Battle against tobacco.

The increase in the number of tobacco-caused deaths over the last 50 years is one of the most tragic developments in the modern history of medicine. The most common cancers globally are stomach cancer, with 669,400 cases diagnosed each year, and lung cancer with 660,500 new cases yearly (/). Those rates are not stable, however; lung cancer is actually overtaking gastric cancer. This is the situation for a mainly self-induced, avoidable—in other words, preventable—disease. To win the war against cancer, we must first win the battle against tobacco. A study of cancer mortality trends between 1960 and 1980 in 28 industrialized countries, conducted by the United Nations' World Health Organization (WHO), showed that the age-adjusted mortality rate for men increased by 19% in that period. Lung cancer mortality increased by 76% for men and 135% for women (2). Over the last 20 years, mortality rates from lung cancer in women increased more than 100% in Japan, Norway, Poland, Sweden, and the United Kingdom; more than 200% in Australia, Denmark, and New Zealand; and more than 300% in Canada and the United States (3). A WHO survey of smoking prevalence between 1975 and 1986 in 65 countries showed that, of the 30 countries with the highest rates, 21 were "developing" and nine were "developed" nations. It is estimated that one of three males above the age of 15 smokes cigarettes in developed countries, and one of two in developing countries. The rates for females are lower, but they are rising rapidly in developing countries. For years to come, cancer mortality is expected to increase in nearly all regions of the world, owing to a general increase in the age of the populations and an increasing use of tobacco. Cancer incidence is increasing globally, in spite of the enormous body of knowledge accumulated in cancer control over the last 40 years. The earlier-mentioned WHO analyses revealed the limited impact of treatment on overall mortality from common cancers and, consequently, the urgent need for strengthening preventive measures, especially tobacco control. Nothing would have greater impact today on cancer worldwide than the effective application of current knowledge about cancer control. Existing knowledge is best implemented through national programs that set the right priorities and strategies for use of available resources (4). Methods have already been worked out for estimating the cost-effectiveness of various measures (5). It sounds simple and straight forward enough. Is it then being done? Unfortunately, usually not. Only a handful of countries have established national cancer-control programs. The lung cancer mortality trends so far show us that the fight to control tobacco-caused cancers is currently being lost. Where do we go wrong? Early screening and diagnosis have proved inefficient in reducing mortality from lung cancer in controlled studies; the benefit of therapy is modest at best. Nevertheless, therapy is still receiving the bulk of the available resources. Even if effective therapies are found, they are likely to be unavailable to the majority of the world's lung cancer patients for decades. At present, primary prevention constitutes the only available means of reducing deaths from lung cancer. What are the lung cancer specialists doing in light of these facts? The Fourth World Conference on Lung Cancer in 1985 offered 38 scientific sessions. None dealt with primary prevention. Only one concerned supportive care, but 90% addressed symptoms caused by therapies. In fact, 21 sessions addressed therapy; two, diagnosis; four, pathology; and three, epidemiology. It does not help to change names to "innovative radiotherapy" or "neoadjuvant chemotherapy," or to change "immunotherapy" to "immunomodulators." It may help if part of the 90% of resources that goes to therapy, with a cure rate of around 10%, could go to prevention of the 90% preventable. A WHO Expert Meeting held last July also recommended that governments promote the introduction of programs of palliative care for the eventual incurable victims with tobacco-induced cancer in countries that accept the marketing policies of tobacco companies. One day, hopefully, the right priorities also will be reflected in the types of intervention studies undertaken, grants awarded, and scientific papers published. The world's two most common cancers, lung cancer and stomach cancer, are associated with lifestyles, and the former is increasing and the latter is decreasing, without any major interventions from the cancer-research establishment. The lessons from the McKeown analysis on change in mortality in tuberculosis (6) may illustrate this phenomenon and make the concept easier to accept. The discovery of the causative agent, tuberculosis, introduction of chemotherapy, and development of a vaccine contributed insignificantly to the worldwide decrease in death due to tuberculosis. The decrease in mortality was due to lifestyle changes—changes away from crowded, unsanitary living conditions. Changes in mortality from lung cancer and stomach cancer may be as strongly dependent on lifestyle changes. How does the future look? Out of today's estimated 660,000 lung cancer cases a year, one-third are in developing countries (/). In developed countries, many of which have health legislation, price policies on tobacco, and na-