Tobacco and Public Health - TCSC Indonesia

MICHAEL J. THUN AND JANE HENLEY 19
in the early twentieth century, with mass advertising campaigns to glamorize smoking
of particular brands of cigarettes (Slade 1993). Free cigarettes were distributed in
military rations to allied soldiers in the First and Second World Wars.
Collectively, these changes caused a large increase in the number of people smoking
manufactured cigarettes, greater daily consumption of cigarettes, and a much greater
surface area of tissues exposed to the carcinogens in tobacco smoke. A dramatic increase
in cigarette smoking occurred first among men in the United Kingdom and United
States, and later among women. In Britain, nearly 70 per cent of men and over 40 per
cent of women between the ages of 25 and 59 were currently smoking cigarettes by the
mid-twentieth century (Peto et al. 2000). In the United States, 57 per cent of men, and 28
per cent of women, reported current cigarette smoking in 1955, the time of the first
national survey (Haenszel et al. 1956). Despite widespread smoking, little scientific
attention was paid to the negative health effects of cigarettes before the mid-twentieth
century. Rottman had reported a small cluster of lung cancer among tobacco workers in
Leipzig in 1898 (Rottmann 1898). Several correlation studies noted the statistical association
between the rise in cigarette consumption and the increasing population rates of
lung cancer in men (Adler 1912; Tylecote 1927; Lickint 1929; Hoffman 1931; Arkin and
Wagner 1936; Fleckseder 1936). Raymond Pearl described reduced longevity in smokers,
based on family history records at the Johns Hopkins School of Hygiene (Pearl 1938).
Several small case-control studies of smoking and lung cancer published before 1950
found a higher percentage of smokers among patients with lung cancer than with other
diseases (Muller 1939; Schairer and Schioninger 1943; Wassink 1948). A series of skintesting
experiments in rabbits were either negative (Leitch 1928; Passey 1929), or demonstrated
some increase in skin tumors (Roffo 1931; Cooper et al. 1932) after prolonged
contact with tar extracts from cigarettes. However, the tumorigenicity of tobacco extracts
appeared to be less than that of coal tar, and interpretation of the animal experiments
was complicated by controversy about the temperature at which the tar was extracted
from tobacco for the animal experiments, compared to the typical burning conditions in
a cigarette (Doll 1998b). Only in Germany were doctors and the Nazi political authorities
concerned about the potential cardiovascular and reproductive toxicity of ‘nicotinism’,
which was not at the time based on sound scientific evidence (Doll 1998b).
It was the extraordinary rise in lung cancer that began early in the twentieth century
among men in the United Kingdom, later among men in other countries, and subsequently
in women, that finally drew serious attention to the hazards of smoking (Doll
and Hill 1950; Wynder and Graham 1950). Lung cancer had hitherto been a rare disease.
The increase in the age-standardized death rate from lung cancer among men in England
and Wales had begun by 1912 and accelerated sharply after the First World War (Doll
and Hill 1950). The number of lung cancer deaths recorded per year in England and
Wales increased approximately 15-fold over the 25-year period between 1922 and 1947,
far in excess of the increase in the size, or longevity of the population. In the United
States, where cigarette smoking began later and vital statistics data on mortality did not