Media Briefing: Secondhand smoke, Public Health White Paper
|“The right of the individual to choose their own lifestyle must be balanced against any adverse impacts those choices have on the quality of life of others”.
The Wanless Report on Public Health ‘Securing Good Health for the Whole Population’.
“There is something else we have learnt during Government. The biggest advances have always been due to the boldest reforms… We will address this in our forthcoming White Paper on public health, making it easier for people to make healthy choices about eating, living and working in smoke-free environments, and taking more exercise.”
Speaking to a conference of global health experts in Edinburgh, (former Health Secretary) Frank Dobson said he had been a supporter of a ban on smoking in public places for a long time. He refused to criticise Dr John Reid, the current Secretary of State for Health, by name, but he made it clear that he feared his successor would fail to implement a total ban. “There is a danger we will come up with some stupid, pathetic compromise,” he said.
This note sets out the key issues and facts around smoking, in advance of the Government’s White Paper on Public Health. The White Paper is intended to spell out how the Government intends to meet the “fully engaged scenario” for public health, set out in successive reports to Government by Derek Wanless. The White Paper could be published between 15th or 20th November, but these dates are tentative only. The Department of Health has a major conference on tobacco and health scheduled for November 22nd – it would be hard to hold this if the White Paper remains unpublished.
1. The first part of the paper (paragraphs 3 to 18) sets out key facts about smoking, including secondhand smoke in workplaces and enclosed public places. The second part (paragraphs 19 to 29) sets out the Government’s policy options and comments on them. Ending smoking in the workplace will protect the health of non-smokers currently made ill by this avoidable health and safety risk. It is also the single most effective thing that the Government can do to cut smoking rates; it will be impossible for the Government to meet its own targets for cutting smoking rates by any other means.
2. ASH can be contacted at any time for advice, information and comment on the White Paper. Telephone number: 020 7739 5902. We provide out of hours media cover, please ring the ASH office number and listen to the answerphone message for contact details, or try 07887 641344 (mobile). The ASH website has a great deal of information on smoking and health: particularly in the factsheets section (click on “facts, stats and pics” in the top left hand box on the front page). ASH will circulate a further short briefing note before publication of the White Paper updating any intelligence on its likely contents. ASH is developing a number of case studies of people who have been made ill by secondhand smoke. We also have partial lists (pdfs) of smokefree pubs and hospitality venues.
Smoking and Health
3. Tobacco use kills around 114,000 people in the UK every year, more than 300 every day – as if a plane crashed every day and killed all its passengers. Smoking-related illness accounts for around one fifth of all deaths. About half of all regular cigarette smokers will eventually be killed by their habit. Smoking is the UK’s biggest cause of preventable death and therefore a top public health issue. Smoking causes at least 80% of all deaths from lung cancer, around 80% of all deaths from bronchitis and emphysema and around 17% of all deaths from heart disease. Thirty per cent of all cancer deaths can be attributed to smoking.
4. About 12 million adults in the UK smoke cigarettes – 27% of men and 25% of women. Adult smoking rates vary only slightly between different parts of the country, as defined by the Government Office Regions. For example, in the East of England 27% of people smoke, in the North West, 28%. In Scotland 28% of the population smokes; in Wales the rate is 27%.
5. Smoking rates are highest among those aged 20-34: 38% of men and women in this age group smoke. Among older age groups prevalence gradually declines with the lowest smoking rate among people aged 60 and over: 15% smoke in this age group. One reason for this is that older people are more likely successfully to have quit smoking, another is that about a quarter of smokers die in middle age. More than 80% of smokers take up the habit as teenagers. In the United Kingdom about 450 children start smoking every day. About one fifth of Britain’s 15 year-olds – 18% of boys and 26% of girls – are regular smokers – despite the fact that it is illegal to sell cigarettes to children aged under16. Most smokers want to quit; this is true for all socio-economic classifications. The Office of National Statistics survey “Smoking Related Behaviour and Attitudes” puts the proportion wishing to quit at around three quarters (Smoking-related behaviour and attitudes, ONS).
Smoking and Class
6. Smoking is heavily related to social class. Men and women in manual socio-economic groups are more likely to smoke than people in non-manual occupations. 20% of men and 18% of women in the professional and managerial groups smoke compared with 32% of men and 31% of women in routine and manual groups. Smoking is the greatest single factor in the different life expectancy between social classes. The second Wanless report gave the following table (5.1).
Proportion of Males Dying Under Age 70
Source: Department of Health analysis
7. The single policy step most likely to encourage more smokers to quit is to end smoking in the workplace. This intervention is justified because secondhand smoke is also now known to be a serious health and safety risk to non-smokers. Ending smoking in the workplace will therefore be good for the health of smokers and non-smokers alike.
8. The scientific evidence that secondhand smoke damages the health of third parties is now incontrovertible. It has been confirmed by the Government’s Chief Medical Officer (CMO) Sir Liam Donaldson (in July 2003) as well as by the heads of all of Britain’s thirteen Royal Colleges of Medicine (in November 2003). A recent leaked report by the Government’s Scientific Committee on Tobacco and Health (SCOTH) estimates that non-smokers exposed to passive smoke have an increased risk of lung cancer of 24%, and an increased risk of heart disease of 25%. SCOTH identified children and bar staff as two groups in the population particularly at risk from secondhand smoke (see Leaked Government report shows extent of health damage from secondhand smoke). Other groups of employees at particular risk include workers in casinos and other leisure venues.
9. The non-smoker breathes “sidestream” smoke from the burning tip of the cigarette and “mainstream” smoke that has been inhaled and then exhaled by the smoker. Tobacco smoke contains over 4000 chemicals, some of which have marked rritant properties and some 60 of which are known or suspected carcinogens (cancer causing substances).
10. According to figures presented to a conference of the Royal College of Physicians in May 2004 by Professor Konrad Jamrozik of Imperial College London exposure to secondhand smoke at work leads to approximately 700 deaths from these causes annually from lung cancer, heart disease and stroke combined (One hospitality worker dies every week from passive smoking, RCP, 17 May 2004). For comparison, the total number of deaths from all industrial accidents in the UK in 2002/3 was reported by the Health and Safety Executive as 226. Jamrozik also estimated that on average one worker in the hospitality industries dies from exposure to secondhand smoke each week.
Secondhand Smoke in the Workplace
11. Many UK workplaces are now non-smoking. White collar and office workers in particular are likely to benefit. However, many workplaces continue to permit smoking. Many such workplaces are operated by small firms and employ relatively low-paid staff. Workplace smoking is of course also common in the hospitality trades – restaurants, pubs, casinos etc. Using Government data, ASH has calculated that 2.2 million people work in places where smoking is allowed throughout and a further 10.7 million in places where smoking is allowed somewhere on the premises (Smoke Freedom Toolkit Published: Also Key Figures on Workplace Exposure).
12. Ventilation and similar systems cannot eliminate all smoke and therefore at best only reduce risk. Ventilation standards are voluntary and are designed for comfort, not for safety. Studies show that ventilation systems are usually not well maintained, making them even less likely to be effective. It would require much higher ventilation rates than most commercial systems offer to reduce health risks significantly (although even these would not be fully effective). Such systems would be very expensive, noisy and would cause discomfort and are therefore most unlikely to be installed in commercial premises. (See www.repace.com for the work of James Repace and associates. Repace is an international expert on smoking and ventilation.)
13. It is known that ending smoking in workplaces is a simple and cost-effective way to encourage smokers to quit. The Wanless Report stated that: “the voluntary approach to smoking in the workplace has had limited success” and that “Some studies estimate that a workplace smoking ban in England might reduce smoking prevalence by around 4 percentage points – equivalent to a reduction from the present 27 per cent prevalence rate to 23 per cent if a comprehensive workplace ban were introduced in this country.” (Box 4.2).
14. A number of other countries and local jurisdictions have acted to ban smoking in workplaces and enclosed public places. They include Ireland, Norway, California, Massachusetts and the city of New York. Small business and tobacco lobbyists often claim that smoking bans may damage business, particularly in eating and entertainment venues. There is no good objective evidence for this assertion. The most authoritative review, by Scollo and others, found that (from 97 studies worldwide) all independent studies found no negative impact on takings, and negative studies had tobacco industry backing and most used subjective measures (Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry, Tobacco Control, 2003).
Secondhand Smoke: Devolved Government and Councils
15. Local councils currently have limited powers to act on smoking in public places. Liverpool Council has responded to this by promoting a Private Bill in Parliament to give it powers to end smoking in all the city’s workplaces (Liverpool City Council (Prohibition of Smoking in Places of Work) Bill). The Leaders’ Committee of the Association of London Government has also voted to seek powers to act on workplace smoking in London (Councils push for capital smoking ban, The Guardian, 13 August 2004) Other Councils seeking to act include Manchester and Poole (contacts available from ASH). The National Assembly for Wales has called for similar powers to act in the Principality (Wales seeks smoking ban powers, ePolitix, 19 October 2004) and all the major Northern Ireland parties have called for an end to workplace smoking in the province.
16. The Scottish Executive is to announce its policy on workplace smoking on 10th November. This follows a public consultation which resulted in a record level of public interest – about 54,000 replies were received, 40 times the previous record response rate for any previous Executive consultation. An overwhelming majority is believed to have backed legislation and it is likely that the Executive will back legislation ending smoking in all Scottish workplaces (Executive to adopt smoking ban after 54,000 speak out, The Scotsman, 25 October 2004).
17. There are essentially four options for legislation on smoking in workplaces and enclosed public places. It is not yet clear which if any of these options the Government will prefer. However, Health Secretary Dr John Reid has confirmed that “the status quo is not an option” (Reid pledges action on smoking, The Guardian, 24 September 2004).
18. The main options are:
· National legislation ending smoking in all workplaces, on the Irish model. This might be introduced at “variable speed” – e.g. allowing longer for restrictions to be introduced in the hospitality sector than in other workplaces
· Legislation to give local Councils, and possibly regional and devolved assemblies, powers to end smoking in workplaces and enclosed public places, roughly equivalent to the position in the United States
· Legislation to end smoking in most workplaces and enclosed public places, with exemptions for specific categories, for example pubs. This is essentially the legal position in the Netherlands
· A continuation of the “voluntary approach” to smoking restrictions in some or all categories of workplace and public places.
19. All the options short of an outright ban are open to serious objections.
20. Local legislation has been an idea floated by the No10 Policy Unit and others including Chancellor of the Duchy of Lancaster (and Labour policy czar) Alan Milburn. However, this would increase the regulatory cost to business, particularly to large employers in the hospitality sector. Major restaurant chains and hotel chains would be at worst neutral about national legislation but would strongly oppose local action, as it would lead to different rules in different cities, towns and regions. The British Hospitality Association says that the Government has “only two feasible options: continue with the voluntary approach or legislate for a total ban on smoking in workplaces (as in Ireland, Norway and, from 2005, Sweden)” (see www.bha.org.uk/policy).
21. A possible variation on the local route could be a form of licensing – local Councils would be able to permit smoking in particular premises, if these met conditions including protection of children and minimising health risk to employees (Smoking ban for pub and office, Times Online, 03 November 2004). The “default setting” would be that workplaces and enclosed public places should be smokefree. However, this is open to the same objection as above; it would result in different rules in different local authority areas.
22. John Reid’s “aides” have floated the idea of an exemption for “wet-led pubs”.
23. However, exemptions for particular sectors would be hard to justify, and might lead to challenges for example under the Human Rights Act. Dr Reid was embarrassed in early October by the leak of the latest report from the Government’s own Scientific Committee on Tobacco and Health, which singled out bar staff as ”heavily exposed at their place of work” to the health risks of secondhand smoke (Leaked Government report shows extent of health damage from secondhand smoke). Any attempt to exempt most pubs, but include for example gastropubs, restaurants and hotel bars, would be fiercely resisted by employers who might feel that they were being put at a competitive disadvantage. Employees still affected by scondhand smoke might have a case against the Government under, for example, human rights legislation. Since the date of “guilty knowledge” under the Health and Safety at Work Act is now passed for secondhand smoke, employers who continued to allow their employees to be exposed to this health and safety risk would be likely to face consequent legal actions. Any such exemption would therefore be a highly unstable solution.
24. The “voluntary approach” to smoking restrictions in the hospitality industry has been tried and has largely failed. After the publication of the “Smoking Kills” White Paper in 1998, the principal trade bodies within the hospitality industry, working with the Government, agreed to draw up a Charter to deal with the problems of passive smoking. Despite extensive publicity within the hospitality trade to promote the Public Places Charter, compliance with the initiative was low. In discussion with the Department of Health, trade leaders agreed that 50% of all pubs and half of the members of the Restaurant Association should be Charter Compliant by January 2003, with 35% of that 50% restricting smoking to designated and enforced areas and/or have ventilation that meets agreed industry standards. In its progress report published in April 2003, the Charter Group revealed that 46% of restaurants and pubs surveyed still allowed smoking throughout, with 22% having separate smoking and non-smoking areas. Less than 1% banned smoking completely (See ASH Fact Sheet on Smokefree Legislation (pdf)).
25. Leading pub chains have attempted to revive the voluntary route. In September, the pub chains Enterprise Inns, Mitchells & Butlers, Punch Pub Company, Scottish & Newcastle Pub Enterprises and the Spirit Group, which together run around 22,000 outlets, today pledged to ban smoking at the bar by the end of next year and make 80% of pub space non-smoking within five years (Smoking ban ‘not tough enough’, The Guardian, 09 September 2004). However, this would not affect the remaining 33,000 pubs around the country, and would in any event not adequately protect pub staff or members of the public, who would still be exposed to drifting smoke from smoking areas.
26. The pub companies have claimed that an end to smoking in the workplace could cost the UK economy £3.5 billion and lead to the closure of 5,000 pubs. There appears to be no serious evidence to back this hyperbolic claim, which is flatly contradicted by, among others, the Government’s Chief Medical Officer, whose latest annual report estimates that a policy of creating smokefree workplaces in the UK would bring a net benefit to society of between £2.3 and £2.7 billion a year, equivalent to treating 1.3 to 1.5 million people on hospital waiting lists (Annual report of the Chief Medical Officer 2002).
27. If the White Paper includes a bodged solution on this central issue, or worse fails to make any specific commitments to action, it will be widely attacked as a failure by the public health lobby and others. It will also ensure that the Government cannot meet its own ambitious targets for reducing smoking prevalence rates, or the “fully-engaged” scenario for public health advocated by Derek Wanless. According to Wanless, this would require a fall in the number of smokers from 26% now to 17% of the population by 2011 and 11% by 2022. The Government will not be able to contain NHS spending as proposed under the fully engaged scenario unless these targets are achieved. If current rates of decline in smoking prevalence continue, smoking prevalence will still be at 22% by 2011 (ASH submission to the Choosing health consultation – pdf)).
28. The White Paper is likely to contain a number of “eye-catching” secondary initiatives on smoking. While these are welcome in themselves they are no substitute whatever for radical action on smoking in public places, and will not make major contributions to cutting smoking prevalence rates. Likely moves are:
· Greater use of celebrities to promote a non-smoking and public health message
· Early moves to a fully smokefree NHS (a surprisingly large number of hospitals and other NHS facilities still allow smoking somewhere on the premises)
· A move to a “negative licensing” system for retailers who unlawfully sell cigarettes to minors. – retailers shown to have sold to minors could lose their license to sell tobacco products.
Public Affairs Manager