Smoking Kills 

Smoking Kills 

Author: Conrad Keating
Overview
Richard Doll, the larger-than-life subject of this book, is best known for how he, ‘more than any other physician’, conclusively demonstrated the health hazards of tobacco. This biography however paints a grander portrait of the man as the epidemiologist who ‘pioneered the randomised control trial‘, ‘developed the tools of epidemiological inquiry‘, and ‘taught a generation of younger medical scientists and physicians to apply these across the whole field of medicine‘. Arguing that Doll almost single-handedly ‘changed the health of a nation and caused a revolution of medicine’, the book explored how he applied his ‘inimitable single-mindedness to the cause of saving people from avoidable disease and premature death‘. The biography contends that the field of medical statistics was ‘built substantially’ on his ‘scientific contribution‘, and that he ‘brought insight and imagination‘ to epidemiology – ‘a subject that was on the threshold of an age of discovery‘. And beyond commemorating his remarkably diverse contributions to his chosen specialty, the biography also narrated his colourful life outside of healthcare – from being ‘a political revolutionary‘ and communist, to being a humanist distressed over ‘the injustices in health caused so largely by poverty’ (pages xv, xvii, x, 17, 125 and 144).

Manface Goathorn Smoker. Jeremy Brooks on Flickr. https://www.flickr.com/photos/jeremybrooks/3027136137/
Synopsis
The vivid picture of Doll that this biography paints is of ‘a driven scientist’ who had ‘a religious zeal for science’, and who was ‘dispassionate when faced with the evidence‘. Lauding his qualities of diligence, ‘quiet decisiveness‘, ‘willpower‘, and ‘determination‘, the author also portrayed him as a courageous man who took on ‘the vested interests of the tobacco industry‘. The book also variously characterised him as ‘a perfectionist‘ for whom ‘work was an all-consuming passion‘; ‘an archaeologist of ideas‘ who was ‘intellectually clever‘; and a ‘professionally conservative‘ who practiced ‘scientific caution‘ as he was ‘prone to ideas but not to excitement‘. In exploring the personal qualities that played determining roles in his success as an epidemiologist, the book referred to his very early ‘interest in mathematics‘ as crucial, illustrating this with how comfortable he was with the Chi-squared test even as a medical student. The book also noted how ‘his great intuitive skills‘, and his ‘ability to see patterns‘, made him perhaps the most influential epidemiologist in medical history (pages xvi, ix, 26-27, 58-61, 100 and 142-143).

Mathematics. Tom Brown on Flickr. https://www.flickr.com/photos/t_e_brown/8677750589
In its exploration of the major influences on Doll’s career, the author highlighted the prominent role played by his mentor, Austin Bradford Hill – ‘a quiet unassuming, private person’ who ‘taught an innumerate profession to think quantitatively‘. Further depicting Hill as ‘an inspiring scientific collaborator’, the author described how he recognised Doll as ‘a physician who could think statistically‘, and ‘offered him a post in the MRC‘s statistical unit in 1948’  – the institution where Doll ‘elected to make his career in medical statistics and epidemiology‘. The author argued that it was Hill who transformed Doll ‘into a hunter-gatherer of data, initially as his student, then assistant and finally collaborator‘, adding that ‘Hill’s greatest contribution to Doll’s career was that he passed on to him knowledge and attitudes to science’. In describing the effective collaboration they enjoyed, the author said Hill and Doll together ‘set in motion a fundamental shift in scientific thinking, and ushered in a new epistemology‘ which the author said guided ‘the minds of demographers and epidemiologists‘. Beyond Hill, the book also credited the influence on Doll of Francis Avery Jones, a man who the author said shaped medical epidemiology by using innovative statistical methods to establish the occupational risks of peptic ulcers (pages 54-63, 65 and 74).

The dangers of tobacco was the key backdrop of this biography of Doll, and the author set this in post World War II Britain – a time when smoking was rampant, and the incidence of lung cancer was rising exponentially. Pointing out that ‘smoking was generally regarded as innocuous‘ at the time, the book noted that more than eighty percent of men, and forty percent of women smoked then. In describing the extent of smoking during that period, the author remarked that the habit ‘was as entrenched among doctors and scientists as it was in the rest of society‘, and he illustrated this by pointing out that both Hill and Doll were themselves pipe smokers. And in depicting the medical hazards of smoking after the war, the author said that ‘for the first tome the number of deaths from lung cancer…exceeded those from tuberculosis‘, with Britain having ‘the highest lung cancer rate in the world’. The book went on to narrate how the association between tobacco smoking and lung cancer was first made, and in this regard he described the emergence of the so-called tobacco smoking hypothesis, and he credited the influential study of the tobacco smoking habits of workers carried out by Edward Mellanby, and the post mortem certification studies performed by Ernest and Nina Kennaway. It is notable that tobacco hypothesis was not the only lung cancer theory at the time, the book referring to such other aetiological considerations as atmospheric pollution, ‘arsenic in cigarette smoke, radioactive dusts and drugs‘ (pages 77-83).

Right at the heart of this biography is ‘large-scale study into the aetiology of the epidemic‘ of lung cancer which Doll carried out on the recommendation of Hill – a remarkable breakthrough because ‘epidemiology had been concerned almost exclusively with infectious diseases‘ before then. In illustrating the high quality of this seminal study, author particularly referred to its research protocol which included a ‘wide-ranging’ questionnaire which detailed the ‘life histories‘ of hospital patients with and without lung cancer. The book also reviewed the results of the trial which confirmed the association between tobacco smoking and lung cancer – an outcome the author characterised as ‘one of the defining medical discoveries of the twentieth century’, and as ‘the most important discovery in the history of cancer epidemiology‘. The author argued that the results not only showed that cancer had causes, but that ‘the environment and people’s lifestyles must play a significant role in the origins of the disease’. And in documenting the follow-up studies to this influential trial, the author highlighted ‘the first major prospective study of smoking and death’ among doctors, what he said Doll used to establish ‘the principles of cancer progression and epidemiology in mathematical form’, and to develop ‘a biological theory of “multiple mutation” that has stood the test of time (pages 83-87, 110-112, 122-123, 130-132 and 179-180).

Smoking Bar Graph. Fantasy creature on Flickr. https://www.flickr.com/photos/21179443@N00/3472881975
The skepticism and hostility that followed Doll’s findings formed a key theme of the book, and the author reviewed this from various perspectives. One such point of view was of the cynicism of the medical establishment which ‘widely doubted and generally ignored‘ Doll’s results. In explaining this reaction, the author noted that ‘doctors had not yet come to understand that chronic diseases could have multiple causes‘, and that they saw how Doll’s results contradicted Koch’s postulates – the ‘intellectual foundations of causation in diagnostic medicine’. The book also chronicled the fightback of the tobacco industry which the author said first ‘took care to persuade the media that no one should pay attention’ to the study, and then ‘dedicated itself to undermining‘ the studies. Beyond these two groups, the book also showed that the results were met with resistance by the political class, and with indifference by the general public. It was perhaps not surprising that Doll’s subsequent studies, which ‘provided early conclusive evidence’ that asbestos causes lung cancer and mesothelioma‘, was also ‘met with denial, suppression, coercion, intransigence, intrigue and litigation‘ by the asbestos industry, a situation that led to what the author labelled ‘a struggle between the forces of scientific freedom and corporate suppression‘ (pages 96, 105, 158-109, 145-178 and 187-197).

Opinion

This exhaustive account of Richard Doll demonstrates the value of open-minded but scrupulous research in broadening the perspective of medicine and launching it in new directions. The biography highlights its subject’s wide interests and convictions, and sets his work in the context of the wider social and political atmosphere of the time. The book’s exploration of such themes as the war against cancer was particularly enlightening. The non-chronological narrative and the slightly disjointed story-telling marred the biography, and level of detail given to the more mundane themes also seemed rather excessive. The content was however exhaustive, and the lessons clear.
Overall assessment

This book not only chronicles the research work, carried out principally by Doll, that launched the field of medical epidemiology, it also highlights its inner workings and invaluable influence on healthcare. The narrative establishes why epidemiology and statistics have come to cut across the spectrum of medicine and become central in validating the rigour of all research. The book’s educational value is also evident in its explanation of basic medical statistics, and I recommend it to all doctors.
Book details

Publisher, Place, Year: Signal Books, Oxford, 2009
Number of chapters: 26
Number of pages: 495
ISBN: 978-1-909930-04-9
Star rating: 4
Price: £6.99

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