ARTICLE SUMMARY:
Prior to groundbreaking reports published in 1950 and 1964 that definitively associated lung cancer with cigarette smoking, the habit was considered harmless and normal—even sophisticated. Numerous anti-smoking measures enacted after these important findings, and advances in lung cancer diagnostics and treatment represent a major public health success, but there is much work still to be done.
The rise in the popularity of smoking starting during the First World War. During the war, when cigarettes and tobacco were often issued as part of a soldier’s rations, General John Joseph “Black Jack” Pershing reportedly stated, “You ask me what it is we need to win this war. I answer tobacco as much as bullets.” Smoking rates were at their peak in the US and Europe after World War II. At that time, cigarettes were mass-produced and cheap, and physicians advocated smoking in tobacco advertisements (A famous ad read, "More doctors 
smoke Camels than any other cigarette"). The practice was glamorized in movies and culture, and claims by the tobacco industry that smoking was safe went completely unchallenged. Smoking was deemed a normal and harmless habit. However, around this time, the medical community started to notice a peculiar new trend: a surge in the number of lung cancer diagnoses and deaths. (Prior to this, the disease was considered an extremely rare malignancy.)
At the height of cigarettes’ popularity, in 1950—the same year as the start of the Korean War, the first credit cards (from Diners Club; see image), and when Julia Child enrolled at Le Cordon Bleu cooking school in Paris (bon appétit!)—a landmark paper was published in the British Medical Journal (BMJ) that would begin to paint a much different view of the practice, and the growing lung cancer problem.
The paper, by epidemiologists Sir Richard Doll and Sir Austin Bradford Hill, reported on a case-control study that compared lung cancer patients with matched controls. It was the first to confirm suspicions that lung cancer was associated with cigarette smoking. For the study, they designed a short questionnaire, administered by social workers to 650 male patients in London hospitals. The interviewees were newly admitted patients with suspected lung, liver, or bowel cancers. To reduce bias, the interviewers were not told the suspected diagnosis. They also interviewed hospital patients with other diagnoses. After the proper diagnoses had been made, it was startlingly clear that those in whom lung cancer was confirmed were smokers, and those without diagnosed disease were non-smokers.
The results were so compelling and unexpected that Doll and Hill took the results to the Medical Research Council head, Sir Harold Himsworth, who advised them that the results might be peculiar to London, and suggested that they repeat the study in other cities. So they studied 750 similar patients in Bristol, Cambridge, Leeds, and Newcastle, according to a biography of Doll, published in BMJ in 2005. Before seeing their results, the researchers thought that the most likely cause of lung cancer would prove to be pollution from coal fires and the expansion of the motor vehicle industry at that time. Unfortunately, their paper was largely ignored by the public, and the tobacco industry disputed the findings.
Then in 1964, a landmark Smoking and Health Report by the US Surgeon General concluded that smoking cigarettes is definitively linked to lung and laryngeal cancer in men, a probable cause of lung cancer in women, the most important cause of chronic bronchitis, and efforts should be made to urge current smokers to quit and non-smokers not to take up the habit. The effect of these findings was powerful. Just one year after its release, Congress passed the Federal Cigarette Labeling and Advertising Act of 1965, which required the first warning labels on cigarette packages.
Numerous anti-smoking measures followed, and they continue up to the present day. In 1973, Arizona became the first state to restrict smoking on some public places, and in 1988, a Surgeon General report concluded that nicotine is addictive. Then in 1990, the US Congress made all domestic airline flights smoke-free, and in 2009, Congress authorized the largest federal tobacco excise tax in US history.
These important changes over the 50+-year span since the Surgeon General’s report have positively impacted smoking rates. In 2018, 13.7% of American adults smoked, compared to a staggering 42% in 1964, according to the Centers for Disease Control and Prevention.
However, the practice is still a serious concern: lung cancer is the leading cause of cancer death worldwide. Cigarette smoking is responsible for more than 480,000 deaths per year in the US, including more than 41,000 deaths resulting from secondhand smoke exposure. This is about one in five deaths annually, or 1,300 deaths every day, according to the CDC.
Mainstay treatments including surgery, radiotherapy, or chemotherapy, or a combination of one or all of these, have changed little over the last 50 years, and they have not impacted mortality rates. One of the most prominent device companies looking to make a sizable impact on this troublesome disease is Auris Health Inc., founded by surgical pioneer Frederic Moll, MD, in 2007 (Auris was acquired by Johnson & Johnson’s Ethicon Inc. in April 2019 for about $3.4 billion in cash, plus additional contingent payments of up to $2.35 billion). The Monarch Platform, FDA-cleared in March 2018 and indicated for use in diagnostic and therapeutic bronchoscopic procedures, is a flexible endoscopic technology that holds promise to fight lung cancer by allowing physicians to diagnose (and eventually treat) hard-to-reach, small peripheral nodules with greater precision. (For more information, see recent coverage in MedTech Strategist and Market Pathways.)
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