RNAL USE ONLY FOR 19E M T 3 ~1 b8 & Rit I B A-A SMOKING ISSUES CLAIMS AND RESPONSES BATCo document for Province of British Columbia 22 April 1999 n-!' -^ V11 A' '~ H A B 1..T -.. . , - . . i IV[ ~ I -k I N U OR ADIDICTIO.11~'--' IM H76 IWS BATCo document for Province of British Columbia 22 April 1999 CONTENTS Cigarette Smoking: Habit or Addiction What is Addiction? Page 2 Cigarette Smoking and General Definitions of Addiction 3 Physical dependence Psychological dependence Tolerance Relapse Craving 4 Dangerto the individual or to society Loss oi 4f-control - compulsive use Conclusion Definitions of 'Tobacco Dependence' or'Nicotine Addiction' 5 The American Psvchiatric Association The US Surgeon-General Psvchoactive erfects 6 Drug-reiniorced behaviour Stereotypic patterns of use The Royal Society oi Canada Conclusion If Nicotine is not addictive, then why do people smoke? 7 References CZ) f 00 BATCo document for Province of British Columbia 22 April 1999 -7, CIGARETTE SMOKING: HABIT OR ADDICTION Over the past few years there have been a number of suggestions, culminating in the publication 0~ the US Sur~,c.1?z-Ge.,ierrzl'4 Report entitled 'Nicotine Addiction' in (1980, that cigarette smoking is addictive. The potential for addiction is presumed to be due to the presence of nicotine in cigarette smoke, because nicotine has been shown to act on the brain to produce minor psychological effects. This document considers the question of whether cigarette smoking can, on the basis of scientific evidence, be considered to be addictive, and proposes alternative reasons for why people smoke. What is Addiction? A major problem %vith the subject of addiction is deciding what the word actually means. In everyday usage, the erm 'ad dicnon' is applied to many behaviours which people enjoy and therefore find it difficult to give up. For example, people claim to be addicted to certain foods such as chocolate. or to television oav ooeras. or to work. The Shorter Oxford Dictionarv lists a number of activities that have been described as addictive, including work, business, study. sport. play, melancholy, wine. vice and praver. Besides the evervdav use of the word 'addiction', it is important to know whether or not there is art accepted meLiica I or scientdic definition. A review of medical literature reveals many different definitions of addiction or'devendence', a term now preferred by many scientific authorities. T-o , pe stresses the all-importance oi 'physical dependence" major t~ypes or medicai derinition exist. One ty to a drug, %vhich would be shown by the presence of a 'withdrawal syndrome' (severe physical and psychological stress) -hen the dmg is no longer available or used. The second type of definition concentrare~ prmarfly on the notion of 'compulsive use', implying loss of control over use of the substance. There has been considerable disagreement between scientists and medical bodies in developing a sati5facton- definition of addiction, and in agreeing which of the two above processes is the more important feature of the problem. Some definitions of addiction stress the importance of more sociologically-based criteria e.g- deterioration of individual and social functioning as a result of use or the substance. Some definitions of addiction state that physical dependence is crucial; others do not. Some involve toierance and the need to increase the dose of the subject in question, and some do not. Some specify. compulsive use and uncontrollable craving, and some do not. The meaning of addiction and dependence is confusing not only in everyday usage, but also to scientists. Examples of some or the -note recent definitions of addiction and dependence by medical authorities are given beio,,-: World Health Organi;a.;mi (1969)2: Drug dependence is "A state, psychic and sometimes also physical, resulting irom the interaction between a living organism and a drug, characterised by behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic errects, and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present". National Institute an Drug.Abuse (1979)3: -An addicting substance is one that has (1) pharmacological properties leading to compulsive use: (2~ a capabilitv of producing organ and/or behavioural toxicity; (3) a use pattern associated with adverse social consequences". Although each individual medical definition of addiction can be crit icised for lack of completeness or failure to take into account all possible factors, a number of key concepts emerge when they are considered all together. These include: ~ physical dependence ~ psychological dependence ~ tolerance ~ relapse U-1 ~ craving CD ~ danger to individual J:~. CZ) ~ danger to society/adverse social conwquences ~ loss of self-control /compulsive use C__ BATCo document for Province of BritiSh Columbia 22 April 1999 The following section considers what these terms actually mean, and whether they can be said to apply to cigarette smoking. CIGARETTE SMOKING AND GENERAL DEFINITIONS OF ADDICTION The question citwhether ci:,-3rette smoking can be classified along with drugs that have for manv years been believed to beid~-*icrive can be approached by considering whether or not smoking fits into the criteria listed abo,-e that are normally used in general medical definitions of addiction. Physical dependence Physical dependence occ--.f- when the body has become so accustomed to a substance that it adapts itself to the drug's preence.As a result of this adaptation, when the substance is no longer available. or when an attempt is rra--'e :o discontinue use, the bndy reacts adversely, and a 'withdrawal syndrome' is observed. The emstence or physical dependence can only be inferred by the presence or a measurable withdrawai ~vndrome. Shuftnan (1979,~ conclude%~ :.hat the pre5ence of an abstinence [withdrawall syndrome is crucial to e ~ derinition of drug je:, n -ence". However, the existence or not or a tobacco withdrawal syndrome is still a matter or controversy. There is still a conflict amongst those scientists who believe that the symptoms occasionali 'v oi~~en-ed insmokers who give up are a result of a withdrawal syndrome because the bodv is depenzent on nicotine for its normal unctioning, and those who believe that .hev are merelv svmvtorns or trustration encountered by people who havegiven up something that they enjoy. S% mptoms observed `he- 7eOFle give up smoking differ widely from one!ndividual to another, in manv people have no i_=~cant symptoms at all. Whatever the degree of symptomatology that is expenenced, it is minor zornpared to that experienced by people who use -hard' drugs such as heroin and cocaine. A smoker %--noinas given up may typically experience ubjectivechanges in physical or psychological functions e. zhanges in mood, arousal and appetite, inabilitv to concentrate, ;r.-'.tabiiitv and anxietv. In e-,=eme cases. headache and constipation may occur. Psychological Psychological dependence an extremely difficult ractor to quantifv, because it is inevitabiv based on dependence a subjective assessment of :-er state by the individuals concerned. The problems inherent in the use of this term reflect the pro'-'Iems discussed above with the meaning of the word 'addiction'. In theorv. people can be 'psychoioe-c.2~11v dependent' on anything that thev enjov doing that would make them unhappy if they stcipped. 5,-.entifically, the oniv available measure of.potential to cause psychological dependence rate the substance in question for its abilitv to produce euphoria .n those individuals who use 'A'arburton (1988,P has argued that nicotine is not scored highly on euphona/liking scales. Tolerance The concept of 'tolerance' ~s based on the idea that, as the use of a given substance continues, the individual might need to take progressively higher doses of it to maintain the same level of effect that he obtained when he firs, irarted to use it. This is because the body adapts itself to the frequent presence of a drug; this adaptation is called 'tolerance'. Evidence that tolerance occ-.ir5 in cigarette smokers to the presence of nicotine is lacking. The only evidence that exists is for aierance to the effects of nicotine on the body that some people experience "hen they first begin to smoke e.g. nausea, headache, palpitation. These effects rapidly disappear. However, no scientific studies have vet been published that suggest that tolerance might develop to the reported psychologicai e:`ects of nicotine i.e. its ability to reduce stress and improve performance. Relapse Relapse in smokers -.vho have tned to give up is also a matter of .some controversy. Some authors have %vritten that relapse rates for cigarette smokers are the same as those for heroin addicts. However, with cigarette smoking, millions of people worldwide have given up successfully and ,vithout the professional he:p usually required by heroin addicts. In fact, fafft and farvik (1978), commented: "While --ve rnavcontinue to %%,oncler what drives the ex-opiate iddict to relapse, given the multiple motives forimoking that have been postulated and the number ot cgarettes that a cSZ610VOS BATCo document for Province of Brit!Sh Columbia 22 April 1999 heavy imoker mav have consumed Over a I 0-year period, we may find it remarkable that relapse is not universal". Once they have given up, some people do indeed begin smoking again. However, this does not necessarilv mean that they are 'addicted'. It may mean that. for them, the perceived benefits of smoking are great enough that they prefer to continue to smoke. People frequently give up certain behaviours or habits, only to begin again. Craving 'Craving' is a rather tenuous concept that no scientist has been able to define satisfactorily, because it does not apply solely to drugs, and certainly not soiely to 'addictive' drugs. People can 'crave' for anything that they enjoy doing, once thev are deprived of it or are not able to do it at a particular time. Are all such behaviours 'addictive" The tVorid Health Organisation (1957):noted that a term such as 'craving' with its everyday connotations should not be used in the scientific literature to describe (certain kinds of alcoholic drinkinz behaviour) if confusion is to be avoided". Kozlowskiand Wilkinsvii (2987)s point out that tobacco researchers and alcohol researchers may be talking about different phenomena when they use the word 'craving'. They suggest that, with tobacco, the effect is a mld one in which 'craving' is equivalent to missing or thinking about smoking, compared with severe physical withdrawal 5VMPtOMS in the case of alcohol. Danger to the Whether or not cigarette smoking causes certain diseases has still to be established, and further individual or to society scientific and medical research is required. However. even if it should be established that it consnrute~ a health risk, humans frequently mclulge in behaviour that may involve potentially harmful consequences, e.g. flying, driving. The fact of participating in an activity that has a risk associated vith it does not mean that, one is addicted to it- In spite of regular warnings by health offic-.1s that certain behaviour (e.g. eating certain types of food) may entail harrnrul consequences. these behaviours are continued. In manv definitions of addiction the concept of harmful consequences has also been used to rere r to adverse social consequences. Heroin use can lead to serious consequences f or society e.g. theft. prostitution and spread of disease, but it cannot be claimed that tobacco use has led to such consequences. The Ainencan PsychiatricAsizoc!ation (198,- commented about tobacco smoking: there is no impairment in socal or occupational functioning as an immediate and direct consequence of its use" Loss of self-control Loss of control over intake of a substance is %videlv held to be a major component of addictive compulsive use behaviour. It ~s widelv observed in alcoholics in particular, for whom one drink invariably leads to more, to 'he point of intoxication. It is less conceivable that this applies to smokers. The concept of . 'compulsion' also hardly seems to apply to smoking. Many smokers have patterns of smoking behaviour bv which thev smoke at work- but not at home, and vice versa. Manv smokers retrain for periods, for practical or religious reasons, with no apparent difficult%-."' relatively long Conclusion In summarv, the evidence that tobacco smoking is able to fit into classical definitions of 'addiction' is unconvincing. For any given criterion it is not possible to show that tobacco smoking fits or can be satistacton1v likened to the effects of'hard' drags such as heroin or cocaine. However, noting that it was extremely difficult for tobacco smoking to be classified as 'addictive' by these methods, some authorities e.g. the American Psychiatric Association and the US Surgeon-General have constructed definitions of addiction that are specifically designed to classify smokmg as addictive. Nevertheless, ever. in these cases the evidence remains unconvincing. This will be discussed in the next section. Lrl C:) -r- CD c0 BATCo document for Province of British Columbia 22 April 1999 DEFINITIONS OPTOBACCO DEPENDENCE'OR'NICOTINE ADDICTION' The American The AP.-111, in the ig8o edition of its'Diagnostic and Statistical',lanual of.Mental Disorders'(usually Psychiatric Association referred to as DS.M III) produced a set of criteria specifically defined to detect 'tobacco dependence'. The remed version of this manual, DSM III-R, published in 1987, substitutes the term'nicotine dependence'. This derinition stresses the importance of vithdra-al as a characteristic of dependence. although notes: "in any given case it is difficult to distinguish a withdrawal effect from the emergence ot psychological traits that were suppres-sed, controlled, or altered by the effects of nicotine or from a behavioural reaction (e.g. frustration) to the loss of a reintorcer". It is generall1v agreed that -his is noz a particularly helpful definition: it begins by assuming a prior. that nicotine L~- addictive t the definition provides no criteria to decide either %vav) and simply provides a set of criteria ior:ecognising a set of symptoms which may or may not represent withdrawal. T'he U5 Surgeon-General The US SurSeopi-Generrrl. in 1988~, published a report entitled 'Nicotine Addiction'. The Surgeon- General also noted that nicotine or tobacco smoking did not fit readily into standard definitions of addiction. His response was different from that of the APA, who produced a narrower definition of tobacco dependence alone. Instead, the Surgeon-General broadened the definition of addiction ;o widely that it could now include smoking or use of nicotine (as well as virtually any other behaviour that peopie revilarly indulge in). The 5u rgeo n -Genera I's criteria for addiction fall into nvo categories: primary criteria and additionai criteria: Primary criteria Highly controlled or compulsive Use Psvchoactive eifec!s Drug-reiniorced behaviour Additional criteria Addictive behaviour often involves: stereotypic patterns of use use despite harmful effects relapse follo,ang abstinence recurrent drug cravings Dependence-producing drugs often produce tolerance physical dependence pleasant (euphoriant) effects The Surgeon-General's criteria for addiction are open to exactly the same criticisms as previous definitions of addiction, and there is no justification for considering it as definitive. More importantly this definition of addiction differs in various important ways from previous definitions: M the 5urgeon-General relegated certain key criteria of previous definitions of addiction (tolerance. physical dependence and euphoria, or 'psychological dependence') to the bottom oi his list, as occasional, but unnecessarv correlates of addiction. (ii) these previously important criteria now take second place to some new, and rather vague, criteria e.g. 'psychoactive effects' and 'drug-reinforced behaviour'. Most of the Surgeon General's criteria, and the reasons why they do not easily apply to tobacco smoking, have been discussed in the previous section. Ho-ever, the ne, criteria are discussed on the next page. sg?,610tos BATCo document for Province of BritiSh Columbia 22 April 1999 Psychoactive effects This criterion is a new one for definitions of addiction, or in the field of zubstance use in general. It is also a trivial one, and to consider it as a primary criterion is highly queitionable. 'PsychoactivitV means that the substance in question can alter mood by its etfec:s an the brain. Many substances have effects on mood, but this does not make them addictive. Different substances can have very different psychological effects. Minor trancluillisers such as valium or bar*nirurate--- depress mood by seclating the person who uses them. Substances such as amphetamine lead to sn.-nulatory effects on mood and general activity. Heroin and cocaine, whilst inducing euphoriant effects. irnpair performance and judgement. Nicotine, in contrast, is not usually reported to induce euph ina. improves performance and concentration, and has been reported to induce either stimulatorv or depressant effects on mood de,pending on the person's circumstances. Anti-depressant drugs alter rnood to improve a state of depression, and yet there has never been a suggestion that thev are add:cnve. Similarly, major tranquillisers are used to improve mood and other psychological procez;es in fflnesses such as schizophrenia, but are not believed to be addictive. It is cleariv invalid -o use. as a major component of a definition of addiction, a concept that applies to the mariv d:-ferenreTects of many different kinds of drug, some of which are clearly not addictive. Drug-reinforced This criterion is included on the basis of studies carried out in laboraton,- ani-nals. Studies show that behaviour animals such as laboratory rats can be trained to produce a certain behaviour te.g. pressing a lever in a box) by giving them a reward. The reward is said to 'reintorce the be-aviour, and thus another word for 'reward' in this situation is 'reiniorcer'. Some e,idence ~uggei-.~ that nicotine can act as a reward in such situations. Some scientists have argued by analo~:v tha- niconne is therefore like heroin and cocaine, which can also 'reinforce' behaviour in this , ay, an_~ that therefore it is, like heroin and cocaine, addictive. However, mariv different things C2'.1 aC- aS 7e,, ards tor laboratorv rats, ,ho cannot bv any stretch of the imagination be considered to lead e\c-.-inc lwes. Novel food or drink, chocolate. access to a female for the deprived male rat.... ail of theme induce a rat to press a leper in a box. 'Addiction' is not a necessary carollarv. Also, eariv studies in this field suggest that rats will only press a !ever -,, oi~tain nicotine under certain conditions: if they can predict when the nicotine is goiniZ to at-.% e. and if thev do not have to work en, hard tor it. In contrast, rats will press a lever hundrci~~ or even -housands of times, under virtualIv anv circumstances, to obtain a dose of heroin. It is thererore 7L:,,*e invalid to state, on the basis of such results, that nicotine is like heroin. It is in fact far more like 'ood. chocolate chips. or sex. Stereotypic This means that a behaviour may develop into regular temporal and pi-ysical patterns of use. The patterns of use implication is that use becomes less flexible. less an activity with social -neaning, and something done primarily for its own sake. This may apply to heroin, but it does not appiv to cigarette smoking, which for many people is an activity in response to certain social situanons. or to the end of a meal, or the arrival of a cup of coffee. Heroin use -nay be primarily under the control of withdra%val symptoms, but cigarette smoking is more frequentiv under the control o-, -he particular situation in which a smoker finds himself. In addition, manv other human activities develop into regular patterns. Eating is one of them. Is eating also addictive because, like heroin use, it is usually cartied out in response to physical symptoms (i.e. hun,-,er)l Again, this criterion is so broad as to be ineffec"Ve. The Royal Societv in 1989 the Health Protection Branch of health and Welfare Canada recuested the Roval Societv to --t to the Roval Societv was: of Canada prepare a report entitled 'Tobacco, Nicotme atid Addictiorr'7'. The question ru -which is the most appropriate term ('addiction', 'dependence'. or 'hab:- mr-mation') to characterise the nsk of dependence on nicotine and, bv extension, the use of tobacco croducts". Beginnung -ith a pnorl assumption that nicotine does have the capability of inducing dependence. this report comes to the follo-ing conclusion: "The term dependence. as recommended by the World Health Organisation, is potentially ambiguous unless further specified *ny the use or modifying terms that limit its general applicability to drags of different pharmacological classes. The terms habit, habit formation, and habituation are even more ambiguous. vaguely derined and scientifically ill-founded in relation to drug use, and should no longer be used in this context'. It i; then concluded that the term 'addiction' is more appropriate; however, along with everv other group that have considered 9 P,7610POq BATCO document for Province of BritiSh Columbia 22 April 1999 this issue. Roval Society finds it necessary to produce yet another definition of addiction: Drug' addiction;_4 a ~tronglv established pattern of behaviour characterised bv (1) the repeated if- jdmini~=cwn of a drug in amounts which reliably produce reintorcing vchoactive effects and Ps. great dirnizu;ty in achieving voluntary long-term cessation of such use, even when the u5er is strongly morvaced to stop". What the Royal Society do not take into account is the fact that the term 'addiction ~~ ecually ambiguous, because of its everyday usage and it is completely arbitrary- to decide to ~er-ne this term more rigorously and not one of the others. _g does no, vem Conclusion There have "_een two responses to the realisation that nicotine or tobacco smokin comrorta~;~ =o standard definitions of addiction. One, the response of the American Ps'. chlatnc Association. :s :o assume a priori that nicotine is addictive, and to concentrate simplv on producing a list of A~azno~~.; criteria'-that can help to recognise certain characteristic 'symptoms, ot S-.Vln,~ up cigarettes. The secor.-' n-7e or.response is typified by the report of the US Surgeon-General in 1988. A-z 1-as been discusw,~ above. this report broadened the definition of addiction so far that it has become meaning;e-z- 7nvial activities fall into the various criteria Just as well as does heroin use, and one is therefore'en -.,-,-h the choice of accepting virtuallv all dailv acrvities as addictive. or of re~ecrng the der-nition 3i :nappropriate and invalid. Warburton '4z~-:3 took the latter approach. He notes: "The Surgeon-General's Report con,:'udes nicotine :5 3~~,~~znve on the basis of ten criteria. These criteria do not fit nicotine use very veil. e\cept in a suve-_~a; 4ense Of course, nicotine use can be called an'addiction'; someone.'ike :`e Surszeor.-Cenerai. just has to say that it is However. the most important measure r.or ac claim is e,ren-nentai verification, not political pronouncements, however masterful". 7 IF NICOTINE IS NOT ADDICTIVE, THEN WHY DO PEOPLE S.MOKE? I anv sc:en.-_s:s have suggested reasons for why people smoke. Their theories range !rom uggesnons M tha: peopie are zenetically predisposed to smoke, to proposals that certain personality character-stics predispose.a =erson to smoke. However, the most widely accepted idea is that smoking pro,-,des cer-ain ps-,-_-oicgicaI benefits for the smoker. It is presumed that this is due to the presence oi nicotine ir. :oi:acco smoke. Professor Da,-.d Warburton and his colleagues at Reading University in the UK have carried out a number of ~rud;es which suggest that nicotine, or cigarette smoking, can improve attention and vigilance troces4_zes and thus enable people to function more effectively in tests of pertormance. Warburton 1,a-c theonsed that smoking is an activity that has the function of controlling arousal, i.e. the smoker imokes to increase arousal when bored or fatigued, and to reduce arousal when bored or tense. He conCiLdes that people smoke not because they are addicted to nicotine, but because of the beneficial eiffec-s of smoking: "The beneficial effects from the functions that smoking serves for the individual the iiunctional model sees smoking as an important resource thus, smoking is a purposeful ac-vity for smokers; it provides them with a resource for managing their lives". (Warburfon. 19-59). ZgZ6 I O~09 BATCo document for Province of BritiSh Columbia 22 April 1999 REFERENCE5. 1 U.S. Department of Health and Human Services (1998). The Health Consequences of Smoking. Nicotine Addiction. A Report of the Surgeon-General. US Department of Health and Human Services Publication No. (1969) (CDC) 86-S406. 2 World Health Organisation. (1969) WHO Erpert Committee on Drug DePendericc. Sixteenth Report. World Health Organisation Technical Report Series 407 Geneva. 3 National Institute on Drug Abuse (1979). In 'Cigarette Smoking as a Dependence Proccss'. Krasnegor. N.A. (ed.), Research Monograph 23, NIDA, Rockville. 4 Shiffman, S.M. (1979). In: 'Ci~arefte Smoking as a Dependence Procc5;. K--asnegor, N.A. (ed.) Research Monograph 1-3,155-185 NIDA. Rockville. 5 Warburton, D..M. (1988). In. 'The Psychopharmacology of Nicotirzr'. Lader M. (ed.) Oxford Universit-v Press, Oxford. 6 Jaffe, J.H. and farvik, M.E. (197,S). In 'Psychopharmacology, A Generaton o.; Progress'. LiptonM.A. et al (eds.). Raven Press Ne, York. '). Erpert Committee on Mental Health..Addiction-producing Drugs. 7 World Health Organisation (1947 Seventh Report of the WHO F_\pert Committee, WHO Technical Report Series, 116, Geneva. 8 Kozlowski, L.T and Wilkinson. D.A. G 987). Use and Misuse of the Concept of Craving by Alcohol, Tobacco and Drug Researchers. British Journal of Addiction, 820), 31-36. 9 American Psvchiatric Assocarion (1987). Diagnostic and Statistical Manual of Mental Disorders. 10 Pomerleau, O.F and Pomerieau. C.S. (1984). Neuroreguiators and the Re!ntorcement of Smoking: Towards a Biobehavioural Explanation. Neuroscience and Biolichm-ioural Re-,reu,. 8, 503-513. 11 American Psychiatric Assoc-.a bon (1980). Diagnostic and StatisticaiManual oi Mental Disorders, 111. 12 Roval 5ocierv of Canada. Tobacco, Nicotine and Addiction.August 31 (1989). 13 Warburton, D.M. (1989)_ Is Nicotine use an addiction' 7he Psychological Bulletin 4, 166-170. C=) Z:- C:) 00 0 D S BATCo document for Province of BritiSh Columbia 22 April 1999 , -'l- -%~` -- .. Ln CZ) .I:z. C) 1.0 rIj CC) 10 BATCo document for Province of British Columbia 22 April 1999 S M 0 K I N G A A k 1r THE SCIENTIFIC -V' '"! ! V 11 1 1 IV Y 6 11V I 06 Z610VOS BATCo document for Province of British Columbia 22 April 1999 CONTEN-rS page Smoking, The Scientific Contro~ersy 3 What this 5-,Llet ~sall about What type or e-lence is there for a role of smoking in disease? Lung Cancer 5 Trends in ILL7.z cancer and in smoking Ethnic and - -'ifferences in lung cancer Occupationad ~ac-ors 6 Enwonrn-al racrors Other facto.-i a4sociated %vith lung cancer Heart Disease 7 Trends in he---t disease Other factors :n heart disease Does gl%arz up smoking affect heart disease? 8 Lung disease (Bronchitis and emphysema) 9 Trends in i=g disease Other factors in lung disease Summary 9 References C:) -C~:. BATCo document for Province of British Columbia 22 April 1999 SMOKING: THE SCIENTIFIC CONTROVERSY What this Booklet Over the past three decades many medical and -scientific studies have been carried out to investigate is all about whether there are anv differences between smokers and non-smokers in their chances of developing certain diseases. .,4any of these studies have claimed thatsmokers do have a higher risk than non-smokers of developing diseases such as lung cancers other lung diseases and heart diseases, and have claimed that it is cigarette smoking that causes these diseases. The purpose of this booklet is to discuss briefly whether or not these studies in fact show that smoking causes diseases and to point our some tacts that have not recei,ed as much publicity. but that suggest that the subject .~ much more complicated than is usually reahsed. What type of evidence The studies that have claimed that smokers have a higher risk than non-smokers of developing some is there for a role of diseases are statistical studies.The scvennstswho carry out this kind of statistical studv are smoking in disease? epidemiologists, and the science is called 'epidemiology'. Epidemiologists study the patterns ot -a disease in populations of people. and -hen try to decidewhat factor is likely to have caused that disease. For example, an epiderniologistvill look at the pattern of lung cancer in a particular country, and then look at what the people ho developed lung cancer did during their lifetime that might possibly have increased their zhances or developing the disease. If one particular factor. for example, smoking, occurs more often in people who develop lung cancer than in those people who do not, then epidemiologists might suggest that it was the smoking that caused the lung cancer. However, there are many problems %vith this type of approach. For one thing, it is very rare to find that oniv one factor is associated in this way with a particular disease. So. ;or example. where epidemiologists have found that smoking is statistically associated with :he development of lung cancer, they have also found that manv other things that people do, or are exposed to. are statistically associated with lung cancer. Those factors include environmental pollution, diet and exposure to certain chemicals as a result of certain occupations. Even more important, this type of study can only draw the conclusion that a factor such as smoking is statisticallv associated with a disease: they cannot prove that a factor causes a disease, particularly when there are many different factors zhat need to be considered. In order for firm conclusions to be drawn about causation of a disease, additional kinds of evidence are necessary: for example, proof that a particular cherrucal or type of exposure can cause disease when systematically applied to laboratory animals. There are two ty es of statistical association. and epidemiology alone cannot distinguish between the . p two. The two types of association can bereferred to as 'direct' and 'indirect'. A direct association would indicate a cause-and-effect relationship. An indirect association is one that arises by accident or coincidence with no real causal relationship. For example: there is an indirect or coincidental relationship between reading ability in children and their height. This is because, as they get older, they not only get taller, they also tend to read better. So the causal (i.e. real) association is clearlv between reading ability and age; height is coincidental. In this example, common sense teUs us that age is the important factor (once we think of it). But in relating to complex diseases common sense does not always help, and if we only have information from such statistical studies then we just cannot say whether an association is causal or accidental. 3 (-n C) .t. CD r\J BATCo document for Province of BritiSh Columbia 22 April 1999 In the case of Qmokmg and disease, we do not have much information from other types of study to help us decide whether the association is causal or not. This is because nobc>dv knows vet how diseases such as cancer and heart disease start. and what factors could affect the way they develop. We do not know whether or not smoking could cause the diseases because we do not understand the disease procen;- A number of scientists over recent vears have pointed out that because we do not have this information, it is,.,-ron-z to assumethat smoking is a major cause of diseases, because we cannot distinguish L-erween a direct and an indirect association. There are also problems about how the studies are actually carried out. For example, if an evidernioloc-, wanted to investigate whether there was a statis-ical association between smoking and heart disease, he would first have to have access to a group of people who had died of heart disease. The only wav'he would know what his group of people had.died from would be to examine the cause ot death recorded on their death certificates. However. *he British Medical Association in 1986 said that in the UK. a quarter of all death certificates were inaccurate: the cause of death was probably wrong. In the case of smoking, as well as the uncertainty about whether or not the statistical association that has been obse,-ed is a causal one or not, there is also a lot of evidence that does not fit comfortabl% with his idea. A simple smoking causes' claim is not consistent with all the evidence relating to lung cancer. other lung diseasec. or heart disease. 4 C) .P-. CD U4 BATCo document for Province of BritiSh Columbia 22 April 1999 LUNG CANCER Lung cancer was first observed :n miners a century agu, before cigarette smoking became popular. Early in the present century, it was suggested that smoking might statistically be a-~~-ociatecl %vith lung cancer', and in the second halt of this cenrum. manv other studies have suggested t~t? sime. Ba,ed on these studies (essentially epidemio,iogical'), mainstream medical opinion took the 'quantum leap' from association to causation and concluded a causI relationship bet,-n mokingand. lung cancer. Ho,ever. be!o re it can confidentiv bestated that smoking is a potennal cause of lutig cancer. a number of other possible factors have to be taken into account. and some tacts that do not fit simply with this idea have to be explained. Trends in lung cancer One way of trying to see whether or not smoking is likely to be a major factor in lung cancer is to and in smoking compare trends in cigarette smoking to trenis in lung cancer. When this is done for manYcountries. it is found that there is often no relationshir. For example. the UK Royal College of Phys:c-.ans in 1983 published a report in which it showed that lung cancer rates for men up to 65 years old in the UK %vere at their highebt in the early 1960s. and then began to decline. Yet it was the second half of the 1960s before cigarettes -ith lower tar me.isurements be, gan to be intToduced, and -he 1970s (a decade later) before LIgarette LO(ISUMption be,_,an to go do-n. This confirmed the work of other scientists-- ho concluded that the hi, ghest death rates from the maicr three so-called smoking-associated di:~eaes (lung cancer, other lung diseases Lind heart disease) occurred ing -no smoked less than later generations n which these generations of people %, diseases could be seen to be decreasing. Belcher; noted the relativelv low rate of lung cancer in the group of women who haJ smoked more than anv other in the historv of the UK. All of these studies would suggest that smoking cannot be the major cause of lung cancer. Simdarlv. in a number of countries where lunz cancer is still increasing it has been uggested that it is lung cancer in non-smokers that is inc:easint, against a background of decline, or no change in lung cancer in 5mokersl-i Ethnic and sex Another factor that would be difficult to exviain if it were assumed that smoking were a major cause differences in of lung cancer. ,s the fact that there are large dirt.erences in rates of luniz cancer amone different races lung cancer or ethnic groups, and between men and women, regardless of their smoking habits So. for example. Hindsand his co-atithors, discovered that among Chinese and Japanese women who smoked, and -ho were li%ing in Hawaii. there were fewer casesoit lung cancer than "or Hawaiian women who also smoked. Women in Hong Kong have a very high rate of lung cancer compared to women in other countries and in fact thev smoke less-. In contrast wornen in most other countries have lower rates of lung cancer than men, even if they smoke the same amount6. BitrchJ concluded that the lack of consistency. either among different countries or between the sexes, shows "that no simple causal interpretation of positive associations can be sustained". He maintained that "we encounter so many paradoxes evidence for interpreting causal relations becomes completely undermined". Occupational factors Ever since lung cancer was first reported among miners in the last century, awareness has increased that people in certain occupations are exposed to certain chemic ils that are believed by some scientists to be capable ofcausing disease. The Royal College of Physicians in the UK in 1983 said that many different occupations were associated with lung cancer, and the Toxic Substances Strategy Committee in the USA in 1981 concluded that occupationallv-related lung cancer deaths were rising. A list of Some of these occupations and the chemicals involved is given in Table I - V6 Z6 I O~OS BATCo document for Province of BritiSh Columbia 22 April 1999 Table 1 Some of the occupations and occupational chemicals associated with lung cancers: Mining .................................................. ............ Arsenic Foundry work ................................................ Asbestos Welding .................................................. ......... Bischoromethyl ether Shipbuiding consmuction .............................. Chromium compounds Painting .................................................. ......... .Mustard ga:.! Tin mining .................................................. ..... Nickel refinement chemicals Sugar cane farming ........................................ Polycyclic arornanc hydrocarbons Cotton working .............................................. Acrylonitrite Pulp and paper %vorkers ............................... Beryllium Masons ............... ......................................... Vind chlori,!e rile-setters .................................................. ..... Sulphuric aci Z; Janitors and cleaners Printing vorkers Trucking service orkers Warehouse /storage workers Sheet metal workers Boilermakers Wood industrv ivorkers Butchers Some scientists'!' have argued that many of the diseasei have been claimed to be associated -ith smoking are telated to working conditions and that 4mokine has been used to divert attention a%, a~ from these hazards. One group of scientists" has arg-.ied "tat :n some populations, occupation can account for up to 4C6, of all deaths from lung cancer. Environmental factors The outside air that evervone breathes contains a number oi chemicals. manv of which have also been suggested by scientists to be potentially harmeul. These zhernicals come from a varietv of sources, including ractories and industrial processes, and :-.;me-, from vehicle exhaust. Johnson listed 99 chemicals for %vhich guidelines exist regarding -heir cuanti"- in outside air. Some epidemiological studies have also indicated that there is a itanstical association between living in areas high in air pollution and the development of lung ca ncer It is not oniv the air outside that contains chemicals that ha,-e been suggested to be harmful. Al: buildings contain chemicals that, again, can come from a variety of sources. Some chemicals seep in from outside air, others arise from carpets and furnishings. -rom office materials and from heating and cooking equipment. Attention has particularly been paid to the presence of a radioactive gas. radon, in manv homes in the USA and in Europe. The gas collects in the ground in materials such as granite on which houses in many areas are built. and can seep up into'houses and other buildings. Levels of this gas have been stated by regulatory authonnes in these countries to be alarmingly high in manv homes, and to be associated with lung cancer`. A number of studies haw identified particles in the lungs of toth smokers and non-smokers, the source of which is assumed to be urban (citv) air - one such sr-,dv forund that 809c of the mineral particles in the lungs of urban cigarette smokers can be assumed to come from urban air)3. Some of these particJes are suspected to be cancer-causingi 6. Other factors associated Apart from these major factors that have been associated with lung cancer and to which many people with lung cancer are exposed. many other scientific studies have pointed out a number of other factors. A list of such factors is provided in Table 2. Table 2 Factors that have been associated with lung cancer: Radon gas14 Diesel or petTol exhaUg35 Dietary cholesterol and fat'- CD Vitamin intake3- -i-11 Personality /Stress;' C) Genetic factors (lung cancer families)15 Environmental pollution!3 BATCo document for Province of BritiSh Columbia 22 April 1999 HEART DISEASE In the westem world, heart disease and other diseases of the blood Circulation SV5tern ('cardiovascular' diseases) are the major causes of death. A number of medicalauthorities have suggested. on the basis of epidemiological studies showing a statiticai association between smoking and heart disease, that smoking is a mapr cause of the disease. As with the evidence for lung cancer. the story is notas simple as it mayappear anti a number of other factors have to be taken into account. It is also important to note that smoking is statisticall 'v associated with some types of heart disease, and not all. For exampite, it has been obse.-ed that smokers are less liketv than non-smokers to develop this hypertension. or high blood pressure'9. Further, a number of recent epidemiological studies have failed to find an, association berveen smoking and heart disease-:0,21, and in those studies that have claimed to rind an effect. it is a small one. The -Framingham Heart Study is widely recognized as the largest and longest investigation of heart disease, and has been described as the "cornerstone" of research on coronan- heart disease:-. And, bv the British.Medical journal, as "the Rolls-Royce of epidemiological studies"-'.'- The analyses from this study not only confirmed that ex-smokers had a lower rate of heartd;seae than people ivho have never smoked but determined that "cigarette smoking was not found to be a significant predictor of coronan, heart disease" in either men or women. One scientist concluded that the Framingham data substantially disagreed with "conventional wisdom" as set out bY the USSurgeon General and others regarding cigarette smoking and heart disease3-1. Trends in heart disease A number of scientists and medical authorities, including the UK Roval College of Phvsicians in 1983, have noted that there are striking differences in the rates of hear-, disease in di~rerent countries - regardless of the smoking habits of people in these countries. For example, Japan has a very low rate of heart disease compared to countnes such as the USA. which is very high. However, the percentage of men who smoke in Japan is considerably higher than the percentage who smoke in the USA. Marmot et al-N, reviewed heart ciiiea~e rates in a number of councries. and came to the conclusion that trends in deaths from heart disease in men were not related to trends in cigarette smoking. Whiist it is frequently stated by medical author-ties that heart disease is increising in man 'v countries, a number of recent studies have suggested that it has been decreasing for some time: For example. Ragland et al (1988) claimed that heart disease in the USA has been going down since 1%0. Other factors in It is well recogrused by medical authorities that there are a number of factors other than smoking that heart disease have also been associated with heart disease. However, it is often not recogni5ed just how many there are. Hopkins and Williams in 1981 identified 246 different factors that had been associated with heart disease. It would be virtually impossible for any epidemiological study to take into account all of these factors, and that the effects, if any, of smoking would be virrually impossible to establish-e. Apart from smoking, these included amongst the most significant; diet. high cholesterol and salt, high blood pressure, alcohol, overweight and stress. U'1 C:) 10 r1 _J 10 CYN BATCo document for Province of British Columbia 22 April 1999 So. althouch smoking has been claimed to be a major factor, it is only one of the very many powible risk ractors for heart disease (diet being the main current contender), but it is not an overstatement to --av that the cause of heart disease is unknown at the present time. To o,uote the conclusion of a conference on coronary heart disease reported by the British Medical lournal tEditorial 1982): "Professor Geoffrev Rose and other soeaker5 from the United States and Europe seemed agreed that "In population studies dietary changes had the most important effect on me incidence of coronary heart disease - much more than did changes in smoking... the relative freedom ot the Japanese trom coronary- heart disease, despite their very heavy smoking, t%as good evt,ience that tobacco was no great threat to an otherwise healthy heart". Does giving up Some scientits have carried out studies to s",whether, if peopie gave up smoking. thev %\ould have smoking affect a different risk of heart disease than people ,-ho carried on smoking. None of the three major studies heart disease? that were camed out (in the USA, the UK and Norway) provided anv evidence that the i-roup who stopped smoking were any better off in terms or heart disease risk than the group \,-hich carried on smokLng-'--'-`. This has led some experts, such as Oliver3l, to conclude that: "perhaps c:Ezarettes are not the relevant risk factor". Ln BATCo document for Province of BritiSh Columbia 22 April 1999 LUNG DISEASE (BRONCHITIS AND EMPHYSEMA) Lung (or'respiratory') diseases such as bronchitis and emphysema have been common in many countries for centurim and before smoking became a widespread pastime were usually attributed to factors such as occupational exposures (e.g. mining), poor and damp housing conditions and air pollution or'5mog'. However, in recent decades manv medical authorities have clairned that in fact it is smoking that is the major cause of lung diseases. A gain, there is evidence that is notconsistent with this simple conclusion. Trends in lung disease Lung diseases such as bronchitis and emphysema are known to have reached their peak :n most ,%-e-*.em countries in the early part of this century, when living conditions and environmental conditions were poor. These diseases have been decreasing ever since. The introducrwn or 4moking ,,as not followed by an increase in these diseases, and so, once again, there is no relationsrut) berween smoking patterns and patterns of lung disease. Other factors A large number of scientific studies have suggested that factors other than smoking are associated in lung disease %% irh iung disease. The most important factors are social class3l which may be related to poor housing and ,orking conditions; occupations such as mining and workplace exposure to things like dust, gas and umes-;'_2 air pollution - from the more general, such as 'smog', to the more specific. much as diesel exhaust-'4-3'. The presence of lung disease in childhood is also related to tune jiseasemlater life, regardless of smoking habits. SUPNIMARY Although a number of epidemiological studies have claimed that smoking is itatisticaily associated %,-:th a number of diseases i.e. smokers have a higher rate of certain diwaseshan non-mokers. we have to think verv carefully about what this mears. We cannot be sure whether or not itmeans that smoking causes those diseases. A nurn~er of eminent 4 c-.entists have suggested that people who smoke differ in many other ~ay5 from peopie -.,-ho do not smoke - in terms of personality and lifestyle - and their chances of developing vanou4 diseases could be a reflection of any one of these, or all of these other differences. At the moment it :s imoo5sible to draw any firm conclusions because most of the studies we have to work vith are 5 tatisn.cal studies which cannot prove cause and effect. i he oniv wav in which progress can be made in understanding he causes of diseases ziuch as lung cancer is by carrying out further medical research into the details of the processes that are related to the development of these diseases. Unfortunately, for diseases such as cancer and heart disease, we are a long way from understanding them. 5 ome relevant facts are summarised here- Where epidemiologists have found that smoking is associated with the development of lung cancer they have also found that many other things that people do, or are exposed to, are assocated with lung cancer, including environmental pollution, diet. exposure to certain chemicals from certain occupations etc. This type of epidemiological study can only draw the conclusion that a factor such as smoking is staristicalIv associated with a disease; they cannot prove that a factor causes a disease. particularly when there are many different factors that need to be considered. If an epidemiologist wanted to investigate whether there was a statistical association bet-een smoking and heart disease, he would first have to have access to a group of people who had died of heart disease ffrom the cause of death recorded on their death certificates). Ho-ever, the British Medical Association in 1986 said that in the UK a quarter of all death certificates -r~ inaccurate: The cause of death was probably wrong. 9 2 ~7610~0~ BATCo document for Province of BritiSh Columbia 22 April 1999 A simple 'smoking cau-zes' cairn is not consistent with all the evidence either for lung cancer, lung or heart diseases. In a number of countrie, where lung cancer is still increasing, it has been suggested that it is lung cancer in non-moker, 'hat is increasing against a background ot decline or no change in lung cancer in smokers. Manv of theii~ease~ -.hat have been claimed to be associated with smoking are related to working conditions, and that ;rnoking has been used to divert attention away from these hazards. The Framinzham Heart '_;tud%~.. confirmed that ex-smokers had a lower rate of heart disease than people who ha% e never rmoked, but determined that cigarette smoking was not found to be a significant predictor orcoronary heart disease. Although smokinghas i~een accused. it is only one of the very many Oossibie risk factors for heart disease (diet being the main current contender) but it is not an overstatement to say that the cause or heart disease i~ unknown at the present time. In population itudie, dierary changes had the most important effect on the incidence of coronary heart disease - much more than did changes in smoking the relative freedom of the Japanese trom coronary hear- disease. despite their heavy smoking, was good evidence that tobacco %vas no great threat to an othe-ise healthv heart. Some scientis- have,:3-ned out studies to see whether, if peopie gave up smoking, they would have a dirierent ri!~" o; hear: _'isease than people who carried on smoking. None of the three major studied that ~-ere carned ou- t in che USA, the UK and Norway) provided any evidence that the group %%-ho stopped smol-ng , ere any better off in terms of heart disease r-sk than the group which carried on smoking- 10 Ln CD BATCo document for Province of BritiSh Columbia 22 April 1999 REFERENCES I Adler 1. Primary malignant growths of the lung and bronchi, a pathological and clinical study. Longmans, Green and Co. (1912). 2 Todd G F et al. Cohort analysis of cigarette smoking and of mortality from four associated d`seases. Tobacco Research Council Occasional Paper 3 (1976Y 3 Belcher J R. The changing pattern of bronchial carcinoma. Br. J. Dis. Chest SI:37-95 (19S7). 4 Hanai A; Whittaker j 5; Tateishi R; Sobin L H; Benn R T, Muir C S. Concordance of histological classification of lung cancer with special reference to adenocarcinoma in Osaka. Japan, and the North-West region of England. Int. J. Cancer 39: 6-9 (1987) 5 .-\nton-Culver H; Culver B D; Osann K E; Kurosaki T, Lee J B. Incidence or lung cancer by histologic type from a population-based registry. Ann. Ivieeting Amer. Assoc. Cancer Res. Proc. 9 :253 0988). 6 Hinds M W et al. Differences in lung cancer risk from smoking among Japanese. Chinese and Hawaiian women in Hawaii. Int. J. Cancer:!7(3): 297-302 (1984). 7 Ka`o L C et aL Active and passive smoking among female lung cancer panents and controls in Hang Kong. J. E.p. Clin. Cancer Res. 4(2): 367-375 (1983). 8 Burch PRI. Smoking and lung cancer: the problem of inferring cause J.R.Statist. Soc. A. 141 Part A:437-4719 1978. 9 Blot W 1. Lung cancer & occupational exposures. In: (Lung cancer): causes & prevenrion. Verlag Chemie International 1984. 10 Sterling T D; Does smoking kill workers or -orking kill smokers' Int. J. Health Ser,lces S: 437-452 (1978). 11 S;monata L, Vineis P; Fletcher A C. Estimates of the proportion of lung cancer attnbutable to occupational exposure. Carcinogenesis 9(7); 1139-1165 (1988). 12 Johnson L D. Air pollution - toxic or 'hazardous' air pollutants. In: The Chemicai Industry and the Health of the Community, Ed F J C Roe. Royal Soc. Med. (1985). 13 Shy C M. Air pollution and lung cancer. In: Lung cancer: causes and prevenrion. Verlag Chemie International (1984). 14 kelson 0. Room for a role for radon in lung cancer causation? Med. Hvroth. 13: 13-61 (1984). 15 Churg A; Wigg B. Ty , pes, numbers. sizes & distribution of mineral particals in the lungs of urban male cigarette smokers. Environ. Res. 42: 121-129. 1987. 16 Sasaki Y. Kawaj T; Onyama K; Nakama A; Endo R. Carcinogenicity of extract airbome particles using newborn mice & comparative study of Carcinogenic & muragenic effects of the extract. Arch. Environ. Health 42: 14 - 18 1987. 17 L:nn Nf W; Stein S. Personality factors in lung cancer. Gerontologist 21. (Special Issue) 161 A Oct 1987. 18 Kramer A; Graham 5; Burneit W; Nasca P; Familial aggregation of lung cancer satisfied by smoking. Amer. J. Epiderniol. 126, 766 198-1. 19 Green M S; Jucha E; Luz Y Blood pressure in smokers and nonsmokers: epiderniologic findings. Am. Heart J. Ill: 932-940 (1986). 20 Lapidus L et al. Smoking a risk factor for cardiovascular disease in women' 5cand. J Prim. Health Care 4: 219-2-14 1986. 21 Menotti A; Seccarecia F; Pasquali M. blood pressure, serum cholesterol & smoking habits predicting different manifestations of arteriosc!erotic diseases. Acta Cardiologica XL 11 (2): 91-102 1987. Lrl L Leaventon P E et al. Representatives of the Framingham Risk Nlode] for coronary heart disease C:) mortality: a comparison with a national cohort studv. J. Chronc. Dis. 40: 75-784.' 1987 X~.- C:) BATCo document for Province of BritiSh Columbia 22 April 1999 23 Minerva Vieiws. Brit. Med. J. 299, 524 1989. 24 MarmotM G. Sooth,*V; Beral V. Changes in heart disease mortality in England and Wales and other countries. Health trends 13,33 (1981). 25 Ragland K E; Selvin S;.Merrill D W. The onset of decline in ischamic heart disease mortality in the United States. Amen J. Epidemiol. 127(3): 516-331 (1988). 26 Hopkins PN; Williams R R. A survey of 246 suggested Coronary risk factors. Atherosclerosis 40: 1-52 (1981). 27 Hiermann 1; Ve!ve Byre K; Holmes 1; Leren P. Effect of diet and smoking intervention on the incidence of coronan, hea.-i disease; report from the Oslo Study Group of a randomised trial in healthv men. Lancet 2: 1301 ~ 1 Q8 15. 28 Rose G; Tunstail-Pedoe H D; Heller R F. UK heart disease prevention project: incidence and mortalirv results. Lancet ': 1062 (1983). 29 Stallones R A: Multiple authors. Risk factor intervention trial. JAXIA 248 Vol 12 1465 (19S3). 30 Oliver M F Doe- control and risk factors prevent coronary heart disease. BMJ 283; 1065 k 1982). 31 BurrM L; Hollidav R M. Whv is chest disease so common in South Wales'). Eoiderniol. Commun. Health 40:140-44 (1987). 32 Nernerv B' Brasseur L; Venter C; Frans A. Impairment of ventilatory function and pulmonan. gas exchange in non-moking coalminers. Lancet 11 (8573): 1427-1430 (1987). 33 Kom R J; Docke,- D W; Speitzer F E; Ware J H; Fern B G. Occupational exposures and chronic respiratorv S%711-~toms. Amer. Rev. Respir Dis. 136:298-304 (1987). 34 Euler G L, Abi:~ev D E-Magic A R; Hodgkin J E. Chronic obstructive pulmonarv disesase symptoms effects of long-term cumulative exposure to ambient levels of total suspended particulates and sulfur dioxide in Cal=.-rua Seventh-dav Adventist residents. Arch. Environ. Health 42: 213-21-1 (19S-1). 35 Garschick E: Sc~enker M G; Munoz A; Segal M; Smith T J; Woskie R S; Hammond 5 K; SLeizer F E. A case-control st-u-4v of lung cancer and diesel exhaust exposurem railroad workers. Amer. Rev. Respir. Dis 13;: 1242-1 1987). 36 Wynder E L; Her'.,ert J R: Kabat G C. Association of dietary fat and lung cancer. J. Natt. Cancer Inst. 70 (4).631-637 1987. 37 Willett W C;.',Iac-\Iahon B. Diet and cancer: an overview. N. Engl. J. Med. 310: 633 - 697 1984. 38 Seltzer C C. Framingham study data and 'established wisdom' about cigarette smoking and coronar-,- heart disease.J. Clin. Epiderniol. 42(8): 743 - 1989. 12 Lrl CD BATCo document for Province of BritiSh Columbia 22 April 1999 (.n (Z) _rn:. CD 110 CPJ C) N) BATCo document for Province of British Columbia 22 April 1999 A. CrITMS AvtyJT AC= SMOKT~r- FACE 1. When government or other groups claim that smok:.rq 1 is harmful, they take evidence fran scientific and medical experts into account. 2. Thousands of deaths every year are caused in this 3 country by tobacco. 3. Smoking has been proven to cause disease. 5 4. it is not credible simply to state that smoking 8 does not cause these r1i --. 5. If smoking did not cause disease, there would be no 9 hea.lth warnings on cigarette packs. 6. If smoking has not been proven to cause disease, 10 why do doctors advise people to give up smoku)g? 7. Tobacco - contains toxic and cancer-c-ausing 11 chemicals. 8. Smking is addictive. Smokers can't quit because 13 they're addicted to nicotine. 9. Smoking must be addictive because people car--y on 15 cooking even when they're told it may be harmful. 10. Cigarette smoking is an addiction comparable to 16 hex,oin and cocaine addiction. 11. Smokers die yourxger. 18 12. 90% of a.U lung cancer patients are smokers; surelly 20 this ixxilcates that smoking causes lung cancer. 13. You are working for a company that is selling a 21 product that is clainxi to kill people. 14. Tobacco industry employees are no better than 22 drug-push-rs- 15. Would you advise a pregnant smoker to give up 23 smoking or to continue? 16. Would you like your children to be~ smokers when 24 they grow up? 17. cigarettes with low "tax" and nicatine are safer. 25 18. You say you spend a lot of money on research; 27 however, this is small compared to your advertising Ln budget. C=) .P- C) Cli BATCo document for Province of BritiSh Columbia 22 April 1999 2 L0 !9. Do you think that people should practice moderation 2S in smking? 29 20. 'Ihe tobacco industry coald have produced a safer cigarette years ago, but did not do so because it would have shown that existing cigarettes were trLsafe. 20 ZI. People who give up smoking have reduced risks for certa-Ln rii--,- compared to oontiriLtng smokers. 32 22. Heavier smokers are more likely to develop sane r1 i -- than light smokers (i.e. there is a dcse-respomse relationstup) . 3 23. SmakiM causes social costs. 35 24. The tcbacco industry does little to resolve health questions aboat smking except to deny that smok-u-q is hantful. 26 25. The 'Itaz~', nicotine- and carbon monoxide in tobacco -ke are dangerous. 39 26. Smok~.ng causes lung cancer. 42 27. Smoking catruess heart disease. 28. Smoking causes eqZysema and other chronic lung Un CZ) Un BATCO document for Province of British Columbia 22 April 1999 CLAIM wneri gove=ryant cr cr-her groups claim that smoking is harmful, they take evidence fran scierr:ific and medical e)q3erts into account. RESPWSE we frequently find teat claims made against swking do not accurately reflect the scientific sn-,dies and reports upon wtuch they purport to be based. e.g. - 1986 Re=c= of the US Surgeon-General: The Health Consequences of IrTvol-.-rY smadrig. r1 he ove-nall conc-lusions of the Report state "involuntary sncking is a cause of disease, including lung cancer, in healthy nonsmakers". Fawever, this does not reflect the body of the Report, wnezre it is considered that t~m evidence is adequate only for lung ==e-r, and even then, all of the studies that were car.--,ed oL,--- on EIS and lung cancer are sevemly criticised for poor met.-=dology. if, hawever, you asK whet-hex there are eminent scientists ar=)d the world wto believe that =.P--e are a number of urwv;wered questions in the - of smoking and healt-Ii, or would regard the current evidence as being inadequate to es-----lish causation, the answer is clearly yes. Many such scientists have pu!~Iished their views over the years, aTd many more have testified at T-IS C--,-=--essiwal hearings to this effect. Un C) X-1. CD CD (71 BATCo document for Province of BritiSh Columbia 22 April 1999 1. see Apeendix 1. U1 C) C) ID (..-j CD --4 BATCo document for Province of British Columbia 22 April 1999 rIAD4 hou-s.-c-ds of deaths every year axe caused in this country by tobacco. FrrPONSE The simple fac,- is t~~at we simply do not understand the mechanisots of rrany of the ii--- that have been associated with.smking. Until we know t~.e mecharLism, ;.e cannot fully understand the causes. if you take any one individual who has been clained to have died as a result of s=king, and look at his lifestyle, it is usually found that not only was he a swkar, he was also exposed to diesel exhaust and other envixwuental pollution; he may have been exposed to toxic chemicals as a result of his occupation etc. etc. No-one can ever tell which of the various factors that any individual is exposed to, if any, caused his disease. The kird of ntmi)r games that are often played have no root in scientific or medicall fact and are irdications of the extent to wtuch the srcki:ig and health issue has become politicissad. !here are various discrepancies even amongst. the health authorities %~tlo quote these figures about deaths from cigarette smckizig. In Australia, for example, figures varying fr= 23,500 per year down to 16, 000 per year are quoted by var.-ous individual hea-lth authorities. Ln CD -C-1 C:) (D BATCo document for Province of BritiSh Columbia 22 April 1999 - 4 - RZF ERENCE 1. Burch, P.R.J., "Can epidemiology become a vigorous scieance? HOW big is The Big Kill?" IRCS Med. Sci. 14: 956-961, 1986. C) 4-1. CD BATCo document for Province of British Columbia 22 April 1999 CL~ -TI! Srck-ng has been proven to cause disease. tie ar-I--r Trot 62 (4): 755-760, April 1979. 5. Birch, P., I-Ihe Surgeon General's 'Epidemiologic criteria for Causality. I A Critique, 11 QT r*nron Di ~- 36 (12): 821-836, 1983. U.S. Public Health Service, office on Smoking and Health, The H--lt-h Conseauences of Smokirc: A ReDort of the Qlraeon r-*-r-Al : 1982, Department of Health and Human Services, OHRS (PHS) 82-50179, 1982, p.44. Segi, M. , et al. , (eds) , CAry-r M,,rr;41 itv and Mrrbiii tv St--tistics: Jai:)an and the World, Japanese Cancer iatIon, - GAW Monograph on Cancer Research No. 26 (Tokyo: Japanese Scientific Societies Press, 1981). Ue, P., (ed.), Tobacco Corimintion in V-i- rN-nt-ies, Tobacco Research Council, Pasearch Paper No. 6 (4th ed.: Edirburgh: T. and A. Constable Ltd., 1975). 6. Hockett, R., Statement, United States, House, Committee on Energy and Commexce, Subcommittee on Health and the EhvLrcrz3errt, Smoki,= prev-nticn EA-tion Act, Hearings, 98th Cmxjress, First Ses ion, March 9 and 17, 1983 (Washington: Govermwrt Printing Office, 1983), pp.841-851. U.S. Public Health Service, office on Smoking and Health, The H--1th Conseauences of -qffckir=: rA-,. A P--rt of the Silraeon GenerAl: 198 , Department of Health and Baman Services, DHRS Publication (PHS) 82-50179, 1982, p.218. Ln Ln BATCo document for Province of BritiSh Columbia 22 April 1999 - 41 - 7. Mauderly, j., -Diesel Exhaust Is a Pulmcnary Carcinogen in Rats E>qxr.ed Chronically By Inhalation," P-0-,m. A-1. Tbyicol. 9: 208-221, 1987. 8. Sterling, T., "Does Smokirxj Kill Workers or Working Kill S;mokers? or The Kitual Relationship Between Smoking, O=pation, and Respiratory Disease," Tnt--7-tion-1 J-n-1 of H-lt"~i S-,vi- 8 (3): .437-452, 1978. Macdonald, E., -Air Polluticn, Demography, Cw=x: Houston, Texas," J-r-1 of the Ampi-n Mmi-I Wmon's Association 31 (10): 379-395, 6 atober, 1-976. Kissen, David, "Possible Concentration of t~e Psychosomatic Approach to Prevention of lizig cw-~oer," V ii-I Offi--, pp.343-345, December 24, 1965. Schrauzer, G., Statement, U.S. Ccngress, House, C=Dittee on Diergy and Commerce, Subcammttee on Health in the Livironmem"t, Ccmr-h--ive Smokim Prevpmion PA-tion Act - Avoerri",, Hearings, 97th Congress, March 5, 11, 3.2, 3.982, p-747. C:) _9 :~- C:) BATCo document for Province of British Columbia 22 April 1999 - 42 - C-~;-v 27 s-r-K-M causes hea-rt disease. F-=CNSE: scientists do not really know what causes heart disease and smoku-ig is c-'-y one of many pos; ible "risk factors" that have been associated with 11 :. in fact, as of 1981, nearly 250 factors other than smoking had been -dentified as statistically associated with cardiovascular disease. :tese include age, heredity, diet, cholesterol, stress and obesity. rzant to understand, however, that "risk factor" does not rean intervention trials wtuch have att~-~ to te-st the t~-eory that reduction in cigarette smoking (as well as other risk factors) will lead to reductions in the risk of dying F coronary hear-, disease a- ::)) have genexally failed to support the claim that smoking is a causal ~.==r. For exuple, in the United States, the Maltiple Risk Factor -:-terver=cn Trial (m=) was designed to examine whether reductions in c---:arette smoking, high blood pressure alevated serum &.olesterol d reduce the risk of dying from OV~Although scrie of the pa=--icipants in the study were successful :.n reducing the levels of these r:-sk factors, the study itself fail to demonstrate that reducing these "risk facltzrs"4significantly reduces the chorces of dying from coronary ha---m disease. Ln C:) -C-. C) BATCo document for Province of BritiSh Columbia 22 April 1999 - 43 - 1. Hopkins, P. ard R. Williams, "A Survey of 246 Suggested Coronary Risk Factors," 40: 1-52, 1981. 2. Werko, L., -1he Borderline Between Health and Disease, Prevention or Tteatment?," r--lv Pb-- of Cora-v H,--,,-t Dis---. The Possibilitv of Pr-iictlcn, Ws. J. Walenstram, et al. (Stockholm: Ncrd.Lska Bokhandelsis, Forlag, 1973), pp. 341-362. EzUtorial, "very Early Recognition of Corcrary Heart Disease", Er Med 1 : 1302, May 21, 2-977. 3. Multiple Risk Factor Intervention Trial Research Grmip, 111-1ultiple Risk Factor Inta-,vention Trial: Ptisk, Factor changes and Mortality Results," JAMA 248 ('-2): 1465-1477, 1982. 4. Lunct*xg, G., 'mm= and the Goals of the Journal," JA M 248 (12), 1501, Septe=bP-r 24, 1982. Kolata, G., 19ieart Study Prcch~ces a Surprise Result," Sci 218: 31-32, Oc'-zb,--- 1, 1982. Oliver, M., "Does Ccntrol of Risk Factzxs Prevent carcnary Heart Disease?," 3r Med J 11: 1065-1066, October 16, 1982. Editorial, -1-rials of Corcnary Heart Disease Prevention," Lance 11: 803-804, October 9, 1982. LrI C) cc BATCO document for Province of British Columbia 22 April 1999 - 44 - CrA7M 28 Smoking causes er;mse=a and ather chronic lung A i------ Rr-,FONSE -he origin and develloppent, of emphysema and other chronic lung cli--- are poorly urderst-oa-1.1 Researchers have studied the possible role of many suspected factors in addition to smoking, including air pollution, Occupatiorf exposures, childhood diseases, adult infections ard genetic disorders. But they have yet to find wbat acnially causes th~ rii--:, although it has been shown that they typically occur in older Persons- in their efforts to dete-=Line the cause of these di--,-, scientists have exposed experimental animals to various substances, including tobacco smoke. Interestingly, such experiments have fail to prcchice enphysem in animals e-Vosed = tol:qcoo smoke while air pollutant exposure b0 resulted in this disease.' U1 CD -t~- CD BATCo document for Province of British Columbia 22 April 1999 - 45 - REFERENCES 1. 3. and M. Lebowitz, "C:iaract-e-ristics of chrorlic Bmry--,Iit:.s i_1 a War--,, Dry Region," Ar-- Rev P-04- Dis 112 (3): 365-370, 1975. Kilburn, K., "New Clues for the E7#rysemas," Amer J Med 58 (5): 591-600, My 1975. 2. B=.-ows, B., et al., '"Me Relatiomship of Childhood Respiratory Illness to Adult obstructive Airway Disea , "Am Rev Respir Dis 12.5 (5): 751-760, May, 1977. Quanjer, P., et al., "Epidemiological Follow-Up Investigaticns of LLz-)g Funct-,on. SE1:1CR Working Group Meet=g, I--- J P--mi- Dis 57: 309-322, 1976. Ste--Iir=, T., "Does Smoking Kill Workers or Working Kill Sz%Akers? Cr The ML=~&l Relationstup Between Smokang, O=ipaticn, and Respumtzrl Disease," ~nt J H~lth -S-v 8 (3): 437-452, 1978. 3. Aviado, c., staterent, Lirdted states, K-, C=udttep- on Energy ard Ccc-.,-~, Sub=rmittee on Health and the Envircrmient, Smkir= ?--evprrt-,on Education ~-t, Hearings, 98th C=xjress, First ion, March 9 and 17, 1983 (Washington: Gove=mient Printing Office, 1983), pp.610-2331. 4-1~:- CD Ul CD BATCo document for Province of BritiSh Columbia 22 April 1999 AC71VE SMOKTWG: SUMM-1-~. SHORT STATFmFNvM/PF-PONSrq - There are marv eminent scientists around the world who believe that there are a :-=bp-- of unanswered questions in the area of smoking and health, or would regard the current evidence as being inadequate to establish causation. - We lark unde--stan:Ling of the mechanisms of many of the di----- that have been - iated with smokjrq. Until we understand the mechanisms, we cannot understand the causes. - An individual smokear is exposed to many other risk factors that have been associated with lung cancer: diesel exhaust, air pollution, occupational che~micals etc. How do you know which (if any) of these factors caused his lung cancer? Similarly, 246 risk factors have been identified f= heart disease. - In Hong Kong there is a very low rate of smoking among women but a very high race of lung cancer. - 70% Of Males in Japan smoke but they have one of the lowest rates of heart disease in the world. - In 1983 the LK Royal College of Physicians noted that the numbers of deaths from, -'Ung cancer were at their highest in the 1960s and then began to decline. However, it was not unti.1 the 1970s - a decarie later - that cigarette consumption began to go dcum. - There is a close stat~-stlcal association between the heights of children and theiz- ability to read, but no--cne would suggest that the association is causal. As children age they become better readers and become taller. we have to be very careful before jumping to conclusions -i= On the basis of statistical associations. - women smokers have been claimed to be at a lower risk for lung cancer than men even when they smoke the same a=unt . - Smokers are less likely to develop hypertension (high blood pressure) than ncn-smokers. Hypertension is a risk factor for heart disease; in theory, then, smokers should be at lower risk of heart disease. - Studies that have followed up people who gave up smoking to see whether they have a lower risk of heart disease have not found this to be the case. - Although it is very easy to incIuce lung tx~ in laboratory mumals by exposing them to diesel exhaust, this is not the case for cigarette smoke, where the vast majority of such studies have failed to find a significant effect. - we are not saying that =*-u-q does or A not cause these we are saying we do not know. - if, as sane people claim, individual cheadcals in tobacco smoke are able to cause cancer, why is it that when we expose laboratory animals to whole cigarette smake it not cause cancer? BATCo document for Province of BritiSh Columbia 22 April 1999 - -he word "addiction" has =r_ to --*an all things to all people. People clauu to be addicted to sports, to chocolate, to TV scap cperas.... - Are you seriously suggesting that the A of cur population wtz =cke are no better than drug addicts? - It is a smoker's individual decisicn to decide whether to acce= the claimed risk from smaking, as wit-h all other activities he ray undex-ca.ke that have been cl-i-r-i to have risk associated with ttam. - Smokers in marry countries are largely --enL-ted in the lcwe_r socioecormic classes. They my have a lugher risk of develcp-,)g scme r1 isp- because of ot-her factors such as occupation, poor diet, housing conditions etc. I - if smoking, simply, causes lung =ncer, why do the va--. mjor'--::Iv of smokers not develop lung cancer ary-1 why do non-smokers develop _'t? - we are not in the business of qJvLng radical advice. Smokers wculd seek their own medical advice if they are worried about the pc-,,--ntial effects of smoking on thei= 11malth. : would like to thj~ that my ---iUdren are able to grow up in a society where they can make the-,- own choice about smoking or any ot.her lifestyle factors. we make low-tar prah=ts to satisfy ccrmm-er demand, and to follow government re*Lir--- - if and when scientis-ts can tell us, on sound scientific grourr-s, that a certain modification will enhance the safety of cur product t-hen of c=-se it would be in cur best interest to give it very serious consideration. Ln C:) X::1. CD r1 j BATCo document for Province of BritiSh Columbia 22 April 1999 B. frATMS A"Yr FWTWOM"rAT. 'MPACM SMDKE PAGE 1 . If we accept the claims that have been made aga=-. 1 active smoking, are we not- also forced to conclwie that "passive smckin;r' must be harmful to health - albeit perhaps to a lesser extent? 2. Exposure to errvi--cTm*ntal tobacco is ha=xfU, to 3 the health of n=%smokers. 3. Sidestream smoke contains higher concentrations of 6 toxic and cancer-causing chemical than mainstre= smoke. 4. It has been proven --hat nonsmokers can develop lt=q cancer as a result of exposure to environmental tobacco sucke. 5. Environmental t,,+- smoke contains cancer-causi:nq 10 substances. How can you claim that it is not harmful? 6. It has been proven that nonsmokers can develop 12 cardiovascular disease as a result of exposure to envir=mental tcba smoke. 7. It has been proven that adult nonsmokers can develop 14 respiratory disease or pulmmi&ry dysfunction as a result of exposure to envirmmwntal tobacco smoke. 8. It has been proven that expcsurp- to envi==ental 16 tobacco smoke can irpaix the respiratory health of children. 1 9. Scientists have showm that thousands of nonsmokers is the each year ftom wqxx=e to environmental tobacco smoke. 10. People who work in offices where smoking is permitted 20 require more tims off because of their exposure to co-worker smoking. 11. Miy should we accept your word about the health 22 effects of environmental t over that of disint~d and ob)ective medical authwities such as the U.S. Surgeon-General? 12. Even if, as you say, envircnmental tobacco szv:dm is 24 not harmful to nmmwkers, you cannot deny that it can be irritating and annoying- 13. Some people are allergic to toba smok in the air. 26 14. Nonsmokers have a right to free air. 28 15. Environmental tobacco is a major source of 30 indoor air pollution. 16. If nonsmakers, even children, have cmpx*= of EIS 32 such as nicotine in their blood, how can you say that they are not exposed to significWTt levels of ErV. Ln C) 4 ~:- BATCo document for Province of British Columbia 22 April 1999 (7-A--m :f -we accept the claims that have been made against active smk.:--q, are we ..c-: also forced to conclude that 'Ipa~- i smokaxig-I must be h=.f-.U to health - albeit perhaps to a lesser extent? R, ~- Urz,:ever one's views of the health effects of active smoking, _**,: does not fc1low that rcnsmoker exposure to environmenta.1 tcbacm involves a health risk. Mwze is a clear and largely urrwaver-,ng consensus a--=-q scientists that one cannot extrapolate frcim active smok-JLng data to erv--armental tobacco smoke. The reasons are several. There are clear differences in chemistry between the ra.!-,i-stream smoke to which an active smoker is exposed and the Mrs to which the rxxL~ is exposed. EM is a combination of sldes'---eam smoke (i. a. the --k coming off the end of the cigarerte) and exhaled mainstream smo . Bit before the rmonsmmker is exDosed to that mixture, agiM - and even more significantly - very substantial dilution with the surrourduq air occurs. As a cormAxpience of these rxxxsmokers are exposed at most to trace amounts of smoke, ard the smoke is riot even ide-r-,"Al from a chemical point of view to the mainstream smoke to utuch the active smoker is exposed. Extrapolation is also inappropriate because of differe.-ces in routes of exposure. The active smoker holds the cigaret-me in his or her mouth and breatl~ deeply before exhaling. Me rcnsmaker's exposure to EIS, by cmytrast, is primarily through the nose, with its natural filtering mechanism, and is not followed by the taking of a deep breath. These dIffere-rices are of mxh significance that virtually all scientific reseat-ch on EIS, as well as analyses of the ETS scientific literatt;re, have recognized that conclusions ccncerrung the possible health effects of EM must be based an research f=Lsing soley T M not by attempts to extrapolate from active smoking data. incead, the phrase 'Tassive smoking" is a clear and Tnial-eiinq misnomer. The phrase is used by antismokers, despite its inappropriateness fx a sc.le---ific standpoint, for its political implications - irdeadd, in much the same way that the equally inappropriate Phrase "involuntary smoking" has been used. R=ases like 'Ilpassive" or "involuntary" smaking are no more apprcp-ately applied to -To-- to EM than they w-ld be if apsciied to an individual Is exposure to the smoke Prod-ad by barbeque gr-,Us, auto exhausts, cooking txnes or fireplace smoke. Their use reveals the extent to which, in the case of ETS, members of the antismckiM =mtinity are prepared to sacrifice science on the a-tar of the-4- political agenda. Un C:) -9 ~. Lr- U1 BATCo document for Province of British Columbia 22 April 1999 1. See e.g. Wu, :., "Summaxy and C=Y-luding Revarks, "Dwironmental Tobacco -&=ke- Proceedings of the International. Symposium at McGill University, 2.989, D ichon and J Wu (ads .) Lexington: D C Heath & Co): 367-375. Ln CD Qr CY" BATCo document for Province of BritiSh Columbia 22 April 1999 2 Exposure to errvi=z=tal tabacco smok is harmful to the health of nonsmokers. PrqPONSE Tobacco smoke in the air may be annoying or bothersome to some people, but it is n= a demonstrated hea-Ith hazard for nonsmokers. MeasureTents taken urdp-- no=al, everyday conditions jn~icate that the contribution of ETIS to the a= we breathe is minimal . For example, typical nicotine measurements (Much are particularly revealing because nicotine is larigely unique to toba smoke) range from an exposure equivalent of 1/100th to 1/10OCth of one filter cigarette pLar hour .3 Thus, a rxrtmmoker wmad have to spend from 100 to 1000 hours in an office, retstaurant. or public place in order to be exposed to the nicotine equivalent of ju.-., one cigarette. moreover, more than 20 published studies have examined the possible association between M exposure and lung cancer in nonsmokers. While several of those -b-iies; report statistically significant associations, the great majority of those saxiies do riot provide even statistical 4 support for an association bec-ven E7S and lung cancer in nonsmkers. in addition, most of the stuLlies on EIS and luncf cancer in nonsmokers are not cagnpletely reliable because they failed to consider other potential factors in disease causaticn, such as diet, occupational and home e-,qx)sures to pollutants and heredity. Recent st:udies; have reportvl?-t these risk factors are associated with luM cancer in ryxwokers. Although same people have suqjgested that exposure to M ray increase the risk of c;artUovascular disea in non:smokers, scientists continue to _qqnstituents; have in'the possible question what role, if any, ET~ development of heart disea - Even the 1986 U.S. Surgeon General's Report, which focused exclusively on ErS, conceded that further studies were needed "in order to determine w involuntary smokiM increases .Dither the risk of cardiovascular disease." silnilarly, studies which have assessed the influence of MS exposures on asl-hm-ti- are rx:o- om-clusive. While the data from ac studies have been ir~eted - suggesting a genxt- response to ETS,?.- the data frcm four other studies reportedly showed no significant, objactive changes in asthmatics even after prolonged, heavy e5qDoSure to EIS.- Even in the few studies suggesting a possible link, researchers wftm unable to rule out the influence of emotional and psychological stress on the patients. Thus, the claim that exposure to EIS is a cause of any disease in (-n nonsmokers is scientifically unjustified and -ted. C) CD BATCo document for Province of BritiSh Columbia 22 April 1999 REYERENCES I. Kirk, et al., "Environmental Tobacco Smoke in Indoor Air," Indoor -nd A&is-t Air n-litv, eds. R. Perry and P.W. Kirk (London: Selper Ltd., 1988): 99-112. Sterling, T., et al., -Envi=mental Tbbacco Smoke and Indoor Air Quality in Modern Office Work Envir=ment," J OccLm Med 29 (1): 57-62, 1987. 2. Eat--tx3ti, et al., "Assessing Exposure to Err-rizonmental Tobacco Smoke," Trdoor And Amhipnt Air 0-1itv. eds. R. Perry and P.W. Kirk (London: Selmer Ltd., 1988): 131-140. Ogden, and Maiolo, "Collection and Analysis of Solanesol as a Tracer of -Environmental Tobacco Smoke (=),I' Trx1oor and Ambient Ai- Qual , eds. R. Perry and P.W. Kirk (London: Selper Ltd., 1988): 777-88. Proctor, "The Analysis of the C=7tribution of ETS to Indoor Air," Trdoor and Ambi-nt Air 0-litv, eds. R. Perry and P.W. Kirk (L=-don: Selper Ltd., 1988): 57--66. 3. P-i , et al., "Pollution Atmospherique par la Fumee de Tabac (Atzospheric Pollution by Smoking)," Ann. Ph-rm Fr 36 (9-10): 443-452, 1978. Translation. Carson, J.R. and C.A. Erikson, -'Results from a Survey of awircrzental Tobacco Smoke in Offices in Ottaum, Ontario," "wiron Te-1=1 T-tt-S 9: 501-508, 1988. Hirxis and First, "C-A-tions of Nicotine and Tobacco Smoke in Public Places," Few r-1 J Mpel 292 (16): 844-845, 1975. jenkins, et al., "Development and Application of a Thermal Desorpticn-Based Method for the Detarminaticn of Nicotine in Indoor Ehvir=Mexrts," Tr,],-r And Azr#,i-,&- Air O,-1itv, eds. R. Perry and P.W. Kirk (Iondcn: Selper I;td., 1988): 557-566. mramatsu, et al., "Estimtion of Personal Exposure to Ambient Nicotine in Daily Environment," Arr-h r-- rr.-ron H-Ot-h 59: 545-550, 1987. 4. Lee, P., Mi-1---ification of Smoki,= F-hit- And P--ive Smo)lir=: A Beview of the 'Fvidenoe. T"t Ar+l of nr- ard rwiron H-Ith, Suppl. (springer-verlag: Berlin, 1988): 73-77. 5. DeSex-Tes, F.J. and T. Matsushima, "Meeting Report: Mirtag-is and ( n Q=inogenesis by Nitropyremes and amow 0w=therape=cs,11 Mutat - C) Res 164: 4, 1986. .9. 6. Anonymous, ,Lung cancer in South China," Oncolocrv Tires, VI= (6): 33, 1986. J.N., et al., "Lung Cancer and Indoor Air Pollution in Xuan 7. Kzmford , Wei, Ciina," Sci 235: 217-220, 1987. BATCo document for Province of British Columbia 22 April 1999 8. Gao, Y.T., et &I., "Lung cancer Among Chinese wcuien," Int J r';,r)cer 40 : 604-609, 1987. 9. Koo, L., et al., IIUfe-Hi_--t:ory correlates of Lrrviromrenta., Tobacco R-~: A StL~ of Ncr--king Hong Kcng Chinese Wives with Smok=Ig Versus MOr-Mking h%Lsbands," Soc Sci Med 26 (7): 751-760, 1988. 10. Koo, L., "Dietary Habits and Lung Cancex Risk Arcrq Chinese Fenales - Hong Km-Jg Who Never S-k8d," MJt-- Cal-~-- 11: 155-172, '1988. 11. Schievelbein, H. and F. Richter, -rhe influence of passive Smking on the Cardiovascular system,,, Prev Med 13 (6): 626--644, 1984. 12. Rylander, R., 114orkshop Perspectives," Tobacco Smc*,-: P-rt fra, a wori-h= an Effec- -nd ;-,,e T-vels, eds. R. Rylarxier, et al., IN--- J P--mi- Di-, Suppl. 133 (65): 143-.L45, 1984. 13. U.S. DeDartment of Health and Bmian Services, The H,-Ith conseau-Ces of Tnvoll-ft-V Smakirn: A F-rt of the Sl=eon GeneanI (U.S. oHHs: Washingt=i, 1986): 14. 14. Dahm, T., et al., "Passive Smoking - Effect on Br=xJIial Asthma,,- 80 (5): 530-534, 1981. Might, A., and A. Bruslin, "Passive Cigarette Smoking ard patients With Asthma," W J Ax,-t 142 (3): 194-5, 1985. 15. Ing, A. and A. Breslin, "The Effect of Passive Cigarette Smoking on Asthmatic Patients," Pr---Iirx=, The Thoracic Society of Australia, October, 1983: 543. Abstract. Lebowitz, M., "The Effects of Erwircnmental Tobacco Smoke Exposure and Gas Stoves on Daily Peak Flow Rates in Asthmatic and Non-Asthmatic Families," TbIoacco smoke: P--rt from a Work-hoo on Effect- -nd F---_ Tpvpl-,, F)- J ResDi~ Dis, eds. R. Rylardex, at al., Suppl. 133 (65): 90-97, 1984. Shephard, R., wt al., "Passive' Exposure of Asthmatic Subjects to cigarette -Itm-ke," -w.ixm Res 20: 392-402, 1979. Weidemann, H., et al., "Acute Effects of Passive Smoking on I=g amcticn and Airway Faactivity in Asthmatic Sub3ects," 89 (2): 180-185, 1986. Ul CD LrI ~10 BATCo document for Province of British Columbia 22 April 1999 CLAL4 3 Sidestream smoke contains higher concentrations of toxic and c.ancer-causing chemicals than mainstream smoke. ?r';PONSE This cl-im is based on a fundamental of envi--crmezrtal t---cco smoke. Mis question refers to fresh sidestream -k , with meazurements being taken :Ln t~e laboratory only a few mi.112meters frar the e:-d of the burning cigarette. A nonsmoker would burn his or he-- nose if olaced at that distance fram a lit cigarette. nie- ETS to whi= the ncr=r~ is exposed is , - -L --I of aged sidestream and eKlaled =ainstream s-.cke t1-t iq v,--,,v subsr-ntip-11v Wuted bv the s-i-Oi-c ai,. As a =nsequence of this dilution, nonsmokers - even in the 11-kest" er7v,--=ments such as a crowded pub or bar - are exposed at mos to trace 2--mmts of chemi-I that can be attributed to tobacco smoking. indeed, a sexies of studies has shown that a rxwmmnkar would have to spend several hurdred hours in the "smokiest" bar and even longer in the typical office or restaurant e.,j....ent to be exposed to the nicatine equvalert of a single cigarette. Ln CD -9 ~1 C~I U-i ON C=) BATCo document for Province of BritiSh Columbia 22 April 1999 1. Reasor, M., "Scientific Issues Regazding exPosure to Enviromnental Tobacco Smoke and M=n Health," Cl--ina the ai,: r-.-Livr-~ on F,jvi,unff.,rr.1 Tobacco Snrke, B. Tollism (ed.) (lexington: D.C. Heath & Co., 1988): 7-14. 2. see e. ., Hirxis, W. and M. First, "C---X-4A-tiOns Of Nicotine and T,obacco Swk- in tp,~Jic Places," t&-- r-1. J. Med. 292(16): 844-845, 1975; P-rws Release, "Study of Air Quality in 100 N.Y.C. Restaurants, offices Shows Tobacco in Insignificant Factor," The (U.S.) Tobacco Institute, Dec. 10, 1986. CD (--j ON BATCo document for Province of British Columbia 22 April 1999 CLAZ4 It has been proven that nonsmokers can develop lung cancer as a result of ex;x)sure to environmental tobacco -r- (-ETS-1) FESPONSE The primary support for this claim lies in the mmber of t i it has been repeated and the tendency of many to accept urx=ritically claims that are purportedly based on science. Zn fact, of the 23 epidemiologic stuclies that have investigated a possible link between ETS and ncn~r lung cancer, only 5 have claimed a =atistically significant association between exposure to E7S (or, more precisely, marriage to a smaker) and the inci of lu:ng cancer among nonsmokers. The remaining IS studies found no such a iation. None of the 5 posit-,ve studies ruled out the ve--y high probability that the q-- 11 increased risk being reported was due to factors or circumstances having nothing whatever to do with exposure to M. These so-called confourding factors include diet, occupational exposures, heating and cooking sources, radon, automobi-le exhausts as well as a myriad of other factors. At a recent intax-iational scientific syrposium at McGill University in Canada, attended by more than So investigators, nut a single scientast voiced an objecticn to the unanimous; conclusion of the ETS/lung cancer panel participants that scienoe has been triable to ystdblish any relationship beta- ErS and nonsmoker lung cancer. Indeed, a mmter of resear=biers expressed the view at the syrposium that such a relationshipwas so improbable !h5t devoting adclitional resources to the issue cmad ncr. be justified. Ln C) aN r\J BATCo document for Province of British Columbia 22 April 1999 1. See Wu, J., "Summary and concluding remarks," Ewirormental Tobacco Smoke: Proceedings of the Irr-termationa.1 Symposium at McGill Uruversity 1989, D Eccbichon and J Wa (eds.) (Lexington: D C Heath & Cc 1990): 367-375. 2. See ibid at p128-132 (coamwits of Dr F J C Roe). U1 CD Ji.- CD C14 ON BATCo document for Province of BritiSh Columbia 22 April 1999 MUM E~wircnmental tobacco ("ETS") ccntains cancer-causing substances. How can you claim that it is not harmful? RrqPCNSE ~:he focus on purportedly "canoer-causirxj" substances in MS is a classic exanple of the search for the red herring. Many chemicals have been classified as actual or potential ca=inogens in animal studies. But the results of such sMylies are, at best, of uncertain relevance to humans. in amition, the chemicals so classified are tnily ubiquitous: they occur naturally in the environment, both outdoors and in virt:ually all indoor spaces, and also am present in a bedilde-ring array of the foods we eat, from hambuztjers to orange juice. AlthcLx;h same of these chemicals can be found in M in trace am=yts, thl EIS levels are dwarfed by the contributions fx other sources. In amition, epidemiological sbylies have been unable to ccnfim a Stat cally significant associat-icn be=qeen ErS and wry type of (j4 01 13 ATCo document for Province of British Columbia 22 April 1999 1. See, e.g. Schievelbein, H., "Are Them Really Important New Firdings About Passive Smoking?", Oeff. Ges-The-il-l-WeS. 44(0): 454-456, 1982 (rdtrcsardnes); Hollowell, C. and R. Miksch, "Sot=ces and - Concentrations of Organic C=qpounds in Indoor E~nvircnments,ll Bull. N.Y. A-M. Mad. 57 (D) : 962--z)77, 1982 (volatile organic ccmpcunds) . 2. See, e.g. Layard, M., "Errvirormental Tbbacco -I-- and Cancer: The Epidemiologic Evid 11, rrivirom-,on-l TH-cco Smo)-: Prr---iincrs of the TrIl-ly-tior-1 Svw-iim at Wr-ill Lt7iversitv 1989, D. Echobichcn and J. Ri (eds.) Lexington: D.C. Heath & Co. 1990); 99-115, "Panel Discassin on Lxu-ig and Other Cancers", ibld at 2.17-136. V1 CD .C- CD BATCo document for Province of British Columbia 22 April 1999 CIAIM It has been proven that nonsmokers can develop cardiavasc-aar disease as a result of e3qzcsure to environmental toba smoke (I'M") FPqFONSr This claim has been rejected repeatedly by official and unofficial scientific reviewing bmi throughout the world, including the United States Surgeon QN*xal, U.S. NatiorkU Academy of Sciences and the L-idependTrit Scientific Committee on Smoking and Health in the United Kingdom. No studies have appeared since those reports were prepared warranting a change in their conclusion. Of the 7 epidemiologic or popalation-based studies that have been conducted on the EIS/cardiavascular disease issue, 3 have reported a snail, but statistically significant, increased in