Saturday, December 10 1999
David is the author of "Denial and Delay--The political history of smoking and health, 1951-1964 , Scientists, Government and Industry as seen in the papers at the Public Records Office (in Great Britain)". Thank you for taking the time to be with us and may I ask you to introduce yourself?
Yes - first: thank you for the invitation! I came into tobacco control at the age of 48, when I was made redundant after a 25-year career in the coal industry and applied for the post of director of Action on Smoking and Health (UK) and was appointed.
I was Director from 1991 to 1994 and I remain a member of the ASH advisory council.
Things were unrecognisably different then with almost no inside information from leaks from the industry and a government determinedly opposed to legislation. We gave priority to campaigning on tax and passive smoking, but we also collated all the arguments against tobacco advertising and supported a backbench bill to ban it - doomed, of course, but good propaganda.
At the end of my time with ASH - I am now the director of the Continence Foundation, a charity concerned with bladder and bowel problems - I spent a lot of time in the Public Records Office looking at all the papers on tobacco. Files were then open as far as 1964 - a convenient date, as it was the beginning of real attempts to curt smoking and the year there was a change of government.
1. Reading your book is - at first - a little discouraging because so much of the bureaucratic inertia you expose is still at work in many Health Departments over the world: you just have to cross the Channel (see what I mean?). One of the main lessons to be learned seems somehow for advocates to be very cautious about the many ways the Health Department(s) can ´ prevaricate and postpone any decisive action to discourage smoking ª. The documents you quote prove it but how do you explain this reluctance, this refusal to take action ?
In the period my book deals with, the case against tobacco was scientifically established but people remained to be convinced. Epidemiology was a science in its infancy and poorly understood, and people were reluctant to face a very unpalatable fact - after all, almost all men were smokers! Besides, there was the not unrealistic hope of a technical quick fix: it seemed quite likely that a single agent might be found that caused cancer and that it could be removed.
Not only that, but the idea of Governments advising people on life styles was entirely new then: it was seen by many as improper, and the British government explicitly decided that its role as far as adults were concerned was merely to publish information and leave them to decide. When they found that most people had heard of the claim that smoking was linked to lung cancer, they were happy to think their work was done!
Today things are different and it is much more difficult to pardon inaction.
2. The health ministers don't push the issue either (except one or two). The obvious culprits are the Finance Ministers (mostly concerned with tax revenues) but still: how come almost none of the Health Ministers comes forward ? are they so totally controlled by their own bureaucracy that remains in place while they never stay that long ?
Look at it in human terms. Health ministers are not powerful members of a government, they have careers to pursue, and they generally do not want to pick quarrels they cannot win. Tobacco, in the period I have studied, was a powerful, respectable industry with excellent connections - see how often their top people visited Ministers and the top officials in their departments. Tobacco tax supplied 14% of total tax revenue in the early 1950s and the Treasury was determined not to jeopardise this valuable income. And no-one (probably) outside the industry understood how addictive nicotine was (though the eccentric doctor at the start of my book had guessed it in the 1930s), so there was a very real fear that people would stop smoking en masse with disastrous results to the economy.
So the chance of winning in a confrontation with tobacco was poor, and governments until the 1960s chose not to make the attempt.
What was less forgivable was that health ministers did not make the case vigorously to their colleagues in other departments. No doubt they reckoned that they were only "passing through" health, so that it was tempting to leave an awkward topic alone. And they were under little pressure to act except from a few activist doctors! When it comes to political decisions, disease and death in the fairly remote future count much less than opposition and unpopularity in the present.
With all these mitigating factors, however, I think the people with
most to answer for are the medical officers in the health department in
the 1950s. They were the supposed experts and their job was to give
unbiassed expert advice. Regrettably they largely failed until Sir
George Godber took over. Their medical colleagues in the official
Medical Research Council comment early on about the "the great
reluctance of the Ministry's M[edical]
O[fficer]s to accept what we regretfully believe to be the 'facts of
life (and death)' on smoking and lung cancer". Interestingly, the
officials in the Scottish Office were much more inclined to take
vigorous action: they were further away from the Treasury and had
different medical advisors.
3. But what about the Parliament ? there are a few pointed questions by MPs but on the long term, not much, I mean no sustained interest. Not much either from the media. How do you explain this lack of interest ?
The lack of attention in the press is a surprise. When the research by Richard Doll and Austin Bradford Hill was published, the Medical Research Council expected it to make big headlines and it was almost ignored. When the health minister made a cautious statement in 1954, the press did nothing to follow it up. Two factors are worth mentioning. First, the press then was much tamer and more deferential than now: what politicians said was reported respectfully and in extenso and rarely questioned. Even the practice of seeking instant reactions from interested parties was rare.
Secondly, there is a suggestion from an industry source - quoted in my book - that they used their huge advertising power to influence the press to play the story down. This is not in the official records but it seems highly plausible. In Parliament a small number of MPs pursued the matter vigorously, but there was no campaign in the community to back them up and they could do little more than force the health officials to keep their case for inaction under review.
4. The bureaucratic strategy is clearly defined when you write: "doing the minimum to protect the government from criticism for doing nothing while avoiding creating any effort for action one might to answer". In that strategy the role played by committees seems a key element. The French have a saying : if you want to kill a decision, refer it to a committee. Is the committee-mania dead today ?
Surprisingly, the official committees in the story told in my book were not of this classical defensive kind. The most important the Minister's cancer and medical advisory committees, which provided Dr Horace Joules with the platform he needed to force the issue onto the official agenda, and the difficulty he had was largely because of the opposition of senior medical people who could not bring themselves to believe what the epidemiology told them.
Later, when (exasperated at the lack of government action) the Royal College of Physicians produced their 1962 report, the committee of officials that examined the possibilities for action was an inevitable method of tackling the issue. But even with (at last) strong political backing from the two ministers concerned, the vested interests of the Treasury and the industry department were too powerful for legislation to be agreed.
5. The bottom line is that 13 years passed between the demand by Dr Horace Joules that a campaign be launched by the Health Ministry about the dangers of smoking and the launch of such a campaign. Is the balance of power much better now ?
Undoubtedly, yes. The differences are partly the much greater knowledge we now have both about smoking and about the viciousness of the industry, partly the realisation that we need a strong campaign in the community to back up even the strongest arguments for unwelcome action. Health ministers will often be glad to have pressure put on them to act: it gives them strength in their arguments with colleagues to be able to say that failure to act will reap loud criticism. This was the lesson the Royal College of Physicians learnt when they set up ASH in 1971, nine years after their first report: they realised that making a strong case was only the beginning of getting action. You have to win hearts as well as minds, to make the case in the public media as well as in the scientific advisory boards.
Do you have anything else you would like to add?
Two things. First, although much has changed since the 1950s, I suspect that there are many lessons to be learned by studying from the inside the way the system worked then - lessons that will perhaps be especially relevant to countries that are not far advanced in tobacco control.
Secondly, this inside view is anyway quite fascinating: the personalities, the ways the bureaucracy works, the power plays, the devices - above all, the rich mixture of what is just the same and what is utterly different in that period not so long ago.
Thank you David for taking the time to be with us today and let me add that anyone who wants a copy of Denial and Delay can contact you : [email protected]
Comments