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r Voli 315 No. 10 CORRESPONDENCE 3. ReminBtoa PL, Form.a MR. Gemry EM. Msd. IS. HoBelis GC. Ttow- hrid8e F1.. C1mmt smok'tn8 ttmds il the unised states: tbe 1981+1983 be8.r- farsl risk faaor sttrreys. IAMA 1985; 253:2975-8 . 4. t:wey LS. Musbinski b4i. Wynder EL Smoki.g b.lin io a Eapim6sed populstio.: 197U+1980. Am J P.Nie Healdt 19i3; M1293-7: 5. National Centa fa Heshb Statistics. Natiooi Cea fa Hraltb Ser.ices Resatch. Office of Health Rese.ecl. Statisncs, asd Teeloolo87. He.lttt.. United Stson. 1981. Hyamville. Md,; Dtpwmat of Haltlt aod Humsn Services. 1981. (DHHS publicatian ao: (PHS) 82-1232:) RISING MORTALITY FROM CANCER OF THE TONGUE IN 1'OUNG WHITE MALES To tir Editer• Recently, concern has been raised oue< the health implications of the increasing use of snu6, espeeially by children and adolescents.t Snuff contains amounts of carcinogenic nitmsa- mines that exceed by orders of magnitude the nitrosamine content of other consumer produets." I examined mortality statistics in the United States to determine whether there has been any rise in the rate of cancers of the mouth. The deaths from tongue cancer in white males from 1950 through 1982 were tabulated itnm the death-certi5cate tapes of the National Center foc Health Statistics. Deaaths from tongue cancer for three decades and for 1980 through 1982 are presented in Table l, accord- ing to the ages of the decedents. Mean annual mortality (e SE) iwas calculated with use of data on the number of white males of the wrrnponding ages in the United States in the trtedian yesr of each period, as obtained from Census estimates. The atortality from tongue cancer fim the 10-to-29 age group rose more than twofold' during the permd' examined. This rise was statistically significant by a test for trend on a log-linear model (P - 0.004). Because of the Iow number of deaths from tongue cancer in that age group, it is difficult to estimate when the in- creaae began, bur graphic analysis' indicated that it ttuy have be- gun in about 1974. No increases were seen among older men; a ltattge in the 30-to-34 age group in 1980 to 1982 was not sta- tistically significant. The observed increase in mortality from tongue cancer is consistent with an increased use of snuff by chil- dren and adoltscents. The latency period observed for the develop- ment of cancer will be shortest among the youngest group of patients. The rates for cancer at other sites in the mouth were also exam- ined, but no upward trend in mortaGty was observed in the same age groups. The other sites in the mouth that would be espee[ed'to be a/feaedby 1nuB are the lips, checks, and gums. The gums and cheeks are often not listed sn• ntcly on death certificates and prob- ably are often classified as wth, ttot otherwise specified." Lip cancer predominantly affects the vermilion border, and most casa are associated with exposure to sunlight. Therefore, the faa tharno incrEased rate was found in mouth subsites other than the tongue is not surprising. Cancer of the tongue has long been treated as a distinct entity in medical Gterature, and it is more likely to be cor- rectly specified on' death records. These preliminary data emphasize the importance of close medi - nl observation of young users of snuB The use of this product by children and adolescents should be strongly discouraged. Cancer registries in areas in which there is a gn.ardeal of snuff use should' observe the incidence of all forms of mouth cancer. Rockvillt, MD 20854 RoseaT H. Dsrut, Pn.D. 8612 Bunnell Dr. 1. HeaMd appiicaiom of smotekss mb.eco .se. JAMA 1986•r 255:1015-8.. 2. HoHmsns D. Hariey NH. Fnenne Ii!VdsmslD, Brmeemsoe 1CD. Cateino- 8eeie s8ean 1e snu$. JNQ 1986; 76:4357. 3. HoHmas D, HecEu SS. Nicodoe-derited N-mooamim .nd tob.cco- tdated csa cmtmt stus and fsmte doectium. Caocer Res 1985; 45:935- 44. 4. Pqc Fs. tbOadative s.mcfisas. Taeh.omeaics 1961;a:t-9. N 0 T 1 e E BAN ON SMOKING IN INDUSTRY T. t4r Ediler: Pacific Northwest Bell is a Seartlr-based telephone company with over 15,000 tmployces. Oa July 15,1985, its mans.ge- ment annotmced that a new smoking policy would go into effect on October 15 of that year. The new policy was so straightforward that its essence was contained ia one terse sentence: "To protect the health of PatificNorthwesrBell employees there will be no smoking in company facilities." The ban on smoking has now been in effect for six months, and the results are impressive. Although the company initially received some complaints about the new policy, not a single employee has left because of it. Enforcement of the ban has not been a problem even though the company has over 800 o8ices in three states. There have been no lawsuits against the company, and the two unions that represent the workers have supported the measure. There are cur- rently no platts to modify the ban in any way. The results at this company will almost certainly encourage other laege companies to consider such a ban. If widely adopted, these policies might have a dramatic e6ett on the natitMt'Y smoking habits. Theoretically, they would encourage people to quit smoking by inceasing the social pressure against it and by restricting the time available for it. Although such an outcome has not yet been docu- mented, the results at Pacific Northwest Bell have been encourag- ing. At the satne time that it announced the smoking ban, the com- pany allo announced a program foi reimbursing employees for participating in smoking-cessation programs. In the first six months of this program, 1044 employees requested reimbursement for the cost of cessation ptagrams. On the basis of previous company sur- veys, this represents 25 percent of all company smokers. This con- trasts sharply with the results of the cotapany i previous efforts to encourage employees to participate in smoking-cessation programs.. During the 26 months before the smoking ban was announced, employees had the opportunity to participate in cessation programs sponsored by the American Cancer Society. These programs, which were Gee and conducted during work hours, were poorly attended. During the entire 26-month period that they were offered, only 331 employees signed up for them. If poliaes that ban smoking do encourage employees to quit, they promise handsome dividends to managers who are concerned with "the bottom line." Studies have consistently shown that employing smokers costs a company substantially more than employing non- smokers. Kristeint found that it costs an additional $336 to i601 per year to employ a smoker. Weiss reported that the cost can be as high as $4,700. Physicians should be particularly interested in the smoking poli- cies of hospitals. Although the smoking restrictions in most hospi- tals involve only segregation of smokers or prohibition of the sale of cigarettes,' two hospitals-the Public Health Service Indian Hos- pital on the H'opi Reservation' and the Group Health Cooperative Hospital'o! Puget Sound' '- have shown that banning smoking in hospitals is possible. It is now time for all hospitals to consider such a ban. Smoking is the greatest cause of premature death and dis- ability in the United States,` and it would be ironic if health care institutions let the general business community take the lead in banning smoking in the work place. Mtcnwtt. J. Mi.xTtn, M.D. San Francisco, CA 94110 University of California AnrtzTm Futat:HSace. Pn.D. Seattle, WA 98101 Pacific Northwest Bell Ro.ean RosnEu Smoking Policy Institute Albers School of Business- Seattle, WA 98123 Seattle University 647 This matariat' may be prote0ed bl+ copyright law (rlue 17 U.S. 6cde)~. Talble t. fiAorlallty Rates from Tortpus Cartosr asttwrtp Wltite Males .- in the United States. N70-t9!! Yswn 1960.1969: 1976-19" I900.t9tt r wm. rasat _ftk~xmr r... f•adu 10-297.7¢1.9(16) 9.6e9.9(26). t2.634:I(43). 18.4s4.2(19). 30-34 48=9 (26) S1x1o (7,3) 4Tx9 (29) 38216 (14) 35-39 119=1D (62) 112=15(39) 123x16 (63) 13s_27 (23) t

648 THE NEW ENGLAND JOURNAL OF MEDICINE Sept. 4, 1986 1. Kristein MM. How much can businessexpectto pto&t from smoivng eesta- tioo? Pnw Med 19B3t' 12:35&Sl. 2. Weis WL. No ifs. aads or Mus-wEy.rarkplace smokins should be ti.aned: Manage World 1981; SeptembcrJ9ri4. 3. Eouoer VL, Wilaer SI. Non-smdons policies in hospitals. 1 Public Health Policy 1985: 6:197-203. 4. Rhoades ER. Faubntks LL. S®oke-6ee facilities in the Indiao Health Serv- ice. N Eagl l Mea 1987;,313:1518. S: Bledsoe T. No smokin=at Gtnup Heahh Coopaative of Puget Sound. N Easi 1 Med 1983; 313:894. 6. United States Dep.nmaar of Health. Educatioo. and Welfare. Office of Smoking and Health. S"niokiRy and ticaith: a report of the Surgeon Genersl:. Washington, D.C.: Goretnment Pnntiny Of6ee. 1979. (DHEW publicadon no. (PHS) 79-50066.). EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY IN A PATIENT WITH MILD HEMOPHILIA To t/4 Editor. As Mttllty states in his editorial (March 27 issue),' extracorporeal shock-wave lithotripsy is becoming the technique of choice for treatment of renoureteral lithiasis. Even though renal patrnchymal' damage occurs in all cases, renal subcapsular he- matotnas are the only major complications and can be treated con- servativdy-s'' We recently treated a 6B-year-old man for hypovolemic shock after extracorporeal shock-wave lithotripsy. He had a history of chronic obstructive pulmonary disease and laryngectomy for a benign vocal-cord tumor nine years before, with severe postoper- ative bleeding. He was seen for abdominal pain, lumbar hematoma, and weakness eight days after undergoing lithotripsy in another hospital because of lithiasis in the left renal pelvis. Preoperative study had been normal but did not include determination of the partial thromboplastin time; the procedure was aarrled out under epidural anesthesia and was unremarkable.s The patient was discharged 72 hours later in spite of hematuria and abdominal pain, which were considered to be "normal" after lithotripsy. On the eighth day he came to our hospital because of progressive deterioration. He prtsented' with hypotension and oGguria, which were treated by transfusion and infusion of fluids. Abdominal radiologic and echographic study showed a large extracapsular perirenal hema- toma with extension into the retroperitoneum. Conservative treat- ment was carried out, with improvement. Progressive reabsorp• tion of the hematoma was observed. The partial thromboplastin time was 10 to 15 seconds over that of control, and factor VIII was 25 percent, suggtsting hemophilia. During the hospital stay, he had nosocomial pneumonia with respiratory failure that ne- cessitated mechanical ventilation, and a urinary tract infection. The patient was discharged 46 days later with normal renal function. Since the work of Chaussy et al.,6 the indications for shock- wave lithottipsy, have been expanded because of the low incidence of complications. In a recent series of 15 patients treated with lithotripsy, 4 (27 percent) had subcapsular hematomas that were detected by various techniques of renal imaging.' Our case of extracapsular hematoma occurred in a patient with mild hemophil- ia not detected preoperatively.. We believe that extracorporeal shock-wave lithotripsy must still be considered a major inter- vention. J.A. At.vwnaz, V.M. GAUncw, EJ. At.ra.a, ji A. Cat.rwtant:ottA, M.A. Bt.asco, exa A. Nufaz Madtid' 28041, Spain Hospital "Primero de Octubre" 1. MnBey AG' Jr. Sboclt-wave 1&hotiipsy: .wessieg a shm-b.o{ taheology- N Eo=) I Med 1966; 314:643-7. 2. Alvarez E. Apottaei6e al esodio dd diapdatico. evolaeibe y snumietmo de loo trammtismoa teaales. Madrid. 1973 (doctmd thesis). 3. Chaassy C, Schmiedt E. 1bcArm D, SchWkr 1, Bnwm H. Lield B. Eaas- eorpcteal'stioct-w.ve lit6ovipsy (ESWL) fa orcataoeat d aroliftriau. Utol- ojy 1984; 23Sappl s.S9-66. 4. Mulley AG Jr. Carbon KJ. Lithoaipry. Aaa Intern Med 1985; 103:626 9. S., Sctimiedt E. Cbmssy C. Exttawtpaat shoct-wave lithottiqy of kidney and uteotric stones. Uiol hx 1984; 39:193-8. 6. Ctuusry C. Schmiedt E, Jocham D. Bteadel W. Forsstnann B, , Wvther V. Fust clinical experience witti,exnacotpoceilly ioduced deatritctioo of kidncyy stones by shock waves. J' Urol 1982; 127:417-20. 7. Hunter PT. Nermsa RC: DrylieDM. et al! Dur~ mu1'imsgia~ fcllow- iog exeneotpoad sbodc-wave litlwaipsy. I Urol 1965: 133:SupId:170A. atiwaet. IN VITRO AND IN' VIVO RESULTS SUGGESTING THAT ANTI-SPOROZOITE ANTIBODIES DO NOT TOTALLY BLOCK PLASMODIUM FALCIPARUM SPOROZOITE INFECTIVITY To flu Flftor. We have reported that a mouse monodonal anti- body directed against the cizcumspotozoite antigen and serum of mice immunized with recombinant and synthetic dreumsporozoite peptides strongly inhibit the entry and development of Pfannadarrt fulciprton sporozoites in hepatocyte culture.' Nevertheless, even though this inhibitory activity is oRen pronounced in culture, it is very rarely complete. Since it can be argued that in vitro results are often of question- able relevance to an in vivo situation, we attempted to assess the extent of correlation between our in vitro results and observations made in patients in endemic areas. To examine this relationship, we collected serum from three persons living in three holoendemic areas in West Africa (Cameroon, Congo, and Mali). The samples had anti-sporozoite antibody titers that were the highest observed among samples from several hundred subjects studied thus far. The titers, directed against the sporozoite surface as determined by reactivity with "wet" preparations in indirect fluorescence assay = ranged from 1:50,000 to 1:100,000, which is as high as or higher than corresponding titers of adults receiving as many as three infective bites per day (Druilhe P, et al.: unpublished data) and apptaximately 10 times higher than titers of mice with a high response to artificial peptides with Fteund's complete adjuvanL The subjects' serum samples were tested for their ability to block entry and inhibit development of Pn fokipmton sporozoites in a hu, man hepatocyte culture system''' and under the technical condi- tions described elsewhere.! Despite the high level of spororoite sur- face-sped6c reactivity, the inhibitory activity of these samples in vitro was only 82 to 88 pereent, indicating that 12 to 18 percent of the parasites in an inocul'ttm were unaffected by the antibody. The presence of P. fdsifranoa ring formi in blood 51ms of one of the subjects at the time that serum was obtained demonstrates that some sporozoites are able to evade the protective action of naturallyy acquired antibodies in vivo as well as in vitro, even when these antibodies atr presentat high levels. Therefore, these specific anti- bodies do not consistently protect against disease determined by invasion and multiplication of parasites in erythrocytes. Antibodies elicited in humans by synthetic or recombinant pep- tides may be more effective than those produced in mice. Whether total protection will be achieved by vaccination with thex prepara- tions, in contrast to the incomplete protection observed under natu- ral conditions of immunization, must await vaccine trials in hu- mans. However, our results do suggest that an antigen or antigens specific to a single stage of the parasite may be inadequate as a vaccine designed for complete prophylaxis. S. Mutont, D. MAZU>!, M.D., P. Datmxz, M.D., N. Bctwatm.a, wtm M. Duas, M.D. 75013 Paris, France Groupe Hospitalier PitittiSalpEtrie.re 1. Marier D, Mellouk S. Beaudoio RL, et al. FSat of aoa'bodies to tecombi- n.nt sod synthetic peptides oe P. JBlcipmmr sporomoisea in vitro. Seieooe 1986; 231:156-9. 2. DtuiAe P.Pndier O. Mato JP. Miltgea F. Ataaa D. Pateat (3. Levels of antibodies lo PlaaaAX%.n Ihlciparrw spotoroun surfsee 1otlpns roaeet soalaria transmiasioa nues and are pasisteat in absence of te-iafatim Infect L- (in pteas). 3. Smith lE. Meis JFGM, Pomndusi T. Vethave 1P. MasAa=e Hl. In-vito culaue of emoaythtoeytic form of Plaa.odima fafdpera a in .duh Eum.a hepatocyrea, I- ncet 1984; 2:757-8. 4. Maaer D. Bcadoin Ri'-, Mellouk S. a al: Complete development of Aepatic stages of Pfavaodiwt /dciparum in vitro. Scieacs 1985; 227:440-2.