Tobacco in the UK

1
Tobacco in the UK

• Clive Bates
• Director
• Action on Smoking and Health

2
King James I counterblaste

• ...a custome lothesome to the eye, hateful to the
  nose, harmful to the brain, dangerous to the
  lungs, and in the black and stinking fume
  thereof, nearest resembling the horrible stygian
  smoke of the pit that is bottomless (1604)

3
Tobacco in society

• Unique consumer product
• Kills 1 in 2 when used as intended
• Addictive
• Almost unregulated
• Pervasive drug use
• Nicotine self-administration
• Dirtiest possible delivery system
• 10 million dependent on nicotine

4
Who smokes?

• 13m smokers
• 28 men
• 26 women
• 15 professional
• 39 manual unskilled
• 82 start as teenagers
• 70 want to quit
• 4m try in any year
• c. 300,000 succeed
• 10m ex-smokers

5
Health impacts

• Harm to smokers
• 120,000 UK premature deaths per year
• over 50 health impacts
• addiction c.10m dependent in the UK
• Harm to others
• lung cancer, heart disease, asthma
• pregnancy complications and cot death
• 17,000 hospital cases per year in under-5s
• welfare

6
Some impacts

• Cancer
• Heart Circulation
• Respiratory
• 20 fatal illnesses
• 50 non-fatal illnesses
• Widespread addiction
• Cost burden
• Productivity

• Deforestation
• Indoor air pollution
• Waste Litter
• Ozone depleters Pesticides
• Labour exploitation
• Fires
• Criminal activity

7
Smoking since 1948
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Teenage smoking
9
Steep rise in teenage smoking
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Health inequalities
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Smoking and deprivation
UK CIGARETTE SMOKING BY DEPRIVATION
80
70
60
prevalence
1973
50
40
1996
30
20
10
0
0
1
2
3
4
5
Poorest
Most affluent
DEPRIVATION SCORE
Jarvis (1997)
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Politics two views

• A legal adult consumer product that people are
  free to choose if they want to enjoy the pleasure
  of smoking, knowing and accepting the widely
  publicised and usually overstated risks.

• A lethal product with over 50 known health
  impacts - including harm to non-smokers - sold by
  a predatory industry which nurtures teenage
  smoking until nicotine addiction takes over.

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Age at which smokers start
US data 1991, Institute of Medicine
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How it works - part 1
Younger adult smokers are the only source of
replacement smokers... If younger adults turn
away from smoking, the industry must decline,
just as a population which does not give birth
will eventually dwindle. (RJ Reynolds, 1984)
15
Appeal to kids
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How it works - part 2
A cigarette for the beginner is a symbolic act. I
am no longer my mother's child, I'm tough, I am
an adventurer, I'm not square As the force
from the psychological symbolism subsides, the
pharmacological effect takes over to sustain the
habit. (Philip Morris,1969)
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Addiction to nicotine
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Responses

• Informed choice v. disinformation
• Tobacco promotion
• Taxation
• Smoking in public and workplaces
• Smoking cessation support
• Reduce harmfulness of the product

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White Paper Smoking Kills

• Ban tobacco promotion
• Raise taxes and control smuggling
• Help smokers quit - 60m over 3 years
• Public campaigns - 50m over 3 years
• Legal protection in the workplace
• Hospitality industry Charter
• Tighten illegal sales measures
• International approach
• Regulation for the product

20
Tobacco advertising

• the banning of advertising was followed by a
  fall in smoking on a scale which cannot be
  reasonably attributed to other factors
• The balance of evidence thus supports the
  conclusion that advertising does have a positive
  effect on consumption.
• Clive Smee, Chief Economist, UK Department of
  Health 1994

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Advertising ban is broad

• Any commercial communications with the aim or
  effect of promoting tobacco products
• Sponsorship
• Direct mail
• Free gifts
• Promotions
• But some exemptions

22
Tobacco sponsorship

• Phase out by July 2003
• 2006 for Formula One and Embassy snooker
• Subject to conditions
• Reducing money
• Reducing advertising
• Replacement sponsors will be found

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Tobacco promotion

• EU Directive 98/43/EC
• UK regulations in 1999
• Bans advertising in 1999
• Sponsorship in 2003-6
• Brand stretching
• Limited exemptions
• Increased anti-tobacco promotion

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Anti-smoking programmes

• 50 million over three years
• Large increases
• Targets for 2005 and 2010
• 1. Adult smoking 28 gt 26 gt 24
• 2. Pregnant women 23 gt 18 gt 15
• 3. Teenagers 11-15 13 gt 11 gt 9

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Warning...
The tobacco industry has succeeded where many
health education programs have failed because
they capitalize on the deep social needs that
most compel adolescents to fit in, to exert
independence from parental control, and to
demonstrate physical agility and sexual allure.
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Price of 20 cigarettes in 2001
Price 4.21
Taxes 3.34
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Affordability of cigarettes
28
EU tobacco taxation
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Attitudes towards smoking
Source Office of National Statistics, 1997 data
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Passive smoking exposure
Public Places
Home
Work
Health and Safety at Work Act
Charter and market forces
Campaigns and culture
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Smoking at work
32
Cost of smoking at work
Source Health Canada (1995 study) 1 Euro 1.5
C
33
Reality check
34
Workplaces with Smoking Policies (1995)
80 target
Source NOP (1996) Smoking in public places 2nd
survey report
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Health and Safety

• Health and Safety at Work Act (1974)
• "to provide and maintain a safe working
  environment which is, so far as is reasonably
  practicable, safe, without risks to health and
  adequate as regards facilities and arrangements
  for their welfare at work".
• gtgtgtgt Development of Approved Code of Practice
  (ACoP)

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Approved Code of Practice

• ACoP is quasi-legal like Highway Code
• Gives meaning to Health Safety at Work Act
• Employers must take all reasonable and
  practicable steps to reduce or eliminate passive
  smoking exposure
• Presumption in favour of banning smoking
• HSE consultation - decision Spring 2000
• Main concern is hospitality trade and perceived
  conflict with Public Places Charter

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Smoking in public places
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Public places charter
The signatories to this Charter recognise that
non-smoking is the general norm and that there
should be increasing provision of facilities for
non- smokers and the availability of clean air.
39
Public places charter

• Targets to be achieved over agreed timescales
• A written policy on smoking
• Implementation through non-smoking areas, air
  cleaning and ventilation, as appropriate and
  whenever practicable
• Communication to customers through signs
• Monitoring of progress
• Sharing expertise

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Charter signage
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Proportion of non-smokers who live in a household
with at least one smoker
Source SCPR (1996) Health Survey for England,
1995 (under 16s assumed to be non-smokers)
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Smoking cessation

• Money - 60m over three years
• Specialist clinics and NRT
• Health promotion
• Poverty focus
• Health Action Zones
• Free NRT for low income smokers
• Priority guidance to NHS
• Cancer and heart disease strategies

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Cost effectiveness
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Illegal sales

• Illegal to sell to under 16s
• New Enforcement Protocol to address inadequate
  law
• Id cards - good for retailers
• Doubtful efficacy

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Product regulation

• Forthcoming EU Directive
• Tar
• Nicotine
• Additives
• Labelling
• But...
• Low tar approach failed
• Nicotine regulation difficult
• Major rethink needed

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International

• WHO Tobacco Free Initiative
• WHO convention
• Foreign Office guidelines
• Development spending
• EU subsidies (750m)
• Action against smuggling

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Anti-Smuggling measures

• 209m over 3 years
• 1000 Customs officers
• More sanctions and penalties
• Public awareness campaign
• 2.3 - 3.0 bn revenue
• Contain at current levels 20 market cf 36
  without package

48
and the tobacco industry?
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Advertising

• EU Directive overturned
• New primary legislation
• Possible new EU Directive

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Cessation

• NHS National plan
• NICE referral NRT and Zyban
• New sources of information ASH
  website SRNT
  database new
  Thorax guidelines

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Workplace/Public Places

• ACoP future in doubt
• Voluntary approach not acceptable
• Public Places Charter progress slow

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Smuggling

• Gvnt. Policy 209m over 3 years
• Real problem not White van man but organised
  crime
• Need change of tactics licensing and tracking

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Tobacco Regulation

• HSC recommendation re TRA
• EU Product Regulation Directive

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International

• Framework Convention on Tobacco Control
• International collaboration
• Working Groups established

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