The connection between smoking and lung cancer produced public health campaigns that incorporated persuasion as well as legislation.
Tobacco had been used in the Americas for centuries before travellers introduced it to Europe. It first reached England in 1565—but the new pursuit of tobacco smoking wasn't popular with everybody. In 1604, King James I wrote 'A Counterblaste to Tobacco', which dismissed smoking as 'loathsome to the eye, hateful to the nose, harmful to the brain [and] dangerous to the lungs'.
Smoking becomes an established habit
Throughout the 1600s, demand for tobacco continued to grow. It was said to have medicinal as well as recreational value and it was even used to ward off the plague. In much the same way as burning incense, the pungent smoke was thought to protect against the toxic fumes of 'miasmas'—based on the belief that diseases were caused by airborne vapours, characterised by their foul smells. At the height of the plague, smoking was actually made compulsory at the elite boys' school Eton College.
By the 1700s, most tobacco came from American plantations, where slave labour ensured a cheap and plentiful supply for European markets. The ready availability of tobacco was reflected in the steadily increasing size of British clay pipe bowls.
The use of snuff, a powdered form of tobacco that was inhaled into the nasal cavity, grew during the 1700s and further increased imports. But there were voices of dissent. In 1761, London physician John Hill performed possibly the first clinical study into the effects of tobacco and warned snuff users that they were vulnerable to cancers of the nose.
However, throughout the 1800s pipe smoking was a broadly accepted social habit, even though the medical journal The Lancet was publicly debating the health effects of tobacco in the 1850s. Significantly, the Regulation of Railways Act passed the UK parliament in 1868, mandated for the provision of both smoking and smoke-free carriages.
The rise of smoking
Until the end of the 1800s, cigarette smoking was rare. Cigarettes were handmade luxury items and accounted for a tiny fraction of tobacco sales. But in the latter part of that century, automated cigarette-making machines made them affordable and transformed the tobacco market.
This lucrative new market was fully exploited, but concerns about smoking persisted and the Children's Act of 1908 included a clause forbidding the sale of tobacco to under-16s.
By the end of the First World War (1914–18) cigarette sales had exceeded those of pipe tobacco. And where pipe smoking was seen as a male preserve, cigarette marketing was targeted at both men and women. It's estimated that by 1949, 81% of men and 39% of women smoked.
The link between smoking and illness
While excessive smoking was discouraged, its apparent benefits as a stress-reducing pleasure generally outweighed major concerns. Vague associations with illness were well known—one slang term for cigarettes was 'coffin nails'.
But during the 1900s, links to lung cancer began to emerge. As early as 1912, American doctor Isaac Adler had reported an increase in levels of lung cancer, although there was some debate about whether this was simply due to improved diagnosis.
By the 1940s the rise in incidents of lung cancers was confirmed. In the UK, epidemiologist Richard Doll (1912–2005) joined a team led by Austin Bradford Hill, who were investigating possible causes for the increase in lung cancers across the country.
Pollution—possibly coal smoke or car fumes—were thought to be the most likely factors, but close analysis of the statistics highlighted a correlation with smoking. Hundreds of newly diagnosed cancer patients had been interviewed, and those diagnosed correctly were almost invariably smokers.
The doctors survey
Doll and Hill's initial findings were met with scepticism. They followed these up in 1951 with the launch of the doctors survey, in which a questionnaire on smoking habits was sent to all registered British doctors. Because of the limited sample size and limited tobacco consumption, the study was focused on male doctors.
In 1954 they published the initial findings of this survey. It 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 heavy smokers. The incidence in non-smokers was negligible.
Their research on the smoking habits of the nation's doctors convinced most remaining sceptics. It also prompted the government to respond. The British Minister of Health Iain Macleod held a press conference at which he chain-smoked throughout, but he conceded that a link between smoking and lung cancer had been proven.
Public health campaigns
So began the slow decline of smoking in Britain, accompanied by a long battle of wits between the tobacco industry and health campaigners. The government was cautious about the economic implications of a decline in tobacco revenue and did not wish to appear over-protective. So despite mounting evidence throughout the 1950s, its own health campaigns did not swing into action until the mid-1960s.
Smoking was considered a lifestyle choice rather than an environmental factor over which people had no control. As such, public health strategies initially focused on education and persuasion rather than legislation and compulsion, although progressive tax rises made it an increasingly expensive habit.
Tobacco manufacturers and advocates of smoking framed it as a civil rights rather than a health issue, while also disputing the medical evidence with experts of their own.
Anti-smoking campaigners had an uphill struggle to counter decades of slick, seductive advertising presenting smoking as a cool, sophisticated pleasure. If existing smokers could not easily be persuaded to give up smoking, then they wanted to ensure that the next generation should not be seduced by this image of smoking.
In 1962, the Royal College of Physicians' report 'Smoking and Health' made recommendations for the restriction of tobacco advertising, further checks on the sale of tobacco to children and smoking in public places. They also called for clearer information on the tar and nicotine content of cigarettes.
However, it wasn't until 1971 that a voluntary agreement with tobacco companies introduced health warnings on tobacco products.
In the 1980s, evidence established the dangers of passive smoking and this changed the whole approach to smoking in public spaces. People, and especially children, who did not smoke were being put at risk by inhaling other people's smoke.
Various bans were introduced in the UK over subsequent years. Beginning with voluntary workplace bans, these measures progressed through compulsory public transport bans to the 2006 and 2007 legislations which outlawed smoking in all enclosed public spaces.
In the UK and other Western countries these measures contributed to a decline in smoking. But in other parts of the world, where the health risks of smoking are less emphasised, tobacco sales continue to increase, as do the many smoking-related health conditions.
Suggestions for further research
- Adler, Isaac A. 'Classics in Oncology: Primary Malignant Growths of the Lung' in CA: A Cancer Journal for Clinicians, Volume 30, Issue 5 (Sept/Oct 1980)
- Oreskes, N and Conway, EM; Merchants of doubt: how a handful of scientists obscured the truth on issues from tobacco smoke to global warming; Bloomsbury Press, 2010.
- R Doll and A B Hill, Smoking and carcinoma of the lung. Preliminary report, British Medical Journal, 2 (1950), pp 739-48
- R Doll and A B Hill, ‘The mortality of doctors in relation to their smoking habits’, British Medical Journal, 1 (1954) pp 1451-5
- I Gately, Tobacco: A Cultural History of How an Exotic Plant Seduced Civilization (New York: Grove Press/Atlantic Monthly Press, 2003)
- M Hilton, Smoking in British Popular Culture, 1800–2000 (Manchester: Manchester University Press, 2000)
- S Lock, L A Ramsey and E M Tansey (eds) Ashes to Ashes: History of Smoking and Health (Clio Medica 46), (Amsterdam: Editions Rodopi B V, 1998)
- S Milov, The Cigarette: A Political History (Cambridge, Massachusetts: Harvard University Press, 2019)
- X Zhou and S L Gilman, Smoke: a Global History of Smoking (London: Reaktion Books, 2004)
- The Tobacco Atlas (6th edition, 2018)