Unlucky Strike

 Private Health and the Science, Law and Politics of Smoking

University of Buckingham Press, 2013

 PREFACEUS cover 001

 The evils of smoking are a settled issue. Smoking is bad for the smoker and those around him. “Smoking causes lung cancer, bronchitis, emphysema, heart disease and cancers in other organs including the mouth, lip, throat, bladder, kidney, stomach, liver and cervix…” says a prestigious British report[1], feeling no need to document these scary claims. “Half of all smokers will die prematurely” it adds. Environmental tobacco smoke (ETS) is almost as dangerous as mainstream smoke: “ETS has been shown to cause lung cancer and ischaemic heart disease, and probably to cause COPD, asthma and stroke in adults. ETS is harmful to children, causing sudden infant death, pneumonia and bronchitis, asthma, respiratory symptoms and middle ear disease” said the Tobacco Advisory Group of the Royal College of Physicians in July 2005[2]. These conclusions are echoed by every recent official report, from the Surgeon General in the US and to the Royal College of Physicians in the UK and comparable bodies in almost every part of the developed world.

I grew up at a time when almost everyone smoked. I did not see smokers falling from their perches all around me and, as it turns out, most of the smokers I have known have lived to pretty good ages. I had not read these grim reports. When I did, I couldn’t help but wonder, just from my own experience, if the dangers of smoking might not be just a wee bit exaggerated.

My personal tipping point occurred when I found out that despite massive publicity to the contrary, smoking has no public cost. It puts individual smokers at risk. It does not put the public purse at risk. Strike one against the received view. Prompted by this surprising discovery, I looked further into the facts. The more I looked, the weaker the case against smoking as a public health issue became.   Is ETS really dangerous to children? How do they know? Does it really cause sudden infant death? How do they know that? Proving that smoking can cause an ever-growing list of ailments requires a scientific case that is often impossible to make, for logical, ethical and practical reasons. The case against ETS, in particular, is exceedingly weak.

So, if smoking has no public cost and the medical case for third-party harm is weak, why are smokers victimized in so many ways? I tried to find out – and the answer is not pretty.

 Smoking has been controversial ever since tobacco came to Europe in the sixteenth century. Fifty years ago, almost everyone smoked. Fifty years before that, smokers were in the doghouse – cigarettes were illegal in several U.S. states early in the twentieth century. Smoking has always been a ready source of revenue. It has also been a source of health problems, real and imagined. The mixture of pleasure, money and health risk means that smoking is rarely treated fairly by politicians, health professionals or the public. Now, tough anti-smoking laws are almost universal.   The misinformation about, and unreasoning hostility directed at, smoking and smokers – and the sight of smokers, usually poor, puffing desperately outside in winter weather – is one reason I wrote this book.

 I look at four questions: What should we – government, the state – want?   “Life, liberty and the pursuit of happiness”? – the U.S. Declaration of Independence implies that the ‘joy of smoking,’ should be part of public policy.   Is it? How about health? And longevity? Is a long life for everyone an absolute good? And what about productivity – how much should we value the productive fraction of a citizen’s life? In short, what is the common good? Evolutionary biology doesn’t answer these questions, but it should make us skeptical of simple answers to them.

 The second question is simply factual: how dangerous is smoking, really? Is it dangerous to others – the problem of secondhand smoke? Well smoking is risky for the smoker, but less risky than most people now believe.   It is probably not dangerous to other people.

 The third issue is cost: Smoking-related illnesses are costly and painful, no doubt. But we all get sick and die; dying is rarely pleasant; and the fact is that smokers tend to die a bit more efficiently than the rest of us. They cost society less not more than nonsmokers.

 Fourth, what do the answers to these questions tell us about policy? Public cost, possible harm to others, the pleasure smokers get from their habit – and the uncertain value of longevity: how should these guide law and custom? Do actual policies in the US and UK make sense in light of the facts? They do not. The dominant attitude to smoking makes little sense. In addition to an instinctive aversion displayed by a few – an aversion that is more pervasive the rarer smoking becomes, I suspect – the general animus encourages tendentious science, perverts law and tempts politicians into dubious practices. When large amounts of money can be made at their expense, it’s no-win for smokers.

 The facts should make society much more relaxed about smoking than it is.   But prejudice and perverse incentives in the political and legal systems have pushed policy in the opposite direction.   It’s time for a re-think and a redress.   Let’s see if you agree.

John Staddon, Duke University, Durham, North Carolina, July, 2013

 [1] Public health: ethical issues. Nuffield Council on Bioethics, 2007. A report prepared by a Working Party chaired by Lord Krebs. P. 105

[2] Going smoke-free: The medical case for clean air in the home, at work and in public places. A report on passive smoking by the Tobacco Advisory Group of the Royal College of Physicians, July 2005. See also Passive smoking and children, by the same group, March 2010