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mainstream inhalation. Because~.women have relatively recently become major users of tobacco products, however, t~ieir smoking h~ibits are more s~milar t0 those of the women in. the United States and their younger male counterparts. Alcohol Consttmption The use of alc,ohol in conjunction with tobacco is known to increase the risk of "cancers of the mouth, larynx, and esophagus (18). These survey data confirm the stereotype that wine is the most frequently consumed alcoholic beverage in France ¢Table 5) among men and nonsmokers. Some additional, nontabulated data TABLE BI~V|;RAGE CONSU).II*I ION Alcohol Males Females Nonsmoker Long-term ~onsmoker " Long-term .V ¢~. ,',' C~ ;V e4 .V ~'~ Wine only 123 41 409 " 34 207 36 101 26 Wine and beer 22 7 91. 7 8 I 17 4 Wine anct licluor 47 16 .~17 26 68 12 82 21 Liquor or beer 18 6 71 O 56 10 52 14 All three 20 7 191 16 1,1: 2 2l 5 Never drink 71 24 140 I I 220 39 120 31 Total -30 t 12t9 570 393 "'>~ lOyenrs. I T105280012

3,12 "~VYNDER ET A~.. are of i,~tcrest: the highest Bro,port~on~ of ndr~dr~n,kers was found among recent " This group is almost entirely below 30 years of age. A~er recent smokers, nonsmokers had the largest proportion of nondrinkers (24%). But 4[% of ~,~s ~ank w~ne (alone). and ~ t~ of t~:m d~ wi~¢ w~th~r a~to~ or in: ~0¢~P~i~t~o:ns ~t~ atcontrol' eon,~u~-ption /'~.y a|so account For variation ot" alcohol-related cancers within. France. Table 6 contrasts the alcohol consumption patterns between Manche.. a largely rural area in Brittany, and Paris. and shows a marked increase, in the former, of not only liquor consumption, but also usage of all three types of alcoholic beverages. Manche and neighboring Calvados have very high rates of esophagus cancer, and are also regions of much higher con- sumption of alcoholfc cider and certain other beverages than Paris (13, 14). Epg4tentiolt) gic Considerations The .p~,~,n.t study has con_cot:ted itself with the epidemiology of some smoking- .v~:t.~d,; vea~ir]~l~l~:i.~ Frane.e. Whitle th~ pere~n.tage of nonsmokers d~.es not differ muc~h~ ~.a~~ng ~he United' States, United Kingdo,m, and France, there are consider- a.bl!e differences in inhalation, "drooping,." and drinking practices among older men and women in France (3, 7. 13. 14k It is possible that the lesser inhalation practices in older French men are the result of" the high pH of French_ black tobacco, which y!eld a larger amount of free nicotine, and thus contribute to a lesser likelihood of deep ~nha!adon, .A" !so, the habit of"drooping." which is .rein--. tively common among older men in France. makes deep.inhalati0n less likely, although possibly increasing passive inhalation of sidestre~.m smoke, We suggest that the lesser degree of inhalation and the greater proportion of"" drooping" and alcohol drink.ing among older Frenchmen are factors associated with low rates of lung cancer and high rates of esophagus, larynx, and oral c~avity cancer.. Prolonged exposure of oral cavity and esophageal tissue caused by the retention of the cigarette in the mouth with the increased exposure to sidestream smoke could account for the international differences in these mortality rates, The Manche Paris Wine only Wine and beer Wine nnd liquor • Liquor :rod beer truly All ~hree' Nondrinker Toml I I 17.7 73 28.6" 2 3.2 22 8.6 5 8. I 39 15.3 2 3.2 23 9.0 31 50 0 .'15 13.7 I I 17.7 63 24.7 62 255 ~ ln¢lude-s ak-ahol[¢ eider. Tt052800t3

fivefold difference in laryngeal cancer rates between France and the United, States poss~bth,laes. Not o'ul~y do wome~ hav~-~s~ tobacco and, alcohol exposure but deep inhaling and "'drooping" is encountered far less frequently among women, it is suggested that these practices could account for the noted sex dift~,rences in tobacco-related diseases. The higher nitrate content of black tobacco may also affect the reported lower lung cancer rates in France since experiments indicate that tars obtained from higher nitrate tobacco cigarettes have a reduced tumo¢ yield in mouse skin (61. It is signifiea~.,t tha:l; :,~i~'~ lg~ls of A~merican~ c gare,~tes have been rising in, .recent years, during t~ period, or' decline in mr and nicotine. It also appears that these ca,g~r rates ha~ ,~~,~ :b:_~n [nerea~s~d"d~etectably b7,~ the:, h,ighe~" n trosamine content animal~, some ~i,t'~s~,ami~nes ha~e l~e'en found tt~ be organ specific for the e$0phagus--,a finding which might also apply to man. and thus contribute, to creased rates of esophageal cancer. It is reasonable to asst~me that tobacco and/or tobacco smoke are the sources of the initiating carcinogenic stimuli, and that alcohol (ethanol) facilitates the reactivity of some tobacco-assoc~a!ed initiator. ~But'clearly such a relationship does not obtain tbr the lung and, therefore, cannot, be associated with the_low rates of lungcancer in France, These data co~afirm the results ofoth~r studies~vhich imbilcate th~ highe~ iotal alcohol intake in France, in the. development of Cancer of the upper alimentary tract, particularly in llne with the fact that alcohol has been shown to significantly enhance the development of these cancers in smokers 1 18). Furthermore. we may conjecture that if tobacco smoke is inhaled less, more smoke is retained within the upper alimentary tract and may thus contribute to the reported higher rate of upper alimentary tract cancers in France. In Franc'e, as in other countries, both smoking habits and the cigarettes them- selves have changed over the years. Table 7 shows changes in the tar and nicotine le.vels of French, British, and American cigarettes, both filter and nonfilter, over a 15-year period t9, 10, 141. The decrease in tar, even in nonfitter 6igarettes. as well as the increased preference in all three countries for tilter cigarettes is likely to have an ameliorating effect on lung cancer rates. A lower lung cancer risk among smokers of low-tar cigarettes has been noted in the United States by Hammond as well as our group t 161. On the other hand, reduced tar and nicotine levels might lead to an increase in deep inhalation of the smoke, and thus counteract some of this reduction.in rates of tobacco-related diseases. Finally, the rapid rise in the. proportion of French women who smoke may cause a rise in their lung cancer rates, as seen in the United States and England t4. I0) C,ONOLUSION The lower rate of lung cancer in France, as compared with England and the United States. is a~sociated with the lesser extent of inhalation among older French smokers and the greater prevalence of "'d?ooping'" the cigarettes, The T105280014

314 WYNDfiR ET AL. TABLE 7 BRITISH. AND AMERICAN CIGARETTES. Nicotine 2.0 2.2 1.4 1.9 France 1976 14 24 1.0 1.5 England 1975 17 25 1.3 2.0 United States 1976 17 26 1.1 1.6 S¢mr¢'e. Refs. (9, IO. 141. higher rate ot~ oral cancer in France compared with these two countries is consis- ten~ with+ ,the 'high cons9mption of ateohol in, Fra, t~e+e, and, the fact that propor- ,ti++ +~t¢l~y nao~r,e older Preta~:l~rncn held the lit c~g,a++e~ttre in +he mouth for extended periods of time. Yo,unger French smokers inhale more and "droop'" less than older smokers,. perhaps as a consequence of lower tar and nicotine levels in newer French ciga- rettes. It remains to be determined whether the future rates of tobacco-related cancers in France +will become more like those of the United States and United Kingdom as the French adopt re.ore comparable.smoking habits. That is, it seems possible to predic_t that not only will the sex differences in rates diminish but also. that the mortaliW rates for lung cancer will increase (+while those of larynx+( esophagus, and oral cavity might decrease). Continued monitoring of tobacco- related diseases in France in relation to cigarette consumption is in order. ACKNOWLEDGMENTS We wish to thank the following persons for thei~valuabl¢ assistance in administering the queslion- naires: Michel Froidevaux. Victor Marengo, Phillippe Dard. Phi.IIippe Girault. Jean Pierre Huc. Herve Juille, Jean Lepagno, Pierre Lerminet. Marie Louise Lorillot. Stephan Thorn. Gilles Vuillierme. REFERENCES i. Armi'tage. A. K.. and Turner. K. M. Absorption of nicoti~ae in cigarette and cigar smoke through the oral mucosa. N, ture (Lomlonl ~26. 1231-2332 (19701. 2. Brunnemann, K. D.. and Hoffmann. D. The pH of tobacco smoke. Food Cosmeud. Toxico/. 12, 115-21 f 1974). 3. Department of International Economic and Social Affairs. Statistical Office. "'Demographic Year- book," 29th issue ( 19771. United Nations. New York. 1978. 4. Doll. R. Surveillance and monitoring. Int..I, Epith,mlol. 3, 305-314 t 197,1'L 5. Hammond. E. C.. Oarfinkel+ L.. Seidman. H.. and Lew. E. A. Tar and nicotine content ofeiga- retie smoke in relation to tlealh rates. Em'/e+m. Re:+. 12. 263-27,1 (19761. 6. Hoffmnnn. D. Unpublished da~.~. 7. International Labor Office. "" 1979 Yearbook of Labour Statistics:' 29th issue+ United Nations. Gene,~a. L980. ~, Ledez. P. Personal ¢ommuoieation. 9. L¢¢. P. N. (Ed.) "'Statistics of Smoking in the United Kingdom. Research Paper I." 7th Tobacco Research Council. London. 1976. Tt05280015

10. Levin, D. L., Devesa, S. S,, Godwin, J. D., and Sil~crman. D. Cancer Rale~ and R~sks£" 2nd ed. U.S. DHEW ~bl. (NIH) 7~6~1. 1976. TI05280016