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Sir Richard Doll

 
Epidemiologist who showed that smoking caused cancer and heart disease

William Richard Shaboe Doll, epidemiologist Medical Research Council 1946-69 and regius professor of medicine Oxford University 1969-79 (b Hampton 28 October 1912; q St Thomas’ Hospital Medical School, London, 1937; CH, OBE, FRS, DSc, MD, DM, FRCP, FFPHM), d 24 July 2005.

Sir Richard Doll was the world’s most distinguished medical epidemiologist. He established his reputation alongside Sir Austin Bradford Hill, showing that cigarette smoking caused lung cancer. He then went on to show it caused bladder and other cancers, and cardiovascular disease. He did seminal work with Richard Peto on the health of doctors and their families, demonstrating an increased incidence of suicide and liver disease. He also carried out major research on the risks and benefits of the contraceptive pill, on low level radiation, and the dietary treatment of gastric ulcers.

Doll went to work with Bradford Hill at the Medical Research Council in January 1948. Government statisticians had drawn the MRC’s attention to a huge recent increase in lung cancer deaths, and the MRC held a conference to decide whether the increase was real and, if so, whether a cause could be identified.

At the time, said Doll, smoking seemed a normal and harmless habit. Eighty per cent of men smoked. Doll and Hill both thought the most likely cause would prove to be pollution—smuts from coal fires were terrible in those days, but had been for decades, and the expansion of the motor industry had meant more tarring of roads, and more exhaust fumes. There was a known association of pipe smoking with lip cancer, but that was thought to be caused mainly by the heat of the pipe stem.

Doll and Hill designed a short questionnaire, administered by social workers, to 650 male patients in London hospitals. The interviewees were newly admitted patients with suspected lung, liver, or bowel cancers. To reduce bias, the interviewers were not told the suspected diagnosis. They also interviewed hospital patients with other diagnoses. After the proper diagnoses had been made, it was startlingly clear that those whose lung cancer was confirmed were smokers, and those who were given the all clear were non-smokers.

The results were so compelling and so unexpected that Doll and Hill took the results to the MRC head Sir Harold Himsworth, who advised them that the results might be peculiar to London, and suggested that they repeat the study in other cities. So they studied 750 similar patients in Bristol, Cambridge, Leeds, and Newcastle.

While they were doing this, they were beaten to publication in the Journal of the American Medical Association (JAMA 1950;143:329-36). Hill and Doll went to the BMJ’s then editor, Hugh Clegg, and the BMJ published their paper quickly (BMJ 1950;221(ii):739-48). Doll said later, "It was a principle that I have adhered to ever since: namely, that if you find something that is unexpected and is going to be of social significance you have a responsibility to be sure that you’re right before you publicise your results to the rest of the world. This does at least require repeating some of your observations."

The government took no action on smoking for several years, but Bradford Hill advised that it was the researchers’ job to report, not to campaign—otherwise they might get too attached to their conclusions. Instead, they tried to disprove their findings by doing a prospective study of doctors’ smoking habits—a cohort study to compare with the case control study they had already carried out. A similar study was done in the United States, sponsored by the American Cancer Society and carried out by a doctor who disbelieved Doll and Hill’s results.

This study of doctors soon showed that there was a strong association between smoking and lung cancer and also between smoking and cardiovascular disease. Although there were only 36 lung cancer deaths in the first 29 months of the study, after four years there were 200, almost all of them in heavy smokers. The incidence in non-smokers was negligible. Doll and Hill began publishing their results in the BMJ in 1954(BMJ 1954;228(i):1451-5).

It was not long before they were visited by two men from the tobacco industry—the chairman of Imperial Tobacco and his statistician, who disputed Doll and Hill’s findings. Five years later the statistician told his employers that unless they accepted that tobacco smoking caused cancer he could not work for them any longer. So they said their goodbyes, and the statistician made the last use of his expense account by taking Doll and his wife out to dinner.

William Richard Shaboe Doll was born in Hampton, Middlesex, the son of a general practitioner, and educated at Westminster School. He wanted to read mathematics at Cambridge but did badly on the entrance paper, having drunk too much of the Trinity College beer the night before. The admissions tutor rang his father and said he could have an exhibition but not a scholarship, so in pique Doll switched to medicine, which is what his father wanted him to do. He later said the Trinity ale was "the best drink I ever had." He then studied biology quickly and was accepted at St Thomas’ Hospital Medical School a year later, graduating in 1937.

During this time he became concerned with the rise of fascism and joined the student socialist society.

Doll wanted to do research after qualifying, but in 1937 this was impossible without either a private income or becoming a consultant and earning enough to do it in one’s spare time. So he spent six months as casualty officer and anaesthetist, and six months as a house physician, still at St Thomas’, for which he received free beer and free laundry, but no pay.

He then wanted to be a house physician at the Royal Postgraduate Medical School in Hammersmith, attracted by the research possibilities and the £100-a-year salary. Someone else had just been appointed for six months, but he was told he could have the job after that. Instead he took a night job as resident medical officer at the London Clinic, which needed someone because they advertised that there was always a doctor on the premises, day and night. The last thing any of the consultants wanted was for anyone else to see their patients, and he was called from his bed three times in six months. "This," he understated, "suited me very well." Meanwhile, he carried out research under the cardiologist Paul Wood at Hammersmith, attempting to find a method of assaying vitamin B12, and to find a cause for hypertension, which was then thought to be a unitary disease.

During the 1938 Munich crisis Doll had joined the army’s supplementary reserve, and a month after he finally went to Hammersmith as house physician war broke out and he was called up. He was in the army from 1939 to 1945, being posted to France and the Middle East. He worked in Egypt, Cyprus, and then back in Egypt, where he ran a ward for serious infectious diseases—diphtheria, typhoid, typhus, polio, and smallpox. Later he was posted to a hospital ship in the Mediterranean, and took part in the invasion of Sicily. He described these as some of the most enjoyable years of his life. Doll’s Dunkirk diary, detailing his experiences as a battalion medical officer in the retreat to Dunkirk, was published in the BMJ in 1990 (BMJ 1990;300:1183-6, BMJ 1990;300:1256-9, BMJ 1990;300:1324-8, BMJ 1990;300:1385-7, BMJ 1990;300:1449-52).

Doll contracted renal tuberculosis in the middle of 1944 and was discharged early in 1945 after a nephrectomy. He convalesced by working as a psychiatrist in an army hospital for six months. He later said psychiatry was too difficult for him: "I felt that one was putting oneself in the position of God and I wasn’t very good at it."

He returned to St Thomas’ as a junior medical assistant, and got on badly with the young doctors who held senior positions and who assumed that he knew nothing about medicine after five years in the army. Later, as more doctors were discharged from the army and jobs were in short supply, he disliked the levels of obsequiousness that were expected.

At that time—1946—his friend Dr Joan Faulkner, who later became his wife, was working at the Medical Research Council’s headquarters. The MRC was seeking someone to support the gastroenterologist Sir Francis Avery Jones, who was studying occupational aspects of ulcers at the Central Middlesex Hospital. Doll had meanwhile been taking a course on medical statistics at the London School of Hygiene and Tropical Medicine, and his resulting research was reported to a committee that included Sir Austin Bradford Hill, who was impressed. Doll went to work with Hill, thus starting the most important part of his career.

The 1950 BMJ paper on smoking and lung cancer was largely ignored by the public. Doll said that "if there was a report of it in the newspaper or on the radio, the reporter would always be careful to mention a doctor so-and-so—who had been put up to it by the tobacco industry—saying the research was controversial and the link wasn’t proved." Journalists smoked—even television presenters while discussing the report on camera—and newspapers earned huge amounts of money from tobacco advertising.

The Department of Health’s cancer committee was not convinced by the findings and thought that urging people to quit could start a mass panic. Finally, on 12 February 1954, the health minister Iain Macleod held a conference to announce that the government accepted the link. He famously chain smoked throughout the event.

The Royal College of Physicians brought out a report in 1962 that linked smoking and death, and this turned the tide of public opinion. The first politician to raise tobacco taxes was Denis Healey in the mid 1970s. Doll sent him a congratulatory letter.

The tobacco industry in the United Kingdom has continued to question the link. In 2002, in a civil claim brought by a Mrs Margaret McTear, whose husband had died of lung cancer aged 48 after smoking 60 a day since he was 9, Doll appeared as an expert witness, refuting the defence claim that the industry did not know of the association in the early days.

Richard Doll’s father had promised him, when he was in his early teens, £50 if he didn’t smoke until he was 21—not for health reasons but because he thought it a waste of money. However, Doll succumbed to pressure from his elder brother. He smoked two ounces of pipe tobacco a week and five cigarettes a day throughout his time as a medical student and when he was in the army. None of his teachers told him that smoking was harmful. He gave up when he discovered the association with lung cancer. Later in life he often pointed out, in interviews, that if people gave up immediately they could avoid most of the later risks of tobacco.

Doll worked for the Medical Research Council until 1969, meanwhile working part time with Frances Avery Hill. They had four beds for research purposes at the Central Middlesex Hospital, and during this time Doll showed that a bland diet was of no value in the treatment of gastric ulcers. He was also honorary associate physician at the Central Middlesex Hospital and taught medical statistics and epidemiology at University College Hospital Medical School. In 1969 he became regius professor of medicine at Oxford, retiring in 1979.

Green College Oxford was Doll’s conception. It was originally intended to be exclusively medical, but this met with opposition within the university and it is now partly non-medical. It was named after Cecil Green, founder of Texas Instruments, its main benefactor. One of its many achievements has been to incorporate many of the academic people in Oxford who had no formal links to the university.

Doll has received many awards and prizes. He was nominated several times for a Nobel prize. In 1971 he was knighted, and in 1997 he became a companion of honour.

He said that he had enjoyed every minute of his career. He was an easy man to get on with, greatly admired, well liked, and helpful to his juniors.

He remained well and productive until nearly the end of his life, apart from failing eyesight. In April 2005, when the new Richard Doll building opened in Headington on the outskirts of Oxford, he performed the topping-out ceremony but decided not to move his office there as the journey was difficult and he didn’t drive.

Earlier this month, aged nearly 93, he had a mild heart attack.

Predeceased by his wife, he leaves a son and a daughter. [Caroline Richmond]