HC/S2/07/02/A

Health Committee

2nd Meeting, 2007 (Session 2)

Tuesday 6 February 2007

The Committee will meet at 2.00 pm in Committee Room 1.

1. Impact of the smoking ban on public health: The Committee will take

evidence from:

Professor Jon Ayres, Head of Department of Environmental & Occupational Medicine, University of Aberdeen;

and then from— Dr Laurence Gruer, Director of Public Health Science, NHS Health Scotland;

and then from— Andy Kerr MSP, Minister for Health and Community Care 2. Subordinate Legislation: The Committee will consider the following negative

instrument—

The Food Hygiene (Scotland) Amendment Regulations 2007, (SSI 2007/11)

Simon Watkins/Karen O’Hanlon Joint Clerks to the Committee

Room T3.40 Email: healthclerk@scottish.parliament.uk

HC/S2/07/02/A

The following papers are attached for this meeting—

Agenda item 1 Cover Paper by Convener/Clerk SPICe briefing paper Paper by Prof Ayres Final Report of working group ‘Towards a Future Without Tobacco’ – Summary and Recommendations Scottish Executive’s evaluation strategy for the smoking ban article from Journal fo Public Health Submission from the Minister for Health and Community Care Agenda item 2 Abridged Subordinate Legislation Report The Food Hygiene (Scotland) Amendment Regulations 2007, (SSI 2007/11)

HC/S2/07/02/01 HC/S2/07/02/02 HC/S2/07/02/03 HC/S2/07/02/04 HC/S2/07/02/05 HC/S2/07/02/06 HC/S2/07/02/07 HC/S2/07/02/08

Agenda Item 1 HC/S2/07/02/01 6 February 2007

Health Committee Hearing: Impact of the Smoking Ban on Public Health

1. The Health Committee was the lead Committee for the Parliament’s

consideration of the Smoking, Health and Social Care (Scotland) Act, which introduced the ban on smoking in enclosed public places in March 2006. The Committee reported on the Bill at stage 1, and considered detailed amendments at stage 2.

2. As this is one of the major pieces of legislation that has been passed

by the second Parliament, the Committee has decided to carry out some initial post-legislative scrutiny and examine early signs of the impact that the Act. It is quite early in the process to undertake this, since much of the research that has been commissioned has yet to publish its findings. Nevertheless, the Committee is keen to see what the early indications are prior to the end of the session. A SPICEe briefing is attached.

3. One of the few pieces of research that has published its findings is a

study of the impact on the health of bar workers. Professor Jon Ayres of Aberdeen University will commence the Hearing by reporting on the study that he has undertaken. A summary of findings is included in the Committee papers.

4. The Scottish Executive has commissioned an extensive evaluation of

the impact of the smoking ban on health. This evaluation is being managed for the Executive by NHS Health Scotland, and Lawrence Gruer, its Director of Public Health Science will outline the work that is being undertaken. A summary of the evaluation being undertaken (published in the Journal of Public Health) is provided in the Committee papers.

5. Dr Gruer also chaired the Scottish Executive’s Working Group on

Smoking Prevention which published its report ‘Towards a Future without Tobacco’ in November 2006. The report examined in particular reducing smoking amongst young people. A copy of its Summary and Recommendations is included in the Committee papers.

6. Finally, the Minister for Health and Community Care, Andy Kerr, will

give his impressions of the early impact of the Act, and details of the parallel work that is being undertaken to promote cessation of smoking. The Minister has provided a paper which covers some of the other aspects of the Act, such as enforcement, in addition to the public health issues.

Roseanna Cunningham

Convener

Agenda item 1

06 February 2007

HC/S2/07/02/02

HEALTH COMMITTEE

BRIEFING PAPER

SUMMARY OF RESEARCH ON THE EFFECT OF THE BAN ON SMOKING IN PUBLIC PLACES

INTRODUCTION A comprehensive research programme is currently being coordinated by NHS Health Scotland, which will examine the impact of the Scottish smoke-free legislation on 8 different outcomes1:

1. Knowledge and attitudes 2. Second-hand smoke exposure 3. Compliance 4. Culture 5. Smoking prevalence and tobacco consumption 6. Tobacco-related morbidity and mortality 7. Economic impacts on the hospitality sector 8. Health inequalities

It is anticipated that some results from this study will be available later this year. However, the following briefing summarises research and statistics to date, which give an indication of the effect of the smoking ban on health, smoking behaviour and public opinion.

INDICATORS OF THE EFFECT OF THE SMOKING BAN

TOBACCO SALES

In October 2006, press reports on figures from Imperial tobacco (which controls about 50% of the Scottish cigarette market) suggested that since the smoking ban came into effect, sales of cigarettes had decreased more in Scotland than in other parts of the UK. In the month following the ban, Scottish sales had fallen by 8% but by September this had fallen to a 3% decline, matching the UK wide trend. However, on average, the Scottish decrease over the months following the ban amounted to a 5% drop in sales - 2 percentage points higher than the rest of the UK.

1 Haw SJ et al (2006) Legislation on smoking in enclosed public places in Scotland: how will we evaluate the impact? Journal of Public Health. 28(1): 24-30

1

Imperial tobacco has claimed that this mirrors the trend seen in other countries where a ban has been implemented, in that there is an initial dip in consumption but it gradually diminishes over time.

SMOKING CESSATION SERVICES

There have been a number of anecdotal reports from around the country regarding the effect of the ban on the demand for smoking cessation services: • NHS Greater Glasgow – reported a three-fold increase in attendance at

intensive support services since the introduction of the legislation2 • Grampian Smoking Advice Service – 59% rise in people registering with

the smoking advice service in April 2006 compared with April 20053 • Borders – In the 3 months prior to the ban, 1500 people sought help from

the smoking cessation service compared to 2000 people for the whole of the previous 12 months4

• Fife – The number of people who have stopped smoking in Fife has doubled since the smoking ban came into effect5

• Smokeline – The number of calls to the Smokeline in the 26 days prior to the ban was double than normal6

Bath University Cessation Study In November 2006, Bath University released results of a study which analysed the demand for smoking cessation services in Scotland before and after the ban7. The research supported the above reports in that it found in the 3 months leading up to the ban, the number of people seeking assistance with stopping smoking increased significantly. For example, in the period of January to March 2006, the largest smoking cessation service in the country seen demand rise by 43% (from 5,209 to 7,476 people) while in other parts of the country demand almost doubled. However, the research found that this increased demand fell away as soon as the ban was in place. This finding led the researchers to warn that the potential health gains of smoking bans may be lost if sufficient cessation services are not in place. Prescribing of Nicotine Replacement Therapy Data from ISD Scotland shows that at the point when the ban was introduced, the demand for prescribed smoking cessation products increased by 150% but then fell back to previous levels within a few months. This would appear to be in line with the findings of the Bath University study of smoking cessation services. Prescribing levels are set out in figure 1.

2 NHS Greater Glasgow & Clyde press release Smoking Quitters on the Increase 26 September 2006 3 Press and Journal Smoking ban prompts 72% rise in number of people aiming to quit 7 June 2006 4 BBC News Smoker quit in light of ban 25 May 2006 5 The Courier More staff to help smokers give up 10 July 2006 6 The Scotsman Smoking ban sparks leap in efforts to quit 31 March 2006 7 Bath University press release Health benefits of smoking ban could be lost 29 November 2006

2

Figure 1: Prescribing of all smoking cessation products, Scotland 2004-2006

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

Mar

-04

Apr

-04

May

-04

Jun-

04

Jul-0

4

Aug

-04

Sep-

04

Oct

-04

Nov

-04

Dec

-04

Jan-

05

Feb-

05

Mar

-05

Apr

-05

May

-05

Jun-

05

Jul-0

5

Aug

-05

Sep-

05

Oct

-05

Nov

-05

Dec

-05

Jan-

06

Feb-

06

Mar

-06

Apr

-06

May

-06

Jun-

06

Jul-0

6

Month

Def

ined

Dai

ly D

oses

May 2001: NRT allowed on

prescription (including

Nurse scripts)

Public Smoking Ban Introduced 26/3/06

Source: ISD Scotland

RESEARCH WITH BAR STAFF Aberdeen Study of Air Quality in Bars As part of the Scottish Executive’s evaluation of the ban, the Department of Environmental and Occupational Medicine of Aberdeen University has been measuring the exposure of 360 bar workers to environmental tobacco smoke, in particular levels of particulate PM2.5. Early findings have shown an 86% reduction in exposure to environmental tobacco smoke. Dundee Bar Worker Study Between February and June 2006, Dundee researchers monitored a number of health measures in 77 bar workers8. Each measure was taken before and after the ban with the following results: • The percentage of bar workers experiencing respiratory (e.g. cough,

wheeze) and sensory symptoms (e.g. red eyes, sore throat) decreased from 79.2% before the ban to 53.2% 2 months after the ban

• Forced expiratory volume (a measure of lung capacity) increased by 5.1% percentage points by the 2nd month

• Serum cotinine levels (an indication of exposure to second hand smoke) decreased from an average of 5.15 ng/ml to 2.93 ng/ml by the 2nd month

8 Menzies D et al (2006) Respiratory symptoms, pulmonary function and markers of inflammation among bar workers before and after a legislative ban on smoking in public places Journal of the American Medical Association. 296: 1742-1748

3

• Average white blood cell and neutrophil count (an indication of infection and inflammation) decreased by 8%

• Bar workers with asthma also experienced less airway inflammation and improved quality of life scores

Cancer Research UK Survey of Bar Staff In August 2006, 545 interviews were conducted with Scottish bar staff on behalf of Cancer Research UK9. When asked if they thought their workplace was healthier or unhealthier since the smoking ban came into effect, 76% of respondents felt it was much healthier, 16% thought it was slightly healthier, 6% thought it was no different and 1% thought it was much unhealthier. In response to the statement ‘the smoking ban will have long-term benefits on my health’, 53% of respondents strongly agreed, 24% of respondents tended to agree, 8% tended to disagree and 7% strongly disagreed.

PUBLIC OPINION POLLS

Forest Poll A poll commissioned by FOREST found that 63% of the Scottish public think current policy on smoking is about right, 24% think it has gone too far and 11% do not think it has gone far enough. The majority of those polled were opposed to further restrictions such as banning smoking in private homes (76%), private cars (69%), open air parks (66%), outside pubs and clubs (61%) and at work (61%). Scottish Executive Poll Repeat polls by the Scottish Executive have found that: • In May 2005, support for the smoking ban was 56% rising to 61% by May

2006 • Overall, 73% of respondents thought the ban has been very successful or

successful. Broken down by smoking status the results were 83% of smokers thought the ban was very successful or successful compared to 82% of ex-smokers and 60% of smokers

• In the May 2006 survey, 49% of respondents did not allow smoking anywhere within their home, 24% allowed smoking in certain rooms of their home and 29% allowed smoking anywhere throughout their home

ECONOMIC IMPACT

Whilst not relating to the health impact of the ban, there has been another significant study which published its findings in December 2006. The study by University College London10 examined the short-term economic impact on public houses in Scotland by comparing sales and the number of customers 9 Cancer Research UK press release Scottish bars healthier since the smoking ban 11 September 2006 10 Adda J et al (2006) Short-run economic effects of the Scottish Smoking ban International Journal of Epidemiology, Dec 14

4

before and after the ban. A number of pubs in the North of England were also used as a control group and data was gathered by telephone interview. The research found that after the ban, the net difference between the Scottish and English pubs showed sales in Scotland were 10% lower than English sales and Scottish customers were 14% lower. However, these figures refer to the net difference in growth between the two areas and not the absolute change in sales and customers. For those pubs taking part in both surveys, Scottish pubs showed a 0.3% drop in sales, compared to a 9.7% growth in sales in England; while customers in Scotland fell by 3.6% compared to 10.2% growth in England. The researchers concluded that, at least in the short term, the ban has had a negative economic effect on public houses. Kathleen Robson SPICe Research Date

Note: Committee briefing papers are provided by SPICe for the use of Scottish Parliament Committees and clerking staff. They provide focused

information or respond to specific questions or areas of interest to committees and are not intended to offer comprehensive coverage of a subject area.

5

Agenda Item 1 HC/S2/07/02/03 6 February 2007

BAR WORKERS’ HEALTH AND ENVIRONMENTAL TOBACCO SMOKE EXPOSURE (BHETSE)

Jon Ayres, Sean Semple, Audrey Naji, Shona Hilton

Department of Environmental & Occupational Medicine, University of Aberdeen

Fintan Hurley, Brian Miller, Scott Dempsey, Karen Creely Institute of Occupational Medicine, Edinburgh

Mark Petticrew MRC Social and Public Health Sciences Unit, University of Glasgow

The Bar Workers’ Health and Environmental Tobacco Smoke Exposure (BHETSE) Study is funded by Health Scotland and the Scottish Executive and is part of a national evaluation of the smokefree legislation, It has been designed to assess the effect of the smoking ban on the health of bar workers in Scotland. In addition, exposures to environmental tobacco smoke (ETS) will allow comparison of any changes in health status to changes in levels of exposure. Attitudes to the smoking ban before and after the ban have also been obtained but are not yet analysed. 371 bar workers from a range of pubs and bars in Aberdeen, Aberdeenshire, Edinburgh, the Borders and Glasgow provided lung function tests, answered questionnaires and gave samples of salivary cotinine (a marker of cigarette smoke exposure) in the two months before the smoking ban was implemented. Two to three months after the ban the health and personal exposure measures were repeated. The same data are currently being gathered for a third time, one year after the initial baseline measurements (to account for changes attributable to seasonality). As a consequence we have not analysed any of the health related data. Data acquisition should be complete by the end of March and analysis sometime during the summer. An additional element of the study involved direct measurement of air quality in 41 (53 visits) bars in Aberdeen and Edinburgh during the two months leading up to the ban and then again in May/June 2006. We have analysed the exposure data from the pre- and two month post-ban periods and have shown a large fall in ETS levels in the air of these pubs and bars. The mean level of ETS (as PM2.5 – particles with a diameter of 2.5 micrometers or less) before the ban ranged from ranged from 8 to 902 �g/m3 with an average value of 246 �g/m3. The ETS levels recorded pre-ban exceeded the US Environmental Protection Agency (EPA) ‘unhealthy’ guidance limit for outdoor air of 65 µg/m3 in 81% (n=43) of the visits with 58% of visits (n=31) recording levels above the US EPA ‘very unhealthy’ index level of 150 �g/m3. Almost 40% (n=21) of pub visits produced PM2.5 concentrations above the US EPA ‘hazardous’ air pollution level of 250 �g/m3. In the UK average 24 hour outdoor PM2.5 level is around 10 to 20�g/m3.

The PM2.5 concentrations measured during the 53 post-ban visits ranged from 6 to 104 �g/m3 with an average value of 20 �g/m3. Ninety-four percent (n=50) of post-ban visits recorded PM2.5 concentrations less than the 65 �g/m3 US EPA ‘unhealthy’ level with the other three visits providing concentrations less than the 150 �g/m3 level. This represents an 86% fall in ETS exposure as a result of the smoking ban, values comparable to findings from other countries (parts of the USA, Italy and Ireland) where bans have been introduced. This study, the largest of its type yet undertaken in association with a smoking ban will allow assessment of any changes in lung function and respiratory symptoms as a result of the ban. Recently published data from Dublin following the ban shows significant improvement in non-smokers’ lung function in bar workers.

Agenda Item 1 HC/S2/07/02/04 6 February 2007

‘Towards a Future Without Tobacco’

The Report of the Smoking Prevention Working Group

The Aim of this Report

More than any other single thing, the cigarette has blighted the health and shortened the lives of people in Scotland for over a century. Tobacco is now known to be a highly addictive substance that seriously damages the health of both smokers and people exposed to tobacco smoke. If the health of people in Scotland is to be improved and inequalities reduced, smoking prevention must be a top priority.

This report makes a comprehensive series of recommendations intended to protect and dissuade all young people in Scotland from starting to smoke and to deter adults, individually and collectively, from encouraging or enabling them to smoke. Their full implementation should take Scotland much further towards a future where smoking tobacco has become a thing of the past.

Summary and recommendations

Chapter 1 Why do some people become smokers and how can this be prevented?

The active drug in tobacco is nicotine. Nicotine is highly addictive, acting on the same parts of the brain as other psychoactive drugs such as heroin and alcohol. Addiction to nicotine can develop within weeks or months of starting to smoke. However, few young people are aware of nicotine's addictiveness and many young regular smokers do not think they are addicted. Whilst recognising that smoking is unhealthy, many young people think it has some benefits such as helping to cope with anxiety, controlling weight or creating a positive self-image and identity. Many other factors contribute to encouraging young people to start and continue smoking including: parental attitudes and behaviour; friends who smoke; and the availability, cost and perceived attractiveness of cigarettes. An effective smoking prevention strategy should therefore both reduce the availability of cigarettes and other tobacco products and discourage young people from wanting to smoke.

Chapter 2 Current patterns and trends in smoking by young people in Scotland

In Scotland in 2004, at age 13 about 5% of boys and 7% of girls are regular smokers. At 15, about 14% of boys and 24% of girls are regular smokers. In the last ten years, boys' smoking rates have fallen much more than girls'. Rates for boys are among the lowest in Europe, for girls among the highest. Smoking rates continue to rise through

the late teens and early twenties. Among 16-24 year olds in 2003, 32% of men and 29% of women are regular smokers.

Substantially higher rates of smoking among 15 year olds are associated with: having a parent or elder sibling who smokes; living with a single or step parent; having lower levels of parental supervision and spending more nights out with friends; truanting, being excluded from school and juvenile offending.

Regular smoking is more common among disadvantaged young people, especially girls. The link with disadvantage becomes stronger with age. Smoking is less common among girls of South Asian origin, but data for other ethnic groups are lacking. Regular smoking is strongly associated with the use of alcohol and other drugs, especially cannabis. Among 13 year olds, 48% of smokers had used other drugs in the past month compared with 1% of never smokers. Among current smokers at age 23, the majority have used other drugs in the last year.

Chapter 3 Sources, availability and marketing of cigarettes to young people

Thirteen and 15 year olds in Scotland have little difficulty in buying cigarettes from shops, indicating a widespread disregard for the law of age of purchase at 16. Research shows that vigorous enforcement of age of purchase laws may help reduce youth smoking rates. Given that the harmfulness of tobacco is at least as great as that of alcohol, there is a strong case for raising the age of purchase of tobacco to 18. While raising the age of purchase of tobacco has not been shown to reduce youth smoking rates on its own, it may well do so as part of a comprehensive package of control measures including vigorous enforcement and a negative licensing scheme for persistent offenders. Raising the price of cigarettes through increasing taxes has been shown consistently to reduce youth smoking rates. This is arguably the most effective measure that can be taken to reduce smoking by young people.

Packets of ten cigarettes are particularly popular with teenage smokers. Smuggling of cigarettes currently accounts for a significant proportion of cigarettes in circulation, particularly in disadvantaged areas. There is good evidence that the marketing of cigarettes has been successful in encouraging young people to smoke. Whilst advertising and sponsorship have now been banned, opportunities still exist for other forms of marketing. Positive images of smoking are still found in the media including the youth media (eg magazines and films).

A series of recommendations are made aimed at making cigarettes less affordable, accessible and attractive to children and young people.

Chapter 4 Evidence for the effectiveness of smoking prevention programmes

Several major long-term, comprehensive American state-wide smoking prevention programmes appear to have contributed to declines in teenage smoking rates, although it was several years before the effects were seen. A small number of media campaigns have been shown to contribute to reducing youth smoking rates, as part of a wider smoking control strategy. They were intensive and long-lasting and used strong, carefully designed messages on TV, supported by other media. Some multi-stranded campaigns involving community action have been effective but the contribution of community action and its possibly effective elements have not been clearly identified.

Reviews of the evaluations of large numbers of mainly American school-based smoking and drug prevention programmes show that most are ineffective in reducing smoking rates. Some programmes using social influence methods, including peer-led approaches, reported positive short-term effects on smoking rates but it is unclear why these were effective and other similar programmes were not. A peer-supported preventive programme in South Wales is showing early promise.

Few programmes appear to have addressed the underlying factors associated with higher rates of smoking and other drug use by young people. Although rates of smoking and other drug use continue to rise after leaving school, few preventive programmes have focused on this older age group.

Chapter 5 The current policy context and smoking prevention initiatives in Scotland

The new legislation on smoking in public places has the potential to make a major contribution to smoking prevention by reducing young people's exposure to second hand smoke and reinforcing a negative image of smoking. Over the past eight years, there has been a series of anti-smoking adverts on Scottish TV that have achieved high viewer awareness and accurate recognition of the message but an unknown impact on smoking behaviour. Websites and other new technologies are beginning to be used to promote anti-smoking and other health messages but their impact is not known.

A major recent study has shown that most Scottish schools are providing education about drugs including tobacco but there is great inconsistency in the methods and materials used, the training of staff and the level of coordination within and between the primary and secondary school curricula. An anti-smoking campaign using community development principles did not achieve changes in attitudes or behaviour in the local community. A pilot programme of various different types of smoking cessation services for young people in Scotland did not prove to be effective in helping smokers quit. Both these initiatives offer useful lessons about how to proceed in the future.

By reducing the proportion of parents and other adults who smoke, action to increase smoking cessation among adults (eg cessation services, taxation and smoke-free environments) may in the long term make a major contribution to smoking prevention among young people.

Chapter 6 Implications of the research evidence and recent experience in Scotland for future preventive initiatives

There is good evidence that a comprehensive integrated approach to smoking prevention can reduce smoking rates among young people. A well-designed on-going, intensive, multi-stranded media campaign can contribute by conveying potent messages to large numbers of young people. Target audiences should include girls and young women in disadvantaged circumstances and young people in their late teens.

Given the equivocal research evidence and the inconsistency of drugs education in Scottish schools, there needs to be a careful reappraisal of how it is done. The Ambitious, Excellent Schools agenda and the Health Promoting Schools programme provide a framework within which a comprehensive new approach to drugs education including smoking prevention in schools can be developed. Further detailed work will be required to design its content and integration into the school curriculum as a whole. The message on tobacco should be uncompromising: never smoke. Effective support and management of pupils with behavioural or family problems is highly relevant to smoking prevention. Informing parents about tobacco, alcohol and other drugs and their responsibilities in this regard should also be an integral part of drugs education.

Given the large number of young people who start smoking or become heavier smokers once they leave school, universities and further education institutions should play a bigger part in discouraging young people from smoking (or misusing alcohol or other drugs).

Given the lack of impact of the only Scottish community development based initiative for smoking prevention and of a series of pilot smoking cessation services for young people, any plans for future initiatives of these types should take full account of what has been learned from these studies and should be fully evaluated. There is a need for innovative research studies that aim to identify ways to prevent children and young people in disadvantaged circumstances from starting to smoke.

In the long-term, increasing smoking cessation among adults who are or will be parents is likely to contribute to the prevention of smoking among young people. Where cessation is not attained, stopping smoking in the home may also contribute to the prevention of smoking among young people.

Recommendations

Targets

1. New separate targets should be set for boys and girls at both 13 and 15 as follows (See paragraph 2.24).

% regular smokers at these ages

Rate in 2002 SALSUS

Rate in 2004 SALSUS

Target for 2010

Target for 2015

Target for 2020

Target for 2025

Boys age 13 6 5 4 3 2 2

Girls age 13 9 7 6 5 4 3

Boys age 15 16 14 12 10 8 6

Girls age 15 24 24 20 15 10 6

2. The following new targets should be set for 16-24 year olds (See paragraph 2.25).

Rate in 1998 Scottish Health Survey

Rate in 2003 Scottish Health Survey

Target for 2010

Target for 2015

Target for 2020

Adults age 16-24 35% 30% 25% 20% 15%

Research

3. Priority should be given to commissioning research that can provide a clearer understanding of current knowledge, attitudes and behaviour relating to the use of tobacco, alcohol and other drugs among 16-24 year olds. Regular surveys of 13 and 15 year olds should be continued (See paragraph 2.26).

4. All the new measures proposed in this report should, if implemented, be subject to rigorous evaluation to establish their impact and cost-effectiveness (See paragraph 2.27).

Reducing availability

The Scottish Executive should implement an integrated series of measures aimed at substantially reducing theavailability, affordability and attractiveness of cigarettes and other tobacco products to young people. It should:

5. ensure that much greater efforts are made to enforce the prevailing legal age of purchase. These should include: the use of proof of age; active test purchasing; prosecution with heavy fines and education of retailers and trading standard officers (See paragraph 3.6).

6. introduce a negative licensing scheme to enable vendors who repeatedly sell cigarettes to under-age customers to be prohibited from selling tobacco products (See paragraph 3.8).

7. amend the current offence of selling tobacco products to anyone under the age of 16 by raising the minimum age to 18. There should be a sufficient delay between amending the legislation and its implementation to prepare both customers and retailers for a smooth transition. Its impact should be carefully evaluated (See paragraph 3.13).

8. urge the UK Government annually to increase the price of tobacco products at a rate faster than inflation (See paragraph 3.16).

9. make representations to the UK Government to urge that health considerations are taken into account in the decision making process of EU policy concerning the taxation of tobacco products, as is required by the Framework Convention on Tobacco Control (See paragraph 3.17).

10. refer the issue of the sale of packs of ten cigarettes to the UK Government for consideration in the light of further research into its likely impact (See paragraph 3.22).

11. commission research to ascertain the extent to which young people in Scotland purchase cigarettes in packs of ten (See paragraph 3.22).

12. commission research to ascertain the current extent of use of smuggled or personally imported tobacco by young people (See paragraph 3.31).

13. ensure that Customs and Excise and the police in Scotland both put a high priority on activities aimed at reducing the influx of smuggled tobacco (See paragraph 3.31).

14. urge the UK Government to maintain and if necessary increase the investment in staff and equipment needed to control the influx of smuggled tobacco (See paragraph 3.31).

15. urge the UK Government to review the appropriateness of the current limits for the importation of cigarettes from other EU countries for personal use and the effectiveness of the controls thereof (See paragraph 3.31).

16. urge the UK Government to work collaboratively with the EC and other Member States to help develop a comprehensive international protocol on illicit tobacco as agreed at the first Conference of the Parties of the Framework Convention on Tobacco Control (See paragraph 3.31).

17. reinforce the UK Government's intention to require graphic photographs of smoking-related diseases to be displayed on cigarette packets (See paragraph 3.37).

18. together with the UK Government and other devolved administrations, look at ways to reduce positive images of smoking in the media and associated publicity materials, including reviewing any additional measures which might be taken to strengthen the ban on tobacco advertising and promotion introduced in 2002 (See paragraph 3.38).

19. prohibit the display of cigarettes at the point of sale, to be replaced by a simple list of the brands available and their prices (See paragraph 3.39).

Discouraging young people from smoking

The Scottish Executive should also implement an integrated series of measures aimed at discouraging young people from starting to smoke and encouraging and enabling young smokers to stop:

20. Building on previous work by Health Scotland and the Health Education Board for Scotland, an on-going, multi-stranded media campaign should be designed and implemented to discourage the uptake of smoking by young people of any age. One strand should have a strong focus on developing messages and using media that will have resonance with girls and young women in disadvantaged circumstances. Another should target young people in their late teens (See paragraph 6.2).

21. A comprehensive reassessment and reform of education on tobacco, alcohol and other drugs in Scottish schools should be carried out by a working group whose members bring expertise in drugs education research and delivery and in the design, integration and delivery of complex educational programmes across the curriculum. (See paragraph 6.5).

22. Given the importance of parents' influence upon whether or not their child will smoke, an integral part of drugs education in school should be to inform parents about tobacco, alcohol and other drugs and their responsibilities in this regard. This should mainly be done by sending parents clear, consistent information at regular points during their child's progress through school (See paragraph 6.6).

23. At the relevant stages, parents should be encouraged by midwives, health visitors, general practitioners and hospital doctors, nursery staff and teachers to create a smoke-free home and not smoke when their children are present. (See paragraph 6.6).

24. Embracing the concept of the Health Promoting School, all schools should develop an holistic approach to the health and well-being of their pupils. The aim should be to ensure that the school's ethos, policies, services and extra-curricular activities all foster the health and well-being of all the pupils. This should include having and strictly enforcing a school no-smoking policy covering everyone using the school grounds (See paragraph 6.7).

25. Given the association between smoking (and other drug use) and mental health problems, truancy and juvenile offending, all schools should have effective systems

for the assessment, support and care for such pupils, including the ability to liaise effectively with social services where necessary (See paragraph 6.8).

26. Given the clear evidence that many young people start to smoke or progress from occasional to regular smoking (and drink heavily or use other drugs) once they leave school, Universities, Colleges of Further Education, student associations, the National Union of Students and other major training providers should be invited to explore how they could better enable students or trainees to avoid starting to smoke or misuse alcohol or other drugs. This could be developed within the framework of "The Health Promoting University" (See paragraph 6.9).

27. Research studies should be commissioned to test innovative, carefully designed ways of protecting and dissuading young people in disadvantaged areas from starting to smoke or becoming regular smokers (See paragraph 6.11).

28. All community-based youth organisations should be encouraged to adopt clear no-smoking policies and to use the opportunities open to them to reinforce the message about the addictiveness and harm to health of smoking (See paragraph 6.11).

29. In the light of the recent poor outcome of the pilot smoking cessation services for young people in Scotland we recommend that active consideration is given to developing other approaches within a carefully designed evaluation framework (See paragraph 6.12).

Making things happen

30. Given that implementation of the recommendations in this report would largely affect young people, a representative sample of young people should be consulted to seek their views on the recommendations (See paragraph 6.14).

31. The recommendations in this report should be used by the Scottish Executive as the basis for developing a fully resourced five year Action Plan, with built in performance measures subject to monitoring by the Scottish Ministerial Group for Tobacco Control (See paragraph 6.15).

Agenda Item 1 HC/S2/07/02/05 6 February 2007 Legislation on smoking in enclosed public places in Scotland: how will we evaluate the impact? Sally J. Haw, Laurence Gruer, Amanda Amos, Candace Currie, Colin Fischbacher, Geoffrey T. Fong, Gerard Hastings, Sally Malam, Jill Pell, Calum Scott and Sean Semple

Journal of Public Health VoI. 28, No. 1, pp. 24–30doi:10.1093/pubmed/fdi080 Advance Access Publication 17 February 2006

© The Author 2006, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

Legislation on smoking in enclosed public places in Scotland: how will we evaluate the impact?Sally J. Haw, Laurence Gruer, Amanda Amos, Candace Currie, Colin Fischbacher, Geoffrey T. Fong, Gerard Hastings, Sally Malam, Jill Pell, Calum Scott and Sean Semple

Abstract

Background From 26 March 2006, smoking will be prohib-ited in wholly and substantially enclosed public places inScotland, and it will be an offence to permit smoking or tosmoke in no-smoking premises. We anticipate that imple-mentation of the smoke-free legislation will result in signific-ant health gains associated with reductions in exposure toboth environmental tobacco smoke (ETS) and personaltobacco consumption as well as other social and economicimpacts.

Methods Health Scotland in conjunction with the Informa-tion Services Division (ISD) Scotland and the ScottishExecutive have developed a comprehensive evaluationstrategy to assess the expected short-term, intermediateand long-term outcomes. Using routine health, behav-ioural and economic data and commissioned research, wewill assess the impact of the smoke-free legislation ineight key outcome areas – knowledge and attitudes, ETSexposure, compliance, culture, smoking prevalence andtobacco consumption, tobacco-related morbidity and mor-tality, economic impacts on the hospitality sector andhealth inequalities.

Conclusion The findings from this evaluation will makea significant contribution to the international understand-ing of the health effects of exposure to ETS and thebroader social, cultural and economic impacts of smoke-freelegislation.

Keywords: air pollution, public health, tobacco

Introduction

The recent disagreement in the UK Government that precededthe publication of the Health Bill1 contrasts sharply with thepolitical consensus in Scotland a year ago that accompanied thepublication of the Smoking, Health and Social Care (Scotland) Bill(2005) and its subsequent smooth passage through the ScottishParliament. While similar arguments were made for and againsta comprehensive ban both north and south of the border, theview in Scotland was that everyone should be protected fromexposure to environmental tobacco smoke (ETS) in public

places. This led to the conclusion that a comprehensive ban wasthe only possible solution. Evidence from the Republic of Irelandthat this was a workable approach was very influential.

From 26 March 2006, smoking will be banned in wholly andsubstantially enclosed public places in Scotland, and it will be anoffence to permit smoking or to smoke in no-smoking premises.

NHS Health Scotland, Rosebery House, Haymarket Terrace, Edinburgh EH12 5EZ, UK

Sally J. Haw, Senior Public Health Advisor

NHS Health Scotland, Clifton House, Clifton Place, Glasgow G3 7LS, UK

Laurence Gruer, Director of Public Health Science, OBE

Public Health Sciences, University of Edinburgh Medical School, Edinburgh EH8 9AG, UK

Amanda Amos, Reader in Health Promotion

The University of Edinburgh, St Leonard’s Land, Holyrood Road, Edinburgh EH8 8AQ, UK

Candace Currie, Director of the Child & Adolescent Health Research Unit

Information Services Division (ISD) Scotland, Gyle Square, Edinburgh EH12 9EB, UK

Colin Fischbacher, Consultant in Public Health Medicine

Department of Psychology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1 Canada

Geoffrey T. Fong, Associate Professor of Applied & Social Psychology

University of Stirling and the Open University, Stirling FK9 4LA, UK

Gerard Hastings, Director of Cancer Research UK Centre for Tobacco Control

BMRB, Ealing Gateway, 26-30 Uxbridge Road, London W5 2BP, UK

Sally Malam, Senior Associate Director

BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK

Jill Pell, Professor of Epidemiology

Scottish Executive, St Andrews House, Regent Road, Edinburgh EH1 3DG, UK

Calum Scott, Health Economist

Department of Environmental & Occupational Medicine, University of Aberdeen, Aberdeen AB25 2ZP, UK

Sean Semple, Lecturer

Address correspondence to Sally J. Haw.Email: sally.haw@health.scot.nhs.uk

E V A L U A T I O N O F S C O T L A N D ’ S S M O K E - F R E E L A W 25

Unlike the planned legislation for England, the Scottish legisla-tion2 will cover all workplaces including pubs, restaurants andprivate members clubs. There will only be a small number ofexemptions such as residential accommodation and designatedrooms in adult care homes and psychiatric units.

The Health Bill1 proposed only a partial ban for England,but in February 2006 the House of Commons voted to includeboth pubs that do not sell food and private members clubs withinthe legislation. Both the Assembly for Wales and the NorthernIreland Office have already announced their intention to imple-ment a comprehensive ban. Therefore, if the amendments to theHealth Bill are passed by the House of Lords, a comprehensiveban on smoking in enclosed public places will be in place acrossthe UK by the summer of 2007.

This legislation has the potential to have a major impact onpublic health across the UK. The aim of this article is to presentthe logic model of expected outcomes that provides the frame-work for the evaluation strategy and to describe the extensiveset of interrelated research studies that have been commissionedto evaluate the impacts of the forthcoming comprehensive banon smoking in public places in Scotland.

Health impacts of smoke-free legislation

We anticipate that introduction of the smoke-free legislationin Scotland will result in health gains associated with reduc-tions in both exposure to ETS and personal tobacco consump-tion. The associations between exposure to ETS and lungcancer,3,4 coronary heart disease (CHD),5,6 respiratorydisease7,8 and stroke5,9 are well established. A recent study hasestimated that the elimination of ETS from public placescould result in a reduction of about 400 deaths per annum inScotland by 2024.10

Health gains because of the Scottish law may be realizedmuch more quickly in some groups, particularly those who arecurrently heavily exposed to ETS or at high risk of CHD. Astudy of bar workers in the Republic of Ireland11 has recentlyconfirmed earlier US findings of an improvement in respiratorysymptoms following the implementation of a ban on smoking.12

An analysis of routine hospital admission data from Helena,Montana found a dramatic reduction in the incidence of acutemyocardial infarction following the introduction of smoke-freelegislation.13 While this study has been criticized for its weakdesign, the findings are consistent with predictions based onresearch findings on the adverse physiological impact oftobacco smoke.14

Workplace studies indicate that smoking bans and restric-tions lead to a reduction in the number of cigarettes smoked bycontinuing smokers and an increase in quit attempts and suc-cessful quitting. Complete bans are associated with a greaterreduction in active smoking.15,16 We anticipate that the healthgains from reduced personal tobacco consumption followingthe introduction of the legislation will match or exceed thoseresulting from reduced exposure to ETS.17

Other impacts of smoke-free legislation

One obstacle to the introduction of a comprehensive ban inEngland appears to have been a concern about public opinion.New data from Ireland indicate that support among smokersfor a comprehensive ban rose after legislation was introduced.18

Support among smokers before and after the ban rose from43 to 67 per cent, from 45 to 77 per cent and from 13 to 46 percent for bans in workplaces, restaurants and pubs, respectively.After the ban was implemented, 83 per cent of Irish smokersalso said that the legislation was a ‘good’ or ‘very good’ thing.

A second concern has been the potential negative economicimpact on the hospitality industry, particularly pubs and bars.The evidence here is not as robust as for the health impacts.Overall studies demonstrate a small positive effect on profit,19

but the possibility remains of a negative impact on the hospital-ity industry for some types of businesses or for businesses inparticular geographical areas.

Evaluation framework and strategy

Logic model

Health Scotland in conjunction with Information Services Divi-sion (ISD) Scotland and the Scottish Executive have developedan evaluation framework to describe the expected short-term(up to 2 months), intermediate (>2–12 months) and long-term(>12 months) health-related, attitudinal and cultural and eco-nomic outcomes. The framework is presented as a logic model(Fig. 1) and has been adapted from one developed by the USCenters for Disease Control and Prevention.20 Our evaluationfocuses on eight of the 12 key outcome areas identified in theframework – knowledge and attitudes, ETS exposure, compli-ance, culture, smoking prevalence and tobacco consumption,tobacco-related morbidity and mortality, economic impacts onthe hospitality sector and health inequalities. Assessment ofeach outcome will be based on a combination of secondary ana-lysis of routine health, behavioural and economic data as wellas research commissioned to address specific questions. Theresearch will focus on intermediate impacts up to one year afterimplementation of the legislation, while the routine data willpermit changes to be monitored over a much longer period – 3years in the first instance.

Routine health and behavioural data

Several useful routine health and behaviour data sets are avail-able in Scotland. The Scottish Morbidity Record (SMR) pro-vides discharge diagnoses on all Scottish hospital admissionsand is linked to death data from the General Register Office forScotland (GROS). Diagnostic accuracy of SMR data is esti-mated to be 97 per cent compared with case notes.21 Initialanalyses will focus on temporal trends in hospital admissions(SMR01) for CHD and asthma and CHD deaths.

ISD Scotland’s Practice Team Information (PTI) providesdata on all consultations from a representative sample of

26 J O U R N A L O F P U B L I C H E A L T H

45 Scottish practices, which include about 6 per cent of theScottish population. Analyses will focus on trends in consulta-tions for CHD, chronic obstructive pulmonary disease (COPD)and asthma.

The Scottish Household Survey,22 an annual populationsample survey, will provide data on smoking prevalence. Moredetailed data on quit attempts and levels of tobacco consump-tion before and after the implementation will be available fromthe 2003 and subsequent Scottish Health Surveys.23

Routine economic data on the hospitality sector

A number of indicators of performance – employment, turno-ver, profitability and openings and closures – will provide adetailed picture of trends in the performance of the hospitalitysector. The Labour Force Survey (LFS)24 will allow compari-sons of employment levels before and after the legislation, andgross domestic product (GDP)25 data will provide an indicationof trends in turnover in the sector.

In the longer term, the Office of National Statistics (ONS)Inter-Departmental Business Register (IDBR)26 and AnnualBusiness Inquiry (ABI)27 will provide more detailed data onemployment, turnover and profitability. Along with LiquorLicensing Statistics,28 these sources will also track openings andclosures in the hospitality sector.

Primary research

Seven studies have been commissioned to address specificresearch questions. All employ a before and after design. Asummary of study designs is given in Table 1.

The changes in CHild Exposure to ETS (CHETS) study andthe Health Education Population Study (HEPS) will measurechanges in child and adult exposure to ETS. Both HEPS andCHETS will assess population level changes in ETS exposurefrom any source. In addition, CHETS will also determinewhether there is any evidence of displacement of smoking intothe homes of children who live with smokers. Both studiesemploy a repeat cross-sectional study design and will collectdetailed data on awareness of health risks associated with ETSexposure, self-reported ETS exposure as well as salivarycotinine, a biomarker of ETS exposure. HEPS will also collectdata on attitudes towards the legislation.

The primary focus of both the STudy Of Public placeIntervention on Tobacco exposure (STOPIT) and the study ofBar-workers’ Health and ETS Exposure (BHETSE) is on healthgains achieved within one year of implementation of the legisla-tion. STOPIT is a prospective study designed to test the hypothesisraised by the Montana study13 that a reduction in ETS exposure isaccompanied by a rapid reduction in the incidence of acute coro-nary syndrome (ACS). STOPIT’s prospective design allows

Figure 1 Logic model of expected outcomes associated with smoke-free legislation.

Short-term Intermediate Long-term

Expected Outcomes

Implementation

of smoke-free

legislation

Enforcement of

smoke-free

legislation

Increasing awareness 1of health risks of ETS,

change in attitudes

towards ETS exposure

Reduction in exposure to ETS 2 Reduced ETS exposure

Increasing compliance with 3 smoke-free legislation

Sustained compliance with

smoke-free legislation

Increasing support for 4 legislation and change in

smoking cultures

Reduction in smoking prevalence and tobacco consumption 5

Reduction in tobacco-related morbidity and mortality 6

Reduction in costs to health

service of tobacco-related

illness

Variable economic impact on 7 hospitality sector

Reduction in 8 health inequalities

Sustained cultural change

E V A L U A T I O N O F S C O T L A N D ’ S S M O K E - F R E E L A W 27

patients’ smoking status and levels of ETS exposure to be deter-mined thus overcoming some of the methodological problemsassociated with the Montana study. Specifically, it will be pos-sible to determine the extent to which any overall reduction inincidence of ACS is due to reductions in incidence amongsmokers and non-smokers. The findings from STOPIT will beinterpreted within the context of temporal trends in CHD hos-pital admissions and CHD deaths determined by analyses ofthe routine health data sets.

The BHETSE study will follow a cohort of bar workers andassess changes in their ETS exposure and self-reported respiratorysymptoms 2 and 9 months after the implementation of the smokingban. Measures of particulate matter of less than 2.5 microns(PM2.5), an air-marker of ETS exposure, will also be taken inselected premises. Unlike the Irish11 and US12 bar worker studies,BHETSE will also test associations between reduced ETS exposureand objective measurements of lung function – forced expiratoryvolume in one second (FEV1) and forced vital capacity (FVC).

Table 1 Summary of commissioned research

Study Aim, design and data collection

Changes in CHild Exposure to EnvironmentalTobacco Smoke (CHETS)

Aim: To determine change in childhood exposure to ETS, including exposure in the homeDesign: Repeat cross-sectional survey of probability sample of Scottish Primary 7 children

(11 years)Data collection: Baseline, January–February 2006; follow-up, January–February 2007.

Self-complete questionnaire on smoking status and self-reported exposure; saliva sample (for cotinine assay)

Health Education Population Study (HEPS) Aim: To determine change in adult exposure (non-smokers) to ETS in the home and public places and changes in tobacco consumption (smokers)

Design: Repeat cross-sectional in-home survey of probability sample of Scottish adults (16–74 years)

Data collection: Baseline, September–October 2005/February–March 2006; follow-up, September–October 2006/February–March 2007. Interviewer-administered question-naire on smoking status, self-reported exposure and attitudes towards smoking and legislation; saliva sample (for cotinine assay)

STudy Of Public place Intervention on Tobacco exposure (STOPIT)

Aim: To determine change in the incidence of acute coronary syndromeDesign: Multi-centre prospective study of hospital admissions for acute coronary

syndrome. Entry criteria: chest pain + raised troponin on admission/within 12 h.Data collection: Continuous May 2005–April 2007. Research nurse-administered

questionnaire on smoking status and self-reported exposure; admission blood sample (for cotinine assay)

Bar-workers’ Health and Environmental Tobacco Smoke Exposure (BHETSE)

Aim: To determine change in respiratory health of bar workersDesign: Prospective cohort study of bar workers from five urban and rural areas in

ScotlandData collection: Baseline, January–February 2006; follow-up, June–July 2006 and January–

February 2007. Interviewer-administered questionnaire on smoking status, self-reported exposure and attitudes towards smoking and legislation; lung function [forced expiratory volume in one second (FEV1) and forced vital capacity (FVC)]; saliva sample (for cotinine assay). Air sampling for PM2.5 in selected premises

Qualitative Bar Study Aim: To determine changes in attitudes and behaviour in relation to smoking, smoking restrictions and the cultural contexts in which smoking and drinking take place

Design: Qualitative pre- and post-study of bars and their customers in three communitiesData collection: In-depth and paired interviews, direct observation, air sampling for PM2.5

Qualitative Community Study Aim: To determine impact of legislation on attitudes, behaviours and experiences of indi-viduals, families and communities

Design: Qualitative pre- and post-study of four contrasting communities. Nested case study approach

Data collection: Baseline, September 2005–March 2006; follow-up, April–December 2006. In-depth interviews, focus groups, direct observation of enclosed and outdoor spaces

International Tobacco Control (ITC) Ireland/UK Scotland Extension

Aim: To determine changes in smokers and non-smokers attitudinal and behavioural response to smoke-free laws

Design: Quasi-experimental prospective cohort survey of probability samples of smoking and non-smoking adults in Scotland, the rest of the UK and Ireland

Data collection: Baseline, February–March 2006; follow-up, February–March 2007. Telephone survey on smoking status; quit attempts in smokers; attitudes towards and compliance with legislation; social norms about smoking, smoking behaviour in public and private venues

28 J O U R N A L O F P U B L I C H E A L T H

Two qualitative studies have been commissioned to assessthe impact of the legislation on smoking behaviour and smokingcultures. Both will use a range of qualitative methods includingin-depth interviews, focus group discussions and observation inenclosed and outdoor public places. The Bar Study will exam-ine changes in attitudes and smoking behaviour among bar cus-tomers from selected bars and changes in the cultural contextsin which smoking and drinking takes place. It will study threecontrasting (high, medium and low affluence) but geographi-cally related communities located around a single urban centre.The Community Study will examine the broader impact of thelegislation at individual, family and community levels in twocontrasting local authority areas, one urban and one semi-rural.In each local authority, two communities, one of high and oneof low affluence, have been selected for study.

Finally, the International Tobacco Control (ITC) Ireland/UKScotland extension will use a quasi-experimental prospectivecohort design to compare changes in attitudes towards legislationon smoking in public places in Scotland, England (control) andRepublic of Ireland. It will also compare social norms aboutsmoking, self-reported smoking behaviour in both public andprivate venues and self-reported smoking cessation and quitattempts. Data will be collected by telephone interview fromnationally representative samples of smokers and non-smokers.

The outcome areas, outcome measures and data sources aresummarized in Table 2. Baseline data collection are now underway in all seven studies to enable before and after comparisonsto be made.

National and cross-national collaboration

The findings from individual studies will begin to be availableabout one year after the implementation of the legislation. TheCLEAN Collaboration (see Members of the CLEAN Collabora-tion for members) will then combine these and the routine mon-itoring data to create an integrated overview. We anticipatethat the findings will make a significant contribution to theinternational understanding of the health effects of exposure toETS and the broader social, cultural and economic impacts ofsmoke-free legislation.

The plans for a comprehensive ban on somking in publicplace across the UK provide further opportunity to build onthe Scottish evaluation. We are thus in discussion with colleaguesto develop a UK-wide evaluation strategy in preparation forthis eventuality.

Acknowledgements

We are very grateful for the support given by Sarah Davidson,Molly Robertson, David Palmer and Mary Cuthbert of theTobacco Control Division of the Scottish Executive, Edinburgh.We also thank Luke Clancy of the Research Institute for aTobacco-free Ireland, Dublin; Shane Allwright of Trinity

College for Health Sciences, Dublin; and Steve Babb of the USCenters for Disease Control and Prevention, Atlanta, for theiradvice in developing the evaluation strategy.

Contributors

All authors reviewed and approved the final draft of the art-icle. SH and LG developed the evaluation framework andare responsible for the overall co-ordination of the evalua-tion. CF and CS developed the specifications for the analysisof the routine health and economic data sets. AA, CC, GF,GH, SM, JP and SS designed and are supervising the prim-ary research. Other members of the CLEAN collaborationcontributed to the design and supervision of their respectivestudies. SH also contributed to study designs and is guaran-tor for the article.

Members of the CLEAN Collaboration

NHS Health Scotland: Sally Haw and Laurence Gruer.ISD Scotland: Colin Fischbacher and Diane Stockton.Scottish Executive: Calum Scott.CHETS: Candace Currie, Patricia Akhtar and Dorothy

Currie, CAHRU, University of Edinburgh, Edinburgh.HEPS: Sally Malam and Ruth Gosling, BMRB, London.STOPIT: Jill Pell, University of Glasgow, Glasgow; Stuart

Cobbe and John Rodgers, Glasgow Royal Infirmary, Glasgow;Frank Dunn, Anne Wright and Nat Hawkins, Stobhill Hospi-tal, Glasgow; Timothy Gilbert and James Young, HairmyresHospital, East Kilbride; Paul MacIntyre and Jacqueline Dou-gall, Royal Alexandra Hospital, Helensburgh; David Murdochand Anne Andrews, Southern General Hospital, Glasgow;David Newby and Sharon Cameron, Royal Infirmary Edinburgh;Keith Oldroyd, Joanne Kelly and Fiona Stevenson, WesternInfirmary, Glasgow; Alastair Pell and Judith Anderson,Monklands Hospital, Lanarkshire; Stuart Pringle and HelenMarshall, Ninewells Hospital, Dundee.

BHETSE: Jonathon Ayres, Sean Semple and Anne Ludbrook,University of Aberdeen, Aberdeen; Fintan Hurley and GraemeHughson, Institute of Occupational Medicine, Edinburgh;Mark Petticrew, MRC Unit, Glasgow.

Bar Study: Gerard Hastings, Douglas Eadie and SusanMacAskill, University of Stirling and the Open University,Stirling; John Davies, Derek Heim and Alastair Ross, Univer-sity of Strathclyde, Glasgow.

Community Study: Claudia Martin, Scottish Centre forSocial Research, Edinburgh; Amanda Amos and DeborahRitchie, University of Edinburgh, Edinburgh.

ITC Ireland/UK Scotland extension: Geoffrey T. Fong,Department of Psychology, University of Waterloo, Waterloo,Canada; Gerard Hastings and Louise Hassan, University ofStirling and the Open University, Stirling; Andy Hyland,Roswell Park Cancer Institute, New York.

E V A L U A T I O N O F S C O T L A N D ’ S S M O K E - F R E E L A W 29T

ab

le 2

Su

mm

ary

of

ou

tco

me

area

s, o

utc

om

es a

nd

dat

a so

urc

es

AB

I, A

nnua

l Bus

ines

s In

quiry

; BA

R, Q

ualit

ativ

e B

ar S

tudy

; BH

ETS

E, B

ar-w

orke

rs’ H

ealth

and

Env

ironm

enta

l Tob

acco

Sm

oke

Exp

osur

e; C

HE

TS, C

hang

es in

CH

ild E

xpos

ure

to E

nviro

nmen

tal T

obac

co S

mok

e;

CO

MM

UN

, Qua

litat

ive

Com

mun

ity S

tudy

; GD

P, G

ross

Dom

estic

Pro

duct

; GR

OS

, Gen

eral

Reg

istr

ar O

ffic

e S

cotla

nd; H

EP

S, H

ealth

Edu

catio

n P

opul

atio

n S

tudy

; ID

PR

, Off

ice

of N

atio

nal S

tatis

tics

(ON

S) I

nter

-D

epar

tmen

tal B

usin

ess

Reg

iste

r; IT

C, I

nter

natio

nal T

obac

co C

ontr

ol Ir

elan

d/U

K S

cotla

nd e

xten

sion

; LFS

, Lab

our

Forc

e S

urve

y; L

IQU

OR

, Liq

uor

Lice

nsin

g S

tatis

tics;

PTI

, Pra

ctic

e Te

am In

form

atio

n; S

HeS

, S

cott

ish

Hea

lth S

urve

y; S

HoS

, Sco

ttis

h H

ouse

hold

Sur

vey;

SM

R01

, Sco

ttis

h M

orbi

dity

Rec

ord;

STO

PIT

, Stu

dy o

f P

ublic

pla

ce In

terv

entio

n on

Tob

acco

exp

osur

e.

Ou

tco

me a

reas

Ou

tco

mes

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

Da

ta S

ou

rce

s

......

......

......

......

......

......

......

......

......

......

......

......

......

......

Pri

ma

ry r

ese

arc

h

Ro

uti

ne h

ealt

h a

nd

beh

avio

ura

l

......

......

......

......

......

......

......

......

...d

ata

......

......

......

......

......

......

......

....

Ro

uti

ne e

co

no

mic

data

CH

ET

SH

EP

SS

TO

PIT

BH

ET

SE

BA

RC

OM

MU

NIT

CS

MR

01

PT

IG

RO

SS

Ho

SS

HeS

LFS

GD

PID

PR

AB

ILIQ

UO

R

Kno

wle

dge

and

attit

udes

Kno

wle

dge

of h

ealth

ris

ks

ETS

xx

xx

xx

Att

itude

to

ETS

exp

osur

ex

xx

xx

Sm

okin

g ru

les

in h

ome

and

cars

x

ETS

exp

osur

eS

elf-

repo

rted

ETS

exp

osur

ex

xx

xx

Bio

mar

ker

of E

TS e

xpos

ure

xx

xx

Air-

mar

kers

of

ETS

exp

osur

ex

xx

Com

plia

nce

Rep

orte

d sm

okin

g in

pub

lic

plac

esx

xx

xx

x

Cul

tura

l cha

nge

Sup

port

for

legi

slat

ion

xx

xx

xC

hang

ing

soci

al/c

ultu

ral

norm

sx

xx

Sm

okin

g pr

eval

ence

Sm

okin

g pr

eval

ence

xx

xx

xx

xTo

bacc

o co

nsum

ptio

nx

xx

xx

xx

xQ

uit

atte

mpt

s/m

otiv

atio

n to

qu

itx

xx

xx

xx

Toba

cco-

rela

ted

mor

bidi

ty a

nd m

orta

lity

Toba

cco-

rela

ted

hosp

ital

adm

issi

ons

x

Toba

cco-

rela

ted

CH

D d

eath

sx

Toba

cco-

rela

ted

cons

ulta

tions

xx

Inci

denc

e ac

ute

coro

nary

sy

ndro

me

x

Res

pira

tory

sym

ptom

sx

xx

Lung

fun

ctio

n m

easu

res

xx

Eco

nom

ic im

pact

sE

mpl

oym

ent

xx

xTu

rnov

erx

xx

Pro

fitab

ility

xx

Bus

ines

s op

enin

gs a

nd

clos

ures

xx

Hea

lth in

equa

litie

sD

epriv

atio

n in

dice

s (d

eriv

ed

from

pos

t co

de)

xx

xx

xx

xx

xx

xx

xx

Occ

upat

iona

l dat

ax

xx

Inco

me

xFa

mily

Aff

luen

ce S

cale

(AFS

)x

Leve

l of

educ

atio

nx

xC

omm

uniti

es s

elec

tion

base

d on

ass

essm

ent

of

high

/low

aff

luen

ce

xx

30 J O U R N A L O F P U B L I C H E A L T H

Copyright declaration

The corresponding author has the right to grant on behalf ofall authors and does grant on behalf of all authors an exclu-sive licence to The Faculty of Public Health to permit thisarticle (if accepted) to be published in the Journal of PublicHealth.

Competing interests

All authors declare that the answer to the questions in yourconflict of interests form at http://www.oxfordjournals.org/our_journals/pubmed/for_authors/conflict%20of%20interest.pdfare all No and, therefore, have nothing to declare.

Funding sources

The research teams for CHETS, HEPS, STOPIT, BHETSE andthe Bar and Community Studies were commissioned by HealthScotland and are co-funded by Health Scotland and the Scot-tish Executive Health Improvement Directorate (SEHID) toconduct the respective studies. The ITC Ireland/UK Scotlandextension was commissioned by SEHID and is co-funded bySEHID, Cancer Research UK and the Flight Attendants’Research Institute (FAMRI) and the US National CancerInstitute. The Centre for Tobacco Control Research is corefunded by Cancer Research UK.

References

1 Health Bill 2005, Part 1. London: The Stationary Office Ltd, 2005.

2 The Smoking, Health and Social Care (Scotland) Act 2005, Part 1. Edinburgh: The Stationary Office Ltd, 2005.

3 Brennan P, Buffler PA, Reynolds P et al. Secondhand smoke exposure in adulthood and risk of lung cancer among never smokers: a pooled analysis of two large studies. Int J Cancer 2004; 109: 125–131.

4 International Agency for Research on Cancer 2002. Monograph. Volume 83. Involuntary smoking. Available from http://cie.iarc.fr/htdocs/indexes/ (4 January 2006, date last accessed).

5 Whincup PH, Glig JA, Emberson JR et al. Passive smoking and risk of coronary heart disease and stroke: prospective study with cotinine measurement. Br Med J 2004; 329: 1–6.

6 Law MR, Morris JK, Wald NJ. Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence. Br Med J 1997; 31: 973–980.

7 Chan-Yeung M, Dimich-Ward H. Respiratory health effects of exposure to environmental tobacco smoke. Respirology 2003; 8: 131–139.

8 Carey IM, Cook DG. The effects of environmental tobacco smoke exposure on lung function in a longitudinal study of British adults. Epidemiology 1999; 10: 319–326.

9 Iribarren C, Darbinian J, Klatsky AL, Friedman GD. Cohort study of exposure to environmental tobacco smoke and risk of first ischemic stroke and transient ischemic attack. Neuroepidemiology 2004; 23: 38–44.

10 Ludbrook A, Bird S, van Teijlingen E. International review of the health and economic impact of the regulation of smoking in public places. Edinburgh: NHS Health Scotland, 2005.

11 Allwright S, Paul G, Greiner B et al. Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after design. Br Med J 2005; 331: 1117.

12 Eisner MD, Smith AK, Blanc PD. Bartenders’ respiratory health after establishment of smoke-free bars and taverns. JAMA 1998; 280: 1909–1914.

13 Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. Br Med J 2004; 328: 977–980.

14 Pechacek T, Babbs S. How acute and reversible are the cardiovascular risks of secondhand smoke? Br Med J 2004; 328: 980–983.

15 Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: systematic review. Br Med J 2002; 325: 188.

16 Levy DT, Friend KB. The effects of clean indoor air laws: what do we know and what do we need to know? Health Educ Res 2003; 18: 592–609.

17 Ong MK, Glantz SA. Cardiovascular health and economic effects of smoke-free workplaces. Am J Med 2004; 117: 32–38.

18 Fong GT, Hyland A, Borland R et al. Reductions in tobacco smoke pollution and increases in support for smoke-free public places following the implementation of comprehensive smoke-free workplace legislation in the Republic of Ireland: findings from the ITC Ireland/UK Survey. Tobacco Control in press.

19 Scollo M, Lal A, Hyland A, Glantz S. Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry. Tobacco Control 2003; 12: 13–20.

20 Starr G, Rogers T, Schooley M, Porter S, Wiesen E, Jamison N. Key outcome indicators for evaluating comprehensive tobacco control programs. Atlanta, GA: Centers for Disease Control and Prevention, 2005.

21 Harley K, Jones C. Quality of Scottish Morbidity Record (SMR) data. Health Bull 1993; 51: 72–79.

22 Scottish Household Survey. Welcome to the Scottish household survey web site. Available from http://www.scotland.gov.uk/Topics/Statistics/16002/4031 (4 January 2006, date last accessed).

23 Scottish Executive. Scottish Health Survey–2003 result. Available from http://www.scotland.gov.uk/Publications/2005/11/25145024/50251 (04 January 2006, date last accessed).

24 National Statistics. Labour Force Survey. Available from http://www.statistics.gov.uk/STATBASE/Source.asp?vlnk=358 (4 January 2006, date last accessed).

25 National Statistics. Gross Domestic Product. Available from http://www.statistics.gov.uk/cci/nscl.asp?id=5900 (4 January 2006, date last accessed).

26 National Statistics. Inter-Departmental Business Register; a key survey source. Available from http://www.statistics.gov.uk/cci/nugget.asp?id=195 (4 January 2006, date last accessed).

27 National Statistics. Annual Business Inquiry. Available from http://www.statistics.gov.uk/abi/default.asp (4 January 2006, date last accessed).

28 Scottish Executive. Liquor Licensing Statistics. Available from http:// www.statistics.gov.uk/StatBase/Product.asp?vlnk=559&More=Y (4 January 2006, date last accessed).

Agenda Item 1 HC/S2/07/02/06 6 February 2007 Submission from the Minister for Health and Community Care

SMOKING HEALTH AND SOCIAL CARE (SCOTLAND) ACT 2005 – SMOKING BAN ELEMENT INTRODUCTION Overall the implementation of the new smoke-free laws has been extremely smooth with few compliance problems and high levels of public support. This submission provides an overview of the work undertaken to build compliance in the run-in to implementation. While it is too early to say precisely what impact the ban is having in health, economic and behavioural terms, it provides an indication of experience to date, including enforcement activity. Building compliance The Executive worked with a range of external organisations and a co-ordinated work programme was developed with the following key elements:

• the setting up of a National Smoke-free Areas Implementation Group to advise on the process, chaired by the Health Minister, comprising key stakeholders from industry and affected organisations;

• partnership working with other national government organisations to ensure

consistent messages and advice;

• working with key external alliances to ensure supportive PR and effective counters to misinformation from opponents of the legislation;

• an extensive public and business awareness raising campaign, including TV,

radio and cinema ads and ambient advertising on the health risks of passive smoking and informing the public about the effects of the legislation and when it would be introduced; the communications programme also included a dedicated clearing the air web-site;

• timely guidance to businesses on how to comply, developed in consultation

with business interests, with specific guidance for the NHS, local authorities and care service providers; (215,000 copies of business guidance printed and 5000 copies of the NHS and LA guidance)

• a leaflet drop to all households (2.6 million); • working with enforcement interests to draw up guidance to ensure a consistent

approach to enforcement throughout Scotland; and • direct briefings with business interests.

Monitoring the impact of the legislation A comprehensive Monitoring and Evaluation Programme is in place which will monitor the health, economic and behavioural impact of the legislation in the short, medium and longer term. This will provide data on 8 key outcome areas – knowledge and attitudes; second-hand smoke exposure; compliance; culture; smoking prevalence

and tobacco consumption; tobacco-related morbidity and mortality; economic impacts on the hospitality sector and health inequalities. Scotland will therefore be at the forefront of international knowledge on this issue, helping other countries learn from our experience. An international conference sharing the research experience from Scotland and other countries that have gone smoke-free will be held in Edinburgh in September 2007. Enforcement Statistics Information received so far from local authorities suggest that the implementation of the smoke- free legislation has been uniformly successful across Scotland. The law is being enforced by environmental health staff from local authorities. The Environmental Health profession has considerable experience in working with businesses to build compliance with the legislation. The approach is to provide support and assistance to businesses to help them comply, with formal enforcement action used only when it is warranted by the seriousness of the situation. General Information - Basic Compliance Statistics 26 March 2006 to 30 Sept 2006 The following data has been collated from returns from local authorities in Scotland. Premises Number

inspected No smoking in premises – number compliant

No smoking in premises - %age compliant

Hotels

2,967 2,925 98.58

Restaurants

4,685 4,647 99.19

Licensed premises

8,741 8,654 99

Other

36,520 35,438 97

TOTAL

52,913 51,664 97.64

Legend Hotels – the whole premises including bedrooms, bar areas, dining rooms Restaurants – all food establishments where diners sit in to eat Licensed premises – premises licensed for the sale and consumption, on site, of liquor e.g. pubs, clubs, bingo halls Other – workplaces, takeaways, taxis, vehicles, care establishments, other Fixed Penalty Notices Issued Premises 11 Individuals 210

Health Impacts and Smoking Cessation It is too early to say precisely what the impact of the Smoke-free legislation has had in health terms although early indications are that they have been positive. Tobacco related morbidity and mortality is being measured as part of the extensive monitoring and evaluation programme and this along with figures on people accessing smoking cessation services and the number of successful quit attempts will be available later in 2007. However there is evidence that many people have used the ban as an incentive to quit smoking with Smokeline receiving almost 27,000 calls between January and the end of March 2006, a sharp increase in the number of prescriptions and sales for Nicotine Replacement Therapy (1 million prescriptions for smoking cessation products in March 06 alone) and anecdotal evidence from Health Boards on increased numbers of people accessing smoking cessation services. In addition recent figures released by Imperial Tobacco showed that tobacco sales fell by around 5% in Scotland at the time of the ban, and that sales continue to be down by 2-3%. Dundee Study on Bar Workers Health Recent findings from a study of bar staff by Dundee University showed significant improvements in their respiratory health within 2 months of the ban being introduced. The study involved a cohort of 77 bar workers in Tayside and found a 32.4% decrease in participants reporting respiratory symptoms (wheeze, shortness of breath, cough and phlegm) and sensory symptoms (red or irritated eyes, painful throat and nasal itch, runny nose and sneeze). The team also recorded reductions in levels of nicotine in the bloodstream and breathing tests showed improvement in lung function of as much as 10%. This particular study does not form part of the official monitoring and evaluation programme which the Executive are undertaking in conjunction with Health Scotland. Aberdeen Study on Impact on Bar Workers Health Initial results from one of the studies from the official monitoring and evaluation programme carried out by a team from the department of environmental and occupational health at Aberdeen University, suggest that levels of air pollution in Scotland’s pubs have dropped by 86% since the smoking ban was introduced. The study involves around 360 bar workers and measured their exposure to fine particles known as PM 2.5. The health study assessed the health of bar workers before the ban through a questionnaire and measurement of lung capacity and will be followed up one year on to analyse whether the ban has made a difference to their health. Public Opinion The majority of Scots are supportive of the new law. 53,000 Scots took the time to respond to the Executive’s public consultation, with 80% in favour of legislation. Results of a recent poll by Cancer Research UK indicated 84% of young Scots – 18 to 24 year olds thought that a smoke-free Scotland is ‘something to be proud of’.

Cancer Research UK also published results which showed 92% of Scottish bar staff say their workplaces are healthier since the introduction of the smoke-free legislation. Even bar workers who smoke are overwhelmingly positive about the health effects of the new law with 89% reporting their work environment is now healthier because of it, and 69% believing it will benefit their health long term. Other issues Noise/littering There is no evidence at present to suggest that public disorder has increased significantly since the introduction of the smoke-free legislation. However there have been some reported instances and anecdotal evidence from Environmental Health Officers which suggest an increase in the number of complaints relating to noise generated outside pubs and clubs. These problems are not insurmountable and local authorities and the police already have existing powers in place to handle excessive noise and anti-social behaviour if necessary. Local authorities are responsible for handling the problem of litter and they will be keeping the issue under review as experience of the smoke-free legislation grows. There is also no evidence from other countries where smoke-free legislation has been introduced that this will be a long term problem The new law will help people to cut down the number of cigarettes they smoke, and therefore the numbers leaving premises to smoke will reduce through time. Economic impact It is too early to report on the economic impact of the legislation in Scotland; however this will form part of the comprehensive Monitoring and Evaluation Programme co-ordinated by Health Scotland. While we recognise that some individual businesses might be affected by the ban, there is no evidence to date to suggest that the ban will create a long-term economic problem for the hospitality sector. A Scottish Licensed Trade Association survey published last year seemed to suggest a downturn in trade of 10.8% since the introduction of the ban. However, the results were based on returns from only 365 of their 1700 members (Scotland has more than 5,000 licensed premises), and this can not be regarded as particularly representative. Also it seemed to be in direct contrast to the CRUK survey, published in June 06, which found a quarter of Scots are more likely to visit pubs more often now public places are smoke-free. Many of the large pub chains have reported an increase in sales since the ban was introduced mainly due to an increase in food sales. (E.g. Punch Taverns have reported increased food sales of between 9 and 20%). Impact on Bingo Halls The Bingo Association claims the new smoke-free laws are having a devastating, and disproportionate, impact on Bingo Operators (i.e. because 60% of the bingo players are smokers). It blames the introduction of the new laws on the closure of 5 clubs and the loss of hundreds of jobs. It also argues Bingo Operators are treated unfairly because, unlike bookmakers and lottery ticket sellers, they have to pay VAT on stake

money as well as tax on profits. They have, therefore, launched a campaign aimed at getting the Chancellor to repay £10m of bingo operators VAT to compensate for a 20% plus drop in revenue as a result of the ban. The decision to take forward the ban was made on public Health Grounds. Pubs, bars and bingo halls are areas where there were particular risks of heavy exposure to second hand smoke. Although we accept some individual businesses might be affected by the ban, there is no evidence to date to suggest it will create a long-term economic problem for the sector as a whole. Bingo halls have been smoke-free in Ireland since the mid-nineties without significant impact on businesses. We are monitoring the impact of the hospitality sector as part of our comprehensive ‘Monitoring and Evaluation Programme and the results will be published later this year. Smoking Prevention Working Group Report – Towards a future without tobacco An amendment was made to the Smoking Health and Social Care (Scotland) Act to enable Scottish Ministers to raise the age for purchase of tobacco products. The Smoking Prevention Working Group, a sub-group of the Scottish Ministerial Working Group on Tobacco Control, was set up to make recommendations to the Scottish Executive to assist the development of a long-term smoking prevention strategy to stop young people from taking up smoking. It was also asked to advise on the question of evidence to support raising the age of sale for tobacco products from the age of 16 years. The Working Group report was published on the 22 November 2006 and made 31 recommendations including one to raise the age of tobacco sales to 18 years. The Scottish Executive are currently consulting on a draft Order on raising the age for tobacco sales in tandem with consulting on the other recommendations set out in the Smoking Prevention Working Group report, Towards a future without tobacco. Responses are invited by the 28 February 2007. The Order will be laid before the Scottish Parliament as soon as possible thereafter. The actual date that the change in age will come into effect will be dependant on the outcome of the consultation. In addition I have acted immediately on some of the reports recommendations. I have:-

• written to the UK Government urging them to ensure that duty on tobacco products are increased at a rate higher than the rate of inflation and that health considerations are taken into account in EU tobacco taxation policies(recommendations 8&(); and that action to tackle smuggling remains a priority (recommendations 13 to 16).

• Accepted in principle, subject to the outcome of the consultation, that

recommendations contained in the report should be used as the basis for a 5 year action plan for consideration by the new administration following the Scottish Parliamentary elections in May 2007.

SCOTTISH EXECUTIVE

Minister for Health &... Community CareAndy Kerr MSP

Roseanna Cunningham MSPHealth Committee ConvenerThe Scottish ParliamentEdinburghEH99 1SP

St Andrew's HouseRegent RoadEdinburgh EH1 3DG

Telephone: 0845 7741741scottish .ministers@scotland.gsLgov.ukhttp://www .scotland.gov.uk

l2. January 2007

HEAL TH COMMITTEE HEARINGS 2007

Thank you for your letter dated 9 November 2006 about the evidence sessions in early 2007. Thesecond session on 6 February will review the implementation of the smoke-free element of theSmoking Health and Social Care (Scotland) Act 2005.

The introduction of Smoke-free public places on the 26 March 2006 is undeniably the mostimportant piece of public health legislation in a generation. The case for reducing smoking andexposure to second hand smoke to improve health is indisputable. Passive smoking is not just anuisance it is a killer.

In conjunction with NHS Health Scotland the Executive has put together a comprehensivemonitoring and evaluation programme to monitor the health, economic and cultural impact of theban. The findings of the evaluation programme will not be available until later this year when theywill be presented at an international conference on 10 and 11 September 2007 in Edinburgh.Scotland will therefore be at the forefront of international knowledge on this issue, helping othercountries learn from our experience.

Consequently, I will not have the outcomes from the monitoring and evaluation programme in timefor the session of the Health Committee on the 6 February, however I attach a memorandum whichupdates the Committee on progress to date in implementing the Smoke-free legislation.

ANDY KERR

INVESTOR IN PEOPLE

Agenda Item 2 HC/S2/07/02/07

6 February 2007 Health Committee

Subordinate Legislation Committee Report - Abridged

Negative instrument

The Food Hygiene (Scotland) Amendment Regulations 2007, (SSI 2007/11)

The Subordinate Legislation Committee has raised no issues in relation to this instrument.

Simon Watkins/Karen O’Hanlon

Joint Clerks to the Committee Room T3.40

Email: healthclerk@scottish.parliament.uk