Profit Before People: The commercial determinants of health and lessons from the tobacco epidemic (2023)
Foreword - Alice Wiseman, Gateshead Director of Public Health (including a PDF version)
It's hard to imagine how a seemingly innocent plant can by human action, become one of the deadliest products in history. Yet it happened in plain sight and has made huge profits for the industry that sells and promotes its consumption. If tobacco products came to market today, with the knowledge that they would go on to kill over half of regular users, I wonder what the reaction would be? Over centuries the tobacco industry was ruthless in its pursuit of financial profit from these dangerous products. They used a range of tactics which delayed policies aimed at protecting the health of the public regardless of the damage caused to Mams, dads, sisters, brothers, nanas, and grandads. It has taken over 60 years to reach the point where smoking is finally declining and the active deception, denial, and motives of the tobacco industry have been exposed. And yet cigarettes, and other tobacco products, are still freely available in our shops.
As the evidence of smoking harms became clearer, the tobacco industry framed smoking as an issue of individual freedoms and choices. Through a range of marketing campaigns and related activities, the industry continued to promote their products and target new markets and further normalising smoking. Public health advocates began to expose the truth about the burden of harms caused by smoking, and the complex range of factors that underpin it. In 1962 the Royal College of Physicians first outlined a comprehensive strategy to tackle smoking.
Few wished to hear that this product was responsible for significant levels of illness and death though, and a BBC report from the day it was published showed that smokers were not too concerned about the findings at the time.
Significant lobbying and misinformation from the tobacco industry meant it would be a further 36 years before we fully implemented this in the UK. Due to this delay many people experienced significant preventable harm and premature death.
In my first annual report as Director of Public Health for Gateshead I talked about the loss of my own father, aged only 54, from this lethal product. Most people I have spoken to over the past few years have their own personal story of loss in the hands of tobacco. The fact that the loss of all these loved ones were completely preventable makes it feel even worse.
This has driven on advocates of public health and instead of accepting that smoking was too hard to tackle, tobacco control approaches have been developed with multiple strands of work implemented in parallel and over the short, medium, and long term. And the results have been stunning:
In 1998, 27% of adults in the UK were smoking when a national target to achieve a prevalence of 21% by 2010 was set . In the North-East region we have shown a steady rate of decline in smoking prevalence from 29.0% in 2005 to 13.1% in 2022. This represents a staggering reduction of 52.2% drop in actual smokers.
When people were better protected from industry influence, they did not choose to smoke. The vast majority of smokers wish they had never started, and I am yet to meet a smoker who doesn't want the next generation of children protected from taking up smoking. But we cannot relax in the face of a powerful industry. Recent research suggests that rate of smoking decline has dropped from 5% to 0.3%, likely due to the COVID-19 pandemic, meaning fewer people quitting.
Our smokefree ambition for the North-East is to reach 5% prevalence by 2030 - but we want to go further. I want to see a North-East, and especially Gateshead, where no one experiences the harm and devastation caused by this lethal product. It might have taken over 60 years, but I think we can now confidently say that while the tobacco epidemic had a beginning, we've now progressed beyond the middle, and are today looking towards the end of tobacco. In October 2023 it was fantastic to see the Government commitment, following recommendations from the All-Party Parliamentary Group on Smoking and Health, and the Khan Review, to a smokefree future.
When I think about what we can learn from the tobacco control experience, I see many similarities with other harmful commodities. The pervasive nature of alcohol, ultra processed foods, and gambling in society (for example) have all the hallmarks of the tobacco industry playbook - profit and normalisation of the product take precedence over harm that is caused to people - your friends, families, and communities. People experiencing harm, illness and dying from entirely preventable causes. I see the same tactics - misinformation (underplaying the link between alcohol and cancer for example), challenging and delaying evidence based measures (the Scottish minimum unit price story), marketing of products and multi buy food offers (the majority of buy one get one free offers are consumed as additional calories rather than spreading the cost for those with low incomes (as the industry would have us believe) with additional profit going straight to industry shareholders) and the persistent unrelenting tactics used to lure people into gambling with a glimmer of hope on the back of substantial harm. Finally, industries suggest it's solely down to individual choice - people should responsibly gamble, drink, and eat, even though, and I am no business expert, I am pretty sure they wouldn't spend billions on marketing and promotions unless they were certain about increased profit.
As a public health expert with a statutory responsibility to protect and promote the health of the population, it can feel incredibly daunting. Policy continues to be influenced by companies whose explicit aim is to maximise shareholder profit. We haven't made anywhere near enough progress on protecting the population from other harmful products and industries, and much of the rhetoric on alcohol, gambling and ultra processed food is very similar to that of smoking back in 1962. However, I reflect on how daunted my public health predecessors must have felt in the early days of the fight for protection from tobacco and how grateful I am that they persevered with tenacity and passion. Their pioneering work and bravery have saved many lives and will save more in future generations. The public health voice must get louder in this space, people's health and well-being should come before profit. Public health policy needs to be protected from industry and, conflicts of interest in research and education need to be explicit and controlled.
I hope this report will help us to not only end the tobacco epidemic, but also to think about the other wicked issues that are doing so much damage to the health of the public in plain sight of everyone. This can feel overwhelming but as we've shown in this report there is hope. We have done it before with tobacco and we can do it again. We need people and communities to understand how they have been manipulated into thinking this is all about individual choice, but we can only do this by exposing how industries have literally wallpapered our lives with their version of the truth.