How impressive are existing tobacco control measures?
The Tobacco Control Plan (TCP) for England 2017-22 was published by the UK Government in July 2017 and identifies key specific areas of focus including, prevention, supporting smokers to quit, elimination variation in smoking rates, and effective enforcement. Since the preceding UK TCP, smoking prevalence has substantially reduced from 20.2% of adults smoking to 5.5%. Whilst this is the lowest level since records began, there is room for improvement with unanswered questions about why more has not been done to curb tobacco usage (1).
The Joossens and Raw Tobacco Control Scale (TCS) was first introduced in 2006 and was originally based on six policies described by the World Bank which they say should be prioritised in a comprehensive tobacco control program. It is used to measure the implementation of tobacco control policies and is scored out of 100. The TCS was last reported in February 2020 at the European Conference on Tobacco or Health. The most recent TCS rates performance against eight measures, including; price of cigarettes and other tobacco products, smoke-free work and other public places, pending on public information campaigns, comprehensive plans of advertising and promotion, large direct health warning labels, and treatment to help dependent smokers stop (2).
The most recent UK TCP has measures to address all eight of the TCS indices and in addition, also has a policy to protect public health policies on tobacco control from commercial interests (3, 4). The UK has consistently ranked number 1 out of 36 European countries assessed in 2007, 2010, 2013, 2016, and 2019, with a current score of 80 out of 100. Clearly, the UK takes tobacco control seriously, so what is holding it back from a perfect score?
The most recent UK TCS score shows two areas of particular interest where points are lost; price of cigarettes and budget, where 5 and 10 points are lost respectively.
In 2013, the UK Government began reductions in public health budgets after splitting Public Health England from the NHS and embedding it in local authorities. Thus, local authorities took on the responsibility and financial burden of population health. The current Public Health grant of £3.1 billion a year is £850 million lower than in 2015/16 (5). Further still, smoking cessation and tobacco control services have also suffered further budgetary restraints due to wider reductions in local authority funding. It is clear, that local authorities have struggled to deliver their statutory functions whilst maintaining investment into other important initiatives such as public health. Consequently, it seems that tobacco control measures have suffered. Only time will tell what the full impact of this will be on smoking prevalence, quit rates, and consequent illnesses but one would expect health and social care to need increased investment at some stage to deal the with consequences. It seems short-sighted to cut funding for public health initiatives now only to need to fund the NHS in the long term to manage the associated health consequences.
However, the answer may be a part of the problem. The UK TCS score shows a loss of 5 points due to an unsatisfactory levy on the price of cigarettes. Whilst it has been postulated that this is in part due to the weakness of the pound, it does provide a potential solution whereby increasing the taxation of tobacco above inflation could act as a disincentive to smoking whilst generating revenue for use in public health initiatives. Indeed, tax increases have been shown to be highly effective in reducing smoking prevalence and tackling inequalities. Further still tobacco tax increases are the only tobacco control intervention proven to reduce inequalities (7). Calculations have suggested that a 3% rise in taxation on cigarettes and 12% rise in taxation on tobacco could result in a net benefit to public finances of £439.7m per year (5).
However, there is an argument that the high cost of cigarettes fuels the illegal trade of tobacco in a black market which was worth £2.5b in taxation in the UK between 2016/17 (9). Though it should be noted that this has been rebuked by suggestions that price increases by manufacturers for their products do not incur similar accusations of driving an illicit trade in tobacco, so why should tax increases incur such hostility? (6,10)
Needless to say, effective smoking cessation strategies resulting in a fall in the prevalence of smokers may actually result in a reduction in the black market trade of tobacco products due to a reduction in consumers, thus minimising the loss to taxation and tax expense of policing (8). Another compelling argument to invest in evidence-based smoking cessation strategies.
It is important not to be complacent and assume that an excellent track record in curbing tobacco usage ensures sustainable gains. In contributing to 50 serious health conditions and 78,000 deaths per year in the UK, tobacco remains one of the leading causes of preventable illness and death. The UK government has an opportunity to implement evidence-based policy to increase tax revenue and reduce the prevalence of smoking by increasing levies around tobacco-based products.
- Towards a Smokefree Generation A Tobacco Control Plan for England [Internet]. 2017 [cited 2020 Nov 26]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/630217/Towards_a_Smoke_free_Generation_-_A_Tobacco_Control_Plan_for_England_2017-2022__2_.pdf
- Joossens L. The Tobacco Control Scale: a new scale to measure country activity. Tobacco Control. 2006 Jun 1;15(3):247–53.
- Craig L, Fong GT, Chung-Hall J, Puska P. Impact of the WHO FCTC on tobacco control: perspectives from stakeholders in 12 countries. Tobacco Control [Internet]. 2020 Nov 26 [cited 2020 Nov 26];28(Suppl 2):s129–s135. Available from: https://tobaccocontrol.bmj.com/content/28/Suppl_2/s129
- Barber S. Tobacco Control Policy Overview [Internet]. Parliament.uk. 2017 [cited 2020 Nov 26]. Available from: https://researchbriefings.files.parliament.uk/documents/CBP-8116/CBP-8116.pdf
- Arnott D, Titmarsh R. Written evidence submitted by Action on Smoking and Health [Internet]. Parliament.uk. 2020 [cited 2020 Nov 26]. Available from: https://committees.parliament.uk/writtenevidence/11331/default/
- Curbing the epidemic – governments and the economics of tobacco control [Internet]. World Bank. World Bank Group; 1999 [cited 2020 Nov 26]. Available from: https://documents.worldbank.org/en/publication/documents-reports/documentdetail/806771468344642501/curbing-the-epidemic-governments-and-the-economics-of-tobacco-control
- Hill S, Amos A, Clifford D, Platt S. Impact of tobacco control interventions on socioeconomic inequalities in smoking: review of the evidence. Tobacco Control [Internet]. 2013 Sep 17 [cited 2020 Nov 26];23(e2):e89–97. Available from: https://tobaccocontrol.bmj.com/content/23/e2/e89.
- Chaloupka FJ, Yurekli A, Fong GT. Tobacco taxes as a tobacco control strategy. Tobacco Control [Internet]. 2012 Feb 16 [cited 2020 Nov 26];21(2):172–80. Available from: https://tobaccocontrol.bmj.com/content/21/2/172
- TMA response to the consultation held by the APPG on Illicit Trade 13/04/18 [Internet]. http://the-tma.org.uk/. 2018 Apr [cited 2020 Nov 26]. Available from: http://the-tma.org.uk/wp-content/uploads/2018/04/APPG-response-on-Illicit-Trade-final.pdf
- Representation from ASH and the UK Centre for Tobacco and Alcohol Studies to the Chancellor of the Exchequer [Internet]. https://ash.org.uk/home/. 2020 [cited 2020 Nov 26]. Available from: https://ash.org.uk/wp-content/uploads/2020/01/ASH_UKCTAS_Budgetsubmission2020FINAL.pdf