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SMOKING KILLS A CRITIQUE SUBMISSION TO DEREK WANLESS

A report by

The Royal College of Physicians, and

Action on Smoking and Health

12th January 2004

SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS


Content of Smoking Kills 1. The key objective of Smoking Kills was to reduce the prevalence of smoking by a combination of population strategies (advertising ban, high tax, health education, smokefree public places) and individual strategy (smoking cessation services) and so improve population health and reduce health inequalities. 2. Smoking Kills aimed to implement these strategies by partnership rather than legislation, but with an undertaking to monitor outcomes closely, take tougher action on strategies that did not prove effective, and fund research into areas of uncertainty. 3. Smoking Kills defined targets for reductions in smoking prevalence against which its success should be judged. These targets were generally modest, and for adults required only a continuation of the secular trend since the early 1960s.

Implementation of Smoking Kills 1. Smoking cessation services have been widely implemented, are generally effective and successful, and provide excellent value for money. 2. The advertising ban has been implemented, but by private members bill after having been dropped from the governments legislative programme. 3. Health education and advertising has been funded, but was slow to be implemented, and was relatively underfunded. 4. The government has not delivered its policy of continued tax increases at above the rate of inflation. 5. There has been minimal progress in making public and work places smoke free. 6. Smoking prevalence figures have fallen slightly since Smoking Kills, in line with its own modest targets, but not sufficiently to have a marked impact on public health or social inequalities in health. 7. There has been no formal review of progress since Smoking Kills was published and little research progress.

What should be done now 1. Legislate to make all workplaces (and hence most public places) smoke free. 2. Progressively increase the real price of cigarettes to smokers. 3. Reform the regulation of all nicotine products to ensure that smokers who cant quit using nicotine are provided with safer nicotine formulations than cigarettes. 4. Continue to fund cessation services to ensure that high quality services are available to all smokers who want to quit. 5. Engage doctors and other health professionals more effectively in addressing smoking as a medical problem, and intervening to reduce it. 6. Sustain a high frequency and intensity of mass media campaigns to encourage smokers to stop and to denormalise smoking. 7. Enforce the advertising ban and close loopholes as they appear 8. Set new and much more ambitious targets for reducing prevalence based on what international evidence suggests could be achievable.

Other changes necessary to ensure successful implementation of the fully engaged scenario and reduce health inequalities 1. Set up an independent research and advisory group to update Smoking Kills using high level input from experts in the field. This should be regularly revised and updated in the light of experience and, in particular, in the light of the progress made in reducing smoking prevalence. 2. Establish a Tobacco and Nicotine Regulatory Authority to rationalise regulation of nicotine products and implement effective harm reduction strategies. 3. Make Public Health a cabinet-level appointment, to facilitate cross-departmental policy integration on smoking and other public health priorities. 4. Increase the scope and infrastructure of public health practice to engage more actively in population measures to improve health.

1.

INTRODUCTION

This report has been prepared in response to a meeting between Derek Wanless and John Britton (RCP), and Deborah Arnott (ASH), on 17th December 2003. As requested the report addresses: the content of the 1998 White Paper Smoking Kills; the subsequent implementation of the White Paper policy; and what should be done in future to reduce smoking prevalence and harm.

Set out below is a more detailed analysis at individual policy level.

2.

THE 1998 WHITE PAPER, SMOKING KILLS


Soon after coming to power in 1996, the government made a strong public statement of intent to tackle smoking1;2. Smoking Kills, the white paper published in December 19983, was the first policy statement on tobacco control published by any UK government. Smoking Kills declared that government has a clear role in tackling smoking and a responsibility to protect children from tobacco; and that government intended to ensure that those who do not smoke are protected from those who do, and that the number of people smoking in Britain falls3. Other objectives included reducing smoking in young people, helping adults to give up smoking, and to offer particular help to pregnant women who smoke. The main domestic policy initiatives were to: 1. Ban advertising and sponsorship, and restrict promotion inside shops 2. Reduce affordability of cigarettes by increasing tax by at least 5% a year in real terms 3. Introduce specialist smoking cessation services throughout the UK 4. Develop a sustained and coordinated health education campaign 5. Restrict tobacco smuggling 6. Implement a voluntary charter on smoking in public places which is sensible, practical, and will deliver real improvements 7. Consult on an approved code of practice on smoking at work 8. Fund research into specified uncertainties in evidence on smoking and smoking cessation, and to monitor and evaluate the above initiatives

Other initiatives, including options to reduce under-age sales, introduce ID cards for children, tougher penalties for retailers who sell to children, and a new code on the siting of cigarette vending machines were also discussed. Targets were set to reduce smoking; the targets for 2005 (relative to values in 1996) were to reduce prevalence o o o in children from 13% to 11% in adults from 28% to 24% in pregnancy from 23% to 18%

Smoking Kills made it clear that the government intended to achieve these objectives, where possible, by partnership rather than by legislation. However the government undertook to monitor outcomes closely and to consider tougher action where measures prove less effective than hoped, including legislation if action in partnership failed to deliver.

Smoking Kills, and the public statements preceding publication, promised a serious commitment to reducing smoking prevalence through a package of population and individual strategies. As a result, and because of the undertaking to monitor progress and take tougher measures where necessary, Smoking Kills was widely welcomed by the health community.

3.

IMPLEMENTATION OF SMOKING KILLS

Five years later, it is clear that some of the policies outlined in Smoking Kills have been implemented and are delivering results, whilst others have not been implemented, or are failing.

The areas in which policy has been implemented are: The tobacco advertising ban: this was implemented, though by more circuitous means than originally anticipated, due to lack of commitment from the Government. The bill was brought forward late in the first Labour term, ran out of time before the 2000 election, was dropped from the Queens speech for the next parliamentary session, and enacted only as a result of a private members bill. As a result the ban did not come into force until February 2003. The debacle over the backtracking on the ban on sponsorship in Formula 1 adversely affected the credibility of the strategy. Smoking cessation services: services providing behavioural support and pharmacotherapy have been established as standard NHS services throughout the UK, and last year engaged with over 230,000 smokers4. Nationally they have achieved success in line with what was predicted from the research literature. Smuggling: The availability of smuggled (and therefore lower price) cigarettes in England has fallen from 21% of all sales in 2000/1 to 18% in 2002/3. Controlling smuggling needs to continue to be a priority for HM Customs and Excise to ensure that the real price of cigarettes on the street does not decline.

The areas in which government has failed to deliver on White Paper policy, or in which policy has failed are: Tax: Tax was increased by 5% in real terms for 1999 and 2000, but by inflation only since 2001. The affordability of cigarettes has remained stable since 19994, and cigarettes are more affordable now than in the 1960s. The tax escalator of

5% was dropped as a result of concern about the rapidly expanding level of smuggling of cigarettes into the UK. Now that this is under control the Government should re-introduce the escalator. Smokefree workplaces: The approved code of practice was sent out for consultation, as promised, but that process was completed in 2000 when the ACoP was sent to Ministers to be signed off and there has since been no further progress. It is still not clear whether the government intends to proceed with it, but civil servants in several departments have advised us that encouraging smokefree workplaces is not a current priority. Meanwhile, the proportion of fully smoke free workplaces in Britain, having increased from 40% in 1996 to 48% in 1999, has since increased by only 2%, to 50% in 2002. Smokefree public places: Smoking remains common in many public places. The voluntary public places charter for the hospitality industry has in particular failed to deliver significant reductions in passive smoke exposure in pubs. By April 2003, more than one in three (36%) pubs were still completely noncompliant with the charter, whilst of those that were, nearly half (47%) still allowed unrestricted and unventilated smoking throughout5. Only 8% of pubs provide separate smoking areas with ventilation5. Almost none are smokefree. Underage sales: Progress is reported to have been made in policing underage sales4 and in restricting vending machine location. However there is no evidence that young people who want to obtain cigarettes find it any less difficult to do so now than before these measures were implemented.

Other aspects of implementation that have been slow or problematic include: Public education: There was a delay in setting up the campaigns, and total spending on education has been low at between 12 and 15 million a year from 1999 to 2003, of which less than 60% has been spend on advertising campaigns. The net spend on advertising is well under 10% of that spent on advertising and promotion by the tobacco industry during this period. So far there has not been any detailed research into the effectiveness of these campaigns, though previous evidence indicates that if sustained at a high intensity and frequency they can be expected to reduce smoking prevalence by about 1%6. It is not clear whether any such research is being carried out comprehensively as opposed to one off feedback on the impact of individual campaigns on public perceptions. It would, for example, be interesting to compare the effectiveness in England with Wales or Scotland where campaigns have not been run. The education budget for this year has been increased to 39 million. The NHS Quitline is still not as efficient or effective as it should be and, for example, does not proactively suggest getting help in the form of drugs or services. Cessation service funding: funding for services was allocated for a fixed three year period. Prevarication and/or brinkmanship over whether and by whom funding would be awarded for subsequent years, in early 2002 and again in 2003, caused considerable job insecurity and loss of good faith amongst cessation service staff. Many of the high quality staff who had established the services were forced to move elsewhere purely because of funding insecurity.

Cessation service monitoring: The government has adopted self-reported cessation at 4 weeks as the main cessation outcome measure for monitoring purposes. Of smokers truly abstinent at 4 weeks less than 30% are likely to be abstinent at one year 7. Self-reported cessation is also far less reliable than measures based on objective validation by exhaled carbon monoxide measurement. Self-reported cessation at 4 weeks is therefore a very poorly representative indicator of true long-term cessation. Cessation service targets: Targets of 800,000 four-week quitters have been set for the three years from April 2003 approximately double the current throughput and likely to be difficult to achieve. Setting unachievable targets demoralises staff and encourages artificial inflation of figures. Cessation service use by health professionals: Health care professionals, and particularly doctors, have generally failed to adopt and implement clinical guidelines on smoking cessation practice8;9 into their routine work and hence to encourage smokers to use the cessation services available to them. According to clinical practice guidelines, all healthcare professionals should be checking smoking status in all consultations, providing brief advice to quit to all smokers, and arranging cessation support for all smokers who want to quit8;9. To date however the available evidence suggests that: Only about one in three smokers recalls advice on smoking cessation from their GP in the past five years10;11. This proportion fell between 1999 and 2002 by 2%, to 35%10 Only 4% of smokers reported in 2002 that they had accessed a stop smoking group in the previous year10 Half of hospitals in Britain still do not provide inpatient smoking cessation counsellors12 The limited audit data available indicate that hospital inpatients who smoke are not systematically identified, or where appropriate referred to smoking cessation services13;14 Doctors in the UK are not trained in clinical aspects of smoking cessation15

This failure to implement basic clinical guidelines on systematic identification and referral of motivated smokers has been and remains a significant obstacle to the success of the cessation services. The consequence is that cessation services are currently failing to deliver at anything like their maximum potential. However, cessation services alone are essentially an individual intervention which will not and cannot be expected to deliver significant falls in prevalence. Achieving this will require strategies that influence smoking behaviour across the general population16 and require commitment right across Government, not just from the Department of Health.

Meeting targets The latest figures available indicate that adult smoking prevalence in 2002 was 25%10 (down 2% since 1999, target for 2005 26%); in children in 2002 10%17 (up

1% since 1999, 2005 target 11%); and in pregnancy in 2000 19%17 (change since 1999 not available; 2005 target 18%). The objective of reducing the difference in smoking rates between non-manual and manual occupational groups has not been met; the difference in prevalence in 2002 was 11%, exactly the same as in 1998, and indeed as in 199017. Smoking in the most disadvantaged groups in society are extremely high, at over 70% in 199618, and there is no evidence that this situation has improved. The government is therefore close to meeting the overall prevalence targets for adults but not in children, not in the most deprived, and very probably not in pregnant smokers, who under-report smoking by about 3%19. These prevalence targets themselves were in any case unambitious in the case of adult prevalence requiring only a continued rate of decline that was less than the average for most of the decades since 1960. Given the magnitude of the health effects of smoking, more ambitious targets are surely appropriate.

Research There has been little reported research into uncertainties in the above policies, and aside from the smoking cessation services, little evidence of monitoring or evaluation of the implementation of Smoking Kills.

4.

OVERVIEW OF ACHIEVEMENTS TO DATE


The policy initiatives in Smoking Kills have been successful in establishing local smoking cessation services, banning tobacco advertising, and reducing tobacco smuggling. The main areas of failure are in influencing the numbers of smokefree workplaces and public places (and almost all enclosed public places are also workplaces), in which there has been very little progress, and in tax, which the government has failed to increase in line with its declared policy in Smoking Kills. The public education campaign has been implemented but at a relatively modest level of investment. The government has to date failed to honour its commitment to assess progress and take tougher action, and if necessary legislate, in these areas of failure. The government has also failed to review progress, deal with failing measures, or incorporate and capitalise on new ideas on harm reduction that have developed since Smoking Kills was produced.

5.

WHERE NEXT?
For the Government to achieve the fully engaged scenario and for its strategy to

reduce health inequalities to succeed it needs to achieve the maximum possible reductions in smoking prevalence, to minimise incident smoking in young people, and minimise harm from nicotine addiction in smokers who prove unable or unwilling to quit. The opportunity to improve public health through these measures is immense on a scale similar to that of some of the major public health reforms of the 19th Century20, but achieving these benefits will require courageous and strong leadership. We suggest (see ASH submission to Wanless for more detail) that it is necessary to implement a comprehensive tobacco control strategy which would : 1. Legislate to make all workplaces (and hence public places) smokefree; 2. Progressively increase the real price of cigarettes to smokers; 3. Regulate to make safe sources of nicotine available to smokers who cannot give up smoking 4. Continue to provide effective treatment services for smokers who want to stop; 5. Engage the healthcare professions in implementing smoking interventions into routine care; 6. Continue and increase investment in long-term mass media and public education campaigns to motivate and encourage quitting and denormalise smoking; 7. Enforce the advertising ban and close loopholes as they appear. 8. Reduce incident smoking by role-model effects of the above strategies 9. Monitor the impact of these policies, and adapt to change 10. Raise the political profile of tobacco control and of public health in general In many cases the policy priorities now are the same as in 1998, and simply require more resolve in implementation. New areas of priority for policy arising since Smoking Kills comprise the engagement of the medical profession in smoking cessation, and harm reduction. All of the available initiatives have individually small effects on prevalence21, but experience elsewhere indicates that collectively, when applied across populations, these small effects can add up to a significant overall impact on prevalence 21;22. The policies that would now reduce, or are highly likely to reduce smoking prevalence and smoking-related disease in Britain are:

1)

Legislate to make all workplaces smoke free Smokefree policies in public are effective in reducing prevalence because they encourage smokers who work or visit to quit smoking, reduce passive smoke exposure to employees and public, and reduce exposure to the smoking role model for young people. Research also shows that smokefree workplace policies help discourage smoking in front of children in the home23. Passive smoke exposure in pubs and restaurants is very high three or more times higher than exposure sustained from living with a smoker24-26. Conventional ventilation and/or designated smoking areas are not effective in preventing exposure27. Introducing smokefree policies at work reduces the absolute prevalence of smoking in the workforce by about 4%. Partial restrictions achieve approximately half of that effect28.

Voluntary restrictions are much less effective than legislation in reducing smoking and passive smoking exposure, particularly for employees in relatively low skill occupations29. Smokefree legislation would therefore help to reduce social inequalities in health. If the approximately 50% of workplaces in Britain that are not already smokefree were to become so, about 320,000 employees in Britain would quit smoking long term. There would be further reductions in prevalence arising from secondary effects of smokefree policy on smoking in visitors to workplaces, and the spouses and families of employees. This policy is highly cost effective, because (in contrast to the introduction of smoking rooms and/or ventilation systems) the cost to the employer is minimal. The cost to society is the cost of providing smoking cessation support to smokers who try to quit costs that should already be covered in the smoking cessation service budget. Policy in the UK now needs to be driven by legislation because the voluntary approach has stalled in general, and failed completely in pubs and bars. An alternative means of implementing smokefree policies that would avoid the need for further new legislation would be to classify environmental tobacco smoke as an occupational carcinogen (as currently classified by the International Agency for Research on Cancer30), thus invoking control under UK COSHH regulations. Since almost all enclosed public places are also somebodys workplace, this would in effect achieve the objective of making public places smokefree.

2)

Increase the real price of cigarettes Increasing the real price of cigarettes decreases cigarette consumption and the prevalence of smoking. Overall, in the UK the prevalence of smoking currently falls by around 0.3% per 1% real increase in price. However this effect varies across socio-economic groups those on high incomes are relatively unaffected by price, but in low income groups the fall in prevalence per 1% increase in price is closer to 1%31. The escalator to increase prices by 5% above the rate of inflation each year was abolished because of concerns about the growing level of smuggling. Now that smuggling has been more effectively brought under control HMT should consider re-introducing the policy of increasing the price of cigarettes above the rate of inflation (a more detailed submission on this will form part of the budget submission to HMT by ASH and other health organisations). The overall elasticity of about -0.3 means that gross tobacco tax revenue is not reduced by the fall in consumption, in fact it increases. This is therefore a highly cost-effective intervention, since the only costs involved are those of preventing and prosecuting smugglers and bootleg distributors. For moral and ethical reasons it is essential that tax increases are backed up by the continued availability of free cessation services to help smokers to quit. It is also important to make the smoking public well aware of a policy of progressive tax increases, to stress the longer term commitment to making cigarettes unaffordable and thus reinforce the financial benefits of quitting as soon as possible.

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3)

Make alternative and safer sources of nicotine available to smokers Smokers smoke, above all else, because they are addicted to nicotine7. 80% of smokers making an attempt to quit will fail in that attempt. Many will go on to further attempts and eventually succeed, but there are also many who will prove unable to overcome their addiction in the context of currently available cessation support. There is also a consistent hard core of up to about 4 million smokers in Britain who declare that they do not intend to quit smoking10. Half of all smokers who cannot or will not quit smoking will die as a consequence of their smoking. These smokers need a safer source of nicotine, and have a basic right to access the safest nicotine products32. The current legal framework favours cigarettes over all other nicotine products, and therefore perpetuates the use of cigarettes as the most common source of nicotine used in society33. The current regulation of NRT as a medical therapy presents a significant obstacle to the commercial development of safe and acceptable alternative clean nicotine products for smokers, as such products would not be licenced under current regulations34. These regulatory obstacles need to be removed, and replaced with regulation that favours and encourages the development, promotion, pricing and retailing of safe nicotine products in direct competition with and at significant advantage to cigarettes33;34. The likely impact of these measures is unknown, and there is no international precedent. However, pure nicotine is for practical purposes a safe drug, far safer than tobacco smoke7, and it is therefore highly unlikely that more widespread use of medicinal products would have anything other than a beneficial effect on public health33;35. Consideration needs to be given to increasing market freedoms to tobacco products that are not associated with the major health risks of smoked tobacco, such as oral snuff (currently banned in the EU but this is subject to a legal challenge)36;37. Experience of these products in other countries indicates that they can provide an acceptable (and less dangerous) alternative to cigarettes for up to a third of male smokers 38;39 Experience of smokeless tobacco in Sweden has been strongly favourable to the public health38;39 but there is no experience of the impact of de novo introduction of smokeless tobacco products on smoking prevalence and harm reduction. The effect of introducing smokeless tobacco products must therefore be carefully monitored and supervised40. Ideally this should be achieved for all nicotine products either by bringing their control together under an existing control agency, such as the Food Standards Authority or Medicines Control Agency, or preferably a stand-alone nicotine and tobacco authority with a remit to minimise the proportion of regular nicotine users in society, and amongst them, the proportion regularly obtaining nicotine from smoked tobacco33;41. The cost of this initiative should be charged to the tobacco industry, on the polluter pays principle, for example through a system of licencing.

4)

Continue to provide smoking cessation services for all smokers Smoking is a chronic, relapsing, addictive behaviour. It is therefore unethical to tax or impose other restrictions on smoking without making high quality cessation support available.

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Smoking cessation interventions providing behavioural support, counselling and pharmacotherapy are all effective, and best practice (regular counselling support and pharmacotherapy) increases the chance of sustained long-term cessation in any quit attempt by a factor of six or more9;42;43. All smoking cessation interventions provide excellent value for money, costing less than 1000 per life year saved, which is better than most other interventions in medicine44;45, and far better than most interventions recommended to date by NICE46. It is important that cessation services deliver the highest level of cessation support acceptable to each individual smoker, and to as many smokers as possible. Services should therefore be available as widely as possible, to achieve greater population reach without compromising on the intensity of support provided. Any targets imposed on smoking cessation services should take account of the need to deliver a range of services. The current high targets on numbers of smokers setting a quit date and achieving four week self reported cessation may drive services to provide low intensity, high reach services to the disadvantage of more intensive options. Inappropriate targets are also a significant threat to staff morale, to the maintenance of quality as well as quantity, and to valid reporting of results.

5)

Integrate smoking cessation into routine health care delivery. Smoking cessation interventions are still not a routine and systematic component of health care delivery yet are much more effective in reducing disease risk than most other current routine medical practices. For example, smoking cessation halves the risk of recurrence of myocardial infarction, a much greater and more cost-effective impact than that achieved by other routine interventions such as therapy with aspirin, beta blockers, ACE inhibitors or statins, but in clinical practice is the least likely intervention to be applied. Over 80% of statin prescribing in primary prevention of myocardial infarction in primary care populations is indicated solely by smoking47. Smoking cessation is the only intervention that changes the natural history of chronic obstructive airways disease or reduces the risk of lung cancer, but only half of all UK chest specialists has direct access to a smoking cessation counsellor 12. Health professionals, and particularly doctors, have yet to embrace the concept of nicotine addiction as a medical problem, and particularly as a problem that should be given at least the same priority as other preventive interventions. The fact that the BMA conference in 2000 voted against the provision of NRT on NHS prescriptions is an indication of the scale of this professional misconception48. A major programme of education for health care professionals, with the intention of engaging them in implementing good cessation practice 8;9, is now essential. This is necessary at undergraduate 15 and postgraduate levels. Smoking cessation needs to be fully integrated as a high priority into clinical guidelines for all chronic diseases influenced by smoking including cardiovascular disease, respiratory disease, diabetes, and many others. Targets for smoking cessation numbers may now be more effective if applied to the clinicians who see the great majority of patients who smoke, instead of simply to the services providing them with cessation support. Targets or other incentives should perhaps instead be used to increase: o The proportion of smokers advised to stop in GP and hospital consultations

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o o

The proportion of smokers in the local population who use the services The 6-month as well as the 4-week success rates of stop smoking services, with carbon monoxide validation where possible. These outcomes focus more appropriately on areas that are under the control of the health professionals concerned, and reflect the quality of the service provided.

6)

Public education and mass media campaigns Paid mass media advertising campaigns are effective means of reducing smoking in all socio-economic groups49-51, but they need to be sustained and invested in sufficiently to give a high media weight. It remains important to maintain varied and effective public education initiatives on smoking effects and stopping smoking, with telephone support for further information to individuals expressing interest in quitting. Advertising also needs to continue to address smoking in the home and exposure of children; self-enforced restrictions on smoking at home are effective in reducing exposure to children but are currently imposed by less than 20% of households52. Advertising can also reduce incident smoking in young people53. Graphic health warnings on cigarette packs are also effective54 and the government should seek to introduce these in line with the new directive at the earliest possible opportunity. It is also important to act to reduce the branding and perceived positive image of cigarette pack designs, for example by requiring cigarette packaging to be generic. Public education campaigns can provide excellent value for money, costing under 1000 per life year saved44.

7)

Enforce the advertising ban and close loopholes The new tobacco advertising and sponsorship legislation needs to be carefully monitored and any loopholes closed quickly. The tobacco industry will always look for opportunities to promote its products and exploit loopholes in legislation or other opportunities wherever possible There are current weaknesses in monitoring and control of below the line promotions by the industry. The industry should also be prevented from researching how best to target young people and start them smoking. Other examples include product placement of cigarettes in feature films and TV programmes aimed at or attracting youth audiences.

8)

Reduce incident smoking All of the available evidence suggests that preventing experimentation with cigarettes by adolescents is difficult. The general consensus view is that the most effective way to reduce incident smoking is to reduce exposure to smoking role models and hence the perception of smoking as an attractive adult behaviour. The recent sustained fall in youth smoking in California, following the introduction of systematic tobacco control measures aimed at adults, supports this view55. Strong non-smoking policies at school also reduces youth smoking56, possibly by reducing contact with other smokers57.

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9)

Monitor policy and adapt to change The above policy recommendations are made in good faith to state what on current knowledge are the most effective, or potentially most effective, individual and population strategies to reduce to burden of smoking-related disease in society. They need to be included in an updated Smoking Kills which should be developed by an independent research and advisory group and designed to help achieve the fully engaged scenario. Once completed it should then be regularly revised and updated in the light of the progress in reducing smoking prevalence. It is therefore crucially important to measure the effect of these policies carefully, by regular monitoring of smoking behaviour. It is also essential to identify problems in implementation and remedy these quickly. All of the above requires adequate investment in the management teams to implement the policies, and in effective and responsive research. Historically, investment in tobacco policy implementation has been limited to the Department of Health and has been inadequate.

10)

General public health policy and smoking Smoking has been a recognised major public health problem for 50 years or more, but smoking prevention has not been and in many cases is still not a major priority in relation to other public health activity. This is clearly a failure of policy and practice, arising at least in part from the inevitable pressure to deliver health services for sick people now, to the detriment of investment in future prevention. This imbalance needs to change to afford much greater priority to the prevention of smoking, obesity and other avoidable major causes of chronic disease. Implementing effective public health policy requires strong political leadership and cross-departmental policy integration, particularly in relation to tobacco. In the case of Smoking Kills, implementation was the responsibility of the Department of Health but the proposals cut right across Government from HMT to the Department for Work and Pensions and the DTI. The Department of Health delivered the measure in its direct control smoking cessation services but where other departments were involved, progress has tended to be much less rapid. To help to overcome these difficulties, public health should be represented and budgeted as a separate ministerial post at cabinet level with crossDepartmental responsibility.

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