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Philip Morris

Smoking and Health 640000 - 790000 the Continuing Controversy

Date: 19790110/P
Length: 133 pages
2060460623-2060460756
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Kornegay, H.R.
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PUBL, PUBLICATION, OTHER
BIBL, BIBLIOGRAPHY
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LEGAL DEPT
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PARE, PARENT
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N28
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Afl Cio
Agriculture
Air Force
Amed, American Medical Association
American Academy of Allergy
American Assn for Thoracic Surgery
American Cancer Society
American Chemical Society
American Heart Journal
American Petroleum Inst
American Statistical Assn
Annals of the Ny Academy of Sciences
Appropriations Comm
Archives of Environmental Health
British Medical Journal
Business Week
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Columbia Univ
Congress
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FDA, Food and Drug Administration
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Hew, Dept of Health Education and Welfare
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Intl Agency for Research on Cancer
Intl Archives of Occupational + Environm
Johns Hopkins
Journal of the Irish Medical Assn
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Mayo Clinic
Medical World News
Mount Sinai School of Medicine
Natl Heart Lung + Blood Inst
Natl Inst of Neurological + Communicativ
NCI, Natl Cancer Inst
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NIH, Natl Inst of Health
Ny Times
OSHA, Occupational Safety & Health Administration
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TI, Tobacco Inst
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Who, World Health Org
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Author (Organization)
TI, Tobacco Inst
Named Person
Aronow, W.S.
Astrup, P.
Barnard, C.
Becker, C.
Belcher, J.R.
Bridbord
Burch, P.
Califano
Churg, J.
Devees
Fisher, R.
Framingham
Fraumeni, J.F., J.R.
Gilliam, A.E.
Gori, G.B.
H, W.
Hammond, E.C.
Higgins, I.
Hirayama, T.
Jones
Phillips, G.B.
Rueper, W.
Russell, Mae
Salvaggio, J.
Scamlar
Selikoff, I.
Silverman
Stedman, R.
Surgeon General
Terry, L.
Tower, D.B.
Vandenberg, S.
Vest, T.C.
Vincent, R.G.
Yerushalmy, J.
Master ID
2060460229/0756

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Page 1: jxz45d00
5" Smeklnq and Naalth 1964-1979 T N t C 0 N T 1 N u I M c C 0 N T R 0 Y C R 5 Y T R E T u B A C C 0 1 N S T I T C T E 1875 I St,tec, H. Y., Yeahlnetoe. D• C. 20006 January 10, 1979 20B0460623
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b1b Ta01e of Cont.nta Prefar. Pale v 0vervi.r -- Smoking and Health 1979 1 Public Smoking 13 Smoking and Over-All Mortality 35 Women and Smoking #7 Cancer in the Work Place 71 Lung Cancer 87 Other Cancers 103 Cardiovascular Oisease 119 Chronic Obstructive Pulmonary Disease 139 Appendix 153 This volume is publlshed by The Tobacco Institute in the belief that public discussion about tobacco smoking la 1n the public lnte•est and that the smoking controversy must be resolved by scientific research. iii 2060460624
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547 Oe• ia.a set betofe as ad.eeat-e ef tMUas bj deY parttea a br.ader, dHpnr, sere ebleati.• •eHtNrlrlen of the tiese• O.er a hu.dred yaara a0o, Yilitas atlitt. the LnI1i.\ crttic asd aaaalrst, tut his fiapr ss the sn! •t the Srebles. Taa may atree rith his rh.m he aaidt The origin of a11 science 1a is the desiro te kne• caaaaa; and tbear161a of all falea enie.ce asd isqosture is fa the desire to accept false nausaa rather than oas; or, .hinh is the aa.e thlsa, t• the •a illiaasas to ackno.ledte our ova ijaorasee. It is tise for a11 Oartisa to this contro.arq to adult that thare 1a auch that ir unknorn. Doint so .111 as- courap research to reduce the deficit in out kao.l.d;a asd lacreaaa our undetatandiAt. In that svirit, •e offer for cooatdaratian this docusent, uhlch -- rhile unt intended to be e=hauatl.• -- rate.• ao.e of the questions tn the continuint asoklnt and healch contro•ers7. E~ G7^'.. Iornets7 / rreuldant. The Tobacco Institute ]anuar7 10, 1979 vi 2060460625
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tittaea years heve passed elaes [\e release sf ataeklst and Deatth' -- the first aad perhaps the n.at •ldely publicised of a series of such raports prepared by the Dqart- se.t nt Sealth, tducatton aad Welfare. D uplte illtos sf dollars epent sleee that tlae both by the te.eruast aad the tmkaeco industry ae saoklas and bsalth-ralatad rasearek, easy qm u tloss about the ralatlanshlp betvu n a.oklns aad dlseaae rm.ai raausvsrad. Nov, au to 1961, there re scatlscieal rnlatioeahlps and ae.eral working I.ypothafas, but no detlnitlve and final anavera. Desplte clals to the eoncrary, no One -- Sn seVare- saat or ioduetry -- can eaplaie the reported au oclaciona of saoklns with lung cencec, heart dleuee,e.phyee.a, low lntanc birth reltht, and yes, even cancer of the pancreas. No one knows why -- or how -- a cancerous growth betine. whether it !e tn the lunt, pancrus, or bladder. No one knows why the valle of huun arteries beco.e clogged with l3plde or how clote that can lead to stroke get thelr start. No one knoue why pretnanc vo.en who afoke have lighter fnf.nts Ion theeverage than vo.en who don't uoke, or why so.e voaen, whether or not they e.oke, have saaller 1 r 2060460626
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I Ua tcfaeta. fetssttsts ha.e snt P toeen that elgaratte sNke er aey ef tke thousands of ita constltueets ss foned ia el(ta- ro[ts smeke uuse human df.se.se. Ner ha.e ecieotista deaeoatrated that the healthy I soasaeker is har.ed by h1s netghbor's clssretts ssaking. )ut because snae agenales in the O.S. governaeet, meebers of the medlcal profession, and others who just doe't like cigarette smoke act and react u it all the claims about smoking are sclentiflc certainties, Tha Tobacco Institute sets forth here certain evidence which relaEes to such Judg- tonts• A coeeent eade by the U.S. Surgeon General in his foreword to the 1964 report is as relevant today as St was 15 years ago: The interrelatlonshlps of smoking and health undoubt- edly are coaples. The subject does not lend itaelf to easy ansvers. Nevertheless. it has been iocress- ingly apparent that answers must be found- Pubilc Seokin¢ Other people's smoke has never been shown to cause di.ease in nonsmokers. Sclentlats, reseerchere, government officials and even tose vell-knovn anti-ssoling spokespersons have stated 2 2060460627 ,
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S. I M that easking In -eklfe -Laru daee see hate the healghy sao- boaker. geae -eteeu •a? tled the tobacco axeha at •t-ste U1\efieg to eotte CIreYOatgEree. Last yeare • gt\dJ ealdeated by Dastah and grtttsh resaurehers found "traalicarr dlgeatarte bat no evidsace of lescing adveru health effects fres cigs- tKte smake in otherriae healthy indieiduala. Sose persons who favor banning tobacco smoke is public places cite an article published Sut year claisieg that eaposure to cigarette snoke resulted in changes in the eeereise performanca ability of pacieeca with aevere angina pectorta. What is usually tgLored is that this study is eub]ect to aevere criticie^ for faulty design as well to unsupportad conclusion^ based an patients' eelf-deacribed evsptass. Some nonaeokers clats to S. allergic to tobacco sUoke. flovevar, oeither cigarette seoie oor any of the eos- poaeots as found in cigarette eaoee has been desonetrated to be a huean allergen. Noeasokers he uke such a clai• sose- tiseJ cite a siudy which shove that esokere as rell as non- seokera reacc poeitavelf to akln tests with tobacco leaf eitr~~c, but this is an Snapproprlste aubstance to use in allergy testing for tobacco aaoke. Another clate freQuen•:r •ade by aoti-aeekera. that ehildrea are har u d by their parents' aeokiag, is ^aialy based on several studies pubitaned In the lace 19600 and 1970e suggesting that fgarecce ..to say be responsible for 3 2060460628
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561 ad..r.e effects tn childre.. lo.. a t, qsasti.u ha.e ba.s raised aks.t katk the espetla..tA1 a•th.da ud the rdltsllltty •Q the ce.elsnt.u . Morsaver, ••uaber af ratsat atN t.d `a•a jlllfl to de.opstr.te •drers• effects 1a sYildr.• •f •opki.t p+re.ta. 0ther psople's smoke has never kesn shovn to c.rse 4160400 to Oonaalnk.ra. O.er-A11 Mortality SSI! u.: O-L re.ulte Iroa fla.ed poeulatien studies JU tri.htep peonl. ¢1 a[crlbuttne lirae nu.bars 1 letjl Joar'r So •aokin may Oe lSsleadine L" f! I lVat FllT.ttable. Asa.rtions that aoaa.okera as a group llve longer than s.ekers are based un studies that rer• poorly designed and statistically fla.ed. pnr e.a.ple, they involved saaples not representatlve of the general U.S. population. Despite theeu problus, data from the reports are still used to sup- port • variety of cLai.s abouc asokera' orta11t7, including the eherte that several hundred thousand Americans die each year because they smoke. With such use -- and •isuse -- of dsts. It 1• probably not surprislnt that a caveat io tSs 1944 SSurgeon C.neral's report 1a often overlooked: "Statiacical sthods e.nnot establish a c•usal relselonship..." 4 ~44 2060460629 1
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ssz ltenes aad fsskiu Iateuietsat fisdlnae 11" sj,rjies jj WjIZA Janj ," jhalr chlldren lake jj l..enalble j!, d.ras•Jgj- IL",(`j toaelusioas frs j" 11j(. preanasc. Outeame Although the abbreviated 1977-78 LY report to Cos- grsas coacludes that cigarscce srokin{ is "probably cassally associated" with increased parlnatal ortalit), St :elidu as data which indicate that any clalss of a causal rs.e:tosabip have a highly Questionabl• foundation. The data sug(as• that such faetors as history of prrvtous pretnane7 loss and hospital pay status (public •s. privace) have greater effects on preg- nancy outrose than saternal asoking. The data provide support for the Lelief that adverse pregnane7 outcosas -- indeed, the health and life or death of the child itself -- say be pre- dstersined by who the sother is -- her constitution or lnnate characteristics -- rather than whether or not she ssoku . Ssoktnt and Carlv Menopause Research which aooeare to indleaca that ssokers undergo •eoopeuee earller then nonssoker haa baen used to support a clai that snokers sre deprivln/ theaselvee of the "proteotinn" fron heart attacks believed to be provided by teselc see norsones until change of life. 5 2060460630
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aaa Ba.ev.r, this claim is not supported by heart disease mortality statistics uhlch show no "Ju.p" during the saeopsrul age epe -- tach aa .itht ba eepetted it ler$a au.bera sf rot»• were euddenl) deprived of "protectton" against this disease. The almost single-minded concentration an auoking evident in nuch r uaarch in this area sa7 result io a failure to consider other factore that s,y be involved. For asasple, Public aalth Service research indiutea that enopauae begios earlier in black rooan, in white women fros lorer inco.e levels and rural areas and in leaner uosen. Oral Contracentivea The scientific literature doea noc support the clais that oral contraceptive users who stop eaoklns decrease thei.r disease ratea significantly. ihia point vaa reeentl7 +ada In a Con{reaatoncl hearing during which a decision by the rocd and Drug Administration to require a printed warning -- uhich, in effect, iapliea such an aseurance -- cuae under attack. In dlecu u ione on this tsaue, concern has been expressed that the reported etattecical relationship between oral contraceptive use, asokiny and illness may cause scien- tists co overlook other factors that aay esplain this relation- ship. 6 2060460631
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554 rases and lnne ealter l casparieon of international lung eaesr patterns i.ilee aarfena queatfons about the rlaf• teat the larger nn.ber of •o.en saokina today accounts for their risin5 luq cancer rates. Such a conparison indteates that lun5 cancer psttarns is roneo ars differant to various coao-cies and are dissialar fros .ale pacterns. [.en rhen alloranee is aade for the later popularity of stokln= a.on' ron.an, there is to eonslscsnt trend of increasing ortalir7 rates. So.e seientleta have questlonad nhether tha teceat increu e in lung cancer ortalit7 is ore arttflciai than real. Th us querles have baen •ade because physicians appear to be ordaring .ore diagnostic cesta for roaen they know to be s.okars. Therefere, it •a7 be possible that .ora lung cancer anoa{ ro.an ia being diagnosed because rare reliance is being placed on dia`nostie techniques not available in the pasc. In addition, a role for occupational a",r other environsencal exposures has been suggested by research con- ducted in heavily industrialired couoties. Cancer en the Work Place Tha al.ost exclusive focun on indivldual saoklnt habits to the atudv ot dteease Y have delaved _esdad research inco possible occucational and envlronantal causes. 7 I 2060460632
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565 , T\e aaeevecueae lest ltptsmbar by t• Seerst.eT CalIlfaas tbat at lssst 20 perceet of 11 eanears u9 be ettqe- tlou 11y related brought sagry denials fre anti-sO.tisS researchers ud arganttatione uhose own altieatal differed aignlficantlT froa tht naw asti.att. The authors of the report refnrref to bT the Secretary .etuatly utt.ated that bitrees 21 and 38 percanc of all cancers were eccupatlonally related. They attributed a aisable proportion of all oceupatlonal caucers to asbestos asposure and noted that 'perhaps the ost tttportant lauon to be learned tro• che asbestoa story is that a•ajor health disaster can de.elop vhile its early unltasta- tlone are lost by being attrtbuted to other factors.' Lung Cancer T6a fii urt to conaider grittcallt 1) i.portanc dlaanostic ad~aneea. Z) ehaeaee in the raportad fraaueneies of lun cancer cell ttots and ]) trenda Sn cigarette consunntion end lune cancer nnrtalltr d.ta rais.e serious cuestloos about .ns conclusions regarding a.oklne. What some have called the "eptdesic" in lung cancer .ortaltt7 in this century has been :inked by some to the increased popularity of s.oklnt. Bore.er, it hes beon specu- lated that this reported Sncreaee sey to fecr have bean created lau0ely by 1mproveneots Sn d1.{nn.tlc tachniQues -- in other uords, ore lunt cancer cases have been reported because e 2060460633
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ass pkyaleiaee .eee better equipped to ftad thas. tsaa if at least a perttea e/ tka "epideate" fs real, treads i• 1ass saaesr death rates can not be eatLefactorll? e.plataed by cigarette eatavapttea patteraa. •ritish reeearcher has rqorted a elailar pkeao.- snon !o the United [ingdom that he coetends ts aora censisteat with the eonstitutioaal hypothesis than the saeking-eaauttap theory. An apparent change in the reported frequencies of lons caneer call t7pse rae observed !n 1977. A researcher noted a shift in the histologic types of lung cancer found at a major cancer center -- from epldersoid, or aquaaous-eell. which has been ore strongly associated with cigarette saoktni, to adenocarcLnoaa. which is only weakly associated. Up to this polnt, at leaat, ad.nocaretnosa has been the ptedoalnant histologic type of lung cancer reported tn vonsn and ln non- a.okars. 6aeause vf this reported lnereasa it the lung cancer cell type not generally au octated with cigarette s.oklna. serious doubt ts cast an the role of smoking lu the develop.ent of this disease. Other Cancers The establlshaenc of anr relationship betveen aok to - i and caneera of the lar.nr, esoehatua and bladder au _at involve constdarable ruesauotk, hecauae of hti• vastly different incidence natterns and trenda a_f these d_1ae.ea, and eulclgls .u.g.et.d eaus-a,. 9
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r 567 incangruftiea in the treads ot teeideses tates fer "ether cancera." such as caecars of the oral ea.ttyo bladler, esophagua, lar7n and pancreas, sra alaost !q oasible to raconcile <ith the efgare[t.e s.oking cau ul hypethal/s. Theae trends, as descrlbed last year, include such aaoaalies as iecidence rates that rfae, fall or reraln stable dapending on dlsea<e, aea and race. Moreo.et, ner evidence indicates that a nu.ber of these cancers say be associated with alcohol consu.ptinn and that the a uoclation of alcohol with cigarette saoking o y not only confound the relacionships but aay hide other correla- tiona. In addition, recent work has inplicated occupational e:poauree and nutritional faccnrs in the etiologies of noae of thes• cancers. . Cardlovaecular Olse.ae A fair appraisal of the evidence, e:aalned tn !ts entfriZi, lndicate1 thag the rt~k of coronary heart dlseaae 1a s[ron¢lv associated with genetic and lifestyle factors. In 1977, the direccor of the governaencal agency responsible for cardiovascular research told a Congressional eon.itcee that "we still don't know the etiology of arcerio- aclerosis and h7perteaefan" nd that his researchers are still testing the "hvuocheais...chat lowering choleacer.l and ceasatlon of aaoking will delay or prevent the rnaet uf 10 2060460635 I
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bbe haart dia.ast' (e.phasis dddad). Mu.ohlle. statl.ttelaN .ars tiN iag that daatk rates tat heart disea.e ea.ti.ud ths dstil.e that bola i tha lats 11406 -- t a11 sH troapa, 1s Mth sarea aed 1• bath .hlteo aea saa.httes. Thore aa nn• eeldenns t• 1971. 1977 aad 1971 that iitastylas, personality pattarns anl hor.onal ishalasees ara i.pllcatsd in coronary diseass. •a i.portanc devalopaot to urdio.ascalat rssesreh. was reporc.d in 1977, by a group of rsaearchars who repartNd that they were unable to duplicats their pre.ious fladlnge, which tbr7 sei' had suggested a causal role of carbon .onoaida (CO) in ths dseelopaant of cardlovaaculsr dttau t. Io a presentation describind their findin{s, they said 'no direct toxic effeet of C0' could be dsnonatratsd. Chronic Obstructive Pu.nonar• Disuse The uncertaincles and unknovea Se the .a ic• uo er- standins E-L COpD pernit no fSrn conclusions ab~ut s.okina. Chronic bronchitis and enphysena are highly corpLa aod poorly understood disease.. Despite serious saps in the aedical kno.ledae in this area, claims sbouod that these dlteaaes are caused by saokint. The validity of uch claim. Sa challenged by a recent National 6eart, Lung and 13ood Insti- tute statement that "the exact etiology of a.phlseaa aN other chronic lung diseases ie unknovn... 11 ~ 1 2060460636
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an pubilt tneklee Tbis ewld hswe bess the sharta.t chapter 1s tlis tsllottiss, casideriel the rirst iiem to be presestU teie., let it .oe't bs, botsuee the syths which he.e irevn np staeed tke whole subject of public .okinl (so.ecifes t.lled "puslve stwkla+') ust be distussed, Despite those yths, the recent tescieoay of the sas .he baa directed the /overnoent's smoking aad baalch resu rch pro/ra for ore than 10 years u y ee`1 sae.arias the situation. Dr. Gio N. Gori of the National Cancer Imstituta was asked by a Congressional coenittee last Octoter, 'Is Other people's s.oke has never beee ahorn to cause disease in ncnsnokers. there evidence to sus{est that there eay, be an increaee in ris2 of heart and lung disease to a nonsaoker by being in the presence of s.okeraT^ laplied Gori: Yell, this ia a difficult question to ansver, Mr. Chairu n, because the answer that I have to give as a scientist say not please always the anti-seokln{ forces. but the fact reaains chat we really do not have toneluslve scientific evidence about the adverse health effects of passive smoking on the bystander [and) in the usual tonditiona under which eso`.inN is practiced, che evidence does no0 tndicate that the casual bystander fa aeriously har.ed by smoking (1). 13 2060460637 f
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lery retest research -- two pqets pahliakdd to the •oeaed -ait of 1973 -- easliru this appeaiasl. Is eas. Aiah appeated Is the Assriea• Nadieal Asseclatisn'e Arehiaal of ^nvtrsauaatal lulth, a CauMlu teaa teaed that phyeislaylul tespaasea to aaoka upoerre is aocsal adult^ covld -s desaribad only as •aiaisal" and said 'argusaats coseersiag stte-r rest on ayq tosatoln`y' -- Soathar vorda. on bow the subjects said they telt, a highiy unreliable standsrd (2). In the aecond, Danish and lritiab sciestlata wrote 1n Iaternatioaal archieea of Ocaupational and Levironsental ^ualth that they found "transitory dlacostort" but that eon- stituant^ of neither the as phase nor the particulate phase of aabienc ciaarette asoke have "a lutine ad.eru health affect in otherwise healthy Sndlelduals" (3). Like the Canadians, the ru earchers said their test sltuacioos were realistic and typical of rooo in which aaakers pather. Carclnogenic effecte have not been dauoastratad in husans. Nor do any studies to data establish that breathing others' tobacco sseka either cauaea lunt disease or vorsens the atatua of patients with eaiatlat dLaeue (4). And It has not been established that atnospheric tobacco saoke haa s causal role In coronary h u rt dlseaae in eoeaaokare (5). Yhat a•1- da..ce there to that aubienc cltatette smoke may affect CO sufferers has been called deflciaat (nea ba.ov). 14 2060460638
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aa1 gitreeaniaes d reeaat toeknlque of sees ralaarakdrs ba/ bdes te na-ssero levels of specific cigarette aeeka enapeasnto ia .ariena psbltc pfae u and then assesaee that tke tea- emekers, by eerely being pressot, would tnbale the aFsiealent ef so easy tigarettae in so nany houta. Oee such etperi.ent in os Tork •ae described i 1177 et a]olnt conference of the Anerttan Chemical Society aad the Chemical Institute of Canada (6). One of the researchers tnld hor they had isolated tiny a.ounts of aitroeaalno la cigarette saoke Iro, laboratory smoking achinas. Then they designed an apparatus to u asure the conpounds also Sn the anoke produced betueen the .achina's puffs (the sideateas a.oke, in effect). Nett they fitted the apparacua, consisting of two, gles-s jars full of "trapping salution", ao.e tubing and a battery-operated vacuue pump, into an attache case. And they headed, attache case in hand, first for a smoky Neu York coanuter train bar car and then for a saali aetropolitan bar "frequented prinar117 by cigarette-a.okiug clientele." The amounts of nltrosaalnea they crepped in their glass bottles, they told their fellor ehuiate, lndi uted that customers Sa the bar could have inhaled in eo hour the 15 2060460039
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562 ,aoa a.sut sf atttssuataaa as a a.eker af sise to 14, e.aflltsr elDarsttsa. the r.ssarchsrs thau dtaeusseJ the "sbstts.aisas' ef tbs[r sapertasat. ptrst at all, they sers dauliag with ".elacilss" •aieh ehsa{e swiftly io the at.osphere (if aet Ea s$lus battle with "trappint" soluctoe). Then thata were the two assa.ptloss on which their eetinates were baaedi sas, that ths •ade of lahalatioa in breathlnt and ueklat are eo.parabls and, tuo, that "saa's aaoklnt conditions ars aynospsoas with thess of the test sachlas." Than they ad.ittsd that setthsr assuq tten uas true. And they have yet to publish their raanlts 1o e scientific Joureal. The •easuresent of nltrosuaioes in tobacco aseke has besa eontroveratal. E.en the 1971 EE4 report to Congress coa.entsd that nitroasaiosa reportedly found in s.ake aa7 be "artlfacts depsndent on the sthod of s.one collectlon" (7). A Qatversit7 of California chealst hse satl.sted that at the trace asounts ottro"aataes were reported Ie alde- atreas saoke. eaokint as nan7 aa 100 cigarettes in a saall roo• rould product ea17 3 nanotrasa (3 ona-bi111cnthe of a gra.) of the co.pound per liter of at. (E). Ee aaid chat at this concantracton a carcinogenic effect could not be de.oo- trated in •ni.ala. 16 1 2060460640
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aea Carboa Mono.ida There vee considerable furor last July at the pd11- cation of as etpari.ent by an avowedly •et1-el(afetts teeter- ehar ta Californfa -- colncldenta117 just before that sute voted on a proposed statrvids restrictive public smoking .eanure. Dr. Yilbert 5. Aronov wrote that remaining two loura at a time Sn snoks-laden rnoer adversely affected 10 patIlent with angina pectoris (9). The research has been roundly criticited since then for faulty atudy design as vell ae unsupported conclusions based an self-deecribed e7nptoas of severely tll patients who Xad no doubt been advised, as are sort angina aufferers, to avoid streesful s1[uetlons (S, 10-16i. Calling the study "flaved." a Los Angeles chest apeclaltst wrote in The Loa Angeles Tteer: goth Sneestigators and sub)ecca .ere evare of their eiposure to the saoke and, ohvtouel7, that such erposure Sght he harnful. toreover, the major neaeurenent of the atudy -- the orcurrence of chest pain -- v u subjective. Io other vorde, the test subJects' reports of chest pains while etercisen{ could well have been Snflu.ared by their bellef that they had been harned by exposure to cigarette enoke. Considering this, aa vell as the eurlously low variation in the sublects' carboa7heeotlobin laeela (vlth and without e.posurel. I llad tha atud) aueetlenable and sorely to oeed of confiru tlon (17). 17 2060460641 ,
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564 Cerket7hsaeglabtn (COMk), retarrad te by the Lse Assaiaa pbraleias, Sa the key to tha ehee$se sade asa/sat cigarettes le both the heart g/USaue aru aad 1• psDlie aNk- fy . COIb ta ereated 1 the blood ohan csrboa soaaalde, fras shatever the aource, coebinea with red blood plpast. Clafsa about the alleged health effset ot CO aa found in cigarette sseke (see also Cardlo. ucular Disease) appear to be based on research which ehosa that an average a.oker has higher levels of COgh than an avaraje sosasoker. Lrperisenta in reat ruc u under varying atsoapberlc conditiona, with varying nunber of cigarettes and other tobacco producta burned or ssoked by volunteere. have ahovn increaaaa of CO In the rooo atr. An Snportant point to ra- senber is that when indoor areas are adequately ventllatad. CO levels should be reduced to a point that no adverse atfecta will occur in persona aod groups expected to be present In such envtronnents (18). The few studlea that alao neasured the COflb levels In anokers and nons.okere in theee test roona found that even under severe conditions there vas not an appreciable increase in COBb (19). In what Sght be considered the eoet aatraae aaperl- sent, Sncldenta117, four peraone got intu a sna11 turopean car, vindovs up tight, inside a closed garage (20). Tvo 18 -MO 2060460642 J
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565 sostsrs peeked 10 e yarsttss ta as hser, ud the eoeh te.als tese sharplp ts all abJscts. stedtes bass measured CO ia the stasphsre e.der N rs realistic cesditioss. Co.btnsd rss.lts sf thsse studies iadiests that CO frem s.oks asasursd 1e sarul daily sttnatie.s rarsl7 ssessds 10 parts per .illion (21-26). Ci{aratts ssoks is, of eourss, pot the oa17 scures of CO ia the ataosphers. 7ha •ost predoainant odarn souree is ashaust fro the tnternal-conbustion enetns (27). CO 1s also a natural body constituent created by nor.al natabolis.. l.ceatl7 a Canadlan researcher rsporced that high levels of CO ars generatsd ehen pots and pans are placed over otharrlse elaan burning gas flanea during the cooking of a.eal (2E). sicotine The qucstion of nicotine absorption by nons.okers has been Snvestigated by sose scientists. These studiss, in both ezperisental snd real-life situatlons, have shown that oonseokerr are ezposed to in.ignificant a.ountz of tobacco s.oke. In fact, uhen a German researcher found that the nonsnoker takes up on17 a s.all fraction of atcetins, hs concluded that 'when speculating on possible haalth hat.rds by passive anoking, one .a7 ignore nicotine" (29). In order to discover the pocstble ph7siological 19 2osaasos4s
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666 stfdetr of asped.re ta ateatisd, ether rde urabard resardad b asrt rataa blood prosoures alaetreea dt.Orao taadls p aad •kis t.sperat.ra te se.aaekara is atparilestal reNSs •itb baa.) roscaatratioas of tobacco s.aka. eaa of tkdae )erd- saters saa N aaurably affected (30). York Perfornanc. Any ciafos that tobacco e.aka, or the CO is tobacco a.nks, adversely affects work prrforsacca ara not rarranted by the esidencn. The 9LY 1975 report to Contraan a1d that shat erldeuce there 1s 1a that area is cooflictfoa and aar "payeho- aoter" afNet of CO esposure "reaaloe unclaa" (19). The Pederal Aviation Adsinistratlon addreased the poiat recently tn its denial of a patltfon that s.okin{ be banned ln the cockpit (31). In fts denial, tha FAA cited concluslons of Air porce scientists ca effects of abnorsally bigh levels of CQ on performance. The aaenc7'e nasa rel.aso about the pacition denial said: FAA aaid the iaforsetien submitted by the petitioaers to support their rontention that smoking t.paira petforaanca "1s too Snconclueiea to •arrset the fesuance of the raqueatsd rula"...iaA toseaded that ssokinr can reduce the blood'a ory`en-earr)1s{ capability bui said the.e 1r no e.idenca at preaast that this hea any daletarioua effect on perfor.aace. In fact, the agency noted that there 1 evtdesee that the body adapte to the effects of a.all aaeuata of carbon aonor:de by tncreu tnr tts red blood tall 20 ( G0C70'f60644
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sa.. .... th.a, its sap$es-esrr7ta, eapakiliq. It ttll.d the petitiesere' failera ts addrsss this plst a sajer detieisscy ln thar ar@YM.at (li). Aatinsal laetit.tes of ealth panel sf seisstists also co.sidered the auestlos of eockpit ssoklns early L st year at the request of the Surseon Gensral, perhaps as a result of the p1A turndoun and the tAA'a view that the ori{isal petition was deficient. - After a thorough review of ths scieotific litsraturs as vell as infor.ation obtained fro• t'- Departunt of Defuse and the TAA, the IH etperts ta.e to the sa.a conclusion as the 1AA. Ssoking by the pilot -- even if he or ahe is a regular ssoker -- the7 said. "is judged to have ne{1i`ible effecta an physi logical and psrchosotor functfons and thers- fore on flight aafet7, especia:l7 vhen tospared to overall perfor.ance skilla desaeded of pilots" (33). Smoking :± airplanes brings up another aspect. Is it the cigarette s.oke ftaelf or the .iLg of cigarette sroke that bothers tLe typical person who objects to publsc aaokin57 [ecentlr, a trial plan in which eeokers ut aeross the aisle froa noaesokers uas tried by Yeatern Afrlinel. Yescern enHtneers said the trial produced a torrent of eos- plaints and blased psrchological ^ffects rather that any 21 2060460640
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568 satilatta prebin (34). the lor.er avtstiea Niter e! Wettd lrose 1lt.raetto.el, ceaentiea on that reetere trial roe, a.4d, 'tt a@ ws that all a eaes.oker eeeded •as to jn .e.eeee e.okiaR. s.d that .as ssnuRh to .ake hi thiak ke eeeld s.a11 tke aaaas. t's afraid this to just eas sore lutaacs skere alotioaulfsa sets to t4e way of establLhed scie.tlfit Letse (33). A1lereel So.e nonseokere, of course. ae7 they are not just bothered by seoke, they ate al.o ellertic to tt. Indeed, for.er Surgeon Geaeral Luther TerrT steted in 1977 that "thsre are a few people who are actually allergic to tobaceo smoke and can be .ede tll froa exposure" f1bi. Despite Terr7'e belief, oeither ctRarette s.oke, ner any of fts toaponenta as found in seoie. hae been de.on,tratad to be a hu.an allergen. Researchers at the Maeo Cltni< reported to the Aaerlcan Aeadeey of Allergy Sn 19'S that they had tried, snd failed, to find evidence of tobac-e ssote allergy in their t u ts with patienta (37). Last re.r, after anal)tlo{ the pertinent literature and dfscuastna his own reseercA work at Tula%e Medical Center, Dr. John Salvattto told a ConRressional coaetttee that "there Sa no proof that tobacco s.oke is aller- 22 r 2060460646
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WO qalt 1 sian" (3g). Clatse about toUrco allergy te primarlly }ree rasu rch that hae bess doee with tebaceo jW. titratts o[ laaf produce alletgic rsactloa 1 asa,a people -- b.rh smokara I]" nesaeekera -- usually these .ho arr othlrwlaa allerslc (31-42). Whether cigaretta sanke or ey af !ta eosatltveets is alLarg.oie cannec be rea-leed, hoseeer, 1 tuts with tobacco leaf. Dr. Carl ecker sed colleagues froa Cornell Medical College have reported isolating a brown pigueeted •olecule (ter.ed "tobacco glyeoprotain") from both cured laaf and fro• smoke. The7 claim it is an ellergen (43-45). These taperi- sental pathologists hate speeulated that "tobecco glycoprotein" pay be reaponeible for so.e of the disaae-aa which haee been statistically associated with aeeking. lecker'a reports were of special interest to guasell Stedaen, who for years directed wotk with tobacco leaf aad tobacco smoke condensate at the Departaent of Agriculture Eastern Regional Research Center in Philadelphia. Indeed, Sted.an, who is retired nou aod serving ss a bioche.ical consultant to Tesple Unlvereity. trl.d to duplicate the published isolation procedures of beeker. Scedaan said he found that aue step 1n gecker's aethol introduced aa yet unidenclfied extraneous cont4atnanta into the brown plgaented 23 2060460647
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570 matattal teelatea, tkae tested b•eeke-r fer aller{aaie pr.pry H tFaa. dad, SeeUaa .rete last ree te the Iena dSrteal- tary Tekatta Inkcaa.tttee (aa) thel Ietker'a sepaFatl.e techsitee bad already baee docoaeeted, as early ae 1971. de lstredscise 'eu.ataotial cheaical u terlala' f.te rkat aae tai¢ad (47). Ia his statement. Stedman coateeded tkat far a sambar of reaseaa he was 'uacoeeinced' that keckar had dasoa- etrated the pruence of a huaan allerien in either tobacco asoke _os aaoke coadenestt. For e u apla. Stedman rrete that eeker has not specified whether the 'jl7coprocein' rlth which he had produced allergic reactions to volunteers .ae froa tobacco laaf or tobacco eaoke condensate. Although lecker aaeu.ad that the aateriala were ideatical. Stedman noted that he bad coneluded froa his own research that they rere aufte different chemically. Stedman alno stated that he was not sure whether the material lecker had extracted even was a sl)co- protein. Pareut/Child Eftect• A favorite slogan recently of those urging laSlala- tlon to restrict public eaokink has been that cigarette e.oke can cause reepiracory disease in a child. Or if they rent to be more dranatic, ancl-publie-eaokere say eoaethiog eatchP, such as the declaration of a Mer York physician chat ^The 24 2060460648 ®
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571 larpst area of ehild .bus. ts par.nt.l saaktege (ag). Tk.c saeL.r.' children h.ve .ore r..pirat.ry a1lm.st. X11fe.e th.ir parats aaek* te strictly ceel.etsral. oe! .pideafelogie.l raeauch has kun does ee the qeeftlu s.r. asd .kroad. bat qe inve.tigator he. be.e able eo daoucrats that cigarette .aak. !n'the ho.e is responsible for a ekild' pickieg ap a g.ra or cough. Sose have report.d that eigar.tt. saoks a.y be re.ponsible for adverse eff.cta in )onsg.t.rs (49-59). gut th.ir work has been questioned b.cau.s of faulty study dasign or suspect ronclu.iona (19, 54). gpideaiologtsts whose own research in smoking and nonaaoking boaes in three Aeerican cities was published Sn 1971 (55) wrote on the subject again in 1978 1in iriti.h Medical Journal (56). First they .uae.rited their earlier cooclusioes that neither lung function nor respiratory alaptoaa of a non.eoking husband or wife were affected by a smoking apouse and that parental smoking appeared to have "no effect on children's respiratory syapto.s° or "lung function." Theo they suggested that "the only definite evidence" that parental smoking aa1 affect chlldren's respiratory systeea raa a gritish study (57) indicating that the lnfants of r smoking parent. have aore respiratory illn..s during the first year of l1fe than infanrs of noneeoklna parents. 25 2060460649
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572 gut they poteted out that ts the •aee papeilttee thtn .as nat true fe ehildren agrd ane to ttve )aats. Aed they eeneluded that 'at peeaeat thers ts na fte• •etde.ee that tb.ee t1l.oseea it children undet aoe )eat hae• • eettese ead laalfg effect as no aseaae -f respiratory itlness or disisiehed 1e.a functloe has been found tn the oldet chlldtu ef s.oYifg parenta.' At least four other studlea haee failed to delon- strate adverse effeets nn childran of s.oking parents (56-61)• tlther envlron.ental and socloeconeaic factors that have been aesociated with resplratory s7mptoes and disaesea include a'cooking effecc" identified 1n a four-year study of 5,700 youagscers in Leglaad and Scotland (62). Boys and girls fron ho.es in which gaa was uaed for cooking had .ara coughs, 'eolde going laco the chest" and bronchitis than children rhos• ho.ee had electric ecoves. ihe researchers concluded that products of fuel conbustlon .Ight be the cause of the Snct.ssed reapiratory illness. Conclueion Public snoking has oot been shorn to cause disease in nons.okers. As a past preeident of the Aaeriean Association for Shoraclc Surgery recently stated; An aseertfon that tobacco sacke Is a health haaard 2c ~ 2060460650
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573 to the normal noea.oker ie untenabl.. The ral5ht of evidenee as it e.iat. fn th. rorld literature doe• not support a nlal• of adverse health afects for thoee e:pe.ad to "pa.etve aaokfna" (63). Speculation that reaction to publlt a.okln{ way ha.e payehological or emotional oriSine 1s worth toaeld.rln5. A.edltal eolu.ni.t noted recently that ".y.pto.a .ay eoae fro aaSat rathar than fro• the eaoke ita.lf" (64). tlo added that: ...rhat is Srritatln6 or annoyint has not yet in any scientific study baea ahoro to be dangerous to the non..oker. 27 2vsoasos51
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I 574 kefeeeacee for Public Snokine 1. Goe1, G J. EearinHs before the Committee on Interatata aed Porei{n Coa.arce (Subco.nlttee on Oversight and In- v u tiEatioaa) an Cigarette SnoklnH and'Health - Update 1978: pp. 4-58. Oct. 6, 1978. 2. -P1.., P.E., at a1. Ph7a]olotlcal Effect, of Anute Paaaive Eipoaure to C18arette Snoke. Acehlves of Environ.ental Health 33/4: 201-213e Ju17-AUSust 1978. 3. Hutod, C., et al. Exposure of Passive Saokara to Tobacco Snoke Constituents. International Archives of Qntupa- tional and Lnvironaental Health 42: 21-2q, 1978. A. Moser, E.M. Teati.on7 before the Tobacco Subcon.ittee, Committee on AEriculture. U.S. House of lepresentativea, 95th Congress. Second Sesalon. Serial No. 95-000: pp. 35-40, 25H-282, Sept. 7, 1973. 5. Enoabel, $.1. Teati.on7 befor, the Tobacco Subno.aittee, Committee on AErlculture, O.S. House of lepresentatlvea, 95th Congress. Second Session Serial No. 95-000: pp. 49-55, 322-330,. Sept. 7, 1978. 6. Eruona.ann, L.D., sod Hoffuann. D. Volatile N-Nitro- sanln u in Tobacco S.oke and 3o Polluted Indoor Envlron- .ents. Delivered at the 2nd Joint Conference sponsored by the Chenlcal Institute of Canada and-Anerican Chaa cal Society, Montreal, Que.. C.nada, May 29-June 2, 1977. 7. U.S. Public Health Service. The Haalth Consequences of S.okine. A teport of the Surgeon General: 1971. O.S. Dapart.eot of Health, Education and Welfare. Washington. DREW Pub. No. (HSM) 71-7513. 1971, 458 pp. 8. Sch.aurer, O.N. Teati.on9 for the Subcon.ittae on Tobacca. Committee ae Atrlculture, U.S. House of tapre- aentatlves, 95th ConHreae, Second Session, Serial Mo. 95-000: pp. 139-157. Sept. 7. 1978. 9. Aronov, W.S. Effect ~f Paealve S.ok1nE on Angina Pat- torla. Neu England Journal of Medlclne 29911: 21-24, July 6, 1978. 10. Aviado, D.N. Statesent before Lnvirooa ntsl Control Co..lttee, Chicago. III., ee entered luto record of the Tobacco Subto\aittee. Committee on AErlculture, U.S. HCuae of tepreaentattves, 95ch Cun{reas, Second Session, Serial No. 95-000: pp. 185-223, Sept. 7, 1978. 28 2060460652
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575 11. goeker, •.N. Teetimoe7 before the rukeomeittae aa takecco. Com.ittee oe Agritulture, U.S. Ineaa af Sapre- ee.tetl.ee, 9Sth Congreae, seeond Saeetoa, gerial ge. 95-000t pp. 66-68, 337-3e5, Sept. 7, 1178. 12. CaoN1.7. A. Lettet: Nev 1621,64 Journai of M.diet.e 299/16: 897, oet. 19, 1978. 13. Iieher, [.[. Teeti.on7 before the Tobacro 6ubcouittee, Coasittes on Agrlculture, U.S. Nousa of kepreeantatitea, fSth Coegreee. Second Sesslon, Serfal Mo. 93-000t pp. 2-I0, 232-371, Sepc. 7, 1978. 14. [icke), l.J. tu tiaon7 for the Tobacco Subco..ittee, Coulttu on Agriculture, U.S. Houee of leprea.ntatives, 95th Congrese, Second geaslon, Serial No. 95-000: pp. 133-135, Sept. 7, 1978. 15. Watte, C.L. Letter: Nev England Journal of Medieine 299116: 897, Oct. 19, 1976. 16. WakeAea, H. Letter: Nev England Journal of Med3eim• 299/16: 896, Oct. 19, 1978. 17. Iliden, A.H. No: Environ.ental S.oke Can Irritate, not Inlure Others. Loa Angeles tt.ee, Part 5: 1, Oct. 29. 1978. 18. g7lender, !. W-,rkahop eesulte: 4.i. Perspectives on Invirooneutal tobeccc Smoke gffects. In: Lnvl:on- ..ntal Tobacco S.oke Cffecta nn the Non-Seoker, Report fro• a Workshop. University of Geneva.-197i. 19. U.S. Public Health Service. The Health Cooeeduenc u of S.okeng: 1975. U.S. Departmeot of Health. Education and Welfare. Washington, DREW P•tb. No. (CDC) 76-8704, 1975. 225 pp. 20. Srch, M. The Signlffcance of Carbon Moooride During Cigarecte Smoking Inside of Aucoeobiles. Deuteche 2eicachrift fur Gerichcliche Medirin 60/3: g0-g9, 2967. 21. Sradkovski, 0., et el. 6od7 6urden of Carbon Monoxide rroe Passlve Smoking [n Offices. Innere Madltln 3(6: 310-313, Septe.ber 1976. 22. Cole, P.V. Coepararive Effects of Ataoepheric Pollution end Cigarette Smoking on Carbo.vhe.oglobtn Levels in Man. Nature 255/5511: 699-7C1, 1975. 23. Anderson, C., and Dalhavo, T. Health Risks 9ue to Paas3ve 21) zosa460s53
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$76 tookLet. Letattidetsten 70/33: 2a33.2i36, Aut• 13, 1973. 24. trlits. D.P., eai Core, M. Coatotbrrto to the Auens- •oa[ of tapeaure ef gaa-g.okere to Air Pollntiss fr. Cltkrstte and Cigar t.oke in Occuptsd tpees. t..lrea- Haatei tesearnb S/2t 192-209, 1972. 25. U.S. Departesat of Tranaportatfon, Pederal Aviatfoa Adsfefatration. U.S. Depart.ant of ealth, 4iutatie snd Yaitare, National Institute tnr Oecupational fafety and eaith. t.alth Aspecta of Saoking fe trauport Aircraft, toekville, Nd. AD 736097, December 1971, ts P9• 26. farke, t.P., •t a1. The Ptoble• of Passive gtaktet. II. Inseetlgatioos of CO Lere1 in the Auco.obile After Citarette Stoklnt. Internacionales Arcbie fur Arbaits- qadisln 33/3: 207-220, 1974. 27. Dlsepbad, M., and Lhrllch, L.R. Carbon Moeo=Sda Concen- tratfon Trends fn Urban Atnospherea. Science 176: 193-194, April 14, 1972. 2!. Sterling, T.D. Testi.on7 before the Tobacco Subcoa- sittee, Coaalttee on Agriculture. U.S. Bouse of tspresee- tetlves, 95th Coattess, Second Session, Seriat No. 95-000: 41-45, 252-297, Sept. 7, 1973. 29. Rloaterkotter, V. State of the Medical Debate on the Thene °Passlve SnokSng". Dellveredto conference on Passl.e Ssoking to the Workplace. apoosared by Savarian State Mlnlster of Labour, Munich, Germany, March 31 - April 1, 1977. 30. tatke, t.P., and Slelehert, A. On the Problem of Pae- aive Snoking. lnternatlonaiee Archlv fur Arbetteaadizln 29: 321-322, 1972. 31. U.S. Department of Transportatton, Federal Aviation Adainlscration. Denlel of Petlclon of the Airline Pllota Committee of 76, Pub11c Cftlzen't Health Research Group and Aviation Conauaer Action Project to aaend Part 91, Pedetal Aviation Regulationa: Aeg. Docker No. 15616, Aug. Z2, 1977. 32. U.S. Department of Tranaportatlon. Nevs releaar. Peti- tlon to tan Smoking by Airline Flight Creve Dentad. Sept. 1, 1977. i3. Nacloeal Institute, of Neelch. Cigarette Saoklnt an.. 30 206046060554
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577 Alrlise Pilotu H faets of 8.okiee aud 8.akiy itkdrsval oo Plight P•rforta>ee, • kaport of as gspart Paeol of Co u eltant•. U.S. Dapart.ent of ealth, tdoaatias ead Voltsro. Yashtneton, April 1918. 81-97, Sept. 7, 1918. ]A. Aanoefetsd Press. ous.ok•r Weaa is •ad or lesel tatko.aaek, .J., Runday getord. Jul7 10, 1977. 33. berliag, R.J. Letter; The WaehleSto Postt A-16, - July 7, 1977. 36. Terr7, L.L. I a : S.oke kan ifndla• Croaafire, by Prauk 9anDusen. The Atlantic City (N.J.) Prals, Oct. e1, 1977. 37. 11eDougall, J.C., and Cleich, G.J. Tobacco Allergy -- Pact or Papcy7 Journal of A11.erp and Clipical Iuun- olog7 57/3: 237, 1976. 38. Sal.a881e, J.Z. Testl.on7 bafor• the Tobacco eYbco.- itt•a, Co..Ittee on Agriculture. U.S. House of Rapre•en- tatlves, 95ch Congress. Second Sesalon, Serial Ro. 95-000: pp. 46-49, 298-321, Sept. 7, 1978. 39. Pu hkln, tt.M., and Landa7, L.HJ. Cutaneous Reaetions to Tobacco Antigen in Aliergic and Noe-Allar{ic Children rith the Direct and Indirect (Local Passive Transfer) Methods of Te-sting. Journal of Allergy 10/3: 2a1-2A5, 1939. 40. Pontana, 9.T., ec a'1. Studies in Tobacco H7peraensitle- St7 III. Reactions to Skin Teets and Peripheral Vascular Responsas. Journal of Allergy 30: 261-2A9, 1959. 41. Harkav7, J. Tobacco Allergy in Cardiovaacular DSseau: a Review. Annals of Allergy 26: 417-459, 1968. 42. Speer, p. Tobacco and the Non-S.oker. A Study of Sub- lettive S7.ptoau. Ar<htvsa of tnviron.ental Healch 13/6: a43-446, 1968. 43. gecker, C.G., et a1. Tobacco Allergy: I..adiate Cuta- nooua Hypersensitivity to an Antigen Purified fro. Cured Tobacco and Present In Cigarette Smoke. Federation of A.erScan Societies for Czpereseotal Eiology Proceadings 35/3: 673, March 1, 1976. 44. Reeker, C.C., et a1. H7persene/tlvit7 to tnbaceo Anti- gen. PtoeeedlnRa of the National Academy of Science USA 73/5: 1712-1716, May 1976. 31 2060460655
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578 43. iseksr, C.C.. and Dabls, T. TebACCe Allergy nad CArdia- eaaealar Dlaesna. Cardloeascalar Nedletae 7/8t 031-636, Aa{nat 1979. 46. Stadaan, t.L. Testlaoa9 fnr the Tobaceo lsbesaialttas, Ceaafttne an Atrteulture, D.S. louae af Heqrasantntiau, f5th Coalrn.s. Sncoad leautoe. Ser1a1 lo. 95-000t pp. l2-f}, i.pt. 7, 1976. 47. Cbruabach, A., aad Sodbard, D. lol7aerylaside Oal [lne- troDhereaia. Selence 172: 440-445. April 30. 1971. 49. [iee, J.S, Statnnoot dall.ared bafore the A prius Cancer Societ7't 7atloeal Cosnlaaion on Smoking and pnblic lolfel, lhlladnlphta. Juee 16. 1977. 49. Caneron, P., et a1. Tbe Healch of Ssokera' aad on- saokera' Cblldren. Journal of A1lerty 43/6: 336-341, Juno 1969. 50. Caauren, !., and lobertaon. D. tffect af tneironuntal Tobacco Saake on lan117 Health. Journal of Applied Pa7chololy 57/2: 142-147, 1973. 51. Luauecte, A.J., et ai. Soae Insedteca ttfer:te of A Smoking [nvironaent on Children of tleneetary School 1s•. Joarnal of School,Health 40/10: 533-536, Deceaber 1970. 52. Colle7, J.1.T. teepirator7 Synptone to Children and Parental Smoking and Phlep Production. eritish Medlcal Journal 2: 201-204, 1974. and Davtea. A.M. Iofaat Adalaafona to 53. Sarlap S. , , 54. Hoapital and Maternal S.okint- 1974. U.S. Public Health Service. The of Saoklnt. A Report of the Surgeon Departnent of Healch, Education and Lancet .. 529-5]2, Sealth Conae9uenceo Oeneral: 1972. 0.5. uelfere. Va.hinacon. DHCV Pub. No. (HSM) 73-3104, 1912, 156 pp. 55. Schi111n1, 1.5.t., at a1. Lung luortton, teaplratory 01un6ee, and Smoking it lanilfee. Anertean Journal of tpfdealoloty 106/4: t7c-2b3. October 19'1. 56. Schilllns. H.S.v., and louhoye. A. Letter- tritlah Medlcal Joureal 3: 595, 1975. 51. Culley, J.I.T., at al. :nfluence of leuetee Smoking and Parental Phle6a on Pueuaonla and ltaehttte in Early Childhood. Lancet 2: .031-1034. :9'.. 32 2000460606
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579 S8. BAy, C.M., et al. The Chattanoop School Childres ited7, ttleets ot Con.uait7 8apoeure to sitre8an pioaida. Jaurnal of the Atr pollution Control Aasectatio 20/9t 582-38t, tepte.ber 1970. St. 8aa.er, D.t., st ai. Air poliutios sed Childh.N Lewer teaplratory DSSeaua: tspoaure to Indoor Air pall.taats inelndlnt Sidsntrea• S.oke. 68th Alr pollatio Costrel Assorlatlon Abatracts: 157-158, Juna 15-I0, 1973. 60. Leleoits, M.D., and lurrors, !. Reepiratory t7sptoue talatad to S.oktnt 8ables of pan117 Adults. Chest 69/1: 68-50, January 1976. 61. Lerrlbljo, t.p., at al. Chronic Monspeclflc taepirator7 Dls,e u a in Children, Five Tear po:lor-Op Study. Aeta paadlatrlcs Standanaelca Supplerant 261; 1977, 71 pp. 62. Mella, 2.J.Y., et a1. Aarociation 8atreee Gas Cooking and Reaplratory Diseu a in Children. 8titith Medlcal lournal 3: 149-152. 1977. 63. Lantston, B.T. State.eot before to.tronaental Control Co..itta_e, Chicago, ILL., as entered Snto retord ot the Tobacco Subco..lttee, Coe.ittee oo Agriculture, 0.5 e touse of tepreaentatl.es, 95th Contress, Second Sualon, Serial 95-000: pp. 158-184, Sept, 7, 1978. 64. 8nlberats., M.J. Smoking and the Nouaaoker. 8er York Tinu Syndlcate, for release Kay 12, 1978. 33 2060460657 ,
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590 I 1aokigft and O,.Sr-AI1 /Iofjelltr 'll]t is •ot unt.elosabla to speculate ohat the klad of u a eho bacoao ragulat cigaretta ssokers are, tc a•odetate dagreet le.s iahutantl7 able to sur.iee to a rlse old age eh.f aoa,- saekars.' "Seoktag aad 9eelth: 4port of the •dvisory Cosa ttee to tce Surgeoa Genaral of the Public 9ealth Serefce^ 196• ( I ) thls senttaent, buried in the report ralaasad lanuery 11. 1964. iis not ao uoreaaooable apecula_foa today. tut the ortallty statistlce chat report developed on reported saokar/nonsaoker differences are still beiog used -- and abused. or Sastante, the gg9 report to Congress of 1917-7g ade the stateaent, based on onlT three population etudiu. The use of reaults from flawed populatioa studies to frighten people by attributtng large numbers of deaths yearly cc ssoking •ay be wisleadiog and is aost regrettable. that °aver-all mortality rates fOr cigarette aokerc are about 70 percent higher than thoee of nonsaokers," and discu uloa of saoker/ooos.oker sortalicy differences occupied al.osc half the report (i). gC9 Secretary :alifano took the mortality rate 35 2060460658 •
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581 t.pltcations one atep turthert saying in January 1978 (and often throurh the yeur) that sare than 700,000 persone died io 1977 trem eancer and heart disease for rhich ".sotint •as a major factor" (3). ' " For a•ore cosplete erpositlon of the so-called 'eatu s du thr" concept, see Appendts. Meantise, her.'s hov ost of thees aort• of titurea vera derived. The caleula- tloea sere based on the population surveys (4-12) on vhich the first Surgeon Geoeral'a.report (1) relied so heavily. Governeenc staclsciclans cook data fros the sevsa eutve7s. conducted in various araae, in various groups of people, over veryist periods, and considered for the sest psrt only vhether or not the ublects smoked. The atatls- ticiens then reanal7sed the data and computed what they called a mortality ratio (snokers n. aonr.•kere) of 1.69, "A aorcaltt) ratio hithar than 1 Lsnlies (emphasis added7 that the group of a.okers haa a higher over-all death rate than the non-ssokars," they said !n the 1964 report. Lspressed another way, the sortality difference Sa 68 yerc.ot, and the 1977-76 report aulhore rounded 68 off to "about 70 percent". that's the ercesa percent of deaths observed ever vhat itht have baer erpected had anokers dlei ac the se.e rats as nYYseokera. Lut, a the authors of the 1964 report pointed out, 36 2060460659
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582 the aortalitf diftsr.nce in the seven surveys varied troa sa percent higher !o tritish doctors (S,6) to [3 percent higher for an •.etitaa Cancer Sociatlp survey roadurcel by volunteers (11,12). and the 1966 authors alsa drar attsation to the pnu ibility ahat bias ariainS from what aere high aoarauponsa - rates ".1ght account for aortality ratio of 1.3'. Thie ralsaa qusstioaa about the other blaua that might affect the accuracy of the 1.66 figure. Still rith us? Lat's get on, thsn, with some of the 'raaknassu" of the surveys fro which the 1.7 aortality ratio ras computed. Some have -aaa enumerated by the Snrarn- senc paople thaiaalvas (1,2', cas pointed out by others. !ut first let us consider aoothar not unraasoubla speculation by the authors of the first report: [T)ha low death ratss for noa-saoksrs (lower than D.S. Seaaral deach racssl suggest the possibllic7 that the studies ranruitad unusually healthy sroapa of noo-s.oksrs (1). Dasltn Weaknesses •.arlcan Caacar l-otiets surveys (10-13). "Nen in 25 states' sas the largest of the seven surveys. The authors of the 1pa6 report said that this survey ad the earlier "aaa Sa aias staces" survey "duffst from the difficulties that the pcpula- tiaas tudiN sra hard to defins, that the smokers and so.- 37 206a4so660
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M3 e\okera were recruited by a larae nueber of •olYateer workers. atld that aanpleteness In ths reporting of deaths ras hard to achisve, siate thia depends an rsporta from the eolutsere' (1). What they didn't say was that the larger Canter Seetety surre) round up with a sals long eaneer death rate trlan as high as that of U.S. ealu nationwide aad wo.eo'a rate three ti.es aa high as that of U.S. teesles. Death rates observed for coronary heart diaeass and asph7sua were 10 to 40 parca.t hi{her than sale and fa.ala nattoaal ratas (1L), all of rhich leada to the not unreasouable speculation that the .olanteers enrolled u ay who were already 111 with theae disaases. lf persons with allesed seakiat-relatad 111a rere o.errepresentad in the ACS populatian, so.rere reaidenta of coaatal and urban araas, including the lnduetrialired lorth- eaatp CJe tlouata:n etates and the Northaeat tier were earlnded eatiral7. There was an o.erabundance ef better-edunated, aative-born, Protestant +hites and a dearth of blacks (14). Aad aap of the ACS surve7 states tuc: dea aleo.t all the so- called lu q cancer hot spocs identified In the rational Caacer Isseltuta' neu "cancer atlas° (15) (eee chapter on Cancer is the Yerk Place). Oae findiat troa the later Ar,T survey 1a surpriaiat aad distorklag if ena believas that tobacco caueee diassset 38 2060460661
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584 )toa uho ssokad-ttpra ealy -- ae well sa those who s.ekad pipeo only -- bad leoar ortality rattoa thas thoas who aaoLad ao tsbaeco at all (1). This ttaditg ean aot aasily be dissitsod as a qalrk of aatara baeause the kritf.h doctors stody (S.s) clas reported this "Yaeoarnity". Lha U.S. veterans survey (7.16). Jn.t as oar.prasentatia ot tka total U.S. population aa the •Ci's pradaalsaatl7 fddla aad upper soetoseososie subjeoOS. the atera.s .ara mostly whtt.-eollar. skilled workers rhe snr.ed ia Vorld Vat I. Skair nrokln0 hsbits, unfortunately, sars recorded ssly rhsa they first ratnrnad their quutlonnslras (So two •sas,l 19!d and 1957). Reporting on later data tros the aaua popalatio (L7), the HtV 1977-78 report to Congress aoted a a.aahaosu "tha lack of Lntor.ation about aere roeaet chan{u ina.okiq hakits' (2). One of tha strange LlndlnSs: tatarans •ka ad smoked cigarettes aod othar produets for ZS to 35 yaara ksd lo.ar mortality ratios than those aaokina only 15 to 14 pesrs (1). )ritlsh doctors sur. n(5,6,1h). An obvious drawback in tki• snr.ey is that its subjects ur<a highly aelactsd. krltlsN prsfasstonal ssa who shouldn't be considered eoaparabls ta saq pasral 9.5. population. Nera Laportantl7. the survey aetrallp shwad that quittiei smoking did not reduce .ortalit9 -- tba ssstt oppostta ttad(ng Lroo that elai.ed by sasy who ha.a cited 39 2Q6Q4C''SQC7f)2
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it u proof that ellarettss short.e 11-.es. whse a etak faeter has bsec associated to a poputs- tioe vrth Ssersuod laeideeee of e disaeee (er daath), ra.e.al sf that risk factor should resrlt Sn a drop Is ehat diaoase (or " death) is that popuiattca. A Sa pereest vednetlos te etpretta seekl0{ brtvaan 1f51 aod 1945 ddid act chae{a tha o.er-a11 death ratau i theaa years in tha Brltish dectors /11)t Aed ahere •ast the rasle~e-tba-risk-laeto[vOd-tnduea-tba-[!st theary-- at.laast as far aa tha Iritish aacters were coeesrsed. Aeothar probla with the ph7sltlaes snrveT was refsteed to brlaflT before, that of "noors.posss biaa'. Oaly tvo-thlyda of the doctors who vere sent questionnaires replied (11. Ie other words, ons [n avery three Irttreh doctors ca.- tattad either was oot Saterest.d enough to raturn his qseu- tlesnatrn (er had eona reuoa oot to) er al0e {are asuvara that wra rejected as loconplete. There is to ear of kuorln{ If those who do est participate in a sur.ay of this sort are slsllar to these eha do. The authora of the iritish doctore survey •rota later that a e uple of their aoeraepoadeers indlcated thaq differed is several respects fro a saqia of raspoadaata, asd the authsrs [ait "sura that the ductors vho ehese to aasrer •ere aet rap- rFeeutatt.a at the tetal" (1I). That such esrespetus saa eartseslT btae this sort of l0.utllatioe and lead ta a"spat• at ds.bta' has baee eaprrsaed eloquently by osa of the euthefs 40 ' 2060460663
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ot the saaa nurvs7 of rttteh doctart (201. tt 1n not surltlilot that ehe authors et the 1964 tupert propart7 •arned thac "nona of the l~pelatless .as due y sad, in psrticrlar, to be ropressatative of the Q.l. eale pa slatlea". Or that Chn7 coattaued: 'Aa7 sea.er to the qe.e- tie• 'to •hat ksaaral populatloo of aa can the resaits ba tps11ad1' arst tarol.o an nlusnt nf uoverltiable )rdg.eat... Tte aevna tudiu differ coaaldsrab)7 is aisa. They var7 also La the e a aat to rhleh th q arr free froa asthodologic .eat- usea' fl). Alaent a doeade later a tanadtso researcher cosasnted os the aethodologleal problaas in the surve7s befara a. Aaerlcse ftatlstlcal lssoclation .oatlns• s iecluded a eo.- Slatat chat "fav if an7 of the nae7 atudles reVetciLs • llsk bet.aaa s.otlns aad diaosan ha.o ever been published in a prtLclsal statistical ]ouraal rbars the sthods of aaupling sed date 9991761.0 .ould have received adsquate rsvisa' (14). Ie view of tha an7 critical dafaecs So thsae surv¢7s, hs sa{- goated that researehers should reevaluate thefr past reltoea n• the.. •stnciatloa vs. Caree Leq feryattsa /n 607 clataa of btah aerteltt7 ratiee s*A/sr tsness deaths to saokars 1a the careful caveat trittu 41 J 2060460664
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587 lato t h a ttr.t 5urSann G .n.r.l'a rapert bY I t a euther.. They s.ldt Statr.tiral e.thods canout establish proof of a eauaal r.lationsh(p to an auaociattoa. Tbs carsal eioaiticaoc* of an aasociation St • fatter et ]ud{- ..et that Sou b.Tood any stat.u nt of statistical probability (1). Masy who ha.e appoa.d seokie5 app.ar to ta(cr causality from an.ocietles Sn all cau..s of death (iscisdia5 ateideata and suicides) which have raported a.okar/aoa..ot.r mortality r.tioo lars•r than that aa{Sc number 1. That fatio.- al abstsntion from smoking u•u1d auto.atica117 prelet5 the li..s of thoae eho had s.akod !s a.ost unr.asonable speaala- tlea. •ad that's ssactlT what a re11-raspect.d so..rna.at heulth statistician told an American Cancer Soci.t) oe.tie` . recently: /M)ost of the larSa-.eala atudlu ea aaoki.5 aad he.ith ha.e t.ud.d to Ia.astiSate the role of smoking Sadapaedsnt of other behavioral .ariablaa. sath as alcohol coeuucption and other lifest)le factors. oec.patioa.l a.d aariron.antal hasards aad c.rtai psychological factors. Tks.. .ariablas are tao.a to be rsiatad to h.alth ststue ... Thos it .aT •.11 ba that the eliaisation at saoki.{ without aaT chaa{as te tka other factors .111 ha.e only a partial i.paet ea health etates (.apbauls add.d)(21). 42 .~. . ~ 2060460665
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sex Q.eclu~l i thee ud !.r the pu t ral/eete oe tat,olattoe eur.eyt to tedlee talaaea ! diaeaea eau u tlee /e esaa to ea.ere eritleiaa bieasee •t the eeq 1ehePa4t reatetiaaa is theae et.dill. /.et aatepa\.• .ttpo...tt at asetlas ha.e teeneal.r/ tei.i "!e raat/ened lrevteuall. the esotere aed tae-ar.t.ra to t0aia etad Ne •df dltter rith ratlect to atAat .artaliaa thet .leht 1.rluo.ee the death rata.° "feottes ..-d aeltht teprt at the Ad.leery cos a tte. to tbe fYt(f0e Oe.eral it the r.olta a.ltN f.tvlca" 1 9 6 t tl) *ilLalat asauqtioa that avert disease eaaeeiated with elaliy to taraed by aaelleg ereate a etedtbltla/ ea>•.." tho.ae 0. Ieet, K.D.. Il.f.l.fil) 43 2osoasosss
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sa9 1. U.S. Tub11e salth Service. S.ottn{ and laalth. Raport of the •d.iaor7 Committee to the rurpas Csesrai et the Poblic salth Sar.ica. kashlnRtoa. U.S. Departanat of aalth, [detatlea and Yalfara, TaS Pub. Do. 1103. 1966, 3S7 pp. 2.' D.S. Tolllclaalth Service. The Daalth Csassqosetaa at Saokln6: 1T77-76. D.S. Dapartnant ot aalth, Sdocatian and Yaltare. laahta6cea, July 27, 1976, 73 pp. 3. Calilaae, J.1. Address of the SecrstarT of salth, [decaties aad Yailars before the stional Intaraia.cT Couaeil on S.ekina and lsalth, YaahlaDtaa. D.C.. Jan. 11, 1971. 4. Saat, 1-Y.2., at al. t Canadfan Stad7 of Mortality is lalatlen to S.okinS abits. a Praliolear9 kqort. Canadian Jonraal of Public aalth 521 99-106, 1961. S. Doll. t. Personal eouunicatioa to tha Surp on Coaaral'a Advisory Committee ea SaakiaS aad laalth (1). 6. Dell, R., and Rill. •.3. Lung Cancer and Other Causes el Dearh in Rslatlon to Snokio6. Dritish Medical Jonr.al 2: 1071-10e1, 1936. 7. Dora, 1.P. Tha Mortality of Snokars aad !ee-S.akara. Procosdia{s of the Social Statiatiea Section, •.srlcaa Statistical associatioe 31-71, 1936. a. Dnen. J.1., at al. Lua3 Cancer Mortality Lap.riancs of Mss is C.rtaie Occupations in Californis. 6sricao Joursal of T.blic aalth S0t 1d73-16l7, 1960. 9. D.na, J.t., Jr., at al. Calitornis Stata DaTartsant of Tabllc lulth. SPScial Report to the Surlse General's Advisory Connittas oa Saekie6 and lsalth (1). 10. la..ead, i.C., and orn. D. S.ekia3 aad Death Rates -- Report oa 44 Moath of Pollo.-uP e 1D7,7/3 ssa. Part I. total MortalitP. Part It. Death Datoa by Caosa. Jsarnal of the A.arica Medical isaociatian 166e 1139-72, 1216-130D, 1T36. 1L. as.asd, S.C. SPaeial lsPort to the Surp sa Caaaral's NoSaorp Committee oa Srokta{ and aalth (1). 18. sss.ad, t.C. Spseial Rarort ta tho Surlaos Osasral'a 6drturT Committee aa iskiq aad salth (1). 44 2060460667
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590 13. ausoed. S.C. Ssettai te lrlattoa to the Death lates of Oat Milltes Maa aod Moten. Ie: Ssesetel, u., Nicer. npidosioloSicsl Approaehta to the Study of Cancer and Other Diseases. 6tthtsda, Md., 0.l. Public talth Service, atinsal Cancer lostitutt Monoir[ph 19, Jassary 1966. pp. 127-20d. 14. Sterlisi, T.D. tha [tttet of Salf~-Stlnctios pattors is the Study ot Saokini sod Lunt Caacar. prsasatad to tb• 6ie- •etrics Section on Statistical Aapects of popelatios Mtsaareb of the Atarlcaa Statistical Uaoelatioa, AsS. 16. 1972. 15. Maaas. T J., at a1. Atlas of Canter Mortalit7 for U.S. Cosacias: 19f0-1969. atieaai Cancer lsstitscs, U.S. Dapart.aat of laaltb, tdueatioo and Welfare. Vaaelqtos. DlLV Pub. fo. (113) 73-760, 1976, 103 pp. 16. [aha, t.A. tha Dote Study of Ssekirq aad Mortality ltosi U.S. 9staraea: taport an tiiht aad Oaa-salt Tears of Observation. ln: 6easaaal M., editor. tpidatiolatieal Approaches to the Study of Cancer aad Otbar pisaaaas. tethesda, )(d., U.S. Public Health Service, atiosal Caster Inatitace Monotraph 19, January 1966, pp. 1-27. 17. taSot, S. S.okie= asd Canaral Mortality Atosi U.S. paterans 1954-1969. U.S. Departatat ef iaalth, idseaties and Valfara. Maahlastnn. DM[V Pub. o. (11t) 74-544. 1974. 65 pp. 16. Dall, t., and till. •.S. Mortality in talatiee to Saolist: Ten taara' Obotr.atleoa of lritiab Doetors. tritilt Medical Joernal 1: 1399-1410. 1964. 19. Salttar, C.C. Critical Appraisal of the loyal Colle{a ot Physicians' 243-216, 1972. teporc on Smoking and taalcb. Lascst lt 20. 111, 1.1. 9tatiatieal Mtthoda in Clinical and pra.oati.e Msdicint. t. and S. Li.la6stone Ltd.. tdiabtrah sad Leades, 1962. 21. Vilson, t.Y. Stateatnt bafort the Aatrieas Canear Ssci- stp's atiooal Cotaisslon an Smoking aad Public Policy. pfiladalphia, Just 16, 1977. 22. 9ett, T.M. 141 Jazak. M.t., ot al, editors. ta6oarsb oa saakly teba.ior. tack.illt, Md., U.S. Public /ealt\ tsr.ies, atiosal 1 utituts oa Drri Abuse ono{rpt iT, Dons.bar 1977. pp. 226-229. . 45 2060460668
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591 yo.en and 3noklna after two dacades of dasovn[1nt smoking aad clai.ent •proof' that citarette cause various dluu .s and disorders to es, aati-sookin{ or{aalsationa have in raeest Teare laoatbed special casqat`ns to persuade vo.an that theT. toe, are ad- .aroal) affected by eigarattu . Their alaruos asua117 begin with the char{e that the ro.an who a.okas to prepascT .a7 harm bar tafast. There aro clat.s, too, of reported tncrea*ee to lu { cancer ortalit7 in voa n as a result of their saokiat. lacaasa of this aor anphasis an the ladies, we devote a Ieconaiatant tindin{s troa studies of o.okint .n.as and chair thildren aake t t.poealble to drar eoo- vinclnt conrluaions fro the data. chapter here to what RLv aas called 'the anoktn{-ralatod problems unique to vosen^ (1) -- and a look at eoae of the oeasplainable Lng cancer ortallt7 trends for women. PraAnanc• Outcoa • sizable sattion of the 1EY 1177-7J report to Can- gr..s oe s.okiet and hu !th (1) was devoted to s0akta$ YsM  a.d their presuasrtsa. It concluded with the stro.g layoays that rl8aretts sooking vae "probabi7 causa117 asaectsted' 47 2Q60460668
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592 .lth htgher Sate tetal and lnfant aorta11t7• Rnvr•rr, the actual date ealnly relied upon by the RCN authors tn reachi1y this concluston suggest that any relationship between maternal smoking and pregnanc7 outcome is far from clear and any clai u of causality have highly Quu tionable toondation. The study relied upon by RLY to that last report to Congress was a retrospeccive analysis at Johns opkins of S1,a90 birtha recorded in 10 teaching hospitals Ss 1960 an4 1961 (2). Dat-a u.ra collected on infast birth relght. intast norta11t7, prematurity and placental complications. The statistical anal7ses of the data on Snfane mortality Sndlcated that a history of a previoua pregnancy loss, the •atber's hospital tatus (pr3vate or public patient -- a socioeconomic indicator) and a variable related to age and number of prevlons pregnancies had "greater effects" eo perinatal mortality than .acernal anoking level. Io their analysse for pre.atucity and placental coapliu ttonst the reaearehars found that previous pregnancy lose and hospital pay status vere .ore strongly related to unfavorable outco.ea chan aaternal saokiny level. the reported laportance of prevloua pragoancy history and hospital pay status strongly Indlcates that a nother"s prageancy e:perience say rell be determined by who the .otler is -- bar constttutlon or innate ch{racterlstlta -- tether tha rhathar'or not she uokes. The conpleaitt of all et 48 2060460670
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593 thaes findtngs and the areas to which the data point for further research afn• striklnlly inconslstent with ths unsrsr.- 10g aad esclusice e.phasis on the aother's ssokin' habits. Lyqv-btrth-Vei.ht Dables Like sost other pregnancy studles, the work at Sohu orllns found that ssokina vao.a on average have sallsr 4.fants than nonsook.rs -- Sore of what are eallad lev-birth- v.ight (LBV) babies. LIV infants slsh 2.500 gra.n -- abo.t 3.3 pounds -- or 1 u s. Vhy and how this happsos has oot bes esplaiaad. iut the possibiltcy chat a couen factor predisposes ro.en both to s.oke and to have a higher proportion of LlV infants was recently dsa<rlbad by the direetor of a child health study who sug{este, that "the snaket and not the oookins" .ay d.tsrsioe vhether a ro.an has an LBY infant (3). IDr. 3ss van den 6ers took over dtrtccloe of tha large P13- funded California study froa the late Dr. laccS Teruahalny, who first proposed, as early u 1964 . tne Sypothesis that a oothar's s.okins say rervs as a oarker !or -- but not as a eausal factor Sn -- the birth of L6V totaota (4). Tarushal.y contended that Snstfective rando.iastlaa mad the probleo of ra1f-selsctien in studies co.pariog saokios mad nou soking •ochers ads it dtffic.lt to draw any iafsr- uatas fro• the obssrvatfon that snoH rt .a. to have oore LIV isfants S1. Ie psrhaps hfs best-knorn study, ha identi- d9 2060460fi71
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594 fled a group of women who besan to s.oke after their first children v:re born ~b). CoapatinR the birth uel{hta at chil- dren born before and after the women began saoklns, he dis- covered that both `roups ef children were lighter than the chlldren of nonsaokin; nnthers. Re taid this indicated so.e women vill have s.aller infants vhather or not they s.oke. Two resuchers published data ia 1977 that appear to support Terushaiscy's hypothesis. A Ratlonal Instltutes of 8esith epidesiol.gist found that dtfferences fn .eso birth weights of infants born to women who s.oked during ume pre- ansnc7 but not another were "aore consistent with the self- salertion h7pothesl.° thao the causal h7pnthe.is (7). An Australian who worked with rpcprds of 1.200 •aternity patients coocluded his findinsa were "co.pstible" with the theory that taternal snoklnR does not cause !8W but Se "an Snder" of sone other factor or factors (8). perinatal Mortalitv Any c L ls that maternal snokln; durlnS pregnancy Ss causally related to increased perinatsl fortality fs not supported by the scientific evidence. Yerushalay, for e:aaple, found that the vortalit7 rate of L8v fnfaats was considerably lover or those with enokin= •others than for those veth Rpns.ekip[ othsrs (9). He contended that hLs data ar8ued a{afnst the proposition that cigarette svokin{ aets ae eo external factor that interferes with tetal develop.ent. 50 2060460672
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595 in 117E, cha editor of the tricioh Journal, rubflc tealth, wrote that evidence that saall infants of a.oking •othere do jot share the high •ortalft7 of Snfsnts of the sa.e seight bore to nonsmoking ochars "has been disregirdad.' te suggested. 'Ye .a7 tall roaen that if they smoke their baby say be saall. lut (vef should not clai risk to Iite' (10). inentaneovs Abortion In the 1973 EEV repo:t to Congreu , the last specif!- ca117 to discuss spontaneoua abortion, the auchors said several stodies had reported finding * significantly higher, dose- reloted incidence aeong cigarette aaokers. Eut ths7 conceded that "the lack of concrol of significant variablas other than cigarette a.eking does not permit a fira conclusion to be dra.n about the nature of tha relationship" (111. }o firs conclusion about the "nature" of the rels- tienekip can ba dravn tow, either. ' A recent study by Aer York rese.r^hers did aassrt that s.ekieg ta "a risk factor" for spontaneous abortion (13). •a.eeer, tbe researchers found no statiatica117 significant ralatieu hip batvaas the amount s.oked and-the rataa of qen- tau o.e abetttas. Moraovat, their eaphasis on certain data is the stedy was criticised by another rasearchat, who suid this tecae .agaified "the apparent effect of a.eking" So the higher- S1 2060460673
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596 risk age ;roupe -- the yonnaer and older sothers-to-be (1J). Re suitasted that if sose of the vo..n were e.aklnt "becauee they vere uptight ebout a flounderlna prOaeancy" that fact 'silht distort the picture lurt enough to Oaks it appear that smokiad 1s an etiologic agent of spontaneous abortion, .hen in faOt it a7 .erely ba a.ore prevalant behavior characteristic l0 a troubled pregnanc7." pailure co :oneldrr this aod a eusber of other tactorr caused his to cnnclud0. he said, that "we are still at a losa for the cause of apontaneous abortion." That s.okin{ 1a e risk factor for poctaneous abofftlon is not eupperced by ocher etudlae, which have failed to ahov any significant link vith sOokint. thas• include two published since 1976 (14, 15). Another. conducted in Sweden, esa.ined a variable that is not always e•osidered. It found that an overall increased risk of spoetaneous abortion aLeon{ mnklng Vonen Yae alnoat cospletely due tY the fact that the pregnancy vae unwanted (16). A Dritlah Medical Journal edttorial ef less than a yeor ago puta the reported rela!ionehlp Sn perfpecGlvO nore succinetlt than anything we could ray: what rau.ins to be sstabllahed te whether the aaa0alation betveen cigarette e0otlnt and spen- taa.oua abortion is cauaal...Onlr by identifying a•sch ulsn by vhich ciSa[ette esuktnt cauld l1ve rise 90 apontaneous abortion could ve 0e confldent of a causal relation (17). 52 1 2050460674
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597 Conaenital Maltor..tiae A ph)atcian appaertnt bafore an Anerican Cuter Sucint) "farat' at eaohlat etirred the oudiaace with hia charge that aaeklnt ta "likely to eaaae birth defectn* (1t). la.aear, his oplalon was not shared by aoother phpsiciaa, appnsrlnt at a atailar ACS °forut' two veaks later. The sacond doctor uid> ...1 doe't think anToae hau idancifLed •boolate evidanca that this (contenital alfortutlon) Sa a result of the chronic or e.en a'ute saoklms of the aocher (19). Tbnsc conflicting opinions, espec1a11T vichln oaa anci-aaoklat artatleation, reflect the Lnconclusi.e sclentific flndiata 1a tkla area. Several larte-stale population studies have failed to establish a relationship between aaokint and congenital salfot- antlon (9. 15. 20. 21). Another, et ainint contealtal ul- foraatlon diagnosed during the first five Teara of lifa, tonad that favar each condltLoes occurred in ehtldran bera to vote who stoked during pregnancy thsn to votes who tavnr staked or ce roaao who stopped ac ac.o time before beceaint prtsaatt (22). L•a the Sar Tork rsa.arcbsrs who repurtel aa u.oeiatioa batasat seeking and epeeteasoua abortloa cencluded, attar ,tadT : et tb• scltttttit littracurc en saokint aed tafaat .altoraa- S3
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tion, "it it unlfkaly that r.okint aets to cauoa fetal .ous.- lfas" (12). That e.otionalis can o.orrido oblectl.o aaa2)sts 1 ant area of pratoane7 and childbirth 1s illustrated by tho b-aadlinos vhieh atcoapaniad the release of a ocadT by a pitts- barSb pathologist rho claiud atarnal soking vas related to con{anital alfor.ation (23). Although ans hosdifno raad °Saby {rain Def.ct Linked to Saoklnt" (24), era.laatio of the research paper revealed that the pathologist hsd doncribod this finding only aa ao "apparnnt au ociatioa" that "r.Qairas fnrtber analysis." Thin sort of proviso, of conrna, •assr appears fa headlinas. Child Dov.lon..ot •nothar favorite claim of anti-.aokars is that •aokin{ durinf propnanc7 rstards the aubsa aont {roatk asd laar.int abilit7 of the rhild. 2n fact, siY Sacratart Callfaa. fa early 1/f• spoke of the "doalop.ontr117 disablad" Cbiidron of taokin{ aochars (25). The bu is far thu a aliagationaT Lpp.rnntit it is datt fro• as oa-to1aS porinatal ond child folln*"q •trd7 1s Arttat• .bick ladtcatod rbat the chlldrnc of oskiaa aatb.ra lassad b.biad the ehildrs of cas.okitS .ot\ora 1a p\7aital sad Nacel dsoslop.a.t ths authors did aoto that tts 54 2asoasos7s
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ass effett of smoking ddrint pretnency is "ralati.ely seall" in coapart-eoe with the effects ef eoee othar faccora, auch as social cla u a.d the nu.b.r of older and younpr ehfldree in the houe.hold (2!). In tha lritlsh cua7, the chl3dren of s.ekin6 vothere were on the average 1 e.nclsetar -- ot only about thraa-tenthe of an inch -- shorter then ehildren of nona.okint .oth.ra (26). There vae also a four-.auth dlftereece 1e r.adln{ ability between tha two troups of children (27). lot analyaie of physical growth shoved that a number of other factors were aaeociatnd with size at afe 7. for eseaple, the child of a binrcollar faatl7 vas oo the averate 1.3 ceeclnecers shorter thaa the child of wealthier parente, while the fourth-bore child .as usually 2.3 eenciseters shorter than the flrat-bor.. In a later report troe the a ue 6ritieh ecrdy, reeearchers esanlned the children at ase 11 and measured only utnor differences Ln either height or aeocal develop.sat of children born to a.ekin{ and noas.okir.t oothers (21). They also reported that theee differences were lue than the effects of some of the other factors considered. por lostaece, the difference between a child frue a household with ao older children set one from a household with three or fore vaa, on tYe avarage, 16 ouths for general ability. 21 onthe for r.a.di.`, 16 •onths for athe.atics, aad 4 cencisetara ler height. 55 2o6o4so677
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s00 Th• results of the srttl.h etudl rere incons(ctent with those of lobs• tlopktna tesearcters who followed chilAren het of aaeting and nossoetlae a^ther. le 1962 •ad 1963. The7 reported: 'At four sad ss.se Te•rs there was ne siiaificast liffereece le sirhar p,7sicsl easursaests or !at•lleat•al faactlonlag" (29)• Despite such studles, thare ars still those who look only at vhather the aother •aoked durtn{ presnancy ta eaplain possible dlflar•aces 1n children's grovth and luralaa sk111n. this aborteoaing +a• apparent to the 1977-70 IV r•porc to Con`rss ansookla{ aod hsalth (1). Tbs authors dlscussd • Californla study 1n which children of saukin` sothers .ete foaed to be aharter at age five chan children of aoaasekiag aothers (30). !ut the !Cy writers dldn'c tsdccat• that the study showed a difference of ac17 0.9 centlaeters. aad that the researchers had ttrlbuted near1790 percent of the earla- tlons to "parentaI stature alooe." Only 2 percent of th• .9 esetiaa[er differsece could possibly be due to asaoelatiaa with aaekina -- about 7 nne-chcusandths of an Such -- accordlq to the California io.esclsators. Oral CanGrateetiv.a The sciee[itic lltsratura do•s not support the claim that oral eostrecsptive users who stop saoklng sllnifitastl) d•ersass their dlsaasa r.css. In other rerds, there la,as 2060460678
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601 •ct.atific basls for any asauraat• ahet oral contracepti.. •oers are not likely to de.elop cert.in dlaeau u if they step sbskts{. The sa. .araios iaaert aow raq.lted by tba pad.ral poad asd prug •daaistratiaa in oral co.tracsptive patka{es ls rffeet i.pli.s such asearaoea. •nd the pD• case .adar attack at a Ooagresaioaal hearieg lasc fall for ice deeislo• reqsiris{ the e• iasatts. Several pretiaast statistlciass who bad asulu d the studies relltd upon by the agency a iti dseisi.s tsstl3i.d (31-34). llaa otrd that: The .aralne as stated Ittplies that there is a eavsal affeet of Clgarette asakieg on the lneldeota of cardlovaseular disea.a. so statistical study aas establtsh eauaulity. At best it can astabllsh a b1gh probability of possible interrelatioaships (33). The studlea uhich th. statirttciaos critleitad elaised to have showo that a.okers •ho use oral eootraeeptivas have an iocreased risk of cardto...cutar dlsaase (33-34). ~Their eessura, tha stacistieians said. .as based on statistical o.atsu us, inadequate sample stte and othet •athodolo(,ital probls.s in the studies. Sose of these reakeessas had baa• noted by the authors of the original r.porte: Thsse estl.ates of risk...attll oeed to be latsr- pr.tad rith eautions as a nusbor ot au usptlens ba.e neeaasarily had to b. ..de tn their caleulatioa a.d the ar{!e of error is itkely to be fairly .ida (33). It te asseatial to point out that the •ortality sottu tss used te this paper are baaad o. a.all 57 2060460679
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rebera ad a7 be sub)act to largo saepltng .rrero. Thoaa alti.ates ara also eub]ect to upward and dnvavatd biatal, which a7 aat cascsl each other out... The sat effact of thaaa varioua factora coaeot be estilated without eddttto u 1 research, rreferabl7 ta differ.et aattleda (37). Thaua estinatea (dauth-ratas) are based oa teall auskar sad ate nscnesarily pprosimats. 9tthort •sre dat it ia aot poaoible to eu elna the tntar- ralattoaahips of a(.e, a.okiag, aad darattan of oral ceatracsptt+e uae...(3J). ievsral rltnsaasa espretasd tostern that a atatisti- eal rnlatioaship batraes oral coetracepttvo uso, s.eking and tilneae aT Snfluance acieatiats to ovarlook ocher factors that may e=plaia tho obsorved rolatioeahip. Two other reaearehera urged !e the iritiah ysereal Laecet that scientiata act let 'ptaco.ceised ldeu affsta ebjsctivitT' Se esa.lnacion of othor paaaible hypotheses. Lett unaearerod tn raaearch so fac, they vrote, ia the ee.- fouedia{ quaucion of ealf-oel.cctao (19). •ed the' aakedt Ia lt peaaibla that the soeeo who aeoke and naa oral eostraca0ci.ee (particularly tha older group) ata aisplT raflactiva of a eore flaaboTant lifest7le which say rell ieelude eore acrasa, ore alcohol. eore sedication (iaeludleg 'doroera' and 'uppars'), ov arijuaea usaT...Thars asese to be nothi.g i the data which sould anarar ooce and for a11 the quastioo -- to it tha seoker or the eUek1.s which create risk differsoco sad is it tha oral toatrar taptiva usa.r or oral-toatracaptt.a uaa which te at the botta of it a117 ThaT eoaeludal that "sea.hov aptdenlologceal aN latsratat' atudlea eust ba destgnad to dlatlaguteh teey tke 58 206046Q680
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603 pessibls settoleslea•" What they callod -the six o( taetarr". rhlek taelede tesattcs, thoy rrote, "nay ba sora eoepies chaa r• think." t.etiea sod Earl• Mseosaaae lc a eidely puhlicisad stsdy which appeared is 1977, {oatca researchers reported they had toe.d that smokers sder=u enopaase earlier then oaes.okara (40). Ateerdis{ to ea.e volentary health auoelationa and aett-s.okera. tkis qpeared to present a health hasard, because asset ot ehaage of Llte supposedly deprlvee a rooan of the •proteetlea' she 1s hallotad to havs lrem feaals sex bor.ones (aatro=us) agai.st cardiovaseular dis uee (CTD) in bar reprodoctlve years. lavarsr, this claim cae be disputed fer several rsasens. litat, the CrD vital statistics doe't sqport sach a theory. If ro.ee actually lost aess form of hor.onal protac- ties with the onset of nanopauss, reported CTD deatb rates prssa.ably would Ju.p durina the senopausal a q apaa -- rather thae coatieua ths aepeetad steady increase. •o editorial is Laacee examined this qu ution a tav estks after publica- tien ot the leste research. asd it paiatad autc Martailty statistics do sot aass to suppart tha ae{{eseios that the aesopauss has acy effect e ria risk a/ C<!D (careaary heart dlssaue), slnes the death-tete [ro• the dlseau tncrease atn.dlly rltb adtesclsl asr (41). 59 2060460681 J
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sot Two researchers who studied trends in CDD mortality data for voaea in tnaland sna valar concluded that voaen de fg[ losu protertion from C11D after the senopause (e?). Sncoodly, evidence incoosistant with this elaf• •ao leen p.resentad in s study of pressnopauul voaon with advasead hardnnaaS of the arteries (43). The rasearchers fonnd that the vnsen did gqj, have oatroSan deflcieocins, as ni{ht be e:-ectad in the hornonal protsction theory. Iaataad,.tkq tound that a fenlly history of coronary disaasa, hy-artaastus or diabet u was ^tha most consiscenc s1cS1o faetor' tenad asoat the vosen• piaally, a studyot vonan who undsrvaet surgary for removal of their ovsrl u-- a procedure rssultiag is eatroaen daprivaclon -- reported that they had no more eoronary artery diuaaa than to aSe-satchsd control Sroup (44). The aechors wrote that "our data support prevlous reports which w estYas the protective affact of astrosen on devalopnant of atharoaclerotic coronary artery diseaae." amonS th• facts that are not aentioned by those elaisini a^aokin=-urly ^-nopauee llnk Is that other •arlablss have baaa aaaoclatad with the nnaat of aenopauaa. For la- staacss a public taalth Servite study of 1,200 vosas tsvad that the udian aanopau u 1 ata teaded to be lover to llack va*na and 1n vhlte vasan from lover tacose brackets aad rural araas (tf). 60 2060460682
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605 The pef atud7 alse potnted to a fatt that hes been disrussed in sther studtue that lean re.en underto •enopeuse siljhtl) earlier, •nd the thlener their neasured srinfelda, the earlier the chanae in their aesaa. The leauness factor also vas reperted by other rese.rrhers in a 1976 study (eU . •nd what everyone has torgetten 1s that re.ae who aaoke hara been found cn be leaner than roaee who do not (t7-19). fo oee is left to vonder, if leaner ro.en eaperiencs earlier •enopaute, is it becauae they are luner, or because they a.nka, or becausa of tha kind of persona they are? fioaen and Luna Cancer Soae peraoes who dlsapproreof cigarette smoking cla!• that the larger nu.bnr of vo.en s.oklng aecounts for their rising lung cancer death ratas. This clain does set atand up vall under critical scrutiny. d asjor weakness ln the c1a1• e.n be ae.n 1s  eosparfaon of ioternational lung cancer pattarns. Lueg cascer death rates for U.S. rosan have reportedly besa risiaB faster year to year than those in sen arn u the early 11600 (!0). The U. S. eituatian I- draaticallT dlffarent frc• 61 o ,.n - ., - ,a 2060460683
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s0s that I. tnrepa. I. a Yorld ^talth Organltatlon raport, a protusor of actnarial aciaaea rapartad in 1577 that vbilo sqa's lnng caaear death ratu had rlsna relatively stosplT in fipo tnropaan eountriaa, oena of the •epa'• ratu had risna nt6niftcnntlr. is tact, the over-all inn5 eancar aor- talitt is prnnch voaao had dropped (SI). Is cda Qsicad tiagdv dqcliniqg rat u of incraun have baas oNarvnJ is toanSnr •aana; •isatc ucuutl~, a dornhill crend in aale ratea has been reported in the older ago grcapt (51). Thua, lueg cancar occorranen pattarns is •eaaa differ in various eouncrias and they are ^lno qutta dtaatailar from thosa of u lu. Lven has alioraece Is •aJa for the later popularity of saoking anong vuun, there 1• atill qe conalatnnt trend of iGetaaalet lunt cancer •ortalitl ratan. Thesa data are not at all coapacible with the tenaqatlon that the cause of lueg cancer in both nqaab is the aaaa agent -- cigarette aaoktag. Soao scieacitca beltavc that the racast rise 1s lung cancer in roaon to oere •rciflcial than raal, -qcanaa ph)aidians ordar diagnontic tetta •ora fraquantlt nov tar •ou n patiaaca they know co be aaokarn. Per •naaple, a dacter at the Yala Madical School reported that erqr a 17-taar parlnd kespital racords Sndicatad a drautle 1Nruaa Is The •da of •patn• tttar taatt for •oaal :uag taiqar patlaare, ^q tauqntadt "thit iaeraase is the search ratq tat gaws, imap 62 2060460684
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607 pou ibly piay a role 1s carieus recent rsports of ri.int ratu nt lat essc.r io .osn" (S1). Thar.for., it is highly likely that or. lunt taae.r asont .oo.n in b.int dlap oud because of the era tr.q.a.t application of diagnostic t.etsiq.ss th.n ia the earlier y.ars -- vh.n saay cu.s sitht sot ha.e baas so diatno.ad. Often o.arlooked Sn the berrlsd atte.pts to p.t the full kla.e for vos.n'a lung cancer nn s.okint is th. fact that the proportion of casa of this dissnss .ith tha call type that has bun se.t frequently as.oeiated vich s.ekl.s hau eh.nt•d •.ry little in the past 25 years (54.55). This rai..s the question at .hy r.a.arch.ra ha..n't ohsar..d a ismsnsa Snersu 1n squauou.-call lung cancers Sf ths causal agent is ci{sr.tte a.oklnt. Si.p1. .:pl.natioas for this so-eall.d °epfd..lc' of lung cancer in vasen based solaly ea s.okins habits are clarly inad.quat.. lse.nt studi.s ha.e sutteated that iadustrlsl or occupational ..posur.s nay be l.portanc in lung case.r unsa- ties in vo.en. • study in Los Angeles County repertad as Sncreaued risk of lung cane.t in vot.n vro vork.d as h.aotl- cians. a u e.blers and valtra..es (56). Incr.aued 1u.e canter •qrtality rates fer ron.n v.r. reported in counties ia the 0.{. is which certain heavy Induatrl.s ara loeat.d. Io ssu . the rat.s for vo..n v.re nore than a third higher tha the as••rsl 9.1. rate (57). 63 2060460685
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608 TDe sead for f.rtkar eeeupatiee.1, jaer..lhic aed eeela*oaa.ae •cadlu ef .o..a sad di....e akould )a r.-a`elted tra• tka.. aad aisilar ra.aarch fladiaSa. • siagls-.i.d.d taese ea .okit` ka.p.rt the search fer laag aa.ear cus.tiaa• 64 2oso4sos8s
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609 Rojarsneoa /or Yas.e and tookiea 1. D.t. Publle Health tarvlco. Tha Health Cousqo..eu of tookint, 1977-7t. U.S. Dopaetsaat of Naalth, idoea- ti0 and Y.lfars. Vaahinttoe. July 27. 197t, 73 pp. 2. Nayar. M.t.. st al. Parioatal t.asta Associated •ith Natsrosl tNoklet Durte3 Pratnane:7. ANSrica• Jouroal of- Npido.tolop 10]/Si d6a-A76, Msy 1976. 3. •aa ds• tsrt, N.J. INt LLY 2n iafants of t.okars Nnt talatsd Just to tsoktnt Itsalf, by Aasstts 0sstrsichar. Ok. Oyo. Nso 13/4: 1. 27, Prk. 15. 1974. A. tsrsohal.y, J. Moth.r's Citarstts t.okint aad Survl.al sf INtast. Aa.riCa Jourasl of Obstetrics aad 0ylOC03097 tt/{i 503.313. Feb. 15. 1964. . !. Tsruahalq , J. taif-tslsctioe -- A Major rraklaN tN Ob urvational ttudi.s. Proeu dints of tha 6th tarkalsy tyaposiu• on Maths.atteal 6tatlattes and Probability. anl. •t 229-762, 1972. 6. Taruahaisy, J. Infancs with Lov tirth voitht toen Ssfesa thdir Mothora Startsd to Soots Citarottas. A.aricaa Jorr.al of 06statrlca and Cyescolo q 112121 277-2t6, Jan. 11, 1972. 7 Sllvarlun, D.T. Maternal S.oklnt and tirth Veitht. A.sricae Journat of tpids.ioloty 10S/61 S12-SI1, Juna 1977. I Deso.ae, J.V. Sandoataod Controlled Trlal of Aoti- l.akint Advies in Prateancy. Srltish Jouroal of Prsvao- eta snd toeial Msdteies ]1i 6-1I, 1977. I Tarushaisy, J. Ths Nstatiooship of Parosts' Citaratts ~. tNSkiet to Outeo.o of Prssnaecy -- Iopllrstlooa as to tks ProklrN of Infsrrtnt Cauutlon froo Obsorvsd Aalocts- ttona. A.arican Journal of tpldau oloty 97/6, •s1-A56, JoNS 1971. 10. takartsoo, J.t. Health and tducation -- taaklot. Public l.altk 93/2t So-!S, 19711. 11. 9 1. . pkkllc taalth larvicoI tho Health Conssjuucss ot LNakty t I97I. D.t. Dopartasnt of Naalth, tducatts aad Yalfar.. Yaaktattoa, DNLY Pub. No. (NLM) 77-L706, 1972, 261 pp. 65 206046aB$7 P!, !
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$10 12. [liaa. J., at a1. teektag: A tisk Pactor tet Speetasee.a Aksrtioa. a. {aSland Jooreal of Medicine 297/15: 793- 7f6, Oet. 13. 1977. 13. ctaan. .[. Letter: ar [aSlaud Jouraal ef Medtciae 2S9/2: 113, Jae. 12, 1979. 114. ASker.aa, i., at al. Maternal Pattera Associated with Petal Chro.oso.al Asasaitas is Spoataaeoae Akertloaa. arltfsk Jonraal of 006tatrtea and C7secoleS7 421 621-627, aoiast 1976. 13. in..lar. 9.S. TLs fffact ef Ciaaretta Smoking o ths rlolSht aad Leabth of the sa {orn. Z. Aratl. Pertaild. 71z 293-297, 1977. 16. cnllaader. S., sd callan, I. A Prospective Study oi Sooklas aad PraSaaneP• Aeta OYatatrica at CyaaeeloSiea Scauda.a.tca S0/1: 63-94, 1971. 17. diterial. Cigarette Smoking and Sponcaasaa akortiea. Mrltiah Medleal Journal 1: 259-260, 1978. 1{. !'sar, l.J.-P. Staceaaat Datora the Asarita Cancer Society's atloeal Cosaiaslon on Smoking and raklle PolicP. lostoo. Juae 2. 1977. 19. Allen, J.1. State.eat before the Aaarican Caatar Soe1- atP' atieaal Coaasslus an Saekiaa aad Public Pollcy, rktledalphia, Juaa 16, 1977. 20. Oatario Departaent of salth. Second Report of the Perieatal Mortality Study Sn Teo Onleeratt7 Teachla{ lospltala. Toronto, Canada, Ontario Dapartient of lealth, Oetario Psrinatal Study Co..lttee, rol. 1. 1967, 27S pp. 21. o111aSs•orte, D.R., at al. Aanor.al Adolaeeeat Prl.l- Pareas PraSaaac7: Association of aace, casa CYOrioaic is.ate.a aoetopl Produetion. and 0auklai. A.arieaa Jearaal of Ohatstrlcs andCyneculeS7 126/2: 230-237, 1976. 22. was da lara, 7.J. tpida.ielptic Oksarratieas of Pra- aatarltPl 2ffaeta of TaYaeco. Caftea aad Alcohol. Iaa daad, D.Y., aad Stanley, P.J., editors. Tha 4Pidatielap of Pre.atarit7. Orka 6 aeanaraaakerS, falti.sra -- Ws.AeM, 1977, pp. 167-176. 22. UaaPa, L.L. aalatioasaip of CiSsrette Smoking to Ceaaaa- Ltal •aa.alies aad Parlawtal Daath: • ProaPeetl.a 66 { 2060460688
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611 Study. Anerican Journal of Pathology 90/2: 259-294, rebruar7 1978. 24. aeye, H.L. In: keby Srein Deteet Linked to S.okieg, by Dolorea predarick. The Pittsburgh Press, March 12, 1973. 25. Callfano, J.A. Addreea by the Secretary of Maalth. [dutatloa and Welfare before the ational InteraSency - Council an Snaking and 8ealth, Yaehingt-oo, D.C., Jan. 11, 1975. , 26. Goldstein, H. Factors Influencing the Height of Seven Tear Old Children -- eaulte from the National Child De.elop.ant Study. Hu.ae Siology 43: 93-111, 1972. 27. Daeie, 0.., at al. Pro. Sirth to Se.en: The Second Report of the ational Child Develop.ent Study (1958 Cnhort). LanStan in association uith tha atlonal Childrnn'e lureau, London, 1972. 23. {utlar. 1.1., aad Goldstein. H. Snaking ie Pregnancy and Subaequeat Child Develop.ent. Sritieh Medical Journal 6: 573-575, 1973. 29. Hardy, J.S., and Mellite, t.D. Dou Matarnal S.oking During Pregnancy Have a Long-Tere iffectun the Child? Lancet 2: 1332-133k,.1972. 30. Yingerd, J., atd Schoen, t.:. r.etora IntlueoelnS Length at Birth ud Height at pire Teara. Pediatrice 53/5: 737-7A1. May 1974. 31. tautanbaun, N.A. Hnaring before a Subcaa.ittee af the Co.aittee an Go.ernnent Operations. U.S. House of lepre- sentatiree. 95th Congreu , Second Session. Quality ot Stieetifie Evidence in PDA Regulatery Decleiona (The Adoption of an Antismoking Yarelnt in Oral Contraceptive P111 Labeling). Oct. 4, 1978, pp. 7-1a, 30-35. 32. Cot, G.M. Hearing before a Subcoeetttee ot the Coa.ittee on Government Operationa, U.S. eouse of lepreeeatatiraa, 9Sth Congru a, Second Seastoe. Quality of Scientific L.idance in FDA Regulatory Decislons (The Adoption ot ae Antieneking Yarning in Oral Coatraceptive Pill Labeling). Oct. A, 1975, pp. 15-29. 33. Ctbboae, J.D. Hearing be(ore a Subeornittaa of tke C.Gnittee on Goverouot Dperatlons, U.S. ouae of lepre- N ntati.a., 95th Congreu , Second Sese/en. Quality of Stientific Lvldence in FDA Regulatory Detieione (The Adoption of an Antisnoking Wareing to Oral Contraceptive 67 2060460089 ~
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612 - Pill Lakellg). Oct. A. 197e. pp. 35-132. 34. tudea, T.A. aarQag ketera a tubeo..ictaa of the Co.mlt- caa es OoTeraasnt Oparatiosa, U.S. ouae of tapreaanta- t1.es, 95th Cengrus. fecend gataion. Quality ot Sciasti- t1e t.ideeea in FDA Ragulatory Deciaiaaa (The Adeption of •atiuekiag Varntng in Oral Concraeeptlee Pill Labal- int). Oct. a, 1978. pp. 132-13a. 33. Masa. J.1., and tnnan, V.9. Orsl Contraeryti.ea and Death fro• M7ocardial Scfarctloa. iritish Mrdieal Jouroal 2: 245-248, 1975. 36. Maan. J.t., at al. Oral Centrateptiee Daa in Older VoNas and patal M)oeardial tnfarction. /ritish Medical Journal 2: da5-N7, 1976. 37. Join, A.R. Mortality tisk Associated •ich tha Daa of Oral Coetraeaptieaa. Studiaa in pa.i1T tlaaning l/3: 5D-5a. March 1977. )!. eral, V. Mortality Aaong Oral-Contracapcisa pa,era. Laneec 2: 727-731. 1977. 39. seack, D.C., and McRaan. 8.t.. Letter:• Lancat 2: 1024. 1977. a0. Jick, 6.J., at a1. talatioo letreen Saoktng and Ags of tatural Menopauaa. Lancet 1: 115t-1355, 1977. a1. tditorial. Coronary ®eart Disease in Young Vo.en. Lancet 2: 282-283, 1977. 42. ®eller, t.p., and Jacoba, B.S. Coronary 9aart Diaeaae Sn telatlon to Aga, Sex, and the Menopauau. tritiab Medical Journal 1: 472-a7i, 1978. 43. gngel, S.J., at al. Coronary Artery Oieeaae in touog Yoman. Journal of the Anaritan Medleal Aaaocittion 230/11: 1531-1531, Dec. 16. 1974. , 44. Mancheater. J.M., ac a1. preu nopausal Caacration and DoCuaentad Coronary Atheroaclerotis. AteTitan Journal of Cardiology 2e: 33-16, July 1971. 45. MacMahon, /., and'Voreheatar, J. Age at Maeepausa: O.E. 19{0-1962. Public Yaalth Service. U.S. Departaest of fsalth, [dueatcen aad Valtare. Washington. DRtV leb. o. (gaM) 73-126g. Octoeer 1966. 46. 3ertlaad, M.C., at al. Soue Acheragaoic Coocoaltanta of Manopauae: the praetngha• Scud7• Aaeriean Journal 68 ! 2060460680
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613 ' of EpldeaioloS7 103/3: 30.-311. Septeaber 1976. 47. kSalke. I. Variation in Heleht and Weight in the Nor- veElan Population. Srltiah Journal of Pte.eative sea Social Medlcine 25: 192-202. 1971. 40. t1EH1as. M.V. and el.lsbart, M. Characteristlc of Saokers and tonaaokers !n Tecuaaah, Michigan. II. Tbe - Distribution of Selected Physicial Messureaents aad PhysloloSlc Variables and the Pre.alence of Certain D1ae4su in Saokera and No,nsaokers. Aaetican Journal o! tpldsaioloE7 66/1: 60-77, July 1967. 49. Eoptaysaki, J. He13ht and Weight of Adults in Crarov. 111. Weight by Age and Cigarette Saokin3. Epldaalclosy of oniafettioue Disuses. tpidsaioloSicsl levier 26/4: 452-464, 1972. 50. Scknelderaan, N.A., and Le.in, D.L. Epideaiolosy of Canear and Tobacco Use: Trends and Trend Indicators. In: Proceedings of the lyd World Conferenes on SaokinS aad Health, 1975. Vol. 11. Public Haalth Ser.ica, U.S. Departaent of H ulth, Educatlon and Welfare. Washington, DMEH Pub. No. (MIH) 77-1413, 1977, pp. 73-84. 51. lsejaain, k. Tranda and Dlfferentiala 1n Lung Cancer Mortality. World Health Statistical Report 30/2: 118-128. 1977. 52. Adelscain, A.M. Current p1ta1 Statistlcs: Methods and Interpretation. British Medical Journal 2: 9S3-9H7, 1978. 33. Palnstsin, A.l., and vells, C.K. Cigarette Saokina and Lung Cancer: Tha Prohleaa of "Detection alan' Sn EpldealolnHic lates of DSsa.ae. Clinical Research 22/3: SSSA, April 1974. 34. arley, E.I.S. Cancer ef the Lung in Hoaen. Ihorat 31/3: 234-264, June 1976. 55. Eennad7, A. Relationship Set.een Cigarette Smoking and LatnloSical Type of Lung Cancer So Woasn. Thorax 2E/2: 204-206, March 1973. , 56. unk, .H., at al. Lung Cancer Risk Ason6 Ssauticlau aad Other Paaaie Vorkart: krl.f Coaaunleatlon. Journal af the atloaal Caster Iestiture S9/S: 1423-1425, Mo.eaker 1977. 37. slat, Y.J., aad Prauneni, J.7., Jr. Arsenical Air Pellutioa ud Lung Cancer. Lancec 2: 142-143, 1973. 69 2060460691
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. 614 Cancer in the Work iLte After RLV Secretary Cali[ano announced befora an Apt.-CIO audience in Sapt uber 1978 that at ltaat 20 percent of all cancer in the U.S. ay be vork-r.lated (1), a nava ruakl) for health profeasionals began it report on the spaerh l8ke tbia: HiY has leaped into the idst of the continuing dis- a{ree.ent over just hov cuch cancer 1s cauud by vorkare' azpoaura to carcinosens on the job (2). Previous u tf.ates had ranged only froa 1 to 5 pareent, and there uere l.oediate co.plalnts after the Secrs- tar7' talk from busineas interests, the American Cancer Society and so.e scienciste (2-12). Tha reason for the ACS complaint was not iraedtataly discernible. Its national preaideat aaid only that the figure uas "totally out of line. .uch too high" (9). The The almost aaclusive focus on individual saokins habits in the study of dieeaee aay have delayed neadad rasu reh into possibla occupattonal aod an- vfron.antal cauers. t..cat of bu.insss and Sndustrial leaders. fightia, sear- ianrnasias gnearnaant rsaulatlon 1n the work plaee. •as 71 2osQ46os92 ~
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615 a bit nore easily understood. The ner study nn which Secretary Lalifsao base-d kis 20 percent estimate was rrlttan by 10 Public salth fervice scientista, including the director of the ational Cancer Institute (13). They were quite explicit in their critl.eisn of the earlier -- and lorer -- estlaato of work- related cancer by half a dosen epidemiologists here and abroad, all of .ho., interestingly enough, are longtine foes of cija- rettos and sone of .ho have attributed a speclfic percent of cancer deaths to eitarette smoking. The P®5 scientists wrote that "it is a reductionist error and not in keeping with current theorie-s of cancer eausation to attespt to aasitn each cancer to an exclusive single causa...patrerns and trends ]n total cancer tncldeoce (and nortallt7) in the U.S. are consistent with the hypothesis tkat oeenpationally-related cancers co.prise a substantial and lacreaafng fraction of total cancer incidenee." "The fact is that cancer is a dinease of incerae- tisu .' one of the authors said subsequently. "!y ascribing a caacer to ain`1e causa, we precluded looking at other causoa" (14). asotbar of the 10, who described hinself as "no fan of cigarette saokiet," said that "you can't lay (all) the bla.e O tiprettes). The cause of cancer ara such nore coq les. ff ip cansad by Lhe interaction of sany factora" (1S). 72 20004r-,0603
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616 Ths n•r st.d7 oriaiwatad duri•t intoraal disenssiens by scisatists who rar• skeptical about ler etenpatiesal eateer ostiutes (1t). The 10 seiaatists co.pleted it for snbaasion to the Occupational Safat7 aad a.lth dds3siatratio (otS1) dnrint,bsar4ata ea •na.plat aas rulss proposed by OSt• to raSalate caecar-cansLaS substancau Ln the work placa (17). Sacratar7 Califano said that the 10 authors of tbs stndD. who Lseludad ph7sicisns and biestatiatieians. actaally astiaatad that between 21 and 33 pere•ac of all eanesr cssas could be attributed to work exposure. tat. he said, '.a ehosa the orn censsrvativa figure because this is the first study of this kind na'.a doas •nd because rs'1i he delas a lot nisra studies to rnfiaa it" (1s). The pSS aeiantiats attributed a•isabi• portiom of accspatianai tancers to asbestos erpowre (•e estimated 67,000 daaths 7ear17), the rsat to other substaeess associated 4n past studies with Saer•ssad c.scsr iecidenea or death rates (asa Table 1). The7 listed a dosaa oceapatioas i which cancer deaehs ara sbaoru ilf heth, but fer which s specific causa ha.a bun idsatifiad (aea Table 2). •larhapa the oost Lsqortaat leasca to be laarsad trs the asbestos stes 7.• chq wrote. '1a that a naJK pabl4e I bsalth di ustar eta dsvalap vhrie Lts early aifaatatieu •ra lost by baisS attrlbuted to other tsccors" (U). 73 2060460694
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617 inble 1 Chemicals tasotiated rlth Cancer Induetion Sn Man •ttaet.d Slssues Cka.ical and Sakstanter Otaans •skestos Lunt, pleura 6 parlton.u., esophatus, rtonach, eolon/reetu• Arunnie tup4ratory tract l.nreun llead-tottSnt orsanr Chromium lespiratory tract Caal tar pitch, .olatila 6 toke oven Luns, laryn., emiaaions sk1n, scrotu Iron oxide Lung, laryn- iekel os3dea tesplratory tract petroleua distillaree Lun`, larynx tetinatad o Yorkera Porentially Lrnused . dstloatnd o• tseess Caneers Per Sear 9.000,000 to 11,000,000 67,000 1.500,000 2,100 - 7,300 2,000,000 240 - 1,600 1,500,000 2,600 - 46.000 60,000 160 - 800 1,600,000 1,300 - 3,000 1,370,000 3,800 - 5.000 3,000,000 2,400 - 12,000 iouree: brldbord at a1 1978 (13) 74 2060460695
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618 'Tbs •abastos Stor." Claiaa ara bsing ada that aaoking workers ohe ars eapeted to u beatos ha a s13n1ticantl7 ineroaswd rffsks of da.elepiag laas cancer. oro a r. those who .aks snek claims oftaa o a rlook the estraaly eoaplst relatiosship bat.aan etespatloaal aaposure and the Sucraaaad risk of certain dlsaasal that basa baon discussed by various seiantists asd ressarchars, iacladin{ thoss who prepared the oor p03 report. Such nlaiu ,.oree..r, de not take Snte account the taet that in ost studiu of asbestos uorkars saoking habita ha.a aot baas Qstarninsd. Is soas ochsrs, tho data ha.a bou laeoqlats. Claiu that asbastos workers who saoks do ha.o aa laereased risk of daa lopin{ 1un3 cancer were pda 1a a 1968 rreport (19). That tudy, by Drs. Irving Salikoft and Jacob Chars of Mounc Sinai School of Msdicina and L. Cuylar lauosd of the American Cancer Society, was the first to take saokinj late account. In that study, 3alikoff and his eolloatu u ealeulatad that asbsaeos workers who saokad had 92 times the risk of d/isg of lua` .aaesr thao workers who had aeichsr a.okN aor bass a=posad to aa)u cos. Thay ada this ealeulatloa os tho basLs of records fro an iasulacion uorkars ualos. uhieh reportedly showed that only asbestos vorkars who swhad kad 7S 2060460696 -
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619 Table 2 Occupational Groupe in Which tacess Cancer Incidence Au geen Reported vithout Identification of A Specific Etlologlc Agent Percent Occaeational Crouea Cancer Sit.e Eseese keootted Coal .Sners Stomach 40 Cheelete Pancreas, 64 lTrphoid tiesue 79 Foundry vorkers Lung S0-1S0 Te:tlle workers Mouth and phar7ns 77 Printing prus.en Mouth and phar7ua 125 (newspaper) Metal Sners Lung 200 Coke by-product Large intestine, 1!1 uorkers pancreas 312 Cadalua production Lung. 135 uorkers prostate 248 lubber lnduecry Processing Stoaach, g0 blood-forming organs. 1440 Tire building Bladder, brain, ga 90 Tlre curing Lung 61 Furniture vorkera Nasal cavity and sinuses 300-400 Shoe workers Nasal cavity and einuees, 700 blmod-forning or3ans 100 Leachsr vorkere Bladder 1S0 Source: 6ridbord et al 1976 (13) 76 2060460697
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620 died of lung csneer. \ased en'the riported association of saakia{ with lnaa eancer aorcnlit7 aad the aucciatica of u butos ezpesure with tha ea.a disea u, they concluded that the coabiucia et saoking and asb utos ezposurs creatss a risk that is larger than the ezpeeted co.binatioa of the two separate risks. .6ols~is-`r.ac.r-ekan-cht-sus-e[-tbe-p.res This concept is referred to in epideniology ss "eynersisn". 1 considering studies which ha.e suggested such an interactioz becs an asbsscos and saek3nZ, a 1971 ps5 pnblieatio as asbestos mentioned the Selikoff stud7. The report said that the findings do sujgu t such •o effect. But. che report added, "The relation of the statistiu 1 interaction to the pathefenesis of lung cancer is uncertain° (20). The risk of lung csncer io nonsmoking asbestos workers ras discussed recently. Speakin` at a eonfereece on pollutants and high risk groups. OSHA's director of careia- oSen identificaticn and clusiticatien said laat luea that reu nt studies indicate a ti.a- to 15-fold excess risk of lnns cancer in asbeatos workers who do net saoks (21). Aey conclusion that it is the smoking which is r u pensibla for the raported increased risk of lung caacer i• the saekins asb.atos worker is a_o_j justified on the basis ef available evidence. 77 2060460698
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621 Nanni rNew Cluea Just two nonths afcer his anaouuceaeec that 20 psrcnat of O.f cancer ca ua probably originate in the work plase (1), Secretary Calffano beSan a $40 million proiraa to fiad ont ort about the che.ical hazards that •.ericans .a7 be uepoaad to at work, at ho.e, .harever they are. e said the 'pkaao.eaal technological advancea" in this country have bton{ht with thaa attloua h ulth harards, "as in the tase of aabtatos.• and directed four of his !LV atenciet to .ork quickly "and with a11 available resources to ldeotif7 and coatrol the any toxic subltances co which our citizens are anpotad." e said rtlatlvtl7 few of the sora than 7 nillfon cheal u 1t nor known to .a have been ceeted for carclne- jsolclt) and that aa many as 6D,000 are nev believed to be •r have bean in conaerclal usa, with 600 to 700 nnw onas oatering coaserca yearly. B• order.d stepped-up animal taatln{ at ZY and put in charge of the whole program one of the aathera of bit tancer-in-the-vork-place report, Dr. David P. lall, director of the Natlonal loatitute of Cnvlronnental iaalth Sciences (22). The a.panded testin$ proaraa .ar provide ne clues •bs.t tkosa ubaraetea vhinh appareetl. cause tantar En antaals, tad therttore a7 cauu raseer ln hunaas. Thlt 78 2060460699
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622 inforaatlon say assist epidenlolosists in analyzing unusual geographic patterns they have found irn cancer lneidence. The•e patterns Save been documented in several recent CI studies including: • A eoepilation for every county in the contiguous 68 states of nuabers of canter deaths and epe-ad]uated death rates, by slte, se= and raee for the years 1950-69 (23). • Tha "Atlaa of Canner Mortality for O.S. Counties 1930-69," which gives th• aata lnfor.atfon ;raphically, with color-coded aaps showing geographic veriacion• ;n cancer Sncidante at the county level. The authors noted that "the .aps for lung canter indicate that encesslve mortality is'n_t lini•ed to highly populated urban areas where cigarette smoking aad air pollution are •nac prominent" (emphasis added). The •ap• snabls epldeniolofists io both public and private sectors to do correlation studles vlth data on draographic and •n.lron- •ental variables eollected on a c,uncy level (2A). • A similar atlas with data on U.S. nonwhites (25). • another aet of napa indicatinp counties in which 16 d1f- farent anufacturlng 1nduatries have facilities and associated de.o{rapnlc data concerning e.ploynent and ocher population t-ntersation. The•• aps, the authors wrote, reveal industrial cauaty clusters ehac uy provide a "useful point of departure" 79 2060460700
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623 tor more in-depth local atudias to ewaluate orcupatiocal factars in cancer (26). • The cancer etlases ha.e beon the basis for •aey studies already. NCI ru tarchers, for inatance, rscantlT coq ared cancer mortality ratas for counties with and vithout petroleun refineries and discovarad an excess of cancers of the luns, nu al cavity and sinuaes in those tountias with refiasriaa. Th q drev no firs conclusions about cause, but they surmised that the high rates of lung cancer !o oou n ailht be due to a"pollucinn hazard spreading beyond the oerkplacs^. ihey did suggest industry-ride epidaaiololical atnliea to clarify the cancer risks a.ooa various lroups of petroleum workers and to "evaluata the possible effacts of patroth uical a.iasions released into neighboring coo.u- •ttiss" (27). "Shere'a soaethina horrible out there, but're don't kaow what it ls," one of the researcher, told buainasa Yeek (2t). The q Eatine reported in the sana story that one lar{s oil coapanT had just added an epidesiolotiat to its staff aad, with other tonpaniaa, ras participating Ln a tu.or- registry program in which all cancer morbidity and aortalit) ratord of onploysss are funneled through cha American patro- la.. iastttnca to ffoan-tsttsrial Institute for Cancer laaearnh t• Nar Tsrt. Thers, researchers look for patterns tist aijht p-.lNt to a ta.ea. 80 2060460701 '
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624 Canear epideaiolot7, tnci4enta1ly, has base until recestly the specialty of a ralatisely saall nuaber of sta- tisticiass and health practitioners, vhose work was largely sponsored by the gu.ernaent. The circle is tfght and there is great deaand on ehoae vho are already doing aost of the work. Joseph I. prauaanl. Jr. for inatanca, who co-authored the petroeheaical a•arsey (27), vas also one of the priae ae.era behind the 1976 cancer atlas (24) and a aeaber of the teaa of scientists who wrote Secretary Califano's cancer-Sa- tbe-vork-nlaca report (13). lrauaeni told Nuafneas Neak that NCI had doubled its epideaiolog7 taff in two 7eara and, like other scieetists q.oted in the article, besoanad the lack of qualified enriron- aestal rofaarchars to fill newly crutsd poeitions in gerern- aent and induacry (29). Conclusion garee years ago, Dr. Yilhela Nueper -- one of the d u sa of ru earch on occupational tarcinogenasia -- warned chat: naa espoaure to aany of thue agants (potential Ynase eartiaogsas) is not only videspread, but alao efta tate.aa, and aost of tha are used without obaarviag aay real precautiona. This laok of precau- tieta aay eaatiaua aa long as the espoaed public can be peravaded that the ain lung cancer hasards are liaitad to cigarette aaoking (30). 81 2060460702
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625 Dt. taapar, rhoca occupational raaaarch an cancar ®sµ i• the 19200 shaa he nncad an a1.rslaS Socr.aaa to 1vnS canear liaca tDa tuer of the century around induatriallsad cittas La Ca.tr.l Surop., racai.ad a special Public Gaalth Ssrviea asar/ last fall nara onths before hia death at 44. for Yia '.iatoa •nd nourata^ (31). iha sar p[S report aay well toeus naadad sttan- tlaa -- as rncogaitad na long ago by Dr. Ru.par -- en tha role of otoqational a:paaur.a in tha d..alopnant of dipaasa. 82 2060460703'
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626 tefer nc s for Can er lo the Vork Place 1. Caltfsno. J.A. Lt u rks of ths Secretsr7 of lestth. Lducstian and Velfare to the APL-CIO Natloeal Confer.nce oe Occupacional Safety and 8ealth, VashioLton, D.C., Sept. 11, 1974. 2. Msdicsl.VOrld Nrns. LLV Study Llases LiLLsr Praction of Csncere oe Jobs. Oct. 2, 1978, pp. 18-19. 3. GebrinL, P. Study Sees 202 of Cancer Cases •s Work- Related. The VashlnLton Post, Sept. 12, 1978, pp. dl, A6. 6. LseL, 1.A. Letter: The V u hlnLton Post, Stpt. 26, 1976. 5. talnnd, L.A. ere reltase fros the ManufacturinL Chemists Association. Vashietton, D.C., Sept. 13, 1978. 6. Whelan, L.M. MeVe relesse from the Aneri<sn Council on Science sad eesich, Men York, Sept. 13, 1976. 7. lardinL, I.L., Jr. Ners rsltass ftos the Society of the plancits Industr7, VasbinLton, D.C.. Sapt. 15, 1978. s. eerLer, P. In: United Press Inttresttonel wire dip- pacch, 7:31 PED, Get. 25, 1976. 9.-Leffsll, L.D. In: Sase Scientiets Doabt New Cancer cLstisace-s. The Tobacco Observer 3/5: October 1978. ~sc~ peco, L. In: Sose Scientist. Doubt Nev Cancer fstiutes. 1.c~- The Tobacco Observer 3/5: October 1978. 11. Cari, C.L. In: 8[V Study 8lases etLter Fraction of Canesrs on Jobs. Medical World Nevs, Oct. 2. 1976, p, 1t. 12. Vyader, L.L. Ia: LLV Study 6lases BitLer Prtctlon of Csscors os Jobs. Medieel World Nros, Oet. 2, 1978, p. lt. 13. Lridbard, L., at al. Lstiaatsa of the prsetion of Cancer fo the Dnttod fcaces Related to Occupational Paetors. lationul Csneer Institute, atlonal Instltute of tnviron- sescal  u 1th Letsneea, aclonal Iostitute far Occupa- tiosll Safety sad Mealth, U.S. Deperenest of 9ealth, Ldncutia• snd Welfare. Washington, Sept. 15. 1976. 83 2060460704
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627 14. S[hasidaresn. N.A. Ie: Increase in tetteate of York kelated Capcer Dve to Chaate in Study Method. The Caneer Letter a/A0e 6-7. Oct. 6. 1976. IS. lrtdkerd, K. Iae Ga.t. Se Uatists Oisruss Mev Theory. The Io6aice Obaer.er 3/3: 1, October 1976. 16. Satttottl, 0. Iaterviev with The Tobacco Observer durlnS the Hatianal IaatLtutes of Health Conference oa Caorer Treventlea -- Quantitative Aspects. k.ston. 9a.. Eapt. 25-26. 1976. 17. •sos rtlaasa fro the Occupational Safety and eealth Adaltiatration, U.S. Depart.ent of Labor. May 15, 1978. 16. Califaot. J.A. Int.r.iav on CIS MornSna News, Sept. 12, 1979. 19. Salikeff, I.J., at al. Asbestos Ezposure, Sucking. and 7soplaata. Journal of the Asartcan Medical AssocLa- tisn 206/2: 106-112, April 6, 1968. 20. U.S. Foblle Eealth Servioe. Asbestos: An Inforsatloa Eesosrca. ational Cancer Institute. U.S. Deparceent of Healtk. Educatien and Welfare. 6.thesda, Md., DREW Pub. e. (YIH) 75-1601. Ma7 1970, 105 pp. - 21. I.faata, T.T. OccupatLonal Health Practice and H16h Hlsk Croups. Pralenttd at Conference on Pollutants and ltsk ESsk Groups, A.herat, Maas.. June 3-6, 1978. 22. atloaal Iastituceu of Health. Major Protran Will Coabat Ikrlat of Cha.ical Hazards 1o En.ironsent. NIE Record, o.. 29, 1978. 2S. Yasea, I.l., and NeteT, T.V. U.S. Cancer Mortality by CsaatT: 1950-1969. D.S. Dep.rtaent of Health, Education ud Welfare. Yaahlnacon, DHEV Pub. No. (NIH) 76-613. 1973, 729 pp. 24. •.ass, I.J.. at el. Atlaa of Cancer Mortality for U.S. Cs.atlss: 1930-1969. National Cancer Institute. O.S Sq artatlat of  ulth, Education and Velf.ra. Washington, KYCY Pub. o. (YIY) 7S-7S0, 1976, 103 pp. 23. rassa, I.J., at al. Atlas of Cancer Mortality A.ooS U.S. Ye.rkltaa, 1950-1969. Hational Cancer Institute, D.S. 9/aparta6ut 6I iaaltk, tducation and Yeltara. 9aahlnEton, 1ttY Pub. Ys. (1I/) 76-1201, 1976. 143 pp. B{ 2060460705
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628 26. Stone. S.J., at al. OsoSrspnic Patterns of IodnscrP' in the Onlted Statese An Aid to the Stucy of Occuparfonal Disease. .ouroal of 0ccupational Medicioa 20/7: a72-477, July I97C. 27. slot, V.J., at a1. Cancer tlorcalit7 in U.S. Counties with Patroleum, Induatries. Seienca 19l: 51-5'_, Oct. 7, 1977. 20. slot, V.J. In: Osing Caacer's Aatee to Track Its Cause. iustaesa Veak. Hor. 14, 1977, pp. 69-70, 75. 29. frauaeai, J./., Jr. Inc Dafng Cancer"s 2ate to Track Ita Carse. Iustnsaa Week, Nov. 14, 1977, pp. 69-7D, 75. 30. luaper, V.C. Lung Canter and Snoking in Perspective. In: Trankel, C.J., editor. Lav7ots' Medical CyciopNla of Taraonal In)urSaa •nd Allied Specialties. 9o1. S levised, Pt. 1, Sections 77.1a to 38.99. The Allen Saitk Co., Indianapolis. 1972. 31. ational Institutes of Healch. Hueper eceives Dirae- tor's Award. tlIH lecord. Oct. 3, 1979. 85 2060460706
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629 La aa. CGreiu.a of the lost •as au of the firat dYsaasas to be associated, i .odar tinas, •ith tobacco uoka (1). D ua ga.ata.ait officials aad sciaatists opposed to s.okiy ocplai tka reported drazatic incraa.a in lung cancer death ratss absar.ad i this taatary by polatinj to the coacsrrsat risiay popularity of s.okiat. 2hay hava also tried to attrt- bats the apparent racaat decline to the rate oi increase of oala lu= cancer .ortalitT to a dacrassa ia s.okint aad the i.trodactio of the aas low 'tar° ci{arattas. lhaao uy be The fallara to conaidar critically 1) isportant diagsostic ad.aacas. 2) chantsa in the reported fraqsaaeiu of lung cancer call types and 3) trands i tigsratta cosss.ptio and lung cancer aortallty data raises sarioss qsaations about any conclsaions ragardiat a.okia{. easy aad alasantary atplanations of lunt cancer causation, but ckay aarieasly o.arsi.plify the sltuatloo and ltsera critical . V.sacisaa shith aael to be acaalnad. Ciaenoatic irror • critical sauiuttoa of the reported lacruu ia 6ssl cancer .srtalitp srst taka iato accouat ehaaaoa is diasasatic tackui4saa. :k. lacraass. elaiad by ao.o to be 67 2W04607Q7
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630 •opidafin.' any Ls fact have been crerted lartelyby radieal inqroveaenta In diagnostic taehniquae that have becooa arail- abls to phyaitisaa. In other words, oora luot caneer kas baa fnnnd beeanse physicians were better aqulpFed to fiad it. ta.ificattosa of this nov ability ce fiad last eaoeor were discussed oora than 20 years ago by a IIatioaal Cucer Iastitata hiostatiatlcian. In 1937, alatandar . Cillisa tit.rnd ont that if the error In dlaNnoals of lant eaater were otly 10 percent In 1914. dacrau int to 2 peTcant 1s 1930 after Sntroduction of soat of the nw diagnostic tools a.d tachniloea we know today, sala lung cancer death rates .oald have only doubled in the 35-year period instead of the 2f-fnld iseraasu indicated by national records (2). parthar raaaon to question the validity of the 'Lpideaic' tan be found in what hau bean taraad the tasdeney toward o.ardiatnoala of lung cancer. It has been suggested that prl.ary Lnnt cancer bas betonu a"popular" disease to dia{aoae So aookara -- in other .orda. physicians are flndinn more laat cancer (whether or not it actually atinta) because they are lookina ore for it. Ona Nav York chast specialist pt it this aayl The prodigious laereaae In lung cancer durlat the pddt thros deeadaa is aot due to the onposura of ths papalatton to an allatad tareiaoten but ia the ostaral sau aquoscs of the •ldeapread uss of tsch- siqsas sot previously a.a11ab1e. The tatalsa istarsst 1a last cancer has also produced a teNaaey B8 2060460708
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631 tnwatd oVeTdisSoosls of the diausee on the basis of radinlojic, binpsY, aad c7toln4ic findlnSs nhitn are ofcaa sot substantiatnd by autopsy (3). Trands is Dnsth Rataa and Snoktns Pattetna Ivan !f one tasuass for the sake of atSasosat that at laaso a portion of the 'spideaic' is real, the trends is daag cancer death ratss cuaaut be etplained satisfactoril9 by oaekias pattarns. as loas as 20 rears aSn, statlaticiaas forecast a decline In lue5 cancer aortslltP. Ths7 based their predictions pri.aril7 on anslrrss of luna cancer death rata treads of the firat half of the century. Thsy also ackanwledSsd such factors ae the dra.atic inersasa in the satfr st of the population aost susceptible to cantar (the •Sad) aad the o.ardiaSaoaf of the disease ta aaotsrs wich atcoapaay- fa$ nndardiasaosis in oaaoet.rs (.-b). In 1961, the MCI scscistectan. Or. Gilllaa, aade a forscast about U.S. lung cancer death ratu, basing it nn his aaalyti of aorcalit7 trends. d decline since 1945 in the rate of ineroase f laay cancer aorcalctr, he said. tndlcaeed chat "the diaaaae •ili reach a paak s.cn5 the rhtte aels populatina 1a the fsraNSable future snd thoa atart to decliae" (7). Isde.d, within sit aontno a r.searcbar rspdrtsd 89 2060460709
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682 that lan8 tantar death rat.s to _the Seattle aru had ceased to risa in porsoas under 60 and predicted that they would plateau 1a 10 to 15 paara (0). Ln 1965, Cre.at Britaia'a kagiatrar Caaeral ade a aiallar forecast for his tountr7 (9), as did Caaada's dlractsr of cancer statistics Sn 1966 (10). aubasaunatL7, [CI statiatltians atca.ptN to •laata the leveling lnng cancer death rates in aaa rith ehatsns la tkait aaokin` rata (11). And others jueped oa the basdo`oa, also attributing the change 10 ortality rataa to naokiag treads (12, 13). •nothar epid uiolo6iat was .ore akeptltal, hn.o.ar, .h.n he .roca in 1974 that it did oot aaam likal7 that aaokiat pattnrns could explain lun` cancer in the D. S., Rngla.d and Yalas. Iac ij`Sns, who is •all-koouo for his asti-tobatco vit.a, said that the flattoolc6/doclina of ase-spacitic wr- calit7 rates in kritish nen "appaars to have pret.ded the rnduction in cigarette s.ckln{" (14). !e evan aug{eatad that lritain .a) be "rltnssslng a saturation pbano.aaon. ..that thoaa .oat susceptible to the disease have now developed lt, with the result that the peak of the epidenic 1a now paatol purth.r support for relactisg the auokiag-cauaatlsa iatsepratatiaa vaa provided in 197S by a 6rttlah tkeraeit anr{aon, Dr. J. k. lalchar, who noted the ehasgea i aQa 90 ' 2060460710
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sas ud tseid.-ace tattaraa of l.ag caaear i his coaacr7. . sPOealat.d an .hst ea.s.d the ch.as..:- •t. ck.y da4 to the discovery of th. s.istisukiP .t elgar.tee sa.kias to braehisl eattiaesa aad tha aabea4s.at aaeiaul caaPaiga a{.i.st the kahit} lhia aeaas a likely a.si.atios aacil it is reall..d that th. fall t the prc..tass taeraao, ta tks rae. - aad s..at.ail7 of th. ra. it.elf la the t•sapr asa groups •as hapP.alat a lo.{ alo as 1930. It seaa. .era likely that the tall ia the prcaataba rate of tactaaso •kieh data@ back for at l.ast fifty 7urs k u e...c.ally 104 co as actual fall Sa the rac. itself. Skis process kas trogra.a.-d steadily ...r a.a7 7•ats, aad r.Pre.aatn the sataral history of eartiseaa .f the breachaa (15). Lv. or. racantl7. Profr u or thi3liP larch of ch. Oaiv.rslty of L.ada suaaarla.d .uch of his o.a work Pakllshad .Sac. 1972 d.aon.tractel the lack of corralacios bat..ea suakiag treads a.d chasN Sa Oriti.h lcsg caae.r death rat... Io .)as.ar7 1977 •nrch wrote Sa th. iritiah Medical Journul: l2]ke detailed chan{.s ia r.cord.d death rat.a tees laa{ canear 1 ia`land aad Yals froa 1901 to 1970 .er. .trikla{17 a7nchronoaa in the two •as.s. 4hes the .a]or eao.e of the increases had a slaalca- peas laPact an both ..aaa aad conld net hate ba.e cigarette a.oklns b.cao.e the incraase in coasa.qtlee of cigarett.s by .osea lasg•d aes. 30 7.ars behisd that et s. (1{). Ootch aid that Poat-.ort.a studia of the fr.%suc7 of la.a eaasar iadieat.d that th. .ost iaPorcant factor 1• the taeraaae of recorded lra` eaac.r has k..n eliaical diapoatic aera. 91 2060460711
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694 talt-telectloe -- Tke Conatitutioaal .oethelts Is 1976, cha iCS Snterpreted date froa ita 25-stata atady an ladlaattat that asu who saaksd eitarettu with lo.ar 'tar" sad aieetise )Selda had lo.er lunt caacer aortallty (17Y. Ce.saatist aa thue daca to 1977, kos.ar, eas tritish ressarehar •ass't so asres Dr. M.1.5. Sasasll, who haa 1o.5 had stress aati-saokia5 •ins, said that drania5 aach  eoaein- aloa t tka present ti.a eould be praaatora, "as the saokars who ehaapd their cigarettes rara self-ael.ctad" (15). 5a1f-salactloa is an iaportant part of tha "eoutltu- cioaat hTpotheais" first Snjaeted catu the saekin5 sad health eoatro.aray •ura than 20 yaars ato by Sir tonald tishar, raeo5siaad then -- u now -- as the father of •odara-day statlstioa (1p). Tka Surgeon General's report Sn 1964 das- eriled it aa ae "altarnati.e N7pothasts that both the ssakiat of ti5arsctes and eaneer of ohe lont here a coaaon oause which d.t.r.laas both that an individual •ba11 •<cca. a saokat asd alsa that ba aha11 be predisposed to 1ua` caaeer" (1). The constlcutional hypothesis bas baeo discussed trsqnsntly Sa reoant years. Professor lurch in 1a51aad. !er isataaee, has .aintainad that the data on a.okin5 tad martalit) !a his coaatr7 are sora eonstataut with the coastito- tiual tksery thaa the aaekiaa-eaasetion theory. dod he hasa't kesitasad to aaT so. 92 2060460712
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sas titea 1972 ptotaasor gur,h haa kaaa published satas- aiva17 oa bia theory and haa provoked eonaldarakla diaeuasios aad eoatrovats7 in tha aadical litaratura. lut aona of this dialogaa •ithi the aeLanLlti. eetauaitf about tha eausa af inag catear baa appeared 1n any of the i4 raports to Congrau oa atoking. Diffarant Types of Luaa Canear That there are several distinet t7paa of lata canear -- dlatinguisbad by the appaarantas of tba talls in the traor nndar aicroacopic ar.aination -- is ua11-knorn. gona typaa bava stronger statiatical aaaociationa with eiga- ratta smoking that other t7paa. . gpida.iologital stndlas havs indicatad. for Lnstanca. that elgaratta saoking is aora stronal7 aaaociatad with apidar- aa1d, or aeaasous-eall. cancer of tba lang and is not asaoei- ated, or on17 weakly so, with another aalor typa, adano- carztitou. rhera haa baan little discussion of lung cancar by cell type in the 7aar17 ggY raports to Congraas on atoking aad haalth, bnt St haa baan ganarall7 accepted that adsae- sareiaasa is •ora eo.aan la uoaan and in noua.okara. I 1977e a Naa [erk raaaarehar. Dr. lonald C. Vincent, reported that patYalagiata at taa.all fark Ya.orial Iaatituta were tladiag a rapia daeraasa la s4uasaua-eall eareiao.a, aad 93 2060460713
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636 Fipur. 1 - tM Ctanpiny HistapatholoqY of Lung CGno.r 1Y68-1Y76 N. ts62 10 /' ueam ®rOnfat.p - ~..~...~~ _-..~_-. -..._ ~AN.ew Ml>rW p ' -- 53 55 e7 ea 71 73 YEAR OF oIAGNO8I5 souer. VUC.m .t al. 1i77 (20). 94 2060460714 ~.- ~ ~ - Bpu.moua ~ . -BmYI
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637 • eerraspoadteg incrusa Sn •denocarclnoaa (see Figure 1). !e added that Sf their data proved to be representative of aatioeal trends. 'adenocarcinoai will soon become the sost prevalent type of lueg uoc•r in the United States" (20). Speau Ltteg about the factors re•ponsible for this de.elopunt. Dr. Vincent .entloned the Sncte4sing Sneidanu of long cancer in ro.en, nodiflcations in the way pathologlsts ileatify lany canesr tell t)pes and environmental and oceupa- tioaal ageat• and alterations that have occurred over the last few years Sn elgarett••. Be conceded. however, that his taam had considered uch factors as "length of s.oking hlscory. form of tobacco used, quantity of tobacco used, age haoit started, degree of inhalation and the u•• of filtera", and that they had been 'unablt to equate the histology of lug cancer •itb an7 of these factors". The reasons for this developaenc, if it ultimately prove• to b• represencative of the national etperience. re.ain aaknor, . One vouders if this reported increaae in adeno- tarelnou say have a s1a1Lr basia ae the over-all lung cancer 'eqiduic' diseussad abov -- that is, observer variations. [Mch of th• over-all "epid•aic" say h• due to changes in elielclats' techniques; ueh of the •denocarcinos• increase sry be du• to sodificetions in the ray pathulogists claaulf) lnf{ caacar eell t7pes. 95 2060460715
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sas As a case in point, three patholotists in Connecticut reappralsnd the htstepatholaty oi-:49 lung cancer ea.as fron original tiseua apacissna and shoved the rat. of atreesant with past readinFs was only 63 percent (21). Thsy re.iaved cases that had been interpretad betveen 1953 and 1959. On thair reappraisal, the peresntate of cases elassified ae adenocarcinosa Sntraaasd narkedly, while the percentage of alnaaous-ce11 eareinosa decreased sijnifieantly. Thesa in.estisators suggested that a reappraisal of anfoci<tions betvsen specific histological types of lnns cancer and ssoklnt was warranted. ev H.pocheais -- Diet Other de-.elopaa..ts in lung cancer in recent years include a nev esphasis on what sitht be called the "diet kypothsaie". An epidasiolotist in Japao who 1a known to be strongly ancl-cobacco reported last Saptasber that satins Hresn asd yellow •esatables daily lowered tha risk of lung cancer L ssokars and nonssoker alike (22). "Thi cass as a surprise to aa, because I thought that only cigarette ssokls{ could Lsfissaca tha risk of lung cancer," Takaahi Hlrayasa told a uadieal Yotld avs reporter (23). Stndiss la aninala and husana In recent years bave LsdLestsJ tkat dietary .Ltanfn A, which traen asd yellow 96 2060460716
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639 •at.tab(ns are high in. .itht ha.a an inhibitory aflrct 04 pul.asar7 carefnotaa u ta. par ataapla. a atud7 In Mor.a7 poalkdarad rltaats A tntaka and snokint habltn to ralatioa to aubsnqnsat da.alop.ast of luot cancar. Ths author said that kis fladints were in accord with atparlaantal rasulta Lu aalnal atudcu and "eall for further •aglotation of tha rols of uttltiosal factors ia the dsa lopannt of luat eancar" (24). s addad that tLa association of luot eanesr with eigarntts uskiat "aa7 have h.ld back" atta.pts to stad7 r.latlonnbipa batwaan outritional factors and luat cascat. rkathar regular eopsuaption of araan asd 7nllow vystablss ot a dnftnisoe7 of 7itaaln A should be cossidars4 isyortaat In lunt cancer eauution is not claar. ut a apseial Calk fsrca nsntiat In 6tnckhola's fa.ous t.rolioak Inntituts 1a 1977 ttook it seriously. Alchouth tna aciaatlata •ars strsatl7 apposad to sfoklnt, they aatd that the a.idancs as H ta.ia A Ls "tEouthc-pro.ekint and nsads to ea followed up" (2!). An1na1 t:nnclaantation lasulta of sans asiul a.partsaats ha.a bss applied t• rt to srpport the elais that cigarette snaka eausas ea.esr. TYSra are .sa7 arioua. perhaps trraaol.abla. prs- •la„ ia •s7 satrapolation af astaal results to bu.aas. Luas 97 2060460717
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640 eaeat ef the type satoeisted nith cigarette asokiy is ssa bu sat baat prodaea-d is ati.als is Lahalatios sttdias (It). •ad savera eriticis baa basn levelled at eartala st sha atadlas baeaaaa of anrsallatic sapsrlsaatal aitastiosu sbich esald scarcely be coaparalls to tha huaas saparisaes -- far tutatea. a=trasslP high dosagas over a abort period ot ttao (I7-I9)./ Shara ara, ob+ioaslP, also algnifleaat diffaraseas bst+sua the tissues of aa and laboratory aal.als, atd chac aataa it difficult to draa any cotclatioos aboat the bssa rslsvasca of atlsal results. Coeclusion Tha elaia that cigaratts smoking causes lung catur has aoc been sciantificall) proven. Tha charga lgnoraa basic atssolvad scientific questions concarnlag call t)pss, aalsal s=p.riaeatatlon, ssoking patterns and lung cancer rates, dietary Safluaac. sad diagnostic varlatiooa. Lung cancar is a complex dissaaa. aod a ena-sidad attack on cigarette aaoklag as the causal agent does nothing to advance the search for it cases and cure. Yithit a generally negative presentation os saotlag. the pathology dapartosnt chairman at UCLA told a Public lsaltb i,ar.ica atistitg aa1P a year aad a half aga: •Ltb.s{b spidssiological data has clearly established the aalatascs of a correlation hatraen asokleg aed 98 2060460719
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641 [lai easearl. a elur-tut eauasf ralatleuhip bart.• e1{aratta •aatit` aad easear Eaa tot l.at dt.eutratad (30). 2060460720
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642 tafsr.nces for Luar Cancer 1. U.S. Public ealth Service. Snoktnt and ealth. keport of the Advisory Coonittse to the Surgeon Oansral of tka Public laalth farvice. HashlnSton, 13.3. DapartUaat of ealth, Hdueation and f:elfars, pE5 Pub. o. 1103, 1964. 307 9p._ 2. Oillia., A.G. Trenda of Nortality Attributed to Carcino.a of the Lsot+ Possible Effetta of laulty Cartificatio of D.aths to Other la.piratot7 Disa..es• Cancer t/6: 1130-1136, 1995. 3. Eoaaablatt, N.1. Tha Incressa in Lung Cancer: Ipldanic ., or Artilactf riodical Couaterpoint: 29-a0, Mareb 1969. 6, Lesa, T.Y. S.otiaS aed Lunt Cancer. The Darfen praaa, Ltd., tdlsbar{b, 1939, 32 pp. 3. Leea, T.Y. Letter: Laneet 1: 1116-1117, 1965. 6. Laoa, T.Y. Lactar: Lanaet 2: k43, 1965. 7- Ctliiaa, A•C., at al• Tranda of Mortality Attributed to Carcino.a of the LunH: Tha Declining tato of Incraaao. Cancer 14/3: 622-62E, May-Juna 1961• t. laennbolt, l.T. In: Lung Caneer, Heart T11s May le taar feak, by John karbour- Louisville Tir u,o.. 13. 1961. 9. Cuaral La{istar Office. The tefiatrar Ganeral's Statls- tleal ta.ie• of Eo[land aad Malea for the Tear 1962: 9att III, Cosentary. London, Eer Majesty's Stationary 0991eo, 1963. 10. lktllipa, A.J. Aa Analysis of the iocraass in Lung Cancer fn Canada. Canadian Medical Association Jouraal 95: 1172-1174, Dac. 3, 1966. 11. t Jnaidar.an, M.A. and Levin, D.L. Trands in Lung Caneer: ortaltt7, lacidaacs, Dlatoosfs. Tr u t.ant, S.ok1eS ~ sMd Orbanlsattas. Cancer 30/5: 1320-1325, Mn.e.ber ° 1972. 12. flyaddrs E•L. EtloloSy of Lunt Canesr, tsflectio.s aM T.o Decadas of Haaaarch. Oancar 30/3: 1332-1339, /o.a.ber 1972. 11. t.rn, D. In= Lunt Cancer Droppio{ A.ont Aneri un Ken, by Jaaas lodgers. Haltinora Meua A.erican, Oct. 24, 100 2060460721
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643 1974. p. 3A. 14. ittlaa. I.T.T. Ttsnds St lsapirstor7 Cancer Mortalit7 i the United Statos and in tetland and Walau. Arehi.eu of tn a roaaantal aalth 2A/3: 121-129. Narck 1974. 13. eleher. J.t-. Tha Chantint pattarn of troeehial Ca=t16- o.a. trttiah Jouru 1 of Dia.aaaa of tha Cbaat 6!s 267=231, 1975. 16. terch. p.t.J. Letttr: lritish Modieai Jovraal la 163, 1977. 17. ta..ond, i.C., at al. "Tar" and leetina Coatant of Citarntte Ssoko 1p talatioa to Death tatea. tn.lraa- ratnl tsaearch 12: 263-274, 1976. 1i. tv u ell, M.1.t. Saokint proble..: Ae Overview. In: Jarvit, M., at 41, aditora. taaaareh ee Snoklnt taha.ier. atloaal Inacltuts on Drug Abus.. U.S. Dnpartaant of taalth. tdacatlon and Yslfare. tock.111s, Md., IIDA ' Research Moaotraph 17, Dacanber 1977, pp. 13-34. 19. 2laher, t.A. Snoklnt: The Cancer Coetro.ara7, So.a Attupte to Aasnea the 2vidsaea. Olia t and lo7d, idiakartb and Loadon, 1939, 47 pp. 20. Tincaat, t.G., at 41. The Changing tiatopatholop of Laet Caaeer: A le.lev of 1682 Casas. Cancer 39: 1667-1633, April 1977. ]1. Taaaar, l., st al. A leappraiaal of tiatopatbolo p is Lntt Cancer aod Correlation of Ca11 T7pu with Aetecedaat - Cltaratta lnoklnt. Aearlean te.isv of tesplrator7 Dlasasa 107: 790-797. 1973. 22. tira7au_, T. D1et and Cancer. Dali.arad at latloaal Cancer Inatitute Coafarancs on Cancer pra.ontlon - Qaae- titativa Aapactn, taatoe, 9a.. Sept. 23-2t. 1971. 23. Srq a.a, T. Ios Japan: Colon Ca Moviat pp. Nadical YetU Neve. lo.. 13, 1975. 224. tjnika, 1. Distar7 Vitaain A aad lunan Lung Cancer. t.terutleeel Jeuraal of Cancer 13/6; 361-363, 3973. 23. Cadnrl.t. t., et s1. A1r Pollution and Cancnr, tlak Ideasa..et NathodolotT aad fpidasiolotical t.idants: lsp.rt ef a Tepk Group. 9avirooaoacal aalth parapac- tivee 221 1-12. 9`abruap 1976. 24. pnrst. A. ttatau nt fer the Subcoanlttas oa toaltk. 101 2000460722
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644 CnsUlttnn on Labor and publie Molfaro. 0.5. Snaac.. 96th Conlraoa, Sncond fassiea, Ct6aratto 6.okia5 and Di- a.aaa, 1976, pob. 19, 1976: pp. 100-116. 27. [aaalar, 2.2. Oaccharle, Cyclaaata, aad laaa lladdar Coaeart la L.id.nca of an Aasoeiation. Jonraal pf tka Aanrteas Madical Aaaooiation 260/at ]a9-3S3. Ja1y 28, -197t. 28. Staaffor. .p., and [i.dvyl, . Intorattloa aad pl D.paadaaeo of Ltfaeta of leotlna aed Carbon Meno:ida ta C1larntt• Saaka Iehalatioa Izparlasnta with lata. Agants aad Aetions 7/S-6e 379-566, 1977. 29. kair, Y.J., at al. Apparatus for Direct Inhalatio of Cilaratts Saoka by Do p. Jonrnal af Applied Physiology t6/6: Ss7-eSO, 1964. 30. •a Lanekar, J.L. Saoklns aad Dianaa.. In: Isrvlk, M.L., at a1, adttora. kasaa[cb on Saakln` {nbavior. Jarvik, M.i., at al, editors. atiooal Institutn on Drug Abuse. O.S. D.partannt af 6 aie6, tdueatioo and Ynlfara. lockvilla, tld.. DIDA loaaareh MoaoSrapb 17. Daeubar 1977, pp. 2J0-260. 102 2060460723
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645 ocher cancere etY's yearly reports to Congress have cited various prospeetive and retrospective popuL tfon surveys to support claias of atatiatical relationahipa between ciga[ette smoking sad cancers of the oral cavfty. bladder. esophagus. laryn and pancreaa (1, 2). [ovevat, close eta.inatlon of the tnci- desce rates of these diseases reveals .any unaaplafnable patterna that are almost iupossible to reconcile with the kypotheais that ct{arette smoking causes the.. The incidence rates usually cited for these cancere, aad tbair ti.e patterns, have been derived fro data'collected The establishment of any relationship betveeo seok- kini and cantece of the laryn:, esophagus and bladder ust involve considerable auessvork, because of the vastly different incidence patterns and trends of these diseases and ultlple suspected eaases. is two large-aeals studiea, conducted 25 years apart, by the pablic 8u ltb Service: The Second National Cancer Survey (itCS). 1967-t9, and the Third National Cancer Survey (TNCS), 19il-71. Source daca froa the rirat National Cancer Survey. 1937-)9, ara no longer available, but conparative daca fro• eke Seeond sad Third, for the seven geographic araaa that Ckap kad Ss eoaaos, were published by the National Caneer 8aatltats last ysat (3). More than 20,000 cancer c-asea were Aaelodpd to tha.ifC6, .ote than 124,000 in the TNCS. 103 20sQ4so724
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646 Figure 1 Incidence Rat.s• par 100,000 Populat/on from Second National Cancer Survey (SNCS) (1947•q) and Third National Cancer Survey (TNCS) (196f}71) SNCS TNCS SNCS TNCS SNCS TNC° % 0 C1INCER ORAL CAVITY SITE a PMARVNX q BLADDER { 0 - WhM mab p- nonwnur male ESOPHAGUS p- whib famala Q- nonwhlta Nmata 'Aya aAjaate0 to the 10l0 U.S. Ooouunon atanaara. ioarer.OMw ano Sllramun 1976 I(3) 104 2060460725
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647 Ths graphs in piture 1 illuatrvice such inconsruiriee ns incidence rates rialnR, fa111n1 oi reaalnin{ stable depend- ing eo diauaa. lender and tate. [ven when one eou lders the no~called '1a{ period° -- the tiee between the action of the nlie{ed causal agent (acarctu` saokint) and the diagnosis of the disease -- the Rraphs atill do not support the claie that cigarette saokln{ is the cauaal a pot. For e:aeple,'ooerhlte uale rates for caaeers of the orsl cavity and phar7a: .era up by almoet 40 percent in 25 yeara, while the rates for white sen aad so.an were down by approai.ately 30 percent. The rates for ueanhlte feaales decreased, coo, but not so sharply. Turther, ulfilar peculiarities in the rate paccerns cao be obssrved for ca.eer of the bladder. The rates for sales, both white and aevhitev increased aarkedly -- especially the nonwhite sale raee, which nearl7 doubled. The rates for both groups of feaales were sharply down. Soaa critics of cl6arettes have clalaed that blacks 824 ether nonuhites •a7 have been slower to take up rlgarette asakin{ in any nuabers and are therefore later in shoriaa teereaaes in the °el{arette-ralaced" diseases. Thle contention f sot supported by the daca, as illuatrated in Figure 1. On the other hand, the ationa: Cancer Institute researchers have sa{peted another explanation for these trends in nenvhitee, aNel] that other factors such aa ac ues to sedlcal care and laprs.ad d1a{aosie say partially aeplain the increased inci- daaea ts aase of these dlsa.aes ln blacks. 105 2060460726 '
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648 Sut chaes factors cao hardly aceount far tha Ju.p to o.ophap al eocar is nonrhite salea while white .ale iscidasca va dropping. tha incresae in bladdar tanear ia sos.bica . ua• while [t dropped !n nonwhite vesen or tha dacrease Sa orsl/pharpageal canc.r in nonvhlce •osan rhile it cltsbed ataqlp in noe+hita .ta. Othar published studies and survqa indicate that no Lir• stat ueets of causality correctly eao be adn about s.okin{ snd any of th.ss esneara which have bsen tatia- tieall7 linksd vitb e1{arattes. Oral/pharv ual 6ancere Although claioa have baan aade that eaokin{ causes oral aod pbar7ngsa1 esaears, such eontaetiona are not supported by sa eaanination of the available literature. A oa.Nr of stadies, for e:uple, hava failed to establish a relatioaahlp betwaen s.okins and oral cancer (4. S) sad a.oktns and pharys- pal caeeer (S). laeant studies on tobacco and oral and pharyniaal easesrs have e:ulned the possibility of a substaatia117 kighar risk for developoent of chaaa caneara Sn indlvlduals who bstb s.eke and drink. One study in 1977 reportad suck a• t.erausad risk in patlants ssasinad in 20 hospitals Sa e1gbt Au rica• titias (6)• Yn.evur, this raa nec ceaftr.ed by tro 206Q460727
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649 otk.r atudfas of oral eaaeer patieeta publishad th• aaaa year (7, •). Istarsstiatl7 anouth, eu (7) pointed to another tatter -- poor dantitioa or tooth spaclai -- as a.ora laper- taot risk faeter than either eitarettas or alcohol. •ttaapts to atud7 the possible tafluaeess. of cita- rattas aad alcohol in the development of aral and phar7apal caaears are cosplleatad, because lodi.ldoals who s.oks also are •ero likal7 cn driak. 7harafora, it is diffSeait ce dataraioo shat -- if any -- rola th ue social hablts play. taoobataal Caac.r • kiostatistitian fron the tetareatiosal Agency for Su u reh on Cancer la prsoca recencl7 reeisaed worldwide pattsr4a of ssoshagul cancer aol certain epidsnlologleal data (p). a conclud.d that "tbo data_stroatl7 aottoat that factor associated with povsrt7 ead specific llsitations of dietary intake incrauo auseaptibtift7 for this dtaauo." This rea.archer noted "aaceptiona117 high ratns 1• a..a arus,• and "a bitber iacideact anont tha lower aoe1o- asaaonis `roaps," ont .arkedlr t females. a aaid tkat althoegh thnte ta a statistical aaanccation vtth tebaeeo aad baavy als.hol use !a the 0.6. ud dastera ioropa, is oek at 944 reat at the world they ra not "facters of major 1oper- taaea.a 107 2060460728
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ss0 "• coaaiderahle array of etternal factors have baaa aasoclated with the disease," he said, "but none strongly e.ongh ar with sefflcisnt conslstency between countries for tkair etiological role to be basic." Is aaother recent atudy, rse.archers ecasininp the Sncldence of eeophaSaal Canter in Southern lran found that the risk of this cancer in sales and feaalu •as "at Laast nearly equl," evea though cigaretts smoking and alcohol consuq tioa are "al.ost saclusl.ely ala" habits la this region (10). This obaer.atlon led the to speculate that "it ssus probable that the etiology of the dis.esee in th1 region is sot eaplainable by association with tobacco smoking and/or alcohol ssa, since these habits do not correspond with the epidemiology of the disease as found ln this study." Lar.osaal Cineer •fter examining nearly 200 patients with laryngeal carciaoaa, an inSllsh otolaryntolo{ist questioned the claf• that aaokiag easses this cancer (11). te obsar.ed that "the laeidanes of laryngeal cancer has rs.ainN •ora or lose caaataut for 70 years -- e periad in which tobacco cosss.ptioa .•.(ku) rises sbarply." •a alss .araed that " uy data aleNiat a eortalatio between heavy elaarett• s.okin-q asd larfs{eal eartiaama aust be interprated with tautioo because 1 the e.tlrs population the incldence of larysaeal earclseu 108 2060460729
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651 has beta reaark•bl) constant." The tritish physici.n"s conclusions •re supported by ths •ork of •a •r{sntinien who eraained the efoking habits of Igf cancer patients in three cities (12). gtatistical asalyais of the data, he said, revealed "r•luas [fer saakiag) that are net significaot, consequently not inditating • depen- dsacy between the prasence of the studied cancer and the saokiag habit." ie said, "de can therefore hypothetically assuaa that other factors, besid u the significance af the •asking h•bit, aust logically affect the etiology of thass patholagiss." Saoking apparentl7 also aa discounted as a causal factor by •ritiah scientist who investigated the possible relationship betasen alcohol and tobacco use and lar)ogtal cautar by sasainina disease and death rate patterns (13). 0as problsas he aaid, is that trenda in aortality tatss Sn different •g• group show contru tin{ charactaristies. e foead, after drawing up ti.e trend charts by five-year •ga gr•aps, that the sort or less consistent fall in dtath-rata is both sexes -- rSile per capita consuaption of alcohol aad cigarette use rost So both sexes -- "would aeaa to be iaesapacihl• with the hTpothesis that tobacco and/or alcohol srs MJor caasal agoaa." 7sfora Yia discuasion of the dsta oa larTagsal casear. k• bad teaasatsd an the nsed to usa all a.aiLble data 109 206a460730
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652 Sn att.nptint to deter-ntee diae u e c.usation: "7here cae be eo doubt that epld.aloloatsts have the profe.aional re.po..- ibility for elucidatin{ the causes of disease with all [he ingenuity aed thoroujhness they cao coa und." lut vlth a rr)naas" rsr. in adical journals, he •lso nated that "cr)leS wolf lo the abaeuce of the earsuder fs generally held to be counterproducti.e." )ladder Cancer A nuaber of studies era.lnin; the incldenee of bladder cancer have found no uaoclation betveeo cigarette smoking and the occurrence of bladder tumors (14-16). Iocou- siatencies 1u the coacluslcns of reports eaaslnin{ the rele- tlonship between s.ekcn` and bladder cancer and "the relative seakneas of the evidence for an sssociacion in feualea^ led the journal Lancet to "suggest the need for caution in lnterprets- ciea• of such studies (17). Aajor paper on bladder cancer uaa published by the ational Cencer Institute in late 1978 (18). The tro so.ereuest epldealolegisca looked at the geographic pattatna idssctfled in their 1nstltute's "cancer atlas" (19) (..a Cancer I Workplace ebapt.r). iladdar cancer saps, according to th.sa resurchera, sksred "s!{siflcan[1y higher" rates among aales in the Porth- 110 2060460731
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JNCI ,.: CifFARTPAfNP QF (+EAt'H FpuC.Aii(ita A•4li r41 .~ • 653 Figure 2 Journal of the National Cancer Institute Oclooer 978 voiume 61 M,mcer 4 a1,n r..y.ltr. - .r~aY NdISYW inyltyft a F~ 2060460732
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JNCI 653 Figure 2 Journal of the National Cancer Institute Oc1oDP, 1978 vowme 61 N,mDer 4 „'. bEFAFT~AENT Of nEWH FpULAh(jr. ANl. y..f . i• , ' t... 1n•nAr• ..~K.• Ydfar~ .ny~l,lp.~ .y ~bMn 111 2060460733
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664 east and Sa eoustlas with hear) concentratton• of planta .aaufacturlna d7es and piasencs, phar.aceutiaal preparations. pertrssa. cossotics and certain other toilatrlas. The authors conflrsed an incraaae to bladdar cucar 1• urb u areas. which one of thso had previously hypotheslaad to be due to heavier cliarette ssokins in city dwoiiars (I0). es they said, "CS{arects ssokin{, however, to not likely to ba responsible for the elevated sortaliry !o the lortheast, 1 as such as the available national surveys show only s.all ragloaal difforencaa in asnkia{ practices." They also noted that bladder cancer is the es1T 'asoklus-relatad" cancer for which death racea a.on{ •alas Ss Morthern urban araas are lover in blacks than to whites. Th q sursisad that the lovar risk aight be due to 11s1ted esploTSSnt opportunities for blacks, especiallT pro-1960, la indsstriss where workers aT be atposed to chs.ical carclno- aus. In another study published Sn late 1976, MCI epidsnl- oinMlMts associated the levels of certain contasinanta of sssicipal driuking water with bladder cancer in both ases. Tko reaaarehar said an interaction of chlorine with nthor sahstaneas la water trutsant planta, and sosatllu tontaslss- tios fr.os isdustr' create tribalosetbansa (TBtla) to .ary1n{ qsantltl.s. Ths researchers said bladder caacsr rates showed the stroaNut and ost consistent association of all caacsra 112 2060460734
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ooLosvosnz Ltt steaa 9112 aT ra.sa 000'0T aa42 sao lo rpaoasiJ '(!Z) Lseang asana0 TsaoTOSn paSql sq2 eT P•aa.oa cotaaTnded T.2o3 aq2 ;0 3r42 oa (roo.aoM-sns pua oosaoN q2oq) s2aapTSSa 4s20 oT pano; saoepTaaT sqf psasd -.eo Paa OL6T Paa 9961 aaaw2sq aasie aqa aT DaT3T2aap.T s.s1a a.acae TTr PazLT.a. 3a43 4r30 UT Lpn2• 3asosa r UT Pa3sa3a -aoaap t.w .Taa4oadL4 ucsAON aq3 oa oot7d.ass •a0 •2... ;o asn •q2 UT uoT3snapo• 900339 Ls43 PoN '2aos sATaaTPPe sq2 6TTsTasdsa 'dnap ao •s;;oa '.a2 'oaarqc2 'To4ooTr 00 aaaao.p• Lsq2 •r 'pons.oosqd a43 lc; aTqTraodasa rt s;TT lo Lsw rnoT.s3sqa IraosaoN 0,43 3044 PazTeaq2odL4 nsoq arq iI '(FZ) r~T2.Tndod ao.aoN LT2oeaT.opaad 9no.• LT3usnDSa; srsT ano-an o2 ps2aodsa a a q aws4 saaaasa „pa2sTaa-9aTqoa„ psTTsa-os sq8 „•.eT2 rTY2 af alaTa IOU eT dTqaaoT2aTaa 042 7e •aoeatlTOiTa 043. 2V42 PaDnToaoa pql toT3foss s32aae'/ta q2iw aDT2aTDarrs sqi PaaTSfas oaodal sq3 ;o sao43ne *41 '(ZZ) „foTq~.s ;o ssaasn6a ao0 427968 oql„ 0o 320403 9L6T 042 oT 3asas2.2 s Lq p.2satsnTTT st 'saasa 2T2sraaa.d oT oaaearaa 7e sanira s.TSnTaaoaaT sq1 s.alaaaL aq2 0 '(IZ) PaT7n2a Llanoa 043 ;e uoT3aztT°TafanpcT luTpnTaaT '.ooccal 20440 ;0 1aiZooa aaala aput sansodas M83 ats47 VTT• 999
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sbs taater ry lltry aherad no sisaittcaoc dlffereete by religion ia paecraatlc cancer incidence. soth Moranes aad non-Mornena, aa aatter of fatt, had a low fncldence of the diseue eo.pared to TICS lntidence, .hich, osid the Utah r.searchsrs, •raisas the queation of othar, unidentified factors." Concluaion ' In a paper pubL:ahed 1n early 1978, one of the top epiduiolofiats at the National Cancer Institute re.iased, aeh as .e did at the beginning of chis chapcer, che incidence of eone of the cancsrs with which saokln{ h.s been 1lnked (25). Giscussing the trends !n "head and neck cancers" he oated aany of the aa.e.inconsfetenclee re 414. 4nd he nalde For these dlsaases, at least. St is cot likalT that any one single etloloi7 •ill g1.e a aatis(actory e:planatlon...f/hat does this cap17T It iqlies that w.'re got to lnnk for aore clues. . . ne• clues should laad to nev lnquiriee and eae anneera. 116 2060460736
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657 Eeferences toL Other Cancers 1. O.S. Public gealah Sarvice. The Health Coneequenca, of S.oking: 1974. 0.5. Departaent of Realth. Educatloe and Yelfare. Waahfngton, DEEY Pub. No. (CDC) 74-8704, 1976, 124 pp. 2. O.S. Public Eealch Service. The Butct Conaaquencu of S.okiegc 1975. D.S. Oepart.eat of gealth, Education and Yelfare. YaahinEton, DEEY Pub. tia. (CDC) 76-g70A, 1175. 235 pp. 3. Oevnaa, S.S., and Silversan, D.T. Cancer Incidence aud Mortalit7 trands in the Onited Statea: 1935-7f. Journal of the gational Cancer Institute 60/3: 545-571, March 1979. l4. E1-Mett7. S. Oral Cancer in cha Onitad Arab Eapublic. Oral Surger7, Oral Medicine 6 Oral Pathology 2A/2: 260-2A5, August 1967. S. Caderlof. E., at al. The Eelatiooship of Smoking and So.e Social Covariablas to Mortality and Cancer Norbiditr. A Taa Taar Pollov-Op of Saoking in a Probability Sa.pla of $5,000 Swedish SubJects Age 18-69. Eerolinaka Inati- tate, Stockhol., Sweden, 1975, 91 pp• 6. YTndar, E.L., and Stellaaa, S.D. Coaparative Epidaaiology of Tobeaco-Eaiatad Cancers. Cancer Eeaearch 37/12: 6608-4622, Deca.bar 1977. 7. Orahaa, S., at al. Dentition, Diec, Tobaeco, and Alcohol in the Epide.lolog7 of Oral Cancer. Journal of the Rational Cancer Institute 59/6: 16L1-1618, Oeoe.ber 1977. g. Erovne, E.M., and Yaterhouae, J.A.N. Alcohol and Tobacco Mabits in Oral Squa.oua Cell Carcinou . Internaclnnal Asaoeiation for Dental Research Abacracta, No. 210, 19770 9. Day, N.E. et al. Soae Aepects of the Epideniolog7 af Eaophagaal Cancer. Cancer Research 35/11 (Part 2): 330A-3307, Noveaber 1975. 10. Sadaghl, A., at al. Cancer of the !sophague in Southern Irae. Caneer 40/2: 861-g45, 1977. 11. SteLL, P.M. Smoking and Laryngeal Caucer. Lancet 1: 617-618, 1972. 115 2060460737
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658 12. perrara. r.A. teolotltel Anal7sis of Lung Cancer Sa the City of La plata. Proceedings of the 204 International . Clean Alr Contraaa: 2aa-2a7,.1970. 13. Sureh, T.t.J. Are 901 of Cancass preventabls7 ItCS Madlcal Sciences 6: 353-356, 1978. 14. van der Varf-Masalnt. 6., aadtaalen, J.C.A.I. Occapa- tioes and Snokln6 tabics of eladder Carcinos tatlocs in tottsrdau. Jaarboak van taukarondasoak an tankarbast- rijdlni in Maderland No. 19: 77-85, 1969. 15. Anthony. t.M., and Tho.as. C.M. tu.ers of the Urinary laddar: An Analysis of the Occupations of 1.030 latleats in Leads, tntland. Journal of the Matlonal Cancer Institute 45/5: 579-695, MovenLer 1970. 16. Schievalbein, S., at al. Ir7ptophaoe Matabolisn, Cancer of the Urinary lladder and SnokinS tabits. Zaltsehrlft fur tlinischa Chenie und tlinische liochanie 10/10: 445-449, 1972. 17. tdltorial: S.okiot and Cancers of the lladder and tidne7. Laneat 1: 635-636, 1971. 8t. tlot. V.J.. and irsuaeni. J.p., Jr. Geographic Patterns of Bladder Cancer in the United States. Journal of the National Cancer Institute 61/a: 1017-1023, October 1978. 19. Mason, T.J., et al. Atlas of Cancer Mortality for D.S. Counties: 1950-1969. National Cancer Institute, D.S. Departnent of Saulch, tducacion and Welfare. Vashint- ton, OttV Pub. No. (MIt) 75-760, 1976, 103 pp. 20. praunani, J.l., Jr. Citarette Saokint and Cancera of the Urinary Tract: Geographic Variation in the United States. Journal of the National Cancer Institute a1/5: 1205-1211, No.enber 1966. 21. Cantor, t.p., et al. Aasociattone of Cancer Mortality rith talosethanee In Drinkint Water. Journal of the National Cancer Inatitute 61/4: 979-985, October 1978. 22. U.S. Public Su lth Servlce. The tealth Conaa9ueneea of Seekint: A teference Cdition. U.S. Depertaent of tsaith, Education and Welfare. Center for Disease Coa- tral, Atlanta, 1976, 657 pp. 23. tnntron, J.1. Cancer Mortality A.ont Mor.oes. Csnner 36/3: t25-661. Sapteaber 1975. 24. Lyon, :.L., et al. Cancer Iocideace So Mornona and 116 2060460738
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659 ~oa-Mor.ona in Utah. 1966-1970. M.r [o63aod Jeurnal o! Madicla• 194/3e 129-133. Jan. 15. 1976. 15. lchn.tdarman, M.A. Ttm• Traad.: Onit.d Scat.. 1953- 1973. tar7ngo.coP• SuPPI. !!/1 Part 2: 4t-a9, J.nuary 1976. 117 2060460739
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Cardiovascular Dieeaea In 1949 in praainghas, Maaa., the U.S. Iublic ®autth Service started a prograa of close surveillance of more than 5,000 adult not and ronao selected by rando^ saupling. The major objective was co accespc to detersine why individuals would develop evidence of coronary heart disuse (C9D). Through quutionnairea and painstaking observationa, the reaearchera would record the varlablu in lifeapyle, environmental characteristice, faailial traits and other factora believed to relate in any way to CHD. Then they would see which of theae variablea were most qnnaon in those persona A falt appraisal of the evidence, examined in its entirety. indioatee that the risk of coronary hsarc disease is strongly associated with geaetic and lifestyle factors. who did develop heart disease symptoms. And they would try to analyse statistically the relative isportauee of each of the variablea in the occurreuce of those symptoms. From that cosaunity-vide study, there developed the concept of "risk faccors" In C9D and other diseasea (1). The lraaingh u study or£qinally found statistical relationships batrean heart disease and high eerus cholesterol level, sleeated blood praasure, cigarette saoking, obesity and low 113 2060460740 -
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r 'F'1 PltAAk Amk ame. . _ 661 vital capacity (1). the rssesrchers stated last year that sln+ated blood pressurt "hae btea confiraad as the donlnaat coatribater^ to halrt diaeaae ia the pranioHban atudy, bat that thnf are coatiouinH to study the possible role oi other 'risk factors" in the ds.alopaent of heart diuaus (3). Tho preataoe of an usociation. hort.ar, is naitbtr proof at causality nor a deaoastration chat the aitinacion or reNaction nf a risk factor rill prevent the occurrsaca of disease (4), though ons ai{ht not knar that froa the statenents of sote Sosarnnant health officials (5-7). Dr. Christiatn lernard, thc faaous heart surgeon, has provided an illuetrative analogy an this point: (T)ha statistician can do no aort than point out the a[iat.nce of an aasociatlon bstrs.n two ariablsai be eanfot prove a causa-and-rtfect relationship betrten thea. Stated aort tinply, sa ascocistton betrtaa a particular diet and the ineidsoce of toronary htarc disease can be deaonstrated, buc that does not by any a.ans p,Eore that following Lhat dl.t caus u b urt disease. I an sure an asaociatiee could be shown betreen tha absesee of la9s aad the inabilit7 to respond to the t.rbal coaood ']uap.' Hut this would not pro.e that poople heer rich their 1.Ha (!). Tbe director of the Heart, Lunt aad Hlood iasticute rasehod auch a tonclualon, hore.er, to addresaiat a atttinH of tdleal rritars in 1977. He told chtt chat alialnation of s.okiag would reduce CUD aortalit7 by 150.000 deachs per year (9). Lau thao ia onths lacsr, un Capitol Hill to justify kis laatttuta's budset. he told Houae •ppropriations Cotalittee 120 2060460741
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662 masbus that "q still dea't baav the atialsA of artarteaelat- es1a asd hypartaasloa" (10). is said his rassarchara are "taattaa tha braathaaia...ebat Sovattat ckelaatatol aad esssatlsa of saoktal will da147 at -ravaat the uaaae of kaart dlsaasa" (ssqhasis added). , it.bacesu obvloua that aci•etiats taa• ilttla more abaut C1D eausatiaa now than they did to 1f64 vhaa the oridiaal tacyaos Osaaral'a rrport said that "the basic cassa or esuaa^ of eoreaar7 heart disaasa a're obscsrs" (11). Out thiaa .eisntists do kaoo Ss' that heart diaaaaa death rats^ are dot,s. I. taet, a ssatint was aallad to Ilashlagtea last Oeto-ar to discuaa a 14-7ur low In kaart diasaos death rates (12). tital atatisties -raaautad at the saaciaa raeaalai a 24 parcant deeraasa ersr-all to C/0 slaea 1160. while deaths from all tsasss dropped osly 17 parean. tataa for esrabrovaacalir dissasaa were doen inc more (13). saa Table 1. lleatiag participaeta, who iacludsd heart and prblia -saltk apacisllaca from acreao the aatiea. -asica11,7 aaraed that the doersaaa to the death rataa for the satios's laadlag sesao of death was rsal a.a aet ]sst soaa statistical a-arrs- tioa. •ftar all, the ratu were dova is both ouas, is hsak •httaa asd •aaskitaa and is all ^ga araopa (14). But they said •ot decide •hathas iqroved traatasat tscbaiqvas Of rassat paats or 1qrevasaat is what -aaet raaaarehaea tail 122 2060460742
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Tabla 1 Nr Cost of Doeru.a So Mortalip 6atoo Onitod Stat.a, 1968 to 1976 lor.oo. AS• 35-7s, b7 Sa od taes Caa.• of Dsatb Tar C.nt of Dacr..u 1968 to 1976, br ba[ and Sae• Vh1to Mon Vhita Vo. _.n Mon.bita Man Monub4ta Vn..n 11 Coronary taart Di..aaa -I1.0L -26.75 ' -30.75 -39.12 -2d.3! L.r.bro.aeular Di.oas. -30.62 -30.65 -43.7% -47.11 -3I.7E Major Cardiora.- - enlar Disnaaa -20.9Z -26.12 -33.2Z -60.7Z -26.6i A31 Causos -15.35 -16.62 -20.62 -32.7Z -17.3i Sourco: Se.al.r L978 (13) 122 2060460743
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664 -a.arita's risk factor profile" should be given credit for tha brighter picture (15). aftar all, as the raainghu projact dlraetor had aetd urlisr 1n the yaar, sanf parsons have baco.a .ora health coaseiooa •nd hav• "jradually ebsnood thsir life-styles with ta0ard to dairy products, ..areiaa, naiahc-.atthing, astihypor- taaalss trsatssnt, sad ci{aratts s.otln6•" yhis bos all eoi.eidad with the decline 4n coronary .ortaiity. be said, "bot the o:istaaca of a causal ralatlnnahip L uaelaar" (16). •tto.pta to dator.iaa the eausaa of heart disease hasa bssa coapiteacad io the lsat tar years by the racosnitioa of otSar possible risk factors. yhasa ineluds tautly history of heart attaek (17), arhan vs. rural raaidanea (18). •iral lhtdetios (1f) and a factor eallad "aceulturation" (20, 21). lhis last variable -- to uay, one of chs oora worthy of further in.aatihation -- tolstsa to the departure of yooa{ar potnooa froa the traditional aad faa17-oriaatad ways of their aidars. d.a tbait lives ehanp, so do their risks of oalar heart disease. •nd this anhaocad risk ean nat be sr- plalaad statistically by ehansu io d1at, eholait.rol lavals, blood praasoro or a.oklns. • rsesat o=a.pls of this was reported from a eoa- tlaiag Fl/-elndad otldy of C/L lecidanta !o Japannso citlaans aad fadivUuals of Jtpsooso a.eostry la avatl aad,Callfornta 123 2060460744
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665 (20). Aaother eaa.ple 1s the eaperienee ot a a.all, eloae-knit Italian village Sn Pennsylvania that over the yeara bee.aa nete like a typieal Anerfcan tuburb (21). The streases of aodera living attend fron elty to tlay iaing co..unfty, from esacutfve offiea to fatayard, which brings us to another relatively unaaplored variable Sn heart dis use, the Type A behavior pattern. Persona who exhibit a Type A behavior pattern are chronically in a hurry, pushieg coestaatly to keep up with the Joneses, seeking taaog- aftfon and advancement, suffering t.ua what the two physician rasearthura who have identified the paturn call "paucity of tfee itself" (22). Thu e Type A peraona, as oat could guess, are nora coronary pro. Pour papere published aicce 1977 add to the growing literature on the suh)eet and strengthen the belief of aany seleatiats that further erpioration Se warranted (27-26). A potantially unifying link with a wide variety of these "risk factors" ras poatulated recently by a Columbia 11oi.erpity physician researchar in a study of aale heart patiaots. This resaarcher baliev.a that an fabalance Sa tea kornoa u in the bloodatreaa •ay sccount for an individual settiag baart dtsease (27). Cnmu etiog on his resaarch. Dr. Gerald g. Phillips told Tha ev York Tiaas further scudles are oeeded co eu.lne 124 2060460745
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waa.s and a)dar •.e vho hare heart attack,. 'e eetd he eapecte to find the saa. Labalante it then. And 1t turther studies by hiaseif and others sustain h1a theerr, he said, "lt should not be difficult to chanae che blood horaone levels In order to prevent a heart actack" -- by diet. druts or other eans (26). Tha Tlaas co..ented that Lt Dr. Phillips' theor7 1e rttbt, "horaona ehan`ee could arplain why heart attacks occur .oat oft.n Se older aen •ad in poat-.aoopaua.l voaen" (2f). Two 6rltiah reaaatehers alac hare speculated that hor.onea say p1a7 a rale in the develop.ent of CHD (30)s pro• their study of aortalit7 rates In tuglaud and Walses th q concluded that "furthar studies are oeeded to clarify (th• role of ale sex horaaaea) In the aa•iolotJ of C9D In a.L." Deaptta thla e.phasis on the deterainatlou of "risk factora", physicians and researchers haee questioned vh.th.r they are really relevant in •a) discu ulon of th• d.e.lop.eot of CeD. For eruple. a v.et Virginia heart specialist vrata in daerfcan aeart Jouroal that "a11 of us kae• that every good cardiolo{iec .ust repeat these %orda (ba called hypareholost.roleaLao e.okteg and obesity the vsaSfc laeastatioa"1 three or four ciaae dat17 to ruttlrs hls bs11.f is what has been accepted as causative factors 125 2060460748
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667 of this dread illness. However, few of theae ralaclonehlps have proved deflnittve". He also suggested that: Our pri.ary need in cardiology today is a fe• heretics who rill abandon the practice of equating otatistical asaocfatlon with the etiology of athero- oclarotic heart disease. This uould seao a greater unphaais on the causation of atherosclerosis ltaalf H1). A physician in Ireland considered what ha called cha "aa9or risk factors", but hia weren't ecactly the aasa three as the Weat VSrginiaa'a. Re tasa to the saru general conclusion as the A.erican, hore.er, writing in Journal of the Iriah Medical Association that there is "ao .vidance in .an to support the eonteotion that the control nf elevated liplds, cusatloe of cigarette a.oking or the control of hypertension retarda the davelopsent of the atherosclerotic process or delays oha rate at which coronary artery acenoses develop once these processes are established" (72). As a.ell-knorn Aa rlcan epide.iolo`Sst has written 1n a• England Journal cf Medlcine li.itations in the eurrant kaowlad{e of the etiology and sethods of prevention of C[0 "argue for broadening the search for contributing causes and possLble dynauics of patho`enesls, rather than .araly lntao- slfyin{ the study of the far traditional 'risk factors'" (33). 126 2060460747
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668 Carbon Nonoridt Cacbon aonoaids (CO), a colorlass. odorlesa ad tastalaas tas produced by the burning of an7 atarial contain- inS carbon, has been thought by aan7 to be the eoaponart of cigarette .oks that iSht enplain the statistical asaoala- tion betaaac .okin{ and CID. In early studlaa, rabbits chronically esposud to CO and fed a high choLasterol diet were found to have aora arterial nhna; u sifilar to early atherosclerosis in nan than 414 aniaals on a ainilar diet but not CO-arposad (34-39). "Doas CO play a role in arterioaclsrosisT' one of the .ost prosinaut researcbars in aokinS and health askad rhetori- cally of an American Cancer Society audience in Philadelphia 1! .ontha ago. AnaoarlaS his o0o Question, ba said, "It certainly aorks in rabbits, but there's eonsidarabla doubt whether it warks Sn aan" (40). Yall. no. it doasn't appear to rork in rabbita, either. poal Aatrup. one of the researchers who did the aaisal anperi.ants .:th CO, recently reported that ha and his Sronp have baan unable to reproduce their results (41-43). In 4 prasaatatlon daaeribinS theaa fiadinSs. thay sald that "no direct toxic affect of CO" could be deoonatrated (42). 127 2060460748
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stito9vosaz 6Lt .asq3 anq a.a.ap 22004 doT.ap oa Laosp..3 • qaTn pa3aTaoa.o .T laTwn.e .aasnalTo„ •L.a.noa3aoa .q3 psaTaa.on .sTaT.Lqd q.TaTa9 .oo •V •.anT.n.3Tt T•aTP•• •qa Lq p.aaoddn. ios •as .e..•Tp aa..q asn.a aio.e oaa.qoa oT pano; o r3noood.oa a.p o ao .pTSOOOU noqaao •aoT3oaTO asqa ..T.ta •.ao;sa.qi •(V~ 'S~) eT•UTas 2003 aT aaaaond atcsfoasq» sqa .ae.nT;ai .eTwasqao ne •spaqas>sas •sasTaTaT 03 p.tts; soTaoaTC •asfssop 7Tn.TTa.a loT.n .aTpn3e ta.Tas PI •(91) „3onoo ITa.TTa.aan pn. .wT..saa u. LTotsos.a 7oa. aT L•p 204 s13sasfTa SZS o2 S[t Ltala•Taoadda oa 3asTs.Tnbu„ a.• .po.. -Ta.d.a a..qa aT ps.n .uTaoaTO ;o ..f..aP LTTap •3no ps3aTod cn..Taada. qane p.33npooc .aq oqw asqaaaasaa ano ea an9 •.aoa.Ta+d.a t..Ta• ;o .3Tn.. s4a eodn p.TTaa s..q •.•..TP ia..q .a.n.> .oTancTn 3141 nTatc nq. eoaTaoaTO8 aqj •(ry) ,,aasL ao; p.3a.dens LTq•TlTO.n[an a..q .aq aaT3ooTo„ 3aqa LL6t •T p•a.3e oq• •a.qoaa...a o..aa0 a Lq p•2aoddn. $T aoTaT.od aTi •(TL) •and -ino ane.q .....aaoT aaqwao. 21 aa4a oaqo c.qao saa.q .qa to saTaoaTa ;o aa.;;. oa.aTp Lo• pano; .aq .ao on aa; o.. aaqi tacanor 3a ay caaTaa.V UT LTanro.a .iua. aaTtsToade aapsq .no •.idt.m. neL 4zne ae; •TS.q .qy p.aoTa..nb .aq .aaT>T.Lqd put aa.4aa.aeas ;o a.qtno a•..a..Tp aa..q .a.n.a aoTaoaTa 3.41 .pea u.aq .w.4 ..T.ta qfnuqaTT 699
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670 is-ae satiafactory epidaaiolotlcal or e.peris.ncal aetdene• to iaplieate the eontancs of snoks with di.sass of the coronar7 erteries" (+7). Stroke g[W's 1975 report to Congraaa on seoking and health (dg) said there has been 'conflietiat e•idanea oc whether there is as ineraaued risk of carebro.ascular diaease due to seoking." In 1977, there ras e.idence fron Johne gopkina ra- searchars thet further confused tha issue. Shair apidaatolosical study of the diffarance in stroke mortality ie three U.S. cities vith lov, iatat.adiate ud higb rataa of cerabro.ascular disease was unahla to account ter thaa on tha basi• of eaeking (49). Sh y.concludsd that "thara ia s sttang possibility" that phynieal and oeial sa.ireaesntal faetors other than thoss presently known "aaD aecacat for the obsa-rved geographic differences in eortalit)." Ths Jobns lopkias in.estisators noted that tiadiass 1s past resnarch work by othars had also bu n"incunsistaat". dlchosgh rassarehsrs ln the past ha.e studied risk laetor assoeinted with eardloasculsr disaass as poselble causes of stroke beearse they assu.ed all thasa dlssu u are related. tkis liaa ef apaealatio bas baaa diacouated. 'Cerebro.a eslar disaaaas ara not simple sataaaloas 129 2060460750
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671 Tabla 2 23-Y..t Tr.nda of A6.-Ad)u.t.d Mortalit) !e rh. Onit.d 6r.t.. C.r.bro.a.cular Di...... 6.art Di...... Daath./100.000 D.cr.as. (2) Daath./100.0D0 D.er.a.. (2) 1950 66.6 -- 307.6 -- 1960 79.7 -10.22 266.2 -6.62 1969 66.3 -23.02 262.3 -14.62 1976 51.4 -42.a2 216.7 -29.t; 6oure.: To.or 197Z (S0) 130 2060460751
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672 er asala{ias of eardio.ascular dls.asaa," aaid ene pat official rneantly. "The fact ia that strokes are peuroloaical diaocdara aad naeroepidsalelotieal problsas" (50). _ sa ta Donald 7. To.er, who heads paa's sational Institute of eurolotlcal aad Coanunicatiea Disordars and Streka, sad the snphasas rere his, not eurs. Dr. Tower addressed the Synposium en Yorld learology ia llontraal in Saptsnbar 1974. Stroka, he said, Sa "probably the nost devastating and disabling ot bu.an disordera.° pra.a- Ldnt Sn esa q country rajardlaa of aeononic, ethnic or cul- taral eharaetaristiea. And stroke "ought not to be aquatad epedanioloiically or patbaphyaioloticaliy" with a ievascnlar disease. "4han one saantnss stroke nortality owr the past 23 years, the aq-adluscad rata has decreased strikingly -- over 42 percent in the laas quarcar century (saa Tabla 21 aad a da- sreasa nearly 50 percent greater than cbat tor heart diaaua.' Da said hypartenainn appura to ba an inportant risk factor ia atroka, but that there are countries like iSaria and SanaSal nith high Sneldsncas of hypnrtansion and of stroke but very low iaeidnaca of heart attacks. Hith cholestarol level, an aatab- lisbed risk factor in countries like the U.S. and Japan, be Nid. peae "little, a any, risk for stroke" in the lfriean lenntries. - "Ya do not yet have the sns.era," said Dr. Io.ar. 131 2060460752
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LLT '(TS). .eosaa owoaqan asL a ao3 on op sss..lp aTaon.p.ea.qa. .oap .TP Pn. doT..ap 02 P.oTa..P sT.nPTSTPsT 3. LaTao6Y. a... sq=« :ssaosTaS 3o La psa• ;aol •.e •qa 30 .TseaT .qa nT P*qTaa60P TTsw .d.qa.d .. aoTaasn.o QHp 10 fnTpa.a.a.Pon TsaTPs• lasaano 30 2o.a:• .qZ '(9T) •vqa faTL3TPo. 3a La»T))• aTan.doa.q1 pa• s.T1a...ad .qa 1noq. pao sss..TP asTnau.eTpasa •T saoaas3 q.Ta 3o sToa .qa anoqs asTaTad.ys P....ad:. LPasT ..aq .a.TfoTOTPa.o aa.uT.oad 3o a.qs. T :sasP .qa PoTPna. osTe s.q oqw a9TaTasTl.a. SHd • POP aoaa.nTP saT Lq acTa-.aaqo Ia.a.a s qaT lpnjaooa oa PsTdTasnC sq aq1T aT 'QH] 3o aus.doT.aP .qa qaTw p.a.Tan.as LTPSaoddn. ,,.aoaas3 q.Ta„ yo ad.a.oa sqP sanpoad PsdTeq LPnas sqfaissat sqa la ;aew qq soaTS e1.9
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674 Mfar.oc.s for Cardio.aseular Dlasaso 1. Darbar, T.k. Tho PraainShan Study: A lJasd to Cootieoa. Medical Tribune, Oct. 12, 1970. 2. Da.bar. T.k., at al. Sy.posiun nn Artarioselaropip: Tbo tpldaniolegy of Coronary foart Dia.asa -- the Praniqba dsRuiry. Proceedings of the loyal Society of MadicisH 33: 265-271, April 1962. 3; [annsl, V.6. leesnt Tindfa3s of cha PranlnSban Stndy. Resident and Staff Physician: 56-71, Januar7 1975. 4. Varko, L. Tho ordsrlins pst.esn ealtb asd Dinaaas. Prn.antioa et Traatnant7 A Perspsctl.a. In: Valdsastrou at a1, editora. iarl7 Phasss of Coronary 6art Diaaaoa: The Possibility of Prsdletion. ordiaka /okbodslss Porlas, 1973, pp. 341-362. 3. Callfano, J.A. Lattar to all Members of Congrsss. Jan. 11, 1978. 6. Calffanu, J.A. tanarka of the Secretary of taaltb. {dueatlon aad Welfare to the Associaclon of State and Territorial Laalth Offiefals, Denver, April 20, 1979. 7. Califano, J.A. konarks of the Secretary of taalch, {deea- clon and Welfare before the teonoaic Club of Chiea{o. April 20, 1973. S. karnard, C. tsart Attack: You Don't aaa to Dia. Dalaeorts Prasa, ar Tork, 1971. 9. Levy. l.I. Cardio.ucular Dlaeaaa: Pasc, Praasnt, asd Prospscts for Pr.snoion, addrsns to Mid-Atlantle Chaptar of AN riun Medical Vriters Aascelation, iathnada. rd.. Oct. 13, 1977, as reprietod in Medical Con.ueieatfona 6/2: Suusr 1976. 10. Levy, k.I. Tsatinony bsfora • subeossittsn Of the Copit- tal on Apprepriations, U.S. Dauas Of lapraanntativas, 95th ConSrsss, Second Sosslon. on Dopartnsnta Of lealth, iduea- cioa and Welfare appropriatious for 1979, Mateh 3, 1978, Part 3, pp. 317-461. 11. O.S. Public aalth Service. Smoking and lsalth. soport of the Advlsory. Coanittss to the SurSaon Gsastal Of Cha Public lsalch Service. Washington, U.S. Departsont of talth, Sdueatioe and Welfare, PDS Pub. Mo. 1103. 1964. 347 pp. 133 2060460754
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676 12. toasttar. A. Hurt Dlseasa. Onitsd Prass In[erna21ooa1 .cre dtapateh. 11:S9AHD, Oet. 24, 1975. 13. Stealer, l. Chan6ss !n CHD Risk 7aetors. Addrus to Con- far.sca oo the Decline ia Coronary Heart Disaasa Morta11c7, Dt.laion of eart and paueulnr Disaasea. Hational leart, Lusl aad Hload Instltuta. National Iostltutes of loalth, U.S. DaPart.ont of lsaith, idueation and Welfare, Oet. 26-25, 1978. 14. Thea, T.J. Meoorandun to kobert I. La.7, director, iatloaal aart, Lung and elood Inatituta, Oct. 27, 1977. 15. The lue Sbeat. Drug tasaarch taports 21/44: 4-5, o.. 1, 1978. 16. tssssl, Y.H., and Gordon, T. The Haunt Dacllns 1a Patal Heart Attaeka: What Caused It7 Prlsar7 Cardiology: 10-11, February 1975. 17. Pords, 0.1., and Thelle. D.S. The Trosso esart Study: tlsk Pattors for Coroaar7 Heart Dlseasa Related to the Oeeurrasea of M7ocardlal Iafarctlon in First DaSres lelati.ns. Aanrlcan Journal of HpldenioloHy 105/3: 192-199, 1977. . 18. Carela-Palsiari, M.1., at al. Orbao-tural DSffarsnces in Coranar3• Heart Dluase in a Low laridance Area: The Puerto hien Heart Stud7. Aaerltan Joarpal of Spidestolo57 107/3: 206-215, 1978. 19. Hdltorial: 91rus Infection and Atharostlerosia. Lantot 2: H21-622. 1978. 20. Mar.ot. M.G., and S7sa, S.L. Arrulturation and Coronar7 learc Dlsassa in Japsnasa-ASaricaaa. •.arican Journal of Hpldeslolo57 10s/3: 225-247. Oct. l., 1976. 21. Orasnbart, J. The Asnrrunisacla• of tuaeto. Science ers 113/23: 37H-379. 352, June 10, 1978. 22. lessssan. t.l., and Prlsdsan, M. Assoclation of Specific Hsha.lor Pattern in Oosen with Stood aad Cardiotascular 1lndinHa. Cireulation 24/5; 1173-115a. lo.eabar 1961. 23. Matth..a, [.A., at al. Cos9atltt-.a Drl.a, Fattarn A, asd Csrosar7 Heart Dlsaass: A Purthsr Aas17s1s of Sosa Data tro• cha Yestarn Collaborative Group Study. Journal af Ckrasle DSs.a.a 30/S: i09-e96, August 1917. 24. llssaachal, J.A., at a1. Type A 6ohaafar Pattern aad Cerssar9 Atharoselarosis. Clrculation 35/e: 63N-639, 134 2060460755
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676 Octabar 1115. 23. artu s. L.N. hahaaloul Pra.anttoa of Iseh olc aart DissaJa. Caaadiaa M.dtcal Aasociation Joarnal 119: 599-603, Sspc. 23, 1979. 26. trank, L.A., at 1. Typa A 6oha.ior Pattsrn and Corour7 AaRtolraphie Plndla{s. Journal of tha Anariean Nadleal Aasociacfoa Zd0/6: 761-763. Aug. 25, 1978. 27.-Pbilltps. O.S. Ralatinnship tocroan Sarus S.t Ner.on.s aud Glneoaa. Insulis and Lipid Abnoraalitlas if aa .tth Nyonardial Isfaretioa. 9rocssdia2 of the atioul Aesda.y of 3oianeos USA 74/4: 1729-1733, Apr11 1977. 20. Phi1329s, C.l. In: Shift in lalanee of Sat ler.ea.s Links-d to tsart Attacks by Man, by Larranea t. Altsaa. Tks av Terk Tinas, April 27, 1977. 29. or.nas Laa1s Nay ba In.ol.od in Raart Attacks. Tho .. Tork Tiss, May 1. 1977. 30. Nallar, l.T., and Jaeobs, t.5. Coronary Raart Disaass in tslatioe to ASS. Saa, and tha Manopauna. 9rltish Msdieal Jootnal 1: 472-474, 1970. 31. takuttb, I.6. Lattar: Aaarican tsart Journal /0/6: R09-10, Daea.b.r 1975. 32. nrtaa, J.l. Lattor: Journal of the Irish Madical Aasociation 69/13: 357. 361, Aug. 21, 1976. 33. Jonkins, C.D. Psychological and•Soeial Precursors of Coronary Disoasa (First of Two Parts). lao Lntland Jouraal of Medicine 2!d/3: 2A6-2SS, [ab. 4. 1971. 34. Astrup, P., at al. lnhanelnt Influanea of Carbon Nas- oiida.aa Ch• Darolopnont of Athsraaatoata in Cholutotol- Ivd labbits. Journal of Atharosclsros!-s Rasaarch 71 343-334, L967. 33. Vasntrup, J., at al. Actsloration of Spontanooua Intiul- S.biacisal Chaatsa lo Rabbit Aorta by a Pralon6ad Noderats Carban Moao:ids tnposurn. Aets Pathalo{ics Nicrobiolotie /eaada.a.ics 73t 353-362. 1969. 36. t3sidssa, t., at al. Oltraatructural Intiaal Changes is thn Rabbit Aorts sftar a Modorats Carbon Noaoaida t:ponurs. 6.tbsrasclsrosls 16/1: 67-92, 1972. 37. t)aldsas, t., at a1. ltfacta of Carbon Monoalda aa y.eardiaa: Oltrsstraccural Chanjas io tabbits After 135 2060460756 °

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