Smoking is a public health issue
It is now a matter of common public acceptance that smoking causes ill health. This statement can be backed up by huge amounts of authoritative literature (Dobson et al 1999) (Smoking Kills 1998) (Choosing Health 2001)
The subject of this essay however, is whether or not it is a Public Health issue. We will argue strongly that it is and produce evidence to support this stance.
The Wanless Report (2002 ) defines Public Health as The science and art of preventing disease, prolonging life and promoting health through organised efforts and informed choices of society, organisations - public and private, communities and individuals
On that basis we would suggest that the argument is already made since there is little doubt that smoking - both active and passive - will shorten life and cause disease.
The evidence to support this statement comes from papers such as that by Prescott ( et al. 1998) who carried out a huge study looking into the effects of primary smoking and the risk of myocardial ischaemia in the general population. The results of the study were absolutely unequivocal with a finding of an increased risk of myocardial infarction in women of 2.24 and in men of 1.43. the reasons for the sex difference are several including genetic factors (Bennett 2004) and hormonal factors (Chapman 1999)
To take a step further back, we have to define Health
An authoritative definition of Health comes from the WHO who currently tell us that health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity. ( WHO 1992). A difficulty with this definition is that today many people confuse the attainment of happiness with the attainment of health (Kemm 2001). Ironically, in the context of this essay, Freud also offered us an observation on the definition of Health when he observed that most people equated well-being with happiness rather than health (Freud 1975) and he amplified this by observing that he had been advised by his doctors to give up cigars in order to improve his health. He commented that he was far more healthy but much less happy (Saracci 1997).
Although Freud's comment was clearly flippant, it does exemplify a deeper truth, that part of the problem with smoking is the pleasure that some people derive from it. One can always advance the argument that in a free society one should always have freedom of choice to damage yourself if you wish. (Hegel 1971)
That is clearly the case, but in adopting that view you must also accept two further consequences of that position. One is that society is expected to pick up the bill when you are ill (via the NHS) and that by smoking, you may not only damage yourself but you may well damage others through the medium of passive smoking. (Kuhse & Singer 2001)
It is these latter points which actually make the issue one of Public Health.
The Public (in general terms) are expected to fund the necessary treatment when you become ill. This is not an isolated incident as over 200,000 patients are diagnosed annually with some form of smoking related malignancy and over 120,000 will die from the disease. This is quite independent of those that develop other complications of smoke-related illness. (NHS Cancer Plan 2000). If you add to this number, the carers and the other economic costs to the community, the argument that it is not a Public Health issue clearly fails.
We have raised the issue of passive smoking as one of the criteria for suggesting that smoking is an issue of public health. The evidence for this is rapidly accumulating. We can point to the cleverly designed study by He (et al.2004) which was able to point to the statistical differences in illness rates between those industrial workers who had a constantly smoky atmosphere to breathe and those who were able to avoid it. There is little doubt that choosing to smoke where others will inhale the smoke is a demonstrably anti social behaviour.
As if to underline our view, we can point to the fact that the Government takes a similar view as it has produced a series of Government White Papers (Choosing Health 2004) (Building on the Best 2003) and regulations (Saving lives 1999) which are all aimed at improving the health of the nation by reducing its collective exposure to cigarette smoke
Bennett & Gottleib 2004 Passive smoking more risky for women with a missing gene. BMJ: 2004 Vol 26 320-322
Building on the best 2003 Department of Health: HMSO. 09/12/2003
Chapman S 1999 Smoking and Women: beauty before age? BMJ, Mar 1999; 318: 818.
Choosing Health 2004 Government White Paper consultation on improving people's health 28.6.04 BMJ, Dec 2004; 319: 1522.
Dobson et al, 1999; National Centre for Social Research, RCP, 1999;
Freud S. 1975 Letter to Lou Andreas-Salome, 1930 May 8. Cited in: Sigmund Freud house catalogue. Vienna: Löcker and Wögenstein, 1975: 49.
He, T H Lam, L S Li, L S Li, R Y Du, G L Jia, J Y Huang, and J S Zheng2004 Passive smoking at work as a risk factor for coronary heart disease in Chinese women who have never smoked BMJ, Feb 2004; 308: 380 - 384.
Hegel GW. 1971 Philosophy of Mind: Being Part Three of the Encyclopaedia of the Philosophical Sciences (1830). Wallace W, trans. Oxford: Clarendon Press; 1971.
Kemm 2001 The pursuit of happiness Cancer Nurs. 2000;23(1):20-31
Kuhse & Singer 2001 A companion to bioethics ISBN: 063123019X Pub Date 05 July 2001
NHS Cancer plan 2000 A plan for investment, a plan for reform Department of Health. HMSO. 27/09/2000
Prescott, Merit Hippie, Peter Schooner, Hans Ole Hein, and Jørgen Vestbo 1998 Smoking and risk of myocardial infarction in women and men: longitudinal population study BMJ, Apr 1998; 316: 1043 - 1047
Saracci R 1997 The world health organisation needs to reconsider its definition of health BMJ, May 1997; 314: 1409.
Smoking Kills1998 A White Paper HMSO: December 1998
Wanless report: HMSO 2002 World Health Organisation. 1996
Ethics and health, and quality in health care-report by the director general. Geneva: WHO, 1996. (Document No. EB 97/16.)