Education and information to
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".
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.
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.
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
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
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.
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
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
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".
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".
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.
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
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
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.
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.
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.
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.
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.
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
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".
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".
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.
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".
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.
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
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".
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.
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.
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.
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
- 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
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
277 Ev., p.5. Back
Pre-Budget Statement (1999), p.94. Back
Ev., p.223. Back
QQ52, 55. Back
Ev., p.490. Back
HM Customs and Excise Annual Report 2000, Cm 4616,
Official Report, 21.3.00, c 869. Back
Tackling Tobacco Smuggling, HM Customs and Excise,
HM Treasury, March 2000, p.5. Back
ibid., p.1. Back
ibid., p.11. Back
ibid., p.11. Back
ibid., p.12. Back
Ev., p.6. Back
See eg Ev., pp.200-203. Back
Ev., p.5. Back
Ev., p.510. Back
Ev., p.501. Back
Nicotine Addiction in Britain, p.143. Back
Pharmacia and Upjohn Discussion Paper 1, 1999, p.9; Nicotine
Addiction in Britain, pp.145-46. Back
Q120; see further Q1299 and Q378. Back
Q371; see S Parrott et al, "Guidance for commissioners
on the cost effectiveness of smoking cessation interventions",
Thorax, 1998:53 (Suppl 5, Pt 2). Back
Pharmacia and Upjohn Discussion Paper 1, p.26. Back
QQ1293-99; Q1302. Back
Ev., p.536. Back
Q126, Q1280 and Ev., p.588. Back
This would mean that smokers currently receiving free prescriptions
would not have to pay for NRT for a period of up to six weeks. Back
Ev., p.536. Back