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Anne Charlton, Tobacco or health 1602: an Elizabethan doctor speaks, Health Education Research, Volume 20, Issue 1, February 2005, Pages 101–111, https://doi.org/10.1093/her/cyg097
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Abstract
A few years before the death of Queen Elizabeth I, a booklet entitled Work for Chimny-Sweepers or A Warning for Tabacconists [sic], was published. Written by a doctor who called himself Philaretes, it was the first publication to present the health risks of tobacco use. Using continuum content analysis, which follows each of Philaretes's main messages over the subsequent four centuries, this paper sets his publication in the historical context of the medical and social frame of reference in which it was produced, and charts the development of each theme in later scientific research. In the setting of contemporary Tudor medical theory, based on ‘the humours’, Philaretes discussed many of the health risks that later research has proven to be true. In common with many early attempts at health education, the principles of Philaretes's approach appear to be what were later to be called the Health Belief Model and the KAP formula. By providing information about serious personal health risks and, thus, increasing the readers' knowledge, he hoped to change their attitude and consequently their behaviour. Overshadowed by King James I's much less scientific Counterblaste to Tobacco, Philaretes's publication deserves more credit than it has been given.
Comments
A. Charlton's article "Tobacco or health 1602: An Elizabethan doctor speaks (February, 2005) provides an interesting analysis of a little known historical document on tobacco use: Philaretes (c. 1602) "Work for chimny- sweepers, or a warning for tabacconists." Indeed, the provision and analysis of this document is a significant academic achievement. Charlton's interpretive analysis of the document serves its purpose in the context of the her premise of health education promotion; at the same time it also suffers from several shortcomings with respect to historical and contemporary understandings and explanations of tobacco use. These shortcomings can be described, generally, as "retrospective bias" or imputing current constructs into the past, and an "factual fallacy," the tendency to believe that current research is objectively derived (ahistorical and non-socially constructed) and therefore "true."
Before discussing these two counterpoints, it is necessary to revisit the thrust of Charlton's analysis. She suggests that Philaretes was a man ahead of his time, with regard to his discussion of the dangers of tobacco use; his claims "later research has proven to be true." She suggests his text was one of the first examples of health education promotion, which she suggests fits nicely with current health education models (e.g. the KAP model).
There may be little need to dispute the claim that what Philaretes produced was indeed a health education pamphlet (even though one could read it along the same lines as King James' "Counterblaste to Tobacco," depending on the hermeneutic fore-structure which guides one's interpretation). The areas of dispute, however, are those that pertain to two strategies Charlton uses to support her claims that Philaretes, given the circumstance of his time, was predictive of future and proven dangers of tobacco use.
First, Charlton uses several current concepts and constructs in her interpretation of Philaretes claims, most notably the concept of addiction. From an historical perspective, this strategy can be quite problematic. One need not simply get hung up on semantics or terminology, but addiction, as we know it today, is both qualitatively and operationally different. The tendency to do so can be understood as a retrospective bias (to quote an old saw, "hindsight is 20-20"). Let us examine one of Charlton's interpretations of Philaretes work to elucidate the retrospective bias.
Charlton first observes, "Philaretes talks of addiction, and also of passive smoking, and illustrates them with one of his lengthy anecdotes..." (p. 105). She then presents an anecdote about a "learned and expert Phisition," who speaks of his tobacco usage as a remedy but also of apparent "craving" for it. (The issue of "passive smoking" is alluded to in the anecdote where another physician is "mervaylous annoyed therewith" the tobacco smoke.) Now, the point of contention with regard to Charlton's claim of the physician's "addiction" rests on the physician's report that for want of tobacco, "I finde myself hart sick that day, till I have tasted thereof" (p. 105). Charlton interprets the physician's hart sickness as addiction and appears to use the term interchangeably even though there are neither historical nor contemporary precedents to do so. Historically, we note the use of the term "hart sick" in Shakespeare's “Two Gentleman of Verona." In Act I, Scene I, Protheus speaks:
He after Honour hunts, I after Loue; He leaues his friends, to dignifie them more; I loue my selfe, my friends, and all for loue: Thou Iulia, thou hast metamorphis'd me: Made me neglect my Studies, loose my time; Warre with good counsaile; set the world at nought; Made Wit with musing, weake; hart sick with thought...
It is also attested in Robert Garnier's “Antoine†(1595) in the following:
Where are those sweet allurements, those sweet lookes, Which gods themselues right hart sick wuld haue made What doth that beautie, rarest guift of heau'n, Wonder of earth? (lines 695-697)
While one could entertain the similarities between Protheus' neglect of studies, loss of time, and his "warre with good councile" with regard to his love for Julia and the sweet allurement and sweet looks described in Antoine, those similarities are empty and ill-founded on the evidence presented. There is no mention of drugs in either. It is further important to recognize that the "hart sickness" is in reference to the acts themselves, e.g. being "hart sick with thought, the sweet looks that right hart sickness, and not the material substance. These historically based examples are also supported by a more recent use of the term. For example, the Glaswegian Daily Record featured a sports headline from 6 September 2005 that read "Dons left hart sick by latest setback," which referred to a sports injury and delayed comeback. One admittedly must work hard to associate such hart sickness with addiction.
A final note on hart sickness pertains not only to the metaphorical nature of the term, but the current physical location of addiction. The current physical location of addiction is not in the heart at all, but in the head, specifically the brain, in the so-called "pleasure pathway" situated around the nucleus accumbens. Philaretes could not have predicted it as such, since he was, of course, limited by the knowledge of his time.
With regard to the second point, Charlton notes that Philaretes claims have, by and large, been proven by current scientific research. However, this claim may be appropriate only insofar as it attempts to support her premise. Under scrutiny and upon review, it does not address the controversies that exist in the field with regard to the allegedly addictive nature of nicotine. Indeed, there are those disputes in the field that argue against the nicotine addiction hypothesis and the effects of passive smoking.
First, Dar and Frenk (2001, "A Critique of Nicotine Addiction) reviewed over 700 empirical studies and, at the risk of oversimplifying, suggest that the nicotine addiction hypothesis is untenable based on empirical research. Their argument suggests political and social attitudes and biases as the more likely "culprits." Furthermore, there is dispute as to the degree of harm "second hand smoke," "environmental tobacco smoke," or "passive smoking" actually renders on others (See for example, Boffetta P, Aguado A, Ahrens W, Benhamou E, Benhamou S, Darby SC, et al. (1998). Multicenter case-control study of exposure to environmental tobacco smoke and lung cancer. EuropeJ Natl Cancer Inst 90(19):1440-50.). By far are these claims proven. In fact, since the U.S. Surgeon General 1988 report that stated nicotine is addictive, research has increased rather than decreased (Snel and Lorist, 1998, p.83)! Why would this be necessary if already "proven" to be true?
Finally, Charlton notes studies that suggest tobacco use leads to decreased sperm motility and density as well as reduced fecundity in women. She advances these studies to support Philaretes claims (as well as support his predictive validity) that tobacco used caused "sterillitie and barrenness" (p. 106). However, let us reflect on this claim for a moment. Philaretes made his statement 400 years ago now, and, as Charlton notes, his health education is likely to have had little effect. That means a great lineage of persons using tobacco somehow had to have reproduced! Surely they did not reproduce by fission or budding, but were able to inseminate and germinate despite their tobacco use. Philaretes logic, and indeed Darwinian logic, which Charlton notes, would have these species "select" out of the gene pool due to decreased ability to reproduce. Darwinian logic suggests only those that leave offspring are viable species. However, we know this is clearly not the case. The entire philosophical and biological basis of the heritability of addictive disorders is predicated on a species ability to reproduce. No offspring, no transmission of genetic material from one generation to another. No transmission of genetic material from one generation to another, no transmission of defective or "addictive" genes.
In sum, Charlton provides an interesting analysis of this historical document. Her claim that Philaretes work is a first work in health education promotion is deserving, although with the caveats that the historical interpretations and current research disputes make her other claims questionable.
Conflict of Interest:
None declared