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MOKING YOUTH RESOURCE MANUAL FOR STUDENTS AND TEACHERS JUNE, 1965 ® STATE OF WASHINGTON ~ 0 DEPARTMENT N O F H E A L T H ~ a 0 ~ ~~ ~

Youth Advisory Subcommittee

DANIEL J. EVANS Governor BERNARD BUCOVE, M.D. Director SMOKING AND YOUTH A RESOURCE MANUAL FOR STUDENTS AND TEACHERS JUNE, 1965 Dedicated to thoae who do not wanJt to be gu4ti,b.be abou.t emok.i,ng. JESS SPIELHOLZ, M.D. Chief, Division of Health Services GEORGE SPENDLOVE, M.D. Chairman, Subcommittee Smoking and Health

SMOKING AND YOUTH A RESOURCE MANUAL FOR STUDENTS AND TEACHERS Prepared By The Washington State Department of Health In Cooperation With Youth Committee Explorer Scouts 4-H Club Future Farmers of America Future Nurses of America Future Teachers of America Girl Scouts of the USA Horizon Club YM CA YWCA Youth Council of Churches Voluntary Committee American Cancer Society Washington Assn. for Health, Physical Education, & Recreation Washington State Heart Association Washington State Medical Association Washington State Public Health Association Washington State Tuberculosis Association Washington-Northern Idaho Council of Churches Washington Congress of Parents and Teachers Subcommittee State Department of Agriculture State Department of Health State Department of Institutions State Department of Public Instruction Washington State Library University of Washington Washington State Association of Local Health Officers i

FOREWORD The following resource manual presents facts which will help students, teachers, or others who are interested in the smoking pro- blem to form their own opinions about smoking. The discourse does not pretend to be exhaustive, but offers additional bibliography for those interested in a more thorough exploration. Young people have complained that they don't want to "just be told it's wrong or bad to smoke", they want ungarnished facts so they can make up their own minds after weighing the benefits and disadvantages of smoking as it affects them personally. It is with this in mind that an approach is made wherein the authors have attempted: l. To relate the history of tobacco 2. To show the cost of smoking and who pays the bill. 3. To show the constituents of tobacco smoke and summarize their effects on the body. 4. To explore the reasons why people smoke. 5. To compare social statistics of smokers with those of non-smokers.

SMOKING AND YOUTH A RESOURCE MANUAL FOR STUDENTS AND TEACHERS Table of Contents Page I. TOBACCO AND THE GROWTH OF THE INDUSTRY .......... 1 A. Origin - Discovered . . . . . . . . . . . . . . . . . . 1 B. Cigarettes Introduced and Popularity Increased . . . . 1 C. The Economic Giant . . . . . . . . . . . . . . . . . . . 2 II. THE ECONOMICS OF TOBACCO AND SMOKING . . . . . . . . . . . 3 A. Economic Importance . . . . . . . . . . . . . . . . . . 3 B. Cost to the Individual . . . . . . . . . . . . . . . . 3 Selected Morbidity Measures, Figure 1 . . . . . . . . . 4 C. Cost to the Nation . . . . . . . . . . . . . . . . . . 5 1. Lives Lost . . . . . . . . . . . . . . . . . . , 5 2. Cos t to I ndus t ry . . . . . ~ . . . . . . . . . . . . . 5 D. Conc l us i on . . . . . . . . . . . . . . . . . . . . . . 6 II1. CONSTITUENTS OF TOBACCO SMOKE . . . . . . . . . . . . . . 8 Major Classes of Compounds in the Particulate Phase of Cigarette Smoke, Table I . . . . . . . . . . . . . . . . 8 Some Gases Found in Cigarette Smoke, Table 2....... 8 Carcinogens and Co-Carcinogens . . . . . . . . . . . . . . 9 IV. THE EFFECTS ON THE BODY . . . . . . . . . . . . . . . . . . 10 A. Smoking and the Respiratory System . . . . . . . . . . 10 1. Lung Cancer . . . . . . . . . . . . . . . . . . . . 10 Animal Experimentation . . . . . . . . . . . . . . . 11 Clinical and Autopsy Studies . . . . . . . . . . . . 11 Statistical Population Studies . . . . . . . . . . . 14 Mortality Ratios: Chart 1 . . . . . . . . . . . . . 16 Mortality Ratios: Chart 2 . . . . . . . . . . . . . 17 Deaths: Due to Lung Cancer, Chart 3........ 18 Mortal i ty Ratios: Chart 4 . . . . . . . . . . . . . 19 2. Chronic Bronchitis and Emphysema . . . . . . . . . . 20 Ci 1 ia, Figures 2, 3, & 4 . . . . . . . . . . . . . . 21 Emphysema . . . . . . . . . . . . . . . . . . . . . 22 i i i

Table of Contents - Continued Page B. Smoking and the Heart and Blood Vessels ........ 23 Buerger's Di sease . . . . . . . . . . . . . . . . . . . 24 The Hea r t . . . . . . . . . . . . . . . . . . . . . . . 24 C02 . . . . . . . . . . . . . . . . . . . . . . . . 24 Hydrogen Cyan i de . . . . . . . . . . . . . . . . . . 25 N i cot i ne . . . . . . . . . . . . . . . . . . . . . . 25 C. Smoking and the Body in General . . . . . . . . . . . , 25 D. Conc l us i on . . . . . . . . . . . . . . . . . . . . . . . 27 Expected and Observed Deaths, Table 3 . . . . . . . . . 27 Death From All Causes, Figure 5 . . . . . . . . . . . . 28 V. PSYCHOLOGICAL ASPECTS OF SMOKING . . . . . . . . . . . . . 29 A. Why People Smoke . . . . . . . . . . . . . . . . . . 29 B. Is Smoking An addiction or an Habituation? ..... 30 Mortality Ratios for Ex-Smokers and Current Smoke rs , Tab l e 4 . . . . . . . . . . . . . . . . . 33 V I . ADVE RT I S I NG . . . . . . . . . . . . . . . . . . . . . . . 34 V11. SOC I OLOG I CAL ASPECTS . . . . . . . . . . . . . . . . . . . 36 Characteristics More Prominent Among Smokers Than Non-Smoke rs . . . . . . . . . . . . . . . . . . . . . . 36 iv

I. TOBACCO AND THE GROWTH OF THE INDUSTRY A. Origin - Discovered Christopher Columbus (about 1492), on first trip to the New World, saw the natives blowing smoke from their mouths and nostrils. The Indians had discovered how to wrap tobacco leaves in the delicate inner husks of maize to form crude cigars. The superstitious New World Indians thought tobacco had various mysterious properties and medicinal effects, and they commonly used it in peace pipes as evidence of good will between the individuals and tribes. Thus the Europeans gained their first knowledge of tobacco and its use in smoking. B. Cigarettes introduced and Popularity Increased Cigarettes were first introduced as a European novelty just before the start of the Civil War (1861-1865). Cigarettes re- mained unpopular and their use was considered vulgar for many years. In 1880, only I percent of the tobacco consumed in the United States was in cigarettes. Between 1910 and 1915, tobacco used in cigarettes amounted to only 7 percent of the total domestic consumption. During World War I, the popularity of cigarettes rose so that in the United States the usage of tobacco in that form increased to 26 percent between 1920 and 1925. By 1961, 83 percent of the total national consumption of tobacco was in cigarettes. In 1956, about 400 billion cigarettes were bought in the United States. Smokers then regularly spent more than $4 billion annually for cigarettes. In 1963, the total number of cigarettes smoked in the United States exceeded half a trillion (524 billion). Only part of this can be attributed to an increase in population. The 1962 adult per capita smoking of cigarettes was 4,005 annually com- pared to 3,650 in 1956. In 1964 the number of cigarettes sold decreased to 511 billion. Presently, six major companies manu- facture 51 different brands in 69 sizes and packages. Filter cigarettes now constitute about 55 percent of the total number of cigarettes sold. -1-

C. The Economic Giant From an insignificant beginning, discovered by chance, tobacco smoking has become a habit which affects the economic and physi- cal well-being of mankind. When the average American smoker lights up 20 cigarettes each day, 365 times each year, at a cost of $125 per year, he or she helps to support a fantastically huge industry that rolls out 524 billion cigarettes (over one-half trillion), 7 billion cigars, 71 million pounds of pipe tobacco, 65 million pounds of chewing tobacco and 33 million pounds of snuff. This provides a livelihood for 750,000 farm families. American smokers spend about $8.0 billion dollars yearly for tobacco products. Federal, State, and local taxes on tobacco products total $3.2 billion. The tobacco companies spent $40 million for television adver- tising in 1957. This increased to $115 million in 1962. Total cost of tobacco advertising was in excess of $250 million last year. Thus, we see that tobacco, on the one hand, is a segment of the American economy and, on the other hand, constitutes a sig- nificant threat to the health and well-being of the American people. THE PRETTY KITTEN THAT MAY EAT THE HAND WHICH FEEDS IT -2 -

Il. THE ECONOMICS OF TOBACCO AND SMOKING A. Economic Importance Tobacco interests have saturated mass communication media with statistics designed to show the economic importance of the tobacco habit. The government of the United States, they claim, depends on taxes derived from tobacco. Obviously, this contribution to our tax structure ($3.2 billion) is important and could not be abruptly with drawn without disturbing our present system. However, few citizens stop to consider that the annual 3 billion dollars which are seen as such an important part of our tax structure are contributed by us and for us, and that if we didn't take the money by a tax on tobacco, it would be available to be taken in some other way. Likewise, the five additional billions of dollars which go to support the 750,000 farm families, the 96,000 men and women involved in tobacco manufac- turing, and the $250,000,000 worth of advertising would not disappear if tobacco use were reduced. This same money would be available for other businesses of far more significance than the tobacco industry. Consumers paid about $8 billion for 523 billion cigarettes in 1963. That is no small item, but is only the down payment on the total cost to America of tobacco and smoking. Little is said about the millions of dollars of our taxes which go toward providing price support to tobacco farmers, increased welfare, the cost of fires, the costs to industry and especially the price paid by the individual smoke r. B. Cost to the Individual Smoking is expensive. The money spent on cigarettes (at 30 cents a pack) by a man and wife who together smoke an average of three packs a day would, if saved and invested at 4 percent, in thirty years amount to $14,800. Even more important is the very high cost of illness and disability related to smoking. (Research in the State of California indicates that chronic conditions and disability due to chronic illnesses among smokers between the ages of 25 and 64 are almost double the rate for non-smokers within the same age brackets.

FIGURE 1 SELECTED MOREIDITY MEASURES,-MAIES, BY SMOKING PRACTICE CALIFORNIA MEAITH SURVEY, 1955 Chronic Conditions with Days of Disability Some Activity Limitation Due to Chronic Illn.ss 2D 10 0 40 : 20 0 1 i ': : :h i _ 25-44 45-64 25-44 45-64 Years Y.ara Mot.: For Intervi.w period February 15, 1955 - Aprll, 1955 Source: State of California, Department of Public M.alth, California M.alth Survey, 1954-55.1 What does this chronic disease and disability cost the individual and his family? It is impossible to say exactly but figures representing realistic estimates of the average cost can be ar- rived at. Available statistics suggest that a.non-smoker, be- tween the ages of 25 and 44, whose salary is $7200 per year may expect to lose $175 annually on account of chronic illness or disability. The man who smokes, at a comparable age and with the same salary, may expect to lose approximately twice as much ($350). For workers, aged 45 to 64, with the same salary, the estimated average annual loss from chronic illness and disability is $528 for non-smokers, and $1056 for those who smoke. At this rate loss of income from disability caused by smoking would cnst the millionc of familiec in which the breadwinnPr smokes more than all of the families supported by the industrv Catrn. The loss of income, however, is still only a portion of the cost, as anyone knows who has had to purchase medicine, hos- pital care, laboratory service or the care of a physician. 1CIGARETTE SMOKING AND HEALTH, A Review of Studies by the California State Department of Public Health, 2151 Berkeley Way, Berkeley, California, Page 15. -4- u+ 0 W N CD m 0 IT ~ -- -~.-.~...-•,..'.c.-w~we.Tt3Ml:~.Y+.r~_..~+.F."•S,'!+r"~-.n~..s~wr.~a--.!~9~r3a'!'N', ~.. .~. . ' ..i~. - . " .. _ ~ . . . ' . . - •~ ' . . . , . . ~ .

C. Cost to the Nation l. Lives lost There are now one million children in the United States who will die prematurely of long cancer because of smoking if we do not c hange our habits. We cannot ignore the pain, suffering, broken families, and heartaches caused by all of these deaths even though they cannot be measured. The unmeasurable costs would at the moment of anguish, probably be greater than all of the money in the world for thousands upon thousands of people who will be affected. Hospital and medical bills constitute a stag- gering burden to families of victims, to welfare agencies, and to the taxpayer. We are told by Hammond,who recently completed studies which con- firmed and extended other important studies, that total mortality caused by tobacco is probably about six times greater than deaths from lung cancer.2 That makes 6,000,000 people now ali.ve who will die prematurely of illnesses caused by or associated with smoking. In the State of Washington we are now losing in excess of 4000 lives per year from causes associated with smoking. 2. Cost to Industry What does smoking cost industry? Although an estimate is dif- ficult, we can enumerate several costs which would have to be included. These are: a. Absence from work because of illness. ( We already know that chronic disease and disability are twice as high among smokers.) b. Excessive time off to smoke. (Many workers cannot smoke on the job.) c. Lower physical ability. (The smoker is more easily fatigued.) d. Earlier retirement due to disability. (This means the end of the productive part of a person's career, and the cost of retirement income to industry. 2 HAMMOND, E.S., "Smoking in Relation to Mortality and Morbidity", presented to the American Medical Association, Port- land, Oregon, December 4, 1962. -5-

e. Cost of smokers' fires. (In the United States there are approximately 1,000 home fires every day, one-third of which are due to the carelessness of smokers.3 Add to this cost the•value of our national forests that are consumed by smokers' fires, and we have another impressive sum to include in the already astronomical cost of smoking.) f. Additional janitorial expenses. (Smoking is a habit which requires constant clean-up and refinishing.) D. Conclusion The economic problem created by smoking is staggering. To many, there appears to be no solution. The "smoke cloud" must be cleared away and the problem examined realistically in order to tell how big it really is. We must decide, too, whether the major problem is the smoking one-third of our population which is going to be adversely affected or the employment and economic welfare of that one-two- hundredth of our population that is supported by the tobacco industry. Suppose we could inoculate everyone in a way so he would never suffer pain or illness. Hundreds of thousands of doctors, nurses, ho:;pital employees, drug manufacturers, pharmacists, laboratory technicians, etc. would be put out of work or business. Would we hesitate? Will we decide in favor of the one two-hundredth of our citizens whose jobs or livelihood at this time, depend on tobacco, or in favor of future children? Will we continue to let this big industry introduce into our homes and nearly every aspect of our lives with the compulsive influ- ence of its advertising? Will we condone the manipulation of our minds so we instinctively feel it is necessary to smoke in order to be successful in love, athletics, popularity, and business? The economic future of the cigarette industry, not the economic future of the United States, depends upon our answers to these questions. 30chsner, Alton, M.D., "Lung Cancer and Its Relationship to Smoking", Narcotics Education, Inc., Box 4390 Washington, D.C., 20012, Pamphlet, pp. 15, 16. -6- - , ,

DO YOU WANT TO BE A STATISTIC?

III. CONSTITUENTS OF TOBACCO SMOKE The tobacco leaf contains thirty odd identified chemical compounds which, when combustion takes'place, represent a complex series of reactions that result in nearly 300 other chemical compounds. This multitude of compounds exists as fine droplets suspended in a gaseous phase comprised mostly of nitrogen and its oxides, carbon dioxide and carbon monoxide.4 See Tables 1 and 2. TABLE 1. Major claasea of compounds In the particulate phase of cigarette smoke Class Percent In particulatee phase NumDer of compounds on lyn Toxic action Acids 7.7-12.8 25 Some Irritant Glycerol, glycol, alcohois 5.3-8•3 18 Poss(Dle Irritation Aldehydes and ketones. 8.5 21 Some Irritant Aliphatic hydrocarbons 4.9 64 Some Irritant Aromatic hydrocarbons 0.44 81 Some carcinogenic Ph.bols 1.0-j.8 45 Irritant b possibly I te-carelnep.nlc L 66% 254 - u *water 27%. a TASt,$ 2. Some gases found in cigarette smoke Compound Safe level for Curicentra-.. industrial Toxic action on lung tion exposure' (ppm) (ppm) Carbon Monoxide 42.000 100 Unkhown Carbon Dioxide 92,000 ............................ None Methane, ethane, propane, butane, etc. 87,000 500 None Acetylene, ethylene, propylene, etc. 31,000 5.000 None Formaldehyde 30 5 Irritant Acetaldehyde 3,200 200 Irritant %.crolein 150 0.5 Irritant Methanol 700 .............................. I rri tant Acetone 1.100 200 Irritant Methyl ethyl ketone 500 250 Irritant Ammonia 300 150 Irritant Nitrogen Dloxide 250 5 Irrltant Methyl Nitrite 200 .............................. Unknown Hydrogen Sulfide 40 20 Irritant Hydrogen Cyanide 1,600 10 Respiratory enzyme poison Methyl Chloride 1,200 100 Unknown 'The values listed refer to time-weighted average concentrations for a normal work day. n 4SMOKING AND HEALTH, Report of the Advisory Committee to the Surgeon General of the Public Health Service, U.S. Department of Health, Education, and Welfare; Public Health Service; Washington, D.C., pp. 51 and 60. -8 - g

The gases themselves are highly toxic. For instance, carbon monoxide, the familiar lethal product of the automobile engine exhaust, com- prises about 8 percent of the volome of a puff of cigarette smoke. If the full dose of carbon monoxide in one cigarette could be in- jected into a person's blood stream at one time, it would be suf- ficient to cause death, but when inhaled it is so dilute as to be relatively innocuous. Aside from the gases, tobacco smoke consists of small particles and droplets of material. The material which can be condensed from cigarette smoke is commonly referred to as "tar", a sticky mixture of chemicals, including poisons, (Hydrogen sulphate and hydrogen cyanide), and substances such as phenols which are highly irritating to tissues. Up to 90 percent of the tar and other substances is retained in the lungs by those who inhale cigarette smoke. A person who inhales the smoke from 20 cigarettes per day transfers a cupful of these substances into his respiratory tract each year. Cigar and pipe smokers retain only about 10 percent of the substances in their bodies, probably because most of them do not inhale. Repeated ap- plication of these substances have produced cancer in animals in laboratory experiments. Studies of the body's responses to smoking have usually shown that one of the most important of the ingredients of tobacco smoke is nicotine. A cigarette may contain as much as 20 milligrarns of nicotine. Cigar and pipe tobaccos contain more nicotine, but their smoke is rarely inhaled so that little nicotine is absorbed. On the otherhand, the deep and prolonged inhalation of the much lighter and less irritant cigarette smoke permits the absorption of up to 90 percent of the contained nicotine. Microscopic examination of cigarette smoke shows a remarkable amount of debris, including shreds of tobacco, paper, charcoal, and ele- ments of filter tips. Filters do not substantially reduce the hazards. Carcinogens and Co-Carcinogens Of the many compounds found in tobacco smoke, seven are known to be carcinogenic (cancer producing). It is true that the carcinogens are in small amounts, but when the dosage is repeated hourly, daily, yearly, there is an accumulation which may ultimately lead to very serious consequences. 5CONFERENCE REPORT, OREGON'S FIRST SMOKING & HEALTH INSTITUTE. Oregon State Board of Health, 1400 S.W. 5th Avenue, Portland, Oregon, 97201, Page 5. -9 -

In addition, tobacco smoke contains a number of co-carcinogens. In themselves, co-carcinogens may be harmless, but when they are in company with a carcinogen, they strengthen its effect and speed it up. For instance, one of,the major components of tobacco smoke is phenol. Laboratory experimentation has shown that extremely small amounts of a carcinogen will produce cancer when followed by or accompanied by repeated exposure to phenol. This means that a small amount of a carcinogen (possibly not enough to be harmful) in company with a bit of co-carcinggen (which is in itself harm- less) becomes something dangerous. IV. THE EFFECTS ON THE BODY A. Smoking and the Respiratory System l. Lung Cancer THE SURGEON GENERAL'S REPORT ASSERTS A DEFINITE CAUSAL RELA- TIONSHIP BETWEEN CIGARETTE SMOKING AND LUNG CANCER. "Cigarette smoking is cau,ally related to lung cancer in men; the magnitude of the effect of cig- arette smoking outweighs all other factors. The data for women, though less extensive, point in the same direction. "The risk of developing lung cancer increases with duration of smoking and the number of cigarettes smoked per day, and is diminished by discontinuing smoking. "The risk of developing cancer of the lungs for the combined groups of pipe smokers, cigar smokers, and pipe and cigar smokers, is greater than for non-smokers, but much less than for cigarette smokers. The data are insufficient to warrant a conclusion for each group individually." 7 What is the evidence upon which this indictment is based? The evidence which proves this causal relationship falls into three categories: (1) Animal experimentation, (2) Clinical and autopsy studies, and, (3) Statistical population studies. 6Baldwin, Ben H. Couch, Gertrude B. and Richardson, Charles E. TEACHING ABOUT SMOKING AND HEALTH. Office of the Superintendent of Public Instruction, State of Illinois. 7SMOKING AND HEALTH, Report of the Advisory Committee to the Surgeon General of the Public Health Service, U.S. Department of Health, Education and Welfare, Public Health Service, Washington, 0. C. Page 31. -10-

Animal Experimentation. A.H. Roffo of Argentina reported that he had produced cancer by painting tqr-like tobacco extracts on the backs of rabbits. Since then, there have been numerous studies in which animals have been exposed to tobacco tars and the component chemicals. Seven of the chemicals which have been established as cancer producing (carcinogenic) when applied to the skin of laboratory animals are: (a ) (b) (c) (d) (e) (f ) (9) Benzo (a) pyrene. Dibenzp (a.i.) pyrene D i benzo (a .h . ) anthracene- Benzo (c) phenanthrene Dibenz (a.j.) acridine. Dibenz (a.h.) acridine- 8 7H-Dibenzo (c.g) carbazole. Other chemicals (co-carcinogens) in cigarette smoke help to pro- mote cancer production and/or lower the body's resistance to cancer producing agents. Until recently, cancer of the lung had not been produced in lab- oratory experiments. Laboratory animals do not smoke cigarettes and inhale. Consequently, experiments that attempt to duplicate the conditions of human smoking of cigarettes usually fail. When rats, for example,are put in a chamber and exposed to concentra- tions of cigarette smoke equal to that which humans inhale, they die from the acute effects of nicotine. Clinical and Autopsy Studies. A century ago, Bouisson reported a remarkably thorough clinical study of 68 cases of cancer of the oral cavity in a hospital in France. Two-thirds of the cases were cancer of the lip, the others were cancer of the mouth, tongue, internal surface of the cheek, tonsil, and gum. He was able to ascertain the habits of 67 of these patients and found that 66 smoked tobacco and the other chewed tobacco. Bouisson noted that cancer of the lip ordinarily occurred at the spot where the pipe or cigar was held. 9 $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, Public Health Service, Washington D. C., Page 56 9CIGARETTE SMOKING AND CANCER. U.S. Government Printing Office, Washington, D. C., PHS Publication No. 1103, Page 7. . . . ,:-•'r'7*Y . , . .. . .-__. _. . . r... .. .i . :'Y . r . . . . , . . , ~

In 1936, Doctor Alton Ochsner, and Doctor Michael DeBakey, both New Orleans physicians, observed that nearly all their lung cancer patients were cigarette smokers. Since the increase in the inci- dence of lung cancer paralleled the increase in cigarette consump- tion, a causal relationship was suggested. Studies of large groups of smokers and non-smokers have been carried out in which slides of bronchial tissue were studied. The pathol- ogists who looked at the slides didn't know anything about the background of the slides other than the numbers on the slides, which were picked at random. Considerable numbers of cells with atypical pre-cancerous nuclei were found in slides from smokers, and the numbers increased greatly with increased amount of cig- arette smoking. In heavy smokers, the he number of pre-cancerous cells had also increased with age. A few years ago, tissues of the mouths of smokers and non-smokers were examined microscopically under ultraviolet light. This was done because it is known that some of the carcinogenic substances in tobacco smoke fluoresce under ultraviolet light. The study showed that when a person smokes tobacco, fluorescent material penetrates into the cells of the lining of the mouth. In other words, it showed that material from tobacco smoke actually pene- trates into the cells. 11 During the last 15 years, a large number of studies have been made of the smoking habits of hospital patients. In all of these studies, which included a total of more than 8,000 lung cancer patients, many more smokers, particularly heavy cigarette smokers, were found among patients with lung cancer than among patients with other diseases. 12 Several studies have shown an association between cigarette smoking and cancer of the bladder. In this connection, it should be noted that betanaphthlamine, a carcinogenic chemical to which analine dye workers were formerly exposed, concentrates in the urinary bladder and causes cancer of that organ. The same may be true of some of the carciogenic chemicals in tobacco smoke. 31 10 Auerbach, 0., Stout, A.P. Hammond, E.D., Garfinkel, L. C HANGES IN THE BRONCHIAL EPITHELIUM IN RELATION TO CIGARETTE SMOKING AND IN RELATION TO LUNG CANCER. New England Journal of Medicine, 265:253-67, 1961. 11 CIGARETTE SMOKING AND CANCER, US. Government Printing Office, Washington, D. C., PHS Publication, No. 1103, Page 7. 12 IBID. Page 7 13 IBID, Page 7. -12- :---~-~~:~, ~ ~ ~ . } •

"Extensive microscopic studies have been made of tissues lining the bronchial tubes of men and women who died of various causes. The findings may be summarized briefly as follows: "When people die of lung cancer, additional tiny cancers can some- times be found if the entire lungs are examined microscopically. In other words, lung cancer victims occasionally have two or more separate cancers in their bronchial tubes. In addition, they have numerous carcinomas in situ, i.e., cancers which have not invaded underlying tissues. The cells of a carcinoma in situ appear to be similar to the cells in the main mass of cancer which killed the patient. Similar cells, the nuclei of which look like the nuclei of cancer cells, are found widely scattered throughout the lining of the bronchial tubes of these patients. "Similar studies have been made of the lungs of men and women who died of causes other than lung cancer. Cell changes characteristic of carcinoma in situ rarely are found in the bronchial tubes of people'who never smoked. On the other hand, many such changes occur in the lungs_of cigarette smokers. Moreover, the number of abnormal cells increases with the amount of cigarette smoking. The linings of the bronchial tubes of most heavy cigarette smokers who died of causes other than lung cancer closely resemble those of persons who died of lung cancer. That is, they contain what appear to be carcinomas in situ as well as many cells with nuclei identical in appearance to the nuclei of cancer cells. "The bronchial tubes of cigar and pipe smokers usually show some similar changes but much less than those of cigarette smokers. "Among cigarette smokers, the number of cells resembling cancer cells increases with age, i.e., with the number'of years of ex- posure to cigarette smoke. Few if any such cells are found in the bronchial tubes of non-smokers, and there is no evidence of increase with advancing age. "The bronchial tubes of ex-cigarette smokers who have given up the habit for at least five years, more nearly resemble those of persons who never smoked than do the tubes of persons who smoked cigarettes regularly up to the time of their terminal illness. Thus, it appe3rs that abnormal changes in the bronchial tubes of cigarette smokers gradually disappear if the person stops smoking. "in non-smokers, only slight differences were found between the bronchial tubes of those who lived all their lives in rural areas and those who lived all their lives in cities. -13- . ,. _ , . . . . ~ , .~«.

"These microscopic studies show that when human beings are exposed to cigarette smoke over many years, progressive changes occur in the cells which line their respiratory passages. In many instances, these changes terminate in death from bronchogenic carcinoma. Fre- quently, however, the changes are reversib)e if smoking is discon- tinued before invasive cancer develops." '+1 Statistical Population Studies. Numerous studies of a third type (statistical-population or epidemiological) have produced additional evidence. These investigations take two forms, retro- spective and prospective. In retrospective studies, the smoking histories of persons with a specified disease (lung cancer, for example) are compared with those of appropriate "control" groups without the disease. Twenty-nine such retrospective studies for lung cancer alone have been made in recent years. Despite many var- iations in design and method of study, all but one (which dealt with females) showed that proportionately more cigarette smokers are found among lun~ cancer patients than in control groups with- out lung cancer. 1 "In the prospective studies, large numbers of men were enrolled as subjects, and questioned about their smoking (or non-smoking) habits. Over a period of time, their medical records were checked until, in many cases, nothing was left for checking except death certificates. Study of those death certificates permitted crude death rates and specific death rates (by cause) to be computed for various types of smokers as well as for non-smokers. Results from these comparisons of the death rates of smokers and non-smokers, once again pinpointed the association between smoking and specific diseases." 16 "Two large-scale prospect,ive epidemiological studies were started in the fall of 1951. One of these was carried out by Doll and Hill for the British Medical Research Council. The other was carried out by Hammond and Horn for the American Cancer Society. 14CIGARETTE SMOKING AND CANCER, U.S. Government Printing Office, Washington, D.C.,PHS Publication No. 1103, Pages 18-20. 15TEACHING ABOUT SMOKING AND HEALTH. State of Illinois, Office of Superintendent of Public Instruction and Dept. of Public Health, 1964, Page 20. 16 IBID Page 20. -14-

"The British study was outstanding from the standpoint of accuracy of information, since all of the subjects were physicians. The American Cancer Society study was fa-r larger and included a com- parison of urban and rural residents. "The findings of all of these studies are remarkably similar; indeed, they are as close as could possibly be expected considering that different population groups with different age distributions were studied. None of these, nor similar studies, has presented con- flicting evidence. For the sake of brevity, since other studies showed essentially the same results, this presentation will be lim- ited to the findings from the American Cancer Society study by Hammond and Horn. "After designing and pretesting a questionnaire in the fall of 1951, over 22,000 American Cancer Society volunteers were trained as inter- viewers for the study. Between January 1 and May 31, 1952, they enrolled subjects in 394 counties in nine states. The subjects, all of whom were men between the ages of 50 and 69 filled out a simple questionnaire relative to their smoking habits, both past and present. A total of 187,783 men were enrolled, filled out questionnaires, and were traced for the ensuing 44 months. Death certificates were ob- tained on all who died and additional medical information was obtained on those who were reported to have died of cancer. Altogether, 11,870 deaths were reported, of which 2,249 were attributed to can- cer. "The most important findings of the study were that the total death rate, from all causes combined, is far higher among cigarette smokers, than among pipe and cigar smokers and among non-smokers, and that the death rate increased in direct relation to amount of cigarette smoking." 17 Some of the important findings from the American Cancer Society study of Hammon and Horn are indicated in the charts which follow. "Chart I shows relative death rates in relation to tobacco smoking. Men who never smoked had the lowest death rate and men who smoked only cigarettes had the highest rate - 69 percent higher than non- smokers. (In Chart I.and others presenting "mortality ratios", the number of deaths of those who never smoked is expressed as 1.00 and tht other categories are compared to it by expressing their mortality in ratio to 1.00.) 18 17CIGARETTE SMOKING AND CANCER, U.S. Government Printing Office Washington D.C.. PHS Publication No. 1103, Pages 8-9. 18CIGARETTE SMOKING AND CANCER, U.S. Government Printing Office, Washington, D.C., PHS Publication No. 1103, Page 9. -15-

Chart 1 MORTALITY RATIOS: TOTAL DEATHS :o 1.69 1.5 0.s 1.4] In _-- NEVER OCCAI'L CIGAR PIPE CIGARET CI"R(T fMOKEp ONLf ONLY ONLY ONLY 4 pTNER Mortality ratios 1or total causes of death by Ufetime hletary ot smoRMO."N WHICH ONE WILL GET SHOT? -16-

"Chart 2 shows death rates in relation to the amount of cigarette smoking. From this chart it is apparent that the total death rates increase progressively with the number of cigarettes smoked; the death rate of men who smoked two packs or more of cigarettes a day being nearly two and a guarter times as high as the death rate of men who never smoked."ly Chart 2 MORTALITY RATIOS: TOTAL DEATHS :.s t.o :.t3 LN E7o Is 10 1.34 too r ---~--~ ------ 05 NEvER IESS THAN q-1S t0-39 40+ SMOKEO 10 CtOARETS 0CARETS CIOARET! CIOARETt MoAaffty ntloa for MW tavs.s of d.aHM by numb.r Of dpr.tb0 smoW daRy .A tlen Of Mrolbn.nt k1 atuNdy."" 19CIGARETTE SMOKING AND CANCER. U.S. Government Printing Office, Washington, D. C. PHS Publication No. 1103, Pages 9-10. -17-

Deaths: Due to Lung Cancer "Chart 3 shows the number of men per 1000 who will die of lung cancer increases with the amount smoked. 20 100 90 80 70 60 50 40 30 20 10 0 LESS ONE PACKS PER DAY a.. r r 6- » . NONE Chart 3. '-z OR I TO OVER ONE 20 205. J. Cutler and D. B. Loveland, Journal National Cancer Insti- tute, 18:1, 201ff., 1954 -18-

Chart 4 shows that the lunq_cancer rate as reported on death certifi- cates was over ten times higher amonq men with a history of cig- arette smoking than among men who had never smoked. Death rates for cancer of the oral cavity, larynx, pharynx, and esophagus were five times as high for cigarette smokers. Cancer deaths in several other sites were also more frequent among cigarette smokers than among non-smokers; cancer of the bladder was over twice as high for cigarette smokers.21 Chart MORTALITY RATIOS: CANCER DEAfHS L.M 10.73 10.0 .-" 9.0 ~ r ?.o ~ !- 6.0 ~ 9.0 l.coM. P La 1n, Es lharl opt+ 5.06 r"1 m. OOp r 2 4.0 . OtMr CGnifo- ~t~ 3.0 w~/ Soecific ~fK 0 ! SitM 1.11 . l9 1.00 1.23 1.00 1.35 1.00 1.00 1 00 0 1.00 1 0 . . I n d . n n n F] ri n [i [I . o •.o IEVYII OGWT " GICAAET /EVEA OrARLT IEVEA OGRET KYlA GKARE IEYER C16WT f qif[D , Ar01QD lYORlD ]tlOKFD riOKFD lnMED Wartalfb nHo~ fa .kes d cunar for dprrtb snwk.n omnpsre0 ts m.e ~ ho n.W a+w" 21CIGARETTE SMOKING AND CANCER. US Government Printing Office Washington, D. C., PHS Publication No. 1103, Page 12. -t9-

2. Chronic Bronchitis and Emphysema "To best understand what the diseases called 'chronic bronchitis' and 'emphysema' are, and probably more important, to understand the relationship of cigarette smoking to them, we must first become a ittle familiar with the structure and function of the lungs." 21 "Imagine if you will, the lungs as a cherry tree tipped upside down. The windpipe or trachea, is the trunk; the bronchi that divide in the lungs are much the same as larger branches. The bronchi branch out, and finally terminate in small bronchioles, which would be the equivalent of the twigs on the cherry tree. The che~rieswould be loosely comparable to the tiny air sacs of the lungs, called 'alveoli'. The trunk, branches, and twigs of the lung serve to transport air in and out of the lungs, but it is only in the alveoli that oxygen enters the blood,and that the waste product of the body, carbon dioxide, is passed off. The alveoli are formed by a delicate membrane of fragile flat cells and capillaries. The lungs have over 750 million alveoli. It has been estimated that if these could be opened up and spread out, the total exposed membrane of one person would be enough to cover a full-sized doubles tennis court. "The body is well designed to protect this delicate structure. Inhaled air is moistened, cleaned, and warmed in the nasal pas- sages. A unique cleansing system collects debris, including bacteria, dust, and other foreign matter and propels it out of the body. This system is activated by the respiratory cilia. These consist of countless numbers of microscopic hair-like structures, which line almost all of the respiratory passageways except the walls of the air sacs. "The cilia beat in unison at a very rapid rate, and move the thin mucous blanket which normally covers the bronchi, up and out of the lungs much in the manner of a conveyor belt. The mucous is sticky and catches bacteria, dust, and soot, transporting it up the windpipe to the throat, where it is swallowed or coughed out and passed out of the body. White blood cells catch bacteria and other tiny particles in the air sacs, and they are often caught up by the mucous and similarly disposed of. This is a major part of the self-cleansing mechanism of the lungs. If it does not function properly, not only bacteria but irritating particles can accumulate in the lungs with disastrous results. 22CONFERENCE REPORT, OREGON'S FIRST SMOKING & HEALTH INSTI- TUTE, Sponsored by Oregon_Interagency Committee on Smoking and Health, Oregon State Board of Health, 1400 S.W. 5th Avenue, Port- land, Oregon 97201, Page 9. -20-

ti ti r "The relationship of cigarette smoking to lung disease, has to do, in part, with these matters. Recent studies have convincingly shown that cigarette smoking'very often cripples the cleansing mechanism--the cilia. One or two cigarettes can have an anesthetic effect - that is, the cilia stop beating. That is temporary and of little consequence. However, long term exposure to cigarette smoke appears to destroy the cilia. The body attempts to protect itself against the irritation of the smoke by building a thicker lining membrane. This is similar to the formation of a callous on the hands or feet. However, such tissue has no useful function in the lung. The self-cleansing mechanism is destroyed since the new tough cells have no cilia. This process is shown in Figures 2, 3, and 4. All Figure 2. Normal Respiratory F- o;,~a j;-- - Membrane Figure 3. Development of Hyperplastic Tissue Figure 4. Loss of Cilia which are Replaced by Tough Squamous Cells CILIA COLUMNAR CELLS GOBLET CELLS BASAL CELLS BASEMENT MEMBRANE CONNECTIVE TISSUE SQUAMOUS CELLS BASEMENT MEMBRANE ~ ~ -21- TV CONNECTIVE TISSUE

"In order to remove debris from the lung after the cilia are d estroyed and replaced by tough squamous cells, the body resorts to cough. Mucous is secreted in greater amounts due to the irritation of smoke. This also has to be removed by cough, and may obstruct the small air passages, leading to bacterial infec- tion. "We have discussed two ways in which the lungs attempt to defend themselves against chronic irritation - but these are not normal, and can be the eventual cause of more trouble - chronic cough and excessive production of mucous. In fact, we label these the chief symptoms of the disease chronic bronchitis. This is not to be confused with the cough and mucous that often follow a cold. These soon disappear and the body returns to normal. Chronic bronchitis, on the other hand, persists for years and eventually causes scarring of the entire air passageway system."23 A very few minutes without oxygen results in death. When cells fail to get enough oxygen to burn their food, muscles weaken and finally become paralyzed, the brain falters, the mind loses con- sciousness, the heart stops beating. One can't help but be im- pressed with the very great importance of adequate oxygen to our welfare. During peaks of physical exercise respiration and circulation are used to their absolute capacity with the•exerciser gasping for breath and the heart beating rapidly. The amount of physical exercise possible before reaching capacity depends on many factors which are adversely affected by smoking. Emphysema - The disease, emphysema, is usually accompanied by chronic bronchitis, though on occasion it may be present indepen- dently, just as chronic bronchitis is not necessarily accompanied by emphysema. The chief and most important symptom of emphysema is shortness of breath on exertion. This may be mild or severe. It is often progressive, leading to increasing disability, which may last for years and terminate finally in death from respira- tory or cardiac failure. Emphysema is a degenerative disease. The.lungs are enlarged due to overinflation. They lose their normal elasticity and resist compression. The usual elastic recoil which accompanies expira- tion is missing. These fa6tors make it difficult or impossible for the patient to breathe a sufficient amount of air to care for his physiological needs. 23'CONFERENCE REP.ORT, OREGON'S FIRST SMOKING AND HEALTH INSTITUTE, Sponsored by Oregon Interagency Committee on Smoking and Health, Oregon State Board of Health, 1400 S.W. 5th Avenue, Portland, Oregon 97201, pp. 9-10. -22-

Along with the overdistension and loss of elasticity of the lungs, there are serious degenerative changes in the internal lung structure. The delicate membrane forming the walls of the air sacs (alveoli) is largely destroyed and the spaces occupied by many alveoli coalesce into fewer and larger spaces. There is a consequent reduction of total alveolar membrane in which the essential exchange of oxygen and carbon dioxide must take place. While the deaths from emphsema are fewer than from lung cancer, the more serious side of this disease is the reduction and loss of work capacity due to shortness of breath. Life becomes a burden when one cannot walk up a flight of stairs or becomes breathless in taking a bath or dressing. Physicians specializing in lung diseases have long noted that among patients disabled by or dying from emphysema, a non-smoker is a rarity. Most emphysematous patients have a long history of inhaling cigarette smoke. Even when faced with this crippling disease, they will often decline to quit the habit. Recently Dr. Oscar Auerbach, a noted pathologist, has demonstrated in statistical terms the actual changes observed in lung tissue obtained from smokers and non-smokers. Three types of change were noted: rupture and loss of alveolar membrane, scar tissue formation, and thickening of blood vessel walls. All three of these changes occurred far oftener in smokers than in non-smokers --and more severly in heavy (2 pack) smokers than in light smokers The importance of cigarette smoking as a cause of disease is much greater ~5an that of atmospheric pollution or occupational ex- posure. B. Smoking and the Heart and Blood Vessels "Studies of large groups of people have shown that cigarette smokers in particular are more prone to die early of certain cardiovascular disorders than non-smoke~s26 Chief among these disorders is cor.onary artery disease... 24McGRADY, PAT, "Cigarettes and Health", Public Affairs Pamphlet No. 220A, Pages 10,11. 25SMOKING AND HEALTH, Reprot of the Advisory Committee to the Surgeon General of the Public Health Service, U.S. Department of Health, Education, and Welfare, Public Health Service, Page 302. 26SMOKING AND HEALTH, Report of the Advisory Committee to the Surgeon General of the Public Health Service, U.S. Department of Health, Education, and Welfare, Public Health Service, Page 317. 24 -23-

The mortality ratio for coronary heart disease among cigarette smokers (1.7) is much lower than the mortality ratio (10.8) for lung cancer. However, the total number of premature deaths from coronary heart disease is much greater (660,000) than the number of deaths from lung cancer (39,000). In seven studies, reviewed in Smoking and Health, 27 it was found that heart dis- ease among cigarette smokers represented from 32.9 to 51.7 per- cent of all excess deaths. It is therefore obvious that cigarette smoking is related to a very large number of deaths from cardio- vascular disorders. It has long been recognized that certain diseases of the blood vessels of the extremities are much aggravated by smoking. The hands and feet are mostly skin and bone. Nicotine sharply re- duces blood flow through these areas, thus further impairing their nutrition. A particular type of disease of larger blood vessels, Buerger's Disease, has been ascribed almost exclusively to tobacco since it rarely occurs in non-smokers. Buerger's Disease involves a loss of the blood circulation in- fingers and toes sufficient to cause the tissues to die for lack of blood and ultimately leads to amputation due to gangrene. Smokers having the disease first notice frequent chills and cold extremities. (This is relieved by ceasing to smoke. A return to smoking aggravates the conditions.) The heart is the "most wonderful pump in the world (and) does an astonishing piece of work. It pushes the body's 12.5 pounds of blood or about 12 gallons through the body every~825-30 seconds. This amounts to more than 17 tons in 24 hours. That's more than enough to fill a big tank truck. The only rest the heart gets is that time between heart beats. This means when it beats faster, there is less time between beats for rest. It automatically beats faster to carry an extra load of physical exercise, smoking, illness, or excitement. At least three dif- ferent constituents of tobacco smoke cause the heart to beat faster, thereby depriving it of rest; they are: C02 which causes the respiratory system to work faster in physical exercise to prevent too much C02 from accumulating in the blood. 27 IBID 28 Lawrence, T.G., Clemensen, J.S., & Burnett, R.W. Your Health and Safety, Harcourt, Brace and World Science Program, New York, P. 121. -24-

Hydrogen cyanide (HCN), a very poisonous substance which prevents cells from using oxygen and makes the respiratory system work faster. Nicotine, which in low concentrations is a stimulant. Of course, one who has smoked for many years, and has emphysema, bronchitis, high blood pressure, coronary heart disease, or one of the many other diseases associated with smoking would have a faster than normal heart beat usually. One can easily understand why coaches don't permit their athletes to smoke. A smoker starts his competition with a tired heart because it hasn't had enough time to rest. At ten beats per minute increase, (one cigarette can speed the heart from 20-50 extra beats per minute) the smokers heart beats 4,000,000 more times in 20 years than it would if he didn't smoke. C. Smoking and the Body in General Seventy milligrams (1/400 of an ounce) of nicotine, if taken at one time, will kill a person of average weight. The nicotine content absorbed from one cigarette is about 2.5 milligrams. 29 "The actions of nicotine in humans are highly complex. In the muscle of the heart and adjacent to blood vessels throughout the body are specialized structures known as chromaffin cells. These cells manufacture adrenalin, which is discharged by nicotine. The adrenalin stimulates the heart to beat faster and harder. Larger quantities of blood are pumped per unit time and the blood pressure is raised." 3'0 To the beginning smoker, nicotine causes nausea and vomiting, probably resulting from the indirect stimulant effect upon the central nervous system. Nicotine first stimulates the nervous system then depresses and paralyzes it. It inhibits cell division. (When nicotine is given to mice at certain stages of pregnancy, their litters either die immediately or develop malformations, usually of the skeletal system.) 29McGRADY, PAT, "Cigarettes & Health", Public Affairs Pam- phlet, #220A, p. 14. 30 CONFERENCE REPORT, OREGON'S FIRST SMOKING AND HEALTH INSTITUTE, Sponsored by Oregon Interagency Committee on Smoking and Health, Oregon State Baord of Health, 1400 S.W. 5th Avenue, Portland, Oregon 97201, Page 6. -25 -

Smoking reduces appetite, aggravates peptic ulcers and other stomach disorders, dulls the senses of taste and smell, reduces one's wind capacity and endJrance, and when nicotine i absorbed in excessive amount, depresses rather than stimulates.~l Cancer of the urinary tract and of the bladder, and tobacco amblyopia (a rare form of blindness affecting smokers) are other disorders in which tobacco smoking plays an important role. Cigar smoking is related to cancer of the larynx and pipe smoking to cancer of the mouth especially the lip. "Five retrospective studies and two prospective studies have shown an association between maternal smoking during pregnancy and birth weight of the infant. Women smoking during pregnancy have babies of lower birth weight than (do) non-smokers of the same social class. They also have a significantly greater number of premature deliveries...than the non-smoking controls." 32 Life insurance companies are beginning to provide differential premiums to non-smokers. The list of such companies is increasing. As soon as ways have been developed to determine for sure that individuals do not smoke, all companies will probably be forced by competition to offer insurance for lower rates to non-smokers. Four companies which at present offer better rates are: The Executive Life Insurance Company (California), The Fortune National Insurance Company (Wisconsin), The Great American of Dallas (Texas), and State Mutual of America (Massachusetts). 31SMOKING AND THE PUBLIC INTEREST•, The Consumers Union Report on, Page 90. 32SMOKING AND HEALTH, Report of the Advisory Committee to the Surgeon General of the Public Health Service, U.S. Dept. of Health, Education, and Welfare, Public Health Service, Page 343• -26-

D. Conclusion Cigarette smoking adversely affects the body. Tars are deposited on the walls of bronchi and alveoli, and may eventually cause a change in cell structure that results in cancer, chronic bronchitis, and emphysema. Absorbed materials, particularly nicotine, are carried throughout the body by the blood stream and produce other effects. It has been shown statistically that cigarette smoking shortens life from a variety of causes--cancer, emphysema, bronchitis, heart disease, and others. (See Table 3.) TABLE 3. EXPECTED AND OBSERVED DEATHS FOR SMOKERS OF CIGARETTES ONLY AND MORTALITY RATIOS IN SEVEN PROSPECTIVE STUDIES i Underlying cause of death Expected deaths Observed deaths Mp•tality ratio Cancer of lung (162-3) 2 1 1.8-3'3 _~0~ Bronchitis and em hysema (502,521.1) 89.5 546 6.1 Cancer of larynx f}61) 14.0 75 5.4 oral cancer (140-8) 37.0 152 4.1 Cancer of esophagus (150) 33.7 113 3.4 Stomach and duodenal ulcers (540.541) 105.1 294 2.8 Other circulatory qi eases (451-68) 254.0 649 2.6 Cirrhosis 'of liver ~581) 169.2 379 2.2 Cancer of bladder (181) Coronary artery disease (420) 111.6 6,430.7 216 11.177 1.9 1.7 Other heart diseases (421T2, 430j4) 526.0 888 f.7 Hypertensive heart (440-3 409.2 631 1.5 General arteriosclerosis 450) 210.7 310 1.5 Cancer of ki3dney (180) 79.0 120 1.5 All causes 15,653.9 23,223 1.68 33CONFERENCE REPORT, OREGON'S FIRST SMOKING & HEALTH INSTITUTE, Sponsored by Oregon Interagency Committee on Smoking & Health, Oregon State Board of Health, 1400 S.W. - 5th Avenue, Portland, Oregon 97201, Pages 6,7. -27 -

Numerous carefully designed and well documented statistical studies indicate a positive correlation between increased mortality rates and cigarette consumption. (It is estimated that each cigarette smoked shortens one's live by 14 minutes, or about 71 days per year for the one-pack-a-day smoker.34 FIGURE 5. DEATH FROM ALL CAUSES 180 160 140 120 100 80 60r 40 NEYER LAPSED CIGAR (20 20 20 PIPE ...CIGARETTES SMOKING STATUS " Against this overwhelming burden of evidence, the tobacco industry has presented only one statistical study of a significant number of persons which purports to prove that there is no relationship between tobacco- smoking and cancer. This study covered 45,455 person-years of exposure among employees of the American Tobacco Company over a four-year period (they do not say how many employees). They say they found the death rate from cancer of the trachea, bronchus, and lung to be the same as that expected for the population as a whole, although the percentage of regular smokers was said to be higher by about 50 percent for both men and women than among the population as a whole. If evidence with this scanty type of documentation were produced by any other group, it would be entirely discounted by the statistical experts who have criticized the findings presented above on purely technical grounds.35 34Marten, The Honourable Eric, Minister of Health Services and Hospital Insurance, on behalf of the Province of British Columbia, "Statement on Smoking and Health", November 1963, Page 2. 35SMOKING DEMONSTRATION PROJECT, American Cancer Society, Conn. Division, Inc., 1044 Chapel Street., New Haven, Conn., 1963, pp 16,17. *CONFERENCE REPORT, OREGON'S FIRST SMOKING & HEALTH INSTITUTE,. Sponsored by Oregon Interagency Committee on Smoking and Health, Oregon State Board of Health, 1400 S.W. 5th Avenue, Portland, Oregon, 97201, Page 7. -28-

V. PSYCHOLOGICAL ASPECTS OF SMOKING A. Why People Smoke Tobacco smoking, especially cigarettes, is habit forming to the fullest degree for most people. Its grasp upon many individuals is very great--it is called by some, an addiction. People trying to stop find their will power is often too weak to overcome the with- drawal symptoms. Smoking, the diseases it causes and aggravates, plus premature death associated with smoking are all self-inflicted. People are not compelled by law nor by initial physical need to smoke. The over-all effect of smoking has not been found to be beneficial-- either physically or psychologically, although there are arguments about the psychic aspect of it. (The Surgeon General's Report does recognize the possibility of beneficial effects in the area of mental health.)3b With all of these known facts, why do people begin to smoke? Many different reasons are given: 1. Striving for adolescent maturity 2. Identification with smoking parents 3. Reactivation of infantile needs 4. Striving for peer approval 5. A few parents approve smoking 6. Rebellion against parents 7. Curiosity 8. Sociability37 "Smoking appears to be not one behavior, but a range of psychologically diverse behaviors each of which may be induced by a different combina- tion of factors and may serve different needs. Therefore, no single explanation can suffice. "Social stimulation appears to play a major role in a young person's early and first experiments with smoking. "There is suggestive evidence that early smoking may be linked with self-esteem and status needs although the nature of this linkage is open to difficult interpretations. 36SMOKING AND HEALTH, Report of the Advisory Committee to the Surgeon General of the Public Health Service, U.S. Dept. of Health, Education and Welfare, Public Health Service, Page 345. 37YOUTH SMOKING & HEALTH ADVISORY COMMITTEE MINUTES, April 18, 1964. -29-

Scientific evidence fails to support the popular hypothesis that smoking among adolescents is an important expression of rebellion against authority. 41 Many smokers state that they smoke "to reduce nervousness," to counteract tension and for support "when under stress or strain ". The committee which prepared Smoking and Health for the Surgeon General agrees that, "Stress seems to be related to smoking as it does to a score of other habits. There is some evidence that the experience of stressful situa- tions contributes to the beginning of the habit, to its continuation, and to the number of cigarettes consumed."42 It appears that there is no single cause or explanation of smoking but that smokers may start, continue, or stop smoking in Fesponse to inner (psychological) needs and external (social) influences. The evidence that cigarette smoking constitutes a major health hazard is overwhelming and has received widespread publicity. Yet, smokers continue to indulge in the habit. Why? Today,there are many who began smoking before the case against tobacco was documented by the present monumental accumulation of statistical, experimental, and clinical evidence. The social pressures, supported by massive and continuous advertising, led many into what they hoped was a harmless social practice. Now, the smoker finds himself a victim of almost overwhelming psychological dependence (habituation) on tobacco often augmented by physical dependence (addiction) on the nicotine in tobacco smoke. It becomes easy, almost necessary, to find ways "to rationalize themselves into some secure spot where they are the exception to the statistical rule..."43 We all like to believe, "It can't happen to me." However, a detailed study of the Surgeon General's Report "would reveal very little that is truly reassuring for the heavy smoker since one or another of the seven studies spreads its statistical umbrella to indict heavy smokers, light smokers, members of all age groups, ethnic groups, foreign and native born, both sexes, those who inbaled and those who did not until, indeed, there was no place to hide." 44 41SMOKING AND HEALTH, Report of the Advisory Committee to the Surgeon General, of the Public Health Service, U.S. Dept. of Health, Education, and Welfare, Public Health Service, Page 376. 42lbid., Page 373 43TEACHING ABOUT SMOKING AND HEALTH, State of Illinois, Office of the Supt. of Public Instruction & Dept. of Public Health, 1964., p. 44. 44Ibid. 30

The confirmed (habitual) smoker continues with excuses: "I'm too old to quit now. It isn't worth it to qu'it." Here again the evidence indicates otherwise. Mortality rates for ex-smokers are consistently lower than for smokers. (They are, however, still consistently higher than the death rates for those who have never smoked.) The data in Table "4" suggest that any smoker who can stop smoking may add years to his life. TABLE 4.-1'do'rtality ratios for ex•smol:ers and current smokers of cigarettes British doctors i Men in 9 Stotcs U. vetor S. ~ ans i Canadian veterans ~ Vien in St&tc 2S s E c•ciFOrcttcs .............................. 1.04 1.40 1.41 I 1.42 1.50 Current ciForettcs ......................... 1.44 1.70 1. 79 1.65 1.53 Ec-ciaarettrs nnd othcr .................... 1. 21 1. 29 1. 21 1.18 1.51 Current cigarettea ond othcr ............... I 1.05 1.43 I 1. 48 1. 23 1.54 "GET ME OUT OF HERE:" 45SMOKING AND HEALTH, Report of the Advisory Committee to the Surgeon General of the Public Health Service, U.S. Department of Health, Education,and Welfare, Public Health Service, Page 93. 31

B. Is Smoking an Addiction or an Habituation? The World Health Organization Expert Committee on Drugs. ... 38 created the following definitions (of addiction and habituation) which are accepted throughout the world: "Drug Addiction "Drug addiction is a state of periodic or chronic intoxication produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include: "l. An overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; "2. A tendency to increase the dose; "3. A psychic (psychological) and generally a physical dependence on the effects of the drug; "4. Detrimental effect on the individual and on society. "Drug Habituation "Drug habituation (habit) is a condition resulting from the repeated consumption of a drug. Its characteristics include: A desire (but not a compulsion to continue taking the drug for the sense of improved well-being which it engenders; "2. Little or no tendency to increase the dose; Some degree of psychic dependence on the effect of the drug, but absence of physical dependence and hence of an abstinence syndrome; "4. Detrimental effects, if any, primarily on the individual." 38SMOKING AND HEALTH, Report of the Advisory Committee to the Surgeon General of the Public Health Service, U.S. Dept. of Health, Education, and Welfare., Page 351. 32

"Thus the tobacco habit should be characterized as an habituation rather than an addiction, in conformity with accepted World Health Organization definitions, since once established there is little tendency to increase the dose; psychic but not physical dependence is developed; and the detrimental effects are primarily on the individual rather than society. No characteristic abstinence syndrome is developed upon withdrawal."39 However, "...correctly designating the chronic use of tobacco as habituation rather than addiction carries with it no implication that the habit may be broken easily."40 Despite this explanation many physicians feel that smoking can be an addiction. HE JUST THINKS HE'S SAFE. 39SMOKING AND HEALTH, Report of the Advisory Committee to the Surgeon General of the Public Health Service, U.S. Dept. of Health, Education, and Welfare, Page 354. 4olbid, Page 351. 33

VI. ADVERTISING "Consumer's Guide", May 1965, page 226 quotes the following statement about cigarette advertising: "I firmly believe that future generations will view cigarette advertising with the same uncompromising horror that we apply to slave labor, slavery, or the burning of witches. Certainly smoking has already killed more people than these three practices put together." This is from a letter to the Economist. If this is really true perhaps we should devote time toward a better understanding of how advertising affects us as individuals. First of all let's admit that it doesn't affect everyone the same. Second we should guess from the fact that tobacco firms spend in excess of $250,000,000 per year on advertising that advertising does motivate many of about 5000 more teen-agers to become interested in smoking each day. Let's explore how advertising preys on the mind to influence our attitudes and actions. We laugh and joke about the frequently repeated advertisments always inferring that a man is a he-man, a woman beautiful, that smokers are wealthy, happy, attractive, influential, popular, and whatever is desirable. We each think that this oft repeated stimulus has no effect on us. Its repetition doesn't usually irritate or offend. Ask the man who smokes if he smokes toappear masculine. He will deny it emphatically, but let's examine the facts. Research conducted at Harvard indicates that feminine men are more likely to smoke and also more likely to smoke excessively. In fact the more feminine they are the more they smoke. The laboratory will help understand some of the mechanisms involved in making these feminine men feel masculine if th ey smoke,in fact in making all of us think of the smoker in ways calculated and engineered to sell cigarettes. It's sort of like hypnotism in which we are unconsciously mesmeritized into thinking what the suggestor wants us to think. In the laboratory if we take an isolated frog muscle which still has the nerve attached we can cause the muscle to contract by stimulating the nerve with a small known charge of electricity. This contraction•can be measured by attaching the muscle to levers which register on a revolving drum. By continually decreasing the amount of electricity in each stimulus to the nerve at 30 second intervals, we finally reach a point where a shock or charge will not stimulate the muscle to contract. -34-

Now if we increase the frequency, give this same otherwise ineffective shock as rapidly as we can, there is a summation effect an d the muscle does contract. Thisineffective shock is known as a subliminal stimulus. The small stimulus alone at widely spaced intervals cannot cause the muscle to contract, but if given repeatedly at short enough intervals it can cause contraction. Advertisers also talk about and use this subliminal approach in their advertising. They give us subliminal stimuli that we laugh and joke at, but unconsciously we are all affected. Look,for example, at the hesita- tion our legislators have to pick on the industry, the feminine male smoker, the fact that poor people smoke at a younger age and more frequently, and the unsuccessful "drop out" in school. Who does smoke? There are many people who smoke who don't really know why they smoke. As a rule, the reasons given by advertisers are just good reasons to the gullible, but if we listen to, read, and watch tobacco advertisements we are more likely to experience the summation effect and subconsciously believe. IF YOU SMOKE, STOP! IF YOU DON'T SMOKE, DON'T START! -35 -

VII. SOCIOLOGICAL ASPECTS Coping with the problem of smoking will become easier as we achieve greater understanding of the one who smokes. Investigators have tried to discover demographic variables (age, sex, socio-economic level) which distinguish the smoker from the non-smoker. "As far as is known from actual data, few children smoke before the age of 12, probably less than five percent of the boys and less than one percent of the girls. From age 12 on, however, there is a farily regular increase in the prevalence of smoking. At the 12th grade level, between 40 to 55 percent of children have been found to be smokers. By age 25, estimates of smoking prevalence run as high as 60 percent of the men and 36 percent of the women. There is a further increase up to 35 and 40 years after which a drop is observed. In the 65 and over age group, prevalence of smoking is only approximately 20 percent among men and four percent among women. .................................. ".. there is rather consistent evidence that smoking patterns are related to socio-economic level in that the lowe~_or working classes contain both more smokers and earlier starters.'4b" Characteristics More Prominent Among Smokers than Non-Smokers 1. A higher percent of smokers live in cities rather than in the country. 2. A higher percent are veterans rather than non-veterans. 3. A higher percent are laborers, craftsmen, salesman, and entertainers rather than professionals. 4. A higher percent are residentially mobile, rather than residentially permanent.47,48 ~'SMOKING AND HEALTH, Report of the Advisory Committee to the Surgeon General of the Public Health Service, U.S. Dept. of Health, Education, and Welfare, Public Health Service, Pages 361-362. 47Haenzel, W., Shimkin, M.D., & Miller, H.P., "Tobacco Smoking Patterns in the United States, Public Health Monograph, 1956, #45. 48Lilienfeld, A.M., "Emotional and Other Selected Characteristics of Cigarette Smokers, and Non-Smokers as Related to Epidemiological Studies of Lung Cancer and Other Disease", JOURNAL OF NATIONAL CANCER INSTITUTE, pp. 259-282, 1959, #22. -36-

5. A higher percent are children of lower parents.49 class, rather than upper class 6. A higher percent have smoking parents. If one parent smokes, 25 percent of the children smoke. If two parents smoke, 33 percent of the children smoke.50 7. A higher percent have fallen behind their age-equals, do not partici- pate in extracurricular activities and are taking scholastically less demanding school work.51 8. A higher percent are effeminate men.52 9. A higher percent have lower quitting rates. Social groups with low smoking rates (professionals, farmers, and older people) are likely to quit smoking sooner than those with high smoking rates. "No smoker personality has been established but certain personality factors have been reported to be associated with smoking, among them extro-version, neuroticism, and disproportionate prevalence of psycho- somatic manifestations."53 49Horn, D., "Behavorial Aspects of Cigarette Smoking", JOURNAL OF Chronic Disease, Pages 383-395, May 1963, Volume 16. 50GILBERT YOUTH SURVEYS: A Research Study Conducted Among Young People for the American Cancer Society, New York, 1959. 51Horn, D., Courts, F.A., Taylor, R.M. and Solomon, E.S., CIGARETTE SMOKING AMONG YOUNG PEOPLE, for the American Cancer Society, New York 1959. 52 McGrady, Pat, CIGARETTES AND HEALTH, Public Affairs Pamphlet, #220-A, Page 16. 53SMOKING AND HEALTH, Report of the Advisory Committee to the Surgeon General of the Public Health Service, U.S. Dept. of Health, Education, and Welfare, Public Health Service, Page 376. -37- - u,..•_ 7_,*•-r, ,.. ."•...-c-r.,-,p..,

ANIMAL EXPERIMENT

50328 8099 ( ) !-RU Tr/ DON'T BE GULLIBLE, LEARN THE TRUTH.