For another five years the Government adhered resolutely to their decision to leave any ‘propaganda’ to the initiative – and expense – of the local authorities, adroitly deflecting all attempts to persuade them into any form of intervention.
The first such attempt came on 12 July, only a few days after the statement in the House. Quoting the Parliamentary Secretary, J K Vaughan-Morgan, who had said in answer to a question after his statement that ‘there is no promising line of research which is being neglected for lack of funds’, Dr John Burton, the Medical Director of the local authority-financed Central Council for Health Education, wrote to Sir John Charles, the Chief Medical Officer, proposing that research was essential into
the educational aspects of prevention or early treatment of cancer. . . I feel particularly uneasy because of what I consider the unprofessional way in which we are approaching the educational side. While many hundreds of thousands of pounds are being spent on laboratory research it is being assumed that the educational aspects – on which, as far as I can see, the whole preventive policy now rests – are to operate with no accurate data and as yet no indication of any capital investment.
This eminently reasonable proposal set the pattern for the next few years, with the Government prevaricating while local authorities and the CCHE did what little they could to publicise the dangers of smoking.
The CMO referred Dr Burton’s letter to the MRC, and Sir Harold Himsworth replied at the end of August. ‘I think’, he wrote, ‘ there is some substance in his suggestion that such questions as the reason why people smoke and find the habit difficult to abandon, and the best way to conduct education on the subject, might be investigated.’ However, no specific proposals for such work had been put to the MRC, and the area was ‘fraught with difficulties for the investigator’, being ‘uncharted territory between medicine, sociology and psychology, and few techniques have been devised for their investigation’.
Himsworth suggested that Burton should be encouraged to pursue his ideas. Sir John Charles scribbled a note on Himsworth’s letter: ‘Mr Emery – I have spoken to Sir Harold Himsworth about this. In effect it means that the M.R.C. do not consider that it comes within their field. Sir Harold also wonders a little in whose field it might lie. It may be that we will have to look at Dr Burton’s proposals ‘ad hoc’.’ Emery, an Assistant secretary, wrote back to Burton in November seeking ‘some elaboration of the plans and possible methods’ for the research he had proposed, but by that time the argument had switched to the much more immediate point of money.
In September, Emery had rejected Burton’s request for financial assistance from the Ministry, suggesting instead that the CCHE obtain payment in advance for orders for publicity materials placed by local authorities. In October, Burton replied seeking a Ministry guarantee of £1,500 against possible losses on the production of materials. Miss Crawter, the Ministry’s Senior Publicity Assistant, recorded her opinion that the CCHE would be able to continue without help, but ‘unless the Ministry shows continued interest publicly in this campaign from time to time, local authorities (many of whom are naturally apathetic) will not think the Ministry is in earnest about the seriousness of the warning, and will tend to postpone or drop public education.’ Emery nevertheless refused the guarantee. Within days the CCHE complained again about lack of financial support from the Ministry: ‘so much capital’ – about £1,500 – was locked up in their current stocks of posters (in particular, a leaflet about polio) that all new ventures were blocked. Burton wrote again to Emery on Christmas Eve 1957, complaining that the ‘Ministry is being rather hard on us. . . It looks as if we will have to restrict all new publications until March’. Miss Crawter recorded in January 1958 that the ‘greatest need’ was for a filmstrip for use in schools: Dr Burton was thinking of making it himself so as to reduce the cost to about £60. Burton wrote again in February, saying that the CCHE had been forced to realise £1,000 of its £3,000 investments and run down its stock by 25%.
Meantime, the County Councils Association intervened, writing in January to seek ‘a vigorous publicity campaign undertaken by the Government on a national basis on lines similar to the campaign for diphtheria immunisation which proved so successful.’ S A Heald, the Ministry’s public relations officer, commented that the diphtheria campaign, launched in 1942 at a cost of about £20,000, had cost £60-£70,000 a year from 1945 to 1949 since when it had been run on a reduced scale. It had used local and national press advertisements, billboard posters, films etc. A campaign on this scale on smoking was very unlikely to get Treasury approval ‘quite apart from the Treasury’s inevitable reluctance to spend money for the purpose of reducing revenue.’ Referring to the policy that local health and education authorities should be responsible for the campaign, albeit with Ministry of Health backing, he added: ‘It is fair to add that of all the major health problems on which l.h.a.s. (sic) have been asked to take action, this is the only one which has not had any direct support from the Ministry in the shape of publicity material or facilities.’
In March 1958, Emery’s boss, J P Dodds, the Undersecretary in charge of the Home Health Services Division, addressed the problem:
My own tentative view is that in the absence of fresh scientific information . . . and in view of the known opposition in some quarters, the luke-warmness in others and the general financial situation, we ought not to think in terms of making any sort of publicity splash. On the other hand, it would be politic for the Minister to be known to be pushing at this subject, even though rather gently . . .
He suggested a £3,000 ad hoc capital grant to the CCHE followed up by a circular to local health authorities seeking a report on progress. A S Marre, the Undersecretary for Finance, suggested that the circular should be undertaken first, with a possible approach to the Treasury held in reserve in case the local authority replies showed the present arrangements to be inadequate.
This was the proposal put to the Minister, Sir Derek Walker-Smith, by the Permanent Secretary, Sir John Hawton: ‘I am not sure whether you will think this a good moment to stir up this controversial subject again. A progress report would of course help to defend you against any criticism of ‘not bothering’, but the matter is so quiet now that it might be better to wait and see?’ The Minister replied:
I think perhaps the time is ripe for a new Circular asking for a Progress Report, as suggested. The qn. of financial aid for CCHE is, of course, another matter – with which presumably would be linked the qn. of Govt. responsibility for the contents of publicity material.
When, therefore, in April the County Councils Association sought an answer to their January proposal, Emery’s reply referred to the intended new circular and a review of action since the circular of June 1957. The CCA sent another reminder before in July 1958 they and the other local authority associations were consulted on the draft circular, which was not finally issued until 14 August.
Meantime, the tobacco manufacturers themselves had produced two new reports, one citing fifty quotations from experts by which they sought ‘to illustrate, by means of extensive quotation from original sources, the conflict of opinion’ on the subject. Of the eight experts cited (who included some who were consultants to the industry), three accounted for two-thirds of the fifty quotations. At the same time the TMSC also published ‘Smoking and Lung Cancer’, a five-page ‘interim report’, in which they raised questions about (for example) the basis of the statistics (was better diagnosis the origin of the increase?), alleged anomalies (such as the non-smokers who did and the smokers who did not contract lung cancer), and alternative theories involving genetic, psychosomatic and environmental factors. The report concluded with renewed reference to the industry’s funding of and cooperation with the Medical Research Council and an assurance much more guarded than an earlier one made by Imperial Tobacco in March 1953 (quoted in note 18 to chapter 1):
. . . chemical research by the manufacturers continues and will be pressed forward; and if it were ever to reveal the presence of a substance in tobacco smoke in quantities considered likely to be injurious to health every effort would at once be made to remove it or to render it harmless.
Against this discouraging background of official procrastination and industry prevarication, the CCHE and some local authority officials took small steps to educate the public. Miss Crawter, the Ministry’s Publicity Assistant, remained vigilant. When a dentist from a Buckinghamshire County Council dental clinic wrote to the Ministry seeking information about lung cancer deaths and Ministry of Health publications on the relationship between smoking and lung cancer she minuted: ‘It seems outside the usual dental range’. Miss Forrest, Senior Dental Officer in Dental Health Service, replied: ‘Thank you for letting me see this. I agree it is a bit unusual from a dental officer. He appears to have come recently to the Bucks. staff and must be very young as he qualified only last year. Some time, when I meet his chief, Mr Kew, I’ll try to find out what kind of lad he is.’ Whether the lad received the information he sought is not clear.
Buckinghamshire figured also in a report to a conference of Medical Officers of Health in January 1958: the local Deputy MOH had made ‘a papier mâché model of a chinless moron with a cigarette end drooping from his lips called ‘Smoky’. These were to be placed in the halls at Secondary Modern (or Grammar) schools . . . the aim was to make the ‘smoking boy’ look ridiculous.’
Miss Crawter reported in September 1957 on a CCHE committee meeting:
Dr Burton had the following suggestions: . . . The production of a poster showing a cigarette with the smoke curling from it forming the word ‘cancer’. (Another poster headed ‘Smoking’ and showing a doctor leaning forward over a table with the footline ‘My advice is don’t’ was turned down by the Chairman of the Committee, Dr Pirrie, after considerable discussion in which I said that it would be ‘knocking’ the cigarette manufacturers and that in any case the CCHE would get nowhere as the tobacco people had so much money.)
By May 1958 the poster with smoke curling into the word ‘cancer’ had been banned by the Censorship Committee of the Poster Advertising Industry. The CCHE Fieldwork and Materials Committee were told this was ‘because the inference (sic) . . . was that one cigarette would cause cancer, which they held to be grossly untrue.’ The matter was referred to the local authority associations. When they backed the poster, Miss Crawter minuted her chief:
Our position on this poster is a difficult one . . . I think the reason offered by the BPAA [British Poster Advertising Association] may be a genuine one, and people are so stupid that there may well be some who would draw the inference claimed by the Censorship Committee. On the other hand, there may be unseen pressures at work. In my opinion we should steer clear of involving ourselves in this matter.
Heald replied: ‘I entirely agree with your view . . . any approach we made (if we felt able to do so) would, in my view, be unlikely to have any effect and might even prove embarrassing to the Dept. in certain circumstances.’ In October, Miss Crawter was back at the CCHE committee:
I again drew attention to the interest the tobacco people might have in this poster, and that they might feel the poster was inimical to their interests. (I felt this concealed warning was the most I could do); the unanimous feeling round the table appeared to be that it was fear [i.e., by the poster industry] of offending the tobacco manufacturers which was creating this situation.
In August 1958, Dr Scott, the Medical Officer of Health for London County Council, wrote to Dr Goodman at the Ministry enclosing a newspaper advertisement for Churchman’s Tipped cigarettes which featured soldiers from the Parachute Brigade and complaining about Army cooperation with the tobacco companies. Dr Goodman wrote to Heald: ‘I am rather surprised that Dr Scott should take this up with us which is the sort of thing that some of the less responsible medical officers of health might do!’ He sought advice on a reply, adding ‘Incidentally, he does not mention the one point which I feel is vulnerable, i.e., the supply of duty-free cigarettes to members of the Services.’ Heald took the matter up with the Director of Public Relations at the War Office (‘Whatever the circumstances, this sort of thing is, of course, extremely embarrassing as the Government has a rather difficult row to hoe in this particular field’) eliciting assurances that allowed Dr Goodman to reply to Dr Scott: ‘Further permission [to take photographs of servicemen for advertising purposes] had been in fact refused . . . before our representation was made.’
Two further examples illustrate the ambiguity of the Ministry of Health’s position on smoking and the defeatism of their attitude to ‘propaganda’ – what we should now call health education. The first is their response (November 1958) to a proposal by the National Savings department to refer in a booklet for young people on the virtues of thrift to ‘the dangers to health involved in smoking’: ‘We would not say . . .that smoking was a danger to health without some qualification such as ‘heavy smoking’.’ The second, the following month, is a minute from Heald to the Undersecretary for the Home Health Services Division, J P Dodds, opposing a Government press advertising campaign which, he claimed, would be impracticable because it ‘would only produce a whirlwind advertising ‘blitz’ by the Tobacco Industry and would get us nowhere. We cannot hope to stop adults smoking . . .’ and should therefore concentrate on the young. It could be useful to have a survey of the public to establish that people generally know of the risks of smoking: ‘Those who continue to smoke in spite of this knowledge choose to do so as a calculated risk as they have every right to do as they prejudice nobody’s health but their own.’
The circular to local authorities issued in August 1958 produced replies which were summarised in a note produced in December:
Many authorities strongly urge the need for a national propaganda campaign. It is widely felt that what is being done cannot combat the volume of advertising by the tobacco interests, and that the only way to make an impression is to mount a campaign more akin to that undertaken in connection with diphtheria and V.D.
Many local health authorities also wanted enforcement of the under-age sales law by the police and ‘prohibition of smoking in cinemas, theatres, restaurants, teachers’ common rooms, in public transport, on television and in various other places’.
Dodds discussed the replies with Dr George Godber, one of two Deputy Chief Medical Officers, soon to become a notable Chief Medical Officer but not at this time responsible for smoking policy, and with Heald and others. He then sent a minute through the CMO, Sir John Charles, to the Deputy Secretary, Dame Enid Russell-Smith. The action proposed was minimal: other departments should be informed of relevant suggestions from local authorities; the Ministry of Education should be urged to cooperate (‘It is likely that they will require some persuasion’); the Royal Society for the Promotion of Health should be urged to run a seminar at its annual congress. Dr Godber’s suggestion that a summary of the local authority replies should be published was rejected because of the embarrassment of rejecting so many suggestions; the ‘widespread demand for national publicity’ should be met only through the CCHE and not by the Government, but the Ministry should be ready to take up with the Treasury and the Cabinet the question of financial assistance to the CCHE. It was also noted that the Government Social Survey could be used to show that a high percentage of the public already knew of the risks of smoking, thereby taking some of the pressure for more propaganda off the Minister – but it was considered doubtful that a survey was justified simply for this purpose.
The Minister, however, had no such doubts: he agreed the recommendations, such as they were, including the survey, but decided first to consult the Cabinet Home Affairs Committee. His paper made little of the demands for national publicity:
No new factors have emerged which would suggest that there should be any change in the policy the Government has hitherto pursued, that of limiting its action to making the facts about smoking and lung cancer known and leaving the individual to make up his own mind. My colleagues will no doubt agree that we should continue to base any measures we may take on this general approach.
There is no positive evidence that the publicity so far has led people to stop or cut down their smoking; indeed, the total consumption of tobacco has gone up. It would, therefore, seem desirable to have a firmer foundation on which to estimate the extent of public knowledge of the risks of smoking, by means of which we can gauge the degree of success of the propaganda measures hitherto employed.
Derek Walker-Smith recommended ‘a small scale social survey’, noting it might take up to twelve months. ‘The survey would probably reveal that [the relevant facts] were fully known to the public’, he said at the meeting, ‘and this would provide an answer to criticism that further action by the Government was required. In the meantime, a partial answer would be an intensification of the activity in this field of the Central Council for Health Education who might, however, ask for renewed Government assistance for the purpose.’ He therefore proposed, as the paper puts it, that ‘subject to Treasury agreement, we should not exclude the possibility of making a small financial grant to the Council, if a request therefore (sic) is made’.
His colleagues were doubtful about the survey: ‘If the survey showed that the public were already fully aware of the facts, it could be argued that little purpose had been served: if, on the other hand, the opposite conclusion were obtained, pressure for a national publicity campaign – to which there were a number of strong objections – would be aggravated.’ They agreed to the survey on condition that it should be kept secret until they had been able to consider its results, and in the meantime they rejected any question of a grant to the CCHE.
The survey took rather less than the predicted twelve months and a draft paper on the Social Survey’s work was circulated to other departments by the turn of the year. It revealed that a pilot survey addressed to 83 adults and 71 young people had found only one person – ‘an old lady of 87, a non-smoker’ – had not heard of the association of smoking and lung cancer, and that the full survey had therefore been abandoned. Surveys by the Department of Public Health and Social Medicine of Edinburgh University had found a similar level of knowledge of the alleged connections – but ‘that a much smaller proportion accepted that the connection had been proved, and that a negligible number of people had given up smoking because of this.’
The Ministry of Health saw no reason for concern in this last circumstance and circulated a draft paper for the Home Affairs Committee, but the Scottish Office, under the influence of its Chief Medical Officer, Kenneth Cowan, now embarked on the path which it pursued for several years, albeit with little obvious result, of urging a more active policy on London. ‘We are a little unhappy here at the paper’s apparent acceptance that we can do no more to counter the increasing incidence of lung cancer,’ they wrote in February 1960: ‘. . . It might be argued that we have not yet really brought home to the public the risk that smoking involves and the scale of the problem.’ The Ministry replied with an amended wording, designed to avoid the appearance of complacency, which the Scottish Health Department felt constrained to accept.
The paper was taken at the Home Affairs Committee on 29 April 1960, with R A Butler in the chair. Echoing the words in his paper, Derek Walker-Smith said at the meeting:
It was clear that the Government’s policy of bringing the facts to the notice of the public (using local health authorities as the main channel of information) had been effective, and that no new departure of policy was required at the present time.
The Committee noted that the CCHE had not renewed their request for financial help and accordingly agreed not to make any grant. The Minister made no reference to a recent letter from the County Councils Association pressing for ‘vigorous publicity campaign undertaken by the Government on a national basis’ – still less to one from Middlesex County Council to the same effect enclosing a report from their Health Education Officer calling for condemnation of ‘the practice of manufacturers exploiting the school boy market with paper packs of [four] cigarettes at a price of sixpence, and the practice of selling single cigarettes in shops.’
Derek Walker-Smith got his way at the Home Affairs Committee, but not without attracting the attention of Lord Hailsham, the Lord President of the Council and Minister for Science, who had been unable to attend the meeting. On 5 May he wrote a cautionary letter to the Minister:
. . . I have been chewing over the issues raised in your [paper] and am wondering whether we can feel quite happy at leaving the question of publicity where it stands at present. Can we feel quite justified in accepting a state of affairs in which the public, and particularly the young, are bombarded heavily with persuasions of various kinds to take up or continue smoking, while their education in the risks of smoking is still so limited as at present? There has been a great deal of very useful and difficult work done in evaluating the connection between smoking and lung cancer and I cannot help feeling that we have a responsibility for pushing it very clearly before public notice.
I have noted from the minutes of last Friday’s meeting that you are proposing to consider from time to time whether any further stimulus is needed to local authorities in the provision of education on this matter, and I do very earnestly trust that you will agree with me that this is a question which needs watching very closely.
I am sending a copy of this letter to Rab [Butler].
Walker-Smith took ten days to send a soft answer:
While we cannot hope to compete with the tobacco manufacturers in the scale of our publicity – and indeed our declared object is effectively to make known the risks and to leave the individual to decide for himself – I entirely agree that there is a duty on us to see that what is put out is as effective as possible and is directed to the right audience, i.e., the young and those who have responsibility for them.
Hailsham disappears from the record for the next two years – but then returned with a vigorous interest.
Meantime, a significant new player entered the debate. The August Royal College of Physicians, founded in 1518, now made its first intervention in a public health debate since 1725, when it had protested to the House of Commons about the rising consumption of cheap gin. In 1604 when James I published his famous Counterblaste to Tobacco, the Royal College rejected his proposal that smoking was damaging to health. Now, however, they appointed a committee to look at the effects of smoking and atmospheric pollution on health. Sir George Godber recalls that he and Dr Charles Fletcher, who became secretary and prime mover of the committee, had plotted its creation. Fletcher, who was a member of the Standing Medical Advisory Committee,
had approached me about M[inistry of] H[ealth] inaction. I suggested that he and I should separately approach the new PRCP [President of the Royal College of Physicians], Robert Platt, who was an old friend of mine, and suggest the RCP set up a committee on Smoking and Health. He agreed and wanted me to be a member but I could see that being inhibitory and advised against. I think this was 1958. I told [Sir John] Charles what I had done but pointed out that I was a Councillor of the RCP and this was not a Ministry proposal.’
Platt readily agreed the proposal and indeed chaired the committee and in January 1960 Fletcher wrote officially as its secretary to Godber to
ask the Ministry of Health . . . what they are actually doing now in respect of the cancer of the lung problem. In particular, what steps, if any, they are taking to assist local authorities with ‘health education’, and if the Ministry have any evidence of any effect of anything that they are doing.
It took until March for Godber to reply to this enquiry, and the eventual reply was bland:
The Minister’s policy is to bring effectively to public notice the risks involved in smoking and to do this through local health authorities . . . The first action was to send a circular to local health authorities in June, 1957, enclosing a copy of the statement by the Medical Research Council . . . and asking authorities to take appropriate steps to bring the facts to notice. No publicity material is provided directly by the Department but suitable material is available from the Central Council for Health Education and elsewhere including, for instance, a film in the Government Central Film Library. The material provided by the Council includes bookmarks, posters and leaflets.
Local authority replies to a follow-up circular had shown that they were concentrating on children and young people. ‘The Ministry has no precise information about the effects achieved by publicity . . . ‘ but published reports showed ‘widespread knowledge’ although there was ‘no evidence that as a result people had given up smoking.’ This reply did not satisfy Fletcher and he continued to write over the next few months with detailed enquiries.
In the interval until the Royal College of Physicians finally published their report in March 1962 its anticipated publication was increasingly used by the Ministry of Health as an excuse for inaction – without any concomitant signs of preparation for subsequent action. During this time there are two sequences of papers on the files that provide a striking contrast between attitudes in the Ministry and in the Scottish Office.
First, between December 1960 and March 1961 there are transient signs of disquiet on the part of the deputy secretary, Dame Enid Russell-Smith, about the increase in spending on tobacco advertising and the extent to which it was directed towards the young. Board of Trade figures obtained in December 1960 in order to answer a Parliamentary Question showed that press advertising of tobacco had risen by over 50% in the first three quarters of 1960 compared with the corresponding period in 1959. Dame Enid wrote to the Permanent Secretary: ‘I find the increase in expenditure on advertising startling and wonder whether we ought not, after the Questions have been answered, to try to establish how far, as alleged, it is directed at young people.’
She commissioned an enquiry, and in January 1961 a principal in the Home Health Services Division, W M Judd, opined:
There can be little doubt . . . that the cigarette manufacturers are increasingly directing their advertising at the young. This is obviously so with television advertisements . . . which, with few exceptions, portray physically attractive young couples indulging in the delights of smoking brand X.
He quoted from an editorial in the trade journal Tobacco (September 1960):
The increasing importance of welfare state women, teenagers in particular, as buyers of all manner of produce has become especially marked in recent years in the tobacco trade. As buyers of cigarettes their importance has become more and more emphasised, as anyone who has studied the trend of manufacturers’ advertising may be well aware.
and from ‘a Guardian article . . . which Tobacco has reproduced without comment’:
. . . [tobacco] manufacturers seeking to introduce a new brand tend to concentrate their promotional efforts on teenagers and other young smokers, who are not yet set in their ways.
and took the matter up with the Board of Trade, telling them that Dame Enid ‘finds the increase in expenditure on tobacco advertising startling’.
Not so the Board of Trade, where another principal, C B Selby-Boothroyd, author in the next few years of many highly opinionated memoranda based on his own sceptical brand of commonsense, replied briefly that no further information was available but that television advertising was ‘clearly pointed indiscriminately at the public with no age-bias’.
Judd’s boss, the assistant secretary Mrs D M O’Brien, found this a ‘rather surprising generalisation’ and doubted whether ‘the Board of Trade are being as helpful as they might’. She approached them through the Ministry’s press office to be told that, following the ‘withdrawal of controls on the import and usage of tobacco’, they no longer had the close connections with the industry of previous years and were unable to help, although her new informant ‘personally would not be so definite’ as Selby-Boothroyd about the lack of bias towards young people.
At that stage, however, the Ministry of Health press office was advised by advertising industry sources that ‘the inclusion of young people in the advertisement visuals does not restrict the appeal of the advertising to the young’ and that under half of those aged 16-24 were ‘regularly exposed to commercial television’. ‘In summary,’ wrote the press office informant, ‘I should say that such evidence as we have confirms the Board of Trade view that advertising is pointed indiscriminately without age bias. Its aim is to establish brand loyalties – smoking is so firmly accepted as an adult practice that the tobacco manufacturers see no need to suggest to the young that it be followed but try only to influence the selection of the brand, and this is equally important at all ages.’ This argument, promoted by tobacco and advertising industry sources to this day, was taken as the last word: on 1 March, Mrs O’Brien minuted: ‘This matter can now rest . . . I am satisfied that the view that the advertising of the cigarette manufacturers is directed specifically at young people is a matter of conjecture and not of known facts . . .’
The narrow focus and perfunctory analysis of this, the most intervention-inclined episode on the Ministry’s files for many years, contrasts sharply with a perceptive and well-researched eight-page critique of Government policy with proposals for action that the Scottish Office Health Department submitted to its Ministers (and copied to the Ministry of Health in London) just three months later.
The memorandum’s author, T D (later Sir Douglas) Haddow, secretary of the Scottish Department of Health (and later Permanent Secretary at the Scottish Office), started by quoting evidence from polls and prevalence surveys, summarised thus:
In short, Government policy has apparently succeeded to the extent that it aims to let people know about the possibility of a link between smoking and lung cancer. It has partially succeeded to the extent that it seeks to persuade them to believe that smoking may cause lung cancer. It has failed to the extent that it might have been hoped that the spread of knowledge would reduce the percentage of people who smoked or who started to smoke.
He expressed sympathy with local authorities’ doubts about their ability to compete with the ‘high-pressure publicity efforts of the tobacco manufacturers’ in the absence of strong Government support.
He then quoted WHO figures showing Scotland in first place in a league table for incidence of lung cancer (and England and Wales in second place), referred to the increase in deaths from lung cancer in Scotland, now accounting among men for ‘1 in 15 of all deaths compared with 1 in 34 in 1950′, and the lack of any prospect for a cure for a disease which in 80% of cases was fatal within a year of diagnosis.
He produced a series of sharp criticisms of ‘the present policy of encouraging local authorities to put the facts before the individual and leaving him to decide what to do’, including that ‘people are not usually adult and responsible when they start smoking’; that ‘to some extent smoking is a drug addiction’ which people could not quit; the overwhelming disproportion of tobacco advertising compared with publicity against smoking, and the evident lack of wholeheartedness of the official campaign.
Saying that ‘the evidence against cigarette smoking is certainly no less conclusive than that on which public health action has often been based in the past’, Haddow then considered whether a major publicity campaign should be directed only at the young or at the whole population, rejecting the former because lung cancer would be a very remote threat to the young, who might act in defiance of the campaign to ‘demonstrate resistance to adult authority’, while even if successful it would take 20-30 years to affect the lung cancer rate. Besides, there was evidence that people who quit smoking at any age reduced their risk of developing the disease.
He proposed a £1 million campaign directed at the general public – ‘on the scale of ‘drinka pinta milka day’ – which, rather than being expected to reduce consumption greatly by itself, would have as its prime purpose to ‘create a climate of opinion in which other action, notably fiscal action, might be possible’, for ‘it is doubtful . . . if any very large cut in consumption would be made unless the price of tobacco was also raised considerably.’ In 1947 a tax-induced price increase from 2s.4d. to 3s.4d. per packet had cut consumption by 15%, but now the price was substantially lower in real terms than after that increase in 1947. A 50% increase in tax that resulted in a 30% cut in consumption would still produce an extra £42m. annually, compared with which the cost of the publicity campaign would be small.
The support of the medical profession would be vital and he proposed that its members and Government Ministers should be advised themselves to stop smoking to show the seriousness of their intent. He recognised the political difficulties of his proposals and that there might be some loss of employment in the tobacco industry, but asserted the primacy of tackling ‘one of the most important health problems now before us’.
Such clarity of thought (parts of the memorandum could well have been written today) undoubtedly came as a shock to Ministry of Health officials and Medical Officers, who immediately set about neutralising it. Mrs O’Brien proposed that the Scottish Office be warned that ‘we would not dismiss as lightly’ as they the efforts of local health authorities, ‘a trickle’ of annual reports from whose Medical Officers of Health was arriving, which would enable them to review whether more should be done. ‘We have continued to turn over in our minds what more might be done’ but the Scottish ideas were ‘a very big advance from the present policy’. Dismissing controls on advertising (which the Scottish Office had not proposed), she called their tax proposals
quite unrealistic politically and economically. It is one thing to use an increase in tobacco tax for revenue raising or as a regulator, for economic reasons, of the productivity of the industry. It is quite a different matter to seek to disturb the economic structure of an industry to regulate a social habit, however unhealthy it may be.
She asserted that the ‘mammoth publicity campaign’ would fail to soften up public opinion while the fiscal measures would ‘mobilise the opposition of a powerful industry. . . Moreover, the [Scottish Office] paper makes no reference to . . . .the effect on national production of depriving workers of tobacco’.
Instead, she tentatively suggested two alternative approaches: advice by the Ministry on how to quit smoking (‘I realise that this is liable to raise loud horse laughs from the public but if we were to back it up by the promotion of research for a drug to facilitate the breaking of the habit this approach might carry more conviction’) or ‘a public pronouncement by the Minister openly condemning the consumption of cigarettes as the cause of disabling and ultimately fatal respiratory diseases and lung cancer . . . This goes a great deal further than anything that has yet been said but can be fully supported by medical evidence’. Against this she added in manuscript: ‘But I suppose that it follows from this that all officials of the Ministry would have to set a good example!’
Her boss, the undersecretary J P Dodds, invited the views of the Ministry’s medical and public relations branches. R Goulding, a Senior Medical Officer, commented on the Scottish policy proposals to Dr Goodman, who had been appointed Deputy Chief Medical Officer in 1960: the Scottish approach ‘is certainly a bold one but of doubtful practibility (sic) . . . Before any bold step is taken the backing of the medical profession must be secured and there are still numbers, perhaps a majority of doctors who are not sufficiently convinced that the evidence against tobacco is strong enough for preventive action to be taken, though I feel that a positive statement from the Minister (not the M.R.C.) might help many to resolve their doubts . . . I am convinced that a considerable increase in price would do more than anything else to cut down consumption but that the pressure to do this should come from unattached scientific bodies and from the weight of the medical profession (has the B.M.A. any policy on this question?) and not from any official sources.’ Before producing his own comments, Goodman asked Goulding: ‘Is there – or is there likely to be – any drug which has a significant effect in helping people to stop cigarette smoking? (Short, of course, of a big dose of potassium cyanide.)’, getting the prompt reply: ‘As yet, and in the foreseeable future, not a hope.’ Goodman then produced his comments:
We have been holding our hand (a) to make sure that diminution in smoking would not come about through the present Government policy . . . [I]t is clear that this has not happened. (b) To await some new report, or pressure from outside, which might give a peg on which to hang an initiative.
No new research since 1957 had served this purpose, but the report from the Royal College of Physicians committee was expected in October, and
there might be merit in awaiting its publication, particularly if we can get the R.C.P. [as against its committee] to make a pronouncement . . . We had also been hoping – quite vainly – that a change in social habits or an increase of taxation on tobacco for other reasons might have had an effect; or that a natural decline in the disease might occur.
Such whistling down the wind having failed, Goodman proposed several concomitant lines of approach: a publicity campaign such as the Scottish Office proposed; ‘a large increase in tax’; ‘increased pressure to prohibit smoking’ in places where it was not allowed in other countries – a matter for local authorities and private concerns; ‘provision of, and research on, ways to help people give up smoking’ (although a ‘deterrent drug’ was unlikely); and publicising Doll and Hill’s finding ‘that the lung cancer rate is reduced if heavy cigarette smoking is given up even after long periods’. In addition, he suggested:
Since cigarette smoking is known to be more harmful than pipe or cigar smoking, a switch might be effected – with the aid of the pipe manufacturers? i.e., don’t be cissy and smoke cigarettes; top people smoke a pipe. (Does the Queen smoke?).
Such a mixture of stray good sense and nonsense from one of the Ministry’s key scientific staff contrasts sadly with the professional analysis from Scotland.
From the Public Relations division, Heald produced one of a long line of mildly sceptical but reasonably professional memoranda on ways to run an effective campaign. He was doubtful about tax increases: ‘although there is an initial fall in consumption . . . the tobacco addicts soon find the money again. Most of [the young] seem to have money to burn.’ As to advertising, ‘it would be difficult in principle to justify a selective ban on tobacco advertising without treating alcohol in the same way, although pressure might be exerted to control the form of advertising.’
Summarising, he wrote: ‘Example has more influence than publicity’, while no publicity campaign ‘will have any effect unless the facts can be clearly, simply and forcefully stated without qualifications (which simply provide loopholes for argument and doubt).’ However, with such clear advice ‘to the young, not to start; to smokers, it is not too late to give up or at least (as a first step) to reduce smoking to not more than a packet a day; to parents, doctors, teachers and organisations, to set a good example in public and especially with the young, then not only will some effect be produced, but the Ministry can feel that it has done all that is reasonably possible and effective in tackling a most difficult problem in regard to which the decision must rest with the individual; in the light of his knowledge and appreciation of the facts and the risks involved (just as he decides whether to fly, or to cross the road in the face of traffic.’
With this internal exchange of views, the Scottish proposals were put on the shelf pending the report from the Royal College of Physicians. Early in September, Mrs O’Brien seems to have discussed possible actions with J P Dodds, but he minuted her ‘We agreed that there is nothing useful to be done before the R.C.P. report becomes available’, and there is then a series of minutes enquiring when the report is to be published.
There was a new approach at this time from the Tobacco Manufacturers’ Standing Committee. Geoffrey Todd, now its Director, arranged to see Sir Bruce Fraser, the new Permanent Secretary, ‘in order to explain . . . what the manufacturers are doing in the way of research. He does not wish to broach any new grounds or argue a case.’ A briefing from an unidentified medical officer says:
Research activities of the T.M.S.C. appear to have been instituted rather as a defensive programme . . . [An aide-memoire by Todd] rather emphasise[s] the, not unnaturally, biased approach to the subject which is apt to make one slightly hesitant to accept this research project as purely disinterested.
Todd followed up his (unminuted) meeting on 4 August 1961 with a letter to Sir Bruce proposing that the TMSC entertain him and his Minister, now Enoch Powell, to lunch. This led to a flurry of minutes on the file which established that there was no precedent for such a meeting, despite a suggestion by Todd to the contrary. Officials surmised that the request was probably stimulated by expectation of the Royal College of Physicians report, and the Minister was advised to decline the invitation. He did so in a letter of 30 August, alleging an over-full diary.
Six weeks later, Todd was chasing for a reply to a proposal that blood donors be asked whether they smoked, so as to enable an investigation of a possible genetic connection between smoking and a blood group antigen, suggested some years previously by Sir Ronald Fisher, the TMSC’s scientific adviser. Dr Goodman noted: ‘I know Fisher and his work and I know Todd personally. The latter is relatively harmless but the former is an enfant terrible who is dangerous because of his statistical eminence.’ The suggestion was therefore refused.
Todd, however, was still pursuing his personal meeting with the Minister. A letter of 26 October from Martin Madden MP to Powell forewarns him:
I thought you might like to know that we have invited Mr and Mrs Geoffrey Todd to join us at dinner on Thursday 2 November. Geoffrey Todd is the Director of the Tobacco Manufacturers’ Standing Committee which deals with smoking and cancer. The Todds are old friends and your common interest did not occur to me at the time.
I am certain that Geoffrey Todd will not introduce his ‘shop’ unless you want to encourage him . . .
It is unlikely, however, that Todd would have gained much from an encounter with Powell, whose powers of analysis would easily have seen through industry prevarications. Indeed, Powell’s impatience with slack thinking was soon exercised – but on woolly thinking in the RCP report, not on some industry special pleading.
1. PRO file MH 55.2224 [back]
2. PRO file MH 55.2224 [back]
3. PRO file MH 55.2203 [back]
4. PRO file MH 55.2224 [back]
5. Smoking and Lung Cancer – The Conflict of Opinion, Tobacco Manufacturers’ Standing Committee, London, December 1957. The most quoted expert, with 17 citations, was Dr Ian Macdonald, of the University of Southern California School of Medicine. Dr Milton Rosenblatt, of New York Medical College, was cited nine times, and Dr Harry Greene of Yale University School of Medicine, eight times – PRO file MH 55.2232. [back]
6. Smoking and Lung Cancer – Interim Report, Tobacco Manufacturers’ Standing Committee, London, December 1957 – PRO file MH 55.960. [back]
7. The Daily Telegraph reported on 20 January 1959 that grants from the Tobacco Industry Research Committee had reached a total of £1,142,850 – PRO file MH 55.960. [back]
8. This and the following items are found on PRO file MH 55.960. [back]
9. PRO file MH 55.2203 [back]
10. H.A.(59)18, 11 March 1959 – PRO file CAB 134.1977. [back]
11. H.A.(59)Th, 20 March 1959 – PRO file CAB 134.1976. [back]
12. Previously Medical Officer of Health in Essex – see chapter 1, note 8. [back]
13. Mentioned in Dirty Business, by Peter Pringle, Aurum Press, London, 1998 – an excellent overview of the tobacco industry conspiracy, especially in the USA, that started in the 1950s and has only recently come unravelled. [back]
14. A Counterblaste to Tobacco, London 1604, reprinted in facsimile 1969 by Theatrum Orbis Terrarum Ltd, Amsterdam, and Da Capo Press, New York.
15. Personal communication, 19 January 1998.
16. The letter is dated 18 January 1959 but the context makes it plain this was in error for 1960 – PRO file MH 55.2226. [back]
17. An undated note on the file (probably March 1960) shows the following sales of CCHE materials on smoking for the entire period 1956-59 (with the rider that only in 1958 were all items available throughout the year): two different pamphlets: 196,000 and 43,000; bookmarks: 364,000; five different posters: 19,000, 3,000, 12,000, 2,000, 10,000. – PRO file MH 55.2226. [back]
18. PRO file MH 55.2227 [back]
19. One way they did so was apparently to keep the Scottish memorandum from George Godber, now Chief Medical Officer: his first knowledge of it was when he read the draft of the present work. (Personal communication, 19 January 1998). [back]
20. At about this time, the Medical Research Council files reveal their Committee on the Aetiology of Lung Cancer being consulted by Austin Bradford Hill and Richard Doll ‘on whether they should extend their prospective survey of about 40,000 members of the British medical profession, begun in 1951, beyond the 10-year limit now approaching. For the survey to maintain its value in relation to the aetiology of lung cancer it would be necessary to make arrangements for requestioning the participants about every five years and this was a heavy task. The Committee were unable to offer any positive advice since while they thought the prolongation of the survey might yield interesting information, they could not be sure that the labour involved would be proportionate to the value of the results.’ – PRO file FD 1.7792. In the event, of course, the research continued, and Richard Doll, with his new collaborator Richard Peto, was gloriously able to publish in 1994 his forty-year follow-up report, showing that regular smoking kills about half those who indulge in the habit and does so through at least 24 diseases – BMJ 1994; 309: 901-11. [back]
21. PRO file MH 55.2227 [back]
22. PRO file MH 55.2232. The same short note states how valuable the TMSC’s statistical papers were proving – the industry, however, discontinued publication of them after 1985, when economic analysis of tax increases was becoming more prominent in tobacco control and Treasury thinking. [back]
23. PRO file MH 55:2232 [back]