SMOKING AND HEALTH PROMOTION IN NAZI GERMANY
From the Journal of Epidemiology and Community Health (1994; 48:220-223)

PREFACE

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From the late 1920s on, Fritz Lickint published a series of detailed reviews of smoking and lung cancer trends, of ecological associations, autopsy series, experimental annual studies, and clinical reports which, he already considered in 1929, left no doubt that tobacco smoke was a major cause of lung cancer. In 1939, Franz Muller, from Cologne, performed what is generally recognised as the earliest controlled study, in which the smoking histories of 80 male lung cancer cases were compared with those of 86 ill defined control subjects. A markedly higher proportion of the former were found to be heavy smokers.

This activity occurred against a backdrop of official concern regarding the health damaging effects of smoking. Conti, the Reich Health Führer, established the "Bureau Against the Dangers of Alcohol and Tobacco" in 1939. In 1942 an "Institute for the Struggle against the dangers of Tobacco" was established at the University of Jena, under the directorship of Professor Karl Astel.

Originating from this institute in 1943 was the first formal case-control study of smoking and lung cancer, a convincing investigation in which Schairer and Schuniger showed a sophisticated understanding of the potential biases which could distort the findings. They included both population and clinical control series and examined whether changes in smoking pattern consequent upon illness could lead to artifictious results. It can now be calculated that the dose- response association between smoking and lung cancer risk in their study is significant at the p<= 0.0000001 level.

The institute from which this study came was supported by 100,000 Reichmarks of Adolf Hitler's personal finances.

The investigation of the health effect of smoking was not restricted to lung cancer. The 1938 annual report of the Public Health Service (Offentliche Gesundheltsdiesnt) considered that "the nervous disorders of every sort which are being reported in increasing numbers from nearly every part of Germany are for the larger part due to excessive indulgence in tobacco and alcohol"

In 1939, Lickint's monumental 800 page study "Tabak und Organlsmus" was published by Hyppokrates Verlag, the editorship of which the censorious Kurt Klare had taken over from Erwin Liek, a doyen of Nazi medicine from the early years. This reviewed a huge body of work on the association between smoking and ill health, much of it carried out or published in Germany. In the same year, research into the effect of smoking on chromosomes was commissioned by the Reich Health Office.

Tobacco had long been considered a potential "genetic poison" by the Racial Hygiene movement in Germany, clearly the high level of concern regarding the health effects of smoking was strongly connected to the goal of general improvement of the Arian "race".

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In March 1939 there was an attendance of 15,000 at a conference on the effects of tobacco and alcohol consumption. At this meeting Hans Reiter, president of the Reich Health Office, charged all the medical societies of Germany with the responsibility for determining scientifically the degree to which tobacco caused disease. At the official opening of the Institute for the Struggle Against the Dangers of Tobacco, Reiter outlined a research agenda which should guide its work: statistical inquires, clinical research into the effects of tobacco in humans, and experimental animal research.

Propaganda against smoking was also disseminated by the Hitler Youth and the League of Germany Girls. In 1939, Göring issued a decree forbidding the military to smoke on the streets, on marches, and on brief off duty periods and in the summer of 1942 the Federation of German Women launched a campaign against tobacco and alcohol abuse.

Self restraint was supplemented through restaurants and cafés being forbidden to sell cigarettes to women customers. Smoking was banned - for pupils and teachers alike - in many schools. Teachers were also expected to set an example to pupils outside of schools by not smoking. In July 1943, a law was passed forbidding tobacco use in public places by anyone under 18 years of age.

Transportation, workplaces, and public buildings became targets for smoking reduction campaigns. Thus it was considered criminal negligence if drivers were involved in accidents while smoking, and in 1944 smoking was banned on trains and buses. Aside from work-related antismoking propaganda, smoking was prohibited in many individual workplaces and public buildings, including government bureaus, hospitals, and rest homes.

The advertising of tobacco products also came under strict control. Advertisement could not give the impression that smoking had any :hygienic values". Furthermore, tobacco manufacturers could not "represent the use of tobacco as a sign of manliness, nor ridicule opponents of tobacco.

They may not make advertising appeal to women and those interested in sports, nor picture smokers at the wheel of automobiles.

In accord with much current health proclamation theory, there was considerable endorsement of the goal of smoking cessation from role models. Thus, Robert Ley, the leader of the German Labour Front, attested personally the benefits of non smoking. While many other influential figures joined this roster, the state performer in antismoking propaganda was Adolf Hitler. As one magazine put it: "brother national socialist, do you know that our Führer is against smoking and think that every German is responsible to the whole people for all his deeds and emissions, and does not have the right to damage his body with drugs?"

Take, for example, the celebrated North Katelia heart disease prevention programme. Initiative efforts were made to modify the coronary risk factor profile in north karelia in Finland from the early 1970s, and the success of the program was announced. As the figure shows, the declines in ischemic heart disease mortality in North Carelia were no greater than elsewhere in Finland - - it was simply that, unlike with King Canute, the proclamation that heart disease would be prevented was made just as the tide of ischemic heart disease was beginning to ebb.

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The emigrè Jewish physician and energetic campaigner against the Nazi regime, Martin Gumpert, [..] discussed "the Führer's distaste for injurious smoking and drinking habits" which it might be thought, would "produce beneficial results for the national economy and the national health". He considered that the large increase in alcohol consumption and drunkness in Germany reflected "The abstinent Hitler, who from conviction never takes a drop of alcohol, and whose movement first emerged from the beer halls of Münich, now drives the people at whose head he stands into fatal alcoholism."

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The history of smoking and health in Germany, which cannot be taken to start in the post war world with a population free of restrictions on smoking, shows the inadequacy of simple diffusion models.