Another barking mad idea from a doctor

A letter in this week's British Medical Journal has been press released around the world and may feature in today's newspapers. Although it appears to have been written by a precocious child, it is actually from the pen of a grown man, and a doctor at that.

The letter is actually an online comment to an article in the BMJ from last month. The BMJ must have been so impressed by its startlingly original contents that it deemed it worthy of a wider readership.

Fundamental re-think on smoking is needed
Paul D Jepson
F2 doctor, public health

Excuse my naivety, but isn’t smoking’s continued legality one of the most important factors accounting for its slow rate of decline?

If you mean that fewer people would smoke if smoking was illegal, then yes, but it's not quite as simple as that, is it?

Any other drug causing a fraction of the morbidity and mortality of tobacco would have been outlawed long ago, putting aside alcohol for the moment.

Why should we put aside alcohol? Perhaps because it doesn't fit your argument?

In 2010 mephedrone became a class B drug following widespread media coverage and reports of some deaths in the preceding months, although the evidence surrounding the dangers of mephedrone does not exist.

I agree. Mephedrone should not have been banned, as I argued in The Art of Suppression. Unfortunately, we live in prohibitionist times and there is no greater engine of prohibition than the public health establishment, as epitomised by the British Medical Journal.

This is in stark contrast to tobacco, which is responsible for around 100,000 deaths each year in the UK. Why should smoking get special treatment?

I suppose because 1.5 billion people worldwide like consuming tobacco and people can function perfectly well under the influence of nicotine in a way that they can't under the influence of party drugs and amphetamines. The majority of people believe smoking should be legal so it is. We call it democracy and, in a free society, informed adults have a right to put what they like into their bodies even if it carries a risk to their health. The question is not why should smoking get special treatment, but why shouldn't drugs be legal?

For mainly economic and political reasons, adults with enough change in their pocket can walk into their local shop and buy a packet of cigarettes. They will not be judged and will not feel ashamed: smoking is an acceptable addiction.

If that is true - and broadly speaking, it is - it is not for want of trying from the denormalisers of public health. Every effort is made by alleged health campaigners to stigmatise smokers, demonise tobacco and villify the manufacturers. If this hate campaign has not yet led to actual lynch mobs, it only shows that the general public are more tolerant than the British Medical Association. That, again, answers your question as to why smoking remains legal.

If the tabloid press were to publish a list of the names of the more than 250 people killed by smoking related disease each day, would the government be as fast to react as it did for mephedrone?

[splutter]

[wipes coffee from keyboard]

Assuming this to be a serious suggestion, I will attempt a serious reply. Leaving aside the extraordinary distastefulness of the idea and the unconscionable invasion of privacy, the main problem is that such a scheme would be impossible to carry out. No one is able to name these hypothetical 250 people because doctors and coroners very rarely list smoking as a cause of death. Although the BBC recently affected shock at the reluctance of doctors to name smoking on death certificates, all smoking-related diseases are multi-factoral (ie. have more than one cause) and all smoking-related diseases can be contracted by nonsmokers.

So while there is a good chance that a smoker who dies of lung cancer developed the disease because of his smoking, there is a chance that he would have got it even if he had not smoked. In the case of heart disease - which is the biggest contributor to the 100,000 figure - it is impossible to say that smoking was the cause of any one death. This lack of certainty in individual cases is the main reason why personal injury lawsuits against tobacco companies tend to fail in court.

Imagine a fat smoker with a family history of heart disease, a poor diet and a stressful job. Can a doctor say with any certainty that his heart attack was 'caused' by his smoking, his diet, his stress, his genes or his diet? It can't be done. The 100,000 figure comes from assumptions taken from the epidemiological literature based on aggregate data from hospitals. It is an estimate. It is not based on a running total of clinically proven 'smoking-related deaths'.

Even if such a list could be created, who is going to pay for the column inches in the tabloids every day? Since this letter was written by an authoritarian doctor of public health, we must assume that the taxpayer will, as ever, be expected to foot the bill. And why only tabloids? Are we to assume that smokers do not read the broadsheets?

Finally, on a practical note, the great majority of the 250 daily deaths would be of people in their 70s, 80s and 90s. Smoking prevention campaigns are largely targeted at people in their teens and twenties. It is doubtful whether listing the names of people who, for the most part, enjoyed the proverbial 'good innings' is really going to have desired the shock value for the target group of devil-may-care youngsters.

People’s attitude towards drugs should be evidence based, and not informed by politics or popular opinion.

Quite so. Let's legalise them. Prohibition didn't work with alcohol, it doesn't work with drugs and it won't work with tobacco.

How must smokers feel when they are encouraged to quit their habit by the same government that welcomes tobacco taxes so gladly?

I suppose it makes them think that politicians are greedy hypocrites. A valuable lesson learned, no?

While smoking remains legal, the number of smokers is never going to fall significantly—no matter how much taxes rise, how plain cigarette packets become, or how many millions of pounds is spent on cessation.

Smoking rates have actually fallen very significantly over the years and may continue to do so. Admittedly, they have flat-lined since 2006, when the government began listening to the 'experts' of tobacco control and introduced divisive, ill-considered policies like total smoking bans, graphic warnings and display bans. Maybe the politicians will learn their lesson and withdraw their funding from astro-turf anti-smoking groups in the same way as it has recently stopped funding Alcohol Concern. (Rather than try and raise money from the general public, Don Shenker has realised that the game is up and has resigned. Cheers!)

Perhaps the smoking rate will continue to flat-line. Or it might start going back up. Or it might fall again. Who knows? It's none of your business and it's none of mine either. The risks of smoking are universally acknowledged and there is a great big warning on every pack saying 'Smoking Kills'. Having accepted that prohibition doesn't work, we must also accept that informed adults have the choice to smoke or not smoke. There really isn't more to say on the matter. You live your life and I'll live mine.

As I mentioned, this letter may be the subject of some news coverage today, presumably because it raises the spectre of the 'next and final step'. I'll be on BBC Radio Sussex at around 9.50am talking about it.