1
1267 1. King M. Health is a sustainable state. Lancet 1990; 336: 664-67. 2. King M. Medical care in developing countries. Oxford: Oxford University Press, 1966. 3. Taylor C. Reply to Maurice King. NU 1991; 2: 33. 4. Haran D. Overpopulation and death in childhood. Lancet 1990; 336: 937. 5. Carr-Hill R, Nuura A, Varherisser C. Overpopulation and death in childhood. Lancet 1990; 336: 937-38. 6. Potts M, Anderson R, Boily M-C. Slowing the spread of human immunodeficiency virus in developing countries. Lancet 1991; 338: 608-13. 7. World Development Report 1992. Development and the environment. Washington, DC: World Bank. Published by Oxford University Press. $16.95. 8. Mitra A. More on "Human Entrapment". Natl Med J India 1992; 5: 39. 9. Potts M, Rosenfield A. The fifth freedom revisited: II, the way forward. Lancet 1990; 336: 1293-95. 10. King M. Over-population and death in childhood. Lancet 1990; 336: 1312-13. 11 Antia NH. More on "Human Entrapment". Natl Med J India 1992; 5: 39. Tobacco’s toll "... smoking is a factor, and an important factor, in the production of carcinoma of the lung." In those words, cautiously and with no talk of calculating the global burden of tobacco, Doll and Hill put the case for causation before a largely unsuspecting world. 1 That was over forty years ago, preceding the study in British doctors with which the lung cancer and smoking connection is usually associated. We now know that cancer of the lung is not the whole story: for every tobacco-associated death from that cause there are two or three from other diseases. That has made a bad situation worse. So, predictably, has the increase of lung cancer in women, who came to the smoking habit later than men. Not all is gloom, however. Smoking is on the decrease in the United States and Canada and, more tentatively, in parts of Europe, and the benefits in terms of certain health indices are already discernible. Stopping smoking helps: unless a tumour or other severe cardiorespiratory lesion has already developed, it is not too late. Furthermore, there is now sufficient confidence in the associations for estimations to be made, for public health and health education purposes, of the mortality burden of smoking; and organisations such as the US Surgeon- General’s office and the UK’s Health Education Authority have already done this. In October, 1989, the World Health Organisation convened a consultative group on tobacco-related mortality. The calculations presented in detail this week (p 1268) are the outcome of a process that began then and continued with presentations at the 7th World Conference on Tobacco and Health and in WHO’s Tobacco Alert in January, 1991.2 "Obviously crude" is not a label normally stuck on a set of calculations by Peto and colleagues, but the information for totally confident arithmetic is not available. They have had to make assumptions but have exercised them conservatively, and the few estimates that have been reached by other routes do seem to fit in with the figures presented this week. As Peto and co-workers note, these are approximations despite their apparent precision-but one could lop a zero off some of them and still be impressed. Peto et al make use of 1984-88 deaths in an American Cancer Society study of the smoking habits of a million people in 1982 and mortality in the ensuing years. Total mortality in that study was less than expected, confirming that this huge cohort is not a random sample of the US population. That is one of the reasons for caution. The appendix to Peto and colleagues’ paper (p 1278) contains the first published data from the American Cancer Society inquiry. Readers may by now be sated by press coverage of the crunching numbers developed from this appendix and national demographic data, so we will not repeat them. "Better that than Alzheimer’s disease" is the response to such information that one sometimes gets from fatalists, but the wasted lives enumerated here are often in middle age. That fact and the predictions for females are the major public-health messages of this paper. National governments in the developed world now have estimates of the burden of mortality that smoking imposes on their citizens, male and female. What should they do with them? On May 15 European Community health ministers met to discuss a ban on the advertising of tobacco. They postponed a decision. Opponents of a ban have fallen by one (Denmark); by November, Germany will have had another look at the evidence; and that may be long enough after a general election victory (during which advertising hoardings were provided by cigarette manufacturers) for the UK government no longer to wish to stand alone. If children could be persuaded not to start3 there would be no need to talk of banning smoking-a ban which would be unenforceable anyway. In the United States cigarettes are fast becoming "socially incorrect", and figures in last week’s Economist point to a 30% reduction in cigarette consumption between 1982 and 1990-which brings us on to developing countries. Peto and colleagues are now repeating their calculations for other parts of the world, though this exercise may prove more difficult. One estimate is for 1 million deaths a year in the 1990s out of a world total of 3 million (with a range of uncertainty of ±50%). Faced with falling demand, manufacturers are not cutting supply but seeking and creating new markets. The developed countries, in which much of the cigarette manufacturing business is based, will not be forgiven if they recoup their lost incomes from the increased exploitation of the emerging nations- which include South America and, these days, eastern Europe. In China there is now official recognition, so long denied, of the dangers of tobacco. The Chinese will remember how another product, opium, was forced on their country 200 years ago to finance the export trade. 1. Doll R, Hill AB. Smoking and carcinoma of the lung: preliminary report. Br Med J 1950; ii: 739. 2. Anon. Tobacco Alert 1991 (January issue): 4-7. 3. Vickers A. Why cigarette advertising should be banned. Br Med J 1992; 304: 1195-96. 4. Anon. The search for El Dorado. Economist 1992; 323: 21-24.

Tobacco's toll

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1267

1. King M. Health is a sustainable state. Lancet 1990; 336: 664-67.2. King M. Medical care in developing countries. Oxford: Oxford

University Press, 1966.3. Taylor C. Reply to Maurice King. NU 1991; 2: 33.4. Haran D. Overpopulation and death in childhood. Lancet 1990; 336: 937.5. Carr-Hill R, Nuura A, Varherisser C. Overpopulation and death in

childhood. Lancet 1990; 336: 937-38.6. Potts M, Anderson R, Boily M-C. Slowing the spread of human

immunodeficiency virus in developing countries. Lancet 1991; 338:608-13.

7. World Development Report 1992. Development and the environment.Washington, DC: World Bank. Published by Oxford University Press.$16.95.

8. Mitra A. More on "Human Entrapment". Natl Med J India 1992; 5: 39.9. Potts M, Rosenfield A. The fifth freedom revisited: II, the way forward.

Lancet 1990; 336: 1293-95.10. King M. Over-population and death in childhood. Lancet 1990; 336:

1312-13.

11 Antia NH. More on "Human Entrapment". Natl Med J India 1992;5: 39.

Tobacco’s toll

"... smoking is a factor, and an important factor, inthe production of carcinoma of the lung." In thosewords, cautiously and with no talk of calculating theglobal burden of tobacco, Doll and Hill put the casefor causation before a largely unsuspecting world. 1That was over forty years ago, preceding the study inBritish doctors with which the lung cancer andsmoking connection is usually associated. We nowknow that cancer of the lung is not the whole story: forevery tobacco-associated death from that cause thereare two or three from other diseases. That has made abad situation worse. So, predictably, has the increaseof lung cancer in women, who came to the smokinghabit later than men. Not all is gloom, however.Smoking is on the decrease in the United States andCanada and, more tentatively, in parts of Europe, andthe benefits in terms of certain health indices are

already discernible. Stopping smoking helps: unless atumour or other severe cardiorespiratory lesion hasalready developed, it is not too late. Furthermore,there is now sufficient confidence in the associationsfor estimations to be made, for public health andhealth education purposes, of the mortality burden ofsmoking; and organisations such as the US Surgeon-General’s office and the UK’s Health Education

Authority have already done this. In October, 1989,the World Health Organisation convened a

consultative group on tobacco-related mortality. Thecalculations presented in detail this week (p 1268) arethe outcome of a process that began then andcontinued with presentations at the 7th WorldConference on Tobacco and Health and in WHO’sTobacco Alert in January, 1991.2"Obviously crude" is not a label normally stuck on a

set of calculations by Peto and colleagues, but theinformation for totally confident arithmetic is notavailable. They have had to make assumptions buthave exercised them conservatively, and the fewestimates that have been reached by other routes doseem to fit in with the figures presented this week. AsPeto and co-workers note, these are approximationsdespite their apparent precision-but one could lop azero off some of them and still be impressed. Peto et al

make use of 1984-88 deaths in an American Cancer

Society study of the smoking habits of a million peoplein 1982 and mortality in the ensuing years. Totalmortality in that study was less than expected,confirming that this huge cohort is not a random

sample of the US population. That is one of thereasons for caution. The appendix to Peto and

colleagues’ paper (p 1278) contains the first publisheddata from the American Cancer Society inquiry.Readers may by now be sated by press coverage of thecrunching numbers developed from this appendixand national demographic data, so we will not repeatthem. "Better that than Alzheimer’s disease" is the

response to such information that one sometimes getsfrom fatalists, but the wasted lives enumerated hereare often in middle age. That fact and the predictionsfor females are the major public-health messages ofthis paper.

National governments in the developed world nowhave estimates of the burden of mortality that smokingimposes on their citizens, male and female. Whatshould they do with them? On May 15 EuropeanCommunity health ministers met to discuss a ban onthe advertising of tobacco. They postponed a decision.Opponents of a ban have fallen by one (Denmark); byNovember, Germany will have had another look at theevidence; and that may be long enough after a generalelection victory (during which advertising hoardingswere provided by cigarette manufacturers) for the UKgovernment no longer to wish to stand alone. Ifchildren could be persuaded not to start3 there wouldbe no need to talk of banning smoking-a ban whichwould be unenforceable anyway. In the United States

cigarettes are fast becoming "socially incorrect", andfigures in last week’s Economist point to a 30%reduction in cigarette consumption between 1982 and1990-which brings us on to developing countries.Peto and colleagues are now repeating theircalculations for other parts of the world, though thisexercise may prove more difficult. One estimate is for1 million deaths a year in the 1990s out of a world totalof 3 million (with a range of uncertainty of ±50%).Faced with falling demand, manufacturers are notcutting supply but seeking and creating new markets.The developed countries, in which much of thecigarette manufacturing business is based, will not beforgiven if they recoup their lost incomes from theincreased exploitation of the emerging nations-which include South America and, these days, easternEurope. In China there is now official recognition, solong denied, of the dangers of tobacco. The Chinesewill remember how another product, opium, wasforced on their country 200 years ago to finance the

export trade.

1. Doll R, Hill AB. Smoking and carcinoma of the lung: preliminary report.Br Med J 1950; ii: 739.

2. Anon. Tobacco Alert 1991 (January issue): 4-7.3. Vickers A. Why cigarette advertising should be banned. Br Med J 1992;

304: 1195-96.

4. Anon. The search for El Dorado. Economist 1992; 323: 21-24.