The following interview with Dr Fleur Fisher at the British Medical Association HQ was recorded May 13, 1993. At that time she sat on the BMA’s Ethics Council; she also managed the library and the internal information services. At the time I was researching a subject that never came entirely to fruition, although there are other documents on this website related to it. See in particular the four pamphlets by Judith Hatton. I cannot in all honesty recall any details of this interview, although I appear to have done quite a bit of the talking myself! It is reproduced here more or less verbatim, so please excuse any repetition. I am unable to comment in any way, manner, shape or form on the allegations made against Dr Fisher in connection with the death of Carol Felstead which is in any case not related to anything herein.
Question: What is the BMA’s present policy on smoking?
DF: You’ll see that as you come in the gate; you don’t smoke anywhere, not even in the courtyard here. Our present stance is that quite clearly smoking is a major cause of preventable early death in the UK. The policy of the BMA is that we are convinced that all the evidence shows the involvement of tobacco.
Q: The latest figures for premature deaths, straight from Sir Richard Doll himself, is 150,000 per annum in the UK. I find that figure totally unacceptable.
DF: The Big Kill itemises the fatalities due to smoking by region.
Q: I find this publication ludicrous. The late Professor Burch published a critique of The Big Kill, which at the time claimed that a total of 77,774 deaths in the UK were directly attributable to smoking. Professor Burch pointed out that: “The biologically ignorant but numerate reader might be forgiven for concluding that epidemiology is not only a rigorous science but an incredibly accurate one, with an implied error in mortality estimates of less than one part in 77,774. The scientifically trained person can be expected to ask: How were these impressive figures calculated?” Burch made a critical analysis of this figure and concluded that it is worthless. Seven years later we’re being told that this figure was virtually a 100% underestimate. By Doll and Peto especially. To paraphrase Professor Burch, I may be biologically ignorant, but I am fairly numerate, and, having looked at the mortality statistics it is obvious to me that this figure is wildly exaggerated. The mortality statistics for the UK for 1990 are as follows: 641,799 total deaths. Taking out all the men who died age 85 and over, and all males who died age 24 and under leaves 591,942. 150,000 is 25.3% of this figure. Take out all the women who died 85 and over, and all females who died 24 and under, and you’re left with 485,518 people in total who might conceivably have died prematurely due to smoking. That is 30.9% of the total deaths in this band. [ASH and the HEA use a lower figure, 110,000]. Professor Doll’s view is that if everybody packed in smoking tomorrow then after a period of time there would be an appreciable increase in the life expectancy of some 150,000 people, that is they would reach an appreciably greater age. The Imperial Cancer Research Fund claim that the average years “lost” by smokers who die prematurely in “middle age” is up to 23 years. Lesser figures are also used, Professor Doll said 10 years.
DF: I find those figures very difficult too actually.
Q: I don’t like to call this propaganda because it’s all done with the best of intentions.
DF: When we’re talking about deaths from other diseases, the question is, to what extent is smoking a factor? For lung cancer we’ve got a pretty clear idea, not all but most deaths are attributable to smoking. There is still much discussion about cardio-vascular disease, other cancers and so on.
Q: I don’t think there’s anything controversial or revolutionary about the idea that smoking causes or is at least a very major factor in lung cancer, but there are certainly other important factors involved, in particular, air pollution. Eysenck has some slightly unorthodox views about personality and stress in the genesis not only of cancer but of other diseases. In particular he argues that the connection between cancer and personality has been clearly demonstrated, but that the establishment has drawn a virtual curtain over his and other people’s work. He says it is either ridiculed or ignored.
DF: That’s extremely dangerous and it’s not the way to get at the truth.
Q: How familiar are you with Eysenck’s research?
DF: It must be ten years since I read much of Eysenck so I couldn’t comment without re-reading his work.
Q: Eysenck says that Professor Doll’s 150,000 figure has no scientific meaning, and that Doll’s criticisms of the late Professor Burch are unfounded. Eysenck and others have also found environmental and particularly racial factors in lung cancer. Most studies have been carried out on white males above a certain age. With lung cancer, the risk ratio in whites is around 10; in Japan and Singapore this falls to 3.8; in other countries they are even lower. This does tend to indicate that there are other factors involved.
DF: Yes, and there are different types of lung cancer as well. I think the question is what other factors are there other than smoking? Are we looking at pollution, asbestosis and what else? Clearly industrial pollution is a very big factor, as far as I understand the evidence, within the UK smoking is clearly correlated with lung cancer, and it’s quite a major factor. If you look at the case of women, as they smoke more, the death rate of women from lung cancer is clearly rising.
Q: This is more or less the ICRF view, that smoking and nothing else is responsible.
DF: I think the agenda of the ICRF and other bodies involved in cancer research is to try to eliminate the preventable causes as far as possible. They may not be perfect, but smoking is clearly a major cause of lung cancer in our society, it is a cause of preventable disease, and smoking is clearly correlated with cardio-vascular disease as well, and although this may not be the whole story, it is a major part.
Q: Simon Wolff has calculated that there are a million tons of carcinogens pumped into the air in the UK by road traffic alone.
DF: I wouldn’t dispute this at all. The fact is though that smokers get lung cancer far more frequently, and CHD. On the other hand, he is absolutely right to be concerned about air pollution.
Q: Professor Wolff believes that air pollution and smoking have a synergistic effect on lung cancer. The correlation is well established.
DF: I think the answer to this is that we know that many diseases are synergistic in their origin. Many diseases are multi-factoral, there can also be an inherent genetic susceptibility. The important thing is to give the general public clear information when you have it, even if it isn’t the whole story.
Q: The general public hasn’t been warned about air pollution to the same extent as it has been warned about smoking.
DF: Certainly we at the BMA are concerned about the quality of air. This is something we have spoken to the Government about and made representations about. This is an on-going part of our policy. But the one thing about smoking is that people are able to assess that fairly swiftly themselves, which they’re not able to do with air pollution. From a behavioural point of view, the interesting thing is that smoking - certainly in women - is heavily correlated with poverty and deprivation.
Q: Smoking does relieve stress I believe?
DF: That’s the way it’s perceived.
Q: Eysenck (and others) have found a strong correlation between smoking and personality. He’s found for example that smokers tend to be extroverts, that they tend to drink, and that they lead an unhealthy lifestyle and so on.
DF: That’s a very interesting observation; people have said the same thing about cancer of the cervix: women who develop cancer of the cervix tend to have lots of sexual partners and to smoke, etc. That was before the virus which transmits it was discovered. Doctors tended to be very judgmental about women’s behaviour. I do know that some of Eysenck’s work on personality is similar in nature to this, so it’s a cart and a horse thing really, isn’t it?
Q: It’s not exactly a new idea, is it?
DF: No. And we are now reaching the point where we can identify certain genes which make some people much more susceptible to certain diseases than others. We know that lifestyle affects this. All these things are interactive.
Q: If I can turn now to heart disease. It’s “common knowledge” that smoking is linked to coronary heart disease, but Eysenck and others have found no significant link between smoking and CHD. I’m thinking here particularly of the intervention trials, most of which seem to have given the “wrong” result. Attempts to reduce mortality by encouraging people to change their diets, to exercise, and give up smoking, have been spectacularly unsuccessful. If people stop smoking for example they reduce their risk of dying from lung cancer, but they simply die of something else. The only thing that happens is that the patterns of disease and mortality change. Eysenck says that the suicide rate in particular goes up.
DF: There have been a number of studies in this field. Looking at the epidemiology of people who took part in these studies it is possible to identify people who are at risk from coronary heart disease. But this isn’t the whole story.
Q: Another thing, we’re still being warned by the media that eating saturated fat is bad for us, and generally we’re still having this “unhealthy lifestyle” nonsense forced down our throats. And that’s what it is, nonsense.
DF: I couldn’t agree with you more about that.
Q: Le Fanu says that for smoking, every way you look at the figures you get by far the strongest correlations in epidemiology. But the high fat diet high cholesterol heart disease hypothesis doesn’t fulfil any of the required criteria, in particular Koch’s postulates and Bradford Hill’s canons. Le Fanu says that this is basically an idea that has been sold to the public on powerful imagery.
DF: We do have some epidemiological data that saturated fat does indeed have a high correlation with coronary heart disease; I don’t think we’ve got the reverse.
Q: Eysenck’s view is that interfering with people’s diets, forcing them to change their lifestyle, does no good and may cause a great deal of harm. The point is that we’re being fed all this “healthy eating” stuff by the health education lobby as though it’s gospel, when the evidence is at best ambiguous.
DF: There is some evidence that children who eat a bad diet have a high incidence of cardio-vascular disease. There is also a strong correlation with poor diet, heart disease and poverty.
Q: The latest attempt to improve people’s lifestyles is the doctors’ survey.
DF: The banding system. This is basically an attempt to focus on cardio-vascular disease and other aspects of lifestyle. Doctors are asked to collect information about smoking, to ask about diet and to give advice about diet in context.
Q: Is there such a thing as a healthy diet?
DF: We’ve got pretty good evidence that dietary fibre is important, so we can give advice on fairly good grounds of the importance of eating adequate fruit and vegetables. Most doctors will feel fairly secure as regards the evidence for saturated fat, ie don’t totally live on fry-ups.
Q: Is there going to be an element of compulsion in this lifestyle survey?
DF: No! You can’t compel people...okay, it looks as if we’re living in 1984, doesn’t it?
Q: What I mean is: is this yet another attempt by the state to control what we eat and what we do?
DF: No, I think it’s an attempt to ensure that when doctors see people they have the opportunity to give them advice about what is a healthy lifestyle. The question I think you’re asking is: to what extent is that advice based on scientific facts? Doctors will be asking about smoking, sugar consumption, about diet, about their weight, and about exercise.
Q: Obviously this information will be fed back to the authorities and will appear in the General Household Survey or similar official statistics, and of course to the medical profession, which is only proper. But is this all going to be kept totally anonymous like an opinion poll? Some people might be worried that it breaches confidentiality.
DF: Nobody’s keeping a file on that, and this is something I find fascinating myself: to what extent is any information nowadays kept private and confidential? Information is put on computers, and computers are networked, and this is a major issue nowadays. The AIDS issue has led to confidential information about people’s sexual behaviour reaching the public domain. Principles of confidentiality have been broken right, left and centre.
Q: So there is no question of Mr or Mrs Smith who is four stone overweight being ordered to cut out the French fries, or to stop smoking or to stop drinking?
DF: No, of course not! What the doctor will do is discuss with the patient what the implications of this are for his or her future health. It’s a question of taking a clinical history and sharing information about the risks of a patient’s health.
Q: Returning to smoking, how happy are you personally with the accuracy of the HEA’s statistics for example?
DF: If you look at not only lung cancer but other forms of cancer, you will see that smoking is one of a multitude of factors which are responsible. I don’t know how these figures were arrived at, but as I am aware, and as you are doubtless aware, many diseases are multi-factoral. Nonetheless, we do know that if people do smoke and they give up smoking, the risk of lung cancer goes down remarkably. Equally, we know that smokers are much more likely to suffer from gastric ulcers.
Q: One thing I am very suspicious of is the so-called cancer epidemic which the cancer industry would have us believe we are suffering. The greatest determinant of cancer is age, and it may be that the reason so many people die of cancer nowadays is that so many people now live to a ripe old age.
DF: Age is a very great determinant of course but it is only one of many factors. The older you are the more likely you are to contract cancer. I don’t think there is a cancer industry, but the fact is that people do die of cancer, and cancer is a lot more common in older people. We’re faced with an ageing population, and it’s ageing quite markedly.
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