It can only be a matter of time before smoking in Britain is confined to consenting adults in private. The workplace ban in Ireland has been acclaimed as a great success by politicians and public health authorities alike and similar initiatives are being introduced in Scotland, Wales, Liverpool and elsewhere. Our local hospital is planning to go smoke-free on New Year's Day 2005 and patients who now wheel their drips and drains to huddle in squalid stairwell smokers' ghettos will be banished to the streets. Our receptionists, already consigned to the bin-shed, will no doubt shortly also be forced out into the rain. The logic of New Labour public health policy points towards the erection in public places of a modernised version of the mediaeval stocks in which smokers could experience the full force of popular moral disapproval of their stigmatised behaviour.
The government has skilfully manoeuvred itself into a no-lose position on smoking. Having discreetly sponsored anti-smoking propaganda, it can now adopt the posture of reluctantly acquiescing to popular demands to introduce the sort of authoritarian measures that this government favours in a wide range of policy areas. Health minister John Reid is so confident in the strength of the consensus behind more coercive anti-smoking measures that, while he presides over the introduction of these measures, he can afford to indulge in gestures of condescension towards those for whom smoking is one of life's few pleasures.
It is now more than 40 years since the Royal College of Physicians took a public stand on the dangers of smoking and more than 20 years since epidemiologists suggested that ‘passive smoking’ caused an increased risk of lung cancer and heart disease. The quality of the evidence for the dangers of passive smoking has improved little over succeeding years. What has improved is the propagandist skill of public health campaigners in extrapolating from marginal increases in relative risk to claim significant numbers of deaths attributable to passive smoking.1 Medical invective against tobacco seems to have intensified in inverse proportion to the strength of the scientific evidence against passive smoking.
The key factor in the rising profile of doctors in the crusade against smoking is the medical profession's shift away from identification with the individual patient towards a wider endorsement of state intervention in personal behaviour in the cause of improving the health of the population. The proposal (expected in the government's forthcoming public health policy) that GPs should provide patients with ‘personal health plans’ has provoked some criticism — on the grounds of the associated cost and administrative burden. But there has been little objection in principle to the notion that GPs should interfere in patients' lifestyles, not only in relation to smoking and drinking, diet and exercise, but also in intimate matters such as sexual behaviour, child protection, domestic violence, drug abuse, teenage pregnancy. It is ironic that at a time when doctors are widely condemned for being paternalistic, we are also encouraged to intrude in patients' personal lives to a degree that would make a Victorian patriarch blush.
It is possible that banning smoking could save lives. There is some evidence for this from the country in which the link between smoking and lung cancer was first scientifically demonstrated.2 The government in Germany in the 1930s ‘launched an ambitious anti-smoking campaign, involving extensive public health education, bans on certain forms of advertising, and restrictions on smoking in many public spaces’.2 Women and younger people were a particular focus of anti-smoking propaganda and restrictions on sales. Furthermore, ‘activists called for bans on smoking while driving, for an end to smoking in the workplace, and for the establishment of tobacco counselling centers’.2 Although it seems that the Nazi campaign did not succeed in reducing overall tobacco consumption until the later stages of the war (when production and distribution were disrupted), it did contribute to a reduced rate of lung cancer among women, possibly preventing 20 000 deaths.2
For the anti-smoking zealots, the loss of civil liberties resulting from their widening range of bans and proscriptions is justified by the anticipated health gain. Yet, as the great microbiologist Rene Dubos, observed, health should not be considered an end in itself, but as ‘the condition best suited to reach goals that each individual formulates for himself’.3 By curtailing the autonomy of the self-determining individual, authoritarian public health policies infantilise society, weaken democracy, and diminish humanity.
- © British Journal of General Practice, 2004.