopcy increase waa the 

obeorvatlon by Ya rnard (62) 3n Lktglar,d, and Karanor and 

Saphir (63) In the Uni.ted Statee, that oertain tumora formeriy 

dS.a:E;nor,ed ns sarccenas were, S.ncatuai5.ty, cancers of the iunn . 

The trensiem of thece oa t ceil tutnors from one oategory to 

Another automatically roau lted In P.n autopsy lncrease of lung 

canoor wh5.c+h wat; only appar•ent . The frequency of incidence 

of oo.t ce .l3l tumox• s v•r,r5.es r:9.th d5ffe:rcnt pathol .ogfata3 ldhft•weS1 

(116) :'oun(i that oat cell eancers cornpr :caed as high as 

S41 pe :vicent of n.].5 iun3; cs noe p s while many others found the 

i.nolderwe much lower . 


• 

0 

0 

12 5'E?5 

7:t is Interesting to observe the di .sdain with whioh the 

proponents of the smokfcng-eancer theory reject improvernont In 

diagnosis as a ma jor factor In the increase of lung cancer . 

Neverthe ;.osa, every d9 .agnostio faoi.9 .i..ty used at present to 

deteot 7unt^ c:ancer wa,s either dlscovcmeR or perfected within 

tho past three deoader. - the perlod of the great inc reaso of 

:cung cancer . 


Bronchosoopy, one of the most a .niportant diagnostic pro- 

aeduros, had boen aval.lab7.e f'cm many ,year•s but was scarcely 

used prior to 1930 because of unwarrantod anxiety as to 

possible hasa :ods . It is of hi .stori.oa7 . 9.ntorest that at the 

isrompton Hmapi.tc4 in X•ondon, renowned for speoi.al4.zation 1n 

pu3.monary d7 .scases, only one bronohoe.eopie oxamination had 

boon performcd prlor to 1925 . Wi.thin three decades the number 

of bronohosoopior, exceeded 800 pc:r year, . 

Nor more than a oentw^y physicians had been attcmpting 

to fiiagnosa lung cancer by exam9.nati .on of the sputum for 

frat;ments cotital.ning rna),i.P.nant tissue . Although suoeess was 

aohs.eve@ sporadi .cal7 .y, the prooedure was tedS .ous and hampered 

by technica7, dlfficaiti.cs . In the 1930's staintng teohniques 

mere deve9 .oped wh7.oh fe;ci .7.itated sputum exami .nation but the 

pr•ocess remerined ossontial7y a resoarch procedure . In 1943, 

Papani.colaou described a staining teohm :i.que which within a 

f.'ew yoars became app7 .7.cab7 .e: to the r•out5.ne examination of the 

spubum . 'the "Pap" smoar for cancer ce7 .1s In the sputum and

• 

• 

• 

13 1876 

broneh5al aspiratc has 00606 sign5 .ficantl .y to the dia€5nostic 

e.pproacb duri .np: the two dtlocados 1n which it has been ut5 .l .9.tied . 

SurgS.cail exp7.orat9 .on oPthe cheE:t is anothor procodure 

whAch has added to the no.rsbor oR cases dAagnesed, grS .ar to thr :: 

7 ;'h0's, exp7.oratory th.oraootomy was o4'ten oona5 

:.eat9.ona wcre .dexod e0 pro•oedure of laO resort and the indvery 

limited, 

SS .nc:o then rc-f3neinentr. In suxg; ;.ea3l t€ohniqtte and anesthesia 

have tuztio thin a :;a:Pe Fro< :edure with oY.•.dc dia€;nostio l.nd9.oa- 

t) .oilE . 

7.n 5.9k9, aP r.pori. %rout the Mayo (ri5 .n5.c by Johnson (f!`) 

showed that 50 percent of the lcmg canoers had beon diagnosed 

only after a urg3 .oa7 exploration . ArSng the past two doead e s 

Anto~eost In thoracic v urf.ery has S.ncre a sed tromendous3y and 

thonacotomy ts a rout7no procodu :re In ( :.xactical7.y all hosp5.ta3 :, 

dt .sc7 .esj .ng casec of 5.unp; cancer wh :i.oh wouad other•wise rema] .n 

undi.agnoocd . SurE7ery has E ;].so been of d5,agnost9.o value i .n 

the anoreasnd rutmber ot' biopsy oxami_nat7.ens utilizing now 

techniou e s . 

The C;A•ce;teet contribution to i,unE cancer diagnosis ttas 

bean the va :t znc:rease 4n Y,-ray

• 

• 

e.h 1&'l7 

a fa r crcater• reoogniti .on of lung canca r than was pr•eviourly 

poscd.b7.e . ClAn :tca! M expcrS.enoe has show n how easily lung 

cancer may be mistaken for 1',ncumoni.a, tuboroulosS.s, lung 

absoess, brain tunior or even abdom3.na7l dAseaso In the absenoe 

oP apprapri-ate di .apa',ostio invcstigat9.on . Plow much relaab :114.t .y 

can bc placed on lung cancer• mortai.ity stati.[sticrs duri .nE ; an 

era nhcn the disease sais not clinically di .at,nosab].e4 

ACCURACY :rN ])7:AON09l:£S 

Thc vast improvemontz 9.n diagnoct7e 4 .eehnAdueo have mado 

9.t possible to detoot £ :reater nu.mbers of lung cancers but have 

elso revoa7 .ed th a t there arc rnany pi.tfa?.ls An diagnosis not 

sunpeoted previ .ous"c,y . Autopsy studi.cs have shown that cases 

cP3.at?nor>od o2l.nica] .1,y ar, lung canoer, even with biopsy c:on- 

ftirmation, may actually be seeondary canoer.» . It is now ws:i.A 

established that thc lung has a great affinity for metastatic 

tumors and ths.t 30° 1b0 percent (a7.2,i .3.3) of a7 .7l cancers produoe 

secondary pulmonary gronths, some of wh5 .ch may simulate 

br.•onchacen:te carcd.ncana . Llhen non-pulmonary cancers spread to 

the bronch :ca l tubes a9 .il the rnani9os;tations of primary lunf ; 

cancer may bc reproduced recultinf; in erroneous diaf5noses . 

In apite of all the progress m'.de in d9 .ai;nostic techni..yues, a 

ponitive di.fsorent9.ation between prRmary arrtl secondary lung 

cancer m^.y not be pocs, .ble t:i.thou.t autopsy exclusion of other• 

pri.rma :ry sltes . 


Tho present oJ.essi .fi.cation ttf lung e.encer dc

15 ] f>'78 a 

two cate€:orles : ( :c) xungg eancer, r,pocffied as prinkary ; and (2) 

lung eanoor, unspocfficd as to primary or secondary, ISxami .na- 

tion of lung cancer rnortalAty ntati .stS.c ;s fo1' 1961 and 1962, the 

7.atest years for whi.ch dtat have been completed, reveai .e some 

interos'c9 .nQ factE+ . 

k'er the year 1961,.out of a tota7l of 38,929 lung oancer 

deaths, on7y 7 .9,1s6? (50 percent) were spec5.ff.ed as primary 

lnny, canr,er. . For the year 1962, out of a tota7l of 41,176 lung 

canc+er deaths only i.G,866 ( 0 6 percent) were spooffY.ed ae 

prima r ,y . The renvalndess raere unspecif4od which means that the 

lung canc:ers rnay have been primary tn thc+ lung, or, may have 

sproad to the lung fr.om tumors origA .nat:i .ng 7.n other organs . 

Phc stati .sti.cAan amd epAdemiolog?.et, 7aokt.nr experience 

i .n o3 . :i,nioa5 M d2a gnoe:tic probl.ems, are o,t,•ten totally unaraare of' 

the dfifYLcu9.ties 1n d if£'orord;iat7.ng beto:eeh primary and 

seoondar,y7 .un(; cancer• . Even when oaset: are specified ao prA . 

m?nry S.ung oancor thS.s docs not neooesariJ .y mean that the 

diagnosis waa correct Sn a17. oason . 

Xt has bcccane zncreasinf59 .y apparent to olRnlofans and 

patho3og S.sta mork9 .nt: 7.ti the S9e1d of ].urn; cancer that sputum 

eY.ami .nati.ena for cancer OelLs and even biopsy exanlAnations may 

yie) .ct ni; .u7.cad9.ng lydormat, .oa . Ureat reli .aneo i.s pS.aced en the 

h? .E;tolog9 .ca1 f? .ncif .nfs obte,5.ned by examfn ation of t, 1ynmph node 

or of' bronchial tissue but, posStAve di .fferonti.atlon butrreon 

pr).Iiler.Y and secondary ea.neer's is not a .LWaya possf.Il7 .e . 


• 

• 

• 

)6 1879 

ln a recent aUtOpGy 6tudy (65) of cancer of the pancreas, 

it was Pound that ] .9 porcent of the caE46f: bad been di.agnoE .ed 

dmd,nE, Wb ac primary lung oancer . Other reports of 

crroneoousl .y diaCnosed lung canoera on the basis of biopsy 

examination have ineZu.doc canoers of thr, k3dnoy, adrena :e,ovary, 

thyro?.d, st.omaeh, and reetu .m, anas muoh as the cases apeoY .f9-ed 

as pr :i .ma•ry lung cancer were not aA1 autops] .ed, there is a 

si.p;nificant potent?.aR nouaroe of error to be conoiderod . 

The Adv9.cor3 Conmittee to the Surgeon (leneral pleoed the 

(,reatost reliance on atr..tSatf.cal oomputati .ons in arr9 .ving; at 

i4.e conc7-usions o.rf a eausai rolationshtp botween smoking and 

Aan" canoer . The Repm•t atstos, "In reoent years, about two- 

th3.rdn og the cortiiacation of' lung cancer deatha have boen 

basod on m:e.oroscopS,o extmeinat5.on eS' tisuue from the primary 

e9.te and the porcentage As oven higher for deaths under 75 

yeurs ." The two rePerencea cited to vaJ .f.date the above state- 

eaont appear as vory tenuous endorsements . 

Onc report (66) te an evaiuat9.on of ac:curaoy 7.n a sor.ies 

of 1,L}S7 death certiPS .oates 7.n Pennsylvania . The oonclusion 

with respect to prl.mary lung oanaer was ba ted on a tota3l of 21 

c:ases wp.th no raention m,vde of the number of d9.a4nosos based 

on autoto ;y . 

The soconii rcY.orence (67) dp.scusses the general aupoots 

of ca.nccr citagiwsi.s but prersonts no partieufi.ar data on primary 

lung caneer• . A etudy brse+d on 27. lung aaneer cases without 


0 

0 

17 

i88o 

autopsy c onfirmat7.on is 9.nade0uato authority for a bronG state- 

ment i.mp3ying that over two - thir ds of all the lung cancer 

deaths were confirmed patho3.og9.ca11.y . 

IinPl.i 01+ 1NCRFIASE 

The so - caJ.lod sbpidemic" r9se In oortS.f7ed lung cancer 

dcaths In the United States has followed a pattern that, when 

serutinSZed ob,9eoti.vely, is more indicatS .ve of progrese in 

dlagnos5e: than of a true i.norease of the diseese . This 

pattern shoces a proGresef.ve deeline in the rate of increase 

of lung cancer and was fully elaborated upon by Gillian (66) 

In his stndi.cs at the NatSona1 Cancer ansti.tute, It is 

regrettable that the Ac3visory Commlttoe ciis:reaarded this signi- 

f i cant eontrfibution to 9t o epidemiolog,7.oa1 consi.derations . 

The earlS.cat statistAes avaAlab:ce (Pab:!e I) show that the 

number of cort.7.fS.ed Lung eancer deaths in the United States was 

373 in 1 9 14 , and 956 in 1920 . A3.thoup,b these figures are rd.d3.c- 

ulously low when corepared to the 7,ar(,e numbr.rs of oases re- 

ported In hluropean Anstitutions during this era they represented 

an l.ncrcase of more than 1 50 peraent, A comparable trend was 

noted In the reco-rdc of the Nuatropoli.tan liife Insurance Company 

which uhowod an increaee of 3 00 percent In the standardized 

annuel dcath rate from 3ung canccr among its po3.iey holders 

betwcen 191 7 and 1926. It is to be emphasis:ed that this tre 

mendous inorcase ocourr& before the era of widesprea d 

ci.C r,rctte emolc4ng . In the succeed :t.nF; yc'ars the total numbor of 

lung ccncer oascs incr. ca.::od but the rate of inerease decl.ined . 


_18- 

TABLE I 

MORTALITY OF LUNG CANCER IN THE UNITED STATES . 

r>~~ Yea Ni i mbe' x of De a t~is " Percnt e I nc rease 

~ 

1914 371 (No comparative data) 

1920 956 158 

1930 2,357 146 

1935 4,237 '/9 

1940 7,127 . 68 

1945 1.0,922. 53 

1950 . 18,313 67 

1955 26,827 46 

].960 37,500 39 

w Data for 1925 not available 

YearF 

1931 

1935 

1940 

1945 

1950 

1955 

1960 

MORTALITY OF LUNG CANCER IN NEW YORK STATE Number 

Data for 1930 not available 


TABLE JI 

. of Uestha Percent Increase 

i;Sl

• 

0 

18 

Setween 1930 and 1935 .the tncrease was 79 percent ; be- 

tween 1940 and 1945 it was 53 percent ; and between 1955 and 

1960 3.t was only 39 peroent . A comparative study (Tab1e 11) 

180 

of the lung cancer mortality statlsti.cs of New York State (no 

fi gures avai7 .ab7 .e before 1937 .) ohowod the greatest- rate of' 

increase, 64 percent, between 1931 and 1935, Sinae then the 

ra.te pro greeci.vely declined and botweon 1955 and 1960 it was 

only 18 percent . 

FJow As it possible to reconcile the declining rate of 

increase of lung cancer with the 200-PoJ.d 9 .ncrease In oigarette 

consumption during the same period? 7Y tobacco is a cancer 

producing agent there should have oecurr•ed a progres0ive rise 

in the rate of I ncrcase . A logical exp7anahion for tho pro- 

Rressi.vo dcoxi .ne In the rate of i.ncroaae In that 1t is a 

ref7.eotion of the increasing ability to diagnose lung cancer 

durinf: the past three decades . 

In the early 1930 ' s the mortality attributed to lung 

cancer was 9.ncr.eas ing among the white male population at the 

rate of epproxi.mate9.y 10 peroent per year . Phereafter, this 

purcentage declined regalarly and by 1958 the lung cancer 

deaths were increasing only at the rate of 5 percent annually . 

Among tho whito female population, the rat e of lnerease de- 

clinod fr•om approximately 6 percent per year in the earlier 

per] .od to about. a. Perc:ent in 1958 . mThe recorded ] .ung cancer 

deaths amung the non-whitc popu2ation, ai .thougk much smalter 


• 

• 

411 

f~ 9 1883 

in number, showed the same downward trend in the rate of in- 

crease . The hSk:her rate of lncrease in the norrwhi.te popula- 

t5.on wes consistent with the acee3.crated i .mprovement in 

rned9.oa 2 £aoii .ities In rcccnt ycars for thi .s group . 

The progmeosive dce] .ine in the rate of increase is a very 

cigni.ficant factor in eva7.uating the earoinogenie effect of 

tobacco . If smoklnpg produced lung eancer„ directly or i.n- 

direc:t3.y, the incroascd consumption of eigarettes would have 

resui .tcct in a sustai.nect or greater rate of inorease . The faet 

that the oppor,ite has occur•red implies that there is a rela- 

tivciy fi .xed preva7,enee of lung ceneer in the population and 

that w i .th each succood9.ng decade the 9.mprovement In df.agnostic : 

tochrri.gucs resulted In the recognition of a greater numbor of 

casee. . .Nentua79.y, the incidence of lung oanoor wi11 bo 

stabi7 .i.•r•ed as it has boen for many other canoers in which the 

i.nvesti.gative procedures have boen standardi.wed for long periods 

of ti.rne . 

The expa:ri.enee in the dec2ining rates of i.ncrease of the 

certified cases of lung cancer i.s very ¢ind .lar to that which 

or.curr.ed in the Qerman pstho7.og4c institutes in the late 19th 

and ear] .y 20th centuries . This was the era when the diagnosis 

of 1o.ng cancer cou.ld onRy be definito7y established at autopsy . 

In aa.mo.a e11 of 4ie major hospitals the rate of increase 

fo3.lowcd a definite trend conr,isti .ng of a suddon rise, oorres- 

poind7 .n,rc, to the period in whioh pathologie diganoatic eriteri.a 


• 

• 

• 

20 188 1s 

iuere estebi.ishod, £o1l .uwed by a decAine in the rate of in- 

crcaso as the diseaso beoame better knortn . 

At the Moabi .t Hosp :tta7. In Bor19 .n, Wah1 . (69) £ouna a 300 

percent inorease in the percc:ntaC;e of Aung cc:noers to all 

cancera between 1917 and 1 .92, . The £o1.1ow).ng year the rate u2 

i.nereaee had Boclinod to 17 percent . 

Schonheri• (70) reportcd simfi-1ar £indi .ngs at the Pathoio- 

gTc Hyg9.eni-o :Inst9.tute of ChomnS .trl cotnpari .ng the periods 

1Sy8 .4 .9i.6 and ] .9i9-7.92fr there was a 110 percent increase in 

P.ung cancer autopai .cs wh3.ch S.'e11, to 24 percent in the next : 

Sou.r years . 

Comparab7 .c ohscrvntf.ons (seo Table 71:T) wore made by 

Matorisa (71) in 7Sôppau, by SohSesingerr ('(2) in SsRpef .g, by 

I .M€;enu) .f (73) in Gotti ..ngon, and by t,olxcr. (7ib) in Prague . 

At St . FtarthoRome w 's Ftosp',•tal in hondon, MitaxweA l and Niohol-- 

son (75) fovnd that the qrcat increase in the autopsy In- 

ot..dence of xun;; cancer had occurred betwoen the periods of 

1884-3.888 and 7.89h - 1.898 . 

Tn u rapli, i .ncrease 5 .n the inci.de:nce of a disease when 

now c7.i .n5.ea1 or patho l ogi.ca7, d7 .agnosti.o teehniques are Antr o•- 

dncod has beon obazervod repeatedly . An exoe3 .5 .ent example is 

endobronchf.a5l toberoul .oci.s, a very common eomp7.icat9.on of 

pro€:x" o asive pulmona ry tubercul .osi .s . The condition has been 

undetreted by pathoi.ot;4sts in thoucands OP aatOpsios pe.r£ormod 

in L'hie e.ountry and alrroaci . 1n the early 1.y30's elinical and 


III 

• 

. 

21 18 5 

bronctmsoop :i.o stud.i.es establ5.shed the ex1stermo oR' endobroru+hIai 

tuborcul .as4s 2nct th3s wass ref3.eoW immediately In a tremc,ndou .e; 

>•?.eu In ncepopsy i .r,bi.dence . 

Tho Re P ort .of the Advi .sory Oommi .tteo states (page 135) 

that 'lung Cancer rnortal;cty amon g males has ri .sen at a fai.rly 

cormtant rate o,.nce 7 .9;,0" end ctt.e ;. rordon, et a1 . (76) of the 

1'ationaa l ( :enc:er :[nst.i.tutc as refe :venom . hovtever, there seoros 

to be anmc dlsdarAty betrreen the i2eCior t' e :intprprotatior, a .nd 

OordoW art.i.c2c: xxhich statos, "hor, wh3te males a.nd fomales 

cun d for nom uhi.to met2es the 'inorease In Mort.a5.ity for cancer 

oi' tho }.ung: and bronahu.s ttas greatost between 1950 and 1935 and 

hae s :inoc tenQod to decezerato ." '.!'ho a.rt',.ole a3r;o noted that 

the 7 .norense i .n lung cancer mortality began xf.multanoouel.y for 

•r,17l ailu5.t uge 1;:rouC,s suf;gereti.nE i.t was c :aucied by i.noreared 

diaCnos,t ; .c c,warones,e . 

3NrC U%;TR7EtpV7073 

Canaer c,f.' the ].ung oecu,rs gredor;tinantSy among males . 

]n the Un7.ted 9tatea in 9 . g30 there s¢ora 1,Li ;18 lung cancer 

deat.he In maie s r.nd 1,039 in fema :ces (rati .o - 1 .$ :1 .) . 7n 

7 .9 h 0 thore were 6,0 5 ( mcilos anfi 2,029 femalo 7.ung caneor, 

deat.hs (ratio = 3 :1) . fA deocdc la,ts:r• the :re meme 14,922 

rncito and 3, :i97 1 fem,9.o doaths (ratp.o =1l .11 :3.) . For 3$60 the 

.il,ure& worc 30,800 m :e2ee and 5,000 fen a les (rati.o , 6 .2 :1) . 

9'hm h,nof;rossa .ve w i.dening; of the eox rat3 .o QurAn g recent 

[iecauc :: h„s baan :i.nterprcted by many 06 an O.ndloat .ion of 


-23_ 

TAELE III 

LUNG CANCER IN EUROPEAN HOSPITAI .S IN . ., 

LATE 19TH AND EARL~TH CNTUR ESI- . 

. _._._~.~ 

Percent 

Total Percent 

City Institution Author Years Cancers Increase 

. MOABIT Moabit 

, Hospital 

Wahl . 1917-1918 3 .53 ' . 

1923-1924 

. 14,08 300 1924-1925 16 .45 17 

1925-1926 12,35 . ' 0 

1926-1927 13 .10 ,' 6 

. 

. CHEMNIT7.PathologicBriese 1898-1916 4 .51 

Hygienic 

Schonherr 1919-1922 9 .50 ,1 .10 

Institute 

1923-1927 11.80 24 

TROPPAU Pathologic Materna 

. Institute 

. 

ZURICH Pathologic 

Institute 

. . 

LEIPZIG Pathologic 

Institute 

' . 

: 

' 

Probst 

Seyfarth 

Schlesinger 

GOTTINGENPathologic Feldnea 

. Institute 

. Simrosa 

Engenolf 

DRESDEN 

PRAGUE 

. 

. 

L`riedrichstadt, Reinhard 1852-1876 0 .92 

Hospital 

Wolf 

. Junghanns 

1877-1894 

1893-1912 6.46 600 . 

. . 1913-1927 10 .73 24 

Pathologic 

Institute 

Holzer 1895-1 .899 

. . 1905-1909 

. 1915-1919 

1920-1924 

1912-1914 2 .08 . 

1915-1917 7 .14 :240 . 

1921-1923 8 .00 12 

1906-1910 1 .13 

1911-1915 3 .34 190 

1916-1920 6 .12 83 . 

1921-1925 7,17 .17 . 

~ 1900-1906 5.01 ' 

1907-1913 -- 

1914-1918 11 .23 120 

1924-1929 13 .20 .18 , 

1852-1879 0 .62 . ' . 

1880-1908 0 .90 , 61 

1906-1912 2 .59 190 

1921-1927 4 .43 70 

0 .78 

2 .24 

4,81 

7 .98 

. IANDON St, Bartholomew's Maxwell 1884-1888 3 .91 

. Hospital , , and 1694-1898 7 .83 100 

Nicholson 1904-1908 7 .1.7 . 0 


190 

110 

66

0 

• 

27 

f;E'cater diF.C'.noGt'J.e acCur2cy 7.naGmUAh FiBfl lunf( cancer has been 

found to be: p.°ti:cinNAn :ant :i.y a d5sea :>e of ineQr,c . In 1c)i:7, 

C7.enmtonsee and l:usk (77) obr+erved that• the Sung cancer sex 

rat4.o 9.n ]knrna :r•k between 1936 and 1945 vas 0 .4 :}1 urhereae the 

ratio in a spocSta7l diagnostic c].3nie S .n Copenhagen rcae 7 .2 :1 . 

( I'hie wc17l iurown cstudy tc v s ornitted in the Fceport) . Lou sex 

r.ctioa wcrc foo.nd In many of the iung cance+r stud2ec £n the 

ifsG7 

19th century and reflooted the d, .Rlf.'4.cultieu in diffcrenGAttt4ng 

beto:eon primary and metaetatic irnrolvement . 

The dAsparity 

In eerx d i stribut5.on han led to assurnptiona by those unfrarniiiar 

v:?.th f:ho b9-ologloal cha raetesn9 .sties of tho d4 .xe:ase that 

grredomi .nsance In the male 3.si the rosu7.t o f heavicr smokLnC 

habitu . Tho validity of this inter•pret-ntion ie readily 

cha) .icn['.ed by (3 .) sox fi :iatribut9.on of lung cancer before the 

cra o t cif;arotte smokir,f; and (2) th¢: 1.ack of any effect of the 

i.neree,csed oonsumpti.on of cigarettes by females on the sox ratio . 

7t in epparent from Tabie IV that 7.ung cancer was predan- 

inant5.y a dS.senso of ma7.ec during an cra in whteh o9 .garette 

eruck ;.ng ncs vi rtua5.iy non - e:a.lstenL . YLot?t nf the studies shota 

a fie>: ratio of at lea[tt ,jt1, and eome rAre co0lparabl .e to 

rati .os roported ya5.thin the p, ;ct de.oado . I0 S.n of considerabie 

interce:t thet as car7 .y as 1895, Wo1f'a c:asen of "prirnre 1unGOn- 

krehe" from the Areodmn municf.pal hosp5_tals shotued a d9,utrS- 

but9.on of 6 :73 favorF.n{6 thn rnnle, and Passler, 9 .n 1896, found 

a ratio oli 3 :1 in h eeJ`J.ected Se1.î.ea of 68 eases . 


Aut tl'-or A _ .Years_ 

-25- 

. TABLE. IV . 

1866 

SEX DISTRIBUTI.ON OF LUNG CANOER , 

BEFORE CIGARETTE SMOKING ERA . . . 

Place 

as `-~ -~es 

Fema R_aCio 

Hare, H . 1630-1880 Collected Series 90 33 3 :1 

Buday 1870-1888 Kolozsv6r 9 ! 1 9 :1 

Harris, V . 1882-1891 London . . 52 17 9 :1~ 

Passler, H . 1878-1894 Collected Series 50 18 . ~ ~ 3 :1 

Wolf, K . . ~ . 1885-1894 Dresden 27 ~ 4~ 6t1 

West, S . 1897 London . 47 14 3 :1 

Lenhart:z 1893-1899 Leipzig . 13 1' 13 :3 

Feilchenfeld, J . 1894 -1900 Berl in 20 ' 2 ~ . ~ 10 : 1 

Riechelmann, W . 1895-1901 Berlin ' 21 ~ ~.6~ 3 :1 

Watsuji., S . 1904 Berlin 4 1 4 :1 

Redlich, W . . 1900-1905 Berlin 26 5 5 :1 

Haberfeld, W . 1887-1906 Vi .enna' 48 . 20 . 2 .4~:1 

Karrenstein 1908 Berlin . . 24 8 ; 301 

Feldner, 0 . 1908 GBttingen . ~ 6 1 . 6 :1 

Seydel 1900-1909 Munich 16 4 4 :1 

Adler, I . 1842-1911 Collected Series 269 ~93 . 2 .9 :1 

Dormanna, E . 1901-1911 Munich 7 . ~~ 1~~ ' ~ 7t1 

Weller, C . 1878-1912 Collected Series . . 70 17 4 :1 

King, I> . 1875-1914 Boston 36 9,'~ ~ 4 :1 

Rau , W . 1909-1914 Dresden- 

. Friedrichstadb ~ 2 . . ~ 6 .5 :1 

Briese 1898-1916 Chemite 44 : 16 . 3 :1 

Lavrinovitch 1915 Petrograd 42 . 19 ~ 271~ . 

.Jeff6, R,' 1915-1918 Vienna ~ .~ 92 ~ 8~ - ~ 11 1 1 

Passey, R .'~ ~ ,1894-1918 Great Britain 579 . 182 . . ~ 3 .2 :1 

~ Rau,-W.~ ~ . 1914-1919 Dresden- 

Friedrichstadt 22 5 . . 4 .4 :1 

Eichengrun, W.' 1902-1919 Cologne ~ ~ ~ 32 ~ 5 . 6t4 


0 

• 

• 

, :Cn t,'arG'F YathoJ .ofy, 11SnAcyt }tiRtory Entd ll4.oCnoaf,c of 

Af'SOCiS,onc, o,. vhe t+ledAaciinura, puhliahed In 1889, the ratio 

was a].ao ;Sr1 In a eox•Aes Gf 122 oaeoa . Narr1[:((8) S.n 

1892, made a comhf .ned Etudy of St , Hsrtholomewrs Hospltal. and 

at tho Of.ty o. London HotepAtal f.c¢• llircaeeu of the ChosC and 

found a ratio exceediuF+, 3 ;1 . Lonhartz (79), 9.n Leipzig, ro- 

ported a ratio o5' A :1 In 1699, and P'ef.iohenk'eAd ( 52), in 

1901, a ratio oS 7.Of1 In Berlin . 

Yredanf.nauoe ox lung cancer In the male in the 19th 

century waa ev :Lder,t In both the J.ndf.v2dual necrop[+y atud9.ee and 

In the oo3loctCd sor7.Os of cases . Ad) .orra ( 5 () oollected 

B!].`P .CO apsnncd more tt,an seven deeadee and included caaee Procn 

London, i'raruo, l3oriin, Jetia, Heme, kar3.a, li7 .aaS;ow, St . Petero- 

burK, Zur :ich eud evcn Hrookiyn . 

ISOOp :ite the varlet.y oY rxoux•ooa the overal]l tO.oCure of male 

predilee0 :eon was v3.md1ar to Roichoiraanr5 (!30) report In 1901, 

f.'rem the J+rof .dr5.chohn.6.n klo ;rpital in Hor1in, Karrenetef .nre 

(56) 7 .n 1908, from the Un:rverr,ity oP Se r7.in, and Hriesera (E31) 

report, in 7.916, from the Patfiologic - HyOi .enP .c+ xnP;tit'ute of 

Oh 9mo7 .tz . Weller (£Sf.), who wae among the first Amer4can pathoi- 

ofrgr;tr; to bcuome 5 .nt-nrestod In bronoha5onf.o earcfaioma, 

reported, in 3913, a uorf.ecs of B7 eol9 .eetect oaees with a sex 

ratio of.' 1y ;}„ 

]:n eoorno 9.octanoor; S .t wae: possible to £'o11ow the sex ratio 

of !.unfr, cancer thr-euf;h aevera7M per9.od ;:s 1.n the sarne Snetitations . 


lip 

• 

III 

21E iF590 

In 1.925, L%orbl.inger (83) completed a noorospy st•ady previouely 

arif;f.natcd by Laesohka at the Pathoi.ogio 1nst3.tUte of Jena . 

Lung cancer prorian9 .natod In tho male for ear :h 1.uatrum beginning 

with 1910, and the ratio £or the 15-year poriod was 4 :1 . 

Poterc (8 0 ) found .a rati.o of 3 : 1 between 1905-1908 at the 

P7oabit and Urban Hospitals of Seriln and a ratio of 5 :1 be-- 

twcon 1 .917--1922 . At tho Dresden and B7rdodrS .chctadt hospital.s 

and nursing liornee, Junghanns (85) found a ratio of $ :1 in the 

per5.od 7.893-1897 and again In the period 1898-1902 . 

Dormanne (8f,) found a sox rat9 .o of almOSt 7 :1 at the 

Un ;.voruity o£ Munich in 1901-1911 and agair, in 1922a.931 . 

In ColoBnc, L•'ichengruni and Essor (87) found a ratio of approxC-matel 

1919 . 

y 6 :1 In the period 7 .902 -1914 and a 9 :1 ratio In 1914- 

We of therroet aignif'ioant studiec+ wa .s that of Passey and 

ltolmes (BG) £ro :u a group of teaehing hospite .ls in England and 

SeOtiand cOver9 .n[( a periRd of move than ;i0 years and inolUd.ing 

the cree boforo and after the anset of hoavy cigarette smoking . 

T;r*y found a se.n rata.o of 3 :1 for each of the periods 1894-1898, 

1.899-190z, and :i909-1913 . 7letween 191lI-3918 the ratio wae 

4 :1, and betwoen 1919-1923 it was again 1 :9. . The highest ratio 

was 4 .5 :7. wh9.ch occurred in the period 1924•-1928 . 

Thc offd.nA.Oy of lung cancer for the male was present before 

and after the onset of the a ;.f;arette smoking era . Some of the 

pex ratios in the 19th century reports were actually higher 


411 

41, 

25 1895 

than those obtained ! .n recent studles . The alleged oorrols- 

ti.on betwoon smok? .pE, and male predominanoe of lung oancerr is 

based on a statistic.al aasooiat-ion which S.Cnores the faot 

that t•he disease favor.ed the male whon cif;Arette smokine was 

soarcely known . 

T h?.o point was emphaeized in a report: by Tbrahim (89) 

from the Dacca Medical Co9 .lego Hospital In Ea st Pakistan where 

he found a sex ratio of 9 :1 in a group af 20 lung cancer 

oaaes whioh 4 .no :Luded 1f : non•-smokexre, 4 occasional smokers and 

2 heavy smokcrn . Cigaretto smok3.nC is a rrarity 1 .n l ast 

Yuk :latani the popular method of smoking is the hukka pipe 

w).th the water filter . 

LUNC CANCER I1V NLM0.LES 

T.here has boon a progrowa9 .ve increaoe In oigaretto 

coneumpt-S.on by mo:nen for moro than four decades . A survey 

of smoking patternr, by the U . S . Bureau c£ the Census In 1955 

stated that 7.8,000,000 women, 18 years of age and over, had 

reported uae of tobacco, and that 15,000,000 had at one time 

or anothor been reKUlar cigarette smokers . The corresponding 

figuroa for rnon were 38,000,000 and 31,000,000 respectively . 

The survey aoknow7.edCe>d that 9 .t had underost'irnated cigarette 

oonou.mpts.on by 15 peroent on the basis of comparable tax 

data, and common observatP.on sul;gosts even a greater margin of 

oxror . 


Ae.cord9 .n€r, to the varA.ous prospeotive and retrospective

ill 

• 

• 

26 18,10 

studioc 

cigarette emoking is a1lefSed to be a potent oaroino- 

genie agent . 1t ls difficult to reoonoile this conclusion with 

the oontinued predominance of the diaeaae in rnales despite 

the prodf_gious rise 1 .n cigarette eonstun.Xkion by femalea . Ucr- 

Ang all the years of incroase female smoking there has not 

boon the si7.ghtest narrowi .ng of the ae x ratio indioative of 

a rolative ine :cease of 1u.ng cancer amon .g women . Xt has already 

been omphaoASed that the sox ratio han actually widened, . Inas- 

mo.ch aa di.agnoatic faeilitiea are equal7y avail.able to both 

seY.e6y it S.a mora logiea7l to a6ablme that the predominance in 

rnales is the result of sex predileotfonc of the disease 

rather than of srnoking . 

Data from the U . S . National Offiuc of Vita1 Statistics 

ahom that lung cancer death rate bet.woen 1930 and 1958 i.n- 

cmeaeed twclve ti .mes fcr men and three times for women . The 

greate.at inoreaae among women occurred betvreen 1930 and 1 .950 

du.ring whloh t?.me the rato rose from 1 .5 per 100,000 to 4 .0 

por 100,000 . Sinco 1950 .the rate showed little increase . The 

maieafema7 .e r•at i o w9.th reepect to mortality rates was 1 .7e1 

i.n 1930 apd 6 , 6e1 in 1958 emphasiaing the relative decrease 

among woman dur ;.ng an era of heavy cigarotte emoking . 

[4orta9.ity statistica in suoeeedi .ng years show no indioa- 

tion of changing trende, The total. inoreaae of male lung 

cancer deaths between 1959 and 1962 was 4 ,665 ." The increase 

'Mortaltt,v c:tatist7 .co for 1962 estimated by Arner},ean Cancer 

soc9.ety . 


• 

. 

• 

2( 1893 

of femaie lung oancer deaths for the fnur••year period was 

333 casen, averaging iose than 85 caser., p er year . 

It is evident from the foregoing that the tremendous in- 

crease in cigarette smoking by women di,d not result In any 

comparable rise in lung cancer deaths w' In redu.ction of the 

sex ratio of the d7.sease, llaring the past few years the female 

lung cancer death rate has remained virtually stationary . It 

is soAentlficali.y Incongruous to attribute the etiology of 

iung cancer to cigarettes when niore than 15,000,000 regular 

womon smokers show an annual lnerease of loss than 85 cases . 

The rapld edoption of smoking habits by women about 40 yeara 

ag,o wouid have rosulted in a continuing epidemic of lung cancer 

Sf toba.cco woro the oausative a .gent . 

AOR DXSTRXflU'1ÌON OIr TANO CANCRR 

Observatf.ona for oonsiderabiy more than a century have 

shown that lung canoer 1.s primarily a disease of older age 

groups with most caseo occurring In the 5th, 6th, and 7th 

decades . Simons (9.11) 1.n a co7.lected series of more than 

5,000 caaes found that $0 percent had occurred between 40 and 

70 years of ap,o . Lung cancer is uncommon below the age of 

40 and rate during the first three deoados of life . It is 

seen, In irable V, that the predi7 .oetion for older age groups 

was noted cons9 .stentiy 4.n all the statistical reports before 

and after the onsot of heavy cigarette smoking . 


Walehe, W. 1846+ 

Reinhard, W. 1876 + 

Hare, H . . 1880 + + 

Buday 

. Before Onset of Heavy Cigarette Bmoking 

. 1888 + 

Harris, V. - .1891 + + 

Pessler,'H, . 1894 + 

Wolf, R. 1894 

West, S,-r 1897 + 

. Lenharte 1899 1- + 

Fellchenfeld, J . .19D0 + + + 

• Riechelmenn, W . 

Sehrq E . 

: Watsuji, S . 

Redlich, W . 

HaberEeld, W, 

%errenstein 

Seydel 

Adler, I . 

Dormenns, E . 

'Weller, C . 

Ring, D . 

Rau ._ W . 

Brlese 

Deced~~ 

AuthorYeen .4th• 5tn~ 6thy7th•_Bth . 

+ 

1914 + 

-31- 

TABLE V 

F.GE DISTRIBUTIOM OF )JJNG CAWCER . , . '. . 

+ 

+ + 

1914 + + + 

1916 + 

~~. •*Decedes in which meJority 0 


Fronccy, K . 

Henf, 0 . 

'Fiehberg, M 

After Onset of Heavy Cig¢rette Smoking 

___.~..sea 'I=f--_ . . 

AuthorYen[ 4th, 5th 6th, 7th1 8th i 

. Shennen, T, . 

Schonherr, E . ' 

Wahl, S . 

;Mazwell,J,~ 

Ruhn, C . 

Freemont-Smith, M . 1929 

Schlesinger, M, 1929 

Funk , E . . 1930 

Buschbeck, H . r 1930 

Sitson, A. ' 

Jaffe, R., 

Harvey, C .~ 

' Halpert, B . 

ASng, A, 

Frled, B 

. Rosenblatt, M .~ 

Ibrahim, M . ; 1953 . 

Sebour, M ., 

. 1915 + 

. 1960 MeoFarlene, l. 1960 

+

• 

• 

• 

2e 1695 

The age distribut9.on of lung cancer has a definite rele- 

vancy to the etiolo gAca7l consS.derations . It has been alloged 

that cigarette smoking produces a omnui,ati .ve careinogenic 

effect over a period of approximatoly two docades . If this 

concept 7 .s va].id, the sogrnent of the ei6;arr.tte srnoking popula- 

tion wh ;.ch began smoking in thecar.ly teen ages should develop 

lung cancer before 40 yetu>s of age . No indication of this 

has occurred in over 40 years o£ heavy c9.@:mrette smoking . Aata 

frona the Hori :d Ii;aJth Orf:anization shew a sirnilar curve of age 

dl.etri.buti.on in the United Statea, the IInit:ed Kirrgdom, Oor- 

many, and 'Staly with the greatest ncmrber of oases between 55 

and 6 4 years of ago and only a small proportion before 44 

years of age . 

The agc at tahioh the t.ung cancer patiemt started to smoke 

hao no relation to the age Sn which the di sease was aoryui .red . 

Patients whe began amokS.ng 9.n the early teen ages and those 

who began 20 or more years later developed lung cancer during 

the later periods of life, namely, in the 5th, 6th, or 7th 

decacie, 

kurthermore, there is no evidence that the lung cancer 

patg.ent who wae a heavy smoker developed the disease at an 

earlier period of 7i£e than the pat .tent who was a light smoker . 

If t.obscoo is a potent oarcinogen the arnount consumed and the 

duration of smoking should have some re7 .a.ti.onship to the onset 

of the ciisease . Yar,acy (90) studied the srookinA' histories of' 


0 

• 

29 

115 men rrS .th lung cancer and f.'ound that they had acquired 

tho disease at appro x i.mateiy the samc age roCardless of' 

whcthcr e:mokinp, had becan started at six years or at 41 years 

of eige . :Ct waes also fov.nd that the number of e9 .garottes 

1696 

oonswned daily dS .d not 1nfluence the age of onset of disease ; 

the light smokcr wae. aPfoc ted with lung ctqioer at the same 

a ge as the heavy emo}cer. , 

htfAi7AN OIT, tUNO ChNC} :}t PU 70).fL CPNCERS 

llu.r•S.nE; recent years lung cancers have comprised roughly 

1015 per•oent of a7)l eancers diagnosed at nocropsy and 

nat5.onail morta7.8ty statist5 .cs have followed a sflm5.lar pattern 

of di .etribut :Lon . It i.s of conside rablo i nterest, therefore, 

to obscrve that t•he same relat5 .onehip was present before the 

era of eigarette s+noking 1n certain }suropean institutions 

with a long hP.story o f experienoe in lung otnwor, 

M1uau:e?.1 and NAcho:i.son (75) found that between 1894 and 

1E98, the percentage of 1u.nt;' canooro to total cancers at the 

St . }artho5,omew's Hospital tsas 7 .83 . Bonaor (91) 

found the peroentage oi' 1.unf, cancers at the Leeds General In•. 

fP.rmary to be 13 .6 in 7.895, 8,1 i.n 1899, and 10 .9 S.n 1910 . 

Hampeln (92) frou :ui a :t2 .5 percenta &c betweon 1894 and 1899 at 

the IU . ga Nospito.l . In Dresden, a'unghanns (8Ji) found the por•- 

cont.age to be 1 .7 .6 between 1893 and 1897, and 9 .3 between 1898 

anf 1902 . Seyfarth (g3) famd a percentage of 11 .23 in Loip- 

e.i.(i betwcen 1 €inc3 3914 1938 .Jaffò . and Ste.rnberQ: (9}+) foo.nd a 


30 1 697 

] .0 .73 percentaEe in Vienna between the years 1915 and 1918 . 

Lipsch ;.tz (95) found 11 .3 peneent between 1919 and 1923 at 

the Nat:iona7 . Rouearch insti-tute in Zwiclrau . The large pro- 

• portion of Sun(; cz,ncern amc+nG tota7l cancurs in these reports 

is compar•r,ble to current reiationshipr. . In institutiona un- 

fand.liar with lung cancer the ratios were lower in the pre- 

cigarette ora and r•osc stcadiYy mith increaoinp, knowledge of 

the dise:ase . 

'i7iN• Rl~7'X107,WSCf~E . LiV1A$NCR 

'1'he I'ceport of the LuivYSm,y Committee oited certain patho- 

logical 9.nvestigations (96, 99, 125) as corroborative evi .dOnoe 

of a rela4.f.oneh9.p between smoking and lung cancer . The results 

• of theso investi .gatl.ons rhowed that patholog ;iea9l chances 

occurri .ng in the epitho5 .9.al . ].ining of the traohea and large 

bronchial tubce wero much more cornmon in smokers and in lung 

cancer pa t ients than in non - nmokors . 'fhere were three types of 

changes obucrve6 and each was found to increase with the number 

of oi.Earetten smoked ; among thc ex-ciGarette smokers, the 

changes wcuro far 'd.ess noF.loablo . 

The opeoi .fi.c patho7.oGi.ca1 changee were : (J.) loss of 

cilia of the surface cells, (2) hyperplaa9 .a of the basa7l oells, 

• and (3) the presexme of atypical ce11s . 73eoauee the changes 

vwre found 'xn smokera and in lung cance r patients the Report 

deduced that thcs.o chanCe,s, eepec1a11y the advanced stages, pro- 

bably represented prc-canoe r otts eondi-tionc . . In the 3udgment 


31 1896 

of the Report, the missing link between smoking and lung 

cancer had been estabiishe:d . 

• There is, however, a major fallaoy in the assumption that 

these pathological changes lead to lung eanoer . The ehanges that 

wero found In smokors wore looated in those parts of the brom - 

chia7l tube:s In which lung cancer seldorn devolops : There were 

other significant inoorir,istencieE: . The advanoed pathological 

changes (oarcinoma-in-situ) were found equally distributed 

arnong the largo and sma17l bronchial tubes whereas it is now 

we11 established (126, 127, 128) that 7.ung cancer predomi.nantly 

originates In the smaaler bronchi, or, more peripherally . 

In a recent pathologi.ca7 W study of lung canoer oases 

• oporated at the Dootors ffospi.tsl during the past 15 years it 

wa :s found that almost 90 percent of the cases had originated 

in tho smallor bronchi or In the dista7l brcnohioles . 

The tendency for the alleged pr•ootu,aerous changes to occur 

in parts of the bronchiaA tubes seldom Involved by lung eanoer 

was aloo noted In a study (129) similar in coope to those 

cited In the Report . Yt was found that the most advanced 

changes ocourrod at the carina, the si.te of the largest 

broneh I , and that the chtmges were least evident In the smaller 

bronchial tubes whore )un g cancer develops most frequently . It 

was also noted that "bronehi.al epithc :Siu.ra may be perfectly 

norrnal In heavy smokers, even In men who have smoked from 

adoa.oocenoe and reached a oonoumption of 40 cigarettes daily .a 


. 

• 

. 

r 7.8yy 

An interee.t£ng £.nadvertent eomtrSbut :ion to this subject 

S.s a study (130) of the df.utr£but£on of cigarette smoke In 

the bronch9 .a7l tubes . 7.t• waa dernonstratod that the greatest 

concentration of smoke oceurred In the 1 .argu bronchi just 

bea.ow the trachea, where lung cancer is n eldorn found, and the 

least concentration of emoko In the por7 .pher.all parts of the 

lung, where lung oancer Aa eommon . This inverse relation- 

ship bc+twoen the concontratlon of the i.nhaled smoke and the 

site of origin of lung canoer does not support a causal 

asson£atSon . The concentration of smoke was greatest in the 

parta of the bronchi associated with the most "precanoerous" 

ohangee• and the f'owest lung caneers . 

There were otherr paradoxScal results in the patholofS£- 

cal stud9.ea cited Sn the Report . The moderate and 7.ess advanced 

"prooanceroua" condit7.ons were found with groatest frequenoy 

in the iargo bronchia7l tubes whcre lung cancer seldo.m 

occurs, and wero found with least frey.uency in the small tubes 

Y'.here lung cancer coimnonty oeours . Tho findings of so many 

instancos of carcinoma-Sn-s£tu among the smokers was a most 

unusual observatr7.on . 

This 1eeSon 4 .s generally considered a rar•ity in non-• 

cancer patients and a su mrrViry (].00) of eleven other studies 

compr£o£n g almost: a thousarid non-canoer patients showed that 

caroinornn-9 .n--a5 .tu had occurred In only one Snatance . The 

Report savr fit to i.nc7.ude in its evidence a study of certain 


w 

• 

33 19ua 

ce7.S.s in bronehial epithei .ium which wore presumed to typl.fy 

the ex-smoker . The a1leRed specifioity of these oe11s ia 

extremely douht :fui . . T.hey are de8enerated oe11s of the 

op ; .theJ.2a1 lini.ng in which the nuoleus has contracted to 

aaaume an eccentr3e position beeause of aeeUmulation of mucus, 

These oo].la have boon observod in many inflammatory conditions 

of the respiratory traot . They may also be found in the 

natal sooretiona of smokers, and non-smokors, alike, who 

happen to have coavnon colds . 

7t must be emphaaised that th e allc[;ed preeanoerous ' 

ohangesv observed in the bronchia7l lining of smokers are the 

same c+hanges that have bcen observed in patients with inflamma- 

tory dlseases of the lunt for many deoades before cigarette 

smok9 .ng became wAdospr.ead . In early 1876, it was noted (97) 

that one of the oomp7 .S.catione of pneumonia waa an atypioal 

grovrth of the celt.s of the bronehial lining . 'Phese changes 

trere also found in eases of chronic pulmonary tuberculosis 

and were weSl dcxorihod 9.n 1895 (32) . 

Similar cha.ngos were notcd (98) in bronohopneumonia and 

in ini'luenza . The pathological alterations described in the 

Roport as identifiable wi.th cigarette smoking occur oommonly 

in a variety of pulmonary condi .tions inoludi.ru; bronohiectase, 

bronohopneumonia, tuberculosie, and lung abscwas . They repre- 

sent the natural protect9.vo response of the bronchial 

epithelial co17 .s to i.njury and oocur, a11,ko, in smokers and ! .n 


34 1901 

. non-smokors . The pro5 .i.feration oP cells from the germinal 

layer of the epf .t•hel7.um to form a new type of tissue, 

squaroos mctap7 .aeda, is a natural process whAOh attempts to 

recreate the typo of epithcllum which oxir>ted in the embryonic 

state . These changes are very common and if they led to lung 

cancer, tho i.noi.denoe of the disoase would bc many times 

greater . There have been studies (117,118) which showed a 

relationship betv.een post-d.nflammatory changes and lung cancer 

but the latter changes were not observed 9 .n the studies 

aseociatin g smoking and lung cancer . 

1n spite of all the evi .dence that negates the etiologicall 

si.gnificance of the pathologioa]l changes found in smokers, the 

• Rcpork concluded that these changes help to establish a 

causal relationship between smoking and lung oanoer . R`he pro- 

c4.se wording of the oonclusion ia most interesting t "It may 

be cone].uded . . . that pome aC tite advanced opithelial hyper- 

plastio lesions with many atypical eo11s, soen in the bronchi 

of some clgarette smokers, are probably premal4.gnant ." One 

may speculate as to why a conclusion couched in such equivo- 

ca3l terms should be used to scientifically evaluate such an 

lmportant relationshf .p as amoki.ng and lung cancer . A baef .o 

• knowledge oP the comnion inflammatory reactions of the 

bronchi does not ,jueti .fy such extrapolative predictions . 

it i.a also impii . ed in the heport that thnro are two oato- 

gorf .es of 3.ung cancer and corroborative studies (131,132) 


• 

35 

are cited . The f7.rst, ep3,dermoid and anaplastic, ) .s assooia-ted 

1902 

with sraok ;,nF• but the second, adenocarci.noma, is assoolate.d 

with non-smokS,n g . The arguments agai.nrt such a oonoept are 

dect .s3ve . The oategories ar•e, in fact, determined by the 

si.tc• o1' orS(+rin from the br•onchAa]l tract . The epadermoid tumors 

originute in the brronchi and the adenocarcinomas in the ternr7 .nail 

bronchl .oles . 7:f smoking has a car•ci.noCer,lo effect and pro- 

duces epA .dormoid car•cinoma then this ef!'eat must stop abruptly 

at the ,junctioal bet ween bronch9l and bronchW .o7.ea . 

8'urthormore, Snasmuch as 1unG canoer has a predilection 

for only certaS.n segments o% the lung f.t• must aiso be assumed 

that oi.C:arctte smoke has a preternatural affinity for these 

partA.culsr seUmonts . 

'1'tili lr:Xl'I :FSP-0t3N'PAL~ 1iJI1)IfldCNI 

One o f the ma j or obstacles In ootablSr>hing a oausal 

relationship tetween srnok9.ng and lung oa,ncer• has boon the in- 

ability to obta4n b1o).ot;9 .ca7l oonf7 .:rmation of'the statistical 

association . Mpite the many attempts to produce bronohoCnic 

carci.rmm?. In the expcrarnental anAma]l by exposure to cigarette 

emoko, the results have beon dismal fai•iures . Mioe have been 

fr•equent] .yy used 5.n those experimonts because of the tendency 

of cer•tai.n strai3ne to develop sporloaneous lung tumors . Uni- 

forml .y net;ati .ve resu7.ts wore obtained by Campbell (12k) In 

1936, by Lorenz (119) In 19 0 3, by Fssenbert5 (120) In 1952, 

and Leuehtenborger (a .0P) 9.n 1960 . In not a single tnstanoe 


0 

• 

• 

3b 1903 

has bronehogeni.o carc£noma boon produced experimentally by 

exposure to tobacco smoke . The other• forms of experimentation 

1nvo7.ved d5.raot application of fobacc:e extracts or smoke 

condOnAates . 

Again, 4.t was Cunnd impossible (129 .) to produce broncho- 

gen9.c earc9 .noraa with one glaring exception . itockey (101) 

Inf.nted tobacco tar on the left ma5.n bronahu.s of dogs three 

to f9.ve tirnos weekly through a fistu7 .a . Out of 130 dogs 

used in the exper :tnient thero wae : one s,hich obligingly respond- 

ed w5.th the production of invas4 .vo carroin oma . The Report 

acknow! .edges that thi .s work has not boon conPirrnnd and there 

are aspects of the experi.ment which ovokc skepticism r.ogard- 

S.ng the S .mpJ.?.catS .ons . 


It would seem roasonably that such overwhelrninf ; evidenee 

of the lack of lung cancerr producing properties of tobacco or 

its Products should he an S.rnportant consideration i.n the 

ova7.u.ation of a eausa7l relationship between cigarettes and 

lung caneer . However, in the Report, these ttogat5.ve results 

aro treateG ae Sncxdonta93 flnctings and an extended effort S.s 

rne;do to reconci? .o the failure to produce bronahogenic OareSn- 

oma er.parimenta lly with the smoking-ounoor theory, 

Yrcooding the disouasion on the carcinogen5oity of 

tobacco, the Report subtly vitiated the negative findings by 

emphas5 .•r,7 .ng that "faii.uro to produce cancer in a given test, 

by a@:fven m?teriaA, does not rule out the carcinogenic

• 

37 

capacity oP the same niaterial in another• spacies . . . u In 

another sects .ou, the Report stated that certain poiyoyoiic 

aromabio hydrooarbons In cigaretto smoko have been denignated 

as ceroinoBeni .o on the bae.i.a of tests In rodents and that 

thoreforo onc can "rea.sonabiy postulate" that the same sub- 

etancea may a.i.so be caroi.not;en:io 5n oue or rnor•e tiusuos of man . 

The faia.uro of some invoati.gatore to produce akin canoer 9 .n 

niioe by applyi.ntt vurioue : tobacco pro2uots 5 .c rationaSized 

by oxp7 .tmations cri.tioizing thc technAque of the expex4 .ments . 

The: ]ieport efuotos ev9 ..dence that okin oanoer can be 

inducoG in mah by indus'tr'sal e> :posu.re to Ftoots, eoai tar ar,d 

pitch, and mi.neral. o :i .ls . Tt then statos that lussmuch as eome 

of the hyipooarborre• are also present In tobaooo smoke "It ie 

reasoi,ob7 .e to asisume that these oan be eaxwirrogenic for niau 

al.eo ." Th$.a type of ey) .1o(;fati0 rCaaon :lnE; impl :LOatin(/'g tCiba00o 

an a caroi .nogen o'vems a very weak argumer,t when oonfronte@ by 

thc many mi7.7.i.on-years of exposure af the fingers of the smok- 

ing popuaation to tubaoco without produoing oancer of the akin . 

The oxpo rimcntai . ovAdenco sngt;est•1ng that certain hydro- 

oarbono in oSfiarotto smoke, are ea.roSnogeni .o for man Is not 

substantiated by the low prevai.onoe of lung cancer In smokers . 

Tho statASCioal ri.eh of srxpo¢ure to 1un g cancer is generalAy 

prasen8ed 1n terms of oomparlson between smokors and non- . 

srnokers . The most recently pubiielzod :report of Nammond found 

110 Yuhg canccrs In 36,c)y 5 smokers and only 12 lung canoors in 


904

0 

• 

0 

3B z9o5 

a"raztched" group of an equal number of rmn-bmokers . The risk 

S.n the smoking group was 171 times that of the non-smokers 

but the prevalence rate of lung cancer among tho smokerswas 

only 0,3 per•c.cnt, or, one 5 .ung cancer in every 333 smoker•s . Sf 

c:i.garotte omoki.ng 9 .o a potent oancer produoing agent, it 9 .s 

difficuit to explain why 36,865 smokere in the study group of 

36,975 v:ore not affected . 

CHI?ONSC S3HONCNX.'fYS AND TdMPHX55T1N 

Phe maniYeot•at5.ons of chronic Tronoh7.tis have been 

deecribod for a3.most P00 yearolut~ the ReporC of the Advisory 

CommS.ttee concluded that cigarot•te emokin€, vras the most irnport- 

ant oause . The d}.aeaGe was desor0.bed by Coato (122) In 1767, 

by Euuihara (103) in 1808, by baennoo (104) 1xr 187.9, by 

Fberlo (123) S.n 1830, and by many others vthose oboorvatl .ons 

antedated the era of o9 .garette emokin(5 by many decades . It is 

daffS .cuJ.t to unde.ratand how cigarette smoking can be impli- 

oatod ao the "4nost lmportant cause" of bronohitis when the 

di.seane was so prevalent before cigarette consumption became 

wP.desprea.d . %t is al.so difficult to understand how a causal 

ro9 .ati .oneht .p can be oatablisbed between smoking and chronic 

bronchitis when tho ].a.ttcr has boon defined 7 .n an arbitrary 

manner, unre7.e:eed to specS .fie pathologl.oal, biochemioal, or 

physiological criteria . 

C:hr•oni.c tsonoh5 .tis has been defined as a disorder 

characterized by productSve cough on most days for at loast 


39 ] .gCCi 

three monthe of the year for not ].oss than two suooeasive 

years . The Report acknow].edp,es that the di.agriosis of chronic 

bronchi.tis requ.iros thcoxolusion of other bronohopulmonary 

diseasos which produce identi.oal symptorns . 

The crux of the problem is that the conolusions of the 

kdvinery Cosimi.ttee wore bascd on epidemi.oloKioal studios from 

whieh other di.seanos had apparontly not been exeluded by 

appropriate d iagnosti.o examinations . In most of the studies 

the di.af;nosis was estab9.ished solely on the basis of porsonal 

recol7.eotion . Chronic or recurrent productive cough may re- 

su7.t from a variot ,y of pulmonary conditions ranging from 

tumor to a7.3orgi.o rhiniti.s . Recurrent seasonal oough it a 

cornmcn syrnptom of many diseases . Resid= inflammatory 

changes rasulti.ng from bronohopulmonary i.nfoctions in ohi.].d- 

hood frequont].y produce cough and other respiratory symptoms 

in adu7t life . Symptoms interp:reted a s chronic bronohiti . s 

by the i.nguiring epidemio]ogiet may trttvo an entirely di.ff'erent 

rneani.nF: in ciinica7. ruodi.cine . 


The history (1 05) of ernphyseraa a .].so antedates the era of 

oi.garette smoktng but the Report found that smoking was 

assfiei.ated with an increased r iak of dying from the dieease . 

71hi.s correlation as very tenuous because emphysema is not a 

speci.Ric ent9.Ly . It is an anatorei.cal and pathologioal oondi- 

t5.on of the ai.r spases which occurs in a varioty of disease s 

ineiu.ding baotorial pulmonary infectlon involving the smaller

• 

• 

iLO 1JO7 

bronchi, tuberculcais, silicos9.a, and non-apeoifio pulmonary 

fibrosie . J•,lnphysema rmay be found at autopsy In patients who 

presonted no pulmonary s,yrnptoms during life and, oonversely, 

nay be entirely aboent at autopsy In pati.ents presenting a11 

the typieal rrvmptrnns, st gns, and X-ray features of the dieease . 

The fi.ndl .nt;rr In pulrnonary function tests are not specific 

for the d?.agnoc :irr of emphysema . Yn sonie i .nstanoes the di .seasu 

is a7.ready fer advanecd in ear7.y adult iifei in others the 

symptom e beoorne• apparent; oni.y with advraneing age . The ehanCes 

found In the lungs at autopny ran go frorn local sub-pleural S .n•• 

voiverocnt to estonsi.vo b9.latera7l alveolur destruction with the 

formation of gi.ant air vesicles . The fact that a clinical 

diagnoeia of.emphysema ba snd on eymptoron rnay bave absolutely 

no relationship to the actual ctisease deatroys the validity 

of any etatisti .oa7 O oorrf:lati-0lts . 

1iY :cllFNYAY~6pSCAT, FVlA1iNC Pt 

A7.though the epidem .ologica3 surveys purport to investi .- 

gate the prevalence of chronic bronohYti.a and emphysema, the 

a.bsonco of e,tandardi.red di,aGnouti .c criterl .e mi3itatos against 

any accnrate evaluation . The atatiati.c :a)l studios have oon- 

centratcd on eymptoms which are supponrad to be t•ypioal of the 

di.seacee, under i .nvesti.Eation . The oonclusl.ons ooneerning 

chroni .c: bronehitiu and c:mphysema conta9 .ned In the Report• of 

the Rdvisory Committee are therefore based on the asooci .ati .on 

betwecro smold .rrp; and eerfain symptone rather than on a 


• 

0 

0 

relat5onahS.U botvwon f;mohi,ng :i.nd spec4Sic d1nP .ascs . 

The x•c•HuAts of a acr :wo 04' studiea rovea7 .ed th+at i .n tcwc-rfl) 

. [rWokGi'6 CoRi :hF :d rtlLiPO t :ha.il T"(ltl-3rfi01F.et"6 . f{OY:flvHr, the k".I,dp 

varS.€tionF in the inoldmnec± of couf;h =uEF :oate; that this sryn?p- 

torn, reg•a.rd7.cr..psotora.t5.en of sputunl m, .e a0 . .o eauatoci wi .th c:moklnE, 

V1t.h no4t oi' tho atu6i .ozr eriranat :i.ng frorcr" the samc eouroes as 

the erarveys on cou8h . 'i'hm isYe3 .dencs" of spu.tum productioh f.n 

the nmokcrc : rz.ngert frcnr 71A pa ;:reelnt, to 6H„7 poro©ut . ; 5.n tho 

non . .r.rrolccrs thn ran[!c wa frcen 0 to £'ll .0 pe :r•oent . T'ho S;opar-t 

found ;t 5.ntorecR,ing t•h .t 9n moctt oi' tR"ee studlos the non-umok

• 

• 

42 1909 

irrocone5 .lable . Unl.ess coughing is a ncrvous habit it £s 

tho reoui,t of a physioloAoa1 r•ofRer.to ol£m£nate the sputum 

whf.oh has aecumulated £n tho traoheobronchAall tree . The 

sputum cannot enter the pharyr,x under ita oran power ; £t 

must be eou(,ned up . The dtseropaney between the inc£danoo 

of• c+putumpr•oduct.i.on and coup;h exemplifies the type of 

irr•esponc£hlu tabu3 .ati.on that has been u1 i.lAZod in the eatabli .e,h- 

rnent of Lopor•tiant concl .u.s7.ons . 

In 2'ab].c• 3, page P8lI, of the Rcport e.rr 7.£ated a summary 

of utud£ees on the prevalcnco of both cough and sputum in re1 .a- . 

tfon t:o smoki.n7;. 1'he rsm€ie was from 7 .2 peroent to 51 .0 per- 

cent In the srnekors and from 0 to 8 .9 percent in the non-emokers 

. Not iistod in tho table £e e report by Oswald and 

h]edvoi. (iC6) whkch included oeea67.ona1) cough or eputum :un 

addition to the more fropuent and persistont symptoms . This 

e.tudy of mor•e than 5,000 poreonn found 63 .7 percent of t he 

rca 1.e eanokora and 47 .7 pemcont of the niale non-smokers w5.th 

cough or eputun ; among the femalea, 63,2 percent of the smoicers 

sputurn . 

s and !!7 .'( percent of the non -amokeres had cough and/or 

Again, it rnmy be pointed out that popu .lntion prevalence 

stud7.cs of sputum or cough., no matter how paf.nstakinCly done, 

cannot contribute sufficiently accurate data for valiA eon- 

clus£on ::, . )a n u y- be further emphasi .wed that even i.f cigarette 

smokers have morc cou@Sh and moro sputum than non-smokers : this 


43 1910 

does not neoessarily indicate that these a,ymptoms are rc- 

8lsotod Sn per•wanent pat•holoK+-ca5l ehanges in the traoheo- 

~ b;aonchial tree . 

The prevalence of' breathlesanoss among smokera wae also 

stud9 .ed . The resuits showed variations of 1 .nc±dnnco simiSar 

to the surveycs cou@;h and sputum . In one st :udy (107) approxi- 

mateiy 25 percent of the male smokers and 1.7 percent of the 

non-smokors adm9.tted to breathiessnoss . 

. In anothor study (1 .0£4) the female non -nmokers were moro 

breathless than tho srnokers . Ifowever, the i'enale amokers over 

!!5 years eoughed and expectorated more than the non-smokers 

• even though they wore iosn short of breath . 

i 

Still another study (7.0g) found mor e shortness of breath 

In both maie and fernale non•smokers than In the smokers . 

Experience In his'r•ory taki,ng has made it very apparent that 

sub,tootive evaluation of breat-hlesaness ds fraught with 

potential error . There are any nutnber of phyalologloal oondf.- 

tiona oapabl .e of produeS .ng sensations of breathlessness 

9aic?.ud :tnC anxiety ayndromea . Latent oarGiovasouiar disease, 

thyroid ctisorder•s, anemAa, and other org ;€mic diseases may 

aiso be mahifc:sted In cxertional shortnoss of breath . 

A correiati.ve study botween smok3 .n@: and breath}.ossness 

mu&t exoludo all other causes by oomplete examination Snolud- 

i .nC. laboratory stud9.os . The ftepor•1 : of.tes seve.rai studias 

correla.tin€; 


smoking wi.th a heterogeneous asnortment of

• 

44 1911 

rospiratory conditions ranginp ; from "chest illnoss" to 

"0.rrevere4blo obutruct] .ve lung di.soaso ." Among males the 

prevalence of theso cond5.tions were found higher in smokers ; 

among femai.eo the differences were loss marked and in some 

aurvoys there rvero no differencos found between smokera and 

non-amokors . 

SUMMARY 

i. . Historica7l studies ahow that lunf: oanoer had been 

prevalent for a century before the era of widespread smokf .ng . 

2 . Progress in the diagnoois of lung oancor during the 

past three deoades has resulted 9.n the recognition of far more 

cases than was prev3.ousAy possible . 

g . The rate of incrwase of lung cancer has progressively 

declined in the past 40 years despite the 200-fold inorease in 

cigarette consumption . 

) L. i,unt; eanoe .r hae occurred predorninantly in males in 

the 19th century and in the ora of cigarette smoking; the sex 

predilection ir, a biolofgicnl characteristic and not a resutt 

of urnok?.ng . 

5 . 1'hore has boen no oanparab7 .e S.ncreaso of lung cancer 

1 .n forc a lcs despite the prodigl.ous oonsu!npti .on of cigarettes ; 

the rate in incroase has already been stabi9.ieed In females . 

6 . Lung ccn,oer has ooourred prodanP .nantly in the 5th, 

6th, and 7th decade0 during the 9.9th oentury and In the era of 

cigarette smokdng ; the age distribution has not been influenced 


ill 

0 

0 

45 1912 

by duration of srnoking ov by smoking habits . 

7 . Sn institutions with long expsrience In lung oancer 

the peroontaGe relatlonshi .p of lung cancer to total cancer Sn 

the 19th century was similar to peroentagos prevailing at 

pl''eElent . 

fi . Tho pathologAcal evidence presentod In support of the 

smokinF;- J ung cancer theory is eauivooal antl the conclusions 

are unwarranted . The greatest number of alleged pro-canoerous 

oonditions in smokers v+ero f ound In bronchial tubes that are 

7c:aat Involved by lung canoor . 

9 . There is nc+ valid experimental evidence confir.ming 

the smoking-7.ung cancer theory ; bronohogonic carei.noma has never 

boon produced by exposure of experimental anima7.s to tobaooo 

smoko . 

10, The a5.legations that bronchitis and emphysema are 

related to smoking are based on the most tenuous assumptions ; 

the d5seaseo are defi .nod arbitrarily and the conclusions are 

thereforc meanYngiess . 


• 

• 

!46 

(3) 

HI~'LHNNCFvS 

7.913 

K1.np, 0 ., and Newsholme, A . : On the a1 .leyed i.noroase of 

OaneOP, Pryg,, R~yal,Soo., hondon 14 : 209, 1893 . 

(2) Laennec, lt . : Traite__Ae_1.!AUSeultttion Med3 .ate~et de,s Mala: 

dS.es dee Poumons et du Coeur, Paris : J, S . Chaude, 

181 .9 ; 4th od ., 1937 

(3) Porbcs, J . : Treatise on Disea .ses of th.e Chest, Londona 

T . & C . Underwood, 7.521 . 

(4) Andral, 0 . : Hecherchos su .r liexpoctorat7.on dans 1es 

. d3fforcntes maladies de poitrine, Paris : USdat,Jr ., 

1821 . 

(5) Douillaud, 3 . : Observations sur le cancer des poumons . . . 

J ._ .Oonipl,_,dq .,Dica,._des_SC ._med . 289,1826 

(6) HeyS'older : llu. oancer des poumons, ArcYdves Gen, de,_Mod . 

1837 . 

(7) lterard : Tumeurs oncephaloldes d l une fo rme sAnguliero a 

ia surface des p oumones, Pu1A ._Soc ._anati._de_F'ar1_s_ 

3.: 13, 3898 . 

(8) firnal : Cancer epitheloiAo du thora .x :, ete . . .., Oaz•, de iiopO 

l'!_ : 78, 1Fhts . 

(9) Lebert, H . : Du cancer des orCanes de la respd .ration, 

Yh~!s :(o)_ogie Faa.holoEliquc, Parir ; : J . fl . issi111er, 

Vo1 . 2, p . .',90, 18!!5 . 

(10) Charcelay, M . : Massa enoaphaloi .de volumineuso dans 1e 


plevre droite, 12, 7837 .

• 

47 19111 

(11) Nionneret, E ., & Fleury, L . : Cancer oP the lung, Congrna- 

ium de Med . YrFit . 1 : 167, 18146 . 

O.`r) Harc, Ia . : Carnours f.nvoAving certain nerves, London Me :,d . 

Oaz . 1 : 16, 7.838 . 

(13) rancoast, N . : Superior pulmonary r.u7c.us tumur, J .A~M _A. . 

29: 1391, 1932 

(31:) Hughes, H .P7 . : Oaees of malignant disease oP the lung, 

q_uy!s Hosu : he~. 6 : 330, 1841 . 

(7.5) Idacbachian ; On prS .mary cancerous degeneration and ulcer•a- 

t:ton of the lung, T.ondon I~7od . ._Oa~r . Y2 : 23, 1842 . 

(16) Hurrowe, G . : Caso of extensive oare9noma of the lungs, 

Medlco_Ch1r ..,frdns . j: 119, lERW . 

(17) Graves, R . J . : C33n3oa1_LOC1:uroe, ., Brit ._ Mea .__J ., P . 902, 1857 . 

(22) Uudd, 0 . : On soree of the effects of primary cancerous 


tumours withYn the chest, MedS .co-Chir . Trans . 2fL :

• 

• 

• 

48 

2).5, 1859 . 

Wi:.a.ignant dis:easc: o;f the lung, Lr}nqot . ]. : 489, 1852 . 

(24) a ldaldeyer, H . : ]i ;i.e e.ntv;?.ekelung der oaro9.nome, Aroh .. _f . 

~p¢h• .__Anat . ?.Id : 140, 7 .868 . 

b ; Uher• don Yrobe Sannn9 . . k7 .in . Vortr . 

.. . . . . ._ ._._. . . .. . . ., . . . ... , _, . .._ ._.,~._ . . . .._. . ._ . ..~ .._~ . 

No . 33 ., ChArm :Se No . 10, 18'72 . 

(25) Per7 .s, Wl . : Zur CeiouistAk des Lungenoaroinoms, Archb,y._f . 

patk, .. . Anat . 56e 437, 78'72 

(26) peor•gi, 19 . : Tt3 .n Fai.7l von prS.maron Lungenoareinom ohne 

t•k:tastosen, k:crL . ]Ci .in .,,ldchne:chr ., No . 28-29, p . 413, 

7879 . 

(27) Ro4.nhardt, W . : Iier pr).maro Lungerdcrebs, Arah4v~ S . Ka7.gk . 

? 9 : 369, a•878 . 

(28) 19irch-N9.r•tschfeid, P . : Das primare Caroinom der Lungen, 

i,ohrhuoh cter,poUh . Finat ., Leip2ig : F . C . Vogel, Vol . 

2, p . 462, 1.6Ei2 . 

(29) gesse, H ., and Hartung, F . : Der Lungenkrebs die Serg- 

kraukk:rAt in don Sohneoborger brugen, Vl .ertol,aahreohr . 

f .,, [c:r?,uh5...,_trgd, 30 : 296, 18'79 . 

(30) Si.egel, J . : Luz__Pcnnt?.~ica.

0 

0 

49 195 .6 

(33) Passler, SL : Uober d.ae primaro Caroi .nom der Lunge, 

Arohi .v Y, ._ paCh : Anat_. 145 : 191, 1896 . 

(314) Yrankel, A . : Zur Dia6Snootik der Brunthohlengesohwu3 ..ato, 

btsch .__med ._4IC_hns~chx• . 7.'_l,: 1345, 1891 . 

(35) 3chwulbc, J, : Zur Lebr•e von den primaron Lungen-und 

BrueCi'e) .l~cschsvuieten, DEsoh mcd ., .Wohnsohr . 171 

1235, 097 . . 

(36) N .artmann, N . : Uper 3Fung_cultz~ebs vorn 13rnnohus aus_gehen, 

K9.e1 : P . Peters, 1896 . 

(37) KinS2, U . : Pri.msr•y cancer of the lung, N,R,J .M, 2i_ : 

828, 7.9g8 . 

(38) Lehlhach, C . : Cono of primary encephalod.d cancer of right 

7.ung, S_oo,_NilsF Jer6ey, p . 150, 1870 . 

(39) Loomis, /: .7 LeeS.qreEj,en Atseue Ee p~_the,kaeofrato~ftans~ 

New York ; 

Wi7.liam Wood & Co„ ).876 . 

(i!0) llelafield, S . : Yrimary cancer of the lung, in Ca_so 

Siof,ortc_Of._'i'um~rg_of' the Lung;,_,18E~8-1888, unpublishod 

notobook, Neei York City . 

(iL"i) Pepper, W . : 71wo cli .nloal ] .ectur•es o n primary intra-thoracio 

oarcinoma, ra1] a, ,i?ed Ttmen, 9 :97, 1878 . 

(h2) Van O,.oson : Cancer of tho lung, Me@,,,Reoor,_d_16s 495, 1880 . 

(43) Ri.pley : Pri.mary i.nf'iltrating meduJ .7.ary caroinorna of the 

7.un(;, Mcd_ Heuurd. 7_8 : 691, 7.880, 

(44) Hompor, 0 . : Pr .trnary cancer of the lung, 7`rfa_ns~,_~:nd,A_agn 


State Mod, Soc ., p, 170 1880

411 

• 

• 

50 1917 

(N5) Janenay, 7ii . : Primary carcinoma of the lung, MeQ._ReoorQ . 

230 215, JB63 

(46) Hoilanxi : A specimen of oncophalo7Q eanoor of tho lung, 

172, 1.884 . 

(47) }{odcnpy1, li . : tAUitipie nom growthu of the lung, PrT, 

p . 19, 

3895 . 

(!!(S) rie Count, B, g . : Primary carcinoma of the lung, Trt~ns, 

ChSCS: p. f;&th,, Svc . !!.: 67, 1899 . 

(49) Ad1cr, X . : 9'he df .agnor7.s of malignant tumors of thc. 

aung U , tu .x,fa . i. . E> 5 : 173, 1896 . 

(50) Wcinbarger: fl¢S.t'rage zur K1S.nik der rnalignen Lungen- 

gosoh :•luJ .ate, 2.teohr ._ f, .-_KCfEk . 2t 78, 1901 . 

.17 .i .an 0 . : iur X>S.agnos.tiaohen Ve .rwertung der .(51) KS oboren 

Sronchoskopie b,.e hungenoaro9.norn, Tiex`^l,-_kiAn ;, 

1Vohnc.chr . i.(. : 4y7, 1900 . 

(52) b'eSJ .c:henf.eld, J . : He£troy;q .,_PUr, Stcxt;tst!,k, ~d, KaauiatS .o 

dori_Cax~cincnn~, l .elps9 .g : P1, Rbering, 1901 . 

(53) Rioc:k, H . : itrcbs-, :itatistS,.k, 1!tunohc,ne Kastner & Caliway, 

1904 . 

(511) Y'eidner, 0 . s]trellot•at :xs ;t11: ,nnoh don eektlons-protokollen 

dea 3athoi ..of,lech_l+natomio~hen Snst .iLute zu Ootting ;on, 

vo:n Jahr

0 

51 

1918 

Kasu3.otichoc zur F'rago dos prA .maren Bronchial und 

Lungondrobe..es, (-horS ..to_A.un . 315, 1906 . 

(57) Adler, T, : I'rE;maYsV Mali~nant Cirowl.hs, .o!` the_LUnZ and 

Sr•onchi, Mew Rork : Longmanc, Green & Co ., 1912, 

(58) Jackson, C . : Moehan2.sm of phyeieal signs in nooplastlc 

diseases, J~._A .)h_A. Q 639, 1930, 

(59) Jaffe, R . : 9'ho prS.mar•y carcinoma of the lang, J .Lab ., & 

Ciiq,.. ..Med ..,20, : 1227, 1934 . 

(60) Harve:,y, C . : Cancer of the 1u.ng : A clinical survey of 100 

caees, Ned . J . of_,AUetralf .a 2 ! : 565, 1936 . 

(61) Graham, B ., and S9.nger, J . : Suceessful removal of ontire 

7.ung for carcinora a of the bronchus, J.A,M.A . 101% 

;37a, 1923 . 

(62) Da ;rnard, W . : The nature of the 'bat••ce7 .7.od sareemao of 

the medAastinum, J . Pabh, and 1k!p t_, 2 ;? : 241, 1926 . 

(63) Karancr, H ., and Saphir, 0 . : Sma3.2l ee3 . :l carcinoma of the 

lung, E: 553, 1930 . 

(64 ) Johnson, C . Fl ., C1aCott, 0 . T ., and Good, C .A . : The 

importance of exploratory thoracotomy 1n the diagno- 

efa; of certain pulmonary 7 .osS,onc, ,3u_r,go Ky 21 : 

21e, 194, 

(65) Lisa, J ., 71r5.n i dad, S ., and Roeienblatt, bi . : Pu7 .monar.y 

rnanA .fe[;tatione of carcinoma of the pancreas, Canoer 

7.7 : 395, 190 . 

(66) Mor@.yama, 1•&, ?3au.rn, 41, S ., Haensze7., 41 . M ., and 


! 

0 

• 

52 

Matt7 .so.n, Lt . V : 1ngulry Into d1aR . .nootio evidenoe 

1919 

I 

supportinf;rnod9 .oa1 c:ert5.ficuti.on of death, Amer . 3 . 

of Pub7.io floalth 48 : 1376, 1958 . 

(67) Haenazol, W . : Mortallty and morbidity statlstios on a17l 

forms of cancer, A_ote ._Un . ZnL .,_CEmoer 17 : 837, 1961 . 

(68) G9 .119 .am, A . 0 ., M, .lmoro, Li . ff., and Lloyd, J . W . : Trends 

of mortality at.trlbutod to carc:inoma of the lung, 

Canow, lh : 622, 1961 . 

(69) Weha., S . : Uber die 2unahrne dea Lungenoaroinoms, 2tachr . 

f ._ Kret+n . 25-: 302, 1927 . 

(70) Sohonorr, 3i . : floitrar zur Stat3 .stik und KtinS.k der Lungen- 

tumorcm, ztsuYu• . f,,_Krory.27 : 436, 1928, 

('(7.) Materna, A . : Gur K1S.ni.k und Pathologie dea prlmaren 

LunC;or:krobses, Seri .tra~e, .e___,k1L?~Chir . 132: 708, 19z

0 

0 

53 1920 

mortality trends in the United States, 1930-1955 . 

Part 3:}: : Hnd rebu3.ts and mortality tronds in 

canoor, Nat l 1 . C[+noer Inet . Monopnr . 6 : 131, 1961 . 

('t'I) Clemrnonsen, J ., and riusk, T . : On the apparent increase 

In the incidence of lung oancer in Denmark, 1931 - 

2!i3, 1 947 . 

(78) ttarmi.s : IntrathoraoAc groiaths, Sta_Wmtholomew!s Nosp . 

lto. 28 : '73, 5.892 . 

(79) Lenhorbz : D?.c boaart5.gen Neublldungan der Lungon, in 

Isbatoin, kJ ., and SchWalbe, J . : Itar/dbuoh dor 

Praltc5sohon_fAeda,zin, Stuttsart : P . Enke, Vol . 1, 

P . 490, 1899 . 

(80) Roichclrnan, W . : Ri.nc Krebstat9.otik vom patho1o81eohe- 

anatomloohen Standpunkt, Bor7 . ._k17._yWOhnschr . 321 

728, 1902 . 

(Si) TirAeac : Znr Kenntni.sa des prlmaren X;ungenkarzinoms mit 

statlalsohon 6+ngabon, Frankfurt . E_tschrri' . Path.23 : 

48, 3920. 

(8'r.) 19e71er, 0 . : Yrlrrar y caro7.noma of the 1ar2:er bronchi, 

nrchiv f . 7:nL .,MeQ . 51. : 314 , 193.3 . 

(83) 13erb7.i.ngor, W . : ilber Ole Lunahmo des primaren Lungen- 

) rebsas In uen 7ahron 1920 bis i924 , K11n . Wohnsohr. 

4 : 9?.3, 7925 

(84) Poters, 41 . : Ubor das Lunt;enearcinom, 2t $ohr . F . Krebs 3 7 : 

56l, 3932 . 


. 

0 

51! 1921 

(85) J"un[!hEmna, H . : Der K.robs der Lungon, Hronchlen und 

oberon Luftvoel;o, GCSChr .f, KrobFl,A : 572, 1929 . 

(86) Uormanns, It, : 13o7 .traG zur Frage der 2unahme der ftroUs- 

kr•ankhe4 .t, Zt_e_cYU .^, f, _ Krek~s . :9 : 40, 7 .933, 

(87) Ki.chenGrrm, W ., and Esser, A . : Statistik ubor die tn 

don wmen J .902-1926 S .m Path . :[nstitut Augusts 

Hospital Itoln obdua9.orton CarcAnornfal) .o m5.t bceon- 

dcrer fieruchsS.ohtigung der Frago der hrebszunahme 

naoh dern Rr ; .et;o, Ztschr . % . Krebs 'r.14 : 63, 192'(, 

(88) Passey, H„ and Ho7 .rnea . J, : The Snr,S .dence of intra- 

thoraolc neotiiao5,a 3 .n the teaohdng hosp5 .tals of 

Grcat ]iritaSn, 1.894-1928, Ruarti_. J'. Mod . 4 : 321,1935 . 

(89) lbrahim, A7 . : }Sronchoy,cn3 .o caroinorna in Fast Pak4stan, 

nss . vr. . chect„ 26 : 266, 1954 . 

(90) passey, H . : Some pr5.blomc of lung oanoer, IrvanoeL .2 : 

3.G7, 1962 . 

(91) Sonser, G . : The S.nc7.Aenoe of tumours of the respiratory 

tract 7.n Loods, 3..._Ftyl;z. 28 : 340, 1929, 

(92) HampcS .n, P . : HauP9 .gkoi.t und Ursachn des primaren Lungen- 

carz7xwms, t79 .t1., a,d . Gren~tteb .., d,, med, u,_Ohir, ;i_6 : 

1t45, 1923 . 

(93) 8ayfcuPoh, C . : Lugonlcaru4 .namo 9.n Le4.lrzif;, Ptsch ._med, 

47chnr~chr . L .k : '1 .1197, 192l4 

(9!t) Ja .TXe, P, . J ., and SternberC, H, : Y,rS.ogrpathologPsohe 


iiriahrang:en, Ar . titv F;_~o?ch. ..,l1n2L . 2 ;fi, : 346, 1927,

• 

• 

• 

55 1922 

(95) lilpsoh9 .tz, M . : Ubor die 7,unahme dos £ronohusoarinoma Sn 

1otGcen Jahraehnt und die dSa(,nosti.sohe Sierwertung 

der i3ronohoCraphic, Dtsoh. med G)jnnahr . 5 5_.: 1708, 

5929 . 

(96) Auerbaoh, 0 ., oL._7. . : Caro :,,noma-4.n-sAtu tmd early Anvau7 .vo 

carcinoma ooeurr9.ng i.n the traehcobronohiai trees 

in casos of bronehial carc+inoma, J . of 2'hor, 4urU . 

;4 : 29 8 , 1957 . 

(97) 1ir5.odlandc :r, C . : l~kperimental Untcrsuchungen uobor 

oh:c•onischo Pneumonp .e und Lungensehwindsuoht, Arahlv_ 

f . path . Auat . 61 : 325, 1876 . 

(98) a McKenzi.c, W Iip7.thei.motapJ.as?.a bei l .ronahopnomonAe, 

7,9Q : 350, 1907 . 

b l:'internitz, M• C ., et• e.7_ . : The Y?a3t;ho o~„of.' . Xnfluon•r,a, 

Now tiaven : YaSO University Prer.+s, 1920 . 

(99) Auerbach, 0., yt .ai .,. : Changea in the br.onohia)l ep9.tho19.um 

1n relation to smoking and oar•cinoma of the 1ung, 

97, 1957 . 

(100) Abrd, 1) ., et a?, . : ]iyspiastS.c 1es9.ons of the bronchial 

tr•ee, Canecx 7.4 : 1226, 1963 . . 

((101) Rookey, I? . ]?., et al . : Facperimerhal s :tudy of effeota of 

cigarette sii+oke oondensato on bronohial mueosa, 

J„A .M Jy . 7,82 : 1904, 1962 . 

(1D2) Mohtonbcmger, C ., ct- Q . : A corre7.ated historogi .oaA 


oyto7.oEacai-, and oytoohernxoa3l stud•y of the

0 

tasiehoobronoh9a7M tree and 7.unbe of rnioe exposed to 

cif-,'a:rettc smokv,Canoox, 1"~ : 7'rl., 1960, 

(].03) a riadham, C . : Obscrvat9 .ons on the SnfAammatory AtSeotiats 

of the Kucous AYemb ranoa of the Eironehiae, London : 

Ca?2ow, 3808 „ 

Kokes, id . : n,aro~. Rco oer LhEDia,gncsi&,tnG, ireat ;men+• of 

Ma ecs_ oS' Lhc Clrost, Yhilado :Lphi .a, A . 17aldie, 3 .637, 

(SON) Mennoo, 1 . 4`raite dc• L"AU6onJtatl .Dn h7edtate, 4tli ed . 

VoI . Y, Yar1.s, J . 5 . Chau.do, 1837, 

(105) I,ou9s, F7 1•r,•~c ;archcs on F7nphycema. uf the Lun~c, trans . 

by `l' . flteetttrdsoh, Jr ., Phi7adoiph4a : I1unp;7.isox, 

Ameriec.n P6odioal Y .9.brary, 1838< 

(J06) O : w a:.id, h . C ., anti Gledve i , V . C, : Chrorcl.o bronohl .tis : 

The cffec:t of o9 .tarc:ttc smok2nEb ?qJLoeb 2 : 843, 1955 . 

(A07) lu•nsem, P .Pd„ et aS. .. : New York City ltea3.th Dapartment 

ohronic respiratcry dlsease snu•ve ;p, May, 1963, 

3Mr1m Repart to Advisory Cnnm9ttee . 

(1U(i) Ri .ggS .ns, _( .ì' .T . : 17esp1rnf.ory symph.oms, bronchSt§ .s and 

vent2.latory cah;cc5 .ty 1n a ranGOm uampie of an agri-ou3 

.tnra3, popu3 .:,tion, Srft : Me~, ..J. 2 : 1198, 3957 . 

(3 .09) J .i.g(ans

• 

c17 

J,A .M.A . i . : P2t.(i, 1947 . . 

(].i]_) Stmons, 1 . : Yz-7mary Caroinoma of tho l,un g , ChAcago : 

Yenrbook Pub]i-shers, 1937 . 

9.9?11 

(11P) Wi.7afla, R . Fl . : Yathqlog;y_of!i'umnrF+,, 3rd od ., WashLngton, 

D . C . : }3utterKor•th & Co ., Ltd ., 1960 . 

(5 .7.3) 7'ri.nidad,, S ., IJ.sa, J . P. ., and Rosenbiatt, N .H . : 

]3ronr.hof;eni-c camoi.noma stimulatoa by motastati .c 

tumors, Clance3• ? .,6 : 15P1, 1963 . 

(7.:U!) Spai .n, D . : Recent ohunges in re l atti .vo frequency of 

vcu,.ous hSAoloEr,lc types of bronohogenS.c carcinoma, 

8;i . : 477, 1957 . 

(11"i) i:,co, S ., and 2' w o, T . : N9.stoAo6riea7i t;ypin); of lung 

eance rs in Hong Kong, Eri.tQ. Oanoer.1f. : 37, 1963 . 

(if.6) Whi.twcl1, F . : 2'h e hAstopathology of ].ung cancer i.n 

zdv[:rpool : The spoc7.fici.ty of the hAStologl .oa3. oell 

types of 7 .wig cancer, llrlti .._ J..._Canoor q : $A-0, 1950 . 

(17.'7) k3cavcr, ]) . L ., and Scha.piro, J . L . : A consAder•ati.on of 

chron9.c pulmonary parenchymal inflammation and 

alveo]ar rcSat3onshdp, A 0 J . . M . B1 : 879, 1956 . 

(318) Raeburn, C ., and Spencer, H, : hung sear cancers, Br1t . J . 

Tqberc . 51 : 237, .1,957 . 

(119) a Lorene h„ Stervart, H . Q, ].k,ntel, J . N„ and Nelson, 


C, V . : T3,^ effects of br•c:mth3.ng 9:o&aeco smoke on 

rt.rain A mf .oe, C~ :ricoi~_lipr ., 3 : 123, 3943 . 

h] : srcnz., lt . : );xp3rTmontal etudies on tobacco smoke,

• 

• 

0 

5K 

f~rc-c . }daLs7. . Cancer Conforcnoe, p . 203, 19!•9 . 

(320) l ;e:eonberf .t, :~ . h9 . : Cagaawtte e:aolce ar,d the inoldence of 

priitlFq'V n001i1,aEBlin Of' thN lu,n[{ a.n albSno I11ic:C, 

SOACYICE:. 1,).(i : 5h?., 1952 . 

(12i ) a Poaooek :, p .R . : CfF:arette oniok3.ng by laboratory an9 .mwle•, 

Sevelth _ . lntox .r (on~resn, 7, ondon, ondon,Cauar p . 153, . 

. Y. c .' .`, $ . 

b . . . : CS.gareate smokMo or:perS .rnents, }?.•rf.L, 

)~n~ . . Catfoar C : , . . . :t.e??, ~ . 

h_Ann :~ai Repo.rt,Fart 2, 1957 . 

(la2) Coyteo ?r Eto_dc P : ~[,~iki,[; du Youraon, Paris : HorS .t+cârt 

fi.1 :,, 17hY . 

(1?3) )'^boOe, Y lee,rSt1Eq ge{_Lhc l :act$,oe, oP P1ehYC~ .ne, YhS1ade^3 

.phaa : John CrS.gg, 1830 . 

(7.28) Campbell, w : 'l.'he effeot of exhaust gasee from Anterna5 

oombunt5 .on cnYginc:¢a eand o!' tobsooo owo)ce upon mf .ee, 

YMt 5 Llxpex )r.th .a ..Q 1)+6, ) .93G< 

(1P5) Auerbaoh, 0 ., Stouf,, P, . Y ., Hammond, )3 . C ., and CarCAn).c3 ., 

W Ohanges in bronohial epAthelS.um In relation to 

c.q .fwr•e:tte smol ,.ng and 1n ro7 .at?.nn to 7 .un(; oanoer, 

ICeq~ )ric,tun~_ .1,)ICC). . 2G5 : 253, 19b7 . . 

(i'lC) C¢mj .anc7„ ): : . H ., f+oaor, R . L ., Coui.aoiY, ld ., }Seald, 3 . Pi ., 

anu Wi.n, 8 . L . : Tho a.pparont sites of orfg4n of o 

c:uroixianas of the 7.un(;, k:ad :tglo(';y . fLS.: 1, 1962 . 

(12%) ) ;9.chowi, A . F . : Cited S.n (larland, ot n7, . : The apparen6 

s:ttos o£ ortg5n Of care? .nomas of tho lung, ii2dtology . 

'(f, : ?, i952 . 


• 

• 

59 1926 

(128) WaJ.Lor, J, B ., and Fryoe, A, Pfl, : Tho nit•e of orig9 .n 

of J.un cancer anG AtiH relation to h i stoioGloa3 . 

Lype, 9lhorax J.,O : 117, 1955, 

(J.9y) C :enn,.ngham, 0•J„ and 4JAnotan :iey, P: . P . : F.yperplacSa 

anGW mot•aplasd .a i .n the 1»ronchi .a3l opStihel7.um, Fnnaic . 

c; Lh FtoV i7 CoJ icg;e,_cF SnAg;ecm : .. ?~ : 323, 1959 . 

(130) G7 i cld :in, 0 . 0 . ; lnrauetion or bronchy.a3l cancer by 2oea1 . 

rnaes :.ng of carcanogon ConeentraLe 3n outdrAft0.ng 

rnucus, ~„2horaclo sur€ . 3J . : 238, 1958 . 

(3 .33 .) 33rc :e•1ov, ):, ., Hoagai.n, L ., &;,Fmuaeen, 0 ., P,nd ltbrares, 

B . R, : OGOu[1at3.Ons and (l :lgarBtte 91llok'1nE; B.6 Me$ers 

In 1unp; canoer, J, Am, Pub11e Hoat ~ . ._, 

J._ . ... h, uU : 17x, 1954 . 

(3.32) Do11, Y.,, tlS7 .7 ., A .}3 ., and Kroyberg, 7. . : The s9.gnifloance 


of cc5.1 type S-n Io1a0A.on to the actio]ogy of lung 

cancer, }ir7,t, J, COnO(:r 3.J. t~I(i, 1957 .

c-! 19'l.9 

Si.À'1'kMIiNT OP IxN . Stlidb)Kt)V C: . Sf,Atk'YSItO 

A esl i+hciBon C . .osunex•t~, ea physr .c.ittn, gener[al pntholoCisrt : 

anteY'ested i)1 t9.bJSue CIiN(¢lo[91k? fl .nti an eXp6ri1¢Fnta)l patllo)o( ;l'.st 

• onF;agecad for ovex• 7[i yearF: in dnvc,r :tip:nting tnechunistnsc of 

C1AnG(Itln . }.1V co2k(3QjG and (pfld4(tRJI scho4l . G3uCn0io6 t9@?'H at 

hrsrvcu^d, and I pa°acx•i.cofl and taught ptxtholog:y in Y ostcma 3'or 

?F year,i . Fn 'JL'EM A UFUS Pz•esident : of the Aoa i?nNlond L

. 

• 

• 

e`L 

hawtun boErq ;s : tha,t Ietly M aet tt eir sace.cptibzl4ty f:a 

davo7c p c: corEaSn kin d of clio:ri .es Q e.oric,u s Mar

• 

• 

C?1EEaHPP;, EelCohol9.Eq11 flnn @ev@rC trAupLa . 9)hey ilKllilde[i E 

nltU1h@Y of IBCVp tith Cvj.O61Ybo o£ e8Cee6Gitrp Ilorvoid9 Citbl'Qy 

eeXprGGIIC(1 by ot'CrPtl'f,in,r .11Q; tho3r ph,WEACH7 CPpBCitieC In 

vurS.oue trays, PhcArthur, a i5arvarc+ psycho},ogir .•.t, from h4 .e. 

v9-et'ry0int htae E'oupd the emmo i'eaturor> In S .ung ec=.ncer 

})atientr+, eon:e of tvhcm h.e+ dusorihce am "l.f.vinn In overcSr4 .vc" . 

fxil 0Y;C651JAltt Q@GOF£pti .bn o1' EEGGh P p01'Fbn, naNOly TtoS6, 

the fatnous oditor oY the 18etv Yorker wnga.a;S.nc, aho clied o%' 

]ang Cauoer, In In tha lnook "Tho Yostiru tvt th Ross" by Janlsxa 

'F.'iturbcr . 6tnl ;t of the ausu had cviCence of ]onA continued 

].nk'I1/1!Hp Y:t9on Vl1.th AnSOC£Seeli of thCY bi)OYIChSi a116 lunt`; . 

iho ot.be.r ar .ndi.lep: In the sen w7th nguelxousl ]wtg cnneer 

that cU .r.tit .VuSeho d thcavn f.'roln ot .her g rout,el uae h pere iotence 

ok noxc,eil tes;ticul.a.x auc4 prot;tftt9.c structure into late c1iA8Se 

L',g0, v/hCn 15(/rt IDPn C.Ito1Y So111(> te3E+tj.6ula1; nt'rojihy atiti rYYOHtFSU .C 

0n7SrCò m oilt . A"InH .lB" £F.ctAr l .on(Y, rdCOQp1SZ.Fp in llln g 6a_ntler 

Nnencc+d to Z .nvo7.vo pV r,ont5nued aetf,vo production of malo sea 

hormo [eG :. 1JCyoilCi t110 Eltrpr(i g0 . 

'%Oo £'O1Y 5NUll18b \Y%th th'06 051nRer tyl4' vere nvn71 .ah1C 

2or afoc,tnnto an•r.YysBc . 

En tvoracm anc; eomm naen ndenoactrci4nomp.s of the luug 

ul,loaxed to e±rtse 1roo-l abnorwel intornlal proceseon thut 

:inv0l.vCf7 feldnGrYikR7 eFtro[BCfniC hoY'HWn[tl 6tLYllnlatieel'1 . ThiE1 

:ICaQ 9c. prcr4cmtly being £olloWot) by h£'urtiu+r s4 ;utiy of Sp 

a.rCol.fi :xoa c+n :.eH ol' wmaon trith lan(c eteut+er frrna Ylolafiold 


I 0 

• 

• 

kospital, llec' York . 


1930 

8ubscqucntly, Dr . Mar,}oric J . Williams, then pathologist 

at Tomple 1'A. Oenter and now Chief of the Pathology Section 

at VA CentrF.l Offico, and I niado a similar study of 100 

mcn with lung cancer autops= from Temple, Texas . Their 

e:nvironmontnl exposurc v cvero not analyaed . As was proviousl .y 

found, mo rt shoerv>ci evidence of underlying chronic inflamura- 

tory 7ung ilzsea se . 'i'he men with squamous lung cancers again 

sheWed thu greateF,:t tendenoy to preservnti .on of the norma l 

t.eE:tf.enlnr Ftructere in Into middle nge . Ilest factors wore 

thus found to be 4raportant in respect to the development of 

th.e typo of lung oaneer.• r>scribed by son :o to cigarett :e smokin!- . 

19ore recontl.y in a c:tudy of tho d:egenerative lung 

disenso omphysecna, which according to J . P . Wyatt, a leading 

authori.ty, predorninates markodly In mon, host fact. or ® were 

faund . Thore tvoro endocrine chaugon in men with emphysema 

nC:Boef.ate[i eithor with overgrowth of br'eAFt tifr8u4 micro^ 

ahopinnlly or with i,t:n prosorvat:9.on In a normal state . In 

contract maniy other rfen had hreant atrophy . 

7fioee host factoa• studies aro rel .evant to tho i .nveati.t ;a-ti 

.fanv of rm7.utionshi,pr botwoen cigarette smoking and lung 

cr.ncer in the fol.lovring way¢ . Icven if one accepts n heavy 

inhnleiticn er.posure= at the r•at.e off two paoks per day for 

20 yenrs, only a ermnll minority of mnle cigarette sr,kokers 

(soracrvbnt Ace.© than 3 per 100 men-yeare) developod tnta] .

c6 )JS1 

lung ca.ncor . As with nl.l factors nu:pectod of being weak 

c:arci.noLons, a vari.oty of significant contributing factors 

aro ) .il .•oly . itost factor studied previously described hnve 

• i.ndfeated at l.east two : (1) chronic inflnmmatory lung 

0 

diseaso ; probably bactori.nl, viral or both ; (2) Lormonal 

faOtore, particui .Nrly evidence Of persi .Ctent mal.0 sex 

hor,'mene productioel into lato middie a6e . The maj or point 

i.s that the dungor of cancer is not apparently spread ovonly 

nr.aoni{ heavy smokers . It affects particularly men, some with 

oxconsivo nervous energy, often with ehroui.cal.ly inflamed 

bronchi and luugs, and coeae with evidont nbundant male 

horwonn ) production . ]Vouen, men with decreasing male nox 

hormoucs nnd certnin othor groups are 1esEs affectod . 

ln summury, thero 1s evidonce for mu] .ti.ple factors 

An lcuig cancor dovclopraent, and extonsive scientific investi .ga - 

tian suhould cwn tinue to determine what role, if any, al l the 

factore i .ncluding cigarette smoki .ni; may pl .oy . The subject 

of the enuew of the lung cancer ir;cw t c)osed but just barely 

O]renQld . 

s/ Sheldon C . $omers, N .1) . 

tYr21'IaNSHO)i8 : 

nesoci.ate Pathologist 

peh ., s, 190s 

]idi.tori.nl Rcvicwt "Tho ]3ndocrino ared Genetic Fnctors 

in Cancer of thc Y.nmg" . GrowtL, 1064, 28, 1••1U . 


• 

• 

0 

c6 

McArthur, C .C . The Personal and Social Psychology of 

]93fl 

Smoking . In '"fobacco and Hea7.th", C .C . Thomas, Springfield, 

Ill ., if^61, pp . 7.01-,0 . "SmokinG and Ilo£dth", U,S . Dept . of 

Health, Mduaation and Welfare, Washi .ngton D .C ., 1964, 387 pp . 

Sommose, S .C ., "Host Factors in Fetal Human Lung 

Cancor", A .M .A . Ar•ch . Path„ IOSS, G5, 104 . 

Somwers, S .C ., "Pulmonary Hmphysem a, Healed Myocradia7. 

1nS:arCts and other Disease Correlations with Male Bree,st 

Structure" . Ana .J .HOd . S¢a ., 1964, 245, 341-44 . 

Thurber, J, "The Years with IM£ :a"„ Little, Brown f+ 

Co ., Bostoas, 1957 . 310 pp . 

Willinms, M .D ., and Sommers, S .C ., "Endocrine and 

Certain other t:haliRC9 in Men with Carcinoma of the Lung" . 

Cancer, 1962, 15, 109 .-17 . 


Wyatt, J .P ., V .W . Fin:chor and B . .C, Sweet, ^Rmphysoma" . 

Ani . Rov . Re£ip . Dis ., 1964, 09, 533 -60, 721-35 .

• 

• 

ra I 

S'fÀ'CFIMRNT OP Tfik:Ol1OS U . STLiKL1NGp Yh .U . 

lntroduction And Summary Of Concl .u ::ions 

lnformation collectod so fkr on the link betweon smoLi .ng 

1833 

and various dieeYatiF.f ha^ rHS .Eed a CQrtnill amollnt of di.sa(;reCmeni : 

In the sci .ontific comm umi.tp . Off hand, dirsagroements among 

seionti.ents have al.ways, bcen holpfu l in elucidat .ing solution 

to problems . 

'cGic useiull function of .r,ientifi .c disagreomr,nt . 

is somewhat di.minislred when it becomes a meltf.er of public 

. However, the fact that thi.s disagreeuwnt exists is in 

con-corn 

no way elimi .nn.ted by reports of committees or of organi .zations 

who study cerl.ain health prohlemm in a professional mannor . 

'171e conr.ensus of tho sci.ontific communi .ty i.s nei.ther 

measured OaEil.y nor In this consensus decisive In e.Cientific 

hattorc . Scfent.is:ts have too often viff.nessod that the correct 

i.nterpretation about the state ofnatnre was advanced by the 

rnf .nori.ty rathor than by the via j orit.y . In faet, the opi.nions 

of sc.ientistc: or of the scientific commani .ty are of no con- 

e.oqucmce to facts: ofnature, If emoki.ngdoes caus+e dfsease 

then the body viil.l respond to it, if it does not then the body 

v,ill not, irre gn rdLer;s of wli6t Opinions we, the Surgcon-Gen- 

cral, or comrlittce o appoi .nted by anydody raay hold . 

1, for one, am convinced that the anCwer to the problem 

ofwhCther or not Emohillfg of tobacco causRs disease is not 

y4t NI1hNt.alltiated sufficiently so tflat a firm poEitfve or 

I1P.Gative 1'erClfCt eall be rCndered, 1 vi .ph to C/fiplaeiLe thnt I 


a 2 ]£r3 4 

ar0 teSW yin(, lyith P cHvPct to tbE : adE!Quacy of the evidCnFC for 

saPport .ing ff .,a.ll verdicts rather thcn advancinf: one myself- 

The reason n on whioh 7 baso my own eoncluaions may h e svmmar-- 

i.aod an fol.loltis= 

1., A mmmher of nntmall stod3 .es have nttcmpted to producol 

.un .^- caucr,r by mea.ncu of c.igarot .tn snnlm . The r.oe.ults 

of r,]l thess f>t .udies have boon ue ;r.atlve, 

2, A'pidemAoio ;;i .c:a7l wi.donce+, Gae,ed rior..tly on st .atioti .c.Al 

m+.ni .cml ;at .ions, is nac.lsar, confli .ctinG , and in mau y 

ways .tmpoz.eiDlc• to interpret . 

It in a rai.mp7e fact the.t the public suid ropeatable produc- 

tion of n phenomcnon is the prer.o[duisiEC for proof of c.ausa - 

•tiDn in al l zcioncees and curta.i.nly In bio .loCy . Al l er.pori-. 

wcautc that hav v a?.termpted to prodncc lunYg cancer by tho cm_• o .f 

cilro .rot'

• 

• 

ra 3 

rnakes up sciemtd.fic procrf . on the who] .e though, whf.le there 

are no pre,cise rules, there is genera] . agreement among inves-tiB 

.ators on the major aspects and methods of a work that make 

it scientific, Floxevcr, not all docisions, oven those made 

by soivnti .stc, are noc:arssari.ly sci.ontiRic:, This has beoorne 

9.ncreaeingiy clear in the l .nst few years when scientists 

have bcen asked to make deci.sions which have public import 

183& 

either i.n war or In the nrcn of publi c health . In dealing with 

our I>resont problem it i.e very importn .nt to koop In mind when 

s+uch deci.sioaes are motivated by purposes of science and when 

they nre motivoted by public health or other oocessitios and 

cims . 

The scientific decisio n proces6 seeks to dorive solf corr , 

t.ainod statemmts of fact about the existence of phonomena or 

essociat9.one : . The sci.ent .ist has learned that correct stat 

.e-meuts of faot 

l bestow upon man immonse 1>owors to manipuYato 

and modi .fy natcu•e to his benefit and sat.isfaction . He hns 

loaruod also that to bo offective scienti.l'ic deoisions must 

be rcachcd by str7 .ngent and hard -headed ru7es . frimary among 

these is that the soismtist c.annot be i.nfl.uenced by extraneous 

motivue . It does not matter whether these motives arise 

from the noblcst rnost selflees aeipi .rations : or from the basest 

drive for self aggrandi> .ation . Any possible influoncos on 

sci .ent .if9 .c decisions t.hat are not relcvant to the problem it.- 

sel .f are direct or implicit sourco h of bi.as, Incl.udod In sucT 


- 

ra 4 

sources of biasos nro considerations of tho social or Holiti- 

cal consequences of the scientific decision itself . The 

cnro with which extraneous motives are eliml.nated from the 

scientific process is reflected in the manner in which 

. aro usually documented 

. The conclusion is documented : 1, to have a more than 

reassonably hi.l;h probabil :lty of being correct> The 

preferred demonstration is to specify the conditions 

by v:hi.ch tho phenomena can be produced publicly and 

at will . 

'L . Iti-s shovm that alternativo conclusions either have 

a high probability of being i.nc:orroot or have a much 

lower probabili .f.y of being cora•ect than the prefer- 

red stntemont . 

3 , It is dernonstrated that sourcos of bias which are 

its con-clusione 

3936 

extraneous to the evidence itself have been elirninat - 

od from any influcnce on the decir>fon process . 

It is gemerally recogni .zed that spccial care must be tak- 

e.n if dccisionc on medic.al or biological fact are based pre-dcnid 

.nant.ly on cv .tidcnce of Etati .st.ical assoc,iations botween 

agent and dieoae :c, Such ar, aosocietion does not reach the 

status of z scientific fact until3 the di.eense itself can be 

czlJ.ed forth or prevented undor controll.ed conditions either 

Li man or in noinin].s, Correct conclusions es to cause and 

effect havo trmero drawn purely from epidsi®i.ologieal coincidence 


• 

0 

• 

w 5 

in the past . Those occasions have boen more than counter- 

balanced by the many ins :t.r,nces in which exclusive reliance on 

statistica l association has provcn to be mislonding,. Woll 

aceepted epidomiolo6i.ca1l findings have been confirmed by ex- 

poxd.mr.ntc that tested the suC.f:este.d asscroiationa under labor- 

ator,V conditions . 

It in at the point of scientafic versus action oriented 

attituden that interpreters of the data On smoking and health 

hnve failed to reach a common understanding and appreciation 

of their respecti.ve points of vierv . For the proponents of 

)p?7 

public action the demonstrated statistioal association between 

smoking and increased incidenc:e of mortality is conclusive . 

For the proponents of hnrd-headed scientific judgment, the 

statie,tical association does: not representadeniuate evidence 

on which to base conclusions, Thereforc : action orientation 

hn& led to the repetition of basically the 

.i.n st.atisticn snme study, demon-strating over and over ngain that cortn 

l coin- 

cidences do indeed exist and the scientific orientation has 

kc:pt on be Jng di .sturbed. hy the constant occurring anomalies 

within the statistical evidence, the laek o]' adoo,uato method- 

ol.ogy, and above all, by the failure of laboratory exporimonts 

to produce posi.tive ovidence of a presumed offect of smoking . 


Eixperi.meutnl ftvi .deuce on Attempts to Induce Lung 

(:wtlC-0r with Tobacco and Tobacco Fmeke ' 

'Pho report by the Snrt;eon-Genoral's (:ommittee on Smoking

• 

s 

ra6 

and Heaith point.e out most ndoquat.ely thn9t while broncho6:enic 

carcinomas can be produced In a variety uf animal„=s by many 

r ast, 

euhe.tancon, such ttinmr€. cannott bo producod by tobacco extractr„ 

F,moke, or condensat :es . 

"9'he lunl ;s of mi .cc, rate, hamstors und primates Lave 

bocm found to bo susce.pti.ble to the induction of 

bronchogeni.c carci.noma by the admird.stration of poly - 

cycJi.c aromv.ti.(: hydrocarbonu, ourtcrln niet.al .~., radio- 

Acti .ve S:nbEtSncen, and Oncopt,elliC Vir'uSeF. . the hiF,to• , 

patlwlogic: c:he.ractort .stcF: of the tumors prodrroe(1 arc 

Si.ndlar to those obCOrved in nlan a11d are fFeqllent .l y 

of 1,he squamous variat.y . (Bl.IohinF[ and 11ea1 .1.h, p, 

167) 


"f.romicho(toniec carcinoma has not boen produced by the 

appllcat5on of tobacco extracts, sniokc, or conden•€ 

.atos to thn 1.unE( or the traeheobronchial t .roo of 

oxporamoutal . ani.male with the possiblc exception of 

doF'F+•" (Snmki.ngand }lealth, p, 165) 

As thc firstt quote points out, it has been well . estab - 

1Lshed t.bst hroewLo((emi.e car•c.inoma s can ho produeed in ani- 

n:a1s . A n(nibor of studlos publie;hed in the litoraturo havc 

t:o i'ar fai.lcd to dernon5arate the same for ci .lraret,te smoke as 

a cauv:ati.vc agont . One shonl.d be atvaro P.t this point that. 

ihe Fmmber of etudics appoari .ng in the 7 .i.terat.urc may be nds- 

1 e Bdinft . 'rh.ere YF ; a d0(ttnnented tendency of :lciAnt.l.fi.c reportFe

• 

0 

ra 7 

to publish only pocitive: results and avoid the publicatdon 

of neRativo rosults ns much as possible (95) . Whatever• thc 

ea6e might be, expcrimelltal facts appear to be as follow's . 

Bssonborg (13), Muehlhock (29), and Louchtenber(;er (26) 

exposed mico to cigarette smoke wit.h no reecQts on the forma-- 

t.ion of canccrs . Aoren z et al (3l .) and Leuchtcnberger et al . 

(27) di .d not obs,erve an i .ncrease in pulmonary ndenomas in 

rni.ce that i.nhaled ciCarette smoke , beuchtcnborger ot al (25) 

doe[:: describe a series of microscopic chan[;'es in the lungs of 

mic:c exposed to ci .l:arette smoke resembii ng somewhat those 

found by Aucrbach e t al (2) (3) (4) (5), . However tro dose 

responeo ef .Peot was reported, The norpholoF:ica1 findings 

couavi .e:tod of bronc.ld.tie with prol.iferation of the opithel .ium . 

Sorne areas of bypcrplasia showed atypical changes . iiowever 

1 939 

the change s wore reversible when exposure to smolce War, stopped, 

Such pathol .o R i.ca1 changes are uanally not considered ceir-t 

.ain enough are i.ntli .cators of actual damage to tisstte . In 

di.scussi.n(i Lhi . ;: ovi.Gcnce, the Sur6:eon - Gencral's report con- 

elude6 : 

"'fhe production of bronchogenlc carc.inomas 

has: not been reported by any investigut.or oxpos- 

in4'n experim u nta1 anlmals to tobacco smoke," (page 

165) 


Most e xperimenl .c in which tobacco tars were brought i.n , 

to Gireot contuct with the LunG ?nd the tracheobronchia] tree .

• 

• 

ra 8 3940 

of espori .mental a.ni .mais have yielded neRa .ti.ve result (41, 

42, 43)~ it should he pointed out that producin6'g carcinomaa 

by painting ekin epithc:lium with or without additional addd- 

tives such as olive oil or killed tuborculo bacillus i .s real- 

ly not ovidenco that such carcinomas c :au be produced by to•hacco smoke, 

It cannot be denied that one of the most significant piocec; 

of clomontn on the rclntionuhip botwomn smokin[r and heal .i:h, 

ecpecially on the rol.ationchip betwoon smoking and the causa- 

tion of tumors is tho fact, that . it hac not bocn possiblo to 

prodUcO such tumors i.n Pnimay5 w1W ordinarily respond to other 

i.rritent, by formi.ng the eamo type of tumors found in man, 

This ie not j ust lnck ofer.perimontal evidence . It is nmLative 

evidence to the hypothecis that smoking causes bronchogenic 

t.umors . 

'fhere are howevor, certain dangm•s in gmioralizing from 

animal oxporimcnts . These dangers should a,lways be kept in 

mind . Snmetiuce nE;oute+ which are not hnrmfu l to man may be 

so for animnls and sometimes agents vihich are harmful to ani-male 

may fail to result in simi.lar afEoct.s on m a n . 9herc+ aro 

di.fforoncoo in the rosponses of different, animal speci_os of 

which, of cource, man ie one . 


0ne of three pocsAbillties e,xistea with the interpretation 

of datna on animal s . The fi.rst one in that e,mekin{; per se 

docs not cauro bmonchoconic tomoro . The second one is that

• 

• 

ra 9 

with respect to smol

• 

0 

0 

ra 10 

pnthwnyse and c.ould be the effect of the acctimulation of rneny 

events acting over u long period of time, the applicnti.ou of 

epidemiological tools and methods have led to li.ttie more 

than confusion< There arc many (iangors nssociated w i.th the 

unquestioning nccoptanee of epidr,mioloe7 .ea1 evidence, I 

poi.nt here to l.engthy disnusoi .ons which 7 end othorc have 

undertuken in such areus as the associat .ion between load or 

between l.ow doso radiation and ecrtai .n diseases (22) (45) 

( ;i0) (51) (56)e It i .s vi .th tho sxucrPi .c9.on that cnidomfolo(ti- 

cal and e:tntissti.ca3. evi.donce ie: oftc.n anrbi.,guoues and, unless 

collcctad tri.th the greatest of care, br, n rclativcly J.ittle 

vr4tw that we mnst approach existinC evi .dencc on smoki.ns 

a,nd ItnaES cancw• or other health aff setc . 

J would summarizco the views of others as weJ1 as of my 

own with re a poct to exi .eti .nr epidomioJogac :al evidence by 

mnint .ai .nin6' t:hmt it iu unclear- insufficient, and hopalers ,- 

ly confounded wi.th many cxtraneous factore< Specifically I 

wouXd cmphn.e ;i .ze the followirq; : 


J, 'fhe aEr•OCSAtion hetween ci.t;areti :e consumpti.on aud 

fno:coasos of aay disonrm over tt.ne f5 not menpi"p- 

fuJ., (In contrast, t .h0 laclc of such an assoniat9on 

J94? 

would be a Gignifi-0ant il'idicetlon that no cFw sai . fe- 

J . .^.S . :IonS6i .p hetween s;moicznRg n.nd heaJ .th oxi .F.t .ed), 

8, 9'hc riepWntfenG which have boon sampled show so 

n:?nY RnolrlnlieS when Cempared to cen9J5 (iata that

• 

• 

rn 11 

.:ono,'me ; o n a nc,;cd on thei .r atudy rs•em less then 

RNftF.i .n . 

., 'PUahni .gues used to measunc the effect of smolcing cm 

diennr,e are often un5uitablo, . 

1943 

4, it . W uuclmar 4ror pre•soot date whi.th if any disease 

i.l= or S .r net cuut:cd by Smok>_n8 :, 

5 . 611pa1'Mit 4`fiWG11D on htHlth CB :.n In4 teeonnted for by 

fSCt4V' :v othOR thF ;n E :ni'vning . 

A2;ociatiou 7: ;:t:enea C'igarette Consumpt .fon and Lung C'ancer Over 

9'imc 

TII'JAe has Loon & OUnFrF&erahlo Ancrea6e in the repart.ed 

AP3n]t 0c lAql UanJ9r ]n tho last few dQCbdei . Ther0 hne also 

lman an inc,a&ero in ti,& e : :noimt smolaled during the sarne time, 

(12) (1.ri)(1,7) i2ta) ( :I?7 (?•W .. 7.t As oot 't .un hov:ovcr that 

one crn : :cnoA'ad,- r,,,q'ti,i .ng Lrom thin oBSVPVed covarintion . Tho 

uprocni o f dln=:ctiW t hA t n•r.u baon rused durint; tho uame time 

hra inc .rent:cl) j1, ::4 as rcuch as Lss ihe c wowh of gaeolino, al- 

coho"f, or r :,rett ni,li Ilairy proc;uctes couo U me6 . Over any hhort 

perind of time thl,re [ : oro rea] trm :ds a_, wo13l us apparent fluc- 

tre'.t.i.ans an0 myclc& tvhi.ch, by thei.r eheer number anu by the 

fact t that LhiitG ;s c-11bcr ;('o up or down, aiWayU mnflt give the 

apr-nWxr,nce of ev m o sorL of sn aseiociation 11 thir,i typo of 

ovi drucm v,e r ,x ,:ve v a.cc.eptod at al.l us pointing toward r.n 

asr:nai-sa4on . 3'iie truth c,f the mati .e n i s t :hntt an i-ncreace in 

cmoiisg and lins incrcaso :lr, f.ung can ier de : 60 m are ovl.dence 


• 

• 

ra 12 

of cau_:ali.ty than t.he increase In the co D sumption of meat 

and dai .ry producte :: and the i.ncrease in lung cancer or the in- 

creaso in smoking and tha t of either nati .onal inc .omo or the 

national deht ., 


The cusious aspect about the ti .mo-xerd.al rolation he- 

9 .v;oon inr,i.rlcuce of srnoking and disease i» the foot that while 

the rol.ativel.y short t .1nw cofluctuations between these i nci .- 

dents, by thcroselvcs, are not proof of cr .usality, the failure 

of such aacoincidence svould be f .mporta.nt negative datao Thexe 

is a 1?oSf•i .bi.3ity that euch negative evidellce fE apDearin€[ now . 

Gilli.am etf al . (15) detected a decl.i.ne In the rate of fnc.rease 

In the i .nci .demc :e of 3.cm g carwor wLi .ch can not be related to 

rny deeline In the ra.tc of increase of smoking . . If those 

ubr:ervat .tourw ahoul.d t ur n out to be true and if a doclinin€ ; 

trend In lung cancer r,lwul.d develop in the next few yeare : 

such a ta•e:nd woul .d ho ntrong cvidence against a causal ae :socie ., 

tion hot.wo on smoking and lung cancer, 

Samplin€. cnd Suit .ahi .l .i .ty of the Sanqp led Populations 

The fol.low-up of populati.on i .s s.n extromel.y difficult 

Y,nd e>'.ponC•i.ve upde.rte_]dn€ ; . It is conYenient therefore to 

t;cleclt popu7ttions whi.ah a.rc easy to follow . Those might be 

groups of i_rldividuale readily avai .lahi.v for study and willing 

to pe r tici.pa.te or groups of i .ndividne .7e: 1.hatcan he used to 

Relcct SaNplA& within their own Cnvi .rehmont . Under ei.ther 

eOndif.i.on thC 5am{)l.in(' Eitu3tion 1s far 1°rom l .dLal ., Specially

• 

• 

• 

ra 13 

OBkNli .i .ed gCoupn di .ffer alnloF.t by (lefinitiOn from the (;eheral 

popnl .af .i.ou, This differenco may er.erft itsel f In many waye, 

a) .1 or ;omo of w hich rnay bear iniportantl,y on hoaltho Yor in- 

s tFnee 3.f bU wOTO to SLu(iy a//o pu)at1Dn Uf poGl6men beeaUFO 

postmcn are readily ovailabl.e vre would also st 

.ttdy a populn-timn thcrt does agroat 

: deall of walking as well as other phy . . 

:;i.cal. e:xcrci .ses .. P.nother r,spcct of eca .r:rpli.nFg for populations 

whi.ch furni.e:hh the Prec:cntt evidence on the r :moki.ng-hoalth 

li,nk W wort:hy ofl not•e . 79ce tondeno,V haei been to select amocig 

ro) .a.f .i .ve) .y ol.der nre P:roups .. The roason for the celoction 

In t.hat l.cm(g cancer, the }n•imary health problem of Lrterest., 

occ ur s: rith e(

• 

• 

roc.rui.f.ed by n) .ur.P.e numher of vol.wrteer wor9cers of the 

Aiaori .r,an Cr.necar 3oe.iot.y . Vcc),unt.eer wor9eers of the Arnw•i .cr,n 

Canc.er Soc.icf.y may con :;i . N t lerhely of relat7 .vc S of cnnuer 

vi.ct.i.M r-. or of indd.vfdtte:ls with strong convici .i.ons on cruicer 

and ais Fuch cun not be conFi6erod unbfas,od wi .th respeet, to 

t.he effe .c.te, oi : :rnnhi .nY~ on c ..noer . 'fhu fa( :t t.hat, a lzreo nuru- 

hor of sqe,h tvoxRCr . wa r involved % e $ i n rw wmy eli.mirnclla 

1946 

po'LC,i)i) .e hJ.NFRFM in4ro/iUCOd bS' this pTrt:icnlar lil4tho(i of selee- 

tion, ltccausca of this source of bias the populat.ion studiod 

hy l .rn» : :a nd ;_s: L mposr,ib1e to define . . 

Anot,her pro4J .e,ra r+ith all prtscnt rctud4eer wau that w5thout 

e)CCelnti.(RI the pCr cent of ryRP, blO rCt)1.1efJ to qt1e51.1Onna4reE1 

or to f01).Crl9--00s hKVe boon GAtrO[dcl .y t.T4@11., The p(Gr eent 

ofur.aFJ.o rmter?zf in fo) .).ow~ups ru•o Civen in the taliln bclow 

v:hich hrs boen £atcon frrna Smokinr: r :nd t.on).th (paF[e pf), 

9'el0.e 16 .Wbt•nent.alqes of usable ropl,iem in five studiec 

lirit4r:h U,S . C :all.forni.a Cal.ifornir. Canad'aan 

eloctors vetoruns occupatAontal f.npion voterane, 

cih Fi8,F.S 83 56 G7 

F:hat eFfect i.he lec) : nf respoue.es has had on the observed 

rocnk9e, :it oxtremely hszrd to deYi .noa Certninly , whnt.evor 

none)ar:kocre can be baseti on such iucompl .etn surveys are depend- 

- 

ont on ex /tirc':at nueibor of as6unLpt.i.onv, which one has Lo be vri.19 . . 

iqt ; t0 tlni .:C . 


4notlmr mosYt di.&turbinl ; A©ai= s: .bou.t the vnriouss s a w ple

• 

• 

0 

1'll 1 ù ~n•1% 

pocz~l.nt .i~pe is the Prcct Saet ihsT da ceb rtt;'re?013 ~uh 

oiher orad5`~ thc- V . : . G•>fu~utca 7.ti tesm.~. oA their Gisensc 

pa!SrsCt,e1RV~ low 

th : 


:S :.nce, ihc^ 'tat•lo bo :kw ha :+ kDun teic•sn Imr. S :nolc1np: ruld

~ur.Y ~s. rR

• 

• 

ra lE 

Lic :pect.inn of thic tnblc &hows the following : 

1 . . There rrc lar ge diYferences amon@ : the study populatfous: 

with recpectt to dcach r'ato, 

2, ivith corae excoption, the Qenth r.ato of null thcrse popu- . 

latiou s (i.ne]udL1g heavy smokor,s) is wny below ttat fo :r 

white U„ S . pi9).© n . '1'here are a nreat ntlhlher ef PRpl.anf .. 

Lions that (6ay be aciVEnCed to eIIplni.n Lhi5 . 

I :UV/eVGT, 

1.t it1 one t.hin([ to advRllCe CknA.anntlons to Ecfotlllt for 

dir,crepanc:ioe i .o datn in mhiekr no die.crepancy ohould 

e%iR t and tllbth&r One to noe t,he4e (IatH plus the eY. . - 

plmuationa as : a baois i'or fi .rin conclugions about a 

phenomena such as &mokintq and hoalth, 

ln b[onoral, we mny surr,mari.zc that n7though a numher of 

oCridoudul.ogicel. ntudiv :: have aiade available nomo informat:ion 

on the dk.PfCYCnc'GS ill death r'atefs hEtV/OQ/rl 6GIoI9Cr5 a1HI nUn .FlplolaPrE, 

it xe genorally true that t .hoso populntionl eeom to bc hirh5y 

:rol.ect .ed, di_1'for i'ram each ot.lrer rmd from the E 

:enrral populra-tion in thely doath 

.ra,te¢, eu,d hnvc a very loAV Sbllow-up ros- 

pouz;c rntsi . 'fhe cxt.elNto rvhich suc.h c:a .mp].ing pucul.iarfitios 

can di.stor8 the ob:crved pattern of' dicqase for a populnt .ion 

hnvo b .^.cn deeionr :truted and ceil,aussqod (6) (44) (5]) 02) (5G) . 

Unti.l adequate and roae.ouuhly unbiasod e,nmplec are obtai .r,ed, 

the memits oS thc obs:ervnt.flonF on aise= patterns exhibited 

t,y t .hev;o popu7 .etionc ate difficult to ,jttdgo . 


ln'on i .f' S .hnep gyokinlntiAt1m aA'e acccapte : as providing the

• 

• 

0 

ra 1 .7 19b6 

be :.~t data availahic a .t the momr,iit, the compar'i.son of smokorce 

nnd non-er :okoe•s mortrlity mnde possiblc by them raises more 

qneetion .: than Pt providOe: a.nswers for . lbremost among thec ;o 

arv : 

1, Row to ntoa :,ure the effectt of sool:ing ; and 

? . 'the paohlem of the overrl .l vorrusthe r:pocif4c effect 

of €•moLing, 

tde,asuron,ent: of tLe Y:ffect of Gmoking Or, D3 .sanso 

The covnperisons of raortali.ly inei.dance betvc,en smoh:ers 

and non•-e .inoieer :; has been b[,sed predominantiy ori mortalll .y 

xati.os, 'Phis mortnl4.ty ratio i-e obt .afned by dfv9.ding tho 

ag:c specffic doat.h rat.o for d"xeoase of smok .ors by that of 

nom-smoLars . 'A`be rat.i.o should be in the approxzmate reCzon 

of unity Sf no di.ffcrence cr.ACts hef.vcan amokers wnd non-smokers 

with respoc :t to thH deat:Y rato of the e.pceffio dfss+asoo Table 

).9 (pa9e 102 froie 5mokinfg and 1lealth) abi .ch is rolev&nt to the 

onsui.uk (ASCUSrSi,on is rapx•oducod helov)o 


~_~ l~_ ~ 

VnNOrlrymux~I~[[N , 

)IV . 

. : 

/' ~ 

LyubC OMUxE Nn1.llp 

nb 

144 ~ i ll 

S 1[ 1 irl~od : »o teo ` a 

.u 

~" 

. ' 

s.w ~%o i il . l. 

wn . . . . . . . . . . .. . . . . . . . . . 

. . 14 i n° 

` Alo~n,[um . . . . . . . . . . . . . . . . . . . 

. 

y . 

le 

Y~IIrc.v4}1 . . . .. . . . . . . . . . 

r nil~rt i . . . L ° I ° v 


~~ 

MaEinn 

NrltlblY 

°af .. . . .. . . . . . : . 

: i q'° .tw 

L` 1 3 

Nc. n 

y^ 

. 

l 

AaIJe ' ~f. rv~[I x~~blaom~~/1/..: : . I~WI ; 

i ee.~d Loo. B i 

44 

n~ya~ 

~ I b il ' Il f 

. . .. . . .. . . . .. . . rya 

/ 

. . . .. . . . . . . . . . 

. . : 

. 

. . .L _ 

10. . yyta 

_ ~ ~ _ : . 

. I

a 18 

P.052 

We find i.h i t cancer of the lung hn, the highest mor4ality 

ratio, bronchitis and emphysema the next highes:t, followo d 

by cancer of the larynx, and so on . From this ranking the 

conc}usi.on i s reached by some that the most important effect 

of emoki.n¢ is on cancer of the lung, etc . But does the mor- 

tnlity ratio really fndicatc what weight e,hould be given to the 

associai.ton botween smo€ci.n€; and various diseases? Yhore are 

altogether 15,653,E: expect:ed deaths from all oauses . Of 

these, 6,430 .7 woulei be expected to be due to coronary artery 

di.seaeo alone, It stands to reason that it non-cmokers have 

roughly 45 percent of al .l deaths due to coronary artery di 

-soase, eanokorsr even if 

all 26,2 23 deaths had been duo to this 

cause could not have had a mortality rat.io higher than 4 . 

There Is a limi.tation here to the maximum size of the mortsl.ity 

rati.o .. Yet the mortality ratio increase to 1 .7 for coronary 

artery dincano actually reprerent.r, a very large numbor of ex . 

cess deathe„ on the othcr hand, the expected ntnnber of deaths 

due to cancer ofthe lung among smoker s turns out to be 170,3 . 

This rcpreecnts rouChly one percent of the total number of 

expoct.ed deaths. Thcrefore, a relaidvely small increase i n 

the lunH canccur deathc amo ng the smokers could possibly yield 

a lar€;o inc:rea ue in the mortality ratio . The mortality ratio 

Is thereforo dependent on the actual proportion of deaths 

irom spccific oauces within the popui.ation , 


The c;ucst .+.on whie,li now rc:maicie unanewered is if the

• 

0 

ra 19 1953 

incrcasc in the percentage of death due to coronary artory 

discase obeerved in thi.n popul .ati.on Indicates a greater or a 

l .ec:e,cr effect of smoki .n{; than daathr, due to cancer of the lung 

or hronchll.is or emphyscma or cancer of t .he larynx? 6ven if 

rmokinfg had the effec t ascri.bed to it, is this effect mcasured 

aecuratoly by the mort,ality ratio? This is by im means a 

monor point . Yn tcruas of possihle confounding hypotheses it 

woul.d bc very suggestivu i f one would say thatt the major effect 

of E¢ilokin(; i(; On eorona'!.'y artery disease since soniC of the 

di .ffc:rences between smokers and non -smokers are procie0ly in 

those mcdieaA O regions which are u[-:ually r,ssociated with coro 

.y artery disease, It should Ure pointed out here that 

nccordi.nE; to Borksoo'e published calculai :ions the effect 

of i.un9 canc,]r is actually minioaal as compared to that of 

certain circulatory diseases (f3)o 

The menz.urem©nt of the effect of smoking is important , 

The us,o of mo•talit.,v ratio to define the specific effeet of 

sar,old_n2, i .f such a dofinition is possiblo (and there is good 

rea :,on to ma i.ntai.n 'ihat . it is not) 1s of 9uestimiahlo va] .i.di .- 

ty, 

R'hat ViscaEro Is Ca.used Py Smoking? 


bnc very eerioue& ryuesti.on raiesd by the ava@ .].able epidemio- 

logi.cal data concorns the increaso fn deat .h for all causes 

for .mohors as cornparnd to uon-rvmokore„ Whether or not one 

aeeC[t.F the NPPtality ratio af: valid, it is obvious that 

.nar

• 

• 

• 

ra 20 ) fe52 

smokorr: in tho e:aral7) .ee died at a fk , tor rnte iban oon- . mokers 

fro(n p!"aCtioal)y a).) 111ESOaGese Ytiere ie enly one diECaso, 

cancer of the i.ntestine, for which smolcersv c71.e at a losser 

rate than do non - e,nwkere:, nnd one di .senee, cancer of the roW 

tum, fo y which th e rni .ce: for both smokers and norn•smoP;err, are 

a)ilce . The conolus;ion t.hat hae boon i9rn.wni.n the pav t from 

euch data vinrz that emokxore diffor from non--e :mokers in thoi.r 

Lot :x1 PPtttcr u oi' mori:R1ity . This haE Q,iven riFe t .o the cc'r- 

i.oun gucstion if one c.an ascribe an effect of s:woking to zi1)l 

dirreasr,tz'I !be- cone)u :;ion that a11 excoena ryrorte.lity i6: c.ouced 

by r .rnoki.ng hae proven very rmgoNu)a.r In the Past> l t rfoet i 

seern unrozs:onable thr.t one part'xcu)ar egent would cause a)Jl 

those damnf;os . On the othcar hand it 1 n not too un) .ikclv to 

come up with coneir:tent difter'encos in a11.) meacuros or in the 

6'ho).e (>mttePn of i .) .1nCF54': iF f,erioll& biflceF are i,ntrodueed 

tbllou(;h inadCrlnEtte sa v )111ng procedures, For inEltanee my 

&Edbòci .at.cE and I 6howed thflt Llndor OOYtai .b conditions a heilth)' 

popoa.at.ion rnny he mado to n py,ear to have erither a higher or 

:r )owar donth rate thau the c:omgarnblqi 1„e.neral poUulation 

dePending upon how ono ari•nngee the data (52) . 

Mopr, the bohrcd d,iffcrencee bei :weeo smokerc and non--sewlo-, 

era havc: to be recogni_ze>d as one of the mo.Jor diffi .cultie :: 

iJ, nmkf.ng the oxistting: eCiiderniologica)l da't8 palatable . Seme 

n rr6hor ;- (A.ncluti .u g thoqc, rospuneib ) e i'or Lamohing and Hsa11 .h) 

have cPur:.on to bypasn th'r :,~ proS :J .em by W inkg a tiseate by 


• 

• 

ra Z1 

l9hs 

discnsa ceaapcrison betwc=e,n shokers and non-esmokers and letting 

eome outridc eriterion (e.ur,h os aatnti.ECti.aal signif.icnnce) 

decSdo on whether or not the obeerved difforonce indicates tho 

caxist.oncc of a real effeet duo to cmoking . ]t. is ei®plo to 

denlonFtrate that stleh n(rroeedure i .lJ f:tatflstiCFJ.Iy aE weli as 

lo€4lcnlly unatonnd, 

L.et us* t,seurnc we test whothor or not differonoos in denth 

ratcvil rclate to polit.ioa.l percuaraion . A 1ErrGe samplo of whi .to 

mel .c*s i.r-n divifle:d xe; to Hepuhl .ican or Ire:rwcrati .c regic,.tration 

E:nd fnilowcd for s,ome t .i.me es in the smok :ing e:tudies . A 

disoae;e by df .sc2 ::e oompsrie,on of doat .h rates in both pupula•t 

.iAn4: iFmade next . Where e, ]Lir(;e di.filerence as CICflsUred by 

L;tetastienll t .er't appeNP'H in the /JiiPeA6:C IHte it is a6eribed 

to d :lfYorenc.es in pol9ticnl belie€p 

Quite obviously no one would accept r..onclueionn based 

on tiueh a Oo m pn .S'i5bn, Me Vlould rea3Gn that even though 110 

di.ffrnrenecn in the rato of dmnisr, of Uornocrnts and ]tepublicans 

u:cy r,>;0. ::t, randor.i eeleet3on vould nl.ros t ae.•eure that for some 

di .seaa.e: : :, i r:o vc Por•mm s t.s: nnd for otheres ruose ]tepuhli.can, dted . 

P:c tvould bo eoncarued in ler

• 

• 

ra 2!, 

1956 

nlTenr i .o exiet f:or a l.rxge number of dieerr;e n,ortalily rva.tlos .. 

Lot St: bo cs :vumed thatt t,here docs er.fet- e difaorence in mor- 

1 .aJi.ty pvat.tern botwcon r=nmktire nod non-,n;rm;rkors, one would 

calx.ct that, by ehaoce e,lono, for some diseasos this df .rfnr- 

once would be Yargor anG for otbors i .tt would be ttmallcr . Oh-- 

sorvinP: viithin the da.i.n thai, raoirb of the rniooases are differ- 

ernt a.nd few of them Rre arlEke one wou2d be i'orcod to the con•- 

7.usGon that the p:oncral i,attern of mortallty >s difforcnt --not th2t on? 

.y Forae o4t .hosc diseasec diffrar nud othory do not, 

Y'o do any othnr viay ks to ignorae soneo data and e :eloct othcrs 

for onc'r• purpoyov . Tbe reason thA .o 1'oi.nt has becomo such a 

bone, of eont .emti .on ic t,hatt obviounly two hi .nds of conc'lur ;i.on 

can be dravm horc+ . One con assurne t:hat ciP:arotte smokini; 

eaunoe Just. W-ncticaily every disoasm known to man or ono 

could n,orc: re:me+onably aesmne that tlve differences exhAbitod 

in the various srs:~(!Le Go6,ul .atione bct t cc:n smokors and non-emok-. 

el'C. ArN duo to r:o111e faOteY s other than f:Ipoki.n(r' . 

Other Foe-norc 'i'hat Could Account For t,he Observed lli.fforenee 

Hntv:ecm Smokc :rs en

• 

• 

that amo)cinE is oncs of the chexractafi$ticH of this atyi .e of 

lii'o, On the other hand, other individua)s live n :tyle of 

) .i .fc vfiicli is ccanerk) .1y consxi.dcred hea).thy of which non---smol :- 

S.nK iF one of the S,n(;FOdiCntf:o Thus the B.€59ciAtion one 

obsorvc : ; mary not bo hctwvon cigarotte emo4 :ing nnd dir.osse 

but it mny be be.tween n cort a in stylo of life nnd di .noNe,o, 

('Pho fbYlowicq, cioscriptlons of study findinfSs have boen taken 

ulurc .et: vorbni . :(m from t.he Sm-goon- .Gcnerni's rohor t on 6wokinC 

nnd Hoa)th .) 

Scvcrnl Stud9es reported thrat : heavy Smokers el-eo driN ( 

P l.cohor'LC bcvoro.gcv cr.ees:rivoly p.6), (33), (h5) , Kricdman's 

t.ylrc A rnon (t.ho coronnry typo) tend to be heavy eamudcors ( .R.) . 

Smokers nI'e Fliid to be IaDre oR®il .y fln(;CI'ed and to Dat Ino1'C 

whnn under c=txe^;n (55), . They have Uosn roported to marry of- 

tcniel•, to changc ,iob o nio rc frequontly and to be morc ofton 

hospi.t:Eil.iaed d S t')- The concent.ration of e.ercmi cho7.ne.toro3 

trea becn found to bc Sl.ightly hi .hhes in Smokers than in nmrvsr 

.rolrcre : (8 ) , (t), (1)), ((+6), (5 6 ) , alt.hou g h aome stud :iee+ 

hnve found no rolntions:hip (J.)p (23) . (ane invosti gat.owr found 

m1€:o not only that c?o rom cholestc;rol wnu higher in srno)cors 

p.hrur in nou-emoker :; but r,ls,o thmt. it, rcniaf .ned highcr in thoe e 

19h0 Nto p 11ed EBWkinl! ( :1) . Smokers 81 ;40 ilRv e higher heSirt 

rnter; thfun non-erensors (e)„ One ntudy Round an cxcoss of 

f0qo)Celrp Who WCrC 30 )SellCfJnT 

m oveYtVei ght flnd the Eub,j'eets who 

leorc 40 (+crcernt or moro ovcrweflght nrnre a)I reBcOnr smo) :ere,, 


ln&%

• 

0 

rn 2 4 )fltiN 

blr.o 1,hu non-sfilokCrF hr+a a 1'.rrater frocjuency of indi .v,i.(lu£:}.x, 

aAth ]0 ga ::reaut or morc uudervmif ;ht thrsu did the e-mokcr& (5G), 

Sisokcrs not o a)y havo certaio yrhyGfnal ohnrnctor5.st6,ola thrt 

would malco t .hcit,El .y Of tl:,cci .rualntory syr .t .cnt, bu9 : thoi.r fxsychcrlogica7' 

ch£(r£ar.tor9.eotics : nro i .n Y,ine viith the hyPothe£+ia aUvonc(Alhcrc . 

Y'hL t ;e nCr411 n :icture) CPtFrC:knC1 fronl 5],2 tbtn(ii.C'3 if. One (rS E16ok- 

vrs t(intii.nEt to live 1.'tn(,tc,r rne more i.nSen :ooly an(? to b(i more ; 

£-ocAnlly cmtf[od .n6 . Studios, usk.u¢ bch£,vforr,.l rnt.her t .lr£aa 

ys ; ;e,choAof ;kcr+l toet :; supuortthfle pi.eture (10) (35) . Mosa, 

c:tu0ior; euGPomf, the contention thntt neuroi .icinm oefine(i, 

arnonG othors, by th(t ex9e.touce of r-:nxfiety si.atec, nervousnoss, 

e.oYrnLic symPtoinu, nnue.un7 res4lesfineris Su terms of ,)ohs and 

roci .ctencc, ie: Meed £(sf,oci£rted wit .h £anekf.ng hrbits (24) (3U) 

(S•5) (S! :) . Other re7.cvunt evEeencc f.nclud,a ::; the lnrg,o 

8iffcrcncev; hottaotm the moriulity of emoke .r& and rrou-s(nokor :s 

toheo comp .arcd by mnrStrl stuto2, oduc.ot.ionnl levels, uuo of 

t.rwaetr.d]ivors, and doriree of cxerc.Ke (Pet@e 10U, Tahi.e 78, 

Sr.iok3ne anG 14o2) .th), 


($e.(' Table 16 ou th6 followi .n({ (mp{e)


• 

• 

]9C0 

f.l.Y the roferences cited above are includod in the report 

ou SraoNing and kloai.t.h E!re woll as othern thflt would indi .eatc 

that E:moltin(; nlny lie a response to fru5trntion and failure to 

nchievo ctatuE: (20) Eand may be eecomE>an£cd by impulsivr, and 

robo1.17ous bchavi.or (R2) ( .`, ;.) ( 4 7) . In short, s pScture qui .to 

in harinony with our hyFrothesin of differences in style oC life 

cm,.rgoE ; both In phye,ic(al and In psychob,oEtica l tox'nrs, 

C1onC) . u&i onED 

I have P .tlCm pted to su01m(iri!(i FSomC of the rGabonF why E3 

numher of invoetd .certor,, feel that the E'+roh7 .em of the rolati .on 

hct .ween sreol(intr and healtiE is far from olosed . To the cont.rary, 

thc ovidcnco a[°&vea rr, to pcrin t to a number of studies which ought 

to be done rtightt now . 


SnVIDtari'r :inip the di . f ferOGCeEa nUtonlg investiratoRs 9nd 

c6;Hec:in2lg tr v tween nw own iE,te r 6vretation of the da9 .a and thvt 

of oMr2 I wovld strcas again the fo11ov7inl= hoints : 

l . Labaretory i .rrvestigat£oEis us i ug ci.harett.o smoko as 

a11 i .ndeP(pndeAY4t variahl0 have net heon Rh7e to L/ro-d(ICe 

=nChOC[enie Ca.rCinorOa : ?n ArIl01n7 .6 which or .' 

d£nRrily re4[aoOd wil.h t11iE d£Ferdf§e to a vElriety et 

trrl .tEStits . 'Yhire may be the e;trougest and nrost con•- 

V£ n cinL: fie(fC o f evldenC4l warning iElve(lttgators fPerh 

thC coPclUtifpe that s nIo1V .tl^ CIqU .^,eEi 1 .(Ent; CanC9r . 

l . k11JidPDlio) .oP.i('.a7, Stttfi].JR hffvG Co17CCtr`.d datrf with an 

C)c to cost, to vuch Eh (-!2odi ! :hNt thCi.r xcs;ultN are

• 

• 

too u,nhS&uoue Eor claar-out ! .3n:rrpretat.i.ans . 

'PhL• riNaEt9 of the exiSting Ovidetlce compels rne to t4)0 

major conclursioas . The first ono is that oxistin(r evidenc e 

does not o r trab3.feh any Sirm causa] rolati .onship between smok- 

in g and di.aer.se, The second is that existing evi,dence does 

indicate a numhor of Smport.ant problem areas which should ro- 

ccivo thorough study, 

hIh;L1oGHApnr 

396) 

1 . Achooon, 6 . M„ Jorr.soP, t7 . J . M, Tobacco smbking nnd servrn 

lipids :in ol .d mc:n, y)ri.t Mod J 2 : 1 .102;-1171,1961 ., 

2, P.uerbnch, O„ Gorc, J . H., Norcoann, J, B., Petrick, T, G ., 

Smnlin, H . J ., FScuhs;nru, G, t. ., Kasseuny, A, 1' ., Stout, 

A J' . Cbtuil ;es in the bronctriall epi,thelium in rolatioa to 

crotolrinf; nnd caneer of tlre lun5 . Ntiw F.nR J b4ed 256 : 

07-104, 7 .057 . 

3, Anorbach, O„ Petri .cd;, 'f, 6„ Stout, A . . P ., Statsinger, A . L„ 

Y

• 

• 

• 

C:hanl:ecs in hronchi.ai opithcliwu in rolation to cigxrot.tc 

smokinC and in rcil .ation to lu~th r-encor,. Now ltng J Mod 

265 : 2[i3-.'r267, 1961, . 

19G'l 

6 . Gorkson, Jo, and lilvehack, L, Competing exponential riuk a , 

v:ith partic,ular roi'ereuco to the f.tudp of smoking n .nd l .un.{ ; 

czocer . JoAoS>Ae CrS : 415, SePt,,, 1960, 

. {tlaekburn, 11 ., Rroo-.ek, J ., Taylor, kk .% . h . ( 

7!s 1-11e- .1.1?R, 1960 . 

.n enioke.r& and nonernokcres :onrtaon cireula-y tory tncanm•cmonte i 

.. Circulation 

E . ksronto--Stovr rt, R . Cigarette smoking and iechaoroic: hear t 

di.nuase . ISri.t Mcd J . 1= 37f1 ;aEiG, 1961, 

S . Damon, A . Const9.tution anc4 [mioki .nF . Science 1.94 : 339 .-341., 

19G1 . 

10, Lavis, R . CiCorette smoking mot9vation ntiWy .. Research 

Sc'vi-ceNp London, 19560 

1.1 . Anwber, T' . R .,, h.nnnel, tN . 13 ., Rovot&kie, No, Stokes, J ., 

r(ugan, A ., Gordon, T . Sonso factorn atssociatod with the 

dovelopment of coromrn.ry henrt d-xeaoauo . Six years' foilov-uP osspcr 

.4euoc in the k'raminP-ham ntudy . Amer .Ja Yublic 

lhtalth s!a : 1349-1.s68, 19590 

12„ l+bl1, R . Etiology of lung cancer . Advsncos Cancer Ros W 

1 . - 'u0, 3955 . 

13 . Rc,nenherg, Jo M, Cigarette smoke and the incidenec of 

pnAiua.ry nooplcenas of the 7 .nng in aYhino rni.eeo Science 1 ..6 ; 

;,6a-A, 1Rp,2 . 


a 2ft 1963 

79, PT1cdmHnn, M ., Itoscn[dnrl, P,. R. Association oispecyfAc 

ovcrt Lohnvior p•r,ttorn vrith blood and cardiovescular find . . 

~ ine.s, JkMA 169 : 1286=1286, 1069 . 

15, Gi .J.li.am, A . G .,. Rilruoro, B, K .., and tdoyd, J, P7, Trcnd s 

of rt,ort ul i .t .y attributed to cF'rc5.nomsa of the 1ung . Tho 

dccli.ning rate oP incrcase . Cancor 147 628--G28, 1963 . 

. Gordon, 1„ Crit.tonden, M,., t ;aensze] ., w, Canccr nox•Lality 

.116 

t.rendr- fin the United States, 193U-1955 . Part il : k:nd 

rcrall.s nnd mortali.ty trends in cancer . Nat, Cancer ]nst 

Monogr No, 6 : 131•REi5, 1961 . 

17 . llacnr;zol, {Y„ 6hirnkin, M, lA ., Millor, H . 1>, 7bbc;cco 

. s ;r„okin6; pat.torns in the Un3ted States . Pub Uoalth Monogr 

No . 45 : 7.•-111 ., 18,56 . 

18, With, (1 . P7 . UiYference bCtV.'een snlokerfi and non-smohQYF.., 

AMA Arch lnt Med 101 : 377, 2050 

19 . llolland, J . J, ni.ssertatio innugur . mod, chir, sist,ons 

carcinomar lnhii i,nferrior7s abstluc coctfone persnuatum . 

]n : Wolff, J, lli.e Lohro von der lirobskrrwhhei .t Jena, 

]AII . Co : . A, p . 52-4R, 

AG, ]BOrn, li, Rehavd.oraf aspectc of ciFaretto smokfng, 

~ J, Chr•or~i .c. Dis 16 : 3E3 .95, 1963 . 

7;7 . B n rvoncr„ M„ Keys, A„ Ormn, 1% ., V idanzN, F„ Rrozoh . J, 

. Ci_gnrotte smoking, serwn-cho W sterol, blood-pressuro, nnd 

body fatnces . Ohscrvaa.imic in linland . ].mucot 1 : 

4EY_ ;! ; d , 1 : :5£~ 


• 

• 

ra 29 

]ta64 

22 . Y.ehoo, Ro A ., Parbon L.eckurec, J Roy lost I1abli.c Reelth 24 : 

177, 1061, 

13 . Nont.tinen, A . Cigarette sa oking auid serum lipidu in young 

men . i r i,t. Aiec? J 1 : 1115 - 1)17, 1962 . 

24, Laut.on, Yd ., Phillips, R . Tho relutionshi 

Mec7 b'ci 112 : 3C7-.h0'1., 1956 . 

.ogical .p betvocn excos-sive cillarette smokin0 and psycholtensAon 

. Amer J 

2 :;, hcaichtontrer{•,er, C ., Leucbtenbergor, R ., lkrol.i.n, P, F . 

A corre].ated hie:t.okoUi.cal, cytological, and cytocb,emicul 

eotudy ofl the traehoobronchiai trec &nd lungs of mice 

ox(o sod to eigarette smoke . 1 . Alronchit3.s w ith atypt .- 

cal e p theli.ai changes in mice expoaed to cigarette smoko . 

Canoor 7 .1. : 4 DO-.606, 1058 . 

2(; . Lcl+chtenbcrger, C ., Imtlchtonbcr ger, R ., 2ebram, W„ Shr. .fi'cr, 

P . A correlated hi¢;tologi_cnl , cytologien7 . , a nd cytochnmi .- 

cal. study o :f the troacheobronchial tree enad lungz : of rui .ca 

exposed to cigarette srookeo 1Y . Verying respone :es of 

ana,jos bronchfi to cigarette snmke . Absence of broncho- 

gc:rde o o rci.nonua aftcsr prolonged exposure, and dic,apper:r .- 

ance of bronchial lesions aftor eossation of exposure, 

Cancer 1 .3e lfsi•32, 1960 . 


27 . Lnawld :oubery;er, R ., bouchtenberl;er, C ., Zobrun, A' ., 

Sh[affor, P . PA cor'relatAd hi.stolop,ical, cy0ological and 

cyt .ochowi .eal study of the traeheobronchial tree and lungs 

ef ,rSc:o ezpmeed to ci .garet.te smoke . 11Y . Unaltorecl

• 

• 

• 

ra $) ) f>GE 

iutorvi .ctr inP.e,rraction patterne,, . J Ahnorm Soc Pe.yehol. 56 ; 

3TY•-3H . )flSS . 

3 :: . A?cArthwq C ., rcldron, Po, t>.tckiuson, J . 9'hc pcyc.holoCip 

of smokinG= J P,bnox•rn Soc Psychol 56 : 28l-75, 1cJ5® . 

RG . 61iS .1os, V . C . 7rulEOn, M . k' ., AicCeinn, A9, B„ Nhit .o, P . U ., 

6taro, 1' .. J, Piot L1ood )-iCdde and health of ltaJ.inn men 

4n Ibnt .on . Ann Intm•n Mod 98 : 117G•1900, 1358„ 

37 . Milmore, G . Y ., Conovcr, A . C . Tobacco e.onsunrption fln 

t.he Unitctl St .nCO :r., ) .RfiCr0 fs5`s . Ihal .,li.c Uonlth 6ion g r h'o . 

F6 : 3 .313,, )17bC+ . 

38 . kuaniie, V . Smof,inC;, dr.inMng, and nervouenc+r.c;, l .n.ncot 2 : 

1F,8-8 . 1H59 . 


SF . l/uhlboG'V :, Oe C..nroAnugooo WericinCf va11 Signrott .onYooL" LfJ 

h4uFr.on . :VOOer1 T . Gonoo ::k . E9 : ?.87P,-H, Lp56 . 

40,. Ni.ol ::en, t,,, laenudcanemi, J . Uronehirtl cnrci.nonia - .._ A 

pandomic . 13,- Inci.denc.o and t .obacco conr :nmption in 

var7onc countri.es . Dru,Ssh Mod £:u11 1 : I9h-D, 1055 . 

41 . Pczcock, P . Yt, Ctp,nrolae smoki .nC; by Yeborut.org rundmuls . 

Ss:venth Internnt :F.onal Cnncer Conkrcc':s, Londmn , Jnl .y G-12, 

108 . Ahataacte : of papcrs . p . 153, 

4p . PerrcocS, P . H . Cin s+rertto ennoY.Lu{ ; os:porimonte . ]trit. 8mp 

Cancsr CamgmiSn, Slith Axm Rep, Paro 2, 1957 . P . 303 

d :. . Vr acwoL., P . R . l: :xperi .rnentall cigc retts+ emol :S.ng by dnmes- 

t .ic: So V Cfo . 0.:ri.t J, Cnncer 9 : 461, 1y5P„ 

Ra . riavcn9os,, Antoliu, Yn . ll . Rnd4olokiiat5 Und Fpi .derdol .oF.y,

• 

• 

ra sl 

45 . 

Ru :di .ol.ogy, VoA, 74, No . 6, pp, 873-975, Juno, ) .060, 

(9 d :i tor i. o ). ) 

)nci 

Sanugo r , R„ SY.lvarma n , 8„ Turner , IR, Neoplaraa fol.low- 

in[r thOrn peqtie Ar'radi .ation for honi g n conditions ill 

ch4ldhood . Rad9o) .o(Cy 74 ; 860-804, 1960, 

G6, Snednvisk.y, D, A ., Gi).)i.o-rn, P., G,., Corufiel.d, J, 9'he e :tatis : . . 

t'rca)I ausoci .ati .on bet.ween suroo)einR and careinoma of the lunr, 

J Nst Cancer )nst : 7.9 : 77,37- .5K, 1953 . 

47 . SchonPOlci, J, Spnc4al rePortt to the Selrpeon Gonornl's Ad .. . 

'Vi.FOry l.efutlittee on SnYO3CinQ and RCf.).tH, 

6F. . SrriakSng aud F,oalth, Beport of the Advisory Comdlit:tee to 

ther Snrd;con-Gonerat of the f'uhlic liealth Service . 

49 . Storl9 .ng, "1' .U, FRIL).icP.t7An deefr :) .OnP and their possible 

CfTFOtS ob irlf0l"erlOe9 drawn lrCRll teEttS ef siinnifieMnep -- 

or vi.ce versn . Jourv'ial of Tho Ar„ev£ean Statisti .cal As&oc4e- 

'Lion Vol . SQt 30-3!, Af :rrcal 1859, 

60 . 3teri.inp;, '1'-ll, Spzdetaiology of di .sea.ae aesooi .atect wi.ih 

Iead, 4rchive#: of Suvi-rolvueK'itnl lloalth, Vol . 8 : 

(333-3 .8, Ccb . lt?G5 . 

5) . Btorlin4f, 'f .)i ., Sacnyer, 1 : . L„ r=xad 7>hair, J . J, Radiation 

epidcomi.olof,y, Cnncer 10 ; 489, ) .GF?, 

LR . Stor:).inG, W,U ., T'hei .r, J . J ., and Rustag ;i, J, New develop_ 


roonts in chrontc dSsoano ep£.dem£ol .o£r,y : corapet.ing T9.skp 

ruld e) .igltriiit:y, Arncric:an lndusi.r'i .fil. Hygienc Aseooiation 

Jolrz•ne.), Su : O3 ..679G, Nov .- .Pr.:c ., )J.GR,

• 

• 

0 

53, Socrnnicrring, S„ Th, Do Morbi.e Vacorum Absorbetlti .wu 

C

• 

• 

ty l . 

The ilonoratrle John 0 . Yn a tore 

307 Post Office Annex 

vrovideace, Rhode le.l.nnd 

War Senator : 

AMCiRICAN CANCEVt SOCIETY 

Rhodc Island Aivinion, Inc . 

333 Grotto Avenue 

Provi .dencc, ii .I, 02006 

March 26, 1965 

TRmple 3-69'70 

The Yabli.c 8ducntion ComnAittee of the American 

Cancer Sgeietyr Ehode Island llivi6i.on, Ino, on MP.rch 

15, 1965 enctorsod S1'iNATE IIII .J. 547 which in currently 

troinl; considered by the Senate Commerce Committee, 

Thi.s: bSl.l would regala.te cigarette labol .ing and adver- 

tising . 

i`he overwhelming evidence to support the relation- 

ship botw[:eb cignrett:e suoking and lung cancer gives 

us a i•e€qonsi.bi3ity to support effeot :ive measuree that 

r ii7 lead to a do wnward trendi.n cigarette smoking . 

Therefore vro xrc urgi.ng you to support SE:NA'SE BILL 547 

introduced by Senat.or Maarine Neu.ber6er of Oregon . 

If thiF aep,i.E:Aation ia enact .od into law, I believe 

that cQarette smoking will docreasre and the incidence 

of l.ung cancer r;77.1 rt.leo sho w a downward trend, If' you 


1(066

• 

• 

0 

ty '1, 


hnvo rmy quoeti.ons coneornin(, the position of the Amorican 

Cancor Society, p].ease fool free to contnet me . 

Sincerely, 

s/ John 7vrner, 11, M . D . 

Chairman 

Public Education Committee 

1970

• 

• 

• 

N YB02h (32)A/:1.IF. 

WESTERN UNION 

TXLEGRAM 

1965 MAR 2 0 PM 1.2 53 

A M7.Y021 M'7.22 Mt72 DL PD 22 EXTHA MIAMI FIA 29 NFT 

UON 1t'ARREN C MP:GNUSON , CHAIRMAN COMMI7"1l-.k ON COMMERCE 

US SIF.NF.'I'N WASH00 

I'LEASE DD ALL YOU CAN TO GET PASSAGE OF I :ITHICN THIE NEUHNItGBF[ 

ItILL (,5',5.7) OH MAGNUSON HILL (S,55U) Nk:GAHAING LAUBLLING 

AND AUVL:flTISING OP TOEsACC :O . TIIN FUTURE O7? UNTOLD THOUSANpS 

WIId. I117!E,NO ON THI:S, 'I'HOUSANIIS WHO 1YIId, AIF: OR BR TOTALLY 

I11SA61LFG) PHYSICALLY FItOM TOBACCO USAGE - IF THE PRESENT 

IiATA OF SMOKING CONTINIEES LNTTP:It W1LL FOLLON 

C.HANhF',S F'Y'A'A'C JR MU ASSOCIATE YROFP; :;SOti OF MEDICINE 

UNIVHItSMTY OF MIAF7I SCHOOL OF MEPJICINS CHIEF CREST DISEASE 

SIICI'ION JACKSON MWN.ORIAL 11OSPITAL , CHAIEtMAN , NLONIpA 

COMMI'["IEE; ON SMOICING AND HIIAi.'PN MIAM H'LA, 

NFD030 (39)AAIIii 

1565 MAIt 10 PM 12 55 

A M2Y0'l.3 M7.Z'h MC22 11 Pll 22 EXTRA MIAMI k'IO 29 NFT . 

]10N GkIO A SMATHERS 

US S'FNATIC WASNOC 

PLEASE UO ALL YOU CAN 1,10 Gb:f PASSAGE OF EITHIffi TN6 NBUHEHGEEE 

I11LL (S .G67) ON MAGN'USON BILL (5,55G) REGAHDINO LABEILLING 


1977

i TY 2 

0 

AND ATNK}t'fTSIND OF AYIAACICO . 'L'H3Y FU'fURI: OF UN9'OLA THOUSIIN ➢S 

IPILL DLiPRNll ON T13IS , TUOUSANbS WHO NTLL UTN OR HE T(0'ALLY 

ItISl:JtldtY! Y'UYSTCALLY ~'Y,Oht 4'013AQC'0 USAGE - TI' THE YkTiS&NT 

ItA9ri; OF EibIONIN(i COPvgTNUEtS T,ti'f'L'Iilt WILL FOLLOW 

CHALLR5 P'A'ATJ+ JR MU ABADCIA'!9f YROY'HBSOR OF E".6iUJCTNJi 

UNIVT,1tSXTY OF }1TA1,11C SCUDDY. OF MIiDICINI: C ➢{IEF CHEST UISEASE 

SFIC9'TON 3AC:I(SON 6UiMORJAP, IiOSY%'CAL~ CJiAIiiMACo, FIAItIDA 

CCh;t,7IY'T.'P4; ON f M067NG AND Iff;AJH'N MIA51I I'LA , 


I'3%2

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S'fATY,MENi` f1k' SIGM17UND L . V41GENS, N .D . 

Ni:Ali'1' !ii"lÀCH$ ANU C7GAIt7iTTS SMOKING 

At the outset 1 should like to make i .t clear that I 

will roee9ve no remuneration for this otatonvont, that. I 

have no connect :ion w3.th any tobaeco c:ornpar,y and that I 

have never emukod coigarottee, if FI have any perr,onal 

feclSnge about tobacco coar.pani .ec, 9.t Is one of annoyance . 

1 do rwt care for their televieion cornrcaorci .n.ls . 

bty rear ;ons for mat;f .ng this statf:wcnn t are twofold . 

I beliove that the ovidonco l .inkin6f hoart attacks with 

ciCarettce tmuokinr Is far from eoncl.usri .ve and that such 

a rclati .ont ;hi.p r>hould not be presented to the ltubl .ic ac 

an e ;:tablished faot . Secondly, I believe there Is a 

growing trndency to accept without question medioa l judg- 

rnant.e if t.hey are actvanced by por :one : of omi .nenco, i .f they 

aro publiehed in leadin g medical. ,journal s and if they 

aro sttpported by a number of invest.i€„ators . This ought 

not to be E;o, A71C valAtiS.ty of a Medi.Cal conCluGiAn should 

Uo judged entirely on the noundnees s of the evidencc devo ., 

loped to cup poxt it . P do not believe that the evidence 

tbat has: beon prenwrted to as,socia .te heart attacks with 

ci(;arret.te tnnoki .e g Is incti.sputablo . 

a'bi s evirlenoe is based alrnot,t entirely on the fact 

that n high pe rcentage of raen who arc treate.d for heart 


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r ;ttachs rre+ heavy cigauette srr,okers . This hrat been found 

) ;. Aa nPmbcr of i.n4ependent i.nve5lti[(a.tion9 nl .L of whiCh 

ur nd essentinlAy the samle mothod of ctudy . It may woll 

bc true that . reo n whor o caroore: Snvol .vo more than an 

nvnrajro dc :6rec: of ra€qious'rbi7lity ond who nre s :ub,ject to 

tennSOnr .:, nnxieties aud worrics develop syliipto®s of heart 

ntt aChIS n1K1 S .rtdulho iri }denvy cAC{arette Fil'6oN:inG more often 

thnli the c,vcra go Porr :on . 9`his does not prove that cigar- 

otto Faro3cinG cnurror< hc.nrt r.t4:rtckr: . They rnay both be the 

resu :.t oi' the snrme so t of cond9tions . !a : aa+n grow older 

t.heir h..ir tulrns € ;ray rued thei.r arteries hnr.den . ThiF : 

doen no't prove that gray hair oaucoe hardening of arteries 

or vicci ve .rsa . 

'i'ho truth of the matter is that these studies examine 

only a ]iroStod seGment of the lta•ge number of people who 

have rerl7 heart nttac . .ks aometimo during their lives and 

nccswr.c that th,.t, celect e.l;t;7aent is ful.l .y rre}:resontative 

oi' tho ent.ir'e g.roup . A 6rrorat mnny persoins have real hottrt 

nttrtelCL nnd never F.eek ntedi.cnJl help . When a mnn hns a 

(5enl12ne itE:urt &ttac7S a}' .:ortion of hiE heart muF.el .e Is 

de/?r$ .t'ed ofnollrishment nn(j degenerates . In faet it 

bccomer d nad ti-sr:uo . Yf he survivee, ns he very often 

@eon, the deatd muscle S . 6 replaced by soar tissuc very 

aUtailnr to thet wAi.ch C,rown 7,nto any healin g wound . 

W oss' d.csth ooours on t.he nr+me day as the f3 .rst attack, 


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a patholo€:ist who oxami.nos such heat•to can easily identify 

the dnraa€;cct area, which is culled an infarct . At least 

one -half of the i.nfa.rcte: thr.t patholoCtatF: find at 

antop s ie& are onos who5e prCF:ence was £tOt fiuspCcted during 

]ifo . Thi.n is a widely rcco€'niv,ed fact although there may 

bu somc d'zfference of opi .ni.on as to how frequent)y it 

occurs . 

In adGition, p3oplo can have typl.ca] eymptoms of a 

hcart attack without any real in jury to heart museie . 

SYi.th iuerehci .ng d9a.gnos:ti.c .skill it has become possiblo 

for the heart specialist, to di.ot4nRVi ch between genuine 

and fn]ec heart at.t:acks: i .n most i.nstanccs . Sometimes, 

howovor, the hcart at nut.opsy fa9 . :ls to show evidence of 

a hen v t at.t.nclc even though cl .i .ni.cal tcsi :s during life 

indi.cated tdrxt euch in ;lury was present . From my own 

arperaonco I ectinrate thn.t some IJi porccnt of cases 

di.agnoned £es havi .ng renl3 heart at.tncks durin6 life are 

not confirmed by post--mortem osami .nation . It is thus 

npparent, tha t tho c.ii .ni .col studies which show a relaticm- 

ship between cigarette ranoking and hca.rt attacks arc based 

on an inco mq>lete, highly solective and not enti .rely 

acCUTate EnmplO . 

In order to coxifirui their results it is necessary to 

prove that evidenco of heart attack£a is found morc comnionly 

at autops y Sn heavy ci .€;arette smo@:eu& than in non -smokers . 


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Yo my ksowlo6tyre there is no report that wnlces thas claim . 

In my study based on findinCs in 989 autopuies in men 

performad at the New York Votcrans Adminisi :rati .on Itospi- 

tal3 and reported in Bcfence (Vol, 1 .35, pp, 975-97'), 1962) 

no si6nificantt rcl.ati .oushi .p between ciE,arot :te smoking and 

dnmvge of the heart could be demonstrnted . Admittedly 

thAs study is olEto based on a hi .((hly aoleetod group of 

hospitalfned veterana and t :he sample in not larGe compared 

to E;omo of the otatietfoni e.tudi.es lraned on persons 

under medical ob:IUrt•tttion but a11l ki.ndE/ ef heart infaretF 

aro dncluded, the eilent ones as woll arrc t.he symptom .• 

pr.oduci.ng onos, Purf.hc:zro'ore, the 8puriAUEs ones are 

exc:luded . It i.s obvious that further studi .es of this 

naturo on autopey findiuE ;s i.s nocenaary . 

Clinicians baae their clain',s on only c fraction of 

the toal number of heart. attacks . It may be that this 

fractior, is reprosentati .vo of al l hoar t at.tacke . My 

findinlCs would lndlcs.te that It i.C not . You can not alwayF 

ee t iveate the Wa and ehape of.' an iceberg from tho portion 

that protrudes above the water l .ovel . 


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AfrV1iRT1SiNG FA7DENA1'I:ON Ok A61BR1CA 

655 FVrdison Avenue, Now Vork 

Y7ae:hington 13ereFm : 1725 K 8trcot, N .W . 

'!'ho tIC=norabl.e 19arren 6lnpnuson, Cha.irmnn 1Narch 12, 1965 

Ecma.te Commerce Committee 

Senate Ilf f iee lln f id i hQ 

N'ae:biugton, tD . C . 

Doar Mr . Chafru:an : 

In antici.pation of the henrings beginning Afarch 22 by 

your Cosmri.ttee on bilas : rclnti.ng to exf,nret:tes and smoking 

productn and contaAni.ng rostriotions nlld requirements re - 

in.ting to the packaging nnd advertislnf, of such products, 

the Advertising Yoderation of Amnricn, on behalf of its 

memberstdp, wishes to renffirlu the staud It took when this 

.1ogSsleti .on wa n f'i.rst introduced In 1964 and to again to go 

on r ocord as beiin g oppoaod to certain provisi.ons oi' the pro- 

posod logisluLìon . 

The Advc r i:ini.ng BederntAon of Anxmfon is thc oldosti ;nd 

lnrg o st e,dver•t5sing orgnnir.at:i.on in tho worid . It is the 

only horie.ontal ussoc9 .at.ion in the advertising field and 

reprus.cnts every facetnnd ctratum of the advert.isi .ng ; bus-i 

.nosrs . Al'A hae tr.cuty-fivo other irahc r ta.r.t advertising 

nse:ocintions auG related organizntions directly affiliated 

vith it and reprosontcd on its Board of biroctors . Our 

Koderati .on a :lao pon'sornserN a very tun iquc and effective publi.c 


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opint-on Sorso •at tbe gzz,gr„ raot> ; lovel in i .ts 7NQ v.9£i.i.iated 

advortis :iaig cY.ubc tb y on€Cbout tbo country with a tota l mmob :a^•= 

: : :hi .p o f nforo thfln 25,000 

bin¢;e Siz: Soum3in(; an 1905, the AVfi Isar, becn dodi.aa.tc=d 

to art

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7 . Vio arc. compJatcly in rtcc :ord wit.h tho though4t that 

t,he pubY .d.c hnrs uvery ri@:Lt to be ini'o rhod, t.h9'oug;h tt proh'r aei 

oi pilhl,iA An£orbYati .olln i4n d eCitleN$ i on, co1lCEirnfltl(; produ(:tS 

thono cxoes :c=ivz une mery i .nvol .ve eoriouc hessl.th irRZardn„ D.n 

the aRrc of ciNtes

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the forc:e of ) .acv , r.uQ 2nvolci.ng the pc+nQ'4t.iec . 

! . We bolLovc t:ha.t our econior.i.c•c ryt;tcnn can opcr2te 

Alt4cc5n9Sd17 .y ofi).y Sf t0o regard (,OVCrn1!,e11t YO[nI1B .tfionE Bk 

a 7as ;t >_•aE;or4: vlhen nY.i othcnr mon.nrs hnve bean given a feAr 

tx'&al anr,3 fai .le6 . 

. . tk:e8uvo of the Svalsort:an•t ecwn,omEc, inq+licn .ti .one 

invoivod, too, vr : do not Lwl.ieve this erztremeYy con9:roversinR 

unf, Nr•cus,Gont=*roQ,tirrg :6og1sl .atzori s:hou'id br, rt!nhod through 

tco r•n&ntmont i.ocau :;e of Po3 .flt.i .cral mac!rocli.oncy or fln ancxor 

to k UlXaNr§ (.tatCit&•ntH, fRatl Ca!Hjra$tUlff [7eE19.gnflft tO eatl6b 

105'Ffs hyt%tQr4 .a or otheP n(YIJG :a7,F to public OG!Ot9.01ffi1.3.6rit On 

the lanr-L of 14.es r,ropononte regarcilc*ce : of hotr r'Anooro they 

taxy ht: in tho .x• te)ke.fr . . :'aW N:atOrlttl5 SUn(1 the pta.nUfacttRre of th09e pLÒduc :tfc, 

a.nd vlonl.d have e:ezi.ouE conwoe;uonoen for thc~ econoa!i .e well~ 

]£kQ 

i:airrg oir otu^ n ;'r.i.on'0 r,N,xrSCUlturra axld niv.nafa.cturAul„ iuterest :e . 

Grl a7se2dy di .t:turbing uncmYloyraont probSenl 9n our country 

c:ou7.d raoCdt c:or4.ai-ni.y ba3 Snt,crntd4.find and tvcnrt3oned if the 

toh.-.oco iuch!tatry was• toprylod from fte Noyi .tiwt an ono of 

the inx°e;cet cmip3oyors An the nat.ion and one : of the mos:t 

S.nq;ort.ant contn•AhutosF: to ot!r natSon'sc thrivSng eoonovy . 


d, 'Lire cipi .rc*t .t•c, colr,Ntua£ers have recontly adoptod a . 

:n•rna

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volunt ary ndvcu•t :i .eznf; code for the industry upon which the 

i.nk 3s he?:rdly dry . AS.rvady, holvevor, thiu code has made 

itf,r,).f tcit and has clxGhkod the rnothod of aFrpea.l and tone 

of CiQlHretto kdvertiF^, :IA(I, Climinat .llt(,° to a considerable 

eat.cnrt v:hat p*ropone n t:u of the pr•o posed 7.eCiGlatf.on most 

strcnuou€;ly ohiec2ed to - - nennely, tneesed.as aimed at our 

youth A 4 .ch might inctuce, them to b e t;f.n stnoking . . It 1G 

ecPta9n that Pr~, thi n vo).rnntary oodo i .5 put Anto greater 

uce tvnd given uw re tide to worh, thexo will be other 1m•- 

por t.ant hc:ne£+.t.a .. 

7 . Y7o he).flove that 1::o tnahe advcrtisinE : the "whS.ppi .ng 

hoy" in thfs controv< :rrey over the harmful effects of smokin g 

cij{Ilr."ettefi in nn effort to cure the x@S111t and not the cauEe . 

11,, afte .r lonE: Ftnd er;ceflrl study and seseaxc :h, the etnoking 

of ci,@.arettos is dofinf.toAy and irrefut.alriy determined to 

be an ar4tyorooly danrerous hoaN .th hhzetrd nnd drestflc action 

9 .e: deemcd tiw on]y solution, then the p .rohibi.tion of the 

mknufacanro of oif,arotteu; x+hould ho considoro@ as the Xogica)l 

nolutiAn to the prob7em . 1£, howCvex•, the right to menu- 

fticturc thoro con2inuoci to be en ;loyed, theet most certainly 

the right to a6.vortia:e cl .laarotaoa dn tr,uc, eornpet9.tivo fnshion 

vme.t t,1e.o be enyoyed without unfo.t.r or disariminetory 

r cstr+ctf.ons axr ref;uletionG . 

Tn r.:mmaary of our pos :i.tSOn, it in our ntrong recomr end- 

rtti.on n ithtaU tdro com;o i itoo : 


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F . StrAko from t.hose hills ne dangerouE:, disorimintt- 

tary nnd prf,cePiont .. ::otti .ng: aeny imovi s ion reduit•A n (; tho 

auivortiF,cr to carry in cach aclvortieecu•nt th e warning that 

"hsbltua.t cii;a vc'tte asc,tcin(c is i .n;uriour to hcep .th", or 

s:nc+h othc r intormktAorv n

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Al.9P;R .7ClAN AE .SOC'Y.ATION OW SCRO61 .. AUN7N1S2'gA'!'OBS 

3101 l6th Sta•cet:, N .W ., V/arzhi.ngton, Cr . C . 

B9arch ;, 1901, 

'1$6 NonGN£Lle W5.8'Ten (i, Idlfn g nUEtoli. 

'CNe Unl .tr,d Stnt :es Senate 

S7ara6Angton 25, D . C . 

U"salP S(inator Yd@(;nRGOn ; 

'd$p AN(+£ie .nU kEi9pC .'lfl'Cflon o f SVhoo1 kd miU}.69q'A.toY6, L6W 

1n lt& A(/(Ith ypf:(e o$' FNPViCCti, i.k a pYi\pktN, pTo feLWiAll£ l 

£csoc:i .rlt.i .on o f cahooF . udnsinistratore, w9 .th b monborchip oS 

1L,OOD . Mo have boon ::nfortnod that 9.n the near future yoh 

vd :Ctl ho cottdracti,ug op;n heari.naR on S . 669 and S . 547, 

concexvu,d c;lth the 301,0109g and/or advorti.ci,nN of cigaretter; . 

The krnerracan Aasoci.ktion of School Aelmieli[rtratorc+ 16 

vitally c:oncernnd with 9 :ho roAationehip Uotisoon arnoki.ng 

and h4fl)th, and i.t liYiN thi6 COLCOrn thOLt phòlnpteG our 

AlaooAat.i.on to hcmcnue n consti.tuent ruomhor of the N£tiona7 

Yutorrtttaanoy CounoAA. orn Stwoking anli }toelt.h . 

WLUt; tho Strr:oon Ci:nnoraa.'e Iteportt mxfo raleased, we, 

pnrhapu n2ong Wh uril7Aoas of others, hocr2nte v1ta11y con- 

cerned on rohdi.n ;; eaitch ratntowentn as : 

1 . "Oigzir•ettr, r :crok5ng Ar £eos+oc,9.atod with a 70 

px :vcont amoraew o 4n the . . . death Wot+ of tnaloe . . . 

2 . "C4g£rotte f:raokahg ih+ cauca,R7.p s•elnted to 

.LnnE: C£bCOP in 


L1GlG . . , ° 

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n, "Cigeevotto smoking is tho mnst iv}portant of 

th , cnac: cs of chron9.c bronchi .tir, in the United states, 

and Ancrcaroe, the r isk of dying firom ohronic bronchi9:As 

and em7ihysoma. ." 


d . "Et is crdtahllshod that malo cigarette smoke,rs 

htavo a hi.Ch Genth ra.to from coro»avy hoart dieoaso ; 

hS.Ghor 4hnn that 0 .1' non-smoki.ng ioalen ." 

i4o carneetly hopz •r.nd rospoctfula.y roquost that the : 

Congroee3 give opocial at4.ontion to tho 1»rohhlem of amaLîng 

an a hexlth h.nm-6, wid that it do all Within its poWCr to 

prooludo snmk.S.ng tsy chilcbrmn . We hc]ar,vo that e.peciffo nnd 

htandRtory WBA'ning r1~La(.:a(,os (+n all cignrottO packages and 

ativorti.~4ng vould ha n Ci.ant step 9.n thio diroction . 

Sincerely yourc, 

/r:/ ['orrost B . Conaor 

)te.®out ivo Fecxetnuy 

]AKd

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AM1sRTCAN CANCER SOCTk:T1 

1).ai .noiF: DiviFion, .inc .. 

3i S . Wnba.:h Avenue, Chicago, Illinois 

The llonorablP warron f : . Ddagnuson 

(.`haiPlBan, (7oPIDittce on (:eMlOerce 

United States Senet.e 

Washington 25, D. C . 

Uoar Seuator f]a6"nue :on : 

D9hrch 24, 1965 

Nonrly two qenrc: aC9o the ]:111nois Divisi.on of the 

Americen Cancer Society i.nitiated efforts to obtain warnf .ng 

)abo7.c: on ci. p arette pacha .ge, in the State of lllinois . Vle 

havo sue :pondod our action ih this rugard ponding the outcome 

of offorts to ohtain such l .a.boLing on nia nrtional level and 

]9S5 

hav® expreqwod our suppoxt of the ponition taken by the Federa7 . 

'trade Commicci-on An this regierd . 

Accordingly, in the reatter of vari .oue bills now before 

the Fennte in roL;a*'d to cigax•etto labo7 .i.ng, the Illinois 

Div£e=iwi of the Amerfcau Canoor Society wirrhe[ ; to exproSs 

its support for the Sieuborgor Bill (Fi . Sd9) because it would 

c;treargthen the posi .tion of the 1'edora] . Trade Conunission and 

sot, out now nuthori,ty for federal regu7 .ati .on of cigarett .e 

adverti .ring . 

We boll.ove the adoption of this mnarrure wil.l help to 

rr,duae the sterndA9.W nvounti.ng number of prernsturo deathes cnu&od 


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by cigaa•ette emoldug, a hr.b9.t which poroa; the greatest 

publ .ic hoalth, m:ontce of our t3ertcs . 


S1.neerei,v, 

Aog;er A . 3Carvoy, M .D . 

X>rce• Adant .

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AIA(4t¢1CAYV CO1.LpOS NEAIlCN APS(M:IA4'ION 

Nono:eablo Warren 0 . Ma{r,nuson 

Chairman, Corvmittee on Commerco 

United Stater. &enate 

IYaphi.nY,t.on, b . C, 2051 .1 ; 

hiy Aear Sir : 

March 5, 10g5 

Uecauso of my bohoorn for tho health of four million 

e.ollege studcnts, I ask you to snpportt thc Nouberger. (5 .567) 

fietllin(r with cigarette advortieing and ].abeling . In my 

opinion, cigarette fanoki .ng ix one of the chief health 

problemu facinf: collegc r•tudents today because 1.t wi7l1 

interfcre with the uti .li.zation of col.lcgo education by 

i,ncrensing respiratory ills, such as bronchitis, emphysema, 

a.nd by producing early dcathe from lung cancer . If we as 

a nati.onn arc concerned about hi .gher education, we should also 

be ooncerned about hoal .t.h matteren which limit the utilization 

of such an education . 

8ucaur.o of our concerns, the Amcri .can College Nealth 

lwsor.i.ation, on April 28, 1961, adopted the following reso- 

7vtions : 

NHI{NBAB, n. preponderance of scientific evidence (with 

c:cant counter evidence) indicates an ar;sooiati.on relationc,hip 

and suggest.s a causal relationship between cigarotto smoking 

and ewmo diseases, nnd 


1967

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WllERAAS, the cigxret.to smoking habit often is acquired 

now by young peoplc : ei.tlxer not long boforo they commence 

col.lege, or v:hile they are a.ttending college, and 

{'lltPtlttiAS, collego s c.nd universities aro i.n a particularly 

advnutngoouss position to undertake an effective educationa l 

effort to stop a nd to provent Cigarotto smoking by collego 

e.tudents:, 

THh'R&N'OFE, BE IT k19SO7 .VN','ll, that tho fanerican Colloge 

tlealt.h Assoei .ation, roeogni.eing tho above mentioned relai .ion-• 

shf .p. betwoon cigaret4:o smoking and some diseases, urges i .ts 

cnti .rc mmabarship - - both i.nstituti.onnl and individual -• - to 

nttempt, in whatever wayc+ considered most suitable, to dis•, 

courage cigarette smoking by college students and future 

aimnni . 

The eorwerns felt by our organiu.ati.on i.n 1962 have 

been we1.1 conf'irme:d by the Surgeon Gonoral's report and other 

roports since that time . 

k1 though the tragic morbidity and mo rtality occurs later 

i.n 1340, c:oll.ege r,tudcnt.s who smoke report a significantly 

1 g&Ei 

€;retrta:r nnmber of physical complaints t.han non-SmokerS . This, 

of course, intorfcres with their woll-boing while in colloge . 

Studontc: arC iucl9.rmd to feel that: l.awmakers who are 

sesponsihle for such regulation by failing to approve this 

a.ct li .torally give tac:it approval to ci.garotto smoking . 

'iherofoyo, the studentr-s feel.rnore eomfort .nblo about smoking 


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cigarettes . 9he lavnnakors should indicate that they are 

concorned about this problern, that they ronl .i.zo it ie a 

GOrioU6 hapnrd, and give proof of their concern by taking 

appropriuto action . 


Respectfully enbml .tted, 

/cl/ l.oona Fi . Yea"r, M . D, 

]rroe,idont . 

7969

AP6f3?:ICAN DENTAI ASS0CIA27.ON 

IVashi.u(,t.on O:£ficc 

$ui.to 1200, 1750 peunGylvania A .vonuo, V . W ~ 

The Nonore.bAC VYat:'r.'en G . Muhvurson 

Chairnan, Sonato Conmrorco Cormnfttco 

Son:at:c= OffAc:e l;ui.3.ding 

4dashir,gton ::F, D.C . 

llen v Senator t.tagn118o 11 7 

Uaroh 31, 198 5 

I am wrAtinC you on hohalf of thi American TAVntu.l 

Anfioz:i.ati.on concerning S. 559 and S. 547, bi.lls rclat.ing 

to the labe3.in(c and c.dvertiei.ng of ci.garotter : , 

'Pho Amcn acan 1lentsr7. Aosoci.atfon Is rnost. oyrapathstle 

to the purposos consraon to both hA7.le:, bel8evem these pur - 

proses to be prope» and dceirablc, and u :e(;oc the Senate 

Cmnncroo Co ; mittce to take favoreblo actAon consonant with 

tI1C111 . 

h cm1.iG'rci of the dontftl profensdon have been doeply 

e:oncorvmd its mo.no tiam about the heaa.th hnc,erdu oie :mol:fng . 

24iPC, concern has becn ertrengthonec] and deopened during our 

activitiee to a ioendln(; mewbor of the Nntional I:nteragoncy 

Counci.l on 5Yno1:91tp, and fYctn3.th 


At its 105th mwu r.7 ec:€aion, hold November 9- 12, 1964 

in San hranoi.coo, the, Apu r Scmn Aonta.l Ar+n ocfat.i.on'c hour:o of 

1K,le€;ate.r. ptarse:ed the follonin(C rev;o3utfon : 

3990

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°ROS;ol.vod, that 4 :he nembers of the Amorican Ibnta7 

As;+oc2atiooi b ;: oa7.7csd upon und encourhE;ad to tuidertnko 

an culucatiatnl efi'ox•t to i.nf'orm thoir pni:i.ents of thc 

iu :n .7.th havaards of the nso of CobftCbo aand, ee,pecf .a).1y 

wit.h young proE.lc, to warn sgeS .nnt ncx;u3.r9ng the habi.t 

of cigpro'ii:o suwlefnR: .n 

a'hc kind of ri'edere.l activities tBn t ciould be aarthorized 

by 6 . :i ;,h and S . 5.( V9on7d hC*o o3mNtoriRl i:eEistAlWe to 

tho dontxl profc.eion in thc oduontionhll off'ort 8t is 

undortnkzng to a,.Aort puticnts of the holsYth Ihazax•ds of smelcd 

inC and vre sur,port thciv cnanctment . 

Tho Ao B ocint9 .on vrouP.P, approciEatc hatvi .ng this letter 

an odo n pa v t of the record oY tlm Senhto Cck Amezwo Comsiittoe 

heari.r, on S, u&9 •r,nd S . M7 . 


Sincorely yourc, 

/[;/ Iioarnx•d J . Ffis,dhnmor, DOS 

Ho®ber, CcruncJ .l on Logislntion 

l~hl

• 

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• 

bi l 

N.tIskYCAN X)a1PSPAl7ER P1Ig) :,1S1/BR,S ASfiOClAT10N 

Nonorab7c t'darreap 0 . tfat;;nuson 

750 Third Avcnue 

Now York, New York 

ChaArraan, Soncto Connnorcc, Committee 

Psnate Or:Pice 15ui1ding 

IYaehAnt;ton, D . C . 

Doar Pnr . Chairro:nr ; 

lSerch 17, 19C5 

1'h e Amuri .can Nowspag e r publi .shors Anrociation subm .its 

f.ts vicrrrn in this letter for tho ror,o:rd of leoari.nrs: to be 

hold by your committee boainu9.ng March 22 on two biil.s, onn 

of tvhich, E317. S, 547 by Senator Neuborgou (Oro .), would 

i.mposc spccfa l restri.c:tions on tho advertini.nt; of ci.[;ecrotte :, . 

Th e ANPA isn a trade ac s ociati.on of daily nctrsPapors 

©it:h more than 900 mombarr havi nN moro than 90 percent of 

tote) U .S, daily ncwr,paper e9 .rcuiation . 

)992 

!D'xil. S, hx7 would authoriac tho Federal T.•ado Comnaisnion 

to c?i.rt:ct thet 01) . c9{ ;rtx•ctbc advertirin„ -i .uelude a statemont 

to the effect t:hnt snoki.ng ir, in$urtious to lheaith . It would 

afloo nuthorAee the FTC to "Provide for the elimination of 

aill advcrtis5 .iqg mat:ter vihich tends to make cigarette anooking 

attractive to chiidren," 

Ni,snt anc7 foremost, thic: Asswciation wishes to ompLasiro 

that it taNO n no positiou acn to thn merfts or ctomerits of 


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bl 2 

1993 

ciliarettc amokin€; . Tho Acesoc:iation recognizes and appreciates 

tho legititnate interee:t of the 1'odera l roven•nment in matters 

which ma,y be found to affoct tho henlth of citisons . 

Yf cignrctto smoLing is found to Ua a nati .onal health 

hazard, we thi .nk thntt thc problem should bo attaeked diroct7 .y . 

P7e rmte that your Coumtf .tteo will alno considor Bill 

S . 559, introduced by you, calling for the i.nclusion of 

warnf,nt; e.taten:etnt,s in cigarette labelint ; . I'he latter bill 

docrs not rair.c the sorzous conntitutional and public policy 

QUGGtiCnlE: that are rait :ocl by propc.sed reE:tPietions on ei[;ar- 

ett.e adve :rtf .r,3.ng . 

It ?& difficult to follow the logi c ox the precise 

roanon& for the proposed advertising roe.ttdetions . Tho 

Governlilcrht would be plaeedin a etrenge position . It 5nb- 

sidi7er. t.he farnwrs who grou tobacco, t .hen it taxos not 

on].y the Groroore but al .ro the tobacco mn .nufac,turers, whole-se 

:7.orr and rotailern, then imposes additional taxes on the 

swolsern t.homrolvea. 'lb f'ollcrvr that with a Governmont ro- 

qu.ireutcnnt thut every advertfnoment r,te.te affirmatively that 

smoki .ng iE; inyuricns to hoaP.th puts the Governm©nt in the 

untoaablo positt.on of sinmltaneouetly subsidixing and taxing 

an itom which the Govermnont says wf.l] dosicroy its citizens' 

heaY,ih . 

When the Y1 .S . Sur6oon Genoral early in 1064 issued his 

roport on snmlc9 .nC and health, newspaporu and other media gave 


• 

• 

• 

b3 's 

that report the West possi .blo disee m inn .ti.on, No claim 

can be niado that there hae: boon an inforrW on failure, The 

general eonelueions of the burgeon Gancral'r report were . 

wide:).y dx.f:sominated to the public by nomspr,pors and other 

mcdin . 

Sincc then a nationa3l cft;arotto ncivertising code 

eponE:orod by thee nation's ma,jor c :iry,arettc: manufact.urers 

haa boon adopted . 9.`ho codo provides that adverticing may 

not be usod in any media, i.ncluding nowsha.pers, unless it 

hao: been subruittcrci to the adufinietratcm a .nd determined by 

him to be in c :o:upliaraoo with the c:ode . The code also barA 

the use of to :,timouials ox• ondorsemente: from athletes or 

cclcbri.tAer., 4.f such u=.e vould havo a spor,ial appear to 

young people, and catogoricel .7.y prohibf .ts a :ll advortising 

dorignod to appcar to pereone under 21 . 

This Acsocia.tion bci .ieves that the code is praiseworthy 

in that it providos seif-policing by an i.mportant tax-paying 

€:e unaent oa: American inductry . The code should be givon an 

opportunity to prove its vrorth . 

Now an to the o,ueastions of Constitutional law, 

Yt .ts a ftmdamcntall bclief of our Association that it 

]nf;d 

should be logai to advertise S :ruthfully any product or sorvi .co 

it is l.cg;a7, to seAl, No instrnmonta .lity of government should 

adcpt any law ow ru1.e to prohibit or c:urtail dissomination 

of i.nfo•rrnatien through truthful advertiei .ng . 


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Cigarettes are logitimhto articles of commerce . The 

tobacco i.ndnsary is an important segment of our economy . We 

respectful.ly submit that fundamental auestions of consti .•• 

tational law es me1 .Y1 as of public policy are raised when 

Covornment ecehs to rc :ru9.nte the right to publish truthful 

advertising concerninA legitimate articles of commerce . 

1995 

We be].ievo eaoh publi .shor has not only the right but the duty 

to determine individua7.ly the content of his newspaper . 

This appl .ies es much to the advertising content as to the 

news cont.ont . 

Tho ANC~A tukes r,o posi .tion on 1:i .11 S,. 569 introduoed 

by you rcY.atfng to iab .,li.ug reQuiromentc : . But we do believe 

thnt restrieti.enC on adverrti.sing such IIFe nre proposed in 

1}Y17. S . £iA7 invndo areas of individual choice of expression 

which are protocted unctov the Constitut ;i.on . That Bill offers 

a dan geroues precedent . 

We csre living i.n n conlplex society arrA all of us are 

subject to many risl ::s evory day . 

poople di.e in automobi .lo accidontei . Should the auto 

muker s be required to Sne,ert warnings in their s.dvortisements? 

.Airplrules crar.h . Should we force the airlines to 

include wnrning statennnte in their ads to that effect? 

lt is snS.d to be he rmful to eat too much rich food . 

Should wo require food producerc and scl .le ru to mention this 

Ract in thoir ndvertisements? 


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II any doctors F:ay that it is hazardous to Kome adultH to 

dz'ilik milk or to ent eggs . peri.le ere ase.ociat.ed with liquor 

and beor, electric light sockots, gasoi.ino, engaging in ath- 

letic activitioai, using products in aerosol containers, 

]D96 

Al.l t.hose nay be daxigaroux, y'ei : it can hardly be reryuircd 

that advertisemontc for those products mui ;t contain warning 

Htatement s . 

11 t.hc advori:ising l.et;is:latS.on now proponed should he 

enaeted, the procedent wouAdbe established that could lead 

to totelitarian restrfcti .ons on the right of businessmen to 

advertise their Inòducte : and the right of nowepapers and 

other uwedia to dooide independently their policies as to the 

content of advortir,emeti'ts which they will accept for publ .icati.on, 

plense l.et ue omphaf;iw.o the obvious, Our Association 

does not condone mir:) .oadi.ng or untruthful advertising . The 

memUers of our Rss:ooiation have a long and pnaiseworth record 

of rejecting ndvortisemonte which are not truthful and re- 

sponea.bl.e or which miea•eprcisent the product advertised . Many 

publi .ehere: profc r not to advertise partioulfx products . But 

wo cannot ap, .ree that Congress or any govozauuental agency should 

dotermine the ccmtents of advertisoments of legitimate artic :les 

of commcrce . 

If there ia any fUrthez• information tlzit : Association 

can supply, ploaee let uh k.noe/ . 

k'S.tU high esteem . 


0 

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Siuoorely yoars, 

/e,/ b9 . B', Arumist ead, III 

11 . 

1087 

Y!, Ar inistoad, III, Chairwlaa 

Foderal Laws Committee

e x x»s!e 

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, 

oigue~ t:+tCa reei.Ral).v, 

cJ kwr.y .Y, .5'nadcra.3 . 

8/ k!o€F`q ~f . Scfl,dclY, ArocACIBUS: 


AlAbiC$.OBY , :io,31GOY. YGi'A Eh ASf:4c9,£dS.U11

0 

• 

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a•7 2000 

A.1'iGFr?Sl'%SING .. . ., Afi AN'1'Y-.R3+3NbktdY,kfn3 .actf,an 

c:hS

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• 

cr aooa 

?S;G oi 4 . .N .A, m oiaborF : i.nveat over $1,000,000 in advortfsi .ng 

annSSS7 .Ay, Wost 100 member oomy.anfoc : kpmnd lesa than 

$F00,000 each year . 

G. .N .A . mu,eibe:rs u[,a ovory adveWni .nti medfum in t.he9r 

advc :r25t:+fn£; proF.ruNs . a'hoy repxor>entt the bulk of the 

nataonul nuppo ;rt for t.olevAsion as 87 of the 100 lead4ng 

usera of the,C modfurs carer A .N .A . mr3enbore . Nowever, tho 

mctw;rt :is:i,n€t f .nvc:eainee.t :[: of

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e3 iUOe! 

A .)7 .4, nnbwS .trs th9 .e r.tateines,t fn the cauar> of two 

f'uhdeaP.c:nte) princ;5plec Wcb ar© ir,l}?ortnht to the public 

a9 a lVhole, not n;HrCAy to adv9rti6e8N . They ar0 : 

19hcre the luw pex•mitu5 a product to bc Oold to 

the (yer=il public, 4.t >fhould allow t.hrt product to bo 

n6.vertie,.ed to the ponvral pubY.i.c . 

Nlhc:re m•rndat:e,ry instruct4.onez or cautfonn uro 

cour.:P.dor oc?. nce;e s c,,u.ry to the pub)i.c goou , thnir propo :° placo 

i.n wAth the pacha6•:i`!ty of the yr roduct ., not An itH adve!•-tir 

;5.nh . 

1'he f' :Lre.t prfll'iciple fo) .lowts dtrect :ly frote the lvrolaEeo 

tbftt £.(1v6rt1iF.in[f P.P4 bene7ldoi.ay, if nott indicpenEabl.e, to thb 

(f:LOhnkdS.R fltlucturG: of our nNtf.Gn . AdvBrti.8i11g 'J.6 d l,1ne 

(SU a non bo t)te rnass d9.c+Cri.bution which I n turn supportkt reasc; 

productioa und mak.a s poeecibl .e macs coueu mption, the totalS .ty 

o8 whS .ch is: the ve ry b ..oe of our oconomy . Furt6ormoro, 

wi-t.hout advan°i :i(+iu(g rovonueG to e:upljon•t them, our proat sls,dia 

of infOrlnGt :iAIA, newc4 rL nfi OhtortaSlnlnCut could no 1(ynQJGP 00rvCe 

thc bY•OHOd p'.Ibl.ic . Pk .Nt would go oUt of HfrliPtencR . fhphe 

Vhi.ch RN'vi.ve(4 wOll] .d6 hhave to chaFQ(() pr1C06a too hi gh foY 

moclt peopA .c to prxy . 


lYE YCcofitlA%e, of COUrbe, that ecorlolniR ar(;unlent6, and 

(>Ven the BtRbi.l .ity Of thH nat1G11 ' cf preFN atld eohlMUnil:atiollC 

ICadi.r+a lauraat t(llco (accond place whorc a produe :t ie cancArne+d 

LOat tLreK.ti,ne public sai'ety . Ltu t the public 4F3 e.ustomnri .Xy

a~ 2003 

denAod free r..cooce: to products o£ thr.t cntot:ory . Xf n 

3r.roduct tn not so dnni:e.rous, thnt its purohueeabilit .y should 

• bo rostr£ctor3 or prohS.hi.ted, theu thc puh7i.c good vrhich 

flotnG from ndverti.r:inf'r+hould not be mecrifi .ced, 

ri'urthermore, me, long es cfgnrett .es fony be sold to 

the pubAf .c, :1t i .rs hAgh3y icapoa .°tant - for rat le a et two mu ;ior 

ronsons7 - that thero bce vAf;orouP intE rba.°nnd compctition . 

V: :thout cuch cenpotitfon there woukd be the inexornble 

avoY.ution tocrnrd monopoly which ico t+bteorrent to our baeic 

canc:cptn . 

Furth¢ ;rmoro r.oaapetition in the vdto3 stimulus toward 

product improvemont . 4ihnt cou3d b® a shrmper spur to over• 

• coaai.ng e.uch drnwbuclcs as ci.gairottus may he suenpoctad of 

bnv i ng than the r.ompetit.ive ndvccnt.a geo va mnnufacturer cmald 

nnti.c.i.pnt.e from c,ueoef,efu3.3.y o3.Aminnti .rep such dnngers fram 

hAC.: p roduct •• - prov5.dcd he c:an lot the public know about it 

in lei .c rcitvor tirsing2 

ttut A.nter-brcurd compotition subsls9 :e on radvertis•i.ng . 

FY9thont: the r.c.pahf.9ity of radvcrtimi.ug thau°e is little ronson 

to believe the,t ranr,ufr .cturert; could commi,t themsolvos to the 

larF[e^ .nAe` A.nvoetmcnt of cnpitrtl, the dovotion of mnn•-hours, 

• the cxen•e:ise of znFtenuity that mucrt be inspired iR whatever 

honStb prob3emer mny atte+nd ci.gnrette snmk.i ng are to be 

c3.i.19i .u v toci . 


AcrcorGangly, i f ei gwxrttes are to bo publicly sold,

ch 2004 

thGiP 0lAnnfabCUPOrF' shbuld have the freedom to adverti6E . 

And t hir enhnuxd be r; freaiowr In fact not in theory . 

Vor It to be Rreeoorn In Yact advertising uhould not. 

be Idf3nQntor :U.y cJ.V,tt(er6P7 wSt19, forE)bodi.n(ZE of a dil'b $ate to 

thotier vAeo ]ook upon or Pfaton to the advertfsomont . Such 

adven tAS9.ng would e:in+p7y not be vered (ttn7osc It Is determAnod 

that the advortit:ca3 eavoatcs have no aff'oet.l.ve dmtcrrmtey ; 

which wouYd harASy he a sonnd basis for proscribinA thon:) 

and (;onttrcs s; tai(„Irt juet as woll forbid It forthrightYy ns 

rec9niaro thnt It be r..o pat4.ornoN . 

17c hs.vo the an:n. mp7.o of many e.rtic9.oe, vihosc danger 9.s 

Por more dePinit.o7.y c:stahlAOhedl than th it of ciQarett:eo . 

'l.'raditiona3Ry, whmtcvcv^ e,froci.a.l. vrarninli s, or i.nstruotiono 

have been de0 mcd neceElinlPy for thCIG have been consi(i,'ned to 

pY.C'1^.'.R.ti.n1{, and not to advertiFlinE'. ( Wg ., foo£in, drugs 

EtndfKrE:pi Stfib6, haM.nr@OtES £SubiJtnncb6, economic poisons, etc . ) 

There are a nwdbc:v of valid roar,ottes for this . 

Ono 

the A .M .A . f'0c).6 part:icuPerRy 4nn)ificd to speak to is the 

fect that r.dvortisf.ng In a corMrcnnfcatA.on forta all of Its own , 

It u:u s t opnx ute within cxtronwRy rostxi.cted litnits oftivie 

or e:pace , It in not t9oriCncd or nble totransmit oompro .- 

hona:hvo trce.tf.r:oc: ut,aon, or oncyc4op&dio hnowledge of, a 

proct£mt . 


'i'hc, purpose of adverti.f:f.ng In to croate a favorabie 

Fuii'a nhont 00 itc M that will be conducfvo to its purchase .

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0 

c0 800f . 

Yts: f:oc.hniquor, necer :varAll .y are morre EynboAi.c, ni] .ucavo, 

ursoeintAve +bhem eapoUikAaxr.tAmxas_, A.c}vor9 :£ei .hg in eaore 

oloe.cly e.ki.b to the ?i.tore,ry the',te to the 7i.te+xal, to : :r't 

$or1AE: oR C3YpF'CF'Ri.b)1 'LIIPJe to eIt(;fl}te6t'iii[,t plR4il!@l .CZ pUd FiYUe-- 

pri.n5a7 . 4"o ,Porco 'npron a:e;.vortAe:i.et(p the job of c.ntn).ogfng 

dE>tuA]G tEDYI)-Q vlol :etEr i.b(t bPt(uY.Cv nF;tA9r6 Nf,d 1Hake N WRp'Le 

o," taie, e .eone+y that €roc;r.. £nto it . 

G,FVo rI"euta)_ di .v;trBi .on oY' tvttt:.t rcuat Uppramr tn adver- 

tECi11(r, g VO1Y)SS IH`, ttllrt(3llR>L1Pnt to j ;.rohY .bhiCi011, '$hp 6otOj/oUi .tfloH 

oi u r ad.voxiAeeis~ealt i.r: a hi(;h1y SRi .73.efe tA.nl9 er,ec£kY9sad 

p)kt.GPf3F ; . We hi1CrW tl'IN.t 90FPFRbgly' £IaFJi[411i,S'3 .4allt C:hfltaQ' e B AA 

H}1!'SrAtnCl •--or evhnl o f F,& k7ord --•- Ata.y HSri .o4fi:ly aptOr At.6 

C>£$,'UUtiVPSriRS:.d . 11dvC+S'G'Jb'C rG D.rG+ not Mf))y to ri .ph the LnCrSlk .GE 

P.ho.t rrc hoeQOd t.o rnn o oarqrsiCen whi.ob Ania.ttcrog ce,py t.hey 

{cxs). et,lfl f,e°c:r,t thm vory p;urprosao o f t.hcir 2uvea.ntment . 

Wtc:vrer dctexi .l.ad An..orTn•.ti-on Ctonyrd+cs be).ioaars s+houRd 

hC GOIn:nMptG+tC, to CeS.Iiar6fttca f14W1CG+rG by Ci .(ga}•Citte IGCtlil£a( :LL1TQ;r :r 

oan 4?e+ raorri oosnpx7 .crEG:%,y ttesd n>ore. anpprroq,r5.lctohy feaoorporatcei 

7.nta ps;Ahti .np•: the.iet advort.i.nf-eeg . Hvax•yome v:ho ueos tho 

pnôclnct vou7d i:huc: be oxproG;ed to the nnxersap;o at the very 

untrmt oPs s:ver~•y ucie . 


V'c, r¢aogixi .tse, Exr+d do not ; chur-x'roPl with, the prroposi .tion 

thrit svp edvc r tfeom oerb cannot colhte+axt AtOC1R tvAth a ha7 .i'a 

trelis b , r.erd thx35., to thce extent iurthcar S.n .Porn R ti.on 9rs roquired 

t ci>vi-t, .N ela,Vptivcrtrc in what un rcdvoxti .r:cr has ele :atnd

• 

• 

• 

C'I 

to hhy, hC tkh4YVl(t not b0 R)108 .r.t the uso en(i r•a2e oS th e 

cuaareocaS.ty 9 .i:ce7£ . .r;P, howc+vor, S .t S .t, w117ing that tho 3tom 

kto £'roo]y trvt•iYEahS .o to the pub7 .9 .o, i .t ehou7(i not 6rc3dc the 

i3kSb$iF11 OWSt Hn(i Y .IVrjvoy'ttdqt CfOOnotfiS .c £uP]Ct£On, flCCvBrS]£01Irt; . 

'PR(" ]JY'OGQ'lOFIt 14oll1.Q bC !in AIYEJflC3,£041k1 UY/© $nd, OrecF3 £Ubclll .LitOCi, 

hflrCi tl0 cOEit;(1}.n, 


C :®nsPt ;tearF : :ey vi .th tho.t eatsco}+t, the AecocAati .on of 

79otzorinl . Cuv(rxt4n(ar>r• rc

• 

• 

• 

isY~lES+FRN COYRdPY" TBSAAISAC)s•07`1CA L SOC8Y11X 

2YG N . Wozshiotk4.an Avontte 

Se.a•( ;dri.Itt :.tore, b . C . 

lyas;r vouacor MgmtFYO+ : 

2001, 

Wra}ter Ci . C!ormvttd.ng, .Xx• ., 7>rersS.ec:rst 

Lfe.xch ).G, 19016 

fi3czx: :, tre o .Qvfe;crd that the ktca•l;en Corn:rty (Yd .J" .) 

EÎ~asS^nc° usse on arigm.x•et lanbo7Ang . This vrott) .d he 

c+ous :S .r:C(:bt wi .kh xp°ccsr,nt requix•omeu,te o9 thc k•e(ierEi2 1•'oo3o a :nd 

1?sa(s lac9m :4nkntx•t,tAon tlsr,t 7pe .tcerl :drol/.y :afax•xosu3l non•.nrcrecr9l>tSor., 

re!:E•aeaGEesf;Eng lyroe3ue5 :cr eerrrry mr ;.x•rrflngs, eeutfon not :3.ces nud 

6osraq ;c T.oxP :O orr 'dr.bOy axtd f,naavrte: . Sone of those Pae 

rnoMrr•s:9.e7ncrsu d.,•vt•.k, anbAhPatnrvuixror.+, :;7ecpittg y>9.7.yra,

• 

0 

0 

hea W he rno:9r. .•l .uor: rwt2 tabllot s , llnxatpvcrr, nnd nas:c+ end 

eye dF'e})C 

. Our cmacern Sn thts vr.ttor, f9rst made ytublio si,any 

monthe: t+.p;o furAng thc Ykr'cuidcnati .pi term of rey predc,ceuz;or, 

.t . Ituuson Mrmwhnn, ropxc,r:eattc e ee .nt4nueA 9.nteroct in 

cduc:ot'acut an tho rnu(,n5tudo of thSe ; y,ublic : heea]th probll.em . 

We, the,roforc, do lvish youx vct7ued le(;iolati.on n 2,g,eeciy 

voy ::Te throu( ;h r,Xl the tr.ect,ani .cr: of the Ship of Ste.te on 

the hotemm Oon you tmvo P.ird.shoc7 with your committoc, 

hc:nxl.nf;a, which staa't t?arch 22 . 

Si.neeF6rl.y y'en2'6, 

Saii .tor R' . F;rotvnin(;, ,Ytr . 

Pre+6S.dc :nt., 

(COpi.eF, oS Xottex• eont to 6enntore Ce?so mad WS7.l .imna .? 

H}'ItG?ai COU10'CY PEA/JIACPS'u'CYCfIY, BOC%P'kY 

G . .T, Vx Denv., R .k' ., fio¢nrotnry 

`f:$ IJ, Ruby rnVC ., PlE .l2.pinde3 ltRrh, N©W J(7YHC1V . 

2008 

hlalY : - r"or raloare llednesdny, N,taroh YY and thorca&te r -•- 

h'RehehTaCh, 1'1„Y ., t$:TCh }7 - 

YionYth hav,hrd c ;apn9,ngr. a.nd edotlunto d9rections for 

ureo oh c.£EVarct peelang< ; Xx.boAca vns urgod &,dr,y by the t§vr(am 

Cotmty Phr.rt:n :eouti .m). Socfety . 

I7aXtox 6P, Hrcamin(„ dY• ., pharmaolat of Ber•trenfieid, YremRoont oP the Gocfoty, ea 


.id, "Ovoa•vnceJ.pr)nC ecfentA2i,c

• 

• 

e3 2009 

evidenco reportod by Surgoon (foneral lrather L . Terry's 

Advir;ory Cot,nmittec on Smokfng and Health has ,justified the 

ronAi :;tic ncod Sor count:orwonsures : to protoot the well-• 

bci.nA' of the Amorioan poople ." 


lu•owninrr, snid the v£ows of the LIerE ;en county 

phaa;aane.caticaR Soc:iety h ad boon sont f.n a, lottor yestorday 

to Yi . f? . Sanzitor S . nn r ron T=taenuson (li„ Washington), 

chai.rnrtnn of the Eonate Comraerce CommAtt.oe, which plans ci.x 

Gaye of Irenri.ngci, r,turti .ng on 1A;crch 2r, on tohacoo-hoaAth 

lotriF3lntion . H

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0 

'1.010 

6f9~, li"A q 1P jr~•C':/:Oii~ !)I ^vl£ Pt,f, .C.C[4jJj f~ (i~AF; ((i'Pp V(r :4L1aYiQ:F: 

/o (bA$3C n w[,Q .j.GD£ SYf7 45 ::E4(G {VrF, l of, 3@c:7 .0 iilFa 'CJVUPrrF•° 

, . .a4r etp tY c . . l .e.i;.>.cM./1 vx•trti(tetrt, Pk t1e .i e .ar,:; 

li[Si.4iPC•).(11 ''~S liYt!!, :,, F :XC :oXrj .i .( . Fi%]),Fy fecfi4"2c11@ 1Cdwc :Tt1o`s, 

7 .FY ;Lr{W&', hit(n 4(rm kOG1 f3y6 C%5`(it .(u DoCuJl'L 

o7a 'tl .e lla 1 u9. 8r.tk6cc .'i [, i:er:7.s4-lp r,i .g(rrt,L [ .n'sierf :, hnr; bcx :rr 

t 1(e( . .V).C •p1 .OCt 4¢• £ 4va&Y . da malN"c~ . E[IC11 tV1iC*, Id_ flRi.(ip 

At4 IC9iv f rb5 .1'eC1 . Vh''Lh afiCl[P(e(a o.f.5,eI/ i :foi9 11 .0(( C(IIwCr" 

6te(1 6i=I1ON ll (Ci . .S6b, y i :hbLp( c2COPfY.k,V flk'LCF'y di.F,CC! :O, L•ltiftnll% .4 ; 

tt -,ruc.SrMr r t t c .=,.-?s\c .t-, :p . 4h j( A.cuHr E awil (f oag&"vtt 

r'•h31)E', Ie ( ;Y, i [ C' :e'i: 19 :UPt1( ;b tiltf. ((t_r.cJV.fi+el' fti"C; br!y)C.P 

GJaImCy 4rS` 4ibaYli i ;p .C3 L; LOS

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ty ?. 

CANCRIt COOItpINA'fINO COD7MIT'PkE 

01" TIfP S7"ATli OE WASHING^xON 

e/e 

1:`T.&hiiE(;t011 State MOdiCal. AEneCial.iOn 

3309 SevontU Avenue 

77tre NoeleraUle 19arren O . 47aCUU ::on 

Sonate Of.fice bui.].dfitA 

Wachi.ni:ton, D . C . 805 :c0 

Uon• Sc :uator MaGnuE;on : 

8eattl .e, Washingtal OPl .01 . 

k'ehruary l0, 7 .005 

It has cotr.e to t.hc n.ttention oF the (:ancer Coord£na-• 

tin(; Coimnitteo of the Stato oF 14huh9n};ton that you have 

introduced Sonnte D3i11 560 to rerulato £ho lo .bel.Sng of 

ci(;nrottou, nnd for other pu7•posos . 

590 •r.re eoEpiizant of ,vour i .nterest In the controll 

of cancer In the pa .ffont as ov.preacod i .u the IIoone - 

Afa„mrvvn Itil .) . . The Coranti.ttee voted unrulimeusl .y to cao-• 

mc*,nd you for your• offol•t In the past and f.he present, 

nand hope to seo it oxtcrnded £n the futtuê i'at^ this good 

pL+rpe se . 

I EaI ene7osinC a copy of the fleso .luti.on paesod by 

the Wnuhington St.ate Modical AsE :ooiati.cnl rcgardlng 

ci .gax°ett.es 01 Ats l .ast. Annuasl Meetin[; . I hone it hiill 

he of velue to you . 


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RBSOIAI9'lO1i 

(Smolcing) 

Most E .3.nGerely yours, 

2012 

s/ Aav?,d Iietheny, M .D ., Cha}rmf a 

Canccr Cloordinating Commd .ttoo 

State of Washington 

54111 .R1iAS,thcre i& overw:holming evi .denn,~e of a defini .te 

c:mFlative rol.ationstd .p between the smoking of cigarots 

nnd the over .dLicroa.si.ng inc:idonco of lung cancer, and 

WKF,RhAS, there i.s also good ovidenoo that illness and 

deatfi from other common dSr,rasoe such r .c emphysema and 

coronary artery heart dAsoase i .s much fd .gher in ci .garet . 

6GIokR1'f: tltan in other persons, now theref(.re 

RK YT kB.OLVI&D, thn.t the Washington State Afodical . 

Associataon regards smoking aes a si.gni.Ai.cant health 

harard and goes on rocord as strongly dicacouraGing smoki .ng, 

and be i.t furthoi> 

R13SOLVli6t, that i:liie AFSocintion oppo ;nes all adver- 

tieinS and other i .ndar.r.nonts that mi .ghtt t:empt young poople 

to start smotcing, and be it further 

RP,SOLVR:R, thatthe Wa,chinFton State NSedical AssoeAat.ion 

will e.ontinuo to endorso, encourage and cooporato with 

efforts of itf ; mombere Fuid other health e.Gencies, to 

di.NBCntli .nflte inforliYati .V11 0oncerGing the po.itive relationship 


• 

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b6$N!een $hc? fC mokin[ ; ei /:i . gNf'Ris R nd d580NCi0 ; to urge FUYd 

nc:eA.st ciCero t e,mokcrf: to c! i sc:on.trnue thc : habit ; and to 

dr.scourage t.hrou(!4e ctdneN$ion, young poop7o from smoki .ng . 

(+ilhcrt G . P:ndo, AolegaLe 

K9ng County Medical Society 

2013

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STAA2' OF 6Yri.RtFtA1Xr DR;hIAFtRtfr;LT1' OF I*UBYdC 111'iAhTH 

4230 lioe3t ll.th Avr-.nuo, Uvnver, Colora,do 80220 

H, L . Cleere, h1 .17„ M . P ,H ., Diroctor Phone 356-56U7 . 

'1'he klonorahlcr Warren 0 . Magnucon 

C}nearmpn 

Senate Conme rco Comm 9tteo 

U, ii, : enntc 

iva .shinnton, A, . C, 

My doar 8ena'i.oY 61aCrmFson : 


lfarc:h 23, 3965 

A,f.tcr carefu l c+tuQy of Bills propoafing f'ederal action 

on Yahc, :ci.n(c a,nd advortisin g of cir;arott :on whieh hnve 

boon ini:roduoed in the 80th Confiro&s, we support oi.ther 

S . 547 or S, SticJ . in view of the oxtcnsive study and 

ev7ua'Giet/ of 01 avai.Iable evidence, the Colorado State 

nc:akth Delrar truont concurs with the findin gr> of tho 

Advisory Cotard.t0eo to the Surgeon Genera7l of the U, S, 

Inrtal.ic 1Hea].th Scmvice that. : ^( :i{;arett.e EunukinG ir a 

hea].th haxos•d of r.ufficiont importance in the United 

Stat.o :: to wa»rant al yropa•ia.te remedial ac.ti.on ." 

1't in o!' vita7. AnTortanco thrt the public receive 

ndaduate finfos•mation reGarct9n6 the posaiGle hea7 .th 

hFW,ardH of ci .i aTett{! E,'dllo16in6' andl tPe t'h1n1 :r that the h'l1t : 

Rholl . .ld have :folne res'jKrnf:i .h]l.ity fOr snJ7e1'vif,5of1 of 

eiQAXettC IabF.lfn(g and advCrti9J. .nC . PoP thib rOaFon, we 

2014

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t y a 

would favor eithe,r S . 547 or S . 559 over Ff .lt . 885 or 

R .R . 3014 . 

Sinceroly yours, 

2015 

s/ Roy L . Cloore, 11 .L ., }d .P .H . 

Director of Public Health 

ADOI°PF.p Dy a'Rt ; COLOItAt7O STATS HOAR11 OF HEA6TH 

January 13, 7.954 

SIR)3RPIAS, the 9 .EUxoas :f.ng frequency oP lung cancer ica 

of Crca .t pub7,ic•c health concern, and 


t9lltsRNAS, thore is mounting evidence, based on Enedi .cal, 

publio healtlh and zstE,tiE:tioal fi.lldings, of the association 

o f the umountt and Den g th of cigarette smolci.hG history 

and tho incic+ence of diE :eane fncludinE ; lung cancer, other 

lung co7lditLons aild corona.ry heart dif3enEie, and 

WIPERFAS, thore As an growing tendopmy for porsons to 

begin Eawottfnf, at an earl.y age, which in turn incroases 

the potontial of lung eara :er and othor diE:easos in their 

adul t ycE rs v9wn they should be inatcing t.hoi.r greatest 

caNltrAbution toa.•onomic nnd family life, and 

MREA6, no present method of treat9.ng tobacco or 

f9.ltcrin€; sauo] :e har•: beon proven effecti .ve in roduoine; the 

hsrmfu.ll effects of ci .Caret :te suaoRing, therefore 

D)r IT R3sSOI•VStD, the the Colorado State fioard of 

1:oaYth urge parents, eachoulE:, college^., uni .vorsitics,

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voluntary and public health agencies and tho various 

public Anformation modi.a to conti .nue or i .ni.ti.atc intoa- 

si.vc cducationall progrnms to i.nform the public, parents, 

and young poople i.u parti.cu7.ar of the modicaY and health 

haGaNd9 ef Bfu4kSng, and b3 it 

PqR'fYlF,ft H16SO1NS :p, that all schools An Colorado be 

urged to prov9.de c,ontiuui.ng opportunity throu6hout the 

echooll curriculum to help ear.h student come to a sound 

pereonal doci.siou whethw• he viSlll or wi] .7l not smoke, to 

dolay the timc ho may begin smolcinG , and to stop or 

mo6orn.to the amount if he is uov, smokin[t . 


7.0Y6

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COIpkAlq T9FIENCOIASIIS ASSOCIATION 

163$ Vi .no Street, Uonver, Coiorfldo 80206 

Phone (303) 3SY.- .4827 March 29, 7 .965 

NollorablA Warren 0, NaQ7%U son 

Seirate Office Ctuilding 

Washington 26, U, C, 

Doar Senator bingnueon : 

]t i.s our undcrFltandi .ng that henri .ngs are taking place 

regardi.ng Senate bi .ll.[+ 559 and 547 proposing federal govern- 

tnent action on th® laboling and/or advcstising of cigarettee : . 

A'hrough the Nati .onal %nteragoncy Council on Smoking and 

Noalth and the Colorado Itnt.eragoney Counc:i.l on Smoking 

and NCn1.th, ithn£; beon called to onr att:ention that the 

proposed Seao.te bAl,1, Af enaetod, will ensure that a1.1 

persons wi.l.l know that oi.gxrotto smokl .nC i.s potentially 

harmful to their health . Af: a volunteu•y health agency 

concerned with the many respiratory di seas :es affecting 

the Aia.rican public today, we believo that 1t ie necess- , 

ary that overythi .ng be done to cal l their attention to the 

probloms caused by cigarette emoking a n they relate to 

these di.soa9es . 

We are especially concerned that the Senate bills 

arc 1 i.von favorabl.e cenflideration over I :bUGe bills 885 

twd 30)4 whioh spocificail .y exclude the hcdornl 'Cmado 

Cornm6stei,on from responsi .b ility for supcrv .i.oion over 


2017

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cigarctto advertfei .ng . 

It is our sfncoro hope that you wi .11 consider these 

aspocts in further dfscucsS .on of Sonnto bf17s 559 and 

547 . 


Respoet.fu5ly yours, 

s/ Rona .lti A . M11).er 

Execul :S.ve Dlrector 

2016

• 

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ty 8 

CCh7141iCTYCUT HYiAVPN DRAGUI: 

c/o Connecticut Heart Associ .ation 

65 A'othoxsfi.old Avenue 

Hartford, Connecticut 06314 

Etarc:L 2D, 1965 

'fho ltonorablc Warren C, ri4a,r7•nuson, Chairman 

Committee on Camnorce 

United Statos Senate 

IVashington 25,D . C . 

ilear 8enator 69aUnuson : 

IIn .llumary 1964, the Connecticut Health Lea6ue, a 

confedoration of Connecticut aGenciea+ i.nterested in health 

problems; adopted at its membership meeting a resolution 

concorning tbe dangors o f cSt;arette smolcin6 and the 

dic5omiuation of kno wlodgo about such dnnk,ers to the 

public . H'he broad type of mcmbershi.p In the Connecticut 

Health Lea gue 3.s il.luetrated by the lis :ting of the momber 

aGonc9.es on this letterhead . 

Yt is out undorstandi .n ;, that the Senate Commerce 

Committ:oe of which you aflre Chairman is currently conducting 

hearSnge on two bills, S 559 and fi 547 . Both of those 

bills provide for labolin g and di.ssominati,on of informa- 

tion i.n a marrnor which i.s in keeping wi .t.h a rosol.ution 

ndoptod by the Connecticut lleal.th hoaguo . PassaCe of 

c:ithcr piece of proposcrd leg4slat,ion would reproccnt a 


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conctroctS.ve nhPraaoh . 5 E97 nppoars to ho ei73glrt]y more 

el>oox83e i.n etrenGtheu ..nG the por:Atf.on of t.h¢: I'cderal 

'dknda Co.+~m ;ic~~i.on and, thorerforo, perhnpn prefornhle 

1eg451aLSon . 

The tioard of CN.reetarF: of the ConnoctAcut Health 

Yn.n gue hno authoaYred this c:tatoment to be fS.)ed w1 .th 

your commfttoc . 


SS .ncc :re].y yonre., 

B/ ni11 .t6n Geyer 

pre&f.dent 

2020

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ty 10 

IDAHO bI1PARTR9EN'P Ol' HRAIIfH 

6tatehOnsO 

Boise, Idaho C3707. 

Thc Horwrable Warren O . AiaGnuson 

Chairrrean, Comiafttee on Consmerne . 

U . S . E:enate 

WcBhingt.on, n . C . 

Uoar Senator 61a.gnuson : 

March 1 .9, 1965 

The %dalro State nalu+rtrnent of Hcalth woul.d like to 

comp]i.rdent the ConmuStt.ee on Cornmorce oftho United St.atos 

Senate for Hivi.ng such thorough r,onsicieraai .on and 

deli.b3ra.4:i.on ar: well as holding publt.c: hcarings on variour; 

bi11 .s prolro .si.nC federn,l government actSOn on the labeling 

and/or ftdvertisfng of oAgarett :es . 

Inasmuch as it will he imgossiblc, for any of our 

sta .f t of the Uepart.ment of Health to be px•esont at the 

hearings on the bi.11s (S .8ù9 by !0'aSnusan and 9 .fiAO by 

NeuberE,er) eie redur.st this letter he x•cad into the records 

afr e'Catinle Onr pOsi.ti011 O» the lab0li .ng and/or advert.is- 

i.ng of the hc:nl .th lxnzards on cit;arettes . 

1'ha Irepax•tment of Health believes the Heuberger, 

b9.i1 (5 .627) wfllD provide for sgecific aud rnandatory 

vax•nt .n0 mesr+eTes on eflCesrrette paekal';eo and mil .ll also 

b®lp iu €9.v5.h:5 this warninK on aY .l advortzsing conducted . 


2021

• 

• 

• 

We support the Neuberger ltill 

2.022 

United Statee Public. Tbe lYea .lth S'er.vice, the phyxici.ans, 

the v.edi.cal societies, tho state dep®rtmonts of health, 

the vo).ontary hen]th aIXencios and other rrotqpn too numer- 

ouo to l .9st all reaogniao that cigarette smolcing is a 

health hr.zard . The dAagnuson bill (S .55f1) is a clear 

roognition by the Qohgress o8 our country thnt ci .garett .e 

smoking Yf.n a danGeron .^ 

s and serions threat to health . 

While this bil.l) does not reior to ndvertieinG and l .enves 

the l•bderal 4'radc Com ni.ssion free to sot up advertising 

controls and re gnelations this bill is moving in the 

propi:r direction and the ldaho Department of Health 

supports this bil.) ., 

Nc believe two bill.s by the Honorable Walter Rogers 

of Texas (R .R . 68`5 nnd i .tem succossor H,R, 3014) do not 

provide for the Vedoral Trade Co mmission and other federal 

aQenci .eFw to interpret their existing authority to cover 

act.ivi.ty in t.ho fic)d of cigarette smoking advortisin g . 

Yn ll .R . fiS5 we noLiced the rorulation of advertising 

i.h given in tho title and purpono portions of the bill 

but tna],oc: no tnontion of ndvcrtisinG in the reain body of 

tho bi)1 . 

We in tho field oi' public honl.th have Or$anized state 

intor•-agr.ney committees on sraoleA.ng and hc:nXth ; conducted 

educationai pro6ram°Np written vo2unros of peunph)ots ; 


• 

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produced many good fl.lms a11d aUdio••vistial aids ; have 

lVitnefi3ed the 6'Lnte )3oaYd13 of Health adopt resoLutions 

Ag a i nGt 6IDo)4in g ; al.l of those netiv).tief7 are necessary . 

Ibwevcr, if the npproach nsed by the ifagnunon bill (8 .559) 

and thu NbuborGOi' bil] . (5 .557) arc pas xed with defeat of 

the Rogers Bi11r. 11 .H,880 and 13 .)t .301.d a big t:tep A .ll 

have heen t:elccn to r.ave through proper wa.rning nnd edu- 

CatS.oi tilRJly American WeE . 


Your aonnidoi•ation to those pxoposal s is appreciated, 

Since re) .y, 

co/ ))on It . lByboo, Chief 

2023 

Health };duontimi & Traini .ng Section

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IN7`X:RAGRNCY COUNCIL ON SMGICING 

333 Grotto Avenue 

Providence, II . 1 ., 02900 

Thc Nonorable Warren C . Ma€{nuson 

Chairman 

Committoo on Commerco 

United States Senate 

Washington 25, A . C . 

Doax Senator Magnuson : 

7ilmhurst 3-2950 

6"arch 22, 1005 

At a meet.i.ng of the Rhode Is9.and Interagoncy Council 

on Smokiug he).d on March 1'u, 1961 a motion was made to 

support Sonatc hi11 S . 5 2 '/ placed bofore the Senate by 

Sonatror idoubargcr . Tho n otion was adopted by a unanimous 

voto . 

Our Council fools, that it is quite important not 

only to provA .do for speci.9lic and mandatory viarning 

,a,^sea€ce r on every cigarotte package but that such spociffc 

and mandatory warning mossages should appear in all 

cigarette advcrti .sing . We feol that the effort to dis- 

courage sraok9rng nood» ovory moopon possiblo to combat the 

groat appeal to smoke ca Carottos . Of the three bills 

before the Senate Conhna.tt.e.o on Conmorce, the bill S, 547 

by Senator Neu,borger 3 .s: the stron gest and would, thorefore, 


2024

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ty 14 

be i:ho nrost oxibctive . 

IVO hopc thvtt you will rcGisl :or our support of 

Smintor lioubargor'® bi .ll. with tho Sonnto COWneroo 

CormuP.ttac . 


65ucerel,y yours, 

e/ John Turner, 11, M .D . 

Chairman 

2025

411 

• 

ty 1s 

NEW CAS79,1:: COUN'1"M' JUNIOR HIGH CONt7IIUSNCF ON SMOKING 

Sponsored by 

iblaware Heart AF6ociati .on 

Dclawaro Tuberculosis & HcnLi:h Society 

Awori.can Cancor Society, Uolawaro Division, Inc . 

Dolaware L:ter -Agoncy Counc9l on Smoking & Health 

IVarren G . hiagnuson 

Chairman, Coswittoo on Commerce 

U . S . Sonato 

IBnshingten, D . C . 

My dear Sir : 

1305 Delaware Avonuc 

{qi.imington 6, Delaware. 

March 26, 1 .865 

i'ho Delaware Inter-Agoncy Counc4.1l tm Smoking and 

Health supporta: the proposed Iegislati .on as writt:en in 

the two bi.lls 8 .547 and 5 .550 . We definitoly opposo 

H .R .30).d . 

Our Ynter-A;oncy Council has boon workin(, with stu•- 

donts sSnce ].06'h on the various aDpocts involved with 

this E3e1'iouE hOalth pllehleID . We have hold four conferenceC 

conducted and plnnnod by student londers on a statewide 

bnsi.s . Ln the discusfsions, the quoc.tion of warning and 

advort:i .si.hg wan a!ways a maJor topi .e . The oonsensus of the 

group Icaderc: was that n warning on tUe packages and 


202G

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advertisin[; ,:tcor9.ntt anây youth ru,ulcN hrtvo aa dec9 .ded 

c:?fec(: toward thoir henA.th . 

'A'he attacheci rogartt i.ndSOatoe the covora€e for ono 

yotur as i .t p Drvains to youth . 

Ovor 30,000 studonts have 

p,artYeipatod Sn the6:e. ProCr :ure, St is frorn their reactions 

end si:atwnont.c: that tvo feo :l that somc form oR warning ehould 

bo placed on the packages . 

%n conclus:ion, the E1eYasiare %nf.cr-AGoncy Couvo4l3 on 

6moki.ng and Heal.th endorset: the recobwwnda.tion made by 

the hational . liater-•AL;ency Council as S.t relates to the 

7,oU :i€ :2at9.on now hef .n(`g caircur;sod . 


Sincorely yours, 

2079 

e/ 7?rtmk F . Pierson, J ., Cha irnni, 

Ik,lnw'nro Yntor- -egency on Smuld.ng 

and iYeea7th 

8secutivo Secrotary 

Uc+davve ro 7utercu7.osics and goaXth 

Society

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LNTLRAGP;NCY R.1iYtklT 

an 

SMOKING AND ItEAL'd11 P)IOORAAf 

foa' 3'A'ATIi Or b)31 .ANARFI 

Fohtunry 1., ] .9fi4 -.. FeUnpsury 1, 1965 

AMtaRYCAN CANCRac EoOC%FTY, Do).mmnre Division 

D]G) .AIYAIYIi HEART ASS(CSAT'YCN 

D1:LAIVARP: 'CpY:SkCIfIASIS ANU HEA .ITIU SOC1riYfY 

2026 

hoe[ttion Tyln of. AnUaeneo No , of FstSmated 

Pi1rn Aud9 .ence 

b'1?)3RUAILY 

Mt . P 7.oasant Sr . DiEt9r Yanol . Students 

BPaakor -- A . 1Proljch 

$'R J .OS /,RnUBI 

FpoNce r - Dr . )nnn5han 

Arbwn 'i°cch trp fn Stnolco 

:;poolmr -Dr.• . Gronf 

Epalkar -- Dr . Iannihatx 

.eld d'uvmsund BTA Yr^,aial . St.tedont>5 

Showings 

3330 

ColwyC)c Ie: Smolainn Worth I4`r 1 700 

Spealeer - Dz• . Wz)h 

0 ;;Ectovm Jr . High Ie. Smolcinn Worth It? 4 250 

J?• . lfigh Conforenao Up Yn SmoYce 1 275 

Spc ;A ;ex• - D,•, ]t . S a !np 


550 

90

ty 1.6 

RranQyw$ne Hoa.lth Is Smoking Worth It? 6 200 

Claese: 

; Spoakar - Ur, tYhAt:ney Tape 

Boyn CP.uh In Smoking Worth it? 1. 50 

P,randywine Slvriu60. Is Smoking Worth It? 8 200 

Jr . ll9.{;h 

Chrietiahn.lligh fichoo7 Is Smoking Worth It? 4 400 

Howard Il :+gh Sohool Is Smoking Worth It? 1 4 00 

Spnakos Dr, IonnihEnn 

MARC H 

SuloF~ittrium Up in Shuoke 

I:avor Corp Is Smoking Worth It? 

0glotovvn Sr . ]iiSh Up in 6moke 

2029 

1336 

ciulront CO . hxpor5.- IIc: Smoking Worth It? 1 60 

mentul. 5t , 

lYm, 1Conry Comh . Up In Smoko 

Sc:hool. 

P .A . ciuPont };S .E;h Is Smoking Worth it? 1 1300 

SponkeY ^ Dr, {9h5tnoy 

Cin .ygoni.lii.gh Is Smoking Worth It? 3 1200 

Spoakoa's - llr, AaF.'\YItF. 

l . A . J . Morris 

No . 80 7 0hHat: 

L . L, Iteuci9.n(; IIiOh In Smoking Worth It? 1. 200 

School 


250

• 

• 

• 

Corpuis Christi Is SmokhaS Worth It? 1 525 

Spe aker . .. Ur . Vaudorvort 

Vctora.n'e llospitn .l •Pi.mo YOFYS The Y'rSOCOr l . 

6p0e9cor - br . Meflalc 

]4evr Castle County Is Smo]ciuVl;• Worth Yt? 3 350 

Workhour:o 

Speakor - ]ar . VancEorvort 

Forri s School )'].l. Choose the High ] ]25 

F.peRicfS` -4oC S loboj iftn ]Cont] 

Sussox Couni .y - 13 Is Smoking Worth It? 17 2587 

]CSgh Schooln 

(Spons:orod by Student Council) 

APRIL 

GoorOr.towu ]tigla IYp Yn Smolao 

Iurd Ita7.t.iaaoro High Up Ln Srmlce 3 &]0 

i>a.dun Floadrnuy Ya; Smohing Worth It? 1 400 

Spenkc:v - Dr . F . 0'3Ar4cn 

Oa2

• 

• 

• 

ty `1. .0 

L'aynsrd Jr . YiAgh Up In Smwlee 

hfnnUl - ))k, .AOllny 

Irr- SholLenberger 

DSSl :e Tfrown 

Conra6 kl .gh tksUool . 

Iorcd b olaPYxrr 

Oglcto wo Sr . llAg h 

P owC s Srroos.al 5cbooa . 

nsetrlo2 ; 

Yotortu}'s Y€os .pi:fn7 . 

CAaymoni. 8cbool 

A} .exf .0 L, t3uPor7ti IYS 

Up In Smoko 

SmokAng ou6 You 

T .2 : . S1i .@os 

Up In Smoko 

(iy'ieRker - llY` . .I'[dAHeE $OPfAJ ."2+ 

19m . Henry C:omEprc:hon-.Acoeromb5 .y 

er.vo School 

INf .I.n.i .n(,Eon pc3>if.c Up lo Smoke 

ScYmo)s 

Iaurcl High ;:cHool. T .R. S15dos 

YF1CA 

Spoalccr •• ]ar, Ortwz Fmokf .tkC & You 

SyYGaker - Ib.' . IfG1'i'o).'o 


Rlvs, Y, E . Crorf:on 

JUI,Y 

2051 

850 

G00 

G 140 

20

• 

• 

ty ^•1 

XM1!C.A - V Mon's Club Up In Smoke 1 25 

Spenlcer - NAar7.in Time Pulls Tt,o R9.gger 1 25 

Yfowory 

!Do] .nc,r,rc Conferc,nc:c %fi S!noking Worth It? 1 110 

of Youth AEo©11biy 

19m . Mme, High :chool. Smoking &%ou 5 180 

CK:TOhY:U 

Hed C`] .e,y Pron . Church Up In Smoh.o 1 125 

Spc+rcke+r -Dr, k[offord 

Wn . Porna Iligh School Up fn Smoko ]G 640 

Win . 1'enn High Sohoo] Ti1m Fnllln The TrigGer IF 560 

Conrs.d HSgh Sr .haol. Uy; In Srnoke 3. 050 

Spenkor -Im . 7bi,xrda 

DSLT state Convont9 .on •.S7seaker -• Dr . Charles F1nmRey, 225 

Health lSdtlcatore: konn . State, Display and 

3.A terpturr. 

1'rosr: Ccnifersncc for Kent & SuFsex Cocnoty Fchoo3 it 

Editors eoo-shonsoreca by Nr.vrs••Journral) 

Sg,vak.ex° - Dx• . Hofford 

NOVR MDLR 

C1zEymont Ye Smoking Worth Xt? 1G 000 

ll:.ae,C70,•x• Up In Smokc: 

Governor Hxec,n Up In Smoke 2 135 

Hot!Yth Ck:nter 

Covexd5r kx,acou Ys Saoking Worth lt7 2 135 


2032

• 

• 

ty 29, 

Ilea].th Ceuter 

11eUilfarr Time 1V 11s R`ho 4'rigger 

St . 1FhS.] 1ip's lath . Smotanl, and You 1 35 

Church 

St . Aiban's Atpis . Up in Smoko 1 25 

C:huxch 

St . All.inn'e 1?g.i .n . Sn;oking ated You 1. 25 

Churc.h 

Caosrzr' k6duey, ls fimokSnS Vlorth It? 5 ]fi0 

lyi d(:ovl J.le is Sraokin(t Wc+rth Yti' 2 160 

Mf lton Sraokin(; and You 5 9) . 

Soai'oxd, 9••lf Club Smokinl; and You 1 30 

Coni'erezce 

p"i'A INealtlr Conrai .tteo F7moking end . You 1 20 

met e.t h.cadomy of Mod.f.c3.uc 

St.udent Nurses, Up In Smoke 1 9 

Hi.lYord }losp . 

Delslea.rn 

Dayn.rd Jr . High 

D1iCRMR7) 

S mokS .ng and You 

]rs Smoking Worth It? 5 150 

fiayard J'r . kii .(;h Smoki .nC and You 5 150 

Mfddl .etown Hil;h Smoking and You 2 tao0 

Uni .tul. Club 


3 in '1,0,000 

(borrowed f rom 7th Day Adve=nti .©t) 

7'imo Yhtlls 1'he Cx•i .CE;nr 1 75 

2033

• 

• 

• 

ISridgeviZlo i:chool Fimei dru] .Y.o 'l'ho fr•S.Y,Qer 

$r={

0 

• 

9:y 24 

SPJi1''Ly k1CAdQ'Ufi?ItOrS 1t'IYY .031 N(:tt': N0 . OUntiftY (liF•trAbUt :in(; 

point . A Y'Ga^31i.ng+ Ckt>41o \YaF CiFVCl.opte(7 $L lf3SC COop6T'Ut'2CC]y 

uitit tltc Sttao i)apartment of PoW.Sc 7us,tx°uct4on, Statu 

ECc :[ni tG .,Y,t3 )^Lye9.r,al }kioaat9on AsmaAati.on and the State 

172arr1 oi Hoa) .`ch . GUadoc+ aa•v stoc&od Sn the Ststo bepn'rt- 

)aut of Pnb]H Yn&-trnr.t.f.on, ldocclth n o ei physScal Ih.lwsti .on 

EHtd. ISA,VO ),ôA 4q;gnod to £ .Ll Fofin(14R in tb? St .'e,4G . 

rar:xr: ast:r -. ati.strtnstc e 

7Si:udout ;titoM= i'rom 2 .-L.W - 9 . . .A ...C4 26),tJ7.G 

F>tucterrl : Xk£crmi:vro 8trow B .-l ..f:4 . .. g . .l .-C;i 10, 21B 

9'oaehn,r's RcSoroncc 2-7- .C4 ~ fn .x ..M 

9 ..1-{in -. 2 . .1. .6:4 236 

Yne?rvs

• 

• 

bl 1 

LIAGAGIWP 1'UI3):,]ISIII;RS ASSOCIATION, INC . 

F2agnzAne Cemter, 575 l .oxingi :cn Avenue 

Wocr York, W, 1' . 

9 bs Honorable 19nsren G. Uagnusen 

Clttstrman, Couonittce on Cow;roroo 

Un .4to21 Statos Sonate 

SYRRh4nI{t4n, 17. C. 26$1G 

tly Clear Spnator tlal;'nUSCnI : 

E9nrNl 28, 1065 

The lla2nv.ine 1=r.ehern Ac

• 

• 

bl 2 

a'Oa' t1IP prodll0t . ThiF. &hprOAch in the bost way to roach 

the r.onrsunv,r, and i.t raRi.ntalne tho traditional dietinction 

betcm,en the functions of product labol.ing and advertising . 

Thank you for cc.nuf.doring our vicrrs, 

S :Lncorel.y, 

/a./ Claarloe U . Ablard 

Vice Prc&idont 

FAÀTEtAL;NT ON PROYOSED 

CYOARh"1'MÈ: AbVERTYSING AND 

LAI}gy,ING LROISLA ;f1ON 

Ibfore 

CO:Spo l'fTBF: ON COblh9h'l:CE 

UNITIOFJ STAT7:dS SENATE 

k:y John lC . MYOrUert, Presido nt 

hfagar,ine riub] .Arhorr Association, Inc . 

March 23, 1965 

A'hc Rtaga o f .nc Pcil?lishort'i Aeroocf.ation in mr a 8sooiat.ion 

of =c hundred and nine magav;ino publf.ehorn of the United 

:tatcs Publi.rshinr over thrue hundred dif€or.ent nlagazines of 

general intoreret, laost of which accept adv'ertisillg, The 

1dal ;a,ii.no Pnbi.f.nhcrc Asr:oca.ation appreciaten the opPostunit.y 

to testi . :Py bec :auso among the quustions be4orc this Com m ittoe 

is thaf: of thc propor xroY.e of advertieing in our natior n and 

tha a pyropriet .c relatlonshit> which Edaould oxist betwoon 


2037

• 

0 

b1.3 

Gcrvcrmnont and advert.isis,g . 

As carriers: oS advertieihp•, magarinon are f .ntorested 

in 9.er;l.olatic,n which afiectr advertising . I hope to convoy 

to you our vi .ows on thr role of advertising 1n the bueiners 

coumuiity, tho oxtont of industry eolf-rogulntion which now 

prevaale;, and the need for rertraint 1n legislating advor• . 

tifiing requirementF : . 

In our v iew the role of advertisi .ng in our nation is 

that at promc.ter the occnromlc goals of Our free enterprise 

by : 


1 . Stinm lntin g product compotition and improvourent ; 

2 . Reducing oonr:umer prices through competition ovor 

a nc.tiorewide meu^ket ; 

8 . tlel.pinl, tho gzôwth of the oconomy, in terms of more 

3ob r and 6 :zroator national productivity, keep paco 

with the f ;rowth ef population ; and 

1 . Provf.ding the eoonomic ionndation for essential 

comn :unicntl .onr., media . 

2038 

F,dvortieint; ie a vital ine,trument in our whole competi .t- 

ivo prcceue, ti`tw rop,uUt.ion o£ advertising to require it 

tco rnont ito ahligfntionr to the public ie a legitimate aim 

of Govw^nmont• Tha : advortieing 1.nduetry recognfzed this need 

nnd p].nyed a raignif.icnnt role in the os,tablishmbnt of the 

Fc:dw'cl 9•wado CowmiE.rion which, in aocordanoo with trnditional 

,pudici.a.2 typo proccdurcr, her the authority and renponeibility

. 

• 

• 

bA 4 

to pwevont fc .lruro avd faAnloaciS.ng oAeoxt2nAng . 

2039 

Tlre 7r:ocSS.[r whSch dcpc,nd in varyin;x c3ol:roee: on advertisP .ng 

for sulypart or,nrr.2wo th :7i.r ,jndbsueart aac to tho propriety 

oa eau.y Nvort ieaom

0 

• 

• 

k• 1 5 

corrc :ctf.on of utmoen . it. hrsF, alreaNy rcuu .ltod. In chaugee 

£u poc7raSfng ilenign and aGvertl .cing, hoth nn to contont, snd 

n ;.l,ocl . 

The code hcia+ born In effect lor•e t.hun a yea .r . We 

ti0ievc that thc, tohocoo dndtlr::try shnul4 be given an oppot'•• 

tunity to provo that rc7.4P-•ro€Nlut9on c:en be effoctive . Lnst 

yer:r na R.dvort .£ .o9u,. t:dvinory C

• 

. 

0 

b? G 

the flSoGt CareflLY aE6cN9glOntt of ocionti).'ic 6vit#CnCO, 

r:tnt9ntica9t pro,yeotflons, p€ :ycho2og:y nul, judgment . This 

i .€< the vrif+c type ofaction that Qangrorf ; has• taken regardin(; 

SS.al01T(tb2.6 pro[1VCtE, V!(rox e llC, and drll({Et„ 

A raryulveluont the

• 

• 

• 

R Y . Y . 

11FdY'F~'A'1':k;HA' o}' 6YAY7 .1'Pl . 

Statr, ngM1?tr,VSnnci 

402 W . PridxtoP£ F:trCmt,r lA . S.t .Susolô, McF . 

7,'iar: piouoraFiYa tias•aRn tF . IdHt"nueron, ChaArr*,aa 

Ccm+.wl .t:too oea Co mn:¢ya.o 

i.i• ., . .¢:m ;,.to 

L9c n L_ington 5 s , 1% C . 

li ; ; ;c r S i?r : 

p.lnzch 11, 7.SSi: 

'a'k.C R#xrpY.crm9 C:otr

• 

• 

0 


Vcvy frnSy yours, 

/h/ ISay K, Lawa),•c6c 

[CHy R . L "" wktrtt«, 6M1 .Tl ., M .P .H . 

Cic9.eS', llfv3r:Aon of Adult 

}y; I e,YCL fio xvAqcrs; 

Chias.emar l , ;dtarvler,d Committoo 

OFl s 1 u 01AAS g~ ftlil 1 liAfi~ .~a1

• 

• 

'A'A~i Ck~tlr4d(YNVY~AI'd4i Ol~ lUAC6ACFiUSk ;CTB 

27spftrttncnt of Public henkth 

U9v4c . W of Adult fioulth 

170 hloston Gtrcot 

dnmn9ec4 ffiT1cAn, tFasnaclwse4.tc, 

Bonetor N[t yso n G . Ffia,gnu o on, Chni ra rui 

('o1Alf4:3'c'e c fnt!Ildttoo 

Seneric 0'2ico ]?eiildin(: 

Yrur,h kng4 .on, 14 C . 

]}eut• Honn6os 18nFP~usotr ; 

March 8, 

An 'sho govorn mont oS'Fi.cSnfl in tho Com monwenlth of 

Mar1n a cbee

• 

• 

hlx 

SG'.nfltoF 17kd'%'GR C : . p:11tr(;nloon 

Cio:dnK+r'cC COL1ttLl't.tlee frhEYir9ntln 

Dnited etctee. ::3nato 

Wnarh9,nEton 7G, I) . O . 

IK+flr F;tenL'.tor }IAf;nuGot! ; 

S't'A'8'P: Clx' k91Nt71SSOTA 

Y1,t.r,rtnrrouf. of i;duoat9.on 

CttrrtonninY Offico Yaul 3, 6!innrE+otn 

t.lflrch ].7, 1955 

F'o ra.ro g.aoac.od to RoF.rn thatyou nro npon£aorinr fl bi31 ., 

S . 6u9, for tho purtaooe of 1aboYlnf; cigarette y,nckngon . The 

E~eppGrt: t'.hat SGn[ttox IdE!ubP.rger la f•;iving to thi.s: 6orioun 

pnU1S.c henlth pxoblom 5.4 nYeo mont OratiSyiug 

204& 

.nce tho Surgeon B.nn,rnl's Pu,port un . 6lnokingnnd . Si 

Health 

ovcu• aa yc+c.r ef!o, ts tatai:e i.nt,erngency comtni .ttoo on r,moking 

nedd honlth 0t±s: bcon orfarni.zed . The Statc I1Myrartmont oY 

L;ducn.t9.on, Steltc S1oEalt.t, llopnrtmont:, 1linnomotn R7adictel Society, 

P :.i11nuHOtks, Qancetp SoeiCty, PinneEtotH . IIL-art A£tEto[a.ntioll, bind 

tho E!iruxosott! 'r'uhercu7 .o:;3r: nnd Hefl3.th Rs?nocintion nre 

Yef1rGHPlttpd . A'hC t41nn©Eiottl (1hapt:Qr of the P'tltnr'G 1''6MnIPrc 

e .¢ A)iiCF`)G(L hn.F. Ql£:e . (;'J.verl E :utYFioY't to thiFi intUr'Af?:ency e:On, 

€ya .ttNE: . 

fVAtsiAy, n ser£cs oi:' iois;crvi.cc oducationnl cli.nics ou 

7nbnoea )ideeorstion havo Beon cemciuutod ios•• c.lcmontF.ry and 


• 

• 

0 

hi 1 

oocondary schooll todchcrr• . Tho attond,aneo at those onc-day 

clinios Peas bcmp exco21 .on9 :, which i .r.t%icates : the intorest of 

oducatovs in tho prok .lesuv: of smoki.ng and health . Other 

ednotitionnl proj,A'nmq ti'411 bco developed for the future . 

Hb b*9.ievc that odncatF .on can make e significant contrA 

bntion to tixie : publi .c hoalth problosn, bat i 

'1.048 

:d by other rzoane, or r~etbodse .t must be snpplo-lnontod nreR r,'upporte The propo ::al 

to labc 1 eitrur,atte paol:aees c:oncernint: the hoalth huzards 

of sutokk .ng wronlc; be a vory vaYi!a,ble adsunc5t to a continuour : 

public heult.h aducnti.oh prograxa . Tho kodoral Trado Commiseion 

should bc RA .ven the nutdaor8t.y to cont.roll the tuivcrtising of 

ciy;nrufaev u.e rnee inon.ns, of hnvi.nt; a continuoue program . 

You cc.nco+^n ubout su!okin(; and ho&itb is very nn!ch 

upprociabc+d . 


Sir,corely, 

/s/ Fnriey u . r3ripbt 

A^S1SIANT CO19M1SS1ONI+.N

• 

• 

• 

k~l 1 

Senator A;Cwauvl V . LonA; 

lhr} .tr.d 8tntos Ss:nator 

Hsnntc Of'f'ice 1:n9.Y.dinr 

IYnehanl .,ton, U . C . 50024 

Isas S ;oiator S;ong : 

6SXSS(IURI LIROAUCA8T1:YaFz ASSOCIATION 

15%1 hast Nigh. Btroet, J'offorson City, A9ir,courA 

lNdreh 15, 1965 

P'ik'st, Y.icaeo accept tho aratitudo oR the Nirtsouri 

Ccroadcnatorr: Aeaocf .ntf.ou for the fnvore you have r:hown us 

In tho l,nst n!.lf, the i.nterast you contf.nue to display in our 

incluntry . 7`hcy Yrs vcry much npprociatod . 

Now ngn9.n, tvc cn17l on your holp . We ca11 your attontion 

to thc rrcont B"i`t: r.•u).nug concerninF, the wasnint; uiernsngoc to 

be oaasiod on cigaretto adveri:isi.nE ; . As you know, unloss 

further rsctlon In teLC:n by the Cc.ngrocn, by the courts or 

1•y the Noderal 'Prrade Comm insioa, an YTC rule wil .)l go f.nto 

offoct on ,Yulv 1 of th9.n yenn• which willI roquira emcrng other 

th.`,a4;O tlra.t a lahol bc pltaced on onoh pacL : of cigarettes 

r',nd Lha.t a r:tntoment. Lc Inecn^pora .ted In oig'aretto n[7vor tise - 

he,ntF: Aa nll undi.e including radlo nnd to)ovision . 

Un7.c a :: ths W 3ng Ps; ae.e+cindod, ft will require that 

onr^ of the Yo?L10%ill[; r[ta..t(:NUnt s apl.E+nY In each cigarette 

commarct .nl on r [:.dio and, tolovisi on : (a) "CAY/'P10N-••CIOAhHT'Pk : 

F.MO1qNG 1R A 1lF,AYA Ft: }iAlAkli : 'Phs Snrgt+on Goncral'e Ar1viF:ory 


ZO@

• 

. 

Connafttoo oxti aaolcYaE• on } 4 r,itb har• ec.:,uC . -h.aA nig :arc:tto 

Evnoktiag contr ;hutcs strsh^Rffiv!aall to Gio!ri2d co1 . :(.'k9 .'ic+7r 4~Y wUdgiriq ;: 

fbe cyu„"•.A2a OT tdhe pacti:.ttct . TauiiYloDitY .iyr a baroadoa,nto•ei' 

x•or}.toasR.h ;.Z99;y c,Ucs+Pn u, cftct,xtiSowOni :r: M F1eeu *ii^.t t.7aQr 

fa'aa2 £$ ~.CCtahPr :ei u'A F.ouocaty, S'a'rz°taci6'G {tT?A PppB tûYte . {`2 ..e2 .: ..g 

.lud . vs>st on tLr =t . :. .v r .f ^,fi;v :'.9rod ri^c , fr: i'or Bnyoalt7 

4Jor °r^, .Irc o° xhe brai : .a :aeSs3sntil 1'axORrM .cnzi . 

Yn ndc73j:i"oA, 4k;e* 

r+c:op, r :IO o .nsirrraea.s.y bAra:ar,` i . : : cE007rdncl iry ' 

rciavs Î_sm t t, a;e ry of Phe . arormcenrt . 

;a ups5'n'br tr, iltcr ptthlf.o 6 .n that 

fhcra r,.rcriiiSC:r ;.apr vntlioa.7l vAevv on % : r:ubtcrot, Alro . 11 

(1fEiCS'?llt7mC'r.er,d tgc9atc .c the], :v-c.fl:r,ltet Ir[3d'i .a., 7Tieatrei a(IVer- 

tir,otv,trts : eM ;YCi c,s>;iry tho L•.li,A In ruc+h an«;8 . .'l tyym m .o to 

h e _:navcie.iri a , •rt¢:xn ; N * . car4oec5tsr .g orvalf K 4 M ff; Per . ' r 


.i ov t1_r , te 001 7 6 .,_ •~nqsccedon9 .ra K c:ua, o£ aman 

4 arnr S~u .~@ M in roza ~.£^9aeg tF, r r tc. :a' x .r} siaus=l . ab 5a %r'C "~ 

2048

• 

• 

0 

%ri.Y? hs Pro•r.C (;rc,et7y Gnd, mc. wflx 

FAj?jnt/'4 :AGC; pQlaP' tlil•?&ti.U,: vu q5' YtlLlI £OE+) . :P.L[;d". 1J1 Gt2S 1 :92LC$BY`„ 

29YPaPk y0u . 

G£m::oso7l~~ 

/r,/ 


Os'9

• 

• 

• 

bA 5 . 

Eiotrox•4th7r: Fieam ot . (d . A1r< gnu ::o n 

Cp m ir•m~ 

(,`QidYdYttE:e On UGLîNFY•CG 

Ylug.to

• 

. 

. 

of tbe Eo :cintcf: enf the k7i.s:'trict of Co7.umb£a, hxgeniserd 

i14 lfif@i, t}AQt MFI/1 tOlrft.y y'o(,voUCkntE 6ioro fban (",('(IC/ ncVl :)¢$ .iX3r[3' 

of thnf ;ct f+os•o Wn SyfaQpl eFro UoektAcis, mcwt oi' the ret

• 

. 

• 

b) 3 2052 

hut- svonlct po :=e a ca}r,+cACi :t thrcat to ottx• nntion'e : froc (Aroni, 

rn af.gaa7Afj .cfrnt r :ogaaont of Lvhich i,a roprarented by the mornbcrc 

of our A.ec:a :9 .nt.flon, Pnvoductt ndvortis+ing is our mombcvrrs' 

ceox,oanAc: :aifebinoci, and nP snhstdnt .f.x7 vednct :ion In tatch 

advorticinlt e:ou :ki obvioue;P.y ilnkxarik our nAawboa•c' contS.uucd 

er.iotc:nccr and lu.do}xndonce . 

In ondorcS.nF[ the rtgsht of Antsinofl sutefn to ru,vortisa 

oAf,ec.Uvco?.y any AgaA product, thr : )',trstion,al Fdf .tor :.a7. 

IA^fioe2lltACRa, G$ e(NBYf :R, doOfi 11ot a[iVo0t1tA3 dOCC+}It1.vC a•dVQI .'-• 

t+avin4 cre e ;uy6o ut that ar, risCht, to au9vesrtfine doccptf .vei.y 

eNP.iltf :, . Our I:Bf:OLY.ht4An htiE' COO :B4bit(Ant[SV fought Cihcp}tti.vEl 

ndvor t r.rsfini; . Selood, lwo hexvo c .ften nct:od a n s kind of "ftottor 

L$uCni{Iflflr ; fIl1P0a11 " ]ln hP.tpinl : Oltr P4onthOkFi to @NAkd aQainHt i,nftd•° 

v¢>.°tonCl.y acoopting daace pt :ivic edvortzsangiri their advortfsr .ng 

ofS'11n1Afi, 

YBoct cortnan).y, &owovor, ssn; do not r;ubcicribc to tho 

notion tha:t advcrticiug rrhich feils to r.ot forth poncihl .o 

nrr;aercaat:a tcpyaier.•t ueo of thc ndvcrt.3ocd parolluct in ftil.ec or 

}naulceclAniE= %t,tiood, r:houZd p,overmneuit prelxcym3 to dictate 

to nGvc:rt.P-nors tho c:otltont o :f their f9dvertf6inf;, 1t wou7.d 

trond upon rAnks,c thatt nzao axot or ;Zy 7,oaa};.noooYit.od hut, In 

ovr• vr.en, canxtitataoaarxl .]ly•ganotoe.COCi . We bolfevo that the 

rr :iyart to advortzaa Sct,Atirnrztc 7*rtS .cal.c:n of ooinm2rca, in ae ; 

pcseunn :ivc tortou ts poc,nnhlo, In a necer.nax•,y A.uoident to 

thc x1ftM to s(e :L9 . Mg8'r.fxaato ra•ti[:1o :, oS ctonovo

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08 cour.se we app l.aud tho efS'orts of any trusl .noan group 

to reNt'Llxto ite own aCrvvxt,fier .t,ry, . In thifn coxubectl.on, we 

uotr, tha :.tt ci!tarcrtto taanufstcturern 7.ant yoar adopted a CitCe.r•• 

otte A@ves•ti.gi.ng Coctce, v^hieh bec+u}7e offiaially effective 

on .aU1nRk'y 1, M : . In otxr HOCiety anG Hef»loliy, Ftllf- 

ro(ntils.tf.on hae trndi.ti.onn.l.l.y treon preYerrreci to (;overne,u¢t 

:(ntorvent9.on . Xt wca+16 be particulerly rogrettable for 

cotnpul.sory u&nePt3einlq wnrni.nige to be iiapos :od at a time 

wLnn the c:i.,;arctte i-nGus,try has t.akan eotcspEV to ref ;uln-te 

i .i:ec lf . 

In cxpresr,ing. our eppot ;ition to the advortiaang pro-• 

vicvionu oir 10, fr9V and the ffi4'C'ti "'i.'raCee Relaulntion 1Sul.e", we 

wSsAi to Inaho Mar that our Ar,ecrrir .t4.on hns no viea on the 

barsie eo9ontR.isc ie. ::uoc it?vc .Lvca9 -•» i .e ., whethor cfgrsetto 

amols2nE flc, or is r,ott a asip;uffi.cnnt, hoAlth pr•oblem . We &lso 

7DG3 

wish to F)'GntC ihilt: t"e take no po£+'iti .oll Whntn

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oor .ccrn5nt" V WD W 8 . bW 7Lesc lulln new oosmer-noG 

u:it.& Fa ;te:r1 :1 ;crye,ircmmtl4s ; S'uyp elt :raz :i .f.s, i.nhc:7Sn(: r ;n6 

D.F\T1'tiPipr FEtr(; FSE bL1G :Cl : )+MiY` t'bm:9 .t£00 q)1 (_:CMpABFCO 1CG1' 

f:9l j4F QW t--bUP1 , S .'i .Spr; (t f l;,bihi':iOn, Oodp(,BO :i 

oi the W?£pa (J'lfe:ox~ (i or.oi, e.io.be- tmcl onoh torr9tox•y o£ 

1 .he 7qiii .oa Fa Ic•, p ;+< :.ob r, t.o tJio cffcet 

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ilrr t, .t^£" W F11] ( 10, .; I ,'i n 6H( ['fc_ tIP's'i .

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cowmox°ci O Wo, 'I'oGr. Y roorc- thtm Mevcutes>n tnil)ion pooplo 

(ic :l,ciiQ 5 " euBo)e o r in pt+eL o n tob a r,e:o i'or thcir l .ivel k 

l Wo[:, Pbatora), ctatc. [ .nrl ]ncr,I tsae ; c :n t.obnccc. ruu i .nto 

bi :U.ions o1 r,tollars . Aa oau, of' Amm•i .ee,'s ptv .eeil` :•I or :portF, : 

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eo%7h(e t oUp t12) :ItLOn . .C,3-I'rD yiliF>ntE Qi :i.i6S$ . 

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pf t1,C U,i .Y.Wy 1,)PQQO)', lib(IvV SNiOMF 3YC p,Ofo Yrorr0 16 

vrillOqk of t.)'1'ifl Or/( .flll , 

"Up t .o t,t,av ir, nono oi' £hot:o i4cldn hrrs the oxrset 

c:nre9 .l,oPc-ni.c ccldou of s•aolr'rnR 1,oen cluc•i(±atoB, Wiih 

czaoir~ of tho 7wrD, c?'i)âc.t ocmtTOt Fn'P .crc :o)h smol ;a r.ttd 

onyen i.sn ohviovr :, la',t acli :h em-ci_a,o>.a, o£' t.ho bl2(r,cler a 

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tLF( £ . COM UC:a9ez iry)ri-uZ+£urt . 11ie1ow G , nrlc oi tLey`r k- 

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) c .,2n In 1, ao iv .rbS t .4Y £.e. (.,cuivo:,pam: . 

",lAC L( n Iflv. RO n ..te'}0~l .ic r£c .c>'re : : c .3 e5a s :AY :iecis , 

n14x.rbkot" rax ron( : 1 a i : :rodccrr. . ki>(: wetcv tostcC, 

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1GftN v• .t'G•i t .R.y )iN W})p(f) R.Q .ill(v (IILRJ .)I . 

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ty )e 

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to OA )1C`PLOIIL, pVRRkigatlf"- 'l )7CiGCllt. . !11( :T6 V/FS F4t the 

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(lC))Q,(?Li : .° 

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ei the ae.o{-uJ I l o h P sia)< .:e au ; .no,c Id M9O 0}giNv, bp tcnr.e s , 

to 7U"CCr9'sF11:61)1eW , e;Mel, in wwo oS the VitmS ;n t. e.onP)ex . 

Tr:y},£ophns, 

I 

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1.1}(YAIi'f}Rtil :'f Ui~ 1];PQIiiJk'A'7U}•;, B}kiC6H Elk},Yr, Unt,g.7e vi,e ut .a^kod with th.eEO tlubstleuaos: 

l,mpo } O oir.ctaoa . 

kLO )u'ob}c:•ct.i?7 zta. .xincQ S.a i,o H0y Inqn,v Poo}rle 

Gevc,) .a) :eQ b) n dlBox (.a u ccx° i .lr o7(1 e{yo wftLoutovor Hev :uO 

bbO (ij0'9GG }/IOVi1fQ;],p 10 c:I M piSOP.1G of t816 2r061(;ti0 klgfA6 

5 :4il .1V' . A £AÈ1'c}A AiNE F'tI!MO fQr3' lltl:u,P!!11V•-OCG11k'}'iL(' 

x't'.4 r, torie} .- ti :.t.hp n i .hc. Lndy . } .hsr; Fc.L•uI :£.o8 elttontion 

(c a I-{i1 :'q :iFeta6( : CR!)-(K7 tl"yy3t4} lhSl, Ofeb of thC FA . .GAI} 0f 


2055

• 

. 

ty 0 

prnino nt:idc tb[,t fovc oE ::sut3 .c7) bul .]diut, bl¢,otcr; mith whioh 

the bociy cso(atcc protcSn 

.v Srs morlah7ly . A'eyptcq"br procoFa;oA vR .t./d.t, the body 

r.htou ;;h ?our mt : ; .e. stn(rosl into e roS .r,tavuly hawm5cse 

: ctub-cdarico, ui 

.oofiir~rzr~aidc . Orw of the AotcrrneQfutoe Sn thie 

p?roErdi'

• 

• 

0 

demelcytr(,tion of thor ::c r>buormnlitios ys :a8sstl .ng the onset 

of LBnddos ot=!doen", they wrg .tc . ^}l, oxder to do this one 

vVn7 .(i he;vc to mOxFUro the ptata.exri of tryY=tohhe.ey mote.boMm 

Su a ve,.t+t u(naLex oF tlolina .}, sub ;ioot[I xnGW foll.ow t.l'wnl £or 

f:

ty 2, 

T/i)i 1;A14XÀ` t)d' S141H1N0 ON Ity,h)ul+k:fl CNtCYNOChNS .+ 

W,IC, . ) :.c:rr, Pf, 6ar9d.n, )^ .T;, i-oveas, t1 .S .0. Woo P. 7„ Uonozyk 

pnpaartwoal9, of Surgox•y, L[ni .vcrr,ity of 1'oronto . 

It hari hcxou pi:•ovou rwte.tietiora)Y.y that smoking iu 

tsrsoeiatoti vi .th canccer of t.ho bronchus, caneor of the lip 

tnd cExo prono to caa¢or of t.his 

or(san, 

up to nor i.ra noncr of tha se fie)ds har; the oxaot. 

c auoS noP•bniC eA.tSo[[ of E, ynokU, g beaa olucidatoct, Yfit .h 

G4t"eS1,4)%G of tdlc )VD(•1 tiiyGC+t 6o[athC+t betVh^.[+n Smokti altd 

o rgma ia obvia u e,, but cri .t.h otutinons of the b)addor x 

mruv [auY.t.1c, rc).htions;hi2} nnt[:t oxist . AN a baakground for 

the Pxr.ntont Snt;uity int.o the [n[nuaor by vihicb smoking 

may Snititn4o e[nrc.i .nanp of the b)n d der, [x briof review of 

the trc•r•kk in the fio).d ot tx yptol:lan ma:tnboliem i[•, rotjuirect• 

Yt h[re: bc.c:n w o)J) c[.asb).Se.hcd that ost ae r oi' the 

uain, ey bla8dc 1 o[rn bc: Atiduced by cmftuc:t rv5.th c :ho[ni .culs 

in t:hc: rtritte En [n,au Rnd ropc'rtiuced expcv-Jnu :,ut.ai)y in 

ardn!fal.e: . a'he coa, . .on cie+novd .na, .t.or oftopiCr:] onrci .nogcnic 

subts tanccr; ci[s found to be tho orthonmi nolhono), confiGura- 

t.i .on, ono in v.4dch the irydroxyl. [rnd nmisio radi.on)s aaw 

tadjacwnt to onro anothox on the bcnPo Ho ri.ng . 


A ccnyrh Fcu, ovcic .f:enour: ana)oCoos: 10 o ineiuEtr•ral 

2076

cevOAt.(;cnN unst enu,priaios, on the motx..bol.9c px• ..edaetr, off 

the orstro ftc+9,d t:rYTtophF :_r, . 

Y.nePOCot1, A byc r ox.v antNt°estrlkie, r o S@ h,eu bec+n sbovnt 

to bo enxcznognn5-o 9.u nnSrna lF' auci 4A pr®sont in the urino 

of ba0{i(i0r CGfY1L'm pfitStdnt r to a ILi'CrutCr QO€rGG thRn in 

tloh'14!4 .) P , 

5oo br.e.{o atmoYr:sr)4Ey ;n puet5unt.c: Wh b1ne7der cnnoe

) 

aftca hc:vang uf:oj,ped e=mGl :.4nE~ . 

CJi((art•t:te flf,lOltt}In M.drC?èF?SL•d the Cx.:CPTtioll 6f ' 

CEJ`Cf.YiG(;GYIYC C+}+QpAUF.1f1HOjlhCieO).E: $h the Ih r iNie of te .l ) fltlh,fflctF3 

t4ithS111t OXOGj7tiPAl . `/7Af+ fi,UX°GflE:O PAO([C(l i`.CCN 32 pBlbCiilL to 

C;4 Pcxc

'PY Y. } . 

Sormt.o :n VtFlrxr.n G, 61rrC:rr(recrn 

.:cntnto OktS .oc)!ui ..1.QSrq; 

i4ns:hi.uC:Eoln, D . C . 

FOrrF 8(oR&tor fiiBgIIllROlu 

'fNT ; :"1'qt7 : OT' w . FSI)]PCiT6'il 

I)SSPkitT)dR)d9] O)r }4d :Ap .Cll 

oLYM)•g4 

6?erch 1, lS1(;E; 

4i0 ;PO Oi the Oc .11vYC$S.ob t.h n t GontPOl of Ft(avert9.G2n[( 

a : . " Q lnlic]4.u4: of ai) :ear-ott,ot: tri.}.a trtsist cous4,e7exably vrztL 

QG•OroL:i.pe[ C:ô)tiD$ by oCe"C \+oYtt)1 . '1'hG 14EtSOGN} CRtFu5t1òj'ih0 

w7r ;ch Ilcrta tEAl .os H toiA of rr cfttvstcr of n 3033100 of our 

poop7e cwexy yea.a• by prcv:(.tv.ro dcat,h, nltct ovon wo rse, 

s, . );.rorstor laeN,bc:r or cimoni .c 65ecrac, (4i snLili1:y and 

:3nffOr9.n(( liRtF{i bC tt0®td;P77 .

ty n• 

contiuue at s 41?.00,000,G00 xnte pea; yntcr• then nu equF7 

PxvOs;tau= ;ci w :,artTatory to (cflve yownp : paop3 .o z fa4 .r ohntitoc= 

at 'r-mpso^titt7) guck4".+nent . 


BYnGCS'OJ.y, 

s / FSnrncanc4 L'uc.ove, 

Ch[,,Psms,ss Intc3y•-d[ 

:mmy ifcax3t.h, liduca.ti .on S 

lYeS .f.'nx°e TroprVeM ( :ommittoo 

s/ GcoiRO R . elx•ne7ove, M .U . 

cheirmwn 

Eutc;r-Anmxoy Subcemmit :t:ee on 

Rmokis,¢; e,nd liGS .7 .th 

2080

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