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Comment Germany 2202Journal of Epidemiology and Community Health 1994;48:220-223 Comment J Epidemiol Community Health: first published as 10.1136/jech.48.3.220 on 1 June 1994. Downloaded from Smoking and health promotion in Nazi Germany George Davey Smith, Sabine A Strobele, Matthias Egger In his recent paper in this journal "A birth ations, autopsy series, experimental animal cohort analysis of the smoking epidemic in studies, and clinical reports,'1 12 which, he West Germany", Brenner' presents data already considered in 1929," left no doubt that showing that smoking rates increased tobacco smoke was a major cause of lung dramatically from the late 1920s onwards and cancer. In 1939, Franz Muller, from Cologne, that the reductions now being seen are limited performed what is generally recognised as the to men with higher education. His conclusions earliest controlled study, in which the smoking are that intensified education programmes are histories of 86 male lung cancer cases were required among teenagers, together with res- compared with those of 86 ill defined control trictive smoking policies at the workplace and subjects.'3 A markedly higher proportion of on transportation systems. Brenner believes the former were found to be heavy smokers. that the relatively limited progress made This activity occurred against a backdrop of against smoking in Germany is due to the slow official concern regarding the health damaging adoption of antismoking campaigns compared effects of smoking. Conti, the Reich Health with other countries such as the USA. In this Fuhrer, established the "Bureau Against the commentary we show that, contrary to these Dangers of Alcohol and Tobacco" in 1939.'4 assertions, energetic antismoking campaigns In 1942 an "Institute for the Struggle against were adopted in Germany at a very early stage. the dangers of Tobacco" was established at the Indeed, all of the activities Brenner now com- University of Jena,'5 under the directorship of mends were vigorously implemented during Professor Karl Astel. Originating from this the Nazi period in Germany, with, as he institute in 1943 was the first formal case- clearly demonstrates, little effect on stemming control study of smoking and lung cancer,'6 a the growing tide. convincing investigation in which Schairer and Schoniger showed a sophisticated under- standing of the potential biases which could Smoking and health: the German distort the findings. They included both popu- http://jech.bmj.com/ contribution lation and clinical control series and examined While accusations about the health damaging whether changes in smoking pattern con- effects of tobacco stretch back over the cen- sequent upon illness could lead to artefactual turies, a particularly strong tradition of results. It can now be calculated that the dose- scientific investigation emerged in Weimar response association between smoking be- Germany and was developed during the Nazi haviour and lung cancer risk in their study is period. Take, for example, the case of smoking significant at the p<0 0000001 level. The on October 1, 2021 by guest. Protected copyright. and lung cancer. While there were earlier anec- institute from which this study came was sup- dotal reports, from Germany and elsewhere, ported by 100 000 Reichsmark of Adolf Department of Public commenting on a possible link,5-7 the 1928 Hitler's personal finances.'4 Health, University of study by Schonherr in Chemnitz8 is con- The investigation of the health effects of Glasgow, 2 Lilybank Gardens, Glasgow sidered seminal9 in focussing on the smoking smoking was not restricted to lung cancer. The G12 8RZ habits of a series of lung cancer patients. The 1938 annual report of the Public Health Service G Davey Smith small group of women in this series apparently (Offentliche Gesundheitsdienst) considered of sort which Institute of Medical did not smoke, but, Schonherr concluded, that "the nervous disorders every Sociology, University their cancers could have been caused by are being reported in increasing numbers from of Hamburg, inhalation of their husbands' smoke. A case nearly every part of Germany are for the largest Hamburg, Germany due to excessive in tobacco and S A Strobele series, originating from Vienna and published part indulgence in the Munich Medical Journal in 1936,10 alcohol".'7 In 1939, Lickint's monumental 800 Department of Social reported a high prevalence of heavy smoking page study "Tabak und Organismus" was pub- and Preventive cancer. The author lished by Hippokrates Verlag,'8 the editorship of Medicine, University among patients with lung of Berne, Berne, concluded that although it was not completely which the censorious Kurt Klare had taken over Switzerland proved that smoking was the cause, this was from Erwin Liek, a doyen of Nazi medicine M Egger most likely. As in the Chemnitz series, how- from the early years. '4 This reviewed a huge Correspondence to ever, no controls were studied. body of work on the association between Dr G Davey Smith. From the late 1920s on, Fritz Lickint pub- smoking and ill health, much of it carried out or Accepted December 1993 a series of detailed reviews of smoking published in Germany. In the same year, re- Accepted for publication lished January 1994 and lung cancer trends, of ecological associ- search into the effect of smoking on chromo- Smoking and health in Nazi Germany 221 somes was commissioned by the Reich Health set an example to pupils outside of school by J Epidemiol Community Health: first published as 10.1136/jech.48.3.220 on 1 June 1994. Downloaded from Office.'4 Tobacco had long been considered a not smoking. In July 1943, a law was passed potential "genetic poison" by the Racial forbidding tobacco use in public places by Hygiene movement in Germany; clearly the anyone under 18 years of age.25 high level of concern regarding the health Transportation, workplaces, and public effects of smoking was strongly connected to the buildings became targets for smoking reduc- goal of general improvement of the Aryan tion campaigns. Thus, it was considered crim- "race". Thus Professor Karl Astel, SS member inal negligence if drivers were involved in and director of the Jena Institute for Racial accidents while smoking,26 and in 1944 smok- Policy and Human Genetics as well as the ing was banned on city trains and buses. 14 Institute for the Struggle Against the Dangers Aside from work related antismoking propa- of Tobacco, was renowned for striking cigar- ganda, smoking was prohibited in many indi- ettes from students' mouths, as part of his vidual workplaces and public buildings, campaign against "racial deterioration".l9 including government bureaux,26 hospitals, Astel's racial hygiene activities in Thuringen and rest homes.'4 included the intense harrassment of Jews, The advertising of tobacco products also homosexuals, and the mentally subnormal, the came under strict control. Advertisements proposition of a "preventive death sentence" could not give the impression that smoking for antisocial elements considered to be poten- had any "hygienic values".27 Furthermore, tial murderers, and an active role in the estab- tobacco manufacturers could not "represent lishment of the Nazi euthanasia programmes, in the use of tobacco as a sign of manliness nor which over 70 000 people deemed to be men- ridicule opponents of tobacco. They may not tally or physically defective were murdered.'4 make advertising appeals to women and those In March 1939 there was an attendance of interested in sports nor picture smokers at the 15 000 at a conference on the effects of tobacco wheel of the automobile".27 and alcohol consumption. At this meeting In accord with much current health promo- Hans Reiter, president of the Reich Health tion theory, there was considerable endorse- Office, charged all the medical societies of ment ofthe goal of smoking cessation from role Germany with the responsibility for determin- models. Thus, Robert Ley, the leader of the ing scientifically the degree to which tobacco German Labour Front, attested personally to caused disease.20 At the official opening of the the benefits of not smoking.20 While many Institute for the Struggle Against the Dangers other influential figures joined this roster,'8 the of Tobacco, Reiter outlined a research agenda star performer in antismoking propaganda was which should guide its work: statistical inquir- Adolf Hitler. As one magazine put it: "brother ies, clinical research into the effects of tobacco national socialist, do you know that your in humans, and experimental animal re- Fuhrer is against smoking and thinks that search. '1 every German is responsible to the whole people for all his deeds and omissions, and does not have the right to damage his body Health promotion under the Nazis with drugs?'".2' The scientific research into the health effects of smoking went hand in hand with extensive http://jech.bmj.com/ health promotion activities aimed at reducing Health promotion and the King Canute the prevalence of the habit. Popular health principle magazines such as Gesundes Volk (Healthy Brenner shows that despite this intense health People: Journal for the Health and Entertain- promotion activity smoking continued to in- ment of the Workforce), Volksgesundheit crease. This was recognised at the time, and it (People's Health), and Gesundes Leben was perhaps with some glee that the Berlin (Healthy Life) contained warnings against the correspondent for the J7ournal of the American dangers of smoking.2' There was also a journal Medical Association - a regular if somewhat on October 1, 2021 by guest. Protected copyright. Die Volksgifte (The Popular Poisons) devoted cynical reporter on the crusade against tobacco to the campaign against alcohol and tobacco.'4 - noted that cigarette consumption increased General interest magazines and newspapers in 1938 from 609 per head to 676 per head.26 also drove home the message, which clearly The processes acting in such a case have a meshed well with the goals of racial hygiene: more general form within health promotion, the improvement of the national-biological re- which can be termed the King Canute prin- source of the health of the population.
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