EDITORIALS
pre-market testing of "use-effectiveness" (a comparison of results read by women doing the test at home per instructions in the package with results read by a trained technologist) can and should be applied before such a test is released for over-the-counter sale. 3. False negatives can occur although rarely (as would be true with any test). However, if the pregnancy is a normal one, the falsity of the test will soon be evident. If it is an ectopic pregnancy or a threatened abortion (which may give false negatives) it seems doubtful that the false result would alter the behavioral course or outcome that would have occurred if the over-the-counter sale had not been made. Furth-ermore, appropriate labeling, which should advise both repeat testing and health care regardless of test result and should spell out the cautions and the meaning of false negatives, could well motivate more appropriate health behavior than would have occurred if the sale had been prohibited (whether the pregnancy is normal or abnormal). 4. False positives can occur although rarely (as would be true with any test). However, it must be assumed that the test would be repeated by the care provider before undertaking a legal abortion or initiating ante-natal care. 5. Finally, there are a series of arguments such as those of encouraging illegal abortions or asserting that any woman who questions whether or not she is pregnant should be counseled at the same time that she is tested. These are debatable points but given the holes in the health care system and the stigma attached to unwanted pregnancies one might
question whether the availability of over-the-counter sales would have any effect upon the current delivery status of either illegal abortions or counseling services. One might also speculate about the vested interests of those who raise such arguments. The outcome of this dialectic appears to support the view that over-the-counter sales of pregnancy tests of proven effectiveness and "use-effectiveness" are justified now, in the U.S.A. However, this Editor can claim no special familiarity with pregnancy testing, much less expertise in the field. The intent of the exercise was to raise the issue for debate and resolution in public, professional, and bureaucratic forums. One wonders why it has lain fallow for so long. Responsible professional groups have not addressed the issue. The manufacturers have initiated no action. There are no outcries from the women's liberation movement, the free clinics, the women's clinics, or the neighborhood samaritans who have used these simple tests for many years (on prescription of a friendly physician). Isn't it about time for someone to pick up the ball and move?
ALFRED YANKAUER, MD REFERENCES 1. Greenberg, D. S. The FDA Investigates Itself. New Eng. J. Med. 21:1157, 1975. 2. Pregnancy Tests-The Current Status. Pop. Reports, Series J, No. 7, Nov., 1975. Dept. Medical and Public Affairs, George Washington University Medical Center, Washington, D.C.
The Cigarette Smoking/Lung Cancer Hypothesis The persistent controversy regarding the role of smoking in lung cancer cannot be resolved merely by escalating the force of arguments pro and con. That these arguments are becoming increasingly sophisticated and more vigorous serves to demonstrate that the issue is hardly trivial. Let us, therefore, carefully examine the nature of the problems we confront and seek to identify means of approaching them in the best interests of both the scientific community and the general population. In a recent issue of this Journal, Sterling's critique of American Cancer Society and other studies challenged the apparent association between cigarette smoking and lung cancer.' In addition to insisting that uncontrolled selective factors bias the ACS findings, Sterling cited a number of epidemiologic observations which presumably cast doubt on the importance of smoking in the etiology of lung cancer. He emphasized that these observations demand further appraisal of current evidence about environmental and industrial factors in the complex causal web of cancer. Only by the most careful reading of Sterling's article can one avoid the impression that cigarette smoking should be discounted as a contribuiting cause in lung cancer. In the same issue of the Journal, however, Weiss states that 132
"... the evidence in favor of the smoking-lung cancer hypothesis is overwhelming."2 With reference to studies not included in Sterling's survey, Weiss cites further support for the smoking-lung cancer hypothesis: "No matter where we look, the association is consistent, strong, and specific. . ." In this month's issue of the Journal two communications constitute additional rebuttals to Sterling's charges of spuriousness.3 Sterling's reply to these communications also appears.5 Clearly, there is substantial interest in this debate, and the publication of this series of papers is intensely provocative-although more of heat than light! Study of the arguments from all sides reveals some common ground upon which we might proceed more dispassionately. While debating the relative importance of smoking, we, can, nevertheless, agree that cigarette smoking is at least included in the array of causal factors. A concern for appropriate public health policies and activities relevant to smoking and cancer follows from this agreement. Continued divisiveness around the precise contribution of smoking has potentially two tragic consequences for policy. On the one hand, to insist that smoking independently accounts for lung cancer is to construct an obstacle to future investigations and reappraisals of environmental carcinoAJPH February, 1976, Vol. 66, No. 2
EDITORIALS
gens. On the other hand, there can be no question that widespread cessation of smoking would result in more good than harm. To dilute the importance of smoking is to foolishly divert us from an important goal. The precise degree to which smoking may be indicted in occurrences of lung cancer cannot be determined at present. In his discussion of the difficulties inherent in estimating the magnitude of a causal relationship, Greenberg6 shows that in simply choosing relative or attributable risk, one distorts the measurement of effect. Surely we have a professional and humanitarian responsibility to cease bickering in an area where currently available investigative strategies and analytic techniques preclude any precise determination. Why must this paralyze policy planning? Can we not concede that experimental proof will not be forthcoming, that new observational studies cannot greatly enlighten us? Since we do not expect to know the exact position which smoking occupies in the causal network of cancer, how much longer can we postpone action? Weighing the consequences of action choices, we can refer to Greenberg's decision model6 in which the degree of proof needed to recommend an action increases with the severity of consequences following a wrong decision. This kind of analysis leads us to accept present evidence for promoting campaigns to discourage smoking. It also emphasizes predictable requirements for more stringent evidence about the' merits of more potent policies. To act now at the first level of intervention can simultaneously clarify our subsequent interventive policy goals. Our wisest course, then, is to move simultaneously in three
directions: 1. The promotion of antismoking campaigns;
I
2. The conduct of carefully designed community-based intervention trials to estimate the impact of cessation of smoking on health states; and 3. The conduct of carefully designed studies, and perhaps reanalysis of existing ones, in order to elucidate accurately the role of environmental and industrial factors. In short, we must not continue evading action in favor of argument. We possess both sufficient empiric grounds and a strong moral obligation to proceed from where we are, through conscientious intervention programs and creative environmental studies, toward refining our understanding of lung cancer etiology.
MICHEL A. IBRAHIM, MD, PHD Dr. Ibrahim, Chairman of the Journal's Editorial Board, is Professor of Epidemiology, University of North Carolina, Chapel Hill 27514.
REFERENCES 1. Sterling, T. D. A Critical Reassessment of the Evidence Bearing on Smoking as the Cause of Lung Cancer. Am. J. Public Health 65(9):939-955, 1975. 2. Weiss, W. Smoking and Cancer: A Rebuttal. Am. J. Public Health 65(9):954-955, 1975. 3. Bross, I. D. J. Commentary, Am. J. Public Health, 66:161, 1976. 4. Higgins, I. T. T. Commentary, Am. J. Public Health, 66:159161, 1976. 5. Sterling, T. D. Commentary, Am. J. Public Health, 66:161-164, 1976. 6. Greenberg, B. G. Problems of Statistical Inference in Health with Special Reference to the Cigarette Smoking and Lung Cancer Controversy. J. American Statistical Association 65:739-758, 1969.
ABORTION SYMPOSIUM SPONSORED BY U. OF TENNESSEE
A National Symposium on Abortion will be held on March 5-7, 1976 in Knoxville, Tennessee, at the Hyatt Regency Hotel. The symposium is sponsored by the University of Tennessee Departments of Non-Credit Programs and Educational Psychology, and the Volunteer Medical Clinic. The target audience include-s physicians, attorneys, abortion clinic personnel, psychologists and social service agencies. Workshop subjects will include Administration and Funding of Clinics, Legal Responsibilities of Clinics, Advanced Techniques of Pregnancy Termination, Malpractice, and Birth Control Update. Direct inquiries relating to the conference to: Tina Sieg, Volunteer Medical Clinic, 313 Concord Street, Knoxville, TN 37919; direct inquiries relating to registration for the conference to: Department of Non-Credit Workshops and Programs, University of Tennessee, 1629 Melrose Avenue, Knoxville, TN 37916.
AJPH February, 1976, Vol. 66, No. 2
133
pre-market testing of "use-effectiveness" (a comparison of results read by women doing the test at home per instructions in the package with results read by a trained technologist) can and should be applied before such a test is released for over-the-counter sale. 3. False negatives can occur although rarely (as would be true with any test). However, if the pregnancy is a normal one, the falsity of the test will soon be evident. If it is an ectopic pregnancy or a threatened abortion (which may give false negatives) it seems doubtful that the false result would alter the behavioral course or outcome that would have occurred if the over-the-counter sale had not been made. Furth-ermore, appropriate labeling, which should advise both repeat testing and health care regardless of test result and should spell out the cautions and the meaning of false negatives, could well motivate more appropriate health behavior than would have occurred if the sale had been prohibited (whether the pregnancy is normal or abnormal). 4. False positives can occur although rarely (as would be true with any test). However, it must be assumed that the test would be repeated by the care provider before undertaking a legal abortion or initiating ante-natal care. 5. Finally, there are a series of arguments such as those of encouraging illegal abortions or asserting that any woman who questions whether or not she is pregnant should be counseled at the same time that she is tested. These are debatable points but given the holes in the health care system and the stigma attached to unwanted pregnancies one might
question whether the availability of over-the-counter sales would have any effect upon the current delivery status of either illegal abortions or counseling services. One might also speculate about the vested interests of those who raise such arguments. The outcome of this dialectic appears to support the view that over-the-counter sales of pregnancy tests of proven effectiveness and "use-effectiveness" are justified now, in the U.S.A. However, this Editor can claim no special familiarity with pregnancy testing, much less expertise in the field. The intent of the exercise was to raise the issue for debate and resolution in public, professional, and bureaucratic forums. One wonders why it has lain fallow for so long. Responsible professional groups have not addressed the issue. The manufacturers have initiated no action. There are no outcries from the women's liberation movement, the free clinics, the women's clinics, or the neighborhood samaritans who have used these simple tests for many years (on prescription of a friendly physician). Isn't it about time for someone to pick up the ball and move?
ALFRED YANKAUER, MD REFERENCES 1. Greenberg, D. S. The FDA Investigates Itself. New Eng. J. Med. 21:1157, 1975. 2. Pregnancy Tests-The Current Status. Pop. Reports, Series J, No. 7, Nov., 1975. Dept. Medical and Public Affairs, George Washington University Medical Center, Washington, D.C.
The Cigarette Smoking/Lung Cancer Hypothesis The persistent controversy regarding the role of smoking in lung cancer cannot be resolved merely by escalating the force of arguments pro and con. That these arguments are becoming increasingly sophisticated and more vigorous serves to demonstrate that the issue is hardly trivial. Let us, therefore, carefully examine the nature of the problems we confront and seek to identify means of approaching them in the best interests of both the scientific community and the general population. In a recent issue of this Journal, Sterling's critique of American Cancer Society and other studies challenged the apparent association between cigarette smoking and lung cancer.' In addition to insisting that uncontrolled selective factors bias the ACS findings, Sterling cited a number of epidemiologic observations which presumably cast doubt on the importance of smoking in the etiology of lung cancer. He emphasized that these observations demand further appraisal of current evidence about environmental and industrial factors in the complex causal web of cancer. Only by the most careful reading of Sterling's article can one avoid the impression that cigarette smoking should be discounted as a contribuiting cause in lung cancer. In the same issue of the Journal, however, Weiss states that 132
"... the evidence in favor of the smoking-lung cancer hypothesis is overwhelming."2 With reference to studies not included in Sterling's survey, Weiss cites further support for the smoking-lung cancer hypothesis: "No matter where we look, the association is consistent, strong, and specific. . ." In this month's issue of the Journal two communications constitute additional rebuttals to Sterling's charges of spuriousness.3 Sterling's reply to these communications also appears.5 Clearly, there is substantial interest in this debate, and the publication of this series of papers is intensely provocative-although more of heat than light! Study of the arguments from all sides reveals some common ground upon which we might proceed more dispassionately. While debating the relative importance of smoking, we, can, nevertheless, agree that cigarette smoking is at least included in the array of causal factors. A concern for appropriate public health policies and activities relevant to smoking and cancer follows from this agreement. Continued divisiveness around the precise contribution of smoking has potentially two tragic consequences for policy. On the one hand, to insist that smoking independently accounts for lung cancer is to construct an obstacle to future investigations and reappraisals of environmental carcinoAJPH February, 1976, Vol. 66, No. 2
EDITORIALS
gens. On the other hand, there can be no question that widespread cessation of smoking would result in more good than harm. To dilute the importance of smoking is to foolishly divert us from an important goal. The precise degree to which smoking may be indicted in occurrences of lung cancer cannot be determined at present. In his discussion of the difficulties inherent in estimating the magnitude of a causal relationship, Greenberg6 shows that in simply choosing relative or attributable risk, one distorts the measurement of effect. Surely we have a professional and humanitarian responsibility to cease bickering in an area where currently available investigative strategies and analytic techniques preclude any precise determination. Why must this paralyze policy planning? Can we not concede that experimental proof will not be forthcoming, that new observational studies cannot greatly enlighten us? Since we do not expect to know the exact position which smoking occupies in the causal network of cancer, how much longer can we postpone action? Weighing the consequences of action choices, we can refer to Greenberg's decision model6 in which the degree of proof needed to recommend an action increases with the severity of consequences following a wrong decision. This kind of analysis leads us to accept present evidence for promoting campaigns to discourage smoking. It also emphasizes predictable requirements for more stringent evidence about the' merits of more potent policies. To act now at the first level of intervention can simultaneously clarify our subsequent interventive policy goals. Our wisest course, then, is to move simultaneously in three
directions: 1. The promotion of antismoking campaigns;
I
2. The conduct of carefully designed community-based intervention trials to estimate the impact of cessation of smoking on health states; and 3. The conduct of carefully designed studies, and perhaps reanalysis of existing ones, in order to elucidate accurately the role of environmental and industrial factors. In short, we must not continue evading action in favor of argument. We possess both sufficient empiric grounds and a strong moral obligation to proceed from where we are, through conscientious intervention programs and creative environmental studies, toward refining our understanding of lung cancer etiology.
MICHEL A. IBRAHIM, MD, PHD Dr. Ibrahim, Chairman of the Journal's Editorial Board, is Professor of Epidemiology, University of North Carolina, Chapel Hill 27514.
REFERENCES 1. Sterling, T. D. A Critical Reassessment of the Evidence Bearing on Smoking as the Cause of Lung Cancer. Am. J. Public Health 65(9):939-955, 1975. 2. Weiss, W. Smoking and Cancer: A Rebuttal. Am. J. Public Health 65(9):954-955, 1975. 3. Bross, I. D. J. Commentary, Am. J. Public Health, 66:161, 1976. 4. Higgins, I. T. T. Commentary, Am. J. Public Health, 66:159161, 1976. 5. Sterling, T. D. Commentary, Am. J. Public Health, 66:161-164, 1976. 6. Greenberg, B. G. Problems of Statistical Inference in Health with Special Reference to the Cigarette Smoking and Lung Cancer Controversy. J. American Statistical Association 65:739-758, 1969.
ABORTION SYMPOSIUM SPONSORED BY U. OF TENNESSEE
A National Symposium on Abortion will be held on March 5-7, 1976 in Knoxville, Tennessee, at the Hyatt Regency Hotel. The symposium is sponsored by the University of Tennessee Departments of Non-Credit Programs and Educational Psychology, and the Volunteer Medical Clinic. The target audience include-s physicians, attorneys, abortion clinic personnel, psychologists and social service agencies. Workshop subjects will include Administration and Funding of Clinics, Legal Responsibilities of Clinics, Advanced Techniques of Pregnancy Termination, Malpractice, and Birth Control Update. Direct inquiries relating to the conference to: Tina Sieg, Volunteer Medical Clinic, 313 Concord Street, Knoxville, TN 37919; direct inquiries relating to registration for the conference to: Department of Non-Credit Workshops and Programs, University of Tennessee, 1629 Melrose Avenue, Knoxville, TN 37916.
AJPH February, 1976, Vol. 66, No. 2
133
