Tobacco Control Strategy

Bob Blackman Excerpts

Thursday 17th December 2015 Westminster Hall

[Bob Blackman (Harrow East) (Con)]

It is an honour and a pleasure to serve under your chairmanship, Mr Betts, as I do weekly on the Select Committee on Communities and Local Government. It is also a pleasure to follow the right hon. Member for Rother Valley (Kevin Barron), who has almost a lifetime of experience of dealing with the tobacco industry and ensuring that the country wakes up to the fact that tobacco and the products that the tobacco industry produces will, if they are used in the way that is intended, kill us. They are the only legal product that will achieve that. I declare an interest in that I speak as the chair of the all-party group on smoking and health. I thank the vast plethora of organisations that have contributed to the debate by supplying me with facts, figures and determinations.

I remember in September 2013, on the first Tuesday back after the long summer recess, we held a debate in this place on standardised packaging for tobacco products. The predecessor of the Minister for Public Health was in post, and some 22 Members contributed to the debate. The Government’s position was that they would not introduce standardised packaging, and the Opposition’s view was that it would be the wrong thing to do. Less than two years later, however, it has come to pass. Government policy changed quite radically as a result of pressure from MPs on both sides of the House. I pay tribute to the work that has been done over many years on tobacco control. The key point is that we must continue to bear down on smoking prevalence, so that we see a reduction year on year.

High taxes on tobacco, to prevent people from starting smoking, are part and parcel of that strategy, which has continued for the past 25 years on a progressive and comprehensive basis. Action on stopping smuggling was started in 2000. We are the only country in the world to have smoking cessation services available free at the point of delivery to smokers. We were the first to introduce them, and we are the only country that has continued with them. I think we should be proud of that. We have been at the forefront when it comes to comprehensive laws prohibiting advertising, promotion and sponsorship by the tobacco industry of our sports and activities.

Over the lifetime of the current tobacco control plan, a substantial amount has been achieved, such as the prohibition of point-of-sale tobacco displays in large shops from April 2012 and in small shops from April of this year, and the ending of smoking in cars carrying children. That measure was introduced in the last Parliament, carried through at the behest of Back-Bench MPs and implemented with Government support. Some of the action is still to be implemented, including the introduction of standardised packaging for tobacco products. That, as the Minister is no doubt aware, is the subject of attacks in the courts by the tobacco industry, but it should come into place in May next year. The new tobacco products directive and the illicit trade protocol will also come into effect later next year.

The new measures together have been very effective in driving down the prevalence of smoking. For the first time since records began, fewer than one in five members of the adult population smokes, and we are seen as a world leader in tackling tobacco. Our leadership has been acknowledged internationally since 2007, and the UK has received the highest score and the top ranking in Europe from the European Cancer Leagues. This year, the Department of Health received the prestigious triennial Luther Terry award from the American Cancer Society. I know that the Minister was pleased to receive that award, and we must congratulate her and the Department of Health on it. We were only the second country in the world to pass legislation to implement standardised packaging for tobacco products. The legislation is being challenged in the courts, but we feel sure that the Government will win that challenge, as they have done in many other cases, including on smoke-free laws, advertising and point-of-sale displays.

Having said that, we must recognise that there is a lot more to be done. Almost one in five adults still smokes, and smoking remains the single biggest cause of preventable deaths and premature death. As we have heard, smoking kills almost 80,000 people in England every year. In London alone, more than 8,000 people die prematurely from tobacco-related diseases, and more than 51,000 hospital admissions can be attributed directly to smoking.

Smoking is the leading cause of inequality, and it is responsible for half the difference in life expectancy between the rich and the poor. As a general rule, those who experience disadvantage have smoking rates higher than those of the general population, and that fuels cycles of deprivation. We have heard that nearly eight out of 10 prisoners smoke, and that people who are homeless smoke. Rates of smoking are also much greater among those who live with a long-term condition, such as asthma or diabetes. That, in turn, has an impact on the national health service. We know that health interventions are less successful for smokers than for non-smokers, and non-smokers tend to have much shorter hospital stays and fewer complications as a result.

In my constituency, Harrow East, which is within the London Borough of Harrow, 13.1% of people still smoke. That equates to 24,855 people who still smoke. That is lower than the national average, but in Harrow 209 people still die from smoking-related diseases every year, 1,410 hospital admissions a year are caused by smoking and 80 people die from lung cancer each year. We know that 90% of lung cancer is attributable directly to smoking. Every year, 55 people in Harrow die from chronic obstructive pulmonary disease, which is also known as emphysema, and 60% of those deaths are caused by smoking. Although smoking rates have fallen significantly among children, from 10% in the early 2000s to just 3% last year, we must not become complacent. It has been estimated that 207,000 children—11 to 15-year-olds—start smoking every year. In Harrow, that is 551 young people starting smoking every year.

Government and public sector action to cut smoking rates is still, clearly, necessary. As such, I was delighted to hear the Minister announce earlier in the year that there will be a new tobacco control plan. The current plan runs out in just two weeks, at the end of the month, so we look forward to hearing from the Minister when the new strategy will be in place. For the new strategy to be successful, it needs to be properly funded. In July this year, the Chancellor announced an in-year cut to public health funding of £200 million, which amounts to some 6.2% of the total budget. That has been compounded by further cuts of 3.9% each year to 2021, which were announced in the Treasury’s spending review. That, according to Public Health England, translates into a further cash reduction of 9.6%, in addition to the £200 million of savings this year alone. Those cuts are already having an impact on local authority spending. I am very disappointed that the local authority where my constituency sits is cutting its public health funding by 60% over the next three years. That has had a severe impact on the stop smoking services, for which funding is being cut from £299,000 in the current financial year to just £20,000 in 2017-18. My local authority is not the only one making such reductions and that is deeply concerning because there may be a return to young people starting to smoke and fewer adults taking the opportunity to give up.

According to the National Institute for Health and Care Excellence, stop smoking services are some of the most cost-effective healthcare interventions—far more cost-effective than the drugs needed to treat smoking-related diseases when they start to develop. Stop smoking services are considerably cheaper than treating long-term conditions caused by smoking, such as lung cancer and coronary heart disease. There is considerably stronger evidence for the effectiveness of stop smoking services compared with many prevention interventions such as, for example, NHS health checks.

What is more, smokers are four times more likely to quit successfully with the combination of behavioural support and medication provided by services compared with unsupported quit attempts. In the previous financial year, more than 450,000 people set a quit date with stop smoking services in England and 51% had successfully quit after four weeks. Those figures include nearly 19,000 pregnant smokers, 47% of whom successfully quit. I was pleased to see in the official statistics released yesterday that the Government have reduced their ambition to cut smoking in pregnancy to 11%. If support available to those women is cut, it raises the question of whether such achievements can be sustained and built on in the future.

Services play an important role in reducing health inequalities. Poorer smokers, who find it more difficult to quit as they tend to be more heavily addicted, are more likely to be successful with the support of those services. More people from routine and manual groups use the stop smoking services than any other socio-economic group and, as such, the services can help reduce health inequalities. They also help to prevent the uptake of smoking among children, although assisting adults to quit is their most important element. Children growing up with both parents who smoke are three times more likely to start smoking compared with children whose parents do not smoke. The cuts to public health funding, which I referred to, have been described, unsurprisingly, by the King’s Fund as the “falsest of false economies”. The reductions do not only affect my constituency, but people all over the country. For example, Manchester City Council, which is part of the new devolution deal, has already announced that it will not fund such services in 2015-16, and there are numerous reports of planned reductions in other local authorities—and that was before the announcement of further reductions in the spending review.

As well as reductions in budgets, a great deal of change is taking place in local services, and it is not clear that new approaches are properly evidence-based. A recent survey conducted by ASH for Cancer Research UK found that more than half the respondents—53%—described some form of restructuring of local smoking cessation services. One in five described a shift to an integrated approach, in which smoking cessation is delivered as part of a wider lifestyle package, including, for example, measures to tackle obesity and reduce the harm of alcohol. This has meant the loss of important specialist support.

The changes taking place within services raise questions about their efficacy and outcomes. In particular, the shift to integrated services or lifestyle choices has limited support from the evidence base. An authoritative Cochrane review did not find a significant effect in reducing smoking from those interventions. Will the Minister tell us what steps the Government will take to ensure that smokers continue to have universal access to stop smoking services that meet NICE standards and are free at the point of delivery?

Given the pressure on local budgets, and reductions to funding for local authorities, it is crucial that the NHS picks up the baton and does more to support reductions in smoking prevalence. Not only will this support local authorities, but it is essential for the viability of the NHS and the long-term impact that taking no action against smoking would have.

The NHS five-year forward view rightly states:

“The future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.”

The forward view also notes that this has long been a policy objective, stating:

“Twelve years ago, Derek Wanless’ health review warned that unless the country took prevention seriously we would be faced with a sharply rising burden of avoidable illness. That warning has not been heeded—and the NHS is on the hook for the consequences.”

It is important to note that even after additional Government funding of the NHS, there is still an estimated potential shortfall of £22 billion by 2020. That is likely to be closed through some efficiency savings, but there will still be a funding gap, which will have to be met through reductions in services, longer waits for treatment or reductions in demand for NHS services. Clearly, the latter possibility requires a much more sustained effort to improve public health and to tackle the major causes of illnesses, particularly smoking, but we have seen a reduction in NHS activity to tackle smoking over the last few years.

The number of GPs recommending that smokers quit and directing them to further support has declined markedly. In addition, services to support people to quit smoking in secondary care—already far from universal—are also under threat. For example, the reductions in specialist stop smoking services in Manchester have resulted in the end of funding for smoking cessation services at the city’s world famous cancer hospital, the Christie. The service will now only continue through charitable funding made available by the hospital.

Smoking places a significant burden on the NHS. Getting smokers to quit can prevent diseases from developing but there is also great value in supporting smokers who are already sick to quit. Many diseases are improved if a person quits. For conditions such as cardiovascular disease, smoking can be a major risk factor in further illness or exacerbation. For people who have developed cancers, including lung cancer, quitting improves the effectiveness of treatments, the likelihood of successfully treating the cancer and five-year survival rates. Even when smokers have an illness that is not related to smoking, quitting can improve the outcome of their treatments. Those who have quit have much better surgical outcomes and reduced recovery times in hospital.

About 1,260 hospital admissions a day in England are due to smoking—amounting to one in 20 of all admissions. It is estimated that smoking costs the NHS in England around £2 billion a year. In the local authority where my constituency sits, the NHS spends about £6 million on treating smoking-related diseases every year. Reducing the number of people who smoke delivers immediate as well as long-term savings to the NHS. Evidence suggests that if we could increase the rate at which smoking is declining by an additional further 0.5 percentage points a year above the current rate of decline—0.66 percentage points—the NHS could save at least £117 million a year by 2020. That estimate does not include the contribution that reducing smoking makes to conditions that are made worse but are not caused by smoking, such as diabetes.

In short, helping patients to quit smoking should be a core part of NHS business as a means to save lives, reduce costs and improve outcomes. What steps are the Government taking to ensure that the NHS does more to help smokers to quit in line with the implementation of the five-year forward view? To ensure that the radical upgrade in prevention and public health called for in the NHS five-year forward view is achieved, our tobacco control strategy needs to be properly funded. We know that tobacco remains the primary cause of preventable and premature death in this country. Despite that, we have already seen mixed services cut, and the impact of such disinvestment is only beginning to be seen. If we are to continue driving down smoking rates and ensuring that people do not die early from smoking having suffered years of disability, we need an ambitious and comprehensive strategy and to ensure that such a strategy is properly and sustainably funded.

We have already heard that public health and stop smoking services budgets are declining. We must conclude that that effect is likely to continue and is likely to be long term. There is clear evidence that reductions in public spending on tobacco control, together with less emphasis on new policies and on enforcement of existing policies, are likely to slow, halt or even reverse the long-term reduction in smoking prevalence rates. In New York, for example, sustained investment from 2002 led to a decline in smoking rates until 2010, when the decline ceased following funding reductions. Investment was reinstated in 2014, and the rates of smoking cessation began to improve again.

An early indicator of the effect of both national and local spending reductions on tobacco control is given by the smoking toolkit produced by Professor Robert West of University College London. The results for 2015 show a small increase in smoking prevalence over 2014, a fall in the proportion of smokers who made an attempt to quit—from 37.3% in 2014 to 32.4% in 2015—and a lower success rate for quit attempts, from 19.1% in 2014 to only 17% this year.

Clearly, the tobacco industry needs to fund the control of tobacco. As we have heard, the gains we have made run the risk of being reversed, so funding for tobacco control is a good investment by the Government. In advance of the spending review, the all-party group that I chair published a proposal to fund tobacco control with an extra £100 million a year to reduce smoking, combined with a 5% tax escalator on tobacco, which could deliver more than £11 for every £1 invested in the NHS. As we have already heard, spending on tobacco control is extremely cost-effective, but national and local resources for tobacco control and stop smoking services are far from secure, so the Government need to find an alternative, sustainable source of funding.

The report published earlier this year, “Smoking Still Kills”, was endorsed by more than 129 public health organisations and recommended the introduction of a new annual levy on tobacco companies to help fund evidence-based tobacco control and stop smoking services in England. In the United States, the principle of charging the industry for the specific costs imposed on the public purse is well established. In the US, the costs of the levy are apportioned to tobacco companies according to their market share in the country. That concept has received broad-based support in Congress because it is understood to be a charge related to a specific cost, rather than general taxation.

The Chancellor said in 2014:

“Smoking imposes costs on society, and the government believes it is therefore fair to ask the tobacco industry to make a greater contribution.”

His decision not to proceed with a levy on the industry in the 2015 Budget was disappointing. Rather, in the 2015 autumn statement, he suggested that future funding for local public health delivery could be met by returning business rates to local authorities. However, one of the primary purposes of public health interventions is to improve ill health and address inequalities. There is a fundamental flaw in his proposal because richer areas, which have higher business rates, have lower rates of smoking than poorer areas with lower yields from business rates.

Applying that principle, the Local Government Chronicle has highlighted that there will be clear winners and losers from returning the national share of business rates to local authorities. The five areas outside London that are the biggest winners from the proposal have an average smoking rate of 16%, whereas the five biggest losers have an average smoking rate of 20%. In Harrow, 138% of the national share of business rates would need to be returned to the council in order for it not to lose out if the revenue support grant is ended and the council instead has to rely on business rates. If that were to happen, Harrow would be the 35th worst-off authority in the country, out of 125 unitary authorities.

I have two more questions for the Minister. How will the Government ensure that tobacco control is properly funded locally and nationally so that prevalence rates continue to fall, with consequent benefits for the NHS and public health? Equally, what analysis have the Government undertaken to determine that using business rates to fund local public health activity will not further reinforce existing inequalities?

Despite being a lethal drug, tobacco products can be sold by anyone in England almost anywhere—a licence is not required. The sale of tobacco used to require a licence, and signs above pubs and shops from that period still state that they are licensed to sell tobacco and alcohol. Local authorities in England have powers to shut down a tobacco retailer, if necessary. However, that requires the local authority to take legal action against the retailer, which is both time consuming and resource intensive. What is more, reductions in local authority budgets are affecting the work of trading standards departments across the country, which could damage enforcement work on illicit tobacco in future years.

In 2013-14, there were only 34 convictions in England for selling tobacco products to young people, and there were no restricted premises or sales orders, yet 44% of young people who smoked said that they obtained tobacco directly from shops. We were pleased to hear in the autumn statement that, as part of the obligations under the illicit trade protocol, the Government will consult on the introduction of a licensing scheme for tobacco machinery and the possibility of licensing tobacco vendors. Licensing retailers is an important step that was recommended by ASH in the “Smoking Still Kills” report and endorsed by more than 120 public health-related organisations, and it would enable the Government and local authorities to promote higher standards in the retail market and clamp down further on illicit sales. Such a system would also protect legitimate retailers and simplify the action that local enforcement officers can take against those selling illicit tobacco both within and outside the retail setting.

I congratulate the Minister on the Government’s success throughout the last tobacco control plan in taking major steps to drive down smoking rates. Successes have been lauded, not just in the UK but internationally, but the plan has come to an end. We need to build on the achievements that have already been made by implementing another ambitious and comprehensive strategy. We have heard that, in recent months, some local services have been cut and that others are likely to follow. We have also heard about the impact of similar cuts in places such as New York. With that in mind, I urge the Government to think about how the strategy will be not only implemented but sustainably funded to ensure that the UK remains a world leader in tobacco control.

We should be ambitious in our outlook and look forward to a tobacco-free Britain much earlier than 2035 to enable our young people to live much longer and much healthier lives and to encourage people who have unfortunately become addicted to this lethal product to quit smoking much earlier so that they can improve not only their life expectancy but their quality of life.