The Royal College of Physicians (RCP) has long
recognised that tobacco smoking is a major health hazard, and
since publishing its first report on "Smoking and Health"
in 1962 has played an important role in raising public and professional
awareness of the public health impact of smoking.
The RCP considers smoking to be an addiction typically
established during experimentation with and short term use of
smoked tobacco in teenage years, typically resulting in a longterm
dependence on cigarettes and sustained smoking for many years.
Half of all regular smokers die prematurely as a consequence of
smoking.
This burden of entirely avoidable mortality, which
currently accounts for over 100,000 deaths per year in the UK,
falls disproportionately on the poor and disadvantaged in society
and contributes more to social inequalities in health than any
other known avoidable cause.
Preventing smoking is therefore the most important
public health priority in the UK, and the RCP is committed to
the promotion of all strategies likely to reduce the prevalence
of smoking.
The RCP recognises that passive smoking (exposure
to environmental tobacco smoke or secondhand smoke) is a significant
public health hazard in its own right, but also that smokefree
policies in public and workplaces have a further important health
effect through their impact on the incidence and prevalence of
smoking. Smokefree policies are therefore an effective means of
both health protection and health promotion.
In July 2005 the RCP published a comprehensive report
on passive smoking, which recommended the implementation of comprehensive
smokefree legislation in all public and workplaces, without exception,
throughout the UK. The key conclusions and recommendations of
that report were:
1. Passive smoking currently kills about
12,000 people in the UK every year. These deaths are entirely
preventable. 2. Most of the deaths are caused by passive smoking
at home, but about 500 each year are due to exposure at work.
Exposure is particularly high for some workers in the hospitality
industry, such as bar workers.
3. There is an unanswerable moral case to protect
all people from passive smoking at work. All employees have a
right to work in a safe environment, and all employers have a
duty to ensure that they do. 4. Comprehensive smoke-free legislation,
making all public places and workplaces completely smoke-free,
without exception, is the only effective means of achieving this.
5. A clear majority of the public supports smoke-free legislation.
Where enacted in other countries, smoke-free policies have proved
to be extremely popular and attract high levels of compliance.6. Comprehensive
smoke-free policies also improve public health by helping existing
smokers to quit, and discouraging young people from starting to
smoke. As a consequence, smoke-free legislation will also generate
longterm health improvements and reductions in social inequalities
in health.7. Preventing passive smoking at home, particularly
for children, is a public health priority. Home exposure is prevented
only by encouraging parents and carers to quit smoking completely,
and/or by making homes completely smoke-free.8. By helping
smokers to quit smoking, and by changing usual patterns of smoking
behaviour, smoke-free policies in public and workplaces increase
the number of smoke-free homes. Strong and sustained health promotion
campaigns are required to enhance this process. These and other
population and individual-level interventions to encourage smoking
cessation are the most effective means of reducing ETS [Environmental
Tobacco Smoke] exposure at home.9. Making the UK smoke-free
would benefit the economy by about £4 billion each year.
10. We recommend that the UK Government
enact comprehensive legislation to make all workplaces and other
enclosed public places smoke-free at the earliest possible opportunity.
The RCP thus takes the view that radical and comprehensive
smokefree policy is a crucial public health and health protection
priority. The RCP therefore welcomes and fully supports the proposal
to introduce smokefree legislation in the Health and Health Protection
Bill, but disagrees in particular with some of the proposed exemptions.
The RCP responses to the questions posed in the current
consultation are as follow. Where appropriate, to provide a source
for a review and summary of the evidence supporting our responses,
we cite the relevant chapters in our recent report, 2 provided
as an appendix to this document in pdf format.
1. Definition of smoke or smoking
Although the evidence on smoking and passive
smoking effects relates predominantly to tobacco smoke, many of
the major constituents of the tar and vapour produced by burning
non-tobacco products are similar to those in tobacco smoke, and
are consequently likely to be similarly harmful. The RCP would
therefore support the adoption of a definition which includes
all products used with intent to inhale smoke.
2. Definition of "enclosed"
In view of the additional value of smokefree
policies as a means of "denormalising" smoking and consequently
both reducing smoking prevalence and increasing the numbers of
smokefree homes [see Chapters 3 and 7], the RCP proposes that
the legislation should apply to all public and work places irrespective
of whether they are enclosed.
3. Proposal to include some other non-enclosed
public places
The RCP would support the inclusion of all public
places that are part of or in a built environment. Exemptions,
if any, should be restricted to outdoor areas in open countryside.
4. Proposal to delay implementation of smokefree
policies in licensed premises
The RCP sees no justification behind this proposal.
Experience in Ireland and New York demonstrates that implementation
of comprehensive policies in all premises is effective and achieves
high compliance [see Chapter 15]. There is no clear advantage
in delaying the implementation in licensed premises, but there
is disadvantage arising from the health effects of continued exposure
of staff and customers to passive smoke. Licensed premises should
become smokefree at the same time as all other work and public
places.
5. Proposed exceptions to permit continued
smoking in licensed premises that do not serve food
The RCP sees no logic or justification for this
exemption. All licensed premises are workplaces, and people working
there are entitled to the same protection from the health effects
of passive smoke as in any other environment. Exposure to passive
smoke is especially high in licensed premises [see Chapter 3]
so the need for protection of workers in these environments is
a particular priority.
6. Exemptions for residential premises
The RCP considers that the only exemption should
be the private home of the smoker. Residential accommodation (such
as hotels, nursing homes, halls of residence) that is also a workplace,
and/or includes non-smoking residents, should be smokefree. There
are however some special cases, such as prisons or psychiatric
institutions, where smokers are detained against their will and
are thus deprived of the option of smoking in their own private
home [see Chapter 14]. In these cases exemptions should made,
but in a context of provision of maximal cessation support for
the smoker to quit if he or she chooses, and of preventing exposure
of other residents or staff to tobacco smoke. From a moral and
ethical perspective, the human rights of the smoker in all of
these circumstances are outweighed by the rights of others to
a clean and safe environment [see Chapter 10].
7. Membership clubs
See comments on licensed premises above.
8. Practical implications in the workplace
Experience from the many parts of the world
where smokefree policies have been implemented demonstrates clearly
that smokefree policies are effective and successful, in almost
all circumstances [see Chapters 9 and 15]. It is however crucial
in implementing smokefree policies to ensure that as far as possible,
smokers are provided with cessation support to encourage and promote
quit attempts.
9. Signage
Signage is clearly important for public information
but only especially so if there is likely to be confusion over
where smoking is and is not permitted. The RCP proposes that non-smoking
should be the default in any public or workplace, and that signage
should be required to reinforce that message.
10-12. Penalties, Defences and Enforcement
These are crucially important areas and we would
advise the adoption of policies that have proved successful in
other countries, and particularly the Irish experience. In Ireland
the general approach is similar to that outlined in the consultation
but fines are substantially higher. Responding rapidly to episodes
of non-compliance in the early days of the smokefree legislation
was also crucially important, and appropriate resources need to
be made available for this. The experience in Ireland suggests
that the need for these resources falls rapidly over time [see
Chapter 15].
13. Proposal to restrict smoking at the bar
Smoking in an enclosed place is harmful to everyone.
Exposure of staff in pubs and bars is especially high [see Chapter
3]. Making the bar area smokefree does not protect staff from
exposure, because smoke drifts. Partial policies such as this,
or the use of ventilation, can sometimes improve subjective air
quality but does not prevent exposure to harm [see Chapter 5].
This proposal is therefore ineffective and also potentially counterproductive,
since it implies that non smoking areas within rooms where people
smoker are somehow safer. They are not. The RCP opposes this policy.
14. Timetable
The RCP considers that the optimum time of year
to introduce comprehensive smokefree legislation is the spring
(in Ireland the date was late March) and that the sooner the legislation
is introduced, the better. To give time to prepare the public
(and to allow the further increase in public support for the legislation
that follows the announcement of legislation, see Chapter 9) the
announcement of intent should be made as soon as possible, and
the date no later than March 2007.
15. Effects on binge drinking
This concern arises from the proposal to allow
exemptions for pubs that do not serve food. The RCP opposes those
exemptions. If all pubs are required to become smokefree, this
concern is redundant.
16. Effect on health inequalities
The prevalence of smoking is highest, and the
potential benefits of preventing smoking greatest, in the poorest
communities. Exposure to passive smoking is also highest in these
communities [see Chapter 3]. It is therefore self-evident and
particularly important that comprehensive smokefree policies apply
in all communities, so that all can reap the maximum public health
benefit. The proposal to exclude pubs that do not serve food will
in the long run exacerbate health inequalities, since these pubs
tend to be located in poorer areas.
17. Comments on Partial Regulatory Impact
Assessment
The RCP supports Option 2. We are persuaded
by the experience of New York and particularly Ireland that concerns
that the policy would not gain public support and may be difficult
to enforce are entirely unfounded. We estimate the cost benefits
to society of Option 2 at about £4 billion per year [see
Chapter 11]. Our analysis is that any adverse effect on the hospitality
trade is likely to be extremely small [see Chapter 12].CONCLUSION
The RCP supports this legislation but believes strongly
that it does not, as proposed, go far enough. We urge the government
to learn from the experience of other countries and implement
comprehensive smokefree policies in all public and workplaces,
without exception, as soon as possible.REFERENCES
Twigg L, Moon G, Walker S. The smoking epidemic in
England. London: Health Development Agency; 2004.
Royal College of Physicians. Going smoke-free:
the medical case for clean air in the home, at work and in public
places. A report on passive smoking by the Tobacco Advisory Group
of the Royal College of Physicians. London: RCP; 2005.
Royal College of Physicians. Nicotine Addiction
in Britain. A report of the Tobacco Advisory Group of the Royal
College of Physicians. London: Royal College of Physicians of
London; 2000.
September 2005
