Forewords Preface Prologue I: 1951-54 II: 1954-57 III: 1957-61 IV: 1961-62 V: 1962 VI: 1962-64 Epilogue Appendix

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Denial & Delay

Chapter 2:

1954-57:
Neutralising the MRC Findings

The public did not entirely ignore the risks of smoking: many of them wrote to the Minister of Health and a file in the Public Record Office[1] preserves some of their theories and proposals. One correspondent claimed that lung cancer was caused by the sulphur in matches, another blamed petrol lighters, and a former TB nurse blamed the Russians. A State Registered Nurse blamed stray contaminants on the fingers of smokers, and other writers pointed to causes quite removed from smoking: exhaust fumes, salt-petre in artificial fertiliser, dust from rubber tyres, chlorinated water supplies or contamination from wild rabbits. A woman enclosed the fading and torn manuscript of her grandmother's remedy for cancer, which involved boiling a poultice of figs in milk, and an eighty-one-year-old claimed that dog-ends were being sold back to the manufacturers for re-use as an economy measure.

Amid the paranoid suggestions of far-reaching plots ‘to destroy our health and security, as I have for 15 years on end warned H M Ministers of State at risk of being murdered for doing so' and those out for gain (‘I believe I know the answer and would let you know by return of post if you are interested, providing I am not to be forgot when proved') there are sensible letters also: a correspondent noted that cigarettes were now smoked down to a very short butt owing to the shortage of tobacco; another suggested experiments on monkeys, and a Miss Marjorie Marrian - not the only one to point to the potential risks to non-smokers - proposed studying lung cancer in non-smokers working in smoky areas such as usherettes in cinemas. One person complained to the Minister of the failure of the Daily Telegraph to publish anti- as well as pro-smoking letters.

Tom Hurst - who went on to long years of service to the National Society of Non-Smokers[2] and was the originator of the UK's No Smoking Day campaign - wrote to the Minister that he and his wife proposed to initiate a campaign to persuade smokers to quit smoking and asked: ‘Would you, Sir, be prepared to support such a campaign, subject to the details being settled by your department?' The reply stated that ‘the Minister feels he is unable to support campaigns which might mislead the public into assuming that a causal relationship between tobacco smoking and cancer had been definitely proved.' Another letter was from the president of the Non-Smoking Publicity Society, who sought withdrawal of tobacco advertising on public transport.

This wish to control tobacco advertising was soon echoed in Parliament, where the Bill to establish commercial television was being discussed. On 31 May, Dr Barnet Stross, Labour MP for Stoke on Trent Central, moved an amendment to ban tobacco advertising from the new channel, and the Home Secretary, David Maxwell Fyfe, undertook to consult his colleagues on the point. When the General Post Office, responsible for broadcasting, wrote accordingly to the Ministry of Health, M R P Gregson, an Assistant Secretary, suggested to Dr Goodman: ‘I think it would be quite wrong to ban tobacco advertisements on commercial television. Why pick on tobacco - what about alcohol?' Goodman responded: ‘I entirely agree. If and when (a) a causal association is proved (b) public opinion accepts that all tobacco advertising might be immoral, a ban might be considered. We are very far from either at present.'

Gregson therefore replied to the GPO, in terms agreed by the Minister, that ‘any hasty and ill-considered ban such as that suggested would mislead the public into assuming that a causal relationship between tobacco smoking and cancer has been definitely and unequivocally proved.' He referred to the research being undertaken and the ‘large sum of money' provided by the industry for such research. ‘In view of this, it would in the Minister's view, be wrong to take any step such as that suggested.' The next day the Permanent Secretary's private office notified the Chief Medical Officer and Mr Gregson that ‘Mr Partridge, of the Imperial Tobacco Company, is coming to see the [Permanent] Secretary on Wednesday, 23rd June', and Partridge himself wrote to Sir John Hawton a few days later to say that the purpose of the visit was to talk about the Television Bill debate. Sir John minuted after the meeting: ‘I replied to him broadly in the sense of the letter sent by Mr Gregson to the Post Office on the 16th June and he seemed perfectly satisfied and said that that was what he expected.'[3]

This complacent attitude in the Ministry of Health is brilliantly illuminated when at just this time the British Medical Journal published the first report from Richard Doll and Austin Bradford Hill on their study of British doctors - a report brought forward owing to the unexpected strength of the case it made against smoking.[4] The event passes without notice. Not even a press cutting is filed.[5] The Ministry maintained in public that it awaited further research: in fact it ignored research and was moved to action only by external pressure.

The research nevertheless continued.[6] The MRC held a conference in June 1954 and set up two working committees - one chemical, one biological - to oversee research on ‘the chemistry of tobacco smoke in relation to carcinogenesis'. These committees met - sometimes together - roughly once a year and reviewed technical research papers. In 1954 and again in 1956 visits were paid to the Imperial Tobacco research laboratory in Bristol. Further papers were published by Doll and Hill and by other researchers, but the story was now one of politics, not of science.

Horace Joules, dropped from the Standing Advisory Committee (Cancer and Radiotherapy), was still a member of the Standing Medical Advisory Committee (SMAC) and he persuaded it on 8 March 1955 that although the former committee covered ‘the nature of the connection' it was within the SMAC's remit to consider publicity. He urged that ‘it was vital that the public should be reminded constantly of the known facts and of the risks involved in heavy smoking.' He succeeded, and the SMAC advised the Minister that it was ‘desirable that appropriate action should be taken constantly to inform the public of the known connection between smoking and cancer of the lung and of the risks involved in heavy smoking'.

Once more the Ministry of Health had to face the problem. R L Briggs, a principal in the Ministry, consulted Dr Goodman and then wrote to Gregson:

the Minister could agree to make a further announcement . . . but not at this stage to keep up a steady barrage of propaganda as [SMAC] want. Apart from the uncertainty which still remains about the culpability of tobacco - though we have admitted that it seems to have some measure of culpability - no doubt the Chancellor of the Exchequer would be interested!

The Ministry produced a paper for the Central Health Services Council (through which the SMAC's advice had to be routed) in which the history of the SAC(CR)'s consideration of the matter was related, including the report of the Government Actuary's committee and the Minister's announcement the previous year. It recalled the SAC(CR)'s advice in 1949 against cancer education of the general public. The CHSC had agreed that it was wrong ‘to make the public cancer-conscious by fear', but had left the door open for local authorities to undertake publicity. In 1952, the SAC(CR) had recognised the value of ‘reducing the delay between the onset of symptoms and consultation of the general practitioner' and had positively advised that local authorities and voluntary bodies undertake cancer education: the Minister had accordingly issued a circular to local health authorities in August 1953.[7]

The CHSC did not meet until October 1955 and then they rejected the SMAC's advice. It would be ‘wise' to await the outcome of research, including that financed by the ‘considerable sum' provided by the tobacco companies. Besides, ‘it was understood that further research by the Medical Research Council was throwing some doubt on the causal connection between smoking and cancer of the lung.' It is not clear who provided this misinformation, but it doubtless encouraged Imperial Tobacco's secretary, Partridge, who visited the Ministry of Health Permanent Secretary, Sir John Hawton, shortly afterwards to find out what had happened.[8] (These visits and telephone calls were almost routine: he had called previously in July - ‘He wanted to know whether there were any developments since the M[inister]'s answer [to a Parliamentary Question] in the House on the 27th June.' - and in March 1956 we find him consulting Sir John on the wording of Imperial Tobacco's annual report. The following month he sought help with a plan - later dropped - for Dr Clarence Cook Little, scientific director of the US Tobacco Industry Research Council (later known as the Council for Tobacco Research), to meet ‘leading medical correspondents' during a visit to the UK.)

The subject would not go away. In March 1956, the Minister of Health, now Robin Turton, in an exchange in the House of Commons, stated, presumably without realising the implications: ‘There is a causal connection between smoking and lung cancer. That we know.' The next day Partridge was on the phone to Sir John to protest, and a few days later the Treasury's Second Secretary, Sir Herbert Brittain, wrote to express concern that the Minister's remarks went beyond Iain Macleod's 1954 statement, which had conceded only the ‘presumption of a causal connection': ‘We have a close interest in the public discussion of this subject [lung cancer] and its association in such discussions with smoking, because of the very considerable revenue (£660 millions) which we derive from tobacco duties.' Sir John hastened to reassure them: there was no change of policy: the Minister's words were ‘an oral slip'.[9]

But by then the Central Health Services Council had bent to the reiterated will of the SMAC and transmitted to the Minister its advice in favour of constant publicity ‘as a matter of urgency'. The minutes of their meeting on 13 March record their conclusions:

(a) Propaganda on this subject was not analogous to the ordinary type of cancer education which was aimed primarily at the early detection of cancers: it was rather a piece of purely preventive medicine.

(b) Propaganda on smoking and lung cancer was becoming urgent. The public were constantly exposed to propaganda in favour of smoking and efforts to inform them of its connection with cancer had so far had little success.

(c) There was already sufficient evidence of a causal connection . . . to justify a centrally directed propaganda campaign, for example through schools and general practitioners.

Further, it was difficult to define ‘excessive' - there was a straight-line correlation between the number of cigarettes smoked and the risk of lung cancer, and the risk even for heavy smokers was reduced if they stopped smoking.[10]

The Minister was back in the firing line. He immediately came under pressure in the House of Commons[11] to say what he was going to do. The Chancellor - now Harold Macmillan - was quick to enter his caveat:

Dear Robin

The effect of smoking on the incidence of lung cancer is very much back in the news. I gather that you have decided that you will have to make some statement on the subject, and that you have it in mind to refer this in draft to the Home Affairs Committee.

In view of the enormous yield of the tobacco duty, the subject is one in which the Exchequer is very much involved. I would therefore like to have a talk with you about your statement before it is considered by the Home Affairs Committee. Our Private Secretaries can fix a time. -

Harold Macmillan

Turton replied reassuringly[12], and it was not until 11 April that he put a paper to the Home Affairs committee of the Cabinet[13]. It summarised the evidence on smoking and health and quoted the chairman of the MRC's committee on the subject, Professor Alexander Haddow. He had pointed to the known potent carcinogen 3:4-benzpyrene as a likely agent in causing lung cancer but admitted that the chemical work, owing to ‘natural experimental and technical difficulties', was inconclusive. However:

The fact that a causal agent has not yet been recognised should, in my opinion, not be allowed to confuse the main issue, namely, that there is a statistical association between cigarette smoking and the incidence of lung cancer which (again in my opinion) is so massive as to be incontrovertible; and the simplest explanation of which is that there is a causal connection between the two.

Turton, however, stated that the evidence, however ‘incontrovertible', was ‘not conclusive enough to justify the kind of national propaganda campaign which my advisory bodies urge' and proposed only to answer a Parliamentary Question with a ‘progress report' on the research, in which he would say that although progress was being made, there was ‘not yet any scientifically conclusive proof', so that he felt unable to go further than making the (briefly summarised) facts known.[14] Moreover, his statement should not (he proposed) come until after the impending Budget, and he had persuaded an MP with a question on the House of Commons order paper that it should be postponed.

The Lord President, Lord Salisbury, was briefed on Turton's paper by the MRC and his own office.[15] H B Lewin, a principal in his office, complained of the excessive caution of the proposed statement (‘so carefully worded' with ‘so many qualifications') which resulted in the Minister in effect reneging on Iain Macleod's 1954 statement that it was desirable that young people be warned of the risks of excessive smoking. Landsborough Thomson, now Sir Arthur, in a restrained minute, nevertheless made it clear that the Minister of Health was understating his case. His Council's ‘own assessment of the degree of proof already attained' would ‘almost certainly' be ‘substantially higher . . . [A]bsolute scientific proof of causation . . . is always difficult to achieve' but already in this case ‘the evidence is stronger than that which, in comparable matters, is commonly taken as a basis for definite action' - a formulation that was to reappear, and disappear, the following year.

The Cabinet Home Affairs committee met on 13 April with R A Butler in the chair.[16] Lord Salisbury dutifully reported that the MRC would have preferred a stronger statement. ‘The evidence linking cancer of the lung and smoking had increased notably since 1954, and was now stronger than would normally be regarded as justifying action.' In discussion, the need ‘to retain a sense of proportion and to avoid creating anything resembling panic' was set against the fact that lung cancer was ‘dreaded' and that there was ‘little doubt' that proof of the causal connection ‘would be obtained, and probably fairly soon'. The Chancellor confirmed that it would be ‘most inconvenient' to have the statement before the Budget, and the proposed statement was approved subject to endorsement by the full Cabinet.

The paper to the Cabinet repeated the main points put to the Home Affairs committee. At the Cabinet meeting on 19 April, Turton said that

The statement which he proposed to make was restrained rather than alarmist. It would not satisfy those who felt that the situation demanded a general propaganda campaign, in the schools and elsewhere, against smoking. He considered, however, that this would not be justified in the absence of direct scientific proof of a causal connection between smoking and lung cancer.

But he did not get things all his own way:

The Prime Minister [Sir Anthony Eden] said that, in his view, the time had come when the Government should determine their attitude to this problem and decide whether or not they should take a definite line on it. He proposed that a small Committee of Ministers should go more fully into the problem and submit their views and recommendations to the Cabinet.

This was agreed[17], and the Committee was set up with R A Butler, the Lord Privy Seal, in the chair, and with Lord Salisbury (Lord President of the Council), James Stuart (Secretary of State for Scotland), Harold Macmillan (Chancellor of the Exchequer) and Robin Turton (Minister of Health) as members. Its terms of reference were

To recommend what policy the Government should adopt in the light of the statistical evidence which appears to establish a relationship between smoking and cancer of the lung, and to report to the Cabinet.

The Committee - known as GEN 524[18] - met a week later to consider a revised and rather inept draft Parliamentary Answer in which Robin Turton tried to take account of points made at the Cabinet meeting: ‘The extent of the problem should not be exaggerated . . . in 1954, for men aged 45-74, out of every thousand deaths eight were from motor vehicle accidents, eighty-five were from cancer of the lung and seventy-seven were from bronchitis' - the contribution of smoking to bronchitis had not yet been highlighted. However, it included the information that ‘by giving up smoking the risk can be materially reduced' and the statements that the Government believed the time had come to draw the facts to public attention and that ‘more should be done to foster research towards developing a cigarette which is free from carcinogenic substances'.

The Committee, however, decided that the statement should minimise any ‘expression of opinion or concern' by the Government. The statistical comparisons should substitute strokes and apoplexies (112 deaths per 1000) for road accidents; the advice about giving up smoking was ‘unnecessary', as was the reference to developing a carcinogen-free cigarette.

Turton produced a redraft. It quoted the MRC committee chairman as saying that the risk of lung cancer among heavy smokers was twenty times that in non-smokers and said that the Government considered that ‘the public should be kept informed of all relevant information as and when it becomes available'. This version was put to the Cabinet in a paper by Butler which stated the extent to which the Government should accept responsibility in some detail:

Any statement on this subject should not involve the Government too deeply in responsibility for dealing with the possible consequences of excessive smoking. From the point of view of social hygiene, cancer of the lung is not a disease like tuberculosis; nor should the Government assume too lightly the odium of advising the general public on their personal tastes and habits where the evidence of harm which may result is not conclusive.

. . . the Minister's statement should, as far as possible, rest, without comment, upon the views of the medical experts, and it should aim to hold the balance evenly between unnecessarily alarming public opinion, and dismissing the whole question as unimportant. A statement falling between these two extremes would be as clear as can be expected in the present state of our knowledge, and should also take care of the substantial Treasury interest involved.

The statement ought also to anticipate the expected new report from Doll and Bradford Hill and ‘do so with the minimum of ostentation, i.e., preferably by way of an ordinary Parliamentary Question.'

The Cabinet approved this version with minor amendments[19] and the same day Turton arranged to see Sir Alexander Maxwell ‘as Chairman of the Tobacco Advisory Committee of the Board of Trade' - presumably to inform him of the terms of the statement, although there is no minute of the meeting on the file.

The result was that, when finally on 7 May Turton delivered the agreed answer in the Commons (reproduced in the Appendix), with the addition in answer to a supplementary question that ‘In my view, in the present stage of our knowledge, a national publicity campaign would not be appropriate', the tobacco companies were able simultaneously to issue a statement to the press emphasising that the evidence was ‘conflicting and very incomplete' with a great deal more research needed before firm conclusions could be drawn. They stressed that the ‘suggestion that smoking may be a contributory cause of lung cancer continues to be based mainly on certain statistical enquiries' which could ‘never constitute proof of a cause and effect relationship'. They made the most of what anomalies they could find, claimed that ‘tobacco is a great boon to many millions of people in this country and throughout the world', and anticipated later industry lines of enquiry by suggesting that ‘the benefits, psychological and physiological, it may confer are not yet fully understood and might well be a subject of scientific investigation'. They allowed that an excess of anything was harmful - but what was excess? - and concluded by stressing the need for the research that their £250,000 was funding.[20]

After such a masterly performance, the companies must have been disappointed that The Times the next day was critical of Robin Turton, saying that his statement had ‘added nothing to public knowledge and subtracted nothing from public anxiety'. It picked on ‘ministerial fatuities' and called for an end to ‘platitudinizing', giving a long list of discerning questions that needed answers. While ‘it is foolish to press a science for more certainty than it is capable of giving' nevertheless ‘the time has come for his Ministry to summarize the ascertained facts, put them into plain language and publish them in a cheap and arresting format'. However, the industry's disappointment at such criticism must have been as nothing compared with the disillusion of Horace Joules and his allies whose efforts over five years had been rewarded so meagrely.[21]

The tobacco companies now consolidated their position by formalising the group that had provided the £250,000 as the Tobacco Manufacturers' Standing Committee (known later as the Tobacco Research Council). It was already in action - complaining about a Ministry of Education handbook that included the MRC's claim that the risk of lung cancer for heavy smokers was 20 times that for non-smokers: the calculation was Bradford Hill's but it had not been scientifically published - before its formation was announced in a statement issued on 3 August. Maxwell was its chairman, and Sir Alfred Egerton FRS and Sir Ronald Fisher FRS had ‘consented to act as Scientific Consultants to the Committee'. Egerton had been Professor of Chemical Technology at Imperial College from 1936 to 1952 and Secretary of the Royal Society for ten years to 1948; Fisher had been since 1943 the Arthur Balfour Professor of Genetics at Cambridge and was a past President of the Royal Statistical Society. Fisher, in particular, was a valuable ally to the industry.[22]

Lord Salisbury, however, had privately but formally asked the MRC in May ‘to review the evidence . . . and to prepare a statement of their considered assessment of the significance of the present knowledge'.[23] The resulting Ministerial statement did not come until June 1957, and for the intervening year the Government merely brushed the issue aside. Numbers of questions were asked in Parliament pressing for publicity. The answers followed the same line: for example, in November 1956 Robin Turton claimed that the recently published second report from Doll and Hill[24] merely ‘confirms the statistical association . . . about which I made a statement in the House on 7th May . . . I do not consider that a [national] campaign [of information] such as the Hon. Member . . . suggests would be at present appropriate.'

The SMAC in December repeated its advice on the basis of Doll and Hill's new report that the Minister should ‘constantly . . . inform the public' of the risks and the CHSC agreed - but to no avail. The Ministry files contain a report of a conference in January 1957 of the Central Council for Health Education - a joint body of the local authorities - at which Dr John Burton, its Medical Director, ‘spoke of the contradictory attitudes towards smoking and cancer; the Minister refusing to do any anti-smoking publicity; the subsidy for the tobacco for troops and old age pensioners; doctors' personal attitude to smoking and their shrugging off their failure to stop by attributing it to "lack of will power".'

In March 1957, Marcus Lipton, Labour MP for Brixton, who had been the principal author of recent Parliamentary Questions, obtained an adjournment debate on the subject.[25] He referred to the prevalence of smoking - two in every three men and two in every five women were smokers, and 2s 6d (12.5p) in every pound spent in the shops went on tobacco - and complained of the Government's ‘old gramophone record' of waiting for better information: ‘The Government are very actively concerned in doing nothing at all'. He condemned as ‘probably the most disgusting and immoral thing that any Minister of the Crown has ever said' a remark by the Chancellor of the Exchequer, Peter Thorneycroft, that ‘We at the Treasury do not want too many people to stop smoking' and quoted Dr Horace Joules and Dr J G Scadding, also a member of SMAC and the leading chest physician of the day, to reinforce his call for Government publicity to counteract the £2¼ million annual press and television advertising for tobacco.

He was immediately accused of ‘scoring cheap points' by Richard Fort, the Conservative MP for Clitheroe and a lay member of the Medical Research Council, who claimed that even Professor Bradford Hill thought further statistical analysis necessary, to which should be added animal research and work on air pollution. Shedding crocodile tears for the ‘really tragic increasing rate of lung cancer' he deplored Marcus Lipton's speech as ‘merely rais[ing] a smokescreen rather than throw[ing] clarity on this difficult problem'. This was an apt prelude to the reply to the debate by J K Vaughan-Morgan, the Parliamentary Secretary at the Ministry of Health, who rehearsed history at length and deplored ‘unnecessary sensationalism' and ‘hasty' conclusions. A week later a written answer revealed that the death rate from lung cancer had risen from 279 per million in 1950 to 389 in 1955.[26]

By then the Medical Research Council had produced its draft statement on smoking and lung cancer.[27]

So far, no adequate explanation for the large increase in the mortality rates from lung cancer has been advanced save that smoking is indeed a principal factor in the causation of the disease. Absolute scientific proof of causation, as distinct from circumstantial evidence, is always difficult to achieve; it might in this instance never be achieved, there being no obvious method of devising a crucial experiment in man.

The draft discounted the likely results of the Council's own chemical and biological research and proceeded:

In scientific work, as in the practical affairs of everyday life, conclusions have often to be founded on the most reasonable and probable explanation of the observed facts. The evidence of a causal relationship between smoking and lung cancer, which is now extensive and very detailed, follows the classic pattern upon which many advances in the past have been made in preventive medicine. The recognition of the risk of cancer run by chimney sweeps and tar workers, for example, came many years before the responsible carcinogenic agents were isolated, and it was action based upon the purely statistical and epidemiological investigations of Dr Snow which stamped out cholera epidemics in this country seventeen years before the infecting organism was first seen under the microscope . . .

After reviewing possible causes of the continuing rise in lung cancer deaths and its strong links to tobacco smoking, the statement attributed a ‘relatively small number' to ‘specific industrial hazards' and ‘an unknown proportion, probably not exceeding 20%' to atmospheric pollution. The evidence, however, pointed to smoking being responsible for ‘a major part of the increase', and the ‘most reasonable interpretation' was that this was a matter of ‘direct cause and effect'. The final conclusions were:

(6) Conclusive proof is unlikely to be obtained unless it becomes possible to study the effects of a reduction of smoking on a mass scale.

(7) The evidence now available is stronger than that which, in comparable matters, is commonly taken as the basis for definite action.

At the Ministry of Health Dr Goodman was characteristically unimpressed. ‘It is a re-appraisal, not the presentation of new evidence, and the M.R.C. position has advanced primarily because of the failure to produce any rebutting evidence. . .' He criticised the use of the word ‘direct' in ‘direct cause and effect'.

In my view, a major source of the smoking habit is during compulsory service in the Services, when cigarettes are cheaply and easily available and there is nothing much else to do but smoke. There is no doubt that smoking is diminishing among the educated classes but this has not yet affected consumption figures but the example of these classes will eventually have an effect. Apart from education, a restrictive increase in taxation on tobacco would not I think greatly diminish revenue because the addicts would continue but might reduce the numbers acquiring the habit.[28]

An Assistant Secretary, R W Bavin, after consultation with Dr Goodman, wrote to the Undersecretary, J E Pater, on 1 April: ‘The Chancellor of the Exchequer would no doubt strongly oppose publication, and the tobacco companies would do all they could to rebut it if it was publicised' but conceded that there was little possibility of avoiding publication. As to further action, some restrictions on smoking in public places might be possible but ‘exposure to other people's smoke is not thought to be of great importance' and the effect on smokers' consumption would be insignificant ‘as I know from personal experience in North America where such restrictions are, of course, in force.' Propaganda would be difficult ‘without a definite, clear-cut, easily understandable theme' which the MRC statement did not provide, as

1. . . . we do not know how smoking causes lung cancer and

2. . . . we cannot say that it is the only cause.

How, he asked, could a propaganda campaign be conducted? There was little alternative but to work through the local health authorities, but while they were routinely in touch with mothers and young children - the usual focus for health education - they had much less contact with men. ‘The influence which might be exerted on the effectiveness of such a campaign by the opposition of the tobacco companies would also have to be considered; and of course, it would be necessary to carry the Treasury and, indeed, the Cabinet . . .' He then ventured the unorthodox opinion that perhaps ‘the Government should itself somehow communicate with the public direct' rather than rely on press and radio to report statements in Parliament - presumably ‘some sort of leaflet' might be produced for sale or free distribution.[29]

Sir John Charles, the Chief Medical Officer, was less complacent than his subordinate Dr Goodman: he wrote to the Deputy Secretary, Dame Enid Russell-Smith:

The new MRC statement is much more positive than anything that has come from them hitherto. It does not reflect new knowledge so much as a more intensely held conviction that excessive cigarette smoking causes a considerable number of avoidable deaths. It is clear also that short of some unexpected discovery on the chemical side, they do not expect to have any more convincing evidence than they have at present . . . [As to] practical repercussions . . . I am attracted by [Mr Bavin's] suggestion of some sort of pamphlet . . . though it would presumably stimulate a counterblast by the tobacco interests.

Dame Enid was not attracted by the idea of a pamphlet: in her memorandum to the Permanent Secretary she saw any publicity as being handled by the local health authorities, and if they wanted a ‘popular pamphlet for the man in the street' it would be prepared by the Central Council for Health Education ‘subject of course to our approval . . .':

If this kind of pattern were followed, direct Government action would be kept to a minimum, effort would be dispersed, and it would be much more difficult for the Tobacco Companies to organise counter-action.[30]

On 10 April Sir Harold Himsworth, the Secretary of the MRC, forwarded a revised version of their statement to their Minister, the Lord President, now Lord Home, observing that it was ‘suitable for publication if that is desired'. The revision attributed up to 30% (rather than 20%) of lung cancer deaths to atmospheric pollution, compressed into a single paragraph the two quoted on page 46 and omitted conclusion (6) (as quoted above) altogether.[31]

One of his staff minuted to Lord Home that he would no doubt wish to consult Sir Harold Himsworth about the report and

You may like particularly to ask Sir H. Himsworth what force to attach to the last paragraph 6. of the conclusions of the memorandum

- that is, after the omission of the original conclusion (6), the conclusion quoted above as (7): ‘The evidence now available is stronger than that which, in comparable matters, is commonly taken as the basis for definite action.'

This troublesome pointer to the need for Government action was obviously giving cause for concern. The consultations that ensued are not evident on any of the files, but by 23 April, when Lord Home put a paper to the relevant Cabinet committee[32], he felt able to say that the MRC considered their statement suitable for publication ‘apart from Conclusion 6'.[33] At an ‘office talk' on 1 May the Minister of Health, now Dennis Vosper, concluded

it would be quite impossible to resist publication of the M.R.C. statement. It would, however, be desirable if Conclusion (6) were omitted, particularly if the Government were not at the same time announcing that they were going to take action on the statement. The only possible danger was that the existence of a Conclusion which has been suppressed might possibly leak out.[34]

The Cabinet committee met on 7 May, with R A Butler in the chair.[35] Lord Home, who had previously warned his colleagues that the MRC were about to publish in their annual report the statement that

So far no adequate explanation of all this statistical evidence has been advanced except that of direct cause and effect - that smoking is, indeed, a principal factor in the causation of the disease [i.e., lung cancer] [36]

now proposed that the Government publish the MRC statement simultaneously with the Council's annual report.

Dennis Vosper urged the exclusion of conclusion (6) but then turned to matters of cost. If the Central Council for Health Education were required to undertake a publicity campaign, they ‘would certainly ask for some financial support'. Central funding of the CCHE had recently been ended, leaving it dependent on the local authorities, and Ministers were reluctant to reverse that policy. Dr Charles Hill pointed out, however, that even £10,000 for leaflets would be ‘a considerable proportion of the total income of the CCHE. But this might only be the beginning, since a campaign with pamphlets alone would be ineffective and the Council would no doubt wish to use all the modern media, including television, with a consequent increase in expenditure.'[37]

Peter Thorneycroft, the Chancellor of the Exchequer, warned that ‘any campaign with Government support, even if carried out indirectly through the CCHE, would need the most careful consideration; for once this course was embarked on it would be difficult to resist the pressure for an intensive propaganda campaign which would distort the proper functions of the Council' and lead to pressure to renew its grant. Besides,

The Committee were already aware of the enormous contribution to the Exchequer from tobacco duties and the serious effect on the Commonwealth, in particular on Rhodesia, that a campaign against smoking would have.

The Committee noted that the tobacco companies ‘would be certain to embark on a powerful campaign of publicity in opposition to the CCHE. They should, however, be given advance warning of the Government's intention to publish the MRC's findings, and the question of the need for further research should be discussed with them as well as with the MRC.' Meantime Lord Home, wearing his other hat as Commonwealth Secretary, would enquire what other Governments were doing[38] and the Minister of Health would draft a statement.

The process of drafting took three weeks. The CCHE were not informed ‘as this would set rumours flying'.[39] The Ministry of Education commented on an early draft:

It is not quite accurate to say that the Handbook included advice on how best to discourage smoking by children. The emphasis in the Handbook was on self-control or restraint and it did not say in terms that children should be advised not to smoke.[40]

The Ministry of Health's Public Relations and Principal Press Officer, S A Heald, suggested that the Minister's Parliamentary statement be accompanied by a lobby conference, a press conference, a recorded statement for radio, a television interview and so on and be followed up with leaflets, a poster and a filmstrip and that an approach should possibly be made to the armed forces medical services. Discouraged by Dame Enid Russell-Smith and Sir John Hawton from anything beyond a lobby conference and a circular to local authorities, Dennis Vosper recorded: ‘I would have thought that we shall need to take all action suggested by Mr Heald in connection with my statement but little or nothing of the action suggested for follow-up publicity. This is for the C.C.H.E.' In keeping with this policy of a burst of self-publicity without effective follow-through, a sentence in the draft Ministerial statement put to the Minister's private secretary on 27 May saying that ‘The Government . . . will not hesitate to stimulate further action if, in their view, this appears to be advisable' disappeared from the version submitted to the Cabinet committee on 31 May.[41]

The paper proposed that a Ministerial statement be made after the Whitsun recess simultaneously with the publication of the MRC's annual report and ‘special report' on lung cancer (from which ‘they . . . propose to delete the last conclusion (No. 6)'). The draft Ministerial statement, which had been agreed with the MRC and the Scottish Office but not with the Treasury[42], said that the MRC now advised that ‘a major part' of the increase in lung cancer was ‘caused by smoking tobacco, particularly in the form of cigarettes'.

The Government feel that it is their duty to ensure that this latest and most authoritative opinion is brought effectively to public notice

but proposed to do so only by circulars to local education and health authorities. The Councils for Health Education in England and Scotland would assist local health authorities, but not - as the covering paper to the Committee made clear - act independently: by charging for their leaflets they should be required to cover their costs.

The proposed statement continued:

Once the risks are known everyone who smokes will have to measure them and make up his own mind. People have a duty to themselves, and to the community which bears so much of the burden of illness; perhaps, above all, if they are parents, they have a duty to their children. In a matter so personal they must be relied upon as responsible citizens to act as they think best.

It concluded with two paragraphs about the continuing programme of research, complete with acknowledgement of the ‘generous benefaction made in 1954 by a leading group of Tobacco Manufacturers'.

The draft was discussed by the Cabinet committee on 3 June. The paragraph quoted above on personal responsibility was considered

too emotional. A bare statement of facts which did not endeavour to point a moral would have a greater psychological impact. The Government should not seek to intrude into the sphere of an individual's personal responsibility. It was, however, important to stress this element of personal choice since direct Government action was excluded.

The next day a revised version of the statement was put to the Cabinet itself[43]. The offending paragraph was reduced to two lines:

Once the risks are known everyone who smokes will have to measure them and make up his or her own mind, and must be relied upon as a responsible person to act as seems best.

The Cabinet met on 6 June with Harold Macmillan, now Prime Minister, in the chair. They agreed two further amendments to the draft:

(a) The Government should not admit a ‘duty' to warn the public of the connection between smoking and lung cancer. This disease could be differentiated from those, such as tuberculosis and poliomyelitis, which were infectious or contagious;

(b) The opening sentence of the statement should be amended to indicate that the risk of lung cancer was greatest in connection with heavy smoking of cigarettes.

As a result the final version of the statement attributed the increase in lung cancer to ‘smoking tobacco, particularly heavy cigarette smoking' and had the Government feeling it ‘right' to ensure that what it now called ‘this latest authoritative opinion' (rather than ‘latest and most authoritative') was brought to public notice.

Before the statement was made there was further interaction with the tobacco industry. Partly this concerned the timing of publication of the first annual report of the Tobacco Manufacturers Standing Committee (TMSC)[44]. More significantly, on 30 May the Minister of Health's private office was warned - probably by Heald - that

The Lord President's Office propose to show the draft Parliamentary statement before it is made to representatives of the tobacco companies financing the research. I have emphasised that on our experience this, if it is done, ought to take place on the same day as the statement is made.

Nevertheless, it would seem that the consultation took place in time for the TMSC to produce a considered response to the MRC report on the same day it was published and the Ministerial statement was made - 27 June. The TMSC statement sought to reassure smokers:

At this stage any conclusions are a matter of opinion. The Medical Research Council have expressed one view. Other authorities in the scientific fields concerned have expressed different views . . .

The MRC had produced no new evidence; the whole subject was ‘exceedingly complex'; estimates by the MRC were ‘open to authoritative criticism'; there was indeed statistical evidence to contradict the view that smoking caused lung cancer; and the manufacturers were unaware of ‘any carcinogenic substance in tobacco smoke in quantities which conceivably could cause cancer in human beings from smoking'. Their conclusion was:

In the opinion of the manufacturers, there is no proof from any scientific field that smoking is a cause of lung cancer. The statistical evidence certainly does not prove a causal connection. The pressing need is for a comprehensive attempt to close the gap between fact and speculation by further research

- to which the manufacturers would continue to give all the help they could.[45]

In the event the Ministerial statement was made not by Dennis Vosper, the Minister, who was in hospital for an emergency abdominal operation, but by his Parliamentary Secretary, J K Vaughan-Morgan.[46] He easily turned aside pressure from MPs to commit expenditure to the publicity campaign by local health authorities, to ban smoking in public places or take other steps.

The press gave the statement heavy coverage with near-universal emphasis on the fact that (as it was put) people were being left to decide for themselves. (None pointed out that there was never any question of compulsion: the alternative to the Government's passive line was a more vigorous presentation of the facts.) The Daily Mirror got out its biggest type for its page one headline: ‘SMOKING AND CANCER AND YOU - It's every man for himself!' and had a centre-page spread inside. The Daily Telegraph had a two column report on page one and a leader that said the MRC report ‘carries the question no further. The evidence remains wholly statistical, and such as it would need no medical knowledge to collect'. It then backed the Government's policy: ‘Civilised people are not morons. They know that there are risks attached to most pleasures and duties. Let them know what the risks are, and give them the right to decide whether or not to run them.' The Daily Express said ‘There should be no question of the Government organising an anti-smoking crusade. The public must be left to make its own choice.' The Times was less emphatic but broadly supportive of the Government line, mentioning in particular the need for ‘stronger pressure' on the young and raising the possibility of bans on smoking in theatres and other public places.

The exception was the News Chronicle, which splashed the story across the whole front page: ‘Smokers: It's Up To You - "Cigarettes can kill" Warning' and proceeded to mock Vaughan-Morgan for his unwillingness or inability to answer questions at the press conference about stricter enforcement of the ban on sales of tobacco to under-16s, the idea of smoking bans in public transport and cinemas and theatres, restrictions on tobacco advertising on television, on hoardings or in the press, or advice to GPs on how to deal with patients wanting advice on stopping smoking:

Here is an example of the tactics of the tall, bespectacled Parliamentary Secretary:

Do you think lowering the death-rate from lung cancer would be a good thing?

Well (after a pause) I don't think it would be a bad thing.

To achieve this will you tell the public they ought to stop smoking?

I think it is up to the public to make up its own mind from the facts they are given.

In its leading article the News Chronicle said: ‘This is literally a life-and-death matter, yet the statement in the House was muted to the point of being casual.' The findings needed to be ‘hammered home . . . The lead should come from the Government. The subject must be tackled urgently, forcefully, convincingly and continuously.'

The Government was unpersuaded. A circular was issued to local health authorities the day the statement was made[47] and the Ministry of Health again settled down to a period of dogged resistance to the activists who sought more than a circular by way of Government action to warn the public of the dangers of smoking. The baton now passed from the Standing Advisory Committees (and notably Dr Horace Joules) to the local authorities and the CCHE.

 

Notes

1. PRO file MH 55.1012 [back]

2. A deputation from the National Society of Non-Smokers (now reborn as Quit), led by their secretary, the Rev. H V Little, went to the Home Office on 6 March 1957 to press for bans on smoking in public places and to protest at the failure to enforce the prohibition on selling tobacco to under-16s - PRO file MH 55.2224. A few weeks later the Home Office replied complacently to a Parliamentary Question on under-age sales that they ‘had no reason to think that the provisions [of the law] were not adequately observed' - PRO file MH 55.2220. [back]

3. PRO files MH 55.1011, MH 55.2232. The MRC also continued friendly contacts with the industry: a note of 29 May 1957 to the Privy Council office records that ‘some two months ago we did have a conference with their scientific representatives on the question of research. We shall probably hold others from time to time.' - PRO file MH 55.2220.  [back]

4. BMJ 1954; i: 1451-5. [back]

5. In fact there was little press coverage. (The Times (25 June 1954) gave the news six column inches on page 3 under the headlines ‘Lung Cancer Inquiry - Doctors' Smoking Habits Analysed'. It spoke of ‘further evidence on a likely association between excessive smoking and the occurrence of lung cancer' and mentioned the weaker evidence of an association with coronary heart disease.) This may have been partly the result of work by the tobacco companies: Tony van den Bergh, now a member of the Advisory Council of Action on Smoking and Health (ASH) but then personnel director in Godfrey Phillips Ltd and managing director of Markevich Black & White Group, says (personal communication, November 1996) that the companies made full and successful use of their influence as major advertisers to reduce to little or nothing the attention given to the matter in the press. Van den Berg was also chairman of the tobacco industry's National Joint Negotiating Committee and confirms that the industry used its links with the trade unions to ensure that they too were well briefed with the industry's viewpoint. [back]

6. Sir Richard Doll gives an overview of the development of the statistical evidence on smoking and the objections raised to it in his article ‘Uncovering the effects of smoking: historical perspective' (Statistical Methods in Medical Research 1998; 7: 87-117).  [back]

7. CHSC(55)6 - May 1955. PRO file MH 55.1011 [back]

8. PRO file MH 55.2220 [back]

9. PRO file MH 55.2232 [back]

10. CHSC meeting on 13 March 1956 - PRO file MH 55.2220 [back]

11. There were Parliamentary Questions on 20 and 26 March and 16 April. [back]

12. PRO file MH 55.2220 [back]

13. HP(56)49 - PRO file CAB 134.1254 [back]

14. If this policy of inaction pending scientific proof had been pursued to its logical conclusion, it would probably have prevented any action until the publication forty years later of research by M F Denissenko et al showing that benzo[a]pyrene diol epoxide, found in tobacco smoke, damages the P53 gene in the identical way found in victims of lung cancer: ‘Our study thus provides a direct link between a defined cigarette smoke carcinogen and human cancer mutations' - Science 1996; 274: 430-432. [back]

15. PRO file CAB 124.1670 [back]

16. HP(56)9th - PRO file CAB 134.1253 [back]

17. CP(56)99 - PRO file reference CAB 129.80 and CM(56)30th - PRO file reference CAB 128.30 [back]

18. The Committee's papers and minutes are all on PRO file CAB 130.115 [back]

19. Cabinet, 3 May 1956 - PRO file CAB 128.30 [back]

20. PRO file reference MH 55.2232 [back]

21. Sir George Godber, Deputy Chief Medical Officer since 1950, comments (personal communication, 19 January 1998): ‘Yes! H[orace] J[oules] used to upbraid me regularly.' [back]

22. Tobacco Manufacturers' Standing Committee annual reports are available at the PRO for 1956/57, 1957/58, 1958/59 and 1959/60 (PRO file MH 55.2232). They are plainly printed, unpretentious booklets with technical descriptions of chemical research and (in the first report especially) statistical arguments tending to undermine the link between lung cancer and smoking. See also note 44 below. [back]

23. Cabinet paper C(57)135, 4 June 1957 - PRO file CAB 129.87 [back]

24. BMJ 1956; ii: 1071-1081, 10 November 1956. [back]

25. Hansard, 1 March 1957, cols. 1641-1652 [back]

26. Hansard, 11 March 1956. The rate was 188 per million in 1945, as stated in the draft MRC statement of 8 March - PRO file MH 55.2232.  [back]

27. I have been unable to locate any MRC file relating to the statement, but the draft on the Ministry of Health files is dated 8 March 1956 - PRO file MH 55.2232. It is therefore equally unclear both who in the MRC was responsible for drafting the statement and how the Council approved it - whether at expert, official level or through a meeting of Mr Richard Fort MP and his colleagues. The provenance of the suggestion regarding conclusion (6) of the draft (see below) also remains tantalisingly obscure, although one can be forgiven for believing it originated in the Government. The published version of the statement is given in the Appendix[back]

28. Minute, 28 March 1957, on PRO file MH 55.2220 [back]

29. By the end of the month the Ministry's Public Relations and Principal Press Officer, S A Heald, was advising a limited publicity campaign (PRO file MH 55.2203):

Such an information campaign would save the Government from a charge of having failed to take special steps to ensure that the facts were known and need not cost more than (say) £10-£20,000. This would cover the cost of inserting one or two prominent press advertisements in all newspapers (excluding local weekly newspapers), printing posters and a leaflet.

This publicity action would be supplemented by Ministerial action - e.g., Parliamentary Statements, answers to Questions, and possibly a Press Conference, and interviews on B.B.C. (sound) and B.B.C. and Commercial Television Services.

In this way the Government's warning would have been placed prominently on the record, leaving the individual citizen to assess the risk and make his own choice. [There would be follow-up action by] voluntary societies - e.g., Central Council for Health Education - and by youth organisations and education authorities. [back]

30. PRO file MH 55.2232 [back]

31. It is unclear from the files I have located who was responsible for these changes - see note 27 above. The revised version of the quoted paragraph reads:

In scientific work, as in the practical affairs of everyday life, conclusions have often to be founded on the most reasonable and probable explanation of the observed facts, and, so far, no adequate explanation for the large increase in the incidence of lung cancer has been advanced save that cigarette smoking is indeed the principal factor in the causation of the disease. The epidemiological evidence is now extensive and very detailed and follows a classical pattern upon which many advances have in the past been made in preventive medicine. It is clearly impossible to add to the evidence by means of an experiment in man.

- PRO file MH 55:2232. [back]

32. The committee, known as GEN 588, had been appointed on 24 April 1956 but had not yet met. [back]

33. The committee, known as GEN 588, had been appointed on 24 April 1956 but had not yet met. [back]

34. The same minute by his private secretary recorded that ‘the minimum action' to discourage smoking that could be countenanced - but implicitly also the maximum envisaged - was to ask local health and education authorities to ‘take whatever action they considered appropriate to make the information known' - PRO file MH 55.2232. [back]

35. Those present, apart from Butler, were Lord Home (Secretary of State for Commonwealth Relations and Lord President of the Council); Peter Thorneycroft (Chancellor of the Exchequer); Dr Charles Hill (Chancellor of the Duchy of Lancaster); Dennis Vosper (Minister of Health) and Lord Strathclyde (Minister of State, Scottish Office) - PRO file CAB 130.127. [back]

36. Paper GEN 588/3 - 2 May 1957 - PRO file CAB 130.127. [back]

37. Dr Hill also quoted Bradford Hill and Doll to cast doubt on the MRC's suggestion that up to 30% of lung cancer deaths might be attributed to atmospheric pollution. The Committee agreed to ask the MRC to re-examine its conclusion. The MRC subsequently amended the reference to say: ‘on balance it seems likely that atmospheric pollution plays some part in causing the disease, but a relatively minor one in comparison with cigarette smoking . . . A proportion of cases, the exact extent of which cannot yet be defined, may be due to atmospheric pollution.' - GEN 588/4 - 31 May 1957 - on PRO file CAB 130.127. [back]

38. The CMO took advantage of a WHO meeting to find out what other nations were doing. The USA, Canada, New Zealand, West Germany, the Netherlands, Norway, Denmark, Sweden and Finland were reportedly all concerned and in the main accepted the association of lung cancer with cigarette smoking, though there were doubters who pointed to the possible contribution of atmospheric pollution. ‘Statements such as our Ministers have made have been exceptional . . . Direct action against smoking under governmental auspices is also very rare': Switzerland had produced a leaflet for schoolchildren and gave lectures to national service recruits; Sweden had produced a ‘small poster on the line of "cut it down".' There was a general tendency to use the voluntary health educational bodies and an inclination to use schools. In Finland smoking was not allowed at ‘conferences or committees of a public character' - Appendix B to GEN 588/4, 31 May 1957 - PRO file CAB 130.127. [back]

39. Minute by Sir John Hawton, Permanent Secretary, 8 May 1957 - PRO file MH 55.2232. [back]

40. Letter of 21 May 1957 - PRO file MH 55.2232. [back]

41. Paper GEN 588/4, 31 May 1957, by the Lord President and the Minister of Health - PRO file CAB 130.127. [back]

42. The paper noted that ‘the Chancellor of the Exchequer has a number of reservations'. These had been set out at length in a letter the previous day (30 May 1957) from James Collins at the Treasury to P Benner, the Minister of Health's private secretary: ‘Our general comment on the statement (which lies behind most of the amendments which we shall be suggesting) is that it goes further than is necessary or desirable; in our view it goes too far beyond the factual description of the situation created by the M.R.C. report; it strays, if I may put it in this informal way, too far into the "missionary field".' The letter attached a list of proposed amendments designed to make the statement as anodyne as possible. - PRO file MH 55.2220. [back]

43. Paper C(57)135 - 4 June 1957 - by the Home Secretary and Lord Privy Seal (R A Butler) - PRO file CAB 129.81. [back]

44. Sir Alexander Maxwell, as chairman of the Tobacco Manufacturers Standing Committee, wrote to Sir John Hawton on 7 June 1957 with the typescript of their first annual report, and about the same time Partridge asked Sir Herbert Brittain at the Treasury for advice about the timing of publication of the report. Brittain consulted Sir John Hawton (11 June), suggesting it should come out before the impending Government statement, and this appears to have been agreed and acted on: six copies of the printed version of the report were sent to Hawton on 19 June. The report ran to 18 pages, emphasising the funding of MRC research and then reporting on the industry's own research. ‘The scientists advising and working on behalf of the manufacturers have kept in touch and exchanged information with those working on behalf of the Medical Research Council', it said. Two pages dealt with 3:4-benzpyrene, of which ‘only extremely small amounts . . . infinitesimal quantities' were found in cigarette smoke, where it was ‘most improbable' that it could be ‘in any way injurious'. The report also included a six-page paper by Geoffrey Todd, apparently based on an earlier report by Sir Ronald Fisher, casting doubt on the interpretation of the statistics of smoking and health - PRO file MH 55.2232. [back]

45. Statement to the press, 27 June 1957, included in ‘Smoking and Lung Cancer', 3 July 1957 - PRO file MH 55/960. [back]

46. This was no doubt a matter of relief to Heald, since Vaughan-Morgan, unlike Vosper, was a non-smoker. Heald had minuted the Deputy Secretary on 14 June 1957, presumably with the reports of Iain Macleod's chain-smoking at the 1954 press conference in mind: ‘One point is in my view of major importance and involves the Minister's decision. A lot of importance will be attached by the Press and by photographers to whether or not the Minister is seen to smoke or not at the time when this statement is made and immediately thereafter. If he doesn't smoke, though he is known to be a smoker, this will be regarded as highly significant. If he does, on the other hand, it will be regarded as a gesture intended to modify the seriousness of the statement he has made.' - PRO file MH 55.2220. [back]

47. Copies of circular 7/57 were at the end of July issued also to the Colonies - PRO files MH 55.2224, MH 55.2226. [back]

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Forewords Preface Prologue I: 1951-54 II: 1954-57 III: 1957-61 IV: 1961-62 V: 1962 VI: 1962-64 Epilogue Appendix

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