1 Blackwell Science, LtdOxford, UKRESRespirology Blackwell Science Asia Pty Ltd Original ArticleHistory of tobacco and healthaw Musk and NH de Klerk Respirology (2003) 8, INVITED REVIEW SERIES: TOBACCO AND LUNG HEALTH History of tobacco and health Arthur William MUSK 1,2 AND Nicholas Hubert DE KLERK 2,3 1 Sir Charles Gairdner Hospital, Nedlands, 2 School of Population Health, University of Western Australia, 3 Centre for Child Health Research, University of Western Australia, Western Australia, Australia History of tobacco and health MUSK AW, DE KLERK NH. Respirology 2003; 8: Abstract: Tobacco comes from plants that are native to the Americas around Peru and Ecuador, where it has been found since prehistoric times. It was brought back to Europe by early explorers where it was adopted by society and re-exported to the rest of the world as European colonization took place. Smoking tobacco in pipes of one sort or other gave way to handmade and then manufactured cigarettes, especially during the First World War. Smoking rates increased dramatically during the 20th century in developed countries until recently and rates are still increasing in underdeveloped countries. An epidemic of smoking-related diseases has followed the prevalence of smoking. Scientific knowledge of the harmful effects of active tobacco smoking has accumulated during the past 60 years since early descriptions of the increasing prevalence of lung cancer. The first epidemiological studies showing an association between smoking and lung cancer were published in In 1990 the US Surgeon General concluded that smoking was the most extensively documented cause of disease ever investigated but governments worldwide have been ambivalent and slow in taking action to reduce smoking. Tobacco smoking is now agreed to be a major cause of a vast number of diseases and other adverse effects. Since the 1980s passive smoking including exposure in utero has also been implicated as a significant cause of numerous diseases. In response, the tobacco industry has managed to forestall and prevent efforts to control this major health problem. Key words: adverse effects, cigarettes, smoking, tobacco. BACKGROUND Tobacco and mankind have been associated in the same way as food and tea since before history began. Its ancient origins and how it subsequently insinuated itself into modern society have been described in detail by Gately. 1 Nicotiana tabacum and Nicotiana rustica are native plants of the Americas having evolved in the Andes around Peru/Ecuador. Men came across them (along with more useful plants such as tomatoes, potatoes, maize, cocoa and rubber) about years ago when they migrated to the American continents from Asia across the Bering Straight land bridge. Tobacco is thought to have been Correspondence: A. William Musk, Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Verdun Street, Nedlands, WA 6009, Australia. cultivated since about BC. The use of tobacco was universal throughout the American continents (and Cuba) by the time that Christopher Columbus arrived in North America in The practice of smoking appears to have arisen from snuffing, as snuffing instruments are among the most ancient tobacco-related artifacts that have been found. However, tobacco was not only sniffed and smoked but chewed, eaten, drunk (like tea), smeared over bodies (to kill lice and other parasites), and used in eye drops and enemas. It was blown into warriors faces before battle, over fields before planting (it is still used as an insecticide in agriculture) and over women before sex. It was used medicinally for its analgesic and antiseptic properties and as a cure for a variety of ailments. It was offered to the gods and used in religious ceremonies. It had both real and mystical qualities. All sorts of implements were invented and used to administer it but the most enduring method of administration ever since these distant times has been smoking. Tobacco was smoked rolled up in cigars but the most popular method in ancient times
2 History of tobacco and health 287 was in a pipe of one sort or other which came to serve both social and ritual functions. The first Europeans to smoke were members of Columbus crew when they reached Cuba in Almost from the outset, smoking was described as an evil and harmful practice by the Europeans but it seems that spiritual revulsion and danger to health have never been sufficiently long-lasting to prevent people from engaging in tobacco use. The first European smoker is reputed to have been imprisoned in a dungeon in Spain for 3 years by the inquisition for smoking in public on his return from America. However, the purported medicinal properties of tobacco resulted in its seeds being brought back to Spain and Portugal for cultivation there, initially in palace gardens, thereby commencing its long association with royalty and with royal endorsement. It is one of the many ironies of tobacco that two of its first claimed medical properties were its potential to cure and also to prevent cancer. This latter claim resulted in tobacco being used by healthy people (initially in France as snuff) who, like many who have succeeded them, became addicted. The British first obtained their tobacco by plundering Spanish ships en route back from America. Sir Francis Drake brought tobacco back from his circumnavigation of the globe in 1580 while some tobacco may have been brought back from the Caribbean in the 1560s. Sir Walter Raleigh brought tobacco back from his first Virginian expedition in Gately states that tobacco was certainly in use in England by 1571 by shipmasters and others coming back from the New World. 1 Smoking was taken up in the court of Elizabeth I, even by the Queen herself, and then of course by affluent English society and anyone who could afford it; tobacco was expensive so the English started to grow their own. Tobacco use has since spread worldwide as European colonization proceeded during the subsequent centuries. King James I of England is famous for his accurate and prophetic description of tobacco smoking as a custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs and in the black, stinking fume thereof nearest resembling the horrible Stygian smoke of the pit that is bottomless. 1 Manufactured cigarettes, made by a combination of hand and machine and later by machine alone, were first marketed in England in the 1850s. Their convenience, especially in the trenches in the First World War has resulted in them being the most popular nicotine delivery devices ever since, especially since their construction with cork tips and then filters and especially as their contents can be readily manipulated by the manufacturer. 2 Unfortunately the smoke from cigarettes is more acidic than that from pipes and cigars and requires inhalation into the lungs for effective uptake of nicotine, while the nicotine of pipes and cigars can more readily be absorbed through the oral mucosa. Uptake through the lung provides not only a more immediate sense of satisfaction to the smoker as the nicotine is short-circuited to the brain, but also exposes a much greater surface area of respiratory epithelium to the smoke, which enhances its rapid absorption and potentiates the addictive nature of the product. Cigarette smoking has been taken up worldwide since then and has been described as a tragic accident of history. 3 ADVERSE HEALTH EFFECTS Active smoking Scientific proof of King James I s assertion and the wisdom of the inquisition have taken time to accumulate but there has been indisputable evidence that tobacco is the leading preventable cause of death in developed countries, and has been for over half a century. A rising incidence of lung cancer was first observed in the 1920s and 1930s by pathologists and other medical practitioners. 3,4 The first major and almost conclusive evidence in the modern history of the effects of smoking on health occurred in 1950 with the publication of four retrospective studies of smoking habits of lung cancer patients. 5 8 The first longitudinal study of this association by Hammond and Horn confirmed increased death rates for cigarette smokers according to the amount they smoked. 9 In July 1957 the US public health service issued its first statement on cigarette smoking as a cause of lung cancer 10 and in 1962 the Royal College of Physicians of London 11 reviewed the scientific evidence available at the time on smoking and health and concluded that the relationship between smoking and lung cancer was a causal one. The US Surgeon General commissioned further investigations which came to virtually the same conclusions: 10,12,13 that cigarette smoking was a serious hazard to health and is related to illness and death from lung cancer, chronic broncho-pulmonary disease, cardiovascular disease and other diseases. A further report was issued in to incorporate a great deal of new research and reviewed the growing understanding of the bio-mechanisms whereby cigarette smoking adversely affects the human organism and contributes to the development of serious illness. None of the conclusions of these early reports have been found to be significantly incorrect in the mountains of data that have accumulated over the years that have followed. Additional associations have been demonstrated and in Australia, a country with less than 20 million inhabitants, tobacco smoking kills smokers and 2400 non-smokers each year. 3 This toll exceeds the deaths resulting from alcohol abuse, AIDS, traffic accidents, murders and suicides combined. One regular smoker in two dies from a smoking-related disease (i.e. dies prematurely). 15,16 Smoking is now identified as a major cause of heart disease, stroke, peripheral vascular disease, COPD, cancers of the lung, oral cavity, larynx, oesophagus, stomach, kidney, bladder, pancreas, cervix, vulva, penis, anus, and possibly others. 3,17 19 Other health problems such as impaired fitness, peptic ulcer disease, premature skin ageing with wrinkles, osteoporosis, impaired fertility (including impotence) in males and females, snoring, abortion and ectopic pregnancy, inflammatory bowel disease, cataracts and
3 288 AW Musk and NH de Klerk increased complications of surgery, diabetes and hypertension 3,19,20 exist. Cigarettes, and cigarette lighters may cause burns directly, and cigarette smoking is associated with risk of setting fire to property with potentially devastating effects. Tobacco smoking increases the risks associated with various occupational exposures particularly asbestos, 21 where it acts multiplicatively to increase the risk of lung cancer and contributes to the long-term effects of occupational exposures on bronchitis and lung function. 22 bronchial responsiveness in children with asthma and enhance sensitization of children to allergens, and suggested that these early changes may be the precursors of impaired lung function in later life (such as through retarded lung growth or persistent bronchial hyper-responsiveness). The review also concluded that passive smoking contributes significantly to the risk of sudden infant death syndrome and may increase the risk of death from all causes. Environmental tobacco smoke exposure Environmental tobacco smoke exposure has more recently been shown to be an important cause of smoking-related diseases especially since the casecontrol study of Trichopoulos in of the smoking habits of the spouses of non-smoking female residents of Athens, although the dangers of environmental tobacco smoke to children were demonstrated in the 1970s Since then, further evidence has accumulated and knowledge of the effects of environmental tobacco smoke exposure has increased, as may have been anticipated given the nature of the exposure and the known dose response characteristics of carcinogens. In the 1997 review of the literature by the National Health and Medical Research Council of Australia 27 it was estimated from 34 studies that people who never smoke but live with a smoker have a 30% increased risk of developing lung cancer compared with people who never smoke and live with a non-smoker. This estimate did not take into account exposure outside the home or the effects of passive smoking on current smokers or ex-smokers. The report also reviewed 48 studies of the relationship between passive smoking and asthma and it was estimated that children exposed to environmental tobacco smoke are about 40% more likely to suffer from asthma symptoms than children who are not exposed, such that about 8% of childhood asthma in Australia is attributable to passive smoking and the effect is greater in the children of mothers who smoke more heavily. On the basis of 25 studies, it was also estimated that children exposed to environmental tobacco smoke during the first 18 months of life have a 60% increase in the risk of developing lower respiratory illnesses such as croup, bronchitis, bronchiolitis and pneumonia. It was estimated that 13% of lower respiratory illnesses in Australian children 18 months of age or younger are attributable to passive smoking. On the basis of 16 studies it was estimated that the risk of heart attack or death from coronary heart disease was about 24% higher in people who never smoked but are exposed to environmental tobacco smoke. There were studies that showed that environmental tobacco smoke exposure is also associated with symptoms of upper airway irritation and short-term changes in lung function even in non-asthmatics, but there was no direct evidence to implicate passive smoking as a cause of COPD. It did point out that maternal smoking in pregnancy and postnatal exposure to environmental tobacco smoke may alter lung structure and function, increase THE ASBESTOS ANALOGY The chronology of events surrounding the scientific discovery of the harmful effects of tobacco parallels that of asbestos. Asbestos is also a substance that has been used since antiquity; it was used in the wicks of the lamps of the Vestal Virgins. Its harmful effects were not clearly demonstrated until the 20th century when asbestosis was identified as an obvious hazard of exposure to asbestos (in the 1920s). 28 Sir Richard Doll demonstrated its connection with lung cancer in 1955, only 5 years after he had shown that tobacco smoking caused lung cancer, 29 while Christopher Wagner showed its association with malignant pleural mesothelioma in There was subsequently, and had been previously (particularly after a German report indicating an association with lung cancer in the 1930s and other sporadic reports relating asbestos exposure with endothelioma of the pleura 29 ), intense activity by the asbestos industry attempting to obscure and discredit this evidence, in very similar fashion to the way tobacco companies have behaved in the last 50 years. 31 The subsequent sequence of events has been somewhat different. Asbestos use and handling in the developed industrialized world has been tightly regulated and virtually eliminated, with the provisions often being somewhat less stringent for chrysotile (white asbestos) although this process took nearly 20 years to start and another 20 years to complete). However, there is still little effective regulation on tobacco consumption with the exception of regulation of sales to children, and in some more progressive societies, of tobacco promotion and smoking in enclosed and public places. These actions have had a disappointing, although significant, impact on tobacco sales such that tobacco use is still widespread. The explanations for the differences in the ability of society to control tobacco and asbestos are unclear but there are clear differences in the ability of the manufacturers to circumvent legislation and litigation, and different perceptions of the victims of diseases caused by the products as to who is responsible for their diseases. In the instance of the smoker with disease there is a much greater tendency to accept blame for having inflicted the illness on him or herself even though the tobacco industry has been found to have withheld information for decades about the addictive and deleterious effects on health of its products. 2 The tobacco industry has been much more able to influence the political process than the asbestos industry, which has been much more readily identified as a vil-
4 History of tobacco and health 289 lain inflicting its product on people who must work with it for the financial wellbeing of themselves and their families. Collective legal and legislative action (through the trade union movement) has been more readily available to people with asbestos-related diseases than to individual people with smoking-related diseases. The anti-smoking movements have had few financial resources to engage in litigation and it has only been in the recent past that lawyers, with altruistic motives or with realistic expectations of contingency payments, have been willing to challenge the tobacco industry. Lastly, cigarettes are probably the best designed addictive drug delivery systems ever devised, while the attractions of inhaling asbestos dust are few. THE FUTURE While smoking rates have been declining in developed countries they continue to increase in much of the developing world. Politicians worldwide have been complicit with the industry, further impeding progress towards smoking control. The known benefits of tobacco to health are few (weight control, improvement in mood 3,32 ) and cannot justify the continued marketing of tobacco. CONCLUSIONS The tobacco industry has consistently refused to accept the evidence of the harmful effects of active and passive tobacco smoking and also that nicotine is addictive. It has continued to promote and sell its products even where regulations are most stringent. It has often been described as unique among American and worldwide industries in its ability to forestall effective government regulation and to hold effective public health action at bay through skilled legal, political and public relations strategies designed to confuse the public and to allow it to avoid (until recently) having to take responsibility for the death and disease it inflicts while marketing its lethal products. 2 This has seriously impeded the ability of governments to control this major health problem. Had tobacco been a new pharmaceutical drug in today s society it would never have been licensed for sale to the public. Given that tobacco has been used and marketed for so long it would have been withdrawn from the marketplace as thalidomide was withdrawn when its ill-effects became known. In fact nicotine has been regarded as a poison and has been scheduled in the Poisons Act in Western Australia for decades. The weak links in a system which should protect the public from the poisonous and deadly nature of nicotine and the chemicals which accompany it in tobacco, whether they be administered by inhalation or other means, are the politicians who are supposed to protect the public s health interests. The lack of government resolve in cutting tobacco use has been a continuous feature since the 1950s, typified by the British Chancellor of the Exchequer saying We at the Treasury do not want too many people to stop smoking. 33 Latterly, some state governments in Australia have at least diverted tobacco taxes towards research into health promotion and lowering smoking rates, although it is not completely clear, given the widening differential in smoking rates between rich and poor, whether this is not just another tax on the unemployed and working classes, similar to state lotteries. Current information indicates that tobacco smoking is still responsible for huge numbers of deaths in Western societies where anti-smoking activities are slowly gathering momentum. If trends in these activities continue, especially if they are successful in financially disrupting the industry, then real improvements in health will follow. It will be important that the gains achieved in these countries are also achieved in other countries where the prevalences of smoking remain unacceptably high and are still increasing. As long ago as 1990 the US Surgeon General pronounced that it is safe to say that smoking represents the most extensively documented cause of disease ever investigated in the history of biomedical research 19 having by 1989 examined over reports on the relationship between cigarette smoking and disease. 18 It would be interesting to compare the costs of this documentation with the current expenditure on prevention and then with the profits still being enjoyed by tobacco companies, their shareholders and those to whom they pay tax. REFERENCES 1 Gately I. La Diva Nicotina. The Story of How Tobacco Seduced The World. Simon and Schuster, London, Glanz SA, Slade J, Bero LA, Hanauer P, Barnes DE. The Cigarette Papers. University of California Press, Berkeley, Winstanley M, Woodward S, Walker N. Tobacco in Australia. Facts and Issues. Victorian Smoking and Health Program, Melbourne, White C. Research on smoking and lung cancer: a landmark in the history of chronic disease epidemiology. Yale J. Biol. Med. 1990; 63: Doll R, Hill AB. Smoking and carcinoma of the lung. Preliminary report. BMJ 1950; 2: Levin ML, Goldstein H, Gerhardt PR. Cancer and tobacco smoking. A preliminary report. J. Am. Med. Assoc. 1950; 143: Schrek R, Baker LA, Ballard GP, Dolgoff S. Tobacco smoking as an etiological factor in disease. I. Cancer. Cancer Res. 1950; 10: Wynder EL, Graham EA. Tobacco smoking as a possible etiological factor in bronchogenic carcinoma. A study in six hundred and eighty four proved cases. J. Am. Med. Assoc. 1950; 143: Hammond EC, Horn D. The relationship between human smoking habits and death rates. J. Am. Med. Assoc. 1954; 155: US Public Health Service. Smoking and Health. Report of the Advisory Committee to the Surgeon General of the
5 290 AW Musk and NH de Klerk Public Health Service (Washington). US Department of Health Education and Welfare (PHS) Smoking and Health. A Report of the Royal College of Physicians on Smoking in Relation to Cancer of the Lung and Other Diseases. Pitman Medical Publishing Co Ltd, London, USDHEW. The Health Consequences of Smoking. A Public Health Service Review, 1967: PHS USDHEW. The Health Consequences of Smoking. A Public Health Service Review, US Department of Health, Education and Welfare, The Health Consequences of Smoking. A Report to the US Surgeon General: Public Health Service, Health Services and Mental Health Administration DHEW (HSM), Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking. 40 years observations on male British doctors. BMJ 1994; 309: Peto R, Lopez AD, Boreham J, Thun M, Heath C. Mortality from Smoking in Developed Countries, : Indirect Estimation from National Vital Statistics. Oxford University Press, Oxford, US Department of Health and Human Services. The Health Consequences of Smoking. Cancer. A report of the US Surgeon General. US Department of Health and Human Services. Public Health Service, Office on Smoking and Health, Rockville, 1982; DHHS (PHS) US Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1989; DHHS (CDC) US Department of Health and Human Services. The Health Benefits of Smoking Cessation. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990, (CDC) English DR, Holman CDJ, Milne E et al. The Quantification of Drug Caused Morbidity and Mortality in Australia, 1995 Edition. Commonwealth Department of Human Services and Health, Canberra, Hodgson JT, Darnton A. The quantitative risks of mesothelioma and lung cancer in relation to asbestos exposure. Ann. Occup. Hyg. 2000; 44: Morgan WKC, Seaton A. Occupational Lung Diseases, 3rd edn. WB Saunders & Co, Philadelphia, Trichopoulos D, Kalandidi A, Sparros L, MacMahon B. Lung cancer and passive smoking. Int. J. Cancer 1981, 27: Colley JRT. Respiratory symptoms in children and parental smoking and phlegm production. BMJ 1974; 2: Harlap S, Davies AM. Infant admissions to hospital and maternal smoking. Lancet 1974; 1: Leeder SR, Corkhill R, Irwig LM, Holland WW, Colley JRT. Influence of family factors on the incidence of lower respiratory illness during the first year of life. Br. J. Prev. Soc. Med. 1976; 30: National Health and Medical Research Council. The Health Effects of Passive Smoking. Commonwealth of Australia, Canberra, Merewether ERA, Price CW. Report on the Effects of Asbestos Dust on the Lungs and Dust Suppression in the Asbestos Industry. HM Stationery Office, London, Doll R. Mortality from lung cancer in asbestos workers. Br. J. Ind. Med. 1955; 12: Wagner JC. Some pathological aspects of asbestosis in the Union of South Africa. In: Proceedings of the Pneumoconiosis Conference, Johannesburg, February Lilienfeld DE. The silence: the asbestos industry and early occupational cancer research a case study. Am. J. Public Health 1991; 81: Pidoplichko VI, DeBiasi M, Williams JT, Dani JA. Nicotine activates and desensitizes midbrain dopamine neurons. Nature 1997; 390: McCurdy RNC. Smoking, Lung Cancer and You. Linden Press, London, 1958.