"All human beings are born free and equal in dignity and rights"
A version of this article was originally published on the New Statesman on 28th March 2014.
Creating the First Tobacco Free Generation
Humanity has never developed anything more deadly than the cigarette. The combination of its addictive power and devastating health effects, coupled with historical social norms and powerful advertising campaigns, killed 100 million people in the 20th century. The World Health Organisation predicts that this continuing epidemic will kill 1 billion more in the 21st. Tobacco products cause the death of 50% of their users and, for each death, 20 other people suffer from a smoking related disease. This cycle of suffering and death is unconscionable and it is now time to play the tobacco endgame.
The solution proposed here is to prohibit the sale of cigarettes to people born after the year 2000. As this generation reach 18 in 2018 they would be prevented from buying cigarettes for their lifetime in a move that would progressively phase out cigarette sales. It is not expected that this policy will instantly prevent all people from smoking. Instead it aims to progressively de-normalise cigarette smoking and over time reduce the number of people who become addicted to nicotine. For the full rationale behind the policy please see Berrick AJ, The tobacco free generation proposal, Tobacco Control 2013;22:i22-i26.
Each year around 207,000 children start smoking. While the proportion of children who have ever smoked it declining slowly over time; in 2012 23% of all children had smoked at least once. The prevalence of regular smoking increases with age from <0.5% of 11 year olds to 10% of 15 year olds.
Smoking causes over 100,000 deaths in the UK each year, all of which are preventable. This is more than the deaths from obesity (34,100), alcohol (6,669), road traffic accidents (1,850) and illegal drugs (1,605) combined. Alongside this, around 460,000 NHS hospital admissions per year are attributable to smoking.
The evidence around the positive effects of stopping smoking on individual health is well established. However, The Lancet recently published a large meta-analysis showing the incredible effects that smoke-free legislation has had on child health, including reducing premature births and hospital attendances for asthma attacks.
Free Will and Choice
Smoking is a choice made by children that results in an adulthood of addiction and an early death.
This move may be unpopular among people who view banning the sale of cigarettes as a restriction of personal freedom. However, choosing to take up smoking is rarely an informed choice of adulthood.
By the time smokers reach adulthood, the majority continue smoking to relieve the unpleasant sensation of nicotine withdrawal, rather than to gain any pleasurable effect from the nicotine itself. Addiction, by definition, is not an expression of free will. This is reflected in the fact that 2 in 3 smokers wish they could stop and 9 in 10 wish they had never started. If smoking were a true choice, there would be far fewer smokers in the world. For further detail and debate on the fallacy of a “right to smoke” please see Van Der Eijk & Porter, Human rights and ethical considerations for a tobacco free generation, Tobacco Control, Pub online 10th October 2013.
Legislation and Prohibition
Legislation is often the most effective way to implement a life saving public health measure where education and incentives alone will not work. The inevitable comparison of this policy with alcohol prohibition in the 1920s is hard to ignore. However, substantial differences exist between the nature of alcohol and the nature of tobacco:
In recognition of the harms caused by tobacco, over time there has been a supportive public response to tobacco legislation, including health warnings, advertising bans, smoke-free public places and preventing smoking in cars with children. It would be surprising to suddenly see a large proportion of the population take up clandestine smoking in response to this kind of ban, particularly as current smokers would be able to continue buying cigarettes without hindrance.
This policy proposal originated in Singapore with the support from the National Cancer Centre and has since resulted in a coalition of leading cancer centres from 10 countries in Asia signing up to the Goyang Declaration, a commitment to develop and adopt policies towards a tobacco free Asia. Prohibiting the sale of cigarettes to people born after the year 2000 was unanimously approved by the upper house in the Australian state of Tasmania, however has not made it through the lower house as yet. The policy is also actively being considered in Finland.
This proposal makes no statement about how this policy should be implemented and that would be up to any government who passes such legislation to consider. However, we currently restrict a number of products by age that requires shopkeepers to ask for ID and this should be no more challenging than that. There will be a crossover period where there will be people aged 21 who can buy cigarettes and aged 20 who cannot, however over time this quirk will become less important as a larger portion of the population are prohibited from buying cigarettes.