State of play: smoking
Throughout this Cancer Prevention Action Week, we are reviewing the current state of public policy for the major risk factors in causing preventable cancers.
Tobacco use is the area where historically there has been the strongest policy action to prevent harm. Much of the progress in extending life expectancy over the later part of the twentieth century and early part of the twenty-first can be attributed directly to success in reducing levels of smoking, and the UK has been a world leader in this. It is also the lifestyle factor whose link to cancer is most widely known and accepted.
Why do people smoke?
Why people start smoking and why they continue to smoke are subtly different questions, but the answers to both lie in wider determinants of health: socio-economic background and personal circumstances are major drivers of smoking behaviour.
Analysis by the Office for National Statistics and Public Health England shows that the likelihood of someone smoking increases in line with the level of deprivation in their neighbourhood. Smoking also correlates very clearly with a person’s housing tenure (renters are more likely to smoke than owner-occupiers) and occupational group (workers in routine and manual occupations are more likely to smoke).
Smoking uptake flows through generations: young people who are exposed to smoking behaviour, for instance via their parents, are more likely to see smoking as normal, more likely to have ready access to tobacco, and more likely to try it. Once they are addicted, they also find it harder to quit: in communities where smoking is still very visible, quit rates are lower (although attempts at quitting are no less common), and these trends reinforce each other. The reverse is seen in communities where smoking is less common: each generation is less likely to see it as normal, less likely to take it up, and more likely to find it easy to quit when they try.
As this implies, changing patterns of smoking behaviour is hard and takes time. Growing awareness of the harms caused by smoking brought rates down in the later decades of the last century, but more so among better off and more educated people. The ban on smoking in indoor spaces in 2007 built on many years of shops, restaurants and other facilities first having no-smoking areas, and then often banning smoking entirely. These changes made smoking more and more inconvenient, and marginal in society, an effect amplified by a ban on tobacco advertising, and requirements to sell cigarettes in plain packaging, and hide them from view in shops.
Smoking cigarettes has also been made more expensive. From November 1993, there was a commitment to increase tobacco duty by at least 3% per year, and by at least 5% from 1997; and it had been on a rising trajectory even before that. A slightly more complex set of rules was introduced in 2017, which has maintained the effect of annual rises.
However, despite a history of strong action in the past, tobacco policy in the UK appears to be faltering. The Government set a strong ambition in 2019, for England to be smoke-free (defined as only 5% of the population smoking) by 2030. Wales has also set a target of 2030, and Scotland 2034. However, the independent Khan Review, which published its findings last year, reported that the English target will be missed by seven years without further policy action, and by 14 years in the least well-off parts of the country. Cancer Research UK has separately estimated that the England target is due to be missed by nine years.
The Government has yet to respond to the Khan Report: it has committed to doing so as part of a health disparities white paper, which has been subject to delay and was even reported to have been cancelled by the Truss administration (although health ministers later confirmed that it would be published). A new Tobacco Control Plan should then follow, but is similarly overdue. The bold interventions recommended in the report would, if implemented, be a striking but welcome departure from recent policy approaches. The recommendations include:
- Increasing tobacco duty markedly more steeply than recent rises
- Significant investment in smoking cessation services across the NHS
- Progressively increasing the age at which tobacco may be bought, effectively prohibiting its purchase by people born after a certain date
- Licensing for tobacco sales, to reduce the number of outlets where it can be bought
- A “polluter pays” approach, in which the costs of these measures would be met at least partly by a levy on tobacco manufacturers.
Scotland, Wales and Northern Ireland all have tobacco control plans of their own, although some of the tougher actions proposed in the Khan Report would require UK-wide legislation by Parliament.
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