The Khan Review – Redefining UK Smoking Cessation

UK headlines have been dominated in recent weeks by the results of an in-depth review of the UK’s current stop-smoking services. The review was commissioned by now ex-Health Secretary Sajid Javid. Javid tasked former Barnardo’s CEO Javed Khan with picking apart the UK’s SSS (Stop Smoking Services) and identifying critical areas for improvement.

The decision was made off the back of a concerning report by Khan himself, among other experts, who collectively determined that under the current resource, the UK’s ambition to achieve a ‘smokefree 2030’ would be difficult. In fact, it was reported that the target could be missed by as much as 7 years, with the most underprivileged in our society not seeing positive change until at least 2044.

The resulting 15 actions raised by Khan to avoid this, could have a staggering impact on the way we approach smoking, vaping and cessation. With ramifications for both consumers and retailers alike. While only four of the fifteen actions are flagged as ‘must-dos’ by Khan, it is likely more than this will be followed up by government. This assumption comes off the back of an increasing number of anti-smoking propositions, which were further championed following the revelation that youth smoking uptake spiked massively during covid lockdowns.

Printing smoking kills on individual cigarettes, raising the national age of sale (as seen in New Zealand already) and introducing vaping to SSS are but a few previous suggestions from parliament that have been echoed in the Khan Review.

Why Conduct the Review?

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.”

Khan’s Action Plan

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.

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.”

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 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.

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. 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.

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.

Retailers might feel the sting if Clark’s predictions come true, with a reduced footfall a likely result of reduced ability to stock and sell tobacco products as well as vaping. Despite being a growing category, NGP like vaping products are still dwarfed by the potential income a store can enjoy from cigarettes.

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.

Khan also 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.

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, stating:

“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.”

“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.”

If this were to become a reality, the results for retailers could again be questionable. If tobacco products are removed from shelves or heavily taxed/restricted, vaping footfall could be a natural replacement for that lost income. If they were a permanent part of SSS however, this could further reduce footfall to stores that were only getting their device for cessation purpose, and purchased it from a local store because they cannot get them on SSS. The results remain to be seen.

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.

Khan wants the NHS to take stronger action against smoking, by upscaling treatment and primary care across all its services, with a specific focus on smoking prevention for first time users and also to prevent relapse. “Senior leaders in the NHS need to champion prevention and stop-smoking treatment as an organisational priority.”

Looking to improve the lives and wellbeing of mothers and children, Khan highlights the benefits of doing so 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.

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.”

Time Will Tell

With the review’s actions now facing practicality assessment by government and national health leaders, time will tell how many of the fifteen will become a reality. The impacts of the above a clearly significant, with many unknowns surrounding the impact on businesses synonymous with tobacco products or the act of smoking itself.

Banning smoking outside bars and restaurants could encourage more people to stay at home. Retailers may lose footfall from regular tobacco shoppers, who would also purchase impulse products or general groceries as a part of their visit to that store. While KMG’s like Sainsbury’s or Tesco could weather this shift in consumer behaviour, smaller retailers could face challenges. This could add untold hardships for those already struggling to recover from the impacts of the pandemic.

Ultimately however the public health impact could be equally huge, with immense benefits to society and the organisations that keep us healthy, namely the NHS. The line must now be drawn by Government, balancing public health against the needs of the economy.

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