The stigma of smoking

It is more than a year since a sullen 12-year-old girl was dragged into my surgery by her exasperated mother who wanted me to find out the cause of her intermittently withdrawn and defiant behaviour.

After a period of silence, followed by an outburst of anger and tears, the background to the conflict emerged. The girl, who had learned at school of the health risks associated with smoking, had discovered a packet of cigarettes in her mother’s handbag. She was frightened that her mother might die and angry that she had betrayed the family, not only by her filthy habit, but also by trying to conceal it. The mother was full of remorse, that her guilty secret had been exposed and that she had found herself incapable of overcoming her compulsion to smoke despite her awareness of the risk to her health and the implicit threat to the integrity of her family.

I was reminded of this scene while watching the latest anti-smoking adverts on British TV, launched to coincide with the House of Commons vote to ban smoking in a wide range of public and private places. The advert features a young mother, clearly in the terminal stages of lung cancer, who expresses her feelings of guilt and remorse that a cancer caused by her own smoking will soon take her away from her children. In turn, her daughter expresses her anger and grief at the fact that her mother is expected to die shortly as a result of a disease resulting from her smoking. This advert is clearly designed to make parents who smoke feel guilty – and to make children of parents who smoke feel angry. Its objective is to use children as an instrument of the campaign to deter adults from smoking. The inevitable result is that the sort of scene played out in my surgery will unfold in households throughout the country.

It is a sign of the times that there has been no storm of protest over the increasingly manipulative and moralistic character of anti-smoking propaganda. In the crusade to reduce mortality from smoking it is considered legitimate to exploit the deepest fears of parents and children. While the law seeks to prohibit smoking in public, the new anti-smoking advert seeks to proscribe it in the private sphere, fomenting domestic strife to achieve this objective. At a time when a wide range of civil liberties are under threat it is alarming that the strategy of using children to police their parents’ behaviour – reminiscent of totalitarian regimes – provokes so little public disquiet.

The immediate casualties of the war on smoking are people with lung cancer and other smoking-related diseases. This month the Lung Cancer Foundation launched the Lung Cancer Patients’ Charter, calling for greater government spending on a condition that kills more people every year than leukaemia, breast cancer and prostate cancer combined, yet accounts for four per cent of the national cancer research budget. While breast cancer enjoys a high and sympathetic public profile, lung cancer – which kills nearly three times as many people every year – is stereotyped as the smokers’ disease. As a result, patients with lung cancer fall far behind those with other major cancers in terms of the provision of optimum care, information and treatment. Yet, when the Lung Cancer Foundation points out that one in 10 sufferers from lung cancer never smoked, this seems only to reinforce the distinction between those considered deserving of sympathy (and healthcare resources) and those labelled as victims of their own lifestyle choices and hence considered undeserving of public concern. As the smoker has become a pariah, sufferers from lung cancer have become the lepers of the twenty-first century.

In the era of evidence-based policy, it is worth noting that there is little evidence to suggest that more coercive anti-smoking policies are likely to be successful. The shift from the approach of providing public information on the dangers of smoking in the 1970s and 80s, to the bans and proscriptions – and the promotion of medicalised ‘smoking cessation’ therapies, such as nicotine replacement – that have become increasingly prevalent since the 1990s, has produced diminishing returns.

Whereas between 1975 and 1990, the proportion of men smoking fell from over a half to less than a third (a fall of about 20 per cent), between 1990 and 2003, the rate fell by a further four per cent. The proportions smoking in the 20 to 24 age group remain high – 37 per cent among men, 38 per cent among women; indeed, there are signs that smoking is increasing among teenage girls. As might have been expected by anybody outside the blinkered world of health promotion, moralistic anti-smoking propaganda directed at adolescents has proved counterproductive. Smoking provides not only a focus for defying authority, but for teenagers in the grip of another contemporary health panic – that surrounding obesity – it provides a means of suppressing appetite.

Watching the parliamentary debate on smoking bans, I was struck by the similarities between the sanctimonious posturing of MPs calling for more coercive measures and the self-righteous outburst of the girl in my surgery. Though hers was an honest and appropriately immature expression of distress, the MPs expressed only the familiar bad faith of politicians seeking to compensate for their loss of legitimacy by claiming moral rectitude. This priggish posturing reached its most hypocritical among Labour MPs who sought to justify authoritarian measures by rediscovering a long-dormant concern for the welfare of the working classes, excusing the ban as a supposedly life-saving protection for waiters and barmen who work in smoky environments.

The debate reflected the increasingly childlike character of political discourse. Children understand moral issues in terms of black and white: the average 12-year-old is capable of being as censorious as a Jesuit and as implacable as an Old Testament prophet. (This is one reason why many parents of young children occasionally find respite in a cigarette.) It is a reflection of the degradation of public debate that political and medical authorities are now reduced to invoking the simplistic morality of children to make them feel good about themselves. While they bask in the warm glow of righteousness, smokers, those suffering from smoking-related diseases – and their families – are cast into the darkness.

Dr Michael Fitzpatrick is author of The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA), and MMR and Autism: What Parents Need to Know (buy this book from Amazon (UK) or Amazon (USA)).

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