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

2. Goals of tobacco control

3. 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

4. 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

5. 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

6. 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 ...

7. Key attitudinal markers in England
Smoking Toolkit Study

8. 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

9. 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:

10. 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

11. 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

12. 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

13. 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)

14. 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

15. 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)

16. 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

17. 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

18. 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