Tobacco and Public Health - TCSC Indonesia

GRAHAM G. GILES AND PETER BOYLE 487
The importance of adequate intervention is shown by the low lung cancer rates in
Scandinavian countries which have adopted, since the early 1970s, integrated central
and local policies and programs against smoking (Bjartveit 1986; Della-Vorgia et al.
1990). These policies may have been enabled by the limited influence of the tobacco
lobby in these countries. The experience in Finland provides convincing evidence of
the favourable impact, after a relatively short delay, of well-targeted large-scale interventions
on the most common cause of cancer death and of premature mortality in
general.
With specific reference to women, current rates in most European countries (except
the United Kingdom, Ireland, and Denmark) are still substantially lower than in the
United States, where lung cancer is now the leading cause of cancer death in women.
In several countries, including France, Switzerland, Germany, and Italy, where smoking
is now becoming commoner in young and middle-aged women, overall national
mortality rates are still relatively low, although appreciable upward trends have been
registered over the last two decades. This is particularly worrisome in perspective, since
smoking prevalence has continued to increase in subsequent generations of young
women in these countries. Thus, the observation that lung cancer is still relatively rare
in women, with smoking at present accounting only for approximately 40–60 per cent
of all lung cancer deaths cannot constitute a reason for delaying efficacious interventions
against smoking by women. The currently more favourable situation in Europe
compared with the United States, together with the observation that smoking cessation
reduces lung cancer risk after a delay of several years, should in the presence of
adequate intervention, enable a major lung cancer epidemic in European women to
be avoided.
A proportion of lung cancers, varying in various countries and geographical areas,
may be due to exposures at work, and a small proportion to atmospheric pollution
(Tomatis 1990). The effect of atmospheric pollution in increasing lung cancer risk
appears to be chiefly confined to smokers. Lung cancer risk is elevated in atomic bomb
survivors (Shimizu et al. 1987), patients treated for ankylosing spondylitis (Smith and
Doll 1982), and in underground miners whose bronchial mucosa was exposed to radon
gas and its decay products: this latter exposure was reviewed and it was concluded that
there was ‘sufficient evidence’ that this occupational exposure caused lung cancer
(IARC 1988). A greater risk of lung cancer is generally seen for individuals who are
exposed at an older age. Investigation of the interaction with cigarette smoking among
atomic bomb survivors suggests that it is additive (Kopecky et al. 1987) but the data
from underground miners in Colorado are consistent with a multiplicative effect
(Whittemore and McMillan 1983).
The overwhelming role of tobacco smoking in the causation of lung cancer has been
repeatedly demonstrated over the past 50 years. Current lung cancer rates reflect cigarette
smoking habits of men and women over past decades (Boyle and Robertson 1987;
La Vecchia and Franceschi 1984; La Vecchia et al. 1988) but not necessarily current