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80 CIGARETTE LABELING AND ADVERTffiING REPORT OF A TEN-YEAR FOLLOW-UP STUDY OF THE SAN FRANCISCO LONGSHOREM MORTAIITY FROM CORONARY HEART DISEASE AND FROM ALL CAUSES NesuT O. BoaDxtn, M.D., M.P.H., HYSUN H. HECtftnR, MY.HL and LFSTSa BRE6LOw. MD.. M.P.H. The Hean Direue Contrd Proar+m, Bureau of Qironie Diwsr+, Cllifomia Stah Deyanmem . of Public Hwlth.2151 Bertel.y Way, Berkelay 4. CaWomia (Reeeiv<d 30 T... rm6o 1962) . IN 1951, a multiphasic smeening examin..iion was conducted among members of the Intemational Longshommen's and Warehousemens Union (ILWU) in San Francisco. California. A total of 3994 longshoremen, comprising two-thirds of the _ ILWU membership- participated. The details of the examination, the dexription' . of the population and the results of the screening teata, as well aa follow-up", diagnosu, have been previously published [11. The 1951 examination of this populalion has served as the base point for a longitudinal study including: 1. Ten-year mortality follow-up for the group examined in 1951. 2. Ten-year morbidity follow-up of thox examined in 1951. 3. Arepeat multiphasic screening examination performed in 1961. .' 4. A study of health. vslue patterns among respondents and non-respondents ~ - to the 1951 and 1961 examinations. The present communication reports the results of the 10-year mortality foilow-upp of those longshoremen who were examined in 1951. It deals with mortality from' all. causes, but particularly mortality from coronary and artatioederotlc heart - dilLase (International Statistical Classification Codea of 420.0. 420.1 and 420.2). BtiCKGROUND INFORMATION Participation in the 1951 multiphasic acreening examination progmm was volun- tary. It was offered to all longshoremen in the San Francisco Bay Area who were eligible for bencfits under the Welfare Plan of the Union. To qualify, a man had to be a member of one of the ILWI7loml unions in 1951, with a record of working not less than 800 hours during the preceding'year-1950. All such eligible long- shoremen- a total of 5503, were requested topartidpate. Close control, however. was not kept on the eligibility of the longshoremen participating in the tost, and over 100 noa-eBgible men were actually eaamined. The age rlistribution of the gMsszooi CIGARETTE LABELING AND ADVERTISING 81 3994 participants in the 1951 multiphasic screening examination is presented in Table I. For comparison, the age diptributions of a11 employed males and of all employed longshoremen in the San Francisco Bay Area, according to the 1950 census, are also presented in Table 1. • Tnma 1. Nuweu .rm raacxrarAoe os t.oponaMrwen ~ rn 1951, arn.oreo w.r,es a>re ror.u. tnrrosnoaeNU+w M Suv Fiuaasm Btr .ae. 1950, ev ,we .. t 1950 Cwuus. , _ 1950 Cenaus- Ase group t.unsehorennn acnened . 1951 EmDloyW loneshu,emm and Total Lun®hommm emptared creened mNea 1951 F.mPloyed lonphoremen and TotN employed nuln Neyedorn Nu. No. No. Tohl ' 3994 , 922 4, 59386 ,1 100 100 Iro 1a24 2 70 60,8t7 t 1 10 25-34 331 762 156,516 9 IS 26 35-4 1,096 1" 132,839 27 31 26 45-l4 1,385 tp80 121.163 33 30 20 55-64 973 688 77,235 22 IB I 13 65 d o.er ` 297 213 23,244 7 4 4 Mcdian a e 4g ' o - a 46 4 - 'In San Francito.0ealand Mehopolitan Ana. ~ ._ -}Ia than 0. S per caat. .. . ~ ... , , Notes Pereent.ps ue rounded Indeeendeoqy and the todl. on addltino, may not yve IOD per oent It is important to emphaeize the uniqueness of this population for the purpose off epidenuological inveatigatfon, particularly a longitudinal study of 10 years or Ionger. Some of the characteristic featurea of this population relevant to the . present study arec - I. Age distnbution. Table I comparns the age distribution of those longshore- men who took the test in 1951 with that of the whole employed mate population and with the total group of employed longshoremen and stevedores -in the San : Francisco Bay Area in 1950. As can be seen from this table, the median age of the longshoremen examined in 1951 was almost ten years above the median age of the employed male population in the San Francisco Bay Area. 2. Prepaid medfcaf eme. A prepaid, comprehensive medical care program has - provided medical care for the members of the International Longshoremen's and Warehousemen's Union since 1950. The medical cara program,-cunuacted es s 'service plan' with the Kaiser Foundation Health Plan on the Pacific Coast, has provided hospital and out-patient eare for this population throughout the San Francisco Bay Area. The Kaiser Foundation Hospitala and the Permanent I

82 CIOAItETTE LABELING AND ADVERTISING Medical Clinics, located at several places in the Bay Atea, am convenient for . prompt utilization by the Union membership. I 3. Availability of medical records. Due in large part to the nature of this medical care program, practically all of the men examined have been under medical surveillance since 1951. Complete records of medical care, including hospital admis- sionx and clinic visits, are available for review. In addition to these records, the Union and the Welfare Fund have maintained up-to-0ate records on each indivi- dual's houn of work, retirement, death and disability insurances of various types, and places of residence. This population presents, therefore, a somewhat unusual combination of indivi- duals in the relatively older age brackets, with prepaid medical care recorded under a unified system, andwith complete records of employment, retirement and current whereabouts available for investigation. In interpreting the results of this study, one should note that this population by no means tepresents the general population of the San Francisco Bay Area. . I METHODS AND MATERIALS As was mentioned above, the examined longshoremen population has been under medical surveillance since 1951, with complete medical and other records available. Review of these records through 30 June 1961, disclosed that among the 3994 longshoremen examined in 1951, there were 655 deaths. Death certificates for all the 655 decedents were obtained through.the facilities of the California State Department of Public Health. Causes of death were determined and coded aa.^ord- ing to the 7th Revision of the Intemational Classification of Diseases [2]. Table 2 presents the distribution of various causes of death by age at time of death. Because the whereabouts of 30 men, most of them non-eligible in 1951, could not be determined in 1961, they were considered lost to follow-up. Thus. by 1961, the follow-up status of more than 99 per cent of the total eligible and non-eligible men . originally examined in 1951 was known. Since the numbers of withdrawals from the study.(i.e., lost to follow-up) were so few, they were considered for the purpose of this mortality analysis to be alive in 1961. - The, 1951 examination provided information on systolic and diastolic blood pressure, electrocardiographic abnormalities, chest X-ray findings, height and weight and cigarette smoking in this population. The association between these findings and the risk.of dying from coronary heart disease and other causea of death was determined. To facilitate the ,computations, a program based an the general principles of the life table was written for the IBM 7090 computer.' Two important factors were incorporated into this program: I ' I. Aging. , An individual ages as he proceeds through the follow-up period and his risk of dying changes accordingly. ' 2. Competing risks. An individual is subject to various causes of death. To allow for_ the aging factor, each of the ten years of observation was considered separately. •As an individual survived each year, he was reapportioned into the ~The authon erc anmfut to professor Faum MNSev snd Mr. R¢u.an Kwausut, of the UCLA School of Public Health for wvidns the computer praaram. Aeknowladpasat is also extended to the Weetern Data Protessiog Center for providing computer facigties. 6Ct969200i CIqARETTE LABELING AND ADVERTISING ]J~I~~ 7. i r g 59 °$ rR A E ss

84 CIOARETTE LABELING AND ADVERTISING next higher agc. For example, a survivor of the entire follow-up petiod, who was 38 years of age at entry. was considered to havc contributed one person-year of observation to the cohorts corresponding to ages 38. 39 .... and 47. Similarly, a deredent of the same age, who died 3.7 years a(ter entry, contributed one person- year of observation to the cohorts of ages 38, 39. 40 and 0.7 person-years to the cohort o?age 41. . The procedure for dealing with the problem of competing risks can be, perhaps, most readily illustrated by the following sketch: _._.. . N, N,-d. I I' I' I 1 I I I I I Ir 0 l The horizontal line represents the unit interval of observation and is denoted by t. N, rafers to a cohort of individuals of age x alive at the beginning of the year interval, d, the total number of deaths occurting in the cohort, and N,-d, the number of survivors at the end of the year interval. The marks above the line denote the time during the year interval when death wa: due to one particular cause (e.g., coronary heart diseast) and those beldw the lint the time of death from all other causcs. For each age x, it was assumed that t;te instanteneous risk (force of mortality) associated with each cause of death was constant over the unit interval and that these risks were independent. For simplicily we shall consider only two causu of death, namely coronary heart disease and all other causes. Let A: denote the net risk of death associated with coronary heart disease and A, denote the net risk of death from all other causes. Under the model of constant and indepen- dent risks (31, the net annual probability of dying (na coronary heart disease is given byt " ' t/,=I-uP(-A,1 . . . . (I) where rf,'refers to the annual probability of death if coronary heart disease were the only cause operating. Thereare two common procedures for estimating A;: one is based on a frequency interpretation and the other on the time when each death occurred. For the frequency estimate, only the number of individuals beginning the interval, Ne the number surviving the interval, N,-d, and the number dying from coronary htart disease, d'„ are required. The esfimati of A~ in this caae is given by: . a In N N'dI . . . (2) For the time estimate, the time when each death occurs is required. Like the frequency estimate Equalion (2), the time estimate can be derived by the method of maximum likelihood. Tbe estimate of A.in this case is given by: d: (3) : (N,-dJ+It where Bt refers to the total length of time which all decedents, d„ lived during the interval.. In other worda. the denominator in this formula corresponds to the ODt9692'00T CIBARETTE LABELING AND ADVERTISING '85 total length of time lived by all individuals of age x, those who died and those who survived Ihe interval. In this report, Equation (3) was used to estimate the net risk of dying. RESULTS . Based on the above-mentioned equation, calculations were made for each single age, but for simplicity in presentation, the findings werp consolidated into 10-year age groups. Table 3 summarius the mortality expcrience in this population during the period 1951-1961. It presents person-years of observation apportioned to each age group and number of deaths and death rates from all causes as well s,s from coronary heart disease. The rates are expressed as per 10,000 person-years of observation. For the total group, the death rate from all causes of death was 176 per 10,000 person-years of observation. The death rate from coronary heart disease was 53 per 10-000 person-years of observation. It can be men from Table 3 that the risk of dying from all causes, as well as from coronary heart disease, increases markedly with age. Also, as can be seen from Table 3, there was no death from coronary heart disease below the age of 35 yr in this population. , Taatl 3. Surr.uaY or uotrum axseatenee: ILWU roRTAUry STUDY, 1951-1961- . Causes of Death Age group ' Pmaon-mra of AII muea ohzrvatian Coronary heart dinease• ' (I) (2) (3) ~(4)1 No. Ralct (5) (6) Total 37,249 655 - L 176 - 197 53 Under 35 1,344 ` € 7 0 0 . 35-14 7,736 ' ' 44 57 9 12 45-54 12,544 132 ]o5 37 29 55-64 10,452 219 ~ . 209 70 67 65-74 4,672 207 ' . 443 60 128 75 @ over 501 33 1,058 21 419 . •Intemational Statlulcal CIaulBration Codes 420.0, 420.1 and 420.2. tl4rto,000pppn-ynn . Martnfity Jrotn tvrnnay heart disease By mortality from 'coronary heart distaae is meant all deaths attributed, on death certificates, to arteriosclerotic heart disaese, including coronary disease (Inter- national Statistical Classification Code of 420). Of the 3994 mtn tested in 1951. 197 died from this cause during the p.riod of 1951-1961. Cigmette smokin8 turd cornrray henrr dinase mortaliry The questionnaire administeted ip the 1951 multiphasio screening examination provided enough information to unalyae Ihe longshoremen's mortality data in t i i

86 CIOARETTF. LABELING AND ADVERTI6IN0 relationship to cigarette smoking, Based on the answen given to the questions asked in 1951, those longshoremen who took the test,were divided into two groups. those who smoked morc than a pack of cigarettes a day-called 'smokors'.-and those who either did not smoke or smoked less than a pack of cigarettes a day- called 'nonsmokers. The repeat multiphasic screening examination conducted in thir, population in 1961 revealed that among the survivors of the original cohort, the changes in smoking pattern were insignificant. Among those who were classified as 'nonsmokers' in 1951, the¢ were morc who, in 1961, were classified as smokers than vice-versa. On the basis of the results of the 1961 examination, therefore, it is safe to assume that any change which did occur between 1951 and the time of death among those longshoremen who died in the interim would tend to dilute the association between cigarette smoking and mortality observed in the present study. It complete data were available, the observed difference in mortality between smokers and 'nonsmokers' in this study would probably have been greater than what is found.' TAacc 4. I3rATH nATEe rnUM CDanNARY HEART DISGS M NFN WInpVI AnlpWArlrOA R6A7ID To CARn10PurMONA1IY D15V.ara IN 1951, 9Y AGE AND aY sYOSMD: ` -ILWUNORTALnvarwY,1951-1961 smnken Nonsmoken Aae arouD 35-M 45-54 • 5563 67-74 . Person-yean ofobservation 2,553 3,787 2;347 590 Death Pnaon-years . Death rate'ofobservation nte' 4 3,275 12 26 4,746 6 72 3,826 16 152 1,561 77 Ce,onery hurt diserse u classified under ISC Code 420 . 'R.te per 10,000 perwn-ynn of observation The 'true' mortality gradient, if any, associated wiL't cigarette smoking and mortality from coronary heart disease might be maskd if ascertained in the presence of other important variables believed to be auoiated_ with increased risk of dying from this disease, such as age, blood pressure, and electrocardiographic abnormalities. To ascertain the possible association between cigarette smoking alone and' coronary heart disease mortality, we selected those longshoremen - who, in1951, revealed no abnormalities related to cardiopulmonary d'tseasea, : i.e., persons with diastolic blood pressure below 90 mm Hg, systolic blood pressure below 140 mm Hg,no electrocardiographic abnomluli es, and no chest X-ray abnormalities:' We then grouped these 'normal' individn:-lsinto smokers and'non- smokers: Table 4 presents the association of cigarette ~noking with the net risk of dying from coronary heart disease. It can be secn lr. t. over the age of 45 yr. in each age group the smokers of one or more packs of cigarettes a day experienced a much higher death tate from coronary heart disease than did the 'nonsnsokers'. Too few deaths occurnd before the age of 45 yr for reliable estimates. Further- more, other factors associated with increased risk of mortality from coronary heart disease are so common in the age group of 65 yr and over that they may interfere with the identification and measurement of an association which might exist iDtssszooi CICARETfE LABELING AND ADVERTIeINQ 87 between cigarette smokinS and coronary heart disease mortality. Therefore. for the purpose of this report, the analysis was limited to the age groups 45-54 and 55-64. As can bc en from Table 4, for both age groups 45-54 and 55-64, a significant (P<O.OI)sediRerence in mortality tar each age group existed between smokers and 'nonsmokers: For the age group 45-54, the mortality ratio amonc smokers vs. 'nonsmokers' was 3.2. For the age group 55-64, this ratio was 4S. Blood pressure in 1951 and coronary heart diseare mortality 1951-1961 Grouping the individuals according to their 1951 systolic blood pressure readings• and associating it with mortality from coronary heart disease during the ensuinc 10 years, we found a consistent and positive association between coronary heart disease mortality and elevated systolic blood pressure, Such positive mortality gradient was observed both among smokers and among 'nonsmokers : Table 5 prc- sents rates from coronary heart disease for persons in each 1951 ssystolic blood pms- surc interval, smokers and'nonsmokers' being shown separately. This table indicalcs that for both smokers and 'nonsmokers', the higher the systolic blood pressure in 1951. the greater.was the risk of dying from coronary heart disease during the ensuing 10 years. Among smokers aged 45-54, in those with a systolic blood pressure below 130 mm Hg in 1951, the death rate was 27 per 10,0_0Dperson-yeun of observation; those with a systolic blood pressure over 170 mm Hg had a death rate of 109 per 10.001) peraon-years of observation, a mortality diHerence of 82 and a ratio of 4.0. Similar results, as can be seen from Table 5, were found amonc 'nonsmokers', a diBerenee of 37 (P C 0.01) and a ratio of 5.6. ~ • TAarE 5. DGTH aATE] rRON Lp1oNARY HEART DnFAra, aY ayeHale aLUpD emStDa[. ' ' ILWUHnar - . _- urY arwY 1931-1961 ~.yds 1.1..,.1 p,,.qy.• w L•'y 4% 54 Snwkcn 1\s. „1 ,.10.•1,.,,4t.1 ,.,,. S)7 _7 \Mn 14 N,mm,o4v ,q n.lu•.a. an 11? $ 11" •s r.-. ., .t... .. . ........ . . - t t~ 1 . • •. ~ ,., i tlax.cs uf ~rod W, w. ln cach [l,us of syslolrc bluud prww[• anJ h: both age gmupa, thc roron., y heart disease death ate was subsWntially higfia among smokers as eompared t,.'nonsmokers', - Table 6 presents similar results in regard to diastolic blood pressure. By and large, the higher the 1951 diasiolic blood pressure reading the greater waa the risk ef , ~

88 CIGARETTE LABELING AND ADVERTISING T.ULL6. DCAlH_ MIDeROAtCORONARYlrtARTmrGae,lYntAfIOYCnIpODrRr9rn~a~ 1t.WUrAORTAUTYaIVOY.1951-7961 Smokers Nommokeo . Diastolic blood Age group pressurc in b951 : <g0 -3{ - g0-89 43 90-99 > 100 55-64 <gll g0-89 90-99 a1g0 Parson-yean Death Person-yean Death of ubaeMticn rate' of observation nte• 1527 26 1700 2115 47 2947 17 961 52 1507 33 445 69 1020 20 1059 761 1447 21 1521 59 2704 15 669 194 1521 I6 369 163 954 147 Coronary heart disease af clasihed under ISC Code 420 •aate per 10.000 pctson-yean of observetion dying from coronary heart disease. However, the gradient for diastolic blood pressure was not as steep as for systolic blood pressure.' As can be seen from Table 6, for smokers aged 45-54, death rate increased from 26 per 10,000 person-years of observation among those with diastolic blood pressure of less than 80 mm Hg to 89 among those with diastolic blood pressure of.over 100 mm H8. a difference of 63 (P < 0.01) and a ratio of 3.4. Among nonsmokers similar results were obscrvcd. Death rates increased from 6 per 10,000 person-years of observation among those with diastolic blood prcssum of less than 80 mm Hg to 20 among those with diastolic blood pressure of over 100 mm Hg. Furthermore, for each diastolic blood pressure interval, in both age groups, the risk of mortality from coronary heart disease was higher for smokers than for'nonsmokers' (P <0.01). Using the World Health Organiration's criteria' 4or diagnosis of arterial hyper- tension [4] we classified these men, according to their bl.xid pressure readings in 1951, into two groups: 'hypertensives' and'nonhypertewives'. Table 7 presents mortality rates front coronary heart disease in these two groups. It clearly indi- cates the diRerence in mortality from coronary heart disea.e between hypertensives and nonhypertensives (P<0.01). It also indicates the dilfercnce in mortality rate between smokers and nonsmokers in each of these two grcups. Table 7 also illus- tmtes the interaction between smoking and blood pressurc and their compounded effect upon mortality from coronary heart disease. Tproughout the age range 45fi4, the mortality from coronary heart disease among ': vperfenrive smokels was approximately-9-10 times as high as that of 'nonhyperter::ve nonsmoked. EiecbocardiographFc findings in 1951 and coronary hr•+r' - ~sease ntortafiry 1951-61 The results of the 1951 multiphasic screening examina; on indicated that, of all longshoremen who took the test. 666 individuals had 'abnormal electroeardio- •According to the WHO recommendation, the following sut-oR points arc secommended for ihe de5nitlon of hypcrtension: (1) Nonnotenslon-below 140)90 mm Hg; (2) Hypertension- systolic blood pressure 160 mm Hg of over, or diastolic 95 mm He or ovtt, ur both; (3) Bordedine-the residual e:tegory. In thia analysis Normotensivea and Bordadines were combined and the population was grouped into Nonhypertehs(ve! (I and 3) and Hypertensives (2). - CIGARETTE LABELING AND ADVERTISING 89 7Aarr 7. DuTx RATn rROw CIMONAR'( HGRT otesAde. AMONp NyeaRTRNIIVn ILWU MuRTAUrr aruoY, 1951-1961 AND NoNrMlFRlErntvn: Smoken Nommoken Aaegroup Bloodpeessure status' person-Years ofobservation Death ratct Persun-yeaq ofotiservation Death ntet 45-54 Hypertensives Nonhypertensives $83 4,169 125 29 1,871 5,303 32 - Il 55-64 HYPe^ensi`Ta Nonhypenenaives 931 2.697 ISO 93 2.219 - 4,407 95 16 Coronary heart disease as dassiaed under ISC Code 420 - •According to the WHO recommendadon, the following autpfl poin0_ are recommendcd fnr the dc5nitian of hypertension; (1) Normotensior-helow 140/90 mm Hg; (2) Hyperknsion- fyetolic blood prcssurc 160 mm Hg or over, or diastolic 95 mm Hg or over, or both; (3) Burderline-the residwl cetegory. In ahis anslysis Normotensives and Borderlines were , combined and the populaoion waa aroupcd inte 'Nonh-'HYp~rtensives' (2). Ypartensivei (I and 3) and tRate per IO,OOD person_years orobeervation grams'. The other 3328 me't had electrocardiogram fsndings'within normal Iimils'. Tab1e $ presents coronary h,art disease mortality raGa according to the 1951 °tectrocardtogrephtc findings. Both for smokers and 'nonsmokers', and in each age group, the men Who had abnormal eleetrocardiograms in 1951 had a death rate approximately three times as high as those who did not have abnormal electrocardiograms. It is also of interest to note that smokers with abnomtal eledtrocardiogrsm had a coronary heart disease death rate almost three times Rs high as 'nonsmokers' with abnormal electrocardiogram. Similarly, among permm with normal electrocardiogram, smokers' mortality from coronary heart disease was also more than twice as great as for'nonsmokerg'. Height and wright in 1951 mrd coronary heart dirtase mortality 1951-1961 In the 1951 screening examiuatioh. height and weight were measured for all longshoremen participating in the test. Body weight for height was graded ec'rord- 3ng to Metropolitan Life Inaurance Company standards for 'medium' frame. The examined longshoremen were, on the average, 17 per cent above this standard. Using the MetropoGtan tablea of weight for height, the examined longshtnemen who. DGTn t1ATp raoy CVnoNARY rnART npEV[ ~ry EIECntOCARn1naRAlHrC rlNptNm IN 1951: ._ _ ILWUYdtTArmarrmY,1931-1961 Electrocardiographic Smnker. -_ Nonsmokers 4c Age group findings in 1951 petaon-yean f DeathPtrrson- ye an yean Drslh o observation rate• ofobxrvalion rate' 45~54 AbnomW . Normal 586 4454 102 38 1020 6134 79 152 556c Abnormal 3n3 - 223 049 ... 96 . Normal 3031 96 5479 31 . Coronary heen disease ae classified under ISC Code 420 Rate per 10,000 perwn-yeen of observation - 7fiZ9692A0Z

90 CIUARETTE LABELING AND ADVERTISING in 1951, revealed no abnormalities related to cardiopulmonary diseases, were grouped into four classes, referred to as follows: 1. Not overweight. Those who were less than 10 per cent above the standard weight for their height, as well as those individuals who were at or below this standard. . 2. Slighrly overweighL Those men who were 10-19 per cent above standard weight for their height. 3. Moderately overweight. Those individuals who were 20-29 per cent above standard ard weight for height. 4. Markedly overweight. Those individuals who were more than 30 per cent above standard weight for height. ' TASLE 9. DEATN RATrS FROM LVRONANY NE.tRT D15EASE AMONG MEN WRNOUr ASNORMALmFS RLLAI£D TO CARDIOPULMOXARY DISEA5E5 9Y WE1GtrT CLASOnCAT1ON IN 1951: ILWU MoRTAUtt nvnr, 1951-1961 - Smoken Nonsmokers Age group Weight classification• Pcnun-years ufolnervation . Death ralet Pe1Mm-ycaa ofobservntion 13eath reiet Not overweight 389 . 21 279 6 7 0 43-54 Slighfly uver.rsight . Moderately dverweight 962 1383 28 28 109 1574 ' 28 Markedly overweigM1t 1055 22 1797 0 ' Not overweight 222 43 247 0 . . Slightly overweight 536 75 605 36 55-64 Moderately overweight 955 .109 1320 11 ' . 'Markedly averweight 735 88 1653 12 CoronaryheartdiseaseasclassifiedunderISCC.ude420, b . 'The rour claues are defined in the test a ove tRate per 10.OOD Penon-yaars of observation - Table,9 presents the mortality rates from coronary heart disease, in the two age groups; 45-54 and 55-64. according to the above classification of weight for both smokers and 'nonsmokcrs'. The•mortality ntes, both among smokers and 'non- smokers and,in each age group- varied only slightly and irregularly with the above-mentioned weight classifications. For example, among smokers aged 45-54, the mortality rate was 21 for those who were 'not overweighP, and 22 for those who were 'markedly overweight'. Among 'nonsmokers' aged 45-54 who were 'markedly overweight', the coronary heart disease mortality during 1797 person- years was 0: and among markedly overweight 'nonsmokers' aged 55-64 the rate was only. 12 per 10,000 person-yean. By and large, considering all the sbove- menlioned weight classifications, there was no indication of a steady gradient between coronary heart disease mortality and degree of overweight in this popula- tion. In most categories of weight classification the mortality from coronary heart disease was higher among smokers than among'nonsmokers'. To ascertain the association of obesity-in terms of excess body fat-and mortality from coronary heartt disease, it may be neL'essary to use more refined insuuments fof measurement and for classification than merely placing people into Utissszooi CiUARE1TE LABELING AND ADVERTIQINO 91 categories of overweight. The Metropolitan standard tables used in this study may be too ctude a measure of obesity for epidemiological studies. The rcpeat ~multiphasic screeni n g examma(ton conducted in 1961 included a series of anthro- pometric measurements. These measurements may allow a morc accumte assess- men[ of obesity in each individual. Thcy will be used to study the relationship of body weight and coronary heart disease mortality in this population in future sludies, Mortality }ronL all eauses and dg arette sntokin g _ Using the above-mentioned classification of longshoremen into smokers and 'nonsmokers; we determined the relationship between mortality from all causes and cigarette smoking among men whose tests in 1951 revealed no abnormalilies. Table 10 presents death rates from all causes among men without findings'of hyper- tension, electrocardiographic and chest X-my abnormalities in 1951, for smokers and 'nonsmokers'. It can be seen from this table that in the age groups 45fi4. TAlts 10. DEATN aA7ta noM Au c.usce IN MeN wlrnour AaNOaalArltM.f R_aulEO TD CArI33110PUG1oNAaY DIIIAaES aN I951 ,aY AO[ AND RY SMOnrNO: - ILWU MnaTASm SniuY 1951-1961 , Smokers Nonsmoken Aae arouP Person-yran of observation Deam • Persnn-5'ean Death 35-44 u33 rale - of obM:rvation rate• 45-54 3787 35 9 7275 40 - 55-64 ' 2 i47 2 . 4746 51 65-74 590 226 3926 97 ' ]561 327 ,. Rale per 11 ,000 perwn-yean amokers of one or more packs of cigarettes'a day experienced a much higher mortality than did 'nonsmokers'. It should be noted that Table 10 describes 1he inrelatio1951nshipnot didbetweenrevealmortality and cigarette smoking among those individuals who. , any zbnormalities of cardiopulmonary disease. Examination of the relationship of smoking to general mortality among all those who took the test in 1951, irrespective of the results of the tests, discloses that the differcnm in mortality between smokers and'nonsmokens' ia even greater. - TA6La 1. DEArN RArEa axOM ALL CAUlrS, nY sYaroLtC aLOeO PREIIURC: _ _ ILWUEroRTAUrvnvDY, I9S7-1%1 __ S moken NonSmoken Age grouP Systolic blood Pressurcin 1951 Person-yean ofobaervatfon Death . rate• Person-yean ofobscrration Dcath rarc• <uo 45-54 130-149 I57 7 ~6 91 2413 46 150-169 7 131 2912 72 > 170 40 189 1177 76 369 353 672 223 <130 I3 '/ 1067 159 (S30 71 0.14 55-64 1380 290 /50.16': > 17G 647 524 324 534 2401 1558 125 IGO 'gate per 10,000 person-years of ubwnan on 1117 304 t

I 92 CIUARETTI•: LABELING AND ADVERTISING Mortaltry Irom all causes and blood pressure Table 11. presents the relationship of 1951 systolid blood pressure readings and 1951-1961 generaL mortality for the two age groups. 45-54 and 55-64. Thc higher the systolic blood pressure, the greater was the risk of dying, not only from coronary heart disease (Table 5), but from all causes as well (Table 11). Similar results were observed in all age groups. Note also the difference (P<0•.01) in mortality in each systolic blood pressuri level and in each age group between smokers and 'nonsmokers'. Table 12 presents the relationship between general mortality from all causes and diastolic blood pressure. Iierc again the positive and consistent association between the level of 1951 diastolic blood pressure and subsequent 1951-1961 mortality is evident. Also the difference in mortality between smokers and 'nonsmokcrs' in each diastolic class and within each age group is apparent. TaatY 12. DrATt aAIS! iaqa A1.c C.USn-!r ntaSroue elAOU )aatluag: ILWUsroxr4un'anror,1951-1961 Smokert Nonamoken Age group Ointnlicblood pressuecin1951 Person-years a[observation Death raie• Person-yeen ofobservation Death rate• <80 1527 79 1700 <7 80-89 2115 128 2947 54 45-34 . 90-99 961 133 1501 119 >100 di8 424 102D 137 S8a0 1059 1?v 1447 104 80-89 1521 243 2704 118 55-64 90.99 669 403 1521 145 >100 . 369 623 954 325 •Rate per 10,00o penun-yean of obserntion i . T4sre TI. Durn a6r[s raorn ALL cwusn awono san wtraour aervo.u.unaa - .[ulrn ro c.xoarus.sroH6ar pnvass ev svcturrr cuuamcwran+ m 1951: . ' ILWU NoareLm' eruar 1951-1961 Smokers Nonsmoken Aso groap Weight dassification Pknon-yean Death Person-yean Death I in195t• ofobrerruion ratet ort>b+eraWOn ntet . Noto.erweight 388 117 279 70 hdy orer..eight Sli 962 93 1096 26 45-54 g hloderately owr..elght 1383 . 56 1574 55 Markedly o•erweight 1055 66 1797 52 Not o•e.weight 222 196 247 605 102 99 35-64 . Slightly o Yrweight Modcraiel overweight 536 855 241 218 1320 1~ •Markedly overweight 735 234 1653 •The four classes are defined in the teab p. 1261 tRato per 10,000 prrson-yean orobserqtion VVI969700T CIQARETTE LABELING AND ADVERTISING ' 93 Mortality from all causes and height and weight in 1951 Table 13 presents mortality from all causes among men without findings of hypertension, electrocardiographic and chest X-ray abnormalities in 1951, and weight classification described prcvious)y. It can be seen that there is no consistent gradient between degree of overweight and mortality in this population. If any- thing, it appears that those who were lighter in 1951 may have experienced higher mortality rates during the ensuing 10 years. . DISCUSSION ~ Perhaps the most significant finding in the present study is the positive and sustained association between cigaretle smoking and increased risk of mortality from coronary heart disease and all causes. irrespective of other factors'such as hypertension and electrocardiographic abnormalities, which are also associated with higher mortality. Cigarette smoking has been shown to be associated not only with increased risk of dying from lung caneer- but also with mortality from coronary heart disease and other causes [5-7]. In the present study, smokers of one or more packs of cigarettes a day experienced higher mortality than 'nonsmoken', irrespective of other factors which arc associated with increased risk in mortality. Other epidemiological studies of the general population [5] have also indicated that cigarette smoking is associated with increased mortality rate- Although many explanations have been suggested in the recent medical and scientific literature as to why cigarette smoking increases the death rate from eoronary heart disease and all causes. the meehanism by which cigarette smoking affectsmortality not only from coronary heart disease. but many other causes as well, remains obscure. More research, particularly prospective studies in the general population and perhaps in younger people are needed to shed light on this issue. Whatever the mechanism. the fact remains that cigarette smokers experience a much higher death rate than'nonsmokers'. For the purpose of prevention of pre- mature death in the general population, these epidemiological findings may be helpful in planning programs in the community. Curtailment of cigarette smoking would be likely to reduce substantially the mortality from coronary heart disease as wdl as from other chronic diseases. Early detection of the chronic diseases has been advocated for a long time as a means of preventing premature death and disability. Ideally, the best way to detect most of the chronic diseases would be for every person to have a periodic, thorough health examination. Obviously this is an impractical solution to the probr, lem, at least at the present time. One practical alternative is the multiphasic scteening examination. It should be emphasized that multiphasic screening examination.does not provide diagnosis. It is the use of two or more laboratory tests, examinations or praadures, applied rapidly and on a mass basp. to determine presumptive evidence of unrecog- nized or incipient disease. It must be followed, for those with positive screening results, by thorough clinical and laboratory examination for the determination of final diagnosis. The advantage of multiphasic screening examination lics in the, fact that it is simple to administcr, it is relatively inexpensive and, in most cases. ~ acceptable to the community. .117ove all, as shown in the present study, it can be a reliable indicator of the need for action to prevent prema[um mortality. A 45-979 0-63-pt. 2-7 a ~ -

94 CIGARETTE LABELING AND ADVERTISIitd simple, so-called 'casual', blood pressure determination in 1951 in this population showed strong relationship with mortality during the ensuing ten years. A simple three-lead electrocardiogram taken in 1951 also revealed useful information as to the subsequent mortality of this population. And simple, crude questions provided enough information on this population to differentiate the mortality experience of the respondents in regard to cigarette smoking. Obviously, one can apply these tests to the general population for the purpose of finding those conditions which rcquire early attention. The results of thq present study indicate that multiphasic screening examinations should be encouraged as an effective casefinding tool. AI- though we do not know the etiology of many of the chronic diseases. such as coronary heart disease, we can, by means of a multiphasic screening examination, detect the susceptible individuals in a population. By instituting early medical care and)or by advocating changes in some of the factors and personal habits associated with increased risk of mortality (such as cigarette smoking) we may alter the course of many of fhese diseases in our population. SUMMARY I. The results of a ten-yesr follow-up on mortality from coronary heart disease and from all causes, in a previously-examined population are presented. 2. The association between cigarette smoking and mortality from Coronary heart disease and from all causes among those men who, in 1951, revealed no abnormaG- ties related to cardiopulmonary diseases, was ascertained. It was found that over the,age of 45, those men,who smoked more than a pxk of eigarettes a day esperienced a much higher death raJe than did the'nonsmokers'. 3. Grouping the individuals according to their 1951 systolic and diastolic blood pressure readings, and associating it with mortality from coronary heart disease and from all wuses. it was found that the higher the systolic or diastolic blood pressure in 1951, the greater was the risk of mortdity during the enming ten years. Howevcr, the gradient for diastolic blood pressure was not as steep as for systolic blood p{xssttre. Thrbughou,t the age range 45-64, the mortality among hypertensive gmokerg was approximarely 9-10 (imes as high mr that ot'nonhyperlen.rive nansmoker.f. 4. Both for smokers and'nonsmokers, and in each age group, the men who had abmormai eir.•etrocardiograms In 1951 had a death rate approstmareiy three times asfiigh as thore who did not have abnormal electroemdiograms. 5. Using the Metropolitau tables of'weight for height, the examined men were grouped'into four classes referred to as 'not overweight'. 'slightly overweight'. 'moderately overweight' and 'markedly-.overweight'. The mortality rates, both among smokers and'nonsntokers' and in eacb age group, varied only slightly with the above-inentioned weight classification. We found no indication of a steady gradient between mortality and degree of overweight in this population. 6. The value of multiphasic screening examination as an effective ease-6nding tool for early dctection of chronic diseases has been indicated. CIGARETTE LABELIN6 AND ADVERTISING 95 1- WrJwcasr.n, E R., B REFERENCES aev.ow, I_, BrJi,oc, N. B.. W.ntm, A. and Mnxwa, B. K: Multiphauc screening of lonphoamep with or{anittd medical tollow•uP• Amer. J. pu6l. JJlrh 42, 1572, 1952 . 2. Manuat ot the Inlemational Statistial Clefsificetion of Diseafee, Injuries and Cauaea p( DeaN, World Health Organiaaslon, 71h Rerision, 1957. 3. Besrsor., 1. and Er-veaant, L: Competing and eaponential risks, with panicuLr refertnee to the smdy of smoking aad lung nneer, l. Amea.rratbe. Arr. SS, 415, 196p, 4. Hypenanaion and. coronary heart disnse das.ifimtioo,,and oriteria tar epidemiologiol ntudies, WJd HJrh Org. Teehn Rry. Srr. Na. 168, 1959. S. emok n 1. T., Daweej, T, R.. Ku.nmq W. B.. HESUn, A. 3, and Kun; H. A,: Cigarette 8 and eoronary heart diaeme, New EngJ. J. Med. 266, 796.1962. 6. Dogu, H- F.: Tobacco comumpdoa and monality from canoer and other diaeiyes, pa6( HIM Rep., Waalt 74,581, 1959. 7• Dott., R. and Hnc, A. B.: Long eancer and mher alures of death in rtla4op to amoking, - Brir. med l,2,1071.1956. SVT969200I

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RI i Ookte6 E1.tory 7A67E S. MQALIIY 09 lEW)dR StlWaq b7 C00.1EItr ANOVNf SNOYED Ittio of observed to eap.eted oumber af deetbs (ell ceuse.) by trye of amekin6 history and curreot emaont mked, July 1936-Decmber 1936 9ltfo of ebse d tV eYleeLe ber of el s Ctprette ody .96 1.29 1.K 1.77 Ciprette and ether 1.09 .9S 1.37 1.72 Ctprette and cigar 1.09 .90 1.30 1.73 Cigarette and ptpt 1.00 1.03 1.36 1.88 Ci6erette.cipr,yiye 1.14 .K 1.41 - 1.46 3-4 e usbe -6 Cips euly 1.05 .71 1.00 .99 C16ar eed pipe .93 1.14 .99 ,67 les. tWo f pipe bel7 •K .96 1.12 .98 f 'OW*c t beerved de ethe tt keG ~.r d lete tbeo 40 or 1.99 25 205 1019 663 137 1.79 72 159 492 319 39 2.71 13 35 91 36 19 ' 1.40 27 71 232 180 21 1.73 32 53 149 83 19 f er e er d 900 9 or ene c.' -2 d -6 r 1.44 20 62 .97 79 26 1.33 - 40 - 101 47 32 6 fu t em k de 20 or e ' leee tb.n 33 10 - •20 or re 1.21 ' 6 44 73 45 29 G r oeeths - covDutW b y m l p l y l f e6 t h t e euoAer of per.w ye.rs etpoevre 1e each a6e iroop for eech amokfn6 t history r.ior7 by the ap-specitic deeth retes of per.ooe vhobad ve.er ameked.

112 CIGARETTE LABELING AND ADVERTISING xA6L8 6. --Itl8L1LITY Oy 88 .f OMAR SM010119 8Y AI/DOMI 81101PL Racio of observed to eapected soeb.r of daatbs (all causes)-by mckin8 bistory, curraet aod trriree aauuot woked for peraona smoking 10 1954. - ILrnnt Raxivm Smnkf 81 t .na.ne -mked emamt enoked Cigarette only me pack or lase ncre than a pack C18aretta and cigar me pack or lese mnre than a pack Cigarette and pipe one pack or less moie tbaa e pack Cigarecte, eigar, pipe 1.59 1.81 1.16 1.92 1.27 1.81 me pack nr 1e.. 1.22 enea than a pack 1.50 Cigar only , leee than 5 ' 5 or more Clgar and pipe less than 5 oigart .86 1.07 1.08 5 or mce efgar. ' .93 Yipa only 1.48 1.75 1.12 1.76 1.15 1.72 1.12 1.54 .83 1.11 less thoo 10 1.05 1.06 10 Y 1.06 1.11 grpeetad number of deatha besed on t6e deatb ratea of peroons oho had cover s.uked. ?A812 7. --ROR7ALI7Y 0r g2-8tp102RS BY R62D88t NCIOR 898R BROIQD Ratio of observed to expected oumbar of deaths (all eaoeea) by .mking hietory end .uftev amw,ot oobed. --MortQity Auaber of Snoki A1 t t1 observed deathe Cigarette only me pack or ltes 1.27 417 • enre tban e pack 1.52 304 CfBarette and oigar me pack or less 1.26 rpre ckan a peck 1.27 CfBarette and pipe one pack or iese 1.21 woretb.n a pack 1.31 Ciprette, eigar, ptpo one pack or lus .97 nnre than a peck 1.50 Cigar only laoe thea 5 5 or more Ciger an.d pipe lees tben S cigars S or rore cigaro lips only 1.59 1.33 1.29 1.19 107 42 173 81 144 81 94 56 62 31 1eu than 10 1.14 50 10 or more 1.3] 29 e'speetad meber of deKM 1wM a tlr drth wto. af Mrew 1AO Ctd Mroi tikad. vST9G9Z00Z ~x: A«a -x axa - -- - -e.: ...... ~°~ ~~~ xaS sgm $sR Siti aS.Z . An7t 73:,2 .i.iN . .iw .yw.; rw.. rOw ..r wiOw »SS $R: xxs aax a-~ ~ ..e wa.w e$$ ,,, 444 113

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116 CiGARETTE LABELING AND ADVERTI9ING CIGARETTE LABELING AND ADVERTISING Liu u. In4w.rti w a4VyM1 CIORap 6envp M[l.ef /IYp1.RCn1!>ttLWn .t..[../ N-ut.aN ~F.r [t Web 4 a.ew M. ep1MlY Walt ap.tb. .nta. W.[eeL,y (14~16)) lf] (m) a. .qb.ry. Pw-14.1») at W[ee d bWbr (ny b 4vnr .f am..F (lfl) T wllt..,t lYYrW fAA-laa) x u...., .tta t..r p .a.[ .! pt[..u (lfa) al .M reeta-(11l-If1) M c..[.r.[ uW, Ilb) u a..kul. nu.) n u.,atu (4o~fa1 ua . (lw~a]a) Ua Yt.n...t.[alt 4...~w fFID~ LtA M.Mwel[ .b(~t. elx.altl. (4l- 422) laa by.rt.ytw stl t~t 61..Y. H4~FI1 na O.ura ttt.rtWlqY4 (.b) lV a M1.aaa. Yl[~. ()aO) 1 Ctb.r 61W... .f ItR. nlttl.iyt .y 6... t[u. (fn-a./) 4 l.b awa tw) w n . m..r e .[a..e r Cuns {aw.a.u al CI[[Fe. t.! ltrt !le I tx y Ixludc[ ueL[lYlq W Wt[11.t0n W... y-R.[tr~Wa.[ Wer-r.l.t«a /eltlaly ty ~.[ N MeW H.[..[~ .e apr.et....lY 4% er .p-Y.FttItC.Kb fls...b Ww ut WN (l.[IWIy . vY.[!Y1 tY W[rlYt.y W...) .r Fe.W~W-M~rNwW.a [.F..ee wla w.ulyaly. . 2..3 B°°_39all a a 117 9ST9692'OOZ

118 CICARETTE LAHELINC AND ADVERTISING wY 14. tnali[II 6r COIW CI9taT4 w0¢I161'[Oll f1K2/IC CAOYt n.IC012 O® t«30 te N/nrM [. /meuM d.r st aurl,t H Yrrem .M F/e teryl0[y mMM [t[extu. re111] r.nmt mxtt ^hM• Nl] I94NOC~6ti 19N. C/m« Ot leq (16[,t41) C.«.t Of ptOSttt/ (1/1) C/n«r nt .wth. M[2V xp~tp/ ([w-Iee,150) e e Of 61e6dtr (41) un<[ si rte..rF (I]i) Yv1fLOxe 1).phm[r (200.1V]) Cenrer, MM1er 4rx o-rc.r a in{:nl .I.V w (I)9-14) C/M.r ee tterr (160) 4..Irt/ (]04) lne~snl/ 4Y.911 lrenrFltt[, .~brr/m, -.(m (100~s21) u[txeleMte (mes/r]) « . rt dCre.:a (420) OanrF:.atte tlvmle .:MOe:rdu4 4zGt]2) xYpern«tm wt4 Mst atm/w (44V-il[[ Cenerel etmra[FwttN/[(6)Y) x Ll....~~44.K11 pexexl /avlx.l//t9m CF~NNIa n.pNttl. (511-34) CKe6)r tb~x/ttt Wet el..w 4w-itq ~ ryrel)[tr /6lnnr ()10) rf]!-5t]) Ol/6rtm (260) 0ieer Of rrsrh W a.uYw C/renOa. sf ttmt (3[q S Y w.ao D..a ]a . L6/ 3 I6 1 00 2.30 e.60 i IO . l W aa 2.73 11 . •.]0 a.ua l.a le 11 0.6) 00 I 1l 1.11 I.a 1.]) fi 0.. n I.OU t.00 ] 1 30 1.12 1 50 1.00 C1/ l.4 Y.IS ] ] . n.n 0.79 2.13 I 1 1.70 1.16 1.99 11 ]9 2.m L/S ].]0 ll Y 1.11 t.1e 1./1 I10 f39 1.10 l.Y 1.12 11 ]1 I.St 1.]4 l.Y a O 2) 0.4 1..61 I:Y 16 2.00 1.10 2.1/ II S] t.4 1.11 1.4. A 1) 1.0V 1.II - t O.Y a.N 0.// 4 16 0.]) O.ll 6.11 1 1 1.00 O.M I.10 • 1 4 0.61 0.16 l.M 3 2 50 1 ] 61 S.Y ] 12 . ].00 . S.ti 6.11 . 22 I/ Inrled[r mdrn2tY uM eeetrtNtrer /mw N Wa. L yyte[y nyee at W4r te/N m th/ YetL rOd/ (em ~ W mwt mAM (te0M109'4M//111.V /.6 Wtrthut[rl euent) O/ nr0/m . n.p0 W O[N e04.4« mlr xm/tOmll]. 4sissszooi n 4 2] ] le .O ]1 CIGARETTE LABELING AND ADVERTISING rull 1). rolCµflf w p,lOAl ]IR yLQa 4[b H M r• [xdp[[CI]IC Gt134S ""~ " OC nrte« MO WO rtw4eiNShe~rta vtw ee13 (11[etlm h(etm]) Nt> 4%-Ori~p.r 1956. Ot•r/« b. `2 4[IS ef e6e.e..a tm/a y Crmer-u lOry (16 l6]) -1-:IS C/ecrr at Ommt[ (vll 4 1.04 C/:rer O[ mutF, Oh/ryv rOpM1.xe. f140-1Y,150 ] eenrer Ot med6er peq) ] ~ ~ C/Otm Of /term (I511 3 1.61 iu115y/jf tAhm// (2Po-m]) ... 6 0.15 Cen.e., OtM1er fnm. r ef p.xr/// (13/) IS 0.>3 - C.MK O2 InGttlmr /Y ~e (I51-194) lY nf Ytam] (la) 1 wx®G (Ial ] Ix.a~4 (4w<9I) ]rm•F¢a, ~Fl/~. 11 6 .etertxrl.mtte (e0umr..) wrt dlxer/ (1]U) 41 MopCM1e.wat. (M1renle Mx.rdtttt (4]INt2) 16 x eeru«1on .[[n h.mt C[nee[l . aeO~Yl) If (450) r lewleealr 21 pnrre m anxt h.rt Cerr.~ax(~~p%x1m/ f)]O.1X) Cwlenle n.OM1eltlt (]9]- 94) enr«i1e rnnx.HO Fxn aw.« fuo-4la> 2rr.1].u .[Irm. (]]4) etnrr eWe[/e nr rt.a . [ilmttddur ut Yne[Ott p[vsn) nteunter (]69) Vlcnc Of rtameh ma Cm~ eemx (rie,rip CtrrSxl/ O[ llm[ WI) ] 1 n.[] 0.30 LM 6.66 L Snelnar/ uN/rl]tq mt OmtrtAtm] et.x/ areeeY. . j/ [.netNtte~tfine~tiva//~eNW tF~ tvne14/n[.Odn.19/n end rmtrttu[Or] .q er Yrm« •... F/d mmt .~6yw OrONq W uxi b6/ea mll me//te«llr. 119 2NY It. Iq4L11{ m QOp40 (IfAt [19aa nM 3ttCl>tC G031t Yn..e wxrv.d t0 r-nem6 mWr e1 deeN/ l n mr rM uWleril mlN YI> e104r/ m Wa^d / atn. ll[ttW ht[ewl, Nlr 113(• AraM[r 1956. Olx/// ea[- uot•te}Or[eF. Y Cmeer e[ lus (1{2.16]) --Y) 1.66 Y««te(l)1) W..r .[ .wth, eFerynt ..TFeor ( le0-u6,lw) iu 12 ].35 2.4e (ul tlNder (YI) . w ] Y.)0 r. r e( [ta..rh (1s11 f I.W twllryet tt~~em/ (]oo-ros) Cme.r, utMr fOtr ]2 0.92 LN - ..er nt nner/« (u/) Gne n .0p er Ot Int6etl«/ w m (IS}.134) Sl l.fi 4neer Of hlMj (160) { 1.20 (.ntxt/ (]m) . . ll l.] Its..4~1/ f4Y.t15) M O.f) arw~eM1ttte, .mFii.r, r. (500-]1]) 2] 1.0U irttrt061r[atte (OpOme]) Fxrt dl.e.x-(4$0/ ]l) 1.01 )mrliewt/r mrmle eMOe/edltlt (4)1-.22) M O.a 11rpe[Nxlm rtth FIMt atem. (44Q-4U) a5 laa dxrn .rarleal.r«l. 45U) 74 Y./1 ryper[.n.tm rteAS.t h.ut L....~K4a41) 19 1.]{ a mr/1 /NI/r la/Iw. mt~wea]61 - mpe44 (392- 92 0.94 Sx) / LOO R~Re/C rM~tle Wtt atru/t. t4I0K16) . 0.42 alt/e[ (I30) . aea el.e./.e .2 uxr, c141/d6/r ent Ymrw !56]-Ser) e4ynt (]YI [[ ]] l.)O 1.10 Olce[ Of [twaeF /n/ p/- mnr (SLV.41~ <Irrnnr4 e[ lteer (341) IS R] .Il y L~IHee .K/rlrW W Omtrll.am3 e2 aeth. j/ 6ryectM em2x e[ W[N M.M m tlw WtFx rfrmmt6r.0«Of4/th [ieelwty y~q.rl]try /M t tilhrter] rOt) 2 9pt/m/ Ne ~ w r vahW e[~rb uei d e« I] mcmlm6ly. ..JO-

m CIOARETTE LABELING AND ADVERTISING CIaCPD1M !)r 4e1 R[efYW. Ifn/wr.3b ef Mfe\ ILLL.\ilYwl itatLtlef•n. w%n11. G•.Itn YNk•n •M .Pf.ruty .v14b1. pepN•t1% tm rella.ly a14 .n S• d•bt te W. ib.n uM tM PalN.l le . po•%etfn .tu4y. '1b aY4 .. repeeted 'Wam. In.eftut, fur tn1. p.tn•4Yfn( mn4rlbe- elw. •n 1..1d•m. ef un Me pa.t 4vM1<.1 tfee to vur knwl.d(, er xort•11tr ma 11. n- qlll IP pivntnP~ •nonalu w mt.ry.•t•aMn. l.ttu t. .utin(. It 1. aru11 r.ur.•bl• W1 /•r •4a1•t/cf.n. eoald afily rIW 40 und•rt•k• e llttli l. •till kndm .MUt e . md •f- \ a l.0„LUt N.a eauld .nr4lny f•el Rwl f.et. vr ut\ td• pnM nuun latt u el Me JvA por4d Mr.. Ir lb r3r.t tf.• 1. 4 M eo YIp 1 l •+ 1!nll o^p.. .•M •11 Me 14r pf •Mkt el•L• utl nwutvsl•la. fe.t M fw t- l.• .% 1•4d. •ulQI1uJ Me Ni tf ur .1y t. v.¢•11 r1.! K Olly ua r.lf W en tA e]Nt ltwt •EENtna w b 1.1 pf bin/ Or Frt1<ul•r tlw•N. •Waf .un.a.ntl 1..Id.nc.. unt11 le.Mrdr •nd Nq- eut clurlr .. f.ot. µau•t Mlen IyyetMU. 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P.make. tl~ w tllne wl f tr vra ~ e etre :ufpet nr eta., •+ e k . ee e•Ilr eeron y efRet wn ten maaftr nttP fe r.,pe. .emmnewr, ee I nbe eytee, atseae P lr Ye em artke upw te. e [ettLRtt ,p t p.mwx m t me •m xm ae w me'n tt. ewrt~a. ue.-Erntmleule etuy M..11 ~p ft• Pnae ur•t atrre~ e tn t• epter. w!ee- mm ue .Iqt' oe Pl •a~ten m me etmr, rlm nepeee tnCP to teml at•lfb nk ba tm mlrelttr rtv •per or Imt.lewt u...a.. -tw~ tna/lma r em yt. 1 maalm pr o! ~Mp~µ tneM r~ p \ Pna to tmc e k r ne nttc tlw f P/u~k etetf. l~afn ~ te t.fuy_I ~ry.. r _ . .. . .a wytwe a a'tq.r .mt.e. Mmmtp~..„ p1XLePep.a atemine tmt tma L s.n4 ~eu m- t. er m"O" em nftee~p..nw.pt\m _ Mee roo v P nne s,. 6tualn r °Ot f IP ttet wY mlp In tb nyt .n wJe .y r]Itl .4tlalyl emPtam ttilm pf ty mrot~•e'me m' tMtreLm:. slctoXfulm eetleler er emea n..pa elrrtrt.e taP. nr nkt t.,an A reu n[mte. m.. n- werv% t b e r ttyr ..~te emeeerMe , epnaeeuttee uta.. n.alerMten eF{y, o! rneltt.e p.e ana..(3) C ~tilm .f tete um. °°P"nema .eon, eruYw Mnn Marp P'~cW.l~rt~-aL~o r~ile.e~.y erpt<aaw. A 6netaeet ef rvrx ut t u•eer tv a ym f eaX wn : • e ran rw .nattpn~or .~ucplc"•p rnr u n 1 tM •ina . aun•ttnne.t31 ent,. a Xre•e ae• -er mm~tlm epu:t pe acNnt f ka6 by ueen er PiPe a up. 1f e..ewt tep um. uf erretect tme uta e~n~r e ~Protk 127 I I

128 CIGARETTE LABELING AND ADVERTISING n u talr u.tmE. af ~rtua. S\e L.Smne. or penPa/b' ilff.n.e.. -meter. bY Y inaea emaim ab~M. tu tb p..Ale. of l b.lalm .Im• 441. 4uo16 Fn.mtl) C na sut b.er ~.n . hee ~ t) 6itA I. m.ulla. of urptS b tn. o.. . a t Le .ffecl.etiil ph.LClo13u1 Lc'..F of , a.u w e e nrLW afmvY rw m arwT er Yrm.a .OOhe.W yytl. it 1. et.Y to ...".. Y•t M .tu6mb.(S) 6. SNiat1P. ur . PSO- el®.ntb .ut.r. IoEa~ wn . lPl f.ctor. u mtlnt Ptbn. L. a. anplf SbV W.. m.n of ..a q rvaV i] Mvr+to.. u. Wt V y . br c11Pn• ui0 tu Y.u.. ba S.MLtim 6:lf<eexh .4eant for tG. tai.i4LL . p ..oUa. of tM.. 6a<.161 Luv! C. wrlm. Yt.w-ieo o tGa tt b f .m m:..1+0 n .vpgea .n eOt al.eelme.n um6 t aetio 6o aetia/c.. a ctual/ aw wr) 14tt4 y nla/m a..Ma. tiua irt Ny u t..! lelv.ealm m t41. po1Rp[. 6o.f.'. rltun. boe aem[ll b nlMv'. tG. em•Laim t4t NLLe tcaaeeee ef tM etoio[al(. tt"•.tr> K bibr mttcv< of .PY. uJ Ypiv+G twuLCp of Mntlpt me\.nlc.~ P.tleuLelr [14 n.p'~t to .mtt IeM1.t.a ~V Ii~u De va:Etfui ~etGn.~ IoNLtlm Y.tctta. t i.5I avllea met~.biS ty Yw.tim- teslm e esl.e intLMe. Xtne lufe[wtlm M... 11'atlRtn m uP[e•v.b .uta.6e.< m..c ~.4 ..1 7erYJ1 or ....1 of tVtY f1uL4 for eueol^:e- of Nrotm• m ob..mt. nrv... . /ai!uvie~.te tlnt m1 ir"^ nrteeoa..oro...ala.eemt.a .It4 t\e ti..m.. •Ll \Le p.etlm. metlm.C.iP..n .ItEef Ixlute6 I. fb pKo6it pr..r4a or {te Sc!tatlllc Mrl.cfr-lPr6 tu tG Saexca L.LUary P..t..4t C.ttee or .n In .aY .t4e.f pl/eoln{.(J~ 8e1utLNta tC.e.WeEl{b.W.uLG prw16. i0O1. mtW1Y apatl. or uarl.y Namr tb .tnt:.tlnl em+rf.W. ?r y1P 4.t r1}r e. tn e/pntt.. mM••Pn..a • owp .. oaLP. Netan or w.f tey l utl eobmt tl p p tC mLrt .a1i0u. t)pl. Irm ..ml tb gn..l pupil.{lm YnG ttu. te ..m.4b pvap' tl.t PY Mn Ktrerly u4.t.•nt lltt uN al...n amrancu.. 81uLe ..IMm. ef .•L.ce/mb/ tem 4.v.16.6 h Sli 11Y1/ Yl.6.r t\raurL .tui1 or fEentlul ..eC hm-Lemtlc.l tule.• H fouM tat LveetLPl tuu. w ta on ofbe 1MLr fu t\ar .Mtua 6.eLt. eyvl em-tLmilPi lyL. ne awYt r,.,.e .p.r! ID alff..mn a.1.m~ub.IT) Nr{Mr .alma. .lmi wrE 14m. Y. tw. wt11.LM h Vr. C.rettn. bE.ll Tu7m.. irm..by o! ibaLeLL .bv.n{. a im Jmm to{11u. WL..nitr. .4tNr ilns ..b411.L1.t tv rr mtuf.etlm tla e.rau abto...eul.r em6lum. .MI . r..Llbl bnae.rr. .ne w a=.4we ro..nt - m. .[.aY nl.bn ef u.et em<ltfm..m moo~ pqe4 .m.•.y tbu <h.o l.et1.6 .ue\ • ciaucnl6l atto.~ tn.a roma ~a eo Pt my Ma .y ein.« of W lbM1 or ~i.eieabompYrots.t w •..<••t•r~Ll i~tm~ . or /nCid\pb of abaN IC t11. aa/ery. tif ewrn. 1f tt.e tl~ .rnn.. re. nl.- nu nein.~i.e m Nw~b.~alMn...~p lnelaenc.. T ae-eo<-pt.tr mtwLVi tbt bl. nutLm.l1D fumL.M. L. ao n Se eiq.. n LteepnbttP- It .aula ivt-.b. ti - tY\ PGI.b •ipl.mtli for tY etm...t eee.Ltlm•. furtMr .tetlalea e4nr..tlm. am. cPa corry mMc\ el.awi to e[lml pr. p..n•. NY m tM ...miNlm tf .nlutloa .. ..ot~n{ rlth u1..r ee N. .bre\ .M b Ite ema't_m P.~eb Ma..tea l mt•- l l E m <unfenm.n RR e.walelly ubnal.6 ..p.il~nbl etu6lM tta< 4 .I be Gf nnt1Y Tau [PAVSbG in wl. fu11. o vµ e %a:no109/lit.M iN. t eea.alM m 9e .Grn e mtle of-4tmi to .4pee<M ) ua vI .Ml.llml p.nm. min --o<.nof N.tYr • M yefA4 Sru. 4bn 4....e. -t nNl.r : Y n r. m e tl r:peette .m..n of 2.tlJ. Niet nfL.cl. e. p tEer Meit SM um e[ ptp orwntb.. tn..oei.v •t.n-te. r.- to un W ' M a .f tb nltlnlr .tMy ...m1al/A.. t]~Le tl. .unleC or ulr.r amot x. Cu CL :Ve. : 4. l l - .n m rnLlr-nnE.nteeG. u b etJelr .n.m ' v:rtPlly un prnluc v t -/Mna tYt Parte hp {Im Yl G.:..~aPn f uw x nP-un. .M tfe tnr cmic. e.. fon atlie-n..q.et~a to tu bmY..t Vmp < nnel r la<rrMS titetaf) Mcto[. ..reeL.lli .Ina ltn-tm.re1 el , n~llLrt pn. v 11 - • p.ycYo-pba.tn(LSl fY[tcry. M labt .IWL 6. •.psc<eC LLm to Vloy . nl. In C.bnLYm( tb f.Rmevl .nfa:unt or .otSM •NUU W ..N r • .'p+le% ef tW... ... ' 4wn emaltlP. 1. ort•n .ff.eaL.• tv p4111aIP. SM .ff.rt. of elopntt. .mFNO ~ Tal[ ..entlP Ymbm e4an. .tu61.G tbe Ln1S 11 e 1 ..P~nrebl obG.e. 4f tumo ..eJeeb ?:9z 909200Z CIGARETTE LABELING AND ADVERTI9ING sincy .rl m.n'ytlm 6rtye. l.my oa°tl^i und tev.y ae.,yel c y. aen reMfStA or n.uhl-it1P lo..at '4 o~PYr 1li.lY 4vt irq- t`mV(-c 1 u1t111..r c nb.l. W N [•t Y L hrty~ w .bp [t a . -t :~.u1 lvtl eo-ie/ a : ..' of ric.:. nn.li. t A.e\ tw.r orTt].ae Yd iL tolyLVYbr4-y Lout m. inoCny~ tb [.ctoro orI Mlnuteltim. y2yllltle iCr.cttm~ leny le Ibtlm• aemol em.y.pt/a tl6 mcntn...n •"°ua. 'Lfo mlwt eb.m. 129 I

130 CIdARE1TE LABELINO_ AND ADVERTISING of mtim N. !q afeeAM. It 1e uM 1 1~ ih/tmry ut the eleretlme att Mpeee.m. tL tey b lme ceneee y L• m Sam in a oe er}lustear uai t Iely- nb. m euvW!! thet 1n encY!m <r rectnn Le luroleea. lvfly<v~+LC6 u< IGelpetle ef peoaueiee te e vbe !ct We efcaly. ..y vell W eveee <p.~. Le{ tyOereletlplly. 'rhere We Me ~ch r.Net p<tnttee! ul-dete the v mehLV net tt 1 L-atOatm - iTS p.f tf ivuele hover.r, .eee w m te !e eciwlV ^.L Te--uolr eel vn` tt•e Le m tiva L4e - 1 t, ro t fY L e, ecd uec te pe ud lee t at W ~mt~ af 1 tlWar ttlejL4 b ebeln3cF .tteetlve p.e.R^ m a[ luee emcne or rHactim iu Ieeiaeme. Ifl.rL We vtmmlpcleb6 for tueta. vlth to. p[CRLL./t1 oG .bpe.et n.. yhee te< au.e.. w :1r melNrta b .ceuya' hy lohele- t wv..mu. .L .:vLe- .the.mu)• L tbfxd <cc. - u-~Dyeatetnf~ ! e•eey oe q remral to 6 yfei ev~a St t mmtwele telt y: It u neee em(f<aed ur n. ee .a G1N.e. mt p ed ta:Ety p leLL. Yhe 9 rel of We remL IeopM^e! 9 1 A.Llnea e. ! reebe~ t[ tt ee erelLlile. thewp vfth LLeetlci~ae. t< till tha m1e(mt0 bx Lew. eprylete wfeee~to6 e[ the -rOla p~/Yra nf tX ptefeeelm pivea kEe Y.r m: b[t<e enem:e.ay ~nth imw.wtnt rteuet:m b tY ee rvctr n[ eumu !v e Nr LMe<ilec of tteem.wibe.. etillrt• 1~ .F fLi: s... Geenltet ttu{. ef It S-r.i.fm mve.l.e theLr It uf elppt'SL urfeee [ne e eLeeb L7 e[[!ye•y'ery c..l af-nu.ma hiuA. Tv1e Y~o•lna5ercr etea tee eirLCe<Y of ell hnye. tflle ia euamc ertee vi:e feepctfctae. iC aeetrq pvbvtielly ' ~e<tiw. mlwtta! b.oai-te!) cm 1.ev! ~e D-<aime. nl.-miMd or <cvtml p ee te b Lle <ue eh my [WS11J Y- t tEe N•+1 eMlcttim uf mLelv : Lniltty ettum the r<alv [ pnct_eal lp l:S fm tW :Lra tlm in efetyq. It ie aDVt<ully pyfet2le! t0 4nab the e<Ltl•e aefXe to Wlch ewqy m:yultme <e elnemaie lemW b Aelµ- pnYL u W•c Y' of mlccLr fb tbt u the tvbl eee [ ewtl ti<n mbol v. ntmh~. •bp hpm.inµy ~.T~ paa peoyc.elr.Y, t•a•bpuett). vrscLlmlity ~a eKlbcy. E9Z969ZOOT It f wr11 tnMe t PLSeL o( nR tht i. alm. s uv)efom. !br e Lme t mtloueG te vbtLer t6L: e t cy<ateeem we We bu tufectim t<e mtem L tbV.a. It fe rtparma tWt We P~evllen<ecf pelLdn / ce 1_peit! <t ynu<e acimtly Le bv-m-tb O?ta Cf mlt. ic wt ... .q<. Thf. se.un :e ..rybd to bve h <eeeN\ tha e!e tYt Pllet<. aW 1 hN or a Ppce a/ the Llat pf p.e 4 luurLea{. bve. t. etery ! e teroyt e e<ey w1umL ecm<alc < V w Lyet b tLe fe~n ~ e paec-lll' 1 tL tam ae - f< E mly <f m ix/aequcb mdee-. e e nf fde t ulup <f pellyre ~ 11av M y ttet . 1vpLe alef.ey euppl ct t luppl/ pteeln •1]9iaFLase wu a elL1) ° Ye+ eM1caN ba ei.eeee !ea pteeeP:a W veiu.. af ee te cvlttret<Sm1 iM mrel e[ them-tta~lfttaeNla b hviml. vheo tm lbtlaticll relatlm net•nfe letRSle esMtfw !na lwe cmeex .a. rint t<wrt<a. t< re mh1. te e prtvp tatm ~eytvtaMeLei thee .~ rc e[ be etnwe .bLLesi g<n - Ltl - f theae .ILet te p tetn lep.- mite et Levele nf n1 81 1 O~ 4 lna eeerth fa~ t~a _•f e pe uea f< 1<ne t hbaa yf an cvy nle iL"e~ti8^tnn md vlth eme.mrrt ttmtmq.i beo lmfce Oelleee le ;ttely tMt bin mYe ct eq etpl/ Cectt dl <t or opeeYrt< c gE for Euoa tl .es. 19e 1 tail ~ `~atd ec! L Lm]ml! M eLmlv te Lt:<n n'Sa'o:cee 4h1! Ybt a: eiev. X.my lu- veeaq.tere nw eepeet :u f/M tUt Lt tahacce eea.< r- e eqy etCOiflemt erfeet th the eemLe.eerccm ~ etf<tuey It vtt\ m te or e ow-:eicclfN• \ca:..<t, <e~QenLl oF lyi4rstetl< eL-t•eter Iv .omLwfm .vm w otb:e. /y tee elucfmtlm ef oym e'feete md m t}e ur<'n far! wtlshct0[yp t ~a'eeaal cul. the :c ucY cLial. e~t.]nlp b p-L®.ry nreYe nr aCibay hco=c:ortL. It eeem te .< reey mf<:Nn.b tmt [ L LOpyL . 6ar1Pe! fSeleee y'- . !1L<Le tee . cuopn- .uh<we .e <-y ptme lyy <i(prnyelr ma eee»tlmtl~• ee te <wb trtne e.hllc Ce.nna [u mppn!^!"y ~eadte2 v ••ei<p ^<! ecemay e[ e rholly wcert.:nle..l.eey. lv q ep(vtm• t?e <lue twt mv mlf nee.~, ua eetto~ay .eem b m awtimee a-~h /.ae,ar~fe. f3r<y~ tv v.b:c. AL inte•sttm te!]ltnL• tee m c~~t henlen ejwcue mvl. ee. _ Fatlrely CICARE7TE LABELINQ AND ADVERTIBINQ Lerge <wler ot l.me cmce: cs - I_~ °'t~ a :mltr ~rlu t- r -a < tRe utuL ena ttrero-•1 43 rl<. er tble mt~ [ rr eaue:~eL r e<y cun-~n e.~e(~ltmt be . r lee S ~ r ma o 9neum 9 re(lyj y,ya 41raeQy eay fcu1V..] lpPemcte. LLmy c[ ifoee. Pte. alo<owr/ n[ eqyv el.e. a oemd 1.uC cejter vfctlm ehpltd pecl(le ~L~1 Lyu [m tlet etl v lu t!e lfule ma luenaat<~y toce e f t in the <euml V Ye11 pm ae LpL eM e[f~tlwwe. thry nf <mtrvl <r pmventim. einli rolLUyetyole.. . p. 3. Ccvplnpc. t.9.. Gnnm~ C.A.r !ca Yynaee. c.L. ~=j p.cAU<tlea ee hcci u~ r Picee:~lea~ea[c~• -~u~ J• LittLe, C<.C. 3S~• ~ep,,K uS - ~entlrf mc.aoi STqp xmma . .ave ccmtstm Yav 1¢t~~' \. Cc>vveee. D.~ maDeveie. P}'. Leeyni!`Le~cP.v-.calta-- ]'fttoie /e W ~~T ~ ro~ 9 mMC. em L"."' 13• !}l'-(I§jE 4)-. S•tla, n.P. •Ibb<co Lau[sciurty ty- Cnm1•be` H m~•~ St~: • 94t~a e. of gi<t~y rim S- 9uth, C.V. Dlftereate get.le. 9myn ~ A'~ . A.X.A.lArc Lvo! of - 6• fk.wur~ c. tl.lann. e. em Dlett..m< J. 1Nme eYOlcs nf 9mttv/. .. ~ TA t• Pftbr. R.•t. v~ 9.`w. l~. J'°t~r..mr-'----' Pbbr', A.A. Cemle ma W ~. 596 (1y56~ .. • b - e• ~, e.e. Le.111l1 eµ ~cm o.C°mJ~ p[!um 9. _a s+fdnt, t ' P.e~ - ~.~a< ~. 1 1 . CwAx' P., 9Celn' B.L...S wt~pa•lo< ;YTv_pe: S C , eate. M.. ppttavax. y: ~ b te -p. Eft.. t f L v.+[rm ~- ~~T'S4 195'!7. n:sbv_ mrr ma 9_ri G v .EO e o.L.'I. .ya 1. t ~- Pt~~ Ll. YaeL e ulte D.g.aLytlm, igyye[ 6mnLCltLm. cmer! fl9fel.~ L/. /iye, Y CLrtpic Nlwr . Ofeeean iu Petimt. vtth f~c..ec. yy 9tv4 . ictve 959)-~. ~. C<Ox! C. /<!t H<toc! fe }ybl BYW Iema C... 131

132 CIGARETTE LABELING AND ADVERTISING Dleeueeion faul tMier, Dniverelty or Chicago Ine Re_e situeHnn Ther exiaE reporte of e number or l.r6e. eeele etedlee dealing with the aedetetlon of emoking erA mnrtality. Stsrtln6 elth the obeereetlen that the reported death rate for luog < r hed Increesed e.rkedly Sn recent yaeu, Doll :ndClll conducted f rotroape[tleeetudy vhl=h s nnd to Intlcate a nlatlenehlp betueen anoYing eM Cencer of the L.me• The epeclal dlfflcultlee In the lnterpre- tetlon of the resultd ot retnepeeti[e iiudiee 1ed Doll enE H111, and 1.6Ne.w+.u.nd and Ilern. teo do aepanEe Vnewe- liv. etual... aM a5e1n eeukini .aened to b. SepllceE[d. xw'>veT, eerleve questions v refeed eaout tEe vMerpreculon of thee! proapecsl.e etudlu a1ee. Plret ... the qu=etlen of aemplhfg technique. In the v:_ ond-x atvdy the . bJ 2te .ereru;lyd ~ y :Clunteen E the pepua tton r'.lea t difficult to d.rlne at any rae, to study. In tn. Dou-x1i1 study ihe populetlen--ell 9rltlah pnyarcton.--vu 4a11 defined, nut the propertlon of nonreepcn<enY ue a4nuE as IerCe a= the prepertlen f mkara ena f elnce nothing u.e km.an aeut the nenreepnaente, tberd eVVearoa-tob..d eFCeeefoni. pe.emllleaa. for bl.aea .aeouon n.r.. 9econd vu the queetlon of poaelble blu.et sa in~LCUrdalee In-reaponsutq the r+lled qr tlonneln end In tM d1a[nesea cf cause of death. ^91rd, as 9erkeon nu evpnutteE, thn r•euite of butEprotpeetue ituave. < :u 1Jleete thee only a minor par- ueon oe < of tn. Inerc. e 1. death rete eeen5 ceken In attributed to lung center. It e of death -wro tnnt e maet .ll U he elevatud i e,W elnoat txe- thtrde~of the tnenau Se attributed to ncry arten liieate, rather tT.n to ionC = ekeun eacnete that this n pNovonevon rn ^_ceke u 'Mt be tet.en ef eviLance tnnt t ro SnAnmtn•iC fisnyln tfism~tAOfelcn or, at least, that the efrett trg fa e fen tal one end net ape- o r: nilv thct or cmc r prnducer. Cthvre, cotle cpetrtr) deeM SntCepdt- Ibll;:; vneen-tM g.n.ra1 and the e. [P.o nnlC ereet. in ant e ent, hw e do e n to te §eteing enre Men u. had e[leineil, terb'ained for. ~ At thle pe:nt it nay be ell to ` wn yeeJurlete. I suapeet that ^ok_nC eally ls bad foe ww a Melth, x ena tbet peole not elnadf elerea tn the habl: ought to M edtlsed ne.t to take St D9t969Z00Z np. an the other hend, I tbink that m of the queetlone Nieed abeut the Inte.prc6atlon efttie Dcll-xill-tna~ xannorA-Y.rtrn etudle. .1. ntrlrial. I don't [ noider ttP quealo nron trlrial .n settled beyond r nebie doubt, e~ I.wld like to . nora n luelr. idenc. on the euLJe[t, If St tep be lud. The problen xw St •® to ee <hat ve <m profitably dlade the preblee a Sntee- pntatlon Snto two qris. Pint, Sa the ueecletlen betneen . meking ani mrtallty (lmg cepoer ud -a11) fo,nd In the aiudy ppyuletlene e eampling ertifeet due to nen- ren::oe..laafion} "Seeend, euppesing that the cbeereed a=Sat1 in tLe 5smple fnn the aNJI ycpuletlan 1. not e Canyling.rtifect, does it lndinte causation? It night be, for ea.nple, tb.t factoq verbre n aubJect to Snduatrtal na=arde which eane e end other lllve.eea ind, at the se et1M, but for quite independent reasons, they tend to be Meey e®kera. A populatlon eVna]ating of factory meek- end otnere nignt Enen anou n eci- a3ev betwau amkleC .nd m>rtellt}-.61tn aoer not-iegetePlE-bausetion. Indeed, x. A. PSehek u:gee u nnt to orerlook the poee1b111Ny that ean[er oa aea mekln( in the that peopl t N Mrlr e.~ S11nuelelg`~toaaekntTeaelld n rcutle= effeet produe>a by ee.qkln5. F1na11), • fer ea lunC < nune le < rned, by nay h. erlona dwEtM.bout the 3nEeyee Menee oi . lung c r dle/nosls frmsnuklng filetory. Alung vancer nlnQ In e emokqr y MVe eppn- ctabl~better chame of beln~dl/1 aptroaed tben e oeeurring In e nun. ker. Ca+trib.tinn of the V. . St Se fnr e the ampltng yteblem Sa rned, tne V.A.eeeudp peyuletinn bae outstanding advanteges ne r the pop- vletiee+ ! veti6eted in the yresleua p'_oc9?Et1.eetualCa. ITe pdwlet!en ta =eia]ie or precise derLtlCen, and e.n) hnract f tt . t SncCle fnr It wttneu n fng cnt s ch lnal.IduaL tne-eeCn 1 for laalning ebont Lu event of dnth ee almst foolproof nM, altMUgh tne n reepen- dcnta beve untnwn sroklns hlatoelee, tnely deethe e kell telleked uy . O,e of the eeepoMents. If the e .n LTO,envantagee een[erped by os of this CIGARETTE LABELING AND ADYE8TI8ING 133

134 CIGARETTE LABELING AND ADVERTISING VOL e0 1476 :f tudy of Iturg rancer cases and controls disclosed a number o/occupations drd appearrvl to Aaue an increased risk of pulmonary cancer. To examine tLis possibility a prospectine study was undertaken. The results of a prcfiminary analysis arc Irrest•rrterf here, and some of the sources nj aneertainty are rliscuased. a ~G CL.NC=:2 tJ.OR":.LITY EXPERIC.7CE OF MEN IN CERT.a-v OCC::?ATIONS IN CALIFORNIA M7•n E. Duun, Jr.. M.I)_ MS.PJl. £.AP.II.A.; Geuqe Llnden, MPJL; .nd Wter 8rnlmu, 11D, MP.II., £.dP.N.A. D runq'ftlu: man°u 1949-1952 a case- rontrol sludy ammig male lung cur- rrr ca.ca mul matehed controls in 11 taliforni° hoepil°l% yi,•Ided data on oc- .npation aud tobacco use as principal ,ariaLla,. The findiitg,s in regard to o-,lwaro o.o snplorled the now well olahlished positive arsoeiatiqn of cig- arrlte smoking and liability to death frnm lung cuncer. In considcrtng the distribution of oc- , nlmtione 1 elwecn can-, and controls, it xa> arbitrarily deeided that any case or ,'ontrol would Iro a:>igned to a xpecihe ,.rupation if he had worked at least lire yearm in the occupation. Interest was further limited to thoue occupations to which at least five casen or five con- trola had been assigned. This study' dixlosed a number of occupations to be more frequent among the lung cancer cases than among the controla. For one of these. welders, the excese among cases as compared to controls was statistically significant; for a number of othera, the excessive frequency among casea as compared to controls bordered on significance. On the basis of these- findings, we undertook a prospective study in which populations of workers engaged in the suspect occupations were meeehtbled and their lung cancer experience observed during auxeeding yeara through a CIGARETTE LABELING AND ADV$RTIBING 135_ sc,vcL of doalh records. T Legan in 19j1, hc atudY fn arldilimt to tbc sp on death .°po lhis report is based grou ezpermnce lhrough 1958. I++, ILv sludy incfu,lnl a, - group rcpreM•nling workers frome::.. Plan of Study Public utiliq• doctric enmpan;,.,. this group the few workcry ,y~, . The populations ussembled for stud any of th° suspect occu -' wcre limited to y excludcd Tbe remaimler 3~64 men in the age range ycnra. pounger ° broad spcctrum of cluded because their lung men cancer were ex. ex. occup:n6.,,. „ one might expcc[ in ILc perienm wuuld contribute little to th¢ maintenancq and power study while their mtmbers would add large pohfic utilit or.a considerably to lLe . Y f, ni:ation,' Popul°tion lista The qnestfonnai.ex used (or being searched for matcl,ing with re• lecuon from the mcmben of thc corded dcaths. Older workers were ex- ~c~r - pa[ional greups werc os amtl I eluded becouse of thcir small numbera brief as pos,ihle in the inlerest of t i,p~ and the uncenainty of the ap death ratea plicable 6esiJrororslallah ngtnge andfnnn, . l:vtimates populalians ranging Lctween indicated that milted sulncquent death len Ihousand would provide reasonoble 9atchin g. The Social Security mm~i,.r assuranco of idcntifying o°cu extremely u~eful for ehis puri,,,,•; haring as littlc as Patians Smoking practice was ri.k of lun~ ° t'volold incrensed confined tu , i_,,. cancer. An ex teu° usq years of smoking, and rurm,.; her of at least 14 hmg ca~etrd deatha °r last avem~ (when s e daily con,umpiim,, 'fi„twofold risk would r respondent identified hinuelf in LG ,.. a significant obr,erved P oride cupation and the Icngth of time hr cases or number of 21 been in the occupation. Question., 0.93) has been slmw A Probability of each specific oecupation u( inlcroi fill these n aceeus°ry to (ul. tablished the specific nature of tl„~ conditiaru? A populetion of work. IVelders, for examplo, the sise heing sought would prodnce asked as to kinds of welding equip,u,i,:. such an expected number within five ' observation. Years of welding rods, and metals with vhi,l, Exploration as to the best muns of they worked- Some sheet eollectin do weldin metal wod,•r, study led g to a d ~Pula'eion tolable for the the culinary tredo, coo~ not. prid,i„ unian work through tin uiah ks had to be di.~ otgani:etiom, Local union offic g ed ifOqj °thSS kitahen worken pmvided namea and c's such as pantrymen, kitchen workere in addresees of wsite hellxY,, Ihe uccup°tions of interro ~ end othera, I{rspondcma thn. and questionnaires were l. identified thnmselves a covering letter u fled with only in the e aa belonging nol ing of idenlif in ~-roting the furnish- P~ific occupationa beiug , Y g data and infor studied but dao in bro.d subelnws as to length of time rnation wilhin each occu ti ex r'ence fn the and nature a of work examination. P° on for sepama• pe r particulr Cigareue smoking experience~av® taleo requested. Resulfs Eunher detafls es to the meehanf the data es of Table 1 gives the number of mru were gfven elsew here.^cropection he phre.^ -ase S of the stud y collected (nr-each of the stud say hero that the na ~ it to tfons within th y I'OpOI- P°nse rate avera d' a e age span Leing sutdirJ. ahour 85 per cent after th $e nd rheir percente rea mailin 8e diseribulfon by tcu. 8a- year age groups. Tha welder, and ssi9sszooi

136 CICAREITE LABELINC AND ADVERTISING „. rcprGOnt IhC nvo Citrcme•s in EO IIIeW1 Ix?PUlatlonY o\'er a period of time, to a~c df.tribulion-the former it is naceaxaary lo calculate tile man- ,~ lhp youngc>t asd Ihe latter the ycars of expopure to ri.k of mortalily Tbc rontrola lie near the middle nnd a1,0 to allow for the aging ol tile . t. ,~ in respect so age. pnpulazions. 11re renrrna Erom mailed \;,t all pt: occupations shown in qucslionnairca for any particular occu- tLlr I 'cre su=penacd of incrcased pation came in over many months. To ram:,•r risk frniu the original casc• simplify corrttlion fnr aging (and not .,,nu f twly. ~umc r:nne into tile introduce an appreciable error), we con- pn-rnt tudulatimtsP.oyucts fcf h'ucrstatedaug ncthhe persontisnr nthnro- ;uc tile 1'op Pat ocmP ~ g and are inclndcd bceuuae o[ thuir maimng of the calendar year after the .isiLlc numbera aml fnr such hclp date the questionnaire was eompleted• mipht lunvida in nndcr,:tanding 11c was counted one year ulder for each e rhararterisGrs and Liasta Iserv6ar euceeeding person-year (ealend¢r). This II -tudy. Thc sheet mctal workers prncedure led to tile accumulation of o,t ,I mg welding are one such group; person-years by each study pop,slation, yhunL,:rs not working with asLcaos at the end of calendar year 1958, shown al:cr. Two su.pect groups-clectric in column (2) of Tablo 2. We did not nn,l,r.c.rnne uluraton and marine engi- correct for person-yean lost aa a result .n.l 6rcmen-f:otdd not Ite found of generaufRlonglthavc ub n followed. lu .od!icient numhem for atudy Lut are these pop would in 'a:1Lid,~d Lucause they were auspect in Such a correction, however, tl.! uriginal cascrontrol study. lsrinturs volve a pereon-ycar'e reduction in the a,:ra inrlnded because it was poseible order of 2 per cent for any group at •, rnlhxt an adequate population easily, the end of 19 . g. The txpce~ lung .nd Ihcy have been reported to have cancer deaths, discuaaed further on, increased lung cancer risk.r would be reduced by about half a use 'tv datcrmine the significance of tile for the palnters, who have the largeqt :,a•,; rancerrrartalily experience in eapected numiser, aad something less T.blu 1 Hale. 86-64 Yaar• of Age in rhe Oecatsas:ana( >»udy poPulati°°a pccupationalGroup Tmd Number Welder. 10''']5 Palntcg 12,512 Gook. 9$98 .A.bo-to..orker. 7Jr16 Printare .llarine en:,incen i,ta Ia110 Elcctric inidae cune opcrmnr. 318 Plumbera (no asbexor) 7 ~ Sheet metal workem 3.O13 Cootrol. 8$69 99Z969~00T Per cenl 01 Total in Age Group, 3544 - 4S'S4 WOs 58.0 32.6 9.4 36.0 37.4 26.6 301 42.1 27.7 382 37.3 23.8 3&3 39.6 T1•1 39.7 35.1 75.2 41.8 39.6 18.6 45.1 3;J 19.5 47 8 33.0 19.1 . ~$ 2~ 41.7 . CIOARETPE LABELING AND ADVERTIrfIN(; 137 T„hlu of :{.,,.riencu rnr &ui, fMr,n.,t;un Tbn.,rah 19:.L•, pml oa•,.r,,,; end E.J~ss.d Luna nnd All (:,necr Dc:,dr. for Thi. r•eriod U ...., W. I d c.. I l.l l// l 19 16.9 1 12 n ~- 98 . .I l,mrn .37,x70 hI I: :z 891 45 1 . 1..26 SI Cnuk. 26,IIW 27 ]6.tl 1.37 1.41 'SY v„rAcra 'L'I,hu7 19 13.7 13' 1 1 ' I rinu.re -22 :ul al.a 1lorinc ' 7.7 Offi 0.75 lh 19.1. 5.757 ; 41ect 3.7 ~ 1'3" I'~ 8 y,p c.onc uperataq l,llh0 . 0.5 _ 1'Inmbera 2d,908 16 12.9 11 Ls SBrµmnal 1•p 1.07 Yf :f8_i wnrken 11,767 3 h.x O.Ia .. Co:ttrole :1aJV4.1 0.411 LS Li.R 17 I9N 0.86 O,xy 3l 'rnml. r25U3 ±v5 139 vvu 113 - . axl 307 •x... ~„ rmw, n. w un. n.ss. aw, w aw 1'lf.>, fr rW.o Pl Jr.•. lya, last. •.a p7J. Rv. v... l.. M.s. PI • n a ,b,) nX. .• than tbis for 11,c nthrr groups• (Fur' specifie rates for men a5-61 vear...i inlcra~rupaliunal frroup romparir.ons m ag., for olher rancet murtuliq ba. Lr„ x•b rorreclion is of little importanrn.) sliglu. For Ihis preliminarp~ aunh.i•. (:ahimns (7) and (3) of Table 2' then, and until the 191i0 Ceruus nuuu- imlicnte the ranrer deaths for all but oration is availahle. Ibe 19a/1 Iling cenrer death, (hereafler referred specific other cancer ran•s yirld t1nlo an oWer rancer), aml thc lung csncer expected numbec+ in column (31 „i deatb» (f.S.C. ralex 162-163) that have Table 2. The ratio of ohservnl lo r.. occurred in Ihe arrupmioual tral Iwpulatiuns. An fmmediale and con• pected other cancer deaths is 1:4r.ILun prfuh~o. arises aa to the ralra to uae f qor com~uestion Th one e for all controls study grmtps puting expxted numbere of lung re exrepl most dr•ficiem in udn•r cancer ot eancer, having only about Iwolhinl- anrl her cancrr' rlcaths lo compare of the expected numbrr, and rar a8 witb these oLnervrd numhrrs. California +roups taken together the olaenvJ num- h~ undcrgone tremendous population Iser u fii per rxnt of Ihe expny.vl num. !; wth since 1950 and population cali• her, Thie apparent defirfl in u16,~r mmt9 hy age and sex are uncertain. eancer deaths will be disrmaf•d laler, Such estimates as are available for the Cali(ornia male Any uncertainly about the prnfmr populalin in recent yesn indicate that any ch.n in a - Se ge- ago-epecific other canttr rates to u. ia minor compared to finding ,uil:WLlr ,

138 CIGARETTE LABELINO AND ADVERTISING agc•ryrrific lung cancer rates for cum• pWimg, expecled numbers. Lung can- cer mortality rat s for male> have con• tinued to climb since 1950 but how fast und whrlhrr the rate of asccnl is differ- 'ent fur digerent age groups is nncer- tain. T6e estimates of-increase for the lotul l.nited States seemed more rcli- aLlr thnn California data becanso of California's rapid population change. TLr eslimated increaue, based on United States data, from 1950 to 1956 for tLe male agc-slxzifrc respiralory canaa rates were as follows; 35-M1 yearw 22 per cent; rl5-5M1 years, 23 pcr cent; 55-41 years, 40 per cent; (rLfi9 years, 65 per ttnt. The corresponding Cali- fornia 1950 age-sPeoifrc lung cancer rates w re increaued Ly these pereenb aoes mtd used to compute the expected numbers of column (h). Inspcctian of dte ohlerved and ex- pected lung canarr deaths in lhe various occupatimwl groups indicates ahat the ratios are all greater than 1.0, cxcapt for the sheel metal workers, dte printers, and the control population. The only signtficant deviations from the exp:cid number are an exeea's of observed lung cancer deatlu among painters (10.9>2 V'1rF1• ) and asignificant de- ficicncy in lung cancer dealhs among printers. As noted above, this latter occupational group had an excess of other cancer deatha. An important factor to be consid- ered in tLe lung cancer experience uf a population is its smoking practices which will be conridered next. Cigarette Smoking Habits The informa(ion collected on smoking praclices was limited lo cigarelln smak- ing, since the association of this hubit waL increased risk of lung cancer is f,rmfy established and quantificd. Ci,",a- reue smokers included anyone smukjng cigatettrs regularly for at lenst one year. The majority of regular cigarette CICARETTE LABELINO AND ADVERTISING smuk.•rs apparcnlly think oI f I' 139 rm e'onsumption in trrnt. r da,ly To dmermiue thc ot:rr.; . rrtles of puak., of c,ga- of a - dl r I rn,~ ri.k (or a rough fractiou ur multi.lc 1'ohulation for Lm r.u. tLcrrof), Lut :Gcn an of it. 1 result omoking In:uiun. os~.g g oplwrtmtity to necessary to havr rclulivc ri.k. ' il i, t n them.elves amuml a modol poinl to vprious ,mntilit~ the . :"'~ ) ma Y Le p..ycLolo icall q uf .muking. to underslale t4eir g Y molivated huve dcvrlu (l:i:, ~r. con.amrplion• TLe Ia•d rurh relaii,i~ ri,k.. „r park-a.da smuke they ran Lu cum mterl Y c psked wLelLer lie lwdies of 1 fru,n .ar.~u. srnukax rnurc or Iras tlran lhis n dala'~•-° .liucc lhr can rnroncile ILe I thismm,n[ tive aeolc of .mukiuh ill lh arom dex[ties his eon>riense Ly LrLeving P°'ses is somcwhm diRen~ut from ih u a tngc Irs, ratLer 1io "rnokes most Americnn nprdi,.•., little than u pnek or a were uSf the prutlyd J.n.r more. Our categori.., ihen, f d to develop ILc relmitr daily consumption were less than fire tdue ud to rigarelte mrkiup rid cigareurs: y Populutroo one pack; alwut ont• and ~ n ru . t:rr ebout half a lwck; about lrJLulion of thc canhmn In- P"d n tu ru 1-r . I'.. - - and about two parks a halL . Thie w Packs; lelions by ,..mokrn c g nl nar as to be of lung cancer d alh.itn• each n answered as of present practice last smoking for thox who lmd qor wnit. Len and computud relatrve ri.k., pr,. ,lunrrr Lulalion helow TnLle 3 aLows thc cigatetle smokin in ihe ta pallern for the various study Vopulas smDiffrrencaa in uge . rlistriLuti,pr ,r tiona. It is Immcdimely apparent that tnken~r y populationa n. i„i tLe control into acrount in tLis computaii•ma purlion of uo amokersltlun larger, pro- (men over 55 years hav,• mure u,ur. occupational groups any of the smnkers and fr•.wrc Ireav- . ) nr.kr ' In consider,ng Table 2 we noted that thewrclal prin[ers, ah ect ive risk,rforttheavJer all the occupaliunal groula except the categories mnrferaleJ metal wnrker& and run. „'ktctrols had ex Pational comparisons o(Frcfativr•r r,r~~ perienced more lung cancer from smoking the eRect is Jm.un,r- Celi orniaamalegh~ 1i exPecterl of the quentiel - be e: eineJ, POPulatiou, This might The rclative risks in the carnru, eoviec h ~ smoking lofs[the part, by the smoking cnlegorirs hrre are .wrru.wlrn occu mtionaf her th V°Puluions. 1 h'g an have usually been fmunl from other data. (This - is not the rr. _ Amaum.of Ci••arene Smnking I'oyulanun di.tribmlm, ^e <5 21.2 l.uuacmc.ra . Relatire r:xl:• 7 29 1'/ ' 6et Po-pcrcrnta6e of Populaiam m'wnokeo, - - n'°'aeq . h uf [he corrqp"ndm5 smokrng cateaonm ~ Le[ pr, ej. P,. ... eta. r<Pre.rm We C lung unrer d,•nrh. ,o and denhr i^ n, h of 1Le enr nun.mokerr, end Cs, Cl, ...... te ., tt r?twnding.mnklna rawgorin. Pre :m lune r.m,r Rehti.e rlak.~Ce/p.~,Co/PO.- °=_C' P_Ct pnCr PsCa . ~PIC. ; mca , anq so fnrm. ?4 peck I I•eck 1'/~ 1'scke 2 Yark. ti au~,l ~.g 12 141 41.5 ]3.5 Ll 4.8 'S 32 13 g ? ' 19 - 25 4sTss9zooZ

140 CIGARETTE LABELING AND ADVERTI$H•f6 cuil of du• poncfblc operation of othcr _ i i t genu- lactorv in ad lition to and i I p n Irnt of snmkutg in +omc of these a: ipat o wl mufu•; such a factnr nuhl acui II) 1 ironse the ~radicnt ) U'it6 unit relative risk based on onl) t h..g c n rr dcaths umung nan- m k r.>, it r; obtioua that these deter- nuoatron.. ar ,+ubject to large sampling error. llawever, as will be shown later, in corranu„ t]re lung eancur eapect- anry Of a iven population, the popu- lalimi s smoking pauem is a more im- p„rlant e arnble titan is the relative r',ek ~inokr g •radwnt. If tbv total weighted relative risk 31 dAenuined for lbe study groups by mulnpl)ing the appropriate I>Lrcenlages af Tnhlc 3 with tlm smoking weighting iartors as dctcrmme.l above from the LmIrJ data, and the total weighted rrlallce r1=k for each populution divided Ly that for the controls, the contribu• tion to relative risk provided by smok- ing pallerna will be aa follows: Controls \Pelden 1'.Inreo Cooks l'IUmIMn A.In:+tmworker. Uarinaengineers I'rinten 5h.ct metel aorkere Elactric bridge cr.neopentorr 1 1.14 1.15 0.97 1.16 1.14 1.2S 1.05 1.01 1.09 As pointed out earlier, the excess of uluerved lung cancer cases as compared to the expected number might result, iu part, from the smaller proportion uf nommokcrs in the specific occupa- tional populations as compared to the ,:nntrol population and presumably Of Ihv general population of men in Calf- lornia. The observed to expected ratios of Talrlc 2 were divided by the rela- tire riek smoking factors above to ob• tain tlm lung cancer relative risks cor- esTssszooi rrrte_d for cigarette smoking in column (6) ofTahle 2. Only the crcr•ss lung caneer draths for cookL would actually be .hghtly increased. The excess Inng ancer dradte for painters would lose atnnaical +ignihcance with the ex- perled oumlkr becoming 27.7 when correctcd for smoking pattern olpainters (2t.1 X 1.15-.27.7). . This correclion for expected lung cancer deatlv.' in the study populations aesumes the appropriatencv of the lung canaer relative risk assignments for smoking categories; and tim smoking pattern or the control study population ts rrpn•.entative of that for all men in California. As noted above, the total weighted lung cancer relative risk resulting from the smoking pattern of a population is rather insensitive to the relative risk gradient used. For ex- ample, relative risks were adapted from Hacnsacl and Shimkin° as follows; non- >mokers-1; lere than a pack-6; one pack-10; more than a pack-13; and not smled-l0. Grouping the smoking distributions of Table 3 appropriately and using these relative risks, and again giving lhe total weighted relative risk of the control population a value of 'unity, the lung cancer relative risks change little from those last calculated and derived from the weighting factors provided by the pooled data from all study groups. The maximum change was for marine engineers, now 1.21 instead of 1.25. Other changes were limited to differences of 0,01 or 0.02. Resulta of two other California studies permit a test of the second assumption, f.e., regarding the smoking pattern of all California maln. The first is a study Of urban air pollution effects on lung cancer experience of about 70,000 Cali fomia men, respondents f rom the California Division of the American Legion. They replied to the same smok•. ing questionnaire as that used for the occupational populations, with results by age groups, and compared to the CIOARETTE LABELING AND ADVERTI9INp 141 rnulrol+ of Ihc pr.,ynt sludc, a+ vbuwn samc inrroaw•d frryurm)' n( bnir bl w, There n ohqou I' cer dcaths. N,trt of r.:m~ lalwr ~) ^uod ngreemrn[ lcus Ilu csre,,. at ..n Ihrs, h o n di,•. of Ihe re. t• ia apparrntly Ib, r. uh Of Ila• port,d smnkir fiucures, Dp more univerwl and Al.r, agegroupss uonsum ' hra,:ier ri¢arcu,~ Ihe Cahfornia Hrnhh ptron by the urrupal t nal of 19iSurvey Ixing studi Kroup.. . 0- I'a'.rd on liousr•hold interviews trol _ ad °x eompared to Ille r.m. of a probubilily wmnplr of [hc California P^pulation, and Cubinrma I'apulaumt vul inrlnding generally. After rrmaving t~t~~ on informnlion attributahle ~moking prnt+Imwed close to sruoking prauirt.. a n•em nl ill Ih,, ru ro excess lun ~one. 1 I rtions of non- g cancer morl dtlt ~ +mokrrs with Ih,. G ulings from in most ofthe s1udY poPr Imr m,,, Iwl eiun .lud Y the air Several ) poprduion au I Ibr other cnnsidcral un. palrnml +ludy w"" affect the results of 'ould eonlrols. Tbr Califprnia is the amly.rs Ibr HrJI[h lnnxy rpmnliGed.makingrliffar- rcliability of the a t~nl rndy from nc- Inlh•r tw male cancer death `I makea lh o+ludu•y; llus rules u.d for rnm. e compirison of distrih Puting lhe expected lun8 nll,-r amokm raleg ution by cancer deadis ' an`I o ca nuyati.factory. m Ihe stud • I[ .eema rcasonoble Seeond. I ) PoPula...... - lo say that the P°re'r could result from failnr,~ a•igarclle smoking pattem of to identify oll raneec drath., tha pational romrol. I+ tlm occu- have occurred I 1O1!' more like that o( in lhe sturly pnp,Jation. a11 Colifornia mcn Ihan is that of an through ovtrqight during of the npccific occulyr[ional grou>s Y out-ofslale migration• cte.rlc~lnrl~II ud• the 1 with is the delcit one would exp,•.ot /an,l possible exceptiot.of the caoks, generally fotmd in other +,m;h,r pm Ofher Comiderefiont ' '•Peotive studies) in the carly Ix.rmd nf follow-op of a working populu/ior, To aummorixe the anal ' °r+mhled for study becaure tliase in,a. at Ihia poiny it a t o~ ys's of data pacitated and dying of disrasc at iLr pational f fu' that Ihe occu- time the population wa.. gmups now under study have • would most likely be oss„mLh.l _ missed. - Smdy Crouq 3.5-4J - 45-54 55-61 pol6ntnn StuJ r Air PolL l - - Air ~ - JtudY _ Conrroh U on gn,J Y Stud Y Cnntrole pollmion $rudy Study Cnnuolr Nenomokerr 26 2B 1.cnx Wnn . 24 25 30 31 oncMck 14 16 1 One peek 37 39 5 15 17 20 lfurethan 37 39 30 31 one psck 22 ra Ammmt not 20 17 +uted t 1 2 1 _ _ 2 ( 7otal 1Dp 10) 100 10D )oo I00 4$-9f9 O_63-pi, t-IU i

142 CIOAffETTE LABELING AND ADVERTISING Tlu- Gn., rmu.idrratiol. has alrradl. L•cn di.ru>rell. \\'c lu:.:e no way of knnxin¢ w'hal prolwrtinn of our >tudy Iwpulalion,. mrJ the dvatb> tlral nup• b:nr oreurrvd :unun;; tlmm, hacc lucn i-l Ly outmikration. A rorrph c+li• c:alr front looking at fragmcnt, of data In. lir.uv. thal tlri, may rmt bc more ;Lrn 2 Iwr rrnl per yrar. Some of these n:Al hCromC .uhpnluvPl inmigranlN. •1'L•• lo.. from mrnight on death srarrh- inp wc luaiare is inron>rquculi:J. Indc- prn~Lut •urchrm with tbr smnc r.crtiG- caba L.nq. rr~uhcd 1n near perfect dupli- rotioat of findings. To czarninc the tlilrd quc>fion, we &urminrd for all rmtccr dcatb, in onr I"'p°Imion wheaher deadt had nc• rurred within the first year starting wilh the date the questionnaire was romplcted, or aftcr the hrst year. The . FnxtPrrwn-Yeer Ape Group \nmhar Lungfnnrer Deptlw- Ilote OlherCanrer Deutlu Rau 35- J5- 55- 65- Tord ^_:•717 't;NB 13,599 66,i/4 i 1YA 18 57.2 2U 123.3 43 10 36.1 20 81.7 3'I 294.5 3 - - I'enr•mYnnAfurFlre t Age LmyC orrr OtharGncer Group A•nmLrr, ncaWn Rue Ilenth. Ilme Tuhlu f-Dcath tt+uea Icr ]00,000 fur l.mrg Grnuer ond Othee Grnee+ During hlra I'rrwn•Yr:or ard After Fira 1'eraon•Yenr for A11 grudy Gruup. C mLimd 35- 45- 55- 65- Tutal 50.167 61•003 38.222 6?95 155,709 1 43 70 f5 129 popululion for eomputnlion of rolea for thc firat poqomlrnr was tlrc number In the occupatioual study group, and diereafu~r the total pcr.,on-yeare minus tltc numhcr in the audy group. The t~lung canrcrn and other canccrs found in these two periods in all study groups eomhinrd and Ihe eorreslwnding rates ore gicen iu '1'able -0. Conlrary to the 6ndings of other eimilar pru.l'rctivc snidics, there is no rvidrnre of a large Jchcit of Imrg r•an- rrr and other canrer draths during the Gmt pcr.on-year of follow-up a eom- porrd to the perioJ after the ftrstpcrson- year. The fnpulation is moving up out of a^c group 3541 and up in16 t6c age group mcr 65 years as it uges, uusing constantly changing ago distribution pal• lerns in thev+ agc groups• Age groupa 45-54 and •a5-61 are best suited, therer 20 60.6 138.7 192.5 18 62 84 22 I86 3.5.9 107.5 219.8 368.9 ln. F - I r • n . . ..t lo. ~ .m„ , a.ne..t nr 4 .r • ,.'Y m~f i .n.. ssarm.anir,.. JeW rl 65 .r. ~ . n .n . . 11•,.. rr., .re L.Ivl.d .1\ 4nlw 091969z00z CIQARETPE LABELING AND ADVERTISING forr, for examininS Ihi, qur.tiou. Por the.c two age group,. therr is eume irr- creane in tho aM •-.Lr.vific rme: aflr•r the Grrst person.ycar excrpl for other cancer fur agc group 55-61. tt ik not unlikcIy Ihat somc warkers nirk or ailing at Ihe time lhey rcreived their qmsliommires were dixlwsed lo respond since the slnJe was concerned with heallh aspPL'1F aI their occnpJholls. This was evidencerl by a numLer of death rrscorda within tbe first mordh fnllowing completion of the quration• nnires. An exlrrme example is one prinler's qur.tionnairc (whiclr was eliminated) submi«ed ..ubsequent to hia 143 16.3; rle.) The rr=ulling oh.vnr(l ot,.r ecpecled ratio will tben Lc os :bown, ' or..i..re„a 4m,.y SV.ddrm Palnic . 6'nnke A.Lrans workere Pnntere .tlar~aenAine[rs F.lenric Lridge rune operaan PlumLcrr SMr•t mrtd .orkrr. Conuclu recent draih by his rridow. Lnn can• cer deaths ocrurring during S Under the.re condilioo,, lhr pa{ne.n the first ~ and cooka would have significant rv. pecon-year were sqltrrcd fairly evenly cessrs of lun - S cancer. over tlre 12 monlhs foll i ow ng esponse. Deaths from other caneors w,eru some- what more frequcrv iu tbe midJl d Direussion latcr monlhs than in the oI lbe first non- ear earlier montlu:. ~ y The analysis of the dnla from lhi. Earlier it was poinlcd out in Table study is far from definite at this Ilne.. 2 Ihat ull study groups eambined showed perheps not until the 1960 Cen..u.. Jala make possible the computation of a;,,., a 15 per cent deficit of ather cancer specific cancer mortality rates for tLr deaths (Obaerved/Exltected=0.g5). The inlercen.al years in California will i6r ]wx{blo soumes of deficit that have been final analysis Ile possible. AI.o this examined make it seem likcly that thia will allow time for all the sbldp f'oPu~a' may he an adequate approximation of tions to accumulate ftve yvara of nwr whal the deficit may prove to be. Using tality esperience. this as a mcanure of dle probahle deficit It is clear that ovrcall inrrrav,l in luqg cancer JralLs as well, we cod relative ri.k,y such as lung camrr in arrive at some revised cslimutes of the certain occulmtions being inve.ligatrd olucn•ed and expected lung cancer here, can be miaradiqg whrn a poavr demhs in the various occupational study ful and almost universally arling furmr groniks. In the following toble, the is operaling. Cigarette smoking is onv observed lung cancer dcatlw of Table such factor in lung cancer. The idemili- 2 have becn increased to eliminate the cation of a second variahle po.itivvly estimated deficit hy dividing each L 0.85. The empected lung caucer deaths a ndentofwamokfng ram'er Lul indr.•. are cornxted for smoking practice by This swamping effeot waemwcllrltd mnn. multiplying the expected numher for etrated by Stocks and Camph,:ll."' 7•h.-c each occupational group in Table 2 found that a ninefold increased riek by the smoking factor as determined for lung cancer among urban uon: for that occulwtion. (Thus, expected smokers as compared lo rural nun• lung cancer deaths for weldrrs are smokers all but disappeared when 16.9X1.1M1=19.3; for paimers-2M1.1X urban•rural comparisons were made he• 1.15=27.7; for r.ooka-16$X0.97= tween heavy emok<rs. - 0.5J 19 15.0 I.J; 4 6.3 O.n3 20 19.8 I.nl

144 CIGARETTE LABELING AND ADVERTI8INl7 'Ib ilhi.tr:ur the puinL let m asmne m,• hatc a t pnhllinn of 100,000 .mn :mwng u.hom 30 P,•r cent arc nrnn- .n k rIlLlh. 5). A.tlmc alw that IL Illn, em -rr rate for nonsmokcrs m u n Ix•r 100,000 and for all calegorie. (:Inokers tu~,elber it is ten timea r.xtcq or 100per 100,000. In sueh a ~,upnlatiun of men, thrn, Ihe annual h.ng canrer rate will bc 73 per 100,000 f10 X 3f1000 + 100 X 70,000) ( 100,000 100,000 ) A...+ulne now wr have a er•rond (wpu• I:nion of mrn Ibat is identical to the fir*l ezerpl Iha men in the second papu- lulion are cafwsed to a pulmonary car- cino4rn 5hat acls indcpende.ntly from IoLarro no'r; mtd a>wme Ihat the lu Ig canr,•r rate for 4he second poPn• Intlon is 110 per 1f10,000 (1.5 times that of the firA poptdation). The excess o( 37 cuae, per 100,000 over the rate for t1LC hr+t poptdation (110-73) is indrpcndcnt of tobacco usc and would In• found in smokrrs mld non.mokers with equal frequellcy. We wmdd ezlxrt Ihe lung rmtcer rate among nonsmsker, in lhe second population would he 47 per 100,000 (10+37) and 137 ammtg smokern (1011+37). The relative risks between tbe two populaiiorls for non- smokec., then, would he 47/10 or 4.7 and 1371100 or 1.4 for smokers. cet of Srunking Farror for Inrlependently 'fnlA. S---Ilh..rr., I+rnssurru Elarerdr Arring Oeeupctionul s6 Wh.re Orcupulimral Fartar Incrrn.es I.onu C.ncer Rate 15 Over That .1 General Papulatiun - LungQnrer LungCuncer DcmhRsle De:al Rate - Per _ im.kina 1'ateeory . Po_pnl„rion It) /81 Sonunok.en 30,000 N,okers 70,000 Allreuperin 100,000 Pe/IOq000 Total' 100,n00 Frnm Lung(aneer Cenerd lkrv,pntional Ikath R<Inire Pepulation Puaor Rate Risk 1b) (S)+(31 (3) (4) 10 37 47 ~- 4.7 100 37 ' 1.^.7 1.4 73 37 117 1.5 R'L•re 0ceupnionsl Fnetor innre.;es Lung Gneer Rale Twntnld ' N.nsmoke_rs 30p00 10 770'• gJ tilnokrre 7Up110 100 77 , 17h . 1.7 Allretesodn 100,000 . 73 - 73 Ir,S - 2.0 R'here Occuyetinnd Fartur Incmuu Lung Gncer Risk Twufold lo Abee.rce of Smoking Nonrmnken 30,000 . 10 10 23 2.0 5moken 70,000 100 10 110 1.1 83 1.1 /41 ,{Ilraegorin lOD,O(10 73 10 .he. ,M' IMFI•Ir~.°,IA J,..Lr rn. el,l,r .1 'rl. t°. . rMr nru. ,..~.. o, J.•:..»Id h:y,l w ,4 .w h. Y nrn., a.r.a..i . .u. . o4Z9s9zooZ CIGAREITE LABELING AND ADVERTIRING 145 In a similar manner, if a ula- tion cngag P°P _ eralion of sourcra of dcftr It of ,m.,.r cd in an dccupalion Las trvlcc deaths in tbc tud ' the ratc of lung cancer [ban would be t ° Y I!opldullo c t I hrllr. ezpecled from eneral fQ la pcr cenldcficit aalwlupd h,r 6 Population ez- deaths other than 41111" cancer lo hu pericnce, this may actually rn rese t d an eightfold increesed risk if itcould an a equate approzlmation. be examined in the absence f h Most of the study occupatiun+ hn l o t e effect of the smoking factor. The final illustration is eoncerned' with an occupatimlal factor that would doul.le the risk of Inng cancer if there were no smoking factor operating. The donbling cffect would only be evident among nonsmokers, and for the whole occupational Population this hazard would be difficult to identify since it would increase the lung cancer risk only 14 per cent (Table 5, 83--' -73=1,14), If it turns out that some of the nccu- pations being studied do show a signifi• cant excess of lung cancer in the range of 1.5- to 2-fold, it is of.interest to ' realize that this could repreacnt a car• cinogenic factor of considerable im•. portance in its own right• The convenx of this must also be kept in mind as a p°subility, w'{th occupational expo• sure enhancing the effect of smoking. Summary a arger proportion of cigarutc nl " : . o , r and heavier consumption than Is Iru,. for the control population. Thc appear to be quite representul:.c „i California males generally in rc,ry•,.t to cigarette smoking. Relative ri-k' fnr each occupationn as tomparcd to Il:c conlrol Population are cromputed, ron- sidering the smoking distribniion of tbe controls aa representing unit rclatite risk. Correcting the observed lung eanrrr deaths for the apparent deficit in our study conditions and the expected lnou cancer deaths for smqkfng pmctf,.,. leavea at least two occupations wilh tentative ezcesero of lung.cancer ri.•k. These are cooks and paintero. The order of magnitude of orer-aII incmaxd lung cancer risk we can o,. peer in these populations now apfxwr. in the 1.5-fold to 2-fold range. Tlli> would represent an incnosed rink frum the occupational exposure in Ihc ran_,• of S• to 9-fold f or nonsmokem, if tle. A rase-control study of lung cancer oceupation's factor were acting in.(n caseq and matched controls disclosed pendently from the smoking factor, a number of occupations to have an apparently increased risk of lung cancer., REFERENCES To ezamine thesa u: x,..rua r..: Possibilides further a Prospective study is now under wel .rJ.e.ll. uilsLl Populations of inen engaged in these a cal.;,'s iu rM c.:..n c...,4,,..., and mher specific oecupatione, includin ;`'' s'-'Inuu o,.e.,.,u„ /s ,4, w.e, a group serving as a centrol populstion, 1~: °rer 1. I,e„,n• nu. unlsrnu were assembled and we are now follow. s x n L' L1e°a e•/ a,,,. ing their lung cancer ex rience r, s a• n. u.. •r ° nen'. Q"" 'rr rw Pe by. arie. - Ivtr.l n°.r. /r. rrew..u.,J - searching these populations for mate a. c,,.n°r 1• nor.' he5 wo,4„y ala ch.n n'erryµ, Irrx with all mele lung catmer deaths of a u."I• w., ,.e saw.• R, a. awl.r r.,. California residents. '.r. •.e xru.,.uivr °r t„r n,.Onl a miw s,,s„ e„ rwr c..wn.r r. re,. Q,,., Y Preliminary analysis is 1• r-'- rr'lur-lµr ()°,o. ars. 61e at this time P0'° 'a b o,n, R., w xln A- 1. r.v r.ere, „e o,s., eraaeE a( aneerlmn C.r. Rel.nse u a.,41y. A rr•+~•I postcerlsal agerapecific cancer rnone °r Mn4 I• lit ^r°n °• '4, ...nuw °1 amu rates and the Y w. 1. nJmlalm IN... lol. Iqs. need for additional follow• r. ara x. r, nh,,,, c,,,,~s,w. .r x..,.u~r . up time-at least five yean. Cuasid- rr" c°'^° •°e o,h„ x/.,,,y r.A ae.n4 a.e. . reMl-rrr tr.lr). IrIR

146 CIGARETTE LABELING AND ADVERTISING e.a. Lafi.a twam-ua: L'ss. w. ............................... . ++an 1'...,,J C+mp4.11. /. )I. Luna C.sa, U<Yb nma\.,..nJ 1.I LiranN, 'fhc vah,.n crc n so,5nrd with tlm Durreu ol Chronic Di,caas, Smm D.PUrP PeLllc IIeaL6. Urrkrln,, Calif. . p. . nrc ut.d L.forr a Solnt Sexien of Thu Amcdun In,ha.~'ial Thc InJu.vlal \Icdiral A.,nciatlnn. and the Occupmlonal IL-IiL ti,ninn of tIw Aoreriran Pnhlin Ileahh A...oriation at the EiehtPxventh A„noal \(rninq in Atlontic City, N. 1.. Octohcc 20, 1959. Smoking in Relation to Mortality and Mor_ 6idity. Findinas In First Thirty_Four Months ot Follow.Up in a In 1959 1. a Prospsct(ro Stud 9 Started 6. CUYLEB HAMMOND, Se,D.; S4Wtlwl R....rr:/J Se°tlun, 1f.dle.i .{ff.b~ Departrw.ns q/ tA. ,4..yNaw Q.we~/ Sscbty, /ne.r N.y Yri, Nw. Yari .. nepriuted from the JOURNAL OF TIIB NATIONAL CANCER INSTITUTE U.S. DEPABTMENp OF HEALTH, EDUCATION, AND WELFAItE ro°uc esu.'ru asa.ICs parlOL.c INi]'nvrps or nL...Tn 147 i4issszooi

148 CICARETTE LABELING AND ADVERTISING Smoking In Relation to Mortality and Mor- bidity. Findings in First Thirty-Four Months of Follow-Up in a Prospastive Study Started In 1959••t E. CUYLER IIAMMOND, Sc.D,t Statistical Raeeorch Seotton• Madleal AQetn Depnrtmane of the Amerfnn Gnwr Socfetyr Ine., Nev York. New Yori SUMMARY 1) After aneweriog detailed questioe 442,094 men. agad 4g-E9, wero tmeed for ao avemge of 34.3 monthe 2) Death rates were far higher in elge- rette .mokere than in nonemoken, higher in those who started cigarette smoking at a young ege than in those who started at an older age, and higher in cunenteigarettesmokere thm iu et- cigamtte emokera who hed quit far a year arlunger.-Death vatee increased with amomt of <igamtae omoking and degree of inhalation. 3) Death ratee from the following diseases were much higher in eigarette •mnken thao Io oovemakem e.neer of the lung, buwl e..eity, pft•rynr, laryn., eeophagua. bledder. and panereesi gastric ulmrt emphyeeruat und aortia aneurysm. Coronary artery disease death rates were highly rdated to cigarette smok- iog among mcn io the miqale-ege groupa but lees highly related among men In the old-aga groups. 1. age gmup 40-59• the coronary ertery diweaee deeth.ate wae 1.95 tima. o high amnng light cigarette amokers as among uou- amoken aad 3.00 timu aa high among beaey eigarttte emoken o among oon- amokera. 4) Death ratea of eigamtte emokeo and oonunokeo were studied In relatiun m many other factora, ench as bngerity of parents and `randpen- eaa, e.ueer In pareuY mud eibRngs, height, eremire, aleep• ram. raDgfoo, education, marital stp.tu nerrous ten. nd prior hietory of eertain die- e sn. W ithin er<ry group eu.died, the death mte of mao who emoked 20 or mare cignr<ttce a day was considerably higher than that of nonoNokeq. 5) Nonemokem were motchod inditidually with men who emoked 20 or mum ciga- mttcs per day, the 2 men io each matched peir being s milar tu ege, height, r.ee, nativity, religion, mar:ml etntus, reridence (urbeo or rueal), eer- taio occupational exposures, education, drinking habite, nervous teneion, uea of tranqu0ir<m, sleep, erereiee, health at time of enrollmenq and past history of cancer, beert ditetee, stmke, and higL blood ptcesure. Altogether 36,975 such pain wem found. During the st•.dy, 1,395 of the 36•975 cigarette amakere died, while only 662 of the nonunoken died. Of the cigarette emokem, 110 died with lung uncerand 656 with cor onary arterf disease, whik', of the oon- smoken, 12 died with lung r.neer and 306 with eoronnry arterr disease. Ern- phyeema caused the death of 15 eigae rette amokem but only 2 nonemoken. 6 T'he proportion of inen hosp:talimd during the first 2 ycaa of the atudr was considerably higher amona cigarette o•ookem th.n ameeg nonemoken and Inctesed with amount of elg•mtta smoking and degree of iahatatioo: ) Nat Caseer luet 02. 1161-11ag,1966.. . aealr•n D.mmks n. ttN. • vnrena u mr mexnu ei ta Amedm ueEUa A.wwi.c rntheE, On., D..mt.e 41tn. • TWt Yaay wre m.Ee p^eleie ai tht w^WUfm at a. reei•eu~ ~efinew wrrtar etar Awtwe n•neer aneHr, tnt~ ate mtmWs af Y AnWm aea nuol amlr min N tin AmMan Cnaar emetf~ taP. tlrtr MYik erputmNn raPPtrmr a.pr ol drte aounNr, utl mu) Petdeiror wEO taa0k•C uitomJi•° re el•mm• ef sumt of dr.la. Lanm eveobi. N.A, wr• M prY •t•elm m wlrtlng th• d•1. Alea Haa rop~rY•a tM mdleg sf entabeml•~ rW b1Yeq ntlYY laeoni ML kLA, reM kep, tN Httr 9eqvs u+rh0.nt u..npdw wr! z4Z9sszooZ CICARETTE LABELING AND ADVERTISING 149 PREVIOUS PROSPECI•IVE studies of inen (1-B) showed that death ratesc 1) are far higher in cigarette amokets than in nongmokera, 2) in- creuae with amount of cigarette smoking, and 3) ore lower in ea-cigarette gmokels thnn in cuxrent cigarette smokers. Certain diseases, such gg cancer of the )ung, buccal cavity, and egophagus, and gggtrio dcme, were highly aseociated with cigarette smoking, but about ha)t the excess deaths aegociated easu. with cigarette smoking were attributed to coronory nrtery dis- The present study is gimilor in generaj degign to the Preceding progpgc- tive studies but includeg a great mnny lnctorg pty.iong)y not, or only par~ tislly, covered . Since it fully confirmg the esrlier 6ndingg, I will concen- trate on new materialwhich includeg an analysis of; 1) death rates in relation to degree,of inhalation of tobacco smoke, 2) death rates in relation to the amoking habile of inen over the age of 70, 3) death rates among nonemokerg and cigaretta emokere alike in maqy charactgristicg other than their emoking h.bitg, and 4) hogpiGligatioa and the occurrence of certain digggegg in relation to gmoking habits. The study also provides additional in[ormation on the death rates of cigarette smokes in relation to the age at which t6ey bagan to smoke. PROCEDURES The design snd objeeUvee of the study, eome preRminary gndinge, and Informetioo on many oherecta4tita of tbe subjects (induding their smoking habits) hgw Eeen deeoribed eleewhere (7-13), The proredu.w an briegy outRned: ..Between October 1, 1959, and Febmvy 15, 1960, 6g,118 voluntaer worken of tka Ameriean Cancer Boeiety, Ing., enrolkd i,078,'g0( men and women /n a prqpeeDve etudy, care being t.ken to toniude s0 eegmeate Of the poWlaflon. - Enrollment wae by families (i.e., households). with the.peeigeation tbat thero be at leaet ons pereon owr the ago of 45 in eaeh family enrolled. AR mEmptnt of theee familiee over the.ge of 30 wete requested to fiB nuf detailed, oenfidential queetionndrEg Eontaloing queg0ooe 0o family hietorYr past dpeaeee, present phyeical eomplalnts, oteupaNoq oecupattooy orposuree, various habits, and many other faatota, Only Rliterafn, parune top 10 to anewer a quettionnaire, and ppenne who could not be traced were exciuded. Tbe eubjeetee were traeed annually and once every 2 years they requeetod to OB out a brief queeUOnnaire. Wbenever a doath wero wp reported, we obi.itbd a epPy pf the death BMta or local health dep.rtmenR Whm eanoer vi~s pyoDnned bbtologio eerOgcate tYp> from of the the neophym. on a deata OertifiEafe• we asked the dOetOr for Informgtfoa on the diagnoeis and the Tae study area includee 1,131 counties of all eiaet and typea lu 25 Btatee.t TiuN of nbeo euuntles did not eemplete the latest follow-up in time to be lodudad in this toport. Altogether 1,070,47~ eubJecta were eorolled In the other 1,11a eounthr, but 22,291 of the quaationoahea were unueabb beeauee of /ncompletenen, lack of proper IdeotifiEatluo, or bebauee the subject wag younger than 30 left a net total of LOtg,188 men and women eHeetively enrolled iu twhe yt1iq ~tpinyo.. In the third folio ~ p4(oh began ~~ 1.1~, ).1,0H7,07g (g0.0j6) 9[ thMaub)eota ~/ele meEew(y „ ~~~ LbmrnyYle~ i.esy4Na.~'Yaik,~p raoteey.IwWese,krtny, ~•~s.'hy, W YYMrie. ~•t. Ottr, enna. psa..

150 CIGARETTE LABELING AND ADVERTISING Thie report ie based on the recorde of 422,094 men between the eges 40 and 80, traced through txptember 30, 1962. As of that date, 19,208 had died and the survivors bed been in the study for an average of 34.3 months. The total experience for thb group cov<re 1,178,799 man-ycara, an eliowanm being made for deaths. - As s first etep in analysis, the subjects were divided into 6-year age grou W by data of birth. Theee datcof-birth cohorts will be referred to by the agce of the men at the start of the study. In Alinetances, we computed death rates eeparately for each 5- year cot.ort by dividing the number of deaths by the number of man-yean of expori- enoo. To reduce the sire of the tables, death rates will be presented for 10-year or broeder ago groupe. Theec rates .ro agebtsndardiaed, based on the fryear eohort rates etsndardised an the age distribution of all the men in the study. Since we did not emoll persons too ill to smwer a queetionnatre, death rates were , low during the first few months of the studyp and, lor the bmt 34 months as a whole, the death ratee were considerably lower than death rates in the total nrsle population of the United fitalce. Such temporary depression of death rates resulting from the exclusion ef ill persons from enrollment in a prospective study gradually deeressea with time (d). An analysis of smoking in relation to death rates during the first 10.3 months of follow-up was presented previously (9). Detailed figures on changes in death rates as the study progrenes will be presented after the aubjeets hava been traoed for anothqr year or two. MORTALITY BY TYPE OF SMOKING Tablo 1 shows the number of men, the number of deaths, and death rates by age and type of smoking (lifetime history). As in previous studies, mon who never smoked regularly had the lowest death rates and men with a history of regular cigarette smoking had by far the high- est death rates. Cigar smokers had somewhat higher death rates than nonsmokers. With all ageg combined, tbere was little difference be-n tween the death ratee of pipe smokers and the death rates of men who never smoked regularly. Two methods have been used to evaluate the degree of relationship between smoking and death rates. One method is to divide the death rate of smokers by the death rate of nonsmokers to obtain a morfality ratio. The other ie to subtract the death rate of nonsmokers from that of emokern to ascertaio the difference in death rates. Text-figure I ehowe the results of each of tbeae two procedures for men with a history of only cigarette smoking compared with men who never smoked regularly. - In age group 40-49, the death rate of inen with a history of only cigarette emoking was 2.37 times eB high es the death rate of men who never smoked regularly (i.e., the mortality ratio was 2.37). Thia ratio declined with age to 2.01 in age group 50-59; 1.66 in age group 60-69; 1.49 in age group 70-79; and 1.18 in age group 80-89. On the other htmd, the difference ia death rates between cigarette smokers and nonsmokers in- creesed with age up to age group 70-79. For example, in age group 40-49 the death rate of inen with a history of cigarette smoking exceeded that of uonemokere by 347 deaths per 100,000 man-years. In age group 70-79, the death rate of cigarette smokers exceeded that of nonsmokers by 2,286 deaths per 100,000 man-yeare. CIGARETTE LABELING AND ADVERTISING 151 Tasaa 1.-Number of men, number of de.the, aed agp-etandardfsed death rates by type of smoklna-(6tetima history) sha a8a at start of study Type of smohing (lifadme bietory) Age 40-49 Ago 60-E9 A 60-69 840-69 1 7079 Bo-~g9 Never smoked Number of ineo rglrly Pi e on 24,666 03,514 21.890 79,009 10 273 2 222 p 1 Pipe and ci sr 2,689 2 4, 012 3, 628 10, 328 , 2, 276 , 612 g Cigar onl ,583 4,756 4,221 11,560 2 354 523 y Cigarette and 3, 893 7, 229 6, 298 17.218 , 2. 864 688 other Cigarette onl 20,692 67 37.775 21, 622 86, 889 6,200 684 y Unknown ,328 174 80, 107 3$ 313 179, 748 7, 1S0 661 Total 127 glb 342 276 702 1;2 3b . , 767, 736 90, 166 38g, 606 31.274 6, 315 Number of deaths through September 30, 1962 Neveremoked regularly Pi l 177 625 1,172 1 974 1 293 64 pean y Pi e and / 13 87 228 , 32g , 271 8 172 S, 015 p o gar Ci ar nl 27 91 227 345 330 154 771 o y g Cigarette and other Cigarette only 30 359 1 I4 161 1,171 38E 1,570 682 3.100 378 964 7e8 201 829 1,126 4 265 Unknawn Tofal 8 , 1, 782 $ 913 6, 060 2,1 0.32273 6,71378 13, 139 7. R13 4, 505 2113 0 1, 604 , & 247 10.208 55 Never emoked' Death nke per 100,000 man-year. (age.atendardixM) regularly Pipe onl' 253 17 652 1.899 812 4.621 11 857 1 228 Pipe and et r 1 36 754 2, 200 900 4, 374 . 11, 254 , 1 282 6e Ciod Cigarettev:ud 9 ~3 663 767 I, 88b 2, 17g 848 963 5, 118 4, 834 11, 869 11, 471 , l, 29g 1, 368 other Cbrarette onl 475 60 1,005 2, 832 1255 1 5, 9D7 12 469 1 742 y Total p 131l 3, 143 1, 506 0, 906 , 13 056 , 487 1, 060 2,546 1.2 23 6,427 , 12, 087 1 B6g Within the category designated "men with a history of only cigarette smoking," the lifetime bigtory of expoauro to cigarette smoke varies with age. For example, there are more ez-emokers and fewer current smokers in the old-age than in the middle-agegmups (11, IS). Furthermore, etate ot health has a considerable influence on whether a smoker giveg up the habit, and this varies with age (1d). Among those still smoking, there are more heavy smokers, more deep inhalerss , and more who took up the habit early in life among men now of middle age than among men now old (11, 12, 14); but old current smokers have generally been emoking for more year6 than have young current smokers. This, together with the problem of selective mortality, makes it di@icult to interpret the changes in relation to ager Be shown in teltt-6gure 1. A more detailed analysis will be made after the subjects have been traced for a longer psriod and may throw more light on the gubject. Cigarette Smokera The relationship between cigarette smoking and death rates can be m9et readily studied among men with a history of only cigarette smoking. 40.gp - 02, 464 13,217 14,437 20,070 02, 779 1g7, bb8 969 472, 094 E4issszooz

152 CIUARETTE LABELING AND ADVERTISING MORTALITY RATIO L!. NMg D6rfBENtC W ~ AeL N tCMe 0 1244 >a r I~ A6E MeYEANB "n r-r . ..en.....w,.ww.o T.xr-naoxs 1.-MnrtalitT ratio: death rata of inen with a historY of oul7 cigarette amakmg divided br death rate at mea who never amoked regularl7. DiHereaee (in death r.te/100,0D0 man-Yean): death rate of inea with a histalY of only cigarette lowking mluua death rate of inen who never amoked tegohvly. Theee men were divided into two groups: 1) "currentcigerette emokets"- thoae who were smoking cigarettes regularly at the time they enrolled in the study, and 2) "eacigerette smokers"-those who had stopped smoking before enrollment. Findings in these two groupe are eummariaed in tables • 2 through 5. As in previoue studies, the death rates of curtent cigarette emokere increased with the number of cigarettes smoked per day (table 2). This trend was most pronounced in the younger age groups. In age group 80-89 there were so few heavy cigarette emokere that the death rates were unstable statistically. The relationship between death rates and current amount of eigerette smoking is illustrated in text-8gure 2 in terms of mor-s tality ratioe for men between the ages of 40 and 69. We computed these mortality ratios by dividing the age-standardized death rates of the cigarette emokere by the age.tandardigod death rates of inen who never smoked regularly. In eeveral retrospective studise of smoking in relation to lung cancer, • emokers were asked whether they inhaled (15-18). Data from the first of theee atudiee (15) gave the impression that inhalation is unimportant in respect to lung cancer, but data from later retrospective studies (1B-18) v4T9sszooT CIOARETI•E LABELINO AND ADyERTIBINp MORTALITY RATIOS TOTAL DEATBS =./e AGE 40-69 ..ar ~ I ~ 153 MlKw p e H Marn m-U Io! ~aWll• neaelalr;4[TTalW,Eaee1 T.xnnaoee 2.-Reletione~hlp between death ~~d eurnnt amount of mpnl,y .mokiua ln tenon o( moryBtr ntqt rar .grM4D.ad69. T•RLa Z--Age+i.nd.rdind death n amoker. with hbrorY of oNF olaerette e~kln0'~ men-ya.n of eunent .mokeil regyl.rlr an ahewn )or oamth ntr at mm wpa novsro wrhaa M{e at .tut of atudy Amount, Inhalation aod Bua a9e at etart of woLhig 40..49 6p-gp s0-ep *0-69 Wtel _7. 7D9 e0-n 40-89 Total, curteot cipntte - -emokerc - - 643 I, Numher pec day 1-p 10.1D 411 a,337 1,810 7,010 15.012 a,17a 146 ~~ 1,351 010 a, gp9 1, a76 e, bla 14, 859 z0-3D 597 40+ 640 I 3, z71 I,aaa l. 828 J.a17 s~ 3z,4ab 468 l1,,774 ssa 6.000 DeKree of lnhahtkxo 772 1. None 7, 0811 lal3n, 4J4, ,,e4a 4J4 Y,tbe ana 8light BZS t. IA4 a, a9b 495 1 Deep 1, 330 A 887 11, 7a8 7,777 Modenta 306 3,305 1 667 1. 404 , 608 8, Da7 827 14, O8a 1 aa, ' 3gei i~ ebe e, !s, co4 Ag aet taet at eoqqna eJa .a4o so4 9, + sas at.a4a 1a~-iY ~~ $ 4a4 1 160 a 684 <la 712 i, : 3a7 g;eae ia+ns i:9z.B 727 1 703ioo a: ~ 745 eea 1 741 7. 7Da la. 780 $ 560 869 9, a8a I8.14a Ragl Never emoked ngularl) 253 652 ~enl!leYelethlspeeF 1.809 j 812 4.871 li ~9a7 f.7a9 gave the opposite impresksion. No inforumstion on inha]ation 1s svailable f Some smokenCdeliberate Previously undertokeD (1-8).t eome tend to take it on y drawIu~ ke deeply into their lynge and ~ NtO ~B°' The latter , genernl(yssythat Po~H~ettif.lluteol~rlF.~r 1 l/wuu~re.~~'r4Jrbea,aay,.yw~k...b,a IMr IakrYd Itrlyy~M'~etne wke~lt ry /kq4M w. I~~y~V ~ewrrltrrM

154 CIGARETTE LABELING AND ADVERTISING they do.not inhale (although they must inhale eome emoke). In thie study, current cigarette emukere were asked: About how much do you inhale whon smoking cigarettes? Do not Inhale 0 Inhele elightly O Inhele moderetely O iuhale deoDly 0 Table 2 and text-figure 3 show increase of death eath rates with the degree to which cigarette smokers eaid they inhaled. For example, among mon between tho ages of 40 and 69, the doath rate of cigarette smokers who said they did not inhale was 1.64 times ee high as the death rate of non- smokers, while tha doath rate of those who said they inhaled deeply wna 2.22 times ae high ae the death rato of nonsmokers (text-fig. 3). The relationship between death rates and degree of inhalation increased with age. In age group 90-79, the death rate of deep inhalere wae only slightly higher than the doath rate of men who said they did not inhale, but in older ago groups the death rate ot deep inhalera wae much higher than the rate of inen who said they did not inhale. 2.5 ,e MORTALITY RATIOS rrr TOTAL DEATHS 1fe AGE 40-69 ~aa 1.44 nn ' ~~ L_1 .._.LL...L_t.. IL-N eeln YMMT Y-QIYte erV WeeFe - eewLMLY Y[GeF[Orwalatpe p aCM[T]r 9YOe[ Tsxnnouns 3.-Relatlonehlp between death rates and degree of Inhalation in amma of mortality ratloeTor maa between tget of 40 aad 60. Table 3 ehows death rates of current cigarette smokers aged 40-69 in relation to both number of cigarettee smoked per day and degree of inhela- tion. Among men smoking the gpme number of cigarettes per day, death rates generally increased with degree of inhalation. Among men inhaling to the same degree, death rates generally increased with number of cigarettes smoked per day. Current cigarette smokers were asked at what age they began to emoko. Their death rates were found to be inversely related to the age at which they started the habit (table 2 and text-fig. 4). For example, among men aged 40-69, the death rate of cigarette smokere who started smoking after the age of 25 wae 1.42 times ae high ee the death rate of inen who never smoked, while the death rate of those who started smoking before ' the age of 16 wae 2.29 times ae high as the death ra4 of men who never smoked. s4tssszooi l;.igerettee Per day CIC'>RE1TE LABELINQ AND ADVERTI6INp o( ou 8`A 8~ toardIred doah retce pur 100.000 m.a- smoki~t ei mokcre with cu-rnmt an e~ 4~0 at eteriit°ry of anly i4gerot~ moYnt of emOklag aod ds f etudY cleseilied b greo of inhaieYea y 1-9 10-I9 20-39 40+ Tbta7 Deerae of Inha4tion Noue 6light Moder.N ~ Vggg - V Total i; s~a 1 664 i; 6s~ ~.g~ i'9ea i;619 aao I; 1: e°e Table 4 ehowg death I 403 I. 671 1, 801 2,003 l. 60>f I'27g Ias2 1: 652 1 774 7, 610 i55 clgerettee smoked per day and age a e~9 in relation to both number of meR who smoked the same number of h they began te gmoke. Among mOd'~g 4h0re~ 4 azt~e agema ~ aoe d~ner°gBillo~ma B ym ~ who ~ d igarettm d per day, de We have conaidered .. generally in~eae~ with number of extent of exposure tbreO variablee, all of which ,na~ of inh 8~ y~edemoke: number of cignrette~s ag ~~ the ~~ eaeh variable and a at etert of emoking. Death rntoa inter'ulated• For exemple, men wh ° coneiderable extent generally tend to inhale the o amoke many ci they were fewer emoke more deeply than do ~t~e ~ day begm ty~b~a~ d~Yn(I1, 14)• Furthermp m who emoke per da B age re• cig td emok )•ter iu lif0 (I,E), °~ s0eep~t j•D~ea bo begin the habit.omewhst 'mpO~•nt, eioee it is not oDl ~tte smoking eeeme particularl +Dh.i.EiuDU and a„m~ f r~agu°e°ttes•am° d a Teer d•~&w~a nf 0 AGE 40-69 i - asr ta Loo aeYER ba - ' " ~ u"' .n fa106-t.rm. q 4-Relatfonehip 6et ~~ t~rr[ M~amg . morf.lfty r.tfoafor meo~b.t~ nyew, 01 iD~ed E rott• smokia• 11,0111,11 I ~op

156 CIOARETTE LABELING AND ADVERTISING TAeta 4.-Age-etandardised deatb rates per 100,000 maa-yean of current eigamtte emakem with hietury of only eigamtte emokmg. Men aged 40-g9 at start ef etudy elasei6ed by eurmnt smnunt of smoking aed s8e smoking was begun Age emoking wm begun Cigarettes perda7 25+ 20-24 - 15-19 GIg Total 1-9 961 1,039 1,589 1,407 1,279 10-19 1 226 1,324 1,642 1,679 1.552 20-39 , 1 203 1,420 1,750 1,871 1,652 40+ , 1,247 1.376 1,097 I, 899 1,774 Total 1, 160 1,367 1,741 1,860 1,610 Table 5 shows age-etandardimd death rates of excigarette amakers aged 40-89 in relation to the number of years since they last smoked and to former amount of smoking. Rates for current cigarette emokere and for men who never smoked regularly are shown for comparison. Among ea-cigarette amukers who previously amoked I to 19 cigarettes a day, the death rate decreased steadily with years since lasb smoking. Even those who had given up the habit less than 1 yoar before ennllmeos in the study had lower death rates than men currently smoking I to 19 cigarettes at enrollment The most striking finding shown in table 6 ie that, among men who amoked 20 or more cigarettes per day, the death rate of those who had stopped smoking less than a year before enrollment in the study was considerably higher than the death rate of men gnloking cigarettes at the time of enrollment. However, the death rate of the excigarette smokers decreased with length of time since last srmoking. Those who had stopped amoking for over 6 years had lower death rates then current cigarette amekere. This was found in a pnvioue study (t).. As described in (15), the explanation followe; I1lness most often leads a amoker to give up the habit. Thus recent ezmtokers, ae a group, include a high proportion yre of er-cigantte emoken T"ta 6rAgastandudised death rates per 100,000 man- es with history of unly cigarette smoking. Death rstee of curteot cigarette smokers with history of only mgamtte smoking and of men who never smoked an shown for eomparmon. Men aged 40-g9 at start of study Smoked 1-19 uigarettes Bmoked 20+ eiga[efMs aday aday o mm of deaths rate of inea of dedoke nto &s-emo ~amtfe amokmg) loo 221 2 <1 1-4 1,118 2 755 40 99 1, 327 1, 247 e3', oso 366 , 1, 718 5-9 , 2,552 79 1.077 8,688 287 1,229 10+ 6 962 129 703 10, 788 334 1 008 , Total e:-amoken• 12, 277 347 955 31,054 1.172 , 372 1 Carrent eiZamtta amokerl 31, 6/3 1, Aea l,'+oa 97,778 3.703 1, 6113 Never emoked tegulady 79, 9g9 1,074 813 79,069 1,974 812 •grmbartetWntamE.MrweYSYM nW W n.aaMa s4issszooi CICARETTE LABELING AND ADVERTISING 157 of inen in ill health. In wnsequence, the death rates of ex-heavy cigarette smokers aro very high during the succeeding few yeare. Since this eelective effect gradually diminishee with time, ex-smokam who gave up the habit many years ago do not include so many men in poor health. Thore is a corollary to this finding. When a cigarette smoker fn ill health gives up the habit, he is thereby removed from the class of inen designatedae"currentemokeraP Thereeuftofthiaiethattheeubeoquent death rate of the group designated ae °current amokers° is lower than it would be otherwiee. In addition, ill health often loade a heavy cigarette smoker to reduce his daily coneumption of cigarettea (1J), This removea eome meo in poor healtk from the claae deeignated as ~,eurrent very heavy amokere^ and further reduces the death rate in this group. Pipe and Cigar Smoken Pipe and cigar smoking is now far less common than cigarette gmokiog and relatively few subjects had a history of only pipa smoking or only cigar amoking. For this reason, the age-epecifio death rates for these emokers were rather unstable statistically (particulsrly in certain age groups) and a highly detailed analyeie e€ the data is not warranted. More detailed figures will be reported when the subjects have been traced for several additional yeace and mon deaths are available for aoalyeis, fluence Table 1 on e6 the ows likelihood pipe and cigar emoking appears to have relatively death ratee, However, ill health has considerable in- elihood that a pipe or cigar smoker will give up the little t 08). influenceuence on Apparently bacauae of this, ex-pipe smoken had tiighelr death rates than current pipe gmokers, and ex-cigar smokers had higher death rates than current cigar smokers. This is shown in table 6, which is confined to men between the agea of 56 and 84. Most pipe and cigar smokers said they did not inhale the amoke. Among those who did, most eaid they inhaled only elightly; some said they inha)ed to a moderate degree; and very few said they inhaled deeply (1!). Current pipe and cigar emokera who nported at leaet some inhala-. tion had higher death retee tban men who never smoked regularly and far higher death rates than pipe snd cigar smokers who ewid they did not inhale (table 6). Ameunt of pipe or cigar smoking eeemg relstively un- important as compared with whether the smoke is inhaled a6least alightly, CONTROL ON. OTHER VAR(ARLES It eeems likely that other variableg influence the degree of aes.ociation between oigarette smoking and death rates. Tu investigate this ponsi- bility, we divided the subjects into various groups, each group identified by some partioular characterietic. Within each, we ascertained the death ratee in two subgroupe; 1) men who never smoked regularly and 2) men currently smoking 20 or more cigarettee a day at enrollment, The latter 45-819 0-65-p,. 2_I1 Z&

I 158 CICARETTE LABELING AND ADVERTIBINa I 1 CICARETTE IdHELiNp AND ADVERTIRINp ~ 159 TAew 7. Age.et.odardiaed death ratce per 100 000 meo, aeed 40-69. Mco who never smoked regulariy man•yos,e comparud w for ith varimouous surrently emakiag 30 or mom ei ar eroupe of _ e etW a day at Qme af enrollment TAU,. e.-Ageatanderdiud death ratoe per 100,000 man-years of men with history of only pipe emoking, men with hietory of only cigar emoking, aod men who never amoked regularly; agee 65-.64 at etart of study Smoking history Number o/ nwo Number of deathe Death rate Pipa emokem (toteq 8, 206 654 2.238 Ex-pipe emoken 2.388 236 2.792 Current pipe smokeo (tutal) 6, 818 418 2,012 1-8 a day 3,338 266 2,031 10+ a day 1,091 13l 1.643 No inhalstion 4.090 278 1,874 Some inhalation 1,382 108 2.408 CIger emokem (totep 13,246 987 2,347 - Ex-eigar emuken 4,272 406 2.703 Current eigar smoken (totN) 8,974 581 2.150 1i p dey 6,299 421 2, 120 6+ a day 2,556 147 2,135 No inhaletion 7,235 430 2,044 Borae intialabn 1, 384 110 2,695 Never smoked regularly 48,962 3,243 $ 113 Nal.eme emlanl aot.r 41d aetMW eeeaet re me W aet rlYedeYes efklbeYlNa subgroup included men who smoked only cigarettes and men who smoked cigars or pipes in addition to cigarettes. The results are summarized in table 7, which altowg age-gtandardir.ed death rates of men between the ages of 40 and 69. The variables studied ware: longevity of parents and grandparents; cancer in parents and gib• lingg; age of mother at birth of subject; number of siblings; height of subject; religion; education; race and nativity; certain occupations; place of residence and occupational exposures; frequency of fried foods eaten; degree of nervous tension; use of tranquilizers, laxatives, and antiacid medicines; history of disease; marital status; amount of exercise; houre of sleep; degree of baldness; circumcision; and years lived in present neigh- borhood. Altogether, we studied 85 groups of men as identified by these variables. Within_ every group, the death rate of the cigaretto smokers was substantially higher than that of the nongmokerg (table 7). Most groups are adequatelp identified by brief legends. However, a few require further explanation. yonpspiiy.-'ihe subjects were asked the age (or age at time of death) of their parents and grandparents. Fifty-five percent were able to give the approximate age of both their parents and two or more of their grand- parents. A subject is more apt to know the age of a grandparont whom he knew than a grandparent who died before the subject was bnrn. Therefore, it seemg reasonable to suppose that ages are more likely to be recorded for grandparents who lived to an old age than for grandparents who died at a relatively young age. For this anal.ysig, long-lived families were defined am follows: 1) the subject's father or at leagt one paternal I tlppen---- las -f---V - r.mllr blelv lnpouwa ~(wenq araeap,r. .ale) r ehert-e.M Ibv.em, PaeCy.w e.nYl eennr 1+ (p.ney UNmp) C,nvr r+ fn.vnla Ybay.) lnnrunC;aaooeM ebor4awd+aour AIe1N mMh.YNMMeuUset >o-N as-Y Io-N YNe1ev Nuuler N hvtbe,r M rhl.. Nabe 1 9 aYONe NUlbtof rab}Y 0aryv) UeeNN eew nFu »aa Nf Arnwyed.W Iree Ee.J vw• New Ctv. tllr Iwkvl~ ~e ter ou 7ee Nn e14 dr. LeN Lan Luo Lna Lsl Lerr• m fe1 ~ rte fae am fN ~ 1.8211 l.Ir. L<m l,Ys LYr Lrn Le! LIn I,Nr Deeau~ Im o== pYu e/,a,lGqp pe eqepatyay eapqun aaM A{eybudvdne4 ..dFlb4le,'.. Ne.ee Cle.. iNUee1 m+~ fee, uy eq 'tb.n w. aeur~ee amalti Ile UeeY..eqme aN 'h.e er ybvp-.a„aq,~Y arav,u. l,ebr l,eer rro 1,Y6 ellr-®pnOW..04~YM eN I.eW fY LAa rMeeve bWarr YY Ne aYecme c.wY+rr rnmen D-rt^A aeatkN, wt.mm.a. r.4alNa Naee 1-fUmyawa Les 3.111 Iu I,IDa Mal Lmo nu l.tle ® LYI rAe 1.QY l. e1a Lrer laa IN fee eN Ltor Len Lp1 1./0 t.w LaN l,m 4u1. 1ee er. LIeM Lola ;la toa t a Yan Y pn.N Nyhkp,ass, U wu° • le+" D.ofeemmeu.ykyv 'n.aaouwa N.UanVeyhna t/rYl..e Ne laothr Anu.ud,eqlrlav No eatkdll m.4kyN ati om• Lero =.nr.b H rN' Llra Nnn. le-Ir an Lme ellebt ap} mt I.Nr s.eN,sy NatnThr.reerr a1e LNI n<arr Mm°.° m e0e^ap erYet tkr YbYe a, b, v a L.eNe aYT Yal Lem LIIN 3fiU• 1,YM r.NM ne raT LYI LMS• L>Y• ae L71a m LIM rl1 LYa rl Ln1 rN• LUe• Nr LNr eee r.eee o~ ew k~ ~ LeMear,MOMrqela UAYrrrywtppmµqereL y>taeeb.paebreba 44issszoot

160 CIGARETTE LABELING AND ADVERTISING 'P.nu 7.-Ageatandnrdired death raten per 100.000 mso-years for various group. of m®, aged 40-69. Men who n.,ver amoked regularly compared with men currently emoking 20 or more cigarettes a day at time of eamlammt-Oontinued Ars.md.NWJ a..unW Nrv meW mntae mF r nmmmrruEYWr nNWlr W A{a+IVW..dlua Ee.o nW CIM Ne e relW metd +• bee/amlaeywe wwwb aEy eWe ps) 9.mm. q ;oID• ;m. Naw 1!r 4no I 1. 120 ;YM aWel ~ Yl I.nr . ea taa ateer.r ss r,rs 1 al! L 'U1 MYN Y LY4 . eu yra . On Lfs o4.+m.am le} l.r,p %M. nunpbWltlNOVOW Yr LIN eosb.ekb /M 4W nemameYN Nr 4rN NIn Tb~.rl.wMmrl.m penpuwpttWw WwW tiq~e. 'USrI~ErNa.f.00taµmr. wn.WO..ee~~pYrMr,rmm Ja.Irl~emW,uuo~Am .m. grandparent lived to 80 or older; 2) the subject's mother or at leset one maternal grandparent lived to 80 or older; 3) neither parent died before 60 and at least one parent lived to over 70. By this definition, there had to be long-lived progenitors both paternally and maternally. Shorb lived families were harder to identify. For this analysis, relatively ahortd lived families were defined as follows: 1) subject stated the ages of at least one parent and two or more grandparents; 2) none of the progenitors for whom ages were stated lived to the age of 80; and 3) at least one parent and one grandparent died before reaching the age of 70. Residence and oerupatfonaf Aietury: The subjects were divided into three groups by place of residence: 1) rural as defined by the Bureau of the Census, 2) "town or suburb," i.e., residence in a town of 2,500 to 49,000 population or in a small town or rural area in a metropolitan county, and 3) "city," i.e., residence in a city of 50,000 or more population. The "town or suburb" dwellers and the "city" dwellers were each subdivided into two groups: 1) those who stated they had been occupationally exposed to gases, duets, fumes, chemieale, solvents, oil products, %rays, or radio- active material and 2) those who said they had not had any such exposures. Nervous teneios. Tbe following question was asked to obtain the ntbjectb self-assessment of "preesureo or "nervous tension": Many people oompl.ln that their work or bom"tuatfoa putr them under pree.ure or nervoml tension. How muoh prer.ure or nervous tenton do yeu fsel you sre under? None 0 . 88gat 0 Moderate O Severe 0 As another way to identify people presumably suffering from nervous tension, the subjects were asked whether they used tranquilizers. Dfeease Aietory.-A list of diseases was printed on the questionnaire wd the sqbject was asked to check any he bad ever had and whether be e4ts(;szooi CIGARETTE LABELING AND ADVERTISING 161 was "sick at present." Wo divided the subjects into two groups: 1) men who said that they were "sick at presenV'or had a history of cancer, heart disease, stroke, or high blood pressure_ and d 2) men who answered those questions negaLively.-fixercfaa.-The subjects were asked: How mueh erereiee do you get (work or play)? None Q Slight O Moderate 0 Heavy 0 Those who chocked "none" had extremely high death rates. This might be because eerious illness can prevent exerciee. Therefore, the analysis in relation to amount of exercise (table 7) was confined to men who said that they were not "sick at present" and had never had cancer, heart disoase,etroke, or high blood pressure. As would be expected, death rates varied with many factors studied. For examplo, death rates were far higher among people sick at the time of enrollment or with a history of certain eeriove dise.ees than among people not sick and without a history of these serious diseases. Death rates were somewhat higher among men who itsd not been to high school than among men who were college graduates. Within each of the 85 groups studied, the death rate of inen currently smoking 20 or more cigarettes a day was considerably higher than the death rata of inen who never smoked regularly. HOSPITALIZATION AND DISEASE At the time of the second follow-up (which started on Oct. 1, 1961, but took many months to complete) all the surviving subjects who were traced were requested to anewer a second questionnaire (text-fig. 5). Approximately 96 percent of them did so. Table 8, confined to men between the ages of 40 and 69, summarizes the findings in relation to the smoking habits of the men as reported in the first queetionnaire. In compiling this table, we assumed that all the men who died before the second follow-up were hospitalized between the time they were enrolled in the study aad the time of their death. We counted diseases reported on death certificates of those dying before the second follow-up and diseases reported on the questionnaires filled out by survivors. The relationship between smoking habits and hospitalization was essentially the same ae that between smoking habits and death rates ae previouely described (table 8 and text-fig. 6). For example, 14.4 per- cent of the men who never smoked regularly ware hospitalized; 19.0 percent of all men with a history of only cigarette smoking were hospital- ized; and 22.0 percent of inen currently emoking 40 or more cigarettes a day were hoepitslized. Among current cigarette emokere (with-a history of only cigarette smoking) the percent hospitalized increased with number of cigarettes smoked per day and with depth of inhalation and the per- cent hospitalized was greater among men who started cigarette smoking

162 CIGARETTE LABELING AND ADVERTISING .` .nc ~ r.Na..,..bw.rnNW.Nw..rN/..,W oU.Y«tMSrr T.r0 rYO YI a.nldl j i. /1... rw Md . swriesl .M,.r:..Yw aY~t. HS.r r.f D Ne D i a •rsl[ .I l/N.1.r.n,NwN1: . !1 wnb~~ Y._.ty_N. O . H asi. el r'n., ,nwn.n,e lxa..peMd.p.s.r.ulwrNnerarMe.dnbrl.rrS.r Y.r0 H.O--- n •m': WF.1 4fnn,..r TaxS,nouge 6.-Seeond folbw-up qutetlonnaire (started In Oct., 1061) on hes-' pita9tatlon, operations, and serioue Aieeeeeo accurring siaae October 1, 1969. before the age of 15 than among men who etarted at an older age. This pattern was found in every 5-year age group from 40-44 through age group 85-89. In the analysis just described, men who died were included with men who eaid they had been hospitalized. This had little effect on the findings (table 8). For e:ample, in exactly the game analysis (but excluding men Tana 8.-Peruent of inen hmpitnliaed, percent reporting cancer (other thsn skin cancer), percent reportieg heart dieeue, endpe reeat reporting gaetrle or duodcnal uleer between aart of study and eecond follow-up (apProdmately 2 yn)~M~~ aged 4U-e9 at start of study. Perceutagre w staud.rWaed for age 8e.a detai4 mnktng k,alt. - Percent hoep4 f+Rred Percent reporting canoer Percent roporting heart dieeeee Percent reporting gastric or duodenal ulcer Never smoked regularly 14.4 0.44 1.38 0. 39 Cigar, pipe 16.6 .49 1.67 .40 Cigarette and other 17.9 .76 2 46 .65 Cigarette only 19.0 .gY a 7a .70 Current cigarette amoken* 19.4 .91 2 96 .77 1-9 a day 16.5 .76 4. 10 .67 10-19 a day 18.1 .78 2 69 .69 1039aday 19.7 .96 3.09 .90 40+ a day - 22.0 1.13 3.26 .94 Do not inhale ' 16.8 .74 243 .69 Inhele elightly ' 17.7 .81 2.68 .72 Inhale moderately 19.2 .90 3.00 .7g Inhale deeply 21.9 1.04 8.36 .gg A c emokl waa begun Y6+ ~ 1& 9 . 64 172 .60 20-24 111. 3 . 81 2.71 .74 16-10 19.9 .98 3.08 .76 <16 21.3 1.06 8.1g 1..06 'waY . hMSr rf eelr rlprrrq ava W M. CIGARETTE LABELING AND ADVERTISING 25 PERCENT OF A1EN HOSPITALIZED WITHIN TWO YE4Rg IAqe 6roup 40-69) I eTs 163 ~LI~IIIIIk~~~ ~ M.a. ^KNr '• a-n :O.rf - s+o.ea :w. . o.. o.. c.. errLLMLr ORY ~ - cuurrre wau.. Taarnuoaa 6.-Relstiomblp betrveen smoking habits and honpitaliration. who died), 13.2 percent of the men who never smoked were hoepitalized; 16.8 percent with a history of only cigarette smoking were boepitalized; and 19.6 percent currently smoking 40 or more cigarettea per day were hospitalized. In this analyeis, we were interested in the incidence of certain diseases rather than their prevalence. Thus analyses of cancer, heart disease, and gastric and duodenal ulcers were confined to men who on the first questionnaire said they had not had these diseasea up to that time. The percent of men reporting these diseaeee (or dying of these diseasea) during the first 2 years of the study wag considerably higher among cigarette smokers than among nonsmokers and wee related to amount of cigarette smoking, depth of inhalation, and age at which the subject began to smoke (table 8). Obviously, the reports of people on their own illnessee are not always correct. However, judged from the phraseology of the answers, many subjects must have consulted their doctor before answering the second questionnaire. For example, many gave the technical name of an opera- tion and many specified the histologic type of cancer. Granted that the dieeeee named by a subject may be incorrect, subjects who reported they had cancer, heart disease, or gastric or duodenal ulcers were almost cer- tainly sick, even though in some cases the_ diagnosis may have been other then what the patient supposed it to be. CAUSES OF DEATH AO the beginning of this analysis, we had obtained copies of the death certificates for 18,224 (96eJo) of the 19,208 deaths among men between the egea of 40 and 89. Deaths were elaaeified by "underlying wueer' ao- G4T9G9%OOt

I I 164 CIGARETTE LABELING AND ADVERTISING cording to the rules of the International Statistical Classification of Diseases, Injury, and Causes of Death! Except for cancer, this was based on information on the death certificate. When cancer was reported un a death certificate, we requested the certifying doctor to inform us of diagnosis and the histologic type of the neoplasm.. At the beginning of this analysis we had received replies from 77 percent of the doctors. In some instances, the doctor amended the death certificate, and in such instances we classified the death according to the doctor's information. As mentioned earlier, the total death rate of pipe and cigar smokers was not much higher than that of men who never smoked regularly. However, as shown in table 9 (confined to men between the ages of 55 and 84) the death rate of pipe and cigar smokers was considerably higher than that of nonsmokers from certain diseases, euoh as cancer of the buccal cavity and pharynx, larynx, and eeophague,and gastric ulcer. This finding is based on a rather small number of deaths from these diseases, but it is consistent with findings in previous prospective studies. The lung cancer death rate wae higher among pipe and cigar smokers than among yean by underly ogor+ueetof death. Menawho 0o ereetmoked ngularly wmpamd ~ }ged with thoee with hletory of ptpa or eigar~ing who aever emoked oigarettes; Never enwked Hislor~ ~~;pe or ..regululy_ only CIOARETTF, LABELING AND ADVERTISING 165 nonsmokers, but the death rato from this disease wae much lower among pipe and cigar smokors than among cigarette smokers. This_ is also con- sistent with findings in previous prospective studies. - Table 30 summurizes the findings for men who never smoked regularly and for men with a history of regular cigarette smoking (regardless of whether they also smoked cigarv and pipes). We calculated mortality ratios by dividing the age-atandardizud death rate of cigarette emokere by the agewtandardized death rate of nonsmmoke5s. The deuth rato of cig®rette smokers was several timee as hlgh se thut of nonsmokere for the following diseases: cancer of the lung, buccal cavity and phatynz, larynx, esophagus, bladder, and pancreas; emphysema; gastric ulcer; and aortic aneurysm (noneyphilitic). For several other diseases, including coronary artery dieesee, the death rate of cigarette emoken wae considerably higher than that of nonsmokers. Cancer In some instances there was doubt as to the primary site of cancer. At a later date we will present data for cancer deaths by primary site and histologic type separately for thoee cases in which the diagnosis was based on firm evidence and for thoee cases in which the diagnosis was based on less certain evidence. We cannot do su at present becauee we have not yet heard from all the doctors from whom we have requenlsd this infor- lnation. Number Number For cancer as a whole (i.e., for all sites combined), the death rate of of ' Underlying oauee af death deaths Death nte of deatbe Death rate cigarette smokera was coneiderably higher than the death rate of non- smokers, tbe mortality ratio being 1.98 in age range 40-69 but somewhat ncer (tot.l) C 485 828 385 0 887 80 less (1.75) in age range 70-89. Most of this difference was accounted for by the high death rate of i t a n L 23 17 3 3 c garet e emokere from cancer of the lung, g u Ruccal cavityi pharyax 4 3 12 1 4 buccal cavity and pharynx, larynx, esophagus, bladder and pancreas Larynx 2 2 2 2 ~ 6 , . The relationship between cigarette smoking and death re0ae from lun Eeophagua ~ Other eites 454 302 338 834 g cancer appears to increase with advancing age. For example, in ago (totrl) d t irculator 1 ~ 1,485 1,418 group 40-6D the lung cancer death rate of all me_n with a history of ciga- an c y Hear Coronar 1 801 4 9 907 955 1e1 rette smoking was 7.86 times as high as that of men who never sm k d y h h t 245 165 174 o e , while in a e ro 70 h ear Ot er Cerebral vaeculv 383 236 2 8 231 g g up -89, t e mortality ratio rose to 19.07 (tablo 10). Thi b Other ciroulatey 118 78 s was ecause the lung cancer death rate increased greatlywipl Other disemee (totaU 3 O 230 7 271 10 263 9 advancing age in cigarette smokers but increased very little with advancing age in nonsmokers - . Emphysema 86 31 . pneub,nNa;lnflueua r i l 63 6 81 4 12 11 For the entire age range 40-89, the age-standardized lung cancer death ce Gastr c u Other ead sB-deflned 287 188 214 202 rate was 11.4 per 100,000 man-years for nonsmokers and 127.1 por 100 000 Acoidente; violema{ euldder 107 78 76 78 , man-years for current cigarette emokere with a history of only eigarette tifi r 3 086 2,010 2,217 130 A smoking (11:1). The age-standardized death rate of curreot cigarette ra ee Total death cer No death certlOUW d total G , 8, 243 8 2,112 2,352 133 2,259 smokers (with a history of only cigarette smoking) increased greatly with u b f i raa er o n m c garettes smoked per day (text-fig. 7). - rlu • d b Table 11 shows the lung cancer d ath rat i f V aa ° .In mpuy .mpnr.ma, we E.p..tee Om ,b.Mrf tlEwns te tb Intw/Wlw.l 14t. w .nJ.meer•em..aWtb un aEe.ta eenlawN r.iqklot ueqrbl.ennaa Craa, w" aodfq /W aw taw~ ••MaasfmpayuppeaodlrlemppwYMa T 1e e es o ex-c garetto smokers in relation to how long it had been since they last smoked. The lung cancer asitY4lMOnM,MJ. waunr.nsr au~bm,vatYeea oeissszooi

~ ~ e~l c0 ~ O Tsu 10.-Number of deaths and ege4tendardlsed death rates per 100,000 man-years by underlyin6 eauses of death. Men who never srmoked ~l regularly compared with men with history of elgarette smoking Age 40-69 Never emoked regularly Age 70-89 aucory c,aerace Naver smoked Hlsto eeigerette smoking __.-ae ktnz Num- Num- mor- i.um- _ her of Death ber of Death h8ty her of Death ber uf Dath fa8sy ratio IIndertying cause of death - deaths rnte deaths rate rstio deaths rate deaths rate Cancer (total) 336 137 1,999 275 L 98 237 701 440 1,222 1.75 Lung. 27 11 610 88 7.86 6 14 99 257 19.07 Lced estdty: plmrynx 3 1 60 7 & 54 3 9 6 21 .33 ryw 3 1 30 4 &58 0.. 0 6 16 8 1 82 4 &67 1 3 7 21 8.82 g°js~daN° ' T 3 65 10 &31 8 25 26 79 &ig gfdzey 12 5 60 7 L 43 6 15 8 22 1.49 Prostate 36 14 88 14 0.97 65 185 69 207 L 11 Psoerea° 16 6 132 - 19 2.95 15 45 31 88 1.90 Llver; biliary psaa8ea 9 4 47 7 1.84 6 18 7 19 1.04 &omech 27 11 108 16 L 39 30 90 41 123 1.38 C'elon; reetum 80 33 227 33 0.98 46 138 60 158 1.14 yeukemie 17 7 94 13 1.87 15 45 29 71 1.58 Lymphome-godgkln'sdiyase 39 16 101 16 0.91 11 33 15 42 1.29 4ltherepeciliedsites ~ I` 170 j.4j 21.82 45 18 27 17 53 174 81tes unknown Heart circulatory (total) 1,201 490 5,813 836 1.70 1,341 3,911 1,648 4,725 1.21 Other tieart 843 345 4,287 627 1.82 792 2,337 1,052 2, 910 1.25 Aoxtleaneuryam 138 56 543 78 1.39 167 478 216 659 1.38 Oerebcs] vascular 19 8 156 24 2 96 9 26 40 110 4.25 Other circulatory 18 1{ 67 145 86 i: s 262 ~ 261 734 0.94 79 262 1.13 Other diseases (total) 211 ~ 1' 169 161 1.83 229 673 377 1,056 1.37 ~pb yM~t~t '8.83 4 12 71 189 15.52 Pneumonfe;fnfluenra 17 7 97 14 1.97 50 145 77 Other pulmonsry 224 1.54 lieetric 21 9 109 1g 1.89 18 63 39 109 2. 03 ulceij Duodeoel ulcer 3 1 49 7 6 38 4 12 15 36 2 97 GSrrhusia of liver ' 8 8 44 6 1. 97 12 37 16 85 1. 47 Nephritis; nephroaie6 224 10 5 11 1825 5 18 1.70 6 18 7 18 0.98 Disheta 26 1l 12 L 14 24 67 20 58 0.97 Other speciEed dinaea 89 13 L 21 28 82 26 72 0.58 111-defined diseesea - 73 30 811 44 1. 46 69 205 95 269 1131 7 8 38 6 1.83 14 42 9 26 0.62 Accidents; vklence; suicides 134 58 616 T0 L 20 37 108 61 175 1.62 Total death eertifiesta 1,892 773 9,345 1,342 1. 73 1, 844 No death eerti6wtee . 92 38 533 76 201 97 6' 289 2' 108 7' 291 1.00 Grand total 1,974 811 9.878 1,418 L 74 1,941 6.692 2,634 7.469 1.31 Na: NwWler neb.n GseG m ba! nb. artled b onma. tlmltran[ e°m. tL.c teowe. . 'fineeusrubmn4v.mtmd,aeesrafte.rS.o.yl.me f~VeTOns'11E or.nbout EmurLnb. tOxtk atorc.nd wwleluna vkr. INtpNtYS, npEreW, euJ utler kleuq Ayo.e,, MCe- G

168 CIGARETTE LABELING AND ADVERTISING LUNG OkBtEn AGC-6TAt81N811IF0 DEATH RaTEB-IfE RANGE 40•gg ~ ~ soo ~ Iw $ ~ wo ~ so A p ry[yt~g Ff ,e~t tD-]B- - M• a,e+ru atpLYar MMInlelncY[rTte WneDaOAr Tex~noaae 7.-Ageatanderdimed lung eanew de.th rates for nommotms and eurrent cigarette smoken ranging in age from 4U-9i', death rates of light smokers who had stopped gmoking lees than i year before enrollment in the study (and heavy emokers who had stopped smoking for less than 5 years) were higher than the rates for those cur- rently smoking cigarettes at enrollment, becauee symptoms of lung cancer (or a diagnosis of lung cancer) often result in a smoker giving up the habit (lg). Lung cancer death rates of ex-eigarette emokere decreased merkcdly with length of time since )ast cigarette smoking. Men who had given up smoking for several years had lower lung cancer death rates than current cigarette smoken. Twar.n 11.-Lung cancer age-rtandardi]ed death retee per 100,000 nvn-yean of ex- eigarette emoken with a history of onl Wggrsette emokin8g• llesth rates of ourreut ~~ .~~kedmare~ownlor~eorymop.~ eou. a Mm .ged o4069 1i a M~entu~dho oeeer 8 ked 20t WPretten s.. ttee . Smokd 1-1~9 Wg.re Number N~hQ a[ Death Number f Exl~ ~/e~~ I~ .+t ig•r dn61 of men 1.118 deKhs s ].t+ 6a nun o o 9;B05 1-4 1 1 6-9 . 2,652 798 30 10+ KsmaIease Q~ 1S,277 1 10 6 27 , 31, 064 Current cigarette 543 62 66 07.776 emokem ~ Never smoked regularly 79,069 27 1/ 79,959 •g.amut.r oet MWy te. om6r N L.+aea 4•aMMV rn r.eM. zeZ9ssZOOZ Number D~th of deaths nta 0 3 11g 16 72 12 74 87 28a 137 27 11 CIGARETTE LABELING AND ADVERTISING 169 Coronary Artery Diseses Table 12 ehowe death rates from coronary artery disease by smoking habits and age at start of study. In all age groups except the 80-89 age group, the coronary artery disease death rate was highest among men with a history of only cigarette smoking. It judged by mortality ratios, the relationehip between cigarette smoking and death rates was very high in age group 40-49 but decreased with advancing age. Pbr example, the following mortality ratios were found when the coronary artery disease death rate of current cigarette smoken (with a history of only cigarette smoking) Nee divided by the coronary artery disease death rate of inen who never smoked regularly: 3.48 at age 40-49; 2.39 at age 60-69; 1.66 at age 60-69; 1.40 at age 70-79; and 0.88 at age 50-89. T.ter.. 12.-Cmomr~ artuq diaeaae, Agoatanderdired death rates from eorunary artery disease per IOO,a00 m.o-yeere br emoking habite aud e at Wrt of et d •g u Pipe and Wgar ' Ciur only Cigarette and other Cigarette only Never emoked regularly Pipe onf r suo- 8mnking habits 4PBi9 60~9 60-~89 Y 7A079 &1-B9 Total Tota1T ourreat elp]ett• n4n~. 584 1,060 669 l, 493 663 1,384 773 1,861 718 7037 730 763 637 672 705 803 2,800 3,797 3, 476 3.948 a, 200 4,870 2, 694 3,078 2,540 - 2,240 3,131 2, 663 3,520 2,767 2,948 3.80 9,655 516 820 538 662 eie 760 904 878 78e 854 984 1,138 5} 209 676 1,202 601 2,374 816 739 20.24 273 643 1,316 678 2,086 3,981 812 15-19 301 890 1, 486 748 3,486 6,054 1,003 G15 816 707 I,417 744 3,679 7,065 1,031 •cm.et awuw m.r.r weh.6re.r a wr dn,rer.m,urr. Among current cigarette emokers with a history of only cigarette smoking, the death rate from coronary artery diseese increased con- sistently with amount of smoking in age group 40-49 and in age group 60-69, but this trend wes not found in the older age groupa. Text-figure 8 ehows the increase in death rates from coronary artery disease with amount of cigarette smoking (expressed by mortality ratios) for age group 40-69 in which a very pronounced trend was found. That the trend did not hold in the older age groups may be because man who have heart attacke often give up smoking or decrease their daily consumption of cigarettea (13). 83 278 62 313 136 303 132 305 100 517 268 .e10 841 346 1,906 4,324 976 382 1,610 4,107 $68 380 1,027 3,943 986 366 l, 863 4, 285 1, 171 663 . 2,630 4, 800 1,322 661 2,763 a,78r 287 663 1,398 214 601 1,188 254 632 1,489 281 689 1,437 393 723 1,313 one 405 8light 223 Moderate 292 Deep 290 Age smoking was he4ua 1 8 per y a ,0-19 20-3e 40+ Degree of IuhaWAon Was Numher d __r.___,,w I

170 CIGARETTE LABELING AND ADVERTISING a. MORTALITY RATIOS --- rX1RONMY ARTERY DISEASE AGE 40-59 ea ^. as eCYte 1-.r le-./r - M-!9 A01 LIn2D - aLfaaaRY alaRaDFneY1CTTCalamCDlaY TexT-rlouaa 8.-inerrtase in death rates from coronary artery diseeese with amount - if cigarette smoking (ekpreesod In mortality ratios) for age g.oup 40-59. The death rate from coronary disease generally increased with the dee ee to which cigarette emokers said they inhaled. While the pattern is-not completely consistent in this respect (i.e., a few figures, such ae the figure for noniuhalets in age group 40-49, are rather badly out of line), it seems to hold for all age groups. The pattern was eomewhat more consistent for the age at which current cigarette gmokere said they began to smoke: In general, death rates from coronary artery disease were inversely related to age at start of cigarette smoking. Table 13 shows coronary artery disease death rates of excigarette emokere. The picture is much the same us for total deaths: Recent excigarette smokers had a high death rate from this disease, but the rate decreased with length of time since lest smoking. Excigarette gmokera Taar.e 13.-Coronary discaee age-etandardimd death rates per 100,000 man-years of e:-uigarette emnkere with history of only cigarette emoking Death ratee of Durrent cigaretteamokem with history of only cigarette enloking and of men who neveremoked Are showa roe compariaon. Men eged 40-09 at start of study 8moked 20+ cigarettes a da>: Number Number Death Number Numher Death of inen of deathk rate of inen of deaths rate Esamokere (yerte ainee last cigarette smoking) t ,118 9 21 ,628 7 95 14 2,755 48 605 8.050 153 701 5-9 2,552 40 545 8,588 113 488 10+ 5,852 57 309 10,788 144 431 Total ea.mokersa 12,277 164 450 31,054 477 555 Current oigarette emokere 34,543 616 660 97,779 1,663 735 Never smoked regularly 79.959 848 346 79,969 843 345 •atmntrn vat MWOC tan mwtseot n.. aoq hd meklsg /e amlttd. EeT9sszooT CIGARETTE LABELING AND ADVERTISING 171 who had given up the habit for several years bad lowor death rates from coronary artery dieease than current cigarette smokels. MATCHED PAIR ANALYSIS It hae sometimes been suggested tbat the association between cigarette smoking and death rates might conceivably result merely from an inci- dental association between cigarette smoking and somo other factor(s) which bee a great influence on death rates (19). This is extremely unlikely in light o(: 1) the quantitative relationship between death rates and the degree of exposure to cigarette smoke, 2) the finding that among ex-cig- arette smokers death rates diminish with length of time since last emoking, 3) the known biological effects (P0) of some of the components of cigarette smoke, and 4) pathologic evidence of the effects of cigarette smoking upon bronchial epithelium and tissues of the lung parenchyma (21, 22). Never- theless, we decided to investigate the matter by etudying the death rates of cigarette emokers and nonsmokers who were alike in many character-s isticv other than their smoking habits. This was accomplished by a matched pair analysis carried out ae follows: - Two groups of subjects were identified: 1) men who never smoked regularly and 2) men currently smoking 20 or more cigarettes a day at enrollment in the study regardless of whether they also smoked cigars or pipca. These two groups were then divided into 5-year ago groups. Within each age group, we matched men by pairs, each p=r consisting of a nonsmoker and a cigarette smoker. The two men in a pair had to be alike in all the following characteristics: race (white, Negro, Mexican, Indian, or Oriental); height; nativity (native-born or foreign-born); residence (rural or urban); urban occupational exposure to dusts, tumes, vapors, chemicals, radioactivity, etc. (yes or no); religion (Protestant, Catholic, Jewish, or none); education; marital status (single, married, widowed, divorced, or separated); drinking of alcoholic beveragea; eloop (under 6 hours, 6-9 boura, or 10 or more hours per night); usual amount of exercise (none or eome); severe nervous tension (yeg or no); use of tron- quilizcrs (yes or no); "sick at present^ (yes or no) ; history of eancer other than skin cancer (yes or no); and history of heart disease, stroke, or high blood pressure (yes or no). The matching on height, education, and drinking wee carried out as followe: Height was recorded in step-intervals of 1 inch, and tho 2 mcn in a pair bad to be in either the same category or in adjacent categories (e.g., a nonsmoker 70 inches tall might be matched with a emoker who was (59, 70, or 71 inches tall). Education was recorded in 5 categories: 1) no high school, 2) some high school, 3) high scbool graduate, 4) eomo col-, lege, and 6) college graduate. The 2 men in a pair had to be in the eame education rstegory or in adjacent categories. The drinking of alcoholic beverages wes recorded in 5 categories: 1) none, 2) occasional only or not over 4 gleagee of beer or wine a day snd no bard liquor, 3) 5 or more glasses

172 CIGARETTE LABELING AND ADVERTISING of beer or wine a day but no regular drinking of hard liquor, 4) 1 to 3 drinks of hard liquor a (lay (whiskey, gin, rum, etc.), and 5) 4 or more drinks of hard liquor a day. The 2 men in a pair had to be in the eame drinking category. In respect to age, the matching procedure required only that the 2 men in a pair be in the enme 5-year age group. Wheu the matching was completed, we found that the average age of the nonsmokersiu the matched pain was a trifle older thau the average age of the cigarette smokers in the matched paire. The matching procedure was carried out with an IBM 1410 computer. The records for the nonsmokers were put on one magnetic tape and the records for the cigarette smoker3 on another. The records in both tapes were then sorted in order by the codes for all the variables under oonsidera- tion as described. Thus on both tapes the records were arranged in blocks, a block being defined as a group of records identically coded in all the variables under consideration. By use of random numbcn, the records within each block were arranged in random order. The 2 tapes were then compared block by block. Blocks found on only one tape (ti.e., unmatched blocks) were discarded. Matching blocks of equal length (i.e., the eame number of cigarette smokers as nonsmokers) were accepted as matching paira. For example, if a block of 2 cigarette smokets matched a block of 2 nonsmokers, then 2 matched pairs were identified, the first cigarette smoker and the first nonsmoker being the first pair end the second cigarette smoker and the second nonsmoker being the second pair. If the matched blocks were of unequal length, then the ercese records in the longer block were discarded. For example, if a block of 5 cigarette smok- era matched a block of only 2, then the first 2 emokere formed matched pain with the 2 nonsmokers, and the lavt 3 emokels were discarded. Thus the eacese. (discarded) records were selected at random since, within each block, the records were arranged in random order. A matching procedure of this sort tends to eliminate subjects with unusual characteristics or unusual combinations of characteristics. For example, since thare were only a few extremely tall emokere and only a few extremely tall nonsmoker , there wae little chance of an extremely tall pair of mry being found who were alike in height and all the otber characteristics under consideration. Likewise, since men who were well at enrollment greatly outnumbered men who were sick, there was lees chance of matched pain among men who were sick than among men who were we1L Thus the men included in the matched pairw tended to be thoee who were average in respect to several, if not all, the characteristics under consideration. This was exaetly the type of men we wished to study. The extent to which men with a history of serious disease were elimi- nated from the matched pain ie illuatrated by tbe followiog figuree. In the original population (i.e., all nonsmokers and all current 20+ a day cigarette smokers between the ages of 40 snd 79), 1.8 percent of the men said they • b'ad a history of cancer (other than ekin cancer) and 16.6 percent said they had a history of heart disesae, stroke, or high blood pressure. After Vetssszooi CIGARETTE LABELING AND ADVERTISING 173 the matched paire were selected it was found that only 0.4 percent of the men in these pairs hnd a history of cancer (other than ekin cancer) and 11.8 percent bad a history of heart disease, stroke, or high blood pressure. (The figures quoted apply equally to the cigarette smokers and the nonsmokers in the matched paire, since they were matched on history of disease as well as many other factore.) Since the matched pairs included a smaller percentage of men with a history of serious disease than did the original population, it was expected that death rates in the matched pairs (both the cigarette smokers and the nonsmokers) would be much lower than the death ratoe in the original population, and this prnvod true. With so many characteristics to be considered, many men could not ba matched. However, the computer found 36,975 matched pain of mon (36,975 nonemokere and 36,975 cigarette smokers), such that the 2 men in each pair were alike in all the specifications outlined. The results of this analysis cra summarized in tables 14 and 15. Of the 36,975 nonsmokers, 662 (1.8%) died and, of the 36,975 cigarette smokera, 1,385 (3.7%) died between the start of the study and 5eptember 30, 1962. This difference is statistically significant (P<0.000001). As shown in tablo 13, within every 5 year age group from 40-44 through 75-79, many more deaths occurred among the cigarette emokens than among the nonsmokers. Table 15 shows deatha in the matched pain classified by cause of death. Of the 36,975 cigarette smokers, 110 died of lung cancor, while, of the 36,975 nonsmokers, only 12 died of lung cancer. Cancer of the buccal cavity, pharynx, larynx, and esophagus took the lives of 12 of the cigarotte smokers but only I nonsmoker. Both cancer of the pancreae and d cancer of the liver killed far more cigarette smokers than nonsmokers. Emphy- sems resulted in the death of 15 cigarette smokers but unly 1 nonsmokor, and aortic aneurysm accounted for the death of 30 cigarette smokers but only 8 nonsmokers. Coronary artery disease was the principal cause of death among both the nonsmokers and the cigarette smokers. However, 654 of the smokers died of this dieeaee compared with only 304 of the nonsmokers. T,tau 14.-Matehed pair analyde: men who never emaked ,egululr metebed with men currently amokiug 20 or mere eigarettea a day at earellmeat Never smoked regularly Ci anttee 20~- a dar Age Poup Number ef inea Number of deatke Number of ineo Numlror of deathe 4D-44 3,410 15 3,410 40 45-49 10.468 59 10,468 192 a0-54 9, 688 123 9,683 252 55-59 e,634 135 6,534 323 60-64 090 t 990 a 264 Ob-89 2, 83 8 . 4 , 083 193 70-74 747 94 747 99 75-79 W6 160 33 ToW 3e, e67 ee, 975 1, 3" IS-979 0-65=p,. $-12

174 CIGARETTE LABELING AND ADVERTISING TAnnn 16.-Matched pair 1oe1yeie: number of deaths from various eauee among 36,976 men who never emokud regularly eod 30,975 men currently emeking 20 or more cigarettes a day at enrollment. Age range 40-70 -- Number of deathe Underlying cause of death Never emokcd regularly Cigarettes 20+ a day Cancer (toMl) 96 201 l 12 110 .nng Buccnl cavity; pharynx 1 3 Imr nx 0 3 y us hLo he 0 6 p g Bladder 1 2 Pancreas 0 16 biliary passagea Liver 1 7 ; Stomech 9 10 Colon; rectum 20 25 ccifud sites r Oth 43 64 sy e Site uoknowu a 16 d circulatory (total) H t a 401 $64 ear n - 304 654 Eoronary Other heart 30 64 rtic aneurysm A 8 u Cerebralbazcular . 44 84 Other circulatory 16 Other diseeses (totaB 73 127 s ma Em h 1 15 e p y Gaxtrie uleer 3 5 Cirrhosis of liver 9 17 Other specified diseases 69 86 Ill-defined diseases 1 Accidents; violence;euieidee 58 66 Total death terti6catee 628 1,308 77 No death eertificatea 34 1 385 Grand totai 662 . Such factors as race, height, education, religion, nativity, residence, occupational exposures, drinking habits, sleep, exercise, severe nervous tension, and sickness are nssociated with a host of other factors including heredity, environment, mental attainments, and personal characteristics. Since the 2 men in each inatched pair were selected for their similarity in all the characteristics mentioncd, they were almost certainly similar in many other respects. However, they differed greatly in smoking habits: One never smoked regularly and the other smoked 20 or more cigarettes a day. During the same period, far more deaths ecculred among the cigarette smokere than among the nonsmokers. It is hard to escape the conclusion that this difference in number of deaths wag due to the difference in gmoking habits. REFERENCES (1) Dor.L, R., and HILr., A. B.: Lung cancer and other aauen of death In relation to emoking; second report on mortality of British doetors. Brit Med J 2: 1071-1081, 1960. CIOARETTE LABELING AND ADVERTISING 175 (.D Her.rono, $ C., and Hovw, D.: Smoking and death ratee-repmt on 44 months of follaw-up of 187,783 mcn. Part I. Total mortality. Part II. Death ratee by cause. JAMA 166: 1150-1172;1294-1308, 1958. (3) Donx, IL: Tobacco tonsuumpGon and mmtelity from cancer and other diseases. Public Health Rop 74: 681-693, 1959. (4) Dunn, J. E., Ja., Lrnonw, G., and BarsLow, L.: Lung eaneer mortality experl- ence ef inen in certain oceupations In California. Amer J Public Health 60: 1475-1487, 1960.- - (5) BreT, E. W. R., Joera, G. H., and W.tLCnn, C. B.: A Canadian study of mortality in relation to smoking habits, a preBminary, report. Cenad J Public llealth 62: 09-106, 1961, (0) Done, J. T., DAwesn, T. R., H.rrwnL, W. B., ILauw, A. B., and IGnn, li, A.: Cigarette smoking and coronary heart diseeee. Combined expcrience of the Albany and Framingham studies. New Eng J Med 26: 796-801, 1962, (7) HAMUOpn, E. C.: Cancer etiology: new prospective spidendological study. CA 9: 177-178, 1959. (8) --: Smoking in relation to physical aomplNnts, Arch Environ Health (Chicago) 3: 146-164, 1901. (9) -_--[ Prospective studies on smoking in relation to death r.tn. Bulletin de L'Inetitut International do Btatletique, 33d Beesion, Purls, 1061. (10) -: $ame preBmiuary findings on physical oomplainls from a prospective study of 1,064,004 men andwomen. Amer J Public Ilcdth 1: 11-23, 1064. (11) HArrouo, E. C., and Gannx:ny 4: Smoking habite of men and women. J N.t Canoer InetTl: 419-442, 1961. --(lE) .-; Changes in eigarette smoking. J Nat Csncer Inst. In prrm. (13) H.rrroao, E. C.: The influence of health ou smoking habits. Presented at the -Btatiet;® Section Meeting of the American Publio Health Association, Kanem City, Mo-, November 13, 1063. -- -(/O .-: Inhalation in relation to type and amount of smoking. J Amer Statis- tical Am 64: 36-51, 1959. (16) Dow„ R., and HrLL, A. B.: A study of the aetiology of osreiaama of the lung. Brit Med J 2: 1271-1280, 1952. (16) LtceraT, F.: Xtologie und Prophylaxe des Lungenkrebees ab cin Problem der Gewerbehygiens und dee Tabakrauehes, Dresden, T. BeelnkopB,1053, 212 pp. (17) Baeer.ow, L., Ho.our, L., R.srusesa, G., and Asurs, H. K.: Occupat)ons and cigarette smokiog se fsaton In lung eanoer- Amer J Public Health 44: 171-181, 1954, (18) Bcxw.an, D., and DeMorx, P.: L'eoqu0te trao9alse eur 1'4Uologie du cancer broncho-pulmonahe: r01e du tabaa. Bem Hop P.ris 33: 424-437, 1057. (19) A.arn, H.; Relationship bctween human smoking habits and deathh mtse. Cun Med Digest 22; 37-44, 19g5. (d0) The Riologio EReats of Tobacco. ( Wynder, E. L., ed.), Hosbo, Litt4, Brown k Compwny, 1955. ' (dt) Aasu.cn, 0., Broor, A. P., HArrorno, E. C., and G.wnaeeq L.: Changes in bronchial epithelium in relation tosex, ago, ratdenoe, smoking and pneumonia. New Eagl J Med 267: 111-119, 1962. (M -: Smoking habits and age In relation to pWmouary ahangest rupture of alveolsreeptums, fibraeie, and thickening of wags ofemall atteris aod arterioles. Nsw Engl J Med 269: 1046-1064, 1963. seissszooi

i ~ 0.~ R (~{~ f'

178 s.rre wpnrrml Iy tlm volunleen. Mrt, slnce we wem mnble In 1 te the .kwh thcvte nr othe o/g- ciul d.nvme t to vnify tbe f n. these we.re clnsiged as knt io fnlluw-up in tlw Sgurn given aMve. T.eu l.-a/.TTesr.e/ En.urin /e ( f ~T~ ~ S.dlr,a IuM/.n //Nbry1wd dy M- r CIGARETTE LABELIFG AND ADVERTISING r. .r...r.........., uPn eJn a.A F~ rw.m ...la.ur rna ,..w ww r.r Iiaensed- SMmkin, and Milkr• have raposted the rnultr of a survey on smokinghuhih in a mpte- senmtive sample of the United States populatlon condnetedby the CcnrulBUreau as a part of the Current ynpulatiun Survey In Febmary, IKS They compared our findings with theln Iorr mcn in the me age rangc. Aemrd'mg to their analysis, the two studies were tn clase agreemmt as to the pro- portian of inen with a history of regulu Nga.e1M emok(ng. Death Rda by Type of Srnekklg Tahk I ahows the number af rn-ye.n of e.- pnure. to r(sk by type of smnking ( hlerime history) und by five_year age gmupr. Thrmsghout thu re- port. Ihe age gmnpalwayerrcfers to the ageoF the mokeJ had the lcwest Jeath mte. Mm with a hhtnrry d regular cigarette smnking who abo .muked dgan ud pipes had a death rate some- l Fla. 1. TwJ dsW rNw b> trp d ndN{ (IJp4aes hlvmry) anL M.P •t •nn d nudv. what lower Ihan thnt of inen who smoked cigarettes mly. The dealh rate of inen whu had urwlked only 1%pn was jueeslightly above the rate fne men who nevn emoked--fLe death rntc of ngar smoken wa+ slightly higher than that of pipe smoken. 1. nnler to sumrnesise these bnJings, we mm- puted-the numberr of deaths which woukl have eanrte.J amm.g mrn in each smnking eategory if tAeis age-spa(gc denh rmes had been nanly the as thase fnr men who never am:rked.'iLb .will be referred m as the ' n ed u ber of deaths. The obsesved number. of~heth divided by ehe tio- pneed number pves the mortdtiy mNa By dd'mi- oon, the morlatity ratfn fee rllm who nste smoked is 1.00. In ahw woN.. the death rate of inen wha T... l-Tred UwAr wd Danh llwe hr InOpUp MwTwn le TYM AlMYg (4//aae NYen) eW Ov Aar r 51ws d ssade .. . •.w a e.Mr ~ ~ ~ ~ ~ ~ .. . . .. . nw.,._.. ar. .a u n ,.,u.. ~a..r.da...rs. ..... ._ ns n..nn..n......... ..... I ena ...._ .............._. . _. ..... .~n aw I oaw.ur....nar..e,.w.,ror.w.r .I..rrw..m.wr.~,....w..rsar.o...ae.r....r- meo at the t(mee they were enrolled In 19% Table neva emoked 'u taken u a oontrd agolnrt which 2 shuwsthe wnesponding number of de.tlu end the death rata of mm In vrious rmnking ntego- duth ntes per 100.000 man-yeane ne are mmpared (fig:2). 1. all Iwr age gmups. by far the hlghest deNh A total of 4wg deatM omlrmd amoog men w'ah rate wu that Inr-snen with a histary af reNkr a hutory of regul.e e1g.rM, emoldng ooly. Only elgarerte rsnoking mdy (gg 1). M® wha never Rggl d lhae rnm wouM M.a dkd bmweel Jam 4sissszooz CIGARETTE LABELING AND ADVERTISING uary, 1951 aad Ocmbeq 19S,S, had their agn rl~'ific Jeath rnte heen Ilse s.me as fnr men wlw never smoked. Thb digerenr.e of 1.783 deatbh ^tensticvlly signigcant (P<o.0p1). "n, -e rnurl.Ly tia (4dOfi t$g2t) k L/M. 1. aher .rorde, the wora aua-ar -- ooK ~ ~~_i Z ~~ w r ~ ~ iu tle G-wleallry retln fn toei drWW by M1pr d.eek- In< death rme d thne dgasette smoken wes egtk higher Ihan the dedh sae nf a oompenbk group of inen who norc. srroked, age being takm Inm mnsWenriwr. Thn moneliry ntb w.. 1.13 far men wilh c h4- tary of segulu-clguatte smoking wlm .bo smaked cgan or pipb, them being 2,910 ub.ervsd agaimt 4028 eepecled dntlx. Thk digseies ir rtatistically sigslficant (p<(10Bl) It ir Me.meky that there wllh ud.ed snroting h.b(Ir had snmewlut knner death ratp Wae mrn who rssabed rJgerena .. s. w .w kYn 1-TUJ de.M nrw y wereet arw,rt d kprpl, wdl.a at nr d y.a0oey ad br p mdy. TIIb ir partly due tu the fact that them wem fs.n, henry cigarette reeokerr unn,g ehoue with misN Isu•b'its then am®g thwe wln smol.d dga- rethi on.r. Howe.V. IIW dlls Yul atlmly an.nent forlkaJigassm: - . ]79 The nortality rat(n wo 1.P2 for nren wlth a history of cigar rmnk(ng only (P25 nhservM deaths aguinrt Tgl c.pected deeshr ). Tte diHnrnm is rta. thliully JgniBcant (p<0.0g1). For mesr with e history of regular pipe unnking only, shere were T/1 obrervell-dea0n, mrnporcd-wlth &M espected deaths, giving a munality ntio of only 1.1g. WMk MIS digerenae b significam (p<QOY)-the ngect d pipe smnking eeenv tobe smcll u omnpered with the efeat of dgarette smoking. 61B Mathr oocurnsd among m.s with a hbtary of occasiun.l smoking as mmpared with 390 eryected deaths. This dige.ence ir nnt tlatunrdly slgnifsnnt (P=OAg). It appean that acculaul nnokieg hs little, if any, ege<t on deeth rate. De.th R.M by Aseunt of C/g..rte 9rkbg The nl.r with a history d regulv dgvette rmokking only wem lau(fied by their mnvq wt d agarette emolung at the tlme of 9us eaning in 1g52 In all four age graupe the dntA rner hsve..ed smrknly with rmunl nf ug.ret(a FV. 1-Yew.gry nlis (r rrsl .wly d d.drr 6y ornwt amwr Ilu®1 d d~raM. se,yly, smoking (tebk e and Be. 3). Tlro mortaBry ratb saee fmin 1.00 for. men who nesp rrmked to 1.81 far nmke: ofuMce oneJlalf park a dayr trs 1.70 for anwken of ane-half m ane p.ck e day, to l.gg for smokm ul ine tn rwn paclrr a day, and ro 211 lur smok- af twn pecke a rm-a dey (fig, e). In other wa.de, the denh nte af inen melring regukrly et a r.te of ba tEan m.Jreif paek af aigarelta a day wu 34% higher than that of nlm who nevet rmoked, the dnth raN of ines smoking arre ro two packs a day wr ggtk higher thun that of inen who nevee wunked, errd the deeM rae d men smoking t.w Paeks or more a day war IY1S higher than tAatof ineo who nerv rn¢ed. SL^ flndingr fw men with e history d h.Nng emuked dguetev regul.rly and plpe s tlgan u weB aq .Irosen in tabk 3 by aaoslnt d dgueUe s.nkbg ! 1g62 The asuof of pip .od tlpr .0

180 CIGARETTE LABELING AND ADVERTISING unklnR uf Ihe.e rmn wilh ,ni.ed IrsLits Iwe been di.mg:ud,d Iw (1) ciguetle mmnkinR aPPeRn tn husv lur ra se eRrct nn Ibe e.ehrew r nFU U u:mkina •n:d (2) we knew d nn nuinghd wm n cnnven numher, o( elgan or nomher of I'1 fdsnll ba.er,' 1 q al. t mbensof¢g- etl .. Ah. t . Il eI lhe d Ih 1 1 en 'd d 1 / 'F fl knghutnolqle iforml f eo with h 1 ry of tiSarelle kingb,ly fl ll'R the t- mlnt ni ciga- ..u. „nnkna conm, v. Ihe merl with miaed snmk- mµ habits bnd a dr.ub rwe 11% lawer, than men wilh a history nf eigmclt< smoking onlF ThI. wns IarFCly acmnnleel for by men who were rnrreMly smoking hmh clgurs and cignnues in 1052, Ihis gnnnp linving e death rate 29% lower than Ihat of men with a history o( regular egarelle snnking anly. hxlnl cntirvly nr IaJ cul dnsvo In nn:,dorml xmnk- inp. For a niparison. tahb 4 alsn slmws Orc m,mlwr nf dealLs wul derh ruter fnr men •vho tre still smoking regulerly in 1952 and for msn who nc+n smokrvl. 1Le mrn with a hrsl ry rd egulxr A'relte mnking who were not smok R g renn F lurly n 1952 h I 1 ll m In d ,n Ih.,t uf n- wbo e sull smnking ga Rer rcgrhdY hnt hlgher thzn that of inen hul.d ,-er nnakeslL whst b mme mrprbing• rhe eagar nnnken und d,e pipe am ken who gave tip ILe hubis had dauh rates higher Ilwn those of inen wln were still smok- ing dEan ar pipes IegukrlM TLe interpretnlion of th.: e camparisons is aonlpliealeJ by the feet that illneu is mre of the reasons why a perwr may give np smuking Howeeer, n more delaikd analysl. of tbe data clnn6es the pistum. Ta.ra >-Ter.t MMM aed IMn.1 gae. per 1WpM Nanyean Sr Anwm n) Smling aM by AH er Sl.n n) Srady nnn_. a. .ayw wy r .nfryuc.w- 1.+ Mn. M1.~u IN,Y Rm . Yw dwa R.r..IM-a.nr The rk 0 1 of cypr amok . who smoked nn A Id 1 of 10,1196 men with u history of reguWro ome Ibe / 5 gu day and nf plpel amoken who 6gnrelte s oking only d that they had sfopyed snmked no more than 10 P pef h of wba® a day smnk g The.e mcw wv clad4d by the knith, dilfered , ry little from Ih d tb ote ef inen who nf t/me sion they last anlaked i. e., nnder I yeuq vcr smnked. Ilowever. cqfar snmken and Pipe 1-10 yeasa, and 10 or mure yenn, and by Iheir unoken who smnked on than tbu amwnt had um preeious nlaunt of cigasette smoking, dealh rnen agnigcanJy higher than me.n who . 1. e., under one pack a day msd ^rle park or nuue smoked (p<0.008 fur ogar rmokers aod p-0.06 a day (fig. 6). 'nlore who eAd that they Iwd (or pipeamoken). Inpped smoking ciRarettes leaa Ihan a year Ixiore Death Ratea for Euesokns they were quetimled had a higher demll nte than Table 4 showr Iha number af dealhs and death Omc wha were atig rmekmg In eur opiNan, thi- raln for mm with e hislory af neular ntukirq{ reNeclsOleegMdhpahnnsnsnllmghalwuMher whn .ad In 1952 that Ihey eiehs had givm up tIN Mm Ihe ee.esee; that h. mme peopla gM up 83Z969z00T I CIGARETTE LABELING AND ADVERTISING 181 rlmklnR ml~y Mrmne Ih ry a.e 111. There were sumPtinn of eig:vettn. Tlm fnik.ving Ibrm .cts uf pnd.drly r,d, nren mong Ihqe wlm had emnpui.vnm show mnrl:dit mrins in relalian n ~mlumd mwking Ins than a year before the.n,dy chnnge in tlrc amonnl nf a rene erwkin . 77p m Isream. Tlds wonld osmunt far th5 Algh death gnl mmapw ruon indieales that (1) foe dmse n,. Tena - -Tulel OMh. and pean llarn ew Irli.rYU Ar.n-Yrn.. (ti. Itpe.y ef Megulsr SRw4ry er Ne4/ea Is Caw.q SnqA/N /n InSp .ad ae Aae M 54n uf Slede ar.m.u.n. 4 a. r l.,vw,.....~wle~......... ...rs ..e-.w. w .1 ......u...r. y. rnle in tins gmnp. Hnweveq rnan who 6ad stopped ,AinR fnr a year nr kmga had a lower death nn tl.m tlune wlm swntinuM to snroke reaulady, lhc nnnality mtio wal 1d1 for men vho wen n rnnly rmnking lese Ilmn one peek day of cig- .nyle. in 1052, MmtalOy ntia (or enlmken w/io M1dl lIrevknuly smnked at this Ievel wen (I) 201 fLU tlu.c who h+d aopped snmking (or Ins Ihan r m>,vR (2) 1,]fl for /tieq who had rmpped enmk- Ibc bn 1 to 10 Yeara, and (3) 1.09 (or thnoe whu lud slnpP-d nwking for 10 yean or long¢'Rle ,Imp In Hw Innrlul0y ra0u from 141 to I.kM u slmislkallysiRniflcanl (p<Q001). - 'llnnmrmlity ratio was 2.02 for men .vho wen rrmly nnnkinR nne paekor mare a day Of elp- mu,i in 1162. Rf mmtolity ratius fin esarmkera wh„ Lud pmv/omly mnked a1 thir le¢el were 11) al f Ilom who I d noptwl rmking fw Ins 11 ynr (2) 1g_fortlmsewhohadllopped kA fn 1 to 10 ya n and (3) 1.60 far those I II.1 Ileal.mnking far 10 yearr or longer. 11 laluhnll thc mm1 I ly Ib frem 102 lo ISO y slgnifiomt (p<0,02). n l~gar snoken who h.d gnen up the habk ka e ynu Lfom the quabmlfng ahn had e high ,k:ilh mte. Tm rale dmpped fa thnse .nh moro th.m a vear.d alstlnerxw.hot remalned rdalirely 6igh, lirn p.YUm far plpn Imuken .m saughy the rane Death Rates far ]lqee Wka Rahced A.rrw of Snekf.g A e;msMlnahk nmrber of inel witll e hktory af nXnlar dgarettc smoking ouly smnkad ugueRn n'goJ.rly in 1752 bat hW sW doen ol thefr m- nnllY amoking one-half pack r, nnre o( cigarmlo day the nlodality rntio wu. 1.82 (3.159 ulncnxd denlM arW 1.710 2speued dealhr), (2) fnr Mlnsn r.vRenlly srmkng ks than ane-hnif Ik,ek of eiga- re0rr a day who had art down (rMn u Idglicr nwunt the rrlvnlity rallu wal i.P1 (lM oburved dnlhs and 78 eapec4d de.thr) ,, and (3) far tlwre nln'^Oy unoking I?e than ane-half paek Ir n®1-. s2111 4M'k'WfA iw*1@~ Fln 1-Alalrliry Mly (a, yd wnalyr af detlhr N wen ehwe te. wa~a w~b rden adal ud Ywe NII aneHV tl{valtae ng rnta a day who had rlera regularly smnked any higha ammmt the mortality nlb was 1.24 (StT obseived dea1M uid 272 npectd deetha). The .avud mrnparhm Indmate. that (1) for thow ounatb' smoking ow pack a more M dg. .IatH. - day eh. aaoetaiq nulr .r YOi (h32! .

182 CIGAIiETTE LADELING AND ADVERTISING h. I L,d aI6S9 pecteJ 1 n)(2)r thne tly s k F .I,If t Pnck sJ q tt a1 yI h I cut dow fbseRvoJ a t tLe r I IY r 198 (490 o daIha -d 122 1 t l.kud ) nd (3) f'h e u,rnentlysnnkrrFnnrhnifm 1-ck°r iF""r'£ one a day wbn had ne.er reg;brlY snmknl any higha nt tlw I 1'tv -lio bas 1.09 (1,581 6 va.l deeths .d,M`b!tn i,xYl'y,:edes s tha h ( I ) Im ibn.e 'ltu Hdnl ml- ~ ~tt r tly r nhl N' « re 0 kr sd dg'^ '. . a 1aIhe mnrlnlny rallo wJ 2.2J ('sgq Ine rl dcatin mxl 118 erLNed deatlu). (2) f r th«e em r tly s,nd g one io two pxi -f 9arella • 1nwl n had n t k,w•n f.mm a h 8ha a mt the mnr ed IY rxap .rm 3 16 (142 nl md Jcaths an 1'S emika.d J atlnL anJ (8)(-1hMe r y smoking one io two rycks of nF+retles a Jay-whn had ncver regularly amnkeJ any higlsa amonm dm Imnnliy ratm was l ee (921 hrer.rad death, .MI 495 equcrcd dentln). As shown above, 'bme who hm) •moked two or mme packs of ngarella a daY aN whe hurl a+,t down to mse ro twn packs a day had a highv m«- ,mdcr :D yeen old. 81.8s snid that they Iss•IC o ite,r Ihey rt d .Ur am1 ly 7.2s wid dan ihe . beg hen d" e M Y. . nld or M1o mmewhat nl+leJ to Ibe npa a11~hmL thc mas heg:m~ k'n8 Farr example, ady 317% of thnse who smok d one pck « f.F ttcs 'I'y hel:nnnnk'nF ft tlre;ge 119, By W 54.1R W d e ho s ke I M thm ncM1 II rymk a day l+ryan rmoksv8 ufter tbe nFV M 19 . 71m ma. In if,e , ge grouln ~ nml SSdN Iw•F•'e smnkmg t., sm h t Y F+ npr on tba awnFe. Pmn the men 1 tl aga R np 9mB4 anJ eSBF Th,xe . I Isxi knl csF± II rcg,J rly In,t whn lu 1 mplwd I r:oking h 1 - t( a.ge, stnrted nk ng at alsm,t d. ne aks. who nm,king eigaretle~ e8s1ly ,n 1M152. Fnr er- . nFle, 40'x tJ A,me - ho I ad smpp'd smnk,ng starh.l mm4 8. Iler the R of 19 11y mn lnm. 41% of Ih ently nmk N'F' nes F lady lad nartm) srmking aller Ihe n8e nf 19. Men with mnkg hnhita (/ 8 tte snd other) M8v'sal ok' F sifrr/etles .1 I st lenn the semc nFes as men who sirwkel ,ganMa nnly. Taau 0.-06x+r./ Vem. Erp.fd' Nue,0.. nf U.vtlu nY C.neM Am.nu.' M C'M/tte SxnklMl ••d t91'ean ul C/wnwe S:mF/+et rr. .- ,w. nl arnM - ti . P . n nM r ,..,.r ,xa,~":a.n.x.C"..r:..aa,nw..,..n.......r.:r.,w„~:i"• . na,...,. ality rmin thun tMne who wa< anrently •mnkns8 T.hk 5 shows Ihe nnmlwr of ohsnrval nnd ex- two momre M1,eks of aga ena n day. 'lhc mMl F"cmd dmths and m«t 1'ty tiM f« mrn wnh :. sonable eaplvnat;on wouM PPe•r to he that hvlnry of reg,dar oBarHte snnlm,8 only by rnnmt xwne of the Ise.rvy smokm wlsol rst down slightly .nnnnt of smoking and by Ys'^'s of smnkinp Ti,en rxlia J Ircnd in mortality h h did Iwcmm nf ,Ilnm or senow sympmmc T6e monality ratm of inen ha olc~o uaQe highaansountsMnne-halftoo p~ garc day was a trifie InwerManthesn«tahty raeoof inen wlm did not a't aowm The mortnhty ratio of inenn wlso a:t rbsw Irnm higher uMS tn ku Ihan one-half pvek a day ww aFWeN'bl) krwe thnn the . marahty ratio nf thou who did mt cot down. All th ga m J ad, these figurer ru8gs.t dut uin8 d Iro high moont lo a low amounl ~g muw m • reanawn nl the of eigared nmka death r'el Unfonnnately, dan e rnst ava ilahb lo meke a mnre detailyd analysh by finre nlatlon- ship• as was done in the ean af inen who stoOPed amr,king aingelber Duralion of Snwking okinM la a0.er~~ 6 myularly, with g°" y who ,n 1F52 emakin Rm they were $FY..aiJ dut theY b.y 6 w e an to l'wa. a19e;M with years of rmoking fa- men enrrently wnnkinF kas d n -half pack of eipnata a day. Sane rd these men had Previmnly smukN mare thoo m,e- hcP pack e day wd then a,t ,Inwn tn Im. AmMF mm mok g mw.-half to one pack of c:ganttes A day,the mortality mtio warl«slorllms, wholwd .rmked less than 25 yean d,m fa these win lual smoked 15 Y an ae lon8a. but the r1lPcnnre rs mt rratul eally significant. Tire ,mnmhly Inu dn m:l alqKarlo be related to the yem of smok °enue a usr«nlly nmokln8 one pack « maa nF1 day. Unfnnuuately, then we smt enonld' c to mnke a detailed amlyrss ol Ihe three varialda~ (I) yem of smoking, (2) wrtent arnmmi nf sndinF. aN (3) masimum amoant a1 smokiab F« this masols. oae •hould be rnsltow N Intapretkr6 Shaa h8asa. 1 CIGARET'pE LABELING AND ADVERTISING 183 UrWn Vmur Pw.l Fbe men w«- cl s,fied lem the fnl lcNsne.lhe fax areas Jaailpsi 1e h sine ,xch 8'n p an hng lo the add ~ing ~ir ~F•'• only •bm t one fm,nh the Inlal resan pvar nn the 1'nnuLitnn <.omMnN aever'I :,wking nle- mnk ng qr,nl'rm ni wlleaal in 1955; 1. C't'ra gnnn In der to nbtaim mon nhle mtes. The of nva W.OOp Ivsli h um iti6 inehrded men from Rc rlwc,Ac deaJi me of the eMnhinad- [M Angela, S:m F anebm, MmnaPnlfs, Ch/rago• (d'nr' who 8rnnp Detmrc, PuBaks, P , sre.a smoked N Ih«n wlar snmknl Newark.. •N nther~a~ Sm~w' Pittsburgh nn" ~. nnal/y only) wa «N .: s hasir fnr pyn. 8 Ne. 8 Cilia of IO,OpO Is' i'ng the npeaN numbar ol death, and w«- T nwn M lbryy. Y t 1 ty raIIM ~o^e M smnli r"r"' qnwW onv~ h II . m'~s f tyR n! ksnshy'. Nyyn ue r a~kea iwe N•hn' I"e .erA M Flr Araw - msl rr:nkevlh hl/lhw Jeath n/e tlw ; m•n wl,n hwl eR I 1 TI . n, anI M,Iler • ahn famd Ildr 1 he troe (M the lindN _ Smla u . wMM. ...... _.. " rr u. r. St ntlavlisin8 th i u, e p rca fk uM armN wr•+,w.n r n. „ M w.w.mw- u fa age, thn dnth rate w.s 18y/hi M1 ~Ij n sa , b PI,VUU IaFULtbn. 1 T gmnP, a canrntN winr ~,684 m citia of snmaways a so 1u0p9 eroup a( rnu /i e inNp~r~'~ dh ararsh- hout khr«-hltnls.~n( the d's(fnrana In n,nl nras~rnlalion and mm IWhsg hr town « •Re-n mlaNieN death rata baw, ehc nnl the IUSp ; on~~nlitan tbanlla w de6rad b pMrlalqn and the largee eity M!p,Mti.m rlya nun of J s, a/ ehe Uniled Slaa. UodouMNly. [++'nd N,en smoking haMtr wen P f ,ne mn live in . mnll towo Mrt mm- alwml, umte lo werk in a brge asy. 4. Punl aeas. Thu ArMysb b m'.,~q s'n Ipl al nren with Mral route .ddrasa y~aa in MAn ~INn of death nla by u«sking hohns hw ~"I I'°^ `°"mirn and tuwns o( ndry e. elnnaly for each of the nine natam ^'M IM nd nwm m ~an,wtropoYmn awnt:x. wli ch the m,dy w;u rsasJuaN. Smoking bm, H~a p rn unuble lo elasify A@41 of the men :n w` sOn'binN in the •w,e wn thb way MenMC the4 Wdsnsa wero srnbN far the urben- Y a pnvimulY dc- mry fw Jw nx uudao rnrul analysis In ~ II Fmr agr. Tal h B J mvr Jw 8 8rs' m in pa4; of thn nlne rta« tlw I. 11 ram of Paacnln e diaibalion of the y h^h a hi.rory a/ rtpulw n8onyt mnking bilisl pplll.;lim ie eaeh ol tlre group b,,.r.w hav then the death role of IuMta ual I gm:n wbo had '1' aee. sd bbM 7 ahoses the numb~a wv`y rntlkad « smoked mIY oceaimully. i~4e. eas °f'kallo aN death nls by rmoyos MMi. (« ~• tM de.eh a of smnlrm of orq ~ "°ro ^r yrg•:atld a dry wa cVyYtmllyld~ sva t e In all (...... grm Iss in nll fY . eet Wthhh e FexFvM lna+r:iW ru~ aw. . r» .,m onc o! the aernh,nal gm,rp mN o Luir Inr mn. .. ..~a- • --_ lumsms• the rn«mlrry ratrM fn h r 1 • ns rs - the fm, .ge Frn MW ntinn In rhnx nf r np. 8tnm6nlirr.l to - - fnMrtinm of the IY54 - the agc dis- A tatal death rate was 8nnlmg smnking hnlpa, the ass si xs .e u' in dina f ~° In tln• nrrnl nnn than or mnm 1 `^mn"lanm, M the whlte rnda x~ ~~~ *_ n_ P^Vnlamn af We Unkal Staa. tin• dcaln rnre for n'M in the nnal e c 8aralc amnk- ess wem olmMt idmUanl in Ih M1he molu ~ of H e fn,r n.cn.. in ana d 14090 to ~c higisa nmM;B mn living men in the Mh . ~'~ p'In t Ikm tlum ansmsg Inhl enas, Imt Ihe IIPr•renea hl mn. Y nlme is nnt statntlcallY NBnigomf 1 F-q611. Rmth mta al nnw 4 tlre UnihH Sfatr. eawnlly ImJ t br rancwhal kwer Ilmn dath mta /n ntia p yar, a rnmpral with hNll •7~ !x•r iau.IMp t!er for mn, ., aitia af b0.p)o M~r 100,01p Prv year JiB k Iu n, w. .+enro a! 9.2%. Roweva. them wa u mmallrr MoFOrtion 0( aj . . W rtl/e •kd nm in a,a- a, wm •.rs a.. ryai.m of rrsen ho never rmokal nr smnkerl ~/y n o`°°innaPy in noal atea ah nn in hr ui (h 8<ta.Iaie .. n.s .. :- _- ns 8). R eM«I Bhimk' 68T969Z00T

184 CIGARETTE LABELING AND ADVERTISING dtl 1 dt of mro whn nmkW -g tl x n1t- 1<r rs. GmWung the m. n al grnnp wnh an k n of rme 1. k or moee o[ .:garavlcs a.I:ry, Ihe -mm"allty otinr by state wem ar Inlln C ff Vu, 221, 111'non, 2iyL lowa, 118; nbcing:m, 11.1. Minncsolu- 1 gU New lersey, 220; Ncw York. LtlS; Prnnsyl.unia, 1.'!tk-nml Wismnain, 1]2 TI' uYon s gre Icr than wnuld be ee- penad mn idering the nre of the sampks (p_g45) GumpMSen d Sludy Pniud. One of the pnq..us of cnntim:iog the snnly for .mther twn yean a/ter the publreation II ur &st fnulm/y was m determine wlather any alqrrcciuble ch.nRes would ocnn in the rnorcdity ratws ( L e., close in tlre nvn periab, eaayt IMA the mnnality r,nia for amokn 4 "I 1u/1 highe in Ih I t two ym . II' - in the ea 1 erp~ nod Hnw- ever, the dignmces are nnt smthlindly s/gniflrum. Indepndent Check un Folkn.-up We anticipated that sonw nf the mhmlc<r re hs 'eht be 1 1 to u.rme Ihat tbe I IMS I irmrt of lw cMse /r r.:ds or rela_ uvn) wen ali t I thcy bem Il tl cantmry. Tbu difficulty mnv nkely to Ye in the ase of snhjects who wed. A. a sul Ip 1, we mked ehe mnrcbers m remrd all changa of addren. In order to make an InJepernlmt eheck of the folbw-up wark dune by the rnenrchers, we sc knnl a wmpk uf 3g,5g3 men finm ehren gmups: Teeia 7.-rerel tNnh. nd Perih Mn M IPe.0ati) Men.yren 6r sw,Jte[ ftelY., bv Ap - 3ren :I atwty, wf /a Ner .n^.e....•...:r..n..,...:.~.. . . .. ..r , ,....r .~.a ,rr.,... rr ..... r .u...: w.... the :kwh rntn of smnkere am cnmlured with the death vte uf nonsmoken)- As of the r.waN dare for. renieing data presmted in our gul nporh the .vlantmn had rspusted 4,g51 deetln occurring in the period from fanumy, 1852 Ihraugh lk+ober. 1g53. Subeqnenl in/anrulim re.eival fmm the volrmtr.cn raued this to a letel af 5,0gg They re- pnrted 6,80/ deat6s which oaaned d rmg tbe nest twn ye.n (r e from Norembn 1g53, thrwgh October. 1g55). Table g tlwes the u Iser of deaih, and death ratn for eeds of tbeto ewo f'niodr for severel amoNng cnegw/s. -Ibe edaNnnhlp betweeo entoNng heblta end tMah reep wae quite o6tssszooi (1) a reprAUntelivr wmale of ivn of the d who wid that they had never s:mked, (2) all the nm wilh a hetery o/ reguL r argnrnle snwk-. h.g unly who were wrnmlly smoking one m Ivo packs of cigarena a day In 102. arnl (3) ell of tbe mm who were Ntmntly smeking Iwn or mue packs o/ aigarnies a day In 1952 For ehe wke of beNty, we refer lo Ihme Imt Iwo groups rombimd u"Aeavy aigaretle smnken." In the fiut week d Novembn, 1955, we malkd e brief qrwtWmure (uking ~rra°t eigarette smoking habits ud date d blRh) lo .11 uf Ihw wbleas exMg tnme whom we knew m b deed.'Dte folkwHag rWanl CIGARETTE LABELING AND ADVERTISING u Ixintnl mr tlse faa rd the questmmeaim: '11 tl .in whn.w mme ntrysr u. ms the mher ride d Ihn cnral Is rkwl chuak In re end mtum this conl,' In nnln tn nbinn ar rnnpkVn coynage u pon /hle, gvo nn.erelve mndmgs weeo ruey the 4rt bring eeati6rd muif reqniring ah.r ehe arldrnsce sign a reeeipt olnl whia# was remmed m ru by ehe Pust olgae By the end of Ibrs muling p.nttm, wc had nbta:nml Informatlnn on all buf 2,135 of the '195&) men in Ihe .ampln Vrmr.h on Ilw e 2135 were enl Iu the respa<i.e dlNShnn of the Ariwruzn ooncer Sociey7or fnnher ehecking and 1,428 of Ihem wero found, ifius, 37b16 of the men were suaoarfully traced (4gYy of thee rampk). ImMnndeney of thu. Ihevolunteen eent w rw- tine lnllaw-up rcpmta on Iheu mm, logelhn o{tb reparts on .11 the whn nbr In Ibe study. 185 se:rrchns are ue cbse ea anuld he ens.<tnl on the hoss of sampling vu ution (p_63g) F:nlrr the I.dure of the vdunteers In relnrt mm. deudu had rady a Mr/al egrst nn the nmrtality rntiru, o Indlentnl by the folbwoig .vmpmmmnr. F/nt.,~ap~ applied the ago-qrengc:kath rate for rnndred Io tl e ma ye of ex- Im•nre to ruk d heavy prelle n..hes , ider- Ing only the repona snbmnlN by the .ol rrilman. Thu gave 1,425 obre.vnl denUu venus 712 ca pennl dalbr, a mortanty mtiu of 20i) Neet, we cnrtied out the sanre proeedum, InehMing all M.vthe but Ineluding as olire only Ilune sn repwnN both by rohmtem d by indepmrknt trueing. Thb gere 1,41117 observad death. venns ]44 ea- peded deaths, a rmwlality mUO of 2g1. Finally, we aauldned all cuea teueed hy eieber mre of the T.w e-tnq.nm. d TM.I UMr wd 4wA n ' wea h. mep a~ are,.yem fur fJ.nwl fw.Al Crepw4s /m er S4n n/ EIWr h hrkW lwwr. IsMD. nrrwd ek;eeder 1 W9 ed NewwAe. /LLS9. t•,wr.~ lkNber, INU __ nn...n. - live . aM.,. ., .n 1.m: n .r..prwr waTn.n..nYr.nnr..nr.L We formd that Ihere wn e tlme bg In the ro- two psomlum. This poning of a.ne deathr by dse volunlaera. Vrvollp vnsrn 752 ea gnve 1,4gT nlverveJ dcnlu about Ts af the deaka were repnrled orse folkw.. IKKlod Jealhs, a nwrtaliq mtb nl I9pI up later then they should have bien m Tlme Tremla _T.hle 9 shnws* Iw mmJ. riaJ Inr parled~The death men for mm whu luntsm mbsed Ins than 3s of Jnthr hid heavy uguretle smqkers vm ith Jm rkmT r.ltu fnr they had hn 1 e nr mnre oqtpo i,nwn to rrymrt~ white mula the Unitnl Stales in Iwo Iwnmlr F the enti pen 1, the uml parllog of deaUu of time: J ry, 10.Y1, ehrangh Onoher, 10.53, and by the wlunlenr e meed to Ir Slx. The mwt Novemlxr, ItISy Ihrough Octobe., 1955. 7fie fig- tmpommt fimlmg of Ihildaaimg pocadrne was usn for mnln lo the Unital Stan have hron ual- µhat fnNem nf the volunlren m repM rnme death+ )mted Ier eRing of the pop:dalnm and fa se+.mnl u unr InfN m. the smnNng habiu of the mm, v nnion. The figrrn in thir sn:JY lnelaJe all the A toteaf IA13f dnne/u rsea5lired ornong men wbn mm eroced by the wk:mem, by Inrlelrenrlent knk oF which BTj /PI.fA) were repwted becing, or by bmhh by the vonmteeu aM 58 (Sf/%) wne inord by The death nle of the men wla never srmk.d inJqx,.ndem trncing. A totel of 1,41Yf dea.lhr w.Z was far bxer ehae the death nte in Ila Uuin.d ~(~ g)t ~vy ug.eetle smoken, W whkh 3rolm /n ell four age gtoupa in )wJr purinds 4 eM 74 4.gs re~~ ~~° YOk'nt~ fin1e' TI'e °GO of 1he death rate of mus wlw nevee ( ) ww found bY Itdependene Iraelnb emoi d ro the deetn r.q in the United Slatea tae r The Pmmr.gd o( de.IM tmt nporled by 16e w~ oeerehrt with ym. i JI Iwu. Ye Poup. WI

186 CICARETTE LABELING AND ADVERTISING l1w deuth rnle of tbc heovy eigarnb smnkas u slightly Icss tlun the rate in tl United Staics in Ihrro of the fau age grnnps sn thc fi t t . purial. 11 the scamd t I M tlu denh t 1 tl h vy 'g tt kef - lighr. dIh -t (I-I m 1 in the U taN Srulc: Iw a~wunts r:mhmF (mn 7% ill th oge grap gSbASte I9'x in tlm age lPOUp 5559. Tbe reasun fn 8 }IV .e - Ith t of tf Inly pol I1'mn will I1 swil later 1 th 1 rt A;e._It Is well knnwn that ag s emnled on denL i.xtlfisur mx 1 y m ect~ J f, we were lmt ~ nprised ta f,nd Ih t dte age as n- mrdrd ar thu dcalb certificute JiJ nnt alwaYn a8ree with the ge mtvred un the smoking q,es- tionndre in 10.52 We also found same digerelues het" age as recmds.l on the original qusstion- iu 1952 and date of birth as rawnled on the ronoe mailedqneainnneireosed for the Indeperdmf ceck on folMw-up. - In ankr-to determine wiwther disa.eparru> in dm rr.vrding of age andd have hud any apprn+- ahle eHect on the raults d Ne study, we compneed Taau 0. fr.nvrlnn ef Uarh IWer qr /Wpb Are, Y..n. ef ar A W/w. Nnn' S"^f°f e/y EyJwlM $ rv.terr rv.terr Lv Rt N Sbn 44 5Yde WaA ThwWMre Ma4 eeaxlMio. M UwoMSraa sor .wam~rwT•.-. r.Y ys n x~a m uw .,sa s,m uw '. aee ma the maMUlity ratio of heavy agarette smn.k..s aa cornprred to rnen who never bswbed in three dif- lerent wnys. First,. we made an analysis Inclnding all traa.d subla+s aM anrmdng tbat tlk original smtement nf .ge wns amect- Thu gav mmtality rmio of 1.99. Second, we made an analysis cunAned to tlaue cmea where dw fnforrratkm an ilre-mailed qnesMOmnire or deah artlf ax wm u ngreerlrent witb tile age . r originally st ted Th ws true of 89% aJ tlm ases. The matahly rutro was 107. Finally, we made an analysis anuming that the Infnrmnlinn m Ihe iwlled quesUOnntlre or death eertigcate was mrreet ng+rdkss d the age re- co.ded on the aiginal quattawlre.'I61s alm euve s mondlty raNU af 2.07. As ahawn abave, the analysis based un the a.• rumptinn that the odginal atatement of age w.a ' cn treat gave the bsvet mortality raUo'D.adore. it appaars that If thme war a anug aystametk blu in age as originally statnl, it was in swh a diree tian as to praluce an omderesHmae nf the degrm of assocmn betn death rate and Inovy Nga- U smok h 5 f I f tm fent Ch k F il w vp-Tc eak. Jahly sure thnt nn ermr wlu Intrmlused by Irepndmg ol deaths, all nf ahe nrhlecb with New frasey nddresses were clxekerl ogmnst tbe f list of 1 d nce tt 11 e t t M Ncw J rsey 'n 1951-d 1955 Ti . ccon pl6lml thmugh th q+eratmn of 0. Marguerde F. Ilall. Dimctar bf tlie Ublon of Vind Statulin 'md Admimsbatlon of the New Jeney SmldDepaitmcrA of Huuldt. Amnng those mbjects previnnsly naad in Iwu ways, no deaths were found which were oa eBFn rapnned by the wlnntecrs or d'umvmed In the mail tnefng. , EB<ct of Sc.eenfngOut III Me. 1. retmsprFtiv studfes nf habtts in relwim to diseae, sableces are nm quptioned amil after they beenme ill. Cunr.eivaMy. iilness eould bib tlre way which a person answen qumtwm alcnt hb hebit.. In dnagnmg tlus pmsl'Mive sanly, we mught to avoW this pasibility. It wm fa this na- sm that we instmcts.l the volnmeen not in enroll a learnif they-koew he had lung cancer or if he seriously ig Irom any diaeare. Obv/nusly. tllu procedure was nnt as dgdent as scrcenfng Mm-l peetive suhjecb by mediml eaaminattnm (wlnch ndt feasible). NevMhcbs, the results Indicam that the volunleen were mmes 'mtian in caming aut their iminrtioor. Tlds b shown by the fallnw- ing figures. - (Itnly 24 of the 187,783 nsen died within ane-k ulter lhey wem 4uestionl 39 died in the semud week, 3g in the third week, 46 in the fanih week, and 45 in the fifth week. Of the 24 wlsu djerl io the fint week, nooe died nf aneer. Ie uf heurt altacks. 3 of oenM I h imnhage, and 5 of v.rinru alk musn. O ly 12 died of cancer wnLm ae montb aftm .hey were questioned; 19 dinl m an srs.ed month, EI in the third eh. 30 in tiw ' IavOi, nnd 35 1. the BftA mant4 Deaths aca,rdng In the Mt several weeks wem predom/nintll dirt ro rebtively mthlen nn (n g., bnan mtuks, urokes, and nccwlrnts). Althnugh a few mcn ai.d af rnn«r within a shnrt tinn aher they were qae- timed- a etudy of the reaords emes thnt it b nnlikely that the volontees whu mmllal Ihrnl knew that they had canccr. Far eiampk, one man had a thuramtomy, nine days afni he was mmlled Io tlx rmdy. It was for/al tbut Ir had lung canaq md he died five dan later. The esdmlon of seriously Ill men naturally rs- sulted in very low death atn ' the early Iwn of the study. It b gmerally6greed by nduariu thN the selectfv.e effect of rereming eut dek pu- ann by medical erandnatlon Is 9•ea< during tM grrt yeer, dhninirbaa npMy with tlme, Ir reWNdy CICARETTE LABELING AND ADVERTISINO slight nflerr tlre third yeaq and fm all prea/cal pur- pnc. ux•ars ng within five years. Mr. PelwaN A. Lcw of d. M.Impohme lde Imumnee Cmnpa y fvo~s' tno tbe nes (from mterrvrnpanY atudws) e ndanl ordinary I fegin urehiwee~in 19Who 51 1U%Tlie la.wh rate rme fmm 4V/ per 1/p,BpU rnen in the Bnt year Aer Inrrthnse ol insumnce to 847 the nest ye.nr.; n .. ase of S9x, By mmMrlrnn, tlm death rate f ou suh/ecjs in the mme age gmup was 1415 m•.r IW,9pU man N the ppd,al Jsnuery-Detn. hr, 1952, and rose ro I,dro the nesl Year., an In- rrease of oNy 32x. We mncludc that the screening out N ill men by our volunteen was far lus ecirne etian Ihe medical mereqng applied tu.pplieams (or standard life imnranm. By the same token, then is reamn no bdieve that the egeq of saeening by our vchrnteen wureoh nwre rapldly.Vulunteen would be unaware of nwuympmns.Ne aonditlms which a physfrian wonld Fnsd,-. 187 m the sanre peiorl of time and tlm cormsponding sln for ho had he1J rtaodard onlinary life laIn the fi Ines for 5 to 15 yean nt eme perlnd, the denth nxe of inen m the sturly wu. far Mlnw dw mmpnmhle mte Inr the United States prq~ I 1 (II e., only nbmlt B4x of the 6uv r te). We tt ihnte this lu the fnet thm III mm were largely eaeludnid by the Wnn- teen- However, the dentb te rose rapidly with tinn as the egec[ of this sefa2am were og. 1. the lut year of the stndy (November. IW4, through Oelober, 1955), the nt< for an study gra~p-.rn 82% of the nte far the white mak populntim of the Unfted Stntes in Hm age grnup ;A51, glx fn te age grm-p 51i59, 78% in the age graip gpg4, and 8Sx tn Ihe age gmup flSBg. As pevimuy desnibed, tbere 6 rtuon in ml. pose Ihat the egme af sneer~ing out ill nnn had nnrly wam ull by the Wt Year of theetorly. Thea, fon, It appears that the death nte W tud W re y T.eu 10.-Cwapry„n a/ y).wA Anel pn Ilp,IOJ Ma,.ybn ef Mw M TA4 Srd • TWI WArye Na4ly:dyy„ ry Uan.4 5rfo wy rM,~/ Eewyhy Nobm o/ ySfwdM M 9rWy .yrh IA.I al - . xwr We r+wwm..rl _an_,e.wr.. vr.b b. u a~sw b.o bw v:.' un v.ns a.r. u aii '~~---~~ . . r/r V. a. b~. as iap tse saw rw Jn u stir ~r r r y r r- ~ W eun a •.'OOnnanr ~.m nMn .' . Iti~11e Mn~ 4r~,r.a aaurim.na.~.~y..i~.pyy~~ M lr~ r w n r.n w~s,nnM rn.nnllr ar. W..y C?n!wriwn with IRMh Hatrs in dw United Sbter The independmt elseck en falbw-up (s eusly descTilwd) nveaaled that the vnlunteenlailed ro repurt S.Ix of the deaths whfeh aeually ae nrrred. 7be perc e.ge rif additional dr.ths rmt reported by the volunteers was 1.8x for ee perird of January, 166P, throught)crober, IgSEi 3% far the perlorl of November. IgSE, thmngh ~ber, IgST. 35% for Ihe pmind of Navemhn, 1953, through Oetober. 1931: and 11.4% for the Iserlod of Nuven' ber, 1954. tthrough Ocrohm, 1955. Table 1g dnws the death nter by age far all the men In tAe etudy by time pnlndr, the nte Iseksg .d)nrtM rm nnaer- eponing of dwtlu by the percenbga Sive. above. Also Imwn fnr mrnpn(on 6 the death rate ef white malet b eM Vated Statr af the rmse age papulaHnn wmdd nahlgee at ebart 81% m g8x af the rate for white mala in the genv.l Untted States pepuhti.m. This relatfvely emnll differewe Is partiJly ascmmted for by Ha folbwing fams. The study wrs carried out In Z194 aamHCs. Wc applied tbe age_efrtd8c death rate for the white m.le populatian in each of tiwe vountfes in 1g59 ro the rurmber of sublcess relected fean ach and larrounind thom lar twhltemaltles~the Unlted gtates rn1959 by the following onmtmn: bex In the age gmup 1.Ex in Ihe age gmup S5S9, 3.gx in te nge gronp gp84, and E.gy. In the age gralp RI Sd. Aa jmHng the figurn giren earlier by these amoums, It appears that in the Wt year oe the study te age- rpeei& death la afour rtudy populanon was .bout CAk ef that d the gencal whae m.ln pqm- . .r is1ssszooi

189 CIGARETTE LABELING AND ADVERTISING 188 CIGARETTE LABELING AND ADVERTISING Iann, n tbe snuly nrca 'n ILe age gmuP 50.5f, eler u gV'+ in Ihe nge grm p 35-Sg nlrool 81% In the M group 61tg4, :md alnut 61s in the age group n. nn n,nndrgdig.n anlrnTrahlyau I mnl m a slieht JrKrn: of srcirec r scka'tlnn And la Ihe f.ct Ibm tbe volnotecn did nnl mmll m nhn ,. fm n Inrgtr sr n nch inshhllmrr mt:J hmpituls aml uda-rcalnsis sanntmimm. Nrilhn hd ihryenmll it rom Inl.nels msd simi-. hn 6rnnla Ilnst mnld nm huvr heen tnceJ. The hol tlml the urcawmnnm c seler9nn nF otir amdr pnpnlann • mlaNVdy Jipht u ndlcated by ILIs mmryoson. As shown in mhk 10. the death mte of inen w•Im hed h Id c ndard ordinnry G(e Inn rnnm 1•'IINn fm 5 1 15 ynn was only G'1R of i6e nai• fm the wbne mnk pnqJonnl of the Uon.l St 1'n Ihe nKe gmnp 50-6f auJ Iv S9S of that 'd II e nge grmrp fl5_eg in the perlod of No- vemlrr, IgSf, through Onnher, 1955. 7hase Inn had behl hfe innnalsee pnheia lasg elmnph far the egect of malical releUion lo weu n9. 71w1r deulb rmrs w re far bwer Man the .atn of o4n rlody pnPJUtkm. Hokkn oF snmlad ordinary life in.rnnn 1 l ein, h.e 6rgAy podsmis 7n Me mM- dle and opper emmmic prvm, and meh invnnnee ' rmt rnkl lo pomPk in JanKerous «cvpaUOm, to In,plewah quesumrahM hnhil., ne to peopl. with 1mpaimwnta thmughl to have an 2Hec1 on maslalily. 'Flro sliKht sacirr..nlamic sek:c[sas of mo sub jecta cnldd hnve hnsl no in9rnarca on Ihe gnJin® of Ihis smdy unkn the disnihutim by sor vannomic eWra digr•m1 mahmlly umung Ibe ugs- rrlle nrokm ar ereroMrttl witli the nrn whodld not smoke dgamla. AsmrJmg tu Moriyamn and Guralmck,' nmong men in tAn agc gremp 5•Sbf Ihs fnllowing seL Uan ol dath rata to mooeamurmk dav (m Indicalul by occupaltnn level) is found: L AKriavltnml wndas, inclndlnK farm ovnen, have the Mwat death rale. 8, tb.npation kveh I and ; mmprising profenlunah technical, nlministn- iivg anJ managerial worken, have a deeth nN alwut 9ss IsigMrthan ngrknlnrral wwkna, 5. Oan. pnhm kveh 3 and 4, compriaing ploprktas arld akricil saln, skllkd, uid somis4llled-wnsken hove ddeolbnte abrw g4 higher than that of wnrkas in leveh I and 2 4. Ocapalinn kvel 5, r.ompri g lahoren have . death rote ahout 47% high,•r than IMI nf worken in kveh I and2 7Lm, r 1 (C I'f N. Jersey. and pm - syboli 1Ie l ed in ideh I1 1 t:c ciqi ( Ih- ~'r IKrd+))N1, 41r.1ri'ileh u w clas fal nw•u amvl 54gt 1 o Ihal in Iha . muh+ hy ocanryufon kvel '11 olu -w•aro as f Ilows: PAO. of dlu Ngamnc smekera unl 29s of Ihe mcn who rhd na a nn4 aganvta wen of nrn puti n ksx•la I md ^_. IgYA en193%, nsl*•rtn•dy, tn re aF IIm M\YIIWInrll IeN•h 3 amI 4; 5% a11rI SR, rahee- nvely, waa of omspnthn k:I S ard 21e and 3%. ,roheevirclr, wne .grknlgnnl .wkan. It I6 of interest that dw prnimrtion of inem m amlunm level 5 was the 5anw far ng•velle nrarken u Im men who did not smnke cigarettn. Comidering this lglt fllel tltyJP givenlyllmv ynma 1 G r I- k it Is appa rmll t tlw sl ghl dig ren in Jislr In 1'mt by ottnp:niun leveh he twam 'K tt k 1 conce wl evesmuknl dga uahdd only a tl i.l egect on rdutive dath mla nf Ihne two g 1 of mbjcata. Check for Pmsible Researeher Eiar A. previnurly deudbed, the tinte Irend in ~kush rata I' ats that tl e I nlecr. shd a gwl pll of u.' g t eeri ly all mrn as hnln avnl 11 the _ sy 1 as is 11 . pect betwm tle uls. liun nf smokcla nnd th .I sinn of Iwl ,mlkn, it ~0ppeum slut ehe pmpnrtiim of 111 mn scrccnv d Mn .y6 . Iwen liglll higl f luny knvne mmk Ihao-fo. mm 1 ever slsrnkcd TI . b .uggalnl by the fna Ihm Ihe mnrtahty rnun fnr heavy e garette slnoken, avnnpared with mm .rhn ever slmrki, w nvbot Ilighn In the 6u1 Idni yenn nf-tbe ahdly Ihnn M Ilie earliv pnio~l (tahle 9). -Neverlhelay it Ir m ble tls;l, mmrary to imtrnelionr, so fewsriruardxmi dehherutrly sele<Ixl men wlgs lung caoacr nr olher henl dis rasa. lf any raearclwrs mtoally did hrlect os m:nse m five or more such nick men, It b rynbalJe tinq at lensl one of them dlesl witbin the ncat two yeam (1t this wae nnt so, I:a. of Ihe snrt under mnsiJ. eritlon anhM have litde -w ' gdmisc -tfre muhs of a nudy of this type.) Converuly, If a ie.earrAer seleclnl fi.•s or nwre mr.o and nme of them diesl within two years. H is an indicalirm that she prolwbly eaclnded men with lang mnm u1M o.thee fatnl Aiumes. As a check, we mnde a sperenl unnlyrv iminding only rmearchm and snlryecla who nset gse follow. mg qualificmions: 1, The rese.amher enmlled und Inttd Iwl len than 7 mn more than nA lnrn. L At kasl gve of thae_ men had u history of regrJar c:g.vellesmoking and at kast two nerer rmakeJ c_:garena regrlhlrly. 9. Nm a singk dealh eaclmal g-ihese mrn s4lring the penml of Jamury. 1952, through Apdk I115f. We flmnd gat 5,495 msearchm met Ihese requiremmh with 55,2g5 anen. 35,1347 0l whom Iwll a Wstory of .ugular aga- reue smnking and 2q21g of wimm never smokeJ riglnntta reNUlarIY A was Inu of th t dy •u a- wl1 I Ih 1.ar Ite rkt. s IM, aI I ow A/ 1 Y f[l •'Iu ' 1'n/'1M enmW.l elgannu r gaI ly Doring d s inF lg months from Alay, 1Q5/, Ilsrnngll fiurbeq IsYaS. 1p5g demfn omlrreJ among lhecigaretle s/llnken und 493 deaths oesslrrcd nmsmg thc - who nersr il„oka eignretla ryh,dady. only 710 daalha wanpl lulve ocs.rned ammg the ngurrtte smoken had their ageopalgc dealh rota bsael tlsen snme u fre rrlan who eeaermioked agrR+w regnl.sb'•. 7ne mortulilv mtln IMwcros Ihese twe grcaps was Ihere- fine I,IKe 110-nr 1.49. As enrepared with thn, n tbcrntm sl.dy 7,]1g d adu ocavrred ammg with n hi.mry of regnlur tlgarette smoNng, Alan wlwuu 5(Ya5 w+adA hiwe ac~uried A.deheu age. rprei& rkmh rnla he.m Ihe same as far men .vlw never urwkni ngnrnt mlio w 1 a relpd.dy. The nwrtalily dilfe.renre fw~wem tnesn. twa e.; l.ag .nd L.g) h na aatia. naatactr r P- Irally s gnific et We oon luded eba ehe eae.rch~ . . a-grwrry bere nnt hi.ud. Changer in 9mokhrg Habits InciLentnl mthe independent nacing ofmbj.m by mAit (as prevlously dmnibed), wa obtalned informolion nn tln rvrrent cigarNte smokiog habin n of the peri«I of Novemher, Igng, to January, 1g59 1 dd tinn to nc~ bjecb we wuM1ed m Iram by I we xent quert . narrs to repre.enta• I/ve nmpla of I1001eo 1 Sro bjcns in eaeA of the nher rrlloking ealegorkr. l}. qnaliml A1 evrmnt amwnt of cigarette .muNng .as idesNed to the had entirely stopped smnking by 1952 had ranmed reg,I ci& elte .mukmg in 1965-195g. Howevn, nn L rlha a1mlYSis It s.as farmd thnt J49R of Ihose who h d I.opped sm^krng fnr Ien than mse Ynr w ge kmg regularly and g.•Itk were moking e paek nr mnre nf agaretta n day in 19RS 1455 In contmst, only 7.7s of those wlro had ,inpped smnking for one to gv< yeon nrd 21s of Ihme who haJ stnpped smnking for five ynws or Innge.c reaumed regular tlgaretle srmking. About anequ.rter of ehnle whoavt down to as+sional smoking took up regtlar Ngareue smoking ognin. Ove threequnrten of tbe ho smoked cigaretter mguhrly In 1952 wen rtill smoktng Ngn• reu<e nt the same ksvel or at an adjacem level-in 1g5S1B5g. Howeser, many of them had glvar up rngular-r.igeraw smnkmg.. Thn proPOrtiori of mm giving up the habit was mu<h grealer anwng the l~ght smoka. (591s) than anwni the havy, smek• (14%). On Iheh ather husd, a fairly Yrge pra- pnrtian ol tlnAe whU farmerly wen 1M1eY cigarette mwkaa repnaed amnkmg tnentor d.ur .rlwnnu. Tuu ll.~//n.w/NadaY H.Nn IITaWa F"-A. S~eY~w199,T*..O Naons1. 1W, C.naard wN NakY a.:mi "Cr,:m au,•n.•mrr - Ynbr M~ A„W..1 nw ree^.1 CMe.,. an.planling qualirm asked in 101 The addh I.a.d Kmnin rce fnllnwed througfi Ihroe muilfnge, .nJ .J.nn 15s reldial Tabk• 11 shnws nurent cignMte srrloking habits reiforld ' 1.L5-1Wgmmpored with the habits i ILc a.mu nnn as rsavrded on Ihe cmnking qua- m.nl: n s mlkan.l m 1g52 Of the men who wld dut Ouf had nescr smnkeJ np tn 1952, kas than 1:. saN dwt Ihsy were smoking agarelta regu- Ldy 1 qseolxsl 1gSS195g. gimilarly, of ilw n 1 s kf pipn or cigan regularly x w6o I ad smnked ag smua oerssinndly in Ihe past Ine n 1 king agaretla m 1951. nonly 2a+a ntnnnl rc~mJarngnretle smoking in 195S195g. On Ihe nllwr h mJ, af inen who wem smokin5 dgn- r.m+.wcadmullv in Ig52 and had nevv smoked nClnela rr•gnl:lrly tlp to that tlele. 17.SS retr•lted repula' rtgurege smoking fo 1(/SSIgSg. 'na.e, f ml in 1gsawh> hed regularly aelnked riV+rnwr kY who rmpptd anpkNg Iarm a panlC vd.rly kllnesting goup• Only 7.2% d thew who Age had little inguelua on absnge in smoking hahits. e.celA omnng snrnken o/ lwo p.cb or more a day af cigarena. in this grmlp, the pm- anlage of Ihme giving up the ha1sH wr greatot /n the older uge gmups. As previously nmed. nrmr currently srmking bolh cigarelta mW dgon in 1962 had bw~er r1aaJ1 rala Ihan men who smoked only eigarNta. The r.- quahoning ol the mbpcn gives e eh.. u to a possibk reuon for thu. Amrelg nam enrrently smoking onsi pack m nsore in 1952, Ilm Iws• .xnnge of thore relorting no reguksr dgar.lte smoking In 1955-195g wu about awlx as higis for who had bRO arlluking both [Igan aml clgi recom mlta a fer men who hsd baen smnkissg only ciganeta. Fm eremple, ammg the tcvo p+clu or mh e a day cigarttte srmkers in 1952, 07 f dann abo moking cigan regul..ly ks 1g6S reporled no regular dllaMteameking N 1g55-.195g, n eompn.d W Ih 1]li of ines Ndl a Irhlvy of ragulv algaretM sndMg only_. ?;6Z969z00T 1 45-979 o-bs-p. 2-13

190 CIOARETTE LABELING AND ADVERTI(dINO Of thme who wesc Mill emoking cignetla regu- Wrly in 1955dH5A. 9E% mid that they med fillm-iip cignrcltn.'11.e pmporliml uring glter4ip elgureltn :u 2W% anwng thwe..ho .moked smder ane Pack u d:y aml 25% nmone thom who mioked one peck or Innre :I day. Tlm dumg® in nrmking hnhib of our subjecH m:p o::t have b~ typical of what occurred amenp men of the mme y{e tn the United Stmm.. e whok gome miuln h.ro been Inguelsred to change their mkmg 1 nIsIH by the puhlbatbn of our gnt re- pmt in 111054. Sw mu••f Ifetwens Jun. I and Muy 31, 19J2 Inimmnllon obmind on the sr:.dking habit, of IgI,7g3 white .nrn hetween the apea nf 50 and 9p The.e were then Insced through Odnber 31.1955. A lotal ol 11,g711 dentlis were icllorted Irldng tha paild nf Hme. Thc tmal eqMHenee covered 961.75J man- yeAge being taken into eonsHlerat/no. the death rut f mnn with n hlstory uf nglllnr Ngnrette smok- ing mdy wm found to be 68% higher thnn that of e oomqmbk givu, of inen who never snloknL 714 deuth nte M dgerme smoken tilrrraud with the mu:nt ul cigarette .mok'mR A.R n:nn with e histary of regular cigarette rmoklvR only, the death r.ie .d tlwse anaking twn or mae packr of cl8a- rettes n:lay in 1B5£ wm 123% higher than Ihat of men whn neva:mnk«I. Abn, the death nte of inen with a hkulry of mgolar tlgar smoling only wx 22x hlgLer than that of n:m who nevee smoked, and the death rate of I.im MIb n hbtay 9f regulu qpe nlloking anly w.. 12% hfgfim ah.n that of mtn who qwu rntoked. The death rete of Inen who hnd smoked ony usiondly wu nd dgnifiuntlM dlAemn flnm the death nar uf inen who never smnked, and the death rate of mm who had pvm~ up dgurette rmoking for a ye.r or rlwre be/we being enrolled In the study wm lower tWn thut of Inm who wne smok- Ing clgumnes regularly at that time. lfie findings In the last two yean of the shnly fsdly oonfirmed the Andings which had previously b.en re1~arted lar the hc Palt d the mxjy. Mnny chedn wen made to ddenNne the re1M- Wlityy of there 6rdinlp. and no errun biuee were foundThx euuld be.e a mdulM eHmt on them. na1 W. SrM H. (19) (P. Hemmmd/• Tfi4 rdr wu mede yawb4 bv the .mnnabn d Ihe A,ienR •eluMeer weM1m, nrle hnhh detwmeelr, meny dryonim, nd RAn.d ef dlasu d the Me..1nn G SWny. Ia.rtnr.. CerB:Jd. MA.. (:.mnue L new Pmc>; M~~I<~.dµ m~M#" u:t Helbelt Setln.n. IIJ.eenr, 1. Nrm:m:d. g.0. rd Hww D.: Hdubdep 9n.... pmnen SmoMiy lleb9..W 9-+M Mae+: )db.+.p Sudy af IBI,Tee Mmy j. A M. A. 19m1J161]9t1(Ap41) IY5/. t Nwnwd. W4 MY~1n M. l.: wd Mllkr. H. P.~ Tn h..m Sninlba PM1Hmm Ie UNId Sutu, hatlk Ha94 MumIVM4.3, U. S. Ppnwwet of HalM1. PAuuIMn nM Welf.s. 19m. 3. Narnad. W, eJ SMmYIe. M. 6: 9nd:FU )enen. :A FqiJenbbd el 1n:n/ C.r!r Y Unttad 9u/n- A:e They Gniwatlblet 1. N.L Oea lul IM1r1T-1NI (Ivnr) Iwa. 4. MuIYeK 1. M. ud CwdnMt, L: 9empnanl .N sxl.l CL.. 01/ "nsv. In MsuWr. Ie llmd..tl bifm M ra~d.d~ Yn~1:. M~tM ~trl ~4 ~ CICARETTE LABELING AND ADVERTI87N0 191 ' SMOIONB AND DEATH RATES_REPORT ON FORTY-FOOR MONTHS OF FOLLOW.Up OF 1877gS MEN - H' UgAill IMTLf sY CAl/9g & Qlybr Hum:lmd, Sn.D. r Drdel Nan, Ph.D. New Yw4 fielween Jan.1 and May 31,1952, tnformation ww ohlainvl on the mlaking hnbitr of 187.783 wbne me's brtwerw the age, of 50 epd W who were then wsvd through fh~t 91; 1953 Durblg thit yerind of time, l l,g]0 af Ihe men dird: The total rapmenay M'h~ W7•J58 man-yean. Ar de.eribed in p.lt 1 P'Per,' wc found that the total death rnte (from II casnn romtiine:l) wp much higher ing than .m:mg men tw°`/'lloohad~nev¢ssmnkMsrig.. . Sta regularly and that the dmth rate inarea.ed with moum of rigarette slmkinb Peri 2 of this sQdy ir mnenned with death rmq front spe- f:c urea in reletlon to smoking. Gma of death wee arrtained fmm duth mtlfiarer. MH ul ererr inrt«1ce that cancer u mentlp:rd we wrnte to tAe bct hnspltxl, or Iumnr regktry b htain morn detailed infarmetlnl. Caux of death as arated on deah cerHfireta b hHCct to ®nr. Wrtin:lndy when. Hle doctor wliu IT th ceaigcae hu liltk or nu opwauniry to t ly the putient before death and no emopry le nP°f°..med.~Wfl wme Pleared to find that the diag- dnnlln esen rnrd mrermmpieallr in 7g%o( the bed tu cancer and Hvt In Iha mejmitY ku.e liuk douh11h1tfd Wthe ~idensw wu ruch as to Mowever even m wee due to this direyre. there le sonletimn doobeWU mI he ...6 pdm.ry te, apecmlly when Ihi diuaee hu .heedy spreed widely by the Hme of flrse dlegnmii. A eomewh.t anajogour utllatioo acems in eeW in devtlu u enbed to dbeum of the hart eIM 1 j )he deed: phr feer ywctrk euurer Ann b..n .xrdied 41 r.k.nw ro smo4tn9 bkir, in o an:y of le))e] mM belre.n Me n9.r a so nnd d9 O.rnO Me w~ N rAe rn:dY I/p)0 W Men a:wr di.d f ' rnrrepcW. 1) p•e..d cvwr y cmwe e. reP er ler rAe mld cnrer reped.d a rn:1r ir wnr fewq rhnr Me deeM roM n.w. AiiMr eneny npv. lor cfynrerre .eokerr. Mnn omon9 men An •r:.n.w rmek.d, rhW Nw m«.ralirY :brie N- adw/M rM,wmber W dywerlp InulM Per. de), andMaMe dwM rarer.w. Aiyhn mn1= PY and e:yer.mµrr rhen eneny aem M uee« nnokN. A/erel ef ),.lld dwMr necvey e:lwny r.yuy, eiqvene rn:eYwr, en e.r.n d 2Adf nrar M. I,651 M^rrovldAm.onun.dAedM. p..per(hr lar eenrnnk.... CwwyrY dirwr~rwwly far f].I X nf M. e.cery yn9 ronr« a-. caued Ier 1].J% eW cvncr d«Aer riM hk..ke fs 13.3%. An en.emel) AipA esw. eiurien b.erae,l ciyarene naakinY ad deeM nn.a b mm riA Iwp r«ww .w fewld in rwvl e.em er we// ar M brge cdin. The nlnn Mwwru:r rpdt.y of ML re:dl wr Me Ai9A .Ilakkl0 w11 M- raM dwM rre. d9..rrr c a ~e:m; 01et b, m.uy WHenls ruHnr hnm ti.o a mpn eluding vqcular flmmn In I6is sl.as. of dlseses, ar:d It b rome- tem (IMenntiolly~niontbe~ m'1 nerwur sys- Hmec dilgLVh ro ray whieh /peygn snnditim wu AfiAI. (3) Imon ~'Tld and M0. the undmlying ar prisMpel nuu of dqat/N. Indtred, m{sres:Jmp anhme, ingunnzu,° pnamontl~ary tlon ha. peeof enemqinp b meke md a dNHVC dIIHr, and etlw pulnnmary disease but er4el ~ing Fm. these rmuonr, we Bnt mede m.nal le cleuf- ~lum. (/ntenytiena yp numbns Wl~ N tW.~O' ]. .nd SROS fy/ng ehe devth. inm Bve brmd ntegoda: ~/. (d) all athcr disasu, nsd mnmr (Intemmional gMtiafrel Clasi6cmio(1) (5) numb«r F.gWEgpp ued micWa (Intemnlim.l Disen.es, Injuriea arld psny of Deatli Ikt numhen )1b8a6), (2) hnrt end unalatory dkeetm,-in- Crnvel FNdio .:..o.n+w..Inr..+r...A-rw'-. Table I rhowe the numbes of dmh and dnntls eu.iaw: .°~: m u,+. n: r cr.a r rM.:~y ratd pv 1 WpgO nrn-fw•n for ~)~w..lr.,re a"""'r+.~.wr amuked:(Y) mmwiNehiMOry(1) reg6rdgr+stM °^°khlgI m.oY of whw. .la cmekd dlnre .nJ Pbw: .nd (3) .B otht WMemr, fnrludln8 Pi, Esissszooz

F_.i t14 a.R l.°a:e0 [! ;iI ii lITa 144 p!_^ se! ,..------ r :•l fa Ea'F kIx af9'F_+a° t.i. ••• -•• •a..iC IIYf BE i_F 177 as °aT sr• sat °ES xa:f. SSI .s.6;~ f'{E A!d }}!.!_l aa_l a!! aaa.aas ese Ell dll ::}_ e}l.vae ate•n•.aR ea° ••_ _.. " •ia=!f ==SEA} It..iei Adltac el!l:L: niFa•a tla aal !?lACi!tta= laG-...y.°F_......_ •- tt•.a• _! ;'@4.l i} .sd[ eEc edn_ •c.v x;. x_r_ eax ••a eta 3Aa.°.i yS1 Vl~' Vy. Sha.lla ija: S.1 •_ ~ 1-a S+.a S'_a Y•_~ V VS-V=-Vk-VS-VS yY scbapfd•6t•bk•. --..._.i.=•.F.. :SE. i!t :SE iFG YaR ii1F ..Ft .3_ ••_._t =p..t1] acl 4.~}' !}_ •sz •ix••• _ax Ca: -._._.....iP .iN ~~A:;.p t_~ tAf !?e !.> is! R?: :'xt :?t :dl :a Ees ill t" :a• ;as :3d ld3 q i}l d(i ;4E_ ilP, sit!}I az_a apF ?It -.- eee.3ti °-t3 a6;lg; }il xg3 ati ld!!iE P!"S- S1A •P- a.- ena idl 4.9 0 Fit E-F•. all sci °.a -.. ade.•_•'x"•• sst ta• ~~ iE[ 5491_i1 fa s_Ea_aid a: aas .}s_.•=• •F==.x lis_ 3u °•_._ ~ 'f e $ 1 ' 1 smm ~~~~g•~ A I `iig@ aEt iwi iid a3e ca_a aza -°c.s3a •a- •a• -r .Ea aa° t°3 lIF, i:l }!! iiI'i:=ie_ asn aoa 3a-i •.• e•- •ea g_e_ s_.• i3E~1 °SS djt 517 eda cd. -ct •.F .la.•a_ _-..i- ap. aE. ~ Si IiE ElE tFa c°. •ac •ee.d. •-• •.• •az e/c x.a Ell'ds SES ti° tets}a •a- •r._.••• -t• sd°.sfa i:_E. E. 1 E F. Y E f! !. E!!E! ~3 ES F [• 3•6 ' ~i_E ta.1€r'F le~ 1 ?a Es~.l=s•t? _-1ca:cs }1j~ E A 4 t[• L i ~ L6 L a 55p = 3j 9s !°'u :jTFE~s ~~~; ''ggg5F a~'.~ '8sB ~ ~1_v - ~ ~. VJ s$a ~~.' 3y 'L °y E'~8°a ' c ~ 9 E- E L~ • ' gveyE~y'~ 'G~~'S~Y~ . .i.c ''''$$$i ! i'8~ T

I t -E f-[:_i 11 a,[/R [CS R[5 /aP. tq ![__i l5r [[c.!_44_ [[! 5[! _[R5 [_4_[ It[ ![1 l[ j .. --_ [ n _ _ ssa _L¢ Yzo .•_ I i=a!s_/•_5••t-5ae•a••v-_L-eC~•e•--•-s,_6•cs"..a..- . l6 - ; :i5 [a 'a- t5s !3s . n : ::: }5 .- ..I - :., . . .Aa _ . . . ^ em-[ft5="ca-5- /d - C2/"p2 'f~SLL:GilaR.?99i*aj..:£C[REaF::LLxin..•[G-}rLLA[SY.RF:' _ a9e •aR •s£ •is .Ff..a. _.. eas <[p-25 ...... j~iLL'i_L-aaJ/icl-L:SC:[i•YLL7#•L= Rar.[ll.a[psLr.- -[sag£aas-e2-e-aa~.2..._.;..naref=[• ^ ft . - ..p. ~~€€REL! •$0 aR LaY.•2• Ll-.Q2 - -ce e_a.a:LS . •n- !2 - 1s'L••s•-i•-a:LLs.lcca_•,." ~PY[-L•ax-:-•tes[4::assc-.•5.5•e--.••_"-_ ., ' S L_ I1 ? s a 5 s L ! s s L 5 j?.iij.li.€:~ €+I €>? €•`i .4i €IF €i? tl? 4:i #E3 !:`'i !E F_1il5:LCC'--[• 1+xf£fi4aHAg,~ WAm"T1v4&0lA ![I 0 s=$J~~~.5l.~ &~'2SIw~4~E~ya 3'.£E a ~q ~~ ~. r E= E d O+ ..~I 3''$$a ~'B~;~S.$E S~nEU~99.~ea:S9~S nB~ - ?' i

196 CIGARETTE LABELING AND ADVERTISING T.eu S-NUmAar W W. Bnnhr nd MorRw.l.r C4.rm~5^iakme Onl Aw d N SIart.ASl.de hn Alen wtl5/lu.nr --Y-- `::~° ~_ - - M1nti <M 41 ll m w. el n Ip .. . .x m ti~............... ... w• ............. . • r Y Vaw•NYwr GM 1• w . ....................... K r.Mr1Y we •aarrY •..n nr •1 ~. .Y aRw ~•Yn 1. we .rmw N wn~n A M1• n1 w N w.~ lb•wi~'•n.r•..Tuul.-<M.•mdvmg.ewtrr•~PI~ ~MO.In~CIP wdiyOWs.YNimryMparbWSd- . e n r tw en. " . rv w ; lu . ,.._ . . s. w . r :e , n.n CIGARETTE LADELINC AND ADVERTISIN(3 197 Tim 448 cusra were hudnr, cloanified as folMw.: JOY microsmPically Prored-ca.e: of bronchogmlc mrNmmew other than sdmnearcinoma, ]£ micro- smPic.gy Pns• ~do~d bronrhdgens wlcnocarNnomae, YI[. A-Mi...giy nner ba Nts nf e•ner. rytk• (nr elevelte .nwkva N Mpsad with 11ny fw - dn ie.a •dwl. . . . . . . I nry.ogbmsarmma. 9] ceses in wAich dingnmu wu h.serl on s-ny nm clinical evMmce only, mrl 13 uesea in which the diuese mey m may rwt hero been miammpically Mm•ed (1. e.. in(onnatinn fmrn derth mNgnte only).Admocamnoma of the Inonrhns is vxuldercd sePentely herynte some inretlgaton' hare suq- gnted thet this fnnn d burg e:nm mey 1: le.u Taaa l-Na.S.r nl UrrAr ad .1qeSra.4~diud Uaeth - llwn' f.nw Lny, Cannr Ae 5mriaw N.bb , e... .............. n ia . .Y . ... ....nerra..w.W~ ~°:S'nl:r:.: :~~:(n:.~Sr onrr nn....r r.b. -.n a.y.ntb -y xb. umnatul with mmking thm em othn (omtv The inding., ve ehown In tables 4, g, end 0. am anm'st- ant with this theory, but withatly 32 arxs we canmt be ren. Navalhele.., eWe form of brwrclw Nde urc/nori. ...u h/pJr ned with Ng.- mne snoking. Twmty-yie a11M 32 dealha ocnnml amng m with a hbtoryof y lar eig.vene moking mmlwred with only eia eqacad dendu. The Jigcmnro of YA J ths 1. nwloiically rngnlSswnt (P o.~1.. . Of the tm "ic Ily nl vrd euaa (otlx•r thnn ade 'nr.na), ^AS werp well canhlirlu,-0 an helnrt hronchuti ic in nngin. Tlre dinhnlmix in the mhe,r 14 war less certain (e. g., Jmgnmik lwsed on clinicnl and ._ray finding. In tln. IonN wid. can- rer pmvel by biuryy of u-ineta.tntie site). T.ne 14 /maxnaln eoa, In .11 of which the pmientr e ngamte amnkm, hace been vdddeJro - Ihe gmnP which wig bereofter be d«riln.dar well-mtabli.hed ca.cl of bmncbogenk c.runoma. <.dnding .denonrnhlome. - thJy four mm win nevn amoked Jid of we1L caablished bronehagenie -umnome (enclnding ademsnrclnom.). Since this 4 e amdl oumbei to ure u a beae (or rrwAagt) ngc., ws anmmarised .~.~~4 ~. L ~ ls _ ~r ~: YAr rlrm h.o '.& 1& Y/L 1-.tee-riaM.nlb.d dulh •am ds tn wen- NWid r..n N hr~bneme aLw.m. leshiaw d dwm.rclm.rl ha bw d.n.iiy e• alaviged 6en Yk- 14M hlnery. - Ihe finding., ar alnnm in tehle 7, by coml*ning dcuth mtn st.ndur.liavd to the ege distrilnuion of the white meb populntinn bf the Vnilal Slute In 1gs4. Fig,we 3 dsnwa the egeatendnnlitaH dcmh rntes fw well.esteblhhcd cuo by tylw of smnNng (elussified (rom lifetime hbtory). The nnmbers at the bottum of Ihis ggnre Indicate the emmsimmling i.mher o( mm who weeemrollnl in IgS 2 2 Tlre mtv were Irrw !er men who nerer s.mYul, ocv. rimul emokm, and 'gar anoken. PiPe imoicn hnJ an apqmlablr highv rate.Tlw nm (nr mm with e hiamry of regular eigerette smnking only waa g9 Nmn u high u eha nte (er mm wlro nover rmukeA. P+gnre 4 ehowe rhe ma for mm with welb eetab4shed ooa (mckrding denoe.rerwm.) by .rnwint af dg.retts.nroking for..n wgh . bYtory 96T969z00Z

198 CIOARETl'E LABELING AND ADVERTISING of npllm udl muth anmmmt d tlgartle somkiag. The agoNamW Ilred death rale fur rmoken of two m mwe ro~nnmt,Ihe y a ge-NrlunhM rell deah n e yvr. fmn minnrn.tiieldly Psmerl ~. dlt hined, was only 177A pn 100~ per Ymr for men who neva amnkal. In ntlNn worJs, amonl; rmnkurr nf twn packr of dNarena a day, sMe deneM1 mte Irom hmndwgmk earchwma lorre h highez than thc totnl death nle dae to n oa a(men who pene smakod. Ar shown in figure 4, mtea fm men who Iwd pvm rrp cigarette Imoking were kmer tMu the .alas fm men who wue rnwking dgaietla regw lurly N tM ilmn of ylwdtinnwg /n IgSS. Figme 5 dxsws rM egestandsnbeeJ death mere (•It. eslnhlishN cnn ludine .dem''ardnorna) fw. with e history of rtgalcr-dgtrtn^ Ig'SA m~y, wwho had stopPed evnldng dgnrqtae in TSl v: OU ipra LSl R'z ({,le rLat San vlr. 4-aee'nrd..dl.d drNk rw dee sr .ell. IaM111dwE mwr d hmxLaWr nrdma. tad..lw d .d.mcwn®-ia br arreN nows d dYrelte..edimle by prcvimu daily c.nnrmlrtkm af dgaretla and hy mber of yean dnce they Md lart rmoked. The rate lut rrlel nnrnltly enuking lere than ralo pack of den•r.etor a dahad~ luwas rd~motd tg1A0110 per Year.7lnne .1. . Iwe" at thls Ievel but Md given up tlriokin8 lor fs^m k m 10 yeen was 353, and tM nte for those who Mly B& The eate mgnuolcw.rmtly smokin8 me .1 pack m mme of dgaselles a day /n 11bR was 1 .1 pzr Igpl9p9ller Y~-'17qra wflo had~ nl a g kwd Mtt Md up fair zlmkeJ et Jlni 81ven I mm 1 W 190 Y~m• ve TrA• .nd tlre nte for ehore M hml Pwan up uroWl{ for 19 Yr.n a. bnga B0.5. motlng. The mwbr of Y. of dNrala 0 weg n tM .mount d mding. ..eo. to M ar bnportum. l1s folb.biggus eB deelb Irom bmg anc<r. Far men with a humry nf regrdar clylrelte smokmg only who wrr*e smoking less than death .ae a eh pc IOp.000 pergytur Ia ttha.e r.waa.:u nr .... a 2'w m well- YIe n. Aw.+md.rAlr.J dealA wl.. LIUMI nnu d Lslew~ u~ihew Ir.rluN.e d .kns.Npnr)d gclr iw snn .Ia: Iwa mnlad an~Y. uw •n NanP•d with Il.ne h. wrr oi. rd 11eanfw p.- NW navkint L 1e34o who hul smrYW fm leas than 15 ytan amI Itg lar Ihmc who hari mloked far 35 ycnn or kngo. Among rlnnkva of one-Mlf In me pack day. eM fatm wem 54 for Ihora wlla MJmxlkcd for kur tMn 75 yean anrl Ig3 hr e- who baJ rmaked for 3R yenrs m kmgtx. Fm ruenkrnt d onu m two pwks a duy, the rmee wem bal m ~m e IpertLdY. For amaken ef tww pa dayy tM eatn were IJg aml 293 rerl"u'hxlY. ,ks eapcefed, Ilie dealh rate Ilue m helg amza ( g-ntaMi.hod cme. esclluis ol nlrmncarcino- ma) wu foulld to nw higher /o raimn than in ruol areas (table g) TTe age•aamlardirarl Iknth ratu was 34 per 100,909 in nnal aren• as mmMmrl wgh fig qr 1g11,900 1g dtl° of Il.er 59p0U Iq"dasbn. TnNS 6._ MN N•ralA Oar n i.ar Cewv, 4 Ud.a' 11eN cba/a/4e•. -- (!! Alw .Nf IN Ar rrd ..sues, .. ~ws .. + w ases w . s w.a.nNarr...r....r... . n . • nnm. is e • r ..xr N.o.... ........ ......... • ..ryAwr~~rawN - N Yas.wrNlr wN/w4 Wr.r N }lowover. dgudtc.moking Y rllere wrmm• among dq dwdlen than anlong mu In rllral - 5tend• erdla<dfor arnking Mbus s wdl aa lor Vla the rde wY 79 F° 1.99Jq9 in rlud .rss and 641N+ 19Q909 Y oWs of or.54fp0 p^Prl-O- 7hs" CIGARETTE LABELING AND ADVERTI6IN(i when stnnrLrdizcd for Mlh fnemrr, ehe eate was $lill $AW lower in mral arear than in large citia. 'll l. digemnee may be dne to some famo, prnluc- g ImIF nmrer arrodaled with cily life m to bettn nue gnrling anrl diagmris in dtb than in mml arqq. - . 199 ratio was Ig00 in the gnl part of the rtudy and 31 % - the re..ond pn t of the mnly. Correspmld /nR figl forr wella~sr blisherl nses escluNVe nf uJeaoearannma are Inn mtnblc to make endl a cnmMrimn, hrcau.e of the small numher d de.Jhr dua m thir disewe emag lnen wM. Ic.er rmrrkM. Tnw 0.-NarNyr ef LyAr /g,n LMV n/ Sg..d fJMel 3ner iry S.N/ne ri.6na The r:rte of denhs dlm m Irmg cancer was low I.rrlYn+rul~ hho ne.wr-smoked cigarettes mgu. g amnng cigarelte r ken in large eiliu., small cttln, sulnlrbs ana towm,, and mml areae (Xg. g). Whale.er Ilre urban factar may M, its egect on these rates b rnrall ns mmpared wlth tM gen of cigarettea, as shown by the relati.e Mighti of the han oo this eh.n. A pldson ww made bdween the fnrdings In t6u Rrtt pan nf the m.dy (Iamrary,l9tiQ through Oztober, 19S1) with Ihegetdingr 'n the last two ynn of the .tndy ( November,lgSJ, ehrnagb Oeto- O-- r. ®. rr ~ .V. G-Aar-a.M.nWwl deelb rwu da. ra wtll- inahYdN eun d hnwrhnlenre rwpnum. (wehmve d aL..euelnniel by nbu.«N law&arlon. ~In br n.nNrn .nntm Y r.iM Iks /w .Iw a+ .eN/d mreYrh.~rh.~Irlry her. 1955). Gm<illoring all dee1M reponed ar due m lung cana , the mortality ralin of mal with a hi.twy, nf redldm dgarette nwklmg only was 9.04 b the Srst fmrt of tha rtudy and 14.00 in tM semnd part of tiw ndY. For mm wtth a h4tory of regu.. Lr dgarpte vnoking onlY mho wqez.rrrenlly snmlung o0o peak or nnre a day, the Inartagty Howecer, the rate of Aeatlu. dlw to lung c.neer was nlhee~.lrlppartofiMsewly.Tereinls oth death mtes nrul rusam far Ihere Irerldr wem dir.vruJ in part I of this paper, Cnncer nf rha EaoitllnGrs fwrOnr, Fflarqvr, MontA, y...... d k•Ip Trrbuceo moke ( or rnli. nnd A c_hial rec.eriwn t ining rnntcrial from tnb smoke) erenac Inln di mn cmllnu,11 wilh Ihe Ilps, nlolllh, lmlgne, pharynr, larym, :nd eu.phugns. The denht of 127 tubjenr were amil. ut«I to primary eam:e o(thne snrs (tuhk 9). I~IY ri: of ehese nu.n had ne...r smnkah anJ throe wme oavunenl rmoken. The wMr 11g h:ul a hirmry of «gnlar sm.kinS One 1 1.1 ml fmmern nf Ihe 127 eancen were micro.mpiellly Omv«I an.l ly 4 of these were In men who nceer smoked cnr/sidedng mirnncwpically pmwa ca.us adyy the mmnlity meto was 7.00 fnr mm with a llirtmy of mgulnr ngaeette.moking (tm ny nf sahmn nmked pyra ard dgan or wdl as dgumtta), S.gO fnr men wM orllnkal onh cig.trs, and 359 for men wlm smnkd only pipa. Still wnahledng miara- renpicaly ymved rnra. 52 hnd a history of meari regular dWUetle smnking ooy, 7 had a history nf regular pipe emnking only, 10 had a h4lory of regular cl6ar smoYing unig and 8g hed a hulery nf two or Ihrce" of rmNing. The figllra nrg, geat thae pipe and dgor ing may be mnm imFOrtant eMn dgardte r king in mbtinlr to oF one n mleo of tM rila indnd..d 1n ehir gnup, hut the number of coses 4 nrt slllikfent far e Niable evahuuan of this point. Comidedng mimorcopieally prn.•ad cma, ont of 3/ deaths fmn aer.r. of Ne phagus ory 1 ns of a man who had never smokd, nf 25 JatM fmm canrer of eM pMrynt only 2 werc of mat who had oesv. rrinked, and of 16 deaths fran urlar of eM longue onlY I wu of a man who had neeer rmnked. No dWM of rtlen who rreer mlulud I r~sissszooi

-1 200 CI6AREITE LABELING AND ADVERTISING were repurled emmrg 24 cas° of ar of the smtuUally dgaigevst (P=0.4J). Tmre wu no Iveyn., 14 c.uee of c.ncer ol the mooth, and Icne assac.at ~ ~N~nhty~iin ol ~Ig+mte of cmMer af lhe hp. wilh ennttr flhe Canrcr n( the CeN/omiearp Spetem.-Tehle 4. smnken u lbl hx mm 5, mel B shmr . summ.ry f the gnJinga for the abm,.dr and 1.50 for men with c r ul the pne- ]P.A:dmil fmm cercer of the 8enitaunnnry ry+tem, aeu In mitlw eare was tl J N ace between 9A7 of which caseswem nnaosmpmally prnved& n~rved and crpected d vtha acrlnticall n F Tlw momdity rmia ior men with a Idsmry of regu- eent (p=9.12 and p=010 rap +ivdy). 1ar ci¢.vMie smokmg wce 1.'I1 fvr all cases and Cn cn o/ tM f.y; ph'nl ,r 1 lfcnnr I ielir 1.111) fm mnxoseop,cellY p~^ved mse. Far smokes Sgsteln_-77wre wem 221 deotl e.'hml to nrcr af ..,e pnck n. ,mn e dny vi devettm, the rrmr- - of the IYmPhene anJ henut 1 u ryst m Tlu+c nhty ratws were 294 for JI eo+u and Sd2 fa included lymphma onra and reth+dmaamna. 80 mismscopicdly proved cusa. Theee nlios aa ng Nodgk/nt dlseue, ~ nwln(rc~Y10). 1<ukem1m m&in<ly greahr than 1.0p (P < 0.001 N bM kemi.• B8, m maaaa . rhnwad m Indhatim of an evaiminn with ago Of these Sfd cosa. 100 epperendy originated in .eneaoukin& Hodgkini dlrow.u well u lympho- the Madder. 61 in the ktdney. 185 in the pmstrte, verwu E. end 10 mlier prtr, nf the genitourinary syslem Tuu l~ a uu r~rh 8u?r N r+u~4. Ckernee (teble IU). We say -ep0armtlY became in mmy ~ M mn,w. sm M Cn.+ N Cenao.d~.rv. />4 ( theae cam the mmor involved two or mae d a~, w~N Xurrrevsiear Sen•r there nrgem, as well u aberr by stru.clure. end ehe d«+u orme0snes eapresed dwbt u to 1M asea bcmmn of ehe pdmary, 1Nm. nmenR nx., ... -. ._°-- -e - . ....... - moking, tliere were 59 dutln (rom m;crampially Rae; crr vr~i4+.n' w^~ ~~w „" . -_--.a wn..n.v..r.r............ m n. s,,....... -_- wdh Zf ed dutbe, a dl9acsee d 32 dea_ ..... nr .:n and a mortalnY raio of 217. This dl6mmb .A. ...:... ,w n acop~ieclly- pmued avueen, ef the pmsUte• ehero ^ ..... ... r v nken mm e - ne m 77 dth amane igar ur, pared with u espected deaths (monahty : tn, were 1.75). and thu diBerencn is slalidically sngnihmnt (P-0 fG). In usa a( miawmcopically Proved cau- cer of the kidmy, therc SS demhr amnne agnretle .mukeq mmpered wlh 28 expected da ths ( nmrtollty ratlv, L58): this dlge.eme u net rtati.tically signi6cant (P=0.50). Cnnce. o/ Ihe Digul/a Sy.remrThem were 114g deaths attributml to ranmr of the digutive sYStem (crdwive d the 42 u.u af mnm af ehe empha- g,u), of hkh Bd9-cveu wem miaaroP;dlY pmved. 7he monality ntio for mm with a history uf regulu cigaretm smoking wu 1.95 fnr all mao hn11.211vemm wlth microsaopiully proved cua. 7he sas to whlsA the 89g eues were a.aribed wem tte,r:auls, 2N1: pancnas. 15R Iiva, gallWadda, and biliary p.wages. 70, eolvn, 2°A: raNam, 119; and dhu and m;certain s0a hr ehe digeaUVe rystem, St (table 10). Tm mml rtdking uso.iatbn with dgareMe the smukhng seu for dealM ueribed to enRxr of l;v.er• the mertelity ratlo being 4.5g fm nwr with mivoscopically Iryo`wd cm°The w° h one of if nut ma ~ Ihaa n.er thme waa dwbt u lo ehe pr;nury ille. Thea wu . negY/ve wesiatimi belweea siga- rflle rmokine ud ~, Q,C.s ~ ~ _ not dw eobe (marJifY sa.cmne aad retialmucama. appeimd to ho nno eiated with aigercne umWng, bui In neither was the sligerenee between abserved vnd expccted deaths statutinlly signi6auL For mu9lpb myo lurna, the obrerved number of deaths enwng aV". relte smders was smdkr tbnn the cMM'd num- her (12 sasus 1g), h,d with w fcw asn, this di8erenee Ir nnt rtaurtically elgniheaol. Cnncer o( Other SOm. 'Iben wae 162 dmtle (ran eancer of dha apecigmi s9a, d wWCh 143 were d peUeob rithen .Ivdliy na auucutlan Takeo r. 8tm'p• . .vu4td with Nguvlte wokin& 71n 162 ames d br.us; 71; plwna, 6; mUvary elaml, 9; ather ra- phamry direue.., 7: melaemrn, 17; rkin. 9; e)e. L thYroi4 4 bma k3: drta.L d: Mwn, 8; seoneo CIOARETTE LABELING AND ADVERTISING five tlsa,q 5; und Miwr sinn, g. None of Ihqe slutsed a staUsuc:dly slgnigc.nl dejee of uuaa- Unn with algurene rmnking Imbilr. pr+mnry ile ox,ld not he Jmennlned In g9 cnea, 52 nf h h-nc mlm.rnpkwlly prnved rnneu. 7bne sM tl I,nwed u high degrae of e..o.iaum with smnk,ng hahila. Hearl and Cirtulalory Dluuer Of the 11.870 domW / the aduly, 7523 (81s) were mtrJwned to direme of the Maa vral elreu- latory .ysiem (inch,dng sutnJnr loionsd the ernlr.l nervmn aplem) The Intenutimwl SmHs- th.,l CI 6o,ilmt oI-Dssen.es Inlener, and G,ues of fkad. S+ah eevuiao, meke. pmNSlan fnr db- tinguishmg between 47 speri6c rh.eare entnier ,n theae genenl tegarmr (lncluding aome ralha BuelY dero:bed .vedilim,s). 7be u,ly dU6n,lry ir that /nmany imtma. ;n this study two urmore of these dieeares were preamt arrd apMrmlly am- HibWed tu death WIn 1. >bnrluY rule, dm m awe,r>..;.y dlr.re hr t nw,m d riwnnenmlmg. . Cerebral vureuLn leion. were remded ar u cantributin8 fucler m 135 (7g.yx) W Ihe 573 dwih. aleributal prfmurily tv hypmemlve hart duea.e aud In 140 (40x) d the 5.297 dolhs at- tnbuteJ primmlly m vasvury artery Aoease. Gno. arv artery d'nese wu ran.ded as a mnMhutmg fann. in Si (1.gR) nf Ilre 1,g59 deaths auvibed to ttuhrul ve.cnlar kskws and l9 (fl9i) of Ihe rka,Ov araib.d primunly tu other he.rl end cimr latury dlseana. A11 lokl, eertbrol vessulu kclonr ware rannled In 4q) deatlu atMLutN primarily to m,ne dher muw, arul w.onary attery diuuu wm rs..orded in 98/ dpthr altrihuted to amne atier cmne. We anempled lu analyse 8,e data fer uuh of the many eanb/nNion, bul this tnmed oul to be fruhlera. 71,me(sae, we tumed to the rwul pmsedure of deoifying eech sk.tb aemading 201 lu the premmed prindpal underlYin, eame, re- q,rdkss of how many otlar condilinn svere rneu-. f ed. F' sf J vidN the 7,5J% deaeu dne Io ha,rt n I ci I tnry dncae<r Inm fwr romnary n tery Jsnue (q2Y= deatln), nthen ceart dbnuo (911 tln,tin), arebml vmmho ksim. (l,(s5fl tths), nud othcr nr.+Jvinry dimusm (^S ths) 7he 6gnm frK th < slrnvs en l l ke 1, 2, 1'A Gam, ry rlery rli.cau and Ihcr rv I Imy Ibenu, ho.vs.l hrgh 1.8rce of a.,n- cl mon wnh eigeiett smuking; c<.cl ai vasn lur lesiom showed-a navlerate degree of . mnnn w Ih Ngqate smuk,n8; and mher henrt Ilrea.o showerl n rmall deg.ce ne aurnetum wfth sagmotte moking C mnnry Anery Otrena.-EarwarY attery d,r-. vnre 1s of pertiavlar, portnnre. heemue 8 aa.mmr fnr a WrBe proporlumof RII deuds in the United Stuta, the highest ntm being arnrmg mm in the nMa age gmnpa. 1 rhY study, it aaaunr.j fm 44.es of ell dearb. Thercfor., even a mnlerate lKramtage ,ncrease in dc,ths hnm this nure har an apprec{nb4 e8eq on the latal de.dh nle. In all four age g6mps the skath rutes frnm eorr. narY ertery, ddisease wem far Ligher-ummR men wllth history of regulnr'dguetle m,nking thw en.mg men .vho never smnkd (see Iuhk 1). There were J,181 deathr frani Itii. n,rt .mmg Ihe efgu- nlte smikee., whereas mly 1073 xvorhlheve dIN if theh age-speci/b dewh rutu had hn.i; the raow a for meo wLo never smoked (p < 0.a01). As rhrwm by the mnrteliry ratio of 1.7p, the death rate fnm, this euurc nf t/ese eigareHe rn,nken wu 70t higha than for e cemparable 8mip of mus who never amoked DeaM rates due to evmury, artery disease haveased with the anu,mt of cigarette smnking. Amatgri;en with a hUlay nf reg,rbr cign- retle rmeking enly. the mvtality nNin rue fmrn 1.29 fa mm smoking less tharr one-IuJf pwk of cignrell.a a day to 1.99 /a rmokers of ane.hnlf to one pack a day, en 115 fa amukcn of one to two puks a day. and to 141 far .mokrn of twv pueks ammeeday(6g.7). Man with a hist~ry of dgu smnking only also had higher death t,a frorn mmnory artery Jis- aues ehen men who nevm smnked (ol.v. evl lenehr, 429, eapvc2d Jeaths, 3I9, retio,1.25). 71is di8ereoa is rtatiakully aign;geant (p < 0A(d), 7herates hx pipe npien.wee ah;wl the a rrp u for men who neser smokr.l. The dcgree ol asmdalion with cigarelle emAing u higher fa Jr.thr apxigcally rkssirrile;l u duu to artcrinsclcmt'c heort diuuw tLan Inr druths skuvilwl as due_ tv nrunary Ihnanlxwir,.minlirm, a arcludou a ta myocvr(hal infnrulon. F1gnm 8 shows morWllty ralla fa ,nm wglr a hhtmy of ragulur tlga.ettv ar,nking only, onnpar- /ns Ilwe fv m® who had rmplwd rmnldng with Owe for ms who wwa tmnMvg regvlarly in 195i ssZ9s9zooZ

202 CIGARETTE LARELING AND ADVERTISING Tlw Imrndtry nt4n of inen who had given up mrding Mr 10 yean or longer were much bs dilw. fm1 u dtosmrkcmnmmt ly' g tuk .- 1 c.e anln t T e nnrtalily ratios f. who Ind gwm np mok ng for lw than a y"r.vcre higher th m the - pmding r dia far who were still mdmg In 1&52. Thhlgh men raua for Omm who l~ad topped somking fo kss thnn a yenr may have beem due to the in lruim In this grrmP of snme men who haJ recmtly rmPlsM smnkin0 Iwr.rua of aYmMonu oF heart duTh~anocfaNon be.veen eigarene smaking and death rat clue to enranesY anery dlsease was about the same the last twu yean of the rtudy (No- vemher, L95], through OcnobeqHR6) as In the enrlie/purt of the study (January, 1P5$ thruugh Ocmber. 195]). For esampk.-comparnng all mar with a Inslory of regular..igarette snwking to men whn never smoked• the inortalfty ratio was 1,74 in the Ont pan of tbe study and 1.69 in the sesond Purt of the study. The JiOermce between thae twn rntins u not etatletially signiSnnl. The mnr- tality ratiu fw men with a history of regular eiga- rette" smoking only who smoked one pack or mme of ngu It s day wa. 200in the Snt part of the study and 2 2) in the setmd Pan of the study. Other Neort fNsemn._Other hean diseases ao oountea for 911 (7.7x ) of the 11,570 rkatla in the Ody. Thls gmup mnsuted ef iBf deaths from dsmmle rh mst e heart disease, 973 fmm byper- tensive hc n d' eme, and W l hom munllaneous ahor he.vl dis n• sududinR many whieh re desmhed In vague or rompeclfie ~ersn. Ohmnk rheum t c heart diseaw showed ~h ton wnh cigantte smoking (muru0ry• ratio 005) Hy- pcrtees e h art d'uease showed only a sMghr de greenl latlao with clgarene srrokine ('nostal- 'ty rutio 1.15). Thh war eut dctistlnlly rigNgcant (P=0.2e). Tu aher dealhs asnlbed to hurl dlseme showed . slatinicnlly signiflmnt degree of auodetfon with clgaMte m ting (mortality t 1.Jg,. P-016) Smne of thew u sea were pmlr6ly J e to eosomcy nery diseue mta some mher nreulatnry diseme. The vldeva s.u.enn to NJteate that wronary ar tery d se's the anly impnnant fhmn o/l.:urt disease I h is os i t 1 with snaiing hahus. CnchnJ VetcuMr lsanna. Vascular ldan of the centn( nerwus rystem were mmrded as the un- derlying nnse of 1•O50 (g.Sx) of the 11$f0 deaths. A taal of 550 dealhs due to th6 gmoP of di.eans, oend d among ssen with e hutary of regular dRa'etle smnking as compard with 4P8 ealwcted deaths (a (IiQernn of 128 deaths and a nrMdity mrto of 1.]O). Thb dl0ertmw Y alathtinlly rigulg- <nnt ( P=%01). TAe dealh nte bwumd with the ammmt of c/garene smoklnF the ruorh4ty ntb being 1.0 foi mm rnmking one fMefi a m:e d NgveHes e day. Of the I•" deaths In rhls category. 237 wen eudbuted to cerehral thmmba.is m emlalbm, 70 were attributed to awmb I hcmonhage. and gl were attnbuterl m other vasc.Jur Ininn. of the cemrnl nervws system Casn dmcr0+a1 as cerel.al thmmhorU shosrnl efnnt the sume deDee of reb- flumhip to nnding habita u did eares deicrfbed as ce bral hemurhage Orher Cbculntory DYeaer-The 25 deaths clm- nfisal in table 1 unda'uther circulatory disavm' mnsOted af So atnllwtd tn hype.t rlro direase without mention of hnet, JO atsnlrun.f ra plilebitlr and eminlbm (iotematiurul list numbera 103-189h 50 ttnhuted ro gcnenl ancnosckroau, g0 mtrlb- uted so aorHc anmirysm (.mruyphJit/e), and Yf arcributed to mirnnaneousatbn cimdntory di.- asm• includin8 urysna and thmmbnaglith oblirvms (S nsn). Hypenenlre diseuea showad m avncletlon wRh dgaratG mrnldug (mataOtY ratio 1.00). fl u x nl L; ,r i. Iw .: '. ,.( '.... Fq e MMa11rY rarlar Aw n mm.ry rnry dl.rr g.rv fw, mw wLe na.a. noyprd nnoklM Pr.d wnE tlum lar - wha. nwr mYd wd tMS. Iw .m pip r.d/M In 1P52. General amdmckrau and the gruup Mclml/ag phkbith md embolhm both showed a modemte degree of auonation th dga.rette_ rmdung How- eve. there we e not m y ns.m uid m neither diseme was ehe mrasalion staliNkully signrficnot SialyY/Cht of the dnths from aoruc aneuryrm oa+neA among men with a history of regrdit cigu- retle rmnking, compnred with only 25 ealossed desthe. Thb digere e of <] deaths (mortality ratb . &72) is at'u4Hri'Ily tigolficant (P=0.0115) In the mbcellaneous group (which 4 duded ather, areurysms, ganlVrme, Md thmmbom&itir obhteraas), 18 of the deatha maamd among meri with a bhtury of n;ular eigamtte amldng, ~ pMed with only 4 eaperxd dnths. - Pulnwrury Dixases Only 338 dearha were umibed to pulnqoa_ry d/teup nther eh.om Nga Ineue.Ma ~ 41 m ut~anet p~. attributed b pneu CIGARETTE LABELING AND ADVERTISING 203 mmnnry edscmdeais• 70 to mthma, and P7 to aher lfie mortality ratio for cigarate nnnkers was 9dl Qudmnnury diseasn, ineluding hmndhiW, ahatta /u thiss group of coses. Thb dlger<nm /s nntlstinlly of hI g P, rmarmios s, vul hrmchiectaals (Intar- significant (P=0.02). nenn I lit t mhen Sqt5R mM520.5Z7) A total Civhaeb o/ the Luer.-0f 1S/ tkatln msvihed m of .,11 denlu frmn II of these cuu.n aasnml drrhair of the 11 83 nmsrreJ . F with 1nwk g~ wnh a history oi ngular dgarette a h'nrury of eiqnrrri _ smnk-ng• ur rnm 116 43 F Pumd w Ih 81 eaPer4crl de0hs (a erlnaaed dea0ss. Thu digereue N 40 I mths (mrr- ^LOr of 150 ikmtlu a,nl upanhly ratio of falrty ratb 1.0]) u stathtwnllv s/gnlRe t(P'0n5). _A5)TI I'if.n.up h atatistimlly signigeanl AemainJer 0 Direnxa-7he remaming 1189 (P f O.pll) denthr wen ntMMdnl tu05 di0erenr sprclfic sha 711e mund0y mNa fa men with a hinery of ' mns. ~slm the tegnry 'wgni-wd unknon n'4n g' vle nklnR were .. (olb..r fnr cnma. T.WnS thl entire grmip mgnhn, the msrr mm d fl m d nrc liity ratio was rknh -mte of th g rette smrken svm slightly ~.'J11 1 1[~c di0ereun bn obeerved and h/gher than thm of ine whn nevsr snwYurl (irv I~ed 1 mh. was naislscallY 'gnigonl tality ratio I W) bn tiw digerence wm not araW- (p < n0of); for anh a, the mmmlity ruin waa hcnlly signlfinnt. Diabetes, whMt ncmmotra fa IJ0,1 r r e notsmnstlnllyngm6rant(P -0-gg); 162 of these-deaths, dwwed ussMntlan with for puI ms y t Jwaabsh• the monaldy mtm was umking habirs No single nne of the oiher 97 spe- :1'!, nd this was not statistically ngnigecnt eige disnsm showed a aatistlally sigoignot assn- (P-0_4); and for other Pulmnnary disnse, the alatiui wfth snmlung hebies mortality rarb was 2,g2. aod thu w.n srolutkally aignificant (p_OtDS~, - Cm.nwnt Other Di.erm Other Invenigauons h.ve P'cvkmslY~ rqsortai an OnJY i.ilMl (8.9xj of the 11 ass°olntion bMxcm' s'nnking habilr nd ay of ,gR/ deaths wete tlsee diseases fa which we fmind tlw death mre tn ntnsi -t 1 t t..n other thcn ennnr, cardiac• be higher ee"ng c garette smnken thnn among am- arrodat y lpr 1 ry diseaser and secldmh, vnoken. The literature on this Mrblm is m erlrn- vink I le Th were dnulrsl into 101 tlx (pamudarly In mbNnn to lung eanm) thut md iSck I. :.. r tres llas rhr y egrry'vugua It if posribk for us to rewew it indm spnn men M Mulh"Onl tlsrt•a sho.ed labk hme However, we murt mrntirs rlwt dw amnak/n h111Ytrlpnifinnt degree of MOeietfon with lind gr lunglve tuJ nnca pmrterl Iry DMI and Nill' g In thHr Prapui. s Gd.e nd Duodonnl Ulcrn F/ftYbne dwthr Y of H Itidr phyalefw wem enmimlly the mme nn fimliogs. m u0 l ted t gmt ulcen, and all af Ihem Wo me fully eware of thc fun tbw nnuc uf Jmh r~ss'rrrrl mng men witEhistory of egular u irlerl nn death aenificun /a not ulwnys wr nnk p TI Y dlvid.el by smnking habits m rert 'I7 Fore it is pa I Ie that snn na rhe arsn-wron fnllnrva I_t ry of reg I r cigarette smok ng only, d't' s f I let soking Icd t and mtnin rrrcod,a In, f F I g ne unokmg and ako spec fe d' ua mey hnve rc.ulted f.un s. n'w 1 Io ngar vnuking 11; histury of ppe dugna s. Fa-esample it is mac vuhk dsat the nnkisg mdK 2; histary of cigur smnking only. 2; usociar'wn f.wal betwem dgurate snaking urnl anJ hbtury of hnth piR md cigar smukine but no death ascr.ibed to Pulmonory mhercuknis may buve ngvett mnking• 1. 77r death rate from gutrk rm Iled I um swsfusinn hrtwan tuhrsu hn .nd Ncer for min with e hbtory of reguWr </garetle lu g ncer. It b ulsoo connlwabk tba 0 f tivcly moking mly wm dmut five limn ai high w the smill avociatian fosmrl Isetwan Ngnrene smnk/ng rato lur ngau and pipe smnk.n who nnxr nnnked and deah frorn arehrul vaualur Ieslnna may ksve csg:mtto tty;ularlyr resulted fmm uscribmg .anrEJealhn t th uac Custr c I n were rn nrted u a eonmbuting which were a.mnlly due tn rrnonary artery J- lacmr - 11 I alln msi IseJ to eome aher one In re.pect to curu.er• we rlid rmt dg asd I Jnh (thb In I I t' r the 51 enn desv/1Md above): ¢rt Bnte infommation ulane ha olgonnl ud It us- llm mmmlty ratio for eigarc0e smoken wm 3.10 .1 formation /mm tiw doetar• Iwpital, or tmren In Ihu prnp of cusn (P=0.05)- reginry. In 7" of rhe carea elmsifiml as eunacr /n Srventy-three demlu wem d0ubaad tu JuowlerW this repen, the diagomis was mimnaipinlly wm- nlcern Flfryy f of them were of inen with a his- finrcd. We Ymmd a high degree of tims tay rd g W'grtte smoking, cmnparesl with 25 bet tlgarette mwking anJ m«osco t udl exlwn 1 dnnhs. Thh di0erenn of 20 deatlu (nmr- proved nncer (all sites eomhoned). It is eztnancly talityratin2.1g) pstxtisrlcullysiguifkmn(P=00). unlikelY that this cuukl huve bnn Iwnduml hy Oualennl uk.rrs weru listnl u a mntrihming ermrs ln d'mginsis. it follows thatlhem must he facclor fn 46 deu0n ascrdsed m rame orher came a high degee of ssxutiun betwern aignrnie (rhis in mhlitiml to Ow 73 nsn descrl6ed above). emokNg and nas of ane er more prlm.ry rites. ssissszooi

204 CIGARETTE LABELING AND ADVERTISING The next pml lem as to deennine which pn d6e , te or t. f c ea ,- Ived rn d s I tnmh.r A I tg Ity Ya fmm d I d lh t the 1 :ry st c nm olways I al bl- 1 cl tl. n-nty Tl f ll - F I t' 1'm were f J Fint. I g tt rhow 1 e ly Irigh tL Rrr++ of f db e tt ok n6 Tm nest h:Fb t P r ll g' dt mnking wm fm ceem 1 tEe f 11 ing t n bbeJ hp longue, fl f mn nh. phary hr yna, and eerh- agu '11mr a.II slta dt enly rpnnl t aRa- ¢c smek material I srolved or -mmlemvl f:nm .ign ne smoke. Appm.imntely &5%oflfie uuncnsdm belwecn cigarette smokmg and mivo- irnMcallY pm.xd canar f all srta canbimd) was accaunted hx by the assonatlon between dRarette moking and cancer of tlw sita /mt mentiooed. No etie Mlwr thin iho.e /oie mmHoned showed a esncnmly high degree d wen.nan-s.ilh dRarette rmnking (nmmr of tbr Ever bNng a Vmsibin es-_ ccreon). Seu.nd, ehe dcgrre of anocialbn between ciga- mue snwkinF and dedhr attributed to lung canae.r wm hiFb l ea r miaacopinlly pmved and with gord I s to tbe p'mary site th fw the total f,rn r(IncWding ar he minas.copl eally redged nrd casm with doubt as eo primary aite). The rame wu tn¢ foe nncer of the genito- urinary syfeem. Thlnl, ennsiderinR all daths oedhed m eaoe<r of the gastmmtetrnxl rysl ( ce)M emphsgus), thae wm ooly a smdl degree of as 'adws with ciguctle nmbng In Ihb Rp p of casa, the asm- elatiws ws bwer fer. mlrnnmVKally Pmved easa than fm the mtal gruup. Furthenrwre, there wa consirbrable dnubl w to the primuy site d meny of thae au+, particularly thore aaeribed m the Eva. .... .... C Gnsldving this evidena, ehne Is ne doubt In aur mindr a to the wliJity ef the msociatitm fomld hetween-ugarettesmoking and svncer of the long end the asndution Found between moking end eanm of otha sita directly espo.Rd to tobacco .moke pmrtuc'b. 'fhe evldence ulso suggesta that ihere ia a renl arsacWeion between dgeran rmdt- iag and eance done ar mare uta In the genito- rinary aYStem. Cenridering the vxnoua dhe within the gmitouri.nary ayrtem, calrm of the bladder d.rred the highest dsg.ee of ensodegou wRh cigarette amukbg The nemn of the eHdma is rrlds as m leaye doubt .s to whdher a eeal u.oumim emts be- tween tlgan+te .moking and moer of Ifn galm- irµannal syaem (u<epe saphagm). 71ro apparent asmi ceou cuuld have arbes through mydjqpnal/s ef prinsary site he seroe esser (a. g. rrinnry ae.er of tM lung with nxtma.M te the u.er Iseing e.ru.eawly.aalEedm Pimuy eane: of the u.er). oo%ssszooT In seeking to evaluate the Im^ilwlities oulined abovve -- must keep thr thl Rs ' I(I) thulikel'1 lof a ply "k F one P rncm F r dbrass f oll . r^ (I au, (-) tbe m:mber f I~ eT - J I t aol of Ibe nvn du- auer I I I/3) Ihc ' gri I.de of tlm ar parmst a. uuim detwmr msnk/ R I ulres and eaah of the two Jmres invnl 1. One pb sngia t to ilbunnte the rnim. Let un cun ida tbe hypmhesu that tbe aw:ciatfon h.md h.t -. 'gamue srnnking and tbalh frnn mnmory anery duense reultnl from a conbnion (in w:me easa) ben.een camary ertery discue md Iune cancer A tnl 7 of 5,~ sknbe wem aa- ilwd to corona/y unery d se, and thac was a digerenc< a77,3gg bnween the oleervni and ear pected number of dealhs.monF nieu with a hutory :i( reg.dar cngmdte srmhing. All tokl- timm wcm onA' iJg deatln uctibrJ t I ng cmrcer vnd mmt of these wele m'crosmp lly pmval mun Cnr the hypothes' to bee cormat- one mnst anume that at leut 1,3Bg lung can cr deahr wcie mbsed a r..~...~.. r ~v. :.~.w r..~. .wa u.Oe+ o . a~.... e 0©..a.~ «n,.,..,..... y;~.. r 5- Rq a_Eaer.u dsehs r:eng nrw .IIb a luur d rruuMr ryawee snd4d. rmo eueh and wen dlagnmcd instead m due to nnry artery direnm. \pe kaw 0 up tn dm eemk:r to de..irle the likelihood of thu nmurinCThe moat imporam finding of this study wm tbe hlghdegree of auoeiation behroecn ciga notm smoking and the total dmth rme (gb 9). Emns In diagn is no aller how great, hu.r nn eRnt on this 6ndiog. Tlwrefnrem if the assreiutim bwid between eipprette imnklog and deethr fmm somc pnNarhv daease (e. g., nnoer ef the drer) wr due ro vmn In d'ugnosY, It only rraans that ehe nue degroe uf anorietbn between cige.ate smuk- Mg end death feeen sotnc abcr specific disease (a. g, hmg ndcer) b grwter lhqn the Bgnres given in this report appear to bnlicate. A taul of 7,318 deaths occurred mmng mw with a htsmry of reguWr a.geruda mnking, whew er ly 4,g51 would heve occ.:ncd 'f elr• .ga- spedfic death nta d the smokcn had been the .eme as lor nun who naa tmoked (Bg. 4 Tlre digeraxe of g,g9S m.y be euWdered m'enm dea1W. CamserY dYe.se xccounted for 64.1f of the oaals, de.ihe .nnng elprwb .nnkerr: 3.g CIGARETTE LABELING AND ADVERTIBING 205 !'°'a+'runmal fnr lass nmcer of olhnr sna rlm L,m Th e . e relatne Impr.tanc. d the arstaYw nnw nN f« 1enrt and dam.y e IbhJ nbve N depemlen( nn el.e mrmhor nf lun di: nss~gxSgil 15x ~ebry othel r h ..aideareaar l(abn. aha 4th.Bx; an tk-rhe urhnted t each drscaa ns-wnll m Rme nd duedenal has 2gi cirrhosir of the tl ir J W of essrcdrtim wRb cnga tt . rmk'n~ tlver LSx, ar~d dl other diseeGa comMnal 6AS, b wns feund dwt 1he death eut of ith S.,mn.q Inng anea who b d given up eg'rett smoking rmd year he nnre before haing urdimi nµim 7here b a h/gh degree of assosintlon between Y w bwer thu the d nh rnte f eo hri tmnl Aaeh r.em xnd ugurale annking, e Far bwa ~e sm°Idng R W e~a regularlY ut that ti:nc. An drRme of ..rnelatlnn bt.wen eorJ Jenth ruta .nd remely h ph .. In11m Letwa~en eiFamne ciF+r nnnk~nF, and a small degree of asoeiatMn 4f g med rloutb mea frv man witls thia d/.eam hawa . d t. f de th r en and pipe rmnking. 77,a sg fd In nnul areu w well ae in large nlx. d.bi nnrm of informutian fn. thia stud on If arnnhing habip ero taken inta aonsidemtielq Jirens 'nvnlvedm was ceu.e af dath u eea.Kded tbe 1-1-9 nraer, death rate wa .anewlwt higher 0o de.th hnlga.ea, npPbrmntedM more de- ~tinthanlnnnalereu. leikd rmeGeal /nfamatien In mrp in W,ich an- r xI W nM1H./1R11Or.H.mme:nl). cer wa memioeed. r ... ,w.de p,.Yl,k 6y eM The folloWng n lat:nnshipr with ciAmrette nnok- n:h I'aws m .Wrlmn.r .erkrn,,r.te Ir.ehh d~s la. ;,;I;Y Ing arc enrlent. (1) n anemely high mrndatinr rhw ~.n' and re+rmod d dlN.bm d he An,mnn Grv m. few h.e..a. nwh as nnaer ~the Inn . tan- ]~-5%+Nr. V~~~° ~wfnkd• M.A. (praam. G PenY. of ~Iw larynr- at:mnf the tha R . Iao,.rJ c.p, y,A.A nd xerba grtdnu., at.R.l.. I Iru. nrl L.dentN.NWr. gmtrk Idren (2 ; ) a sxry hi few Jireya h ~ erm"'d0n ~ a eue , m mem l I a nMlg c ment . m:rneq I H,xn.n.l. dm.bn 1 ulier, annl< nna rYrm. and cunm of the e. C. «al Hn.n, p: y,µym .,d o.,F MnJJa (3) e h: h u.uiation fm fln' nmmanH tl edrNed4...apNler,Te;iMm~ h.oy such a awnm ^, a n mbee oI 1. Tdd M>WI4. L A M A. rMr1ID0.11h ry arte d/.nre, a~nhmu Y TreM.r. A. E.: gNpny N Gn.ef pue of he liver, ami aacer of eeveral a/ta; (4) a mod- tu te'/0.sary (p,e.. g) t¢cg. M l. 4 sr. A. -le asson'tlun for mebral arculcr Iaimr, and a 4~!n. E. A.:C m N t_,n -. (5) liul no asmeiatiat fin e number N dir- G d luy: E.d,.n:in d iT.bin,,; Prmr~.Iw4n ~:4 eue. Including ch.m(c rhaumenc fevern e`+^lik &,kw,,. Am,ul as..uyt Ne.. y.e. io.U. Iv... nivt b[art dlRiWe, utha' h hYPatm- YM. Anwken (:aer gyytr. I,w. IR51 G. " on ytASpln. ephritb arM nephrnrb, phrnrb, ~l~l: '~ l~• R.. and Hnl. A l luuR Gaee. aud ply, dlebele., Iql r d p.wk In ReheM re e,.oY4:., garad nrpm ax of the rtetunL nanmr of Wa mlanz aed 'rarws of ipj~jlpmyef M~ Daeeaa.9le 4. F artpll-tW1/Mm. t om 45-979 0-65-p. 2_ 14

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II 210 CI6ARETTE LABELING AND ADVERTIRINd rwte w 1W IeMlee r IIJ. fwY.Y Y W erl[YY.[/ FWn ~uWel Ox~ irl.~ dMl Yt~ Mrt~.l ..Yi Y StlJ 1eYe4 w TW J.Wtlle Yufe T.Y uw4 li Lri i tl li w n . M 4 r, N 4 Y M Y x 4 4 YYT .. r W 4 tl r[W .. s 41 .Tx W Y IYin11Yx.~eet ewr W 4i yIIY 1fY.W W en~r! W Y..M\Yr rGwY W rxtWY'.er..a (yyywN.\fW/wV/YYWnWdn/ _ e.x. Yenr Y. 1rr=r ~eu~ ~.fx.~w. Y.~ IYW OWeYr M~~~ .W Ynvr 4r sYU « ..~ he a r: ii y~i 4v u.ne . ~ X\ xM 4 1 YY4 f.e -ws.en. O.r r. Is rr 4r e/tw~~l r r.\M rYfY w W OW en.ew. y y~ V x prrxY r 4xYe lTxn1 {.YI rrMOr IL~Yr - 4 r tlY4 tl tl r iYr 1Y 1 N IM per amp4r le nliner amYn( IOe Ivi unwr. pt4eLL MYMr ee tlPwtue emNM Ver nn dla ~ Npn.'e.i. eele lut nm lw 4 Ypt /Ixaeiner.Me m r Oebna pbll/ M/ne-4. e/ wYle. M w ede that IEe aelt 10 Tabr V nn le ee I ra eWtlep. .ue.'n maee pl w4e pE.erwn, YOp n.e. (e.ne . Mpu ' NrluleM u]IU Ip 1N n nle Yt ntln{ In 10e 1Ye{ uwer wllen4 [alf. Eu/ lne Olnrnv[w btwwn 1Ee Olxix feeex . f nSM4 Y• vut tnet. ]n Tep4 V] e Oew e4rnleC IM rpn/41e b eb h tner Il4r tlmr ef Oe eereer ena Or t4e efwl4 e w .nM .m.emn. rM.. 1. . unEeaTu. wn. n/ pillenle l Ern wmmrmed eme.IM el M nrll\r ille. Inee tne meer rY0leele. Tn. numl.r M elyretl.. wvYea el IM JW f lRe OIE M\ppnr 4 erw.a e n. . M 1.. .Ypx[: M. be [arMp[si .mn.n{. Tnce ie rnreie WIIY npwmw bn b me( . MIIm4 Yu u rnlMwr: Ipre e e[Ilr{ {r at /~ b 14 Yeen 315 6 elpre~ln: ter . rlrtlei eN vl Il In 10 pnra ii1 elr.nuulmr ..uai.{.i{. t)0 4 ie Yeen. ii'] elRnnlW: ier r e4rllnt e r M 10 n t\ qeuw l10 el(rnllw. T4 IWiunt4ee0 nevn u IM un H mU ere pWnntlW Ie etM. wptJ4 l0e so7ssszoor TM rlul .LIMIb ee Oe4ri11e ebw IMt IM Yx rymn pppr al lne IeTa 4 enpwl~[ we WEenrx M11. Hvweiee. M Ym4111/ IM1xli w- el Ib Ye( IMxIY M1OIaIY lurwlng el ell eW TMn e4 Olilxr re el aellt/ twm [ewr pir^nelYnt In /M lwa lerin [IIM, nrOUY ne YaIbYM. . b IM rW at He $wle 11 Waee ea YMOIIn mw[tIYe1Y. )tvnewr, tnle Aetl ll'v le e e Wnwt wenM Iv IM rWe /Or Yelx. TMn ' 1 Ir in~ pimNblll/ t[ns nnnr p11M lu{ en4 has peen nn1N Odtqel 14 eenbn .n w emell M 4 an. e.n.]u L.Ipr, ae.r uo m4. •wnet be Ine lut [eenr Wllule. 14n Ir r WFee propwllon Ot xnv\en ]nM emui nYlpl pll.nle nferln{ M1xn xM na M1em Nner dlrren. Porlner. 1\e ,.n I~ m.ePqlw Y 4lete0 e.1{Oer"nrnet I4 w r 0~• CIdARETTE LABELING AND ADVERTISING ' NMrYV {nrbuwp IOee emp4 IM ewenen I. W . . JuYMxuNemx, 41Y P:eerl: a/Irnnlra nnlNan.~w . n N1yey 4 .nY wnn me aa et ..nel In. IW New IUYU Walee {yle Crnnr CaYn[Il. ne4reMee if °nen tw,r Wn14 4YU Ao-lwx-, m.. wnl enel. .n4ee: .. e: ~'Mwrln{ eM f.rt~.~i x spiwxMr w Mer ces In 211

!1 212 CIGARETTP] LABELING AND ADVERTISING pRen rHe CiD'rRAL IxerrrD'rr OF RADIO2HRRAPr (DIRICfeR: PROrID&IR 8. YuerARALLto), HRI111RC1, PIRLA6- SMOKING AND PULMONARY CARCINOMA by Marja Kouiumiea The increased incidence of pulmonary carcinoma registered in the last I'ew years has aroused interest in the possible factors affecting its gem-sis. Intensive xtudies have also been made of the possible role of smt,king on cancer of the lung. As early as the end of the nineteenth century $oaxMHRtxo suspected onI,.king to be aseociated with pulmonary carcinoma. At the turn of the oentury BRO.seH, obviously the first, succeeded in producing experi- mentally malignant proliferation on theskin of guinea-pigs by smearing it with 'tobacco-juice . Later too the cancer-producing quality of to- ba, ro tar has been investigated by means of expenmente. Its relationship to cnncer growths of the respiratory tract has been investigated also in Fiuland, acconling to a personal communication from EnrALA-Hotaxl- BF.TALA, snd phantoms as well as animal tests have indicated that the abuilrption of tobacco tar and its accnmulation in the respiratory tract is most pronounced in the regions where cancer growths are generally situated in man. What the cancer-producing agent in tobacco actually is still awaite solution. Besides tobacco tar, arsenic among other substances (DoLL and HILL) has been suspected as a contributory factor. Arsenic is used for dusting the seedlings of the tobacco plant to expel peate. Inveetiga- tione made by the KxNNAWAV group prove, however, that even extensive statistics fail to support the hypotheslathat tobacco treated with areenic- Z taining preparations is more conducive to cancer than tobacco free m any contact with arsenic. S. Mr.s^rANALt.to ascertained in 1944 that patients with cancer of the throat were almost without exception smokers, and that they had started Preentnl at the Cm,Rreer of the Northere Arooistion ef Rediolo®. Helmnk,, Jane, .1902; eubmilrnl for puhlieAiioq Oct 3, 18h'J. Vozss9zoOZ CIGARETTE LABELING AND ADVERTISING 213 to smoke at a considerably younger age than the patwuts of the eom- e material not suffering from cancer of the rrspiratorv tract. - 9=c3 published during the list few years in diffenmf cmmtries on the smoking habits of patients suffering from pulmonary ,arriuoma or cancer of the respiratory tract generall,v indicate with imrcasiu',, rlcurnPys an association with the smoking habit. Thus, for instnnr,•. nf the Btht pulmonary carcinoma patients of the Americans, R'rNDEU mn,l f 7RAHAr• only 2 per cent were non-smokers or light smokers and 96 per cent had smoked for over 20 years. The number of women among pnticnts with pulmonary cancer has been found small everywhere, 6•iu4 onle alamt 10-20 per cent. This has been ascribed to the fact that thrv moke Ir.s. As it is of interest to know how Finland compares in this respect the writer has made the following investigation. The material covers 351 cancer patients exnmintrl over the couc+e of 16 years at the Central Institute of Radiotherapy of the 1lniversity of Helsinki. The diagnosis was verified histologically und the putien5s were questioned at the time of taking their case h1YI01'IP9 uhout their smoking habit. Furthermore, the writer has placed 494 pnti,•nts exnmiucd during the eame period at the Central Institute of I2adiotbernpy in a special group. In these cases there was no biopsy vrrif'ieation of the diagnosis, but, judged from the clinical picture, roentgen exnmination, bronchoscopy finding (not infrequently) or operation, the condition was one of pulmonary carcinoma. The control material has been collected by the writer from the Medical Out-Patient Department. Data on the smoking habit was obtainwl in 300 male patients of the eame age living in similar eircumstmnccs. The inquiry was made, without selection, of every man over 44) vcarsof age who attended the Department, from February I to 1larcll 14, 1932, and in whom there was no reason to suspect cancer. As a nwtter of curiosity the writer also chose 15 women over 30 years of age and not suffering from cancer as control material from the same hospital. None of the women smoked and had the writer continued the inquiry only the 24th w•oman would have been found to have been a smoker. Ibealts of the Writer's inesttgatlons The material covers only 15 women in whom the diagnosis is confirnter by biopey; 2 are smokers. The figure for non-emokere among the 18 caee without blopey verification is also 2. With such a amallmaterial of womet no definite conclusions can be drawn and the study will consequcnth be restricted to men only. Among 330 men with pulmonary eareinoma and in whom the diagnosi was verified histologically, emokers account for 99.7 per cent (i. e, ther

I I 214 CICARETTE LABELING AND ADVER'1'IRIIQU Table I f)u{ri6ution af fAe rnatniaf by - and awnpa age at elarf ol inoedfpation - No. of a•..r I Per Aeerage.gq, 1'e. Pulm. Hbry.y + %.1 55.7 )lulr ........... ........ ' 336 Pemelr ................. 15 1 _ !.a_ __ 49.9 100.a 66.3 l 36l T I on 1'a. pulm. N„ bfaPl %.L nk• ................... 476 >I Yemnl. ................. _ IB I 9.a Tu1al 494 ' IOO.o s„ r .... uele ............... F,~eul ................... Tolel 300 %• f6 i.e 315 1/10.a 69s 57.u 6at 6t.i 61.+ 56.9 was but one non-smoker). The ratio is approxirnately the same, or 99.r per cent, in 478 eases without histologic verification. Of the 300 cases of the control material, smokers total 82 per cent (hence, 54 men are non-slnokcrs). Tabae 11 Ape of n•Aith men darwaf uu•4inp Itilo reue Su. Per i 11-IG yn.m 1H-40 yeem 81--i11 ye.n .. Per Na Pw \a. i Por No. ~ Nu. I eenL I art oent 1. c. pulm. Hi„pq~ +........... 53 I 17.4 I96 I 28.e t'e,,•. ........ . :an 8 f. 1 n • If pr: 23.9 113 90.1 C.,eo . _ 376 9 • t0 11.3 52 tt.f cewv .. . 2!1_ I . !.__.-. 7 r-e, y l.an, 1.. 3. P_ ti6 P.r <ent 1--:1 %' 47.y. f- 3, P< 0.1 Pero.nt 3 --:/ ~: - la.a, f3, P> 0.1 Pnr aent t86 134 103 Q.e 36.. D6 I e.1 I 6' 1.r I I . 1 __ Y r„mlmri.m of YrouP^ 1 and 2 7• . Ln~lul,illl,v•~ftlwtmt6yplt6e.iethatt6.+uPM~.rednNnen°tMraaeP~p°aH°° g....i.tauMA. Arh, N.dBd,qiw. Lb1.3Y. sozssszooi 4Lr r7 I ea I 41.. 67 1 47.t 8 1 e.t 1 CICARETTE LABELING AND ApyERT78INO 215 The average age at which the smoking habit started was I:i.; years for male smokers with pulmonary carcinomu confirmed bv biopsy and 15.3 years for Patients without biopsy verifirution. Thc figure is Ie.e years for male smokers of the control material. lratirntx u-ith pulmonary carcinoma have consequently commeneed to smoke nut'lir•r, mnny in childhood. A striking feature is the high number of horN wlw etuLrted smoking at the age of 10 years or younger. With thenl thl, potential cancer-producing elements in tobacco have had time in the rouree of the patient's life to irritate the mucous membranes of thr respiratory tract over a longer period, and in childhood mucous memhranrs nlnc be more sensitive to irritation. In Patients with pulmonary vrriunnut confirmed by biopsy, irritation due to smoking has continued before the verification of the disease for 39.7 yeare on art average (42.o yrur., in patients with no biopsy verification) and for 32.1 years in patients without plllmonary carcinoma. The duration of the irritation is thus g-1(1 vears longer for cancer patients than for those of the control material. Table Ill Type of nnoki9p (a.mr) I ~ y rer yu, aot So, rcm 5,,. aot 1. C.. pulm. Biopy +..,,,, 370 2 , I 74 3. Cti I %.f I 5 l.e I _. Im m. No biop)' ...... 361 961 97.r 10 o.n - ~ 9. 3„ eenmr ............... - _ 389 Ae.f 17 u.. _ 1 Y,r .. 0.16. f l. P,. 70 Pee oent 1- 9 a' '-H.c.. f 1, P. a: Per uent -'""-' 3 y.6..u, f. . 1. P r 1.:, P.r aent C'igar-smoking is rare in Finland at the social levels to which the Patients of the material chiefly belong. Patients with pulmonary car- cmoma are almost all cigarette emokere. No difference has beron found to exist between smokers of tipped and untipped cigarettee; all three groups contain an almost equal number of each. Persons with pulmonary carcinoma have admitted, to a greafer extent than the Patients of the control material, to noticing that amoking causes irritation, the ao-called smoker's cough. The percentage of patients with emoker e cough among 188 emokere with biopay-verified pulmonary carcinoma is 87.x (89.1 mnong 174 Patients without a biopsy verification), where.as the figure is only 50 per• cent for 248 smokers of the control nlaterial. Vo. nf Pee mLte.; ripr: rer . .6ii14

216 CKIARETTE LABELING AND ADVERTISING Table IT TYFe of tonaker (men) Sw ' P Rudrnto 6) I Llght r) OcrwnnN i `U• MrIL `o• Rnt I'4rt . 1 h pulm IS p. +~~ .... 197 . 61.2 98 ' 31.9 ]8 3.a - -- I lew. .. .. .. ..... . . 307 / ~ Y t'n pulm \ I 1 ... .... Ybl 67.11 110 ; 20.1 P:r i- ,'uce ....................... 41G . . 9. No 94 : 39.f 59 ~-r4.o 18 i 7.n ~ C..w .. ...... ..... .. PJa ' __._..- ._ . _ _._._ . „) ooa 1'^'~k,a Lml ,x m-.re ot ee"rvrw. per day. Iq P'•'t"1 nf rllnn•Ite. per da,v. •) I hnn ', lu,ebt of rinarelle. per +Ip'. 1- .. ' n•x. f 9, P.85 Pee mnt I_-.r a, !W. '. t -. P< 0.1 Per eent _. .s : lian. / 1. P< 0.1 Per gm1 Statixtirnl trc:dment of the data has htrn carried out according to CiRANER. ThPW fPnldta nrL• identical for patlent4 with pu111Wnarlr c8rcrllolm with ornithout histological verification of the diagnosis, and the groups arr ulso ntutiaticully equivalent. SUMMARY The im'e.+liuntim„•"mpriw•e 351 pulmonary carcinoma paGenta in whom the diaanaeie .ae cmdino,rl hi+toh%irnllr nnd 4!N patients with pulmonary carcinoma not vrrifinl by binpny. Th,• rnnlnd mxtrrinl conaiuta of 315 patients. The oonclueione refer principally to rneu nnd th,• pulmunurr ran•.inoma patients are almost all emoken who have emok,d henvilv fnr decndrn. In rolnlutrieon with the control material, they have et.rtsd smoking ymmg.•r, uften I'rom rhfldhol.l• and have smoked continuously for about 40 years, i. e atl areroue ul' NI/I ' yeern lonaer than patients free from cancer. Theee circnmetaneer are prolu.bly of .+ipuifinumr in the pelleein of pulmonary carcinoma. %UHAMMENFASSUNG Ui.• I'Ideenn,lowy und'wu't 351 Patienten mit Lurytenkrebe mit hietologieeh beetaip- ter Dingn"..• und 1U1 1'util•nd•n, hei denen die Irtholoaiech-anatomieche Verifikatiolr fehlt. Dn. l',•rpleirh.+mnterinl hent}ht an.315 Patienten. Die Behlunefolgerungen besieh.m eich hnlqdrii'.hlirh nld )liiuuer. die Luupenkrebepatienten warrn feet alk xit Jahrxehnten atarke Itunrh•a. Im Ser>!Irlch nnlrl Kuntrollmaterial haben rie fr0haeitiger xu rwchen .n(trfanurn. oft Wkon in der Kindheit• Rie haben regelmiasig etwa 40 Jahre lang geraucht, im Dnn•hwhuitt e1w,1 NIn ,lahre litnaer ale die Patienten ohne Lungenkrebe. IHeeer Umatund iet v:nhrsrln•inlieh flir die Genese dee LungrnkreMea bedeutungevoll. CI(7ARETTE LABELING AND ADVERTISING 217 RESUME L'enquete port,e eur 351 mahLdee atteintn de cmrerr d,r ponrn„r, ,.nnfirmd hietologi• quement et 494 cee de cancer du poumon non valrifie par l,iulrie. I,,' cn,nl.. t,iuoin com- prend 315 eujete. I,ea aouclurione concernent eurtout dre hunmlr•. ••t h~< rn,rlndee atteinta drMa eandcer du poumon eoni prexque loue rlee fumcura qrli ont In•ouemq fum pendant )lea dee. ComparEa su groupe G:mnin, ila ont commened a fumrr pln. j w. ,~ xuuvent d2a Ieurenfance,etontfum6eontinurllernentpendantenuron40anv,c' tn,hu. ,•nmov,•Oue 8 l 10 ane de plue que lee eujet.+ indemnee de cancer. Cee faitn .nnlpcuhnhlrment rm- portante dana 1s genFie du cancer dn fmumon. REFEItENCE6 Enom-a, A.: Theoretieehe und experimentelle 1'ntereuchwlyen zm- ISithoKrneeix nnd Hietogeneeie der malignen (Ieeehwulete. Virchnwe Arch. )wth. Anut. 162 (Ifllaq,32. CaerEtt, H.: Hathematical-Methode of 8latiatia., p. 445. Alnlqcot .c 1S'ik>rll. !'pluwla 1945. Dere, M. E. and KESaew.tv, E. I..: The Aruenic Content nf Tuh,lcc„uml Tobaeoo' 8m k E it J I o e. r . . Cancer 4(1950), 173. DOLL, R. and HrLL, A. R.: Smoking and Carcinoma of thr l.nnp. I'ndin,imlrv IirleqF Rrit. tf J. 2(1950), 739. i ERMALA, P, BeTXb:i, K. and Hourr, L. R.: Per+oual eonuoruuro,li,lr KaxxLw,tr, E. L. and Kaxs.wec, N. M 13tudum af the lurnlem, ul 1'nnu•r uf the ~ Lung and Larynx. Rrit. J. Cancer p(1951), 153. i Hoer.ta.tteto, tl,: Uberdari hnrynx-undHypopharyuekarainom, ihn• Rautg,•nlrchundlnng ~ und die Ergebnilme der Therepie. Acts radiul• 2, p944), 13. Wvsuxn, E. L. mld l]ann.Lx, F. A.: Tobacco Smoking ae a I'rnxildr RtinlnPi, Factor in i Itmnchiopenic Carcinoma. A Htudy of &H Pruvnl Cam.. .I. 1.31. 1. 113 ( I9:+q, :11!1. sorssszoot

218 CI(L1REITE LAHELINU AND ADVERTISING Extrait du 3ulletin du Cancer Avn& r918 Fi: 4R 5• L'enc,uete franga:se sur ='e-iologie da cancer bro :cbo-pulmonaire Analyse ditaillee par Pierre F. DENOIX, Dankl SCHWAR'rZ et GeorQes ANGUERA - EUT DE L'ITUDE Notrc cnqu0te a dEjl fait 1'objet de 2 publications : la 1F^ (Schwartz et Denoix, 1057) cwdiait 1'association entre consommation de tabac et cancer des bronches, la t= (5chwartz, Denoix et Anguera, 1857) ttudiant Is m&me association pour les dillcratts cancers de Phomme, examinEs loeslisation par localisation. Ccs publications ont, pouc notre pays et pour le tabac de nature particuliere ,pi ou y cun.umme (tabac noir), confirmC et, sur certains points, prBcisd les resultats dca tr's nombreuses enquAtes ell'ectufes ailletn5; nous avons, dans 1'ensemble, moutrc quo Ic problbme no doit pas 8tre posd en terrnes . cancer des bronches- eq(::rcttc Y ntais Cn teCmes a canCertabac •, 1'assotiatlOn existant pour toua In canccn dcp voics nero-digestives supFrieures (et sans doute aussi pour le cancer do In vc,..ic). Pour Ics localisntions de type respiratoire (bronches, larynx), c'est la cigacttc sculc qui est cn cause; par aillenrs pinspiration de la fumfe joue dgalement cn rLlc in,, urtant, et ocs 2 considErations sont sans doute li6es, car 1'inapiration dc la fumCW est souvent pratiquFe par les fumeurs de cigarette, rarement par In funmurs tlc pipe. Pour In localisations de type digestif (cavitd bucetle,pharynx, u.upha,;c), ISas.ociation e.vste tant avec la pipe qu'avee la cigarette; par ailleurs, 1'inspiration tlc la fumlc nc jouc aucun rAle. Dmts le eas du cancer do bronches, notre dtude quantitative a ea outre con- fume Ics pnint+ suivants, ddja signalh dens d'eutres enquCtes : le risque augmeate aou. ov uxcno, ia5b, r. {6, x• 1. CICARE4TE LABELINO AND ADVERT78IN0 219 evec la consommation; pour une consommation donnFe il augmente avee 1'inspi- ration; il diminue si Ie sujet s'nt arr2_t_E de fumer, et d'autant plus qu'il s'est arrltd plus t8t. Ces diverses considErations - pour ne citer que In plus importantes - donnent A penser quo le tabac n'apparait pas seulement dans le probl2me comme facteur associ€, mais qu'il joue selon toute vraisemblance un rDle causal. C'est d'ailleurs l'opinion aetuellement adoptfe par Im majoritd des cherchcurs. il fant bien dire cependnnt qu'une telle conclusion reste, en toute rigucur, critiquablc. On a en elret men6 2 ent6gories d'enqu®tes : - dans In unes (enquetes prospectives) on a montrf que Ies fumeurs sont plus exposCs il certains canccrs que lea non-fumeurs. Mais rien ne permet d'nffirmcr quo In fumeurs difrCrent des non-fumeurs por le seul usage du tebac, toutcs choses Egales d'ailieurs. Le sujet qui, 3 un moment donnC, chois_it do fumcr, so distingue pcut-ltre du non-4umeut par un complexe de facteurs caractCriels, ou sociaux, ou familinux, etc., parmi lesquds pourrait se trouver la cause ricllc du cancer; - - - dans In autres (enquMes rCtrospectives) on a montr6 que In cancCreux des b:unches fumaient davantage que les tEmoins non-cancErcux. \Inis Ih encore il est nFcessnire de rechercher si In ennc6reux et In tEmoins dilRmnt par Ic seul usage du tnbae, toutes choses Egales d'ailleurs. II appamit finalement que pour mieu: connaltre le rGle du tabac, il faut prendre en consid8rntion toute une sdrie d'nutres facteurs. Dans le ens des enquCtea rEtrospcctives par exemplq on doit explorer Is groupe cancircue et le groupc t6moin pour une gamme trds Ctendue de carautCres descriptifs (niveau social, professions, habitat, antEc6dents hErlditairos, antCcFdents pnthologique, etc.). Si In 2 groupes sont, II part I'usnge du tabac, strictemcnt comparnbles A tous points de vue, le r01e causal du tabse apparaltra plus vraisemblable. Si In 2 groupcs difftrent S certains fgards, par cxemple par le milieu social, ou familial, il faudrn comparer leur consommntion de tabac A milieu social ou familial constant. Des analyses do cc genrc ont d6jil !t6 eRectu&s; ellcs n'ont jamais, ju.qu 8 cc jour, pcrmis d' . innocenter .]e tebae. Cette attitude n'est toutetois quc provi-. soirc, In plausibilit8 du rule causal augrnentant seulcment, d mesure quo Ic nombrc des faeteurs esplorH est plus 81evf. C'est ce role particulier quo nous avons assignL• H notre enqulte, d'erplorer les malades sous des aspects plus divers qu'il n'avait btC fait dans In enquetes prCcBdentes. L'emploi d'un questionnnirc ttiy titendu ct tris detaillf, le recours a plusicurs groupes tfmoins, la stricte correspondance cntre chnque cancGrcux dca bronclms et In tcmoina do m@me ilgc, intcrrogEs par le mcme enquCtcur dnns des conditions comparables de tcmps et dc lieu, enfin 1'ann- ]ync stalistique dCtatllie des riponses, nous mettent en mcsurc : - d'une part d'Ctudier Ic rBlc du tabac do manitrc tris critique, comptc tenu des autres faetcurs esplorfs; 4ozssszooz

220 CIGARETTE LABELING AND ADVERTISING = d'autre part de rechereher des facteun, autres que It tabae, 6ventuellement associds an cancer des brnnches. C'cst ce double travail que nous presentons ici. DCFINITION DE L'E•NQUETE Cette ddfinition a dfjl et6 1:onn6c de faqon prfcise (Schwartz et Denoix, 1957). 9ous en reproduisons iei 1'essentiel. Type de Cenquete. - L'enqu2le est du type retrospcctiJ, c'est-A-dire qu'elle portc sur des sujets interrogfs II un moment ou ils sont dEj3 atteints par ln maladie etrdiFe (cancer des bronches), on au eontraim indemnes de cette melndie (tC•moins). I.e mode de crorrespondanee entre on eanc,Sreux des branches et ses t6mo_ins est defmi plus bas (nppnrcillement). Populations esploreer. - L'enquEte a porte sur 5 populations, d'hommes uniqucment, choisis dnns Ies hbpitaux de Paris et, pour une faible part, de quelques grande9 villes de province, dd5nies comme suit ; - I = Cancers broncho-pulmenaires. 2= Cnncers des voies a€ro-digestives sup6rieures, jusqu'au larynx inclus 3 = Autres cancers. 4= Dinlades non cane(;reu_x (malades hospitalisEs dans.un service de mfdecine gfm3rale, snuf ceux atteints de tuberculose pulmonaire en evotution). - 5= Non malades (accident6s de Ia circulation et du travail). Dlodc d'appareiilement. - A chnque csncEreux des bronches interrogt devait correspondre, dans chncune des populations definies ci-dessus, un homolobmc d'Age voisin (tranches de 5 ans), pris dans le m2_me groupc d'hOpitaux etinterrogl S ln m@me 6poque par ie meme enquAteur. Chnque enquCteur avait pour mission de rltolter dans toute Is mesure do possible tous les ens de cancer des branches se pr@sentant dans son groupe d'hbpi- taux. Les tFmoins dtaient recherchEs ensuite d'apr2s Ia n`gle indiqufe ci-dessus. Questionnaire. - Le questionnaire, trts etendu, comportait non sculcmcnt une partie relative au tnbnc, mais de nombreuses autres rubriques relatives k In situation ComiRnlc, socinlc, profcssionnelle, 9 1'nlimentntion, etc., dont le d,aail scra donnE plus loin. L'interrogntoire des matades durnit em-iron 20 minutes. 3lamhe de renquek: dossiers reaueillia. - L'enqu6tc a commenci• en octobre 1934, et continue encore. Ln rlsultats exposEs ici correspondent aux dos.iers recucillis pendant une pdriode de 2 ans. Noux arons pendant cette pFriade interrog6 602 cnncBreux des branches, dunt Ie diagnostic peut Ctm considirA : - dmw io7 cn. (soit 6S %), commc tumcur maligne primitive, confirmEe par 1'bistolu~ir (:SS1 ms) on cupposi•e d'apris In cytologic (56 ens); 80?;969Z00T CIGARETTE LABELING AND ADVERTISING 221 - dnns 56 cas (soit 9^ /), eumme tumeur mnligne conBrmEe par I'histologie, mais sans indication de type ni d'origine; (le diagnostic des 189 eas restants, soit 23 %, Etnnt base sur 1'examen clinique). Chacun do ces canet:rcur a pu reeevoir un homologue dans les eatEgories 4 (mnladcns 430 esdnoq e'obtenirancElesrcuxh) et 5(non malades), mafs il n's 6tf possible que dans omologues des sEries 2(cancers des voies aEro~d~a ~estivessupEzieures) et 3 (autres cancers). - Nos 002 cas de cancers se r8partissent done comme suit : - 430 cancers des bronches en sEries compl@tes de 5; - 172 cancers des bronches en sdrics incompPetes, ne posstdant que les tQmoins 4 (malades non canc8reux) et 5(nom malndes). ' PLAN DE L'GTUDE Nous avons $ comparer diverses populations (cancers des bronches, tEmoins.--) pour on certain non{bre de caractdres descriptifs des sujcts, qui sont les r(•ponses sux questions du questiannaire. Nous appe!lerons ces enracMres dcscriptifs Ics crlttres. (La liste de ces critZres figure nu tableau II.) Dnns une premi8re partic du travail nous chercherons lesqucls, pnrmi ecs crit2res, earact8riscnt splcifiqucment Ie groupe a eanr! r des hronches ., c cst-h- dim le dilrerencient tnnt des non-cnncFreux que des nutres canedrcux. Cetto prc- mic`m partie constitue I'inten(aire des crit2rea speri)rquca. - Dans une deuxieme partic les crit@res spfcifiques scront i•tudiCx en fonetion de Icurs associations nmtndlcs et de leur association 6vcntuellc avcc 1'usngc du tnbne. On examinern notammcnt si, pour one valcur donn8e d'un do ces cri- tire., ln eonsommntion des cancAreux des bronchcs reste plus i•Icvi~e quc ec1lc des tEmoins, et ri•ciproqucment. Cette deuxieme partic constitue 1'rtude des aaso-_ ciations partidka. I. - IxvE.a•AU;E Dya CnrT}:nEa sTLC1Etq1'Ea MAthode emplqvEe. -\ous avons procdd6, pour chacun des erittres sucecs- aivement at la sEric des opFrntions suivantcs (qui cst rEsumi+c nu tnblenu I) : PrnniLe opr'rntime. - Compnrnison entre cux des 2 crm;pes ti.muins non cnnc6reux (tEmoins mnlades .I, ct tcmoins nceidentEs 5). 1'm;r In mnjorite des eriti•rec. ces 2 groupes tFmoins sont strictcmcnt mmpnmblrs. On petit nlors. pmn- ecv critdres, (omlrc les 2 groupes en I groupe unique tCmoin non ennc_imux. 1'mrt quo!qucv eDti•res e anormnux s, Ics 2 groupes t6muins thlicrcnt. Le eus dc crs criti•res <crn cnvisnge p!us loin. - 45=9)9 O-RS-pq. 2-p

222 CIGAI(ET'1'E L\BELING AND ADVERTISING TABLEAU I \ttmm.a POUR >.'swve.rAtae DES cvxases srdmnQUne Lnaenu& I - cnnceq dee hronches. 2 - cancen des volee eCro-dlgeadves eupdrleures. 3 ~ aUtr(e CnnCCA. 4 ~ lCmulns malades. 5 ~ llmoim ecddentb. 4-5 (eas normal) TCompars[son 11 kn 602 cancers destnon- ~ ches et 1204 temolns'~ . (4+5). \ Compnrnlro 1 entee tb nmtns non cnncEreux .. (f021lmolne 4 d 6nR , ti•molnn 5). \\A ~ I - .(4+5) filtsree eltminee. f 3#4+5 et3-1 \ Crltdres • cancer •. ~ t0(4+ 5) Gompnralson III enlre - 430 entees eeneers 3 et 860 tamolni (4 + 5) qutres fventuahtb. Crl- teres specmquts • cen- eer des brondms... 81 on expliquc pnurquol I des 2 popul.0ons eet • anormale •, 1'vutr. est prlse comms tAmoin et les operations 11 et III puunulvles \ Ilormslenlent. \14f-5 CAthes~~mormanx ' AulresQventualltM:examendlreet. Dcustlme op(ralion. - Comparsison du groupe e cancers des bronches s au group< timoin comtituE ci-dessus. &'it n'y a pan de dilf6rence. le crit~re n'cst pas n•tcnu tlnvantage. 5'il y a dillbrence, le erit?ss eat seumis &]a 8e uPEration dc tv~mparnison• Troiaibne oplrntion.-On ex&mine, pour Ie crlt8re ci-dessus, le groupe r nutres e:utcers r. Si cc groupe diRtre Egalement du groupe tdmoiq et qu'en outre iI ne pr~.ante pns de dilfi•rence avec le groupe e cancers des bronches e, le criti•re consitlFrf c:vnvti•risc Irw cmtcEreux en g6nFrni. Dans toute autrc C'centualitd, le critdre cnrnc• CIGARETTE LABELING AND ADVERTISING ' 223 t6rise spEcifiquement Is groupe a cancers des bronches a. C'eet le petit nombre des critdres de cette dernidre catEgorie qui cunstitue 1'inventaire des critlres apfeifiqucs. Dans cette 3e op6ration, le recours au groupe r cancers des voies &Cro-digestives supdrieures s permet une comparaison supplfinentaire, qui prfcise davantage encore la position du groupe a cancers des brnnches x par rapport ttunt e autres cancers .. Les 8 op6rations invoqu6es ci-dessus ont port6 : - pour 1& lre et Ia 2• sur tous Ies cas de cancer des bronohes aveelw tEmoins correspondants, la ire portant sur 602 t6moins malndes et 002 tfmnins accidentds, et I& 2s sur 602 cancers des bronches et 1 204 t6moins non cnncfreux; - pour Ia Se sur Its sEries compl2tes : 480 autres cancers cempar6s A 860 t6moins non canc8reux et 1 480 cancera des bronches. Lea seeuils de probabilitf adoptfs pour les significations ont Etd : 1 p. 100 pour les edries de 602 sujets (opErntions 1 et II), 5 p. 100 pour les sEries de 480 sujets (opdration III) (cette dilTErence d'attitude correspondant, tant 6 In di1T@rence d'elfectif entre les 2 cas, qu'A une dilMrmce volontaire de e stratfgre s:]cs 2 pre- mi2res op8rations sont des tris pot'tant sur un nombre trds 61evd de critdre, et on essaie le plus possible d'6liminer les significations fortuites en rCvluisnnt Ic risque de 1r9 esp2ce; te souci est moins important dens 1& 89 opdration, qui ne porte plus que sur un petit nombre de caractbres retcnus 6 la suite des opdrations pnhi- derttes). Cas des erltPres a anormaux a. - Nous appelens ainsi Ics critcres pour lesquels, 91a Ire opfration, on trouve une diflErence entre 1cs 2 groupes tEmoins non canc6reux. Deu.c fventualitds se prdsentent d&ns ces cns exceptionnels : - lr• ehnnrualitl: on apergoit une raison dvidente expliquant qu'un des 2 groupee eoit a anormal ,. Q'est le cas-par exemple du critMc : exercice de la profession de mason, qu'on trouve plus frdquemmcnt chez Ics tC•moins accidentEs (13 %) que ches les tdmoins malades (7 %) : 1'explicntion t•vidente est que In profession de maSon occasionne p&rticulidrement souvent des nccidents. Pour les crit2res o0 cette dventualite s'est prFsentBe, nous avons Climind Ic groupc tdmoin •&normnl r(les t€moins accident8s dans 1'exemple prde(dent) et eonserv! 1'autre. Avec le groupe ttmoin ainsi choisi, les operations II et III unt Eti eRcc- tudes normalement; • - 20 luentunlifE: on n'aperqoit pas d'explication dvidente de 1& diR6mnce cntre tfmoins. Cette dventualitd, trts exceptionnelle, a donnE lieu ch&quc fois a unc . discussion particulic're. Rdsultata 'obtenus. - Les rEsuitrtts obtenus sont prEsentds au tableau II. Ce tableau donne d'abord Is liste des crit2res d¢duits du questionnnirc posc, qui sont au nombre de 160. (Les Eldments relotifs 9 la consommation dc tabac, sozssszooz

224 CIGARETTE LABELING AND ADVERTISING i•tudf6s dans Ies publicutiuns pr2cAdentes, ne figttrent pse sur cette liste. Ila seront rrpris plus loin dans pttude dea assoeiatiuns pnttellesJ TABLEAU it LIaSn BT CLAee1FlCnim'r nns CnlTenne tt9xnde 'i OpCratlon I : companisan entre tlmnlns non can<freux. , menllon A mn1 10 . . . I'I Sl JI9lreoep, crltEre uvur I OPlntton II compnrulssn cerllhx dlscAml pht tfmoins. .• menpon D (I JM'vmlcc, ' ' SI 1 Oplrntlml III tomprulson evee les • nutn cancen r. 51 Ice autrei euncen . diRErcnt des tlmolnp et ne d1flCrent enpaa en eeneen des brnedle edtlre • cancer •. •. mention C ~ rl ec des bronches • mentlon CD • I t 12 anc iI Autree Oventuelitfs : erillre eplcidque. a o s q 13 J< ue mo1llC environ tone sur ~ V. A nCes do P° 9ulte~ r o ° 2 n e e e 14 Et~ v ! n Iss ur nnnb qu'un e . 15 II rencctlf. 19 17 18 RGyvLTAT nne Oe6lunoaf III CnIT1:nFJ , ~ i I, 13eu de nelssanee : I I ComperRleon 11 Componnban entre ravicers entra temOtns des bronchea et $melns IlI Cnmperalsan .vN Im autre° eancen Distnn[e d Perts (ou eax qnelque; D • ,. C grnndes vllles de LIW d'Imbltutlon : ~ 2 Mluel : dixunee b Peda (ou ens•. 4ue1- • D. • ,. C ques Rranda vllia de 1'enquCW . • • • • ' ' 3 Rabitnel : 6rande vllle, petite vlRe, D•. ,, C . . . . . . . I comDngne . . • . . . . . • ... . . Lleu de trnvnrl : b ' I alr li n. 'u .~• D•, • 4 A 1'Int(rlevr ou h 1 . • • • • • . ~...... u. netite vllle, eamPaHne . 6 Cla°se sndnle (protesslun uoer.,o, . s f , sen etlnduslri[Ie,comnerqnnU an art esnpiol•Cs, uuvrlcrs, cultivetcun). proresatons : . A 7 Situation aetuelle (uctif ou ntui:c ~ i. . tl Nombre de professlons exereles. : ; • Conditlons hnbituelks de travail 1 j , 9 Aesh ou debuut. 1 . 23 V<rnrle. . . , , • Compnsitlon, , , . . 25 Reli ImpreMUn. nro. - 26 Chimle. 27 Tdnture. 28 Dolasena 29 Bnulnngerle• 30 Vlnnde,7eaterle. 3l Textlln. 32 Culr. 33 Dals . 34 Conduelaun : vlhicules hIpPumoblles . •~ A 35 36 cutomcblW. 37 Ouvrkn epCC411.nds gins .ar sur rnil. 39 Alonm mo[hlnes, 39 Denslnn[eurs teehnlelens. 40 InRlnieun et [adrsl, I 41 Cmplo)ds ds bumnu. I 12 Cmplqvq de commene et d•lndustrle. 43 Servl[n, . I~ 44 Sontl, enselanamenL I 45 Armw. Produlh cenedrlglnee msnipuli•s ; 49 Aniline et dlrit•!s• 4] Anthroclne, predolts Rromnl/ques, 1 bensldlne. 48 I 40 Arsenlc. . Amiznle. 'I "0 Asphnite• . a t9 Chnudronnvle. - ' ' 20 A)urtcur. 21 22 EI°ell So-iF CIGARETTE LABELING AND ADVERTISING CmTtnes I DESVLiA1 Dee O/OnA)IOYe I Comporelaan entm tlmo]ns If Cumparalean entre annten dn hrnnehea et tlrnohls AveC ou °ans aCtivlte tnnscnluln• Exntlce pendnnt plus d•un an d•un m vwntes PperECnant snx [ntpbqrlea ARrlculturo. Mmine. )II , curcllrcs. Terroerement NnGO nerle , . couvertur a 1 - - ' • - P olnberle • Tmvoil I For r0° mltaux. ge, eoulell te. , ... .. . .I.. .D D.. 225 III Comporalson ovN 1!s uutrn eaneert . CD 0T?:969~OOZ

226 CIGARETTE LABELING AND ADVERTISING R''rdYLTAT U8a ardrl.rYrone CnITR.axe 1 Comparelson entsetdmolns 11 Campem(son enlre cuncers dea bronches ct tCmotnl- III Gomp:refrnn avee les autres caneen 51 Dcnsol ............... I. 52 Gh.umetes. 53 Clmrhon. 1 }pute~ minhelea. Slrkcl. 51; 1-a1n111nm . A 57 Suic. 59 Hullee de meehlne 59 Gaudrons. 60 Sulfate de enfvre. . Produits el-dessus groupda en : 61 Nln(rnux. 62 DrCnnIques. Sitnntion da fumille : 63 CPlilnlaire, mntlC, veuf, dlvorcl. . GI Arec ou sons enfante.. )fariae s : 6'e Nambre do mnNagea. 11 Age au premler sriarlege. Herldlt! el progdnese : C9 . Age dc In m!rt 0 la nptssanm do sujet. 68 Vonbre de blres. L9 Nombrc do ssurs. i0 C nguinltQ do pdre et do la mdre. 71 Lxlsl•nce d'un jumenu. AntOcldenls canctreux dana Ix tamllle: 72 Nombre. 73 Itip:srtition par g4nQratlan (oollat4a anx, Parehts. (,ronds-parmta). I 74 R(parlltion Par 11gnCe (Pnternelle A , I mntecnelle). 75 Age moyen des su)ets qul ont de lll s e. I rnncCrcum dans leur fnm 96 • Amblancc fmnllinle avnnt In 15 • , mmBo (divorce des parents, maK do ) ?r d I c . pArc ou e n m I:4 Granpe nnnguln (A, D, 0, AB) f9• I -s Ithfvs.a (+ ou -) Q). II 411 Cmelcur des'roux, xu V, : 3" aa I 31 l:borrux : 2tnt A 30 ans. s8 nalatt. (1) NltSylifs fnible+. zzzssszooi CIGARETTE LABELING AND ADVERTISING GalTf.r1EP I 6ompomtsan n,tre t6molns 63 alplgmentstlon. I P4 calvllie 85 8 Denllllou : dents perdues . - . . A . . . 5 E4 • denb ptnlues el nml P6 remplnh4s.-.. rlllP . . . ...A 87 . plloslti pFnlralc. 88 89 ' bllosltf do Iz 2• phalange . T l d ~ 90 91 n ll - PaWs : en nn do crolssance. - -- 02 ec_luel. . • musimum attelnt nu A mur s do la vic. AnlhAdents palhologlque : -- l ' 93 Nombrc. 4 Existence d'un nntFcEdentlmlholo¢iquel d un des groupes sulvants (dCpnis~ par )es 2 preudere chlRres ae la! nomenclaturc O. \I SJ. - Tuberculase (00-01). . 95 SYphilis (02). 96 Antres Infection, vdnddennn (03) 97 . \lulwlles inleclicuses dbrlglne Lstes- 99 tinale (04). Autres maladles mlcroblenves (050G 07). 09 \Inl rlin d strus (U&Og). i t0U 101 I PnISWLame (11). Autres malmges Infeelleuses et pnr0-' lp3 sltNses (10-1Y-13). Raladles .les Flandee endoerbsesl (25 A 2P). f 103 ~ ]Inladles lu sanp (29). ~ 101 105 Psyebondvroses (:M-31-32). LEsluns r^uenPAres du syetlme ner-I li 106 veua ce1 d (33). llnl ldies h:OT sm::qnlres du syrtlme~ I 107 ncn-eux ccnlral (34). - Autres mnlmlies du eysl2me nen•eux~ c LLral P loa ln9 II 11!1 m cl p ripbPrlque (3i.30). \fntadles del'¢II (3iJx). \luladles do 1'oreille (:/D). I1LUmalirme arOrulalre algn (lo-l l). . A tl l , , \lalndie toronnrknna (.L) ~ Autres mnlmRes lu eann (43). . . . . .1~ Ilypertasslon (1)). RfeIrLTAi nes apRqATroxs II Comparnlean entre canccrs des bronches et tdmolna . D . ~ 227 Iff Compnralson ovec les avG<s aoncev . . f'.D . . . CD .CD

228 CIGAIIF.7TE LABELING AND ADVERTISING Rtsul..ur ua npte.nous Ce:rtau F I 11 Comperdeon IIf Comperelson mtre wncers Umpvc4on avec Im uutrq eullyd tlmoln. dne branchea ~nnn et llmalus - 11{ Meladles des vtdns et des velnes (45-46). 115 Bronchlte ehronlque (50) . . . . . - • • • . .D . . . . CB 11g Aulrn ageellom respb'atolrm (e7- . . . IB-}9-51-52) . . . . . . . . . - . A 117 Maladbs de 1'eslomac 118 Appendfclle, hernle (55-58). 119 Autres maledW de 1'sppureB dlgesllt (57-58). 12/1 Maladles des arganm g!_nlto-arleWes (59-8061). 121 Moladles de 1. peau (g9-7p-71). 121 Maladles der or (7Y73-71). 123 Autresmladks et sgectlons msl determinles (75 C 79). 124 Acddents (80 s 99) . . • . • • • • . D . . . . C 125 Inlerventlamehlmrgktles(wddeo4 exclus) . . . . . . A 126 Tumeun bfnlgnn : nombm. 'a 127 AIW81e. Chae moral dans 1'ennle qol prdeldu Is m.lad/e k 128 Existence. t29 Dplel avant le msled4. 130 Inhuletbn : de gas de gueree. . . . . A . . , . D , . . . CB 131 d'aulrn ges toaqua. 132 Prbunnler de guerr•. Allmentatlnn : Bolsson : 133 Vln (nombre de Iltrcs pur semslne) •.. A 13e C/dre (nombre de lllrcr par •enulnc). 135 DIlr<(nombr<d<IllrCSparsemstne). I3g Aplrltlrs (nombre d• s•eoes par . scmulne) . . . . . . . . • . • • . . D . . . CB 137 Aleoul tulal . . . . . . A 13g rwrB.nw. . . . . . . A 139 C+e! (nombre de lhud per.emans). . . . . . . . D . • . C11 Alinscsdalbn : 1av Ileginm (mlae, earnl, vlBetarlen pur, eYle lellagee et 2Yte). 141 9'.l,,phagle . . . . . . . , A 142 ILnLilude d• bulra au de menger cluud. CIGARETTE LABELING AND ADVERTISING R4u:.1.T nas oegMTrowa f.lllienY I I 11 229 III r Cum ersis p on Compardmn entre cancers Comperelson eetre tlmolns des pronehes evec les eutres at tlmui.e I enocers p em . . ... 1•4 Polssons. • . • . . ' ' • . . . - . . . D • Coqulllages : crus, 1e8 147 • Escargote• eul4.. . . . .............. D . 148 • Cmsla ! . CB r • . . . 149 Suere ; 9wntlte eenwmmM . , ' ' ' • - D • ~ CR ~ , , 1 • MIeL . D • • , . . C 151 Al l . . 152 • Dignon. 153 • $niade. 1 54 f Cuudimenlr. 155 Sel. 156 • ConOserlm• 157 Consammotion rdguBlrp d. pVt• rechaurtea 158 159 16 . Frfquenca dee rcpse eu resteunnl. .I. . . . Fonetlonnement gastrlqu. bsbltuel .I. . . D . . .I. . • c 0 . Fonetlonnemet lt naestlnsl babltuel. On notera que ces eritt?rm ne sont pu indlperdante, tant du fait des lirhons naturelles entre certaina d'entre euics que du felt de on a testE per groupements multiples eRectuEs; exemple : . - la frlquen<e des antteEdeats canelreux gdg- Ipare a~ ence de ces anf(~eddents par q!nlntion (cotletEreu; pateatg, - la frlquenoe de cea antEoldents par lignfe (paternelle, maternelk.-•), - Ia frlquentt par groupe de localigatiotts, etc, Le tableau II donne ensuRe les rlsultats obtenus pottr chsque operation ; Rres"ie oPdrat'°n- - 1,es rlsultets de 1e Ir+ lrc mlonne ; on voit que lee erklpw e anormeux a operation sont donnh par la de Ig. (mention A) eont au rwmbm Ga eritdres seront ltudils plus loin. Nous donnons d'abord pour lea gutrce crit2ras les rEsultats des oplrations suivanteg• Drosrbi16 o1&ahoa• - Leg rlsultatg de Is 2• oplrat'aon sont donnls pnr Ia 2• calonne du tableau II : les critlres sans rnention sont ceult pour lesquels leg eancers des brunches ne diR2rent pas des tEmoins, et qu'on Nfmine. Les autres, pour ksquels cette diBlrence existe, iunt notFs D. Ces critlres sont nu nombre de 19. %t?:9sszooZ

230 CIGARETTE LABELING AND ADVERTISING Troisilmc ophatiun. - I<a r'lsultats de Ls 8• oplration sont donnds par Ia ,' 8e oolonne du tableau II. On vnit que les 19 aittres D ae partagent en 8 groupn : ' In I< let comprend les critdres notfs C, c'eet3dire e eanxr en gfnlral e, pour lesquels lea r autres cancers e diffdrent ausni des tfmoiuu et ne diff2rent pas des cancers des bronchn. Pour In 7 crit2res aiwi elass6s, l'ex>meo du groupe .. cancers afro-digestifs ea apportE uw con8rmation supplfroentaire, montrant . qu on a flnalement pour cea c+it2res un ensemble homogLne de eanctreux et ~ un ensemble bomoglw de non canetreux, avec uw diffErenee nette entre cn' - . + sgroupn Ces 7 crit2res sont': ' - Ie lieu de naissanee, - le lieu d'habitation actuel, ' - le lieu d'habitation habituel, . - le lieu de travail, . - Ia frEquence des accidents, - Ia quantitd de sueoe consommde, , - In fr6quence dn repes au restawant, la diRbrenee ttant que lea eancfreux sent nFi, habitent et travaillent plw loin de . Paris et dn grandes villes, sont moiw souvent victiron d'accidenta, cowomment ., davantage de suere, et prentlent moins~saouvent leun repas au reetaurent. Now n'avnw Iws retenu ces crltlrn, car : a) D'une part, ils no sont pas epEciBqun des co^µ'+m: des bronches (et par conaEquent ne sawaient . expliquer r Ia coneommation do cigarettes de ces derniers, puisqu'ila intervienwnt au mtme titre pour toun lea caneEreux, elon que Ic tnhae ne singulerise quo lea csnclreux des bronehn et des voin aEso- -digntives supfrieures). ' b) Its pourraient <ertes, du point de vue thlorique, nous intEresser-comme ' fncteun Etiologiqun du rancer en gEniral. 11 eat elair toutefois qu'eu seul examen dn 7 vihres en question on doit penser 1 on effet d'fehantillonnage, lea 7 diffF. . rcnces s'cxpliquant simultandment si pon admet que 1a r]ient2k dn h8pitaux . porisicns s'btend plus loin pour les caneEreux que pour lea tEmoins, atteints do - maladies moiw gravn ou victimn d'aocidenta slu pleee (•). 2. I< 4• groupe, qui n'a pes ttf envisago daw l'expo96 do notre mlthode, ni dans lea rEsultats du tableau II, et que nous indiquons seulement pour mfmoire, comprend In critbtes dont la signigcation, bien qw vtri8fe au seuil I p. 100 dans ~ 1'op'rution 11. n'existe plw, meme an seuil 5 p. 100, dam Popention III portent ,: sur lea africs compl2tes (soit par le fait du haserd, soit patce quo m strin, (') Seul le crltlro . comommetbn de eucre • no donne par Iku e une /nterpretelbn auul ImmPdl.le. L'e.cb do eo,nommatlan der wnsfreu: e'a.pllqut Peut'tnR p•• ler dindrencer d'heuut/llomwse qul vlranent dYtro mentbnnl.r. ri point mMts loutetols uno elade per- llculldre, que nuua novs propoanne da reprendro ullhkuremenl. CIGARETTE LABELING AND ADVERTISING 231 rappebns-le, diffdrent des 002 rlejea ineomplbtn pae kur eRectif plus faible, et kw lge moyen plus dlevb). Cat crithes sont .u nombee de 9: . - 1'euercice de la professione forga et ouutellerie a, . - Ia coneommation d'Epiaa. Ia profession e forge et coutel4rie e(d'ailkun tmina ftdquente ehea lea ean. otreux des bronchn que chea Ics tEmoiw) n'a paa 6tE tetenue. La eotuommation d'dpicen (plw faible ehes lea canetret¢ qne cpa ba tfmoitu) a'a pat davantage dtd retenue pow le moment. en Le 8• gtoupe comprend lea crit2rn notta 13111, c'esLbdiro rpdeitiquea e caneer den bronchea a(soit que les e autres cencera s no diB2rent pas dn tlWOins, soit qu'ils en diffbxnt mafs diff2rent dgnlement des cancen des bronches). Cn crit2rca eont au mmbre de 8, que now 8numfzow dans 1'ordredu ques- tionnaire : - exercice de Ia profession e venerie ., - pilositf de la 8• phalenge, - frEquence de 1'antEcfdent : maladie coronarienne, - (rEquence do 1'antfe6dent : bronchite chronique, -- consommation d'apdritife, . , - oonsomm.tion de eeff, - coneomtnation do coqui8egn cuNa, - eonsonunation do rtustecps, Catxeass .ROxtuux. - Ln 18 txitNes e anormauz a aoat Etudib 1 par I ea amxxe, selon 4 mltltade indiqufe plua haut. Cdte ltude permet d,tliminer 14 t'rit2reae ew lee 18, et d'en cooaerver 2 enmme sptejRques. canuer des bnanches w Ce /ont : - un caraetdee dentaire (nombte do denta perdues), - lYnhalytioa de gas de guem. Inv8lrraae ara carlaaa seEmnQUae, - Pernu les l98 erit2rq exatninb, aous ne retennna 8nakment eomltu sptciHqltes e oanoee des bronebn e que Ira sdvante t a) Ip 8 crithes obteow aptls la ee opfration portant sur Iq cdthea nomunx (ezereace de 1a profession e verrerie ., etc.). b) Ln 2 rrit2res obtenw de la mlme faqnn parmi ka erit2rea a.normau: e (dents, gas de guerre). . e) L'eoeembk des eittres tel.ti6 an t.bac, et phas prfci.tmetlt b la cigarette (ennsomnution, ouniLare do tumer, etc.), que ttoua n avon. pes ntentionnh au tableau 11 pnece que Pftude de en hcteure a ftd falte antlrieurement (Schwartz et Ilerloi:,1987). Noua gaoupow s'enaembledecq facteure en I eeit2re global e tabac a Ezzssszoot

232 CIGARETTE LABELING AND ADVERTIBING L'inventaice des crit2ns spdci8qurs eomplend sinei 111 eri0res. II eK ropnt-. .entf au t.blew III. Les ¢itlres sont rangls dens ce tableau par ordre dEcroiscent de sigoi8eation . pow Ia cumparafson. cnncees des bmnches-tlmoins e(1). On a mentionn6 en outre sw le tableau Is va)eur a k seens des diffdrences cowtYtEee entro eencEreuz des bronches et tEmnine, par des snhfnuu oh, pow mieuz situer aeY populations duu 1'ensemble de notreltude, now avow Isit Rguser A titre indiceDiles S populations de notn: enqulte. On ne sewait terminer cette 1TS ltepe que constitue l'inventaire des clithes splci6ques, sans observer d'emblfe sYr le tableau III k rOle extrlmement per- ,ticulier, jou6 par le ls.eteur tabec : permi tous les critlses spfeiflques, ebueh par ordre de signification, il vlent en tBtq et tr2s largemeot, weun des autreY ne . donnant• m0me de loin, une signification ewsi llevte : siwi, pormi 7rs 180eris2rw snoisaglh daru Ies campora4ons. doN 11 di/fheneient spdeihqremenl Iss ranrln+w, deo branehes des Ilrnuins, oYCYn ne ssagYlariae a.e sanees. d'une /atnnemnpYrab)eau faeftur enbae. - CIGARETTE LABELING AND ADVERTIRING TABLEAU I11(volr Yy®ds pep pNyyn4) t nYnn.nL Ytl unleq IelCmtOeY Bo/swn : n[d (oombn ds t.s.es per ramMna) ... . Sem. oe naxlnurtoY moln. de I 1 OOp Opp (p0 0,000 001 O,OOO0S n denis prdoy..... del 0.0001 e DenG (A) ; oomE TABLEAU III W 1 e dn AOmaeletbo : e Co . vaYr.nt nYS ar a.. re an0un P qP ed4(%daempmm.~) ..0,001 J 'Uyendr C. B. : Ceurrm do O:aoeLr. G A. D. : C.va+n da voka Wudl/aWVS. wpktYWer. C : Au1er e.nnn. T. : TtmoWe noY noeelaw (meledr al emldsW6). Pom Ir erBNw eYamen: on a noY le potltlan do : T. It. : Tdmolm mWdm, . ' professlon : (qve0 dY nrnl (% do vary) y . . uldNdmls p•ILObdlquq . .001 T. A. : TEmolns .eddentlr. ' l mWdM stoon-a-m- (XI•( 0p01 ~ (Le pnpdet on . .nnnmele . OyYn eolre prnYlbba.) La 1• wlonoe Indque N rull do uplar.Uan pour le eomperel.oo eexa d. WmeLw ~ lfmulns dem 1'oplrelbn II. N. 3. - Iw syna e eaAd. ertehY Mteros Indlque que Iseqow tkne wnwpYW Wes s'ent he posees qY'an.-usN rm 1. a.o1ta do I~mqulte, done eur. Yne YYMW aHsnY do DnlwY : ep4uB (nomyr. a Wlb verns Wt MmWq)I 0.01 ~ 1'.0mtlt. ywf i% d y rea°d' p°`I wlebpo4We) ont (1) Cot ordre do elsmenronl a'e pee Id do slWOntlon rynureoM, ne emdl-n qw pnn quo lee rompsrelroas ne porlml pn toutes ev le mtnu eOecW : W ettlhp noth e ns portrnt que iur une mo1t11 enrlem do le popul.tlao, q be erlllw . enmmsw: wr Yw mdtY rulement do llmolns. Lt elussement da erltMes per ordnde YMOeetlno Indque toutdou, dber mn14e eppro• eLle, l7mpnn.nee :alsllw do orllhp, doot art.bs .out bulemeat d/nl0utlb, ludu qw d'.ulrt. lS wal pew . ~i~asszooi AOmenlalon • (X do eOnbmmntwYS) ~ 0.01 InhWtlon do ps a Motors (A) (X do pol.) . . . . 0,01 posmoY a°°Tnn oy ro.ourwws C CA.D. CA.D. C, T. CB. /o ta la y CAL I 1I,71 0 14.8 C T.A. C.A.D. (T.Y.) C8. 111 e 11,0 / 1 0 CA.D. T. C C T. CA.D. C6. T. CD.A. C. 07 p;0 CA.D. T. C CB. ;l J_ I CB. 0,1 pT_ T. CA.D, C. > 2.0 CB. 1,! T. C C.A.D. Cg 9t 76 e 31 C T. C.A.D. C$ 10 ~e la C~- T.A. CA.D.~ CB. (f.'Y.) ~ t ~y I'9 ~ 11 233 0

234 CIOARETTE LABELING AND ADVERTISING II. - YlrrODS ses aseocrA77ota rArniumas La 11crithes spfcifiques retenus peuvent ne pas Etre indfpendants : B est possible, par excmple, que dane Is population gfnlraleIesaujetaboiventd'wtant plus dc rsfE qu'ils fument davantege de cigarettes; s'il en at ainsi, il peut sa faire que In csuc6reux des brooches apparaissent comDle grands buveure de ralf seulement parce qu'ils wnt grands fumeun, ou inversetnent, et qu'un seul des 2 crit2res doive ltre retenu du point de vue dtiologique, Cautre n'aysut qu'un rAle d' a aecompsgnement .. II importe done, en premier litu, de connaltre les liafsont statistiques entre In 11 critlres. gtant donnd le r01e privil@giE que joue k facteur tabsc, nous nous limiterons, pour commencer, i rechereher les liaisons pouvant exister entre le facteur tabac et In 10 autree critlree : ce sere Is panic A de notre Etude. . Dens Is panic B nous rechercherons si, h valcur 6gale d'un des crittree, In eonsomnution de tabee reste plus Elev6e ches In canefreu= des bronches qua chez In tlmOlns. ~ Dans 1a panic C nous rechercherons si, A veleur Egele de ba coneommation de tabsc, In autres QitLen gardent encore une signification propre. Les parties B et C pourmient no porter que sur ceuz des 10 crit2ree qui, dsnc Is partie A, ont montr6 une liaison avee Ie facteur tabac :..si, en effet, un ciitdre est indEpendant de la consommstion de tabac dans Ia population g6nErale, aueun de ces 2 facteurs ne peut avoir seulement un rAle d' e aceompagnement a de 1'autre, et chacun a une signification propre;'cependant, si on veut savoir comment les risques se combinent pour les 2 facteurs, il reste utile derecbercher leurs eReta partiels. Les parties B et C porteront done eur tous lea critlres spEcifiques. Les groupes utilisfs pour cctte ltude sont In 008 cancEreuz des bronohes et In 1204 tfmoins non canotrem[ (602 tfmoins seulement pour Its crittles e anorv maux .). La mnsommation de tabac envisagle est celle des 10 derniAxs annMa avant In meladie, ou evant 1'interrogatoire pour In tlmoins. En outre, pour 8tudier des groupes relativement humogtnes, nous avons fliminb !n sujets fumeun de pipe, ne.conservant ainei que In sujets quf, au coun des 10 dernihes snnlqs, ou bien n'ont fumf que Is cigarette seule, on bien n'ant pas tunlf. Ir consommation enri- eagEe se rfduit sinsi L la consommation de cigarettes. . Les donnles de baee servant pmv 1'ltude des assotistions partielles figurent au tableau IV, dant 1'interprftation et ks conclusions seiont cemmentles en B et C. Cee donnfes de base sont In suivantes : pour chscun des critlrea sptei- fiques, le tableau IV donne le tableau h double entrfe des effectifs, csntlreu: et ttnwins, pour cluque niveau de consomnutioa de cigarcttes et cheque niveau au critPte. sizssszooi CIB.LRETTE LABELING AND ADVERTIBINti 235 140,46 Dmnea.yetha ws E01 e.neErws tla Daa emdquz, ~. &w ~roiM a aombrct repkr.r! nbeut ee..t16) N^tatlona ;umz alm tumwur eroDma~ T. • umel,, .z l , y. nunt l e. : ..rortlmr L .. + de mrntlun : Pa d•euoeLtloD ulmOr.tlva ++ 2 s•~etl"D •VnlOestWe aa reu0 O OS ° a'...4R , . nn .Igda5l lava eu ro11 00, . N. B. _ Povr In W tlrn~n t!. ~aso~~d d'awel.tlay nlealvn). un~ A(• .nmmeux .), t+etude ne upol.~9ue ule uus duMd'enQUet.. PDU.yrmnka des nl Pu l Aot4W°aDL4. ~°IWhM : DW ec.Nou a _ P one umaloa . ... L C B 17~ Is 16 4 ]~0 bp m IZS ~a8 2!] I ~ 40 47 79 _ f+ ++ ^ OJ~IOM Da p010tfTa0)JOVa (10 d.l'Dllra eonh.) . t10I l011291 ,01 ~It~l'~I.~ 76 T. C. D. T. C. B. i C B AnteWdenp P~tpnlDylqua 2 bruuealte, aD fanclbn d. h 'emannatlon a 30.e. I 6a14 (DOm ~~ Psr wmslnr) • 81a1 da dent. (A) DDmbro dedad* pqdua ~ AOIwDtsum cagM sults DOn oui .ign1- Oeaues 0. 0 10-1s 90-2G > 30 .1a114 Oenlen O uU4 aon all ~,~ e „ 12SI ! lyl 33 62 • 47 14 a 7 5 132 4 0 s 4 + 1-9 I n-,o 7- 1+ e 22 10 u n 211 31 29 47 21 64 + ~~11011~i=Ilo~a + ++ I ++ la71 7711481122 75 48 09 la 34 29 38 57 a ls ss 29 ++ slDar 014i1na ++ ++ ++ ++ 0 ++ ++ ++ + ++ ++ ++ ++ + 0 j

236 CICARETTE LABELING AND ADVERTIRINO CI()ARE7TE LABELING AND ADVERTISING 237 Cette mtme mEthode a dt6 .ppliqube a toum ke c.itlre. .pfeillquca (sutt peur I'.nt6o6dent a meledie eocon.rie0oe b at k travefl du vecre, ke eQechi6 ltant trop hi61a). ' TABLEAU V Lum.oMe sxils ly Cnree118n eetm.neun e" u Cuwwrr.?lon Yt aa.nerrn (pe0nhnm des tlrno(n. non wee4eua) A) As.oddkne eMro le Is~ talmom d la Olltrar eri/hce ryEe(flyuee snit a.ecbe.dKr.i 1. nOneommdau de edf Pr exemPle et Iiee 1 r mn.nm• natiao de cipte<W de°e V P^WI'tiO° Le b6keu IV fourniR peue la population n(leL.otlDOU del.pup+du+ne yfnFrek), 1.1lpatitian dee eRectife pr eunwmm.tio0 de oetd (6 ~a) p.1Ur cigarettes (4 clean~ L'uwdntaun entx m 4 crithee peut !t[e t de eee dooohs p.r 1s mftLnde eluqique (III \ Y depfs do libtztE). On trouve \r : p. Cette velew indique que 1'.unciNion entre lea 9 crit2ld e.t A28 slgW- lic.tive_ On regarde .bn .on .em:: plue Is cunwmmaNun de ceft eet blevle, @Ine tr.nde eet 6 proportion de geulds tmneun: Is li.iann enmt.tle e.t done pocitive. 9T%969ZOOI ud~. Notetbns ecpAment Ir eundntlwe : . . . P.. do mentloo : On. d'u.od.llw IBnlnuUve. + : nnualetlon dynlBealve nu .eull 0,U8. + + : eua4dnllen dBnnlPatlva .o eeuY 0,01, (on n'. p.. obwvd d'.+aoelalew ntynnvn) N. H.- Pav ks en/eme notb •,1'1[utl. ne porte qw.m I ennde d'enquBte. Ponr W pltBlw noth A (. ms.ay .). 1'fteda ne Omtm qw.ur 1 rule dea popul.tkeM tlmolw. Carenee . ' L•A:w• evac .a COMNYY~}me ni pnln/TIq 118 Ant6cldent e.wr8lte cheonlqw : - ao twayn do In noowmmellon du 10 dme4w mnf.. - an lanetlw, ddo 4 mew:n.eue. d 30 m.. . . + + . . . 130 Conlenmelbn do utd . . . . . + + . . . . • BO • Nompne do denta pp,/nee.(A) :: . . . ' ~ Ide • M fonwnu.yon eaqWi.yu eulu. . . . , . . 23 'MvNI do verte . . . . . . . . . . Non tstM (efe tY I t 111 An1b2Aent mdedle oeronulenw. . . . e rep hl dey) NaR iMtN (eQeetlb /rep IYbleq 134 Eonwmmetbn d1p41W. . • . , . , . , . • + • • • • • 88 • Plladld do 1. ]• phd.np. 1eB • Cen.ommnttw do etwlab. 130 hlud.tlon do pe ds Brro (A). Lea rfeultNa de eette ftude eont prdeent68 w tableau V. On y v0it que 1& ooowmm.tion de eigarettee eat lite pncitivement : - \ la aomommation de alE, - a 1% ton.ummetion de mqtull.gn coite, - \ 1o aauonunatian d'.plritifa On n'epepoit pae de lieieon entm 1. aww0olo.ti0n de ciprettee at 1'.pp.ntlon de 6ronchite chnoniquc. l1.in on peut wPPosem'+ que crortaxne bruneLiteuz out dlnuwf kur consown.tion epr2. PePpuition de la mdndie. C'eet pourquoi noue .vwu ezanun! & nouvew 1'Bewei.tion en utille.nt cette foie Is eonemllu.tion de cig.rettea de..ujete i Eo suu : it apperatt alon uue luiaon pn.itive trl. BiQniBcetive, 45-979 0.65-pt 2-IB

238 CIdARETTE LABELING AND ADVERTISING pour cn a erit2rei an moim (antfofdent brunebitique, oomommation de c.ff. oomomrmtioq de coquiltages euits, mo~tion d'aptritiL, ), t'6tude da auro- eiatiom p.rfielks s'impore pour voir si 1'un de eee erit2:ew, on k facteur t.bac, pourrait n ltre qu'un facteur d'aceompagnemenR Bw ceth Ftude (voir B et C), nmu prtndrom en outre en comidfration, pour la bronebite chronique, Is coneom- m.tion 9 !0 qm. B) Signi/katicq propre do Ioehur 1aDne Soit un crit2re aptci8qm, tel qqe 1& connmmation de cefE. Nan voukns uwvo'u ci, pour une eonamnution de eafd doqnfe, la canoheua des broqoha fument davantaye que lee tlmoins. Le tableau IV fmmriS pour ch.que nivnu de conwmmation de osff (par . ezempk Ia clasee 0-9), la nSpartitfon des tEmoim et den cincfreux dea branches en non fumeurs, petGtt6 rnoyem et grands fumeun. On peut vo'v ei m rfpartitiom diBtrent par un test de Xe i E degrfe do IibertE. On ttouve, pmrt cette elasse 0-9, lr valeur Xs m 95, ind'quant une difffrenee tr2s signiRntive. Le eene de eette diRd.ence at le wivant : la c+n^s'+'•* da bromha comprennent moim do non tumeqrs et de petits fumeure, et davanta;e do gran& fumeu*si tls eomonunent done en moyenm davanfage do cipretta pour ceth valeur donnfe de Ia consonurutioq de cafk Ce nfailt9t at exprimf, dam Ia ligne eomespondant b cette eoneomnwtion de cafE, et dans In dernilro colonne du tableau, pv k rymbole }}.. Si on e:amine alon le tableau IV dam eon ememble, et notamment Is demi2re colonne, on voit d'emblfe que pour fow In eil2rea, d poqr ehq'ue nieenq de ra eriidrn (eeuf loreque 1'eRectif eet trds faible), la eonsmnmation en ti(ardfes da oan- eheus da 6ruerArs reste toujara enpfrianrs a adk da tLmoiw d'qqs fqtvn siani- /ievUna" d Ir plus auoeqt ble ei`ni/katioe. On pout dom dire (sous rherve do eritiqua gdnfraks qui snuot e:posEa plus loin) que In cancFieun des b.orohn fument davantye que In tEmoim . touta cbwes Egales d'ailleun .. Ainsi 1& pri.e en conuidfration d'un tr2a grand nombre de aitdra desaipti6 da mjets m permet en aueune fywn d' a iqnoeenkr r le tabac. C) 3igniQcatiun proprt da arbse er(1La spleiJl9qrs Cette signification est recbereJ,te par Ia mMm mNhode qm eidenm, mais en invenent Ie rUk des fectemt. Soit \ examina par a:empk d, pour uqe mnsommatioq donqh do ci`uettn. telk que 10-.19, In canebreux dee broneba boivent davantege de cafE qm In 4Z2i969Z00Z CIQARETYE LABELING AND ADVERTIRIN(} 239 .'tit6moim. r.e t.bk.n IV Po« ~repow dnae~ O0D`0nwai°° dq cl.arettee, la repar. tlmoint et dn bronchcs eq ~rands, trte B+ande buvem. do eatf. On peut voir el en ~t°' ntoy~' la nooMeuu dea ~ que la lu:nn eat tMa ai`qjgqp~ t d~~ai k~muaanr• broneha 6oivent dqvaqtaQe do q(g que In tfmoim, Ce tf. eet ezprnm64 ro~u~bnne~10-1~9 oqey~tfa i+ar jom, et dsne Iq li`qe e s~3pd- flration.de n uhat ~. L'e:amen de ces notati ~ ti~ 4 no~on ~- i•• . ai4lra,doamdes ~' d~ ~ I~s ooeenpondant suz diBhent. Noqe ~n~ti~4si8ni8eatioqpropredechacqnd'entreeun, ; pasum ri-0eeeoue en revue en dives erit2ra, daaa une dlscnaaion . d'ememb4 teqant oompte. >t la fole des uQniBntiom notla au tableau iV, et des indintione que penvent apporter Ia littEr.tme on d&ve.nes eq _ , ~~ teurIa10eritlnsepttiqqy~sutreaq dk~o~~u~ : par I° aitlra qui nom seqbknt kn i pour finir par nuz qui nous sembknt diqna d'ttre retenm. ~~ tnqa' ' oue llimineroqs d'abord In 2 Qit2res eulvanb : i - i'cnthldent: rnqludfc eornqmieqqe. i - /s b•woQ do vervc, i tin pourrait ~, d~ leto.s de 1, malqdie eqociation entre meoqanpue6 invoqua uqe ~ antleGdent cbes la _ eweHeu: des hanneher Nne, damw ~ a m aitLe omqute dqm k n' d ~t p~ feaion e travail do LL'on m ts V~K' i, In eReetj(j eq ~ q Jon .oqt d fai . fer plus loin 1'amlyee. Nom ne eb.Njtqnm done pe. A interPrEten . Nom dlinu ta ~te le eeitln : eon.nmqtion d'ap(ritile. B apparptt en eBet, dSme ~ 9m con.oqun.tion eet life k°ene°mma~tiou bd phil~i f~. ddaw~e Pe+k 4u'a conepon uati~on tEg lye ~~t~q . tlmoim (tableau IV). On t~" des ~uq~' at trM vcisine do celk des meat en rysnn do eafaieuq avedl c~~n ~ ee eritlre at apparn ici unique. propre. saW de 4°Yorette. maie qu'il q'a .ucuq eBet L•:natan &m dmym7f.ak k me aa S ait?iea wiv.qe. : - k auammotiqn do av.ew[s, • -/a piiwiM de ia Ye p/iatqqg.. Ua constate cu.ieusement, sur le tableau IY, que c'est pour la eata'Roek des nnq fmqeuy do cigaratet (consonuprtjoq des 10 d diRdreqeieqt In eanclreu: dn broncha dee tEmnim.~Or~, ca' ) q'1e ea aitlrn non fumeura que. k cancer dee broneha at le moin e w~~°t Pour ea faebeur sueeeptible d'ltre inerlmint prNeqte uq int~rtt e~e~ ~~ que tout Cependnnt 1'qepeet insolite de en 9 eritAree, et 1& di1Ba,e~wrpdtee kur : ~

240 CIGARETTE LABELING AND ADVERTISING eble, noue incitent b Is prudenee.Il faut lei eocae rappekrqa'bls adte dea 100 eom- p.r.bom eHectuha dam 1'opfration 11 svec k seuil de aiqni8cation 1 p.. 100. ii eat normal qu'un petit nombre de crit2ta (do 1'ardre de 2) bknt dhlsib tigni- bvatifa skn qu'ils ne k soat psa. La a aitirea en jeu illustnnt bieu Is situation ccuelle du etatiaticien, bfaitant entre k risque dc 1f• apbm (laiaaer lcbapper da faeteun du cancer bmncbo-pulmonai.e), et k risque de 9• apda : attribua une valeur b da facteun dont l'infervention iei ne nursit ehe considfr6e comme claire... Ii nous paralt raisonnabk d'dliminer peovi.oi.ement les 6 critlra, tout en nom propmant de Ia Etudier i nouveau dana Is suite de notrc enquNs. Lea 4 vitlea qui 8nakment retieodlont notre attention aont: - i'anNeldent.• bronebife eAroniqut, - la mnaommation de ea(d, -. I'[ICt da daW, . 1^ Brsneb'ua cbroniyrc. - a) BaPpekw le eem et la v.lav de Is diEfrence camatt.tle (tableau 111) : 1'ant4e4dent . baonchite chronique • urt plus trfquent cha ks cancEleuz des b.uuehaa (96 loie aur 100) que eha ka tfmoim (16 fois aur 100). Ce rf.ult.t conbeme entibmment aelui de 1'enquete Nttapective de Doll a llill (1969). b) L bronchite chmnique at, par dlkun, life 8 1'uaye du tahec. C'est a que ouue avom iudiqu6 an tableau V, en tenant eompte de la oomouunataon de cigaretta satfsieu.e l I'.pparition de eette maltdie. Si`nalom en pardculler que Is bronchite a ff6 obeervEe (voir eQeatiB du tableau IV, s•oupe tfmoin) 6 foia .ur 100 pom In non fumeun, et 16 foia wr 100 pour lea grands fumeun. Ca nkiul- tate con&ment oeuz des enqultes prapectivea de llammond et Horn (1Yb7) (sunnotl.litm par m.ladia pulmondra en Ebntnl eha leu fumeue.). de l/dl et fkv4e Nill (1966), qui observant une mastalit6 par bmnehite chronique 6 foia plus cha bn g[soda fumeun que e6es la non fumeun, sinai que eeuz des enqulfee ellectufee am 1'ftiolo`ie de la bronabite ch.ooique, notamment par PhilSps, Phillips et Thomp.on (1964 a 1Y66) qui ont Rconou k rble important do Ia ciga- rette. Cette 1iai.nn a mbme rebu une eonflnoation de nature plm eoncrbte par la travau: d'Auerb.eh a cdlalqrateurs (19a7), qni ont mnatat! PaltEntion des bronches dans da wtop.iso de lumeun, altEntion d'rutant plus Qrude que Is consommation de eigaretta avait ftb plm fkvEe. c) On peut, dam m conditiom4 .e demunder d Is frfquence fkvle des bron- t ciuteuz dana Ie grtmpe a osocer da biomMi • netr+duit pse asukment k fait qu'il s•art de granda fumeun, 4 b.onchite u'app.r.if.ant ici que ommm crit2re d'accompagnement. • II m aembk paa qu'il en .oit simi. L'ezamen du tableau IV muntle en eUet qu'd ,onaoxmlalion dpie dt eibar.pse (qu'iI s'agiae de Is ooouommatioa ntoente, an i so .uu), on tmuve plus de blonchiteuz ehe; ke amfecux dee bloocba que CIGARETTE LABELING AND ADVERTISING 241 chez ka tEmoiw : eeel at du moiw vlei8f /pnque oette eomommation de ciba- rettn at flevfe (16-19, ou 96 a plua): ps,r mntre, Iwwr la uon fumeuea, ks propotGOm ne diBhznt ~ti ~'~"n an hy aultout si on raqade 4 conaomuytioo 8 60 pas am~t~ tivementt elka aont mlour, paraiuent mhiter 1'athntiou .Wna• C. &altata nom 1° On doit d•ebord ae de~¢ les raieom auivante.: mander ai 1'ezcri de bronehiteuz an.tatd duu k 6rouPe • canar des bmncha e eat r6el, ou a•il ne r6ulte pas oeukmeqt d'uu biuia, ><+ eanofrcuz des broncbn ae nppeIant plus fbkmeut et esountant davantage leur psaxe pulmon"irr. Or. a'i1 en ttait simi, on m voit ps. pom,quoi ce bi.is 20 ap et W rdtr aitplm) rdtrait a Pan an aurto p.e e1sY Ia eba au ~ jct3 b o-~ation de cigarettee lkvEe (10.1Y, wha_ Ii noua chiteuz mnatatW dant le kmble done que 1•ezMi de brdn- L. 8t,,pe • anca des b.owha a at n41. .wociation • bronehitecanca dn per siDeun avee Ia r(aultata de Caae at b~~ s ainai uuu en Evidenoe concorde Wr cancar dea bmncha tm E ~(1D~)• qui at observlune mortabt6 bmnchite chmniquq p kvde dan. un bpupe de 1 421 aujeq .oo3'tant de 9° Ee faft que 1'eze2a eaiate aurtout eha la yWjeb b eon.ommation de ciga- Ln 'n°9ues .e4tiL ~~ ~mt ~ In4rprltE du polm de vue 4 da efkMid du Pour Ia crit4ra • bmachite • et • cyuette ., .alcul(yE~qm.' tableau IV, eunt repneth .u typkau VI : on comtats que la roor rAet.6.tu vt lbaouo su+nn eZZSS9zooT

242 CI6AREITE LABELING AND ADVERTISING rclpares, aaW fcwwrr.- nox na ura ~nwrr.nox oa co.wann (xor..xl+oux) . SloelnmitoM (nouawe na raau - 0 __- IA _ 10.1i >'b rMl .6rA1Nx) . n. e I 4 a 13 ++ 1W1U a . 3 to tt ++ g0.1D 12 4 15 23 ++ > 30 (4) SI Sp 23 + Sbinlnnnm + ++ $• CyerrW a I/xl b arM V,ne.a Coxeerr.nox on eu.aeer.. (xoosa/»ua) gwmnune. ux na.n r4nut•at e IA ' 1a15 >'p as t 4 S 15 ++ 6.15 . 1 4 7 IS ++ > te 3 S 11 27 ++ slnnketlon ++ + ehite ehroniqw• ei elle n'arymmte pm k dqw do um:r des bronelw Pour un rljet non funr~ur ou petit tumeur, mulliplie m rieque par f envQon x'il fume plw de 10 ei8eretlex pv jour. Ainsi lo btonchite chronique, ea t'nheeme du 6iotetv t.b.e, panlt wu eRek eur Ia ditmninaNon du enneer des brooches. Par contre, bnque k aujet fume modh6ment ou beauceup (plw de 10 eige- tettex par jour)• k bronohits eerait i envie.8er daw 1'ftiolu8ie do ce canuer. L'intcrprftation que now venom de proposer repose surtout la conxidErition det rlnsves . non fumeun r el a petita tumeun • dont 1'effectit ett hibk pnur les r.netreux des bronches. Elle demande une eon8rm.tion que now cberaheronx qound lwus dispoeerons d'eRectiff plusllevh. 1.n avmpunlwm ddewm ent Hd rep,itee en optreet eur kt dWert Nuupet dee etend.r- dl..unna par iR. On a retrarrt Ya mtma retultatt.On e tiNemenl ehaeH s vu4 Y PeuVnen- lalbn do rWtue pour tet eranr4ldei N prehenanat pu do rdL qu'In Inldml a.V\el.V b CIQARETTE LABELING AND ADVERT18INa 243 tumdr. D ne perell pm eo aw ami INN mm n'.rom inN dleetf do reletbn entn 4:ren d'btpysr 1e b'q{e et Ie hlt a•ebe etrant ds brmebw Wranlqw, Nom dat brorety ~q lunlt ym .Q<t nv 1'!q d'.pptrllbn. 1' ~~°pu, pommlmo4e, Oat°lyl' Wr.utawo do moe,r diCErenx-OMlMOHonla ooJl.. - a) RaPPebw d'.bord 1e .eot at 1. valeur de la la c.nclreux des bronc eo ~mmatioo moYenne de cat6 eet plus importante chex difflrenoe bautement 9 ehez kx tEmo(ro (14,7 tauea Pu. e~w rontro 11,g, en b) Par ailkun ~~Beative). . oommaion de ~~1Op ~ '~E ea IiEe poriHvement ! 1, con. P~~~ qci8arettea da0s 4 populat.on tlmoin e:pbrbe (tabknu V); aigonlone oonxummakionmo o~ ~n xetn.ine, eN de 8.7 ches k. no0 fumeun Ooaotr ~ etre ] ~•eyeg ~~~ °) On P~t, dam oea conditiwu• ae demandee ei la Onasomm.tbn do eafa dkvEe (tane k groupe e naocer des btoncbee . w q a'+8it do grande tumeun 4 haduit p.e e~at k tuk u'fl enthe d'eenumpagnement. eOpeOmmakio0 de caff a'interyen.ot id qw ~ 11 ne aetnbk p.d qu'II en .oit aiou. L• .. bronch~ea ~~ L~ do ei8ardfey Ia cowommat;on de afE dex m~ en etkk Phkure , oLRe des tEmoinx I xui at du moi des eujets tumantumenn et ponr lee eujete Rtm.nt 10-1g eigarettp ~~ Pou lee cigairett e<+lst maie non siBniHcative. 20I1 semble ~ low la diBNence mt daw k mhne 1'usa8e du tabnc. prFsente une q~ k~• ~Peod.maxnt de Le tabkau VI indique les ri.quml 6ib ~tlve nvea k n.noer dee bmaehex. et cafl. L'examen do ee tablew °O17"Potd.nt .ux tacteun cigarette semble, le risque augtnente en fooction de I.~emuqmmation deconk, daw 1'en. d) Pour avoir une vw w rieurea saaltttee uttee umelfiell cancen. onbtl4 ~~a~p% ~ alro-diBeetive. .uptt locdieation du eanotr. . vih m groupn oorteepopdnpt! ciue k tlmoin tnchamn al.detek ~s' 00 a talt t»trespondre i chaque xujet e.noheux ei. pnrmi ke tocdliuta~nlotn ~dentE do la edrie. Now avow pu ainsi chereher oonwmmatfoo de att• Cetle ~~eO~nt ~~+atiaa pmitive aveo In ntnai.tlon nltd ob.eevde pour um u.atlk kali..tk 1 osophage•~ a~ renteell que .f la cuneumtlutbn de alfE inteevenait aeul o t ~me m pa8nement de la oo eatrnt aurait 6tE obtervfc, non pour oeite bral• ~~oa de oigaette., 1'n..oci.tioa k pharyns• ou k larynx• qlu anmpqeaneot~ ~p~ Pow 4 eavitb buenle,. Denoix et An8ltera, 1g57). ~ de ~ timxun (Scpw.rtx, Le rble du qtb daw 1'atiolo8ie du eatlpw bnnebo.pylarma{t,e, et peut-Btm sT7ss9zooZ

244 CIQARETTE LABELING AND ADVERTIBINd tgakment du cancer de 1'seophage,' mfrite dono d'btre mvhyb. On ne aturait dfduire de noe seulen donnEa ai Is coneontenation de cafd intervknt iei par une action gfnbrale, ou eptci8quement eancEeig2ne (rapPeknaque Kumtone etHueper, 1936, ont extrait du bensopyrbne de goudtoM iawe de ia torrbfaction do odb), ni meme ai ex edle dolt tfx coneidlab comme au.al ou atukment comme celui d'un faeteor aetocif. Ce facteur nous paralt toutefole ee manifeeter ki d'une fapoan eu0ieamment significative pour etre pria en eoosidfration dana des enqulke ultEeieutee. Nou. av°m, pr pA°tlpa, meqarcL{ .'ILsIRdt uM Wlmn antr° e°ur°meullm dn e.ld at . brmcnua Nout n'erena pat oCwve uu. [.W Wl.on. Nou. danaWm.4 m°uln, pum mem°Iro. que Is taetommetka do eted pnett ew eoet wr pdae d'upp.rltl°n. Praktol°pn ou Ia btalWtlaa do nnw dn bronNa. a° gfd dee deub. - a) Noua rappeknt que k nombre de deub perdues eat plus fkvfi ebea kr canebreuz des broochn (16,8) que ahea In tbtnoina acadenbh (12,6) et la sujeta 4 autrta eancert .(1f.t).. Ce r6tultat toincide avee eemt qu'a sigtmlfa Wynder pour tn eaocen des beonchee et du larynx (196E), tinai que de 4 avitE bucrak (1957). b) On peutae denutder si Ia mauv.i.e denture des eanebreux des broochn eat en rapport avee leur omnotnwtion Elevde de ei6arettec.ll ue paralt p.s en ltre tinai, puisqu'on n a p.s obeervf (voir tablew V) do reletkn entre en 2 car.etlm. . c) Ik toute manibre, ti on compare Ia denture des tti,nuftetu des brnnehra et deu tlmoiue a coneommafioo 6gale de cigarettes, on observe (tableau IV) que la dilfhence rnte significative, du moina pour lea owyena et In `rande funteuq. Paur In non tumeura et In petite tumtun, 4 diRftettee u eat paa aigni8cative. Ceci peut llre dA au fdt que ks eHecfife ront rdativement 4iWea. On noteatoutefae que, pour en ntfgowid de aujeb, l'ftat des denta des c.ncEreuz et des tlmoine ett aqes voitin et, on at teotA de peo.er que pour let non fumeure at kt petits fumeun, ce facteur aeetit aana eHet. . Le rOle des facteuu a tomommation de cigarebte.s et e btat des dents 9 peut ehe exprimE en termea de risques (tablew VI).: on voit que 1'ttat des dents ue modf6e pat k risque des non fumeutt et petita fumeurn: pour k+ moyena at granda fumeura k rirque eat Is mlme pour les dentures bonon ou mauvaiw, maia 2 foia plua grand ponr ke denEute t.2e mauvainn. Noua augglrona t'interprEtatkn auiv.nk : le mauvait ftat des dents at 1if d'une tatott gfnbrale a t'apparition de divenw aflectionn, que noua avone citfn en - anelytant k teoupe dea tEmoins mEdiwtx (voir annexe), at pareni krquelln ae trouvent, en pmticulier, ln aRectione respitatoites nun cancbreuun. La mwvaise denture, ou ka tacteuu nuzquela elk est lile, ne poutreient, teula, occationner Ie catteer du poomon, maia ti k sujet nf, an outre, moyen ou grand tttmeur, un tedt mauvaia ltat des dents multiplk son risque de tancer brontho-puluwnairc (par I env4on dana notre Etude)• . CIO.tRETTE LABELING dND ADVERTIgINO 245 doll w a.~m.MUdr .1, M meuvWr denu at lu a6rlbM dr 2 a4ire. . meuv.We eeo4 . at . Mo~ r Nak.l nlt q~uq 1°trve°4 mulement ew u u.4na eve° Y.u4q ou tl, tu eontn4e, ~M y 1 N p°tlmlt Nom av°m veA6d qm ebem de. etltler per.n aru4 an nb °a°CUU a u r04 propre. Non, avuns dg.lemenl, p.r prlnelp., rocherchd .'n as4t.n an. WY°n en et ro°mmmakn do afd. Neur n'nv°na p.n obwvA uM taib payun, w wt dm dmlts d'.pP rlll°°u~iral4atbn do e.nor dr branW.. e.nluro Mnlt uet aRet .w 1'1pe Nnw evom, per eontro. Imuve une relabn evK 1'bbtot°ale : Y en tampmy tu ptpporlkM r.l.tivn do lype. Fp olnm uM nupl.aqum, on e<.rrv° que Ir e.M4eua do pnuman a/rh m.uvW° 4enlum compw° (82 q,.q,tre 69 Pr°POrtlnu plus ekvbe eo tYpea epldermotdn quo k..utre. %). Ble° qM qtle d1Olm°ee pil day6rsBV. t 0.06 M anud Mmttn er e°m• ~muaQ~t~ u°m uulle a M p.s luntr tmqpte do Wy.d b pprllr,lnr ~ YO° eos6r 40 ri°r de guerra. - a) None rappeluna que la proportion de tujeh qans nt plue llevEe ebez ln ancfreuz des bennebet (la %) que chea ks tfntoine accideut6 (e %) et ches lea eujeta . autrn ranaera .(7 %). 6) On n'apeeqoit p.s do relation entre k fait d'avoir t•tf gar4 at la qpmazons, tion de ci6aretkn (tableau V). ea~~~ toute maui2re, ti on cmnpare Ia proportion de tujete g.rEa ehn ka (tableau IV~ brunches et ka t6moiM 1 oon.omm.[ion 4916 de eiearettea dilffinnce ftaot trh k qu'elk eet en g6nhd plta fkvh chn Ip pteuyen, Is prhente un intErlt.. aigniflntive pour 1a elnte dn nun tummua. Cette dame Pm'timdkr : on obeerve en elfet cltea In 102 tujeta (p~oportion 4%) et chn ke cancfteui des brune4ea q~' 4 8~ aur (Proportion 87 %); cette difhenee, ttulpf 1. ~ aur 16 eujete aigni 1lcative (p < o.t1994)1 unai, ehea eea ajetr petitesse delf~ ~ at h.u terne nt ~~Nouft ra ~~ a~~t~ du risque . cancer des broacbn~ de guerre 10 derniben pamtfea. D 4 contommatiea de tigarettea en caute eet celk da pourrait .'asir de tujeta qul ont 11tmf do fayytt plus ou ntoins apptfciable au eoun de leue vie. Notu avone alma elterd:f, parnti lea 19 aujeta ci-denau., eeux qui, outre la ceteatiou ~~ a p~t~ t>Eqdent In 10 deruihn anoh., avaknt Par jour su plus pendant toute leur vie : epue avooa tiroi obtenu 8 canetteux des broncbe., patnd Ipqud.4 li.ah, proportion trla aup(qfcure a celle des tlenuina (.i6ni6estion a o.9os). 11 noue .emble, daua cce conditiMU, ktique de tuPp?Kr que ka gas de atterre peuvent jouer un rble dane Yftiolagie du caneer des bronchea en 1'ahaenoe du fae- tetu cigarette, et mlme ezplupter un ppurcentage pon li des bronchee ehea ku nonfumeun. ~~~kdnpsdetmneen d) 11 fautezaminer dana quelle meoue lea f.ckun a qay do Coetra . et a bron-chite chronique peuvent N.e lih. Now avona dlja si6nalE, dans 1'analyae de Is population . t6moina enaladn • (voit't),~ que lea tujeh bospitalit6 pour a6'ectiona pulmonairn prhentent uOe .. auormelelnent blevle de Qarb. - ozzss9zoot

246 CIGARETTE LABELING AND ADVERTISING Si, d'wtre part, noun examinonr, dana k population e tfmoinr accidentA ., d'uue part la rujett garE+, d'autre pat lcr wjeta non gaxdr, noW cautatoW qw Ia proportion de broncbiteux at plur dkvh chet la premiea (24 %) que chea lee autrer (10 %) : cette dIREa'eoce at trb tieniNative (et ne e'explique pae par une d1NErence d'6ge). 11 n'ett done p.e douteux qw la sujete earfs [ont nettement plw e:po.fs a la bronchite qw Ia autree. Cette eoncJWion eoineide avee celk de Case et I<a (1955) (*). On doit alon se demuder ei kn gas de Rueae n'asiaient pu eeuknunt par 1'intermtd'uire de la bronddte chronique. C'eet 1'opinion de Caee et Lea.. NoW auriooe tendana \ peoeer diRArvmvas..t• pour Its rai.oW auivanta : 1e Quand now coWiddroW uniqWment ler eujeta eon attcintr de btoneldte chroniqw, Ia proportion de gasEe rate pIW 6levte chex ke ancfreux da broncha que ches kr tEnaiW (11 % contre 7°/m diBfxna tignidntive i 0,02). Se Nnue evoW montrt qw Ma gas de Eutne .ugmentaient le risque cancer des bmncha chex la non fumeurs; cette 6Rvation de risque ne paraft pouvoir ttre expliqute per le r6k de 1s bronchite, qui remble exister eurtout chea la eujetr moyeW ou grands fumeun. Si, plus prfcisfinent, noW revenons su ax citfi phu beut. dee 77 eujcb gaals qui ne fument pae Ie cigarette depuia 10 aW au moins, on observe qw 6 rujete eur ka I n'ont pae dfclarf 1'antdcldent bronchite ehroniqw. SW la 4 sujets g.zH qui, outre ta oettation da_10 derni8res ennfea, ont fmn! 5 eigarettee par jour auplw pendant toute kur vie, et qui doivent vrai.pableble- ment kur eancer au gas de `uerre, aucun n'a rignal6 1'antlofdent broncbite chroniqw. Nouw penaons done que Ies gas de guerre. indlpendaaunent de lew r6k indirect par la bronchite chtwdque, qot un rAle propro dane l'ftiologie du raoov bivncho-pulmooaire. Peu4ttx cette distinction ed-elle un peu rptci<uce, et lile i la mani2re de dt6nir Ia brvnebite. L'important tat que kegaa de guerle pae.irent pouvoir agir en 1'absence dn facteur eidarette• poaribilitf qui now temble probld- m.tique daW k ae de la bronchite c6roniqW. III. - D/acusatoN Dra sfeDMm L'analyre eBectu[e daoe cetfa 6tude peut 6ke aitiqufe towbkndea aapeete . que noW n ignoroW pae : k ehoix da populatiom tfmoina et, br.qu'elkt diRlrent, ~ je choix de eelle qu'on dfis4te e noemele e; k cboix de, eritlres decomparnieon, dont cerLtio faeteua inttreeeant. peuvmt avoir 6t! umi.; 4 etratfgie utilirEe pow lea opfrationt de oompaniroW= k cholz der .euile de eigniflcaNon; le tri, ..(-) Ge wtsuq ent ebrrve, wr 1961 Wf W pfY, qW plee de 86 p. 10nlt.kvt vtbleta e. bmeMlte rbmvlqve. Cette prapv.tl.n ut bae.ovP plus dlavb qw leee1nU vwl. 1o dlrtfrevd ,~ivvM1n w~etr. wlw 'tM~ a n~e.rm enm.~ve~, te,ut., .At de 4 dtOnitbe de h bronddN dvan~tqw. CIGARETTE LABELING AND ADVERTIBING 247 ftude d•areoci.tkm ~~~ a ~~ b'encher r, do ~ttx qtd mtritent uue P.rtkllaM at 4 d nl tbode utRieEe Inur examina aa auoei.tioW ~! 1'artielks Pm' e°epla de'aiG r , a, et noo tou. 6)a feie : clucun de cer choix, dont lurioW Rtula peuvent 6tre fonafo n, mmpurte une pert d'arbitrairo qu'on pent q iti ~ c~Oe do ~ cr Qua poumit !4e dlBnitive e le eeul feit que kr populatioW tlmoiW pour l , que qua critdra, t'w2ront diffdenta, coqDnperei! - si beroin ltait -- leur i f mper ec[ioo, et pemettrait de refuter toute 1'Elude. C 4"indnf qn'~ crithe ' V° ~ apn)i l opfratien II eouS rltexte y a pas de die' d ' d ~tro °I~ ~ux a bronahea et tEmuins, pourteik danr une corrfktion psttjelj~, d ro~r° ° P critfra, Aytion et modifler, k rble da auttn til6o^qua q~ 1~• et bien d'autre, qul pourraent 6tre fonnulda - tont pIW , Ella ront Anakment de I ordre. : a~ ww ~.ut~,' qo opnP~lier , nctre analyee ron e matque de pulasaoce e; pwt ltre niE : Ia poRution vJw 6tiob6ique, ont pu now lohapper. Ceci ne I'akoolume, pa* msoque de tEa m~ni ~9.. Wr nu~nque de critlret .dEquate, difficile 6 introduin; dsm ~' 1'6tude dEtaiREa du Paychitme, out pu fchappa \ notre ao t~uNe do eet ordre, et d'auttq tecteun encae, NoW peWOW avoie Yk. Yait ooue ns pr6kndune pae ltre exhaWti(a. pruofd6 1 one ea nun Enun:lrh, doivent te refifter. ~~on d6j6 large. 00 da crit2r.y, mlme On peut eluuite noW critiquer w I. plan de 1' e eeteur e: now aurioW, du fait dee namhenra comp.r.i.on., reptnu da orithee ean. vakur. Ce reprorhe n'at popu~tipu d'une~t~ e~~nt retenoe difl6remient k. eaneheox da autra II f.ut ajouter yu~enbie deeort6 ka q"C kw rpk ne p.ealt pv fute de dpute. ~ultn~ta marqumb at cohdeenb reneondam Iite~ ~evsdnot du ~mupe flmw~ ~~nt da tv~euRab qui .`uid6, en p.rtioW{Q. notre choix ounra'ver, dane le ear der ctit2ren ..noroyqx e. Que l'exirleace mtme de teb aitkes eonetitue en roi une aitique de 1'lehantilbnneqe seest ~ rcup~be.Meie noW pemoW que bien da enqultee r6hqepectiva n'ont Eehapp6 de c.itFia. vinYemt qu~un .aul groupe tEmoin uu un petit nombm k pla~ de Ia ~caueaDtf,teeel oe ~~nW ~ p~ ftre d•em616e interprltW qp d'obxrvatlo4 que la n6tre, ~ut ~ nW• Il y a 16 une rtgle inh6rente aux enqulta PY PlW qu'une auhq oe u laquelk nuue eonuna reeth $d2)ee dam 1'Enone6 dc nos ~t ~~r. et 6 CnnCIWI9W. Zzzss9zoot

248 CIGARETTE LABELING AND ADVERTISING On a'dtudid 009 oanolrenc des btoncha• dont cbsaua oomporte un tltnoin eu4de non oeneteeuz at uo tlmoin nccidentb de mlme Age, intertoe6 a la mEme lpoque par le mlme enqulteur. Panni ce. 602 tynclxux dee b:oacbn, 400 pae- ttdent, outre ks 9 tEmoiui pttt!fden6. m ttmuio a sanae des voies alwdige.tives supEriewei . et un temoin a autae twar . appn.:llfs aamme ci-dea.us. Les ean- oEreux dn bronehea ont !td compen!s eai 4 euttee populetions pour 160 ait2t's dlflnieuunt lb .ujete au point de vue mBieu social, profession, Beu d'habitation, nntfddentt patholaQiqun et b!rldit.La, elimentation, tsbea, cte. Cee eamparaieons ont permie de /etenir 11 arithet diQlrencinnt de f.Snn trls si`nifleeRive 1ei nacHeu= dee bmntiLn des outtea gruupet. ' a) On econstat6 d'abord que, pntmi ces 11 critt'ree, Ie plus marquant eet 4 aanwnuuation de cigasttey aucun des 10 auttet a'appruahent, tMme de loin, son degrf de si0ni0cation. . b) On a mmtnt6 eundte qn'\ nivew tpl de chncun de ors 10 aritltea Is aontommation de eigntettes des tvtocfieu: dee btonches neirte tt lu siptiBotivement suplrieure i eelk des tttmina On peut done drte, em quelque sorte. et dabs In mesute de 1'ezpbration faite, qm b°nOfir"ict des btoncbm fument plu. que ke t6mnim . toutee ebnees dQatta d'ullcuts w Les 9 oomt.tetioos prladdeutes eon6cment, uae fois enwre. Is vesisembleaee d'une relation de nuse a eHet entx 1'usege de Is cigarette et le nnaet des btone6e. <) On & e:.min6 enBn Ie Mle des 10 wtta edtltes. Pnrmi oeux.a, e ont NM leovieoitement ahetdumN, eo[t qu'Bs mettent en jeu de ttop petite oombtri de sujete, solt que kue rCk semble se ttduire a L sede aortllation avee Is aon.otn- metion de c4naettn, ou tlaulter du risque de 1n esplce. non ndgliQeable sue un aussi grand nuubre de oompwisoos. On a done 8n.ktnent retmu a cril2tes, de sioBeAtion fY.ee : 1'autleddent btonchite cbmnique, . - la conanmmat'wn do c.4, - Y meavds 6tat des denb, -Yepadepw». Ia role de ehnaun de txe aithn e dt4 e:aualnd, campte tenu de w s.acintians fventuelks avec !n wtte at avee la'conmmmation do aipretto, et on a aundn qua ebecun avait tln rNe ptvpte. H semble qu'on pui..e en outtq qUOique avee quelques rE.erve., sue{fiee hs ttndee d'ectioa suivnnh : . - 4 btonehite chronique, et Y ttls meuvnis tlat des dente. multipBereient Is risque a eanar des btonches e, suttout, sitton ezclusivementr si le sujet ast en autte moyeu on Sesnd htmeut': . - les ges de gueete muklplietaknt le eisque . pescer des btoneha a mlme en CIGARE7TE LABELING AND ADVERTISING 249 debas de 1'usa`e de b'Jg.nette. IIs •pourtaient ezpliquee une proportion non n*b9'e.ble des antete des btvndry mn dus A la eigatette. dLn 4Eboceit2l re. ci.det.us pe ..y..jent p~ ~p en impnchnoe, du puque int vueagique: A Ia aun.ommntion de otduettes.~nOn seNement patve ettins d'entte eux n'ont de e0k qa'appyy a 1'ueaye de 4 eignrette, m.is encore pnree qu'ile multiplient Is tisque l ua degrf per 8 enviton, Up01• ~oauP mai'dre (multiplication ka fumeun tuo . ef n.~ ~ 4~~ muhiplfe a tieqoe Pnr plua de 10 pour yen. par !0 i 46 pour ks ga,nds lypKUn). (TYaoail dtt Moupe d'1Ctudee ror to /umLe du ta6ae, Inditpt Nohnud d'Hq8(dne ef .4qv7et dF:plqYevtioninduehieUc dp Tabaee d da Aqumenp•) , y' ANNBZB ' CNrTBRR68. ANORIfwOX . NOw ~ ~ ~ a~7[aw' • .Outs.wa • eest pn, y~u~a~pw. I~. IeaperettY~a M eoa~..Y.~ pateat .er 1. de4.a!eMtulor Ca alflne uet nalde A dew le'In Nj,M h t.0y.n tt..t eem ea eaaia.. do f{. Neu eepptlpm e• ~ p~~mNende adnptee ph. l'6taM ae eu vlttne : en oAyey .1 uae de. ~ Yeutn au~nue temole pO1p ~ Nbua e~en4 -.t yue er ew aa .aapte CeN~ puur Y.une ar cumpe.leuoe -.laeu 0 y a IYu ae p.odp~ a w. alr emuW ~~1~. ~Y „~• aR Ylts d4euuw M<a). enYn Wt uM6,e. t.e. Neu1lW wel Mircuish an (b) aer w taUlam tdeume. den. ib. 40 ~~ th. Mt~ •~ ta caar.. •WeY~..nmtw waaeel..m~ 7. dYMmt p~ ~ry. ~ ~t m~~} - IA,PtapmWn de eo1Ne eemet an eetlvuy ea _ .'~wplyw fedleeeenl pr Is felt Q W ptenWe (aedaeot4 de le etreaell.e .eelN py,uCArt tn w~ eat.~~~wt r.w~ * a~ W @u tnvelll.nt earaa Neoe ewae dene ean.ldqe t+peletba eum,ae . e pu eo®e Ne•yq Y Am~ua~ ~ Pap4.llee eW ~ reuapee.Wa e.a~ d~e. Wdem q~rUoto/p q rUoto/pq a dWaeeu.e. Is w.etwu devenlyn 16. Nepna.Ne, - La properllun Ae wjae ey.nt e.4te Y PWatepYn de ee.tue wt pl.. Ye.b a.. w temode e.eldrat.. cet e.qe .'e.wyue eP edmagunt ~ IaYpt oceeauuw de. eeaeenY phu trequemmeot qu'uee eut>e• 9w eelte ecldeetMl 1.~p~epu~ieUu. aa UmWam sul.da ut R Wur se edtYe• Y ppulensn dee 1lmqw Ctlle~cl e'lealqr pee ae auUnate .yW/MaOw. ye entk. eet lOWad. moln pow 1•oPMlleo IL Y~3~T7seB h bb. - Yba. YWUOa. aNse IelarPNytlua, p mlme rlwil.l qw psat uetoawrY Mzssszooi

250 CIQARETTE LABELING AND ADVERTISING SI. ManlpuMfloan de IemN. -IL proportion d'wvrlsn aynl manlpuM do bwtd nt plus 41.6. ches M:a tlmolm mdadea. On pourrall eiPSqwr nl nets en admettant que, pour certalna do ma Idmolna, 1e mWdN Mloelle rbnlla do la manipulallon do benrd. Pour vldflm celts hypo- tht[e, nous avons dlvl•l w tlmolna en pluabun goupea d'aprN kur maAdk aetwlla (etfeetbw reaplrLLOlres, cardlo-vaeculabea, elc.), et mherch! d 1'eaels • b.naol • pouvalt !tn localls! l un do ces grouper. Pilte dlmarehs n'o pas danns do rdullst poallll, 1'eactr • benwl • aembinnl unitormlmenl rlp.rll dans toua ko groupm. Par eilieun 1'exameu dYnmmbd do nm S populetlons monlre que, pour es mlttro, elka wnl loutm eomparables, t 1'eaoepllon do grnvp • ttmolns maladea • qol prlsenta un eaels por rapport aun 4 autree. C'nt donc blen ce groups qW paraltllro • anormal q blm qua nooa n'ape.- uvlons pes d'ezplkallon bglqw. Noua arons admis que mlle • anpmaW • rtmlts do rleque de t•• mpln : nppebna qu'avs[ le m/l do I p. Ifp uttllei noue .vaw 1 dmnes spr 196 de mndura 6 le .Ignlikatlon an dehon ds lou4 dl9trencs rlelk. En 1'abrent< do twla dillben[e entn hq 4 wtm popnlatblm, le erlttn n's ps !td ntenu daventqe. . 6]. Slluur/an de f^^dlle. - Laa tlmnlna aahlentda wnt plus muvant mnll., mWa wavmt elllbalalres. veuB. on dlvart![, quo W tlmolnr mWdn La co•npwWOn do nsa 5 pnpWtlona pour se crittra manln qn'e11et wat toutas dl9drenta enlre ellea, tvau It dnveeunt aulvant par ordn noWant de la proportion do m.dY' Tlmolns maladn Itmdw aeddwlls C. ahe•.dlgntlh Autm C. C. do broneAer 57% 65% 72% 75% W% n (aal h9 tealr nmpl, d'un bt.ls d'debwUllonn.ge. La population do malodar prNenu on Jo•ar donnd \ 1'hdplW dllttre an sllel do la populallon Mntral. do eu1.t, attelnte de ntts mWdle paw uw double nlsw : 11 ] a un 1•r blsl[ aotrs 4 pwulatlon glnFrale e Is population entranl t 1'hdpllel (OnYtpn, 1916), et uo 9• blab, lN an tempa do stJow des m.ladn! 1'h6pllal, entn pnpulatlon enlrwte el populallon pfl.®ls un )our donn! (Sdm'aela st Anguera, 1957). Id, par eaemple, an conUatare que pow wa mabdle dunnls Iro elltbat•Im vont plus feelMment . que In marke e 1'bdpltal, at y reslent plus langlempe. les blols en qwallon, dane one enquUa rdtmpectlva, dependent prtndpelenxnt de 2 tmr teun : la Snvltd do la meledk (les bla4 wnt plus lalbles peur uw maladle gnva mrnm k rancer qw pour une maledls btnlgw eomma nlln des llmelna) m la hlqwnn des puusgm do 1'eo- qultaor dana 1'h6pltU (4 blal[ W au temps do sltwr nt d'aulanl plus Importapt qua I'enqulleur passe plus raremnt). Nom avons Pu mnntm qw 1'ordro do elamemenl c/Aauus dn S groupm. en as qul mnnrns bur situation do IamWe, e'e:pllqoe mtRramml par ks Nals d'lebanllllonnage. 11 r•ale toulelo4 h vdrUler qpa m dt9lromm Wonl pas w ds rlpercuraba aw 16 consumma- tlon do t.bae obrervla dana bn S debaalllbna : e'erl bNn Ie en, car nuus avont conslatA qu'll n'eaats anw.e nwelallea wtn la situation da famllte el la wnsommalbn de tabac do noe wlete. cw [r1Ure : a dow ps 6ld mislm drvaWga. 6f•-65 tle. Drmulen dra su/e/e. - tln . nat! : . - le Ir• ann!e d'enqulte.la nembn de denla perdun; - la R• annte d'enqnln, le nombre do denta perdx• al nan nmplaedn. .~ Ls alltre ee prlmnta, eluenne dn 2 annfes, comm:. • anomal •.m cs •ens qw W tNndna lnabdn ont uw plns meuve W deatlllen qw In tlmolns accldwtls. . On peul cherchm h npllqwr odte dlgdreneasn wppafant qn'ona partle deatlmolna mWdn ou.alenl, en relallen evac kur n1alWte actuelle, um dentitlon pankullhement m~avWe. Pour tuter eetle hypolhtse, wns avow divltd m llmolns an pipdsun groupea d'aprls leur m.1edY octwlls (eMeliwa resptraalret, nrdbvmeulaMae,, etc.) at reebereh! U certalna do m groupts prlwntalenl one dentition par14u9lroment mwvahe, eomparda te.t onx aulm gnupn qti a leun pnpm tlmina eeeMeotb. CICARETTE LARELINQ AND ADVERTISING 251 Nwe avons obaervd qu'ane dentltlon pwlhmlltnment maov.lre rar.cllrlwll lea Idmdna maladea Imapltellste popr : - a9eellona mplralolm, - agnlbne dlgeal/vaa,- - cerUlnea alleetlona cbrnnlqtms. Cm SrouPm, le demin notammenl, nprdrenteol uoe parl amm Imporlanle do 1'eRedll do 1, popul.tlon • tlmolna mWdn ., qul appanll alnel, d'aaa f oo denlllbn • anormelemnt • mauralae. K °~wk m1e PaPWUou h Cetle teCon do volr panlt lo9lque. Tontetala 1'Impoulbluu do loeallser la manvWe dmUtb. S de. 9roupm ltroilemenl dlllnla de maladies la nnd molne wtldabanls, m on peut edllqun romme wbllraln k felt da ddcldar qua 1ee tdmolw matedea aont • anermaua • el b Mmdw acddenlb • normeuv ., . SI on regarde abn la populatlon dn • autm onprs •, on anwtate qw Deqad rl : - trts vohlne do celle des llnolns aeeldmtts, - dgnldcaUvement dlgMenls do ea11e des tlmdns mdadm. SI en9n on examine la populatlon • teocere dm vulee alro-0Igestivn aupdrleum •, w wnalola qu'elle m platt, do point do vue dentl//oo, a on nlvou Intemldluln entro Iss ttmolaa atddmrtls el In lfmolna mal•dn. M•I• al on ,elln Im eanelnux do la eavlle bu[nle at do larynt, dont Ia . mauvelee dentillon a!la dgndde (.Vyn9er, 195g el 1957) el gl eangrmde par eoa dunnen, la popnlatlon •, cence.s des vdp olro-dlgesllvea wptrleures • devlmt taut A talt vuylne do la popu. lallun • tlmolns anldentla .. Cea oonaldtratlons nous mmblent ean9nnn k euaeltse • nornml • dm tlmdns aeddentb et Is nracltre • anormal • dn tlmolns mal.dm. -- L'aplruUOn 11 eliectule evau/t. en prenent eomme groups tdmoln nelul do acdJenlh mwtra que 1s dentltlon Ues ks nnedreoa des brondus m anormalemmt nuuvalae (plue anrnm qus chn les Ilmolns maladn). , . .. D naw.emble, en canduslon, qw Is vittn • nombnllevd do dwta perdum • doUlln relanu dea[ Is dercrfptlon dn eanelreua dn brancMs aemme on ed .... m•Is mmmun avae d'autres agectbns (at natammol dq pe[Ilom~~l rplrlllque, nums). . IdraWm son nwt- 91. polda arluel. - On natera qua, pow la poldt en Iln do erolwaea, airl qw pnur la pulds maalmum Otlelnt as wun do lo vM. In 2 popubllont tlmclw w prtmntmt pm do d10lrence signlncative. Cdte dlfflmce n'eshle qw peur le po41s wlpel, qm nt plus falbls ehes Iw tloeelns maladn qua chn ks tlmolm eeddenth. Le polda acwel devalt, d'aprta le que.llenaalrq dl.Igner le putda prlcddant 1. msladle aeluelA. On psul aupposer• d'aprb an qul prhNle, qw atY d!9- nllbn n'a paa !td eomdemenl mpedh tlam la [lpoum dn wJels, el qw le a!ld urtatd par p mu4dN uctuelle. polds en quptlou Noua evons prltdrl, dans m eondltlonr, w pm teep wmpte do n w1Mn- t10. Rbumm/.meort/wte/nofpu.-4propwtbndawJa.aywt pathaloglque Ie Mumotlsme wtkulan a/g9 ml pWa llavds [bea Im 1lnw~W ~°n a°It[!d°t ~~IWet. Slah U p11 dleompom tea tlnolna m poupn d'eprte le motlf do 1'baepltatlut/on asl do suJete ryant w le Mumetlsme arllculalm alge nt lonlle! an rou ~ « vW qw hcW Ilsls pour a1leMbns caNlo-vuculalm dlvenea, lea aulm g p° wWNlame°t bnplta• Cetla eonstatatbn permet da cnnU 6~opnllanl.atneuxs mWdea dlrcr wmma • anonoay - to Pupu6lbn dn MmoYs pow a Mllrs. En pmanl alors cemuM r!1lr.n[e b population dn tdrnobu •rddamlN, on no note pu do dlrtlraoce avee In [.ncdrcua dw brondnn; M erlltn .'mt dow p.n rclwu. 116. Al/sellana mplnlufm, pufm Wue hyrchffe chnnpw, - La prnporelo" do soJds syanl rlgneld ra anMctdenla palhologiquss e[t plus llsvM drn Ip tlrndns molndea. Muls <et aasla eel Ince11M au: ldmulna actuelkmwl bospltallrla pour Nleellons mpiealutras, In sntm w N dlalinguant pna do tlmolnt accldenlb. - On peut danc eonddlra wmm. a anurmele • powce eriltrala populatba do tlarolae mdadas, EZ?;969?'OOT

252 CIOAREITE LABELING AND ADVERTISING et pnndre eomme 9rnupe tlmoln ealul do aeeldmlds. On na wte .kn pa do d196nnee slglll- 9eellvo avee k• eancdreux da bronches. Lo crlttn n'esl pa mimu. 195. 1nOrnnHum eDkurplmin (weldenla ealm). - La frdquenn do w Inlerventlons nt plm dlevde ehet les tlmoins maladee. C.el exeh peul s'expllqwr pn kuf possd palhologlque plus chargd. Cette population e4 done con.ldfrde comme ••narmde • ponr ce nlltre. En ultl4ent Is populallon des tdmolns anidenllr eamme groupe ldmnln, on ne nuk pss de dltldlanca dgnl- 9callve avec let canefreus des braneheL. Le erlttn n'ed pLs tetenu. 1]0. 1n/InlaNon do pue b puene. - La propnrtlen do aul•t• gaMs at plus dkvde chaa les ttmolns malada. Mals eat e.ats ert loealkd do felun lrls dgniflcxtlve anx su/eta adudkment hospltalhds pour .Ifeclbn des vola raapkalolra. 51 on retire le grnupa do ceus-cl• 1'feh.nt0lon nstant dc lbnolna malade• ne dlRke plw de 1'dehantllbn do ldmolns aceldentds. Gtu eonsta- lulion pnmel do suppomr qw 1' • enomalk • at la fail dee tlmdns malada. A tltre de lusliflcallon mppldnentaln, on pml asaminn k cas do k popukUon • autns aneers •. On eonslate qu'elk eomporle un pournnlaga do gesls trls 4AWn de k population • Itmolns seeldenlds •(vulr lableau 111). Cn eonslddratDmfnous pnalssmt fasllfler la dlcltlon prine: In opdralions ultdrleuras do eompu•Wa monirent akn qua k ailln est,apddllqua • cancer des bronches • (1). - 153. 137. 198. Consomma/lon do a/n, a/rool kkl, NDpl4nle ettnlqun - On eonALLe. pow na S<rlkns, quo Ie olveau d'akonlWlloo ed plus tkvw eM1et ks tlmolm malsdes qua Na W tlmolna anldentb. Celle dlRtnace i eapllqlsn Wlmml, car les mlcls do k pnmUra population sent Irdquemmenl hospltallsds poar maladies Ildn Q 1'd<ooHune. . La population • tdmolns mal•dn • a done Nd tgminda pour ee uRln, at e'ml la population da acddentfs qal a dld ntenw.. En Mabtd eelk popuktlann at e1lPmtlw tr1s prob.bkmeel d'un nlveau akuollqae axagM6, llmt donM 1• relation cannue enlra I'skoollsma el b seddent. do la clrcukllon ou du travail (c'nl d qul a Nt congrnl6 dans Schwads. Dennls al Angwn, 1957). L'optnllon 11 de mmp.nlsun enlre ks nnnn des bronchael In tlmolns acel.kntb na rFvlknl eucune dlfldrenw elgnl0calive, ta nltlra a dld, nkn Is ddb flimkd do I'dlude ultdrleon. En Mollld, calla absenee de dlglrenee lalra d ponser que 1, population • tennr dn bronches • est, dla aual, d'un nlvau akaollqua trop fkvd, N wggtra 1'Influmce posrlble du laeleur almnl puur <e ranex. Une ttude plus poossb ee umbk pu poWbk aa dehars Cun nerotennnl de mellkms popu• lallwu tdmolw pour ir alttn. 141. ToehppDa/k. - La pnpodlon do enlelr tarDYpbaga eY plus Islble eDn ka ttnmlm oeeldentb. Nout n'evona pas pu trouver d'InlarprNHkn .alobk de ntle dNdrence. Now, supposens provlselramenl qu'elk rdsulte do rlsque do pnnikreaspta. L'esamen des b populations mantn quo la proportion do eu)ols tachypagne ed 1t mMte dane lauler 1. populNlons, 61'escep- tlon de le population do tlnmin. eeeldenll., pom 1•qwlla e1M at p4ue bNbk. NouL pentem qw e est nik-cl qul esl, par k 1.1t du ML•rd, enermak. LeL.utrw, en patkulkr celle da onalnua de. brandn. ne pMamtanl •aetlna singukrltd, la crlttn a Qld d11mIM. 1) Tssble.n Maunid. lw t.blaau VIINWnu 1'Inlerprllalkn st In rdsultalr eapesds d- ' dessus mllen wr crlttn. Ort nuten qw : 1• Sur Ip 16 erlttres • anornaus •, 2 en fln do eomple mddtent d'!tra eonshkMs eomme spfclflques • nner des bronahn .: ee aonl la msuvala deatllkn et 1'Nbdalon do gas de guern. Ce• 2 crlttraa onl doncltd nportlL dans 1'Invnlabe do edltna tpdelflqw• (ISbk•u 111)- (1) La population • aanpn da voW atro=dlpsllvn roplrkuns • eumpane an poureeelcp do g.aQs dl0hent do nlul do L populalka • tindns aceldentts • et vekin do nlul do Ia popuklkn • eanun das broneha w Nds elk at .wpnte a priori .ut.nl qae eaa denlitra. vzzssszooi CIUARETTE LABELING AND ADVERTISING 253 Re On a pu kouver uw e.pllcatkn vWbk pow 14 da 16 erktree . anarmaux n Dana 2 ees seulemenl;\luute d'explbalkn vslabk, oom avona admle qua la dlllMenee observie pouva/t Msulln du rlsque de pnmltn arptca. La frfquence do en ue-9 rur ld0-eat loul A fal de /nrdre do grandeur de ca qul pouvalt Qtre altendu en utllkeni k seull de slgnlflcetbn I p. 1U9. TABLEAU Vfl IxTenrnQTwT1eN tr cmn1ULIUN Pena LiS CnITQBn • ANnarrAUx • lJprnde C. B. : edltio rpldflque • r+nar da DroxDm . N. H. - Poor ks allbn nulb •, 1'Mode na porle qw mr una annh d'enqulle. - GrtMn . .._ _ Slgne do 1• dllldrooce, mantbnn4 daw la population fugda anormale • E_xplkalon valabla rnouvae ~ncluslan aPMe laa eedn.Tlnxa . roun L''nNOUwue. II III aT ~ Ttmolna Tdmolns ~. malod.. .ecldevUs 7 Sllwtlon pre/mymdk w twlk (% de auleto m actl.lll/. . . . , . . . , } ProtaWens e~mWet (trdqwnn) : IS M•Mna . . . . . . . . . . • . . . } 33 Tnva11 doi bok . . . } 51 Yaolpulaloe do bental. . . , ,}. . - 63 Situalkn do famllk (X do '''' . noa mE A ` ~ ~ } •g5 Nd n a tleota perOna . . . . }, , ~ • . . • 6 & •g5 Ilr Numbn do den4 pasdws . . el nan remplaeder . . , , , } pl Polda aeluel . . . - -- AnllMdants p.thobglqun (frF qwnr.) i 110 Rhumetkms dkukDn .Igu L tld Anecllona aspinlalns (au- tres qw Dnwhlle tDronl- qw) . , , } 125 Inlerventloo r ehkueplWn. , , ,} ISO Gas de guerre. . , , , . ;}- , , • • • • • - - , G & 1J3-137-13g Akwlisma. . . , ,}. . . vok taale ldt TadlrPhagM. . . . . . . . . e na 45-979 0-65-p. Z-1] # FI

254 CIqARETTE LABELH'Hi AND ADVEBTIBINd BIBLIOGRAPHIE AuseaACU (O.)rOtne (J. B.). Fouan (J. BJ, Pernlcr{ (T.OJ, S.nun (H. J.), Muuaar (G. E.1, Kaesnunv (D. Y.) N Stoue (A. P.). -Changee In the bronehlal epllheBUm Ip ralatlan tu amdring aed unur of the lung. Nnp-England J. oJ Mtd., 17 Jenvltr 1957, 11N, 97-101. Bulufan (JJ. - Limllalkn ol lhe applkallen of rorefald W ble avalyNa to hmpltN Date. Bla-, nutrln EnB., Juln 1918, S, ne S, f7-5S. _ C~ An 1 vellon nlo the pedbllly lh~ettpo/wnlog byMm Iavdmrgaar In tM 151~. Ontr~er night be a fa<lor n the prurluctlan pf eaopeeela. Wel. J. o( Prewnt' and Social MM., avrll 1955, 0. n. 2. Dou. (R.) et Htu. (A. D.). - A rtm1Y er the nlMlpgy of exclnome or lhe lung. Brll. MN. J., 13 dfcembm 1052, ne 1797. 1171-1 285. iondA(eeeondHraport an~Ye m 1.~/7 1 BratlM Dpctora. We/.aMeA•Jh.'10enoveambn 1950, 1i, 1071. Han.anu (E. C.) et Horln (DJ. - Smetlng In nLllen to death nlee. Annwl Meellnp >l Qw Arn. AIN. An. Neap York CIeP, 4 Juln 1957. Kun.rsIS et tnsrsw. - Polycyelk aramalk hydraearharo In teSw raele. J. a/ Nae. Coneq lnsr., Jonvler 1935, y7ue0. Pnll.urs (A. SI.). Pmtirn (R. W.) el Tuounon (J. L). -Chronlc cough : endydr of ellologle Inelen In a eurvay pl l 274 men. Ann. o/ InWn. M<A., .001 1956, {S, se 0. Plu~un (B. W.), Puewn (A. M.), Pavu. (A. M.) lit Paeona (D. V.)• -Chronk braneNllf, a negkcled dltlma enllty. Dls. .1 Chrtl., 1951, 9Se 510. Seuw.avs (D.), Denols (P. F.) et Anougn. (G.). - Radlerehe dn loetllutlene do eaneer aetotlfet eux neleun tab.e at .keal cbee 1'hpmme. BuB. du Cannr,1957,44. IM 2, S3"1. Salwners (D.) el Dsnols (P. F.). - L'enquen Mn{alp aur 1'flnlpgle do cancer brPnchpo- pWmonYn. R4b do labse. SemI dn IIJp. de Parh, 30 ettobn 1957. 33- annM, ne e&7. Snr k nrmq 0 aa bJoAit~ On I~Ilau d)ea b 1'!°p11LL °°Imunknllullne~Nae/pnaldeq Slat., Storkh~olm, 1957, 30- eeukn. Wvhuxh (E. L.), Bnou (I. J.) at Dav (E.). - A ftudy ol envhunmennl fsglma n cancer of the larynx. Cancer. I9S9, 1. ne 1, MLHO. Wvnusn (E. LJ el Bnou (1. % mM A 195o7~ 1, k 1157~1 ~d7 mW~ 4ncq. An apProach to Ita . prermlbn. Brll. Md. J., 1 CIQA8EITE LABELiNU AND ADVEBTIBIN6 255 L'ENOUETE FRANf;AISE SUR LITIOLOGIE DU CANCER BRONCHO-PULMONAIRE. ROLE DU TABAC Nr Daniel Scnw.grr el Pierre F. Dneon (•) P r. Je 111 nVUfrq, Jen. au rmirt 7 prys, pnnenl r laur Je t.len rtnefnue Ju puumpm et an nurnbre bienplm tleYe Je Hmuim,, uol n your objet ae aO1 Ne Ju tebc Jem Ihnlogle do cancer h i p 1 one e Naue n'fnu Ne b. pb id b l ele Je e Irere.. yul ont Ne Mnlx an r< e el Jieculft Je racwr, nts mninenle, nolamment Ptr Unn (a). N'Ynder. O1. uamrmrnu (5). Nun. n repPelkrune pae Jae.r. rn;;e In nnmbremes vilinun. <n.unane, uu Jiuu. I u nnl t 1 1 n Jn Jinnn enC ehe, Janx enr Ir< A enJe najurlf. I n.lbuer an mnne le lle J'un Iuc0. r mnuinemrnt aunpif, et prob1s41ennnt 1oVenanl aprM rtnl ,/'aulrq w n rrdemi - y,r'vre. ham'ayr Jen Jaa ,Ilreriiunt rW II aemblair .' pnrime d'nnwn une m/prmal rmuven.. le - dem~nlJe It 1 qn A YY pun rorn(trli tt n/le rone dt nbec (le leb¢ nY ria ¢' NuJi!), rqYt tYOna viYf aua ttlerrnlOm qireNnett I) r.hneiun t plueieun PppWnluna tenroirm Mmt eeo.rm rbertbf Pn It e rthnun 1'ob.'ev:1 j e . atint Ie chYlt lYUprm erbinain JSne (e,: lemuin nnu. amne .mr.i trmn peer latwlo li, premme wnprennntlbn umen Ireaguln: - D'aetre pan, ee an qW eppre/m 1'uoge Meme du Iabec, rnwcipele dllficullf de I'Innrprfialipn nunh nl aue newmmellnrr flnee de ciranlla pnumh n'elre .,m. Iweur bf A an arrtn reneY aui eenlt k Yral rea. aable Je punl de eue <e I 5'il en Heltlimi, In •A.1nt do pmrmn deYreieel dl9fnr, dn temdm per. "mYinr an /Kteur auln qn 1'ange dY Itbaf. DNt ',tt In recher.chn e9altha a n jnur, un n'e pn pu '.'.ue en ANenn de. tne feneun, tl CaM n r/nultal can aui nehn f rhypqheee nuule n Yreinm. rcr tlnl4. Meh an ne nuren yua pPler I herqn '.yue jpur da.anlage le Xne dn laclnn upkrfk dml numbre nndllKnrn dlretmment la YnltrnlWann an xenin C~ len Ie Pupe ee cuneidF Ilen d Irfe mWlipln nn qui nn.thue I'aepect Ie pl . nn:rlier de.mmer .MN. LYIUJe eanpkh de cn Jeenhn. el de hun 'rdatbna mutnlln, nl acluelhmenl en coure, el Ine 'in Bune publkatipn seP.rfe. t'euJe he Inrallullunt tancdreuta. eulrn aue h :mun Ina fgalemeel 1'nbjH Cuee punlnrwe efparh. tUw n'npntrnrn dGK Id Ma reaul/ee do rmin en• .'b w mue Ie esul pnint de eue qieam : cnmw. rln e mfnu[ dll pumm~rr n dn Ihrrelm !n n I' , .Tln: rre rYnge do lab ne a.um flerMu Ilnlerrngatprn A en trerM Ilpmbn # yurn/nu aem rappun dirert nec I'Imge du labec, 'dln qn : niweu emiaL pnlesefuM btbilet elhatim A lanilh, anlfa'fdnla bfrldilelm, aallcfEnls n/ho- IRWen, habiladn elimenleire., ee.- De lelln yuetlbm unl euuYenl 9gurf d.n. In yuea. 4.mirn der mly4ln Frherhnle., mate mur e.pu `e.r,rnup Nargl hcbemp de 1'qhrrorylpln. Ceee dn- . an eatenelun eeall un rkubk.Cut : ' 11 iaPenit Cune Van de reaher<'Ihr dn /arleun BIO• `riytet mlrn yae 1'unge do labee [ ttu.-nl, len qut a lallwbn almnplrtrpn, ke mehAM aMMeem, In '. -n:NJente Irt.Mllum, lk., m peuvenl Mn Nmke n lenanl cpmph Je Inn nlello,;e mtleNln tl de - nqiraro aemellyen pfnel:rs,. ' pfgrrlly fYYtne~n .en r pr.n m dn meLJn nY ertue, r~ rler Imn mahdn Cn Lpjt ahgnrin a IfrnrNn. irn os t'nWfu_ M dtle elf ulllnfet dem ,raM[n enyuMn, mab nnn I IerquMe eel do trpe Nrne/rtrll, t'M.fdin mrNle .mhrnhnnt dme hIrlenle nn dn tondhiom de I". eur dn mjele ietnroge. , m mnmenl ab ib mnt aJa cpnwr.bant. I deH aneine par le malwie N Mih (n.cer do ppempM, n nlemion a dn Iacd W nuae nr,clrenn .uha aue u" .u mnlrene IMemre rk teue naldk (elemky. te h bnlrntipn b eM-pulmenin nqrle di cprreamnl nn antn e a'ntNeu, aY pmmea Npm ea a'ha hf W If t trl la locaurenurr au' el en 1lmW .n dflinl plm Wa (eppanillmrtnQ. fennn parmi ds t Inallmtlmlt M e0elan avn le In p~rlaln CA•q.Olle$ 1. rnmee a 1 ba : cmef butnle,, ph.rye., ' . r mepuhegs ek v i aril df1A h0 rpbire dt ne L'ennYete Ilnnf eur n popul l/nm, d'Imnrmn unpue, a.es ftuJea, rt be unT Inni numbrqan que h menl, chpiMe dam he hEplltua rk Puh (•) et puur un pwmnn, et nen dur me mlme seqrrele aYn rln cm.. lelbh part, de 4nl9un greMn eilln dt plpNnq (•). Miwu Airtrine nnrparebilisf. dfMnin curnne ruX : ]) nlenriun de 1'Inhrrogaeulre dee naladee. ~ I' Ca,teers frentAt-plnrrnWrs (lennn rmlitlln N pnmlllYe aet bnatbee, de le IrMfe N du py.nm). ' T Cnncna Aer rtfet aFtdlrnnrtt npirNen.. (hl-. mqn nallgnn prlmieiree dn mlee efr>digeetbet aupn tlmrn, jupuSa brynx i 1n d'une pen, n eu prlure d'amn pan). Y.lolres nrwn (snwule alatllnn primill.n de lo- nliuliwn eutret qn I tt 2 r'LEenn). 4' Malaln eml rerrrfrtn. (m.lede- lptpl1a11eln Jene wrNre rh mfJteke gMhtle. Mrrl leua enelnM Je lubercrrkae pulmunaln an fYrambn). T Nerl maeNx Iqr4mtb de Ie ein.lelbn n du ere- I wee du tabae. ixoae o'anuslr.e.orr. SZ?;969z00T i m.rir.l n.....w. vlg~. r.r Isa.r) ,npmpr. e. .~~.qm d°awelmn eennln r/aee-

256 CIQARETTE LABELING AND ADVERTISING sur, un IlonroloZue J9[e volein (IranSn do 5 anr/. yris elc...). n tenanl corapG d[ kun tn[tfl[NOn muluYlnm dans k mfine gruupe d'nbyilaun, n Inrenegf a k meme Cetle HuJe [un 1 k r luus ,wr dt cnm'sr du pou- epoque pu k vNmt e qufkur. -e.ia-,lire kx AID caq arec po . b un In 2 ho- I Chayue enquthar evtit pour mi[rinn de [fcaXer dane I n dn Yrml i(malldn non umtml.) tl !(non loun k nkwn do ponibk lous In cry Ue nner do I dn). 1 Igumnn ee pr:xnunr dans wn g[aape d'hbpitaua. I.n (7Jn nmarwaa qut I'f.nanlilIOn J[. M2 [annn Je I Nmwn. fklenl rtchennb 1.41 d'apYe 1 Ygk iml: .vlle I Jem2nr p..nk inf lun slrlclement caminrame! qufe cl-0mre lehv Jn I:el famtn ,k In memlrt . c nl en eNel pout I lvs Itunn qu il a fl! le plus uumun In a Un Ie QlrtS1 10mrAIR. p p n canv Urllitil. JY tnwv I 1 c[nvln 'amplFlani kn nb- Le qu talioulaln porf L cnaque n.bJe, bfs N endu rnn . kn IA v J aff ef ompkln anYimenl I cv,mrk 0 a nb dJ pmr hsul• demr environ 20 minule. J rn un suhnnnll n 6un npr(.enleid nror LRe) ; cmle 1U prrtk Melia au tabn hait panicvlihement dNail- ob/elllun n'enl[he rkn L I. valeur do uomparaieum de If[ : le mlY Ndl Inkrrotf wr k mode de tannmma- In Premiere partir, uul nronl faile[ e ege 'e0sl, meh elk lion (aiCantll, tlgm ppelkr qwmitlt 1 ftr aun di- e eon n pplYn m po r ubllsn Onn! la Ilen- versn fpuqun rk ra vn, wr en babUmhs prtdominam k pequl -ae L une-meillnn reyrleentelion, In to U[v! le minRn do lumer, 1'age au dfbul. Ien a.rNe 111. 1 te Jn utnc . du puunlon reneillLn. ' ntuYa elt_ Cn remYgnememr am perlni[ emnin i_ Dnm rn Jaix parlin on a ftutlif enaemMe In tli- Ik 1 nnr In w/Yr do divenn /anne qui [eranl Ufll- d, po v nnm NNr tompk do degrf de nknPlnloin. x.ure nUU n dieQ 1' L.+ Inisifine-pYll! MrlnYln In M. R L*~gTe .mpnrrl.on des ri+uDnla ulon que le diaNlomic M prenn himoloRique ou non, el m /omSbn du IMAIeRe qU4ERLle. Ivpv n Ct• eo ,L,Glune. . L'enquNe a[ummen! n wtoble Ip5/. el mnlinu! N1tUn I,n rfwllatt e pnafe ki tnrtspmllkm au[ Ike. Dfelt/nln/ ml Nmpm. ' ' slen rteve Ilis penJaY une periuk Je Jeu! ana 4s remelglNmenk obkws dan le nlrlionnaim m~ Nwa avons ppManl tttle phkdt inkrn/f d02 laneb oln pennir d'mllke[ almultukminl dlli(menle crilt :. r[u[ do poenon, dum le dla{nuYi[ peut Nn eonYddrf-: qul runl dfNng N-dnenu , chacun a Nf alkclf J'un.r - dan! 10f cu (wit A! %) minnle mmeur mellpm Infro do dffini/ion qu'olr inuver. reporif nr Ie! dnn primilivr, [onlirnh par ChiNUlogN (1!I m) w wpyo-. tabkwt do YA/rn. sfe d'aDlfs la cytobgk ('J6 ca!% a) MNr dt munmmalioe do Inlaa (ciganne, NR- dam SO [o (wit p r}) comnle mmeur mel/gne col. c/gueL flrmh ptr I'hlsrologk, mala senr inmcalbn a type nl - Noue nfy0perun a Pun{e do clgart. de ronromm. 'd-urlgln. tbn abrmumenl inlime d.u cWCUne do 5 pnpulY:nu - Ot Uulteostk do IE ca! rMlnb, amt ]3 %, Nanl e[plurfn (maln do I w1Y wr 2110 rumint plus de i,i baaf aur I'eae-meddinlque). ~- Pn per loud On pem don Year[r In ruleb n 1[ali• Ch.aun de cn caufnu! ! W runnlr an homWogu! gorin : non hlmeun, imnnn de YPMtt YIIIe. do Nlv dana In calfgorki !(maladn non caneNtu) H S(nn [eule, ou do clLarYle et pipe. rnaadn). m ir 11 n e flf pomibk que dam 130 cn d'ob- La dbl2nation e lumtur de ciperetit e lans euls :. lenir les hmm~loryn dn rtrk. 2(Banzn das nin [fru- dka:ion eNignera dan! Y yul suil Ie euiY Iumanl, n"' lim:fun supfriwret) Y 3(aunee cmnM- Ia cigarm! reule, mi[ b r.garuk n la p!pe. De ndnn Sous avans dont : pourle PiM. . . Pour dflinlr le fumnr de clpaMle, uN d! pOS, mo ~a30 nncen du poumnn n rlrke compNn a 3: ufiONrona MnMt P[e, lenla ranln do deur nneru+i. 11] nnnea do paumon !n lfun IllnmpRtn, nepo` vanb : sfdam qu[-b IFmin-1 (md.dn non nnair[ua) el S. Cd/fe[ k relm a Mnf I! YgaMN, w k I+p (non malWn). 1 rtben de t[ maln I clgantte w I ineum de kR pa[ IDUr n moytn.e pendam In lo dsnkfes nh•• AW>e Yp%MCRATpN R Yp PIIWMTATqN Dtl RQYLTAT3 Pu ne e'tn) [. P Dan[ une pnmkre pntle. Iluur mmparerons In ranttr[ do pnuman aux 4 amrn Dopula110M, !n tt qul tnncerne lunpeI do lahnc pun atf dllMnmf aapeM1. CeIN compu. wn sert Inte eur In 130 lfNn [ompib In avmprenent ebacuu Ie unefmle do pouman el !a 4 hemoloylns.2' Dns nne dennifine pallk Ilmm nY[lpenn ke dn. ifnntn c.raclfriYqun do nmpoNmrml do fumnr (mo- de Je mrmommaliuq quamilf lumtp manBee do lum.p hI kr eMle U. .er.iae .ni e~e ler .emieitur.-n de l[nr [[rl, reni k m.kAk (ou avam I'Lge a[fuel pour Ib 'mnine). CrUhe m; le wIY a lumf ia ClgaMn ou k pee' ralene d•e! Illoln 1 tlpnMe w I Rramnn Je u•: par lour en moyemN pnYam nu nwina 5 aa de ra t: b) NMn do ronrnmal/en (quanNk hnkL CrJlf[r A: mveau de nntammallon dLar•Ne IPn' mmbn dl clprnln (inminn dt tabnc) lunk N+./ I' ' nmo)enne pendant In 10 dtrnRln annfes avam In e' ladi! (w nam rye a[tnl pou. ke Ifnlolnr). Crlefn n, : k mfine qn ci-dmem, nak Plpwp rNfr[m[ Menl enln la 30' Y 1. 2Y annfs dll nuu'- Ce.lNn, mce.raaitrmNm wemis L dn inen.eOmM mfmoin, n![ca lama's o111iN kl que nmin un r~' . nmle de 1+Yln ke wlete en ynin, mmn' yranUe knwn s.nl lmk tomPte do la bYlw Uv... wmnalioa Y wnerY de I'errfl tqal dan la vleilk.e CICARETTE LABELING AND ADVERTISING Lv mnlefu .-0emwa rhnpilule les etllfna Nlm L' que do rfNnuY I a,w•e o*d* ,~i~°..... .~ , Nmn nerann rouvnl aments, J le [ t J a tdnlnrer do fumeur U t A nik n .tion feal No u[ b Jauona A tel e0e' ' lenevea mtsuinnk: - -- - dem Pelin Immdm . .... _ . ..... mam . .MUrenflum[urf .......... ._..... GranJ! i mwrr ... .10 1 M Tru Srlndn lumnn .... plu. Je 4 Dnn. ch.cune do rn trancnn k[ on ut .cr[p,uliere : enl[! ]D el b cig./Iou.r par tnWk• Ia wmmatinn k Plu. irfQuenle nl m. On ne dnra doac [vnsWenr ql e In grandr /umeun Gulknmmenl . n y n e A n¢am m par luur mmu Imk comme do luren eo[[ement [YculfeCerl a qm a fail ..nf lef CraPhiqun, ou le painl moeen pnur rnsque :LU[ [un dunc y!nlnlemnt plq prbclle duu born yu[ do le mfJieue. c) Maoihe do /rlmer. Sous n'Nudkron ki qu•ua [kuement en 2 calf[n[les• .be que le[ lumeun inhaknl ou n'inMlnl pu la nr. e:x (u a norf I'llaUilude peddomiunkL d) Arelea. Dn a IION .I ke iumeun :fMem urfN! prerlnira nrnl au df/inilieemenl d[ lum[r, !n tacluant IlaturelM oul anl1 paMMar aua premkn rympld.u da 1! mMdk. Tnl! ftATle[IqeN. L'etploiktbn alalluine qm wN n 1l11 apptl qe'! ds Ie.no rWaqun : comparakuns de pwlrnmagn w do • ebis de pournmaH par Ia mtlf+ode du %', do moyur net lur Ie NN elaWqu[ d[ eanpu.iWn de a kLandl• Inm impnnanls, Yc._ Danr un Cu ewlfmlY lahklu It AI dlnkn COWNIt, nnl-Jernifr[ IiQne). k pelilene dn e)Iec1iN a rmpt[hf J'm,lirer le M' DOU[ uM LwnWmm~de pournmapea, el 257 P[ R - - p pt ^ La dJRrnkf d! coanailrt la Irtquntt F conduit l ra- uncer k I d! kl rJ[qlre a>ulu , mais k rayyoq pc/Pt, 91rfaulle mmfJiannrnt do donnfn 4 I'e. .utre, Iournit un nsyue reNltf, proymtmnnll au ruque . btclll. Lt lukur P flen! par dflinhka k nltme qutY qut roiel ka .wrhLanllllak nuld4b (pnin M me ra. Y! / rs• [lnds fumeun, ke ~- q relill. a Rnt lomn nmpe[ainOn. YfniraMp rn e sour-hhanil lom Dans la deucieme panie dt n trneiL o4 aws Nulions In Jin nf ' Ip a du sampwtenenl Ju lumeur, us nl.ulenns In ruqun relalik noll alultmenr pwr chpn 4raelfnrlpuf nWlfmtlll (npu~ eVrrnpoeJaal f Ia yuanlilf funlfe, ou \ 1'imlakllon, mc...), m[ auM ' puur dn rombinaiauna de cn nrut4iapul, par eaels Ple pnur k~ moyep lumwn khapni k lum/e : le tfm qee r[la(IE m to dernkr car, peot frn nlnk Par le rapport do epntils do apur-fchenlman e muyeha lu- meun inMl.nt k honh a chn ke canclreua do pmmoa tl In IfinYllr ' En rlalik nou. s prtndra! pn comrs ruqrre relull tt rapPOrl d'efleclik, urY une pamilf Vmponlonnelk : celle<i ana aNecminh en caesnaM dt danwr k v• Itm I au nque d0 rmn Imntun (L). a Non nPpelon mle In rinyun ainY dNinis pour It. dlven frleun aMieagb lonl dn rymboka nuhfmnL qunne /ai..nt auumnnl nyyel L nN Lypurm!! Je ' aurNN. LEOENDC PODR LA PRESENTATION DPS RPSDLTATS Le[ Itgeude[ Opumm wr [n[qlk IlMe... Non raypekn InuleMk 1N nm.tinn adapN[ puur 1/1- . diquy qu'uns dlliflevice tY [ignllkYive ; diMfrene pnRM YnUkaliw as .euil p,m...,+ o.wil OAL...+} dI1NrNN~ ntg.Nn elpiFlutl.! au ani QM. ... , .. auMYI OAI....--. I,. -[OMPAUIfyM ptl DaN(LgM/% W IOYYpN ' rt C6 AYTMY WPyLATNINt b donnln Sdunm au Iabkalr 1 ne1 Nf romPatin de la laew . wnanle : pwr cha4u! do/ke (pu lcemVl[ pwr R~pcunn[rg[ dQ lumeure) on a anlnpuf d'aburd aetre tu[ ks tfmnin nen nrclrwll (mekdy non cancF ~ t tt nnn luk • Denl [Annn da [ra n[ alnr arr-. ti[rpMqh I eunr Yt na 2 populalinnl. ' milisd is on cla.i q mNhmk i fla n k ' le r N lement cwnWrlbin ( diiff h»te wr k Caklll de probam'linf nul dee dlnnnCOranu/Nr[nn Ypni--. 4 ~ M1ryraMn . fcuive au suil Upl). FJk! !nl Yun /U mNngee qmr cwstlmer um poMatiml Ifnwin uMquq a kqu[Ils on eDfrimilaN ora eliwu, comPamf wnmkremn /kremn/ la papulequ. caeulnutn 1, 2 N u t tiu m ammem d.[e qui wn k. s Y 1 Le rl.Wta Ye cYk aumpaniun a def uenl nnnf wa. Iw n k Inul dn aquta, Me q-k sonl ckruqwmeni k labk.u I lonq.'d fltlf YgYlkmlf. ' Eo neWffun L4u.r11 do table.u 1 pnvM d•tno.cer 1n 4 ul.fA avn-k re f. linn dfNnk pn GnheM (1). Mitanka : mulion.neWffun 2 fihanl llonr ubknn ,4t! IIINn eyUfk, ! M pY ctlui d.e pP1 [enchw. do poumon el cY[I dn 1' li PoPUklbn n' 3 t tulrn caonn . rn di1Nn, . 2[ 603 Ifmuint el. L I'inifrieur G ctr fAmlinons, dtu. en u[u pdm, do proupe (dpoin. IorW pu lea popul. [om.he amivon bmmoiliea,iek qr. W!alnlpk, ler uom 0 4 Y 3 e mYedn .oe e.[drw[ I n e noe e moyen lumnn e. $nieal A~ k propn[tloa dn may[In .~• e tlkamlmn Yrl[teaeR PmpnEln entn. kmrun danr YManillon do nll.'!iw[, PI k yrnpanbn 41n d'eprb n qulvieet d•Nn dif. ' Ju noyeru lumeun dan I'hMm/lloe Ifmoiq P la 1r4 a ne peul qu-PW irappf py k Yrker [olnpar.biNlF unne Ju n,un Au puu P a.n la popYaliun y/nhaN. an k donuk[ du labat da cn 1 poptlallak pouYUl Y in-2 Ich.millan aopl repryenMiM m mooln que !rb EIINrtnls prr Iwr dlRMIbO. . k riput d! cncer do poumo[ pour .n enym fu.rlr 9' La popmallm t utar du pelsoe e di1Nn w wn- a putlquemenl : nain do pwp IftwY Owt nYpw euarfqlN !1 L[W r. 1I sz79sszooZ

1002696227 Y.+e - •...r.. !n mld V. WYa.I aP ma!m va nvpeN nqm mb,fonD I"°Ie v aga v:.oa esn .y.>.~ ,wvev'.axp~l v_~I °Y l MaNp.a -'9 .emn>v • a a Y"v.a •.R .ae..nai Id 1aa14eNaaa emInw xp auuep DII3 'aUM a xmaefla _- ap Ywwnl ml anpd apnx aalul n llq auwr mvu) alwa wll alwa>dld q no Mld n v alwran n/wwYY mld weD^ n p aaaa:,l : iuuep uwLluWwuw aP iywu un 'w!nOil OI me iPyD eii - ap al luanwa p I awnl +nOd anLU p mla Inud 'apluaylG aaa pna a4aJ uxumtl pnu)waa nl Ipl>I udnvwuromoa p wa. 'vollslayal !s NWN iHlwaf) (B anD>Va .md me Y4Yi+ ap Iaw+W Iv nea14a1 a'1- . 2Y a I: an.ry4e1 al nrtr awq u0u ~Ilvxp aiuap ql awnb,qn w u SanbwpioY nn Pla] p IuaaW,mY1pDla aad manlP m~Inaa >dp -a] qp mweyl p aldO+d uwW]yluan el laaY an Iwu aPa+wun1 :ry a.bw mb a.wN vP vo alma.l m -aneiaq maann nvpi»ld uOlml.>•:w n mb al uql ual0 ; wp v YNI+a al ma na +a YryW x mnv ilx bniu 'amO/d umlay -nl al IVMwllip ua anbal a] iln]la] aupni m0!( yuala m. mnM4] IVU qaw'aNni,l p mn,l ard lwlno, ( nwe adW ap alnawy mp mbnl al 'ip av anDiplil}Dlaa xnar vaa'alnaa Ylale]U vl mnY W Im0 adl,d Y>viliDlJ ip n0 JWia a11Yi91J no YnNU owxM,d rl led a pwnl ap101 in,,wnb al la w +1 Yp anDwa ax anelPn awxpp a4dnaaud a, •V 'A »r Iwllaulyly ia llp wd no .wymn p n M~ •iwalau.va aqW]aa iM mv'uwl an"p'd P lm'IUawYNUI lo fii nh/wD,. M:1 mMnul na aawnu0] p naawu snbrya mud Sui.(aw nuwd mP aat, -IV] n mb) unlaiPUn] aum p waa a1 wnavn/ amYa •n+a4e ml 'uqmnl uuu aap 14nY inbul al mnwla < a"Id "+l lu>r IIID I slelm i unaunl al luua >a IwW a YY nn1Vr1 no anbu. aal unpwda RY a.b!4dnD al 'aaquvnp meu u wnx mansa p Ynxwy a,l mD awea -w adld la awaau p xwwnl YI inb awvn'i~n T, rl ,aWM p sNl.uew alylu .i Did luv,u idM la >4a+rd wv"D auyu n axd nad i Iwwn/ alwe adp p np •alnw ~u p unawn/ q anb lalnala>d ua aupmlwnx muu p0 awval] p Ynauln/ aar ' Lv nmiyDl ai a"ep u0a - 'IJ) In xwmlp ..ae .dq al RP > malmWm a mYa no vwlwln'alnm adW aP n"'qwa alwAu no ana oyDanr IwvlDln pY.d ilYnmd mb'uvwnl]IIO] aPrJ "nl ap umaedOld.el .nb nWel 'nrmDaq TMld luiu- uOla:y]Vw iwM, al ainwlY up in4Va Yn el mr ~Mip la YWnaa no VIYW111 YI •aian/ na101 ilruwb ailwlea w a vl ap nrw bilva aaapwp np a>IUaWna,W Ynwm a: IY vai4n al auaP nOa - xp Va,IVYm .I iy wu'ildww /uewl ea ubinYm y~yaa w a: P"?u:)1 ainaf Yl lun -ww xuaW el inWN> aunna mx mb aaalnof. amN Juin Iqab > iwJ Iewmu +n.ulnl al y. 'aMwl and an! awP sy aYd UmPadapul a.d lura au anbnnurymm m,aP aa, .I x"ad Iry s wM. nn a+dM N aVd w aan! 'NvnJ >IilwW Y w/a"wu"aw] ry ipOW /Y nD uaa+ "q ud a./is.q(+ aP apwev aapW p Wuwn! . INM uap I CY aalyal al yada p'al W u Dw an V[ Iw (`a) Yn 1 uw P bna x awa% pa 1 YO Ilad w aD »'a,lYa1 p ai. yllalPa aMa aam b aunliua SPrl a, wnl wp p. YwmnOa t e"IValwau ai wLI ba• n 1 1 Irai W YL x. lYn i a+ u I nOd uw Od P naa~,aa] ap ayli:d il a/Y rDf WD ti l 1>/ t bau Y Yp I D I,ya 4 (6191 Dym ,I rl Od YI lIA . !/>"D"pe D w ixr:y y .'6[bCq e,nlrodp0'01 i IayuD allp P xw.i Ho Ni w Ilb9J vux aW a urp YnWnul IvnN i.wvp/l/p I) .l ya na M vp a YYww unbl aun P a P/! H Y nl aa4 x bill wwY a/% t p exd lupu ad:d Iw,av w113 .1 nD O J 9 Y w/rd y 1, eneyvl: -VOYIp nra.ulv mbr 1 Inr fn YYlYW(, no Odlrwww a"a xil-P la pawwe a I an~ ya .nod anb Iwi ao EY nealyal nr f VPaI Vu uev la maymw Iwl ) au!Ownl (LL.n • naY u"aa edww a1IJ falaYSlp p Vultww w] nUP mn a n x nOwn"d n i] M >I ?'l a: YiW 'IY neal4n nr amw"a alnw wllamuwmw el aP -M /x r r awww '/uwaa aai+edlil0, .uunnnUOd ., • anrl w0'wr1]u0/ w Vwean aP VnawN a1a14] adld m Yupllew-aalu: Vnal ar aldw"a Inn: . Yw.aja p aem.l t arnb aulean n p alnn.l i,.d ana/lewilab apnp ... var /a4ue 'u nele4n '> . nruauair na Inunyl al 1."n •uwlemd in,Wenb 'vxlawlu0awa an pnm) niauy nn low~ " . w l ~. . W, l VR(1 Ona ani'adld n ar a IaI a ww n V Ynwdluw I u r aP ai, o],. el ap al.leh+ 4N s>I I ap Va anld aw:Wtm innd ( 'ma w WO,d >qN 1/! /,,r ll La'' Oa~d uvneapuDn wn .wne aIV D P"0 118 B II pl auY a 1oa iwa ry M 1 n' e]IweDn u aiwnl illlwnb u" IeW Nwnuw mlalVwnmo] a a. 1~]wn>I lm ^S ~w] el 1na,a Ia yd:Q u _ 'analnr aena» lyd xaYm aN Yw vailleur aallil an n p vWw p..d lai w,u 11 .Irw f anY,.w> +: xVUI]!!''YINI~i•ap, Dnlnnl W oaalrLaan uanwmM p uenulo nl+ + :YY.u.w t w:nwWmupa .nal lmd 1'annw•" ?'P Ix'xmm olaa.ln an Ynaw wnvwnwa w t n) m Y u ml ul mMl anb a~luin no nWYd er I/aalaa YI - lal la upuwd nn .N, ..~ aw anil ,nnu 'udwd uonni a+w ;mo >al +YeawO+ mel n lnu wVDn lun w:y .wnn a alala0a e llwd VuY d. a p a'Ydwd +nxY nal Iw YnaUq man aa u:IP! 'Pn4o Ifn I . IY Y - lui Inry~ a a+nali u 1 ul ~aiw I-I 1,;. nn yN nu an nTl. a 1 n la l . u0>el an 'aum aY. W al .uer YnOllwl wyn sawvpuln o'.n drvnlnli+ ua aW mbimwnqnln.l"Ynawy .nur:' Inp tP luawxnau lu0a uuwnud no anaywa] w1 a,ap aluaP aa f!lp Y p o '>u1M alad eal anb lam"1 'I iuaaua vnlJ lua!I wnl .nuo a1 anb nJwma :fJ an!e;9nwa:wn iva II : aaluvlwad>nul aad Iw1ywY an / nDiiiu; W,o wwYil)In wa .IaW '.',la •adld al t>I W' v5 1 ai Wenun 1lili E ywM al Wanrol mld ,wl y4W. Y,n.uwo puYa iId lu0a nl ~uuloWil ane qmdw0, al Id aed IumauIWIP a mwnl wwnOd np inYiwm 1.1 avD YlvWUUa p aunuan>IWN sxIGYM1 u xa>anca na :mr.ax.a AINW111 na 1xlW11Y01WOi nd p11Yat'/w tL.lrxY -'ll '+NUlrl W>Ie4u1 ulal,N p un4lutlnaC n +W w 'adld m nwandnl ap vOlaOdO+d I+>d lu 'Vlw:il ad:wa p ln9umn aa au'Ynawnl aWYt p aiuvdum] mblOnb alyuwua .a auan • Yvaydn >anllaaa'P^+it ailva ap aYVa] a wqnnduJ vl '. wulnOd nP twue] i uolWlnaod n ap Yw,il/!n el a.nb Ymblauw "p (mmoxa : xa) wd wlna,n a •Ixu4q ' 'aa) ]eqel vu04n11 -. 1 a9uvl.l ]anr wnnmxe.P inaN Y9>P un 1. in aa .P YunnY b Yu.l/uw Ynv] w apali a110 a Ilan Ilp,~iuO0aiW4 Ya - sa/wllidna vau,laaa!M1O,ia wy mwo I uOllanldOd n+'b ladd Wal n u eW u0 Od no ,aaum + ad Iwll al , il mD alla] a yYli w10x Yv] anDe4] wvp w aP uwN!P r) a a awy PuYE al Iurlnu4iV ainblla4il dnwnia4 P4viD w laa 11 aIaw IU0 nv yu t+naPil ~]ur] aiP a~dujd q+wd m,pwil adnvli ny pna >naull ~ul lw vqP1111uaP m Ilma ry W"va14e1 al +ni Iu>wslnaa IP m i Y,npidua YMWaiIPO+i> aapi xp lYVDa . inClWy a av' a41wIlWDW MavawW IIV.1a! aP 'OI a:W 10 I pl ,a . .. . .. µ~] a•no V wr Mn~ ,>A~~ i I.. .u.wav M1l a~l y y . I ~ 4 r x ~ a I1 a a I •a •:.,rr: ~1 Q.I a~.N w N.^/ I p m ]mlxrM Yll ~ ' 1 1 I [H [al aYl -<I •aYl la «fal oniVMaaYa I I N w Nu la. n ' ~ S:mt.na o l .... In a3 {1 I Y s tl ~ n I u j 01 nx w n _Ih a. -a N ..x Il 4 N w f .aqnnmsa '.n.wnM .p (~1 1w uc~ y wNNx, a;sl •wu"j M1I a~/,w/=.Nirs xourlmnma+ va vPpla ,a nuu.nu.oaxw RU I No en an ...q.. wx ww - .~aa n ...o .w.r :M.~...n .:o"' ~J I wsep ... .. . .. ... ,~ . . p w:n.n.V . . i _ a I 1 .... . ...... .... .. uqq~uw q aa nyr.Y .dm .e ..wai r + ..41. •n . -: 3anoal aiaVel.a.. v w ~.n..ro mavr, wlnPldOd al mD I nm14n al lna Illlw YNOU uo .y ' Vlwn•]?,d Ylinbw Wp uniinv ial IwnMN ne ealW] m,nnu,a ap Yw" mNlll al ]an. H'Iwlwn"w aa,uuiGiGn J ryal I M+d laul x a14W.Mn aiNr .SI : WiwY l"4nP no Iwua+ -lua^>M'+>Wnl p x1Yau WYUYVn tnltl Ww ax WI ! axwl n >6v14men 1ua1nYUl all - !alPaaal., n an aaama >waww !nD Y w,allnylad w•ai.v!i anld aw"v"b - am rvawnl Ynaxnl VOWn^d ir a.al 'allm a nwe6la iln x^I Yn IeY ww A'xnM il W r/1, ap u I a P 1 mnp anW WOn YwvDP p YwWnl xl ! adW I W nua aVIWI 4:IaW1 ul xID a1WVD1] al Wanaa a4d W>Wnl all ' aqOWa.al mD anawnl Waaaw mld IIIOr uqvnm Paniyaua Y/ - 4 Iwnlm al Im oplelawa aawvilllp aiP w>a al •C 'P+a141W1 +npd I ane >pnl wld an"aneay Yn,ua Imx un tYnn1114/P 1m (aY1) vlOlllil allnula al la (1'61) wwd no aviwnut] al Ylw awaai/llp al ,n0/ +eJ YlwtaN u> a>imN M111urM ml m0'! >wri' aP : a+P .n w ap bnnpuld ua.V wnluw I ana 3mv4] I ap vuluw nUna weaay al no allal la (Y• OD1 ulauyl aJnO,a al P (fl66)upwnpdnpawiauuw/Yl > +i1lVrlwnaw -y ap aM.Wavnod al awd aM !.,u] altV mp 657i DH(BIS83AQV QDIV DNI'I3HV7 37S3NVDID 1 flHI971.83AQY QtiY DHI73HVa1 3,L1,47IVDID 899

CIGARETTE LABELING AND ADVERTISING I- La Vountite mn12c ul finnnialbn ne aunt nat indo -..hnm1 cnek le tmneur nu mal. C'ent ce-rluon-virilie m In li8n.v • tennin e an labluau BI : on roir yue la proporli0n do ~niuiunl la Nunl elne c naiJtrablemrnt en un Je Ia ynandlelum:e (Je 'Cj k a bl !A). eoe au tubleau @, rni eeprime le mFmc duulnt : mlcisb0alnnl la IunLLe unnl Je Plus granue lumeurr -Vui ne I'inhalent pn (18,3 ng./lour cOnere 12,T). leua kalcul indiyne 4ue cu dilltrewn aunt IrM .Iguli- ::ina fA>nl JonM le eena Je a'elk Ila;wn, oo duit ae deman- ,.hea Ien c • do poum ry yui wnl de gramk ~n e1 tlui innalen( wrenl, rn Jeea prttirukrike .mnl Yune de 11mn euuont w lentnire cnaNw une ,ni/n'aliDn peupfe. l:'M cc QW nl eymink d-/4aww, )- 4 nMau BI, mnnln yw, /OUr chepne nbNU ee n, 1. . e inhalcnl plur w'renl yue ra~L'ielia/at~on etdmm un rJlt pr0yre.inJlpn nnt Je 1. Vuandle lumle. Cel elkl nl Bailleun Mmi n urVue yne la nlnummalion nt FWa .iWC Iwur In peliu fumeun, il 1'lY / 261 meurc do cinarellt wuk (2T 1` wntr.e !6 S4. Jilftnwe Irla signilicslire), .nit tlene le wbleau. C2 yui exprime It mlme ri+d- . tel : Ile IIPna e kmeln a onlrenl mn In lumcun do Ngnnfle el pipe wnl plualrlVuenn cnee Isa Inmeura n'inbalant pn k lulete do cignnlle yue chez caue Oui 1'inhalent (14 R cooln 7 %). 11 enr /ini pr0urt yw In lumeun de cigoretle, Jee rlu'ile wn e oulre lumeun de prpe, lument kur ciga- Mlt aulnnment Yue 4a lumwr. do rigareere renk. Cvlk JininCliOn, (annlatle ici en prenalll fom c cbunnce ka dia Yernkrn+nnhye'llend d'eprle Iaanleau CI bir aue tulek aYnt hlm! la piw e u ment yuekenyue de kur r e. Elle ni e oulre wab Ywl yue wil le nivwu de conwmmalinr n cigareltea : w ruit tur Ia nbkau F'3 yue pwu. eMyue niu/w de eaanmmalion do cig+M- ka ke-aulm lumanl tiganlle n pipe inhaleol nwln wu- 'venl 1+ lumh M k cig+relts yw lea /umeun Je clgaMle asuln -Le /ait 4w la lendnlu i lumer la cigarnn teuk n I. tendance A inhaler la lanrle do Ia cigvelte aillcnt Je pair, et yue In cawtrna do pounv ee d W i+guent par e tn d ,, na rywr In tdv geanJr lumeun -us pactlcWarill., owe c1lMUieent / r.4v.chn u: sle uhnau 82 men/n y0e, puur In wlna n inhelwl dneou. al elka Oltoukm I'un 0e I'nm chn n hmeur, . :a la lumi~e, n-wi bien 4w Uour ceue yul I'inAaenh ka Ir d aWeun- a an eonlnlre u0e rignilicalinn propn. ~ 0 2- Ln i.Wnua Cl b q W moeuml yue pwr kn h- .. wnl Je pius grnnJe lumeun. La Vu.nlllt con- a dunc un rElt Proyre, IIWlpM®mnl r4 la quoun 0 tigaelM eNe• huW !en yue pour lea lulwun k de lumer. Cn eRel en Teilleunpim mayul do cig+rdk N yipq 4a urcbeua do ynunwn Innakm .c ke wjen qui Cinhden/ pae ga cfln In autrta, plue wurtel Yee ks kmNw la lumle Je k sigantee ; ~L le r01e relalil Ye le yu.ntik /unle el de I'Inn+lr g~nhantinn a dpnt.n.dgnlgcaliaa pwpn,. IrWipmd.m• .. appacall ainei trla NiwmeM : M Cmw a un rhle nl do mOde dt [Wamelotli0p. ,ayre, n elln peu.ent apir en awnpwblion : ka cantF 3• Lt kbb+u 0 monfn yu'! mtnkn do lumer mn. h me r• Rhu lumeure iehaket beaucouV plu. eourent (prN me anhYallon w.on IMY.Ynn) ln prNNence Jla nn- .e 2 lu4 plus) pi il : nl nnrmal pour dn pe111a Iawun, ~re+e du poumen pour la cigamle nu4 wM4k ; elle .I n' n tb eancYreux 4ui ntinhalent pu wm de huu[oup plue nt loubbb upltlliuMe yut pmr k..u/eb .'InMlnt >esk fumeun yd'e n'eu wrmal pwr dn aulne IfiWr Pose' um pn (rluanlire tumM plus grande de !g A). Si On namin n 111lmt prohllme an tenanl wnpte do Cn rElee rpnik pnrenl llne Iw wr Ie uhleau &i, 9ui nilen y Non .'arone pu fait hglrrer Ie ubkeu pour ' In ripuee relnll. : It rEle dt la euntommatqn ae +rtralllylr la plan1a11onA on Iwun yu'h mankn dc fu- r rha9ue ligne : il vuie rtwue r mwlann k q11Mne dn nwlreua ~r 1. cige- p WoPorliOnnellemeM .ela quntit! /umle chea Iet aulne Cu; ninhelenl ptF Mfe wule auhaitk, maia e'nt pa. tignlhcalne. o+ee 9ue prOponionMlemmt cnez lu wien yui inha- Si I'nn Ikm cvmyle de I'ellwyblt de my rlwhan on .d. Le rJk de I'inWlnion w Ill dan. cbayue nlonne :Nn wnclan 9n la prtkrenn dn canclnue pOm la ei- . . neyue nt muhiplit pu 2.A pour ka petib lumeun, g°etn eeub nt emeimkk. yuand o. Ile comp+n oua IF ue reXa diminue Ohn Le graWe lumeun +~^a h mankn de lumn lg+4 ; mu. .rwr doiw id rXdk`rXdk de b avntkai0n a~wremment . le rVyue nl, en nbYlmle, 2 luk pW+lkv- ellea In uw npllcalnn M aek ym inNlenl paradou:e apah n (.1) : ei pwr ule c mmetion Cie dinre iW ues wnl npnnh wr k graphi9ue B3, dennh de cicannc+ k anln Wnuw en onre la pipe a un : en ++j0uk en uutre k rnyze re:ail Jea wn lumeura nwx rnatll e cw`er do paumoe e 2 fnle plw IaiCle yue k lumeur do <:g In cnk, nn lim . paNe aa lail ' Q Mede do ronwmmellon t/ brMludon. ` I• Cn den e'aratlldWwuee Im wnl pn i+!lJlerldnnke .M kWllxm normal ; ieun VuVn eldCe en eemni- -yl In Ilgnn e ItmOiw a: . .. . wit Oans 1! lahlsu Cl : b bblew nwnln d'aburd r b lumeun do pipe eeuk inlMant la fumh (k k i p(el wm nsa (g !4) ; il mnnne mfuin yue k. lu- 'zun de cig+rettq Inreyu'ila IIImeM n ouen Is pipe, iln %I4.1 mpiw wunnt la fumfe do la elLatnn que W lu- yue k lunlnr de ri:aMb el plp e mum uecda+rt h IWaler la lumh do ¢igornn. ExVliuliun poptkAe a:ti.wenl : ba .Yi®ren donnb rtonlrmrl yu'en mayeyy le ri:pue e.! 2 IpA p:iu yrnN poi un hmeur de viSnn:e ae.lle Qxpaur un fummor de cgaretle el pipe (labinu A) n 2 la:e plua gtaeJ lgalrment pwr on wlet 4ui iehak que p0ur un si . n'inha:+nt pae (Iabbau B). S dalm b lumv+r+ do tipa- renn nzke In4:altlt Ioua. . ue hmwc de elprflle et F: !, nillhalaN, b pMktenca dn eencdrelu pow k T

262 CIGARETTE LABELING AND ADVERTISING tAaleAU% 11~ L qvnina LnM n InMMrYn _ W = fvnmr q pa.a ..~w~.p,Yr w {a/erM. - pen IY n~WeeW4.:w "(i.s•-1 M 1- Yw 401F i.. i 1•) M 1-1 tau _ ws au p w MT ln o.nd upwOSMTln enYNUr F Ci/ N l~p W. b..~ 1 u. rrw u+ a,~.,: a S. - ~.w 4MIe Y In .eqlW Inee, y te ,lanw. -Iq r aps a,. - nrMne mMe en . er rl.. wn ., b eTrar'. -1 s.n..'Inw. - 't 1../e 3 aeFn misnC x Iu.N CT e, - nuau. - IluM.n e, v [knMlr no.M n..w ee eqmaYVw. s.wM1~ nl,.u ve<j v ! IaA 6aN, nM . IL4 i roi ryal ~ W.. 11 . Ib.r frA ra,e ..Nr LA ne A tAaLGV[ n . C NM! M .wreans M Ya°Y11s e.m uA 1'.A N,Mr <. .ivrMYn wern:se....e.a. M In~Y/ .a I I ~'nnM.n,e.... ~ I /P l'.nM b IN %In N%e I - ~ µ - „~ ^rY . .,a° ~ W su ts- _ w :1 w'., o la IwM (n,I de Nw Ta o i li W. - tleMln .n ~ Yn J- tees de .awnw,m ~ Me,neyy. b .vi- ~ IYaeMe b b YW 4 msrWn M. I do I,v %In'• au~.. n~ w.a Ld N MmnY ~W. W Y'r eam.n,i !'w 1lI,. Tw W l~Nn .,I w/drr. Cr - Y.Y e. ...ee rmMln I F M Ine.wN. ' a - M = M M tlW.na Ta W n iu.°~nn, . e,. - dlxMMn en Yny.au .ee ,vrsn.n d., r W daa.• MFnn C, tVMnonv?nM e. Oea,.tw lwM. •imt. Pov wnov,h a q. nle.u YuY YM La p~ 1` . 1~. i A , -_ __-_- ImwMn~le'N N a,w N tl N al Iuiwu Ial e. MI f N .t .. ' .. .i CIQARETTE LABELING AND ADpERTIRIDft) .eule rrq,rque[ail e .mml yar I'iNlmalion, y.nalle en feartf In DD Po,rtrtntag~e: w n ra. I H nt, no 1 . J',f, mai..11I 'F n ZT 'A, I'inhalzuun n iePliYUe que .:rlJl[m,nl It pb:aumi'ne. Elle aemble roul[ioie /qUnir . a J:nul J'rnplical.m en n onlrnnl Yue .y lumeula ae ci- _ 1 Pipe Jine[[t Jq lumrun do einareln vule .r IL'u[ mnier[ Je lumer la rll;arnll. Ce pa/nt Nf. upric pltu loin. 4) tt np 1 nx pur IIIfmA n un d Mf re mtre do yarelle It fumeury do aiparetlt el 11 aPc.: I'a pnmieu lumenl plu. eourent la tiyaMle InYle :ou Yue kn nr.mWn (6] 'A mNre 5d p). Mait ce r l l impunvwx, ar Ira propurtpne d! wltla/Ymanr Ia a•Ranlif fWte /siN dilkh peu C11ea ., [ Ju roumcn n Ie. lem oine (lam pAUr lea nJlu x riRernlruule que pou. Iea luleeun de n- ,N 11e tr ylpe). DI ArW.r. Cun. Elude pnrle eur Iea vjen q'ant /am! (aJ la«ae, nt fllenl errnb JlfinirNemenl de tumer Ia N,velte (aranl la naNJie). . 1NfMa/KE ULS ARRp.Ti ' D'apre> lee rinulntT de Ia pnmkre parlia, Itl eujeln ryi u tont afrNlt JePYmer annl pllle nna cMr k, s.e. .ireun Ju punmon que cEn ka flmlipna. On dait d'aperd. . JemenJer N celn conMat.tion sat life an lail yue' b c1,cfreua Ion~Je plua pnntle lum.un. Le lbleau D. tre Yu11 nen eM ' y uf il n y a pu do Mniun entre le yumnMlf fulnfe el la pnAav< A ' 'arrfl. Si en elkt pn examir Its IiynRa r 1lmolm . .n fun que Ie-pnunrnn{t d1nfN ul pntiqutment M vwme, quel que mll Ie niueau Je runnmmatinn Ainei la nM! Jte .rrdtf .Ma.ln ralelrWa N rIwIN pi/ do lail qY'Ib t4M Qfanda funYera, e11e a Yne n- ~ 1 prop (CV( l tl'Ik qut eunlrme Ie nu D pau MuY lerou d c v.e,`n 1 I v ( IY (eM 1ryy a auf la Ia4 J k ) 0 J t doN re y. m1 I 1 l mdlne de I'arrtl .lu J mmYe k rieGYe . anur do Ppumon a Cnn ronclusiun uoin.iJe . .Mle qubnl Muncle Uull ef Hi4 (3) d'aprta Mur enqufN prA.peetive. ' AfE A a'ARRLL. . .. .. Le tableau D. mnnfn que Ita WIYMeua du pnumaq 4 p'ila v ennl arrhfs do lumer 4 ciprtllp N aost ar f' muy<nne 5 aN plus Yrd que lea t/mNnw (]q5 an. ennfre 6,3, yYhena tdl aiRni/icatiue). Par oll6urr leur AQe aauel eet N In11na Le Jflai dtUuia fuuril eat dont plue murt Penriron ! ana olY Is ue- .irr (7l wtreiI,p) - Cn J flfNnN Jnt paa Ilf& au lak qlt IeM c 2rtu. n 1 de IN a pnnd. fumeuq c.r IYQa l 1'anle tt Y pan(r! fumfn anllrlturemeN ne anne paa lib (cnnf4- .ipnifkuloe dana 4 populatbn Iflllun)- QII doit nunc ntribuer mY .iynilication Propre au I.it qu'w relatlutlnenl nremenl dn can<lraua do puumun , qu aYnl «a4 dtplrls IpnRlampa ,4 lumer. nwm.wdl:Wp ~. eA. w~a. .. ryer.v~IV.nnrMnaW 263 nene : mn4.~rrsw Mv o .N ue .r w~a •y u~G.. Nnt: rl M t9 sw -nwuay/:-j~x (-'1 . Y -~JaI~rvuu, P~ unt N.-...Ip W .rW W M NM•1 Wr, an aeamm 4pwlev 1 w ma m~. A,. AnY, e/wava aa Y.uueuY nale 1q1 T I - ' I T - p-. lyeua L 1'n,M I rlw M 1'. I GN, .n A N M N la N I W N Ipn IY a a N r.w ., Ir u u • n I u jar Mn ~..F.Y,I a~ n-~IN Ir 14 e i p. IYreuw ,.bYle La re'paniliaa d4 arkY dana Ie lemp el J'alllean Irh ao9deelM. qe epeseait en el/.t a.r M uEkau D, q_ evnparh aue Nmai1R tv aetMe Pkv'ea unt rarea cllea Iv cancen /I. paema : Ita YINm qui qsnl cevt ile lumer aeanl ]D ans, eet un c.r r Lu poumun, w t 3 luia plua raNm rlae ne ri.d'/que la Irfqueuce nb- le Ilea In Ifalaiea La pfpporllun pave dr ]\]'peuf ea errN tA1N ]D Y.p aea, el d11Nnw .mellt. GZ?/969?'00I

CI6ARETTE LABELING AND ADVERTISING 265 264 CIOARETTE LABELING AND ADVERTISING m NuMal anabaue a enAvteani k d!W lcnlw depule 1'rrrel : nn amVnlre a tnl Ja a'aMYa du ptumnn enrrmant plue dl W ers apree r.rrN (ra a enm 5 bie plw raae Wbn a e'Y etknJnl J:aplla In Iennia). Pey la nM* relatla diminue an Ioli(liqn do dkal, et It /requmce da arrfa Id[anlt (Jfl.l Inlhlmr f 4 en) al I. rneme t]lea k! alu:keua et ke temmn. Cee rlrullele cdllcMnt tec aua do Doll k Hill (3). Ik a Irrenl d'une Ieton prt4cublrenelt euytolir. sur le abkau D., qm dona In rbyun Wetlle : m valt ya k ta du puumeq Ia k e I I do t/tGUe dn (tt 1 .akur N tl 'equ dn lukeun qel . t p cwf de f ma mlt ken ftuYNemsM a mnu que k Itl ttN arrlt! de lu pNn lard. Sa t doule e hut-ll pa dn cnmmt lel'f eie/e Ie ku d nfe Jm ud u pa In tquu, qul M a1f I~ Ik tur W !re d rrla tNte 1 me $rne te 1 drt'1 1 ltaleme 1 te comlae d -reru de tm amk a A I ret. mel m lYa plus :ompkle J- Jernt etetll/ Plu tk t. TouJCUre nbJ qn IYntemEle da avnaidtrallme tl-the Jenw mpntn, . ua litniXeatiun cerlein, que le liryue ce er do pumwn at dmme! Pa. on anlL d Jaient J'rolam pla pelll que I'arha n Ileu plut Idl. IIh - Trry NRI'OWOIOY[ [I LOC{YtAI'qN 1) TYpt Abtelep0ue Le t Eleau 114 imliqut h rlwrllllae da ancen do pp n r tYpa hiero tique, ar/nr qa 1 ........ ' .Vn h Ikrnmd puur Na prrna.pair carwlenelrqlne du Inaeur, In ta MfrWiqat prnnptla de It population d pm (pw nnde fNee dt lunrtura, tell prkhrinapalllcurrere purn le crpmetla, nvnu Jt wn- . de ritann eleN puWnenupe kere de IunN ~ Inhunt le lamh) rmt pnur baqa Ur (ateperi4 Y a'pmpnt It l If/aN . pa dnJlWUf e> Le 1.11 d Wpir travar 1! e 1 I m I ente un ua ue Jv aarlaer do pnumu uaptrYa n: t u mrnle de dial'nue . na~mn: pa 1 Wurl tlrn La cenrPare n dn ami.purrn d leu t4n h M rM direua uleRmq tma e.rer, nput Mrall aFpner dtee nbeelvalium . - u) la ervrlvi celvporle rw Ia candmnt re d1113reM Ja I.u I Wn l Ie lum\urh rl Nr la y n nne 6-evc, eel u pppe vriMriyxn II uN dn.a m a'' menl admir, Jnprb It Irltiaature Jn enmNe! pn% dentea, que Ilnur 1< IYpt ilialumtqee I'eaaralqa ern le luteur ItUac at Iaible, u nulle. /.1Le nnln al• /enil ex fel 4 laible que new ne ppu+pae rien vmiure (m aMrtvil Ioulefos ru! It tabkau I que tt pruupt ne mmMSW que do tremla Iumtun). y la N+k alftnrie, dklltcRl apprklab4, qW a Jil- Ilre pa da Iamunrt pW r le Irp111Jre Je aparellet lumi'a par jnur, af mue dn e hielmutia ane pre._'Llnn Je IYpt - J C . D ql M 1. po . 9 [Cuye rtnttrme yrrcNlra ce Je nlturm Ilyne nun prndlirs, dunl le cu raunrmanm plru (aibN abturerau Ie nwYCrra. ALW It tmeommellun Neete tnneklh chei la can. cfreue do }numun arnit bien'an vara$re Irphlliqne dat tumeun mellPat M/mllivei 3) lncmlallnn aMUmi9rlt. Le tableau II1, donrrc la repabbn rla a'n do nmer. , Par 1«ahaaon enatnmlque. Pnrrr lanee ke locallatiua prhenb 1 nmbn eel. [taM do mNln, n a rNecluf It [oinq a n an In lmWne. Let dltkanla aratlrktkun do la pupulaliw c cer du punan . a rNrouve 1 pwr aiucuru Jr ta IaaIWIbK Lee Oiar.eu InnlWtimt M Wnlaenl Pa. pleneuaf rk-d Nlrmce mla epa. a. DCQI[fN)N pq [[[VITAit R CGN0.YfpN Moa allendrone de I'hlWe wl prttfde la pdm' areah . 1)Nrr1tt evqulk t peealt do comMar une puyuklY. Je cencerenn du peumm f 3 pnpulanena timuia rk n- cruhmem Irh diflfrmt : IIa mnluJeS canrereur (Je Iq'a. I¢etion5 eulra Pl< Vpumpn el rpin ahodite5tivn sa~ pe ) demlda muc ir setder- I rk., nala a t J Pw pn une re F d et I 1 pp rellk 1 P r Ia rl IIlrenl rxttr 1 q J!1 MeM I+ d tabtc (ft do 1 me o- ode de on r. q tt! Im:q dedeeme [W 1, qa In 3 pnpokl Ifma m karenl !t kl 1 mMr- raJln mtre elln. alun qn la pVWlNion e un.vn de pountn > e'lftrltlt do taqnn haulenrenl aitnllkatire rlp 3 poVUlat mn NmW a U rhu¢tl (m r/e a!e eue dn enwkn ali• rle a en I 1 1 I ¢u 1l ppllmentd J I y elN de 3 popul t lenloYr (NOUe pqu < 1 t. qu ulre pnpnl lu dn oea ahwlpnl;vee aM n' 11 J ne la mdma nl't J ppatt Ilt I'ee: ee nNe t In a d pu mon t I ie ' F +)On e mm1d1 kec ! I Iwmenrn In qnallfenl uniyuemen. Jetrvnde Inmerla. a anlF. I;rnrrda Innrnn d'un IYPe peltkulier : n) Itt om, plne qlre In timlolnF IenAona f InMkl+ InmM pmn menre Imide Je eanemnmminn (dtmRn e_rd0. ngarate ct plp) ct 6 mmnuN /um4e eFalr 1 h) ik lumenl u e qliantilf Vla prande. e [iiereln. Inul .u molnn. puur un mWt dt aOnwnmaliun 0 un manifre Je lumer dmllle; e) nMn 11e nm une Prdlfrma pln pellde puur I'rut+ rN In tiparelle. n emtuul de In ciq.rttl! Rult; M'e mflirtln'e Inmbk ferPllyuer, en perlk InniS nGn Ie15T nlanl, prlek falt h I'Inhelm rlCnnlre m(n), c uvonr mmlrt qrre I I nJe cip ttl !e It hrlulcs: Plls w<nt k lumfe do la dtaretN que kt lulnnn• nt clecr.ette el pIM. . La ] aarecl.rnuuun er-IWna oN elnl uae fi.°'' aCUUn prvpre , dlo prilootlNnl an oulre dta ntneae:Nr se.Pt:_rl=Te. _ L n_ ,n,mm •- : Nl:ew nn nruq -iW y. .C1.1 1'-IWur eLl:.. seFJ.ve11 i' 1• irw nuru:wW~+ i r.nr .~... m. d. .r. nn au..a,... ' m r.:../ !e '~rw. ..Y. 6 Ge . N me _ ~ i * _ me~ . m pp r eqa I pv. aa,l xle Naa a I -aY . V .i -~,.. .Y .. N!» l1.. Uaue W o ~g . a p 1\y `w '. • u '.a.aau p.l.um M I I - nN v e'uam ~ tly ~ A a n:larr. A n is n I IW Y I I - w.'u+,.w b( i~ : le u o- a r. e I . - nl I eevn Iql Y e a1mn11. M' "°~rr Ia.1= 1 - raa~ ee I u x. I ~ ' - ~m al ~ 1t I tr I fineM e t I, I a - n>'rrvrx w ae M M ws - ~ wu.wm r . Ir n: ~ n a r• I ~ .~.Ir. wC.Y no ~` ' WInelw.eo.Y. R i a i I tl e l f Lj- aWY = n M ~ i ._ <1 a itla y Ilt a 5•. 11 ' e I It) n.l- i I :- ,W:en i ~ _ I YLrar Tt ; ', I I 0 muemm e. rMnae o v n ' ~ r. + ._ _. r I „ » a A - ta aue avune dkritn :[nl ain4 que rhe. k. eall- ckeut du ppumon it eenle dn petllt lumeun malt qul rbn inhalent e moYena btaucqup ylue qo"1 n'W normal; it eaiae cuw dn Inrlleun liinhalanl pa k ilrmh, m ir qai tlere encl <e parlkulliremenl [nnJa Irrsure. ru_. 3) C4mde dea .rrtk a Jaenf dee rhaNau ftalemenl .n4lrenu : Ia eumoeniton Jte unclnua do Imllmon rt da Nmaine, f nlVe.u de conammaf n stal, imliqa qu'pn.n4contre nkrinmellt rarenlent daaujtle aYanl ceW de hmer qui-tltleH~anclrcu5 dupuummq tl d'euunl plue .aremnl qut It eu)et a.r..f tle /u'mer plut Iq. f) La trole poinle prtcMmk perlnalenl rfaborJa Y prubltlne ltkbpiqa au! I'angk de la a.W iK Lre derra ablatlme principakt q'olt a pu prhenter A I'mlerprflal/pn aunay da paaalaliaa e.ncec do palt rm4n4ac ani kt mlantt! : - Ie premlea nt que 1'unee du ahac pemrail n'ka qu'un heuur lit d un ama faelnr (uu [roVM de facleua) a, qnl anil k ehiuWe rapmrabk da n.cee du pnumon ; ='la deu.ifele nt e Yermn d'tcWnlitunnape r r'tehantilkn do cenetnue rnaill4 a. celui dea 1lmaina, (uu In den.). pournirnl ne perlta rerlanemib da ta1Rf eua do linurlqn ou det lerm:n en [Mhal ; celu ae PrnEUinit 4`-I•fcb.mulonnate eonlyorlait me ielauioa creA par ue faneltr qTlmalique Y Limnien enci.k, uu-IemllYle.' habYlt, Rc) IuLmlma lit l-1'wtr du upat : I'hlunlillan da cuctraua e.nat A 1'bOpiW rerait 0EZ969Z00T

I I 266 CiOARETTE LABELING AND ADVERTISING wr eaemtdr d•en nlee.u rndel pI= Neet qne nlel da dn /uMen de cltarelte et pbe. Ce kk dWt knir an etmobq• ce qul leuutreit kllk oompuaWrl. CNle deu- pn d•4lormaHw au•eppoek k triltre : Inhaktlun n aitme ob)klun, m Iln de tvnpla, Mat pu I•Ikaent nan 46aLMUe. Le IumeM peut inh.ln pk.uu moim , dlRfreme de k premkre, I'uM n 1'auln klunl appN aourenl, plue ue rwlee leten4menl, il peM finrplua n t un ftrker. e o. y Et & I'auK dll IabK, et ttu« moln vik wr •a ti[aMle, ett... Une dercripfron Jn rlMablt rkt d11PlrtMee conkMtta. tomeun de clEerelk at ppt d'en ptn, dn lumeun k On ne peul rlpundn n euute riyueur i eeke doebk NSnNk eeWe d'tu0e ptry kiunt romplt de cu divenn ablectlnn pu:m m~parenl b r•.elmu do puumon p nruYtrMiqun• pennqerfH peeMtlre d'eapllquer In dib In ttmo4e pnur Mu eNk NeMUe de canqerWlaun fennn deeNpun. nutreptiplt, d'fM Iltet i Pa..netlu t.Wt. C[dt n eul Dl ll p'kl p4t impanibk pu.e, en uutre, ea• deue.ek- Irnlilk It .uenionn•ire Ir!• dtnbppt qu: rou• anm Rorin de Wmeun (lemeen de d m reuk, nu dr utlliet, a dnnll nova Int.rdire dYbarder k prabkne de Pre t pipe) dlRtrenl Enm: de ISNn ptr aMaimx le taueaElf evenl d'aeuir fni d'eepbitn luutn la er ciRalelte e nnutkletiWn neeuNln nnll IIt k mode de ronron- briquee do rr.e qeeauenNrte mtebn (knpfnmeM, mNe de rk...l. II noe• etmbk npeMnt que mue pwrnu, dk malt• la•r.nl, leire le renuqut edv.Me : k IMeur (dr peope ~r dauteun) a au / PI .Inll d'Nn in.opu/devnil, pwr 4 r prrr twuauxr ew. wpr .ner.eyx ~. eeyliqu<r Mue In eeiu nppMlk d.m tetle Nude, eUlir r°net .m M s.vweeau n M u.ar n 1nnplw : Wnx r.MUe la bxlYlxr .ueer ax 1 une a/W1 k pM prlaik /lu'une • pl Iluon .w n ml•• nratWtr•a .unt•xunq ..1•e. [. K ~ aa I ok d Lb.d; II dK a 1 Nn lif t b.ule k ry• n°~S n ~ W W . . . . ae.w• ..•u. . .u w•• w kr arm. w .. I'arom d!c Ne .u nk tu Ee <omornalbn fleevl, t I lehaall f fq le, t 4 prNtre partlntlt, pve. la cipnNe-mu4,171eMbtion d'tul8nt qat Irtyumk qut 4 eoesommatiun nl plu• lubk, el l un a'onwmmeDon d'auunt phn Nevk que 1'tnhebtion e•t ylmrart i II dnreil Nn prtnM yu.nd Ia wlel Lnrq di.p.rakrt :II Mme, k t Ia dek u0 n e'eerlte... e Une telk hypol6Ne ri nl nrlq pn leyleaablry ma4 k ehamp dn pmeibilitta en eet elnNlilrtmenl rnerelM. !) Indtpeltlamment de on toeclu•bin rtlelivn an laba4 rrt tludt non permN d'epordn k proERme du dlneue. En t1uMn1 le prNtrent perlkulkR de eaneHwa do poo. pour. le ciOrelk, nea a.one rnndrf qee tl en celnpan dna •eJm, lumantle nreee neerere d, cipretke par )mrq dom ILn Iunenk ee a.fn le oipe, 2eGue , nn.r dulqumon e 0.14 en 2opmlk deuv ..._~ e. .. -v :t Clrniee roJ decf role plun 1nr1 w.m 11 Mnw e[[• ~ n^Y aWnw n w wutla rra ayr ayrw .e.e tn t. ~e ^ ~ mr • w eow. x , aul +.ve.rrew , n M e wtNVlw M tMMw •mt nrrrlrnt erannW . n u r.ueae • n.ue te pm.m . m..eu.v. M M.uW tYw r[qa .• •Ymna4n : Ix nM- eu Mrrn tst Ws t tueoure ru.mt p~• x ekemu r •a:mn.r Imoee. e Inn.xi u Nmn .e n nw•tta w wet .elr snnt n qu• ...wr.naw t• rr.x. x. _ ... . e pnn pw re Y u.wr. an reuw nen eweue ue a.no .n.e. vw xemnue . • ypuYlY. nlee h ms• rarx p •. : a.neu•1•tNru- a na•u/ weeet•e[-®nls pW M •n•w lnun pWr Y tlnrrr1~ tMM•..M : tnN xxwemn. M akuwr. n.M. ylr erme tYwlm ~ eMU . ev.IrnlnaYOn •.Iwn•b M YV ~Mnu eaepr..u . Im mo[I eas ~~ V[ee lu.• s•x wan. vW/M ee•n..ixr~rxr~ri~.•n•r enne r:.mur.. .. . . . . cn •wx.•e yumemM ee• r. . ann ~r . n,..r ewt rer., n a.ure arer t~a•m M aexl .r ..a- Nt. xe•nrwe Nnnrm~~n•t+n k n easai aY1W rN witl tunYw ~ ' ap ]C' :{rtre111-C'. / i~ en d•.s nv, drt de le pipe ennplretere dr rombur- 'r r irm, n m.mme), poi.qa In deux nlela avm-urk a m -me le mlme namM1n d< tiMefM, \pun ne vo.vnr e n tua d! I- .....ya :'.-... ... ... t ~ r'.e•R •~_'r -1.; .~.'.. . ..,.. mi.y Mmre.... . . .. - ..:`i:m~ Nou• mtendon• par It yue : nWnt. l•1 Dou lRl N M. omm o) Cn deur ntQKdn de aulet• Ilokent dlRtnr par p.r m.nllre delumk. Nau. ..one dlonkt yue In (1) Doty (ex,e -xe 1 d l Nt t l t i d 1 i meure e e e e p pe an ma na ke enn nhNer ear nrr•ix <f re riFemre qee Itt lumnn M tiF+retle fal 11u.[ 11 c x±liqee que partlellement Ie~mNrMt 8}Jur TE2'969ZOOZ OIQABETfE LABELING AND ADVEBTB4tM0 GRAPHIOUES DES R15pUES REI.ATIFS (V.• ~y/r•: eii. Y ryw-O, r.yi YY . A pw •r~r t e r.w•nW ~ M IrmYa ~I A. En 4naw L. MOOE DE COINSGMMIATION f~ Cgw. • pp[ (Fumwv. w de dee.M41 © <ywu.J tiM••rere..w••.•n A.by r ~...y., - ... . [r rw1a r •t.L[ brn e.Ir w ' qk..•T wte ' ~ M q b 101 267 B. En 4nsron 4 M MANIEA£ OE FUMER Oluw.•'.lw... IPyrrw~• 1 Y.yreVe ewwl ' Olun.e..ea.e GM.....r h..r B. MwLe,de 6, rY e-_ _7-W M rwMr. M upw.Mk• Mie ~~we W p 20 r 1- D_ En hnew s 1•ltRRET .q.R.Ye .J.IV w krt/lnr r 1.} .'keMr tMr k• Iwr.e. Y.I y uP~ erwwl F4• dar•+r M.. tarv+e f-

N ~ ~ N ~CD VJ N CIO IV

9 o a 'z r~ ~' c- m a e d w~ w°1 m ,~~~''~~.~~~Y~~~~ _ .~ 7) s,;'b~ ~ e9g ~ e a R~. ~• ~. ~ 80 e p. 3a C , e ~ b . ~ p ~ F' £. R w e~ E• . • 5• ~ Y e4 6 • o S p~0.QQQ'''g ~ Yf e3C £ ^ ~ ~ ~ N °S~ ~ ~ ~ G~ ~ ,°~• F~ a~.Sc~fg~ ~Q°! ~do'es~~g~.ebv 4 gP=~ <~ ~s S ? a p~ oq g ~ F+ 3 ~ ~ w~ d ~i~( 6' ~ i ~ ,~ ~ ~ . . C ~ Q ~g m e or a If I a Fw $ g 0 0 F ~y~.~` : • 3e.5 R~ ~ ~ Tabelk 1. Die Znnabme dea primiren Lungencarcinome 9n den Jahren 1930-1937 anter Verwendung der im Pathologiechen Inatitat der Univereitit B61n zur 8ektion gelangteu Fille. . . . Luweeurelaa" ,• E~ ~ L.l1 dm &k. Lhl da O~Mmb . A11er Vet46omf .at d" ~ ~vw oeumF erteloamem% ' le%dv d7Wm• m%de aLhnr Jehr Oao.b ~ lYroen abrr urN+ d. enamb L.W d 9 aenmM dmm• 0."de. . doKb• m a0 10 60 e0 m eU - j .. 1Dihhen mme mktlmm mktbo& ubalrq we "tmlEte bY eb bY bh bY bb bl , a . .. B i a N Oe 71 N - I I l 1 ~970 M ..6Ed 86 .B.Eg _. 7 6 E 0,67 e.li, . { 1 _. i Q ~ .. E1 1 1 3 a 19s1 _ l090 688 119 ~ 11,90 7 7 0 0,70 6,80 i t 4 . . 1 f E a 19EE ..._. i60S ._.. . 681 .._.,.,. ... 1E1 ._...:. 1E,98 _ , _-,_ 9 . . 7 E . 0,87 0,81% 6,72 ._ 6,03% _. .. !. 1 .. . . " : . I E E 6, 1933 .. 114 1 . :•. , gi6 168 1E,85 10 9 1 Q88 6,gg l 1 . r E 4 4 1 a 19341 _1381 10g0 196 15,18 1E„ 1E 0 0,113 6,17 i l 1.935 1d98 1176 190 11,90 17 1{ E 1,07 -g,9g r ; 1 1 '6 , 7 E 1 a r ll 9 1 1930 1630 '1ffi8 . 161 9,88 l8 14 d 1,10 11,18 I { l i , ; g 1l E ; 3 3 a 19E7 1650 1191 142 6,67 17 15 2 1,0.1 11,97 l .. .. . I =~II I1 IEEi 84l l E 1 3 7 V r

272 CIGARETTE LABELING AND ADVERTISING 1D18-10211 boriickeichtigt, neben den in Teb. I sufgefiihrten Ergeb- ni.rnhlen nus don Jabren 1930-1937 zugrunde. Auffallend let Mar der xtcilo Atntieg.im Jnhre 1028,suf den an andererStello niher ein- gcgnngen wird. • Worauf beruht die Zunahme dee primeren Lungenoeroinom8l - 1)ieeo Vrago nimmt in dcr Literatur der letzten Jnhre eino wichtige Stel- Imig cin• lSildet dooh die Erferechung joncr Faktoren, die tiir dieee Zu- Iminno mnOgobend.6ind, eine }drueke zur Liieung do geeamten Krobr problemn iiberbuupt. Vielerlei Ureachen sind bieher zur ErklBrung hrrnngezogen wordon; Vermehrter StraDonsttaub, Autogose, Str60en- hrernng, Knmpfge6e, Rlintgonntruhkm, Griplw, Trauma, Tuberkuloee, die rtcigende Induetrialixierung now. Eino Ubereifietimmung beeteht in. r•ofcrn, alo oxogene Schedigungen In Betrueht gezogen werden. . In den letzten Jebren iet die Bedeutung dee Tsbakrauehene immer mt'.hr in den Vordergrund geruckt. $ie erklirt die etarke Bovorzug{tng d,w mnnnlichen Qesohloehtee und iat um eo erneter zu bewerten, el. , dcr eutrke Anntieg den 1bLskverbreuchee kurz vor und eeit dam Kriege '. mit der Znnahme dez primiiren Lungencarcinome parallel verlauft. . 2. Die Zunehme iea Tabakkoneume. Iiach Angaben do at.Natieohen Ileichesmtm wanlen in Deuteehland jibrlieh et.a 8\lillianlen Zigerreo, 38 Milliardon -Liguntten, 34 Millionen Kilogmmm IMvifent.bnk,170 Millionen St6ek Rollhbak und 1.7 Millionen Klbgramm Schnupf-.. tmhak ventcuert. Der Verbnuch an Zigeretten iat eoit 1907 min mehr a1a do ' Vlmffnelro gestiegen: 1907 wurden 7, 1936 dagegen 37 Millierden vemucbtl In ,ku Jahren 1022-1934 iat dur Zigarettenk,unum um 82% geatiegen. • Der Alkohol- uml Keffneverbrwch iat i,n Gegeneµe dnzu aeruckgegangun (8tmuu). Aneh in den btrten Jabren halt die Stcigen.ng do Tabakverbrwobm. vor-~ m•hmlirh dunh den imnar etarker wmdendm Bedarf an Zigaretfnn verurmcht, - unvannimlert en: Von 1930f1931-1936/1936 atieg der Verbiauch an Ziguetton net _n,7 ant 37,4 Millianlen, d. I• um 21%, dar Verbrauoh an Zigarten .on 7,1 aut 7,n \lillinnlcn, d. i• um 10%. Pi wrrde nicht nur mehe, rondern auoh echkebten . Einlrn grrnucht. Imgcrmt warden in Doutwhland im WirNnhaflaiahr 1p36(103e . fur 'febak 2267100000 RM. und f6r .Ikolmlieclr Getrinka 36708703001iH., -nuumnu•n g82711703g0 RM. aurgegeben, d. A.10,8% dtr ptenaden VdksinMmme.e, . unkFr. nvf ag Hil7ionfea Oeechdul wird, wun/ee /Yr Tabek end AfkAd aerhmuckf. \arrh Xeemnwn-IVeeder iK der Teergehalt do Tabaknudw an enter Stelb . eut die vrrlmlzten Mlaib der Tabakblidter aur6okaul6hron, Die Vorholtung k.nnle d'etwunn-II'ewfer bewnden in den Blettrippen und -nerven nachweimn. . Sarh Air.diuq enthalien die Tabakblktter im Dureheehnitte 26% Rippon. 'Iki tier Tabakhuntcllung werden dieae Abfillt durch Waltan, 8chneiden oder -%•rfew•rn in eine geeignnto Form 6berfkhK ,rnd den vereckiedenen Tabakermug- l ni..-u-in uwhe oder miwler gro0er Mmigs beigef6gt. Fc6her wurde dic.o. Ver, fehmm ~ur in geringem Umfanga angowandt. Dagegen nahm die Beimengung .kr Ilippen in ktztcr 7clt in einem enlehon 6LOe au, dag der inWditehe Vornt m. •\IdAlkn aur Tahakhentellung nlcht meht auneichto, und die Tabakindmtrie daru eberl;ing, T.bakrippen in meigenden Mm,gtut .u importleren. Naeh dur nyt \'r.,ee...ll'ende. migef6hrbn .mtBeMn S1slLtik ebee die Eiduhr van CIGARETTE LABEf.1H0 AND ADVERTISING 273 Rebatdfen anr llenteuungg von Tsbekwuea wurdan lu Jahre • 1927 3628 ds ; . Rippen nwh Deutaohland eingetuhrt. Im J.bn 1931 atieg die Einfuhr wt 1g046 dr- ' 8ie hat lich im Jahn 1932 n.hxu .er.brlsehti indem eie ar( 76637 ds im Werte, ~ von 1479000 RM. anetieg. - - Neumonn-Wender verurtailt diemn abaiohtliehen Zueata von Holsrippcn, die ~ keine Aromaatofte enthalren und bei der Verglimmung achkdlielm gtoffe, var ' allum Teer undMethyWkobnl Ibfem, ala Verfakchung Im giarm do Lebmu- ' nittelge.etra. Fiir die Frape der• etdadiyew Z4naAme dee LttndeeL'rebere iet diese zu- neAmende Venandunp der feerl-te%rndtu, TaBafcrippen ne6en der afi- yemeinen 8feiyernng du TabakzerbraucAea gnez eiekerfieh aic6l luxleutuupa. iw, eeitdem die krebeerzeugende Wirkung dee Tebekteeree durch eaperidmentelle~lUntenuc6ungen eichergeatellt wurde. Ee fet anzu-. nehmen, da0 die holzigen AbGlle besonden den eohkehteron und dn- her -billigeren Zigarren- und Zigaretteneorten zuewtzlich beigef6gt wurden, Sorten, die inletzter Zeit von den Rsucbern bevorzugt wurden. 3. Tebak und experlmentelle Krehaeratugung. Die Bedeutung do T.baka f9r die Krebmntatehung war aehon um die Jahr- hundartwende bekannt. Im Jahn 1900 berioblete RrnrrA in einer Arbeit „Thcae- tieche und ezperimentelle Untenuohungen zur gathogeneaia und Hiatogeneeis der i malignnn GeachwOlete" tther aeine Verauche, dunh die „bekannten Krebaeneger Pardfin, Teer, Ru9 und Tabakrtt" beim Mtenchweinchen Hautknbe zu at- rougen. Rof/o und faer au gkichee Zeit CAilnemter gelang a ha Jahre 1930 sun enten Malo, dun:h Pituelultgen mit, Tabskteer, weloher aum dem Riederechlag dv. ' Tabakrnuehea gewonnen wurde, bei Kaninehen tin Carcinom zu erzcugen. In . den folgenden Jehnn bericktefen Caoper, Inmb, 8ondera und Hirrl, BrAilr<A und Wia/ersuie, L/I Fs Hae 6ber ehnliobe positive Venuch.mgebnve boi '1'icnn, bei denen durch Zufyhr greDerer.Mengen .on Choletterin odor durch•gteinkohk•n- teerpinmlung an mtdenn HauYtellen eioe Geachwul.tdiepo.ition vorlu.r errcugt wmdon war. 1g36 tuhrb RoJ/o weitere umlangreiche Untmsuchungen durch; durch die die - knbeerreugenda Wirkung do Tabakteere im Tiervenuoh aicbergeetclit werdeu konnm. Er atellte dunh Extnks'mn bei venohiedenen Tempcraturen .wieehen .. 0 und 400° 3 De•tillatiooaprodukte dee TabaYe her, wobei eich ein Deatillationr- . ' pmdukt do Tabake, walehea'bei Temperatumn awiaohen 120 und 360° gowmuum wurde, in Tiervenuth ala beaoriden wirkrm erwiee. . Die Vonuchetiere waeden i.3 Gruppen von Jo 20 Tieren eingetoilt, Rel jedkm Tier dieeer Gruppcn wurde eim•s der Deatilhationaprodukta do Tabaka tuglirh eienul wf die lnnenwite der Oluen wfgetrsgett. Die Tiere, welche' mit d1m tnten Produkt (w60rigeElame, entelnndcn dumh Deetillation bei 100-120°) behandelt wordcn waron, boten nach 10 Monaten keine wesontliehe Verfrdorungen an dor gepineclmn HauYtellu- Anden bei den TSernn der Gruppe II, wekhe mit dem 2. Dcetillatimuprmlukt (harsigu Man+•, welche dunh die hmiaontale Dettillation hei 350° gewonncn worde. Sie uulwlt • nehen viekn niher wtgef6hrten ehemieehen Bubetammn auah aromaiecbe Kohlcn- wueenWfte,. Pbenantkreo, Anthre:en, Dcmpynn ww.) gepinecit wonlen wann. Rierven gingen im ereteo Monat der BebamBung 4 Tiem augrundo. lik:i 15 von do reatliehon 16Tiennenhtnden maigne Tumeren, das iat boi 947i1hach PE?r9S9Z00t

274 CIQAREITE LABELIN6 AND ADVERTI6IN6 I CIOARETTE LABELING AND ADVERTIbIN6 275 I Monsten wamn an der beh.ndelten 6talle klelne Papilknne In Erbbeinung ge- [n•ten, welohe R Monate epater den ansbmieuben und hietplogiuchen Chamkter mn C.rcinomen anna6men. Die Ergcbnleeahlen sind bci der 111. Omppe (9e- pinee!ung mit dem Rucketand der Tebakdestilbtion) g3ringer. Ro/fe orklart den Unterechied in der Zahl der durch T.bakteer eruelten Krebefalle (bei eeinen frubemn Vemuchon mit Tebekrauch wamn ee 4%, bei riiMn neenton Vemuchen enter Anwendung von Ileetillatimuprodukten do Tdake dagegen 94%) dadureh, da6 bei den frahemn Venuchen die wirksamen . lkwlandtcile, Herre und Teer, eich nur in gedngen Mengen m dem wanigen Tahek. r.uch, den man den Tieran eingehen konntu; he(anden. Rof/o m.cht alw die numme der entetendenen Gruinome .on der Btfrke and 11eaw der $ubetanz- einwirkung abhengig und Ibweiet diere Annahme dnrc6h den rieeenhefPon Anutieg der 7.eh1 der Oeec6wfilete, die bet der 2. Venucbesnordnung enielt warden. Durch die Venuche Ro/%e wird.die Frsge dec Disposition inein hel- krce Licht geruckt. Waren bei den fruheren Venuohen die Nieder- echiagemengen doe Tabakmuchee allein wegen einer a11su grollenVer- diinnung dee wirkeamen Agens nicht imetande, suf den Ceeamtorgsnie- num cinzuwirken, und mu0te die Umetimmung dee Organismus durch 'Lufula von Cholesterin alleln oder in Verbindung mit $teinkohlentenr rret herbeigefGhrt wenlen, so setzt hier der Tabak, in gro0en Mengen angowundt, eelhet dieee Dieposition. .. . In Anwcndung suf dsa Gebiet der Klinik bedeutet diem: Des Jahre himlurch fortgesetste Rauehen, in deaeen Folge im Lsufe der Zeit eine grolb Mengevon Tabakrauch aqf den Grganiemue einwirkt, fOhrt naoh einer beetimmten Zeitepanne su oiner allgemeinen Umstimmung dee l)rganiemue, welche die EntstehuQg dee Krebees+atp Grte ~der Reisein- wirkeng ent ermtiglicht ' Die Zeitapanne, die zur allgemeinen Umetimmung dee Organiamus rrfoelerlich ist, ist bel Zufuhr gleicher Tabakmengen fur den einzelnen tlrgnniatuue vcrachieden gro0. Hier apielen die physiologischen Ab- we6rvorrichtungen in der Lunge, beaonders die Tutigkeit dee Flimmer- rpithele, eine nioht su Obersehende Rolle. Bei siner mangelhaften Anle6o odcr durch fortgaetzte Uberbeanepruehung gesterten Funk- limt (Ilareberkatarrh!) kommt nine Aneammlung der von su0en in dic Lunge eindringenden krebeerregenden8toffe viel leiohter susttatde a!e bri normaler Funktion. Der Reiz, den dieee Stoffe suf die Sohleim- hant aue0ben, iet daher.viel intensiveql . Aueh die Fmge, welchen Be.tandteilen dea Tabaks die krebseneu- >;vnde Wirkung bmewohnt, ist hier der LBsuag nnher gebracht worden. Rin Produkt des Tabakteeres„ bei 380' gewonnen, welches die Eigen- wheften rler Koblenwaaserstoffe, des Phenanthren, Anthraoen, Bens- p,rren hat, zeigte bei den epektrographischen Untereuehungen von tbrrra, einem 1llitarbeiter Rof/oe, eine Ubereinstjmmung in der Ab- orlNiomqkela mit den sromatiechen Kohlenwe®entoffen, inebeeondere drm Bcnzpyren und dem 1, 2-5, 0-Dibensanthrszen. Bekann6lich sind die osnoerogonen Eigoneohsfton des $teinkohlenteora auf don Cc- halt an diesen . arnmstiechen Kohlenwaeeeratoffen zuruckzufiihren. Ro/fo iet der Aneicht, da0 such die krebseneugende Wirkung des Ta.. bake auf dieecn Gehalt an kondensierten Bonzenkernen und Hydro- kohlenetoffen der aromatiechen $erie zuruckzufuhren iet. Dutch die Versuche Ro/%e let der Nachweis erbracht worden, da0 die Produkte der Tabakdeetilktion Rhnlich wie der f3teinkoldenteer in hohem MaOe krebeerv.eugend wirken. Ro/Jo zioht aus eeinen Ver- suchen folgcride fichliiseoe:' „Dieae experimentellen Reeultatc wcisen auf die Notwendigkeit hin, die Prophylaxo gegen die Krebnkrankhcit, , intensiveu, zu gestalten und die Gewohnheit dee Bauchen zu ver• :. mindern, welche, atatt abzunehmen, immer mohr sunimmt, jetzt haupt- aschlich such bei Frauen. Msn kann sieh leicht die Wirkungen dicecs Komplexes auf die Mundhbhle und die Atmungswega voretellen, ebcnao wie die Folgen dee Tabakmi0brauchea, wenn man bedenkt, da0 aut 1 kg achwarzett Tabeke 40 g Teer extrabiert warden. Wenn man mit einer tuglichen Plnnelung eince Kaninchenohrea nach 9 Monaten einen . Krebs beobachtet, an kann man stich vorstellen, wio gro0 die Wirkungdee Tabake auf die Sohleimhiute einea Rsuohera sein mu0, der tug- Bch 3 8chachteln Zigaretten nmaht, was js im Monat 1 kg Tabsk" auemaoht, d• h. 400 g Teer pro Jahr und 4 kg in 10 Jehretn I" 4. Untenuehungen. ~ : In der Inneron Abteilung des stadtischen Burgorhoapitale in Kuln fet in den letzten Jahren eine verheltniemd9ig gro0e Ansahl vun Er-krankungsfallen an Lungenkrebe zur Behandlung gekommen. Einnuboree.Eingehen suf die Lebenegewohnheiten dioser Kranken brachte<die Festatellung sutage, ds0 ein auffallend grofkr Tcil dns Rauchrn. in sehr starkemMaOe auegetibt hatte- Niuht etaten wunle von den Kranken ein t6glieher Verbrauch von 30-LO Zigaretten oder entapn•-, ohenden Mengen von Zigarren oder Pfeifentabak angegobon. - Dieser klinischen Beobachtung entaprang die Anrcgung zu ditwer Arbeit. Zu ihrer DurchtOhrung wurden teiis die Angaben aue don Kran• . kengeeohiohten berangesogan, tails wurden eie duroh oino oingehendu: pore8nlielre Befragung der Kranken erg"anzt, sum gr00ten Toil aind sic jedoch• dse Ergebnie genau geetellter Fragen, um dmett Beantwortung wir die Angeh6rigen der Vemtorbenen gebeten hatten. . Der Fngebogea, weloher dzn Angehorigen wgeeuult wutrle, hatte folgenden Wortlaut: . 1- IVar Jer Va.forinre, Ren•----., lbarAer} . Aefvwf: . ' IVeew Ia, ri.koek mr wte tapfiuSw Vahruuek an Efparrea, Zfparqye, p/ai/<a-. tnkak} (Bius yu.ure Anya&s, mepfialet in Eaklenl) '' Naoh efnasAetara l.iekieb In der Meohr. %rebebekp/g 7. . SCzssszoot

276 CIOARETTE LABELING AND ADVERTISING An/nnre: ... . Die Angeben sua den Krsnkengercbichten Ober do Rauchen wbienen uns ' deebnlb nicht euereiehend, weil bier meistene nur die gegenwartige Hehe do Tebokverbreuchee .ngegeben wird, und eieh bier oft nur der Vernurk „8tarker ' Itaucher" ader „HII9iger Iteuchcr" findet, weleher uber den tatuicbliehen Tabok- verbrouch gnr nicbte auumgt. In rehr viekn Fallen iet jeduch rlae fruher starker . euegcubte Rauchen vun den Kranken im Verlaufe der Krankheit und rum Zeit- Iwnkt der Knnkenhsursufnahme wegen der dedureh vernrencbren Ver.chlimme- mng der KrankheiGbreehwerden vermindert oder gans eingeetellt worden. Wir ' baben dahcr euch genaue Frsgrn Ober den (ruheren Tabakverbrwah gestcgt: 2. Haue der Veratwbe.e (rsder pcmar+tt, danw 1^d^d daBaarAn'r etapufelH r Autiorl: ' . y' . . Bu eu xrlrAew LrDesejaAral An/uwt: ~ ~ . II'rnn ja, wfe Aonl awr eeia edyfieher Verbrasrk aw Zipanew, Ziprdka,:P,ai/ea-. M6ekT (Bilte penoue Aninerl in ZaLkal) Anlunr/: - . 3. Hauc der VaHwbaw (r9Aer Y6rI:o RmacU, danw fedarA do Bar:rA°4 rmainderl7 ' Anmurl: Bir eu eukdem LeEea.jaAret dnluor/: ~ Ifie AatA wr in dieeem PaBe /rie WplirAer YereraatA an Tabskrmree enrAer ead nneiAer} (Bdb yeust Asqu6eel) . . Antumr/: .. Neben dem IGlucben wurden auch die eurutigen achidlichen Einwirkungen .ud die Atemwege, inebeeandere die beruflichm,, in den I4mie der Vnter.uchungen in drr Yrnbro dcr Xtiologie des primHen Lungencaminems sufgenommen u:d in un.aa Llfgeetellmtg cinberogen: ' . 4. 2denen. Sie :eir Aepabew da.uba macAen. ab der YerNa$ene eaBAread etiao lrrnflirAen Tdt(pkeil oder anrA ca/krAalb derrd6ew der 6inmirLvnp uervnreinipter l../( ldnqrre Zeit kimhrd/ auepeerlrl trar} 8n/Aid4 die w.nreiniate Lu// 8b//e rir :. B. HaecA, Bup, 8taa6, Teer, Demp/e, Verbrennaupe- and Auryu//Ynm. KuFlra- avd dfeWUr/arb. cAeoittAe BIaJ/e, ZipsrNUndumd aler dka/Wd 8ro//er Anlnnrl: . . \1'ritaue der grSgte Toil der Befragten iet in entgegenkommender „ Weinc nnf uneere Wunsohe eingegangen. Die Anechri[t der in Betracht kemmwtden _Personen sammelten wir aue simtlichen grdfleren Kran- krnuontelten Kbins. So stsnden uns su uneeron Untersuchungen die 8ektia:nprutokoUe des Pathologischen Institutes der Univereit6t und d,x lentltologiechen Institutes do :tBdtischen Krankenhbuses Kbin- ?hilheim sowio die Krankengeechiuhten der Inneren Abteilung der Krcu,k,•nanstalt lindenburg, do St.Elieabathkrankenhausee KSIn- Ilohrnlilul, des' etpdtiechen Krankenhauses in KSIn-MGlheim neben dru Krmtkengeschichten aue der Inneren Abteilung des Burgerhoepitab m:d dce at6dtisohen Krankenhaueei in K61n-Douts dankder freund- hrhen Vermittlung der Leiter diner Anetalten sur Verf9gung. Nihere }:iurell:eiten Ober die Arbeit.bedingungen ejnee Teiles rler Bpndwerker CIdARETTE LABELING AND ADVERTISING ' 277 und Arbeiter atu uneerem Krankangut wurden uns aut unaere Bitte bin von den Fabrikbetrleben, in welohen dieee Kranken langere ZeiO hinduroh beseheftig6 weren, mitgeteilt. Aut dieee Weiee haben wir tolgende 96 Krsnkheitafiille sueammen- geetellt' A. I3streme Raaeher. . 1. 736/33. A. K., 8ohloreer, 62 Jshre. .. Extremer Rancher: 760 g Pfeifent.bak in do Woehe: taggeh sinrelm, aoos- tegr mehmw.Ziganen. .. , BmuHpe drRue 8inurirFunyee as/ die Akwteepe: Yetsgrtaub. , Varanpdemfe Srkrme4tul9en der Atau/s9rupw.:. Htt 24 Jabron Lungen- eotaundung. . ~. . Anatowiu3e Dfeynare: Hochgr.dig sertellmde Kreba do reehten Lungeu- . eberlePpmu.mit Kaverne. . . . :'. / . Yikroekopiadle. Bc(and: Aderoeudncm. : . , 2. 1342/36. H.O., Inwllateur,,90Jshre. Eatiemer Rauohe': 199 Zigaeetten pro Tag. 8ona:ipe depere 8iaeird,nyrn mr/ die Atemwgu Bleiataub u. t. - YavunpeAende Srimalaaqas der A/menQ.wyawe: In do Aasmueae nieht sarmerkt. . . ' Awa(oeriacla Diaynoas: Brvwhialearoioem der linken Lmige. Arikro.6epurAer Be/rad: Ca. eulidum. . 3. llg/38. F. W., hoher 8t.af.tie.mrer. Estromer Raucher: 60Zigsretten md hierbei noch vkde Ziptraa pro Tag; r{uehte ununterbrochen~d~en'~gs_m~~'m~s Tag,und die halhe NeahR Boartige drQan 8in.nawnprn aa/ die Alemrqp: Keine. ' Voronpelande 6rkrankwnpea der Alwrwpeorpss: Niaht bekamt. , S/in(erAeGiaOnos: Brmwkislcaroiaom. . 4. 98(37. I. F., Kaulm.on. . Extremer Raueher: IAindeefan 50 Zigsretim pea Tag. 8e.elipe dupere Sinioirlaapes nu/ die AI<nmepe: Kaiw. . ' YamnpAaads Srbew[xepn der AJwrngayone: Nicht bekamt. Klisi.rAe Dinysere: Branohialateinom. 6: 990/37. H. J. Sob., Hei.er, 74 Jahro. Estremx Rauuher: 699 Pfaifeutabak und 10 kleine Zigarmt pro 1Yg• BoneNpe 6aQen 8innirkrnyen ae( die Atemwqpe: Rauch, Rug, Koh.leMaeh (wahraend oiner 16jahrigen Tatighelt ..1e Heieer). . VwnnpeFeade 6rkrunLrnpen der Atmr:nyeorpa.e: Niald hekaoat ' Aaafomi.ds Diapwee: C.roinom do liaken Hwptbmsekua .. 9. 946/49. F. K., Anetreicber und Vargolder, 47 Jahn. Expemer BauoMr: Weohentliob 6Q9 9 MeHentabek. . BoMpe 6eQero ILYnoirLrapn au/ die Alemtrrqs: „K. balte aeban den.73'arbes rlel mit Bleiwei0 gnarboitet." (Nach Aogsben do Ehefrau.) Varawpaherte Brknralenyar dar A/nwny.aryase: Niaht bekeont.' Analomiede Diapnoer: Cartinem dee teebtea Hwptbronehue. 7. eo/39. ll., W., K.ulmann. 69.J.hn. Estaemer Rauohat 40-60Zigareefm tegliar- BosNipe ds/fere f'ismirkaqnt w/ die Atewrrsy.: K.kr, . sEZSSSZOOi

278 CIOARETI'E LABELING AND ADVERTISING ~ CIGARETTE LABELING AND ADVERTISINO 279 VoranprAende B.Lv.n6rxpen der A1nwn6w:nyana: In der Aa.mnem nlebt •ermerkt. - ' RSnirrAe Diap.um: Bmnchuic.roinom. , . , , S. 610/30. V. Q., Kaufmann, 69 Jabm. -. ~ b:xnemer Rancher: R.uchte dwemd Zigarmn and Pleikat.bak tm~motgmw his shcndx, jn .elhet naob im BeSt. ' ~. Sonqigs aspen BisnirMar.n an/ die AYmwyr: Kainn. ~ /'orangeAnule Krkrankrnpen der Alns.yraryame:.10 J.bm bnfe eatum LunB.n• . and Rippentallent:Ondung. . - .[nnfomisate Diap.aee: Bruncbi.leucinom. - . .. ' .Uikroekopi.rAsr Bc/.nd: Plattenepitkeloreioom. 9. 1201/38. S. K., Masehinen6.uer, 63 Jahre. ' . _ V.xuvnwr Rancher: Ihdher 60, sp6ter 30Ziguettm po 1Lg• Soxetipe dnpen Eiwroirlvnges as/ die Atamwede: nSebr rt.rk ver'mmini8t4 Lvtt durch Kunethnt•tet.ub (Calxlith, PmOtmtf)• 'Chemisnhe Zur.mmaneetauug: I'Maal und Ponnaldehyd.•• (Neeh Angaben der 8chmes.) - I'omnprAende 6rkrantrnpen der AlxmnVmrpsnt: In der An.mmwe nioht venm•rkt. - Afinieni. Diapnors: Bmuahi.kuoioom der linkart LunBa 10. 448/38. A. M., Buchdmtker, 63 Jxhn, - l:x4vmer Raucher:. Vom 20. Lebenrj+hre an nuchie er den g.uran Te8 alxr his in die Nacht ununterbroohen Pfeile; er verlsu8te awh der Ptate noch wl dem Krankcnbett. ' 5ondtfgc dsPere Eiwurirlrwpen auJ die Afawwrp: ,Ww haben einr Drvakerei. )hrn ventorbener M.no arbniteM tiglioh mit Blei, swirehendureh aupfteer die ' IY.:fc. Itettutte HWUlewamheu war er mhr unr.nber and den Blei.t.ub n.hm ar erhr gkichg6lHg." (N.ch den Angaben der Ehefr.n.) ~` I'omnqeAnula 8rkra.ktxpes der Atmnnpeurpmse: Niokt bnksnnt.. , .annlomiscAe Diapnose: Branebbde.reinum der nebtM Iwr:ge. • . I1. 77/37. I. B., Ksufm.nn, 68 J.hm. Katrenwr R.ucher: I6 Zigenen tiglioh. . ' .. : oxslige &wQere 8inwirt.mpes au/ die Atrmmeyr: Kaluw ' 1'oran9eA.nde 6rtmul•anpeu der Almanprwp.e: Niokt hek.hnt. Alixi.rAe Diagnose: DronahWc.rniaam. ' . 14. 60/38. C. R., Makrmeirter, 36 Jahn. • Extn:uer R.ucher: 16 Bruilsig.rnn pro 7%8. (Einamal Nlaotin.ergf/tung•) 8oxslipe daJere 8iswirlva9en auJ die Alemrrpt: R. ha hY wr 1t/r J.hren . .ueh mit Bkifarben go.rbeitet. 1'unnqe6ende Erbaa4anpen der Aimaxpaprn4: NickO Imkamt , /iifnische Diapnas:. Brunehl.learcimm. . , . ~ . . 13. 180138. P. W., Dekonteur, 63 Jahn. -. Extremer Rsndwr: 30-40 ZiBarattan kgiieh; teltweier 60 Zig.nttew' SonRig< daQere SisuurRuepes au/ die Alemwpe: Keiw. I'auxgedewle Srkrankunpex der Alsmnd.urpane: Iu der ~Atvmrwn' daht rrnxerkt. G/ixi¢de Diaynaae: Bmnchitleuolnom der linknn LunBe•, 14. 941/35. J. A, hober Stanhbeamter, 36 Jahre. . Exue:ner R.ucher: Durc(faehnittlidt 35 Zi®..etfen pm 11tg.. `Buxwiqs dnjtere Binwirkunyes my d'w ANmrstde: Ktin.. ZAnemnt Idr inblwshur• tr• 34. Vuunyrhr.d 3rbmtlmtys der AOns.Pmrynne: Ottet. R4uoherk.ttn6. Klini.rAe Diaynosr: Bronehi.lwmNom 1m linhen Lungsaunterl.ppen, 15. 40/a7. A. Sob., Met.Bermeiaar. . . B:tmmer R.uehm: 10 Zig.rron (echwere 8arte) tlg8ch, .u6mdem Zipuettm and P[eite. Smutip du)irre L•imoi.duxpew as/ dir Atewewps: F.a tkgliah Sobweklddmpb . and R.nch wdhmrd der Au.6bmtg der Metagsrhardwerkea Varawpehnde Srlmnkuwpen der Adwanysorpana: Niakt bek.mt VauwpeAo:dri Trauxm:. Var 10 Jabren Rippenbruah linlu. . Kliwieata Diapxwe: Branchl.kvcimm der linken Lmye. 16. 496f 88. 1. D., Kanmklui• i. R., 71 Jahm. Rxhemer R.raher:.Rtwa 3-rl mitfekmhwars Zig.nm umd mlode.fm 60d T.b.k ikgPGOh bir anm•66. Iwb"jabn, ~deawh naek mehr+ bitweiMa bat ee die g.n.e Nncht hindnrch ga<suobt. . 8a.d:ys dr6fre Kisroirkunqas nY/ dfs Akmtnqe: „purek dxa ride Skavpielmo, 7mbei et.rk gerxucht nurde, war D. tiQlich .inilpe BNmtlm der verqn.lmten Iaft amgmtst." (Nach AnB.beo- der Rhefrw.) . Yonnprkende 6rlraskunpn der AOn.npmrynns: In der Ao.mrer sicht Varmmerkt. Awam:si.rL Diaynose: Brmtaki.lavdrwm der lioken Lungo, 17. 780/33. (B.. B., W@t, 89 J.hm: - . Rxtnmer Reachnr. (Oen.ue AoBaben rind niaht vorh.nden.) Sonpipe duRere Kiwm:rkunpes auJ die Atemweye: Dauerndm Aubntiai in r.uehigen Riumen, d.ber atfadige. Ein.tmen ran T.b.knuuh. Vmnnpekende Brbasl.npew-der Atmanyewps: In der An.mnw nlaht .eemarkt. . Analemira4 Diatxare: Bronebi.lwreinom.drr Snkm Lnn®n, . Nitn.koVbnter Bs/and:.Cw tol:6um. . 18. 1087/96. A. U., Inrt.ILteur, 68 J.hre. Ratremer R.uchnr. (Oeruue Ang.ben sind alobt vorh.udmi.) . .@osrt:pe ds/fwe Binwirkunpnr au/ di. Alamwepe: BleirWrb u. n. VwnnprJteads P,rlranlunpsw der Aimw.pmrpsne; In der Anamnern niobt .mmerkt _ AnaMmiwAs Diay.ase: Bianohi.lc.rainpm dp lioken Lunge. . Mikrarbopi.cMr Bos.d: (7.. ralidum. . 10. 617/38. J. M., Zollmluatdr, 46 Jabn. ~ Ratmmcr R.aaher: Tiglieb 8 Zig.nen pder 80 Zig•eetten and in S Tnge. . 100 g Plcifent.bak. ., 6mt.Nye anpere Sinteirhanpen nw/ die AMmwps: MuSte dianrtlfnh 8 J.hm lang bci jeder Witterung td6liob 48tanelen Motorrad /alunn. - Vcoanpekende &rLrankanpm der Aixwngwapnse: In der An.mners niaht earmcrkt.' • Analomi4rAe Diaynwei Gminom des linken Hwptbronchu.. 20. 900%J7. . J. O., K.nfnum, 52 Jabre, . E:tnmer Rarcher: 10 Zi®armn and e Zigaretten tigliob. 8anelipe daflers Kiawirkanpan as/' die Atemuxye: Iteiue. ' Vaaxyehende Srlvnwlsye:e der Abn.nyanrpune: 6eit 1015/1916 Ytgeblich. Iwugenbiden; hat var 6 J.bten aum emten Malt Blut .n.®eLutlot.- AnalomieddaDisOaom; Hiiunabes Brwtohi.lsreinom det mchten Obml.ppenr, Alibodoolt.rA.r Br/.ndr Cti .didum... . ictEZ969Z00T

280 CIOABE7TE LABELING AND ADVERTISING 21. 1802J98. F. T., Naurer, 57 Jabre, ' Earemor Rancher: 10 Ziganen tigliob and 100 g'Tabek in; der Waobs. 8oue(pe duQers Binuirkr:npew aeJ die. A/emrorqe: NGllt,, md ZementManb •khrend der Tktigkeit ala Manmr. ` ~ _ Voraupdende Brkru.ku.yes der AMweprmyone: In der Aoamnese oiokt~ nm:rrkt Vore.yeke.du Tes.w:. 1033 .,Lwgenri0•• naoh Iieben e3per achweren Laf. XliNi.cA6 Diapeom: Bronchialqrok:em dnr recbten I.pnge.'.. . 22. 1060135. W. W., Klempner, Denhdeeker und Inmallateur, 87 Jabm.. , lixtremer Raucber: 90 g T.bek nnd 2-3 gtnmpen sm 1Lg.: : 8o.etiye dupers Sinwirkuapm as/ die Akmuepe: „W. war bie kue= aur eeioem Tode ait Klempner. IMehdeeker und InstaUateur tatig. Bele IAt<n der Daeh- . nanen war ee o[t t.geleng in den Dkomp[en t[tig, die durch dae Verduruten der 9ebrure entet.nden. In den bei8en 8ommermoruten hat er oft woebenlang Iqobrr geteert:•• (N.eb Ang.ben der FamiliemnWeh6ngpp ). - 1'oranpetende Brknaalwapm derAlm.:iQ.orpawa.• Iliokk beknmt ' . Aaalomiw•At Diapnase: areinom der Tnehea und der Bmnohien in Hehe der Bgurkanon. Einwacham in den reebten Obm• aod Hittellappen dee Lunge.. ~ ,Vihoebopitater 8e/aad: a. scOdum. - . 23. 40/H8. R. H., Ktlohenchef, 63 Jahm. Extremer R.ucher: 0-8 73germo md 16-40 Zigaretteh Hglicb. . . 6'oeeMipe dupere Siwmirkrnyen ou/ die Ala.wep: Keios• 1'oranpekends Srknnkrwpen der Atrampeoryas:. In der Admrom nioht •Rnwrkt ' ' . Axolomierke Diapuom: BmneHekeroimm 1ni .ecbten'Longena6eryppen. ~. 24. 1250/38. J. W.. Lternenwkrter, 56 Jab:e. ' Extremcr Raueher: g0-80 g Pteilsotabak tagliah. $orelipt A.pere Xiwuirkr:spen wt/ die Ah.rwep{:'Keine. 1'aeupekrnds Xrkrsak.npae der Amrnqsoryase: Neeh de& Kritge Rippentdl• eetiendung. . - ' Ata/owirAe Diapnws: Braoahialmrdnom derr reebten Langs. YS. 796/70. J. W., Hetellerhe8er, 63 J.hm. Extremer Rwc6er: Etwa 60 g Pfnikmtebak prn T.g, an8erdem Zipnm. Noneliye dnasrs /Nauvknepen ae/ die elnnuqt: Yetalln.nb. da .m Bern[ )k•tsll.rbriter. ' .. -. I'ow.:pekoeds Prkionknqew der Afwrxrprpani: In.dar jWmneas nkhi I'ornuyekewda Traww: 2 Jabn ante uitum AOtoun611. . . .1NatowinLe Diapaos:. Beweeh}akemioom dereeobten Lmgs.,: B. Starke Ranaher..: . "0. 1d9Y/79. J. &. Angertellta. 63 Jalne. . . . ~. ~:.. .. - hchr starker Reucher: 60 g Tabak tagOch. ~' do.Mipe dufiere Biwrrirken9en se/ die Akmnrys:'Keins.: g. hklR akk wehmnd drr Ikrnfmue8bung in DOrorkumen tuf. ~ ' 1'.na.gekeude Srkra.kr.per dn A/menpqyaaa! Nioht bekamt' . Xli:eierke Diapnnis: Dronchislmreinmm der reekfen Iwnge•'.: s ."% Y07/97. U. B., Pabrikant .. . &•hr starker Rancher: 8-10 Zigtrran pro Tag.. do"wi9s d.pere Biaerirke.pew ai:l dis AMmeryt: Ke41e.. - • . sEZSSSZOOt CHiA1tE7TE LABELING AND ADVERTISING , 281 Vors.pekede 6rkrmlkm:p:rder AMw»pmrpans: NbM bekermt Xliwieule Diopnorl: Bronotdelatraioom. 48. 8/Y9. J. Ii., Oberpaboha(twr. gf Jahre. Sehr starker Rauchari 40-SO Zigamtten taglioh. . 8oeeti9a da/kre 6iw:eirksapte au/ die Atawu¢po:-Keine. Vomnpeksrde Srkraekaapew der Afwurpmrpaae: Nicht bekannt. Anneomi.cAeDiapnup:-areinom dm lidten Hauptbeunchue. 29. 58/36. W: K.. Angastallter einer Wettennabme. OS Jahn. 'gohr starker Atucher.on Zigaenn und Pleitontabak. (Oenaw Angehen eind nicht vorhudan.) . 8oxrtiye dr/kn Biaurirkenpew ae/ die Aumurys~- Btindigae Eia.tmpr .ae Tabakdunst, de d.uarnder Autenthalt in nwhigen liiuman. Yoranpeksndc Srkrawku.pm der. Atmnpeerpawe: Nioht bekannt Anolo.i.dAe Diapeoee: areiwm dm linken Ilanptbronohua x;r;wkoptiqAer eeknd: a. aolid'um. . 30. 844/90. H. F., Obexinepektor. 66 Jahm. . Sohr starker Raucher: Zigansn und vie) Plaitentabek bie sum Begim der IIrankhei6. (Znldenmagige Ar:g.ben kOnoar nieht mehr gemaeht werddn.) ' BonMipe dupers 8imoirkunpea a./ die Atswwepe: Keine. Vomeptkeedt Srkraak.+WFs der Alwnapwryewe: Nicht beksnnt Awabwirla Dispsore.~n arcinom dee rechten Hauptbmeebw. ' 31. 10Y4/87. P. Soh.,'t5rieeur, 59 Jabre. gohr starker Rewher: Taglich mindmtew 80.Zlgarettann bie sum 6g.Iebem• jahrs, duuah Ii0-g0 Zigecllbe pro Wooba . 6enYipe duQerc 6inurirkungen enJ die Aremuxpt: Keine. Vmuapebade Yrkm.keupew der A/mnnporpr: In dee Am:mnma n:oM .mmeikt AnwomirAe Diap.oae: arainom im IWmn Uutqasobechppen. Nikrorkopi"er B./sad: C+• .olidum.. 32. 947/37. K. H.. Oberpoetmkmter, 88 Jahrer gehr starker Renobm mi4 dem 14. Lbaoelakm. .(Kdoe nhbsre Anpbm moglich.) 6anMiys dnpaeBinwirtrwpen ar/ die Atewee9s: Uagen dnen Ober 10 J.hre beNehenden e6arken Hnsten inhagerte or Terpentin. • Vorarpekewd. Xrkrrnkun9m dm Atmung.orgem: 8ait 10-12 Jahme ants e:itum immer starker sunehmender Hueten. Asaromiuke. Diapnoee: Autgadebutm l.ungenomoinom im linken obeme NlUeueld. . 33. 1910(97. F. W. Z., 1Mmur. 70 Jahm. ' Bohr starker Rancher (genaw AnQaben kennen niaht mahr pmwht werdon). 8oeetipe euAere Siwroirkmyte an/ die AhmwQa• Kelw. Vomspekanda Brkrarkrnpen der Almanytorya.e 8elt 19 Jabrrin weran die ' Atemwege atindig .erecldeimt. Aeeaenaiw.ke Diopwora' WalnuUgroOet Oareirom der reehten Lange, sub• pleural im obemn Teil doa Untsrl.ppew golegen. Jfikraekopi.rAo Be(sad: a. aolidum. . 34. 609/9t. H. P:.'Km/tlabror. 52 Jahre. ' - Rehr starker Rarchw: 8 Zigaeran und mindeNena 20 Zigwettsn tigliah. Hin und wieder tuoY Pidte. . . . . . I I

282 f10ARETTE LABELING AND ADVERTISING 8onsl7pe aupps BimoirFv.yea aa/ die Afammye: sutogaee, da .on Beruf IfrefUohrer. 1'oranyeA<nde Erkranl.:wpen der ApnnnPaoryane: 11104 starker Huaeo, 1928 - Grippe nnd Lungencntaundung. Anafmmieale' Diapaoee: Bmnohialenteinam der reuhten Lunge, 35. 1/38. H. M., Kaufmann, 69 Jahm. Behr starker Raucher: Voan 17. bin 25. IebenjaLra 30 Zigamtten t6gli* uit dem 25. Lebenejehm 8-10 Zigarmn; wkhrend des Knogdiemdea mehr• 8ondipe aupen Einanrhnnpen au/ die Ahn.anps: Keme• . 1'omngeaenrh 6r4raaknnpea der Adnn:eproryana: Nieht bekannt• : til:nische Diapeoee: Bronchidcereinom. .' 36. 470/33. H. Z.. 48 Jehrn, Kaufm.nn. . Urhr starker Rancher: T3glich 25 Zigaletlea RonNige aupen Einwirkwnpew aa/ die A/enifrrpaaKeine. I'eranyeAende 6rkraxkrn/m dsr Alwenqeorymu: Niebt bekannt,~ Annfom:aeAs D{upnoee: Bronchialearoinom an derBihrkation in dm reohten . Lun{lenoberlnppon hincinwsoheend. . . 37. 16E138. J. R., gehln.sser,. 58 Jahre. . . h-hr starker Reucher. (Keine nkhers Angnban vorhanded.)- Vondiye anpere Einarirkrnpen awj d'u Atemaspe: Rt war rott 1918-1936 im , Wrrk Levarckuseon tAtig. Er war in der InalallationewerkstatR der. Buchbinderei. IICpMturecbkwatoi, Pholoableilung, dem Bnubetrieb, der Hotreinigung und drm )hdicinallager naeheinender besehlftigt. 11131 wer er 9 Monnte im Arn• 'Verln•nhctricb n1e 8ehloeeer, .wnt atets In nichtchemiec6en Betrieben fttig. I'omngrAende 6rCmnkanpen der Afmnnyeorprae: Mit 8 urd 46 Jakren Lnngen- rnlriindung mchte, 6fteo HnkentsOndungen. - AnmurnirrAe Diaynows: flvcinom des .eahtmr unteren Hwptbrnnehua. 38. 328J28. B. W., Lehrer, 66 Jnhre. ' ;~ . l4~hr starker Reucher: Tagliah 3-5 Zigarren oder mindeatena 20 Zigamttes rmn 10. Lcbensjahre &b. 8onefipe dnpere Einuri.kunpsn aa/ die Afanwepe: „W. spielte .on Jugend an whr oft Karten.Dabci wurde eo gereueht, da0 es Im Zimmer muwbmal gena dnnkrl su®nh.•' (Nach Angnben dm Ebefrw.) ' I'emnyeAende ,BrkmtJampen'dar Atwnngeorpaaa Im Krfeg Bronchitie, oft Bnn,•binikatnrrh, . I'omnyeAendes Traama: 1016 „Rippenquetechung mit Blutergu9 links". .AaolowierAe Diagnose: Grcitqm dn mobten Uaterb.ppenhaupthronohua.. 30. apf/3g• F. N., Mawhintn.cAkr.ar, 39 Jabm. 8rhr starker Rnaeher: 10 Ziganen t6glleh. D'onqipe dnpere Eiatoirtenpen ar/ die Alemiepe: Nicbt bek.nnt, , 1'onrnprAende irlrent.nyea der A/nrungsorpau: In der Anamoae nicht vrnm•rkt. . . . .leofaa,ied4 Diap.oee: HmnahialmreDmm eiaae Aette ds reohtm' Langen- vlrrhplntu• ..Vi1•rodupiselsr Bs/uad: C., aolklum. 40. 170/33. A• A., Zimmermann, 60 Jnhm. tFbr rlerkei Rancher: R.uchte dauend hei der Arbeft• . Wm.Nge anpers EinnirLvnpan ar/ die A/emurpe: Holsntw6: , 1•omnyrFemle Eraranlxngen der Atmnwgroryane: F46bm oft Brunahiti4 '. .inaronierke Diagnor: C.rcinan des linken HwptMatah.a ; CIOARETTE LABELING AND ADVERTISING 283 41. !4g/36. A. Mo Bteinluuer, 66.Jahn. 9ehr starker Rancher; 30-60 g Pfeitentabak am Tag. . BonMipe anpere Eiwrr'wkr+ypu an/-die Alemtaepc: Ja, bei gteinbruohubeitsa : um1 beim Drnnnenbeu. Voma9tAende SrkraaLwapen der Atmwng.onpae: Mit 35 Jnhmn Rippenfel4 : enta6ndung. . . Aaem,eieahe Diagnose: Chmnieoh-indurimsnde Lungentuberkulore mit Anthre• kpe und verhorntem P6tlempithela.rcinom in efner Kireme. . 42. 25/37. B• 8eh., 81 Jebm, Invalids. Schr starker Raucher: 250 g Tsbak pm Wooke. Sonefipe anpen 6inarirlaaptn anf die Atemmepe: Nicht bekennt. 1'nrougehende., Erhanlvngrn der Afwun9sarpaae: In der Anmmaeee niebt ter_merki. KfiniseAr Diapnose: Bmnebialcucinom. 43. 1083/34. W. R•, Invalids, 68 Yabm. ' Behr starker Raudmr: Zigwetten in der Jugend, Liemuf Pfeife wd .uktn Zig.rron. (Zahlen k6nnen nicht engegeben wardun.) . 8onqips anpere Rinroirkrnpaa artJ die A/rwwyr: Nicht 6ekannt. VaronpeAends B.Isank.nlen dar Al.rwpsnrpawe: Die I.uogea shul eohen roa Jngend an „aahwwb" gnrmen; dnher mu9ts der Bemf ala 8teinmeta frubraitig aufgegeben werden. . . Anafon.ierAe Diayaaaer Broaoki.loareinam im mebten Oberlappen. YiEro.lopiKAu Be/rnd: O.. medullem• '. 44. 6J38. A. W., Ma.ohinen.ohkreer. 60 Jahm, Starker Rancher: 6 Zignrren und 200 g Tabnk Wmrhalb eiror Woche• 8oaetipe arparo 8iauirkrnpea on/ die Alnwrepe: Nioht bokannt• VoranpeAeade A'01banlwwpew dn' A/mnnpsorgawe: Nicht bek.ent.. Analawi.rae Diaynorc: BronehWwralnao im Bemichs d.ee linken unfeee . Braochus, - ; . 45. 88/29. M. B:, &isengie0ar, ap6ler Alth6ndlec, 33 Jahm. Starker R.ucher: 2P-26 Zigaretten tlglioh. SonNipe anpere 8iaarirlwapew aw/ dis Atenrax'.: R,auoh und Uamp/e hei da . Bisengic9aei. VorawpeAeade &rkrawlrnpen der A/mun9eorpane: B, hatte afob im Krieg dm Oeswergiftung augerogen and mit dieser Zeit immer gebuetet. (Naoh Augahn; der Ebofmu.) ' AnafaniscM Diagnoee:.Braaqhi.laarainom Im taokteo L.rngmabarbpp^'t : 46. 705131. J. H., Montenr, 46 Jnhn. . . ' Starker R.noher: 20 Zigemtten t6gliob. 8oeeeige drpere 8inarirknnpen ar/ die Atemuepe: Nfeht bokannt. Vora.paw cnde Brt'rualrnpan dr Ahemqrorpwe: S Jahm nnte exitum „Lu)t - rahmnents9ndung,• Ana/onrisrkt Diapaom: Bronohiakwninum doe 1{nkeo Longeooborleppene• A(:krwtopierAer De/nnd: Platenepithelcararmm. . 47. 1378/36. A. W., Anatmieher, aptmr KeDuer, 83 Jehm. Starker Rauclmr; 6-6 Zi6.nen em Tag. Ab and au Pkila . 8mulige drpere BiawirFrnpen as/ die Alsmwprr Zigmettendunst in den Ora• wirlechnftnn, in danen er eich ffmgem Zeft ala Kellnsr beNtigte. Farhen (Bkf tarben u...) im AoatreicheehmuL . sCzssszooi

CIGARETTE LABELING AND ADVERTISING 1 CIGARETTE LABELING AND ADVERTISING 285 284 Voraayehexde Erkrankuxpen der Ahnaxptarpune: In der AnmmZMte dokt rermerkt. Axa/masrAc Diapnan: Droachi.lmraioom im MitAelgauho0 dee r.eYhs 4mge. .vilmekapisrAer Be/und: Ca. aolidum. ' 48. 22l/36. H. L.. Duchdruaker, 69 Jabre. '' Starker Itaucher von Jugend .n. SonrHge m.Rtn Eimsirkxnyen awl die Alsmwepe: Bkdetaub. L hat 30 Jabrs hng nn der Ratationsmaschino gearboiteG 1908 Bleivergiltung. 1'ornnpeAende Erkronknngen der A/manQprpana.: Niokft bekaunt. ~Arm/oruiache Diagnose: Bronchialcarcinom der linknn Lunge. Jl il•roaknpierAtr Be/und: Platteaepitbelcaninom, 46. 451/36. P. L, Invalidq 77 Jahre. Rtnrkcr Raucher: 6-7 Zigannn N.glicb. Nouefiye uuperc Eiwurirkwnpen awl die Alemoepe: Nicht bekanut. ~1'o.angrAen,k &rlmxkvn6en ikr Atmuapsorpant: In den ktsten J.hnn im NSnler regclmu6ig et.rkor Hueten. . KGuiecAe Diapxave: Hronahiale.reinom~ der reubfeu Lunge: . 50. 563/28. W. F., Fubrunterne6mer. - Starker Rauc6er: 5 Zigarreu taglie6 oder Plef(e. Sonrtige dupen Eix.rirkuapex au/ di< Alemx,e9c: Reine. • 1'o.enyrAem4 6rkroxkunpen der Almuxprorpas: Niaht bekannt.: AxamwiseAe Diapnnre: ltronehi.lnrokmm im nchteo Lungmobarl.ppeo. 51. 2/38. M. V., Agent, 69 J.hm. . Btarker Raucher hir.:um 55. Lebentj.hroM d.oaeh m691ger B.neher. Sonetiqe 4apere Einmirkwxpex ou/ die Akmwrya• „V. mugte als Angmtallter am'l7irekr in achioehler und tNubbaltiger Lolt aeinen Bnruf nut9bea" (Nach AnFmlm: der Ehefrau.) . . . . I'onuyekende Erkroakrnpen dw Ahnrnpeorpoaa: In det• An.mmee' uMht rernwrkt. - .{nn/omiache Diayaam: Beanuhulaaminopt der llukaa Lunga. . 52. 56/38. P. Sc6., Raufnann, 66 Jahre. . . ' 8tarka< Raueher: 2gDg Tabak in der Woohe. Soxqige du/kn 8:ntoirkrxyen au/ die Aranmpr: 7l;.LLatauh belm Umbau (1'Mltenkgcn) van Wohnungon. I'umnprAcxde Erkrank.npmt dar Alxwpeargex.: Io der An.maer niaht •ermrrkt. . . . Klixiarke Dqpnore: BronahWe.raim®. . .63. 135131. R. H., f9ohuhmaeher, 60 Jahm. ,, Ktnrker Rauclmr: Rtwa 67.igunn tagllah. Wmafi6e 4xPere Einruirkxxpnt awl die Areuxrpe: 8tarb,.6lueud dar46 Jihrig® Tldi4kit a1e 8c6uhmachor. ' 1'wnw~ekex~fa-ErWankunpea der Atneuno.orPsne: Nicht bek.adh '.. ' KlixfecAe Diapnon: Bmaahi.laarairwm. , -.. . . 154. Tg7/31. A&, Taufobwffeur, 63 Jnhm. .. Iharkcr Rauchm: 12-15 Ziguattan and 1-2 Zig.rmn Hglick. . Nuxnriye dxaen Bixwirk+xpew au/ die Alemnepa: Autngam: 1'om,.ydam(e ErknnLrmpnt der AhwMmr9aae: Nicht hekaont....; . .anaru,xier4e Diapxarst 1lcaooWnluroinom da linken I.unpnunt.rlappeM. oVzssszooi 65. 63136. M. M., Arbeiter in einer Bkiwei9fabrik, 60 Jahre. Starker Itaucher: 15 Zigarettan pro Tag. Sonetiyc Lu(tere Eimuirlvnyen au/ die AWnwepe:. Bleietaub, wlthrend der Tiitig- kait .le Arbeiter in eincr Blciwei6fobrik. VoranpeAenda Erkrankungen dtr Atrnunprorpane: Nicht bekannt. Anatomiaede Diapnoee: Bronchialcaminom •des reehten oboren Bronchua. 56. 247/38. 31. A., Agent, 53 Jahm. Starker ltauchcr: 5 Zigarren t:glich und 30 g Tabak pro Wocha Sonetiye riu/lere Einwirkunpen au/ die AkmunPe.• Keine. Voranpe5ende Erkmnkunpen der Atmunpeorpaat: IEeine. KRniecht Diapnon: Bronchialcaninom. C. 61i0itro Ltnneher uud Nlchtfsuchcr. b7. 691/36. F. Sch., Furbcr, 48 Jahre. ' Mu6iger Rwicher: 10 Zigarren und ein Paket Tabak in der Wocbe, kein - Lungenraucher. Sonalipe §upere Eixwirlanpen awl (Iie A/emwepe: Anilindampfe heim Farben and Reinigen von KlcidungeetiYcken. -(Naeh Angaben der Ehefrau.) Vorunpekende Erkrankunpen der ,Atmunpaurpane: Niebt bekannt. Anu/o,niecAe Diaynore: IUeiuap/clgro0ei Bronchulcarcinom im linken Ober- lappen nabe dem Hilue. . 68. 1101/29. TI. M., Anrtroieher, 53 Jalue. Mi6iger Raucher: Wenig Zigarren. - Somutige aupere Einwbkunpen awl die Aeemuwye: Farben (Bleifarban!). Vorunqehemle Erkrankun6en der Atxrunpeorpaxe: Nicht bekannt. AnatorniccAe Diapnaec: Bronchialeaninoat im rechten Lungenunterlappen. ' 60. 226/31. J. 0., Ansttroicher, 61 Jahre. MuBigcr Itoucher: 2 'Ligarren tuglicb. Soxatipe dujlers ~rxmirluxpen an/ dic Aten,wepe: Farben (Bleifarben!). Vorunpehende Erkraxlvnpen der AtxmMnpeprpane: In der Anamnrae nickt . vecmerkt. ' . AnatomiuAe Diapnose: BronchiRkarcinorn der linken Lunge. 60. 636/37. H. E., Anetreicher, 64 Jahre. ~ Ala9igcr Raudrr: 100 g Pfcifentabah and 2 Zigarmn in der Wocbe bie sum 50. Lclwuejuhre; danue6etwa die Halite. Smwtipe 4r.pere Einurirkungex aa/ die Atnnuvpe: Farben (Bleilarbonl). Vomn6e4ende Erkrankaxyen der A/muxpeorpane: Nicht bekannt. . ' Anatomiacke Diagnose: Bronchialcaninom dea raehten Hauptbrarchua. AfikroekopierAer Bc/umi: C~ aolidum. ' 61. 10g/38, W. R., An.lmicher. 43 Jahra MaBiger Rauchcr. ' Sontlips dupen Eiuwirkunpea awl die Atemweye: Farban (Bleifarben!). VoranpeAemle Erkrankungen der Atmunpeorpane: In der Anunnme niehl vermcrkt ' Klixiseke D'wQnoet: Dronchialaareinom. 62. 332/32. P. R.,Arboiter in einer Farbenfabrik, 60 Jahre. Me9iger Raucher: Woehentlich ein Pakct Tabak (25 g). ' Sonafige dvaere Eiwwirkunpex auf die Atemueeqe: Parben (Bluiier6on!). VorunqeAende Erkrankanpex der'A/muxysorpene: Nieht bekaMt. AnafonriecAe Dioplwar. Bronehialcareinom dea linken Lunbronoberlappen, 15-979 0-65-pt 2-19

286 CI6ARIiTTE LABELING AND ADVERTISING I CIpARETTE LABELING AND ADVERTIRINO• 287 63. 142/32. F. M., Fabrikarbeiter. 64 Jahro. ~ )lA6iger Raucher; 100 g Pfeifentnbak in der Woebe. Sovenpe dupere &inanrkunpen am/ die A/emuvge: M. hat 15 Jahre lang am llkiofen gcarbeitet; wihrend diener Zeit 3ma1 Bleivergiftung. 1'orrtnyeAende Srkra*k.wnpen der Atmunl7sorpana: 1918 Orippe.. - AnatomieeAe Diapnore: Rronchialeareinom der recbten Lungenoberlnppnq. Vikroekopircker Be/wnd: Adenoearuinom. lN. 736/32. A. F., Seolierer, 62 Jahm. alt8iger Rsucher: 50 g Pfeifentabek and 6 Zigaaen pro Woche. Suxetipe uufkre &inmirkunpex au/ die Alemeorqe: Teerdkmp/e. t'orangeAemle Brkrankunpen der Atmunprapana: Nicht bekannt. , .4natmniecke Diaprwe: Bronchialcaroinom. dfihoekapietk<r Be/rnd: Ca. eolidum. 65. 14/35. L. R., Ilrahtweber, 40 J.hre. . .• 1 . MaBiger Raucher: 6 Zigwetten tiglich: Sonetige daQere Binmirknnpen au/ die Afenmepe: Nieht nkher bckanat. I'nmupekende Ahkrunkunpen der Atmnnpeurpant: Grippe. .anurmnixhe Diagnose: Bronehialcarcinom der llnken Lunge. ' lai. 1144129. J. 8ch., Drahtweber, 34 Jahre. )1a9i6rer Raucher: 6-8 Zigaretten tdglich bie sum Begina der Erkrankung.. Xonefiye 6u/ere Binmirkungen au/ d1e Atemnocqe: „Meralbtaub nnd Olduurt eBhm:ul der Aueubung dee Handwerlu ale Dmhtweber." (Naeb Angaben der lihahau.) - I'ornugrAtndes Traanra: Im Krieg Vertchhttung. I'omnpehendc &rkmnkunpen der Ahnrnpmryane: Niebt bekannt. .Inufomiccke Diapnase: BronChlalcarcinom der linken Lunge. 47. 874/31. O. H., Metallechlelfer, 65 Jahm. ' }1RBibrer Raucher: 60 g Pfeifentabak pre Wache, 3--6 Zigarren eaontagr. •vonqige aupcrr Einroirkanpen aw/ die AtereueQe: MetuDataub, da von Berut V.inllnrbcitcr. ' I'urnnprhenk Erkmnkungen der Atmmnpeeryane: NLcht 6ekann6 ' :Ixnlomiecke Diaynnae: Bronchialearcinom dee linken Lungenoberlappene. .tlikroekopierAer Be/nnd: Plattenepithelosrcinom. n`I. 711/35. P. K., Heir.er, 55 Jahre. Mneiger Raucher: 8oantaga end in der Woebe manobmal elne Zigam. Soxefipe audert Binwirkanpsn an/ dia AMnuupe: Nieht bekannk 1'umngekrmk Erkrankmpen der Annanpeorpuno: In der An.mnr.a nicht YCn11Mtt. /:lieierke Diapnose: Bronebialoaroinom des linken Lungennnterlappem. un. 081/34. O. D., Uhrmauher, 67 Jahre. 11;f8iecr Raucher: 3-4 Pteifen und 2 Ziguven am Tag. •c.1ndiye drffere A'inurirkungen au/ die Atsnrrwpe: Nicht bekannt. I'lunn,/ekende 6rkrunknnpen der Atmnnpempane: Nicht bekannt. :Ixnfnxlisrke Diapnose: Qaruinom dea reohten Hanptbronohua. , Mikm..kopiteker Be/.nd: C.a. rolidum. 7n. 746129. T. A., Werknaiater, 66 Jahre. NaBipcr Itapcher: 2 Zigarron, 2-3 P/eifen un Tag. Son.,(ig< dutlere Biawirkwnpen ar/ dia Atenwqp: Nicht bekannF 1'onrnyrkexde 8rkmnkunpen der A/rnungeorpane: Nicht beWnnt. .4n.dornierke Diapnae: Cardnom des linken Hauptbmnebus. 1 1 1 71. 427/33. R.1L, Bnhreiner, 59 Jahrw. . Msgiger Raucher: 3-4 Pfeifen odor 3 Zigvron ttglich. BOne{i9e dnpC1! Rinleirknn9en so/ die Atenawpe: Hohntaub, de von Barrf ek+hreiner. Hat im Krieg 2 Jatire lang im Unterafaod gelebt. Reit dieaer Zeit d'e enten Atembeechworden. . Vornnpckcnde Erkrankunpen der Ahnnnpeurpnna: In der Anamne.e niohl vermerkt. AnalaniecAe Diapxoee: Carcinom des rechteo Hanpthrnnahua. Mikrorkopiseker Be/nnd: Plattenepitbelearuinom. 72. 499/26. P. W., Zimmermann, 65 Jabro. - MS6iger Raucher. . Sametipc aupere Binwirkunpen an/ die Afenuype: Holutaub. Voranprkrnde &rkmnkanpen der AfwnnQaurpana: Mit 24 Jahren Lungea ent.endung. 22 Jahn apiter etien6Da. 17 Jahn ep6ter eeneut, 1 Jahr daead Grippe. Ana/omiwAe Diapnoee: Brmchial0ielnomm dea liuken Oberlappena. 73. 304/33. J. Qu., Kaufmann, 66 Jahre. Mieiger Raucher: I Zigarre tagBoh und 50 g Tabak wAohentBeb. Bonsripe duQen Binutirkxngsn an/ die A/ernunpe: Keine. Vora>yeAcnds Erkrankrnpan der Atmrnpearpone: Ninht bekannt. Anatomiscks Diapnoee: Bronchialcareinom der reohteu Lunge. Mikroekopienler Be/und: q. tolidum. 74. 182136. H. K., Arbeiter, 50 Jahre. M49iger'Reuuher: 8anetipe duQerc 6inutirkntyen au/ die Alnnwpe: Nioht hekannt. VoranpeAende &rkranhnpen der A/mmnnpearpnne:.1917 „Lungenepitrenkatarrh", 1925 Lungen- und Rippenfelk3nta0ndung. Vurangeksnde Truumen: 1916 Vereeh6ttung, an.ohlie9end Blut.turs. 1917 abermalige Venohhttung, emeut Blutatura. f9eit der enten VenohBttung immn Kursatmigkeit. AnaromiecAe Uiupwee: Bmnchiacarcinom Im reobten Lungenunterlappen 75. 435/35. F. K.. Kaufm.nn, 49 Jahre. M86iger Rauchcr: 5-g Zigaretlen pro Tag, 3 Zigarron in der Woehe. Sonelipe drQere Binulirknnpen au/ die Ateurunpe: Keine. ' VuranpeAende Brkrankuwgen der Atmnny.orpane: Nieht bekannt, Anatomiecke Diagaaee: (:arcinom des rechten Hwptbronckus. 76. 1384/36. Eh. B., $tn.6enbahner, 57 Jnhm. Mlgigar Rauoher. 8onetige drpere Biawirkunpen aw/ die Ateauup<: Nicht bekuint. VamnprAeede 6rkrunkxnpsn der A/mnnysorgane: In der AnamneR nicN vermerkt. Anatumiscke Diagnwe: Bronebialoeroinom im linken Lungenunterlappen. 77. 1396/37. J. R., Metallhohrer, 71 J.hre. Ma9iger Raucher: 1-2 Pleifen Ngllch, 1-2 Zigareen eonntage. 8nna/ige aupere &inwirkanssn au/ die A/emmps: „R. war 17 Jabre lang al' Bohrer t9tig. In diaeer Eigenechaft hatte er folgonde Metalle su verarbeiten: Rotgu9, Meering, OuBeieen und Stahlbleche. Inbalatimum6ghchkeit von )tetsll. eVub iet bei Rotgu6 und Meesing, welche einen geringen PronenWtz von BF. enthalicn, gegeben." (Erkundigungen an der Arbeitwtelle.) Zvz9sszooZ

288 CIGARETTE LABELING AND ADVERTISING I CIGARETTE LABELING AND ADVERTISING 289 I' i VomnprAsnde &rkvanlvnpea de. Atmmumpsorpane: In der Anemnese nicht ewmerkt. Ifhnieehe Diapnwe: Bmnchialcareinom der linken Lunge. 78. 1310/37. H. M., Packer, 48 Jahre. \IAOiger Rancher: Tiglieh nur wenige Zigaretkn. 8onaripe ,tuillere k'inunikungen as/ die Atemuqre: Staub, 8ohatk Aaehe, (Wae rim, 7.cit lang Arbeiter bei der 8chuttabfuhr.) . 1'omnyehcrvle.Brkrankvnpen der Abnrnp.orpawe: Im Krieg Bronchitis. Annfmniecke Diagnose: Bronehialcarcinom der rechten Lunge, AfiLroskopierher Be/vnd: Ca. eulidum. 79. 75g/32. W. 8., Eieenbahneg 45 Jabrn. )lit6ihmr Rnucher: 6-10 Zigaretten am Tag. Sonstipe MuQern Einurirkungen atu/ die A/emvepe: Niebt bekamt. 1'ornngeAende Brkraakangen der Atmwrpewpane: In dekt ArumrMae tticht rrnoorkt. F'omnyekendee Travma: 2 Jahro.nte e:itam Unfall mit HS.ktur von 6 Rippen. Seub dnn Unfall 2-3mal blutiger Auawurf. .Iwntonrische Diapnore: Bronchialcaminom der linken Lunge. :VikroskoyierAer Be/nad: Arlenwardnom. 80. 331/38. A. Z., Zugfrlhrer, 78 Jahro. . M30igcr Raucher: 2-3 Zigarren tdglich. ' :onMipe aupere Einurirkunpen av/ die Aternwqje: Rauch, RuB, Kohlenrtaub (wihn•nd dee Berufeausubung als Zugf6hrer). 1'ornxgekende 6rkmnkrrnpen der Ahnvnpepyane: In der Annoneee nicht rrrmcrkt. .annlomiecke Diapeoee:. Brnnchinkarcinom dea reobten Lungenoberbppr.ns. nl. 874/37. W. K., Behkarer, 48 Jahre. UuBiger ltaucher: 1 packchen Tabak und 5 Rtumpen die ganre Wache. Xonslipe dnlBere $inurirkungea an/ die Alepwege: Rauch, RuB. K. hat 14 Jabre Innc •hn Hnndwcrk ala $r:hloayer in einem Lokechuppen auegeubt und mu8te sich nll in Itnuchfdn6ren und Feucrkisten aufhalten. Hierbei war er atindig der stirketen I:inwirktmg von Rauch, Ru0 und Kohlenstaub,auageeetat, so dag bin Auawurf >trte e<•Immtsig geweeen eei. (Nech Angaben der Ebefrau.) I'onnpehende 6rkmnkunpen der Atrnutpanrpana: 2 Jahn+ ante exitum Bron- hitia• .4.alomierAe Dinpnwe: Bronchialeaeeinom im rechten Lungenoberlappen. a'-r. 601/32. R. N., Emailliemr, be Jabre. JfiiOiVCr Itauclwr: 4 Zignrmn und 50 g Tabsk im Monat. Sou.fi0e unpere Binwirkunyen na/ die Alernwepe: Bleietaub wlbrord der Be- ruf ndibung nle Emaillierer. I•ornuXhenAe Brkrankunpew der Abmnprorpane: In der Anamneee nieht vrnuvrkt. :Inn/nn,isrke Ihageoee: Bronchulrareinom der linken Lunge. . . .Ifikrwlropirk<r Befund: Ca. enlidum. . r3. ;,9u/34. H. L., Fabrikarbeiter. 53 Jahre. '. '. }IeOiFn•r ltauuher: 10Zigareth•n tkglioh. ' •cnndi~e unQere Binwhkunpm an/ die Alemvrqe: K. w.r wihmnd des Krfeges ~•Inbn• Iang uln Arbeiter in einer Munitiondabrik tktig. I'onrnyekeade Brkrankvnpen der Aln.nngeorpawe: In der Arumnese nkht cvmierkt. .. . . . VomnqeAendei Trauma: 2 Jabre ante eaitum Rippenbnrch reehta. Anatomisehe Diagnose: Bronchialcarcinom der ]kdren Lunge. Afikrwkoyier•ker Be/und: Ca. solidum. . 84. 1504/37. A. 8ch., Hausffrau, 60 Jahro. Nichtraucherio. 8onet(pe auflere 6invrirkunpen av/ die Alenruyte: WAhmnd de. Krieges 2jkhrife Titigkeit in einer Munitionsfabrik. VornnOrAende &rkmnkunpen der Annunpeapaat: Mit 30 Jahren Rippenfd. entaitndung. AnalomierAe Diapnose: Bronchialcarcinom der rechten Lunge. 85. 811/29. E. L., Packerin, 28 Jahro. ~ Nichtmuchorin. 6onseige unJ3ere Einudrkunpes nu/ die Alemwtpe: L. hat wlhrend des Krkry,++ 18ngeri: Zeit inteiner ZOndkapeel- und Zundhutchenfabrik, ferner 8 Jahre lercrr in einer Schraubenfabrik gearbeitet. . Vorangehende 6rkrankattgen der Atmunpeorganr: Nicht bekennt. Anatorniseke Diagnose: Rronchialcarcinom des linken Hauptbronehus. 86. 622/33. M. W., Hauafnu, 50 Jahre. Nichtraucherin. Sonntiye 3uFere Finunrkungen au/ die A/emvept.: W. war wibrend des ganuw Weltkriugea ale Arbeiterin in einer Munitionefabrik beanh8ftigt. VorunyeAende &rkrankunpen der Atmunqsorpaee:. Nicbt beknnnt. AnatmniecAe Diageoae: Bronchialcarcinom der tecbten Lunge. Mikroskopiecker Be/und: Ca. eulidum. 97. 105/30. A. H., Heuafrsu, 26 Jahre. Nichtrauchcrin. 8onalige av(iere kin+oirkunpes anf die A/ernreepe: Tabakebub wahrend ein+ 2jihrigen Tktigkeit 410 Arbeiterin in einer Zigarettenfabrik. Vorunprhende 6rkrankvnpen der Almvnlinorpowe: Nieht.t bekannt. Analomieeke Diapnoae: Carcinom des linken Hauptbronchua. 88. 335/30. M. H.; Haudr.u, 64 Jahre. Nichtraucherin. Bonsfige AvDen Biwroirkunpen an/ die Alernwrpu Keine. . Voranyekende•Srkmnkunpen der Ahnnnpsurparu: Nicht bekannt. Asaforniscke Diapnoee: Bronchislcarcinom der linken Lunge. 89. 26f/38. R. 0., Hauefrau. . Nichtravcherin. 8onafipe au//en &inurirknnpen an/ die Alemvrq/e: Rauch-. und 8lureentwirk• lung einer der Wohnung unmittelbar gegenuheHiegenden chemirchen Fabrik. Vorauyekewfe 6rkmnkutrqen der Atmunpeorpawe: Nicht bekaunt. XlinixcAe Diupnwc: Bronebialcarcinom. 90. 1304/39. J. K., Bausirau, 48 Jahre. Nichtraucherin. , ' Sonatipe auffere Einrdrkunpen an/ die Atereureps: Keine. Voranye#ende Srkrankunpen der Atmnnpawpane: 18 Jahre ante eaitum Aufen4 halt in cinem Erholungsbeim fur „Lungenschwauho". - Yomnpehenda Traama: 1923 „Lunbrenri8" dumh 8tura. Anntumier.ke Diagnwe: Bronchialcarcinom im linken Lungonunterlappen. Mikrwkopi.cker Be/and: Plattenepithclcaminom. ?'P?e969Z00t

.~-o- v...#/e•.. sM .L.. 290 CIpARE1TE LABELING AND ADVERTISING 91. 1075133. G. H., Hsudraw 64 Js6re. Nichtrsucherin. . Sonetige duQero Sierairkuu9es au/ die Akmwepa: Kelm. 1'uran9rAende Brkrunkanpen der Atmunpeoryane: In der Anemnsa+ nieht wrmerkt. ' AnabmiacAe Diap.ora: Bronchi.losrcinem im rechten Lungenunterinppen. 92. 640/38. A. F., Hauefnn und Buglerin, 59 Jnbe. ::ichtraucherin. Son.lipt aupers 8iwwirkanpea aaf dic Atesureps: Wsr 30 Jabm l.ng als B6g- 4•rinvon Btarkeweeche t6tig. Nicht baksnnt: 1'orungekende 8rkrankanptw der AMwupaurpaw; .. Aealomisd.e Diap.oa: Brortchielraminom der linken Lunge, 93. 36/35. E. R., H.uatrau, 65 Jshre. Nichtiaucherin. ' . . Sontiq'e'~d'npere Biwmirkuayen as/ dis Atemnspe: Keinm/ . . 1'ornny....nde k'rkrankeAgCn der AtmalrpeelQane:-Nleht bekemlt. .feuromiecbe Dia9noss: Bronchi.katrarom im reobten LrngenobsrLppen. 94. 379/31. L.1f., Artist, 33 Jehre. Nielnrsucher. Nonsfige daptre Siuwirku+pes arf die Atemwt)/e: Nicht beknnut. 1'onrnpeAende 6rMnnkaeyen der Ahwawpeor9ane: Mit 21 Jeh.en Luogen- ,nlxihnlnng. Mit 26 Jahren erneut Lungenenteendung. Mit 31 Jshren ement I.nn4nan•nte0ndung mit R6ckia1l. ' -:Inuron.irAe Diapnoaer Bronehulcsrcinom der rechten Lunge. 9u. 145138. H. M., gohreinermeister, 68 Jehre. Sirbtreucher. Nonalipe auQere Einwirk'anqnr na/ die AumuqM: Holratnub. 1'orangehende Erkrenkanpen der Atmwnpeorpane: Nicht hekaunt. :Indomische Diagnose: Ca. rsmi eperterislis palm. de:t. Ml. 070/3g. A. F.. Arbeiter, 46 Jahre. Nivbtrouchcr. y,n.fige uxpere Ainreirkauqaa a./ die Atemwepe: „F. war von 19Y3-IgBB Im l1m,mollw•tricb des Werkes Uerdingen beech6ltigt. Es handelt sieh bier um ein ,in.nudlrehre Chromat-Lungencsrdnom."' (Mitteilung der Leiteq der Medisi- hrn l'oliklinik der LG., Dr. tVdf/.) I'onrnpeheruh Erkronkun9enn der Atmse9eurpaae.; Mit 19 Jehren „Lungen- yilrsnknnvrlf'.l:finieche Din(pwe: Bronchinlnrcinam dee recbten Lungenunterbppenn. 5. Ergebni98e nn9erer Unter9uehuogen. a) Tabakrouchen. Von ilen hi .•q_ Uirlen RuL• er aufgefuhrten 86 msnnlichen Lungenkrebekrenken_ 1. Extreme Rnucher: 25.=29,07%. _. Sehi starke Raucher: 18=20,93%. 3. Starke Raucher: 13=15,12%. . 4. NiiOige Raucher: 27=31,39%. ' -i: \ichtraucher: 3=3,49%. AND ADVERT1BINp 291 Ein Vergleioh mit den Angaben 9ber den tgg]iehan Tnbakverbrsuch, ' erhoben bei einer gleichen Anrabl von geeunden Mannern dereel6rn ~ Alterettufe, erwei9t, welch ein gewaltiger Unterechied zwinchen dieem Werten und dem normalen Tnbakverbrsuah beeteht, golgende Gegen. uberstellung bringt dies sum Auedruck: Tsbelle 8. Die Verteilung dee tkgliohen Tebak.erbr.uohee bei 8e mtne. lichen Lungenkrebekrenken gegen8ber 8g gesunden Mknnern. Abrolu4 Eehl ProaratW,l tree,- thob &~~ R6e1~''~ (taglj4her Verhewnb von - 10=111 Zigen.,y mo~ sy 35 Zigaretten, mebr elr go g pteifea- t b s ek) . . . . . . . . Bekr Nurks Baar.ler (7-p Zigaeren, 20--35 Zigarettcn, 38--gO g Pfeifen. ) . . . . . . . . . . Sturke Ru.ehrr (4-8 Zigarree, 16 bis 25 Zigsretten, 21-3e g Pfeifen- tabsk) . . . . . . . . dfd~@+Be Raaekd (1-3 Zigerten,.l bie 15 Zige.etten, 1-20 g Pfeiten- t h.k . ) . , . . . . . . . . NichouucAer . 18 18 27 8 3,49 18,Y8 Zussmmen . . , . 86 88 IOOOp ipp,qf Auch die $erecknungder im men en• ~Zen ~giich verrauchten Tabak• g bietet, wie Abb. 2 seigt, einen eehr eindruekevollen Vergleirh. Weit mehr ale die doppelten Mengen (2900g Tabak) wurden vm den 86 Lungenkrebekranken im Vergleich su der gleichen AnsnLl von -- geeunde p CIpARETTE LABELING _n ernonen (1250g) verrsuchtl Auf Grund der ponftiven Rennltate in tler tkr- ' experimentellenForschungwiederhierniedergelegh~n Untersuchungen an einem grnfferen Krankengld, welche die gewaltige Verbreitung den Tnbaknbtwe, linter den Lungenkrebekranken eindeutig unter Deuri. etellen, gelangen wir su der tlberaeugung, da~@ dor Tabakraueken afe eine u.ic7dipe ~at f k e e angaah d ALC.L,Oernlmvpre / primaren Lynyancarciaoraa JealateM. Der riraace eaenknee /h dn Npkh .•er. I AnetiegdeaTabakterbrau w.vehtrn T.bekr m elua in dea ktzten.JaArzehnlu oremm. A - ~f , ie$ an erakr Stelle enLmryenkrenrAren- /ily die ZanaAme dee Frimunz Lan RMIe1 t.o~ d- ~.1 aa er- _...~-_ ,-- noms rerontarortfieA ru nureken. .. . eeuaen Perrmen. • 1 ZI garro = 5 g, I Zig.rette ~ 0,8 g. orusde 41 14 vanenLun. renkrcb- tuentm 81,39 47,68 Uzssszooi

292 CIGABETTE LABELING AND ADVERTISING Dafl unter den Lungenkrebskranken such msflige Rancher und \ichtraucher anzutreffen sind, hier etwa in rJs der Falle-, epricht dafur, dn6 ee auller demTabakrauchen noch andere krebeerzeugende Momente Fibt. In Obereinstimmung hieran steht die Tateache, da8 in unserem Arankengut die Beamtenbemfe und die in reiner Atemluft srbeitenden 14•rnfe, wie Kaufleute, Angestellte, Wirte nsw. sich fast auenahmsloe untor den starken Rauchern befinden, wahrend sich in den moisten Vrillen bei den maDigen Bauohem und Nichtrauchern sonatige, meist IK•mflicbe Einwirkungen auf die Atemwege nachweisen lasrseen. Im Inlgenden soil die Frage gepr(ift werden, wieweit diese Einwirkungen nlx ursechliche Momente Me die Entstehung der Krsnkheit in Betracht rll r.lehen sind. b) 3onatfpe duBere Einudrkunpen auJ die A(emroepe- Von Blair Bell ging die Anschauung sue, dsli das Bleii imetande w•i, cine elektiv zerettirende Wirkung auf die Krebezellen suezuGben. Blair Bell verwandte daa Blei therapeutiech bei Krebekranken und - L•riohtete irber eine be*chtenewerte Zshl (65 bei 300) von Fallen, die ,lurch dieee Maflnshme von der Krankheit geheilt worden eeiri sollen. 9ii,,o An,chauung Blair Belle wurde jedocb epeter von anderen Unter- nirhern beatritten, welche sowohl bei genaner Befolgung der von Blair lldf angewandten Methoden wie such unter Hinzufugung einiger Malifikationen zu vSllig negativen Ergebnissen gelangt sind. Da Beno L•+rlueibt eine Reihe von Fsllen, bei denen bei dauemdem beruflichem honlakt und naeh Vergiftung mit Blei der Krebe efch ungestSrt bef crrhfJtniema8ig jungen Individuen entwickeln konnte. Auf dem inlrmationalen Krebekongre8 in London im Jahre 1928 standen eich hi•ide Anechauungen gegenuber, und Blair Bell wurde hier auf dem ltobietc der Praxis gedch)agen. Baeil'Hume, Burton T. 6impeos, A. P. Thumean berichteten iiber ein v8lliges Vereagen der Bleitherapie. .\u,•h Stanley IV yard kam zu dem Ergebnis, da6kolloidales Blei abso- Inl wertlos fur die Behandlung von malignen Gewacheen eei. \1'ir gehen hier deahalbsuf dieee Ilage naher ein, weil une sufge- 4JIvn i%t, da6 unter den von uns beobaohteten 17rkrankungifallen an l.nn^enkrebs Angeh6rige jener Berufe,in denen dee Blei zur Verarbei- twi, konmrt, in einer eehr gro9en Anzahl vertreten eind. Schon von •~• !nnhrr wurdo darsuf hingewiesen, dsll die Berufe Metallsrbeiter, KL,nipner, Schriftaetzer, Arbeiter in Drvwkereien, verkultnismigig oft mrt.•rJen Knmken angetroffen werden,und die IienntnisaudererArbeiten 1:h,r dnn jrrimfire Lungencareinom, die such die verechiedenen Berufe drr krnnkcn bcrucksichtigt haben, erlaubt ee une, zu behaupten, dafl Ircimifrc Lungcncarcinom die AngehSrigen derjenigen Bemfs- owr•n, in denen ein engerer Kontakt mit Blei besteht, beeondere heufig CIGARETTE LABELING AND ADVERTIB[NG 293 befi{Ilt. Wir etimmen mit Da einer Bona Gber•ein, wenn wir die Annahmr elektiv echiidigenden Wirkung dee Bleis auf die Krebszeflen be.. zweifeln, echon aus der Erwagung heraus, daq das Blei, wphrend dn Berofsarbeit in den Organiemus sufgenommen, einen zereturendm Einflu8 aut den Krebs aueuben bzw. die Entatebung der Krebezellen und das Auftrefsn-von Metaetaeen verhindern mupte. Vornehmlich mti8te dies beim primaren Lungeneareinom der Fall sein, wo doeh das Slei, von den Kranken in gro0en Mengen durch die Atemwege in die Lungen aufgenemmen, die Mbgliehkeit hutte, rlro krelrazerstBrenJe an Ort und $telk Wirksamkeit zur Entfaltung mn bringen, sodng dre Blerarberter gerade von dieeer Krankheit verachont bleiben mugten, - Dae Gegentcil konnten wie feetstellen: Unter 86 mAnnlichen Lunges. krcbakranken befinden eich 17, welche beruflich in auagedehntem Om. fange mit Bleistaub in BerGhrung'gekommen eind. Auf die einzelnen Berufsarten verteilen eich diese Kranken wie folgt: 7 Arurtreicha, 5 Blefarbelter, 3 Inetallateure und 2 Buchdrucker. Von diesen war bei 2 Kranken in der Anamneee eine frGhere Bleivergiftung erwiihnt, wn mit Ruckaicht darauf, da0 wir nur bei einem Teil der Kranken die Vor• geschichte kennen, sehr bemerkenswert fet. Weitere 13 Kranke gr. horten Berufen an, in denen verschiedene Metalle zur VerarbeituaF konunen, und zwar: 3 8vhloeser, 4 hfsschinenechloeser, 2 Metallaehleiter. 2 Drahtweber, I Eisengietfer und 1 Werkmeistec Bel den Metallschld. fern rmd Drahtwebern iet eine Inhalationemoglichkeit von Metull etaub wahrend der Arbeit in etarkstem DLffs gegeben. Auf Grund dieser unserer Beobschtungen neigen wir zu der Annshme, da8 die Inhalation von Bleistaub eiuen fitrdernden Einflup auf dir Entetehung des primaren Lungencareinome aueubt. Die hohe Za1J drr Berufe, in denen Blei bzw. chemieehe Verbindungen des Bleis zur Ver arbeitung kommen, wie iiberhaupt der metallverarbcitenden Berufe, die unter den Erkrankungafallen an Lungenkrebs gefunden werdir, veranlaflt jedenfalls fGr die Zukunft zu einer erhohten Ardmerksam• keit in der Frage, ob eino geschwuleterregende Wirkung der Mctslk bzw. deren Verbindungen allein in einer, mechardschen Reizeinw'irkun: zu suchen ist, oder ob bier eine epezifiech wirkeame Komponente eirw Rulle spiolt. Verschiedene Metalle bzw, deren Verbirnlungcn, wic z. g. dns Chrom, hsben erat in den letzten Jahrzehnten eino zunebmemk handwerkliche Verarbeitung gefunden, was auch fur die olxm angr fuhrten Bcrufearten zutrifft. Die in neueater Zeit gemachten Beobnclr . tungen einer auffallenden If6ufung des prim"aren Lungencurcfuomg le+ Arbcitern in Chromatbetrieben der chemischen Industrie verweivr, auf (lie hohe Bedeutung der Chromate fur die Entstehung des primuren Lungencarefnome• ;k Vpzssszooi

294 CIGARETPE LABELING AND ADVERTISING Nahere Mitteilungen hieraher liegen von Alu.end, Barka und Jaw vor. Vnn 'kn S0 Lungenkn:bskisnken, die in kliniecher Beobscbtung der Verfener stsnden, mtatnmmten 9 einem Arbeitorkreie, welcher in einem beetimmten Betriebetel d,w Oricsheimer Werkee der chemiecben (:m8industria bewWtftig6 war. In dieeem .•it 1951 etillgelogten Werkeabechnitt wurden hsuptWchlich Chromat, Sebwelel- ,fmrr, Sslmiuire und Sulfat hergeetellt. 1linzu kommen noch 6 Falle gleicher Srt vun Cbromatsrbeitem, die durch ambulsnte RAntgenuntereuchung disgneetiaah c,-ktirt wenlen konnten, eoda6 Vertesaer uber inageaamt 15 Erkrsnkungefelle, rmn donen 11 epiter ecsiert wurden, vertugen. 14ozentunt berechnet eich der Anteil der krebekrsnken Betriebsmitgliedcr 6, Cbromntteik.re im Rahmen des kliniechen und smbukmten Kmbebeobnebtunge- _au+lroi Griesheimer Arbeitem von 1928--1938 au14D%I Dieae Feetatellungen x,mlrn durch gleichlsutende Beobachtungnn von Groee in snderen Chromut- Irlrirbcn bestltigt, so ds0 die Tatasche besteht; da6'sile wichtigsten Chromnt- htnken Dcutachfande unter ih h~ ~ ~bsehtungen durch d ee H nsnfttgung .ris•n haben. Wir ergimzen _- .in.•n Bnllee aue unecrem ]Cnnkengut (9g). _ 1niLJli/,rorweiee seigen die altemn, eait mehreren dahren etill~ luka uodJanas -inm rehlenma8ig gr81k'ren Anteil der Erkrsnkungen. A(rorae. Inhn•n diee sal die traher viel echleehteren Arbeitsverhaltnime and die Veralterung dkr Icdmischen Einriebtungen suruck, die eine bygienisch einw.ndfreie Ver. drldnm; tier Arbeit nicht gewihrkieten konnten. :Ituvne, Barte und Jonae mseben den Chromatetaub in enter Linb far die . And,w•ntetehung verantwortlich, weloher in Form des faingemshkmen Bnh- ;m.luknre, des Chromeieenstteins oder des kryetallieierten Bichromster bel der Beruf+auenbung von den Arbeitern in bedeutenden Mengen inbsliert vinl. Neben den ortlichen Itciswirkungen kommt such den Altgemqinwirkungen .I-a rlu•miscben Agens oitra susechlsggebende RuBe su. :1 von den 10 in uneeren Krankheitsf5llen aufgefuhrten Frauen (84, <:.• >zG), ferner tier Arbeiter H. L. (83) waren wahrend des Weltkrieges Zeit hindurch in einer Munitionsfabrik mit der Hereteltung von Vunition beschuftigt. Unter welchen itu8eren Bedingungen sich diese .1rlx•it vollzog; insbeaondere welche ehemiachen 8toffe von den IG;mkrn hier verarbeitet wurden, konnten wir nachtrnglich nicht -mrhr ermittcln. Dem „Handbuch der Berufekrattkhciten' von A-:IxA entnehtoen wir, de6 zur Munitioneheretellung p. a. ven e:uodt wenlen: Kohle, SalpetoR Schwefel, Phosphor, Queckeilber, I:b•i,cvtat, Cbromato, aromatieche Kohlenwaeseretoffe, Pikrinsoure a1w. Die Tateache, dn6 sich die Angabe uber eine fruhere Beschaf- :icnn¢ in einer Munitionefebrik im Rahmen der 99 Krankhcitefalle Iwal wiraerholt, und allein von 10 1+4auen 3 diese Betatigung ausgc- hatten, ven(icnt Beachtung. Die verhnltnismfi8ig gro0e Zeit- bis zum Apftreten der Krankheit, welche bier zwiechen 10 und 1<,1uhn•n liegt, epricht nicht gegen einon ursliichlichen Zusammenhang -xi.,hon dieser 13ctiitigung und der eputeron Erkrankung, winl doch '.. .•mrin cine achr lange Lntenzzcit (bie zu 3 Jahrzrhnten) fiir die Ent- •5'1umg d" primiiren Lmrgencareinome bei gcwerbliehen Arbeitern CIGAREITE LABELING AND ADVERTISING 295 anerkaunt (vgl. hierzu den „Schneeberger Lungenkrnbs" und die „Chro. mat-Lungenkrebae•')• " Der Farber F. Sob. (57) aue unserem Krankengut war wiihrend. eeiner Berufesusubung at'sndig der Inhalation von Anilindampfen aue- geaetzt. AuOer 2 Fallen von gleichzeitigem C,arcinom einer Niere neben Blasenkrebe Leue ( nberga') nind qnilintumoren neeh den bisherigen Br obachtungen nor in der Harnblase, wo eine Anreicherung der wirk- eemen Stoffe zustande kommt, Jokalisiert. DiesbezGgliche Mitteilungen iiber dae Entetehen eines Caroinome der Bronchien au( dem Boden elner lange Zeit bestehenden Einwirkung von Anilindimpfen Ijegen nicht vor, doch iet eine sblche Mtiglichkeit nicht von der Hand zu weisen. Bemerkenewert ist such die Mitteilung der Angeherigen des 9chloseerr W. K. (81), da8 dieser eein $chloeeerhsndwerk in einem Lokechuppen aueubte und dabei der etiirketen Einwirkung von Ru6, Rauch ural Kohlenetaub auegeaetzt war, soda0 sein Auawurf etets grolk- Beimen. gungen dieser Produkte enthielt. Auch der Zugfuhrer A. Z. (gp)ttat einen sehr gro0en Teil eeines Lebens in ru6iger Luft verbracht. Bei diesen Kranken waren die Bchleimbaute der Bronebien einer etandig sich wiederholenden Reizeinwirkung grolier Mengen von inhalierten RuOpartikelchen suegesetzt. Durch intensive Einwirkung von Ru6 hervorgerufene Krebebih dung, wie der 8crotalkrobs derKaminfeger, iat bieher nur an deruu6oren ' Haut beobachtet worden. Wir verweieen in diesem Zussmmenhang aut Versuche von ,6eelip und Benipnae, die 100 Mause elner inteneiven Ru6- einwirkung sussetzten und bei 8% der Vereuohetiere gegeniiber 2% bci . den Kontrolltieren hietologiaoh ein Adenocsroinom der Bronchien nach- weisen konnten. Die im Alter von 26 Jahren verstorbene Hauefrsu A. H. (86) war 2 Jahre lang sle Arbeiterin in einer Zigarettenfabrik tatig. Auf ein hbufiges Vorkommnis des Lungenoarcinome bei Tabakarbeitern winl in der Literatur mehrfaeh hingewiesen. Enper hdlt die Hiiu[ung diescr Erkrankung, die er bei Arbeitern der Zigaretteninduetrie in Leipzig beobschten konnte, im Hinblick auf die geringe Verbreitung dieen Gewerbes in Loipzig ttir beeundem bemerkenswert. SeyJarf6 bezeichnet ' des Lungencarcinom ala eine typieche Berufekrankheit bei Ar•oeitern der Tabakinduetrie. Von den Autoren wird die Reizeinwirkung des inhalier- ten Tabakstaubes zur Erklitrung fLr dae h6ufige Auftreten dos Ltmgen• carcinome bei Tabakarbeitern herangezogen• Iet es aber nicht nahc• liegend, gerade bei diesen Arbeitern snch an den Tabakabueue zu denken! Verwiesen sei ferner auf Fall 45, wo eich die Angabe ciner Gasver• giftung wuhrond des Weltkriegea findet, welehe bis zum Zeitpunkt tier Krebsentstehung forWauernde SehlWigungen der Atmungsorgano hin• torlic6, sp%ssszoot

{I 296 CIGARETTE LABELING AND ADVERTISING . e) Grippe. Im Jahre 1927 wurde Kbin von einer 6rippewelle gr86eren Aru- mn8es heimgesucht, von der ein bedeutender Teil dee Bevtilkerung er- fnOt wurde, soda8 wkhrend dieser Zeit die Krankenhi:ueer der St+dt mit Grippekranken vberf911t waren. In dam dsrauffotgenden Jshre atia6 ,Iie Zabl der Lungencaroinume, die im Pathologiechen ;~ und erreiohte ccrsitnt zur Sektion gelangten, urn mehr als dam Doppe , . ,irro Hohe, welohe die Zahlen der vorauegogangenen Jahre weit iuber- rnot, und die auch his heute nioht wieder beobachtet wurdn. Die Dar-. arlhmg in Abb. I(eingangs aufgefiihrt) zeigt aehr einnigllig dieee ee- Ireblicbo Schwankung nach oben, dureh die der kontinuierliche Anatieg der jehrlich sezierten Lungenkrebefslle eine echrnffe Unterbreehung ,rtshrt. Wir regietrieren hier beide Erecheinungen, die in der Ab- h:4ngigkeit ibres zeitlichen Ablaufes eine nkhere Verbindung zueinander rcrmuten lnasen. Schon Berbtiaper wien im Hinblick auf die in Jens und in anderon St6dten beobachtete deutliche Zunahme der Lungenosroi-e nemo in den Jahren nach der gro8en Grippeepidemie zu Auegsng doe 11'tdtkrieges suf die Bedeutung der Grippe fdr die Xtiologiefrage dee primnron Lungencarcinorne bin. Aekanazy hst eine Reihe von Fallen !n•nehrieben, bei denen im Anschlu0 an eine Grippeerkrankung eine )L•taplasie dam Bronchialopithele nachge*lesen werden konute, die or ol< „pri[cancer8ees Ereignis" deutet. L'ily die Zuaammenatellung der Krsnkheitafl;lle haben wrr neben der Urippe such die iibrigen entznnd6chen Erkrankungcn der Atmunge- ~.rl,ene, wie akute und chronisebe Bronchitis. Pneumonia und Pleuritis 4 riickaichtigt, Affektionen, denen eine begiln.tigende Wirkung suf die Entatehungdee primiiren Lungenoareinoms von verechiedenen Autoren zuerkannt wird. Unter Hersnziehung der une sug6ngliohen 47 Krsnkengeecbe~k~ larelnt wir bei 3 Kranken die Angabe fiber eine frqhere Grippee krmg. 8 batten fruher eine Bronchitie, 3 eine Lungenentz~tndyum :I cine RippenfellontzOndung durcbgemscht, Erkrankungen, . 7,-il schon viele Jahre suruckliegen. Bei 2 Kranken (40, 72) batten -delrc cntzOndliche Affektionen die Atmungeorgane, welohe teet etSn- •tie cinor ,intensiven Stsubeinwirkung ausgeeetst wsren, wiederholt !Mroffen. F.in Kranker (94) hatte in einem Zeitraum von 10 Jahren am:d cine Lungenentzundung durchgemscht. In 28 Filllen war elne .ur:umgegnngene Erkrankung der Atmungsorgane nicht in der Ana- •+movc vcrmerkt. Wir wahlen mit Absicht diese Bezeichnung: , In der .\nnnmese nicht vermerkt", weil dam Fehlen einer Angabe uber fruhere b:rkraukungen der . Atmungsorgsne dieaelben nicht aueechlie8t, eei ee, --il der Krnnke_ eine solche vcrgoesen oder ibre Erwahnung unterlaeeen "u, xci re, da8 bci der Erhebung der Anamnesen diesen Erkrsnkungen sVzssszooi CIGARETTE LABELING AND ADVERTISING 297 nicht mit der f8r unaero Belange notwendigen Aufinerkeamkeit nnd . Sorgfalt nachgeforecht wurde. Die Zahl der Lungenkrebekrankn, die fruher eine Erkrankung der Atmungeorgane durchgemacht haben, ist daher wahrscheinlich grBRer ale die von uns hier ermittolte Zahl. Diees iet daher zur Aufetellung einee Vergleichee mit gesunden Per- sonen nicht geeignet. Die Krankengesehichten sus dem Jahre 1928, die uns wichtige . Aufscbiiieee iiber die Bedeutung der Grippe hiitten vermitteln konneq waren uns leidcr zum grUBten Teil nicht mehr zugAnglich, und tlir wenigen, die uns zugsnglich waren, eagten niehte Bestimmtes sus. Dc, Verbiiltnis der mrinnlichen su den weiblichen Lungenkrebskmnken, - dieim Jahre 1928 zur Sektion kamen, batte, wie wir nachtriiglich teet. gestetlt haben, im Vergleich zu den anderen Jahren keine Abiinderunf erfahren, es belief sich auf 5:1. -Abschlie6end eei noch auf Fall 41 hingewiesen, wo der Lungen. krebs auf dam Boden einer tuberkuloeen Kaverne entetanden iet. Zusammenfass.Dns. Wir haben somit an einem gro8eren Krankengut die Frage gepruft, welche Momenta fiir die Zunahme dam prim'Aren Lungencarcinoms ver antwortlich zu machen eind und etellen ale wichtigetep Moment do- Tabakrauchen heraue. Diese Tateaohe verpflichtet une, durch Aufklerungen und Hinweirr auf dieee Gefahren dam Tabskrauchene eine weitere Zunahme des ]xi- miiren Lungencarcinoms einsudammen. Inebesondere iet die wri' verbreitete Unsitte dee Inhalierene von Zigarettenrauch, durch die d'rkrebeerzeugenden Substanzen in die tieferen Atemwege gelangen, rr bokiitnpfen, wie uberhaupt den Menschen, welche krebebelastMrr Familien entstammen, und allen, die mit chroniechen Katarrhen der Atemwego behaftet sind, vom Tabskraucben abzuraten iet. Aue vielen Hinweisen ergibt sich daneben eine gro8e Baloutung dt^ gewerblichen Schddigungen. Djese Fmge bedarf noch weiterer eia gehender Untersuchungen, die um so vordringlicher eind, ale such hin elno wirkssme Prophylaxe den gewerblichen Arbeitern Sohutz va dieser Kmnkheit su bieten vermag. Auch die Frage, wieweit die Grippe an der Entetehung dee prim6nn Lungencarcinoms betoiBgt fst, iet durch weitere Uuterauchnngen ru klaren. Lltentunerzelehnie. r Alweru, Bovke u. Josae, MOneh. med. W.ebr. 82 (1930). - r A.1nnn:,r. Koneep.bl. Schweiz.Xrste 1ltf.-r Be.blinger, l(1in. Wwhr. reti.-4 Blui.Brf. L.ncet IDtf, 2. - r Bra.cA, Virohowa Areb. I{f (1900). - r Cnoper, Lnrne, 6mefm

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