Tobacco and Public Health - TCSC Indonesia

Introduction
Chapter 32
Tobacco and cardiovascular disease
Konrad Jamrozik
At the level of the whole population, tobacco causes far more harm via its contribution
to cardiovascular disease (CVD) than it does through its effects on either the risk of
lung cancer or of chronic obstructive pulmonary disease (COPD). This occurs because,
in the absence of smoking, lung cancer and COPD are both very rare conditions. CVD,
by contrast, is now the commonest cause of death of Homo sapiens (World Health
Organization 1999). Thus, for a given prevalence of smoking in a population, the small
increase in risk of CVD, in relative terms, that is associated with smoking generates
many additional cases of CVD. By contrast, the much larger relative risks for lung
cancer and COPD associated with smoking generate fewer additional cases of these
conditions because these risks are applied to ‘background’ incidence rates that are
much lower than the lifetime risk of CVD in non-smokers (Wald 1978).
Nevertheless, and despite some relationship between smoking and heart disease
having been described for at least a century (Bruce 1901), more than twenty years
elapsed between publication of the original report on the effects of smoking and health
by the Royal College of Physicians of London (1962), which concentrated on lung
cancer, and the appearance of a report from the Surgeon-General of the United States
dedicated to the adverse effects of smoking on the cardiovascular system (United States
Department of Health and Human Services 1983). Even the latter report is remarkable
for the number of aspects of CVD about which information on the impact of smoking
was either entirely lacking or inadequate to draw firm conclusions. This emphasizes how
much more was learnt about active smoking and CVD in the last two decades of the
twentieth century. That picture is now very close to complete, although, as this chapter
will show, some significant questions remain unanswered and, arguably, we have yet to
distil all of the lessons that might be taught by the knowledge that we have available.
To some extent, history has repeated itself in relation to passive smoking. The first
reports of an increased incidence of major respiratory illness in infants and children who
were passive smokers appeared in the English-language literature in 1974 (Colley et al.
1974; Harlap and Davies 1974), and data implicating passive smoking as a cause of lung
cancer in adults were first published in 1981 (Hiryama 1981; Trichopoulos et al. 1981).
However, another four years elapsed before equivalent studies of CVD appeared
(Garland et al. 1985), even though a literature on the short-term consequencesofpassive