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The smoking disease.

The causative link between cigarette smoking and lung cancer has been verified in a dozen different types of study, confirmed in more than a score of countries, and amplified in hundreds of reports since E. L. Wynder and E. H. Graham' in the U.S.A. and Richard Doll and (now Sir) A. Bradford Hill2 first established a thorough statistical basis for it. Links between smoking and many other diseases have since been detected with greater or less certainty. And reports digesting the research data have followed in profusion. They have undoubtedly influenced many people to give up smokingespecially doctors, who see its effects. But the enormous extent to which this habit continues, and especially its now fast growing prevalence among women, shows that information alone is not enough to deter many people from a course that may lead them to ill health in middle life and a premature death. Some 50,000 deaths a year in Great Britain may conservatively be attributed to the effects of smoking. If the ill health and deaths that tobacco smoking causes or largely contributes to were the result of an epidemic infection, the Health Department would spare no efforts to eradicate the infecting agent. But it is fair to say that no government agency in any country has tackled the smoking epidemic with the vigour it devotes to, for example, an outbreak of smallpox. One reason for this may be that the diseases caused by smoking are regarded as self-inflicted. By taking thought, it is argued, we can avoid lighting a cigarette. Or can we? To judge from the number of people who claim they tried to give up smoking but failed, the act of smoking seems commonly to be as much the symptom of a disease as does a smallpox papule. An appeal to reason is therefore unlikely to have much effect on people in the grip of an irrational, perhaps partly biochemical, mode of behaviour. But antismoking measures, whether they are special clinics, school lectures, or public advertisements, rarely get far away from the rational approach that comes naturally to the professional advisers who have hitherto inspired them. It may be significant that no large, national advertising campaign against smoking has been directed to the aim of showing that it is sexually unattractive and that to abstain from smoking is sexually rewarding. Yet this theme is familiar enough to professional persuaders. The new report from the Royal College of Physicians of London, published this week, deserves to be widely read.3 It sets out the facts clearly and gives voluminous references to published papers. For the medical profession in particular it provides a useful summary of information on the diseases now known to be associated with smoking-especially of cigarettes, but pipes and cigars cannot be wholly excluded. Apart from cancer of the lung (squamous-cell and oat-cell cancers) the diseases for which the evidence shows a causative link with cigarette smoking include chronic bronchitis and emphysema, coronary-artery occlusion, angina pectoris, cancers of the mouth, pharynx, larynx, and cesophagus, cancer of the bladder, and pulmonary tuberculosis. Among patients with peptic ulcer those who smoke have a higher death rate than those who do not, and a mother's smoking during pregnancy may retard the growth of the fetus. Following an earlier report4 from the royal college, the present one brings the information up-to-date and makes some fresh suggestions to counter the smoking epidemic. Here it becomes less convincing. In particular the present report's recommendation to establish smokingcontrol clinics, to be advised by a joint committee of the Health Department and the Medical Research Council, hardly seems realistic in view of the indifferent results achieved in the past by similar clinics with all the advantages of being staffed in the main by enthusiasts. The report makes sensible observations on the advice that individual doctors may give their patients and the example they set them, but many doctors have in fact been doing these things for years and the result has been little better than holding a deck-chair against a tidal wave. It is surely right, however, in criticizing a succession of Governments that have consistently refused the money to combat this epidemic by prolonged, contrivial action rather than brief Press campaigns, occasional posters, and snippets on television. Though Governments depend on the votes of smokers as well as non-smokers, any administration that had the courage to attack this epidemic on the scale required might be surprised at the support it would receive from the smokers who are the unwilling victims of their craving and ashamed of the example they set their children. The twin fears at Westminster of antagonizing voters and losing revenue must give way to confidence in planning a national campaign against a form of