The first time on an airplane is one of those
experiences that leave a stamp on your memory. My first plane trip was about 20
years ago, and I would have great recollections of that flight if not only for
what happened after the 'no smoking' lights went out. Shortly after the 'ding',
a cloud of cigarette smoke filled the air cabin. For hours on end, I was
crammed with over hundred other people in a small, enclosed space breathing
recycled smoke-infested air. Not a pleasant memory.
As appalling as this may seem today, smoking on airplanes was only banned by
most airlines in the late 1990s. Since then, smoke-free laws have been
gradually introduced by many countries in public transportation, hospitals and
workplaces, and more recently, in indoor public spaces such as bars and
restaurants.
Smoking kills up to half of its users. This is the grim reality that slaps you
in the face when you read the tobacco fact sheet of the World Heath
Organization (WHO). A staggering amount of scientific evidence accumulated over
the past 50 years shows that smoking causes several types of cancer,
cardio-vascular and respiratory diseases. Nevertheless, smoking kills over 5
million people every year and the death toll continues to rise, especially in
low and middle-income countries.
To tackle this global tobacco epidemic, the WHO established the Framework
Convention on Tobacco Control in 2005. More than 170 countries have joined this
treaty and agreed to put into practice a set of public health policies to
protect people from second-hand smoking, to combat tobacco illegal trade and to
encourage smokers to quit.
Do tobacco control policies work?
Brazil is one of the pioneer countries in
implementing such policies for tobacco control. In 1990, Brazil introduced the
first rises in cigarette taxes, which doubled cigarette prices in just ten
years. This and other subsequent anti-smoking policies such as smoking bans on
public spaces and tobacco marketing restrictions for instance, led to a
remarkable drop in smoking rates from 35% in 1989 to nearly half in 2008. But
it wasn't known which policies were responsible for this steep decline in the
number of smokers.
In a new study published in PLoS
Medicine, David Levy from Georgetown University used a
computational model to answer this question. Levy found that as much as half of
the reduction in smoking rates was due to cigarette price increases alone,
while smoking bans and marketing controls each accounted for a 14% drop, and
other policies contributed slightly less. The raw numbers are even more
impressive: the model estimates that anti-smoking policies saved over 400
thousand lives over the past 20 years in Brazil, and the prediction is that by
2050 almost 7 million more lives will be saved.
Brazil's success story tells us that anti-smoking measures can work even in low
to middle-income countries, where smoking is more prevalent. However, Levy's
model estimates that an additional 1.3 million deaths could be prevented by
2050 if stricter policies were introduced. So are tougher anti-smoking policies
needed to eradicate smoking all together? The answer might be found on the
other side of the globe.
A licence to smoke
Australia is a country strongly engaged in reducing smoking and protecting
second-hand smokers. In the past 30 years since the first anti-smoking
policies were implemented, the number of smokers in Australia has dropped from
34% of the population to 15% in 2010. Last week the Australian government
introduced a complete ban on tobacco company logos and coloured cigarette
packets, which now have a uniform greyish colour and display health warnings
and gruesome images of people with smoking-related diseases (the company name
is in small print at the bottom of the packet). Plain packaging might represent
the beginning of the end of the smoking industry in Australia, but tobacco
control activists think more can be done.
"We are the first nation to introduce plain packaging, we have the largest
per capita spend on hard-hitting campaigns, some of the most expensive
cigarettes in the world, but still 14% of adults smoke and it continues to kill
more people, by far, than any other cause of death" says Simon Chapman, an
expert in Public Health and Tobacco Control at the University of Sydney
"We don't give up at 14%".
Chapman recently proposed the controversial idea of a 'smoking licence' that
would limit the access to tobacco products. He believes it is unacceptable that
even though tobacco threatens both personal and public health, it can be sold
anywhere and to anyone with hardly any controls. The smoker's licence would be
accepted only in licensed retailers and have a set limit of cigarettes per day
(the higher the limit, the more you pay). The idea is that because the access
to tobacco products would be limited, young people would be put off from
smoking and adult users would be encouraged to quit.
Jeff Collin from the Global Public Health Unit at the University of Edinburgh
is against the smoker's licence:
"I think it's very unlikely that such a proposal would receive necessary
levels of support for it to be politically feasible, and it could jeopardise
wider support for other tobacco control measures, critically including the
active support of many smokers" he says.
Collins thinks the smoker's licence would stigmatize smokers and "shift
attention away from the tobacco industry", which he believes is the
driving source of the tobacco epidemic. He agrees that it is an
"historical absurdity" that tobacco products are so easily accessible
and not subjected to any purchasing control, but he suggests that other ways of
limiting availability should be tested, rather than targeting the smokers.
Collins says "Marketing control is already generally strong in
Europe, but plain packaging would constitute a massive step forward. Beyond that
(...) there is a need for blue skies thinking".
Second-hand smoking: the invisible
killer
But are ideas like the smoker's licence that radical when we consider the
health consequences of smoking not only for smokers, but non-smokers as well?
Over half a million non-smokers die every year from exposure to second-hand
smoke. Smoking bans in public spaces were designed to protect passive smokers
but measures like this might not be enough. A survey done in 2006 by the
Australian Institute of Health and Welfare revealed that smokers are less
likely to agree that second-hand smoking causes health problems, even though it
is well-established that second-hand smoking causes heart disease and lung
cancer in non-smoking adults, and respiratory diseases in children. This
unawareness of the dangers of second-hand smoking puts non-smokers at risk,
children in particular.
A study published in the December issue of Pediatrics on 795 smoking parents reports that
although most parents restrain from smoking in the house, about 70% smoke in
the car, and nearly half of these smoke in the car when their children are
present. Research shows that the air quality inside a car when someone is
smoking with a window opened is similar to that of a smoky bar. A few countries
like Australia, South Africa and Canada have recognised this problem and
started implementing laws interdicting smoking in vehicles carrying children
specifically to protect children from second-hand smoking, but in most
countries this problem seems largely ignored.
The beginning of the end?
Tobacco continues to kill millions around the world but it is not all bad news.
Most new cars don't have ashtrays or cigarette lighters, and crystal ashtrays
are no longer a traditional item in wedding lists. These are signs that smoking
is no longer a glamorous or ordinary affair, and at least in developed
countries, these cultural changes are here to stay.
And there is more good news. Recent research shows that the health benefits of
quitting smoking are even greater than previously thought. For instance, a new
study led by researchers at Oxford University on over 1.2 million women shows that women who stop smoking before middle age can live up to 10 years longer than
those who continue smoking. And even those who stop smoking later in their
lives have about 50-70% less risk of developing smoking-related diseases and
dying prematurely, and these results confirm previous studies performed in men.
The first smoking bans on airplanes 15 years ago caused public uproar. About ten
years later, the introduction of smoke-free laws in indoor public spaces also
caused intense public debate. Perhaps society is not ready for a smoker's
licence yet, but maybe in a decade or two, just as we now deem smoking on
airplanes absurd, we will condemn how purchasing and consuming tobacco
products was once as easy as breathing air.
Image credits: FreeDigitalPhotos.net
References:
Levy, D., de Almeida, L., & Szklo, A. (2012). The Brazil SimSmoke Policy Simulation Model: The Effect of Strong Tobacco Control Policies on Smoking Prevalence and Smoking-Attributable Deaths in a Middle Income Nation PLoS Medicine, 9 (11) DOI: 10.1371/journal.pmed.1001336
Chapman S. (2012). The Case for a Smoker's License, PLoS Medicine, 9 (11) e1001342. DOI: 10.1371/journal.pmed.1001342
Collin J. (2012). The Case against a Smoker's License, PLoS Medicine, 9 (11) e1001343. DOI: 10.1371/journal.pmed.1001343
Nabi-Burza E., Regan S., Drehmer J., Ossip D., Rigotti N., Hipple B., Dempsey J., Hall N., Friebely J. & Weiley V. & (2012). Parents Smoking in Their Cars With Children Present, PEDIATRICS, 130 (6) e1471-e1478. DOI: 10.1542/peds.2012-0334
Pirie K et al. (2012) The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. The Lancet. DOI: 10.1016/S0140-6736(08)61345-8
Tobacco in Australia: A comprehensive online resource
http://www.tobaccoinaustralia.org.au/
This article was published in The Munich Eye on 7-12-12. You can read it here.
