Blackwell Science, LtdOxford, UKRESRespirology1323-77992002 Blackwell Science Asia Pty Ltd8286290Original ArticleHistory of tobacco and healthAW Musk and

NH de Klerk

Respirology (2003) 8, 286–290

INVITED REVIEW SERIES: TOBACCO AND LUNG HEALTH

History of tobacco and health

Arthur William MUSK1,2 AND Nicholas Hubert DE KLERK2,3

1
Sir Charles Gairdner Hospital, Nedlands, 2School of Population Health, University of Western Australia,
3
Centre for Child Health Research, University of Western Australia, Western Australia, Australia

History of tobacco and health

MUSK AW, DE KLERK NH. Respirology 2003; 8: 286–290
Abstract: Tobacco comes from plants that are native to the Americas around Peru and Ecuador,
where it has been found since prehistoric times. It was brought back to Europe by early explorers
where it was adopted by society and re-exported to the rest of the world as European colonization
took place. Smoking tobacco in pipes of one sort or other gave way to handmade and then manu-
factured cigarettes, especially during the First World War. Smoking rates increased dramatically dur-
ing the 20th century in developed countries until recently and rates are still increasing in
underdeveloped countries. An epidemic of smoking-related diseases has followed the prevalence of
smoking. Scientific knowledge of the harmful effects of active tobacco smoking has accumulated
during the past 60 years since early descriptions of the increasing prevalence of lung cancer. The first
epidemiological studies showing an association between smoking and lung cancer were published in
1950. In 1990 the US Surgeon General concluded that smoking was the most extensively documented
cause of disease ever investigated but governments worldwide have been ambivalent and slow in
taking action to reduce smoking. Tobacco smoking is now agreed to be a major cause of a vast num-
ber of diseases and other adverse effects. Since the 1980s passive smoking including exposure in
utero has also been implicated as a significant cause of numerous diseases. In response, the tobacco
industry has managed to forestall and prevent efforts to control this major health problem.

Key words: adverse effects, cigarettes, smoking, tobacco.

BACKGROUND cultivated since about 5000–3000 BC. The use of

tobacco was universal throughout the American con-
Tobacco and mankind have been associated in the tinents (and Cuba) by the time that Christopher
same way as food and tea since before history began. Columbus arrived in North America in 1492.1
Its ancient origins and how it subsequently insinu- The practice of smoking appears to have arisen
ated itself into modern society have been described in from snuffing, as snuffing instruments are among the
detail by Gately.1 Nicotiana tabacum and Nicotiana most ancient tobacco-related artifacts that have been
rustica are native plants of the Americas having found. However, tobacco was not only sniffed and
evolved in the Andes around Peru/Ecuador. Men smoked but chewed, eaten, drunk (like tea), smeared
came across them (along with more useful plants over bodies (to kill lice and other parasites), and used
such as tomatoes, potatoes, maize, cocoa and rubber) in eye drops and enemas. It was blown into warriors’
about 18 000 years ago when they migrated to the faces before battle, over fields before planting (it is
American continents from Asia across the Bering still used as an insecticide in agriculture) and over
Straight land bridge. Tobacco is thought to have been women before sex. It was used medicinally for its
analgesic and antiseptic properties and as a cure for a
variety of ailments. It was offered to the gods and used
in religious ceremonies. It had both real and mystical
qualities. All sorts of implements were invented and
Correspondence: A. William Musk, Department of used to administer it but the most enduring method
Respiratory Medicine, Sir Charles Gairdner Hospital, of administration ever since these distant times has
Verdun Street, Nedlands, WA 6009, Australia. Email: been smoking. Tobacco was smoked rolled up in
billmusk@cyllene.uwa.edu.au cigars but the most popular method in ancient times

History of tobacco and health
was in a pipe of one sort or other which came to serve
both social and ritual functions.
The first Europeans to smoke were members of
Columbus’ crew when they reached Cuba in 1492.
Almost from the outset, smoking was described as an
evil and harmful practice by the Europeans but it
seems that spiritual revulsion and danger to health
have never been sufficiently long-lasting to prevent
people from engaging in tobacco use. The first Euro-
pean smoker is reputed to have been imprisoned in a
dungeon in Spain for 3 years by the inquisition for
smoking in public on his return from America. How-
ever, the purported medicinal properties of tobacco
resulted in its seeds being brought back to Spain and
Portugal for cultivation there, initially in palace gar-
dens, thereby commencing its long association with
royalty and with royal endorsement. It is one of the
many ironies of tobacco that two of its first claimed
medical properties were its potential to cure and
also to prevent cancer. This latter claim resulted
in tobacco being used by healthy people (initially in
France as snuff) who, like many who have succeeded
them, became addicted.
The British first obtained their tobacco by plunder-
ing Spanish ships en route back from America. Sir
Francis Drake brought tobacco back from his circum-
navigation of the globe in 1580 while some tobacco
may have been brought back from the Caribbean in
the 1560s. Sir Walter Raleigh brought tobacco back
from his first Virginian expedition in 1586. Gately
states that tobacco was certainly in use in England by
1571 by shipmasters and others coming back from the
New World.1 Smoking was taken up in the court of
Elizabeth I, even by the Queen herself, and then of
course by affluent English society and anyone who
could afford it; tobacco was expensive so the English
started to grow their own. Tobacco use has since
spread worldwide as European colonization pro-
ceeded during the subsequent centuries.
King James I of England is famous for his accurate
and prophetic description of tobacco smoking as ‘a
custom loathsome to the eye, hateful to the nose,
harmful to the brain, dangerous to the lungs and
in the black, stinking fume thereof nearest resem-
bling the horrible Stygian smoke of the pit that is
bottomless’.1
Manufactured cigarettes, made by a combination
of hand and machine and later by machine alone,
were first marketed in England in the 1850s. Their
convenience, especially in the trenches in the First
World War has resulted in them being the most pop-
ular nicotine delivery devices ever since, especially
since their construction with cork tips and then filters
and especially as their contents can be readily manip-
ulated by the manufacturer.2 Unfortunately the
smoke from cigarettes is more acidic than that from
pipes and cigars and requires inhalation into the
lungs for effective uptake of nicotine, while the nico-
tine of pipes and cigars can more readily be absorbed
through the oral mucosa. Uptake through the lung
provides not only a more immediate sense of satisfac-
tion to the smoker as the nicotine is short-circuited to
the brain, but also exposes a much greater surface
area of respiratory epithelium to the smoke, which
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287
enhances its rapid absorption and potentiates the
addictive nature of the product. Cigarette smoking
has been taken up worldwide since then and has been
described as ‘a tragic accident of history’.3
ADVERSE HEALTH EFFECTS
Active smoking
Scientific proof of King James I’s assertion and the
wisdom of the inquisition have taken time to accu-
mulate but there has been indisputable evidence that
tobacco is the leading preventable cause of death in
developed countries, and has been for over half a
century.
A rising incidence of lung cancer was first observed
in the 1920s and 1930s by pathologists and other
medical practitioners.3,4 The first major and almost
conclusive evidence in the modern history of the
effects of smoking on health occurred in 1950 with the
publication of four retrospective studies of smoking
habits of lung cancer patients.5–8 The first longitudinal
study of this association by Hammond and Horn con-
firmed increased death rates for cigarette smokers
according to the amount they smoked.9 In July 1957
the US public health service issued its first statement
on cigarette smoking as a cause of lung cancer10 and
in 1962 the Royal College of Physicians of London11
reviewed the scientific evidence available at the time
on smoking and health and concluded that the rela-
tionship between smoking and lung cancer was a
causal one. The US Surgeon General commissioned
further investigations which came to virtually the
same conclusions:10,12,13 that cigarette smoking was ‘a
serious hazard to health and is related to illness and
death from lung cancer, chronic broncho-pulmonary
disease, cardiovascular disease and other diseases’. A
further report was issued in 197114 to incorporate ‘a
great deal of new research’ and reviewed the growing
understanding of the ‘bio-mechanisms whereby cig-
arette smoking adversely affects the human organism
and contributes to the development of serious illness’.
None of the conclusions of these early reports have
been found to be significantly incorrect in the moun-
tains of data that have accumulated over the years
that have followed. Additional associations have been
demonstrated and in Australia, a country with less
than 20 million inhabitants, tobacco smoking kills
19 000 smokers and 2400 non-smokers each year.3
This toll exceeds the deaths resulting from alcohol
abuse, AIDS, traffic accidents, murders and suicides
combined. One regular smoker in two dies from a
smoking-related disease (i.e. dies prematurely).15,16
Smoking is now identified as a major cause of heart
disease, stroke, peripheral vascular disease, COPD,
cancers of the lung, oral cavity, larynx, oesophagus,
stomach, kidney, bladder, pancreas, cervix, vulva,
penis, anus, and possibly others.3,17–19 Other health
problems such as impaired fitness, peptic ulcer dis-
ease, premature skin ageing with wrinkles, osteoporo-
sis, impaired fertility (including impotence) in males
and females, snoring, abortion and ectopic preg-
nancy, inflammatory bowel disease, cataracts and

288
increased complications of surgery, diabetes and
hypertension3,19,20 exist. Cigarettes, and cigarette
lighters may cause burns directly, and cigarette smok-
ing is associated with risk of setting fire to property
with potentially devastating effects. Tobacco smoking
increases the risks associated with various occupa-
tional exposures particularly asbestos,21 where it acts
multiplicatively to increase the risk of lung cancer and
contributes to the long-term effects of occupational
exposures on bronchitis and lung function.22
Environmental tobacco smoke exposure
Environmental tobacco smoke exposure has more
recently been shown to be an important cause of
smoking-related diseases especially since the case-
control study of Trichopoulos in 198123 of the smoking
habits of the spouses of non-smoking female resi-
dents of Athens, although the dangers of environ-
mental tobacco smoke to children were
demonstrated in the 1970s.24–26 Since then, further
evidence has accumulated and knowledge of the
effects of environmental tobacco smoke exposure has
increased, as may have been anticipated given the
nature of the exposure and the known dose–response
characteristics of carcinogens.
In the 1997 review of the literature by the National
Health and Medical Research Council of Australia27 it
was estimated from 34 studies that people who never
smoke but live with a smoker have a 30% increased
risk of developing lung cancer compared with people
who never smoke and live with a non-smoker. This
estimate did not take into account exposure outside
the home or the effects of passive smoking on current
smokers or ex-smokers. The report also reviewed 48
studies of the relationship between passive smoking
and asthma and it was estimated that children
exposed to environmental tobacco smoke are about
40% more likely to suffer from asthma symptoms than
children who are not exposed, such that about 8% of
childhood asthma in Australia is attributable to pas-
sive smoking and the effect is greater in the children
of mothers who smoke more heavily. On the basis of
25 studies, it was also estimated that children exposed
to environmental tobacco smoke during the first 18
months of life have a 60% increase in the risk of devel-
oping lower respiratory illnesses such as croup, bron-
chitis, bronchiolitis and pneumonia. It was estimated
that 13% of lower respiratory illnesses in Australian
children 18 months of age or younger are attributable
to passive smoking. On the basis of 16 studies it was
estimated that the risk of heart attack or death from
coronary heart disease was about 24% higher in
people who never smoked but are exposed to envi-
ronmental tobacco smoke. There were studies that
showed that environmental tobacco smoke exposure
is also associated with symptoms of upper airway irri-
tation and short-term changes in lung function even
in non-asthmatics, but there was no direct evidence
to implicate passive smoking as a cause of COPD. It
did point out that maternal smoking in pregnancy
and postnatal exposure to environmental tobacco
smoke may alter lung structure and function, increase
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AW Musk and NH de Klerk
bronchial responsiveness in children with asthma
and enhance sensitization of children to allergens,
and suggested that these early changes may be the
precursors of impaired lung function in later life (such
as through retarded lung growth or persistent bron-
chial hyper-responsiveness). The review also con-
cluded that passive smoking contributes significantly
to the risk of sudden infant death syndrome and may
increase the risk of death from all causes.
THE ASBESTOS ANALOGY
The chronology of events surrounding the scientific
discovery of the harmful effects of tobacco parallels
that of asbestos. Asbestos is also a substance that has
been used since antiquity; it was used in the wicks of
the lamps of the Vestal Virgins. Its harmful effects
were not clearly demonstrated until the 20th century
when asbestosis was identified as an obvious hazard
of exposure to asbestos (in the 1920s).28 Sir Richard
Doll demonstrated its connection with lung cancer in
1955, only 5 years after he had shown that tobacco
smoking caused lung cancer,29 while Christopher
Wagner showed its association with malignant pleural
mesothelioma in 1959.30 There was subsequently, and
had been previously (particularly after a German
report indicating an association with lung cancer in
the 1930s and other sporadic reports relating asbestos
exposure with ‘endothelioma of the pleura29), intense
activity by the asbestos industry attempting to
obscure and discredit this evidence, in very similar
fashion to the way tobacco companies have behaved
in the last 50 years.31
The subsequent sequence of events has been
somewhat different. Asbestos use and handling in the
developed industrialized world has been tightly regu-
lated and virtually eliminated, with the provisions
often being somewhat less stringent for chrysotile
(white asbestos) although this process took nearly 20
years to start and another 20 years to complete). How-
ever, there is still little effective regulation on tobacco
consumption with the exception of regulation of sales
to children, and in some more progressive societies,
of tobacco promotion and smoking in enclosed and
public places. These actions have had a disappoint-
ing, although significant, impact on tobacco sales
such that tobacco use is still widespread. The expla-
nations for the differences in the ability of society to
control tobacco and asbestos are unclear but there
are clear differences in the ability of the manufactur-
ers to circumvent legislation and litigation, and differ-
ent perceptions of the victims of diseases caused by
the products as to who is responsible for their dis-
eases. In the instance of the smoker with disease there
is a much greater tendency to accept blame for having
inflicted the illness on him or herself even though the
tobacco industry has been found to have withheld
information for decades about the addictive and
deleterious effects on health of its products.2 The
tobacco industry has been much more able to influ-
ence the political process than the asbestos industry,
which has been much more readily identified as a ‘vil-

History of tobacco and health
lain’ inflicting its product on people who must work
with it for the financial wellbeing of themselves and
their families. Collective legal and legislative action
(through the trade union movement) has been more
readily available to people with asbestos-related dis-
eases than to individual people with smoking-related
diseases. The anti-smoking movements have had few
financial resources to engage in litigation and it has
only been in the recent past that lawyers, with altru-
istic motives or with realistic expectations of contin-
gency payments, have been willing to challenge the
tobacco industry. Lastly, cigarettes are probably the
best designed addictive drug delivery systems ever
devised, while the attractions of inhaling asbestos
dust are few.
THE FUTURE
While smoking rates have been declining in devel-
oped countries they continue to increase in much of
the developing world. Politicians worldwide have
been complicit with the industry, further impeding
progress towards smoking control. The known bene-
fits of tobacco to health are few (weight control,
improvement in mood3,32) and cannot justify the con-
tinued marketing of tobacco.
CONCLUSIONS
The tobacco industry has consistently refused to
accept the evidence of the harmful effects of active
and passive tobacco smoking and also that nicotine is
addictive. It has continued to promote and sell its
products even where regulations are most stringent. It
has often been described as unique among American
and worldwide industries in its ability to forestall
effective government regulation and to hold effective
public health action at bay through skilled legal, polit-
ical and public relations strategies designed to con-
fuse the public and to allow it to avoid (until recently)
having to take responsibility for the death and disease
it inflicts while marketing its lethal products.2 This has
seriously impeded the ability of governments to con-
trol this major health problem.
Had tobacco been a new pharmaceutical drug in
today’s society it would never have been licensed for
sale to the public. Given that tobacco has been used
and marketed for so long it would have been with-
drawn from the marketplace as thalidomide was
withdrawn when its ill-effects became known. In fact
nicotine has been regarded as a poison and has been
scheduled in the Poisons Act in Western Australia for
decades.
The weak links in a system which should protect
the public from the poisonous and deadly nature of
nicotine and the chemicals which accompany it in
tobacco, whether they be administered by inhalation
or other means, are the politicians who are supposed
to protect the public’s health interests. The lack of
government resolve in cutting tobacco use has been
a continuous feature since the 1950s, typified by
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289
the British Chancellor of the Exchequer saying ‘We at
the Treasury do not want too many people to stop
smoking’.33
Latterly, some state governments in Australia have
at least diverted tobacco taxes towards research into
health promotion and lowering smoking rates,
although it is not completely clear, given the widening
differential in smoking rates between rich and poor,
whether this is not just another tax on the unem-
ployed and working classes, similar to state lotteries.
Current information indicates that tobacco smok-
ing is still responsible for huge numbers of deaths in
Western societies where anti-smoking activities are
slowly gathering momentum. If trends in these activ-
ities continue, especially if they are successful in
financially disrupting the industry, then real impro-
vements in health will follow. It will be important
that the gains achieved in these countries are also
achieved in other countries where the prevalences of
smoking remain unacceptably high and are still
increasing.
As long ago as 1990 the US Surgeon General pro-
nounced that ‘it is safe to say that smoking represents
the most extensively documented cause of disease
ever investigated in the history of biomedical
research’19 having by 1989 examined over 57 000
reports on the relationship between cigarette smok-
ing and disease.18 It would be interesting to compare
the costs of this documentation with the current
expenditure on prevention and then with the profits
still being enjoyed by tobacco companies, their share-
holders and those to whom they pay tax.
REFERENCES
1 Gately I. La Diva Nicotina. The Story of How Tobacco
Seduced The World. Simon and Schuster, London, 2001.
2 Glanz SA, Slade J, Bero LA, Hanauer P, Barnes DE. The
Cigarette Papers. University of California Press, Berkeley,
1996.
3 Winstanley M, Woodward S, Walker N. Tobacco in Aus-
tralia. Facts and Issues. Victorian Smoking and Health
Program, Melbourne, 1995.
4 White C. Research on smoking and lung cancer: a land-
mark in the history of chronic disease epidemiology.
Yale J. Biol. Med. 1990; 63: 29–46.
5 Doll R, Hill AB. Smoking and carcinoma of the lung. Pre-
liminary report. BMJ 1950; 2: 739–48.
6 Levin ML, Goldstein H, Gerhardt PR. Cancer and
tobacco smoking. A preliminary report. J. Am. Med.
Assoc. 1950; 143: 336–8.
7 Schrek R, Baker LA, Ballard GP, Dolgoff S. Tobacco
smoking as an etiological factor in disease. I. Cancer.
Cancer Res. 1950; 10: 49–58.
8 Wynder EL, Graham EA. Tobacco smoking as a possible
etiological factor in bronchogenic carcinoma. A study in
six hundred and eighty four proved cases. J. Am. Med.
Assoc. 1950; 143: 329–36.
9 Hammond EC, Horn D. The relationship between
human smoking habits and death rates. J. Am. Med.
Assoc. 1954; 155: 1316–28.
10 US Public Health Service. Smoking and Health. Report of
the Advisory Committee to the Surgeon General of the

290
Public Health Service (Washington). US Department of
Health Education and Welfare (PHS) 1103. 1464.
11 Smoking and Health. A Report of the Royal College of
Physicians on Smoking in Relation to Cancer of the Lung
and Other Diseases. Pitman Medical Publishing Co Ltd,
London, 1962.
12 USDHEW. The Health Consequences of Smoking. A Pub-
lic Health Service Review, 1967: PHS 1696.
13 USDHEW. The Health Consequences of Smoking. A Pub-
lic Health Service Review, 1969.
14 US Department of Health, Education and Welfare, 1971.
The Health Consequences of Smoking. A Report to the US
Surgeon General: 1971. Public Health Service, Health
Services and Mental Health Administration DHEW
(HSM), 71–7513.
15 Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortal-
ity in relation to smoking. 40 years’observations on male
British doctors. BMJ 1994; 309: 901–11.
16 Peto R, Lopez AD, Boreham J, Thun M, Heath C. Mortal-
ity from Smoking in Developed Countries, 1950–2000:
Indirect Estimation from National Vital Statistics. Oxford
University Press, Oxford, 1994.
17 US Department of Health and Human Services. The
Health Consequences of Smoking. Cancer. A report of the
US Surgeon General. US Department of Health and
Human Services. Public Health Service, Office on Smok-
ing and Health, Rockville, 1982; DHHS (PHS) 82–50179.
18 US Department of Health and Human Services. Reduc-
ing the Health Consequences of Smoking: 25 Years of
Progress. A report of the Surgeon General. US Depart-
ment of Health and Human Services, Public Health Ser-
vice, Centers for Disease Control, Center for Chronic
Disease Prevention and Health Promotion, Office on
Smoking and Health, 1989; DHHS (CDC) 89–8411.
19 US Department of Health and Human Services. The
Health Benefits of Smoking Cessation. US Department of
Health and Human Services, Public Health Service, Cen-
ters for Disease Control, Center for Chronic Disease Pre-
vention and Health Promotion, Office on Smoking and
Health, 1990, (CDC) 90–8416.
14401843, 2003, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1046/j.1440-1843.2003.00483.x by Cochrane Philippines, Wiley Online Library on [16/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
AW Musk and NH de Klerk
20 English DR, Holman CDJ, Milne E et al. The Quantifi-
cation of Drug Caused Morbidity and Mortality in
Australia, 1995 Edition. Commonwealth Department of
Human Services and Health, Canberra, 1995.
21 Hodgson JT, Darnton A. The quantitative risks of
mesothelioma and lung cancer in relation to asbestos
exposure. Ann. Occup. Hyg. 2000; 44: 565–601.
22 Morgan WKC, Seaton A. Occupational Lung Diseases, 3rd
edn. WB Saunders & Co, Philadelphia, 1995.
23 Trichopoulos D, Kalandidi A, Sparros L, MacMahon B.
Lung cancer and passive smoking. Int. J. Cancer 1981, 27:
1–4.
24 Colley JRT. Respiratory symptoms in children and
parental smoking and phlegm production. BMJ 1974; 2:
201–4.
25 Harlap S, Davies AM. Infant admissions to hospital and
maternal smoking. Lancet 1974; 1: 529–32.
26 Leeder SR, Corkhill R, Irwig LM, Holland WW, Colley JRT.
Influence of family factors on the incidence of lower res-
piratory illness during the first year of life. Br. J. Prev. Soc.
Med. 1976; 30: 203–12.
27 National Health and Medical Research Council. The
Health Effects of Passive Smoking. Commonwealth of
Australia, Canberra, 1997.
28 Merewether ERA, Price CW. Report on the Effects of
Asbestos Dust on the Lungs and Dust Suppression in the
Asbestos Industry. HM Stationery Office, London, 1930.
29 Doll R. Mortality from lung cancer in asbestos workers.
Br. J. Ind. Med. 1955; 12: 81–6.
30 Wagner JC. Some pathological aspects of asbestosis in
the Union of South Africa. In: Proceedings of the Pneu-
moconiosis Conference, Johannesburg, February 1959.
31 Lilienfeld DE. The silence: the asbestos industry and
early occupational cancer research—a case study. Am. J.
Public Health 1991; 81: 791–800.
32 Pidoplichko VI, DeBiasi M, Williams JT, Dani JA. Nico-
tine activates and desensitizes midbrain dopamine neu-
rons. Nature 1997; 390: 401–4.
33 McCurdy RNC. Smoking, Lung Cancer and You. Linden
Press, London, 1958.