Addiction (1993) 88, 43-52

RESEARCH REPORT

Policies to halve smoking deaths

JOY TOWNSEND

MRC Epidemiology and Medical Care Unit, Wolfson Instilule of Preventive Medicine,Medical College of St. Bartholomew's Hospital, Charterhouse Square,London ECIM 6BQ, UK

AbstractBritain still has amongst the highest mortality rates in the world for all the major smoking diseases. A thirdof all adults smoke cigarettes regularly and smoking causes one third of UK deaths in middle age. This paperdiscusses factors related to changes in smoking levels and concludes that without the intervention ofgovernment policies, smoking prevalence and the amount smoked per smoker is likely lo rise, particularly foryoung people. Measures to reduce smoking are surveyed and estimates made of the maximum likely effectsfrom health education, advertising control, general practitioner smoking cessation advice and public and workplace policies. A pricing policy is suggested which, with the other policies could reduce cigarette consumptionby a half so that only one in five adults smoke by the year 2000. Ih-edictions are made of the effect of thispolicy package on lives and life years saved. Within twenty five years there would be 50 000 fewer deathsfrom smoking and half a million life years saved annually. This would rise to two thirds of a million withinforty years. Deaths from lung cancer would fall by 38%. The quality of these life years saved would tend tothe average for their age.

IntroductionBritain still has amongst the highest mortality-rates in the world for all the major smokingdiseases; lung cancer, ischaemic heart disease(IHD) and chronic obstructive airways disease(COAD).' The damage from these diseases islargely irreversible by the time they are diag-nosed, and life expectancy short.' Smokingaccounts for over a third of all deaths in middleage and 18% of all deaths in the UK (1 U 000).'A policy to reduce smoking will be central toachieving the targets for the Health of theNation^ strategy. Smoking has decreased overthe last twenty years but not in any consistent

This anick is based on a paper prepared for the Chief Medi-cal OfTicer^ Working Party on feasibility of indicators andtargets for [he Huulth iif thi: Nation.

way and it is by no means inevitable that it willcontinue to fall unless there is a clear policy tocounteract the effects of rising incomes, priceerosion and advertising. Otherwise, the down-ward trend will reverse and has done so alreadyfor some groups. In particular, regular smokingby 15-year-olds has increased from 20% to 25%"'and by 16-19-year-old-girls from 28% to 32%"over the last two years when the real price ofcigarettes fell. This paper surveys factors relatedto changes in smoking and estimates the contri-bution made by changes in different factors tothe reduction in UK smoking between 1976 and1988. Estimates are then made of the maximumlikely contribution to a fall in cigarette consump-tion by the year 2000, from health education,advertising control, general practitioner smoking

43

44 Joy Townsend

IIE.o

o to•£ o

11000

9000

70001-

/ \ /Consumption >

180p

1970 1974 1978 1982 1986

150p

Ji20p1990

Figure 1. The relationship between the price of cigarettes and consumption 1971-1990. Both variables are adjusted forinflation.

cessation advice and public and work place poli-cies. A pricing policy is estimated which, withthe other policies, would he necessary to reducesmoking prevalence to one in five of the adultpopulation which is the government target forthe Health of the Nation strategy. Predictionsare given for the effect of the policy package onlives and life years saved annually.

Consumption trendsThe five distinct trend periods in UK cigarettesconsumption over the last twenty years haveeach been mirrored by a trend in the real price ofcigarettes in the opposite direction, with smokingnot only decreasing when prices rose, but alsoclearly rising when the price of cigarettes did notkeep up with inflation (Figure 1). Similar coun-ter movements of smoking with relative cigaretteprice have been shown for France^ and Canada.^

This responsiveness of cigarettes consumptionto changes in real price and income, has beenassessed using a variety of models" " giving esti-mates of the price elasticity of demand forcigarettes from -0.4 to -0.865, clusteringaround - 0.55 which means that a 1% rise (fall)in relative cigarette price results in about 0.55%fall (rise) in the amount smoked. These esti-mates have been surprisingly robust over timeand place'^ "" with higher estimates mostly forrecent periods of rapid price increase." Higherprice elasticities have been reported for low socioeconomic groups'^ ( -1 .3 for UK unskilledmanual workers) and teenagers''' ( - 1.4 in US),suggesting that on average these groups reduce

not only consumption but total expenditure oncigarettes when there is a price rise. Priceresponse of teenagers has not been measured inthe UK but the substantive increase in teenagesmoking from 20% to 25% 1988-90 when therelative price of cigarettes was falling, suggeststhat the UK response may be similar. Recentrapid price rises in Canada have been associatedwith a halving of smoking prevalence in 15-19-year-olds from 45% to 22% between 1980 and

Most of these econometric studies analysedquantity smoked per adult or per household, asthese are easier to model and estimate thanactual smoking prevalence. However for the USLewit and Coate have estimated the 'smokingprevalence' price elasticity as - 0.3 (quantity peradult smoker effect was - 0.1)

Smoking and national per capita incomeA positive and significant relationship is reportedbetween smoking and real income with an in-come elasticity varying from 0.1 to 0.7. '" Thismeans that for every one percentage increase inincome, smoking consumption is likely to rise upto three quarters for one percent. A conservativeestimate of 0.4 is used for the UK. This is closeto estimates of smoking consumption responseto income differences across Europe."'

Health promotionThe effects of the Royal College of Physiciansreports on smoking and health^" and the TV ban

Policies to halve smoking deaths 45

on cigareltc advertising arc estimated to havereduced smoking by 5 percent in 1962, 1965 and1971.'' Subsequent sustained anti smoking infor-mation has played a major part in reducingsmoking in the UK. Hamilton'' reports for theUS that health education had a significant effectover the period 1953-70 and reduced cigaretteconsumption by 14"A< per year. In Australiareductions of 6-11% have been reported fromNew South Wales mass media campaigns.-'Mass media interventions in smoking have notalways been as successful and of course thesuccess is likely be be a subtle reaction betweenthe methodology of the programme and the re-ceptiveness of the particular audience and by itsnature will have a large element of variation andunprcdicability. But the potential effectiveness isclear both on a national and on a local basis.School health education has resulted in a highlevel of awareness of the risks of smoking and hasaffected attitudes to smoking-'' but studies havefailed to show effects on the uptake of smokingby teenagers. •'• ^ Health promotion is counteredby advertising and there is evidence that this isan important factor in promoting and reinforcingsmoking among young people.

AdvertisingThe tobacco industry spends about £125 millionadvenising and promoting tobacco products inthe UK. There has been much dispute about theinfluence of cigarette advertising on the amountsmoked. The industry has argued that its adver-tising does not recruit smokers or increaseconsumption, but only affects brand share.While some econometric studies have demon-strated an effect of cigarette advertisement onconsumption others have not. It is difficult tomodel the effects of as complex an influence asadvertising. McGuinness and Cowling"''attempted to measure advenising as a stock vari-able a weighted sum of advertising over time.TTieir work, re-estimated by Johnston, suggeststhat a 10% increase in advertising expenditureincreased smoking by 1%. Similar effects havebeen shown for New Zealand'' and the reinforc-ing effects of cigarette advertising on 11-14 yearold children have been demonstrated. ** Effectsof a total advertising ban are uncertain, butestimates from these studies suggest a fall ofabout 10"/i)''' " and 'before' and 'after' estimatesfor New Zealand'" (with no concurrent price

changes) suggest about a 7\"Ai fall after their banon cigarette advertising. The EC directive, ifadopted, might assist achievement of targets toreduce smoking by this order.

General practice smoking cessation adviceand supportAdvice given on an ad hoc basis in generalpractice has been shown to be highly effective'and cost effective.' If GPs were to give adviceand counselling during normal consultations forany problem, to patients who smoke, smokingprevalence might be reduced by as much as5"/(i." This is most effective on an ad hoc basis assmokers have been shown to be reluctant toattend special clinics" and there could beeconomic incentives for noting cigarette con-sumption on patients' records and giving adviceagainst smoking. A recent study of adolescentsinvited for general practice health check' hasshown that 60"/) of 13 to 17 year olds whosmoked, were willing to make an agreement withtheir GP or practice nurse to give up. This maybe an effective way of reducing teenage smoking,and further studies are needed to evaluate longterm effects.

Smoking in public places and the workplaceNon smokers who experience life time exposureto environmental smoke have an increased risk oflung cancer of 10''/o-30%."' Adults with asthmamay experience substantial decline in lung func-tion from an hour's exposure to side streamsmoke.*'' 'ITie Froggat report reviewed the evi-dence and identifies many deleterious effects ofpassive smoking on respiratory function, signsand symptoms and childhood development.'^These findings have added a new dimension tothe arguments for policies on smoking in publicplaces and in the workplace, This has been aug-mented by recognition of the public fire hazardsof smoking which have accelerated provision ofsmokefree transport. But there is still a long wayto go to catch up with the best practices ofcountries like Canada, US and several states inAustralia. An EC resolution has been adoptedrestricting smoking in enclosed places open tothe public, including public transport. Imple-mentation within the UK would support thesmoking targets and recent guidelines from theDepartment of the Environment recommend

46 Joy Townsend

that progress in this direction should be morerapid. In has been recommended by the Facultyof Public Health Medicine^^ that all schools andhospitals should provide a non smoking environ-ment.

Smoking in pregnancyWomen who smoke in pregnancy have increasedrisk of spontaneous abortion, antepartum haem-orrhage, abruption placenta, premature ruptureof membranes and premature delivery. The In-dependent Scientific Committee on Smokingand Health reported that smoking in pregnancyis associated with an increase in perinatal mortal-ity of 28% and of a reduction in birthweight ofbetween 150 grams and 250 grams.'' It alsoconcluded that there was a significant relation-ship between passive smoking in pregnancy andreduced birthweight.

AvailabilityCigarettes and tobacco are amongst the mostreadily available of all products in terms of num-ber of outlets and hours of availability. Althoughnot legally available to those under 16 years age,underage sales are still widespread" • '' and are themain source for underage teenage smoking.

Recommended indicators for establishingand monitoring smoking targetsIn order to establish and monitor smokingtargets, appropriate indicators need to be agreedand relevant data scries identified. The indicatormost frequently used in public debate is adultprevalence. In the UK this is available biennialVby age, sex, socio economic group and region.Tbere is about an eighteen month delay in publi-cation, so the latest available figures are for up tothree and a half years earlier. This primary indi-cator for public health, should be collectedannually. For underage smoking (11-15 yearolds) excellent detailed prevalence data, verifiedby cotinine assay, is collected biennially andpublished within a year." From National IncomeAccounts there is consumers' expenditure oncigarettes and other tobacco, available quar-terly''" with a maximum lag of six months. Theseare in current and constant prices, have theadvantage of being up to date, and combine theeffects of prevalence and amount smoked per

smoker, both of which affect mortality and mor-bidity. They are in money terms which is notalways easily conceptualized, so would need tobe converted, and are based on sales data, whichis not always available from the industry.Fourthly, there is customs and excise data oncigarettes released from bond^' which gives prob-ably the most accurate long run indicator; thesedo not relate to immediate consumption, beingaffected by stocks and expectations in the shortrun, but a three year moving average would givea reliable long run indicator. Price, being closelyrelated to consumption, should be monitoredalso as a quasi indicator.

ResultsFactors responsible for the fall in UK smoking1976-88The UK National Income Accounts show a fallin cigarettes consumption of 22.5%'*'' in the 12years fi-om 1976 to 1988. TTiese data which arebased on sales are used in the present estimatesand the government survey data, which hasknown under reporting," is used to indicateallocation between prevalence and consumptionper smoker. Cigarette prices in real terms rose by39% over the period. Assuming a price elasticityof -0.55, this would have reduced smoking byabout 17% (1.3% p.a.). The 33% rise in realdisposable income per head, assuming an aver-age income elasticity of 0.4, would have resultedin increased consumption of some 12% (1%p.a.) (Table 1). The residual 17% (1.5% p.a.)fall would be from the combined influences ofchanges in health education, access and othertrend effects modified by changes in the advertis-ing and promotion. These influences togetherappear to be of the same order as that of pricerises over this panicular period. The decrease insmoking was due predominantly (82%) to adecrease in numbers of smokers, and to a lesserextent (18%) to smokers reducing their level ofsmoking. The relative price elasticities for smok-ing prevalence and smoking quantity estimatedby Lewit and Coate'"' are used to estimate theeffects of price, income and health education onsmoking prevalence and quantity (Table 1).

A policy package to achieve the UK smoking targetsby the year 2000The UK Health of the Nation'' target of reducing

Policies to halve smoking deaths 47

Table 1. Contribution of changes in price, income and other factors to the reduction in cigaretteconsumption 1976-1988

Effect on number Effect on quantity Total reductionof smokers* per smoker* in cigs per adult*

(%) (%) C'/o)

Price contributionIncome contributionResidence (health influences

advertising, trend)Total

- 13+ 9

- 14

- 19

- 5+ 3- 3

- 4

- 17+ 12-17

-23

•Effects arc multiplicative and the reduced percentages multiply rather than add to the combinedeffect.

Table 2. Policies lo reduce smokinf; prevalence to 20% by the year 2000

Reduction in numberof smokers*

Reduction in cigs percontinuing smoker*

Factor Policy

Total reductionin cigs/adult*

C"/o)

Advcnisingand promotionHealthEducationCessation

Public places

WorkplaceIncome

Price

Income

L Price

Combined

Ban

Sustained

Smoking adviceto 95% GPpatients whosmokeSmoking

restrictionsRise 3.2% p.a.Raise 63%(5.25% p.a.)Rise 1.6% p.a.Raise 55%Package

10

7

- 927

- 52537

- 39

28

14

- 1 334

73146

'Effects are multiplicative and ihe reduced percentages multiply rather than add to the combined effect.

tht prevalence of adult cigarette smoking to 20"/.)is ambitious and needs to be so if the overallhealth targets are to be achieved. There is aconsiderable body of knowledge available inter-nationally on policies to reduce smoking andBritish experts have played an important role intheir development. The proposed target is onlymarginally lower than that reached in NewZealand, and is above the 16"/u smoking preva-lence of professional men and women achievedin the UK," both of which were substantiallyabove current UK levels. This section estimatesthe likely maximum impact of a policy packagefor health education, cessation support, cigaretteadvertising, and restriction of smoking in the

workplace and in public places taking intoaccount likely increases in per capita real in-come. An estimate is then made of increases incigarette tax necessary, in addition to the abovepolicies, to achieve the target prevalence. If realdisposable income per head grows at the samerate as during the previous twelve years (3.2%p.a.) smoking prevalence is likely to increase by9'V., and quantity smoked per smoker by 3.5%(Table 2). As the above studies suggest that aban on advertising would be expected to reducesmoking by between 7.5"/i^'-"''" and lOVo "-'" aconservative estimate of the effect of the enforce-ment of the EC directive on advertising would bea fall of 7% (reducing prevalence by 5% and

48 Joy Tovmsend

Table 3. UK smoking deaths avoided by the polUr/ package

Cause

YearLung cancer*"Ischaemic'' heart diseaseChronic'' obsiruciive airwavs diseaseOther smoking deathsTotals from smoking'

UK deaths 1988

40 400178 30028 90024 300

111 000

% Reductionwith

200018546

17

policy

201938

83546

46

These figures are based on 1988 mortality unadjusted for demographic change andrepresent orders of magnitude.

'Based on Doll and Peto*' 1985, and Cook et a}."" 1986.''All deaths from the disease-'80% of lung cancer, 76% COAD, 18yo IHD and 100% of other smoking deaths

in 1988.

amount per smoker by 2%). Experience fromUS, UK and Australia suggest that substantialand sustained health education could reducesmoking by 10% over the period (between 5%and 17%), reducing prevalence by 7% andamount smoked per smoker by y-'A>. Extensivegeneral practitioner encouragement and supportto 95% of smoking patients to stop smoking,could reduce prevalence by 5%" and amountsmoked by 2%. This is an ambitious coveragebut has been proposed as a target indicator,^^and could be included as a threshold level forextra payments to general practitioners similar tothose paid for immunization targets. Publicplaces and workplace smoking policies arc im-portant expanding areas of influence*' andextension of these policies might well reduceprevalence by a further 5% and amount smokedby 2%.

TTie above effects together could reduce adultsmoking prevalence to 27.5% (Table 2). Pro-gressive tax increases therefore would benecessary to achieve the full smoking target of20%. The substantial and sustained price in-creases required could well induce a higher priceresponse, possibly close to the - 0.85 estimatesfor 1982/4,'" a period of similar rapid price in-crease. This would imply a real price rise of 63%(above the 1988 price level) over the nine yearsto 306p, a 5.25% increase per annum aboveinflation (Table 2). (If the price response werelower, at - 0.5, a price rise of 127% or 7.1'/o perannum above inflation would be required. Therequired price change would have to be moni-tored and adjusted annually). This would raisethe price of cigarettes to about 15p per cigarette,

still considerably below that of other comparableproducts such as a packet of crisps, a chocolatebar, a cup of coffee, a half pint of beer or a fruitjuice. Tax harmonization policy within theEuropean community stipulates minimum butnot maximum cigarette tax levels, Existing pricelevels within the community vary some sixfoldand the problem of price differentials would notbe substantially altered by such tax increases.The assumption of income growing at the samerate as 1976-88 may be too optimistic. If percapita income grew at only half that rate (i.e.1.6% p.a.) a lower price increase of 55% to 291pwould suffice.

Mortality implications of the smoking targetsThese policies to reduce both smoking preva-lence and quantity smoked will result in lowermortality and morbidity. The mortality benefitfrom smoking cessation, the difference betweenthe risks to continuing smokers and to ex smok-ers, increases rapidly with time. There will bealso benefits from reduced recruitment to smok-ing. The relationship between smoking and theonset of disease, and smoking cessation and therate of decline in disease varies between thesmoking diseases. Lung cancer risk increasesexponentially with years of smoking (and propor-tionally with cigarettes smoked per day), and atany age, a person smoking for 35 years is at overthree times the risk of one smoking for 25years.'' The average current smoker's relativerisk of dying from lung cancer is about sixteentimes that of a never smoker. Afrer 5-9 yearscessation, this reduces lo sixfold and after 15

policies lo halve smoking deaths 49

60000

50000

40000 -

30000 -

20000 -

10000

1990 1995 2000 2005 2010 2015 2020 2025 2030 2035Year

(b)700000

600000 -

500000 -

400000-

300000

200000

100000

1990 1995 2000 2005 2010 2015 2020 2025 2030 2035

Year

Figure 2. (a) Deaths avoided by reducing UK cigareue smoking prevalence to 20% try the year 2000. (h) Life yean savedby reducing UK cigarette smoking prevalence to 20% by the year 2000.

years to about twofold. After 20 years it is prob-ably still in excess of the risk of never smokers."Rosenberg reported'' from the FraminghamStudy that iscbaemic heart disease risk of smok-ers reverted to tbose of non smokers after fiveyears. Cook'" has suggested that the increasedrisk is more prolonged. 'Vhe onset of chronicobstructive airways disease is ver>' gradual andbreathlessness only becomes troublesome afterconsiderable damage to the lung has taken place,much of which is irreversible and progressive, sotbc benefits of cessation tend to be more longterm." Tbe results of the above studies and sum-

maries are used to indicate the likely efFects onmortality from the major diseases of achievingthe smoking target (Table 3). Reductions in thetar content of tobacco will ftirther reduce mortal-ity from lung cancer.

Mortality risk from all causes reduces -wixhlength of cessation. The relative mortality risksreported in the British doctors' study*' are al-most identical to those for the US 9 Statesstudy'" and give the age adjusted continuingsmoker's risk as 1.8 relative to a never smoker,reducing to 1.68 in the first year of cessation, to1.3 in the 13th year and reaches the 'never

50 Joy Totvnsend

smokers' risk of 1.0, in the 21 st year of cessation.TTiese values are used to indicate deaths from allcauses avoided by the proposed policy (Figure2). Some 19 000 premature deaths per yearwould be avoided by the year 2000 and 50 000from 2017.

The years of life saved by the policies (peoplealive each year who would otherwise have diedfrom smoking) is indicated in the lower part ofFigure 2 assuming that the average person dyingprematurely from smoking loses 12.5 years oflife. An extra 84 000 people would be alive fromyear 2000, 500 000 from year 2017 and 645 000from year 2032 were the smoking targetsachieved. The quality of these years of life savedby preventive action would tend to be normal forthe relevant age.

Discussion'I'hc main smoking target discussed here hasbeen adult smoking prevalence. Smoking bylower income groups, teenagers and pregnantwomen tend to follow the general level and islikely to be more influenced by the above policieswith some specifically targettcd policies. Relativeto many other European countries,'" UK alreadyhas high cigarette prices but it also has relativelyhigh smoking mortality.' Cigarettes are cheapernow relative to the cost of living than they wereforty years ago, and even cheaper relative toincome changes and prices in countries such asCanada, Denmark and Norway. Raisingcigarette tax, effectively reduces cigarette con-sumption particularly hy those most in need oftargeting.'**" Those on low Incomes who do notreduce their smoking may experience financialdifficulties. Such problems need to be addressedbut also should be weighed against the benefits,particularly to families in these groups, fromoverall reduction expenditure on tobacco and thereduction in childhood respiratory problems andthe devastating longer term social implications ofearly death or chronic disablement of parents.An unskilled male manual worker is five timesmore likely to die from lung cancer than a pro-fessional man, twice as likely to die of ischaemicheart disease and more than six times as likely todie from chronic obstructive lung disease.*"Unskilled manual women workers or wives ofunskilled manual workers are at three times therisk of dying from lung cancer, and four timesthe risk of dying from IHD or COAD compared

with professional women or wives of professionalmen. Until the 1960s, and the divergence insmoking by social class, there was no social classdifference in lung cancer mortality, and socialclass 1 had the highest mortality from IHD."^Smoking morbidity also falls more heavily on lowincome families. The economic effects of smok-ing reduction have not been addressed in thispaper although they have been elsewhere.'^"''^The effect on government revenue is likely to beapproximately neutral, the higher tax rate com-pensating for the reduced quantity bought andthe other extra costs and savings to the govern-ment budget being approximately equal. '' Theeffects on employment could be beneficial, as thetobacco industry is highly capital intensive andalternative expenditure is likely to be on morelabour intensively produced goods. The eco-nomic welfare effects of the poHc\' on theindividual smoker are discussed elsewhere.'*' 'Hconomic theory, is based on the assumptionthat individuals spends their resources to maxi-mize their own welfare and it does not easily dealwith a product like tobacco which is highlyaddictive, which when used in any quantity' in-creases the risk of death and illness and whichthree quarters of its consumers are trying to stopusing. This majority of smokers are looking for anon marginal welfare gain by successfully extri-cating themselves from the addiction. Thealmost universal acceptance of school healtheducation about smoking implies agreement thatthe lifetime welfare of young people will beincreased by avoiding smoking.

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