Epidemiologist Linked Smoking, Lung Cancer

Richard Doll, the British epidemiologist whose pioneering studies of the link between smoking and lung cancer saved millions of lives by persuading smokers to quit, died Sunday at John Radcliffe Hospital in Oxford after a short illness. He was 92.

His 50-plus years of studies showed that half of all smokers were killed prematurely by their habit, losing an average of 10 years of life from cancer and other diseases induced by tobacco smoke. On the brighter side, he also demonstrated that quitting could sharply reduce the risk of premature death, even for longtime smokers.

“Sir Richard’s enormous contribution to medicine ... cannot be overstated,” said Dr. John Hood, vice chancellor of Oxford. His research “led to the dramatic reduction in smoking rates in Britain over the past 50 years, especially in men. This research has saved many millions of lives.”

Doll also performed valuable research illuminating the side effects of oral contraceptives, the harmful effects of radiation, the benefits of aspirin in preventing heart disease and the hazards of radiation.

“He was probably the most renowned epidemiologist in the world,” said Dr. Stanton Glantz of UC San Francisco, a leading anti-tobacco activist. “He was a giant.”

But his name is most indelibly linked to the studies of smoking that he began shortly after World War II.

Postwar Britain was in the throes of a massive lung cancer epidemic and no one seemed to know why. Many researchers attributed it to air pollution because of the presence of known carcinogens in foul air. Others thought it might be linked to the tar used on hundreds of miles of British roads.

“My own guess was that it had something to do with motorcars,” Doll said years later.

The Medical Research Council, Britain’s equivalent of the National Institutes of Health, recruited medical economist Austin Bradford Hill to study the causes of the epidemic. He enlisted Doll, then a young scientist at the council.

The two devised a questionnaire about lifestyle, environmental exposures, food consumption, smoking history and other personal data that social workers administered to everyone entering London hospitals with a possible diagnosis of lung cancer.

At first, the data did not show much. But when Doll went back and checked the patients’ final diagnoses, the results were startlingly clear. Virtually all of those patients whose diagnosis was changed from lung cancer to some other, less serious disease were nonsmokers. However, 647 of the 649 who ended up with a final diagnosis of cancer were smokers.

Doll and Hill prepared a report for publication in 1949, but disbelieving bureaucrats held it up, arguing that perhaps the situation was unique to London. Doll and Hill expanded their survey to more than 5,000 patients in hospitals throughout the country.

When results from those hospitals began to support their initial findings, the scientists got their report published in late 1950. But by then, Americans Ernst L. Wynder and Morton L. Levin had published similar conclusions in the Journal of the American Medical Assn., albeit on smaller study groups.

Doll, who had begun smoking at the age of 18 against his father’s wishes, stopped abruptly at 37 when he saw which way the wind was blowing, calling the habit “a mug’s [fool’s] game.”

Altogether, five papers establishing the link were published that year, but they fell largely on deaf ears. “It didn’t create any impression at all, really,” Doll recalled later.

Tobacco companies rejected the findings out of hand and government officials ignored them, arguing that publicizing the results would unduly scare the nearly 80% of men who smoked.

Looking for further evidence, Doll and Hill decided to focus on smokers rather than cancer patients. Doll wrote a letter to every physician in Britain, enclosing a questionnaire that covered whether, and how much, they smoked. Nearly two-thirds of the physicians, about 40,500, responded, triggering a half-century study that provided immensely valuable information.

Within 2 1/2 years, the team began to see an increase in lung cancer patients among the physicians, but not enough to force anyone to pay attention. By 1956, however, 400 of the smokers had died of lung cancer, but virtually none of the nonsmokers had died.

By 1957, the evidence was overwhelming, and the Ministry of Health called a major news conference to release the findings. Ironically, Doll noted, “the minister who announced it was smoking a cigarette at the same time.”

That study “laid the foundation for the 1964 Surgeon General’s report on smoking,” Glantz said.

The public and the media were slow to accept the findings, but physicians were not. When Doll and Hill started their study, physicians smoked as many cigarettes as everyone else. But by 1971, the doctors smoked only 37% as many cigarettes as other men. Today, only about 26% of Britons smoke.

The doctors study continued to provide useful new information. After 20 years of follow-up, Doll concluded that smokers were twice as likely to die prematurely, and he predicted that tobacco use would kill one-third to half of all smokers.

Another 20 years of data showed the situation to be even worse than he had thought. Half of all smokers would die before 70, he found, compared with only a fifth of nonsmokers. By then, he and other researchers had also linked smoking to 40 other diseases, most notably heart disease.

Their 50-year data, reported last year, concluded that smokers lost an average of 10 years of life as a result of their habit. Those who quit smoking at 60 gained back about three years of life; those who quit at 50 gained back six years; those who quit at 40 gained by nine years; and those who quit before 30 suffered almost no ill effects.

Doll was often quoted as saying that working in the tobacco industry or promoting use of its products was “as immoral as keeping a brothel.”

While continuing his smoking studies, Doll turned his broad intellect to other topics.

In the mid-1950s, he studied the health effects of low doses of radiation, examining about 14,000 patients who had received radiation treatment for a condition known as ankylosing spondylitis. He eventually concluded that contrary to popular belief, even low doses of radiation to the bone marrow increased the risk of leukemia and that higher doses increased it proportionately.

In 1968, he published a report showing that women using birth control pills had as much as 10 times the normal risk of developing blood clots in their legs.

He studied the risks of radon, a colorless, odorless radioactive gas that is present in houses throughout Britain. Inhaled radon produces about 1,000 lung cancer cases in Britain each year. Doll concluded that its effects were much more damaging in people whose lungs had already been weakened by smoking.

In 1976, he was one of the authors of a report that recommended adding fluoride to water in Britain to prevent tooth decay. In 1985, he warned that the dangers of ultraviolet light to sunbathers was much greater than previously thought and urged greater avoidance of the sun.

In the late 1990s, the was coauthor of a report that found that giving vitamin D to the elderly decreased the risk of bone fractures. And in 2002, he published a report based on 150,000 women that found that smoking does not increase the risk of breast cancer, but that one alcoholic drink a day increases the risk by 6%.

William Richard Shaboe Doll was born Oct. 28, 1912, in Hampton, England, near the Thames River. His father, Henry, was a general practitioner and his mother, Amy, was a gifted concert pianist.

He initially rebelled against his father’s demand that he become a physician, planning to enroll at Trinity College to study mathematics. But the night before a crucial entrance exam, some of his friends at Trinity plied him with home-brewed Trinity beer, which had an alcoholic content of 8%. Severely hung over, he flunked the exam miserably.

He was offered admittance anyway, but was too ashamed to accept, enrolling instead at St. Thomas’ Medical School in London. At school, he was considered left-leaning, becoming active in groups that campaigned against racism and poverty.

During the war, he served in the medical corps, participating in the evacuation of Dunkirk, serving at hospitals in the Middle East and North Africa and eventually on a hospital ship in the Mediterranean. In 1944, a bout with tuberculosis led to the loss of a kidney, ending his medical service.

He returned to St. Thomas’ but chafed at the necessity of deferring to senior personnel in the hope of winning promotions.

To avoid the necessary obsequiousness, he turned to research at Central Middlesex County Hospital before joining the Medical Research Council.

He was director of the council from 1961 to 1969, when he was appointed Regius Professor of Medicine at Oxford by the prime minister -- a posting that is considered the medical equivalent of becoming the Archbishop of Canterbury. He held that position for 10 years, and formally retired in 1983, although he continued his research to the end despite his failing health.

Despite his findings, he never proselytized against smokers, arguing that such public activism would make it difficult to alter his position if he encountered new evidence.

Although he castigated the tobacco industry, he was tolerant of smokers, calling it scandalous that they were forced to leave buildings to light up.

He never objected to anyone smoking in his presence, despite the fact that he had developed evidence showing the dangers of secondhand smoke.

Doll was knighted in 1971 and received many other international awards. He was nominated for the Nobel Prize several times but never received it -- an outcome that many of his colleagues considered scandalous.

In 1949, he married Joan Mary Faulkner, who was also a physician. She died in 2001. Doll’s survivors include a son and a daughter.