It’s the largest preventable cause of death. It kills 5 times more people than road accidents do — annually. It amounts to millions of hours of lost productivity and costs our health systems billions. I am, of course, referring to smoking. In this article, I explore the history of smoking, the science behind why smoking is so bad for the health (you’d be surprised at how hard it was to find actual scientific data on this!), the impact of popular culture, advertising, and art on how perceptions to smoking have changed, and the solutions on how we can end nicotine related deaths for good.
Part One — How Smoking became a burning sensation
It is believed that humans began smoking over 7 millenniums ago, primarily in religious rituals — and there is evidence of Tobacco use dating back to ancient Peru and Mexico. It would take another 6500 years for the habit to reach Western Civilisation however, with Tobacco being introduced by Sir Francis Drake upon his return from the New World in the 1500s. It was initially seen as a form of medicine, much like Tea and Opium at the time, although it quickly came to be used for recreational purposes — so much so that efforts were being made all over the continent to restrict its use. The Catholic Church opposed it on the grounds that it was ‘sinful’, and King James I called smoking:
‘a custome loathsome to the eye, hatefull to the Nose, harmefull to the braine, dangerous to the lungs, and in the blacke stinking fume thereof, neerest resembling the horrible Stygian smoke of the pit that is bottomelesse.’
These efforts made little impact, and even moral arguments were largely ineffective due to the lack of reference to Tobacco or smoking in the Bible and other Holy Scriptures. Although King James initially tried to curb the habit through a 4000% tax increase on Tobacco in 1604, he soon realised that moderate taxation and a monopoly on the market was a huge cash cow.
The Industrial Revolution of the 1800s further accelerated the trend in smoking, and the invention of industrial-scale cigarette rolling machines changed everything. Tobacco was now available in a relatively cheap and easily transportable format, and the implications were enormous, there was an almost exponential increase in smoking rates from 1860–1960. There were two other factors behind the rise in smoking rates: the two World Wars, where cigarettes were distributed to soldiers for free since they were seen as a ‘morale booster’, and the trend in commercialisation and branding, which I will focus on in the next.
The 1960s — the decade of the Beatles, the Vietnam War, the Counterculture, and the peak of smoking in Britain and the US. To Big Tobacco, all seemed great, with rising sales and a booming post-war economy. This was about to change however. Although smoking had been opposed for various reasons from the very start, the link between smoking and cancer had become undeniable by the 1960s as study after study confirmed it. This led to a change in tactics on behalf of the Big Tobacco companies, with a massive focus on advertising and branding to combat declining sales. Cigarettes were no-longer a standalone product; they were now tied to a brand — the brand being a reflection of the self. The company which no doubt did this best and changed branding forever was Philip Morris International, who owns the Marlboro brand and created the infamous ‘Marlboro Man’. In doing so, PMI aimed to associate Marlboro Cigarettes with the image of masculinity, strength, adventure, and style. It worked. The brand went to having a <1% share in the market to becoming the largest (in terms of market share) and most recognisable brand worldwide. This was done in several ways, both through traditional advertising, but also through celebrity endorsements and product placements in TV shows — would Sex and the City’s ‘Carrie Bradshaw’ really be the same person without her packet of Marlboro Lights? PMI’s campaign spread like wildfire, with brands across the market trying to emulate it. Its appeal to younger people, especially adolescents, was key, as this is the prime age in which people become addicted to smoking, as we will see. Those who have never smoked before the age of 25 are unlikely to ever begin smoking. However, despite all their best efforts, the tide was slowly turning against Big Tobacco and smoking generally. Smoking rates were down 33% in 1970 from what they had been in 1960, and people began to fight back against cigarette advertising (the first bans came into effect in 1965, and were reinforced in 1980 by an EU directive). The trend was also visible in Art in works such as Mel Ramos’s ‘Tobacco Rose’, which ‘conjures a pinup girl from the colorful world of commercial advertising’. (SAAM)
As more and more studies confirmed the causal relationship between smoking and cancer, as well as the fact that tobacco companies were genetically engineering cigarettes to be more addictive — smoking began to be seen as dirty and as a sign of being uneducated. A study conducted by dating site Match.com found that 58% of respondents viewed smoking as being a ‘deal-breaker’, and smoking (and addiction in general) leads to an attitude of disgust. The abolition of smoking in businesses, restaurants, and other public areas in the early 2000's has further stigmatised the habit, the stigma having had a large impact on getting people to quit or not start in the first place. Once again, this is reflected in art, with works such as Duane Hanson’s ‘Supermarket Shopper’, a critique on consumerism, depicting the Smoker as overweight and unhealthy, and an overall burden on society. (Through this sculpture, Hanson is also showing the form that society is taking on as a result of excessive consumerism).
Where we have not seen a decline is in the developing world. As Western markets have come under increasing scrutiny over the past few years, Tobacco companies have shifted their focus to the Second and Third World. Smoking rates in China, Ukraine, and other NICs are much higher than in the UK and most of Europe, which causes increased health problems and places an ever-greater burden on the countries’ respective healthcare systems. Misinformation means that one of our only hopes at ending smoking-associated deaths — e-cigarettes — have been banned where they are needed most. What we need, both in the UK and (especially) in developing countries, is to look at the evidence and how smoking can end tobacco-related deaths for good. This will be the focus of part two of this article.
Part Two — A new frontier: Why Vaping is the Solution to ending Tobacco use
If we are to understand how we can end the deaths associated with the consumption of nicotine, then we must explore the science behind why smoking is so harmful in the first place. Whilst I was researching this topic, I was shocked at how much misinformation there was online, and at how hard it was to find the actual science behind why smoking is harmful. Whilst there are a vast number of sites online condemning smoking and referring to the long-term effects of smoking on health, very few sources actually explained why it is so harmful. Ironically, the website of Philip Morris International proved to be a rather good source — in their efforts to promote their IQOS line of heated tobacco and their IQOS MESH brand of e-cigarettes, the company have made publicly available the information that they, for decades, have tried to conceal and for many years publicly denied. (Atlantic)
Smoking is harmful because of the inhalation of thousands of combusted chemicals — one of which is Nicotine, the addictive chemical that smokers ‘enjoy’ (as the brain and body adapt and the smoker becomes addicted, smoking ceases to be an ‘enjoyable’ experience and instead becomes necessary to combat the symptoms of nicotine withdrawal. This phenomenon is known as ‘tolerance’). It is not the nicotine itself that is harmful, but the chemical reactions associated with burning the tobacco in order for it to be inhaled. When combustion occurs (combustion of any material, not just tobacco — which contains nicotine), it releases carbon monoxide, CO2, heavy metals, and tar, all of which are toxic to humans when inhaled. It is the burning process itself that causes cancer and is harmful to the body — the tar released when anything is burnt kills the cilia cells in the lungs, and the heavy metals inhaled interfere with metabolic processes. Breathing in any kind of smoke is harmful, including the exhaust from cars (Guardian), the smoke from cannabis, and the smoke released from herbal (non-tobacco) cigarettes that actors use. The smoke released from cigarettes is especially harmful due to the extra chemicals that tobacco manufacturers add to cigarettes — ammonia for instance, (the product used in cleaning products and fertiliser) is added to boost the effects of nicotine and leads to an increased pH level which destroys cells and causes mutations, which can lead to cancer. The combustion of tobacco releases over 6000 separate chemicals, of which around 300 are toxic, and over 70 are known to be carcinogenic. What’s more, smoking (as compared to vaping), is more addictive as a result of a group of chemicals in cigarettes known as monoamine oxidase inhibitors, which prevent the chemical dopamine (the chemical which stimulates a sensation of pleasure — released when one consumes nicotine, but also when eating fast-food or having sex — it is our body’s way of making us pursue ‘good’ things, but has not adapted to the modern world) from being broken down. This acts as an amplifier, which makes cigarettes even more addictive than e-cigarettes where these chemicals are not present. The question then, is how can we deliver nicotine, which in itself is not harmful, to addicts without delivering the thousands of other harmful chemicals which are inhaled when tobacco is burnt? The answer: e-cigarettes.
Countless studies have been conducted looking at the health impacts of nicotine. They overwhelmingly point to one conclusion: nicotine in itself is not harmful to adults. This is reinforced by studies which look at societies which consume tobacco in other forms, such as chewing tobacco or smokeless tobacco. In Sweden for instance, researchers looked at a popular product called ‘Snus’, a form of tobacco which is ingested orally by placing it in the upper lip area. The findings were that when nicotine is consumed in this form (without being attached to carcinogenic smoke particles), there was no increased risk of heart attack or atherosclerosis (the clogging of arteries). Although addiction in any form is a bad thing, it is better to be addicted to something harmless rather than something harmful (and has immense costs to health services across the world in time and resources consumed which could be used to treat other illnesses). This brings up another question — are vapes really much safer than traditional cigarettes? The answer is yes. Although in recent months we have seen a backlash against e-cigarettes (and the first ‘vaping death’) — the health issues related to e-cigarettes have been confined to the US and Canada, and not Europe. This is due to a substance known as ‘diacetyl’, which is banned in Europe. Other issues related to vaping (we have only seen these problems in the US) are all due to cannabis e-cigarettes, which operate in a grey area and are largely unregulated due to the status of cannabis (Vox), which is legal in some states, but illegal on a federal level.
The rise of JUUL and other new-generation e-cigarettes, which are stylish, slim, and inexpensive, will no doubt have an immense impact on converting the remaining smokers away from traditional cigarettes. Vaping, an activity once confined to ‘hipsters’ who blew out huge clouds of vapour and had futuristic-looking devices to deliver their nicotine, has completely changed. The new generation of devices, especially JUULs, are small, discreet, and can be used almost anywhere without attracting much attention. Created by two Stanford techies majoring in product design, they are undeniably made to appeal to the mass market and to a younger audience. E-cigarettes are also able to deliver nicotine in many different flavours, from ‘Lime Drop’, to ‘Banana Bread’. These products are not without controversy however, and critics point out that the modern and stylish look of these products is attracting young people to vaping, people who would not otherwise have begun smoking. Others point out that the different flavours available to those who vape are appealing to young people, and children especially. Whilst this is no doubt true, the flavours and modern conscious design are also a central reason as to why they are appealing to adults and are convincing them to switch. To address this, government and regulators must work with the industry and with psychologists to find solutions to this problem. However, banning these flavours is not the solution, as almost 99% of adults who switch to vaping say that they have done so because of these more appealing flavours.
Other policy changes should be made to facilitate and encourage the switch to vaping, whilst ensuring that those who would never otherwise have smoked do not begin to vape. One such policy would be allowing vaping in some indoor areas where children are not present, such as bars and casinos. The risk of allowing vaping in all public areas, whilst it would no doubt encourage many more smokers to make the switch, is that it could normalise the habit. This is problematic, as one of the key reasons why smoking rates have declined is because it is not seen as normal, and is instead stigmatised. Nicotine addiction should remain this way if we are to ensure that the rates continue to decline, however by allowing vaping in bars, adult-only sections of certain restaurants, and other building such as casinos — it would encourage many more people to make the switch and so improve health outcomes for everyone. The final policy that could be implemented to encourage a switch to vaping is the exemption of vaping products from VAT for 5 years. Whilst they are currently taxed at the standard 20% VAT rate, exempting vape products for 5 years would make their price markedly cheaper, which would encourage people, especially people amongst lower-income groups (the groups where smoking rates are higher), to switch for financial reasons. Although this may lead to a temporary decrease in government income, it would be balanced out by the savings made to the NHS as fewer people will require treatment for smoking-related diseases.
What is clear is that the debate on smoking must continue. We must seek to find evidence based solutions if we are to truly end nicotine associated deaths and nicotine dependency. It will be important to learn from other countries, as well as to pay attention to what scientists and public health researchers have to say. Please feel free to share any you have on this issue on my Facebook page.