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The World is an Addict

THE LANCET

IN the ’50s the medical profession was equivocalin its attitude to smoking and, even into the middle’60s, prominent doctors could hit the headlines bysaying that the association between the habit and therisk of lung cancer was not proved. Now in 1970 theprofession is more or less united in the view that

cigarette smoking, in particular, endangers health.The first reaction of the tobacco industry was one ofincredulity. Its pride in a fine record of producinghigh-quality smoking materials and of impeccableindustrial relations was affronted by the possi-bility that its products might be harmful to health.Some awful mistake was suspected. The scientistsand epidemiologists concerned must have overlookedthe intervention of some other causative factor.

Surely the whole matter could be quickly clearedup by experienced medical scientists, and who betterto organise the necessary research in Britain than theMedical Research Council with the help of E250.000from the industry ? But if the industry at that timewas ill-equipped to face the challenge, the MedicalResearch Council was not much better off, becauseof a paucity of medical scientists with the knowledge,resources, and time to tackle the relevant questions.In due course the money was spent with little moreto show for it than the confirmation that tobacco-smoke condensates may produce skin cancer in mice-a finding already reported from the United States.

In 1956 the tobacco manufacturers set up a

standing committee which, in 1963, changed its nameto the Tobacco Research Council. The objectivesof this organisation, on which every company inBritain that manufactures tobacco products is re-

presented, are " to conduct, promote and co-operatein and keep in touch with research into all questionsconcerning the relationship between tobacco andhealth ". In due course it became apparent thatgrants from the T.R.C. to the M.R.C. or to otherresearch bodies were not going to provide the basicinformation on mechanisms necessary for formulatingless harmful smoking materials. A communicationalimpasse had really been reached; the industry knewall about the science and technology of smokematerials and nothing about biological or medicalresearch, whereas medical and biological researchscientists outside the industry were usually specialistsin the problems of individual diseases and knew

nothing about the science and technology of smokematerials. In 1961 the T.R.C. decided to build itsown research laboratories in Harrogate, and since1962 these have grown in size and in the variety andquality of scientific work undertaken.The latest triennial report of the T.R.C. sum-

marises the results of work undertaken either at

Harrogate or elsewhere under grants from the T.R.C.At Harrogate it has been shown that the carcinogenicactivity for mouse-skin of cigarette-smoke conden-sates (obtained by smoking cigarettes in machines thatmimic average human smoking habits with regard topuff frequency, puff volume, discarded butt length,and so on) can be concentrated into a fraction thatrepresents only 0-2% of the starting material.

Moreover, the majority of the tumour-promoting(co-carcinogenic) activity has been concentrated into0-4% of the original condensate. It is hoped thatfurther experiments will pinpoint the specificchemical agents responsible for these activities andprovide a chemical basis for formulating less carcino-genic smoking materials. In the meantime, it hasbeen shown that the condensible material that findsits way through cellulose-acetate filters is no less

carcinogenically active than condensate from plaincigarettes. Surprisingly, perhaps, for those whodislike " bits " in cigarettes, the activity of conden-sates from cigarettes made from the " stalky " partsof tobacco leaves has been found to be less than thatfrom cigarettes made of

"

leafy "

parts.The demonstration that condensates prepared

from the smoke of small cigars were more carcino-genic for mouse-skin than cigarette-smoke conden-sates has been widely interpreted in the Press as

meaning that cigar smoking is more dangerous thancigarette smoking for man. This is almost certainly amisinterpretation. Almost every epidemiologicalstudy that has provided sufficient data on which toform an opinion has indicated that cigar smokers areat a substantially lower risk of cancer of the lung thancigarette smokers. How, then, can the apparentlygreater carcinogenicity of cigar smoke for mouse-skinbe accounted for ? Does it mean that the mouse-skin

assay model is unreliable for the prediction of car-cinogenicity for human lung ? The basis for answer-ing these questions probably comes from anotherparagraph in the T.R.C. report in which new evidenceis recorded of the difference between cigar and cigar-ette smoke in the availability of nicotine. The alkalinesmoke of the cigar yields up its nicotine content soreadily that it can be absorbed into the bloodstreamthrough the mucosa of the mouth, pharynx, andlarynx. The more acid smoke from Virginia-typecigarette tobacco, however, is more reluctant to partwith its nicotine and is only persuaded to do so ifbrought into contact with the relatively vast area

available for exchange of chemicals between air and1. Review of Activities, 1967-69. Tobacco Research Council: London,

1970.

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blood in the lung. Thus the cigarette smoker is moreobliged to inhale smoke than the cigar smoker if hewants to absorb nicotine. If cigar smokers retainmore smoke in the mouth and upper respiratory tract,are they at greater risk of cancers of the mouth,pharynx, and larynx than cigarette smokers ? Thereis some evidence that they may be.2,3The increasing numbers of anti-smoking cam-

paigners and the valuable research now reported bythe T.R.C. are alike powerless to change a world thatis basically addicted to tobacco. There is, therefore,a case, and indeed a need, for compromise betweenthe retentionists and the abolitionists. Too manypeople who have read and accept the case againstsmoking nevertheless still smoke, and, as long as theydo so, someone will supply their need, if not fromBritain, then from elsewhere. Thus, the search forsafer smoking materials for those who cannot beweaned from the habit is a logical and necessary exer-cise ; and, for this reason, the efforts of the TobaccoResearch Council are commendable.

Doctors or Politicians?NEARLY every aspect of the National Health

Service has been the subject of controversy, muchof it partisan, doctrinaire, and correspondinglysterile. Paradoxically, one subject upon whichdiscussion might have been objective and formativehas hardly been mentioned, and still goes unnoticedin the present talk of major administrative changes.This is the astonishing lack in the service of anythingthat could be called a headquarters organisation.Unique amongst Government-sponsored agencies,the N.H.S. has no central body charged with themaking of policy or with any of the other functionswhich are best met on a national level. The more

logical it was in 1947 to create a separate administra-tive structure for the new service, the less logical wasit to leave these central functions to be met by theexisting machinery of the Civil Service: it says a

great deal for the individuals concerned that this

non-system has functioned at all. But it puts every-one at a disadvantage, not least the public at large,for whom Health Service policy is left to be deter-mined almost fortuitously by bodies designed forother purposes. Chairmen of hospital boards andsenior medical administrators from the hospitalregions meet at the Elephant and Castle and in St.Andrew’s House to coordinate policy in Englandand Wales and in Scotland. If a larger nationalpurpose can be expected to emerge from groupingtogether people whose responsibility is for autono-mous regions, there has not so far been much evidenceof it. For the rest, initiative comes (if at all) from the2. Wynder, E. L., Bross, I. J., Day, E. Cancer, N.Y. 1956, 9, 86.3. U.S. Surgeon General’s Report on Smoking and Health. U.S.

Public Health Service Publication no. 1103. 1964.

several committees where Civil Service and medical

profession meet, the doctors concerned being eitherrepresentatives of agencies such as the BritishMedical Association or the Royal Colleges, or thosenominated by the Health Departments themselves.This sounds like a set-up where gentlemanliness isall, and cosiness is common: the participants cer-tainly suggest in their infrequent public statementsthat the eventual outcome usually satisfies theintended purpose. But it is reasonable to inquire towhat extent the public interest is served by merelyresolving the conflicts of interest that arise betweenGovernment, represented by the Civil Service, anddoctors, represented by their professional associa-tions : and it is not open to doubt that the increasingmilitancy of medical backwoodsmen makes it moreand more difficult for their representatives to dis-

charge the profession’s wider responsibility for policy-making.Good management is as unlikely in the Health

Service as anywhere else unless administrative unityis ensured by a structure that extends without

interruption from the periphery to the centre andback again. The best possible medical and scientificadvice is needed at every administratively identifiablelevel, and this too should be provided not by isolatedcommittees as at present but by a similarly unifiedstructure. The central parts of the administrationand of the medical and scientific advisory machinerywould then constitute a headquarters organisationwith clearly definable functions. Its administrative

segment would absorb most of the medical and laypersonnel of the Health Departments, leaving theCivil Service to its proper function of advisingMinisters upon those aspects of the service for which

they are accountable to Parliament, and leaving thedoctors’ professional associations free to pursuetheir members’ interests.

Given this degree of definition of differing centralfunctions, and given that the doctors had real

authority in the sphere that properly belongs to them,they could then be asked to accept that there is alsoa sphere that belongs to the politicians. The mannerin which the service is financed, the extent to whichthe general Exchequer contributes to it, the relativepriority to be given to health as opposed to education,road building, and so on, are questions of generalpublic concern. Some political matters do affectthe practice of medicine, and so directly that it maybe difficult for the doctors to be objective. But theymust learn not only to be so but also to provide firmdata for the public to make up its mind upon. Theymust do better, for example, in the discussion ofpayments for certain services than simply to assertthat charges lessen their work-load and are thereforedesirable. On the other hand, the actual running ofthe service, the evaluation of priorities in it, decisionsabout what to develop and what to shut down, aboutthe distribution of specialist services throughout the