Tobacco and Public Health - TCSC Indonesia

4
EVOLUTION OF KNOWLEDGE OF THE SMOKING EPIDEMIC
who came to consult them, to put them at their ease. Women began to smoke in large
numbers much later, except in New Zealand, where, by the end of the nineteenth century,
Maori women were commonly smoking pipes. Then, in the 1920s, women began
to smoke cigarettes, at first in the USA and then in Britain, where the practice gained
popularity during the Second World War, as an increasing proportion of women began
to work outside the home and have an independent income. However, in many other
developed countries, women have begun to smoke in large numbers only in the past
few decades.
The reason for the swing to cigarettes
The important change in the use of tobacco, for its impact on health, was the swing to
cigarettes. This was brought about by two industrial developments. The first was a new
method of curing tobacco. With the old method, the smoke that had come from pipes
and cigars was alkaline, irritating, and difficult to inhale. However, the nicotine in it
was predominantly in the form of a free base which could be absorbed across the oral
and pharyngeal mucosa. Blood levels of nicotine could consequently be high and
addiction was readily produced; but only small amounts of other constituents were
absorbed. The new method, called flue-curing, was introduced in North Carolina in
the mid-nineteenth century (Tilley 1948). It exposed the leaf to high temperatures and
increased its sugar content, which caused the pH of the smoke to be acid. In this environment,
the nicotine was predominantly in the form of salts and was dissolved in
smoke droplets, which were less irritating than the free base and easier to inhale. With
each inhalation there was a rapid rise in the level of nicotine in the blood, which
was perceived in the brain, and was particularly satisfying to the addict, but other
constituents of the smoke were also absorbed and distributed throughout the body.
The second development was mechanical: namely, the introduction of cigarettemaking
machines. One was patented in 1880, and was eventually adapted by the Duke
family to work so efficiently that 120 000 cigarettes of good quality could be produced
every 10 hours by one machine, the equivalent of the production of about 100
unassisted workers. As a result, the price fell and a mass market became feasible.
The impact of tobacco on health
Until cigarette smoking became common, very little evidence of harmful effects was
detected—for the good reason that relatively little harm was probably caused. One
harmful effect, which was first suggested more than 200 years ago (Sömmering 1795),
was the production of cancer of the lip. In the course of the nineteenth century, on the
basis of clinical series in France (Bouisson 1859), Germany (Virchow 1863–7), and the
United Kingdom (Anon 1890), additional consequences were linked to smoking, such
as the production of cancers of the tongue and other parts of the mouth. These findings,
are now simply explained because we know that these cancers can be produced at
least as easily by the smoking of pipes and cigars as by the smoking of cigarettes.