Select Committee on Health Second Report


Smoking in Britain

14. In the UK cigarette smoking levels rose rapidly in the first half of the century. By the end of World War II 65% of adult men and 41% of adult women smoked cigarettes.[29] Since 1974, smoking prevalence has been measured as part of the General Household Survey (GHS). In 1974 the GHS recorded cigarette smoking levels of 51% of men and 41% of women.[30] The latest figures are for 1998 and they indicate that in the UK currently 28% of men and 26% of women smoke.[31]

15. In Britain, the market is dominated by two companies, Gallaher and Imperial:

Great Britain manufactured cigarette brand shares %
Source: General Household Survey 1996
By Company
Rothmans [now owned by BAT]
Philip Morris 
RJ Reynolds 
Supermarket own-labels (Japan Tobacco supplies many of these)    

The leading brands are as follows:

Benson & Hedges (Gallaher)
Silk Cut (Gallaher)
Lambert & Butler (Imperial)
Embassy (Imperial)
Berkeley (Gallaher)
John Player (Imperial)
Marlboro (Philip Morris)
Rothmans (Rothmans) [now owned by BAT]     
Regal (Imperial)
Mayfair (Gallaher)
Raffles (Philip Morris)
Dickens & Grant (RJR)
Dorchester (RJR)

Note:   Rothmans has since been acquired by British American Tobacco [BAT]; R J Reynolds [RJR] has been sold to Japan Tobacco, but some brands have been sold to Gallaher. Imperial's market share is now nearer that of Gallaher.

16. Reductions in smoking rates have thus been substantial but they have not been evenly distributed amongst social classes with the result that smoking is a prime cause of health inequalities. The Royal College of Physicians report noted that, over the period in which the GHS has been conducted, smoking prevalence fell by more than 50% in the most advantaged sector of British society, but remained static amongst the least advantaged.[32] Most teenage quitting was from affluent households.[33] The latest GHS suggests that in 1998 in households in the manual group 35% of men and 31% of women smoked whereas in non-manual households the figures were 21% of men and 21% of women. Men who lived in the unskilled manual groups were nearly three times as likely to smoke as those who lived in professional households (44% compared to 15%).[34]

17. The papers we obtained from advertising agencies handling tobacco accounts (see below paragraph 82) showed that the agencies and their clients specifically targeted less well-off consumers. A market research report prepared for Gallaher describes this target sector in unflattering terms:

    "Cluster 1 - 'Slobs'

    27 per cent of cigarette smokers aged 18-24 years are represented by this cluster with 71 per cent of them being C2DEs ... Describing members of this cluster as 'Slobs' may seem unkind, but this title is earned by their low concern with their appearance and the little effort they make to keep themselves informed."

    "Slobs ... downmarket .. less likely to have gone to further education ... committed smokers ... show commitment or concern about little else eg health, diet, appearance, promotions."[35]

18. The present Government gave an early indication of its commitment to combat tobacco in its White Paper Smoking Kills published in December 1998. This set out what they described as "the most comprehensive Government-wide programme of action ever undertaken to protect children from the effects of tobacco and to help the 7 out of 10 adult smokers who say that they want to give up".[36] The White Paper promised over £100 million of new money to combat tobacco. Its key proposals included:

  • Up to £60 million to fund the first national NHS smoking cessation programme with advice clinics and support for adults wanting to quit including one week's free nicotine replacement therapy (NRT) for those entitled to free prescriptions in Health Action Zones (HAZs)[37]
  • A £50 million publicity campaign especially targeting young people, adults who want to quit and pregnant women
  • A pledge to introduce secondary legislation to end tobacco advertising as soon as possible
  • Measures to crack down on sales to children
  • Guidance to health authorities on strategies to tackle smoking
  • A charter with the hospitality industry to ensure that consumers are better able to eat and drink in smoke-free atmospheres
  • Consultation on a new Health and Safety Commission approved Code of Practice on smoking in the workplace

We discuss many of these proposals and their implications in the course of this report.

19. Smoking Kills set out three targets for judging the success of the Government's anti-smoking strategy. These were as follows:

  • to reduce smoking among children from 13% to 9% or less by the year 2010 with a fall to 11% by the year 2005.
  • to reduce adult smoking in all social classes so that the overall rate falls from 28% to 24% or less by the year 2010 with a fall to 26% by 2005.
  • to reduce the percentage of women who smoke during pregnancy from 23% to 15% by the year 2010 with a fall to 18% by the year 2005.[38]

We very much welcome the Government's firm commitment to action to combat smoking in its White Paper Smoking Kills. We do not, however, regard the targets they have set as sufficiently challenging to justify the Department of Health's rhetoric that it is for the first time tackling smoking seriously. The target trends for adult smoking are no more than would be expected extrapolating from the general trends since the 1970s. We believe that the DoH should set much tougher targets and take such measures as are open to it to achieve those targets.

Awareness of the health risks of smoking

Active Smoking

20. Evidence on the harmful effects of tobacco has been accumulating since the end of the eighteenth century, most notably in relation to cancer.[39] A prize winning treatise in Germany in 1795 took as its title "Carcinoma of the lip is most frequent when people indulge in tobacco pipes".[40] The first case-control study of lung cancer was conducted by F H Müller in Cologne in 1939 who concluded that tobacco was an important cause of lung cancer.[41] By 1947 the increase in lung cancer deaths had become so pronounced in the UK that the Medical Research Council held a conference to discuss the reasons for it. Austin Hill was asked to conduct a case-control study to test whether this trend was associated with the increased consumption of cigarettes.

21. The association of smoking with vascular disease occurred rather later. In 1908 L Buerger noted that a rare form of vascular disease (subsequently called Buerger's disease) seldom occurred in non-smokers. In 1931, F L Hoffman noted a statistical correlation between the increasing number of reports of coronary thrombosis and the increasing consumption of cigarettes.[42] In 1940, F A Willius and J Berkson examined the records of 1,000 patients with the disease at the Mayo Clinic in Rochester Minnesota and 1,000 other patients matched for sex and age and found an association of smoking with coronary thrombosis.[43]

22. What Sir Richard Doll describes as a "watershed" in the study of the epidemiology of smoking occurred in 1950 with the publication of a series of case control studies.[44] Two major papers were published, one by Richard Doll himself in conjunction with Austin Hill and the other in the USA by E L Wynder and E A Graham. These drew attention to the risk of lung cancer: the American study concluded that "excessive and prolonged use of tobacco, especially of cigarettes, seems to be an important factor in the induction of bronchogenic cancer"; the British study argued that "cigarette smoking is a factor, and an important factor, in the production of carcinoma of the lung".[45] In 1951 a long term study of the effects of smoking in British doctors commenced. A questionnaire on smoking habits was distributed to all doctors on the medical register and survivors have been contacted regularly since 1957. The 40 year study published in 1994 and conducted by Sir Richard Doll and Sir Richard Peto showed that 80% of non-smokers survived to age 70 and 33% to age 85, whereas only 50% of heavy smokers survived to age 70 and 8% to 85. This led the authors to conclude: "It now seems that about half of all regular cigarette smokers will eventually be killed by their habit".[46]

23. Between 1952 and 1960 a series of huge North American cohort studies were undertaken. These culminated in 1959 in the American Cancer Society Twenty Five State study which followed a million subjects over five years and showed that "smokers of cigarettes had a [lung cancer] death rate of 9.2 times the rate for those who had never smoked".[47]

24. The Royal College of Physicians Report Smoking and Health was published in 1962 to alert health professionals to the dangers of smoking. This report concluded that cigarette smoking is a cause of lung cancer and bronchitis and probably contributes to the development of coronary heart disease and other illnesses. In the USA, similar conclusions were drawn in the First Surgeon General's Report on smoking and health in 1964.[48]

Passive smoking

25. In 1983 the Independent Scientific Committee on Smoking and Health (ISCSH) referred to several reports relating to the health risks of environmental tobacco smoke (ETS). In particular they noted findings that children exposed to tobacco smoke from their parents had an increased risk of respiratory illness and that passive smoking exacerbated symptoms in adults already suffering from coronary and other arterial diseases.[49] The tentative connection between ETS and lung cancer was explored in more detail by the same committee in its Fourth Report in 1988. It concluded that there was "an increase in the risk of lung cancer from exposure to ETS in the range of 10-30 per cent" (that is, people who had been exposed to ETS for most of their lives had a 10% to 30% higher risk of lung cancer than non-smokers who were not exposed to tobacco smoke) and that each year several hundred smokers in the UK died from lung cancer contracted by passive smoking.[50] In 1992 the US Environmental Protection Agency published a report Respiratory Health Effects of Passive Smoking: Lung Cancer and other Disorders which "confirmed the findings published in the Fourth Report on the effects of ETS exposure in relation to lung cancer and to respiratory diseases in children," considered "the effect of ETS exposure on the development of ischaemic heart disease," and also "identified additional links between passive smoking and certain childhood illnesses".[51]

26. The First Report of the Scientific Committee on Tobacco and Health (SCOTH), published in March 1998, offered the most comprehensive analysis to date. It concluded that "exposure to ETS is a cause of lung cancer, and in those with long term exposure, the increased risk is in the order of 20-30%. Exposure to ETS is a cause of ischaemic heart diseases.... Smoking in the presence of infants and children is a cause of serious respiratory illness and asthmatic attacks. Sudden infant death syndrome.... is associated with exposure to ETS. The association is judged to be one of cause and effect".[52]

27. The recent report of the Confidential Enquiry into Stillbirths and Deaths in Infancy indicated that Sudden Infant Death Syndrome (SIDS) was substantially more prevalent in households where an infant was exposed to tobacco smoke. This study concluded that "the more hours the infant was exposed to smoke the greater the risk". Reviewing other literature on SIDS it suggested that "despite the absence of direct experimental evidence, the relationship between smoking and SIDS is probably causal". The report called for "public education about the risks of smoking in the home particularly in relation to respiratory diseases in children" and that health education programmes "should focus on the dangers of ETS in foetal development and particularly in the sudden infant death syndrome". The Committee recommended that "smoking in public places should be restricted on the grounds of public health", and suggested there was "a need for public education about the risks of smoking in the home....".[53]

29   Ev., p.1. Back

30   GHS 1998, p.116. Back

31   These figures suggest that the hypothesis of a recent upturn in smoking in women, postulated in the 1996 GHS, may have been "overly pessimistic" (GHS 1998, pp.116-17). Back

32   Nicotine Addiction in Britain, p.9. Back

33   Q136. Back

34   GHS 1998, p.119. Back

35   Ev., p.564. Back

36   DoH Press Notice 1998/0583.  Back

37   Some 26 Health Action Zones have so far been established in England covering over 13 million people. They aim to "tackle health inequalities and modernise services through local innovation" in "areas of deprivation and poor health" ( Back

38   Smoking Kills, pp.82-84. Back

39   Ev., p.21. Back

40   Ev., p.21. Back

41   Ev., p.21. Back

42   Ev., p.22. Back

43   Ev., p.22. Back

44   Ev., p.23. Back

45   Ev., p.23. Back

46   Ev., p.2. Back

47   Ev., p.2. Back

48   Ev., p.2. Back

49   Ev., p.3. Back

50   Ev., p.3. Back

51   Report of the Scientific Committee on Tobacco and Health,1998, p.27. Back

52   Report of the Scientific Committee on Tobacco and Health, 1998, p.33. Back

53   Sudden Unexpected Deaths in Infancy, The CESDI SUDI Studies 1993-1996, Ed. P. Fleming, P. Blair, C. Bacon and J. Berry, 2000, p.90.  Back

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