One of the important measures found in Budget 2016 is a substantial hike in the price of cigarettes. In view of our burden of non-communicable diseases (NCDs), this – as well as the rises regarding alcoholic drinks — is quite justified and follows upon similar price hikes in previous budgets.
There is strong evidence base at the WHO that has led it to advocate tax on long-term health damaging agents such as tobacco, sugar and alcohol as one of the most effective means to control NCDs. Several countries have resisted the pressures of industry lobbyists and passed legislation along these lines.
Framework Convention on Tobacco Control
Specifically as regards tobacco, it may be recalled that WHO developed in 2003 a comprehensive instrument for regulation of all aspects of the tobacco industry from production to consumption, known as the Framework Convention for Tobacco Control. A majority of member states making up WHO and/or the UN have signed up or ratified the FCTC, and Mauritius has done so too. Its provisions are binding upon the member states that ratify the FCTC.
Two aspects in the preamble concern us here: 1) the devastating worldwide health, social, economic and environmental consequences of tobacco consumption and exposure to tobacco smoke; 2) scientific evidence that has unequivocally established that tobacco consumption and exposure to tobacco smoke cause death, disease and disability (italics added), and that there is a time lag between the exposure to smoking… and the onset of tobacco-related diseases. (italics added)
Cigarette and the individual
In this article I am concerned mainly with the impact on the individual cigarette smoker, and do not go into the wider public health aspects of the problem. The focus on the individual is rooted in my own personal experience and in realities I have faced in my medical practice over the years, as well as in the accumulated scientific evidence on tobacco consumption. I also restrict myself only to cigarette smoking, because the vast majority of patients I have come across are cigarette smokers belonging mostly to the working class. Because of their lower income levels and other social factors, the overall burden on them tends to be much heavier compared to the more well-off sections of the population.
Many studies have established a strong correlation between health and social class: those belonging to the higher social classes tend be healthier and live longer. They can afford better quality of every item of consumption, including a preference for putatively less harmful cigars, as well as have more leisure time for both relaxation and physical activity, among other factors – such as access to and ability to pay for expensive medical treatment when needed – that play in their favour from a health point of view.
Inducing behaviour change
The biggest challenge faced in the control of the NCDs is altering the behaviour of the individual. So to change people’s behaviour is well-nigh impossible, and that is why along with ‘soft’ measures at attempting to do so, such as creating awareness through widespread campaigns and individual or group counselling, the experts have come up with devices such as ‘nudging’, and ‘hard ‘ measures such as imposing taxes which are usually of a legal nature and therefore enforceable. But as pointed out above, powerful lobbies militate against the latter and that is why despite all the evidence that we have, it takes so long to legislate.
The fundamental problem is what has been referred to as the ‘know-do’ gap: despite knowing that something is harmful to them, people will still not avoid it, and this is the case even when they suffer from disease. Now imagine the situation when they are currently free of any medical problem. Such as when we are teenagers, and smoke cigarettes to show off or to experiment.
In my days at the college, I too did so furtively with a few friends. But money was scarce – a stick of Matinee was 7 cents, and my daily pocket money in HSC was 15 cents. So affordability put a natural restraint to such experimentation. Nowadays, however, money is more available – and thus Global School Health Surveys of the WHO (including for Mauritius) have found a higher incidence of smoking in the student population, and at a younger age too.
But when we are young, the issue of the time lag between exposure to smoking and the onset of disease never bothers us – as it still does not bother smokers worldwide. When we are busy indulging in our addiction of smoking, the furthest thing away from our mind is disease or calamity – for they always happen to others isn’t it.
The peculiarity of tobacco is that it is absolutely harmful – it brings no benefit to the body at all. During the time lag, even small amounts of cigarette smoke lead to gradual accumulation in the body of the harmful substance nicotine present in it, along with 4000 other substances which are also harmful in their own way, with nicotine as number one in terms of the damage it causes. It has been extensively established by scientific studies that tobacco is responsible for lung cancer but also many other cancers such as of the bladder, as well as of several lung and cardiovascular diseases. All these constitute the health impact – which is not only serious and debilitating, but can lead to disability (e.g. amputation), as well as premature death (lung cancer, heart attack).
It is not difficult from there to imagine the economic dimension of the problem, as an ailing father may need to take time off work, or may be laid off work. Reduction of income or its loss naturally leads to impoverishment of the family, and there is consequentially the inevitable social impact on the family, with disruption of family life and routine – the spouse having to go out to work if not previously employed, having then to cope with an ailing husband as well as looking after the children if they are of young age. And if they are older, they may have to share in looking after the ill parent, so that their studies may suffer, and they may not be able to go on to higher studies for lack of means and so on. Besides, the stress on the children may itself cause health problems in them too. So the cigarette smoking father, addicted as he is, eventually becomes not only a burden to himself but is responsible for a succession of untoward events which not only disturb his children but may potentially destroy his family.
The irony if not tragedy is that even graphic warnings of the damage and death caused by cigarettes do not seem to put off as many people as the authorities would want. Quite often in my consultation when I have had patients who smoke, I have had to tell them that it will interfere with any medication that I will prescribe, which will result in delaying their recovery. I extract from them a pledge that they will not smoke, and only then will I write out their prescription.
Burning one’s money
In other instances I have resorted to place before them the stark truth of how they are literally burning their money – and put it to them that they could make better use of it for the family. In fact, if the family members have accompanied the patient, their breadwinner, I rope them in to apply the pressure. In the case of a patient who was smoking one 20-stick packet of Matinee per day when the price was Rs. 100 a packet, I wrote down on the paper for everyone present to see that that came to Rs. 3000 per month, Rs. 36000 per year. Then I would ask: if I gave you a bundle of Rs. 10000 in your hand now, gave you a matchbox and told you to put fire to it, would you do that? The response would be a surprised smile, followed by no, of course not. So right, I would continue: if you are reluctant to burn money that is not yours, than don’t you realise that you are literally burning money that you have earned by the sweat of your brow?
And multiply that by the 20 years more of working life that you have, I would add, that would be Rs. 720000 assuming the price remained steady. But of course it wouldn’t, so that’s even more money burnt I would tell them. Then would come my final advice to them: instead of burning Rs. 3000 per month, why not open an account for your child/children, so that by the time they are ready for university you will at least have a fair amount to get them started.
Of course I have no way of checking whether such of my patients did see this stark picture and acted on it as I advised and hoped they would, but at least I felt that I had done my professional as well as my social duty.
Don’t smoke – ‘tout court’!
We can see therefore the enormous health hazards and collateral adverse implications of cigarette consumption on those who are also vulnerable by virtue of their social status, and who are made even more so by this damaging and socially reprehensible habit. And it’s not as if those belonging to the other social strata suffer less from a health point of view if they too smoke cigarettes.
There is absolutely no reason at all to smoke. If you are not a smoker, please don’t start. If you are one, show your family that you care for them by stopping smoking forthwith. There are so many better things to do in life and so many more and better ways to enjoy oneself than to be ‘a fool at the end of one stick with fire at the other end’. Why not be more clever, and stronger, than the cigarette – and the cigarette manufacturer?