TOWARDS A SMOKE FREE AGENDA
FOR LIVERPOOL




Report of the scoping exercise for the Smoke
Free Liverpool Group




Jon Da...
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TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
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TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
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TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL
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TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL

  1. 1. TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL Report of the scoping exercise for the Smoke Free Liverpool Group Jon Dawson November 2003 Jon Dawson and Associates
  2. 2. CONTENTS Executive Summary i 1 Background 1 1.1 Introduction 1 1.2 The Brief 1 1.3 The Research Methodology 2 1.4 The Report 3 2 The Health Risks and Impacts of Smoking 4 2.1 Risks 4 2.2 Impacts of Smoking 5 3 Smoking Prevalence and Inequalities 7 4 The Policy and Legal Context 9 4.1 Introduction 9 4.2 National Policy and Statutory Context 10 4.3 Implications of Court and Tribunal Cases 13 4.4 The Local Context 14 5 Current Service Provision in Liverpool 17 5.1 Introduction 17 5.2 Smoking Cessation Services: Support/Fagends 17 5.3 Smoking Prevention and Education 18 5.4 Workplace Award Schemes 19 5.5 Research 21 5.6 Policy Development 22 6 Public Attitudes to Second-Hand Smoke and Smoking in Public Places 23 6.1 Introduction 23 6.2 ONS Nation-wide Survey 23 6.3 Nation-wide Survey of Attitudes to Smoking Bans 24 6.4 Survey Evidence from Ireland 24 7 The Financial Implications for Employers of Smoke Free Workplaces 26 7.1 Introduction 26 7.2 The Financial Costs of Smoking for Employers 26 7.3 A Model for Individual Employers 31 7.4 The Economic Implications of Smoke Free Workplaces for the Hospitality Sector 32
  3. 3. 8 Approaches to Smoke Free Agendas: the Picture from Elsewhere 35 8.1 A Global Trend towards Smoke Free Places 35 8.2 Key Lessons 37 9 Making Liverpool Smoke Free: Stakeholders Viewpoints 38 10 Summary of Findings 42 10.1 Reviewing the Study 42 10.2 Main Findings 42 11 Conclusions and Recommendations 47 11.1 Introduction 47 11.2 Developing the Smoke Free Agenda 47 11.3 Implementing the Smoke Free Agenda 48 11.4 Supporting the Smoke Free Agenda 53 Appendices
  4. 4. 1 BACKGROUND ________________________________________________ 1.1 Introduction 1.1.1 A Smoke Free Liverpool Group1 was established in mid-2003 to take forward the objective of the Liverpool First for Health Strategic Partnership to make Liverpool a Smoke Free City by 2008 – the year that the city celebrates its status as European Capital of Culture – and to reduce smoking prevalence. The initial focus of the Group is to develop and oversee the implementation of a strategic agenda that will achieve these goals. 1.1.2 The timing of this initiative is propitious. Nationally and internationally, efforts to address the health impacts of tobacco smoking and, in particular, second-hand smoke2 are gathering pace. In May 2003, The World Health Organisation (WHO) adopted the Framework Convention on Tobacco Control – the first international treaty negotiated under the auspices of the WHO. In September 2003, the European Commission announced its intention to work towards making smoke free workplaces compulsory throughout the European Union. In 2004, new legislation in Ireland and Norway will bring about smoke free workplaces, including premises – such as, restaurants, pubs, nightclubs and cafes - where customers, in the past, have been able to smoke. 1.1.3 In the UK, although national legislation may not be imminent, a series of events and initiatives are coalescing to raise the public profile of the importance of reducing smoking prevalence and exposure to second-hand smoke. These include the Chief Medical Officer highlighting the need to address exposure to second-hand smoke as a priority in his 2002 annual report3, hard-hitting national advertising campaigns about the dangers of second-hand smoke, publicity about parts of the United States – such as Boston, New York and California – that have introduced comprehensive smoking bans in public places and announcements by companies that their premises are becoming smoke free. 1.2 The Brief 1.2.1 The Smoke Free Liverpool Group commissioned this study to identify how a smoke free agenda could most effectively be taken forward in Liverpool. The primary aim was to generate a series of recommendations and establish a 1 The Smoke Free Liverpool Group brings together a wide range of partners including the City Council (Environmental Health and Trading Standards), Central, North and South Primary Care Trusts (including the Tobacco Lead for the PCTs), Health @ Work, Roy Castle Lung Cancer Foundation, the Chamber of Commerce and the North West TUC. 2 When non-smokers share a space with someone who is smoking they are being exposed to ambient tobacco smoke. This ambient tobacco smoke is called second-hand smoke, passive smoke or environmental tobacco smoke. 3 Getting serious about second-hand smoke, Annual Report of the Chief Medical Officer 2002, Department of Health Jon Dawson and Associates 1
  5. 5. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ framework action plan. To achieve this, the study involved a scoping exercise designed to: • analyse the national and local policy and legal context for making Liverpool smoke free; • identify existing smoking-related activities in the city; • assess the impact of the smoke free agenda on smoking cessation services; • compile local data on employment levels and within the hospitality and SME sector; • assess the economic impact of smoking at work; • explore the potential for using local licensing or by-laws to further smoke free objectives; • provide an analysis for employers of the potential benefits from introducing smoking policies and smoking bans in workplaces and the costs of not doing so; • explore how to integrate a health inequalities dimension into the smoke free agenda; • examine good practice and lessons from the implementation of smoke-free policies elsewhere; • identify potential methods for making Liverpool a Smoke Free City by 2008 and reducing smoking prevalence. 1.3 The Research Methodology 1.3.1 To address the research agenda, a range of research methods and activities were employed. Specifically, they involved conducting semi-structured interviews with stakeholders and key informants and compiling and assessing data, key documents, reports and other publications related to smoke free issues. 1.3.2 Engaging stakeholders in the research and in defining an Action Plan that would drive the Smoke Free agenda was central to the approach taken. As part of this approach, a workshop session of the Smoke Free Liverpool Group – drawing on preliminary recommendations - contributed to the development of the Action Plan. 1.3.3 Parallel to this study, a survey of second-hand tobacco smoke in Liverpool workplaces has been launched. It is being administered by the City Council’s Environmental Health Service. The findings from the survey will add value to this study. They will provide local evidence and information that can be used to inform the implementation of the Smoke Free agenda and enhance the effectiveness of service delivery. 1.3.4 The survey has been designed to: • build a profile of the extent and type of smoking policies within Liverpool workplaces; • provide evidence of the actual and perceived economic impact of smoke free workplaces; Jon Dawson and Associates 2
  6. 6. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ • explore employers’ perceptions of and attitudes to second-hand tobacco smoke in the workplace; • provide evidence of demand for smoking cessation services; • explore interest in participating in an Awards scheme and a Smoke Free campaign. 1.4 The Report 1.4.1 The rest of this report is in three main parts. The first part (sections 2 to 10) sets out the findings from the scoping exercise. These examine: • the health risks associated with smoking and second-hand smoke and their impacts; • the challenge of smoking-related health inequalities; • smoking prevalence and inequalities; • the policy and legal context for introducing a smoke free agenda in Liverpool; • public attitudes to second-hand smoke and smoking in public places; • the financial implications for employers of smoke free workplaces; • approaches to smoke free agendas in other countries; • the views of Liverpool stakeholders. 1.4.2 The second part (section 11) highlights the key recommendations that flow from these findings. The recommendations primarily relate to general policy directions and actions to take forward the Smoke Free Liverpool agenda. Finally, the appendices present a framework action plan that incorporates key actions and their timing, provisional targets and resource implications. Jon Dawson and Associates 3
  7. 7. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 2. THE HEALTH RISKS AND IMPACTS OF SMOKING ________________________________________________ 2.1 Risks 2.1.1 The links between smoking and cancer, heart disease and stroke are well- established. For instance, during the 1950s and 1960s, numerous studies demonstrated that smoking was a Box 2.1: Evidence that second-hand smoke is cause of cancer.4 Equally, carcinogenic to humans government health warnings and Two influential assessments have recently public health campaigns over definitively declared that second-hand smoke is many years have meant that carcinogenic to people. These were: smokers in the UK are, for the th • the 9 report on Carcinigens published in most part, aware that smoking is 2000 by the US National Institute of Health harmful to health. National Toxicology Program; • the new monograph on second-hand smoke 2.1.2 The health risks of exposure to (2002) from the IARC (a branch of WHO). second-hand tobacco smoke have, however, become a focus • for studies more recently (see box 2.1). Much of this research is based on epidemiological research that has examined the health of non-smokers who live with smokers (see box 2.2). An analysis of 37 studies of lung cancer from Box 2.2: Evidence linking second-hand smoke passive smoking found with heart disease that the “excess risk of lung cancer was 24 per Most evidence linking heart disease with second- hand smoke comes form studies of spousal cent in non-smokers who smoking. There are few studies of the relationship lived with a smoker”. between exposure to second-hand smoke in the Evidence from such workplace and cardiovascular disease. research has led to However, scientific rationale suggests that “there estimates that working is no biologically plausible reason to believe that with smoking co- the hazards of exposure to second-hand smoke that have been demonstrated in the home should workers increases the not also apply in the workplace” (Working Group risk of lung cancer by of health and Safety Authority and Office of between 20-30 per cent Tobacco Control, Ireland, 2002) in n o n - s m o k e r s5. Moreover, the IARC Summary monograph states Equally, US and UK that evidence indicates that being exposed to studies in the 1990s have second-hand tobacco smoke increases the risk of an acute coronary heart disease event by 25 to 30 suggested that non- per cent. smokers living with smokers had an increased risk of heart disease of between 20 and 30 per cent.6 4 Doll R, Tobacco: a medical history, Journal of Urban Health, Bulleting of the New York Academy of Medicine, Vol 76, Issue 3, 1997 5 Working Group of Health and Safety Authority and Office of Tobacco Control, Ireland (2002) Report on the health effects of environmental tobacco smoke in the workplace. 6 (1) Glantz SA, Parmlev WW, Passive smoking and heart disease: mechanisms and risks, JAMA, 1955, 273 (13): 1047-1053. (2) Law MR et al, Enviromental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence, BMJ, 1997, 315: 973-980 (3) Sheenland K et al, Environmental Jon Dawson and Associates 4
  8. 8. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 2.1.3 Moreover, it is widely accepted that exposure of pregnant women to second- hand tobacco smoke causes lower birth weight in babies and that children exposed to second-hand smoke are at increased risk of respiratory disease and sudden infant death syndrome (cot death). This has clear implications for pregnant working mothers and for children spending time in an adult’s workplace. 2.1.4 Within the workplace context, bar staff and other hospitality workers are a high risk group as their workplaces often have high exposure to second-hand smoke. There is a growing body of evidence that provides objective data on the extent of exposure of hospitality workers to second-hand smoke and its impact on them. 2.1.5 There is also evidence that the risks to staff of being exposed to carcinogens persists even when ventilation systems are in place. A study by Manchester Metropolitan University of public houses in Manchester indicated that ventilation did not appear to reduce the environmental tobacco smoke compounds measured. A new study to be carried out by Liverpool John Moores University, in co-operation with the Environmental Health Service, to measure carbon monoxide in the atmosphere should shed further light on this issue. 2.2 Impacts of smoking 2.2.1 Department of Health statistics indicate that smoking kills 120,000 people each year in the UK. On a proportional population basis, this implies that about 900 people in Liverpool die each year from smoking. 2.2.2 In addition, research in California developed estimates of rates of death and ill health experienced by non-smokers as a result of exposure to second-hand cigarette smoke.7 Applying the conclusions of this research to Liverpool implies that between 61 and 105 people die in Liverpool each year from cancer or ischaemic heart disease because of exposure to second-hand smoke. 2.2.3 However, because SMRs for lung cancer and for coronary heart disease in Liverpool are significantly higher than national averages, it could be argued that these figures under-estimate actual numbers of deaths. 2.2.4 In terms of the financial costs of smoking, the White Paper Smoking Kills estimated that treating illness and disease caused by smoking costs the NHS about £1.7 billion each year in terms of GP visits, prescriptions, treatments and operations. On a proportional population basis, this would imply that smoking costs the NHS in Liverpool about £12.7 million per annum. Again, however, tobacco smoke and coronary heart disease in the American Cancer Society CP5-11 Cohort, ….., 1996, 94, 622-628. 7 Health effects of exposure to environmental tobacco smoke by Californian Environmental Protection Agency’s Office of Environmental Health Hazard Assessment. Jon Dawson and Associates 5
  9. 9. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ given the higher incidence of smoking-related diseases in Liverpool - compared to the rest of the country - this figure is likely to be an under- estimate of the actual cost. 2.2.5 The implication is that reducing smoking prevalence and exposure to second- hand smoke could lead to economic benefits for society arising from health care cost savings. However, these benefits have to be weighed against longer life expectancies that may consume more health care resources in later life and revenue generated by taxation on cigarettes and other tobacco products. 2.2.6 Smoking also imposes financial costs on employers and on the city’s economy. Estimates for this study suggest that the annual economic cost to employers of smoking amongst the Liverpool workforce is approximately £28.5 million. Details of this estimate, how it is calculated and the assumptions underpinning it are set out in section 7. Jon Dawson and Associates 6
  10. 10. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 3 SMOKING PREVALENCE AND INEQUALITIES ________________________________________________ 3.1 National data indicates that 27 per cent of adults in England smoke – 28 per cent of men and 25 per cent of women.8 The prevalence of cigarette smoking has dropped substantially since 1978 – from 40 per cent – although the rate of decline has levelled off in the 1990s. Indeed, there has been little change in smoking prevalence rates since 1994. 3.2 This overall rate disguises significant differences between specific groups. These highlight the health inequalities linked to smoking. There are particularly pronounced differences between socio-economic classes and minority ethnic groups. Smoking prevalence rates also vary between different parts of the country. 3.3 Smoking prevalence rates for different socio-economic classes show that 32 per cent of manual workers smoke compared with just 21 per cent of those who have non-manual occupations. 3.4 National data also highlights that men from some minority ethnic groups have smoking rates higher than the national average.9 In 1999, Bangladeshi men had the highest smoking prevalence rates – 44 per cent were smokers. This was followed by Irish men (37 per cent) and Black Caribbean men (35 per cent). In contrast, data suggests that Chinese men are the least likely to smoke (17 per cent). Pakistani (26 per cent) and Indian (23 per cent) men had smoking prevalence rates similar to the general population. 3.5 Amongst women, however, the pattern is broadly reversed. Only Irish women (35 per cent) had higher smoking prevalence rates than the national average. Women in all other minority ethnic groups were less likely to smoke than women in the general population. Moreover, women from minority ethnic groups were much less likely to smoke than men with the same ethnic background. This difference was particularly marked within the Bangladeshi community. Survey data indicated that very few women smoke cigarettes – although about one-quarter of Bangladeshi women chewed tobacco. 3.6 Regionally, the North West has amongst the highest smoking prevalence rates in England. It has a rate of 29 per cent compared to 24 per cent for the South East and South West. 3.7 Up-to-date and reliable local data that could sketch an accurate picture of smoking prevalence rates and inequalities in Liverpool, however, is currently lacking. Previous data in the mid-1990s indicates that smoking amongst 8 Estimates of the prevalence of smoking among adults age 16 and over are obtained from the General Household survey conducted by the Office for National Statistics 9 The Health of minority ethnic groups, Health Survey for England, 1999. Jon Dawson and Associates 7
  11. 11. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ women in Liverpool was above the national average with a rate of between 32 and 36 per cent.10 And, although recent research carried out by HACCRU sought to shed light on the incidence of smoking in Liverpool, the results appear to suggest that smoking prevalence is lower in Liverpool than in the UK as a whole. However, the methodology adopted – a postal questionnaire – resulted in a low response rate that raises obvious concerns about the validity of the findings. It is hoped that surveys being carried out by the Citizen’s Panel in Liverpool and for Smoke Free Liverpool will provide more reliable data. 10 Arden K, Health needs of local people in North Mersey, 2003. Jon Dawson and Associates 8
  12. 12. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 4 THE POLICY AND LEGAL CONTEXT ________________________________________________ 4.1 Introduction 4.1.1 As we have already observed, global and European policy initiatives are increasingly promoting measures to address the health impacts of smoking and second-hand smoke. Equally, an increasing number of countries and cities are introducing smoke free legislation that aims to ban smoking and prevent exposure to second-hand smoke in indoor public places (see section 8). Such legislative changes tend to provide much greater clarity for the introduction of smoke free policies – they often compel employers and businesses to ensure that their premises are effectively smoke free. 4.1.2 The policy context in the UK does emphasise the need to reduce smoking prevalence rates and recognises the dangers of exposure to second-hand smoke. UK legislation relates to prohibiting smoking where it can affect food hygiene or poses a serious fire hazard. The Government has also passed a law to ban tobacco advertising and restrict promotional opportunities.11 But, the absence of all-embracing legislation relating to smoking in public places means that identifying the responsibilities and requirements of employers relating to smoking policies is more complex. Although legal experts have spelt out the likely interpretation of statutory legislation and legal developments, there inevitably remains some “grey areas” and uncertainty. 4.1.3 Employers have to take account of precedents set by court cases and tribunals and interpretations of health and safety legislation that does not – except for specific types of business - explicitly address smoking in the workplace. Equally, it means that initiatives to take forward smoke free agendas – like Smoke Free Liverpool – have to explore and develop creative approaches to achieve their objectives. 4.1.4 This section attempts to piece together the policy and legal framework relating to smoking and second-hand tobacco smoke that will influence and inform how Smoke Free Liverpool will choose to take forward its Smoke Free agenda. Specifically, it examines: • the national policy and statutory context including the Smoking Kills White Paper, National Service Frameworks the Public Places Charter and Health and Safety legislation; • the implications of court and tribunal cases on the rights of smokers and non-smokers and on the factors that employers need to consider to minimise risks of litigation; • the regional and local context, including the potential of using local licensing powers or by-laws to address smoking in the workplace, 11 The Tobacco Advertising and Promotion Act 2002. Jon Dawson and Associates 9
  13. 13. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ approaches adopted by smoking alliances and initiatives in other parts of Merseyside. 4.2 National Policy and Statutory Context Smoking Kills White Paper 4.2.1 The Government’s 1998 White Paper “Smoking Kills” was instrumental in providing a focus on tobacco control in the UK. The Smoking Kills White Paper set out the government’s aim to establish a downward trend in adult smoking rates in all social classes. It set a specific target to reduce the overall rate from 28 to 24 per cent or less by 2010. It also set an interim target to reduce smoking rates to 26 per cent by 2005. 4.2.2 The White Paper indicated that key elements of a comprehensive policy should include: • strong mass media led information campaigns • a ban on tobacco advertising and promotion • price policy and control of smuggling • smoke-free public places, especially workplaces • NHS cessation services • community based initiatives 4.2.3 A raft of major initiatives aimed at reducing the incidence of smoking followed its publication. These have included a comprehensive ban on tobacco promotion and advertising, the development of new smoking cessation services – including a free helpline for smokers - more prominent health warnings on cigarette packets and anti-smoking advertising campaigns. Although an advertising campaign focused on passive smoking was recently launched, measures to reduce people’s exposure to second-hand smoke have been more limited. National Service Frameworks (NSFs) 4.2.4 The NSFs set national standards, identify key interventions and put in place strategies to support implementation. The National Cancer Plan and the NSF for Coronary Heart Disease both have an explicit focus on reducing the prevalence of smoking in the population. To address health inequalities, the Cancer Plan sets an additional target to the Smoking Kills target for reducing smoking. It sets a specific target to reduce smoking among manual workers from 32 per cent in 1998 to 26 per cent by 2010. 4.2.5 Both strategic documents place an emphasis on smoking cessation interventions to address these targets. They also recognise that more broad- based local strategies have a role to play. The NSF for CHD states that local strategies should, inter alia, be developed to reduce the illegal sale of cigarettes, reduce smoking in public places, support national media campaigns Jon Dawson and Associates 10
  14. 14. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ and develop smoking cessation services. The National Cancer Plan restates the Smoking Kills tobacco control strategy and supports local alliances to take actions on smoking. Priorities and Planning Framework (PPF) 4.2.6 The Department of Health published the PPF in 2002. It set out key targets for the NHS up to 2005/6. It included a national target of 800,000 smokers - over 3 years - successfully quitting at the four week follow-up with the help of smoking cessation services. The PPF also included a target to reduce by one percentage point each year the proportion of women who continue to smoke throughout pregnancy. The Public Places Charter 4.2.7 The Public Places Charter was agreed between the Charter Group – who represent various pub and restaurant trade associations – and the Department of Health following the Smoking Kills White Paper. Its objectives include: • producing written smoking policies, available to customers and staff; • implementing good practice through non-smoking areas, air cleaning and ventilation; • using external and internal signs to communicate smoking policies to customers. 4.2.8 The Charter Group agreed to hit a series of targets for pubs by January 2003. By then, it was intended that: • 50 per cent of public houses would have written smoking policies • 50 per cent of pubs would display external and internal signs on smoking • 35 per cent of pubs would have designated smoking and non-smoking areas and/or be ventilated to the minimum standards. 4.2.9 The Charter provides standardised national signage for pubs and restaurants to show what kind of arrangements they have for smoking and non-smoking customers. It varies from smoking allowed throughout, to separate smoking and non-smoking areas with ventilation. It essentially relies on voluntary co- operation from pubs and restaurants to achieve its targets. 4.2.10 However, the charter has been widely criticised. Broadly, criticism is two-fold. First, it is argued that it has low standards embodied within it and, second, that there are low levels of compliance. There is specific criticism that the Charter relies heavily on providing ventilation to clear the air of tobacco smoke despite evidence that casts doubt on the effectiveness of such systems. Studies of the effectiveness of ventilation systems have suggested that they do not Jon Dawson and Associates 11
  15. 15. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ appear to reduce levels of second-hand smoke compounds.12 The Public Places Charter is currently being evaluated and the findings of the report will be crucial to its future and policy development in this area. 4.2.11 In Merseyside, Liverpool John Moores University also conducted research amongst public houses, restaurants and cafes to explore awareness of the Public Places Charter. Because the response rate was low – 11 per cent of establishments – results need to be treated with caution. However, the research found that of 88 establishments that responded, 63 per cent had not heard of the Charter. Public awareness appears even lower. For the study, 50 members of the public were asked if they knew about the Charter but only one person stated that they did. Health and Safety Legislation 4.2.12 As already observed, there is no explicit European or British legislation that bans or restricts smoking in public places other than for specific reasons of safety or hygiene. However, in broad terms, employers in the UK are required to protect their employees in the workplace under the Health and Safety at Work Act 1974. Specifically, Box 4.1: expanding the scope of the 1974 Act employers must “provide and maintain a safe working The HSE has recently served an improvement environment which is, so far as notice on a Hospital Trust in Dorset to address a perceived threat to the workforce arising from reasonably practicable, safe, stress at work. The action illustrates the without risks to health and potential of health and safety law to be applied adequate as regards facilities and to wider areas of health protection. arrangements for their welfare at It has led to suggestions that the HSE or local work”. The Act does not authority inspectors may be able to take action specifically address issues of to ensure that employers comply with a general duty to keep workplaces free from second-hand exposure to second-hand smoke, smoke. but it has been argued13 that its provisions embrace a responsibility on employers to protect their workers from exposure to second- hand smoke (see also box 4.1). However, there have not been any cases brought by the HSE or local authority inspectors to test this interpretation. 4.2.13 Whilst the 1974 Act is the most important legislation affecting health and safety at work issues, subsequent regulations also have implications for smoking at work. Employers have a responsibility under the Management of Health and Safety at Work Regulations 1992, to identify people particularly at risk from workplace hazards. The HSC has stated that this covers people whose health might be particularly badly affected by second-hand smoke.14 12 Working Group of Health and Safety Authority and Office of Tobacco Control, Ireland (2002) Report on the health effects of environmental tobacco smoke in the workplace. (The working group concluded that ventilation is not a viable control option for second-hand smoke. 13 Getting serious about second-hand smoke, Annual Report of the Chief Medical Officer, 2002 14 HSC Consultative Document (1999): Proposal for an Approved Code of Practice on passive smoking at work Jon Dawson and Associates 12
  16. 16. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 4.2.14 The Workplace (Health, Safety and Welfare) Regulations 1992 implement the European Workplace Directive. The regulations do not prohibit smoking at work but require that workplaces make effective provision to ensure that workplaces are “ventilated by sufficient quantity of fresh or purified air”15 They also require employers to make suitable arrangements to protect non- smokers from “discomfort caused by tobacco smoke” in rest rooms and rest areas.16 4.2.15 A draft Approved Code of Practice which could translate the broad requirements of the 1974 Act into specific guidance on tackling exposure to second-hand smoke was brought forward by the Health and Safety Commission in Autumn 2000. However, it has not progressed further and now seems unlikely to be adopted. 4.3 Implications of Court and Tribunal Cases 4.3.1 Despite the absence of cases to test the potential for the 1974 Health and Safety at Work Act to address smoking at work, a series of court cases and tribunals have clarified some issues concerning smoking in the workplace. They provide some clarification of the rights of non-smokers at work and of the duties of employers regarding exposure of the workforce to second-hand smoke. 4.3.2 Specifically, a series of court and tribunal cases indicate that: • employers must consider the presence of smoke in the workplace and take account of its effect on those exposed to second-hand smoke; • employees are entitled to a rest room or area that is free from smoke; • smokers are not entitled to smoke at work unless their contract of employment suggests otherwise. 4.3.3 The case of Waltons and Morse v Dorrington (1997) indicates that employers must consider the presence of smoke and its effect on the passive smoker in the working environment17. The case held that the 1974 Act creates an implied term in the contract of employment for the employer to “provide and monitor for his employees, so far as is reasonably practicable, a working environment which is reasonably suitable for the performance by them of their contractual duties”. The case also determined that the employee is entitled to a rest room or rest area free from smoke. 4.3.4 Employment Tribunals have considered issues such as whether an employee is entitled to smoke at work and the rights of the second-hand smoker. The case of Dryden v Greater Glasgow Health Board in 1992 held that the introduction of a no smoking policy was not a breach of the employee’s contract of employment. The implication being that so long as a contract of employment 15 Regulation 6(1) 16 Regulation 25 17 Smoking policy for the workplace – an update, Health Education Authority, 1999 Jon Dawson and Associates 13
  17. 17. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ does not specify that smoking is allowed in the workplace, the smoking employee does not have the implied right to smoke at work. 4.3.5 There are several further implications for employers and employees arising from these cases. First, employers should be wary of hastily introducing a no smoking policy without consultation with all employees. Failure to consult an employee may mean the employee is justified in resigning and claiming constructive dismissal. On the other hand, failure by an employer to take steps to minimise second-hand smoke may be regarded as a “repudiatory breach of contract” by the employee sufficient to allow the non-smoker to leave the workplace and claim constructive dismissal. 4.3.6 Finally, employers who Box 4.2: Court cases and compensation continue to allow smoking in the workplace risk future • In 1997, US flight attendantsactionalawsuit on million settlement in a class won $300 claims for damages from behalf of flight attendants harmed by second- employees exposed to second- hand smoke. • In 2001, a non-smoking bar maid in Australia hand smoke. Outside the UK, was awarded US$235 k for cancer caused by an increasing number of court working for 11 years in a smoky bar. cases have resulted in employers being ordered to pay substantial compensation to employees harmed by second-hand smoke. Box 4.2 highlights some examples. 4.3.7 Within the UK, a few people have started legal proceedings against their employers for damages relating to ill health caused by second-hand smoke. However, such cases have, to date, been settled out of court. Nevertheless, they flag up the potential costs to an employer that can flow from employees being exposed to second-hand smoke. For example: • an information officer employed by Stockport Metropolitan Borough Council received damages of £15,000 after claiming that she suffered chronic bronchitis as a result of exposure to second-hand smoke; • a casino worker, who claimed he developed asthma through inhaling tobacco smoke at work, was paid a reported £50,000 by his employers in an out-of-court settlement. 4.4 The Local Context Liverpool First for Health and Smoke Free Liverpool Stakeholders 4.4.1 Liverpool First for Health has established implementing a smoke free policy agenda as central plank of its strategic objectives. This provides a supportive policy environment for efforts to reduce smoking prevalence and exposure to second-hand smoke. Support from the Liverpool Primary Care Trusts underpins the smoke free agenda and has provided financial and human resources to ensure its implementation. Jon Dawson and Associates 14
  18. 18. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 4.4.2 The Smoke Free Liverpool Steering Group has been established to take forward the smoke free agenda. Its make-up includes representatives from Liverpool City Council, the PCTs, Roy Castle Lung Cancer Foundation, the Chamber of Commerce, North West TUC and Health @ Work. Licensing Regulations and By-Laws 4.4.3 The City Council’s Environmental Health and Trading Standards Department is playing a leading role in progressing the Smoke Free agenda. An important aspect of its work is exploring the potential of using the City Council’s licensing powers and by-laws to address smoking in the workplace and other public places. A new Licensing Act 2003 will bestow new liquor licensing powers on local authorities. Premises that need such licences include public houses, nightclubs and restaurants – the type of workplace where workers face amongst the highest risks to their health from second-hand smoke. Although final legal guidance is still awaited, initial indications suggest that the new Licensing Act is unlikely to be amenable to addressing smoking in the workplace. 4.4.4 The scope for employing by-laws is also being investigated. Any such move would require approval from Parliament. Other cities – such as Manchester - are likewise exploring the possibility of using by-laws to further smoke free objectives. There is, therefore, potential for Liverpool to collaborate with other cities to draft workable by-laws and to campaign to secure Parliamentary assent. Merseyside-wide 4.4.5 Smoke Free Merseyside is part of the national network of tobacco alliances funded by the Department of Health and has a special focus on reducing smoking prevalence amongst manual workers and tackling second-hand smoke. It is one of five alliances that link into Smoke Free North West. It provides a forum for sharing knowledge and awareness of activities and has facilitated Merseyside-wide activities (see 4.4.7). 4.4.6 Heart of Mersey is a coronary heart disease prevention programme that operates across Merseyside. It focuses on addressing the lifestyle behaviours - unhealthy diets, lack of physical activity and smoking - that are related to heart disease. Heart of Mersey has run Merseyside-wide promotional campaigns focused on these lifestyle issues. It operates a free phoneline and website that includes promoting anti-smoking interventions and services that Liverpool and other Merseyside residents can access. 4.4.7 Across Merseyside, a range of initiatives has been launched to reduce smoking prevalence rates and contribute to national goals. Like Liverpool (see section 5), each local authority area has a smoking cessation service run in partnership with Fagends. In addition, each is developing a range of approaches to take forward smoking-related agendas. These include action plans, recruitment of project officers to take forward smoke free agendas – such as raising Jon Dawson and Associates 15
  19. 19. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ awareness of smoke free issues and encouraging the development of smoking policies in workplaces. 4.4.8 The five local authority areas have also combined their actions to work collaboratively across Merseyside. An example is the Smoke Free Merseyside Passive Smoking Campaign. Organised by Smoke Free Merseyside in partnership with Sure Start and Liverpool Health Promotion Service, the initiative combined a media campaign with training. The Merseyside-wide media campaign consisted of radio, adshell, poster and leaflet promotion to raise awareness about passive smoking and to change public behaviour. There was also a series of “passive smoking” awareness sessions with parents, health visitors, midwives and community nurses. The sessions aimed to highlight the dangers of second-hand smoke and equip health professionals with the knowledge to relay key messages to parents more effectively. The campaign is now entering a second phase. Jon Dawson and Associates 16
  20. 20. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 5 CURRENT SERVICE PROVISION IN LIVERPOOL ________________________________________________ 5.1 Introduction 5.1.1 In developing the approach to be taken by Smoke Free Liverpool, it is important for stakeholders to take account of existing service provision linked to reducing the prevalence of smoking in the city. This will help to integrate current provision with potential new activity, to avoid duplication and to maximise synergy between actions. This section presents smoking-related services and initiatives within Liverpool within the following categories: • smoking cessation services; • smoking prevention and education; • workplace award schemes; • research; • policy development. 5.2 Smoking Cessation Services: Support / Fagends 5.2.1 The smoking cessation service in Liverpool is delivered by a range of smoking cessation advisers. Many “intermediate advisers” such as practice nurses, school nurses, health visitors and pharmacists have been trained to deliver a widespread smoking cessation service. Liverpool Support also delivers specialist services to pregnant women. There is also a worker who delivers, part-time, a smoking cessation in the workplace service. Future plans include working with senior schools to train students to deliver smoking cessation services in collaboration with Roy Castle Foundation and the School Nursing Service. 5.2.2 The service works in partnership Box 5.1: Budget for smoking cessation. with Roy Castle Fagends, which In 2002/3, the smoking cessation budget for provides a free and confidential Liverpool was £570 k. Expenditure totalled telephone helpline. Across £568,347. This breaks down into the following Liverpool there are over 40 stop categories: £ smoking courses. The service offers intensive help and support Roy Castle: 336,192 to smokers wishing to quit. One Central PCT recharges: 60,250 Pharmacy: 42,569 to one and group support are Publicity: 60,161 available. Training: 8,517 NRT recharges: 38,000 Miscellaneous: 22,658 5.2.3 Access to the service is through health professional referrals – This implies that the cost per person quitting at many GP practices have “in- “the 4-week follow-up” was £195. house” advisers - and self- referral via the Roy Castle Fag Ends helpline. Drop-in smoking cessation sessions are held at a range of venues in Liverpool. Box 5.1 highlights expenditure to deliver smoking cessation services in the last financial year. Jon Dawson and Associates 17
  21. 21. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 5.2.4 Liverpool has consistently met its smoking cessation targets set by the Department of Health. For instance, targets for the smoking cessation service in 2002/3 were surpassed for each of the three PCT areas. For Liverpool overall, the target was for 1500 people to have quit smoking at “the 4-week follow up”. In 2002/3 the outcome for Liverpool overall was 2915 people having successfully quit at the four week follow-up – almost double the target. 5.2.5 To date, the smoking cessation in the workplace scheme has delivered support to 32 workplaces whose staff wished to quit smoking. Overall, there were 407 referrals into the service with 278 people setting a quit date and 169 successfully quitting. 5.2.6 Following its success, table 5.1 illustrates the challenging targets that have now been set. Table 5.1: 4 week quit targets for Liverpool PCT areas 2003/4 to 2004/5 Year Central PCT North PCT South PCT Total 03 / 04 1673 708 543 2924 04 / 05 1840 779 597 3216 05 / 06 2063 873 668 3604 Total 5576 2360 1808 9744 5.3 Smoking Prevention and Education Liverpool Health Promotion Service 5.3.1 Liverpool Health Promotion Service employs a Smoking Prevention Officer. Her agenda involves work around the tobacco control priorities to develop smoke free public places and workplace smoking policies and to engage with second hand tobacco smoke issues. The Officer played a leading role in the development of the Merseyside Passive Smoking campaign (see section 4.4.8). Healthy Schools Award 5.3.2 Smoking prevention and education is an integral part of Liverpool’s Healthy Schools Awards. The awards scheme has engaged with all primary and secondary schools in the city and ensured that smoking prevention and education work reaches all pupils. It has also been a catalyst for ensuring that all schools have smoke free policies for their premises and grounds. Schools found to be in violation of the policy can have their healthy schools award revoked. Jon Dawson and Associates 18
  22. 22. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 5.3.3 Liverpool City Council’s School Effectiveness unit has provided educational and promotional materials to support the healthy schools programme. It continues to deliver school-based training to teachers to implement it. If needed, the trainers can also deliver the programme directly to pupils within schools. Kids Against Tobacco Campaign (KATS) 5.3.4 KATS is part of the Roy Castle Lung Cancer Foundation. It operates an interactive web-site and provides smoking prevention materials. The website provides access to information about the Liverpool School Children's Longitudinal Study on Smoking (see section 5.5.1) and to the “World of Tobacco” training that has been developed from its findings. The latter package targets 5 to 11 year olds and looks at issues including the tobacco industry, the environment and human bodies. 5.4 Workplace Award Schemes 5.4.1 Although there are currently no workplace award schemes operating in Liverpool. Roy Castle Foundation is developing a scheme with the provisional title of Clean Air Award. The City Council has also been considering re- launching its Heart of Liverpool Millennium Award scheme that embraced smoking in the workplace. Clean Air Award 5.4.2 The Clean Air Award Scheme would be a national award scheme to recognise employers who implement smoking policies and would provide support for implementing smoking policies in the workplace. 5.4.3 The consultation process to finesse the award scheme and its criteria is continuing. However, the final scheme is likely to comprise a range of awards – currently they are categorised as bronze, silver, gold and platinum (see box 5.2 for details of current criteria). The level of ward would relate to the extent that employers restrict smoking at work. For instance, as it currently stands, to achieve the platinum award, employers would need to have a comprehensive smoke free policy that covered premises, grounds and vehicles. Whilst the bronze award would only require the provision of a smoke free area. 5.4.4 The consultation process for the Clean Air Award has generated debate about whether employers should receive an award for relatively modest levels of action to tackle smoking in the workplace. Some argue that such an award scheme implicitly condones smoking at work. But, most involved in the consultation process have favoured the view that engaging employers who might otherwise be reluctant to take part outweighed the disadvantages. 5.4.5 Moreover, to counter concerns about condoning relatively limited restrictions on smoking, the Roy Castle Foundation is considering including a “statement of intention” within the bronze award. This would require employers to Jon Dawson and Associates 19
  23. 23. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ satisfy the criteria for the silver award by a specified date. Failure to do so would invoke withdrawal of bronze award status. The length of time allowed to reach the silver standard has yet to be finalised. 5.4.6 It is intended that the award scheme will operate on a franchise basis. Organisations wanting to reduce smoking in the workplace will be able to hold the franchise for a fee of £600 – or £500 for each PCT that they represent. In return, the franchise owner will receive training for a Clean Air Award Co- ordinator and access to resources to implement the scheme. The costs to employers would be nominal and relate to the purchase of initial certification and update certification every two years. Box 5.2 Clean Air Award Criteria The following criteria are still being considered. Platinum: • completely smoke free premises, grounds and vehicles • written policy, prominently displayed • regular review process established • no smoking signage throughout premises • in house cessation service or referral to local cessation service with paid time off, for smokers, to attend • inform all suppliers and subsidiary organisations of existence of the award requesting that they consider implementing an effective smoking policy • promotion and publication of benefits of being a smoke free employer Gold: • completely smoke free premises and smoking not tolerated at entrances or exits • grounds (include) – designated exterior smoking areas permitted so long as ensure no exposure to second-hand smoke • vehicles, company vehicles smoke free (excluding lease vehicles used by only one person for journeys to and from work) • written policy, prominently displayed • regular review process established • no smoking signage throughout premises • in house cessation service or referral to local cessation service with paid time off, for smokers, to attend Silver: • smoke free premises with separate, fully enclosed smoking area • smoking not tolerated at entrances or exits but designated exterior smoking areas permitted • written policy, prominently displayed • smoking not allowed when smoking staff share vehicle with non-smokers • smoking cessation advice available for staff, may consist of in-house advice, referral to local services or information only Bronze: • provision of smoke free area • written policy prominently displayed Heart of Liverpool Millennium Award Jon Dawson and Associates 20
  24. 24. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 5.4.6 The City Council’s Environmental Health and Trading Standards Department ran the Heart of Liverpool award. The award criteria relate to food hygiene, nutrition and smoking. Each element is assessed and weighted scores determine the level of award that an employer can receive. From a smoking policy perspective, it is seen as a way to encourage food businesses to offer a smoke free environment. The award has three levels – gold, silver and bronze. The award was first run in 2001 and targeted food businesses in the city. 5.4.7 Feedback from the 40 businesses that have received an award indicated that suggestions from businesses to improve the scheme included training for staff, information packs and a higher profile for the award. 5.5 Research Liverpool Longitudinal Study on Smoking 5.5.1 The Liverpool Longitudinal Study on Smoking began in 1994. Funded by the Roy Castle Lung Cancer Foundation, Liverpool John Moores University uses a variety of research tools to identify the attitudes, beliefs, intentions, knowledge and smoking behaviour of school children and their parents from six primary schools in Liverpool. The tools are administered each year to the same group of children. This enables researchers to track how their perspectives on smoking change as they move through primary and secondary school. Second-hand tobacco smoke in Liverpool workplaces 5.5.2 As observed in section 1.3, a survey of second-hand tobacco smoke in Liverpool workplaces is being conducted in parallel to this scoping exercise. The survey has been designed to: • build a profile of the extent and type of smoking policies within Liverpool workplaces; • provide evidence of the actual and perceived economic impact of smoke free workplaces; • explore employers’ perceptions of and attitudes to second-hand tobacco smoke in the workplace; • provide evidence of demand for smoking cessation services; • explore interest in participating in an Awards scheme and a Smoke Free campaign. Citizens’ Panel 5.5.2 Liverpool’s Citizens’ Panel is to conduct shortly a survey focusing on smoke free public places. At the time of writing, the details of the questionnaire are uncertain but it clearly has the potential to test: • local views about smoke free workplaces – including restaurants, bars and night-clubs; Jon Dawson and Associates 21
  25. 25. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ • the proportion of Liverpool’s workforce who work in smoke free premises • smoking prevalence rates in the city; • whether making pubs, restaurants and nightclubs smoke free would influence respondents’ behaviour as customers - i.e. whether it would change frequency of visits, length of stay etc. Carbon monoxide levels in pubs and clubs 5.5.3 Liverpool City Council’s Environmental Health Department and Liverpool John Moores University are collaborating on research to test ambient levels of carbon monoxide in a sample of Liverpool’s clubs and pubs. The project is at an early stage and the research design is currently being developed. 5.6 Policy Development 5.6.1 Liverpool Health Promotion Service is working with Smoke Free Merseyside and the Strategic Health Authority to develop smoking policies for NHS staff and sites. It is proposed to develop a campaign to support this intervention. Jon Dawson and Associates 22
  26. 26. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 6 PUBLIC ATTITUDES TO SECOND-HAND SMOKE AND SMOKING IN PUBLIC PLACES ________________________________________________ 6.1 Introduction 6.1.1 There is currently limited up-to-date information about public attitudes to smoke free work and public places in the UK. Whilst attitudes to second-hand smoke and smoking in the workplace have been explored by national studies, these have tended to focus on exploring attitudes to restrictions on smoking. They have not generally tapped attitudes to making workplaces or specific public places such as restaurants, cafes and pubs smoke free.18 This is an important distinction. 6.1.2 Moreover, data relevant to public attitudes in Liverpool has not, so far, been collated. Hence, whilst attitudes in Liverpool could be implied to be comparable with national views, there are no independent surveys to support this. The survey with the Citizens’ Panel (see section 5.5.2) could help to bridge this gap. 6.1.3 This section highlights the results of several key surveys that have focused on public attitudes to second-hand smoke and smoking in public places. It highlights the: • 2002 ONS nation-wide survey data about smoking restrictions and attitudes to “passive smoking; • 1998 Guardian ICM nation-wide survey data which did explore public attitudes to smoking bans; • August 2003 ICM survey data about public attitudes in Ireland to smoking bans and its effect on behaviour. 6.1.4 Perceptions of the hospitality industry about the likely economic impact of smoke free workplaces are examined in section 7. 6.2 ONS Nation-wide Survey 6.2.1 The ONS survey on smoking behaviour and attitudes carried out in 200219 indicates considerable public support for restrictions on smoking at work and, albeit to a lesser degree, within pubs. The survey was designed to explore views on second-hand smoking, smoking restrictions and giving up smoking. Key findings included: • 86 per cent of people thought that there should be restrictions on smoking at work; • 88 per cent wanted restrictions on smoking in restaurants; 18 The 1998 ICM poll highlighted in this section is an exception. 19 Smoking related behaviour and attitudes, 2002 Office of National Statistics Jon Dawson and Associates 23
  27. 27. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ • 87 per cent thought there should be restrictions in other public places such as banks and post offices; • 54 per cent thought smoking should be restricted in pubs. 6.2.2 Importantly, the survey also revealed that people had a high level of knowledge about the effect of “passive smoking”. 90 per cent of respondents thought that passive smoking increased a child’s risk of getting chest infections and over 80 per cent thought that it would increase a non-smoking adult’s risk of lung cancer, bronchitis and asthma. 6.2.3 Other findings relevant to the economic impact of smoke free policies and the rights of the non-smoker included: • 55 per cent of non-smokers minded if other people smoked near them; • 66 per cent of smokers said that they do not smoke when they are in a room with a child and a further 21 per cent stated that they would smoke fewer cigarettes when with a child; • 43 per cent of respondents considered whether or not a place had a non- smoking area was an important factor when deciding to go for a meal and 19 per cent when choosing where to go for a drink. 6.3 Nation-wide Surveys of Attitudes to Smoking Bans 6.3.1 In January 1998, the Guardian commissioned an ICM poll that indicated that there is widespread public support in the UK for a ban on smoking in public places, including bars and restaurants. Support was apparent across all age groups and social classes. Support was slightly stronger amongst women than men. The results showed that: • 73 per cent of respondents were in favour of smoking bans at work (59 per cent stated that they “strongly approved” of bans at work); • 64 per cent of respondents were in favour of smoking bans in restaurants and bars (50 per cent “strongly approved”); • 80 per cent of respondents were in favour of smoking bans on public transport (67 per cent “strongly approved”); • 54 per cent of respondents were in favour of smoking bans in all public places – which could be taken to include smoking in the street (40 per cent “strongly approved”). 6.3.2 A more recent Telegraph YouGov poll (December 2003) suggested that support for a law banning smoking has broadly strengthened. Its results showed that: • 94 per cent, 87 per cent and 80 per cent of respondents supported smoking bans in shops, offices and factories respectively. • 83 per cent supported bans in restaurants; • 49 per cent of respondents supported a smoking ban in pubs compared to 41 per cent who opposed one. Jon Dawson and Associates 24
  28. 28. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 6.4 Survey Evidence from Ireland 6.4.1 A recent survey in Ireland was carried out in the light of government proposals to ban smoking in all public places in January 2004 (see section 8). The survey explored whether respondents supported or opposed the proposed ban in a range of premises. The survey found that: • 58 per cent of respondents supported a total ban on smoking in pubs compared to 37 per cent who opposed it; • 81 per cent of respondents supported a total ban on smoking in restaurants compared to 17 per cent who opposed it; • 60 per cent of respondents supported a total ban on smoking in hotels compared to 36 per cent who opposed it; • 55 per cent of respondents supported a total ban on smoking in night-clubs compared to 36 per cent who opposed it; • 74 per cent of respondents supported a total ban on smoking in places of work compared to 23 per cent who opposed it; 6.4.2 The survey also asked whether respondents would be more or less likely to “go to the pub” if the smoking ban was in place. 37 per cent stated that they would be more likely to go to the pub compared to 25 per cent who said that they would be less likely to go. Jon Dawson and Associates 25
  29. 29. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 7 THE FINANCIAL IMPLICATIONS FOR EMPLOYERS OF SMOKE FREE WORKPLACES ________________________________________________ 7.1 Introduction 7.1.1 An increase in smoke free workplaces in Liverpool would have financial implications for the city’s economy and for individual employers. This section attempts to estimate the cost implications associated with smoking for the city as a whole and to establish how employers can assess the likely impact it has on their own workplaces. This section also includes a special focus on the financial implications for the hospitality sector - as it has particular concerns about the financial impact of introducing smoke free policies. There are widespread perceptions from the industry that smoke-free policies will have a negative effect on the trade and turnover of hospitality businesses. 7.2 The Financial Costs of Smoking for Employers 7.2.1 There is mounting evidence that employee smoking imposes costs on employers. In particular, there is evidence that workers who smoke are absent from work more often than their non-smoking colleagues. And time is also lost when workers who smoke take “smoke breaks” in working hours. Other potential costs relate to costs for cleaning smoke-damaged fabrics and decorations and higher fire risks with potentially higher insurance premiums. As section 4.3 highlighted, smoking at work also opens up employers to the risk of expensive claims for damages from employees exposed to second-hand smoke. 7.2.2 As a corollary, several advantages of smoke-free workplaces to the employer stand out. These can be summarised as: • improved employee health and higher productivity; • avoidance of the expected future increase in worker compensation claims related to second-hand smoke; • lower insurance premiums due to reduced fire risk; • lower cleaning costs. 7.2.3 However, there is limited research to quantify the costs of workplace smoking. Most studies tend to reflect circumstances in the United States and have adopted diverse methodologies. However, a study by Parrott et al20 to quantify the costs of employee smoking in Scotland reflects comparable economic factors to Liverpool. Crucially, its methodology is amenable to establishing an 20 Parrott S, Godfrey C and Raw M, Costs of employee smoking in the workplace in Scotland, Tobacco Control, 2000, 9, 187-192. Jon Dawson and Associates 26
  30. 30. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ estimate of the costs to the economy of employee smoking amongst Liverpool’s workforce. 7.2.4 The Scottish study drew on a baseline survey that explored the different types of smoking policies within workplaces across Scotland. The ongoing survey of employers in Liverpool21 should provide similar evidence and enable calculations to be finessed to establish a more accurate picture. Importantly, the Scottish study drew on other studies to inform estimates of the effects of smoking in the workplace and to develop assumptions about the likely costs and benefits of different restrictive policies. 7.2.5 Evidence from the Scottish survey identified different types of costs and benefits for employers depending on the type of smoking policy introduced. For example, where employers allowed smokers to take smoking breaks it was found that: • there was a loss of productivity due to smokers taking smoking breaks; • being able to take smoking breaks was perceived to be unfair by non- smokers – especially when unlimited breaks were permitted; • there was concern about the adverse public image created by smokers congregating at entrances to buildings. 7.2.6 In financial terms, two major costs can be identified that relate to employee smoking. These are: • absence caused by smoking related disease; • productivity losses caused by workplace smoking. 7.2.7 Following the methodology employed by Parrot et al, to calculate these elements and their impact in Liverpool, it is first necessary to calculate: • the prevalence of smoking among employees in Liverpool • the productivity of labour • excess absence from work among smokers. Smoking prevalence 7.2.8 There is no reliable up-to-date picture of smoking prevalence rates in Liverpool. Figures for the Lifestyle survey conducted by HACCRU indicated that smoking prevalence rates were below national averages. However, significantly higher SMRs for lung cancer combined with a low response rate for the survey means that these findings are questionable. National averages indicate a smoking prevalence rate of 27 per cent ( 28 per cent for males and 25 per cent for females). 7.2.9 Whilst public opinion surveys to be carried out in Liverpool should clarify smoking prevalence rates – and, hence, provide a more accurate figure of costs- the calculations at this stage impute national figures also apply at the 21 See section 5.5 Jon Dawson and Associates 27
  31. 31. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ local level. Despite the HACCRU findings, these figures are likely to be an under-estimate. Labour productivity 7.2.10 As for the Scottish study, these calculations employ the human capital approach to calculating lost productivity by assuming that the value of productivity lost is equal to the wage rate. Average wage rates are therefore used to approximate labour productivity. New earnings survey data from NOMIS indicate that gross average hourly wage rates in Liverpool for all industries were £12.05 (£13.27 including employers National Insurance contributions) and £9.02 (£9.85) for men and women respectively. Cost of absence from work 7.2.11 Following the approach adopted for the Scottish study, estimates of the cost of excess absence from work among smokers are based on the results of the Du Pont study in the United States.22 This was a study with a large population (over 45,000) and a diversified workforce. the Du Pont study estimates an excess absence from work among smokers of 0.9 days per year (7.2 hours per year). 7.2.12 However, as Parrott et al point out, the basis for the calculation needs to be treated with some caution. There are clearly differences in institutional structure between the US and UK, and in the penalties faced by employees as a consequence of absenteeism in the two countries. Cost of absence caused by smoking related- disease 7.2.13 Using the above figures, table 7.1 sets out the calculations to estimate the cost of absenteeism caused by smoking in Liverpool. Assumptions underpinning the calculations are set out in box 7.1. Box 7.1: Assumptions for cost of absence calculation This calculation is based on the following assumptions: 1. Liverpool workforce figures based on local area labour force survey (ONS, 2001) – this is not the same as numbers of people working within Liverpool, which is likely to be higher. 2. Full-time and part-time employment distribution for men and women are based on national ratios. 3. Part-time workers included as working an average of 15.2 hours per week (Labour Market Trends) 4. Smoking prevalence rates, wage rates and excess sickness based on sections 7.2.8 to 7.2.12. 22 Bertera RL The effects of behavioural risks on absenteeism and health-care costs in the workplace, J of Occupational Medicine, 1991, 33, 1119-1124. Jon Dawson and Associates 28
  32. 32. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ Table 7.1: Calculation to estimate the cost of absenteeism caused by smoking in Liverpool Male Female Total workers workers Employment: Full time 86112 42484 128596 Part time 9888 33516 43404 Smoking prevalence rate 28 % 25 % 27 % Estimated number of smokers: Full time 24111 10621 34732 Part time 2768 8379 11147 Smokers in employment (FTE) 25312 14527 39569 Excess sickness absence per annum (hours) 182246 102650 284896 Wage per hour (including NICs) £13.27 £9.85 Cost of absenteeism £2,418,404 £1,011,102 £3,429,506 7.2.14 Clearly several key variables will affect the magnitude of absenteeism cost estimates. Most obviously, the assumptions about the amount of absenteeism that is due to smoking. In this context, the figures presented above may well be conservative estimates. For example, in contrast to the Du Pont study, a study using social security statistics in Northern Ireland23 estimated sickness absence to be 7.3 days per annum. These estimates derived from applying smoking attributable proportions to the total days absent from work due to ischaemic heart disease, bronchitis, and other respiratory diseases. Applying these assumptions to the Liverpool case would lead to a seven-fold increase in the estimates of costs to employers because of smoking-related absenteeism. Productivity losses caused by workplace smoking 7.2.15 Table 7.2 sets out the calculations to estimate the cost to employers of productivity losses caused by workplace smoking. The assumptions underlying the estimate are detailed below. 23 Nelson H The economic consequences of smoking in Northern Ireland, Belfast: Ulster Cancer Foundation, 1986) Jon Dawson and Associates 29
  33. 33. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ Box 7.1: Assumptions for productivity losses calculation This calculation is based on the following assumptions: 1. In the Scottish study, 53 per cent of firms restricted smoking to a “smoking room” and 34 per cent of employers operated a smoke free building policy. This figure was comparable to the Department of Health finding that 40 per cent of the UK workforce works in a smoke free environment. However, more recent data now indicates that half of people in work are not allowed to smoke at all on the premises where they work. Nevertheless, this study for Liverpool assumes that smoking policies in Liverpool are similar to those found in Scotland. The ongoing workplace survey should provide reliable local data that will enable more accurate calculations to be made. 2. The Scottish study assumed, in the absence of accurate data, that smokers could take unrestricted smoke breaks in half of smoke free buildings and buildings with smoking rooms – and that in both cases smoke breaks totalled 30 minutes per day. Estimates from a range of studies indicate that a time of loss of 30 minutes per day because of smoking is a reasonable estimate. This is equivalent to 5 cigarettes per day at an average of 6 minutes per cigarette. This study makes the same assumption. 3. Productivity lost is calculated by valuing the time spent smoking at the average wage rate. Table 7.2: Calculation to estimate the daily productivity loss caused by employee smoking Proportion Employ- Time lost Wage Cost of Total cost of ees who (minutes (hourly time per workplaces smoke per day) rate) day MEN Smoke 0.266 6732 30 £13.27 £6.63 £44,633 room Some 0.17 4303 30 £13.27 £6.63 £28,528 free No policy 0.066 1670 10 £13.27 £2.21 £3,690 Total £76,851 WOMEN Smoke 0.266 3792 30 £9.85 £4.92 £18,656 room Smoke 0.17 2423 30 £9.85 £4.92 £11,921 free No .066 941 10 £9.85 £1.64 £1,543 Policy Total £32,120 Jon Dawson and Associates 30
  34. 34. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 7.2.16 Table 7.2 sets out the daily cost of smoking at work. On the basis of a five- day week and a 46-week year, productivity losses total £25,063,330. 7.2.17 As already observed, other costs are also likely to be imposed on the economy because of smoking at work. Costs identified have included: • cleaning and redecoration costs; • damage to equipment and buildings; • damage to an organisation’s image from people smoking; • fire damage and potentially higher insurance premiums. 7.2.18 However, these costs are difficult to generalise, tend to be specific to particular employers or types of employer and are difficult to quantify. 7.2.19 Of the quantifiable costs, therefore, applying the above methodologies and assumptions to calculating the economic costs of smoking amongst the Liverpool workforce indicates direct economic costs to employers of approximately £28.5 million per annum. This comprises £25.1 million from lost productivity and £3.4 million from higher rates of absenteeism amongst smokers. These cost estimates exclude other potential costs such as cleaning, decoration and higher insurance premiums. Importantly, they also do not take account of the increasing risk for employers that they may face legal costs and compensation claims from failing to protect non-smokers at work. 7.3 A Model for Individual Employers Formula 7.3.1 The above section has focussed on identifying economic costs for employers generally from smoking at work and from employees who smoke. However, it could be useful for individual employers to be able to estimate costs for their own organisations. This could also be a useful tool for influencing employers about the type of smoking policy that they implement. Box 7.3: Calculating the cost of smoking for individual employers Number of FTE smokers n Average hourly wage of smokers £y Productivity loss per smoker per day* x minutes Cost of productivity loss per day = (x / 60) x £y x n Multiply daily cost by number of annual days for full-time worker to calculate Cost of productivity loss per annum = £z Average cost of absence per annum** (£b) = n x £y x 7.2 Total cost of absence per annum = £b + £z * smoking breaks in addition to normally allowed breaks ** applying figure from Du Pont study Jon Dawson and Associates 31
  35. 35. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 7.3.2 Box 7.3 highlights a simple formula that would enable employers to estimate the costs to their own company or organisation arising from smoking at work and from employees who smoke. An example is set out in box 7.4.. Example Box 7.3: Example A firm with 30 employees has 9 full-time workers who smoke. The firm has a smoking room. Smokers take an average of 5 breaks per day more than non-smokers that take about 6 minutes each. The estimated cost of smoking to this company using the above formula is: £13, 747 per annum. This equates to £1,527 per smoker. NB. This calculation does not include the cost to the employer of making a smoking room available. Calculation Number of FTE smokers = 9 Average hourly wage of smokers = £12.50 Productivity loss per smoker per day = 30 minutes Cost of productivity loss per day = 30/60 x £12.50 x 9 = £56.25 Cost of productivity loss per annum = £56.25 x 230 = £12,937 Average cost of absence per annum = 9 x £12.50 x 7.2 = £810 Total cost of absence per annum = £12,937 + £810 = £13,747 or £1,527 per smoker Maximising benefits 7.3.3 From a managerial and economic perspective, the simplest policies are likely to maximise benefits for employers. For instance, a total ban on smoking in the premises combined with smoking only allowed during official break times would generate net financial benefits for employers. Evidence suggests that such policies are not expensive to design and introduce – and, given good communication – staff generally comply24. Equally, successfully encouraging employees to give up smoking would be likely to generate additional benefits through further reducing absenteeism. 7.4 The Economic Implications of Smoke Free Workplaces for the Hospitality Sector 7.4.1 Much of the debate about the economic impact of smoke free public places has focussed on the implications for the hospitality industry. Broadly, the industry 24 Smoking Policy for the workplace, Health Education Authority, 1999 Jon Dawson and Associates 32
  36. 36. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ has been concerned about the impact that making premises smoke free would have on trade. It is generally feared that pubs, restaurants, cafes and night clubs would lose custom if their premises became smoke free. Businesses fear that smokers - together with their friends or relations - will go elsewhere or not visit their premises as much. This section explores those perceptions and examines the potential implications of such premises introducing smoke free policies and practices. 7.4.2 The impact of smoke free policies in hospitality venues is likely to have a different dynamic when an area-wide smoking ban is introduced than in the case where some venues become smoke free and others do not. Equally, the socio-economic composition of an area or of a venue’s customer base is likely to affect the economic impact flowing from a change in smoking policies. 7.4.3 This context is particularly important to bear in mind because much of the evidence relating to the economic impact of smoke free hospitality venues has related to legislation banning smoking within all premises. This is an important difference to the current situation in the UK where there is no such legislative framework. 7.4.4 Much of the research into the impact of making restaurants or bars smoke free comes from the United States, where States and cities have required bars, restaurants and public places to be made smoke free. A range of studies has indicated neutral or positive impacts on revenues for restaurants or bars where cities have introduced smoke free regulations25. Scollo and Lal (2002) have analysed a comprehensive array of studies26. These studies have assessed the impact of smoke free policies after they have been introduced and have used objective measures such as taxable sales receipts where data points several years before and after the introduction of smoke free policies were examined and where economic conditions are controlled for. 7.4.5 There is also an array of studies that suggest the introduction of smoke-free policies is likely to lead to a reduction in business turnover in the hospitality sector. However, these studies are based on subjective perceptions and many reflect concerns before the policy is introduced. Significantly, these studies also tended to be funded by the tobacco industry. 7.4.6 Similar conclusions can be gleaned from the relatively few studies looking at the impact of smoke free policies in the UK. Two studies of perceptions of the economic impact of smoke free policies indicate proprietors’ broadly negative expectations of the likely impact on trade. A survey of proprietors about the potential impact of making public houses smoke free found that the proprietors believed that, on average, a ban on smoking would lead to them losing about 25 for example Scollo et al (2003) Review of the quality of studies on the economic effects of smoke- free policies on the hospitality industry, Tobacco Control, 12, 13-20. Glantz and Smith (1997) The effect of ordinances requiring smoke-free restaurants and bars on revenues: a follow up, J of Public Health, 87, 1687-1693; Goldstein (1998) Environmental tobacco smoke regulations have not hurt restaurant sales in North Carolina, Univ, of North Carolina School of Medicine; Glantz (2000) Effect of smoke free bar law on bar revenues in California, Tobacco Control, 9, 111-112 26 Scollo and Lal (2002) Summary of studies assessing the economic impact of smoke free policies in the hospitality sector, VicHealth Centre for Tobacco Control, Melbourne, Australia. Jon Dawson and Associates 33
  37. 37. Towards a Smoke Free Agenda for Liverpool __________________________________________________________________________ 41 per cent of their custom27. Equally, a survey of restaurant proprietors for the Restaurant Association of Great Britain found that over half of restaurateurs believed that a smoking ban would reduce their turnover. 24 per cent indicated that it would be likely to reduce their turnover by more than 20 per cent. 39 per cent thought it would make no difference but only 1 per cent expected it to increase turnover. 7.4.7 In contrast, perception studies of public house and restaurant proprietors in the North East,28 Staffordshire29 and Yorkshire30 that had voluntarily introduced smoke free areas broadly suggest a neutral effect or an increase in turnover following introduction of the policy. 7.4.8 Relatively few restaurants or public houses are completely smoke free in the UK. Equally, there are no systematic studies of the impact on their trade. However, anecdotal evidence from individual restaurants or pubs that have gone smoke free suggests that their turnover has increased. However, it is important to take into account that, generally, those businesses that have voluntarily introduced complete smoking bans have judged that their target clientele would, predominantly, welcome such a move. Typically, the customer profile for such venues has a high proportion of families with children or from higher socio-economic categories. 7.4.9 A consistent pattern emerges from studies about smoke free hospitality venues. They show that prior to smoking bans being introduced, proprietors are broadly pessimistic about their impact on their businesses. However, objective studies based on analysis of actual turnover suggest that the reality has tended to be different with the impact on business turnover being either neutral or positive. Box 7.4: the hospitality sector in Liverpool Data from Environmental Health records indicates that Liverpool has: 410 unlicensed cafes/restaurants 294 licensed restaurants 738 public houses 171 social clubs Box 7.5: the SME sector in Liverpool Data from the Liverpool Business Centre Business Directory indicates that Liverpool has: 6743 organisations with less than 50 employees 342 organisations with 51 – 250 employees 27 The Publican (2001), Reading the smoke signals, Market Report 2001, Smoking 2001, 22 28 Edwards R (200), New study: 76 % of the North East hospitality trade backs smoke free areas and over 90 per cent of publicans recommend other pubs try one. URL: http://www.ash.org.uk/html/press/00720.html 29 Parry et al (2001) An evaluation of the introduction of “no smoking areas” on trade and customer satisfaction in 11 public houses in Staffordshire, Tobacco Control, June 2001, 199-200 30 Yorkshire ASH (2001) Popularity and impact on trade of smoke-free accommodation in the hospitality trade in Yorkshire, 2001. Jon Dawson and Associates 34

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