action on smoking and health 2004

8/12/2019 Action on Smoking and Health 2004

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S MOKING KILLS A CRITIQUE S UBMISSION TO DEREK W ANLESS

A report by

The Royal College of Physicians, and

Action on Smoking and Health

12th January 2004


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S UMMARY OF CONCLUSIONS AND RECOMMENDATIONS

Content of Smoking Kills

1. The key objective of Smoking Kills was to reduce the prevalence of smoking by acombination of population strategies (advertising ban, high tax, health education,smokefree public places) and individual strategy (smoking cessation services)and so improve population health and reduce health inequalities.

2. Smoking Kills aimed to implement these strategies by partnership rather thanlegislation, but with an undertaking to monitor outcomes closely, take tougheraction on strategies that did not prove effective, and fund research into areas ofuncertainty.

3. Smoking Kills defined targets for reductions in smoking prevalence against whichits success should be judged. These targets were generally modest, and foradults required only a continuation of the secular trend since the early 1960s.

Implementation of Smoking Kills

1. Smoking cessation services have been widely implemented, are generallyeffective and successful, and provide excellent value for money.

2. The advertising ban has been implemented, but by private members bill afterhaving been dropped from the governments legislative programme.

3. Health education and advertising has been funded, but was slow to beimplemented, and was relatively underfunded.

4. The government has not delivered its policy of continued tax increases at abovethe rate of inflation.

5. There has been minimal progress in making public and work places smoke free.6. Smoking prevalence figures have fallen slightly since Smoking Kills , in line with

its own modest targets, but not sufficiently to have a marked impact on publichealth or social inequalities in health.

7. There has been no formal review of progress since Smoking Kills was publishedand little research progress.

What should be done now

1. Legislate to make all workplaces (and hence most public places) smoke free.2. Progressively increase the real price of cigarettes to smokers.3. Reform the regulation of all nicotine products to ensure that smokers who cant

quit using nicotine are provided with safer nicotine formulations than cigarettes.4. Continue to fund cessation services to ensure that high quality services are

available to all smokers who want to quit.5. Engage doctors and other health professionals more effectively in addressing

smoking as a medical problem, and intervening to reduce it.6. Sustain a high frequency and intensity of mass media campaigns to encourage

smokers to stop and to denormalise smoking.7. Enforce the advertising ban and close loopholes as they appear8. Set new and much more ambitious targets for reducing prevalence based on

what international evidence suggests could be achievable.


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Other changes necessary to ensure successful implementation of t he fullyengaged scenario and reduce health inequalities

1. Set up an independent research and advisory group to update Smoking Kills using high level input from experts in the field. This should be regularly revisedand updated in the light of experience and, in particular, in the light of theprogress made in reducing smoking prevalence.

2. Establish a Tobacco and Nicotine Regulatory Authority to rationalise regulation ofnicotine products and implement effective harm reduction strategies.

3. Make Public Health a cabinet-level appointment, to facilitate cross-departmentalpolicy integration on smoking and other public health priorities.

4. Increase the scope and infrastructure of public health practice to engage moreactively in population measures to improve health.


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1. INTRODUCTION

This report has been prepared in response to a meeting between Derek Wanless andJohn Britton (RCP), and Deborah Arnott (ASH), on 17 th December 2003. Asrequested the report addresses:

the content of the 1998 White Paper Smoking Kills ; the subsequent implementation of the White Paper policy; and what should be done in future to reduce smoking prevalence and harm.

Set out below is a more detailed analysis at individual policy level.

2. T HE 1998 WHITE P APER , SMOKING KILLS

Soon after coming to power in 1996, the government made a strong publicstatement of intent to tackle smoking 1;2 .

Smoking Kills, the white paper published in December 1998 3, was the first policystatement on tobacco control published by any UK government.

Smoking Kills declared that government has a clear role in tackling smoking anda responsibility to protect children from tobacco; and that government intended toensure that those who do not smoke are protected from those who do, and thatthe number of people smoking in Britain falls 3.

Other objectives included reducing smoking in young people, helping adults to

give up smoking, and to offer particular help to pregnant women who smoke. The main domestic policy initiatives were to:

1. Ban advertising and sponsorship, and restrict promotion inside shops2. Reduce affordability of cigarettes by increasing tax by at least 5% a

year in real terms3. Introduce specialist smoking cessation services throughout the UK4. Develop a sustained and coordinated health education campaign5. Restrict tobacco smuggling6. Implement a voluntary charter on smoking in public places which is

sensible, practical, and will deliver real improvements

7. Consult on an approved code of practice on smoking at work8. Fund research into specified uncertainties in evidence on smoking and

smoking cessation, and to monitor and evaluate the above initiatives

Other initiatives, including options to reduce under-age sales, introduce ID cardsfor children, tougher penalties for retailers who sell to children, and a new codeon the siting of cigarette vending machines were also discussed.

Targets were set to reduce smoking; the targets for 2005 (relative to values in1996) were to reduce prevalence

o in children from 13% to 11%o in adults from 28% to 24%o in pregnancy from 23% to 18%


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Smoking Kills made it clear that the government intended to achieve these

objectives, where possible, by partnership rather than by legislation.

However the government undertook to monitor outcomes closely and to consider

tougher action where measures prove less effective than hoped, includinglegislation if action in partnership failed to deliver.

Smoking Kills , and the public s tatements preceding publ ication, promis ed aserious commitment to reducing smoking prevalence through a package ofpopulation and indiv idual strategies.

As a resul t, and because of the undertaking to moni to r p rogress and taketougher measures where necessary, Smoking Kills was widely welcomed bythe health community.

3. I MPLEMENTATION OF S MOKING KILLS

Five years later, it is clear that some of the policies outlined in Smoking Kills havebeen implemented and are delivering results, whilst others have not beenimplemented, or are failing.

The areas in which policy has been implemented are:

The tobacco advertising ban: this was implemented, though by morecircuitous means than originally anticipated, due to lack of commitment from theGovernment. The bill was brought forward late in the first Labour term, ran out oftime before the 2000 election, was dropped from the Queens speech for the nextparliamentary session, and enacted only as a result of a private members bill. Asa result the ban did not come into force until February 2003. The debacle overthe backtracking on the ban on sponsorship in Formula 1 adversely affected thecredibility of the strategy.

Smoking cessation services: services providing behavioural support andpharmacotherapy have been established as standard NHS services throughoutthe UK, and last year engaged with over 230,000 smokers 4. Nationally they have

achieved success in line with what was predicted from the research literature. Smuggling : The availability of smuggled (and therefore lower price) cigarettes in

England has fallen from 21% of all sales in 2000/1 to 18% in 2002/3. Controllingsmuggling needs to continue to be a priority for HM Customs and Excise toensure that the real price of cigarettes on the street does not decline.

The areas in which government has failed to deliver on White Paper policy, orin which policy has failed are:

Tax : Tax was increased by 5% in real terms for 1999 and 2000, but by inflation

only since 2001. The affordability of cigarettes has remained stable since 19994,

and cigarettes are more affordable now than in the 1960s. The tax escalator of


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5% was dropped as a result of concern about the rapidly expanding level ofsmuggling of cigarettes into the UK. Now that this is under control theGovernment should re-introduce the escalator.

Smokefree workplaces: The approved code of practice was sent out forconsultation, as promised, but that process was completed in 2000 when the

ACoP was sent to Ministers to be signed off and there has since been no furtherprogress. It is still not clear whether the government intends to proceed with it,but civil servants in several departments have advised us that encouragingsmokefree workplaces is not a current priority. Meanwhile, the proportion of fullysmoke free workplaces in Britain, having increased from 40% in 1996 to 48% in1999, has since increased by only 2%, to 50% in 2002.

Smokefree public places: Smoking remains common in many public places.The voluntary public places charter for the hospitality industry has in particularfailed to deliver significant reductions in passive smoke exposure in pubs. By

April 2003, more than one in three (36%) pubs were still completely non-

compliant with the charter, whilst of those that were, nearly half (47%) stillallowed unrestricted and unventilated smoking throughout 5. Only 8% of pubsprovide separate smoking areas with ventilation 5. Almost none are smokefree.

Underage sales: Progress is reported to have been made in policing underagesales 4 and in restricting vending machine location. However there is no evidencethat young people who want to obtain cigarettes find it any less difficult to do sonow than before these measures were implemented.

Other aspects of implementation that have been slow or problematic include:

Public education: There was a delay in setting up the campaigns, and totalspending on education has been low at between 12 and 15 million a year from1999 to 2003, of which less than 60% has been spend on advertisingcampaigns. The net spend on advertising is well under 10% of that spent onadvertising and promotion by the tobacco industry during this period. So far therehas not been any detailed research into the effectiveness of these campaigns,though previous evidence indicates that if sustained at a high intensity andfrequency they can be expected to reduce smoking prevalence by about 1% 6. Itis not clear whether any such research is being carried out comprehensively asopposed to one off feedback on the impact of individual campaigns on publicperceptions. It would, for example, be interesting to compare the effectiveness inEngland with Wales or Scotland where campaigns have not been run. Theeducation budget for this year has been increased to 39 million.

The NHS Quitl ine is still not as efficient or effective as it should be and, forexample, does not proactively suggest getting help in the form of drugs orservices.

Cessation service funding: funding for services was allocated for a fixed threeyear period. Prevarication and/or brinkmanship over whether and by whomfunding would be awarded for subsequent years, in early 2002 and again in2003, caused considerable job insecurity and loss of good faith amongstcessation service staff. Many of the high quality staff who had established the

services were forced to move elsewhere purely because of funding insecurity.


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Cessation service monitoring: The government has adopted self-reportedcessation at 4 weeks as the main cessation outcome measure for monitoringpurposes. Of smokers truly abstinent at 4 weeks less than 30% are likely to beabstinent at one year 7. Self-reported cessation is also far less reliable thanmeasures based on objective validation by exhaled carbon monoxidemeasurement. Self-reported cessation at 4 weeks is therefore a very poorlyrepresentative indicator of true long-term cessation.

Cessation service targets: Targets of 800,000 four-week quitters have been setfor the three years from April 2003 approximately double the current throughputand likely to be difficult to achieve. Setting unachievable targets demoralises staffand encourages artificial inflation of figures.

Cessation service use by health p rofessionals: Health care professionals,and particularly doctors, have generally failed to adopt and implement clinicalguidelines on smoking cessation practice 8;9 into their routine work and hence toencourage smokers to use the cessation services available to them.

According to clinical practice guidelines, all healthcare professionals should bechecking smoking status in all consultations, providing brief advice to quit to allsmokers, and arranging cessation support for all smokers who want to quit 8;9 . Todate however the available evidence suggests that:

Only about one in three smokers recalls advice on smoking cessation fromtheir GP in the past five years 10;11 .

This proportion fell between 1999 and 2002 by 2%, to 35% 10 Only 4% of smokers reported in 2002 that they had accessed a stop

smoking group in the previous year 10 Half of hospitals in Britain still do not provide inpatient smoking cessation

counsellors 12 The limited audit data available indicate that hospital inpatients who smoke

are not systematically identified, or where appropriate referred to smokingcessation services 13;14

Doctors in the UK are not trained in clinical aspects of smoking cessation 15

This failure to implement basic clinical guidelines on systematicidentification and referral of motivated smokers has been and remains asignif icant obstacle to the success of the cessation services. Theconsequence is that cessation services are currently f ailing to deliver atanything like their maximum potential.

However, cessation services alone are essentially an indiv idualintervention which will not and cannot be expected to deliver significantfalls in prevalence. Achieving this wil l require strategies that influencesmoking behaviour across the general population 16 and requirecommit ment right across Government, not just from the Department ofHealth.

Meeting targets

The latest figures available indicate that adult smoking prevalence in 2002 was

25%10

(down 2% since 1999, target for 2005 26%); in children in 2002 10%17

(up


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1% since 1999, 2005 target 11%); and in pregnancy in 2000 19% 17 (change since1999 not available; 2005 target 18%).

The objective of reducing the difference in smoking rates between non-manualand manual occupational groups has not been met; the difference in prevalencein 2002 was 11%, exactly the same as in 1998, and indeed as in 1990 17 .

Smoking in the most disadvantaged groups in society are extremely high, at over70% in 1996 18 , and there is no evidence that this situation has improved.

The government is therefore close to meeting the overall prevalence targets foradults but not in children, not in the most deprived, and very probably not inpregnant smokers, who under-report smoking by about 3% 19 .

These prevalence targets themselves were in any case unambitious in the caseof adult prevalence requiring only a continued rate of decline that was less thanthe average for most of the decades since 1960. Given the magnitude of the

health effects of smoking, more ambitious targets are surely appropriate.

Research

There has been little reported research into uncertainties in the above policies,and aside from the smoking cessation services, little evidence of monitoring orevaluation of the implementation of Smoking Kills.

4. OVERVIEW OF ACHIEVEMENTS TO DATE

The policy initiatives in Smoking Kills have been successful in establishing localsmoking cessation services, banning tobacco advertising, and reducing tobaccosmuggling.

The main areas of failure are in influencing the numbers of smokefree workplacesand public places (and almost all enclosed public places are also workplaces), inwhich there has been very little progress, and in tax, which the government hasfailed to increase in line with its declared policy in Smoking Kills .

The public education campaign has been implemented but at a relatively modest

level of investment. The government has to date failed to honour its commitment to assess progress

and take tougher action, and if necessary legislate, in these areas of failure.

The government has also failed to review progress, deal with failing measures, orincorporate and capitalise on new ideas on harm reduction that have developedsince Smoking Kills was produced.

5. W HERE NEXT?

For the Government to achieve the fully engaged scenario and for its strategy to


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reduce health inequalities to succeed it needs to achieve the maximum possiblereductions in smoking prevalence, to minimise incident smoking in young people,and minimise harm from nicotine addiction in smokers who prove unable orunwilling to quit. The opportunity to improve public health through these measuresis immense on a scale similar to that of some of the major public health reformsof the 19 th Century 20 , but achieving these benefits will require courageous andstrong leadership. We suggest (see ASH submission to Wanless for more detail)that it is necessary to implement a comprehensive tobacco control strategy whichwould :

1. Legislate to make all workplaces (and hence public places) smokefree;2. Progressively increase the real price of cigarettes to smokers;3. Regulate to make safe sources of nicotine available to smokers who cannot

give up smoking4. Continue to provide effective treatment services for smokers who want to

stop;5. Engage the healthcare professions in implementing smoking interventions

into routine care;6. Continue and increase investment in long-term mass media and publiceducation campaigns to motivate and encourage quitting and denormalisesmoking;

7. Enforce the advertising ban and close loopholes as they appear.8. Reduce incident smoking by role-model effects of the above strategies9. Monitor the impact of these policies, and adapt to change10. Raise the political profile of tobacco control and of public health in general

In many cases the policy priorities now are the same as in 1998, and simplyrequire more resolve in implementation.

New areas of priority for policy arising since Smoking Kills comprise theengagement of the medical profession in smoking cessation, and harm reduction.

All of the available initiatives have individually small effects on prevalence 21 , butexperience elsewhere indicates that collectively, when applied acrosspopulations, these small effects can add up to a significant overall impact onprevalence 21;22 . The policies that would now reduce, or are highly likely to reducesmoking prevalence and smoking-related disease in Britain are:

1) Legislate to make all workp laces smoke free

Smokefree policies in public are effective in reducing prevalence because theyencourage smokers who work or visit to quit smoking, reduce passive smokeexposure to employees and public, and reduce exposure to the smoking rolemodel for young people. Research also shows that smokefree workplace policieshelp discourage smoking in front of children in the home 23 .

Passive smoke exposure in pubs and restaurants is very high three or moretimes higher than exposure sustained from living with a smoker 24-26 . Conventionalventilation and/or designated smoking areas are not effective in preventingexposure 27 .

Introducing smokefree policies at work reduces the absolute prevalence ofsmoking in the workforce by about 4%. Partial restrictions achieve approximately

half of that effect28

.


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Voluntary restrictions are much less effective than legislation in reducing smokingand passive smoking exposure, particularly for employees in relatively low skilloccupations 29 . Smokefree legislation would therefore help to reduce socialinequalities in health.

If the approximately 50% of workplaces in Britain that are not already smokefree

were to become so, about 320,000 employees in Britain would quit smoking longterm. There would be further reductions in prevalence arising from secondaryeffects of smokefree policy on smoking in visitors to workplaces, and the spousesand families of employees.

This policy is highly cost effective, because (in contrast to the introduction ofsmoking rooms and/or ventilation systems) the cost to the employer is minimal.The cost to society is the cost of providing smoking cessation support to smokerswho try to quit costs that should already be covered in the smoking cessationservice budget.

Policy in the UK now needs to be driven by legislation because the voluntaryapproach has stalled in general, and failed completely in pubs and bars.

An alternative means of implementing smokefree policies that would avoid the

need for further new legislation would be to classify environmental tobacco smokeas an occupational carcinogen (as currently classified by the International Agencyfor Research on Cancer 30 ), thus invoking control under UK COSHH regulations.Since almost all enclosed public places are also somebodys workplace, thiswould in effect achieve the objective of making public places smokefree.

2) Increase the real price of cigarettes

Increasing the real price of cigarettes decreases cigarette consumption and theprevalence of smoking.

Overall, in the UK the prevalence of smoking currently falls by around 0.3% per1% real increase in price.

However this effect varies across socio-economic groups those on highincomes are relatively unaffected by price, but in low income groups the fall inprevalence per 1% increase in price is closer to 1% 31 .

The escalator to increase prices by 5% above the rate of inflation each year wasabolished because of concerns about the growing level of smuggling. Now thatsmuggling has been more effectively brought under control HMT should considerre-introducing the policy of increasing the price of cigarettes above the rate ofinflation (a more detailed submission on this will form part of the budgetsubmission to HMT by ASH and other health organisations ).

The overall elasticity of about -0.3 means that gross tobacco tax revenue is not

reduced by the fall in consumption, in fact it increases. This is therefore a highly cost-effective intervention, since the only costs involved

are those of preventing and prosecuting smugglers and bootleg distributors. For moral and ethical reasons it is essential that tax increases are backed up by

the continued availability of free cessation services to help smokers to quit. It is also important to make the smoking public well aware of a policy of

progressive tax increases, to stress the longer term commitment to makingcigarettes unaffordable and thus reinforce the financial benefits of quitting as soonas possible.


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3) Make alternative and safer sources of nicot ine available to smokers

Smokers smoke, above all else, because they are addicted to nicotine 7. 80% of smokers making an attempt to quit will fail in that attempt. Many will go on

to further attempts and eventually succeed, but there are also many who will

prove unable to overcome their addiction in the context of currently availablecessation support. There is also a consistent hard core of up to about 4 million smokers in Britain

who declare that they do not intend to quit smoking 10 . Half of all smokers who cannot or will not quit smoking will die as a consequence

of their smoking. These smokers need a safer source of nicotine, and have abasic right to access the safest nicotine products 32 . The current legal frameworkfavours cigarettes over all other nicotine products, and therefore perpetuates theuse of cigarettes as the most common source of nicotine used in society 33 .

The current regulation of NRT as a medical therapy presents a significantobstacle to the commercial development of safe and acceptable alternative cleannicotine products for smokers, as such products would not be licenced under

current regulations 34 . These regulatory obstacles need to be removed, and replaced with regulation that

favours and encourages the development, promotion, pricing and retailing of safenicotine products in direct competition with and at significant advantage tocigarettes 33;34 .

The likely impact of these measures is unknown, and there is no internationalprecedent. However, pure nicotine is for practical purposes a safe drug, far saferthan tobacco smoke 7, and it is therefore highly unlikely that more widespread useof medicinal products would have anything other than a beneficial effect on publichealth 33;35 .

Consideration needs to be given to increasing market freedoms to tobaccoproducts that are not associated with the major health risks of smoked tobacco,such as oral snuff (currently banned in the EU but this is subject to a legalchallenge) 36;37 . Experience of these products in other countries indicates that theycan provide an acceptable (and less dangerous) alternative to cigarettes for up toa third of male smokers 38;39

Experience of smokeless tobacco in Sweden has been strongly favourable to thepublic health 38;39 but there is no experience of the impact of de novo introductionof smokeless tobacco products on smoking prevalence and harm reduction. Theeffect of introducing smokeless tobacco products must therefore be carefullymonitored and supervised 40 .

Ideally this should be achieved for all nicotine products either by bringing theircontrol together under an existing control agency, such as the Food Standards

Authority or Medicines Control Agency, or preferably a stand-alone nicotine andtobacco authority with a remit to minimise the proportion of regular nicotine usersin society, and amongst them, the proportion regularly obtaining nicotine fromsmoked tobacco 33;41 .

The cost of this initiative should be charged to the tobacco industry, on thepolluter pays principle, for example through a system of licencing.

4) Continue to provide smoking cessation services for all smokers

Smoking is a chronic, relapsing, addictive behaviour. It is therefore unethical to tax or impose other restrictions on smoking without

making high quality cessation support available.


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Smoking cessation interventions providing behavioural support, counselling andpharmacotherapy are all effective, and best practice (regular counselling supportand pharmacotherapy) increases the chance of sustained long-term cessation inany quit attempt by a factor of six or more 9;42;43 .

All smoking cessation interventions provide excellent value for money, costing

less than 1000 per life year saved, which is better than most other interventionsin medicine 44;45 , and far better than most interventions recommended to date byNICE 46 .

It is important that cessation services deliver the highest level of cessationsupport acceptable to each individual smoker, and to as many smokers aspossible. Services should therefore be available as widely as possible, to achievegreater population reach without compromising on the intensity of supportprovided.

Any targets imposed on smoking cessation services should take account of theneed to deliver a range of services. The current high targets on numbers ofsmokers setting a quit date and achieving four week self reported cessation maydrive services to provide low intensity, high reach services to the disadvantage of

more intensive options. Inappropriate targets are also a significant threat to staff morale, to the

maintenance of quality as well as quantity, and to valid reporting of results.

5) Integrate smoking cessation into routine health care delivery.

Smoking cessation interventions are still not a routine and systematic componentof health care delivery yet are much more effective in reducing disease risk thanmost other current routine medical practices.

For example, smoking cessation halves the risk of recurrence of myocardialinfarction, a much greater and more cost-effective impact than that achieved byother routine interventions such as therapy with aspirin, beta blockers, ACEinhibitors or statins, but in clinical practice is the least likely intervention to beapplied.

Over 80% of statin prescribing in primary prevention of myocardial infarction inprimary care populations is indicated solely by smoking 47 .

Smoking cessation is the only intervention that changes the natural history ofchronic obstructive airways disease or reduces the risk of lung cancer, but onlyhalf of all UK chest specialists has direct access to a smoking cessationcounsellor 12 .

Health professionals, and particularly doctors, have yet to embrace the concept ofnicotine addiction as a medical problem, and particularly as a problem that should

be given at least the same priority as other preventive interventions. The fact thatthe BMA conference in 2000 voted against the provision of NRT on NHSprescriptions is an indication of the scale of this professional misconception 48 .

A major programme of education for health care professionals, with the intentionof engaging them in implementing good cessation practice 8;9 , is now essential.This is necessary at undergraduate 15 and postgraduate levels.

Smoking cessation needs to be fully integrated as a high priority into clinicalguidelines for all chronic diseases influenced by smoking includingcardiovascular disease, respiratory disease, diabetes, and many others.

Targets for smoking cessation numbers may now be more effective if applied tothe clinicians who see the great majority of patients who smoke, instead of simplyto the services providing them with cessation support. Targets or other incentivesshould perhaps instead be used to increase:o The proportion of smokers advised to stop in GP and hospital consultations


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o The proportion of smokers in the local population who use the serviceso The 6-month as well as the 4-week success rates of stop smoking services,

with carbon monoxide validation where possible.These outcomes focus more appropriately on areas that are under the control ofthe health professionals concerned, and reflect the quality of the service provided.

6) Public education and mass media campaigns

Paid mass media advertising campaigns are effective means of reducing smokingin all socio-economic groups 49-51 , but they need to be sustained and invested insufficiently to give a high media weight. It remains important to maintain variedand effective public education initiatives on smoking effects and stoppingsmoking, with telephone support for further information to individuals expressinginterest in quitting.

Advertising also needs to continue to address smoking in the home and exposureof children; self-enforced restrictions on smoking at home are effective in reducing

exposure to children but are currently imposed by less than 20% of households52

. Advertising can also reduce incident smoking in young people 53 . Graphic health warnings on cigarette packs are also effective 54 and the

government should seek to introduce these in line with the new directive at theearliest possible opportunity.

It is also important to act to reduce the branding and perceived positive image ofcigarette pack designs, for example by requiring cigarette packaging to begeneric.

Public education campaigns can provide excellent value for money, costing under1000 per life year saved 44 .

7) Enforce the advertising ban and close loopholes

The new tobacco advertising and sponsorship legislation needs to be carefullymonitored and any loopholes closed quickly.

The tobacco industry will always look for opportunities to promote its productsand exploit loopholes in legislation or other opportunities wherever possible

There are current weaknesses in monitoring and control of below the linepromotions by the industry. The industry should also be prevented fromresearching how best to target young people and start them smoking.

Other examples include product placement of cigarettes in feature films and TVprogrammes aimed at or attracting youth audiences.

8) Reduce incident smoking

All of the available evidence suggests that preventing experimentation withcigarettes by adolescents is difficult.

The general consensus view is that the most effective way to reduce incidentsmoking is to reduce exposure to smoking role models and hence the perceptionof smoking as an attractive adult behaviour.

The recent sustained fall in youth smoking in California, following the introductionof systematic tobacco control measures aimed at adults, supports this view 55 .

Strong non-smoking policies at school also reduces youth smoking 56 , possibly byreducing contact with other smokers 57 .


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9) Monitor polic y and adapt to change

The above policy recommendations are made in good faith to state what oncurrent knowledge are the most effective, or potentially most effective, individualand population strategies to reduce to burden of smoking-related disease insociety.

They need to be included in an updated Smoking Kills which should be developedby an independent research and advisory group and designed to help achieve thefully engaged scenario. Once completed it should then be regularly revised andupdated in the light of the progress in reducing smoking prevalence.

It is therefore crucially important to measure the effect of these policies carefully,by regular monitoring of smoking behaviour.

It is also essential to identify problems in implementation and remedy thesequickly.

All of the above requires adequate investment in the management teams toimplement the policies, and in effective and responsive research. Historically,

investment in tobacco policy implementation has been limited to the Departmentof Health and has been inadequate.

10) General public health polic y and smoking

Smoking has been a recognised major public health problem for 50 years ormore, but smoking prevention has not been and in many cases is still not a majorpriority in relation to other public health activity. This is clearly a failure of policyand practice, arising at least in part from the inevitable pressure to deliver healthservices for sick people now, to the detriment of investment in future prevention.

This imbalance needs to change to afford much greater priority to the preventionof smoking, obesity and other avoidable major causes of chronic disease.

Implementing effective public health policy requires strong political leadership andcross-departmental policy integration, particularly in relation to tobacco. In thecase of Smoking Kills, implementation was the responsibility of the Department ofHealth but the proposals cut right across Government from HMT to theDepartment for Work and Pensions and the DTI. The Department of Healthdelivered the measure in its direct control smoking cessation services butwhere other departments were involved, progress has tended to be much lessrapid. To help to overcome these difficulties, public health should be representedand budgeted as a separate ministerial post at cabinet level with cross-Departmental responsibility.


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