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I I I I I I I I I I I I I I I I I I -2- 13. Applicotion Record, Volume 11, Tab 9, pages 299-302 and 305-310 Affidavit of Anastasia Erland sworn January 5, 1995 Exhibit "B" - Copy of the "approvals package" 14. Application Record, Volume 11, Tab 11, pages 325-329 Affidavit of Anthony Francis Graham sworn December 5, 1994 15. Application Record, Volume 11, Tab 11, pages 332-343 Affidavit of Anthony Francis Graham sworn December 5, 1994 Exhibit "A" - British Medical Journal Article (October 1994) 16. Application Record, Volume II, Tab 11, pages 344-389 Affidavit of Anthony Francis Graham swom December 5, 1994 Exhibit "B" - "Illness and Death in Canada Caused By Smoking: An Epidemiological Perspective" by Donald T. Wigle dated April, 1989 17. Application Record, Volume 11, Tab 12, page 394 Affidavit of Mark Taylor sworn December 4, 1994 18. Application Record, Volume 11, Tab 12, page 403 Affidavit of Mark Taylor sworn December 4, 1994 Exhibit "E" - Advertisement 19. Application Record, Volume II, Tab 13, page 407 Transcript - Cross-Examination of Mark Taylor conducted February 8, 1995 FAM78%1410wmta~hd I
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f I I I I I I I I I I I I I i -20- i) Mark Taylor, on behalf of the interveners, a large number of health groups and associations, has clearly indicated that it was the view of the interveners in making their submissions to the Government that pharmacists were sending mixed or inconsistent messages and that one of those messages ought to be curtailed to permit the surviving message to be consistent with their role as health professionals. ii) The College of Pharmacists submitted that dialogue was an important component of a pharmacist's treatment plan, that posting cautionary signs respecting the deleterious effects of tobacco consumption was insufficient and that as the professional body reflecting the standards of the professional as a whole, it was opposed to the consumption of tobacco products and therefore believed the Government should remove the right of pharmacists to sell tobacco products thereby removing the perceived message that pharmacists approved the consumption of tobacco products. iii) Dr. Schabas, Chief Medical Officer of Health, submitted to the Legislature that sending mixed messages did not reduce the consumption of tobacco and that by banning tobacco sales in pharmacies, a consistent social message would be sent; that tobacco products were not socially acceptable. r• . I
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I I I I I I I I ' I I I I I -6- I don't know of any research that specifically addresses this issue ofperception of pharmacies. I certainly believe that the ban ng of tobacco sales in pharmacies will reduce tobacco use by young people, both through reducing the number of outlets and through sending a consistent social messaee, but I can't point to one piece of research that categorically proves that. Reference: Ontario, Legislative -Assembly, Standing Committee on Social Development, Official Report of Debates (Hansard), No. S-29 at 5-712, S-721 (31 January 1994) 13. To the same effect were statements by D. McGuinty (Liberal - Ottawa South): I want to speak to the issue of pharmacists because obviously they have expressed some concerns in connection with this matter. First of all, it's important to recognize and everybody agrees that banning sales from pharmacies will not in fact reduce smoking. ' The reason this proposition is put forward by the government is because it is seen as a contradiction for a pharmacist to be selling products which are designed to promote health at the same time as selling cigarettes or tobacco products of whatever nature. Reference: Ontario, Legislature Assembly, Official Report of Debates (Hansard), No. 96B at 4864 (9 December 1993) That brings us to the issue of pharmacies. The government has decided to ban the sale of tobacco products in pharmacies. Many arguments were advanced to the effect that the symbolism associated viith health care.professionals, pharmacists, selling tobacco products was overwhelming and that there was a mixed`• message being sent out here and that this would confuse people, particularly younger people. They would be getting a mixed to
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I I I I I I I I I I I I I I ' j I -9- i) "that, for the guidance of members, a recommended schedule of activities aimed at the progressive reduction of tobacco promotion in pharmacy premises be published. These activities included the placing of all tobacco products behind services counters, the elimination of back bar displays and all activities respecting the advertising and promoting of tobacco, locating tobacco products below the level of the height of service counters and removing_ products from public view." ii) "recommendations which contemplated the development of educational problems, in cooperation with the Ministry of Health, utilizing pharmacists aimed at the prevention of smoking, including the development of suitable materials and encouraging pharmacists to support and be involved in community programs aimed at the provision of appropriate information on the hazards of smoking." Reference: Application Record, Tab 7C, p. 229, Submission to the Standing Committee on Social Development of the Legislative Assembly respecting Bill 119, Exhibit "C" to the Affidavit of James Dunsdon 19. In January 1993, the Ministry of Health circulated a tobacco discussion paper which included the following statement: "as it is contradictory for health professions who restore and promote good health to sell tobacco products that are harmful to health, we propose to: Prohibit the selling of tobacco products in pharmacies". 20. The Affidavit of Mark Taylor, on behalf of the Interveners contains a number of references to the diverse manner and means in which the sale of tobacco by pharmacists conveys a message to consumers that this group of health professionals considers it acceptable to promote such a message. I
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I I 9. Most tobacco smokers in Ontario start smoking regularly in their I teens. The average age at which children in Ontario regularly start smoking is about 15 years. About 28 per cent of Ontarians over the age of 15 are tobacco I smokers. There are now more women cigarette smokers in Ontario. than men. 1 Affidavit of Dr. Anthony Francis Graham, Application I I 10. Record, Volume II, Tab 11, paras. 17-18, pages 326-327 Heart disease and stroke affect all age groups, accounting for I I I I I I about 40 per cent of all deaths in Ontario, or approximately 18,000 deaths each year. Use of tobacco is responsible for about 30 per cent of all deaths from coronary heart disease. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para.19, page 327 11. Tobacco smoking is the major preventable cause of cardiovascular death in Ontario. Tobacco smokers have two to four times the risk of sudden heart attack death than non-smokers have, and almost half-of all coronary heart deaths among men are attributable to smoking. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 20, page 327 I I ' '
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-8- I I I I I 16. Alongside its development of the concept of Pharmaceutical Care, and its own graduated approach to regulatory initiatives, the College, beginning about 15 years ago, urged its members to post cautionary signs in their pharmacies warning of the prejudicial effect of tobacco products. 17. The College perceived that that initial step in the evolution was insufficient either because its members did not post the cautionary signs or because members of the buying public were not dissuaded thereby from buying tobacco products. As a result, the next step in the evolution was for the College to communicate a policy of disapproval of the sale of tobacco products in pharmacies owing to the mixed message that pharmacists were emitting. On the one hand, pharmacists were dialoguing with patients, advising them on the beneficial effects of health care plans and drugs; on the other hand, they were selling tobacco products which practice was seen as sending a message that smoking, although deleterious to their patients' health, was acceptable. Reference: Application Record, Tab 7, p. 222, Affidavit of James Dunsdon, paragraphs 12 to 15 Application Record, Tab 8, p. 248-250, Transcript of Cross-Examination of James Dunsdon, pages 3 to 5 18. When the policy of disapproval did not gain wide spread acceptance, the College established a special Task Force which made recommendafions to the Minister of Health to ban the sale of tobacco products in pharmacies. The Task Force recommendations included: __. .~
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' I I I I I I I I I I I I -5- longer have the tacit approval of an important group of health care professionals. Reference: Application Record, Tab 9A, p. 276, Tobacco Control Act - Ouestions & Answers, Exhibit A to the Affidavit of Anastasia Erland Application Record, Tab 10, pp. 315-316, Transcript of the Cross- Examination of Anastasia Erland, Q. 15-20 12. Furthermore, Dr. Richard Schabas (Chief Medical Officer of Health for Ontario and Director of Public Health Branch of the Ministry of Health) in testifying to the Legislative Assembly emphasized the need for the legislation in order to force exnression of a consistent social messa e by pharmacists: It's very important that we stop sending young people mixed ,~messa es, about tobacco. It's one thing to teach them a o6~ ut heath problems of tobacco in their schools, but when they can go out the door and, yes, go to a drugstore, a place that we associate with somewhere you go to buy things that promote health and that treat illness, we're sending young people a very mixed messaee. I personally believe that's the real crux of the pharmacy issue. Let me answer your question in several ways. First of all, there is research evidence that the mixing of the message is important. Things like the smoking behaviour of teachers, for example, have an important effect on the effectiveness of classroom teaching around toba cc , and the actual smoking behaviour of parents has an important effect on the smoking behaviour of their children. There is ample reason, both intuitively and from a researcFf4 standpoint, to recognize that consistency of inessa e is important. I I
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I I I I I I I I I I I I 1 I I I 12. _ The second leading cause of death, cancer, accounts for 25 per cent of all deaths in Ontario. Tobacco use is the cause of more than 30 per cent of all cancers, including 85 per cent of all lung cancers. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 21, page 327 13. Lung cancer is by far the largest cause of cancer death for men in Ontario, and has matched breast cancer as the most important cause of cancer deaths among women. Lung cancer deaths for Ontario women have increased almost threefold over the last 20 years, paralleling a similar increase in tobacco use among women over a period commencing approximately 20 years earlier. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 22, page 327 14. Tobacco use is known to be a major cause of cervical, gastric, renal, pancreatic, bladder, esophageal, oral cavity and laryngeal cancers. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 23, page 328 15. In addition, tobacco smoking is the major cause of emphysema and bronchitis. Over 80 per cent of all emphysema and bronchitis deaths are caused by smoking. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 24, page 328 .I
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I I I I I I I I I I I I , I I I I INDEX lab Deserlpflon 1. Applicant's Factum, pages 5, 6, 8, 9 and 20 2. Respondent's Factam, pages 7, 8, 11 and 21 3. Interveners' Factum, pages 2-8 4. Application Record, Volume I, Tab 3, pages 97, 101, 114, 149, 156, 161, 162 and 163 Transcript - Cross-Examination of Larry Rosen conducted December 1, 1994, attaching Exhibits A & B 5. Application Record, Volume I, Tab 5, pages 175-177 Affidavit of Brenda Mitchell sworn December 1, 1994 6. Application Record, Volume 1, Tab 5, page 183 Affidavit of Brenda Mitchell sworn December 1, 1994 Exhibit "B" - An Overview of the Position of the Ontario College of Pharmacists 7. Application Record, Volume I, Tab 5, pages 199-207 Affidavit of Brenda Mitchell sworn December 1, 1994 Exhibit "0" - "Ontario Tobacco Act - A Discussion Paper on Planned Legislation" dated January 18, 1993 8. Application Record, Volume 11, Tab 7, page 222 Affidavit of James Dunsdon sworn January 12, 1995 9. Application Record, Volnme 11, Tab 7, pages 229-235 Affidavit of James Dunsdon sworn January 12, 1995 Exhibit "C" - College of Pharmacist's February 10, 1994 - Submission To The Standing Committee on Social Development of the Legislative Assembly Respecting Bill 119 10. Application Record, Volume 11, Tab 7, pages 236-245 Affidavit of James Dunsdon sworn January 12, 1995 Exhibit "D" - Ontario Medical Association Submission dated February 1, 1994 11. Application Record, Volume II, Tab 8, pages 250-254 Transcript - Cross-Examination of James Dunsdon conducted January 26, 1995 12. Application Record, Volume 11, Tab 9, pages 273 and 274 Affidavit of Anastasia Erland sworn January 5, 1995 I
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-3- 1 I I I (1) I 4. 1 I I I I I I I I I I I (2) considering the seriousness of the conflict of interest on the part of pharmacists who in the course of their activities as health care professionals engage in the sale of an addictive and terribly harmful product. Tobacco and Health The interveners have filed an affidavit of Dr. Anthony Graham, the Chief of Cardiology at the Wellesley Hospital in Toronto, which describes the terrible health consequences of tobacco use. The applicants have not sought to contradict a word of this affidavit, or to cross-examine upon it. Affidavit of Dr. Anthony Francis Graham, Application Record Volume II, Tab 11 5. Tobacco is the only product legally available in Ontario today which, when used precisely as intended, is known to be harmful and often fatal. It is beyond any doubt that tobacco use is a principal cause of deadly cancers, heart disease and lung disease. A recent landmark study published in the highly respected British Medical Journal revealed that about half of all regular long-term cigarette smokers will eventually be killed by their habit. Affidavit of Dr. Anthony Francis Graham, Application__ Record, Volume II, Tab 11, para. 13, page 325 Exhibit "A" to the affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11 A I
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I I I I , I I I I I I I I I 16. In summary, over 13,000 Ontarians die each year from disease caused by their tobacco smoking, the equivalent of a community the size of Niagara-on-the-Lake. At least one out of every five deaths among adult Ontarians is attributable to tobacco use. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 25, page 328 17. Tobacco induced diseases and deaths are almost entirely preventable. Most new users of tobacco industry products come from the child and adolescent market. Many of these users become addicted to these products before the age of responsibility or before they leave their adolescent years. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 26, page 328 18. According to reliable statistics, about 10,000 persons commence smoking in Canada each month. Research shows that smokers become addicted after smoking only a few packages of cigarettes. Of those 10,000 starters, about 30 per cent will die of tobacco related illnesses. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 27, page 328 I
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I I I I 1 I I I I I I I I I , I -8- 19. In addition, there is increasingly conclusive evidence that tobacco smoke causes disease and death among non-smokers as well as smokers. Sidestream smoke from burning cigarettes contains greater amounts of carcinogens and other noxious chemicals, including carbon monoxide, than mainstream smoke because the cigarette burns at a lower temperature when the smoker is not inhaling. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 28, page 329 20. The U.S. Surgeon General has stated that it is certain that a "substantial proportion" of lung cancers that occur in non-smokers are due to environmental tobacco smoke. Infants of parents who smoke tobacco have -increased risk of hospitalization for bronchitis and pneumonia as against infants of non-smoking parents, and have a slower rate of growth in lung function than infants of non-smoking parents. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 29, page 328 21. Fetuses are the most vulnerable group of persons exposed involuntarily to tobacco chemicals and carcinogens. Smoking tobacco during pregnancy is an important cause of both low birth rate and infant mortality. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 30, page 329 I
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I -4- I 6. Among young Ontarians who continue using tobacco five to six I times more will die prematurely of disease caused by smoking than will die from car accidents, suicide, murder and AIDS combined. Yet all tobacco- I caused disease and death is fully preventable. In fact, tobacco use is the leading preventable cause of death in Ontario. I I Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 14, page 326 I 7. Tobacco contains over 4,000 chemicals, several hundred of I I I I I I I I which are known to be toxic and over fifty of which are known to be cancer- causing. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 15, page 326 8. As reported by the United States Surgeon General, scientists agree that nicotine found in tobacco is a powerfully addictive drug. Pharmacological and behavioural processes that determine nicotine addiction are similar to those that determine addiction to drugs such as heroin and cocaine. For most tobacco users, nicotine ingestion is a crucial component of their repeated use of tobacco. Affidavit of Dr. Anthony Francis Graham, Application Record, Volume II, Tab 11, para. 16, page 326 ,
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-2- I I I ., , I I I I I I I I 1 I I I Ontario; The Ontario Lung Association; The Ontario Chiropractic Association; The Canadian Oncology Society; Council for a Tobacco-Free Ontario; Physicians for a Smoke-Free Canada; Non-Smokers' Rights Association; The Ontario Medical Association; The Ontario Federation of Home and School Associations; The Ontario Naturopathic Association; The Canadian Council on Smoking and Health; Concerns Canada; Sudbury & District Council on Tobacco and Health; -Council for a Tobacco-Free Wellington-Dufferin; Elgin-St. Thomas Health Unit; The Lung Association, Elgin Region; The Lung Association, Wellington County; The Lung Association, London & Middlesex; The Ontario Public Health Association; and Elgin Council on Smoking and Health. PARTII-THEFACTS 2. The interveners have delivered affidavit evidence with respect to: (1) the immense danger to public health caused by the use of tobacco; and (2) the nature and extent of the conflict of interest position of pharmacists who deal in tobacco. 3. It is submitted that this evidence should assist the court in: (1) considering the factual background of the challenged legislation; and I
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I I I I I I I I I I I I I I I I I -8- - reason for the Gollggg's p~T+ y on thj m9 Pr, and that is the reason w we sunort Bill 119. Affidavit of Brenda Mitchell, para. 11, Anlication Record, Tab 5, pp. 175 Affidavit of James Dunsdon, paras. 17-19, ApFlication Record, Tab 7, p. 223 ii) Ontario Tobacco Strategy 15. The Ministry of Health first proposed to prohibit the selling of tobacco products in pharmacies and other health facilities in a "Discussion Paper on Planned Legislation" released on January 18, 1993. This paper outlined the position of the Ontario government on actions that should be taken throughout legislation to reduce tobacco use in the province. The paper presented the health issues underlying this action, outlined the Tobacco Strategy for Ontario and discussed the purposes of the proposed legislation. In proposing the prohibition of tobacco sales in pharmacies and other health facilities, that paper stated: Tobacco products are a health hazard both to those who use them and those who inhale environmental tobacco smoke. It is inconsistent that any part of the health system sell tobacco products. As it is contradictory for health professionals who restore and promote good health to sell tobacco products that arc harmful to health, we propose to: - Prohibit the sale of tobacco products in health facilities; and - Prohibit the selling of tobacco products in pharmacies. Affidavit of Brenda Mitchell, para. 12, Application Record, Tab 5, p. 176 I
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L. Rosen I I 2 3 4 5 6 7 8 9 ~ 10 , 11 ` 12 , 13 14 15 16 t 17  18 *, 19  20 21 ~ 22 23 ~ 24 25 ~ 26 27 28 ~ 29 30 r 31 I I I blanche on that. 52. Q. But generally speaking, though, that would be your advice? A. Generally speaking, you're better off without tobacco. 53. Q. Right. And---_ A. taithout using tob.acco, I should say. 54. Q. Okay. Have you ever given any of your patients that advice in, let's say,`the last five years? A. Yes. 55. Q. How often do you think you've given that advice? A. Personally? 56. Q. Yes. A. Not that frequently because, as I explained to you earlier, I'm not involved in the dispensary as a full-time occupation. I'm not in the dispensary 40 hours a week. I might--I might be in the dispensary five hours a week, so--in what time-frame did you ask that question? 57. Q. The last five years. A. This is right off the top of my head, I would say 30, 40 times. I don't know. 58. Q. Under what circumstances would you give people that advice? A. Well, if they are getting medication which is indicative of a disease condition _ associated with the use or exasperated--exacerbated by tobacco use, and if I know they're a smoker, I will advise them that probably they will do as much Rosenberger, Weir, Macdonald Paol W. Ro.enbaW, oNid.l Fawminer Toronto, Ontario 01
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I I 1 I I I I I I I I I I I 20. Mr. Rosen agrees that pharmacists are health care professionals whose role is to advise patients on the use of their drugs both prescribed and over the counter. His role as a health care professional extends beyond the prescription laboratory into the area of self-medication which is available in the general retail area of the pharmacy. Cross-examination of Larry Rosen, qs. 18, 22, 114-123, Applicatlon Record, Tab 3, pp. 95-96 Affidavit of James Dunsdon, paras. 5-10, e,pplica '$ecord, Tab 7, pp. 219- 221 21. Mr. Rosen agreed that medical evidence confirms the following statements: "Tobacco products are a health hazard both to those who use them and those who inhale environmental tobacco smoke." "Tobacco users have a high risk of developing serious diseases such as heart disease, lung cancer, chronic lung disease, chronic bronchitis and emphysema, stroke and cancers of the mouth, throat, oesophagus and bladder." "Second-hand smoke, also called environmental tobacco smoke, has been linked to lung cancer in non-smokers and respiratory problems in young children and infants." Cross-examination of Larry Rosen, qs. 31-33, An]jcagon Record, Tab 3, pp. 97-98 22. In his submissions before the Standing Committee on Social Development on February 2, 1994, Mr. Rosen stated: "We therefore believe that pharmacists should be working constructively and meaningfully toward the long-term goal of reducing tobacco consumption for everyone. We should strive for a completely smoke-free Ontario and Canada. To that end, we support the objectives of the government of Ontario as reflected in the Tobacco Control Act (Bill 119) and want to participate with the provincial government in helping curb tobacco use."
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097 . L. Rosen - 7 I. I I I I I I I I 1 2 30 31 26. Q. You have a copy of the unsworn affidavit of Brenda Mitchell, do you have a copy there? A. I think I do. 27. Q. Okay. MS. POSNO: Yes, we have. 28. MR. CHARNEY: Q. If I could just ask you to turn to tab G. A. Ontario Tobacco Act? 29. Q. That's right. This is a discussion paper on planned legislation that was__put out. You see the date down there, January 18th--- A. Right. 30. Q. ---1993. If I could ask you to turn to page 7. Under the heading, "Sales of Tobacco in Health Facilities and Pharmacies." A. Yes. . 31. Q. I just want to ask you about the first sentence there. It•says: "Tobacco products are a health hazard both to those who use them and those who inhale environmental tobacco smoke." And I'll ask you: do you agree with that statement? A. The evidence that's in there appears to confirm that. 32. Q. If you could go to the first page of that report. There are a number of points that you see listed down there, and it you go to the third bullet point there that starts, "Tobacco users have a high risk," do you see that? And that says: "Tobacco users have a high risk of developing serious diseases such as heart Rosenberger, Weir, Macdonald Paul W. Raunber;er, Ol/id.l ExYmiaa Toronto, Ontario
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I I I I I I I I 1 ' I I I I I I I .7. D. ipcs_ lative A ctorv of the TobQcco CPntrol Au i) Ontario College of Pharmacists' Task Force on Tobacco 13. The Ontario College of Pharmacists is the licensing and regulatory body for pharmacists in Ontario pursuant to the Regulated Health Professions Act. In June, 1991, the Ontario College of Pharmacists' Task Force on Tobacco Sales in Pharmacies released its report, which recommended banning the sale of tobacco products in accredited pharmacies in Ontario as of July 1, 1993. Affidavit of Brenda Mitchell, para. 10, Application Record, Tab 5, pp. 174-175 Affidavit of James Dunsdon, paras. 15-16, Appliaation Record, Tab 7, pp. 222- 223 14. In its submission to the Standing Committee on Social Development Respecting Bill 119, on February 10, 1994 (Bxhibit "F"), the Ontario College of Pharmacists stated: The College is aware of the controversy surrounding the issue of tobacco sales in pharmacies. This has been a difficult issue for the profession as well as the College. Self regulation is not always easy and the speculation you have heard aboutour election results reveals some misunderstanding about the objects of professional regulation, as illustrated by the Regulated Health Professions Act, of which pharmacy is a part. While all pharmacists, in our experience, appreciate the health hazards associated with tobacco use, there are differences respecting how to deal with tobacco sales. For its part. the Ontafjo ~`ege of Pharmacists is :I)1\LII[~ti1~~lY•l~/ll7-'~ilI3Q~S/)/};[v._I)hN IJIRIIIIkiP7(-t9wi11111 1[yl}I,iv':1(. faciliEy. is si inco tible with the role of the pharmacist as a Rrofessional pmviding health care to the pubflc. That is the I
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I I I I I I L. Rosen a fair summation of the Committee of Independent Pharmacists' position and your position: on the one hand you're a healthcare professional, and you recognize that smoking creates a health hazard and you'd advise people that smoking present a health hazard, advise them not to take up smokingt on the other hand, you're a businessman and you've got to generate profits to pay the rent and you've got to compete with other retailerst is that a fair summation of the position.that you find yourself in? A. I can agree with that. 151. Q. Let's go back to the discussion paper, which is Exhibit G to Brenda Mitchell's affidavit. A. I don't think I have it. MS. POSNO: I have it. THE DEPONENTe You have it? MS. POSNO: It's right here. THE DEPONENT: Okay. 152. MR. CHARNEY: Q. And back to page 7. Under, again, the heading, "Sales of Tobacco in Health Facilities and Pharmacies," and I had asked you about the first sentence there, and I'm qoinq to ask you about the second sentence, and I want you to. give me as fair an answer as you possibly can. The second sentence says: "It is inconsistent with any part of the health s stem to sell tobacco products." I I ~ I And, gusss, my que on fo you, Mr. Rosen, in r heart of heart's _ t you see the i consistency en being a healthcare pro ess onal and selling tobacco produots? Rosenberger, Weir, Macdonald Paul W. Roseoberter, 0ffldd Examinx Tornnto, Ontario
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I I I I I I I I I I I I ! This is Eichibir 11 Gq to fho Arriaovfr of 8ro.404 rhr" Sworn by mo this 19s ONTARIO TOBACCO ACT A DISCUSSION PAPER ON PLANNED LEGISLATION Ministry of Health ® Ontario Ln JANUARY 18, 1993 ~ N J 01 01
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/n 1 I -S- ii) Ontario Tobacco Strategy 1't6 12. The Ministry of Health first proposed to prohibit the selling of tobacco products in pharmacies and other health facilities in a'Diseussion Paper on Planned Legislation' released on January 18, 1993. This paper outlined the position of the Ontario government on actions that should be taken throughout legislation. to reduce tobacco use in the province. The paper presented the health issues underlying this action, outlined the Tobacco Strategy for Ontario and discussed the purposes of the proposed legislation. In proposing the prohibition of tobacco sales in pharmacies and other health facilides, that - paper stated: Tobacco products are a health hazard both to those who use them and those who inhale environmental tobacco smoke. It is inconsistent that any part of the health system sell tobacco products. II I I , I I As it !s contradictory for health professionals who restore and promote good health to sell tobacco products that are harmful to health, we propose to: - Prohibit the sale of tobacco products in health facilities; and - Prohibit the selling of tobacco products in pharmacies. Attached hereto and marked as Exhibit •G' is a copy of the 'Ontario Tobacco Act - A Discussion Paper on Planned Legislation', dated January 18, 1993. 13. The Tobacco Control Act received second reading in the Legislature on December 9, 1993. In explainir.g the government's reasons for banning the,sale of tobacco from pharmacies, Mr. Larry O'Connor, on behalf of the Minister of Health, stated:
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- 5 - I I I I I I 'I I I , , 1 ' selling tobacco. Q. Will banning tobacco sales in pharmacies reduce tobacco consumption? By how much? Won't people just go to other stores? A. It would be naive to suggest that tobacco consumption will decline dramatically once tobacco is no longer available in pharmacies. There are thousands of other outlets where smokers will buy their tobacco. By reducing the number of tobacco outlets, tobacco consumption should decline slightly, although it is not known by exactly how much. More importantly, removing tobacco from pharmacies will help to reduce its social acceptability and respectability. Cigarettes will no longer have the tacit approval of an•important group of health care professionals. Q. Aren't pharmacists in the best position to give smoking cessation advice? A. In most pharmacies, pharmacists are not physically in a position to interact with individuals purchasing tobacco. Tobacco is usually sold at the front counter while prescriptions.ara filled at the back. Also, pharmacists who rely on tobacco sales may be less likely to promote tobacco cessation. If you ban tobacco from pharmacies, what"s next? Snack foods? A. Tobacco is the only consumer product that kills 13,000 Ontario residents annually when used exactly as the manufacturer intended. It is not like-confectionery. It is hazardous and addictive. There is also no safe level of tobacco consumption and its use is not compatible with good health. Smoke-Free Areas Q. The Bill overlooks many locations that could have been designated as smoke-free, such as restaurants, bowling alleys, cinemas and recreational facilities:'- Why are they not included? 0 1 k N J
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I I I I I A large number of products that were once exclusively sold in drugstores are, because of a change in their status, now sold elsewhere --- in foodstores, conveniences store and gas stations. ' Pharmacists have sought to counterbalance the pressure on their dispensaries by gaining in the retail side of their activities. But if tobacco is eliminated from their stores, the squeeze on pharmacy will intensify because their competitors can and will increase their offerings of health care and related products. we are already witnessing products which used to be the exclusive preserve of drugstores carried in other retail establishments. OUR RECOMMENDATIONs The Committee of Independent Pharmacists recommends that ongoing concerted and determined education and information campaigns are the means by which tobacco will gradually come to decline in use in Canadian society. while we recognize that tobacco use is a very important health issue, the thrust to curb its use must be driven by education if the goal of a smoke-free society is to be achieved. The Committee of Independent Pharmacists looks forward to working with the Ontario government to achieve its tobacco reduction goals with which it agrees almost entirely except for the provision calling for a prohibition of the sale of tobacco products in pharmacies. The Committee of Independent Pharmacists therefore makes two recommendations for change in Bill 119, the Tobacco Control Act: 1. that the decision to sell tobacco should remain at the ' - discretion of the pharmacist-owneri and 2. that pharmacists spearhead a drive by legitimate tobacco vendors to help finance an information campaign through the I I I f I media to educate ontarians to stop smoking. 149
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! I I I I I I Edwards Books and Art v. The Qyueen (1987), 35 D.L.R. (4th) 1, at p. 44: I might add that in regulating industry or business it is open to the Legislature to restrict its legislative reforms to sectors in which there appear to be particularly urgent conoerns or to constituencies that seem especially needy... In drafting its statute, the Legislature can, if it wishes, create categories of retail business which are exempted, even though some unexempted businesses may sell some of the same products. Legislative choices regarding alternative forms of business regulation do not generally impinge on the values and provisions of the Charter of Rights, and the resultant legislation need not be ' tuned with great precision in order to withstand judicial scrutiny. Simplicity and administrative convenience are legitimate concerns ~ for the drafters of such legislation. , ii) Government Puroose , 42. As indicated at para. 15, 16 and 33, supra, the purpose of s. 4 of the Tobacco Control AM is to ensure that pharmacists, as health care professionals, provide proper health care to , their patients. It is submitted that the delivery of proper health oare by pharmacists to their ' patients is an important government objective. In this regard, the following factors are I significant: r i) All parties agree that tobacco products are a health hazard both to those who use t them and those who inhale environmental tobacco smoke, and thtdt•tobacco users have a higher risk of developing serious diseases, such as heart disease, lung , cancer, chronic lung disease, stroke, and cancers of the mouth, throat, ' oesophagus and bladder. Ln N B ~ 1 . . . . , i0 I
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I I I I I I I I 1 I I (3) Letter from N.G TYuong, Pharm. D.; President, Ontario College of (4) Pharmacists to The Honourable Franoes Lankin, Minister of Health, dated June 19, 1991(Exhibit 'D'); Letter from A.J. Dunsdon, B.Sc., Phm, Registrar, Ontario College of (5) Pharmacists, to Lorne Widmer, Health Promotion Branch, Ministry of Health, dated March 9, 1993 (Exhibit 4EI; and Submission to the Standing Committee on Social Development respecting Bill 11. 119 by the Ontario College of Pharmacists, February 10, 1994 (8xhibit'x"). In its submission to the Standing Committee on Social Development Respecting Bill 119, on February 10,1994 (Bxhiliit "F"), the Ontario College of Pharmacists stated: The College is aware of the controversy surrounding the issue of tobacco sales in pharmacies. This has been a difficult issue for the profession as well as the College. Self regulation is not always easy and the speculation you have heard about our election results reveals some misunderstanding about the objects of professional regulation, as illustrated by the Regulated Health Professiorrs Act, of which phannacy is a part. While all pharmacists, in our experience, appreciate the bealth hazards associated with tobacco use, there are differences respecting how to deal with tobacco sales. For its part, the Ontario - College of Pharmacists is convinced that the sale of tobacco In pharmacies, a health care facility, is simply incompatible with the role of the pharmacist as a professional providing health care to the public. That is the reason for the College's policy on this matter, and that is the reason why we support Bill 119.._ _ I
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163 I I I I I I I I I I I I I I I I it is also illegal under various federal, provincial and local laws to smoke in various public places (e.q.• airplanes, workplaces, public buildings). But adults who choose to smoke continue to have the right to use tobacco products. Q. Isn't the only reason the government hasn't totally banned tobacco is because the tobacco lobby is so powerful? A. The qovernment__never intended to ban smoking entirely. This is an unworkable option. Through the public consultation process, all interested stakeholders, including the tobacco industry, were invited to make presentations. opinions from all sides were heard. Policy decisions were based on the most effective_.means of dealing with a serious public--health problem. Q. '-How much does smoking actually cost the health care system? Doesn't the government make more in taxes? A. We view tobacco as a health issue, not an economic issue. In the last fiscal year, the qovernment.colleotdd tobacco taxes of nearly $1 billion. The application'of those taxes have supported our health policy around tobacco use. Costs to treat cancer alone were more than $1 billion. There are also costs for heart disease, lung disease and other tobacco-related diseases (e.g. stroke). While it's obvious that not all canoers are tobacco-related, we know many are, so this gives us an indication of the potential dollars spent. The Ministry of Health is very concerned with the human costs caused by death and disease from tobacco use. The health legislation takes positive'steps to improve the health of ontarians, and above all is trying to prevent children and adolescents from starting to smoke. Municioal Authority Q. What is the current system for municipalities to pass bylaws about smoking in public places? How will that change? A. The Municinai•Act provides general authority.to regulate "for the health, safety, morality and welfare of the inhabitants". Bylaws are very uneven across the .1
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I I I r! I I I The Task Force welcomee the views of pharmacists and other inter- eeted parties on the issues and conditions in pharmacy prsotioe 183 that bear on the process of eliminating tobacco sales in pharmaoi- es. Pharmaaists have been invited to submit their views through artioles in the November/Deoemb6r Newsletters and the October Coun- cil Report. Smokina Incidence The College's aotion in this matter is based on the pharmaci- sts' professional role as a provider of health care services. A number of'benefits are realized from our action. - the role of the pharmacist As a health care professional is reinforced; - it is a powerful statement about the health hazards of tobacco useti - a positive signal is aent to young people (the next generation of'potentiai smokera)i - it may influence established smokers to out down, or quitl - combined with educational efforte, may reduce incidence. - removes the mixed message to the public about pharmacies aelling tobacco products whiie at the same time being health oare oentres. I The action taken by the Coll.ge on tobacco sales has reinforo- I I ed in the minds of the public, health eare ageneies.and other health protessionals the professional role of the pharmacist, per- haps more than any other sinOle issue. The Implementation Task Force, consisting of three community , pharmaoists, the Dean of the Faculty of Pharmacy, University of N ~ m ~
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r I I I , I I About 6000 or one-third of.all coronary heart disease deaths in Ontario can be attributad to tobacco use. Smoking during pregnancy can cause low birth weight " babies. Tobacco smoke also causes many other diseases and health problems in smokers and in non-smokers. Q. In the US, the Environmental Protection Agency has released its report on second+hand smoke. It states that second hand smoke is a cause of respiratory problems in children and lung cancer. Is Ontario's legislation' strong enough? A. Ontario's Tobacco Control Act is, in fact, one of tha toughest statutes of its kind in Canada. The government has a target to eliminate smoking in many places by 1995 and to cut tobacco use in half by 2000.' This legislation is an important first step to achieving these targets. Part of the public consultation process was to review specifically what places should.be included in the Act. Q. Why has the government not made tobacco illegal? If tobacco is so harmful to the health of Ontarians, why is it still sold in stores? A. Prohibition is not a workable option, given the widespread addiction of so many people. While the prohibition of alcohol earlier this century had many short term public health benefits, it was socially unacceptable to the public. We have learned lessons from this experience and we want to address the tobacco epidemic through sustainable and effective legislation. We have struck a balance between public health and the- protection of children on,the one hand and the rights of adults to smoke if they so choose on the other. Tobacco is a legal product. But tobacco is also an addictive, hazardous product and that is why it'is illegal to sell or give tobacco to children and adolescents. And because second-hand smoke affects not only smokers, but also the people around them, the legislative proposals will protect the rights of non-smokers. I
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I I I I I I I I I I I I I I I Prescr,gtion 5: Pass a Clean Indoor Air Act . The legislation prohibits smoking in designated p laces . prescritt{on 6: Reducs the affqrylahility of , cigse es . The Minister of Health supports policies that reduce the affordability of cigarettes Tax policy is determined by the Ministry of Finance. Prascr.iption 7: Ban smokS3,ess tobacco . Smokeless tobacco will be treated the same as other tobacco products. Prescrintion 8: Strenathen nublic education camnaions . Part of our tobacco strategy is an extensive public education program which'will be launched before the end of the year. Public health departments are already mandated and funded to implement smoking prevention and cessation programs. Health Effeots and Costs Q. How many Ontario residents die each year from tobacco-related causes? A. one in five deaths among Ontario adults can be attributed to tobacco use and more than 13,000 Ontarians die each year from it. This loss represents the population of a community about the size of Niagara-On-The-Lake or Kirkland Lake and is almost five times the number of people who die from traffic accidents, suicides and AIDS combined. This represents one.death every 40 minutes due to tobacco. The total for Canada is over 38,000 deaths per year. Q. How does smoking affect health? A. Tobacco users have a higher risk of developing serious diseases, such as heart disease, lung canoer, chronic lung disease (chronic bronchitis and emphysema), stroke, and cancers of the mouth, throat, esophagus and bladder. Tobacco causes about 804 of all lung cancers - a disease that is fatal for almost nine out of 10 people, usually within two years of diagnosis. I
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We therefore propose to: • Prohibit or restrict smoking in specified public places. A public place is an enclosed building or structure to which members of the public are invited or permitted access whether or not they pay a fee. • Prohibitions would apply in the following categories: 1. Places where children and adolescents go, such as: Licensed day-care facilities Nursery schools Children's day camps, including public and private recreational camps Public and private elementary and secondary schools I I I r 2. Health care facilities, such as: Public and private hospitals Nursing homes 3. Places where people must go to carry out routine daily activides, such as: Banks and other financial institutions Retail stores Transit shelters Hairdressing/barber shops Laundromats Adult education institutions Elevators and escalators Restrictions or bans on smoking in other public places could be considered in the future. C) Information about Health Consequences of Tobacco Use Those who choose to use tobacco products, or who are thinking about using them, have a right to be informed about tobacco, its dangers and its health consequences. Nicotine is an addictive substance. Exposure to nicotine usually occurs through smoking tobacco. Voluntary, long-term avoidance of smoking can be extremely 6 204
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I I I I I i I I • reduce the percentage of women who smoke to 15% from the 1986 rate of 24% • reduce the percentage of men who smoke to 15% from the 1986 rate of 28% • eliminate the use of tobacco products by pregnant women These targets, recommended by the former Premier's Council on Health Strategy, were adopted as policy by the government in 1992. (Estimates of smoking rates on which the targets are based are from the 1986 Canada Labour Force Survey.) The Ministry of Health is undertaking a comprehensive approach to achieve these targets. It is: • Developing a media and public education campaign to be delivered over the next few years. • Funding resource centres so that community agencies and organizations have access to information, training programs, expert program consultation and advice, and support for local interagenoy councils. • Providing an inventory of educational materials and a needs assessment to identify what new materials are required. To assist with public health programming, a new document on strategies and activities is now available to local Boards of Health. • Establishing a behavioural research unit in 1993 to study effective tobacco interventions. • Funding Brant County as a demonstration site. Brant presents a unique opportunity because of its four-year participation in the "Community Intervention Trial for Smoking Cessation" (COMMIT) funded by the U.S. National Cancer Institute. Two more communities will also receive funding to be demonstration sites. • Providing a regulatory change to allow 100% funding to Boards of Health for the Tobacco Use Prevention program. • Leading an Interministerial Advisory Committee to co-ordinate initiatives on tobacco-related issues. .201
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• Mothers who smoke during pregnancy are more likely to have 2 0~ low-birthweight babies. I I I I I I I I I I I I I Smoking has declined in Ontario and the rest of Canada over the past 20 years. The Ontario Health Survey estimated smoking prevalence in 1990 was 29.5% for those 18 years and over. The smoking rates were 27.2% for females and 31.9% for males. About 18% of adolescents aged 12-19 currently smoke. More than 50% of the Ontario population aged 12 and over have smoked. In this same age group 20% have quit smoking! People who quit smoking can expect to have improved health, including fewer sick days and health complaints, and to live longer than continuingsmokers. Giving up tobacco reduces the risk of heart disease, lung cancer and other cancers, stroke and chronic lung disease. The additional risk of heart disease caused by smoking is reduced by half within one year of quitting. -A Tobacco Strategy for Ontario These facts explain whythe Ministry of Health has made the Ontario Tobacco Strategy a priority. The three main purposes of the strategy are prevention of tobacco use, particularly by children and adolescents; protection from exposure to environmental tobacco smoke; and support for smoking cessation. The Government of Ontario intends to achieve the following health targets: By the year 1995 • increase to 100% the proportion of schools, workplaces and public places that are smokc-free • eliminate tobacco sales to minors By the year 2000 • reduce total tobacco sales by at least 50%, and by at least 5% in each year of the 1990s • reduce the percentage of those 12 to 19 who smoke to 10% from the 1986 rate of about 19% 2
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I I I r I ' I ' -6- Members should know that the Ontario. College of Pharmacists, the professional regulatory body; --came and asked the government to ban the sale of tobacco in pharmacies, and I am pleased that the Canadian Pharmaceutical Association is on record as opposing the sale of tobacco In pharmacies. As we know, many Ontario pharmacists oppose the sale of tobacco in drugstores and many refuse to sell it. Let me quote from a doctor of pharmacology, N.C. Truong, who wrote in the Financial Post today: 'Selling of tobacco products that are proven to kill people when used as directed Is not providing pharmaceutical care and is quite incompatible with the pharmacists' training. The idea of losing business to other retailers is very hypocritical for pharmacists, who are $iven the privilege to be sole custodians of medication: Privilege also means responsibility toward their patients.' I think those are pretty strong words and of course I'm quoting from today's press clippings. Hundreds of pharmacies have already chosen to eliminate tobacco sales from their stores and have successfully made necessary business adjustments. Pharmacies are not just another retailer. Pharmacists, like doctors and nurses, are health care professionals and are part of the health care system. Internationally, we see this recognized. The World Health Organization reports that Canada and the United States are two of only a very few countries in which cigarettes are sold in pharmacies. In Britain, the Council of the Pharmaceutical Society decided in 1987 that pharmacist members should not sell tobacco or tobacco products. To do otherwise is considered to be professional misconduct. The code of ethia of the council states that a pharmacist's prime concern shall be the welfare of both patients and the public. 177
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I I I I t 1 difficult for those who have become addicted to nicotine, even when they are strongly motivated to stop. Most people are aware of some of the health consequences of using tobacco, such as lung cancer. They may be less aware of its role in many other cancers (larynx, esophagus and bladder), heart disease, and low-bitthweight babies. People who smoke, who are considering starting, or who are looking for suppon of their efforts to stop, should be aware of the health consequences of tobacco use. Warnings currently placed on cigarette packages are required by the federal Tobacco Prodycts Control Act. This Act is being challenged in the courts. Continued placement of warnings on packages may be done tmder provincial legislation. Additional health warnings (for example, an addiction warning) could also be considered. We therefore propose to: • Provide for warnings placed on or in tobacco packaging.that disclose the health hazards associated with the use of tobacco. • Require vendors to post notice of the health hazards associated with the use of tobacco; the size, contents and locadon to be presaibed by regulation. • Provide a mechanism to cottununieate further health information to consumers (for example, benefits of quitting). D) Sales of Tobacco in Health Facilities and Pharmacies Tobacco products are a health hazard both to those who use them and those who inhale environmental tobacco smoke. It is inconsistent that any part of the health system sell tobacco products. As it is contradictory for health professionals who restore and promote good health to sell tobacco products that are harmful to health, we propose to: • Prohibit the sale of tobacco products in health facilities. • Prohibit the selling of tobacco products in pharmacies. 7 2 015' I
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I I I I 1 I I I I I I I I I I I I ONTARIO MEDICAL ASSOCIATION RESPONSE AN ACT TO PREVENT THE PROVISION OF TOBACCO TO YOUNG PERSONS AND TO REGULATE ITS SALE AND USE BY OTHERS FEBRUARY 1, 1994 23?
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I t•:c r. ~ Areas for Further Discussion Plain packaging may make cigarettes less attractive to children and adolescents. It would also make health warnings more visible. Plain packaging needs to be addressed at the national level. We have therefore written to the Minister of Health and Welfare Canada asking him to take leadership on this issue. Public Consultation Process We invite you to make a written submission in response to this discussion paper. Submissions should be received by the Ministry of Health by March 15, 1992. Please send them to: _ Tobacco Legislation Consultation Health Promotion Branch 6th Floor 36 Toronto Street Toronto, Ontario M5C 2C5 Additional copies of this paper are available by calling: • in Toronto 3145518 • elsewhere in the province 1-800-268-1154 • TDD 1-800-387-5559 Copies of the Chief Medical Officer of Health reports, Tobacco and Your Health (1991) and Opportunities for Health: A Report on Youth (1992), are also available by calling these numbers. There will be an opportunity for oral presentations following the period for written submissions. If you are interested in making a presentation, please register by Febuary 26 by calling: • in Toronto 314-5934 • elsewhere in the province 1-800-665-0031 244
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I I I I I I I I I I I I I I 5 12. The College's formal consideration of tobacco started approximately fifteen years ago. Concern about the acknowledged hazards of tobacco use prompted the Council of the College to urge those members who chose to sell tobacco products in their pharmacies.to post cautionary signs which complimented warnings required on tobacco packaging and which were approved by Health and Welfare Canada. (Exhibit "C" at page 2.) 13. In the 1980s, the Canadian Pharmaceutical Association developed programs urging members to voluntarily cease the sale of tobacco products. Both the College and the Ontario Pharmacists' Association supported these initiatives. These voluntary initiatives resulted in some pharmacies removing tobacco products. (Exhibit "C" at page 3.) 14. In June of 1989, Council of the College adopted a policy of disapproval of the sale of tobacco products in pharmacies. The policy was circulated as guidance to pharmacists. However, pharmacists retained the right to make their own decisions on the matter. The policy resulted in a few additional pharmacies removing tobacco. (Exhibit "C" at page 3.) 15. in October of 1990 a special Task Force was-established by the Council. The mandate of the Task Force was to present to the Council ways to eliminate tobacco sales in pharmacies as quickly as was practical. (Exhibit "C" at page 3.)~ 222 r I~
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I t. I I I I 1. r t. I I 11. i. I I , Introduction This paper outlines the position of the Ontario government on actions that should; be taken through legislation to reduce tobacco use in the province. Following consultation with the public, we will draft legislation based on the principles contained in this paper and'the public consultation. We intend to introduce this legislation in the 1993 Spring session. This paper presents the health issue underlying this action, outlines the Tobacco Strategy for Ontario, discusses the purposes of the Ontario Tobacco Act and proposed legislation, and identifies the public consultation process. The Health Issue "Tobacco-related diseases are this province's number one public health problem. The cost in human lives, quality of life and health care dollars is colossal. The circumstances call for nothing less than thorough and relentless action by all Ontarians." These statements were made by the Chief Medical Officer of Health in his 1991 repon'Pobacco and Your Health. The report challenged "health groups, governments and the general public to take the necessary steps to reduce and eliminate this immense health hazard." It pointed out these alarming facts: • More than 13,000 Ontarians die each year from tobacco use. • One in five deaths among Ontario adults can be attributed to tobacco use. • Tobacco users have a higher risk of developing serious diseases, such as heart disease, lung cancer, chronic lung disease (chronic bronchitis and emphysema), stroke, and cancers of the mouth, throat, esophagus and bladder. • Tobacco causes about 80% of all lung cancers = a disease that leads to death in almost nine out of 10 cases, usually within two years of diagnosis. • Lung car,cer death rates have tripled for women in the past 20 years. • Second-hand smoke (also called environmental tobacco smoke) has been linked to lung cancer in non-smokers and respiratory problems in young children and infants.
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~:~..,.~ ~~~
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231 While these voluntary initiatives did res At in some phannacies. removing tobacco I I I I r I I , '•. I I I I products, a large majority continued to offer tobacco for saie. In June of. 1989, Council adopted a policy of disapproval of the sale of tobacco products In pharmacies. The College acknowiedged that It had no legal authority to prohibit tobacco sale and indicated that the policy of disapproval was circulated as guidance to pharmacists who had the right to make their own decision on the matter. At that time, College Council Indicated that It would review its policy on this matter on an ongoing basis. The policy nf disapproval saw.a few more pharmacies remove tobacco, but it became clear that the voluntary approach had reached a 'high water mark', with only a few additional pharmacists making the decision voluntarily, the rest continuing to offer the product for sale. As. a result of this review, inciuding representations from hiterested parties, as well as anti-smoking groups, the Council, In October 1990, adopted the following motion: 'Whereas ft is the Intention of this Councii to work towards the elimination of tobacco sales In pharmacies as qu ckiy as it Is practical to do so, be it resolved that a special Task Force be established by the President, such Task Force to present to Council ways to accomplish this objective and that the.finai report be presented to Council at the April 1991 meeting' A Task Force was accordingly struck with the following terms of reference: 'To assist Council In reaching the goal of eliminating tobacco sates in pharmacies by: 1. seeking the views of Interested parties on issues and conditions in pharmacy practice reievant -to the process of eliminating tobacco saies in pharmacies; 2. identifying the components ol an action plan to achieve the goal of the elimination of tobncoo sales in pharrnacies; I~ &a ZVk J N I J
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I I I I I I I I I I r I I I I I I I 232 3. identifying opportunities for individuais and groups both• within . and outside the profession tc work toward the broader goai of the elimination of tobacco us by society; and 4. reporting its findings and a course of action to the College Council in April 1991 ' The Task Force commenced its work, calling for submissions by inte~ested parties. The subject generated a great deal of interest, with about 200 submissions; the final report of the Task Force was presented to College Councilln June 1991 rather than April. TASK FORCE REPORT The Task Force Report !s appended to this submission. The Report, after discussion, was approved, with one minor amendment deaiing' with guidance to pharmacists respecting the reduction of tobacco promotion. The recommendations included: • that the College request the Minister of Health to table In the Legislature enabling legislation which wouic ban the sale of tobacco products In accredited pharmacies in Ontario Hiith a commencement date of July 1, 1993. This was the key recommendation in the report, and followed an examination of various legal options, including specific reference to the matter In the Code of Ethics for pharmacists or ea,tabiishing a• ban through professional - misconduct regulations affecting members. Although these were possible approaches, it was agreed that Legislation banning. tobacco from pharmacy premises was the best method. tW.».~.av.NlC+ae.ao.t2 599~ 4 I
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~ TABLE OF CONTFNTS 239 I I I I r I I I I I I I INTRODUCTION .................................... ......... 1 ONTARIO MEDICAL ASSOCIATION COMMENTS Persons under Nineteen: ...................................... 3 Prohibition of Sale in Designated Places : ............................ 4 Packaging, Health Warnings & Signs : ............................. 4 Vending Machines : .......................................... 6 Controls Related to Smoking Tobacco : ............................. 7 Inspection : ................................................ 8 Banning Spitting Tobacco ..................................... 10 CONCLUSIONS :........................................... 11 REFERENCES ............................................ 13 .JY 1
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• that this legislation be a cooperative effort between the College and the Ministry of Health. I I I I I I I I I I I I I • that, for the guidance of members, a recommended schedule of activities aimed at the progressive reduction of tobacco promotion In pharmacy premises be published. These ac:tivities Included the placing of all tobacco products behind services counteno, the elimination of back bar displays and all activities respecting the advertising and promoting of tobacco, logating tobacco products below the levol of the height of service counters and removing products from public view. • recommendations which contemplated the development of educational programs, In cooperation with tho Ministry of Health, utilizing pharmacists aimed at the prevention of smoking, inciuding the development of suitable materials and encouraging pharmacists to support and be Involved in .community programs aimed at the provision of appropriate Information.on the hazards of smoking. • a suggestion that the College.e urile the Minister of Health to examine the feasibility of establishing a controilod system of tobacco distribution, using as a model, the sale of beer and liquor. . This report was sent to the Minister of Health shortly after Its adoption. The Health Ministry acknowledged receipt of it In August 1991 and pointed out that a comprehensive provinoe-wide tobacco control strategy was being deveioped. GOVERNMENT PROPOSAL5 In January 1993, the Ministry of Health circulated a tobacco discussion paper which Identified the health Issue respecting hobacco and set out a tobacco strategy proposai inciuding.legisiative initiatives. These proposais had particular focus on smoking in adolescence and included tho following statemerit: f.lu~rr..p~.Arbp~eMm,/1d 2iW U. 233
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I I I I I : I: I r::: . I I I <: !• I I - We also note, and agree with, the one-year commencement period set out in Section 4(3) of the Bill to enable pharmacy owners to have the opportunity to. comply with the provisions of this legislation. CONCLUSION The College, is aware of the controversy surrounding the Issue of tobacco sales In pharmacies. This has been a difficult Issue for the profession as well as the College. Self regulation Is not always easy and the speculation you have heard about our election results reveals some misunderstanding about the objects of professional regulation, as illustrated b!t the Regulated Health Professions Act, of which pharmacy Is a part. While all pharmacists, In our experience, appreciate the health hazards associated with tobacca use, there are differences respecting how to deal with tobacco sales. For its purt, the Ontario College of Pharmacists Is convinced that the sale of tobacco In pharmacies, a health care facility, Is simply incompatible with the role of the pharme.cist as a professionat providing.heaRh care to the public. That is the reason for the College's policy on this matter, and that Is the reason why we support Bill 119. o1) ~, r .• r-
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I I I ~ I I w I I I • Require the reporting of the name and location of retail outlets selling tobacco • Require the reporting by wholesalers of.the volume of tobacco sales by type (cigarette's, fine cut tobacco, cigars), time (for example, by quarter year) in a manner specified by the Ministry of Health. G) Enforcement of Legislation The strength of legislation comes through compliance with the law, supported by enforcement. We therefore propose to establish a system to ensure that penalties for violations against this legislation will be a deterrent to breaking the law. Types of penalties we are proposing are: • Set fines through ticketing. • Fines as determined by the court. • Placement of a restraining order on premises prohibiting continued selling of tobacco products, or other penalties under a licensing or permit system. N J ~ E) Speclat Circumstances There may be-special circumstances that require exemptions from these proposals. Full or partial exemptions found to be appropriate, and not inconsistent with the intent of the legislation, will be allowed. Areas already identified for exemptions are: • Smoking in.4 residential health facility that is the permanent home of the resident. • Tobacco use for aboriginal ceremonial purposes. F) Monitoring of Tobacco Sales' To monitor progress being made in moving toward targets established by the government, the legislation must provide a means to monitor tobacco sales. Knowing consumption patterns will also help with allocating resources for activities to reduce tobacco use. We therefore propose to:
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I ONTARIO MEDICAL ASSOCIATION 23? I I I I I I I I I I I I I I I THE OMA APPLAUDS THE THRUST OF BILL 119, 49ACT TO PREVENT 7~lE PROVISlON OF TOBAfCO TO YOUNG PERSONS AND TO gEGULATElTS SALEAND U,~BYOTNERS. AND BELIEVES THATTHIS IS AN EXCELLENT STEP TOWARDS PASSING COMPREHENSIVE TOBACCO LEGISLATION. The OMA Supports: • increasing the legal age of purchase to 19 • banning sales in pharmacies and other health facilities • banning sale from vending machines • posting of health warnings and age limits by retailers • banning of smoking in designated public places and in all health facilities • inclusion of warnings and other health Information as part of packaging and at point of sale • strong enforcement including fines and ban on sale of tobacco to minors The OMA Strongly Recommends that the Legislation be Strengthened by: • prohibiting smoking in pi_i public places except where exempt by regulation • consideration of licensing if the statutory prohibition has not worked by a given time - • banning kiddie packs by way of regulation • banning spitting tobacco, FEBRUARY 1, 1994 This is C•xbibit %W %'nr. ' Vo 1 r:c A,aidacit or ~ ~ '~"'ant"y .'::a
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I I I 1 I 1 I I I I I I I 2,330 accredited pharmacies. BACKGROUND Although it possesses significant p~armacoioglcal properties, tobacco has historically been considered a recreational substance and has been_freeiy sold in both pharmacyand non-pharmacy outlets in the province. The adverse effects on human health of the use of tobacco are well documented, and the contentious Issue of the appropriatenesp of the sale of tobacco In pharmaoies, 'which are facilities providing health care services to the public, has been discussed by College Council for.many years. COI.L EGE POSITION ON TOBACCO S M patrons on the hazards of tobacco use. I want to emphas.ize that the College's position that tobacco products be eliminated from pharmacies has been consistent since October 1990, spanning two Council elections, and most recently re-affirmed in June, 1993 by a vote of 13 to 6, with 2 abstentions. All members of Councii, whether appointed or elected, share a common public interest responsibility, and policy decisions -established by the College must reflect this responsibiiity; not the economic interests of Its members. The College's formal consideration of tobacco started about fifteen years ago. Concern about the acknowledged hazards of tobacco use prompted the Council of the Ontario College of Pharmacists to -jrge tfiose•members who chose to sell tobacco products In their pharmacies to post cautionary signs which complimented those warnings required on tobacco packa.ging and approved by Health and Welfare Canada. Then, during the 1980s, ths• Canadian Pharmaceutical Association developed programs urging members to voluntarily cease • the sale of tobacco products. The Ontario Pharmacists' Association supported these initiatives as did the College at that time. The College also encouraged pharmacists to educate their
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I 1'. I • Ensure that minors do not have access to tobacco products from vending machines. Minors might respond to the new restrictions on buying tobacco in stores by increasing their buying from unsupervised vending machines. To prevent this, vending machines must be under the direct supervision of an adult, and further restrictions may be considered. • Establish a minimum package size for cigarettes. Price increases have proven to be effective in reducing buying of cigarettes by children and adolescents. Smaller pack sizes of five or 15 cigarettes, nicknamed''kiddie packs," make it easier for youth with limited cash to buy cigarettes. B) Environmental Tobacco Smoke Environmental tobacco smoke (ETS) is the combination of smoke that comes from the burning end of a cigarette, pipe or cigar (sidestream smoke) and the smoke that is exhaled by the smoker (exhaled smoke). ETS is also referred to as second-hand smoke. Breathing in of ETS is known as passive or involuntary smoking. ETS is a widespread and harmful indoor air pollutant. It aggravates pre-oxisting conditions such as angina and respiratory diseases. It also affects pregnancies. More than 3,000 chemicals have been identified in ETS. They include carbon monoxide, carbon dioxide, ammonia, €otmaldehyde, nicotine, tars and other substances, such as benzene, that are known to cause cancer in humans. Placcs where people routinely go for their day-to-day business and pleasure activities should be free from this environmental health hazard. Restrictions on smoking also help change social attitudes about the acceptability of smoking. They may also make smokers decide to quit or reduce their use of tobacco products. Children deserve special consideration. They should be protected from exposure to second-hand smoke to -protect their health. In addition, restrictions on smoking in public places will reduce the examples that teach them smoking is an appropriate adult behaviouT.,_ Most Ontarians live in a municipality with'some bylaws that restrict smoking in public places. There can be considerable differenees among municipal bylaws. The provincial legislation will set a minimum level for these restrictions, and allow municipalities to keep, or add, bylaws with further restrictions. 203 I
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229 I ,1 I . I I I I I I I I ' 1. SUBMISSION TO THE STANDING COMMITTEE ON SOCIAL DEVELOPMENT OF THE LEGISLATIVE ASSEMBLY RESPECTING BILL 119 1•his is Exhibit "b "C ~' to the Affidavit of JL~rn1Gb Qwnwta, Sworn by me this AZ. Da of Jwru,tA*wrj&D, rf 4S' ~mmi AN ACT TO PREVENT THE PROVISION OF TOBACCO TO YOUNG PERSONS AND TO REGULATE tTS SALE AND USE BY OTHERS FEBRUARY 10, 1994 The Ontario College of Pharmacists ffppreoiates the opportunity to make the following submission to the Standing Committee on Social Development respecting 6i11119 (The Tobacco Control Act, 1993). We also oomPliment the Committee on the work It is doing; and the time It Is taking on this important matter. THE ONTARIO COLLEGE OF PHARIuthCISTS The practice of pharmacy Is Included in the list of health professions regulated by the Regulated Health Professions Act, ard the Ontario College of Phannacists Is Its governing body. Established in 1871, the College's mission Is to contribute to the health and wellbeing of the public of Ontario by ensuring that pharmacists provide optimal pharmaceutical care. In carrying out its objects, the College has an overall duty to serve and protect the publlc intersst. While College Council consists of, In the majority, pharmacists elected by their peers, It does not represent the mercantiie interests of pharmacy. , . The College's mandate Includes responsibility for licensing and regulating pharmacists In Ontario, the accreditation ot pharmacies In compiiance. with operational standards, and regulation of the diStribution and sale of drugs to the public. There are currently about 8,230 pharmacists on the College Register and f.v~rHKrw^W'~mo AG 7~1.M . . i
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I i. - I I I 1 I I I . I I Annual funding of $4.8 million has been provided to implement these'initiatives. ln addition, funding for Tobacco Use Prevention programs delivered by local Boards of Health has been increased by 53.5 million. Purposes of Legislation and Proposals A) Children and Adolescents In a long-term effort to create a healthier Ontario, it is essential that we prevent , ehildren and adolescents from ever beginning to smoke. The Chief Medical Officer of Health, in his 1992 report Opportunities for Health: A Report on Youth, states that "Eliminating smoking by young people is the front line in the war against tobacco use. The vast majority of smokers begin their addiction as teenagers. Once established, the addiction is difficult to break. People who reach the age of 20 as non•smokers are unlikely to become smokers." Tobacco is a hazardous, addictive substance. Its distribution should be more controlled. Our legislative proposals are directed at ensuring minors do not have access to tobacco products. We need to strengthen current bans against selling, giving or furnishing tobacco to a minor. The responsibility for this lies not only with retail stores, but with the entire community. Residents must support•their retailers in not allowing children and youth access to tobacco products. We therefore propose to: • Raise the age of a minor, for the purposes of tobacco sales, from 18 (the current law in Ontario) to 19 years. This will remove legal access to tobacco from our students in high schools. It will also make the age of majority for tobacco use consistent with that for alcohol use. And.it will allow the use of Age of Majority identification cards when buying tobacco. • Require tobacco retailers to confirm that the person buying tobacco products is age 19 or older. If vendors are unsure they must ask for photo identification to make sure that the purchaser is of legal age. • Require tobacco retailers to place in stores clearly.visible signs that state - selling or providing tobacco products to persons under 19 years of age is prohibited by law. This will remind all store staff, tobacco buyets and other customers that it is illegal to sell, give or furnish tobaccoto a minor. 4 202
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Li I I I I I I I I I I I I I I I I ONTARIO MEDICA ASSOCIATION COMAENTS Persons under Nineteen: Passage of the Ontario Tobacco Act would put into effect the position of the OMA regarding the health of the youth of Ontario. Raising the legal age of purchase to 19 will aid in the long- --term objective of blocking access of minors to tobacco industry products. This would put tobacco usage in the same category as alcohol. Purchases could then be tied to the use of an Age of Majority Card which is already utilized for the purchase of alcohol. According to the Chief Medical Officer of Health, the behaviour patterns and choices of young people have immediate consequences for health and growth. The OMA supports the emphasis on the prevention of tobacco industry product use by children and adolescents in the Tobacco Control Act. Data from Health and Welfare Canada indicates that the mortality rate attributable to smoking has declined 11 % for men and 9 % for women between 1985 and 1989. However, among women aged 15 to 19, the proportiori of smokers has actually risen slightly in the last 20 years. A study carried out by Health and Welfare Canada in 1989-90 indicates that females are using tobacco industry products at higher rates than males during their teens. Health and Welfare Canada notes that trends in smoking mortality reflect trends in smoking prevalence two decades earlier. That is, tobacco product-related mortality is associated with past tobacco use behaviour because of the latency period between exposure and the onset of disease.(')(2) Targeting the prevention of tobacco addiction among children and adolescents therefore becomes an even more critical strategy for the government of Ontario. -3- 244 .a. r
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250 I I I I I I I I I 30 31 A.J. Dunsdon patient, yes. And those are the subject of guidelines as you see on that page. 10. Q. The dialogue is intended not only from the pharmacist's point of view to elicit information, but I suggest also to provide advice from the pharmacist to his patient? 11. A. Q. Yes. Now then, as I understand it, you have said in paragraph 19 that pharmacists selling tobacco products is incompatible with their role as health professionals. 12. A. Q. That's correct. Then starting at about 15 years ago or early 1980 or late 1970's, the College urged their pharmacist members to post cautionary signs about the uses of or the effects of the use of tobacco in pharmacies? A. Yes. The cautionary signs were to mirror the hazardous warnings that were being developed for tobacco use at that time. 13. Q. And certainly the College, when you say it urged its members, did the College send out a bulletin or an advisory to its member pharmacists? A. At that time we communicated to, pharmacists monthly by a bulletin called the "ontario College of Pharmacists Newsletter," and it contained matters of interest to pharmacists every month. This sort of communication would be an example of what would be included in that newsletter at that time. 14. Q. Did that newsletter or communication Rosenberger, Weir, Macdonald Paul W. Rosenberger, Official Examiner Toronto, Ontario .
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I. I I I I I I I I I I I I p 15. 16. A.J. Dunsdon dealing with posting of cautionary signs on the effects of the use of tobacco go out once or was that sort of urging communicated more than once? A. I don't know. I think that I would have to refresh my memory as to how many times it went out. I know it went out but I don't know whether it was twice, three times, once. I would have to refresh my memory on that. U/T Q. May I ask you to do two things, and I don't want to make this task too onerous, could you see if you could give me an example of the advisory or bulletin which went out which includes such a notification? And as I say, I am not concerned whether it is the first one or one in mid-course, if they went out for a period of time. And could you also, besides providing me through your counsel with that bulletin, tell me, again in general terms, whether it went out on a few occasions over a few years? And as I say, I don't intend you to go and count up every single one and tell me it went out 14 times as opposed to 11. A. M'hmm. Q. Just if in looking it up you can establish that, yes, there were a few and spanned a couple of years, that would be helpful. MR. CHARNEY: Do you think you have copies of the old bulletins that are accessible to you? THE AFFIANT: I will look and see. I imagine we have the files on these things and I will take a look and see. As, of course, we get closer to today, it's--there's more certainty Rosenberger, Weir, Macdonald Paul W. Rosenberger, Official Examiner Toronto, Ontario .
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I I I 1 I 1 I I I I I I I I I I public, especially youth, that there j,t something different about cigarettes, and would be consistent with messages to the population about the health risks and health hazards associated with tobacco industry products. 'In the interest of Ontario's health, plain packaging has been identified as having the potential to be the most important reform in the comprehensive Tobacco Csnh419s;3• A recent study, carried out by the Centre for Health Promotion at the University of Toronto for the Canadian Cancer Society, provides strong support for the inclusion of plain packaging as part of the comprehensive plan to reduce tobacco use, especially by the young. The OMA strongly urges the government to ensure that this component of the comprehensive tobacco strategy is addressed in regulation as stated in Section 5(a), ie., "the tobacco is packaged in accordance with the regulations,". The OMA has stated that smokers, and children and adolescents who may become smokers, have the right to be adequately and correctly informed regarding tobacco, not only as a hazard to their health, but as a leading cause of death. In order for children and adolescents to make health decisions, they must receive the necessary information to be able to do so. "Informed consent" can be achieved in several ways. Warning labels and health messages on and inside cigarette packages, should target children and adolescents, as well as adults concerned about their children. This would help the purchasing consumer differentiate hazardous tobacco products from other products which are safe. - 241 The 1992 U.S. Environmental Protection Agency report on environmental tobacco smoke (ETS) and the accumulating scientific data on consequences of active smoking all conclude that tobacco smoke kills. Therefore, there must be an improvement of information regarding the toxic contents in the smoke which both the smoker and the non-smoker inhale. This information must reflect the magnitude of the risk of using these products. It is essential that the provincial health_..., warnings, which are mandated under regulation to be on the package, reflect an improvement -5-
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I : IIVTRODUCTION 239 I I I , I I I I I The Ontario Medical Association (OMA) has, over the last 15 years, taken a strong stand against society's number one preventable public health problem... tobacco use. Organized medicine is very concerned about this issue as it recognizes that tobacco industry products cause over 13,000 deaths among Ontarians annually. The OMA Committee on Public Health has addressed in detail the issue of smoking for many years. The OMA policies and positions have included: • banning tobacco use from the OMA offices and all-OMA related meetings; • encouraging physicians to actively participate in programs directed at prevention and reduction of tobacco use and involuntary exposure to smoke; • urging both the federal and provincial governments to substantially increase retail cigarette prices and recommending that revenues received through taxation be used to promote smoking cessation programs and ongoing research, and programs to prevent children from becoming addicted; ~ • raising the awareness of all individuals regarding the hazards of environmental tobacco smoke (ETS) in the home; in particular, informing patients and •parents of infants and young children and those with asthma and bronchitis of the long term effects of ETS. I I The OMA has aiways considered the use of tobacco industry products to be one of the most important public health issues. The OMA wishes to strongly signal its support for the intent of the government's legislation, Bill 119, An Act to prevent the Provision of Tobacco to Young Persons and to Regutate its Sale and Use by Others, (The Tobacco Control Act). We understand that the government is striving to reduce tobacco use in'the province and prevent children and teens from becoming involved with an addictive and lethal product through
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I I I I 1 I I I I . I I I I I I I REFERF.\`CES 1. Collishaw, N. E., Leahy, K. Mortality Attributable to Tobacco Use in Canada, 1989, Chronic Diseases in Canada, Health and Welfare Canada, Vol. 12, No. 4, July - August, 1991. 2. Morin, M., Kaiserman, M.J., Leahy, K. Regional Mortality Attributable to Tobacco Use in Canada, 1989, Chronic Diseases ' anada; Health and Welfare Canada, Vol. 13, No. 4, July - August, 1992. 3. Altman, D.G., V. Foster, L. Rasenick-Douss and J.B. Tye. 1989.. Reducing the illegal sales of cigarettes to minors. Journal of the American Medical Association, 261(1): 80-83. 245 .
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I I 1 2 1 3 4 , 5 6 7 I 8 9 10 11 12 13 14 I 15 16 ' 17 18 ' 19 20 , , 21 22 23 I 24 25 I 26 27 28 29 30 31 I I A.J. Dunsdon 25. - 9 Committee of the College, but I would have to, again, refresh my memory as to precisely where it came from. But suffice it to say, the result would be as a result of discussion at the Council before a policy would be adopted. Q. And is it then fair to take from that, that if it came through the Ethics Committee-and went to Council and was debated in Council, that the policy came about as the view of the College that it was compatible with a pharmacist's practice to advise and warn his customers about the hazardous effects of tobacco? A. I wouldn't use the word "compatible." I would use the word, perhaps, "obligation." It would be seen as an obligation, but compatible, I would not--= 26. Q. All right. Let me change it. So it was certainly the view of the College that it was the obligation of professional, the pharmacist in his role as a health to advise his customers that use of tobacco products was hazardous? A. It was seen as an appropriate thing to 27. do, yes. U/T Q. I would appreciate if you are looking and you can, without too much trouble, find if it came through the Ethics Committee and just let me know that fact, that would be good. 28. A. Q: Yes. Thanks. As I read paragraph 12 through to 14 at least, that policy advice which came out in the early 80's, didn't have its intended effect on Rosenberger, Weir, Macdonald Paul W. Rosenberger, Official Examiner Toronto, Ontario 254 .
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23Q: I I I I I I I 'As It is contradictory for health prolessionals who restore and promote good health to sell tobacco products that are harmful to health, we propose to: • prohibit the sale of tobacco products in health facilities • prohibit the selling of tobacco products in pharmacies.' The Ontario College of Pharmacists, in commenting on the discussion paper, affirmed Its policy position respectirny the elimination of tobacco products in pharmacies, reiterated its view that a commencement date for enabling legislation should be in place, and expressed aupport for the idea that premises which contained a pharmacy should be•free of the sale of tobacco. 'Bill 119 was then given First Reading as a government E;ill on November 22, 1993., COLLEGE POSITION ON TFJE BILL The College commends the Introduction of this proposed legislation and supports ," the provisions of Bill 119. Noting that the BIII contains a number of provisions , relating to such matters as packaging, warnings, vending machines and controls relating to smoking, our comments_wili be focused on the matter of prohibition of ~ sale In designated places, as set out in Section 4. The College concurs with the inciusion of. pharmacies as designatad places for the purpose of the Bill. ,` Pharmacies operate In a retail environment and many (but not all)_include a wide variety of goods in their premises. However, unlike other retailers, they also provide , prescription and non-prescription drugs to the public. While accredited pharmacies are established in a variety of community settings, It Is our position that all , pharmacies provide an essential health oare service to the public and, accordingly, meet the definition of a heaRh care facilhy. We note that, included in the definition ' of a designated place, is a retail estabiis,hment if a pharmacy Is located within the establishment or 'customers of the pharmacy can pass- into the establishment , directly, or by the use of a corridor or area used exclusively to connect the pharmacy with the establishment'. We are pleaned to see this definition as it results In , equitable treatment between such establishments referred to as 'non-traditional N pharmacies' and pharmacies that 'stand alone'. 00, ~ cv....+ywwpmae a~x aw ~ co ' M
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r ' 1 2 , 3 4 , 5 6 , 7 8 9 ~ : 10 11 ' 12 13 14 , 15 16 , ' 17 18 r 19 • 20 t _ 21 22 Y 23 ` ' 24 25 I 26 27 28 29 30 31 1 A.J. Dunsdon 253 - 8 that you put these signs up. My recollection was that it would be in the area of the pharmacy where tobacco products were being sold. And the third part of my recollection is that the content of those would be following the more or less equivalents to the hazardous warnings that were being placed on cigarette packages at that time. I don't--- 21. Q. Which is words to the effect that tobacco is deleterious to your health? - 22. A. I think hazardous to your health. Q. Hazardous to your health. A. Something of that sort. I don't recall any specific size being suggested, only that it be posted in the area of the pharmacy where cigarettes may be sold, and it obviously would apply to those pharmacies that were selling cigarettes. 23. Q. Prior to such urging by the Council to its member pharmacists, would it have been the subject-matter of Council? a debate and resolution at A. You mean this matter? 24. Q. Yes. A. Yes. Any matter, any policy decision that is made by the College would be made through its C admin which be a examp ensue ouncil istrat would positi le of I be d as a as op ive th be no on on that. lieve resul posed to the registrar or some ing. I am talking policy here t a matter of regulation. It would the matter and this would be an that in this case, the discussion... t of a report from the then Ethics Rosenberger, Weir, Macdonald Paul W. Rosenberger, Official Examiner Toronto, Ontario 1"
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11119IDS 09:16 $3:7 7$30 HOH.COH. U-ALTH -OSd t~,o07 01; ss,rs/a1 16:os ITlis 327 8?9t COU,I! G 1,VF0 9tHF ••• A0B CO)l. Iik.+.Tn Zoos i 305 ~ 1 . I I sTATRNENT SY RO'!8 GRIER MINI6TER OF HEAIrTB TO !kE LE3I8LATQRL RE TOBACCD CONTROL ACT 22, NOVF1d8PR ;.7., 1983 ! I I I Dratt November 17/93 1:30 p.m. CHECK AGAINST DELIVERY
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I I I I I I I 17. 18. 19. 20. A.J. Dunsdon - 7 25? to what we have done. What you're referring to is a matter which took place 15 years ago. MR. LENZCNER: Q. I appreciate that. A. The one that I'm recalling as, perhaps, a more current example was the policy of disapproval of the sale of tobacco which was issued as a stand- alone communication. My recollection is that it was sent out as a letter to members, and that was in 1989 and that was referred to in our--in one of the exhibits. U/T Q. All right. That's true. And that was the other thing that I was going to ask you for, is if you might provide through your counsel, a copy of that policy--- A. Yes. Q. ---that went out? Thank you. MR. CHARNEY: With regard to the earlier bulletins, we'll make our best efforts to look for those and if they're available, then we'll provide the copies and try to get you an approximation of the number of times it went out. MR. LENZCNER: Thank you. Q. Do you recollect, Mr. Dunsdon, whether you recommended the type of cautionary sign that ought to be put up in the pharmacy, where it should be put up, lettering size, that sort of thing? A. My recollection is that first of all, it was a matter of a request as opposed to a standard or it was not intended to be a position that you must put these signs up. It was a recommendation Rosenberger, Weir, Macdonald Paul W. Rosenberger, Official Examiner Toronto, Ontario .
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, I I I 1 ' ;. I I ' I I ONTARIO COURT OF JUSTICE (GENERAL DIVISION) BETWEEN: LARRY ROSEN and SAV-ON DRUGS LIMITED and HER MAJESTY THE QUEEN IN RIGHT OF ONTARIO AFFIDAVIT OF ANASTASIA ERLAND 273 Plaintiff Defendant I, Anastasia Erland of the City of East York in the Municipality of Metropolitan Toronto, MAKE OATH AND SAY AS FOLLOWS: 1. I am the Assistant Director of the Communications and Information Branch (the "Branch") of the Ontario Ministry of Health (the "Ministry') and as such have knowledge of the matters hereinafter deposed. 2. Question and Answer documents ("Qs and As') are informal notes prepared by program staff and reviewed by communications staff. The purpose of these documents is to provide the Minister with the types of questions that it is anticipated will arise either in the Legislature or in a press conference. The documents provide suggested answers to each question in plain language format. 3. Question and Answer documents often accompany a formal briefing note. They may be reviewed by the Minister prior to or during a formal briefing by program staff on an issue .
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pornographic videotapes. This will be one more step to ensuring that minors do not have access to tobacco products. Controls Related to Smokine Tobacco: r I I I I I I I I I I I The OMA strongly urges the government to continue to strive to meet its health target as stated in the January 1993 discussion paper on the then planned tobacco legislationi "By the year 1995, increase to 100% the proportion of schools, workplaces and public places that are smoke-free". At this point in time there is little to indicate that the government is beginning to move toward fully achieving this goal. In particular, the Tobacco Control Act does not address the control of environmental tobacco smoke (ETS) in the workplace. In April 1983, the OMA hosted a conference entitled "Health Effects From Passive Tobacco Smoke". The OMA has recognized ETS as a health hazard for many years. The OMA recognized a scientific basis for the view that there are short term .(acute) and long term (chronic) health effects from exposure to ETS in the home, public buildings, workplaces and transportation facilities, and that this exposure is a significant factor in serious respiratory, cardio-vascular and other diseases. A 1992 report from the United States Environmental Protection Agency, "Respiratory Health, Effects of Passive Smoking; Lung Cancers and Other Disorders" has concluded that "widespread exposure to ETS in the United States presents a serious and substantial public health impact". There is no reason to think that ETS in Ontario would have any less of a serious and substantial public health impact. The report notes that, in children, ETS is causally associated with many illnesses and, in non smoking adults, it is causally associated with lung cancer. Children_become adults. ETS will have an impact on the health of children and further impact their health as they reach adulthood. -7- 242
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01i04i1900 15:03 FROM TO 773601054 P.06 I I legislating the following measures. • an in=ease in the legal age to buy tobaoco fmm 18 to l9; • a ban on the saie of tobaceo in pharntaeies and other health facitides; .• prohibition of the sak of cigarettes from vaWing machinCS; • a requirnment that tobaoco retailers must post health warnings and age Gmits on their premises; • probibition of smoldng in designated public placea and all hWth fadlities, except for residential facilities such as nursing homes; • a roquirement that•health warnings and other health infortnation be included as part of tobacco packaging; and • provision for an enforcement that includes fines and bans on the sale of tobacco to rninots. The government is seeldng to devote more resources to illness prevention, health promotion and community-besod cam in order to promote a higher level of health and well-bdng for all Ontariazis. Today's leading cause of pieventsble disease, disability and death is tobacco. The Tebaoco Controt Act will directly address this leading cause of disease, disability and death, and result in a major step towards acdtieviag the govemment's overall goals of lAness prevention, health promotion and community based care. The Tobacco Control Act is a ctitioal step towards comprehensive tobacco product control in Ontario. for preventive medicine that we have seen. The OMA strongly supports the ttuust of the Tobacco Contml Act. It provides critical impetus towards what the OMA considers to be the most impottant and innovadve pmvincial legislation The OMA wishes to tnake specific comments persaining to the Tobacco Control Act. _y. M 2.39'A l•n
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I i I I I I I I I I outright in the Toba o Control Act. CONCLUSIONS: The Act targets children and adolescents and demonstrates the government's commitment to health promotion and disease prevention. It is known that smokers rarely start smoking after age 20. No one except the tobacco industry would deny that the use of tobacco products is a major health risk, that it is a major contributing cause of: • cancer of the lung, mouth, tongue, jaw and the throat; • heait disease and strokes; • diseases of the circulation system in the legs and arms;_. • biritting problems for mothers and their babies; • emphysema and other chronic obstructive lung diseases...and on...and on... There is no doubt in the medical and scientific communities that smoking is a major health hazard. Tobacco use is the single most important cause of preventable disease in Canada and in Ontario. Physicians are witness to the results of smoking on an ongoing basis in their office and in health care facilities. At a time when health care costs increasingly consume a major percentage of Ontario's budget and smoking is known to cause disease and disability, it is imperative that the government ensure passage of legislation which is comprehensive, including provincial packaged-based and point of sale warnings and health messages which will prevent tobacco use, particularly by children and adolescents The 3 annual reports released by the Ontario Medical Officer of Health, identify the elimination of tobacco use by youth as one of the main means of preventing disease, disability and death. The 1993 report further states that, based on scientific research, ischemic heart disease, the 24 4. .
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I I I I 1: , I I I I I I , ii I -2- or, where a formal briefing is not required, they may be reviewed informally by the Minister as part of general information on an issue. 4. Question and Answer documents are not policy.documents. They do not reflect the formal position of the government on a particular issue. They are not intended for release to members of the press or to individuals outside of the government. 5. Question and Answer documents do not go through the formal approval process that documents representing official government position are required to undergo. Therefore, unless the Minister specifically refers to the content of a Question and Answer document, the information contained therein is not considered to be the formal position of the government on a given issue. 6. In November of 1993, staff of the Health Promotion Branch developed a draft Question and Answer document for the Minister's benefit at first reading of Bill 119, the Tobacco Control Act (the "Act"). A draft --was reviewed by personnel in the Communications Branch and a final version, also dated November 19, 1993, was prepared. Attached hereto and marked as Exhibit "A", is a copy of the final version. 7. The draft Questions and Answers dated November 19, 1993, identified as Exhibit "B" to Larry Rosen's cross-examination, is a draft prepared by the program staff. When received by the Communications Branch, the draft was edited and reformatted to produce the final version attached as Exhibit "A". 8. To the best of my knowledge, based on my discussions with my staff in the Communications Branch, neither the draft Questions and Answers nor the final Questions and Answers were distributed to the media or the public af-the November 22, 1993 press conference or at any other time. As indicated above, these documents are intended for the assistance of the Minister, and not for distribution.
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is to reduces the percentage of those 12 - 19 who smoke to 10~'o by the year 2000. The Tobacco Control Act as written provides for the statutory_prohibition of the sale of tobacco to minors and of sales in designated places. For this to be successful, it will be critical that the needed resources be allocated for the enforcement of this section of the Act. Enforcement will be the key; without proper enforcement, the government will not be able to meet its targeted -reduction in tobacco use by youth. ... Retail stores supply a significant proportion of tobacco industry products to minors. It is therefore important that tobacco retailers become an integral part of the process of eliminating tobacco sales to minors: The traffic generated in retail stores from the sale of tobacco products is significant and few retailers would risk their tobacco license by selling tobacco to the underaged. . A licensing system would therefore further deter vendors from selling or giving tobacco products to children, including youths who state that they are doing so for an adult. Recent studies have indicated that education alone has had little effect on reducing illegal tobacco sales to minors and that vendor licensing is effective.in decreasing the rate of tobacco use by youth. (1991, Journal of the American Medical Association, 266[22]). The OMA and the health community has strongly recommended that the government introduce a licensing system for retailers to prevent the sale of tobacco industry products to children. Therefore, the OMA strongly recommends that the government closely monitor the enforcement system as currently written into the legislation. The OMA further suggests that, to facilitate this process, the Ontario Chief Medical Officer of Health be required to report annually with regard to the provinces's tobacco reduction targets and compliance with the Tobacco Control Act. If the decrease in the rate of cigarette' use by children and adolescents does not meet targeted expectations within 12 - 24 months of proclamation of the Act, the OMA strongly urges the government to take the necessary steps to implement a licensing system financed by licensing 243 -9- I
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-4- I I 9. The Canadian Oncology Society is a group of physicians whose mission is the particular study of cancer treatment and prevention techniques. 325 I I I I I I I I I I I I I 10. -- The Council for a Tobacco-Free Ontario is a coalition of many health agencies in Ontario whose mission is to promote reduced tobacco use through education. 11. Physicians for a Smoke-Free Canada is a national organization of physicians which is in the vanguard of efforts by the medical profession to combat the epidemic of tobacco-caused diseases. 12. The Non-Smokers Rights Association (the "NSRA") is a non- profit health organization whose mission is to reduce the morbidity and mortality rates associated with tobacco use in terms of both active smoking and environmental tobacco smoke. The NSRA has received the Gold Medal of the World Health Organization for its work in tobacco control. Tobacco and Health 13. Tobacco is the only product legally available in Ontario today which, when used precisely as intended, is known to be harmful and often fatal. It is beyond any doubt that tobacco use is a principal cause of deadly cancers, heart disease and lung disease. A recent landmark study published in the highly respected British Medical Journal revealed that about half of all regular long-term cigarette smokers will eventually be killed by their habit. A copy of the relevant article is attached to this affidavit as Exhibit "A".
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11,19, D) 0D:36 $):S 7:]0 y0a CO.y. k'EAl.id ... os.i - ,. it ti; aa t6:0o e itfi 32' sT o; C091N i?NFO B1e'r ••• lluR :01. yE.kL:R .? e:a ' 30E; I Mr. Speaker: I am proud loday to table Thc TS:bacco ConZ,roi_Act, an important part of Ontario•s Tobacco Stretegy• I I I I I I I I I I This legislation will reduce tobacco use by Ontariaris and prevent unnecessary deaths, since one in five deaths among adults in Ontario ic attributed to tobacco use, and tobaeco-related lllnessna are responsible for 1Y,OCC prever.table, premature deathe. The Tobacco Control Act will prevent young people from taking up a habit that can become an addiction for life, giving ua the power to face a clear enemy to publio hnslth. T am pleased to highlight the major features of tha new legislation: . We vili maXe it illegal to give or ssll eigarettes to anyone 8ndor 19; - . We vill ban the sale of tobacco in pharmaeies and other health facilitiea; . ve vill prohibit the sale of tobacco produets from vending machines: • We will roquira rotailerA selling tobacco to post health varaings and ago limits on their premise4t
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-7- I I I I I .I I I I I I I I I L 23. Tobacco use is known to be a major cause of cervical, gastric, renal, pancreatic, bladder, esophageal, oral cavity and laryngeal cancers. 24. In addition, tobacco smoking is the major cause of emphysema and bronchitis. Over 80 per cent of all emphysema and bronchitis deaths are caused by smoking. - 25. In summary, over 13,000 Ontarians die each year from a disease caused by their tobacco smoking, the equivalent of a community the size of Niagara-on-the-Lake. At least one out of every five deaths among adult Ontarians is attributable to tobacco use. 26. Tobacco induced diseases and deaths are almost entirely preventable. Most new users of tobacco industry products come from the child and adolescent market. Many of these users become addicted to these products before the age of responsibility or before they leave their adolescent years. 27. According to reliable statistics, about 10,000 persons commence smoking in Canada each month. Research shows that smokers become addicted after smoking only a few packages of cigarettes. Of those 10,000 starters, about 30 per cent will die of tobacco related illnesses. 328 N W N J i! r
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I I I I I I I I I 1 I i: 11'14'ql Oq:3' $l:i ;330 ypp C09. HEALTR --- 05A ti J11 Olo 11/1"q.1 16:10 '5:16 3,17 si9: CO)t)l & ISFO 4THF .-- SIOH CJII. HYALV Z~1J -5- While The Tobacc Control Act will give us rQ~Julhtory power over packaQinq issues, we hava wiitten to our federal oountorparts caakinq their support for a national strategy on packaqing. xe feel a national approach would clearly bn the most eTEective way of dealing wiUl this issue. we cannot stand ctill in our fight against the province's number one prevenldble health care problem. This legislation is a majnr step toward achieving our goal oL a heal6hinr life and envirenrcnt for all Ontarians. Thank you, Mr. Speaker. -30- I
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-S- I , I I ' I . I I I I I I r 14. Among young Ontarians who continue using tobacco five to six times more will die prematurely of disease caused by smoking than will die from car accidents, suicide, murder and AIDS combined. Yet all tobacco- caused disease and death is fully preventable. In fact, tobacco use is the leading preventable cause of death in Ontario. The health' consequences of tobacco consumption are set out in great detail in the report of Dr. Donald.T., Wigle, which was prepared in connection with the trial in the Quebec Superior Court relating to the validity of the federal Tobacco Products Control Act. A copy of the said report is attached as Exhibit "B". Tobacco and Tobacco Consumption in Ontario . 15. Tobacco contains over 4,000 chemicals, several hundred of which are known to be toxic and over fifty of which are known to be cancer- causing. 16. As reported by the United States Surgeon General, scientists agree that nicotine found in tobacco is a powerfully addictive drug. Pharmacological and behavioural processes that determine nicotine addiction are similar to those that determine addiction to drugs such as heroin and cocaine. For most tobacco users, nicotine ingestion is a crucial component of their repeated use of tobacco. 17. Most tobacco smokers in Ontario start smoking regularly in their teens. The average age at which children in Ontario regularly start smoking is about 15 years. f
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-6- I I I I t 1 1 , t. I I I r 18. About 28 per cent of Ontarians over the age of 15 are tobacco smokers. There are now more women cigarette smokers in Ontario than men. Medical Consequences of Smoking Tobacco 19. Heart disease and stroke affect all age groups, accounting for about 40 per cent of all deaths in Ontario, or approximately 18,000 deaths each year. Use of tobacco is responsible for about 30 per cent of all deaths from coronary heart disease. 20. Tobacco smoking is the major preventable cause of cardiovascular death in Ontario. Tobacco smokers have two to four times the risk of sudden heart attack death than non-smokers have, and almost half of all coronary heart deaths among men are attributable to smoking. 21. --The second leading cause of death, cancer, accounts for 25 per cent of all deaths in Ontario. Tobacco use is the cause of more than 30 per cent of all cancers, including 85 per cent of all lung cancers. 22. Lung cancer is by far the largest cause of cancer death for men in Ontario, and has matched breast cancer as the most important cause of cancer deaths among women. Lung cancer deaths for Ontario women have increased almost threefold over the last 20 years, paralleling a similar increase ~ in tobacco use among women over a period commencing approximately 20 years earlier. /o 3'.) 7 .
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I I I I I I I I A •A -•n0 09:37 '$3:; T:30 SOH Co7t- HE ALTit ... OSA 0 + ;_ . , 16.10 a as a:-, s-9 i co~nc c:%FO 9THF •-• uoH Coa. NEsL;H Zot: -3-. Indaed, statistics indicate that 24 per cenl ut ontario students aged 12 to 19 nov smoke. As renowned Oxford University epideIDiologi5t Richard Yeto has said, "if you want to kill yourself, the best way to do it 15 to start ;smokingl as a teenager." We want to roaoh young people before they start: The statistics on tobacco use are frightening. Tobar.co causes about e0 per cent ot all lung cancerb, aa well as many other forms of cancer -- including mnuth, throat, esOphaqus•and bladder cancer. Tobacco eauses CO per cent oi chronic lung diseaae, such as emphysema and chronic bronchitis, and one-third of prematut'e deatha due to heart disease. 1 I I I I I S1nce 1970, the rate of lung cancer In women has tripled. it's an epidmnic -- the second leading cause of cancer deaths in women, with the number of deaths nearly equalling that. tus breast cancer. A11 as a result of women atarting tn amoka 20 to 30 years ago.
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iI I I I I I I I _~_31•19•G7 09:75 $7:f ~;70 YOH Col. HEALTH -.. OSA . zu03•o:> :1•:7•97 Ss•o7 $`118 1;~ aTel ^ ~A~OfL. IVFO 8?9F .•. llOH COa• U1LIh ~;103 -2- Tebaeae Use Among Children • Smokers rarely begin their habit after age Yn. . According to the Addictlon Research Poundation, 24 per cent of students in Grades 7 to 13 (OAO) smoke. The numbers are about cqual for males and famalss. Sinee 1979, tobacco use among teens has gradually declined. • accordinq to Addiction Research roundatlon atatistics, between 1977 and 1991 the percentage o: young people tryiag tobacco for the fisat t3ma•Lefere Grade 9 dropped'from 89 to 69 par Cent. Setwaon 1991 and 1993, however, that pereenbayu increased from b9, to 7b per cent. • Between 199i and 1993, smoking increased siynificantly among ntudents in Grade 7, from 6.1 to 9.4 per cent, a So per cent inacuase. Tobacco Use Amoag vomea • Lung cancer rates tor women have tripled in the past 20 ycarc. Today, lung cancer kills almost as mary women as breast cancer. Since 1971, tthe incidence of lung r.rncar has increased much factor in women than man. • More than 1,000 Ontario women die r+reh year from lung cancar caused by tobacco use. ' • The declinc in regular and occasional tobaeco use among hdults has been Ataepar in lsen than women. In 1966, SO per cent of Ontario men used tobacco; today, 33 per cant. For women, levels have dropped from 32 per cent to 27 per cent. • Mothers who smoke during pregnancy are more likely to have low birth weight babies. r -30- 1 301
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/L -8- 0 , Environmental Tobacco Smoke and Secondary Transmission I I I ' 1: I I I I I ` I , , 28. There is increasingly conclusive evidence that tobacco smoke causes disease and death among non-smokers as well as smokers. Sidestream smoke from burning cigarettes contains greater amounts of carcinogens and other noxious chemicals, including carbon monoxide, than mainstream smoke because the cigarette burns at a lower temperature when the smoker is not inhaling. 29. The U.S. Surgeon General has stated that it is certain that a "substantial proportion" of lung cancers that occur in non-smokers are due to environmental tobacco smoke. Infants of parents who smoke tobacco have increased risk of hospitalization for bronchitis and pneumonia as against infants of non-smoking parents, and have a slower rate of growth in lung function than infants of non-smoking parents. 30. Fetuses are the most vulnerable group of persons exposed involuntarily to tobacco chemicals and carcinogens. Smoking tobacco during pregnancy is an important cause of both low birth rate and infant mortality. Tobacco and Pharmacy 31. Pharmacy is a health care profession. Pharmacies form an essential part of the health care system. Tobacco -is•-a toxic product which ultimately kills about half of all regular long-term users. In light of the great harm to public health caused by tobacco, it is a. fundamenL;k] conflict of interest for pharmacists to engage in the retail sale of tobacco.
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91/04/1990 15:07 FRp14 TD 773601054 P.14 I I fees. A liansing system would provide an effeaive enforxmeat system without burdening the police and the court. Bannin¢ SoittinQ a o The Canadian Public Health Association, based on a 1987 sarvey, reported that in the four weeks prior to the survey, about three percent of male students in grades 7, 9, 11 and 13 used smokaless tobacco. A 1986 U.S. study submitted to the Surgeon Gemal states, -The oral use of smokeless tobacco represents a significant heatth risk. It is not a safe substaute for smoldng dgarettes. It can cause smoking and a number of non-cancerous oral conditions and can lead to nicotine addiction and dependence." '[he OMA is concerned that, with the passage and proclamation of the 2obaooo Control Act, the availability of tobacco industry products to teens will decrease and they will then turrl to smokeless tobacco industry products, such as chewing tobaeeo, or dipping tobaoco,'a fozm of wet snuff that is held in the mouth. -ZjdzA %NP" I I I I I I .1 I dangerous substance before it becomes rampant. The provincial government has an excellent oppoitunity to prevent an increase in use of this The behaviour pattern and choices of children Is dependent upon many fhCtors. The popularity of Canadian major league baseball teams is one such factar, as a number of playess from ghese teams iegularly use spitting tobacco. The success of these texms means that the strong ittf3uenae which team members bave on the young is even more Agniticant. The use of spitting tobacco has been banned in Ausualia, the Ifish Rqpubiic, FYot1g Kong and lstaeL The OMA strongiy ucges the government to insurt that spitting tobacco is b=nM -10-
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11•iS•9] 09:)5 t]9' 7,230 NON CON. ilEAlid --- OSA -_,E OOo 013 LS•L'/9.S 16:CR '8'+ie J:i s%3i CJjTl A;I~cV 9THF --- 1:9 Co"'I k!&S.id a o05 I. I I aiqhligbts of the Legislatioa The Tobacco control Act ia a component of the Tohecco Strategy and conoidor.d assantial to achieving the strategy's objectives and targets. The legislation will mrka it more difficult for teens to buy cigarettes. The Tobaoco Control Act will: I I I I 1 I I I r • rdise the age for the legal purchase of tnbacco Lrom la to 19 • ban the sale of tobacco in pharmacies and other health facilities -- • prohibit the sale of tobacco products from vending machines • require retailerF aelling tobacco to posL hralth warnings and age limits on their premises • require health warnings and other harlth intormation as part of tobacco packa7ing s monitor the sale ut tobacco through reports trom distributors and wholesalers • prohibit or reAtriet smoking in desiqnated places • provide an effective enforcement mcohanism that includRa fines anQ bans on the cale of tobacco. ontario's levislotion complements tho federal government's legislation, Ths Tobacco Sales tn Vnunq Persons Act, to be enforced in July 1994. The federai legislation increases the legal age for the purchase of tobacen from 16 to ia, bans the snle of cigarettes in vonding machines except in licensed promicos, and inerenAes warnings on packages. Purpose of Legislatioa • To keep children and teenagers trom smoking • To reduce second-hand or environmental tobacco amoke by banning smoking in a wide ranga of public plaees • To make peopla aware of the health dangers of smoking by placing warnings in or on eigaretto packages and at all retail outlets • To prohibit tobacco sales in e11 health care iacilitiee and pharmacies • To evaluato the progress ot the strategy by regularly monitoring tobaeeo'sdlus volumes • To establish penalties to ennure compliance with tha law.
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I I I I I I I I I I 01/04/1900 15-05 FROP1 TCI 973601054 P.12 The report further finds that ETS belongs in the category of compounds classified by the U.S. Fnvironmental Protection Agency as a Gmup A(Imown human) tatcilmgen. It is ipcomplehenss'ble that a Group A carcinogen, which is In the same eIas'sificaddn as the most deadly •earamogens: arsenic, asbestos, benzene, vinyl chloride, coal tars and radlonuclides, would be allowed in any public or work placo. The OMA strongly supports the restriction of smoking in public places, particularly sites that ch.ildneri and adolesccnts frequent. Children have no way of protecting themselves from exposure to ETS in environments where smoking is allowed. The Tobaxo Control Act has the opponunity to futther protect Ontarians, especially childmt and adolescents, from exposure to ET5 and theaefon: protect their health. Tlie Act as written prohibits smoking in eettain places. The OMA strongly urges that In order to begin to achieve the govemment's goal as stated In the 1993 discussion paper, the Tobj= ConlM must ban all smoking in public places rxctpt where an eaempfion Is provided by way of regulation. Existing legislation, for example, the Smo1d in the Worknlaoe~(1989), has many loopholes and gives no protection to an employee from an employer who wishes to allow smoking in the workplace. The OMA further recommends that the M'inlstry of Health collaborate with the Ministry of labour in order to complete public coasultations and take the neoessaty steps needaJ to meat the government's goal of smoke-free workplaoes by 1995. Such legislation should be brought forward prior'to the end of this government's mandate. dtelativeiy simple amendments to this AZ would achieve this objective. jDSRCedon T6e parpose of the plan<ted legislation, Ontario To¢g= Act is to have a loag term impact ln decreasing tobaeoo use by children and adolescents. 71ie govemment has stated..dhatdts goal -8- I I I I I I I I
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, I I I I I f. I , I I I I I 11,19,93 09:31 t$3:- 7230 1111T,9] 18 07 $'l18 3?' a?9! y0H C011. gE.~Ll'd- ... OSA t do i Olo rnloi k. NFn Ar4F .., unN rnu. H.,i-a Z3„ 300 D r a f t • N o v e m b s r r-7 - i 1 3 0 p. m. YACT sBEET Health Car• Issues • In Ontario, one in five preventable daaths among adults can be attributed to tobacco use. As well, tobacco accounts for an added burden of illness and disability. • Tobacco-related diseases are Ontario's number one public health problem. • More than 13,000 Ontarians die each year from tobacco uac. They represent a community the site of Niagara•on-the-Lake. Tha death toll is almost five times the numhar of people who die Lrom traffic accidants; suicide and AIDS combined. It means that one person dies Lrom tobacco use every 40 minutas in Ontarin. Tobacco users have a higher risk of devreloping serious dicoaces, such as: • heart disease • lunq cancer • chronic lung disease (chronic bronchitis and emphysema) • stroke • cancers of the mouth, throat, esophaqus and bladder. Coronary heart disease aceounls Lor about 18,000 deaths each year. one-third of these can be attributed to tnhrceo use. Tobacco causes about 80 per cent pt all lung cancers. Lung cancer leads to death in almost nine out of 1o people, +.iFUa11y within two years of diagnosis. More men d1e of lung cancer in Ontario than of any other cancer - - more than caneors of bowel, prostate, brain and liver combined. • Second-hand smoke (also known as environmenr.rl tobacco smoke) has been linked to lung canr.ar in non-smokers and rnapiratory problems in younq ahildren and inlants. Tobaoco Ose in Ontario • The proportion of all people using Lobauco has declined dramatically -- from about 41 per cent of Ontarinna in 1986 to about 28 per cent in 1990. Still, sales of manufactured cigarettes par capita in Ontario rank higher than in countries like Italy, France, United Kingdom, Danmarx and Sweden. 0 .
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I I I I 3i662 AG-187 that the risk o° non-Y.cdS::in's ly7phona, a type c: cancer, is related to the extent of weed sprayir.g with 347 herbicides such as "2,4-a". These results are bei:q used by Health and Wel:are Canada and Agricu:tere Canada, together with ot*.er research studies, to decide future policy with regard to use of su:h pesticides in Canada. N CO ~ Ol
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_,__ . _ n.,~.k,,.._.,,;..:..; ..
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I I I I I I I I I I I I 11'14~93 09:3' $3:' T, 30 11•17~97 16:10 'S'316 J:' 8T91 -4- Mother threat, second-hand or environmantal tobacco smoke, has been linked to lung oanoer and heart disease in non-smokPrs and to respiratoryy problema 3n children and infante. That's why the minictry last year introduced it: !ar-rprchlnq Tobacco 5trateqy. Sta tocus is to: • prevent pcoplc, and particularly children and taans, from starting to smoke; * encourage cmnkars to quitJ and • protect people from second-hand or environmental tobacco smoke. Yoit COe. BEALiH -« OS.i Eai; o;; COlU{ Y lNtU 9Tkt --- AUy CUA. Y.6ALa zu.~ 3a9 Legcelation is only one part oi a compruhellsive strategy in our fight against this disease. A soon-to-be-launched public education campaign will reach young people before they har.nna addicted. And we are supporting provinuc-wide community action with public health agencies and our other community partners. We are not alone in our fi4ht. our legislation supports and 5upplemcnts the foderal qovernmRnt's soon-to-be-proclaimed 2obacco gales--to Youpg Pcraona Act. 01 I
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11,19,03 09:37 $3:7 7230 NOH COfI. )~,.iLTH --- OS.i - . . . . _ . ~0:/ 015 t1 1' 9t te:09 B'il• J:P lT91 CO!@I & aNFO 9Tlif --)IOa C09• RE,+::+ .,. 20:1 307 -2- I I I I I 6 ae vill require health varninQs and other health information as part of tobacco packaging; • ve vill monitor the sale of tobaeeo,tbrough mandatory reporta from distributors and vbolesalers; . Re vill prohibit or restrict smokiag ib deeignated places; • 1Pe vill provide an efiective eaforaomont meobaaism that includes fines and bans on the sale of tobacco. This legisletiorl follows an extensive period of publirr consultatinn. The ministry received 240 written submionions and heard 34 oral proesntations. Our consultations confirmed that the legislation's focus -- especially on tobacco ute hy young people -- is right on target. The leqislation comes at a vital timo in the war against smokinq. Betvaen 1977 and 1991, the percantage of young people who tried tobacco for the first time before Graae 9 dropped fYom e9 per cent to 69 pni cent. but that enoouraging trand shows siqns of reversing. The elddicl.ion Researeh Foundation reports that between 1991 and 1993, smoking increaaod significantly among Grade I students in Ontario, from 6.1 per eent to 9.4 per cent. Thatie an increase of 5o per ccnt por cent in the past two years. I I
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I I I I I I , I I I I I 6 ILLNESS AND DEATH IN CANADA CAUSED BY SNOKING: AN E?IDENIOLOGICAL PERSPECTIVE April, 1989 by Address 7 344 Tnis is Exhiblt "(3' referred to m the Affidavlt ot 99. ~40 y CA*+V4 S1vom betore me thls .'S~._q-- ~ ,day ot A CQmm)ssioner eta i o iV Donald T. Wigle, M.D., Ph.D., H.P.B. Chief Surveillance & Risk Assessment Division Bureau of Chronic Disease Epidemiology Laboratory Centre for Disease Control Health Protection Branch Realth and Welfare Canada. Rm. 37A L.C.D.C. Bldg. Health and Welfare Canada Ottai+a, Ontario K1A 0L2 (613) 957-0329 (phone) 952-7009 (FAX)
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~~~ ~, ~ ~;
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I I I I I , I . I I 01/94/1900 15:93 FR011 $ohibit12n of Sale M Designated Placess 773601054 P.08 The use of tobacco industry products causes preventable disease, disabilities arid death. Both the medical and scientific communities have been reporting the health risks and health hazards related to the use of these produccs for several decades. The ban of tobacco sales in pharmacies would.diminate the conflicting mes3ages about the tlsks of tobacco industry product being sent to people of alI ages but especially to children and teens. The link between an addictive and lethal product and the sale of that pt+oduet in pharmacies Is a link which is hot lost on the young. 7'he link must be brokctt. The OMA along with other health community members, consider that It Is critical to prohibit the sale of tobacco industry products in pharmacies to break the link, as stated, and to bring many of the 8,000 member pharmacist profession in Ontario, into the health care system in a meaningful way. This would give pharmacists the opportunity to counsel their clients regarding the use of tobacco industry products, in a manner which Is commensurate with the risk. The ban of the sale of tobacco industry products in pharmacies is one of the most important sections•of the o~Cgntrol act. that is, facilities within the health care system, and especially In pharmacies. The OMA strongly supports prohibiting the sale of tobacco industry products in health facilities, PackaWUg. Hea 1+ gpnin&~,$ enc The manner in which tobaooo industry products are marketed, the packaging, is criticai in achieving the target of reducing tobacco use by children and teens. Every time a dgarette - package is seen by the public it provides a form of advertising. Cigarettes in plain packages would remove tbe ataactiveness of the product. Plain packages would send the message to the -4- I I
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I I I 01i04i1900 15:05 FROM 7?3601054 P.10 upon the minimal warnings required under the federal TobaocaProducts Control Aot. As well, there should be at a minimum, for atample, sn addiction warning on m= package not just on one in eight. The OMA supports the posting of signs concerning the prohibi6on of tobacco sales to children and adolescents, as well as warning signs regarding the health risks related to tobacco products. These signs should be In English and in the languages of the local oommunity. qndjnQ Machtnes: At the present time, under the federal Sale of T a= to Yupgbons Act, vending maohines will be banned from many business establishments in Ontario. When tobacco industry product sales ate banned in many retail establishments, children will try to obtain tobacco industry products from the remaining vending machines. It is esserttial 'that the province ban aln remaining vending machines in order to close the source of tobacco industry products to adolescents before the number., of vending macldnes undermines the province's intended prohibition of tobacco industry products•to minors. Tobacco is a product that when used as directed, causes disease and death. To further ensure that minors do not have access to tobacco products, the Tohaoco Controi Act must include the banning of tobacco sales from all vending machines. A pattial ban of tobacco sales from vending machines will be difficult to enforce. In a notable precedent, New York City has banned the sale of tobacco from vending machines. As well, a study catrled out in Mumesota showed that 14 to 15 year olds are able to procure tobacco products from vending machines located in licensod sites P The ban of tobacco sales from vending machines is an initiativc which moves the government closer to achieving the goal of eliminating tobacco sates to minors. No other products that ate deemed "off limits" to children axe available from vending machines, eg., alcohol or. -6-• I I 2q I i
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I I I I I ~ I I I 01i04i1900 15'07 FROM TO 473601054 P.16 leading cause of death in Ontario, costing the government billions of dollars in health cate expenditures and lost output, can be largely prevented by a change in lifestyle which includes • first, the eIImination of tobaoco use. The Tobatrn C.±ntrol Act; is comparable in many ways to the development and passage of laws requiring the pasteurization of' milk and the chlorination of water, both of pvhich have had significant positive Impact on public health. These issues were also fraught with political hesitancy and strong debate. But they too were based on solid evidence. History has demonstrated the effectiveness of enacting policy on the basis of such evidetwe. - in summary, the OMA applauds the thtvst of Bill 119, An Act (2 »rMt the Pnevision of Tobacco to YoungPqrsons and to Reg,ylate its Sale and iS ~bvOthm- and believes that this is an excellent step towards passing comprehensive tobacco legislation. However, if the Province wishes to meet its goals, the legislation needs to be further strengthened. We aPe&qBy.place emphasis on: • prohibition of tobacco sales by health carc facilities, for exatnple, pharmacies, as soon as possibie; • diminishing the attractiveness of cigarette packages, especially by use of plain packages; • strong provincial warnings on cigarette packages and at point of sale; • an effective enforcement system to prevent the sale of tobacco industry products to clu7dnat; and • rCinoval of barriers for meeting 1995 proi'ineial targets on FsTS, especially by the removal of HTS from.provincial wotkplaces, schools and public places. The Ontario Medical Association is very pleased that the Ontario government will not be missing this opportunity to dentonsOCate that it is comm9tted to the importance of health promotion and disease prevention within the health care system. -12- t I I I I I
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I I I I I r I I t r I I I :r 37664 AC_19~ 3y 1. Role of Epidemioloay in Public.Health and Medicine ^l.9 "Epidemiology" is thc' sv:cy of the causes of disease _.. ..~r.}.aar. pooulations. "Clir.°_cai e•cidet.i=iogy" :s the study of the e;;:cacy or techniques to cia:nose or treat human disease. If one considers the following, Health A Disease 3 Death epidemiologists endeavour to d:scover those factcrs .hic=, cause disease so that cseventive measures car. be de••eloped (e.c. fluoridation to prevent dental'caries). Clir.ical epider.'_clccists strive to identify tests for early -d-iagncsis of disease and treafaients that are effectioe in reducir.g 't*e impact of disease (e.g. there is an crgoir.g study of 90,OC:: Caned_an womes to determine if early cetect:o:: of breast cancer thres:ch special x- rays reduces the risk of death due to breast cancer). Some of t.^.e siy'n ificeRt contributions of epide:'.liclccy to public health and r..edicine since 'rbrld }:ar II i.^.clLdea The discovery _^a= s:-ok:nc causes lung cancer, coronary heart disease, _nphysec.a and several other diseases. _The proof t:at ;o' io vaccin e qreat:y red:ces the ris:< of polio. The discovery t.*.at asbestos causes lu.n., cancer, asbestosis and ::esct^a:io.^= (a type c! cancer) ... persons exposed =_t or e:sewhere. The proof that anti-hyzerter.sive drugs greatl,v reduce the risk of stroke ar..ong persons wi th t::.ch blcod pressure. The discovery .`.at hepatitis B virus greatly increases the risk of li•:er cancer. ` By <_dentif,vinc factors that detercine-disease risk directly in huran popul;tco^s, ecide•^•.iolog;: overcor..es the ?arge ~ N B 01 V) . . . . N CD 9* 00
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. (hl3 is i°.iC(fEu :0 in ~2 AMlbuy Ct¢Nww~ I I .,~~~•~a...,... Obituary • Lesun • Mc&copoHtieal Dient • SuwdinP • Pmonal. Vim • Medfdme..adBoob•• Mioorva e (in doun] ovtdaqf) the Afliaa+l! ol ~. Sworn pet6m. Ne this
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I I 1 I 1 1 0 1951 I . ~ ~ i I ~ = ^ f/ T` f1 n p` ~ ~ i{ ~ ~. __ I I - . ~ i ~ J ~ n ~ ~ I n v ^ ^ ~ 1 y J - 1 I 1 i 1 I I 1956 1961 1966 1971 year 1976 1981 1986 -'- Lung, 55-74 -~- Breast, 55-74 37683 AG-185 FlGURE 7 LUNG CANCER AND BREAST CANCER CANADA, 1951 to 1986 Females, Ages 55 to 74 deaths per 100,000 125 100 75 50 25 5~/ 368 I
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996 L 0 co q~ yg®Vpyp~9y~~ ~~ t.2' Il 8~A.. 'Yi" 3® p~...~~~~.{,~~~~~.~'7/g,'~p ~g,~~~g~,~g~^~~ tI' 1~7 Y ~71 ~ 4J Y V V V ~ r V. ~'~'p~9`8 V S 721119Ij fmm amm~- ewm A ammmmo even wam ~ lv=' *MA! ~ ~
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I I I I I ` I 37685 AG-185 FIGURE 9 57 CANCER DEATH RATES IN CANADA MEN 4 370 2000 1500 1000 500 0 , , 58 63 68 73 78 .8-3.. _ 88 year- I deaths per miliicn panr year other cancers , „ ._ . , , . ; lung ° ; i ; ;
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37684 AG-185 r t(iuKt 0 S Z CANCER DEATH RATES IN CANADA I WOMEN 2000 1'\ ~ , ,~, , ~ ' T 1500 1000 other cancers ~ 3f;9 P ~ I i I I I s 500 58 63 68 73 78 83 88 year deaths per m ;~ •,;c^ p_, ,~-ar , ,:...
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I I I I I I I I I I I I I 37663 AG-185 CONTENTS 34.9 1. 2. 3. Role of epidemiology in public health and medicine. Criteria used for r..akin, causal judcenents irn epide^io? Relative risks of death and illness for diseases }udoeC tc be causally related to tobacco use., 3.1 Characteristics of epidemiologic studies cited i.^n this review. 3.2 Multiple health consequences of smoking 3.3 Coronary heart disease 3.4 Stroke 3.5 Aortic aneurysm 3.6 Cancer .1 Overall ca'ncer tortality .2 Lung cancer .3 Laryngeal cancer .4 h:outh, throat and esophageal cencer .5 ltorbiditv due to cancer 3.7 Chronic bronchitis and emohysena 3.8 overall nortality 4. Dose-response-relations between smoking and :isk of ma;:r diseases caused by smoking: selected results for illustrative purposes. 4.1 Lung Cancer 4.2 Coronary heart disease 4.3 Chronic bronchitis and emphysema 1 4.4 Overall mortality >1u-:ber of deaths attributable to tobacco use :n Canada. 6. Relative imcortance of s:eo:ainz as a risk fac:or `or se`_ecte--* cancers. i. Lifeti-e mortality risks for smokers. 0. Prevention and control of tobacco addicticn '_r. Canada. 9. Conclusion. Appendix 1. Canada Health Survey Mortality Fo11o.-up Study ?ne^dis 2. U.S. Sufqeon Generai: Selected Conclusions or, Health Consee,uences of S:eokinc - Appendix 3. Confidence Linit of Expected Number of Deaths u N O O1
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52069 2863 UOUlOM M ~~ U2U1 m 218 E8 8L • £L . 89 E9 85 =,7= K; 0008 IJ 0000 L V®VNVO NI SHIV3C] 83ONVO oNn-i I.VfNNV ti 3angzi
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I I I I r I I I 37672 .;G-1o"5 3.4 Strc:ce , 35" Although two of the studies cited in Ttble 3.2 revealed r.o significant associaticn between smokir.g and risk of stroke (12, 13), two Canadian (1', 14) and several studies in other countries have de^onstrated scg:__ car.tly in.^reased stra:<e risks :cr s^okers •(Pigure 2). Canadians age 3: ---to 79 •r;;o repcrted saoking 20 cr ^ore cigarettes per day had a risk o= fatal stsc'se 2.6 tires that of never-smokers (11) . . An earlier study ccnductec in ::anitoba revealed a relative risk for infarctive stroke of 2.4 for smokers (14). The Canadian Veterans study, in contrast, revealed relative risks for stroke of 0.8 and 1.2, respectively for sen a^c wo-en (13). . A dose-response relation between amount smoked and risk of stroke was observed in the U.S. V,-erans study (15); the relative . risk of fatal stroke increased froa 1.1 to 1.6 as cigarettes snoked per day increased froo less then 10 to 40 or more (Table 3.2). _ Recently re?or:ec results f:om tne 't.o;olulu Zeart Prcq:ar.. indicated a relative risk of firs: stroke of 2.5 for male saoke:s after adjustment fcr several c:her risk :actors; .his risk increased to 3.5 for ner. srho were still s-=king at the 6-year follow-up (16). U.S. female nurses who c;:rren:ly smoked 1-14, 1S- 24 and 25 or more cc;arettes ce: day, respectively, had relative risks for stroke of 2.5, 2.9 ar.d 3.£ adjusted fo: other r:sk factors (40); for the eiib-croug of subarachnoid henorrhace, the relative risks uere 4.3, 5.1 and 10.3. ^he recent Anerican Cancer Society Cancer ?zeve,:ion Study ;evetl.cd t.`.at male end fenale current cigarette s-c:cers age 35-6s had,..res?ectively, 3.7 and 4.6 times the risk of fac~l stro%e cor.pared to r.ever-s-o:<ers (;1). M
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I I I I I ' I I I I I , I I I I 37687 AG-185 FiGuze 11 SllRVlVAL AFTER CANCER 37`> breast - bladder mouth prostate lymphoma ovary bowel brain Ieukemia stomach lung pancreas i I ,o surviving 5 years c
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I # I I I I I I ^, 37667 AC-135 Rothman recently reviewed Nill's criteria for causal _.^.:erence 3S, in epidemiology (5). Both Rothman and Hill agree that there are 35 no hard and fast rules for causal inference. xmong the criteria origir.ally proposed by Hill, probably the aost i-portan: are: strength of association, consistency, dose-response and bic-logic plausibility. 3. Relative Risks of Death and Illness for Diseases Judged to be Causally Related to Tobecco Use 3.1 Characteristics of Loidemiologic Studies Cited in this Review The main featu'res of the epidemiologic cohort and case- control studies cited specifically in this review are sL_aarized in Table 3.1. A cohort study involves collection of information on various exposures for each person in a group of ostensibly healthy persons, follow-up over time !usually several years) to determine the occurrence of disease or death and analysis to assess exposure/risk relationships. Cohort studies are especially useful to assess the role of smoking in the risk of the multiple health problems caused by this exposure. Fa A case-control stud.~, in contrast, starts with identification of cases (persons with the disease or health ,^oblen of interest) and controls (often persons of the sane sex and age and free of the disease or health :roblen under investigation), coliecticn of inforr..ation on various e>:posures and analysis:..of ex_csure/risk relationships. 3.2 Multiple 8ealth Ccnseauences of Smoking Tobacco smoke is a complex mixture cont_aining over 4000 different chemicals which have been identified to date (b). These include several hundred toxic chemicals ar.,ong which over 50 are
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,.r aw s s go ++W Figure 2 STROKE L58Z 690ZS ACS Cancer M Prev Study F U.S. Nurses 25+/day " " 15-24/day " . 1-14/day Nutr Can 20•}/day M&F Honolulu M Manitoba M & F Can Hffh Survey M&F Japanese Dr.s M British Dr.s M U.S: Vets M Canadian Vets M Canadian Vets F Jap. Hith Centres M Jap. Htth Centres F Swedish Survey M Swedish Survey F 0 Sourco: Lab. Contro for Disoaso Control X 1 2 3 4 5 6tolutlvo iilok for Curront Ctflurotto Smokoru G
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37674 AG-185 `ft The failure to observeincreaseC sisk5 o£ 3troke for _-c:<ers in the Canadian vete:ans study and the Swedish survey may :e:;ec35 9 several factors other than ;he absence of a true causal rcle for I smokine in stroke. For esample1 sudden fatal stre:e cccu:r:.no outside hospital can only be distinguished from coronary heart disease if an autopsy is done. Since fatal stroke occurs r..aialy among the elderly (age 75 or older), autopsies are usually not pei`formed. Based on first strokes, fatal or non-fatal, and incicd'_ng persons below age 70 for whorr stroke diagnosis is more accurate, the Manitoba (14) , ' Ronolulu (16) and U.S. Nurses (40) stc"ies demonstrated substantial relative risks for smokers. Given that sr:oking causes extensive arterial damaee %:.`.ich underlies many strokes, it is highly likely that smoking is a major causal factor for stroke. This conclusion is supzo:tec by the available epidr.:,ioloqic evidence especially from stud?es of relatively younc persons. The U.S. Sure,eon General :ecer.tly confirmed this conclusion and stated "Along withthe recently reported results of other studies, these findings strongly support a causal role for cigarette smoking `in thronboeabolic and hemorrhagic stroke"•(41). , I I I I 3.5 Aortic-Aneurysu (%on-Syohilitic) There has beer. much less publicity about the rajc: ca•.sal role of smoking in disease o: arteries other than the corc::a:,v • arteries. Smoking is the r..ajor cause of peripheral artery disease in the non-diabe:ic population and is a major cause of acrtic aneurysms (AAs)(5). AAS are one of the few r,.ajor diseases for which r..ortality iates are currently increasing in Canada (17). A,1s involve dilatation and weakening of the wall of thA -.ain artery in the body. Each year, about 1800 Canadians die due either to rupture of AAS and fatal blood loss or ot:.er to B 0 l0 to 00 (JN OD P
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I I I I I I I I I I 37671 AG-185 a recent U.S. study (9) •. Relative r+_s'r.s :or fatal or r.cr.-iatal coronary hea:t-disease of 2.4, 2.1, 4.2, 5.4, 7.1 anc 1G.o, respectively, were observed for U.S. female nurses who currently snoked 1-4, 5-14, 15-24, 25-34, 35-44 and 45 or more ci:arettes per day (39). Swedis:^, male current smoxers age less than 4: had a relative risk of 6.0 for fatal coronary heart disease (12). Canadians age 35 to 79 who reported smokiny 20 or more cigarettes per day during the 1970-72 Nutrition Canada 8u:•vey had a relative risk c4 fatal coronary heart disease of 2.8 (11). Not only is smoking the major preventable cause of cardio- vascular deaths, it greatly increases 'the risk of fatal ccrc:ary heart disease among persons who are'already at risk due to other factors such as elevated serum cholesterol or high blood pressure (6). About 47% and 10e, respectively, of ali cardiovascular deaths (mainly CHD but also stroke and other circulatory diseases) Cu:inc .the 10-year follow-up of Canadian men and women who partic:.,:ated in the Nutrition Canada Survey were attributable to smoking. The problem was particularly serious in the younger group, aged 3i-64. In this age group, 52% of cardiovascular deaths aa,ong males, z:G 47% aaong females were attributable to tobacco use (11). 8c: t.`.e sane age group, similar results were observed in the rece-t American Cancer Scciety Cancer ?revention Study; 453 of "-ale coronary heart disease deaths and 41% of,female coronary :eart disease deatt:s were attributable to smokir.g. The correspcz!in; proportions of deaths for cerebrovascular disease were 51% aad 551 for men and women, respectively (41). Smoking caused over 16,000 cardiovascular deaths among Canadians aged 35-79 in 1976, more than higb blood presssure and serum cholesterol combined (Table 3.3). 35 ki
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iI I I I I I I I ' 1' I _ I I .. ' I 37660 AG-185 I i?entifiec .a high'risk of bladder cancer anong r,.erR i.n the Chicouti:ni region of Quebec. I then encouraged Dr. Gilles '°heriault, then at Laval University, to conduct a case-control study of bladder cancer in the Chiccutir.c region. Fe deternined that cigarette s.;.oking an: eaployment in the potrooa at the Alcan aluminum refinery were independent risk factors for bladder cancer. ..lcan has since introduced measures to improve air c,uality in the potroon. bsy collleagues and I conducted a case-control study of cancer of the uterine corpus among women in Alberta. +:e determined that estrogen replacement drua,s, used ._ treat menopausal symptoms, were strong risk factors'=or this cancer. This work and that of others particularly in the U.S.A. resulted in warnings to physicians, the developaient of r.ew and safer estrogen replacement drugs, new treatment schedules (cyclic instead of continuous) and publicity concerning the hazards of such drugs and the need for regular medical follow-up of women who use them. tve have also investigated the risk of lung cancer in . relation to exposure to radon, a radioactive gas present at relatively ;igh levels ia some nines and .^a.n.y houses with those of ct: er in Canada. Our studies, together researchers, have been used as the basis fcr sett occupational exposure limits for urar.ium ^ines and cuidelines for Canadian homes. . t•!v colleacues and i have assessed t.`.e epide-iologic evidence that "involuntary" smoking causes lung cancer a;.+ong exposed non-smo.l•ers. The results, together with ' the work of other researchers, have been used b?rvaricus levels of covernc.ent to support policies"-to ;estric;, s:wking in workplaces and indoor public areas. One of our ocgoi.^.c st%)dies is a follo•..-u, study of the 360,000 Canadian farmers who were active in^1471. Early results, recently ore;.ared for publication, indicate 345
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I I I I . I I I I I I I 1 V.: 37659 .aG-18-5 11 ?t should be r.otefl that differences in the relat:':e resiy35(1 estis+ates in :ab1e 3.2 may reflect not only real risk differences in various --ooulaticns but also differences in ste:dy d esig~, definition of s-ok'_co categories and other factors. Ces.:te such liTitations, _, is important that significantly elevated ralative risks of these .^.ajor diseases were observed in serera: lar;e eoideniologic studies conducted independently ln variCus countries. 3.3 Coronary heart disease The relative risk of both non-fatal and fatal coronarv ;;eart disease (CHD) is i.^.creased among smokers independently of c;:;er risk factors such as elevated serum cholesterol and hi;:: blccd pressure (6). Cigarette smokers have 2 to 4 times the risk of sudden cardiac death ccr..oared to non-smokers (6). Over 604 of non-fatal, first heart attacks among men age 30 to 54 and women age 25 to 49 w--.e attributable to smoking (9, 10). The U.S. Surgeon General estimated that 30% of all coronary heart deaths are caused by smoking (6). Over half of all cardiovascular deaths (aainly coronary heart disease and stroke) among Ca.^.adian r..e.nn age 35 to,79 were attributable to sr..okicc (11;. The overall rela;:ve risks of fat,el coronary hear: disease for current saokers in the studies cited in Table 3.2 and sac::n _n Fiaure 1 varied between 1.6 and 2.8 fbr men and fron 1.3 to 3.0 for women. : lt: cc:gk these are lorrer than t:e relative risks of lung cancer for s^okers, coronary heart disease occurs r..cre frequently and smoking has been and is still very wicespread: Thus sraoking is a major cause of coronary heart disease. =.here is a strong dose-regponse relation between smoking and .is:: cf coronary heart disease (see section 4 and Table 4.1 belo•n) . e risk is :particularly ~,igh for early coronary heart a sease. Relative risks of non-fatal heart attack ranged from 2.5 to ..9 :or male current cicarette smokers`age 30 to 54 were r.evealed in
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T98Z 690ZS ACS Cancer. M , Prev. Study F Swedish Twins M Swedish Twins F Canadian Vets M British Dr.s M Alberta M Alberta F Can Htth Survey M Can Hlth Survey F U.S. Vets M Swedish Men - >15/day Swedish Men 8-15/day Swedish Men 1-7/day Swedish Survey M Swedish Survey F Jap. H1th Centres M Jap. Hlth Centres F Japanese Dr.s - M i Figure 3 - LUNG CANCER Ll J ~ 0 5 Source: Lab. Centro for Dlsouoe Control E !. t E 10 '15 20 25 30 ftotattvo niok for Curront Clflorotto smokoro
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~.r msr. W yw i rrr s+.r m ..r .r s : Figure 1 CORONARY HEART DISEASE ~ , ACS Cancer M Prev Study F, NuYr Can 20¢/day M&F Swedish Twins M Swedish Twins F Japanese Dr.s M Can !-fith Sur,vey M&F Jap. Hlth Centres M Jap. Hlth Centres F Canadian Vets M Canadian Vets F British Dr.s M Swedish Survey M Swedish Survey- F-- California Men M U.S. Vets M Swed. Men >15/day Swed. Men 8-75/day Swed. Men 1-7/day 0 0.5 9 1.5 2 I 2.5 3 3.5 , Sourco: Lab. Contre for Dlaoctoo Control VSBZ 690ZS qolutlvo tilntc for Cnrront Ctonrotlo Smokorn w ~ 0
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I I I 3i658 yG-185 known cancer-causing checicals (7). The nicotine present i tobacco smoke is the agent which underlies tobacco addictior.. 1(, 353 Given the number and the potency of the toxic chec.icais present in tobacco s^oke and the fact that inhaled cher._cals enter the bloodstreaa and are widely circulated throughout the body, it should not be surprising that s:oking causes several diseases including several types of cancer. The major known health conseeuences of sir.oking involve: 1. Direct damage to the lungs leading to chronic brolci:itis and emphysema (8). I I I I 2. Cancers in several organs exposed directly to tobacco smoke (mouth, throat, larynx, lung); to swallowed tobacco smoke particles (esophagus) or indirectly, presutGably through blood-borne tobacco smoke carcinogens (pancreas) cr°tobacco s.:,oke carcinogens excreted in urine (renal pelvis, bladder) (2,3). 3. Arterial dar..ace leading to coronary heart disease (heart attack, chronic heart °.ailure, angiaa pectoris), arterial aneurysms (abdcainal aorta especially), oeripheral artery disease ar.d cerebral artery disease (stroke) (b). The relative risk of develocing or dying fro:: a disease __e to sr..oking is the risk for saokers divided by the risk for r.e*:e:- smokers. For example, a relative risk of 15 for lung cancer deaa: among snokers means that, on average, the risk of lung cancer death among smokeis is 15 ti-es tl:at for gersor.s who never saoket. Relative risk estinates are usually presented by sex and ;say ze adjusted for e.ge a.._ other factors. N CO N N
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I I I I I 37696 AC-185 FIGURE 15 FUTURE DEATHS BEFORE AGE 70 AMONG 100,000 SMOKERS NOW AGE 15 381 males DEAT HS (thousands) p I smoking car acc suicide murder AIDS drug abuse I
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'37661 AC-185 I BiblioSraPhicSuomary. 346 I I I I I r. I I I i a- a xedical Epidemiologist. I studied pre-nedicine and medicine at the Gniversity of Western Cntario beginning in 1960 and graduating in 1966. I then did a one-year rotating internship at Victoria :osoital in London, Ontario. I completed a Ph.D. in Biochemistry at the University of British Columbia during the period 1967 to 197C. b!y Ph.D. thesis related to the control of gene expression in animal systens. I extended this work during two years post-doctoral studies as a Hedical Research Cc_r.ci1 i'eliow at the _nstitute for Molecular Biology in karhus, Den-zrk. I joined Health and Welfare Canada ir, 1972 as a Medical Officer resoonsible for investications intc human exposure to lead. I then studied for 1 year at the University of California in Berkeley and obtained a master of: ?ublic Health in Epidemiology. I returned to Health and Welfare Canada in 1974 and was appointed Chief of the Cancer Section in.1975. Since then ^y responsibili*_ies have expanded to include congenital ~irth defects. ~ F!y work as a:!edical Epide-iologist in T!:e Laboratory Centre for Disease Control of Healt:h and t•:elfare Canada has incluced the surveillance r.nd risk assessrent of chronic ciseases in hu-aas. Disease surveillar.ce studies serve to identify high risr populations ' and _'gortant trends. Risk assessment studies identify factors +`ic:n cause diseases; this kno :edc,e is needed to control such factors and prevent tne occurrence of disease. The major risk factors that I have studied include smoking, obesity, high blood pressure, radiation and environmental toxic ehenicals.' The eoidestiolecic studies that I have led in the Laboratory Centre for Disease Control have contributed to policy decisions in several areas includinc the following examples:
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I I I I I I *. I I I I "5~6i5 AGlss .. - 3 (~ comolications (lo). Those who survive AA rupture o: other complications ex=erie.n.ce high morbidity and nay develop serious co.plicatior.s such as loss of kidney function and loss of blood flow to the legs leading to ar.•putation. _ The relative risk of fatal AA for male saokers in the studies cited in Table 3.2 ranged fror.. 1.6 to 7.2 depending on the stud,v," age group and amount smoked. The strong dose-response re:ations observed in the U.S. Veterans and- Swedish Men studies re`:ect the i.ortait causal role of s:o.ttng .n AAs. 3.6 Cancer 3.6.1 Overall Cancer Mortality A Canadian (19) and two American (15, 20) follow-u? s:.udies revealed that overall cancer mortality risks for current smokers were double those of never-smokers (Table 3.2: Follow-up studies of Swedish (21) and Japanese (22) men revealed 60% or greater increases in overall risk of cancer mortality a-ong current smokers. The Swedish study noted a strong dose-response relation with men who saoked 15 grams or nore of tobacco ;er day having an overall nortality risk 3 times that of aesa:-sac;:ers (note: 1 cigarette contains a~cut 1 gram of tobacco). Table 3.2 includes only those cancer sites for which the U.S. Surgeon General concluded irn his 1982 retort (3) t'at there is sufficient evidence of a causal role for smoking. the U.S. Surgeon General's 198'2 report did conclude that s-oking was a major contributory :actor for several other cancers (pancreas, bladder, kidney). In 1986 IARC published a report (2) in vhich it was concluded that smoking is the major cause of lung cancer and an important cause of cancers of the bladder, renal pelvis (part of the kidney), mouth/throat,.larynx, esophagus and pancreas. This report also concluded that sr,•oking nay be ar. N W Ln kD Of
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37655 AG-185 I I I r. I I - I I I between such exposure and cance.in studies in which chence,bias and confounding could be ru?ed out with reasonable confidecce (1). 351 IRRC has declared ;hat "•definitive evidence of carcinogenicity in hurans is provided by epideniological studies" (1). Th ree types of eplAe^iclog'_cal studies of cancer contribute data to the assessmnr.t of carcinogenicity in humans: cohort studies, case- control studies and correlation studies. Case reports of cancer in hunans exoosed to -particular agents are also revie:+ed. In reaching its conclusions 0.11 epidemioloe,!c evidence of carcinogenicity, I:,RC considers the quality of the epide.^..iolcgic studies in teras of study design and analysis and assesses the results of studies with respect to criteria for causality (1). These criteria include: a) strength of association between exposure and cancer risk; b) reproducibility of results in other enider,.iologic studies; c) evidence of increasing cancer risk as_ level of exposure to the suspected carcinogen increases; d) spec:ricity of an association; e) results from randc:ire! trials (rarely available). The IARC criteria for causality are similar to those used by epidemiologists in general and by the U.S. Surgeon General in cart'_culr.r. ^e criteria used by the U.S. Surgeon Genera: c.^n the anaual reports on the 'r.ealth Conseauences c: S-oking are: a) consistenc.v of the zssociatior.; b) strength of the associaticn; c) specificity of the association; d) temporal relatior.ship of the association; e) coherence of the association. These c:ite=?a are explained in further detail else'ehere (3). The criteria for causality discussed above are subsets of criteria oria:nally procosed by Bradford hill (4). HiLl's criteria for causz'_ inference ir. ._e.piderr.io:ogy included: a) strencth of associr.;ion; b) consistency; c) specificity; d) teaporality; e) biologic gradient (dose respcase) ; f) biologic plausibility; c) coherence; h) experimental evidx'nce; i1 analogy.
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I I I .~ I I I 3765; nG-185 uncertainties of extraoolatina, from animal experinents ,c .*.uaaAns and identifies the causes of actual human proble^s. This dces d`6C'0 mean, however, that the results of other disciplines are not imoortant. Epidemiclogy is of central importance ia the identification of causal factors for disease but draws cn tiie skills of statistician, toxicologists, virologists, etc. 2. Criteria Used for Making Causal Judgements in Epidemiology The cause or causes of disease in humans usually ca.*.^ot be deterained through rigid laboratory techniques. ?his is particularly true for' cancer. It would clearly be unethical to deliberately expose randomly selected humans to poter.tial cancer causing chemicals in order to establish causality. Canada is one of the countries that belongs to the International A.gency for Research on Cancer (IARC). IA;C is affiliated with the 47orld Health Organization and +s probably the most authoritative source of information on cancer causing exposures for humans. As of 1987, IARC had identified 50 chemicals or industrial processes which are known to cause cancer in humans (1). in order for IARC to declare that a cheaical or industrial precess causes cancer in hurmans, it is necessary that there be sufficient epide::iolcgic evider.ce. _. is not necessa=}• that there be sufficient evidence o: carcinecesicitti• in a.:_-a1s for a cheaical or industrial orccess to be accepted as a cause of human cancer. Fcr exasple, arsenic cr arsenic cc-:pounds are <r.oan to cause cancer in hu-.ans but there is only limi;ed et'icence that they cause cancer in animals (1). Tobacco scoice is one of the 50 agents or industrial processes accepted b„v IA.RC to cause cancer in humans (2). IrRC Las also concluded that there is sufficient evidence that tobacco sr„clae also causes cancer in animals (2). IARC considers that a cr.usal relationship has been established'between exposure to an eSent and t:umarn cancer when a positive relatior.shio has biten observed. .
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I I I I I I I I I I I I ' I I I I 37695 AG-185 FIGURE 14 . FUTURE DEATHS BEFORE AGE 70 AMONG 100,000 SMOKERS NOW AGE 15 '`'~~~~ females smoking -~ . I i ~ ; i .i ; , , - ~. _. 1 -- -- ~ ; , , ; , 601 482 98 6 6 7 car acc suicide murder AIDS drug abase 63 3~d P I
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11'15~93 09:31 $3:: 7930 y0H COY. IiE.LLTH --- OS.4 ZOo;01d _ IV1'~OJ I8:06 $:;6 3:' aiAt C9Jfi L tN~U YI3F •-- 3[08 COX. fIE..LTB . . :,JO) r I I I I 1 : I 1 I I I 29.9 NBVS RELtasE - draft Nov. 17, i1s15,a.sa. ftIlTISTRY oP &EnLTH GOVBFNlsENT LEGISLATION RAISES SMOKING AGE 'L2 TOROt+To, November,26 -- ontario'o young poople will fina it harder to buy tobacco producta under legislation lntroduee3 today by Health Minister Ruth Grier. The 2Qbaeco Control Act is part of the ministry's comprehensive Tobacco Strategy, which combines lagislation, public education ana community action. "I am p1a>{aed to be takinq this giant step toward raducing the provinca':s leading cause of preventable death. Currently, nearly one-quarter of our young people smoXe. If we can help them rcaoh aga 20 vithout smoking, odds are they will never start this deadly habil," Mra. Grier said. The legislation increases the luyal age to buy tobacco frorl ta to i9; bans the sale of tobacco in pharmacies and other health facilitico; prohibits salea of cigarettes Lrous v*nding machinoa; requires tobacco retailers to yost health warnings and ago limits on their preemises; and prohibits smoking in designated public places and all health facilities, except tor residential facilitias sueh as nursing homes. "It is 3 tragedy that more than 13,OD0 people a year in Ontario die frnm tobacco-related illnesses," the minister said. "We are now taking action againat a killer that iR addicting ahilaren end teens at younger agea than ever." smoking among Grada 7 students has inorRased 50 per cant since 1991, from 6.1 per cant to 9.4 per cent. This dramatio increase comes after eight years or denline in the rate of smoking. The Tebacco eontre) arr makes it more diiticult for teenm to buy ciqarpt.taa. it also limits second-hand (onvironmental) tobacco smoke, whic:h has been linked to lunry crneer in non-smokers and respiratory problems in children and infants. "we are conqmitted to preventing illness and promoting haalth," said Mro. Crier. "This laqitlation moves us a major step tosward toward our goal of a healthier Ontario." -~0- version francaise disponiblQ F'or more lnlormation, contacts Rhondda Snary communications and Inlutmation IIranoh (416) ~27-4367 b
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I I I I 1` I I ' I I I I I 37693 AG-185 5. Nunber of Deaths Attributable to Tobacco Use in Canada The U.S. Surgeon General recently esticated that s:.oking caused 337,000 deaths in 10 disease categories and a grand tctal3 78 of about 390,000 deaths in the United States during 1985 (41, Health and Welfare Canada has est'imated the nunber oi deaths caused, by smoking in Canada (32). Estimates were produced ;air.g two different methods sunaariaed in Tables 5.1 and 5.2 wi:'s °ull details contained in the attached copy of the relevant re:ererce (32). Method 1(Table 5.1) is based strictly, on Canadian data and yields an estimate•of 35,404 deaths attributable to sao:<ing a-ong Canadians age 35 to 79 during 1985: Method 2 (Table 5.2) uses American relative risk data and Canadian data ctherwise to derive an estir;.ate of 35,131 deaths aQonc Canadians age 35 to 84 c_=ing 1985. From Table 5.2 it can be determined that 30,452 deaths were attributable to ss,okir.g among the restricted age group 35 to 79 as used in Method 1. In summary, over 30,000 deaths among Canadians age 35 to 79 were attributable to smoking during 1985. 6. Relative Importance of Smoking as a Risk Pactor for Selected Cancers The most recent publis::ed Canadian populatio^-cased estimates of the nunbers of cancer cases attri~utable'to s-c:ing were produced in an epidemiologic study of all newly' diagnosed cancers in ALberta during the years 1971 to 1973 (25). The relative risks and t^e population attributab:ee risf-- percentages (?AR3) c: selected smoking-related cancers aie presented in Table 6.1.
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.r .. r m m .- British Dr.s M U.S. Vets M Canadian Vets Bron I Canadian Vets Emp ACS Cancer M I Prev. Study F I Can Hlth Survey M&F i Swedish Men >15/day I Swedish Men 8-'15/day I Swedish Men 1-7/day I ~r .. .. .~. .. ~ ~ ~ ~ w. Figure 12 EMPHYSEMA a i 0 Soiirce: Lab. Contre for Disease Control ~ ZL8Z 690Z5 5 . . ; 10 15 20 ' 25 ilotatlvo nlolc for Curront Cionrotto SmoY.oro 30
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I I I I I I I I I I I I I 375°4 AG-185 irZ Eve=-s.r,c:<ers had sig.^.ificantly elevated relative .isxs of cancers of the lip, tengue/mouth/pharynx, larynx, lung and bladder. The proportion of these cancers attributable to smoking ranged from 37e to 88% depending. An type of cancer and sex. Table VI in re'ere;ce 25 reveals that these esti-at=.s for 373 Alberta are si:nilar to those observed elsewhere. - 7. Lifetime Risk of Mortality for Smokers Canadiarn data on smoking and health were used to es:i=ate the futLre nu:bers of deaths due to diseases caused by sao<ing and certain other conditior.s not knowrn to be caused b_/ smoki ng among four groups of people (33): - male s:o'.cers nox age 15 - female smokers now age 15 - male r.on-s::okers now age 15 - female non-smokers now age 15 The expected numbers of deaths that will occur over the lifetime of these groups up to age 70 were estimated under these assur..ctior.s: the croups -aintain t::eir starting smoking status up to age 70 or death; the groaps ex;.e.r:ence the same mortality risks for smoking-rela=ed diseases as persons who ;articipated '-rn the 1978-79 Canada sealth Survev and were followed for mortality to the end of 1985, the sa_e mortality risk of AIDS as Canadians experienced in 1966 and the same risk of selected other conditions as.Canadians exoerienced •in 1981. The resultiac escimates are presented in Figures 14 and 15 and Table 7.1 which was ext=acted from reference `33. W
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37704 AG-185 I I I I I I. 46. Recent Developments in Legislation to Cor..bat the t,'o=:-~ Smokinc Spidemic by Roener R. Geneva, Wor1d Health Orcanization, 1986 (WH01SM0:HL6l86.1). 4 I 1 I I
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f IcuaE. .0 TOBACCO CONSUMPTION, 1920-1987 LUNG CANCER iV1ORTAUT'(, 1940-1987 CONSUMPTION; KG PER CAPI iA 1950 1960 1970 1970 1980 1990 ~ Am YEAR
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I I I I I I I I I I 3'7692 AG-185 equivalent) had lung cancer relative risks, respectiveiy, cc 22.4 and 29.7 (26,27). 4.2 Coronarx Beart Disease 377 Although less dramatic than lung cancer, dose-response relations between risk of fatal coronary heart disease and aao::.^.t smo::ed have been observed in many studies (Table 4.1). -ea•,y cigarette snokers had at least a doubling of the risk of 'a:ai coro.^.ary heart disease in several studies (e.g. °eca2e ..rc;.is:: doctors, Japanese male doctors, Swedish Survey). As noted in Section 3.1 above, the risks of first non-`_atal heart attack among men age 30-54 and woaen age 25-49 were strongly related to amouht smokedj r•.en who snoked 45 or =ore and women who smoked 35 or more cigarettes per day, respectively, had relative risks of 5.0 and 10.0 (Table 3.2). 4.3 Chronic Bronchitis and Emphysepa very strong dose-response relations between amount s-cked and risk of fatal chronic bronchitis or ea.hyseaa have beer. reported in many studies (Table 4.1). T_r1 several st.dies, relative risks :or heavy scokers exceeded 20. 4.4 Overall Mortality As with coronary heart disease, dose-resoor.se relat?cas between amount smoked and overall risk of death are superf'_cia::, less d•:a^atic than t`:ose for ?ung cancer. Nevertheless, several studies have revealed relative risks of 1.7 or c,reater 'for !:ea•ry s;,okers. , 41
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I I I I I I I I I I I I I I I 3701e8 Ac.-l85 -~ 6 in particularly :a qb. risXs (3). STo::eless tobacco chewing tobacco) is also a risk factor for mouth cancers (3). ; 3 7~3 Relative risks of these cancers for sr..c<ers are hich a.^.d stror.g dose-response relations are appareat (see Table 3.2 and . . .. . . . . . reference #3). - The study of Albertans revealed that 69% cf mout': and throat cancers and 67% of esophageal cancers are attributable to s.oking (25). 3.6.5 Morbidity Due to Cancers Caused by Szaking Y.outh, throat, esophageal, lung and pancreatic cancers are largely preventable by never smoking. However, once these cancers develop, they tend to be aggressive and require major surgery (e.g. removal of tongue, jaw bone, lunc, paicreas/ duodenun, etc.). Despite such treatment and t::e attendant pain, discorifort and sickness, these cancers tend to recur and cause death. Survival rates for cancers caused by sr.eking are presented in Table ..5. ^`_ve-year relative survival rates fcr cancers of the esophagus, pancreas and lung were less ther. 15% in Alberta (29) and United States (30). 3.7 Enohysema and Chronic Bronchitis , Smoking is the major cause of emphysema and chronic bronchitis, often referred to as chronic obstructive lung disease (COLD) (8). The U.S. Surgeon General estimated that 80 to.90s of COLD is caused by,saoking (8): Smokers have very high relative risks fos COLD 'and strong dose-response relations are observed (see Fie':re 12, Table 3.2 and reference `S). l0 N
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# 31678 AG-18S '. 363 I I I I i I cigarettes per day had a relative risk of lung cancer death about 30 times that of never-smokers (27) (Table 3.2). Aaerican women with 40 or more "pac:;-years" cigarette exposure had a relative risk of developing lung,caicer 16.4 times that of never-s--okers (Table 3.2). Finally, sone of the variation in relative risk estimates presented in Table 3.2 is-attributable to differences in categorization of smoking habits (e.g. ever-smokers versus current-smokers) including the definition of non-smokers, variably defined as--never-snokers of any tobacco, never regular smokers or never-smokers of cigarettes. inelusion of ex-saokers or pipe or cigar smokers in the non-smoY.er category reduces the observed relative risk estimate. Although the overall relative risks of lung cancer for current smoking Japanese men in 2 studies (22,18) were "only" 4.3 and 4.5, there were strong dose-response relations (see section 4 and Table 4.1 b'elow) such that heavy smokers had relative risks of 6.8 and 7.5. for worer.) were caused by smoking (25). The U.S. Surgeon General has estimated that 85-87% of lung cancer deaths are caused by,smoking (3,41). A study conducted in Alberta indicated that 82% of lung cancer cases (88% for men, 52% There will be about 15,400 new cases of lung cancer diagnosed in Canada and about 13,400 lung cancer deaths during 1988 (24). The ?i`etime probabilities of developing lung cancer are now about 8.8% and 3.2%, respectively, for Canadian m.en and women overall (24). For smokers, of course, the probabilities are even higher (e.?:" up to 25% for male heavy cigarette smokers). ~ Lung cancer deaths .increas.e-d drarAatically in Canada during the past 25 to 30 years both in terms of actual numbers of deaths (Figure 4) and as a percentage of all cancer._.deat::s (Figures 5 and 6). P ko N 00 Ch to
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~ 37562 ^~-lE5 367 Lcng cancer dea::^. rates have increased c_anaticallo er..or.a Can&dian •ao:r.en Since 1970 (Figure 7)'anL, _'f current trends continue, lung cancer will soor..displace breast cancer as the leading cause of cancer deaths for Canadian wo-e- (43). Z~ contrast to lung cancer, the death rates for all other types cf cancer combined have generally declined over the past 30 years especially among women (Figures 8 end 9). .1 The annual lung cancer death -rate trend for Canadians (-en and women combined) is strongly correlated :+ith per caoita tobacco consumption 20 years previously (Figure 10). This fact is consistent with the epideaiologic evidence that saoking is the cause of nost lung cancers and usually requires 20 years or .-ere to induce such cancers. Survival rates for persons who develop lung cancer are very low (Figure 11). Results from- a recent study of Alberta cancer survival patterns (29) revealed the survival rates for lung cancer oresented in Table 3.4. 3.6.3 Laryngeal Cancer A . I CI U I # I .;e larynx (",oicebox") is one of the anato(r.ic sites directly exposed to tobacco smoke. A Canadian study revealed that 84c of laryngeal cancers among Albertan men were attributable to sr•_oking (25). Relative risks .._ laryngeal cancer for sTokers are hici: (e.g. 8.2 for Albertan male cigarette smokers) and strong dose- response relations are observed (see Table 3.2 and reference :). 3 . 6 .4 6!cuth, T4roat a^c. Esochaneal Cancers Smoking is a oajor cause of mouth, throat and esophageal cancers (3)• Alcohol :s also an importa.^.t causal factor for these cancers and thi* combination of tobacco and alcohol results
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I r. I I I I ~ I I I I L: I 12. Similarly, pharmacists who do not sell tobacco may be much more motivated to provide smoking cessation assistance to their customers than those who do. 13. The pharmacist who deals in tobacco is subjected to strong incentives to facilitate the marketing of tobacco products by wholesale suppliers of pharmaceutical products, who currently also supply tobacco products. In this respect a major supplier has previously urged pharmacists to order "just a few extra cases of tobacco per week ; on the basis that they would receive credit for such orders toward rebates pharmacists receive on orders of pharmaceuticals. A copy of the supplier's promotional material in this respect is attached to this affidavit as Exhibit "C". 14. The fact that pharmacists currently sell tobacco inevitably leads to their engagement with other market practices designed to stimulate the sale and use of tobacco. The tobacco industry has paid pharmacists for the use of prominent space behind the checkout counters of pharmacies. In an article published in the Canadian Medical Association Journal in 1992 entitled "MD's Angry as Most Pharmacies Continue to Sell "Number One Cause of Death"", R. Birenbaum quotes the following statement of a pharmacist formerly employed by Shoppers Drug Mart, which I believe to be true: "Tobacco companies offer up to $5,000.00 and assorted perks, like baseball tickets, as they compete for the most visible four feet of space at the front of the counter" I I 399{ . I
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37676 :.G-185 I I I I I I I I I impcrtant cause of :enal adenocarcinoma (a cancer). type of k_d ney Overall cancer mortality rates have increased a:ong Canadian men for many years and since the mid-1970's aaong Canadian wo^en (23). The increases since about the mid-1950's for men and :ore recently for woaen were almost entirely due to rapidly ris'-rtg lung cancer mortality ratEs (23). There is a remarkabale correlation between the yearly per capita tobacco cor.sunp;ion levels in Canada since 1920 and the lung cancer mortality rates about 20 years later (24). This correlation does not prove cause and effect but is consistent with the overahe!aing evidence :rom epidemiologic cohort and case-control st_u8ies that smoking is by far the-major cause of lung cancer. 3.6.2 Lung Cancer Many epidemiologic studies conducted worldwide have demonstrated a very strong dose-related association between smoking and the risk of lung qancer, an aggressive and usually fatal type of cancer. The landmark study of Canadian veterans (13) revealed that men who saoked cigarettes had a risk of lung cancer death 14.9 tines that c: r.ever-sc,okers (Figure 3 and Te:le 3.2). Similar results were observed for A1=ertan males (2a), British male physicians (26), U.S.'Veterans (15). The recent American Cancer Society studv of 1.2 millio.^ aersons revealed that r..ale and feTale curre"nt cigarette smokers, respectively, -ad 22.4 and 11.9 times the risk of lung cancer death compared to never-smokers (41). Somewhat lower but still high relative risks have been _eported in ot':eL studies (Table 3.2). x.cst early studies revealed Lower relative risks for women than men. Hocte.ver, :s:;ori ng became widespread about 20-30 years earlier in men t:^.an woaien and the prevalence of heavy smoking has been higher among men than women. Pe-ale British physicians who smoked,25 or more k`
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I I I I , ' I I I Persons•.+ith ad•ranced COLD.ray.survive fc_ severa2 years but be incapacitated by '_apaired lung function. £ven slight exertion causes extreme shortness of breath among severe COLD cases. n ry j. _ 3.8 Overall Mortalitv The relative risks of death overall for current or ever- smokers cited in Tab_e 3.2 range from 1.1 to 2.3. The re?ative risk for Canadians xho participated in the :970-72 t7ut:ition Canada Survey and had ever snokec.regularly was 1.7 for r,en and aoaen. TF:e British Doctors, Swedish Men and Sutrition Canada _ Follow-up studies a'_1 showed strong dose-:espor.se relations between amount smoked and overall risk of deat:: (Table 3.2). 4. Dose-Response Relations Between Smoking and Risk of Major Diseases Caused by Smokings Selected Results for Illustrative Purposes A doee-response relation refers to increasing risk of disease as level of exposure increases. E•ridence of a dose- response relation is strongly supportive of cause-effect relations in both human and experimental anisal studies. .vidence of dose-response relations between sraoking •aad lung cancer, coronary heart disease, chronic bronchitis and esphysena and overall cortalit. 4s _-esented in Table:4.i. 4.1 Lung Cancer Very strong dose-response relations between amount smoked and lung cancer risk have been observed in many studies as illustrated in Figure 13 and Table 4.1. Albertan rec and :o:deti, respectively, r.it.`. 40 or more pack- years exposure to c'_;aret*.es had lung cancer relative risks of 22.4 and 17.0 (25). British 7ale and female physicians who snoRed 25 or more cigarettes per day (e: other toSacco , P
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r I I I I I I I I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 ~ 25 26 I I L 27 28 29 30 31 447 M. Taylor DR. MARK TAYLOR, sworn CROSS-EXAMINATION BY MR. LENCZNER 1. Q. Dr. Taylor, can you tell me whether Dr. Schabas is A. a member of your organization? I don't know off the top of my head. 2. U/T Q. Is there any easy way you could look that up and let me know through your counsel? 3. A. Q- Yes. You know who I mean by Dr. Schabas? 4. A. Q• Yes, I do. All right. I would appreciate that, thank you. 5. You say in your Affidavit that the PSC or Physicians for a Smoke-Free Canada, have always strongly advocated the banning of tobacco sales by pharmacies, and my question is whether you advocate the total ban of tobacco altogether? A. The short answer to that is no, but it is--it's a complicated matter. Of course in an ideal world my answer would be yes but I recognize, and our organization recognizes, that in a country with over five million addicts it'would not be practical. And to ban a product to which five million people are addicted, would just not be consistent with practical reality and it would not be possible to reasonably enforce such a law. Q. All right. So scaling down from that you're really saying that if, at least, pharmacists because it's an inconsistent message that they're spreading by promoting healthy drugs and at the same time promoting tobacco? A. Yes. Rosenberger, Weir, Macdonald Paul W. Rosenberger, Offciai Examiner I Toronto, Ontario
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1 I I I 37E97 AG-185 These reaults indicate that in the future there vill be far more deaths caused by szoking among persons who are now young smokers than there will be from car accidents, suicide, murder, AIDS and drug abuse combined. CS 38:? Fcr every 100,000 male smokers who are now age _5, t:.ere will be these deaths before they reach age 70: - 20,421 deaths frcai cardiovascular disease, car.cer a-d emphyse"ta caused by smokinq; - 1,809 deaths =ron car accidents; - 129 deaths frcz AIDS. Corresponding esti-ates for 100,000 female s^okers row age 15 were: - 9,077 deaths from cardiovascular disease, cancer and emphysema caused by smoking; - 601 deaths from car accidents; - 6 deaths from AIDS. R i. I I It should be noted that the above are estimates. °cr exanple, -the authors do not claim that there will. be exactly 9,077 smoking-related deaths among female smokers. The ?cwe: and upper 95% con'_idence limits for these esti^ates, based on -:e variar.ce of the relative xisa estimates used :n h e i r calculation, are presented in Appendix 3: 8. Prevention and Control of Tobacco Addiction in Canada Tobacco is addictive (44) and causes about '34',000 deaths annually in Canada (32). Ironically, the t:ed"tments available for most of the illnesses caused by smoking are relatively ineffective but large fractions of the diseases are preventable by not smoking or ceasing to saoke while still healt:^,y.
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37698 AC-185 I I I I p I I I I The iceaJ pub:ic health strategy to p;e•:er.t ar.d cor.t_ol tobacco addiction would focus on the supply,.cemar.d and _rice c: tobacco as described in reports published by the world :'.ea.th .Organization (45,46). Bill C-51, "he Tobacco Products Control Act, provides some of the elements required for an ideal public health strategy to prevent and control tobacco addiction. Sill C-5! will reduce demand for tobacco by•reducinq tobacco advertising and prcroticn, by strengthening the content and visibility c: health warni:gs and by demonstrating unequivocally to Canadians tiat the federal govern:aent recognizes the enormous burden o: adverse •r.ea!t= effects caused by tobacco. 9. COACLUSIOrI Smoking causes the premature death of over 30,000 Canadians annually. Smoking is, therefore, the leading preventable cause of premature deaths in Canada. Tobacco smoke contains over .4,000 known chemicals many o° which are toxic. Over 50 chemicals present in tobacco smo;te and tobacco smoke per se, are known to cause cancer is a::_-uls, humans or both. The toxic chemicals present. in tobacco snoke are in:alec into the lungs, enter the bloodstream,and are quickly and widely distributed in the body leading to a wide va:'.ety cf diseases. In terms of premature deaths, the major categories c` disease caused by smoking are cancer, coronary heart disease and chror.'-c - bronchitis/emphysema. Smoking causes about 30% of all cancer deaths, 30% of all coronary heart - disease deaths and about 856 of all chronic bronchitis/emohysec,a deaths in Canada and United States. _,n addition, smoking is a major cause of deaths due to aortic 1A
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3 ~'r02 '.G-135 I I I I I I I M 1 r Science Publishers 1988, pp 75-86. 29. Mao Y, Semenciw R, Morrison H, Koch M, Hill G, Fair N, Wigle D. Survival rates among patients with cancer in 22. Konc S, -::eda x, ;okutome S, Nishizu:ni M, X_ratsL~ne ... Smo:cing and mortalities from cancer, coronary heart dLSease a::d stroke in -a?e Japanese physicians. J Cancer Res Ciis r~ p~ Jp Oncol 1985; 110:151-C, i 23. Wicle DT, Mao Y, Semenciw P., Morrison H:. Cancer Patterns i.n. Canada. Can Ned Assoc J 19861 134:231-5. 24. Canadian Cancer Statistics 1988 by Eill GB, Mao Y, Laiclaw J, Sanscartier GP and Silins J. Toronto, Canadian Cancer Society, 1988 (_SSN 0835-2976). 25. Wicle D?, Mao Y, Grace M. Relative importance of smoki:4 as a risk factor for selected cancers. Car. J Pub Fealts 19801 71:269-272'. 26. Doll R, Peto P.. Mortality in relation to smoking: 20 years' observations on male British doctors. Srit Med J 1976; 2:1525-36. 27. Doll R, Gray R, rafr.er B, Peto R. Mortality in relation to saoking: 22 years' observations on female 3:itis` doctors. Brit Med J 1980; 1:967-71. 28. Hirayama--T_. Health effects of active and passive smoking. In Smoking and Health, edited by Aoki K et al. Elsevier . Alberta in 197<-78. Can Med Assoc J 19881 138:1107-13. 30. 1988 Annual Cancer Statistics Review by Sondik EJ, Your.c JL, Ecr^ J4I and Gloeckler Ries LA. Bethesda, National Cancer Institute, 1986, op Iv.9.30-31. ~ 31. Sroking-attributable .;:ortality and years of gotential 1i`e lost - Cnited States, 1984. Morbidity and aortal:ty teeekly Report 1987; 36:693-7. 32. Collishaw NE, Tostowaryk W, Wigle DT. Mortality attributable to tobacco use in Canada. Can J Publ Health 1988; 79:166-9. 33. Mao Y, Norrison E, Nichol RD, Pipe A, Wigle D. The health consequences of saokir..g among smokers in Canada. Can J PuSl Health, in press, 1988.
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37703 AG-185 I I I . I 1 I I 34. HamnOnd EC, Sez;:r.ac Y.. Scok:ng and cancer cn t`e states. °rev :4e' 1980; 9:169-73. 35. Weir JM, Dunn J5. Smoking and mortality: a prospect_•:e study. Cancer 1970; 25:105-13. 36. Johansen H, Seme:ciw R, Morrison H et al. Important 3is:; Factors for Deaths in Adults: a 10-year fol:ow-up of the Nutrition Canada Survey Cohort. Can Med Assoc J 1987; 136:823-628. 37. Williams RR, itor: JW. Association of cancer sites with tobacco and alcohol cor•sumption and socioecononic status of patients: ir•t:rview study from the Third National Cancer Survey. J Natl Cancer inst 1977; 58:525-47. 38. Causes of Death, 1976. Statistics Canada catalogue 84-203, Ottawa, 1978. 39. Willett WC, Green A, Stampfer MJ et al. Relative and absolute excess risks of coronary heart disease among wc^en who smoke cigarettes. R^cngl ,7 '•fed 1987; 317:1303-9. 40. Colditz GA, Bor,ita R, Stanpfer MJ et al. Cigarette sr.okir.Y and risk of stro:<e in middle-aged women. ;: Engl J Med 19u8; 318:937-41. 41. U.S. Department of Health and Human services. Reducing t•*•e Health Consequences of Smoking - 25 Years of Progress. A Report- of the Surgeon General (DHHS Publication No. (CDC) 89-8411, Rockville MD, 1989. 42. Floderus 3, Ceterlo- R, =-iberg L. Smokia-and =orteli-y a 21-year fo11c.+-cp based cn the Swedish wic registry. Int J Epideniol 1988; 17:332-40. 43. !!ao Y, Smith MH. The 1u-c ca::cer epidenic among Canadian women. Chror• Dis Can 1983; 4:33-5. 44. U.S. Department of-Health and Hunan Services. Nicotine Addiction - a report of the Surgeon Gene:al. Roe:ea131e, DHHS, 1988. " 45. Legislative Action to Conbat the Wor"ld Snoking Epide•.,ic by Roemer R. Geneva, world Health Organization, 19.82. 19
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I I w I r I i N I I I ?7700 AG-13> REFERENCES 0 1. International Agency for Research on Cancer. IARC Monographs crn the Evaluation of Carcinogenic Risks to ..u..ar.s. Overall Evaluatiois of Ca°cinoger.icity: An Up.".atin5 of I?.RC 3G3,,) 2. Monographs Volumes 1 to 42, Supplement.7. Lyon, IARC, 1967. Ir.ternational Acency for Research 'on Cancer, Ii.RC Mor,ographs . on the Evaluatiorn of the Carcinogenic Risk of Chemicals' to P?e-:ans, Vol. 38, Tobacco Sr.oking. Lyon: 3r.:err.atior.a: r.gency for Research on c_ncer 1986. U.S. Deaartmer.t o= wealth and Y.uman Services: The cea'-t': 4. Conseo,uences of S.+oking: Cancer. A Report --r the Ss:gea::- General (DHHS(?NS)82-50179), Rockville, MD, 1982. Hill AB. statistical evidence and inference, chapter 2; 5. in Principles of ::edical Statistics. New Ycrk, Oxford University Press, '_971, pp 309-23. Rothaan KJ. Modern Epidemiology,'Little, ToroRto, 's986. 16-21 6. U.S. Departnent of Health and Human Services: The Health Consequences of Smoking: Cardiovascular Disease. A Report of the Surgeon-General (D!iHS(pHS)84-50204), Rockville, MD, • 44 1983. 7. Collishaw YE, Kircbride J, Wig1e DT. Tobac:o sr•.c'r.e i.nn the •aorknlace: an occupational health haZard, Can IMed :.ssoc 1984; 131:1199-1204. 8. U.S. Departr_e.n.t cc wealth and Human Services; The Health . Consequences of S-o:<ing: C*ronic Obstructi^e Lung Dise+_se. A Report of.tae Surgeon General (DHHS(Pe5)84-502Q5), Rockville, MD, 1983. Kaufman DW, -elr..rich S?, Rosenberg L, et ai. Nicotine and - carbon monoxide content of cigarette smoke and the :is'.<s o.° mvocardial infarction in young men. N Enyl J Med 1983; 308: 409-413. _ 10. Rosenberg L, Miller DR, Kaufman DW, et al. Myocardiel .nfarction in wo-en under 50 years of age. J Ar•, ried ?.ssoc 1983; 250:2501-2506. I
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r , I I r I I •. I I .r I ~~,01 ~C-195 cy 1'.. Secencis+ •°.", uorrison Y.?, uao Y, Johansen -, Wig,le DT. t<ajor risk factors for cardiovascular disease nor:ality '_.. adults: results from the Nutrition Canada Survey caiort,: Int J Epideniol 1988; 17e317-29. ) 12. :he Relationship of Smckinq and Soae Sociel Covar:ables to Nortality and Cancer !•lorbidity by Cederlof R, ..ibe:c Hrubec Z and Lorich U. Stockholm, Karoliaska Ir.stitute, 1975, 91DD (part I) and tables (part 2). 13. Departr•.ent of National Health and Welfare. A Canadi=_.n. of Smoking and Eealth, Ottawa, Depart::ent of yat'_onal F.ealth and Welfare, 1966; 137 pp. 14. Abu-Zeid HAH; Choi Nw, Maini KK, Hsu PH, Nelson t:n. Re?at:re role of factors associated with cerebral infarction and cL~rebral hemorrhage. Stroke 1977; 8:106-12. ~ 15. Rogot E, Murray JL. Smoking and causes o: deati among GS veterans: 16 years of observation. Public ':ea1t.`. Repcrt 1980; 95:213-222. 16. Abbott RD, Yin Y, Reed DH, Yano K. Risk of stroke in ^ale ciaarette s:^_okers. N Enql J tfed 1986; 315: 17-20. 17. Laboratory Centre for Disease Control, Hea1c:i and 5ialfare Canada. Unpublished tables of age-standardized :ortal_ty ~ rates, Canada, 1951-1986. 1°. Causes of death, 1986. Statistics Canada Cata:oque ,E4-2G3, O2',tawa, 1988. . 19. Laboratory Centre for Disease Control, Health a.^.d Welfare Canada. Uepublishec results from the Cana!a Hea_t.`. Szrvey Mortality :ollcw-ep Study (see Appendix 1 for descrc. ...... 20. Hannond EC. S_eY_ng in Relation to the Death Rates cf C:e Million Men and secmen. Nat Cancer Inst lt.:o; 1956; 19:127-204. 21. Carstensen 2M, Pershagen G, Eklund G. idortality in re_at'-o^ to cigarette'a.n.c pipe smokinq: 16 years observat.orn of Swedish nen. J Epidemiol Commun Helath 1987; 41:166-7-2:
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I I I I I w f I I I I I I 37699 aG-1E5 aneurysn5, periphe:a_ arte:y disease and fires. There :s ;__ evidence that sme}li.'.cis also aninportant cause of deat`.5 Gce .,, stroke. 381 In terms of the scientific evidence available, the ca:;sa_ role of s-oking ir. the major diseases desc'ribed above is ?-.lv established beyond all reasonable doubt. This conc?;:s'_c: '_s accepted by all leading health professional organizations a-= b; many governments and international agencies includinc: Canadian !fedical Association Canadian Public Health Association Health and Welfare Canada Canadian Cancer Society Canadian Lung Association Canadian Heart Foundation Canadian Council on Smoking and Health U.S. Surgeon General/U.S. Department of Health and Human Services dorld Health Organization International Agency for Research on Cancer so:;e of the U. S. Surgeon General's ma jor cor.clusio::s =.. the health consequences of smoking are presented in Appendix 2. ':e advisory groups `oraed to prepare each of the U.S. _--- cn General's reports are crc:^inent experts fror.. the hr.ite9 ';:a:es and o_he: countries including Canzda.• The prevention, control and the event.al elimir.a:i:^ c: smoking are the major challenges to public health in Ca::al'a and other countries that have successfully controlled the -cst serious infectious diseases. Among young persons today in Canada who continue to smoke, 6 times more will die prematurely`from cardiovascular disease, cancer end emphysema caused by s:oking thao will die from AIDS, car accidents, suicide, murder and drug abuse combined. Ik
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I
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d Iga96'e 13 LUNG CANCER: ®®sE-R9SK RELATION 'rLBZ 690Z5 Brlt. Dr.s M 26•/day 6 24/d ' ' - ay 1 • 1-14/day Urlt. Dr.o F26•/day - ' 16-24/day ' ' 1-14/day U.S. Vote 40•/dayU.S. Vote 21-39/doy U.S. Vote 11-20/day. U.S. Voto 410/day Albortat+t 40•/day AlbortalA 31-40/day Alberta U 21-30/doy . Atborta 4 11-20/day . Alberta Nt <10/day Alberta F 40-/day Atborta F 31-40/day Alberta F 21-30/day Alberta F.11-20/doy Alberta F •10/day ~ Can Vote U 20•/day : i l/Tl~lt ~ ~ ; .}. .. ~ .. .. ; . t 9 . . !Can Vote U 10-19/day Can Voto U •10/day ; . Swodleh tAon 16•/doy Swodloh lton0-16/day ' , . Svrodlah LSon 1-7/day { a JnO. Or.o U 20•/dayJ-_.Cey%:~11 . - - - 10-19/day :%1`l~ i j ' . ' 410/dny . ~L! J. t111h Cntr 30•/day , 20-20/day ' ~-- ' 10-/9/day .' .10/dny 0 * 5 Sourco: Lub. Contr6 for Dtoouoo Cohtrol I. 10 15 1 20 25 30 Rolutlvo Illak for C:utront ClOnrotto Smokorn 35
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I I I I I I 1. I I - I I t .. I 906 thc 33umberr of deit5s io Ooa•smokcrs in each aer t;<oup arn too rmdl to pto%ide a.bie eatimatea nOlSiINN.SVRYjVµei iMVKIHO SIABrr As the obserndono have been msde over such e long time, itLes baapoes(ble to follow mmy mea Into rhdc 11kh-.ond e kwmen Into their I idrd.onde ofllfe. It has, therefore, beeo possible to cwlatate 'aetuadat` stu.tvat cwves for different ategorks of smoker not onb througlwut middle age but also Into old a;e,with reesutts dut arc masonably reliable up to at least tl> yna of ge.Ihexsults 5om 15 years.of age ax ahown for nnn-smoken and contisnswe cigareere unokbn (o flaus'e 1, and for n,x,-rmekee and continuing liaht, moderatc, and bary ciearette rmokers in figure 2.'fhe most tsaable differmcec ae (n the propordons who die beracaa 35 and 69 years of a;e, whk>: raey from 20Ye lo uwymoken to 41% Iu dpnate rosoken as a Mmk and to 50% ia tbore who smoke 25 ormote tiprcaes a day. The absolute diffe:enees between the nmivd probabiliefa of tmokets and of non•smokns become less inaaceme old age, siaopbbecause almottnobody survi.a beyond 100. Sven after middle ake, however, the ctifk+mca between smokay snd non-smoken in rheir emud mestaDty ntw an yuite taye: of tLoee alive at 70, the probab0 tiy of survhing to BS b 41% In notramokers sgaiaa 21e/% la c(garette amokets. Ihe loss of don of tife shown by these figuee is subsmmior dgareae smokers, the atK by whiah half have died Is el;ht years less than for nou•smokas, 20a 40 55 70 AV so a0~ 2oi I O New maked repAOy • CaednuMeOjarnsem+Nan • famennakex RePPrd US t j 333 . do ss . 7o ez lao . sfas-e~rM.qO(p.t,ne+r~ ~raw~v+i(a~.wr JLRknbfrmcmm~(mJ~rl) . while for beaty tlgarette smokers ttis 10 yeus less than for nonmooken- - Atseettnent of the efteas of stopping smoking is eomPliated by tbe fatt that peopM anp fnr dlK..ero reasons, some stoppine (Pardcuiarly In old aee or late middle azc) beause they are W; eoa.ersdy, some may, because they are !tl, spedHeal(y choose not to atop, dda3:i,y; tLn h Is wo tate for any bene& from ao doing.' Mort of those who etopped in the doaoss' cobon are !(kety to h.ve done so not because of an established dloess but to avoid long tesm e$eeo of smoking or to aet m cumple,° and their state of heatth atthe time they atopped (pardctilarly if tbey stopped in eady middle age or beforv) should not hsve distorted matarially the p.etem of their lony tam survivaL'tUe pattern wlll, however, be fubstaotially distorted for a few causes of death dsat arc preceded by long tetm irreversible morbidity, most notably, ehtonic obrtruetive luo; disase.r" R}ie susvhd of cigarette smokers who stopped at diBerent ata Is tompared in 86urce 3 and 4 wld+ that of non+moken and whit that of thoce w6o continued to smoke.'ILoK who stopped before 35 years of age (at a meen of 29 years) bad a ptttem of survi.al that did oot dlffer;lantBcaoth' 6om tWt of non-smokers (f; 3; Por thosa who stopped imr (fit 4) two taUed P_>0•O5). , the susvival was 9ntesmcdiate between that of now smokers .ad that of eoadnuin; amokers; but even ~~ rhovwl,OVopP~'det65•7ayeenofeae(me+n71)eeee) e 75 d a tns be o a ti d ( Q y y n us age epecU c motto ty Its Ipp hs d Th sw e-OaeaCw,tioBeRr rp 33 Mwj e,yanor rn:eAe, vd na.- ekr nnaep.t,• yg mele u0.nea, Aned an e(r WOie dratF roro~o" mror IoYwDnied (fla dwt, et 1eW/BdtlJk drarh,om, fyN d md,i,fowueddparir'eJro",evNm35yeoreJald , ~ 70 . . a5 ~ 100 no 1-OwnD mnnwt (af 6F ~U,~b,e miM tilvne tnuken n.61/iwW ly e.nnr My w.w rwvMy a, dr e..• OM Ha y,rrme,vaikraaKawm . . e . sppreeisbl7 tower thso those uho contmue benefit of stoPpioi in late sniddle aao or otd age Is probabty uaderatlm+ted ta O,eu snalysa beaust some of those who stopped inlata life are 1lkely mbne done ao speclllally beause of being ill. tlNN06 Rt MoteTMJt4 nNC tV tcvtv~[. ovaa9r7.a 1n the coone of• 40'yeart many changes havs occurred that could have modified the effeet of enrokb)g, lodudbryt J,e e(11uwy ur urcJhvl uavtmetro (both theapeude sad pre.essdvd. the prevalence of other faaors that Interact with smokulg, the srpe of tobacco emoked, .nd the amount of tobacco that had bem ansoked in tbe even mae distant pa+s. We have tberdore alcukted the excess risk (cigarette smoken versus mnamokas) tepaatety during dx Lsst half (1951 •71) and the aoond half (1971.01) of the etidy, These exccssa ate shown for 6ve age FouPs In 6gtut 5. No f,gtsce !t p+m for sssco onda 45 )'eass otajela the seeasd half of the study w the smmba of mm m dus age VW in 1971 was tuu mWlto pemdt a retiatsle cotnpasison. As a percentage of the mortality among those wtto had never smoked regularly, the excess among acrmt dRateue smokers' was eondstendy' hipher In the second half tbon in the fusb pardadsrly Btv(/ vOLVr.<a 80p 6ocmes>•19D4 I . in N O m tD N tb W 0
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I I I I I I I I I I I _t n y , aurves for non.uuokas and for aeermr sMoken sboas that the ioeraau in relati.c tisk wss so ex,rtme Uut is eouacerbtlarteed thc .ubsu,,o.l inspre~ent Use[ kaS lakaa place over the past few dKaOes in the suni.a1 of tke oon-amoken (6a s). Overall. tAerefore, then vns prac8cally no ebaqge betpaen the firsc and second hahmotsh ttudy ln the aeeapeci$c pateetns of sus.Ml of dse dgarene smoken (flg 6), even though this u.s a period tabea natioaal mortality nm wire lmprovingnpldb• C~umWO iu iuu,taliq• benaou tLs twu hylra of the «ody are ehown b1 pble Vll for some of the pthudpat eaara of death In aon-smoleen and in conti e[auctte smoken. Pe detailed age epecSfic ncea ue gisea in the appenduJ To atlow tor Z•M/e otthe ausa of darb in the second baitof the study bdng unlaolvn wLr1e oely 0~09Y% wae onkaown fn tbe fex balf,.ad for tbe poaaibWry rbat rome 50 deoths In the 40th year wcte missed, the cause specific mortalitT sms in the wbole of the sccond halt lute bcen moldplied by x~J \`, \ 1 \\ 1•025. As few docton wett unda 45 yaats of age ht the /ge Ate no 4-F/J/Cp n ryNNel (Rn yY 03, ss. a:, N,6 rs vla,Wply,wvAftin r,.fw, Quts aTi MG mi"wa (w nh 1) . 0 IYtI 45-54 $S.a•4 65.y. T524 AS-94 AV t,o s-cen, ers,p.qtic mnwbp•a et(Mmraneea M1br he7d m'ay porafeul corttrms.dseik dwe in wly seeeNAah(WMirKI. An nms el f063: nprne.c 4aNdd/m5 roIS 8es indGar SD second pedod, tM tates in lmilttd to men aged 45 yan aod over and are standardised to a population whh the aea d;'aAbut(on of the person yeaus at tSsk eoa 45 Yean tor lb. whola peeiod. Most of ebese taodardtred ntes, io consequence, are ldgher tben chose treordedln tablea JII V. Idortality in oon-nnokea for the most put decttased: irom eeceDrovosculor diseases by SIYy from ischaemk and other ardlowceulu diseases by SOM/e, and from tecpincory disease other than chmnie nfiatnsaive lung diaue by 3ZY.. I3e lsraa reducdon In mo:tdity attributed to bthct eardio- vascular ditasc" is probably a noaolodcal >tdiet dne to dte greater use of isebaemk heart diseue as a diegoosrk eeras la dte atmM hUf ot me smdy lup0yue of saRuer tetms like mpoatdiil dcgeaeraoon and arteriosderosis. The ttue reduction !n monalit)r &om Isebaemic heart d'ssase is therefoie likela to hatt been grester than the recorded 5gtue. 73e propoltions of lbe leduadon that should be atulbnsed «speeD.,4 m the Introduction of pretentiro maluurts ood 1uyAOved tta®em are not kuuwu twt Wth usustbe appndabto. The reduction of Soy. In moreaUy 6rom the ancen otba tban lung emca that aro auaed In pan by unoliaR aould be cbie9v due to raadom ndatimb sisce the numben of dadsa in eoa-smokenc wero Utma (18 aDd 25) but It could dso tcgCae a reduction (n the pcenslence of esdnogenle agents other than tobaeoo, as most of.be durlss In thM 4110,01, wme from emwr+a of the paneceas and bladder, both of nfikh brre ahet lmpotunt auses. 2Le mostolity (n m»o-atuoken fiom lung cagoer, In cwntcast, aeems to have tenninad eoastany althouig)t the onrnben aee amall. ('!he maeh .krger pcospamdre studies In the United Sptea km.e alro found no material ebange In moltallq due to lunj enncer in nonrnokase betwaan tba 1960s-*od rLhe 1980t1') 7n ueoksrs, the reductions 1n cause apecffie monalitq when they occurred, were smalla then in noa•smo~Cen (cerebrovaecvlar disease was approa- mately eontxs4 wfille ischaemk and other eudia .vsNlar disease, taken tveethers tleaeared by emy CAroO • Itnarter). Tn aeven) instNOee, reductions lo non•amoken wero ecoompanled by fnaoases !a rmokM most notably in tlse mortaliry &om the amcaa other ihm bmg cancer that art aused by rmoklaW 4wt ruplsauuy di"ea wLet ddw chsode obrcucti•e lung diaeases aad fian `olher diseases^i hso8 cancer, MJeh was unUunged io noaamokert, mcreased lo smokm by 19SS. ~ oadidotqthowe'dinaaaedmorolityfnbot6 *+o6-sm.ivaleflr.at.lsMenjdjerm.nwAnseMnee-neelnafimlay(4h1m4raneAaVd 0e !~l~taAd.Faara)s-u.autF,rd,.mlm4auaymeareaieeahkakesseveta,Gb~k~mdo"anr(ui ..non-smokets anl amokm. For cbmole obswewe u=w~annloMdrumrtdaay lunt dlsease the rates in non-amoken ,were based 9 $Mt `rou;Ma 309 8 oc"eu 1994 907 o) to t.1 W W J 12.Z 33 •
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lnts is Exrxoit ". " re'.etteo t0 in the AHldavit of ~R'''~tar~Rj~~,t~ ~y~~ Swom betore tne this . =.=~~ day of 9~~RA.D. 19 -r/tT 1; Commissiort~ L / ~. ~ ~ ~ 7 ~ : . . .. © ...~•r" ~ ~ ~ ~ t's hard to believe how the very phamacies Wat pro- ote themselves as health<adng professionals can s811 promtnently display' and sell cigarettes and tobao- co products dght at the cash. Is tF at really everything you want in a dmg store? At Nutri-Chem Pharmacies, we've dedicated our stores to health fans. Not 'oply do we refuse to sell tobacco products, we offer the widest selection of prod- ucts to helppeopIe live with• out them. Here`s our top S k sellers. 1. Nicorutet 2 mg Can Finally Help You Qutt . Smokin For Good. . Available for the frrst time Would You Buy A Health Product From Solneolle who'S Iixy~llg 1'o Kill You? over the counter and without a prescription, Nicorerte is a. proven method of quitting smokin . If you have tried to quit smoking without success, you know the addictive power of nicotine. Fact is, nicotine is one of the most addictive sub• stances known. ~ The most imporrant factor in quitting smoking is r motivation. desire for a cigarette, it's rela- tively easy to gradualfv wean yourself off Nicorette ~ mg. Nicorette 30's._.....512.99 Nicorette 105's_...5 38.79 You have to decide that you want to quit and must be fully committed to this goal. Nicorette 2 mg is designed toease yourself off nicotine gradually without going through the agony of wtthdrawaL Nicorette works by releasing mcoGne into your saliva. The nicotine is then absorbed through the lining btyour mouth into the blood stream, keeping unpleasant withdrawal symptoms at bay. Once you've beaten your 2. The Life SignO System. Stop smoktng with the medically proven Life Sign System...the break• in smoking research and leading computer scienttsts, Life Sign u recomtpend- edbydyoc- Cholo~gWa, and health profession- als. Use it. Uvough computer that helps to create a personalized Pro you duottgh gradual with• gram based on your parUCU- drawal, lar habit. Developed by experts UteSign System...S89.99 NUTBICHEM -Pharmacies The Store For Health Fansl 1303 RICHMDND RD, 82o-4200 350 ELGIN ST. 232-7366 403 3. CigNo, an herbal ' aid for a smoke-free lifestyle, is an all natural herbal sup• . plement that contains Plantago Maior. Considered by the ancient Saxoris as onf, of the nine saerodhubs, it's • use as an anG•nicotine agent is documented in the Materia Mediea. Research has showo that the active ingredient is a! ~ powrtrful anti-toxin and ..• 'dxtreniely We. . CigNo. ,. « ..~ 51999s 4. For those looking .'~ for a Homeopathic smoking' ;; ~ deterrent pou ean't beat Caladium2A0CH. fMedou„ whenever the craving to smoke occurs, and the tiny .:. granules are melted in the mouth and passed into the . blood stream from the saliva' ' Caladium reduces the urge to „ smoke. The rest is determi•_ nation. • •= Caladium 200CH.'...t 7.00°= i hem Ultra- , ~ V•nes. ':, Avatlable for ,; the fust time ::y wt ot t~~teacription,111tn-a Ytes aro the mosl wmplete :; muki•vitamin in Caroda help replenish the vitamin i:I defrcienciea caused by smok-;•I ing and the stresi of wtth• • drawal. Ultra-Vites 90'5.... ..519.99 ;e1 At Nutri-Chem .J Pharmaciea, we've got more ';/I ways to make you feel good : ~ about yourselr than anyone : else. From Ottawa s lowest :; priced vitamins to altemativr.i; medicines and more, come ;Ej see whp they ca11 us "The Store For Healdt Fans!" ;:I GLL TOLL FBEE 18003636i27 5. Give your body a fighting chance against wJddrewal symp•.;t ; toms with Num• •:. a
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I I I I I I I I I I 006 I .~..rM ..... . pv.y v..u vu.q IIN,VUav type6 01 caaeer), but the eeventh (elacer of the reetum) did, u it had done in our previous repott.- A moderate but studstially sl8nltlaut relation was observed tot coecca of mlaown odgm, as was to be expeeted, as a plopordon of them i7likely to hsve en7an la the long• Table IV shows mortality 6f.ctIIath~ dirMed for 18 ditusa (or povp6 of dix.oa) ot dx taplraray 1ad circulatory sy6tcros; respieatory Wbcn.dosis Is 6xhad6d here rather than wlth iofeetiocs. (xuouk obstructive itula disease (with which an dassed oll deaUu ertribated to "d2rodc brond7lW or •emphy6ema") rhows a nladott almo6t a eaapq as that for cotlces of the luog Polmoaary tubeaWos37 ennAnnn to show a medenwty eion niatlon whL elaisiGed ai No 422 DI 1CD•7 or 429 In tCD•y), aGd amoking, but tecladet data foc enly nine plore deaths tor the todow fotm6 of cacbtovmala daeau beDe than wen recadcd in tht flm 20 yean of dle sWdy. A tltdr absolute impaanee, pardcularky in mkidle a8eW wak but statistically bl*y sipl8ant reledao whh Ahbouab the ortrall mortalio bl even the heade62 mokla` was observed for pnenmo[iW which was .. a(gare2re pAokes! (25 or mon a day) was only aboa much the sama at ali agcs, possibly becaoae ot an twite tbat In noo-smoken, rhts ndo 4 mon e>nreme ta Increased risk as7odated with the praeaca of ekadc lmiddk than ie old SP aad dte rcat aumber of deaths obsnucdre hwp disnaa Althnitgh ttd. ntadoo 4 weak it ia of some importance beause of the substantial mlmber of deaths attdbuted to pneumonh ({K of the total). The fack of a dear reladon of wttmt tobaeco uae wldt dea ftom a6thma is ootl»eondsteat wldt the belief that 6moking a8gn.ose6 the diteue. hsthmt mortafltPln a1i who had eva beea smoket7 (eomb}ota8 attm2t and former smokas) was more rhan dlmhle that in aon.7tooken (8•3 against s•7 per 100000 per yeae), and the rdativety high ate (4 foltntt raloken suggests that the dwelopmeot of pouodaqy 13te . dhesatesila` uduue uxuxml uuny smOken to stop smoking, but duy still remained at somewhat inaaudrlskofdathtromthedisease,. Polmonary heaet disease was the drculaton cause of death that was mosc closely related to emo)d»;, whidl is ha2dly surpdrag. (We hare Induded in tbis atqgory deaths attributed to myocardial deeeneradoo and ooegeodve beart fLnuee that wore usoekted widl d+ronic obswcdae lung disease as well as the few deaths sped8cally «rdfud u due to pulmvouy heart disease.1 Neat most closely related was aoede aneurysm, wuh thc mortality in heavy d;ammte c J,~ ~ . vaseul6r eondinon t6at an be csused by smo ' lan8. bu[ although it muses a groat deal of disabdity, it rarely ewses loss of Ufe. in this study the number of deaUn attdbuted to h(n) aroe under 6o, and hmee did aa 14114 a«parate table entry. (But, atdtongh based on imaIl aweban, the mortality Sotn this di7eau omon2 coeimrdtq dguette amoken was four timp tAet m nwpanoken and three times ttut in fotmer 2(gantte emokers.) The relathely weak propadolxl tJatioo obsereed for the commwa n7eutar dlsear<s, krltaeuJe baec dhem, myoat+dld defrnent(on (a aondithh that i6 be1rK diatno7ad much less often now thm {o dte tirst 20 yer7 of the etuQyt the eetejory uuJudes all deaths uMbuted to rqoclar eauses (more 0" bilf of the tota) mems that the absolute exeeu mottWty finm vawlat (Ilseasea in dgantte smoken was more d2att double that eru(buted to the cancers of the tupleaoory ond upyedlBeWve t7acd that are so moeb mote dotaly reliled to amokio8. Of all the ate8orlei of vati91a2 disease mmined, only two mmor aecporia (ehnnualie be76e di6.a6e and vmoue throa6bosi6) and tbe bttato8meout aroup of "othee ardiovaaeular d'ISeua" bore no 61$ni6ant relation to imoki* Table V ebows aan3le daa for 13 other causaa of dath aod far tlNmowo awc6.'lrvo cond'uions stand out tinbotis of the liver, for which the mortaSity was Ave tima t7 Srat In continuing cigsrette smoker6 at in aon-smoken, and fm dma ae g.at In hny aelnkSl,t dyuotte smoken, and peptic uker, tor which the eotrrapot)dittg excessca were each about ttlroefold. Both these eondidoa7 were hlghly siplifieently related tu smukloj (PcO•001). Seven of the other categories also ibontd hi8her tuorulity ntet in d8antte smoke27 than in poaumoken aad In heavy dgantx amokas tban b2 Ugu, but the relatioa with mwkhlt was dary aip118attt only for a hetcrogeeeout gtovp of "all other Tsi6tv-•,H«rliqynn.kstaa6by«emj8amry.adeamfodiraw .' ' ~OONeamS4p10b000ai10 6 a Ob . Neo- . • CpnMamdtrl O1FafbNen e «+c oeLw ixtren6 tm«xn 4eEw CwaNp«dr•w"r• . NLW No~efde.dg1651Bq ~t~elll) Pasw Orwn 1-t4 1}7e a2S P«tla C...1 2•Yx/3i P23= hIrADW Wmal ~ e 31 1 9 t0 a 4 1.1 7•7 a ~ 7 I2/ 86 ' ~7 rn o it N 1~? me(s4r) I Tl 3 to u il 6 y l 1 - u 54 ~ ' . a { f r M 1 o~h0 tepl~Nteirf2t6 )Nteirf2t6) ao 71 70 , 26 91 7) . 21 tt trt . !•i aaer ~ OiU ('e7ns) . t7NO> t161i p±o) 0 0 n;v~ (n e: ta7 wywrtmu,«e(eq 0 7 16 5 10 21 9 10 7•7 4.3 IrBrwkbwtfweuoiaM) 717 611 ie7 a02 • N2 1071 6" N7 . 7.5 304 ht76e«dlddepKtneaafNl) 61 tt . 17S . ai l~ IM 1e1 M~ u M.J.wnteUn) R72) 15 77 H 1t 40 71 N 73 26 f) 14 04 ~~ )0) 72 !7 44 a/ {l 60 "7f-- _. p . 1 a-0 Crtbeddrameak(976) 67 H . iG e5 750 aN 100 106 7•6 Ya Q«6Wb.VoONK(60'1) . 7t 63 al . 74 at 02 _~.... 60 7t 6 10 46 M...MK.U6) 1 1e . 1! 1e .Ie e1 1 /Y >•6 dlkueqeMeruoylydbwp02S) 16 . 110 lN 167 445 16A 101 101 3.2 !A yupa~lOpyph(t011 1 It . N ' -"'tt It 16 IS e 0$ 04 Mmm~de6«nfwv(12S) t7 It 13 . n 10 i 19 17 -P1 -OS pm..adlorred.elesw(ns) . $4 67.._ rl .w a2 14 67 76 pt 1•6 ~p.ylyti,(yy" 1037 1771 . 10) 1441 I611 1051 1276 1201 IP7 IS9 (i6etdra16/t1/00) (IS01) (2ril) . (2i10) (102Q • (104f) (7M) (1a1a) (3966) . IfmsuK k seYnd K maWiv ttml e rw'd~a'~ ~'~ °N pX Iw e76aadaa tu6 6re 1 n/.MM eM.Ms etwd!r, p'Mw. .bo~eN6eiT,.nd1-79aanipodor~lkw(POSOCQ 007.OOI,W0001. ,. .... . tlvl0s.aao+snt«~,+cmiaa))aar««v0've«ee6+m4eura/ewuramy Op. WbWI>-7V•77.asa•ewlen,we6md14/,1736wdD«aa6dpxaneep., . . In . IiAU vo2.Vhts 309 d otiroaen 1'N4 ~ 0) ID A+ CD W ~ / .
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I I I I , I I I I I iuPcel&IC+ecaRaeaoh Paad tiaueee Studies Uait, H"meM pepsemmt of WdIffcrMar9.Word o%t ettl; R1r)tud Doll, /pnere,y tmu"hm,t RkkAtd Peto, yrofryn.el „aGratnxura i'mmc Heq, te:rareh ap~ttunt ks}dtWhatky.unnr rorarth frtrow ~~y,uatermtarch 2-~rGOndeeceto: r>,A4 un,; au :! Dal R!etmn D. :1 crtcn, C. '+'>nrnm R tirwev M.w,n, e! ee a~roe.. x.e .w '.nn,. N. Vnxlsa 9M .1 H,.d yF MN~<v.W [,.JVqqR. G"'b' ~rjyf,lNR „/>. 21 ItnT. Uet ud ~t K,ed dueu, kX taax, 1ae ,a+w7 inn t.bnr }+nuJ,/1.t."«M,KDwurCnlm,1. re anw L rr+,N 1to. c...", /D-o.eea,.a" w ht„n, ."C ItT,r wY.ir7py" awrYiC fn ee ,arwd N oe,nleqr na ene, eamrlee bj,l. DuliloCnr IYp?W 1FM. Tr Y..uuw enevd, Caawt. HwM Mur1 Mw N wV Ma..¢i 4x.W .eMmm~. D!RlV.inl~tq OGHqkeYAOleqrt.a MM. S. amet rS, `hde, fo D. Nain S, lyrppm 6 tSn M K6Cw r, a a . ai,k amn /or mca' Ww e CNen>, W koh pe 7 Cs.v tas,ie,foa. 31 lv,i. SA p.~ ef pMew nvYi"e MNSn, tn pml. rr nemmeem,aµ M"n t. "epm. nwb r tamr," dnatse! 6rw dnelbt Imrliadau tx hWq Mwe6q, AM.,t hn M llA WMUO MD: VS pp„%am, N arW .,/ liusw Smw, 9+bltt Nwesen/ve,vo) SS E,wet 10, 7v"rx M veMf 16 r.rkM L emYwr " p,enrbp. MOIwOt~fsso. 1• iDemtso el A1np,m aK mood lM h~ AA dt'ne, bmbt d r00! pd RpYm Nbba in Nt000 W MAAMJMN /CtOt' LSVilY, Re lwtt97;k1)13L 13 M,rrn" DhL l~,.n AA tatmreoe, Iw,a pmlkS 6kt m0 exY r..Ms 1.C1. ae mny q spmroeY nrtey w Mm" qw afQ ,19>;pnlHli. x wtnotM. aneate rOmeel w..aa.uNe euoc: a wm,a tAe V .n.peln,t.aaFy1W11Sm36Sd - NMII+.!C'm rt tltrOOl tI p^Yf,~t.+V q Mn 3nM ~T aIQ IM,JRe, It. u hte R tve: A a*atT 1. T.e?l hM C. M"uln t^e,eWeee a aeNaree aesv:: eFrw..vn,:x t» a,a~: wu; n.maa tawa iNtil/r.ItS4t1 . so tw" JA, f,Na u. Ctt".n te»int,ed o"e,..t Y, :rrt N+,l 4, wdd 2{ arta 1. N. s+,k.t a•t A.w>v ..LSr (awm Otba edwe tkhPb r,n,. t.OCl1fi10. wGa,+m+M fL ebeu aA fuecFe ML C.We Or. A.mtro A, IR.nq 1 e.t. A NOCtSY.1 rNF M OrnRM toebt N",S a aWww.~ ,Lbb. W pNmtl/ Irb Y VS atA J A'd Cwrelp VHJk teM1. ., Wtm,a,edA~.atyA.awMKlar,."r.A4.wt,yi,rttla,,:MaC, IM/. SMC Atwep.re, m a. 11110,60 d GtNevtn" aut, ,e tl tepnGbr MP, ) almat,blpMt,s'bf.Itl. t.'WaV,GA T"Y . MIMYb d JaMY et+Mr eaiarbn a,Neto e na at caernv . wev.CweC..e(LwtH9h3dM1. /S f"9na atl, 66m.AN~rdeato, fIW ea N1 N marn hen f,eue.q hawa~w A.M Y~SSha+~iueieqen" Ncxf t., susm .p M a, IS~. ~rttmtl6c r TMttM1U Pm Akmhy!++MNw f. a~.arwn.nre. trslnoo. o.a,a os.,du:.eWrrlw. S.M. IS'Id-0 NN. O.M Mv,fqswnr "ra IrDI. L,etre I, YM. l:e. Yrk ai„a"rwwrMµ 1t91. fAmrHJehwrlNQ Mortality in relation to consumption of alcohols 13 years' obsorvations on male British doctors Richard Doll, Richard peto, fimma Ha1l,Keith Wheatley, itiehardGrey Abstract ObjeetFtw-To assess the risk of death associated with various patterns of alcohol eonstumption. Desigrr-Proep¢cdve study of mortality In reLdon to aleohol drluAhyt hrblte in 1978, ,.Itb eautss of death sought over the next 13 years (to 1991). Subjectt-12321 8rhteh male doctors botn between 1900 aand 1930 (mean 1916) who replied to a postal quesdonnaire in 1978. Those written to in 1979 were the sur9ivon of a lcutg tunning prospective study ofthe effeas of smoldn; that hadbegtta la 1991 andwasstilloondnaie~. Resvvha-a,hien were divided on the basis of their recpottse to the 1978 quesdonaalre lnto two gtbups according to wbether or not they had ever had oa7 type of vascular disease, diabetes, or "Ufe threaten• . ing disease" and into seven groups according to the amount of alcohol they draak.8y 1991 almost a third had died. AU etatietioal aatlireM of momdV were seandardhed for age, calendar year, and smoking habit. There was a U shaped relation between all cause mortality and the average amount of alcohol repoctedly, d7unk7 those who reported dtinktqg S-,a4 units of aleehol a week (corresponding to an arerage of one to two units a tla)') bad the lowest risks. The tantes of death were atouped intn three maln categor;ess •alcobol augmented" eauseef6•b.of all dcathat cirrhosis, liver caneer, upper eePdigeative (mouW, oesophngus, larynx, and Pharynx) caneer, alcoholtcm, poUontag, or ln1ur37, taeheemlo heatt dieeace (33Y, of atl dcatbs), and other cauw. The few deaths fram alcohol augmented causes sbowed, at leaet among regular drinkcre, a proaesthe trend, wlth the risk inrteastng with dose. In coatrast, the asany, deaths from iscbaemfc bean dbease ebotved no elgnl8eant trend among regular drtnkera, but thore ...ee sVgniAeandy. Iewea eutee In ngrlnr drinhera than in non•dr&tkerc. Thc agfregate of all other causes sbowed a U shaped dosaretponse relat;on elmilartotbat forallcsuse mortel[ty, Stm W r p~revi Amse,•& (under p7s or 75 ane older), ~ and period of follow up (first five aad last eight yeart). Some, but apparently not much, of the rxcess motvlity In aon-drlnhers could be ateribnted to the inelusion aeaong them of a small proportion of former drbtkers. ConohwJae-9be eowampdon of akohol appeared to reduce the rlsk of Luhaetnk beact disewe, largely lrTespectlve of amount. Among regular drlaRera mortality from all causes combined intrcased prog7esshely with amount draak abo.e 21 units a.nek, Among Brltlshmea in middle or older oge the eonsamptlon of an aveeage of one or two unSts of alnohol a day is enoclat.d with drulqrantly lower 11111 eause mortaltty thao ic the eoneampdoa of no alcohol, or the oontumptloa of substaotial amounte. Abore about three units (two Amede.a units) ofalcohol a day, protmsivtly greater levels of eonstunptlon are associated with progressively higher all cause moxelity. Introduction It has bttg been recognised that alcohol can cause death awtety, from polsontoib aeddents, or oVOlentx, and that long tetm use eaa laaeeate the Incidence of 'tdrrhosls aad of certain typer of ancer. In recent years, hnavtcer, a7idenr.e haA emelted that the r.gtilar etur sumptioo of amall to modente amounts of alcohol aa also reduce the teak of ischatmic hean diupe.' We now need tecsoosbly quandtativs infotmatton about both the Increases and the deaeues tn mortalhy that are produced by various pancros ol,alcobol c0osuMp- don and about the 79eys fn t<ideh these euy with tes, ate, and the c3dstenee of other ored'uposincg or protea dve factors. Reliable quantitative eKCmcc is, howe+cr, dii<iatlt to obtain. lnformatlon about usual ddaidng babia has to be obtdnod not frora dhcet mcseurcmmt but Lom ancwen Ptovidtd by Indrv)dual people about them- sd.es or tbdr close reladves and frlends. Uolesx the amount usuaUy drunk Is close to zero h is intrimicaly difficult to desetibe, and the descripdon is petvliarlf lieble to bfas. Sor many ptopltq the consumption of alcohol has emotional and moral ovenones, aad. 911 341
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I I I I I I ' -.-. I I . I I I I I -'. I I I dsiql®g babits, thetr use of aspirin, and dsc pte.iovs tnafoeity were). Deaths that occunred In the ycu that a oceurraue of anv vascular disaase. eou.ow UP In 1971, info®adon wros obtained about tbe vital atams and place of saWeaea of 99•1Yo of the mra who had responded to the 1951 questiomslrr, t0074 were known to have died and 2459 to be benng abroad. Those who lived abroad have aot beea followed stoa, nor have 218 others (lys of thow not kaowts to ha.e died) If they then asked to be excluded from rbe study (102); if they had been struck o6'the meClal register for unprofrnlonal conduct (1S)1 or It, bokre November 1971, contact with them bad been lost (s0I)t t7fthe remalnder,10449 are 1mow0 tobarodKd before I November 1991; 118 bare b¢cn tnsorcd at the date they were lat known to be alive (71 taown to have emlgtated and 47 with whom eontaa has been Iost); 10615 repHed to our quesdmtneke e&w I November 1990 aad are thought to haro been alive a year latc, and 506 who did not reply to the qsseNow naire were aacodUi+c after 1 November 199t. - Deatha have been monitored in sevenl o.erbppl~ ways. Caiuusa and S was to us automatically when membeet of the cohort died in Britain. In additiem, tre moohoxd the obimory colutnns of the BMJ'.ud thcMadiwf Dirxmry, and we corresponded directly with the doctors them- , sdvcs, whL people who lived at their last known addtcsses, or whh others who knew them. Our 5na1 round of correspondence began le November 199D, to sotne of the deaths that occurrod In the 40th yeatof the study (November 1990 to October 1991) will barebeen missed. Judged by the number at dskat the atart of this fmal year (11652), the aude dath nte In thst year (480/1 t 652-4•2011000), and the death mtes in the previous four years when standaedised to the age disttt'b»iwn of the 1990 survHon (4•61, 461, 4•65) 4•71; mean=l •1 x4•20), the death nte in the fmal year should have been about l0°/, higher than we recorded (yielding about 543 deaths imtead of 489). The defiaiency has, thereforc, been ahowed fot, when neaeteary, by multtplying rha momlity meerded In the tast yearby 1•1. ttpeat questionnoire was test out wete telaad tb the rryly to the previous quesdonDelre. (1Td"hetps timh the effects pf diaease on mtokta6) OtLatwisc Dg-0 smokers and Oontintttog unokers were enaysed tn ykv 4 ategory In w'hioh they last descsib W themst].a. The tame (s t7ue for 6nma smokess,oteept ttut ttteY «ae dassed u ha.iug «eppM amoft foe progoutady longer pratods as eaeh year passed. The mosvfity atteibuted to aotiatsing setrofoert bat therefoce been silgbdy attWaated by Ieeloding with the deatha md the porsoo years at shk some deaths aod some years at rWc wlsett she mdhidua4 bad r4eoatty become focmer ansoken. Ndwugb inpr{~Iple the mortaliry 4mong aottamoken myht Itkewbe ha.e been slightly taaeued by indudfog wtds the noa.smokert e few ladiriduals who bad recentty beoame smokm, fa practice the dlrtottiao w11I be e.ggglbla, as the peopon tlon of aoa-emokew In 1951 wlto subsequenty starad smoking is amal( (ea befow), most of those who did atut aooo atopped, and the Iite ilueatentog e8ect>< of nowdng genaauty talro manyyaras to appear. MortafitV has beea alculatod aepsatefy fot (p ~U~fepl~ong ooo-smokece (that is, men who ban never bsmoked loo~~on u e~dr) a ad ~ toc r mea o( wb6coo a city fotts who, to the bese of our kmwledgy-ba.e habitually amoTxd (34 oNy Esgfretea, (tl) only pipn or slgats, or 6v) a tkxa botL th+usaa aud tuWeeo in odter fomu. AII taalysa of non•aawken ead of smokers refer to drose ategodea, except whece ategotia pip sed (u9 here beea combined a'other msokett." It is probable, howevec, that some of the roea descr(bed as smok{ng only cigaretta m 1951, Mttiedlarh those In the older ege groupe, m.y have smoked plpa or dgars at an eotUer pertod, ae ioquhles about the way tobacco was smoked previwsly were aot made until 1957 and were then made oaky ofineo emoking pipes or dpn in 1951. Conaequsady, men daad6ed es smokest ott)y of eigaretta dutiog the eeeond botf of the smdy may have bad more pm(onged e(garette use (and heoec gtee9er bwrd) thaa mm of stmihr age who were slmDady elaas6addaelDgtMbrayrar NI morta&y tstce haYe been atandudieed for age apd calendar period by talenlathsg the number of cnvses orauix deaths that would bave beee eapeeud In each $te year For the vast majority of deaths, including many ot' age gtoup and otrh ealetldar, 7aar in eath amoMag those that occurted abroad, ldotmat3oa about the category if the smoking habit bad had no effect on underlying cause was obtacled from official death mortality, summing the cottapondmg obseNed and CeRi&ates. In other innwtees, when no o9hinl hdor. apenednumbera.andmultlpMryttbesatro oftbetwo mation could be obtained, the eause was given In an numben by the tota) death ratt tor the.ges and period obituary or described by I reladve. In 217 b±rtanees tovtrod. Where diBuenca sue Mid to be "ooo- (1V. of all deaths) the cause «mains unknown, stgoi6aot" tlds Implies that the two alded P,akse it commonly because tbe death occurred In a dotmay In grater th,m 0•03, without soy ad/Damscat for tbe which informadon about the medieal cause ofdeeth It ,• muldptidty of eompatisons. not publidy ava7able. Causes wttt eWsi6ed accofdittg to the seventh revision of the International ClassiAa• tion of Diseases° if the death occurred dutiqg the first 27 yean (1951-1978) and acootdiag to the ssindt «vfsion of the internattonat dtssifxatlob" If h vccvrted during d,e lan 1) years (1 Ntrvtssber 1978 tv 1991). Special tnQuirywas made about the evldence for any deaths attributed to lung cancer in the first half of tbc study, but this rarely l¢d to revlsion of the diagnasis; and the cem6ed causes are used for the present analysis. Fuceptionally, deadn attributed to - plcursl maothel;oma were ahnys acFatated 5'om (tmg c+ncee end a apeei.l eneaoty wat treated for deashs that were thought likely to be due to pulmonary heart disease (see below). '. Rsaultts Mwt>Ea rt+sAtoaqrtotuun T6e amoklag habia of tbosc who teplied'm 1951 and sus.hed to the end of 1900 aee eomraetad, in eab1.I, with the amoktng habits of thesa snbjects about 40 years later. Patsly beanut of the disproport(onato attridost of tlw amokera,'but ebieffy because mon doctors wdo aqtoked tu 1911 had ceased to do so, the o.erag ppoopotdon of amokets among thac 40 ytar survi.ae waa tedueed from 62% to eBN., the pmpor. doa ofdnsetts ®otaeeevns teduced frotnStv. to 71/ft and the proporoon Of mtokers of cigarettes only (that is, who were not also sraoktog cigats or pipes) was reduced @om 41'/% to 6Ya. These ehanges wett: not almpb' on aoeompaniteem of sglug, as tMy were much gseater than d+e diffetences seen tn 1951 between one aTnTtaTGt.MLTnODa In calculating dcath rates for dtfftrent caitgodes of 902 DMJ vot.onta 309 8 ocroeeat994 tn N B - m kD N W (0 N ~ .
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I I I I I I I I I I I I I I I I t:r.rtmu4orc{IYtCy Camnl+tuer.es+ein C.wde..g 1e51•11 1911d1 IR7•71 ie11A1 /" vpWyky~ in /ve 74) nJ rr+oca 11 Ir _ tN s1A QaocaambtunwOJesMtdbr=ACC -S as • 5S0 341 ehaaewOWert AtweWnwparrl 2" 167 J22 121 $29 . 184 /16 466 Qndt.bmuodnheedpe,r r tJ 111 a0a Vuaroyk.meraanr 156 1e6 211 . 258 ,tarald+aatn 1626 tl5] 7416 200) CMMarlfcaLtaime 401 271 ste eol ' 1221 e!S t900 ' Sser od,ad w.+o ers sq . Po . . Ne twm6wat~lrv~ q 14 S» t56 N/emu ttri last dMr dos6 '1edWO oteat er mbo.a sW6muiv,tar+. wn.pi,d y J. hwm.J..wl A{,p 1x anexrll w c.u.v w Omttatibb. wrds~ rmeloes. ~csyM M6oasa~rapbel~Wet~oe.W~~N~d'nv~~c a~aadbrpetmOWK4Mkeder.nd on sueh smaU numbers (twn in tha Snt balf aod 10 in du second) that the increase may we11 have been due to rhance. For the aggregote of aU typcs of aucqr that are aot assoeuted" widt cnsoktng the lacrea" in pon- smokers was smaU (11Ve) but 6n smokeri h tras sprnd across a wide range of eancers and was somettbat larger (27%). Diacussiost onusn7tost,poxsot.•nws+U,Ah9CNNSCg In genaal, the raulo ht thls snidy for speci6c eauses of death accord with those In many other atudies. Rdnfotced by other .v1AenM, tbay halpod Irad osara than 30 years ego1b to the conclusion that the associations obsetved betweea smoking habit and mortality are chiefly catssol (n character (see'also the morc recent tvrlews by the US Surgeo5l(3es1eM` and the Iotemational Agancq for Research on CaMa.'t) In most of the causal associations, smokiog eeems to act synagistiuUy with other aetining3cal.agenusuch as consumption of alcohol"•; varioas aspeets of dieMl (evel of blood pressure, blood Iipids, or other cardio• vasctuar risk factors'; or exposure to aebertos,e sadon," or possbly aumc tnRotlve qetotl A The quantintive effea of smoking wDl, drenfote, vary with variation in the prevalence of these other agents. In some instanees smokirsg and other .eslologinl agents may also be confounded, as with the consump•. don of alcohol," various aspects of penonaUty°n and perhaps some aspects of ditt"v Indeed, for a few mmes of death the coefound'wg bttween srnokbSg and other factors may account for tirtusl)y ail the observcd association with smoking, in which cue none of the esceu mortality from those nusa should be uth(buted tu the habn.l3e only pbusiblaeztrpla of Issipotpot associations that might be due to thh, bowcver; are those that involve ebdhotis, sulelde, and other trnumatic cau.n, for which the associalllms with smoking maybe secondary to associations with alcohol and personality. The tlose associadonbetween smoking arsd dtinldne hnbita was wnfumed whco, m 1978, the doctop lo thb study were invited to volunoea fw a conttoUed adal of the value of aspbjn as a prophylactic against the devetopmem of vascular diseue.ln prmiousb healthy men," for the 1978 qucstionnaire also inquircd about the consumption of alcobolie drinks. Among 12122 doctors who «ptied, the ptoponion who drmk 42 units or moro per week (a half pint of bca, a glass Of wine, or a single measure of spirtip each eonsdtuting one unit) increascd progttuively from 2% 12 thox who had never smoked regularly to 20% io toen then smoking 2> or more cigarettes a day. if, therefore, 90g x.::mcvn to e.plain, ss ehe rtstat of oonfoundlnE wlth t.5e eonsumption of alcohol, most or dl of ehe subatardal excess of deaths Som cirrhosis that fs observed when haycia.renc amoken are compared with noo-smokas. Nor would It be ditFlnslt to explain u lean a pan of the excess mortalip from nsitide a¢d poisolsing in cigarette amoken ia the same uq. Sf rhese coulkdons were alro associeted witft the Comvmpeon of alcohol (albe{t less closely than is the case for clf[Ilosia of ttte ljver). The attribution of soma of tLe exeas eswnaUp In cigarette smokers to confoundiag does not, howevet, neceraarily mean that the overaU efttct of smoking on al1 cause mortality is tep than that obsetted, as the foctors with wbi.h tobacco ts confounded anay also have other eSects which tcnd to reduce mottedtty. Ybis Is probably the case with alcohol, the conslmtption of which (at least in moderation) It aseoeistd with a reduced cisk of isc}uemk heart disease."" If, as now setms Ukcly, the eoasuwption of a few wtia of akobol a day eaa reduce the age apecifse roottaliq frota isehaemie bean dlxau, then the eonfopndlpg of cigarette eonsumption with the consumption of alcohol would mean that the total effect of cigarcete smoklbg on Isehaemie heart disease mortality Is atig4ey, wdn thao that hitherto reported. The analysis of our osm date on the effeetc of deohol oonsumption is complea, 'because the doctors recorded as rtoadriuken include sorne evho gave up en beahb groutstts; thb fs reported ia detaU tlsewhercJ' It mey be noted, fwwever, that prelitNttary, estimates of the ntio of the mortBity from ischaemic heart disease In cigarette smokers to that in nonaotoken in the population with both samking and drinking habits Is 1•58:1 without atandudisation for the consumption of alcohol and l•76:1 after standardisation. . Whether the samc is truc of rhe cotsfostndiog with personality, which could contribute to the acen mortality in cigarette smokca from suicide and poiwn- ins, ir another matter. It would seem unUkdy, ad in the abseoce of e6idence to the contrary the eonMbu- doo of these conditions to the exeeas mortality bs dgreu e amokars should p.d,apt be omitted, aleat whh that of lU other causes of violent dcath, whea the eontribution of smoking to the 6keh'hood of premaeure death Is estimated. IJkewise, no daths from these dousa wcte atuibuted to smoking when ettimates werc befag made of the worldwide morasUty that is attributabic to thehabit in developed countiiWe 'f11en rema(o a few causes of death whb:ts, in our rmdy, aro related to smoking for rcasons that am undea. One is canea of the «ctum (table IIf) which was signiflcandy related to smokloi in out previous raport' and continues to abow usuvb the samt relaooo in these data widt twice a many deachs. Coloreenl cancer has not generally been selated to'mokissg in other studies, though it has beenln some.a Coloteast adenomas, however, have consistently been talned to satoking atsd ft has been suggesxd, on the basis of an American cohort atady; that dgarate smoke aets as in iniriariog a8ent and that a retadea whh eaneee wm be observed only after an Induction period of sevatt decades. (In that study a tdedon was recorded for small adenomn with smoking hablts ovcr the ptcvbm 2o years, and Ws dsges adettumss with smolattgbabits mose thaa 20 yeen pre.iously.) if our data for cotoa and tcmJ cancer ate eousbSned, the atsoc(adon with smoking is staU signi5cany but no IonEar partictuerb Gose, and a possibk explanation of our sesdts Is rhat they reflect a teal but weak association between coloreaal eanea.nd amoking that has been iuLated by the play nf ehance, partieululy fue rorad taocee. Whether such an asaocation Is eausal' or refletrs ' DMf vut.tJ.~M!09 8 oCtbaart 1994 . en N 0't t0 to OD W 00
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I ' I ' I I I ' I ' I I I I ..ry.•-- - ..•c 'U[] uRiuei UI VS: next crntuty as the future health e9'ecu of w.^en( tmokitle patterns^" The subsror.tiq differenc9s betwecu the effccs of (obceo during the first 6nd second halves of the preseat study underline the be9d tor 6 7voFlduide network of prospective smdies that ean monhor the ineee6tes, And eventual deaeases,in thls 8r.at 6Pldemi0 througlhout the world, The [mperiJ Cmcer Reseaoeh Pund Ind, pmioody, drc Medlal 8esaa0eh Council bi•e supported mis nud7 (or 9e7u61 decado. 7De Gnolh M9dkal AKOCildoO, Offitetl)e of POpollcOn CenNses and Suneys, the Oeoa61RepiseY Ofiee for Sootlmd, and the 09betsl Medial C6uodllNw consistendy Provided sssleteoce, and )re has had help 66m me Ma9tal xeyster V8i6e fOr No(them 4el7ndl eoa9• IpondiDQ of&d in du We of M6n, Jeney, GueteueJ, and Ndemey, the Deplnlneat of SocW Seeudtr the 0Ln of the Pnmea(er Oeaent; end many Bmiy hald( 6avico 6uthod• tles In!'npand and Wdn and area beatthh iro6Ns ia Seadar.d. We are aatefut to them for their attiet6nee and to the euof indivldu6ls who have helped ehha 6aeod6a* or N tn doe00A 6tld m6lOt2ifdnl records, partltvlUl•': S Attll)HOnL G 8olvkq A Cl.rke, R CoDins, J G8hlaod, N Gray, 8 Ht6xr, J t161ti1.e4, R Heni7, C Hetwekrns, M Huyba, K JamtOtlk, K Jodes, J Kddor, J Knach, R M6d.emuD, J MNbew6, S Mllon, B Nmmm,Std(h S N9non, I Okal, M Pih, A R6dky, R Ripley, F Sius, U Skepg, F Spdur, 6'hompton and M VetseS. The (9u4f 6tkuuoY•ledpnen4 bowtee, b to the m6oS deaon who have npSed to our queulonn6H4/. 71e maamalyt 7r2/ p•ptd by C H9nwod. Thls 18 9nt mort Is dediated to the achievemeno of Ch6.tles flttdar and the memo(y of rts ieitiatoh SH Aasla 8ndlerd Hfll (1897•1991). q.n I D6D R tID AS. SmeEM ,e/ .n,a..m w,Ae (w. R,..Mt R/•O11f0•i?19w1. t CpW e3, Onha, W. T,bwce sswlbt a. 90nA4 Weppe bM b bmrbe)m:uwan,.jAAN 1)97:10:7t9.16. ) we R iDe A6.77w eemsry O(enaea b nN6e. a Ow,Oqw,a,w,. A NMnlew+aXa /r•D 104.:6 t a71 -1 . Uoa4a9d.SHJi161iii~,•.IM::"- '" -~•~ / •r' y' 6 Da1 R hw R 6(aW 0 w,r~." w~0 79 ,IIA ~anras m er M:.p ep.%R µ~,H43,.}t• H 7 MY GOM d POeeW,. l+M.w a.! Wlao te%ou hvnw NeaeM 6 tyY~w Py. bid,.. Ar4ywNn w.:wqce: Rmm Mkelw W SOt6tl6e hhei,Yy, lttl. • fywn Dened A.4(r we+wu Aq+* Itl. Al.,q Gns.. h Oo.~n sw~M,wrO~i~.tHa,w.M d.a.. vro:ru+• OC: a 19 9ats69 dmnt S„41rt .,r/ Aata i16i0ryA Dc ta 9a.n..e,1 9~9oa am. . u L.aae oawa R.6+It d 6,.6A rwtrn~. e M'4 2, xan I M- tlp., 9/ h yw, On,e.r. /M7. Pa4 114 xIP. US Myw. r1tYlMYd W M FMen IaN Reenesh .71 MIwsWadOW M hewiy.,tMdA.6rav1~ .~ t9wp16)t) 8190111014 0. ho R 0111. Mur. e.Y' ww"rwA Au6q e.W. L*wr (MRMIOV Tq 1. IVlfid M GKC. IIM f/K 19 Ddl t, WIY R Ni,a ll, Pea It Maauy b alea, a mali00 A,een' kla.~ql M Mre MMIb 6em6 61j/191071N/i.T I. tS Da0 R PaeAfk seea dqee< 6Wer.tp. amna dweid.M.Ylr Y/utRrM d~d~ ~7W.i~ ~1p1711,N.1191JO1 N1aRWwa Nn{<aKwrra/a LMme bhn R 9k t.Mm,:6 nµ. Yu~,...,/ WAAa.t t9ae tONpI6N Ap.q 6X Mant M Cme6, 1116. ItARC ,oaW6s P06M6aNety It Ope R OdO 1L CYDe/ R 7tMNq K Ha•Paee, C, lmmqi K m of. WUeie HY dPnDM6171t 6W a7kk In )rieA ak 6eee,.1A(S t1a,'tNtl7)i. 16r.lli(Ilpa7plbldeo.w.wlehb.aaGwrea.mr~a/ 0W,L(w n Rw~el N~qll~OrtbWYltle~a xyir~i IJ.YO~ ir.en ~~ i1m:t.l dW/Wm. w r~ ww w«w rld Ir.1 „n. ,9rz Gem. 7nt9, )i SAUw Il iM)bl W PWx9eY tlale. b: vi6 2;, /1a6 A e6 S.6/k N AnAw aW IiMv6 DdM: Oldad C.Aar,iq Par, 10400141. al 1yr NA ae:9lat W MlaOwrr ee.f: 6MUe IC 7tJ6 T, Oew, f. cd.daAWwr..er,Mwl~n6m.o.lad:oRa98e:n,enPaa 19110111144. 27 Gmr A9, Vw MF: GL Cn06e V. P,RC7+rv f. Nwrse A/erAP. a i/lfolMet p6 eMea, e,e,eepeee r atl baan ta Ahh6::eh 6Y,aa 6 w0,6w.Y.....r,r It eYeaaeOa (1W,a. N) Me"+r IMIdOpppleS9FR. . UPMIdrGD90RAP/r.ad6xw,•stwaseaw,l.6•)AwSa AM116E71:797-5!• M MsM, GL Pw, R 7M MwN hi,mq Y<em0e d,Ae. aOaeRtlol OeAetll9ndn{tle i;e u)m+0[z--GV~em v luonc,nlY,c mavd,nw7etiry yvlOOd00+Om aJnn A9v(1 N9romrie 1951 el S10mEv 1910 ndNaadA.d(1 Nea.+Sa 1971 n7f tkr66n1p9u I/P~eemNYY/Brp'vAAa(Yn . A6ea4N re,ma:e6 G~OaPaaY aelQyatln E.ww.w ena. oaaemea C06U 00a Vwevllt MPe:9aot7 .+bw. C(tAeOt Odne eellel N9n..ediol Menac Pa.v+T!a~• 110090u0 AA,he+ten 4aeted• FUn9sad )1a8eoeod Sin Stcab FnlSemed 9bn Secwd Tnl &9m6 MliaaN RH Ma6 F.R iew9d Fbtl Sec6ea 1'Int Ses9d )1)9: Cwrnlw.lr NaatmoRe} •0 6 6 t NA YA 0 NA 0 SIA e7 41 NA 0 1+A NA 0 NA 11 IS NA S(A ef M 91 HA . IV tiA S NA ~. tMV. 71 (•M.A 202 JNVAh o-if10 NKAA - 9:1 Crmmcimolm 9 NA 6 NA 3) NA 0 NA 17 NA 141' NA 7 NA S) NA 96 NA )SI S<A . P1706 0000f ue,amwka 0 NA 0 NA 41 NA 0 NA 0 NA 11 NA 0 NA N NA 61 N•A 175 HA 01711 o002S n a CR.wt~o)aj 5) 0 4 62 fe 169 7 0 9 0 2/S 417 16 0 92 its 100 206 $0 11)7 0)l16 00165 Nnamphtt 0 SS 0 0 44 29 0 0 0 0 97 "NO U 0 7 S7 IT 16 IS) 439 O111e 0W11 )os9: GovbneYa 76 91 14 0 12 112 17 42 6e 0 S97 SO1 24 11S 87 00 2!i 17~! t ) P 6 N.w..~b 17 0. a 0 9D 40 0 0 a9 0 aN 176 Y /x 1(1 xe la 62a #T 0-079t ) SSS9: • Cuvmtmrofa 117 101 70 1x 131 167 Id 26 7$ 6t 1011 997 0 Ifi N 105 106 16)6 177) 04tb7 007)6 N..a1me)A lt 10 0 10 77 12. 0 l0 47 47 6/1 =79 ii $t 67 10 176 S10 00P66 o-10N 60-61: C:nw.n,w.,M 165 )1) fe itl iif l60 e/ 111 t7 Il 1N9 /676 aS M 171 171 101 01 1W> tef, vlert POYA Nc+aam)s 0 0 17 6 211 210 0 9 67 31 90 SIl I 1 30 77 6S 19 1448 9)) 096tt 01e79 6Sia Clalv:twnola 416 401 92 111 40 182 19) 19 77 PS 213) n)7 6 i ! Ui 101 !S ) ifSi i f 001fi Ne7v11,e40 0 9 0 0 )44 )/1 0 0 92 n l200 951 0 o ) l S 0 70•74: CuammNer 496 996 50 261 $04 90 270 ))) )IS 371 7771 i70) 161 111, 144 1~ ~ .020 0 NaaeqM( )1 tt ft o 671 5" 0 n 215 63 t16f lSS) )1 7 1 331 )6--91f1 9926 0 7}19: O Celteoctnw)a 717 6)S 74 91 934 1911 971 627 )17 SI7 S9)0 NSt 163 0 6S2 10pf 101 US 9Y7 9199 796 pS91 099tS 7 O Ne.vanewt 114 st 0 0 uae 65) )S SI 212 uI • enrA f0o6 111 0 99/ e00 17Y Y0 760 e A1 { 0411) aV4N: ' 9 Canentrmo)a 374 7f7 99 50 1964 17)S $14 367 1267 166) 6)et 7)99 '0'""•0 lYM yp 216 l09 14176 7)/ 0 950 6 00c0S 00113 Near.neta 0 0 0 73 1D/) 1152 16 76 799 002 $t/7 9905 0 0 lW 017 14) 26e A )7l 00116 00t61 l,b)1 Csmenu9fo- 242 16t 117 f/0 1215 2009 lole 949 326! 13)9 1999t qM - 00 )110 It" 0 U ~ ~ Na.a.naet y YxY 0 0 1666 216) 0 76 )0N 1259 12101 92p 0 0 0 Otl )I I 6 8 19519 1 Sl71 1 ODOU fv197141.dMai6amselpaKcinw.nm'amedN107.0YaeWnas,(M0t6tlttuwnleOabNe4f61mN9< •Cvnat,edaYt(pn(m Oob wLee Imdblhdh.ve 6e( 6tKalN, ernae aapkd a/,. San dto0aw Itl41111/• t1JaiNdlaOwHOntewnOe2Td+d+)N19U•7hSUmhed6,aIn1971•91. • SD,w, n.a. Wi) la 19t141,.w,i+n•.u.a~ (6ora'odtanryu.oxy' aY0n1 b0 ee.edaaefetCp~.lrrl+l~ t iAf 7t9( aDD6ONK COPt1. [1o W lC 9beatlabe PYIei96M• dN(ae. 910 V N SMJ vow+.us 109 8 ol.(vErtR199{ ~ tD to 0) or. / O
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~ H~~Nanr(oyooovA 1 .ti'eo. Cvm<i.etm OMu,aaln 337 brp~y I __....___ aooAm (Opn CNerrrNaleNnNn a!a u d4adda7u.19r1A1; nrohrfA Pom~e ~Aetx . 1•11 taS/ !•tS Fasa Cram N9V51 IT•SV eS9t Psee,Oprf[)fq ! 12 34 /1 )1 H 12 IS 14 ~q CMeaHMfinaO) s u u ts H. . 90 14 U e-0 a.t . on,esaeMwOiwati9U ts $2 41 /e e7 4t aa It 212 /4 . tit91<dm tSl) 11 1) 34 at 17 1f is 14 1.1 o-t Oe,r duen(S11) as (9 Pr 3: rl a9 ae (7 -61 (i ' Pvk)asY,a(t!a r9 rt a1 tt 4 It 11 a -3.1 -t4 t7amYbpW) I ,v te It el 4 St ol Dd OlageasMf(taU 64 74 1/ a9 Io r9t /1 71 S-0 >9 w..a r rw te~x.ewws4 ~f~q~1r at.aaAa tto 703 ala a4f e17 aai at1 Irt 14 84 (NOireMNst9)n (>A) nNl fidn a9n a7t) (i'17/ (11Si (.,W sdcte.¢q) as 29 r 96 at a7 13 34 tO 4.3 PaYedna(11u 7 1 19 15 14 st to tt 34 Fa rqaicloc(bna(1sP) (7 11 /4 . u 7 aa ta It -07 04 FfWN% I a . te te te ta tt t 71 (d od OrhMaNeatlN) 17 rS ae a) tl 1/ ae le 1•) !9 . AltrwaOMEPObroba 72 H I19 teo 90 IPJ 79 at ti F! C1vet4aaaetg (t1U d6A Pw (at) p0) (Pa) (9a) (191) tfiLa.aetaa I 17 a4 14 33 f0 47 tu 14 *3 1.1 o:a.rdt+aiu(7) cm crry oF) w1 (Is) (1a a9) (4» warotl - 3706 Slts >07s satl asa 39Ra aor/ atlo I)9 17,7 (:oaaao.riw) tUta) (MOb oAa) nr{rl naos) (1a11) (3117) (so)P) V~y~ YwdxMbmwn4r/kaee9a~eulttdNealdrnmdnbMCteeMnWemeaWws,eMdeNrldNdnt,tNaOrwia.ronNesbo,0 t9f,a•S7,adNa ewrpoMtePNmt~tK"fperedr,P4Lre109o1. 4aNX Y~ Yn ~va p~ ~f ~dutfN4x« ae6a~aaotlr e~~en*~4~pyt.. . 1- I I I •r.ntsr,-rnarwaecHqey)welhKhnEiualet.elaeaot . eo418° tUld,tnore speeulatiscly, Alxheimeta diseue" AmnA a0n+tisl Pa (900 mm' -ws only dgAt deaths aete attrlbuted to ulcerttive lt mey be noted, coltds apd 19 w NxAelmv's distuo, howe9a, that tlte annual mortality from dementia (re8uded aa Indudiag dl deatha dassified under 1CD 7dt ra.istott Nos S04•306 and 9tb ravtsion Nos 290 aod 3)1), about half of which is ptobably atmbutable to Ald)dmer's disease, 9ras sloillss as non•smokers (nioc pa 100000) and e9aaaoken p 1 per 100 00). Mo[R+rsltit ax sMOxumHnarr, arAoa No datb tvu obseNed bl men unda 25 yeats of age asd the toal aumbceobserved at 25-54 yws of age was co rauG (67) rhrt mcatdity rates in d(Garat amozrot ntegoda w¢re wbtcet to /uqe andom vadadou. We CiFl~mrokneNf COn."t p,1Ne,Cletln A7tnMOt19n) e1Wap9 POww Aa s27/dg Pmner Cueeet 4~v (tF0 4 qn a2.8 t 104 ) 11) (rd 5134 9S 17( a?S 10V lt•t ISO 4544 S}7 1/4 470 /0P7 )PS dti 75db $74 71•1 10" I17-0 7r•a 7?I "as (Ma 11" 2ta•7 taa`•q )er) ' t7N ~ ~a~t (7r1 rat so-4 a9o t}e al•s o:OC(da,M) (tuS) (460s) ata% 04in n(a7) (5019) NOn4awb"a . (Se.u,rwlq •s.edamads.tstebe,trt.raf~p ww ax, ao, thetdore, usetuUy eompan age aped5c atorWiry tP»eo9ewsdwamwbwdaefc.et9+mle~krAR',weeniaenl0rndnknVfaMr.aayer.+..wb in detailed 9mok(n¢ eategetie7 onty hem abont 35 ~9 ioothd.m.e.Of. " ~erWlatre c~e{ndi d:oaa~d..a~olaoy~9"Imtubne9;n.n<,.eu/r,.eonsl.a ym of aYe upwards, a/dloupt 3t may be noted that uttder 3S 9eao of agc the momlity was higher la d(sanwn,^ euidde. 1ad poisonina. Haoia, which we txtaeat atcoken (1•S per 100 000 pa yar, bascd on 35 had da»ed prevlously as dosely rdated to smokitV is daths) thln In nou-smokca (t • t pa 100 00 pa yeot, iaduded in "otha digestive diseases" as oa(y 25 deaths bued on 17 deatDs). No new rnemben aae tectu(ted wae attributM to it. Tlte mortaGty from hemi: 9ras to the ttudy aftgr 1951, lo dte mottality at 3S•44 higher In auttent rmukVl4 than (n botrsarok9rs aPd In yean of aya was obterwA aemnat eetmely In the 5rit heavy thao in ]iBltt e[gatette smokcn, but the trends ow deada (November 1951 to Oetoba 197t) aad were not mtisdally sigai£cant and the relati9o aas'•mottatiq dusft the fourth decade of the smqP less dos¢ in the second than in the Gnt bal! of the study. Ikatbs atrribtned to btLa Hdeace" (tiu cot deaths ftom etat5c aa.idents or fa8s) were also telated to smokin;, but tea dbarly so than deaths from taidde snd polstxduy. One disease showed a sretktially tignificant tega- ti9o retat(on with smokine oomet,9, parkintonhm. Mortality ftom this coadition was hi`i(a in former smoken thaa, h( contintring smokers, yretilmebly beansc tlse effeas of the disease made «noking diPBcuh, but It was almost the aame in forma smoke» and notiemokcn, M that rhe annual mottal{tf bl e9a (November 1981 to Ottoba 1991) 9Pin have coa- tnbutcd materlallyonty to aan si,u,d u.e/. . TLe dat4 iatabie VI shotv that, for the 40 Pcarperksd of dse atudy as a whole, rhe overall mortaGry 9as twfee N gfeM (n eondnuina dArette rmohaa as in Iitdong aonitFrokera t}uoujhout IDiddk aod eatsy tad age. I1te peoportiona) emn in eigarettc smoken decreased, howevcr, in lata life, and the rado was redocwJ to 1•6.1 et 95-04 yc+f+of qo nnd (•& i+t 9.aes 85 yeats and over. Some of the deaaee can be oselbttted to a redoctiou with aie In the .Perqe amouots amoked by eoadoniat woken (Shown 1° smoken (t6 pa 100000) .ra Iowa than 6s Uklong table 11), soose to the reduction tn rhe Propordon ot non-smokets (20 per 100000), supportin` adier deaths 5em aneer (£ront 24% of all daths 4t ogas _ cvidence that smokh(g itthibin the development (or the 65-74 yars to 11Y. at aga BS yean and over), and somt proIIrlss) of the dkase." No unfut hda,uaGon was totbepregnoeMeeduedoninthentloofdlotnomllty obtained to test the hypothesos that two other dkeasa la dtarette smokas to that in nosl-smokcts that is aeeo tniebt be negadvciy retated to sntoking-.alcerative fordattufmmatdiovasculardiseose(flvm2•satata tn N BhU votuMy 309 6 octoaen 1994 905 N ~ W 4.11
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I I I 1Ai1~ t'J",unl nonn y w:.+a u.w .q.wr .v .... .... .... . ...~........ ..-. ~...~...-. !S~~L1rV~ age acoup and auather (a b showa In table D,), utd occurted to mucb the amc esmeot In eseh tye grorp in 195t: for example, the proportion wtso sa>otro6 c+gareues otly was reduced from $11% to 9Y9 in meu Inhlatly uuder 25 yesrs of oge tad from 33'/9 to 2Ye in men intriallT ag.d eS yaats or otore. hmeqg tM ue- slnokus in 10519Aso raplied in 1990, i i9'9 hsd sapW . .f fsom oncff causa wat skntla to tbat in non-mwkers. wwn. °roM, unr"° CJs",m voe« /uaa.a. For slmpliettY, we aow preteot mortality entet in detail smw's+rls,. rosal 199o-1 col• wwm osr 1951 *ay foe clgorette smokas who had aor a)so regutads• ::nawnNml9S) a/61 196 17 4 84 NS9RA Snloke6 lobeCOe in other fornla and have geOCped r.m..ll..t.,.19s, n 1174 )o 1 44 IA70sl . the eemaioiias emokeis togedler a•ot)w ourraLe Cartmt,em9rr./951• eq,nanen,r 0 SrfS ns 41 41e 4st3pt smoken" a 'od1C[fooaamloken' sr.cr~~0om° 0 en i6 i r~j7 upo~~ Mtsalit7 ~a have been analysed tepuatety for 54 sned8e ausa ofdeatb, or groups ofauses, and for Aat,ao rsettm ess9(w) esetc) nm unctsuoustttom a fids grottp comprlrh>; those dadss for which we -AM d.m.d in ~Y, a Lrtcd.. w.Rl...+liw sla oom du dminaa e.~ ...,.9sm, t.x. p t'= vable t0 diwova a ausc. They ase shoen by c,Anxa..rw,~.wos=a~u~M .we„mdmeca..>ewdn..<wYmw.r9.rwlu smokmg babir tn tAbtes lII•V fa atf the !8 ausa or rVwwbtM ~•n.9n.Tt:dhus6edhmriedeWmraeorolnYdr. prq>p9ofaausecabetsenradividually ssFaet3kfi,v TNtJr`^^^f.Y/OSnYt ~ ar~ ldr~ A.CinMeftlprrten ,ow6a.0„nn.eo .,...M/j...1od Wr dsw•a.r rnt ab S9T) t~ s`•eg sss) t9rr ss.44 t9+ a-s4 rw 1aa ss.a ta7 1v1 siii i:a iii .as toc u+ - _ amoking a some ttsoe during tha fnat9e6iag 40 yan but mon (6Sh) 4ad subuquentb stopped, ad four 5hhsofthosewhohadooatinuedstrrokedottyprprsot cigars bt ]99o. SimituFr, Tay few of tbae who 7rao formaanokersin 1951 badstanedtgaloasdtoodausd eormokein1p90;9gein,oftheS.wbodid,ebuoanaA smoked only pipes or elgare. It oaaboc be nsamed, doctors sn the Umted Kingdom responded to our 1931 questiotmairc, those who did so smoked wmewhtt lees tlsan the eon•respoadenn In 1951,/1ad the krsowk4ge rhat they were the subkcts of t stud! ofibo faal eQeou of tobacco may itsel( have tn9uenaed thefr habits over the next 60 7cus. 4hose who did smoke cigatettes reported atnoktngmuch the aame amouat ateah ege et the bcginMag otboUl the fast and second hahxr utrbe study (table II). ef d1l howe.r, that these changes ue typical o m/e doctors of the same ages, as only two thirds of the MpnTAtSIYnTSMO107t6MASlTANCCAVae . Pipe and cigar smoken tvho hid neva r9julYly smoked cigaretces have basn exatnlned predw111 ' Their rnortaGty from the causos that were elasd9ed p elosely Tetatat sv smukkld (wu~esa vtthe lung, oeha «spiretoty sites, and oaopbagur ehsoolc obatraed7e lung disease; pulmonary tubaados(s; puimonaty T.lau. m-MMOap' RMIMPOW ft~ ' I tLa eiCl.ae' Pe t eo 00o eY I I I AMt ..n.......... Siada~.nnxa (Nc9rdeRN.t9SU9)) USywayinroqriwt9& ~ ~7n ~am UM(79) Wdney(IU) MrdddkW+mdlfW . ew6M (.T/) . t~imwetteeb) Noe7t7Ueid Muhmh (0U S.meFvo.(IN) M~n7sma»Yt14) Dmtt79epF,diiatS4U Sa.mNwart67) ,1Ynl WiCiVI', UVY'1ryUWlV,. Nlut YICW]1W. YULLy' wii (o11nd to be less than 1n cigtrette smokers, tyough aeatu tham m non-smokers, while their mortallta more thas $0 Qestbs. Table III thows du ntes for 17 VpC oE emetr. Heatsse of the pnsdp of oumbas for eome iodi9tdud tppes, sre btve grouped togetha eancen of tbe moum (other t4ea the ealinq glaads), phaYruc (other ehen the nasopbuqnx), and larimr, all of RLtrh were reganted hy d7e International AgeacY for ReseascL on Can¢eN as d'uasa that can be caused by rmo)iog, iato ooe gmup of `uppa rapintoty arroter." T3ae, togedrer ttqOs four of the 6ve other rypee regarded by . the agme) aslble to be ansed bysmoklag (amsen vf dle lung, oqophsgus, bladder, tnd psnaats) +eae in dse Wseat studr all aeary relatmd to smoSdng.lUm types (aocarf of the uppa respintor}' ehes, lnae, and ocsopbtpls) wert particularly closely rolated, with the mocu)tty (n heavy cigarette smokea at Isaa 15 dma tDat in oon-amokers; two other types (aoeecs of tLe bl}dda end pau'Xd9) wese aLvut daee dma snole <emmon In haa9y cigarette smokers thtn in 00n- smokets. Too few deaths (nine) were speei6atqr att4buted to cancer of the renal pekis (the «mabtisg typo rcguded by the agency as able to be caused by amotmg) for use6d suafrslr. Sc9eral studies have euggasttd thR four othet rlpss of cancer, whicb In our atpdf each tawed more than Sp daths, might 9oma sima be coused by smoking. One (asuu of the stomaeb) showeda stadstially dpifia/stselation aith smo" aad uwtha (myeloid Isuk.emtU 9hosred y rpssgina(ly signlficat relatlon wids the amount satoked. The two otben (anaa or the kidney, vrhttti larhsdes bate rentl pdvis, sad cancer of the !!.a) showeb tn this sadn a wak positiva aed noa. sfpd6wnt retation with s7nofdng. Sbr et the -otha seven spect6ed types of cancer that wa examined atso 1f-04 Au sw,a,lre.ean omass7m r~~wwl OIIdY WrU [9enn tNmsl tV%Rt MKo91y141ntrc 703 1104 4% 417 MS 9)S 10 474 14-2 . St-e . (A'.crlYYUcaN» (410 tSSS) p)Sf) 0277 (41e) t404) a6f) ()OSt) . • Irtle9nYeKblydbC74tJ10ta0t/a'dpdYeRaReM~e~4hldaAdktaMleplnidlaXtJYdelalMYddlynWAOr/d1t~49WVCI tbnre)H S•St,rod)4SanROnAafMa(nqWtd)r90S~e0),ra0901~ ~ . }1:M5.ewxnak,n.Mmtnovae,artarentdebKm tutnalaueke,KYRtme ta7.14/rS•lYeSe.nmsdaw.ed:nerl-N.SS74.aedrSatvndraelnnaryy. Cuum..mWS, 1.99 • IS 33~ . N CD (.7 W
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' I I I I I I I I ~ s~ The associatlon (uble V) with peptie Ulceru hkdyro be largely or wholly causal, that with crrhosis is Gtely to be larnelv or whoA9 non-eausat, and the assoefadone with the hcterogcneous group of other diseases to ubie V may reflect some ausal effecu on diseases rbat are not respo»sible for many deaths and whose reladon with smvkiaa bu uot er0eu ~wuu+vuly wwUcd, euma eonfoundine, some misdiagaosis, and some chance fluctustiosu. Lutly, thee was a weak relation with smokloR for deaths from "other violence," aftee suidde, potsoaiqg, mffse accidents, and falls were excluded. Some of these deaths-atrribntcd, for example, to gonshot wounds oould have been unteeognisod eew ef suicide and due to confounding with alcohol and /xraonality. At least two deadss were, howeveb directly attributabk to smoking: namely, those due to eonAagratlon from atuoking (o bed. 0 4i e Obsetntioc, on the mortality of Bridsh doeren with Faemw emol5ng hoblte bc.e been «porttd ot'a a 20 year period (1951-71); now the study ppsiod has been emended to 40 yean (1951 -91) and covets Ovet 20000 deaths • Overall, ehe aass monality of eiyarttce stsakas was appnaimately twice as extttme in the second haN as in the Srst half ofthls study e Twaaty five auses of death were signifiwttly assodated with dgarane msoliog (24 potitively and one oegadvely) e E.ep iu uuddse ege sevypiag smulJog sut* aandatly laasued ihe subsequent expeaatiop of lik-and those wbo stopped before 35 yean of aste had an expectation of life that was not eigMfirantlydiffennt from that of noo-smoken A oompletely new feamre of oue nsulto lo the geotee atottali0' atrributd to cvoke.ad elw to beort direeee absolute and (particularly in middle age) «ladve esttts (if we eombine ischaemlc heatt disease and otber of mortality assodaed with smoking in the second balf cardiowreular diseue, as probably needa to be done to of the study comptted with the fust. When currant takeaceotmtotnosolog.eat chaoges). dgarette smokers were compared with lifelong non- It is eay enough to undamstd why the mtutalitf in _ smokets, the excess morality assodated vritb smoking noo•stswke[s sbould have improved, but why has h oot was already substandal during 1951-71, but h was doae so in ciprette smokers„ a-0to hwe generaUy coneiderebly nwn exveme dadag 1071.91: Dudng raped!need the aase ben•fm of pr.ventioa ssd Ihen,. 1951•7l, the death rates In dgarene staokers were peotic medicine and have had the added advantage of about double those in non-sDtekers tbroughout ntiddle the s•dtch to cigaretus delivering low tar?'Itae ehante ago;duting 1971-91,thecor•espondingdUfeeence'aws inthetypeofdgasenewouldhavebadonlyamoderate nearly trcblo. It, as u Ukely, most of the dsrference effea on the ove;Ul hazards of smoking, for althottds ft in mortality benrcea smokers and non-smoken h should have reduced the haard of lung v.neer"a k actssaUy caused by smoking then a threefold aeeas may weA have had little effect on mortality from the wmdd imply that obotnruo rhhrse of tb. Anrhe la orhe main diwses eaused by tnbacco, partieularly middle sge among the smokerl were caused by tobacco. those that depend on deep ksbalation, sueh as ehaooie Even at oldcr ages the excess mortality assoelated whh obstrucdve lung discasc' end iscbaemic heart disesne.° tobaoco was subsrantialM, grcater in 1971-91 than it rras Whst seems to have been morc Importmt"N is the durfng s951-71. TWs differencc between the apparent "snamring"" of the epidemic of deaths of British men effects of tobacco in the two periods arose bca+use age from smoking with those who reached later middle or specific mor»lity deccased substantially only among old age In the 1970s and 19B0s having had a longa non-amoken. kdr.or of reROlar consumption of dwsttes than mea It may sccm that if there is a differnce of five+yean otthe same agcs would havc had duting the 1950s and in tnedian survival between smoken and tson-msokep 1960s . Another fattor that may be important in the during 1951-71 and a diffcrence of tight yoan duimt mtarlag of the epidemic (but which is impossible to 1911.91 (I+uthelwwuiufig6) tLeaadi(ferau~eufulnn+t ',qusnd(e') b a ctwige (n s1w way ciyercnp hare bean 6V, years (the average of 5 and Byears) might have bem throke(I in recent decades. The mksoolty of doaoes expeaed in the overall resutts, but In fact there +wu a wlso continued to smoke cigarenes in the latter bslf ot difference ot 7V, vears (fig 1). This is because most of the study may have tended to be those who smoked the deaths In nonwmokers oceurred in the sccond half them In a dlffercnt any from that of the greater numba of the study. So mortality in noa-smoken for l9f 1-91 a'ho bad stopped smoking them earller. The fmding d In Sgure 1 is closer to that in 1971-91 than to that a ada6vely Encceased dsk from dgarette smoking In the in 19$1-7(, wheras the mortality in smoked was aecoed half of the atudy Is oor unlqae, fa k panBds approximately consmnt in both hahm of the smdf. the Gndings in the two muske cohort studite canied Aa Improvement In the survival of non-smokei•s was but by tbe American Cancer Sodety, one in ahe 1960t to be expected, as there have been msny aDS/or and onc In the 1980s, which show a sbaBar Increase advances in prevendve and thenpeude rnedidnF Diet orc time in the cxcese mortality tn eigareette smoketa." has improved in several ways. Tbe neatrnent othypeo- Lr quantitative ettimates of ebe current hazards of sendon and isdsaemie heart disease hu Improved tobacco in devdoped eoonaies are m be made," fend rwdonal moreaifty 6rom vasoulae diteasee has tbey ehould be based on fairly reNat epideastoloBteal beca decreasing rapidly), the urban environmmt has e.idcneq such as the second half of the premse smdr become less beavpy polluted with coal smoke, and the or, better (beause h involves much larger numbees), impact of AIDS has had UNe effect on men of the the second mlBion petaon prospcctive atudy In the ssnerations atudied. In the United Sutes, I oom• Uakcd States.°"" But, whatever hs aKe, nD amgk wrison by the Surgeon Oenerel ot twoprospeottve epidcmidoSical study an provide so adequate basfs ststveys of a rmllion people, one in the 1960s md ene lo for asseetlng the woridwide epidmtle of death from the 1980s.foundnoesideaceofachangelntunaancer tobacco: buause the epidemk Is at a di8eteot statse, rates in non-emokcrs over a 20 year period but a big aod is evolving so differently, in different popisladonsM dcaease In the mortality from coronuy heart diuese.n In almost aB developed countries lung cancer rates In I.A;ewise, in the prescnt mucb smaller study th9etm has, Momen ue Dow rising (ttMkh Impedes predktion of over the eame perlod, t,eou uu e.i,kuce of nqrbusge .. tbe s.wtwl Gaserd kr womeql7 in .orue the fAt'es lo In the mortality of non-smoken from hmg mesr, mm are.still rising, in others they ue tdbng, and alrhoughtherehasbeenasubstantialreducdonIntheir in krs developed eountsies whero thero bss oob in T7M1fPORAL7RENn M b:rt55a MORTALrr1'M SMO)W Bldj voeue,y 309 goetoasK1994 909
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I I I I I !~ I I I , I I I Jro o/i(nria! lnOu rit a r„( rov, r~....,. 911 .,.,,r n 9 +r lmptrLl Canar Rese.reh Fand Caneer Studies Unit, \uf6rldDnertoteMef CaWealAfedidae, fbdeUAk tabemny, O,dord OXJ6HE ItkherdDvu.nono,my . wnsueanr Weh,tdPetqp,vJumroJ wtd'wdNaturia t:eitL WhadtY. ,miar ,tuarcAJeDnu Riehanl0rey, rmeor roemh /dlav Isabelte Suthetland. nua.d autvm Corrnpoodntee to: erotnsor poO, oq,wxtam.t, Mortality in relation to amok3ng: 40 years' observations on male British doctors Riehard Doll, Riehard Peto, Keith Wheatley, Richard Gray, Isabelle Sutherland Abstraa Ob/ratioa-To assess the haxards assodsted tddr Wug term use uf tubrxw. Desyns-Prospective study of mortality ht trrladon to smoking babhs assessed in 1951 and sgatn froot time to time thereaAer, witb causes soucbt of deaths over 40 years (to 1991). Coatiouat(on of a study tbst waa last reported afta 20 years' fil)nw up (19S l-7l). Sabjocet-34439 BriWh msle docton.+ho eepiiadd to a poetal questioanatrs In 1961, of whom 10000 had dkd duriag tlxfirtt 20years and another 10000 hate dieddudngthesewad20yean. R..suGs-Excess mortality asseeNted with smoking was about twice as exu'eme during the second balf of the study as it hsd been during the first halG The death rate ratia during 1971-91 (eompas•1ag eoodauing e{garette smoken pith llk- long non-smoken) were approximately threefold at agee 45-64 and twofold at aM 65-84. The excas mortality was chiefly from diseases that caII be caused by smoktne. Positive assodatious with smoking were eoafirmed for death from cancers of ths mouth, oaophagm, pbarSsixr astSmy lvag, tmxeeas, wsd bladdert from elu.otdc abetescttve pulmonary dfsease and other «sp3ratory diseasat from vasctthtr dtsesses; from pepde tdccr{ and (pchaps because of eonfonadlstg by permaaliq and alcohol tsse) from cirehoWs, sufeldss and potsonlag A negatkve associadoa was confumad with de tlta from Parklnson's disease. Those who stopped smoking before middle age enheequently, avn/Aed ahaost all of the excess rlskthat thaywould otherwise luvc suffered, but even those who stopped smoking in middle age were wbaequsatly at substaat(aBy less riskthanmosewbocoatlnuedtosmoke. Conclusion--Ra+tdn from the first 20 years of tMs stady, and of other studles at that time, substanthBy, uunderestimated the hazards of lone tarm uae of tobacco. It aow serms that about half of afl segufae cigarettte smekers will eveotually be killed by their habit. Introduetion . After the two large asaconaot studies of 1950 that showed lung cancer to be olosely related to smoking,' t prospeaive studies were needed that could dtteamne which other dfsestes wcn alto telated to the habit. In 1e51 0ll the doStors in Beitaln were aeked what,they smoked. Most of tbo 40000 who replied were Nsle, and a' prospettNe msdy was started of the causas of death that subsequently occutted anong them."t'he early results oonlSrmed the strong relattonbet(teen satoking sad death from lung cenccr,' and found that smoking was also related to mortality from many other disesses" Deaths have continued to be reeorded and, trom time to time, further questbntssim have been sent to thc surviors. The last report on these rnee BIv(/ vot.uat 309 8 octoa8n 1994 was of the results a(tec 20 .esrs., We now tepon the resNts of fo8owiog them for 0 yean to 1991 and eompate tha apparent eRecu of dberene .wolwrg on morWEty from all causes dttdng the first aad durlag the second hiltes of the study. We report dso the moecstity.duting the entire 40 7earpeetod trom 48 speeiRe auxs of dctth, or groups of auses, In rtun with diBerent smokiag habics, and the effects of stopping smoking at dffferent aga, and we discus,t the uaeat to whieh the aH'eets of smoking on eeeeein eouses of dcsrL ue posidrely or, aegadvely cootounded by the effeets of alcohol. The haasrds of tobacco ba.e been documented by many other studics, which have been summarised by the Royal College of Physicisns,s' the United Ststes Surgeen Gcperal,-1 and the inteMadonsl Agency (or p,esesteh on Ganeer.n n Soms proepeetiw stadies Law been far larger thsn outs; ours, however, has been condwed for moce than ts.ice as Iong as any odtR, whith gMes h some special interest, for long conthntod cigarette use Is psmettlarly harardous," and agatstte use by young men became widespread earlier In Britain than in most orher eouotries. During the first halt (19SI-71) of dds auAy, thnrfnn. thr tleng Mnrnr MrM In middle sged men were higher in Brtdan thsn anywhere else in the wodd, and during the second h.E (1971-91), the hmg aneer rates In mee in old age in btttsin were atrang Cte tttµtest• Henee, a stu6y ef smo)ing aod death amoag British men duting thase yeart may be particularly laformsti.e about the hazards ollona eaat3nued dgarette tsx. Methods Quunae<rn,ttss At the end of October 1951, quest)onnalres were sent to all the men and women whose names were on the British'medisxl tr8lsrn and whn rcaldKt In d» United Rinldom. Simple questions were asked about ibeh smoldog habhg, and tepltet su(1'IeleOtlp eomplete to be used werc teoeMed kom 6194 women snd 34439 men• When Iast reported; one twman bad bew mistakirOly elassl5ed u male, until diagnosed as dyiag of uterine anat. 'Ibe relathely few femak gmoken had aot. In genenl, smoked as tons or u Intensively as the male smokees, so that they do not provide direct i0fotmadon about the e(facu of longlotao smoking" 7Le presrnt report ts therefore restrictcd to the 40 year follow up of the oun 1oqrbia .Luut %Iwugw iu smoking hibha and sotae furthor deails about them wers made of the men In 1957,1966,1977, 1978, and 1900, on the lea two occasions, inqukies wtte also made about alcohol eoasurapdoa and some otber pmonal eharaaetisties. Detailed accouats of the questions asked and of the response rates to the earlier 901 qneatinnnelrr" have beea given pteviouslyJ-' ^ Repliu to our last questionnaire, which was sent out in the ststt of the 40th year of the study, were rtceIvcd from 10807 .

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