sir richard doll (1912- 2005), physician, epidemiologist, teacher, humanitarian, legend, activist,...
TRANSCRIPT
Sir Richard Doll (1912-2005), Physician,
Epidemiologist, Teacher, Humanitarian, Legend,
Activist, Researcher, Public Health lobbyist
Smoking and Health
CONDITIONSTREATED WITH TOBACCO
16th Century
Malignant tumours
Open woundsStomach cramps
Intestinal wormsHeadaches
Diseases of womenAsthma
GoutCough
SÖMMERING 1795DOCTORAL THESIS
“Carcinoma of the lip is most frequent when people indulge in tobacco pipes. For the lower lip is particularly attacked by carcinoma because it is compressed between the pipe and the teeth”
PERCENTAGE OF MEN ATTENDINGMASSACHUSETTS CANCER CLINICS
WITH DIFFERENT CANCERS: BY SMOKING HABIT(Potter & Tulley, 1945)
Use of tobacco(no. of men)
Cancer of:
buccalcavity
respiratorytract
othersites
None (655) 3.7 0.5 22.4
Slight (357) 8.1 1.1 25.1
Moderate (1155) 11.5 2.0 26.0
Excessive (760) 17.9 1.7 23.4
USE OF TOBACCO BY DISEASE CATEGORY:86 MEN WITH AND 86 MEN WITHOUT LUNG
CANCER(after Müller, 1939)
Type of smoker No. of men
withlung cancer
healthycontrols
1Extreme smoker 25 42Very heavy smoker 18 53Heavy smoker 13 224Moderate smoker 27 41
Non-smoker 3 14
1 10-15 cigars, >35 cigarettes, >50g pipe tobacco/day2 7-9 “ 26-35 “ 36-50g “ “ “3 4-6 “ 16-25 “ 21-35g “ “ “4 1-3 “ 1-15 “ 1-20g “ “ “
SMOKING AND LUNG CANCERCASE-CONTROL STUDIES BEFORE 1950
195519.04.5100134Wassink, 1948Holland
275215.93.227093Schairer &Schöniger, 1943Germany
366516.33.58636Müller, 1939Germany
ControlsLungcancer
ControlsLungcancer
Heavy smokersNon-smokersControlsLungcancer
Percent of:No. of menAuthor
TOBACCO AND CORONARY DISEASE(English, Willius & Berkson, 1940)
†Number of smokers and all men in age group in parentheses
*P, one-sided
0.0566.3 (663/1000)69.8 (698/1000)40+
0.2861.8 (202/327)63.8 (275/431)60+
─73.9 (274/371)71.7 (274/382)50-9
<0.00161.9 (187/302)79.7 (149/187)†40-9
Others Coronary disease
P*Percent smokersMen aged(yrs)
TOBACCO AND CORONARY DISEASE(English, Willius & Berkson, 1940)
†Number of men with coronary disease and all diseases in age group in parentheses
*P, one-sided
0.043.8 (38/1000)5.4 (54/1000)40+
─ 6.4 (26/404)5.0 (20/404)60+
0.012.6 (10/388)6.2 (24/388)50-9
0.011.0 (2/208)4.8 (10/208)†40-9
Non-smokers Smokers
P*Percent coronary disease in:Men aged(yrs)
SMOKING AND LUNG CANCERCASE-CONTROL STUDIES PUBLISHED IN 1950
195114.6*1.3*780605Wynder & GrahamUSA
──317430444Mills & PorterUSA
*Lifelong non-smokers, with ex-smokers carefully excluded
13264.2*0.3*649649Doll & HillUK
──21.715.3481236Levin et al.USA
91823.914.652282Schreck et al.USA
ControlsLungcancer
Controls
Lungcancer
Heavy smokersNon-smokersControls
Lungcancer
Percent of:No. of menAuthor
MORTALITY BY AMOUNT SMOKEDRELATIVE TO THAT IN NON-SMOKERS
(after Hammond & Horn, 1954)
1.11.31.060565-69
2.02.21.559460-64
coronary heart disease
2.11.91.157155-59
2.52.11.737750-54
lung cancer
8.84216750-69
20or more
10-19Less than10
Cause ofdeath
Regular cigarette smokerssmoking (per day):
No. ofdeaths
Age(yrs)
BERKSON’S ALTERNATIVES
“The findings were the result of the interplay of various subtle and complicated biases
or
had a constitutional basis, involving people who were non-smokers or relatively light smokers, being the kind who were biologically self-protective and this “correlated with robustness in meeting mortal stress from disease generally”
FISHER’S OBJECTIONS
(i) Smokers with lung cancer reported inhaling less than smokers without (Doll & Hill, 1950) against causation unless it was concluded that “Inhaling cigarette smoke was a practice of considerable prophylactic value in preventing the disease”
FISHER’S OBJECTIONS
(ii) Secular changes in smoking habits could not be related to the increase in lung cancer since “lung cancer has been increasing more rapidly in men relative to women” while “it is notorious, and conspicuous in the memory of most of us, that over the last 50 years the increase among women has been great, and that the increase among men (even if positive) certainly small”
CANCERS CAUSED IN PART BY SMOKING(International Agency for Research on Cancer, 2004)
*Increased more than fivefold
Ureter*Oesophagus Liver
Stomach Nose & nasal sinuses
*Larynx
Pancreas Nasopharynx Kidney
*Oro- & hypo- pharynx
Myeloid leukaemia
Cervix
Oral (incl. lip & tongue)
*Lung Bladder
VASCULAR AND RESPIRATORY DISEASECAUSED IN PART BY SMOKING
*Increased more than five-fold
*Buerger’s disease
Pulmonary tuberculosis*Peripheral vascular disease
Asthma*Aortic aneurysm
Pneumonia Arteriosclerosis
*Chronic obstructive lung disease Hypertension (fatal)
Cerebral haemorrhage Myocardial degeneration
Cerebral thrombosis Ischaemic heart disease
Subarachnoid haemorrhage*Pulmonary heart disease
OTHER CONDITIONSCAUSED IN PART BY SMOKING
*Increased more than five-fold
*Palmoplantar pustulosisReduced growth of fetus
Facial skin wrinklingReduced fecundity
CataractOsteoporosis
Age-related macular degenerationCrohn’s disease
*Tobacco amblyopiaDuodenal ulcer
PeriodontitisGastric ulcer
UK male doctors born 1900-1930: continuing cigarette vsnever smokers. 50-year follow-up of mortality, 1951-2001
Evaluation