1. Prevention

The aim: to continue to reduce significantly the number of young people who start smoking within all communities in Scotland.

Around 15,000 young people (13-24) take up smoking in Scotland each year.  The Scottish Government's smoking prevention action plan 'Scotland's future is smoke-free' has been recognised as an excellent model.  It must be fully implemented over the coming years, within the context of a holistic tobacco control strategy.

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Short term measures

• Supported by new funding, health boards, voluntary groups and local authorities have begun to prioritise youth smoking prevention and involving young people in this work. We must keep up the momentum.
• New Scottish legislation will make tobacco less attractive and accessible to young people.  Government resources must be committed to enforce, evaluate and maintain tobacco control laws.
• Illicit tobacco is blighting communities, and organised criminals don't ask for proof of age.  We must develop Scottish targets to reduce illicit tobacco.  We need a fully-resourced multi-agency Scottish strategy to tackle illicit tobacco, aimed at reducing supply and demand.
• It's essential that young people learn about the dangers of tobacco.  We must ensure that tobacco control continues to be well represented in the Curriculum for Excellence.

Medium term measures

• Tobacco companies spend millions to make their products attractive to new customers.  We must work to reduce the visibility of tobacco and positive imagery associated with its use in Scotland, including calling for a UK law to require standardised, unbranded packaging of tobacco products.
• We should assess the feasibility of channelling the monies recovered from the proceeds of criminal tobacco smuggling/distribution to go directly to youth prevention activities at community level.
• We should explore options for introducing a positive award or incentives scheme for retailers who choose not to sell tobacco.

Long term measures

• In the long term we need to significantly reduce both supply of and demand for tobacco in our communities. Tobacco is uniquely dangerous. It is not a normal product and should not be sold as such.

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SHORT TERM

• Supported by new funding, health boards, voluntary groups and local authorities have begun to prioritise youth smoking prevention and involving young people in this work.  We must keep up the momentum to enable:

• continued youth involvement in the development of smoking prevention initiatives
• meeting existing targets and developing robust new targets to reduce smoking prevalence in young people post-2014
• effective prevention work to be embedded and resourced at local level.

Rationale:

Youth involvement in the development of smoking prevention initiatives
The protection of children and young people from the harms of tobacco use should lie at the heart of every new tobacco control strategy. Involving young people directly in the planning and delivery of services and initiatives ensures there is maximum opportunity for innovate ideas and approaches to emerge.

In Scotland, many young people work together to challenge the might of the tobacco industry. In Scotland, many young people are involved in work to challenge the might of the tobacco industry. For example, Bridges Project, winners of the 2010 Crofton Award involved young people in their ‘Journey of a cigarette’ project. They looked at all aspects of tobacco, including farming, marketing, smoking, addiction, role of the media, and the health impacts of tobacco. 

DECIPHer-ASSIST is another exciting development involving youth in smoking prevention work. This intervention aims to reduce adolescent smoking prevalence, encouraging new norms of smoking behaviour by training influential Year 8 students to work as peer educators. Peer educators are trained and supported to have informal conversations with other Year 8 students about the risks of smoking and the benefits of being smoke-free.

A recent randomised controlled trial evaluating DECIPHer-ASSIST found the programme to be effective in reducing smoking prevalence over a two year period of follow-up. If implemented throughout the UK, it is estimated that the DECIPHer-ASSIST programme would prevent 40,000 young people taking up smoking each year. Internationally and in the UK no other schools-based smoking prevention programme has been found to be as effective in such a rigorously conducted large scale randomised trial. The costs and benefits of the DECIPHer-ASSIST intervention fall within the range of previously reported school-based interventions to prevent the uptake of smoking.

Young people know how best to engage with their peers, and can often be some of the best communicators with adults too. They often achieve results that other organisations cannot through their enthusiasm, commitment, and ability to relate to and communicate with people of all ages. We should learn carefully from the outcomes of existing prevention initiatives involving young people, and continue to build on the successes already attained.

Meeting existing targets and developing robust new ones, with effective prevention work embedded and resourced at local level
In 2008, the Scottish Government produced Scotland's Future is Smoke-free: a smoking prevention action plan.  This plan sets out 27 actions to reduce the attractiveness, availability and affordability of tobacco products to young people.  Many of these actions are currently being implemented, including new legislation to ban in-store tobacco displays and tobacco vending machines and to improve enforcement of age-related sales laws.

The government's action plan also set new targets for youth smoking prevalence.  These aim to reduce smoking rates for 13 year old girls to 3% (and boys to 2%) by 2014.  To reduce smoking rates for 15 year old girls to 14% (and boys to 9%) by 2014.  And - particularly challenging - to reduce the smoking prevalence among 16-24 year olds to 22.9% in 2012.

Underpinning these targets, work to implement the action plan is being carried forward by local authorities and health boards, resourced with a £3 million annual funding allocation until 2012.   Local authorities in particular have been tasked with achieving quantitative outcomes to improve compliance with tobacco sales laws by local retailers, and to work with HM Revenue and Customs to reduce access to illicit and smuggled tobacco. A report on progress towards these goals has been published.

Targets are a key means of both driving progress and measuring performance. It remains crucial not only to monitor progress against targets but to continue to develop, evaluate and assess the impact of different prevention initiatives as part of a comprehensive tobacco control strategy.

To maximise development of effective prevention initiatives, it is imperative that ongoing work is embedded and resourced at local level. NHS Boards, local authorities and their community planning partners in collaboration with local businesses and communities, including local tobacco control alliances, must be responsible for ensuring delivery.

Evidence base:

Scottish Government. Scotland's future is smoke-free: a smoking prevention action plan. Edinburgh: The Stationery Office 2008. 

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

Department of Health. Excellence in Tobacco Control: 10 High impact Changes to achieve tobacco control. An evidence based resource for local Alliances. May 2008.

Towards a future without tobacco. The Report of the Smoking Prevention Working Group. November 2006.

Audrey S, Holliday J, Parry-Langdon N, Campbell R. Meeting the challenges of implementing process evaluation within randomised controlled trials: the example of ASSIST (A Stop Smoking In Schools Trial). Health Education Research. 2006;21:366-377.

Audrey S, Holliday J, Campbell R. It's good to talk: Adolescent perspectives of an informal, peer-led intervention to reduce smoking. Social Science and Medicine. 2006;63:320-334.

Amos A, Angus K, Bostock Y, Fidler J, Hastings G. A Review of Young People and Smoking in England. [online]. Public Health Research Consortium. 2009.

Campbell R et al (2008) An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster randomised trial (2008) Lancet May 10: 371 (9624): 1595-1602.

Starkey F et al. Rationale, design and conduct of a comprehensive evaluation of a school-based peer-led anti-smoking intervention in the UK: the ASSIST cluster randomised trial (ISRCTN55572965). BMC Public Health 2005 Apr 22: 5: 43.

• New Scottish legislation will make tobacco less attractive and accessible to young people.  Government resources must be committed to enforce, evaluate and maintain tobacco control laws.

Rationale:

Over the past 15 years several nations have moved forward with successful campaigns to change legislation in order to reduce the sale of cigarettes to young people.  

In Scotland, the Tobacco and Primary Medical Services (Scotland) Act 2010 was passed with an overwhelming majority on 27th January 2010. Under the Act (from April 2011) it is an offence for any person under the age of 18 to attempt to buy tobacco products, and for any person to buy tobacco products for those under 18. The Act also sees the introduction of a tobacco display ban, due to commence in April 2012 for large shops and April 2015 for all other shops. In addition, tobacco retailers have to be registered to sell tobacco products, through a new registration scheme. Success in enforcing these activities will in turn increase the likelihood of meeting current Scottish Government targets for youth smoking prevalence. A continued Government commitment to funding will remain imperative to all aspects of the success of the forthcoming legislation in the longer term. 

In addition, it remains essential to evaluate and assess the impact and outcomes of the Tobacco Act, and evaluation systems must have high priority in the planning process. NHS Health Scotland has developed a peer-reviewed monitoring and evaluation framework for the Smoking Prevention Action Plan. Studies are in the process of being refined prior to commissioning, in collaboration with stakeholders from a range of sectors. The progress and findings of these studies should be monitored closely in order to assess the impact of current and future prevention initiatives, and to assist in identifying any future gaps for action.

Evidence base:

DiFranza, J.R., Savageau, J.A. and Fletcher, K.E. (2009). Enforcement of underage sales laws as a predictor of daily smoking among adolescents - a national study. BMC Public Health. 9: 107

Hastings G, MacKintosh AM, Holme I, Davies K, Angus K, Moodie C. Point of Sale Display of Tobacco Products. Centre for Tobacco Control Research. August 2008.

McNeill A, Lewis S, Quinn C, Mulcahy M, Clancy L, Hastings G, Edwards R. Evaluation of the removal of point-of-sale tobacco displays in Ireland. Tob Control. 2010 Nov 18.

Paynter J, Edwards R. The impact of tobacco promotion at the point of sale: a systematic review. Nicotine Tob Res. 2009 Jan;11(1):25-35. Epub 2009 Jan 27.

Quinn C, Lewis S, Edwards R, McNeill A. Economic evaluation of the removal of tobacco promotional displays in Ireland. Tob Control. 2010 Nov 18.

World Health Organization. Framework Convention on Tobacco Control. WHO. 2003.

• Illicit tobacco is blighting communities, and organised criminals don't ask for proof of age.  We must develop Scottish targets to reduce illicit tobacco.  We need a fully-resourced multi-agency Scottish strategy to tackle illicit tobacco, aimed at reducing supply and demand.

Rationale:

Illicit tobacco undermines taxation increases and other tobacco control measures such as age of sale regulations. Cigarette smuggling and counterfeiting are a major problem for public health as they lead to the availability of tobacco at less than half the tax-paid price in many deprived areas. This maintains smokers in their habit and encourages young people to start smoking.

Little is known about the extent of the illicit tobacco trade in Scotland, but it is estimated that 10% of manufactured cigarettes and 46% (HMRC - pdf) of hand-rolled tobacco in the UK is illicit.

The UK Department of Health's tobacco control action plan sets out the aim of tackling smuggling, but without any plans for the introduction of Scottish targets.

HM Revenue and Customs and the UK Border Agency published a renewed strategy for tackling tobacco smuggling in April 2011. In it HMRC and UKBA have committed to additional investment in tackling organised crime, tax evasion and avoidance; utilising new powers of assessment and new larger penalties to deter offending and prevent re-offending; and to reduce the minimum indicative levels for customers travelling to the UK from the EU.

The Scottish and UK Governments should work together with agencies including Her Majesty's Revenue and Customs and Trading Standards officers throughout Scotland to set new Scottish targets for smuggling and establish the scale of the problem in Scotland, so that resources can be effectively targeted where they are needed most.

The Scottish and UK governments should also monitor progress of the WHO Framework Convention on Tobacco Control protocol to eliminate the illicit trade in tobacco products. The protocol is currently being drafted by an informal WHO working group. The group will report its proposals to the final session of the Intergovernmental Negotiating Body (INB), which will be held in early 2012. If the finalised protocol is widely and comprehensively adopted, it is estimated it could be worth £5.7 billion to the UK in net present value terms over a 50 year period, save 760 lives annually, and reduce smuggling by up to 80%.

Evidence base:

Joossens, L., et al. Issues in the smuggling of tobacco products. In: Jha, P. and Chaloupka, F. eds. Tobacco control in developing countries. World Bank, 2000.

Scottish Tobacco Control Alliance. Report of the Scottish illicit tobacco summit held at Perth Concert Hall on 21st September 2010.

WHO Framework Convention on Tobacco Control. Draft protocol to eliminate illicit trade in tobacco products. 21 March 2010.

Johnson, P. Cost benefit analysis of the FCTC Protocol on Illicit Trade in Tobacco Products. London: ASH, 2009.  

• It's essential that young people learn about the dangers of tobacco.  We must ensure that tobacco control continues to be well represented in the Curriculum for Excellence.

Rationale:

Most smoking starts in childhood or adolescence. It is uncommon for adults who have never smoked as children to start smoking. It remains imperative to get preventative messages to children about smoking, and schools have an important role to play in communicating them.

We must ensure that tobacco control continues to be well represented in the Curriculum for Excellence in Scotland. In addition, the substance misuse component should be reviewed to ensure that it addresses the gaps and limitations outlined in the Health Scotland 2009 Evaluation of Substance Misuse Education resources.     

There is some limited evidence of short-term effectiveness for school-based smoking prevention programmes which use social influences and other approaches based on the social context of smoking. Most published studies have been conducted in the US and do not provide sufficient information to be able to reproduce the programme, but they do not provide a clear indication of the best way forward. In the UK, the DECIPHer-ASSIST programme has demonstrated effectiveness in achievement of a reduction in uptake of regular smoking in adolescents for 2 years after its delivery. Longer term outcomes have yet to be evaluated, but the DECIPHer-ASSIST approach may well be worth pursuing in addition to tobacco control representation in the Curriculum for Excellence.

West Dunbartonshire council have developed a resource pack as part of the Scottish Government's Equally Well Test Site Area for Tobacco Control in the area of Whitecrook, Clydebank.  The resource pack takes a new approach to tobacco education and extends across all of the curriculum areas and health and wellbeing guidance in Curriculum for Excellence.

Evidence base:

Rooney B, Murray D. A meta-analysis of smoking prevention programmes after adjustment for errors in the unit of analysis. Health Education Quarterly. 1996; 23: 48-64.

Thomas R and Perera, R. School based programmes for preventing smoking. The Cochrane database of systematic reviews. 2006 Jul 19; 3: CD001293.

Campbell R et al (2008) An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster randomised trial. Lancet. May 10: 371 (9624): 1595-1602.

Starkey F et al. Rationale, design and conduct of a comprehensive evaluation of a school-based peer-led anti-smoking intervention in the UK: the ASSIST cluster randomised trial (ISRCTN55572965). BMC Public Health. 2005 Apr 22: 5: 43.

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MEDIUM TERM

• Tobacco companies spend millions to make their products attractive to new customers.  We must work to reduce the visibility of tobacco and positive imagery associated with its use in Scotland, including calling for a UK law to require standardised, unbranded packaging of tobacco products.

Rationale:

The global Framework Convention on Tobacco Control (FCTC) requires nations to ban all tobacco advertising and promotion. In the face of these restrictions, tobacco packaging has become the key promotional tool for the tobacco industry to interest smokers and potential smokers in tobacco products. Logos, colours, fonts, pictures, packaging materials and shapes profoundly affect consumer perceptions of the attractiveness and relative safety of the products. Remove this branding and the results are immediate: young people find cigarettes less attractive and smokers are less likely to be misled about the safety of the cigarettes they smoke.

In a world-first, Australia has recently set out plans for introducing plain packaging from 2012. The move has been heavily contested by the tobacco industry. Recent delays in the legislative process have meant the implementation date has been pushed back to December 2012.

The Scottish Government's Smoking Prevention Action Plan (2008) contains a commitment to consider with the UK Government and other devolved administrations whether a move towards plain packaging of tobacco products is desirable. The introduction of plain packaging is a matter reserved to the UK Government, who have recently announced in their new tobacco control action plan the intention to carry out a consultation on plain packaging, now delayed till spring 2012.

Evidence base:

Moodie C and Hastings G (2010). Plain packaging: a time for action. European Journal of Public Health. 20 (1): 10-11.

Moodie C, Hastings G & Ford A. A brief review of plain packaging research for tobacco products. Report prepared for the Department of Health. 2009.

Hammond. D. et al. (2009). Cigarette pack design and perceptions of risk among UK adults and youth. European Journal of Public Health. 19 (6): 631-637.

Hastings G, Gallopel-Morvan, K and Rey JM (2008). The plain truth about tobacco packaging. Tobacco Control. 17, 361-362.

Freeman B, Chapman C and Rimmer M (2007). The case for the plain packaging of tobacco products.

• We should assess the feasibility of channelling the monies recovered from the proceeds of criminal tobacco smuggling/distribution to go directly to youth prevention activities at community level.

Rationale:

Over the past ten years, the UK Government has introduced various new powers to confiscate, freeze, seize and tax criminals' assets. One notable example of this is introduction of regional asset recovery teams (RARTs) in 2003, bringing together staff from the police, customs, the Assets Recovery Agency and Inland Revenue amongst others. These teams are dedicated to confiscating criminal assets, which are reinvested to build the capacity of law enforcement agencies, and to fund community crime reduction partnerships, education and training projects. Currently five RARTs have been established in England and Wales.

In Scotland, CashBack for Communities is a programme of diversionary activities for young people to increase the opportunities they have to develop their interests and skills in an enjoyable, fulfilling and supported way, using funds recovered from criminals. It includes a range of partnerships with Scottish sporting, arts and business associations to provide diversionary activities for young people in Scottish communities. Resources are focused on areas of high crime. Initiatives aim to increase the likelihood of positive long-term outcomes for those who take part. The Scottish Government has committed to invest over £14 million and over 100,000 young people have benefited so far.

There are also plans for a social responsibility levy as part of the Alcohol (Scotland) Act, drawn up by the Scottish Government to tackle alcohol misuse in Scotland. Licensed premises could be asked to pay a levy towards the cost to society of alcohol misuse, which would allow rebates or discounts for outlets which operate responsibly. The Scottish Government has consulted on the details of the levy and how it might work.

These types of models could be utilised to good effect in tackling tobacco smuggling and distribution in Scotland and in the rest of the UK, whilst at the same time increasing the capacity for innovative prevention activities at local level. Further consideration should be given to the practicalities, merits and challenges associated with channelling monies from tobacco smuggling/distribution to youth prevention activities at local level.

• We should explore options for introducing a positive award or incentives scheme for retailers who choose not to sell tobacco.

Rationale:

Under the Tobacco and Primary Medical Services (Scotland) Act, retailers selling tobacco in Scotland will be required to be on a central register from October 2011. Selling tobacco without being registered will carry a fine of up to £20,000 or 6 months in jail.

Having a central comprehensive list of tobacco retailers will in turn present new opportunities for communication and joined up working with retailers. Introducing a positive award or incentives scheme for retailers who choose not to sell tobacco would highlight the fact that retailers can choose to not sell tobacco products if they wish, and encourage a greater number of retailers to opt out of doing so.

In 2007 the supermarket chain Lidl announced it would cease to sell tobacco products in its 78 stores in Scotland, as part of a wider drive to position itself as a retailer with a strong health message. This action brought Scottish stores in line with stores elsewhere in the UK where they have never sold tobacco. Far from damaging business, Lidl remains one of the UK's recent retail success stories, with over 550 stores in the UK alone and an impressive schedule of new store openings. Tobacco is a declining commodity with low profit margins, and retailers can choose not to sell it without damaging business.

In its spending review, announced in September 2011, the Scottish Government announced it would be introducing a new public health levy for large retailers who sold both alcohol and tobacco.

Evidence base:

Rooke C et al. Tobacco point-of-sale displays in England: a snapshot survey of current practices. Tobacco Control. 2010; 19: 279-284.

Anderson S Hastings G and MacFayden L (2002). Strategic marketing in the UK tobacco industry. Lancet Oncology Aug 3 (8): 481-6.

Khor Yoke Lim, Foong Kin, Tan Yen Lian, Gerald Goh. Surveillance of Tobacco
Industry Marketing Strategies at Retail Outlets. Research Network for Tobacco Control. January 2008.

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In the long term we need to significantly reduce both supply of and demand for tobacco in our communities. Tobacco is uniquely dangerous. It is not a normal product and should not be sold as such.

Rationale:

There is so much more that could be done substantially reduce the harm caused by tobacco use in Scotland. In New Zealand, for example, it has been proposed that the Smoke-free Environments Act could be amended to phase out legal tobacco sales by 2025, Finland has set a target of 2040 for going tobacco-free, as has Guernsey. 

This would require regular reductions in the amount of tobacco released to the market for sale, sufficient to achieve the desired level of commercial sales by a target date. Prices would increase as supply reduced. The price level would be influenced by demand, which in turn would reflect the impact of other interventions to reduce demand and the changing normality of smoking. Introducing a strategy like this in conjunction with a range of complementary interventions that would help reduce demand, would help to ensure that possible adverse effects such as smuggling and illegal sales were minimised. These complementary interventions would include providing best practice cessation support, better information to smokers and the public, strengthened tobacco regulation, measures to restrict supplies that bypass the increases in product price, strengthened enforcement and combating industry attacks.  

As public interest in and support for reducing tobacco-related harm increases in Scotland and in the UK as a whole, more intensive action and a degree of radical thinking is required in order to fully drive progress forward. With a Government commitment to supporting a comprehensive tobacco control strategy in Scotland, the number of smokers who are able to quit successfully will continue to increase, and the number of young people starting to smoke will continue to decrease. It therefore follows that issues of supply and demand will need to be carefully monitored and reviewed in line with continually reducing smoking rates.

Evidence base:

Laugesen M et al. (2010). Four policies to end the sale of cigarettes and smoking tobacco in New Zealand by 2020. New Zealand Medical Journal 123 (1314): 55-67.

Edwards, R. et al. (2011). Daring to dream: reactions to tobacco endgame ideas among policy-makers, media and public health practitioners.

Thomson G et al. (2010). Ending appreciable tobacco use in a nation: using a sinking lid on supply. Tobacco Control 19 (5): 431-435.