Response to Consultation on the Smokefree Elements of the Health Improvement and Protection Bill
5th August 2005 The Royal College of Physicians UK
Background to response
The Royal College of Physicians (RCP) has long recognised that tobacco smoking is a powerfully addictive and major health hazard. 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 1, 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 2. 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 3 . 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
1. Twigg L, Moon G, Walker S. The smoking epidemic in England. London: Health Development Agency; 2004.
2. 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.
3. 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. http://www.rcplondon.ac.uk/news/news.asp?PR_id=276
Please download the full report here :
http://www.rcplondon.ac.uk/pubs/contents/fe4ab715-2689-4a4a-b8c7-53e80386c893.pdf
