Tobacco in the UK

Clive Bates

Director

Action on Smoking and Health

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)

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

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

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

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

Smoking since 1948

0

10

20

30

40

50

60

70Percentage

MenWomen

Teenage smoking

Steep rise in teenage smoking

Regular smokers age 11-15

4

6

8

10

12

14

16

BoysGirls

Health inequalities

0

50

100

Richest Poorest

Lung cancer incidence

0

20

40

60

Richest Poorest

Smoking prevalence

Smoking and deprivation

0 1 2 3 4 50

10

20

30

40

50

60

70

80

% p

reva

len

ce

UK CIGARETTE SMOKING BY DEPRIVATION

1973

1996

DEPRIVATION SCOREMost affluent Poorest

Jarvis (1997)

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.

Age at which smokers start

16

73

11

0

10

20

30

40

50

60

70

80

Percentage of smokers

by age 12 13 to 17 after 18

US data 1991, Institute of Medicine

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)

Appeal to kids

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)

Addiction to nicotine

Responses

• Informed choice v. disinformation

• Tobacco promotion

• Taxation

• Smoking in public and workplaces

• Smoking cessation support

• Reduce harmfulness of the product

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

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

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

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

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 £0

£10£20£30£40£50£60£70£80£90

£100

Tobacco Publichealth

NRT

Tobacco v health spending (£m)

Anti-smoking programmes

• £50 million over three years

• Large increases

• Targets for 2005 and 20101. Adult smoking 28% > 26% > 24%

2. Pregnant women 23% > 18% > 15%

3. Teenagers 11-15 13% > 11% > 9%

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.”

Price of 20 cigarettes in 2001

£0.85 £2.74 £0.63

Price = £4.21

Taxes = £3.34

Affordability of cigarettes

EU tobacco taxation

£0.00

£0.50

£1.00

£1.50

£2.00

£2.50

£3.00

£3.50

Tax

per

20

ciga

rett

es

Attitudes towards smokingSmoking status

Percent agreeing that smokingshould be restricted…

Currentsmoker

Ex-smoker

Neversmoked

All adults

…at work 69 86 92 84

…in restaurants 69 88 93 85

…in pubs 24 57 64 51

…in other public places 70 86 89 85

Source: Office of National Statistics, 1997 data

Passive smoking exposure

WorkPublic Places

Home

Health and Safety at Work Act

Charter and market forces

Campaigns and culture

Smoking at work

Cost of smoking at work

Cost Factor Cost/smokerAbsenteeism C$230

Lost productivity C$2,175Life insurance C$75Smoking areas C$85

Source: Health Canada (1995 study) 1 Euro = 1.5 C$

Reality check

Workplaces with Smoking Policies (1995)

77%

71%

63%

62%

53%

48%

38%

36%

14%

Schools & Colleges

Hospitals and Clinics

Shops

Libraries Museums

Cinemas & Theatres

Banks & Post Offices

Travel

Restaurants &Cafes

Pubs

80% target

Source: NOP (1996) Smoking in public places: 2nd survey report

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".

>>>> Development of Approved Code of Practice (ACoP)

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

Smoking in public places

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.

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

Charter signage

Proportion of non-smokers who live in a household with at least one smoker

47

40

21 19

26

18

12

6

0

10

20

30

40

50

60

under16

16-24 25-34 35-44 45-54 55-64 65-74 75+

Percent

Source: SCPR (1996) Health Survey for England, 1995 (under 16s assumed to be non-smokers)

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

Cost effectiveness

Cost of saving one year of life

£0

£5,000

£10,000

£15,000

£20,000

Smoking cessation Typical intervention

Illegal sales

• Illegal to sell to under 16s

• New ‘Enforcement Protocol’ to address inadequate law

• Id cards - good for retailers

• Doubtful efficacy

Product regulation

• Forthcoming EU Directive– Tar– Nicotine– Additives– Labelling

• But…...– Low tar approach failed – Nicotine regulation difficult – Major rethink needed

International

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

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

…and the tobacco industry?

Advertising

• EU Directive overturned

• New primary legislation

• Possible new EU Directive

Cessation

• NHS National plan

• NICE referral NRT and Zyban

• New sources of information: ASH website SRNT database new Thorax guidelines

Workplace/Public Places

• ACoP future in doubt

• Voluntary approach not acceptable

• Public Places Charter – progress slow

Smuggling

• Gvnt. Policy £209m over 3 years

• Real problem not ‘White van man’ but organised crime

• Need change of tactics: licensing and tracking

Tobacco Regulation

• HSC recommendation re: TRA

• EU Product Regulation Directive

International

• Framework Convention on Tobacco Control:

• International collaboration

• Working Groups established