Sir Richard Doll (19122005), Physician,
Epidemiologist, Teacher,
Humanitarian, Legend,
Activist, Researcher, Public
Health lobbyist
Smoking and Health
CONDITIONS
TREATED WITH TOBACCO
16th Century
Cough
Gout
Asthma
Diseases of women
Headaches
Intestinal worms
Stomach cramps
Open wounds
Malignant tumours
SÖMMERING 1795
DOCTORAL THESIS
“Carcinoma of the lip is most
frequent when people indulge in
tobacco pipes. For the lower lip is
particularly attacked by carcinoma
because it is compressed between
the pipe and the teeth”
PERCENTAGE OF MEN ATTENDING
MASSACHUSETTS CANCER CLINICS
WITH DIFFERENT CANCERS: BY SMOKING HABIT
(Potter & Tulley, 1945)
Use of tobacco
(no. of men)
None
(655)
Slight
(357)
Moderate (1155)
Excessive (760)
Cancer of:
buccal
cavity
3.7
8.1
11.5
17.9
respiratory
tract
0.5
1.1
2.0
1.7
other
sites
22.4
25.1
26.0
23.4
USE OF TOBACCO BY DISEASE CATEGORY:
86 MEN WITH AND 86 MEN WITHOUT LUNG
CANCER
(after Müller, 1939)
Type of smoker
No. of men
with
lung cancer
1Extreme
2Very
smoker
25
4
heavy smoker
18
5
13
22
27
41
3
14
3Heavy
smoker
4Moderate
smoker
Non-smoker
1 10-15
2 7-9
3 4-6
4 1-3
healthy
controls
cigars, >35 cigarettes, >50g pipe tobacco/day
“
26-35 “
36-50g “
“
“
“
16-25 “
21-35g “
“
“
“
1-15 “
1-20g “
“
“
SMOKING AND LUNG CANCER
CASE-CONTROL STUDIES BEFORE 1950
Author
No. of men
Lung Controls
cancer
Percent of:
Non-smokers
Heavy smokers
Lung Controls
cancer
Lung Controls
cancer
Müller, 1939
Germany
36
86
3.5
16.3
65
36
Schairer &
Schöniger, 1943
Germany
93
270
3.2
15.9
52
27
134
100
4.5
19.0
55
19
Wassink, 1948
Holland
TOBACCO AND CORONARY DISEASE
(English, Willius & Berkson, 1940)
Men
aged
(yrs)
Percent smokers
Coronary
Others
disease
40-9
50-9
60+
79.7 (149/187)†
71.7 (274/382)
63.8 (275/431)
40+
69.8 (698/1000) 66.3 (663/1000)
61.9 (187/302)
73.9 (274/371)
61.8 (202/327)
P*
<0.001
─
0.28
0.05
*P, one-sided
†Number
of smokers and all men in age group in parentheses
TOBACCO AND CORONARY DISEASE
(English, Willius & Berkson, 1940)
Men
aged
(yrs)
Percent coronary disease in:
P*
Smokers
Non-smokers
40-9
50-9
60+
4.8 (10/208)†
6.2 (24/388)
5.0 (20/404)
1.0 (2/208)
2.6 (10/388)
6.4 (26/404)
0.01
0.01
─
40+
5.4 (54/1000)
3.8 (38/1000)
0.04
*P, one-sided
†Number
of men with coronary disease and all diseases
in age group in parentheses
SMOKING AND LUNG CANCER
CASE-CONTROL STUDIES PUBLISHED IN 1950
Author
No. of men
Lung Controls
cancer
Percent of:
Non-smokers Heavy smokers
Lung Controls
Lung Controls
cancer
cancer
82
522
14.6
23.9
18
9
236
481
15.3
21.7
─
─
444
430
7
31
─
─
Wynder & Graham 605
USA
780
1.3*
14.6*
51
19
649
649
0.3*
4.2*
26
13
Schreck et al.
USA
Levin et al.
USA
Mills & Porter
USA
Doll & Hill
UK
*Lifelong non-smokers, with ex-smokers carefully excluded
MORTALITY BY AMOUNT SMOKED
RELATIVE TO THAT IN NON-SMOKERS
(after Hammond & Horn, 1954)
Age
(yrs)
No. of
deaths
Regular cigarette smokers
smoking (per day):
20
Less than 10-19
or more
10
50-69
167
50-54
377
1.7
2.1
2.5
55-59
571
1.1
1.9
2.1
60-64
594
1.5
2.2
2.0
65-69
605
1.0
1.3
1.1
42
8.8
Cause of
death
lung cancer
coronary
heart
disease
BERKSON’S ALTERNATIVES
“The findings were the result of the interplay of
various subtle and complicated biases
or
had a constitutional basis, involving people who
were non-smokers or relatively light smokers,
being the kind who were biologically selfprotective and this “correlated with robustness in
meeting mortal stress from disease generally”
FISHER’S OBJECTIONS
(i) Smokers with lung cancer reported inhaling
less than smokers without (Doll & Hill, 1950)
against causation unless it was concluded
that “Inhaling cigarette smoke was a practice
of considerable prophylactic value in
preventing the disease”
FISHER’S OBJECTIONS
(ii) Secular changes in smoking habits could
not be related to the increase in lung cancer
since “lung cancer has been increasing
more rapidly in men relative to women”
while “it is notorious, and conspicuous in the
memory of most of us, that over the last 50
years the increase among women has been
great, and that the increase among men
(even if positive) certainly small”
CANCERS CAUSED IN PART BY SMOKING
(International Agency for Research on Cancer, 2004)
Bladder
*Lung
Cervix
Myeloid
leukaemia
Nasopharynx
Kidney
Oral (incl. lip
& tongue)
*Oro- & hypopharynx
Pancreas
*Larynx
Nose & nasal
sinuses
Stomach
Liver
*Oesophagus
Ureter
*Increased more than fivefold
VASCULAR AND RESPIRATORY DISEASE
CAUSED IN PART BY SMOKING
*Pulmonary heart disease
Subarachnoid haemorrhage
Ischaemic heart disease
Cerebral thrombosis
Myocardial degeneration
Cerebral haemorrhage
Hypertension (fatal)
*Chronic obstructive lung disease
Arteriosclerosis
Pneumonia
*Aortic aneurysm
Asthma
*Peripheral vascular disease
Pulmonary tuberculosis
*Buerger’s disease
*Increased more than five-fold
OTHER CONDITIONS
CAUSED IN PART BY SMOKING
Gastric ulcer
Duodenal ulcer
Periodontitis
*Tobacco amblyopia
Crohn’s disease
Age-related macular degeneration
Osteoporosis
Cataract
Reduced fecundity
Facial skin wrinkling
Reduced growth of
fetus
*Palmoplantar pustulosis
*Increased more than five-fold
UK male doctors born 1900-1930: continuing cigarette vs
never smokers. 50-year follow-up of mortality, 1951-2001
Evaluation