Smoking remains one of the single biggest causes of disease and premature death. Despite efforts to reduce tobacco consumption, in 2019 almost 8.7 million deaths worldwide were attributed to smoking. This is more than have died from COVID-19 since the pandemic began.
And – just like COVID-19 – we see more of these deaths in those with the lowest incomes, as these people are more likely to smoke. Those living in the poorest parts of the UK are expected to live around 9 years fewer than those in richer areas, and smoking is estimated to account for around half of this difference.
The economics are shocking too. The average UK smoker consumes half a pack of cigarettes per day, costing around £2,300 per year. For those in lower-paid occupations, this is likely to represent at least 10% of net earnings. Even before the current cost of living crisis, tobacco expenditure pushes an extra 1.3 million people into poverty in the UK. Meanwhile, it is estimated that the Treasury makes a net ‘profit’ from smoking of around £15 billion a year, and yet at same time, we have cut spending on smoking cessation by 75% over the last decade.
Against this background, Javed Khan OBE was commissioned by the new Office for Health Improvement and Disparities to conduct an independent review of the government’s ambition to make England smoke free by 2030. This landmark report – out yesterday – identifies the interventions most likely to reduce the uptake of smoking and support smoking cessation.
The report calls for investment both in a comprehensive “Smokefree 2030” programme (funded by a radical ‘polluter pays’ levy), and in NHS action across all services. Critically, it also urges HMG to consider increasing the age of sale from 18 years, by one year, every year. Current estimates suggest that the implementation of such legislation would lead to a reduction in the number of smokers aged 18-20 years in England from 364,000 to 255,000 in the first year. Critically, after year one, 18,000 new smokers a year would be prevented. Advocates argue that together, this would create a significant reduction in smoking prevalence, which would move through the age cohorts over time.
This idea follows that of other countries. In New Zealand, progressive legislation means that the legal smoking age will increase each year, such that those born after 2008 will never be able to legally buy tobacco products. Similarly, in December 2019, the US Government instituted T21, raising the federal minimum age for sale of tobacco products to 21 years. Data from the US suggests that this has reduced smoking prevalence in young people by at least 30%.
If we take a behavioural perspective, such legislation makes sense. Friction costs – that is, anything which makes a behaviour more effortful – dramatically reduce the chances that we will undertake that behaviour. For those aged less than 21 years, obtaining cigarettes will become much more difficult, likely putting off some entirely.
Further, it encourages the promotion of e-cigarettes as a substitute for smoking. There is evidence that, to date, e-cigarettes are the single most effective quitting aid. A recent randomised control trial found that e-cigarettes were almost twice as effective as nicotine-replacement therapy (e.g. nicotine patches, gum) in helping smokers to quit (18% in the e-cigarette group had stopped smoking after one year, versus 10% in the nicotine-replacement group).
Again, from a behavioural perspective, e-cigarettes are well designed. They offer a familiar physical sensation: allowing users to replicate smoking habits (for example, stepping outside, holding something in their hand, inhaling and exhaling a vapour). When something feels familiar or certain, we are much more likely to attempt it. Further, there is likely to be less of a feeling of loss or restriction than with other quit attempts (especially important given our intense aversion to loss), as the e-cigarette user can still satisfy existing nicotine cravings without ingesting tar or carbon monoxide.
It is more than a decade since we led the charge in No10 making e-cigarettes widely available, reversing then policy banning them. Current estimates suggest that change saved around a million years of life. It’s about time we made further progress, not least by twinning this most effective route to quitting with the most effective channel to asking – GPs. We need to (i) accelerate the licensing process for e-cigarette manufacturers, making it easier to obtain e-cigarettes on prescription, (ii) offer a stronger-grade, prescription-only offer for those wishing to self-medicate, (iii) better communicate the relative safety of e-cigarettes, and (iv) explore providing e-cigarette vouchers to smokers and other radical interventions such as the commitment devices trialled in the Philippines.
As we said in our recent piece for i, credit should be given to Sajid Javid for commissioning the review, and for putting his head above the parapet on vaping. A combined effort that includes progressive legislation such as T21, along with radical interventions (such as e-cigarettes) to support smoking cessation, is probably the biggest thing we can do to redress the massive health disparities between the richest and poorest in our society, and prevent millions of deaths.