(30) Summary of Symposium on the Problem of Atypical Acid-Fast Bacilli, Bull. Internat. Union Against Tuberc., 29: 76, October-December, 1959.

(31) The Clinical Problem of Infection with Atypical Acid-Fast Bacilli (with D. Bahar, I. Chofnas, R. Foster, and H. T. Barkeley), Transact. Amer. Clin. and Climatol. Association, 71: 21-33, 1959.

(32) Current Concepts of Pulmonary Disease Due to Atypical Mycobacteria (with I. Chofnas and D. Bahar), Transact. of the 19th V.A.-Armed Forces Conference on the Chemotherapy of Tuberculosis, 224–233, 1960.

(33) Present Concepts About Atypical Acid-Fast Bacilli. Bull. of the Nat. Tuberc. Asso., 46: 11-12, April, 1960.

(34) Comparison of Wet and Dry Inflation Techniques for Fixing, Staining and Mounting Lung Specimens (with D. Bahar and H. G. Boren), Amer. Rev. Resp. Dis., 84: 120–121, 1961.

(35) Variations of Disease in Humans Caused by Scotochromogens (with M. Hunsaker, I. Chofnas, E. Whitcomb, K. H. K. Hsu, and D. Bahar), Amer. Rev. Resp. Dis., 86: 114, 1962.

(36) The Tuberculin Reactions Associated with Tuberculous Infections (with K. H. K. Hsu and L. Soriano), Amer. Rev. Resp. Dis., 86: 121, 1962. (37) The significance of Low-Grade Tuberculin Sensitivity (with K. H. K. Hsu), Canad. J. Pub. Health, 53: 313, 1962.

(38) The Tuberculin Reaction Associated with Tuberculous Infection (with K. H. K. Hsu and L. R. Soriano), Amer. Rev. Resp. Dis., 87: 493, 1963. (39) Scotochromogen Mycobacterial Disease in Man (with S. D. Greenberg, D. Bahar, K. H. K. Hsu, M. Hunsaker, and R. J. Jones), Texas State J. Med. 59: 949, 1963. (40) Various Lung Inflation-Fixation Techniques in the Study of Pulmonary Tuberculosis (with S. D. Greenberg, and D. Bahar), Amer. Rev. Resp. Dis. 88: 109, 1963. (41) Chapter 8. Mycobacterial Diseases of the Lung and Bronchial Tree. Clinical and Laboratory Aspects of Tuberculosis, Chapter 9. Treatment of Tuberculosis, Chapter 10. Tuberculosis-like Diseases Caused by Other Mycobacteria (all with E. Wolinsky), In a Textbook of Pulmonary Diseases, edited by Gerald Baum, M.D., Boston, Mass.: Little, Brown and Co., 1964. (42) Surgical Experiences in the Management of Atypical Mycobacterial Infections (with S. W. Law, I. Chofnas, D. Bahar, Frances Whitcomb, H. T. Barkley, and M. E. DeBakey), J. Thorac. and Cardiovasc. Surg. 46: 689, 1963.

(43) Coexistence of Carcinoma and Tuberculosis of the Lung (with S. D. Greenberg, D. Bahar, H. I. Schweppe, Jr., and H. Block, Jr.) Amer. Rev. Resp. Dis. 90: 67, 1964.

(44) A Rapid Method of Inflation-Fixation for Morphologic Study of Chronic Pulmonary Disease (with S. D. Greenberg, and R. M. O'Neal), Tech. Bull. Registry Med. Technol. 34: 82, 1964.

(45) Studies on the Specific Tuberculin Reaction (with K. H. K. Hsu, and F. Jeu), Tuberculin Conversion in Tuberculosis Contacts. Amer. Rev. Resp. Dis. 90: 36, 1964.

(46) Results of Needle Biopsy of the Parietal Pleura in 124 Cases (with N. V. Rao, P. O. Jones, S. D. Greenberg, D. Bahar, A. D. Daysog, and H. I. Schweppe), Archives Int. Med. Arch. Int. Med. 115: 34, 1965.

(47) Treatment of Pulmonary Tuberculosis. A chapter in "Textbook on the Management of Tuberculosis". Editor, Carl A. Pfuetze, M.D., Chicago, Ill.. Amer. College Chest Physicians, 1965 (In press).

(48) Today's Concept of the Tuberculin Test. (with K. H. K. Hsu, A. T. Carreon, and F. Jeu), Dis. Chest, 46: 648, 1964.

THE RESPIRATORY SYSTEM

This chart of the respiratory system shows the apparatus for breathing. Breathing is the process by which oxygen in the air is brought into the lungs and into close contact with the blood, which absorbs it and carries it to all parts of the body. At the same time the blood gives up waste matter (carbon dioxide), which is carried out of the lungs with the air breathed out.

1. The sinuses (frontal, maxillary, and sphenoidal) are hollow spaces in the bones of the head. Small openings connect them to the nasal cavity. The functions they serve are not clearly understood, but include helping to regulate the temperature and humidity of air breathed in, as well as to lighten the bone structure of the head and to give resonance to the voice.

2. The nasal cavity (nose) is the preferred entrance for outside air into the respiratory system. The hairs that line the inside wall are part of the aircleansing system.

3. Air also enters through the oral cavity (mouth), especially in people who have a mouth-breathing habit or whose nasal passages may be temporarily obstructed, as by a cold.

4. The adenoids are overgrown lymph tissue at the top of the throat. When they interfere with breathing, they are generally removed. The lymph system, consisting of nodes (knots of cells) and connecting vessels, carries fluid throughout the body. This system helps to resist body infection by filtering out foreign matter, including germs, and producing cells (lymphocytes) to fight them.

5. The tonsils are lymph nodes in the wall of the pharynx that often become infected. They are an unimportant part of the germ-fighting system of the body. When infected, they are generally removed.

6. The pharynx (throat) collects incoming air from the nose and mouth and passes it downward to the trachea (windpipe).

7. The epiglottis is a flap of tissue that guards the entrance to the trachea, closing when anything is swallowed that should go into the esophagus and stomach.

8. The larynx (voice box) contains the vocal cords. It is the place where moving air being breathed in and out creates voice sounds.

9. The esophagus is the passage leading from mouth and throat to the

stomach.

10. The trachea (windpipe) is the passage leading from the pharynx to the lungs.

11. The lymph nodes of the lungs are found against the walls of the bronchial tubes and trachea.

12. The ribs are bones supporting and protecting the chest cavity. move to a limited degree, helping the lungs to expand and contract.

They

13. The trachea divides into the two main bronchi (tubes), one for each lang, which subdivide into the lobar bronchi-three on the right and two on the left. These, in turn, subdivide further.

14. The right lung is divided into three lobes, or sections. Each lobe is like a balloon filled with spongelike lung tissue. Air moves in and out through one opening a branch of the bronchus.

15. The left lung is divided into two lobes.

16. The pleura are the two membranes, actually one continuous one folded on itself, that surround each lobe of the lungs and separate the lungs from the chest wall.

17. The bronchial tubes are lined with cilia (like very small hairs) that have a wavelike motion. This motion carries mucus (sticky phlegm or liquid) upward and out into the throat, where it is either coughed up or swallowed. The mucus catches and holds much of the dust, germs, and other unwanted matter that has invaded the lungs and thus gets rid of it.

18. The diaphragm is the strong wall of muscle that separates the chest cavity from the abdominal cavity. By moving downward, it creates suction to draw in air and expand the lungs.

19. The smallest subdivisions of the bronchi are called bronchioles, at the end of which are the alveoli (plural of alveolus).

20. The alveoli are the very small air sacs that are the destination of air breathed in. The capillaries are blood vessels that are imbedded in the walls of the alveoli. Blood passes through the capillaries, brought to them by the pulmonary artery and taken away by the pulmonary vein. While in the capillaries the blood discharges carbon dioxide into the alveoli and takes up oxygen from the air in the alveoli.

(Published by the National Tuberculosis Association.)

STATEMENT OF THE AMERICAN PUBLIC HEALTH ASSOCIATION ON H.R. 4244, H.R. 3014, AND H.R. 4007

(Presented by Morton L. Levin, M.D., chief, department of epidemiology, Roswell Park Memorial Institute)

I am Dr. Morton L. Levin, of Buffalo, N.Y. I am here to testify on behalf of the American Public Health Association regarding H.R. 4244, H.R. 3014 and H.R. 4007.

I am a doctor of medicine with a postgraduate degree of doctor of public health. In 1939, I first became interested in and started a study of the relation of smoking to cancer. I was at that time assistant director, and subsequently director of the Division of Cancer Control of the New York State Department of Health. From 1947 to 1959, I was assistant commissioner of health in the New York State Department of Health, and since 1960 I have been chief of the department of epidemiology at Roswell Park Memorial Institute, which is the cancer research hospital and institute of the New York State Department of Health. I have published, as senior or associate author, 11 papers on the relation of smoking to cancer. A detailed list of my experience and publications is attached to my statement filed with the committee.

The American Public Health Association is a national organization comprised of professional workers primarily concerned with public health and the prevention of disease. The health hazards of continued cigarette smoking have long been the subject of study by members of the association. The association is comprised of public health officials and related personnel who are charged by law to evaluate new methods for the prevention of disease and to advise the public regarding the advisability and importance of adopting such methods.

In 1954, the Public Health Cancer Association, an affiliate of the American Public Health Association, adopted a resolution calling attention to cigarette smoking as the major cause of lung cancer and urging that the youth of America "count the cost" before starting to smoke. In 1959, the governing council of the American Public Health Association adopted a similar resolution, citing the probability that more than 1 million present schoolchildren would develop lung cancer during their lifetime if present trends continue. The resolu tion urged that health authorities undertake a broad educational effort "to prevent cigarette smoking." In 1963, the council called attention to the increased risk of other diseases, such as coronary artery disease and chronic respiratory disease associated with cigarette smoking and proposed that educational activities be conducted based "on the fact that the level of cigarette smoking in the United States constitutes a serious health hazard." The resolution also urged legislative bodies "to consider taking action to regulate the advertising of cigarettes." (Copies of these resolutions are attached, app. A and B.)

Since 1954, a large number of other professional health organizations, medical societies, voluntary and governmental health agencies, and research organizations in this country, Canada, and abroad, have reviewed the evidence on the effect of smoking on health (app. C). This evidence includes data gathered from chemical analysis of tobacco smoke, animal experiments on the cancer-producing effect of various chemicals contained in tobacco tar and of whole tobacco tar, the effect of smoking on human lung tissue, studies of persons ill with cancer and other diseases, studies of well persons to determine subsequent incidence of disease in relation to smoking habits and other characteristics, and vital statistics regarding changes in the mortality and incidence of disease. All the reviews of this evidence made by these health agencies have concluded that cigarette smoking is an important health hazard.

How great is this health hazard? One way of gaging its magnitude is by estimating the excess deaths among male cigarette smokers; i.e., the deaths among cigarette smokers in excess of the mortality experience of nonsmokers. Dr. Paul Sheehe and I have made such an estimate, taking into account the age distribution of the male population, the numbers of smokers and nonsmokers, and the number of deaths from various causes in 1962. Over 200,000 deaths, about 1 in every 4, are due to the excess mortality among cigarette smokers. Of the estimated 658,000 deaths among male cigarette smokers, over 33 percent were excess deaths. Lung cancer, oral cancer, laryngal cancer, chronic bronchitis, and coronary heart disease accounted for the largest number-131,000-of the excess deaths among cigarette smokers. These are the diseases designated by the Surgeon General's advisory committee as casually related or which should be considered as casually related to cigarette smoking. Allowing for approxi

mately 20 percent over estimate due to nonresponse bias leaves a minimum estimate of over 100,000 deaths each year among males from diseases casually related to cigarette smoking. It is clear that the excess mortality among cigarette smokers today is one of our greatest health problems and, fortunately, one for which a great deal can be done in the future-if the proper public action is taken.

The most important practical aspect of the health hazard of cigarette smoking is in its preventive possibilities. Numerous studies have shown that persons who stop smoking cigarettes experience, within 5 years, a reduction of over 50 percent in the risk of developing lung cancer. Recent studies reported by Doyle and his associates (Journal of the American Medical Association, Dec. 4, 1964) show that whereas moderate to heavy cigarette smokers observed over an 8- to 10-year period experience three times as many attacks of coronary artery disease, persons who had stopped smoking had no greater incidence of heart attacks than did nonsmokers.

At present there is little that can be offered medically to counteract the effect of cigarette smoking other than prevention, by stopping smoking, smoking less, or by reducing the amount of tar intake. To achieve this requires widespread public education in order to provide individuals with sufficient motivation to change their smoking habits or not to acquire them. Enactment of the proposed legislation now under consideration would tend to provide such motivation. Reasons for adopting health warning and tar and nicotine labeling

1. Animal studies conducted at the Roswell Park Memorial Institute by Dr. Fred Bock and others have shown that the cancer producing effect on animals is directly proportional to the amount of tar contained in each brand of cigarette. A reduction of 30 to 60 percent in tar content resulted in an equivalent reduction in the percentage of animals (mice) which developed skin cancer as a result of application. We do not, however, have direct evidence of any differential effect on humans.

2. The proposed labeling would remind the consumer of the health hazards of smoking, in relation to tar intake, and encourage the use of cigarettes with lower tar content.

3. The proposed legislation would indicate to the general public the extent of governmental concern over the health hazards of cigarette smoking. In Buffalo, N.Y., we have been conducting smoking clinics for almost 2 years to help smokers who want to stop smoking and educational activities among schoolchildren. One of the most frequently asked questions has been: Since smoking is a serious health hazard, why doesn't the Federal Government do something about it? Enactment of the proposed legislation would provide at least a partial answer to that. pertinent question.

4. The cost of a broad-scale public educational program regarding smoking on a scale comparable to the expenditures for cigarette advertising would be great; the type of labeling proposed in these bills would be an effective, less costly, although partial substitute for such an educational program.

It is our view that enactment of the proposed legislation would constitute a moderate, even minimal, but nonetheless effective response of the Congress in attempting to counter the continued drain on our human resources resulting from the widespread use of cigarettes by our population. The American Public Health Association accordingly urges favorable consideration of the proposed legislation which will require labeling cigarette packages with a warning as to the potential injury to health, the tar and nicotine content, and which will regulate advertising which portrays cigarette smoking as a wholesome or safe activity.

APPENDIX A

LUNG CANCER AND CIGARETTE SMOKING

Whereas lung cancer is a rapidly increasing fatal disease which now kills more than 25,000 people in the United Staes each year and if present trends continue will claim the lives of more than 1 million present schoolchildren in this country before they reach the age of 70 years; and

Whereas scientific evidence has established that excessive cigarette smoking is a major factor in the disease; and

Whereas public health officials of the United States and many other countries have pointed out the relationship between cigarette smoking and lung cancer: Therefore be it