Smoking bans in public places, stricter rules on advertising and packaging, and educational campaigns all appear to have helped many smokers quit and deterred others from starting. Almost half of all adults in the UK smoked in 1974, a figure which has since dropped to 15 per cent. But now the government wants to “finish the job” and make smoking tobacco obsolete in England by 2030.
In England alone, 200 people die from smoking-related illnesses every day. One in ten pregnant women are smokers at the time of giving birth, in Blackpool – one of the country’s most deprived areas – one in four pregnant women smoke. In addition to the human costs, smoking costs the UK economy over £14 billion per year, £2.5bn of which falls to the NHS and social care.
In a green paper released on July 22, the Department of Health and Social Care (DHSC) laid out its plans for a cigarette-free England by cracking down on the industry and pledging to help smokers quit or move to reduced risk products like e-cigarettes. “Thanks to our concerted efforts on smoking, we now have one of the lowest smoking rates in Europe with fewer than one in six adults smoking,” the report states, pointing to the successful ban on smoking inside restaurants and other public places in 2007 and the introduction of plain packaging on cigarettes and tobacco in 2016. Taxes on a pack of 20 cigarettes have increased to over 80 per cent of the retail price.
But if England is to follow Sweden and become a smoke-free country – which the DHSC says is achieved when the level of smokers is at five per cent or below – what other measures could the country introduce?
Encouraging safer alternatives to cigarettes would be a starting point, says Peter Hajek, a professor of clinical psychology at Queen Mary University of London. The UK views e-cigarettes as an important replacement therapy for smokers “but we have to comply with the EU directives that ban snus and put much more stricter controls on e-cigarettes than on the conventional ones,” he says. Since 2017, e-cigarette tanks are restricted to a capacity of 2ml and the nicotine content is capped to 20mg per ml – at the time, only nine per cent of vapers reported using stronger eliquids, according to the charity Action on Smoking and Health.
Snus – teabag-like tobacco pouches of purified tobacco, which slowly release nicotine when tucked under the lip – is less risky than smoking cigarettes, Hajek explains. In Sweden, snus has been sold since 1822 and is more popular than smoking cigarettes; a mere five per cent of the population smoke daily. “Part of the reason for this success is that since the 1970s, many Swedes have been switching their cigarettes for snus,” says Hajek. This holds also true for the country’s non-EU neighbour, Norway, which has relatively few daily smokers (12 per cent). The sale of tobacco pouches is illegal in the rest of the European Union, but is gaining popularity in the US and South Africa.
And so is vaping. Although not completely risk free, e-cigarettes are considered much less harmful than conventional cigarettes since they do not involve combustion. It is estimated that some 22,000 to 57,000 smokers in England ditch cigarettes for a vape pen every year – the NHS is considering prescribing them to those wishing to quit smoking.
A recent clinical trial led by Hajek found that 18 per cent e-cigarette users were smoke-free after a year, compared to less than 10 per cent of participants who sought help through the NHS stop smoking services and were using patches, gum or other nicotine replacement therapies. Comparatively, UCL researchers surveyed nearly 19,000 smokers in England from 2006 to 2018: people who used e-cigarettes to quit smoking were 95 per cent more likely to report success than those trying without. “A greater proportion of people continue using e-cigarettes for a longer time than they did with traditional forms of nicotine replacement therapy,” says Jamie Brown, deputy director of UCL’s Tobacco and Alcohol Research Group, clarifying that official advice only recommends people to use e-cigarettes to help them stop smoking.
E-cigarettes may be one of the most effective therapy methods, but are just one piece of the UK’s tobacco control plan and efforts, says Brown. One of the proposals the DHSC put forward for public consultation is a ‘polluter pays” principle, which would force tobacco companies to pay for the damage they cause as is already the case in France, where manufacturers were ordered to help clean up cigarette butts from streets. A fixed levy, regardless of how many cigarettes are sold, says Brown, create a large financial incentive for the industry to shift its focus to alternative nicotine products.
An annual YouGov survey commissioned in early 2019 by Action on Smoking and Health showed that 72 per cent of adults were in favour of manufacturers paying a levy or license fee to help smokers quit and prevent young people from starting. 64 per cent of the survey participants would be in favour of inserts in tobacco products with information on how to quit – another measure proposed in the DHSC green paper. This would come in addition to the gruesome images and plain packaging, which became EU law in 2017. “It’s a kind of refreshed tobacco control policy,” says Brown. “Different things affect different people in different contexts.”
The All Party Parliamentary Group on Smoking and Health led by Bob Blackman, Conservative MP for Harrow East, goes even further to suggest increasing the buying age from 18 to 21. In July, 18 states in the US – a country that is on par with the UK when it comes to smoking rates – have introduced such regulation. Brown believes this could be successful in the UK, considering that increasing the legal age from 16 to 18 has helped to reduce uptake since 2007.
What about paying smokers to quit? In July 2019, addiction and mental health researchers from the University of East Anglia found half of smokers would quit if they were given a cash incentive, shopping vouchers or the return of a deposit. “There’s good evidence that this helps pregnant women,” says Brown, who wasn’t involved in the study. Providing financial incentives to pregnant women as well as people struggling with mental illness, he says, would generally be socially and politically acceptable given that they make up one of the most “vulnerable and high-priority groups.”
Whatever regulations and measures the UK decides to introduce next, Hajek thinks there should be no place for conventional cigarettes. “The end of smoking-related disease and death could come faster if misguided regulations were not keeping smoking alive.”
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