The bioethical implications of going ‘smokefree’
Several countries are introducing prohibitionist policies to reduce smoking - but what does bioethics tell us about the efficacy, safety, or fairness of these policies, by Francisco Blancarte Jaber
In 2018, the UK government pledged that England would be ‘smokefree’ by 2030. In practice, this target translates to reducing smoking rates to 5% or less by the year 2030 (Scotland’s aim is to reach these levels by 2034). These discussions come in the wake of similar plans proposed by New Zealand’s government as part of their policy goal of being an entirely smoke-free country by 2025.
Both proposals take their cue from the WHO’s Tobacco Free Initiative, in which the stated goals are “to achieve the lowest possible level of tobacco use prevalence and the highest level of protection from second-hand smoke”.
Opinions and reactions to these proposals have been varied, with no shortage of pushback from political analysts. It is crucial to point out that the UK government’s plan does not intend on criminalising the sale of tobacco products entirely.
New Zealand’s initiative, however, does include a proposal to ban the sale of tobacco products to persons born after January 1st 2004: “A smokefree generation policy would prohibit the sale, and the supply in a public place, of smoked tobacco products to new cohorts from a specified date. For example, if legislation commenced on 1 January 2022, then people younger than 18 years at that time or those born after 1 January 2004 would never be able to lawfully be sold smoked tobacco products.” 
Comparison to drug and alcohol prohibition
Arguments against these proposals range from concerns over ageist discrimination to pointing out the ineffectiveness of legal bans on psychoactive, addictive substances, which only lead to the creation of black markets. Only last year, South Africa banned the sale of alcohol due to the Covid-19 crisis, which led to a sharp increase in people illegally making their own alcohol, with all the health risks that implied.
There is also a sense in which these bans seem to be historically myopic. The alcohol prohibition era in the United States during the 1920’s, and the resulting emergence of organised crime syndicates, are an often-cited case-study in the ineffectiveness of prohibitionist measures.
It also seems to go in the opposite direction of recent, and very successful, decriminalisation approaches, such as Portugal’s National Drug Strategy of 1999, which sought to abolish all criminal penalties for personal drug possession.
Some arguments against extremely punitive measures towards drugs indeed point out that alcohol and tobacco represent a far greater cost of life and burden to society, and so the seemingly hypocritical stance against comparatively less dangerous substances.
For example, the Office for National Statistics in the UK reported that in 2019, there were 7,565 deaths registered in the UK that related to alcohol-specific causes, the second highest since the data time series began in 2001. Compared with the reported number of 2,883 deaths relating to drug misuse registered in 2019, and considering the fact that this number included the dozens of illicit drugs controlled under the Misuse of Drugs Act 1971 combined, there is a fairly strong case against the harsh punitive measures focused on illicit substances.
There is a danger, however, in following this line of argumentation to its logical conclusion. A comparative argument between the harms of licit and illicit substances fails to understand a core issue of drug misuse and addiction. A person may seek out psychoactive substances for a variety of reasons. Usually to numb their pain, suffering or the trauma that they are self-medicating with substances.
But rarely does their thinking weighing up what is the less risky substances to choose. Many authors have argued that legality is scarcely a motivating factor strong enough to discourage the continuation of drug misuse among those who are addicted.
It is then understandable why some are skeptical about the effectiveness of tobacco bans. People addicted to drugs will continue to exist. Forcing them away from legal and regulated products towards the underground, unregulated illicit drug markets will only expose people to greater risks to their health and safety.
To be clear, the tobacco ban proposals, and the WHO initiative from which they are derived, have good intentions: stopping future generations from being exposed to certain substances could nip the problem in the bud and so improve their long-term health.
But, this asks the question of how to actually enforce such a ban. If the measures were effective, from an enforcement point of view it is easy to see the concerns over authoritarianism.
Certain Southeast Asian countries have very strict drug laws, and overreach of police interventions and presumptions of intent of trafficking (which can be subject to capital punishment) are commonly cited abuses of power in countries like Singapore, where organizations like Amnesty International have lobbied for amendments to exaggerated death penalty sentencing practices.
What about other harmful but legal substances?
From another speculative point of view, a concern over the slippery slope argument comes to mind. Indeed, alcohol and tobacco cause great harm and death every year; but so do refined sugar and high-calorie foods. Cardiovascular diseases (CVDs) are the leading cause of death globally. An estimated 17.9 million people died from CVDs in 2019, representing 32% of all global deaths.
Does banning tobacco on health grounds make a similar fate for refined sugar foods and saturated fats seem more likely? Well, maybe.
This has effectively already been put in practice in school canteens in the UK, where a ban on fizzy drinks and junk food (including the now-infamous Turkey Twizzlers) was implemented in 2006. But this was not an outright ban on them for all regardless of age or maturity.
And again, prohibition once again led to people breaking the rules, with reports of parents passing their children takeaway food through the school gates.
Banning junk food for adults might seem like an overstep - or even a nonsensical idea. But it shows the underlying (bio-)ethical tensions in the debate around banning tobacco.
If someone is old and mature enough to make decisions about their health, do they not have a right to choose? Even if it is not a healthy or seemingly sensible choice. Do we have a right to make unhealthy choices? It is precisely this type of ethical concern that seems to be missing from the discussions around the proposed bans on tobacco.
Alternatives to prohibition
This is not an argument for a total absence of regulation. Nor is it a defense of a libertarian state where collective public health is delegated to individual choice.
It is, however, a suggestion for alternative public health proposals. A reinforced focus on social determinants of health and health outcomes from illness would not only give more effective results in combating addiction, but they would also do it without restricting individual freedoms.
The WHO’s Tobacco Free Initiative takes into consideration such determinants – including education, social and economic welfare, and other measures of inequality - to form their global health proposals.
For example, a report published in 2019 by the Norwegian Institute of Public Health, showed the percentage of the smokers in all Nordic countries (Iceland, Norway, Sweden, Finland and Denmark) was up to four times higher for people with primary education than those with degree-level education.
It is troubling and worrisome then, that governments would draft policy goals that aim for a society to be ‘tobacco-free’ through prohibitionist approaches, instead of reinforcing the public health measures that address the health and social inequalities inherent to the problem of tobacco addiction in the first place.
 Department of Health and Social Care. Advancing our health: prevention in the 2020s – consultation document. July 2019. https://www.gov.uk/government/consultations/advancing-our-health-prevention-in-the-2020s/advancing-our-health-prevention-in-the-2020s-consultation-document
 Scottish Government. Raising Scotland’stobacco-free generation: our tobacco control action plan 2018. June 2018. https://www.gov.scot/publications/raising-scotlands-tobacco-free-generation-tobacco-control-action-plan-2018/pages/4/
 Gene M. Heyman, Addiction: A Disorder of Choice, 2009; Nora D. Volkow & Ting-Kai Li, Drug Addiction: The Neurobiology of Behavior Gone Awry, in PRINCIPLES OF ADDICTION MEDICINE, 2004.
 Garde, A., Davies, S., & Landon, J. (2017). The UK rules on unhealthy food marketing to children. European Journal of Risk Regulation, 8(2), 270-282.
 Indicators for health inequality in the Nordic countries. (2019). Retrieved from https://issuu.com/nordicwelfare/docs/health_inequality_final/1