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Chapter 5 Smoking T HE CONNECTION between smoking and lung cancer was established, to all intents and purposes, simultaneously by British and American investigators following virtually identical scientific pathways. An “alarming” rise in death rates attributed to cancer of the lung was observed in both countries in the late 1940s, in England by statisticians employed by the registrar-general’s office and in the United States by epidemiologists at the American Cancer Society (Lock, Reynolds, and Tansey 1998; Nathanson 1999; Kluger 1996). In 1950 retrospective casecontrol studies concluding, in the words of the British study, that “smoking is a factor, and an important factor, in the production of carcinoma of the lung” were published within four months of each other in the British Medical Journal and the Journal of the American Medical Association (Doll and Hill 1950; Wynder and Graham 1950). Responding in part to the skepticism with which these early studies were received, large-scale population-based prospective studies quickly followed (limited in both countries to men), and, again, the results were reported simultaneously, “on almost the same day” in June of 1954 (Kluger 1996, 168). These results are, of course, no secret. Both the British (Doll and Hill 1954) and the American (Hammond and Horn 1954) studies demonstrated a powerful association between smoking and not only lung cancer but heart disease as well. These associations were accepted as causal by the British Medical Research Council in 1957 (Doll 1998) and by the authors of the first U.S. Surgeon General’s Report on Smoking and Health in 1964 (U.S. Department of Health, Education, and Welfare 1964). Not until thirty-five years after the publication of the surgeon general’s report were these causal relations publicly acknowledged by the industry itself: “there is ‘an overwhelming medical and scientific consensus that cigarette smoking causes’ diseases including lung cancer, emphysema, and heart disease” (Meier 1999, A1:4). And thereby, of course, hangs many a tale.1 Whereas AIDS burst suddenly upon the world, forcing countries into almost immediate confrontation with this new and exotic threat to their 109 populations, cigarettes and tobacco were old friends, and recognition of the dangers they presented came slowly and unevenly. Tobacco was introduced into Europe by Jean Nicot, the French ambassador to Portugal , who in 1560 sent seeds and plants (originating, most likely, in Brazil) to the French court. Promoted as a “wonder plant”—an herbal remedy for countless ills, from the migraines of the French queen mother to ulcers and epilepsy—and legitimized by its royal and noble associations, tobacco use was rapidly incorporated into European culture, permeating “all European social classes at about the same time” (Goodman 1993, 47). Tobacco made the transition from herbal remedy to an essential element in the colonial political economy of Europe during the course of the seventeenth century. For the English and French, it became the sine qua non of settlement—grown in the colonies, principally the American colonies, as a cash crop, exported to the mother country, and re-exported to the rest of the world (Goodman 1998). Jordan Goodman makes a useful division of tobacco’s history into three periods: first, the seventeenth and eighteenth centuries, when tobacco became a key element in the construction of the European mercantile state; second, the rise of the cigarette as an item of mass consumption in the late nineteenth and early twentieth centuries; and, finally, the late twentieth-century globalization of the tobacco industry in the form of giant multinational cigarette companies (1998, 5). I will return to this history in more detail in the context of each country’s tobacco story. The point of these initial comments is to emphasize the massive and well-entrenched economic and political constituencies that tobacco enjoys and has enjoyed for four centuries. Furthermore, though there have long been dissenting voices against tobacco, only in the second half of the twentieth century did these voices become a serious challenge to the tobacco industry.2 The gradual discovery of tobacco and smoking as major public health problems over the past fifty years has generated an enormous professional , scholarly, and popular literature, far more, however, in the three Anglo-Saxon countries than in France, and far less contentious in tone than the literature that surrounds AIDS. Here I summarize very briefly the epidemiologic data on smoking and on smoking-related mortality (primarily lung cancer mortality) from each of the four countries, and describe the major strategies for prevention of...

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