Smoking and the sea change in public health, 1945-2007
Virginia Berridge |
- Today's alliance between doctors and the government to influence individual lifestyles is a relatively recent phenomenon.
- First, it required the medical profession to abandon its culture of secrecy, based on patient confidentiality: this began with the use of television in the late 1950s.
- Second, it required the introduction into public policy of studies linking lifestyles and health risks: this began with a change in leadership at the Royal College of Physicians in the early 1960s.
- Third, it required a shift in the nature of public health from local information giving to central publicity campaigning: this began with the Cohen Report on health education in 1964, advocating a rethinking of the profession of health educators as persuaders, even salesmen.
- Finally, it required politicians to modify their early dislike of the 'nanny state', opened up by Labour politicians' willingness to be more interventionist in the 1960s.
- At first this was limited to communication and mass advertising, not the use of pharmaceutical treatments and the control of public space.
- Smoking was a key post-war issue which epitomised and accelerated these changes: in the 1940s the government gave tobacco tokens as an economic supplement to old age pensions; in the late 1990s, nicotine replacement therapy was free to those in deprived areas as a remedy for inequality.
- Smoking policy was part of a process of cultural transformation which has helped bring about the new ban on smoking in public places, a government act which would have been unthinkable in the 1950s.
- This has involved a sea change away from the traditional assumption that lifestyles were a matter of individual personal choices.
- And the smoking story clearly has implications for other areas of potential public health change: alcohol for example.
Parents should be prosecuted if they give alcohol to their children before the age of 15. Medical evidence says it's dangerous - and it's the government's duty to intervene. Eat your five portions of fruit and vegetables each day. It's good for you says the Chief Medical Officer. In 2007, we are used to these headlines and advice - and to the alliance between doctors and government on which they are based. It is the individual citizen's duty to adopt a healthy lifestyle - but healthy living is founded on advice from doctors and scientists - and often behaviour is regulated by government. That regulation takes different forms and the smoking ban due to be implemented on 1 July 2007 is the latest example.
For doctors to advise about individual habits and behaviour is a relatively new development for the medical profession: government too, had qualms initially when the change of approach came onto the agenda. Such developments were not an automatic response to health problems. The change of attitude developed in the 1950s and 1960s out of new styles of public health and communication with the public, and changes in the patterns of disease.
One obvious alteration after the Second World War was in the diseases affecting the population. High rates of death from bronchitis and tuberculosis were in decline as housing conditions improved and the BCG vaccine became widely available in the 1950s. Diphtheria and scarlet fever were also in decline. The age of epidemic disease was over, so it was thought, - and the new 'diseases of affluence' were more prominent. Cancer and heart disease mortality started to dominate the statistics. Public health practitioners spoke of an epidemic of affluence rather than one of deprivation. Here were new problems for public health.
From a culture of secrecy to a culture of communication
Changes were also underway in the medical profession, among doctors in general and the specific group which specialised in public health. The traditional role of public health had been in combating epidemic and infectious disease, with the tools of immunisation, of sanitation and also of the laboratory investigation of disease. Public health had been a sub section of the medical profession since the second half of the nineteenth century. Its key local official was the Medical Officer of Health (MoH), ensconced in local government as an official responsible to the health committee of the local council. These doctors were used to offering advice and to providing health education. Local councils would run health weeks and the local health visitor was a community figure, visiting homes after a birth had taken place to offer support and education about child rearing practices. The MoH was a public figure, well-known in the local community.
But there was also a culture of secrecy in medicine. This was the model of 'traditional medical ethics', medical confidentiality based on a doctor engaged in a private relationship with the individual patient. Doctors could not be seen to advertise. The act of withholding information was, as the historian David Vincent, has noted, 'at once a claim to probity and a demand for deference - it implies a sense of responsibility which arises from and defines a position of moral authority' (Vincent, p.15). It was part of the establishment of doctors' professional standing, a means whereby they distanced themselves from quacks and hucksters who advertised patent medicines as consumer goods. Professional ethics and the maintenance of these standards were part of the machinery of professional regulation established in the mid-nineteenth century. Doctors who advertised their wares could be brought before the General Medical Council.
In the 1950s and 60s those traditions began to change. Doctors began to speak directly to the public. A 'lifting of the veil' of secrecy which had surrounded medicine took place. The advent of television and of new styles of communication brought possibilities for medicine. Television transmission began in Britain in 1936, was halted by the war and re-started in 1946. The BBC's television monopoly ended in 1955 with the introduction of commercial television; the BBC acquired a second channel in 1963. In the ten years from 1950 to 1960 the proportion of the adult population owning a television set rose from four to eighty per cent.
Some doctors saw the potential of the new communication outlets. Chief among them was Charles Fletcher. Fletcher came from an impeccable medical background; his father, Walter Morley Fletcher, had been secretary of the Medical Research Council. But he also had a passion for communicating with the public. In 1958 his series Your Life in Their Hands showing surgical procedures on television, caused huge controversy. The series had been part of longer term developments in medical broadcasting. The 1958 series had originated in an earlier set of programmes called 'Thursday Clinic' transmitted in 1954 and 1956 consisting of outside broadcasts from St Mary's hospital in Paddington. The work of NHS hospitals had been seen in earlier programmes such as Matters of Life and Death (1951) and Matters of Medicine (1952) and medical procedures were also shown in The Hurt Mind (1957) which dealt with new developments in the treatment of mental illness and in which Fletcher was also involved. Such programmes, and the media controversy over cases of conjoined twins in the 1950s, had begun the re-ordering of relationships round medical confidentiality which up until then had been a constraining issue for public depictions of medicine.
A new style of public health
The possibilities of communication in this 'modern' way coincided with the emergence of a new style of public health. Public health doctors had not, contrary to expectation, become the central force in the new National Health Service. The powerbase of the new service was in the hospitals, not in local government. Nye Bevan, the architect of the NHS, had secured the support of doctors by nationalizing the hospitals and saving doctors from what they saw as the servitude of salaried service in local government. What role then for public health? In the 1950s and 60s some public health doctors in academic life began to argue for a new style, focusing on chronic disease and using the new modes of communication. Here is Dr Jerry Morris of the Social Medicine Unit, speaking on the radio in the 1950s:
We are dealing with a different social situation. The nineteenth century epidemics, bred in poverty and malnutrition, arose from the failures of the social systemBut coronary thrombosiswith its origins apparently in high living standardsseems to be arising from what we regard as successes of the social systemIt is becoming clear that in the modification of personal behaviour, of diet, smoking, physical exercise and the rest, which look like providing at any rate part of the answer, the responsibility of the individual for his own health will be far greater than formerly. It will not be possible to impose from without (as drains were built) the new norms of behaviour better serving the needs of middle and old age. They will only come about in a new kind of partnership between community and individual.
The use of modern methods of mass communication was to be part of that new partnership. So too was the use of risk-factor epidemiology, a new science for public health which emphasized long-term risk in the population from current health habits. Two events in the 1960s typified these changes. One was the publication of the Royal College of Physicians (RCP)1962 report on smoking, the other was the 1964 report of the Cohen committee on health education.
The connection between smoking and lung cancer had been elaborated in the 1950s by Richard Doll and Austen Bradford Hill. But they had not pressed their results on policy makers, preferring to keep science and politics separate. Why did the College take the subject on? The Royal College was not the most obvious body to produce a report on the link between smoking and lung cancer and in fact it had already turned down the opportunity once. In November 1956, Francis Avery Jones, a gastroenterologist from the Central Middlesex hospital, with whom Doll had originally worked, wrote to the President of the College, Lord Brain, urging that the College put out a statement on the effect of smoking on health 'with particular reference to the rising generation'. Brain, a shy reserved man, took a month to reply, only to turn the proposal down. The reasons for his refusal were typical of the time, revealing doctors' dislike of giving advice:
The work of Richard Doll and Bradford Hill has received very wide publicity and must be known, I should imagine, to every doctor in the country, so it is difficult to see that the College could add anything to the knowledge of the existing facts. If we go beyond facts, to the question of the giving of advice to the public as to what action they should take in the light of the facts, I doubt very much whether that should be a function of the College.
Subsequently the College's attitude changed. In 1957 Robert Platt was elected President as successor to Brain. Platt had a modernizing agenda for the profession into which smoking fitted admirably and the deputy Chief Medical Officer, George Godber, was also keen to have action. The College broke new ground by deciding to appeal to the public with its report. The report was to be a 'media event', a novel stance for a medical organization at that time.
The College hired a public relations consultant, Roger Braban, to manage the launch of the report and held its first-ever press conference. Charles Fletcher, who had been secretary of the committee, later gave a flavour of how it went:
On the day before publication a press conference was held at the College and it was crowded. Many questions were asked. When one reporter quoted that the annual risk of lung cancer in heavy smokers aged 55 was only one in 23 the president asked him if he would fly with an airline only one in 23 of whose planes crashed he agreed he would not. Next day there was fortunately no big news and the report got major headlines, Robert Platt on the BBC and I was interviewed on ITV.
The report was also marked by a Panorama programme, the flagship TV vehicle for current affairs, which went out on television on 12 March just after the publication of the report. Fronted by the commentator Richard Dimbleby, the programme interviewed scientists and members of the public about their response and about giving up smoking. The centrepiece of the programme was an interview by the presenter Robert Kee with John Partridge, the Chairman of the Tobacco Manufacturers Standing Committee, and Sir Robert Platt. The stand off between the two men, with Platt robustly interrupting Partridge's defence of the industry, made good television. It was a portent of the future mediatisation of health issues and the premium it put on conflict and opposition.
The report was popular with the public. Originally the College had only wanted 5,000 copies printed and when Fletcher insisted on double that number, had required the committee to pay for any copies which were unsold. But the report sold out within a few days and a second printing was needed. The report had sold over 33,000 copies in the UK by the autumn of 1963 and over 50,000 in the US. It was followed the following year by Fletcher's Penguin Special Common sense about smoking which symbolically linked the medical evidence with a chapter on economic effects and others on social implications and how to stop. Here was a further attempt to appeal to the public, which brought together what was to become a common combination in public health, a review of the science coupled with a self-help guide to individual reformation.
Public health was changing. The 1964 Cohen Report on health education exemplified the new approach. It argued that the old local-information-giving approach was ineffective and that what was needed was a greater degree of central publicity, using habit-changing campaigns and social surveys, as well as strengthening the new profession of health educators. The models came from American social psychology. The new breed of educators was to be trained in journalism, publicity, the behavioural sciences and teaching methods. Training people would involve both imparting knowledge and inculcating self-discipline, a telling new phrase. The new health educator was to be a salesman, persuading people to take appropriate action. Just knowing about the risks of cigarette smoking was not enough: Cohen called tobacco advertising 'propaganda' and it had to be countered in the same way. This was a major change from the even-handed response of health education in the 1950s. Persuasion was now the key. The report led to the establishment of a new central public health agency, the Health Education Council (HEC) set up in 1968 and re formed in 1973. In the early 1970s the MoH lost influence, disappearing from local government and was relocated in the NHS as 'consultant community physician'. The cutting edge of public health was now the mass media campaign.
The HEC ran innovative campaigns in the 1970s. Informed by market research and advertising agencies, they addressed issues like contraception. A doleful pregnant man ('Would you be more careful if it was you who got pregnant?') is still remembered today. One of the first advertising campaigns in 1973 used a picture of a naked mother smoking: it was an early success for a new advertising agency, Saatchi and Saatchi. 'Is it fair to force your baby to smoke cigarettes?' it asked. Such strategies fed into the changes in public health in the 1970s which gave a greater role for advice on individual lifestyle. Although the focus on women and on women's role as mothers was a traditional one in public health, harking back to the early-twentieth century, the intensive use of the mass media and communications strategies was new, as was the stress on the risks of chronic disease.
Politicians also modified their dislike of intervention. In the 1950s, Conservative politicians had been concerned about this new role for government. R. A .Butler, Lord Privy Seal, had commented in May 1956, ' From the point of view of social hygiene, cancer of the lung is not a disease like tuberculosis; nor should the government assume too lightly the odium of advising the general public on their personal tastes and habits where the evidence of the harm which may result is not conclusive.' This was a theme which emerged consistently throughout the political discussions. Governments were not accustomed to persuading their citizens to alter their personal habits and politicians were worried about the electoral implications of the 'nanny state'. As the minutes of the 1950s Cabinet committee on smoking record, 'The Government should not seek to intrude into the sphere of an individual's personal responsibility. It was however, important to stress this element of personal choice since direct government action was excluded.' In the 1960s, Labour politicians, including the Minister of Health Kenneth Robinson, who was a former general practitioner, were more willing to take an interventionist stance. But their activities were largely limited again to communication and to mass advertising, not tackling taxation or control of public space.
By the end of the century, marketing had an added dimension as public health allied itself to treatment-focused approaches which were dependent on the pharmaceutical industry. A new, pharmaceutical public health promoted drug treatments as preventive strategies, 'magic bullets' for social as well as individual behavioural problems. In the 1940s the government gave tobacco tokens as an economic supplement to old age pensions: in the late 1990s, nicotine replacement therapy was free to those in deprived areas as a remedy for inequality. The contrast in state responses shows the change which had taken place over the half-century.
Tony Blair in a speech on public health in the summer of 2006 spoke of the dilemmas which face politicians addressing public health change and the potential limits of state intervention. Little did he realize that he was articulating concerns which had animated his political opponents as far back as the 1950s. The post-war decades saw the establishment of the connection between doctors advising the public on behaviour and government action to reinforce their advice, a connection we may resist - but now take for granted. That post-war change also helped to initiate a process of cultural change around smoking. It is that change in culture which has helped bring about the smoking ban - a form of control that would have been quite unthinkable in the 1950s. The historical example of doctors, politicians, smoking and cultural change offers food for thought about other issues such as alcohol, which are now higher on the public health agenda.
This paper is based on an article for the August 2007 issue of History Today.
Virginia Berridge, Marketing health. Smoking and the discourse of public health, 1945-c.2000 (Oxford: Oxford University Press, 2007).
Kelly Loughlin, 'Spectacle and secrecy: press coverage of conjoined twins in 1950s Britain' Medical History 2005, 49; 197-212.
David Vincent, The culture of secrecy: Britain, 1932-1998 (Oxford: Oxford University Press, 1998).
About the author
Virginia Berridge is Director of the Centre for History in Public Health at the London School of Hygiene and Tropical Medicine, University of London and a founding member of History & Policy. Her new book Marketing health. Smoking and the discourse of public health, 1945-2000, will be published by Oxford University Press in August 2007. firstname.lastname@example.org.