Profit Before People: The commercial determinants of health and lessons from the tobacco epidemic (2023)

The negative impact of tobacco has been widely recognised and we won't go into great detail here. It is sufficient to say that tobacco is the single leading preventable cause of mortality, leading to 64,000 deaths in England each year and harming nearly every organ of the body. Up to two-thirds of smokers die due to their addiction, and it causes untold suffering, with those who start smoking as a young adult losing an average of 10 years of life expectancy⁴.

Estimates suggest there have been as many - if not more - deaths from smoking as from the COVID-19 pandemic. It is both a cause and a symptom of health inequalities in that it disproportionately affects those living in more deprived areas, causing and maintaining poverty through the cost of the product and is a solid commodity in organised crime. 

Around eight million people have died in the UK due to smoking in the last 50 years, with an estimated two million more expected to die in the next 20 years without radical changes to smoking rates⁵ - the stark fact is that the TI have been responsible for 26% of all deaths that have occurred in that half century⁶.  If it wasn't for the persistence of advocates for the control of tobacco, those figures would be much higher.

The toll of tobacco

Smoking deaths 1970 to 2019 in the UK

• 4.79 million men plus 2.95 million women equals 7.8 million total.
• 33% of all male deaths are due to tobacco
• 20% of all female deaths are due to tobacco
• 26% of all deaths are due to tobacco

Tobacco has been described as a wicked problem, the concept of which emerged to demonstrate that while some problems are 'tame' and can be addressed by simple direct problem-solving approaches, other problems are surrounded by disagreement, inadequate or conflicting information, large numbers of stakeholders and webs of interconnected interests - they are wicked because they are highly resistant to change⁷. Tobacco and smoking fall into this category because they are so deeply embedded into the fabric of society thanks to the unrestricted activities of the TI over so many years. Faced with wicked problems there is a temptation to assume that because there are no clear or simple solutions, they are simply too difficult to tackle. This often results in a focus on discreet elements of a problem with an assumption that this will be sufficient - but it rarely is. 

Thankfully, many advocates for public health were unwilling to consider the problem too difficult to solve and in parts of the US, Australia and the UK, work was taking place that would establish the principles needed to deal with the problem. Tobacco Control (TC) evolved over time as a response to the excesses of the TI. It is shaped by an astonishing context: despite the importance of consumer protection in British society, products which are known to kill most of their life-long users are available for sale in shops throughout the land. As banning tobacco products is not an option, the very best that TC can do is to reduce the harm that tobacco inflicts on smokers, on smokers' children and families, and on society overall⁸. The principle of changing 'social norms' to create the social and legal environment where tobacco becomes less desirable, less acceptable, and less accessible was pioneered in California. Between 1988 and 1999, cigarette use in the US fell by 20%. In California, it fell by nearly 50%. 

In 1999, the World Health Organisation (WHO) began work on the development of the Framework Convention on Tobacco Control (FCTC)⁹ which was adopted by the World Health Assembly in May 2003 and came into force in February 2005. This was the first international treaty negotiated with the support of WHO and was developed in response to the globalisation of the tobacco epidemic. It is an evidence-based treaty that reaffirms the right of all people to the highest standard of health, represents a milestone for the promotion of public health, covers 90% of the world's population and has been ratified by the UK Government meaning they will abide by its legal obligations. Taking account of the history of TI actions, Article 5.3 of the FCTC states that: "In setting and implementing their public health policies with respect to tobacco control, parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law." 

TC in the UK became viable in 1998, when the government published a white paper called Smoking Kills, which represented a milestone in public health. It provided a comprehensive strategy and identified funding that put the UK among the world leaders in TC. Over the following ten years, much of what the white paper set out to do was achieved. The high point of the work that was carried out was undoubtedly the implementation of Smokefree legislation in 2007, which literally changed the social and health landscape of the country. 

In the North-East, the decision was taken in 2005 to create a comprehensive and coordinated regional TC programme called Fresh, which had the aim of driving down smoking prevalence. This programme operationalised the key strands of TC and linked them to local activity across the region. That smokefree legislation was approved in 2007 was in no small part due to the concerted action across the North-East, including Gateshead, and coordinated by the Fresh team. To control tobacco use, the following strands of action are required⁹ and should be implemented simultaneously, sustainably, and should complement each other:

• Monitor tobacco use 
• Protect people from tobacco smoke
• Provide support to help smokers to quit
• Warn about the dangers of tobacco 
• Enforce tobacco advertising, promotion and sponsorship bans
• Raise taxes on tobacco

Fresh has taken these strands and expanded them further and the implementation of this comprehensive evidence-based approach to controlling tobacco has resulted in reductions in smoking prevalence across the North-East. We continue to work collaboratively, both regionally and locally, to achieve a smokefree society.

The eight key strands of work Fresh have centred around:

1. Building infrastructure, skills and capacity
2. Advocacy for evidence based policy
3. Reducing exposure to tobacco smoke
4. Year round media, communications and education
5. Supporting smokers to stop and stay stopped
6. Raise price and reduce the illicit trade
7. Tobacco and nicotine regulation
8. Data, research and public opinion

This diagram shows some of the key points over the past two decades since Smoking Kills, illustrating the crucial role of advocacy in achieving policy change and how this correlates with smoking prevalence rates in young people:
    

As the harm of tobacco recedes, so the benefits of improved health and wellbeing increase. But progress is not easily won, and the effects of austerity, the pandemic and the cost-of-living crisis in recent years has seen health inequalities widen, and progress in reducing the gap in life expectancy between the most affluent and the poorest in society has stalled. In this context, TC continues to represent a powerful tool in improving health in communities and is central to any strategy to tackle health inequalities as smoking accounts for approximately half of the difference in life expectancy between the lowest and highest income groups¹⁰.

The need to continue actively advocating and working on TC is ongoing and most clearly made when considering the tactics of a rich and organised adversary in the TI.

This has meant it has taken many years and much hard work to make progress on smoking as a commercial determinant of health:

These achievements would not have been possible without comprehensive and continuous efforts from organisations and members of the public. Public health improvements do not happen by chance and when California reduced its efforts on tobacco control, smoking prevalence increased. These are important lessons not just for reducing the health harms of tobacco, but for other commercial determinants as well. The recently proposed age of sale legislation would be another step in the long journey towards a smokefree society. However, if action of this kind is recognised as important for tobacco, what will it take to see similar action on other commercial determinants of health? 

References

4. Department of Health and Social Care (2023) Stopping the start: our new plan to create a smokefree generation GOV.UK - create a smokefree generation (opens new window)

5. Peto R and Pan H. UK deaths from smoking 1971 to 2019. University of Oxford. November 2021

6. Action on Smoking and Health (2021) ASH at 50 report (opens new window)

7. Johnston, J. and Gulliver, R. (2022) Public Interest Communications. University of Queensland UQ pressbooks - wicked problems (opens new window)

8. Action on Smoking and Health (2010) ASH - beyond smoking kills (opens new window)

9. WHO framework convention on tobacco control 2003 (opens new window)

10. GOV.UK - Fair society, healthy lives : the Marmot Review : strategic review of health inequalities in England post-2010. (opens new window)