Tobacco control – understanding what works
and taking on the tobacco industry
September 13th, 2012
Martyn Willmore
Performance Improvement Delivery Manager
Fresh Smoke Free North East
OVERVIEW OF SESSION
• The scale of the issue
• What is tobacco control?
• What are we doing in the North East?
• Brunel economic modelling tool
• Tobacco Industry tactics
• Are we making progress?
THE SCALE OF THE
GLOBAL PROBLEM
More than one billion people currently smoke
cigarettes worldwide
Cigarettes are the only known product which,
when used exactly as the manufacturers
intended, will kill half of all users
Tobacco is the number one cause of premature
death and disease in the developed world and its
impact in the developing world is increasing
Nearly five million premature deaths occurred
worldwide from tobacco use in 2000, and
projections indicate that by 2020, approximately
nine million deaths will be attributed annually to
tobacco use.
For the first
time in
history, the
biggest
killer of
humans is a
man-made
product.
SCALE OF THE UK PROBLEM
Smoking rates are declining across England BUT
annual smoking-related deaths remain our key Public Health issue:
Traffic:
2,946
Alcohol:
8,724
Smoking:
81,400
Obesity:
34,000
Suicide:
5,377
References:
1. ASH Factsheet, Smoking Statistics: illness & death, June 2011 (http://www.ash.org.uk/files/documents/ASH_107.pdf) NB area represents value
HIV:
529
Murder:
648
SCALE OF THE UK PROBLEM
• Smoking still causes over 80,000 premature deaths each
year in UK. Around 4,200 of these in North East alone
• It is responsible for around 1 in 6 of all deaths in UK
• Smokers lose 10 years of life on average
• Smoking is the single biggest cause of health inequalities
and is responsible for half the difference in life
expectancy between the highest and lowest socioeconomic groups
WHO STILL SMOKES?
Approx. 8.5 million smokers in England:
– 20% men
– 19% women
– 13% of professionals smoke
– 28% of routine and manual
workers smoke
82% of smokers start as teenagers
Nearly two-thirds want to quit
– 4 million try in any year
– Approx. 300,000 succeed
– The North East adult smoking
prevalence rate is now 21%.
PRINCIPLES OF
TOBACCO CONTROL
Established by the world’s first global health treaty - The
WHO Framework Convention on Tobacco Control. This
promotes coordinated action taken at all levels to:
• Prevent children from starting to smoke
• Protect people from exposure to secondhand smoke
and normalising smokefree
• Help smokers to stop
• Also overriding principle to make smoking (and the
Tobacco Industry) less attractive, affordable,
accessible (denormalisation/changing the social
norms)
WHAT NATIONAL
DRIVERS ARE THERE?
• National Tobacco Control Plan released by the
government in 2011 with key aspirations. First PH
topic to have its own dedicated plan
• Legislation. Implementation of the Health Bill around
putting cigarettes out of sight within shops and
banning vending machines. Recent national
consultation on plain, standardised packaging with
over 200,000 supportive responses
• Targets! Continued focus around NHS Services to
help people quit, but increased focus on reducing
adult smoking prevalence, youth prevalence and
smoking in pregnancy
WHAT IS THE NORTH
EAST DOING?
• Dedicated Office for Tobacco
Control – Fresh Smoke Free
North East. Set up in 2005, as
first such office in UK
• “Fresh” is umbrella term for all
partners and adoption by all
local partners - united brand,
messages
• Overseeing implementation of
long term North East Tobacco
Control activity, built around
eight key strands of work
MAIN AREAS OF TOBACCO
CONTROL WORK IN THE NE?
The eight key strands to the Fresh Tobacco Control
Delivery Plan:
1.
2.
3.
4.
5.
6.
7.
8.
Develop infrastructure, skills and capacity
Reduce exposure to second hand smoke
Help smokers to stop
Media, communications and education
Reduce availability and supply
Tobacco regulation
Reduce tobacco promotion
Research, monitoring and evaluation
KEY FRESH PRIORITIES FOR
TOBACCO CONTROL
1. Infrastructure, Skills and Capacity
• Work with local Tobacco Control alliances to develop
effective and sustainable local tobacco control delivery
• To influence national and international policy and decision
making. Advocate on behalf of NE and local needs
• Continue to deliver training and host events to raise
knowledge/awareness of TC issues with key partners
• Convey message that tackling smoking is “everyone`s
business”!
KEY FRESH PRIORITIES FOR
TOBACCO CONTROL
2. Reducing Exposure to
Secondhand Smoke
• Reduce children’s exposure to
secondhand smoke through roll out
of Secondhand Smoke Training
Programme
• Increase awareness of the benefits
of smokefree homes and cars
through the Smokefree Families
message. “7 Steps” campaign
• Address issues around SHS in
settings such as Prisons and Mental
Health Trusts
KEY FRESH PRIORITIES FOR
TOBACCO CONTROL
3. Helping smokers to stop
• Provide support and analysis to PCTs/FTs around Stop
Smoking Service delivery
• Act as North East contact with national policy teams, and
support national initiatives (e.g. New Routes to Quit)
• Help with targeting key smoking populations (e.g. routine
& manual workers, pregnant smokers)
• Engage all partners to actively promote NHS SSS, ensure
effective marketing (internal/external) and signposting
KEY FRESH PRIORITIES FOR
TOBACCO CONTROL
4. Media, Communications and
Social Marketing
• Communicating the risk of
tobacco and rationale for action
cuts across all Fresh activity
• Engaging with public, but also
ensuring that we communicate
messages effectively with
partners
KEY FRESH PRIORITIES FOR
TOBACCO CONTROL
4. Media, Communications and
Social Marketing
• Above the line marketing last
year around support to quit, health
impacts of smoking, SHS, and
tackling illicit tobacco. Plans in
place to build on this in 2012/13,
• Securing PR coverage with local
media. In 2011/12 we secured
over £2.8 million of free coverage.
KEY FRESH PRIORITIES FOR
TOBACCO CONTROL
5. Reducing the availability and supply of tobacco
products – licit and illicit
• Implementation of the North of England Tackling Illicit
Tobacco for Better Health Programme through eight
key objectives
• Working with retailers and trading standards
colleagues to ensure compliance with underage sales
legislation.
KEY FRESH PRIORITIES FOR
TOBACCO CONTROL
6. Tobacco regulation
• Reducing access through high tobacco prices (our
biggest single lever in tobacco control)
• Increase regulation of tobacco products and increase
access to clean medicinal nicotine products, and
therefore support smokers to stop
KEY FRESH PRIORITIES FOR
TOBACCO CONTROL
7. Reducing Tobacco Promotion
• Working with Trading Standards/Environmental
Health colleagues to enforce the Vending Machines
ban from Autumn 2011, and roll-out of Point of Sale
legislation from 2012 and beyond
• Ensuring North East had a strong voice in the recent
national consultation around Plain Packaging
• More work around exposing Tobacco Industry tactics
around promotion of their products (e.g. Social media)
KEY FRESH PRIORITIES FOR
TOBACCO CONTROL
8. Research, Monitoring and Evaluation
• Measuring the impact of smoking on the health and
wellbeing of the NE population
• Quantifying the benefits of Tobacco Control.
Calculating the cost-effectiveness of TC in terms of
health improvements and potential savings to NHS
• Regularly monitoring the attitudes of NE public to
smoking and the steps being taken to tackle it
DEVELOPING AN ECONOMIC
MODELLING TOOL
• Started in 2010, as a joint venture between the three
regional offices. Aim was to explore the economic case for
comprehensive regional tobacco control strategies:
– Build on the best available evidence on tobacco control
– Suitable for use by health and local authorities
– Include health and non-health outcomes
– Include financial and non-financial outcomes
– Based on principles of the Markov model - following a
cohort of current smokers over their lifetime to identify
costs and outcomes
DEVELOPING AN ECONOMIC
MODELLING TOOL - MARKOV
Smokers
Death
Former
Smokers
• Considers the cohort of
current smokers
• Each year they become
– Current smokers
– Former smokers
– Die
• Health outcomes and
resource use driven by
this fluid smoking status
WHAT THE MODEL CAN DO
• Use local smoking prevalence data to produce a series of
‘what if scenario analysis’ for a locality, and:
– Provide potential NHS cost-savings from (primary and
secondary care) by reducing smoking prevalence in the
short term
– Provide potential NHS cost-savings in the treatment of
lung cancer, CHD, MI, Stroke, COPD in medium term
– Provide potential savings in other areas, e.g.
productivity losses, exposure to passive smoking
– Provide estimated impact of TC measures on shortterm impact on smoking levels across local population
WHAT THE MODEL CANNOT DO
• It is not ‘Return on Investment’ tool, as the costs of
generating savings are not accounted for
• Does not provide cost-effectiveness ratios of the
interventions included in the model
• It does not fully reflect the impact of local tobacco
control activity, as the data to support this calculation is
not sufficiently robust
• Model has to make assumptions about “background quit
levels” regardless of local/regional/national TC activity,
and regardless of what the Tobacco Industry is doing
MODEL OUTCOMES
• The model shows the estimated impact of changes in
smoking status (previous slides), based upon three
potential scenarios –
1. The locality has no Stop Smoking Service and no
regional tier of TC activity
2. The locality has a Stop Smoking Service (variable
inputs) but no regional tier of TC activity
3. The locality has both a Stop Smoking Service
(variable inputs) and a regional tier of TC activity
http://www.brunel.ac.uk/herg/research-programme/buildingthe-economic-case-for-tobacco-control
TACKLING THE TOBACCO INDUSTRY
The Tobacco Industry has adopted a range of tactics to prosper
in the latter half of the 20th century. They include –
• Denying the health/addictive risks from smoking, or their
responsibility for the consequences of this (developing CSR)
• Attacking the credibility of published evidence, and those that
oppose the industry (including the use of “front-groups” to do
this on their behalf) to create doubt
• Delaying, challenging and circumnavigating attempts to
regulate the industry or introduce tobacco control policies
TOBACCO INDUSTRY TACTICS
Denying the health/addiction risks from smoking
• Prior to 1990s, the Industry`s
line had been one of denying
the addictiveness of smoking
• 1998 US legal ruling forced
the release of over 40 million
Industry papers and reports
• This revealed decades of
systematic deception of the
public over what they knew,
and how they marketed
TOBACCO INDUSTRY DECEPTION
• “Evidence is building up that heavy smoking contributes to lung
cancer” - Philip Morris scientist, 1958
• “I'm unclear in my own mind whether anyone dies of cigarette
smoking-related diseases” - Geoffrey Bible, Chairman of Philip Morris,
1998
• “No one should be allowed to sell cigarettes to minors. Minors should
not smoke. Period” – Philip Morris 1994
• “Today’s teenager is tomorrow’s potential regular customer, and the
overwhelming majority of smokers first begin to smoke while still in
their teens…The smoking patterns of teenagers are particularly
important to Philip Morris” - 1981 Philip Morris internal document
• “We were targeting kids, and I said at the time it was unethical and
maybe illegal, but I was told it was just company policy” – 1996 RJ
Reynolds Salesman
CORPORATE SOCIAL
RESPONSIBILITY??
• “The continuing commitment by business to behave
ethically and contribute to economic development whilst
improving the quality of life of the local community and
society at large” Making Good Business Sense by Lord Holme and Richard Watts
• Since late 1990s, Tobacco Industries have publicly
adopted CSR and invested in flawed projects to show this:
–
–
–
–
Youth smoking prevention programmes
Education/Academic grants
Philanthropy
Public Health promotion
• Fundamental contradiction – Industry employees have a
fiduciary responsibility to shareholders to maximise profits.
TOBACCO INDUSTRY TACTICS
Attacking the credibility of evidence and opponents
• For decades the industry categorically denied that smoking was
addictive, dangerous, and marketed to children – until their own
evidence showed otherwise. So they now attack both the anti-tobacco
message and messengers (directly and indirectly) to create doubt in the
minds of the public
• “We think that many of the claims against environmental tobacco smoke
have been overstated. Specifically, we don’t believe that it has been
shown to cause chronic disease, such as lung cancer, cardiovascular
disease or chronic obstructive pulmonary disease, in adult nonsmokers. The studies on lung cancer to date suggest that if there is a
risk, it is too small to measure with any certainty” – BAT NZ 2005
TOBACCO INDUSTRY TACTICS
Attacking the credibility of evidence and opponents
• “A ban on tobacco displays will put many independent shopkeepers
out of business. 23 convenience stores in Ontario and 12 in Quebec
closed every week after bans were introduced there” Tobacco
Retailers Alliance, 2009
• In fact, the number of retailers went up by 1.9% in Canada following
introduction of display ban in 2008
• The tobacco industry regularly claims that smokefree policies in the UK
saw 52 pubs close every week following 2007 legislation
• In reality, a BBC investigation into these claims found that the survey
reclassified venues that increased the amount of food sold from “pubs”
to “restaurants” and counted them as “pub closures”
TOBACCO INDUSTRY TACTICS
Attacking the credibility of evidence and opponents
• “High taxation is the acknowledged driver of the illicit tobacco trade”
Tobacco Manufacturers Alliance, 2011
• In fact, Industry complicity and their control of the supply chain,
corruption and lax enforcement are the key factors in the increase of
smuggling; increasing tax on tobacco products has increased
government revenues (Tobacconomics 2011)
• “The removal of branding on tobacco products and the introduction of
‘plain packaging’ makes it easier to counterfeit cigarettes and harder
for enforcement agencies to detect illicit products” – BAT
• In fact, Cigarette packs already carry unique identifiers. Removing the
branding will make no difference to the effectiveness of scanners
VOCAL INDUSTRY SUPPORTERS
“I don’t believe the secondhand smoke stuff. How can
you know? It is all highly
exaggerated. I speak as
someone who has smoked
for 58 years and I’m still here
(and I’m fine, thank you)”
- David Hockney
TOBACCO INDUSTRY TACTICS
Delaying, challenging and circumnavigating regulation
and tobacco control policies
• “Our approach is to fight aggressively with all available
resources, against any attempt, from any quarter, to
diminish our ability to market our products effectively” –
Philip Morris Vice-President, 1995
• The “Scream” test. When the Industry fight back, it`s
usually a positive sign that the measure will be effective –
– Smokefree legislation
– Point of Sale
– Especially plain, standardised packaging
THE FIGHT FOR PLAIN PACKS
• Australia have just experienced a bitter fight to introduce
plain packaging. Culminating in a successful legal case
against Industry challenge over IPR
• UK government has recently completed a consultation on
the evidence for introducing plain, standardised packs –
–
–
–
–
Disruption from FOI requests to Tobacco Control organisations
Mis-representation of the rationale for plain packs at every turn
“Nanny-state” and “slippery slope” arguments
Distorted case put forward around effect on illegal tobacco sales
and impact on small retailers
– Dubious marketing techniques from Industry front-groups
INDUSTRY RESPONSE TO
THE ADVERTISING BAN
POINT OF SALE “DISPLAY”
According to the Industry, this is not advertising
WHAT WE ARE UP AGAINST
A tobacco industry
that has moved
from this..........
TOBACCO ADVERTISING??
....To promoting its
products like this....
THINK INDUSTRY MARKETING IS A
THING OF THE PAST?
THINK AGAIN……
IS THE NE APPROACH WORKING?
IS THE NE APPROACH WORKING?
Decline in DSR mortality rates from Acute
Myocardial Infarction over last decade
RESPONSIBILITY DEAL
Unlike alcohol and fast-food retailers, the
tobacco industry is not part of the government`s
public health responsibility deal, shaping policy
"We don't work in
partnership with the
tobacco companies
because we are trying to
arrive at a point where
they have no business in
this country.” – Andrew
Lansley, April 2012
OUR VISION.....
...to make smoking history for children