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When will people heed the Surgeon General’s warning?
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“I’m doin’ okay” was a recent reply from my patient, a 72-year-old man, when I asked him about his present complaints and how he was overall. At first glance, he seemed to be all right, but when I refreshed my memory about his medical history, I was amazed at what he had been through. Ten years earlier he had a kidney resection for renal cell cancer and then multiple transurethral resections for superficial bladder cancer. He had undergone abdominal aortic aneurysm and coronary artery bypass surgery. Three years before he had bronchogenic carcinoma surgery, and now seemed to have dodged another bullet in the form of a second bronchogenic carcinoma, having just had lung surgery again.
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In the course of our conversation, the patient confided in me that as a young man in his twenties, he was exposed, for a seven-year period, to multiple industrial chemicals as a worker in the ink manufacturing business. He routinely handled “chrome yellow” (lead chromate) and “moly orange” (a coprecipitate of lead chromate, lead molybdenum and lead sulfate). He also worked with benzene. He described being covered with chromium yellow when he went home from work. “My respirator was a rag,” he told me. I wondered if this had anything to do with his renal cancer. (At least, we seem to have accomplished some significant industrial safety measures in the years since the 1950s.)
Of course, having smoked cigarettes for 45 years while working as a salesman aided and abetted this patient’s development of bladder and two lung cancers. The other day I saw some young adults working in a retail store take a “smoking break” outside the store. I couldn’t help myself. I scolded them.
I’m sure it didn’t help.
It reminded me of my college days, when a social gathering of students was referred to as a “smoker” and only the varsity athletes didn’t smoke. In those days, I earned money by spending many hours playing the piano in smoky saloons. Thank goodness, at least in the United States, we’ve chased the smokers out into the street, but how can we convince them of the deadly effects of the habit?
I know when I became a believer. One of my most memorable days in medical school came early in my second year at New York Medical College. The class had a guest pathology lecture by Dr. Oscar Auerbach. He announced that there would be no smoking during his lecture, prompting several smart alecks in our class to leave. They missed a ground-breaking presentation.
Dr. Auerbach proceeded to describe his discoveries linking smoking and bronchogenic carcinoma. That was in 1964, but I remember it as if it were yesterday. He showed slides documenting that part of his research in which he did blinded, serial cadaver lung dissections on people who had died from any cause. Since he had done extensive prior studies, he was able to discern who had been smokers and how long they had been smoking, based on the number of abnormal cell layers he found in the lining of the bronchi.
He next showed how he performed tracheostomies on dogs, and had some of them smoke cigarettes. They became addicted to smoking. After a while, some developed lung cancer, and died; the control dogs did not. That day, nearly 45 years ago, was the last time I lit a cigarette. This probably saved my life, although I still feel that I’m at some risk for a smoking-related illness.
Auerbach’s legacy
The following is excerpted from Dr. Auerbach’s obituary by Floyd Burkhart for The New York Times on Jan. 16, 1997:
Dr. Oscar Auerbach, a pathologist who found the first evidence in human lung tissue of a link between cancer and smoking and is credited with discoveries that turned millions of people away from cigarettes, died yesterday at St. Barnabas Medical Center in Livingston, N.J.
He was 92 and lived in Short Hills, N.J.
Dr. Auerbach’s work was brought to national attention in 1964, when it was prominently cited in the first Surgeon General’s report about the dangers of smoking.
Looking at thousands of slides of human tissue, Dr. Auerbach coded each slide by clues to cell damage he found and whether the person had cancer or precancerous symptoms.
Dr. Auerbach’s results, published in the 1960s, were immediately debated and had powerful long-term effects. After the Surgeon General’s report, a major policy response required cigarette packages to carry a warning that cigarettes could be harmful to health.
An antismoking movement emerged in the 1970s, and new regulations began to require nonsmoking areas in public places.
At one point, Dr. Auerbach trained dogs — 86 beagles — to smoke; 12 of them developed cancer. It was said to be the first instance of tumors produced in large animals exposed to cigarette smoke. The American Cancer Society, which helped finance much of his research, announced that the results “effectively refute contentions by cigarette-manufacturing interests that there was no cigarette-cancer link.” The Tobacco Institute, an industry trade group, replied that it was “impossible” to draw conclusions from work on dogs subject to “stressful laboratory conclusions.”
His study of the slides of damaged organs showed that a pack-a-day smoker had a greater likelihood than a light smoker of a range of lung damage including hyperplasia, stratification and changes in the nuclei of cells. The highest frequency of smoking corresponded to the highest rate of lung cancer.
Other studies showed that when patients quit smoking, the damage began to disappear.
One study of the effects of his findings found that by 1989, in the 25 years after the first Surgeon General’s report on smoking, 750,000 lives had been saved because of people’s decisions never to smoke.
Dr. Auerbach was born in Manhattan and never graduated from high school or college. He began college after taking entrance tests to New York University, then left to enter the New York Medical College in Manhattan, where he got his medical degree in 1929. He worked briefly at Sea View Hospital, a city-run tuberculosis center, and at Halloran Hospital, both on Staten Island, in the 1930s and 1940s. From 1952, he held several positions at the Veterans Administration hospital in East Orange, including senior medical investigator, a title he held at the time of his death. He also taught pathology at New York Medical College for 12 years.
Still smoking
I was fascinated to learn that Dr. Auerbach’s results linking an increased incidence of lung cancer in smoking beagles was first publicly presented, not in a scientific forum, but at an American Cancer Society press conference held at the Waldorf Astoria in 1970. Widespread media coverage ensued, although the results did not hit the medical literature until the next year, seven years after that fateful medical school pathology lecture, which included materials on the dogs.
Oddly enough, Dr. Auerbach’s findings did not stop one of my other pathology professors from smoking, which he did regularly while lecturing. In all my years as a clinical oncologist, I have never heard a patient say that he wished he hadn’t smoked. (I wonder how much extra carbon dioxide is put into the atmosphere by the world wide burning of tobacco.) No wonder it is so hard to convince “the man on the street” of the Surgeon General’s warning!
My patient never heeded it.
Arthur Topilow, MD, is in private practice at Atlantic Hematology & Oncology in Manasquan, N.J.