Lessons for smoking policy from international experience Robert West University College London March 2009

Goals of tobacco control

WHO Framework Convention on Tobacco Control Monitor tobacco use and prevention policies Protect people from tobacco smoke Offer help to quit Warn about the dangers of tobacco Enforce bans on tobacco promotion Raise taxes

What about Scotland? Scotland is already implementing MPOWER Prevalence is falling at the same rate as in England 24% in 2007 What next? GHS 2007

Population-level model of behaviour incidence Participation in behaviours is more common to the extent that they: give pleasure or satisfaction provide relief from discomfort or ‘drive’ states do not cause concern are regarded as acceptable or desirable are readily accessible do not compete with other behaviours for our time or resources and stopping is not considered normative, attractive or easy

Smoking in England nicotine makes cigarettes pleasurable and satisfying for many chronic nicotine intake leads to need to smoke ‘nicotine hunger’ and adverse withdrawal symptoms most smokers are mildly concerned health effects and the cost being a smoker is generally acceptable cigarettes are very easy to access and use being a smoker rarely limits other activities stopping is considered desirable and normative But varies with social grade ...

Key attitudinal markers in England Smoking Toolkit Study www.smokinginengland.info

Principles for reducing participation in smoking Change as many of the parameters affecting incidence as possible make smoking less pleasurable strengthen competing behaviours reduce the need to smoke increase concerns about smoking make smoking less acceptable increase smoking restrictions actively promote cessation

Behaviour change in practice: the EPICURE classification Education increasing awareness and understanding Persuasion changing attitudes Inducement offering incentives Coercion providing disincentives Upskilling improving capacity Regulation establishing rules regarding use, access and promotion Empowerment reducing barriers West R. Tobacco control: present and future. Br Med Bull. 2006;77-78:123-36.

Education Effective when it raises concern Probably the main driver of the prevalence reduction in some countries in the 1960s and 1970s Essential to maintain concern in new generations Still major pockets of ignorance to work with lasting damage to offspring from smoking in pregnancy link with dementia 3 months loss of life for every year continuing to smoke after age of 40 bring ‘old age’ on earlier countering the ‘90 year-old smoking granny’ fallacy effective methods of stopping

Persuasion Raises concern and triggers quitting Uses imagery and social pressure Media campaigns drive spikes in cessation activity and use of support (telephone helplines, medication use, use of NHS services) Events (New Year, No Smoking Day) can provide a cost-effective hook for campaigns Could be improved: greater saturation of multiple channels greater use of news and current affairs more focus on triggering immediate action and use of support services denormalise smoking and normalise stopping more focus on disadvantaged smokers

Inducement Occasionally used ‘Quit and Win’ competitions can trigger quit attempts Other incentives payments for quitting one study found increased cessation in pregnant smokers overall no clear evidence of lasting effect recent NEJM paper (Volpp 2009) suggests potential lasting effect but needs replication with better design

Coercion Potentially highly effective but can be unpopular Outright bans are currently rare Taxation and controls on smuggling are pivotal to any tobacco control strategy price elasticity for consumption: -0.4 smuggling at current levels will kill 4000 people per year (West et al, 2008) Considerable room for further action idea of raising price is popular in England, even among smokers support for outright ban on sale of cigarettes is surprisingly high in England (45%: Smoking Toolkit Study) use of price is undermined by roll-your-own (£1.90 per 20 versus £4.80 for manufactured) smuggling and counterfeit (average of 52p less per so cigs in those who smoke at least some smuggled cigs: Smoking Toolkit Study)

Upskilling Not widely used in tobacco control Studies have looked at social skills training to resist peer pressure to smoke: no clear evidence for effectiveness

Regulation Believed to play a major role in tobacco control but needs popular support age of sale ad bans clean air laws restrictions on labelling (use of term ‘low tar’) Major room for improvement better enforcement of age of sale more complete ban on promotion (point of sale, plain packaging) extensions to clean air areas (e.g. cars containing children)

Empowerment Major component of tobacco control in several countries (UK, US, Japan, Spain, Taiwan ...) Treatment of choice: NHS service offering behavioural support plus medication highly cost-effective Major room for improvement make sure NHS service is optimally configured pharmacy support has low success rates compared with specialists better promotion to improve uptake

Community interventions Package education, persuasion and empowerment at local level local media campaigns and promotional events promotion of support services Little track record yet but some evidence of effectiveness from experimental studies

Conclusions In a country such as Scotland, the following additional measures merit consideration: raising the price to smokers (through UK government action to increase taxes and reduce smuggling) extending regulation to reduce opportunities to smoke and promotion improving effectiveness and reach of treatment for nicotine dependence increasing media spend on campaigns directed at triggering cessation attempts concerted community campaigns targeting areas of high prevalence