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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- - , ,

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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- . ,. _ , . . . . ~ , .~«.