In wealthy countries such as Britain and the US, smoking cigarettes kills more people than alcohol, car accidents, HIV, guns, and illegal drugs combined. An estimated 36% of all respiratory disease deaths, 30% of all cancer deaths and 14% of all circulatory disease deaths are attributable to smoking. This figure rises to 87% of deaths from chronic obstructive pulmonary disease (COPD) and 82% of deaths from lung, bronchus and trachea cancer.
Nicotine, carbon monoxide and tar
Some experts suggest that it may be harder to stop smoking than to stop using cocaine or opiates such as heroin. About two out of three smokers say they want to quit and each year about half of all cigarette smokers in developed economies try to quit, but few succeed even with professional help. This is because smokers become physically addicted to nicotine.
Tobacco smoke contains a deadly mix of more than 7,000 chemicals; hundreds are harmful and about 70 can cause cancer. However, it is the chemical nicotine, which is the addictive agent, and smoking is an effective way to deliver nicotine to your brain. When you smoke cigarettes, nicotine is quickly absorbed through your lungs into your bloodstream, where it is carried directly to your heart and onto your brain. Because it takes only 6 to 10 seconds for each inhalation of cigarette smoke, nicotine does not get an opportunity to dissipate, so the high concentration of nicotine in your lungs remains in your blood until it reaches your brain. Whilst addictive, nicotine is relatively safe; it is the carbon monoxide and tar, which deposit in your lungs and airways that contain the harmful carcinogens.
According to the 2012 US Surgeon General’s Report: “Of every 3 young smokers, only 1 will quit, and 1 of those remaining smokers will die from tobacco-related causes. Most of these young people never considered the long-term health consequences associated with tobacco use when they started smoking; and nicotine, a highly addictive drug, causes many to continue smoking well into adulthood, often with deadly consequences.”
Large and rising revenues of giant tobacco companies
Although sales of cigarettes are slowing in wealthy countries as people move to vaping, (which is not safe) the annual revenues of the giant tobacco companies continue to rise and their annual marketing and advertising spend also continues to rise. In 2016 the world’s leading tobacco company, Imperial Tobacco Group, generated revenues of some US$39bn and the combined annual advertising and marketing spend of the leading tobacco companies in 2017 was nearly US$9bn.
Price hikes and demand
There is some evidence to suggest that price increases of cigarettes reduce their demand. For example, findings of a 2014 report published by the US Centers for Disease Control (CDC), suggested that the smoking rate in the US fell by 15% between 2008 and 2012 when the price of cigarettes increased 40%. Today, it is generally accepted in developed nations that a 10% price hike will reduce demand for cigarettes by about 4%. In 2018, New York raised the cost of a pack of cigarettes from US$10.50 to US$13. Australia has started increasing the average price of a pack of cigarettes from AUS$20 and expects to raise it to AUS$45 by 2020. This represents annual 12.5% hikes in tobacco excise tax, which by 2020 is expected to be nearly 70%; the level recommended by the World Health Organization (WHO).
As an aside, it is interesting to note that the ‘one-size-fits-all’ global excise tax incidence target of 70% proposed by the WHO could be potentially destabilizing. This is because key economic drivers influencing the illicit tobacco trade, which is now a global phenomenon, are excessive tax levels, which result in a sharp decline in cigarette affordability and organised crime’s willingness to supply illicit cigarettes given the opportunity to gain large profits from tax avoidance. The policy challenge is to reconcile cigarette affordability, tax levels and revenues and consumption.
The effects of advertising restrictions and graphic labelling
The 2014 US Surgeon General’s report suggested that, “The tobacco epidemic was initiated and has been sustained by the aggressive strategies of the tobacco industry, which has deliberately misled the public on the risks of smoking cigarettes”. Advertising restrictions of cigarettes have been in existence in the US since the late 1990s and many other countries have restricted tobacco advertising. For example, China, where about half of the adult male population smoke, has banned many forms of tobacco advertising. Further, several nations have added graphic warning labels to illustrate the dangers of tobacco smoking. Findings of a Canadian study on the effects of such graphic warnings reported in a 2014 edition of the British Medical Journal concluded that they could decrease the number of adult smokers in the US by 5m to 9m. Each year the tobacco industry continues to spend billions on marketing and advertising.
Marketing changes but the same messaging
Because direct tobacco advertising is banned in many developed countries, increasingly marketing strategies of tobacco companies have become more subtle and indirect and feature on video games and on all forms of social media, but the overall message remains the same: that smoking is exciting, glamorous and safe. Research suggests that young people who are introduced to cigarette smoking via such media are more likely to start smoking. Also, tobacco companies give significant price discounts amounting to over US$7bn annually to retailers and wholesalers to reduce the price of cigarettes. They also pay retailers over US$200m to stock and display particular brands of cigarettes, and nearly US$400m is paid annually to retailers and wholesalers in volume rebates and as incentives to undertake their own promotions.
Rationing healthcare for smokers
Some policy makers argue that smokers are an unnecessary and self-inflicted higher burden on over-stretched healthcare systems due to the illnesses that they pick up as a result of their own decision. The annual direct costs of medical care in the UK resulting from smoking related illnesses amounts to £2.7bn. Rationing treatment based on patients who smoke is gaining momentum in the UK. In 2016 the UK’s Royal College of Surgeons (RCS) reported findings of a 2015 survey of Clinical Commissioning Group (CCG) leaders, which found that some NHS hospitals were either delaying or denying routine surgeries, such as hip and knee replacements, for patients who smoke. Findings suggested that 39% of CCG leaders were considering new limits on the eligibility of services for financial, value or efficiency reasons. Some reported that their CCG was considering introducing referral thresholds for joint surgery. A 2015 survey of clinicians reported that 75% had witnessed rationed care in their area, and 89% of these respondents said that rationing for smokers was occurring owing to financial reasons. In November 2016, two CCG’s in Yorkshire, UK, announced plans to delay surgeries for many cigarette smokers by either 6 or 12 months if they could not prove they have stopped smoking for two months. In one of the CCG’s almost 14% of adults are smokers.
Factors driving increased demand
Although wounds heal faster and recovery is quicker in non-smokers, there is no evidence to suggest that withholding surgery successfully reduces smoking.
A paper published in a 2018 edition of Medical Ethics, argues that where smoking has, “significant implications for elective surgical outcomes, bearing on effectiveness, the rationing of this surgery can be justified on prognostic grounds”. But warns that although rationing certain surgeries for prognostic reasons is sound, authorities, “should avoid explicit statements, which suggest that personal responsibility is the key justificatory basis of proposed rationing measures”.
It is not only smoking, which increases demand on NHS England’s over-stretched resources. Other drivers include the UK’s aging population, reduced social care budgets, which have led to “bed-blocking”, (where people with no medical need remain in hospital because they cannot be supported at home) and staff shortages. While hospital doctor and nurse numbers have risen in the UK over the last decade, they have not kept pace with the rise in demand for healthcare services.
Smokers may actually be paying for their habits
With regards to rationing treatment for smokers, successive UK governments are conflicted as they are beneficiaries of tobacco excise tax revenues, corporation tax and the taxes of the employees of tobacco firms. When the arithmetic is done, it is not altogether clear that smokers exert a significant extra burden on healthcare resources. Indeed, it is possible that smokers actually contribute more in taxes than is needed to cover the costs of their potential health issues. Without going into a detailed cost benefit analysis, the headline figures suggest that smokers pay for their medical costs caused by their habit in taxes. Although the cost side of the equation is challenging to pin down, we estimate the overall annual smoking-related cost to the UK taxpayer to be some £14bn, which includes £2.7bn direct cost of medical care from smoking related illnesses. Offset £12bn annual cigarette taxes - £9.5bn in excise duty plus £2.5bn of VAT - which 8m UK smokers contribute each year and you arrive at the conclusion that smokers almost cover the cost of their habit.
A range of inter-related factors operating at the individual, family, social, community and societal levels influence whether a young person starts and continues to smoke. This raises a number of unresolved questions that impinge upon health equity, including: How should we treat smokers? How do we treat smokers? Why do we treat smokers in the ways that we do?