Articles

Can cigarettes kill you?

Some specialists blame the smoking habit for the alarming increase in lung cancer, which one expert says will afflict one man out of twelve by 1970. Others suggest the cigarette may be blameless. Here’s a report on the most controversial medical topic of our times

SIDNEY KATZ April 1 1954
Articles

Can cigarettes kill you?

Some specialists blame the smoking habit for the alarming increase in lung cancer, which one expert says will afflict one man out of twelve by 1970. Others suggest the cigarette may be blameless. Here’s a report on the most controversial medical topic of our times

SIDNEY KATZ April 1 1954

Can cigarettes kill you?

Articles

Some specialists blame the smoking habit for the alarming increase in lung cancer, which one expert says will afflict one man out of twelve by 1970. Others suggest the cigarette may be blameless. Here’s a report on the most controversial medical topic of our times

SIDNEY KATZ

IF YOU ARE ONE of the six million Canadians who smoke, your health has become the subject of the hottest medical controversy in modern times. Its source is the chilling question: Is lung cancer

caused by cigarettes?”

Lung-cancer cases have increased alarmingly. Between 19.31 and 19o? the number of annual deaths from that cause in Canada has jumped from 183 to 1,503. In 1931 lung cancer was responsible for 2.6 percent of all male cancer deaths; in 1952 this proportion had risen to almost 14 percent. In 1935 the lung was fifth among seven male cancer sites; today it has climbed to second place, next to the stomach.

The same frightening trend is visible in the United States where since 1933 the death rate for lung cancer has quadrupled for men, doubled for women. In England and Wales lung cancer is detected today fifteen times more frequently than in 1913. Similar statistics come from Denmark, Australia, Turkey, Japan and Switzerland. Dr. Alton Ochsner of New Orleans, a cancer specialist and professor of surgery at 1 ulane University, predicts that “by 1970 one out of every two or three men with cancer will have cancer of the lung or one out of every ten or t welve men living.

A small and vocal group of physicians, surgeons and medical researchers have named the cigarette as the culprit. Typical of these are Dr. Evarts Graham, a lung surgeon of St. Louis, and Dr. Ernest Wynder, of the Sloan-Kettering Institute for Cancer Research in New York, who say, “In general it appears that the less a person smokes the less are the chances that lung cancer will develop: the more heavily a person smokes the greater the chances of becoming affected by the disease.”

They point to the parallel between increased cigarette consumption and lung cancer. Between 1930 and 1953 cigarette consumption in

Canada skyrocketed from 5 billion to 21 billion./ In the last twenty years American smoking has increased from 111 billion cigarettes to 433 billion. Since 1900 the per capita yearly cigarette consumption in the United Kingdom has risen from less than half a pound to four pounds. In Iceland where people are light cigarette smokers primary cancer of the lung is relatively rare. The per capita consumption of tobacco today in Iceland is the same as British consumption for 1920.

Recently Graham and Wynder extracted tar from tobacco smoke, painted it on the shaven backs of white mice for over a year and produced skin cancers in 44 percent of the animals. “This shows conclusively,” asserted Dr. Graham, “that there is something in cigarette smoke which can produce cancer.”

But a group of equally reputable medical researchers refuse to convict the cigarette as being responsible for lung cancer. “While lung cancer and cigarette smoking have both gone up during the past thirty years, a lot of other things have changed as well,” says Dr. Paul Kotin, a University of Southern California pathology professor. There’s the matter of air pollution the air is now full of dusts, fumes and smokes from automobiles, chimney stacks, and asphalt and tarred roads which irritate the lungs. A growing number of industrial workers are coming in contact with new substances which may be carcinogenic, i.e. substances which may produce cancer. “It may turn out,” says Dr. Guyler Hammond, director of statistical research for the American Cancer Society and professor of biometry at Yale University, “that smoking has so little influence on the development of cancer that only a few very timid souls would take the danger seriously.”

The evidence linking cancer of the lung with cigarette smoking has been sharply questioned by other authorities like Dr. R. H. Rigdon and Helen KirchofT of the experimental pathology laboratory at the University of Texas. More lung cancers are bound to show up today, they say, because of improved diagnostic facilities; also, cancer is a disease of middle age and beyond and there are a greater proportion of older people today than at any other time.

Many scientists have pointed out that results obtained with white mice in laboratories do not necessarily apply to human beings. “Perhaps it only proves,” wisecracked one research worker, “that mice shouldn’t smoke.”

The implications of the cigarette-lung cancer controversy are staggering. Millions of smokers who enjoy the relaxing qualities of a cigarette are confused and frightened. A monthly check in December 1953 in twelve American cities showed that cigarette sales are down by as much as ten percent. No figures have yet been released to show a similar Canadian trend but an informal check of a half dozen retail outlets in Toronto indicates that cigarette sales have fallen off.

A decline in cigarette smoking would hit both the tobacco industry and the government economy. Three hundred thousand Canadians are directly dependent on the tobacco industry for a livelihood. Sixty million dollars annually are paid out to farmers for their tobacco crop. Each year, tobacco now yields the federal government over $240 million or six percent of its total revenue. Six of our ten provinces also collect a tax on every package of cigarettes sold. The 1.5 billion dollars collected by the United States government in cigarette taxes more than covers the cost of running the Public Health Service as well as other health and welfare agencies. In Great Britain, 613 million pounds paid into the treasury by smokers meets more than half the cost of maintaining the armed forces. That is why a former chancellor of the exchequer once begged the people, “Please smoke more. We need your money.”

Bright Prospects for Salted Peanuts

Lesser economic reverberations are in motion. The author of one book on how to give up smoking expected to sell ten thousand copies; he has already reaped royalties from eight times that number and sales are still going up. The makers of gum, candy, salted peanuts and other confections see brighter days ahead on the theory that the ex-smoker will have to have something else to pop into his mouth.

The writer recently spent several weeks trying to ascertain the facts about smoking and lung cancer. I studied the literature on the subject and discovered that Index Medicus lists more than three hundred articles on tobacco and health since 1940 alone. I interviewed Canadian cancer and lung specialists, officials of both the Canadian and American Cancer Societies, medical statisticians and spokesmen for the Canadian tobacco industry. Since this problem is not being investigated in Canada I went to the United States to interview physicians, pathologists, chemists, experimental biologists and others who are engaged in tracking down the possible effect of tobacco smoke on the human lung, among them Dr. Ernest Wynder.

Wynder, co-author of the Graham-Wynder reports, is on the staff of the Sloan-Kettering Research Institute, the research division of the New York Memorial Centre for Cancer and Allied Diseases—the largest cancer hospital in the world. His associate Dr. Evarts Graham of the Washington University medical school, St. Louis, was the man who first

Much of the evidenc

other factors as our high

performed a total pneumonectomy—removal of an entire lung by surgery.

Graham and Wynder published their first major report on lung cancer and smoking in 1950. They had carefully questioned 684 lung-cancer patients about their smoking habits and had compared them with a similar number of non-cancer hospital patients in the same age groups. They reported that:

Among the male lung-cancer patients, 96.5 percent had been smoking more than 16 cigarettes a day for 20 years or more. Of the non-cancer patients, only 73.7 percent were in this smoking category. Among the male cancer patients 51.2 percent smoked 21 or more cigarettes a day; only 19.1 percent of the non-cancer patients belonged to this heavysmoking category.

Only two percent of the cancer patients were non-smokers.

Graham and Wynder concluded, “It is rare to find a case of epidermoid lung cancer in a male patient who has not been at least a moderate heavy smoker (16 to 20 cigarettes a day) for many years.”

Two other reports on lung cancer and smoking appeared in 1950. One told of research carried on at the Roswell Park Memorial Hospital near Buffalo by Dr. Morton Levin, assistant commissioner of health for the State of New York, and his colleagues. Some 3,700 cancer patients were compared with 1,300 patients with other diseases. “We concluded,” Levin said, “that there is four times as much lung cancer and three times as much larynx cancer among cigarette smokers as among non-smokers.”

In England corroborative results were obtained by Drs. Richard Doll and Bradford Hill, of the Medical Research Council. Six hundred and forty-nine lung-cancer patients were compared to patients of a corresponding age, with a variety of diseases other than cancer. The comparison showed that:

Lung-cancer patients showed the tendency to start smoking earlier in life, continue longer and were less inclined to stop.

There were nine times as many non-smokers in the non-cancer group.

Only 13.5 percent of male non-cancer patients smoked 25 or more cigarettes a day. But 26 percent of the lung-cancer victims were in this heavy-smoking category.

“We conclude that smoking is a factor in the production of carcinoma of the lung,” was the verdict rendered by Doll and Hill.

In March 1953 the results of another piece of research by Wynder, assisted by Jerome Cornfield, a U. S. Public Health Service statistician, were published. These researchers wanted to investigate a group of men of similar backgrounds. They chose doctors—they all practiced the same profession, medical diagnosis was available to all alike and they were relatively free from industrial lung irritants such as a factory worker might encounter. They tracked down the causes of death of several hundred physicians over a two-year period. They concluded that “the mortality rate among doctors for lung cancer is ten per hundred thousand for non-smoking doctors and 133 per hundred thousand for the heaviestAsmoking (35 or more cigarettes a day) doctors.”

r But it was Graham and Wynder’s December 1953 report that really stirred up a hornet’s nest. They had taken extracted tobacco tar from the smoke of cigarettes and rubbed it on the skin of white mice. Almost half of the mice developed cancer. The irritant had to be used on the mice for over a year to bring on the cancer. In terms of the human life span, this is equivalent to thirty years. Researchers have frequently observed that the “lung-cancer age” is between 50 and 69—after a person has been smoking twenty or thirty years. “Our experiments show that the tobacco tar in cigarette smoke contains an irritant which might be the cause of human lung cancer,” says Wynder.

There’s nothing new in the claim that tobacco may be the cause of cancer. When Ulysses S. Grant, the U. S. president, died in 1885 of cancer of the tongue, his surgeon Dr. G. F. Shrady observed, “He was seldom without a cigar in his mouth.” In 1912 at a time when only 374 lung-cancer cases had been identified and described in world medical literature, a Dr. I. Adler of New York published a monograph in which he suggested smoking was the cause. About this time, researchers observed that tobacco juice caused the skin of guinea pigs to erupt; that pills of tobacco tar placed in the bladders of rats produced tumorous growths. In 1928, Dr. James Ewing, one of the founders of the American Cancer Society, warned of a possible connection between cancer and smoking. In 1935, Dr. Raymond Pearl, of Johns Hopkins University, published a report on smoking and longevity after examining 7,000 men. “There is a sharp difference in the death rate of the smoker and non-smoker,” he concluded. Between 1939 and 1949 there were a number of small-scale investigations into the relationship between lung cancer and smoking in England, the United States and Continental Europe. A typical result was obtained by Dr. F. H. Muller in Germany. Of 86 victims of lung cancer three were non-smokers, 56 were heavy smokers and the rest were somewhere between.

Sorting the Facts and the Fancies

Most Canadian cancer authorities feel that while the cigarette has not yet been proven guilty the evidence is worthy of consideration. Dr. Ivan Smith, head of Victoria Hospital, London, which houses one of the “cobalt bombs” used in cancer therapy says, “Practically all the men I’ve treated for lung cancer have been over forty and have smoked one or two packs of cigarettes a day.” Dr. R. M. Janes, professor of surgery at the University of Toronto, believes tobacco to be suspect although he says conclusive proof has yet to be offered. Dr. Norman C. Delarue, a Toronto lung-cancer specialist, says all reports published “tend to substantiate the feeling that cigarette smoking has a real relationship to the development of carcinoma of the lung.”

But the argument is by no means entirely on one side. Many highly qualified physicians like Dr. D. W. Smithers, of the Royal Cancer Hospital, London, Eng., feel that the talk about cancer and smoking may be much ado about nothing. “We are still attempting to sort the facts from the fancies,” he savs. Smithers and those who share his point of view are convinced the question has not yet been sufficiently investigated. Their objections can be summarized as follows:

1. The “backward” method of research,used in cancer-smoking investigations to date, is unreliable. The “backward” method means eliciting information from sources after the events have happened. In cancer-smoking research groups of lung-cancer patients in hospital have been questioned about their smoking habits in the past.

Dr. Cuyler Hammond of the American Cancer Society asks, “Can you get reliable information, going back twenty and thirty years, from lung-cancer patients in hospital?” They are frightened, worried and often in pain. Many are taking sedatives. Some have undergoneor are about to undergo a major surgical operation. From his experience with “backward” studies in other fields Hammond is convinced the data obtained would be grossly biased.

Furthermore is it fair to assume that lung-cancer patients seen in

dicates there is some relation between smoking and cancer. But it also points to such

rerage age levels, improved diagnosis and air pollution from factories and highways

hospital are typical of all lung-cancer patients? “The people with lung cancer who smoke heavily are the ones most likely to go to hospital,” suggests Hammond. Smoking will irritate lesions in the lung. This leads to bleeding which in turn results in a rush trip to hospital. The nonsmoking lung-cancer victim is more likely to die at home.

To overcome the weaknesses of the “backward” method of research, the American Cancer Society is engaged in a st udy of 210,000 “average” American males between the ages of 50 and 69 living all over the United States. The “forward” method of research is being used. Two years ago they were all closely questioned about their smoking habits. As t he subjects die (as they do at the rate of 5,000 a year) a careful st udy is made of the cause of death. “In two or three years,” says an official of the American Cancer Society, “we should have an unbiased picture of the correlation between lung cancer and smoking.”

2. The increase in lung cancer may be nothing more than the result of our improved methods of diagnosis and recording. It is only within recent years that doctors have acquired the skill of diagnosing lung cancer with reasonable accuracy. Before World War I it was uncommon for a diagnosis of lung cancer to be made before death. In 1904 a series of post-mortems showed that only six of 178 lung-cancer cases had been properly diagnosed. One of the most valuable diagnostic tools, the bronchoscope, was introduced only twenty years ago. The sputum test for lung cancer is only fifteen years old.

Moreover the introduction of antibiotic drugs like penicillin has made it easier for the average medical practitioner to spot lung-cancer cases. There is a great similarity in symptoms between lung cancer and some respiratory infections. These may include hoarseness, wheezing, coughing, chest pains, bloody sputum and fatigue. The modern doctor who suspects respiratory infection may give the patient penicillin. If the patient doesn’t recover the doctor starts looking elsewhere and this search might ultimately lead him to find cancer of the lung.

Some cancer specialists like Dr. Smithers strongly suspect that many of their colleagues have become too prone to write in “carcinoma of the lung” on death certificates. “Many patients who die with symptoms of chronic lung and heart disorders are being labeled as lung cancer,” he says. Smithers points out that death from respiratory diseases is common; death from lung cancer, although sharply increasing, still comparatively rare. Respiratory disease death rates have been moving steadily down while lung-cancer rates have been going up. Can the increase in one merely be the statistical reflection of the decrease in the other?

An illustration of how methods of recording and diagnosis can affect medical figures is provided by the international rates for death from all kinds of cancer. Near the top of the list with mortality rates of over 130 per hundred thousand population are Switzerland, the Netherlands, Denmark, Sweden and Englandall countries with highly organized health services. At the bottom of the list with cancer-mortality rates of 25 or less per hundred thousand are Mexico, Ecuador and Egypt, all of which have poor health services. (Lack of industrialization and a low life expectancy in the latter countries must be considered.)

3. Because of population changes during the past thirty and forty years, the increase in lung cancer may be more apparent than real. We can expect a larger total number of lung-cancer cases because of our increased population. But a more significant shift is in the age structure. In 1931 the number of Canadians fifty years and over totaled 1.7 million; by 1951, this number had Continued on page 86 risen to 2.8 million. Lung cancer—like most other forms of cancer—is chiefly a disease of middle age and beyond. Ninety percent of lung-cancer victims are fifty years old or above.

Thus the most accurate way of judging whether any specific disease is on the increase or wane between any

two given periods is to “standardize” the population figures, i.e. take cognizance of the population changes and shifts in age structure. Comparing 1941 and 1952, for example, you would find that lung-cancer deaths increased in Canada from 547 to 1,503 or roughly by 300 percent. Using “standardized” figures, the increase could be computed at as low as 100 percent.

4. If lung cancer is caused by smoking cigarettes why do so few women get it? Statistics seem to show that lung cancer is chiefly a male

disease. In Canada male patients outnumber the female by five to one. In studies carried out in England and the United States the males outnumber the females by as much as 18 to 1. Since the cigarette-smoking habit appears to be universal, does this disprove the cancer-smoking theory? Or is there something in the female sex hormones that acts as a protective device for women?

This latter suggestion has been dismissed by members of the anti-cigarette faction like Dr. Evarts Graham. He has transplanted male lung-cancer

tissue in both male and female guinea pigs and they grew equally well in both sexes. “There is no inherent sex factor involved,” he says. He feels that the real explanation is simply that women haven’t been smoking as long as men, there are not as many women smokers as men smokers and that female heavy smokers are less numerous than male heavy smokers.

The length of one’s smoking history is of particular importance. Researchers have repeatedly made the observation that the lung has to be subject to irritation for twenty or thirty years before there’s real trouble. But not many women have been smoking that long. As recently as two or three decades ago it wasn’t considered proper for a woman to be seen smoking publicly. “But if the present young heavy female smokers continue their habits into the cancer age (between 50 and 69) we may very well see the wide disparity between female and male incidence of lung cancer disappear,” Graham predicts.

There’s another facet to sex differences in lung cancer. There are two principal types of lung cancer—epidermoid and adenocarcinoma. According to data collected by Graham and Wynder, there is some indication that women and non-smoking males are more liable to contract adenocarcinoma. “Could it be,” they speculate, “that epidermoid cancer is the type caused by the prolonged irritation of smoking?”

5. Air pollution may be a much more important cause of lung cancer than cigarette smoking. An

impressive case can be made in support of this contention. In Canada, United States, Great Britain and Denmark, lung cancer is at least twice as prevalent among urban dwellers as rural dwellers. Pathologists have long noticed that the lungs of urban dwellers are black by the time they are past middle age; only children and people in rural areas have pink lungs. In the industrialized states in the United States, running from New England to the Midwest, the lung-cancer death rate is from 7.1 to 11.9 per hundred thousand people with New York State in first place. In the southern states with regional industrialization, the rate is 7.4 to 9.4. In nine predominantly agricultural states, it varies from 3 to 5.4. These figures seem to support the theory, “The less industry, the less air pollution, the less lung cancer.”

Exhaust from Three Million Cars

There is no doubt that during the last thirty or forty years, along with increased cigarette consumption, the air we breathe has become more impure and hazardous to health. Benzpyrene, contained in automobile exhausts and some types of oil exhaust, produces skin cancer in mice. Between 1912 and 1952, Canadian vehicle registrations have risen from 50,000 to more than three million; gasoline consumption per year from 60 million to nearly 2.5 billion gallons; diesel and fuel oils from small quantities to nearly three billion gallons; coal consumption from 27 million to 41 million tons. In addition, thousands of miles of tarred and asphalt roads have been built and dust from roads has been suggested as another lung irritant.

It has been estimated that each month 176 tons of soot, oil and other pollutants fall on every square mile of Manhattan. The same would be relatively true of cities like Montreal, Toronto, Vancouver, Windsor and Hamilton. Extracts prepared from the soot of twelve American cities produced cancer in mice at the point of injection.

But men like Graham and Wynder, Doll and Hill still feel the critical factor in lung cancer is cigarette smoking. “The urban-rural difference in the lung-cancer rate can probably be explained by the difference in smoking habits,” says Dr. Wynder. Doll and Hill noted that smokers in the city were twice as numerous as those in rural areas; furthermore they smoked more, and they tended to smoke cigarettes more than pipes. Two of the largest tobacco companies in Canada estimate that the average urban cigarette smoker consumes twice as many cigarettes as his rural counterpart.

6. The increase in lung cancer may be due almost entirely to lung irritants which the industrial worker is exposed to at his work. In the past three or four decades factories have turned out hundreds of new products, employing new substances and new processes. Human contact with new substances might ultimately lead to cancer. “The cause of 99 percent of all human cancers remains unknown,” says Dr. W. C. Hueper, a U. S. Public Health Service authority on carcinogenic substances. He lists 27 substances found in industry that either definitely or allegedly cause it.

Industry Fills the Air

Six substances are mentioned in connection with lung cancer. According to Hueper it has been definitely established that exposure to chromates and radioactive substances may lead to lung cancer. On the suspected list is arsenic, asbestos, mineral-oil mists, nickel carbonyl and beryllium.

With complete data lacking, the amount of lung cancer caused by these agents is unknown but it may be alarming. Chromium is used in the manufacture of armor plate, project iles, axles, springs, cutlery, stainless steel processing, pigment in certain inks, paints, enamels, etc. Many workmen come in contact with chromium dust. A detailed study in a German chromate plant showed a lung-cancer rate among the workers four times as great as the general population. Similarly an aboveaverage rate of lung cancer has been observed in U.S. chromate factories.

Or consider the possible dangers of breathing arsenic fumes and dusts. In Deer Lodge County, Mont., where a large proportion of the male population works at smelting copper ore which requires the use of arsenic, the lungcancer death rate is 145.7 per hundred thousand population; in the same state, in the agricultural county of Gallatin, the rate is only 5.2 per hundred thousand. Hueper comments, “The relatively large number of cases of cancer caused by industrial hazards seen in a comparatively short time indicates the possible extent of this danger.”

7. The fact that tobacco tar rubbed on the back of a mouse produces skin cancer doesn’t mean that a human being who inhales cigarette smoke will necessarily get lung cancer. The body chemistry of a human differs from that of a mouse; the skin of a mouse’s back is different than human lung tissue. Again, every animal species has its own peculiarities. Benzidine, a chemical which produces bladder cancer in man, fails to affect dogs but causes leukemia and liver cancer in rats. A mouse exposed to ultra-violet rays will break out in skin cancer but not so a rabbit. Although it is accepted that arsenic can cause skin cancer in a human it has not been demonstrated clearly that the same can be done with mice, rabbits, dogs or fowl.

Certain tars will give skin cancer to men, mice and rabbits but monkeys are immune and rats all but resistant. To further complicate matters certain strains within the same species have a varying susceptibility to disease.

On the other hand, much has been learned about human cancer from laboratory animals. At the beginning of the century technicians handling a new invention, the X-ray machine, began breaking out in virulent skin cancers. In the laboratory it was shown that rats had the same reaction. When dye factory workers in North America and Europe began developing cancer of the bladder the offending substance was identified by its ability to cause cancer of the bladder in dogs. Certain coal and petroleum substances cause skin cancer in men and mice alike.

Many laymen have asked, “Instead of rubbing tobacco tar on their skin, why not have the mice inhale tobacco smoke and then test their lungs?” This has been tried but so far has proved nothing. Short of teaching mice how to puff on a cigarette it is evidently impossible to duplicate the human smoking experience in an anim a 1.

All parties in the big debate about the guilt or innocence of the cigarette are agreed about the next necessary steps in research: find out exactly what substances make up cigarette smoke, determine which if any are harmful, then manufacture cigarettes without these agents in them.

How About Filter Tips?

This is more complicated than it sounds. At the New York University Institute of Industrial Medicine the job is being undertaken by a scientific team headed by Dr. Norton Nelson, pathologist W. E. Smith and chemist Alvin Kosak. The team has recently set down a complete list of the chemicals and compounds in cigarette smoke: 45 substances have been definitely identified while the presence of 35 others is suspected. The task ahead is to isolate each and test it on animals.

It may be that the cancer-producing agent in cigarette smoke isn’t in the tobacco leaf itself hut in one of the many substances added by tobacco growers and manufacturers. Arsenic, which is highly suspect as a carcinogenic, has been found in tobacco tar. This is the result of using arsenate compounds as insecticides for tobacco crops. Tobacco companies add various substances to cigarettes for fragrance, better burning, moisture and adhesion. Could one of these be the culprit? Glycerin, a thick sweetish substance often used, gives off acrolein when it burns—a gas prepared for chemical warfare during World War I. Acrolein is on the list of possible substances present in tobacco tar. Instead of glycerin some manufacturers substitute diethylene glycol. Because of its high burning point it is believed that this compound is consumed by the smoker in its whole state. It is highly toxic.

How much protection is afforded by a filter-tip cigarette? Perhaps the most authoritative statement comes from the chemical laboratory of the American Medical Association. The performance of the average filter tip was unimpressive. It removed only nine percent of the nicotine and five percent of the tar from the main stream of smoke. If you replaced the filter tip with an equivalent length of tobacco, this would remove eight percent of the nicotine and eight percent of the tar. It is possible to construct filters which are much more efficient. But one company that tried it was forced to remove its product from the market: the filter

was so tightly packed that the smoker

had to puff like fury co pull any smoke through it.

What of cigarette holders with removable filter cartridges? The chemical laboratory of the AMA found that many of these filters removed more than half the tar from the first cigarette, but after five or six cigarettes, as the filter became saturated, it became less efficient. The cigarette holder had definite disadvantages. Smokers tended to smoke their cigarettes right down to ash instead of leaving a oneinch butt as they formerly did. This meant they were inhaling tar which was formerly thrown away. Again, the hard mouthpiece of the cigarette holder serves as a nozzle concentrating the smoke on a small area of the mouth. This can lead to irritation more easily than smoking a cigarette in the usual way. Perhaps the greatest disadvantage of all the filter tips and devices on the market is that they give the smoker a false sense of security. “All cigarette filters remove something,” one scientist told me. “But do they remove enough to make any real difference if cigarettes are harmful?”

The most efficient of all filters for smoke is the old Arabian “narghile” or “hookah,” which consists of a pipe with a flask of water inserted between the bowl of tobacco and the mouthpiece. Even better than that, of course, is the human lung with its 1,500 square feet of spongy, absorbent surface.

An Italian scientist once observed, “Research is a game of chance in which the probability of error is great and that of discovering the truth small.” This comment can well be applied to man’s search to discover both the causes of cancer and the possible harmful effects of smoking tobacco. At one time or another cancer has been attributed to heredity, chronic irritation, virus, bacteria, air pollution, birth marks, meat eating, milk drinking, the use of aluminum pots, drinking strong liquor, electrical refrigeration and immoral sexual behavior.

As for tobacco, it has been accused of producing loss of speech, hallucinations, liver trouble, stunted growth, miscarriage among women, black spots in front of the eyes, meningitis and paralysis of the fingers. E. H. Harriman, an American multi-millionaire, fifty years ago refused to hire smokers, saying, “We might as well go to the insane asylum looking for men as employ cigarette smokers.”

Today, from the evidence on hand, it is not unreasonable to accept the explanation that cigarette smoking has some relationship to cancer of the lung. But the answer to just how important it is compared to some of the other suggested causes has yet to be provided by scientific research. ★