|Sir Richard Doll: Smoking Research Pioneer||To Smoking and Health theme page|
3. Additional Information:
The Guardian Weekly newspaper published the following story in May, 2005, in recognition of Sir Richard Doll's contributions to research on the occasion of his "retirement" at the age of 92.
Blowing smoke rings
It is hard to say precisely how many lives Sir Richard Doll has saved in his career, but a million may be considered a conservative estimate. The true figure probably lies in the steel filing cabinets in his small office at the Radcliffe Infirmary in Oxford, or among the stacks of medical journals that surround him, soon to be packed in crates and transported to a sparkling glass and concrete home in a different part of the city. Sir Richard does not plan to visit the new building very often — he doesn't drive, and it isn't within walking distance. There is, therefore, a certain irony in the fact that the unofficial retirement, at the age of 92, of one of the greatest medical detectives in the world will be caused by the opening of the building that will proudly bear his name.
The Richard Doll Building, in Headington, on the outskirts of Oxford, will house several research and medical departments whose work over the past half-century has been significantly influenced by Professor Doll's endeavours. Professor Doll did not set out in life to be a medical statistician in search of the causes of disease, but he will leave the profession as its most famous British practitioner. He has studied diet, radon gas, HIV, ulcers and radioactivity, but he will be widely remembered for just one thing: as the man who proved that smoking causes lung cancer.
He did not achieve this feat alone, and it has taken 50 years to complete the study, but his work bears comparison with the greatest discoveries of the modern age. Because the detrimental effects of smoking are largely self-inflicted, and because 90% of lung cancers are caused by smoking, Professor Doll's work amounts to a cure, albeit one notoriously difficult to self-administer.
Those who call on him for the first time may be struck by the fact that this slightly stooping elderly man with tweed jacket and a semi-halo of white hair is keen to meet visitors at the lift, and then prepare a drink for them with an old kettle in a corner of his office. No American medical institution would allow one of its stars to behave in such a way. There is no computer in his room, and a job dependent on complex comparative data and the constant flow of information is carried on much as it was when its occupier first made a name for himself in the early 50s. As for his emails, "At least 48 out of 50 of them are junk," the statistician says.
Richard Doll was born in 1912, at a time when smoking was just becoming popular. His father, who was a general practitioner near the family home in Hampton, Middlesex, promised his son £50 if he refrained from smoking until he was 21, not because he thought it was harmful, but because it was a waste of money. "I was determined to get it," Doll says, "but I had a brother, seven years younger than me, and whenever we had friends in the house he would say, 'Oh, Richard's not going to smoke until he's 21!' And I finally said, 'I can't stand this any longer — give me a cigarette.'"
He consumed two ounces of pipe tobacco a week and five cigarettes a day during his time as a medical student and an officer during the second world war.
The incidence of lung cancer had increased steadily throughout the 1930s, but no one knew why. Hospital beds filled up with people who arrived with choking coughs and soon graduated to emphysema and mouths full of blood. During the war this became the second-biggest cause of death after military action.
When the conflict ended, Richard Doll began working for the Medical Research Council (MRC) on the causes of gastric duodenal ulcers. But the MRC had also become concerned with the lung cancer rates, and had asked Bradford Hill, an epidemiologist at the London School of Hygiene, to conduct a brief study. Hill had become aware of Doll's patience and analytical skills and asked him to assist. At the time, the most likely cause of lung disease was believed to be atmospheric pollution. Doll's own hunch was that it was caused by the increase in the tarring of roads.
In 1949 Doll and Hill visited hundreds of patients in London hospitals who had been diagnosed with lung cancer or were suspected of it. Most patients exhibited symptoms before they were very ill, and were able to answer a detailed questionnaire. They were asked about their family history, diet and previous diseases, and whether they had worked on the roads. Doll then returned to the hospitals in the following months to examine their diagnoses. "The most striking thing was that if the person was a non-smoker, the diagnosis would always change," Doll says. "But if they were a heavy smoker it was usually lung cancer. It was changed occasionally, but not very often. In 649 cases of lung cancer there were two non-smokers."
Today we may regard these results as obvious and predictable, but the epidemiologists were astonished. German doctors working for the Nazis had suspected a link before the war, and other surveys in Britain and the US had voiced suspicions. But Doll and Hill's numbers were so striking that what others had regarded as an association, they could already claim to be a causation. Doll was so struck by the certainty of his research that he instantly gave up smoking. "It wasn't so difficult."
Others were harder to convince. In 1950, when the first survey was complete, the secretary of the MRC suggested that the results might apply only to London. Doll and Hill thought this unlikely, but agreed to spread their research to Cambridge, Bristol, Leeds and Newcastle. Now the records of 5,000 patients were examined. "And, of course, we got exactly the same results."
Then something strange happened. When the results were published in 1952, no one took much notice. The survey was still considered to be quite small, and the results seemed too simple. Even the most eminent health officials refused to believe that lung cancer was largely self-inflicted. "This wasn't a result of pressure from the tobacco industry," Doll says, "although they did make sure that if ever there was an article about it, it was accompanied by another one from a doctor who said that the link was a load of nonsense." The tobacco industry had an unusual ally. The cancer advisory committee of the Department of Health suggested a period of inaction. Doll remembers being told: "You shouldn't frighten people into thinking that smoking might be dangerous."
Doll and Hill thought there was little use repeating their survey among other lung cancer patients, so they chose another group of people whom the medical profession might regard as more reliable: doctors. In October 1951, the epidemiologists wrote to 59,600 doctors asking simple questions about whether they smoked, and, if so, when they began and how much they consumed — and 40,500 replied. They kept a close track of their health in the following years. By 1954 Doll and Hill were getting similar results to their hospital patients, and they published their first findings in the British Medical Journal.
The incidence of doctors dying from lung cancer was still small in 1954. This may explain why, once again, the findings failed to have much impact on the media and public. But some doctors began to take note, particularly the heavy smokers who believed their health was deteriorating and had witnessed the effects on their colleagues. The wise ones began to warn their patients.
Follow-up surveys continued to be returned to Doll and Hill, and by 1956 the results were unmistakable. More than 200 heavy smokers had died of lung cancer in a four-year period, whereas the incidence among non-smokers was negligible. Only in later years would the effects of passive smoking also be seen.
The Department of Health considered the results for a year. "They set up an inter-departmental committee to advise on what should be done," Professor Doll recalls. "This said — and I've seen the report — that it would be very serious if smoking was reduced, not because tax would decrease, but because they like people to die off at 65 to save their pensions. The committee was chaired by the Treasury. And as a result it was decided to do nothing." But in 1957 the Department of Health did call a press conference to share what it regarded as potentially worrying news. "And the minister who announced it", Doll remembers, "was smoking a cigarette at the same time."
Doll drinks his coffee with a steady hand. As far as he's aware, coffee has no long-term detrimental effects, although the evidence is conflicting. He has other things to worry about. His hearing is still excellent, but his eyesight is failing. "My brain is not as sharp as it was," he says. "I certainly don't feel I can keep up, which is why I'm pulling out. People ask me to referee things, and I don't really feel now that I have adequate knowledge of developments in cancer biology. But I still feel up to date with the epidemiology." His wife died three years ago, "which limits one's life substantially".
When their first report was published, Doll and Hill held a meeting with three representatives from the cigarette companies, and the smokers maintained that lung cancer was caused by the fumes from cars and under-regulated factory emissions.
By 1957, the year after Doll and Hill published their second and more substantial report, the civil mood of that first meeting had changed. The message received by the public was confused, and a process of claim and counter-claim persisted for more than a decade. It wasn't until 1970 that the media became convinced, resulting in great increases in the amount of smokers quitting and the first social shift in the treatment of smokers as pariahs. By then, of course, it was clear that smoking did a lot more than just cause cancer of the lung.
(. . .)
"Richard Doll's influence has been massive," Professor Jeffrey Tobias, a consultant oncologist at University College London Hospital, said. "He has the most remarkable tenacity, and he continues to make highly valuable contributions." Tobias, who chairs the Tobacco Advisory Group at Cancer Research UK, calls it a scandal that Doll has not been awarded the Nobel prize for medicine. "If the prize is intended in a Benthamite way to honour a person who brought the greatest happiness to the greatest number, then I cannot imagine there is an individual on the surface of the planet who is better qualified or more deserving."
I brought it up towards the end of our meeting, and for the first time he seemed a little uncomfortable. "I know I have been nominated for it, but it didn't get any further than that. It's not something I'm worried about. I've had more than enough recognition."
(. . .)
Doll's work on smoking came to an unofficial end last year, when, on precisely the 50th anniversary of his preliminary British Medical Journal paper of 1954, he and his colleagues published their final follow-up report. In all, 34,000 doctors had continued to take part in the 50-year study. The final report was no longer concerned with causation, but with comparative mortality rates between smokers and non-smokers. Men born between 1900 and 1930, who smoked only cigarettes and continued smoking throughout their lives, died on average about 10 years younger than lifelong non-smokers. Those who gave up at age 60, 50, 40 or 30 years gained, respectively, about three, six, nine or 10 years of life expectancy. Cessation at age 50 halved the risk of contracting lung cancer, and stopping at 30 avoided almost all of it. The study also exposed the extent to which smoking hastened the onset of many other fatal diseases. Indeed, lung cancer accounted for less than half of the comparatively early mortality among smokers.
But Doll's greatest legacy lies among the statistical files and graphs at Cancer Research UK. Here, there is clear evidence that the decrease in smoking from the 70s onwards has had a distinct impact on both incidence and mortality. Cancer Research UK estimates that 6.3 million people have died from smoking-related diseases in the past half-century. The good news is that the figures are falling. The percentage of adults who smoke cigarettes in the UK fell from 45% in 1974 to 35% in 1982; today, just over a quarter of adults smoke. Undoubtedly much of the decrease has been caused by a combination of better education, higher tobacco taxes, restrictions on advertising and the partial ban on smoking in public places. When, in the mid-70s, Denis Healey became the first chancellor of the exchequer to announce that he was raising the tax on tobacco to discourage smoking, Doll sent him a letter of congratulation.
Doll was less impressed last year when the government failed to follow the example set in Ireland and ban smoking from all public places (rather than just those which serve food). But he has consciously never been a campaigner. "I've always believed that a research worker should not proselytise and should not concern himself with what was done as a result of his research," he told me. "It was your job to get the facts right, and if you say, 'You must do so-and-so because of this' you will then find it difficult to change your mind if you were wrong. Epidemiologists should publicise the research of other people, not their own."
Three years ago on the BBC radio programme Desert Island Discs, Doll said he had formulated a strategy towards health education: "Find out what the tobacco industry supports and don't do it, and find out what they object to and do it." He told the presenter Sue Lawley something that came as a surprise to those who knew him well. He said the effect of someone lighting up a cigarette in his presence "is so small that it doesn't worry me", a comment which some interpreted as a denial of the impact of passive smoking. In fact, he had just published a study from 12 European countries suggesting the opposite: it was estimated that non-smokers exposed to second-hand smoke are between 20% and 30% more likely to develop lung cancer. In other words, the damage first detected by a young doctor 55 years ago has turned out to be far worse than anyone imagined.
Sir Richard died in July, 2005. Here is a comment from the BBC news service.