Public Health Classics

Public Health Classics
This section looks back to some ground-breaking contributions to public health, reproducing them in their originalform and adding a commentary on their significance from a modern-day perspective. To complement this month’s
theme of the Bulletin, Elisa Ong and Stanton A. Glantz review the 1981 paper by Takeshi Hirayama on the risk oflung cancer from passive smoking. The original paper is reproduced with permission from the British Medical
Journal.

Hirayama’s work has stood the test of time
Elisa Ong1 & Stanton A. Glantz2
In January 1981, Takeshi Hirayama published his
epidemiological study demonstrating that secondhand smoke increased the risk of lung cancer in nonsmoking Japanese women married to men who
smoked compared with non-smoking women married to non-smoking men (1). Hirayama is generally
credited with publishing the first evidence linking
passive smoking and lung cancer, though there were
two other studies published at about the same time,by Trichopoulos et. al (2) from Greece and Garfinkel(3) from the USA. While both studies showed anelevation in the point estimate of lung cancer riskassociated with passive smoking, Garfinkel’s study
did not reach statistical significance.
Moving well beyond its usual efforts to create
controversy about scientific studies that reachbothersome conclusions, the tobacco industry
responded with a multimillion-dollar advertising
campaign designed specifically to discredit Hirayama’s paper (4). The industry commissioned epidemiologist Nathan Mantel to write a critique and used
it, together with a cleverly worded description of the
Garfinkel study, to suggest that it disputed thepassive smoking–lung cancer connection, in advertisements that reached an estimated 80% of theAmerican population (5). This campaign wasparticularly cynical since it was run despite the factthat the industry’s own scientists, after reviewing
Hirayama’s work, concluded ‘‘Hirayama is a goodscientist and his non-smoking wives publication wascorrect’’ and ‘‘that Hirayama was correct, that TI[Tobacco Institute] knew it, and that TI published its

1

Research Fellow, Institute for Health Policy Studies, Cardiovascular
Research Institute, Department of Medicine, University of California,San Francisco, USA.

2

Professor of Medicine, Box 0130, Room 1317M, Universityof California, San Francisco, CA 94143, USA (tel: 415-476-3893;
fax: 415-476-2283; email: glantz@medicine.ucsf.edu).
Correspondence should be addressed to this author.
Ref. No. 00-0752

938# World Health Organization 2000

statement about Hirayama knowing that the work
was correct’’ (6, 7).
The British Medical Journal took note of thesepublic attacks and re-opened correspondence about
Hirayama’s paper to provide him with an opportunity
to respond in a scientific forum. The editors took theexceptional step of publishing Mantel’s criticisms,
which had been addressed to the Tobacco Instituteand not the British Medical Journal, nine months after
Hirayama’s paper was originally published (9, 10).
Hirayama and others demolished the criticisms (9, 10).
The campaign against Hirayama’s findings was
not limited to the United States. The tobacco industry
ran similar advertisements worldwide. In Australia,
the Australian Federation of Consumer Organizations took the Australian Tobacco Institute to court
for misleading advertising over these claims, and won
on the grounds that the advertisement was false andmisleading (11).
The controversy generated by the tobacco
industry attracted the attention of other epidemiologists who sought to see who was right. As a result,by 1986, 13 studies had been done on passive
smoking and lung cancer, and the evidence wasstrong and consistent enough for the US Surgeon
General to issue the first report dealing entirely withthe effects of passive smoking (12), which concluded that ‘‘involuntary smoking causes disease,including lung cancer, in healthy nonsmokers’’. A
few weeks later, the US National Academy ofSciences issued a similar report reaching the sameconclusion (13). Concerning anything other thantobacco, the issue would have been consideredclosed at that point.
As time passed, several independent scientificbodies around the world reviewed the evidence that
passive smoking causes lung cancer (and a widevariety of other diseases) and reached similar
conclusions (Table 1). These reports helped stimulate
the passage of clean indoor air ordinances, which not
only protect non-smokers from second-hand smoke
but also create an environment that makes it easier for
smokers to stop (14, 15).
Bulletin of the World Health Organization, 2000, 78 (7)Hirayama’s work has stood the test of time
Since publication of Hirayama’s original paper,
37 studies of passive smoking and lung cancer havebeen published (16). Yet, needless to say, the tobacco
industry continues to fight against the conclusion that
second-hand smoke causes lung cancer. Recently theInternational Agency for Research on Cancer (IARC)
published a study (17) similar to Hirayama’s andsupported the large body of evidence that secondhand smoke is a carcinogen (18). Years before theIARC report was published, however, the tobacco
industry organized a sophisticated campaign against
the study in an effort to prevent worldwide smoking
restrictions, with the same kinds of misrepresentations it used against Hirayama (19).
Almost two decades have passed since publication of Hirayama’s work and, despite the tobacco
industry’s best efforts, his conclusion that passive
smokingcauseslungcancerhasstoodthetestoftime. nTable 1. Risk of lung cancer in passive smokers: results of study by
Hirayama (1) confirmed by major international consensus reports
ReportYearCountry

Hirayama (1, 9, 10)
1–19 cigarettes a day20 cigarettes a day or more
US Environmental Protection
Agency (20)National Research Council (13)Surgeon General (12)California Environmental
Protection Agency (21)National Health and Medical
Research Council (22)Scientific Committee on
Tobacco and Health (23)

1981

Japan

Relative Confidenceriskintervala

1992

USA

1.61
2.08
1.19

1.09–2.39
1.39–3.11
1.01–1.39

1986
1986
1997

USAUSAUSA

1.34
1.53
1.20

1.18–1.53
nana

1997

Australia

1.32

1.10–1.69

1998

UK

1.20–1.30

naaAcknowledgement

Confidence intervals are two-tailed 95%, except US EPA which is one-tailed 95%(two-tailed 90%).

This work was supported by NCI Grant CA-61021.

na = not available.

References
1. Hirayama T. Non-smoking wives of heavy smokers have a higher
risk of lung cancer: a study from Japan. British Medical Journal,
1981, 282: 183–185.
2. Trichopoulos D et al. Lung cancer and passive smoking.
International Journal of Cancer, 1981, 27: 1–4.
3. Garfinkel L. Time trends in lung cancer mortality among
non-smokers and a note on passive smoking. Journal of
the National Cancer Institute, 1981, 66: 1061–1066.
4. Glantz S. Tobacco industry response to the scientific evidence
on passive smoking. In: Proceedings of the 12th World Conferenceon Tobacco and Health 1983, Winnipeg, Manitoba: 287–292.
5. Chilcote cites growing need for unified action. United States
Tobacco Journal, 8 May 1983.
6. Wells J, Pepples E. Re: Smoking and health — Tim Finnegan.
Brown and Williamson, 1981 (memorandum 24 July 1981
available at http://www.library.ucsf.edu/tobacco/docs/html/1825.01).
7. Barnes D et al. Environmental tobacco smoke. Journal ofthe American Medical Association, 1995, 274: 248–253.
8. Glantz S et al. The cigarette papers. Berkeley, Universityof California Press, 1996.
9. Non-smoking wives of heavy smokers have a higher risk oflung cancer: correspondence. British Medical Journal, 1981,
283: 1464–1466.
10. Non-smoking wives of heavy smokers have a higher risk oflung cancer: correspondence. British Medical Journal, 1981,
283: 914–917.
11. Tobacco litigation: AFCO v. TIA, the case against passive smoking.
Redfern, Australia, Legal Books, 1991.
12. US Department of Health and Human Services. The healthconsequences of involuntary smoking. Report of the SurgeonGeneral. Washington, DC, Public Health Service, 1986.
13. National Research Council. Environmental tobacco smoke.
Measuring exposures and assessing health effects. Washington,DC, National Academy Press, 1986.

Bulletin of the World Health Organization, 2000, 78 (7)14. Pierce J et al. Tobacco use in California. An evaluation of
the tobacco control program, 1989–1993. La Jolla, CA, Universityof California at San Diego, 1994: 170.
15. Chapman S et al. The impact of smoke-free workplaces
on declining cigarette consumption in Australia and the UnitedStates. American Journal of Public Health, 1999, 89 (7):1018–1023.
16. Hackshaw A, Law M, Wald N. The accumulated evidence onlung cancer and environmental tobacco smoke. British MedicalJournal, 1997, 315: 980–988.
17. Boffetta P et al. Multicenter case-control study of exposure
to environmental tobacco smoke and lung cancer in Europe.
Journal of the National Cancer Institute, 1998, 90: 1440–1450.
18. Blot W, McLaughlin JK. Passive smoking and lung cancer
risk: what is the story now? Editorial. Journal of the National
Cancer Institute, 1998, 90: 1416–1417.
19. Ong E, Glantz S. Tobacco industry efforts to subvert asecondhand smoke study by the International Agency for
Research on Cancer. Lancet, 2000: 355: 1253–1259.
20. US Environmental Protection Agency. Respiratory healtheffects of passive smoking. Lung cancer and other disorders.
Washington, DC, United States Environmental Protection
Agency, Office of Research and Development, 1992.
21. California Environmental Protection Agency. Healtheffects of exposure to environmental tobacco smoke. Oakland,
CA, California Environmental Protection Agency, 1997.
22. The health effects of passive smoking: a scientific information
paper. Canberra, National Health and Medical ResearchCouncil, 1997.
23. Report of the Scientific Committee on Tobacco and Health.
London, Scientific Committee on Tobacco and Health, 1998:
1253–1259.

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