Smoking and Health Report of the Advisory Committee to the Surgeon General of the Public Health Service

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Smoking and Health Report of the Advisory Committee to the Surgeon General of the Public Health Service - Part 2 of 3

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LEi7CHTENBERGER, RUDOLF, M.D.-Professor Eidgenossische Technische Hochschule, Institut fiir Aligemeine Botanik, Zurich, Switzerlan& LEVIN, MORTON L., M.D.-Professor of Epidemiology, Roswell Park Me- moriall Institute, Buffalo, N.Y. LIEBOw, AVERILL A., M.D.-Professor of Pathology, Yale.University School of Medicine, New Haven, Conn. LIGGETT & MYERS, INC., New York, N.Y. LILIENFELD,, ABRAHAM, M.D.-Professor of Chronic Diseases, The Johns Hopkins School of Hygiene and Public: Health, Baltimore, Md. Lisco, HERMAN, M.D.-Cancer Research Institute, New England Deaconess Hospital, Boston, Mass. LITTLE, CLARENCE Cootc, M.D.-Scientific Director, Tobacco Institute Re- searchi Committee, New York, N:Y. LouDON, R. G., M.B.-Assistant Professor of Internal Medicine, The Uni« versity of Texas Southwestern Medical'School, Dallas, Tex. MxNOS, NICxoLAS E.-Statistician, Division of Occupationall Health, U.S. Public Health Service, Washington, D.C. MARDER, MARTIN, Ph: D.-Research Psychologist Behavioral Sciences Sec- tion, Division of Community Health Services, U.S. Public Health Service, Washington, D.C.. MATARAZZO, J. D., Ph. D.-Professor of Medicall Psychology, Department of Medical Psychology, University of Oregon Medical School, Portland, Oreg. McFARLAND, JAIaIES J.,, M.D: Professor of Otolaryngology, School of Medi- cine, George Washington University Hospital, Washington, D.C. McGILU, HENRY C., M.D.-Professor of Pat'hology, Louisiana State Uni- versity School of Medicine, New Orleans, La. McHucH, RICHARD B., PhL D.-Associate Professor of BiostatistScs, School of Public Health, University of Minnesota, Minneapolis, Minn. McKENNIS, HERBERT, Jr.-Professor of Pharmacology, Medical College of Virginia, Richmond, Va. MEDALIA, NAHUM Z,, Ph. D.-Executive Secretary, Mental HealYh~ Small Grants Committee,,N'ational Institute of Mental Health, U.S. Public Health Service, Bethesda, Md. MEHLER, MRS. ANN-Resear& Assistant, National Cancer Institute, U.S. Public Health Service, Bethesda, Md. MILLER, JACK, M.D.-Research Fellow in Medicine, The University of Texas Southwestern Medical School, Dallas, Tex. MILLER, ROBERT W., M.D.-Chief, Epid'emiology Section,, National Cancer Institute, U.S. Public Health Service, Bethesda, Md. MILLER, WILLIAM F., M.D.-Associate Professor of Internal Medicine, The University of Texas Southwestern Medical School, Dallas, Tex. MITCHELL, ROGER S., M.D.-Associate Professor, University of Colorado School of Medicine, Denver, Colo: MURPHY, EDMOND A., M.D.-Attending Physician,, The Moore Clinic, The Johns Hopkins University Hospital, Baltimore, Md. NASH, HARVEY, Ph. D.-Illinois State Psychiatric Institute, Northwestern University Medical School, Chicago~ Ill.. xiv

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NELSON; NORTON, Ph~ D.-Professor an& Chairman, Department of Indus- trial b'Iedicine,, New York University Medical Center, New York, N:Y. ORCHIN, MILTON, Ph. D.-Professor of Chemistry, University of Cincinnatiy Cincinnati, Ohio. P. LORILLARD Co.,, New York, N.Y. PAFFENBARGER, RALPH S., Jr., M.D.-Medical Director, Field Epidemiology Research Section, National Heart Institute, U.S. Public Health Service, Framingham, Mass. PAUL, OGLESBY, M.D.-Chairman, Committee on Epid'emiological Studies,. Passavant Memorial Hospital, Chicago, 111. PFAELZER, ANNE I.-Concord, Mass. PHILLIP 1bIoRRIS, INC., New York, N'.Y. PICKREN, JOHN W., M.D.-Chiefy Department of Pathology, Roswell Park Memorial Institute, Buffalo, N.Y. PIERCE, JOHN A., M.D.-Associate Professor, Department of Medicine, Uni- versityof Arkansas Medical Center, Little Rock, Ark. POTTS, ALBERT M., M.D.-Professor of' Ophthalmology, University of! Chi- cago Sehool of Medicine, Chicago, Ill. PftINDLE; RICHARD A., M.D.-Chief, Division of Public Health Methods, US. Public Health Service, Washington, D.C. R. J. REYNOLDS TOBACCO Co., Winston-Salem; N.C. REED, SHELDON C., Ph. D.-Professor of Zoology, Departmentl of Zoology, University of Minnesota, Minneapolis, Minn. REMINGTONRAND, LaD:(Ottawa). Roos, CHARLES A.-Head, Reference Services Section,, National Library of! Medicine, U.S, Public Health Service, Bethesda, Md. ROSEN, S.aM[iEL, M.D.-Chief, Pulmonary Mediastinall and ENT Pathology Branch, Armed Forces Institute of Pathology, Washington, D.C. ROSENsnATT ,, MILTON B., M.D.-Associate Clinical Professor of Medicine, New York MedicallCollege, and Visiting Physician, Metropolitan Hospital,. New York,N.Y. Ross, JOSEPH,N'I.D.-Associate Professor of Medicine, University of Indiana Schooll of Medicine and Head of' Chest Division, Robert Long Hospital, Indianapolis, Ind. SANFORD, J. P.,, M.D.-Associate Professor of Internal Medicine, The Uni- versity of Texas Southwestern Medical Schooly Dallas, Tex. SAVAGE, I. RICHARD, Ph. D.-Professor of Statistics, Florida State University, Tallahassee, Fla. ScHaFFMAN, ZELDA-Special Assistant to Executive Officer, National Cancer Institute, U.S+ Public Health Service, Bethesd'a, Md'. SaHNEIDERMAN,, MARVIN. A-Associate Chief, Biometry Branch, National Cancer Institute, U.S. Public Health Service, Bethesda; Md. SCHWARTZ, JOHN THEODORE; M.D.-Head, Ophthalmology Project, Na- tional Institute of Neurological Diseasesand'Blindness, U.S. Public Health. Service, Bethesda, Md. SCOTT, OWEN-Executive Officer, National Institute of General Medical Sci- ences, U.S. Public Health Service, Bethesda, Md. SELIGMAN, ARNOLD M., M.D.-Chairman, Department of Surgery, Sinai' Hos- pital, Baltimore, Md. 0 I xv

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SELTSER; RAYMOND, M.D.-The Johns Hopkins University School of Public Health, Baltimore, Md. SELTZER, CARL C., Ph. D.-Research Associate in Physical Anthropology,. Peabody Museum, Harvard Uhiversity Cambridge, Mass. SHAPIRO, HARRY, M.D.-Curator of Anthropolbgy., American Museum of Natural History, New York, N.Y. SHUBIx, PHILLIPE, M.D.-Professor of Oncology, Chicago Medical School, Chicago, Ill. SILVETTE, HERBERT, Ph. D.-Visiting Professor of Pharmacology, Medical College of Virginia, Richmond, Va. SIRKEN, Mo:vROE; Ph. D.-Acting Chief, Division of Health Records, The National Center for Health Statistics, U.S. Public Health~ Service, Wash. ington, D.C. SLOAN, MARGARET H., M~D.-Special Assistant to Director, National Cancer Institute, U.S. Public Health Service, Bethesda; Md. SPIEGELMAN, MORTIMER-Associate Statistician, Metropolitan Life Insurance Company, New York, N'.Y. STALLONES, REUEL, M.D.-University of California Schooll of Public Health, Berkeley, Calif. STEINBERG, ARTHUR; Ph. D.-Biologist, Professor in Department of Biology, Western Reserve University, Cleveland, Ohio STEWART, HAROLD L., M.D.-Chief, Laboratory of Pathology, National Can- cer Institute;, U.S. Public Health Service, Bethesda, Md. STOCKS, PERCY, M.D.-World HealtL Organization Consultant, Former Chief Medical Statistician in the Office of the General Registrar (1933-50), London,, England STOUT, ARTHUR P., M.D.-Professor Emeritus of'~ Surgery, Laboratory of Sur- gical Pathology, College of Physicians and SurgeonsColumbia University, New York, N.Y. STOWELL, ROBERT, M.D., Ph. D.-Scientific Director, Armed Forces Institute of Pathology, Washington, D.C. SYME, SHERMAN LEONARn-Sociologist, San Francisco Field and Training Station, U.S. Public Health Service Hospital, San Francisco, Calif. TAEUBER, K. E.-Research Associate, Population Research and Training Center, University of Chicago, Chicago, Ill. TOBACCO INSTITUTE, INC., Washington, D.C: TOBACCO INSTITUTE RESEARCH COMMITTEE, New York, N.Y. TOKUHATA, GEORGE, Ph. D., D.P.H.-Chief of Epidemiolbgy, St. Jude Re- search Hospital, Institute of Biology and Pediatrics, Memphis. Tenny and Assistant Professor of Preventive Medicine, University of' Tennessee, Col- lege of Medicine, Memphis; Tenn. ToMPSETT, RALPH, M.D.-Professor of Internal Medicine, The University of Texas Southwestern Medical' School, Dallas, Tex., and Director of Medical Education Baylor University Medical Center, Dallas, Tex. TbTTEN; ROBERT S., M.D.-Associate Professor of! Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pa. TURNER, CLAUnE G.-Director, Tobacco Policy Staff, Agriculture Stabiliza tion~ and Conservation~ Service, United States Department of Agriculture, Washington, D.C. xvi M I

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VINCENT, WILLIAM J.-Student, University of California, Los Angeles, Calif. VON SALLMANN, LUDWIG, MsD.-Chief, Ophthalmology Branch, National In- stitute of Neurological Diseases and Blindness, U.S. Public Health Service, Bethesda, Md. VORWALD, ARTHUR M.D.-Chairman, Department! of IndustrialJ Medicine and Hygiene Wayne University College of Medicine, Detroit, Mich. WALKER, C. B., B.A.-Biostatistics Section, Research and Statistics Division, Department of National Health and Welfare, Ottawa, Canada WALLENSTEIN, MERRILL, Ph. D.-Chief, Physical Chemistry Division, Na- tional Bureau of Standards, Washington, D.C. WEBB, BLAIR M., M.D.-Otolaryngologist and ENT Consultant at the National Institutes of Health, U.S. Public Health Service, Bethesda, Md. WE1:vSTEIrr, HOWARD I., M.D.-Director, Division of Medical Review, Foo& and Drug,Administration, Washingtony D.C. WOOLSEY, THEODORE D.-Assistant Director, National Center for Health~ Statistics, U:S. Public Health Service, Washingteny D.C. WYATT, JOHN P., M.D.-Professor of Pathology, St. Louis University Schooll of Medicine, St. Louis, Mo.. 7,E:RZavY, FRED M.,, M.D.-Department of Maternal and! Child Health, The Johns Hopkins School of Public Health, Baltimore, MdL 7.UKEL, WTLLIAni, M.D.-Associate Director, Collaborative Studies, Nationall Cancer Institute, U.S. Public Health Service,,Bethesd'a, Md. 714-422' 0-64'-2' xvii 9

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Introduction,. Summaries,, and Conclusions :.wrr~ , . _._ ... ,,4 ..-« _ .. .. _+. .-..--.,

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Y 649994E0

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Chapter 1 Realizing that for the convenience of all' types of serious readers it~ would be desirable to simplify language, condense chapters and bring opinions to the forefront. t'be Committee offers Part I as'sueh a presentation. This Part includes: (a) ani introduction comprising, among other items, a chro- nology especially pertinent to the subject of this study and to the establish- ment and activities of the Committee, (b)! a short account ofl how the study was conducted, (c) the chief criteria used in making jNd=ments, and' (d) a brief overview of the entire Report. HISTORICAL NOTES AND CHRONOLOGY In the early part of the 16th century, soon after the introductSon, of' tobacco into Spain and England by explorers returning from t'he New World, controversy developed from differing opinions as to the effects of the human use of the leaf and prodhcts derived from it by combustion or other means. Pipe-smoking, chewing, and snuffing of tobacco were praised for pleasura- ble and reputed medicinal actions. At the same time, smoking was con- demned as a foul-smeliing, lbathsome custom, harmful to the brain and' lungs. The chief question was then as it is now: is the use of tobacco bad or `rood for health, or devoid of effects on health? Parallel with~ the increas- ing prodtiction and use of t'obacco, especiall~, with the constantly increasing smoking of ci-arettes, the controversy has become more and more intense. Scientific attack upon the problems has increased proportionately. The design, scope and penetration of studies have improved, and the yield of significant results has been abundant. The modern~ period of' inuestigatiom of smoking and healthis include& within the past sixty-three years. In 1900 an increase in cancer of the lung was notedl particularly by vital statisticians, andl their data are usually taken as the st'arting point for studies on the possible relationship of smoking and other uses of tobacco t'o cancer of the lung and of cert'aini other organs, to diseases of the heart and blood vessels (cardiovascular diseases in gen- eral; coronary artery disease in, particular) and to the non-cancerious (non- neoplastic) diseases of the lower respiratory tract (especially chronic bronchitis and! emphysemal . The next important basic date for starting comparisons is 1930, when the definite trends in mortality and disease-inci- dence considered in this Report became more eonspicuous. Since then a: areat variety of investigations have been carried out. Many of the chem- ical compounds in~ tohacco, andd in tobacco smoke havebeem isolatedl and tested. Numerous experimental studies in lower animals have been made by exposing them to smokeand'~ to tars, gases and various constituents in tobacco~ and tobacco smoke. It is not feasible to~ submit human beings to 5 -4::-. v-.::.e";:,:,.: ik'AM .._

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experiments that might produce cancers or other serious damage, or to expose them to possibly noxious agents over the prolonged periods under strictly controlled conditions that wouldl be necessary for a valid test. Therefore, the main evidence of the effects of smoking andl other uses of tobacco upon the health of human beings has been secured through clinical and pat!holbgical observations of conditions occurring in men, women and children in the course of their lives, and by the application of epid'emio- logiealand statistical methods by which a vast array of information has been assembled and analyzed~ Among the epidemiolbgical methods which have been used in attempts to determine whether smoking and other uses of tobacco affect! the health of man, two types have been particularly useful and have furnished information of the greatest value for the work ofl this Committee. These are (!l ) retro- spective studies which deal with data from the personal histories and medical and mortalityrecords of human individuals in groups; and (2)~ prospeetit;estudies, in~ which men and women are chosen randomly or f'rom~ somee special group; such as a profession, and are follbaed from the time of their entry into the study for an indefinite period, or until they die or are lost on account of other event's. Since 1939 there have been 29 retrospectiive studies of lung cancer alone which have varying degrees of completeness andl validity. Following, the publication of several notable retrospective studies in the years 11952-1'956, the medical evidence tending to link cigarette smoking to cancer of the lung, received particularly widespread attention. At this time, al'so, the criticali counterattack upon retrospective studies and upon conclusions drawn from them was launched by unconvinced individuals and groups. The same types of criticism and skepticism have been, and are, marshalled against the meth- ods, findings; and conclusions of the later prospective studies. They will be discussed further in Chapter 3, Criteria for Judgment, and in other chapters, especially ChapterII, Mortality, and Chapter 9, Cancer. Durin- the decade 1950-1960, at various datesstatements based upon the accumulated evidence were issued by a number of organizations. These included the British Medical Research Council; the cancer societies of Den- mark,'orway; Sweden, Finland, and the Netherlands; the American Cancer Society; the American Heart Association; the Joint Tuberculosis Couneit of' Great Britain; andlthe Canadian Nationall Department of' Health and~''Velfare. The consensus, publicly declaned, was that smoking is an important health hazard, particularly with respect to: lung cancer and! cardiovascular disease. Early in 1954. the Tobacco Industry Research Committee (T:I.R.C.) was established by representatives of tobacco manufacturers.. growers, and ware- housemen to sponsor a program of research into questions of tobacco use and health~ Sincethen, under a Scientific Director and a Scientific AdvisoryBoard composed of nine scientists w,homaintain t'heirrespecthve institutional affiliations, the Tobacco Industry Research Committee has conducted a grants-in-aid program, collected information, and i'ssued reports. The U.S. Public Health Service first became officially engaged in an appraisal of the available data on smoking and health~ in~ June; 1956, when, under the instfigation of the Surgeon General, a scientific Study Group on 6

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the subject was established jointly by the National Cancer Instfitute;, the National Heart Institute, the American Cancer Society, and the American Heart Association. After appraising 16,independent studiesearried on in five countries over aperiod'of 18 years, this group concluded that there is al causal, relationship between excessive smokingoflcigarettesandilungcancer. Impressed by the report of the Study Committee and by other new evi- dence. Surgeon General Leroy E. Burney issued a statemea on July 12, 1957, reviewing the matter and declaring, than "The Public Health Service feels the wci_ht of the evidence is increasingly pointing, in one direct'2on;, that Axcessive smoking is one of the causative factors in ltmg cancer." Again, in a special article entitled "Smoking andlLung,Caneer A St'at'ement of the Pi ublicHealthService;"published in the Journall of the American Medicall 1ssociation on November 20', 1959. Surgeon Generall Burnev referred too his statement issued in 1957 and reiterated the belief of the Public HealthServ,ice that: "The weight of evidence at present implicates smoking as the. Eirincipal factor in the increased incidence of lung cancer," and that: "Ciga- rette smoking particularly is associated with an increased chance of de- Nelbpinn lung cancer." These quotations state the position of the Publfc. Flealth Service taken in 1957 and 111959 ont'he question of smoking and health. That position has not changed in the succeeding, years, dhring «hichseveral units of the Service conducted extensive investigations on t-moking and airpollution; and theService maintained a; constant scrutiny '?freportsandlpublications in this field. ESTABLISHi~-TENT OF THE COMMITTEE The immediateantecedent's of the establishment of the Surgeon Gen- eral's Advisory Committee on Smoking and Health: began in mid-1961. On June t of that vear, a letter was sent to4hePresident' of the I:Tnited States: qi;ned' bvt'he presidents of the American CancerSociety; the American Public Health Association: the American Heart Association; and theNa- tional Tuberculosis Association. It urged the formation of a Presidential'commission t~o~ study the "widespread implications ofl the tobacco problem."' On January 4, 11962, representatives of the various organizations met with Surgeon General Luther L. Terry: who shortly thereafter proposed to the Secretary of Health, Education, and Welfare the formation ofi an advi- sorv committee composed of "outstanding experts who would assess avail- able knowledgein this areai [smoking vs. health] and make appropriate rec- ommendations, . . ." On April! . 16. the Surgeon General sent a moredetail'ed' proposal t'o: theSecretarv for the f'ormation of the advisory group, calling for re-evaluation ofl thePublficHealth Service position taken by Dr. Burnev in the Journal of the American Medical Association. Dr. Terry felt the need for a; new look at the Service's position in the light of' a number of significant': develop- ments since 1959 which emphasized the need f'or further action. He listed t'heseas: 7

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