Marketing Health

In the early 1960s Charles Rosenberg used cholera as a sampling device, a window on cultural practices and values in society. This book sees smoking in a similar light. It uses the changed perception of tobacco and the ways of investigating its use in society as an emblem of public health change since the 1950s. The aim is to move from a focus on the role of professionals in public health, on public health practice, to a discussion of the ideology and outlook, the discourse of public health. Public health change can in fact be characterised in three ways, or at three levels: formal institutional change; professional change; and changes in the knowledge base and the ideology of public health. The main focus here is the third level, and how such changes in science and outlook have meshed with changes in policy.

The book analyses the changing ideology and compass of post 1945 public health; and uses smoking as the key 'tracer policy' which explains how public health developed, touching on other issues on the way. Smoking is the tracer policy in four broad ways. Firstly, marketing: the text sees the marketing of public health as defining both the beginning and the end of that fifty year period. In the post war years, public health adopted marketing in using the mass media to speak to and inculcate risk avoiding behaviour in the population: it marketed the science of chronic disease epidemiology to a mass audience.

By the end of the century, marketing had an added dimension as public health allied itself to treatment focussed approaches which were dependent on the pharmaceutical industry. A new pharmaceutical public health promoted drug treatments as preventive strategies, as '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.

Richard Doll always maintained that discovering the link between smoking and lung cancer was a surprise:

Doll was questioned by the historian Roy Porter after he had made this statement. Porter asked how surprised he was by these findings: Doll said 'Very'. Such narratives of discovery are commonly observed in the history of science. Here was a new form of scientific discovery in the post-war period, a discovery of statistical correlation and its impact, rather than a microbe or bacteria causing disease and observed in the laboratory: but the language used to describe its unveiling was the same.

The early history of the smoking and lung cancer connection is well known and has been recounted in a number of different histories. Concern was roused by the gradual increase in the incidence of cancer; a change in the balance of the sexes, towards men; and the increasingly important role of lung cancer. The greatest increase in lung cancer came in males over forty five, where the incidence increased six fold between 1930 and 1945. At first it was thought that these changes might be due to improved diagnosis and better recording and registration.

Research had been carried out in the 1930s by Sir Ernest Kennaway, Professor of Experimental Pathology at the Chester Beatty Institute in London and famous for his late 1920s work on the carcinogenic potential of 3,4-benzpyrene. A detailed examination of post mortem certificates had been published in 1947, and had helped to eliminate occupational and environmental factors. Kennaway pointed to a connection with cigarette smoking, but his work, based on statistical correlations, carried little weight in the context of the time, when such correlations were not seen as central to scientific proof. Laboratory studies also tended to support the connection. Research had also been undertaken before the War in Nazi Germany and by the American biometrician Raymond Pearl, for the insurance industry.

The issue became more urgent post war and discussions between the Ministry of Health and the Medical Research Council (MRC) led to the council convening an informal conference on cancer of the lung in February 1947. The MRC agreed to initiate a large scale statistical study of the past smoking habits of those with cancer of the lung and of two control groups. Who would take the work forward was a matter of discussion: both the Social Medicine Unit under Professor Jerry Morris and Patrick Lawther, who subsequently ran the Air Pollution Unit at St Bartholomew's Hospital, were under consideration. This was the origin of the work carried out in the Statistical Research Unit at the London School of Hygiene and Tropical Medicine (LSHTM) by Professor Bradford Hill and Dr. Richard Doll. The results, published in the British Medical Journal (BMJ) in 1950, concluded that there was a 'real association' between carcinoma of the lung and smoking and that smoking was a factor, and an important one, in the production of carcinoma of the lung.

In April 1963, one D. Kelly wrote to the Ministry of Health about an idea he had in his head for quite a while about anti smoking publicity. After discussion with a German doctor friend, he suggested:

K. Norman Reynolds had written in the previous month. He enclosed a poster he had originally designed for a competition, but was 'alas, too late in entering it'. The word 'Cancer' is spelt in cork-tipped cigarettes, which gets across a point as well as adding to the eye appeal. In the early 1960s, the Ministry was the recipient of 'puffing poems', drawings, the results of a National Society of Non Smokers essay competition for children. Anti-smoking ideas poured in from members of the public.

These suggestions, now yellowing in their folders in the National Archives, are testimony to the change which occurred in the 1960s and 70s in public health, and, indeed, in the relationship between medicine and society more generally. For the talk of posters and home made publicity efforts represented the last gasp of an older tradition of public education. A new era of mass media education and health consciousness was dawning. It repositioned itself in relation to government and to society and 'the public', marketing health. It is argued here that the report on smoking published by the Royal College of Physicians in 1962, Smoking and Health, was a key catalyst of the new modernised and mediatised medicine and public health.

This chapter will trace the history of what Sir Peter Froggatt, Chair of the Independent Scientific Committee on Smoking and Health, writing in the 1980s, called the strategy of 'systematic gradualism' as a major public health and industry area of interest from the 1950s through to the 1970s. By this term Sir Peter meant scientifically informed strategies to reduce risk and harm which also drew on relationships with industry. The history of this approach tells us about the nature of public health and the tensions between different strategic approaches to health risk in the post war years. Techniques of persuasion exemplified in health education and the mass media were to be a central dimension of the 'new public health'. Another key component of that new public health which emerged during the 1960s and 70s was to be hostility to industrial interests. In 2003, the ASH (Action on Smoking and Health ) website, commented:

TV documentaries such as the Tobacco Wars or The Secrets of Big Tobacco told of the forty-year struggle to hold US tobacco companies to account for the damage caused by cigarettes. Journalist histories, The Smoke Ring or Dirty Business. Big Tobacco at the Bar of Justice recounted a thrilling story of corporate greed and duplicity, of big business which cared little for the health of its customers. Hostility to industrial interests now pervades the public health field: campaigners on obesity attack the food industry, and the drinks industry and its influence within government is reviled by some section of the alcohol research community.

This chapter shows how such attitudes are time specific and how different relationships prevailed earlier on. At the time these were related to the perceived legitimacy of industry interests and to an agenda, shared by industry and by public health interests, of removing the harmful components from tobacco, of reducing harm from smoking rather than eliminating the habit. In the 1950s and 60s (and afterwards) some public health interests did work with 'the manufacturers', the term then used rather than the perhaps more pejorative 'industry'. We have already discussed how tobacco industry interests had an historically lengthy relationship with government: this developed into the strategy of voluntary agreements in the 1970s. But it is less well known that working with industry was also a strategy for some, although not all, public health interests.

From the time of the manufacturers benefaction to the MRC to the middle of the 1970s – through the publication of the first two Royal College of Physicians Reports – industry, government and public health interests operated in a policy balancing act aiming to reduce harm from smoking. That strategy continued into the 1980s in a different form, as will be discussed in chapter 9. But the events of the second half of the 1970s and the rise of a new militant public health effectively curtailed it as a major public strategy for mainstream public health interests. The change in strategy also owed something to changes of ownership and influence within the tobacco industry in the late 1970s and the rise in influence of the US industry, alongside diversification on the part of Imperial.

Change was in the air in other ways in the late 1960s and early 1970s. It was a period of transformation in medicine and public health but also within government. The way in which researchers related to government and the mechanisms which brought the two together became more formal and framed by government interests. The idea of rationality was high on the agenda, that there could be a rational relationship between research and policy. This was a technocratic message. The 1970s was to be a distinctively modernising period in the ideology of health, not least in the scientific disciplines considered appropriate and in the mechanisms for bringing research into a relationship with policy.

The rise of the expert committee was a feature of this period. Also characteristic of this emphasis on the bringing of expertise into policy making were the moves to develop 'rational' policies on a cross departmental basis which are seen as characteristic of the late 1970s. The 'think tank' report on alcohol policy, produced in 1979 but only published some years later, was one such move. Public health partook of this rational technocratic impetus. This chapter, and the following one on the work of the Independent Scientific Committee on Smoking and Health, will show how this emphasis on science and policy making operated at the central government level. Smoking, through the four 'expert committees' which the chapters consider, was again emblematic of changes in the ideology of public health and the relationships between science and policy.

The 1970s were a crucial decade for the nature and focus of public health and also for the direction of smoking policy. The strategies of 'systematic gradualism' and 'coercive permissiveness' within public health strategies were increasingly polarised. 'Systematic gradualism' continued to operate throughout the 1970s as the major joint public health/industry/ government initiative but it was under increasing strain. By the end of the decade that alliance fragmented: a new and more militant public health, which had been emergent since the early 1970s, came centre stage. These changes exemplified the direction which prevention and public health was taking overall by the end of the 1970s, and were reflected in government policy documents. The 1970s marked an important transition period.

By the end of the decade a new public health creed had emerged with an agenda which became common to the discussion of a range of health issues. Drawing on chronic disease epidemiology and increasingly on mass psychology, it emphasised economic factors, and the role of higher taxation as a regulatory mechanism. The role of the mass media through mass advertising was central; advertising was either to be restricted or to be used as a public health tactic. It was part of a public health agenda which stressed both individual responsibility and the culpability of industrial interests. This template was to be applied in many areas – diet and heart disease was another – and smoking provided the blueprint.

The 1970s were a crucial decade for the nature and focus of public health and also for the direction of smoking policy. The strategies of 'systematic gradualism' and 'coercive permissiveness' within public health strategies were increasingly polarised. 'Systematic gradualism' continued to operate throughout the 1970s as the major joint public health/industry/government initiative but it was under increasing strain. By the end of the decade that alliance fragmented: a new and more militant public health, which had been emergent since the early 1970s, came centre stage. These changes exemplified the direction which prevention and public health was taking overall by the end of the 1970s, and were reflected in government policy documents.

The 1970s marked an important transition period. By the end of the decade a new public health creed had emerged with an agenda which became common to the discussion of a range of health issues. Drawing on chronic disease epidemiology and increasingly on mass psychology, it emphasised economic factors, and the role of higher taxation as a regulatory mechanism. The role of the mass media through mass advertising was central; advertising was either to be restricted or to be used as a public health tactic. It was part of a public health agenda which stressed both individual responsibility and the culpability of industrial interests. This template was to be applied in many areas – diet and heart disease was another – and smoking provided the blueprint.

Key to this change of climate was the alliance which developed in the 1970s between centralised government campaigning on health and a new type of health pressure group. The rise of media conscious public health activist groups in the 1960s and 1970s dealing with 'single issues' like smoking, diet and heart disease or alcohol was a new development. This chapter will focus on the activities in the 1970s of one such activist group ASH (Action on Smoking and Health), established in 1971; this was an exemplar of more general trends in public health. There, the 'health pressure group' largely replaced the formal public health occupation as a source of public pressure on health issues. The activities of such groups were at the national rather than the local level and they used the national media as the vehicle for their message rather than more localised campaigns. In that sense they were very much in the technocratic,marketing model outlined in the Cohen report on health education in 1964.

However, their role went further than simply conveying health education. Their 'new radical/new social movement' style in fact masked close relationships with government ,both strategic and through government funding. The groups, ASH in particular, were part of an essential policy balancing act for government. These were government funded pressure groups as well as new social movements and part of the 'policy community' which comprised the network of influence.

The creation of such campaigning groups was part of a wider trend .Between 1961 and 1971 the number of registered charities rose from 1,182 to 76,648. This dramatic increase can partly be accounted for by the introduction of more efficient methods for registering charities, but Johnson estimates that around 10,500 of these were entirely new organisations. Just as significantly, these were different to many existing groups. Davis Smith asserts that the 1960s saw 'the appearance of a new generation of volunteers, who were entering existing organisations and creating new ones of their own'. He attributes this to spill-over from a renewed interest in the 'Third World' and overseas development, seen in the expansion of Oxfam which had begun with a European refugee focus, and the creation of Voluntary Service Overseas (VSO). They encouraged a re-evaluation of domestic welfare services which identified a series of startling deficiencies is certain areas, such as homelessness.

Dramatised in a series of 'exposures', (consultancy reports, books and television programmes) these issues became the focus of a new group of campaign organisations such as Gingerbread, Shelter (1965), the Child Poverty Action Group (CPAG, 1965), National Association for the Care and Resettlement of Offenders (NACRO, 1966), Radical Alternatives to Prison (1970) and the Disability Alliance. In the health field, the new campaigning tradition was exemplified in organizations like the Patients Association established in 1963 and the rise of the human rights movement in mental health. There the National Association for Mental Health (NAMH) had its origins in 1940s notions of mental hygiene, but in the 1960s and 1970s, it became characterised by an opposition to psychiatry, culminating in a more radical and political organisation which re-named itself MIND.

The public health campaign groups were different from these new health campaigning groups in that their primary focus was not 'the patient' or the provision or improvement of services.

ASH was typical of the new style public health pressure group of the 1970s. Its agenda by the middle of the decade was an absolutist one which stressed stopping smoking and began to focus on the media – campaigns and banning advertising – and on fiscal moves to reduce smoking through higher taxation. It also began to develop a strong human rights emphasis in relation to the rights of the non-smoker. ASH was one component of a 'new public health' which emerged during the 1970s. The developments in focus, philosophy and scientific underpinning were epitomized in a number of policy documents published during the 1970s.

The new public health was an international movement, and documents such as the Canadian Lalonde report of 1974 were important. In the UK, the government consultative document Prevention and Health : Everybody's Business issued in 1976 was overshadowed by the resignation of Harold Wilson as Prime Minister. The White Paper Prevention and Health was published at the end of 1977. It was influenced by the pioneer 1977 report on prevention from the Social Services and Employment Sub committee of the Expenditure committee.

That committee's evidence was important for another reason too. It gave a snap shot of the players in the public health field and their attitudes towards the end of a decade: it was indicative of the attitudes of some key players. In its report the Committee saw smoking as a greater evil than alcohol and was willing to promote stronger measures for its control. It recommended an advertising ban; an annual price increase; the abolition of coupons; the restriction of cigarette machines; stronger health warnings on packets; more non smoking areas; targeted education; action on weight and smoking; more research into the problem of physiological addiction.

This was the standard public health agenda by the end of the decade. As Alistair Mackie of the Health Education Council commented the key issue was smoking:

The policy and scientific climates changed in the late 1970s and early 1980s. Concerns about the environment re-emerged as part of public health rather than separate from it. Epidemic disease, previously consigned to the 'dustbin of history', suddenly made a reappearance. New alliances emerged within the science of public health; epidemiology was no longer proof enough and gained greater legitimacy through support from biomedicine and the science of psychopharmacology. Occupational health revived as a public health matter. In Britain, the decade was marked at its start by the emergence of 'passive smoking' as a scientific fact and later by the irruption of HIV/AIDS as a central policy issue. The two appeared to be totally different, but as we will see, they were linked in the new public health discourse of environmentalism and infection. This discourse was an international one; and internationalism in public health was a defining feature of this decade.

The environment had been almost entirely absent from the redefined public health ideology which had emerged during the 1970s. Government policy documents placed responsibility on the individual and behavioural modification of individual lifestyle. New concerns about occupational health or about environmental pollution had no particular connections with public health. Rather they had emerged as separate 'single issues' through organisations which had little to do with formal public health. Greenpeace and Friends of the Earth had both been founded in 1971. They were part of the rise of pressure group activism exemplified by ASH in the health field, but the 'environmentalism' of the 1970s had few connections with public health concerns.

Infectious diseases were also remote from 'modern' public health, although in a different way. They were a feature of the past, associated with pre war diphtheria or the even more distant environmentally induced diseases,like cholera,or typhoid, in the nineteenth century. The revolution in high tech medicine of the 1950s had removed the need to worry about such epidemic incursions: penicillin, the antibiotics would deal with it all. The rise of the chronic diseases as central to population health had removed the centrality of epidemic disease. Or so it was thought. The 1980s were to witness a revival of environmentalism and also a revival of epidemic disease but within a different form within public health. The environment and the individual reached a new accommodation.

As the twentieth century drew to a close, smoking epitomised the conflicting tendencies within public health and the changes in its knowledge base. Smoking symbolised more general tensions within public health in the late twentieth century, between environmentally conscious health promotion ideas and the growing influence of pharmaceutical imperatives which stressed vaccination or drug interventions as preventive measures. These tensions were also expressed in different policy agendas. An American clinical pharmacologist characterised the opposition:

Environmentalists and epidemiologists who supported the scientific fact of passive smoking were joined by other scientists and activists from the ranks of 'pharmaceutical public health'. The rise of the concept of addiction to nicotine as a 'policy fact' signified the enhanced role of pharmaceutical interests in public health, the role of treatment and of medicalised ideas: treatment became a public health strategy. The genetic concepts which had fallen from favour in the 1950s and 1960s began to make reappearance. As smoking descended the social scale, the options crystallised round regulation of space and medication of individuals. These were options for public health more generally as it developed different strategies at the end of the twentieth century – spatial, regulating public space, and medical – using drugs and medicines as public health interventions.

These changes were also part of complex moves in the substance use arena. Illicit drugs and alcohol, psychiatric preserves which had used the language of addiction since the late nineteenth century, moved more closely within the ambit of public health. Tobacco, a mainstream public health issue since the 1950s, in its turn moved closer to those substances in concepts and approaches. Smoking and tobacco became an important 'cross-over point' for the incorporation of concepts of addiction into the public health mainstream. In the course of this accommodation, the definition of tobacco itself began to alter and boundaries round its status to shift. The rest of this chapter will examine the emergence of this new view of public health.

In April 2006, Prime Minister Tony Blair appeared dressed in a track suit to publicise the need for healthy exercise and eating. For Harold Macmillan or Burke Trend, Prime Minister and Cabinet Secretary fifty years earlier, to have taken part in such an event would have been unthinkable. But the staged event emphasised the change in the ideology of public health and in the policy response which is the subject of this book. By 2006, exercise and eating were important public issues, poised perhaps to displace smoking, which was seen as an issue on the way to resolution. The change in public health over a fifty year period to the state promotion of healthy individual lifestyles could not have been better illustrated.