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85
CHAPTER 2

 

Smoking and Chronic Bronchopulmonary
Diseases (Non-neoplastic)

CONTENTS
Page
Introduction__._---------------------------------------- 89
Chronic Bronchopulmonary Disease Mortality ---__-_.------ 90
Chronic Bronchopulmonary Disease Morbidity - .-_...------ 96
Studies Relating Smoking to Respiratory Symptoms-__.- 96
Studies Relating Smoking to Pulmonary Function_--- --_- 99
Relation of Smoking to Heredity or to Constitutional Factors._. 101
Pathology Studies--------------------------------------- T04
Animal Experiments------------------------------------- 106
Ciliatoxic Effects of Cigarette Smoke-_.__-___-__---------- 107
Other Factors Associated with Chronic Bronchitis or Em-
physema or Both_--.-_---.------------------------------ 108
Additional Considerations Regarding Smoking and Em-
physema_-___------------------------------------- 110
Cited References......_.__------------------------------- 111
Sapplemental References-_--_------------------------------ 117

271-304 O—67——7 87
INTRODUCTION

Purpose or THs Rerort

This report reviews additional pertinent data relative to smoking
and chronic bronchopulmonary diseases—specifically chronic bron-
chitis and pulmonary emphysema.

The reader is referred to the Surgeon General’s 1964 Report (68)
and recent textbooks for background information on the chemistry of
tobacco smoke, the metabolism and toxicity of specific components
of tobacco smoke, the physics of its retention in the air passages and
the lungs, and the mechanics of pulmonary function.

DEFINITIONS

The scope of this chapter will be limited to emphysema and chronic
bronchitis and it may be useful to present definitions of both terms.
There have been many definitions of chronic bronchitis and emphy-
sema. Those used in the Surgeon General’s 1964 Report had been pro-
posed by the American Thoracic Society in 1962 (37). With the in-
creasing public health interest in chronic bronchopulmonary disease,
attempts have been made to develop precise definitions to categorize
these diseases and to isolate them satisfactorily from other pulmonary
conditions. A task force sponsored by the Chronic Respiratory Dis-
eases Control Program of the Public Health Service and the National
Tuberculosis Association deliberated this together with related prob-
lems for a week in October 1966. They adopted the following
definitions (72) :

“Chronic bronchitis is a clinical disorder characterized by excessive
mucous secretion in the bronchial tree. It is manifested by chronic or
recurrent productive cough. The diagnosis of chronic bronchitis can
be made only if other bronchopulmonary or cardiac disorders are ex-
cluded as the cause for these symptoms. The predominant pathologic
change is hypertrophy and hyperplasia of the mucous secreting glands
in the trachea and bronchi.

Pulmonary emphysema is an anatomic alteration of the lung
characterized by destruction of alveolar walls accompanied by abnor-
mal enlargement of the air spaces distal to the terminal, nonrespira-
tory bronchiole.”

These definitions will be used to describe chronic bronchitis and
emphysema as understood in the present report. They are being used

89
to emphasize the lack of progress in defining the two conditions for
purposes of differentiating them from other diseases of the lung. Ref.
erence may be made to the Surgeon General’s 1964 Report where near-
ly identical definitions will be found.

Inability to distinguish between chronic bronchitis and emphysema
has hampered medical research and exchange of information. The
P.H.S.—-N.T.A. task force report states further :

“Although patients having only chronic bronchitis tend to have
more cough and sputum than do those having only pulmonary emphy-
sema, the array of symptoms, physical findings, and pulmonary
physiologic abnormalities are similar in both diseases.

“Chronic bronchitis and emphysema coexist in many patients * * *”

This statement may help to explain some of the difficulties encoun-
tered by research workers in studying these diseases and why the re-
searchers are limited to describing symptoms and signs observed in the
populations under investigation. It may also explain why it is diffi-
cult to distinguish these conditions in the present report which seeks
to record the research findings related to smoking and chronic respira-
tory disease published since the Surgeon General’s 1964 Report. Re-
search findings on both diseases are not considered separately in this
report but are grouped in population studies, pathology studies, and
animal experiments. Additional considerations pertinent to pul-
monary emphysema are then provided.

CHRONIC BRONCHOPULMONARY DISEASE
MORTALITY ?

Mortality from chronic bronchopulmonary diseases has continued
the upward trend well established at the time of publication of the
conclusions cited in the Surgeon General’s 1964 Report. Deaths in the
United States from emphysema or chronic bronchitis or both have
risen steadily from about 3,000 in 1950 to more than 20,000 in 1964,
as can be seen in table 1.

TaBLE 1.—Mortality from emphysema and/or chronic bronchitis (ISC
codes 601, 602, 527.1) ,

 

 

Year Number Year Number Year Number

of deaths of deaths of deaths
1964_____-... 20, 208 || 1959___.____. 10, 433 |} 1954.--_--__- 4, 877
1963_---_.--. 19, 443 |} 1958_...__._- 9, 328 || 1953...------ 4, 657
1962__-._-.-. 15, 915 || 1957_._-___._- 8, 186 || 1952._------- 3, 846
1961_._-__---.- 13, 302 |} 1956..-..___- 6, 535 |) 1951..---__.- 3, 660
1960__-_._._. 12,426 || 1955_..._____ 5, 616 || 1950_..-.-_-. 3, 157

 

 

 

 

 

 

 

 

Source: Vital Statistics of the United States, 1950-1964 (70).

* All death rates throughout this chapter are per 100,000 population, unless
otherwise indicated.

90
The increase and aging of the population during the same period
does not account for this rise. Age-adjusted mortality rates for emphy-
sema without mention of chronic bronchitis increased about ten times
for men, from 1.3 per 100,000 in 1950 to 12.6 in 1964. A similar, al-
though perhaps somewhat less dramatic, increase occurred among
women, from 0.2 per 100,000 in 1950 to 1.6 in 1964, Death rates from
chronic bronchitis rose less precipitously, doubling during the same
period (69, 70). How much of this increase is the result of improved
diagnosis of these diseases and how much the result of a true change
in mortality patterns cannot be determined at the present time. Asso-
ciations have been demonstrated between these conditions and
smoking.

PorvunaTion STUDIES

Included in this broad category are investigations that collected
‘nformation from a group or groups of persons either by a series of
questions, by some form of physical examination, or by a review of
recorded data such as hospital records and death certificates.

Prospective STUDIES

In the Surgeon General’s 1964 Report, findings from seven prospec-
tive studies were presented, Additional data have been reported from
four of these investigations in the past 3 years. Information relevant
to smoking and chronic respiratory disease will be summarized here.

The study of mortality among policyholders of U.S. Government
Life Insurance policies available to persons who served in the Armed
Forces between 1917 and 1940 was initiated in 1952. Almost all the
293,658 policyholders were white males. Recently Kahn (44) pub-
lished a report that included all deaths from July 1954 through De-
cember 1962, a period of 814 years.

The relation of cigarette smoking to death from bronchitis and
emphysema is presented by mortality ratios in table 2 and by specific
risk of mortality in table 2A. Given the definitions previously cited,
these tables also illustrate the difficulties in separating these diseases.
The first row of table 2 gives combined mortality ratios and the next
two rows give the same data in an attempt to delineate the specific dis-
eases, Mortality ratios are given by the number of cigarettes smoked
per day at the time the men were enrolled in the study. Mortality
from these diseases is much higher among cigarette smokers than
among those who never smoked and rises with the number of ciga-
rettes smoked daily. The ratios are much higher for emphysema alone
than for chronic bronchitis with or without mention of emphysema.

A similar study of veterans was begun in Canada in 1955. Answered
questionnaires were returned by nearly 78,000 men whose subsequent
mortality for a period of 6 years was recently analyzed by Best and

91
his associates (12). Deaths from chronic bronchitis and emphysema
have been summarized in table 3 which gives mortality ratios by
the number of cigarettes smoked each day. Here, again, the mortality
is much higher among smokers and is directly related to the number
of cigarettes smoked. The mortality ratios reported for both diseases
combined are similar to those reported for the U.S. Veterans study,

TABLE 2.— Age-adjusted mortality ratios Jor current smokers of cigarettes
only, by number of cigarettes smoked daily

Cigarettes smoked per day at entrance to study

Cause of death Occasion

never 19 10-20 21-30 +
smoked

 

 

 

Bronchitis or emphysema or both (500-502,

527.1)_..------- 2, 1.0 4.6; 10.0 | 11.8 18,2
Bronchitis with or without emphysema

(500-502). 1.0 3.6 4.5 4.6 8.3
Emphysema (527.1).-___.-.__.____.._. 1.0; 5.3) 14.0] 17.0] 25.3

 

 

 

 

 

 

Sounce: U.S. Veterans study (44).

TaBLe 2A.—Age-specific annual probabilities of death per 100,000
person-years, for current smokers of cigarettes only

 

 

 

Cigarettes smoked per day at entrance to study
Occasional ” 0 All
eld] 19 10-20 21 + | quantities
Chronic bronchitis and/or
emphysema:
Age 55 to 64_____________ 2 12 32 30 39 29
Age 65 to 74..___________ 10 66 100 141 322 113
Chronic bronchitis:
Age 55 to 64... 2-228. 1 5 5 5 5 4
Age 65 to 74... _____ 5 15 22 30 46 23 .
Emphysema without
bronchitis:
Age 55 to 64__-___________ 1 7 27 26 34 25
Age 65 to 74_.__________e 5 52 78 111 276 90

 

 

 

 

 

 

 

1 Annual probabilities of death at each single year of age were combined into 10-year age groups by using
weights proportional to the distribution of the U.8. male Population in 1960. Not shown if less than 50
berson-years of observation at any single year of age in the 10-year interval.

Source: U.S. Veterans study (44).

When the two diseases are separated, the ratios for emphysema in the
Canadian study are similar to those for chronic bronchitis in the
U.S. study, and the ratios for chronic bronchitis are similar to those
attributed to emphysema in the United States. This illustrates the

92
problems of definition and one of the difficulties of direct comparison
between studies, especially when different countries are involved.

TaBLE 3.—Age-adjusted mortality ratios for smokers of cigarettes only
by number of cigarettes smoked daily

 

Cigarettes smoked per day at entrance to
study
Cause of death

 

 

 

Non | 19 10-20 | 21+
smokers
Bronchitis or emphysema or both. ------------- 1.0; 6.1! 410.0! | 10.4!
Bronchitis with or without emphysema (500-502) _ 1.0} 7.0 |13.7 14.6
Emphysema (527.1)_._--.-------------------- 1.0| 4.8 6.1 6.9

 

 

 

 

1 Calculated from (12).
Source: Canadian Pensioners study (/2).

A study among British physicians, the first of the large prospective
studies, was started in 1951 with the sending of a short questionnaire
to the 59,600 registered physicians then resident in the United King-
dom. Usable replies were received from 34,455 men and 6,192 women.
Ten years of observation of mortality in relation to smoking was
recently reported for this population by Doll and Hill (29, 30). Their
findings on mortality from chronic bronchitis as related to smoking
included emphysema and are given in table 4. Only the standardized
death rates were presented in the report but the mortality ratios have
been calculated from them to offer an easier comparison with the
other two studies. Again, it is clear that mortality from these combined
diseases (no attempt was made to differentiate them in the published
report) is strongly and directly related to the amount of cigarette
smoking.

TaBLE 4.—Standardized death rates, per 100,000 population, for
bronchitis and emphysema for male smokers of cigarettes only, by
number of cigarettes smoked daily

 

 

 

 

Cigarettes smoked per day at entrance to study
Cause of death
Never 1-14 15-24 25+
smoked
Bronchitis (including emphysema—502,
527.1)... ie e----------- 5 34 64 106
Mortality ratios_......._.....---..----- 1.0 6.8 12.8 21.2

 

 

 

 

 

SOURCE: Study of British Physicians (29, 30).

93
The fourth of the prospective studies is the largest. More than 1
million men and women living in 25 States were enrolled in this
investigation in late 1959 and early 1960. A report of the first 4 years
of observation was published recently by Hammond (36) and mor.
tality from emphysema and chronic bronchitis as related to smoking
is given in table 5. A slight departure from the usual assignment of
cause of death should be mentioned. When the cause of death was listed
as chronic bronchitis with emphysema, it was combined with emphy.-
sema alone. For this reason, the cause of death in table 5 is not quite
the same as any of the causes listed in the other tables. Again, it is
clear that mortality from these entities is related to smoking for both
men and women. This was the only one of the four studies wit enough
women enrolled to provide meaningful data.

TABLE 5.—Mortality ratios for deaths due to emphysema and bronchitis
with emphysema for cigarette smokers—men and women in 2 age
groupst

 

Men (age in years) Women (age in years)

 

 

Cause of death
45-64 65-79 45-04 65-79
Emphysema and bronchitis with emphy-
sema (502, 527.1)_....- 2-08 6.5 11.4 4.9 7.61

 

 

 

 

 

t Mortality ratios of nonsmokers in the above categories are 1.00 by definition.
' Calculated from (36). :

Source: Hammond, E. C. ($6).

Before summarizing the data presented from these four investiga-
tions, two further points should be made. Excessive mortality was
largely confined to cigarette smokers. The mortality ratio for chronic
bronchitis and emphysema, for pipe and cigar smokers combined, in
the U.S. veterans study, was only 0.99; in the Canadian study it was
about 1.6 (based on only nine deaths) ; in the study of men from 25
States it was 1.37; and among British doctors the standardized death
rate was 15 (compared with five among nonsmokers). Whatever may
be the relationship of pipe and cigar smoking to chronic bronchitis
and emphysema, it is clear that it is substantially less important than
the relationship of cigarette smoking.

In two of these studies, stopping cigarette smoking is seen to have
an effect on subsequent mortality from chronic bronchitis and emphy-
sema. In the course of the followup of the British physicians
(29, 30) it was possible to estimate the number of years a man con-
tinued smoking after he had answered the initial questionnaire. For
chronic bronchitis the mortality rates at first increased after cessation
of smoking and later fell well below the rate for men who continued
to smoke. The death rate from chronic bronchitis, per 100,000

94.
ex-smokers of 5 years or more was 37 compared with a rate of 59 for
all other smokers. Similarly, in the study of U.S. veterans, the mor-
tality ratio for chronic bronchitis and emphysema was 10.1 for all
male current cigarette smokers but only 7.6 for men who had stopped
smoking for reasons other than “Doctor’s orders.”

RerrosPective STUDIES

Wicken (75) made a study of lung cancer and bronchitis mortality
in Northern Ireland. During the 3 years, 1960-62, a total of 1,262 men
and 630 women, aged 35 years or more, were certified as having died
of bronchitis. For each of these persons a control was selected—the
next person in the Register of the same sex and 5-year age group who
last resided in the same area and who died of a nonrespiratory illness.
Personal interviews with relatives of the decedents were carried out
for about 94 percent of the subjects and controls to determine the
decedents’ smoking habits. In addition, a random sample of about
1,500 households in Northern Ireland was selected and one member of
each household was interviewed to obtain details of the age, sex, smok-
ing habits, and other information on all adult members. This informa-
tion on all adult members was used to define the adult population of
Northern Ireland in order to calculate death rates.

Bronchitis mortality for both men and women was associated with
smoking and directly related to the number of cigarettes smoked daily,
as seen in table 6. ‘

TABLE 6.—Age-standardized death rates per 100,000 population from
bronchitis for adults 35 years old and over as related to smoking habits

 

 

 

Number of cigarettes smoked daily Smoker of-—
Nonsmoker Cigarettes, Pipes or
1-10 11-22 B+ Pp or cigars
cigars
Men__.-| (124)! 64 |(245) 189 |(300) 220 |(168) 284 (62) 99 | (289) 118
Women._| (490) 58 | (57) 77 | (20) 118 | (15) 201 |.--------- (2) 165

 

 

 

 

 

 

1 Figures in parentheses show the number of deaths upon which the rates are based.
Sovgce: Wicken study (76).

Using these data, Wicken applied the bronchitis death rates observed
among male non-smokers to all the male population of Northern Ire-
land and estimated that had these rates prevailed, only 45 percent of
the male deaths from bronchitis would have occurred.

RésumME

_ Recent data from the four prospective studies and the one retrospec-
tive study all reveal, for men, an association between cigarette smok-

95
ing and mortality from bronchitis and emphysema. All report an
increasing gradient of mortality with an increasing amount smoked,
This was also true among women although only one prospective study
and the retrospective study included enough women to permit calcula-
tion of death rates. Mortality was consistently higher among cigarette
smokers than among men who smoked pipes or cigars. These are
consistent associations that might be expected if there were a causal
relation between cigarette smoking and these diseases. In addition, if
such a relationship exists, cessation of smoking should be followed by
a reduction in mortality. This did occur in the two studies that in-
cluded information on changes in smoking habits.

These data, then, strongly support the conclusion that cigarette
smoking is at least one of the causes of chronic bronchitis and
emphysema.

CHRONIC BRONCHOPULMONARY DISEASE MORBIDITY
Srupres Retatinc Smoxine To Respmatory SyMPToMs

Most surveys of chronic respiratory disease are confined to the fre-
quency of signs or symptoms of disease. The National Center for
Health Statistics, however, in interviews from J uly 1964 to June 1965,
asked about certain chronic conditions including chronic bronchitis
and emphysema (72). This was asked in a national sample of 42,000
households containing about 134,000 persons. After answering ques-
tions about health for himself and other members of the household, the
respondent was asked questions about their smoking habits. A strong
relationship was found between smoking habits and the presence
of chronic bronchitis or emphysema or both. This is presented in
table 7.

TaBLE 7.—Age-adjusted prevalence rates of chronic bronchitis and/or
emphysema per 100 persons 17 years and over, by sex, and smoking
status—number of cigarettes per day (heaviest amount)

 

 

 

Present smokers
Never Former
smoked smokers
1-10 11-20 21+
Men._......_-._- 22-2 eee. 1.0 2.5 1.1 2.3 3.3
Women._._._.._---._-..._____- 1.2 2.6 1.6 4.0 6.5

 

 

 

 

 

 

Source: National Center for Health Statistics (72, Fig. 5).

96
In another study of the epidemiology of persistent cough, Wynder
(80) and his associates evaluated the smoking habits, occupation, and
residence (urban or rural) in a male population comprised of 315
hospital patients in New York, and 315 in California, and of 239
Seventh-Day Adventists living in California who were not hospital
patients. Persistent cough was reported from 23 percent of the Ad-
ventists (who do not smoke), 45 percent of the New York patients,
and 53 percent of the California patients. Coughing was more fre-
quently reported by cigarette smokers than by those who smoked pipes
or cigars, as shown in table 8. Inhalers also had a higher rate of
persistent cough and the rate of cough increased with smoking in each
age group. Wynder found no correlation between urban or rural resi-
dence and persistent cough. Analysis of the California group showed
a higher rate of persistent cough that was independent of the number
of cigarettes smoked.

Tapie 8.—Percent of men with persistent cough as related to smoking

 

 

 

 

 

 

habits
Ch
Non- | Pipes/ igarettes only Mixed
smoker | cigars smoker
1-10 | 11-20 | 20+
New York patients_---.---------- 14 33 45 46 67 51
California patients--..------------ 22 30 45 74 74 66
Seventh-Day Adventists_---------- 93 |.__--_|------|.-----|------]------

 

 

 

 

Source: Wynder, E. L. et al. (80).

Deane and her associates (28) studied symptoms in relation to smok-
ing in a group of about 500 outside telephone workers over age 40
working in the San Francisco and Los Angeles areas. Symptoms were
reported on a modified version of the British Medical Research Council
questionnaire. Regardless of the definition of the respiratory symp-
tom—persistent cough and phlegm, persistent cough, phlegm, and
shortness of breath—it was consistently experienced by a greater pro-
portion of those who currently smoked cigarettes than those who did
not.

Coates and his coworkers (20) also found among 1,584 postal work-
ers aged 40 or more (all employees of the Detroit Main Post Office),
that for every symptom—cough and phlegm, chronic phlegm alone,
wheezing, shortness of breath—the prevalence was two to three times
greater among moderate (15-24 cigarettes per day) and heavy (25 or
more) smokers than among those who did not smoke. These differences
in symptom prevalence were observed for both men and women but
“chronic bronchitis” was reported more often by men, which Coates
ascribes to their being heavier smokers. The prevalence of chronic

97
cough and phlegm among ex-smokers was no greater than in
nonsmokers.

Very few studies have been carried out to estimate the association of
morbidity and smoking in young people. Peters and Ferris (60) retro.
spectively tallied the number of visits to the clinic at the University
of Health Services for 1,623 Harvard students and 404 Radcliffe sty-
dents. Smoking information had been gathered on these students in
their freshman and senior years. Smokers made significantly more
visits to the clinic in total and for respiratory diseases in particular,
There was a positive correlation between years smoked and the num-
ber of respiratory disease visits.

In contrast to most studies which select population groups, Huhti
(43) studied virtually the entire population, age 40-64, in a commune
in western Finland. Although it was a mostly rural population, some
industrial workers were included. More than 95 percent of the men
and women invited responded to the survey. Questionnaires (based on
that of the British Medical Research Council) and medical examina-
tions were completed for 730 men and 890 women. Only 18.7 percent
of the men were nonsmokers and 21.6 percent ex-smokers, compared
with 86.1 percent nonsmokers and 3.6 percent ex-smokers among
women. Prevalence of both cough and phlegm production was signifi-
cantly higher among smokers than nonsmokers as seen in table 9.

TABLE 9.—Percent of men and women with cough (3 months in the year)
and with phlegm (3 months in the year), related to smoking habits

 

 

 

 

 

 

 

 

 

Cigarettes smoked per day
Non- Ex-
smokers | smokers
1-14 15-24 25+
Cough
Men__.__..---2-2--__ 31.5 40.8 42.4 4.1 8.5
Women-____.._.- 22 oe 10.4 | (8 of 7 women 4.5 13.3
smoking 15+
cigarettes/day)
Phiegm
Men_......__-. ee 38.0 42.9 42.4 10.7 17.7
Women_._.._-..__.-____. 10.4 | (4 0f 7 women 5.9 13.3
smoking 15+
cigarettes/day)
Source: Huhti, E. (48).
RéEsuME

In all the prevalence studies that have been identified and reviewed,
significantly more cigarette smokers consistently reported having
symptoms related to chronic respiratory disease. This was true for
cough, production of phlegm, wheezing, and shortness of breath. It

98
was also true when the respondents were asked not about symptoms
but about disease, that is, chronic bronchitis and emphysema, and in
one instance was reflected in the number of clinic visits for respiratory
diseases. Prevalence of these symptoms increased with the amount of
cigarettes smoked. It was less among pipe and cigar smokers, and ex-
cigarette smokers among whom the prevalence, in some reports, ap-
proached that of nonsmokers.

Srupres RELATING SMoKING To Putmonary Funcrion

Many of the surveys outlined in the previous section on respiratory
symptoms also included lung function tests as part of the examination.
Huhti (43), for example, in his Finnish study took chest. X-rays and
collected information on vital capacity, 1-second forced expiratory
volume (FEV;..) and peak expiratory flow (PEF) as shown in table
10.

Tapie 10!.—Mean values of lung function tests among men and women

 

 

 

by smoking hahits
Cigarettes smoked per day Non- Ex
smokers smokers
1-14 15-24 25+
FEV} (liters):
Men__-__.__-------------- 3.17 3. 30 3. 08 3. 46 3. 39
Women. -..--.--- jew e eee eee 2, 74 (?) ?) 2. 42 2. 32
FVC (liters):
Men.___..---.---.------- 4, 40 4.51 4, 26 4, 40 4,51
Women_-_-_.-------------- 3. 53 () @ 3. 18 3. 19
PEF (c.c./sec.):
Men_____..-------------- 518 537 517 569 551
Women. ...-.--..-------- 431 () (?) 410 403

 

 

 

 

 

 

1 Although this table presents data for all ages combined, the same differences were apparent in each
5-year age grouping.

2 Only 7 women smoked 15 or more cigarettes per day.

Sovxrce: Huhti, E. (43).

Among men the FEV, , value was lower for smokers than nonsmok-
ers. The PEF value was slightly lower, but the vital capacity was un-
related to smoking. In this study none of the values seemed to be clear-
ly related to the number of cigarettes smoked. Among the relatively
small number of female smokers in this study, most of whom smoked
between one and 14 cigarettes per day, almost all the lung function
values were better than in the female nonsmokers. Female smokers
were slightly taller in height and slightly lighter in weight than fe-
male nonsmokers, which may account for this finding. However, fe-
male ex-smokers had slightly reduced FEV. and PEF when compared

99
with female nonsmokers, similar to the relationship noted between
male ex-smokers and male nonsmokers.

Coates (20) observed no relation between smoking habits and vital
capacity or FEV... He did find, however, that the ratio of FEV,,/
VC was significantly lower among heavy smokers (25 or more ciga-
rettes per day) than nonsmokers. This was found for all but the old-
est group of workers, but here the number of subjects was small.

Peters and Ferris (69) asked 133 Harvard College seniors to com-
plete a questionnaire on respiratory symptoms and to perform some
sample tests of pulmonary functions. Of these, 124 responded. When
classified by smoking history, the smokers were found to record more
frequent cough, phlegm production, breathlessness, and wheezing with
or apart from colds. There was no difference in vital capacity be-
tween smokers and nonsmokers. Although the forced expiratory vol-
ume in 1 second (FEV;,.) was less for heavy smokers than nonsmok-
ers, this was not significant by itself. As a ratio of vital capacity this
did show a significant decrease. The air flow rate using the Wright
peak-flow meter and other flow rates determined from tracings of the
Stead-Wells spirometer (FRis%, FRso%, FRes%, FR.%) did show
statistically significant reductions in heavy smokers as compared to
nonsmokers, These data show that relatively young cigarette smokers
have some impairments of ventilatory function, in turn suggesting
the possibility of a rather immediate effect of cigarette smoking on
respiratory symptoms and ventilatory function.

A series of experiments has been done by Krumholz and his asso-
ciates (49, 50, 61) to evaluate cardiopulmonary function in young
apparently healthy persons. The first experiment (49) involved 18
house staff physicians ranging in age from 24 to 37 years. Nine had
smoked at least one pack of cigarettes a day for the preceding 5 years
and nine had not smoked for at least the same time period. Extensive
pulmonary function studies were done at rest and after exercise. The
smokers were found to have a greater oxygen debt after exercise, de-
creased diffusing capacity at rest and with exercise, and decreased
total lung capacity and vital capacity.

In the second Krumholz experiment (50) 10 young staff physicians,
all of whom had smoked at least one pack a day for 5 years, were given
pulmonary function tests immediately after and again 3 weeks after
abstinence from smoking. Six physicians refrained from smoking for
6 weeks and were tested again. After 6 weeks of no smoking, expira-
tory peak flow and pulmonary diffusing capacity were significantly
increased. Heart rate and oxygen debt after exercise were decreased.
After 6 weeks functional residual capacity was decreased and inspira-
tory reserve volume and maximal voluntary ventilation were
increased.

100