2. A generation free from tobacco by 2034:
can targets change culture?
David Robertson, Alliances Manager
at ASH Scotland, Edinburgh, UK
Prof Amanda Amos, Centre for Population Health
Sciences, University of Edinburgh
3. The Scottish Government
Tobacco Control Strategy
“A child born in 2013 will celebrate their 21st birthday in
2034. Creating a Scotland for that young adult, largely
devoid of tobacco use – with all the health, social and
economic benefits that entails – would be an achievement
of which we could all be proud.”
Scottish Minister for Public Health
5. 2034 target by SIMD
(Scottish Index of Multiple Deprivation)
6. Policies to address inequality
Early Years Framework
Getting it Right for Every Child (GIRFEC)
Parenting Strategy
Children and Young People (Scotland) Bill
Child Poverty Strategy
Curriculum for Excellence
Strategy for Justice
Regeneration Strategy
8. Foundations of the strategy
2006 smoking in most indoor public
places banned
2007 age of sale for tobacco raised
from 16 to 18
2010/11 register for tobacco retailers
created
2011 buying tobacco on behalf of an
under 18 prohibited
2013-2015 phased implementation
of tobacco display ban in retail stores
9. Strengths of the strategy
Commitment to standardised packaging
2020 target for reducing child exposure
to second-hand smoke in the home
Audit of implementation of the World Health Organisation’s
Framework Convention on Tobacco Control Article 5.3 on
tobacco industry interference
Youth smoking prevention focus
Improving the reach of cessation services
12. Culture change
The ASH Scotland Charter
for a generation free from
tobacco:
Helping to support the work
of agencies and community
organisations tackling
health inequality
13. Innovation
Community pharmacy support, incentives schemes, REFRESH type
interventions
Smoking in vehicles – no Scottish Government commitment to introduce
legislation, however this is being taken forward by a Liberal Democrat MSP
Stronger commitments to further controls on supply – investigate restricting
number of outlets, times & place where tobacco can be sold, positive
licensing
regulation of electronic cigarettes (e-cigarettes)
14. Summary
Scotland’s strategy includes a target for a tobacco-free generation by 2034
reduction in child second-hand smoke exposure by 2020
cessation service achievement linked to reducing health inequality
it is part of a much wider strategy to create a healthier, more equal and
greener society
it has a very strong focus on protecting children from tobacco and preventing
the promotion of smoking initiation by vested interests it attempts to involve
as many stakeholders as possible
it is sufficiently aspirational that it does not restrict stakeholders from acting
beyond the strategy.
15. For more information about tobacco control in
Scotland go to www.ashscotland.org.uk
Professor Amanda Amos will be available to answer questions on
aspects of the Scottish strategy.
Amanda.Amos@ed.ac.uk drobertson@ashscotland.org.uk
Editor's Notes
ASH Scotland and the University of Edinburgh are pleased to have this opportunity to describe the excellent work being carried out in Scotland led by the Scottish Government and supported and implemented by all elements of civil society. ASH Scotland is one of several independent ASH’s operating in the UK and it has a long history of working in partnership with the University of Edinburgh represented today in the discussion session by Prof Amanda Amos who has a special interest in the relationship between tobacco and health inequality.
You should know that Scotland has a devolved government within the UK with powers over health, education, civil law, cultural affairs and aspects of economic policy with the UK parliament retaining power over social welfare, most tax, defence and macro-economic measures. After a recent referendum in which Scots rejected out-right independence, there are plans for further devolution.
As a devolved administration, the Scottish Government has shown itself to be progressive in a number areas of legislation and, for example, introduced smoke-free public places legislation in 2006 – before the rest of the UK.
Scotland, unfortunately has higher rates of lung cancer and heart disease than other parts of the UK and this has motivated law makers to take, sometimes radical steps to help improve the nations health. Another example of this progressive streak - The Scottish Government plan for minimum pricing per unit of alcohol has been referred to the European Court of Justice.
In 2013 the Scottish Government after consultation with the tobacco control community and wider public interests published CREATING A TOBACCO-FREE GENERATION A Tobacco Control Strategy for Scotland. The strategy sets 2034 as the target year for a tobacco-free society defined as a prevalence rate of less than 5%.
The target is about encouraging children and young people to reject smoking and to encourage adults to support them in doing so.
However the strategy as a whole sets out to provide encouragement and support to people of all ages to quit.
The strategy sets out to be supportive and not to unfairly stigmatising those people who choose to smoke, or who are unable to give up.
The target reflects the fact that we are not taking a prohibition stance and that it is unlikely for smoking to be phased out altogether.
The Scottish Government views tobacco control as a key plank in reducing health inequality in Scotland.
The number of people who smoke in Scotland has declined from 31% in 1999 to 22.9% in 2014 . However, smoking rates in the most deprived communities in Scotland remain disproportionately high.
– 40% in the most deprived areas compared to 11% in the least deprived areas (Scottish Household Survey 2013). This is a key factor in contributing to Scotland’s persistent health inequalities that result in the unfair differences in life expectancy between the richest and poorest of our communities. Tackling health inequalities and their underlying causes is part of our collective responsibility to advance the right to life and to increase life expectancy, taking steps to protect us all, particularly children, from risks to life.
Consequently, tobacco control is not a measure that stands apart from other measures to reduce health inequalities it is recognised as part of a raft of measures that taken together will improve the health of the nation.
This is what smoke-free by 2034 looks like. A steep and ambitious year on year fall in prevalence rates, with a rate of decline somewhat greater than experienced in the last decade.
The key factor in ensuring success will be in maintaining the continued downward trend in the take-up of smoking among young people. To that end, modelling work assumes prevalence rates among 15 year olds will decrease by 2.5 percentage points every two years until reaching a floor of 2%. This, therefore, places a premium on the preventative actions identified in this Strategy aimed at creating an environment where young people do not want to smoke.
In short the intention is to put smoking out of fashion.
Given the clear inequalities dimension to smoking prevalence rates, the Scottish Government have also included 5-year milestones, setting out how prevalence needs to reduce by SIMD quintile to achieve the 2034 target. (SIMD: The Scottish Index of Multiple Deprivation identifies small area concentrations of multiple deprivation across all of Scotland in a consistent way.)
Clearly the action required to effect the required fall in prevalence rates in poor communities will present real challenges. However, this represents the same challenge as the reduction in health and socio-economic inequalities that is at the heart of government policy.
Weights for each domain SIMD
Employment 28%
Income 28%
Health 14%
Education 14%
Access 9%
Crime 5%
Housing 2%
This drive towards creating a more equal society has created other initiatives such as the Scottish Government’s policies to ensure children have the best start in life through
the Early Years Framework,
Getting it Right for Every Child (GIRFEC),
the Parenting Strategy and the Children and Young People (Scotland) Bill; to tackle poverty through Achieving Our Potential
Child Poverty Strategy; to promote employability through Working for Growth;
to improve educational attainment through Curriculum for Excellence;
to reduce offending through the Strategy for Justice;
and to improve the built environment through the Regeneration Strategy
are all relevant to tackling health inequalities in Scotland. Whilst these strategies all offer opportunities to promote tobacco control messages, they also help to create the circumstances in which those messages are more likely to be heard and acted upon.
The strategy has a number of actions under these headings but there is an underlying aim to reduce health inequality.
Prevention is creating an environment where children do not want to smoke
Protection – from second-hand smoke
Cessation – help to give up smoking
The strategy is underpinned by a number of tobacco control advances in recent years and is supported by the UK’s tobacco tax regime which is one of the toughest in Europe.
The Scottish Government is committed to bringing in standardised packaging even if the current commitment by the UK Government is not met.
The target to reduce child exposure is a world first and it has been very useful in ensuring that those who care for children are drawn into activity which supports the strategy. (from 12% in
2012 to 6% by 2020)
The Scottish Government are well aware of the disruptive effects of tobacco industry interference in public health measures and have pledged to direct any funds recovered as a result of legal action lost by tobacco companies, back into tobacco control. Imperial Tobacco, and its wholly-owned vending machine subsidiary engaged in protracted legal challenge of the legislation on competency grounds delayed the enactment of the law by a year in Scotland compared to England
ASH Scotland has played a very active role in supporting youth advocacy in tobacco control. We run an award scheme to recognise the work of young people in running their own campaigns and this led to
The Scottish Government funding an amazingly successful youth commission comprised of young people from across Scotland which reported in 2014 with a number of recommendations for future action amongst which were –
creating smoke-free zones that extended beyond the school gates
preventing shops close to schools from selling tobacco
setting a date after which tobacco purchase by someone born in 2013 would be banned (2031)
Although not yet backed by law, health services and local authorities have been directed to create smoke-free grounds during 2015
Making homes smoke-free – awareness raising campaign, ante- and post-natal services, support for REFRESH-type interventions
Because tobacco control in Scotland is not intended to be tied to the actions of any specific group of people and is very much part of the drive towards a healthier, greener more equal society there is a definite sense that the strategy is only a guide and that the intention is that people should be free to work together to contribute to a healthier culture and to put forward new ideas in order to maintain the momentum towards change.
The Scottish Coalition on Tobacco Control provides a platform to share views with other organisations and with policy makers as it works closely with the Scottish Government, NHS Health Scotland, and the Scottish Parliament's Cross Party Group on Tobacco Control. Its collective approach means that SCOT has become an influential and respected voice in public health, with the secretariat being provided by ASH Scotland, the leading charity campaigning for effective tobacco control in Scotland.
The community and voluntary sector are recognised in the strategy as a vital provider of support to local authorities and the health service. ASH Scotland for example provides a useful information service funded in part by CRUK and the BHF and is tasked with trying out new interventions often in partnership with Scottish Universities.
In particular ASH Scotland manages the STCA which is a forum for local and national stakeholders in tobacco control that allows knowledge transfer and facilitates policy development.
One area where ASH Scotland felt that more needed to be done was in mobilising a broad range of groups in support of a Government target that has not been given as much publicity as it deserves.
With funding from CRUK, ASH Scotland has developed a Charter that organisations can endorse in order to show their support for the 2034 target. The Charter helps to give recognition to organisations already engaged in activity that supports parents to quit, reduces child exposure to SHS, develop health promotion and cessation tools focused on young people and encouraging those working with children to be healthy role models. The Charter also provides a route for organisations and individuals to pledge to develop smoke-free friendly policies.
The Charter supports a level playing field for our young people so that all can benefit from a smoke-free lifestyle and environment.
So far I have been very upbeat and optimistic about Scotland’s approach to tobacco control, however, we still have a mountain to climb to reduce our smoking rates especially amongst those experiencing disadvantage. This includes those on low income, low educational attainment and people suffering mental illhealth. Some of the measures already put in place such as removing tobacco from view still need time to make an impact but there will need to be additional action taken to meet those tough targets set by the Government. Innovation is required.
By equipping pharmacies based in local communities with the skills to support quitting we can ensure that disadvantaged areas have places at hand to offer help
Incentive schemes help to address health inequality by simply providing a family with greater flexibility, to access healthy food and exercise opportunities..
Agencies are able to offer air quality monitoring as a way to support the creation of smoke-free homes
Smoke-free cars where children are present is under consideration by the Scottish Government
Treating tobacco more like alcohol and restricting where it is sold is being explored
Regulation of E-cigarettes to reduce access by young people is under development
An evidence peer-mediated intervention in schools (pioneered in Wales) to reduce smoking initiation in teens is being piloted with a view to becoming established across Scotland
Initiatives to encourage young people to advocate for smoke-free policies are being encouraged in schools and colleges
By imagining a future free from tobacco and setting a time in the near future by when the goal will be achieved Scotland has opened the door to creativity and given a direction to the aspirations of people who want to create a more positive health-aware culture.
Targets have concentrated the minds of those held most directly accountable for progress and success but have also made it essential for the main drivers in health and local government to seek support and partnership in their communities. Voluntary organisations through a complex web of obligations are also expected to support the targets as part of their contribution to strategic outcome agreements entered in to by local authorities.
Scotland will be free of the harm caused by tobacco, therefore change becomes inevitable and ideas that previously could not have developed become part of the public debate about how we can more effectively bring about change.
Standardised packs become a logical step, creating smoke-free spaces for children in cars and parks seem like a natural means by which we can reduce both the presence of tobacco in society and the harm tobacco causes. Countenancing a time in the future when a young person will no longer have the option of being able to buy tobacco at all becomes the focus of debate.
