Case Study C – Smoking

Context

Tobacco remains a leading cause of death globally, killing nearly 8 million people each year. The vast majority of
these deaths are as a result of smoking (Reitsma et al., 2021). In the UK, smoking, which is most prevalent in deprived groups, remains a leading cause of death (Office for National Statistics, 2023).

The Framework Convention on Tobacco Control (FCTC) became the first and only legally binding international health treaty, adopted in 2003 by the World Health Organisation, to mitigate tobacco related harms (Roemer et al., 2005). The FCTC has given the impetus for national governments to develop tobacco control legislation, although the UK was doing so already (Chung-Hall, et al., 2016; Campaign for Tobacco-Free Kids, 2018). The prevalence of smoking in the UK peaked in the post-war period with 82% of men and 65% of women smoking cigarettes in 1948.

A steady decline in smoking prevalence has been seen since the early 1970s (Action on Smoking and Health 2023), and the UK is generally regarded as having one of the most comprehensive sets of tobacco control policies globally. Smoking is commonly highlighted as a policy area from which learning around social change and collective action can be drawn (Cairney, 2019; Pitchforth et al., 2023).

Key Elements of Change

Efforts to introduce and enforce tobacco control began in the 1930s with evidence of a link between smoking and lung cancer. The strength of evidence and a causal link was increased through large-scale studies in the UK and US in the 1960s. Efforts to disseminate this link continued through the 1960s and 70s and international public health networks grew (Reubi and Berridge, 2016).

The UK and other countries introduced a range of tobacco control policies through the 1990s to late 2000s, including restrictions to advertising, sponsorship and to whom and where tobacco could be sold. A significant shift in galvanising social change came with increasing evidence of the harms of smoking to non-smokers (Nathanson, 1999). This enabled a shift in the framing of tobacco control measures. Smoking, which had previously been seen as an individual freedom, was then brought into conflict with the rights of non-smokers to remain unharmed by others’ smoking habits.

The history of tobacco control efforts is also marked by strong contestations. Actors resistant to tobacco control included the tobacco industry but also the advertising industry and some government stakeholders given that the Treasury relied on revenue from tobacco sales. In the initial decades, some of these actors worked to discredit the evidence of the relationship between tobacco and disease. Where they did engage in control measures this was through ‘harm reduction’ measures such as altering cigarette contents rather than reducing use (Berridge, 2007).

The shift in emphasis to the harms of passive smoking allowed a greater role for mid-level actors, including advocacy groups such as Action on Smoking and Health (ASH), local authorities, representative bodies for health professionals and the hospitality trade (Arnott et al., 2007). A coalition formed by ASH was able to play an important role in bringing about national smoke-free workplace legislation. An important aspect of this was to be able to demonstrate growing public support for smoke-free legislation and to understand the preferences of different stakeholders. The hospitality trade and tobacco industry were aligned in favouring voluntary action rather than legislation but, unlike the tobacco industry, national legislation was the next preferred option for the hospitality trade. The risks of passive smoking thus reframed the problem around collective harm and altered longstanding contestations. Legislation was enabled partly because of already shifting societal changes in support of the rights of workers over the right of individuals to smoke (Arnott et al., 2007).

Lessons for Net Zero

The example of smoking legislation provides learning for net zero in demonstrating the potential importance of a shift in focus from individual behaviour to collective responsibility and the rights of those not engaging in particular behaviours; a reframing which was key to overcoming contestation and building public support for regulation. The example also shows the need to engage with, and challenge, a range of actors, including those who oppose change, to be able to coalesce around a focal issue. Finally, the role of advocacy groups or social movements are highlighted.

Smoking: Elements of Societal Change

Multi-factor DRIVERS OF CHANGE

• Burden of scientific evidence
• Health and safety at work (including legal sanction on employers)
• Economics of treatment

Mid-level ACTORS

• Advocacy and campaign groups
• Professional bodies
• Local authorities
• Galvanising ISSUE
• The health of non-smokers

JUSTICE Considerations

• The rights of individuals who smoke vs non-smokers
• Ongoing inequalities in smoking and related deaths

CONTESTATIONS and CONFLICTS

• Individual consumer rights vs. right to healthy environments
• Vested interests and misinformation
• Preferred levels of legislation

REFERENCES

• Action on Smoking and Health (ASH) (2023). Smoking Statistics
• Arnott, D., Dockrell, M., Sandford, A. & Willmore, I. (2007). Comprehensive smoke-free
  legislation in England: how advocacy won the day. Tobacco Control 16 (6) 423-428
• Cairney, P. (2019). The Transformation of UK Tobacco Control, in Paul ‘t Hart, and Mallory
  Compton (eds), Great Policy Successes (Oxford, 2019; online edn, Oxford Academic,
  24 Oct. 2019)
• Nathanson, C. (1999). Social movements as catalysts for policy change: the case of smoking
  and guns. Journal of Health Politics, Policy and Law 24 421-488
• Office for National Statistics (ONS) (released 21 April 2023). ONS website Statistical Bulletin
  – Deprivation and the impact on smoking prevalence, England and Wales: 2017 to 2021
  Pitchforth, E., Gemma-Clare, A., Smith, E., Taylor, J., Rayner, T., Lichten, C., d’Angelo, C.,
  Gradmann, C., Berridge, V., Bertscher, A. & Allel, K. (2023). What and how can we learn from
  complex global problems for antimicrobial resistance policy? A comparative study combining
  historical and foresight approaches. Journal of Global Antimicrobial Resistance 35 110-121
• Reitsma, M. B. et al. (2021). Spatial, temporal, and demographic patterns in prevalence
  of smoking tobacco use and attributable disease burden in 204 countries and territories,
  1990–2019: a systematic analysis from the Global Burden of Disease Study 2019.
  The Lancet 397(10292) 2337-2360
• Reubi, D. & Berridge, V. (2016). The internationalisation of tobacco control, 1950–
  2010. Medical History 60 (4) 453-472