The smoking dilemma; The Surgeon General's Report

What a popular pastime practiced by some 70 million Americans has been called the most important single cause of disability and premature death in the nation today. If you answered cigarette smoking you'd be right. I'm Dr. Ralph grinder professor of health education at San Diego State College. And this is a first in a series of programs on the smoking dilemma. It's now been four years since a blue ribbon Scientific Advisory Committee made its historic report to the surgeon general on smoking in health and this report established cigarette smoking as a major threat to life and health. In the next few minutes we'll focus on the Surgeon General's report and on the recently published follow up report. Our guest today is Dr. Arnall slick a San Diego physician who was a contributor to the surgeon general's report and is now a project director for smoking research San Diego which is a U.S. Public Health Service Project. Perhaps the nation's most ambitious community program to discourage cigarette smoking. Dr. flick while

this fuss about the Surgeon General's report why haven't there are perhaps conflicting reports been given as much attention as the surgeon general's report. Just before I answer that question I just wanted to make one minor correction I really am not a contributor to the report an article that I coauthored as cited in the report but. But that's really not germane to your question. The surgeon general's report is held in a class by itself simply because it is in a class by itself. I'd like to take a minute or two to describe the background of it and why it has this particular status. President Kennedy before his death directed the surgeon general of the US Public Health Service then Dr Luther Terry. And at that time a cigarette smoker to make a definitive report to the president and to the nation on whether or not there was any hazard cigarette smoking articles to that time had indeed suggested there was. Now Dr. Terry by law got together a committee of

people who were as of then uncommitted on the question of cigarette smoking and health. It's of note that the cigarette industry was empowered to veto any member of that committee when it was first formed. Now 10 men were selected I believe the number is 10 representing not only medicine but also representing biochemistry statistics and biology in general. Who were empowered and asked to make recommendations to the president and the nation on the question of cigarets men everybody is pretty well in agreement that this was indeed an impartial Yes Committee at its formation. Now these men faced the task of such magnitude that they had to have some 300 contributing consultants to him to help them with the task and in the course of their task they reviewed over 2000 articles on the question of cigarette smoking.

All articles that had been published to that date were reviewed by this committee. They were assessed they were gone over with the report of the committee was unanimous when it was finally released and the report was of such magnitude that about a year's delay was in effect before it was finally released. Their conclusions were that lung cancer was cosily related. I'm sorry their conclusions were that cigarette smoking was causally related to lung cancer. On other diseases such as heart disease chronic bronchitis they felt that there was a strong association but until some other authority can come up with a report of men of this stature reviewing every conceivable article written to that time on cigarette smoking and bolstered by the opinions independent opinions of some 300 contributors. I don't think that there's any reason to imagine that any other report should begin to have the scientific validity and the stature of this. That's why it's held in a class so it's very substantial in our support

for conclusion. But critics of the report have charged haven't they that the report makes smoking guilty by quote statistical association. From a scientific and medical point of view does the report hold up. Well the question of statistics does come up repeatedly and it's coming up now in the lay press as well as in the scientific press. First of all everybody agrees or at least anybody who's ever thought about the matter agrees that statistics don't prove and cannot prove anything. Now having said that a moment's more thought on the question will quickly lead a person to the conclusion that there comes a point when statistical relationship is so strong that it becomes tantamount to proof because there are certain types of information which cannot be proven in an ordinary sense of the word which have to be proven only by statistics. Now the best example that I can think of is the question of gravity or the question of does the sun rise now. If you want to remember that when Kepler and Newton first formulated their laws of gravity in their laws of motion. They

could not prove that the sun was going to rise the next day. They simply assume the sun was going to rise in x day. Even today we can't prove the sun is going to rise the next day but approximately 5000 or 6000 years of recorded human observation during which time the sun has always risen during which time you have something like a million or a million a half units of observations showing a Sun to have also risen has given people a lot of confidence that the sun indeed is going to rise and for practical purposes we assume it has proven that to morrow morning the sun is going to rise. And anybody who wants to say it isn't going to rise because it has been proven. That's his business but no one is going to listen very long to him. Now with cigarette smoking we have units of measurement of that order of magnitude over a million and a half now over two million men have been followed and observed for over ten years and these men were unselected. In short the order of magnitude of the figures approaches the order of magnitude of the figures that we deal with in astronomical. Events and we have the same type of statistical proofs. Now we can go on beyond that don't have

time to talk about either. But still the report is criticized. It is questioned and I wonder who are the critics of the report. And really what is the basis for their criticism other than this questioning of statistical association. Well people who criticize the surgeon general's report. OK I was going to mention the experimental data on animals showing relationship of extraction cigarette smoke in cancer but I won't go into that. The report is based on more than statistics I'd like to make that point directly grounder there is data on animals other than going to that emotional So the question OK well you know what it comes down to is this no one has taken a thousand people and stuffed them in a smoke filled room for forty five years ahead and re cigarette smoke and then determine the incidence of cancer in those dogs and be kind of inconvenient. You just can't do that type of experiment and in the final sense then you just. Some people are going to be unhappy about the type of relations you can put animals however in smoke filled rooms during your lifetime and you can take extracts from cigarette smokes and analyze them now extractions cigarette smokes have

properties that are carcinogens carcinogenic. Now that word means forms cancer and over 13 elements have been taken out of cigarette smoke which can be shown to be carcinogenic when applied to the skin of animals and will cause in a cell carcinomas on animals. Furthermore animals can be given changes which are the precursor changes to cancer by being forced inhale cigarette smoke and finally autopsy studies on human beings who have not developed lung cancer but who do smoke show changes in their sleep. The lining of their lungs analogous to those seen are identical to those seen in the animals at any rate what I'm trying to get at here without going into it is that the data is more than just a testicle. It's also based on biological properties of cigarette smoke. Now to your question as to who the critics are. Some of the critics of course make their living by selling cigarettes and I won't discuss them any further than saying that there are some critics who don't make a living by selling cigarettes. And they criticize the data on cigarette

smoking and health on basically three grounds. One we've already covered that is statistically don't prove anything. OK. Two they say that there are some missed cofactor that the statistics aren't picking up. That is that there's some factor going along with smoking cigarettes which is really the determining cause rather than cigarette smoking. And the third item that they say is that there are too many diseases associated with cigarette smoking so to be taken seriously. Now with respect to the last item every disease associated with cigarette smoking can rationally be shown to be associated associated with cigarette smoking I won't comment on here we don't have the time. That's where the mist cofactor the only two foot cofactors they can show our psychological cofactors and bodily habitus that is whether your big little small fat short round etc.. And the order of magnitude differentiating smokers and nonsmokers on these cofactors is so tiny as to in my mind scarcely be taken seriously. In any event if these people really believe these cofactors are determinants what they should then show is that cigarette that lung cancer is a psychosomatic disease a FACT that cannot be shown and secondly these people

who are challenging statistics on the one hand are using statistical methods on the other hand to to bolster their own arguments with which is kind of circular inverse reasoning. All I can say is is that the difference in body size between Japanese smokers who get lung cancer in American nonsmokers who don't get lung cancer is infinitely greater than the difference in body size between American nonsmokers and American smokers. This whole argument takes an extended reply and I don't think we have seen of it here. Now in 1967 a followup study was published by the US Public Health Service titled The health consequences of cigarette smoking. This reviewed an additional number of research studies on the question that had been published since 1964. Has this latest report corroborated pretty well the findings of the earlier surgeon general's report. Yes it has and everything. Now as you point out thousands of articles literally thousands of articles have appeared in the medical journals since the

1064 report devoting themselves to cigarette smoking and the sixty seven report reviews these additional thousands. In every instance they corroborate the earlier findings indeed if it weren't for the question of cigarettes being such a big industry no one would even have bothered to do the additional studies. But in every event the additional studies have corroborated the earlier findings namely that lung cancer is cosily related to cigarette smoking item 1 and they've even gone beyond that now showing a chronic bronchitis NFA Zeman is a very likely cause and it is likely causally related to cigarette smoking and heart disease has a very strong relationship. The exact nature of which is is not yet clear. So you're convinced Dr. Flack that this charge that sometimes is leveled namely that there's been some sort of arbitrary dismissal of conflicting views that is views which conflict with the surgeon general's findings. This material doesn't really hold up.

There aren't any conflicting views. I mean literally there are no conflicting views occasionally you hear of a rare study someplace which suggests that there is no relationship. No the in the industry could cite only two such studies in their congressional hearings when they were attacking the labeling law and cigarette packages. And one of these they examined the health records of people working in the cigarette industry against the health records of people over the whole nation. Now you can't compare the health records of an employed population to the health records of the whole population because a whole population obviously includes a lot of people who are too sick to work. But it's based on statistical lack of concern lack of statistics I should say like that that they're attempting to challenge the thousands of articles which are infinitely more sophisticated than that and there is no conflicting data. Now both reports deal with mortality and morbidity of cigarette smoking what about the so-called positive effects of smoking. You know the things that young people get out of smoking it's good for. Well some people claim they're relaxed and feel good when they smoke and they needed to relax. All I can say is that people lived a long long time before cigarettes were introduced approximately 80 or

90 years ago and somehow they learned to relax and be happy. Up until that moment in time and I'm sure if they weren't smoking cigarettes now they would find some substitute mechanism by which they could relax and be happy. Thanks very much Dr. Fleck. The major conclusion of the Surgeon General's report I believe went something like this. Cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action. In view of the things you've just said it seems to me that this is a monument to understatement. Still since 1964 I read recently or some 20 million Americans have quit smoking. I've also read that about that many have also begun. Certainly cigarette sales seem to continue to rise. At the same time it seems that illness and deaths related to smoking also continue to mount. And the next other series will explore further the nature and magnitude of the smoking threat. Thank you again Dr. Fleck for joining us

today. Thank you. You have been listening to the smoking dilemma a series which offers provocative Dialogue Concerning the smoking problem in this country. Guests on these programs include experts in health education medicine and psychology. Today's discussion dealt with the surgeon general's report and attempted to give a general background of all the evidence on smoking has been studied validated and finally compiled into two major reports. Your host was Dr. Ralph grounder professor of health education at San Diego State College. His guest was the director of smoking research in San Diego. Dr. Arnold flick this program was produced by Kate FM of the Radio Television Center at San Diego State College. This is the national educational radio network.