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Outline of options paper on action on smokingSMOKING REDUCTION AND CESSATION IN THE BOROUGH
Smoking is one of the major preventable causes of illness and death. At the Borough
Partnership in June 2004, the Council was asked to prepare a paper to explore what
more could be done locally.
This paper examines the national and regional background in which smoking policiesare being developed. It describes the national, regional and local situation withregards to smoking prevalence, the health consequences of smoking and attitudestowards smoking. It describes current actions being taken by the PCT, local authorityand other partners with regards to smoking. The evidence of effective interventionsis provided and options for taking smoking prevention are discussed. Finally, it isrecommended that a multiagency group be formed to take forward the policies in theforthcoming White Paper and develop a local action plan.
In 1998, the White Paper Tobacco Kills 1998 proposed a raft of measures to stop or
prevent smoking which included:
• setting targets reducing the prevalence of smoking
• banning of tobacco advertising and sponsorship • getting the hospitality industry to work with the government to introduce a • consultation on a new code of practice to protect people from environmental Although in 2000, the Health and Safety Commission (HSC), decided that it favouredthe introduction of an Approved Code of Practice (ACOP) for passive smoking atwork to protect workers, this has still yet to be approved and implemented.
Securing Good Health for the Population 2004 examined what could be done ifpeople were successfully engaged in protecting their own health and preventingillness. It stated that the right of the individual to choose their own lifestyle must bebalanced against the adverse impacts those choices might have on others.
It recognises that the Government needs to support individuals to choose healthierlifestyles through using appropriate policy levers and instruments and highlightsworkplace smoking bans as one of the effective interventions if properlyimplemented.
A consultation paper Choosing Health? included asking what should be doneThe consultation included questions on smoking. Several key agencies such as theHealth Development Agency, Chartered Institute of Environmental Health and theRoyal Society for the Promotion of Health, the London Health Commission and theALG have called for national action to restrict smoking in enclosed public places.
The responses have informed the development of the Public Health White Paper,due to be published in October 2004.
The London Health Commission, LHC, which advises the Mayor on public health,convened a meeting at the end of July 2004 to look at smoking in theworkplace/public places. This group also agreed that national legislation would bemost effective and agreed to lobby for this rather than local legislation. This was donejointly with the Association of London Government, (ALG).
In 2001, the Greater London Assembly set up a Smoking in Public investigativecommittee with a remit to consider improvements for London. This focused on theeffects on the public rather than the workforce. Global restrictions were notrecommended at this time although specific restrictions in taxicabs were agreed. TheGLA is to reconsider how it should act in the light of further evidence that has beenprovided.
The ALG have agreed to develop a private bill concerning banning smoking inenclosed public spaces. This will have to be submitted to Parliament by 26November 2004.
Two national smoking related performance indicators for the local authority starting2005-06 have been proposed which could contribute to smoking reduction: the proportion of smoke-free buildings in local authority control (excludingindividual houses) a smoking cessation target which would contribute to the PCT target The results of this consultation will be available in December 2004.
The London Health Commission is committed to working closely with London PCTsto establish a Londonwide smokefree NHS.
In England 26% of the population smoke, (27% of men and 25% of women) whereas
in London this was found to be 24% (29% of men and 21% of women). In
Hammersmith and Fulham, the household survey was used to measure smoking
prevalence. This found that 31% of the Hammersmith & Fulham population (34%
men and 28% women) smoked, which is higher than the national average.
One of the indicators used to monitor inequalities is occupational class. Nationallystatistics show that 16% of those in managerial and professional occupations smokecompared with 32% in routine and manual occupations. The prevalence amongstthose who are long-term unemployed is 23%.
1 General Household Survey 2002.
2 Hammersmith and Fulham Household Survey 2002. Although question used in the survey was comparable,London figures include 16-18 yr olds and LBHF survey does not. The difference could be explained byHammersmith and Fulham having a higher proportion of the younger age group where there is a higherprevalence of smoking.
3 Smoking Related Behaviour and Attitudes. Omnibus survey 2002 Locally data is not collected according to occupational group, but we can look atother indicators such as home ownership. In London, 24% of homeowners smokecompared with 35% of those who use the rented sector. There is a similar pattern inHammersmith and Fulham where 23% of owner-occupiers smoke compared with37% of non-homeowners. We can predict that there will be a greater burden of illnessand deaths in those people who are living in social housing.
London statistics from 1999 show a wide variation in smoking prevalence betweendifferent minority ethnic groups, with the Irish having the highest prevalence both formen (42%) and women (39%). Some ethnic groups, especially from South Asia chewtobacco rather than smoke cigarettes. Although ethnic data have been collected inthe local survey the sample size is too small to make a meaningful comparison.
Health Impacts of Smoking
Smoking has been identified as the single greatest cause of preventable illness,
contributing to one in five deaths a year and estimated to cost the NHS £1.7 billion.
In the UK fewer than 3,000 people under 65 die in road accidents compared with an
estimated 27,000 who die from smoking.
Cigarette smoke contains 47 hazardous wastes, 50 cancer causing agents(carcinogens) and more than 100 chemical poisons. In 2002, the InternationalAgency for Research on Cancer (IARC) noted that “the evidence is sufficient toconclude that involuntary smoking is a cause of lung cancer in never smokers”.
Cigarettes are also among the most addictive substances.
It is a major contributing factor in deaths and illness from cancer, especially lung,oesophageal and upper respiratory cancer, coronary heart disease and othercirculatory disorders and also contributes to illness and deaths from other causessuch as chronic lung diseases and peptic ulcers. An extremely small proportion ofdeaths is prevented by smoking - for example deaths from Parkinson’s Disease andendometrial cancer.
Not only smokers are affected: environmental tobacco smoke (otherwise known assecond-hand smoke or passive smoking), increases the risk of cancer by 20-30%and the risk of heart disease by 25% in those who live with smokers. Exposure totobacco smoke for only 30 minutes can impair the blood flow to the heart. The BMAhas recently estimated that at least 1000 people a year die from environmentaltobacco smoke, which is more than four times as many that die from accidents atwork.
The exposure of barworkers to environmental tobacco smoke can be 2-3 timeshigher than in the domestic setting. A New York study found that there was 50 timesmore air pollution in a smoky bar than at the mouth of Holland Tunnel (between NewJersey and Manhattan) in rush hour.
4 Tobacco in London: The Preventable Burden 2004 5 Tobacco Smoke Pollution: The Hard Facts Royal College of Physicians 2003 6 Nicotine Addiction in Britain Royal College of Physicians 2000.
7 Acute effects of Passive Smoking on Coronary Circulation. Otsuka et al. JAMA 2001; 286 8 Nancy Miller, Environmental Tobacco Smoke and the Hospitality Industry Conference, Royal College ofPhysicians, 2004. Measured levels of PM2.5 In the UK it has been estimated that 49 deaths a year, or almost one a week, in thehospitality industry can be attributed to exposure at work.
Children are particularly vulnerable to second hand smoke and do not have thefreedom to choose to avoid smoky atmospheres. There is clear evidence thatpassive smoking causes or exacerbates several diseases including respiratoryillnesses, ear infections and can increase the risk of cot death. Around 17,000children under five with respiratory infections are admitted to hospital a year. Theestimated cost to the NHS on management of children’s illnesses due to tobaccosmoke is over £400, million. Women who smoke during pregnancy are more likely tohave low birth weight babies.
Smoking can also cause fires. Around 200 people are killed and ten times thatnumber seriously injured annually in smoking related fires.
Estimating Local Health ImpactsThere have been several reviews of the health of Hammersmith and Fulhamresidents, the latest being the 2003 Public Health Report of the PCT in which theimportance of cigarette smoking as a major causal factor in premature death wasagain stressed.
The London Health Observatory (LHO) have calculated the contribution of smokingto the numbers of deaths, hospital admissions and costs to the NHS in London andestimate the burden for each Borough. Smoking causes 23% of deaths in men and13% of deaths in women.
The proportion of local deaths is similar to the rate in London with 24% of maledeaths and 14% of female deaths attributed to smoking. This estimate would meanthat 210 people die every year in Hammersmith and Fulham because of smoking.
The death rates reflect the prevalence of cigarette smoking in the past as well ascurrent smoking rates. Although action can be taken now to stop smoking and willdecrease the risk of death for an individual, the effects on the death rate in the wholepopulation are sometimes slower to see, as it could be up to 20 years beforediseases manifest themselves.
Smoking also contributes to falling ill and hospital use. The study does not make anestimate on the burden to the economy through loss of work through smoking relatedillnesses, but Londonwide hospitalisation costs are estimated to be over £105 millionin 2001. In Hammersmith and Fulham this comes to £3.14 million. SmokeFreeLondon has estimated 3 million working days are lost in London every year fromsmoking-related sick leave.
9 Professor Konrad Jamrozik, , Environmental Tobacco Smoke and the Hospitality Industry Conference,Royal College of Physicians, 2004 10 Tobacco in London: The Preventable Burden March 2004. 11 However methodology used by LHO would tend to underestimate the number of deaths if the localsmoking rate is higher than the London rate.
12 These figures refer to patients who are registered with Hammersmith and Fulham PCT and so do notexactly reflect costs for all Hammersmith and Fulham residents Attitudes towards smoking
National figures show that 7 in 10 people would like to give up smoking. Theproportion of those intending to give up is similar. Those who were long-termunemployed were most likely to intend to give up smoking (80%). Those who want togive up and those who intend to do so are not necessarily the same: • 91% of those wanting to give up smoking intend to do so,• 23% of those who do not want to give up smoking intend to give up.
Health concerns are the most common reason given for wanting to give up, followedby financial concerns and family pressure. Of those who had tried to stop andstarted, the most common cause for starting was stress or not being a good time togive up.
Most smokers try to limit their smoking in the presence of non-smokers, especiallywhen these are children (87%). The majority of smokers and non-smokers agreethat smoking should be restricted in the workplace and also other public places: Table: Percentage agreeing smoking should be restricted (2002)
SmokeFree London commissioned a telephone survey in London in 2000 toascertain how popular restrictions in eating-places would be. In Hammersmith andFulham, 95% wanted were in favour of restrictions in smoking in restaurants and75% in pubs, with the preference for having non-smoking areas available 59%, ratherthan a complete ban 16%.
Current action and developments
Smoking cessation is a priority of the PCT. Previously the programme was co-
ordinated from Hounslow, but a local co-ordinator has now been appointed. In 2003-
04, the PCT reached 49% of the smoking cessation target, which meant that 249
people stopped smoking for at least 4 weeks. The PCT is currently working to
increase community-based access and through neighbourhood renewal, will be
developing some lifestyle clinics. A wide range of health professionals will be
involved including community pharmacists, 30 of whom have been trained. A total of
11 practices have registered an interest in providing an enhanced service in this
A target for smoking cessation is a key indicator for improving health in all Sure Startprogrammes. Links have been developed between the Sure Start programmes andthe co-ordinator leading on smoking cessation in pregnancy. There is a midwife leadon smoking cessation at Queen Charlottes and Chelsea Hospital.
13 Smoking Related Behaviour and Attitudes. Omnibus survey 2002 Future training opportunities are likely to include acute and community mental healthservices. Support is also provided at Wormwood Scrubs Prison and this is to beextended.
The PCT has a smoking policy which restricts smoking in PCT buildings and supportsworkers to give up smoking. The Council has a smoking policy that aims to provide asmoke-free working environment, although it is left to departmental discretion onmaking exclusions and to provide smoking areas (providing these are not commonareas). The Fire Brigade has a no smoking policy that aims to provide a smoke-freeworking environment, although locally, exclusions can be made. Other organisations,such as Shepherds Bush Housing Association, do not have a written policy butrestrict smoking within the workplace.
All schools have a non-smoking policy. All nursery provision is smokefree. Theoccupational health unit provides advice and contacts to workers wishing to give upsmoking. It also participates in stop smoking campaigns. To provide any smokingcessation support directly would require more resources.
Health effects of smoking are included within the science modules of the nationalcurriculum. Within both primary and secondary schools, health education aboutsmoking is included within the drug education theme. In secondary schools teachersare supported by specialist workers from DrugLink to cover smoking. In primaryschools it is a part of the junior citizenship programme. “Wasted” a theatre in schoolsproduction used for health education includes anti-smoking preventive messages Within the community, smoking prevention is also supported through enforcementexercises of age restricted sales of prescribed goods, of which tobacco is one. Thesehave been included in the Trading Standards Service plan for 2003/2004.
Evidence of Effectiveness of Smoking Interventions
Using treatments such as nicotine replacement or bupropion (Zyban) together with
support through groups or one-to-one can increase the chance of smokers
succeeding to stop smoking.
The biggest controversy currently is over restricting smoking in public places.
Restricting smoking in public places can have two benefits: • Providing smoke-free environments can help those who wish to quit and help reduce the amount of cigarettes smoked in a day.
• Protecting others from the effects of tobacco smoke.
Even tobacco companies recognise that measures regulating smoking in publicplaces are warranted. Philip Morris USA in 1992 estimated that smokers facing atotal ban in the workplace would consume 11-15% less cigarettes and would quit at arate that was 84% greater than the average quit rate. It was thought that wheremilder restrictions were in place, such as having designated smoking areas, therewould be less impact on smoking cessation and little influence on consumption.
14 http://www.philipmorrisusa.com/policies_practices/public_place_smoking.asp Objections to restricting smoking tend to focus on the following issues: There is insufficient evidence on the harmful effects of passive smokingThe harmful effects of tobacco smoke have been demonstrated above. Studies thatsuggest otherwise have either been misinterpreted or are subject to bias, beingfunded directly or indirectly by the tobacco industry.
Separate smoking and non-smoking areas are sufficientThere is no evidence that separate smoking and non-smoking areas are effective.
Public health evidence suggests that smoke free areas may not be sufficient toreduce health risk and that ventilation is not effective.
Philip Morris USA have also recognised this “….while not shown to address thehealth effects of second-hand smoke, ventilation can help improve the air quality ofan establishment by reducing the sight and smell of smoke and by controlling smokedrift….” Smokers rights are violatedSmokers’ rights need to be balanced with the rights of non-smokers who are in themajority. This can be done by ensuring smokers do not smoke where others can beexposed.
Expectation of poor complianceThe smoking bans introduced in New York, Ireland and Australia have not foundproblems in compliance. A universal ban was found to be easier to implement as itwas easier to get a consistent message over to the public and the hospitalityindustry.
Adverse effects on business.
Studies that use objective data, appropriate statistical methods and control foreconomic trends, have not shown any negative economic impacts hospitality industrywhen a smoke-free policy was introduced. There is no evidence in Australia, Irelandor New York that the proportion of smokers eating or drinking out has significantlydecreased since the introduction of a ban.
The voluntary restriction of smoking in the workplace in England has had limitedsuccess with only 50% saying their workplace is smoke-free. Countries where a banhas been implemented have stressed the importance of introducing restrictions in thecontext of protecting the health of employees in the workplace. It is clear that in theUK there is a substantial majority in favour of restrictions in the workplace.
A voluntary code on banning smoking within the hospitality industry, the PublicPlaces Charter has been implemented as recommended in the White Paper. By thebeginning of 2003, 36% of pubs were non-compliant with the Public Places Charter,of those who were “compliant”, 47% allowed unrestricted and unventilated smokingthroughout. Although the preference for the hospitality industry is for a voluntary ban,a universal ban would be preferred to a piecemeal approach, local authority by localauthority, as there would not be a “level playing field.” 16 http://www.philipmorrisusa.com/policies_practices/public_place_smoking.asp At the Conference on Environmental Tobacco Smoke and the Hospitality Industry atthe Royal College of Physicians in May 2004, representatives of the hospitalityindustry stressed the importance of partnership working. The harmful effects ofenvironmental tobacco smoke were recognised and there was a need to work withlicensees in reassuring that any legislative changes was not likely to have asignificant impact on their business. It was also felt that more public disseminationon the harmful effects of environmental tobacco smoke should precede such a ban.
The success in Ireland was in part due to the time spent in building compliancethrough raising public awareness and working with the industry.
Options for Taking Smoking Prevention Forward
Restriction of smoking in public places in order to decrease exposure toenvironmental tobacco smoke and to create incentives for smokers to quit ordecrease the amounts they smoke.
As the Government will outline its policy on regulation in the forthcoming WhitePaper, it is more appropriate to wait for the outcome of this consultation and thesubsequent cross-London deliberations at Association of London Government andGreater London Authority level.
The power to promote wellbeing cannot be used to impose restrictions on thirdparties. Any Council byelaw would have to be confirmed by the Secretary of State tobe valid and the Courts would only enforce a byelaw if it were considered to bereasonable. There is also likely to be concern from local businesses that they wouldlose trade to neighbouring boroughs where a ban does not exist.
Options looking at preventing the uptake of smoking in young people via: • Stronger enforcement of existing law preventing sales to under-age consumers• Mandatory licensing of shops permitted to sell tobacco - consistent with alcohol would also need national legislation to be able to implement and are therefore notcurrently feasible.
However, the council could maximise the use of existing powers through anextension of current activity, which clearly have cost implications for some of theactions: • The council could explore how implementation existing regulation could be improved. This would include increasing the number of enforcement exercisesalready implemented on underage sales of cigarettes. As this is done inconjunction with campaigns on underage drinking and dangerous weapons, thisis estimated as requiring an equivalent of 0.5 FTE post within environmentalprotection.
• The council could explore the feasibility of supporting the hospitality industry in developing and implementing policies for a smoke-free workplace. This wouldinvolve providing advice on developing no-smoking policies and the effectiveness of the different options. This would require an additional 1FTE post withinenvironmental protection for a year over which period progress could bemonitored. (This post would also be key in any awareness raising that is agreedabove).
• The council could adopt the new best value indicators as a local indicator, regardless of whether they were accepted or not as a national indicator.
• The council could provide information on what small businesses could do in banning or restricting smoking, or developing no smoking policies for staff.
Although officer time would be required to develop the appropriate materials thiscould be relatively easily achieved, but whether this will have a significant impacton practice is debatable.
• All partners could assist the PCT in disseminating information on smoking cessation services to the different client groups that they serve.
• All partners could help improve access to services through providing venues for programmes to take place, including housing estates.
• All partners could ensure they develop a no-smoking policy if they do not have one or review the operation of the no-smoking policy if they do have one, toensure that it represents good practice.
• All partners with occupational health provision could assess what more support Conclusion
It is clear that much is already being done. As there are unlikely to be extra
resources, it would be more effective to work together. This could be done by
forming an interagency group of officers to develop a joint strategy with action plan
that would have targets and be time bound.
relevant policies developed in the White Paper • promotion of no-smoking policies in the workplace • identification of incentives for people to give up smoking and training and support • marketing strategy for smoking cessation services • how to work with the hospitality industry to ensure that they are well-informed of • Health promotion and prevention in other settings such as schools, prisons,
APPENDIX I SUMMARY OF PRODUCT CHARACTERISTICS 1. NAME OF THE MEDICINAL PRODUCT 2. QUALITATIVE AND QUANTITATIVE COMPOSITION For the complete list of excipients, see section 6.1. 3. PHARMACEUTICAL FORM 4. CLINICAL PARTICULARS Therapeutic indications In the adult Hypercholesterolemia (type IIa) and endogenous hypertriglyceridemia in adults, isolated (type IV) or in - whe