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RJ Reynolds

the Epidemiology of the Less Harmful Cigarette. A Retrospective Study of 1034 Cases of Lung and Larynx Cancer.

Date: 31 Aug 1977
Length: 36 pages
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Referenced Document
List of Footnotes.
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Hammond
Kuhn
Todd
Ledez
Timm
Doll
Gori
Koch
Kannel
Austin, H.
Saphier, N.
Beattie, E.
Kupfer, S.
Rednor, C.
Spritz, N.
Austin, E.
Hirsche, S.
Peck, E.
Baum, G.
Peacock, P.B.
Anderson, M.D.
Rawson, R.W.
Breslow, L.
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Wynder, E.L.
American Health Foundation
Stellman, S.D.
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Page 1: nup39d00
• ., r 1. Fro:a :.he Division of E. icie-:iology, Naylor Dana Institute for Dis?ese Yreve:lt.ic:1,• t::'c?rican Health Foundation, 1370 ?::en ::e o: tt:e '..:.ericas, .:e:-; Yori:, N.Y. 10019. 2. inis t•:,,r., t:as c•. :ational Canccr Institute Co:'.;.-r;:c*_ ',:o. 1-CP-S5366 a G_r:at No. CA-17613-01. Cc: ,:t~.tions ::ere :^__`o.-e--f! irn part at the ERDA ::ather.atics ar.c! Cc::c::ting L,borator}•, Courant Institute for ,'•:a"::e::atical Sciences, sar_ orted by ERDA Contract E(11-1)-3077 at New York i:niversity. 1,2, THE EPIDEMIOLOGY OF THE LESS HARMFUL CIGARETTE A Retrospective Study Of 1034 Cases of Lung and Larynx Cancer Ernst L. Wynder, M.D. and Steven D. Stellman, Ph.D.
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~..,...aa'ftw..w.....-...~.....,.~..ra,..~..._..,~.....~+..a~w+...•.................,....r.... „ .___.....~.~.~.r.«•.... ..~../L.Y V .... ._... - rY Y 0 ... ....n....ar .. • ABSTRhCT A case-control study of 1,034 male and fc; .-a 1e Caucasian hospital patients with histologically proved lung (.;reyberg Type I) and larynx cancer showed a substantial lower.ingof risk for these cancers among long-term smokers of filter cigarettes, compared to non-filter smokers. The risks also declisned with years of smoking cessation. r:ost lung and larynx cancer patients began their smoking habit with a much higher tar cigarette than is now commonly smoked, so that young people mow starting with medium or low tar brands will experience a lessex risk In view of the continuing trend tuwards greater zn any event. public consumption of lower tar cigarettes, the development of less hazardous cigaret- tes continues to be an integral part of a general strategy towards eliminating these diseases, together with strong anti-smoking campaigns and smoking cessation programs, tA
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< ~.. - ~~:. ~ - ..-._..w .~_ ~. .. +`wllijy~...r._.._........~...:..J-`.r.v--. ~.....w..__ _--.r.._. ~- _ . 'I W.r • s TJ1:: EPIDEMIOLOGX or T(IG LESS IUIRMFUL CIG7IP.ETTE A Retrospective Study _ Of 1034 Cases of Lung and Larynx Cancer Introduction Since the first major epidemiologic studies linking cigarette smoking to lung cancer, a dose response effect has been apparent: the greater the smoke exposure, particularly as measured by the num- ber of cigarettes smoked, the greater the risk for lung and other tobacco-related -cancers. (1-4). -It would thus be reasonable to assume that as a smoker's exposure decreases, either by smoking fewer cigar- ettes, or by smoking cigarettes lower in yield of tumorigenic compon- ents, a proportionately lower risk of developing'tobacco-related can- cers should be experienced. During the past twenty years, consw-nption of lower-tar* cigarette (5-7) has increased, wnile, as judged from experimental evidence, the tumor- (8-10) igenic potential of cigarettes has decreased. While earlier studies have shown a reduction in lung and larynx cancer risk among long-term (11-14) smokFrs of filter cigarettes, compared to smokers of non-filters, it seems worthwhile to provide further, more recent evidence for decreased lung and larynx cancer risk as a consequence of progress made in quan- ' titatively lowering cigarette tar yield. * Total particulate matter (TPM) refers to the material separated from the gaseous portion of cigarette smoke by a Cambridge filter, iohile "tar" is defined and measured by the U.S. Federal Trade Commission as TPM less moisture and nicotine. 9 ,.
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.r..~a+stia......u._..,....v.....r.a......_........ar...aw.~...._.,...s....rrr.+..._.....a......:..n s,r..wv....,.....,-_ •d.r......wa...ra..,... ..~-......y~. : . ..,2- i=a- ..... Following our 1970 report,.we.continued to accumulate data on smoking habits and other environmental variables for patients with tobacco-related cancers!4) Our findings for the years 1.969 to 1976 with respect to cancer of the lung (Kreyberg Type 1, com- prising mainly squamous and oat-cell types) and cancer of the larynx, with special attention paid to the risk of these cancers among smokers of cigarettes with different tar yields, are rized here. A major goal of this research summa- is to determine whether the widespread reduction of cigarette tar yields has indeed been translated into significant health benefits, as measuxed by lowered relative risks for tobacco-related diseases,.and to try to predict what influence further tar yield reduction is likely to have on such diseases in the future. Methods and Materials The data presented here constitute a subpopulation from our ongoing retrospective study of tobacco-related cancer.* Interviews were conducted from 1969-76 in six U.S. cities* by' intervie wers who had under- gone a detailed and uniform training period at our institute and who used a standard questionnaire. Approximately one-third of all * jle gratefully acknowledge the valuable contributions of the follow- ing cooperating institutions and individuals: Memorial Ilospital, Dr. E. Beattie; Mount Sinai Medical Center (N.Y.), Dr. Sheldon Y.upfcr; Manhattan V.A. Hospital, Dr. Charles Rednor and Dr. Norton Spritz; Francis Delafield Hospital, Ms. Esther Austin; Metropolitan Hospital, Dr. Si gmunde Iiirsche; St. Luke' s Hospital, Ms. Evelyn Peck; Miami Veterans Hospital and University of Aliami Hospital Center, Dr. Georcte IIaum; University Hospital (111abama), Dr. Pei_er T3. Peacock; M.D. Ancicr:"• Ilospital & Tumor Inst. (ltouston) , Dr. Rulon {J. Rawson; U.C .L.A. Iiospi- tal, Dr. Lester Fzreslow; V.A. Hospital, Charity Hospital (New Orleans) Dr. Alton Ochsner. .~ 0 .• a ut 0 J
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r.~r.....-slsurlrOWr .r-.~.....r ~..r.w..w...':..,.... ~...ww.~w .+-....... ~ r...,r.s.w. r.. ... .... ....~.....wr... ~..... w ~.. ~a-~;.1t.y.+w.::. ...r.. ~..W.`.ycY`r...~..~ .. ~........ ..-..~r~..f........- .'. w...Y~it patients • were interviewed at N.emorial Hospital in New York City and decreasingly smaller numbers in various hospitals in Houston,-Los Angeles, New York City, Birmingham, Miami and New Orleans. No interview was incorporated in our data base without histo-pathological confirmation of diagnosis. The number of cancer,patients and controls are shown in Table I, with their age.distributions. There were 684 lung and 350 larynx cancer cases. Interviewers were instructed to visit every coherent lung and larynx cancer patient admitted and had a 93% success rate. For the analysis in this paper., only Kreyburg Type I lung cancer is considered, since this type was previously shown to exhibit the strong- est dose-response of all tobacco-related cancers (4,12). The larynx cancer cases $nclude both glottic and supraglottic types, since both types have been sho:.n to be related equally to tobacco usage. (11) Controls:were selected for interview on the basis of absence of a history of tobacco-related disease. Tobacco=related disease was defined as a cancer of lung, larynx,•mouth, esophagus and bladder, all (4) of which comprised the cases in our previous report, and cancer of the pancreas, liver or kidney; myocardial infarction; stroke, peri- pheral vascular disease, abdominal aortic aneurysm; chronic bronchitis or COPD; gastric ulcer; and cirrhosis of the liver. -Distribution of diagnoses among control patients was reported previously.(4) A total of 9547 interviews with control pati,ents who met the eligibility criteria below were available for this study:
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• • (15,16) - The blantel-Ilaenszel method was of the relative risk, as in the preceding paper. estimated as an odds ratio and adjusted for age, The relative risk, is the ratio of the disease incidence in the given population to its incidence ar,:ong non-smokers. For the present study, all interviewed Caucasian patients were included who were either non-smokers (never smoked any tobacco pro- duct regularly), ex-smokers (quit at least one year prior to inter-_ view), or current cigarette smokers. We further restricted the calculations to smokers whose total : cigarette usage was at least twenty years, in order to assure that the known latency period for most tobacco-related cancers was exceeded. We did not attempt to control directly for duration of smoking habit but, as previously noted, much of the confounding•effect of the duration is removed by stratifying on smoke at ages 15-20 age, since most people began to It will be noted in Table I that a disproportionate number of • controls are below the age of fifty. This results from restriction. • of smokers to 20+ years, with no similar restriction on non-smokers who constituted more than 20% of controls, but who comprised very few cases. This does not affect the relative risk calculators since it comprises a separate• age•stratum. U 0 «. a ~
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I .:...,.,." Two important epidemiological factors are quantitative deter- minants of cancer risk among cigarette smokers: daily quantity smoked (dose) and, for ex-smokers, years of cessation. We previously reported_ relative risks (response) for lung and larynx cancer in males and fe- males for present smokers, defined as persons who were still smoking at the time of diagnosis or who had quit within the preceding year. We showed that both cancer sites eYhibit risks which appear to increase approximately linearly with quantity. The effect of smoking cessation. on lowering the risk of lung and larynx cancer was also examined, and showed a characteristic decline in risk for both cancers with continued cessation. In the present study, relative risks have been estimated separately for long-term filter smokers (defined as present smokers whose current brand o:as filter, and who had smoked filters for at least ten years), and non-filter smokers (defined as present smokers whose current brand was non-filter). Results of these calculations are displayed in Figure 1 for both types of cancer. The graphs are presented as age-adjusted rela- tive*risks versus quantity, for long-term filter and non-filter smokers. Among the males, the risk for both lung and larynx cancer among long- term filter smokers was lower than that of non-filter smokers at every quantity level. Virtually the same behavior was noted for womcn.
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.. 6 .. Table II shows the relative risks exhibited by long-term filter cigarette smokers, expressed as a percentage of the risk for non-filter smokers, by sex and quantity. For men, even for light as well as heavy smokers, there is a substantial lowering of risk, rnaging from 11 to 39$ for lung cancer, and 25 to 49% for larynx cancer. The same result (with one exception due to few cases) holds true for women. The effect of cessation on relative risk is shown in Figure 2 for both sexes and both types of cancer. Table III shows the effect of cessation in three different age groups: 50-59, 60-69, and 70-89 years. It is clear from the table that the effect of quitting on the reduction of relative risk is.dependent on age_at diagnosis. .This.is to be expected because current.age reflects smoking duration, and, apparently, the longer one is exposed to cigarette smoking, beyond a certain point, the less risk reduction can be obtained from cessation. As a compromise, therefore, the relative risk calculations represented in Figure 2 are for persons aged 50-69, stratified into two groups (50-59, 60-69), within this interval, and reported as a combined risk estimate. Two important observations emerge. First, male long-term cigarette smokers must have ceased the habit for at least three years before any decline in risk can be expected. The sizable increase in risk asso- ciated with the first three years after cessation, which had previously been reported by Hammond (1), is likely to'be attributable to heavier smokers who quit due to emerging signs of clinical illness, but prior to seeking medical attention. I I .~_.-.....~. _ _ ...~.~ ~ _ ~Y.-..-.~.....,. ~... .~.....-~ -....... -......~.r~.r... ...w..r...s~w..r.~a. ...w.rww
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7 This is our rationale for restricting the term long-term filter smoker to persons who have continuously used filter cigarettes for at for a smoker to receive any benefit from switching to low tar cigarettes. Sedondly, 10 to 15 years of cessation are required before the long-term smoker's risk approaches that of a non-smoker. We conclude from this observation that at least this much time must elapse in order least ten years. , ,I
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, Fpidemiology of Filter Usage One difficulty in a study of this type is the market instability of tobacco products and the changing habits of consumers. When the first major epidemiological studies linking lung cancer and ci garette smoking appeared in 1950, (.3) the average cigarette yielded about 40 mg of tar. Since that time, tar levels have fallen considerably, filter cigarettes have become more-popular than non-filters and smoking habits have changed considerably among different age •groups for each sex. Obviously each of these changes is likely to have an effect on:the present•and future patterns of not only lung and larynx cancer, but other tobacco•related diseases as well. Change of tar levels with time. The sales-weighted average tar delivery of U.S. cigarettes is plotted against year in (17) Figure 3 for both non-filter and filter cigarettes. This quaritity provides an idea of the actual tar level.consumed by• American smokers. As can be seen, tar levels of both types of cigarettes continue to fall (though the tar level for non- filters has beert.relatively stable for 10 years) illustrating that even today's non-filter cigarette produces less tar than the non-filter cigarette of a generation ago. In Figure 4 the sales of filter cigarettes (relative to total filters plus non-filters) over the past two decades is shown~) IIy 1976 nearly 90% of all cigarettes sold in the U.S. were filters. . The past five years have witnessed the emergence of ~ 0 lower tar cigarettes (< 10 mg) which have, in a relatively ~ ~o ON 0 0 . .. . .. .. . , . . ._ . . - • ~ , ... . . . . , , .~. . .w..w.~~+-.-.-..__.-.~r'FMw~r
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trend.is illustrated in Figure 5 in which the market share cigarettes lower than 15 mg in of all tar yield is plotted for the past ten years. The growing popularity of these cigarettes is bound to have a continuing effect on reducing the average daily tar dose for smokers as our continued observations are expected to reflect. Changing patterns of exposure. As tar levels of cigarettes on the market have changed, so has the actual extent of exposure for various groups of smokers. For now, the most important determinant of tar exposure is the smoker's age, because this deterthines the brands ! available at various points in the smoker's life. Figure 6 shows a model calculation of the proportion of a person's lifetime spent smoking filter 'cigarettes, on.the assumption that today's smoker typically be- gan a t age twenty and switched tofilter cigarettes in 1960, when these brands first achieved widespread popularity. About two-thirds of pre- sent day lung cancerr patients fall between ages 50-68 and, as Figure 6, .shoc,rs, could have spent at most 50% of their total smoking- lifetime with filter cigarettes.. Considering that the average lung or larynx cancer • patient today is between 56 and 60 years old, and has smoked cigarettes for an average of 40-45 years, the risk for developing a smoking-related cancer today clearly depends on a history which included both old and new types of cigarettes. a `'s'.rTlr..tt`cT••:•ra~.a.:~'x~ca~tuaw~.tir~.~.~.a~..c.aswr...+....-...~.~-..-~_ .._~ - •--
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DISCUSSION Tobacco Carcinogenesis On the basis of both chemical and biological studies, data indicate that the major, if not all tumorigenic components are con- (18) tained in the particulate matter. With respect to carcinogenesis, a cigarette can be less harmful either by being lower in total yield of particulate matter or by the reduction of specific carcinogenic or co-carcinogenic components. Over the past twenty years, the smoke- condensate yield of U.S. cigarettes and, indeed, of cigarettes through- (8-10, 19-21) out most of the world has been reduced, as shown in studies by Kuhn in (22) (23) Austria, Todd in England, Ledez in France (personal communication) and Tinm in Germany. In addition, as we already stated, both chemical and biological experiments have indicated that the cigarettes of today pro- duce tar which, compared on a gram to gram basis with cigarettes of (2,8) twenty-five years ago, have lower carcinogenicity. Since we have•seen a lowering of total smoke particulates and specific tumorigenic agents, I we should expect a reduction in cancer risk for man, as, indeed, has (12-14) been observed in this and other studies. This reduced risk is reflected by mortality statistics for lung cancer as presented by Doll for Englara~? Both Doll and we attribute this change, at least in part, to lower tar yields in cigarettes. Other Tobacco-Related Diseases In discussing the impact of the less harmful cigarette on rates S of lung and larynx cancer, we need to recognize that such a cigarette o, 0 may not necessarily reduce the risk for other major tobacco-related di- U ut seases. These other diseases include myocardial infarction, chronic 'NO U e,..-...,,, ,~s~.,..,~ ,....... -..~. . _.....~-.._-.~..-~.-----.---....^. .
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......-....~+2...:...~.~14- . Ja..a.a.~~ ..............w.•w ..~..ai u,:...:w .r..~...+..rr..:.:...w.w...t...+w.reli:nA.Y.~.~.w......:w.+:a..w.. w ........:. .... obstructive pulmonary disease (COPD) and neoplastic diseases such as cancers of the pancreas and bladder, . which are not in direct contact with tobacco smoke; and cancer of the upper alimentary tract, where alcoholism plays an important adjunct role. Gori has recently reviewed the epidemiology of many of these diseases.in order to evaluate the effect of less-harmful cigarettes , on future disease patterns (26). He concluded that reduction of smoke intake in general would lead to an overall reduction in these diseases, and that specific disease reduction could be achieved by reducing specific smoke components, such as nicotine and carbon monoxide, which are the two agents most commonly suspected to be involved in the etiology of myocardial infarction.• (20, 27, 28). u
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... ~.,..a...~.v_,....,. .,- ~~_ .r..........,.._~....,..~:....~s. . V.~:Ar.W..... _ i A recent study by Hammond et al. had indicated a reduction (14) in mortality from heart attacks among filter cigarette smokers. This finding, if confirmed, would implicate nicotine, rather than carbon monoxide, as a major contributing factor for coronary death, since the level of nicotine is significa::tly lower in filter than non-filter cigarettes, whereas carbon monoxide levels in'some of the older filter cigarettes may be even slightly higher, and (29,30) certainly not lower than in the smoke of non-filters. Studies by r our own group, as well as by Koch, have also suggested that filter cigarette smokers have a lower risk for peripheral vascular ~ ' .~: --• 32) (31 , disease than non-filter cigarette'smokers, a finding that would x again suggest a role for nicotine but does not exclude other factors The epidemiology of cardiovascular disease is more complex than that of lung cancer because of the etiologie role of other (33) risk factors,such as hyperlipidemia and hypertensiori. ,Any modific- ation of these factors might affect the risk for myocardial infarc- tion independent of cigarette smoking. Long-term studies have not as yet examined the effect of filter cigarette usage on COPD. The development of chronic bronchitis and the subsequent development of emphysema is suspected to be correlated with the particulate phase as a whole, as well as with such volatile components as NOx, acrolein, hydrogen cyanide and (34) certain aldehydes. Some of these components are thought to have their effect by causing an increased production of mucous flow, whereas othersmay inhibit or even destroy the body's natural defenses by affecting ciliostatic properties. Clearly, long-term vt 0 r ~ r ¢`o
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- 13 - epidemiological studies on the effect of not only low tar cigarettes but also those that specifically reduce gaseous components are in order. Epidemiologically, it also needs to be recognized that the effect of cigarette smoking on coronary disease and COPD differs from that of lung cancer in respect to smoke cessation. _Smoke cessation, for heart attacks, seemingly leads, on the basis of studies by Kannel,to a relatively (35) immediate reduction in risk, whereas smoke cessation in : respect to COPD will not lead to a reversing of the process (14,36 ) though it is considered to prevent further progression. Clearly, the epidemiology of the less harmful cigarette needs to be considered separately for various types of cancer, for cardiovascular diseases and for chronic obstructive pulmonary disease. We would submit, however, that a reduction of total particulate matter in cigarette smoke is of benefit for all of these diseases. Epidemiological Considerations Data available from this and other studies indicates that a reduction in the risk of tobacco-related cancers, such as those of lung and larynx, following smokers' changing to low tar cigarettes has indeed occurred and depends on the level of tar reduction and the duration of smoking low tar cigarettes. ,.,..~
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...•..+..... .w0W 17Y1>aara..~.w.r.ir.ra.a ...tx -WA%Ap& .. As the market data indicates, the general trend in la.:er tar exposures for the average smoker is continuuing, leading us to anticipate a further decline in the rate of increase, and perhaps an ultimate decrease in the rates over time (26,29). However, we need to consider that the loo-:est tar and nicotine yielding cigarette, either theoretically possible or now on the market, may not be acceptable to the- veteran smoker, who may object to the taste barriers present in these cigarettes. lYan a public health perspective, the most practical earpromise would be to recognize that a completely safe cigarette smoke8 by only 1% of the snoking public is of con- siderably less ..health benefit than a cigarette with sane adverse effects which would be acceptable to the majority of s+rokers. Ooncurrent with the reduction of the tar and nicotine content of cigarettes is the possible problem of increased cigarette consumption. Indeed, sane short- term studies have demonstrated that when smokers were given low nicotine cigarettes, th.ey te.tided iani.tially to adjust their snoking habits so as to increase nicotine in- take, by such means as inhaling more deeply, taking more puffs, or leaving shorter (10, 37-39) butts. ongoing studies in our own laboratories shcY4 that all three methods can be :sei, even by the sz:-va smoker, as part of the proeess of acclimatization to the new cigarette. (40) It %wuld appear r.a%rever, that as individuals smoke a low tar/niootine cigarette (37) hong for a lo~er time, they gradually cane back to their original eonsumption. term epidaniological studies on the number of cigarettes smked and subjective re- response i.nikalation do not show any significant differences between long-term filter and non-filter smker.s. (2'15weve.r, scme eapensation, which is, of oourse, a possi- bility even in a long-term smoking of low tar/nicotine cigarettes needs to be deter- mined by appropriate biochemical studies. In spite off some success demonstrated by this "managerial approach" to cancer preventi•on,'we need to continue additional approaches to rid society of tobacco-related diseases, particularly education of young pre-smokers and cessation programs for current smokers. At present, anti-smoking education is making relatively little headway with our youth. The number of boys who begin smoking has remained constant over the last decade, and the k
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(42) number of -girls taking up the habit has doubled. New approaches to health education of the young are in order, such as the Know Your Body (KYB) program initiated by our Institute, whereby each child is individually involved in (42,43) health maintenance programs. Anti-smoking propaganda among adults have been more successful for men than women; and among the men, it is evident that in the more'educated groups a significant precentage has been able to stop smoking on their (5) .(44,45) own. Smoke cessation clinics have also had some relative succes Nevertheless, some sixty million adults continue to smoke in spite of all evidence of the adverse effects presented to (5,7) them. As long as society condones smoking, young people.will try the habi_:; because of its apparent "satisfying" nature for many adults, they will.continue. Under these circum- stances, in addition to better anti-smoking propaganda and improved smoking cessation programs, further progress has to be made in the field of less harmful cigarettes. Acknowledgements , We wish to thank Mr. ]larland Au::t:in and Ms. Nancy Saphier for excellent statistical and programming assistance. cr 0 0.0 v 0 0
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Conclusions Nnerican cigarettes and those of other countries to have l. 2. 3. This paper presents an analysis of a retrospective case-control on 557 male and 127 female lung cancer .cases and 286 male and 64 female larynx cancer cases, with special attention to the possible reduced incidence of these cancers among long-term filter cigarette smokers: Our data indicate that both male and female long-term ~ smokers of filter cigarettes ' (10+ yearsZ have a lower risk of lung and larynx cancer than do smokexs of non-filters for every quantity of cigarette smoked. The-overal]l lowering of risk for men-ranged from 11 to 39$. This paper gives relative risks for individuals now in the cancer age group, who began their smoking habits with the early high tar, non-filter cigarettes. At the present time we cannot precisely predict the cancer risk of who have smoked only low tar.filter cigarettes. persons . Nevertheless, we can expect the decreasing-tar'yield among a continuing ameliorating effect on the rate of lung and larynx cancers, particularly for younger age groups since they have smoked the old high tar cigarettes for lesser periods of time. cr Q ~ ~ w
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._,. . ..,..~............_....»..+......,...+..-....,+~i..-...................r.. _....+..........rti....:. 17 . 5. Filter cigarettes with especially low tar content, though so far available for only a short time, are rapidly-increasing in popularity. One may predict that a greatly reduced risk for lung and larynx cancer will be associated with smoking these products, and that this risk will ultimately be expressed in a decline in lung cancer incidence as the total sales-weighted average tar intake declines. 6. A key question remains whether a practical threshold level exists at which cigarette smoking does not increase one's risk for tobacco-related cancers, tobacco-related cardiovascular diseases and tobacco-related pulmonary diseases; such a level might differ for each of these disease groups. 7. The epidgniology of-the less harmful cigarette max differ for Various .types of cancer, for CVD and COPD not only because of the .likelihood that different smoke components may affect their develo~.~ent, but also because their pathogenesis differs in terms of etiological co-factors. Therefore, we cannot necessarily draw conclusions in terms of the LHC from one disease entity to another though it appears that tar- reduction would benefit all. 8. Although the reduction of tobacco-related cancers among individuals smoking low tar cigarettes is to be welcomed, we recognize the continued need for effective anti-smoking campaigns and for smoking cessation clinics. Itowever, as long as society condones cigarette smoking, this habit the young and continued by is likely to be taken up by ~ 0 r ~ a larc~c. sMm~~nt of .ulii1 t s;. ''he l~rsact h.ii:inCul cici;trc~Lt~ ~ J O N
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continues to be an integral part of a generall strategy directea towards eliminating tobacco-related diseases. ,
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w_ - __ "`y_..___ _ __._,,.,,..1_ _ +_ _ _,.yt.-~-_ - -_,r,.a~,.arii;?~:,,,~,......... ~a7.~~~~".-~~.=~.,.......rr REFERENCES 1. Hammond, E.C. Smoking in relation to death rates of one million men and women. Nu:?. Cancer. Inst. Monograph No.19, 129=204, 1966. 2. U.S. Dept. of Health, Education and Welfare, The health consequences of smoking, 1974. (U.S. Govt. Printing Office, 1974). 3. Wynder, E.L. and Graham, E.A., . Tobacco smoking as a a possible etiologic factor in bronchiogenic carcinoma. - J. Amer. Med. Assoc. 143, 329-336, 1950. 4. Wynder, E.L. and Stellman, S.D., The comparative epidemiology of tobacco-related cancers. (submitted) .5. U.S. Dept. of Health, Education ar.d" Welfare, The adult use of tobacco, 1975. (Center.for Disease Control, Bureau of Health Education, Atlanta, 1976). -1 6. Wynder, E.L. and Hoffmann, D., Tobacco and tobacco smoke. Seminars in Oncology, 3, 5-15, 1976. 7. Wynder, E.L., Covey, L.S. and Mabuchi, K., Current o smoking habits by selecCed background variables: their U effect on future disease trends. Am. J.Epid. 100, J 168-177, 1974. 8. Wynder; E.L. and Hoffmann, D., Tobacco and tobacco smoke: studies in experimental carcir.ogenesis. Academic Press, New York, 1967.
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i 9: 'Wynder, E.L. and Hoffmann, D.,- Experimental tobacco ,carcinogenesis. Science 162, 862-871, 1968.- 10. Weber, K.H., Recent changes in tobacco products and their acceptance by the consumer. Proceedings of the Sixth International Tobacco Scientific Congress, Tokyo, 1976. 11. Wynder, E:L., Covey, L.S., Mabuchi, K. amd Mushinski, M., Environmental factors in cancer of the larynx: a second look. Cancer 38, 1591-1601, 1976. 12. Wynder, E.L., Mabuchi, K. and Beattie,'E.J., The epidem-; iology of lung cancer: recent trends. J. Amer-. Med. Assoc. ',213, 2221-2228, 1970. 13. Bross, I.J. and Gibson, R., ' Risk of lung cancer in smokers who switch to filter cigarettes. hm. J. Public Health 58 1396-1402, 1968. . 14. .Hammond, E.C., Garfinkel, L., Seid:nan, H. and Lew, E., Tar and'nicotine content of cigarette smoke in relation• to death rates. Environ. Res. 12 263-274, 1976. 14 15. Lilienfeld, A.M., Foundations of epidemiology. Oxford University Press, New York, 1976. Ch.8. . 16. Mantel, N. and Haenszel, W., Statistical aspects of the analysis of data from retrospective studies of disease. J. Natl. Caner Inst. 22 719-748, 1959. •trv~ sa~~sm . . -• r •~r+rr.:•rwr. ~earvseanaava ra~ n.r~t . ~ ma~+~ra+~ k k ,....r....,.•...~.~.-
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17. Maxwell, .t.C., Jr. The 1976 Maxwell. Report. Tobacco Reporter 103 (11) 16-1.7, 1976; ibid. 54-55. 18. Hoffmann, D., Schmeltz, I., Hecht, S.S. and Wynder, E.L. Chemical stuides on tobacco smoke, XXXIX. On the identification of carcinogens, tumor promoters and carcinogens in tobacco smoke. In Wynder, E.L., Hoffmann, D. and Gori, G.B. (Eds.) Proceedings of the .third world conference on smoking and health, Vol.1 U.S. Government Printing Office, Washington, D.C. 1976. PP 125-145. 19. Wynder, E.L. and Hoffmann, D., Less harmful ways of smoking. J. hatl. Cancer Inst., 48, 1749-1758, 1972: 20. Wynder, E.L., Hoffmann, D. and Gori, G.B.(Eds.) og. cit. Proceedings of the third world conference on smoking and health, Vol.l. U.S. Government Printing Office, Washington, D.C., 1976. 21. Wynder, E.L. and Hecht, S. (Eds.) Lung cancer. UICC Technical Report Series, Vol.25... Union Internationale Contre le Cancer. Geneva, 1976. 22. Kuhn, H, and, Klus, H., Reduction*of smoke nicotine and smoke condensate in Austria during the past fifteen years. Fachl. Mitt. Oesterr. Tabakregie 16, 320-329, 1975. I 23. Todd, G.F. Changes in smoking patterns in the U.K. Proceedingt; of the Eleventh International Cancer Congress. Florence, 1974 24. 'i'inm, V.J. Trendanalysen zurn Problern Verbrauches an Nikotin unrl Fouch:conden- , sat in der Bundesrcpublik DautGch]anc] itly dic Jahre 1961 bis 1975, Beitrlige zur Tabakforsch. 8, 404-414 (1976). cr ! i. %O O M
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25. Doll, R., The contribution of epidemiology to knowledge of cancer. Res. Epidem. et Sante Publ., 24 106-121, 1976; Doll, R. and Peto, J., Mortality in - relation to smoking: 20 years observations on male British doctors. Brit. Med. J. 2 1525--1536, 1976, 26. Gori, G.B. Low-Risk Cigarettes: A Prescription Science 194: 1243-47 (1976). 27. Ball, K. and Turner, R., Smoking and the heart. The` basis for action. The-Lancet, 822-826, 1974. , 28. Rose, G., Smoking and cardiovascular disease. Am..Heart Journal 85: 838-840, 1973. 29. Wald, N., Mortality from lung cancer and coronary heart disease in relation to changes in smoking habits. The Lancet 136-138, 1976. 30. Hoffmann, D., Brunnemann, K. and Wynder, E.L. Un preparation 31. Koch, A., Smoking and peripheral arterial disease. Wynder, E.L., Hoffmann, D. and Gori, G.B. (Eds.)., In op.cit. 281-283, 1976. 32. Wynder, E., Koch, A. and Covey,. L., and Sparroca, D. Cigarette smdcing in Irripher-al arterial occlusive disease. (sulxnitted) 33. Truett, J., Cornfield, J. and Kannel, W., A multi-variate analysis of the risk of CEID in Framingham. J. Chronic-Dis. 20 511-524, 1967. Vt 0 .. u ~ 0 v
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34. Wynder, E.L., Iioffmann, D, and Gori, G.B„ Eds„ Nieotine Yields. Brit. Med. J. -2 414-416 (1975). Plasna Nicotine Levels after Smoking Cigarettes with High, Nedium and Lc 39. pussell', M.A.H., Wilson, C., Patel, V.A., Feyerabend, C., and Cb1e,I op.cit., pp 383-439. coronary attacks in men after giving up smoking. The Lancet, 2 1345-1248, 1974. Gordon, T., Kannell, W.G. and McCee, D., Death and Fletcher, C.M., et al. Natural History of chronic bronchitis and emphysema. Oxford University Press, Oxford, 1976. Tokyo, 1976. of the Sixth International Tobacco Scientific Congress, about by changes in cigarette-smoke yield. Proceedings. Adams, P.I. Changes in personal smoking habits.brought NSM tobacco substitute. Brit. Aled. J.1 1427-1430, 1976. Freedman, S., and Fletcher, C.N. Changes of smoking habits and cough in men smoking cigarettes with 30% Hill, P., Smoking Behaviour in Relation to Nicotine and Carboxyhemoglobin Content of Cigarettes, in preparation. N 0 .u 41. Dept. of Health, Education and Welfare, Teenage Smoking: 6.0 N national patterns of cigarette smoking, ages 12 through,p 18, 1972 and 1974. DIIEtl Publ. No. HSM 76-931, ° m U.S. Government Printing Office, Washington, D.C., 1976.
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42. Williams, C.D. and Wynder, E.L., A blind spot in preventive medicine. J. Amer. Med. Assoc. 236 2196-2197, 1976. 43. Williams, C.L., Arnold, C.B. and Wynder, E.L. Primary Prevention of Chronic Disease Beginning in Childhood The "Rnoa Your Eody" Program: Design of Study: Prev. t:ed.344- 357, 1977. 44. Schwartz, J.L., A Critical Smoking Control Methods. Review and Evaluation of Publ. Health Reports 84: 1 483-491 (1969). Americnn Health Foundation. Prev. Med. 5 454-474, 1975. 45. Shewchuck, L.A., Smoking cessation programs of the
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Table I Number of patients who were either lifetime nonsmokers, current smokers (120 years) , or exsmol:ers by ac7e and sex. (Whites Only) Below 50 50-59 60-69 70-89 Total Lung X* Larynx** Controls M F M F 1.1 F 72 29 41 15 1533 1617 191 46 108 22 1402 1301 215 32 ' 93 24 1318 1104 79 20 44 ' 3 582 690 557 127 : 286 64 4835' 4712 * KreybeYg Type I= Squamous and out cell types ** Glottic and supraglottic types f
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0 Smokers, by Quantity. TABLE II -Relative Risk of Filter Cigarette Smokers for Lung Cancer (I) and Larynx Cancer, as a Percentage of the Relative Risk for Non-Filter Quantity Smoked Per Day Male Female Male Female 61% 89% ' 71% 66$ 86~ 38% , 118 69% . 51$ 79% 53% 33% 75% 103% _ 558 • ..r,: . .~ Cancer Site Lung Cancer (I) . Larynx Cancer ~r'...'!'~^"ryi'qr .. ... . .. . ~ ~ . .. . ...... .._ . ~ . ...... .. : ... . ..: .... . . 'r •. ... . . ... . . .... . .. .. ...
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....a,..«s_~.. __ _... - - ...._ ~. . ,... .. - - -.s,.-... - . - --- --- ...~.........~'- - la.s....~......~.......w.Mr.....+sr.:rr~.,,; v Table III Relative Risk* for DSales' with Lung Cancer IbyYears of Smoking Cessation and Current Age 50-59 60-69 70-89 1-3 38.7 56:5 110.9 Years 4-6 15.4 37.2 ' 62.3 of 7-10 22.3 25.3 14.2 Cessation 11-15 10.8 15.6 31.3 16+ 4.7 ' 2.7 17.5 * Referent is lifetime nonsmokers-
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.~i1Yi~iN.Y....a- - - --- .....ww..rrs..... ,..a...~........,.,~...~s...«.e..,.../W~tl1~SNr.w.>-.w.. x-_ ...~ -"-i.w...... .....,..r..s.~+a+......_. ,r 1. Age-adjusted relztive risk of present (~ 20 years) smokers of either filters ( 10 years) or non-f=iters, by quantity smoked. (a) Lung cancer I, males. N = 143 filter, 190 non-filter. (b) Larynx cancer, males. N= 66 filter, 86 non-filter. (c) Lung cancer I, females. N= 50 filter, 13 non-filter. (d) Larynx cancer, females. N= 20 filter, 17 non-filter 2. Age adjusted-risk of ex-smokers (50 - 69 years old) by years of cessation'. (a) Lung cancer I, males. N = 406. (b) Larynx cancer, males. N = 201, (c) Lung cancer I, females. N= 78, (d) Larynx cancer, females. N= 46. 3. Sales-weighted average tar delivery of U.S. filter and non- filter cigarettes, 1957-1976. 4. Percent market share for filter cigarettcs, 1958-1976. 5. Percent market share for low tarr cigarettes, 1967-1976. 6. Lifetime filter usage as a percentage of total smoking experience, by birth cohort. W
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0 1 PERCENT SHARE OF MARKET FOR FILTER CIGARETTES 1959-1976 ioo, M Z 60 W U w a0 n. 20-1 , 0 T ~`r ~Y"'~ I 58 60 62 64 66 68• .?O ?2 74 76 YEAR FIGURE 4 Yl3S:•--".".....w.on ~ .. _ . . r.~+e. . . . _. r• J
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MARKET SHARE FOR LOW-TAR (0-15 CIGARETTES, 1967- 76 S © ro
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LIFETIME FILTER USAGE AS A PERCENTAGE OF TOTAL SMOKING EXPERIENCE I I (A 0 ~ ~ a
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