Should we now focus on 'the endgame' for tobacco control in the UK? Robert West University College London November 2012

Cigarette smoking prevalence projection to 2030 0.55% pa Projecting in a straight line from November 2006 would see prevalence fall to approximately 7% by 2020, but this includes the immediate smoke-free decline. 0.83% pa Source: ONS

Annual smoking prevalence since 2007 31.9% 15.4% decline% 27.0% 24.1% 17.8% decline% 19.8% 17.9% 20.7% decline% 14.2% A-C1: Professional to clerical occupation C2-E: Manual occupation

Smoking prevalence since 2007 by age No change A-C1: Professional to clerical occupation C2-E: Manual occupation

Cessation activity

Use of support

Harm reduction NRT: Nicotine replacement therapy

Behaviour Change Wheel Education Increasing knowledge or understanding Persuasion Using communication to induce positive or negative feelings or stimulate action Incentivisation Creating expectation of reward Coercion Creating expectation of punishment or cost Training Imparting skills Restriction Using rules that limit engagement in the target behaviour or competing or supporting behaviour Environmental restructuring Changing the physical or social context Modelling Providing an example for people to aspire to or imitate Enablement Increasing means/reducing barriers to increase capability or opportunity Comms/marketing Using print, electronic, telephonic or broadcast media Guidelines Creating documents that recommend or mandate practice. This includes all changes to service provision Fiscal Using the tax system to reduce or increase the financial cost Regulation Establishing rules or principles of behaviour or practice Legislation Making or changing laws Env/Soc Planning Designing and/or controlling the physical or social environment Service provision Delivering a service Michie S, M van Stratten, West R (2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42.

Policy options for tobacco control Comms/marketing Improve impact and targeting of communications campaigns Guidelines Provide clear evidence-based guidance to Local Authorities and promote effective adoption Fiscal Increase the financial cost of smoking through tax and enforcement Regulation Regulate to improve access to acceptable and effective nicotine substitutes Legislation Legislate to reduce exposure to tobacco industry marketing Env/Soc Planning Control density and location of tobacco outlets Service provision Improve healthcare systems to increase the impact of brief advice and cessation support

Options for increasing rate of decline Policy Estimated prevalence reduction per annum 1. Autumn quitting event (Stoptober) 0.01%-0.02% 2. 5% real cost increase (versus no increase) 0.15%-0.25% 3. Effective use of OTC NRT 0.02%-0.03% 4. Double use of NHS support 0.03%-0.05% 5. Double effective GP opportunistic advice 0.05%-0.10% 6. Double use of nicotine for harm reduction 0.04%-0.08% ? 7. Plain packaging 0.01%-0.02% ? 8. Point of sale ban Total +0.55% 0.97%-1.02% 1. Autumn quitting event: evidence from Smoking Toolkit Study of 2% of smokers trying to quit of whom 4% would be expected to succeed long term (+- 50%) with current prevalence of 20% 2. 5% real cost increase: participation elasticity of .2 of 20% of population who are smokers (+-.05%) 3. If OTC NRT increased success rate by 50% then apply Smoking Pipe Model (www.smokinginengland.info) 4. Using data from Smoking Pipe Model (www.smokinginengland.info) 5. Using data from Smoking Toolkit Study (www.smokinginengland.info) 6. Using data from Smoking Toolkit Study (www.smokinginengland.info) 7. Judgement 8. Judgement