Memorandum by British Medical Association
(BMA) (SP36)
SUMMARY
1. The BMA has long campaigned for smoke-free
public places, and welcomes this opportunity to comment on the
Government's proposals for legislation. There can be no doubt
that the UK's doctors want comprehensive action on smoke free
places, with only extremely limited exemptions. About 2,000 BMA
members took the time to respond to the Government's consultation
on its proposals, and thousands more have written to the Prime
Minister to ask for action.
2. The health evidence that second-hand
smoke kills is beyond dispute, but doctors' knowledge does not
just come from scientific papers—they also see the effects
of second-hand smoke on the lives of their patients and their
families. Doctors can see that their least affluent patients bear
the heaviest burden of disease from smoking and second-hand smoke,
and know that this suffering is preventable. They can see that
second-hand smoke kills whether or not there are pies with the
pints.
3. The Government's proposals simply do
not go far enough to protect health. The evidence is very clear—partial
measures will not protect people, and the proposals for exemptions
will penalise the poor. There is robust evidence to show that
the proposals will widen the health inequality gap still further.
They will condemn low paid bar workers to the health risks of
second-hand smoke at work, and smoke-filled pubs and membership
clubs will leave customers at greatest risk in the poorest parts
of the country. The proposals will consolidate the "smoking
culture" in low income communities, perpetuating high smoking
rates, and catastrophic levels of smoking related disease amongst
the poor.
4. Independent, peer reviewed studies show
that comprehensive legislation benefits health. Smoke-free laws
prevent ill health from second-hand smoke, and encourage smokers
to quit. They motivate smokers to protect their families from
second-hand smoke in the home. Countries which have already gone
smoke-free have shown that the only business that suffers in the
face of legislation is the tobacco industry, and that bars, restaurants
and tourism can thrive. Their experiences have also shown that
laws are popular, effective and easy to enforce.
5. As Scotland prepares to go smoke-free
in Spring 2006, the BMA welcomes the government's proposals to
allow the Welsh Assembly to legislate for Wales, and looks forward
to the announcement of plans for Northern Ireland. People throughout
the UK deserve the same level of protection from second-hand smoke.
There is no need for half measures and compromises, and no justification
for further delays. The time has come for a comprehensive law.
6. The BMA welcomes the opportunity to submit
evidence to the Committee Inquiry, and would be delighted to assist
the inquiry by providing oral evidence or further written submissions
to the committee.
INTRODUCTION
7. The BMA is a voluntary, professional
association representing doctors from all branches of medicine
across the UK. About 80% of practising doctors are members.
8. Our response is based upon a long-term
interest in public health issues, and a particular commitment
to evidence-based tobacco policies. Our recent reports include:
Behind the smokescreen: the Myths and the Facts (2005),
The human cost of tobacco (2004), Smoking and reproductive
life (2004), and Towards smoke free public places (2002).
THE HEALTH
EFFECTS OF
SECOND-HAND
SMOKE
9. The evidence that exposure to second-hand
smoke causes fatal illnesses including lung cancer and heart disease
is now conclusive. Major reviews of the evidence by bodies including
the WHO International Agency for Research on Cancer, the UK Scientific
Committee on Tobacco and Health, the US Surgeon General and the
US Environmental Protection Agency have concluded that second-hand
smoke is a major health hazard. The major effects are summarised
in the table below (1).
| There is conclusive evidence that exposure to second-hand smoke causes:
| There is substantial evidence that exposure to second-hand smoke causes:
|
| Adults | Lung cancer
Coronary heart disease
Asthma attacks in those already affected
Onset of symptoms of heart disease
Worsening of symptoms of bronchitis
| Stroke
Reduced foetal growth (low birth-weight baby)
Premature birth
Chronic Obstructive Pulmonary Disease (2)
Reduced Lung function (3)
|
| Children | Cot death
Middle-ear disease (ear infections)
Respiratory infections
Development of asthma in those previously unaffected
Asthma attacks in those already affected
| |
| | |
10. The BMA welcomes the Government's position that it
accepts the evidence that second-hand smoke causes fatal illnesses.
In the light of this, the BMA wonders how the Government can justify
a policy which will leave some people—predominantly the
poor—exposed to the lethal effects of second-hand smoke
in workplaces and public places.
COMPLETELY SMOKE-FREE
POLICIES ARE
THE ONLY
WAY TO
PROTECT PEOPLE
FROM SECOND-HAND
SMOKE
11. Completely smoke-free policies are the only way to
protect people from second-hand smoke. No safe level of exposure
to second-hand smoke has been identified, and the harmful gases
and particles in smoke will diffuse into the available space,
whether smoking is permitted there or not. One US study found
no differences either in the ambient levels of tobacco smoke or
in the amount of nicotine absorbed by workers in smoking and non-smoking
areas (4). An Australian study showed that designated "no
smoking" areas, including smoke-free rooms, provided partial
protection from tobacco smoke at best. At worst, the data suggested
that they provide no protection whatsoever (5).
12. Ventilation cannot protect people from the hazards
of second-hand smoke. Filtered smoke is as carcinogenic as unfiltered
smoke (6), while research from the US (7) and EU (8) has shown
that displacement ventilation technology cannot remove the gases
and particles from the air. Separate smoking rooms leak smoke
into the rest of the building, contaminating the rest of the space
with second-hand smoke. Where ventilation systems are used, they
are often incorrectly installed or switched off altogether. In
one Canadian municipality, 78% of designated smoking rooms failed
to meet the standards set by the law (9).
13. Smoking rooms pose health risks for staff. Even where
staff are not required to work in these areas, it may be hard
for low paid workers to refuse. In addition, staff would have
to clean smoking rooms.
14. Not only are designated smoking rooms and ventilation
an ineffective health measure, they also create an uneven playing
field. Large scale operations can afford to designate space in
this way, and to install ventilation systems, while smaller operators
cannot. In Ottawa, small bar owners successfully won a court case
to disallow designated smoking rooms because they created unfair
competition (10).
15. Internal tobacco company documents show that worldwide
the tobacco industry has consistently proposed voluntary regulation
and "accommodation" strategies, such as ventilation
and non-smoking areas as a strategy to prevent comprehensive legislation
(11). In the UK, leading proponents of this approach, including
AIR (Atmosphere Improves Results) and FOREST receive funding from
the tobacco industry.
BENEFITS OF
COMPREHENSIVE SMOKE-FREE
LAWS
Health
16. Smoke-free laws have significant short and long term
health benefits. In Ireland (12) and California (13), research
studies have shown significant improvements in bartenders' respiratory
health. In one Montana city, the rate of acute myocardial infarction
(heart attack) declined over six months while a smoke-free law
was in place, only to increase again once the law was revoked
after pressure from the tobacco industry (14).
17. Smoke-free laws also have a major public health impact,
because they encourage smokers to quit (15). It has been estimated
that reducing smoking rates by one percentage point per year over
10 years will save nearly 70,000 lives in UK smokers aged 35 to
74 (16). The biggest single factor in reducing deaths from heart
disease in the last 20 years has been smokers giving up. Quitting
prevented nearly 30,000 heart disease deaths from 1981-2000 in
England and Wales (17). California's lung cancer rates have declined
six times faster than in states without smoke-free laws (18).
Smoking in the home
18. It has been asserted that smoke-free legislation
in all pubs will increase smoking in the home and increase families'
exposure to second-hand smoke. There is no evidence to support
this. All the available evidence suggests that smoke-free laws
actually reduce smoking in the home—and especially smoking
around children. This is because when fewer adults smoke, children's
exposure to second-hand smoke is reduced (19), and because parents,
including smokers, are more likely to adopt smoke-free homes after
a policy is introduced (20).
19. In Australia, the proportion of family homes with
smoking restrictions more than doubled after smoke-free workplaces
were introduced. The most dramatic increases were seen in households
where all the adults smoked—smoking restrictions increased
from 2% to 32% of homes (21). In California, the proportion of
children and adolescents living in smoke free homes increased
from 38% in 1992, to 82.2% in 1999 (22), the year after the law
was applied to all indoor workplaces. Survey data from Ireland
shows that the number of smokers who have smoke-free homes has
increased since the law came into force (23).
IMPLICATIONS OF
THE GOVERNMENT'S
PROPOSALS
Exemptions
20. The BMA believes that the most problematic element
of the Government's proposals are the planned exemptions. The
evidence is clear—second-hand smoke kills, whether or not
there are pies with the pints. Nobody should be exposed to it
in the course of their work.
21. Any exemptions to the legislation must be kept to
an absolute minimum, as has been the case in Ireland, Norway and
Scotland. Exemptions should only be considered for places defined
as people's homes, and a very limited number of other premises.
The BMA accepts that there may be compassionate grounds to allow
smoking in certain premises in specific circumstances. Nonetheless,
the human right to live and work without being exposed to poisonous
and life-threatening substances must take precedence over any
perceived right to smoke.
22. The Government's proposals to exempt certain licensed
premises from the legislation are arbitrary and inequitable. There
can be no justification for legislation that will leave low paid
workers at risk, with their health decided by a members' ballot
or their employer's decisions on menu items.
23. There is now evidence that the proposed exemptions
will increase health inequalities. It is also apparent that the
government has underestimated the number of wet-led pubs, the
variations in geographical distribution of exempt premises, and
the impact of the proposals on pubs' decisions to serve food.
EFFECT OF
THE PROPOSALS
ON INEQUALITIES
IN HEALTH
24. In the UK, smoking rates follow a distinct socio-economic
gradient. Smoking rates range between 15% among professional groups,
and 37% among those who are employed in routine jobs. Up to 52%
of working age men who are economically inactive are smokers (24).
25. Health inequalities have increased since 1997, despite
the Government's avowed intention to reduce these (25), (26).
These exemptions will widen the gap between rich and poor still
further.
26. The BMA's Booze Fags and Food report (27 )found that
the proportions of non-food pubs reflected a North/South divide,
ranging from 88% in Leeds, to 5% in Bromley. A survey of the North
East of England found that 52% of all licensed premises would
be exempt, with figures ranging from 81% in Easington, which is
the 6th most deprived area in England, to 23% in Tynedale, which
is ranked 221st (28).
27. In a recent BMJ study (29), non-food pubs accounted
for more than half of all the pubs located in the most deprived
postcodes, and less than one third in the most affluent areas.
The proportions were higher once membership clubs were included.
If these results were modelled for the whole of England, four
out of every five licensed premises will be exempt in low income
areas, compared with two in five in more affluent areas.
28. These proposals will increase health inequalities,
both in terms of exposure to second-hand smoke, and because of
the effect on active smoking.
Health Inequalities and second-hand smoke
29. Bar workers are low paid, and the majority of employees
in the hospitality sector (30) are women with few educational
qualifications. More than two thirds of hospitality workers are
of childbearing age. Exposure to second-hand smoke in pregnancy
poses long term risks to child health, such as low birth weight
(31) and premature birth (32), and women exposed to second-hand
smoke stop breastfeeding sooner than non-exposed women (33).
30. Some other groups are also particularly vulnerable
to the health effects of second-hand smoke. In the UK, 8 million
people have lung disease, 2.1 million have angina, 1.3 million
have survived a heart attack, and 300,000 have suffered a stroke
(34). These conditions are significantly more prevalent in lower
income groups (35). The proposed exemptions will have the effect
of preventing people who suffer from these conditions from working
or socialising in these venues, or forcing them to experience
more severe symptoms in return for employment or social contact.
31. The occupational base of some members' clubs is also
relevant. Members of miners' clubs and boilermakers' clubs, for
example, are more likely to have developed occupational disease,
such as pneumoconiosis, chronic obstructive airways disease, and
asbestosis. Exposure to second-hand smoke worsens the symptoms
of these diseases.
32. Employees in the hospitality sector are paid less
than in any other industry sector (36), and often have little
choice about where they work. Nobody should have to sacrifice
their health to stay in a job. The reality is that customers may
not be able to exercise choice either—many of our deprived
communities are low amenity areas where customers have little
choice of social venues. For some, the only choice is between
the risk of ill health or isolation.
Health Inequalities and Smoking
33. Smoking is the biggest single cause of income-based
health inequalities (37). Smoke-free policies encourage smokers
to give up, and comprehensive policies have the biggest effect
on behaviour (38). Although the motivation to quit smoking is
similar across all social groups (39), low income smokers are
likely to find it more difficult to quit (40). High levels of
smoking and normalisation of tobacco use in low income communities
are important factors (41).
34. If the partial ban goes ahead, the gap will widen,
reflecting the differences in quit rates resulting from comprehensive
bans for the rich and partial bans for the poor. This undermines
the Government's existing targets to reduce smoking rates in manual
groups, and will further concentrate smoking related disease amongst
the poor.
Likely reduction in food-serving pubs
35. There is growing evidence that pubs which currently
serve food might decide to stop, increasing the numbers of exempted
premises. Survey evidence in North West England shows that 13%
of pubs that currently serve food would stop doing so as a result
of the law (42). A separate survey also showed a significant number
of pubs would cease to serve food, especially in low income areas
(43). The BMA is concerned that this will encourage patterns of
heavy and binge drinking, with long term impacts on health and
social behaviour.
36. The difficulties involved in defining "prepared
food" threaten to provide a range of loopholes, and increase
the burden on enforcement authorities. Comprehensive legislation
is simpler to enforce than partial bans.
Timetable
37. There is no justification for the licensed trade
to have a longer lead-in time than other businesses. Each year
of delay condemns an additional 54 hospitality workers to die
as a result of exposure to second-hand smoke on the job (44).
38. Although some legislatures (eg California and New
York) have phased in legislation over a period of time, this is
often because smoke-free bar laws have followed legislation covering
other enclosed places. The UK is practically alone in having no
legislation at all on smoking in public places. Long lead-in times
could lead to momentum being lost before legislation enters into
force. It is important that the public, businesses and enforcement
authorities are given sufficient information and time to prepare,
but there is no reason for this to exceed one year.
Effect of the Proposals on Business
39. Despite the scare stories perpetuated by the hospitality
trade and tobacco industry, via funded initiatives such as AIR
(Atmosphere Improves Results), independent economic analyses find
no evidence that smoke-free laws harm business (45), (46).
COMPLIANCE AND
ENFORCEMENT
40. Evidence from other countries consistently shows
that when smoke-free legislation is effectively and sensitively
enforced, compliance rates are high. In places as diverse as New
York (47), Ireland (48), Massachusetts (49) and New Zealand (50),
compliance rates have exceeded 90%.
41. Countries with a phased or partial approach to smoking
restrictions have found that such policies are impossible to enforce.
In Norway, regulations stipulated that a third of premises should
be non-smoking by 1993, rising to half of the area by 1998. There
was, however, inadequate monitoring and enforcement of these regulations
(51). In other countries, including Ireland, New York and New
Zealand, comprehensive smoke-free legislation was preceded by
partial bans which were less well observed and enforced.
42. Although the evidence shows that most smokers and
licensees respect smoke free laws, there is also a need to make
sure that the sanctions are meaningful. The BMA believes that
the Government must make it a priority to enforce the legislation,
and to resource local authorities appropriately so that they have
the capacity to carry out their duties.
PUBLIC OPINION
ABOUT SMOKE-FREE
PLACES
43. The government has consistently identified a lack
of public support as a barrier to implementing a comprehensive
ban. Yet the evidence from other countries shows that public support
for comprehensive legislation increases during the run-up to implementation,
and once the law is in place.
44. In Ireland, the smoke-free law now has the support
of 93% of the population, compared with 59% before the law was
introduced (52), while in Norway, more than three quarters of
the public supported the law by the end of the first year, an
increase of 25 points in less than two years (53). In New Zealand,
support for the smoke-free bars rose by 13 points, to 69% in the
first six months after the law came into force (54).
45. In the UK, public support for a comprehensive law
has markedly increased over the last year. Support for smoke-free
pubs rose by 11 points between 2003 and 2004, (55) and polls consistently
show that the majority of people support smoke-free policies.
In a recent BMA poll, 7 out of 10 people agreed that protecting
the health of staff working in pubs and bars by having them completely
smoke-free was more important than allowing smoking in such places
(56).
September 2005
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