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Tobacco and public health

Source: Public Sector Executive March/April 2013

Smoking is the country’s biggest cause of preventable death, and thus a huge public health challenge – one which soon becomes the responsibility of local authorities. PSE discusses the issues with Ailsa Rutter, director of award-winning stop smoking service FRESH – Smoke Free North East.

As PSE went to press, the Government had still not committed to plain packaging for tobacco, despite overwhelming support for the idea in its recent consultation, and New Zealand joining Australia in implementing the measure.

A report in the Guardian suggesting it was on its way in was damped down by the Prime Minister himself, who said on March 7: “A decision has not been taken.”

But Ailsa Rutter, who has led FRESH – Smoke Free North East since its launch in 2005, and helped it achieve the ‘Gold Medal’ in the inaugural Public Health Awards in 2009, said it is time for action.

She told us: “The sooner that they can get on with this and implement it the better. Every day of delay, more children will be attracted to taking up smoking because of the glamorous glitzy packs.

“[Implementing the measure] would be fantastic and it would show real leadership from this Government around prioritising tobacco control.”

Rutter used to work in tobacco control in Australia, so has unsurprisingly been watching carefully what’s been happening there since it implemented plain packaging from December 1, 2012.

She said: “It is early days, but we feel there is compelling evidence that this will reduce the attractiveness to children and young people, but will also make the health warnings much more prominent because adult smokers dupe themselves.

“They think if they’re smoking something from a white silvery box that it’s somehow less harmful than another type of cigarette.”

Public health

From April 1, public health transitions formally to Public Health England and local authorities, which Rutter called “a great opportunity for local government to make a real difference in addressing health inequalities within their communities”.

She said: “Tobacco remains their greatest cause of premature death and disease, their greatest contributor to health inequalities – in particular, up to half the difference in life expectancy between the most affluent and least affluent will be down to smoking. I certainly welcome public health going into local authorities from April.

“Look at the responsibilities and powers of local government, reaching across children’s services, adult services, housing, regeneration, community development – there’s a fantastic opportunity here.”

She mentioned three key areas in particular: motivating and supporting smokers to stop in the councils’ role as large employers; commissioning stop smoking services; and reducing the uptake of smoking in the first place, since the vast majority of new smokers get hooked as a child.

“Why they’re getting hooked is because there is a tobacco industry out there that works hard to maximise profits for their shareholders to replace the half of smokers who will die prematurely,” she said. “It’s about changing the adult world that young people grow up into.”

Licensing tobacco retailers

She also discussed whether council control of public health could lead to a licensing regime for tobacco. “You have to have [a licence] for alcohol, but anybody can sell tobacco and I think a number of councils are concerned by that. Councils have got authority in terms of reducing youth access to make sure retailers are compliant with legislation.

“They can work to ensure that other regulations, like the point-of-sale display ban, are being implemented, but also local councils have got a big opportunity to take a holistic, schoolsbased approach.

“The important thing to stress is that education is just one area of work in terms of uptake. There’s no point just spending loads on educating kids if parents continue to smoke, if society as a whole is normalising smoking. This is why we need tougher action in terms of the portrayal of smoking in the media and the glamorisation of smoking.”

She said councils have been “at the forefront of arguably the most important piece of health legislation this century”, the 2007 public smoking ban, which has had better compliance than many expected back then.

“But the job isn’t done regarding secondhand smoke,” she said. “Yes, we’ve got good workplace legislation, but we’re concerned about the exposure of children in the home and cars, and also vulnerable adults, for example, those with cardiac conditions. There’s just not enough awareness about the impact secondhand smoke can have on their cardiac conditions.

“For example, Gateshead Council has just approved a voluntary code through its cabinet to make all of their playgrounds smoke free. Smoking in an area that is purely for kids shouldn’t be the norm.

“We also really welcome the work councils are doing on protecting our communities from illegal tobacco. It’s not out of control, it’s not at epidemic proportions as the tobacco industry would have us believe, but we are concerned that while there is an illegal tobacco market, it circumvents all kinds of regulations. It means that children in particular can get much easier access to generally much cheaper tobacco products. People will sell them without asking their age. If they’re buying products that don’t have health warnings on, it’s more likely to get them hooked.”

Prioritising tobacco

Councils will become responsible for commissioning stop smoking services from April.

Rutter said: “I can only speak from experience in the north east, but I think our local authorities are really prioritising tobacco issues. They understand the significance and importance of keeping that focus.

“They will be responsible for commissioning stop smoking services and we remain confident that they will see that as an integral part of a much bigger tobacco control package.

“I have heard that in other places, that evidence-based approach isn’t necessarily as much of a priority as it is here in the North East. The really important thing to stress is that councils should not think the job is done if they get prevalence down below 20%.

“There is no other known consumer product that will kill half of its customers prematurely. Whatever your local prevalence is, you need to prioritise tackling smoking.

“There’s a risk a local council thinks all it needs to do is to have a stop smoking service. Whilst they’re incredibly cost-effective at the individual level, they cannot significantly reduce prevalence. If you look at the experience of the north east, we have had consistently, for 13 years, the best stop smoking services in England. But from 2000-05, when all of the eggs were just in the basket of stop smoking services, our prevalence didn’t go down – it was only when we said ‘we need to have a more comprehensive approach’, with stop smoking services being just one part of eight key strands, that we then saw a rapid decline in smoking rates. We had double the decline in the north east compared to every English region.

“That lesson has certainly been learnt in other regions that have got a regional programme in place, in the north west and the south west for example.”

“The reality is that the vast majority of smokers will still quit independently of an NHS stop smoking service, but that is not at all to say that we don’t need those services, particularly for people with more challenging needs, such as pregnant women. I absolutely believe the NHS needs to be there ready to support pregnant women to stop, ideally before they get pregnant, as well as mental health service users, and people with pre-existing conditions.

“If a smoker thinks they need the help, the help should be there and it should be free.”

Economic benefits

Councils should try to work with each other “across as big a geographical footprint as possible”, she said. “It’s not going to be costeffective for one local council to run its own campaign.

“Money’s tight, so if they can work across boundaries they’ll get a much bigger bang for their buck that way.

“On the NICE website there is a very handy economic modelling tool for a local council to model the economic impact of tobacco on that authority. It shows the savings it will make as prevalence goes down.

“It’s a timely resource because I worry that some elected members fall for the myth that this is an adult choice: it is a childhood addiction. We have to treat this differently because the tobacco industry is unlike every other industry.”


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