Code 1

Many aspects of general health can be improved, and certain cancers avoided, if you adopt a healthier lifestyle

:: Do not smoke; if you smoke, stop doing so. If you fail to stop, do not smoke in the presence of non-smokers

It is estimated that between 25 and 30% of all cancers in developed countries are tobacco-related. From the results of studies conducted in Europe, Japan and North America, between 87 and 91% of lung cancers in men, and between 57 and 86% of lung cancers in women, are attributable to cigarette smoking. For both sexes combined the proportion of cancers arising in the oesophagus, larynx and oral cavity attributable to the effect of tobacco, either acting singly or jointly with the consumption of alcohol are between 43 and 60%. A large proportion of cancers of the bladder and pancreas and a small proportion of cancers of the kidney, stomach, cervix and nose and myeloid leukaemia are also causally related to tobacco consumption. Because of the length of the latency period, tobacco-related cancers observed today are related to the cigarette smoking patterns over several previous decades. On stopping smoking, the increase in risk of cancer induced by smoking rapidly ceases. Benefit is evident within 5 years and is progressively more marked with the passage of time.Smoking also causes many other diseases, most notably chronic obstruction pulmonary disease (commonly called chronic bronchitis) and an increased risk of both heart disease and stroke. The death rate of long-term cigarette smokers in middle age (from 35 to 69 years of age) is three times that of life-long non-smokers and approximately half of regular cigarette smokers, who started smoking early in life, eventually die because of their habit. Half the deaths take place in middle age when the smokers lose approximately 20 -25 year of life expectancy compared to non-smokers; the rest occur later in life when the loss of expectation of life is 7-8 years. There is, however, now clear evidence that stopping smoking before cancer or some other serious disease develops avoids most of the later risk of death from tobacco, even if cessation of smoking occurs in middle age Table 6. While the rate at which young people start to smoke will be a major determinant of ill-health and mortality in the second half of this century, it is the extent to which current smokers give up the habit that will determine the mortality in the next few decades and which requires the urgent attention of public health authorities throughout Europe.

Tobacco smoke released to the environment by smokers, commonly referred to as environmental tobacco smoke (ETS) and which may be said to give rise to enforced ‘passive smoking’, has several deleterious effects on people who inhale it. It causes a small increase in the risk of lung cancer and also some increase in the risk of heart disease and respiratory disease and is particularly harmful to small children. Smoking during pregnancy increases the risk of stillbirth, diminishes the infant’s birth weight, and impairs the child’s subsequent mental and physical development while smoking by either parent after the child’s birth, increases the child’s risk of respiratory tract infection, severe asthma, and sudden death.

Although the greatest hazard is caused by cigarette smoking, cigars can cause similar hazards if their smoke in inhaled and both cigar and pipe smoker cause comparable hazards of cancers of the oral cavity, pharynx, extrinsic larynx, and oesophagus.

Worldwide, it is estimated that smoking killed four million people each year: in the 1990s and that altogether some 60 million deaths were caused by tobacco in the second half of the Twentieth century. In most countries, the worst consequences of the “Tobacco Epidemic” are yet to emerge, particularly among women in developed countries and in the populations of developing countries, as, by the time the young smokers of today reach middle or old age, there will be approximately ten million deaths each year from tobacco (three million in the developed, seven million in the developing countries). If the current prevalence of smoking persists, approximately 500 million of the world’s population today can expect to be killed by tobacco, 250 million in middle age.

The situation in Europe is particularly worrying. The European Union is the second largest producer of cigarettes (749 billion in 1997/98) after China (1675 billion in 1998) and the major exporter of cigarettes (400 billion). In Central and Eastern Europe, there has been a major increase in the smoking habit. Of the six World Health Organisation (WHO) regions, Europe has the highest per capita consumption of manufactured cigarettes and faces an immediate and major challenge in meeting the WHO target for a minimum of 80% of the population to be non-smoking. In 1990-1994 34% of men and 24% of women in the European Union were regular smokers. In women the rates were reduced by the low rates in southern Europe, but the rates there are rising and seem set to continue to rise over the next decade. In the age range 25-39 years the rates are higher (55% in men and 40% in women) and this can be expected to have a profound influence on the future incidence of the disease. It is particularly disturbing that in many parts of Europe, the prevalence of smoking remains high among General Practitioners, who should set an exemplary lifestyle in terms of health. This should be a target for immediate action.

It has been shown that changes in cigarette consumption are affected mainly at a sociological level rather than by actions targeted at individuals (for example, individual smoking cessation programmes). Actions such as advertising bans and increases in the price of cigarettes influence cigarette sales particularly among the young. A “Tobacco Policy” is, consequently essential to reduce the health effects of tobacco, and experience shows that this should be aimed at both stopping young people from starting to smoke and helping smokers to stop. To be efficient and successful, a tobacco policy has to be comprehensive and maintained over a long time period. Increased taxes on tobacco, total bans on direct and indirect advertising, smoke-free enclosed public areas, prominent health warning labels on tobacco products, a policy of low maximum tar levels in cigarettes, education about the effects of smoking, encouragement of smoking cessation, and health interventions at the individual level, all need to be implemented. It must be recognized that nicotine is an addictive drug and that some smokers who are heavily addicted need medical help to overcome the addiction.

The importance of adequate intervention is shown by the low lung cancer rates in those Nordic countries which, since the early 1970’s, have adopted integrated central and local policies and programmes against smoking. In the UK, tobacco consumption has declined by 46% since 1970 and lung cancer mortality among men has been decreasing since 1980, although the rate still remains high. In France, between 1993 and 1998, there has been a 11% reduction in tobacco consumption due to the implementation of anti-tobacco measures introduced by the Loi Evin.

The first point of the European Code Against Cancer should consequently be:

DO NOT SMOKE. Smoking is the largest single cause of premature death.

SMOKERS: STOP AS QUICKLY AS POSSIBLE. In terms of health improvement, stopping smoking before having cancer or some other serious disease avoids most of the later excess risk of death from tobacco even if smoking is stopped in middle age.

DO NOT SMOKE IN THE PRESENCE OF NON-SMOKERS. The health consequences of your smoking may affect the health of those around you.