The legacy of the tobacco colossus Richard DollBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7311 (Published 14 November 2012) Cite this as: BMJ 2012;345:e7311
- 1McCusker Centre for Action on Alcohol and Youth, Curtin University, Perth, WA, Australia
- 2Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia
In early 1947, Austin Bradford Hill suggested that Richard Doll, who was then a smoker, should be recruited to work on a study of smoking and lung cancer. He described Doll as “a very good worker to whom it is well worth while giving a wider experience of medical statistical work with an eye to the future.”1
In 1950 Doll and Hill published their initial findings in the BMJ (delayed for a year by faint hearts at the Medical Research Council),1 2 and Doll went on to become the tobacco colossus. Others had, as he often acknowledged, published important work. In a linked study (doi:10.1136/bmj.e7093), Sakata and colleagues examine the impact of smoking on overall mortality and life expectancy in Japan using data from a large population based cohort recruited in the same year as the first Doll and Hill publication.3
Countless scientific papers and reports on the many harms of smoking were published in the decades after 1950. In 1962, a BMJ editorial observed that “the causative link between cigarettes and lung cancer is undeniable, and no amount of statistical casuistry has been able to undermine the case presented in the BMJ more than 11 years ago by Dr Richard Doll and Professor (now Sir Austin) Bradford Hill.”4 In 1990 a US surgeon general said, “It is safe to say that smoking represents the most extensively documented cause of disease ever investigated in the history of biomedical research.”5
The first of Doll and Hill’s papers is now rightly seen as the foundation of modern action against smoking, and Doll is recognised as the crucial figure in identifying beyond doubt the dangers of smoking. Doll continued to generate tobacco focused publications for an amazing 55 years, first in association with his mentor, Hill, and later mainly with his great protégé, Richard Peto. Their research confirmed the importance of smoking as a cause of lung cancer and other diseases, its magnitude as a national and global problem, and the benefits of quitting. In publications such as The Causes of Cancer, Doll and Peto set out clearly the importance of smoking as a national preventable problem.6 Doll’s final publication on smoking was in 2005,7 the year of his death, although his epidemiological work with others is still being published today.
Action to prevent smoking has been depressingly slow. The brakes have been applied in large part by the malign influence of tobacco companies and by hesitant or obstructive bureaucrats, whom Doll also blamed for lack of action.1 In 1950, however, Doll acknowledged that 85% of middle aged men smoked regularly and “people found it hard to believe that smoking could be an important cause of disease.”1
Doll’s initial work, followed by the seminal British doctors’ study, provided incontrovertible evidence on the dangers of smoking.7 8 It also stimulated the first Royal College of Physicians’ report on smoking in 1962 and the first US surgeon general’s report in 1964. Many reports by national and international governments and health agencies followed, with calls for action becoming ever stronger.
Interestingly, Doll was initially cautious about becoming involved in advocacy (adopting Hill’s view that the researcher “had no part to play in telling the public about those results, and still less in how it should behave”).9 However, later he became forthright on the need for action. In 1978 he wrote to the chancellor of the exchequer in support of increases in tobacco tax. His scientific publications were written in a style and with conclusions that were likely to draw attention. He often spoke at conferences around the world and adapted to the world of modern media interviews, understanding the value of a powerful quote. He testified in cases against the tobacco industry,10 and he accepted the position of president of Action on Smoking and Health (ASH).
Each year more than five million people around the world die from diseases related to smoking. Failing further dramatic interventions, smoking will hasten the deaths of one billion people this century.11 But smoking has declined dramatically over time in developed countries, and we now have encouraging indications that the increase in smoking is halting in lower and middle income countries. Michael Thun, chief epidemiologist at the American Cancer Society, commented that the drop in rates of lung cancer after reductions in smoking over the past half century accounted for about 40% of the decrease in overall deaths from cancer in men during 1991 to 2003. Without reductions in smoking there would have been almost no reduction in overall mortality from cancer in men or women since the early 1990s. As Thun noted, the payoff from past investments in tobacco control has only just begun. 12
Doll’s work has helped to prevent tens of millions of deaths. As momentum gathers for further action on tobacco control through the World Health Organization Framework Convention on Tobacco Control now ratified by 176 nations, Doll’s legacy will only increase. It is a travesty that he never won the Nobel prize for medicine.
Cite this as: BMJ 2012;345:e7311
Competing interests: Both authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; MD is honorary president of the Australian Council on Smoking and Health and SC is an honorary board member of ASH (Australia).
Provenance and peer review: Commissioned; not externally peer reviewed.