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. 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 Some impacts

7. Smoking since 1948

8. Teenage smoking

9. Steep rise in teenage smoking

10. Health inequalities

11. 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)

12. 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. Politics: two views

13. Age at which smokers start US data 1991, Institute of Medicine

14. 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

16. 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)

17. Addiction to nicotine

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

19. 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

21. 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

23. 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

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

25. 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.”

26. Price of 20 cigarettes in 2001 Price = £4.21 Taxes = £3.34

27. Affordability of cigarettes

28. EU tobacco taxation

29. Attitudes towards smoking Source: Office of National Statistics, 1997 data

30. Passive smoking exposure Public Places Home Work Charter and market forces Health and Safety at Work Act Campaigns and culture

31. 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

35. 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)

36. 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

37. Smoking in public places

38. 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

40. Charter signage

41. 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)

42. 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

43. Cost effectiveness

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

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

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

47. 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?

49. Advertising • EU Directive overturned • New primary legislation • Possible new EU Directive

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