Beyond “Smoking Kills” ACTION ON SMOKING AND HEALTH

Beyond “Smoking
Kills”
A Submission to the
Choosing Health? Consultation from:
ACTION ON SMOKING AND
HEALTH
May 2004
“Just as it is wrong to see action on health as solely a matter for the Government, so it is wrong to say
that Government has no role. We have to strike the right balance between the contributions that the
Government and others will make.”
Dr John Reid, Secretary of State for Health, Foreword to “Choosing Health?”
“Acts of whatever kind, which, without justifiable cause, do harm to others, may be, and in the more
important cases absolutely require to be, controlled by the unfavourable sentiments, and, when
needful, by the active interference of mankind. The liberty of the individual must be thus far limited; he
must not make himself a nuisance to other people.”
John Stuart Mill “On Liberty”, Chapter 3
Contents
Executive summary and conclusions
Summary of Recommendations
Introduction
Secondhand smoke in the workplace
Tobacco and nicotine regulation
Media, advertising and publicity
Pricing and taxation
Supporting quitters, cutting prevalence
APPENDIX 1
Responses to Choosing Health? consultation questions on smoking
P.14
What else can the Government do to ensure that people don’t start smoking and if they
do to support them to stop?
P.13
Who else in society should be involved in helping people not to start smoking and
supporting those who start to stop?
P.14
Should alternative ways for smokers to get nicotine be more widely available?
P.11
Should the Government pass a law to make all enclosed workplaces/public places
smokefree? What about restaurants? What about pubs and bars? Would local
authorities be better placed than central Government to introduce laws?
P. 13 Apart from bans how else could local towns and cities respond to calls for more
smokefree public places?
P.15
Who else apart from Government could be involved in media campaigns to help people
stop smoking?
Executive summary and conclusions
1) Smoking is the biggest single cause of preventable illness and premature death in the United
Kingdom, killing 106,000 people each year. It is also the biggest single cause of inequalities in
health.
2) Therefore, improving the nation’s health requires a significant reduction in the number of people
who smoke. This is not easy to achieve. Although 70% of smokers want to give up, less than 5%
succeed each year. Tobacco in smoked form is the most highly addictive drug legally available
and 90% of regular smokers start smoking before they are 18.
3) The Government already accepts the case for intervention to prevent people from starting to
smoke and, once they’ve started, to help them give up. In 1998 it published the White Paper
”Smoking Kills”, which set out the strategy for achieving this. However, the White Paper targets are
not sufficient to achieve the ‘fully engaged scenario’ set out in successive reports to Government
by Derek Wanless.
4)
According to Wanless, this would require a fall in the number of smokers from 26% now to 17% of
the population by 2011 and 11% by 2022. The Government will not be able to contain NHS
spending as proposed under the ‘fully engaged scenario’ unless these targets are achieved. If
current rates of decline in smoking prevalence continue, smoking prevalence will still be at 22% by
2011, and it would take twenty years to reach Californian levels - 17% [1]. Therefore, tobacco
strategy will need to be revised and updated as part of a new public health strategy in order to
achieve these ambitious new targets.
5) Public health must be given the priority it requires at Cabinet level and across all Government
Departments, including not just the Department of Health but also the Office of the Deputy Prime
Minister, the Department for Culture Media and Sport, the Department for Work and Pensions and
the Treasury. One way of helping achieve this might be to give a specific Minister responsibility for
public health in all relevant Departments.
6)
A national coalition should be set up to oversee the new tobacco strategy under the Public Health
Minister. This should involve Government officials, public health experts, health charities, medical
associations, local government representatives, local tobacco control alliances, employers and
trade unions.
7) The national strategy must also be put into effect at a local level, which will require a greater
degree of co-ordination and planning between NHS Trusts, local government and other key
players at local level.
8) Our detailed recommendations for improvements to the tobacco strategy are set out under the
following headings:
1) Reduce involuntary exposure to tobacco smoke pollution, by requiring all workplaces to be
smokefree;
2) Revise nicotine regulatory structures to allow appropriate development, pricing and promotion
of non-smoked cleaner nicotine products as alternatives to cigarettes;
3) Continue investment in long-term mass media and public education campaigns to motivate
and encourage quitting and to ‘de-normalise’ smoking;
4) Maintain a policy of increasing prices (through taxation and control of smuggling) to ensure
tobacco does not become more affordable over time;
5) Sustain and improve provision of effective treatment services for smokers who want to stop;
6) Enforce the advertising ban and close loopholes as they appear; and
7) Improve surveillance and reporting of market data to inform more effectively the development
of tobacco control policy.
Summary of Recommendations
Main recommendations given in bold, followed by detailed proposals
Public health must be given greater priority at Cabinet level and across all Government
Departments. One way of helping achieve this might be to give a specific Minister
responsibility for public health in all relevant Departments (such as the Department for
Work and Pensions, DCMS, the Office of the Deputy Prime Minister etc.).
The national strategy must also be put into effect at a local level, which will require a
greater degree of co-ordination and planning between NHS Trusts, local government
and other key players at local level.
A national coalition, under the Public Health Minister, should be set up to oversee the
development of the new tobacco strategy. The key elements of an improved,
comprehensive tobacco control strategy are set out below.
1) Reduce involuntary exposure to tobacco smoke pollution by requiring all
workplaces to be smokefree.
a) List secondhand smoke as a carcinogen under the EU Directive on carcinogens. This can be
done at UK level by listing under the COSHH (Control of Substances Hazardous to Health)
Regulations.
b) Introduce legislation equivalent to that which came into force in Ireland on 29th March 2004,
setting out more specific conditions [2] to restrict smoking in all workplaces and enclosed public
places.
c) Alternatively, in the absence of legislation with a general national application, legislation
should be enacted giving:
i) local authorities powers to end smoking in all workplaces in their jurisdictions.
ii) the Secretary of State the power to require appropriate forms of consultation with local
businesses and residents; and
iii) Setting national floor standards to limit the extent of permissible exposure to tobacco
smoke pollution.
d) Whether option b) or c) is preferred, local authorities should be encouraged to develop a
comprehensive local strategy to reduce local smoking prevalence rates, working with local
NHS trusts and other employers as well as other stakeholders. See Appendix 1 for a template
which can be used as a basis for such a local strategy.
2) Revise nicotine regulatory structures to allow appropriate development, pricing
and promotion of non-smoked cleaner nicotine products as alternatives to
cigarettes.
a) A new tobacco and nicotine regulatory framework should be established to enable such
products to be developed and promoted, independent of the industry.
b) The aim should be to minimise the proportion of regular nicotine users in society, and amongst
them, to minimise the proportion regularly obtaining nicotine through smoked tobacco.
c) The cost of regulation should be charged to the tobacco industry, on the ‘polluter pays’
principle, for example through taxation or through a system of licensing.
d) One option would be to expand the remit of an existing regulatory agency, for example the
Medicines and Healthcare Products Regulatory Authority, which already regulates some
nicotine products, or the Health Protection Agency, which has responsibility for protecting
people’s health and already has oversight of poisons and chemical substances. Introducing
regulation in this way could be achievable in the short term.
e) An alternative would be to establish a new Tobacco and Nicotine Products Regulatory
Authority, to regulate all nicotine and tobacco products. This would have a clear and specific
role, but might take longer to establish.
f) A simple first step for the regulator, which could save more than a hundred lives every year,
would be to require tobacco companies to make fire safe cigarettes which self-extinguish [3].
3) Continue investment in long-term mass media and public education campaigns to
motivate and encourage quitting and ‘denormalise’ smoking.
a) Long-term mass media and public education campaigns will be needed for the foreseeable
future, to encourage smokers to quit and to ‘denormalise’ smoking. A comprehensive review
and analysis of the effectiveness of the public education campaigns over the last 5 years is
needed, to ensure that future spend is set at optimal levels and that messages are sharply
defined and effectively delivered.
b) This review should analyse whether partnerships in delivering such campaigns, such as those
with Cancer Research UK and the British Heart Foundation, are cost effective and should be
continued.
c) The review should also be used to help develop a national marketing strategy for the stop
smoking services.
4) Maintain a policy of increasing prices, to ensure that tobacco doesn’t become more
affordable. This will require both tax rises above inflation and firm action on
smuggling.
a) The UK Government should work to support the development of specific international
protocols with binding obligations on smuggling, to ensure that the Framework Convention on
Tobacco Control (FCTC) is fully effective once ratified.
b) The National Audit Office should be asked to produce and publish a report by the end of 2004
on the effectiveness of HM Customs and Excise’s current tobacco smuggling strategy and how
it might be improved.
5) Further improve provision of effective treatment services for smokers who want to
stop and target services at areas with high prevalence rates
a) Targets for cessation services should be re-framed to cover both referrals and success rates
(both of which are routinely collected by the DH). In order to bring the level of the least
b)
c)
d)
e)
f)
g)
successful services up to those of the most successful, further best practice guidelines need to
be developed and widely implemented.
A question should be added to current performance indicators to ensure that PCTs are
required to demonstrate how they have targeted smokers from deprived groups.
NHS Trusts and local health partners, including local authorities, should work together to
collect local prevalence data (e.g. by ward and social class), and then to set and monitor
targets for reducing prevalence rates.
Smoking status should be recorded in all patients’ records and all smokers should be given
brief advice at every stage of their treatment by doctors and other health professionals and,
where appropriate, be referred to specialist stop smoking services.
There should be encouragement to GPs to offer as an enhanced service specialised stop
smoking services via their practice nurses or other suitably trained primary care team
members. The quality of such services needs to be carefully monitored and maintained.
A major programme of education to engage health care professionals in implementing good
cessation practice, is now essential. This should be implemented at undergraduate and
postgraduate levels.
Smoking cessation needs to be fully integrated as a high priority into clinical guidelines for all
chronic diseases influenced by smoking in the community and in secondary care. This should
include cardiovascular disease, respiratory disease, diabetes, and all others where smoking
affects outcomes significantly.
6) Enforce the advertising ban and close loopholes as they appear
a) The British Board of Film Classification is currently consulting on its guidelines for film ratings
and is asking respondents their views on smoking. We recommend that the Department of
Health make contact with the BBFC and discuss with them what guidelines would be desirable
covering the depiction of smoking in films. We suggest that wording along these lines would
be helpful: “Smoking kills. It is therefore desirable that films generally should only show
smoking when there is a clear editorial case for its inclusion. Smoking in films up to, and
including, category 15 should be avoided where possible and smoking should not be portrayed
directly or by implication as a glamorous or desirably ‘adult’ activity.”
b) OFCOM are also currently consulting on new standards codes, which allow for the protection
of young people under 18. We recommend that the Department of Health make contact with
OFCOM, discuss with them the desirability of continuing to restrict smoking in TV programmes,
and suggest that wording along these lines would be helpful: “Smoking Kills. It is therefore
desirable that programmes generally should only include smoking when there is a clear
editorial case for its inclusion. Smoking in programmes for children, and those popular with
children, should be avoided where possible. Smoking should not be portrayed directly or by
implication as a glamorous, or desirably ‘adult’ activity.”
c) Graphic health warnings on cigarette packs are effective [4] and the Government should seek
to introduce these in line with the new EU Directive at the earliest possible opportunity.
d) Cigarette packaging should be generic to reduce the branding and perceived positive image of
cigarette pack designs.
7) Improve surveillance and reporting of market data to inform more effectively the
development of tobacco control policy
a) An annual report on the tobacco market should be published. This should detail its structure,
price variations within categories, calculated price-elasticities, consumption patterns by socioeconomic group, ethnicity, age, sex and other demographics, market share by brand and so
on.
b) A smoking module, covering knowledge, attitudes and behaviour, should be incorporated in
the ONS Omnibus survey every month. The results should be made widely available, in order
to be able to, for example, monitor the impact of media campaigns or price changes on
smoking prevalence.
c) Existing data relating tobacco price and smoking, particularly of smuggled product, are
inadequate to determine effects on consumption and cessation. New ways of studying this
important policy issue need to be found.
d) A longitudinal panel survey should be established specifically to monitor smoking behaviour
and its response to policy initiatives.
Introduction
1. The sharp fall in UK smoking prevalence between the 1970s and 1990s - the largest fall in the
world over that period - has now slowed considerably. The following graph shows a levelling out at
around 27% in 1994. This graph is based on General Household Survey (GHS) data, which show
a prevalence rate of 26% in 2002. ONS Omnibus survey data, which are more frequent and up-todate than GHS, and appear to be comparable, suggest that smoking prevalence is again in
decline, but the rate appears to be slow - about 0.4% per year.
Prevalence of smoking of manufactured cigarettes in Great Britain 1974 – 2022
(Source: 1974 – 1998 General Household Survey; 2000 – 2002 ONS; 2002 – projected) [5]
2. Health inequalities by class have actually increased over time, as the decline in smoking
prevalence has been far higher in social class I than in other social classes. Smoking is the
greatest single factor in the different life expectancy between social classes. The Wanless Report
gave the following table (5.1):
Proportion of Males Dying Under Age 70
Social Class I
Social Class V
Difference
Actual proportion
22%
48%
26%
Actual proportion
predicted if all
Estimate proportion
attributed to
15%
27%
12%
attributed to
smoking
7%
22%
15%
Source: Department of Health analysis
3. Local data on smoking prevalence, broken down to ward or community level, are often not
available. Where they exist, they illustrate the close link between smoking and deprivation, (see
the map overleaf of Blackpool). Smoking prevalence rates are highest in social class V. As a
result those in social class V who do not smoke are more likely than other non-smokers to be
exposed to secondhand smoke at work.
4. The impact of smoking on health inequalities is carried down from generation to generation.
Children whose parents smoke are three times as likely to smoke themselves and are also more
heavily exposed to the harmful effects of tobacco smoke pollution.
5. In consequence children from more deprived families have a higher risk of cot death, the onset of
asthma as well as asthma attacks, respiratory diseases and ear infections. (1.5 million children in
the UK have asthma – one in seven). Children in social class V may be doubly disadvantaged
because they are also more likely to go on to become smokers themselves and suffer the ill effects
of smoking, in particular lung cancer, heart disease and lung disease.
6. The key conclusion from this data is that progress towards tackling the most fundamental
characteristic of social inequality (life expectancy) cannot be made without progress in cutting
smoking prevalence.
7. Since 90% of regular smokers start smoking at or before the age of 18 [6] it might seem logical to
conclude that policies aimed specifically at preventing young people from starting smoking would
be effective. However, research shows that unless they are part of comprehensive programmes,
youth smoking prevention policies are largely ineffectual. At best they may delay the onset of
smoking but have little impact on overall smoking prevalence [7].
8. So what does work? The best evidence on this comes from California where a comprehensive
tobacco control strategy has led to significant falls in smoking both amongst adults and amongst
young people. Smoking prevalence is now around 17% for the population as a whole. The
evidence shows that the most effective policies in helping to protect children from secondhand
smoke, by reducing adult smoking, are also likely to be most effective in preventing children from
starting smoking themselves.
9. This Government has already put in place many of the key planks of a comprehensive tobacco
control strategy, as set out in its white paper on tobacco, Smoking Kills, published in 1998. These
include stop smoking services, an advertising ban, public education and mass media campaigns
and a policy of maintaining high prices to ensure that tobacco does not become more affordable
over time. However, this strategy needs updating and improving if it is to meet the new and
tougher targets suggested in the Wanless report.
10. ASH’s recommendations on how this can be achieved, with supporting evidence, and answers to
the detailed questions on tobacco included in the “Choosing Health?” consultation document, are
contained in the body of this report.
Secondhand smoke in the workplace
•
Should the Government pass a law to make all enclosed workplaces/public places
smokefree? What about restaurants? What about pubs and bars? Would local authorities
be better placed than central Government to introduce laws?
11. Legislation to require all employers to ensure that their workplaces are smokefree is a key public
health measure for three reasons. Firstly, secondhand smoke is dangerous to the health of nonsmokers and in particular is a workplace health and safety risk. Secondly, ending smoking in the
workplace would be probably the single simplest and most effective means of cutting smoking
prevalence rates. Thirdly, this intervention would most benefit poorer and socially excluded
communities.
12. When a workplace goes smokefree it can reduce smoking prevalence amongst workers by up to
4% [8]. Currently we know that people in lower paid jobs are far more likely to work in places
where smoking is allowed, so legislation on smokefree workplaces would also help reduce health
inequalities.
13. For young people smoking is a social activity. It has been described by Professor John Britton
(Professor of Public Health at Nottingham University) as “like an infectious disease which spreads
from one person to another”. Therefore smokefree legislation which prevents young people from
smoking in coffee bars, pubs, bars, clubs and other places they congregate is an effective means
of reducing the numbers starting to smoke. For example, research has shown that young people in
colleges with a no-smoking policy for staff and students were half as likely to smoke as those in
colleges that allowed smoking. And those who did smoke consumed fewer cigarettes [9].
14. In addition there is evidence from Victoria, Australia that smokefree workplaces can be effective in
reducing smoking in the home. In 1989 just 17% of workers were protected by a ban on smoking
in the workplace. By 1995 this had risen to 66%. It is reported that the proportion of adults not
smoking in front of children rose from 14% in 1989 to 33% in 1996. Those who worked in places
where smoking was totally banned were more likely to ask their visitors not to smoke than those
who worked where smoking was allowed [10].
15. The case for legislation to end smoking in the workplace was given strong support by Derek
Wanless in his recent report to the UK Government on public health (“Securing Good Health for
the Whole Population”). He stated that: “voluntary approach to smoking in the workplace has had
limited success” and that “A number of other countries have now implemented a workplace
smoking ban via legislation. Some of this experience has been shown to be successful in reducing
the prevalence of smoking. Public support for smoking restrictions has also been found, in
surveys, to be high…” (para 4.21). “Some studies estimate that a workplace smoking ban in
England might reduce smoking prevalence by around 4 percentage points – equivalent to a
reduction from the present 27 per cent prevalence rate to 23 per cent if a comprehensive
workplace ban were introduced in this country.” (Box 4.2).
16. In its “Big Conversation” consultation document, intended to guide drafting of Labour’s manifesto
for the next General Election, the Government has suggested new powers for local authorities to
act on smoking at work and in enclosed public places. The specific question put in the document
is: “Should local authorities have new powers to introduce smoking bans at work and in public
places?” (http://www.bigconversation.org.uk/index.php?id=701).
17. This proposal was also given some support by Derek Wanless: “If national restrictions are not
introduced, an equivalent city or town in England [to New York] could act as a champion for
smoke-free public places across the country and make a real impact on the health of their
population, whilst piloting a ban on smoking in public places in England” (Box 4.2).
18. Smoking restrictions generally do not require intensive or costly enforcement. This has been the
experience in Ireland and New York, and of course on the London Underground, other UK metro
systems, buses and elsewhere. The reason for this is that such restrictions are generally observed
by popular consensus – they combine the power and advantages of the “unfavourable sentiments”
and “active interference” noted by John Stuart Mill.
19. Support for such legislation is strong across social classes. In particular, support is high among
social classes C2 and DE and higher than might be expected given relative smoking prevalence
rates. A March 2003 national poll by MORI gave the following % results by social class for two
propositions:
1. “all employees should be able to work in a smoke-free environment”
2. “waiters and waitresses in cafés and restaurants should be able to work in a smoke-free
environment”
% agreeing with the following
statements
all employees should be able to work
in a smoke-free environment”
waiters and waitresses in cafés and
restaurants should be able to work in
a smoke-free environment”
AB
C1
C2
DE
87
80
74
70
84
76
75
70
Source: MORI March 2003 sample size 1972
20. The least support for restrictions on smoking relates to pubs. But even here, amongst routine and
manual workers sampled in the 2002 ONS survey, 46%, or nearly half, supported restrictions on
smoking, compared to 65% of managerial and professional workers. Pubs are among the
workplaces with the highest levels of exposure to tobacco smoke amongst employees. Therefore if
the principle is accepted that employees should be protected from this serious health and safety
risk, it would not be justified to exclude pubs from any regulations.
Recommendations
21. The simplest and most effective means of achieving smokefree workplaces would be
regulation at national level. A major step in this direction would be to list secondhand
smoke as a carcinogen under the EU Directive on carcinogens. This can be done at UK
level by listing under the stringent COSHH (Control of Substances Hazardous to Health)
Regulations.
22. However, this may not be sufficient on its own to ensure all workplaces went smokefree in
the near future, because it would require employers to undertake risk assessments and
might also not be sufficiently prescriptive.
23. A second possible step would be legislation equivalent to that which came into force in
Ireland on 29th March 2004, setting out more specific conditions [11]. It may be that both
these steps are desirable or necessary to achieve the objective of ending smoking in the
workplace.
24. Legislation at a national level would be the simplest, least costly and most practicable
means of implementing smokefree workplaces. The evidence from Ireland and elsewhere is
that it would work and would not be costly to enforce. Key opinion formers in the
hospitality trade, which is concerned about the impact of differential implementation of any
smokefree regulation, would prefer national legislation as it ensures a level playing field for
all [12].
•
Who else in society should be involved in helping people not to start smoking and if they
do to support them to stop?
•
Apart from bans how else could local towns and cities respond to calls for more smokefree places?
25. However, in the absence of legislation with a general national application, legislation
enabling local authorities to act in this area would be a welcome and important step in the
right direction. Such legislation should:
i) Give local authorities the power to end smoking in all workplaces in their jurisdictions,
perhaps on a staged basis where the authority feels this would be appropriate, to allow
for adjustment periods for the hospitality trade etc.
ii) Give the Secretary of State the power to require appropriate forms of consultation with
local businesses and residents. These could range from stating an intention and
seeking opinions to staging a local referendum, as the Government feels appropriate.
iii) Set national floor standards to limit the extent of permissible exposure to tobacco
smoke pollution.
26. For simplicity and impact, it would be preferable – subject to consultation and staging
options as set out above – to make any new power for local authorities as simple as
possible. Local authorities could either act to ban smoking in all workplaces in their areas
or not – they would not get complex powers to, for example, make detailed regulations
about smoking and non-smoking areas.
27. If this route is preferred, consideration would need to be given to the appropriate level of
authority to exercise this new power. In areas covered by unitary authorities the answer
would be obvious, but there are clear policy issues to be resolved in other areas. In
London, for example, it might make sense to give the power to the Mayor or London
Assembly, rather than the Boroughs. A London-wide ban would be more logical and
present a lesser business risk than bans in some individual Boroughs, but not others.
28. Local authorities should be encouraged to view any new powers to end workplace smoking
as a key part of a comprehensive local strategy for tobacco control, which would engage
local NHS Trusts and other employers as well as Councils. The White Paper should
certainly recommend that local authorities work together with their local health authorities
and other key partners to cut local smoking prevalence rates.
29. Attached in appendix 1 is a template for local action developed by a consultant working
with ASH and public health experts, which local authorities could use as the basis for
designing such a local strategy. The Government and local authority associations should
work together to develop existing health, social and economic regeneration partnerships to
ensure that setting public health objectives and funding specific projects to help achieve
them are part of the core work of these partnerships.
Tobacco and nicotine regulation
•
What else can the Government do to ensure that people don’t start smoking and if they do
to support them to stop?
•
Should alternative ways for smokers to get nicotine be more widely available?
30. The public health goal in relation to smoking tobacco must be to reduce the death and disease it
causes. It is not simply to reduce tobacco or nicotine consumption as an end in itself. It should not
be forgotten that it is the tobacco smoke that kills people not the nicotine, but it is the nicotine that
people are addicted to and not the tobacco smoke.
31. There is now substantial experience with medicinal nicotine. It is at least 100 times less risky than
smoked tobacco, and has only a few and relatively minor negative effects on health. However,
clean nicotine is currently only available as an aid to giving up smoking.
32. Nicotine is an addictive drug in precisely the same sense as are many illegal drugs, such as
heroin and cocaine. Harm reduction strategies are an important part of work to cut the damage
cause by illegal drugs; the same principle now needs to be applied to nicotine. Not all nicotine
addicts will readily or quickly succeed in breaking their addiction, but all can be helped to stop
consuming their drug by the dangerous and damaging means of smoking cigarettes.
33. New products are therefore needed to give people access to clean forms of nicotine in a form and
at a price that is attractive as an alternative to smoking. Otherwise many thousands each year will
continue to die unnecessarily, and as shown in paragraphs 1 to 9 above, these deaths will be
concentrated amongst the poorer and more disadvantaged sections of society.
34. This kind of harm reduction is practicable and there is clear evidence that it can work. For
example, in Sweden the proportion of men using smokeless tobacco is roughly the same as the
proportion who smoke. Sweden has the lowest standardised rate of lung cancer incidence in the
world and a low rate of oral cancer which has been falling over the last two decades. Harm
reduction strategies have contributed to these health gains.
35. Use of smokeless tobacco, as with medicinal nicotine products, avoids exposure to the products of
combustion. Currently only tobacco for oral use that is intended to be smoked or chewed is legal in
this country. Smokeless tobacco in the oral snuff form used in Sweden, also called snus, is
banned.
36. If, as a result of a current legal challenge to the EU by Swedish Match, oral snuff is legalised, it
should be within the context of regulation for toxicity of all smokeless (and smoking) tobacco. Such
regulation could ensure that smokeless tobacco products on the market are 10-100 times less
dangerous than cigarettes and much closer in risk to medicinal nicotine than smoked tobacco.
However, consumer information and labelling of such products should be strictly controlled by the
regulator. This is to prevent them from being used to attract new audiences to tobacco use and to
avoid misperception among current users of smokeless tobacco that the products they currently
use are safe.
37. Revision of the current regulatory system would be required. This is because less harmful nicotine
products competitive with cigarettes are currently either not licensed for use in this country or are
not being developed. Even if they were developed, they could not be promoted, because of
regulatory obstacles.
38. As pointed out by the Royal College of Physicians [13] and others, there is enormous potential to
narrow health inequalities and dramatically cut the numbers dying from smoking by substituting
safer forms of nicotine for smoked tobacco. It would be a major lost opportunity if policy
recommendations on this were not included in the white paper.
Recommendations
39. A new tobacco and nicotine regulatory framework is needed, independent of the tobacco
and pharmaceutical industry, which would enable such products to be developed and
promoted. The remit should be to minimise the proportion of regular nicotine users in
society, and amongst them, the proportion regularly obtaining nicotine through smoked
tobacco.
40. An assessment should be made of the funding required to regulate tobacco and nicotine.
There are already existing models which give a good idea of the potential range. For
example, the Canadian tobacco regulatory authority employs around 140 people at an
annual cost of around £40 million, while the Irish Office of Tobacco Control employs only
13 people with a budget of under £2 million. The cost would be insignificant compared to
the £8 billion raised from tobacco taxes each year and the £1.5 billion smoking is estimated
to cost the NHS annually.
41. Consumer understanding would also need to be improved through public education
campaigns. Currently most smokers don’t understand that it is the smoke and not the
nicotine that does them harm. Unpublished data from October 2002 found that 57% of
smokers believed that it was the nicotine that caused most of the cancer from smoking.
42. The cost of regulation should be charged to the tobacco industry, on the ‘polluter pays’
principle, for example through taxation or through a system of licensing. However, given
the past behaviour of the tobacco industry [14] it would be critically important to prevent
regulatory capture and therefore the regulators and the regulatory process would have to
be completely independent from the industry.
43. One option would be to expand the remit of an existing regulatory agency, for example the
Medicines and Healthcare Products Regulatory Authority, which already regulates nicotine,
or the Health Protection Agency, which has responsibility for protecting people’s health
and already has oversight of poisons and chemical substances. Introducing regulation in
this way could be achievable in the short term.
44. An alternative would be to establish a new Nicotine Products Regulatory Authority, to
regulate all nicotine and tobacco products. This would have a clear and specific role, but
might take longer to establish.
45. A simple first step for the regulator which could save many lives a year would be to require
tobacco companies to make fire safe cigarettes which self-extinguish [15]. Currently over
6,000 fires are caused each year in the UK by cigarettes and other tobacco products,
leading to over 100 deaths and around 2,000 non-fatal injuries. These tend to be
concentrated amongst those from poorer social classes.
46. If these recommendations are adopted, we would expect, within two to five years, to see
new less harmful, but more attractive, products in development and being market-tested. If
only one quarter of all smokers converted to using alternative cleaner nicotine sources,
this could save tens of thousands of lives a year longer-term.
Media, advertising and publicity
•
Who else apart from Government could be involved in media campaigns to help people
stop smoking?
47. If the reductions in smoking prevalence envisaged by Wanless are to be achieved, and stop
smoking services are to reach their increased targets, a national marketing strategy including
sustained mass media campaigns will be necessary.
48. Advertising also needs to continue to address smoking in the home and exposure of children both
at home and in public places. Self-enforced restrictions on smoking at home are effective in
reducing exposure to children but are currently imposed by less than one fifth of households [16].
49. Advertising can also reduce smoking among young people [17].
50. Public education campaigns can provide excellent value for money, costing under £1000 per life
year saved [18] [19].
51. Following the publication of Smoking Kills the government committed to spending £50 million over
three years in England on public health education on tobacco. The amount actually spent since
then is as follows:
1999-2000
£15.5 million
2000-2001
£13.73 million
2001-2002
£12.3 million
2002-2003
£13 million
2003-2004
£39 million
52. In addition £15 million has been allocated for three years, split between Cancer Research UK and
the British Heart Foundation to run their own advertising campaigns. The effectiveness of involving
these organisations in delivering public education campaigns should be assessed to see whether
this is a strategy worth continuing.
Recommendations
53. A detailed and comprehensive review and analysis of the effectiveness of the public
education campaigns over the last 5 years is necessary to ensure that future spend is set at
optimal levels. In order to do this data such as the uptake of helplines, smoking prevalence
rates, sales/prescription of NRT on a monthly basis will need to be collated and analysed.
54. This review should also examine whether partnerships in delivering campaigns, such as
those with Cancer Research UK and the British Heart Foundation, are cost effective and
should be continued.
55. This review should be used to help develop a national marketing strategy for the stop
smoking services.
56. It is too soon to measure the effectiveness of the ban on advertising tobacco products in the UK,
but studies of legislation introduced elsewhere have shown that advertising bans can reduce
smoking consumption by between 4% and 16% [20]. It is expected to have most effect in reducing
the uptake of smoking. Since 90% of regular smokers start smoking before the age of 18, tobacco
advertising is a known risk factor for youth smoking [21]. Children are more likely to smoke brands
that are heavily promoted and advertising reinforces the habit.
57. Now that advertising is banned, concern is growing about below the line marketing and the role
model effect of smoking in films and on TV. Smoking in the movies has returned to levels
observed in 1950 when smoking was nearly twice as prevalent as it is today. Research shows that
children and young people in particular are influenced to try cigarettes by viewing role models
smoking [22].
Recommendations
58. The British Board of Film Classification is currently consulting on its guidelines for film
ratings and is asking respondents their views on smoking. We recommend that the
Department of Health make contact with the BBFC, discuss with them the desirability of
restricting smoking in films, and suggest that wording along the lines below would be
helpful: “Smoking kills. It is therefore desirable that films generally should only include
smoking when there is a clear editorial case for its inclusion. Smoking in films up to, and
including, category 15 should be avoided where possible. Smoking should not be portrayed
directly or by implication as a glamorous, or desirably ‘adult’ activity.”
59. OFCOM are also currently consulting on new standards codes, which allow for the
protection of young people under 18. Although the guidelines are expected in most areas to
be less prescriptive when it comes to smoking the guidelines should continue to be
predicated on not portraying smoking unless it is editorially necessary and in particular not
showing role models smoking. We recommend that the Department of Health make contact
with OFCOM, discuss with them the desirability of continuing to restrict smoking in TV
programmes, and suggest that wording along the lines below would be helpful:
“Smoking kills. It is therefore desirable that programmes generally should only include
smoking when there is a clear editorial case for its inclusion. Smoking in programmes for
children, and those popular with children, should be avoided where possible. Smoking
should not be portrayed directly or by implication as a glamorous, or desirably ‘adult’
activity.”
60. Graphic health warnings on cigarette packs are effective [23] and the Government should
seek to introduce these in line with the new EU Directive at the earliest possible
opportunity.
61. The branding and perceived positive image of cigarette pack designs should be reduced by
requiring cigarette packaging to be generic.
Pricing and taxation
62. Increasing the real price of cigarettes decreases cigarette consumption and the prevalence of
smoking. Overall in the UK, smoking prevalence currently falls by around 0.3% per 1% real
increase in price, although this ratio may fall as prices rise further and smoking is reduced to a
“hard core”, whose demand for cigarettes is more than usually price insensitive. Real increases in
price through taxation can also only be achieved if smuggling is controlled.
63. In the late 1990s the market share of smuggled cigarettes was rising dramatically and the
Government introduced a new tobacco strategy. This has met its targets. The volume of cigarettes
successfully smuggled into the UK was estimated to have fallen by 1 billion in 2001-2, the first time
this had happened for a decade. Over the last year it has fallen again by a further 1.5 billion, a
drop of around 10%.
64. However, as Derek Wanless commented [24] (Box 4.3) “The presence of smuggling places severe
constraints on the effectiveness of tobacco taxation as a tool for helping to reduce tobacco
consumption. Even following recent successes in reducing the UK smuggled market share, at 18
per cent that share remains substantial and makes a case for further action.”
65. It is time for an independent review of the effectiveness of the strategy now that it is in its fourth
year. An investment of £209 million [25] over 3 years from 2000 to 2003 is estimated to have
ensured tax receipts of £3 billion [26] to the Exchequer which would otherwise not have been
collected – around a 700% return on investment. The investment was largely used to fund 1,000
extra customs staff and x-ray scanners at the ports.
66. However, tobacco tax evasion still accounts for over £3 billion in tax losses (see below), 41% of
the total collected. This is many times more than fuel (4%) or alcohol (9%). Therefore a key
question to be answered is: if investment in tackling tobacco smuggling has produced a good
return so far would further spending produce equally good returns, or is spending now at optimal
levels?
Revenue Collection and Evasion Estimates in major excise regimes for 2001-2
Revenue Collected
Revenue Evaded
(£m)
(£m)
Fuel (GB)
21,900
850
Tobacco
7,800
3,180
Alcohol
6,900
650
Source: Customs Annual Report and Accounts 2002-3, Customs Pre Budget Report on Measuring and
Tackling Indirect Tax Losses December 2003
67. For example, it is our understanding that there are still not sufficient scanners to cover all 43 ports
and points of entry. As the Public Accounts Committee pointed out [27] “more machines would give
better coverage and reduce the need to move scanners about.” The PAC also reported that the
Department needed to resolve operating difficulties associated with the scanners at some ports
and to improve the scanners’ throughput to levels envisaged by the manufacturers.
68. Customs and Excise has signed Memoranda of Understanding with all three major UK
manufacturers, Gallaher, BAT and Imperial; the MoU with Imperial is the most comprehensive. As
a starting point it would make sense for all three protocols to be brought up to at least the standard
of that with Imperial.
69. There are also lessons to be learned from the report on managing alcohol fraud [28], published by
the NAO before Christmas, that could well be applied to tobacco. Recommendations in that report
included:
• The need for better methods for assessing fraud;
• That Customs should develop and implement a better strategy for cross-Departmental
communication and working;
• The National Intelligence Model should be adopted urgently, to address weaknesses in
translating intelligence products into deployment decisions and resource allocations; and
• A more comprehensive performance measurement/management system is required, which
allows the contribution made by intelligence to be monitored, assessed and controlled.
70. It is also not clear yet what impact the setting up of a new UK-wide Serious Organised Crime
Agency will have on the role of Customs and Excise in the area of tobacco smuggling. One of the
responsibilities of the new agency is recovery of criminal assets. This obviously needs to be taken
into account in any review of the strategy, and how to make it work most effectively in future.
71. Large scale commercial smuggling continues to account for the vast majority of seizures, but there
has been a dramatic change in the structure of the smuggled market, with the proportion of seized
cigarettes found to be counterfeit rising from 15% to 41% last year [29].
72. Efforts to contain the diversion of genuine cigarettes into the black market have led to a rapid
expansion in counterfeit cigarettes as a proportion of the market. This is substituting for the
smuggling of genuine product, so there needs to be more focus on policies that are effective in
tackling counterfeit cigarettes.
73. Further change is on the way with the accession countries having joined the European Union;
given the changing balance in smuggling from genuine to counterfeit tobacco products; and with
the Framework Convention on Tobacco Control near to being ratified.
Recommendations
74. The UK Government should work to support the development of specific international
protocols on smuggling with binding obligations to ensure the Framework Convention on
Tobacco Control (FCTC) is fully effective once it is ratified.
75. The National Audit Office should be asked to produce and publish a report by the Autumn
on the effectiveness of HM Customs and Excise tobacco smuggling strategy and how it can
be improved.
76. The total tax take from tobacco is approximately £9 billion and tobacco tax is an important
component of fiscal and health policy. Yet comparatively little data is published about the
behaviour of the tobacco market in response to changes in prices, taxes, smuggling, marketing
etc., and when it is published it is not necessarily timely nor is it on a continued and consistent
basis. For example the Health Survey for England this year has dropped the question it contained
on smokers’ brand choice.
77. Some data is provided by the tobacco industry but it cannot be assumed to be free of bias towards
particular policy outcomes or explanatory theories. The General Household survey and Family
Expenditure Survey do provide some limited data but these are not sufficient to answers questions
such as:
• What is the impact on the market of the introduction of the ad ban?
• What is the sales-weighted average price of cigarettes, hand-rolling tobacco and other tobacco
products and how is this changing?
• What are the price, income and cross elasticities of various tobacco products and types of
brand?
• How do these vary by age, social class, gender or other demographics?
• To what extent does cigarette tax drive the growth in HRT use?
• What are the main characteristics of the black market, by brand, consumer and prices?
• How has the market restructured in response to tax increases and what is the relationship
between headline tax rates and real average prices?
Recommendations
78. An annual report on the tobacco market should be published. This should detail its
structure, price variations within categories, calculated price-elasticities, consumption
patterns by socio-economic group, ethnicity, age, sex and other demographics, market
share by brand and so on.
79. A smoking module should be incorporated in the ONS Omnibus survey every month and
this should be made widely available. The results should be made widely available, in order
to be able to, for example, monitor the impact of media campaigns or price changes on
smoking prevalence.
80. Existing data relating tobacco price and smoking, particularly of smuggled product, are
inadequate to determine effects on consumption and cessation. New ways of studying this
important policy issue need to be investigated.
81. A longitudinal panel survey should be established specifically to monitor smoking
behaviour and its response to policy initiatives.
Supporting quitters, cutting prevalence
•
Who else in society should be involved in helping people not to start smoking and
supporting those who start to stop?
82. Stop smoking interventions that provide behavioural support, counselling and pharmacotherapy
are all effective. Best practice (regular counselling support and pharmacotherapy) increases the
chance of sustained long-term cessation in any quit attempt by a factor of four [30] [31] [32].
83. All smoking cessation interventions provide excellent value for money, costing less than £1000 per
life year saved, which is better than most other interventions in medicine [33] [34] and far better
than most interventions recommended to date by NICE [35]. Currently the stop smoking services
are reaching just over 2% of smokers a year. Their reported 4-week success rate of 50% is likely
to translate into approximately an additional 0.2% of smokers quitting over the long term who
would otherwise not have done so. Although there is variation across the country nationally, the
services have achieved success in line with what was predicted from the research literature and
should continue to receive funding at the current level.
84. However, stop smoking interventions although they are much more effective in reducing disease
risk than most other current routine medical practices, are still not routine and systematic.
85. Stopping smoking halves the risk of recurrence of myocardial infarction, a much greater and more
cost-effective impact than that achieved by other routine interventions such as therapy with aspirin,
beta blockers, ACE inhibitors or statins, but in clinical practice is the least likely intervention to be
applied. Smoking cessation is the only intervention that halts the development of chronic
obstructive airways disease or reduces the risk of lung cancer, but only half of all UK chest
specialists have direct access to a smoking cessation counsellor [36]. Smoking rates are similar for
diabetics and non-diabetics, but smoking increases the risk of serious disease and death in
diabetics from 4 to 11 times. Stopping smoking before surgery can have a dramatic impact on
outcome. In hip and knee operations it reduces post-operative complications by two thirds and
duration of stay in hospital by 15%.
86. Despite this clear evidence, too many health professionals, and particularly doctors, have yet to
embrace the concept of nicotine addiction as a medical problem, and particularly as a problem that
should be given at least the same priority as other preventive interventions. The fact that the BMA
conference in 2000 voted against the provision of Nicotine Replacement Therapy on NHS
prescriptions is an indication of the scale of this professional misconception.
87. Brief advice from physicians is a proven cost effective method of promoting smoking cessation
[37]. Yet the proportion of smokers recalling receipt of advice on smoking from any health
professional in the last five years has fallen between 1996 and 2002, from 46% to 42% [38].
Recommendations
88. Pressure to deliver ‘numbers’ of 4-week successes is creating perverse incentives and in
some cases putting pressure on the quality of service provision. Targets should be reframed to cover both referrals and success rates (both of which are routinely collected by
the DH). In order to bring the level of the least successful services up to those of the most
successful, revised and updated best practice guidelines need to be developed and widely
implemented.
89. Star ratings now include the smoking cessation targets but they are not linked to health
inequalities targets. A question should be added to the performance indicators to ensure
that PCTs are required to demonstrate how they have targeted smokers from deprived
social groups.
90. NHS Trusts and local health partners, including local authorities, should work together to
collect local prevalence data (e.g. by ward and social class), and then to set and monitor
targets for reducing prevalence rates.
91. Smoking status should be recorded in all patients’ records and all smokers should be
given brief advice at every stage of their treatment by doctors and, where appropriate, be
referred to specialist stop smoking services.
92. There should be encouragement to GPs to offer as an enhanced service specialised stop
smoking services via their practice nurses or other suitably trained primary care team
members. This already happens, for example, in the care of patients who are alcohol or
drug misusers, more specialised sexual health services, anti-coagulant monitoring, and
could easily be extended to tobacco dependence treatment. The quality of such services
needs to be carefully monitored and maintained.
93. A major programme of education to engage health care professionals in implementing
good cessation practice, is now essential. This should be implemented at undergraduate
and postgraduate levels.
94. Smoking cessation needs to be fully integrated as a high priority into clinical guidelines for
all chronic diseases influenced by smoking in the community and in secondary care. This
should include cardiovascular disease, respiratory disease, diabetes, and all others where
smoking affects outcomes significantly.
APPENDIX 1
Working Towards a Smoke Free Community:
A Template for Local Action
•
•
•
The overall aim is to protect non-smokers from exposure to SHS by increasing the provision of
smoke free public places. Public places are defined as enclosed, indoor areas in both the
public and private sector, which are used by the general public or serve as workplaces or
meeting places for public bodies.
The ultimate vision to be achieved after five years is that no worker or member of the public is
involuntarily exposed to SHS in an enclosed indoor space. The only exemptions would be
private homes (provided they do not house a child day care centre), hotel and motel guest
rooms (except those designated as no-smoking rooms) and private cars.
Where the template suggests smoking may be permitted in separate, enclosed rooms – for
example in residential homes, certain healthcare facilities and pubs - the definition of such
rooms (taken from the New York City Smoke-Free Air Act 2002) is as follows:
“An enclosed room shall mean a room which is completely enclosed on all sides by solid floorto-ceiling walls, windows or solid floor-to-ceiling partitions, and which complies with all
applicable Building Code and Fire Code requirements.
Any such windows in such rooms shall remain closed while people are smoking in the room
unless the windows open to the exterior.
Any doors shall remain closed while people are smoking in the room expect to the extent
necessary to permit ingress and egress to and from such a room. Such rooms shall be
ventilated in a manner that shall prevent emission of smoke to any other internal part of the
facility and all air shall be exhausted directly to the outdoors so that no air from the room is recirculated to areas where smoking is not allowed.
Employers will not expect any non-smoking employee or contractor to enter the room e.g. to
collect glasses or undertake cleaning duties – until all persons smoking have left the room and
the room is no longer used for smoking.
Where smoking is permitted in such rooms, employers/owners may choose to post signs that
warn of the health risks of smoking.”
THE “WORKING TOWARDS” PRINCIPLE
•
•
•
•
•
No local authority currently has the power to deliver 100% smoke-free status because they
cannot ban smoking in all workplaces and enclosed public places within the city boundaries.
For example, it has no power over privately owned businesses such as restaurants and pubs,
nor in privately owned facilities such as gyms, galleries or bowling alleys. It could be argued
that the Health & Safety at Work Act applies, but this has not been proved and there is no
precedent. So such power could probably only be delivered by changes to national legislation.
(NB: Action on Smoking and Health has commissioned a detailed legal opinion to establish the
exact current picture, in particular with regard to a local council’s ability to set down new bylaws. That opinion will be readily available in the next few months.)
It is therefore of no practical use to establish a “Smoke Free City” status which no city could
conceivably claim, even one that has built up effective partnerships with private sector
representatives. A much more effective angle is to commit local Councils and their partners to
a series of steps which take them from where they are now to as close as possible to full
Smoke Free City status over a five year period.
To that end, this template is based on a dynamic process and defines the increments – not the
minimum standards – that a community must achieve. It therefore sets practical and realistic
benchmarks to show that a city is serious about ending involuntary exposure to SHS over time.
The maximum standards are identified and the component parts to reach that maximum set
out.
It acknowledges that time is required to build the grassroots infrastructure, forge alliances
outside the usual suspects with a new focus on regeneration, environmental and economic
concerns, and to frame the issue to win public and media support.
PARTNERSHIP WORKING
•
•
•
•
•
The central agent in the process is the local Council, or Councils, as the representative political
body for the city
But a partnership approach is encouraged with other public sector bodies and local, private
sector representatives being targeted across a whole range of functions from health and social
services to economic regeneration. Local Tobacco Control Alliances (TCAs) should play a
pivotal role in this.
Expansion of these partnerships outside of the health community to a variety of service
organisations such as Chambers of Commerce, Community Groups, Restaurant Associations
and Hospitality Associations is key and will help to build diversity and reach a larger audience.
Even insurance companies could be targeted such that they make smoke-free a provision of
buildings insurance.
Consideration should also be given to input from the public, and to public debate, as both
smokers and non-smokers will need to have their say, as well as business owners and other
stakeholders. TCAs may be involved in such action.
And the dissemination of case studies from other areas that have achieved smoke free status,
or are working towards it, would be beneficial to ensure methods used by other communities to
engage with the public and other key sectors are shared to benefit from good practice. For
example, the extensive public consultation exercise conducted by the London Health
Commission between October and December 2003 under the banner of the Big Smoke
Debate may be a useful model to refer to for how to gauge public opinion on the need for
greater smoke-free provision. (See www.thebigsmokedebate.com for more information.) Again
Regional tobacco leads and/or TCAs may be involved in such action.
USING THE TEMPLATE
•
•
The template has been designed so that there are some key milestones that can be tracked
over time and progress measured against clear criteria.
Before the actions in the template are started, it is recommended that:
i)
The local authority signs the ASH Charter to publicly demonstrate its commitment to
work towards smoke-free status.
ii)
A smoke-free coalition is in place - in addition to public health reps this may include
partners from the Regional Regeneration, Environment and Development agencies,
plus, for example, local Chamber of Commerce, Restaurant and Hospitality
Associations. The Coalition may form around the local Tobacco Control Alliance but,
because of differences in how individual Alliances operate, it is not sufficient to assume
that every Alliance across England will be able to perform the necessary functions or
have the necessary representation/authority.
iii)
An audit of existing smoke-free provision and policies across all settings is completed
to establish a baseline.
iv)
Wherever smoking has previously been allowed but is subsequently restricted, it is
anticipated full smoking cessation support will be provided to staff, patients etc
THE TEMPLATE
Setting
All local
authorities (i.e.
district and
borough
councils,
unitary
authorities,
county
councils) and
buildings they
own or operate,
including
offices, public
buildings,
schools,
Immediate action required
in Year One after signing
Charter
•
Smoking is prohibited in
all public buildings
owned and operated by
the Council, including all
vehicles owned by the
local authority
•
Council employees and
the public must be
protected from SHS
during public meetings,
in offices open to the
public, in public libraries,
and any council owned
and operated indoor
Medium-term action
required
In Years 2-4 after signing
Charter
•
Local authorities and
their partners run
initiatives to increase
awareness of the
dangers of SHS to:
•
Mobilise public opinion
in favour of a ban
•
Encourage more nonsmokers to appreciate
they have a right to
clean air
•
Increase public demand
Long-term action required
– to be completed by end
of year five after Charter is
signed
•
The local authority
commits to set
reductions in smoking
prevalence and
increased smoke-free
provision as a key public
health objective in all
regeneration bids and
related activities
•
Persuasion and
relevant action directed
at the local private
sector. This might
include the use of
statutory agencies to
ensure the provision of
smoke free
environments and the
protection of staff
visiting people at home
e.g. PCT, Metropolitan
Borough Council
•
Setting
The NHS
(including the
acute sector,
PCTs,
community
NHS)
•
If there are areas or
buildings in these
statutory agencies that
are not yet complying
with no-smoking
policies,, provide a plan
and timetable on how to
deal with them
Immediate action required
in Year One after signing
Charter
•
•
The NHS –
mental health
facilities
benefits to them, are
actively promoted
•
•
Smoking is prohibited in
all healthcare facilities
including hospitals,
clinics, GP surgeries,
residential healthcare
facilities, convalescent
homes. (Although there
is flexibility for individual
regions to decide to
allow patients, not staff,
to smoke in separate,
enclosed rooms as per
the definition above
while the vision of a
totally smoke-free site is
being phased in)
Plan of action and
timetable introduced to
help healthcare facilities
tackle the issue of
people, including staff,
smoking directly outside
the entrance to GP
practices and hospitals.
Smoking prohibited in
communal areas
For patients in
residential mental health
facilities and day
treatment centres,
Medium-term action
required
In Years 2-4 after signing
Charter
•
•
•
Business champions
are identified i.e. those
who are convinced
about the benefits of
smoke-free are
encouraged to argue the
case with other
businesses who are yet
to protect their staff and
visitors
Long-term action required
– to be completed by end
of year five after Charter is
signed
•
Full part played by
Acute Sector and other
NHS in promoting
smoke free
areas/cessation services
Success of tackling
entrance smoking
reviewed
No Smoking allowed
within buildings
Ideally, all smoking
indoors will be
prohibited by end of
year four.
•
By end of year five,
smoking will not be
permitted on any part of
the site, indoors or
external
smoking may be
permitted in a separate
enclosed room as long
as that room meets the
definition above and no
person other than
patients are allowed to
smoke in the room.
Shopping
(including
privately owned
shopping
centres and
malls and
council owned
markets)
Setting
•
No Smoking Policies
introduced in all Council
run Indoor Markets and
shopping Centres
•
Dialogue with privately
run shopping centres
instigated
•
Undertake media
activity to highlight
benefits of smoke-free,
including increased
trade and positive
feedback form the public
Immediate action required
in Year One after signing
Charter
Education
(including preschool
nurseries,
schools,
universities, HE
& FE
establishments)
•
Workplaces
(excluding
hospitality
trade)
•
•
Restaurants
•
Smoking is prohibited in
all Childcare centres,
primary, secondary and
further educations
establishments. This
includes both the indoor
and outdoor grounds.
Meet with businesses
and property owners to
determine if there is a
consensus towards
smoke-free workplaces
The benefits of smoke
free workplaces actively
promoted to businesses
through the media and
via local business
organisations
Conduct a survey of
local restaurant
business owners
regarding smoke free
•
All privately owned
shopping centres and
malls are smoke-free,
with public feedback
allowed to determine
whether food courts are
included at this stage. If
centre management
decide to continue to
allow smoking in the
food courts this should
be restricted to smoking
areas where others are
not put at risk from SHS
Medium-term action
required
In Years 2-4 after signing
Charter
•
Smoking in college and
university bars only
permitted in separate,
enclosed rooms as per
definition above
•
•
•
No bar worker
involuntarily exposed to
SHS
Develop and support
the implementation of
No smoking policies in
workplaces targeting
small and medium sized
enterprises, community
enterprises, and those
employing a high
proportion of manual
workers
Until such time as
smoking is prohibited in
restaurants, all premises
must post signs notifying
•
All privately owned
shopping centres and
malls are smoke-free,
including food courts
Long-term action required
– to be completed by end
of year five after Charter is
signed
•
All education sites are
totally smoke free
•
No worker should be
exposed to SHS
involuntarily.
•
Ensure there is a clear
and well publicised route
for employees who
continue to be exposed
to SHS to get help and
support e.g. via
environmental health
dept or legal advice line
There is consensus
amongst restaurant
owners that areas used
by the public must be
•
•
•
•
•
Setting
Pubs, bars and
nightclubs
Sports Stadia
policies to:
help identify key
business leaders and
supportive business
owners
identify how best to
educate the more
sceptical about the need
for greater smoke free
provision
and to gather feedback
– both qualitative and
quantitative – as to the
benefits of business to
go smoke free
Share case study
examples of how other
restaurants have
successfully moved to
smoke-free
Immediate action required
in Year One after signing
Charter
•
Indoor air monitoring of
all pubs to have been
completed by end of
year one to audit SHS
levels
•
Discuss barriers to
going smoke free with
Publicans – e.g.
economic concerns
•
Share case study
examples of how other
pub businesses have
successfully gone
smoke-free
•
Try to influence new
local licensing laws that
are being introduced
such that smoke-free
becomes a criteria for a
licence being granted
All council owned sports
facilities to be smoke
free by end of year one
•
•
Planning permission
granted for any new
patrons whether a no
smoking area is offered
•
Businesses are
subsequently
encouraged to only
permit smoking in
separate, enclosed
rooms as per definition
above
Medium-term action
required
In Years 2-4 after signing
Charter
•
There is consensus
amongst Publicans that
areas used by the public
must be smoke free
•
All privately owned
sports facilities e.g.
football stadiums, agree
to restrict smoking to
designated areas only
(along same lines as
shopping centre food
smoke free and that
workers must not be
involuntarily exposed to
SHS
•
Ensure there is a clear
and well publicised route
for employees who
continue to be exposed
to SHS to get help and
support e.g. via
environmental health
dept or legal advice line
Long-term action required
– to be completed by end
of year five after Charter is
signed
•
All pubs confine
smoking to separate
enclosed rooms as per
above definition
•
No worker is
involuntarily exposed to
SHS
•
Ensure there is a clear
and well publicised route
for employees who
continue to be exposed
to SHS to get help and
support e.g. via
environmental health
dept or legal advice line
•
All privately owned
sports facilities e.g.
football stadiums, to be
100% smoke-free in
indoor areas, including
terraces and stands
which are either partially
facility – public or private
- is subject to that new
facility being totally
smoke free
shopping centre food
courts)
Public
Transport
Airports
Community
Centres
Setting
Prisons
•
Immediate action required
in Year One after signing
Charter
•
•
Planning
permission and
insurance
All council owned
community centres to be
smoke free by end of
year one
Governors encouraged
to consider the
introduction of nosmoking policies
•
Smoking to be
prohibited in all
enclosed indoor spaces
•
Smoking only permitted
outside the terminal
buildings
Public funded
organisations – i.e.
those that are not
council owned but which
receive some sort of
council funding, are
required to review
smoking policies and
implement best practice
Medium-term action
required
In Years 2-4 after signing
Charter
•
Staff only permitted to
smoke in separate,
enclosed rooms as per
definition above
•
which are either partially
or fully enclosed under a
roof
•
100% smoke free
transport system across
the city – including taxis,
trains, buses, trams.
This includes indoor
areas of railway and bus
stations, including those
platforms that are either
partially or fully enclosed
under a roof
•
Smoking prohibited in
all indoor areas of
community centres
Long-term action required
– to be completed by end
of year five after Charter is
signed
•
Smoking prohibited in
all communal areas
•
Ensure there is a clear
and well publicised route
for employees who
continue to be exposed
to SHS to get help and
support e.g. via
environmental health
dept or legal advice line
•
Prisoners only allowed
to smoke in single cells
Smoking cessation staff
employed by PCTs
target cessation advice
at prisoners in same
way as wider community
can access their
services
•
Plans for any new
publicly owned building
to include a criterion that
smoking will not be
allowed anywhere in the
building
•
Enter into a dialogue
with insurance
companies to encourage
•
Planning permission for
the construction of any
new privately owned
buildings in the city –
apart from private
homes - to include a
criterion that a total ban
on smoking in the
building should be
considered
Privately
owned indoor
recreation
areas such as
cinemas,
theatres, bingo
halls, bowling
alleys,
museums,
casinos,
concert halls
Privately
owned
retirement
facilities and
nursing homes
Premises
owned by local
membership
organisations
e.g. sports
clubs
Private homes
•
•
•
them to make smokefree a criteria of
buildings insurance
Audit carried out of NoSmoking policies at
such venues
•
Venues encouraged to
ban smoking throughout
the premises
Owners encouraged to
prohibit smoking in all
communal areas
Smoking is permitted in
not-for-profit
membership
associations but steps
should be taken to
encourage governing
committees to review or
develop no-smoking
policies
•
Audit carried out of nosmoking provisions in
local membership
organisations
•
Awareness campaigns
developed to encourage
private citizens to
protect others from SHS
(especially children)
•
Privately owned indoor
public places provide
smoke free areas free of
the health risks of SHS
•
No employee is
involuntarily exposed to
SHS
•
Smoking only allowed in
separate, enclosed
rooms as per definition
above
•
No employee is
involuntarily exposed to
SHS
•
Smoking is permitted in
private homes but local
authorities work with
health, housing and
other professionals to
promote smoke free
homes particularly
targeting the homes of
children in deprived
areas.
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