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Stop teenagers smoking to reduce disease morbidity and mortality and save billions

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  • UK parliamentarians are proposing to raise the smoking age to 21
  • Tobacco smoking is the biggest preventable cause of  disease disability and death
  • People that start smoking in their teens are most likely to continue the habit into adulthood
  • Quitting smoking is more difficult than quitting addiction to opiates
  • Smoking harms every organ in your body and causes 90% of deaths from lung cancer
  • Smoking related illnesses cost healthcare systems billions
  • Some UK policy makers are denying smokers healthcare treatment
  • UK smokers may cover the medical cost of their habit in taxes
  • How should we and how do we treat smokers?

Stop teenagers smoking to reduce disease morbidity and mortality and save billions

An influential cross-party group of UK parliamentarians backed by the charity Action on Smoking and Health, (ASH) and 16 other health and welfare organisations, including the British Medical Association, Cancer Research UK, the Royal College of Physicians and the British Heart Foundation, has proposed raising the minimum smoking age to 21 and introducing a levy on big tobacco companies to fund measures to encourage people to quit smoking and to prevent youngsters taking up the habit.

Although the prevalence of smoking has declined dramatically in the UK over the past five decades, the decline has stalled, and policy makers are keen to stop teenagers from starting to smoke. This is because if you begin smoking in your teens you are more likely to continue the habit into adulthood when it becomes difficult to quit, and smoking related illnesses cause morbidity and mortality for millions and cost healthcare systems billions.
 
Further, it is becoming increasingly common among some policy makers to suggest that smokers should be denied healthcare because they represent an unnecessary and self-inflicted higher burden on healthcare systems due to the illnesses that they pick up as a result of their smoking habit. According to ASH, smoking costs NHS England approximately £2.7bn a year for treating smoking related diseases. Although high, it seems likely that smokers cover the cost of treating their “self-inflicted” illnesses by taxes.
 
Teenage smoking
 
The UK's proposal to raise the smoking age is likely to be well received because the British government wants to reduce the prevalence of 15-year-olds who regularly smoke from 8% to 3% or less and reduce smoking among adults from 15.5% to 12% or less by the end of 2022. A 2009 report by the Public Health Research Consortium entitled A Review of Young People and Smoking in England, provides a comprehensive review of smoking and young people and suggests, “Most young people start experimenting with smoking in their early to mid-teens, but smoking prevalence and consumption increases until the mid-twenties”.
 
Teenage smoking increases DNA damage
 
Nearly 90% of adult cigarette smokers in the UK first tried cigarettes as teenagers. The continued prevalence of smoking by children and adolescents represents a significant public health challenge. Studies at the molecular and cellular levels suggest that early exposure to tobacco smoking enhances DNA damage and is associated with the induction of DNA alterations in specific chromosomal regions. Chemicals in cigarette smoke enter your blood stream and can then affect your entire body. Adolescence is recognised to be the period of greatest development for your lungs, and therefore it is reasonable to assume that adolescence constitute a "critical period" in which tobacco carcinogens can induce fields of genetic alterations that make the early smoker more susceptible to the damaging effects of continued smoking.

In addition to raising the smoking age, the UK policy proposal suggests that each tobacco manufacturer should pay an annual fee based on the volume of cigarettes it sells in the UK, potentially raising hundreds of millions for the government. Deborah Arnott, chief executive of ASH, said: “Legislation to strictly regulate smoking used to be considered controversial and extreme by all mainstream political parties but governments now have confidence that tough tobacco regulation both delivers results, and, crucially, has widespread cross-party and public support.” The tobacco industry has fought hard to resist successive British governments from introducing legislation that would reduce its profits.
 
Tobacco 21

The proposed British policy is not new. In March 2015 the US Institute of Medicine published a research report entitled, Health Implications of Raising the Minimum Age for Purchasing Tobacco Products, which suggests that raising the legal sale age from 18 to 21, known in the US as “Tobacco 21”, would significantly reduce youth tobacco use and prevent adolescents from starting to smoke. Notably, the report estimated that,  “there would be a 25% reduction in smoking initiation among 15-to-17-year-olds if the age to purchase tobacco were raised to 21”.
 
According to a paper by the US Centers for Disease Control and Prevention (CDC) published in the July 2015 edition of the  American Journal of Preventive Medicine, three out of four American adults, including seven in ten cigarette smokers, favour raising the minimum age of sale for all tobacco products to 21. Notwithstanding, 11% of adults strongly opposed making 21 the legal age of sale, while 14% somewhat opposed such measures. Today, five American states have raised their minimum tobacco sale age to 21 and more than 425 communities in 23 other states have adopted a Tobacco 21 policy.
 
Cigarette smoking harms every organ in your body

According to the 2014 US Surgeon General’s Report entitled, The Health Consequences of Smoking: 50 Years of Progress, “the century-long epidemic of cigarette smoking has caused an enormous avoidable public health tragedy. Since the first Surgeon General’s report in 1964 more than 20m premature deaths in the US can be attributed to cigarette smoking”.
Although smokers today tend to smoke fewer cigarettes than in the past, this does not necessarily translate into reduced harm: biochemical indices of smoking intensity have not shown commensurate declines. Tobacco smoking harms nearly every organ of your body and is the biggest preventable cause of disease, disability and death. It causes so many different types of cancer including  cancers of the lung, oesophagus, larynx, mouth, throat, kidney, bladder, liver, pancreas, stomach, cervix, colon and rectum, anus, as well as acute myeloid leukaemia. Each year smoking is responsible for some 81,700 and 480,000 deaths in the UK and US respectively.

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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.
 
Takeaways

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?
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