Tobacco control – understanding what works and taking on the tobacco industry September 13th, 2012

1. Tobacco control – understanding what works and taking on the tobacco industry September 13th, 2012 Martyn Willmore Performance Improvement Delivery Manager Fresh Smoke Free North East

2. OVERVIEW OF SESSION • The scale of the issue • What is tobacco control? • What are we doing in the North East? • Brunel economic modelling tool • Tobacco Industry tactics • Are we making progress?

3. More than one billion people currently smoke cigarettes worldwide Cigarettes are the only known product which, when used exactly as the manufacturers intended, will kill half of all users Tobacco is the number one cause of premature death and disease in the developed world and its impact in the developing world is increasing Nearly five million premature deaths occurred worldwide from tobacco use in 2000, and projections indicate that by 2020, approximately nine million deaths will be attributed annually to tobacco use. For the first time in history, the biggest killer of humans is a man-made product. THE SCALE OF THE GLOBAL PROBLEM

4. Smoking rates are declining across England BUT annual smoking-related deaths remain our key Public Health issue: HIV: 529 Traffic: 2,946 Alcohol: 8,724 Smoking: 81,400 Obesity: 34,000 Murder:648 Suicide: 5,377 References:1. ASH Factsheet, Smoking Statistics: illness & death, June 2011 (http://www.ash.org.uk/files/documents/ASH_107.pdf) NB area represents value SCALE OF THE UK PROBLEM

5. Smoking still causes over 80,000 premature deaths each year in UK. Around 4,200 of these in North East alone It is responsible for around 1 in 6 of all deaths in UK Smokers lose 10 years of life on average Smoking is the single biggest cause of health inequalities and is responsible for half the difference in life expectancy between the highest and lowest socio-economic groups SCALE OF THE UK PROBLEM

6. WHO STILL SMOKES? Approx. 8.5 million smokers in England: • 20% men • 19% women • 13% of professionals smoke • 28% of routine and manual workers smoke 82% of smokers start as teenagers Nearly two-thirds want to quit • 4 million try in any year • Approx. 300,000 succeed • The North East adult smoking prevalence rate is now 21%.

7. PRINCIPLES OF TOBACCO CONTROL Established by the world’s first global health treaty - The WHO Framework Convention on Tobacco Control. This promotes coordinated action taken at all levels to: • Prevent children from starting to smoke • Protect people from exposure to secondhand smoke and normalising smokefree • Help smokers to stop • Also overriding principle to make smoking (and the Tobacco Industry) less attractive, affordable, accessible (denormalisation/changing the social norms)

8. WHAT NATIONALDRIVERS ARE THERE? • National Tobacco Control Plan released by the government in 2011 with key aspirations. First PH topic to have its own dedicated plan • Legislation. Implementation of the Health Bill around putting cigarettes out of sight within shops and banning vending machines. Recent national consultation on plain, standardised packaging with over 200,000 supportive responses • Targets! Continued focus around NHS Services to help people quit, but increased focus on reducing adult smoking prevalence, youth prevalence and smoking in pregnancy

9. Dedicated Office for Tobacco Control – Fresh Smoke Free North East. Set up in 2005, as first such office in UK “Fresh” is umbrella term for all partners and adoption by all local partners - united brand, messages Overseeing implementation of long term North East Tobacco Control activity, built around eight key strands of work WHAT IS THE NORTH EAST DOING?

10. MAIN AREAS OF TOBACCOCONTROL WORK IN THE NE? The eight key strands to the Fresh Tobacco Control Delivery Plan: • Develop infrastructure, skills and capacity • Reduce exposure to second hand smoke • Help smokers to stop • Media, communications and education • Reduce availability and supply • Tobacco regulation • Reduce tobacco promotion • Research, monitoring and evaluation

11. KEY FRESH PRIORITIES FOR TOBACCO CONTROL • Infrastructure, Skills and Capacity • Work with local Tobacco Control alliances to develop effective and sustainable local tobacco control delivery • To influence national and international policy and decision making. Advocate on behalf of NE and local needs • Continue to deliver training and host events to raise knowledge/awareness of TC issues with key partners • Convey message that tackling smoking is “everyone`s business”!

12. 2. Reducing Exposure to Secondhand Smoke Reduce children’s exposure to secondhand smoke through roll out of Secondhand Smoke Training Programme Increase awareness of the benefits of smokefree homes and cars through the Smokefree Families message. “7 Steps” campaign Address issues around SHS in settings such as Prisons and Mental Health Trusts KEY FRESH PRIORITIES FOR TOBACCO CONTROL

13. KEY FRESH PRIORITIES FOR TOBACCO CONTROL 3. Helping smokers to stop • Provide support and analysis to PCTs/FTs around Stop Smoking Service delivery • Act as North East contact with national policy teams, and support national initiatives (e.g. New Routes to Quit) • Help with targeting key smoking populations (e.g. routine & manual workers, pregnant smokers) • Engage all partners to actively promote NHS SSS, ensure effective marketing (internal/external) and signposting

14. KEY FRESH PRIORITIES FOR TOBACCO CONTROL • 4. Media, Communications and Social Marketing • Communicating the risk of tobacco and rationale for action cuts across all Fresh activity • Engaging with public, but also ensuring that we communicate messages effectively with partners

15. KEY FRESH PRIORITIES FOR TOBACCO CONTROL • 4. Media, Communications and Social Marketing • Above the line marketing last year around support to quit, health impacts of smoking, SHS, and tackling illicit tobacco. Plans in place to build on this in 2012/13, • Securing PR coverage with local media. In 2011/12 we secured over £2.8 million of free coverage.

16. KEY FRESH PRIORITIES FOR TOBACCO CONTROL 5. Reducing the availability and supply of tobacco products – licit and illicit • Implementation of the North of England Tackling Illicit Tobacco for Better Health Programme through eight key objectives • Working with retailers and trading standards colleagues to ensure compliance with underage sales legislation.

17. KEY FRESH PRIORITIES FOR TOBACCO CONTROL 6. Tobacco regulation • Reducing access through high tobacco prices (our biggest single lever in tobacco control) • Increase regulation of tobacco products and increase access to clean medicinal nicotine products, and therefore support smokers to stop

18. KEY FRESH PRIORITIES FOR TOBACCO CONTROL 7. Reducing Tobacco Promotion • Working with Trading Standards/Environmental Health colleagues to enforce the Vending Machines ban from Autumn 2011, and roll-out of Point of Sale legislation from 2012 and beyond • Ensuring North East had a strong voice in the recent national consultation around Plain Packaging • More work around exposing Tobacco Industry tactics around promotion of their products (e.g. Social media)

19. KEY FRESH PRIORITIES FOR TOBACCO CONTROL 8. Research, Monitoring and Evaluation • Measuring the impact of smoking on the health and wellbeing of the NE population • Quantifying the benefits of Tobacco Control. Calculating the cost-effectiveness of TC in terms of health improvements and potential savings to NHS • Regularly monitoring the attitudes of NE public to smoking and the steps being taken to tackle it

20. DEVELOPING AN ECONOMIC MODELLING TOOL • Started in 2010, as a joint venture between the three regional offices. Aim was to explore the economic case for comprehensive regional tobacco control strategies: • Build on the best available evidence on tobacco control • Suitable for use by health and local authorities • Include health and non-health outcomes • Include financial and non-financial outcomes • Based on principles of the Markov model - following a cohort of current smokers over their lifetime to identify costs and outcomes

21. DEVELOPING AN ECONOMIC MODELLING TOOL - MARKOV • Considers the cohort of current smokers • Each year they become • Current smokers • Former smokers • Die • Health outcomes and resource use driven by this fluid smoking status

22. WHAT THE MODEL CAN DO • Use local smoking prevalence data to produce a series of ‘what if scenario analysis’ for a locality, and: • Provide potential NHS cost-savings from (primary and secondary care) by reducing smoking prevalence in the short term • Provide potential NHS cost-savings in the treatment of lung cancer, CHD, MI, Stroke, COPD in medium term • Provide potential savings in other areas, e.g. productivity losses, exposure to passive smoking • Provide estimated impact of TC measures on short-term impact on smoking levels across local population

23. WHAT THE MODEL CANNOT DO • It is not ‘Return on Investment’ tool, as the costs of generating savings are not accounted for • Does not provide cost-effectiveness ratios of the interventions included in the model • It does not fully reflect the impact of local tobacco control activity, as the data to support this calculation is not sufficiently robust • Model has to make assumptions about “background quit levels” regardless of local/regional/national TC activity, and regardless of what the Tobacco Industry is doing

24. MODEL OUTCOMES • The model shows the estimated impact of changes in smoking status (previous slides), based upon three potential scenarios – • The locality has no Stop Smoking Service and no regional tier of TC activity • The locality has a Stop Smoking Service (variable inputs) but no regional tier of TC activity • The locality has both a Stop Smoking Service (variable inputs) and a regional tier of TC activity http://www.brunel.ac.uk/herg/research-programme/building-the-economic-case-for-tobacco-control

25. The Tobacco Industry has adopted a range of tactics to prosper in the latter half of the 20th century. They include – • Denying the health/addictive risks from smoking, or their responsibility for the consequences of this (developing CSR) • Attacking the credibility of published evidence, and those that oppose the industry (including the use of “front-groups” to do this on their behalf) to create doubt • Delaying, challenging and circumnavigating attempts to • regulate the industry or introduce tobacco control policies TACKLING THE TOBACCO INDUSTRY

26. Denying the health/addiction risks from smoking TOBACCO INDUSTRY TACTICS • Prior to 1990s, the Industry`s line had been one of denying the addictiveness of smoking • 1998 US legal ruling forced the release of over 40 million Industry papers and reports • This revealed decades of systematic deception of the public over what they knew, and how they marketed

27. TOBACCO INDUSTRY DECEPTION • “Evidence is building up that heavy smoking contributes to lung cancer” - Philip Morris scientist, 1958 • “I'm unclear in my own mind whether anyone dies of cigarette smoking-related diseases” - Geoffrey Bible, Chairman of Philip Morris, 1998 • “No one should be allowed to sell cigarettes to minors. Minors should not smoke. Period” – Philip Morris 1994 • “Today’s teenager is tomorrow’s potential regular customer, and the overwhelming majority of smokers first begin to smoke while still in their teens…The smoking patterns of teenagers are particularly important to Philip Morris” - 1981 Philip Morris internal document • “We were targeting kids, and I said at the time it was unethical and maybe illegal, but I was told it was just company policy” – 1996 RJ Reynolds Salesman

28. CORPORATE SOCIAL RESPONSIBILITY?? • “The continuing commitment by business to behave ethically and contribute to economic development whilst improving the quality of life of the local community and society at large” Making Good Business Sense by Lord Holme and Richard Watts • Since late 1990s, Tobacco Industries have publicly adopted CSR and invested in flawed projects to show this: • Youth smoking prevention programmes • Education/Academic grants • Philanthropy • Public Health promotion • Fundamental contradiction – Industry employees have a fiduciary responsibility to shareholders to maximise profits.

30. TOBACCO INDUSTRY TACTICS Attacking the credibility of evidence and opponents • For decades the industry categorically denied that smoking was addictive, dangerous, and marketed to children – until their own evidence showed otherwise. So they now attack both the anti-tobacco message and messengers (directly and indirectly) to create doubt in the minds of the public • “We think that many of the claims against environmental tobacco smoke have been overstated. Specifically, we don’t believe that it has been shown to cause chronic disease, such as lung cancer, cardiovascular disease or chronic obstructive pulmonary disease, in adult non-smokers. The studies on lung cancer to date suggest that if there is a risk, it is too small to measure with any certainty” – BAT NZ 2005

31. TOBACCO INDUSTRY TACTICS Attacking the credibility of evidence and opponents • “A ban on tobacco displays will put many independent shopkeepers out of business. 23 convenience stores in Ontario and 12 in Quebec closed every week after bans were introduced there” Tobacco Retailers Alliance, 2009 • In fact, the number of retailers went up by 1.9% in Canada following introduction of display ban in 2008 • The tobacco industry regularly claims that smokefree policies in the UK saw 52 pubs close every week following 2007 legislation • In reality, a BBC investigation into these claims found that the survey reclassified venues that increased the amount of food sold from “pubs” to “restaurants” and counted them as “pub closures”

32. TOBACCO INDUSTRY TACTICS Attacking the credibility of evidence and opponents • “High taxation is the acknowledged driver of the illicit tobacco trade” Tobacco Manufacturers Alliance, 2011 • In fact, Industry complicity and their control of the supply chain, corruption and lax enforcement are the key factors in the increase of smuggling; increasing tax on tobacco products has increased government revenues (Tobacconomics 2011) • “The removal of branding on tobacco products and the introduction of ‘plain packaging’ makes it easier to counterfeit cigarettes and harder for enforcement agencies to detect illicit products” – BAT • In fact, Cigarette packs already carry unique identifiers. Removing the branding will make no difference to the effectiveness of scanners

33. VOCAL INDUSTRY SUPPORTERS “I don’t believe the second-hand smoke stuff. How can you know? It is all highly exaggerated. I speak as someone who has smoked for 58 years and I’m still here (and I’m fine, thank you)” - David Hockney

34. TOBACCO INDUSTRY TACTICS Delaying, challenging and circumnavigating regulation and tobacco control policies • “Our approach is to fight aggressively with all available resources, against any attempt, from any quarter, to diminish our ability to market our products effectively” – Philip Morris Vice-President, 1995 • The “Scream” test. When the Industry fight back, it`s usually a positive sign that the measure will be effective – • Smokefree legislation • Point of Sale • Especially plain, standardised packaging

35. THE FIGHT FOR PLAIN PACKS • Australia have just experienced a bitter fight to introduce plain packaging. Culminating in a successful legal case against Industry challenge over IPR • UK government has recently completed a consultation on the evidence for introducing plain, standardised packs – • Disruption from FOI requests to Tobacco Control organisations • Mis-representation of the rationale for plain packs at every turn • “Nanny-state” and “slippery slope” arguments • Distorted case put forward around effect on illegal tobacco sales and impact on small retailers • Dubious marketing techniques from Industry front-groups

36. INDUSTRY RESPONSE TO THE ADVERTISING BAN

37. POINT OF SALE “DISPLAY” According to the Industry, this is not advertising

38. WHAT WE ARE UP AGAINST A tobacco industry that has moved from this..........

39. TOBACCO ADVERTISING?? ....To promoting its products like this....

40. THINK INDUSTRY MARKETING IS A THING OF THE PAST?

41. THINK AGAIN……

42. IS THE NE APPROACH WORKING?

43. IS THE NE APPROACH WORKING? Decline in DSR mortality rates from Acute Myocardial Infarction over last decade

44. RESPONSIBILITY DEAL Unlike alcohol and fast-food retailers, the tobacco industry is not part of the government`s public health responsibility deal, shaping policy "We don't work in partnership with the tobacco companies because we are trying to arrive at a point where they have no business in this country.” – Andrew Lansley, April 2012

45. OUR VISION..... ...to make smoking history for children