Active Smoking
20. Evidence on the harmful effects of tobacco has
been accumulating since the end of the eighteenth century, most
notably in relation to cancer.[39]
A prize winning treatise in Germany in 1795 took as its title
"Carcinoma of the lip is most frequent when people indulge
in tobacco pipes".[40]
The first case-control study of lung cancer was conducted by F
H Müller in Cologne in 1939 who concluded that tobacco was
an important cause of lung cancer.[41]
By 1947 the increase in lung cancer deaths had become so pronounced
in the UK that the Medical Research Council held a conference
to discuss the reasons for it. Austin Hill was asked to conduct
a case-control study to test whether this trend was associated
with the increased consumption of cigarettes.
21. The association of smoking with vascular disease
occurred rather later. In 1908 L Buerger noted that a rare form
of vascular disease (subsequently called Buerger's disease) seldom
occurred in non-smokers. In 1931, F L Hoffman noted a statistical
correlation between the increasing number of reports of coronary
thrombosis and the increasing consumption of cigarettes.[42]
In 1940, F A Willius and J Berkson examined the records of 1,000
patients with the disease at the Mayo Clinic in Rochester Minnesota
and 1,000 other patients matched for sex and age and found an
association of smoking with coronary thrombosis.[43]
22. What Sir Richard Doll describes as a "watershed"
in the study of the epidemiology of smoking occurred in 1950 with
the publication of a series of case control studies.[44]
Two major papers were published, one by Richard Doll himself in
conjunction with Austin Hill and the other in the USA by E L Wynder
and E A Graham. These drew attention to the risk of lung cancer:
the American study concluded that "excessive and prolonged
use of tobacco, especially of cigarettes, seems to be an important
factor in the induction of bronchogenic cancer"; the British
study argued that "cigarette smoking is a factor, and an
important factor, in the production of carcinoma of the lung".[45]
In 1951 a long term study of the effects of smoking in British
doctors commenced. A questionnaire on smoking habits was distributed
to all doctors on the medical register and survivors have been
contacted regularly since 1957. The 40 year study published in
1994 and conducted by Sir Richard Doll and Sir Richard Peto showed
that 80% of non-smokers survived to age 70 and 33% to age 85,
whereas only 50% of heavy smokers survived to age 70 and 8% to
85. This led the authors to conclude: "It now seems that
about half of all regular cigarette smokers will eventually be
killed by their habit".[46]
23. Between 1952 and 1960 a series of huge North
American cohort studies were undertaken. These culminated in 1959
in the American Cancer Society Twenty Five State study which followed
a million subjects over five years and showed that "smokers
of cigarettes had a [lung cancer] death rate of 9.2 times the
rate for those who had never smoked".[47]
24. The Royal College of Physicians Report Smoking
and Health was published in 1962 to alert health professionals
to the dangers of smoking. This report concluded that cigarette
smoking is a cause of lung cancer and bronchitis and probably
contributes to the development of coronary heart disease and other
illnesses. In the USA, similar conclusions were drawn in the First
Surgeon General's Report on smoking and health in 1964.[48]
Passive smoking
25. In 1983 the Independent Scientific Committee
on Smoking and Health (ISCSH) referred to several reports relating
to the health risks of environmental tobacco smoke (ETS). In particular
they noted findings that children exposed to tobacco smoke from
their parents had an increased risk of respiratory illness and
that passive smoking exacerbated symptoms in adults already suffering
from coronary and other arterial diseases.[49]
The tentative connection between ETS and lung cancer was explored
in more detail by the same committee in its Fourth Report in 1988.
It concluded that there was "an increase in the risk of lung
cancer from exposure to ETS in the range of 10-30 per cent"
(that is, people who had been exposed to ETS for most of their
lives had a 10% to 30% higher risk of lung cancer than non-smokers
who were not exposed to tobacco smoke) and that each year several
hundred smokers in the UK died from lung cancer contracted by
passive smoking.[50]
In 1992 the US Environmental Protection Agency published a report
Respiratory Health Effects of Passive Smoking: Lung Cancer
and other Disorders which "confirmed the findings published
in the Fourth Report on the effects of ETS exposure in relation
to lung cancer and to respiratory diseases in children,"
considered "the effect of ETS exposure on the development
of ischaemic heart disease," and also "identified additional
links between passive smoking and certain childhood illnesses".[51]
26. The First Report of the Scientific Committee
on Tobacco and Health (SCOTH), published in March 1998, offered
the most comprehensive analysis to date. It concluded that "exposure
to ETS is a cause of lung cancer, and in those with long term
exposure, the increased risk is in the order of 20-30%. Exposure
to ETS is a cause of ischaemic heart diseases.... Smoking in the
presence of infants and children is a cause of serious respiratory
illness and asthmatic attacks. Sudden infant death syndrome....
is associated with exposure to ETS. The association is judged
to be one of cause and effect".[52]
27. The recent report of the Confidential Enquiry
into Stillbirths and Deaths in Infancy indicated that Sudden Infant
Death Syndrome (SIDS) was substantially more prevalent in households
where an infant was exposed to tobacco smoke. This study concluded
that "the more hours the infant was exposed to smoke the
greater the risk". Reviewing other literature on SIDS it
suggested that "despite the absence of direct experimental
evidence, the relationship between smoking and SIDS is probably
causal". The report called for "public education about
the risks of smoking in the home particularly in relation to respiratory
diseases in children" and that health education programmes
"should focus on the dangers of ETS in foetal development
and particularly in the sudden infant death syndrome". The
Committee recommended that "smoking in public places should
be restricted on the grounds of public health", and suggested
there was "a need for public education about the risks of
smoking in the home....".[53]
29 Ev., p.1. Back
30
GHS 1998, p.116. Back
31
These figures suggest that the hypothesis of a recent upturn
in smoking in women, postulated in the 1996 GHS, may have been
"overly pessimistic" (GHS 1998, pp.116-17). Back
32
Nicotine Addiction in Britain, p.9. Back
33
Q136. Back
34
GHS 1998, p.119. Back
35
Ev., p.564. Back
36
DoH Press Notice 1998/0583. Back
37
Some 26 Health Action Zones have so far been established
in England covering over 13 million people. They aim to "tackle
health inequalities and modernise services through local innovation"
in "areas of deprivation and poor health" (www.haznet.org.uk/hazs). Back
38
Smoking Kills, pp.82-84. Back
39
Ev., p.21. Back
40
Ev., p.21. Back
41
Ev., p.21. Back
42
Ev., p.22. Back
43
Ev., p.22. Back
44
Ev., p.23. Back
45
Ev., p.23. Back
46
Ev., p.2. Back
47
Ev., p.2. Back
48
Ev., p.2. Back
49
Ev., p.3. Back
50
Ev., p.3. Back
51
Report of the Scientific Committee on Tobacco and Health,1998,
p.27. Back
52
Report of the Scientific Committee on Tobacco and Health,
1998, p.33. Back
53
Sudden Unexpected Deaths in Infancy, The CESDI
SUDI Studies 1993-1996, Ed. P. Fleming, P. Blair, C. Bacon
and J. Berry, 2000, p.90. Back
