Tobacco Documents Online

j I A ~ ~ C~ AN.C.EL 19mly- NEWS ~ SERVICE 219 EAST 42nd STREET ~ NEW YORK, N. Y. 10017 1 MURRAY HILL 6•4300 -+~ - lY 4, January 7, 1964 TO THE CITY EDITOR: Attached is a compilation of the history of "The Position of the American Cancer Society Regarding Tobacco and Lung Cancer". Your writers may find this useful as a background and for feature material in connection with the issuance of the forthcoming report of the Surgeon General. MAR 3 0 1981

T HE POSITION OF THE AMERICAN CANCER SOCIETY REGARDING TOBACCO AND LUNG CANCER As early as 1936, Dr. Alton Ochsner, former President and now an honorary Life Member of the American Cancer Society, called attention to the growing increase in lung cancer. The distinguished surgeon from New Orleans speculated that cigarettes might be the major cause of the dramatic increase in lung cancer noted in his surgical experience. He observed that most of his lung cancer patients were cigarette smokers. Since that time, Dr. Ochsner has been a strong advocate of realistic research action on the possible link between cigarAttes 'and lung cancer. From the time he became a member of the National Board of Directors of the Society in 1941, he became an advocate of a thorough study of 'thP alarming inci^ease in lung cancer that he had observed in his practice of surgery. Dr. Ochsner was not alone in his suspicion about cigarettes and lung cancer. In 1944, Dr. Clarence C. Little, then Managing Director of the American Cancer Society, wrote in a pamphlet entitled, "Cancer, A Study for Laymen:" "Although no definite evidence exists concerning the relation between the use of tobacco and the incidence of lung cancer, it would seem unwise to fill the lungs repeatedly with a suspension of fine particles of tobacco prbduct of which smoke consists. It is difficult to see how such particles can be prevented f rom becominp lodged in the walls of the lungs and when so located how they can avoid producinP a certain amount of 1/7/64

-2- irritation. One might also question the ultimate results of continued inhalation of the type of atmosphere which characterizes the lower levels of city streets. Experimental work with animals involving these matters is still inconclusive but it seems probable that the lung as an organ is not immune of the effects of chronic irritation and it will in this respect resemble the other organs of the body. Such being the case, wisdom in avoiding unnecessary lung irritation seems to be established." Dr. Little is now Scientific Director of the Tobacco Industry Research Committee. The American Cancer Society became increasingly concerned about the alarming increase in death rates from lung cancer in- ],949, when Dr. E. Cuyler Hammond, Director of the Statistical Research Section of the Society, made a study of "trends in cancer mortality." He reported to the Cancer Prevention Committee of the Society: "The lung-bronchus category is the only site category which has shown a steady and tremeridous increase in age-corrected death rates f rom 1933 to the present time." He pointed out that in 1948 in the U.S., cancer of the lung and the bronchus caused 12,891 male deaths and 3,440 female deaths compared with some 2,000 male deaths and 1,000 female deaths in 1933, and that "only a relatively small proportion of the incrPase can be attributed to the growth and the aging of our population, and it is hard to relievP that it can bP attributed entirely to tn ~ ;~. .~ improvemnnt In diapnosis."

It was noted that the increase in cancer of the lung had occurred in all sections of the U.S. and in most other countries from which reliable statistics were abailable. "Therefore," Dr. Hammond's report said, "it may be assumed that it is due to some factor or factors operating over wide areas_and in very different types of communities." Furthermore, the report added, "it would seem to be a reasonable hypothesis that there.has been a corresponding increase in one or more of the major factors, at present unknown, which are responsible for lung cancer. "If it is discovered that lung cancer is indeed caused by some carcinogenic substance or substances of widespread and increasing use ... there.is reason to hope that we may be able to control the disease by eliminating the cause." Dr. Hammond's 191+9 report strbngly recommended that the Cancer Prevention Committee of the Society and other groups "give high priority to the problem of cancer of the lung." The Hammond report did not suggest cigarette smoking as a possible factor, but as a result.of it, the American Cancer Society's concern in pinpointing the factor began. Out of it the cigarette-lung cancer link emerged. One of the first actions taken by the Society was a grant to Washington University, St. Louis, Missouri, for a study on cigarette smoking as an etilogic factor in lung cancer. The late Dr. Evarts A. Graham and Dr. Ernest L. Wynder (who is « ~ ~ ~ ~,.~

-4- presently associated with Sloan-Kettering Institute, New York) began studying the smoking habits of lunP cancer patients. The Society continued to make grants to the team and by 1953 Graham and Wynder reported that they had produced skin cancer in mice by the application of cigarette smoke concentrate. On October 26, 1951, the Board of Directors of the American Cancer Society directed "that a field study on smoking in relation to cancer of the lung be approved and the necessary funds be made available." This was the beginning of the American Cancer Society -- Drs. Hammond and Daniel Horn study which linked cigarettes to lung cancer. The'Society undertook this study without any preconceived conviction that cigarette smoking might be the major cause of the increase in lung cancer. The Hammond-Horn study diff Pred from others in that it was prospective. It looked forward instead of backward, studying people as they lived and died. Even before Drs. Hammond and Horn were ready to report their first evidence linking cigarettes to lung cancer, significant facts had developed abroad. Drs. Doll-and Hill had concluded f rom a study of physicians in England that there was an association between cigarette smoking and the increase in lung cancer. The Hammond-Horn study, begun in November 1951, was one y ~ ~ L_~ ° of the largest ever undertaken in the field of health. It in- ~ volved more than 187,000 men between the ages of 50 and 70 i.n 394 counties in ninP states across the country. Some 22,000 volunteers assnmblAd data on the smoking and non-smoking habits of this vast group of mpn -- men in the age Proup in which lung cancer is

most common. Each year for a period of four years the volunteers checked on the status of the men originally interviewed. When a death occurred in the group interviewed, the cause of death was established through official death certificates, doctors reports, and for some, autopsy findings and biopsy reports. While the study was still underway the American Cancer Society devoted its 1953 Scientific Session to "Cancer of the Lung -- An Evaluation of the Problem." In opening the session, Dr. C harles S. Cameron, then Medical and Scientific Director of the Society, described lung cancer as "a disease that is well on its way toward the proportions of a national epidemic." Scientists participating in the two-day session expressed widely divergent views on the possible relationship between cigarettes and lung cancer. Dr. Hammond, then in the midst of his massive American Cancer Society smoking study, had doubts. He wanted, he said, "very strong-proof indeed before I would be willinR to state as an absolute fact that I know cigarettes to be responsible" for the major increase in lung cancer. The significance of the meeting was that many physicians were made more aware of a possible cigarette-lung cancer link. At the end of two-and-a-half years, the American Cancer Society was ready to make a preliminary report. The report was made by Drs. Hammond and Horn on June 12, 1954, before the American Medical Association's annual convention in San Francisco. Ln ~

On the basis of the deaths that had occurred since the beginning of the study among the more than 187,000 men, the report concluded that among men between the age of 50 and 70, cigarette smokers have a death rate higher than non-smokers of the same age by as much as 75 per cent. While the report made clear that the findings were only preliminary, it said "the authors are of the opinion that the association found between regular cigarette smoking and diseases of the coronary arteries and between smoking and cancer reflect cause-and-effect relationship." The American Cancer Society Hammond-Horn report received front page news•coverage.' Radio and television treated it as important news. Magazines became more actively interested in the possible link between cigarette smoking and lung cancer. The Hammond-Horn revelations were listed as one of the major news events of 195+. Between the Hammond, Graham-Wynder reports in 1949 and 1950, and the preliminary r eport of the American Cancer Society's smokinp study in June 1951+, much evidence had developed to point to cigarette smoking as one of the major factors in lung cancer. Several American Cancer Society sponsored conferences had been held on the problem of lung cancer, including the question of cigarettes as the possible cause of the great increase. In 1952, the American Cancer Society had formed the National LunP Cancer Committee, which stated at its first meeting: "While work should be continued on whether or not smoking is a ma ior cause of lunP cancer, other possible causative agents tn ca ~

must not be overlooked.". It pointed to such inhaled substances as soot, motor fumes, dust from roads, etc. As a spokesman of the Society said, cigarettes in relation to lung cancer had been placed at the scene of the crime but their guilt had yet to be proven. After the Society's preliminary smoking report in 19 !N, its Board of Directors established a fund of S500,000 for the special study of cancer of the lung and cigarettes. Since that time, the Society has spent millions of dollars on research related to smoking and lung cancer. At its annual meeting in October 19~+, the Board of Directors took,its first action on elertinrp the public about thP possible hazards involved in cigarette smoking. The Board resolved "that the American Cancer Society emphasize to the American people that presently availablP evidence indicates an association between smoking, particularly cigarette smoking, and lung cancer, and to a lesser degree, other forms of cancer .... and heart disease." Also in 1954, tthe Third National Lung Cancer Conf erence, voted that "since the presently available evidence indicates an association between.smoking and lung cancer, be it resolved that the American Cancer Society and the U.S. Public Health Service ... devise and pursue public health education and other measiires designed to control the rising incidence of lung cancer, especially as it relates to cigarette smoking."

Meanwhile, other research studies in the U.S. found evidence that cigarette smoking was related to the increase in lung cancer. In June 1955, Dr. Oscar Auerbach, now Senior Medical Investigatorg Veterans Administration Hospital, East Orange, New Jersey, and Associate Prof essor of Pathology, New York Medical College, applied to the American Cancer Society for a research grant to pursue his suggestive biralogic findings of the relationship between cigarette smoking and lung cell changes. His preliminary evidence was based on microscopic examination of human bronchial tubes and lung tissue. As a result the American Cancer Society made a grant to Dr. Auerbach to help continue the study and a research team was formed which included not only Dr. Auerbach, but Dr. Hammond and Lawrence Garfinkel, both'epidemiologists from the Society, and Dr. Arthur Purdy Stout, the distinPuished pathologist of Columbia.Presbyterian Medical Center and formerly Professor of Pathology at Columbia University College of Physicians and*Surgeons. Several reports have been issuPd since on this research, all•adding new evidehce on the'link between cigarette smoking and lung cancer. In 19569 Drs. Hammond and Horn made a second report on the Society's smoking study to the American Medical Association's annual convention in Atlantic City. They concluded that cancer of the lung is a rare disease among men who have never smoked; that lung cancer is an important cause of death among men smoking two or more packs a day; that the death rate from lung cancer increases with the amount of cigarettes smoked, and that evidence indicates that riving up cigarette smoking reduces the risk of lunr cancPr.

The report also linked cigarette smoking to cardio-vascular diseases. Also in 1956, the American Cancer Society, the American Heart Association, the National Cancer Institute and the National Heart Institute ~oined in establishing a Study Group on Smoking and Health, consisting of seven scientists. They were charged with reviewing all of the evidence so far developed on the problem of smoking and health. After months of study, they reported in March 1957: "The sum total of scientific evidence establishes beyond reasonable doubtthat cigarette smoking is a causative factor in the rapidly increasing incidence of human epidermoid carcinoma of the lung and that smoking of tobacco, particularly in the form of cigarettes, is an important health hazard. The implications of this.statement are clear in terms of the need for thorough con- sideration of appropriate control measures ry the official and voluntary agencies concerned with the health of the people." This Study Group report was widely publicized by press, radio and television. The scientists making the report were: Dr. Richard J. Bing, Washington University Medical School, St. Louis, Mo.; Dr. Rolla E. Dyer, Emory University Medical School, Atlanta, Ga.; Dr. Abraham M. Lilienfeld, Roswell Park Memorial Institute, Buffalo, N. Y.; Dr. Norton Nelson, Postgraduate Medical School, New York University, New York City; Dr. Michael B. Shimkin, National Cancer Institute, Bethesda, Md.; Dr. David v ~ M. Spain, Peth-E1 Hospital, Erooklyn, N. Y.; and Dr. Frank M. ~ 1 Strong, University of ':Jisconsin, Madison, Wisc. Dr. Dean F. ,~,

-10- Davies of the American Cancer Soc.iety served as executive secretary of the Group. Drs. Hammond and Horn presented their final r eport on the American Cancer Society's four-year smoking study in June 1957, before the American Medical Association's annual convention in New York City. This paper confirmed findings'in the pre- liminary reports. They pointed out that the annual lung death. rates were ten times as high among regular smokers as among those who never smoked. Among two-pack-a-day cigarette smokers the rate was more than 20 times as high as among non-smok ers. Men who stopped smoking had a lower cancer death rate. Those who once smoked a pack or more a day, but who had given up smoking for at least one year, had a death rate less than half that of those who continUed smoking. Significantly, the U.S. Surgeon General, Dr. Leroy E. Burney, in July 1957, issued a public warning in which he said, "it is clear that there is an increasing and consistent body of evidence that excessive cigarette smoking is one of the causative factors in lunP cancer." The Surgeon General's statement was based on a review of data thus far assembled on cigarette smoking and lung cancer made by the U.S. Public Health Service. "To help disseminate the facts," the Surgeon General said;'"the Public Health Service is sendinp, copies of this statement, the Study Group report and the report of Drs. Hammond and Horn to State Health Officers and to the ArrPrican MPdical Association with the rAqliest that they consider distributinp copies to local health

officers, medical societies and other health groups." Based on the data accumulated by the Society, the Group Study Report and the 1957 U.S. Public Health Service statement, the Society's Board of Directors, at its annual meeting in New York, . in November, 1957, urged all public health agencies to take "such measures" to protect health as might be indicated by present knowledge of cigarettes and lung cancer. Also in 1957, the Board of Directors of the Society established an Ad Hoc Committee on Smoking and Health. Its members were: Dr. Warren H. Cole, of the University of Illinois College of Medicine; Dr. Johri R. Heller, then Director of the National Cancer Institute; Dr. Ochsner; Dr. Ernest L. Stebbins, of Johns Hopkins, Uni'versity; Dr. Howard C. Taylor, Jr., Professor and Chairman of the Department of Obstetrics and -Gynecolopy, Columbia University College of Physicians and Surgeons; Rutherford L. Ellis, Chairman of the Board of Lip'scomb-Ellis Co., Atlanta, Ga.; William B. Lewis, Chairman of the Board of Kenyon & Eckhardt, Inc., New York City; Monroe J. Rathbone, President and Director,of Standard Oil of New Jersey; Dr. Ira DeA. Reid, Professor of SocioloPy, Haverford College, and Frank L. Taylor, Executive Vice President and Di rector of the New York Herald Tribune.' The Society reaffi.rmed the importance of presenting basic findinrs on the link between cigarettes and lung cancer to the nl:b]ic. Thn Board anthorizPd production of suitable educational mntnria] s, inc~liiciing materials designed specifically for hiph school and co11elFp stmdnnts, and authorized a one-year stiid,y of the smoking

-12- habits of teen-agers in the Portland, Oregon, school system • which would involve nearly 22,000 high school students. Action followed. In December of 1957, the Society began distribution of its leaflet, "To Smoke Or Not To Smoke." The leaflet pointed out that "to smoke or not to smoke is a personal decision" and that the purpose of the pamphlet was to give the public "the information available as of today." Among the things the leaflet pointed out.was that "a man who smokes two packs a day has about one chance in ten of developing lung cancer, while a non-smoker has only about one In 270 of having this disease." S1nce,publication of the pamphlet more than five million copies have been distributed. In late 1957, the Society moved "to bring directly to the attention of the physician" evidence in the field of lung cancer and smoking as it develops. As a result, in 1958, the Society released an exhibit for the medical profession entitled "Smoking and Lung Cancer" and devoted an issue of "CA," its journal for physicians, to the problem. Another important development of this period should be noted: the presentation at the Seventh International Cancer Congress in London in 1958 by the late Dr. Harold F. Dorn of the National Institutes of Health of his remarkable prospective study of the smoking habits of 249,000 war veterans holding government life insurance policies. The findings of this impressive piece of research further documented the relation of cigarette consumption to mortality from cancer and other diseases. In 1958, the study of the smoking habits,of high school ~ students in Portland, Oregon, was begun under the direction of " ~ Dr. Daniel Horn. It revealed, when completed in 1959, that whether or not hiPh school students smoke depends to a marked derree on the smokine habits of their parents. His study found thA pnrcentarP of smokers was highest among children In which ~

-13- both parents smoked cigarettes; lowest in families in which neither parent had been a smoker, and intermediate in families in which only one parent smoked cigarettes. A national survey of 4,320 high school students made for the Society by Gilbert Youth Research in 1959 revealed additional information. At the end of June 1959, one high school student in three was a cigarette smoker. Most of these smoked every day. More boys than girls smoke, 38 per cent against 29 per cent. There was a fairly regular increase from 21 per cent at the end of the freshman year to 44 per cent at the end of the senior year. It was found that the years from about the seventh and eighth grades through the senior year in high school are crucial in the' development of the smoking habit. The teen-age studies found that the w hole constellation of family smoking practicesq family attitudes toward smoking, and-student attitudes toward smoking contributes to the develop- ment of smoking by high school students. If parents smoke, children consider smoking a part of growing up. Studies have found that smokinr is high among those who have fallen behind their age equals in school, do not participate in extra-curricular activities, and are taking the scholastically less demandinP course of school work. "This group, a minority in the school Population," Dr. Horn has said, "has apparently not achieved satisfaction from its peer - group relationships ... It may well hQ that in this group smoking is a compensatory form

-14- of behavior, a symptom of other problems of emotional health." This factor accounted for about one-quarter of the smoking in the Portland Study. At its Board meeting in June 1959, the Society was authorized to intensify greatly its program to alert the public to the dangers of cigarette smoking. The Board called for more vigorous efforts to bring to the attention of physicians and the public -- and particularly teen-agers -- facts about cancer and smoking. At the same meeting the Board authorized the Society's massive six-year Cancer Prevention Study, another vital prospective study. This study, under t he direction of Dr. Hammond, involves more than 1,100,000 persons, and while designed to identify any factors that may be related to the development of cancer, it is supplying new information about the relationship between cigarettes and cancer. Like the Hammond-Horn smoking study, the Cancer.Prevention Study involves a year-by-year check of the people involved. In 1959, the Board established the Committee on Tobacco and Cancer to succeed the Ad Hoc Committee which had guided the Board since 1957. Dr. Taylor was named chairman, a position he held until the fall of 1963. The Committee was composed of distinguished physicians and laymPn, including: James M. Brittain, Director of the Philadelphia Suburban Transportation Co.; Dr..Frank W. FootP, Jr., of Memorial Hospital, New York City; :Dti.Heller; : u. ~

-16- "The vast majority of physicians . . . have with respect to this problem claimed the layman's privilege of ignorance. 'We are not cancer researchers or specialists in diseases of the heart or chest.' 'We do not have any opinion because we haven't bothered to study the evldence.4 "This claim to the layman's status provides a comfortable means of avoiding the issue when we advise our patients, and of continuing, by example, to indicate our indifference or contempt for the evidence on the damage being done to public health. Yet, however, hard we try to pose as such, we are not yet laymen in the public image because for most Americans the physician is the final 6ccessible authority on all matters of health. The physician has an obligation to accept -- or to•re-examine if he wishes the facts on the eff ect of smoking upon health and then to act personally and to advise his patients.in accordance with the implication of these facts." The year 1958-59 saw an exchange of opinion between the Board of Directors of the Society and The Tobacco Institute, Inc. James P. Richards, President and Executive Director of The Tobacco 'Institute, Inc., challenged American Cancer Society policy in a letter to Formc;r Governor Walter J. Kohler of Wisconsin, then Chairman of the Board of the. Society. Richards charged that "a few individuals in the Society seem to be concentrating more on the fight against tobacco than on the avowed basic purposes of the Society." To this NPfford r. Runyon, then Executive Vice President of the Society, responded on behalf of the P.oard of Directors: Ur C1 w v ~ lT

-17- "We repeat and emphasize that no evidence of any kind has ever been produced that is inconsistent with the view that excessive cigarette smoking is one of the principal causes of lung cancer; that the great preponderance of scientific - evaluation accepts this conclusion; and that it also accepts the mounting body.of evidence indicting the cigarette as a shortener of life. "Your long communication and the enclosures thereto contain the dissenting views of various scientists who do not accept these conclusions. Some of these quotations are statements out of context which we believe do not fairly r epresent the scientist"b true opinion. Other quotations are from memoranda prepared-by staff members of the Society for the consideration of its committees, and unless and until they are approved by the Board,.they are not Society policy. "Nothing new was presented to change the conclusions of our Board as to the validity of its conclusions reached well over a year ago; of the wisdom and necessity of the actions since then, and of the consistency of these actions with the objectives of the Society in the fight on cancer ... "It is not necessary for every scientist to accept this conclusion nor f or every other possible cause to be excluded before definite public health action is taken. It would cause unnecessary su!'f erinP and death to wait for absolute proof of a relationship betwoen ciParette smoking and lung cancer ... "The futiire coiirsP of action of the Society will be carefully considered and willl bP decided t-y the Foard of Directors. It will

-18- carry out its responsibility to the public as it sees it, based on the premises stated above and subsequent facts as they develop." In November 1.959 Surgeon General Burney made another strong statement on cigarette smoking and lung caneer, which appeared in the Journal of the American Medical Association. It concluded, "The weight of evidence at present implicates smoking as the principal etiological factor in the increased incidence of lung cancer." The year 1960 was a particularly important one in the progress being made in informing the public of the relationship between cigarettes and lung cancer. In January 1960, the Board of Directors of the Society stated that in its judgment "the clinical, epidemiologicalg experimental, chemical and pathological evidence presented by the many studies reported in recent years indicates beyond reasonable doubt that cigarette smoking is the major cause of the unprecedented increase-in lung cancer." At the same timP the Board also stated that "c•igarette smoking is a i5ersonal habit and that the risk involved is at the option of the individual. The Society, nevertheless, believes that it has a responsibility to do everything possible within its established policies to reduce the•alarming and rapidly increasing number of deaths from lung cancer. To that end the Society will continue to support research on lung cancer and to promote the widespread dissemination of information regarding causes and prevention of the disease to physicians and to the public with primary initial emphasis on teen-agPrs." An exhibit developed ty the Society on cigarettes and lunr cancer for the medical profession Pntitled, "Lung Cancer and Prevention," was displayed bPforP the American Medical Association's Annual Meeting in June 1960. It pointed up the nhysician's responsibility and oPnortiinit,y to protect the nation's health in relation to cirarPttes and 1imP cancer. A leaflet

-19- distributed in connection with the exhibit~described cancer as a "preventable disease." Since its original showing, the exhibit has been seen by thousands of physi.cians -- at state and local Medical Society meetings and other professional groups. The American Cancer Society-Horn report in 1959 on the smoking habits of Portland, Oregon, high school sttidents provided basic background for educational materials designed specifically for high school and college students. Almost coincident with the January 1960, meeting of the Board, the Society launched an effective cancer prevention program -- The Teen-Age Program on Cigarettes and, Lung Cancer. It was designed to make facts about cigarettes and lung cancer available to all secondary school students in an effort to discourage starting smoking and encourage giving up smoking. The program included a color-sound filmstrip "To Smoke Or Not To Smoke?", packaged, together with a teacher's guide as a kit. Since then the program has reached extensive proportions and new materials have been added. More than half of the secondary schools in the country have received a teen-age leaflet "Shall I Smoke?" This has now reached a distribution to teen-agers of nearly 8,C00,000 copies. A 16 minute film -- "Is Smoking Worth It?" was added in 1962. In the film, four high school seniors discuss the problem and relate themselves to it. It points up the reasons for r.ivinP up smoking, and the advantages of not starting for those students who have not rep,un to smoke. Since cn i ~

-?C- the beginning of the program, many.productive conf erPnces have been held with educators, public health officials and students on the problem of teen-age smoking and lung cancer. It will be recalled that the Gilbert Youth Research in 1959 found that one in three high school students wPre cigarette smokers. In 1963, Gilbert did another study on the cigarette purchasing and smoking of teen-agers (thirteen to eighteen years of age) for the National Automatic Merchandising Association, national trade group of the vending industry. In response to the question, "Do you smoke cigarettes?" 29 per cent of those questioned answered "yes". In releasing the second study the Gilbert organization pointed out that the incidence of cigarette smoking among teen-agers was lower in 1963. In 1959, it is worth indicating, the trend in teen-age smokine was believed to be upward. , In June 1960, the Board authorized the Executive Vice President to make a "strong" appeal to the Chairman of the Federal Trade Commission "that cigarette companies not only be allowed but also encouraged to publish in their advertising the tar and nicotine content of their products," that the Federal Trade Commission "arrange with other appropriate Government agencies promptly to establish a standard, uniform test for the measurement of t2iese ingredients." (On January 6, 1964, the American Tobacco Company announced the introduction of a new cigarette that will have its tar and nicotine contents prominently on every pack.) At its meeting in January 1960, the Board of Directors of the Society recommended that the Society "in cooperation with other health aPencies move to create a commission of five to seven outstand- ing citizens of the United States to serve as a Proup to lr V a.: ti, 1

-21- evaluate the evidence of the effect of smoking on health and its implications and that they report to the American people." One of the proposals made was that a direct request be made to the President of the United States to set up a "Presidential Commission on Problems Relating to Tobacco." In October of the same year the Board reported that the. American Public Health Association, the American Heart Association, the National Tuberculosis Association, and the National Health Council had been asked to join in requestinR the appointment of a Commission. The Board resolved that the Society should indicate "to any additional,agencies esked to join in initiating*the move for a Commission that we would like to a sk the President to form a Commission on Problems Relating to Tobacco within a reasonable period of time, and that it is the hope of the Society that such requests go to the President by April 1, 1961 ..." A letter signed by four agencies - The American Cancer Society, The American Heart Association, The American Public Health Association, and the National Tuberculosis Association - went to President Kennedy on J une 1, 1961. It'said in part: "In view of the Importance of this health problem,we respectfully request that you appoint a Commission to consider it. On the basis of the wAight of scientific evidence on the relationship of cigarette snoking to cancer, especially cancer of the lung, to cardiovascular diseases and to other debilitating and fatal disc,asPsz we r.Plieve that siieh a Commission should examine the kr ~.

-22- social responsibilities of tusiness, of voluntary agencies, and of government in the education of the youth of America; and should recommend various ways to protect the public, weighing the costs against the benefits to be achieved and seeking a solution of this health problem that would interfere least with the freedom of industry or the happiness of individuals." In 1962, President Kennedy called upon U.S. Surgeon General Luther I. Terry to appoint a committee to study the problem of smoking and health. The action by the President did not come about easily. _To the joint letter from the American Cancer Society, the American Heart Association, National Tuberculosis Association, and the American Public Health Association, the President replied that the problem properly belonged within the responsibilities of the Department of Health, Education and Welfare. A letter was sent to the then Secretary of the Department, Abraham Ribicoff, from the American Cancer Society asking for an opportunity to discuss the President's letter and work out a course of action. Mr. Ribicoff had not replied at the time of the October 1961 Board meeting. As a result the Board moved to make a personal appeal to the Secretary through Boisseuillet Jones, Assistant Secretary for Medical Affairs for the Department, and recommended that if no results could be achieved through pPrsonal contact the "Society proceed with publication in the press of letters to the President and the Secretary of the Department of Health, Education and Ylelfare."

-23- On-January 4, 1962, the Surgeon General invited representatives of agencies concerned to discuss the problem of establishing a Commission on Smoking and Health. After the conference, the Surgeon General indicated that the request of the agencies, urging a Commission be established, would receive careful consideration. At a press conference-in late May, President Kennedy was questioned about government consideration of the problem of cigarettes and health. He promised to give an answer at his next news conf erence, adding that "the matter is sensitive -enough and the stock market is in sufficient difficulty without my giving you an answer which is not based on complete information, which'I don't have . . . m Before the next press conference the President had been briefed by the Public Health Service. On June 7, 1962, a few hours before the Presidential press conference, Dr. Terry announced that he would appoint an advisory committee to study the effects of cigarette smoking on health. At his news con- ference that day, Mr. Kennedy predicted that the study would take some months and would "go into '63." Dr. Terry's announcement said in part: "For a number of years the Public Health Service has supported research to I determine whether smoking has any impact upon health. Consider- able evidence has been accumulated on this sub1Pct from many sources. It is timely to undertake a comprehensive review of all available data. tr Y ~

-24- "I have, therefore, decided to appoint an expert advisory committee to study the evidence, evaluate it, and make whatever recommendations may be appropriate." On October 28, 1962, the Surgeon General• announced the appointment of an Advisory Committee on Smoking and Health to "make a comprehensive review of all available data on smoking and other factors in the environment that may affect health .:. The second phase of the study, which wil]l follow phase one, will concern recommendations for action. No decision on how the second phase is to be conducted will be made until the first phase has been completed." Also,' in October 1960, the Board directed the Society to "actively provide scientific information regarding smoking and health to key personnel in tobacco and advertising industries, legislation, public health and medicine, particularly to those who express themselves in public media of communication." In his address at the Annual Meeting of the Society in 1962, Dr. Thomas Carlile, retiring President, urged the Society "to utilize every means at its command to mobilize concerned physicians into an effective voice to speak with convIction and authority on the relation between smoking and lung cAncer. Studies have shown that more physicians have stopped smoking than any other group, yet patients complain that their doctors do not take a positive stand or give them firm advice one way or another." u> ~

-25- At an earlier Board meeting in June 1962, a proposal for a bulletin to physicians on smoking and health, to be sponsored jointly by the American Cancer Society, the American Heart Association, the National Tuberculosis Association and the American Public Health Association, was considered. The bulletin would be in keeping with the Board of Directors instructions to the Society "to promote the widespread dissemination to physicians of information regarding the - causes and prevention of cancer." The bulletin would publish abstracts of papers on the subject of cigarette smoking and health. The abstracting and inclusion of articles would be ;the,-responsibility of representatives of organizations sponsoring it. The Board approved. The first issue of "Medical Bulletin on Tobacco" appeared in January 1963, and went to 206,000 physicians and others in the health field. Interest was immediate and the second issue went to 2109000 doctors and other interested persons. The Board of Directors at its January.1962, meeting authorized Dr. Taylor, Chairman of the Committee on Tobacco and Cancer, to appoint a subcommittee to draft a "white paper" to American Cancer Society volunteers and to opinion'leaders giving the evidence of the causal relationship betwPen'cigarettes and health. This action resulted in a detailed and definitive _ pamphlet entitled, "CiRarette SmokinP and Cancer -- The Evidence .Upon Which the American Cancer Society's Position and Program are Based," published in April 1963. The booklet, largely edited by

-26 - Dr. Harold S. Diehl, Senior Vice President for Research and Medical Affairs of the Society and former Dean of the University of Minnesota Medical School, reviews scientific evidence linking cigarettes and cancer, and answers point by point arguments of tobacco industry spokesmen and the few scientists who question, or refuse to accept, the evidence linking cigarettes and cancer. The pamphlet is now receiving wide distribution. Another highlight involving smoking and lung cancer was the opening of the National Cancer Institute and the Society's "Man ARainst Cancer" exhibit in Washington, D. C., on April 2, 1962. While the educational exhibit was devoted to all phases of cancer, important emphasis was placed on the smoking problem. The exhibit/on cigarettes and lung cancer proved a major attrac- tion. It included a statement by Surgeon General Terry: "The weight of scientific evidence resulting from epidemiological and laboratory investi gations carried out in the United States and abroad within the past several years demonstrates that cigarette smoking Is a major cause of the increase i.n cancer of the lung. It is clear that an individual's risk of lung cancer rises in relation to the number of ci.parPttes smoked. r,ver,vone should be aware of these conclusions because of their importance to health." Later displayed at Seattle's World's Fair; in Atlanta, Ga.; Philadelphia, Pa.; and Grand Rapids, Mich.; the exhibit attracted several millions of people.

-27- At the June 1962 mnetinP of the Poard, thA q»Astion of sponsorship by tobacco companies of coll.ep,P athl etic events, with the associated television and other advertising, and the promotion of cigarettes on college campuses was discussed in detail. It was held that this "resulted in advertising appeal to the very are group which the Society is most anxio»s to prPvent from being sub,1nct to the persuasion to smoke." The Board apr.roved a siiPp,estion thAt a letter re sent to a group of approximAtAly 150 presidents of outstanding universitiPs calling attention to the deleterious effects of smoking on hAalth and the propriety of cigarette promotion on 'college campuses. On October 9, 1962, Dr. Thomas Carlile, then President of the Society, wrote a letter to 100 college and university presidents, calling attention to the relationship between cigarette smoking and health. He sai.d in part: "While smoking is a matter of individiial choice for adnlts, the American Cancer Society is di stiirbFd about the efforts that advertisPrs of cigarettes are making to c reate a climate of opinion among young people favorable to ci.parettPs. The tobacco industry spends more than $150,000,000 a year promottng ciParettes identif,ying ci P,arette smoking with athletes, with sophistication, with advt-nture, with romance, with yo»th. On many co11ePe and univr,rsity cnmpusps, cigarette promotion is extensively and intPnsivnly promoted. Television presentations -of many of the ~ t y most prestip,ious co11ePP athletic events are sponsored by cigarette '' companies. We belinvP that such promotional activities are worthy

-28- of special attention because surveys indicate that the younger the age at which the smokinp habit is acquired, the more an individual tends both to smoke and to inhale; both of which increase the risk of lung cancer, and of the other diseases related to cigarette smoking. "In view of this, the Board of Directors of the American Cancer Society has directed that I bring this major health problem to the attention of college and university presidents and raise the question of institutional acquiescence and encouragement of the promotion and advertising of a product which medical and scientific opinion overwhelmingly believes to be harmful." On May 8, 1963, Dr. I. S. Ravdin, President of the Society, sent a similar letter to about 19500 additional college and iiniversity presidents. Some colleges and college newspapers began dropping cigarette promotion. A few days before the ACS Board of Directors was to meet in .Tune 1963, it was announced that most of the major cigarette manufacturers had decided to stop advertising in college news- papers, magazines, football programs, etc. Later the New York Times reported: "The country's leading tobacco companies having decided to drop college promotions are further considering basic changes in cigarPtte advertising." The Times quoted an official of one major manufacturer as predicting: "Within thf next few months the whole 'virility approach' of ciQarPtte advFrtising will be abandoned." It was also prPdicted that "most companies

-29- will probably eliminate the use of endorsements by athletes or other glamorous figures from their cigarette ads." Graphic material for use by physicians in speaking before medical meetings on smoking and lung cancer was prepared and distributed by the Society in 1963. Charts and tables and other illustrative material explained the statistical data and research findings on smoking and lung cancer. On December 4, 1963, Dr. Hammond presented new evidence based on his massive Cancer Prevention Study on the relationship between cigarette smoking and death rates and disease before a meeting of the American Medical Association in Portland, Oregon. The report received front page news and wide radio and television coverage. The report was based on a continuing study of 422,094 men between the ages of 40 and 89 who were enrolled by volunteer workers of the American Cancer Society. All of these subjects were traced for an average of 34.3 months after they answered detailed question- naires. The results not only confirmed findings in earlier studies, but'added a "great many factors which were previously not covered or only partially covered." Dr. Hammond's paper answered numerous questions and refuted arguments raised by the tobacco industry and the scieritists who have challenged various aspects of earlier studies. For example, it compared mortality rates of pairs of subjects -- one a cigarette smoker, the other a non-smoker -- matched for such characteristics as age, race, height, native or foreign born, restdence (urban or rural), religion, education, marital status, alcohol consumption, sleep habits, exercise, nervous tension, drug use, sicknesses, and

numerous other factors. This aspect of the stud,y, known as a "matched pair analysis," involved 36,975 non-smokers and 36,975 men who smoked a pack of cigarettes or more per day. The purpose was to study the death rate of men who were alike in many ways but who diff ered in respect to cigarette smoking. During the course of the study 1,385 of the 36,975 cigarette smokers died while only 662 of the same number of non-smokers died. Of the cigarette smokers, 110 died of lung cancer, 15 of emphysema, 30 of aortic aneurysm, 6~+ of coronary artery disease and 576 of other causes. Of the non-smokers, only 12 died of lung cancer, 1 of emphysema, 8 of aortic aneurysm, 304 of coronary,artery disease and 329 of other causes. "It is hard to escape the conclusion that this difference in number of deaths was due to the difference in smoking habits," said Dr. Hammond. In conclusion, it can be said that over the last 15 years, the Society has'called attention to the great increase in deaths from lung cancer and stimulated research in the field and public, professional and governmental action. Support of the findings linking smoking and lung cancer has come from many national and state medical groups, health organizations, local and state governments, public health officers, foreipn countries and organizations. Nlo single aRenc,y, here or abroad, can claim credit for V 4.~ thP Pxtraordinary developments of the last 15 years in establishine ` .- cie,arettes as thp major cause of the unprecedPntPd Increase in lunr cancer rrortality.

-31- There have been more than 25 epidemiological studies in ten countries showing a relationship between cigarette smoking and lung cancer; there have been numerous studies in laboratories and in hospitals; 19 state medical societies have warned of the risk of cigarette smoking, solemn official statements have come from public health spokesmen in the United States, Great Britain, Sweden, Holland, Norway, Italy, among others. The American Heart Association, the National Tuberculosis Association, the American Public Health Association have all spoken out. The Society was a leader here in demonstrating through research the relationship of cigarette smoking to lung cancer, to cardiovascular diseases, to a reduction of the length of life. When its own research, and research by others, developed evidence that the major factor in the increase in lung cancer was linked to cigarette smoking, the Society has made the facts known to the public and the medical profession. The Society felt from the start that while smoking is a matter of individual choice the people should know the hazards inherent in cigarette smoking. With teen-agers, the Society believes it had a broader responsibility because this age group is not as capable of making a reasonable choice as adults. Thus the special emphasis on high school students and their health. They are the people who will determine the health of the people of the future.

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