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A Tribute to Harold S. Diehl, M.D. (1891-1973) Changing Patterns of Smoking and Disease Lawrence Ga:finkel. M A Those v.ho knew and admired Dr. Harold Diehl were impressed by his outstanding achievements. Dr. Dtehl had a long and distingmshcd career at the University of Minnesnta Medical School. In 1922. he was appointed head of the Deparlmcnt of Preventive Medicine and the first Director of the Student Health Service. He was pro- meted m quick order to the rank of pro- fessor in 1929 and in 1935 assurned the post as Dean of Medical Sciences. During his years with the university. he initiated and promoted stm~e of the most important work in tuberculosi.,, control and did pioneering research on the common cold. As dean. he launched an extensive buildin~ program and attracted a preemi- nent faculty that helped improve the qual- =ty of lhe medical school. His book, too'e- book tq Heahhful Living, is widely used in schnols el public health and has gone through nine editions. After an honored career at the univer- sity. he retired and came to New York City to assume his new post as Senior Vice President of Medical Affairs and Research at the American Cancer Society (ACS). 3"hem his second career stoned, and it was Mr. Garfinkel =s Vice Prc~,~dent for Epidemiof og.'. and Stau.,ttc.~. American Cancer Stx:iety. New York. New ¥~rk. This paper v,a.,. ~rc...enled at the 28lh Annual Meetm,._" af the American Association lot World Health during the 108th Annual Meeting of the American Pubhc ttealth Associanon in Octo- ber. 1980 there that I first came to know him. His ,,,.'as a strong votcc in the Society sup- porling our epidcmiologic research slud- ies. He took as his personal crusade the task of coovincing the medical profcs,don and the government to bring to the public the facts about smoking and health. Just a |~ew of the highlights of his ACS tenuro: He was instrumental in persuading the ACS Board of Directors in 1960 to issue a statement that epidemiologic and patho- logic evidence no longer Icfi any doubt that cigarette smoking increased the risk of" lung cancer. He requested that the American Heart Association. the National Lung Associa- tion. and the American Public Health As- snciation join ACS in writing to President John F. Kennedy to suggest the formation of an independent cornmission to study the problem of smoking and health. Dr. Dichl drafted the letter that eventually led to President Kennedy's asking the Surgeon General to form the Committee on Smok- ing and Health that wrote the clas~ic 1964 report. Dr. Diehl convinced a number of med- ical .~ocicties and voluntary health agencies to issue statements on the harmful ettcct,, of smoking. He wrote letters to prcMdents of 1.600 colleges and universities deploring the in- tense promotion of cigarettes on cam-. puses. Because of his athens, the pro- motions were curtailed, and most cizarettc C~.A CANCER JOUIRNAL FL)P,, CLIN'.C~ANS VOL 3'1. NO 2 MARCH ~,PRIL 198"~ T!04230995

:1-1973) to know him. Hi.,, n the Socicty sup- ~ogic research stud- ersonal crusade the medical profession bring to the public ~g and health. ighlights of his ACS tal in persuading the }rs in 1960 to issue .'niologic and patho- .~r left any doubt that :reused the risk of the American Heart real Lung Associa- a Public Health As- writing to President :ggest the formation mission to study the ~d health. Dr. Diem : eventually led to asking the Surgeon ;~mmJttee on Smok- ore the classic 1964 :d a number of med- tary health agencies the harmful effects presidents of 1,600 es deploring the in- .'igarettes on cam- ~ actions, the pro- . and most cigare,tte JRNAL FC)R CLINICIANS VOL 31, NO, 2 MARCH'APRIL 1981 T!04230996

company advertising in college news- papers and sponsorship of college sporting events were stopped. He helped found the National Inter- agency Council on Smoking. He edited an ACS publication, Med- ical Bulletin on Tobacco. which reported the latest research on smoking and health and was sent Io all physicians in the coun- try. He wrote an important book on smok- ing for a lay audience, published in 1969, Tobacco and Your Health: The Smoking Controversy. His campaign asking the airline's vol-" untary compliance to allocate seating sec- tions for nonsmokers led the Federal Avia- tion Authority to puss such regulations for all airlines. Harold Dichl had a dream. He be- lieved in the public's common sense. If people underslood the health hazards of smoking, the majority would quit. As he said in the preface of his book, "I do not claim to be a disinterested, impartial ob- server or reporter. I have seen too much illness, disability, and premature death attributable to smoking to be that. On the other hand, I have attempted to maintain scientific objectivity. Any bias I may have is occasioned only by a desire to prevent some of the tragic results of cigarette smoking." He successfully mobilized the forces of public health and the medical community to use their influences. The Pattern Today What has happened since Dr. Diehl's death in 1973? Lung cancer rates are still rising, but there is now evidence that the long struggle against smoking is succeeding. According to a 1979 survey by the National Center for Health Statistics, more than 30 million smokers in the United States have quit smoking, and now only one third of all adults smoke, compared to more than one half about 20 years ago.' The public is overwhelmingly aware that cigarette smoking is hazardous to health. Studies show that more than 90 percent of all Americans--smokers as well as nonsmok- 116 ors--know that .smoking can cause cancer and other diseases, Cigareue consumption per capita has decreased by more than five percent between 1973 and 19793 Accord- ing to the latest dala available, the age- standardized death rate of lung cancer in men continues to increase. It must be realized, however, that even for those who quit cigarette smoking after 25 years, the excess risk of lung cancer tends to decrease but does not immediately disappear. Data from the ACS's epide- miologic research studies indicate it is not until I0 or more years of quitting that the mortality rates of former smokers ap- proach those of persons who never smoked.' Encouraging Signs However, there are encouraging signs in the ~nalysis of trends of lung cancer mor- tality for different age groups. In Great Britain, for example, lung.cancer mortality rates in men aged 45 to 54 and 55 to 64 have actually been decreasing. The rates in older men continue to increase. In the U.S., there is evidence that the mortality trends in the younger men (under age 65) are starting to level off, but that they are still increasing at a steady pace in older men. In Great Britain, the age-standard- ized lung cancer rate for men has actually decreased; in the U.S., it is not too opti- mistic to predict, based upon the age trends, that there will be a leveling off, and perhaps a decrease, in the overall male lung cancer death rate by the end of the 1980s. Women and Smoking The picture for women, unfortunately, is different, in young women, cigarette smoking as a cultural pattern started in the 1940s~ about 20 to 25 years after it was generally adopted by men. By the mid- 1960s. we started to observe a steady inex- orable rise in the lung cancer mortality rate in women. By 1977, it had increased to more than three times the 1960 rate--a pattern that paralleled the increase in that for men in the 1940s and 1950s.~ By 1977, the female lung cancer death rate was CA-A CANCER JOURNAL FOR CLINICIANS aboul the same as for colon-rot il present rates continue, it a surpass the death role for brea., become the leading cause of t m women by the mid to late also C'~ 31:2~-45. 1981 .) The rates in the U.S., Great Britain her of other countries are incr rapidly m younger than in (lid "l'ar and Nicotine Anothcr phenomenon is chang pattern.,, and their effects on ~ country and many other co, bacco companies have been tb- lic demand to produce ciga lower in tar and nicotine than t produced 30 years ago. in I* eragc cigarette in the U.S, h;. and 2.2 mg nicotine. The cigar in tar/nicotine (T/N) produced in 198U arc lower in T/N cont cigarette produced in 1950: values are about 17 mg tar nicotine. There is now a srr evidence--from the ACS's stu epidemiologic research studio: who smoke low T/N cigarette. total death rates, lower cot'. disease death rates, and lower death rates than do those wh~ ai'cttes relatively high in T/N. Our studies also shower that nonsmokers die of lung c.' far lower than do low TIN s, nine percent as high in males. cent as high in females. Amo the number of cigarettes smt" was a far more important f death rate than whether the sm high or low T/N cigarettes.' The epidemiologic evidcr mortality in low T/N smokers by an autopsy study publish~ Previous studies had shown tl changes of different kinds * metaplasia, atypical nuclei) direct proportion to the hum rettes smoked per day. The new study was an c histologic changes in the trot, tree in smokers who died in tl VOL. 31. NO. 2 MARCH/APRIL 1~1 T!04230997

can cause cancer • cue consumption :~y more than five d 1979.2 Accord- -uilable. the age- if lung cancer in nO. owever, that even :tte srnoking after k of lung cancer • not immediately ne ACS's epide- • indicate it is not I quitting that the nor smokers ap- ho never smoked) ,,uraging signs in lung cancer mor- groups. In Great g cancer mortality 54 and 55 to 64 easing. The rates .7 increase. In the that the mortality cn (under age 65) but that they are ~dy pace in older the age-standard- ' men has actually it is not too opti- .'d upon the age m a leveling off, n the overall male :~y the end of the unfortunately, is ,,omen, cigarette hem started in the years after it was ten. By the mid- .~rve a steady inex- acer mortality rate had increased to the 1960 rate--a le increase in that 1950s." By 1977, , death rate was ,~IAL FOR CLINICIANS about the same as for colon-rectum cancer; if present rates continue, it will probably surpass the death rate for breast cancer and become the leading cause of cancer death in women by the mid to late 1980s. (See also Ca 31:29-45. 1981.) The lung cancer rates in the U.S.. Great Britain, and a num- ber of olher countries are increasing more rapidly in younger than in older women. Tar and Nicotine Another phenomenon is ch.anging smoking pattern.,, and their effects on health in this country and many other countries. To- bacco companies have been forced by pub- lic demand to produce cigarettes much lower in tar and nicotine than the cigarettes produced 30 years ago. In 1950, the av- erage cigarette in the U.S. had 40 mg tar and 2.2 mg nicotine. The cigarettes highest" il~ tar/nicotine (T/N) produced in the U.S'. Jn 1980 are lower in T/N content than any cigarette produced in 1950; the average values are about 17 mg tar and 1.2 mg niootine. There is now a small body of evidence--from the ACS's study and other epidemiologic research studies--that those who smoke low T/N cigarettes have lower total death rates, lower coronary artery. disease death rates, and lower lung cancer death rates than do those who smoke cig- arettes relatively high in TIN. Our studies also showed, however, that nonsmokers die of lung cancer at rates far lower than do low T/N smokers: only nine percent as high in males, and 33 per- cent as high in females. Among smokers, the number of cigarettes smoked per day was a far more important factor in the death rate than whether the smoker smoked high or low T/N cigarettes2 The cpidemiologic evidence of lower mortality in low TIN smokers is supported by an autopsy study published in 1979.~ Previous studies had shown that histologic changes of different kinds (hyperplasia, metaplasia, atypical nuclei) increased in direct proportion to the number of ciga- rettes smoked per day. The new study was an evaluation of histologic changes in the tracheobronchial tree in smokers who died in the late 1950s VOL. 31, NO. 2 MARCWAPRIL 1981 and in the 1970s. Histologic changes in the nonsmokers were minimal and about the same in both periods. However. the smok- ers who died in the 1970s had far less his- tologic change or all types than did smok- ers matched by age and number of cigarette.,, smoked per day who died in the late 1950.~. Since those who died in the 1970s had to have smoked cigarettes lower in TIN in the last five or 10 years of their lifetimes than did those who died in the late 1950s, it is reasonable to infer that the major reason for the observed differences in the two groups was the changes in the T/N content of the cigarettes smoked in the last years before death.~ Perhaps an even more important result of the production of lower T/N cigarettes is that they enable smoker.,, to give up smoking more easily. Data from the ACS's prospective study showed that in both men and women in two six-year periods--195o to 196~, and 1966 to 1972---smokers of low TIN cigarettes w~re able to quit at a higher rate than were those smoking mod- erate or h~gh T/N cigarettes. The absolute differences were modest, ranging from five to seven percent, but they were con- sistent even when taking into consideration the number of cigarettes smoked per day." These studies were based on brands smoked in the late 1950s and mid-196tas: what we then called "low TIN'" would bc classified as "moderate TIN" today. In the 1970s there has been a proliferation of cig- ",,, an,.. important result of the prnduction of lower T/N cigarettes is that they enable smokers to give up smoking more easily," arette brands with even lower T/N. Brand.', with 15 mg or less of tar now command more than 40 percent of the market.'" "l'hc average tar of these brands is about 10 rag. and the average nicotine content less than 0.8 mg. This has great implications for the fu- ture in our attempt to persuade people to stop smoking. Cigarette companies ma.~ TlO4230gg8

be inadvertently weaning smokers away from smoking. Those who want to quit. and have had difficulty in the past. may now find it much easier after smoking the new low TIN cigarettes. Some researchers fear that smokers who switch to low TIN cigarettes tend to "compensatc"--that is. Ihey increase the number of cigarettes smoked per day. or they may increase their exposure by in- haling more deeply." If this is true over a short term, ACS studies show that this pattern does not appear to hold over long periods of time. Smokers who continued to smoke over the 12-year period of the study and had switched to low TIN ciga- rettes did not increase th~ number of cig- arettes they smoked per day or they in- creased it only slightly,t-" Decline in Cardiovascular Disease Mortality Death rates for cardiovascular diseases have dropped considerably in the last 10 years. Between 1968 and 1977, the mor- tality rate for diseases of the heart in the United States dropped 22 percent, and the rate for cerebrovascular diseases decreased by 32 percent. These decreases have oc- curred in both sexes and across all age groups. Mortality rates for several other causeS(accidents, diabetes, nephritis)have also decreased, while the cancer death rate "... the increase in life expectancy since 1968 is greater than would have resulted if we had eliminated cancer as a cause of death." increased by three percent, and the death rate for chronic pulmonary diseases in- creased by about 20 percent?-' The net result of these changes has been an increase of three years in life ex- pectancy in the U.S. since 1968.~.' This parallels the increase in life expectancy in the late 1940s with the advent of antibiot- ics. To put it into another perspective: the increase in life expectancy since 1968 is greater than would have resulted if we had eliminated cancer as a cause of death. The drop in cardiovascular diseases in the last decade has also been observed, but to a more moderate degree, in Australia, Israel, Canada, and New Zealand. Investigators continue to debate the reasons for the decrease. They cite in- creased use of antihypertensive drugs, bet- ter diets, more exercise, and more inten- sive coronary care units. In addition, the absence of a severe influenza epidemic during the period under consideration un- doubtedly helped keep down the cardio- vascular rate, especially among the el- derly. All these factors have had some effect. But I, and many others, believe that the changing patterns of cigarette smoking are also an important factor. Epidemiologic studies suggest that the decrease in mor- tality associated with smoking cessation occurs more rapidly in coronary heart dis- ease than it does for lung cancer. We are seeing results of the anti-cig- arette crusade. However, there is still much to be done. If Harold Diehl were alive today, he would have hailed our ac- complishments, but he would look forward to the battle on the current issues of the antismoking crusade: ,, Continue research on the low TIN cig- arette. The product is changing so rap- idly that repeated epidemiologic sur- veillance is needed to determine if the newer cigarettes arc indeed less harmful: ,, Support motivational and behavioral re- search into the best ways of getting smokers to quit: • Give the Food and Drug Administration the authority to examine the potential health hazards of all substances in to- bacco products, particularly the flavor- ing additives; • Urge the Federal Trade Commission to seek voluntary agreements with tobacco companies to: restrict advertising on brands of cigarettes in the upper TIN lev- els. eliminate use of all models in ad- vertising, and clearly display TIN con- tent on cigarette packages: • Support an intensified cdt paign to persuade womc: pregnant women, to reduc quitting smoking: • Extend the educational crt agcrs, those occupational carcinogens, blacks, and who are at parlicularly hi.,. ccr and other diseases rcl ins: • Ask Ctmgress to institute :~ based on T!N content as : for smokers Io switch to in T/N: ~, Advocate state and local set aside no-smoking area places. Re:erences I. Mo~,s A J: Changes in cigarc current smoking praclices amo~ States. 1978. Advance Data Health Statistics. No 52. US Health. Education. and Wclfar Service, National Center for I- 1979. pp 1-15. 2. Tobacco Siluati~m. TS-- 17? of Agriculture. 1'~80. p 6. 3 Hammond EC. Garfinkcl 1. disease, stroke, and a()rtic an. in the etiology. Arch Em.'iron Hc 1969. 4. Cancer Facl~ and Figures. I American Cancer Society Inc. 5. Hammond EC. Garfinke[ L ah "'Tar" and nicotine content o: in relatit, n to death rates 12:263--274. 1976. 6. Wynder EL. Stellman SD: term filter cigarette usage on cancer risk: a case-contr,, 62:47 I-,I.77. 1979. 7. Hammond EC. Garfinkei I. al: Some recent finding.,, con smoking, in Hiall HH. Wat,,t~: teds~: Origins nf Human Can. 118 CA-A CANCER JOURNAL FOR CLINICIANS VOL 31. NO 2 MARCHAPRIL lZ." Ti04230999

,~mce 1968 is ltcd if we had " of death. tar discases in observcd, but in Australia. :aland. to debate thc They cite in- rye drugs, bet- ,d more intcn- i addition, thc _'nza cpidemic ~sideration un- .vn the cardio- ~mong the el- ad some effect. ,elieve that the tie smoking are Epidemiologic ,crease in mor- ~king cessation ~nary heart dis- cancer. of the anti-cig- there is slill 91d Dieh] were ,," hailed our ac- dd look forward • ~t issues of the :e low T/N cig- hanging so rap- Aemiologic sur- Jeterrnine if the ,'ed less harmful; ~d behavioral re- ,rays of getting Administration ne the potential ubstances in to- :larl3~ the flavor- : Commission to nts with tobacco advertising on tc upper TiN Icv- II models in ad- ltsplay TIN con- gcs: • Support an intensified educational cam- paign to pcrsttade women, particularl? pregnant wt~men, to reduce their risk by quitting smoking: • Extend the educational crusade to: teen- agers, those occupationally exposed to carcinogens, blacks, and other groups who are at particularly high risk of can- cer and other diseases related to smok- ing: • Ask Congress to institute a gradualed tax based on TIN content as an inducement for smokers to switch to brands lower in T/N; • Advocate state and local legislation to set aside no-smoking areas in all public places. When Dr. Diehl retired from the ACS in 1968. many leaders from the worlds of medicine, science, politics, and busincs.,, honored him. More than 10t') messages were written in a memt~r3.' hook. Anmng them was one from Dr. George W. Beadle who hailed Dr. Dichl's "'achievemenls in covering a w~dc spectrum m medical ac- tivity as it relates to the service of man- kind .... Invariably one individual must and does assume the inspiration.',l leader- ship that is necessary for progress to he both rapid and meaningful." Let us all redcdicale ourselves to con- tinue the battle against smoking and dis- ease to which Dr. Harold Dichl dedicated himself. (~ References I. Moss A J: Changes m cigarette smoking and current smoking practices among adults: United States. 1978. Advance Data From Vital and Health Statistics. No 52. US Department of Health. Education. and Welfare. Public Health Service. National Center for Health Statistics. 1979. pp 1-15. 2. Tobacco Situation. TS-173. US Depaament of Agriculture. 1980. p 6. 3. Hammond EC. Garfinkel L: Coronary heart disease, stroke, and aorlic aneurysm. ~'actors in the etiology. Arch Environ Health 19:167-182. 1969. 4, Cancer Facts and Figures. 1981, New York. American Cancer Society Inc. 1980. 5. Hammond EC. Garfinkel L, Seidman H. et al: "Tar" and nicotine content of cigarette smoke in relation to death rates. Environ Res 12:263-274. 1976. 6. Wvnder EL, Stellman SD: Impact of lung- term ~'iltcr cigarette usage on lung and la~'nx cancer risk: a case-control study. ]NCI 62:471-477, 1979. 7. Hammond EC, Garfinkel L. Scidman H, el al: Some recent findings concerning cigarenc smoking, in Hiatt HH. Watson JD. Wmsten JA (eds'~: Origins of Human Cancer. Cold Spring Harbor, NY. Cold Spring Harbor Laboratory. 1977. pp 101-110. 8. Auerbach O, Hammond EC, Garfinkcl L: Changes in bronchial epithelium in relation cigarette smoking, 1955-1960 vs. 1970-1977. N Engl J Med 300:381-385. 1q79. 9. Hammond EC: The long-term benefits ol" reducing tar and nicotine in cigarettes, in Gun GB (ed~: Banbury Report 3: A Safe Cigarcue': Cold Spring Harbor. NY, Culd Spring Harbor Laboratory. 1980. pp 13-18. 10, Tobacco Situati~m, TS-174. US Depart- ment or Agriculture, 1980, p 3. I I. Schachler S: Pharmacological and logical determinants of smoking. A New York University honors program lecture. Ann "Intern Meal 88:104-114. 1978. 12. Oarfinkel L: Changes in number of ciga- reltes smuked compared to changes in tar and nicotine content over a 13-year period, in Gori GB ted): Banbury Report 3: A Safe C~garette? Cold Spring Harbor. NY. Cold Spring Harbor Laboratory..1980, pp 19-24. 13. Final mortality ~tatistics. 1978. Monthly Vital Statistics Report. US Department of Health and Human Se~'ices. Public Health Ser- vice. National Center for Health Statistics. Sep- tember, 1980. FOR CLINICIANS VOL 31. NO. 2 MARCH:APRIL 1981 T!04231000