4. Government, society and industry

The aim: to continue to reduce significantly the harm caused by tobacco across all communities in Scotland.

To achieve the aims set out in Beyond smoke-free, we need the right targets, policies and funding mechanisms in place.  A relatively small investment in tobacco control has returned a real public health dividend over the past decade.   We have developed important partnerships and learned lessons which are useful far beyond our borders.

While the responsibility for our nation's health must be shared, the responsibility for tobacco harm rests squarely with the tobacco industry.   Imperial Tobacco - just one of the big four multinational tobacco companies, and owner of the biggest selling brand in Scotland - reported profits of £2.6 billion in November 2011, a 4.4% increase from the previous year. The industry must be held more accountable for its activities.

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Short term measures

• We need a comprehensive equality-proofed national tobacco control strategy with clear goals, challe nging targets, a robust evaluation programme, and a research strategy to underpin all areas of work in progress (including work on reducing health inequalities, tobacco and cannabis and harm reduction).
• We must ensure that every local area in Scotland has a comprehensive multi-agency tobacco control strategy.
• We must have committed Government funding to sustain national tobacco control co-ordinating mechanisms and enhance the effectiveness of ongoing tobacco control partnership work in Scotland, ensuring the full involvement of service users, members of the public, practitioners and other stakeholders.
• Through the UK, we are signed up to implement the international Framework Convention on Tobacco Control (FCTC). The Scottish Government should provide leadership through transparent reporting on Scotland's progress, and through committing to publish information about all contacts with the tobacco industry or its vested interests as required under Article 5.3 of the FCTC.
• 4 in 10 fire deaths are attributed to smoking materials .  Standards are being developed for fire safer cigarettes to be available throughout the European Union from 2011.  We need to support speedy progress, while ensuring that fire safer cigarettes do not provide an opportunity for the tobacco industry to influence health policy or increase its customer base.

Medium term measures

• We need the Scottish Government to continue to influence UK level tobacco control issues, and to report on what it is doing to encourage speedy progress on vital reserved matters.
• We must encourage the UK Government to establish regulation of tobacco that is commensurate with the level of harm caused and to regulate all aspects of promotion, marketing, information provision, packaging and sale.
• We must encourage the UK Government to increase tobacco industry accountability by requiring better reporting on tobacco ingredients and marketing, promotions, lobbying spend and tax deductions.
• Through Scotland's relationships with Malawi and other tobacco-growing countries, we must seek higher standards of tobacco industry accountability for the conditions of growers and workers.  We must use our international development funds and trade links to support producer countries to move away from dependency on tobacco growing.

Long term measures

• In the long term, we need to ensure that tobacco companies are more accountable for the impacts of their industry, including the possibility of channelling a proportion of tobacco industry profits back into tobacco control activities.

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SHORT TERM

• We need a comprehensive equality-proofed national tobacco control strategy with clear goals, challenging targets, a robust evaluation programme, and a research strategy to underpin all areas of work in progress (including work on reducing health inequalities, tobacco and cannabis and harm reduction).

Rationale:

Scotland's first national tobacco control strategy, 'A Breath of Fresh Air for Scotland' has now been implemented and in many areas it has exceeded expectations. However, there is currently no commitment from the Scottish Government to develop a new tobacco strategy. This remains essential in order to continually and substantially reduce the prevalence of tobacco use and exposure to second-hand smoke in Scotland. As a signatory to the Framework Convention on Tobacco Control, the UK Government is required by its protocols to implement the global minimum standard for best practice in tobacco control. However, parties are encouraged to implement measures beyond those required, on the basis that comprehensive tobacco control programmes lead to greater reductions in both smoking rates and exposure to second-hand smoke.  

a. Challenging targets

Different countries take a different approach to the setting of targets. In Finland, for example, the Government has become the first in the world to say it intends to phase out smoking completely by 2040, and tobacco control laws are being tightened accordingly. In the Tobacco Control Action Plan for England 'national ambitions' are set of reducing adult and young person smoking prevalence and smoking rates during pregnancy by 2015.

Scottish tobacco control targets have helped to ensure that funding and infrastructure are directed to where they can make most difference. Targets are essential in order to drive forward action on tobacco control. New targets therefore need to be set as an integral part of a new strategy. While it is important that they are clear, ambitious and encourage public bodies to prioritise tobacco issues, it is also important that they better address health inequalities. We need to know more about different groups of people and their use of tobacco, so that we can effectively measure success. They should be realistic, but challenging, and subject to mid-term review.

b. Robust evaluation
A new strategy should be rooted in current evidence of effectiveness but must also include a mechanism for evaluation that will deliver an even better understanding of the methods and outcomes of the interventions within it. In turn, this should feed a process of review which tests the strategy against the evidence and so refines and further develops the strategy's aims, targets and content.   

A systematic, integrated evaluation programme would clarify and prioritise tobacco control research questions and prevent the unnecessary duplication of research effort. It would also provide an opportunity to describe and logically model the relationships of all interventions with all potential outcomes and so map the impact of the strategy and the efficacy of each intervention in achieving these outcomes.

Health Scotland, in conjunction with the Information Services Division (ISD) Scotland and the Scottish Government developed a comprehensive evaluation strategy to assess the short-term, intermediate and long term outcomes of  Scotland's smoke free legislation, which came into force in March 2006. Using routine health, behavioural and economic data and commissioned research, the impact of the legislation in eight key outcome areas - knowledge and attitudes, SHS exposure, compliance, culture, smoking prevalence and tobacco consumption, tobacco-related morbidity and mortality, economic impacts on the hospitality sector and health inequalities - has been examined.

The Scottish Government's Smoking Prevention Action Plan, published in 2008, sets out an ambitious programme of measures designed specifically to dissuade children and young people from smoking. It includes a recommendation for NHS Health Scotland to take a lead on developing a research and evaluation framework to support the action in the plan setting clear timelines, as part of the wider tobacco control research and evaluation programme for A Breath of Fresh Air for Scotland. Health Scotland is taking a lead on drafting a monitoring and evaluation plan in consultation with colleagues outlining the monitoring data that needs to be collected and which evaluation studies need to be commissioned. Evaluation plans have yet to be finalised and progress has been slow.  Concerted effort is now required in order to clarify priorities and constraints, and move forward with an agreed evaluation framework and associated timescales for work to commence and be completed.

c. Research strategy
Research on disease causation, epidemiology, and educational and policy interventions has contributed significantly to reducing smoking rates internationally. Research data provides a sound basis for the development of tobacco control policies and programmes, and it also enables the implementation of FCTC provisions in an evidence based and cost effective manner. Research also provides policy makers and public health with the evidence needed to respond quickly and flexibly to developments in the dynamic field of tobacco control.

A new research strategy should build on work already undertaken, both at national and international level. It should also link into the work of existing bodies such as the UK Centre for Tobacco Control Studies (UKCTCS), the Centre for Tobacco Control Research, the Institute for Social Marketing and the Research and Evaluation Subgroup of the Scottish Ministerial Working Group on Tobacco Control. A new research strategy should address important gaps in our current knowledge, incorporate effective monitoring and evaluation of Scottish tobacco control policy, and facilitate an effective overview of smoking rates and tobacco-related harm in Scotland.

ASH Scotland is aware of a number of gaps in research which, if filled, could inform significant advances in smoking cessation service provision in Scotland. For example, we know very little about effective interventions aimed at reducing smoking in the home. There is little clarity about the benefits of smoke-free homes initiatives, or about which is the most effective method of tacking this issue. These issues are currently being examined by ASH Scotland's Big Lottery funded REFRESH project, findings of which should be monitored closely in order to guide future action.

There is also a relative lack of information about the most effective ways to work to reduce the number of 16-24 year old smokers in Scotland. As recommended in the 2008 Smoking Prevention Action Plan, this should be a priority area for new research.

As the need for cessation treatments to become more diverse intensifies, the use of harm reduction products and strategies to support temporary abstinence from smoking and as a means of reducing harm per se also requires greater attention, especially in relation to those who are most heavily addicted to nicotine. The dual use of cannabis and tobacco is another area that warrants research attention, as highlighted by the Scottish Tobacco Control Alliance's (STCA) 2005 'Fags and Hash' conference, and in subsequent meetings of the STCA Tobacco and Cannabis Working Group.

In addition, we know too little about tobacco use in deprived and excluded groups of the population in Scotland, making it difficult to track progress or to target services appropriately. Estimates show that smoking rates are significantly higher in groups such as homeless young people (94%), young prisoners (79%) and young care leavers (67%).No targets have currently been set for disadvantaged groups such as these, and so progress in reducing smoking cannot be measured. Extent of tobacco use in minority ethnic groups and within the LGBT community also remains uncertain.  A report published by Partnership Action on Tobacco and Health (PATH) in July 2010 made a range of recommendations to improve data collection, access to services and support for LGBT people who wish to quit smoking.

Evidence base:

Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs. October 2007. Department of Health and Human Services, USA.

World Health Organisation. Framework Convention on Tobacco Control. Geneva, World Health Organisation, 2003.

• We must ensure that every local area in Scotland has a comprehensive multi-agency tobacco control strategy.

Rationale:

Effective local partnerships are essential to moving the tobacco control agenda forward. It is crucial not to see tobacco control as the domain of the health sector, but as a multi-sectoral concern. Although most funding and target delivery has been channelled through the NHS, others including local authorities, education bodies, voluntary organisations and community groups also have a huge part to play.

Partnerships need to be strategic and create a joined up approach to tackling tobacco use as a shared priority. Local tobacco control workers should try to involve as many sectors and stakeholders as possible in the development, implementation and dissemination of local tobacco control programmes. Senior leadership, developed Tobacco Control Alliances and the positioning of these within the framework of strategic local partnerships are crucial to success.   

Work at local level should reflect national priorities to achieve the ultimate aim of having local tobacco control strategies that are based on the best evidence of effectiveness and complement national and regional tobacco control priorities.

Evidence base:

Excellence in tobacco control: 10 High Impact Changes to achieve tobacco control. An evidence-based resource for local Alliances. Department of Health, 2008. 

ASH Scotland. Championing tobacco control. Learning from the experiences of local tobacco control alliances in Scotland. A series of case studies from ASH Scotland's local alliances project. March 2010.

ASH Scotland. Tackling tobacco together: The final report of ASH Scotland's Local Tobacco Control Alliances Project (2006 - 2011). April 2011.

Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs. October 2007.

• We must have committed Government funding to sustain national tobacco control co-ordinating mechanisms and enhance the effectiveness of ongoing tobacco control partnership work in Scotland, ensuring the full involvement of service users, members of the public, practitioners and other stakeholders.

Rationale:

Scotland is a world leader in tobacco control, and for the size of our country we punch above our weight. One of the key factors behind our success is our ability to work in partnership; coordinating work, sharing resources and ensuring the full involvement of a range of stakeholders including the Scottish Government Health directorate,  NHS Health Scotland, the voluntary health sector, practitioners, local alliances, members of the public and service users. This has a far greater effect to support tobacco control work than each agency working in isolation. No new resources are needed to facilitate these continued successful partnerships.

Evidence base:

Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs - 2007. Atlanta: U.S. Department of Heath and Human Services , Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; October 2007.

• Through the UK, we are signed up to implement the international Framework Convention on Tobacco Control (FCTC).  The Scottish Government should provide leadership through transparent reporting on Scotland's progress, and through committing to publish information about all contacts with the tobacco industry or its vested interests as required under Article 5.3 of the FCTC.

Rationale:

There is a fundamental and irreconcilable conflict between the tobacco industry's interests and  public health policy interests. The tobacco industry produces and promotes a product that has been proven scientifically to be addictive, to cause disease and death and to give rise to a variety of social ills, including increased poverty. We should protect the formulation and implementation of public health policies for tobacco control from the tobacco industry to the greatest extent possible.

A Scottish Government commitment to publish information about all contacts with the tobacco industry or its vested interests would ensure transparency of interactions, as recommended in WHO guidelines on implementing Article 5.3 of the Framework Convention on Tobacco Control.  Currently, the UK reports on progress in this respect, but Scottish input to this process remains unclear. Reporting on progress at Scottish level would allow Scottish civil society to challenge and engage with this international process.

The recent Department of Health Tobacco Control Action Plan confirmed that the Westminster Government commits to publishing details of all meetings with the tobacco industry (aside from those that discuss operational matters in tackling the illicit trade).

Evidence base:

World Health Organisation. Guidelines for implementation of Article 5.3 of the WHO Framework Convention on Tobacco Control on the protection of public health policies with respect to tobacco control from commercial and other vested interests of the tobacco industry.

McDaniel PA, Smith, EA and Malone RE (2006) Philip Morris's Project Sunrise: weakening tobacco control by working with it. Tobacco Control 15 (3): 215-223.

Yang JS and Malone RE (2008) "Working to shape what society's expectations of us should be": Philip Morris' societal alignment strategy. Tobacco Control 17 (6): 391-398.

• 4 in 10 fire deaths are attributed to smoking materials .  Standards are being developed for fire safer cigarettes to be available throughout the European Union from 2011.  We need to support speedy progress, while ensuring that fire safer cigarettes do not provide an opportunity for the tobacco industry to influence health policy or increase its customer base.

Rationale:

Scotland consistently reports a higher rate of fire-related deaths than the rest of the United Kingdom. Of 47 fatal casualties in accidental Scottish dwellings fires in 2009-10, the most common source of ignition was smokers' materials and matches, accounting for 26 fatalities (55 per cent).

49 states in the USA have brought fire-safer cigarette law into effect, with Wyoming being the most recent (implemented on 1 July 2011).  Legally, cigarettes must demonstrate a greater likelihood of self-extinguishing if not repeatedly smoked, using the laboratory test method E2187 developed by ASTM International (American Society for Testing and Materials). This standard is also the basis for the fire-safe cigarette law which has been in effect in Canada since 2005.

The cost per cigarette of switching to fire safer cigarettes is negligible and there is little evidence of change in flavour or toxicity.  All eight of Scotland's fire and rescue services and the Fire Brigades Union support the introduction of reduced ignition propensity (RIP) cigarettes.

CEN (the EU standards making body) published the standard and test method, European Standard, EN 16156 'Cigarettes – Assessment of the ignition propensity', on 17th November 2010 to complement a first standard published by CEN and ISO in September 2010, ISO 12863 'Standard test method for assessing the ignition propensity for cigarettes'. Both standards were developed to respond to the European Commission standardization mandate, M/425, relative to the fire-safety requirements for cigarettes. Once the standard is referenced in the Official Journal of the European Union, usually 12 months after it is published, companies will be required to meet it. From November 17 2011 onwards, cigarettes introduced into the UK will meet this standard.

Evidence base:

Scotland Together: a study examining fire deaths and injuries in Scotland, Communities Scotland, 2009. (p14)

Fire Safety Standard on Ignition Propensity, Smoke Toxicity, and the Consumer Market. A Preliminary Report. 24 January, 2005.

Connolly GN et al (2005). Effect of the New York State cigarette fire safety standard on ignition propensity, smoke constituents, and the consumer market. Tobacco Control 14 (5): 321-327.

Gunja, M et al. (2002). The case for fire safe cigarettes made through industry documents. Tobacco Control 11 (4): 346-353.

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MEDIUM TERM

• We need the Scottish Government to continue to influence UK level tobacco control issues, and to report on what it is doing to encourage speedy progress on vital reserved matters.

Rationale:

Under the Scotland Act 1998, which sets out the legislative competence of the Scottish Parliament, there are several key tobacco control areas which the UK Parliament retains legislative control over. This includes issues such as tax varying powers and tobacco product regulation, where additional progress is required in order to reduce the harm caused by tobacco in Scotland. On this basis, the Scottish Government must continue to exert its influence and share progress in order to maximise potential for partnership working towards further tobacco control advances at UK level. It is important that the Scottish Government is transparent about its negotiations at UK level to ensure civil society can engage with this process.

• We must encourage the UK Government to establish regulation of tobacco that is commensurate with the level of harm caused and to regulate all aspects of promotion, marketing, information provision, packaging and sale.

Rationale:

Tobacco is a unique consumer product: there is no safe level of use and around half of all life-long smokers die prematurely from smoking-related diseases. Despite the harm caused by smoking, tobacco products themselves are largely unregulated.

The tobacco industry has responded vigorously to the existing constraints placed on the sale and advertising of tobacco over the past ten years. At every point on the marketing mix, opportunities still exist to reduce the attractiveness of tobacco products and encourage children and young people not to start smoking. As product regulation is a matter reserved to Westminster, we must encourage the UK Government to seriously address every one of these opportunities, in the context of the FCTC guidelines.

Regulation must cover all aspects of promotion, marketing, information provision, packaging and sale, and should be controlled by appropriate health and regulatory bodies. Given the track record of tobacco companies in aiming to conceal the harm caused by their products, regulation must be entirely independent of the manufacturers of tobacco and nicotine products. A number of existing regulatory bodies could take on the role of enforcing this regulation and it would not necessarily require creation of new infrastructure.

Product regulation should also cover ingredients that may be included in tobacco products. Specifically - and in accordance with the WHO FCTC - no ingredients should be permitted that enhance the addictiveness or attractiveness of tobacco products. Currently, there is a list of permitted additives to tobacco products in the UK, though it was last updated in 2003. A recent consultation at the EC level sought to gather views on rationalising the disparate systems current in operation throughout the member states to a single harmonised system across the European region. The results of the consultation have recently been published, the EC is considering how to proceed, with a report on progress expected in 2012.

Evidence base:

King J, Accepting tobacco industry money for research; has anything changed now that harm reduction is on the agenda? Addiction 2006; 101: 1067-1068

The Leuven Consensus. 2007.

World Health Organisation. WHO Study Group on Tobacco Product Regulation (TobReg) report on the scientific basis of tobacco product regulation. WHO Technical Report Series 945. 2007.

Deyton L, Sharfstein J and Hamburg M (2010). Tobacco product regulation - a public health approach. The New England Journal of Medicine 362 (19): 1753-1756.

Gilmore AB et al. (2009). The place for harm reduction and product regulation in UK tobacco control policy. Journal of Public Health 31 (1): 3-10.

• We must encourage the UK Government to increase tobacco industry accountability by requiring better reporting on tobacco ingredients and marketing, promotions, lobbying spend and tax deductions.

Rationale:

The current UK Government taxation system enables tobacco companies to deduct marketing costs as legitimate business expenses. This runs counter to public health policy to curb the marketing of tobacco. The UK Government should explore ways in which this deduction can be removed for the tobacco industry.

The Canadian Government, for example, requires the tobacco industry to report to Health Canada its advertising and marketing payments to retailers. On this basis, it has been documented that over the past decade or so, total payments to retailers have increased by 45% despite the majority of provinces having implemented point of sale displays during that time.  Such reporting would also allow enforcement agencies to detect and close down any industry attempts to subvert advertising laws, such as through new media.

• Through Scotland's relationships with Malawi and other tobacco-growing countries, we must seek higher standards of tobacco industry accountability for the conditions of growers and workers.  We must use our international development funds and trade links to support producer countries to move away from dependency on tobacco growing.

Rationale:

Assisting tobacco farmers to transition to non-tobacco alternatives is a key element of comprehensive tobacco control's end-game strategy and specifically required by the WHO Framework Convention on Tobacco Control. Tobacco industry efforts to combat child labour through corporate social responsibility agendas enhance their own reputations whilst distracting public attention away from how they profit from low wages and cheap tobacco. Successful strategies to support producer countries to move away from tobacco growing should take a long term approach aimed at building alliances with tobacco farmers and at creating mechanisms for tobacco farmer investment in local infrastructure.

The Scottish Tobacco Control Alliance (STCA) Working Group on tobacco production was established in 2010 to raise awareness amongst young people and adults in Scotland of the damage caused by tobacco production abroad, particularly in countries with a Scottish connection such as Malawi.  The Scotland Malawi Partnership recognises that there are a huge number of Scottish individuals and organisations with links to Malawi and there is a need to coordinate these in order to improve effectiveness. Various funding programmes exist that offer grants and resources to groups which help increase the involvement of UK community members in international development.  The opportunities associated with these types of programmes should be fully explored by ASH Scotland and other stakeholders with a view to increasing involvement of UK tobacco control workers in this key area of work.

Evidence base:

Jones AS, Austin WD, Beach RH, Altman DG. Tobacco farmers and tobacco manufacturers: implications for tobacco control in tobacco-growing developing countries. J Public Health Policy. 2008 Dec;29(4):406-23.

Geist HJ et al (2009) Tobacco growers at the crossroads: towards a comparison of diversification and ecosystem impacts. Land Use Policy 26 (4) 1066-1079

Geist H, Otañez M, Kapito J (2008) The tobacco industry in Malawi: A globalised driver of local land change. In: Millington A, Jepson W (eds). Land-change science in the tropics: changing agricultural landscapes (Environment & Policy Series). Springer: Dordrecht, NL, 251-268.

Otañez MG and Glantz SA (2009). Trafficking in tobacco farm culture: Tobacco companies use of video imagery to undermine health policy. Visual Anthropology Review: Journal of the Society for Visual Anthropology 25 (1): 1-24.

Otañez MG, Mamudu HM and Glantz SA. (2009). Tobacco companies' use of developing countries' economic reliance on tobacco to lobby against global tobacco control: the case of Malawi. American Journal of Public Health 99 (10): 1759-1771.

Otañez MG, Mamudu HM and Glantz SA. (2007). Global leaf companies control the tobacco market in Malawi. Tobacco Control 16 (4): 261-269.

Otañez MG, Muggli ME and Glantz SA (2006) Eliminating child labour in Malawi: a British American Tobacco corporate responsibility project to sidestep tobacco labour exploitation. Tobacco Control 15 (3): 224-230.

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In the long term, we need to ensure that tobacco companies are more accountable for the impacts of their industry, including the possibility of channelling a proportion of tobacco industry profits back into tobacco control activities.

Rationale:

Since the 1950s, the tobacco industry has been aware of the negative health effects of their products, and of the addictive properties of nicotine. And yet the big tobacco corporations continue to rake in staggering profits, knowingly selling an addictive product that takes years off the lives of their customers.

In September 2009, the Ontario Government filed a $50 billion lawsuit against a group of tobacco companies seeking damages for past and ongoing health care costs lined to tobacco-related illness. The Tobacco Damages and Health Care Costs Recovery Act 2009, which was unanimously passed by the Legislature earlier that year:

• allows Ontario to directly sue tobacco companies for alleged wrongdoing
• allows for the recovery of past, present and ongoing tobacco-related damages
• creates a method to determine health care cost damages incurred by taxpayers arising from tobacco-related illnesses
• establishes the burden of proof required  to link exposure to tobacco products to tobacco-related disease
• allocates liability among tobacco companies by market share.

While the legislation clarifies the process, the government still has to prove its allegations in a court of law.

In May 2010 it was announced that the Supreme Court of Canada has granted the government's request for a hearing before the country's top court over whether the government should be a defendant in the lawsuit.

In October 2010 it was announced that Alberta will be filing a similar lawsuit against the tobacco industry. Additional lawsuits have also been launched by British Columbia, Ontario and New Brunswick.

Beyond Canada, this type of legislation remains rare. But tobacco control advocates around the world will be watching closely as the action around these lawsuits unfolds. In Scotland and the rest of the UK, we should carefully explore these and other potential means of increasing tobacco industry accountability.