Tobacco Documents Online

C21~;d,.~ e vd sz. w. 9. n. sss s36, l~v oe9s ussyyrs ..~ m,~ tA l'r1i F.6ener 5oo.ce Inc. All riplw Raemed. PLL SW`9543i6( )t1p037.2 EtSEV1EA vARIANCE A1VI7 pFSSE>•P[ Rfil"inder, Rejoinder to Ensrtom's Response Lewis H. 1Cu!ler* Uw/vlasn on Pmosuacx. Qawov.ze ScseooeL oc Puauc Flewcsx. Om..nrwexs op Fxeccrwlqor, A527 Cwsrasa N.u, 130 pF,o,e S,.caT, pn,asu,wH, PA 15261 in responx to F%flota't reaponse to my oommencs about his papec l.lnfemmanely he is wong. He Itas a nti.coetecp- cion nfhoth themellmdolagy celaeed cesiovl5ing cessation nnd to r1+e pu6liahed dar+. . . . .. .. . . Fitst, it is obvious that individusts aften ataP malcing hc- s i cause of sympranatology of di,reate, as well as for good heihh neasons. Many older (ndividuals have likely aoepped sMoking bec.uee d+ey have de.xloped.sympwnlatelagy that may raiate to rapiuatory diwea, such as chtoIIip o6rMte- dve pulmomuy dismse. cluonic beomcllitis. as .-lias early chtinges of peiglleel raee4iat d'eemee end eoevnsey heart diaeasa Ptevioue studies fcem theMulciple Risk Factor In- IQVetldan Tdal (MRFCP) etetip, as well as odtcr swdies, f« exesepk, lw.e: iho.en dae deereaoed pulmonamy' fime- eion among e(gerette smokera is a povaful ptedie[orr of the eisk of lung eaeeer, a+eeU as eotaury heutdiaeaie.'Ilee_ desrh rates will be higher fot years among a.ample uf cx- stnokers because sick people who quic sroeking are not heairhy. acld the;doee liqve;a hfghe:r risk of di.eaae. Untii this areoup of eide people who have quit smoking beeou,e of their ill heettlt aee out of d+e popuheiron, thc.e will be an apparent inereasee in tisic of disesse. ineludingbndt oneerr and caodiovaswlardiusee. ABain, thlsJs: well krwwrphe- nomenon and, in faa, ie n obvious Gocn nurnerous publica- s sions chec it is hardly worth rt-ecacing. SKac4 in clinical `,irlals. the failure to show an dBceey of amokitg cessation on lung cancer sater Is a firt.ction of the low quittinR per- cenceges acld rhe small diNeneeccE becveen dle inmrven- cian and conrol groups, and therefore the lack of power. For encnplc, in bfRFIT (11, mast of the lung cancers oc- cunrd among smokers of 26-40 cigarettes per day; 100 of 126 in rpecial itunvenrim (Sll and 87 of 109 in usual eare (UC).Paly 632 of 3318 (19%) of SI and 359 of 3426 (10596) of UC qair smdciceg in the trlal. Althou;Fl this is a 10%diffeeencc and s(4nificane. it Is a udat(valy small e(fect. The percentage dead of lung cancer among smakers over 16 yean folln+w up of 20 or moce cigarettes per day was appro:- imscely 3% (UC and SI combined). 'Ihus among the-273 'Ad.h'ns eurtale.da,er ea Dr. L N. 1CLIkr. Univeeei[r d Pimhu,pb, Grdu.m ScLwl at PuNie Hraleh, OeFmrmmr d Epidemcluey, AS27 (.rabeme Hdl L W L>vora+5amu. PieoWrph. PA t SZ61. A~pr~d f: pabliea,wn un 4 1+4aeh 1999. -((632 - 359) ex-eenokers hetweea Sl and UC in T we would have expected about cight desdu, lf Lng casetion then reduced imlQ cancer mextaliry by. we weuld h6vr eactxcred four ferret dead.s in SI aod a 96 sr duction, e+u ferer deat}u from Il.ne canca.'llle.o is a6vi- a.ely:no pnwer.for comparison berween SI and '11u failure of clinical triaia oo show aa im)mct on calcer . e,oceajlty is, ther~efore, due ro. rj~ difFeeuley of mai taining smoking e:essarlom The intervmuion is inedEeeei+t, the efficacy of the intenrcncimt in reducing the ~ risk aE iatase. Al.b, smoking eessalion has a enosle immediate an coronary heaec dlsesreevenae. Zhus, among the of in- dividea,le.vbo voutd quit saroting: eht•.risk of kdrx cancer will actually u.ereweo somemhar because d.VY w(II not be dying of cltdiovarcular dis.au. To support his' hypxhe:sis, E.astrBm stares tinc lung caneer dcash races aee noa declining among older aie. Ho.ever. 6e is vaoag again (see Health U• Sates 1996r97). F+or whire men aged 45r54lung .. .. death r+res in 19g0 wae 74 oat of 1()O,OOOL in 1990,onc of l00,000: and in 1995. 46'our af 100,000. For aaoe 5~4, rherevne 215 dearhtwrof I00.OOOin 1980,222' -199p, and 188 in 1995. For ages 65-74, rhete were 418 out oE I00,000 in 1980, 438 in1990, decteasitly to 4261 1995. For 75-d4. deaths out of t00,00D wexe 516, in 1980. 93 In 1990, nd 569 in 1995- Tkun, the decline in iang mortality has moved fmm the younger age growps, 5~54. trhrough che older age groups as rhe eohores of ex move dataugis the popularioc4 This Is nor due w j the nevet= -' -- Acswlly, a cahorr analysis will an even greacerderline In lung cencermortality.ln 196 , 5790 of mhlce mell aged 35-54 vere e'egatecte snwlcen. in 1980, when they would be approzimacelv 55-64 a 32% were cigarette smokers: tha diHerence is not due to mortality for cigarette smokeis, but smoking c , and by. 1994--LhUty years [ater-the prc+.aleneo of ' «~ smok(tg wa, around 15 %. The incrcasing pool of ex eta in pacr aceounn for the decline in lung cancer ity. Fucehennore, a curveillusce of selected tobaeco use v- iota in the United Staaes fenm 1996-1994[3] shovn for the ago gsoup 45-44, 16% were ex-unvkere in 1965. ' co 32% in 1991, while the p.reenrage of never-a wac

L EL Xultec 42% in 1965, and 40% in 1991, and the pctcentagc of cut- rent n.nkers wm 41% tn 1965 and 26% ta 1991. In other wonds, tF.e primaty change in the pecca wgz~ of curttenc emolren I, due m the increasing number of former stnnkecs: The age gnxcp 65 and alder had 67% current smokers in 1965t in I980. it tw+s 54%; attd in 1991, 50%. The vercenr- age of cument smeken went ftom 17% to 13% during thi. period, bur the fottner seppkets went fnnat 15% to 36%, again detnnratncing d'te (ett rhat the tnaioriry of the smok- ing ctssazion is due to ex-smokers. The percentage of nevet-smoketa has eiertniniy risen in the 18-24 age group in the Unlted &etest Ita.evero titoaz whn wete 18-7J1 in 1970, btr 1.99o ueee only up to 45 yeats of age, and had PFsolutely no effct09 t6e decline in lnna caneer death nw fromage 45 and up Rbm 1980 on.•atd. Theae is a long incubauon period for diseases euch as lung taocer" The individuals who have mo{zd 30-.i0 ciga- rettes fta day fot 40-50 yeata pto6aMy include a high per- rxrt®ge with wbdinieal hste cancer. as can be identiffed by pathoiogy acvdies of btAehial citaua They will ultimaaety quit smeking, often Ixmune of faI healch, reqtiratoty symp- taas, atvi chronic o6svttctive ptdmonury diseauc ate. Their tisk d lung eatuer wilt remain very high-- pro6ably for the rest of thelr livss. If we eould do a trial in which all of the older ittdGvid:,als 65-74 qult saukietg• and all of the con- ttols continue to stttoke, and exciude ittdividuab, vlto al- teady had lung cancer, then it is likely that these who quit mtokittg will have a romewhat lower risk of lung cancer overw time.'lhis has been showt in regard to the cbanges in pulmonary ftutctian and smolcing ceseation, such as in the Lung Healch Sevdr. lJnfotnnwcely, such a trial for lung cancer cannoc be dotte for dte simple reaum chat it would be ,tnetht®I to ha.,e people cendaue to smoke, and it would be extremely d!(ilculc to gec.tr•eryone to quit smok- ing in the intetvention group. The decline in lung cancar will likely eontitwe as mo.e and more of the coharta af ex- smoktxs move through tho population and a greater num- ber olthe ax-smokcrs quit for good hcalch Itweead of far iil- ness. There is solid evidence that artnk ccssation does reduce the risk of lung caoccr. that the tt ta xnns of reduction of lung catuet is rdated w doee of tlq ci~- retce smoking and the age et which ituHvidual aco}.. rnoking- The results of some of the ' ate furthcr con- faunded by dto faec that smoking c is aho a.voci" atcd with a.ubstantiai reduction in catd" r dise.ae• and therefore exposes an inctening pm{ of ex-smokem to the iong tetm ridts of lung catteer. The poot of e:- smoken in the poptiatiat who remain ar rfalc of lung wn- cer. even though lower than rlhose who aoncinued to stewke, pteseats an lnte.cscing ehallengc for lung cancer ptevendon- Smoking rlscaeion dap dte rtsk d lattg mncer. It doeat'c reduce it to thc ievei Iniividuals who have never smoked during their livea Ass is. this is a weil- lQtacrn Phnnemetwn discussed at gteat t by Peto, ec d.fa1 Unfortunecely, &utront's analysis is Wir similar to ehr infaman R. J. Reynolds advetsisemetts c MAfIT and othec sutdiec, showing rhat smokin¢ had no effeee ari eorottary heart dixase or on tnortality Ae the rinte of ttust ads. R. J. Aeyno(ds vas shn rs to he .aottgw and I believe Dr. Enstrom is equally wrong itt his _ etott. Rafeeent+m 1. Shaten BJ• Kulier t.H, Kjelh.etg MO. St.m J. Ockma JK, Cutter JA. Cohen Jp. tuc.the MRFIT 6tup. l.uttk cancer nmtu[iay nFcer 16 yeara In MRF[T pants in inter- venti.m snd uc.wl-csm cy.wpa. A..n 1497; 7: 125- i36 2. National Cenae fac Ncatth Stntiuiet, fiealt T lFnimd Siaiec, 1996-97 and In1~1' Clutthc+k-Nyatoeilte. Iwnd: 1997. 3. SmdcitK and Tnb.om Coa.m1. 8: C6tngia in cigirecae-s.e4ted disane s:cke and dtar ' Eor pte• stntion and eonaml. N.tinnal Cancer lneti ~ NIH PLeF.lica" tinn N.x 97-4213r Febtuary 1997" 4. Dult A, Peto A. Wh.aticv K. Suthcrla~d L M. uy in RlatNm eu nnv/cing: 40 yaes' oteetv.riarsa .~n male dtitb d,KCwc. $M/ 1904; 3094 a01-91 l.