Tobacco Documents Online

,J

FIRST EOITION Ttlil~ copy i5 issued a8 g lir~l cdilion prinl = irl~J corllahlin(~ rio ~llb~(;r irl(f~'~ A ~cond ~dp(iOll Wlll~ index wirl bo ovall~ble DpDro;4 - ];I; t' TOG9 FOREWORD 'l'h~ I!)1{~! rep=~lt ()11 7*lit' Ih'fll//er (~.J~vlrlrnr'r'~ i~ ,*~nl.g'itt;! Ihl(.~;,,,llH ~l ~lpmllr~lu!n~ive t'vlllu;l(i,m ill ~]~e r~'[lJIi(lll~hill I~,Lw~,~,n ~.il~;~r~.(ll! ~ilkOe l!):~7. ~rln~er ~1~.~ ~ll,{ril Ill[! ~.~?~)ll~ i1~I ilnl~ll;llll i.:~tl~ r~l' IICCUl rili[~ I~ll- iIL~tt~r• ~111.(11111! ili~f!:l.~l~ ~tl~:~l ~]~ IIbq, ~l{I i~=l.t f~l~l ~lr,i liil~, in tile c=l]~liqlvll~cullLr rli~en~ nll~rt~lIily rlLIl~ nl.I Ihl. ~qP ~pl'l~,,itl ill~.'lJJle ill ~he c(~r~.llrllvn~4(ril~l~r ,Ij~t.;l~e rltc~rlt~l~l~ ill f(- i~h~.lv,,l~ ~,1¸ ]iLIIt~ civet two d~culJe~ riutl IhuL chnll~l= h~ hl.~,tl ;i ~m;~ll. Irid. ~lle~l:~ll r~lhh2~ ill~l~]~(~, 1'11i~ inl:re~l.~e il~ I~1¢~r I;~li(y hJl~: t.!~lll i t,~l hi Ihe I;~ elf i.t~rllrq,k~ll~l~ hllllr~lv~-iru~n~ i~1 .~urviv;tl ¢~lli'~ f~r¸ ~1111,, t.;lll~ ~,~. )y~ ]lIIw~ver, L~lese Ill~vlllll!~ hl]ve ~]~lo~l ht ~r~t~n~el¸ Ih~ i~'lll;bt )l:1)1~,* ~llcr~-i~t~ in itHirll~lit~' friJnl ~]1111klnj~ i~l;lled i.~rlll.r ~. inllrly ~1 which Ii~ly~ ~1 iio¢~r [irul~]]o~ [4~r ~(llll.r-Le r n] ~111 v~wll (~1. cut i.~ The Publlo Health $1gnl(loa,lce of this Report (~i~:~r~||o Rllu}ltir, l~. i~l Ihe n:njc~r ~inl~te ~.llll~q! 4~f ,'ltnl.clt. nl~l'Inlll}' in the Ui~ite.I .HL,Le~. ']%h~l'cll~ i'flrdrihH(i~rl ~l~ r~/I Cnrlcer de~llh~ i~ e~(Jnl~lte(I Ii~ he. ;1(I ~ll.t'r'erlt~ rl'hl~ nlf!rtn~ w~. i=lln onff~lll+eql wi~ll r~uil~lll~l~l~r~ (~i~],'(.[ll! ~l~lltkel:4 Ii~v(. I~l~l (.:lru~.l, hll.~e~ iilllil~l~l'~ of ollr l~f:llll~llt~l~l dill ll~I ~lllr~ll(.. Ihl~ .:llnl.f.i¸ ,l,.llIh r~de h~ th~ ¢otJ~t.ly cl~Jtll ~ll. i'~!(~ul:ef~ ~lnll ill~t i.~ril r~ I|~l" !~¢~1~111 I,II cl~l)lhlued il~¢r('~e ill Ih¢! Irll~LI c~lrlccr dt~;lth irlh., the.re I.~lll~ Ill. :1 ~.~l~.~ltlli~s~ ~l.~c~l~o. 'L'~I~I~ ~ till ~i~l~le L~q'(~l~ i~i~ itllt~.~Iil~tl~.~ll (~l~t! Ill r(~;hl(:~. Ih.. riqk c)f CElllCC-I" tltljll~ el]~.c~iy(~ly t hllll iiiliI~ll)~ ~llll~llil~,

I ,, I)l';ll lllltl li* I'yiit[t';I I Clill(l~l dL!il{h5 ~irl~ ~ i~L'tl)t~ i Li I ~,(I wJlh ~llll)kJlil~, 'l'lle,~ ~L~l~'~,J~ ~lre ~Lr~lll~ly zl~l~i;ll~l wilh th~ u~ ill" ci~al~ and i~ij)~ il~ r~hltiv~ rich (Jl' zll h!;l~l Jiwl~d~l. 'l'hu iI~,~ o~' ~ll¢~hlJl Jn L:olljliilcLilll/ L'llll H H'~, ~sophli(~oa~ Cancer "rhi~ yenr, 8,~lf)f) ¢h.;LIh~ IJLl(~ {O e~lil(!(~l' ill+ Ihe I.'~lillli~=Rll~ lll'e p~L~iellL~ live 5 ye~l~' a[~l¸ di~q~rlt~i~ 4ill11 rl]l)~L die witllill (~ JnlJrllh~ U~ldLU,~e~il cllnc~r i~llll~, ~iilt~llel'~ ~l~lve nllll.l~il~ly r~LIjl)~ ~tlJlJ~l~xi- iJiiltl:ly 4 I~ ~ t ~lne~ hi~hul Ill~rl IL~ll~ll]lJkel'~. 'J'hl~ ~l~e (Jl¸~l]cl~ll~Jl IJ~L~ n ~yllel~i~lic illt~rzlcl illn w Jib ~m~]k ill~ th~lL i~z ~ll~' ill~:l ~l~ Ihi~ li~k. Bl,'lddor and Kidney Cancers ()vul' {I(),(X){) AI)]el'i~itJi~ Jill! exl~l:l~!=l I~ d<,viq~Jp I>hi¢ld¢~l" i~rld JIhJl/L,y c~ulcL!l' Ihls ye~Lr. I~l~Jd~l¸ ~]nd hJ~hl~!y ~:~lll~:ul~ will ll(! ru~l~(~rl~ihl~ li)i" ~J tl~t~41 ill" :]{~(llill II~LI h~ I hi~ yu~Ll'. 'l'h~ ~ yu~ll¸ ~l viw~[ ~LiJ]l;4dL'll I~lllt ~L~tW(~i~tl :lfJ ~lll~l ~]~) II~l'l~'tl[ IjI¸ ~l;l~l~h,I ~lllt.q!l:~ lll~! ~l]ll~l~ilq~ r~hll~'~l, wiLh ~li~;llll~ hi~h~r l!~rinl:*l*.~ I~ll¸ i~h,~ I~l~ll lill" J~!lnllh~. P~ncreaiJc C311cef Ihi~ y~.;ll ,'~Ln~ I hill ~ will h~ ~Ln l':it i nliLt e~l ~ L~,II~ )1] ~J~:ll h~. I,ihe c~nl~:J ~ (~l tll~ ILIIIF~ ~J llll I~ll{iJl~l~ t ~1, ~ ~lliC~l ol" I~lt~ Ii;Llll~t t~i~; i:, iJi~ll ~i~l ~ll, wi[h ~lJll~ili~, il wlltlJll Illlll~l~l¸ t~ I~l~ ~ll~OllL ~l{I I}~J~:l~itl IJ;lll~t!~lli~ C;llll ~!J ~l~)~ll!~ll 5 Ll~ ~)~ ill(ll't!~l~ill~ ;ll ;I iil(~l'l~ i ~t Jli~l J~ll I! I h~ll illicit i~l I~l!l. l~llH ~,1+ $1omaoh and Uterine CorvJx Cancer A Ii[ll( ~lt~lwl~l~ll Hllll~l~ill~ ~lllEI ~*llllli~cJi c~lil~it~i• ~lJlll ~,~nl~l~r ~jl¸ Illt~ iih,iijl~ c.~z vi;~ i~ II(~t(~l I IliwL!v~i¸, tll~ jll~lj~lll~Jil{ l~lll Ill! Jl~;l~ hi,El l~lI ~llu ~¢~llil}u~UlCl~ i)l¸~lny ll~'~!i~l iu~l, ~)~¢~LL~U ~l¸ il ~L~ll~i~'Jlt ~:lt ~l

~l~ ~'VI!II( tll~l(Ll~, ttle ~'411~111~1~ ]llt'~.~. [~t~ ~tll~t£'l{ (t~t~ll,'~,l i~l (~1(' (rllllt iO;ell4y ol¸ whe] Ii(.l" ii:l~;~;ive ()r ~llW)llllllilly ~lll~killl~ cliIl~l~ Iiillf~ ¢lLItet!r ill II~=rlqmol~ul~ 'll~lll,i• ellilielltl.h~lit'a[ ~ttlc[ie!; i.X~dlLinI'd Ihi~ J~.~ll{' ill Ihl~ Imsl y(!;¢t. I~]vi[h'llee Ill.iI Iwl~ ul" IIW ~(lldil!s 4ellloli- sll~dUd II ~lali~li~:llly sil~l~ili[~u)l, ~Olll'l;llil~li ImLwet.ii illVll]Llrll:ll'~ ~llll d{illl4 illlll IIII1~ I':lr lel'l" I'{ ~,l{ in IlOllStllol{ [111~ wivl~ ~)[ Ii[IS~}~lil~ls whl) ~lllulced A H,i~4 Illded ;I pIIsitWe z,s~t,'ialiml, licit il. W~l~ I~lll iIIlll.~lv{!ll, it dBes i':dsO lira ~(tl~Cer[I Ilml ill~{~]urll~[ry mnOklnr~ ,ll;~y liege tl ~Zll~ilJtlgI'ltiC risk t~ tile lllln~lll~l{er Airy health risk J estllLilll~ ~l I~111 [llYliilllllllly sr=J(Ne I~x [)(IHIIl'l~ J~ II ~ltl i{lUS I)tlllllc ht!alth {!(llll:l H ii I)c#[ItlS~2 ~1[ I~lle Iiil,l[@ [lilllll?121H Ill II~IIISIIIIIII(!IS ill till! pOl)Ulll~k~ll y;I)@ ;IH! Illdl!=lli~llly expIIse~[. Thel'elole. lilr the IlUll.6e i}[ Ilri!vultlivl~ IIIcllilzille. 11411¢[/.lllre dielale~ tl,tt llltll~;lllOllel~ llvilill L.~IIIIP;III'O (i) s(!cotld-halld I~l[~al:l:~ ~llll~ke Ill Lhe I!'~l(!lll po~ilde. '. Lower Tar Clgarelles i:i~[~lt!lle~ hl~ve sl~lLi~lic~llly k)wltr ile~llll rld~H from lul]l~ C~lllCel¸ I~lurl ~hl ~i~l~(tltl~ ~ulldlel~ wll~l tl~e llorll}ller¢(] i)l¸ hil~her Lar I, nn(ls 'l')=i..t rl!(lll(.(.i] i.i~ll w:l~; ;lifo ii(l((~(I.li)l" II~rylt~.lll CllllCer. Ilow~ver, ¢~11]c1!1¸ ~11!;1111 i'~lll.~ I~,¸ ~=lll~k el~ ~Jl¸ Ic)wl.~ t:l]- ci~l~lLu~ were slill b[l~lliJican L]y Ilil4her [ Jl~lil (]ll..Sl! n(dell I'l~r Ii(lll~ltlolll~lS. I;essallorl el Srllollin9 Sill{e c]~ill/,ll~ P+llllll[Jl)l~ i, 11 CIZ~IS(~ (~1" Itllill~ Cilll('elS, (!11( lllllll~ill~ ~kll~l id~*~ltl ~:l!ss;llil~l are ]~l+J~ell[(!d i=l tlli~ I~e~)Jt. (~lJiLtinK ~nlf)l{ir]l~ iJil~ ~lll~k~l+, even ;libel" tl]~Uty ye~ll.~ or ('il~at.eLtJE+ ~ll]llkillK rl'll+~ iIiot.l~ yt'r~l'~ one i;+ (~l]¸ (r~f~l rl+[ I +.~;, I.~le i~ J-e~ll er ( he i ~lluc|ioll ill eX ~+++F~l I:IIIICI.I" • ri~k. ]"ilL(!l!ll ye~ll'~ lll'iel" £Ll[I.l+ia~ cil+'~IH!IL~+ ~mokilI.E. 'Ehe ~Ol'mer ~ltlllker'l+ ]1]111~ (:lllleOl' lisk, I'()I. e~llrllllte, i~ i~dtJ~ell tie)so [o Ih:l| (~h++~rvt.ll ill ilon~llll~kel~. "l']tj~ S~lt~e I~hlclil)n ill e~lncUr rJ~;k i$ ql[~t!l.vl!(I I~r |11~ ol]l(,J" c~lJiCer ~il (!~ tl~++l)cilll i,(I wJl~ ~m(iklrl~, ~llll(~llt~ arJill(.~ ~lnlJ illll)l(~co111~'l. In ~uIIIfllllly, I]lllny I)l(~nti~;ill,l~ Ii!l!h. lli~lu(,'l iil~ I~wlihll~lll L(~ ~l]ll~lt(~lS who IIIIvl~ I)cell tin,lille tl~ qtlil f~ll I ~leil" (iw111 JL i~+ ii~lll~l,ll(!ll.~=l ill~el'l~Lilll+r I1~ Ill)LI! L~UlI+ I]1~ vllP+( Iil~ljllri~.y t~[ Ic~rnl(!r Ri]l(~ll(,r~. illl)});ll)ly ¢lll~e |l) ~)~ i)l~leelll.~ iluil+ i~11 I+heil' ilwll~ 'Ni I h~ lul Lh~ llill or r~lrl)l~ I ~l)l(ik i Jt~ ci,s~;i [i~ Jii [irlll~l~l Ills. A~ lJ i~]lyl~iCi~lll, I i.nl!lJtllal~t~ ~lll Ilelifl,Ii car(! ilrovid~+l'S, i)llr|~(!tr]lll ly t)l~l~r |lh~i~illrlt+. 14) c(lunsel Ci~[llroll~ ~lllllkt.r~ tl) (lull+ ~lrltJ Lo t~ivl~ Lll[~Jl~ ~1~ iiiLicll ~Ul)ll~rL ILS I~ible. /~s [his Itcl~or++ iloles, a low ,ili 91 & 2I:069 Trends Ill Smelling Prevalence J zun L+rlcolllall~l'lJ bY (hi' II'l'PIl~ ill!¢lilll! ill t'il+:~If'llt! mrll41ini{ I:~h.s hi Ihff= I'Olllll ry 'l'~.l~ly, ~llll~ m~e-I hild Ill ;llhlll ~ ~nzllh{., ii d~.l'ilnq, Ii~lrll rqir ~. ll]SO lll~lle;ll ~ [i) he dl.l!li n ielf~. ~Vllil(. these fil+rUle~ ill(! ('l~('flLJr[]l~iJlrE. t]tl'II' ;Ire '<1ill .~:l lllilli,~l C~Lr{'I.II! ~ltl(~l~el'~ itx I.~ I!~LtlLr~' ~1~11~ ~. ~l~t' i~ltl~ll~l¸ ~[ I"~ll t herllu)r er whil~ per ~'~lllil:~ tJ~l! I~[ t il!lll~'lll.~ h~.l dd~'lin~.d I~ ~r~ ]<+lvest lever ~illce 1!~7. IJu.ll. h;l~ I/~urz ~l ~ll]l~lllli~ll iftl:H.;~, it1 I1~1~ ++~llt~lll]lllliiizl I)f C]lelViltl~ I~l~lll+c(i iii1(] ~11111~ I~lrlh ii1~11 Iv Iiil~llr~ IhP y(lllJl~. WhIiI i1111~l(t tim ir~q. ~f th~.~. [)rl~dll('r~ will h~vl. c.i I~lhn~. ('~ul col" iIiiii I~rily i~ ii nrrl.~ll ; kll(~wre~l~l~ t~l+ ihl. I~1~1~ Jlllll ~..~1 i.ill ~bl Ihq~ ]teltltlt e[lecl~ o[ L)leso I(~hJ~c~'l) pl~lllucl~ i++ lill~ill'(I I!~ll H'III r.~i~h.lrr~. illl]icaie~, hrtwe~r. Ih11~ Illeir tl~;~ i+] Jl,I wilh,)lll tlsll. ~hldil.~ (!rllll]lll'letl il] tJli~ Cq)tln~J~ ;inll (ll~ll!l~; Illl~.(• (l~.mr~ll~+h~h.ll lit1 ill ~1+4~1~ li~+I& (~y O~11 ~tl~M¥ ~1{ ~t.~l~'~ ~lltt£~ttl~t-l~ltlt4 ~t~/I tl~!~.~l..~ Ed,calional Eflorts *l'hi~ I)el]~l),|lll0)t( i~ ¢(~lllllliltr,d to ~OlllJllUilq[ IhP in.Hillll~, ~r el[I]e~llil~tl ~III(P itl[ornl~llillFi lill ~tl[ ollr ~i[i~llr~ r ~,Kllrdlnl~ ] h(. :t~l~i,r ~11 ~ll,~l|ll con~eqtl~Jr]ceq ~)[ f;it~rlkill~. *J~Jlpr~. i~ ]lC) nl~}le illll~r I:~rlt :l!;[~(,l.I i~ t}li~ tll;ll] 1,)1(! Ii~EiIL)l el]lll':lli~ll Ill (lilt y~llrt~. I~ cl~:lvi~l~ (. I [lel. rl~t t~ ~l~lrt sl]l{~l~illl,~, or Lo qllJ( Ihe h[i]~iL be[ore i( Ilecllllll,~ ~lilllr =rll Iq~ triton Ihe rc~t, i)l' the Ii~,lll(~l (.lit0 ¢r~n~ltlllllit.y. Ih~ vl~lllllh~l~ Iil,~fll this COUllt r~'s ir~lJ~L i)re&~irll~ J[ealtll I)1 ell[eJ~l~, Ill,d ul-il=~ ~lrll~rliltl~ will le{l~lce |he i[~v~l~ll~(ill,q (i)J] IhllL cllll~l!r. ~t~ well fl~ ii[h(.i¸ ~;nl~l~(il~l! I elil[ed {Ji~(!ll~=~. ex~lcL~¢ o]1 11iJ~ N~lLi~n'e~ Ile~lll h ]~lw~r.tl N. ]ll+u.ll,,ll, Mi)

F F FOG9 PREFACE h~ July 1957, Dr, Lcroy ]~, Burney i~ued the Public Health Servic~'a first stat~lnenJ, on clgure~e smoking: it identified sJiLuki=lg ~l~ ~ Cause o1" lun~ rqnc~r. E4~,~]l ~ll~ecd Jllg .'~tl~eol~ G~r~er;z J Ii:~i ~l~d occ~*~iOl~ to ]~U~ LlddiLionlll ~zlld .~trorlger Wiirllillt.'~. 'J'[lese htlv~ |inked ~m0king with lung c~cer, wJt]l hear~ disease, with chronic h~ng disease, with othur cancer~, a~d wiLh incre~se~ in overull m~ Lality. With this 1982 ~ate~n~l~t o=~ cigarett~ smokiJ~R and cancer, ] ~m joiaiJ~g ~ny di~th~uish~d iir~d~e~sur~. Drs. Ilul'ney, Lut~e~¸ 'l'~=~, WilJiuln ~t~w~rt, J~-~se Steillfeld, and Julius |~i¢]~m~ad, C~ig~lr~tt~ ~mo[llng, as thi~ Report ~lJahl mat~e~ clear, i~ (h~ ehieJ~ ~ilq~l~, • ~v~id~]~ Cau~ of d~LJ~ il~ our ~o~J~[y und ~.IL~ lu~t illl~ll~l~l~L pu]~tie healLh issue o1" our tJlll,~, h~v~ buen i~reparc~ by t]l~ Public l ]~alt]J ~t vi~ ullll~r the [~:~l,zl'a[ (Jigal~tte Lal~elli~g ~ld AdwJ tiaJng A~t a~d il~ ~u~or, Ihe Public |lea[/.[~ (~igure~l~ Sin~kin~ ~.c~. ~r 196!~. Th~se rep~.'ls havu col~trib- i~ted gl'e~[y to public uJldur~tandi=lg ol" the ha~Jrlh; Ih~L cig;~l'e~.l~ s~nokinl~ pos~ to tho h~u[th ~J Lhi~ N~ti~J~ ill ctJllL~t=~L wiLh prevJ~lJ~ I~Llllllc l[eahh ~eJ'ViC~ i~l~J~ uJi ~nllkiJ~g and health, th~ i~Je~!llL d~cl~JUel~t *:;~llbhh~ the lehhti~ll= ~JlilJ Jl~tw~ell smuJ~ing ~lld ~ ~iJigl~ c~uff~lJy ~1¸ ~li~a~. ¢~lnc~r. 'l'he rl~hitil~r~,Jlip~ IIOLW~24211 ~n/~J]iillg liud [un~.r Cilllc,~r, i1~ W~][ .~ ~it n~l. ~f ill~!lltl[ill~ cllrtliov~Jscll]~r d[~li~!, which ~1~ u L~r~[~r ~o[[ L]li~l~ ~li~L~e t~ Jle |hilled with t~baccu use, and iLS a~llcil~tio~l wiL[~ ~lllo[li~[[ IHi~ be~l~ Lh~ f~ll~Ji~¢:L ol¸ L]LI2 nll~.~t illL~l~t~ i~trc[i. Ml~[I Itf ~xa nliJl~tl h~ [[le de~ail [~r~s,:lLt e~l here, A~ ill lll~vit~w~i y~'~, ~i~ I~l~ltrL hll~ )ll~[!ll jlr~l~lr~[ wil]t [h~ ~lil] =u~d c~'itle~[ review of exl~lls t¥111n wilhhl ~ud l~l]l~i~e Ihe (~llverl~ Incur. On behalf of th~ Public Ile;Lltl~ ~e~'vi~:~, I ~xpL~s her~ lay J ~l~Ct liar their ~pcrlisu a~ld gratitud~ ~r Ihldr help xl

ACKNOWLEDGEMENTS 'l'hi~ ]{~,polt w~ts iPr~,p~lil.d hy IIm I)¢,l)=~rhlil,nl ()( Ih.ullh ll=.! Illlrl~LIi ,HI~rViCI~S ~lillh,i¸ tll~" ~'l~f'*lLI ~ditlJl'~hip f~l¸ the, (~lflfl, ~*1 ~m~d~ht~ ~llfl I h'~dlh..]f~;lllr~ f~.ol~. MI}., M I~ II , A. liJl~ })ill..t~. ()llic~'~", ()1 fi~'~ olt .gin~]lini! :~l=~l I I~';~11 h~ (~llrl~lJIt~ll~ ~;ci~lH i~ic i~l]ilLii ~ w~,lc. [)~s, lql Iv[. I h=rl~. M.I) ~ A~.i~l u~ll A~v'~ll(~! J~r~',~:~lr¸ ill ]~ltl!H;tl Mt,lr~ci=~,~ IIrlivt~l'~it~' ol ~l:lh P.T~lli c~11 Sl~l~r,(~l. N:dt I ,:~k*, (~ily. Ill,ill; ~r~fl EIh'n R I:1 i(~". I~}1 I). ~h.'~ I~.¸. I~1 ;~: onl b~'r - M ~1 r lib), ~;lll( c'r i)l i,w!n t ilul I'lqp~= =lTll~ I livi~h.i ~f ( ~lll ~,r (]t~ltrO], ~]ClIOS.'~)II (lq)]tqlr~'hl~n~iv~ (~llll'~'l (~l'ldl'l¸, [Inivl'r.~il~' ~tl ( hJlili~l Ili~1 Ill I,l~r A ill~,ll,:~~ I,¢1~ A i~i~l,h'~, ( ~:tlil~lr'n i~l '['}1(, ('~lillJa~ iv~h I1~ ~l~:litl(iwh~lll~(, Ihl! ;i~:~;i:~l:ln~q. ~d Ih~, I~:11i~.1~11 (~nc(.r ITislill=l~'. ~l~lr'tiI!LIttlr ly f}l~. (~li~lic~ll I~lli~h,nlll~l!~r~y ITl~lll( Ii. I~1¸ fll:~killF~ ;i v[li[~tlli~. ~hl. COllllliT( (,I¸ ~i.n~,r ~11 [~] I }11 ~,~, i ~illll.ll,~id Jtl:t i ~l~lllr t~, Oil]coon ,Smol;inl~ ~lnd I h,;dt h P;~r L II. Bi~uJt~dt~l/'~.~,i~t~'~rr~./~Jrl~./~'~,~iuh~('~r~rm~/itl' I{i~}lI~]d A. ]h~r~l~Jw. MI)., ~.':~f>~'i~" ])ir~'ctol¸ ~r IIf,~l)i~'~l.~ty M~,~li- ]rr~trlci~¢o, .~rl ]?r.~ i~c ~s(-o, f !l~lifi)t ni;i Ahr~dmm M I,]liell~ld. M.D, MI~.I].. D.~c., Ihdw~l~ily I)i~r~ll. i~li~ll!lJ S~'ivic~" F'r()l~!~!~(ll, .HI!IoIII~I ill Ilyp~ii~lo LIn~l Ih=}~lh" IIc'u~lh. The Johns Hopkins Uniwt ,~ity. ]]ul~i=ll~)r~. ~l~lryl~Md ] )ic-t r ich I |ll~l'lllll]lll, P]I+~). A~ll~illt ~ J)il ~'clIli¸, bllly~llr¸ I )ll.ll rnsli~ll[L N~w York ~J

L):~l. llldl'l~bill*l*, Ill~.~*r*.h {'*KJjdj~)~l¢,h N~lyld)r ;)~.1;i Irl:~lihll~, liH, t'lillJ~+~l] I']l~lr~na(.Jot~y ihl~u~h, I)il'i~iOJl Ill¸ {~il~rUl" 'J'lu~Lhl.':lt, ~al il~iu~l ( '~LII(.*,I¸ I Jl~Lil [~lu, ~lul h~*l~, ~*l~ll~}.r~(I I,~liz~d,~ll~ I~, WL~i~l~u~r, 1'111), A~ni~l~*t~l I~ilucl.r I~t' {~h~llli(~;ll ['d~'il~l~l]l~l~.~i~. Ilivi~i~lJ~ I~f (~IIIL~I¸ (?l~Jihol ~111~} ]~l'UVulili~Jr~, N;i- li,lll~l ( ~ll~'~!l¸ JlI:H il[ll u, Ile[lle~*l~*, M~ryl~ul~l I'~lH IV. h~uiJ/l.ll~ll:~.~.~l~.l~.lull.ll~(~lte(~:r J'i[~i,h~bllJ(~ll)l~y, I)~l~lrlJllL!llL ot¸ J~l~vl~llive M'~(Ji~iJL'~ ~lllll Ili~lll~'l ly, MiLhi.:J JI I,ub.wilz, I~h I)., l'rl~l~(.¸ ,~F h~l~rn~ll M~lli~:il~, (~Jlle~:~ J,: II l,'i~;h*~r, ,It, Phi), A~iale I~f~or r)l" l~ch~)l~l~V, A~oci~le I)ilu~h~l¸ ~[ lhe Wll~hin,~h~ll |)lziv,~l~ily I)iulll~te~ I{u~.~LJx~}i ull(I I.:lh~Ji II I:~il~, l*h.I), I)Jrcclor. M~l~omber-Mtlrj)ily (!~lJl~r' Pruw~n- I'~,ll*~-i ('~:11~11 IJiiJv¢~iLy ol (~lil~Jll[ill ~L J,o~ Arll:c~(~, I,~,~ Iv .I (t~hl~.lli;i. l~s ~lll~:h~, (~*lil4~rt~i;~; ~lld I{~al.~Llch l'~ydlcllu l~,t, V~I~.~~, A~l~i~li~l~i<~l M~i~d ('~L~¸, I~.~lt,~r~L, I~,~ IIL~dlJi II,'hllviol Ill'~'allh hl:4ihll~, IJnivl,l~il~ .I¸ H.lllh~'H] 'l'h,~ udil,~¢~ ~kL~l~l~ with ~L~dih~d~ Ih~ &~llowi[~l~ di~li~ i;ui~hl'd ~, i~.llli~l~, iihy~,ici~l~, ~lJld lll~l~l~ who I~111 I)iq,JJ¸ :~III~I~.H Itb liL~Ji, ~ illllliblL[ilLl~ i li[i(~lI i~ Yi~w~, ill II~ Ill;lilll~ClilJl, iii¸ ~l~i~;lillF~ ill J:lvi*i 1'i. Adams, M I), M 1'.11 , I' A, IJll~:l~lL'y M~lti~:ll AJ'I~ ('liJli~¸, ,~:ll~l I~ I~dli~,l~L, I'JI I), ~ul~il~r ,~lall I'l~ill~ll~(I,l(~L~iul, ~,rlhur I) I li11~, lu,¸ , (~;ll~ll~d i,1~., ~ I;l~;~l:llkl:~ I I ~ J"H,d I; I1,~ L, I'1~ I). I)il'u~l~,~¸, (hu(~rd I~1. I~d~(~l(~,~i~.~, I~w,'ll Vill¢l~nl T. I)(~Vi{~l, M 1), IJilut:lOl'. N~llilm~ll (~[li~u~r hl~lil~ltc'* Ilall~ 1. Igdk, l~h [). A~.~fill(~ l)il'[c(IH, II¢~alth IIz~lll'(I Ass*'~.~lll~t, (ieoll~i~l Io[~, Vi:'~inia ,'4ucticln, A~alylical (h,zuli~tly [)ivi~il)11, ()H~ IIil]~I" N~li.~l~l .[O((~J~ ~ [[~lHi~., MI)~ I~1~ I). As*~l~:i~lle [>ll)[bn~m', J)/ll;llllHt:nl ¢1] J,~('(llll)nlic~, M~*s~'hu~!Ll~ hl~tilolo or 'l'e~'lulu]lll~y, ('mlllH'illl:u, ~l'lhlll' llll]l Ihwes, Jl', M 1)., (~olllrllj~iul~Ul, I~olld an,I I)ltll~ Ill WIJnlH;It; km, ~,;{ It h!, W;Inliilll~l(m ~1~11(! I hliw,rsiI?~, A nl(.~, b~s;~ i~,}~x J,~lJlKl~iuil, M L) , {~llillll[~H~, M:~s;[l:hllsPll~ l,~llw;llll J,il:J]h~ll.~h'i¢l. PI~ I), I)k'l~nllJIl*LIII ~JI J*:~vrJ~r~h~r!~', (IIIJV¢'I~ilY AbHdu~m M I,iliunhqd. ~.1 IL MI~1~, l)~;l!. Ihdw:~ily {)islill- Aulhi~l~y Jl Millul, M I), lJi~loJ', l']pidu~liol~)lZ~ (III~L, N~llii)nal { ildl~llll l{mllle,t}i M. Mos~,I.' M~), ~.l,i~I~,,~l~. id M~.,~[icittt! ~L~(I l)il'I:i!lill, I )ivi:d~n id" l)~lJl~IIll)~ll Y mid (:ill i*:il[ { !;ll'U I~ h~di[ i~l,~, I )*:p~iz hll(~l)[ (I~ Nolriuhl I)l!pal'lll~e~ll r~l" (~tini('~ll MIdich,~. I~,~lillu hllhl,al)', ( Ixlill ~1. I,'.11~ k~lld Ilich~l'd I). II{:~dilglllll, Phi), Jh'all, ,~C~.lId od Pqbli(: Ilu~lilll, I hlivm.~ily ld" M h hii~l~l, A II~l A ~ I)ol. M ich i~;lll x~

l](,iflhy P [{hi'. IPilt'vh,. Natiolmf Uriil1.# lor lli.~illlh .'gl;ili~lh'~i. I lyal l~Ivill~., M;iryllli,l Mc.i[ii!ilw. l)ii~i:l~li¸ I)l (~llrii!~.i' ITon11~iI. Mennlliilil .~ih)mi-l(~llclhlg lh.~illh. (~im.ll Ifnivei~>iiv ~dirfil ( 'i,ll~.~.. New York. N~.w 'lq~n II M~r~hl #%. ~ hlltfi~l~rli~ni~, l~ll I).. I li.l llt~lll, lili~rT# li~li~l llvii~l~ .I ~e]il(ol]~ MI).. l'iol~.~or ~I¸ C~,lllnullily Medi~hle Inld ~i~t'~l~:ini~>, and i)hi'r41pn¸, l**.llviri~illni!lil;ll .~'iences i~il~ipl:iloly. ~II. Siillli Srh~ml ~ff l%ledicille+ Cily L hlivi'i~ily iff N,~w ¥~.i h. Niaw Y,~i k, ~luil ~hillililili. l'h I), #'i~.qislaeil. PIInl~'!~!;ilr. /~l~lil0nl.nl i~[¸ P~.rhnhl. i~Y, (~,lhq~e of S,cilll lilld IIehavlon~il St'iellrt>s, IJliivc't silJ. ~I ~llilll ["h)rida. TiUlilla. Fhll ida Mich;l~l II. Shiniliin. MI). llroPe.'i~ol¸ ]~ni~.iitu~. llel~ilrhlll.nl Ill¸ (~(lllmlunity mid F[illl]ly l%Ii.dirme. ~cli(ll)l i~l¸ l~Ii!liil!hle. [hliver~ily .hl~.~ I.. Sl~fiiili~hl. I%1.I ).> I )~;ul. ~¢hool ol¸ M edicllii!. M eqlii:lil C .'~llcge ~ff Virllini~n. l(i( h mrlli,l. Vilgillia ~l'he i)dil~li~; ~il~o ni:kllowl~ll;e Llle r~mlrlhuiioli~ ill lllc" Ii~lIIiwill.q ~[lill illemllt!Is illi~[ IJl]l(.l~i who u.~i~Ii~d ill l]ic inl~I~ll~l[illll ill¸ ~h~ l'~lh'll W. Adluii~. (~oliy l~ilil~Jr. (?J~alhii~hlJu~e Sel~'ice~i ]Jlvi~iilli~ hll~ll ni;d h ~ Incon l~Oral~iL I Iiicl~ viII(.. ~]iu Ly htiiil llirhm'd II An!;ll hi!n¸. I)hei!1¢Ir. CIi.inrinl4hi~u~le Project~ l)cllalLinil.lil. hilhl mal h~ hlrol ptllaled, l{(tl~h villi,, l%~inn~llilld .li~lui ] .. I llil~ i il.'iky. A ~.~li~:i~l i! llh~i'I hlr l~il¸ l'Itil¢lllnl Ollel~iti~In~, Of]ire on ~,,Ir~l( illi~ mid I h~all h. l~ockvill~'. M;llylluill Ricllnl~l ¢I llnsl. Mi.¢lh~al Tllni:~lali~n (~rlli~lili[llil. l~li.'~i*inl~1~illSl' ~i.rvile~ llivi~i~in, hil~)rliiEilics hlcrlnllor~ilrd. Rot:llvilh.. M~il~land .lllrqtli.lili.~ ~) Illlui~llilld. ~cre~my. Ol~i~e oll ~lli~khlg llliil l le~ilili. l~,ch vilh~. Manylni,] liivi~hm, hili)rlnlilir~ hi'~(pFporlnted, l{ivi!riltn]e. Mai~Izlnll ~lllailli~i II. Cr~chliii~. (~llq$, i~lit~ll¸, lill~l'IiulLilt~ lllld 'l~rllil~tl~igy 'rrllli~ler l~palhlil.rnl, hlF~rlliiitl~ [ncoillOi~iLed, l~o~.~vilh.. M~uy- I k'lii~ M. ( ~i~. l)ala Eiltly M~li~,14ei'. Pul~li~liiiig Ser vi¢+_.s l)ivlsilm, Mmllnl I~ Davi~i. 'rechnie~il IllllsLrlltol¸, lli~rlllliti~p hi~OUl~llliled, IIt~cll~ille+ i~llrylmlll ~Li.lJlilln,i/. |) I)eVoe. i)zlill Entl'y Ol~el'alOl', (}l~,ndnlllioil~ St.l'viresl I)ivifllln. lllhlrinatles |lie01 lllil lltl~d. II,d~ville. MIIlylOml /lildleii L. [)ykslrtl. ~¢~lliOi" Tec}llliciil Edilor. Ilifmlllleri~ Incllrl~elllll- ~d, Ill~ville. ~liliylalill . • O A&I TOG9 ~11~41111 Ii J'l'llh,ll, I'id~l. I IIlIPI, I'llllli!illllij', !;t'llli':, IIIVIJili'll. IIIITM in;nllr~ Irll't)n ii~lllll(*~t. I~i~l.ncr~lh.. Pdl~r ~.lilli~l chldy I"erllllndt~. Wlill.r-I.~dihllTM, (.ll~icl! llll ~qnil~hhll~ ~lnd Ih'~tllh. R.rl(vilS,, I%1~,ryl~l~d ~illlCI) (i]11"4(1ll. (Tiilly Edilol. (]]i.ill'iillgltlll~e lllojpl!ll [h'llnrlliwIII. I lifllrinilllf.~; I rlCOl lll)rlil ~,ll. Ilol kvill(.. ~lil "¢llil It I "~'¢t.illly ~ (~l~l(liil. ~(.ell.l(liy. Illl~lllli~llillli llllll 'rl'rlllilll~ll[~ 'rlllil~li'r I )l>lllll I Jill!ill. hiliil llilll il.~i I lirlll plirlil i~l~ Rllcll vl Ill.. I~¢]ill yllllld IIt.l~'a C. Ili%llli~lll. [~l~llli~g('l. (ll'lllllliet Ihdl. (Th'alitl~hlqtl~l" ~('1" " vires I)ivi~ion. hll]il mill h~ liil!o0 llOl'ill eli. I1~1~ ville. M IiI ylllilll Ib.ginald 7, llll~.ldn~. 1~4 ILII. I%11)11~ ll~.~llll ~lllll~b.I. IIIIi~v i~11 ~illilll i 117 ttilll I h.llll h. R~.lt ville. ~¢1111 yhlnll I)OUl!lli~i Ilnyl..% ]llllllil:lilillli~ ~lJl~lllll~/q", llllllilllalil)li lillii I l~illl~ ~t"i'- vil:l.~i I)iviSlOli. lllfill'llllllir~l hirllilnlltllll.ll. I{ivl'l~lall'. MIIlylliild I'¢lliiri:l I'] IIt.;dy. 'rf!chiih'ill Ilnlilr lililliOli Ch,ik. I)llirl. Illi ~rllrlllhil! aiid IIt.lillh. II~,~vill... ~vllnl) lltiul I~.<~lie ,L ll~.alllre. InlTllliullhm ~l~'~inli~L, (~lelirilll(Imll~l' l'lctircl~ [)t.l~nillllL.inl. Infl)iliulllc~ Inl ill imrlih<nl, II¢lrllville. Ptllilylinllll Shh h'y I{. IIillllliall. lJlllii Elilry (ll~l'ilnllll. (~le'iUillTholil' '¢ll!lVil'l'~; I )ivi~ioll. hil~lli In nl i~ ] ilcoi I,H ull'~l. Illiekvilll'. I~1 Ill 'ililllll Ilolil.l{ ~. Ilulc'hhll~ll, A~l~llrillll~ Ililel:llll" I'lll hll]ll'lllillillll lliill F~III IZl'~lnl I)(w~-IOllliil2111, OIIit'l! till ~llll~llilll( llfill il~'allll, llu¢l/ville. I~lill y Illll II I.lqi~ A I(~(z. (il~lllhle AltlII, (]lOill'itll(hl>ll~l' ~t'lvlrl'~ IIk'i~ioll< I ill'lit ni~ll ic~i Ill f'ol illlial~(l. Iblck ville, M tu'yllll)d I~.ll~lgill~.l I~, I¢~11~1 iIII~11. I'ulllic [llftll'llllt(illl~ ~ll~( I~ldll{l'illillll~ A~-~I~- I~illl. O[Ih'(, llll ~lillJ]{ ill~ IIIId I [l~lll~ll. llnl+kvilh', I~1 Ill ) I;in,I ~Ollll ~> I{ lllil'illl, ~enlttl" IiIItli'llllll lira Anlll~l > ( ll~rhll[lloll~l, ~t~vil'~!~ I)ivi~ioll. lllflli'rlllil i~ Illl Ol polilll'd, Illll'hvilli!. [V~al'J Ilill+l .hllle I~.llu'~. Ihlillhk" AiIi~l. I!l~lllhll411~lli~l. Si.Ivicl.~ liiti~i¢lll, hihlr inllli~<f lii~l)i'lllllllll~il. I{i}clt villi!. I~llyl;liill Willililil II. I.~ZIIII. I)llllll'tllII l)lJOIlllillll~i 'l'(~llniC¢ll #~iflllll(e I)llilTl'l, {Ill'lee Oll ~llllllliiijf lilill I lelnllh. II~'l~vilh'. i%lliiyllillil IMal'il.tnli II. ll¢ll'iill(t', (~Ol~y I+.'llilor~ (TIl'lll hll~lioI1~12 I>i~Liel~l~ II('llall- ili(!nl. I itlbl inlilil.l I ill:ill llOllll i.iI, I{ot'l[ ville. I~l Ill yllllill ¢lliCqlil.li.iiP I~llllll.ll~!k. T(.l:hnillll Illil~ill'tlllll'. IlilOllllalil~4 llil.nil i~lilil- ilOlllllln~ I~', p~.l,in+ ~lllli!lllc;~l Alllll~]~l, (!h'lllilll[hOll~;l' I'l~jl.rl~ I1~.. i)lll I iilelll, hilill inil I il'q hlrlll tl~/I ill I'd > Riir h villi.. Mill) lillul Ililylillliid I( Poole. ]llo(lllrlillli (Joollllnlllllr. (~h'illilij(llllllNe I~l'l!il'cl~l I It.lla~l ii/elil' lllfiil lllal il ~4 li1¢ llrllorlll i!d~ II~lr I~ villl!~ I%1 ai'vlilild Illsht,llli A. Jlill~ltl!l'. ~1~1'91,11117. (111.lil'illl41illll~.l. I~ll{if.rl~; Ilt.l)allinl>ill. I l/l~ll Iiiill it.~. I llclil lllll iiI ell. Ilor I~ ~ilk.. {vlltl'~lillttl Lindli II. ~t'XlOll. lillTIIIliillillll Sllr(i;lli.~l. (~[('lllilll~litllln(' Pl~til'cls I )l.[llll I i)1 olll.. I nl~li'lllillil's llll~ll i)lll'lll i'll. I/l~ k~ilh.. ~illll )'lllllll

(~atol A .%hvrJ'cr, Tc~hltk'uJ (~on~tdl~ml, (~hauqngbolt~e pr,J~evt~ M~CYI~uld TABLE OF CONTENTS [Por~wDrd ..,~,,, .................... , ............... ,.,,~, .............. v Prefue~ ................................................................... xi Ackn owledge~lmlt~ ................................................. ~iii 2. ]~iomedical Evidonce for ])e~mminil~g f~aul~alily ......... 13 3, M~c]laJ]i~]l]~ of Oarcin~lg~nc~i~ .............................. 171 6. C~atinn ~f ~m~iking ...................................... ~:I

F'ART I. INTRODUCTION AND CONCLUSIONS ~CLF~TOG9