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o r i g i n a l c o m m u n i c a t i o n

Smoking and Cancer: A Review of Public


Health and Clinical Implications
Norman Hymowitz, PhD

no effort to provide a critical review of the many excel-


The cultivation of tobacco dates backwards to 6000 BC. Use lent and important studies that lay bare the associa-
of tobacco for spiritual, euphoric, and medicinal purposes, tion between smoking and cancer and what to do about
and its ultimate spread to the 4 corners of the globe, lay at it. Rather, the purpose of this review is to provide the
the heart of the current pandemic of tobacco-related dis- reader with an overview of the topic, starting first with a
ease, including lung, head and neck, and many other forms historical perspective, focusing next on the nature of the
of cancer. While evidence for the carcinogenic properties pandemic of tobacco-related disease, which currently
of tobacco was documented as early as the 1800s, it was grips our planet, providing a brief review of critical epi-
not until the 20th century that the role of tobacco use and demiological findings, and, finally, addressing the issue
smoke exposure in the growing pandemic of lung and other of curbing the pandemic, emphasizing public health as
cancers was fully appreciated. The evidence is now indis- well as clinical approaches. The former approach entails
putable, and current research and intervention activities environmental manipulations on a macro level, includ-
center on mechanisms by which tobacco use and smoke ing the introduction in countries around the globe of
cause cancer, ways of stemming the worldwide pandemic legislation and policy aimed at creating a smoke-free
of tobacco-related disease, and how to help people with planet. The latter focuses on clinical intervention with
cancer quit smoking. With respect to the latter, approach- smokers, particularly within the context of physician
es to smoking cessation that are effective for the general offices and other medical settings.
population of smokers are equally applicable to cancer
patients, thrusting physicians and other health profession- FROM 6000 BC to 2010
als to the forefront of the antismoking arena. However, the The use of tobacco (Nicotine tobaccum) has been
scale of the tobacco pandemic has grown so large that it traced to early American civilizations,1 where it was first
literally will take a village, complete with heads of nations, cultivated in 6000 BC. Tobacco played a prominent role
world-governing bodies, local leaders, physicians, and in religious rites and ceremonies, with the ancient
many others, to pass and enforce legislation and policies Mayans using it as solar incense to bring rain during
necessary to stem the worldwide tobacco pandemic and the dry season and the Aztecs employing Nicotine rus-
to implement cessation programs for smokers and users of tica in ceremonial rites.2 In 1492, Columbus and his
other forms of tobacco across the globe. crew observed natives lighting rolls of dried leaves,
Keywords: tobacco n cancer n lung n prevention n
which they called tobaccos (cigars), and swallowing
policy
the smoke.2 Soon after, Juan Ponce de Leon brought
tobacco to Portugal, where it was grown on Portuguese
J Natl Med Assoc. 2011;103:695-700 soil. In 1565, Sir Walter Raleigh introduced smoking to
England, leading to the cultivation of tobacco in the
Author Affiliation: Department of Psychiatry, The University of Medicine and United Kingdom.3
Dentistry of New Jersey, New Jersey Medical School, Newark. The growth of world trade led to the spread of
Correspondence: Norman Hymowitz, PhD, Professor, Department of
Psychiatry The University of Medicine and Dentistry of New Jersey, New
tobacco to every corner of the globe, and by the mid-
Jersey Medical School, 183 South Orange Ave, Newark NJ 07103 (hymow- 17th century every major civilization had been intro-
itz@umdnj.edu). duced to tobacco smoking,4 ultimately laying the foun-
dation for the 20th-century pandemic of tobacco-related
INTRODUCTION morbidity and mortality. In 1560, the Portuguese and

A
n edition of the Journal of the National Medical Spaniards shipped tobacco to East Africa, where it
Association devoted to cancer would not be spread to Central and West Africa, and in the 1650s,
complete without at least 1 manuscript on the European settlers in South Africa grew tobacco and used
topic of smoking and cancer. However, the literature on tobacco as a form of currency.1 Other key dates for the
this topic is extremely vast, and in this review I make spread of tobacco include the early 1500s, when tobacco

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Smoking and Cancer

was first introduced to the Middle East; the early 1600s, between smoking and lung cancer, but the message was
when tobacco was introduced to China, Japan, and India; largely lost as the medical community was distracted by
1769, when Captain James Cook arrived in New Zealand the disaster of World War II.2
smoking a pipe; and 1788, when tobacco was brought to The accumulation of epidemiologic evidence in the
Australia by the First Fleet.1 As harbingers of things to ensuing decades cast further light on the link between cig-
come, in the early 1600s, the Chinese philosopher, Fang arette smoking and lung cancer.4 The observation that
Yizhi, noted that long years of smoking scorches ones rates of lung cancer were increasing in the 20th century,
lungs. James I of England stated that Smoking is a the results of seminal case-control studies by Doll and
custom loathsome to the eye, hateful to the nose, harm- Hill and by Wynder and Graham in 1950, and findings
ful to the brain, dangerous to the lungs, and in the black, produced by subsequent prospective cohort studies by
stinking fume thereof nearest resembling the horrible Doll and Hill and Hammond and Horn, among others,
Stygian smoke of the pit that is bottomless.1 led, in 1959, the surgeon general of the United States, Dr
Ironically, the ancients, as well as physicians in the Leroy E. Burney, to conclude that the weight of evidence
16th, 17th, 18th, and 19th centuries, strongly believed in at present implicates smoking as the principle etiological
tobaccos medicinal value.2 The Cohilla Indians of factor in the increased incidence of lung cancer.4
California used tobacco to ward off evil spirits named Landmark reports5 by the Royal College of Physicians
Sespes, which caused insomnia. Indians of other tribes in 1962 and the Advisory Commission to the Surgeon
believed that tobacco reinforced the heart and stomach, General of the Public Health Service6 in 1964 provided
opened the bosom, removed mucous, killed worms, and indisputable proof that cigarette smoking lay at the heart
calmed pain in bile colic. Tobacco also was administered of the recent worldwide increase in deaths from lung
against lice, and it was used to cure frostbite, burns, cancer. The reports also suggested that smoking is a
rashes, venereal ulcerations, and malignant tumors.2 contributing factor in cancer of the lip, mouth, pharynx,
In 1597, John Gerard published Herbal, long consid- esophagus, and bladder. Moreover, the risk of develop-
ered a text book of therapeutics. Gerard described the ing cancer increases with the duration of smoking and
medicinal qualities of tobacco for the treatment of head- the number of cigarettes smoked. The risk is diminished
ache, rheumatism, pain of the lungs, catarrh, and for by discontinuing smoking.5,6
removing humors. During the plague of London in 1665, Evidence associating smoking, other forms of
tobacco chewing was considered the most effective pro- tobacco use, and exposure to secondhand smoke to a
phylactic measure against infection. In Philadelphia, variety of cancer and other human ills continues to accu-
where 10% of the population died of yellow fever in the mulate. There now have been 30 Surgeon General
summer of 1793, men, women, and children smoked Reports covering topics such as smoking and health
strong cigars and drank beer as protection against the effects in women, minorities, and children, prevention
American plague.2 and cessation, other forms of tobacco use, and exposure
Scientific evidence against tobacco began to emerge to secondhand smoke. The 1982 Report was devoted
as early as 1670, when the Dutch anatomist, Keckring, entirely to cancer,7 and the 1985 Report was entitled The
described the results of autopsies of heavy smokers as Health Effects of Smoking: Cancer and Chronic Lung
follows: The tongue of the cadaver is black and gives off Disease in the Workplace.8 The 2010 Report, How
an odor of poison, the trachea is covered with soot, like a Tobacco Causes Disease, focused on mechanisms by
cooking pot, the lungs are driedout and almost friable. which tobacco use and smoke exposure influence dis-
Perhaps the latter was among the first observations of the ease processes.9 The Report noted that the cancers that
association between smoking and disease of the lung. In are causally linked to smoking and exposure to tobacco
1689, the Medical School of Paris examined the issue of smoke are oropharynx, larynx, esophagus, trachea,
tobacco smoking and length of life. They concluded that bronchus, and lung, acute myeloid leukemia, stomach,
smoking shortens life. In 1761, the English physician Jon pancreas, kidney and ureter, cervix, and bladder.9
Hill observed that the consumption of snuff appeared to The 2010 Report concluded that inhaling the com-
be associated with cancer of the nose, and in 1795, an plex clinical mixture of combustion compounds in
article appeared in a medical journal that linked pipe tobacco smoke cause adverse health outcomes, particu-
smoking with cancer of the lip.2 larly cancer, cardiovascular disease, and pulmonary dis-
The link between smoking and cancer was firmly ease, through mechanisms that include DNA damage,
established in the 20th century. In 1920, Broders pub- inflammation, and oxidative stress.9 The Report con-
lished an article in the Journal of the American Medical cluded that there is no risk-free exposure to tobacco
Association linking tobacco with cancer of the lip. In smoke, that low levels of exposure lead to a rapid
1928, Lombard and Doering reported that smoking was increase in endothelial dysfunction and inflammation,
more common among cancer patients than nonsmoking and that there is insufficient evidence that product modi-
controls. In 1940, Muller, of Germany, reported the fication strategies to lower emissions of specific toxi-
results of a case-control study that suggested a link cants in smoke reduce the risk for major health

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Smoking and Cancer

outcomes.9 The Report also concluded that the sustained secondhand smoke.1,10,11 Success in the antismoking
use and long-term exposure to tobacco smoke are due to arena, on the scale required to affect the current pan-
the addicting effects of nicotine and perhaps other com- demic, requires a comprehensive tobacco control pro-
pounds that are mediated by diverse actions at multiple gram that includes raising the price of tobacco through
types of nicotinic receptors in the brain.9 excise taxes, banning smoking in public places, restrict-
ing tobacco advertising and promotion, counter adver-
A WORLDWIDE PANDEMIC tising, and providing treatment and counseling for
As noted by the World Health Organization tobacco dependence.10 In developing countries, where
(WHO),1,10 tobacco is the single greatest preventable there is a marked difference in smoking prevalence
cause of death in the world today, killing up to half the between men (50%) and women (9%), an opportunity
people who use it.10 More than 1 billion people world- for prevention exists by discouraging young girls and
wide smoke tobacco, and tobacco use currently kills women from taking up the habit, and by helping those
more than 5 million people worldwide each year. who smoke to quit.10,11
Tobacco use continues to grow in developing countries The lung cancer experience of African Americans in
due to steady population growth, adoption of Western the United States illustrates the importance of discontin-
lifestyles, emancipation of women, aggressive multibil- uing smoking for stemming the pandemic of tobacco-
lion-dollar marketing and advertising strategies by Big related disease. For the past 40 years, the rate of adult
Tobacco, and the addictive nature of nicotine in smoking has been higher for African American men
tobacco.1,10 If current trends continue, tobacco will kill than for white men, as have been rates of lung cancer
more than 8 million people per year by 2030. By the end deaths.12 Since 1990, adult rates of smoking declined
of the century, tobacco may kill a billion people. It is markedly in both racial groups. This was accompanied
estimated that more than three-quarters of these deaths by a corresponding decline in lung cancer deaths.
will be in low-and middle-income countries.1,10 However, the slope of the decline was considerably
Tobacco use is a risk factor for 6 of the 8 leading steeper in African American males than in whites, lead-
causes of death in the world.10 These include ischemic ing to a convergence of rates of smoking and deaths due
heart disease; cerebral vascular disease; lower-respira- to lung cancer12 in 2009.
tory infections; chronic obstructive lung disease; tuber- Since the early 1990s, African American and white
culosis; and trachea, bronchus, and lung cancers. In women have smoked at a similar rate, although prior to
2008, there were 12.7 million new cancer cases world- 2000 the rate of death due to lung cancer among African
wide, 5.6 million in economically developed countries, American women was considerably higher than among
and 7.1 million in economically developing countries.11 white women.12 It is possible that African Americans
The corresponding estimates for total cancer deaths preference for menthol cigarettes may have played a role
were 7.6 million, 2.8 million in economically developed in their higher lung cancer death rates, although the puta-
countries, and 4.8 million in economically developing tive elevated carcinogenic properties of mentholated cig-
countries.11 By 2030, the global burden is expected to arettes remain the subject of debate.13,14 Since 2000, the
grow to 21.4 million new cancer cases and 13.2 million death rate in both groups have declined and converged,
cancer deaths.11 with the 2009 lung cancer death rate slightly lower for
Worldwide, lung cancer is the leading cause of can- African American women than for white women.12
cer deaths in men and the second leading cause in The decline in African American adult smoking rates
women, with an estimated 951000 deaths in men and may reflect the dramatic decrease in smoking among
427000 deaths in women11 in 2008. Cigarette smoking African American youth. For more than a decade,
and exposure to tobacco smoke are the most common African American high school students have had a lower
risk factors for lung cancer, accounting for 80% of lung prevalence of cigarette smoking than other racial and
cancers in men and 50% in women. International varia- ethnic groups.12 In 2009, 10.7% of African American
tions in lung cancer rates and trends reflect differences boys and 8.4% of African American girls smoked ciga-
in the stage and degree of the tobacco epidemic. In sev- rettes, compared to 22.3% of white boys and 22.8% of
eral Western countries, such as the United States, United white girls. If this pattern persists, it is likely that, in the
Kingdom, and Finland, where the tobacco epidemic future, rates of lung cancer deaths in African Americans
peaked in the middle part of the 20th century, lung can- will continue to decline at a pace that will serve as a
cer rates have been decreasing in men and plateauing in model for the rest of the world.
women. In countries where the epidemic has been estab- As in the case of lung cancer, prevention is the key to
lished more recently, such as China, Korea, and several reducing the worldwide toll of other forms of tobacco-
countries in Africa, lung cancer rates are increasing and related cancers. In most cases, prevention entails mini-
are likely to continue to increase, at least for the next mizing exposure to tobacco smoke, preventing smoking
few decades, barring interventions to enhance smoking onset in youths, and helping adults who smoke to quit.
cessation, reduce initiation, and minimize exposure to In some cases, such as cancers of the lip and oral cavity,

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Smoking and Cancer

use of smokeless forms of tobacco is a major target for THE PHYSICIANS ROLE
intervention. It is also important to understand that in Physicians, regardless of the type of patients they
many countries of the world, other forms of smoking, treat, have an important and leadership role to play in the
such as water pipes in the Middle East and Kretecs in antitobacco arena. They may address the issue of smoke-
India, command the attention of the public health com- free lifestyles, as well as intervene with those who smoke,
munity. Given migration and immigration patterns in use other forms of tobacco, and/or expose children or
the world today, it is necessary for health providers and others to harmful tobacco smoke. In view of the fact that
advocates across the globe to be familiar with the physicians see a majority of smokers each year, as a
tobacco products and habits of the diverse cultural group, they may have a significant impact on the health
groups which they serve. of nations, even if their interventions with individual
patients yield only modest results.2,17 Updated clinical
ENDING THE TOBACCO PANDEMIC guidelines for physician intervention on tobacco are
The WHO MPOWER Framework10 provides an available, and, when implemented properly, may yield
approach to tobacco prevention and control on a scale nec- highly desirable outcomes.18 The guideline, Treating
essary to have a positive impact on global adverse health Tobacco Use and Dependence, points out that tobacco
effects of tobacco use and exposure. Key areas for mobi- dependence is a chronic disease that often requires
lizing countries to stem the tobacco pandemic include the repeated interventions and multiple attempts to quit.
following: monitor tobacco use and prevention policies; The guideline calls upon clinicians to consistently
protect people from tobacco smoke; offer help to quit identify and document the tobacco use status of each
tobacco; warn about the dangers of tobacco use; enforce patient they treat and encourage all those willing to
comprehensive restrictions on tobacco advertising, pro- make a quit attempt to use the counseling treatments and
motion, and sponsorship; and raise taxes on tobacco. medications recommended in the guideline. Individual,
The US Presidents Cancer Panel 2006-2007 Report15 group, and telephone counseling are effective, and their
included recommendations for addressing tobacco use effectiveness increases with treatment intensity.18 Two
prevention, treatment, and environmental tobacco smoke components of counseling, social support and practical
exposure that are consistent with the WHO MPOWER suggestions, along with problem solving and skill train-
initiative (see also the report of the Institute of Medicine ing, are especially effective.18 Effective medications are
Committee on Reducing Tobacco Use: Strategies, available for treating tobacco dependence. Clinicians
Barriers, and Consequences16). Among the Presidents should encourage their use by all patients attempting to
Cancer Panel recommendations were those aimed at quit smoking except when medically contraindicated or
regulating tobacco product development, advertising, with specific populations for which there is insufficient
and marketing. The panel recommended ratifying and evidence of effectiveness (ie, pregnant women, smoke-
fully implementing the WHO Framework Convention less tobacco users, light smokers, and adolescents).
on Tobacco Control, authorizing the Food and Drug Seven first-line medications (5 nicotine and 2 non
Administration to strictly regulate tobacco marketing, nicotine) have been shown to reliably increase long-term
and increasing federal excise taxes on tobacco products. smoking abstinence rates. They are bupropion SR, nico-
The cancer panel also addressed the importance of cre- tine gum, nicotine inhaler, nicotine lozenge, nicotine
ating smoke-free environments in homes, college cam- nasal spray, nicotine patch, and varenicline. As indicated
puses, workplaces, and federal facilities. The panel in the guideline, the effectiveness of the medications
endorsed preventing tobacco use initiation via school- may be enhanced by using them in combination and/or
based education programs and discouraging use of when combined with counseling, either in person or via
smoking images in movies, television, music videos, telephone.18
video games, and other visual media with child, adoles- Physicians are also advised to utilize the 5 As par-
cent, and young-adult audiences.15 adigm (ask all patients about tobacco use; advise cessa-
Among the panels recommendations for enhancing tion; assess readiness to quit; assist cessation, either
support for smoking cessation efforts were: (1) add the con- directly, with assistance from office personnel, or via
duct of meaningful tobacco-related activities to the evalua- referral to a quit smoking program; and arrange follow-
tion criteria for National Cancer Institute-designated cancer up). Motivational interviewing is recommended to
centers; (2) make coverage of tobacco use cessation ser- engage the smoker and to form a partnership for treat-
vices and medications a standard benefit in all comprehen- ment planning.18 If the assess step reveals that the patient
sive health benefit packages; (3) adopt the Agency for is not ready to try to quit smoking, physicians are
Healthcare Research and Quality Guidelines for Clinicians encouraged to utilize the 5 Rs (relevance, risks,
Treating Tobacco Use and Dependence as part of the stan- rewards, roadblocks, repetition) to address the issue of
dard of care for all health care providers; and (4) incorporate readiness and to offer assistance when the patient is
smoking cessation services into the comprehensive care of more willing to try. Candid discussion, a personalized
cancer patients, survivors, and their family members.15 health message, problem solving, and encouraging the

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Smoking and Cancer

patient to weigh the costs and benefits of quitting or con- of health benefits.
tinuing to smoke may enhance the patients willingness 3. It may help those diagnosed with cancer to live
to agree to try to stop smoking at a later date.18 longer and decrease the risk of cancer recurrence
or of developing new cancers.
SMOKING CESSATION FOR 4. Quitting improves the effectiveness of
CANCER PATIENTS radiotherapy for some types of cancer.
The concept of taking advantage of teachable 5. Quitting improves healing of surgical wounds.
moments is particularly apt when treating a patient 6. Quitting lowers the risk of infection following
with cancer. There is a body of evidence that shows that surgery.
cancer patients have better treatment outcomes if they 7. Quitting reduces symptoms related to
quit, and stopping smoking reduces the risk of addi- chemotherapy toxicity, such as infection, and
tional malignancies.19 As in the case of patients with heart, stomach, or breathing problems.
other serious diseases, physicians and others who 8. Quitting decreases the need for rehabilitation to
address tobacco in cancer patients may generate quit improve breathing following surgery.
rates far in excess of what is typically obtained with 9. Quitting improves the functioning of your heart
patients without frank disease. Data also suggest that and lungs.
more intensive intervention and follow-up yield superior 10. Quitting decreases physical symptoms and
smoking cessation outcomes than lesser interventions, improves appetite, sleep, and energy.
although even brief intervention by physicians may yield 11. Patients who quit report better emotional well-
positive results.19 Many patients quit on their own at the being and quality of life.
time of diagnosis, and intensive intervention with 12. Patients who quit report experiencing greater
patients with various forms of tobacco-related cancer self-esteem, feelings of self-control, and mastery.
have yielded 12-month quit rates as high as 65%,
although more modest quit rates seem to be the norm.19 The guide also provides an opportunity for patients
The vast majority of those who do not quit report that to list their own personal reasons for wanting to quit and
they made at least 1 attempt.19 do what they can to defeat their cancer. Their responses
It is generally accepted that the same educational, provide fertile material for discussion, whether one on
behavioral, and pharmacological approaches to smoking one with a doctor or smoking therapist or in a group pro-
cessation that work with healthy patients are applicable gram designed for smokers in general or for cancer
to cancer patients.20 Of course, cancer patients present patients in particular. The approach to smoking cessa-
with some unique issues, and it is important to take them tion offered in the guide is behaviorally oriented and
into account. Physicians and others who treat cancer medications are recommended as a way of enhancing
patients must be aware of the tendency to return to positive outcomes.
smoking following successful recovery. Hence, it is
important to give as much attention to long-term main- DISCUSSION
tenance of smoking cessation as to initial cessation.20 While cigarette smoking and use of other forms of
Physicians also must be aware that some smoking tobacco have a long history and once were valued for
cessation medications may be contraindicated with cer- their spiritual, euphoric, and medicinal properties,
tain types of cancer patients. While nicotine is not carci- decades of scientific enquiry and human experience
nogenic, it is capable of accelerating tumor growth and have proved otherwise. Indeed, cigarette smoking, use
suppressing cell death caused by several chemotherapy of other forms of tobacco, and exposure to tobacco
agents.20 These findings should be taken into account smoke lay at the heart of the current worldwide pan-
when recommending nicotine replacement therapy. In demic of tobacco-related disease, a pandemic that her-
addition, nicotine gum, lozenge, spray, and inhaler may alded dramatic increases in cancer rates and deaths in all
not be appropriate for patients with oral cancers.20 4 corners of the globe. Moreover, rates of cancer and
Bupropion SR, or Zyban, is contraindicated for patients other chronic diseases will continue to grow unless steps
with central nervous system tumors because of its ten- are taken to thwart it. At a global level, such steps must
dency to cause seizures.20 include policy and legislative initiatives aimed at stem-
The Memorial Sloan-Kettering Cancer Center ming the production, marketing and advertising of
(MSKCC) Smoking Cessation Guide for Cancer Patients tobacco products, education on a scale that is consistent
and Their Families21 lists 12 reasons why it is important with the magnitude of the problem, societal efforts to
to quit smoking after a cancer diagnosis. They are as promote smoke-free environments, imaginative
follows: approaches to the prevention of tobacco use in young
people, and the availability of evidence-based approaches
1. You become an active partner in your own health care. to cessation for people of all walks of life and from all 4
2. MSKCC doctors advise quitting smoking because corners of the globe.

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7. The Health Consequences of Smoking: Cancer, A Report of the Surgeon


At the local level, physicians have a leadership role General. Washington, DC: US Government Printing Office; 1982. US Depart-
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quit, and minimizing exposure to secondhand smoke. 8. The Health Consequences of Smoking: Cancer and Chronic Lung Dis-
Physicians must also address smoking and smoke expo- ease, A Report of the Surgeon General. Washington, DC: US Government
Printing Office; 1985. US Department of Health and Human Services publi-
sure in cancer patients and their families. They may be cation PHS 85-50207.
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Agenda. Washington, DC: Government Printing Office; 2002. US Depart-
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