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Smoking and Health 1964-1979 T H E C 0 N T I N U I N G C 0 N T R 0 V E R S Y T H E T 0 B A C C 0 I N S T I T U T E 1776 K Street, N.W., Washington, D.C. 20006 January 10, 1979

Table of Contents Page Preface v Overview -- Smoking and Health 1979 1 Public Smoking 13 Smoking and Over-All Mortality 35 Women and Smoking 47 Cancer in the Work Place 71 Lung Cancer 87 Other Cancers 103 Cardiovascular Disease 119 Chronic Obstructive Pulmonary Disease 139 Appendix 153 This volume is published by The Tobacco Institute in the belief that public discussion about tobacco smoking is in the public interest and that the smoking controversy must be resolved by scientific research. 111

Pref ace The American people would be better served if high government health officials and private interest groups which encourage them abandoned the myth of "waging war" against diseases and their alleged causes. The process of making public policy is better served when areas of scientific unknowns are illuminated by the light of reasoned deliberation rather than the heat of emotional rhetoric. Nature will not yield her secrets to media events, propaganda barrages, self-righteous zeal or official fiat. The enigma of cancer and chronic diseases will yield only to the steady advance of scientific knowledge. And know- ledge does not flourish in a lock-step society. It grows best under conditions of unfettered investigation and free, fair and full discussion. Indeed, many scientists are becoming concerned that preoccupation with smoking may be both unfounded and dangerous -- unfounded because evidence on many critical points is conflicting, dangerous because it diverts attention from other suspected hazards. It should be noted that plans for the first report of the Surgeon General's Advisory Committee on Smoking and Health in 1964 called for "the study [to] be concerned not rQ a only with tobacco, but all other factors which may be involved i -p w such as air pollution, automobile exhausts, etc." N -~s V

One does not become an advocate of tobacco by sup- porting a broader, deeper, more objective consideration of the issue. Over a hundred years ago, William Hazlitt, the English critic and essayist, put his finger on the nub of the problem. You may agree with him when he said: The origin of all science is in the desire to know causes; and the origin of all false science and imposture is in the desire to accept false causes rather than none; or, which is the same thing, in the unwillingness to acknowledge our own ignorance. It is time for all parties to this controversy to admit that there is much that is unknown. Doing so will en- courage research to reduce the deficit in our knowledge and In that spirit, we offer for consideration this document, which -- while not intended to be exhaustive -- raises some of the questions in the continuing smoking and health controversy. .p ' January 10, 1979 vi

Overview -- Smoking and Health 1979 Fifteen years have passed since the release of "Smoking and Health" -- the first and perhaps the most widely publicized of a series of such reports prepared by the Depart- ment of Health, Education and Welfare. Despite millions of dollars spent since that time both by the government and the tobacco industry on smoking and health-related research, many questions about the relationship between smoking and disease remain unanswered. Now, as in 1964, there are statistical relationships and several working hypotheses, but no definitive and final answers. Despite claims to the contrary, no one -- in govern- ment or industry -- can explain the reported associations of smoking with lung cancer, heart disease, emphysema, low infant birth weight, and yes, even cancer of the pancreas. No one knows why -- or how -- a cancerous growth begins, whether it is in the lung, pancreas, or bladder. No one knows why the walls of human arteries become clogged with lipids or how clots that can lead to stroke get their start. No one knows why pregnant women who smoke have lighter infants on the average than women who don't smoke, or why some women, whether or not they smoke, have smaller 1

inf ants . Scientists have not proven that cigarette smoke or any of the thousands of its constituents as found in ciga- rette smoke cause human disease. Nor have scientists demonstrated that the healthy nonsmoker is harmed by his neighbor's cigarette smoking. But because some agencies in the U.S. government, members of the medical profession, and others who just don't like cigarette smoke act and react as if all the claims about smoking are sci_entific certainties, The Tobacco Institute sets forth here certain evidence which relates to such judg- ments. A comment made by the U.S. Surgeon General in his foreword to the 1964 report is as relevant today as it was 15 years ago: The interrelationships of smoking and health undoubt- edly are complex. The subject does not lend itself to easy answers. Nevertheless, it has been increas- ingly apparent that answers must be found. cn 0 ~ Public Smoking ~' ~ w Other people's smoke has never been shown to cause r~~.~ disease in nonsmokers. ~ ~ Scientists, researchers, government officials and even some well-known anti-smoking spokespersons have stated 2

that smoking in public places does not harm the healthy non- smoker. Some persons may find the tobacco smoke of others annoying in some circumstances. Last year, a study conducted by Danish and British researchers found "transitory discomfort" but no evidence of lasting adverse health effects rette smoke in otherwise healthy individuals. from ciga- Some persons who favor banning tobacco smoke in public places cite an article published last year claiming that exposure to cigarette smoke resulted in changes in the exercise perfor mance ability of patients with severe angina pectoris. What is usually ignored is that this study is subject to severe criticism for faulty design as well as unsupported conclusions based on patients' self-described symptoms. Some nonsmokers claim to be allergic to tobacco smoke. However, neither cigarette smoke nor any of the com- ponents as found in cigarette smoke has been demonstrated to be a human allergen. Nonsmokers who make such a claim some- times cite a study which shows that smokers as well as non- smokers react positively to skin tests with tobacco leaf extract, but this is an inappropriate substance to use in allergy testing for tobacco smoke. Another claim frequently made by anti-smokers, that children are harmed by their parents' smoking, is mainly based on several studies published in the late 1960s and 1970s suggesting that cigarette smoke may be responsible for 3

adverse effects in children. However, questions have been raised about both the experimental methods and the reliability of the conclusions. Moreover, a number of recent studies have failed to demonstrate adverse effects in children of smoking parents. Other people's smoke has never been shown to cause disease in nonsmokers. Over-All Mortality The use of results from flawed population studies to frighten people by attributing large numbers of deaths yearly to smoking may be misleading and is most regrettable. ~ Assertions that nonsmokers as a group live longer than smokers are based on studies that were poorly designed and statistically flawed. For example, they involved samples not representative of the general U.S. population. Despite these problems, data from the reports are still used to sup- port a variety of claims about smokers' mortality, including the charge that several hundred thousand Americans die each year because they smoke. With such use -- and misuse -- of data, it is probably not surprising that a caveat in the 1964 Surgeon General's report is often overlooked: "Statistical methods cannot establish a causal relationship..." ~ 0 ~ 4 N 10

Women and Smoking Inconsistent findings from studies of smoking women and their children make it impossible to draw con- vincing conclusions from the data. Pregnancy Outcome Although the abbreviated 1977-78 HEW report to Con- gress concludes that cigarette smoking is "probably causally associated" with increased perinatal mortality, it relies on data which indicate that any claims of a causal relationship have a highly questionable foundation. The data suggest that such factors as history of previous pregnancy loss and hospital pay status (public vs. private) have greater effects on preg- nancy outcome than maternal smoking. The data provide support for the belief that adverse pregnancy outcomes -- indeed, the health and life or death of the child itself -- may be pre- determined by who the mother is -- her constitution or innate characteristics -- rather than whether or not she smokes. Smoking and Early Menopause Research which appears to indicate that smokers undergo menopause earlier than nonsmokers has been used to support a claim that smokers are depriving themselves of the "protection" from heart attacks believed to be provided by female sex hormones until change of life. 5

However, this claim is not supported by heart disease mortality statistics which show no "jump" during the menopausal age span -- such as might be expected if large numbers of women were suddenly deprived of "protection" against this disease. The almost single-minded concentration on smoking evident in much research in this area may result in a failure to consider other factors that may be involved. For example, Public Health Service research indicates that menopause begins earlier in black women, in white women from lower income levels and rural areas and in leaner women. Oral Contraceptives The scientific literature does not support the claim that oral contraceptive users who stop smoking decrease their disease rates significantly. This point was recently made in a Congressional hearing during which a decision by the Food and Drug Administration to require a printed warning -- which, in. effect, implies such an assurance -- came under attack. In discussions on this issue, concern has been expressed that the reported statistical relationship between oral contraceptive use, smoking and illness may cause scien- tists to overlook other factors that may explain this relation- ship. 2501443131 6