Ashes to Ashes: doctors debate smoking

To mark national No Smoking Day, historian Professor Tilli Tansey draws on first hand accounts of how the British medical community responded to emerging evidence of the connection between smoking and health in the 1950s.

The link between good health and non-smoking might seem so well established and widely accepted in the UK, that a dedicated day of health messages and campaigns is obvious. But it was not always so. Even the Royal College of Physicians (RCP) had shown considerable reluctance to be associated with emerging work demonstrating the connection in the mid-1950s.

A very early Witness Seminar organised by the History of Modern Biomedicine Research Group (HMBRG) in 1995 invited some of the physicians who first raised concerns and provided evidence of the association between smoking and lung diseases to reflect on those early days. The proceedings of the Witness Seminar and associated symposium were published as Ashes to Ashes: the history of smoking and health; the unpublished records and correspondence from the meeting (GC/253/C/2) are in the Wellcome Library.

The high spot of the meeting was a contribution by Professor Sir Richard Doll (PP/DOL), who recalled working with Sir Austin Bradford Hill, who had been commissioned by the Medical Research Council (MRC) in 1947 to investigate an alarming rise in deaths attributed to lung cancer. They were charged to carry out “a large scale statistical study of the past smoking habits of those with cancer of the lung” (Ashes to Ashes, p. 131) and to compare these results with those from two control groups, one with gastric cancer, and one with diabetes.

The emphasis on smoking had been at the suggestion of the eminent pathologist Sir Ernest Kennaway (PP/ELK), but there was little consensus as to the causes of lung cancer, Doll himself admitting to a suspicion that if they did find a cause “it was most likely to have something to do with motor cars and the tarring of roads” (Ashes to Ashes, p. 133).

By the end of 1949, Doll and Hill had convincing evidence that smoking was an important factor in the development of lung cancer and published their preliminary results. Over the next few years they substantiated their work, and evidence from the USA, Germany and the Netherlands also appeared suggesting a causal link. However there was considerable reluctance from other physicians, from statisticians, and, not surprisingly, from the tobacco industry, to accept the findings.

Hill conceived of a prospective cohort study: to follow a large group of people and correlate their smoking habits with morbidity and mortality records. Further, he proposed that doctors should be that group. By the end of 1951, Doll and Hill had written to every doctor on the Medical Register and received replies from over 34,000. Within five years they had significant qualitative and quantitative evidence to support their earlier assertion.

The Royal College of Physicians considered it no part of their remit to get involved with such business. A presentation by Sir Christopher Booth (papers held at RCP, ACC2013/1) described the often tortuous negotiations involved in persuading the President of the RCP in 1956, Lord Brain (again RCP, MSS 3133-3296), to support a College investigation into the work. It took a change of President (to Sir Robert Platt), the involvement of the deputy Chief Medical Officer Sir George Godber (GC/201) and agitation from  RCP Fellows (including Avery Jones and Fletcher) before the establishment of a College Committee, whose influential 1962 report Smoking and Health [PDF] was described by the British Medical Journal as “a turning point in the approach to one of the most challenging opportunities for preventive medicine”. Sir Christopher was unable to attend the meeting himself, so his contribution took the form of this filmed segment:

 

The film is also  available via the HMBRG YouTube channel.

The archives of many of the Witness Seminar participants are held by the Wellcome Library, including Sir Francis Avery Jones (GC/198) who had originally led ‘demands’ that the RCP get involved in the subject; Dr Charles Fletcher (PP/CMF) who had superintended the writing of the subsequent College reports; Sir John Crofton, the TB expert who had pioneered anti-smoking research and publicity in Scotland (papers held at the RCP); and David Simpson, an early Director of ASH (SA/ASH), the anti-smoking lobby.

Almost 20 years after Doll and Hill first suggested a link between smoking and cancer, the World Health Assembly passed the first of 20 resolutions proposing comprehensive tobacco control in 1970. It was not until 2005 that the World Health Organization’s Framework Convention on Tobacco Control (FCTC) came into force. The FCTC was also the subject of a Witness Seminar, in which key individuals representing several countries contributed their accounts of national and international treaty negotiations. In addition to the FCTC Witness Seminar publication, archival material from the FCTC meeting will deposited be at the Wellcome Library (GC/253).

Author: Tilli Tansey OBE is Professor of the History of Modern Medical Sciences at the School of History, Queen Mary University of London.

You can find out more about the Wellcome Witness series on the History of Modern Biomedicine Research Group’s website or you can follow them on Twitter or connect via Facebook. The Makers of Modern Biomedicine project is supported by a Wellcome Trust Strategic Award.