Sir Richard Doll (19122005), Physician,
Epidemiologist, Teacher, Humanitarian, Legend, Activist, Researcher, Public Health lobbyist
Smoking and Health
CONDITIONS TREATED WITH TOBACCO 16th Century
Cough Asthma Headaches Gout Diseases of women Intestinal worms
Stomach cramps
Open wounds
Malignant tumours
SÖMMERING 1795
DOCTORAL THESIS “Carcinoma of the lip is most frequent when people indulge in tobacco pipes. For the lower lip is particularly attacked by carcinoma because it is compressed between the pipe and the teeth”
PERCENTAGE OF MEN ATTENDING MASSACHUSETTS CANCER CLINICS WITH DIFFERENT CANCERS: BY SMOKING HABIT (Potter & Tulley, 1945)
Use of tobacco (no. of men) Cancer of:
buccal cavity 3.7 8.1 11.5 17.9 respiratory tract 0.5 1.1 2.0 1.7 other sites 22.4 25.1 26.0 23.4
None (655) Slight (357) Moderate (1155) Excessive (760)
USE OF TOBACCO BY DISEASE CATEGORY: 86 MEN WITH AND 86 MEN WITHOUT LUNG CANCER (after Müller, 1939)
Type of smoker No. of men
with lung cancer
1Extreme 2Very
healthy controls
4 5
smoker
25 18
heavy smoker
3Heavy
smoker
smoker
13
27 3
22
41 14
4Moderate
Non-smoker
1 10-15
2 7-9
3 4-6
cigars, >35 cigarettes, >50g pipe tobacco/day “ 26-35 “ 36-50g “ “ “ “ 16-25 “ 21-35g “ “ “
4
SMOKING AND LUNG CANCER CASE-CONTROL STUDIES BEFORE 1950
Author
No. of men Percent of:
Lung Controls cancer
Non-smokers Lung Controls cancer
Heavy smokers Lung Controls cancer
65 52 36 27
Müller, 1939 Germany Schairer & Schöniger, 1943 Germany Wassink, 1948 Holland
36 93
86 270
3.5 3.2
16.3 15.9
134
100
4.5
19.0
55
19
TOBACCO AND CORONARY DISEASE (English, Willius & Berkson, 1940)
Men aged (yrs) 40-9 50-9 60+ 40+
†Number
Percent smokers Coronary Others disease 79.7 (149/187)† 71.7 (274/382) 63.8 (275/431) 61.9 (187/302) 73.9 (274/371) 61.8 (202/327)
P*
<0.001 ─ 0.28 0.05
69.8 (698/1000) 66.3 (663/1000)
*P, one-sided of smokers and all men in age group in parentheses
TOBACCO AND CORONARY DISEASE (English, Willius & Berkson, 1940)
Men aged (yrs) 40-9 50-9 60+ 40+
†Number
Percent coronary disease in: Smokers 4.8 (10/208)† 6.2 (24/388) 5.0 (20/404) 5.4 (54/1000) Non-smokers 1.0 (2/208) 2.6 (10/388) 6.4 (26/404) 3.8 (38/1000)
P*
0.01 0.01 ─ 0.04
*P, one-sided
of men with coronary disease and all diseases in age group in parentheses
SMOKING AND LUNG CANCER CASE-CONTROL STUDIES PUBLISHED IN 1950
Author No. of men Lung Controls cancer
82 522
Percent of: Non-smokers Heavy smokers Lung Controls Lung Controls cancer cancer
14.6 23.9 18 9
Schreck et al. USA Levin et al. USA Mills & Porter USA
236
444
481
430 780 649
15.3
7 1.3* 0.3*
21.7
31 14.6* 4.2*
─
─ 51 26
─
─ 19 13
Wynder & Graham 605 USA
Doll & Hill UK
649
*Lifelong non-smokers, with ex-smokers carefully excluded
MORTALITY BY AMOUNT SMOKED RELATIVE TO THAT IN NON-SMOKERS (after Hammond & Horn, 1954)
Age (yrs)
No. of deaths
Regular cigarette smokers smoking (per day): 20 Less than 10-19 or more 10 42 1.7 1.1 1.5 1.0 2.1 1.9 2.2 1.3 8.8 2.5 2.1 2.0 1.1
Cause of death
50-69
50-54 55-59 60-64 65-69
167 377 571 594 605
lung cancer
coronary heart disease
BERKSON’S ALTERNATIVES
“The findings were the result of the interplay of various subtle and complicated biases or had a constitutional basis, involving people who were non-smokers or relatively light smokers, being the kind who were biologically selfprotective and this “correlated with robustness in meeting mortal stress from disease generally”
FISHER’S OBJECTIONS
(i) Smokers with lung cancer reported inhaling less than smokers without (Doll & Hill, 1950) against causation unless it was concluded that “Inhaling cigarette smoke was a practice of considerable prophylactic value in preventing the disease”
FISHER’S OBJECTIONS
(ii) Secular changes in smoking habits could not be related to the increase in lung cancer since “lung cancer has been increasing more rapidly in men relative to women” while “it is notorious, and conspicuous in the memory of most of us, that over the last 50 years the increase among women has been great, and that the increase among men (even if positive) certainly small”
CANCERS CAUSED IN PART BY SMOKING (International Agency for Research on Cancer, 2004)
Bladder Cervix Kidney *Larynx Liver *Lung Myeloid leukaemia Nasopharynx Nose & nasal sinuses *Oesophagus Oral (incl. lip & tongue) *Oro- & hypopharynx Pancreas Stomach Ureter
*Increased more than fivefold
VASCULAR AND RESPIRATORY DISEASE CAUSED IN PART BY SMOKING
*Pulmonary heart disease Subarachnoid haemorrhage
Ischaemic heart disease
Myocardial degeneration Hypertension (fatal) Arteriosclerosis *Aortic aneurysm *Peripheral vascular disease
Cerebral thrombosis
Cerebral haemorrhage
*Chronic obstructive lung disease
Pneumonia Asthma Pulmonary tuberculosis
*Buerger’s disease
*Increased more than five-fold
OTHER CONDITIONS CAUSED IN PART BY SMOKING
Gastric ulcer Periodontitis
Duodenal ulcer
Crohn’s disease Osteoporosis Reduced fecundity
*Tobacco amblyopia
Age-related macular degeneration
Cataract Facial skin wrinkling
Reduced growth of fetus
*Palmoplantar pustulosis
*Increased more than five-fold
UK male doctors born 1900-1930: continuing cigarette vs never smokers. 50-year follow-up of mortality, 1951-2001