Cancers of the bladder, pancreas, kidney, stomach and cervix are causally related to tobacco smoking and there have been suggestions of an association with cigarette smoking and an increased risk of leukaemia and colorectal cancer although the causal nature of these latter associations has not been accepted.
Because of the length of the latency period, tobacco-related cancers observed today are related to cigarette smoking patterns over two decades ago. Consequently, following any decrease in smoking prevalence there will be a period of time which will elapse before any decrease in the incidence of tobacco-related cancers becomes apparent.
There is now strong evidence of the adverse health consequences of Environmental Tobacco Smoking (ETS) sometimes referred to as passive smoking. On the basis of the available epidemiological data, the United States Environmental Protection Agency declared in 1992 that ETS was a proven lung carcinogen in humans.
The risk of lung cancer is increased in non-smoking women who have husbands who smoke tobacco. There also appears to be an increased risk of myocardial infarction due to exposure to ETS and the adverse health consequences in children whose parents smoke includes an increase in the frequency and severity of asthma and of upper and lower respiratory tract infections.
Tobacco can kill in over twenty different ways including causes such as lung cancer and other forms of cancer, heart disease, strokes and chronic bronchitis and other respiratory diseases. Smokers have three times the death rate in middle-age (between the ages of 35 and 69) than non-smokers and about half of regular cigarette smokers will eventually die from their habit.
Many of these are not particularly heavy smokers but they can be characterised by starting smoking in their teenage years. Half of the deaths from tobacco will take place in middle age (35-69) and each will lose approximately 20-25 years of non-smokers life expectancy: the remaining half of the deaths will take place after the age of 70. However, there is clear and consistent evidence that stopping smoking before having cancer or some other serious disease avoids most of the later excess risk of death from tobacco even if smoking stops in middle age.
It is estimated that world-wide, smoking kills three million people each year: the second half of the Twentieth century was notable in that there was estimated to have 60 million deaths caused by tobacco world-wide. In most countries the worst consequences of the Tobacco Epidemic are yet to come, particularly among women in developed countries and in populations of developing countries, since by the time the young smokers of today reach middle or old age there will be about ten million deaths each year from tobacco.
Approximately 500 million of the world's population today can expect to be killed by tobacco, 250 million of these deaths being premature and occurring in middle age.
The situation in Europe is particularly worrying. The European Union is the second largest producer of cigarettes (694 billion in 1993) after China (1,675 billion) and the major exporter of cigarettes (218 billion). In Central and Eastern Europe there is a continual increase in the smoking habit. Of the six World Health Organisation (WHO) regions, Europe has the highest per capita consumption levels of manufactured cigarettes and faces an immediate and major challenge in meeting the WHO target for a minimum of 80 per cent of the population to be non-smoking.
Currently (Spring 1994) in the European Union, 42% of men and 28% of women are regular smokers. The smoking prevalence in women is artificially lowered by the low rates reported in southern Europe where there is evidence that these rates are rising and seem set to continue to rise over the next decade. In addition, smoking prevalence in the age range 25-39 years is high (55 per cent in men and 40% in women) and can be expected to have a profound influence on the future cancer pattern. It is especially concerning that the smoking prevalence among General Practitioners, who play an exemplary role in health behaviour, remains high in many parts of Europe. This should be a target for immediate action.
It has been demonstrated that changes in cigarette consumption are affected mainly at a sociological level rather than by actions, such as individual smoking cessation programmes, targeted at individuals. Actions such as advertising bans and increases in the price of cigarettes influence cigarette sales particularly among adolescents. Therefore, a Tobacco Policy is necessary to reduce the health consequences of tobacco, and experience shows that this should be targeted via a variety of actions aimed to stop young people starting smoking and to help smokers to quit.
To be efficient and successful, a tobacco policy has to be comprehensive and maintained over a long time period. Increased taxes on tobacco, total bans on direct and indirect advertising, smoke-free enclosed public areas, education, effective health warning labels on tobacco products, a policy of low maximum tar and nicotine levels in cigarettes, encouragement of stopping smoking and individual health interventions have to be implemented.
The importance of adequate intervention is demonstrated by the low lung cancer rates in Scandinavian countries which, since the early 1970s, have adopted integrated central and local policies and programmes against smoking. In the United Kingdom, tobacco consumption has declined by 30% since 1970 and lung cancer mortality among men has been decreasing since 1980 although the rate remains high. In France, between 1992 and 1993 there has been an 3% reduction in tobacco consumption due to the implementation of anti-tobacco measures introduced by the Loi Evin.
Hence, the first point of the European Code Against Cancer is:
DO NOT SMOKE. Smoking is the largest single cause of premature death.
SMOKERS: STOP AS QUICKLY AS POSSIBLE. In terms of health improvement, stopping smoking before having cancer or some other serious disease avoids most of the later excess risk of death from tobacco even if smoking stops in middle age.
DO NOT SMOKE IN THE PRESENCE OF OTHERS. The health consequences of your smoking may affect the health of others around you.
IF YOU DO NOT SMOKE, DO NOT EXPERIMENT WITH TOBACCO. Most who experiment become regular smokers: it is difficult to stop once you have started.