Tobacco Documents Online

References-for Chronic Obstructive Pulmonary Disease 1. U.S. Public Health Service. Smoking and Health. Report of the Advisory Committee to the Surgeon General of the Public Health Service. U.S. Department of Health, Education and Welfare. Washington, PHS Pub. No.'1103, 1964, 387 pp. 2. U.S. Public Health Service. The Health Consequences of Smoking. A Public Health Service Review: 1967. U.S. Department of Health, Education and Welfare. Washington, PHS Pub. No. 1696, Revised January 1968, 227 pp. 3. U.S. Public Health Service. The Health Consequences of Smoking. 1968. Supplement to the 1967 Public Health Service Review. U.S. Department of Health, Education and Welfare. Washington, PHS Pub. No. 1696, 1968, 117 pp. 4. U.S. Public Health Service. The Health Consequences of Smoking 1969. Supplement to the 1967 Public Health Service Review. U.S. Department of Health, Education and Welfare. Washington, PHS Pub. No. 1696-2, 1969, 98 pp. 5. U.S. Public Health Service. The Health Consequences of Smoking. A Report of the Surgeon General: 1971. U.S. Department of Health, Education and Welfare. Washington, DHEW Pub. No. (HSM) 71-7513, 1971, 458 pp. 6. U.S. Public Health Service. The Health Consequences of Smoking. A Report of the Surgeon General: 1972. U.S. Department of Health, Education and Welfare. Washington, DHEW Pub. No. (HSM) 72-6516, 1972, 158 pp. 7. U.S. Public Health Service. The Health Consequences of Smoking: 1973. U.S. Department of Health, Education and Welfare. Washington, DHEW Pub. No. (HSM) 73-8704, 1973, 249 pp. 8. U.S. Public Health Service. The Health Consequences of Smoking: 1974. U.S. Department of Health, Education and Welfare. Washington, DHEW Pub. No. (CDC) 74-8704, 1974, 124 pp. 9. U.S. Public Health Service. The Health Consequences of Smoking: 1975. U.S. Department of Health, Education and Welfare. Washington, DHEW Pub. No. (CDC) 76-8704, 1975, 235 pp. 10. U.S. Public Health Service. The Health Consequences 149

of Smoking: 1977-78. U.S. Department of Health, Educa- tion and Welfare. Washington, July 27, 1978, 73 pp. 11. Burrows, B., and Lebowitz, M.D. Characteristics of Chronic Bronchitis in a Warm, Dry Region. American Review of Respiratory Disease 112/3: 365-370, 1975. 12. Kilburn, K.H. New Clues for the Emphysemas. American Journal of Medicine 58/5: 591-600, May 1975. 13. Ross, J.C. Testimony for a subcommittee of the Committee on Appropriations, U.S. House of Representatives, 95th Congress, First Session, on Department of Health, Educa- tion and Welfare appropriations for 1978, April 5, 1977. Part 4, pp. 3377-3382. 14. Ringler, R.L. Testimony before a subcommittee of the Committee on Appropriations, U.S. House of Representa- tives, 94th Congress, First Session, on Department of Health, Education and Welfare appropriations for 1976, April 10, 1975. Part 3, pp. 210-334. 15. Levy, R.I. Testimony before a subcommittee of the Committee on Appropriations, U.S. House of Representa- tives, 95th Congress, First Session, on Department of Health, Education and Welfare appropriations for 1978, March 8, 1977. Part 3, pp. 395-504. 16. Kueppers, F., et al. Familial Prevalence of Chronic Obstructive Pulmonary Disease in a Matched Pair Study. American Journal of Medicine 63/3: 336-342, 1977. 17. Tager, I., et al. Studies of the Familial Aggregation of Chronic Bronchitis and Obstructive Airways Disease. International Journal of Epidemiology 7/1: 55-62, 1978. 18. Lebowitz, M.D., and Burrows, B. The Relationship of Acute Respiratory Illness History to the Prevalence and Incidence of Obstructive Lung Disorders. American Journal of Epidemiology 105/6: 544-554, 1977. 19. Cohen, B.H., et al. A Common Familial Component in Lung Cancer and Chronic Obstructive Pulmonary Disease. Lancet 2: 523-526, 1977. 20. Burrows, B., et al. The Relationship of Childhood Respiratory Illness to Adult Obstructive Airway Disease. American Review of Respiratory Disease 115/5: 751-760, May 1977. 21. Burrows, B., et al. Epidemiologic Evidence That Childhood Problems Predispose to Airways Disease in the Adult (An 150

Association Between Adult and Pediatric Respiratory Disorders). Pediatric Research 11/3: 218-220, March 1977. 22. Monto, A.S., and Ross, H. Acute Respiratory Illness in the Community: Effect of Family Composition, Smoking, and Chronic Symptoms. British Journal of Preventive and Social Medicine 31: 101-108, 1977. 23. Kilburn, K.H. In: Gori, G.B., editor. National Cancer Institute Smoking and Health Program: Proceedings of the Tobacco Smoke Inhalation Workshop on Experimental Methods in Smoking and Health Research. U.S. Department of Health, Education and Welfare. Washington, DHEW Pub. No. (NIH)75-906, 1975, p. 62. 24. Battista, S.P. In: Gori, G.B., editor. National Cancer Institute Smoking and Health Program: Proceedings of the Tobacco Smoke Inhalation Workshop on Experimental Methods in Smoking and Health Research. U.S. Department of Health, Education and Welfare. Washington, DHEW Pub. No. (NIH) 75-906, 1975, p. 62. 25. Yeates, D.B., et al. Mucociliary Tracheal Transport Rates in Man. Journal of Applied Physiology 39/3: 487-495, September 1975. 26. Warr, G.A., and Martin, R.R. Chemotactic Responsiveness of Human Alveolar Macrophages: Effects of Cigarette Smoking. Infection and Immunity 9/4: 769-771, April 1974. 27. Bowden, D.H. The Alveolar Macrophage and Its Role in Toxicology. CRC Critical Reviews in Toxicology 2/1: 95-124, June 1973. 28. Coudon, W.L., and Harris, J.0. Human Alveolar Macrophage Proteolytic Enzyme Activities in Chronic Obstructive Pulmonary Disease. Chest 73/3: 364-370, March 1978. 29. McFadden, E.R., Jr., and Ingram, R.H. Letter: Journal of the American Medical Association 235/3: 259-260, Jan. 19, 1976. 30. Brown, S.M., et al. Effect on Mortality of the 1974 Fuel Crisis. Nature 257: 306-307, Sept. 25, 1975. 31. 32. Bremner, C. London's "Pea Soupers" Only a Fading Memory. The Washington Post, Jan. 28, 1977. r1j cn 0 C.M. Fletcher et al. The Natural History of Chronic ~ , , ~ ~ w 151

Bronchitis and Emphysema. Oxford University Press, Oxford, 1976, 272 pp. 33. Brown, P., and Gajdusek, D.C. Acute and Chronic Pulmonary Airway Disease in Pacific Island Micronesians. American Journal of Epidemiology 108/4: 266-273, October 1978. 34. Howell, J.B.L. Chronic Airway Obstruction. In: Beeson, P.B., and McDermott, W., editors. Textbook of Medicine. Fourteenth Edition. W.B. Saunders Company, Philadelphia, London, Toronto, 1975, pp. 831-836. 35. Roberts, K.E. Emphysema and Enterobacterial Infections. Letter: Medical Counterpoint 2/3: 47, March 1970. 152

Appendix On two days in January 1978 a public official and a large, private, medically related organization each issued statements which were misleading, inaccurate and which both should have known were unsupportable: In 1977 alone, more than 300,000 people died from cancer, heart disease, and lung disease attributable to smoking. Joseph A. Califano, Secretary of Health, Education and Welfare (1) Last year, smoking was a major factor in 220,000 deaths from heart disease; 78,000 lung cancer deaths, and 22,000 deaths from other cancers, including cancer of the mouth, cancer of the esophagus, cancer of the pancreas, cancer of the kidney and cancer of the bladder. Joseph A. Califano, Secretary of Health, Education and Welfare (2) Cigarette smoking was related in 1977 to: • more than 320,000 deaths. American Cancer Society (3) (V This contention of "excess deaths" has been pivotal ~ 153

to the smoking and health controversy for more than 15 years. Although the figures vary depending on who is giving them and when, and how much shock impact the "authority" wishes to create, they have been quoted, repeated and misunderstood so much that many people accept them uncritically. None who uses the figures can say accurately where they originated. One health official quotes a public relations practitioner as the source while the latter claims they came from "the government." Media occasionally attribute them to their newest source but increasingly provide no attribution at all. This paper will attempt to trace the origin of the "excess death" figures, show how they have been "marked up" (or down) and, finally, will show how vulnerable such statistics are to misuse. Where did the f igures come from which Secretary Califano cited on January 11, 1978, and the American Cancer Society parroted three weeks later? The "excess deaths" concept grew primarily from various pre-1964 surveys comparing smokers and nonsmokers by two Britons, Richard Doll and A. B. Hill, and those of Daniel Horn and E. Cuyler Hammond of the United States. Much of their data was used, in one form or another, in the preparation of the 1964 Smoking and Health report by the Advisory Committee to 154

the U. S. Surgeon General. However, as we will see, that report wisely warned against the concept. In her book, "Smoke Screen: Tobacco and the Public Welfare", published a year before the Surgeon General's report, Senator Maurine B. Neuberger quoted Dr. Horn as saying it would be his "best guess" to blame smoking for "300,000 to 500,000... deaths per year" (4). Horn himself apparently came to regard that as an exaggeration, and subsequently he confined his "excess deaths" estimates to 300,000 or fewer. The Surgeon General's report itself rejected the theory of "excess deaths": "The total number of excess deaths causally related to cigarette smoking in the U. S. population cannot be accurately estimated" (5). Why did the advisory committee take this position? The Assistant Surgeon General, who was vice chairman of the advisory committee, gave the reason at a news conference at the time the report was released: "The Committee considered the possibility of trying to make such calculations but it involves making so many assumptions that the Committee felt that it should not attempt this..." (6). But others ignored this restraint. On January 11, 1965, the first anniversary of the Surgeon General's report, Emerson Foote, an advertising executive and chairman of an organization called the National Interagency Council on Smoking 155

and Health, began a new round of "excess deaths" speculation in a news release: "Estimates made by scientists who have spent years studying the problem, vary depending upon the way that the data are interpreted." Nevertheless, he went on to assert, "It may be said with sureness that cigarette smoking is today responsible for at least 125,000 deaths each year in the United States. Cigarette smoking may be responsible for as many as 300,000 deaths per year in this country" (7). - Once someone, no matter what his or her expertise or objectivity might be, had broken the ice and made the claim publicly, many others felt free to quote it. A month later, for example, Dr. Horn, who had become chief of the Special Projects Section within HEW's Cancer Control Program, told school administrators in Atlantic City that "Emerson Foote, Chairman of the National Interagency Council on Smoking and Health, has stated that cigarette smoking is responsible for at least 125,000 premature deaths this year" (8). In March 1965, the U. S. Senate began hearings to determine what legislation might be appropriate in light of the Surgeon General's report. Foote testified. Senator Thruston Morton told him that Horn had quoted "you as his authority." Foote laid the "baby" on the doorstep of the U. S. Public Health Service. SENATOR MORTON: ...This interests me, that the scientist, the doctor, should be quoting you, the advertising agent. I suppose you quote him. That is the way these things get going. They support N) tn 0 ~ .P ~ W ~ ~ -P 156

each other. MR. FOOTE: Absolutely not. May I correct the impression created? SENATOR MORTON: Certainly. MR. FOOTE: Would you like to know where I got those figures? Or would you care? SENATOR MORTON: I would be glad to hear where you got the figures'. I am merely saying that Dr. Horn is now quoting you as the authority for these figures. MR. FOOTE: If he quotes me, that is fine. I didn't ask him to quote me, and I am not the authority for the figures. Would you care to know where I got the figures? SENATOR MORTON: Certainly. MR. FOOTE: I got them from the U.S. Public Health Service. And they had plenty of time to check the figures over (9). As another source, Foote cited Dr. Harold S. Diehl of the American Cancer Society, who was seated with him at the witness table. But Diehl, in a written statement given to the Senate Committee, passed the responsibility to two others. He said that Dr. Morton Levin of Roswell Park Memorial Institute in New York had given data at medical meetings in 1964 which showed "that among males there are 224,717 deaths annually in the country attributable to cigarette smoking" (10). Exactly 224,717 each year? In addition, Diehl said, Dr. Reimert Ravenholt r'-, ~ 0 of the University of Washington School of Medicine in Seattle ~ W 157 N V CT!

- had published a statement in 1964 which said that "in 1962 roughly a quarter of a million excess deaths in this country were due to smoking." Horn was at the hearing and spoke up. He started to say that the "excess deaths" talk only had to do with re- ported higher death rates among smokers, without the implica- tion that smoking was the cause. But then he switched to assertions of cause, went far beyond the Surgeon General's re- port in this respect, and came up with yet another number -- 138,000: DR. HORN: The figure of 125,000 -- which is a very low estimate of the total number of deaths -- which represents the excess number of deaths, occur in cigarette smokers over what would have occurred if they were to die at the same rate as people who had never smoked cigarettes. It consists of applying the 1962 death rates to the diseases in which a causal relationship has been indicated. These include coronary heart disease, lung cancer, bron- chitis and emphysema, cancer of the oral cavity, cancer of the esophagus, cancer of the larynx, and cancer of the bladder. I am indebted to the original set of figures here, which have appeared in statements of the Public Health Service as long ago as last August, and to Dr. Levin, who has published these figures and is, I believe, scheduled to testify tomorrow. The number of deaths from coronary disease, which is included in that, is approximately 80,000. The number of deaths from lung cancer is 33,500. The number from bronchitis and emphysema is 16,500. Cancer of the oral cavity, esophagus, larynx and bladder, add up to 8,000. This totals 138,000, which is a little higher than the original estimate of 125,000, but is based on applying these to estimated 1965 deaths from these causes. 158