- Email: [email protected]
Lung cancer and tobacco control
Lung Cancer 29 (2000) 75 – 78 www.elsevier.nl/locate/lungcan
Commentary
Lung cancer and tobacco control What do we have to do … more? G. Motta * Department of General and Thoracic Surgery, Uni6ersity of Genoa, Largo Rosanna Benzi, 8I-16132 Geno6a, Italy
Just after being committed as President Elect of the International Association for the study of Lung Cancer (IASLC) in August 1994 at the 7th World Conference on Lung Cancer of Colorado Spring, once back home, I felt obliged to inform the Genoa citizens about lung cancer and the close relationship with tobacco smoking. It should also have represented the starting point of my personal action against cigarette smoking to be developed in the whole of Italy. The IASLC board had approved a ten-point program of tobacco control policy, which covered the most important aspects of the problem, from the tax increases on tobacco product to the plans to encourage smoking cessation [1]. Actually, it was the last step forward for the IASLC, to enter the present role as the world leader Society on Lung Cancer. The second decision was represented by the obligation taken by each officer, to personally pursue antismoking campaigns in his own country. Therefore, when the concerned Director of an Italian newspaper offered me two pages of the local Genuese edition, I filled this space with the following four titles, ‘Prevention and surgical ap* Tel.: +39-010-352982; fax: + 39-010-3537262. E-mail address: [email protected] (G. Motta).
proach to lung cancer’, ‘Three weapons for defeating the killer’, ‘Sparing tissue and pulmonary function through the advanced sleeve bronchial resection and reanastomosis’, and ‘Tar and nicotine: a ravager combination’. The last issue informed in depth about the various carcinogens produced by tar and nicotine while burning as well as the addictive effect of nicotine and its virus HIV epidemic-like diffusion among the young generations. Lastly, updated information was also given on the industrial process of modern cigarette making. The last information, which I had just received during the Colorado Springs Conference [2–4], was presenting cigarette as a finished good made by a mixture of chemically refined and somewhere else previously extracted nicotine, with minced residual of dried tobacco leaves and stalks, tobacco powder, glues, ashes, vegetable strengthening fibers and finally, a series of wetting, moistening and seasoning of other compounds! The Genuese citizens showed great interest in reading such news, as demonstrated by the number of telephone calls I received in the following days and the requests of more information about the real nature of cigarettes! Unfortunately, my own positive feeling of having contributed in some way to the campaign
0169-5002/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 9 - 5 0 0 2 ( 0 0 ) 0 0 1 0 7 - 0
76
G. Motta / Lung Cancer 29 (2000) 75–78
against tobacco smoking, suddenly turned into a worrying problem! Shortly afterwards, I was notified by the professional Order of Doctors of the accusation of trying to get personal profit by promoting my image through improper writing about lung cancer and the connected risk of cigarette smoking. As a matter of fact, and it is hard to believe, I really was under the threat to be banished from the professional Order if I was not able to demonstrate my loyalty and the truthfulness of my writing! The disappointing situation cleared up, God willing, 6 months later, when I defended myself victoriously during a debate held in camera, in front of an investigating commission of Colleagues. I gave them an exhaustive and well-documented lecture on lung cancer, the cigarette smoking epidemic through nicotine addiction, and the carcinogenicity of tobacco smoke. I received strong support from Professor Silvio De Flora, a colleague of mine at the Faculty of Medicine, who allowed me to show the latest highly demonstrative and first-hand findings of his studies upon the carcinogenesis process in the lungs of smokers [5,6]. Meanwhile, I was forced to bear the depressing view of many judging colleagues smoking during the debate! No other comment to this paradigmatic and really disturbing personal experience, apart from the following one: Genoa is the largest port in Italy, through which tons of cigarettes enter the Italian market every day! In the following years, during my official journey for IASLC, I had further opportunity to realize the hugeness of the tobacco sources in the world. There are, indeed, enormous extensions of tobacco cultivation at low expense scattered in developing countries, and supervised by only a few, but very well rewarded experts, who are able to estimate the quality of a whole field through a simple look at the leaves! The other face of the problem, well known to all of us, is represented by the enormous population of smokers world-wide who, even if largely different in their lifestyle according to the geopolitical distribution, are strongly determined to continue their smoking habit, in spite of the warnings received on the demonstrated tendency to
develop, besides cancers of other organs and cardiovascular diseases, lung cancer, starting from their middle age. These epidemiological warnings can not be applied to the populations living in developing countries, since their average lifetime is still much shorter, basically due to other kinds of epidemics and the frequent social disturbances, which on the whole, affect survival. Therefore, statistical comparison with the wealthy population can not be made, as far as the age at risk is concerned, nor other consistent clinical studies on lung cancer in general. On the contrary, what results to be absolutely comparable with the industrialized world, is the incorrigible tendency of smoking cigarettes, strictly correlated with the strong influence exerted, upon all the social strata, by the appealing cigarette packages, the addicting effect of nicotine and, finally the power of the imagery through a diffused advertising. Moreover, the only possibility to objectively evaluate the smoking diffusion there, is compulsorily bound to the official data of the cigarette wholesale, which is not reliable at all! Another negative condition, peculiar to these developing countries is that in reality all official plans for the health control and support, are mainly addressed to the major problem of lowering the mortality rate among children and the younger generations. In other words, this means that while they play the role of an endless source of nicotine in the world, in such countries the long-term health problems of tobacco smoking are still slow to appear! Now, coming back to the core of the problem, we have to realize that, presently, according to the European Committee Against Cancer [7], tobacco smoking is the major cause of all ‘premature deaths’ in Europe. In developed countries such as Europe, Japan and North America, between 83 and 92% of lung cancers in men, and between 57 and 80% of lung cancers in women, are attributable to cigarette smoking. On the other hand, in spite of the largest information campaigns on the relationship between tobacco consumption and cancer, especially lung cancer, and the tobacco control policy developed by the major International Organizations for the Health Control, it is doubtful whether the present
G. Motta / Lung Cancer 29 (2000) 75–78
critical situation will significantly change within the next couple of decades. Lung cancer will thus continue to be an increasingly common cancer in the world and a dominating disease within oncology. Meanwhile, it has become a big burden on the national health care systems with a still rising economical negative trend. While a decrease is registered in lung cancer cases, especially in males living in some highly developed countries where the recipient governments really implement the active policy against tobacco, the overall incidence of lung cancer on a global basis, unfortunately, continues to rise. Furthermore, if one stops to think on how the value of life is nowadays progressively considered less even in the industrialized part of the world, as it appears in the daily news, a feeling of pessimism could easily arise, while the spontaneously question, ‘what do we have to do … more?’ becomes, day by day, more and more difficult to answer. Reflecting on this problem, one can not help recognizing that some positive positions at least within developed countries have already been acquired. The ban on smoking in work places and public areas, transportation, etc., the ban on advertising and promotion of tobacco products, the written health warning upon the products to sell; the increasing number of indemnity trials against tobacco companies already won in USA, and the latest direction sent by the maximum world Financial Authority to the National Agencies, to definitively operate upon the cigarette prices, are great conquests of a tobacco control policy, which started about 70 years ago. Single outstanding physicians at the beginning, then, group of scientists, scientific societies, the government health branches, opinion leaders, the families of patients lost and even, some single brave patients who devoted their residual life span to fighting cigarette smoking publicly, are the representatives of this ongoing humanitarian movement. In such an involving concern, it is normal to ask oneself, how one must consider the position of the health professionals, physicians and other paramedicals, the majority of whom are smokers? Can we still let them play the unbelievable role of one, who is touching fire being sure not to be burnt? Or, even worse, can we continue doing our
77
policy against tobacco, ignoring completely the basic help of their expected capillary action against smoking, which results as effective as being targeted at individuals? Of course, the correct combination of the personal example of being a non-smoker and the professional speech with words properly addressed to the single patient’s personality, could really be effective weapons against smoking, in the hands of these colleagues. Historically, British doctors served Richard Doll [8] in shaping the fundamentals of lung cancer epidemiology on smokers, and many of them stopped smoking and saved their lives after learning the related lesson, since the publication of the preliminary report in 1950 [9]. Nevertheless, in spite of this evidence, the smoking habit and, worse still, a general indifference towards the problem of tobacco, are largely diffuse among our colleagues. In a recent survey among Argentina’s leading physicians [10,11], it was shown that almost 25% of them were smokers while the 40% usually do not ask their patients if they smoke. Moreover, about 40% of the study group reported the non existence of restriction policies in their work places while, when such restrictions did exist, about one half of the physicians did not actually obey such directions! At the end of this concerned analysis, the question could again arise, while now expressed better as, can we afford to ignore this expected help or, instead, should we do our best upon such classes of professionals, aimed at recalling them to a real positive action? IASLC, fully aware of the general critical situation, has recently planned a world-based educational programme on lung cancer and the related preventive actions. It consists of a series of postgraduate medical course directly performed in developing countries where IASLC, besides financially supporting the local medical faculties entrusted in organizing the course, directly sponsored the attendance of its own three-member faculties, which basically served as the scientific core for each course. In the last 2 years, five courses have been given, in Chandigarh (India), Chaing May (Thailand), Sao Paulo (Brazil), Shenyang (People’s Republic
78
G. Motta / Lung Cancer 29 (2000) 75–78
of China) and Amman (Jordan). At each of these, the IASLC faculty worked not only to update the local audience about the major problems of lung cancer, from the molecular to the clinical aspects of the disease, but also to discuss the preventive measures to be taken. In addition, they systematically monitored and properly stimulated the attention of the local colleagues upon the problem of cigarette smoking. Therefore, while including this last really eyeopening world-wide experience among the relevant issues to be considered, we can hopefully conclude that another way to give strong support to the ongoing general plans on the Tobacco Control Policy, does exist. In prospect, the goal can be reached, indeed, provided that we are ready to entrust a new task to the teaching benches of the medical schools. It could mean for the next generations of colleagues a new clause in the Hippocratic oath, I will never smoke!
References [1] Tobacco policy recommendations of the International Association for the Study of Lung Cancer (IASLC): a ten point program. Lung Cancer 1994;11:405–407.
.
[2] Douglas CE. The tobacco industry’s manipulation of nicotine: root cause of the modern lung cancer epidemic. Lung Cancer 1994;11(2):2 – 3. [3] Goodman E. How the mad scientist dispense addiction. Baltimore Sun (reproduced from Boston Globe), March 4, 1994. [4] Browne CL. The design of cigarettes. Hoechst Celanese, 1990. p. 44 – 47. Quoted by Douglas CE: The Tobacco Industry’s use of Nicotine as a Drug. ACSH, Inc., In: A. Golaine Case (Ed.), 1994. [5] Izzotti A, Rossi GA, Bagnasco M, De Flora S. Benzo(a)pyrene-DNA adducts in alveolar macrophages of smokers. Carcinogenesis 1991;12:1281 – 5. [6] Izzotti A, D’Agostini F, Bagnasco M, Scatolini L, Rovida A, Balansky RM, Cesarone CF, De Flora S. Chemoprevention of carcinogen-DNA adducts and chronic degenerative diseases. Cancer Res 1994;54:1994s– 8s. [7] Boyle P. Cancer, cigarette smoking and premature death in Europe: a review including the recommendations of European Cancer Experts Consensus Meeting, Helsinki, October 1996. Lung Cancer 1997;17:1 – 60. [8] Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years observations on male British doctors. Br Med J 1994;309:901 – 11. [9] Doll R, Hill AB. Smoking and carcinoma of the lung. Br Med J 1950;2:739 – 48. [10] Minervini MC, Patino CM, Zabert GE, Rondelli MP, et al. Prevalence of tobacco use among physicians. Am J Crit Care Med Respir Dis 1998;157:3. [11] Rondelli MP, Zabert GE, Minervini MC, et al. Physicians knowledge and attitude towards tobacco. Am J Crit Care Med Respir Dis 1999;158:5.
Commentary
Lung cancer and tobacco control What do we have to do … more? G. Motta * Department of General and Thoracic Surgery, Uni6ersity of Genoa, Largo Rosanna Benzi, 8I-16132 Geno6a, Italy
Just after being committed as President Elect of the International Association for the study of Lung Cancer (IASLC) in August 1994 at the 7th World Conference on Lung Cancer of Colorado Spring, once back home, I felt obliged to inform the Genoa citizens about lung cancer and the close relationship with tobacco smoking. It should also have represented the starting point of my personal action against cigarette smoking to be developed in the whole of Italy. The IASLC board had approved a ten-point program of tobacco control policy, which covered the most important aspects of the problem, from the tax increases on tobacco product to the plans to encourage smoking cessation [1]. Actually, it was the last step forward for the IASLC, to enter the present role as the world leader Society on Lung Cancer. The second decision was represented by the obligation taken by each officer, to personally pursue antismoking campaigns in his own country. Therefore, when the concerned Director of an Italian newspaper offered me two pages of the local Genuese edition, I filled this space with the following four titles, ‘Prevention and surgical ap* Tel.: +39-010-352982; fax: + 39-010-3537262. E-mail address: [email protected] (G. Motta).
proach to lung cancer’, ‘Three weapons for defeating the killer’, ‘Sparing tissue and pulmonary function through the advanced sleeve bronchial resection and reanastomosis’, and ‘Tar and nicotine: a ravager combination’. The last issue informed in depth about the various carcinogens produced by tar and nicotine while burning as well as the addictive effect of nicotine and its virus HIV epidemic-like diffusion among the young generations. Lastly, updated information was also given on the industrial process of modern cigarette making. The last information, which I had just received during the Colorado Springs Conference [2–4], was presenting cigarette as a finished good made by a mixture of chemically refined and somewhere else previously extracted nicotine, with minced residual of dried tobacco leaves and stalks, tobacco powder, glues, ashes, vegetable strengthening fibers and finally, a series of wetting, moistening and seasoning of other compounds! The Genuese citizens showed great interest in reading such news, as demonstrated by the number of telephone calls I received in the following days and the requests of more information about the real nature of cigarettes! Unfortunately, my own positive feeling of having contributed in some way to the campaign
0169-5002/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 9 - 5 0 0 2 ( 0 0 ) 0 0 1 0 7 - 0
76
G. Motta / Lung Cancer 29 (2000) 75–78
against tobacco smoking, suddenly turned into a worrying problem! Shortly afterwards, I was notified by the professional Order of Doctors of the accusation of trying to get personal profit by promoting my image through improper writing about lung cancer and the connected risk of cigarette smoking. As a matter of fact, and it is hard to believe, I really was under the threat to be banished from the professional Order if I was not able to demonstrate my loyalty and the truthfulness of my writing! The disappointing situation cleared up, God willing, 6 months later, when I defended myself victoriously during a debate held in camera, in front of an investigating commission of Colleagues. I gave them an exhaustive and well-documented lecture on lung cancer, the cigarette smoking epidemic through nicotine addiction, and the carcinogenicity of tobacco smoke. I received strong support from Professor Silvio De Flora, a colleague of mine at the Faculty of Medicine, who allowed me to show the latest highly demonstrative and first-hand findings of his studies upon the carcinogenesis process in the lungs of smokers [5,6]. Meanwhile, I was forced to bear the depressing view of many judging colleagues smoking during the debate! No other comment to this paradigmatic and really disturbing personal experience, apart from the following one: Genoa is the largest port in Italy, through which tons of cigarettes enter the Italian market every day! In the following years, during my official journey for IASLC, I had further opportunity to realize the hugeness of the tobacco sources in the world. There are, indeed, enormous extensions of tobacco cultivation at low expense scattered in developing countries, and supervised by only a few, but very well rewarded experts, who are able to estimate the quality of a whole field through a simple look at the leaves! The other face of the problem, well known to all of us, is represented by the enormous population of smokers world-wide who, even if largely different in their lifestyle according to the geopolitical distribution, are strongly determined to continue their smoking habit, in spite of the warnings received on the demonstrated tendency to
develop, besides cancers of other organs and cardiovascular diseases, lung cancer, starting from their middle age. These epidemiological warnings can not be applied to the populations living in developing countries, since their average lifetime is still much shorter, basically due to other kinds of epidemics and the frequent social disturbances, which on the whole, affect survival. Therefore, statistical comparison with the wealthy population can not be made, as far as the age at risk is concerned, nor other consistent clinical studies on lung cancer in general. On the contrary, what results to be absolutely comparable with the industrialized world, is the incorrigible tendency of smoking cigarettes, strictly correlated with the strong influence exerted, upon all the social strata, by the appealing cigarette packages, the addicting effect of nicotine and, finally the power of the imagery through a diffused advertising. Moreover, the only possibility to objectively evaluate the smoking diffusion there, is compulsorily bound to the official data of the cigarette wholesale, which is not reliable at all! Another negative condition, peculiar to these developing countries is that in reality all official plans for the health control and support, are mainly addressed to the major problem of lowering the mortality rate among children and the younger generations. In other words, this means that while they play the role of an endless source of nicotine in the world, in such countries the long-term health problems of tobacco smoking are still slow to appear! Now, coming back to the core of the problem, we have to realize that, presently, according to the European Committee Against Cancer [7], tobacco smoking is the major cause of all ‘premature deaths’ in Europe. In developed countries such as Europe, Japan and North America, between 83 and 92% of lung cancers in men, and between 57 and 80% of lung cancers in women, are attributable to cigarette smoking. On the other hand, in spite of the largest information campaigns on the relationship between tobacco consumption and cancer, especially lung cancer, and the tobacco control policy developed by the major International Organizations for the Health Control, it is doubtful whether the present
G. Motta / Lung Cancer 29 (2000) 75–78
critical situation will significantly change within the next couple of decades. Lung cancer will thus continue to be an increasingly common cancer in the world and a dominating disease within oncology. Meanwhile, it has become a big burden on the national health care systems with a still rising economical negative trend. While a decrease is registered in lung cancer cases, especially in males living in some highly developed countries where the recipient governments really implement the active policy against tobacco, the overall incidence of lung cancer on a global basis, unfortunately, continues to rise. Furthermore, if one stops to think on how the value of life is nowadays progressively considered less even in the industrialized part of the world, as it appears in the daily news, a feeling of pessimism could easily arise, while the spontaneously question, ‘what do we have to do … more?’ becomes, day by day, more and more difficult to answer. Reflecting on this problem, one can not help recognizing that some positive positions at least within developed countries have already been acquired. The ban on smoking in work places and public areas, transportation, etc., the ban on advertising and promotion of tobacco products, the written health warning upon the products to sell; the increasing number of indemnity trials against tobacco companies already won in USA, and the latest direction sent by the maximum world Financial Authority to the National Agencies, to definitively operate upon the cigarette prices, are great conquests of a tobacco control policy, which started about 70 years ago. Single outstanding physicians at the beginning, then, group of scientists, scientific societies, the government health branches, opinion leaders, the families of patients lost and even, some single brave patients who devoted their residual life span to fighting cigarette smoking publicly, are the representatives of this ongoing humanitarian movement. In such an involving concern, it is normal to ask oneself, how one must consider the position of the health professionals, physicians and other paramedicals, the majority of whom are smokers? Can we still let them play the unbelievable role of one, who is touching fire being sure not to be burnt? Or, even worse, can we continue doing our
77
policy against tobacco, ignoring completely the basic help of their expected capillary action against smoking, which results as effective as being targeted at individuals? Of course, the correct combination of the personal example of being a non-smoker and the professional speech with words properly addressed to the single patient’s personality, could really be effective weapons against smoking, in the hands of these colleagues. Historically, British doctors served Richard Doll [8] in shaping the fundamentals of lung cancer epidemiology on smokers, and many of them stopped smoking and saved their lives after learning the related lesson, since the publication of the preliminary report in 1950 [9]. Nevertheless, in spite of this evidence, the smoking habit and, worse still, a general indifference towards the problem of tobacco, are largely diffuse among our colleagues. In a recent survey among Argentina’s leading physicians [10,11], it was shown that almost 25% of them were smokers while the 40% usually do not ask their patients if they smoke. Moreover, about 40% of the study group reported the non existence of restriction policies in their work places while, when such restrictions did exist, about one half of the physicians did not actually obey such directions! At the end of this concerned analysis, the question could again arise, while now expressed better as, can we afford to ignore this expected help or, instead, should we do our best upon such classes of professionals, aimed at recalling them to a real positive action? IASLC, fully aware of the general critical situation, has recently planned a world-based educational programme on lung cancer and the related preventive actions. It consists of a series of postgraduate medical course directly performed in developing countries where IASLC, besides financially supporting the local medical faculties entrusted in organizing the course, directly sponsored the attendance of its own three-member faculties, which basically served as the scientific core for each course. In the last 2 years, five courses have been given, in Chandigarh (India), Chaing May (Thailand), Sao Paulo (Brazil), Shenyang (People’s Republic
78
G. Motta / Lung Cancer 29 (2000) 75–78
of China) and Amman (Jordan). At each of these, the IASLC faculty worked not only to update the local audience about the major problems of lung cancer, from the molecular to the clinical aspects of the disease, but also to discuss the preventive measures to be taken. In addition, they systematically monitored and properly stimulated the attention of the local colleagues upon the problem of cigarette smoking. Therefore, while including this last really eyeopening world-wide experience among the relevant issues to be considered, we can hopefully conclude that another way to give strong support to the ongoing general plans on the Tobacco Control Policy, does exist. In prospect, the goal can be reached, indeed, provided that we are ready to entrust a new task to the teaching benches of the medical schools. It could mean for the next generations of colleagues a new clause in the Hippocratic oath, I will never smoke!
References [1] Tobacco policy recommendations of the International Association for the Study of Lung Cancer (IASLC): a ten point program. Lung Cancer 1994;11:405–407.
.
[2] Douglas CE. The tobacco industry’s manipulation of nicotine: root cause of the modern lung cancer epidemic. Lung Cancer 1994;11(2):2 – 3. [3] Goodman E. How the mad scientist dispense addiction. Baltimore Sun (reproduced from Boston Globe), March 4, 1994. [4] Browne CL. The design of cigarettes. Hoechst Celanese, 1990. p. 44 – 47. Quoted by Douglas CE: The Tobacco Industry’s use of Nicotine as a Drug. ACSH, Inc., In: A. Golaine Case (Ed.), 1994. [5] Izzotti A, Rossi GA, Bagnasco M, De Flora S. Benzo(a)pyrene-DNA adducts in alveolar macrophages of smokers. Carcinogenesis 1991;12:1281 – 5. [6] Izzotti A, D’Agostini F, Bagnasco M, Scatolini L, Rovida A, Balansky RM, Cesarone CF, De Flora S. Chemoprevention of carcinogen-DNA adducts and chronic degenerative diseases. Cancer Res 1994;54:1994s– 8s. [7] Boyle P. Cancer, cigarette smoking and premature death in Europe: a review including the recommendations of European Cancer Experts Consensus Meeting, Helsinki, October 1996. Lung Cancer 1997;17:1 – 60. [8] Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years observations on male British doctors. Br Med J 1994;309:901 – 11. [9] Doll R, Hill AB. Smoking and carcinoma of the lung. Br Med J 1950;2:739 – 48. [10] Minervini MC, Patino CM, Zabert GE, Rondelli MP, et al. Prevalence of tobacco use among physicians. Am J Crit Care Med Respir Dis 1998;157:3. [11] Rondelli MP, Zabert GE, Minervini MC, et al. Physicians knowledge and attitude towards tobacco. Am J Crit Care Med Respir Dis 1999;158:5.