The Disease of Tobacco Smoking and Its Cure

In the spring of 1942 Dr Lennox Johnston, a Merseyside GP, took the train to London, intending to pluck Winston Churchill’s cigar from his lips and stamp it out. The anti-smoking campaigner, frustrated by his failure to convince the medical establishment to take his cause seriously, felt that a strong public protest was needed. Arriving in the capital he first paid a visit to Sylvia Pankhurst for advice about being arrested, finding her ‘both intrigued and approving of his project’.

Born in 1899, as a medical student Johnston had served on minesweepers in the North Sea during the First World War, qualifying from Glasgow as a doctor in 1921. In 1928, as he described in The Disease of Tobacco Smoking and its Cure (1957), a patient and close friend developed pulmonary tuberculosis. Before the discovery of antibiotics there was no treatment for TB but, given the belief in the benefits of fresh air, Johnston reasoned that breathing in cigarette smoke was likely to be harmful and so best avoided. Doctor and patient made a pact to quit cigarettes.

Johnston found it quite easy and noted rapid health benefits, including an end to his chronic cough and episodes of pharyngitis. His friend, though, was unable to quit, and continued to smoke until his death in a sanatorium a few months later. Johnston’s hunch was right; smoking is associated with a nine-fold greater risk of death in people with TB, which drops by around two-thirds if patients stop smoking. According to current estimates, around one in five deaths from TB worldwide are attributable to active smoking.

Johnston later took up smoking again and found quitting a second time much more difficult. Convinced that smoking was a substantial cause of ill health, and curious about the mechanisms that kept people at it, he ordered a bottle of nicotine from a chemists’ shop. He had planned to inject himself with the 40 per cent solution but accidentally spilt some on his hand. First his hand then his whole arm went numb. His chest and neck ached, his heart raced, his vision went black, and he lay on the floor fearing that ‘this was the end’. His wife found him ‘looking like death’ and called his GP partner in a panic. The symptoms passed in a few minutes. Nicotine is readily absorbed through the skin: it’s how nicotine patches work. Child labour is common in tobacco farming and children’s thinner skin makes them especially susceptible to green tobacco sickness, nicotine poisoning from harvesting tobacco leaves.

Johnston appears not to have been the most dextrous researcher. Following two more episodes of accidental exposure to the liquid, his father took matters in hand and used tongs to dispose of the 40 per cent bottle in a furnace. With the outbreak of war in 1939, Johnston’s wife and three children were evacuated to the country, leaving him free to resume his investigations. This time he was more prudent, wearing gloves and using a weaker, 5 per cent solution. He observed the response to nicotine injections in 35 volunteers, finding a greater tolerance in those who already smoked, and that the injections reduced the desire to smoke.

Nicotine craving was intense but short-lived, different in character and developing more rapidly than addiction to cocaine or pethidine, a synthetic opioid (more self-experimentation). Fourteen years of work culminated in a research article he delivered by hand to the editor of the British Medical Journal, who turned it down. The reasons for rejection were the length of the article, the author’s lack of credentials as a ‘mere’ GP and, in Johnston’s view, the fact that editor and reviewer were themselves smokers. He began planning his assault on ‘the smoker in chief’.

Before Johnston could carry out his attack on Churchill’s cigar, however, Maurice Cassidy, Physician in Ordinary to the King, wrote to the Times protesting at the heavy levels of smoking in the armed forces. These men were ‘being trained to fight for their lives. Yet were they being trained for a soccer cup-tie or a boat race can it be doubted that their smoking would be restricted?’ Johnston at last had an ally and with a letter of support from Cassidy he resubmitted a shortened version of his article to the smokers at the BMJ. He was again rejected but later that year his paper found a home, in very truncated form, in the Lancet.

Johnson made an early and astute observation about the link between smoking and mental health, struck ‘by the large number of unhappy people who have told me earnestly that smoking was “their only pleasure”; and I think it is true that smoking takes away to a considerable extent all normal healthy pleasures and substitutes the unsatisfying negative pleasure of appeasing the craving for a drug’. He also thought of smoking as a transmissible condition: ‘like pulmonary tuberculosis, smoking is usually a family disease and its development and age of onset largely depend on whether or not a child is exposed to massive infection at an early age, i.e. is brought up in a smoking home.’ Subsequent research has confirmed this: children born in 2000 and included in the Millenium Cohort Study were nearly three times as likely to smoke in their early teens if their parents or carers smoked.

Johnston was not alone in his concern. In the early 1950s, work by Richard Doll and Bradford Hill from the Statistical Research Unit of the Medical Research Council compared the smoking habits of thousands of people admitted to hospital with lung cancer against those with other conditions. They proved that smoking was behind the huge rise in lung cancer over the previous thirty years and discounted other theories that had been proposed, such as the type of domestic heating used, living near a gasworks, use of a petrol lighter or the 1918 flu epidemic. This should have been a pivotal moment, and the British government acknowledged the link at a press conference in 1954, although the health secretary, Iain Macleod, chain-smoked throughout. Johnston was exasperated that this new evidence did not lead to immediate and radical action against smoking.

With hindsight, the stately pace of change is astonishing. Despite a report from the Royal College of Physicians in 1962, Smoking and Health, there was little action, prompting the college to found the campaigning charity Action on Smoking and Health (of which I am the current chair) in 1971. The country did not get a comprehensive tobacco control plan until 1998. This noted among other findings that cigarettes were actually 60 per cent more affordable than they had been in 1965.

Johnston continued his campaigning. He was convinced that people who smoked or had smoked were reluctant to countenance action against smoking. He engaged in a long skirmish with the British Medical Association to stop smoking being permitted at their annual conference and to remove tobacco adverts from the BMJ. He even fantasised about burning down the BMA’s headquarters, reflecting on this ‘many hundreds of time in bed at night’.

Professional vindication for his pioneering work came with a dinner held in his honour at the Royal College of Physicians in 1976. Cyril Clarke, the RCP president, likened Johnston’s contribution to that of Ignaz Semmelweis, who had discovered the cause of childbed fever and introduced antisepsis to obstetric practice in 1847 but was largely ignored in his lifetime.

Smoking rates have fallen from 60 per cent in 1950 to 12 per cent in 2023, which means there are still about six million people who smoke in the UK. Smoking is responsible for around half the difference in life expectancy between rich and poor, and it kills two in three people who continue to smoke. The Tobacco and Vapes Bill currently going through Parliament will raise the age of sale annually so that it will never be legal to sell tobacco products to a person born on or after 1 January 2009. The first increment, in 2027, will come nearly a hundred years after Lennox Johnston’s 1928 epiphany about smoking and tuberculosis.