Academic journal article Bulletin of the World Health Organization

Smoking and Carcinoma of the Lung

Academic journal article Bulletin of the World Health Organization

Smoking and Carcinoma of the Lung

Article excerpt

In England and Wales the phenomenal increase in the number of deaths attributed to cancer of the lung provides one of the most striking changes in the pattern of mortality recorded by the Registrar-General. For example, in the quarter of a century between 1922 and 1947 the annual number of deaths recorded increased from 612 to 9,287, or roughly fifteenfold. This remarkable increase is, of course, out of all proportion to the increase of population--both in total and, particularly, in its older age groups. Stocks (1947), using standardized death rates to allow for these population changes, shows the following trend: rate per 100,000 in 1901-20, males 1.1, females 0.7; rate per 100,000 in 1936-9, males 10.6, females 2.5. The rise seems to have been particularly rapid since the end of the first world war; between 1921-30 and 1940-4 the death rate of men at ages 45 and over increased sixfold and of women of the same ages approximately threefold. This increase is still continuing. It has occurred, too, in Switzerland, Denmark, the U.S.A., Canada, and Australia, and has been reported from Turkey and Japan.

Many writers have studied these changes, considering whether they denote a real increase in the incidence of the disease or are due merely to improved standards of diagnosis. Some believe that the latter factor can be regarded as wholly, or at least mainly, responsible--for example, Willis (1948), Clemmesen and Busk (1947), and Steiner (1944). On the other hand, Kennaway and Kennaway (1947) and Stocks (1947) have given good reasons for believing that the rise is at least partly real. The latter, for instance, has pointed out that "the increase of certified respiratory cancer mortality during the past 20 years has been as rapid in country districts as in the cities with the best diagnostic facilities, a fact which does not support the view that such increase merely reflects improved diagnosis of cases previously certified as bronchitis or other respiratory affections." He also draws attention to differences in mortality between some of the large cities of England and Wales, differences which it is difficult to explain in terms of diagnostic standards.

The large and continued increase in the recorded deaths even within the last five years, both in the national figures and in those from teaching hospitals, also makes it hard to believe that improved diagnosis is entirely responsible. In short, there is sufficient reason to reject that factor as the whole explanation, although no one would deny that it may well have been contributory. As a corollary, it is right and proper to seek for other causes.

Possible Causes of the Increase

Two main causes have from time to time been put forward: (1) a general atmospheric pollution from the exhaust fumes of cars, from the surface dust of tarred roads, and from gas-works, industrial plants, and coal fires; and (2) the smoking of tobacco. Some characteristics of the former have certainly become more prevalent in the last 50 years, and there is also no doubt that the smoking of cigarettes has greatly increased. Such associated changes in time can, however, be no more than suggestive, and until recently there has been singularly little more direct evidence. That evidence, based upon clinical experience and records, relates mainly to the use of tobacco. For instance, in Germany, Muller (1939) found that only 3 out of 86 male patients with cancer of the lung were non-smokers, while 56 were heavy smokers, and, in contrast, among 86 "healthy men of the same age groups" there were 14 nonsmokers and only 31 heavy smokers. Similarly, in America, Schrek and his co-workers (1950) reported that 14.6% of 82 male patients with cancer of the lung were non-smokers, against 23.9% of 522 male patients admitted with cancer of sites other than the upper respiratory and digestive tracts. In this country, Thelwall Jones (1949--personal communication) found 8 non-smokers in 82 patients with proved carcinoma of the lung, compared with 11 in a corresponding group of patients with diseases other than cancer; this difference is slight, but it is more striking that there were 28 heavy smokers in the cancer group, against 14 in the comparative group. …

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