Raising the legal age for buying tobacco is the government's latest salvo in the war on smoking, and it is working hard to ensure maximum impact. Helen Mooney reports
Last month the Walt Disney Company owner of the Disney, Miramax and Touchstone film studios announced it is to ban cigarette smoking in all its films and place anti-smoking stickers on all its DVDs that depict smoking.
Disney is the first film company to make such a promise and arguably the most significant - few brands have had as strong a connection to young people and popular culture for so long.
Now with a ban on selling tobacco products to under-18s in England and Wales two months away, will the number of teenage smokers finally begin to fall?
Announcing the legislation, public health minister Dawn Primarolo said the government's intention was to 'discourage young people from taking up smoking in the first place'.
It is not surprising the government wants action - about 9 per cent of 11 to 15-year-olds smoke, according to the government's 2004 survey of smoking, drinking and drug use among young people in England.
Yet in the 2003-04 General Household Survey, this rockets to 26 per cent among 16 to 19-year-olds - more than the adult national average of 24 per cent.
Current estimates suggest children under 16 smoke about 600 million cigarettes a year - and two-thirds of these are bought in shops. Add that to the fact that smoking by young people has barely declined in the past five years, and the rising lung cancer rates among young women, and it is plain to see why the government wants to take action.
It is certainly keen to ensure the new law has maximum impact. It is rolling out a campaign intended to make stakeholders aware of changes, including a mail shot to 100,000 retailers in England and Wales and the launch of a website aimed at teenagers to encourage them to stop smoking.
But will the change in the law make a difference? The Department of Health does not sound convinced, even in the document that sets out the case for changing the law. Its final regulatory impact assessment admits 'it is difficult to be certain about the impact of an age increase on stopping children from taking up smoking'.
It continues: 'There is a lack of conclusive evidence from other countries where the age limit has been increased, as it is extremely difficult to assess the number of people who do not start smoking in the first place.'
It also concedes it is possible that increasing the age limit 'will have no long-term effect on smoking prevalence'.
It still has high hopes, though - the DoH estimates that among 11 to 16-year-olds, smoking will fall by as much as 14 per cent when the minimum age is raised.
There is some evidence: in Guernsey the age for buying tobacco was raised to 18 in 1997 when the teenage smoking rate was twice the UK average; now it is half the average. However, NHS Alliance president and public health lead Dr Chris Drinkwater is sceptical. He says the move could act as a 'perverse incentive' - if you ban something, young people will want to do it more.
He says: 'I'm not aware of any real evidence that underpins this, it seems to be a knee-jerk reaction from government. We need a much more sustained campaign and education policy aimed at children and teenagers making healthy choices.'
Other public health professionals are more sanguine. Milton Keynes primary care trust director of public health Dr Nicholas Hicks says the government should be congratulated for capitalising on the momentum created by July's smoking ban.
'There is clearly a difference between 13-year-olds passing themselves off as 16 and those trying to pretend they are 18,' he says.
Dr Hicks says that although raising the legal age for buying tobacco will not act as a 'universal panacea' for stopping children and young people from smoking, it will start to signal that it is culturally and socially unacceptable. This is vital, he says. 'We need to make smoking something that is not socially tolerated and revered in young people. Many still see it as cool.'
Yet the government has to give with one hand if it is to take with the other, he says. If such measures are to make children want to stop, the help must be there through increased funding for smoking cessation services.
'In Milton Keynes, around 60,000 people smoke and our NHS smoking cessation services are only helping 1,500 a year to quit. That's despite around 70 per cent of smokers saying they want to quit.'
The change in the law and the ban on smoking in public places are straightforward, practical measures, and chief medical officer Sir Liam Donaldson has more in mind.
He wants cigarettes to be hidden, and sold from under the counter; graphic pictures of blocked arteries, rotten teeth and gangrene on packets; a ban on the sale of packets of 10 cigarettes, often bought by underage smokers; and a reduction in the tax-free allowance for cigarettes imported from within the EU from 3,200 to 200.
Sir Liam sees the gold standard as California, where the rate of smokers stands at 14 per cent compared with 24 per cent in the UK.
Speaking last month, he said: 'The first thing you see when you go into a supermarket is a wall of cigarette packets. We need to do something about that and let's get that cigarette out of Kate Moss's mouth.'
He said he wanted to 'denormalise' smoking. 'Some people would resent the idea of cigarettes being kept under the counter. But this is all part of the denormalisation. Supermarkets are big, responsible organisations which already help on things like obesity. Wouldn't they like to play their part in fighting a disease that still kills over 100,000 a year?'
Cancer Research UK senior tobacco control manager Elspeth Lee agrees further action is needed. She says: 'This measure alone is not enough, since family and friends are a common source of cigarettes.'
The best-case scenario is a domino effect - stop adults smoking, stop the kids smoking. Yet how far can legislation go to crack down on one of the biggest public health issues of our time?
Association of Directors of Public Health president Dr Tim Crayford says he has heard discussions of banning smoking in the home to protect children. He feels this is a step too far - although parents should be educated not to smoke around youngsters.
Dr Crayford supports the incoming law change. He says: 'Around 90 per cent of people that smoke start before they are 19.'
Action on Smoking and Health research manager Amanda Sandford says increasing the age limit will signal that smoking and alcohol are as dangerous as one another.
One of the knock-on effects from the smoking ban is that adults have started to smoke outside the home, she says.
But there is a limit to how much interference smokers will tolerate. Guidance from the Royal College of Physicians issued at the same time as the smoking ban recommends health visitors ask patients receiving home visits not to smoke for up to an hour before their visit. The guidance has been taken up by some PCTs but making it law or trying to ban parents from smoking in their own homes is a step too far for most.
As Dr Hicks says: 'We don't want to brand parents who smoke as child abusers just yet.'
Gone in a puff of smoke
- 1951: Dr Richard Doll and Professor Austin Bradford Hill conduct first large-scale study of link between smoking and lung cancer.
- 1965: The government bans TV cigarette advertising.
- 1971: Health warnings appear on all UK cigarette packets.
- 1973: The first tar and nicotine tables detail the contents of tobacco products.
- 1976: Dr Doll and Richard Peto publish a 20-year study of smokers and conclude that one in three dies from the habit.
- 1986: New advertising and promotion guidelines include banning of tobacco advertising in cinemas.
- 1987: The London Underground smoking ban is extended to the entire network following the King's Cross station fire, in which 31 people die.
- 1988: The Independent Scientific Committee on Smoking and Health report concludes that non-smokers have a 10-30 per cent higher risk of developing lung cancer if exposed to other people's smoke.
- 1989: A court rules passive smoking can be classed an industrial accident.
- 1992: The first nicotine skin patch is made available on prescription.
- 1996: A lung-cancer sufferer is awarded $500,000 against a US tobacco firm after a jury ruled the company had shown negligence in not alerting smokers to the dangers.
- 1997: The Labour government pledges to ban tobacco advertising.
- 1999: A California court orders tobacco giant Philip Morris to pay $50m damages to a smoker with lung cancer.
- 2001: New EU directive requires larger, more prominent warnings on tobacco packaging.
- 2002: British Parliament passes legislation which began as a private member's bill, banning tobacco advertising, including sponsorship of Formula One.
- December 2002: The British Medical Association calls for a ban on smoking in public places because of the threat to non-smokers.
- March 2004: Ireland introduces a total ban on smoking in workplaces.
- November 2004: A white paper proposes a workplace smoke ban by 2008.
- March 2006: Scotland bans smoking in public places.
- December 2006: Public smoking ban in England announced.
- April 2007: A ban begins in Wales, followed by Northern Ireland.
- July 2007: England's smoking ban comes into force.
- October 2007: Legal age to buy tobacco to be raised to 18.