We have ways of making you stop smoking

[Tobacco is] ‘one of the most deadly poisons’.

Adolf Hitler, 1941

There are striking parallels between the Nazi ‘war on cancer’ and the New Labour crusade against smoking (1). In Nazi Germany, every individual had ‘a duty to be healthy’; furthermore, to ensure that individuals fulfilled this duty, the government insisted on ‘the primacy of the public good over individual liberties’ (2). Tony Blair acknowledges that smokers – and non-smokers – have rights. More importantly, however, ‘both have responsibilities – to themselves, to each other, to their families, and to the wider community’ (3).

To ensure that smokers meet these responsibilities, the government is planning further bans and proscriptions on their activities. In Germany in the 1930s, the medical profession played a leading role in the state campaign to restrict smoking. In Britain today, doctors again provide medical legitimacy and moral authority for state regulation of individual behaviour.

There are of course also striking differences between the Nazi and New Labour anti-smoking campaigns. The anti-Semitic and eugenic themes of the 1930s are absent today; many of Germany’s leading anti-tobacco activists were also war criminals (4). Another difference is in the consequences of an authoritarian public health policy for science. Whereas in Nazi Germany pioneering scientific research took place into the health effects of tobacco, we find today in Britain that epidemiology has been degraded in the service of political expediency.

There has been a marked reluctance among British medical authorities to acknowledge German achievements in research into the health effects of smoking. Yet according to Robert Proctor’s authoritative account, The Nazi War on Cancer, up to the Second World War, ‘German tobacco epidemiology was the most advanced in the world’. In 1929 Franz Lickint, a physician from Chemnitz, published the first statistical evidence – a ‘case series’ study – suggesting a link between cigarettes and lung cancer (5). He went on to become a leading campaigner against smoking in the Nazi era.

In 1939 Franz Muller at the University of Cologne published the first controlled epidemiological study – according to Proctor, ‘an exquisite piece of scholarship’ – establishing a causal relationship between smoking and lung cancer (6). As late as 1943, Eberhard Schairer and Erich Schoniger, working at the Institute for Tobacco Hazards Research at Jena, produced a ‘very subtle study’, providing ‘the most conclusive epidemiological evidence up to that time, anywhere in the world, that smoking posed a major lung cancer hazard’ (7). It was more than a decade later that researchers in Britain and the USA confirmed the findings of the German scientists, claiming these discoveries as their own.

Sir Richard Doll is the leading figure in smoking epidemiology in Britain. He was a co-author of the 1954 study, which showed the link between smoking and lung cancer among British doctors, and also of the 50-year follow-up study of the same population, published earlier this year (8). The headline conclusion from these researches was that smoking leads, on average, to a 10-year reduction in life expectancy. In recent years, however, the focus of the anti-smoking campaign has shifted from the (firmly established) dangers of smoking to the smoker to emphasising the (more contentious) dangers of smoking to others, particularly to non-smokers. In the process, the science of epidemiology appears to have surrendered to the demands of public health propaganda.

In 1988, the Froggat Committee, an independent scientific committee on smoking and health, estimated that passive smoking caused an increased risk of lung cancer of between 10 and 30 per cent and recommended restrictions on smoking in workplaces and in public (9). The case against passive smoking gathered momentum through the 1990s. In 1997 meta-analyses confirmed increased risks of lung cancer (24 per cent) and coronary heart disease (23 per cent) (10, 11). A re-analysis of the same studies three years later acknowledged a ‘modest degree of publication bias’ (a result of the fact that studies which reveal no increased risk are less likely to be published) and adjusted the excess risk of lung cancer down from 24 per cent to 15 per cent (12).

Despite the growing medical (and political) consensus about the dangers of passive smoking, the issue has remained controversial. The Swedish toxicologist Robert Nilsson, while accepting the plausibility of the lung cancer link and the fact that numerous studies appear to show a statistically significant increase in risk, has questioned its epidemiological significance (13). He offered estimates of the annual incidence of cancer in a population of 100,000 resulting from various environmental factors: unknown (177), diet (135), smoking (68), other lifestyle factors (45), sunshine (23)…environmental tobacco smoke (ETS) (2). By contrast, in a population which consumes Japanese seafood (which contains Arsenic) this will cause 12 cases of cancer, where there are traces of natural Arsenic in drinking water, this will cause five cases; eating mushrooms will cause three cases. In other words, the risk of ETS is comparable with that of environmental agents that are generally regarded as an insignificant threat to health.

Perhaps the most fundamental defect of the presentation of the risk of passive smoking is the failure to distinguish between relative and absolute risk. In a critical commentary, the Australian medical research scientist Raymond Johnstone noted that the annual death rate from lung cancer among the non-smoking wives of non-smoking men is around six per 100,000, whereas among the non-smoking wives of smoking men the corresponding figure is eight per 100,000. Now this may be reported as an increased (relative) risk of 33 per cent. Yet in absolute terms it amounts to an absolute (or exposure) risk of one in 50,000, which is, for practical purposes, negligible.

Johnstone’s conclusion was that ‘the most that one can say about the alleged link between passive smoking and lung cancer is that if there is one, then it is so small that it is difficult to measure it accurately and the risk, if any, is well below the level of those to which we normally pay attention’ (14). The alarming estimates of deaths attributable to passive smoking result from multiplying miniscule risks of dubious validity by vast population numbers – an effective propaganda device but statistical sharp practice.

The intense moral fervour and political commitment now driving the campaign against passive smoking has created a climate inimical to serious scientific inquiry. In 2003 the British Medical Journal published a study of 120,000 adults in California over a 40-year period, which concluded that ‘the results do not support a causal association between environmental tobacco smoke and tobacco-related mortality, though they do not rule out a small effect’ (15).

The authors, James Enstrom and Geoffrey Kabat, were subjected to a barrage of personal attacks and unfounded insinuations of dishonesty. In response, they pointed out the selective reporting of the anti-smoking campaigners and their attempts to suppress divergent data (16). They noted that ‘what is most dangerous is the willingness to distort the truth to defend one’s position, claiming all along that science and righteousness are on one’s side’. In an editorial published alongside the original paper, George Davey Smith, one of Britain’s leading epidemiologists, tried to bring some reason into the debate, pointing out that ‘the considerable problems with measurement imprecision, confounding, and the small predicted excess risks limit the degree to which conventional observational epidemiology can address the effects of exposure to environmental tobacco smoke’ (17).

The fact that Davey Smith is well known for his hostility to the tobacco industry, and for his earlier writings exposing its apologetic use of science, did not save him, the authors or the BMJ from the wrath of the anti-smoking campaigners (18).

The drive to impose restrictions on smoking in workplaces and in public has not been in the least inhibited by expert doubts about the validity of the evidence on which it is based. Indeed, as medical historian Virginia Berridge has observed, ‘the coalition advocating those restrictions pre-dated the evidence’ (19). Yet, as she acknowledged, ‘by the mid-1990s, there was widespread agreement that the epidemiological evidence on passive smoking was at least debatable’.

When Sir Richard Doll was asked in 1998 to compare the epidemiological evidence on passive smoking with his work in the 1950s, his response was ‘it’s utterly different’ (20). Recalling that his study had shown a fifty-fold increase in risk for heavy smokers, he commented that ‘for passive smoking the evidence is qualitatively different’. While indicating that he did believe that passive smoking was harmful, he conceded that ‘the quantitative relationship is very weak’, suggesting that his belief was more grounded in loyalty to the anti-smoking cause than his confidence in the figures. When he appeared on Desert Island Discs in February 2001, Doll told Sue Lawley that ‘the effects of other people smoking in my presence are so small that it doesn’t worry me’.

Recent headlines quoting British chief medical officer Sir Liam Donaldson’s statement that ‘we are in the grip of a smoking epidemic’ mark a new low point in the abuse of science in the anti-smoking cause (21). Reports quoted Professor Donaldson’s statement that 106,000 people were ‘dying needlessly’ in the UK every year. Some newspapers provided the further breakdown detailed in the Health Development Agency press release: 1,600 deaths a week, 230 a day, 10 every hour. This alarmist rhetoric disguises the fact that mortality from lung cancer has been declining in Britain since the 1960s; over the past decade it has fallen by more than 25 per cent among men (who account for 60 per cent of deaths).

Closer scrutiny of the report on which these accounts are based reveals that the figures presented are not of recorded deaths but ‘are estimates and should be treated as such’. They are derived from a novel technique known as ‘synthetical statistical estimation’: they ‘reflect expected values for the topics under investigation…and should not be regarded as absolute or exact’. The authors warn that their results ‘must be used with caution’ – a caveat that does not appear in any of the newspaper reports, or indeed in the HDA press release. Though such estimates may be of value for research or policy purposes, using them to scare the public cannot be considered legitimate.

If anti-smoking campaigners have been slow to recognise the German contribution to tobacco epidemiology, they have been even more reluctant to acknowledge the parallels between their public health policies and those pursued by the Nazis. Yet the similarities are remarkable. According to Proctor, the government in Germany in the 1930s ‘launched an ambitious anti-smoking campaign, involving extensive public health education, bans on certain forms of advertising, and restrictions on smoking in many public spaces’ (22).

Women and youth were a particular focus of anti-smoking propaganda and restrictions on sales. Furthermore, ‘activists called for bans on smoking while driving, for an end to smoking in the workplace, and for the establishment of tobacco counselling centres’ (23). Enterprising firms marketed a range of anti-smoking preparations, from mouthwashes to intravenous infusions. Therapists offered hypnotism and a range of counselling techniques to encourage people to quit smoking.

A number of themes recur in the anti-smoking campaigns. In Germany, campaigners asserted that smoking caused infertility among women and impotence among men, dubious claims echoed in the recent British Medical Association report on ‘the impact of smoking on sexual, reproductive and child health’ (24). Anti-tobacco activists have consistently emphasised the particular vulnerability of women, both to the physical effects of smoking and to the seductive power of cigarette advertising. National socialist propagandists railed against ‘tobacco capitalism’ and stigmatised tobacco as an ‘enemy of the people’; they condemned ‘smoking slavery’ and even ‘tobacco terror’ – slogans with an alarmingly contemporary ring.

Scaremongering about smoking as an ‘epidemic’, even a ‘plague’, was as familiar in Germany in the 1930s as it is in Britain today. At the founding conference of the Institute for Tobacco Hazards Research in 1941, Professor Otto Graf warned of the dangers of ‘passive smoking’ and called for a workplace ban.

There are also differences in the anti-smoking campaigns. The Nazi emphasis on smoking as a threat to racial purity and national efficiency is absent in modern Britain. Similar themes today assume a more individualistic form: smoking is depicted a threat to the body, now replacing the nation as a ‘fortress of purity, cleanliness and muscular macho health fanaticism’ (25).

However, the recent advertising campaign featuring cigarettes oozing a viscous paste over a convivial group of young smokers identifies smoking as a source of social, as well as individual, pollution and contamination. The Nazis were more concerned about the economic burden of smoking-related ill-health and the resulting loss of skilled and professional manpower. In Britain, the anti-smoking campaign has recently focused particularly on the differential impact of smoking on poorer communities, a particular theme of the ‘smoking epidemic’ report, which implies that cigarettes are the main cause of class differentials in health in Britain. Whereas the Nazis associated cigarettes with communism, for New Labour it seems that the prohibition of smoking now points the way forward on the British road to socialism (though this goal is not apparent in other areas of government policy).

In this era of evidence-based policy, we can look back on the German public health experiment in relation to smoking and ask – did it work? Needless to say, this is not an easy question to answer. According to Proctor, the Nazi campaign did not succeed in reducing overall tobacco consumption until the later stages of the war (when production and supply were disrupted). After the war, poverty and rationing may have curtailed smoking. He believes that whereas Nazi militarism led to an increase in smoking among men in the armed forces, Nazi paternalism was effective in discouraging women from smoking. Whatever the reason, women in Germany took up smoking at a much slower pace than women in the USA. Proctor calculates that this delay may have contributed to a reduced rate of lung cancer among women, possibly preventing 20,000 deaths over the postwar decades.

The experience of anti-smoking measures in Britain over recent decades is also inconclusive. Contrary to the impression created by the doom-mongers, there has been a dramatic decline in smoking since the dangers first became widely publicised in the 1960s. Interestingly, the sharpest fall took place in the 1970s and 80s, before the current wave of anti-smoking measures. The intensive anti-smoking policies introduced in the 1990s, with further restrictions on advertising, workplace bans and the promotion of a panoply of ‘smoking cessation’ therapies, appear to have had relatively little effect.

There is some evidence that among young people, these measures may have been counterproductive – a danger recognised by the Nazi public health authorities who recognised that ‘forbidden fruit is tempting’. However, the ineffectiveness of more coercive measures in Britain has not led to any questioning of the policy, but simply to calls for more of the same.

For the anti-smoking zealots, the loss of civil liberties resulting from their widening range of bans and proscriptions is justified by the anticipated health gain. Yet, as the great microbiologist Rene Dubos observed, health should not be considered an end in itself, but as ‘the condition best suited to reach goals that each individual formulates for himself’ (26). By curtailing the autonomy of the self-determining individual, authoritarian public health policies infantilise society, weaken democracy and diminish humanity.

Dr Michael Fitzpatrick is the author of MMR and Autism: What Parents Need to Know, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA).

Read on:

spiked-issue: No smoking

Straw nanny, by Dr Michael Fitzpatrick

Smoking out the facts, by Liz Frayn

(1) The Nazi War on Cancer, by Robert N Proctor, Princeton, New Jersey: Princeton University Press, 1999

(2) Proctor, p176.

(3) Tony Blair, Preface to Smoking Kills: a White Paper on Tobacco, London: Stationery Office, 1998: p1

(4) Proctor, p241.

(5) Proctor, p183-4.

(6) Proctor, p194-196.

(7) Proctor, p213-216.

(8) Richard Doll and others, ‘Mortality in relation to smoking: 50 years’ observations on male British doctors’, BMJ 2004; 328: 1519-33. This report finally acknowledges the German contribution to this field.

(9) see The Tyranny of Health, by Michael Fitzpatrick, London: Routledge, 2001: p38.

(10) Hackshaw, AK and others, ‘The accumulated evidence on lung cancer and environmental tobacco smoke’, British Medical Journal, 1997; 315: 980-8.

(11) Law, MR and others, ‘Environmental tobacco smoke and ischaemic heart disease: an evaluation of the evidence’, BMJ 1997; 315: 973-80.

(12) Copas, JB, Shi JQ, ‘Reanalysis of epidemiological evidence on lung cancer and passive smoking’, BMJ 2000; 320: 417-18.

(13) ‘Is environmental tobacco smoke a risk factor for carcinoma of the lung?’, by Robert Nilsson in R Bate (ed), What risk?, London: Butterworth/Heinemann, 1997

(14) ‘Scientific fact or scientific delusion?’, by JR Johnstone in Health, lifestyle and the environment, London: Social Affairs Unit/Manhattan Institute, 1991, p81.

(15) ‘Environmental tobacco smoke and tobacco-related mortality in a prospective study of Californians, 1960-1999’, Enstrom, J., Kabat, G., British Medical Journal, 2003; 326: 1057

(16) Enstrom, J., Kabat, G. ‘Authors’ reply’, British Medical Journal 2003; 327:504-5

(17) ‘Effect of passive smoking on health’, Davey Smith, G., British Medical Journal 2003; 326:1048-49

(18) ‘Passive smoking and health: should we believe Philip Morris’ experts?’ Davey Smith, G., Phillips, AN., British Medical Journal, 1996; 313: 929-933

(19) Berridge, V. ‘Science and policy: the case of post-war British smoking policy’ in S.Lock and others (eds), Ashes to Ashes, Amsterdam/Atlanta: Rodopi

(20) Doll, R. ‘The first reports of smoking and lung cancer’ in S.Lock and others (eds), Ashes to Ashes, Amsterdam/Atlanta: Rodopi

(21) Twigg, L., Moon, G., Walker, S., The smoking epidemic in England, London: Health Development Agency, November 2004

(22) Proctor, p175

(23) Proctor, p201

(24) British Medical Association, Smoking and reproductive life, Board of Science and Education and Tobacco Control Resource Centre, London: BMA, February 2004

(25) Proctor, p219

(26) Dubos, R. The mirage of health. London: Allen and Unwin, 1960, p219.