England goes smoke-free - wider lessons

Long awaited 1st of July arrives, and most enclosed workplaces (including pubs and restaurants) in England will go smoke-free today [BBC]. It's a triumph for all involved - both campaigners and government insiders - following a sustained struggle. It's also a vital next step in dragging down smoking rates - see chart based on ONS and Tobacco Advisory Council data care of Cancer Research UK, [XLS]. Still at about 25%, that's a huge number of people using an addictive product that kills one in two long term users - and does a lot of damage before death.

The ban on smoking in public places has always been justified around protecting non-smoking workers, for which there is the strongest civil liberties and legal basis, but its biggest public health benefit will come from 'denormalising' smoking - removing the societal support for smoking as a normal activity and role-modelling effects - and raising the cost of smoking in terms of time and hassle. The effect should be an acceleration in quitting and fewer starting.


There is widespread support for the ban - 79% agree with it [ONS summary] and a surprising level of support for the ban amongst smokers - 79% of smokers favour a ban in restaurants and over a third in pubs see [ONS full report Table 7.1], a high proportion of whom say they will try to quit [YouGov survey]. The remarkable feature of smoking is that over 80% of smokers say they wouldn't do it if they had their time again, over 70% would like to quit. Most have developed protective mechanisms to rationalise the 'cognitive dissonance' that arises from continuing to do what you don't want to be doing - for example, believing that you will quit much sooner than you are likely to in reality - a idea we once termed a 'delusion gap' [see BMJ article for discussion as above] and a ban on smoking in public places will strengthen the dissonance and weaken the defences.

As recently as 2003 and whilst working in public health, I thought this was still a distant, if inevitable, prospect. But the rapid change of outlook has many lessons for government (and me). Here are some:

• Value the "slow wins". Larger changes in attitudes and what people are willing to accept are possible, given time, sustained effort, credibility of purpose and consistent direction of travel. I think time is underused in policy-making - too much effort goes into to small (usually botched) 'quick wins' and not enough into 'slow wins'. The smoking ban is a culmination of stepwise changes starting as early as 1604, when King James I slapped a tax on tobacco, but more recently, linking of smoking to disease by doctors in 1961, restrictions then bans on advertising, ever more grim warning labels, increasing visceral anti-smoking advertising campaigns, high and escalating levels of tobacco tax, stop-smoking services in the NHS etc. In the 1980s, a smoking ban would have been unthinkable - but the accumulated changes in attitude arising from this long war of attrition (plus some inspired campaigning by my successors at ASH and many others) made it possible in 2007. Today's result has been 50 years in the making and the chart shows the long term change achieved...
  

Governments overestimate their power to achieve change in the short term, and underestimate it in the long term (Geoff Mulgan, Prospect)

• Aim for culture change. Policymakers can't go far beyond what the public will wear and still be elected, but they can simultaneously stay within, but also extend, the envelope of what the public is prepared to accept. In other words, there will be a constant feedback between successful policy developments and 'culture' - the stock of attitudes and beliefs in society - that creates possibilities for further measures. It is very common for the public at large to underestimate the scale of challenges and necessary measures (eg. see road pricing) and therefore a strategy is needed to engage and win hearts and minds for policies that will be welcomed in retrospect but will opposed in advance. This suggests a clear direction of travel is important - even if you aren't sure how to get there... one good example from an unrelated area might be the HMT/Defra vision for the CAP.

• Don't be paralysed by the losers. Governments are usually excessively 'loss averse'. But this shows they can sometimes be bold and seemingly invasive and that sometimes people will welcome a firm approach to solving collective action problems. Most people recognise a majority will be worse-off if policy-changes are predicated on ensuring no-one is worse-off. Even though there was overwhelming support for tougher measures on smoking, it took the government years to take the plunge and it was fought all the way within the Cabinet. I feel the public is sometimes crying out for the smack of firm action on climate change, food, traffic etc... as long as it is a collective endeavour without wholesale free-riding. There's a kind of tyranny of the status quo which would rather continue to frustrate the silent majority than to create enemies of a newly disadvantaged minority... I know that's politics, but it stops a lot of good things happening.
  

• Create the good examples. A major factor in the UK moving to smoke-free policies was the nearby inspired and inspiring example of Ireland, which banned smoking in 2004 [BBC / One year on]. For Britain, this created a believable case study on the doorstep involving people a bit like us, not just in far-off California or Australia. This suggests that piloting and experimentation, or simply smaller scale interventions, may be an area where more could be done. One way of doing this would be to devolve more powers to local government (one reason why some places have been further ahead in banning smoking than Britain is that decisions were taken in smaller jurisdictions - with greater diversity and more local champions to take on the cause). This would create more diversity, more lessons to learn from, more evidence of what to copy and what to reject etc.
  

• Discount business scare tactics. For years, the tobacco industry used the pub and restaurant trade to say that such a ban will be a disaster for business. In fact, no such disasters have ever materialised at the level of the sector as a whole wherever these measures have been imposed - usually the impact on takings is neutral or spending goes up as new customers come in to the cleaner atmosphere [eg. this short review of evidence]. Despite the way the private sector is lionised as the fount of flexibility and innovation, business routinely argues that change or regulation will be bad - and is routinely proved wrong [see Red Tape to Road Signs, by the CORE coalition]. My favourite example was the banning of duty free within the EU - the airports people said it would cause havoc and job losses [BBC]... The reality is that markets respond well to changed conditions, even if entrenched companies don't always - new innovators will sweep away the old. It's just that trade bodies are full of the entrenched companies and often reflect the lowest common denominator views of the those most entrenched and with greatest inertia.