Mark Rowland
In October 2023, the Government announced its proposal to increase the age of sale of tobacco in England. Mark Rowland, CEO of the Mental Health Foundation and Co-Chair of the Mental Health and Smoking Partnership, shares why this is good news for mental health.
For many years now, we have called for a cross-government approach to tackling the mental health crisis. That’s because our mental health doesn’t operate in a vacuum. It’s affected by a whole range of social, environmental, physical, and economic factors.
There are no silver bullets, no vaccine to protect against the risk of poor mental health. However, there is a lot we could and should be doing. We need bold new policy and community approaches that enable us to thrive and that reduce our risk of poor mental health.
Smoking is still the largest cause of preventable death, and it remained in that position even during the pandemic. It is one of the most destructive yet changeable factors that influences our physical and mental health.
What is the tobacco age of sale proposal?
In January 2023, we wrote with 25 other organisations to the Government. We urged them to publish a new tobacco plan with commitments to end smoking and build on the progress made in recent years that has halved smoking rates in the UK (from around 27% in 1990s to 12.9% in 2022[1]). So, when the Government announced its age of sale proposal in October 2023, it felt like a significant potential victory for public health. The Government’s plan would see the age of sale for tobacco increase by one year, every year. This would prevent anyone born on or after 1 January 2009 from legally buying cigarettes in England.
It would be a world-leading approach that would reduce health inequalities and accelerate the progress already made in reducing smoking rates, the only legal product on the market which is likely to kill you if used in line with manufacturers’ instructions.
What has smoking got to do with mental health?
For years, many people have believed a myth that smoking is a helpful way of reducing stress and anxiety. For example, in evidence presented to the Mental Health and Smoking Partnership, the Smokefree Sheffield coalition reported that in Yorkshire, 43% of people still believed that smoking reduced stress.
But we know the opposite is true. Although nicotine provides some short-term relief through the release of neurotransmitters like dopamine, this quickly gives way to much longer and increased withdrawal symptoms, including low mood, anxiety and depression.
We now have clear evidence of the role of smoking in the onset and maintenance of poor mental health. Indirectly, through trapping smokers in a cycle of dependence that worsens physical and mental health (see fig 1). And directly, by increasing the risk of some mental health conditions (such as depression and schizophrenia) and through the creation of addiction, which harms people’s mental wellbeing.
It has also been shown that that quitting smoking improves your mental health, at least as much as some anti-depressants. And we also know the mental health benefits of stopping smoking increase as people abstain from smoking long-term.
The physical impacts of smoking disproportionally affect people with poor mental health. It’s why smoking is the leading contributor to the 10-20 year gap in life expectancy between people with severe mental health conditions and the general population.
Will raising the age of sale of tobacco work?
In England, raising the age of sale from 16 to 18 in 2007 reduced smoking rates among 16- 17-year-olds by 30%[5] . In the US, when the age of sale was increased from 18 to 21, the chance of a person in that age group smoking fell by 39%. Government modelling estimates that raising the age of sale each year will mean up to 1.7 million fewer people smoking by 2075.
This would also avoid the mental and physical health consequences of up to 115,000 cases of stroke[6], heart disease, lung cancer and other lung diseases, saving tens of thousands of lives. And it will reduce some of the £21 billion that smoking costs the public finances each year (almost double what is raised through taxation on cigarettes)[7].
What are the mental health benefits of the age of sale proposals?
In 2021, we produced our best mental health tips, backed by research. One of the most important tips was to avoid the use of recreational drugs and alcohol because of their damaging impact on our mental health. And this should include smoking.
Any reduction in smoking rates will have a disproportionately positive impact on those with poor mental health. It will protect people with an existing diagnosis from the harms of smoking and prevent poor mental health in young people by reducing the number smoking in the first place.
Reduced smoking rates will also benefit people with low income. Smoking increases your risk of poverty and is also a major cause of health inequalities. For example, deaths attributable to smoking happen at a 2.1 times higher rate[8] in the most deprived local authorities than in the least deprived[9]. We know that work to reduce poverty and inequalities are correlated to improved mental health outcomes.
Alongside this legislation, we still need properly funded stop-smoking public health campaigns targeted at the most at-risk communities.
We need stop-smoking services in local authorities as well as within in-patient psychiatric settings to support those already addicted. And we also need to increase access to peer support groups for people wanting to stop smoking and to NHS Talking Therapies to enable them to get the support they need. But reducing the overall number of people smoking in the first place will allow the NHS to focus its resources on smoking cessation programs with the most vulnerable, including people with severe and enduring mental ill-health.
The age of sale proposals are a once-in-a-generation public health opportunity to help create the conditions for better mental and physical health.
We know that 67% of the public support these proposals[12].
But the tobacco industry is mobilising its vast resources to hold conferences, pay for adverts and lobby MPs to persuade us that restricting tobacco use will be an affront to individual liberty and damage the economy. These myths have been systematically debunked by Action on Smoking and Health, but the commercial determinants of health are powerful forces. It’s why we continue to have a health system that treats the symptoms of ill-health while regulators fail to limit the promotion of products that cause many of the symptoms in the first place.
Creating a mentally healthy society means taking bold steps to ensure that profit is not placed above the protection of good mental health.
What can I do to support the age of sale proposal?
The government plan to hold a free vote in 2024 on the age of sale proposals.
You can play your part by:
- Writing to your MP (find out how here).
- Using template smokefree letters in support of the age of sale proposals, reminding them of the impact these proposals would have on the mental health of this generation and the one to come.
- Share this blog to raise awareness of the mental health benefits of stopping smoking.
[1] NHS Digital (2018) Health Survey for England 2017 [NS], NHS Digital. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/he… (Accessed: 11 January 2024).
[2] [3] Office of National Statistics (2018) Adult smoking habits in the UK, Office for National Statistics. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare… (Accessed: 11 January 2024).
[4] Szatkowski L;McNeill A. (2015) Diverging trends in smoking behaviours according to mental health status, National Library of Medicine. Available at: https://pubmed.ncbi.nlm.nih.gov/25180078/ (Accessed: 11 January 2024).
[5] [6] Department of Health and Social Care (2023) Stopping the start: Our new plan to create a smokefree generation, GOV.UK. Available at: https://www.gov.uk/government/publications/stopping-the-start-our-new-p… (Accessed: 11 January 2024).
[7] (2023b) APPG on Smoking and Health launches its Tobacco Control Manifesto [Preprint]. Action on Smoking and Health (ASH). Available at: https://ash.org.uk/media-centre/news/press-releases/appg-on-smoking-and… (Accessed: 11 January 2024).
[8] Department of Health and Social Care (2023) Stopping the start: Our new plan to create a smokefree generation, GOV.UK. Available at: https://www.gov.uk/government/publications/stopping-the-start-our-new-p… (Accessed: 11 January 2024).
[9] Gov.uk (2022) ‘Local Tobacco Control Profiles’. England. Available at: https://fingertips.phe.org.uk/profile/tobacco-control/data#page/7/gid/1938132885/pat/6/par/E12000009/ati/402/are/E06000022/iid/92443/age/168/sex/4/cat/-1/ctp/-1/yrr/1/cid/4/tbm/1/page-options/car-do-0_ine-yo-1:2022:-1:-1_ine-pt-0_ine-ct-59 (Accessed: 11 January 2024).
[10] Department of Health and Social Care (2023) Stopping the start: Our new plan to create a smokefree generation, GOV.UK. Available at: https://www.gov.uk/government/publications/stopping-the-start-our-new-p… (Accessed: 11 January 2024).
[11] (2023) APPG on Smoking and Health launches its Tobacco Control Manifesto [Preprint]. Action on Smoking and Health (ASH). Available at: https://ash.org.uk/media-centre/news/press-releases/appg-on-smoking-and… (Accessed: 11 January 2024).
[12] (2023a) Two thirds of the public back raising the age of sale to create a smokefree generation [Preprint]. Action on Smoking and Health (ASH). Available at: Two thirds of the public back raising the age of sale to create a smokefree generation. Available at: https://ash.org.uk/media-centre/news/press-releases/two-thirds-of-the-public-back-raising-the-age-of-sale-to-create-a-smokefree-generation#:~:text=A%20new%20YouGov%20poll%20for,2009%20(14%25%20oppose). (Accessed: 11 January 2024).