Tobacco and Public Health - TCSC Indonesia

Introduction
Chapter 2
The great studies of smoking and
disease in the twentieth century
Michael J. Thun and Jane Henley
Much of what is known about the harm caused by tobacco use was learned from large
prospective epidemiologic studies conducted during the second half of the twentieth
century in the United Kingdom and United States. To understand why these studies
were so important in documenting the deleterious effects of smoking, one must appreciate
the pervasive grip that tobacco, particularly cigarette smoking, held on the United
Kingdom and its former Western colonies at the close of the Second World War. The
culture of cigarettes was sustained not only by nicotine addiction and by the political
and economic power of the tobacco industry, but also by the symbols and imagery
with which advertising had imbued it, and by prevailing social norms. How could an
apparently ordinary behavior, practised by so many people with so little evidence of
acute toxicity, prove to have such severe chronic effects?
Sir Richard Doll, a pioneer of tobacco epidemiology, has examined the history of scientific
and social factors that led ultimately to the recognition of the carcinogenicity
and pathogenicity of smoking (Doll 1998b). He notes that, in retrospect, the medical
evidence of the adverse health effects of tobacco accumulated for 200 years before it
was generally accepted, in the late 1950s, that smoking caused lung cancer and, in the
two subsequent decades, that it caused many other diseases as well (Doll 1998b).
He cites three factors that contributed to the strength of resistance to the idea that
smoking was a major cause of lung cancer: ‘the ubiquity of the habit, which was as
entrenched among male doctors and scientists as among the rest of the adult male
population and had dulled the collective sense that tobacco might be a major threat to
health’, ‘the novelty of the epidemiological techniques, particularly as applied to noninfectious
diseases’, and ‘the primacy given to Koch’s postulates in determining causation’,
since criteria had not yet been developed to assess the causation of chronic
diseases such as cancer.
This chapter examines the contributions of several large prospective studies, conducted
over the second half of the twentieth century, to our understanding of the
health hazards of tobacco use. The designation ‘Great Studies’ is used to refer to