The Risk Factor Prevalence Survey conducted by the National Heart Foundation in Australian capital cities in 1989 revealed that, for the first time ever, there were more ex-smokers than current smokers among Australian adults of working age. This major landmark in public health went unnoticed, and, well over a decade later, has still not been achieved in Britain. How can it be that the cradle of epidemiology and the home of the British Doctors Study (and all that it has taught us about the harm done by smoking) is itself doing so poorly in tobacco control?

When a survey of over 9000 Londoners in 2002 revealed that 29% were smokers and 27% were ex-smokers, it comes as no surprise that one of the first comments regularly made by visitors from “Down Under” concerns the high ambient levels of tobacco smoke — from the halls of Heathrow onwards. Smoke-free policies are in place on London buses and the Underground, but there are still some smoking carriages on long-distance trains, and many shopping centres permit smoking. Waiting in a crowd for a commuter train at peak-hour is decidedly unpleasant for non-smokers, while pubs and restaurants can comply fully with the “Public Places Charter on Smoking” simply by displaying a sign saying “Smoking permitted throughout”.

Despite the recommendation of the International Union Against Cancer (UICC) that tobacco control should combine legislation, education and cessation activities, the Blair Government has until very recently put all of its eggs in the “cessation” basket. Having nicotine replacement therapies and bupropion available on the National Health Service is undeniably important in removing economic barriers to effective aids to quitting smoking, and supporting this with publicly funded smoking-cessation clinics is unprecedented. However, the “ring-fence” around funding for these clinics is not necessarily permanent, and the overall approach remains decidedly unbalanced when judged against the UICC’s recommendation.

The UK government has conspicuously failed to take a strong lead, either nationally or within Europe, in adopting the regulatory strategies on smoking and the tobacco industry that are now taken for granted in Australia and New Zealand. UK newspapers and billboards continued to carry advertisements for cigarettes until February 2003, a decade after they disappeared in Australia. Sophisticated, community-wide health promotion using prime-time electronic media, now an export industry for Australia, remains virtually unknown as a tobacco-control activity here, with embryonic campaigns only just beginning to emerge. Evidence that the major tobacco manufacturers are well aware of diversion of significant fractions of their outputs into smuggling operations has not prompted effective official action. Consequently, tax has not been paid on perhaps a third of cigarettes sold in London, significantly undermining the use of price as a disincentive to smoking. The minimum age at which children can purchase cigarettes is stuck at 16 years, and packets of 10, known to appeal especially to school-age smokers because of their low price and greater ease of concealment, are still on the market. Warnings on cigarette packets have been enlarged in size and range, but this is a small advance in an environment that, by standards now well established in Australia, remains otherwise remarkably permissive of smoking.

The UK has undeniably made a huge contribution to the science behind effective tobacco control and, beginning with the first report on smoking from the Royal College of Physicians in 1962, has been a pioneer in collating and publishing authoritative, independent expert reviews of the accumulating epidemiological and clinical data as a stimulus to official public health action. It also gave the world the prototypic advocacy organisation Action on Smoking and Health (ASH). Seen through “colonial” eyes, however, it doesn’t have the teeth that have regularly been bared by its Australian counterpart (ASH Australia), the Cancer Council of Victoria, or the Australian Council on Smoking and Health. Meanwhile, the UK Department of Health apparently feels no pressing need to adopt international best practice in tobacco control.

A further consequence of the dearth of effective advocacy is the tolerant attitude of the media, up to and including the BBC. For example, the opinions of vested interests that the wider introduction of smoke-free policies would bring an end to commercial and civilised life as we know it are reported uncritically, and seemingly without any effort to find examples that disprove such assertions. Radio audiences are much more likely to be treated to an aside that smoke-free policies in bars in France have been an abject failure than to one that reminds listeners that active smoking accounts for 30% of avoidable cancers, or that passive smoking measurably increases the risk of lung cancer and heart attack, for example among non-smoking staff in bars. The coverage of smoking issues is truly meagre — it takes 4444 deaths from smoking to generate a newspaper story, but only 0.375 deaths from measles, 1.5 from variant Creutzfeldt–Jakob disease, and 22.5 from HIV/AIDS.1

It feels like a time-warp — the British media now are where the Australian media were a generation ago — which is what the overall figures for the prevalence of smoking show, too. But, it also demonstrates an interesting point — the apparent gullibility of the media here is not so much a case of “who pays the piper, calls the tune” (since advertisements for cigarettes have disappeared from newspapers), but the failure of government and health interests to generate and maintain vigorous discussion about the hazards of smoking, active and passive.

While no less an expert than Professor Sir Richard Peto argues, with good foundation, that smoking-cessation activities will save lives much faster than waiting to create a whole new generation of non-smokers, this view has allowed the UK government to avoid facing up to the need for a comprehensive tobacco control policy. Its targets for the prevalence of smoking in 2010 are embarrassingly modest. They concentrate on short-term indicators for smoking-cessation services without a population focus, and these are likely to be reached simply as an extension of the background downwards trend of an absolute reduction of around 0.25% per annum. Meanwhile, Britons continue to die from smoking at the rate of one every 5 minutes. Roll on 1989!