Tobacco - the enemy within..

Let me start with a story…

There was once a village where the local people faced a grave problem. Every morning – exhausted and weary villagers were to be found drowning in the fast flowing river that ran through their village. The local community set up an elaborate and expensive alert and rescue system which enabled every drowning man and woman to be dragged out of the water, resuscitated and saved.

For years the village community struggled on, but they were poor because all their resources went into the daily lifesaving process. Then one day, a wandering minstrel happened by, and suggested that rather than saving the villagers – wouldn’t it be a good idea to find out why they were in the river in the first place?

I could continue the story with giants, goodies and baddies and elaborate plots but suffice to say, as soon as the locals realised what was causing their comrades to be in the water in the first place, they fixed it and the rescue and repair system was no longer needed.

My recollection of this well-known fable was prompted by a startling report published in the British Journal of Cancer announcing that 40% yes – 40% of cancers diagnosed in the UK each year are caused by avoidable life choices such as smoking, unhealthy eating and excess alcohol. Tobacco continues to be the most significant cause, accounting for a risk factor of 23% in men and 15% in women. I would like to optimistically assume that these figures would drop as public knowledge and understanding increases but there are no indications that this will be the case.

At a time when we are desperately seeking not only cures for cancer but also trying to reconfigure our health services to ensure that we can afford to treat an increasingly unhealthy population surely we should be doing more to stop people developing illnesses in in the first place?

The smoking debate is long running and emotive. There have been accusations of ‘nanny state’, ‘destroying human rights’, ‘restricting personal choice’ and the  pro-smoking lobby even disputes the extent of the dangers of tobacco. In medicine there is a measure known as the Therapeutic Index – which is the ratio between the toxic dose of a drug and the therapeutic dose (i.e. a dose that works). This is a useful measure of the safety of a drug and if the therapeutic dose is the same as the toxic dose then it is likely this drug will never get a licence. Even the rarest of side effects may stop the development of a drug in some cases and yet a massively toxic substance is freely available, with only an age regulation associated with it’s distribution and consumption.

In the UK you can be fined for not wearing a safety belt and even imprisoned for holding your mobile phone while driving (quite rightly). Children are no longer allowed to play with conkers in school without safety goggles. The same children at just 16 years of age can smoke a small piece of paper wrapped around a lethal substance responsible for 100,000 deaths annually and possibly twice as many people suffering life limiting disease. As soon as they are 18, they can buy this lethal substance in packs of 10 or 20 throughout the UK. Even that piece of legislation is crazy – you can smoke at 16 but can’t buy cigarettes until you are 18. I’m sure that makes a big difference to teenage smokers – not.

How can this madness be stopped or at least reduced? Yes, if the substance was banned it would drive smoking underground but surely the number of smokers would reduce dramatically. Yes tobacco -growing economies would be severely damaged but surely alternative crops could be grown? Yes, the UK government would in the short term lose significant taxation income and face huge pressure from the powerful tobacco companies’ lobby but in the long term, healthcare costs from smoking-related diseases would be massively reduced.

At a time when the Health and Social Care Bill is concentrating on the minutiae of who commissions what, disbanding and reconfiguring the beaurocratic process we continue to allocate massive resources on fishing the villagers out of the river. I can’t help but wish more time and resource was spent on stopping them jumping into the water in the first place.

Smoking – How can you change behaviour?

This week, the British Medical Association has called for a ban on smoking in cars, recommending tougher legislation. The main rationale behind this request is that research has shown that toxicity from smoking in cars is 27 times higher than in the home and young passengers are particularly at risk from passive smoking.

The  government has responded with  a call for a balance between legislation and partnership on improving public health. And there is the crunch. How do change people’s behaviour when they are indulging in activity or habits that are clearly damaging to themselves and those around them?

I have been enjoying the recent TV ‘docu-drama’ mapping  John F Kennedy’s brief and tragic spell in power. Love it or hate it, this series provides a fascinating snapshot of life in the early 1960’s. There is a shocking image of Katie Holmes, playing a heavily pregnant Jackie Kennedy writing a letter while smoking a cigarette. This would chill the blood of most reasonable observers today, but forty years ago it was unknown that smoking could seriously harm the unborn child. Yet now – through information, public pressure and maybe the passage of time, although it is not illegal to smoke while pregnant, it is far less socially acceptable. In the UK, following many public information campaigns and possibly pressure from family and friends, approximately 50% women now give up smoking while pregnant. We seem to be ahead of the US, where only about 20% pregnant women are estimated to give up and 17% of teenage mothers continue to smoke throughout their pregnancy.

There are other good reasons to discourage smoking in cars. Many years ago, I had just arrived for a business trip in Turkey and as my taxi driver was driving me to the hotel, he suddenly stopped the car, leaped out and removed his trousers! As all sorts of scenarios started to play out in my head and then I realised, with relief that his trousers had actually caught fire as he had dropped his cigarette in his lap!

Controlling the smoking habits of a population is potentially one of the biggest public healthcare challenges a nation can face. We know that, apart from the human loss and suffering, smoking costs the NHS and estimated £2bn a year.

In New York a few weeks ago, a smoking ban was introduced in parks and beaches. But this is supposed to be a ‘self-enforced’ ban and during a recent visit to the big apple I saw many a cigarette being smoked in Central Park and Union Square.

The smoking ban in public places in the UK has been pretty successful, partly due to the threat of prosecutions for corporate owners but also due to public pressure by non smokers. I would have no compunction in complaining to a restaurant owner of someone was smoking inside the facility.

So how does a government get a public health message not only to register with its audience but to convert that audience to make the required changes and to encourage those changes in others?

Celebrity culture is undoubtedly a powerful force to be harnessed for good. Tragically in 1991, a very well-known UK TV presenter, Anne Diamond lost a baby, Sebastian, to SIDS (Sudden Infant Death Syndrome). She stated a campaign highlighting the simple actions required to reduce the risk of SIDS, which included laying an infant on their back rather than face down, which many of our mothers used to recommend. The effect of this, and subsequent campaigns has been stunning. In 1990, there were 1.77 infant deaths per 1000 live births. In 1991, this was dramatically reduced to 0.61 per 1000. The figure is now dramatically 70% lower than before Anne’s terrible loss.

So let’s keep the pressure up on smoking. We shouldn’t demonise those who smoke but society should certainly censure those who put others at risk through their behaviour.

I hope the coalition can come up with some creative ways to not just educate the public, but to ‘engage’ them, and to encourage them to take more responsibility for themselves and those around them. David Beckham, Kim Kardashian, Justin Bieber? I don’t care who it is, as long as they get the right message across.