Smoking Kills - A White Paper on Tobacco, Schemes and Mind Maps of Law

Download Smoking Kills - A White Paper on Tobacco and more Schemes and Mind Maps Law in PDF only on Docsity! Smoking Kills A White Paper on Tobacco Presented to Parliament by the Secretary of State for Health and the Secretaries of State for Scotland, Wales and Northern Ireland by Command of Her Majesty Cm 4177 11.50 published by The Stationery Office We welcome your comments on this site. Smoking Kills - A White Paper on Tobacco Contents Contents Preface Foreword 1 Smoking kills The facts The risks Passive smoking Smoking and inequalities The cost Government action 2 Government action Tobaccco summit Advertising Tax 3 Smoking and young people Tobacco advertising in shops Enforcement of under age sales Proof-of-age card Cigarette vending machines 4 Smoking and adults NHS smoking cessation services NRT on the NHS 5 Smoking and pregnant women 6 Smoking: action for everyone Ending tobacco advertising Changing attitudes Anti-smuggling drive Research Smoking Kills - A White Paper on Tobacco Foreword Foreword Smoking kills. That has been known for years. That is why a lot of adults have given up smoking. But the number of adults who smoke has stopped falling. Worse still the number of children who smoke is going up, with more girls than boys taking up this deadly habit. Smoking is now the principal avoidable cause of premature deaths in the UK. It hits the worst off people hardest of all. It harms people who do not smoke. It harms babies in the womb. That is why the Government is determined to turn things round. We want to help existing smokers quit the habit and help children and young people not to get addicted in the first place. These objectives can only be achieved by a concerted campaign to reduce smoking. That is why this White Paper spells out a package of measures each of which will add to the impact of the others. A major part of the effort will be targeted on children. As a result of this Government taking a positive position, a Europe wide ban on tobacco advertising and sponsorship is being introduced. This will be backed up by a powerful 50 million publicity campaign to shift attitudes and change behaviour. In collaboration with the Government, the hospitality industry will put in place measures to reduce the amount of smoking in public places. The Health and Safety Commission will be consulting on a new code of practice to protect people from other people's tobacco smoke at their place of work. The White Paper also sets out our proposals to help the 7 out of every 10 smokers who say they want to quit. We are to invest up to 60 million to build the first ever comprehensive NHS service to help smokers to give up. This will be started first in those deprived communities which in England we have designated as Health Action Zones. The extra help, including nicotine replacement therapy, will be targeted at the worst off, who are most likely to smoke and least able to afford it. This White Paper spells out a balanced package of measures which we are convinced will command public support and reduce the 120,000 deaths presently caused by smoking every year. The Rt Hon Frank Dobson MP Secretary of State for Health The Rt Hon Donald Dewer MP Secretary of State for Scotland The Rt Hon Marjorie Mowlam MP Secretary of State for Northern Ireland The Rt Hon Alun Michael MP Secretary of State for Wales Smoking Kills - A White Paper on Tobacco Chapter 1 Smoking kills 1.1 Smoking kills. Smoking is the single greatest cause of preventable illness and premature death in the UK. Smoking kills over 120,000 people in the UK a year - more than 13 people an hour1. Every hour, every day. For the EU as a whole the number of deaths from tobacco is estimated at well over 500,000 a year2. A generation after the health risks from smoking were demonstrated beyond dispute, smoking is still causing misery to millions. Smoking is still killing. ' smoking kills more than 13 people an hour' 1.2 The Government is determined to see a major improvement in health in the UK. To help that, we have proposed tough and specific new targets for health improvement, backed with clear proposals for action to achieve them. Achieving these targets can only be done if we tackle smoking. One of the targets is to reduce cancer deaths. Another will be to reduce heart disease deaths. Cancer and heart disease are the two most common fatal diseases in this country. Smoking is a major cause of cancer and heart disease1. 1.3 The new targets will reinforce our key goals for public health improvement, which were set out with proposed targets in our consultative document earlier this year, Our Healthier Nation3. They are: to improve the health of the population as a whole by increasing the length of people's lives and the number of years people spend free from illness; and to improve the health of the worst off in society and to narrow the health gap Achieving the targets and these key goals will give everyone in our country a better chance to enjoy a full, healthy and prosperous life. It cannot be done unless we tackle smoking. ' achieving the targets and these key goals will give everyone in our country a better chance to enjoy a full, healthy and prosperous life. It cannot be done unless we tackle smoking' 1.4 We made clear in our election manifesto that we intended to take action over smoking. We are doing so with the proposals we are publishing here. Tackling smoking is central to cutting deaths from cancer and heart disease. Tackling smoking is central to improving health in Britain. Smoking - the facts 1.5 Tobacco first came to Britain in the sixteenth century. But smoking as a mass habit is a phenomenon of the twentieth century. So too is smoking as a mass killer. ' smoking as a mass habit is a phenomenon of the twentieth century. So too is smoking as a mass killer' 1.6 Smoking peaked in the 1950s and 1960s, and fell steadily in the 1970s and 1980s4. Currently, there are around 13 million adult smokers in the UK5. But the long downward trend in smoking may be levelling out. Adult smoking rates rose in 1996, the last full year for which figures are available, for the first time since 1972. We may be seeing the beginning of a new upward trend in smoking. Among people aged 16 and over, the smoking rate of 28 per cent in England was the same as in 1992 and was up on the 1994 rate of 26 per cent6. The adult smoking rate is particularly high in Scotland and Walesat 32 per cent6,7. In No rthern Ireland it is 29 per cent8. 1.7 More and more children and young people are starting to smoke. The proportion of those aged 11 to 15 who smoke regularly was 8 per cent in England in 1988. In 1996 it was 13 per cent. The upward trend is particularly notable among girls. In 1988, just one in five 15-year-old girls smoked regularly. Now it is one in three9. 1.8 82 per cent of smokers take up the habit as teenagers6. Smoking is addictive, and many of the children and young people who smoke will go on to smoke all their lives. ' the vast majority of smokers take up the habit as teenagers - many will go on to smoke all their lives' 1.9 Rising rates of children smoking are feeding through into rates of adult smoking as each successive generation gets beyond the age of 16. 1.18 Passive smoking, even in low levels, can cause illness18. Asthma sufferers are more prone to attacks in smoky atmospheres. Children, more vulnerable than adults and often with little choice over their exposure to tobacco smoke, are at particular risk. ' 17,000 hospital admissions in a single year of children under 5 are due to their parents smoking' 1.19 Children whose parents smoke are much more likely to develop lung illness and other conditions such as glue ear and asthma than children of non-smoking parents22. The Royal College of Physicians has estimated that as many as 17,000 hospital admissions in a single year of children under 5 are due to their parents smoking23. They also estimate that one quarter of cot deaths could be caused by mothers smoking. Women who smoke while pregnant are likely to reduce the birthweight, and damage the health, of their baby24. Smoking and inequalities 1.20 Smoking more than any other identifiable factor contributes to the gap in healthy life expectancy between those most in need, and those most advantaged25. While overall smoking rates have fallen over the decades, for the least advantaged they have barely fallen at all. In 1996, 12 per cent of men in professional jobs smoked, compared with 40 per cent of men in unskilled manual jobs. 1.21 Such differences are reflected in the impact of smoking on health. A higher rate of smoking among people in manual jobs is matched by much higher rates of disease such as cancer and heart disease. 1.22 Between 1991 and 1993, among men aged 20 to 64 in professional work, 17 in every 100,000 died of lung cancer, compared with 82 per 100,000 in unskilled manual work. For the same period and age group, among professional workers, 81 per 100,000 died from coronary heart disease compared with 235 per 100,000 in unskilled manual jobs26. 1.23 The close link between smoking and health inequalities was highlighted again recently in the report of the independent inquiry into health inequalities chaired by Sir Donald Acheson27. The report concluded that the relatively stable rate of smoking in the least advantaged groups suggests that simply intensifying current approaches would not be sufficient to tackle the problem. Smoking - the cost 1.24 The cost of smoking is high in terms of people's health. But the cost of smoking is high in other ways too. Smoking is estimated to cost the NHS up to 1.7 billion every year19. And it costs families, especially the poorest, a great deal too. It is estimated that, in 1996, there were approximately 1 million lone parents on Income Support, of whom 55 per cent smoked an average of five packs of cigarettes a week at a cost of 2.50 per pack28. That means lone parent families spent a staggering 357 million on cigarettes during that year. Smoking - Government action 1.25 The Government is determined to tackle these problems. The case for action on smoking is clear. Governments have tried in the past to reduce smoking. But while previous efforts have contributed to the steady reduction in the overall number of adults who smoke, success has been limited. Now, the rise in children smoking and the halt in the decline in adult smoking reinforces the case for new Government action. But at the same time, we recognise that Government action in areas of personal choice like smoking is a difficult and a sensitive issue. Tobacco is a uniquely dangerous product. If introduced today, it would not stand the remotest chance of being legal. But smoking is not against the law. We do not intend to make smoking unlawful. We are not banning smoking. 1.26 Currently, well over a quarter of the people of Britain smoke. The Government fully recognises their right to choose to do so. We will not in any of our proposals infringe upon that right. But with rights come responsibilities. Smokers have a responsibility to themselves - to their own health, and to ensure that in making the choice to smoke, their choice is based on a real understanding of the risks involved. With their right to smoke, too, comes the responsibility to others who choose not to smoke. Just as the Government is determined not to infringe upon people's rights to make free and informed choices, it is also determined to ensure that the responsibilities of smokers to people who choose not to smoke are carried out. That means a balance of rights and responsibilities -for those who smoke and for those who do not. Striking that balance is a clear and tough challenge - for the Government, for business, for local authorities, for voluntary groups and especially for individuals. ' with their right to smoke, too, comes the responsibility to others who choose not to smoke' 1.27 The Government has a clear role in tackling smoking. While it is for individuals to make their own choices about smoking, the impact of smoking on the people of Britain - on their health, in causing premature deaths, on non-smokers and in terms of its overall cost - is so great that if it we re any other cause, the Government would face accusations of negligence for failing to take action. The Government also has a clear responsibility to protect children from tobacco. 1.28 Reducing smoking will save lives. The Government intends to implement a tough and comprehensive programme to ensure that those who smoke are aware of the potential consequences of their choice, that those who do not smoke are protected against those who do, and that the number of people smoking in Britain falls. 1.29 We have already taken action, especially in Europe. The Government's proposals in this White Paper set out the major steps we now intend to take. We will support this new programme of action, with new money - more than 100 million over the next three years. We recognise the scale of the challenge we all face to reduce smoking. But in partnership with others, we are determined to meet that challenge, and to improve the overall health of everyone - smokers and non-smokers alike - in our country. ' we will support this new programme of action, with new money - more than 100 million over the next three years' The consultation document Our Healthier Nation was published for England in February 1998. Similar health strategies exist for Scotland - Working Together for a Healthier Scotland, Wales - Better Health Better Wales, and Northern Ireland - Regional Strategy for Health and Social Well-being 1997 to 2002. Tax Why action is needed 2.12 Research shows that the demand for tobacco products is related to their price30. As prices rise, demand falls. So high tax levels are one important means of reducing tobacco consumption. High tobacco prices are also a deterrent to children tempted to take up smoking. The real price of tobacco - that is, after allowing for inflation - has increased significantly in recent decades. But people's real incomes have also risen. ' when people's incomes increase faster than the price of cigarettes, the 'affordability' of cigarettes goes up' 2.13 When people's incomes increase faster than the price of cigarettes, people can afford to buy more cigarettes - that is, the 'affordability' of cigarettes goes up. This can reduce the incentive to give up smoking presented by rising tobacco tax. 2.14 The graph above shows how the affordability of cigarettes has changed since 1965, when people first became aware of the great health risks associated with smoking23. Cigarettes are still over 60 per cent more affordable now than in 1965. What action are we taking? 2.15 Tax - that is, duty and VAT - currently accounts for almost 80 per cent of the price of a packet of cigarettes. We set cigarette tax at a high level so that the price of cigarettes in the shops will be high. This acts as an incentive to smoke less. 2.16 The Government has committed itself to increases in tobacco taxation. As incomes tend to rise significantly each year, the only way to reduce affordability is to put tobacco tax up by more. The last Government said in 1993 that it would increase tobacco duty by at least 3 per cent in real terms each year. But we believe it is right to go further. ' the price of a typical packet of 20 cigarettes at the end of 1998 is about 55p higher than at the end of 1996' 2.17 In our first Budget, in July 1997, the Chancellor announced that, in future, tobacco duties would be increased on average by at least 5 per cent in real terms a year. Tobacco duties rose by just over 5 per cent in real terms on both 1 December 1997 and again on 1 December 1998. The price of a typical packet of 20 cigarettes at the end of 1998 is about 55p higher than at the end of 1996. 2.18 Because of the high taxation of cigarettes, Governments are sometimes accused of exploiting smokers. The charge is made particularly in relation to smokers who are less well off, because tax and price increases hit most heavily those who spend the highest proportions of their income on tobacco. ' we are going to balance high tobacco tax with real support from the NHS to help smokers quit' 2.19 We recognise this issue, which is why we are going to balance high tobacco tax with real support from the NHS to help smokers quit. No UK government has provided such support properly before. That is what we mean by a comprehensive approach to tackling smoking. Summary 2.20 The Government believes it has taken a number of important steps over smoking. But the steps taken so far are only the start. Further action is now necessary if smoking is to be reduced, and health in Britain improved. 110 million in England, 8 million in Scotland and 1 million in Northern Ireland. Funding in Wales is subject to the outcome of the Comprehensive Spending Review for Wales. Smoking Kills - A White Paper on Tobacco Chapter 3 Smoking and young people Why do children start to smoke? 3.1 Children smoke for all sorts of reasons. Some smoke to show their independence, others because their friends do. Some smoke because adults tell them not to, others to follow the example of role models. There is no single cause. Parents, brothers and sisters who smoke are a powerful influence. So is advertising. So too is sport which is often sponsored by tobacco companies. 3.2 Many children experiment with smoking, believing they will be able to stop when they want to. But smoking is highly addictive and a great many will find themselves unable to give up. 3.3 Unless we take action, hundreds of children each day will continue to take up smoking. Smoking among the young is increasing year by year. Eighty two per cent of adult smokers start smoking in their teens. Some will manage to quit early, but many will continue to smoke for decades, unable to give up and increasingly at risk of serious illness and early death. ' unless we take action, hundreds of children each day will continue to take up smoking' 3.4 Most people know something about the health risks of smoking. But young smokers do not see the risks applying to them31 3.5 Among children aged 11, 1 per cent smoke at least once a week. But by the time they are 15 it is 30 per cent. The to reflect the present nature of genuine specialist businesses. ' although it is illegal to sell cigarettes to anyone under 16, it is clear that the existing law is not being applied effectively' Tough enforcement on under age sales Why action is needed 3.16 Although it is illegal to sell cigarettes to anyone under 16, it is clear that the existing law is not being applied effectively. 3.17 Most children who smoke say they buy their cigarettes from shops9. Of those children who get their cigarettes from shops, only 22 per cent of boys and 15 per cent of girls in England say they found it difficult9. That suggests that many shopkeepers are selling tobacco to children. 3.18 The majority of shopkeepers say they question children they suspect of being under 16 when they try to buy tobacco. But many 14 and 15-year olds can and do pass for 16. We recognise the problems busy shopkeepers face in refusing to sell tobacco to such customers. 3.19 We believe that the majority of shopkeepers do try hard to avoid illegal sales. But we are going to work with local enforcement agencies to make sure shopkeepers comply with the law much more successfully. 3.20 The first priority should be to help shopkeepers comply with the existing regulations. Legal action can be taken against those who flout their legal responsibilities. Under the Children and Young Persons (Protection from Tobacco) Act 1991, local authorities have a statutory duty to consider taking enforcement action at least once a year. However, not all local authorities do carry out checks in a typical year despite the clear problem. The legal powers are there, but they are not being rigorously applied. ' we want to build on what is being done successfully in some authorities to bring all authorities up to the standard of the best' The action we are taking 3.21 We are developing a new Enforcement Protocol, with representatives of local authorities, trading standards officers and environmental health officers, for use by local authorities in carrying out their duty under the 1991 Act. Every local authority should be properly exercising its statutory role in preventing under-age sales in accordance with best practice. We want to learn from what is being done successfully in some authorities to bring all authorities up to the standard of the best. This will build on the Best Value approach. 3.22 The Local Government Association (LGA) and the Local Authorities Co-ordinating body on Food and Trading Standards (LACOTS) are committed to work with the Government to ensure we make the best possible use of existing legislation. We will also be closely involving bodies representing local authorities and enforcement agencies in Scotland, Wales and Northern Ireland. 3.23 There is currently no statutory obligation on local authorities to carry out an enforcement campaign. But the LGA and LACOTS agree with us that every local authority should assess the need for such a campaign and, where a campaign is decided on, it should be run in accordance with recognised best practice. Together we will draw up a detailed protocol of best practice for use by local authorities UK-wide. The scope of the protocol is set out below: Enforcement protocol for local authorities publishing a clear statement on dealing with under-age tobacco sales (and other age-restricted products) assessing the current local degree of compliance, the action required by trading standards officers to enforce it, high risk areas or particular outlets for targeted attention considering the parties with which consultation should take place before the annual review of enforcement action required under section 5(1)(a) of the Children and Young Persons (Protection From Tobacco) Act 1991 acting in accordance with the joint central/local government Enforcement Concordat, with its emphasis on education and help to ensure compliance, with enforcement action concentrated on those who most flagrantly fail to comply with their obligations stressing the importance of local support for moves to introduce a proof of age card scheme as the key tool to enable retailers to meet their obligations with confidence using test purchasing, where permissible, either with under-age children or those who clearly look under-age to gather information about premises likely to be breaching the law or to assist prosecutions detailing enforcement action taken, prosecutions and fines, to act as a deterrent monitoring the action taken and the evaluation of its impact on the scale of the local problem, to inform the next year's statutory review 3.24 A constructive approach by trading standards officers helping retailers meet their responsibilities, combined with enforcement activity targeted at likely problem retailers, should lead to a significant improvement overall. 3.25 If local authorities carry out their obligations under the law in accordance with the kind of guidance outlined above, we can expect much better compliance with the law. 3.26 However, we will expect trading standards officers (enviromental health officers in Northern Ireland) to continue to press for the prosecution of persistent offenders. There will always be cases where prosecution is the only response for shopkeepers who deliberately flout the law. ' we will expect trading standards officers to continue to press for the prosecution of persistent offenders' 3.27 Very effective action is already being taken by several local authorities. North Yorkshire Trading Standards North Yorkshire County Council Trading Standards were pioneers in using young people in test purchases of cigarettes as a means of law enforcement. Test purchases give Trading Standards Officers an indication of the illegal tobacco sales problem in their area, and provide them with evidence they can use to prosecute retailers who break the law. North Yorkshire County Council have found that regular test purchasing and a high profile media approach have been extremely successful in reducing the incidents of reported sales of cigarettes to people under 16. The Public Protection Committee have illustrated their commitment by issuing the following statement: "North Yorkshire County Council Trading Standards Department will: bring prosecutions in respect of offences under the Children & Young Persons Act 1933 (as amended) in respect of the sale of tobacco to children investigate fully complaints in respect of alleged offences under those provisions take other measures intended to reduce the incidence of offences under those provisions including: a) spot checks on retailers, b) maximising the use of media by the publication of warnings, successful prosecutions and health information where appropriate. act on any information concerning the location of cigarette vending machines on premises where children have access. North Yorkshire Public Protection Committee will: Consider at least once each year the enforcement programme in relation to this legislation and the extent to which any such programme has been carried out during the previous 12 months." 3.28 For such offenders, there is scope for making more use of the full range of penalties within the current limit on fines. The maximum fine for this offence was raised in 1991 to 2,500. The average fine is around a tenth of that figure. 3.29 Prosecutions for selling tobacco to under-16s are relatively rare, and magistrates and trading standards officers may need to consider in greater detail the issues surrounding such offences and the ways in which such cases can best be presented to courts. The Magistrates' Association and LACOTS will be discussing how these cases should be approached following this White Paper. As Parliament has provided a maximum fine of 2,500, there needs to be a clear understanding of the circumstances which could justify the higher levels of fine, such as previous convictions, or sales to particularly young children clearly well below the legal age. 3.30 Occasionally there will be individuals who flout the law and do so repeatedly. We do not believe that people who are prepared to behave so irresponsibly should be allowed to continue to sell tobacco. The Government will explore the scope for new measures to stop repeat offenders or their staff from selling tobacco. In principle, we favour the introduction of a new criminal sanction to deal with this problem, and will be looking carefully at the practicality of introducing and enforcing such a measure. Prevention of illegal sales of tobacco in Belfast Belfast City Council are seeking to prevent sales of cigarettes to children by developing both education and inspection policies. Retail outlets are visited twice yearly, and particular attention is paid to shops near schools. Children are used as 'test' buyers of cigarettes so that the enforcers can assess the scale of the problem and prosecute shopkeepers who may be flouting the law. Retailers are informed of their duties and how best to comply with the law through advisory leaflets and education programmes. Advice for retailers who employ part-time or temporary staff, or who have a high staff turnover is a high priority. Essex Trading Standards proof of age card Essex trading standards officers have developed a multi-purpose proof of age card. The card was devised with the help and co-operation of local organisations such as the County Education Department, Police, Health Promotion Officers and Head Teachers and, most importantly, the Council's Elected Members have taken a close interest in the project and supported it fully. At least 3000 cards have already been issued and over half the schoolchildren in Essex will be issued with cards by early 1999. The cards are popular not only with young people, but also shopkeepers and law enforcement officers who know that any young person should be able to prove their age. In a recent exercise, young people trying to buy cigarettes were used to 'test' the response of shopkeepers, 75% were asked for the card. Where these cards have been introduced, the number of complaints about illegal sales of age-restricted goods has already decreased, it is easier to target re sources, and magistrates are taking a stronger line in cases of under-age sales. Essex Trading Standards are sharing their experience with a number of interested authorities throughout England. Proof-of-age card Smoking Kills - A White Paper on Tobacco Chapter 4 Smoking and adults 4.1 Seven out of ten adult smokers say they would like to give up if they could32. But most smokers find it hard to quit. Even those who do manage to give up may have tried many times before they finally succeed. The urge to smoke can last for years, and many ex-smokers find it very easy to start smoking again. But for smokers who do give up, the chances of getting a serious or fatal disease are greatly reduced33. We want to help them in the most effective way we can. 4.2 Research has been done on how best to help people give up smoking. Research shows that there is a range of cheap and effective ways of helping people to quit. Doctors and other health professionals such as nurses, dentists and pharmacists can advise smokers to give up in the course of their day-to-day contact with them for health services. Not surprisingly, when a doctor talks to a smoker about the benefits of giving up, it can be a powerful motivator34. ' nicotine replacement therapy doubles the chances of quitting successfully' 4.3 At the other end of the scale, a full course of specialist counselling combined with nicotine replacement therapy can lead up to 25 per cent of smokers to give up35. Although such methods may not work for everyone, they can significantly increase the chances of giving up successfully. The research also shows that, whatever kind of support is given by doctors and experts, nicotine replacement therapy doubles the chances of quitting successfully34. 4.4 We know that many smokers do not want to quit, and that is their choice. But they should make that choice in the full knowledge of the risks and with the offer of support to help with their addiction if they want it. 4.5 They should also make their choice in the full knowledge of what are the benefits of quitting. Giving up smoking has immediate and longer-term effects. When a typical smoker quits, after: 20 minutes Blood pressure and pulse rate return to normal. Circulation improves in hands and feet, making them warmer. 8 hours Oxygen levels in the blood return to normal. Chances of a heart attack start to fall. 24 hours Carbon monoxide is eliminated from the body. The lungs start to clear out mucus and other debris. 48 hours Nicotine is no longer detectable in the body. The ability to taste and smell is improved. 72 hours Breathing becomes easier as the bronchial tubes relax. Energy levels increase. 2-12 weeks Circulation improves throughout the body, making walking easier. 3-9 months Breathing problems such as coughing, shortness of breath, and wheezing improve. Overall, lung function is increased by 5-10%. 5 years Risk of a heart attack falls to about half that of a smoker. 10 years Risk of lung cancer falls to about half that of a smoker. Risk of a heart attack falls to about the same as someone who has never smoked. Source: QUIT®36 4.6 Taking positive steps to help people give up smoking is not only important in improving the health of the individuals concerned. There will also be wider economic benefits. For example, there will be fewer days off work with illnesses caused by smoking and less pressure on hospital beds. NHS smoking cessation services What we are going to do 4.7 For the first time ever in the history of the NHS, we are investing substantial resources - up to 60 million of new money in England alone over the next three years - to build NHS services to help smokers who want to give up. High priority will be given to the development of services in each of the four UK countries. The new service will mean that GPs andothers will be able to refer smokers who really want to give up for a course of specialist counselling, advice and support. Smokers motivated to give up will also be able to enrol for courses where available without being referred. Each local service will be able to tailor the support it offers to suit the needs of smokers locally. 4.8 As part of the package, counsellors will offer a week's supply of nicotine replacement therapy (NRT) - free of charge to those smokers least able to afford it - to introduce smokers to the potential benefit of NRT in relieving withdrawal symptoms. 4.9 The new services will be located, at first, in areas of greatest need. In 1999/00, year one, the Health Action Zones in England will receive 10 million, ring-fenced specifically for these services. Funding will be increased to 20 million in year two and 30 million in year three, to develop services more widely, subject to evidence of the effectiveness of the investment. 4.10 These are our intentions. We will continue to develop the practical detail of our plans so that services can be up and running as soon after 1 April 1999 as possible. The role of all health professionals 4.11 Most people see their GP at least once a year6, and other health professionals at other times during the year. But at the same time, less than half of smokers say they remember being given advice on smoking by a GP, practice nurse or other medical person at any point during the last five years32. 4.12 GPs, practice nurses, midwives, dentists, pharmacists, health visitors and other health professionals are the people to whom we all look to advise us about our health. Each of those professions has an important role to play in giving the kind of smoking cessation advice which a modern health service ought to provide. Such advice need not take long; the consistency of the message is all important. Smokers need to be aware that those who know about health, advise against smoking. All health professionals working in hospital or community settings should assess smoking habits and provide advice to smokers on giving up, whenever possible. 4.13 Now that we will be investing substantial resources in specialist services, health professionals will have something more to offer patients who smoke. But expert advice will still be needed from health professionals in the course of everyday appointments, check-ups and treatment. Smoking is the biggest single threat to health faced by large sections of the population. It is important that all health professionals provide simple advice to give up smoking on as routine a basis as possible. NRT on the NHS 4.14 To quit successfully, smokers also need to be strongly motivated and able to deal with the inevitable cravings for nicotine. That is where NRT comes in. A course of NRT provides the body with nicotine in decreasing doses until the craving is small enough to cope with. It also provides nicotine without any harmful smoke. NRT is not a miracle cure for nicotine addiction, but it can work for many smokers when used in accordance with the instructions and in the recommended quantities. 4.15 Many smokers are unaware of the potential benefits of NRT. It is usually cheaper than cigarettes (about 10 to 20 a week, compared with about 25 a week to support a 20-a-day habit) and only works if people do not smoke at the same time. It is available over the counter in pharmacies. We are going to raise the profile of NRT and encourage smokers to try it, particularly those who are least able to afford to smoke or buy NRT. Research shows that NRT is most effective in the context of skilled advice and support34. 4.16 To those less well-off smokers who are prepared also to receive the specialist advice and support with which it works best, we will be providing one-week's free NRT. This fits with the evidence which shows that smokers who manage to avoid smoking for a complete week with the help of NRT are more likely to go on to quit for good37. A course of NRT typically lasts only about ten weeks. After that, someone who was spending 25 a week on cigarettes would be able to spend that money on something else. 4.17 We will monitor the effectiveness of this policy over the coming three years to see if alternative approaches to NRT would be better. NRT in shops 4.18 At present, the law allows NRT to be sold only in pharmacies. However, the Committee on Safety of Medicines (CSM) has advised that low dose nicotine gum could be put on general sale in shops to help with smoking cessation.The CSM has also advised that a legal mechanism should be sought to prevent sales of NRT to those under 16. The Medicines Control Agency (MCA) is currently consulting on this issue and any views should be sent by 24 December 1998 to Room 1109A Market Towers, 1 Nine Elms Lane, London SW8 5NQ. We will consider any advice from the MCA following the consultation. Co-operating to improve cessation 4.19 We are going to work closely with the manufacturers of NRT products, with high street retail chemists, and with the medical professions to improve the provision of on-the-spot advice and NRT in as wide a range of settings as possible. We all recognise our common aim in increasing the number of people giving up smoking. A group of organisations has made the following statement of their intent. Statement of intent We welcome the Government's drive against smoking as a leading cause of preventable illness. Pharmacists in both community and hospital practice are particularly well placed to provide counselling, advice and support to smokers on how to give up, and on the range of medical products available to help them do so. We see community pharmacies, and pharmacies in hospital practice, as an integral part of good local smoking cessation services, and we are keen to co-operate with the NHS, and others at a local level, to develop and evaluate them. We believe there is also scope for further development of the role of community pharmacies as health promotion settings, and the support of pharmacists in public health is important here. We look forward to a developing partnership with the Government on smoking cessation. Guild of Healthcare Pharmacists National Pharmacists Association Royal Pharmaceutical Society of Great Britain Company Chemist's Association Action for the least advantaged smokers 4.20 Our priority will be the need to help the least well off smokers. Smoking is disproportionately high among the more disadvantaged. If we are to reduce smoking overall, and reduce health inequalities, we must start with the groups who smoke the most. Smoking Kills - A White Paper on Tobacco Chapter 5 Smoking and pregnant women Smoking during pregnancy 5.1 Smoking during pregnancy harms the unborn child and leads to lower birthweight. New evidence also shows that women who smoke during pregnancy pass harmful carcinogens on to their baby39. 5.2 24 per cent of women smoke during pregnancy, and only 33 per cent of women smokers give up during pregnancy40. The main reason is that smoking is addictive and is very hard to give up. We need to make people more aware of the serious risks of smoking during pregnancy and to offer them help when they try to give up. 5.3 Many parents continue to smoke at home while bringing up children. Children of smoking parents are more likely to suffer illness or even cot death. They are also much more likely to take up smoking themselves9. Almost half of single women smoke during pregnancy40. ' children of smoking parents are more likely to suffer illness or even cot death' 5.4 The problems of smoking during pregnancy are closely related to health inequalities between those in need and the most advantaged. Women with partners in manual groups are more likely to smoke during pregnancy than those with partners in non-manual groups: 26 per cent of women with partners in manual groups smoke during pregnancy, compared with 12 per cent with partners doing non-manual work40. 5.5 Helping pregnant women to give up smoking not only leads to health gains for mothers and their children, it can also mean immediate cost savings for the NHS. This is because smoking in pregnancy leads to low birthweight babies who may need very costly intensive care treatment. Savings to the NHS can amount to between three and six times the cost of providing help to pregnant women to give up smoking19. 5.6 There is good evidence that helping pregnant women to give up smoking is cost-effective. Of course, many health professionals, particularly midwives and primary care teams, already provide advice to stop smoking to women smokers when they become pregnant. What we are going to do 5.7 Pregnant women who smoke will be a key focus of action at local level as our new NHS smoking cessation services are developed. In Health Action Zones, where many of those women most in need live, up to 60 million in new money will flow from April 1999, to deliver expert help where it is most needed. Clwyd Smoking in Pregnancy The Clywd Smoking in Pregnancy project is targeted at all pregnant women in North East Wales. Its aim is to increase the quit rate in pregnant women and to help ensure they do not start smoking again in the months after their baby is born. The project includes training for professionals, such as doctors, midwives and nurses; structured help for women; and evaluation to see how well the project has worked. The ultimate aim is to ensure help in quitting is available to all pregnant smokers, as part of their pre-natal care. 5.8 At the moment, nicotine replacement therapy (NRT) is not advocated in the UK for pregnant women. However, the American Agency for Health Care Policy and Research has suggested that NRT should be offered in pregnancy to the heaviest smokers who are unable to stop without it. We believe research should be done here to evaluate this. That is why we have made this one of the key smoking research priorities for the future, and we will be looking for well-structured proposals to come forward. This may well be a suitable area for joint funding with the pharmaceutical industry. 5.9 We will also support local NHS action with our new national public education campaign. Shifting young women's attitudes and behaviour on smoking will be a particularly important theme. As we develop the campaign we will build in tailored messages to highlight the importance of giving up smoking when pregnant. During Pregnancy 5.10 Pregnancy is an ideal time for women and their partners who smoke to consider quitting; they are eager for information, have access to health services, and are often keen to make changes to their lifestyle. Most women are motivated to do what they can to make sure their baby is healthy. Often this can include wanting to stop smoking. The sooner the mother stops, the better for her own health, and that of her baby. Pregnancy QuitlineTM The Pregnancy Quitline pilot was launched in 1997 and is run by the charity Quit®, with joint NHS and commercial funding. Counsellors give callers information about the service, establish an on-going relationship, and agree a smoking cessation programme tailored directly to the needs of each individual. Contact between the counsellors and client may be more or less frequent depending on the level of support needed in each case. In its first year, Pregnancy Quitline has answered 3000 calls, (in addition to those made by counsellors to clients). 40 percent of clients are aged between 16 and 24, with half being referred by their GP or midwife. Evaluation is under way, but initial results are encouraging. 5.11 Midwives, GPs, obstetricians and other health professionals have regular, one-to-one contact with pregnant women. These contacts are ideal opportunities to offer support and practical advice on giving up smoking. 5.12 Evidence also shows that pre-natal counselling involving at least ten minutes person-to-person contact and written materials specifically designed for pregnant women, can double quit rates41. 5.13 Women need specific and continuing support following the birth of their child. Health professionals can help by encouraging new mothers in their efforts to continue not smoking. For example, advice on breast feeding could include awareness that if the mother smokes, some nicotine will pass into the baby's bloodstream. Advice on how to reduce the risks of cot death could also include support with smoking cessation. Smoking Kills - A White Paper on Tobacco Chapter 6 Smoking: action for everyone 6.1 The Government's strategy will focus on specific measures tailored towards the two key targets of reducing smoking among children and young people, and helping adults - especially the least advantaged - to give up smoking. But there are a number of important measures the Government will introduce which have wider application - cross-cutting measures which will help reduce smoking and so move towards the Government's goal of improving public health in Britain. 6.2 Building on the action the Government has already taken, including our policy on the taxation of tobacco, these cross- cutting steps include measures on: ending tobacco advertising changing attitudes tobacco smuggling research Ending tobacco advertising Why action is needed 6.3 Previous Governments have operated voluntary agreements with the tobacco industry on advertising. But there is little evidence that they have worked. Surveys show that 96 per cent of children say they have seen cigarette advertising in the last six months9. And smoking among the young has been rising for a number of years. ' 96 per cent of children say they have seen cigarette advertising in the last six months' 6.4 The cigarette brands smoked most by children are also those most heavily advertised42. Survey evidence shows that half of all young people believe they have seen a cigarette advert on TV in the last six months despite the fact that it was banned 33 years ago9. That suggests that tobacco sponsorship of televised events has a similar impact to direct advertising. The EC Directive phases out tobacco sponsorship and promotion as well as tobacco advertising on billboards and in printed media. 6.5 Most people want tobacco advertising to end. Sixty per cent of people believe that tobacco advertising should not be allowed at all. Even amongst smokers, 48 per cent agree. Fifty-two per cent of people disapprove of tobacco sponsorship of sports events, 63 per cent disapprove of tobacco sponsorship of pop concerts, and 58 per cent disapprove of tobacco sponsorship of arts events32. What we are going to do 6.6 The Government is now going to put the EC Directive into law in the UK - and into practice. ' we intend to end tobacco advertising on billboards and in the printed media at the earliest practicable change would eliminate tobacco advertising from Formula One on television screens in the UK and across Europe from races staged outside the EU. Brand-stretching 6.21 Brand-stretching means taking a name already established for one type of product and using it for a quite different type of product. When this happens, the advertising of each product indirectly promotes the other because they share a brand in common. This has happened with many brands, including well-known tobacco brands. 6.22 Some tobacco companies may be drawn towards 'stretching' their brands in the face of the phasing out of tobacco advertising. Non-tobacco products might be launched with a tobacco product brand name, logo or other distinctive feature, or a tobacco product might be introduced using a brand name already used for a non-tobacco product. ' we will monitor developments to ensure that this exemption is not used by tobacco companies to circumvent the ban' 6.23 The EC Directive lays down provisions which will make it illegal to advertise tobacco products indirectly using other products. A tobacco product's brand name or branding features may be used on a non-tobacco product, but only if the presentation and the advertising of the non-tobacco product are clearly distinct from those of the tobacco product. 6.24 Member states may allow a tobacco brand name which is being used in good faith for non-tobacco products or services traded prior to 30th July 1998 to be used for the advertising of those other goods or services. 6.25 While we are committed to ending tobacco advertising, we want to minimise the impact on non-tobacco businesses. Our legislation will as far as possible allow the businesses involved time to make the necessary changes to the presentation and advertising of their products. The industries involved have already made representations to the Government. We are keen to hear their views again on implementation issues. Direct marketing 6.26 All direct and indirect tobacco advertising and promotion will be phased out, including the distribution of free cigarettes, cigarette coupon schemes and other brand loyalty incentive schemes. Such schemes and activities encourage smokers to keep on smoking. 6.27 As required by the Directive, we will outlaw any form of commercial communication which has the aim or effect of promoting a tobacco product. Other areas 6.28 The Directive does not apply in the following areas: communications intended exclusively for professionals in the tobacco trade. This means communications not intended for the public, but which are necessary to the conduct of the tobacco trade. Examples might include product and price brochures for retailers; wholesale order forms, invoices and receipts; tobacco duty and import export documentation. This will be further defined in the legislation the presentation of tobacco products offered for sale and the indication of their prices at tobacco sales outlets advertising aimed at purchasers in establishments specialising in the sale of tobacco products and on their shop- fronts or, in the case of establishments selling a variety of articles or services, at locations reserved for the sale of tobacco products...".. We are taking action in this area (see Chapter Three) the sale of publications containing advertising for tobacco products which are published and printed in third countries, where those publications are not primarily intended for the Community market. While the general press will be covered by the legislation, there is a case for exempting publications produced outside the EU and whose main market lies outside the EU. We will monitor developments to ensure that this exemption is not used by tobacco companies to circumvent the ban. 6.29 We have a choice in each of these areas of whether or not to introduce our own controls to lay down stricter provisions where necessary for health protection. Consultation 6.30 We said we would consult fully on the implementation of our manifesto commitment. We are keeping that promise, and will continue to do so. As we prepare draft legislation, we will further update a regulatory impact assessment (RIA) which includes an employment impact assessment. The current draft of the RIA is published today as a stand alone document. Requests for futher copies and comments should be sent to the Department of Health, Wellington House, 133-155 Waterloo Road, London SE1 8UG by the end of February 1999. ' we said we would consult fully on the implementation of our manifesto commitment. We are keeping that promise' Enforcement 6.31 A number of agencies are likely to be involved in monitoring the advertising ban, particularly local authority Trading Standards Officers. We will be involving them in detailed discussions as we prepare to legislate. 6.32 Individuals or organisations with a legitimate interest may be able to bring suspected breaches to the attention of trading standards authorities. 6.33 Proposed penalties for breaches of the law will be contained in the draft legislation Changing attitudes 6.34 Public education programmes are the most direct way of changing attitudes and behaviour, and an essential component in any strategy designed to combat smoking. Research evidence 6.35 Other countries which have taken action over smoking, such as the USA and Norway, have found large scale and sustained public education campaigns to be vital. In California, the Californian Tobacco Control Program which started in 1989 has been the subject of much evaluation. A recent study showed that in 1996, smoking prevalence in California was 18 per cent compared with 22 per cent in the rest of the United States. The study's authors commented: The California Tobacco Control Program has confirmed the findings from earlier studies that large health promotion programmes can have a major influence on smoking behaviour12. The study also observed that the impact was greater at the start of the programme than more recently, and identified reduced programme funding as a possible reason. The importance of dynamic health education programmes is acknowledged elsewhere too. The Norwegian Health Minister, commenting on the positive impact of Norway's advertising ban, said: The effect could have been even better if the ban had been accompanied by a much more active and offensive use of other smoking control measures, in particular, health information and education43. 6.36 In the UK, research reinforces the approach. In 1992, the Health Education Authority began a two-year controlled trial to test the effectiveness of mass media and local support activity in changing smoking attitudes and behaviour. Varying intensities of mass media advertising and local activity were tried in three television regions in the north of England, while a fourth control region had no media or other activity. The final evaluation is due to be published in the near future. However, indicative results suggest that an integrated mass media campaign has a significant positive effect on smoking prevalence. In particular, the study suggests that: television advertising made the main contribution to changing smoking behaviour nationwide replication of the advertising alone might have produced a reduction in smoking prevalence of 1.2 per cent nationally, this would have led to about 100,000 smokers quitting for good44. What action are we taking? 6.37 Adequately funded health education programmes as part of a comprehensive strategy and with sustained funding have a lasting effect on smoking behaviour. 6.38 We are committing some 50 million over the next three years to develop a sustained and co-ordinated new campaign. This is far more than the previous Government was prepared to invest and is, we believe, the level of funding needed to make a real and lasting impact. ' adequately funded health education programmes as part of a comprehensive strategy and with sustained funding have a lasting effect on smoking behaviour' Priority groups 6.39 In line with our target aims, young people and adults who want to quit - especially the disadvantaged, and pregnant women who smoke- will be a prime focus. ' teenage magazines will play an important role' 6.40 The campaign aimed at young people will persuade them to think twice before smoking. As we phase out tobacco advertising, health-related messages will make a greater impact. For years, tobacco companies have spent millions on advertising. Now we are prepared to do the same. The types of media used, and the style and design, must be relevant to the target audience and informed by marketing and advertising campaigns which have a proven track record of success with this group. Teenage magazines will play an important role, and we will continue to collaborate with their editors in getting our messages across. 6.41 Adult smokers who want to quit, particularly the less well-off, will also be a focus of effort. Our new campaign will include advertising and other media activity, targeted particularly at smokers in worse-off social groups. It will encourage them to stop smoking by presenting the benefits of quitting, e.g. feeling fitter and having more money to spend. It will offer help and advice in sustaining a decision to stop smoking, and point to local NHS smoking cessation services for practical support. Education and support is also important for smokers who use NRT as a cessation aid. We will explore the scope for collaborative working with professional bodies representing pharmacies and pharmacists, as well as the manufacturers of nicotine replacement therapy. 6.42 We will develop programmes to inform and motivate women who smoke and who are planning to have children to give up. The national campaign will include materials specifically designed for this audience. Active support will also be Benefits Agency, and with the tobacco and alcohol industries to tighten control over the movement of excise goods on which no duty has been paid. These measures complement a tougher prosecution policy adopted earlier this year which involves urging the courts to use all available sanctions including driving disqualifications, compensation orders for lost revenue, vehicle confiscation orders and revocation of haulage and liquor licenses. 6.57 We have left the level of duty on hand rolling tobacco unchanged in the last two Budgets to reduce the incentive to smuggle. 6.58 An example of UK Customs' pro-active approach is the current "Operation Mistletoe". It involves targeting the busy pre-Christmas period during which more smuggled goods are sold including tobacco. Visits to retail premises are made by Customs, illegal goods are seized and then prosecutions sought. Such action disrupts the illegal trade and protects honest shopkeepers. 6.59 But the problem of smuggling and excise fraud is not unique to the UK. The heads of EU Customs and Indirect Tax administrations around Europe have been discussing ways to address the problems of both tobacco and alcohol fraud on an EU-wide basis. They have made recommendations, accepted by the EU's European Council of Economic and Finance Ministers (ECOFIN) in May 1998, which complement those of our own Fraud Review. UK Customs are now working closely with their EU counterparts to implement the proposals. 6.60 Our immediate objective is to reduce the rate of growth of smuggling. The new Customs staff will concentrate their efforts on areas of greatest risk to enable continued improvement in detection rates. Research 6.61 The Department of Health will be giving high priority to research into smoking when commissioning future research. Further research is needed on: the safety of nicotine replacement therapy (NRT) when used during pregnancy by women who cannot quit but who want to minimise the harm to their babies the safety and effectiveness of NRT: when used as an aid to smoking less (to reduce exposure to the harm caused by tobacco smoke); when used over long periods of time; and when used by children identifying the most effective method of helping different groups of smokers to quit (e.g. school children; pregnant women; lone parents) and in different settings (e.g. GP surgery; pharmacy; hospital; school) the effectiveness of cutting down the amount of tobacco smoked over a period of time as a way of leading up to quitting rather than stopping altogether in the first instance evaluating key aspects of the policies set out in this White Paper in order to assess the effectiveness and health impact of this package, e.g. the health education campaign and the new NHS services the relationship between the brand of tobacco smoked and the nicotine exposure. The Scottish Parliament, to be established next year, may be in a position to implement the Directive separately in Scotland, as may the new Assemblies in Wales and Northern Ireland. Resources for health education on smoking will be made available over three yea r s in England (50m), Scotland (5m), and Northern Ireland (1m). Funding in Wales is subject to the outcome of the Comprehensive Spending Review in Wales. *In Scotland, guidance, advice and materials are already available. Smoking Kills - A White Paper on Tobacco Chapter 7 Clean air 7.1 People are increasingly insisting on a healthy environment and clean air. Forward-looking businesses are already providing it for both their customers and staff. Public attitudes have changed a lot over the last two decades. Smoke-filled buses, trains and cinemas are a fading memory. Businesses that fail to recognise this will increasingly find customers voting with their feet. The vast majority of people agree that smoking should be restricted in public places. Forty-two per cent of people already take the availability of a non-smoking area into account when choosing a restaurant, and 1 in 5 people already do so when choosing a pub32. Provision is improving, but there is a long way to go. Telford Shopping Centre Chris Crane, Customer Services and Promotions Manager at Telford shopping centre said of their change to a no-smoking environment: "The majority of comments and letters received from our customers about our no-smoking policy are extremely supportive. Parents of young children can now shop safely without the fear of their children being burnt by cigarettes in crowded areas, and can enjoy the benefits of clean healthy air. Our customer traffic has increased substantially since the policy was introduced - our traders are delighted and fully support the policy. We are proud to display our Roy Castle Gold Award to reinforce our commitment to smoke-free air." 7.2 We want to build on the progress of recent years. At present, non-smokers are often exposed to the health risks, discomfort and irritation of tobacco smoke, while smokers often get forced to smoke on the street. The friction and aggravation felt by smokers and non-smokers alike is the result of a lack of proper choice. Passive smoking 7.3 The health risks are clear. Passive smoking does carry risks but they are small compared to the risks of active smoking. A non-smoker, living or working in a very smoky environment over a prolonged period, is 20-30 per cent more likely to get cancer than a non-smoker who does not20. Hundreds of people die every year in the UK as a result of high levels of exposure to passive smoke. 7.4 We do not think a universal ban on smoking in all public places is justified while we can make fast and substantial progress in partnership with industry. 7.5 We have looked very carefully at the case for an outright ban, or legal restrictions, like the ones tried in some other countries. A number of countries have tried an outright ban on smoking in bars and restaurants. But such restrictions have proved difficult to implement. We want to work with business and others to achieve real change, highlighting and building on best practice. In public places we want to see real choice for the public as a whole - non-smokers and smokers. ' we want to work with business and others to achieve real change' 7.6 We agree that completely smoke-free places are the ideal, and some businesses have taken the decision to go completely smoke-free. We support them in their decision, and would like to see more. But we recognise that it is not always going to be possible. So the next best thing is separate rooms for those who want to smoke, and for those who do not want to smoke. If they cannot be provided, separate areas are the next best thing, with good ventilation and air cleaning, so that the atmosphere is more comfortable for everyone. 7.22 Customers are famililiar with hospitality premises being evaluated by the number of symbols displayed, with the best- rated establishments given five, the next-best four, and so on. While the categories of smoking policy have yet to be agreed with the industries concerned, we think there are five key levels which should be indicated in any system if customers are to be able to make a real choice: Non-smoking No smoking allowed at any time Separated Smoking and non-smoking areas are separated by walls Designated Areas with spaces clearly defined for smoking and non-smoking Ventilated Non-defined areas but special ventilation equipment used to improve comfort for non-smokers Smoking No segregation or special ventilation equipment 7.23 Ventilation systems can improve the comfort and welfare of the public and employees. The best systems can, provided they are properly operated and maintained, protect non-smokers from exposure to carcinogens. However, without being able to guarantee that such equipment is maintained and operated properly, we cannot endorse it as being as effective as smoke- free areas. We are already in discussion with manufacturers of air-cleaning equipment through the Atmosphere Improves Results (AIR) industry initiative on the development of agreed standards for equipment which we can endorse. Smoking at work What action are we taking? 7.24 We are not going to ban smoking at work. But the Health and Safety Commission (HSC) is going to consult on a new Approved Code of Practice on smoking in the workplace. This will considerably toughen existing measures. The Code will be designed to improve protection of the welfare of all employees by defining the kind of smoking policies employers need to operate to comply with existing health & safety legislation. Consultation will begin in Spring 1999. What is an Approved Code of Practice? 7.25 An Approved Code of Practice is a form of guidance. It gives practical advice on how to comply with the law. If employers follow the advice they will be doing enough to comply with the law in respect of those specific matters on which the Code gives advice. They may use alternative methods to those set out in the Code in order to comply with the law. 7.26 The content of the Approved Code of Practice, if agreed, would be based on the content of the existing guidance from the Health and Safety Executive (HSE)45, so that employers should: introduce smoking policies that give priority to the needs of non-smoking employees, whether the smoke comes from other employees or from customers take special care for people who have a health condition that may be made worse by tobacco smoke ' policies that give priority to the needs of non-smoking employees' 7.27 Approved Codes of Practice have a special status under the Health and Safety at Work etc. Act 1974. Although it is not of itself an offence to fail to comply with the provisions of a Code, if an employer is prosecuted for a breach of health, safety and welfare law, and it is proved that they did not follow the relevant provisions of the Code, they need to show that they have complied with the law in some other way, or a Court will find them at fault. 7.28 Health and safety inspectors from the HSE and Local Authorities would be able to quote a Code on smoking in the workplace in court in cases of alleged breaches of the Health and Safety at Work. Act. In practice, this would put the burden of proof on employers, making the new Code significantly stronger than existing guidance which is entirely voluntary. Consultation 7.29 Details of the likely effect of the Code will depend on its content which will be set out in detail in a consultation document to be released by the HSC in Spring 1999. The HSC covers England, Scotland and Wales. Similar action will be taken by the Health and Safety Executive for Northern Ireland. In Scotland, close consultation will take place with the Health at Work Awards Scheme, which develops and implements workplace policies. Workplace smoking cessation 7.30 Good employers are beginning to offer their staff help if they want to give up smoking. Seven out of ten smokers say they want to give up, and employers who help them do so are likely to find a healthier, fitter workforce, and fewer days missed through illness. Employers can help by: arranging group counselling workshops run by trained health professionals using educational materials made available as part of national anti-smoking campaigns getting involved in local initiatives involving the health authority or other groups Kendall Company UK Ltd Cornwall Some employers are already offering their staff help to quit smoking. For example, to help those of his employees who wanted to quit, the Plant Director of Kendall Company UK Ltd in Cornwall provides free nicotine replacement therapy patches to his employees. The employees sign a personal contract with the company to pay back the costs of the patches if they start smoking again. The scheme continues to enable employees of Kendalls to quit smoking. Government offices What are we going to do? 7.31 Most Government Departments are making a specific policy contribution to the package of measures in this white paper - this document is very much about joined-up government. But we are determined that every Department should also take practical steps to set a good example to other sectors. All Departments will be conducting full reviews of their internal office smoking policies. Policies will be expected to reflect the content of any new HSC Approved Code of Practice. ' all departments will be conducting full reviews of their internal office smoking policies' 7.32 Each Department will be responsible for taking forward its own review. The Department of Health will monitor progress to see that they have been carried out and implemented. 7.33 The NHS Executive has recently reviewed smoking policies in the NHS in England. It has found that virtually all hospitals have smoking policies, but that not all are properly in operation. The NHS Executive will be providing advice in the form of a "tool-kit" to help the NHS ensure its policies are put into practice. Similar initiatives are under way elsewhere in the UK. Smoking Kills - A White Paper on Tobacco Chapter 8 Smoking and international action 8.1 There are over a billion smokers across the world. Nearly one third of smokers are in China. Smoking is fast increasing in third world countries and in Eastern Europe. Smoking now causes 3 million deaths a year worldwide. If trends continue, there will be 10 million deaths from smoking worldwide in about 30 years' time13. 8.2 The effects of tobacco are increasingly taking their toll across the world. Many of the countries in which smoking is increasing fast have limited regulation of tobacco or health education and health care systems which are ill-equipped to handle the consequences. In parts of Africa tobacco companies are using advertising and marketing campaigns, sponsorship of events and price wars to promote cut-priced tobacco46. 8.3 We, in concert with other Governments, can take steps to counter the global trend. It is important that we provide strong support. Smoking kills around the world; we need action around the world. European action a) Pressure for EU tobacco tax changes What are we going to do? 8.4 The Government opposes harmonisation of tax rates across the EU. The Government will only agree to any tax changes where it is in the interests of Britain to do so. The Government is pursuing a clear policy in the UK over the taxation of tobacco. 8.5 We would like our fellow member states to agree to increase the minimum levels of duty which apply across the EU. Such a step would be to the benefit of public health across the EU, and would reduce the scope for profit to be made by smuggling tobacco into the UK from other EU countries. We cannot achieve this without the agreement of our EU partners, who will retain the right to veto any such changes - as Britain does with proposals from other EU member states. 8.6 We will continue to argue our case and to persuade our EU partners. Specifically, we would like to agree the following changes with them: significant increases in the minimum rates of duty on all tobacco products the introduction of a cash minimum duty for cigarettes an increase in the upper limit for the flat rate ("specific") component of duty on cigarettes 8.7 This final change would help enable us to avoid making tobacco tax increases in the form of proportional ("ad valorem") duty. Increases in ad valorem duty are less effective because they widen the price range of cigarettes on the market, encouraging smokers to switch to cheaper but equally unhealthy brands rather than to cut down or, preferably, quit altogether. Industry (DTI) and our embassies and high commissions will continue to provide advice, to which UK companies are entitled, in the sale of legal products. However, in keeping with the current practice of Ministers and officials not becoming involved in the advertising or promotion of tobacco products at home, guidelines will shortly be issued to representatives in our diplomatic posts instructing them to be scrupulous to ensure that they follow suit overseas, taking into account local circumstances. Smoking Kills - A White Paper on Tobacco Chapter 9 Judging success 9.1 We will judge the success of this White Paper by measuring our performance against three challenging targets, on children smoking, adults smoking and smoking during pregnancy. These targets are all set for the year 2010. However, as smoking is a key cause of cancer and circulatory disease (two of the four priority areas in Our Healthier Nation) the targets also include an indication of where we expect to be by the year 2005 to check on progress. We have decided to keep the number of high-level targets small to concentrate attention on the most important areas. These targets are for England: separate targets are being set in Scotland, Wales and Northern Ireland. ' we will set targets for smoking cessation services in the NHS' 9.2 We will also be monitoring progress in a number of other areas to check how the measures are working. In particular, we will set targets for smoking cessation services in the NHS, and will be looking for improvements in the provision of smoke-free areas in public places. Children smoking 9.3 Our immediate aim is to halt the rise in children smoking, and then to see reductions in smoking levels over time. This is the most challenging area. It is also essential if we are to re-establish the downward trend in adult smoking levels in the future, and secure the continued decline in cancer and heart disease deaths in generations to come. We will be looking closely at the level of smoking among 15-year-olds, particularly girls, as an indicator of success in this area. However, success in achieving our aim will depend on changing attitudes and behaviour towards smoking across a range of ages from 11 onwards. Aim: to halt the rise in children smoking Target: to reduce smoking among children from 13% to 9% or less by the year 2010; with a fall to 11% by the year 2005. This will mean approximately 110,000 fewer children smoking in England by the year 2010. Note: This target is for improvements measured against a baseline of 13 per cent smoking prevalence among 11-15 year olds in 1996. Children smoking in this target means those aged 11-15 who smoke at least one cigarette a week. ' our aim is to re-establish the downward trend in smoking among the adult population as a whole' Adult smoking 9.4 Our aim is to re-establish the downward trend in smoking among the adult population as a whole. We also want to tackle the inequalities in smoking between those most in need and those most advantaged. Smoking prevalence among adults over 16 fell from 39 per cent in 1980 to 29 per cent in 1990 (ONS figures). When the previous health strategy, Health of the Nation, set its target in 1992, it was against a background of consistently falling smoking rates since the early 1970s. However, despite a further fall to 26 per cent in 1994, the 1996 figure was back at 28 per cent. This suggests that smoking in the adult population may be rising again, which makes our task the more challenging because we must first re-establish a clear downward trend. Our target also reflects our concern to reduce the wide differences in smoking between the social classes as part of a strategy to cut overall smoking rates in the adult population. Aim: to establish a new downward trend in adult smoking rates in all social classes Target: to reduce adult smoking in all social classes so that the overall rate falls from 28% to 24% or less by the year 2010; with a fall to 26% by the year 2005. In terms of today's population, this would mean 1.5 million fewer smokers in England. Note: This target is for improvements measured against a baseline of 28 per cent smoking prevalence among men and women aged 16 and over in 1996. Adult smoking means anyone aged 16 or over who smokes at least one cigarette a day. The objective is not only to see smoking in all socio-economic groups reduce to a new average figure of 24% by 2010, but also to reduce the difference in smoking rates between manual and non-manual groups. We therefore want to see a rate of change in manual groups similar to or greater than in non-manual groups. Smoking during pregnancy 9.5 Smoking during pregnancy is a special issue because the health of the child is at stake both during the pregnancy and from breathing parental smoke during childhood. Smoking during pregnancy also strongly reflects the link between smoking and health inequalities, and children living with parents who smoke are more likely to be smokers themselves. We believe it is important to set a specific target for smoking during pregnancy to focus action both in terms of health education and NHS smoking cessation services. Aim: to improve the health of expectant mothers and their families Target: to reduce the percentage of women who smoke during pregnancy from 23% to 15% by the year 2010; with a fall to 18% by the year 2005. This will mean approximately 55,000 fewer women in England who smoke during pregnancy. Note: This target is for improvements measured against a base line of 23 per cent of women in England who smoked during pregnancy in 1995. Approved Code of Practice on smoking in the workplace, to clarify the requirements of existing Health and Safety at Work legislation. Consultation will begin in Spring 1999. Choice for non-smokers and smokers in pubs and restaurants. Representatives of the licensed trade have agreed to make year-on-year improvements in facilities for non-smokers and smokers. Signs inside and outside licensed premises will enable customers and staff to choose. Progress will be independently monitored and we will agree targets for improvements. Smoking policy reviews in all Government buildings. All Government Departments will be conducting full reviews of internal smoking policies. Policies will reflect the HSC's new Approved Code of Practice. Tough enforcement of law against sales of tobacco to children. We will work with local government enforcement representatives to develop guidance on how to implement obligations under the law. A single, cross-industry proof of age card. We will work to bring together and encourage the manufacturers of all age-restricted products to develop a national scheme. Support for Europe-wide initiatives to protect health. The European Commission is considering proposals to be put to the Health Council in the first half of 1999. We look forward to seeing the proposals and to working constructively with our fellow Member States. Tough industry code to prevent sales to children from vending machines. The National Association of Cigarette Machine Operators have strengthened their code governing the siting of cigarette vending machines to prevent their use by under 16s. Non-promotion of tobacco products, or events overseas. UK embassies and high commissions will be taking care to avoid involvement in events which advertise or promote tobacco products overseas. Full support for international tobacco control work. We are fully committed to international efforts to tackle smoking under the auspices of the World Health Organisation. Reform of CAP regime to cut tobacco growing in the EU. Farmers subsidised by the EU to grow tobacco will be offered one-off lump sum payments to give up their "quotas". Smoking Kills - A White Paper on Tobacco Joined-up government SMOKING AND JOINED-UP GOVERNMENT The whole of Government is engaged in the tackling smoking: Co-operation between Departments in England, Scotland, Wales and Northern Ireland to ensure a UK-wide approach DTI and DCMS involved in minimising detrimental impact on sport and retail industries of EC Directive to end tobacco advertising HM Customs and Excise-led strategy to tackle tobacco smuggling and fraud HM Customs and Excise also providing pressure on EU duty limits HMT committed to tobacco duty increases DH contributing cash for NHS smoking cessation services and mass media awareness campaign, and working with the pharmaceutical industry HSC to consult on Approved Code of Practice on work place smoking DH has agreed a Charter on smoking in public places with the hospitality industry DTI working with the ventilation and air conditioning equipment sector and the Atmosphere Improves Results industry initiative to improve the installation and maintenance of equipment All departments signed up to review internal smoking policies DH and Home Office working with industry to develop a proof- of-age system Home Office to explore a new criminal sanction for repeated conviction for sales of tobacco to under 16s Local government committed to tougher enforcement European Commission to looking at tar, nicotine, labelling regulations DFID working with the WHO to tackle smoking internationally MAFF backing the new quota buy-back scheme to reduce EU tobacco growing DfEE tackling smoking through the Healthy Schools Initiative Smoking Kills - A White Paper on Tobacco Who we have consulted WHO WE HAVE CONSULTED We consulted, or received representations from, the following: Action on Smoking and Health (ASH) Alliance of Independent Retailers Area Health Promotion Managers (Scotland) ASH (Scotland) Asian Business Network Association for Business Sponsorship of the Arts Association for Non Smokers' Rights Association of Community Health Councils for England and Wales Association of Convenience Stores Association of Independent Tobacco Specialists Association of Licensed Multiple Retailers Brewer Blackler Ltd Brewers and Licensed Retailers Association British Darts Organisation British Dental Association British Dental Health Foundation British Diabetic Association British Greyhound Racing Board British Heart Foundation British Horse Racing Board British Hospitality Association British Institute of Innkeeping British Licensed Retailers Association British Lung Foundation British Medical Association British Retail Consortium British Thoracic Society Business in Sport and Leisure Cancer Research Campaign Central Council of Physical Recreation Chartered Society of Physiotherapy Clay Pigeon Shooting Association Co-operative Retail Society College of Occupational Therapists Committee of General Practice Education Directors Community Practitioner and Health Visitors' Association Company Chemists Association Confederation of British Industry Conference of Post Graduate Medical Deans Consumer Health Information Centre Convention of Scottish Local Authorities Coronary Prevention Group Council of Heads of Medical Schools and Deans of UK Faculties of Medicine Douwe Egberts Coffee System Smoking Kills - A White Paper on Tobacco References References 1. Callum C. The UK smoking epidemic: deaths in 1995. London: Health Education Authority, 1998. 2. Peto R, Lopez AD, Boreham J, Thun M, Heath Jr C. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 1992; 339: 1268-78. 3. Our Healthier Nation. Consultation Paper presented to Parliament by the Secretary of State for Health. February 1998. London: The Stationery Office, 1998. 4. Wald N, Nicolaides-Bouman A, eds. UK Smoking Statistics. Oxford: Oxford University Press, 1988. 5. The figure of 13 million smokers is based on estimates of cigarette smokers in the UK, obtained from the following sources: Thomas M, Walker A, Wilmot A, Bennett N, Office for National Statistics. Living in Britain: results from the 1996 General Household Survey. London: The Stationery Office, 1998. ONS Monitor Population and Health 1996, PP1 97\1. London: Office for National Statistics, 28 August 1997. Northern Ireland Continuous Household Survey, 1996/7. Northern Ireland Statistics and Research Agency, 1997. 6. Thomas M, Walker A, Wilmot A, Bennett N, Office for National Statistics. Living in Britain: results from the 1996 General Household Survey. London: The Stationery Office, 1998. 7. Lifestyle Changes in Wales. Health in Wales Survey 1996. (Technical Report no 27). 8. Northern Ireland Continuous Household Survey, 1996/7. Northern Ireland Statistics and Research Agency, 1997. 9. Lindsey Jarvis, Office for National Statistics. Smoking among secondary school children in 1996: England. London: The Stationery Office, 1997 10. Joosens L. The effectiveness of banning advertising for tobacco products. International Union Against Cancer, October 1997. 11. World Health Organisation. Health for all. Database: European region, 1998 12. Pierce JP, Gilpin EA, Emery SL, White MM, Rosbrook B, Berry CC. Has the California tobacco control program reduced smoking? JAMA 1998; 280: 893-899. 13. Peto R, Lopez AD, Boreham J et al.: Imperial Cancer Research Fund and World Health Organisation. Mortality from smoking in developing countries 1950-2000. Oxford: Oxford University Press, 1994. 14. Office for National Statistics. Population Trends Number 93, Autumn 1998. London: The Stationery Office, 1998. 15. Doll R, Peto R. The causes of cancer: quantitative estimates of avoidable risks of cancer in the United States today. J Natl Cancer Inst 1981; 66: 1191-1308. 16. Law MR, Hackshaw AK. A meta-analysis of cigarette smoking, bone mineral density and risk of hip fracture: recognition of a major effect. BMJ 1997; 315: 841-846. 17. Meltzer M, Gill B, Petticrew M, Hinds K, Office for Population and Census Surveys. Surveys of Psychiatric Morbidity, Report 3: Economic activty and social functioning of adults with psychiatric disorders. London: Her Majesty's Stationery Office, 1994. 18. Doll R, Crofton J, eds. British Medical Bulletin: Tobacco and Health. London: The Royal Society of Medicine Press, 1996; (vol 52). 19. Buck D, Godfrey C, Parrott S, Raw M, University of York Centre for Health Economics. Cost effectiveness of smoking cessation interventions. London: Health Education Authority, 1997. 20. Hackshaw AK, Law M, Wald NJ. The accumulated evidence on lung cancer and environmental tobacco smoke. BMJ 1997; 315: 980-8. 21. Law MR, Morris JK, Wald NJ. Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence. BMJ 1997; 315: 973-80. 22. Cook DG, Strachan DP, Anderson Ross H. Series of papers: health effects of passive smoking. Thorax 1997-1998. Eds Britton JR, Weiss ST. 23. Royal College of Physicians of London. Smoking and the young: a report of a working party of the Royal College of Physicians. London: Royal College of Physicians, 1992. 24. Department of Health and Social Security, Department of Health and Social Services Northern Ireland, Scottish Home and Health Department. Fourth report of the Independent Scientific Committee on Smoking and Health. London: Her Majesty's Stationery Office, 1988. Chairman: Sir P Froggatt. 25. Peto R, Jarvis M. [Personal communication.] 26. Drever F, Whitehead M, eds. Health inequalities: decennial supplement: Office for National Statistics. London: The Stationery Office, 1997. (Series DS; no. 15). 27. Acheson D. Independent inquiry into inequalities in health. London: The Stationery Office, 1998. Chairman: Sir D Acheson. 28. Dorset R, Marsh A. The Health Trap - Poverty, Smoking and Lone Parenthood. London (1998). The Policy Studies Institute. 29. Labour Party. New Labour because Britain deserves better. London: Labour Party, 1997. 30. Townsend J, Roderick P, Cooper J. Cigarette smoking by socioeconomic group, sex, and age: effects of price, income, and health publicity. BMJ 1994; 309: 923-927. 31. Sutton S. How ordinary people in Great Britain perceive the health risks of smoking. J Epidemiol Community Health 1998; 52: 338-339. 32. Freeth S. Smoking-related behaviour and attitudes, 1997: a report on research using the ONS Omnibus Sur vey produced on behalf of the Department of Health. London: The Stationery Office, 1998. 33. United States Department of Health and Human Services. The health benefits of smoking cessation - a report of the Surgeon General. US DHHS. Public Health Service, Centers for Disease Control. Center for Chronic disease prevention and health promotion. Office on smoking and health. DHHS Publication number (CDC) 90-8416,1990. 34. Raw M, McNeill A, West R. Smoking Cessation Guidelines for Health Professionals. A Guide to Effective Smoking Cessation Interventions for the Health Care System. Thorax, December 1998, 53, Supplement 5. 35. Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1: the Lung Health Study. JAMA 1994; 272: 1497-1505. 36. QUIT, Helping Smokers to Quit. London: QUIT, 1994, updated 1996. 37. Fowler G. BMJ 1997; 314: 1827 and references cited therein. 38. Marsh A, McKay S. Poor smokers. London: Policy Studies Institute, 1994. (Research Report; no. 771). 39. Hecht SS, Carmella SG, Chen ML, Salzberger U, Tollner U, Lackmann GM. Metabolites of the tobacco-specific lung carcinogen 4-(methylnitrosoamino)-1-(3-pyridyl)-1-butanone (nnk) in the urine of newborn infants. Abstracts Papers Am Chem Soc 1998: 216; 32. 40. Foster K, Lader D, Cheesbrough S. Infant Feeding 1995: Office for National Statistics. London: The Stationery Office, 1997. 41. University of York NHS Centre for Reviews and Dissemination, Effectiveness Matters, (1998), Vol 3, Issue 1. 42. Barron J. Young teenagers and smoking in 1997. London: Office for National Statistics. 43. Bjartviet K, Lund KE. The Norwegian ban on advertising of tobacco products: has it worked? Norwegian Cancer Society & Norwegian Health Association. 44. Health Education Authority, London. [Unpublished research.] 45. Health and Safety Executive. Passive smoking at work. Sheffield: Health and Safety Executive, 1998. 46. Cigarette wars in Africa. Lancet 1997; 350: 793. 47. Office for National Statistics: Business Monitor 210: Q2. Overseas trade analysed in terms of Industries. London: The Stationery Office, 1998. 48. Parrott S, Godfrey C, Raw M, West R, McNeill A. Guidance for Commissioners on the Cost Effectiveness of Smoking Cessation Interventions. Thorax December 1998, 53, Supplement 5.