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PRO BONO PUBLICO

Part 1

Given below are brief descriptions of two studies conducted to assess the relationship between tobacco smoking and lung cancer.

Study 1: was a survey-based retrospective case-control study. The author compared through questionnaires and medical histories, the smoking behaviour of lung cancer patients with that of a healthy ‘control’ group of comparable age. The questionnaires were sent to the patients' relatives, the histories obtained from medical records and diagnosis of death due to lung cancer confirmed by autopsy. There were 96 cases (86 males/10 females) and these were divided into 5 classes (extremely heavy smokers to non-smokers). The results showed that lung cancer victims were over 6 times as likely to be extremely heavy smokers. Further the healthy group had 4 times more non-smokers.

Study 2: Followed up and extended the earlier study. Questionnaires were sent not only to relatives of those who had died of lung cancer but also of other cancers (stomach, colon, prostate, esophagus and tongue). This sought to determine whether smokers were cancer prone or had a special predilection for lung cancer. Sampling was done of subjects of similar age who did not have any cancers. Data from their study has been refashioned and shown below:

Odds Ratios for Lung Cancer with Different Comparison groups amongst Smokers

Smoking Category	Group 1 (General Population)	Group 2 (All other cancers)
Very Heavy	16.6	8.8
Heavy	5.8	5.6
Medium	7.8	7.0
Moderate	1.6	1.4
Non-Smoker	1	1

Tested for Trends (P<0.00001 in both comparisons)

Part 2

The second study described above was conducted at an Institute for Tobacco Hazards Research set up by the Government. The state was concerned about the health and welfare of many of its citizens and undertook a series of steps to counter tobacco smoking. Some of the steps are given below:

- Smoking was banned in the offices of the Air Force, postal services.

- Smoking was banned by uniformed police

- Restaurants and cafes were prohibited from selling cigarettes to women

- Tobacco coupons were denied to pregnant women.

- It was illegal for anyone under 18 to smoke in public

- Advertisements for tobacco products were strictly regulated (both content/form)

• Ads that showed smokers as athletes were barred
• Ads were not allowed to ridicule opponents of smoking
• Images of masculinity were barred
• Ads could not be directed at women
• Ads could not be shown in films/billboards
• Ads could not be used in text sections of journals/newspapers

- Large scale production of nicotine-free cigarettes was started

- Research institutes were involved in developing nicotine-free cigarettes.

- Research was fostered into the psychology/psychopharmacology of smoking.

- Methods were developed to assist people to quit smoking.

- Tobacco manufacturers were pressured to convert their factories to non-tobacco ends

- Acreage for tobacco farming was controlled.

 

Part 3

The studies were conducted in Germany between 1939-1943. The Institute for Tobacco Hazards Research was established at the University of Jena by a grant of 100,000 marks from Hitler who not only abjured alcohol and tobacco but was also a convinced vegetarian.

Muller the author of the first study is regarded as the father of tobacco epidemiology and has been called "the Galois of tobacco science" (Proctor 1999). He was a member of the Nazi party and the Nazi motor corps. He presumably died in the war. The authors of the second study were Eberhard Schairer (a member of the Nazi party) and his student Erich Schoniger.

 
Reference:

Proctor, RN (1999) The Nazi War on Cancer (see chapter 6, The Campaign against Tobacco), Princeton University Press, Princeton, NJ, USA.

 
Comments:

I presented this problem to the class in sections. Each section raised a large number of issues. The students in general approved of the measures taken and when queried as to the locus of this study, almost unanimously felt it had to be either the United States or Canada since these had the most health conscious responsible governments. When presented with the final section, there was a sense of disbelief. We had an interesting discussion around unethical practices in one domain being counterbalanced by sensible, reasonable measures in another. This proved to be one of the more thought provoking problems used as it forced students to reconsider their assumptions.