Tobacco and Public Health - TCSC Indonesia

in 1995 was approaching the maximum previously recorded in the United Kingdom.
In women the proportions have generally been much lower, but in 1995 were approaching
the figures for men, in both the United Kingdom and, most notably, the United
States of America. In all four categories the increase in female mortality has been progressive
and in the United States and many parts of the United Kingdom lung cancer
has now displaced cancer of the breast from its position as the leading cause of death
from cancer in women.
Developing countries
For the developing countries there are few quantitative data, apart from those for
China, where cigarette consumption per adult increased from about 1 per day in 1952,
to 10 per day in 1992. Two studies are particularly revealing. One, a case-control study
of a million deaths in men and women in 98 parts of China, both urban and rural,
obtained information about the deceased persons’ smoking habits and compared those
of men and women who died of cancer, respiratory disease, and vascular disease with
those of men and women who died of other diseases, postulated not to be due to
smoking (Liu et al. 1998). The other, a cohort study of a quarter of a million men aged
over 40, in 45 selected representative areas, provided mortality rates by smoking habit
over a 5–6-year period (Niu et al. 1998). Both led to the conclusion that about 12 per
cent of deaths in middle-aged and elderly men were attributable to smoking, while the
case-control study provided the much lower figure, of 2–3 per cent, in women, few of
whom, outside the big towns, had been smoking for long. However, the pattern of
mortality was different from that in the developed world, with a much smaller proportion
of attributable deaths due to ischaemic heart disease and lung cancer, and a
greater proportion due to stroke, chronic obstructive pulmonary disease, and cancers
of the oesophagus, stomach, and liver.
Future expectations
RICHARD DOLL 13
What then of the future? For China it is relatively easy to predict, for the prevalence of
smoking and attributable mortality are reproducing what was observed in the United
States 40 years previously, where cigarette consumption per adult had been 1 per day in
1910 and 10 per day in 1950, and the risk of premature death in smokers, attributable
to smoking, increased from 1 in 4 in the early 1960s, to 1 in 2 in the 1980s. For Chinese
men who began smoking before they were 20 years old, after the revolution in 1949,
the risk is already 1 in 4 and must be expected to become 1 in 2 in 20 years time. Twothirds
of men now become smokers before 25 years of age and, if present patterns continue,
about 100 million of the 300 million Chinese males now under 30 years of age
will be killed by tobacco. However, the number of female deaths attributable to smoking
in the future may be relatively small, as, contrary to what has happened in the West,
progressively fewer women have been starting to smoke, and the prevalence for those
born between 1950 and 1964 is now only 1–2 per cent.