ABOUT ASH

  1.  Action on Smoking and Health (ASH) is a London-based health campaigning charity, working to eliminate the harm caused by tobacco. As smoking is the major recognisable cause of social inequalities in health, ASH welcomes the opportunity to contribute to this consultation. Set up by the Royal College of Physicians, ASH is funded by the British Heart Foundation, Cancer Research UK and the Department of Health.

EXECUTIVE SUMMARY

  2.  Tobacco use is the major preventable cause of death killing around 114,000 smokers each year and responsible for 29% of all cancer deaths[94], 17% of deaths from heart disease and 80% of deaths from chronic obstructive lung disease (see Appendix 1 for a more detailed breakdown).

  3.  There is an iron chain linking deprivation and smoking.[95] Smoking accounts for half the difference in life expectancy between social class 1 and 5. Death rates from tobacco are two to three times higher among disadvantaged social groups than among the better off.[96]

  4.  Our submission relates only to how tobacco control can contribute to reducing health inequalities, by reducing smoking prevalence.

  5.  Increasing the price of smoking is the most effective means of helping smokers quit.[97], [98]However, tobacco tax is strongly regressive and for those smokers who don't quit it can increase health inequalities, particularly for less affluent smokers. On the other hand, genuine price increases do help lead some smokers to quit and make very substantial health and welfare gains for those that do quit. This poses a dilemma, which can be resolved only by making the greatest possible efforts to motivate and assist smokers to quit in response to increases in taxation.

  6.  Preventing people from starting to smoke or helping them quit requires measures at population level that impact on all the key levers, price, promotion, place and product, also known as the marketing mix.[99]

  7.  The NHS impacts on smoking behaviour at individual level rather than population level. The NHS is responsible for identifying smokers, providing individual smoking cessation services and routine follow up where necessary.

  8.  Services provided by the NHS directly can only realistically make a partial contribution to the overall reduction in smoking prevalence, but broader population measures are always going to play a more significant role in reducing smoking prevalence overall. The DH target of 800,000 4-week quitters over three years represented at most 160,000 long-term ex-smokers who would not otherwise have given up smoking during that time frame. This represents a prevalence reduction of around 0.1% a year[100] or a quarter of the current rate of decline.[101]

  9.  Both population and individual measures need to sit within a comprehensive, adequately funded tobacco control strategy.

  10.  Targets are necessary to incentivise effective action to reduce smoking prevalence, and specifically target the most disadvantaged smokers. Targets need to be more ambitious if health inequalities are to be significantly reduced.

A COMPREHENSIVE TOBACCO CONTROL STRATEGY

  11.  Tobacco control is central to any strategy to tackle health inequalities and to any prevention strategy. Stopping people smoking is an intervention which can act before disease develops, so it is more effective than any screening programme[102]. For example 61% of aortic aneurysm resulting in death in men is due to smoking (see Appendix 1). It also results in an immediate reduction in costs to the NHS, for example in costs of hospitalisation for heart disease[103] and statin use.[104]

  12.  Since the white paper Smoking Kills in 1998[105], many significant measures have been achieved, such as a ban on tobacco advertising and promotion and comprehensive smokefree legislation. However, the UK still lacks a co-ordinated national strategy, as required by the WHO's Framework Convention on Tobacco Control, which the UK has ratified.[106]

  13.  Such a strategy should be adequately funded and include comprehensive measures to tackle smoking prevalence as set out below, with a proper process in place for monitoring, evaluation and updating the strategy over time.

  14.  Illegal drug use is estimated to cost the health service only around £0.5 million each year compared to the annual cost of smoking-related diseases of £1.7 billion. 15 The Government spent £736 million on treatment and prevention on illegal drugs in 2005-6[107] (not including all the crime and enforcement costs of illegal drugs). Yet it is estimated there are only around a total of 350,000 problem drug users.[108] In comparison spend on tobacco control by DH was less than £150 million in 2005-6, for 10 million smokers.[109]

THE EXTENT TO WHICH THE NHS CAN CONTRIBUTE TO REDUCING HEALTH INEQUALITIES

The NHS Stop Smoking Services

  15.  The NHS Stop Smoking Services, first introduced in Health Action Zones, are a very cost effective means of tackling what is chronic relapsing disease, tobacco addiction. A recent analysis shows that the average cost per life gained for every smoker was under £700, one of the most cost effective interventions and well below the benchmark of £20,000 per quality-adjusted life-year saved (QALY) that is used by NICE to determine whether a treatment should be funded by the NHS.[110]

  16.  Furthermore, the findings of the evaluation of the services were that the services are effective at reaching more disadvantaged smokers.[111] This is supported by the survey figures from the ONS studies which show that in 2005 8% of routine and manual workers said they had been referred or self-referred to a stop smoking service, compared to 4% of professional and managerial workers (and 10% of intermediate workers).

BRIEF INTERVENTIONS AND THE QOF

  17.  Over 80% of the population visit GPs at least once a year and the figure is higher for smokers.[112] But QOF scores show that socially deprived areas receive a lower quality of primary care and that social deprivation is an independent predictor of lower quality.[113] Brief advice by doctors is effective in reducing patients' smoking and NICE guidance has been issued on this topic last year.[114] GP practices should all be advising smokers to quit and referring them to Stop Smoking Services where appropriate, but this is only happening in a minority of cases.[115], [116]

  18.  The QOF currently awards 41 of the 74 points available for smoking for simply recording smoking status. The remaining 33 points are awarded for giving smoking cessation advice only to patients in specific disease categories by which time it may well be too late.

  19.  Together with the Royal College of Physicians and the Royal College of General Practitioners ASH recommended that the QOF be rebalanced using the existing points to award most of these points to doctors for ensuring that 90% of all smokers were given smoking cessation advice and referred to stop smoking services at least once every fifteen months, with less for simply recording smoking status, but our proposals were not accepted.

  20.   Recommendation: The QOF is currently being renegotiated again, and the HSC should also call for a rebalancing of points awarded to prioritise smoking cessation advice and referral.

SMOKING CESSATION IN HOSPITALS

  21.  More also needs to be done to enable patients to access smoking cessation advice and services from secondary care. For example, smoking cessation is the only intervention that changes the natural history of chronic obstructive pulmonary disease (COPD) or reduces the risk of lung cancer, but only half of all UK chest specialists have direct access to a Stop Smoking counsellor.[117]

  22.  In addition health professionals in hospitals are not making best use of existing services. A survey in one hospital found that while 20% of inpatients smoked, less than a third were given smoking cessation advice, despite the hospital having a smoking cessation service.[118] Furthermore while there were high levels of awareness amongst health professionals of the local Stop Smoking Service in a District General hospital, only one in five had referred smokers to the service.[119]

  23.  We have been told that in some PCTs there are problems for hospitals in developing smoking cessation services, because PCTs are concerned that smokers quitting in hospitals won't count towards their quit targets.[120]

  24.   Recommendation: That the HSC should examine why it is that smoking cessation is not routinely provided in hospitals and what can be done to remedy this situation.

THE NHS AND LOCAL AUTHORITIES

  25.  The NHS needs to collaborate with Local Authorities in order to be most effective in helping reduce health inequalities and smoking prevalence should be one of the areas specifically targeted. In the North-West of England local authorities and PCTs have collaborated effectively to reduce smoking prevalence, particularly in Liverpool[121], and the North-East has an innovative model with PCTs funding their own regional office of tobacco control[122], which has also been very effective.

  26.  ASH and the Chartered Institute of Environmental Health have developed a briefing note for local authorities on how Local Area Agreements can be used to reduce smoking prevalence and tackle health inequalities.[123] CIEH, the Faculty of Public Health, the Trading Standards Institute and the Association of Directors of Public Health sent this briefing note to all Regional Directors of Public Health and local authorities and encouraged them to ensure that Local Strategic Partnerships adopt smoking prevalence as one of the stretch targets in their Local Area Agreements and work together to develop action plans.[124]

POPULATION LEVEL MEASURES

  27.  There is evidence from jurisdictions with strategic tobacco control frameworks, such as California and Australia, on how to bring smoking prevalence down and such measures are both inexpensive and highly cost-effective compared to health interventions to treat disease once it has developed. Population measures rather than measures targeted at individual subgroups have been found to be particularly effective.

  28.  There is also good evidence that smoking prevalence only continues to go down when all policy levers continue to be used to the full.[125], [126], [127]

TAXATION AND SMUGGLING

  29.  The most effective means of reducing smoking prevalence is price increases through tobacco taxation, which is also most effective with poorer and younger smokers. 4, 5

  30.  HM Treasury has made clear that it does not believe that increasing taxation on tobacco products is a lever it can use at the present time given the continuing high levels of smuggling. Reducing smuggling therefore is a priority.[128] It is also crucial to reducing health inequalities as less affluent smokers are more likely to use contraband tobacco.[129]

  31.  While much has been done to tackle smuggling, further measures are needed. In particular we would like to see the government actively supporting a strong global protocol to the WHO Framework Convention on Tobacco Control, as set out in the WHO expert working group's template, which was agreed by the last Conference of the Parties as a basis for the negotiations due to start shortly. We would also like to see strong support for the timetable which envisages the protocol being put to the Conference of the Parties for adoption in 2010. Smuggling is a global problem and requires a global solution.

  32.  Furthermore we would like to see the UK signed up to the anti-smuggling Agreements that the European Commission and all other EU Member States have signed with Philip Morris International (PMI) and Japan Tobacco International (JTI), two of the top three tobacco companies in the world.[130], [131]As a non-signatory the UK will not benefit from Agreements which ensure that both companies are required to control the illicit trade in their products and to pay heavily if their cigarettes continue to be smuggled.

  33.  The UK refused to sign the PMI agreement, arguing that as PMI only had a small market share in the UK, it was not relevant. This argument will not wash with Japan Tobacco, which recently acquired UK-based Gallaher, the UK's second-largest tobacco company. With an almost 40% market share, JTI has a significant stake in, and control over, the UK tobacco trade.[132] (Gallaher will fully join up to the Agreement in two years, but the general compliance obligations apply immediately).

  34.  In 2005-06 of the 2 billion smuggled cigarettes seized by Customs, about 200 million were Gallaher brands, making them the UK brand with the biggest share of the smuggled cigarette market. If the JTI agreement had been fully in force at that time, the UK would have received over £100 million in seizure payments from Gallaher.[133]

  35.  ASH is calling on the Government to urgently reappraise its strategy on smuggling and sign the EU accords with PMI and JTI.

  36. HM Treasury reduced VAT on nicotine replacement products from 17.5% to 5% for one year from 1 July 2007, to encourage more smokers to quit. Research carried out for ASH shows that the reduction in tax has transferred through to the retail price and there seems to have been a positive impact on sales, although there are a number of confounding factors.[134] We would therefore like to see the Treasury sustain this reduction in taxation of such products permanently in the next budget.

SOCIAL MARKETING

  37.  Mass media interventions are expensive but highly cost-effective on a per capita basis. Paid mass media advertising campaigns have been found to be an effective means of reducing smoking[135], [136], [137], and can be targeted to be specifically aimed at lower socio-economic groups to tackle health inequalities, but they need to be sustained and have high impact. Such campaigns can also reduce incident smoking in young people.[138]

  38.  Mass media campaigns are also needed to continue to address smoking in the home and other private places such as cars. This remains the major source of secondhand smoke exposure, and those from disadvantaged backgrounds, particularly children, are worst affected.[139] Self-enforced restrictions on smoking at home are effective in reducing exposure to children but are currently imposed by less than 20% of households.[140]

  39.  Mass media campaigns are also a necessary and very effective driver of smokers to the Stop Smoking Services. This is illustrated by what happened in the second quarter of 2006 when the campaigns were stopped. Without the impetus of mass media to encourage people to quit, the number of successful quitters through the services fell by 17% from the same quarter in the previous year, from 76,000 in April to June 2005 to only 66,000 in April to June 2006.

  Source: COI.

  40.  As the table above shows, it was not just that the media spend in that quarter fell to nothing, but also that the media spend in the previous two quarters was more than a third down on the previous year. The level of spend on the services is believed to have remained fairly consistent year on year over this period. 16

  41.  The conclusion of numerous studies of mass media campaigns has been that the key to success was maintaining a consistent and sustained level of advertising over time.[141], [142], [143], [144] This is hardly surprising, since given this is the lesson of commercial advertising, why should it be any different for social marketing?

  42.  The US Centers for Disease Control has put together recommendations for spend on mass media campaigns, based on the spending levels in the four states which had effective tobacco counter-marketing campaigns which had been successful in changing both attitudes and behaviours. CDC recommended a spend of between $1-3 a year per capita. The CDC mid-range recommendation of $2 per capita would give an annual spend of £50 million p.a.

  43.  However, since 2004-5 the level of spend has fallen, to £22.7 million in 2005-6 and £13.5 million in 2006-7. DH may argue that money is being allocated locally to target key groups of smokers more effectively, and so tackle health inequalities. We would argue that this should be in addition to mass media spend and not as an alternative.

HARM REDUCTION

  44.  The Government have committed to consult on a harm reduction strategy for tobacco control. It's the tobacco smoke that kills people not the nicotine. While the gold standard should always be quitting, a harm reduction strategy should give smokers, in particular the most disadvantaged who find it harder to quit, access to less harmful forms of nicotine in a form and at a price that is attractive as an alternative to smoking. This must be accompanied by effective marketing so that people understand that it is not the nicotine itself that is harmful but that the harmfulness of delivery varies greatly.

  45.  A switch of only 1% of the population a year from smoking to less harmful nicotine sources, a conservative target, would save around 60,000 lives in only 10 years.[145]

OTHER MEASURES

  46.  Also necessary are:

—  A comprehensive three year review of the smokefree legislation and revision of the regulations where necessary;

—  Development of a strategy for tackling smoking in private places such as the home and the car;

—  Strengthening of restrictions on residual marketing for example a complete ban on point of sale advertising, and generic packaging for all tobacco products;

—  A ban on vending machine sales of cigarettes;

—  Introduction of positive licensing for retailers.

TARGETS

  47.  Reducing inequalities in smoking rates is crucial to a reduction in health inequalities as is recognised in the DH PSA target on smoking which is "Reducing smoking rates to 21% or less by 2010, with a reduction in prevalence among routine and manual groups to 26% or less."

  48.  On current estimates smoking prevalence is declining by about 0.4% per annum.8 Overall smoking prevalence in 2005 was 24%, with smoking rates amongst routine and manual workers still at 31% and no sign of the differential being eroded. At current rates of decline smoking prevalence among routine and manual workers is likely to be at around 29% in 2010, a full 3% above the target. Yet these are not ambitious targets and are nowhere near the "fully engaged scenario" envisaged by Wanless of 17% by 2010 and 11% by 2022. 10

  49.  HMRC targets to reduce smuggling are also relevant to health inequalities and to reduction in smoking prevalence, as low income smokers are much more likely to smoke smuggled cigarettes.[146] Currently (taking the mid-point) smuggled cigarettes have a market share of 14.5%, but it is still the case that over 50% of hand-rolled tobacco (HRT) consumed in this country is smuggled.[147] This is of particular concern as HRT is most popular with routine and manual male smokers (42% of men in routine and manual occupations mainly smoke HRT, compared to only 25% of the population as a whole[148]).

  50.  The current PSA targets are54:

  By 2007-08:

—  reduce the illicit market share for cigarettes to no more than 13%;

—  A new, specific operational target for HRT announced in March 2006 of reducing the size of the UK illicit market by 1,200 tonnes—equivalent to around 20 per cent.

  The target for cigarettes is achievable, but new, stretching targets need to be set for the future. Despite the new strategy for tackling smuggling of HRT, the target for HRT is unlikely to be reached.

  51.  ASH was therefore concerned to hear when we met with the Minister Angela Eagle at the end of last year that new PSA targets for HM Revenue & Customs to reduce tobacco smuggling will not be set after the current targets expire at the end of this financial year. She stated that this is only a "definitional issue" as reducing smuggling will be a Departmental Strategic Objective, but unless specific targets are published, our view is that there will not be clarity about what HMRC is expected to achieve. It is also crucial that HMRC continue to collect and publish the information about the outcomes, in other words the estimated range of illicit market shares of both the cigarette market and the hand-rolled tobacco market and specific details about the breakdown of the market.

  52.   Recommendation: That the HSC call Angela Eagle, Exchequer Secretary to the Treasury who is responsible for HMRC to give evidence to the Inquiry about the government's tobacco smuggling strategy and targets.

January 2008

DEATHS CAUSED BY SMOKING

  1.  One in two long-term smokers will die prematurely as a result of smoking—half of these in middle age. One quarter will die after 70 years of age and one quarter before, with those dying before 70 losing on average 21 years of life.[149] It is estimated that between 1950 and 2000 six million Britons died from tobacco-related diseases.[150]

  2.  The most recent estimates show that around 114,000 people in the UK are killed by smoking every year, accounting for one sixth of all UK deaths.[151] This is more than three times the number of deaths from obesity, the second major cause of ill-health and premature death.[152] The table on the next page shows the percentage and the number of deaths attributable to smoking by type of disease, based on the latest available breakdown (2002 data).

  3.  Deaths caused by smoking are five times higher than the 22,833 deaths arising from: traffic accidents (3,439); poisoning and overdose (881); alcoholic liver disease (5,121); other accidental deaths (8,579); murder and manslaughter (513); suicide (4,066); and HIV infection (234) in the UK during 2002.[153] For more on deaths from smoking in the UK and worldwide see:www.deathsfromsmoking.net

  4.  Smoking also causes or exacerbates many other conditions, which even if they are not deadly can cause years of disease and distress. For example fertility is 30% lower in female smokers. See table for a detailed breakdown.

  * Studies have shown that smoking appears to have a protective effect against the onset of some diseases such as endometrial cancer. However, the positive effect is so small compared to the overwhelming toll of death and disease caused by smoking that there is no direct public health benefit.

95   ASH press release 9th October, 2006 Major Online Mapping Project Shows "Iron Chain" Between Smoking and Deprivation http://www.newash.org.uk/ash_b5hdcln5.htm Back

96   Acheson, D. Independent Inquiry into Inequalities in Health. London, TSO, 1998. Back

97   Jha P, Chaloupka FJ. Curbing the Epidemic:Governments and the Economics of Tobacco Control. World Bank, 1999. Back

98   Hu T-W, Sung H-Y, Keeler TE. Reducing cigarette consumption in California: tobacco taxes vs. an antismoking media campaign. Am J Public Health 1995b;85(9):1218-22. Back

99   http://en.wikipedia.org/wiki/Marketing_mix Back

100   West, R. Stop Smoking Service Quality and Delivery Indicators and Targets. A Briefing for the Healthcare Commission. July 2004. Back

101   Jarvis MJ. Monitoring cigarette smoking prevalence in Britain in a timely fashion. Addiction 2003;98:1569-74. Back

102   Carvel, J. Brown plans killer disease screening on NHS for all men as they reach 65. The Guardian 5 January 2008. Back

103   Naidoo B, Stevens W and McPherson K. Modelling the short term consequences of smoking cessation in England on the hospitalisation rates for acute myocardial infarction and stroke. Tobacco Control, 2000; 9: 397-400 doi:10.1136/tc.9.4.397. Back

104   Wanless D. Securing our Future Health: Taking a Long-Term View. Final Report. London, HM Treasury, 2002. Back

105   Department of Health. Smoking Kills. A White Paper on tobacco. London: The Stationery Office, 1998. Back

106   WHO Framework Convention on Tobacco Control. Adopted May 2003, Geneva. http://www.who.int/tobacco/framework/en/ Back

107   Home Office website accessed 9 January 2008. http://www.drugs.gov.uk/drug-strategy/funding/ Back

108   Drugs-facing facts The report of the RSA Commission on Illegal Drugs, Communities and Public Policy. RSA March 2007. Back

109   UK Tobacco Policy and Expenditure-An Overview. ASH, 2007. http://newash.org.uk/files/documents/ASH_667.pdf Back

110   Godfrey, C. Parrott, S. Coleman, T. & Pound, E. The cost-effectiveness of the English smoking treatment services: evidence from practice. Addiction, 2005; 100(suppl.2),70-83. Back

111   Chesterman, J. Judge, K. Bauld, L & Ferguson, J. How effective are the English smoking treatment services in reaching disadvantaged smokers? Addiction, 2005; 100 (Suppl.2), 36-45. Back

112   OPCS 1996. Back

113   Ashworth, M. Armstrong, A. The relationship between general practice characteristics and quality of care: a national survey of quality indicators used in the UK Quality and Outcomes Framework, 2004-5. BMC Family Practice 2006, 7:68doi:10.1186/1471-2296-7-68. Back

114   Brief interventions and referral for smoking cessation in primary care and other settings. Public Health Intervention Guidance no.1. NICE. March 2006. http://www.nice.org.uk/page.aspx?o=PHI001 Back

115   Coleman T, Wynn A, Barrett S, Wilson A. Discussion of NRT and other antismoking interventions in UK general practitioners' routine consultations. Nicotine and Tobacco Research 2003;5:163-8. Back

116   Taylor, T. Lader D. Bryant, A. Keyse, L. McDuff, TJ. Smoking related behaviour and attitudes, 2005. London: Office for National Statistics, 2006. Back

117   Campbell, I. A., Lewis, K. E., and Preston, L. A. Surveys and assessement of secondary care smoking cessation services in the UK, 2001-2003. Thorax 2003;53 (Suppl III):iii42-iii43(Abstract). Back

118   Warner, A et al. Smokers admitted to hospital: Role of junior doctors, smoking cessation services and smoke-free hospital. BTS winter conference 2006. Back

119   Elsheikh, A. The NHS Stop Smoking Services: Hospital staff awareness and the pattern of referral to the local (Basildon and Thurrock) Services. BTS winter conference 2006. Back

120   Personal communication from Medical Director of a large teaching hospital. Back

121   See submission to HSC Inquiry from Smokefree North West. Back

122   For more information contact Fresh North-East http://www.freshne.com/. Back

123   CIEH ASH briefing paper on Local Area Agreements and smoking prevalence http://newash.org.uk/files/documents/ASH_673.pdf Back

124   ASH press release 3rd December, 2007 + links to documents http://www.newash.org.uk/ash_be2tdd0a.htm Back

125   Hill DJ et al: Smoking behaviours of Australian adults in 1995: trends and concerns. Med J Aust 1998; 168: 209-213. http://www.mja.com.au/public/issues/mar2/hill/hill.html Back

126   Tobacco Control journal supplement : 2003; 12 Supplement ii. Back

127   Pierce, J et al. Has the California Tobacco Control Program Reduced Smoking? JAMA. 1998;280:893-899. Back

128   PSA 18 Delivery Agreement 3.15 http://www.hm-treasury.gov.uk/media/5/A/pbr_csr07_psa18.pdf accessed on 5 January 2008 Back

129   Chief Medical Officer. Annual Report of the Chief Medical Officer on the State of Public Health. London: Department of Health; 2005. Back

130   Details of the EU Agreement with JTI accessed 8 January 2008 http://ec.europa.eu/anti_fraud/budget/cig_smug/2007_en.html Back

131   ASH press release 9 July 2004 & briefing note. http://www.newash.org.uk/html/press/040709brief.html Back

132   ASH Briefing on Gallaher and Japan Tobacco International. http://newash.org.uk/ash_4oup4ckq.htm Back

133   This is based on HMRC estimates that in 2005-06 2 billion cigarettes were seized. Of these, 18% were genuine UK brands. Gallaher brands accounted for 49% of these brands (ie around 9% of the total). 100% of tax and duties owed on the first 90 million and 500% thereafter at £3.91 per pack in 2005-6 see Tobacco Factsheet table 3.3 http://www.uktradeinfo.com/index.cfm?task=facttobac Back

134   This report for ASH is currently being finalised. Back

135   Reid DJ, Killoran AJ, McNeill AD, Chambers JS. Choosing the most effective health promotion options for reducing a nation's smoking prevalence. Tobacco Control 1992;1:185-97. Back

136   Hill DJ, White VM, Gray NJ. Australian patterns of tobacco smoking in 1989. Med J Aust. 1991;154:797-801. Back

137   Department of Health Economics and Operational Research Division. Effect of tobacco advertising on tobacco consumption: a discussion reviewing the evidence. London: Department of Health, 1992. Back

138   Siegel M,.Biener L. The impact of an antismoking media campaign on progression to established smoking: results of a longitudinal youth study. Am.J Public Health 2000;90:380-6. Back

139   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 July 2005. Available at: http://www.rcplondon.ac.uk/pubs/brochure.aspx?e=4 Back

140   Blackburn C, Spencer N, Bonas S, Coe C, Dolan A, Moy R. Effect of strategies to reduce exposure of infants to environmental tobacco smoke in the home: cross sectional survey. Brit.Med.J. 2003;327:257-60. Back

141   Hyland et al. Anti-tobacco television advertising and indicators of smoking cessation in adults: a cohort study. Health Education Research, 2005. Back

142   McVey D., Stapleton J. Can anti-smoking television advertising affect smoking behaviour? Controlled trial of the Health Education Authority for England's anti-smoking TV campaign. Tobacco Control 2000;9:273-282. Back

143   Erbas B. et al. Investigating the relation between placement of Quit antismoking advertisements and number of telephone calls to Quitline: a semiparametric modelling approach. Journal of Epidemiological Community Health 2006;60;180-182. Back

144   Levy D. and Friend K. A Computer Simulation Model of Mass Media Interventions Directed at Tobacco Use. Preventive Medicine 32, 284-294 (2001). Back

145   Lewis S. Arnott D. Godfrey C. Britton J. Public health measures to reduce smoking prevalence in the UK; how many lives could be saved? Tobacco Control 2005; 14.251-254. Back

146   Chief Medical Officer. Annual Report of the Chief Medical Officer on the State of Public Health. London: Department of Health; 2005. Back

147   HMRC Departmental Report Integrating and growing stronger Spring 2007 http://customs.hmrc.gov.uk/channelsPortalWebApp/downloadFile?contentID=HMCE_PROD1_027505 Back

148   Statistics on Smoking: England, 2007. The Information Centre 2007. Back

149   Peto R. Mortality in relation to smoking: 40 years' observations on male British doctors. BMJ 1994; 309: 901-911. Back

150   Peto R et al. Mortality from smoking in developed countries, 1950-2000. Oxford Medical Publications, 1994. Back

151   Peto R et al. Mortality from smoking in developed countries, 1950-2000 (2nd edition). Oxford University Press, Oxford. View report. Back

152   National Audit Office. Tackling Obesity in England. Report of the Comptroller and Auditor General, Feb 2001. View press notice. Back

153   Mortality statistics 2002., Office for National Statistics, 2002; General Register Office for Scotland 2002; Registrar General Northern Ireland, Annual Report, Statistics & Research Agency, 2002. Back

154   Nicotine Addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. RCP 2000 (for percentage of smoking-related deaths). Back

155   Mortality statistics 2002., Office for National Statistics, 2002; General Register Office for Scotland 2002; Registrar General Northern Ireland, Annual Report, Statistics & Research Agency, 2002. Back

156   Cigarettes: What the warning label doesn't tell you. American Council on Science and Health, 1997. Back

157   Hutchinson, D et al. Annals of Rheumatic Diseases, 2001; 60: 223-7. Back