Being strategic about smoking

In 1996 adult smoking rates in Britain rose for the first time since the 1970s.¹ No longer could it be assumed that the slow but steady decline in smoking prevalence which had occurred for the past 25 years would continue. Stronger policy measures to control the use of tobacco, prevent children from starting to smoke, and help smokers to give up were urgently required. Last month, in its white paper on tobacco, Smoking Kills, the government set out a wide range of policy measures in a carefully thought out strategy for the United Kingdom. It aims to re-establish the downward trend in adult smoking, to result in 1.5 million fewer smokers by 2010 and to save around 3000 lives a year.²

Most significant is the commitment to implement the European directive on tobacco advertising ahead of the union’s timetable. By 2000 tobacco advertising on billboards and in printed media should have ended. However, tobacco sponsorship of sports and arts will continue for a further three years and global sports such as international football and Formula 1 motor racing can receive tobacco sponsorship in diminishing amounts until 2006. As yet no targets for reduction have been agreed. For a country where female deaths from smoking related diseases are among the highest in the European Union, and more than three times the union average,³ this timescale is slow. Sporting bodies have already had two years to replace tobacco sponsorship, and some were ready as early as 1991.⁴

During this interim period children will continue to be exposed to extensive television coverage of tobacco sponsored sports. A single grand prix provides the equivalent of about fifty 30-second cigarette advertisements,⁵ and children’s recall of brand imagery is high.⁶ A further risk is that the tobacco industry will mount a coordinated effort to increase sponsorship before the full ban comes into effect, as happened in New Zealand and California.

The rights and choices of smokers and non-smokers are emphasised throughout this white paper but there is no new legislation to enforce smoke free areas. Instead the government proposes a charter to encourage pubs, restaurants, and hotels to provide well ventilated smoking and non-smoking areas. So far progress towards smoke free food and entertainment has been slow.⁷ Many restauranteurs and publicans believe that a complete ban on smoking would harm their businesses when they compete with those who provide a choice. Without the consistency of legislation and powers of inspection, such measures are little more than good intent.

Well funded media campaigns to raise awareness and motivate smokers to quit are a crucial part of a comprehensive strategy.⁸ During the early years of California’s tobacco control programme, which included extensive media campaigns, the rate of decline in smoking prevalence was significantly greater (1.06% per year) than in the rest of the United States (0.57% per year),⁹ but the initial effects did not persist after a reduction in programme funding and an increase in promotion and lobbying by the tobacco industry. The UK government proposes to invest up to £110m over the next three years in public education targeted on children, young people, pregnant women, and working class smokers and direct support for smoking cessation. This is generous compared with previous expenditure, but only a third of that spent per head in California. Clear leadership, proper coordination, management and accountability for different elements of this programme, including unpaid publicity, will be crucial—otherwise there could be a serious risk of fragmentation. Establishing a national multiagency steering group and a small, dedicated task force of experienced staff seconded from leading agencies, such as the Health Education Authority, Action on Smoking and Health (ASH), and the NHS Confederation would be one way to address this. Another could be to ensure that all NHS senior executives have local targets for tobacco control incorporated into their personal objectives and annual appraisals.

The intention to help smokers in the lowest income groups by providing them with one week starter packs of nicotine replacement therapy through referral to specialist clinics is welcome. Nicotine replacement nearly doubles the rate of smoking cessation achieved by simple advice from general practitioners or more intensive clinic interventions.¹⁰ Although in the first year such schemes will be available only to smokers in health action areas, this measure favours the less well off. Twenty seven per cent of smokers are concentrated in the lowest 10% income group.¹¹ Not only are they likely to be more nicotine dependent¹² but around 70% have no serious intention to quit.¹³ For this measure to help the most disadvantaged smokers the approach to behaviour change will need to be carefully tailored to meet their needs and preparedness for change.¹⁴ National media campaigns should be designed to play a complementary role.

Finally, the white paper recognises that affordability of cigarettes is a major determinant of smoking and commits to increasing tobacco taxation by an average of 5% a year in real terms. It also promised a major offensive against tobacco smuggling and fraud, which should place Britain in a good position to argue the case for increasing prices throughout the European Union and reducing the large differentials in tobacco prices.

Only time will tell whether the policy measures described in the white paper will help reverse the rising trend in smoking prevalence. Government action alone can only achieve so much. Doctors and others who campaigned so vigorously to end tobacco advertising must now direct their efforts towards revitalising professional interest, publicly debating the part health professionals can play, and regaining momentum. There is much, much more to do.