Scottish Government

chapter 1 smoking and health -progress in Scotland

Introduction

Over 13,000 people in Scotland die every year as a result of smoking ¹ with deaths due to coronary heart disease, stroke, lung cancer, chronic obstructive lung disease and a range of other diseases. It is estimated that 1,500 - 2,000 of these deaths are due to environmental tobacco smoke ^2,3. Significant progress has been made in tackling smoking in Scotland. However, approximately a quarter of all Scots still smoke and people living in the most deprived areas of Scotland are more than twice as likely to smoke as those who live in the least deprived areas. Rates of smoking vary considerably between geographical areas. The recent Scottish smoking atlas estimates smoking rates in Community Health Partnerships in Scotland range from 18.6% to 37.5%.

2006 was a particularly significant year for tackling tobacco-related harm in Scotland as restrictions on smoking in enclosed public places came into effect on 26 March.

Progress in tackling smoking

The last 10 years have seen a number of important policy documents and strategies. These include wide-ranging actions on prevention, education, protection, controls and reducing health inequalities.

In 1998 Smoking Kills, the UK White Paper on tobacco, set out a range of measures to tackle tobacco-related harm. In addition to UK action on tobacco advertising, tobacco taxation and smoking in the workplace, it provided a framework for action in Scotland. New funding was provided over 3 years for work on smoking prevention and the development of specialist NHS smoking cessation services. In 1999 the Scottish Public Health White Paper "Towards a Healthier Scotland" confirmed tackling tobacco as a Government priority and set targets for reducing smoking prevalence. In 2001 nicotine replacement therapy became available on NHS prescription adding further impetus to smoking cessation services.

In 2003 the Scottish Executive re-established a Tobacco Control Strategy Group to coordinate action across the national agencies and to assess tobacco control policy. Improving Health in Scotland: The Challenge published later that year, made tobacco a special focus topic and committed to review tobacco control policy in Scotland. Following that review ⁴, the Scottish Executive launched an action plan, A Breath of Fresh Air for Scotland, in 2004. This set out proposals for a national debate on actions to minimise the impact of second-hand smoke. Following national consultation, the Smoking, Health and Social Care (Scotland) Bill was presented to the Scottish Parliament in December 2004. The Bill set out comprehensive legislation prohibiting smoking in virtually all enclosed public places. It received Royal assent in August 2005 and was enacted on 26 March 2006.

"Smoking causes over one in five of all deaths in Scotland and is the leading preventable cause of ill-health and premature death."

Smoking prevalence in adults in Scotland aged 16+

Impact of the smoke-free legislation

A comprehensive evaluation has been set up to examine the health, behavioural, socio-cultural and economic impacts of Scotland's smoke-free legislation using a combination of analysis of routine health, behavioural and economic data and 8 specially commissioned studies ^5,6. Full results will be available in 2008 but the preliminary findings are very positive.

Impact on air quality

A study of air quality in a random sample of 41 pubs in two Scottish cities found an 86% reduction in PM2.5 particles after implementation of the legislation ⁷. PM2.5 is small particulate matter of less than 2.5 microns in diameter. Ninety per cent of PM2.5 comes from tobacco smoke. The data on air quality indicate high levels of compliance with the legislation and are consistent with national compliance data from Environmental Health Officer inspections ⁸. Of 67,219 inspections of pubs and other workplaces conducted to the end of 2006, 98.8% were compliant with the smoking regulations.

Early impact on health

Reductions in second-hand smoke exposure have been accompanied by early improvement in health. A study of 77 non-smoking bar workers in Dundee showed a reduction in respiratory and sensory symptoms and an improvement in lung function one and two months post-legislation ⁹, although seasonal factors cannot be ruled out as an explanation. Another study ( CHETS) surveyed 2500 primary school children before and after the legislation and measured cotinine, a marker of exposure to tobacco smoke ¹⁰. Children reported no shift of second-hand smoke exposure from public places into homes following the legislation, and there was a fall in cotinine levels. In the Health Education Population Study, adults reported no change in exposure to smoke in homes and a reduction in exposure in public and work places ⁵. Again, the reduced exposure was confirmed by falls in cotinine levels.

There is also some evidence of improvement in health at a population level. Recent research suggests that second-hand smoke increases inflammation in blood vessels and increases the stickiness of blood cells, making it easier for blood clots to block arteries and cause heart attacks. In common with other countries, emergency hospital admissions for heart attacks have been falling for some time in Scotland. Heart attack admission rates fell at an average rate of 3.8% per year in the ten years before the smoke-free legislation. For the six months following the implementation of the legislation the annual rate of decline increased by more than six-fold to 25% ¹¹. A separate study of people admitted to coronary care units in 9 major Scottish hospitals found a 17% fall in admissions in the 10 months after the legislation compared with the corresponding 10 months in the preceding year, with a larger reduction among non-smokers. ¹¹ These changes are very encouraging, but it will be important to confirm that they are sustained over a longer period.

" Significant progress has been made in tackling smoking in Scotland in 2006. Considerable challenges remain, in particular in preventing young people taking up smoking, but the potential health rewards are huge."

Impact on use of smoking cessation services

There were 46,466 recorded quit attempts during 2006 and an estimated 4.3% of smokers in Scotland made a quit attempt with an NHS smoking cessation service ¹². Statistics on smoking cessation product prescribing ¹³ show seasonal variation, with the first quarter of each year being the peak period. There was an especially sharp rise in prescribing in the run-up to the introduction of the smoke-free legislation, in March 2006. Calls to SMOKELINE, ¹⁴ the national quitting-smoking helpline, rose in the run-up to the legislation, peaking at 6,593 in March, falling to 2,658 calls in April, then reverting to the levels of previous years.

Smoking prevalence

Smoking prevalence for the adult population aged 16+ ¹⁵ was estimated as 25.0% in 2006 compared to 26.2% in 2005.

For children, ¹⁶ 69% of 13 year olds in 2006 reported they had never smoked compared to 59% in 2004. For 15 year olds the corresponding improvement was from 39% in 2004 to 47% in 2006. In 1996, 30% of 15 year olds reported that they smoked regularly. In 2006 this figure was down to 12% for boys and 18% for girls.

Support for the smoking ban

There is strong and increasing support for the legislation. A repeat cross-sectional survey of Scottish adults aged 16-74 years found that between September-December 2005 and September-December 2006, support for the legislation rose from 88% to 93% among non-smokers and from 53% to 65% among smokers ¹⁷.

Future developments

As we look ahead there is an increasing focus on the challenge of preventing young people from taking up smoking. In 2006 a Smoking Prevention Working Group was set up as a sub-group of the Scottish Ministerial Working Group on Tobacco Control. Towards a Future without Tobacco, published in November 2006, contained 31 recommendations about reducing availability, discouraging young people from smoking, further research and new targets for 13 and 15 year olds. A key recommendation was the proposal to raise the minimum age of purchase from 16 to 18 years of age. The Working Group also recommended a comprehensive reassessment and reform of education on tobacco, alcohol and other drugs in Scottish Schools. A national consultation on the recommendations is planned in 2007.

Significant progress has been made in tackling smoking in Scotland in 2006. Considerable challenges remain, in particular in preventing young people taking up smoking, but the potential health rewards are huge.