Smoking in Public Places
A Consultation on Reducing Exposure to Second Hand Smoke
Towards a Smoke-free Environment:
Lessons from Home and Abroad - Report of a National Conference
9 September 2004
SUMMARY OF PRESENTATIONS
SCENE SETTING | Chair: Prof Gerard Hastings |
Opening Address
Jack McConnell, MSP, First Minister
Jack McConnell, First Minister, was unable to attend the Conference, but pre-recorded an address because of the importance which he said he attached to the issue of smoking in public places. He welcomed delegates and emphasised that the Conference was a critical part of the consultation process.
Mr McConnell highlighted Scotland's poor health record and said that devolution offered politicians the opportunity to improve public health and to encourage individuals to make personal choices in favour of a healthier lifestyle. Action on smoking was a key part of that campaign and he was committed to wide ranging action.
Mr McConnell said he regarded the current consultation as a very important process to test views on smoking in public places and to shape policy for the future. He acknowledged that the issue was controversial, but that we owed it to those affected by smoking-related illness to have the debate and to study best evidence from around the world. This would help to secure improvements in public health in Scotland.
Tom McCabe MSP, Deputy Minister for Health and Community Care
Mr McCabe also welcomed delegates. He emphasised that, in spite of media reports, the consultation on smoking in public places was a genuine consultation and that no decisions had been taken on how to improve smoke-free provision in Scotland. He indicated, however, that the Executive was prepared to take tough decisions and ones which some people would not support, but only when it had listened to people's views, analysed the research and looked at the evidence from around the world on the potential health and economic impact of any action.
He voiced his support for the consultation process which he said allowed there to be a serious debate about responsible citizenship, to get people talking about health and to consider the impact of the choices they make. He echoed Mr McConnell's views on the opportunities being presented to make a real difference to the quality of life in Scotland.
He outlined the two streams of the consultation process. The first, a programme of research on the impact of passive smoking in mortality and morbidity in Scotland; current practice and attitudes in businesses across Scotland; and an assessment of the individual evidence on action to control environmental tobacco smoke and its potential impact on the health and economy of Scotland.
The second, a direct consultation with the people of Scotland on whether to introduce statutory controls on smoking in public places, accelerate smoke-free provision through voluntary action, or a combination of both.
Mr McCabe reported that the consultation had prompted significant public interest and that the number of responses to date - at over 27,000 - was nearly 20 times greater than any other consultation the Scottish Executive had carried out.
The Minister acknowledged the concerns of the licensed trade about action to restrict smoking in public places and the impact that might have on business. He indicated that that was why the evidence of impact from Ireland, New York and other places who had taken a lead in this area was so important.
He urged those attending the Conference to be prepared to listen with respect to what the speakers had to say and to acknowledge the diverse views which would be expressed.
Overview of the health risks associated with second-hand smoke
Dr Peter Boyle, Director, International Agency for Research on Cancer (IARC)
Dr Boyle indicated that it would be impossible to talk about the harm of indirect smoke without looking at direct smoking, which obviously carried the most significant health risks.
Tobacco smoking and health
Half of all smokers will be killed by their habit, one-quarter in middle age; one-quarter in old age.
Lung cancer was a 20 th century disease, with mortality rates increasing from the beginning of the century and peaking in the late seventies and eighties before falling, in lie with tobacco consumption.
Cancer mortality in Scotland for both men and women was one sixth higher than in other parts of the UK, reflecting higher rates of smoking prevalence.
The IARC Monographs on the Evaluation of Carcinogenic Risks to Humans had established that mainstream smoke had 3,996 constituents, including 69 carcinogens, 11 of which were classed as Group 1.
Tobacco related diseases included those of the respiratory system, cerebrovascular system, and gastro-intestinal system.
In women, tobacco related illnesses affected the reproductive system, the health of new born babies and the endocrine system.
Risks for cancers of the lung, oral cavity, pharynx, stomach, pancreas, liver and urinary tract are directly related to magnitude and duration of smoking. Risks have been proven to reduce on cessation of smoking. Magnitude in reduction increase with duration of cessation.
Involuntary Smoking
Dr Boyle explained that involuntary smoking is the exposure of a non-smoker to second-hand tobacco smoke composed of smoke exhaled by the smoker and side stream smoke from the smouldering cigarette and from the mouth end of the cigarette between puffs, diluted with ambient air.
The overall evaluation of the 2004 IARC Monograph was that involuntary smoking is carcinogenic to humans. The evidence was indisputable. He cited a significant number of studies which provided evidence of the health risks of passive smoking, with risk increasing with increased exposure.
Lung cancer
over one-third of cancer deaths are caused by smoking;
non-smoking spouses of smokers have an average 20-30% increase in lung cancer risk;
never smokers exposed to second-hand smoke at the workplace have a 16-19% increase risk of lung cancer.
Cardiovascular disease
Acute stroke
Also increased risks of childhood respiratory diseases, Sudden Infant Death Syndrome (SIDS), middle ear disease, asthma in children, and eye and nasal irritation.
Risk in the Workplace
Research has highlighted that non-smokers exposed to second-hand smoke in the workplace have a 16-19% increase in their risk of lung cancer, with one worker in the hotel or catering industry in the UK dying every week as a result of exposure to ETS at work. Research from the USA suggests that there were increases in pulmonary function in the first month after exposure to ETS ceased.
Deprivation
There has been a big reduction in lung cancer in men since the 1950s, reflecting reductions in the prevalence of smoking. However, this has not happened across all socio-economic groupings and there is now a huge gradient of lung cancer incidence between the most and least well-off members of society. This gradient is also reflected in smoking levels with highest smoking prevalence in the most deprived communities.
Conclusion
There is robust scientific evidence which demonstrates that there are significant health risks associated with both active and passive smoking. Health risks are greatest among the most deprived members of society, whose smoking prevalence is highest. Law-makers should protect the majority from the health hazards of the minority. The IARC and the World Health Organisation support the Scottish Executive in efforts to reduce exposure to second-hand smoke.
Setting controls on ETS: What the research tells us
Dr Ron Borland, Cancer Control Research Institute, Victoria, Australia
Dr Borland reported on a unique study following cohorts of 2000 smokers in four countries - UK, Canada, the USA and Australia.
The study showed:
levels of ETS controls vary both within and between countries, with the UK currently lagging;
restaurants are more likely to become smoke free than bars;
most smokers come to embrace smoke-free, but only accept it in bars;
compliance with controls is high;
there are no apparent adverse economic effects of smoke-free areas;
educating the public about the health risks of passive smoking will encourage support for smoke-free areas, especially before implementation.
When smoke-free environments are in place:
there is strong consumer preference for them, including by most smokers;
smokers can and do adjust, getting more control over their smoking and reducing their future health risks;
smoke-free may discourage smoking uptake;
it does not drive smoking into homes;
there are no documented long-term adverse economic effects (except perhaps on the tobacco industry, and gambling); and
implementation will be facilitated by ensuring that the public understand the need for controls and the benefits.
He advised that the Scottish Executive's current consultation on smoking in public places was a useful way of engaging with and educating the public on this issue.
As the session had over-run, the discussion session was combined with that following the second session, before lunch. Mr McCabe left the conference to return later in the afternoon.
THE IRISH EXPERIENCE | Chair: Dr Sinead Jones |
Going Smoke-Free: The Irish Experience
Dave Molloy, Chief Inspector, Office of Tobacco Control, Ireland
Mr Molloy's presentation covered the background leading up to smoke-free legislation in Ireland, which was introduced on 29 March 2004; the national debate which has taken place on the issue; and implementation and compliance issues.
Background
Legislation did not come in overnight. Ireland has had legislation restricting smoking in some public places since the early nineties, the focus being the protection of public health. The need to protect workers from ETS in the workplace was recognised as far back as 1993, but it was felt that the climate, at that time, was not ready for legislation and that there would be problems over implementation.
The decision to legislate for smoke-free workplaces followed the publication of the Allwright Report in 2003, which set out the international evidence on the harm caused by ETS. An 18-month delay in the introduction of the legislation was caused by a legal challenge from the tobacco industry. This provided the opportunity for a public debate on the issue.
National Debate
The debate focused on the following issues:
Health effects of ETS. Robust evidence, supported by medical profession in Ireland, was unequivocal in terms of the harm posed by ETS. This encouraged media support
Civil liberties. Irish Council for Civil Liberties stated that the rights of non-smokers to be protected took precedent over the rights of smokers to smoke where they wished.
Ventilation. No authoritative institution claims that ventilation addresses the health effects of second-hand smoke. It's simpler, cheaper and healthier to end smoking in the workplace.
Economic issues. Foremost a worker protection measure, however economic argument needs to be looked at seriously. Independent economists, commissioned by the OTC, found that the weight of evidence, even if studies were imperfect, was that bans have little or no effect in aggregate. Both businesses and government should be alert to the fact that they may be liable to litigation from workers exposed to ETS, now that the health risks are clear.
Ban would be unworkable/unenforceable. In the run up to legislation, there was a need to brief the decision makers, raise public awareness and gain support, undertake media campaigns and prepare support materials.
Compliance
The OTC built up compliance with employers and managers, including the licensed trade, in run up to introduction of legislation.
Model procedures were recommended to licensed trade (eg smoke-free policy, "no-smoking" signs, remove ashtrays, have procedures in place.
A compliance line was set up to empower people; compliance was prioritised in the health inspection programme.
A media campaign was undertaken to raise awareness and promote smoke-free.
6-Months On
compliance levels high (publicans report no difficulty in implementation);
tourism numbers up;
bar sales are down 1.3%; to put this in context, there has been a decline in the bar trade over the last few years.
The impact of controls on the hospitality sector in Ireland:
Tadg O'Sullivan, Chief Executive, Vintners Federation of Ireland (VFI)
Mr O'Sullivan spoke on behalf of the VFI, which represents over 6,500 rural publicans, and on behalf of the Licensed Vintners Association (LVA) which represents Dublin publicans. He was critical of the conference programme, which he considered was skewed towards the anti-smoking lobbyists. He spoke as one who was not a pro-smoker, but as one who believed that if a person chooses to smoke, then they should be accommodated within the hospitality sector.
The health case
Mr O'Sullivan asserted that the Expert Group report on the health effects of ETS in the workplace did not provide scientific evidence to link exposure to ETS and tobacco related mortality. It pointed to the need for further research, in particular for the hospitality industry.
Despite this a blanket ban was introduced, without consultation with the public or the hospitality industry, and as a smokescreen to NHS failings.
The health and safety of bar staff and customers is an important issue for the Vintners' Federations and many premises have invested heavily in modern ventilation systems. Evidence, commissioned by the American Cancer Society, which reported in the British Medical Journal in May 2003 did not support a causal link between ETS and tobacco-related mortality, although it did not rule out a small effect.
Imposition of total ban
Mr O'Sullivan said that alternatives to a total ban were not explored in any meaningful way.
A compromise solution would have been more beneficial. The licensed trade "Customer Choice and Common Sense" proposals included commitments to:
50:50 smoking/non-smoking areas;
a ban on smoking at counter areas;
the installation of high quality ventilation systems; and
a review and assessment of progress at the end of 2005.
This was rejected by the Irish Government out of hand.
Economic Impact of ban
Mr O'Sullivan refuted the assertions from what he called pro-smoking lobbyists about the economic effects of the smoking ban in New York. Where bans had been imposed, the effects had been immediate and severe. Independent studies undertaken show 2000 job losses; a loss of $28.5m in wages and a loss of $37m in gross state product. In British Columbia in Canada, a ban was reversed due, in part, to its disastrous impact on the hospitality trade. In Ireland, members of the VFI are experiencing a drop in sales of between 15-25% since the introduction of the ban. This will worsen over the winter months. Publicans in border areas are particularly hard hit. No evidence was presented to support this.
Bar workers, despite what MANDATE (who represent only 8% of all bar staff in Ireland) may say, support the VFI's compromise solution..
Overview
since the ban was introduced, the licensed trade have worked hard to ensure compliance;
it has resulted in the devastation of many businesses and ruined the atmosphere and fun (the craik!) in Irish pubs;
the Irish Government should take action towards a workable compromise to ensure the survival of the Irish pub;
the Government's political party has lost seats as a result of the ban;
the Scottish Executive should listen and learn from the Irish experience and provide people with choice to drink in a non-smoking or a smoking environment.
The view from behind the bar
John Douglas, General Secretary Designate, MANDATE Trade Union, The Union of Retail, Bar and Administrative Workers, Ireland
Mr Douglas said that MANDATE was seen as the authoritative voice representing bar workers in Ireland, with over 3,000 members in the bar trade, mainly in the Greater Dublin area. The Union has been supportive of the ban in smoking in the workplace because of the health and safety considerations, and in particular the proven harmful effects of ETS. Much of the debate in Ireland has focussed on pubs. MANDATE's view was that any attempt to exclude bars from the legislation would be treating bar workers as "second class workers".
He presented his interpretation of events leading up to the ban from the Union's viewpoint, echoing many of the issues covered by Dave Molloy. He determined the introduction of the ban to be a success, due to the following key ingredients:
Effectiveness of ban
View from behind the bar, 6 months on
little or no enforcement problems;
quality of working life has greatly improved - there is no desire from bar staff to return to smoke-filled workplaces;
publicans have implemented the ban and have invested heavily in outdoor smoking facilities;
impact on jobs has been marginal; smoking ban only one factor behind the licensed trade's continuing difficulties, which include increased price competition, changes in lifestyle, level of indebtedness and high level of excise duty.
Conclusion
ETS can kill; the health of workers is not an issue for compromise;
a bar worker's life is just as important as an office or factory worker;
a total ban is the only effective measure to protect the health of workers;
the Irish experience proves that workers and the general public will support a ban when the health implications are explained - the public will put health before profit.
Discussion session
Dr Boyle and Dr Borland joined Dave Molloy, Tadg O'Sullivan and John Douglas to participate in a discussion session.
The following is a summary of the questions and discussion which followed.
Whether a voluntary or statutory approach would be most likely to be successful in influencing the least affluent members of our society?.
Dr Boyle said that we needed to develop new ways to deal with the most deprived members of our society. Deprived communities needed to be targeted to lessen their dependency on tobacco. Clearly efforts to date had not worked.
A point was also made from the floor that by banning smoking in places like workplaces and pubs, smoking would be 'denormalised' in deprived areas and lead to lower smoking prevalence.
Had the caring profession in Ireland now become 'second class' citizens due to the exemptions in the Irish legislation for nursing homes, care homes and psychiatric hospitals?
Mr Molloy responded by saying that the exemptions in the Irish legislation were related to the constitution which regarded these places as peoples' homes. Guidance to employers, however, makes it clear that they have a duty of care towards their employees and that they should, where possible, try to ensure that people smoke outside. Where this is not possible, exposure to ETS by staff should be minimised.
The French have legislated for a minimum air quality. Could this not be considered as an alternative to an outright ban?
Dr Boyle said that in France, legislation was introduced a number of years ago which sought to introduce smoke-free areas and impose minimum standards of ventilation. The law was now in disrepute because the implementation period (at 5 years) was too long and people did not comply. In France there is now no adequate protection against ETS in public places. The lesson to be learned was that action had to be taken quickly after the public debate.
A plea was made by the licensed trade that should change be introduced, it should be incremental and not immediate.
Mr Molloy said that the evidence on the dangers of ETS had strengthened over the last few years, particularly with the IARC ruling it as a Class A carcinogen. In addition, society has moved on to be less tolerant of other people's smoke. Voluntary action has seen many smoking restrictions already introduced. A complete ban is easier to implement and to enforce. Tadg O'Sullivan acknowledged the high level of compliance in Ireland, but said it was at enormous economic cost.
How does the OTC know that there is 97% compliance with the law, how is it enforced and at what cost?
Mr Molloy said that there was already a cohort of environmental health officers in place in Ireland who, amongst other things, enforced existing tobacco control legislation. There are only 40 inspectors who deal with tobacco control alone. In 7000 inspections of premises there was 97% compliance with the law. He referred to the general public's compliance line, which had been very successful, and indicated that the public were enforcing the ban.
Health argument is well made, but a compromise solution should be able to be found, based on air quality standards. If it can be done for large petro-chemical plants like those in Grangemouth, why not for ETS - that is, if there is a will to do it. Unemployment, which might be caused by a smoking ban, is also bad for people's health.
Dr Boyle responded by saying that the Health and Safety Executive set standards for our pollution, which should be within safe limits. Regarding ventilation, the weight of expert evidence suggested that the force which would be required to remove ETS would need to be of tornado-like proportions.
Mr O'Sullivan pointed to research undertaken by the University of Glamorgan which suggested that standards could be achieved. Mr Molloy disputed this by referring to ASHRE (American Society for Heating and Refrigeration Engineers) who will not set standards for ventilation for ETS, in light of health evidence, because they could not guarantee it was safe. No ventilation companies will claim to remove carcinogens from a room.
A plea was made to the Scottish Executive to ensure the integrity of the consultation, as media reports and the balance of the conference suggested that minds had already been made up.
Prof Hastings spoke for Mr McCabe in reassuring the audience that the consultation was genuine and that decisions would not be taken until all of the evidence had been examined. Following that theme, a publican called on the Executive to test ventilation systems themselves. His own smoking bar had been tested against a non-smoking ban in Glasgow and had been found to have lower carbon monoxide and carbon dioxide levels. Prof Hastings said that if the necessary evidence was provided, the Executive would look at it.
A question was raised about the impact of recent research published in the BMJ, on the evidence provided in the IARC monograph? This questioned the strength of evidence linking ETS and ill health.
Dr Boyle said it had no impact, because the IARC report had already been completed. He called into question why the BMJ had published the report, which he said was not robust.
WORLDWIDE EXPERIENCE | Chair: Dr Ron Borland |
Making New York Smoke-Free
Dr Thomas Frieden, Commissioner of Department of Health and Mental Hygiene, New York
Dr Frieden gave a comprehensive overview of experience in New York in implementing smoke-free workplace legislation and its impact, on both health and economic grounds.
Legislation was introduced because smoking was the leading preventable cause of death and ill-health in New York City, with 10,000 deaths per year, 1,000 of which relate to second-hand smoke. The legislation was part of a five-part plan to tackle tobacco-related disease, along with increased taxation, cessation, education and evaluation.
Framework for debate leading to introduction of legislation
Frame as a workplace health issue. The health risks of second hand smoke are clear and indisputable. All workers deserve equal protection.
Smoke-free legislation does not hurt business. There is robust data from areas which have introduced it.
Not a trade-off between health and economics.
Much progress has already been made in introducing smoking restrictions. Smoke-free legislation is a natural progression. A matter of when, not if.
Need to gather and examine local data to support the case. For example air quality studies showed that a smoky bar in New York had 50 times more pollution than the Holland Tunnel, regarded as one of the most polluted places in New York. Measures of carbon monoxide or carbon dioxide are not best indicators of air quality - what people should be looking at are particulate matter levels.
Tobacco industry will lobby extensively against legislation, but their dire predictions of the past about smoke-free laws have not come true, thus reducing their credibility.
Level playing field is very important.
Public support for legislation will increase with public awareness and education.
Ensuring compliance
Evaluation
Impact of legislation in New York
fewer New Yorkers are exposed to second hand smoke at work and, unexpectedly, at home;
air quality in bars has improved;
no negative impact on economy of bars and restaurants, and some very positive data on tax receipts and liquor licences;
97% compliance with the law;
combined with increased taxes and free nicotine patches, smoking prevalence has significantly decreased.
Lessons learned
gain early support of key policy makers;
focus on worker health and safety;
put workers front and centre;
document that smoke-free workplace laws do not harm businesses;
expect strong opposition, particularly that backed by the tobacco industry;
educate employers and the public about how they can comply
Smoke-free workplaces legislation should be one component of a comprehensive tobacco control programme - which is part of a comprehensive public health policy.
Over the last three years, prior to the ban being introduced, 3 bars had gone out of business each day. Dr Frieden could not guarantee that no bars had gone out of business in the last year as a result of the ban.
Bringing in Nationwide Controls in New Zealand
Nicola Holden, Ministry of Health, New Zealand
Mrs Holden described the journey New Zealand had taken to make work places smoke free. Legislation was to take effect on 10 December 2004. This was only one component in a comprehensive programme of tobacco control, covering taxation, cessation and education.
Purpose
second-hand smoke kills approximately 400 New Zealanders each year;
right of workers to healthy workplaces;
legislation seen as only way to protect workers, particularly in the hospitality sector, provide clarity of roles and consistency for businesses.
Legislative journey and coverage
4 year process, built onto existing and limited legislation; some of the delay was caused because it went through Parliament as a Member's Bill;
ventilation was the biggest issue raised during the legislative process;
original Bill included ventilation as an option to remove ETS; evidence to Select Committee, which indicated that there was no safe level of exposure to tobacco smoke, caused ventilation option to be removed;
legislation passed in December 2003, allowing a 12 month bed-in time, to assist industry and in particular, the hospitality industry, to adjust;
legislation covers herbal products, as well as tobacco, unlike New York and Ireland. There are no punitive measures for smokers, only employers;
similar exemptions for residential care homes, prison cells and hotel rooms.
Impact on business
employers wanted a level playing field, which meant as few exemptions as possible;
predictions of business downturn are the same in every country where legislation is being introduced; no evidence to suggest this will happen;
litigation issues have been raised with businesses.
Implementation and future
working closely with hospitality industry to ensure smooth implementation, including a mass media campaign;
resources being developed for affected settings;
baseline data being collected to ensure robust evaluation of effect of ban;
increased cessation support services to accompany ban; some uptake in services in advance of ban;
local bodies looking at further smoke free places, e.g. parks and other public places;
smoke-free homes media campaign.
Provincial smoke free provisions across Canada
Janice Forsythe and Melodie Tilson, Ottawa
Both speakers spoke as advocates of smoke-free provision: Ms Forsythe spoke about smoke-free Ottawa and Ms Tilson about provisions across Canada, including British Columbia.
Smoke-free Ottawa Campaign
Ottawa has been 100% smoke-free since 1 August 2001, including bars, restaurants, casinos, bingo, bowling and billiard establishments. Ms Forsythe explained the campaigning process, which began in 2000. This involved:
building effective partnerships with public health bodies;
making smoke-free provision a local election issue;
public awareness campaigns, including public consultations, and media work.
This was undertaken prior to a crucial Health Committee meeting at which all of the evidence was presented. Bylaws, in support of a smoke-free Ottawa, were approved by majority vote in April 2001.
Challenges
Pub and Bar Hospitality Organisation, which spring up when the by-laws were passed.
Enforcement. The bylaws covered all workplaces, which was intended to cover all hospitality venues. However private clubs sprang up to get round the legislation.
Both of these challenges were countered by highlighting to the media and local politicians the lack of robust data on which the challenges were made and providing information from well-founded research.
Smoke-free Ottawa: 3 years later
compliance 99%;
public support 70%;
adult smoking rates fell by 5%;
no impact on overall restaurant/bar sales;.
123 new restaurants/bars opened, 90 closed in year after an (despite 9/11 impact).
has encouraged neighbouring Quebec to campaign for smoke-free.
The Domino Effect and British Columbia
Ms Tilson explained that Ottawa's smoking ban has had a major impact on other provinces; many of whom have since banned smoking in all workplaces, including bars and restaurants.
In British Columbia, legislation was introduced in May 2002 which permitted designated smoking rooms in the hospitality sector. Employees have the right to refuse to work in these areas and exposure should be limited to 20% of their working time. It was reported that, in reality, these issues are impossible to regulate and that ventilation systems were not enforced.
Recommendations for Scotland
no designated smoking rooms (unlevel playing field, costly, health concerns and unpleasant);
education (before and after legislation and targeted at both public and business);
strong enforcement (aimed at proprietors, adequate resources, stiff penalties, publicity).
Discussion Session
The following is a summary of the questions asked and the discussion which followed.
What terms of reference were the Canadian speakers invited; who is covering their costs and has anyone pre-viewed their presentation?
Ms Tilson explained that they had been invited by the Scottish Executive, who were paying their expenses (like other speakers). Their terms of reference were to discuss the situation in Ottawa and to talk about what was happening in Canadian provinces, including British Columbia. Ms Tilson said that they did come from a biased perspective in support of smoking bans. This was due to their backgrounds in health organisations and the evidence of the harm to health of second-hand smoke.
A Consultant in Public Health Medicine in Glasgow, who was a Canadian, voiced her support for the pro-active approach taken in Canada and said that we had much to learn from it, here in Scotland. She considered that the consultation process and speakers' representation at the conference was fair and urged Scotland to introduce smoke-free legislation.
Is it possible to separate statistics on the effects of ETS in the home and in public places?
Dr Frieden said it was not possible to disaggregate data. However, in New York city they had been able to document how many people were exposed to second-hand smoke all or most of the time, at work or at home. A small majority were exposed more at work, than in their homes.
If there has been no loss of income as a result of the ban in New York, why have waivers been granted?
As context, Dr Frieden explained that even pre 9/11, New York was in deep recession. The events of 9/11 had worsened the situation and the hospitality industry was still in decline. This decline is also reflected in Ireland. In New York State as a whole, federal drink-driving legislation now only allows one drink in a bar before driving, and that has hit business.
Over the last three years, prior to the ban being introduced, 3 bars had gone out of business each day. Dr Frieden could not guarantee, of course, that no bars had gone out of business as a result of the ban. Some parts of the wider New York state had offered waivers to those businesses which had suffered a percentage fall in business (approx 15%). As no statistics had been produced which could categorically state that this was due to the ban, he felt that the granting of waivers was not helpful and had caused confusion.
In areas where smoking bans have been in operation for some time, what evidence is there of new customers being attracted to bars?
Dr Frieden provided some anecdotal information from the Boston area which indicated that some bars, previously frequented by hard drinkers and smokers (usually war veterans), had attracted different and younger customers since the ban. Takings were up, primarily due to increased trade in food.
Why was the Deputy Minister for Health addressing the conference, rather than the Minister for Health. Was this a reflection of the importance of the issue?
Dr Mac Armstrong, Chief Medical Officer for Scotland, explained that the responsibility for health improvement was delegated to the Deputy Minister as a way of sharing the health portfolio. It was acknowledged that some explanation to that effect in the morning would have been helpful.
On the assumption that a ban on smoking in public places would drive smokers to smoke at home, what provision would be made to help young people affected by parental smoking?
Dr Borland reiterated the findings of his on-going research, which indicated that smoke-free public places did not increase, in general, smoking levels in the home, although there would be individual cases where that might happen.
Dr Frieden said that the introduction of smoke-free legislation reduced smoking prevalence, particularly in young people. This was confirmed in New York.
It was emphasised that smoke-free legislation needed to be accompanied by increased education and enhanced smoking cessation services. Experience in Canada suggested that this was denormalising smoking amongst young people, particularly in social settings.
THE WAY FORWARD FOR SCOTLAND | Chair: Professor Phil Hanlon |
International Evidence: Health and economic consequences of controls on ETS and potential impact on Scotland
Anne Ludbrook, Health Economic Research Unit, University of Aberdeen
Ms Ludbrook explained that the research comprised a literature review of the legislation existing in other countries and of the health and economic impacts of ETS, along with the modelling of the impact of a shift from the current voluntary approach on smoking in public places in Scotland to a workplace ban. The focus of the study was on the leisure and hospitality sectors and the workplace. The research was not due to be completed until the end of October and so the findings being presented were provisional results only.
Flavour of legislation in EU and OECD countries
UK appears to be the only EU country with no legislative restriction (although data from Germany was not available);
in effect, however, only a minority of workplaces in Scotland have no restrictions in place;
in the hospitality sector, 15 out of 25 EU countries have some form of legislation but are not necessarily well complied with, or enforced;
there are a number of bars or restrictions in the hospitality sector in Australia, Canada, USA, Ireland, Norway and New Zealand.
Modelling health impacts of ETS for Scotland
Ms Ludbrook said that the study had concentrated on lung cancer and heart disease as there were fewer well-documented studies for stroke and respiratory disease. The provisional results related mainly to passive smoking in the home, where the majority of studies had been carried out. However, where studies had been carried out in other settings, the results had been broadly similar. Based on the current estimate of 439 lung cancer and ischaemic heart disease deaths in Scotland due to passive smoking (Dr Hole, Glasgow University), 71 were calculated as being attributed to non-domestic exposure. Over the next 30 years this was due to rise to 233 deaths per annum, from a total of 500 deaths (more non-smokers being at risk). This was a conservative assessment as it was based completely on non-smokers, rather than including former smokers.
Economic impact on the hospitality sector
The majority of studies which had been undertaken covered both bars and restaurants. Very few studies separated out these two sectors. The studies also looked at economic impact in aggregate, rather than for individual premises or geographic areas. What also had to be borne in mind was the level of turnover in businesses in this area e.g. in Scotland there are around 5,000 openings and closures of businesses over a 3 year period, without attributable effects to policy changes.
Notwithstanding the caveats around the published literature, the overall economic impact is nil. The review might include, however, some studies which showed a little economic benefit or a little negative economic impact, which cancelled each other out.
Summary of health and economic impacts
conservative estimates of savings in the workplace exceed the worst case scenario for losses in the hospitality sector;
additional savings for the NHS still to be calculated;
most likely economic impact is a net gain for society in resource terms;
health benefits are in addition to this.
A Statutory Approach: creating a level playing field
Stuart Ross, Scottish Licensed Trade Association (SLTA)
Mr Ross offered the apologies of Gordon Millar who had been due to speak, but who had taken ill the day before. He raised concerns about his perceptions of the bias of the Conference which he said was heavily laden in favour of health propaganda.
Mr Ross said that he spoke on behalf of the SLTA and the Scottish Beer and Pub Association which, together, represented about 3,500 licensed premises and whose members supply all of Scotland's pubs, hotels, sports clubs, night clubs and restaurants. He indicated that the Associations were fully supportive of Scotland becoming a more smoke-free country and were committed to providing more comfort and choice to non-smokers and to providing a pleasant work environment for staff. However, he made the following points:
tobacco was not a banned substance;
research showed that 67% of pub goers are also smokers; and in some deprived areas this could be as high as 80-90% of pub goers;
a total smoking ban would greatly reduce turnover, perhaps with the exception of food suppliers; 25% reduction was already being reported in Ireland; and would have a catastrophic effect on both large and small businesses and the Scottish economy as a whole;
a total ban on smoking in public places was not an option at this time.
Whilst significant progress has been made through the Voluntary Charter, he recognised that legislation was required to create a level playing field within the industry. Five radical measures had been submitted by the Voluntary Signatory Charter Group to Mr McCabe for his consideration. These were:
smoking should be banned at the bar counter in licensed premises;
smoking should not be permitted where and when food is being served;
all licensed premises should be required to allocate a minimum of 30% of total floor space as non-smoking (40% in year 2; 50% in year 3);
every licensed premise should have a smoking policy sign at the entrance;
smoking should not be permitted back of house (where public are excluded).
At the end of year three a review of progress would be made and further action decided at that time. This was similar to an approach adopted in Norway who were now moving to a total ban over a period of years.
The consultation process
Mr Ross also voiced the licensed trade's concerns about the consultation process and that the Executive had pre-empted the findings:
the Minister for Enterprise and Lifelong Learning had already announced he was in favour of a ban;
the First Minister, following a short visit to Dublin, had said that something approaching a total ban was desirable for Scotland;
the consultation questionnaire did not ask whether the public supported a ban which would make licensed premises smoke-free, probably because a 2003 UK Government Poll found that 80% of people did not want a ban in licensed premises;
there is confusion over whether any legislation would be based on the workplace (over which the Scottish Parliament has no jurisdiction) or on public health grounds, because of the wording in the questionnaire;
the Scottish Executive has marked the questionnaires distributed through the licensed trade;
attempts have been made to discredit the licensed trade's efforts by accusations of manipulation of responses, without evidence.
Smoke-free Tayside: Not just a pipedream
Paul Ballard, NHS Tayside, Public Health Directorate
Mr Ballard provided an overview of work being undertaken in Tayside on tobacco control. He explained the geography and demographics of the area, including the severe levels of deprivation, particularly in Dundee City where 50% of the population were in depcaps 6 or 7. There was a significant smoking problem in Tayside and a strong association between smoking and deprivation. NHS Tayside and its partners were undertaking a range of measures to tackle health inequalities and develop a non-smoking culture. Amongst these were measures around smoking in public places. He indicated that NHS Tayside fully supported any measure to ban smoking in public places in Scotland, which it saw as critical to reducing smoking prevalence. He emphasised the importance of partnership working in this area. Mr Ballard outlined the key elements of local work to restrict smoking in public places:
NHS Tayside and the 3 local authorities in Tayside (Dundee City, Perth and Kinross and Angus) have adopted no-smoking policies in their premises, with minimum exceptions (terminally ill patients, psychiatrically-ill patients, those for whom the NHS had become their home and local authority residential units).
high rate of registrations and awards within Scotland's Health at Work (SHAW) covering a total of 25,000 employees;
Children's Certificates in pubs required a separate smoke-free room or completely smoke-free premises;
Dundee City Council is making it mandatory for all cabs to be smoke-free;
A pilot has been established between NHS Tayside and a few pubs, removing tobacco products from the pubs and instead offering Nicotine Replacement Therapy products;
Preliminary discussion has taken place looking into introducing byelaws to ban smoking in public places under local authority legislation; the outcome of national work in this area will affect any decisions taken.
Mr Ballard ended by stressing the need for political support and leadership to achieve goals in this area.
Discussion session
Mr McCabe joined the speakers for the discussion session. The following is a summary of the questions and discussion which followed.
Whilst understanding the concerns of the licensed trade, the debate should be about public health, not economics. Is it true that the Belhaven Brewery In-house pub is about to become smoke-free?
Mr Ross said that Belhaven had been making much effort over the last year to provide more comfort to non-smokers. When the In-house Pub for visitors becomes smoke-free, smokers would be able to use the brewery garden area adjacent.
Someone who had worked in cessation services for around 10 years made the point that one of the main reasons for relapse of people trying to give up smoking is going to the pub. A ban on smoking in enclosed public places would contribute significantly to improved public health in the future.
Now that the medical case had been made against passive smoking and the evidence is in the public domain, are we not morally and legally obliged to act? Is there not now a case for future litigation against employers, those organisations who might block legislation and the Scottish Executive itself for failing to act, if someone develops a disease through passive smoking in the workplace in the future?
Mr Ross said that the licensed trade was behind measures for more smoke-free places and a staged approach over a number of years to totally smoke-free.
The Chair synthesised the debate by saying that the health lobby supported a move to a complete ban on smoking in public places because the medical evidence was so strong, people in the workplace had no choice and a total ban had worked elsewhere. The licensed trade favoured a more staged approach.
Where does the evidence come from in respect of the economic impact of smoking breaks at work?
Ms Ludbrook drew from research which compared employers who had smoking restrictions, which allowed workers to leave their desks for smoking breaks (usually about 20 minutes) against those with totally smoke-free policies.
If the consultation finds in favour of a ban, how soon can we get one and where?
Mr McCabe said that Ministers were committed to announcing policy intentions by the end of the year. The timing of any action coming into force would be determined by what decisions were taken. The consultation was ongoing until the end of the month and Ministers would take time to consider the findings, along with the findings of the research, some of which was highlighted today. He made it clear that Ministers had had no access to the research before today. The only thing that was clear was that the Executive would take action.
Why do we not have an outright ban on tobacco products, if they are so bad for us, or would it be too costly to the Exchequer?
Mr McCabe said that the debate was not about a ban on smoking and disputed the assertion that we gain economically from smoking. The UK Chief Medical Officer's recent annual report indicated that there would be a 2.3 billion Exchequer benefit if smoking did not exist in our society, notwithstanding the black market already existing in the UK.
Why do smoking policies in Tayside exempt those in psychiatric settings? This is a fundamental issue for those with mental health problems.
Mr Ballard agreed that smoking cessation services were critical for that client group. He said that there had been profound discussions around exemptions to the smoking policy in Tayside and that they had been advised, for duty of care and humanitarian reasons, to exempt the client groups highlighted. The policy is, of course, being reviewed and will take into account experience in practice.
Concern was expressed that ventilation was still being proposed by the licensed trade as a solution to the health risks posed by passive smoking. The author of the University of Glamorgan Study, highlighted earlier, had indicated that in his study to date, half of the establishments where air quality was being tested had either incorrectly installed ventilation in the first place or it was being inadequately maintained. Ventilation increased comfort, but did not remove the health risks of ETS. The question was posed to Mr Ross as to how he would defend possible litigation some years hence on the basis of the protection afforded by ventilation.
Mr Ross said that the licensed trade had not included use of ventilation within its proposals, so he did not consider that there was a question to answer.
Why was the licensed trade not consulted when the decision was taken to make Children's Certificates in Dundee smoke-free?
Mr Ballard said that this was a question for Dundee City Council.
Following the consensus on the need for objective, evidenced data, a plea was made that whatever decision is reached, that there will be a commitment to the funding of the research and evidence gathering necessary to enable the assessment of the impact of controls (social, health and economic)to be made, in order to review policies and to ensure that others also learn from our actions.
Mr Ross asked Mr McCabe why he had not included a question in the public consultation about smoking in licensed premises because that's what the debate has all been about; and if there is support for a total ban, will the issue be passed to Westminster as they have responsibility for workplace legislation?
Mr McCabe confirmed the Executive's commitment to evidence gathering and dissemination.
Regarding the consultation, it is about smoking in all public places, not just about the hospitality sector. On the Scottish Executive's competency, whilst health and safety legislation is reserved, there are extensive public health powers here in Scotland which would enable legislation to be drawn up and be legally binding.