Firstly, let me say you write very well, you're a pleasure to read. But there is a couple of points I wish to take up. You say:
"Translated into everyday terms, that’s about £0.12 for every cigarette lit—a silent debt paid by the public system and, ultimately, by society as a whole for each puff."
Yes, it is of course true that society pays the costs in healthcare. But isn't this the very reason public healthcare was setup in the first place? Specifically to look after the poor and socially disadvantaged? The very same groups you have pointed out bear most of the harms from smoking? The problem I have with this argument is that it is public health groups, specifically Tobacco Control, who use this argument to lobby for more pain and suffering to be inflicted on these same groups by raising the excise tax on smoking.
You introduce the above by pointing out:
"England alone, smoking accounts for around £2.9 billion annually in healthcare and social care costs."
Ok, but compared to what? How much do Muslims cost in healthcare and social care costs? If I asked this question in public I would be called a racist. It would be pointed out that it is wrong to target a specific group like this. Yet targeting smokers by counting up their costs is perfectly acceptable practice? This in country where public healthcare was deliberately setup to look after the less fortunate?
Furthermore, by what calculation does one come to the conclusion that if all smokers gave up smoking that healthcare and social care costs would diminish? I know you haven't made this argument but it is the implied implication of quoting these costs.
Do non-smoking deaths cost less than smoking deaths? Has anyone ever provided the evidence for this? Would the costs of pensions decrease if everyone gave up smoking? - or would they increase? Would the social care costs be less if all smokers gave up and lived for an extra 5 to 10 years? Who has ever provided any evidence for these implied claims of reducing healthcare and social care costs?
Anyway, I don't mean to be having a go at you personally, I agree with most of what you have written and very much enjoy your writing.
Paul, first of all, I want to thank you for the generosity of your words and the care you’ve taken in engaging with my text. Your comment is valuable because it does not stop at disagreement; it opens a space to think more deeply about how we narrate tobacco, about the figures that inscribe themselves on human skin, about the inequalities that repeat like scars, and about the social injustice that persists.
You are right to remind us that the NHS was born to protect the most vulnerable. This is perhaps one of the greatest civilizational achievements of the postwar period, and nothing should ever make us forget that public healthcare exists to care, not to calculate who weighs more or less on the collective scale. When I wrote that each cigarette amounts to £0.12 in costs, it was not to put a price on lives, but to reveal that the cost of tobacco does not end with the pack: it spreads through the system, seeps into the statistics, and above all falls most heavily on those who already breathe less air of rights.
I also share your concern about the punitive use of this argument. Regressive taxes are a cruel paradox: they disproportionately affect precisely those who suffer the most from dependence. This is an important warning: no health policy can reproduce, under the pretext of the “common good,” the very inequalities it claims to fight.
I also agree that the economic equation is more complex than it is often suggested to be; indeed, I recognize this in my own writing. Chronic illnesses raise costs, premature deaths reduce pensions, and long-term care. The scientific literature is far from unanimous, and presenting this balance as a simple arithmetic is a mistake. That is why I don’t insist so much on the financial ledger, but on what the numbers conceal: human suffering that could have been prevented and inequalities that become more visible when translated into figures that political power cannot ignore.
The analogy you proposed, asking “how much do Muslims cost,” is, in my view, dangerous because it conflates two distinct realities: identity is not a choice (although I simplify this notion, because some identities have aspects of partial choice, such as religion, while others are totally non-choice), whereas smoking is a behavior, albeit one deeply conditioned by social determinants. But I understand the essence of what you meant: whenever we reduce a human group to a line item in an accounting sheet, we run the risk of opening the door to stigma and exclusion. And in that sense, you are right.
Here, I allow myself to engage in self-reflection. There is a dilemma in the classical trajectory of knowledge in public health: from scientific data to the academic article, from the article to journalistic mediation, from journalism to public reception. Each stage both translates and transforms. And in my case, there is yet another layer of mediation: I write in Portuguese, and I know that translation can alter the rhythm, the density, even the strength of certain images, even after revision. The risk of journalistic writing (mine included) is that, in interpreting and seeking social metaphors, it may end up instrumentalizing economic discourse and leaving room for punitive readings. My intention was to shift the debate from the biomedical and statistical plane to the social one, to show the cigarette as a marker of class and regional boundaries. But I acknowledge: by privileging image and denunciation, I risk losing analytical precision. Perhaps it would have been useful to bring in concrete public policies or international comparisons that could have anchored the critique more firmly.
In the end, I think we are closer than it seemed at first reading. It is not about blaming smokers, but about understanding that smoking is not a free and equal choice for everyone: it is a habit shaped by inequality, by the seduction of desire, by vulnerability. The challenge is that public policy should not respond only with taxes, but with real support, with possible alternatives, with the same solidarity that founded the NHS.
If the cigarette leaves scars, it is not so that we can tally the debt, but so that we can understand the wound that keeps it burning. And on this point, Paul, I believe we agree: the fight against tobacco cannot be reduced to an accounting of pounds and figures. It must also be an ethical, social, and political analysis of how to protect the vulnerable without turning them into targets of stigma or punishment.
"no health policy can reproduce, under the pretext of the “common good,” the very inequalities it claims to fight."
I live in Australia where the excise on cigarettes is so high that it has spawned a massive black market. And yet, in the name of 'helping' smokers this is pretty much the argument that those in PH and Tobacco Control make.
"The analogy you proposed, asking “how much do Muslims cost,” is, in my view, dangerous".
I agree, it was poorly chosen. I should have chosen to compare costs with those freely choosing to play sport and other dangerous activities that are all covered by public healthcare.
"My intention was to shift the debate from the biomedical and statistical plane to the social one, to show the cigarette as a marker of class and regional boundaries."
I agree that was clearly your intention. And basically you succeed it doing so. I just happen to be a grumpy former smoker and now vaper that has heard these arguments for years. Do you know that In Australia they calculated the costs of healthcare and social costs of smoking to be 33 billion dollars a year? This calculation was made in 2008! Can you believe that? UK has almost three times the population; and Australia estimates the costs at ten times the amount? So to say it again, I get kind of grumpy when these figures appears.
"In the end, I think we are closer than it seemed at first reading."
I agree and would recommend your approach far more than the current approach of Tobacco Control groups. However, one area I kind of disagree on is that I am much more an individualist. I think giving people the information regarding the harms of smoking is sufficient. Allowing people to freely choose less harmful products such as vapes and nicotine pouches would also go a very long way in reducing the harm. I attach a paper that makes the point about education being the most significant factor in the reduction of smoking.:
Anyway, I want to thank you for your extremely generous reply. I know writing takes a lot of time (especially when you write as well as you do) and you must be busy. Cheers
Another excellent blog, Claudio. Those in the lower socioeconomic class often have higher prevalence of smoking rates. Sadly, due to the UK's recent about-turn with regards to safer forms of nicotine (vaping), and insisting they are upgrading regulations, to curb youth appeal. With banning disposables, and later in 2026 taxing vaping e-liquids, even those without nicotine, as well as a possible flavour ban. These proposed draconian polices will not produce fewer smokers. If anything, it will only boost illicit supplies of cigarettes. As well as boost the illicit supply and demand for vaping products. It sends the wrong message to the public by insisting that vaping is equal to smoking. While public health advocates still insist that those who cannot quit smoking with traditional methods, vaping offers them a harm reduction alternative to quit smoking, which can spare them from smoking-related diseases related to combustible tobacco use (cigarettes). I'm sure the same graph would showcase the same results in many other countries. Those in the lower socioeconomic classes, those who identify as LGBTQ+, and those who work in service industries often have higher smoking rates. Over-regulations on vastly less risky forms of nicotine, vapes, Snus, & oral nicotine pouches just keep a population trapped in smoking. Ensuring that a set percentage of people will remain trapped in smoking habits. Public policies should always be based on science and evidence, and not based on fears or ideologies for a nicotine-free world. As a nicotine-free world will never exist. There will always be a set % of people who will use nicotine recreationally. The same as there will always be a set percentage of people who use caffeine, or drink alcohol. A Puritan world will never exist. So why not push for more harm reduction methods in all vices that people may have? Thanks again, I always enjoy reading your blogs/ articles.
Hi Jackie, Thank you very much for your thoughtful comment and for expanding the discussion in such depth.
You've highlighted a critical contradiction: when policies that claim to “protect” the public end up deepening inequalities. As you rightly note, the most vulnerable populations are often the most affected by smoking. Making safer alternatives less accessible through bans, punitive taxes, excessive regulations, or unaffordable products does not reduce harm, but entrenches it.
Framing vaping as the same as smoking is not only scientifically inaccurate, but also ethically wrong and dangerous. It weaponizes fear over evidence and ultimately keeps people trapped in cycles of harm.
I completely agree: public health policy should be based on science, not ideology. And it shouldn't be subject to the desire for profit.
A world without nicotine is as implausible as a world without caffeine or alcohol or sex. The truly good way forward is pragmatic; it is always the most reasonable: to expand harm reduction strategies across all “addictions”, so that public health starts saving lives, not defending unattainable ideals of perfection.
Once again, thank you for your meaningful participation. It's views and comments like yours that make writing worthwhile.
Firstly, let me say you write very well, you're a pleasure to read. But there is a couple of points I wish to take up. You say:
"Translated into everyday terms, that’s about £0.12 for every cigarette lit—a silent debt paid by the public system and, ultimately, by society as a whole for each puff."
Yes, it is of course true that society pays the costs in healthcare. But isn't this the very reason public healthcare was setup in the first place? Specifically to look after the poor and socially disadvantaged? The very same groups you have pointed out bear most of the harms from smoking? The problem I have with this argument is that it is public health groups, specifically Tobacco Control, who use this argument to lobby for more pain and suffering to be inflicted on these same groups by raising the excise tax on smoking.
You introduce the above by pointing out:
"England alone, smoking accounts for around £2.9 billion annually in healthcare and social care costs."
Ok, but compared to what? How much do Muslims cost in healthcare and social care costs? If I asked this question in public I would be called a racist. It would be pointed out that it is wrong to target a specific group like this. Yet targeting smokers by counting up their costs is perfectly acceptable practice? This in country where public healthcare was deliberately setup to look after the less fortunate?
Furthermore, by what calculation does one come to the conclusion that if all smokers gave up smoking that healthcare and social care costs would diminish? I know you haven't made this argument but it is the implied implication of quoting these costs.
Do non-smoking deaths cost less than smoking deaths? Has anyone ever provided the evidence for this? Would the costs of pensions decrease if everyone gave up smoking? - or would they increase? Would the social care costs be less if all smokers gave up and lived for an extra 5 to 10 years? Who has ever provided any evidence for these implied claims of reducing healthcare and social care costs?
Anyway, I don't mean to be having a go at you personally, I agree with most of what you have written and very much enjoy your writing.
Paul, first of all, I want to thank you for the generosity of your words and the care you’ve taken in engaging with my text. Your comment is valuable because it does not stop at disagreement; it opens a space to think more deeply about how we narrate tobacco, about the figures that inscribe themselves on human skin, about the inequalities that repeat like scars, and about the social injustice that persists.
You are right to remind us that the NHS was born to protect the most vulnerable. This is perhaps one of the greatest civilizational achievements of the postwar period, and nothing should ever make us forget that public healthcare exists to care, not to calculate who weighs more or less on the collective scale. When I wrote that each cigarette amounts to £0.12 in costs, it was not to put a price on lives, but to reveal that the cost of tobacco does not end with the pack: it spreads through the system, seeps into the statistics, and above all falls most heavily on those who already breathe less air of rights.
I also share your concern about the punitive use of this argument. Regressive taxes are a cruel paradox: they disproportionately affect precisely those who suffer the most from dependence. This is an important warning: no health policy can reproduce, under the pretext of the “common good,” the very inequalities it claims to fight.
I also agree that the economic equation is more complex than it is often suggested to be; indeed, I recognize this in my own writing. Chronic illnesses raise costs, premature deaths reduce pensions, and long-term care. The scientific literature is far from unanimous, and presenting this balance as a simple arithmetic is a mistake. That is why I don’t insist so much on the financial ledger, but on what the numbers conceal: human suffering that could have been prevented and inequalities that become more visible when translated into figures that political power cannot ignore.
The analogy you proposed, asking “how much do Muslims cost,” is, in my view, dangerous because it conflates two distinct realities: identity is not a choice (although I simplify this notion, because some identities have aspects of partial choice, such as religion, while others are totally non-choice), whereas smoking is a behavior, albeit one deeply conditioned by social determinants. But I understand the essence of what you meant: whenever we reduce a human group to a line item in an accounting sheet, we run the risk of opening the door to stigma and exclusion. And in that sense, you are right.
Here, I allow myself to engage in self-reflection. There is a dilemma in the classical trajectory of knowledge in public health: from scientific data to the academic article, from the article to journalistic mediation, from journalism to public reception. Each stage both translates and transforms. And in my case, there is yet another layer of mediation: I write in Portuguese, and I know that translation can alter the rhythm, the density, even the strength of certain images, even after revision. The risk of journalistic writing (mine included) is that, in interpreting and seeking social metaphors, it may end up instrumentalizing economic discourse and leaving room for punitive readings. My intention was to shift the debate from the biomedical and statistical plane to the social one, to show the cigarette as a marker of class and regional boundaries. But I acknowledge: by privileging image and denunciation, I risk losing analytical precision. Perhaps it would have been useful to bring in concrete public policies or international comparisons that could have anchored the critique more firmly.
In the end, I think we are closer than it seemed at first reading. It is not about blaming smokers, but about understanding that smoking is not a free and equal choice for everyone: it is a habit shaped by inequality, by the seduction of desire, by vulnerability. The challenge is that public policy should not respond only with taxes, but with real support, with possible alternatives, with the same solidarity that founded the NHS.
If the cigarette leaves scars, it is not so that we can tally the debt, but so that we can understand the wound that keeps it burning. And on this point, Paul, I believe we agree: the fight against tobacco cannot be reduced to an accounting of pounds and figures. It must also be an ethical, social, and political analysis of how to protect the vulnerable without turning them into targets of stigma or punishment.
"no health policy can reproduce, under the pretext of the “common good,” the very inequalities it claims to fight."
I live in Australia where the excise on cigarettes is so high that it has spawned a massive black market. And yet, in the name of 'helping' smokers this is pretty much the argument that those in PH and Tobacco Control make.
"The analogy you proposed, asking “how much do Muslims cost,” is, in my view, dangerous".
I agree, it was poorly chosen. I should have chosen to compare costs with those freely choosing to play sport and other dangerous activities that are all covered by public healthcare.
"My intention was to shift the debate from the biomedical and statistical plane to the social one, to show the cigarette as a marker of class and regional boundaries."
I agree that was clearly your intention. And basically you succeed it doing so. I just happen to be a grumpy former smoker and now vaper that has heard these arguments for years. Do you know that In Australia they calculated the costs of healthcare and social costs of smoking to be 33 billion dollars a year? This calculation was made in 2008! Can you believe that? UK has almost three times the population; and Australia estimates the costs at ten times the amount? So to say it again, I get kind of grumpy when these figures appears.
"In the end, I think we are closer than it seemed at first reading."
I agree and would recommend your approach far more than the current approach of Tobacco Control groups. However, one area I kind of disagree on is that I am much more an individualist. I think giving people the information regarding the harms of smoking is sufficient. Allowing people to freely choose less harmful products such as vapes and nicotine pouches would also go a very long way in reducing the harm. I attach a paper that makes the point about education being the most significant factor in the reduction of smoking.:
https://www.ingentaconnect.com/content/png/ajhb/2022/00000046/00000001/art00008;jsessionid=14dud1vgkxpjm.x-ic-live-03
Anyway, I want to thank you for your extremely generous reply. I know writing takes a lot of time (especially when you write as well as you do) and you must be busy. Cheers
Another excellent blog, Claudio. Those in the lower socioeconomic class often have higher prevalence of smoking rates. Sadly, due to the UK's recent about-turn with regards to safer forms of nicotine (vaping), and insisting they are upgrading regulations, to curb youth appeal. With banning disposables, and later in 2026 taxing vaping e-liquids, even those without nicotine, as well as a possible flavour ban. These proposed draconian polices will not produce fewer smokers. If anything, it will only boost illicit supplies of cigarettes. As well as boost the illicit supply and demand for vaping products. It sends the wrong message to the public by insisting that vaping is equal to smoking. While public health advocates still insist that those who cannot quit smoking with traditional methods, vaping offers them a harm reduction alternative to quit smoking, which can spare them from smoking-related diseases related to combustible tobacco use (cigarettes). I'm sure the same graph would showcase the same results in many other countries. Those in the lower socioeconomic classes, those who identify as LGBTQ+, and those who work in service industries often have higher smoking rates. Over-regulations on vastly less risky forms of nicotine, vapes, Snus, & oral nicotine pouches just keep a population trapped in smoking. Ensuring that a set percentage of people will remain trapped in smoking habits. Public policies should always be based on science and evidence, and not based on fears or ideologies for a nicotine-free world. As a nicotine-free world will never exist. There will always be a set % of people who will use nicotine recreationally. The same as there will always be a set percentage of people who use caffeine, or drink alcohol. A Puritan world will never exist. So why not push for more harm reduction methods in all vices that people may have? Thanks again, I always enjoy reading your blogs/ articles.
Hi Jackie, Thank you very much for your thoughtful comment and for expanding the discussion in such depth.
You've highlighted a critical contradiction: when policies that claim to “protect” the public end up deepening inequalities. As you rightly note, the most vulnerable populations are often the most affected by smoking. Making safer alternatives less accessible through bans, punitive taxes, excessive regulations, or unaffordable products does not reduce harm, but entrenches it.
Framing vaping as the same as smoking is not only scientifically inaccurate, but also ethically wrong and dangerous. It weaponizes fear over evidence and ultimately keeps people trapped in cycles of harm.
I completely agree: public health policy should be based on science, not ideology. And it shouldn't be subject to the desire for profit.
A world without nicotine is as implausible as a world without caffeine or alcohol or sex. The truly good way forward is pragmatic; it is always the most reasonable: to expand harm reduction strategies across all “addictions”, so that public health starts saving lives, not defending unattainable ideals of perfection.
Once again, thank you for your meaningful participation. It's views and comments like yours that make writing worthwhile.