Guest Blog by Stuart Carroll, Senior Health Economist and Epidemiologist
There is no smoke without fire. An old but dangerous saying, which given recent events in the world of British politics should chasten many not to judge a book by its cover. The ongoing trend of trial by media is, a bit like the comeback of the Backstreet Boys, worrying and distasteful conferring some truly inimical consequences for the cornerstones of our basic, and long-standing, judicial principles.
In the world of public health, the claim of no smoke without fire has been promulgated with unequivocal valediction in the case of cigarette branding. Following Sir Cyril Chantler’s independent review, we are told a cigarette should be judged by its cover, or more to the point its packet. Just like legislation banning any form of advertising or sponsorship, Sir Cyril recommends plain packaging and the outlawing of any form of cigarette branding. The Government is now preparing draft regulations for a final, and supposedly short, consultation. Its rationale is rooted in ongoing attempts to cut the number of smokers in the UK and, more to the point, the incidence of smoking, particularly amongst young people, which is currently estimated at 200,000 a year. This is an admirable and important aim, which successive governments have struggled to achieve.
From my point of view, smoking is a vile and damaging activity that is perfidious to the aims of public health and improved national well-being. I have seen first-hand the effects smoking had on my late Grandfather. His emphysema was unpleasant and restricted his final days quite markedly. As a non-smoker, I have absolutely no vested interest in this debate and frankly think people must be off their rocker to smoke at all given all the compelling public health information to the contrary. It is not trendy; knackers your health; reeks the hell out of your clothes; quite literally creates a stink; and costs a fair few bob to boot. I also have no sympathy or empathy whatsoever for the tobacco industry; a sector for ethical reasons I could never work in.
Similarly, there is no doubt that the Government has handled this issue poorly, having u-turned with all the grace of a dilapidated oil tanker and procrastinated worse than Terry Griffiths lining up a red at Sheffield’s Crucible Theatre. To watch Diane Abbott last year opportunistically make political hay all over the 6 o’clock news helped redefine the meaning of nadir. Thankfully, Ed Miliband showed the world of public health some much-needed clemency with a North Korean style firing in Labour’s 2013 reshuffle. The Government’s communications strategy has been haphazard and naive rendering open accusations of “playing for time” and pandering to the tobacco lobby.
Yet despite the prevarication and my own abhorrence for smoking, I don’t see this issue as an automatic slam dunk, as some have presented it. There are a couple of important matters of principle and empiricism, which in turn should guide strategy, that need to be debated and challenged.
Let’s look at the empirical issue first. The business of public health is inherently complicated. The Marmot review, and reams of well-publicised research in this area, emphatically make that point. Branding might be one influential factor, but evidence shows it is peripheral to the more fundamental challenges around social mobility, aspiration, deprivation and poverty, health inequalities and, perhaps most important of all, education. To what extent, would non-branding help solve these more entrenched problems and what would be the cost of legislating and enforcing such a policy? Is the cost-benefit really worth it or would the government not be better of spending precious time and resource advancing a truly integrated public health strategy and national plan of action to tackle the root causes? Despite increasingly hard-hitting and “take a look at this diseased lung” style education, people are still smoking. Is this really down to resplendent branding, colourful packaging and the seductive use of clever wording? Or is it actually something else that is more deep, difficult and societal? I think the argument around branding leading to increased incidence needs to be further tested and must surely go beyond subjective opinions and be based on some hard-hitting data and statistical analysis. The “market research” in favour of the prosecution seems weak, as exemplified by the Australian data used at the vanguard of this debate.
I am not disputing there might be a direct link, but the notion of young people seeing colourful cigarette branding, bowling around to the local corner shop to buy a pack of 20, and then lighting up with giddy delight needs to be quantified, or at least better qualified. It has to be remembered that as with anything in life, certainly government policy, there is, as we economists would say, an “opportunity cost”. We might be better off focusing on the real causes rather than obsessing with branding. However, I am open to persuasion.
Yet then there is the important matter of principle. After all, principle should guide government policy. To what extent should the government be running a “nanny state” and is there not an argument in favour of freedom of choice? It has to be remembered smoking is a legal, and therefore a legitimate, activity and all political parties and governments have propounded, at least rhetorically, their intrinsic defence of liberty and freedom. The government is not, for quite understandable reasons of practicality and common sense, proposing the prohibition of smoking, which would only ripen an already rampant black market and, of course, be impossible to police. That would be more nutty than a Monty Python sketch.
Nonetheless, a policy of prohibition (not one I could viably support because of the exigent practical realities although eliminating smoking does have appeal) would be principled and consistent, whereas currently we are saying smoking is legal but you have to look at a horrible picture whenever you buy a pack of fags and cannot smoke hardly anywhere due to a “public” smoking ban. In both cases, as an individual British citizen and utility-maximising non-smoker, I am over the moon. Yet, we have to remind ourselves that the activity itself is legal. Take the smoking ban. The ban actually covers privately owned establishments not owned by the “public”, and thus approaching 100% of all pubs, bars and restaurants in the UK. Although I am not seeking a reversal of the current policy, which benefits me, my health and washing machine directly, I did at the time of the legislation question whether the state should be telling private property owners what they can and cannot do with a legal activity. Publicly owned buildings or areas, such as parks, libraries, schools, hospitals, leisure centres etc, absolutely fine, but where does it stop? Surely, the logic of this policy should apply to private house parties and anything else of a similar nature. The same also applies to branding. Is this really the best way to promulgate public health and frankly is it the role of government?
The lofty tax plonked on cigarettes I have no problem with: it costs the NHS a fortune so people should pay for their stupidity and the sad inevitability of expensive future ill-health. That is basic economics. The issue here is, where do you draw the line? Is the Government implementing an honest policy? Government policy is essentially pursuing an incremental and furtive strategy of outlawing a legal activity without actually making it illegal. There is an uncomfortable contradiction in all of that. Furthermore, there is the issue of consistency. Although they are not exactly identical and there are differences, should we not be applying similar standards of government intervention to booze, fatty foods and extreme sports? These public health minefields can be, and in many cases are, just as dangerous as smoking with analogous consequences for the NHS and often resulting in premature mortality.
Of course, some people reading this blog will be shouting out loud, “Don’t care about principles if it saves people’s live”. I totally get that both for personal and professional reasons. As someone who works in public health (my friends and family are sick of hearing about public health!), I am not arguing against action. I am just questioning whether the principle and logic of policy, and its proportionality and efficacy against its stated objective, sufficiently withstand the perspective to the contrary. For me, the Government case lacks the very thing it now wants to enforce: compulsion.
I also do not believe pushing, sermoniser and telling people what they can or can’t do with a legal activity is the role of government. Moreover, I do not think this approach to public health actually works. The old saying “nudge rather than push” rings strikingly true on matters of public health as does the business of improving education and tackling root causes. It certainly confers more wisdom than “no smoke without fire”.