Tobacco and Public Health - TCSC Indonesia

Clarke 1985*
Hellberg 1986*
La Vecchia 1986
Zaninetti 1986*
Brisson 1987
Kataja 1993
Becker 1994
Brisson (CIN 1) 1994
Brisson (CIN 2/3) 1994
De Vet 1994
Olsen 1995
Scholes 1999
All non-controlled
Morrison 1991*
Schiffman 1993
Kjaer (low grade) 1996
Kjaer (high grade) 1996
Sasagawa (cancer) 1997
Sasagawa (CIN) 1997
Derchain (CIN 1) 1999
Derchain (HGSIL) 1999
HPV controlled
Combined
Luesley et al. (1994) studied 167 women referred to a colposcopy clinic with cervical
smears showing mild dyskaryosis. Histological outcome was made on the basis of a large
loop excision of the transformation zone (LLETZ). Current smoking was associated with
an odds ratio of 4.6 (CI 2.29–9.37) for high-grade disease (CIN 2 or worse). In addition,
lesion size was found to be significantly larger in smokers (p = 0.007). Similar results were
reported by Daly et al. (1998) who also reported a dose–response relationship between
the number of cigarettes smoked and the risk of high-grade disease in women with mildly
abnormal smears (OR 5.85, 95% CI 1.92–17.80 for women who smoked more than 20
cigarettes per day). Unfortunately, these studies did not include testing for HPV and did
not adjust for sexual variables other than parity and contraceptive status.
Interaction with the human papillomavirus (HPV)
ANNE SZAREWSKI AND JACK CUZICK 463
0.3 1 1.9
Odds ratio – log scale
5 10 25
Fig. 26.5 Smoking and cervical neoplasia: case–control studies—CIN of all grades. *Unadjusted.
In 1982, Zur Hausen suggested that the HPV might be the primary cause of cervical
cancer. Although it appears to be one of the few complete carcinogens (i.e. not necessarily
requiring other cofactors) it is clear that carcinogenicity is greatly accelerated when
cofactors are present. He postulated that, in the case of cervical cancer, both smoking
and HSV were possible cocarcinogens. Since then, the evidence implicating HPV as the
major causal agent has become overwhelming, with a number of high-risk types identified,
in particular types 16 and 18 (Munoz et al. 1992; Walboomers et al. 1999).
The number of studies which have included information both on smoking and
presence of HPV infection has increased considerably in recent years. Early studies
used assays of limited accuracy, but more recent studies have mostly used a consensus
PCR system or hybrid capture II. These studies will now be considered in greater detail
(Figs. 26.1–26.5).