The Conservatives have embarked on an endgame tobacco policy, but is it a well-informed path to a smoke-free society or a weak attempt at improving public health long-term?
On Tuesday 7th November 2023, King Charles III delivered his first King’s Speech as monarch, opening the parliamentary session. With his tone somewhat forlorn, his statements swamped in his swathes of fur and jewels, and the crowded House reminiscent of a school assembly in the early hours, neither the King himself nor the attendees seemed enthralled by his address. Among the allusions to international energy markets, hooligan pedicabs, and – presumably resentfully spoken by His Majesty- plans for licensing new oil and gas fields, the King confirmed plans to continually increase the legal smoking age, under the proposed Tobacco and Vapes Bill.
These plans were previously outlined by Rishi Sunak at the 4th October Conservative Party Conference, who proclaimed them to be “the biggest public health intervention in a generation”. The ideas originate from former Barnardo’s Executive Javed Khan’s review on tackling smoking in the UK, in which he recommended raising the legal smoking age year after year. Based on assumptions of enactment by 2027, this would mean individuals currently 14 years and under in England would never be legally allowed to buy a cigarette. The bill also incorporates higher funding for cessation services and restrictions on the sale of vapes, and looks likely to pass; Labour reportedly has no plans to oppose it, and a public consultation on the relevant issues is underway.
Continually raising the smoking age is one example of an endgame tobacco strategy, a type of public health intervention aiming to eradicate tobacco use completely. Other endgame methods include regulating the nicotine content of cigarettes, raising their pH to make them unappealing or increasing taxes on tobacco. These strategies depart from the never-ending dance of targeting individual smoking behaviour and instead place the onus for change onto societal systems. Despite their aims appearing idealistic, anti-smoking policy history is littered with previously unthinkable wins, such as Norway’s 1975 ban on the advertising of tobacco products, the UK’s 2007 indoor smoking ban and 2012’s introduction of plain packaging for cigarettes in Australia.
Smoke-free generation policies specifically are supported by research that suggests initiation into smoking at a young age is the critical point for determining future behaviour and that access control is, accordingly, an effective way to reduce experimental smoking in young people. In addition, stepwise age restrictions neatly dodge issues with public outcry and the economic and healthcare collateral that bans removing the privilege of smoking from individuals could unleash. Perhaps for these reasons, smoke-free generation proposals have been introduced in Hawaii, with the Netherlands’ Smoke-Free Generation movement hot on their heels.
New Zealand was previously lauded around the world for passing a package of ‘Smokefree 2025’ endgame policies in December 2022, which bundled together an assortment of regulations alongside raising the smoking age, including reducing sales outlets and nicotine content of cigarettes. This was neatly bolstered by increased funding in research and healthcare and enhanced cessation support, including services tailored to Māori and Pacific communities to accommodate for health inequities. However, New Zealand’s new government have unexpectedly announced plans to rescind these laws, prompting strong criticism from public health officials who had praised them for their comprehensiveness and interdisciplinary approach.
It is unclear how New Zealand’s dramatic U-turn will affect England’s plans, which had been on track to follow their star-student precedent; a spokesperson for the Prime Minister has stated his position is unchanged. Loss of this key role model notwithstanding, issues with UK public health infrastructure and an NHS damaged by lack of funding risk the plans not living up to their endgame aspirations. Although the Bill includes a package of policies, raising the smoking age is emerging as the focal point, with its protective cushion of funding and resources at risk of being diminished as it progresses through Parliament. In addition, despite the rare championing of preventative policy in a public health system trapped in a cycle of reactivity, its impact on healthcare services will be minimal for a considerable period. Therefore, as the NHS must still cope with smoking-related issues from the entire current legal smoking population, the legislation may turn out to be inadequate; a promise of a shiny present, for now, is out of reach.
Other arguments against the proposition include claims it will push young people into the illegal trade of cigarettes. Although glamorisation is a key factor in adolescents’ smoking behaviours, this argument is not supported by research. Firstly, social norm models suggest that although illicit trade may occur in the first few years, as role models age and become less appealing, this behaviour will rapidly decline. Unsettling predictions of rampant black markets and shady back-alley sales, akin to those of alcohol prohibition in the 1920s USA, are apparently falsely perpetuated by big tobacco companies themselves.
Black-market arguments are often paired with hysteria regarding the freedoms of young people and the rise of the nanny state. Again, these prove exaggerated compared to the reality; young people in New Zealand are reported to believe smoke-free generation policies would protect their freedoms, and smoke-free generation policies have been confirmed as consistent with the Universal Declaration of Human Rights and the Convention on the Rights of the Child.
However, the ban does raise questions for the future of public health more broadly as we move into an age characterised by abundant data and high rates of chronic disease. Which individual behaviours can be deemed the state’s responsibility, and how far legislation can reach, is a debate that cannot be shied away from. The role of vapes illustrates how public health is plagued by ever-shapeshifting end goals – is the nirvana to be strived for tobacco eradication, with ‘clean’ nicotine use persisting, or should nicotine addiction be included in endgame policies? The proposed vaping restrictions are welcomed amidst emerging evidence that nicotine may disrupt cell regulation, however, balancing its value as a cessation tool versus its own risks will prove difficult.
Overall it is clear that the smoke-free generation policy is an appealing soundbyte for a government hurtling towards a general election with few public health successes to its name, the King’s Speech confirming that Mental Health Act changes and anti-obesity measures are to be left in the dust. Nonetheless, the significance of the introduction of an endgame tobacco strategy should not be minimised. Whether it will become a policy defined by its incrementalism, and what type of precedent it sets for public health legislation in the future, remains to be seen.