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Lung Cancer: Causes and PreveMion PrxWlnQt of fhe lrtt.mvtlond LurV CcncOr Updvft ConhMcO, hNd !n Iil.w Or*oreA Loulslcna, Morch 3,5, 1963 Edled by M.ft Mtz.11 and Po1cyo Cocr+m ~ ~ i1!¢T~atiOnal Ci W GO N FA CD N

Contenta Keynote Addras: The Control of Lamg Cincer Richard Petc and Richard D*U I Chaprff 2 Lung Cancer in Scandinavia: Time Tpends and Smoking Habits 21 Laly Teppo Gaapter 3 Trends in IIamg Cancer Inodence and MoralitF in the United Satd 33 Snnm S DrveyoQ john W. Horn, and Roger R Connelly ChapUr 4 Lung Cancer and Occupationil Pacposures 47 Wi11im j. BJot Chaptef 3 Air PoRudon and Lung Cancer 65 C'arf M Shy Chapcer 6 The Causes of Lung Cancer in Loaisiznz 73 Pelayo Corrr.a, I~da Ar'ctZimW Acw IIi:abeth FonMmx, Nancy Dolceges, Youpvr$ 1,in, WOam H'a!,-.rsl, and tii'iMmie D. johnson Chapw 7 The Causes of Limig Cancer in Tac~ 83 Patr;do .iL Bufflkr, F.inda WOm,a Pick1S Tfwmar j. Moswy and f.7wrla Contost C'J+cpter 8 Recent C'sse - ControZ Studies of Lm: Cancer in the United States 101 Linda fPd7imps PicATR Pelayo Corrio, and Flizabeth ForitJiaw Chaptcr 9 The Epidemiologic Meaning of Frstorogr in Lung Csnces 117 john WBerg ~

f3icQten 10 Lung Cancer in Noasmokrrs and Low-Risk Populations 131 Chapter 11 Jaeph L Lyon, FLecera D. Aaloa, and John W. Gardner Ecogenetico of Lung ('ancer: Genetic Stsscepabi'litT in the Etiology of Lung C.ancer 41 Chapter 12 Jo1w J. Mukfi)eiII and Allen E Bale Trends in hi'istologic Types of Lung Cancer, SEF.R, 19'13-1981 133 CJlcpts.13 Constancc P", John W. , Horni, and Thwar E Goffman Saeening for Lung Eincer. The Mayo Lung Project 61 CJia' ptet 14 Robert S. Fontmna and Willime F. Taylor Lung Cancer in japan: Effects of Nutrition and Pasuve Smoking 175 Chapcn 13 Taksm H'waymna Nutritional Status and Chemoprevention in Relation to Lung Cancer 197 Chapter 16 Peter Grenuuald and Willicm D: DrRw ritamin A and Lung Cancer in Louisiana 211 Chapter 17 13arbarn p 1.egwdew, alfrecro rvpa-s, and 1PAt iavx A John= Prevention of Smoking in Adodeacents: Current Perspective on a Sodal-Behavioral Intervention 19 Chapter 18 RicAmrd L Evmu The Biology of Lung Cancer vis-f-vis the Emerging New Biotechnology 229 Chapter 19 Merle Misell Transforming Genes of Human Lung N Grcinomis CO.D 235 N Geaffm 115. Cooper CJ CJ C~D N N G~3

A Cbapte.20 In vtro Studies of the Bialogy of Luag C.acer 247 ChaQtss 21 Deswnd N. (',m,uy, Adi F. Gatdar,, Frm,eir Cwtima, med JoAn A Mwia Radio.ctivity and Ggarette Smoke 263 ~'Jiapser 22 Tlwntai K We~trrs andfimteph R DiFranza Luag Cancer Inddence and Type of Cagarette Smoked 273 Chaptn 23 Persr N.Le4 Smoking Cessation Prograaa and Lnag Cancer 283 Ciaptes 24 ETkn R Grits Cancer preveation and the Smoking, Tobacco, and Cancer Program of the Nationil Cancer Lzstitute 97 ('Jiaptn 23 faseph W. C,d'lat Lung Cancer and Smoldn& ReSectioas and Unresolved Lwues 313 Frmtt L Wynder and Marc T. Goodrnmr Subject Iadent 323

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PtefCCA . TIu main cause of lung cancer is dgarette smoking; about that the saentific work repnrted in this book l'eaves no doubt. Approximately 90% of the deaths from lungancer and'almost one-third of the deaths from cancer of all kistds can be traced directly to smoking. In 1982, about 129,000 Amrrians died from smoking-rrlated cancers, according to estimates from the Office of Smoking of the U.S. Department of Heal th and Human Services. Buc ancer is not the only disease smokers have to fear: the habit also causes elevated rates of heart disease. According to research reported in this volume, about one in four rrgular cigarette smokers will be killed before their time by the habit. And the magnitude of the problem is greater than usually is rtalised': Of every 100 healthy young male smokers in England, statistia predict that one will die a victim of violent citae, two will be killed in traffic acddents, and 25 will die from a disease brought about by agarrttes. Similar proportions of deaths will occur in the United States. Women are quickly gaining equality with men in the lung cancer arena: in 19$2. lung cancer surpassed breast cancer as the leading cause of ancer deaths among women in eight states. The pattern, which is believed to be nationwide, is attributed to an increase in smoking which began among women 30 years ago. The cost for smokers is high in terms of dollars as well, as health. In Louisiana, where 2,100 persons die every year from lung cancer, more than $300 million annual'ly are spent on the purchase of; cigarectes and medical costs and loss of earnings account for approximately, iS86 million per year. Thestate--espedally its southern area-has one of the highest cancer rates in the nation, and many of the studies in this volume look at some of the reasons. Several papers demonstrate that smoking no longer can be considered' a personal habit concerning only smokers. Passive smoking-smoke inhaled' from nearby smokers-increases the lung cancer rate. Rexarch conducted in Japan has demonstrated that nonsmoking wives of heavy smokers suffer a lung cancer risk at least twice as great as nonsmoking wives of nonsmoking husbands. Research has also shown that radioactive materials are a common component of cigarette smoke. Other studies in the book explore the relation- ships of nutrition, smoking, and lung cancer: a precursor of vitamin A that comes from green and yellow vegetables can perhaps lower cancer risks. Smoking can work synergistically with occupational exposure to ancer• ind'udng agents to increase dramatically the risk of lung cancer. Studies have shown that some individuals may have genetic factors that make them more susceptible to certain environmental carcinogens. )d

Cigarette smoking is a form of d'rug dependence because nicotine u an addiction-catuimg drug. And cigarette smoking is knourn to ause cancer. The addiction to this toxic drug produces many times more deaths than addictions to tnarijuana, morphine, and cocaine combined. Yet those drugs are illegal. Why then, one may ask, are cigarettes advertised and sold all over the world? When cigarette addiction began about 60 years ago, its deleterious effects on bealth were not known because smoking-induced cancers can take as long as 30 years uo develop. Now, cigarettes are a multibillion dollar industry, with extremely well-organized lobbies and advertising efforts. Well over $1 billion: each year are spent on efforts to promote this addictive and deadly drug; that sum is more than the total budget of the National Cancer Institute. What can be done? Some of the research in this volume explores the alternatives. Abolishing smokin`, of course. is unrealistic, but other efforts bttld promise. Reducing tar 'un cigarettes may. over the yean, reduce cancer rates, but in absolute numbers, lung nncer deaths are likely to go on increas- ing well into the twenty-first century due to saturation marketing efforts and increases in absolute numbers of smokers. Public education efforts about the deadly effects of smoking are inadequate at the present time and could be made much more effective. And legislation-with higher taxes-can make a differ- ence. In Finland ambitious new laws were enaaed' in 1977: these laws prohibi- ted' advertising and sales promotion of cigarettes; forbade smoking in all public places except in designatedareas; outlawed the sale of tobacco products to persons under 16 years of age; reserved money from tobacco tax revenue [or developing health-oriented government tobacco policy; and made the govern- ment responsible for establishing the limits of harmful components in tobacco products. Finland now leads the world in reducing lung cancer deaths. espedalty in younger individuals. The bat way to change smoking patterns, which would automatiolly aEfett lung cancer occurrrnce, is to convince young people never to begin smoking. Parents must be aware of their responsibiliues as role models and sehools should make a health education program emphasizing the hazards of smoking a part o[ instruction from kindergarten through college. The college students fiom Tulane's Chapter of Alpha Epsilon Delta, recog- niting the hazards of smoking. helped with various phases of the conference and continue to sponsor antismoking actiwicies. In fact, plans [or this book began when Alton Ochsner became an honorary member of AED (the National Fre-Mediczl Honor Society). We were seated around a banquet table in a New Orleans garden district restaurant when the International Lung Cancer Update Conference was first discussed. Dr. Ochsner planned to present a short history of lung cancer at the conCerence. for as he told us ....... this disease has grown up with me. It did' not exist when I was a medicaf' student." Unfortunately Alton Ochsner died before the conference convened, so this volume lacks his historical perspective. Nevertheleu. this book is dedicated to the memory of Alton Ochsner and we were pleased to have his son. John Oehsner. participate in his stead. We gratefully acknowledge the continuing CID co ~ ~ ~ ~

sik aid of the student members of AED and' their antismoking efforts; as well as the help of Diana Pinckley; Director of Tulane Univenicy Relations, and her efficient staff for their aid in cover design and'various aspects of production: The organizers of the conference are especially indebted to Lorraine Mizell. whose untiring work helped make the meeting a success and whose concinu- ing efforts and administrative expertise helped produce this monograph. The conclusion is clear: cigarette smoking causes lung cancer. ff scientists and' concerned citizens can communicate that simple message to the public.. the cigarette advertising salvos and lobbying efforts may all be for naught There will then be hope of controlling this disease. Merle Mizell, PhD Pelayo Correa, MD

aclknowledgmenta I speak on behalf ofTulane Medical Centerwhen I~ say that we are pleased and proud that Tulane Univetsiry has served as one of the cosponsoring univenities of this International Lung Cancer Update Conference. It is fitting that this monograph be dedicated to the memory ofAlton Ochsner,. MD, an honorary alumnus of Tuiane School of Medicine. He served on the Tulane faculry for many years as professor and chairman of surgery, prior to establishing along with fourother Tulane department heads what has become the Alton Ochsner Medical Foundarion Dr. Ochsner, an internationally known sutgeon, dedicated his life to the elimination •of lung cancer. We have come far in the battl'e against lung cancer, but there is still much more we can learn about the etiology, prevention, treatment, and ultimately the elimination oflung cancer as a significant cause of human suffering. It is through participation in cooperative efforts such as this international conference that we hope to provide an exchange of information which will lead to even more answers about lung cancer. folnt J: Wats1. MD. CJiana{!o. TYlaru C-4sivers~ .4tedical'ftntn I am glad to acknowledge the success of the joint efforts of our institutions: Louisiana State Univessiry, Tulane University, Cancer Associ=tion of Greater New Orieans, and t!u Board of Regents in organizing and carrying out the International Lung Cancer Update Conference. The conference addressed an issue of gnnt impottance to our community and provided up-to-date prexntaaons by some of the best international experts in the field. The conference has already stimulated' important discussions in our scientific community and has established an objective scientific basis to approach the lung cancer problem in our state. I hope the impetus provided by the conference will continue until' a strategy for prevention is developed. Ala:+l f. LArson, MD, Lle+an Gctsuiana Statt Universiq ScMo!' of Medidne in Neto Or{wtsr The Louisiana Board ofRegents and its Advisory Committee on Research and Development are pleased to have had the opportunity to sponsor the Interna- tional Lung Cancer Update Conference. The state of Louisiana. its citiiens, and its institutions of higher learning are all beneficiaries of this meeting. sr

As a result ofbringing ;tie worid's authorioes on,.ing cancer research together in New Otieasts to presenr and euhange reseuch findings about the state of the att in this field, the world has seen that Louisiana is seriously concerned about this dread disrase and intends to promote soentific research in order to address this probleta.'Therefore the state's image with the srienti5c community has been eahanced worldwide. I,ou*a,'-na's dtizens have benefited Erom this conference because they received the most current and reputable advice from the foremost expests in the field about what they on do to enhance their chances of living lung-cancer-ftee liva- Tttey tearned that this discase is largely selE-inllicted. Finally the scholars, scientists, and medical practitioners in Louisiani s inst} tutions ofhigher learning, as well as the scientifu community outside our coUeges and univetsiiies, have benefited from the opportunity to exchange infotmation 'rith, ask questions of, and interact with the experts who participated in this conference. The Internationil Lung Cancer Update Conference was atremendous success, and we at the Board of Regents are aaremely pleased to have been a put of it. Nifllusa Aroen.au+4 PliD Canesissio+ur of FfigAe. £dueatio+s Lo+dsiara B_W+d ' of Regents Sponsoring a conference is an uncommon event for the Louisiana Board of Regrnts'Researeh and Development Prograrn. Generally only research projeas which address issues that are of particular concern to the sute (eg, hazardous waste, economic developmen[ wetlands, the st3te's high incidence of cancer) anr supported with these stste-appropriated funds. Since one of the goals of this program howeve.r, i's to upgrade the quality of research in Louisiana's instin} dons of higher learning. the Board of Regents and its Advisory Coatmitue on Research and Developmetu decadedthat sponsorship of this conference not only was appropriate, but also would be a decided investment in the future of quality cancer texarch in the state. In sponsoring :his conference, the state provided its scientists a rare and perhaps unique opportunity to learn from and exchange ideas with the world's foremost authorities in the lung cancer field in a convenient iocuion and forutn. The knowledge and information the state's sciendsts gleaned as a result of thu conference should stimulate interest in this area. as well as promote the submis sion of research applications to the R&D Program that are at the forefront os knowledge in this field. The response to this conference from the Louisiana scientific and medica communities was overwhelmingly positive. The Board of Regents was fortunscc that the organizenofuhe conference were responsible and talented individuali who undertook this task in a serious and dedi:ated manner. Their hard work anc combined talents, in conjunction with the outstanding speakers and excellen soenrific presennaons, made the conference an unequivocal success. On behal 0 N