Tobaccosis

The term tobaccosis in this essay denotes, collectively, all diseases resulting from the smoking, chewing, and snuffing of tobacco and from the breathing of tobacco smoke. They include cancers of the mouth, nasopharynx, larynx, trachea, bronchi, lungs, esophagus, stomach, liver, pancreas, kidney, bladder, prostate, and cervix, as well as leukemia. They also include atherosclerosis of the cardiovascular system - coronary heart disease (with ischemia and infarction), cardiomyopathy, aortic and other aneurysms, cerebrovascular hemorrhages and blockages; renal failure and peripheral vascular disease; emphysema and chronic obstructive pulmonary diseases; peptic ulcer disease and regional ileitis; cirrhosis of the liver; immunological deficiencies and failures of endocrine and metabolic functions; and fetal diseases and perinatal disabilities.

Tobaccosis is the foremost plague of the twentieth century and thus joins the most fearsome plagues that devastated humanity during this millennium such as the Black Death, smallpox, malaria, yellow fever, Asiatic cholera, and tuberculosis. But unlike microparasitic plagues, whose victims experienced pathognomonic disease manifestations within days or weeks of exposure, tobaccosis is an extraordinarily insidious disease entity of long latency resulting from exposure to tobacco for many years or decades and manifested by increased occurrence of any of a broad spectrum of neoplastic and degenerative diseases ordinarily associated with advanced age. Thus, the powerfully malignant nature and magnitude of the tobaccosis pandemic went largely undetected during the first four centuries of its global march; and it is only late in the fifth century of the post-Columbian world's exposure to tobacco that the extent of tobacco's depredations is being fully revealed. Because of its leadership in the production, marketing, and use of tobacco, the United States has borne much of the brunt of the tobaccosis pandemic. Hence, this historical account deals mainly with the U.S. experience.

Origin and Peregrinations of Tobacco

Tobacco is native to the Americas and was extensively cultivated and smoked by the aborigines there. The addictive weed was first encountered by Christopher Columbus and crew on the island of Cuba in November 1492. For some years it was known as paetun and by other names before it was given its common name, tobacco, from the pipes in which it was smoked on the island of Santo Domingo.

Increasingly cultivated and used by Spaniards and blacks in the West Indies and by Portuguese and blacks in Brazil during the early decades of the sixteenth century, tobacco was introduced to many European countries during the latter decades of that century. In 1559 tobacco seeds obtained in Lisbon by Jean Nicot, the French ambassador, from a Dutch trader just returned from the New World were sent as a medicinal to Queen Catherine de Medici and the House of Lorraine, thereby initiating tobacco cultivation and use in France and gaining lasting fame for Nicot.

Tobacco was brought to England in 1565 by John Hawkins, returning from a second voyage to Florida, but it did not gain immediate popular use. Two decades later, Walter Raleigh established a colony on Roanoke Island in Virginia. When Francis Drake visited the ill-fated colony in June 1586, the governor and others returned with him to England, bringing with them the tobacco and pipe-smoking practices soon popularized by Raleigh and others at Queen Elizabeth's court. By 1600 tobacco was widely used in all the maritime nations of Europe.

Meanwhile Portuguese traders carried tobacco in the latter 1500s to African ports and to India, the Spice Islands, Japan, Macao, China, and elsewhere in the Orient; and Spanish traders carried it to the Philippines. Other European merchants trading in the Levant took the weed with them throughout the East. Thus, by the end of the seventeenth century, tobacco was widely available and used in virtually all trading nations of the world.

Tobacco in Europe

Among American Indians, from Canada to Brazil, tobacco was widely smoked for its intoxicating effects, as a medicinal, and for ceremonial purposes. The spread of tobacco use from the New World gave rise to the first great drug controversy of global dimensions. From the onset, opinions regarding tobacco differed radically. Used by Indians as a remedy for aches and pains, snake bite, abdominal and chest pains, chills, fatigue, hunger and thirst, tobacco was extolled by European purveyors for its miraculous curative powers.

Yet the popularity of tobacco in England was challenged by James I, who became monarch of the British Isles after the death of Queen Elizabeth in 1603. His "Counterblaste to Tobacco," published anonymously in 1604 and considered extreme and rather quaint during intervening centuries, can now be appreciated as somewhat prescient:

And now good countrey men let us (I pray you) consider, what honour or policie can move us to imitate the barbarous and beastly manners of the wild, godlesse, and slavish Indians, especially in so vile and stinking a coustome? . .. A custome lothesome to the eye, hateful to the nose, harm-full to the braine, dangerous to the lungs, and in the black stinking fume thereof neerest resembling the horrible stigian smoke of the pit that is bottomless. (Quoted in Austin 1978)

The following year he organized, at Oxford, the first public debate on the effects of tobacco, at which - to get his point across - he displayed black brains and black viscera allegedly obtained from the bodies of smokers. To discourage tobacco sales and use, James I increased the tax thereupon 40-fold; but when use and smuggling increased, he reduced the tax in 1608 to one shilling per pound of tobacco and sold the monopoly right to collect it. With the establishment in 1607 of his namesake colony on the James River in Virginia and on the initiative of John Rolfe, tobacco quickly became its principal crop and export. In 1615, 2,300 pounds were exported, in 1618, 20,000 pounds, and by 1620, 40,000 pounds.

" An outbreak of plague in London in 1614 gave further impetus to smoking, in that doctors declared that steady smokers were not as subject to infection as others and recommended tobacco as a disinfectant. At that time, 7,000 shops were selling tobacco in London, with use spreading among the poor despite high prices. By 1615 tobacco imports had risen to such an extent that James revoked his 1608 monopoly grant and reassigned it at a higher price. In 1620 he ordered that all tobacco bear the government seal, and in 1624 he decreed that only Virginia tobacco be imported. Thus, despite the high costs and discomfort of smoking, chewing, and snuffing and despite intense repressive actions of such sovereigns as King James I of England, King Christian IV of Denmark, Tsar Michael Romanov of Russia, and Sultan Murâd of Turkey, tobacco continued to increase in popularity.

Snuffing Cancer

Among the lower classes, pipe smoking was the common method of tobacco consumption; among the Eu ropean upper classes during the 1700s, pipe smoking was largely supplanted by snuffing (the practice of sniffing tobacco dust). Within a few decades the widespread practice of snuffing generated the first clinical reports of cancer caused by tobacco - cancer of the nasal passages, as described by an English physician, John Hill, in 1761:

This unfortunate gentleman, after a long and immoderate use of snuff, perceived that he breathed with difficulty through one of his nostrils; the complaint gradually encreased 'till he perceived a swelling within. ... It grew slowly, till in the end, it filled up the whole nostril, and swelled the nose so as to obstruct the breathing... he found it necessary to then apply for assistance. The swelling was quite black and it adhered by a broad base, so that it was impossible to attempt to the getting it away . .. and the consequences was the discharge of a thick sharp humor with dreadful pain, and all the frightful symptoms of cancer . . . and he seemed without hope when I last saw him. (Quoted in Whelan 1984)

Also in 1761, the Italian anatomist Giovanni Battista Morgagni described lung cancer at postmortem without identifying its cause. A few years later, in 1775, Percival Pott described a scrotal cancer epidemic among London chimney sweeps, documenting the carcinogenicity of chimney smoke, which should have alerted many to the pathogenic implications of chronic exposure of respiratory tissues to tobacco smoke.

Although tobacco-induced lung cancer must have produced many thousands of deaths from the sixteenth to the nineteenth century, all such progressive chest diseases were lumped under the rubric of phthisis or consumption until the late-nineteenth-century scientific advances of histology, bacteriology, and X-ray. At that time, because of the often obvious relationships between snuffing and nasal cancer, pipe smoking and lip cancer, tobacco chewing and cancer of the mouth, cigar smoking and cancer of the mouth and larynx, there was a growing realization that tobacco use produced cancers of directly exposed topical tissues.

Nineteenth-Century Wars and Tobaccosis British soldiers returning from campaigns on the Iberian Peninsula during the years 1808-14 introduced cigarettes to England. Likewise, veterans returning from the Crimean War (1853-6) increased cigarette smoking in Britain - a practice soon brought to the United States by returning tourists, including New York society women.

During the U.S. Civil War (1861-5) the use of all kinds of tobacco, including that of cigarettes, in creased, and after the war tobacco factories mushroomed. By 1880, with a population of 50 million people, the United States consumed 1.3 billion cigarettes annually, 500 million made locally and the rest imported. Nonetheless, chewing tobacco — a U.S. concoction of tobacco and molasses - remained the leading form of tobacco in the United States throughout the nineteenth century. Along with a great increase in tobacco consumption during the nineteenth century came increasing reports of tobaccosis, especially cancers of directly exposed tissues. Although medical science was still in its infancy in the nineteenth century, occasional astute clinical observations gradually increased people's awareness of the pathogenicity of tobacco.

In 1851, for example, James Paget saw a patient with leukoplakia ("smoker's patch") on the tongue where he always rested the end of his pipe, and "told him he certainly would have cancer of the tongue if he went on smoking" (quoted in Whelan 1984). And in 1857 Lancet commented:

Tobacco . . . acts by causing consumption, haemoptysis and inflammatory condition of the mucous membrane of the larynx, trachea and branchae, ulceration of the larynx; short, irritable cough, hurried breathing. The circulating organs are affected by irritable heart circulation. (Quoted in Whelan 1984)

In 1859 a French physician reported a remarkably thorough study of 68 cases of cancer of the oral cavity in a French hospital. Ascertaining the habits of 67 of these patients, he found that 66 smoked tobacco and the other chewed tobacco. He also noted that cancer of the lip ordinarily occurred at the spot where the pipe or cigar was held.

In 1882 the Boston Medical and Surgical Journal offered this prescient view of cigarettes:

The dangers, then, which are incident to cigarette smoking are, first, the early age at which it is taken up; second, the liability to excess; and, third, the bad custom of inhaling the smoke. These are dangers super-added to those attendant upon the ordinary use of tobacco, and should be considered by all medical men.

Despite such examples, however, leading physicians of the late nineteenth century were generally oblivious to the hazards of tobacco. In the monumentally detailed Medical and Surgical History of the War of the Rebellion, prepared under the direction of Surgeon General of the Army Joseph K. Barnes by J. J. Woodward and colleagues and published in six huge volumes from 1875 to 1888 under the authority of the U.S. Congress, there are only two comments about tobacco: that tobacco clyster may be used for the treatment of zymotic disease and that abuse of tobacco may cause "irritable heart." Nor was tobaccosis frequently mentioned by John Shaw Billings, founder of the Index Medicus, the National Library of Medicine, and author of voluminous analyses of late-nineteenth-century U.S. mortality. William Osier in his classic 1892 text, The Principles and Practice of Medicine, devoted only three sentences in 1,000 pages to the effects of tobacco.

With the advent of cigarette-making machines, which made possible the nearly unlimited production of cigarettes, and portable "safety" matches (introduced at the turn of the century), which enabled smokers to light up whenever and wherever they wished, the stage was set for a vast increase in cigarette consumption. However, as tobacco companies intensified promotional activities, a powerful antitobacco movement developed, led by Lucy Page Gaston and the Women's Christian Temperance Movement, which substantially curbed cigarette sales during the 1890s and early 1900s.

Twentieth-Century Cigarette Tobaccosis

A comprehensive view of evolving tobacco use patterns in the United States during this century is presented in Table III.8.1, which documents the progressive trend from cigar smoking and the use of "manufactured tobacco" (pipe tobacco, chewing tobacco, and snuff) to cigarette smoking. Annual production of manufactured tobacco increased from 301 million pounds in 1900 to a peak of 497 million pounds in 1918 and subsequently decreased to 142 million pounds (1988). During the twentieth century, cigar production oscillated between 4 and 10 billion annually, with more cigars produced in 1900 (5.6 billion) than in 1988 (3.2 billion).

Meanwhile, cigarette production and consumption increased more than 100-fold, with consumption increasing from 2.5 billion cigarettes in 1900 to 640 billion in 1981, then decreasing to 562 billion in 1988. On a per capita basis in the United States, annual cigarette consumption increased from 54 per adult in 1900 to a peak of 4,345 per adult in 1963. Since then it has decreased to 3,096 cigarettes per adult in 1988.

The foremost determinants of national cigarette consumption can be inferred from the trend changes seen in Figure III.8.1. Cigarette consumption doubled during World War I, when cigarettes were included in soldiers' rations sent to France. It doubled again during the 1920s, propelled by innovative advertising campaigns and augmented by radio and cinema. But then it decreased during the early years

3,500

3 3,000

1 2,000

o 1,500

V JD

0 19

Figure III.8.1. Annual consumption of cigarettes by U.S. adults (18 years of age and older), 1900-88. (Data from the Economic Research Service, U.S. Department of Agriculture.)

of the depression of the 1930s, only to increase during the latter part of the decade, presumably in response to intensified advertising in magazines, on billboards, and on radio as well as in response to the incessant smoking of popular film stars and other famous personalities.

During World War II, when cigarettes were made freely available to many military and some civilian groups, consumption almost doubled again-from 1,976 cigarettes per adult in 1940 to 3,449 in 1945. After the war, cigarette consumption continued upward until 1950, when scientific findings showed smoking to be the principal cause of a rapidly increasing epidemic of lung cancer. However, tobacco sales soon recovered.

Intense wrangling over the validity of research findings on the harmful effects of tobacco generated so much confusion that in 1962 Surgeon General Luther Terry established the Advisory Committee of Experts, whose landmark report on 11 January 1964 rendered an authoritative verdict: "Cigarette smoking is causally related to lung cancer in men; the magnitude of the effect of cigarette smoking far outweighs all other factors. The data for women, though less extensive, point in the same direction."

Again the tobacco industry took vigorous defensive action with intensified advertising; but when a fairness doctrine required that advertising messages on radio and television be balanced by antismoking messages, tobacco advertising was discontinued in the broadcast media.

1964

Surgeon Califano

General's Report

I Nonsmokers Rights ..Movement

1964

Surgeon Califano

General's Report

I Nonsmokers Rights ..Movement

00 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

Figure III.8.1. Annual consumption of cigarettes by U.S. adults (18 years of age and older), 1900-88. (Data from the Economic Research Service, U.S. Department of Agriculture.)

Tobacco, Advertising, Cinema, Radio ,

Great WWI / Depression

00 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

Table III.8.1. U.S. tobacco production and consumption, 1900—88

Tobacco products produced

Cigarette

Mfg.

consumption

tobacco

Total in billions

Total in

Per adult

(lbs.

(18+

Year

X 106)

Cigars

Cigarettes

billions

years)

1900

301

5.6

3.9

2.5

54

1901

314

6.1

3.5

2.5

53

1902

348

6.3

3.6

2.8

60

1903

351

6.8

4.0

3.1

64

1904

354

6.6

4.2

3.3

66

1905

368

6.7

4.5

3.6

70

1906

391

7.1

5.5

4.5

86

1907

388

7.3

6.3

5.3

99

1908

408

6.5

6.8

5.7

108

1909

431

6.7

7.9

7.0

125

1910

447

6.8

9.8

8.6

151

1911

424

7.0

11.7

10.1

173

1912

435

7.0

14.2

13.2

223

1913

444

7.6

16.5

15.8

260

1914

441

7.2

17.9

16.5

267

1915

442

6.6

18.9

17.9

285

1916

466

7.0

26.2

25.2

395

1917

483

7.6

36.3

35.7

551

1918

497

7.6

47.5

45.6

697

1919

424

7.1

53.9

48.0

727

1920

413

8.1

48.1

44.6

665

1921

387

6.7

52.8

50.7

742

1922

420

6.7

56.4

53.4

770

1923

413

7.0

67.2

64.4

911

1924

414

6.6

73.2

71.0

982

1925

414

6.5

82.7

79.8

1,085

1926

411

6.5

92.5

89.1

1,191

1927

396

6.5

100.2

97.5

1,279

1928

386

6.4

109.1

106.0

1,366

1929

381

6.5

122.8

118.6

1,504

1930

372

5.9

124.2

119.3

1,485

1931

371

5.3

117.4

114.0

1,399

1932

347

4.4

106.9

102.8

1,245

1933

342

4.3

115.1

111.6

1,334

1934

346

4.5

130.3

125.7

1,483

1935

343

4.7

140.1

134.4

1,564

1936

348

5.2

159.1

152.7

1,754

1937

341

5.3

170.2

162.8

1,847

1938

345

5.0

171.8

163.4

1,830

1939

343

5.2

180.8

172.1

1,900

1940

344

5.4

189.4

181.9

1,976

1941

342

5.6

218.1

208.9

2,236

1942

330

5.8

257.7

245.0

2,585

1943

327

5.9

296.3

284.3

2,956

1944

307

5.2

323.7

296.3

3,030

1945

331

5.3

332.3

340.6

3,449

1946

253

5.6

350.1

344.3

3,446

1947

242

5.5

369.8

345.4

3,416

1948

245

5.6

386.9

358.9

3,505

1949

239

5.4

385.0

360.9

3,480

1950

235

5.5

392.0

369.8

3,522

1951

227

5.7

418.8

397.1

3,744

1952

220

5.9

435.5

416.0

3,886

1953

209

6.0

423.1

408.2

3,778

1954

204

5.9

401.8

387.0

3,546

1955

199

5.8

412.3

396.4

3,597

1956

185

5.8

424.2

406.5

3,650

1957

179

5.9

442.3

422.5

3,755

1958

180

6.4

470.1

448.9

3,953

1959

176

7.3

489.9

467.5

4,037

1960

173

6.9

506.1

484.4

4,174

1961

173

6.6

518.0

502.5

4,266

1962

169

6.8

529.9

508.4

4,265

1963

168

6.6

543.7

523.9

4,345

1964

180

8.6

535.0

511.3

4,195

1965

167

8.9

562.4

528.8

4,259

1966

162

8.0

562.7

541.3

4,287

1967

158

7.3

572.8

549.3

4,280

1968

159

7.7

570.7

545.6

4,186

1969

161

7.5

573.0

528.9

3,993

1970

165

8.0

562.2

536.5

3,985

1971

158

7.8

576.4

555.1

4,037

1972

154

10.0

599.1

566.8

4,043

1973

152

8.8

644.2

589.7

4,148

1974

153

813

635.0

599.0

4,141

1975

155

7.4

625.0

607.2

4,123

1976

153

6.7

688.0

613.5

4,092

1977

155

5.8

673.0

617.0

4,051

1978

156

5.6

688.0

616.0

3,967

1979

156

5.1

707.0

621.5

3,861

1980

163

4.9

702.0

631.5

3,851

1981

162

5.0

744.0

640.0

3,840

1982

160

4.5

711.0

634.0

3,753

1983

159

4.3

668.0

600.0

3,502

1984

159

4.5

657.0

600.4

3,446

1985

158

4.0

665.3

594.0

3,370

1986

148

3.9

658.0

583.8

3,274

1987

143

3.2

689.4

575.0

3,197

1988

142

3.2

694.5

562.5

3,096

Total

25,285

555.9

28,004.7

26,366.1

2,387 av.

Source: Economic Research Services, U.S. Department of Agriculture.

Despite these setbacks for the tobacco industry, sales ascended during the early 1970s. During the late 1970s, however, consumption began to decline under Joseph Califano as Secretary of Health, Education, and Welfare, a trend that fortunately has continued, for several reasons. Among these are increasing evidence of the harm to persons who are chronically

Table III.8.2. Per capita adult consumption of manufactured cigarettes by country, 1985

Cyprus

4,050

Netherlands

1,690

Cuba

3,920

Sweden

1,660

Greece

3,640

Suriname

1,660

Poland

3,300

Trinidad and

United States

3,270

Tobago

1,600

Japan

3,270

Algeria

1,590

Hungary

3,260

China

1,590

Canada

3,180

Hong Kong

1,580

Iceland

3,100

South Africa

1,550

Yugoslavia

3,000

Tunisia

1,470

Switzerland

2,960

Barbados

1,380

Lebanon

2,880

Nicaragua

1,380

Libyan Arab

Costa Rica

1,340

Jamahiriya

2,850

Fiji

1,320

Kuwait

2,760

Mexico

1,190

Spain

2,740

Democratic Peo

Australia

2,720

ple's Republic

Republic of

of Korea

1,180

Korea

2,660

Guadeloupe

1,080

Austria

2,560

Morocco

1,070

Ireland

2,560

Indonesia

1,050

Czechoslovakia

2,550

Honduras

1,010

New Zealand

2,510

Chile

1,000

Italy

2,460

Paraguay

1,000

Bulgaria

2,410

Guyana

1,000

France

2,400

Iraq

980

Germany, Fed

Dominican

eral Republic

2,380

Republic

980

Germany, Demo

Reunion

940

cratic Republic

2,340

Congo

920

Israel

2,310

Thailand

900

Singapore

2,280

Ecuador

880

USSR

2,120

Panama

850

United Kingdom

2,120

Sierra Leone

830

Denmark

2,110

Jamaica

820

Saudi Arabia

2,110

El Salvador

750

Romania

2,110

Benin

740

Syrian Arab

Côte d'Ivoire

710

Republic

2,050

Vietnam

670

Belgium

1,990

Pakistan

660

Turkey

1,970

Iran

620

Norway

1,920

Senegal

610

Colombia

1,920

Cameroon

610

Philippines

1,910

Guatemala

550

Venezuela

1,890

Kenya

550

Egypt

1,860

Angola

530

Malaysia

1,840

Zimbabwe

500

Argentina

1,780

Sri Lanka

500

Uruguay

1,760

Lao People's

Portugal

1,730

Democratic

Finland

1,720

Republic

490

Jordan

1,700

Togo

460

Brazil

1,700

Madagascar

450

Mauritius

1,700

Liberia

450

Mozambique

430

Cape Verde

210

Zambia

400

Zaire

210

Malawi

390

India

160

Ghana

380

Chad

150

Nigeria

370

Burma

150

Peru

350

Nepal

150

Bolivia

330

Sudan

130

United Republic

Niger

100

of Tanzania

330

Ethiopia

60

Central African

Afghanistan

50

Republic

280

Papua New

Bangladesh

270

Guinea

30

Uganda

260

Guinea

30

Haiti

240

Burkina Faso

30

Note: An adult is defined as someone 15 years of age and over.

Source: WHO Program on Smoking and Health.

exposed to smoke generated by others and stronger antitobacco activities by official and voluntary agencies at national, state, and local levels, as well as the vigorous campaign mounted by Surgeon General C. Everett Koop.

World Tobacco Trends

During recent decades, as antitobacco movements have hobbled tobacco promotion and sales in some of the affluent countries and as income levels have risen in many less developed countries, the multinational tobacco companies have intensified their advertising efforts in the less developed world, resulting in the global tobacco consumption pattern seen in Table III.8.2.

The leading countries in the production and consumption of tobacco are China, the United States, the Soviet Union, Japan, the Federal Republic of Germany, the United Kingdom, Brazil, India, Spain, France, and Italy. World production and consumption of cigarettes now exceed 5 trillion annually — more than enough to raise the world tobaccosis death toll substantially above the current level of about 3 million annually. Fortunately, during the 1980s the World Health Organization began to exercise forthright leadership in supplying information on this difficult issue, though it had not yet applied financial and personal resources commensurate with the nature and magnitude of the tobaccosis pandemic.

Nature of the Tobacco Hazard Addictive Pleasures

Although it has always been obvious that tobacco contains a substance (nicotine) that yields psychic

Table III.8.3. Percentage of U.S. adults who smoked regularly, 1945-85

(%)

1945

48

36

42

1950

54

33

44

1955

54

25

40

1960

52

34

42

1965

52

34

42

1970

44

31

38

1975

42

32

37

1980

38

30

34

1985

33

28

30

40-year

46

31

Source: Estimated from survey data by Gallup Poll, National Center for Health Statistics, and Centers for Disease Control.

pleasures not obtained by the smoking of other plant leaves, only during the 1980s did a strong scientific and societal consensus emerge that nicotine is truly addictive - just as addictive as heroin or cocaine and much more addictive than alcohol.

Indeed, cigarette smoking is now the most serious and widespread form of addiction in the world. The proportion of adult men and women who have smoked cigarettes in the United States during the past half-century is indicated in Table III.8.3. Half of adult men smoked at midcentury, this proportion decreasing to 33 percent in 1985 and 30 percent in 1987. Likewise, smoking by adult women decreased from 34 percent in 1965 to 28 percent in 1985 and 27 percent in 1987.

Lethal Poisons

The smoke of burning tobacco contains several thousand chemicals and a number of radioisotopes, including hydrogen cyanide, nitriles, aldehydes, ketones, nicotine, carbon monoxide, benzopyrenes, aza-arenes, and polonium 210, an alpha-particle emitter and therefore the most powerful contact mutagen, more than 100 times more mutagenic than equivalent RADs of gamma radiation. The combination of an addictive substance (nicotine) and more than 50 potent mutagens (especially polonium 210) has made tobacco the foremost human poison of the twentieth century.

Pathogenic Mechanisms

When tobacco smoke is inhaled deeply into the lungs, most of the tars contained therein are cap tured and retained by the respiratory mucous blanket. Soluble components are then promptly absorbed into the pulmonary circulation and conveyed by the systemic circulation throughout the body. Less soluble tars trapped by the mucous blanket are raised by ciliary action and coughing to the pharynx, then swallowed; thereafter, they pass to the esophagus, stomach, small intestine, portal circulation, and liver. Hence, chronic inhalation of tobacco smoke exposes the entire body - every tissue and cell - to powerful mutagens and carcinogens, thus hastening the malignant cellular evolutionary process and accelerating the development of the broad spectrum of neoplastic and degenerative diseases constituting to-baccosis (Table III.8.4).

The differences in mortality among smoking and nonsmoking U.S. veterans amply confirm the pioneering findings of Raymond Pearl, published in 1938, showing a great decrease in the longevity of smokers. In fact, the life-shortening effects of smoking are now so obvious that it seems incredible that they were generally overlooked for four centuries. Among persons who start smoking in adolescence and continue to smoke a pack of cigarettes daily, the average loss of life is roughly 8 years - approximately equal to the cumulative time actually spent smoking.

The most surprising finding of prospective and pathological studies - that the majority of tobaccosis deaths are caused by diseases of the cardiovascular system - initially generated incredulity, and indeed the phenomenon is still not well understood or fully believed by many. It nonetheless deserves full credence and is central to understanding the nature and magnitude of tobaccosis.

The fabric of evidence that cigarette smoking is a major cause of atherosclerosis is woven of these evidential threads:

1. The epidemic increase in ischemic heart disease in the United States during the twentieth century followed the rise in cigarette smoking and occurred particularly among those age-sex subgroups most exposed.

2. Individual studies document a close relationship between heavy cigarette smoking and early coronary disease.

3. There is a plausible pathogenic mechanism by which tobacco smoke could damage vascular tissue: The absorption of inhaled tobacco smoke results in the circulation of polonium 210 and other toxins, with injury to endothelial and other cells, causing cellular damage, clonal proliferation, intramural hemorrhage, lipid deposition, fibrosis,

Table III.8.4 Deaths and mortality ratios among smoking U.S. veterans, 1980

Mortality Observed Expected ratio

Cause of death

deaths

deaths

(O + E)

All causes

36,143

20,857

1.73

Respiratory diseases

2,139

483

4.43

Emphysema and

1,364

113

12.07

bronchitis

Influenza and

460

259

1.78

pneumonia

Pulmonary fibrosis

144

48

3.02

and bronchiectasis

Pulmonary

81

36

2.27

tuberculosis

Asthma

90

27

3.28

Cancer of directly ex

3,061

296

10.34

posed tissue

Buccal cavity, pharynx

202

33

6.12

Larynx

94

8

11.75

Lung and bronchus

2,609

231

11.29

Esophagus

156

24

6.50

Cancer of indirectly ex

4,547

3,292

1.38

posed tissue

Stomach

390

257

1.53

Intestines

662

597

1.11

Rectum

239

215

1.11

Liver and biliary

176

75

2.35

passages

Pancreas

459

256

1.79

Kidney

175

124

1.41

Bladder

326

151

2.16

Prostate

660

504

1.31

Brain

160

152

1.05

Malignant lymphomas

370

347

1.07

Leukemias

333

207

1.61

All other cancers

597

407

1.47

All cardiovascular

21,413

13,572

1.58

diseases

Coronary heart disease

13,845

8,787

1.58

Aortic aneurysm

900

172

5.23

Cor pulmonale

44

8

5.57

Hypertensive disease

1,107

724

1.53

Cerebral vascular

2,728

2,075

1.32

disease

Peripheral vascular

20

6

3.52

disease

Phlebitis and pulmo

214

175

1.22

nary embolism

Other diseases

1,333

724

1.84

Ulcer of stomach, duo-

365

92

3.97

denum, jejunum denum, jejunum

Cirrhosis of the liver Nephritis, nephrosis, other kidney disease Diabetes

All other diseases

No death certificate found

Source: Data from Rogot and Murray (1980).

and calcification. Though often overlooked, ionizing radiation is a powerful cause of atherosclerosis and premature death from cardiovascular disease.

4. Prospective studies of heavy smokers matched with nonsmokers for numerous confounding variables have consistently shown the relative risk of death from atherosclerosis to be much higher for smokers and directly related to the number of cigarettes smoked.

5. Members of certain religious groups that eschew the use of tobacco, such as Seventh-Day Advent-ists and Latter-Day Saints, have markedly lower morbidity and mortality rates from atherosclerotic disease.

6. Quitting smoking is ordinarily followed by a reduced incidence of coronary heart disease, among specific groups and for the entire population.

7. Experimental studies in animals have demonstrated that tobacco constituents are potent causes of atherosclerotic disease.

The evidence is clear, consistent, and compelling that tobacco smoke is a major cause of atherosclerotic disease and death.

Epidemic Curves

Temporal relationships between twentieth-century epidemic curves for cigarette smoking and death from coronary heart disease, lung cancer, and emphysema/COPD (chronic obstructive pulmonary disease) are presented in Figure III.8.2. The figure shows the massive epidemic of coronary heart disease beginning in the 1920s - a few years after the World War I doubling of cigarette smoking; followed by epidemic lung cancer beginning in the 1930s - 20 "pack years" or 150,000 cigarettes after World War I; followed by epidemic emphysema/COPD beginning in the 1940s - the third decade after World War I. Furthermore, as tar content and per capita cigarette smoking decreased during the last 2.5 years, mortality from coronary heart disease and cerebrovascular disease decreased.

404

150

2.69

349

261

1.34

315

221

.97

2,801

2,100

1.33

849

390

1,000

1,000

1900 19101920 1930 1940195019601970 1980 1990 2000

Figure III.8.2. Cigarette consumption and tobaccosis mortality in the United States, 1900-87. The asterisk indicates that the population exposure to tobacco tars is decreasing faster than the cigarette curve. (From Economic Research Service, U.S. Department of Agriculture; Vital Statistics of the United States; WCHSA Archives [personal communication]; Ravenholt 1962; Walker and Brin 1988; U.S. Department of Health and Human Services.)

1900 19101920 1930 1940195019601970 1980 1990 2000

Figure III.8.2. Cigarette consumption and tobaccosis mortality in the United States, 1900-87. The asterisk indicates that the population exposure to tobacco tars is decreasing faster than the cigarette curve. (From Economic Research Service, U.S. Department of Agriculture; Vital Statistics of the United States; WCHSA Archives [personal communication]; Ravenholt 1962; Walker and Brin 1988; U.S. Department of Health and Human Services.)

Magnitude of the Hazard

Although some astute observers attributed lung cancer to smoking during the 1920s, 1930s, and 1940s, there was little general awareness of this relationship until the publication of case-control studies in 1950 showing that almost all (more than 90 percent) of lung cancer patients were smokers. The association of smoking with cancer of the lung was so obvious, consistent, and understandable that many scientists were readily convinced that smoking was the main cause of that disease. But when a number of prominent statisticians (who were themselves smokers) criticized these studies because of possible biases inherent in retrospective studies, massive prospective studies of morbidity and mortality differentials among smokers and nonsmokers were launched about the same time by the British Medical Association, the American Cancer Society, and the American Veterans Administration. (Among the many publications resulting from these studies were those by Doll and Hill [1952], Hammond and Horn [1958], Dorn [1959], and Rogot and Murray [1980].) The studies showed that smokers not only died from cancers of directly exposed tissues of the mouth, larynx, and lungs, but also died at a greatly accelerated rate from a bodywide spectrum of diseases, especially cardiovascular diseases (Table III.8.4) - thus confirming the finding of Raymond Pearl in 1938 that smoking exerted a profound life-shortening effect.

Furthermore, a matched-pair analysis of American Cancer Society prospective data by E. C. Hammond (1964) enabled this author to construct a Lung Cancer Index to total tobaccosis mortality and the estimate of a quarter million U.S. tobaccosis deaths in 1962 - equal to the sum of all deaths from accidents, infection, suicide, homicide, and alcohol. Truly, for those who smoke a pack or more of cigarettes daily, tobacco is an environmental hazard equal to all other hazards to life combined. In 1967 this estimate was updated to 300,000 deaths for 1966.

During two ensuing decades, U.S. lung cancer deaths alone more than doubled from 48,483 in 1965 to 137,000 in 1987. In 1984, with the help of the Multi-Agency Working Group at the National Institute on Drug Abuse, seeking to achieve an updated, realistic estimate of U.S. tobaccosis mortality during the 1980s, this author applied proportionate analytic methods to 1980 U.S. mortality data; 485,000 tobaccosis deaths from cigarette smoking were estimated that year (Table III.8.5), as were

Table III. 8.5 Estimated number of deaths caused by cigarette smoking in the United States, 1980

Anatomic site or nature of disease or injury No. of (ICD number) deaths

Malignant neoplasms (140-209, 230-9) 147,000

Diseases of the circulatory system (390-459) 240,000 Ischemic heart disease (410-14) 170,000

Other vascular diseases 70,000

Diseases of the respiratory system other than 61,000

cancer (460-519)

Emphysema (492) 13,000

Chronic bronchitis and other respiratory 48,000 diseases

Diseases of the digestive system (520—79) 14,000

Diseases of the esophagus, stomach, and duode- 2,000 num (530-7)

Cirrhosis and other diseases of digestive system 12,000

Certain conditions originating in perinatal pe- 4,000 riod (760-79) (caused by maternal smoking, low birth weight, and other congenital disabilities)

External causes of injury (E800-E999) 4,000

Injuries caused by fire and flames (E890-E899) 2,500

Other accidental injuries 1,500

Miscellaneous and ill-defined diseases 15,000

Total 485,000

Source: Ravenholt (1984).

5 Million Deaths from Tobacco

Tobacco

Alcohol 1 Million Deaths from Alcohol

Other | 300,000 Deaths from Other Addictions AIDS | 70,000 Deaths from AIDS

Figure III.8.3. The price of pleasure: deaths from addictive substances and AIDS in the United States, 1980s. (From Ravenholt 1984 and Centers for Disease Control.)

more than 500,000 tobaccosis deaths from all forms of tobacco use.

This estimate was accepted and used by the American Council on Science and Health and the World Health Organization, but not by the U.S. Office of Smoking and Health (OSH), which preferred a more "conservative" estimate of 320,000 tobacco deaths in 1987, raised to 390,000 in 1988.

Suffice it to say that the annual tobaccosis death toll - whether the OSH "conservative" estimate of 390,000 or the more complete estimate of 500,000 tobaccosis deaths - is far greater than mortality from any other preventable cause of death in our time and more than 25 times greater than current mortality from the acquired immune deficiency syndrome (AIDS), which emerged during the 1980s as a newly recognized and formidable disease entity (Figure III.8.3).

Conclusion

Tobacco owes much of its destructive power to the fact that its lethal effects are not immediately discernible. Initial reactions to smoking like nausea and respiratory distress usually subside, and many persons continue smoking, chewing, or snuffing tobacco for several decades without apparent serious injury or death. When serious illness does occur, it assumes such diverse forms that few comprehend the common cause.

Only recently, during the fifth century of post-Columbian tobacco experience, has medical and epidemiological science advanced sufficiently that the diffuse nature and great magnitude of tobacco's depredations have become fully evident. In the twentieth century alone, we tally these numbers:

In the United States the smoking of 26 trillion cigarettes and 556 billion cigars and the consumption of 25 billion pounds of "manufactured tobacco" (pipe tobacco, chewing tobacco, and snuff) have produced:

more than 2.9 million deaths from lung cancer, more than 7 million deaths from cardiovascular disease, and more than 14 million deaths from all forms of tobaccosis.

During the 1980s, the U.S. tobaccosis death toll was roughly 500,000 annually, for a total of 5 million deaths in the decade. Moreover, even if all tobacco use ceased immediately, many millions would still die of tobaccosis in ensuing decades.

In 1989 the world's inhabitants were smoking 5 trillion cigarettes annually and consuming millions of tons of tobacco as cigars, bidis, chewing tobacco, and snuff, as well as in pipes and hookas. The tobaccosis death toll was more than 2.5 million, and that in the twentieth century more than 50 million.

Considered a global entity with an extraordinarily diffuse, subtle nature and with lifetime latencies, tobaccosis poses the ultimate challenge to epidemiology and to world public health and political leadership.

R. T. Ravenholt

Excerpted and reprinted with the permission of the Population Council from R.T. Ravenholt. 1990. Tobacco's global death march. Population and Development Review 16(2):213-40.

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