Does banning smoking work?

Wednesday 15th Nov 2023, 12.20pm

As the UK government proposes new plans to reduce the number of people who smoke, we talk to behaviour change researcher Nicola Lindson from the Nuffield Department of Primary Care Health Sciences to find out how the plan would work. Could we see a generation that is smoke free? Would banning flavours in e-cigarettes stop children from taking up smoking? Tune in to the latest episode of the Big Questions podcast to find out more.

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EMILY ELIAS: Prime Minister Rishi Sunak has come up with a plan to cut the number of people addicted to cigarettes.

RISHI SUNAK: So I propose that in future, we raise the smoking age by one year every year. That means a 14 year old, that means a 14 year old today will never legally be sold a cigarette, and that they and their generation, can grow up smoke free.

EMILY: It is that easy? On this episode of the Oxford Sparks Big Questions Podcast, we’re asking, does banning smoking work?

Hello, I’m Emily Elias, and this is the show where we seek out the brightest minds at the University of Oxford and we ask them the big questions. And for this one, we have sought out advice from our friends at the University of Oxford’s ‘Let’s Talk E-cigarettes Podcast’.

NICOLA LINDSON: So my name is Nicola Lindson. I’m a senior researcher at the University of Oxford. I’ve been at the university now for ten years, and I look into ways to help people quit smoking, basically. So looking at the different ways that we can help people and what works best. And what I’ve started to also look into a bit more recently is helping people who live in social housing in particular, or people in financial difficulty, to quit smoking.

EMILY: Okay, so Rishi Sunak came out with this pretty big plan at the Conservative Conference, about banning smoking. Can you just walk me through here, What is it that he is proposing, exactly?

NICOLA: Yeah, so the reason why this has kind of come out now is that in 2022, a government commissioned independent review came out, which was written by Javid Khan. And this was one of the things that he suggested that may work to help to reduce smoking rates in the UK. So, what it would actually mean is that there would be legislation which would make it an offense to sell tobacco products to anyone who was born on or after the 1 January 2009. So the way that would work is that from 2027 each year, they would raise the age, the legal age of sale for selling tobacco, by one year. So currently it’s at age 18, but within a year, in 2027, it would go up to 19. Then it would go up to 20 the following year, then 21, then 22, and so on. And that basically means that a 14 year old now will never be able to buy tobacco.

EMILY: Okay, so does this plan come from any other countries, or are we the only ones that are going to try this strategy out?

NICOLA: So, currently, there aren’t any other countries using this approach, but actually, in January of this year, New Zealand were the first country to announce that they were going to use this approach. So, they’re also bringing it in in 2027. So, at the minute, this isn’t even running in New Zealand, but they will also introduce it in 2027 is their plan. So, we don’t have any data as yet to show how effective it is, as we’re kind of the second country in the world to propose it.

EMILY: Okay, so we don’t have any data to know how effective it is, but do we have any sort of inclination of how this compares to other past smoking ban type policies?

NICOLA: Yeah, so what’s really interesting is there have been cases where the age of sale have been raised in the past, just not quite in this way. So, for example, the UK changed the age of sale previously from 16 to 18. And, in the US, there have been some states that changed the age of sale from 18 to 21. And what we’ve seen from that is when the age of sale for tobacco was changed from 16 to 18 in the UK, it reduced prevalence in that age group, so the 16 to 18 year olds, by 30%. And we know that that was because of this smoking ban because that was a three times greater reduction in what happened in terms of reduction in older adults. So, we can say with some confidence that that drop in prevalence in the younger people was due to that ban. In terms of the US data, what we saw there was the smoking in people aged 18 to 20 fell by 39% in the areas where the age of sale was increased. And again, we can see that that was probably due to the ban because in the areas where the ban wasn’t put in place, we didn’t see that same drop in prevalence.

EMILY: But a ban feels like a very heavy handed way of dealing with a problem. What do we actually know about how people respond to giving up smoking or quitting smoking? What does the research tell us actually works?

NICOLA: So obviously when we bring these kind of policies in, what’s really important is to make sure that we can also support those people who are already smoking to quit smoking. And we know that the best way to help somebody to quit smoking is through using some form of behavioural support, like counselling and a medication. So, there are a number of different medications that people can use to quit. I carried out a study that was completed this year and was published this year, trying to look at the best ways that people can quit using a smoking aid. And what we found were that the most effective were two pill based medications called cytosine and vereniclin, and also electronic cigarettes. They were closely followed by using nicotine replacement therapy, but using two forms of nicotine replacement therapy at the same time. So rather than just using a patch or gum on its own, what we can see is that if people use, say, a patch and gum together, then that’s much more effective.

Now, there’s kind of a caveat to these results, because although those pill based medications were found to be really effective, they’re not currently available in the UK. We hope that they will become available within the next couple of years but at the moment, the best bet for people is either an e cigarette or, as I say, using two forms of nicotine replacement therapy at the same time, and ideally doing that alongside some form of behavioural support, which is usually something like counselling.

EMILY: And another element of the plan that Rishi Sunak put out it does involve cracking down on e cigarette flavourings. This is probably your wheelhouse of specialty, thanks to your podcast, Let’s Talk E-cigarettes, but is that something to be a bit cautious or weary over?

NICOLA: Well, potentially, yes. And it is something that there’s kind of a lot of debate about at the moment because there’s kind of an assumption that it’s only going to be children that are interested in using flavours in e-cigarettes. And this is why this has been suggested to be banned, because what the government want is for e-cigarettes to appeal to people who are quitting smoking, but not to appeal to children. And that’s completely understandable. Ideally, what we don’t want is people using e-cigarettes who haven’t smoked because although we think they’re much more safe than smoking, they’re unlikely to be completely safe. However, what we do know is that there are a lot of adults using e-cigarettes with flavours to quit smoking. So there has been some evidence that if flavours are banned, then more people actually then begin smoking cigarettes, and that counts for young people and for people who may have quit smoking using e-cigarettes in the past, it may mean that they’re more likely to relapse to smoking. So, we do need to be really careful about this because what we don’t want is if e-cigarettes lose their appeal, for more children to actually smoke cigarettes. We have seen a real drop in prevalence of the number of young people smoking. and we don’t want that to start going back up again. So we can’t assume that the only people using flavours to begin with are young people. But also there is a risk that if we take away flavours, then young children are more likely to smoke cigarettes. So it’s going to be a very careful balance. And one of the potential ways that we could find that middle ground is by keeping the flavours, but just not marketing e-cigarettes at children because there are cases that we see in marketing now where it does look like the aim really is to appeal to children, and it’s using kind of names and visualisations that aren’t really going to be appealing to adults.

EMILY: It is a really difficult balance of a lot of different factors at play. I mean, is it realistic to think that there could be a generation that is smoke free?

NICOLA: I think there could be and there has been some kind of modelling by the Department of Health that has said that with this policy of raising the age of sale year on year, that we could see very, very low numbers of children smoking or young people smoking by 2040. It’s unlikely to be completely eradicated while cigarettes are available in some form because not everybody goes into a shop and buys cigarettes. But the thing is, as well as just stopping people from buying cigarettes, what this policy will do is basically denormalise smoking. It means that less people will be smoking. It’s just seen as less of a normal thing in our society to smoke, which we’ve seen happen over the years, and this is one of the reasons why youth prevalence has dropped. But any policies like this are just going to make it seem more unusual to be smoking as a young person.

EMILY: So you will, I guess, be very keen to see what data actually comes out of this policy in the years to come.

NICOLA: Yes. I mean, it will be really interesting. I really do, based on the data that we can already see, think that there is going to be a positive impact of this but it will be interesting to see how quickly that happens and look at the other potential unintended consequences of this and how these can be mitigated. Things like better regulation of sales and things like that. So, it’ll be really interesting to see how things pan out over the years.

EMILY: This podcast was brought to you by Oxford Sparks from the University of Oxford. With music by John Lyons and a special thanks to Nicola Lindson. And check out her podcast ‘Let’s Talk E-cigarettes’.

Tell us what you think about this podcast, the one that you’re listening to. We are on the internet @oxfordsparks. We also have a website: I’m Emily Elias. Bye for now.

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