Policy responses and statements

Name of organisation:: Department of Health
Name of policy document:: Consultation on the future of tobacco control
Deadline for response:: 8 September 2008

Background: The Cancer Reform Strategy 2007 announced the Government’s intention to consult on the next steps in tobacco control and the further regulation of tobacco products, and to consult with stakeholders on measures to reduce the significant harm to health caused by smoking for those who are addicted to nicotine and not able to quit altogether.

This consultation is the first step in developing a new national tobacco control strategy and covers four main areas:

Reducing smoking rates and health inequalities caused by smoking: including trends in smoking prevalence, regional patterns and health inequalities and tackling the supply of cheap illegal tobacco in our communities.
Protecting children and young people from smoking: reducing young people’s access to tobacco, reducing exposure to tobacco promotion, and protecting children from secondhand smoke to prevent future generations suffering poor health caused by tobacco.
Supporting smokers to quit: including NHS stop smoking support, increasing access to, and take-up of, quit services among high smoking prevalence groups, supporting young smokers to quit, supporting pregnant smokers to quit, and how best practice can be best shared.
Helping those who cannot quit:considering the potential of a harm reduction approach in tobacco control to help people whose addiction to nicotine makes it extremely difficult to quit altogether.

COMMENTS ON
DEPARTMENT OF HEALTH
CONSULTATION ON THE FUTURE OF TOBACCO CONTROL

The Royal College of Physicians of Edinburgh is pleased to respond to the Department of Health on the Consultation on the Future of Tobacco Control. The College retains a keen interest in health outwith Scotland, as many Fellows and Members of the College reside and work in England. It is therefore appropriate for the College to comment. It is a useful and well prepared and researched paper which carries the firm and unequivocal support of College Fellows. It identifies a range of achievable options for improved tobacco control.

In response to the specific questions:

Question 1

We note the current background reduction in smoking prevalence for the whole population of 0.4% per year. We will be keen to see a continuation of this trend in principle, and acceleration where this is possible. It may not be realistic to aim for 1% per year but a rate of reduction greater than 0.4% - say 0.5% - may be achievable with greater focus on worthwhile interventions. A particular challenge will be the groups highlighted both in the question and the text who merit particular attention. A specific challenge is the prevalence of smoking amongst pregnant women and some ethnic minority groupings. There is a lack of evidence of effective interventions in these areas. Any strategies to address these matters should incorporate evaluation of interventions, sharing of good practice and a blend of societal as well as group and individual interventions in order to create the social conditions to allow people within these specific groupings to be successful in quitting. We do not offer specific targets by years as suggested in the question but join the Department of Health in its aspiration to create a smoke-free society.

Question 2

College Fellows do not underestimate the challenge posed by the need to reduce inequalities caused by tobacco use. It believes that there should continue to be a balance of population-wide and specific interventions that take into account the needs, cultural and social factors that cause people to continue to smoke. There should be designed personal smoking cessation services for individuals and groups in high smoking prevalence areas and networks. Given the lack of evidence of effectiveness until now in specific groups, for instance pregnant women, objective evaluation and structured approaches that allow positive external influences to create the conditions for smoking cessation within families and communities should be an element of the intervention.

Question 3

We support the 6-strand strategy put forward by the Government in this document.

Question 4

The College supports the substantial investment put into reducing smuggling and other illegal activities that frustrate attempts to reduce tobacco consumption. These measures were prominent in the "Smoking Kills" White Paper of 10 years ago and their continued investment is necessary. We question whether the labelling of tobacco products on which tax has properly been paid are sufficient measures, although we appreciate the perverse incentives of tobacco availability by other routes and the lack of evidence that indicators of quality in, for instance, packaging is a disincentive for consumption. We encourage increased collaboration between enforcement and intelligence agencies and others, and prosecution of those found to be selling illicit tobacco.

Question 5

The College supports Government action to keep the issue of smuggled tobacco products in the public eye in order to encourage disclosure by members of the public, clear intentions for potential prosecutions related to this area and the social marginalisation of criminal activity. We also appreciate the balance between law enforcement and counter-cultural trends amongst those most marginalised and therefore most likely to wish to continue smoking.

Question 6

The College would favour the positive licensing scheme for tobacco retailers as already exists for fireworks and similar hazardous products. Any retailer who wished to sell tobacco products would have to seek a licence, which would have to be displayed. Any breach of the law, such as selling to under 18s, the detection of which is now possible by test purchasing, would mean a first warning and fine for a first offence, and then withdrawal of the licence for any subsequent offence.

Therefore, deterrence comes through a law enforcement route which would have effects on reducing demand and availability. A robust tax policy that delivers a progressive increase in the price of tobacco should also show through in reducing demand for tobacco products among young people. The issue of packaging is a matter addressed later.

Question 7

We agree that there should be restrictions on the advertising and promotion of tobacco accessories such as cigarette papers as part of the overall approach to reduce availability of tobacco associated products.

Question 8

The College favours Option 3 of those set out, bearing in mind evidence from other countries and of efforts already underway by cigarette manufacturers to circumvent existing restrictions. The cost of refitting should be borne by wholesalers/manufacturers which have profited from the promotion of sales by these means in the past.

Question 9

The College believes that there should be restrictions on vending machines. We appreciate the practical difficulties in implementing and enforcing these matters, and are open-minded about the preferred option. There should be close monitoring of the market share that vending machines offer, especially to young people in order to ensure that it falls progressively.

Question 10

The College believes that plain packaging does have merits, whilst noting the less strong evidence to support such an initiative. The risks of inducing a counter-culture and therefore a higher consumption of apparently illicitly acquired tobacco products seem low.

Question 11

Accepting the various arguments relating to the size of cigarette packs, the College believes that packs of less than 20 cigarettes should be banned and the sale of smaller numbers of cigarettes, such as by opening packs and selling single or a few cigarettes, made illegal. The reason behind this is not solely a matter for domestic policy making but also to signal to other countries, particularly where young people are induced into tobacco smoking, to take equivalent measures in the interests of their own young people's health.

Question 12

While second-hand smoking in the home affects children and is an important public health matter, it is difficult to see that any legislative approach would be effective here; this area is one more for public education and "social marketing" to induce society to change and public attitudes towards families and the nurturing of young children.

Question 13

Priorities should go into understanding the determinants of smoking continuation amongst groups that still hold on to a high prevalence of smoking, such as groups identified elsewhere in this document. The evidence base for effective interventions for these groups is not as strong as in other areas. There should be work to ensure monitoring and validation of equity of access to smoking cessation. There should be work put into evaluate efficacy of websites and help lines.

Question 14

The Government is taking the correct line in easing access to ‘stop smoking’ services by whichever provider, and putting effort into assuring the quality of advice and services, no matter who and where these services are provided. Non-statutory services can be particularly innovative in offering services, particularly to marginal communities where their understanding of access to services and adjustments is perhaps greater. NHS ‘stop smoking’ services should also take account of wider theories of promoting a healthy lifestyle, such as self-esteem and a sense of control over one's life which often underpin an individual's ability to address their smoking addiction, as well as other adverse influences on health and well being.

Question 15

The College believes that this should be a mixed economy of communication and referral. Hospitals remain an important setting for quitting from smoking and the engagement of NHS settings as well as less formal and non-statutory settings, as a wider network of local and nationally provided services should be an element of improvements in communication and referral.

Question 16

Policy makers should not forget the hospital as a suitable setting for smoking cessation advice. Neither should there be a bar to repeat attempts to quitting. The ethos of services should include a positive encouragement to try again.

Question 17

The College supports in principle the Government's vision of a smoke-free society. It appreciates that such a vision will take time to achieve and that harm reduction approaches are compatible with a strategy that is on its way to achieving such a bold aim. In principle, the College believes that nicotine containing products are not risk free. There should be full regulation, and their composition should be fully established. There might yet be a case for permitting addicted smokers to go for perceived reduced harm products but there will always be a risk that these will, in time, become attractive to non-smokers (and especially young people) as an alternative to starting conventional tobacco smoking. Harm reduction, however, is about acknowledging negative influences and bringing people into lower risk categories. The College appreciate the dilemmas that harm reduction can bring but supports the Government's courage in seeking to strike a balance between smoke-free measures and environments, and reduced-smoke environments that reduce harm on the way to achieving its overall objective.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[4 September 2008]