Tobacco in the UK
Clive Bates
Director
Action on Smoking and Health
King James I counterblaste
• ...a custome lothesome to
the eye, hateful to the nose,
harmful to the brain,
dangerous to the lungs,
and in the black and
stinking fume thereof,
nearest resembling the
horrible stygian smoke of
the pit that is bottomless
(1604)
Tobacco in society
• Unique consumer product
– Kills 1 in 2 when used as intended
– Addictive
– Almost unregulated
• Pervasive drug use
– Nicotine self-administration
– Dirtiest possible delivery system
– 10 million dependent on nicotine
Who smokes?
• 13m smokers
–
–
–
–
28% men
26% women
15% professional
39% manual unskilled
• 82% start as teenagers
• 70% want to quit
– 4m try in any year
– c. 300,000 succeed
– 10m ex-smokers
Health impacts
• Harm to smokers
– 120,000 UK premature deaths per year
– over 50 health impacts
– addiction c.10m dependent in the UK
• Harm to others
– lung cancer, heart disease, asthma
– pregnancy complications and cot death
– 17,000 hospital cases per year in under-5s
– welfare
Some impacts
•
•
•
•
•
•
•
•
Cancer
Heart & Circulation
Respiratory
20 fatal illnesses
50 non-fatal illnesses
Widespread addiction
Cost burden
Productivity
•
•
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•
Deforestation
Indoor air pollution
Waste & Litter
Ozone depleters
Pesticides
• Labour exploitation
• Fires
• Criminal activity
Smoking since 1948
Percentage
70
60
50
Men
Women
40
30
20
10
0
8
4
4
5
19
19
0
6
2
6
6
7
19
19
19
8
4
7
8
19
19
0
6
9
9
19
19
Teenage smoking
Steep rise in teenage smoking
Regular smokers age 11-15
16
14
12
10
8
6
19
82
19
84
19
86
19
88
19
90
19
92
19
93
19
94
19
96
4
Boys
Girls
Health inequalities
Lung cancer incidence
100
Smoking prevalence
60
40
50
20
0
Richest
Poorest
0
Richest
Poorest
Smoking and deprivation
% prevalence
UK CIGARETTE SMOKING BY DEPRIVATION
80
70
60
1973
50
40
1996
30
20
10
0
0
1
2
3
4
Most affluent
DEPRIVATION SCORE
5
Poorest
Jarvis (1997)
Politics: two views
• A legal adult
consumer product that
people are free to
choose if they want to
enjoy the pleasure of
smoking, knowing and
accepting the widely
publicised and usually
overstated risks.
• A lethal product with
over 50 known health
impacts - including
harm to non-smokers sold by a predatory
industry which
nurtures teenage
smoking until nicotine
addiction takes over.
Age at which smokers start
73
80
70
60
50
Percentage
40
of smokers
30
20
16
11
10
0
by age 12
13 to 17
US data 1991, Institute of Medicine
after 18
How it works - part 1
Younger adult smokers are the only source of
replacement smokers... If younger adults turn
away from smoking, the industry must
decline, just as a population which does not
give birth will eventually dwindle.
(RJ Reynolds, 1984)
Appeal to kids
How it works - part 2
A cigarette for the beginner is a symbolic
act. I am no longer my mother's child, I'm
tough, I am an adventurer, I'm not square …
As the force from the psychological
symbolism subsides, the pharmacological
effect takes over to sustain the habit.
(Philip Morris,1969)
Addiction to nicotine
Responses
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•
•
•
•
•
Informed choice v. disinformation
Tobacco promotion
Taxation
Smoking in public and workplaces
Smoking cessation support
Reduce harmfulness of the product
White Paper: Smoking Kills
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•
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•
•
Ban tobacco promotion
Raise taxes and control smuggling
Help smokers quit - £60m over 3 years
Public campaigns - £50m over 3 years
Legal protection in the workplace
Hospitality industry Charter
Tighten illegal sales measures
International approach
Regulation for the product
Tobacco advertising
• “… the banning of advertising
was followed by a fall in
smoking on a scale which
cannot be reasonably attributed
to other factors”
• “The balance of evidence thus
supports the conclusion that
advertising does have a positive
effect on consumption.”
•
Clive Smee, Chief Economist, UK
Department of Health 1994
Advertising ban is broad
• Any commercial
communications with
the aim or effect of
promoting tobacco
products
• Sponsorship
• Direct mail
• Free gifts
• Promotions
• But some exemptions
Tobacco sponsorship
• Phase out by July 2003
• 2006 for Formula One
and Embassy snooker
– Subject to conditions
– Reducing money
– Reducing advertising
• Replacement sponsors
will be found
Tobacco promotion
• EU Directive 98/43/EC
• UK regulations in 1999
–
–
–
–
Bans advertising in 1999
Sponsorship in 2003-6
Brand stretching
Limited exemptions
• Increased anti-tobacco
promotion
Tobacco v health
spending (£m)
£100
£90
£80
£70
£60
£50
£40
£30
£20
£10
£0
Tobacco
Public
health
NRT
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%
Warning...
“The tobacco industry has succeeded where
many health education programs have failed
because they capitalize on the deep social
needs that most compel adolescents: to fit in,
to exert independence from parental control,
and to demonstrate physical agility and sexual
allure.”
Price of 20 cigarettes in 2001
Price = £4.21
£0.85
£2.74
Taxes = £3.34
£0.63
Affordability of cigarettes
D
en UK
m
a
I re rk
la
Fi nd
nl
Sw and
ed
Fr en
a
Be nce
l
G giu
er m
m
an
N Au y
et s
he tri
rl a a
nd
s
Ita
G ly
re
e
Lu Por ce
xe tu
m ga
bo l
ur
Sp g
ai
n
Tax per 20 cigarettes
EU tobacco taxation
£3.50
£3.00
£2.50
£2.00
£1.50
£1.00
£0.50
£0.00
Attitudes towards smoking
Smoking status
Percent agreeing that smoking
should be restricted…
Current
smoker
Exsmoker
Never
smoked
All adults
…at work
69
86
92
84
…in restaurants
69
88
93
85
…in pubs
24
57
64
51
…in other public places
70
86
89
85
Source: Office of National Statistics, 1997 data
Passive smoking exposure
Public
Places
Work
Home
Charter and Health and Safety Campaigns and
market forces
at Work Act
culture
Smoking at work
Cost of smoking at work
Cost Factor Cost/smoker
Absenteeism
C$230
Lost productivity
C$2,175
Life insurance
C$75
Smoking areas
C$85
Source: Health Canada (1995 study) 1 Euro = 1.5 C$
Reality check
Workplaces with Smoking Policies (1995)
Pubs
Restaurants &Cafes
Travel
Banks & Post Offices
14%
36%
80% target
38%
48%
Cinemas & Theatres
53%
Libraries Museums
62%
Shops
63%
Hospitals and Clinics
Schools & Colleges
Source: NOP (1996) Smoking in public places: 2nd survey report
71%
77%
Health and Safety
• Health and Safety at Work Act (1974)
"to provide and maintain a safe working
environment which is, so far as is reasonably
practicable, safe, without risks to health and
adequate as regards facilities and arrangements
for their welfare at work".
>>>> Development of Approved Code
of Practice (ACoP)
Approved Code of Practice
• ACoP is ‘quasi-legal’ like Highway Code
• Gives meaning to Health & Safety at Work Act
• Employers must take all reasonable and
practicable steps to reduce or eliminate
passive smoking exposure
• Presumption in favour of banning smoking
• HSE consultation - decision Spring 2000
• Main concern is hospitality trade and perceived
conflict with Public Places Charter
Smoking in public places
Public places charter
The signatories to this Charter recognise
that non-smoking is the general norm and
that there should be increasing provision
of facilities for non- smokers and the
availability of clean air.
Public places charter
• Targets to be achieved over agreed
timescales
• A written policy on smoking
• Implementation through non-smoking areas,
air cleaning and ventilation, as appropriate
and whenever practicable
• Communication to customers through signs
• Monitoring of progress
• Sharing expertise
Charter signage
Proportion of non-smokers who live in a household with
at least one smoker
60
50
Percent
47
40
40
30
26
21
20
19
18
12
10
6
0
under
16
16-24
25-34
35-44
45-54
55-64
65-74
Source: SCPR (1996) Health Survey for England, 1995 (under 16s assumed to be non-smokers)
75+
Smoking cessation
• Money - £60m over three years
– Specialist clinics and NRT
– Health promotion
• Poverty focus
– Health Action Zones
– Free NRT for low income smokers
• Priority guidance to NHS
– Cancer and heart disease strategies
Cost effectiveness
Cost of saving one year of life
£20,000
£15,000
£10,000
£5,000
£0
Smoking cessation
Typical intervention
Illegal sales
• Illegal to sell to under 16s
• New ‘Enforcement Protocol’ to address
inadequate law
• Id cards - good for retailers
• Doubtful efficacy
Product regulation
• Forthcoming EU Directive
–
–
–
–
Tar
Nicotine
Additives
Labelling
• But…...
– Low tar approach failed
– Nicotine regulation difficult
– Major rethink needed
International
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WHO Tobacco Free Initiative
WHO convention
Foreign Office guidelines
Development spending
EU subsidies (£750m)
Action against smuggling
Anti-Smuggling measures
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£209m over 3 years
1000+ Customs officers
More sanctions and penalties
Public awareness campaign
£2.3 - £3.0 bn revenue
Contain at current levels: 20% market cf
36% without package
…and the tobacco industry?
Advertising
• EU Directive overturned
• New primary legislation
• Possible new EU Directive
Cessation
• NHS National plan
• NICE referral NRT and Zyban
• New sources of information:
ASH website
SRNT database
new Thorax guidelines
Workplace/Public Places
• ACoP future in doubt
• Voluntary approach not acceptable
• Public Places Charter – progress slow
Smuggling
• Gvnt. Policy £209m over 3 years
• Real problem not ‘White van man’ but
organised crime
• Need change of tactics: licensing and
tracking
Tobacco Regulation
• HSC recommendation re: TRA
• EU Product Regulation Directive
International
• Framework Convention on Tobacco
Control:
• International collaboration
• Working Groups established