The understanding of cigarette smoking as addictive and nicotine as the central addictive component is now well known and seemingly straightforward. Years of anti-smoking campaigning, as well as the mass advertising of nicotine replacement products, have together promoted a relatively new disease and addiction narrative around cigarette smoking.
Yet, the story of smoking and lung cancer in terms of health policy and NHS responses was not initially so focused on promoting a disease and addiction framework. Instead, the cigarette, and its impact on cancer outcomes, was initially placed within a specific postwar scientific framework focused around epidemiology. This statistical reference allowed for the formation of a new public health policy based on ‘risk factors’ and the role of individual lifestyle choice in determining health outcomes. Smoking represented an important issue in legitimating the role of epidemiology as the cornerstone of public health with prevention used as a major policy position in the postwar period. Within this context, passive smoking became a secondary major issue in relation to cigarette smoking that widened this public health discourse to include issues of environmentalism. Risk was therefore applied to a broad public rather than on the smoking individual alone, which had wide ramifications for the prevention agenda.
Early Royal College of Physicians (RCP) Reports in 1962 and 1971 had recognised that smokers might be addicted to nicotine but the wider public health discussion around smoking still focused on personality and inheritance as motivating factors. In response the NHS established anti-smoking clinics throughout the country from the early 1960s that provided advice on quitting alongside information provision aimed at discouraging the uptake of the habit amongst non-smokers and children.
It was recognised in the 1971 RCP Report that smokers ‘craved’ for nicotine yet it wasn’t until the 1980s that behavioural studies in both Britain and the United States confirmed these unofficial findings that nicotine itself was addictive. The certainty that nicotine was addictive offered a new medical model for understanding and discussing cigarette smoking radically different from the previous behavioural-focused epidemiological construction of risk. Therefore, in more recent years smoking cessation has become closely linked to the medicalisation of cigarette smoking in terms of nicotine addiction. While prevention has remained an important part of the anti-smoking agenda, there has been a greater understanding of the addictive nature of cigarette smoking.
Throughout this changing narrative of cigarette smoking and public health policy, the NHS has played a number of central roles in applying and translating public health policy around smoking. In particular, the physical locations of the National Health Service, from the GP surgery to the hospital have been made smoke-free in efforts to make non-smoking normal practice. As a result, non-smoking working environments have been made compulsory for staff smokers as well as patients, visitors and contractors. The NHS has also run important anti-smoking clinics, providing advice on quitting smoking and since the 1990s they have provided important nicotine replacement therapy to people wishing to quit. They have also formed an important support and advisory role in the launch and continuation of campaigning initiatives such as Stoptober and the general, year-round Smokefree initiative. Such Stop Smoking Services provide advice, support and encouragement to help people kick the habit for good.
Thus, a treatment model of considering cigarette smoking in curative and preventative terms has emerged within both public health and NHS provision since the 1960s. While this model has remained less medicalised than other addiction treatments such as methadone for heroin addiction, the use of over-the-counter pharmacy provision of nicotine products has constructed an important secondary site for enacting NHS policies on smoking cessation and the centrality of addiction to quit programmes.
A shift from prevention to addiction and from behavioural change to the provision of treatment plans has charted a major shift in the cultural perception of smoking within wider social life. An anti-aesthetic has been constructed around smoking that has been supported by the inclusion of shock images on cigarette packages, the advertising ban on smoking products and the environmental smoking ban in the workplace. That smoking rates have more than halved since 1974 reflects a sea change in both public and private attitudes to cigarette smoking that has made an accepted habit socially unacceptable in twenty-first century Britain. While the NHS continues to foot the costly bill for smoking related illnesses, both the National Health Service and the Ministry of Health have looked upon the significant reduction in the numbers of smokers and the increasingly unacceptable nature of smoking within public discourse as an important on-going public health success story.