Intended for healthcare professionals


Smoking and lung cancer—70 long years on

BMJ 2024; 384 doi: (Published 20 February 2024) Cite this as: BMJ 2024;384:q443
  1. Nicholas S Hopkinson, professor of respiratory medicine
  1. Imperial College London

Last week was the 70th anniversary of the UK government’s acceptance that smoking causes lung cancer.1 Cases of this previously rare disease had risen 10-fold since the end of the First World War, and epidemiological work by Richard Doll and Austin Bradford Hill had put the role of smoking as a cause beyond doubt.23 The health secretary Iain Macleod famously chain-smoked his way through the press conference. Macleod, considered to have coined the term nanny state to ridicule the “perishing nonsense” of speed limits on motorways, died of a heart attack at the age of 56 in 1970.4

In 1954, around 80% of men and 40% of women smoked, yet the actual policy response to this newly understood risk, and other health harms due to smoking including tuberculosis, bronchitis, and blindness was, to say the least, rather muted.56 The chancellor of the exchequer commented: “We at the Treasury do not want too many people to stop smoking.” Although smoking rates are much lower now, progress to get here has been painfully slow—in 1971, an approach based on voluntary agreement with the tobacco industry was still being taken, and the first Government Tobacco Control Plan “Smoking Kills” was not published until 1998, an astonishing 44 years later, with around 30% of adults at that point still smoking.78

Two bad ideas linger around the story. The first is that, in a country where 4.2 million (or nearly 3 in 10) children live in poverty, the suggestion that we are subject to anything approaching an over-protective nanny state is ludicrous.9 The second is the sense that smoking is somehow an economically productive activity, or that it at least pays for itself through taxation. However, smoking doesn’t just kill two out of three long term users.10 When the health and social care costs of premature disease and disability, the loss of economic productivity, and the expenditure of money in a way that has a much lower economic multiplier are taken into account, the cost to UK GDP, estimated at around £89.3 billion/year, far outweighs the tax take from tobacco sales of around £11 billion.11

It has taken a lifetime to get here. A delay accompanied by millions of premature deaths.12 Perishing nonsense indeed. But a tobacco endgame is in sight, with policies to raise the legal age of sale for tobacco products incrementally and create a smokefree generation now on their way through parliament with cross-party support.13


  • Competing interests: NSH is chair of Action on Smoking and Health ASH(UK), and medical director of Asthma+Lung UK.

  • Provenance and peer review: not commissioned, not peer reviewed.