John Watson, Deputy Chief Executive of ASH Scotland, looks at the Scottish Government’s ambition of a tobacco-free generation by 2034, and argues that such a society would be transformative for public health and undermining inequalities in Scotland
THE Scottish Government likes to make the occasional foray into longer-term, more ambitious or visionary targets. The new mental health strategy will run for 10 years, and a series of climate change targets have been set up to 2050, also the year at which it is hoped to see an end to deaths from breast cancer.
Meanwhile the tobacco strategy launched in 2013 introduced the commitment that a child born that year would celebrate their 21st birthday in 2034 as part of Scotland’s first tobacco-free generation.
Some commentators, perhaps used to criticising politicians for short-termism, may wonder whether setting targets so far over the political horizon simply equates to kicking an issue into very long grass indeed. But the pledge to shift adult smoking rates (currently at 20%) down to a residual 5% did come with a series of intermediary targets.
The continuing dominance of tobacco amongst public health harms is demonstrated by the scale of the benefits on offer to MSPs, should they achieve the target of a 12% smoking rate by the end of their term in 2021. The combination of an extra £100million for the poorest communities every year, savings of over £100million for NHS Scotland, Scottish employers carrying a million fewer sick days annually and saving a further million from reduced smoking breaks should appeal across the political spectrum.
“The combination of an extra £100million for the poorest communities every year, savings of over £100million for NHS Scotland, Scottish employers carrying a million fewer sick days annually and saving a further million from reduced smoking breaks should appeal across the political spectrum.”
There are few better examples of the prevention agenda. In health as is in so many other walks of like, avoiding costs and illness altogether is more effective than trying to right wrongs after the event. But what would this tobacco-free society look like?
Firstly it does not mean smoking is banned. Most smokers started as children and most smokers say that they want to stop. So the 5% smoking target really means reducing smoking to the small number of informed adults who actively choose to do so. That feels like a careful accommodation between state intervention and individual freedom, which even the most ardent libertarian should be able to live with.
Some groups in society already know what this looks like - amongst the richest fifth in Scotland the smoking rate is now in single figures. But we can learn more by considering the groups who do smoke.
The smoking rate is four times higher in the poorest areas than in the richest. A third of tobacco is used by people with mental health issues. The smoking rate is around 50% for those with a long-term disability or out of work and seeking employment. Around three quarters of the prison population smoke. Crucially, in all of these groups, most of the smokers say that they want to stop – yet tobacco continues to cost them an average of £1500 a year while greatly increasing their risk of cancer, heart disease, dementia, stroke and diabetes.
“The idea of smoking as freely undertaken lifestyle choice must be consigned to the dustbin of history, where it should be joined by any inclination to blame people for their experience of illness or poverty.”
The idea of smoking as freely undertaken lifestyle choice must be consigned to the dustbin of history, where it should be joined by any inclination to blame people for their experience of illness or poverty. Far from being a free consumer choice, the likelihood of smoking is hugely determined by social and economic factors – and their impact on anxiety, boredom, employment, self-esteem, access to alternative coping strategies, hopes for the future and so on. Over and above the strong chemical addiction, this is about people seeking a coping mechanism for stress, “me time” or a break from mundane routine. These experiences vary so widely between different groups that we can see why some groups seek out a coping mechanism more than others.
Looking at who smokes, and why they smoke, it becomes clear that achieving this tobacco-free goal is about addressing the factors that cause some groups to smoke and make it more difficult for them to stop. Increasingly discussions on tobacco and health are all about inequality. And achieving a tobacco-free society, with all the health, social and economic benefits that would entail, is largely a matter of closing the inequality gap that characterises and drives smoking behaviours.
It might be said that we should just focus on reducing inequality so that smoking will sort itself out. Yet while smoking is not in itself a root cause of poverty and inequality, it does exacerbate those problems and is a mechanism through which inequality translates into health, social and economic harm. Payday lending is also an effect and driver of inequality, rather than a root cause, yet there are few voices suggesting we should leave that industry unfettered while we get poverty in hand.
Similarly making tobacco cheaper might reduce the immediate economic costs, but by removing the main restriction on the market it would hugely increase health and social costs. I have yet to hear anyone suggest that cheap alcohol, for example, is the answer to community needs.
“It might be said that we should just focus on reducing inequality so that smoking will sort itself out. Yet while smoking is not in itself a root cause of poverty and inequality, it does exacerbate those problems and is a mechanism through which inequality translates into health, social and economic harm.”
So alongside, integrated with and complementary to, efforts to directly address poverty and inequality we need to see action to support those addicted to tobacco, explore less harmful coping mechanisms and protect children from the commercial interests which profit from getting them hooked.
Looking at payday lending again, such companies insist they provide a legal and legitimate business that conducts its affairs responsibly. They post positive mission statements committing to meet people’s needs. They are subject to certain regulations, which they consider to be strict. They insist that their customers know what they are doing and willingly engage. Yet any reasonable analysis of how this industry impacts on vulnerable people suggests an entirely different picture.
Payday lenders are available on every high street, with particular concentration in the poorest areas – where their market is very much concentrated. They strongly resist attempts to regulate how they market and sell their products and cry foul over the interfering desires of the nanny state controlling people lives and restricting their freedoms.
All of which makes the payday lending industry closely analogous to the tobacco industry. Except that amongst the community of organisations and alliances which work to support disadvantaged people there is widespread acceptance that payday lending is targeted at the most vulnerable people, damages those people and should be understood as a parasitic attempt to make money by preying on the vulnerable.
It’s time we looked at the tobacco industry the same way.