Worldwide, tobacco is recognised as the largest single cause of preventable ill-health killing over 5 million people a year – 600,000 due to the effects of second hand smoke (passive smoking) alone. While about 22% of the world’s adult population smoke (36% of men and 8% of women) there are large regional differences. As smoking rates in Europe and the developed word decline tobacco use will increasingly become a feature of low and middle income countries – currently one third of the world’s smokers are in China. In coming decades, therefore, the burden of disease will be unequally distributed around the globe and concentrated on the poor.
The World Health Organisation (WHO) Framework Convention on Tobacco Control  recommends five policies for curbing tobacco use:
- smoke free environments;
- cessation programmes for tobacco users;
- advertising bans;
- health warnings on cigarette packs; and
- higher taxation of tobacco.
According to WHO, only 5.4% of the world’s population was covered by comprehensive smoke free laws in 2008. Smoke free legislation has been restricted almost exclusively to the developed world, with most of the world’s population still exposed to tobacco smoke. Many countries are tied economically to the tobacco industry, with an agricultural sector linked to tobacco production, cigarette factories providing employment and vested interests wishing to maintain and support the industry. Although the lifelong costs to health through exposure to tobacco outweigh increased revenues, there are obvious, immediate disincentives for some governments to reduce their tax take by implementing effective tobacco control. Despite the positive impact on the health, well-being and economic productivity of their citizens that tobacco control brings it is a sad fact that globally 170 times more money is collected in taxes on tobacco production than is spent on tobacco control.
Health inequalities and prevention
Scotland has adopted WHO’s Framework Convention and is making progress in reducing tobacco-related harm in the Scottish population since the smoking ban in March 2006 . Nonetheless, Scotland still has over 13,000 deaths a year due to tobacco and 15,000 young people start on the conveyor belt towards ill-health and premature death each year. The difference in life expectancy between smokers and never smokers is greater than that between the most affluent social groups with about 10% smoking and the least affluent where over 40% smoke.
To help combat widening inequalities and reduce the appeal of tobacco to young people, two pieces of legislation were published under the Scotland’s Future is Smoke Free banner: A Smoking Prevention Action Plan in May 2008  and the Tobacco and Primary Medical Services (Scotland) Act in January 2010 . These change how tobacco is marketed and sold in Scotland by:
- restricting point of sale advertising;
- raising the age one can buy tobacco to 18 years;
- prohibiting the display of tobacco products;
- banning vending machines;
- heavy fines of up to £20,000 for unregistered tobacco retailers; and
- criminalising proxy purchase of tobacco (purchase of tobacco for people under 18).
In the UK the inequalities gradient in tobacco use is pronounced. As a consequence, there has been an increasing requirement to ensure that Stop Smoking Services engage people from lower socioeconomic groups, those with particular health problems or difficulties in accessing traditional services, such as pregnant women or people from minority ethnic groups. In the UK, smoking in migrant groups is generally at the same or slightly lower levels to the local population but some ethnic groups have higher rates (notably 40% of Bangladeshi men and 29% of Pakistani men).
With migration an increasing part of the Scottish landscape we are continually refining our services to cater for the needs of migrants. Lothian’s Minority Ethnic Health Inclusion Service (MEHIS) has co-ordinated the development of a national resource to help people from a range of minority ethnic groups quit by explaining how the NHS Stop Smoking Services work. We also run a successful Polish language service. Two Polish language groups have been established and promotional materials produced in Polish. Services are also tailored to meet the needs of other minority populations. For example, most staff have received deaf awareness training and promotional materials have been produced in British Sign Language. Even without release of the resources to implement the Prevention Action Plan we have been working with high schools and youth groups and providing interventions designed to increase the proportion of smoke free homes. Smoking indoors and exposing children to the toxins in environmental tobacco smoke is more common in Britain than in many other countries, even our colder or wetter neighbours. This means that the current situation is not inevitable and change is possible.
NHS Lothian has clear outcome targets set by the Scottish Government and is on track to achieve them. Between April 2008 and March 2011, we anticipate that 11,218 clients will have stopped smoking and with some significant service changes there is now improved access for clients. The number of groups offered across NHS Lothian has increased to 60 per week to meet demand and provide a fast response to referrals. Subsequently, the number of referrals to the service treatments provided, and their success, has increased significantly year by year.
With staff being encouraged to share good practice and a robust induction and continuing education programme in place, the enhanced skills of the Stop Smoking team have also increased their effectiveness and subsequently more of those clients setting quit dates are successful (see Table 1).
Table showing success of Stop Smoking strategies over time.
* Percentage is based on total clients with a quit date in this time frame
Source: National Smoking Cessation Database 2010
Stop Smoking Services have also addressed smoking in the workplace, both for NHS staff and for local employers including council staff. A dedicated staff member has been allocated to develop services tailored to meet the needs of workplaces and to date 41 local employers have engaged with the service. Hospital-based cessation services have continued to develop and link with services based in the community. The local services are also enhanced by the national pharmacy cessation scheme. The local coordinators work closely with community pharmacies to ensure that clients receive the appropriate level of support.
- World-wide tobacco is the main cause of preventable ill-health.
- According to WHO, only 5.4% of the world population is covered by comprehensive tobacco legislation.
- Globally, 170 times more money is collected in taxes on tobacco production than is spent on tobacco control.
- Locally, nationally and internationally, we must continue to push for tobacco control.
- Smoking cessation is one of the most cost-effective treatments available. The cost-effectiveness of stop smoking treatment services is proven and “represents excellent value for money compared with many other healthcare interventions .” Funding for this treatment service, unlike other clinical services, is based on short term funding. It is vital to ensure that funding for smoking cessation treatment is maintained so that the 22% of the Lothian population that are regular smokers can access treatment . Further investment is required to increase the level of service available to hospital patients, visitors and staff. Funding for smoking prevention should be released to enable evidence-based approaches to prevention and early intervention to be introduced with smoke free homes as a priority.
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