A bold British plan to end the tobacco epidemic

A new report, independently commissioned by the UK’s Secretary of State for Health and Social Care, provides cutting-edge recommendations with the aim of achieving a ‘Smokefree 2030’. This reflects the UK Government’s ambition to reduce the smoking rate from 13.5% to 5% by the end of this decade. Written by Javed Khan OBE, MD, and published by the UK government on June 9, 2022, the report, “The Khan Review: Making Smoking Obsolete”, assesses the impact of public health policies currently in place and finds that, “without other measures, England will miss the 2030 smoke-free target by at least 7 years, and the poorest areas of society will not reach it until 2044.”

“To have a chance of reaching the 2030 smoke-free goal,” he concludes, “we need to accelerate the rate of smokers’ decline by 40 percent.” This is the final message: “Smoking kills and ruins lives. But it doesn’t have to be like that.”

The Khan Review is relevant not only to the UK but also to the US, as we will explain.

The report offers a series of evidence-based recommendations – including four “critiques” – to accelerate progress and save more lives faster. They serve both as benchmarks for our friends across the Atlantic and as a model for what the United States could do the same more effectively to end the tobacco epidemic here.

In both countries, despite historic progress, smoking remains the leading preventable cause of death. There are also glaring inequalities. The poorest and most vulnerable populations are those most likely to continue smoking, making tobacco one of the main contributors to a significant increase in health problems and a reduction in life expectancy. for the most disadvantaged people.

The “must-haves” of the report include:

  1. Increase investment. A global financial investment is necessary for smoking cessation treatment. The report advises that if the government is unable or unwilling to provide such funding directly, it should “make the polluter pay” by imposing additional taxes on cigarette manufacturers to cover the costs.
  2. Increase sale age. The government should raise the age of sale from 18, by one year, every year until no one can legally buy cigarettes. (The federal minimum age in the United States is 21, with no annual increase.)
  3. Promoting vaping as a harm reduction approach. The government should also increase its promotion of the use of e-cigarettes to help people quit smoking. The report states: “We know that vapes are not a magic bullet or completely risk-free, but the alternative [of combustible tobacco use, or smoking] is much worse.”
  4. Improving prevention in the National Health Service (NHS). Prevention must become a central part of NHS tobacco control efforts. It must offer smokers quit smoking advice and support in “every interaction they have with health services”, including with GPs, hospitals, mental health care providers, midwives. women, pharmacists, dentists and optometrists.

The report also proposes other evidence-based policies, such as requiring tobacco licenses for retailers, changing the appearance of cigarettes and their packaging to reduce their appeal, expanding public places without smoke, investing in media campaigns, increasing cigarette taxes and ending duty-free privileges for tobacco products.

Finally, Khan urges the government to accelerate its plan for health practitioners to prescribe e-cigarettes (in addition to their continued sale as non-medicinal consumer products), especially in disadvantaged communities. This will help make harm reduction approaches acceptable to those who need reassurance from a physician and accessible to those who cannot easily afford e-cigarettes at retail.

These recommendations resemble New Zealand’s ambitious Smokefree Aotearoa 2025 plan, which aims to end smoking and promotes e-cigarettes as having “the potential to contribute to the Smokefree 2025 target and…disrupt significant inequalities that are presented”.

Contrary to the consensus of governments and public health organizations in these countries, the United States is mired in a polarized debate pitting concerns about the risks of e-cigarettes for young people against their potential to help addicted adult smokers quit. . The focus on youth protection has, to its credit, succeeded in reducing youth e-cigarette use by over 60%, to 7.6%, over the past 2 years, at the same time. that youth smoking rates have dropped to an all-time low of just 1.5% (alleviating concerns that youth vaping is encouraging smoking).

Youth vaping is no longer an “epidemic”. But these efforts, which too often inaccurately portray the risks of e-cigarettes, have led to significant public misunderstanding about the significantly lower health risks of e-cigarettes compared to combustible tobacco products. This, in turn, has hindered the promotion of tobacco harm reduction to the more than 30 million adults who still smoke.

Recently, the FDA announced that it would ban Juul e-cigarettes due to what it described as a few unresolved issues related to potential toxicity, although it said it was not aware of any there are no immediate hazards associated with the use of the product. Advocacy groups were quick to tout the decision as rewards for a product that became popular with children starting in 2018. Yet while more than 2 million adults have switched from cigarettes to Juul, potentially avoiding more than a million of smoking-related deaths in the coming years, Juul is not more favored by young people, with only 0.6% of young people reporting having used a Juul product in the last 30 days.

Some experts have noted the irony that an e-cigarette popular with adult smokers trying to quit might be banned while billions of aggressively marketed and far more dangerous combustible cigarettes will continue to be sold with impunity. .

More positively for public health, the FDA continues to promote policies to significantly reduce the appeal of conventional cigarettes, such as reducing nicotine to non-addictive levels and eliminating menthol as a signature flavor. It has also in recent months authorized the sale of 23 brands of electronic cigarettes based on the agency’s assessment that they are “appropriate for the protection of public health”, the standard set out in its governing law. . Adhering more consistently to this “risk continuum” approach for different tobacco and nicotine products would align with the progressive approaches currently being followed in the UK and New Zealand, and perhaps greater confidence that the United States can simultaneously support adult smokers while protecting youth.

Let us not forget that the overriding public health objective must be to protect the public from harm, especially serious harm. The greatest harm to health is overwhelmingly caused by the inhalation of combustible tobacco smoke, which is responsible for virtually all “tobacco-related” deaths. Millions of adult smokers face imminent harm and even death from their use of combustible cigarettes.

Nicotine is addictive, but it is not the cause of many diseases resulting from the inhalation of burnt tobacco, a fact unknown to the majority of doctors. It is our clinical duty to help smokers quit where possible, supported by cessation medication and advice. And for smokers who cannot or do not want to use withdrawal drugs, we should encourage them to switch to significantly less harmful sources of nicotine, such as e-cigarettes.

Every day, more than 1,300 Americans die from smoking. At the same time, to our knowledge, there have been no credibly reported deaths caused by exposure to the aerosol of nicotine-based e-cigarettes. The UK and New Zealand are now leading the way in the battle to end the epidemic of tobacco-related illness and death. The United States can learn from them.

The opinions expressed are those of the authors and do not necessarily reflect the views of any organization with which they are affiliated.

Clifford E. Douglas, JD, is Director of the University of Michigan Tobacco Research Network and Adjunct Professor in the University of Michigan School of Public Health. Caitlin Notley, PhD, is Professor of Addiction Science and Head of the Addiction Research Group at Norwich Medical School, University of East Anglia. She is director of the “Citizens Academy”, involving patients and the public in research.


Douglas is co-principal investigator for research conducted by the Center for the Assessment of Tobacco Regulations, which is funded by the NIH/FDA. He is also an advisor to the Smoking Cessation Leadership Center at the University of California, San Francisco on behavioral health and smoking. Notley runs a program of work on smoking cessation and relapse prevention, including trials funded by the National Institute for Health Research in the UK

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