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 twentieth century. The World Health Organisation predicts that this continuing epidemic will kill a billion more in the twenty-first. Tobacco products cause the death of 50 per cent of their users and, for each death, 20 other people suffer from a smoking related disease. Allowing this cycle of addiction, suffering and death to continue is unconscionable.
One solution 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. This would have the effect of de-normalising smoking for an entire generation of children and slowly begin to reduce the harm caused by tobacco. Evidence published today in the Lancet shows the incredible effects that smoke-free legislation has had on child health, including reducing premature births and hospital attendances for asthma attacks. It’s time to apply the lessons from this evidence to the population as a whole.
This move may be unpopular among people who view banning the sale of cigarettes as a restriction of personal freedom. However, starting to smoke predominantly takes place in childhood and adolescence, as 80 per cent of smokers start in their teens. This decision is heavily influenced by peer pressure and a desire to appear more adult, rather than being dependent on rational choice. Almost 99 per cent of people think adolescents should be prevented from taking up smoking and to achieve this smoking must become socially unacceptable. This is particularly important as someone who starts smoking at age 15 is three times more likely to die of tobacco related cancer than someone who starts in their mid-20s. 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, cannot be 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.
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. 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 per cent 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.
While smoking is still seen as socially acceptable in daily life and believed to be an expression of free will it is unlikely that there will be sufficient political will to call for an outright ban. However, this policy presents an opportunity to intervene for the generation who have not yet started smoking to prevent them from perpetuating the cycle of misery and suffering caused by nicotine addiction. It’s time to play the tobacco endgame and begin building the first smoke free generation.
Dr Tim Crocker-Buqué is a Speciality Registrar in Public Health Medicine