TOBACCO by LGA publications

TACKLING TOBACCO AND NICOTINE DEPENDENCY

TACKLING TOBACCO AND NICOTINE DEPENDENCY ‘Investing in our nation’s future: The first 100 days of the next government’ was launched last year by the Local Government Association (LGA). It set out the challenges any new government will face in May 2015 and provided a local government offer on how to help them deal with the most pressing issues. The transfer of public health responsibilities from the NHS to local government and Public Health England (PHE) represents a unique opportunity to set out a local approach to tackling tobacco and nicotine dependency and change the focus from treatment to prevention. We are calling on government to help people live healthier lives and tackle the harm caused by smoking and dependence on nicotine by reinvesting a fifth of existing tobacco duty in preventative measures and supporting licensing and trading standards departments to better tackle the black market in tobacco.

We believe that health and crime reduction are important issues for the people we serve and that making the link between the taxes and duty they pay and the human and financial cost of these issues will be welcome. Additional resources would enable local councils to respond to the specific health and social care needs of their communities in ways that they know will be effective. By implementing the range of policies outlined in our 100 days document we will save £11 billion on the cost of the public sector and empower local communities to have a real say in their own future. It is often said if tobacco was discovered today it would never be legalised. It is easy to understand why. Smoking is the primary cause of premature and preventable death, accounting for nearly 80,000 lives in 2013 in England.1 The death toll from smoking is greater than the next six most common causes of preventable death combined – drug use, road accidents, falls, preventable diabetes, suicide and alcohol abuse. This is despite the fact the smoking rate has fallen considerably since the 1950s when the link with lung cancer was established beyond all doubt. The graph in Figure 1 shows that smoking contributes significantly higher than any other single factor to the burden of disease and disability in the UK. The negative percentage for alcohol is the protective effect of mild alcohol use on ischaemic heart disease and diabetes.

FIGURE 1: BURDEN OF DISEASE ATTRIBUTABLE TO 20 LEADING RISK FACTORS FOR BOTH SEXES IN 2010, EXPRESSED AS A PERCENTAGE OF UK DISABILITY-ADJUSTED LIFE-YEARS.

Tobacco smoking (including second-hand smoke) High blood pressure High body-mass index Physical inactivity and low physical activity Alcohol use Diet low in fruits High total cholosterol Diet low in nuts and seeds High fasting plasma glucose Diet high in sodium Drug use Ambient particulate matter pollution Diet low in vegetables Diet high in processed meat Diet low in seafood omega-3 fatty acids Diet low in fibre Occupational low back pain Diet low in whole grains Diet low in polyunsaturated fatty acids Lead exposure -1

Disability-adjusted life years (%) Cancer Cardiovascular and circilatory diseases Chronic respiratory diseases Cirrhosis Digestive diseases Neurological disorders Mental and behavioural disorders Diabetes, urogenital, blood and endocrine Musculoskeletal disorders Other non-communicable diseases HIV/AIDS and tuberculosis Diarrhoea, lower respiratory infections, lower respiratory infectious diseases Neglected tropical diseases and malaria Maternal disorders Neonatal disorders Nutritional deficiencies Other communicable diseases Transport injuries Unintentional injuries Intentional injuries

Source: Murray, Lancet 2013-381: 997-1020

The background In 2001 the number of adult smokers dipped below a quarter for the first time – half what it was in the mid 1970s – momentum slowed in the 1990s but there has been a steady downward trend since the turn of the century. Today about one in four men (24 per cent) and one in six women (17 per cent) are smokers.2 However, the figure masks the gap seen between different income groups – for example smoking prevalence is twice as high among people in routine and manual occupations than those in managerial or professional jobs. The pattern means smoking is the single biggest cause of inequalities in death rates between the richest and poorest. Cigarette smoke contains 4,000 different chemicals which damage the body in many different ways. Smoking is linked to more than 50 diseases, including heart disease, strokes, respiratory problems and a range of cancers. But it is not just smokers who are at risk. The people around them are also vulnerable, especially children, because of the risk of second-hand smoke. Research shows the offspring of parents who smoke are more likely to suffer respiratory problems, such as bronchitis and pneumonia as well as problems of the ear, nose and throat, including glue ear. The Government has set clear targets for reducing smoking rates. Its strategy published in March 2011 said the ambition for the end of 2015 should be to see smoking levels for adults reduce to 18.5 per cent (from 21.2 per cent at that time), 15-year-olds to 12 per cent (from 15 per

cent) and pregnant women to 11 per cent (from 14 per cent).3

Did you know? • One in five adults smoke – a figure which has dropped by about 25 per cent in the last decade.4 • The average number of cigarettes smoked per day among current smokers was higher for men (12.5 per day) than women (10.8 per day); older smokers had higher consumption.5 • Smoking prevalence is higher in certain ethnic groups, such as Bangladeshi and Pakistani men and Irish men and women.6 • Unemployed people (39 per cent) are twice as likely to smoke as those in employment (21 per cent).7 • Twenty two per cent of 11 to 15 year olds in 2013 reported that they had tried smoking at least once.8 • Some 14 per cent of pregnant women say they smoke with rates particularly high among teenage mothers.9 • The 2007 Adult Psychiatric Morbidity Survey that found that 42 per cent of all cigarettes smoked by the English general population are smoked by people with a mental disorder. • People working in routine and manual jobs are twice as likely to smoke as people from professional and managerial occupations.10 • 33 per cent of tobacco is consumed by people with mental health problems.11 • 31 per cent of men and 24 per cent of women who had a limiting longstanding illness were current smokers.12

• Among men, the highest proportion of current smokers was found in the West Midlands and the lowest proportion in the East Midlands and South West.13 • Among women the highest proportions of current smokers were found in the North East and Yorkshire and the Humber, and the lowest proportion in the South East.14 • 35,414 million cigarette sticks and 7,077,000 kg of other forms of tobacco were sold in the UK last year.15

The cost of smoking • The cost to the NHS of treating smokingrelated illness is estimated to be between £2.7 billion and £5.2 billion a year.16 • From March 2012 to April 2013, total expenditure on NHS Stop Smoking Services alone was £87.7 million, almost £63.2 million more than in 2002/3 when expenditure was 24.5 million.17 • Local authorities across England are spending an additional £600 million on social care as a result of smoking-related illness.18 • Taxation of tobacco contributed £9.7 billion to HM Treasury in 2013/14. However, the wider economic costs top £13 billion once factors such as lost productivity, cleaning up of cigarette butts and smoking-related house fires are taken into account.19

have failed to keep pace with rises in income. 20 • The loss of productivity and productive output and absenteeism caused by workers taking breaks to smoke and time off for smoking-related illness has been estimated as between £6.1billion and £9.8 billion annually.21 • A conservative estimate of the cost of smoking-related fire is £507 million annually.22 • Around 200 million cigarette butts are thrown away every day and cigaretterelated rubbish is the country’s biggest litter problem – accounting for around 30 per cent of it.23 The cost of clearing these cigarette butts is estimated at £342 million each year.24 • Tobacco smuggling is a significant threat to UK tax revenues. Her Majesty’s Revenue and Customs (HMRC) estimates that duty was not paid on around 9 per cent of cigarettes and around 38 per cent of the hand-rolling tobacco smoked in the UK in 2010/11, with associated revenue losses of approximately £1.2 billion and £0.66 billion respectively. 25

• UK household expenditure on tobacco at current prices has nearly quadrupled from £4.8 billion in 1980 to £18.9 billion in 2013. Nonetheless, cigarettes are much more affordable today than they were in the 1990s because tobacco duty rates

Tackling tobacco – a local approach There is now less than 100 days until the country votes for a new government – one that will determine the future of our nation until the end of the decade and beyond. Launched in July at the 2014 LGA conference, ‘Investing in our nation’s future: The first 100 days of the next government’ sets out local government’s offer on what the new government will need to do – in its first 100 days – to secure a bright future for the people of this country. The LGA is calling for a new relationship with central government underpinned by three key principles:

We are calling on government to help people live healthier lives and tackle the harm caused by smoking and dependence on nicotine by reinvesting a fifth of existing tobacco duty in preventative measures and supporting licensing and trading standards departments to better tackle the black market in tobacco. We believe that health and crime reduction are important issues for the people we serve and that making the link between the taxes and duty they pay and the human and financial cost of these issues will be welcome. Additional resources would enable local councils to respond to the specific health and social care needs of their communities in ways that they know will be effective.

• more devolution of power to elected councillors

“Smoking imposes costs on society, and the government believes it is therefore fair to ask the tobacco industry to make a greater contribution. The government will shortly launch a consultation on introducing a levy on tobacco manufacturers and importers.”

• community budgets would be the preferred mechanism of delivery for government departments • financial settlements should be tied to the lifetime of the parliament for all the public sector.

Rt Hon George Osborne, Chancellor of the Exchequer, Autumn Statement 3 December 2014

FIGURE 2: PUBLIC SUPPORT FOR ANTI-SMOKING MEASURES

WHAT, IF ANYTHING, DO YOU THINK THE GOVERNMENT SHOULD DO ABOUT SMOKING?

92%

PROVIDE INFORMATION INCENTIVISE PEOPLE TO STOP SMOKING

73%

BAN SMOKING IN PUBLIC PLACES BAN SMOKING ALTOGETHER MAKE TOBACCO COMPANIES INVEST AGAINST SMOKING

74% 45% 78%

Source: Mludzinski, T (2012) Presentation: ‘Public spending, behaviour change and government intervention’: Ipsos Mori: www.ipsos-mori.com/Assets/Docs/Events/CIPFA_conference_TMper cent20Presentation_040712.pdf

Tobacco duty receipts Duty on tobacco raised ÂŁ9.7 billion for the Exchequer in 2012/13. The graph below shows tobacco receipts and the percentage of GDP over the last five years. The most likely reason for the fall of 1.6 per cent from the previous year is downtrading by consumers to cheaper tobacco products plus the slight decline in smoking consumption which has recently been levelling out. FIGURE 3: DUTY ON RECEIPTS

ÂŁbn 12.0 10.0 8.0 6.0 4.0 2.0 0

2009-10

2010-11

2011-12

Cash revenue

2012-13

2013-14

Percentage of GDP

Source: HM Revenue and Customs, Monthly and Annual Historical Record, 21 November 2014: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/376863/20141112_ Octreceiptsbulletin.pdf

Reducing by five percentage points the 80,000 deaths from causes attributable to smoking would save 4,000 of the lives lost each year to smoking. Helping smokers stop is extremely cost-effective. The cost per life year saved of a comprehensive treatment service is about £900. Many health economists and officials rate a treatment that costs from £5,000 up to £10,000 per life year saved as very good value for money.26 Stopping smoking significantly reduces the risk of over 50 diseases, of which over 20 are fatal. For example, the risk of myocardial infaction or stroke falls by around a half within the first two years after stopping smoking. Relieving the NHS of just five per cent of the burden of treating smoking-related illnesses would save between £135 million and £260 million a year. Cutting down by five per cent the loss of productivity and output and absenteeism caused by workers taking breaks to smoke and time off for smoking-related illness could save between £305 million and £490 million. A five per cent reduction in smokingrelated fire could save over £25 million. Cutting out five per cent of the cost of clearing litter made by cigarette butts would save over £17 million.

What needs to be done? “…[T]he future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.” “If the nation fails to get serious about prevention then recent progress in healthy life expectancies will stall, health inequalities will widen, and our ability to fund beneficial new treatments will be crowded-out by the need to spend billions of pounds on wholly avoidable illness.” The NHS Five Year Forward View, October 2014 NHS England’s five-year forward view report sets out how the health service will tackle rising demand and funding constraints. The report said the NHS had been “prone to operating a ‘factory’ model of care and repair” with “underdeveloped advocacy and action on the broader influencers of health and wellbeing”. In the report, NHS England warned that without a greater focus on prevention, “recent progress in healthy life expectancies will stall, health inequalities will widen, and our ability to fund beneficial new treatments will be crowded out by the need to spend billions of pounds on wholly avoidable illness”.

The NHS agreed with the LGA that “English mayors and local authorities should be granted enhanced powers to allow local democratic decisions on public health policy that go further and faster than prevailing national law – on alcohol, fast food, tobacco and other issues that affect physical and mental health.” The Government’s tobacco control plan for England said that, in relation to smoking, the focus should spread across six internationally-recognised strands: • stopping the production of tobacco

Local government’s role in tackling smoking and nicotine dependency “Local authorities have a responsibility to address health inequalities, and smoking is the primary reason for the gap in healthy life-expectancy between rich and poor.” Fair society healthy lives [The Marmot review].

• making it less affordable • effective regulation • helping smokers to quit • reducing exposure to second-hand smoke • effective communications. Clearly, some of these strands are heavily influenced by national policies and agencies, for example the tax system plays a key role in price. However, the last four strands of the strategy place local government at the heart of the fight against smoking at a community level. The strategy said that this should involve much more than just providing local stop smoking services or enforcing smoke free legislation, calling on councils to develop partnerships in tobacco control that adopted a mix of “educational, clinical, regulatory, economic and social strategies”.

It is generally agreed that a multi-stranded approach to tackling smoking and its effects is the most effective, as the Government’s strategy recognises. Local councils at the heart of their communities and as leaders and facilitators of local partnerships are strategically placed to be at the forefront of such an approach. They host the Health and Wellbeing Board for their area and they are key partners in the local Community Safety Partnerships. In addition, a number of their statutory functions are essential to an expert coordinated role. Public health As the public health authority for the area, the local council has the expertise and experience to ensure that services are in place to help smokers to quit. Council elected members and officers know the communities they serve and how they are made up. This makes it easier for them to target the groups in the population who are known to smoke the most and who find it most difficult to give up.

Public health staff have the background to understand the evidence for what interventions will be most effective with their communities. They also have working relationships across the council with key colleagues, such as environmental health and trading standards teams and with the local NHS and pharmacies. These relationships make a population-level multi-agency approach a real possibility. Trading standards Local authority trading standards’ teams have powers to stop the supply of counterfeit cigarettes and to tackle sales from pubs, mobile traders and people’s homes. They can also tackle underage sales and illegal advertising. They work with Her Majesty’s Revenue and Customs and with the police through local Community Safety Partnerships. Education Local authorities have close working relationships with schools and colleges in their areas and are now responsible for the school nursing service and the child measurement programme. This gives them a unique conduit to children and young people and a means of communication about the dangers of smoking and how to give up. Communicating with communities Councils have many links into local communities of place (eg through ward councillors), of identity (eg through churches, mosques and community groups) and of interest (eg through council-funded voluntary groups, sports and leisure centres).

In addition, they communicate directly with all residents in their area on a regular basis and often through websites and social media. This gives them many opportunities to promote the no smoking and stop smoking messages and help and support services. “Local government has a critical role in the fight to reduce smoking rates and thereby improve health and save lives, especially within the poorest communities.” Action on Smoking and Health, The case for action on tobacco use and smoking

What could local councils do with more resources? Councils already do a very extensive range of work to tackle smoking, from public health smoking cessation services to enforcing advertising regulations, stopping underage sales and investigating and prosecuting producers and purveyors of counterfeit and illegal tobacco products. However, much of the £2.8 billion budget for public health is spent on the essential services we are legally required to provide such as sexual health services which take up 25 per cent of the health budget and drug and alcohol services (30 per cent) which are predominantly demand led. Much of the health budget goes into costly treatment, leaving relatively little to be spent on prevention and innovative, multi-stranded approaches.

Below is a list of activities which we would like to take on to supplement our current work, if we had additional resources. • We could take the lead in investing in a concerted effort to develop a multifacted smokefree strategy for our area, involving the council, the NHS, schools, colleges, local employers, the fire service, the police and local retailers. • We could get together with neighbouring councils on tobacco control, working over large geographical areas to achieve greater efficiency and effectiveness. • We could undertake much more preventive work, eg by working in schools, colleges and other community settings to ensure that children and young people understand the harm that smoking causes, how addictive it is and receive help to give up if they need it.27 We could help schools and colleges develop a ‘whole-school’ or organisation-wide smokefree polcy in consultation with young people. We could involve local celebrities in this work using personal testimonials that children and young people can relate to. • We could make more imaginative use of social and other media and the internet to get across the message about the dangers of smoking, for example by making promotional presentations targeted at particular groups in our communities, such as pregnant teenagers, or ethnic groups with a high proportion of smokers, involving these groups in developing these message and make them available through the media that they most use. 12

• We could train more council staff and other community workers in public health, environmental health, trading standards, housing to ‘make every contact count’ by giving information about the deadly dangers of smoking, stop smoking advice and referrals for support • We could work through community mental health teams and child and adolescent mental health teams to make mental health services smoke free for children, young people and adults with mental health problems, who account for 30 per cent of smokers in England. • We could further use our own role as one of the largest employers in each area and work through the forums we have established with local employers to develop and disseminate smoking cessation programmes in workplaces, including those employing manual workers and shift workers, who are most likely to smoke. We could fund mobile units to support this work. • We could invest more in rigorous evaluation of smoking cessation interventions among particular groups in our communities to understand which are most effective and where our efforts are most fruitfully targeted. • Our trading standards teams could do more proactive work with local retailers to ensure they understand the legislation prohibiting under-age sales of tobacco, how to avoid illegal sales and request proof of age; and what fines they could face, giving examples of successful local prosecutions.

• We could follow the recommendations of the House of Commons Public Accounts Committee’s 2013 report on tobacco smuggling and work more closely with HMRC to cut public use of illicit tobacco in the UK.28 • Councils could explore the impact of e-cigs on reducing tobacco dependency and tackle the sale of counterfeit and underage sales of these items.

With more funding to prevent and help people to stop smoking, every council could follow all of the examples below as part of a much wider coordinated approach. In Liverpool, attempts have been made to break the cycle of parents and children who smoke by working closely with children’s centres, which coordinate early education, childcare health and family support in the most deprived areas. Evaluation of the scheme has shown that just over half of smokers accept a referral to the service – this includes both help with quitting and support in making homes smoke free through steps such as smoking outside. To increase awareness in the London borough of Tower Hamlets, the NHS and local council have been working in partnership to highlight the dangers of shisha smoking as well as reminding smokers and businesses that the ban on smoking in public places applies to them. Information leaflets have been distributed to businesses by environmental health officers, while an interactive website has been set up that explains the risks. Talks have also been given to local students. In the North East, North West, Yorkshire and the Humber regions trading standards, public health and stop smoking services, local police, HMRC and the UK Border Agency have come together to tackle easily available and cheaply priced illicit tobacco. Since the programme started in 2009 illegal tobacco use has decreased by a quarter.

NOTES 1. Health and Social Care Information Centre, 2014, Statistics on Smoking 2014: www.hscic.gov.uk/catalogue/ PUB14988/smok-eng-2014-rep.pdf – most of the statistics in this document are taken from this publication. Where they are not, the source is given. 2. Health Survey England 2013 statistics on smoking: www.hscic.gov.uk/ catalogue/PUB16076/HSE2013-Ch8adult-cig-smo.pdf 3. HM Government, 2011, Healthy Lives, Healthy People: A Tobacco Control Plan for England: www.gov. uk/government/uploads/system/ uploads/attachment_data/file/213757/ dh_124960.pdf 4. Health Survey for England 2013 www. hscic.gov.uk/catalogue/PUB16076/ HSE2013-Ch8-adult-cig-smo.pdf 5. Health Survey for England 2013 www. hscic.gov.uk/catalogue/PUB16076/ HSE2013-Ch8-adult-cig-smo.pdf 6. Health Survey for England 2013 www. hscic.gov.uk/catalogue/PUB16076/ HSE2013-Ch8-adult-cig-smo.pdf 7. Health Survey for England 2013 www. hscic.gov.uk/catalogue/PUB16076/ HSE2013-Ch8-adult-cig-smo.pdf 8. Health Survey for England 2013 www. hscic.gov.uk/catalogue/PUB16076/ HSE2013-Ch8-adult-cig-smo.pdf

9. Health Survey for England 2013 www. hscic.gov.uk/catalogue/PUB16076/ HSE2013-Ch8-adult-cig-smo.pdf 10. Health Survey for England 2013 www. hscic.gov.uk/catalogue/PUB16076/ HSE2013-Ch8-adult-cig-smo.pdf 11. Public Health England, 2014, From evidence into action: opportunities to protect and improve the nation’s health: www.gov.uk/government/ uploads/system/uploads/attachment_ data/file/366852/PHE_Priorities.pdf 12. Health Survey for England 2013 www. hscic.gov.uk/catalogue/PUB16076/ HSE2013-Ch8-adult-cig-smo.pdf 13. Health Survey for England 2013 www. hscic.gov.uk/catalogue/PUB16076/ HSE2013-Ch8-adult-cig-smo.pdf 14. Health Survey for England 2013 www. hscic.gov.uk/catalogue/PUB16076/ HSE2013-Ch8-adult-cig-smo.pdf 15. www.uktradeinfo.com/statistics/pages/ taxanddutybulletins.aspx 16. Health Survey for England 2013 www. hscic.gov.uk/catalogue/PUB16076/ HSE2013-Ch8-adult-cig-smo.pdf 17. Health and Social Care Information Centre, 2013, Statistics on NHS Stop Smoking Services, England: www. hscic.gov.uk/catalogue/PUB12228 18. LocalGov, ‘The care costs of smoking’, 15 October 2014: www.localgov.co.uk/ The-care-costs-of-smoking/37422

19. Policy Exchange, 2010, Cough up: balancing tobacco income and costs in society: www.policyexchange. org.uk/images/publications/ coughper cent20upper cent20-per cent20marchper cent2010.pdf 20. Health Survey for England 2013 www.hscic.gov.uk/catalogue/ PUB16076/HSE2013-Ch8-adult-cigsmo.pdf 21. Ibid. 22. Ibid. 23. Incpen, 2014, Litter is everyone’s problem: www.incpen.org/ displayarticle.asp?a=1190&c=5

27. Smoking prevention in schools reduces the number of young people who will later become smokers according to a systematic review published in the highly-respected Cochrane Library: www.phc.ox.ac.uk/ news/smoking-prevention-in-schoolsdoes-it-work 28. House of Commons Public Accounts Committee, 2013, HM Revenue and Customs: Progress in tackling tobacco smuggling: www.publications. parliament.uk/pa/cm201314/cmselect/ cmpubacc/297/297.pdf

24. Policy Exchange, op.cit. 25. Health Survey for England 2013 www. hscic.gov.uk/catalogue/PUB16076/ HSE2013-Ch8-adult-cig-smo.pdf 26. Campaign for Tobacco-Free Kids, ‘Promoting Stop Smoking Services’: http://global.tobaccofreekids.org/files/ global_dialogue/cdt11.pdf

Local Government Association Local Government House Smith Square London SW1P 3HZ Telephone 020 7664 3000 Fax 020 7664 3030 Email info@local.gov.uk www.local.gov.uk ÂŠ Local Government Association, January 2015

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