Lessons for smoking policy from international experience

1
Lessons for smoking policy from international
experience
Robert West

• University College London
• March 2009

2
Goals of tobacco control
3
WHO Framework Convention on Tobacco Control

• Monitor tobacco use and prevention policies
• Protect people from tobacco smoke
• Offer help to quit
• Warn about the dangers of tobacco
• Enforce bans on tobacco promotion
• Raise taxes

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What about Scotland?

• Scotland is already implementing MPOWER
• Prevalence is falling at the same rate as in
  England
• 24 in 2007
• What next?

GHS 2007
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Population-level model of behaviour incidence

• Participation in behaviours is more common to the
  extent that
• they
• give pleasure or satisfaction
• provide relief from discomfort or drive states
• do not cause concern
• are regarded as acceptable or desirable
• are readily accessible
• do not compete with other behaviours for our time
  or resources
• and stopping
• is not considered normative, attractive or easy

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Smoking in England

• nicotine makes cigarettes pleasurable and
  satisfying for many
• chronic nicotine intake leads to need to smoke
• nicotine hunger and adverse withdrawal symptoms
• most smokers are mildly concerned
• health effects and the cost
• being a smoker is generally acceptable
• cigarettes are very easy to access and use
• being a smoker rarely limits other activities
• stopping is considered desirable and normative
• But varies with social grade ...

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Key attitudinal markers in England
Smoking Toolkit Study www.smokinginengland.info
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Principles for reducing participation in smoking

• Change as many of the parameters affecting
  incidence as possible
• make smoking less pleasurable
• strengthen competing behaviours
• reduce the need to smoke
• increase concerns about smoking
• make smoking less acceptable
• increase smoking restrictions
• actively promote cessation

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Behaviour change in practice the EPICURE
classification

• Education
• increasing awareness and understanding
• Persuasion
• changing attitudes
• Inducement
• offering incentives
• Coercion
• providing disincentives

• Upskilling
• improving capacity
• Regulation
• establishing rules regarding use, access and
  promotion
• Empowerment
• reducing barriers

West R. Tobacco control present and future. Br
Med Bull. 200677-78123-36.
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Education

• Effective when it raises concern
• Probably the main driver of the prevalence
  reduction in some countries in the 1960s and
  1970s
• Essential to maintain concern in new generations
• Still major pockets of ignorance to work with
• lasting damage to offspring from smoking in
  pregnancy
• link with dementia
• 3 months loss of life for every year continuing
  to smoke after age of 40
• bring old age on earlier
• countering the 90 year-old smoking granny
  fallacy
• effective methods of stopping

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Persuasion

• Raises concern and triggers quitting
• Uses imagery and social pressure
• Media campaigns drive spikes in cessation
  activity and use of support (telephone helplines,
  medication use, use of NHS services)
• Events (New Year, No Smoking Day) can provide a
  cost-effective hook for campaigns
• Could be improved
• greater saturation of multiple channels
• greater use of news and current affairs
• more focus on triggering immediate action and use
  of support services
• denormalise smoking and normalise stopping
• more focus on disadvantaged smokers

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Inducement

• Occasionally used
• Quit and Win competitions
• can trigger quit attempts
• Other incentives
• payments for quitting
• one study found increased cessation in pregnant
  smokers
• overall no clear evidence of lasting effect
• recent NEJM paper (Volpp 2009) suggests potential
  lasting effect but needs replication with better
  design

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Coercion

• Potentially highly effective but can be unpopular
• Outright bans are currently rare
• Taxation and controls on smuggling are pivotal to
  any tobacco control strategy
• price elasticity for consumption -0.4
• smuggling at current levels will kill 4000 people
  per year (West et al, 2008)
• Considerable room for further action
• idea of raising price is popular in England, even
  among smokers
• support for outright ban on sale of cigarettes is
  surprisingly high in England (45 Smoking
  Toolkit Study)
• use of price is undermined by
• roll-your-own (1.90 per 20 versus 4.80 for
  manufactured)
• smuggling and counterfeit (average of 52p less
  per so cigs in those who smoke at least some
  smuggled cigs Smoking Toolkit Study)

14
Upskilling

• Not widely used in tobacco control
• Studies have looked at social skills training to
  resist peer pressure to smoke no clear evidence
  for effectiveness

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Regulation

• Believed to play a major role in tobacco control
  but needs popular support
• age of sale
• ad bans
• clean air laws
• restrictions on labelling (use of term low tar)
• Major room for improvement
• better enforcement of age of sale
• more complete ban on promotion (point of sale,
  plain packaging)
• extensions to clean air areas (e.g. cars
  containing children)

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Empowerment

• Major component of tobacco control in several
  countries (UK, US, Japan, Spain, Taiwan ...)
• Treatment of choice
• NHS service offering behavioural support plus
  medication
• highly cost-effective
• Major room for improvement
• make sure NHS service is optimally configured
• pharmacy support has low success rates compared
  with specialists
• better promotion to improve uptake

17
Community interventions

• Package education, persuasion and empowerment at
  local level
• local media campaigns and promotional events
• promotion of support services
• Little track record yet but some evidence of
  effectiveness from experimental studies

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Conclusions

• In a country such as Scotland, the following
  additional measures merit consideration
• raising the price to smokers (through UK
  government action to increase taxes and reduce
  smuggling)
• extending regulation to reduce opportunities to
  smoke and promotion
• improving effectiveness and reach of treatment
  for nicotine dependence
• increasing media spend on campaigns directed at
  triggering cessation attempts
• concerted community campaigns targeting areas of
  high prevalence