In August 2002, an 89-year-old man sat in a California courtroom and did what he had been doing, in one form or another, for more than half a century. He told the truth about cigarettes.
Sir Richard Doll was white-haired and frail. He had come to Los Angeles to testify against cigarette company Philip Morris in a case brought by Betty Bullock, a 64-year-old lifelong smoker dying of lung cancer. Doll was, more than any other living scientist, the reason the world knew what cigarettes did to human lungs.
The columnist Steve Lopez, watching him on the stand, called him “David to Big Tobacco’s Goliath”. The industry, Doll told the court, had been “thoroughly immoral, and deserve whatever they get”. The jury convicted Philip Morris of oppression, fraud and malice.
On Tuesday last week, nearly a quarter century later, the British parliament did what Doll’s life work demanded. It voted to raise a generation that will never legally buy a cigarette. The bill, expected to soon receive royal assent, bans the sale or supply of tobacco and vape products to anyone born in 2009 or later — permanently. Britain’s health secretary, Wes Streeting, put the logic in four words: “Prevention is better than cure.”
But this is not only a British story. It is also an American one, told in a foreign accent. And it is 76 years old. In 1950, two papers changed what the world knew about cigarettes. In May of that year, a young medical student named Ernst Wynder, along with surgeon Evarts Graham, published a case-control study in the Journal of the American Medical Association showing a powerful link between smoking and lung cancer.
Four months later, Doll and Austin Bradford Hill reached the same conclusion in the British Medical Journal. By the late 1960s, after the surgeon general’s 1964 report and decades of confirmation, the question of whether smoking caused lung cancer was, in scientific terms, settled.
What was not settled was what we were going to do about it. Prevention rarely fails all at once. It fails in stages. There is the recognition gap, where warnings are missed or ignored. The evidence gap is where people demand more proof than reason requires. The translation gap is where knowledge does not reach decision-makers. Finally, there is the implementation gap, where known solutions are not fully carried out.
On smoking, the US closed the first two of those gaps a long time ago. It has never closed the last two. Tobacco remains the leading cause of preventable death in the country, killing roughly 480,000 Americans every year — more than Aids, illegal drugs, alcohol, motor vehicle crashes and firearms combined.
Every day almost 2,500 children under 18 years of age try their first cigarette, and more than 400 of them will become new, regular daily smokers. The five largest cigarette companies spend close to $22m a day marketing a product we have known was lethal for most of a century.
None of those numbers is in serious dispute. Yet the US national response has been an accumulation of half-measures. A federal minimum age of 21, passed only in 2019. A menthol cigarette rule, proposed in 2022 and formally withdrawn in 2025 before it ever took effect. Graphic packaging warnings, mandated by Congress in 2009 and still, 17 years later, tied up in industry litigation. None of them, taken together, amounts to a strategy built to end the epidemic.
Britain is attempting to build prevention into the structure of ordinary life, so that one generation will simply never be introduced to a lethal product. The US is still debating whether that product should be marketed at a slightly lower volume.
Forty years ago, in testimony before the US Senate, Wynder identified the failure we are still living inside. “I am convinced that we will never have preventive medicine in this country unless we politically want it,” he told the committee. “As scientists, we discover. As scientists, we need to apply. And I can tell you, after 35 years in this field that application is often more difficult than the discovery itself.”
Wynder had named the problem. American prevention does not usually fail for lack of evidence. It fails for lack of political will to act on evidence it already possesses. Big Tobacco understood this earlier than most: if you could not win the science, you could win the delay. And still the industry spends billions a year persuading new children that a killing product is part of adult life.
We can do more, and we should. Congress should take up generational tobacco legislation modelled on Britain’s. The Food & Drug Administration should reinstate the menthol rule it withdrew last year. The graphic warning labels Congress required 17 years ago should be on every pack sold tomorrow. States should raise tobacco excise taxes and spend $3.3bn on tobacco prevention, the Centers for Disease Control & Prevention recommends. None of this requires a new discovery.
Doll and Wynder did their part. Both of them closed the recognition gap and the evidence gap on smoking, and trusted the rest of us to close what remained. The question now is whether we will, or whether we will let another 480,000 Americans die this year, and every year, while the debate continues.
• Davis is professor emeritus and the former Guy S Parcel chair in public health at UTHealth Houston School of Public Health. He is author of The Preventioneers: Diseases, Disasters, and the Discoveries That Changed Our World.
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