Memorandum by Asthma UK (SP05)
INTRODUCTION
1. The following submission is made by Asthma
UK. Asthma UK is dedicated to improving the lives of the 5.2 million
people currently receiving treatment for asthma in the UK, 4.6
million of whom live in England and Wales. We work with people
with asthma, healthcare professionals and researchers to develop
and share expertise to help people increase their understanding
and reduce the effect of asthma on their lives. We monitor the
needs and priorities of people with asthma, and they consistently
tell us that other peoples' smoke has a major impact on their
everyday lives. We are part of the Smokefree Action coalition
and the Smoking Control Network and we would like to be considered
for oral evidence to the Committee.
2. Our submission explains why we need comprehensive
smoke-free legislation ie legislation that restricts smoking in
all the places where people go to work or socialise.
THE NEED
FOR COMPREHENSIVE
SMOKE-FREE
LEGISLATION
3. Comprehensive legislation is important
for England and Wales because it will save hundreds if not thousands
of peoples' lives every year. The number of negative effects of
second-hand smoke is staggering. As little as 30 minutes exposure
to second hand smoke is enough to measurably reduce coronary blood
flow in non-smokers (1). The Department of Health's Special Committee
on Tobacco and Health (SCOTH) states in unambiguous terms that
second-hand smoke causes lung cancer, ischaemic heart disease
and a variety of respiratory diseases (2). The Royal College of
Physicians recently announced that second-hand smoke is responsible
for 12,000 fatalities in the UK every year, 600 of which are due
to exposure at work (3). Respiratory diseases are becoming increasingly
serious. They are now responsible for the majority of emergency
admissions to hospital, and are responsible for more fatalities
than Coronary Heart Disease (4).
4. Why is comprehensive smoke-free legislation
important for people with asthma? An individual's right to smoke
does not trump the right of those around them to breathe clean
air. For people with asthma, smoke is a potent lung irritant,
and even a small amount is capable of triggering asthma attacks.
For those that suffer from severe asthma symptoms a smoker's decision
to light up in public places can have very serious, potentially
lethal, consequences. Legislation that makes public places smoke-free
is important for people with asthma because of the big improvements
it will bring to their lives.
— The vast majority of people with
asthma—82%—say that other people's smoke makes their
asthma worse. Many of these people cannot go to the public places
where other people smoke.
— 40% of adults with asthma say they
avoid smoky pubs and restaurants (5).
— In the lead up to the last general
election, Asthma UK conducted a web poll that found that restricting
smoking in workplaces and enclosed public places was the most
important election issue for people with asthma (6).
— Comprehensive legislation is important
because it will help to reduce the number of people who develop
asthma in the future. Exposure to second-hand smoke at work doubles
the risk of acquiring adult onset asthma, and living with a smoker
increases the risk of developing asthma by five times (7). Children
whose parents smoke are 1.5 times more likely to develop asthma
(8).
5. Exemptions create significant enforcement
issues. Exemptions complicate matters because they create the
need to differentiate between smoking and non-smoking premises,
and increases the need for enforcement officials to ensure compliance.
By comparison, comprehensive policy makes things much simpler.
People come to expect clean air in public places, and social pressure
largely replaces the need for formal enforcement authorities.
DEFINITIONS
6. In our recent response to the Department
of Health consultation on the smoke-free elements of the Health
Improvement and Protection Bill, we raised two objections to the
proposed definitions of "smoke" and "smoking".
The rationale provided in the consultation document for limiting
the definitions to refer to tobacco and tobacco-containing substances
is straightforward: the accumulated medical evidence examines
the effect of tobacco smoke on the general population, and there
is a lack of evidence on the health effects of other kinds of
smoke. From our perspective, the legislation needs to recognise
that any kind of smoke is capable of triggering sudden asthma
attacks and needs to restrict smoking altogether, regardless of
whether that smoke comes from tobacco or something else. Limiting
the definitions also leads to practical difficulties. For example,
those responsible for ensuring compliance need to be able to immediately
and unambiguously distinguish between tobacco and non-tobacco
smoke. Limiting the definitions will inevitably lead to confrontation
and disputes, which will undermine the ability of proprietors
and staff to enforce rules. This in turn heightens the demand
for appropriately empowered enforcement officials to settle disputes.
A definition of smoking that covers smoke from all substances
would be much more straightforward.
7. In the same consultation response we
also expressed reservations about the strong emphasis on restricting
smoking in "enclosed" spaces. The legislation should
focus on protecting people from exposure from other peoples' smoke,
whether it be outdoors or indoors. We have no major objections
to the proposed definition, provided that it is accompanied by
regulations to clearly identify "open" public places
where smoking should not be allowed. Regarding public places that
fall outside the definition, we support the proposal to include
regulatory powers to cover gaps left by the definition of "enclosed
public place". We also agree with the suggestion that sports
stadia are an example of kind of a public place that should be
included. The principle that should guide the selection of other
places should be simple: it should to restrict smoking in places
where non-smokers (both workers and other members of the public)
will be exposed to other peoples' smoke. Examples of such places
would include bus shelters, outdoor garden areas of pubs or clubs,
and outdoor theatres or music venues.
EXEMPTIONS
8. On the issue of exemptions of pubs that
do not "prepare and serve food"—We strongly object
to the proposal of providing exemptions to pubs that do not prepare
and serve food. There are at least five reasons why these exemptions
are unacceptable.
— They are not based on, nor are they
supported by, health evidence. There is no health evidence underlying
the decision to permit smoking in pubs that do not serve and prepare
food.
— With exemptions, the legislation
fails to protect many of those most at risk. Every person has
a right to work in a safe environment, and every employer has
a duty to ensure that right. The SCOTH report identifies that
hospitality workers are most at risk from the harmful effects
of smoke (2), and with exemptions, the legislation fails to protect
many of these workers. We are particularly concerned about hospitality
workers with asthma. For people with asthma that work in smoky
environments, a shift of several hours leaves their lungs continually
agitated for a long while afterwards. Doing simple things like
climbing a flight of stairs, or running to catch a bus can bring
on debilitating attacks of coughing or wheezing. They come to
lead progressively constrained lives, and live with a much higher
risk of having a serious, perhaps fatal asthma attack. Worst of
all, living continuously with symptoms causes irreparable damage
to their lungs, and over time, these people will experience dramatic
decreases in their lung function (9).
— Exemptions make the policy complicated
to the point of being unworkable. They will require the introduction
of licensing systems, which themselves need significant investment
of time and resources. The operation of these systems will hinge
on definitions for intrinsically ambiguous concepts such as "serve
and prepare food". The creation of loopholes and confusion
are virtually guaranteed, and will ultimately undermine effective
enforcement.
— Exemptions undermine government targets.
Reducing the number of places where people can smoke helps people
to change their smoking patterns, and helps them quit (3). In
the Choosing Health White Paper, smoke-free legislation
is clearly presented as part of a larger strategy to help people
quit smoking (10), but providing exemptions in the legislation
will seriously undermine Government's ability to meet its targets
for reducing smoking prevalence. It is absolutely critical that
smokers who have asthma are encouraged to quit. 25% of people
with asthma smoke, with dramatic repercussions on their health.
They experience accelerated decrease in lung function after the
age of 30, and to make matters worse, smoking reduces the effectiveness
of corticosteroid asthma medications. Without this cornerstone
treatment for preventing asthma attacks, their ability to control
their condition is severely undermined (11). Another health target
that exemptions undermine concerns the government's efforts to
combat binge drinking. Exemptions will create pubs that specialise
as smoking and drinking venues. Food slows the penetration of
alcohol, mitigating against its more extreme effects. Because
food will not be available, exempt pubs will be much more likely
to become places where problem behaviour is more likely to occur.
They are also likely to become enclaves that reinforce dysfunctional
behaviour. Dependency on alcohol and tobacco are mutually reinforcing,
and the emergence of specialist smoking and drinking venues are
more likely to encourage rather than discourage unhealthy habits
and problematic behaviours (12).
— Finally, exemptions deepen existing
health inequalities by discriminating against lower socio-economic
groups. Prevalence of smoking is higher amongst these groups (13).
Incentives for pubs to switch to serving only alcohol will be
stronger in lower income areas. Lower socio-economic groups will
tend to experience fewer incentives to stop smoking, and as a
result will tend to be exposed more to second hand smoke and suffer
more serious health consequences (14). Studies from the UK and
elsewhere illustrate a strong association between high asthma
morbidity and mortality among lower socio-economic groups (15),
and we expect that the proposed exemptions will exacerbate existing
health inequities for people with asthma.
9. Exemptions—Residential premises.
People have the right to a home life. Places such as prisons and
residential psychiatric institutions are a challenge for the legislation
because they are private residences in some ways, and public places
in others. There are additional complications because they are
often home to people with behavioural problems, and complete bans
run the risk of creating additional difficulties. For instance,
experience in America illustrates that banning smoking in prisons
can lead to cigarette smuggling and other disciplinary problems
(16). Complete bans also raise human rights concerns. For example,
it is not right to deny cigarettes to people with mental illnesses
who have been institutionalised against their will. In circumstances
such as these, the legislation needs to find the right balance
between individuals' right to smoke in their home, and the duty
to protect others from the effects of that smoke. The legislation
should also provide an environment that encourages people to quit,
but does not coerce them to do so. In order to meet this balance,
we recommend that group residences be required to create designated
smoking areas where residents and staff can go to smoke, and where
that smoke will not affect other residents or employees.
10. Exemptions—Membership clubs. We
strongly object to proposal of making private clubs exempt. This
is because the staff of membership clubs would not be granted
their basic right to a safe work environment.
ENFORCEMENT ISSUES
AND PENALTIES
11. Offences, penalties and defences—The
offences and defences are suitable, but the proposed penalties
for establishments failing to enforce smoking restrictions need
to be revisited. In particular, a £200 fine for failing to
discourage patrons from smoking does not provide a strong enough
incentive for enforcing no-smoking rules. At £200, establishments
opposed to the legislation could decide to flout restrictions
and expect that the revenue gained from smoking patrons would
easily offset the fine. The fine should to be higher, and it should
increase with repeat offences, possibly to the point where liquor
license is revoked after multiple offences.
12. Enforcement—Exemptions make enforcement
complicated. By comparison, a comprehensive policy will be much
clearer and easier to enforce. One of the biggest benefits of
comprehensive legislation from the point of view of enforcement
is that the public comes to expect clean air. In public places,
social pressure becomes a powerful curb on smoking and drastically
reduces the need for enforcement by formal authorities.
13. Smoking at the bar—The consultation
document recognises that the proposal of restricting smoking around
the bar will not result in any health improvement. This proposal
cannot be considered a serious alternative to restricting smoking,
and we consider it to be unacceptable.
TIMETABLE
14. Timetable—The time for the policy
to be introduced is far too long. Clearer, simpler legislation
without exemptions would be easier to implement and require less
time. Given the severity of the health effects of second-hand
smoke, the policy should come into force as soon as possible,
certainly much earlier than the end of 2008. Evidence suggests
that advancing the schedule by one year could save 600 lives (3).
DEALING WITH
OBJECTIONS TO
COMPREHENSIVE LEGISLATION
15. Given the weight of evidence gathered
and presented in the SCOTH report (2), and given that the Regulatory
Impact Assessment (17) found that a comprehensive smoke-free policy
offers the greatest net benefit, the proposal for exemptions seems
puzzling. However, since exemptions have been tabled, we think
it is worthwhile to briefly address the strongest objections to
comprehensive smoke-free legislation.
16. Fear of negative economic effects—Objections
to comprehensive legislation are often based on the fear that
there will be losses in employment and revenue in the hospitality
sector. The tobacco industry has been particularly active in promoting
these fears. They have commissioned numerous studies to distort
scientific evidence (18), and by playing on fears, they have encouraged
hospitality industry associations to carry the debate into the
public sphere (19). It needs to be emphasised that fears about
negative economic impact are groundless. A recent review of the
evidence illustrates how partisan the tobacco industry-supported
research really is. It illustrates that the only studies that
predict negative economic impacts are those supported by the tobacco
industry. It also demonstrates that the findings of these studies
are highly suspect, as they tend to be based on the expectations
of worried club and bar owners before smoke-free policies are
introduced. More robust studies—those not affiliated with
the tobacco industry, and based on much more objective data such
as bar receipts after policies have been introduced—overwhelmingly
show that smoke free legislation does not bring economic harm
(20). The sheer number of positive experiences with comprehensive
smoke-free legislation in other countries ought to be reassuring.
Ireland and Norway have implemented smoke-free policies with no
attributable negative effect on employment or revenue (21) (22).
In New York City, businesses actually appear to have had a substantial
increase in revenue after comprehensive legislation came in (23).
17. Prioritisation of individual choice—The
second objection made against comprehensive smoke-free policies
is that they infringe on smokers' rights to choose whether they
smoke or not. Once again, this is a position that has been largely
promoted by the tobacco industry. The tobacco industry has pro-actively
lobbied for tobacco control legislation that enshrines individuals'
right to choose to smoke. It does this for a variety of reasons.
One is that the medical evidence has accumulated to the point
that the industry is no longer able to dispute the proof about
the extreme negative health consequences of its products. Another
is to repair declining morale amongst its employees (24). Most
of all, the tobacco industry knows that comprehensive smoke-free
policies help people quit, and as a result, they have much more
drastic effects on their sales than do partial restrictions (25).
It is important for policy makers to remember that the argument
for individual choice is a diversion. An individual's right to
smoke does not trump the right of those around them to breathe
clean air, and the vast majority of the public understand this.
A smoker's right to light a cigarette in a pub should not outweigh
the right of people with asthma to be there. Nor should it outweigh
the rights of the pub's workers to a safe working environment.
Policy makers do not have to worry that comprehensive legislation
will go against public opinion. Experience in other countries
has been that comprehensive legislation becomes increasingly popular
once it comes in. Surveys with nationally representative samples
in Ireland show that support for the smoke-free law was strong
at the outset (67% supported the law) and grew steadily afterwards.
That support grew to 82% after the law was introduced, with 95%
recognising that it was a positive health measure (21). There
is every indication that comprehensive legislation will be just
as popular in England and Wales. The National Assembly for Wales
has already voted in favour of comprehensive policy. Studies carried
out by the Office of National Statistics for the Department of
Health indicate that in England, support for smoking restrictions
has been steadily increasing since 1996, and is currently higher
than it was in Ireland before the legislation was introduced (13).
And for the 4.6 million people with asthma people with asthma
in England and Wales, comprehensive legislation will certainly
come as a welcome breath of fresh air.
SUMMARY
18. Reasons why people with asthma need
comprehensive smoke-free legislation:
It will dramatically improve the quality of
their lives:
— People with asthma will no longer
be excluded from going to public places where other people smoke.
— People with asthma working in smoky
environments will no longer have to put up with continual asthma
symptoms, and they will not suffer the degree of long-term respiratory
damage they otherwise would.
— It will encourage smokers with asthma
to quit, and as a result, they will realise dramatic improvements
in their quality of life.
— Smokers that live with people with
asthma will be encouraged to quit, which will also improve living
conditions of people with asthma.
It will reduce the number of people that develop
asthma in the future:
— Exposure to second-hand smoke at
work doubles the risk of acquiring adult onset asthma.
— By helping reducing the number of
parents that smoke, the legislation will contribute to reducing
the number of children who will develop asthma. Children with
parents that smoke are 1.5 times more likely to develop asthma
than those whose parents do not.
September 2005
NOTES AND
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