"All human beings are born free and equal in dignity and rights"
A version of this article was originally published in the August 2014 Edition of Pan-European Networks Government publication.
Humanity has never created 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 – more than WWI and WWII combined. The World Health Organisation predicts that this continuing pandemic will kill 1 billion more in the 21st[i]. Persistent smoking, as an activity, has a risk of death of 1 in 2[ii]. For each death, 20 other smokers suffer from a smoking related disease[iii], which include at least 12 different types of cancer and a range of heart, lung and vascular conditions.
The amount of harm caused cigarettes is unparalleled. Society would rightly be outraged if they were invented and marketed today – you only need to imagine the application for regulatory approval required for such a product. So why, given these facts, can an individual walk into a shop and buy something that is likely to lead to addiction and an early death?
The most powerful reason is that smoking cigarettes is considered a normal activity in society. Historically this has been because the harm from smoking was unknown or uncertain. However since the harms have become apparent it has resulted from the concerted efforts of the tobacco industry to alter the public’s perception of the safety of smoking. In 2011 the industry spent $8.37 billion on marketing activities in the US alone, equating to $27 each for every man, woman and child. This is despite high levels of legislation restricting the type of advertising allowed.
The Illusion of Choice
If it was the case that people took up smoking following informed and rational consideration of the risks and benefits, then there would be less need for meaningful action to reduce the availability of cigarettes. However, the evidence shows that this is rarely the case. If someone makes it through adolescence without taking up smoking, it’s rare for them to then decide to smoke in adulthood. Eight in 10 smokers start in their teens[iv] and almost all are hooked by their early 20s. This decision is heavily influenced by peer pressure and a desire to appear more adult. While smoking is seen as a rite of passage it will continue to be desirable to teenagers. Tobacco companies know this, which is why1 in 10 students aged 13-15 across the world have been offered a free cigarette[v].
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[vi] and 9 in 10 wish they had never started[vii]. If smoking were a true choice, there would be far fewer smokers in the world. This then raises the ultimate question: – given the cycle of addiction, suffering and death caused by cigarettes, how can we begin to undo their hold on society?
Banning the sale of cigarettes to people born after 2000
The policy adopted at the British Medical Association’s Annual Representatives Meeting in June 2014 proposes banning the sale of cigarettes to people born after 2000. This move would gradually phase out the legal sale of cigarettes to people, even as they enter adulthood. As this generation reach 18 in 2018 they would be prevented from buying cigarettes for their lifetime.
The philosophy behind this policy requires a radical change to some widely held ideas and beliefs relating to smoking cigarettes. It is not expected that this would 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. Importantly, it is not the act of banning sales alone that would reduce consumption, but the message this creates as a society – that a product causing this level of harm is no longer acceptable.
This proposal would not affect the sale of cigarettes to people already addicted to nicotine. A total ban on cigarette sales would be difficult to justify ethically and would seem disproportionately unfair to those currently addicted, despite the health benefits it may bring.
We’ve all got to die of something
Life, after all, is a terminal condition. However, the normalcy of smoking means people substantially underestimate the harm caused to both individual smokers and a population as a whole. There is a huge difference in dying from something over which you have no control, compared with dying from an addictive behaviour that is potentially modifiable. Typically smokers develop a chronic smoking related illness and die in middle age[viii], around 10 years earlier than their non-smoking counterparts. While there is the quantifiable harm (deaths, illness, working days lost etc.) there is also the unquantifiable suffering of watching a friend or relative die prematurely. This proposal would begin to create an environment where these years of life lost to smoking begin to be prevented.
Legislation and prohibition
Legislation is often the most effective way to implement a lifesaving public health measure where education and incentives alone will not work. Smokers already know cigarettes are harmful, but are powerfully addicted to nicotine, therefore find it hugely difficult to change their behaviour and break the cycle.
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. Most people who smoke are nicotine addicts responding to withdrawal symptoms who wish they could stop[ix]. In contrast, the majority of people who drink alcohol do so recreationally for its pleasurable effects. Alcohol is substantially less addictive than nicotine and so a much smaller proportion of drinkers become alcoholics. If 90% people who drank became alcoholics there would be total public outrage.
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.
There are a number of practical hurdles to implementing a policy of this kind, even when the lobbying power of the tobacco industry is discounted. There would be an arbitrary cut-off age, where individuals aged one year younger would not be able to buy cigarettes. More work would need to be undertaken to establish how a policy of this kind would fit within existing law. It is important to note that this is not a proposal to criminalise smokers, but instead prohibit the sale to people of a certain age. Many other products are already age restricted, including tobacco and alcohol, although usually to young people. The process should be no more onerous than current practices such a checking identification at the point of sale, aside from it would be required for all adults rather than young people.
Surprisingly this kind of legislation has been used in the past to great effect with a similarly addictive product. Opium smoking was eradicated in both Formosa and British Ceylon between 1908 and 1957 by requiring current smokers to register to be eligible to buy opium and the prohibition of supply to any new smokers[x].
Precedent exists on using date of birth as demarcation, although in a different context. In 1957 the UK government began to phase out mandatory military conscription in part by passing law that the threshold date of birth for eligibility for National Service would be 30th September 1939. Men born after this date were no longer required.
Cigarettes are not a normal product and therefore the normal rules do not apply. Creating the first tobacco-free generation is a radical idea that will require much strength from politicians and the public. However, once it has been achieved, we will all wonder what took us so long.
References:[i] WHO Tobacco Factsheet, ; http://www.who.int/mediacentre/factsheets/fs339/en/. [ii] Cancer Research UK, 2013, from http://bit.ly/1mQhbAt. [iii] Smoking Statistics, Illness and Death, ASH Factsheet, April 2013. [iv] Young People and Smoking, Ash Factsheet, January 2014. [v] Global Tobacco Surveillance System Data (GTSSData), from http://www.cdc.gov/TOBACCO/Global/index.htm. [vi] Smoking Statistics: who smokes and how much, Ash Factsheet, October 2013. [vii] Gallup Poll Social Series: Annual Consumption Poll, 2012; http://www.gallup.com/poll/157466/smokers-light-less-ever.aspx. [viii] Vollset, S. E., et al., Smoking and deaths between 40 and 70 years of age in women and men. Ann Intern Med, 2006. 144(6): p. 381-9 [ix] Nicotine and Addiction, ASH Factsheet, June 2013. [x] Berrick J. The Tobacco Free Generation Proposal. Tob Control 2013;22:i22-i26