I have come across libertarians who believe that there’s nothing wrong whatsoever with smoking and that the dangers from secondhand smoke are nonexistent. Me, I tend to trust the medics on this. Smoking kills and I think there’s certainly a case for some restrictions on smoking in public, if only for reasons of etiquette. But what to make of this report from the British Lung Foundation?
Smoking may be a sign of psychiatric illness, experts say. Doctors should routinely consider referring people who smoke to mental health services, in case they need treatment, they add.
The controversial recommendation from the British Lung Foundation, a charity, comes in response to a major report, Smoking and Mental Health, published this week by the Royal College of Physicians and the Royal College of Psychiatrists with the Faculty of Public Health. It says that almost one in three cigarettes smoked in Britain today is smoked by someone with a mental disorder. When people with drug and alcohol problems are included the proportion is even higher.
The reason is that smoking rates have more than halved over the past 50 years, but the decline has not happened equally in all parts of society.
‘Smoking is increasingly becoming the domain of the most disadvantaged: the poor, homeless, imprisoned and those with mental disorder. This is a damning indictment of UK public health policy and clinical service provision,’ the report says.
The Independent’s health editor adds: ‘The nation’s dwindling band of smokers, skulking outside office doors, already resent being treated as pariahs. The suggestion that they may be dotty, too, will only enrage them further… doctors would be remiss if they did not consider whether a patient’s fag habit disguised an untreated mental disorder.’
So cigarettes cause craziness. Er, wow! But is it really that simple? Premier mental health blogger Seaneen Molloy has pointed out potential flaws in the Lung Foundation’s thesis. She writes that ‘causation does not equal correlation. A lot of people who have mental health issues smoke, ergo, people who smoke must have mental health issues?’ Seaneen also outlines the obvious practical problem with referring every single presenting smoker to an already overworked mental health service. And she draws on her experience from both sides of mental health care. ‘But in this environment, where you enter and go through the mortification process… the freedom to smoke is an important one. It gives a sense of bodily agency and autonomy in an environment where such things are flagrantly disrespected.’
I would add that there is an ideological movement against smoking, made up of government funded ‘charities’, career activists and public sector organisations that appear to be immune from national austerity. These are professional anti smokers who came up in the 1980s when Big Tobacco was the enemy. The world has changed since then, tobacco companies are nothing compared to the pharmaceutical cartels, but the caravan never moved on.
In 2007 ASH got its dream of a public smoking ban, but people continue to smoke. The tobacco control industry has never understood that some of us, more of us than the Independent’s health editor thinks, know the risks and make the decision to sacrifice potential quantity of life for quality and short term pleasure. All the No Smoking Days and glossy PR and Department of Health money can’t change that. So the tobacco control movement demands more petty tinkering – plain cigarette packages, restrictions on vending machines – without ever arguing for what it really wants: a complete ban on the sale of tobacco. Tobacco control activists don’t come out and have that argument because they know it’s an argument they’re going to lose.
There is also the question of enforcement. Pubs got round the 2007 ban by introducing heated outside smoking areas. The ones that didn’t went to the wall. Plain packages, if and when they come in, will likely flood the black market with cheap, easily manufactured smuggled tobacco. You’re not supposed to be able to buy cigarettes in pubs, but every one of my locals sells packets openly behind the bar. And some pubs will simply defy the ban. Last year a hilarious ‘special investigation’ by the Manchester Evening News found that at least fifteen of Rusholme’s shisha bars were letting people smoke inside. This put the city’s political elite in a difficult position between the Scylla of wanting to police people’s leisure time and the Charybdis of not wanting to offend Asian cultural traditions.
Seaneen writes that poor people are more likely to smoke because the working classes have never shared the ridiculous bourgeois taboo against tobacco. It’s a taboo with a long and reactionary history. Feminists of the late nineteenth century were smeared as ‘pallid, tired, thin-lipped, flat-chested and angular’ women, living in an ‘atmosphere of tea-steam and cigarette smoke’; women for whom ‘[t]he time of night means nothing until way into the small hours.’ And the Lung Foundation’s press release reads like something from the fevered drug wars of the 1980s.
We know more or less how lungs work. The mind is a stranger place. Anxiety, depression, psychosis, entropy and disorder are things we are only just beginning to learn about. The reasons some people develop mental health problems are complex, all bound up with biology, genetics, environment, and the circumstances of a unique human life. Simplistic general solutions help no one. And this particular idea could set a bad precedent for the principles of free healthcare. There are already resentful whisperings to the effect that people who overeat or drink too much have somehow ‘brought it on themselves’ and shouldn’t be treated. Should people who have smoked all their lives be turned away from crisis centres?
It is what Ben Goldacre identified as the dark side of the ‘you are what you eat’ philosophy. As Goldacre says, this is ‘a manifesto of rightwing individualism – you are what you eat, and people die young because they deserve it. They choose death, through ignorance and laziness, but you choose life, fresh fish, olive oil, and that’s why you’re healthy. You’re going to see 78. You deserve it. Not like them.’