Better Health For All

• By Deborah Arnott
• Chief Executive
• Action on Smoking and Health (ASH)

In the UK, smoking kills around 100,000 people a year (1). To replace those who quit or die, the tobacco industry has to continually recruit new smokers. As most people start smoking before they’re 18 it is children and young people who the industry must recruit (2). Advertising and marketing has been shown to increase the appeal of cigarettes to children and tobacco manufacturers design their packs to be glitzy and glamorous with often novel designs resembling such things as perfume packaging.

This is a tactic that works: around 207,000 young people start smoking annually in the UK (3) and exposure to tobacco marketing has been shown to increase this risk (4). Children from the most deprived backgrounds, where smoking prevalence is highest, are most likely to be exposed to tobacco packaging (5). Of those who become lifetime smokers, 1 in 2 of will die of a smoking-related disease (6).

Standardised packaging is the best way to protect children from the lure of sophisticated tobacco industry marketing and the FPH’s new manifesto for public health in the next parliament rightly identifies standardised packaging as vital in giving children the best possible chance of achieving a healthy future (7). However, to maximise the public health gains possible from standardised packaging we need to act now to make sure legislation is voted on by this Parliament.

As part of The Children and Families Act, which became law in February 2014, MPs voted in favour of powers enabling the Government to introduce regulations requiring standardised packaging for tobacco products (8). Since then, the Government has published and consulted on draft regulations. To bring the legislation into effect, these regulations need to be put before Parliament for a further vote. The revised Tobacco Products Directive from the European Parliament, which contains a series of measures intended to deter young smokers including larger health warnings, will be implemented in the UK by May 2016 (9). Because measures have a cumulative effect, implementing standardised packaging at the same time will maximise the public health gain; for this to happen Parliament must be given the chance to vote on the regulations to introduce standardised packaging before the next General Election.

The tobacco industry is running a well-resourced and highly misleading campaign against the introduction of standardised packaging in the UK, but the evidence base for the measure’s effectiveness is now well-established. In April this year, Sir Cyril Chantler’s government-commissioned independent and comprehensive review of evidence reported that there is a strong public health case for the policy, concluding that “the body of evidence shows that standardised packaging… is very likely to lead to a modest but important reduction over time on the uptake and prevalence of smoking and thus have a positive impact on public health” (10).

Moreover, despite claims from the tobacco industry that standardised packs will lead to an increase in tobacco smuggling, the proposed packs would contain the same security markings as existing packs and would be no easier to counterfeit. Sir Cyril Chantler stated in his review that he was “not convinced by the tobacco industry’s argument that standardised packaging would increase the illicit market, especially in counterfeit cigarettes” (10).

An industry-commissioned report using sales data from Australia to claim that there has been an increase in tobacco sales since the introduction of standardised packaging has been widely dismissed. Although the industry reported a small (0.28%) increase in sales year on year, they did not report the increase in the Australian population between 2012 and 2013. Adjusted for population, tobacco sales per person have in fact fallen (11).

Tobacco industry efforts have also failed to dent the popularity of standardised packaging, which currently has strong support from the public, politicians across the political spectrum and the public health community (12). A YouGov poll in March 2014 found that overall 64% of adults in Great Britain support or strongly support plain standardised packaging with only 11% opposed to the measure (13) and when Parliament voted to give the Government the power to introduce standard packs through regulations, 453 MPs voted in favour and just 24 against.

Evidence from Australia, the first country to introduce standardised packaging in December 2012, has been encouraging. Soon after standardised packs began to appear in shops, smokers reported that they found cigarettes in these packs less appealing or satisfying (14). Research has also shown that smokers consuming cigarettes from standard packs were 81% more likely to have thought about quitting at least once a day during the previous week and to rate quitting as a higher priority than smokers using branded packs (14).

Every day since the publication of Sir Cyril Chantler’s review in Spring 2014 hundreds of children have started smoking and the public health community has a responsibility to ensure this number stops growing. You can help make the case for standardised packaging by writing to your MP and urging them to encourage the Government to bring regulations to Parliament as soon as possible.

References and notes
(1) ASH Fact Sheet, Smoking Statistics: Illness and death, 2014
(2) Office for National Statistics. General Lifestyle Survey Overview: A report on the 2011 General Lifestyle Survey. 2013.
(3) ASH Fact Sheet, Young People and Smoking, 2014
(4) The packaging of tobacco products. March 2012. The Centre for Tobacco Control Research. Core funded by Cancer Research UK.
(5) Marmot, M. et al. (2010) Fair Society, Healthy Lives: Strategic review of health inequalities in England post-2010 Marmot review secretariat, London
(6) Doll, R. et al. (2004) Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ 2004; 328: 1519
(7) Faculty of Public Health, (2014) Start Well, Live Better – a manifesto
(8) Children and Families Act 2014
(9) Tobacco Products Directive 2014
(10) Standardised packaging of tobacco. Report of the independent review undertaken by Sir Cyril Chantler. Kings College London, April 2014
(11) Is smoking increasing in Australia? The Guardian, June 2014
(12) The Smokefree Action Coalition an alliance of over 250 health organisations including medical royal colleges, the BMA, the Trading Standards Institute, the Chartered Institute of Environmental Health, the Faculty of Public Health, the Association of Directors of Public Health and ASH, all support the introduction of standard packs.
(13) The poll total sample size was 12,269 adults. Fieldwork was undertaken by YouGov between 5th and 14th March 2014. The survey was carried out online. The figures have been weighted and are representative of all GB adults (aged 18+). Respondents were shown what a standard pack could look like, including larger health warnings as in Australia.
(14) Wakefield M et al (2013); Introduction effects of the Australia plain packaging policy on adult smokers: a cross-sectional study; BMJ Open 2013

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• by Madeleine Harris Smith
• Policy & Advocacy Manager
• Alcohol Health Alliance

Every single hour a person in the UK is killed by alcohol (1). Every single month, 75,000 violent incidents take place where the victim believes the offender to be under the influence of alcohol (2). Every single year, 1.2 million people are admitted to hospital due to alcohol-related causes (3).

Behind every single one of those statistics is a loved one – a friend, a parent, a sibling, a child.

And alcohol does not just harm the individual drinker; it all too often affects innocent bystanders, through its role in child abuse and neglect, domestic violence, family breakdown and crime and disorder. And as well as the human toll, alcohol costs our country £21 billion every year (4).

The availability of alcohol has increased far beyond the local pub, and is now 61% more affordable than it was in 1980 (5). The majority of alcohol is now sold in supermarkets and off licenses, where it is routinely offered at less than cost price to entice people into stores (6) – a can of super strength white cider, such as Frosty Jack’s, can currently be sold for about 16p. Of all alcohol sold, very cheap products play the biggest part in driving alcohol-related harm (7).

Due to existing health inequalities the cruellest effects of alcohol are felt most by those who can least afford it, due to existing health inequalities. Even though as a group they don’t consume as much alcohol as more affluent groups, people in the most deprived areas of the country are disproportionately more likely to experience the impacts of alcohol-related crime, are more likely to suffer the impacts of alcohol-related health conditions and are more likely to die from an alcohol-caused condition (8).

There isn’t one ‘silver bullet’ to fix this epidemic, but in terms of building an effective alcohol strategy for the UK, implementing a minimum unit price must be the foundation stone. A minimum unit price would allow all alcoholic beverages to be priced based on their strength, with stronger drinks, such as high-strength white cider and spirits priced higher than their lower-strength alternatives. This precisely targets the products that are consumed by young drinkers and people drinking harmful quantities, without penalising moderate drinkers, including those on lower incomes.

Research commissioned by the Government as part of its consultation on the Alcohol Strategy confirms that minimum unit pricing is far more effective at tackling alcohol-related harm than the Government’s current ban on the ‘below cost sales’ of alcohol. A 50p minimum unit price would result in a reduction of 50,700 less alcohol related crimes and a reduction of 35,100 hospital admissions by year ten, alongside an overall reduction in alcohol consumption of 2.5%.

Minimum unit pricing would not adversely impact moderate drinkers, with the price of the majority of alcohol on our shelves and in our pubs remaining unaffected. In fact, moderate drinkers across all income groups would spend just 78p more on alcoholic drinks per year (9).

Minimum unit pricing would play a pivotal role in tackling health inequalities without penalising moderate drinkers on low incomes. As lower income households disproportionately suffer the harms of alcohol, they would see the greatest benefits from minimum unit pricing.

Data from the University of Sheffield suggests that routine and manual worker households would account for over 80% of the reduction in deaths and hospital admissions brought about by a minimum unit price and yet the consumption of moderate drinkers in low income groups would only drop by the equivalent of two pints of beer a year (10).

Minimum unit pricing would also reduce drinking among children and young people, as they are particularly sensitive to price changes, as research into tobacco pricing has demonstrated (11). The affordability of alcohol, and particularly the attractive price promotions in off licenses, supermarkets and other shops, means that it is often cheaper for our children and young adults to drink than to participate in other social activities such as going to the cinema or bowling (12).

We experienced a devastating setback for public health when the Government ‘U-turned’ on implementing a minimum unit price last year, citing a lack of evidence that the level of problem drinking would be reduced without ‘penalising those who drink responsibly’. This is indicative of the misinformation that surrounds the policy and that it is our job, as public health campaigners, to try and dispel.

Alcohol tears apart families and damages entire communities – its impact is felt across the board and there is not a neighbourhood in the UK that remains untouched. We are experiencing nothing short of a national crisis because of alcohol – we must act now to stop this.

1)  ONS, Alcohol-related deaths in the United Kingdom, registered in 2012 – ONS. 2014. Accessed June 19, 2014.
2)  ONS, Focus on: Violent Crime and Sexual Offences, 2011/12. 2014. Accessed June 19, 2014.
3)  Gov.uk. Reducing harmful drinking – Policy – GOV.UK. 2013. Accessed June 19, 2014.
4) HM Government, March 2012 ‘The Government’s Alcohol Strategy’ Cm 8336 201, para 1.3
5) Health and Social Care Information Centre. Statistics on Alcohol: England, 2013. 2014. Accessed June 19, 2014.
6) Bennetts R. IAS Briefing Paper: Use of Alcohol As A Loss-Leader. Institute of Alcohol Studies; 2014.
7) Bennetts R. 2014, Ibid
8) North West Public Health Observatory, Centre for Public Health, Liverpool John Moores University. New Local Alcohol Profiles for England reveal the poorest suffer the greatest health harms from booze culture.; 2012.
9) Holmes, J. et al, Effects of minimum unit pricing for alcohol on different income and socioeconomic groups: a modelling study’ The Lancet, Published online February 10, 2014  Last accessed 30 May 2014
10)  Holmes, J. et al, (2014) Op Cit.
11)  Zhang, B., Cohen, J., Ferrence, R., and Rehm, J. The Impact of Tobacco Tax Cuts on Smoking Initiation Among Canadian Young Adult. American Journal of Preventive Medicine, 006;30(6):474–479; Rice, N. et al. A systematic review of the effects of price on the smoking behaviour of young people. (London: LSHTM, 2009).
12) The Cinema Exhibitors Association Limited. UK cinema – average ticket prices 2000-2013, Last accessed 18 June 2014; YouGov. Cinema cost concerns mount. Last accessed 18 June 2014

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This blog is the first in a series that looks at the story behind each of the 12 priorities in Start Well, Live Better, FPH’s Manifesto for the 2015 General Election. The Transatlantic Trade and Investment Partnership (TTIP) could impact on one of the 12 priorities: the ability of a UK government to provide a universal healthcare system, free at the the point of delivery.

• John Middleton
• Vice President for Policy,
• United Kingdom Faculty of Public Health

The Faculty of Public Health is concerned about the damaging potential of the Transatlantic Trade and Investment Partnership (TTIP) for public health, environmental protection and sustainability.

TTIP is being touted as a major benefit for trade between the European Union and America.  But the means by which greater trade is to be gained is through deregulation of standards of health and safety, standards in consumer safety, environmental, and public protection.

The deal is also likely to further add to global warming and climate change.  Alongside the TTIP is a secretive and disturbing quasi-legal instrument known as the Investor State Dispute Resolution scheme (ISDS). This process enables investors to sue governments if they believe their right to profits are being damaged by national policies which may be promoting health, or protecting workers or environments.  The proceedings of ISDS are already evident around the world and should be a concern to all those working for better public health and the environment.

A lot has been written about the TTIP and its implications for the NHS.  Trade unions, politicians, the Royal Colleges and the Lancet have voiced concerns and called for NHS services to be exempted from the trade agreement.  UK government ministers have not shown any inclination to ask for the NHS to be exempted from the agreement, which would be in their powers to ask for.  Why would they? When the stated objectives of the Health and Social Care Act 2012 were to open up competition in the health service? Bizarrely, they have also implied that TTIP will offer a competitive edge for the NHS – a great service that should somehow play on the world stage, subsidised by the taxpayer. We are short of midwives in the UK so how we would sell such services to the US or Europe is a mystery.

European commissioners have issued reassuring statements that the NHS will be exempt. But EC commissioners cannot give such assurances. Once the TTIP is signed and provisions for the Investor State Dispute Resolution (ISDS) are in place these are legal agreements for which grievances and claims for compensation can be pursued in a quasi-court.

Any company with a stake in the NHS now could easily cry foul, take recourse to the dispute scheme and claim compensation if their NHS pickings are not to be protected indefinitely.

TTIP and the ISDS are secretive, policed by a few international lawyers, in a self-serving arrangement, using their knowledge and expertise as the arbitrators, or the advocates. The process, rides rough shod over national law, undermining the entitlement of states to legislate for the improved public health and protection of their citizens.

TTIP presents a much bigger threat to the public’s health, much bigger even than the potentially devastating impact on the NHS, TTIP threatens health and safety conditions, hard-earned workers rights, terms and conditions and protection in employment and threatens local and global environmental safety and controls, carbon emissions and global warming.  It also threatens to dumb-down consumer safety standards – for example through raising permitted levels of antibiotics in foods.

FPH’s manifesto for all the political parties in the next election includes major recommendations for laws designed to protect and improve the public’s health. A sugar tax, minimum unit pricing of alcohol, a living wage, and reducing carbon emissions  – all of these proposals could fall foul of TTIP and its ISDS. If a future government chose say, to accept the overwhelming international and national evidence and implement a minimum unit pricing of alcohol, The Big Alcohol companies could well demand compensation for lost profits, likewise Big Food, on a sugar tax.

It’s easy also to see the ‘chillers effect’ making governments think twice even about implementing such legislation. Multinational companies demand complete freedom to sell their goods whatever the consequences to society. In the case of alcohol, governments pick up the cost of policing violence, and treating disease; other private and public employers pay the costs of alcohol in workplace inefficiency and absenteeism. Big Alcohol pockets the profit.

Strong intellectual property protections afforded under TTIP to pharmaceutical companies may dangerously increase the sphere of influence of big pharma over national regulatory standards. The sovereign power to promote access to medicines and EU transparency requirements over clinical data is at risk.

Supporters of the TTIP quote Obama’s promise of an average $680 per household benefit from the trade agreement. Even if this figure is correct and we take it at face value, would it be a gain worth having? $13 a week gained per household set against potential losses of salary, jobs and working conditions, and the environmental damage of extra consumption for our children to cope with?

And of course, past evidence of major economic change suggests benefits are not delivered equally. There will be big winners and therefore big losers. The narrow margin of benefit is such that gains for bankers, investors, and industrialists will mean loss of money and jobs for many, and destitution heaped on the poor.

Trends towards widening inequalities in income over 40 years in the UK and other parts of the world have been accompanied by widening gaps in the ill health and life expectancy between rich and poor. In 35 years since the Black report, Whitehead, Acheson, Wilkinson and Marmot have all expanded this overwhelming body of knowledge.

Economic inequality causes health inequalities; poverty kills. We can expect widening inequality in health if this trade agreement is signed.

Supporters of the agreement also suggest fears of over use of the ISDS are also unfounded. However, there are recent examples of investor-state disputes which threaten health and the environment which suggest that recourse to these processes is likely to become more common and more damaging to sovereign government’s attempts to legislate for health and the environment.  These were illustrated in the  New Scientist

The most visible at present is the Phillip Morris Uruguay case where the Marlboro man is asking for compensation for lost earnings as Uruguay prepares the most severe health warnings on packs in the world. Surprising perhaps that a tobacco company now says this public health measure will work and will hit them in the pocket when they have denied such measures will be effective throughout the history of tobacco control. Swedish energy giant Vattenfall is taking Germany to the arbitration tribunal for its decision to move away from nuclear power following the Fukushima disaster.

Lone Pine, the multinational oil and mining company, is suing the Quebec government for  $250m over their decision to place a moratorium on fracking.  Occidental was recently awarded over $1.7 billion compensation following their eviction from Ecuador, despite having broken Ecuadorian laws. Achmea, the Dutch health insurance company sued Slovakia for the change of health service policy, which required health insurers to operate on a non-profit basis. Veolia is suing the Egyptian government for raising the minimum wage of water treatment workers.

The potential benefits of TTIP for the UK are projected to be in pharmaceuticals, the motor industry and chemicals- in any objective sense, in the context of global warming, these are all industries we need less of – to protect our environment, to stop poisoning people and, increasingly in the era of big pharmacy, to stop damaging our health.

None of these industries are now major job creators per given investment and could only increase at the margins. None of these have any credibility in terms of social and corporate responsibility.  The whole idea that economic growth for its own sake is a good thing now needs to be seriously challenged.  GDP does not buy us happiness. We need a more sustainable people-centred economy, which supports localism. The very businesses to be sacrificed in this deal are the so-called American  ‘mom and pop’ businesses; the main proponents of this deal are the multinationals. Living within our means in order to protect our children’s future is the new imperative.

For all these reasons, it is right that there is a growing disquiet about this sinister and clandestine negotiation. FPH believes it will damage health, create poverty and damage the environment now and in the future. It will make prospects for laws to protect and promote the public’s health far less likely to happen in the future.

If you are not an advocate for this agreement, it is unlikely the benefits will be coming your way.  It is likely to benefit only a very small proportion of people in the upper echelons of societies on either side of the Atlantic, or in far off tax havens. If you are not for it, you should be against it.  Anybody who is not heading a big multinational company should reject it and campaign vigorously to ensure it never becomes a reality.

This blog is reproduced by kind  permission of  New Scientist,  which published a shorter version  of it on November 1st  2014. This was part of a larger opinion feature about TTIP.

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