Hugh Tunstall-Pedoe
Dundee, Scotland

Doll and Hill’s 1956 publication¹ linking smoking with lung cancer had one quick result—others were delayed by years. My school biology class displayed a cigarette butt among the specimens in our classroom, labelled “Fagendia cancercausia”. A year later when being interviewed for a place at Guy’s Hospital Medical School, most of my interrogators were exhaling smoke, waving it away while questioning me. Tobacco smoking had been shown to be a potentially lethal addiction, but first emphases were on it as a personal choice. In later decades societal pressures led to more profound changes.

Tobacco came to Europe from America. Smoked in clay pipes, it figured in Native American peace ceremonies. Fashion later moved to wooden pipes, as clay was fragile. In Europe, it was promoted as health-giving. Inhalation of tobacco as snuff and chewing tobacco ran in parallel, but smoke was king. Cigarettes, “baby cigars,” lit by matches, aided rapid consumption.

Two World Wars generalized smoking in the belligerents. For Britain, Virginia tobacco was a World War II strategic cargo. Although rumoured then that smoking impaired athletic performance, the 1930s Nazi doctrine that it was harmful to health was treated with disdain elsewhere, linking it with their obsession with racial purity. In WWII cigarettes were used as currency and gifted by visitors to wounded soldiers. In the late 1960s, workers in a cigarette factory placed packs of 100 on the trolley as it wheeled their smitten colleagues away in the pioneering Belfast mobile coronary care unit.²

As a child I remember that the prize I won at a funfair but given to my father was three cigarettes. I collected stamps, my twin cigarette cards that had come with every pack before the War but were still collected. Children were discouraged from smoking but cheated behind school bicycle sheds. My parents smoked cigarettes occasionally, allowing the two of us odd puffs. In my late teenage, a non-smoker, I bought a cigarette lighter, thinking it would be a social asset in mixed company, but I never used it!

Vignettes from later decades

• The early girlfriend who discovered menthol cigarettes, urging me to try them—as a non-smoker, I was repelled.
• My future wife, a physiotherapist specializing in chest diseases, was a non-smoker, to my delight.
• In the late 1970s I attended a committee debating a proposal to omit the loyal toast at the annual dinner. I supported the toast but disliked an ancient formal tradition that the toastmaster would follow it with “You may now smoke!” But at least there was no smoking while eating.
• When my London hospital opened a rehabilitation unit, I found chairs clustered round tables where numerous ashtrays overflowed with discarded cigarette butts.
• In 1981, friends took us to an upmarket French restaurant in London. I was shocked to find people smoking at many tables before and between courses. With bad ventilation, it was ruining the atmosphere and the taste of the food.
• Traveling on the London Underground with my family, I objected politely to football supporters smoking in a non-smoking compartment. The response was obscene, shouted abuse. Smoking was banned on the Underground afterwards when a discarded cigarette butt fell through the gaps in an escalator and started a fire that roared upwards and killed people. Smokers became portrayed as potential killers. With alleged harm from passive smoking, this promoted shutdown of smoking spaces.
• Scottish women in the 1980s were the most “liberated” in international comparisons—their exceptional prevalence of cigarette smoking equaled men’s—but linked to the highest coronary heart disease mortality in the world.
• As head of a new research unit in 1981 in Scotland, I practiced “guided democracy” and got my staff to declare it a “no smoking” area. Personnel officers cautioned me that mentioning this in job descriptions would scare off applicants, but it attracted them—one even accepted a pay cut to join us.
• I found a shop in the hospital concourse selling chocolate cigarettes for children.
• My research was publicly funded but attracted donations in memory of heart attack victims. At the presentation in one pub, you could barely see across the room for cigarette smoke. The captain of the ladies’ darts club presented a cheque—reluctantly putting down her cigarette to do so. She invited me to speak. I gave thanks and reported work we were doing, but pointed out there was a lot we knew already about diet, exercise, and not smoking. Early small donations ceased, but I was later well funded through the British Heart Foundation, which gets numerous bequests.
• An outpatient clinic nurse disappeared briefly and returned stinking of cigarette smoke. I rebuked her. The stench was so strong she must have smoked in an unventilated hideout somewhere.
• In the 1980s, European drug companies discovered coronary prevention and marketed blood pressure and lipid lowering drugs to that end. During a break in proceedings at an international cardiology conference, I toured the exhibits and found many staffed by agents smoking regardless of what their stands proclaimed.
• In 1991 the London Secretary of State published the The Health of the Nation listing sixteen key areas for action—coronary heart disease was the first. The BMJ asked me to write a critique of the draft proposals for this.³ I wanted the millennium target to be a 50% reduction in premature CHD deaths, and “to raise a smoke-free…generation of teenagers.” Major reductions in smoking and CHD mortality have since occurred. Tobacco smoking may progressively be timed out by government legislation—although challenged and supplanted in places by other recreational drugs.

References

1. Doll R, Hill AB. Lung cancer and other causes of death; a second report on the morbidity of British doctors. BMJ 1956;2(50001):1071-81.
2. Pantridge JF, Geddes JS. A mobile intensive-care unit in the management of myocardial infarction. Lancet 1967;290(7510):271-3.
3. Tunstall-Pedoe H. The Health of the Nation; responses. Coronary heart disease. BMJ 1991;303:701-3.