SUBMISSION BY NHS LANARKSHIRE

Prohibition of Smoking in Regulated Areas (Scotland) Bill

We are delighted by the Scottish Executive's proposal to ban tobacco smoking in almost all public places as we consider that its implementation would significantly reduce the health, personal, NHS and societal burdens of smoking.

We anticipate that this normalization of non smoking would have three important benefits:

i) the majority of the adult population (approximately two-thirds), who are non smokers, would no longer have to tolerate the unpleasantness of stale tobacco and environmental tobacco smoke (ETS), particularly those working in the hospitality industry;

ii) a reduction in the number of smokers or the amount they smoke, and thus a reduction in the personal, NHS and economic consequences of smoking related diseases;

iii) a reduction in the health effects of passive smoking, in particular for children.

In Lanarkshire the prevalence of smoking in people aged 16+ years is over 30%, the figure being slightly higher in men; in 2002 27% of pregnant women were smoking at the time of their booking visit; and 8% of 13 year olds and 21% of 15 year olds smoked were regular smokers (at least one cigarette each week).

Smoking-related diseases are our commonest causes of death, and of these more than 800 deaths are estimated to have been attributable to smoking in 2002 (Table 1).

Disease No. of deaths, 2002 Estimate of deaths attributed to smoking(1)

Ischaemic heart disease 1266 228

Cerebrovascular disease 422 51

Chronic obstructive pulmonary disease 285 217

Cancer of bronchus and lung 423 343

Total 2396 829

Table 1 Deaths attributed to smoking in 2002 among Lanarkshire Health Board residents

1 Attributable risk based on data for UK in 1988, and is therefore only a guide to numbers.

In 2002 deaths more than 1 in 7 of all deaths were therefore estimated to have been caused by smoking.

The effects of passive smoking are best documented for children. Smoking during pregnancy accounts for a third of perinatal deaths; it contributes to low birth weight; it is now thought to be associated with behavioural disorders and increases the risk of diabetes in later life. Children whose parent smoke have an increased chance of developing a range of diseases including asthma, middle ear disease, and sudden infant death syndrome.

Smoking related disease are chronic, and incur primary and acute care resources as well as considerable human suffering. Although we do not have access to disease specific costs, the average costs for acute care in Lanarkshire are shown in Table 2.

Acute care in Lanarkshire Average cost per case

Inpatient £1561

Day case £389

Outpatient £44

Table 2 Costs of providing acute health care in Lanarkshire in 2002

Many of the recent arguments have focussed on employees being able to work in an environment free from ETS. Smokers' counter argument has been that if they do not like tobacco smoke employees should choose to work elsewhere. The hospitality industry (e.g. public houses, restaurants) are often staffed by some of the lowest paid employees who are prepared to work the unsocial hours this can require in order to ensure an income. Their employment choices may be limited by their skills, and their social and financial situations.

In Lanarkshire, as elsewhere, there have been various campaigns and efforts over many years to reduce both the incidence and prevalence of tobacco smoking, but with limited effect. Most of it, however, has focussed only on smokers, and not on the wider population.

The key question is whether a ban on smoking in public places will reduce smoking prevalence. Its introduction will not only affect smokers, but will also benefit non smokers, who themselves will help to police it by their reactions if someone should start to smoke in a banned location. Also, as smokers are banned from smoking in increasingly more locations, the amount of time available to them to smoke will reduce. This suggests that at population level the health burden of smoking should gradually reduce.

Health promotion theory argues that an environment which supports desired behaviour, or is obstructive to undesired behaviour, will help to increase or reduce it respectively. Studies have shown that when the initiative is applied to a whole or 'closed' population situation such as this, it has been effective.

California and the Republic of Ireland have already shown that the introduction of such an initiative is feasible in Western democratic cultures. In the case of California the normalization of non smoking using a wide ranging approach to reduce tobacco consumption, in ten years has resulted in:

· a 57% reduction in cigarette consumption;

· a decrease in the number of heavy smokers;

· a significant decrease in the prevalence of adolescent smoking to 7.7%; and

· an increase in the 12-13 year olds who have never smoked.

In the UK fiscal policy has kept the cost of tobacco high, the smoking advertising ban is in place (although not quite universal); and a smoking ban would be a significant extra factor in normalizing non smoking. We therefore believe that the evidence supports this additional and major initiative, urge that it should be adopted, and strongly recommend that the Executive should either implement it in all public places, or should state that it will extend the ban to all public places within a further three years.

BIBLIOGRAPHY

1 Lanarkshire NHS Board. Lanarkshire Smoking Cessation Strategy. Hamilton: Lanarkshire NHS Board, 2003.

2 Currie C, Fairgrieve J, Currie D, Akhtar P. Scottish Schools Adolescent Lifestyle and Substance Use Survey (SALSUS) 2002. Smoking, drinking and drug use among 13 and 15 year olds in Lanarkshire, 2002. Edinburgh: Child and Adolescent Health Research Unit (CAHRU), The University of Edinburgh, undated.

3 Information Services Unit, Lanarkshire NHS Board from data issued by General Register Office. Mortality tables, 2002. Unpublished internal document, Lanarkshire NHS Board.

4 Bostock Y. (editor). The Smoking Epidemic Counting the Cost in Scotland. Parliamentary Constituences. Edinburgh: Action on Smoking, and Health Education Board for Scotland, 1992.

5 Grauer L, Parkinson J, Haw S, Moore M, Duffy S. Reducing Smoking and Tobacco-related Harm. A key to transforming Scotland's Health.

6 Scottish Health Statistics. Costs Book 2003. Section 2, Report 310. R310: Provision of Health Care - Acute Services April 2002 - March 2003. ISD website: www.isdscotland.org/isd/info3.jsp?.pContentID=2574&p_applic=CCC&p_service=Content.Show (downloaded 23rd April, 2004).

7 Bennett P, Murphy S. Psychology and health promotion. Buckingham: Open University Press, 1997.

8 Cancer Prevention and Control Program, University of California, Dan Diego. Final Report. December 26, 200. The California Tobacco Control Program: A Decade of Progress, Results from the California Tobacco Survey, 1990-1999. San Diego: California Department of Health Services Tobacco Control Section

Mr David Pigott Dr Dorothy Moir

Chief Executive Director of Public Health