We know 'smoking kills' but still do it – what will actually make us quit?

I am among the one in five people in the UK who smoke, contributing packet by packet to the £18billion we spend yearly on tobacco products.

My parents have kept the habit their whole lives, as did both sets of grandparents before them. Having started in my early 20s and maintained a box-a-day addiction ever since, in many ways I’m a walking target for tobacco companies.

In theory, that should also make me a target for health interventions, too. But I see the gory pictures on the box and ignore them, I pay the extra duty each time it’s upped, and I continue to light up despite knowing the implications.

I’m not alone in this – stats show 14.1% of British adults smoke despite extensive measures from the government to curb the habit So what’s not working?

Why am I, and millions of others, seemingly resistant to tobacco control policies, and what will it take to end smoking for good?

We’ve undoubtedly come a long way since the 1960s, after a landmark US report showed a causal link between tobacco and lung cancer – and successive governments have introduced their own legislation around smoking, with one recent change the ban of menthol, skinny, and crushball options.

A bill was recently tabled in Parliament that would require manufacturers to print warnings such as ‘smoking kills’ on cigarettes themselves, and councils are being given power to create ‘smokefree pavements’.

In this time we’ve seen smoking rates fall considerably, but progress has slowed since an initial drop following the introduction of tobacco controls.

The percentage of smokers in Britain is between 65% and 30% lower than in 1965, but just 7% lower than it was in 2006. This follows a similar downward trend to most countries in the developed world, with smoker numbers falling dramatically in the 1970s before stagnating in the decades following.

Smoking remains the ‘single largest avoidable health risk’ and the ‘most significant cause of premature death’ in the EU, and our NHS currently spends £2.5 billion a year treating tobacco-related illnesses.

To meet the government’s goal of ‘eradicating’ smoking by 2030, more needs to be done.

Smokers’ rights activists have argued against what they call ‘punitive’ measures to reduce tobacco usage. It’s also been argued that the steepest drops in smoker prevalence came about as smoking’s harms entered the collective consciousness, rather than due to public policy.

FOREST (a pro-tobacco group funded by industry giants) claims that providing information on the dangers of smoking – and the introduction of alternatives like vaping – had a bigger impact than bans or price hikes, saying: ‘The more coercive and detached smoking policy has become, the less effect it has had on smoking levels and therefore upon public health.’

In reality, it’s hard to quantify the exact impact of any one policy or initiative.

Hazel Cheeseman, deputy chief executive at Action On Smoking And Health (ASH) tells Metro.co.uk: ‘We’ve gone from being at the bottom of league tables in terms of smoking prevalence to having some of the lowest rates of smoking in Europe – all over the last two decades.

‘And that’s because we’ve put successive things in place and we’ve not gone and said “one thing is going to fix the problem”.’

Asked whether she believes policy or public opinion has been more effective in curbing smoking, Hazel says: ‘I think they come together. Clearly they are reinforcing each other: you get a change in public attitudes, then governments feel more confident about bringing in further measures, then further measures cause smoking rates to change as they become mutually reinforcing.’

Comparing our own stats to those of other countries doesn’t demystify much about what works.

Myanmar is one of the countries where smoking is most prevalent, with almost half of the population using tobacco. A number of laws similar to those in the UK (including indoor smoking and advertising bans, and health warnings on packets) have been in place since 2005, but the number of smokers has remained mostly static.

Smoking in Greece – another country with a high proportion of smokers, the highest in the EU – has also stayed largely the same, despite extensive measures.

While these examples don’t discount the effectiveness of tobacco control policies, they do highlight how cultural norms and attitudes can be a major factor in how well they work.

In that sense, we can say our own anti-smoking measures have been a victory, as the perception of smoking is far less favourable than in years gone by – especially among the young people targeted by this messaging.

But if people know the risks and are being deterred from smoking at every angle, there must be a reason behind its continuing popularity.

On a personal level it’s stubbornness and nihilism. I like being able to go outside and de-stress with a cig, and don’t have a positive outlook for the future of humanity. It’s very much a ‘might as well enjoy small vices while the world burns’ mentality.

Robert West, Professor of Health Psychology and Director of Tobacco Studies at University College London, says this might have something to do with cognitive dissonance, a common source of resistance for wannabe quitters.

He tells Metro.co.uk: ‘Almost all smokers have some level of dissonance – whatever they might say. One of the tests is, if there was a pill I could give you, and from the moment you take this pill you would never want or need to smoke another cigarette as long as you live, would you take that pill?

‘The vast majority of smokers would say yes.’

If quitting was as easy as that, we’d all do it. The desire to stop smoking is only one part of the journey – and for some that’s where it finishes.

Robert says many people are resistant to anti-smoking messages ‘because they’ve tried in the past, it hasn’t been a great experience, and they’ve lost confidence’.

He adds: ‘But it’s like rolling dice. If you keep rolling, you will get a six. However many times you’ve tried in the past makes no difference to your chances of success the next time.’

That tables with Robert’s assertion that desire to quit is less of an indicator of cessation success than the number of quit attempts a person makes.

‘This is where building confidence comes in,’ says Robert, ‘and showing people that it really is simply a question of trying and using whatever methods are available to give yourself the best possible chance.

‘Keep doing that and just keep rolling the dice.’

Robert says we can’t discount the medical science that’s helped people quit more comfortably (and therefore be more likely to try again if they mess up).

‘About 35% of smokers in any one year will try to quit, and it’s been much higher than that in the past.

‘But the things that influence your quit attempts are not the same things that help you quit.

‘So for example, being worried about health or money or the cost of smoking doesn’t seem to predict whether you’re successful or not.

‘What predicts whether you’re successful is essentially dealing with the dependence that smokers have on on nicotine.’

Largely, smokers support tobacco control measures, and want to quit. The problem is getting out of that mental cycle to inspire action, which is a lot harder when experiencing cognitive dissonance.

Hazel says: ‘If you’re doing something that is harmful to you, you either stop doing it, or you have to change the story that you’re telling yourself about what you’re doing, because your brain can’t cope with the two things at the same time.’

Those who have made no or few attempts to stop smoking have been termed ‘hardcore smokers’ in the scientific community. This group are particularly resistant to societal pressure to quit, and tend to underestimate the health impacts of tobacco use.

Those in manual jobs are more likely to be in this category – and two and a half times more likely to be smokers overall. Deprivation and unemployment correlate heavily to whether – and how much – someone smokes, too.

This presents a conundrum for experts, as tax rises eat into addicts’ money and have the potential to entrench inequality further.

The price of cigarettes in the UK is already the fourth highest in Europe. For a single person under 25 living on Universal Credit’s ‘standard amount’ of £257.33 a month, three packets at £8.55 each represents almost 10% of their income.

Hazel says: ‘Raises in taxation have shown across the world that if you reduce the affordability of tobacco then you reduce the consumption of tobacco – it’s fairly straightforward economics.’

That may be the case, but it’s a stick over carrot approach.

Nearly half (44%) of local authorities no longer have a specialist stop smoking service open to all smokers in their area – thanks to funding being slashed by up to a third over the last ten years. Smokers are seeing only negative reinforcement without the tools to break free from their addiction.

Like ASH, Matt Hawkins, co-director of Compassion In Politics, is calling for more funding from Westminster. However, he feels a more holistic and balanced approach is necessary.

Matt tells Metro.co.uk: ‘Compassion messages are especially effective in prompting long-term change. They not only help individuals to feel supported through difficult transitions but can address some of the underlying problems – anxiety, depression, self-criticism – that fuel unhelpful behaviours.

‘Fear messages, by contrast, can shock – and in that way provoke – but they are less effective in developing a positive commitment to a goal, behaviour, or strategy. They also run the risk of promoting social stigma: labelling, in this case smokers, as irresponsible, for example.

‘While it is important to communicate the risks involved in habits such as smoking, we need to ensure the public appreciates that changing behaviours is never easy, requires support, and that difficulty can vary according to a person’s life history and circumstances.

‘Finally, to be effective, public health campaigns have to go beyond messages: imploring people to be healthy won’t work in environments that push people towards unhealthy behaviour.

‘Financial pressure, the absence of career and social opportunities, poor mental health support – all these factors and more can make it much harder for individuals to make and sustain healthy life choices.’

From the outside, health policy looks like a middle-and-upper-class person’s game. Working groups and committees of MPs and academics sit in boardrooms to discuss our lives, deciding on things that are unlikely to ever affect them.

It’s only natural that some working class smokers feel patronised and like they’re being made examples of, as poorer people bear the brunt of ‘progressive’ schemes while tobacco firms’ profits rise.

If policies designed to protect our overall health primarily impact society’s most vulnerable, perhaps they’re aimed in the wrong direction. Perhaps the next step in tobacco control is to focus on the industry instead of the individual.

The burning question I had when researching this article was: ‘If smoking is so bad for us, why is it legal?’

It may seem simplistic, but that little voice inside my nicotine-ravaged brain can’t reconcile messages about how cigarettes could kill me with being able to freely buy – and pay through the nose for – them on every street in country.

A landmark report by Professor David Nutt ranking drugs based on the harm they cause (both to the user and others) placed tobacco sixth of the 20 studied. Sitting between cocaine and amphetamines on the chart, tobacco was considered to be more harmful than banned substances such as ecstasy, cannabis, LSD, and methadone.

The only other legal drug among those looked at was alcohol, which came out top of the list for damage.

It stands to reason that, if government was fully committed to ending tobacco use for the greater good, they’d take steps to block its sale.

According to Hazel, however, it’s not that simple.

She says: ‘If you were to ban the product tomorrow, the likelihood is that you would have a very significant illicit market. If you have an illicit market it’s much more difficult to control who is being sold to, much more difficult to control the price of it, and so on.

‘So if your goal was to have fewer people smoking, banning it wouldn’t get you that.’

It’s a valid point that restricting the sale of tobacco may encourage counterfeiters, but one that props up the legitimacy of corporations already behaving unscrupulously without consequences.

I’m anything but a proponent of prohibition, yet fail to see the logic behind criminalising certain substances and not others. If we’re trying to end demand, surely we should cut off mass market supply.

ASH may be worried about illicit tobacco because of its health implications, but you’d forgiven for questioning the motives of some decision makers.

The tobacco industry’s tactics to get – and keep – people hooked on nicotine are many. From donating heavily to pro-tobacco think tanks to ‘wining and dining’ MPs, corporations employ various methods to influence those in power.

Spotting these ploys isn’t always easy. For example, Philip Morris International, the parent company of Marlboro, spent billions setting up the ‘Foundation for a Smoke-Free World’ in 2017. The move was criticised by campaigners, who thought it an underhanded way to ‘renormalise’ the habit while keeping up appearances as a responsible business.

Big tobacco has its fingers in every parliamentary pie, fuelling distrust in policymakers and blurring the line between truth and propaganda. It leads us to ask ourselves why smokers are demonised while manufacturers flourish, and who should take responsibility for the harm caused.

Untangling this web of money and authority was never going to be an easy task, but it would set a precedent that our nation’s health is the priority and cannot be bought.

New Zealand has recently shown that it can be done, this week revealing a groundbreaking ban on cigarette sales for those born after 2008. No one currently aged 14 or under will ever be able to legally purchase cigarettes there, effectively phasing out smoking for generations to come.

Robert and Hazel both say a ruling like this is unlikely to see the light of day here. In lieu of reform from the top, the onus is once again placed in the hands of the public to take responsibility for quitting a highly addictive substance that’s readily available and effectively state-sanctioned.

How can we get people to quit smoking for good?

Robert says that there’s still hope on the horizon for an end to smoking, but believes it’ll be propelled by medical breakthroughs over trade bans.

He feels that the licensing of cytisine, a drug he calls ‘the oldest stop smoking treatment in the world’, could change the game around cessation.

Speaking about the drug that comes from laburnum seeds and is currently already sold in countries like Poland, Robert says: ‘It’s very safe, it’s effective.

‘In an ideal world, you could go out and buy it from the chemist (you don’t need a prescription) and it’s cheap as chips. It could be like the aspirin of smoking.

‘It would capture the public’s imagination. And it will come. In fact, it may well even come next year.

‘But I would like to see the government saying they’re behind this.’

Although they don’t agree on much, ASH and FOREST both hail e-cigarettes as a significant breakthrough in offering a healthier alternative for quitters.

Hazel says next steps will likely be focused on youth smoking and furthering negative associations with smoking, without stigmatising smokers themselves.

‘The more uncomfortable people feel about their smoking, the more likely they are to make a successful quitter,’ she says. ‘Particularly in the way that young people see the world, we don’t want them to see tobacco as normal.

‘But there’s a balance to be struck between not normalising something and alienating people.

‘Most people will try to quit many, many times. About half will not succeed and will die from their addiction.

‘Stigmatising smokers is not helpful, because we need people to feel able to engage with treatment, engage with support, talk to their doctor.’

The All Party Parliamentary Group On Smoking have proposed raising the legal age of smoking from 18 to 21, as well as ‘polluter pays’ laws that – quite rightly – would see tobacco companies footing the bill for the environmental impact of their products.

Both are overwhelmingly popular with the public, but Sajid Javid was said to be ‘deeply sceptical’ about the plans.

I had hoped that looking into the mechanics of smoking would give me a new zeal to quit. In reality, I feel more jaded than ever.

Despite well-meaning individuals working towards a common goal of better health for the population, corruption muddies the waters around tobacco control. Personal efforts feel like wading against a tide of misinformation and vested interests.

The best way to break out of that self-defeating mindset – according to Robert – is to lean into community and speak to others who’ve gone through the same thing.

He says: ‘When people quit, they often don’t make a big deal of it, and so you don’t really have a sense that there’s a lot of quitting going on.

‘If we made that more visible, if it was clearer that there’s a lot of people out there constantly trying to quit, then – humans being social creatures – that norm would take hold and people would go “yeah, actually, you know what, I’ll give it a go”.’

In a perfect world, tobacco companies would never have been allowed to flourish. They wouldn’t be giving free cigarettes to children in the developing world to get ‘new markets’ hooked. They wouldn’t be spending billions covering up the devastation they’ve caused through deliberately engineering deadly products to be more addictive.

In the not-so-perfect real world, the industry’s aggressive methods mean smoking won’t be stamped out any time soon – and smokers themselves will be blamed for the consequences.

All we can do is channel our anger at the carte blanche Big Tobacco have been given towards something more positive; whether that’s kicking your own habit or fighting for increased funding for cessation services.

The government have a job on their hands if they plan to eradicate smoking in just eight years, but as individuals all we can do is try to after ourselves as best we can.

As Robert says, the best way to succeed with quitting is to try, try again. The next cigarette I have likely won’t be my last, but one will be.

Even if I feel like a lost cause right now, perhaps I can be a cautionary tale for young people on why they shouldn’t start. Perhaps seeing people like me pour money into smoking, struggle to quit, and face the consequences over and over is deterrent enough.

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