Tobacco Documents Online

Inside: Roast pork-new method ensures safe cooking in microwave oven PAGE 3 ACSH decries cigarette ads tying health, elegance to smoking PAGE 4 The search for the 'Fountain of Youth' comes up dry PAGE 8 Fluoridation: still a topic of debate PAGE 13 VOLUME 5, NUMBER 4 declined dramatiaally in the Unite&States in recent years. In the 1950s, autopsies were performed in approximately 50 percent of all deaths„whereas today the autopsy rate is only about 15 percent. Being Certain The primary purpose ofl the autopsy is, of course, to determine why a person died. "Only by autopsy can we be virtually one hundred percent certain of the cause of CONTINUED ON PAGE 2 SEPT/OCT 1984 PRICE: $2.00 NEWS & VIEWS PUBLICATION OFTHE AMERICAN COUNCILON SCIENCEAND HEALTH • 1995 BROADWAY 0 NEW YORK, NY 10023 (212) 362-7044 The First Amendment and Cigarette Promotion A Total Ban on Cigarette Advertising: Is It Constitutional? Are warning labels on cigarette ads which depict elegant, healthy men and women smoking strong enough to alert the public to pre- ventable death? Cigaretle advertising is a major source of revenue for many magazines and newspapers. Publishing the Iruth about smoking, near an ad promoting it, would most likely provoke the wrath of the adver- tisers, the tobacco companies. The Autopsy Is Slowly Dying The demise of the autopsy threatens the health oflthe living. By Cathy Becker Popescu ALTHOUGH IT IS SAIDTHAT DEADMENTELL NO TALES, the living can actually learn a great deal from the dead. The information which an autopsy, or post-mortem, examination, can provide to survivors and to the medical community can be invaluable. For more than 100 years, autopsy has been an integral part of medical practice and a fruitfuli source of inedical knowledge. Unfortunately, the rate of autopsy has by Larry White CIGARETTES ARE THE LEADING CAUSE OF PREVENTABLE DEATH IN THE United States, are addictive and have no safe minimum exposure level. They are also the most adver- tised product in our society. It is a rare urban dweller who can pass a day without seeing several cigarette ads in one form or another. According to the Federal Trade Commis- sion,, two of the five top magazine adver- tisers are cigarette companies; R. J. Rey, nolds is the single largest magazine advertiser. Cigarettes are the most heavily advertised product in American newspa- pers. Almost half the billboards in the United States carry cigarette ads. There have been numerous actions to con- trol cigarette advertising in the United States. The FTC, which has the authority to regulate false and misleading advertising, forced cigarette manufacturers to withdraw misleading claims 25 times between 1938 and 1968. Congress required cigarette man- ufacturers to put health warning labels on cigarette packages in 1965, and, in 1970; made the warning a little stronger and CONTINUED ON PAGE 4 While the loss of revenue from cigarette ads would be a serious financial problem for many publications, the more serious concern is the human and social cost in death and disease caused by cigarette smoking.

The Dying Autopsy CONTINUED FROM PAGE 1 death," says Dr. Stephen Sternberg, Chief of the Autopsy Service at New York's Memorial Hospital. In a worrisome number of cases, the autopsy findings are surprising. Autopsy revealed~ elinicalimisdiagnosis in nearly one- quarter of the cases studied at a Boston teaching hospital. A similar rate of misdiag- nosis was noted among a group of 100 autopsy cases examined at a Honolulu hos- pital. Other studies have indicated that only 53 percent of autopsy-proven cases of myocar- dial infarction (heart attack) and 60 percent of cancers were correctly diagnosed while the patient was living. The cause of unex- pected sudden death was diagnosed cor- rectly less than half the time among a group of Swedish adults, with a large number of deaths being erroneously attributed'to coro- nary artery disease. Incorrect diagnosis of the cause of death is especially common among the elderly. The introductiom of sophisticated: neww technology in recent years has not greatly improved physicians' ability to diagnose dis- ease. Data from the Boston hospital study indicated that the number of incorrect diag- noses remained constant from 1960 to 1980, even though use of nuclear medicine, ultra- sound and CAT scan procedures increased dramatically. In fact, Iooking back even fur- ther; it appears that diagnostic accuracy has not' improved much since the early 1900s. Although, modern diagnostic procedures do provide useful information4 in, some cases they can be misleading due to misinter- pretation or overreliance on their results in, lieu of clinical data. In addition„advances inm medicine that prolong people's lives have left them vulnerable to more complex dis- eases which may be difficult to identify. Autopsy is especially valuable when a per- son who is not under a doctor's supervision dies and when death occurs accidentally, unexpectedly or under suspicious circum- stances. In such cases, autopsy may be the only way to determine the exacr cause of death~ Benefit to Survivors There is far more than heuristic value in determining the cause of death. Autopsy can directly benefit surviving family mem- bers, sometimes revealing a condition which could affect them. Since the tendency to develop heart! dis- ease runs in families, it would be important' for the children of a middle-aged' man who die& suddenly to know if heart attack was responsible. Certain hereditary or genetic illnesses can also be detected at autopsy, which might affect future ehild~bearing decisions or medical treatment. Wilson's disease, for example, is a poten- tially fatal hereditary disease in which cop- per accumulates in and destroys the brain. Since the symptoms can mimic those of 2 many other conditions, the disease is often difficult to diagnose while the patient is alive. A diagnosis of Wilson's disease at autopsy can literally save the lives of other family members, since it can be successfully treated if caught in the early stages. Autopsy results can provide comfort to bereaved friends and relatives, who might believe that they somehow caused or con- tributed to the death, when im reality, theyy could have done nothing to prevent it. Con- versely, if the autopsy shows that a family member's actions did contribute to the death, such knowledge, however painful, may prevent future tragedies. Autopsy findings: may affect insurance settlements if the cause of death is deter- mine& to be different than the physician's diagnosis. Medical malpractice may even be revealed through post-mortem examina- tion. Benefit To Society Autopsies also benefit society as a whole. One of their most important contributions is their role as a form of diagnostic quality control. By checking clinical diagnoses against the cause of death as determined by autopsy, a hospital can tell how good a job its physicians are doing in detecting and treating illness. In fact, until, 1972, all hospi- tals were required to perform autopsies on at least 20 percentof all patients who died in order to maintain~their accreditation. The educational value of the autopsy for physicians, medical students and' research- ers is unquestionable. Cross-checking clini- cal diagnoses with autopsy results allows Mondino, shown presiding at a dissection, in 1316 wrote one of the first textbooks entirely devoted to the study of anat- omy. In modern medicine autopsy plays an important role in studying the natural history of disease. However, progress in understanding the natural his- tory of disease, as well as advances in therapeutic tech- niques, are seriously threatened by today's low rale of autopsy. (From Ketham;, Johannes de.. Fasciculus Medicinae, Venice, Cregoriis„ 1507.) physicians to learn from their mistakes, thus enabling them to provide better care for future patients. Clinicopathologic con- ferences, where clinical and pathological findings are discussed, provide practical teaching forums for medical students and physicians. As Pamela Cramer, Director of Labora- tory Management of the College of Ameri- can Pathologists, notes, "Autopsy is our only assurance that quality medical care can be provided." Autopsies play an important role in studying the natural history of disease. Alzheimer's disease, a type of dementia, can be studied only by using human brain tissue gathered during autopsy, since there is no animal model for the disease. Autopsy data have beemimportant in revealing the patho- logical processes which occur in victims of Acquired Immunodeficiency Syndrome, or AIDS. The organism whichicauses Legion- naire's disease was identified in lung tissue recovered at autopsy from victims. Researchers can also discover valuable information about conditions other than those which caused the death of the patient undergoing autopsy. Post-mortem examina- tions have elucidated the relation between atherosclerosis and serum cholesterol levels. Precancerous lesions found in the respira- tory tracts of smokers who died of other causes contributed to our knowledge of the effects of smoking. Unrecognized environmentalJ or public health hazards may be detected at autopsy. The repeated recognition of rare liver tumor CONTINUED ON PAGE 6

Taking the Trichinosis Hazard Out of Microwave-Cooked Pork A method evaluated at Gerling Laboratories, Modesto, CA, ensures safe micro wave-cooking. w By Richard A. Greenberg HILE SOME MIGHT DEBATE MY WIFE'S CONTENTION THAT MICROWAVE COOKING ranks only slightly behind the electric light as mankind's premier technical achieve- ment, it certainly has impacted greatly on American culinary practices. Frozen left- overs, for example, can be resurrected within a minute or two without impairing the taste or texture of the original'version. An&microwaving can cut dishwashing time in half, given the ability to cook and serve on the same plate. Microwaves penetrate further into food than do the longer electromagnetic infrared waves we get from conventional cooking methods like broiling or baking. Thus, we get more quickly the molecular motion that generates heat and it happens throughout the food mass rather than from the outer layers in. Furthermore, because the air inside a microwave oven remains at room temperature during the cooking process (instead of heating up as it does in a gas or electric oven), heat from the cooking food escapes from the surface,-leaving the surface of microwave cooked foods considerablyy cooler than those conventionally cooked. L i For most foods there is no health problem, real or poten- tial, in taking advantage of the microwave oven's speed and versatility. 7 7 For most foods there is no health prob- lem, real or potential, in taking advantage of the microwave oven's speed and versatility. A likely exception showed up in 1982 when a team of Iowa State University scientists demonstrated that, pork roasts and chops, infected with Trichinella spiralis larvae (the cause of trichinosis), still contained viable larvae after undergoing microwave cooking which produced center temperatures exceed- ing those known to kill the larvae in conven- tionally cooked pork. The researchers, W. J. Zimmermann and P. J. Beach of I.S.U.'s Veterinary Medical Research Institute„reported the presence of viable trichinae in 9 of 51 experimentally infecte& samples cooked with procedures "generally recommended by the oven manu, facturers or the Pork Producers Council." We imagine that this finding di& not bring unrestrained joyto the boardrooms of either industry, A further study in the same laboratory, published in late 1983, outlined a six step instruction for consumers for microwaving fresh pork safely, but made clear the authors' feeling that the problem was far from over. A much simpler and thoroughly effective answer has emerged from work carried out at the Gerling Laboratories, Modesto, CA. In their presentation lasr month to the ASME - AICHE National Heat Transfer Conference in Niagara Falls, N.Y., C. Sand- burg and J. Gerling described their experi- ments with a new device for measuring tem- perature in "severe electro-magnetic environments," i.e., pork roasts cooking in microwave ovens. They observed that the surface evapora- tive cooling of the roasts during microwave cooking washaving a really profound'effect on temperature. Indeed, they reporte& that their measurements showed that "the outer surfaces of the roasts were cooler than the central inner surfaces with a temperature differential of 40-50.° " A time-temperature curve showed that "the outer surface temperature [of a 3 pound, 4linch diameter boneless pork roast] never exceeded 130°F, which is several degrees below the thermal death point of tri- chinae," even though the center tempera- ture reached 170°F. The answer? Develop a cooking proce- dure which stops evaporative cooling. This L L In 1982, a team of Io wa State University scientists demon- strated that pork roasts and chops, infected with Trichinella spiralis larvae (the cause of trichinosis), still contained via- ble larvae after undergoing microwave cooking. yy was accomplished by cooking, the roasts inside a microwave-transparent cooking bag. The bag holds in the moisture from the beginning stages of the cooking process and quickly develops a saturated atmosphere around the roast, preventing subsequent evaporation. Tests showed that roasts microwave-cooked inithe bags attained sur- face temperatures which exceeded by a safe margin that required to ensure trichinae destruction. Americans typically cook their pork well done to ensure its safety from trichinae. Thus, trichinosis from, pork occurs usually among ethnic groups who consume it raw or rare. It is good to know that, by simply using a plastic cooking bag, we can safely eat microwave-roasted pork. t I;' P ~ ~ ~ h 3 ~ > ~ U z Richard A. Greenberg, Ph.D., is Associate N Director oJACSH. V 3

Editorial On The Ethics of Cigarette Advertising Senator Reed Smoot (R-Utah) once described cigarette advertising as "an orgy of buncombe, quackery and downright falsehood and fraud." That was in 1930. I wonder what Senator Smoot would'have to say about the tux- edoed Barclay man, the Satin business- woman, the Marlboro macho man; the Players cocktail gala, and the Kent jock, enjoying a smoke as he towels down in the locker room, Most of today's ads emphasize vital- ity with suggestions of health, outdoor activity, femininity or masculinity, suc- cess, romance, pleasure or relaxation. Young people are shown bobsled'ding, taking a smoke after a swim or tennis, or whooping it up at an all-American ice cream parlor. A lovely girl' in a country setting,invites us to "take a puff" of a Salem. A handsome man offers a Bar- clay to a waiting lady off camera. Young womem flaunt their newly found inde- pendence in ads for Virginia Slims and More. The "man's man" - the rough and tough cowboy '- shouts his sup- posed virility in Marlboro Country "where a man belongs." Benson and Hedges Delux 100, Sterling and others suggest a "touch of ciass"' with accom- panying pictures of caviar, champagne, silver trays, Rolls Royces, expensive sports cars, and Steinway pianos. What Would E. T. Think? A visitor from another planet proba- bly could' not comprehend that these ads, which total over 1.5 billion dollars in revenues each year, are promoting a product that is our nation's leading cause of premature death, accountingg for over 350,000_fatalities each year. If he was aware of these statistics, he might conclude that our society had some unique set of ethics which encour- aged the selling of death, and made it' all look like fum How would you like the task of explaining to an extraterrestrial drop-in that Americans had a firm com- mitment to good health and therefore moved quickly to ban chemicals like EDB, which cause cancer in laboratory animals but which have never been shown to cause cancer in humans - yet the same society tolerated the promo- tion and sale of a product that kills some 1,000 Americans each day? No long-necked, bulging-eyed crea- tures have phoned home to me yet with those questions, but a few weeks ago my six-year-old daughter, while flipping through a magazine, asked why "they" allow those ads, "when everyone knows cigarette smoking makes you sick." The simple answer, of course, is that ciga- rettes are a legal product and in our freee society, advertising is a: basic right. Cig- arette companies want to promote their product, magazines want the revenue, and the transaction is as American as 100 percent natural, organirapple pie. Besides, the ads have warning labels, making it a matter of free choice; if peo- ple are stupid enough to avoid the warn- ing, that's their tough luck. But is it? Isn't the cigarette phenome- non unique? Perhaps now, some twenty years after the first Surgeon General's report, confronted with some 40,000 medical and scientific references which have documented consistently the extraordinary hazards of cigarette smoking, we should give some careful consideration to the ethics of tolerating cigarette ads. Particularly we might want to re-evaluate the ethics of mis= leading - fun-filled, health-oriented - advertising of a deadly product. My instinctive reaction to the possi- bility of Congress mandating an adver- tising ban on a legal product is negative. After all, one might argue, if govern- ment is given the cigarette inch, they will take the full regulatory mile and who knows what ads they would sup- press next. But actually, as attorney Larry White points out in this issue's lead story, faced with the task of decid- ing on the constitutionality of a ban on cigarette ads, the courts as well as Con- gress might recognize the situation for what it is: a unique problem demanding a unique solution. The ultimate legal issue might not be the right of tobacco companies to advertise, but their right to obscure health risks with misleading innuendo, i.e., the association of smok- ing with success, health, and happiness. Under those circumstances the industry might maintain its "right" to advertise but only in the form of (if youl will for- give the expression) tombstone-type ads, where the hype is absent and only the bare-bones facts about the product (name, quantity, tar andinicotine levels, price, etc.) are presented, much in the same way stocks and bonds are adver- tised. Cigarette Ads: A Unique Problem A number of factors put the question of cigarette advertising in a class by itself: Cigarette Advertising CONTINUED FROM PAGE 1 ordered it to be put on advertisements as well. In 1970, Congress banned cigarette advertising,on radio and television. Cigarette ads still abound in the print media, however, and one of their major functions is to subvert the health warning. The smokers depicted in the cigarette adver- tisements are quite healthy and active;, they obviously'are not suffering from lung can- cer, heart disease or emphysema. The warning label that is presently requiredon all cigarette packages and adver- tising is simply not noticed or read by the vast majority of consumers, and the'FTC staff has concluded' that "a substantial majority of the public remains uninformed about the hazards of smoking:" Congress is presently considering new warning labels that probably would be somewhat more effective in alerting con- sumers to the dangers of smoking. But what- ever new warning is mandated, itwill be put on advertisements for cigarettes, which will undoubtedly detract from its impact. A Major Social Problem More than 53'million Americans continue to smoke and large numbers of young peo- ple take up the habit daily. Clearly, cigarette smoking is a major social problem that requires far-reaching solutions. One approach would be to ban the sale of cigarettes. Itis within the power of Congress to ban the interstate traffic in cigarettes. This is, of course, politically impossible and (rb of questionable wisdom as our country's bob experience with Prohibition has shown. N' A more sensible approach would be to ~ ban the promotion of cigarettes. Although ~' this has already been done in the broadcast N` media, many people assume that it would be ~' unconstitutional to ban cigarette advertising in the print media. This view had some valid- ity a few years ago, but recent Supreme Court decisions indicate that a total ban on CONTINUED ON PAGE S _ 4

We allow a product to be advertised which kills 350,000 of us annually. How do you answer a six-year-old who asks, "Why?" First, let's recall that as a society we never made a decision to allow ads for a deadly product. The ads began some 30 years before scientific studies con- firmed that cigarette smoking was life threatening. Second, the cigarette is the only legal product available today which is harm- ful when used as intended. Alcohol, for example, must be used in abusive quan- tities or unacceptable circumstances (i.e., before driving) to pose a hazard. Automobiles, while a contributing fac- tor to some 50,000 deaths every year, are reasonably safe when used appro- priately. Obviously all advertising is to some extent hyperbole-whether it is the pro- motion of shampoo, baby food, soda or bathing suits, the models are gorgeous and the setting is idyllic. But in these cir- cumstances, the hyperbole in the ads does not entice consumers to purchase an inherently hazardous substance. Third, maybe we should face up to. the fact that the warning label is gener- ally unnoticed and ineffective, and will probably cont2nue to be so in its newer, more explicit form. The warnings tell of risk, but surveys indicate that: American consumers have little knowledge of the magnitude and nature of that risk. Probably unique also is the repressive influence cigarette advertising revenues have on the free flow of negative infor- mation about cigarettes in magazines and newspapers. Whether the pressure to spike pejorative statements on smok- ing comes from the tobacco companies themselves or is simply perceived as pressure by editors, it is clearly there. So CONTINUED FROM PAGE 4 cigarette promotion might indeed withstan& Court scrutiny. Although a ban on cigarette promotion is not now politically feasible, it may be that in a few years changing attitudes about smoking and the growing awareness of its dangers will make such a ban possible. The First Amendment If there is a constitutional objection to a law banning cigarette promotion, it would be found im the language of the First Amendment, which states, "Congress shall make no law . . . abridging the freedom of speech " These ten words, part of a larger guarantee of religious liberty, freedom of given the paucity of negative messages on cigarettes, relative to the omnipres- ent positive messages in advertising, and noting that 90 percent of smokers tell surveyors that they wish they could quit, one begins to wonder how much freedom of choice is really involved here. Impact of an Ad Ban Only the most naive individual would believe that a total advertising ban would have an immediate and signifi- cant downward effect' on cigarette sales. Some 50 countries now have taken legis- lative action or entered into voluntary agreements imposing restrictions on advertising of tobacco products. Of these 15. have banned advertising, including socialist countries which pro- hibit all advertising. But there is no con- vincing evidence that cigarette con- sumption has declined as a result. And it might be argued that the banning of radio and television cigarette ads in 1970 had no depressing effect on sales (although a counter-argument here is that all that electronic advertising was simply transferred to print). But in deal- ing with the cigarette phenomenon, one must recall that it took some 60 years for the cigarette to get its grip on this country - and that grip will not be loosened overnight. "Our ads aren't intended to encour- age people to smoke" the Tobacco Insti- tute still whimpers as it sees the intensi- fying concern in this country about smoking and shortened life span. The cigarette folks even have the audacity to claim that they especially dontt want to L L Allo wing cigarette advertis- ing as we do now, actually has the effect of reducing the flow of information to the public. The greatest under-reported health story of the century is the epi- demic of cancer, heart disease, lung disease and other conse- quences of smoking. 5 ~ i encourage children to someday take up smoking. This is about as ridiculous as a cosmetic company saying it didn't want little girls to learn about lipstick. The industry has staunchly maintained that it advertises only to emphasize brand differences, but this is clearly a smoke- screen. Cigarette ads primarily sell one thing: the social acceptance of smoking. As noted by Emerson Foote, who pro- moted Lucky Strikes during the 1930s and then left advertising to bring the message about cigarettes and health to the public, "The implied message is 'if it is all right to advertise, the product can't be that bad."The converse of this, of which the industry is fully aware, is that if it is not acceptable to advertise, then there must be something wrongg with the product." Right now, smokers are understand- ably worried and unsure of the legiti- macy of their smoking behavior. Ciga- rette advertising reinforces their behavior by suggesting that lots of good-looking, healthy young people do it so "don't worry," So we are facing the dilemma: While we are not questioning the industry's right to informational advertising, do we want to continue advertising with glamours elegance and a strong hint of good health, a product which kills 350,000 of us annually? If your answer is yes, how would you explain your stance to E. T. or an inquiring six-year- old? Elizabeth M. Whelan Executive Director, ACSH the press and the right of assembly, are the perennial subject of lawyerly debate. Constitutional protection has tradition- ally been concerned largely with expressions of political and social ideas that relate to matters of public interest. Few theorists have argued that all speech must be free from regulation. Obscenity may be banned and words that incite a mob to violence may be outlawed. The government may regulate, within reason, the time, place, and manner of speech. The citizen's rightl to speak out on political matters is inviolate, but he cannot speak in the middle of a busy street. Com- mercial speech, including advertising, was CONTINUED ON PAGE 6 5

Cigarette Advertising CONTINUED FROM PAGE 5 historically not considered to be covered by the First Amendment. When the Federal Trade Commission was given the right to deal with unfair and decep- tive business practices in 1938, deceptive advertising became a prime target. In 1942; the Supreme Court confirmed the notion that commercial speech is not protected' byy the First Amendment. When the ban on broadcast advertising of cigarettes was chal- lenged on First Amendment grounds (by the broadcasters, not the tobacco industry) a U.S. district court ruled that Congress had the power to prohibit the advertising of ciga- rettes in any medium. If this were still the law„there would be no doubt that Congress could ban cigarette promotion. However, in 1976, the Supreme Courtruled that purely commercial speech does enjoy some First Amendment protec- tion. This case, Virginia Board of Pharmacy vs. Virginia Citizens Consumer Council, 425 U.S: 748 (1976), opened a constitutional can of worms. Since then, the Supreme Court has struggled to deal, with the problems inherent in extending the First, Amendment where itihad never applied before-advertis- ing. In, the Virginia Pharmacy case, the Supreme Court struck down a state law that made it illegal for druggists to advertise the prices of prescription drugs. The public needed this kind of information, the Court said„ and had a First~ Amendment right to receive it; the interest of the state in;preserv- ing, the professionalism of pharmacists could not justify the law. Unfortunately, the Court seemed to go beyond the facts of the case at issue and made some very sweeping The Dying Autopsy CONTINUED FROM PAGE 2 at autopsy, for example, sparke& further research which led to the recognition of vinyl chloride as an occupational carcino- gen. The effects of drugs and other medical treatments can also be evaluated at autopsy. This is especially important in assessing the effects of chemotherapeutic drugs used to treat cancer, many of which have toxic effects on the body. By checking the various organs for signs of toxicity or spread of can- cer, researchers can design more effective and less harmful! chemotherapy regimens. Examination of the tissues of patients who have had prosthetic devices implanted has enabled researchers to determine the best design, as well as criteria for selecting patients who would most benefit from such devices. By the same token, post-mortem examination of accident victims is instruc- tive in the design of safer automobiles„lad- ders, motorcycles, etc. 6 and misleading pronouncements. Despite the strong language of this case, there were indications that the court did not intend that commercial speech would be treated with the same deference as non-com- mercial speech. Some speech just seemed like it shouldn't be protected for a variety of practical reasons and the Court had to pinch some of the bloom off Virginia Pharmacy in order to uphold laws that~ restricted com- mercial speech. In a 1978 Ohio case, the Supreme Court was presented with the argument that the First Amendment should protect a lawyer who personally solicited clients in a classic ambulance chasing situation. Although 6 L A more sensible approach would be to ban the promotion of cigarettes. " there was nothing deceptive or misleading about the lawyer's "speech," the Court held that the state had the rightto forbid this kind of activity. The next year the Court decided that it was permissible for the state of Texas to forbid optometrists from practicing their profession under a trade name. Trade names did' not convey any useful information, the majority of the Court reasoned, and', it~ was the informational function of commercial speech which brought it the First Amend- ment protection. A number of legal! commentators criti- cized the Court for deciding cases simply on their individual'merits and not establishing a principled body of law regarding commer- cial free speech so that legislatures and Con- gress could predict with some degree of Why So Few? Considering all the benefits of autopsies,, why are so few performed? Several factors have been implicated in the decline of the autopsy's popularity. One major cause may be a general feelingg among physicians that modern diagnostic techniques have eliminated the need for autopsy to establish an accurate diagnosis. As several studies have indicated, however, this is far from true. Misdiagnosis is still astonishingly common and the accuracy of diagnostic techniques can be determined only by examining the patient after death. Another factor may have been the Joint: Commission on Accreditation of Hospitals' decision to abandon its requirement for a minimum autopsy ratG in 1972, a step which Memorial Hospital's Dr. Sternberg calle&"a: bad decision and at the very, least a step backward for medicine." There is also speculation that increasing fear of malpractice suits has caused physi- cians to be less than enthusiastic in request- ing,autopsies and that pathologists have lost interest because their findings are often ignored.. accuracy whether a law would be found validor not. The Court was also given poor marks for interfering in economic regula- tion under the guise of protecting speech. By 1980, the Court began to recognize the prob- lems it~ had'created and to attempt to bring order out of what appeared to be chaos. In 1980, the Court struck down a New York state regulation that forbade a utility from~sending out notices promoting the use of electricity. Finally, with this case, the Court systematized the rules regarding com- mercial free speech. The constitutional anal- ysis provided in this case has withstood the test of subsequent cases and emerged as a guide for determining whether a law regulat- ing commercial speech is constitutional. The Court finally made it clear that eom- mercial' speech enjoyed a kind of "second class"' protection under the First Amend- ment. Any false or misleading speech could be bannedy since the constitution does not prevent the government from "insuring that the stream of commercial information flows cleanly as well as freely." Even more impor- tant, the Court recognized that some com- mercial speech could be banned though, it concerned entirely lawful conduct and was not misleading. According to this ruling, if the govern- ment can show an important reason to regu- late a particular type of commercial speech, and if the regµlation, in question actually advances the asserted governmental inter- est, and if the regulation is not more exten- sive than necessary, the government's power will notbe limited by the FirsLAmendment. Insofar as such advertising is misleading, it can be banned without further analysis. Those who know the facts about smoking CONTINUED ON'PAGE 7 Cost is another factor. Since fees are not charged for autopsies, the hospital must absorb the costs of performing them, which may be as much as $3,000: The attitude of surviving family members may also discourage the regular perform- ance of autopsies. While the coroner or medical examiner can legally require an autopsy to be performed in cases of suspi- cious, accidental or mysterious death, or when there is evidence of a public health hazard, undernormal circumstances a fam- ily member must give permission for a post- mortem examination. "It's a difficult situation," says Dr. Eve- lyn Godin-Ostro, a third-year resident at a New Jerseyhospital. "Five minutes after the patient dies, we have to ask for permission to do the'post'. The family usuallydoesn't know what an autopsy entails and they're afraid that the bodywill be completely muti- lated." Unless the physician makes it clear that the pathologist's incisions will be unnotice- able at an open-casket funeral and that valu- able information can be gained by autopsy,CONTINUED ON PAGE 7

Cigarette Advertising CONTINUED FROM PAGE 6 might reasonably argue that~ all cigarette promotionlis misleading, since its purpose is to induce people to buy a product that is both harmful, and addictive. However4 many people do not yet understand the full dangers of smoking and the idea that eiga- rette advertising is intrinsically misleading may not be accepted by the courts in the near future. But a law that banned cigarette advertis- ing would most likely be constitutional even if such advertising were not found to be intrinsically misleading. The government's justification for such a law would be to reduce the incidence of smoking related dis- eases by reducing the number of smokers. This is certainly an important state interest that would pass constitutional muster. Furthers the total ban on promotion of cigarettes would not be more extensive than necessary. Indeed, only a total ban would be effective. Foreign experience, as well as American experience with the ban on ciga- rette advertising in the broadcast media, shows that tobacco companies will transfer their vast promotion budgets to whatever type of promotion is allowed. In Italy, where there is a ban on cigarette advertising imthe print media, but not on other types of pro- motion, the tobacco companies sponsor sports and artistic events and have found many other ways to promote cigarettes. Not surprisingly, consumption has not declined since the advertising ban went into effect. Norway, by contrast, has a strict ban on all forms of cigarette promotion. Since the ban was instituted im 1975 there has been a signif- icantdrop in cigarette consumption, accord- The Dying Autopsy CONTINUED FROM PAGE 6 family members often refuse to give their consent. Some of the problems concerning consent for autopsy could be avoided if familiess were to discuss the issue in advance. A sur vey of Psychology Today readers indicated that 83 percent either approved or did not care if an autopsy were performed after their death. If the desire for an autopsy or organ donation is expressed before death, surviving family members can avoid making what may be a painful decision during a time of grief, and may even be prepared to take the lead in requesting an autopsy. Religious objections are sometimes raised, but except for Orthodox Judaism and the religion of Islam, there are few reli- gious edicts prohibiting autopsy. Occasion- ally, funeral directors will discourage family members from consenting to autopsy, because it causes a minor delay in receiving the body and may make embalming slightly more difficult. A Major Public Health Problem Whatever the reasons, the recent decline ing to the World Health Organization. Behind the purely legal questions involv- ing commercial free speech are important ethical and political principles. A sense of justice no doubt led to the reasoning that laws which keep useful information from the public are unconstitutional. 11s, Afolr1'f)1t. The smokers depicted in the cigarette ads are healthy, active, happy people who are a far cry from those suffering from lung cancer, heart dis- eases or emphysema, results of cigarette smoking. In the context of a proposed banion ciga- rette promotion,, this concern, takes on an unusual twist. Eliminating cigarette promo- tion woul& reduce the flow of information in the rate of autopsy' is a major public health problem in, this country. Even more disturbing is the fact that'post-mortem examination is least likely to be performed in those cases where it, would be most useful. The rate of autopsy is especially low among those who die in old age, even though, the proportion of the U.S. population over 65 continues to grow. Older patients account for a large proportion of all hospi- talizations and physician visits, indicating a need for enhanced knowledge about their health problems. Yet, while nearly 60 per- cent, of all deaths occur after age 70 and errors in diagnosis are most common in this age group, these deaths account for less than seven percent of all autopsies. Autopsy is also unlikelyto be performed in cases where death apparently occurred due to a common condition. Of the 69 causes of death listed in Vital Statistics of the United States im 1977, autopsies were performed in more than 50 percent of cases for only six: homicide, abortion, other com- plications of pregnancy, meningococcal infections, baccilary dysentery and amebia- sis, and "other external causes." These six hardly atall: Almost all cigarette advertising is merely the association of smoking with an attractive image and its loss would not affect consumers' abilities to choose intelligently. It is expected that any ban would allow advertising at point of sale, and it is there that any useful information, such as tar and nicotine levels, as well as price, could be dis- played. Allowing cigarette advertising, as we do now, actually has the effect of reducing the flow of information to the public. The greatest under-reported health story of the century is the epidemic of cancer, heaa dis- ease, lung disease, and other consequences of smoking. This story has not been reported as it should! have been because tobacco advertising is allowed. Cigarette advertising is a major source of revenue for many, if not most, newspapers and magazines. Editors are fearful of pub- lishing the truth about smoking because they know that such stories will provoke the wrath of the tobacco companies. The loss of cigarette ad vertising revenues would be seri- ous for the many publications that have become dependent on them. But even more serious is the human and social cost in death and disease that is a consequence of the sup- pression of the truth about the hazards of smoking. The First Amendment is one of the great- est achievements of our free society. But it was not meant to be and should not be used as a refuge for an industry which is responsi- ble for the premature deaths of 350,000 Americans annually. Larry White, J. D., is a free-lance writer in - Berkeley, California. conditions account for less than two percent of the nation's deaths, and hardly constitute our mosGserious public health problems. By contrast, autopsies were performed on less than 10 percent of the nearly one million deaths ostensibly due to cardiovascular dis- ease and only 11 percent of the nearly 00 400,000 deaths attributed to cancer. Unless there is a revival of interest in the ~ autopsy by both the public and the medical ~.i profession, we may be up against a major t= stumbling block in our war against disease. N We cannot hope to increase diagnostic accu- CQ racy without the ability to check clinical ~ diagnoses against those confirmed by autopsy. Progress ini understanding the nat- ural history of disease„as well as advances in therapeutic techniques, are seriously threat- ened by our low rate of autopsy. Even our national health policies and priorities may be misdirected if they are based' upon vital statistics which are inaccurate. The dead have much to teach us, if only we will let them. Cathy Becker Popescu, M.S., is a Research Associate with ACSH. ~ ; 0 c ~ v > QJ 3 z" x V) a 7

-~. he A ft -ms.._ - c 'I & er ld ~ . As from t l ~ f s n Sweden io cAGro ~~~ensfo~ #1 ce, the cream was so the am6°~-ii Rg . THE'80sSEARCH FORTHE FOUNTAIN Many ads claim that if you take certain supplements or follow the advice given in popular books, you can live to be 150. Are they right? Or are people who answer those ads just throwing their coins into the fountain? by Kathleen A. Meister PONCE DE LEON DIDN'T DO TOO BA.DLY.. Although his search for the Fountain of Youth failed, he managed to survive his ini- tial explorations and he may have regarded the discovery of Florida as a nice consola- tion prize. His modern counterparts are often less fortunate. A recent investigation by the Select Com- mittee onAging of the House of Representa- tives revealed that longevity seekers in the U.S. spen& more than $2 billion a year on quack anti~aging remedies. The committee described the sale of these products as "the fastest growing segment of current medical quackery." During the course of their inves- tigation, the committee staff and its expert consultants reviewed several hundred prod- ucts promising to arrest or reverse aging. Not one of them proved to be of any valuee and some were dangerous as well as decep- tive. No one has yet discovered a means of pre- venting aging in humans or extending the maximum human life span. Experts agree tharthe maximum life span of human beings has not increased during recorded history, and many of them believe that it has not increased since Homo sapiens emerged as a species. What has increased is the propor• tion of the population that comes close to reaching this maximum. There have been enormous gains in human life expectancy (which is average life span), particularly in the twentieth century. These gains resulted from the prevention of premature deaths rather than an extension of maximum potential life span. Population statistics indicate that if all premature deaths could be prevented, peo- ple would live to be about 85 (give or take 10 years). Some optimistic scientists stretch things a bit further and suggest that the max- imum life span is closer to 100 or 110 years. Responsible estimates go no higher. There is no documented case of a person living to be more than 118 years oldL (For a discussion of claims to the contrary, see the box on page 11.) It is entirely possible, of course, that a way of extending the maximum~ human life span will be discovered in the future. This is one of the goals of gerontology-the branch of science devoted, to increasing our under- standing of the aging process. Gerontolo- gists have made substantial advances in dis- covering how and why humans and animals age. Some of their findings have received widespread publicity and have been miscon- strued by overenthusiastic longevity-seek- ers. Many of the popular prescriptions for life span extension are based on misinterpre- tations or overgeneralizations of geronto- logical discoveries. The Potions of Pearson and Shaw Perhaps the most famous of the propo- nents of dubious anti-aging regimens are Durk Pearson and Sandy Shaw, authors of the hefty best-seller Life Extension and the more recent Life Extension Companion. Pearson and Shaw have compiled a long list of substances that they regard as beneficial in extending life, on the basis of animal experiments or theoretical considerations. They have beeni administering these sub- stances to themselves since 1968. The Pearson/Shaw life extension concoc- tions emphasize antioxidants, but they also include many other substances. The "per- sonal experimental formula"' which they themselaes take comprises 31 chemicals, including prescription drugs (e.g., L-Dopa, Hydergine), essentiali nutrients (zinc, sele- nium, large doses of most of the vitamins), other substances that occur naturally in foods (e.g., choline, RNA, bioflavonoids) and antioxidant foodiadditives (e.g., BHT). Pearson and Shaw are so enthusiastic about their multi-chemical warfare against aging that readers of their books may suspect that they would throw in the kitchen sink, if they didn't need it to mix their potions. Pearson and Shaw's basic premise is not totally without scientific merit. One current gerontological hypothesis says that damage to the cell's genetic material by substances called free radicals may be a major cause of aging. Antioxidants in the cell can trans- 8

The Ultimate i Anti-Aging & Prevention FOUNTAIN OF YOUTH contains all of, the nutrients that research has shown to help oxygenate the cells and prevent premature aging of body and'skin OF YOUTH COMES UP VERY DRY form free radicals into less reactive and pre- sumably less harmful substances. So far, so good. But to leap from this reasonable but unproven theory about events at the cellular level to the proposition that ingesting vast quantities of antioxidants will extend human life is more than most scientists ean~ swallow. What do the experts think of Life Exten- sion? Dr. Stephen Barrett, Chairman of the Lehigh Valley Committee Against Health Fraud, Inc.: ". . . the book's presentation of experimental data is biased and uncritical." Dr. Fredrick Stare and Ms. Virginia Aron, son of the Harvard School of Public Health4 writing in the Journal of theAmerican Med- ical Association: "Some of the health advice in this book would be humorous if it, were not so dangerous. The actual' nutrients rec- ommended would have to be considered as drugs when taken as self-prescribed supple- ments and in excessive doses." University of Southern California geron- tologist Dr. Caleb Finch: [Pearson and Shaw] have swallowed whole a library of sci- entific studies without really digesting them. What they're doing is like taking every pos- sible cure for the common cold'at once:'' The House Select Committee on Aging summarized the expert views this way: "Most experts believe this book represents a misinterpretation of sound aging research. . . . Isolated unsubstantiated reports are used to validate their hypotheses." The known risks of the Pearson/Shaw regimen include headaches, intestinal disor- ders and kidney damage. There may be addi- tionalrisks that have not yefbeen identified. Few of the formula's components have been tested for safety in humans at the doses rec- ommended. The entire combination has never been tested on any creature other than Mr. Pearson, Ms. Shaw and their followers. The use of prescription drugs by healthy people has aroused the greatest concern, but the more familiar food-related ingredients in the Life Extension concoctions should not be overlooked. Many of them are dangerouss in very large quantities, although they are quite safe in the much smaller amounts found in a normal diet. To give just two examples: Pearson an& Shaw's "personal experimental formula" includes two grams of BHT daily. This is within one order of magnitude of the dosage fatal to rabbits. The formula also includes 1.75 grams of vitamin B, a day. Long-term consumption of two grams a day has been shown to produce disabling sensory neuropathy in humans. The Life Extension regimen is not cheap. In addition to the formula components, it involves visits to a physician willing to pre- scribe the drugs and frequent medical exam- inations and laboratory tests to detect possi- ble side effects. Dr. Barrett estimates the annual cosCas between $1,000 and S2,000. The commercial potential of this program has not gone unnoticed. Sales of the sub- stances recommended by Pearson and'Shaw have skyrocketed. Some health food storess now have "life extension" sections, and many ads for food supplements prominently feature products recommended by Pearson and Shaw. The Florida-based Life Exten- sion Foundation sells books, supplements, and a life extension newsletter, and directs people to physicians sympathetic to the cause. Not all of those who stand to profit from Pearson and Shaw's ideas endorse them, however. The House Subcommittee on Aging reports that the Sandoz Pharmaceuti- calCompany, which produces several of the recommended prescription drugs, com- pletely disapproves of Life Extension and of the proposed misuses of its products. Eat Less: Live Longer? Like Pearson and Shaw, Dr. Roy Walford has writtema mass-market book on life span extension; but in all other respects he is in a very different league. For one thing, his Maximum Life Span is a much more accu- rate and entertaining book. More impor- tantly, Dr. Walford is a respected gerontolo- gist. He heads the research laboratory for the study of immunology and the aging process at the University of California, Los Angeles, and serves om the National Acad- emy of Sciences Committee on Aging and', the National Institute on Aging Task Force on Immunology. Most gerontologists do not believe that our current understanding of the aging proc- ess is sufficientto justify advising the public to make any changes in their lifestyles in the hope of extending maximum life span. Dr. Walford disagrees, and he gives very, specific advice of this type in his book. The regimen he recommends has three distinct advan, CONTINUEDON'PAGE 10 9

Search for Youth CONTINUED FROM PAGE 9 tages, from a consumer protection stand- point, over that of Pearson and Shaw. Most people could follow it for several years with- out: risking physical harm{although its very- long-term safety is uncertain); it is suffi- ciently difficult and unpleasant to prevent people from undertaking it easually; and it is poorly' suited for commercial exploita- tion. Dr. Walford is a proponent of under~ feeding-what he calls "undernutrition without malnutrition." LL Pearson and Shaw are so enthusiastic about their multi- chemical warfare against aging that readers of their books may suspect that they would throw in the kitchen sink, if they didn't need it to mix their potions. ~~ Underfeeding is the only treatment which has been proven (well, almost proven) to extend the maximum life spans of mam- mals. In the 1930s, Dr. Clive McKay of Cor- nell University first showed that if labora- tory rats were restricted, starting at the time of weaning, to a diet that was substantially lower in~ calories than the diet which they would freely choose, both their average and maximumJife spans would increase. This phenomenonihas been demonstrated repeatedly in rats and mice, but, the original version discovered by McKay is unsuitable for use in humans for several reasons. It' restricts growth and interferes with normal sexual'development. There also seems to be a segment of the rodent population that can- not tolerate it. Although most of the animals live impressively long lives, a few die before reaching maturity. Many attempts have been made to extend the life spans of laboratory animals through dietary restriction that starts in adulthood, and thus cannot interfere with growth, mat- uration, or survival to maturity. Most of these experiments have led to little or no improvement in longevity and a few have actually shortened the animals' lives. Recently, however, Dr. Walford and his UCLA colleagues succeeded in substantially extending the life spans of mice by under- feeding that started in mid-life. Dr. Walford believes that the keys to the success of hiss underfeeding regimenare the gradual rather than abrupt imposition of the restrictedidiet and careful attention to the nutritional ade- quacy of the diet, in order to achieve under- nutrition* (a deficiency of calories) without malnutrition* (a deficiency of other essen- tial nutrients). ' These are Dr. Walford's uses of these terms. In conventional nutritiom terminology; a defi- ciency of calories wouldbe described as malnu- trition. In practice, what the Walford regimen amounts to is a moderately low-calorie diet, very carefully planned to ensure nutritional adequacy. It differs from other low-calorie diets in that it is not discontinued when the dieter achieves the weight generally recog- nized as ideal by medical authorities. Instead, it is continued permanently, to achieve and then maintain a substantially lower body weight. Dr. Walford thinks that this regimen can and should be attempted by humans. Manyy other scientists disagree. The regimen has never been tested in animals other than rodents, and many people think that itt would not be prudent to attempt it in humans until it has been proven safe and effective in a wid'er variety of animal'species. Also, there is evidence from epidemiolog- ical studies that indicates that underweight people do not live as long, onrthe average, as those of average bodyweight'. In some stud- ies, this difference in longevity was found even when smokers (who tend to weigh less than nonsmokers do, and who have an increased risk of early death) and people with chronic diseases (which might cause weight loss) were excluded from the analy- ses. Dr. Walford believes that these data do not contradict the animal evidence. He sug- gest'sthat many of the underweight! people in the epidemiological studies may have been malnourished as well as undernourished, or that they may have been naturally thin rather than underfed. These explanations are plausible. It is difficult to achieve nutri- tional adequacy on a low-calorie diet with- out carefuliplanning, and there is reason to believe that natural thinness might not have the same consequences as deliberate undea- feeding does. It is equally plausible, how- ever, that the differences between the human and animal data reflect real differences between mice and men. The failure of many of the animalitests of adult dietary restriction is another cause for concern. Dr. Walford believes that those tests failed because the regimen was imposed too suddenly or because the animals were malnourished, and that his regimen suc- ceeded because it was gradually imposed and'nutritionally adequate. Some other dif- ference ini experimental conditions might account for the differences in results, how- ever, and that factor could easily be lost im translation when the regimen is applie& to humans. Finally, some scientists still doubt whether dietary restriction really extends maximume life span, even in rodents. They think that the "normalP' lifestyle of a laboratory ani- mal may actually be detrimental to longev- ity, most likely by inducing obesity, and that dietary restrictionm may merely correct this situation and restore the animals' real maxi'- mum, life span. The maximum life spans of rats and mice in thewilds in the absence of predators and disease, are unknown, so the laboratory situation cannot be compared with the natural one. Gerovital Gerovital (alSo calle&GH3) remains pop- ular as an anti-aging remedy despite more than 30 years of use during which no scien- tific evidence for its effectiveness has been, developed. Its main ingredient is procaine hydrochloride, best known to Americans as the local anesthetic Novocain. Gerovital, which was first introduced in Romania in the early 1950s by Dr. Ana L L No one has yet disco vered a means of preventing aging in humans or extending the maxi- mum human life span. Experts agree that the maximum life span of human beings has not increased during recorded his- tory, and many'of them believe that it'has not increased since Homo sapiens emerged as a species. Y) Asian, has been~ claimed effective against practically every illness and physical change associated with aging. In controlled scien- tific studies, however, it has not produced benefits in elderly patients. There is some support for the idea that it may act as an antidepressant, but the evidence on this point is contradictory: The Los Angeles Veterans Hospital con- ducted a comprehensive review of all the evi- dence on Gerovital in 1975, and concluded tharit was not effective. There is no new'evi- d'ence thatwould invalidate that conclusion. Gerovital's main ingredient, procaine, is not completely harmless, as has often been claimed. It can produce side effects in some patients although these are rarely severe. Dietary'Supplements A wide variety of so-called nutritional products have been promoted as anti-aging remedies. Some owe their popularity to Pearson and Shaw, but many others have been promoted independently, and have been profitable since long before the publi- catiom of Life Extension: Current examples include the following: SUPEROXIDE DISMUTASE (SOD): Superoxide dismutase is an enzyme natu- rally present in all body cells which protects against the potentially destructive effects of superoxide, a byproduct of the cell's use of oxygem It has been suggested'that the level of this enzyme present in the cell is an impor- tant factor influencing that cell's rate of aging, buU this idea is controversial within the scientific community. There is no con- troversy, however, over the idea that dietary supplements of SOD might have beneficial effects. All of the evidence indicates that they cannot. Dietarysupplements of SOD do not influ- ence the level of SOD in bodyceils. This has been demonstrated in an experiment with. CONTINUED ON PAGE 11 10