Tobacco Documents Online

smokers had significantly more evidence of inflammation in the smallest areas of the airways and chat t4is infLammatien was.prabatiiG reversible when smoking was discontinued. Hale at al.in an article published. in the same journal demonstrated.for the first time t:1ac smokers dying, withouc obvious heart disease had thickening of the puLeonary blood vessels., These data,suggest a response co reduced oxygen concentrations in the smaller airways reLated.to cigarette smoking., The toxicity of cigarette smoke to innocent bystanders as well as to smokers was shown by a recent study of Dahms et al.. (Chest 80 530- 534, 19.81)'. Ten patients with bronchial asthma and ten normal ind!ivi- d'uals were exposed!to cigarette smoke in an environmental chamber., Pulmonary function tests (the.FEV1.Q) decreased 217% in the asthmatics but not i,n the normals. The asthmatic patients were not particularly sick and were ambulatory. A,substantial percentage of the general populaeion has the sort of reactive airways demonstrated by the asthmatic so that the study emphasizes a major public health concem. O W W

cable below shows deach rates for two hypothetica?'. popuTacion.sacaplas; a group of 100,000 smokers and another group of 100,000 non-smokers. The number of , deaths expected in the subsequent ten years forthe two groups of inen betweea the ages of'55 and 59 are shown. Only the four most common causes of death.associated with smoking are shown in this ca]lculation.. Non-Smokers S'mokers Coronaryelrtery Disease 6,168 11,454 Lung Cancer. 257 3,223 Stroke 1,066 1,600 Emphysema 69 860 Total Deaths Expected 7,560 17,137 This analysis;shows that for each 100y,000 population sample in the age group 55-591years, the.smoking population will have 9,577 more deaths than the non-smoking population. If one assumes that the total hospital andiprofessional cost of'each individual prior to death averaged $10,000, the total excess health cost.of the smoking:group is close to 100 million dollars. Since there,are about five million men in the United States between the ages of 55 and 59, the total. excess health cost in that age bracket is five,b"illlion dollars. NEW 2.NIJ COITFIR.`SI.~f.r. EVIDE2iCE IS CONTI`IUTALLY, PUBLIS T'r.ED Each year a large number of pumlications from.laboratories around,the world conzirm the relationship between cigarette smoking and human disease.Many different types of studies have been performed-- epidemioiogic study of deatfi rates, results of stopping smoking, studies of lung function,, and e.Yamination of tissues at autopsy in smokers andnon-smokers. A brief selection of several recent papers follows,. Each of these has been published in a highly respected, peer-reviewed medical journal. Two recent studies have shown increased life expectancy in individuals who discontinued smok::ng, compared to. those who continued'

has issued 13 subsequent reports an smoking and health. In 1976,, the National Heart, Lun4 and Blood Institute. a component of the ozestlRious National Institutes of' Health, concluded its:Task Force Report on Preve, ition. Control and Education in Respiratory Diseases with the following recommendation: "Cigarette smoking is the single most important risk factor for. diseases of the lung,. It.is known to cause or exacerbate.not only the respiratorg diseases discussed in this report, but lung cancer, cardio- vascular disease and.stroke, as well. Reduction, or ideally, elimination of cigarette smoking,weuld have a major impact on national health and, on the social and economic costs that are a consequence of smoking- related dlseases., The problem of smoking warrants the highest.'priority in all programs concerned with diseases of the lung. The most important target groups for antismoking,programs are preadolescents,and adolescents who have not yet started to smoke or in whom the smoking habit is not entrenched."' In a free society, government cannot directly order aboSition of destructive behavior but must.consrantly warn of the consequences of such behavior so.that individual citizens can make imformed choices. Such. destructive behavior accounts for a large component of the annual mortality experience. In I980'„ for example,, approximately 700,000'died from.coronary , artery disease, 180'„000 from stroke, I05,0Wfrom lung cancer,. 30,000 froml .bladder cancer, 7,500 from esophageal cancer and 60,000 from emphysema and other chronic obstructive pulmonary diseases!. The common factor linking these one million deaths,more than half of the total deaths each year„ is a demonstrated relationship to cigarette smoking. Many of these.deaths are related;to multiple factors includingr heredity, exposure to environmental agents and excessive dietary cholesterol as well as to cigarette smoking., Cigarette smoking, however, is the single 3ost imnortant factor--manv times more imflortant than anv other risk factor. Detailed epidemiologic data allow separation of the mortality directly related to smoking. The Geller-Gesner Tables, published: by Robbins and'Hall in 1970!, have been used by many physicians who practice "prospective,

AMERICAN ~' LUNG I~SSOCIAUON The'Chnstmas SeafPeople a 3 1740 Broadway - New Yor1t, N.Y. 10019 •('212') 245-8000 THE I1CORTeY*ICE OF THE FEDERAL GOVERNMENT' Edmund C. Casey„ hLD., Plesidenr Conrad M. Fowler. Preridenr-Elecr Rii:hard.Sinaheimen, Pair-President 1h'alfer J. Hamheq Rire-President Edward M. SdwetL.M.D.. Vict-President Roslyn Bilfond'. Secrnrary Bernard G. Koplow. Treasurer James A. Swom[ey, J4anaging Director IN THE PREVENTIONi OF SifOKING-RELATED DISEASES Testimony in Suaport of H.,R. 5653,. a revised version of H.R. 4957 the Comprefiensi've Smoking PYevention Edncation.Act by The American Lung Association Preparedl by Stephen M. Avres, M.D. Chairmany Smoking or Health Committee February 1982 FauudeC 1n 1904„ m..Ameekan Luaa Amodalien..iaAudn atstlated aa+ocnuomuuouohour N. vs., and a mm[ev,.,«uonl m. ~euw, rym~ s«im

The environmental sanitation. movement of the early Twentieth Century with an emphasis on pure drinking water and sanitary waste disposal provided clear evidence that maintenance of the public health was a major responsibility of government. :fore recentLy, the widespread adoption of'.cigarette smoking has led to a new epidemic of preventable deaths that can only be eliminated by direct action of publiic health authorities. Like the Black Death or Plague of 1348-1350 which killed one third of the popu]latioa, cigarette smoking leads to, the premature deaths of' large numbers of a nation's population.. Adoption of H.2. 5a53„ the "'Comprehensive Smoking Prevention Act"would piece the United States government squarely in the role of defender of the public health. The Federal Government must attemp.t to eliminate as many of the hundreds of thousands of deaths due to cigarette smoking as possible and to reduce the billions of diollars spent for the care of: people• with tobacco-related diseases. Every effort must be made to discourage young people.from starting smoking and to help confirmed smokers stop smoking. The increase in cigarette smoking among,:;dolescent girls has been particularly alarming and there is reason to believe that a group of societal pressures are responsible for this situation. Lung cancer was at one time extremely rare.in.women; its dramatic increase in.the past decade is a stark reminder of the,risks of adolescent, cigarette smoking! KNOWLEDGE AND BELIEF Why do people smoke? The''Roper R'eport commissioned by the tobacco industry warned that most people knew that cigarette smoking, was harmful and,that many smokers desired to ston. This public opinion organization detailed a,series of'problemsf that threatened the continued viability of the tobacco industry and emphasized particularly the spread of'health knowledge among the public and the growiag,activism of non- smokers. Unfortunately, the,knowledge that cigarette,smoking is dangerous is not necessarily translated into abstinence. Behavioral scientists have d'eve2oped.the."health.belief" model to explain why individuals

-;av "kaow" that a narticular behavior is, harmful even thou¢h thev do~ act translate this knowledge into appropriate action., They know buct they do not believe. Health education is pitifully primitive in the. United States, health educational spots have markedly declined from television programming;, and the miniature "warning" an cigarettes and cigarette advertising is ineffective. ?,t.one time, when a surgeon general had not been appointed to office, the tobacco industry ridiculed the printed warning by pointing,to the non-existence of the.individual whose name appeared'on the cigarette package. Rotation of warning labels that would constantly remind potential smokers of specific diseases produced by cigarette smoking each.time they reached for a smoke and wouldihave an important effect on conarerting,fact;i.hto belief. While clearly less effective than the billion dollar advertising blitz launched annually by the tobacco industry, such rotating labels wouLd be an important first step. A casual inspection of advertising material convinces most observers that its mission,is to~encourage non-smokers to smoke and to keep smokers smoking. Rotaciom of labels should be followed by ocher health educational techniques such as the publication of an anti- smoking message of'identical size next to each smoking advertisemenr.. Free,choice in a.free society is only possible when each individual is informed. Crying "fire" in a crowded; theatre is not dissimilar to encouraging one's neighbor'to regularly inhale smoke. SMOKING DQES' CAUSE HL?fA.y DISEASE Although the tobacco industry characterizes the linkage of cigarette smoking and human illness as the "Smoking and Health Controversy,.'"' the only controversy is the,unwillingness of that industry to voluntarily phase out cigarette production and to O encourage individuals,to stop smoking;. The evidence establishiag,the ~ toxic nature.of cigarette smoke has been.accumulating;sincethe w -publication of the first report of the Surgeon General in 1964. Since N=' then,thousands of articles documenting the harmfuL effects of cigarette m' smaking have been published and the; United States Public Health;Service

wicti the habit. Doll and Peto (British Medical.Journal, 2: 1525-1536, 1976) followed 3+,000 physicians in Great Britain for 20 years; half af the physicians followed stopped smoking during that period. Deatns zcom chronic obstructive lung disease decreased by 24% in the physician group while the decline was but 4% in the general public..The death~ rate faom lung,cancer in physicians who continued to smoke was 16. times that observed in lifetime non-smokers; the deacin rate for physicians who had refrained from smoking for from iive to nine years was six times that of non-smokers and fell to twice the.rate of non-smokers after fifteen,years of abstinence. The study also demonstrated,an important relationship between the duration and the,amount of smoking and the occurrence of 1ung.cancer, dose-response relationships that strongly support the concept of direct causality. Friedman and associates (New EngSand! Journal of ?fedicine 300, 213-217, 1979) followed 4004 men and women over an eleven year period' after an initial evaluation. The mortality rate in smokers was 2'.6 gFeater than that in non-smokers and the differences could not be explained by any of 48', baseline characteristics. In a Sater study, the same group (New England Journal of Medicine 304 1407'-1410, 1981) studiedithe effects of stoppzng,cigarette smoking on death rates. The overall death rate was 2.22 greater in those who did not stop smoking compared to those who did;. 0f great importance was the observation that among those individuals who had coronary artery disease at the time of the initial observation, the death rate in those who continued to smoke was 3.92' times that in the group~ that stopped' smoking:. Evidence that cigarette smoking may produce an acute myocardial infarction (heart attack) was presentedi by Hartz et al (Journal of the American"Medical elssociation.246 851-853. 1981). Heart attacks were 2'.27 times more common in the heavy smokers aged 35-49 comnared to. non-smokers; they were 1.95 times more,common in the heavy smokers aged 35-65. Both lung function studies and pathologic studies on human . lunv,s have shown the deleterious effects af cigarette smoking. '[dhite and Froeb (New Ehgland Journal of Medicine 302 720:-723, 1980) observed that lung,function was 3'19% lower in individual's smoking more than two packs of cigarettes each day compared to non-smakers. Of' great interest,lung '.unction was 13X lower is non-smokers workin:g,in a smoke-Eilled' environment compared to those in.a fresh atmosphere.' Cosio et al.