By far the biggest causal factor in lung cancer is smoking. Links between disease and smoking have been recorded for hundreds of years and the link with lung cancer has been reported since Franz Hermann Muller in 1939.²² In 1950 three epidemiological studies provide the first evidence that smoking causes lung cancer.^23,24,25 The landmark study in the UK was that carried out by Doll and Hill, and reported in the British Medical Journal. This was a prospective study of 40,000 male doctors that compared cigarette consumption with lung cancer deaths, finding a strong dose response relationship.²⁶ This study was reported on again after 40 years in 1994,²⁷ estimating that the link was in fact even stronger than initially suggested. To the present day new evidence is reported that smoking causes lung cancer, making the link ever stronger.²⁷

Exposure of non-smokers to Environmental Tobacco Smoke (ETS) has also been strongly linked to an increased risk of lung cancer.²⁸ The extent to which the risk is increased is widely debated, it seems very difficult to quantify ‘exposure’ to environmental tobacco smoke. A recent meta-analysis of studies into ETS²⁹ has reported a publication bias in the literature and subsequently suggested that the increased risk is in fact lower than the previously reported 24% and estimates the increased risk to be nearer 15%, this is still a significant risk.

Exposure to carcinogens in the work place have been implicated in several industrial situations; asbestos dust, chromates, nickel, arsenic, radioactive materials, mustard gas, silica dust being examples.³⁰ Of part icular note in the context of law suites is the link between asbestos and mesothelioma.³¹

It has been shown that there is a familial tendency to develop lung cancer that cannot be explained by shared environment.^32,33 Though associations have been made between various metabolic polymorphisms and markers of mutagenic susceptibility, no single genetic factor is sufficiently predictive to be of diagnostic use, and in the context of complex extrinsic factors such as smoking, the relative contribution of individual genetic factors in lung cancer susceptibility is unknown. This area requires further study before application in such areas as screening, prevention or treatment, which could potentially have a large impact on how lung cancer is tackled.

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