Contra Khan and the myth of the rational smoker

Sources this week revealed that the Government’s upcoming white paper on health disparities (likely based heavily on the recently published Khan review) has been delayed until the new Conservative Party leader is chosen. 

Amid leadership debates and desires for a revitalised direction for the country, we have been presented with the perfect opportunity to put a stop to what has been a defining feature of the past decade in politics: a doggedly persistent walk down the road to paternalism. One of the most indicative features of this marked shift is the now infamous Khan review. While the review contains some positive suggestions and highlights the troubling lack of awareness of smoking alternatives, the rest is replete with poorly substantiated research leading to condescending recommendations.

The review acknowledges declining smoking rates which are currently on track to hit 6.3% by 2030, just 1.3 percentage points higher than the government's Smokefree goal. Yet it fails to discuss whether its interventions are really necessary to encourage such marginal shifts in behaviour. The recommended measures might appear more reasonable if smoking rates had remained unperturbed by the rise of safer alternatives and changes in attitudes, but this is not the case. 

The review also relies on the argument of protecting the public purse; that eradicating smoking will free hospital beds, reduce waiting times and save billions. In fact, in the absence of smoking, the public purse would be hit with an annual bill of almost £20 billion from increased spending on pensions, healthcare, other benefits and foregone tobacco duty. There would be savings of course, but at roughly £5 billion, a rather sizable deficit would remain.

The essential question ignored by this report is whether or not we think adults are capable of deciding to smoke, irrelevant of whether it is harmful. John Stuart Mill eloquently explained that "If a person possesses any tolerable amount of common sense and experience, his own mode of laying out his existence is the best, not because it is the best in itself, but because it is his own mode."

As a society we have agreed that we should allow the practice of some activities which we deem unethical, dangerous or otherwise negative. Few people think open water swimming, adultery or drinking should be illegal. Evidently, personal danger, immorality or the existence of negative externalities are not sufficient criteria for outright prohibition. This therefore begs the question: are there any criteria besides public opinion and political expediency? As John Humphreys observed, those in authority can simply take the helm and bravely "ban things and treat us as children who are not sufficiently mature to assess risk for ourselves".

We do not want, nor should we want to live in a risk-free society, unencumbered by temptations and decisions. Perhaps so long as adults are informed and derive some form of enjoyment from smoking, the optimal number of smokers is not zero. And they are indeed informed. For decades surveys have found that practically everyone knows that smoking is harmful, and that we even overestimate certain risks, such as that of lung cancer. 

But surely addiction precludes rational participation in dangerous activities? Perhaps at some level. But when only 40% of smokers actually plan on quitting in the next year, and 10% in the next three months, the objection is somewhat tenuous. There may well be some degree of addiction where being so addicted removes one's ability to rationally make decisions, but it seems extraordinary to suggest this level is reached while the majority of smokers are happy to continue smoking for at least the foreseeable future. What Dr Khan may think of as the myth of the rational smoker, may not be such a myth at all.

The fundamental flaws in government paternalism aside, here are the headline sections from the report:

Stopping the start

Most recommendations in this section involve making it impossible, inconvenient or expensive to legally buy tobacco. The most extreme suggests raising the age of sale of tobacco by one year, every year. Given that most smokers started before the age of 18, it is clear that in this case as with many historical prohibitions, illegality is not a sufficient criterion for cessation. The age of 18 is also an extremely important one; it is the age at which we can buy alcohol, vote, and get married or join the army without our parents’ permission. To raise the age of smoking would be to assert that adults who are capable of making these other incredibly important decisions are not intellectually capable of deciding to smoke. 

Given that illicit cigarettes are cheap and easily accessible, Dr Khan’s call to significantly increase tobacco duty would only exacerbate the illegal cigarette trade, as demonstrated by a study (which included the UK) that found that a €1 increase in tax per pack increases illicit market share by between 5 and 12%.  

The review’s praise of mandated packaging and advertising bans are unsurprising but disappointing, given the breadth of research showing that plain packaging has no effect on actual usage. In most cases, advertising affects brand preference rather than uptake of new activities. Despite Khan’s expressed concern for underage smokers, the argument for allowing Stop Smoking Services to provide them with vapes to aid them in quitting smoking is not mentioned in the report, while mandating an on-screen warning while tobacco products are visible in films is.

He also recommends banning companies from giving out vapes for free, yet provides evidence that "free vapes significantly increased demand for stop smoking services, particularly in the most deprived quintiles”. This insistence on government-run programmes and unwillingness to allow the private sector to contribute is baffling.

The report also comments that snus is far less harmful than smoked tobacco, and mentions Norway, where it has all but replaced tobacco smoking in young adults. Surprisingly (or perhaps unsurprisingly) Dr Khan comes to the conclusion that he has not been persuaded that it adds additional value, and should not be a priority for the government's legislative time.

Quit for good

Happily the report then takes an optimistic turn, and highlights the safer alternatives to cigarettes. Dr Khan discusses public misinformation about vaping and lack of awareness of other nascent alternatives such as nicotine pouches. Whilst he suggests a mass media campaign to correct these issues, simply replacing the current health warnings and images on cigarettes with ones concerned with alternatives would be a far more cost effective and targeted way of disseminating this information.

System change

The review continues with suggestions of how the NHS needs to do better at helping those who want to quit do so, especially in the area of mothers who smoke, given the alarming statistic that one third of teenage mothers smoke during pregnancy. The financial incentive schemes mentioned in the report deliver good value outcomes in reductions in antenatal and postnatal complications. Disappointingly, they are rarely used.

Dr Khan does however continue to assume that all smokers wish to quit, and advocates implementing targets which, as demonstrated by this review, are likely to lead to ill-advised and unnecessarily restrictive policies. 

While the review suggests organisational improvements that should certainly be adopted in order to help those wanting to quit, and rightly highlights the issue of misinformation concerning smoking alternatives, many recommendations either ignore the case for individual responsibility or ignore research on the impacts of his suggested policies. Right now we have been given the opportunity to show the new Conservative leader that conservative values cannot be squared with this neo-puritanism; that they must lead the slow climb back up the slippery slope; that something must change.