Dr Horace Joules was Medical Director at the Central Middlesex County Hospital and already a member of the Central Health Services Council (CHSC) when in December 1948 the Council appointed him one of its representatives on the Standing Advisory Committee (Cancer and Radiotherapy), one of several such standing committees that advised the Minister of Health, through the CHSC, on a variety of topics.[1] Richard Doll and Austin Bradford Hill’s report in the British Medical Journal might have caused barely a public ripple, but it did not escape Joules’ attention, and he brought it to the notice of the Committee (hereafter ‘SAC(CR)’) at their meeting on 18 January 1951. He suggested that the Ministry of Health conduct a publicity campaign about the dangers of smoking. The SAC(CR), chaired by Sir Ernest Rock Carling, ‘a life-long heavy smoker now in his late 70s’[2], rejected the idea: this was only ‘a preliminary report’ and it would be ‘premature to base conclusions on it.’ The SAC(CR) agreed at least that the Medical Research Council should be investigating the matter.[3]
Sir John Charles, the Chief Medical Officer since 1950, accordingly wrote to Harold Himsworth, the MRC Secretary, asking about its ‘committee’ on lung cancer, which had apparently ‘not recently been active’. Himsworth replied that there was no such committee, only a working party set up after the two original conferences to supervise the ‘clinical-statistical investigation’ by Bradford Hill and Doll and the laboratory experiments by Sir Ernest Kennaway. He reacted strongly to the SAC(CR)’s ‘doubts as to the validity of the findings of Bradford Hill and Doll. I find it difficult to understand on what scientific grounds your Committee’s opinion could be based, because it has been said of this work . . . that it is ‘the best practical lead we have ever had in cancer research’; though I might qualify that by pointing to mulespinners’ and chimney-sweeps’ cancer, I certainly think that their work has this degree of significance. It is a point perhaps not devoid of interest in relation to any proposal for organising centrally directed publicity on the subject, that the national press (for reasons which can be guessed) almost completely ignored the Hill and Doll report . . .’
‘Hill and Doll are satisfied,’ Himsworth wrote, ‘that the case against smoking as such is proven, and that no further statistical inquiry on the general aspect of that problem is necessary’, though they were pursuing more detailed investigations. Himsworth ended by saying that the MRC had ‘already organised a statistically conclusive investigation’ while laboratory work by Sir Ernest Kennaway was ‘in active progress’.
Green’s brief, on which Himsworth had based his reply, reveals that the tribute to the work by Bradford Hill and Doll came from Kennaway himself. It also reported:
Doll tells me privately that he has heard from Joules that the negative attitude taken up by the Minister’s Standing Advisory Committee on Cancer, to which Charles refers, depended on a reluctance by some of the members of the Committee to condemn smoking for personal reasons, or because of a supposed possible adverse effect of a decrease in cigarette-smoking upon the National budget, through loss of taxation. If there is any suggestion that the Minister’s Committee is really influenced by considerations of this kind, I am sure you will agree that we ought to take a very firm line in endorsing the view of Kennaway, Hill and Doll that the positive correlation between smoking and cancer of the lung is proven, whether we like it or not. I think it important, moreover, that our two cancer conferences should be given due credit for starting a very active and fruitful programme of investigation, instead of being talked about, by those who should know better, as if they were abortive.[4]
The SAC(CR), which met twice a year, considered the MRC’s reply in July 1951. The Committee was unconvinced: its
view remained that the investigations . . . had not produced evidence of a direct relation between smoking and carcinoma of the lung. It was known that there was an increase in smoking and an increase in the incidence of carcinoma of the lung and there was evidence from Dr Doll and Dr Bradford Hill that patients with cancer of the lung had been heavy smokers but no direct evidence of a certain relationship. From discussions the individual members had had with Dr Bradford Hill it was not thought that he would agree with the Secretary of the Medical Research Council in saying that the case against smoking as such was proven. It was felt that in spite of what the Secretary of the M.R.C. had said, the M.R.C. should carry out further investigations on the relationship.
The SAC(CR) was therefore able, doubtless with some relief, to decide again that a Ministerial publicity campaign would not be justified.[5]
The same month, Austin Bradford Hill wrote to Himsworth setting out his plans for ‘a ‘forward’ inquiry . . . This would involve taking individuals with known smoking histories and then seeing over the next few years, say 5, how they die off, both from cancer of the lung and from other causes.’ He reported the 75% response to a trial random sample of 200 names from the medical register, one of whom had by chance been Himsworth himself, and suggested that with 60,000 persons on the register a sample of 40-45,000 answers might be obtained. The BMA would handle the mailing ‘without reference to itself’, and the Registrar-General had agreed to report all deaths of doctors. The cost would be £1,800: ‘This, I regret to say, is considerably more than the sum I mentioned to you personally for in that I was including only the postage involved; I (professorially) forgot that I should first have to print something to send by post and buy envelopes to put it in! The cost of paper is so great today.’
The sum was approved and Landsborough Thomson, now the MRC’s Second Secretary, wrote to Bradford Hill, mentioning the increased estimate and the MRC’s difficult budgetary position. This elicited a handwritten note from Hill from his Buckinghamshire home expressing contrition[6] but saying he believed ‘the inquiry may give a good return in other respects too than cancer of the lung, for the heart diseases may prove interesting.’ The circular to doctors was then issued, explaining the reason for selecting doctors for the study: ‘The population most likely to be willing to assist in such an inquiry and to give accurate information is clearly one trained in observation and appreciative of the value of research – namely the medical profession.’ [7]
In the SAC(CR), Horace Joules returned to the fray in January 1952. ‘Since he first raised this matter he had seen 40 cases of cancer of the lung in his hospital, not one of whom had been in the habit of smoking less than 25 cigarettes a day.’ The SAC(CR) conceded a request for the opinions of Dr Bradford Hill and Sir Ernest Kennaway. These were accordingly obtained: a minute by an anonymous civil servant in the Ministry of Health comments that Joules ‘is as you know the main protagonist against smoking – on the CHSC, on the SAC(CR) and in the Press’. Sir Ernest reported little progress: ‘No specific carcinogenic substance, except arsenic, has been identified as yet in tobacco smoke’ (there were reasons for doubting the importance of arsenic in the inquiry). Bradford Hill said he had nothing as yet to add to the 1950 article in the BMJ pending results from the study of doctors: there was a ‘real association’ between smoking and lung cancer, but it was not necessarily causal.
Joules was unable to attend the SAC(CR) in June but wrote in strong terms to his colleagues:
Since I first raised this matter, eighteen months ago, approximately 20,000 people have died from this disease. Some of the most respected citizens of the realm are included in this number . . . I wish to make this last appeal to the committee, to ensure that young people in this country are made aware of the risk of excessive smoking. Surely this is the least we can do in the face of the ever increasing number of deaths. The replies of successive ministers to questions on this matter show they are relying on this committee for medical help. So far I feel we have failed to give this and I trust this state of affairs will not continue. Should the committee not feel able to give this advice I hope this letter can be inserted in the minutes as I do not feel that my protest should pass unrecorded.
Influenced perhaps by the reference to the deaths of ‘most respected citizens’ – without doubt Joules intended King George VI, a heavy smoker, who had died of a heart attack after an operation for lung cancer in February 1952 – the SAC(CR) began to move. It still held that the evidence was ‘insufficient to justify propaganda’ but it officially advised the Minister that ‘the statistical evidence at present available strongly suggests that there is an association between smoking and cancer of the lung’ and the Minister should publicly admit the probability of the relationship. The minutes record: ‘A proposed amendment to insert ‘excessive’ before ‘smoking’ was not carried.’
Seeing the minutes, Joules wrote to the SAC(CR) secretary asking rhetorically what evidence would be ‘sufficient to justify propaganda to prevent this ever increasing mortality’, and with hindsight we obviously agree. But it is notable that at the same meeting the SAC(CR) cautiously amended advice it had given the Minister in 1949 ‘that it was undesirable at the present time for any cancer publicity to be carried out by any central government organisation direct to the general public’ by suggesting that he
should encourage local authorities and voluntary bodies to carry out exploratory schemes of cancer education to enlarge the knowledge of what can be done in this field and that there should be further facilities for educating doctors and medical students in the early recognition of cancer.[8]
The horror of cancer at the time led to its being virtually unmentionable; doctors had few methods to combat the disease and little advice to give about avoiding it; and the Ministry of Health was worried that education would lead to public panic. A 1955 review of policy says it was thought unwise ‘to make the public cancer-conscious by fear’.[9] Mild leaflets about cancer from New Zealand and the USA were obtained early in 1952 but minutes on the file show that their like was unthinkable in the UK, while the official who acted as secretary to the SAC(CR) wrote to a Senior Publicity Assistant in the Ministry, Miss B Crawter, that ‘some members of the SAC(CR) are strongly opposed to any cancer education of the public’. In April William Shepherd MP (Conservative, Cheadle) wrote to the Parliamentary Secretary at the Ministry of Health, Patricia Hornsby-Smith, following up a Parliamentary Question that had suggested such education. He said that he did not ‘for one moment suggest that there should be a publicity campaign about the dangers of smoking in relation to lung cancer’ – only education about ‘more general aspects of the disease – such as the recognition of certain symptoms . . .’[10]
The SAC(CR)’s cautious advice to the Minister was forwarded in October to the CHSC, where Dr Joules (as a Ministry minute reveals) ‘instigated’ the Council to refer it back to the SAC(CR) for reconsideration.[11]
Before the SAC(CR) met again events had moved on apace – but not towards public propaganda. In August the tobacco industry made its entrance to the debate. In 1952 the Imperial Tobacco Company, a highly respectable enterprise with the connections that might be expected of the dominant company in an industry that generated over 14% of the Government’s tax revenues, had about 80% of the market in the United Kingdom, and it was Imperial Tobacco that made the move. The first contact was plainly with the Ministry of Health, although no trace remains on the files, for we find Dr Green of the MRC confirming to Dr Neville M Goodman, the Senior Medical Officer in the Ministry responsible for cancer, that he had
mentioned to Himsworth on Saturday that ‘someone high up in the Imperial Tobacco Company Ltd’ would probably call on him in September to discuss a scheme of cancer research. He was very interested to hear this, but we are both a little disturbed at the thought that you may inadvertently have given the intending visitor the idea that the Council are not themselves interested in receiving benefactions for medical research
– an idea that he asked Goodman to correct. Goodman replied that the company seemed to want ‘to repeat on a larger scale the Doll-Hill inquiry, in which they claim to find many flaws’ and to do so without the participation of Doll who, they hinted, ‘seemed to have made up his mind on the subject’.
This led to a meeting on 9 October 1952 between Imperial Tobacco and the MRC. The company was represented by its secretary, E J (John) Partridge, and D A Clark, an economist in his office, the MRC by Himsworth (now Sir Harold), Green and Landsborough Thomson. Green’s note reports that ‘Mr Partridge . . . explained that his firm were naturally unhappy about the suggested association between cigarette smoking and cancer. They were doubtful about the statistical validity . . .’ of the published study, but they ‘seemed a little disconcerted when we told them that a further paper dealing with the interrogation of 2,500 patients with cancer of the lung and 2,500 controls was to be published by Hill and Doll in the British Medical Journal in December; this paper had the same general conclusions as its predecessor. . .’[12]
The company was clearly at this stage unsure how to react to the threat to the industry. Partridge talked of putting up money for a new study and was invited to make proposals, but at a further meeting later in the same month (at which Dr Goodman took the place of Landsborough Thomson) Partridge said that Imperial was no longer interested in re-running the Doll/Hill study although they would like to discuss their doubts about it with its authors. He agreed first to submit a memorandum. Partridge then ‘said that his firm were considering starting independent experimental work’ on similar lines to the experimental laboratory work the MRC had commissioned and ‘they would welcome the advice of Sir Ernest Kennaway and of other established experts in the field . . .’ However, when it was suggested that one helpful step would be to second one of their chemists, even part-time, as an assistant to Sir Ernest Kennaway, ‘Mr Partridge was rather doubtful as to whether the firm would have a chemist to spare . . .’
Partridge wrote immediately to Goodman with six pages of objections to the statistical validity of the Doll/Hill study (these concerned the selection of the control sample, the accuracy of self-reports of smoking habits, the lack of rural inhabitants and other matters) and on 30 October Green forwarded his letter to Bradford Hill, commenting:
He seems to have set [his points] out fairly and reasonably. . . but I think you will have no great difficulty in answering him. He is, of course, in the sad position of not wanting his doubts to be resolved, but, with that limitation, I do think he is making a serious effort to look at the prospect with an unbiased eye. He is certainly a very nice man.
The event was a meeting a week later at the London School of Hygiene and Tropical Medicine between Imperial Tobacco Company, represented by Partridge, Clark and Geoffrey Todd, their statistician, and Bradford Hill, Doll and Green from the MRC, who kept a record and commented:[13]
The meeting was very friendly . . . It was pretty clear to me that Mr Partridge and his colleagues felt that Hill had answered all their queries in a way which left hardly any loophole for doubt, though they were naturally reluctant to concede this . . .
and Green was obviously appreciative of the way the researchers performed, as can be seen from his letter of 7 November to Bradford Hill, which has to be quoted in full, ‘Dear Tony,’ he wrote:
I send you these cigars in grateful (if ironical) appreciation of your tactful handling of the tobacconists yesterday, and in gratitude also for your advice, help and hospitality over many years.
I hope they are tolerable and have sufficiently matured (I know little about such things). I hope much more, of course, that they do not plunge you, of all people, into the equivocal but dangerous category of a ‘heavy smoker’ – but I hardly suppose there are enough of them for that.
Yours ever . . . [13a]
Bradford Hill’s reaction is not recorded – but cigars were not covered by the questionnaire sent to doctors[14] and for long were regarded as relatively innocuous.
At the end of January Partridge sent a new, expanded version of Todd’s statistical objections, and in February responded to a request from Green with a form of words that the MRC could use to report the meetings to the SAC(CR):
We have had informal discussions with Tobacco Manufacturers on this matter. They consider that the evidence . . . is far from conclusive and that there is a considerable weight of evidence against the existence of such a correlation. In their view there is no proof whatever of any causal connection.
The Manufacturers have assured us, however, that they have a full sense of the importance of the problem. They have in hand a programme of chemical research into the constituents of tobacco and tobacco smoke which was started some time ago in order to obtain information required for general trade purposes. They are intensifying the aspects of this research that will throw light on the problem now under discussion and all their resources will be used to complete this work in the shortest possible space of time.
The Manufacturers will keep in touch with biological and other research which is being carried on in other Institutions and will cooperate whenever possible with research workers engaged in these fields.
The SAC(CR) met on 5 February 1953. The MRC reported on the work it was sponsoring: Sir Ernest Kennaway hoped to make progress now that he had managed to borrow from the Eastern Gas Board an assistant to do spectroscopic and chromatographic analyses; Dr P R Peacock at Royal Beatson Memorial Hospital, Glasgow, had failed to find benzpyrene or other known carcinogens in tobacco smoke, although claims had been published of carcinogenic effects in mice.[15] A paper from the SAC(CR) secretary reported:
The Imperial Tobacco Company has requested that a paper prepared by one of their statisticians and entitled ‘The statistical study of Tobacco Smoke in relation to the aetiology of Carcinoma of the Lung’ should be submitted to the Committee’
but (he wrote) the paper was long and technical and would be circulated later with ‘an expert statistical opinion . . .’ The SAC(CR) was provided with Todd’s own summary:
The argument of this paper is that if tobacco is . . . a factor [in the production of cancer of the lung] then it must have been so over a period of time and consequently that it would be a fair test of the validity of the hypothesis to apply the current risk of death from lung cancer, induced by causes connected with smoking – assuming that such causes exist – to the population at risk in earlier periods and to see if the theoretically expected deaths, after making allowances for deaths from cancer of the lung from causes not connected with smoking, approximate to the recorded deaths. Judged by this test, the hypothesis is untrue.
It is then considered whether there is any reason why the hypothesis should be valid at the present time but not in earlier years, and it is concluded that the hypothesis could only be true now if some changes in other factors had turned tobacco from an innocuous substance into one which is now a factor in the production of cancer of the lung. No such change has in fact been demonstrated.
The paper went on to contest two of the assumptions made by Bradford Hill and Doll.
The SAC(CR) had a confused discussion. Horace Joules referred to the new paper by Doll and Bradford Hill which reported that risk ‘increased with age and in simple arithmetical proportion to the amount smoked’. The public anxiety and press attention meant that the ‘Ministry should arrange for authoritative information to be given to the medical profession and to the public’. He won some support, but the meeting ended with a decision to circulate the Imperial Tobacco paper and ‘meet again shortly’ – or, as a correction to the minutes won by Joules had it, ‘within a month’.[16] The minutes might say so, but the SAC(CR) did not in fact meet again until November.
That same day (5 February) Goodman, the Medical Officer at the Ministry, brought Partridge and Clark to visit Green at the MRC. They sought an early reaction to Todd’s paper, which they hoped (they said) to see published in the BMJ.[17] Partridge reported that Todd was inclined to see as ‘derogatory to himself’ the idea that the SAC(CR) might seek independent advice on his paper and those by Doll and Hill. ‘I [Green] said that it seemed to me that he had much less to complain of in this respect than Professor Bradford Hill and Dr Doll. . . Mr Partridge accepted this point of view.’
Partridge said that his chairman (Sir Robert Sinclair) was considering whether to mention the controversy over smoking and health at the company AGM and read a rough draft of a possible statement.[18] He also asked for suggestions whom to ask for advice on planning ‘biological experiments on the constituents of tobacco smoke’ and Green provided names.[19]
This was typical of – very frequent – dealings between the company and the Ministry and MRC at this time: the impression yielded by the papers is that everyone was facing a problem together; there were different emphases (the AGM draft ‘erred in the direction of too emphatically denying the validity of the Hill and Doll evidence, but otherwise it seemed to me harmless for its purpose’) but a solution needed to be found cooperatively if not in collaboration. So, Green provided an introduction for Imperial to the MRC’s Pneumoconiosis Research Unit in Cardiff (where, a report to the SAC(CR) at this time revealed, Dr B M Wright ‘is examining, with an ingenious apparatus of his own invention, the effect on mice of living for long periods in a heavy atmosphere of tobacco smoke’).
Five days later Partridge provided a revised version of Todd’s paper, and a further revision came the following week (and another in June); on 2 March Bradford Hill sent Green his response, and on 9 March Partridge sent Todd’s rejoinder.
At this point the paper (running to over 30 pages), response and rejoinder were circulated to the SAC(CR), along with a letter published in the British Medical Journal[20] from Dr R D Passey, Professor of Experimental Pathology and Director of Cancer Research, University of Leeds, which is worth quoting. Dr Passey’s letter pointed out that lung cancer had increased in parallel with not only the growth of cigarette smoking but also the ability to diagnose the disease. No carcinogenic agent had yet been found in tobacco smoke, let alone been shown to be capable of producing lung cancer. Often in the past correlations had led to false assumptions of cause: for example ‘In the early years of the present century it was taught, and it was in the students’ textbooks, that breast cancer might be related to the bone and metal supports of the corsets of the Edwardian days; but in the intervening 45 years the incidence of mammary cancer has not fallen.’ If smoking caused lung cancer, why did it not also cause cancer of the mouth, tongue and pharynx? ‘In point of fact, there is some slight decrease in these sites.’
He continued:
In the early ‘thirties it was the fashion to ascribe lung cancer to the tarring of the roads and to the exhaust fumes of motor vehicles, but the failure to demonstrate any higher incidence in those specially exposed to such hazards resulted in the abandonment of the hypothesis. Then the traces of arsenic in British tobaccos received the blame, but that belief, too, has been discredited. The industrial pollution of the air we breathe has been considered a factor, in spite of the fact that, while lung cancer figures are rising, the aerial pollution is definitely decreasing. When doctors disagree it is bad for the patient.
It may be that a proportion of lung cancers in man are induced by tobacco smoking: at the moment we do not know, but let us be sure of our evidence before we scare our public. As a profession we have that responsibility.
Meanwhile Sir John Charles, the Chief Medical Officer, had asked Percy Stocks, now Senior Research Fellow of the British Empire Cancer Campaign, to suggest referees for the conflicting papers. Stocks suggested names, including the Government Actuary, Sir George Maddex KBE, who in the event chaired the panel, but in his reply he commented:
In reading [Todd] I was struck by the absence of any appreciation of the long period of time which must elapse between the initiation of the malignant process in the lung and death resulting from it, which suggests that it has been written by a non-medical statistician. If the average period is 15 or 20 years, as it probably is, the argument in parts I-III and the statistical method applied appears to me to be nonsense, since it presupposes deaths to occur in the same year as the cancer was initiated.
Sir John Charles replied by return, asking what evidence there was for the 15-20 year development period:
Surely this is in great part an assumption, based on the analogy of the activities of skin cancer. If, however, there is actual evidence other than that I have mentioned in support of the thesis, could you let me know what it is?
Stocks pointed out in reply:
The evidence in favour of a long induction period of 15-20 years for lung cancer is not based only on analogy with the action of carcinogenic agents whose nature and induction period is known, such as the chemicals affecting the bladder and skin. There is also internal evidence from the findings in Doll & Hill’s investigations, which show, for example, that 98 per cent of the men with lung cancer who had smoked began to smoke before the age of 30, but nevertheless 90 per cent were over 45 when cancer was diagnosed. How can this be explained unless either the carcinogenic poison was gradually accumulating in the body for 15 years or more in most cases before the malignant process began, or else the malignant process took that time in most cases to develop to the stage when it could be diagnosed?
Further, he argued, those who smoked less, although at less risk, did not seem to get lung cancer later, indicating that there was a prolonged latency period.
Parliament had taken little interest in the debate about smoking and did not begin to put pressure on Ministers for another two years. However, Harry Hynd MP (Labour, Accrington) gave notice in March 1953 that he would raise the matter in an adjournment debate. The preparation of the Minister’s brief reveals that the Ministry’s caution attracted criticism from the MRC. Dr Goodman at the Ministry recorded: ‘We must clearly remain completely uncommitted, since we genuinely do not know at present whether tobacco smoking – and particularly heavy tobacco smoking – is a causal factor . . .’ He conceded that it was accepted ‘generally, but not universally’ that a statistical link between smoking and lung cancer had been proved, but it was not necessarily causal. The SAC(CR) needed time to consider Todd’s criticisms of the statistics, the inconclusive laboratory attempts to find carcinogens in tobacco smoke, the alternative hypotheses (he mentions atmospheric pollution, road tar and exhaust fumes) and other matters.
The draft brief was sent to the MRC for comment and Green, after consulting Himsworth, wrote back: ‘We both feel that in an effort to be cautious the compiler of the brief has been unfair to Hill and Doll’, whose work was planned and extended, not ‘based on impressions and prejudices’. It was ‘improper’ for the brief to suggest that their statistical evidence could be ‘lightly discounted’. The brief remained cautious, however, and the speech notes for Patricia Hornsby-Smith, the junior health minister who replied to the debate, say: ‘Cannot accept even this report [i.e., Hill & Doll] without further enquiry: statistical evidence of association – not universally accepted . . .’ The Minister was subsequently criticised by a Miss Mary Baker who wrote from the Morton Hotel in Russell Square to say: ‘It hardly behoves the Ministry of Health to be two years behind the times on a matter that has lately aroused so much public interest . . .’[21]
Sir George Maddex was now commissioned, along with other distinguished statisticians[22], to study the work of Bradford Hill and Doll and the criticisms by Todd and Passey. The panel questioned both Todd and Hill and Doll, having given them notice of the intended lines of questioning, and they received further late amendments to his paper from Todd. On 12 November, Sir George submitted their report to Sir John Charles, and it was promptly circulated to the SAC(CR) in whose name it had been commissioned.
The report runs to five pages, with appendices drawn from the papers submitted to the panel, some of them additional analysis by Hill and Doll of their original results. The report is moderately worded but decisive. ‘We have carefully considered the criticisms Todd has made of the conduct of the investigation. We have come to the conclusion that Doll and Hill took every practicable care to avoid possible introduction of bias into their results and that, so far as we can see, they have been successful . . . We are therefore of the opinion that the main conclusion reached by Doll and Hill, that there is a real association between smoking and cancer of the lung, is firmly established.’ Although the relationship was not proven to be causal, ‘all the other possible explanations we can think of are ruled out by the careful matching of lung cancer cases and controls. There is therefore a strong presumption . . . that the connexion between smoking and lung cancer is causal.’ However, Todd’s analysis showed that it was unlikely that the whole increase in lung cancer over the past 30 years was due to smoking, and the panel was cautious about Doll’s calculations of risk.[23]
The SAC(CR) met on 23 November. The minutes record its conclusion:
The evidence was sufficient to justify advising the Minister that the association was real and that the Panel’s suggestion that the association was causal was acceptable. Young persons should be warned of the risk attendant on smoking and it should be made clear that the risk apparently increased in proportion to the amount of tobacco smoked. The risk from cigarette smoking was apparently greater than from other forms of smoking.
It was decided that a draft of the advice to be given to the Minister should be put to the following meeting. A note to the members of Sir George’s panel with which each was sent his own duplicated copy of the report mentions the ‘considerable impression’ it made on the SAC(CR) ‘many of whose members as a result changing (sic) the views they have previously held on the subject. The last has certainly not been heard of the question.’
The SAC(CR) might have been moved, but there were those in the Ministry who had not. Over the next few days Medical Officers and officials sent each other minutes about the drafting of the advice the SAC(CR) should be recommended to give the Minister. M R P Gregson, an Assistant Secretary, discussed the matter with Sir Ernest Rock Carling, the chairman of the SAC(CR), who had been (Gregson’s minute records) the sole dissentient at the SAC(CR)’s meeting (he ‘feels that the evidence is insufficiently conclusive’). They concluded that ‘the recommendation, if it is to be any way acceptable to the Committee in their present mood, will have to stress . . . (i) reality of the association, (ii) the presumption of causality, and (iii) the justification for warning the younger generation.’ Gregson provides a draft:
That an association between smoking and cancer of the lung has been established and, in the absence of evidence to the contrary, there is a strong presumption that the relationship is causal. Whilst further research is needed to establish the presence and nature of the carcinogen and the extent to which it operates, there is an obligation, in view of this presumption, to warn young people of the risks attendant on smoking, risks which are apparently proportionate to the amount of tobacco smoked. While the risks from cigarettes seem to be greater than those from any other form of smoking, it is not possible to state any number of cigarettes below which the risk can be disregarded.
Two days later, after he has spoken to Dr Goodman, who in turn consulted the CMO, he provides a new draft that takes account of the CMO’s suggestion that it be ‘toned down a bit’. So ‘there is an obligation . . . to warn young people’ becomes ‘it is desirable . . . that young people should be warned’, and the lack of a safe threshold is omitted altogether.
The next day further comments from the CMO, Sir John Charles, are passed on to Gregson: ‘The objection to this draft is that it does not sufficiently take account of the qualifications (other factors, qualifying phrases, etc.) contained in the Maddex report’. The next draft is half as long again; the presumption of causality is now to be made not ‘in the absence of evidence to the contrary’ but only ‘until some positive evidence to the contrary is found’. And stress is laid on the ‘other factor or factors’ that may be at play and the ‘further research’ that is needed.[24] More drafts ensue, and finally the version put to the SAC(CR) is as follows (italics added for ease of later reference):
(1) It must be regarded as established that there is a real relationship between smoking and cancer of the lung.
(2) Though there is a strong presumption, until the contrary is shown, that the relationship is causal, there is evidence that the relationship is not a simple one, since:-
(a) the evidence in support of the presence in tobacco smoke of a carcinogenic agent causing cancer of the lung is not yet certain;
(b) the statistical evidence indicates that it is unlikely that the real increase in the incidence of cancer of the lung is due entirely to increases in smoking;
(c) the differences in incidence between urban and rural areas, and between different towns, suggest that other factors may be operating, e.g., atmospheric pollution, occupational risks;
(d) the effect of smoking may be dependent on the presence of other constitutional factors common to those who smoke and those who develop cancer of the lung.
(3) In view of the probable existence of other factors, no reliable quantitative estimates can be made of the effect of smoking on the incidence of cancer of the lung.
(4) Although no dramatic fall in death-rates could be expected if smoking ceased, since the development of lung cancer may be the result of factors operating over many years, it is desirable that young people should be warned of the risks apparently attendant on excessive smoking.
The SAC(CR) met on 22 December 1953 to consider this suggested advice to the Minister. Members recognised the need for caution but found the draft ‘hedged around by too many qualifications’. They omitted the words italicised above and amended the final paragraph to add back that risk appeared proportionate to the amount smoked[25], but the advice they adopted was still substantially weaker than they clearly had had in mind at their previous meeting. ‘The Standing Committee was at first disposed to accept extreme views and advised the Minister to take some sort of dramatic action’, notes a Ministry Undersecretary in January 1954, but ‘under the influence of [the draft prepared in the Ministry] a rather more moderate conclusion was reached’.[26]
Horace Joules was plainly dissatisfied: a minute on the Ministry file records that ‘the Chairman mentioned that the Committee’s advice would automatically go to the CHSC [Central Health Services Council] (and he told Dr Joules that he would have another chance of raising the matter there).’ But Joules’ days on the SAC(CR) were numbered: he had rocked the boat too much. A minute on the file records that his appointment was due to expire on 31 March 1954. ‘Dr Joules was originally suggested by the Department, but his reappointment has not been supported by any of the organisations we consult.’[27] His replacement, Dr Janet Aitken, in accepting the invitation, wrote to the Minister: ‘I am not really an expert from a medical point of view in cancer and radiotherapy’.[28]
The Minister, Iain Macleod, pre-empted the CHSC, deciding that a statement had to be made without delay.[29] But first the tobacco industry intervened again. Dr Goodman, the Medical Officer at the Ministry, had had a meeting on 28 October 1953 with Dr E L Wynder, the leading researcher in the USA and co-author of the study that (as recorded above) prompted immediate publication of their results by Doll and Hill:
He is a young man ‘far gone in enthusiasm’ for the causal relationship between tobacco smoking and lung cancer. (I had been told when I was in New York this spring that he was the son of a revivalist preacher and had inherited his father’s antipathy to tobacco and alcohol. The American Cancer Society were very suspicious of his early work for this reason.)
Wynder, however, had talked of the ‘large grants’ the American industry had made for research:
He said that the American Tobacco Companies were anxious that parallel research should go on in this country and were prepared to make funds available to any ‘neutral’ body which would undertake it, e.g., the Ministry of Health. I told him that I thought the Medical Research Council were the proper body to approach in the first place . . .
The minute was copied to Dr Green at the MRC, who commented:
Dr Goodman’s slightly ‘sour’ minute about his talk with Dr Wynder seems to me symptomatic of the great reluctance of the Ministry’s M.O.s to accept what we regretfully believe to be the ‘facts of life (and death)’ on smoking and lung cancer . . . The news about the plans of the American tobacco firms is interesting, if true.[30]
On 18 December, Sir Alexander Maxwell, who occupied an ambiguous position between the tobacco industry and the Board of Trade[31], handed to Sir Harold Himsworth, the MRC Secretary, a memorandum rehearsing the industry’s doubts about the link between smoking and lung cancer but making an offer of £250,000 – over £4 mn in 1999 money – over seven years ‘for specific research into the real cause of cancer of the lung. Such research would, of course, embrace other possible factors besides smoking.’ Maxwell signed the memorandum as chairman of the Tobacco Advisory Committee ‘on behalf of the leading U.K. Tobacco Manufacturers’.
News of this offer reached the Ministry of Health during its consideration of the SAC(CR)’s formal advice to the Minister. J E Pater, now an undersecretary (and remembered by Sir George Godber as ‘a steady pipe smoker’[32]), prepared a three-page minute, with annexes, which went through the Chief Medical Officer to the Minister. Pater advised that ‘any kind of propaganda campaign’ would be ‘premature until there is a good deal more reliable evidence’, but that a statement of the SAC(CR)’s advice would be ‘reasonable’. He saw merit in an early statement before the CHSC met, since ‘on past experience, any modification made by the Central Health Services Council on this subject is more likely to be unhelpful than helpful’. But by-passing the CHSC would require ‘an urgent reason’, such as perhaps a Parliamentary Question if one were put down. (If not, he saw no alternative to awaiting the CHSC, since he would scruple to take the ‘rather dubious step’ of arranging for a Question to be asked.)
It was left to the deputy secretary I F (later Sir Frederick) Armer, to advise that a two-month delay in revealing the SAC(CR)’s important advice might be open to criticism. Iain Macleod agreed: ‘This, of course, is a problem that we have seen coming for a long time and is one that requires very delicate public relations handling’. He rejected delay and asked for a paper to be prepared ‘at once’ for the Cabinet Home Affairs Committee.
The paper[33] was issued four days later. The first draft had said: ‘. . . the statistical evidence leaves no doubt that there is a causal relationship between smoking and lung cancer, even if we do not know how or to what extent one causes the other’ but this was annotated: ‘Can we look again at [this] which seems to go just a little too far?’ and the final version said nothing so inflammatory. It began by rehearsing the background, quoting the SAC(CR)’s advice, mentioning the tobacco companies’ offer to the MRC, and noting that in America the industry had published ‘advertisements to the public stating that, while they do not accept a causal relationship, they are financing independent research.’[34] It then proposed making an early statement to the House of Commons but resisting any demand for propaganda.
Before the Committee met, the Treasury asked to be kept informed, and Iain Macleod accordingly wrote to John Boyd-Carpenter, the Financial Secretary:
. . . I needn’t say anything about the financial implications of any ill-considered statement in this field for we all know that the Welfare State and much else is based on tobacco smoking. I would, however, like to make a point here about the political implications of delay. [He explained the risks of criticism if the Ministry delayed publishing the SAC(CR)’s advice.] Moreover, the prime mover in all this is a man [plainly Dr Horace Joules] of extremely advanced left wing opinions[35] and would not hesitate to embarrass the Government if nothing appears soon. The subject is clearly one that the papers are bound to make much of and I need not enlarge on the unfortunate affect (sic) that it would have if we were accused in the Press of holding back this sort of information to bolster, as would be suggested, the revenue. My only anxiety is to make whatever statement should be made as quietly as is possible but I feel that we must move soon if events are not to overtake us . . .
Boyd-Carpenter agreed that ‘delay should be avoided’, and simultaneously Pater advised on ‘the latest developments . . . which I have heard from the Treasury. It appears that representatives of the tobacco companies were seen there on Tuesday and were reasonable in their attitude.’ The companies had originally wanted no publicity about their offer of cash for research (‘presumably because they were fearful that the making of the donation might be publicly interpreted as indicating the implicit acceptance by them of an association between smoking and cancer of the lung’[36]) but had been persuaded that a statement would have to be made. Now the approach of the Imperial Tobacco’s company AGM became a factor in deciding the Government’s timing. Moreover, their offer obtained for the tobacco companies an inside track on the preparation of the statement: Pater advised that the Treasury wanted the terms of the Minister’s statement to ‘be agreed with the Treasury and the tobacco companies’ (who would be shown the draft by the Treasury) while ‘a statement to be made at the same time by the tobacco companies would be agreed with the Treasury, the M.R.C. and ourselves . . .’
The Home Affairs Committee met on Friday 5 February 1954, with the Lord President of the Council, the Marquess of Salisbury, in the chair. The Lord President oversaw the affairs of the MRC[37], and Sir Harold Himsworth had written to him on 1 February: ‘The comments by the tobacco manufacturers . . . have not hitherto been characterised by good sense, dignity or a judicial appraisal of the evidence. It is certain that when the Minister of Health makes his announcement it will elicit a rejoinder and it is to be feared that this may be intemperate.’ As a result the MRC might have to publicly disavow what the companies said. Care was therefore needed over the manner of announcement. Sir Harold, indeed, met the tobacco companies on 4 February at the offices of the solicitors through whom they had until then – anonymously – communicated their proposals. He warned them in unequivocal terms of the independence of the MRC and that the Council would not hesitate in case of need to comment ‘adversely or otherwise’ on any statement from the manufacturers and he gave them the opportunity to withdraw their offer, which they declined.[38]
Lord Salisbury’s brief for the Home Affairs Committee from his own office recognised that an announcement ‘may well be unavoidable before long . . . But the possible effect of an announcement on the Revenue clearly cannot be ignored. The yield of the tobacco tax is about £600 millions a year – i.e., considerably more than the cost of the Health Service. The television programme about two years ago’ – it is revealing that there was nothing more recent to refer to – ‘seems to have had little effect on smoking. But it may well be that people paid little attention to that programme, thinking that if the matter was really as serious as was suggested, the Government would have made an announcement. If this were so, the effect of the Minister of Health’s announcement might be to bring about a serious reduction in revenue, which it would be very difficult to replace by any tax as little objected to or as easily collected as the tobacco tax. I need hardly say that these considerations are advanced not as an argument against making an announcement if one is considered justified on the merits but as one for weighing all the more carefully the case on merits for making one.’[39]
At the meeting, Macleod made a long opening statement, saying that ‘there was no doubt in his own mind that a relationship between tobacco smoking and lung cancer had been established’. He proposed an early statement, timed just before the Imperial AGM, so that the company could then announce the offer to the MRC, which would, however, not meet to consider the offer until later.
The Committee agreed that a statement had to be made, despite the ‘serious repercussions on revenue from the tobacco tax’ that Boyd-Carpenter noted it might cause. ‘[T]he announcement should not cause undue alarm by implying that a causal relationship . . . had been clearly established by other methods’ than statistics.
A sub-committee was appointed to agree the terms of the statement and to consider how to deal with the tobacco companies’ offer: Lord Salisbury had cast doubt on the propriety of the MRC accepting the money, and it had been suggested that it should instead be diverted to the British Empire Cancer Campaign. Boyd-Carpenter, however, was worried that refusing the money might lead to public embarrassment and ‘might result in the Government having to put up the money for the research instead’; besides, research commissioned by the BECC would not have the authority conferred by the Government-backed MRC.
Lord Salisbury wrote on 8 February to the Chancellor, R A Butler, seeking his view of the propriety of accepting the donation: the MRC would ‘loyally accept’ a Cabinet decision to decline it but ‘with deep regret . . . £250,000 is a vast sum, and most valuable research could be done with it. It would, moreover, be an immense help to the Council, in their desperate struggle to balance their budget.’[40] Later the same day Boyd-Carpenter later replied with the Chancellor’s views, namely that ‘it would be a pity to lose the £250,000. On the other hand, he sees the point which I think was troubling you of the doubtful propriety of the M.R.C. accepting direct this money from an outside and highly interested body. He felt therefore that the difficulty could be best got over if the tobacco companies could be persuaded to make the gift to Her Majesty’s Government . . .’
The Home Affairs Committee had decided that the matter was serious enough to be reported to the full Cabinet, and a short paper (‘the statistical evidence does seem to indicate that there is a causal relationship . . .’) was circulated on 8 February[41]. The same day the Minister issued a paper[42] to the new sub-committee, proposing an answer to a planted Parliamentary Question that would quote the SAC(CR)’s advice and conclude:
I accept the Committee’s view that the statistical evidence points to a causal relationship between smoking and lung cancer, but I think it is only right to draw attention to the fact that there is so far no firm evidence of the way in which smoking causes lung cancer or of the extent to which it does so. Any further action must await the results of research into the causes of lung cancer, and this research is being vigorously pursued.
This elicited criticism from Sir Walter Monckton, the Minister of Labour and National Service, who objected that
the phrase . . . ‘the statistical evidence points to a causal relationship’ goes a good deal further than [the SAC(CR)’s] view . . . that ‘there is a strong presumption that the relationship is causal.
He produced an alternative version to ‘reintroduc[e] the element of doubt which the [Standing Advisory] Committee did not feel able to rule out completely’:
I accept the Committee’s view that the statistical evidence points to smoking as a factor in the production of lung cancer, but I would draw attention to the fact that there is so far no firm evidence of the way in which smoking may cause lung cancer or of the extent to which it does so. Research into causes of lung cancer has been pressed forward by the Government and by other agencies in view of the increase in the incidence of this disease, and we must look to the results of its vigorous pursuit to determine future action.
When the sub-committee met the next day, Macleod said he ‘was happy to accept’ Sir Walter’s version. Indeed, he said that ‘he, accompanied by the Secretary of the Medical Research Council, might give a Lobby Conference on the morning of the 12 February [when the statement was to be made] to try to ensure that press comment on his statement maintained a sense of proportion.’
As to the tobacco companies’ ‘gift’, the sub-committee decided that diverting the money to (for example) the BECC ‘might appear to indicate a lack of confidence’ in the MRC. It was necessary to ‘remove any suggestion of influence being brought to bear’ on the MRC but there were doubts about the companies’ willingness to give the money to the Government, who would pass it to the MRC, since it would not then get the same tax treatment as a gift to the MRC, a charity. The device the sub-committee produced was that:
the Secretary of the Medical Research Council should be advised to inform the tobacco companies that the Council could not themselves directly accept the money and that the proper course would be for the companies to approach the Minister of Health for advice as to the proper channel for the gift. The Minister could then advise the companies that the money should be made available to the Medical Research Council and all doubts about the propriety of the gift being accepted would thus be removed.
The proposed Parliamentary Question and answer were reported[43] to the Cabinet at its meeting on 10 February. Macleod said that it was ‘desirable that young people should be warned’ but repeated that he would ‘hold a Lobby Conference with the object of encouraging the Press to maintain a due sense of proportion in their comments on his statement’. Sir Winston Churchill, the Prime Minister, said that the Minister ‘should also make public as much as possible of the facts and arguments on which the Standing Advisory Committee had based their advice’.[44]
The lobby conference (actually a press conference) and statement went ahead as agreed. The Ministry issued a three-page briefing paper which subtly emphasised the doubts and uncertainties of the situation while ‘paying tribute to the valuable pioneer work of Dr Doll and Professor Bradford Hill and other workers who have given us what little information we have’. In his Parliamentary Answer, the Minister referred to the tobacco companies’ gift:
I should also tell the House that before these recommendations were considered by Her Majesty’s Government the tobacco companies had offered to give £250,000 for research. They have, on my advice, agreed to offer this money to the Medical Research Council.
The Parliamentary statement and the briefing paper are reproduced in the Appendix.
The tobacco companies[45] issued a simultaneous statement ‘with a full sense of their responsibility to the public’. They referred to the limitations of statistics, the lack of proof that smoking caused lung cancer, and the evidence that other factors had to be at work (some non-smokers contracted the disease while only a ‘very small proportion’ of smokers contracted it; and it was more common in towns than the country, indicating a possible role for air pollution). They had arranged the previous December to provide £250,000 over seven years for research by ‘an impartial and responsible medical body’ and on the advice of the Ministry of Health they had asked the MRC to ‘undertake this responsibility’.
At the press conference, as the News Chronicle noted the next day, Macleod chain-smoked four ‘large-size’ cigarettes, lighting one from another. Macleod was flanked by Sir John Charles, noted by the press as a non-smoker, and by Sir Harold Himsworth who ‘carried a pipe but did not light it’ (as the Daily Telegraph reported) and who suggested that smoking might become dangerous at a level of more than five cigarettes a day.
The press gave the Minister’s statement moderate but passing attention. Macleod’s warning against ‘uninformed and alarmist conclusions’ was widely reported. The Times gave its report most of a column on the main news page, opposite the leaders, and devoted its second leader to the subject, one (it said) of ‘intense public interest’: the implications ‘may indeed be serious but, as the Minister has, rightly, been at pains to point out, a proper perspective must be maintained’. It suggested that ‘moderation in all things’ was the ‘soundest rule’ pending further research, for financing which the tobacco companies were commended. The Daily Telegraph put a short report down a column on its front page with a fuller report inside. Its leader remarked that statistics ‘as is well known, can prove anything; and it is perhaps rather arbitrary to infer that smoking is so much responsible for the terrible increase in deaths from cancer of the lung.’ (Two days later a diary item recorded that the Chancellor of the Exchequer, R A Butler, had ‘exclaimed lightly’ at a recent Conservative Party gathering ‘For goodness’ sake do not stop smoking’, adding ‘He spoke from the heart’.)
The News Chronicle, Daily Express and Daily Mail all put small items on page one about tobacco share prices falling sharply, with fuller reports inside, the two first making much of Macleod’s chain-smoking. In a leader the News Chronicle praised the tobacco companies for their ‘due sense of their public responsibilities’ and said there was cause for ‘concern’ but not ‘panic’. The Daily Herald also put the share price on page one but its inside report, ‘by the Herald doctor’, did everything possible to play down the risks. The Daily Mirror by contrast gave most of its front page to its story predicting ‘4 New Moves’ – all research-related. The Observer the next day had a well researched background piece on page one, but the Sunday Times made no mention of the story at all and there was little reference to it anywhere in subsequent weeks.
The Ministry files contain none of these cuttings nor any follow-up correspondence. Politically, the issue went into hibernation. The risks of upsetting the public had been carefully avoided without ignoring the troublesome advice of the experts, and the panacea of further research had been applied at no extra expense to the Government.
Notes
1. PRO file MH 133.450. Sir George Godber, then a medical officer at the Ministry of Health (but not responsible for policy on smoking either at this time or until he became Chief Medical Officer), writes: ‘Horace Joules was a founding member of the Socialist Medical Association and was appointed to the CHSC by Nye Bevan. He was a good physician and M.S. [medical superintendent] of a good hospital.’ (Personal communication, 19 January 1998) [back]
2. I quote Sir George Godber (personal communication, 19 January 1998), who sees Rock Carling’s reluctance to act against smoking as sadly out of keeping with his distinguished record, from his service as a surgeon in the Boer War to his pioneering advocacy of radiotherapy. [back]
3. PRO file MH 133.453 [back]
4. PRO files MH 55.1011, FD 1.1992 [back]
5. PRO file MH 133.453 [back]
6. Bradford Hill had forgotten also the labour of opening the 40,000 returned envelopes: in May 1952 he wrote to the MRC recalling a verbal agreement that he pay his sons (‘the price being 2/-. a hundred forms opened and scrutinized which is just about an hour’s work’) and asking for cheques for £12 for one and £13 for the other boy. ‘Most of the remainder of the envelopes I opened myself partly as a misguided form of relaxation, partly to inform myself of the nature of the results; but this, of course, represents a freely offered labour of love.’ [back]
7. PRO file FD 1.1992 [back]
8. PRO file MH 133.453. A circular was eventually issued to local authorities in August 1953 encouraging them to attempt some health education about cancer in general (PRO file MH 55.960); and in November the Ministry filed a cutting from the East Anglian Daily Times reporting that the Medical Officer of Health for Essex, Dr Kenneth Cowan, had told a rally of scouts and guides at Chelmsford: ‘If I were in my adolescence . . . I would never start smoking. I have two pipes and a packet of cigarettes in my pocket, but it is too late for me to really worry, because it takes years and years of smoking to produce a possible serious result.’ He urged them to abstain – and at the end of his talk he lit a cigarette. A Ministry annotation in an unidentified hand says: ‘Cowan, to my knowledge, is a fairly heavy smoker. This is probably a very good line.’ – PRO file MH 55.1011. [back]
9. PRO file MH 55.2220 [back]
10. In March 1953, Miss Crawter minuted to her boss, the Public Relations and Chief Press Officer at the Ministry of Health (S A Heald) that she had fended off a proposal in the Central Council for Health Education (a joint local authorities body) to issue a leaflet summarising the facts about smoking. ‘It was difficult to discover from whom this desire emanated, other than that “there had been a lot in the press about it”; it seemed to me to be premature and I ventured to remark that the press and the B.B.C. were giving plenty of information, that it was not possible to suggest any positive measure of prevention (since the CCHE did not intend to discourage smoking) and that in my view the proposed leaflet was not health education . . . The matter has been deferred for six months. (I view this suggestion as the CCHE jumping into a controversial matter to boost their sales, and believe that they would have regretted the leaflet in a few months’ time, as they might easily have biassed it in a direction which ultimate opinion on the subject would not have supported.’ Heald recorded: ‘Miss Crawter did well to intervene to kill the leaflet (as much in CCHE’s own interest as in the general interest).’ PRO files MH 55.959, MH 55.960 [back]
11. PRO files MH 55.1011, MH 133.453 [back]
12. This paper (BMJ 1952; ii: 1271-86) included the new data from the extended study requested by Himsworth in four other towns (see above) as well as the original data from London. [back]
13. PRO file FD 1.2015. Richard Doll writes (personal communication, 23 October 1996): ‘As to our meeting with Partridge & Todd, it was friendly! Todd made three points: (i) that smoking histories were too unreliable to use, (ii) that the correlation between cigarette consumption and lung cancer in different countries was too small, only 0.5, and (iii) that lung cancer was obviously due to atmospheric pollution. Bradford Hill responded that if smoking histories were unreliable this must have made the association appear weaker than it actually is, that the correlation was unusually high for that sort of data, and that if lung cancer was due to atmospheric pollution, go and show it!’ [back]
13a. PRO file FD 1.2015 [back]
14. Sir Richard Doll (personal communication, 23 October 1996) points out that cigars were included in all the later questionnaires, starting in 1957, following reports of low risks in the American case-control studies. [back]
15. Graham, Wynder & Croninger (Science, 14 November 1952) had claimed ‘tar from cigarette smoke will produce malignant growths when painted on the skin of mice’; J M Essenberg (Science, 21 November 1952) had reported that prolonged exposure of albino mice to tobacco smoke ‘greatly increases the incidence of the primary neoplasms of the lung’. [back]
16. PRO file references MH 133.453, MH 133.456 [back]
17. They apparently asked Goodman to help them get it accepted: Partridge wrote to him on 9 March saying the paper had been submitted to the journal: ‘You may remember that you very kindly promised to have a word with [Hugh] Clegg [editor of the British Medical Journal] about publication when we were able to advise you about the despatch of the paper to him.’ The attempt was, of course, unsuccessful [back]
18. The statement was made at the AGM, on 17 March: ‘. . . I think it desirable that I should say something about a subject to which a certain amount of public attention has recently been directed – the proposition (which incidentally is founded on a suggested statistical correlation) that in some way smoking could be a contributory cause of cancer of the lung. I am conscious of the risk that anything we say on this matter might appear to be prejudiced. I can assure you, however, that we have been following very closely the research on this subject. We have a very real sense of the need to view this matter objectively, and it is in that spirit that I would state quite categorically that the available evidence is far from conclusive and by no means constitutes proof that tobacco can be a contributory cause of this disease. It is said that there is a statistical correlation; but there is, in fact, a considerable weight of statistical evidence against the validity of the accusations that are made against tobacco in this connection. Moreover, possible correlatives other than smoking have been suggested by several medical authorities. It has never been our policy to make exaggerated claims for the smoking habit, or to say that it confers on those who indulge in it benefits other than the pleasure and peace of mind it may bring. Equally, however, we can assert that in our manufacture we do everything possible to maintain the highest standards of purity and quality in our products. We shall, of course, continue to keep in the closest touch with all the investigations that are going on, and if it should ever be proved that there exists something harmful in tobacco, even in the minutest quantities, which could conceivably make smoking one of the causes of this disease, we should, I hope, be the first to take steps to eliminate it.’ [back]
19. Sir Harold Himsworth recorded a discussion on 7 April 1953 with Professor Alexander Haddow, one of those suggested by Green, noting that Haddow, approached by Partridge, had told him that he found Doll and Hill’s case strong and had ‘warned [Partridge] off undertaking biological experiments’ but had said that ‘the tobacco people either had or could easily get’ information about the chemical composition of smoke and tars. [back]
20. BMJ 1953; i: 1362-3, 14 February 1953. [back]
21. PRO file MH 55.1011 [back]
22. Professor M J Kendall (London School of Economics), Dr W P D Logan (Central Statistical Office) and Dr P L McKinlay (Superintendent of Statistics at the Scottish General Registry Office). [back]
23. PRO file MH 55.1011 [back]
24. PRO file MH 55.1011. The Ministry attitude can be contrasted with the advice from a ‘recent’ editorial in the British Medical Journal quoted by Dr Goodman in a brief attached to the minute (quoted below) that went to the Minister: ‘all we can do is show that the probability of a causative connection between an agent and disease is so great that we are bound to take what preventive action we can, accepting the theory as though the proof was absolute until further research leads to some modification.’ (I have not been able to identify this editorial.) [back]
25. The final version of the last paragraph was as follows (the changes from the Ministry version are italicised): ‘Although no immediate dramatic fall in death-rates could be expected if smoking ceased, since the development of lung cancer may be the result of factors operating over many years, and although no reliable quantitative estimates can be made of the effect of smoking on the incidence of cancer of the lung, it is desirable that young people should be warned of the risks apparently attendant on excessive smoking. It would appear that the risk increases with the amount smoked, particularly of cigarettes.‘ – PRO file MH 133.453. [back]
26. Minute, quoted below, by J E Pater, Undersecretary, 19 January 1954, which eventually went to the Minister – PRO file MH 55.1011. [back]
27. Sir George Godber writes: ‘Horace Joules enlivened the CHSC and SMAC but his political background meant that he was dropped fairly soon. If he had not rebelled we might never have got them moving.’ (Personal communication, 19 January 1998) [back]
28. PRO file MH 133.450 [back]
29. PRO files MH 55.1011, MH 133.453 [back]
30. PRO file FD 1.2009 [back]
31. A Board of Trade file opened in 1955 records that Sir Alexander Maxwell, a tobacco leaf merchant, was appointed Tobacco Controller in 1940 to deal with wartime shortages. He had two committees to advise him – the Tobacco Manufacturers Advisory Committee and the Tobacco Distributors Advisory Committee. After the war, he became unpaid Tobacco Adviser to the Board of Trade while continuing with his own business. The TDAC had last met in 1949, but the TMAC, commonly known as the Tobacco Advisory Committee, was still meeting ten times a year on Board of Trade premises and with Board of Trade servicing. However, it was operating purely as a manufacturers’ association: the Board of Trade (the file records) rarely had need of advice and never asked the Committee for it. Maxwell, moreover, was inclined to use his position to obtain or seek to obtain commercially confidential information lodged with the Board of Trade by tobacco companies, which he was not above making use of for his own ends and revealing to others, again to the Board of Trade’s embarrassment. The Board of Trade decided to wind up the two committees but did not succeed in doing so until Maxwell retired three years later – PRO file BT 258.284. [back]
32. Personal communication, 19 January 1998. Given the high prevalence of smoking at the time, especially by men, most of the officials dealing with the subject were inevitably smokers. [back]
33. H.A.(54)9, 26 January 1954 – PRO file CAB 134.916 [back]
34. This reference is to the notorious ‘Frank Statement’ published in 448 US newspapers, on and shortly after 4 January 1954 which announced the establishment of the Tobacco Industry Research Council (later the Council for Tobacco Research). It is now on record that this was from the start no more than a public relations move, the creation of the PR company Hill & Knowlton (see, for example, pp 39-40 of Glantz, Slade, Bero, Hanauer and Barnes, The Cigarette Papers, University of California Press, 1996, quoting internal tobacco industry documents). The British industry’s offer seems to have been less cynical, since the MRC’s research, unlike the CTR’s, would be genuinely independent. [back]
35. Joules had been in the summer of 1951 chairman of a scientific delegation to Russia from the Society for Cultural Relations with the USSR and praised his hosts for already then publicising the link between smoking and lung cancer whereas by contrast ‘in this country . . . he had had little success in publicizing this fact’ – The Times, 15 August 1951. [back]
36. Brief, 1 February 1954, by Sir Harold Himsworth for the Lord President of the Council – PRO file CAB 124.1670. This paper is further quoted below. [back]
37. The Lord President derives his title from his role in the Privy Council, of which the MRC is technically a committee. [back]
38. Minute, 8 February 1954, from Sir Harold Himsworth to the Lord President of the Council – PRO file CAB 124.1670. [back]
39. PRO file CAB 124.1670 [back]
40. PRO file CAB 124.1670 [back]
41. C.(54)47 – PRO file CAB 129.65 [back]
42. GEN 456/2 – PRO file CAB 130.100 [back]
43. C.(54)51 – PRO file CAB 129.66 [back]
44. C.C.(54) 8th – PRO file CAB 128.27 [back]
45. Calling themselves ‘a group of leading tobacco manufacturers in the United Kingdom’, they listed themselves as Ardath Tobacco Co Ltd, British-American Tobacco Co Ltd, Carreras Ltd, George Dobie & Son Ltd, Gallaher Ltd, Imperial Tobacco Co. (of Great Britain & Ireland) Ltd, Godfrey Phillips Ltd and J Wix & Sons Ltd – PRO file MH 55.1011. [back]