House of Commons - Health

Select Committee on Health Second Report

II MEASURES AGAINST SMOKING

Other measures to reduce and deter consumption

159. The primary weapon of Government action to reduce smoking has for many years been price. In its memorandum the Department concluded: "it is generally recognized on all sides that the single most effective policy for reducing tobacco consumption is price. Successive governments have therefore regularly raised excise duty on tobacco products as a means of discouraging consumption." They suggested that the current Government has committed itself to raising tobacco duty by 5% per annum in real terms.[277] Since 1993 successive Chancellors have indicated that they propose to increase the duty on tobacco products by a sum greater than the rate of inflation. The current Chancellor of the Exchequer in his 1999 Pre-Budget statement, however, indicated that this policy was not now guaranteed.[278]

160. The tobacco industry has argued forcefully that the great disparity in price as between the UK and the rest of EU has given great incentives to bootleggers. In turn they suggest that much of the tobacco distribution in the UK goes through unregulated channels in that bootleggers are unlikely

to exercise much scruple in selling their products to children. Imperial told us that it estimated that cross-border trading now comprised at least 80% of hand rolled tobacco sold in the UK and at least 20% of cigarettes.[279] The counter arguments put forward by ASH is that the great majority of tobacco smuggling comes not by means of the "white van trade" but through highly organized large scale activity; and that smuggling also occurred in low duty countries.

161. We endorse the Government's strategy in using price as a weapon of tobacco control although we believe that a number of factors need to be taken into account in pursuing this strategy. Firstly, as we have noted previously, smoking is already an activity strongly skewed towards the poorest groups in society. The addictive nature of nicotine means that this product is not one that the poorest smokers can easily sacrifice. So we believe that if this strategy is not to add to the social and health inequalities which smoking generates, the highest priority will need to be given to other smoking cessation services targeted at these individuals.

162. Secondly, we believe that if the Government is to make price its main weapon against smoking there needs to be a more explicit recognition that the duty increase is a health-promotion tax. We were surprised that the Department's officials had conducted no systematic analysis of the costs of smoking to society as a whole in the UK.[280] We asked the Department to estimate the social costs of smoking and they arrived at a figure of £2.32 - 2.35 billion per annum to cover fire damage to property, the costs of treating disease caused by passive smoking, the costs of treating smoking related diseases amongst current smokers and invalidity benefit relating to smoking related diseases. The Department admitted this analysis was "patchy".[281]

163. In terms of the income tobacco products yield in the UK the figures are not in dispute. HM Customs and Excise collected £8.2 billion in tobacco revenues in 1998/99.[282] It is within this context that we think the views of Dr Yach, Programme Manager of the WHO's Tobacco Free Initiative, need to be assessed when he told us "we find ... that when there is earmarking of tax for tobacco control activities, you have greater levels of public acceptance and you have a sustained institutional capability in countries to continue tobacco control beyond the pricing mechanism ...".[283] The Chancellor has, recently, shown himself willing to hypothecate some of the additional moneys accruing from the duty increases on tobacco towards the NHS. In his Budget Statement in March 2000, the Chancellor raised cigarette taxes by 5 per cent above inflation (25 pence per packet) and said that "every penny of the extra revenue....[would go] to funding our hospitals and the National Health Service".[284] We believe that, given the huge imbalance between the amounts the Treasury receives from smokers and the amount it spends on treating diseases caused by tobacco and on smoking cessation, the Government should earmark some of the increased tobacco revenues directly for smoking cessation strategies. We also believe that the Government needs more precise data on the actual costs of smoking to society.

164. If imbalances in tobacco duties between different EU countries prompt smuggling we believe this is a matter for law enforcement agencies. HM Customs and Excise itself estimates that £2.5 billion of revenue was lost as a result of tobacco smuggling.[285] The Government recognises that tobacco smuggling is on a "strong upward trend" and has designed a strategy to tackle it. This strategy consists of: a national network of scanners to detect high volume smuggling in freight containers; marks on packs to make identification of smuggled goods easier; tougher punishment for convicted smugglers; more customs officers; and a publicity campaign to raise public awareness.[286] The Government has committed up to £209 million over the next three years for extra staff and resources for Customs. This will fund up to 950 extra staff devoted to combating tobacco smuggling. Although these figures are not yet finalised, an immediate allocation of an additional £30 million each year from 2000-01 was announced in March 2000.[287] The Government hopes that this will "slow the growth of smuggling in the next financial year, and ... put smuggling into decline in the third year".[288] It estimates the new measures will result in an extra £2.25 billion being collected in revenues and VAT over the next three years.[289] We do not believe it would be appropriate for health policy to be shaped by the activities of criminal gangs. With this in mind we welcome the additional funding the Treasury is providing to boost Customs and Excise in their efforts to secure compliance with the law. In Section IV below we discuss the role of two tobacco companies in respect of charges that they were implicated with tobacco smuggling.

Education and information to consumers

165. In its memorandum the DoH pointed out to us that "successive governments have also invested in education campaigns warning consumers of the dangers of tobacco products".[290] The Minister for Public Health told us that the Department had recently "massively increased the budget for campaigning" and that a three year, £50 million new campaign had just been launched, which included television advertisements, billboard posters and telephone support lines.[291] We welcome the fact that the Government has launched its ambitious recent campaign. We are not, however, convinced that the Government has enough knowledge of the reasons why people smoke to make such a campaign fully effective.

166. The Minister for Public Health also assured us that the disbandment of the Health Education Authority (who gave oral evidence during our inquiry) to be replaced by the Health Development Agency did not represent any downgrading of the public health anti-smoking resource, and that the HDA would work towards more "evidence based" campaigns.[292] We welcome this assurance.

167. Information to consumers has for almost 30 years also been provided in the form of health warnings printed on cigarette packets (from 1971), and later on other advertising and promotional material.[293] The warnings, which began with the wording "WARNING by HM Government. SMOKING CAN DAMAGE YOUR HEALTH", have altered over the years. The Tobacco Products Labelling (Safety) Regulations 1991 were required following a European Council Directive which established a general warning to be carried on all unit packaging of all tobacco products, and additional warnings exclusively for cigarettes.[294] Other information made available to consumers includes, as we have seen, the machine tested levels of tar and nicotine.

168. The Chief Medical Officer (CMO) told us that evidence suggested that "warnings do make a contribution to stopping people smoking" but that they did not account for a "big percentage of behaviour change". Warnings were less effective in children than in adults and benefited from being frequently changed so that people did not simply switch off when they saw them.[295] We asked the CMO if he thought there should be emphasis on cancers other than lung cancer and he agreed that it would be helpful if more people were aware of the contribution tobacco made to oral cancers.[296] He also told us that the Health Education Authority's recent advertising campaign, drawing attention to the effects of smoking on the ageing of women's skin, had been "highly effective" with young women.[297]

169. We are, again, not convinced that the health education authorities can target their audience effectively without greater knowledge of what motivates people to smoke. We would draw the attention of health education authorities to the materials we have uncovered from the advertising agencies relating to the motivations of young and adult smokers. We believe that if this material were to be analysed carefully it could yield important information which could be used to dissuade people from smoking.

170. The health warnings themselves are partly a matter for the EU. Nevertheless we think it important that the information provided by public health authorities on cigarette packets, and given out in public health campaigns (in schools, workplaces, via primary care or through other media) adopts a greater variety of messages and conveys information not yet addressed in the health warnings. We believe that the general assertions that "smoking causes heart disease" or "smoking causes lung cancer", whilst having a place in an overall educational strategy, are not in themselves sufficient.

171. In its market research the Consumers' Association concluded that "most people are aware that smoking carries health risks" but that "awareness of some smoking-related conditions was higher than for others". In particular, they noted that "the increased risk of cardiovascular disease ... was not well recognized".[298] Given that heart disease kills more smokers than lung cancer this seems to us an alarming finding.

172. We believe that the Department of Health should instigate a much more comprehensive and sophisticated educational programme. From our meetings with public health groups in America we think it is vital that young people should themselves be actively involved in dissuading their peers from smoking. The Roy Castle Lung Foundation, which has particular expertise in the area of smoking and young people, suggested "peer to peer education by young people about tobacco is likely to be much more effective than lectures and admonitions from adults".[299] We believe that messages for young people, who are often not impressed by arguments that their life will be shortened by smoking since death for them seems such a distant prospect, should range from information on the way smoking makes them less desirable socially to the ways in which tobacco makes poor people poorer. For example, the fact that smoking can damage skin and teeth should be made clear. There is also evidence that male potency can be damaged by smoking.[300] This is a particularly strong message for young men and we recommend that the Government and health authorities make greater use of it when communicating the dangers of smoking. We further recommend that this message be included as one of the health warnings on packs.

173. So far as adults are concerned, it is our view that the Department should take account of the fact that smoking is skewed towards those in poorer and less well educated households, as the advertising agencies do in many of their campaigns (see above). We believe that the Department should examine the ways in which the agencies have marketed their advertising to this sector and copy some of their most successful strategies. We think it important that public health authorities, as well as conveying the risk of smoking attempt to convey the magnitude of the risks of smoking, in terms of stressing, for example, the numbers of years of life lost by an average smoker or the fact that smoking kills half of all lifelong smokers, and half of those before the age of 69. We think it important that adults should be much more aware of the benefits of quitting in respect of the surprisingly rapid health gains, not least in terms of the speedy improvement in likely life-expectancy that quitting yields.

174. For all age groups and all social classes, we believe it is essential that the packet contains clear and effective labelling to the effect that tobacco products are drug-delivery devices creating addiction through nicotine; we note that the Chief Medical Officer told us he thought it would "help a great deal" to draw attention to the addictive effects of nicotine.[301] We also believe that packs should have a contact number to gain access to NHS smoking cessation advice and programmes, a suggestion mooted by the Health Education Authority.[302] Messages should appear on all packs, stating the addictiveness of, and damage to health caused by smoking. In addition, a variety of health messages - such as that relating to male potency which we recommend above - should be used on certain packets. These messages should be harder hitting and more relevant to consumers than those currently used.

Nicotine Replacement Therapy and other treatments

175. Nicotine replacement therapy (NRT) aims to break smokers' dependency on tobacco products by offering them moderate levels of nicotine to alleviate withdrawal symptoms and breaking the association between smoking and nicotine.[303] Gum containing nicotine was first marketed in the UK in 1981; in the 1990s patches, nasal sprays, inhalators and sublingual tablets have all become available.[304] Nicotine replacement therapy is currently available within the NHS free for one week to those entitled to free NHS prescriptions, following trial provision in the Health Action Zones.[305]

176. We asked the DoH for their views on the efficacy of NRT. Mr Baxter told us that NRT "doubles the success of any quit attempt regardless of the intensity of intervention" and was "an effective route to smoking cessation" provided the treatment was followed for its full course.[306] Dr Milner expanded on this to indicate the range of possible effectiveness: if the intervention was simply "brief advice" from a GP plus NRT the effectiveness increased from 2% to 4%; if the patient attended a smoking clinic with regular group therapy sessions with follow up and relapse sessions, quit rates of over 20% might be achieved.[307] The Secretary of State also suggested that NRT worked best within a "structured programme". He added that "even within a structured programme the evidence suggests that it will benefit a maximum of around 25 per cent of people who give up smoking".[308]

177. A number of individuals and organizations criticized the restrictions placed on the availability of free NRT on the NHS. Sir Alexander Macara, former Chairman of the BMA Council, told us that it seemed "very regrettable that the ability for doctors to prescribe for their patients an effective drug which would really effectively help them is so restricted".[309] Professor John Britton of the RCP also took issue with the number of restrictions placed on NHS availability of NRT, suggesting that NRT was "one of the most cost effective medical treatments available", with estimated costs in the range of £200 to £800 per life year saved.[310] The Pharmacia and Upjohn Discussion paper describes the NHS policy of one week's free supply for exempt individuals as having "limited credibility amongst informed audiences".[311]

178. We asked Ministers what the rationale was for limiting NRT to one week's supply. The Minister for Public Health told us that NRT was provided free for the first week since that was the "toughest week" for those wishing to quit; thereafter the costs of purchasing NRT, which amounted to £15.50, was "comparable" to the costs of buying cigarettes.[312] We put it to the Secretary of State that this argument might appear logical but that limiting free NRT to a week's supply might well, in the end, be poor value for money. It seemed to us that the pull of nicotine addiction was likely to be very high at the end of the first week; whilst smokers would then make any number of sacrifices to obtain cigarettes, which they craved, they would be less likely to make the 'rational' decision to purchase the NRT alternative.[313] One Health Action Zone, that in Tyne and Wear, told us that its experience led it to conclude that a week's free supply was "not sufficient" since "it cannot be assumed that the money saved by not buying cigarettes in the first week will be used to buy NRT in the second and so on".[314] The Secretary of State conceded that these were "reasonable points" but argued that the UK was already ahead of anywhere else in the world and was, effectively, conducting an "enormous public trial" of the efficacy of NRT.[315]

179. We asked the Department what the current costs of the NHS NRT programme were and what the costs would be of making NRT freely available on the NHS. We were told that the costs of the current programme were £7.5 million over three years and that extending NRT to make it freely available on the NHS would cost £84 million.[316]

180. Professor Britton of the RCP suggested that one way forward might be to make free NRT conditional on "a certain point of success" in that most people who failed did so relatively quickly.[317] We believe there would be considerable merit in making NRT available on the NHS. However, we doubt whether the current policy of providing free NRT for one week establishes the crucial link between smokers wishing to quit and the Primary Care Team. We look forward to seeing an evaluation of the work being done in Health Action Zones with NRT. If NRT is shown to increase smokers' motivations to quit, we believe the Government should consider making NRT available on prescription[318] - available from smoking cessation clinics - for two weeks at a time, up to a maximum of six weeks in total. We also believe that once General Practitioners are able to prescribe NRT on the NHS this will motivate them to offer more comprehensive smoking cessation services.

181. We further suggest that the Government may need to address other anomalies relating to the prescribing of NRT. For example, Tyne and Wear Health Action Zone pointed out that "there are problems in promoting NRT as an aid to smoking cessation within some target groups because of the contra-indications to NRT, which include severe cardiovascular or cerebrovascular disease and pregnancy." Also, "NRT is not licensed for children". We agree with the Tyne and Wear Health Action Zone that "the risks of smoking outweigh the adverse effects of NRT".[319] The same issues raised by NRT are also likely to occur in respect of an emerging class of oral therapies. Evaluation of such therapies should be an important task for the National Institute for Clinical Excellence.

277 Ev., p.5. Back

278 Pre-Budget Statement (1999), p.94. Back

279 Ev., p.223. Back

280 QQ52, 55. Back

281 Ev., p.490. Back

282 HM Customs and Excise Annual Report 2000, Cm 4616, p.22. Back

283 Q293. Back

284 Official Report, 21.3.00, c 869. Back

285 Tackling Tobacco Smuggling, HM Customs and Excise, HM Treasury, March 2000, p.5. Back

286 ibid., p.1. Back

287 ibid., p.11. Back

288 ibid., p.11. Back