Blackwell Science, LtdOxford, UKRESRespirology1323-77992002 Blackwell Science Asia Pty Ltd8286290Original ArticleHistory of tobacco and healthAW Musk and

NH de Klerk

Respirology (2003) 8, 286–290

INVITED REVIEW SERIES: TOBACCO AND LUNG HEALTH

History of tobacco and health

Arthur William MUSK1,2 AND Nicholas Hubert DE KLERK2,3

1
Sir Charles Gairdner Hospital, Nedlands, 2School of Population Health, University of Western Australia,
3
Centre for Child Health Research, University of Western Australia, Western Australia, Australia

History of tobacco and health

MUSK AW, DE KLERK NH. Respirology 2003; 8: 286–290
Abstract: Tobacco comes from plants that are native to the Americas around Peru and Ecuador,
where it has been found since prehistoric times. It was brought back to Europe by early explorers
where it was adopted by society and re-exported to the rest of the world as European colonization
took place. Smoking tobacco in pipes of one sort or other gave way to handmade and then manu-
factured cigarettes, especially during the First World War. Smoking rates increased dramatically dur-
ing the 20th century in developed countries until recently and rates are still increasing in
underdeveloped countries. An epidemic of smoking-related diseases has followed the prevalence of
smoking. Scientific knowledge of the harmful effects of active tobacco smoking has accumulated
during the past 60 years since early descriptions of the increasing prevalence of lung cancer. The first
epidemiological studies showing an association between smoking and lung cancer were published in
1950. In 1990 the US Surgeon General concluded that smoking was the most extensively documented
cause of disease ever investigated but governments worldwide have been ambivalent and slow in
taking action to reduce smoking. Tobacco smoking is now agreed to be a major cause of a vast num-
ber of diseases and other adverse effects. Since the 1980s passive smoking including exposure in
utero has also been implicated as a significant cause of numerous diseases. In response, the tobacco
industry has managed to forestall and prevent efforts to control this major health problem.

Key words: adverse effects, cigarettes, smoking, tobacco.

BACKGROUND cultivated since about 5000–3000 BC. The use of

tobacco was universal throughout the American con-
Tobacco and mankind have been associated in the tinents (and Cuba) by the time that Christopher
same way as food and tea since before history began. Columbus arrived in North America in 1492.1
Its ancient origins and how it subsequently insinu- The practice of smoking appears to have arisen
ated itself into modern society have been described in from snuffing, as snuffing instruments are among the
detail by Gately.1 Nicotiana tabacum and Nicotiana most ancient tobacco-related artifacts that have been
rustica are native plants of the Americas having found. However, tobacco was not only sniffed and
evolved in the Andes around Peru/Ecuador. Men smoked but chewed, eaten, drunk (like tea), smeared
came across them (along with more useful plants over bodies (to kill lice and other parasites), and used
such as tomatoes, potatoes, maize, cocoa and rubber) in eye drops and enemas. It was blown into warriors’
about 18 000 years ago when they migrated to the faces before battle, over fields before planting (it is
American continents from Asia across the Bering still used as an insecticide in agriculture) and over
Straight land bridge. Tobacco is thought to have been women before sex. It was used medicinally for its
analgesic and antiseptic properties and as a cure for a
variety of ailments. It was offered to the gods and used
in religious ceremonies. It had both real and mystical
qualities. All sorts of implements were invented and
Correspondence: A. William Musk, Department of used to administer it but the most enduring method
Respiratory Medicine, Sir Charles Gairdner Hospital, of administration ever since these distant times has
Verdun Street, Nedlands, WA 6009, Australia. Email: been smoking. Tobacco was smoked rolled up in
[email protected] cigars but the most popular method in ancient times
 14401843, 2003, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1046/j.1440-1843.2003.00483.x by Cochrane Philippines, Wiley Online Library on [16/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
History of tobacco and health 287

was in a pipe of one sort or other which came to serve enhances its rapid absorption and potentiates the
both social and ritual functions. addictive nature of the product. Cigarette smoking
The first Europeans to smoke were members of has been taken up worldwide since then and has been
Columbus’ crew when they reached Cuba in 1492. described as ‘a tragic accident of history’.3
Almost from the outset, smoking was described as an
evil and harmful practice by the Europeans but it
seems that spiritual revulsion and danger to health ADVERSE HEALTH EFFECTS
have never been sufficiently long-lasting to prevent
people from engaging in tobacco use. The first Euro- Active smoking
pean smoker is reputed to have been imprisoned in a
dungeon in Spain for 3 years by the inquisition for Scientific proof of King James I’s assertion and the
smoking in public on his return from America. How- wisdom of the inquisition have taken time to accu-
ever, the purported medicinal properties of tobacco mulate but there has been indisputable evidence that
resulted in its seeds being brought back to Spain and tobacco is the leading preventable cause of death in
Portugal for cultivation there, initially in palace gar- developed countries, and has been for over half a
dens, thereby commencing its long association with century.
royalty and with royal endorsement. It is one of the A rising incidence of lung cancer was first observed
many ironies of tobacco that two of its first claimed in the 1920s and 1930s by pathologists and other
medical properties were its potential to cure and medical practitioners.3,4 The first major and almost
also to prevent cancer. This latter claim resulted conclusive evidence in the modern history of the
in tobacco being used by healthy people (initially in effects of smoking on health occurred in 1950 with the
France as snuff) who, like many who have succeeded publication of four retrospective studies of smoking
them, became addicted. habits of lung cancer patients.5–8 The first longitudinal
The British first obtained their tobacco by plunder- study of this association by Hammond and Horn con-
ing Spanish ships en route back from America. Sir firmed increased death rates for cigarette smokers
Francis Drake brought tobacco back from his circum- according to the amount they smoked.9 In July 1957
navigation of the globe in 1580 while some tobacco the US public health service issued its first statement
may have been brought back from the Caribbean in on cigarette smoking as a cause of lung cancer10 and
the 1560s. Sir Walter Raleigh brought tobacco back in 1962 the Royal College of Physicians of London11
from his first Virginian expedition in 1586. Gately reviewed the scientific evidence available at the time
states that tobacco was certainly in use in England by on smoking and health and concluded that the rela-
1571 by shipmasters and others coming back from the tionship between smoking and lung cancer was a
New World.1 Smoking was taken up in the court of causal one. The US Surgeon General commissioned
Elizabeth I, even by the Queen herself, and then of further investigations which came to virtually the
course by affluent English society and anyone who same conclusions:10,12,13 that cigarette smoking was ‘a
could afford it; tobacco was expensive so the English serious hazard to health and is related to illness and
started to grow their own. Tobacco use has since death from lung cancer, chronic broncho-pulmonary
spread worldwide as European colonization pro- disease, cardiovascular disease and other diseases’. A
ceeded during the subsequent centuries. further report was issued in 197114 to incorporate ‘a
King James I of England is famous for his accurate great deal of new research’ and reviewed the growing
and prophetic description of tobacco smoking as ‘a understanding of the ‘bio-mechanisms whereby cig-
custom loathsome to the eye, hateful to the nose, arette smoking adversely affects the human organism
harmful to the brain, dangerous to the lungs and and contributes to the development of serious illness’.
in the black, stinking fume thereof nearest resem- None of the conclusions of these early reports have
bling the horrible Stygian smoke of the pit that is been found to be significantly incorrect in the moun-
bottomless’.1 tains of data that have accumulated over the years
Manufactured cigarettes, made by a combination that have followed. Additional associations have been
of hand and machine and later by machine alone, demonstrated and in Australia, a country with less
were first marketed in England in the 1850s. Their than 20 million inhabitants, tobacco smoking kills
convenience, especially in the trenches in the First 19 000 smokers and 2400 non-smokers each year.3
World War has resulted in them being the most pop- This toll exceeds the deaths resulting from alcohol
ular nicotine delivery devices ever since, especially abuse, AIDS, traffic accidents, murders and suicides
since their construction with cork tips and then filters combined. One regular smoker in two dies from a
and especially as their contents can be readily manip- smoking-related disease (i.e. dies prematurely).15,16
ulated by the manufacturer.2 Unfortunately the Smoking is now identified as a major cause of heart
smoke from cigarettes is more acidic than that from disease, stroke, peripheral vascular disease, COPD,
pipes and cigars and requires inhalation into the cancers of the lung, oral cavity, larynx, oesophagus,
lungs for effective uptake of nicotine, while the nico- stomach, kidney, bladder, pancreas, cervix, vulva,
tine of pipes and cigars can more readily be absorbed penis, anus, and possibly others.3,17–19 Other health
through the oral mucosa. Uptake through the lung problems such as impaired fitness, peptic ulcer dis-
provides not only a more immediate sense of satisfac- ease, premature skin ageing with wrinkles, osteoporo-
tion to the smoker as the nicotine is short-circuited to sis, impaired fertility (including impotence) in males
the brain, but also exposes a much greater surface and females, snoring, abortion and ectopic preg-
area of respiratory epithelium to the smoke, which nancy, inflammatory bowel disease, cataracts and
 14401843, 2003, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1046/j.1440-1843.2003.00483.x by Cochrane Philippines, Wiley Online Library on [16/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
288 AW Musk and NH de Klerk

increased complications of surgery, diabetes and bronchial responsiveness in children with asthma
hypertension3,19,20 exist. Cigarettes, and cigarette and enhance sensitization of children to allergens,
lighters may cause burns directly, and cigarette smok- and suggested that these early changes may be the
ing is associated with risk of setting fire to property precursors of impaired lung function in later life (such
with potentially devastating effects. Tobacco smoking as through retarded lung growth or persistent bron-
increases the risks associated with various occupa- chial hyper-responsiveness). The review also con-
tional exposures particularly asbestos,21 where it acts cluded that passive smoking contributes significantly
multiplicatively to increase the risk of lung cancer and to the risk of sudden infant death syndrome and may
contributes to the long-term effects of occupational increase the risk of death from all causes.
exposures on bronchitis and lung function.22

Environmental tobacco smoke exposure THE ASBESTOS ANALOGY

Environmental tobacco smoke exposure has more The chronology of events surrounding the scientific
recently been shown to be an important cause of discovery of the harmful effects of tobacco parallels
smoking-related diseases especially since the case- that of asbestos. Asbestos is also a substance that has
control study of Trichopoulos in 198123 of the smoking been used since antiquity; it was used in the wicks of
habits of the spouses of non-smoking female resi- the lamps of the Vestal Virgins. Its harmful effects
dents of Athens, although the dangers of environ- were not clearly demonstrated until the 20th century
mental tobacco smoke to children were when asbestosis was identified as an obvious hazard
demonstrated in the 1970s.24–26 Since then, further of exposure to asbestos (in the 1920s).28 Sir Richard
evidence has accumulated and knowledge of the Doll demonstrated its connection with lung cancer in
effects of environmental tobacco smoke exposure has 1955, only 5 years after he had shown that tobacco
increased, as may have been anticipated given the smoking caused lung cancer,29 while Christopher
nature of the exposure and the known dose–response Wagner showed its association with malignant pleural
characteristics of carcinogens. mesothelioma in 1959.30 There was subsequently, and
In the 1997 review of the literature by the National had been previously (particularly after a German
Health and Medical Research Council of Australia27 it report indicating an association with lung cancer in
was estimated from 34 studies that people who never the 1930s and other sporadic reports relating asbestos
smoke but live with a smoker have a 30% increased exposure with ‘endothelioma of the pleura29), intense
risk of developing lung cancer compared with people activity by the asbestos industry attempting to
who never smoke and live with a non-smoker. This obscure and discredit this evidence, in very similar
estimate did not take into account exposure outside fashion to the way tobacco companies have behaved
the home or the effects of passive smoking on current in the last 50 years.31
smokers or ex-smokers. The report also reviewed 48 The subsequent sequence of events has been
studies of the relationship between passive smoking somewhat different. Asbestos use and handling in the
and asthma and it was estimated that children developed industrialized world has been tightly regu-
exposed to environmental tobacco smoke are about lated and virtually eliminated, with the provisions
40% more likely to suffer from asthma symptoms than often being somewhat less stringent for chrysotile
children who are not exposed, such that about 8% of (white asbestos) although this process took nearly 20
childhood asthma in Australia is attributable to pas- years to start and another 20 years to complete). How-
sive smoking and the effect is greater in the children ever, there is still little effective regulation on tobacco
of mothers who smoke more heavily. On the basis of consumption with the exception of regulation of sales
25 studies, it was also estimated that children exposed to children, and in some more progressive societies,
to environmental tobacco smoke during the first 18 of tobacco promotion and smoking in enclosed and
months of life have a 60% increase in the risk of devel- public places. These actions have had a disappoint-
oping lower respiratory illnesses such as croup, bron- ing, although significant, impact on tobacco sales
chitis, bronchiolitis and pneumonia. It was estimated such that tobacco use is still widespread. The expla-
that 13% of lower respiratory illnesses in Australian nations for the differences in the ability of society to
children 18 months of age or younger are attributable control tobacco and asbestos are unclear but there
to passive smoking. On the basis of 16 studies it was are clear differences in the ability of the manufactur-
estimated that the risk of heart attack or death from ers to circumvent legislation and litigation, and differ-
coronary heart disease was about 24% higher in ent perceptions of the victims of diseases caused by
people who never smoked but are exposed to envi- the products as to who is responsible for their dis-
ronmental tobacco smoke. There were studies that eases. In the instance of the smoker with disease there
showed that environmental tobacco smoke exposure is a much greater tendency to accept blame for having
is also associated with symptoms of upper airway irri- inflicted the illness on him or herself even though the
tation and short-term changes in lung function even tobacco industry has been found to have withheld
in non-asthmatics, but there was no direct evidence information for decades about the addictive and
to implicate passive smoking as a cause of COPD. It deleterious effects on health of its products.2 The
did point out that maternal smoking in pregnancy tobacco industry has been much more able to influ-
and postnatal exposure to environmental tobacco ence the political process than the asbestos industry,
smoke may alter lung structure and function, increase which has been much more readily identified as a ‘vil-
 14401843, 2003, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1046/j.1440-1843.2003.00483.x by Cochrane Philippines, Wiley Online Library on [16/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
History of tobacco and health 289

lain’ inflicting its product on people who must work the British Chancellor of the Exchequer saying ‘We at
with it for the financial wellbeing of themselves and the Treasury do not want too many people to stop
their families. Collective legal and legislative action smoking’.33
(through the trade union movement) has been more Latterly, some state governments in Australia have
readily available to people with asbestos-related dis- at least diverted tobacco taxes towards research into
eases than to individual people with smoking-related health promotion and lowering smoking rates,
diseases. The anti-smoking movements have had few although it is not completely clear, given the widening
financial resources to engage in litigation and it has differential in smoking rates between rich and poor,
only been in the recent past that lawyers, with altru- whether this is not just another tax on the unem-
istic motives or with realistic expectations of contin- ployed and working classes, similar to state lotteries.
gency payments, have been willing to challenge the Current information indicates that tobacco smok-
tobacco industry. Lastly, cigarettes are probably the ing is still responsible for huge numbers of deaths in
best designed addictive drug delivery systems ever Western societies where anti-smoking activities are
devised, while the attractions of inhaling asbestos slowly gathering momentum. If trends in these activ-
dust are few. ities continue, especially if they are successful in
financially disrupting the industry, then real impro-
vements in health will follow. It will be important
that the gains achieved in these countries are also
THE FUTURE
achieved in other countries where the prevalences of
smoking remain unacceptably high and are still
While smoking rates have been declining in devel-
increasing.
oped countries they continue to increase in much of
As long ago as 1990 the US Surgeon General pro-
the developing world. Politicians worldwide have
nounced that ‘it is safe to say that smoking represents
been complicit with the industry, further impeding
the most extensively documented cause of disease
progress towards smoking control. The known bene-
ever investigated in the history of biomedical
fits of tobacco to health are few (weight control,
research’19 having by 1989 examined over 57 000
improvement in mood3,32) and cannot justify the con-
reports on the relationship between cigarette smok-
tinued marketing of tobacco.
ing and disease.18 It would be interesting to compare
the costs of this documentation with the current
expenditure on prevention and then with the profits
CONCLUSIONS still being enjoyed by tobacco companies, their share-
holders and those to whom they pay tax.
The tobacco industry has consistently refused to
accept the evidence of the harmful effects of active
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