frank_davis (frank_davis) wrote,
frank_davis
frank_davis

The London Hospitals study

The London Hospitals study  was the first British study to investigate possible causes of the growing epidemic of lung cancer. It was published by Richard Doll and Bradford Hill in 1950. Bradford Hill was a statistician, and Richard Doll was a young doctor. In the study, several hundred lung cancer patients in London hospitals were questioned about their past smoking habits and other behaviours, to see whether any pattern emerged. 

Many years later, Sir Richard Doll wrote:

By the time we had data on several hundred patients it was obvious that the principal difference between the patients with and without lung cancer was their smoking habits, and we had to make up our minds whether the association was due to chance, bias, confounding, or to cause and effect. The evidence that led us to conclude that it was due to the last (and which led me to give up smoking in 1949) is described in our first paper... (source

In fact, the results eventually showed that in 649 cases of lung cancer, 647 were among smokers.

And these are impressive numbers. And they were reproduced in Sir Richard Doll's Times obituary in 2005.

He and colleagues at the council interviewed hundreds of lung cancer patients. Doll thought that the increasing incidence of the disease might owe something to the hundreds of tonnes of tarmac being laid down across Britain at this time, but soon discovered that in 649 lung cancer cases there were only two non-smokers. Doll himself gave up the habit two thirds of the way through the research (source)

It certainly looked like a very strong case had been made. The lung cancer patients were almost all smokers. It very much looked as if it was smoking that was causing lung cancer. Richard Doll clearly thought so, since he promptly gave up smoking. It also appeared to have convinced Sir George Godber:
 
Almost half a century ago we learned that smoking was the main cause of lung cancer. Albeit our knowledge in 1950 was so limited,... (source)

Godber was later to become one of the principal instigators of the notion of passive smoking - the idea that smokers not only harmed themselves, but also the people around them.

The London Hospitals study generated a storm of controversy. If Richard Doll and George Godber were convinced by it, others were not. Among these was Sir Ronald Fisher, widely regarded as the father of statistics, who was able to obtain Doll and Hill's data, and to show that smokers who inhaled tobacco smoke were less likely to get lung cancer than those who did not inhale. Fisher eventually wrote a short book on The Cancer Controversy.

There is another approach that can be taken to studies of this sort. If 65% of some population eats apple pie every day, and the rest never touch the stuff, then 65% of hospital patients from this population can be expected to be apple pie eaters, if eating apple pie neither increases nor decreases the risk of falling ill with any disease. If more than 65% of the patients are apple pie addicts, then eating apple pie becomes a risk factor. And if less than 65%, eating apple pie offers protection.

So, in the same way, we ought to ask of the London Hospitals study what fraction of its overall sample population were smokers, for this would give the fraction of lung cancer patients that might be expected to be smokers, if smoking carried no risk.

And this figure is available in Table 4 of the study. There were 2 non-smokers and 647 smokers in the lung cancer study group. And there were 27 non-smokers and 622 smokers in the non-lung-cancer control group. So that, in the study as a whole, 97.7% of patients were smokers. This being so, we would expect that 97.7% of lung cancer patients would also be smokers, if smoking was unconnected to lung cancer. Instead we find that 99.7% of them were smokers. Is that particularly alarming? All we have discovered is that in a population in which nearly everybody smoked, nearly everybody with lung cancer also smoked: which is precisely what would be expected. Just as if nearly all the patients in the London Hospitals study were Londoners, it would be expected that nearly all the lung cancer patients would be Londoners as well.

Looked at this way, the London Hospitals study tells us nothing. If anything, it might even be said to give smoking a clean bill of health.

Nevertheless, when Doll and Hill commenced their next study, the much more well known British Doctors study, the focus was entirely upon smoking. The doctors were only asked about their smoking habits, and about nothing else at all.

The London Hospitals study has been rather overshadowed by the subsequent British Doctors study, but it's arguably a much more important study, because it was the study that first linked smoking with lung cancer, and defined the subsequent study. 

How anyone responds to the London Hospitals study depends on how they look at it. If - as the Times reported in Sir Richard Doll's obituary - it is seen as 99.7% (647 out of 649) of lung cancer patients being smokers, then it very much looks as if smoking causes lung cancer. And this was the conclusion to which Richard Doll seems to have jumped even before all the results were in. And it seems to have also convinced George Godber.

If, however, it is pointed out that, in a population composed 97.7% of smokers, 97.7% of lung cancer patients can be expected to be smokers, the fact that 99.7% of them were smokers isn't in the least bit surprising. 

Richard Doll and George Godber went on to become antismoking titans of post-war Britain. The critics of the London Hospitals study have faded into history, and are almost completely forgotten - to the point that most people don't even know that there ever were any critics at all.

Tags: cancer
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