We are pleased to submit evidence to the above Inquiry. The Royal College of Physicians (RCP) plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 20,000 Fellows and Members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare.

  The following submission addresses the terms of reference 1-3 as set out by the committee, and is based on our work with the RCP Tobacco Advisory Group, and our work on alcohol, including with the Alcohol Health Alliance.

  The consumption of cigarettes and alcohol are the two most important habitual and correctable causes of ill health in the UK. These factors disproportionately affect the most deprived members of our society and contribute to many thousands of avoidable deaths each year.

  Our highest priority recommendations are to reduce the use of cigarettes and the consumption of alcohol in the most disadvantaged groups in our society. Our recommendations for actions to achieve these aims are:

—  Appropriate incentives and targets must be set for smoking cessation services throughout primary and secondary care

—  An increase in the development and delivery of smoking cessation services, including within secondary care and mental health institutions

—  Cigarette pricing must be successively increased above the rate of inflation

—  There must be a clamping down on smuggling and illicit "faghouse" sales

—  Continued, sustained, varied, imaginative advertising and other social marketing campaigns to reduce motivation to smoke—in particular targeting disadvantaged groups

—  There must be further constraints on the brand imagery, promotion and availability of cigarettes for sale—the implementation of generic plain packaging, removal of display gantries (making cigarettes an "under the counter" product), enforcing laws on sales to minors, removal of vending machines, licensing (positive or negative) of retail outlets

—  Prevention of product placement and imagery in films, TV and other media—for example, by banning smoking in TV programmes shown before the 9pm watershed, and applying 18 classification to all new feature films featuring smoking

—  A Nicotine Regulatory Authority must be established to oversee necessary changes to the nicotine product market

—  Alcohol tax should be raised to provide adequate funding to bring alcohol treatment and prevention services up to the level of services provided for users of illegal drugs

—  Targeted waiting times for alcohol treatment must be introduced

—  The availability of alcohol must be reduced, particularly below-cost selling through supermarkets

1.   The extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas eg taxation, employment, housing, education and local government;

ALCOHOL

  1.1  The misuse of alcohol in the UK is a major cause of health and social problems, with disadvantaged groups in society bearing a disproportionate brunt of the damage. The Department of Health programme for tackling health inequalities recognises that it is disadvantaged areas that particularly need improved alcohol misuse services[175]. The Royal College of Physicians working party report "Alcohol: Can the NHS Afford It?" (2001) estimated that the use of hospital facilities resulting from alcohol abuse places a considerable financial burden on the NHS, inpatient costs alone accounting for 2-12% of total NHS expenditure on hospitals.

  1.2  The Prime Minister's Strategy Unit (2003) estimated that the annual alcohol-related costs of crime and public disorder were put at £7.3 billion, workplace costs at £6.4 billion, and health costs at £1.7 billion. Around 17 million working days are lost annually due to alcohol abuse. Alcohol is responsible for 70% of deaths from liver cirrhosis. A report from the Chief Medical Officer (2001) stated that across both sexes and all age groups between 25 and 64, the annual mortality rate from chronic liver disease rose from 659 in 1970, to 3073 in 2000, a rise of 466%. This is at a time when deaths from chronic liver disease in Europe are falling.

  1.3  A report from the Association of Public Health Observatories shows that lives lost, rates of mortality, admission to hospital, incapacity due to alcoholism, visits to a pub/bar and binge hazardous and harmful drinking all show much higher levels in the more deprived regions of England compared with the more affluent regions. It also shows this gap to be widening, with the effect on regional economies with proportions of the working population claiming incapacity benefits due to alcoholism[176].

  1.4  The most effective and cost effective strategy for reducing alcohol harm is to increase price and reduce availability[177]. Evidence suggests that increasing the price of alcohol could decrease alcohol related deaths[178], yet alcohol has become more than 50% more affordable in the last 25 years. In 2001 the Alcohol Harm Reduction Strategy for England found that alcohol causes 22,000 deaths, and the estimated cost of alcohol related harm to health, crime and the workplace was £15.4 billion—a figure which does not include human costs of crime, nor damage to families and children, which were felt to be incalculable.

  1.5  In contrast the income from alcohol duty was £7 billion, with a further £6 billion in VAT[179]. Raising overall alcohol related taxation would have the double benefit of reducing harmful levels of consumption, whilst providing more than enough funding for the exchequer, to bring alcohol treatment and prevention services up to the level of services provided for users of illegal drugs.

  1.6  Given the current alcohol problem in the UK—to increase taxation on alcohol, and to improve treatment and prevention services seems both sensible and fair.

SMOKING

Contribution of smoking to health inequalities

  1.7  Smoking is the largest recognised cause of premature death and disability, and is responsible for about one in six deaths each year in the UK. Smoking causes a wide range of fatal and non-fatal diseases, the majority from three diseases: lung cancer, heart disease and chronic obstructive pulmonary disease. Smoking is especially prevalent among socially disadvantaged individuals, who are more likely to have grown up in a household with exposure to tobacco smoke, more likely to become smokers, more likely to start smoking at a very young age (when the brain is still developing, possibly leading to irreversible developmental changes leading to sustained nicotine addiction), likely to smoke more cigarettes per day, and to take more nicotine and tar from each cigarette than less disadvantaged smokers. Disadvantaged smokers are no less likely to want to quit smoking, or to use cessation services to help them to quit, but are less likely to succeed.

  1.8  As a consequence, the most disadvantaged sectors of society have benefited least from the downward trend in smoking prevalence that has occurred over recent decades in the UK. As the figure below shows (data from the General Household survey, provided by Prof Martin Jarvis), smoking prevalence has fallen dramatically in the most affluent sectors of society over the past 30 years, but hardly at all among the most disadvantaged. Since smoking kills approximately half of all regular smokers, the persistence of such high smoking prevalence in the most deprived social groups has exacerbated health inequalities in the UK. Smoking is indeed the largest recognised avoidable cause of social inequalities in health1. Reducing the prevalence of smoking among disadvantaged groups should be the highest priority in any strategy to reduce social inequalities in health.

Smoking prevalence and socio-economic disadvantage
CIGARETTE SMOKING BY DEPRIVATION
IN GREAT BRITAIN: GHS 1973 & 2004

2.   The distribution and quality of GP services and their influence on health inequalities, including how the Quality and Outcomes Framework and Practice-based Commissioning might be used to improve the quality and distribution of GP services to reduce health inequalities;

SMOKING

  2.1  As shown previously in this evidence, the NHS could achieve a great deal more in terms of identifying and intervening in smoking at individual level, and ensuring that cessation services are configured to deliver the necessary interventions in all healthcare settings. It is necessary to introduce measures that will ensure that all smokers have their smoking status identified at all health consultations, and help with cessation (behavioural support and pharmacotherapy) delivered if accepted. Recent changes to the Quality and Outcomes Framework have led to a substantial increase in the ascertainment of smoking status by primary care doctors, but little if any increase in intervention. In secondary care, consultants and junior staff who provide smoking cessation therapies and behavioural support for inpatients who smoke remain in the substantial minority. There are many reasons for this, but success in other areas (delivery of statin therapy to reduce cholesterol, for example) indicates that if the NHS prioritises this behaviour, it will occur. It is vitally important to set the appropriate incentives and targets to ensure that this happens throughout primary and secondary care.

  2.2  As a further consideration it is also important to review the scope and targets set on cessation services, which tend at present to be configured (for entirely understandable and justifiable reasons) to deal with the largest numbers of smokers as efficiently as possible. Whilst this approach maximises the numbers of smokers treated overall, it also tends to abandon smokers for whom attendance at standard cessation services is difficult or impossible—those in secondary care or mental health institutions for example. At present, hospital trusts have no incentive or requirement to treat smokers in their care, and as a result, valuable opportunities to intervene at times when smokers are particularly susceptible to change, are being missed.

3.   The effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity, including whether some public health interventions may lead to increases in health inequalities

ALCOHOL

  3.1  Up to 12 million people in this country are dependent on alcohol or drink hazardously compared with 300,000 problematic drug users. Providing drug treatment for users of illegal drugs is a high government priority but there is comparatively little provision of treatment for alcohol related problems.

  3.2  As a consequence, 67% of dependent or harmful drug users have access to treatment, compared with 5.7%[180] for alcohol. The budget for the UK drug strategy in 2005-6 was £1,483 million[181] but there is no dedicated budget for the UK alcohol strategy.

  3.3  In addition to the absence of dedicated funding for alcohol treatment, there are no targeted waiting times for alcohol treatment and very few alcohol services for people with alcohol related chronic disease, many of whom do not have the features of alcohol dependence and as a result are under the radar of addiction services. In contrast the National Treatment Agency waiting time target for a Drug Intervention Program (DIP) is one week. Ensuring the provision of adequate treatment for adults and young people would significantly reduce the harm caused by alcohol misuse.

  3.4  Furthermore, despite the wealth of evidence showing that early interventions in hazardous drinking are both effective and highly cost effective[182], alcohol prevention strategies are unfunded and as a result very few exist.

  3.5  Alcohol treatment and prevention programmes must therefore be properly funded to ensure that the gap in services in this area of public health is addressed.

SMOKING

Preventing smoking

  3.6  Preventing smoking requires a combination of policies operating at population level that make smoking less easy, affordable, acceptable or even desirable to new and existing smokers, and policies at individual level that encourage existing smokers to quit. These two approaches work synergistically, since it is typically the population level policies that stimulate smokers to want to quit, and the individual approaches that are crucial to their success.

  3.7  Policies that operate at population level to reduce the drivers to smoke (or "denormalise" smoking) tend to be outside the remit of the NHS, and include:

—  Price—increasing the price of tobacco products decreases consumption, provided that alternative (ie smuggled or other illicit) sources of tobacco products are also closed off

—  Mass media health promotion—high impact and varied advertising campaigns and other promotional activities that encourage smokers to quit, and young people to avoid starting

—  Smoke-free policies—preventing smoking in public and in the workplace has a substantial impact on smoking prevalence.

—  Banning all advertising and promotion of tobacco products

  3.8  However, measures which operate at individual level to support cessation fall predominantly within the NHS remit, and involve:

—  Systematic identification of smokers in all health consultations

—  Individual promotion of smoking cessation to all smokers

—  Provision of the most intensive cessation support with which smokers are likely to comply, to all who express a desire to attempt to quit (the more intensive the support used, the more likely the smoker is to succeed)

—  Routine follow up and repeat intervention where appropriate

  3.9  Over the past 10 years the UK government has made dramatic progress on almost all of the above measures, and deserves credit for doing so. However there is a great deal more that could be done (see below). There is also an unaddressed need to deal with the large numbers of smokers who will not, or are not capable of, quitting smoking in the short or medium term (see harm reduction, below).

Further population measures required to reduce the prevalence of smoking

  3.10  The following measures would help to denormalise smoking in the UK, and particularly among disadvantaged social groups, still further

—  Successive increases in cigarette price above the rate of inflation

—  Clamping down on smuggling and illicit "faghouse" sales

—  Continued, sustained, varied, imaginative advertising and other social marketing campaigns to reduce motivation to smoke—in particular targeting disadvantaged groups

—  Further constraints on the brand imagery, promotion and availability of cigarettes for sale—the implementation of generic plain packaging, removal of display gantries (making cigarettes an "under the counter" product), enforcing laws on sales to minors, removal of vending machines, licensing (positive or negative) of retail outlets

—  Prevention of product placement and imagery in films, TV and other media—for example, by banning smoking in TV programmes shown before the 9pm watershed, and applying 18 classification to all new feature films featuring smoking

Further measures to improve cessation interventions

  3.11  Development and delivery of smoking cessation services is very much within the NHS remit. The UK has led the world in development of cessation services, and the targeting of funds through the Health Action Zones was in particular crucial to establishing the foundation of that success. However, a great deal more could and should be done. According to successive Government Omnibus surveys, whilst the proportion of smokers accessing cessation services and using cessation therapies have increased progressively in recent years (see figure below), these proportions are still very small. In 2006 only 10% of smokers were referred to specialist cessation services; only 17% recall receiving advice from their doctor or other health professional.

Recall of cessation interventions in the last year by
current smokers UK 1999-2006 ONS Omnibus surveys

  Source: ONS Omnibus surveys.

  3.12  The improvement in these proportions is welcome, but smokers' reported desire to quit suggests that the figures could and should be much higher (see following figure). Whilst the reported proportions related to self-reported aspiration that may not in practice translate into action, they indicate that many more smokers might take up cessation services if properly approached and encouraged.

Intention to quit smoking, UK 2006
Omnibus survey, ONS 2007

Percent

  Source: Omnibus survey, ONS 2007.

  3.13  There are several reasons why smoking cessation interventions have not been more widely used, and chief among them is a failure by health professionals to embrace smoking cessation to the extent it deserves, or indeed to the extent that they have embraced other preventive interventions. Doctors, nurses and other health professionals are still not trained to deliver smoking cessation interventions, and some do not see it as their job to do so (see figure):

British GP attitudes to smoking interventions
Vogt et al, Addiction 2005;100:1423-31

Percent

  Source: Vogt et al, Addiction 2005;100:1423-31.

  3.14  The NHS could therefore achieve a great deal more in terms of identifying and intervening in smoking at individual level, and ensuring that cessation services are configured to deliver the necessary interventions in all healthcare settings. It is necessary to introduce measures that will ensure that all smokers have their smoking status identified at all health consultations, and help with cessation (behavioural support and pharmacotherapy) delivered if accepted. Recent changes to the Quality and Outcomes Framework have led to a substantial increase in the ascertainment of smoking status by primary care doctors, but little if any increase in intervention. In secondary care, consultants and junior staff who provide smoking cessation therapies and behavioural support for inpatients who smoke remain in the substantial minority. There are many reasons for this, but success in other areas (delivery of statin therapy to reduce cholesterol, for example) indicates that it the NHS prioritises this behaviour, it will occur. It is vitally important to set the appropriate incentives and targets to ensure that this happens throughout primary and secondary care.

Harm reduction

  3.15  Even with all of the above policies in place, many people, particularly from socially deprived groups, will continue to smoke. There are currently about 10 million smokers in the UK, and international experience indicates that it is unlikely that this figure can even be halved within the next 10-20 years. In other areas of medicine, harm reduction strategies are used widely to reduce the harm sustained by unhealthy behaviour, but this approach has not been implemented in smoking. There is a great deal that could be done in this area, with huge potential to benefit those smokers who are least likely to succeed in quitting, who are in turn those most addicted—that is, those from disadvantaged groups. These policies were outlined in a recent report from the RCP (Harm reduction in Nicotine Addiction;

see http://www.rcplondon.ac.uk/pubs/brochure.aspx?e=234 )2.

  3.16  The principle behind harm reduction strategies for smoking is that nicotine addiction, which is the main driver behind smoking behaviour, is not intrinsically harmful; it is the other constituents of cigarette smoke that kill. If smokers could be provided with safer sources of nicotine, preferably from pharmaceutical sources but possibly from other tobacco products, the harm they derive from nicotine consumption could be drastically reduced.

  3.17  The measures we suggest involve radical changes to the current nicotine product market, in which cigarettes are currently the most available and least regulated products whilst medicinal nicotine is highly regulated and relatively inaccessible, to one in which the reverse applies—so that smokers are given strong incentives to switch from smoking to use alternative, less harmful sources of nicotine. We also advocate removal of some of the barriers to competition and development that currently inhibit the development of more effective cigarette substitutes. The fact is that the current system of legislative control on medicinal nicotine products, which is designed to protect the public, actually has the opposite effect through discouraging the development and marketing of innovative nicotine products.

  3.18  The RCP report argues strongly that the status quo needs to change, and recommends the establishment of a nicotine regulatory authority to oversee the changes necessary. Some of the roles and functions of that authority are summarised in the table that follows.

  We argue that the establishment of a Nicotine Regulatory Authority, with the necessary powers to implement the above functions, should be a high priority for the NHS and government. Implementing effective population and individual tobacco control measures will have a major impact on public health, and particularly on health inequalities. Whilst other aspects of health behaviour are undoubtedly important to address, none is more important to general health, or to the health of the most disadvantage in society, than effective tobacco control.

SUGGESTED ROLES AND FUNCTIONS OF A NATIONAL NICOTINE REGULATORY AUTHORITY

Functions at initiation

—  Baseline measurement of all current nicotine product use

—  Ensure full implementation of conventional tobacco control policies (Box 1)

—  Permissive licensing of medicinal nicotine products for use as smoking substitutes

—  Substantial relaxation of restrictions on marketing and sale of medicinal nicotine products

—  Removal of tax on medicinal nicotine products

—  Communication of objective health risk information for nicotine products and promotion of harm reduction principles to smokers and the public

—  Establishment of ground rules for monitoring the use of health messages in promoting the use of lower hazard nicotine products as substitutes for smoking

—  Imposition of generic packaging for all tobacco products

—  Prohibition of retail display of smoked tobacco products

—  Strong graphic health warnings on smoked tobacco products

—  Setting of tax and consequently retail price of all nicotine products in relation to their likely relative risk to health

—  Prohibit all sale of nicotine products to individuals aged under 18

—  Introduce licensing of retailers of all smoked tobacco products

—  Assume responsibility for overseeing nicotine product delivery and toxicity monitoring

—  Mandate the introduction of reduced ignition propensity cigarettes

—  Take expert advice on how current restrictions on smokeless could be reformed to public health benefit

Continuing functions

—  Regular monitoring of trends in nicotine product use, promotion and availability

—  Monitoring impact of licensing and marketing relaxation on medicinal nicotine use, and revision as necessary to promote public health

—  Progressive increases in tax on the most hazardous products

—  Continued promotion of health information on different nicotine products and development and monitoring of mass communication strategies to prevent uptake, promote cessation, and reduce harm

—  Progressive reduction in retail licenses for smoked tobacco products

—  Monitoring and policing of illicit and underage tobacco and nicotine trade

—  Work with the commercial sector to promote competition and innovation in the medicinal nicotine market

—  Monitoring and prevention of smoked product placement and new methods of marketing (eg internet, viral marketing)

—  Act on expert advice to set framework for licensing of low-hazard smokeless products and possible test marketing

—  Progressively incentivise minority, high risk smokeless tobacco users to quit or else migrate to safer products

—  Identify and respond to new developments or threats to health from new or existing product development or promotion

—  Control of expenditure on tobacco control interventions to ensure evidence based and cost-effective interventions are used

—  Support nicotine regulation and tobacco control approaches in resource-poor countries

January 2008

176   Association of Public Health Observatories. Indications of Public Health in the English Regions 8: Alcohol. August 2007. Back

177   Academy of Medical Sciences. Calling time-The nation's drinking as a major health issue. 3-1-2004. Academy of Medical Sciences, London. Back

178   Anderson, P. and Baumberg, B. Alcohol in Europe: A public health perspective. 2007. EU Health and Consumer Protection Directorate General. Back

179   Institute of Alcohol Studies. Alcohol: Tax, Price and Public Health. 2007. Back

180   Alcohol needs assessment research project (ANARP). 2004. Department of Health. Back

181   Home Office: Drug Strategy: 2005-2006 funding, 2006. Back

182   Chisholm D, Rehm J, Van OM et al. Reducing the global burden of hazardous alcohol use: a comparative cost-effectiveness analysis. J Stud Alcohol 2004;65(6):782-93. Back