Hypothetical Scaling

I do like it when someone poses an intriguing question on Twitter (or anywhere for that matter) that gets the ol’ grey matter churning. Not only does it make me think, it also makes me consider the implications of my own thinking – which is largely based in personal experience and opinion (on particular subjects), with some foundation in fact.

This question, posted by Gillian really got me thinking.

In order to reduce smoking rates, where would I place “cessation” on a scale? It’s a tricky one that is full of implications. In this instance I’ll be using a “standard” scale of 1-10.

My initial thinking is that cessation on its own would rank poorly – somewhere around 2. But let’s look at this a bit closer. What exactly is “cessation” and how is it driven?

The “what” is an easy enough answer – the end of smoking. The second part is a lot more complex. There are various programmes in action worldwide, and taking an overview look they are all driven by similar underlying principles – coercion. We’ve seen on Twitter how some services use, shall we say less than salubrious tactics to get smokers to take a look at themselves in a negative way – part of the stigmatisation principle. There are of course other examples that use better language and are more encouraging to smokers looking to give up.

But here’s the crux of why, in my opinion, cessation on its own ranks poorly – how do you get smokers to convince themselves to give up smoking? This is a large point that is sorely overlooked by all cessation practices. Not one of them, even those that have former smokers in their ranks, are working towards encouraging smokers to change their minds. Many smokers now are deep in the mindset of “I smoke because I enjoy it and I want to smoke” – the hardening effect (which does exist Simple you dunderhead) – no matter what encouragement or advice is offered, those that want to smoke will not stop.

That is a very broad and simplistic view of course as there is some evidence that the “hardening” is actually softening, but I doubt that is anything to do with the approach taken by cessation services on their own – their messaging hasn’t really changed. The “best thing for smokers to do is quit for good” type line that keeps getting trotted out, which is of course true it is the best thing for smokers if they want to. Key point. Getting smokers to believe they want to quit is not the same as getting them to quit. Two different goals, which is why cessation on its own can possibly be self-defeating as it is but only one aspect of the whole “problem”.

There are of course many ways to address the “smoking problem” (not that I believe there is one in this context) as cessation is but one part. Supply & Demand. Cutting the supply would have an effect, for a short while but those smokers that don’t want to quit will find ways around that – black market trade, grow your own are two examples of how smokers will continue despite a legitimate supply shortfall. Theoretically there could be limits imposed on manufacturing, but that’s unlikely to stick and will most likely lead to other sources being utilised.

The trick therefore would be to cut demand. Policies exist to try and mitigate that demand, but on their own they don’t work. Sustained campaigns from public health groups and sock-puppet charities have done little to curb the demand – in fact, as Clive Bates points out here, the sustained “war” has had the complete opposite effect on the tobacco industry, they’ve grown and at a far greater scale than before the policies and the whole “war” started. Yes, smoking prevalence has fallen but until recently it’s been stagnant. Even Australia, where they have some of the “toughest” laws have noticed a drop in the prevalence decline. Despite all their “interventions” including eye watering excise taxation, plain packaging, bans, age restrictions and the continual re-emergence of the “smokers license”.

So what to do?

Decreasing demand isn’t a straightforward affair – taxation only has a limited lifecycle viability before there’s zero return for the effort expended. Plain packaging simply does not work as the majority of smokers don’t care about the packaging. Bans are merely an inconvenience and have substantial unintended consequences for other industry sectors. Of course the other method is stigmatisation – making smokers feel bad about themselves, which of course works so well doesn’t it?

Is there a straightforward answer? Not really no. Clive has his own thought processes detailed here, though I highly doubt we are anywhere near an “endgame” scenario – let’s face it, other than banning smoking in public places (including cars, and if some cretins get their way your own home if you happen to work from there occasionally), tobacco control has been pissing around the edge of the “problem”.

There is no one simple solution to bring prevalence rates down (nor I think should it really be necessary, but that’s just me) – effective solutions need to be elastic to fit the scenario. There needs to be a support network in place to help those that want to quit_ _this network is not for encouraging people to quit, but for supporting those that want to – a marked difference. There needs to be an infrastructure for incentivising cessation – which could take many forms, a simple “quit smoking to buy a car” won’t cut it, it needs to be fungible. The methods available for cessation need to be as broad and varied as possible – any and all methods should be embraced, endorsed and supported.

Smokers who want to quit should be able to enjoy the opportunity not feel like they have to because someone told them they smell, or that smoking rots their teeth or any other ridiculous nonsense – those in public health and tobacco control have forgotten, quite deliberately, that smokers are real people and a lot of them are frankly pissed at “The Establishment” for their treatment. Not to mention the continual digs by members of the public – imagine that, state sanctioned bullying – natch.

If they really wanted to bring the prevalence rates down, they need to understand the people who smoke. But then, it’s never really been about health has it?