The Khan Review: Making Smoking Obsolete

The Khan Review: Making Smoking Obsolete Oliver Norman

The Khan Review: Making Smoking Obsolete

The results of a landmark review of the UK’s Stop Smoking Services (SSS) are in, and 15 clear and challenging actions have been recommended that would overhaul the national cessation remit if passed by parliament. The ramifications of ‘The Khan Review’ could redefine the way smokers and vapers go about their daily lives.

For some time now the UK government has been ramping up its focus on the issue of national smoking rates. The damaging risks of smoking encompass more than just individual health and wealth, but also apply massive pressure to an already strained NHS. To make matters worse it has been recognised for some time that these issues are hitting our least privileged communities the hardest, with smoking rates far higher amongst poorer areas across the nation.

The years since 2019 have been particularly dramatic, with lobbyists, healthcare experts and politicians ramping-up the debate on tackling smoking rates; all with a view to bringing the current 15% national rate down to 5% or below, to hit the official target of a ‘smokefree 2030’. Fears have mounted however that, if current SSS resources remain unchanged, this target will not be hit.

Propositions to correct this issue have been making headlines for some time both domestically and abroad. New Zealand for example has introduced a strict new policy that means people born after 2008 can no longer buy tobacco products at all. Closer to home we have seen recommendations to print smoking kills on individual cigarettes as an enhanced deterrent. Even vaping, which has been the subject of taboo for years when mentioned as a cessation tool, is now being thrust into the spotlight. A landmark NHS vaping trial, followed swiftly by a call for manufacturers to submit vaping devices for medical licencing to the MHRA.

A Plan to Make Smoking Obsolete

In a likely response to the propositions made to date, and the growing concern of missing the 2030 deadline by a significant margin, UK health secretary Sajid Javid has taken action. He commissioned Dr Javed Khan OBE, former Barnardo’s CEO turned anti-smoking tsar, to build a plan to level-up SSS nationwide, and fill the gaps to make a smokefree 2030 possible.

Khan has picked apart every aspect of the UK’s SSS, and has now published his official findings, with 15 key recommendations, backed by substantial evidence, that could turn the tide in the battle against smoking. Of these 15, only four have been flagged as ‘critical’. These are must-do’s according to Khan, who states that if any meaningful progress is to be made, must be heeded by parliament.

The 15 actions have been divided into a 4-stage plan, with each area focussing on specific changes that would completely reshape the way smoking, cessation, and even vaping are approached by the general public. Each stage includes one of the four critical actions raised, with an intent to create a holistic upgrade to SSS, even if government engages in the most minimal way. His goal is to create an environment where, from the earliest possible age, people are discouraged from smoking, and current smokers have second-to-none support in quitting for good, rendering it effectively obsolete in society.

Khan wants to shine a new light on the smoking issues in the UK, stating in his review that “Most people don’t see smoking as a problem anymore. As a nation, we’ve moved on. Smoking in restaurants, pubs and clubs has long gone. It’s no longer common for living room ceilings to be stained yellow from chain-smoking in front of the TV. You have to be my age to have any memory of tobacco adverts on TV and billboards. The problem is less visible.”

He reminds us that despite reduced visibility, the facts remain:

  • Almost 6 million people still smoke in England
  • smoking remains the single biggest cause of preventable illness and death
  • approximately 64,000 people are killed by smoking each year, that’s around twice as many people as have died from coronavirus (COVID-19) in the last 12 months.
  • when used exactly as recommended by the manufacturer, cigarettes are the one legal consumer product that will kill most users – 2 out of 3 smokers will die from smoking unless they quit.
  • in 2019, a quarter of deaths from all cancers were connected to smoking.
  • smokers are 36% more likely to be admitted to hospital and need social care 10 years before they should.
  • around one third of adult tobacco consumption is by people with a current mental health condition, with smoking rates more than double that of the general population.
  • people with mental health conditions die 10 to 20 years earlier, and the biggest factor in this is smoking.
  • smokers lose 10 years of life, or around 1 year for every 4 years of smoking after the age of 30.
  • the annual cost to society of smoking is around £17 billion with the cost to the NHS alone about £2.4 billion – this dwarfs the £10 billion income from taxes on tobacco products.
  • making smoking obsolete in England would lift around 2.6 million adults and 1 million children out of poverty.

He goes on to comment:

“During this review, I have asked myself, "if cigarettes had never existed and were invented tomorrow, what would happen?" The answer was simple. They would not be legalised. They would not be allowed into our shops and supermarkets.”

It is for these reasons and more that he has stressed the vital impact of ratifying his recommendations. Without change, Khan has confirmed fears that the 230 deadline will be missed by at least 7 years – with positive impact being felt by the poorest and most vulnerable in society by as late as 2044.

Step One – Invest Now

The first stage of Khans action plan includes only one ‘critical’ recommendation, with 3 options to achieve it. The clue is in the name, this area of focus is all about injecting additional money into SSS to give it the agility needed to meet demand and provide the level of care to help people achieve long-term goals.

He recommends that and additional £125 million be invested to reach the 2030 target. This includes investing an extra £70 million per year in stop smoking services, ringfenced for this purpose. Khan has acknowledged the financial pressures faced in the wake of Brexit, COVID and the war in Ukraine, and as such states that “If the government cannot fund this themselves, they should 'make the polluter pay’ and either introduce a tobacco industry levy, or generate additional corporation tax, with immediate effect.”

Polluter Pays

Khan has expressed his belief that individual taxpayers should not bear the burden of funding a solution to a problem they didn’t create. He said “I am asking why should taxpayers have to pay for the health and other consequences of the tobacco industry’s lethal products?”.

He highlights that despite high duties of circa £10 billion annually, the tobacco industry makes significant profits of £1 billion per year in the UK alone, with far more being made internationally. He goes on to point out that the profit margin on tobacco products is significantly higher than the margins on any other staple consumer products – being as high as 67% compared to the average 12% - 20% typical of other industries.

A tobacco ‘polluter pays’ levy could be introduced in the form of a charge applied as a percentage of these profits. This already has wide public support. A recent Action on Smoking and Health (ASH) and YouGov survey suggests that 76% of adults support a levy. In addition, a levy was put forward by the All-Party Parliamentary Group (APPG) on Smoking and Health in their own 2021 report on delivering a smokefree 2030. The smokefree 2030 fund model, developed by ASH, projects that this could raise £700 million each year across the UK.

Corporation Tax Surcharge

Another option to source the funds for Khan’s plan would be to enforce a tax surcharge for manufacturers of tobacco products, similar to that already in place for banks – it would be a percentage of their profits. Alternatively, it has been suggested the amount could be scaled based on the market share of the manufacturer, meaning the biggest contributors to the problem would pay more and vice-versa.

Either approach targeting the tobacco giants has seen significant approval not only from the public but also in government, with Professor Chris Whitty, UK Chief Medical Officer commenting:

“The tobacco industry makes its massive profits from getting young people addicted to smoking, something that will kill or severely disable many of them. It drives a high proportion of cancer deaths, heart disease, stroke and chronic lung disease, and is the preventable cause of many of our health inequalities. Second-hand smoke also harms non-smokers."

Step Two – Stop the Start

This section of the Khan Review is focussed on youth access prevention, as well as developing a societal norm that smoking is not welcome. This would be achieved through recommendations two through seven.

Raising the Legal Age – Critical

Similar to the steps taken in New Zealand, Kahn wants government, at the very least, to raise the national smoking age from 18, by one year, every year. This would make smoking less and less accessible for each subsequent generation, with many never being legally able to buy the products at all.

Khan notes that “Current smokers would not be prohibited from their addiction, but over time this action would help to protect millions of children and young people from ever becoming addicted. It will create a future society where smoking is no longer in demand or even relevant, as the legal age of sale to smoke tobacco becomes higher and future generations avoid becoming addicted to this deadly and costly practice.”

The review highlights that the positive impact this type of action has already been observed in the UK, with a 30% reduction in smoking rates amongst younger demographics when the legal age was raised from 16 to 18 in 2007.

Simon Clark, director of the smokers' group Forest, said: “Creeping prohibition won’t stop young adults smoking. It will simply drive the sale of tobacco underground and consumers will buy cigarettes on the black market where no-one pays tax and products are completely unregulated.” With many others claiming it would restrict personal freedoms.

Sir Chris Witty has once again backed the idea however, claiming attempts by tobacco lobbyists to make any debate around smoking legislation about health vs freedom are 'dishonest'. Saying the tobacco industry has addicted millions of Britons 'at a very young age'.

Reinvent tobacco design

Following in the footsteps of printing smoking kills on cigarettes, Kahn has advised drastic updates to the aesthetics of tobacco products, with an intent to making them unappealing to anyone, but especially the young. He would see a literal “life wasted” countdown printed on them, so the smoker has to ‘watch their life burn away as they smoke’, with the time lost quantified before their own eyes.

This would come in tandem with packaging redesign beyond the current green/brown we’ve gotten used to seeing, and significantly more negative portrayals of smoking in media, with actual health warnings to be displayed on-screen whenever a character smokes in a scene in a TV show or movie.

Retail Restriction and Enforcement

Unsurprisingly a major focus of Stop the Start is to provide an additional £15 million to trading standards, allowing them to more effectively police the restrictions already in place, as well as the additional rules Khan has put forward. These include stricter licences for local retailers, but total bans on selling tobacco for all major supermarkets.

If put in place, this would massively reduce the availability of tobacco to anyone who may want to smoke, and make life for those attempting to quit, that much more temptation-free. The implications on profit margins and retailer livelihoods however must be carefully considered here. Unless vape kits and e-liquids replace tobacco on shelves, and in popularity, local shopkeepers could feel the pinch.

Smoking Ban Outside Bars, Restaurants and Outdoor Areas

Another idea that could have drastic financial ramifications from loss of footfall for an already ailing hospitality industry. Recovery from the impact of lockdown is still ongoing, and presents many businesses with hardships. A decision to outlaw smoking anywhere near these premises could drive a large portion of customers away – only time will tell how the industry might adapt to this.

Ultimately Khan seeks to prevent as much public exposure to smoking as possible, for both young and old. He would call for not only hospitality areas to see expanded smoking bans, but also the creation of more and more smokefree zones”. These are outdoor areas like parks and beaches, which Khan would have ringfenced from smoke and possibly even vapour if his recommendation passes into law.

No More Duty Free

A twofold attack, Khan wished to not only make tobacco products unaffordable by raising duties by more than 30% beyond their current levels, which are already high. In addition, duty free import would become illegal, with free entry abolished at UK borders.

Step Three – Quit for Good

One of the most interesting actions from Khan’s plan falls within the third section, focussed on giving people the tools and support to help them quit permanently. Recommendations eight through ten are designed to ensure this can happen. Alongside plans to invest a ringfenced £70 million into SSS, Khan asks for an annual £15 million towards media campaigns inspired by the success of the social media-led covid safety campaigns. The critical action identified here however, shakes one of the biggest taboos in smoking cessation.

Offer Vaping as a Substitute to Smoking - Critical

This does not only mean getting approved vaping devices and e-liquids into SSS organisations; Mr Khan also seeks to ensure accurate education is provided not only to the public, but health experts as well.

The review identifies that there has been a significant volume of misinformation, and a general lack of understanding at all levels of society about the benefits vaping can offer potential quitters. He notes that this lack of education has effectively prevented numerous people from accessing vaping as an alternative, stunting it’s ‘massive potential’ to help those who most need it.

Ultimately Khan wants to see a healthy SSS, with adequate funding to provide the level of care required to achieve the nations goal of a smoke free 2030. He notes that “Well-funded SSS are extremely cost-effective and form a key part of improving health outcomes and reducing the health inequalities gap. “

“They significantly improve people’s chances of quitting smoking for good. This should be reflected in effective local commissioning, with updated guidance showing what the universal offer for every SSS should be, weighted to smoking rates in local areas to allow us to level up the communities which need it most. An effective helpline is vital to provide a route into quitting: a central point of contact for the public and a central number for advertising campaigns.”

He wants broader recognition of the role vaping should already be playing in helping people to leave smoking behind, stating that:

“There is lots of confusion, even misinformation, about vaping. The most common relates to its harm. I have spoken to the very best academics and scientists across the country and internationally. They all told me that vaping is far less harmful than smoking. In cigarettes, we know that it is not the nicotine that kills you but the other thousands of toxic chemicals such as tar and carbon monoxide. Vapes give smokers the nicotine they crave but protect them from the toxins they would inhale from a cigarette.”

He goes on to acknowledge that some might argue that “people should be encouraged to quit all forms of nicotine”, however he stresses that the “overriding public health priority” is to get people to quit “as quickly, completely and permanently as possible”. The review states that vaping shouldn’t be flippantly regarded as a “silver-bullet” solution, or that they are risk-free, however “the research we do have is clear that they are at least 50% and probably closer to 95% less harmful than a cigarette”.

You can learn more about the effectiveness of vaping and other NRTs like patches and gums when quitting smoking in our blog, Finding the Right Alternative.

Step Four – System Change

The fourth and final stage of Khan’s holistic approach to overhauling cessation resources focusses on long-term, impactful change to the systems and institutions tackling smoking. Once again there are a number of recommendation from 11 to 15 that include injecting more funds into SSS and the NHS. Beyond this we can see he is calling for better research and more recognition of the impacts of smoking on mental health, not just physical.

NHS Should prioritise prevention – Critical

Khan wants the NHS to take stronger action against smoking, by upscaling treatment and primary care across all it’s services, with a specific focus on smoking prevention for first time users and also to prevent relapse. He wants hospital trusts to provide more reports on progress in this area, and also promote broader messaging against smoking in general.

He notes that, “People listen to their healthcare professionals individually, but they also listen to the NHS collectively. So, it’s important that the NHS is providing messages to patients through VBA and the Better Health campaign, but also providing wider stop smoking messaging as an organisation. The NHS communications campaigns and communications channels are a key opportunity to direct smokers to treatment and remind them of the risks. Senior leaders in the NHS need to champion prevention and stop-smoking treatment as an organisational priority.”

Extra Support for Pregnant Women

Khan wants an annual sum of £15 million to be made available to support pregnant women and get them to stop smoking. He states that “Smoking in pregnancy is a leading cause of health inequality for mothers and babies. It increases the risk of stillbirth, miscarriage, and sudden infant death syndrome, and babies born to mothers who smoke are more likely to be born underdeveloped and in poor health.”

While not only improving the lives and wellbeing of mothers and children, Khan highlights the benefits to the NHS itself. With the support he intends to provide, “tackling smoking in pregnancy would save the NHS up to £87 million a year, just in terms of the costs of treating complications during pregnancy”. He goes on to note that this does not take into account the cost of treating infant diseases as a result of maternal smoking.

Tackling Smoking and Mental Health

The links between nicotine addiction, smoking and mental health are unavoidable. Anyone who smokes or has smoked understands the perceived ‘stress-relief’ of lighting up. The reality though has been consistently proven to be the contrary, nicotine and indeed the other harmful chemicals in cigarette smoke can have an incredible impact on a person’s mental health, which you can learn more about in our blog, Nicotine and Health.

There is a direct correlation between existing mental conditions and smoking rates too – those with a diagnosed mental health condition are statistically more likely to be a smoker, with the effects of nicotine on specific conditions ranging from minimal to profound. Khan states in his review that “1 in 4 of people who seek medicine to help them quit smoking are currently taking antidepressants”.

Dr Adrian James, President, Royal College of Psychiatrists said: “It’s a myth that smoking is beneficial to mental health. This misconception undermines progress towards improving the health of our nation, both physically and mentally, and allows a vast number of people to justify a habit that is killing them.”

Khan’s final point on the matter is poignant: “People with mental health conditions die 10 to 20 years earlier, and the biggest preventable factor in this is smoking.”

In Conclusion

The Khan Review presents possibly the most radical approach to tackling smoking rates seen in the UK for many years. There has already been some backlash against his recommendations, however the majority have been hailed as a welcome change to limp wristed attempts in the past.

Medical experts like Chris Whitty and beyond are in full support, taking up torches in the tobacco giant witch-hunt, that we leave up to you to decide if it is justified!

The future for vaping seems bright however, if parliament only action Khan’s 4 critical points, we will almost certainly see vaping products take a long-overdue place amongst established options for people who want to quit smoking, only time will now tell how many, if any, of the proposals make it through parliament and into British law.

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