One year into the smoking ban in England it is still too early to predict its long-term effects on public health but there are reasons to be cheerful, says Stuart Shepherd
Those who can remember decimalisation, first time round for The Generation Game and Kevin Keegan at Liverpool FC will also remember Roy Castle. He was a versatile entertainer: an actor, singer, presenter, tap-dancer and jazz musician and host of children's TV show Record Breaker.
In 1994 at the age of 62 Mr Castle died of lung cancer. He had never been a smoker, but had spent a lot of time playing his trumpet in smoke-filled venues. His death and the subsequent work of the Roy Castle Lung Cancer Foundation helped bring concerns about the health risks of passive or secondhand smoking to the fore.
Growing evidence of the public health impact of passive smoking and a concerted lobby over several years from ASH UK (Action on Smoking and Health) and other members of the Smokefree Action Coalition later culminated in what is widely known as the smoking ban. This was legislation contained within the 2006 Health Bill to protect the health of workers that made almost all enclosed public spaces and workplaces in England smoke free.
Much was expected from the ban when it came into force on 1 July 2007. Patricia Hewitt, who was the health secretary at the time, told the House of Commons it would save thousands of lives. Chief medical officer for England Sir Liam Donaldson called it "one of the most significant health reforms for decades" and anticipated "the single biggest improvement in public health for a generation".
One year on, it looks as though initial optimism was well placed, with perhaps the most impressive outcomes an unexpected bonus from the legislation.
Decline in smoking
The Smoking Toolkit Study published on 1 July - the first to examine the impact of smoke-free legislation on smoking rates - shows a dramatic decline in the number of smokers. Funded by pharmaceutical companies and Cancer Research UK, the survey shows smoking prevalence went down by 1.6 per cent in the nine months leading up to the ban - a figure that grew to 5.5 per cent in the first nine months after the ban. Over the next 10 years, it estimates, this will prevent as many as 40,000 deaths.
"To be quite honest I expected nothing," says Cancer Research UK director of tobacco studies Professor Robert West. "But these figures show what amounts at the absolute minimum to 400,000 fewer people smoking: the largest fall in numbers on record.
"This is contrary to what I thought would happen, I must admit. In Ireland [where a workplace smoking ban was introduced in 2004] there was a small decline in the rate of smoking after the ban before it went back up again. With most offices in England already smoke free, the focus was on pubs, clubs and restaurants. Given that this seemed like a smaller change of circumstances than Ireland, I thought our results would also be smaller."
Figures on the use of NHS Stop Smoking services substantiate these findings. Of the 462,690 people to use the services between April and December 2007, around half - over 234,000 people - reported they were still smoke free at their four-week follow-up. This represents a 22 per cent increase in the number of successful quitters compared with the same period in 2006.
While this all points to more support for smokers looking to give up, the focus of the ban was not actually to reduce the prevalence of smoking. The primary objective of the smoke-free legislation, as public health minister Dawn Primarolo notes, was to reduce worker and public exposure to secondhand smoke.
"As well as the medical research showing secondhand smoke seriously increased the likelihood of lung, heart and other diseases, evidence also demonstrated that the view that simply having better ventilation on a premises would make things all right was mistaken. It did not eliminate the risk.
"Non-smoking bar workers were found to be inhaling up to six times as much smoke as the average non-smoker. But studies show that one year on from the implementation of the ban, there has been a 76 per cent drop in that exposure."
Longer-term research monitoring the broader health impacts of the smoking ban will be available for the legislation's three-year review.
The lack of English government research to link the ban and the numbers of emergency admissions for acute heart attacks before 2010 is in contrast to reporting from Scotland in 2007. The Scottish government announced that, as well as seeing an 86 per cent reduction in secondhand smoke in bars, a study of nine hospitals had found a 17 per cent reduction in heart attack admissions, compared with a figure of 3 per cent per year in the 10 years before its 2006 ban began.
One year after introducing its ban in 2004 Ireland reported a 14 per cent drop in hospital admissions for heart attacks. Results from a study in Piedmont in Italy found admissions dropped by 11 per cent in the first five months after a similar ban came into force there in 2005.
In England the Daily Mail took it on itself to try to fill the knowledge gap, obtaining figures under the Freedom of Information Act for admission rates for acute heart attacks from 114 hospitals. It concluded that in the nine months after the ban there were 1,384 (three 3 per cent) fewer heart attacks compared with the same period the preceding year.
"The impression was that the number of myocardial infarction or heart attack patients coming into accident and emergency was on the way down anyway," says clinical vice-president of the College of Emergency Medicine Don MacKechnie. "The effects of smoking tend to be long rather than short term, so you wouldn't necessarily expect a fall in the first few months.
"The statistics are interesting but this is a multi-factorial condition and other interventions have to be considered. Something that has been in place for longer, for instance, which improves the management of people at risk and helps reduce heart attacks, is GP screening for high blood pressure and cholesterol."
At this early stage policy and public affairs manager at the British Heart Foundation Ruairi O'Connor takes a similarly cautious view of claims linking the ban to reduced numbers of acute cardiac episodes. However, he acknowledges that there are reasons to be cheerful.
"The small studies to date give us cause for optimism that the legislation is doing what the government's scientific committee said it would do - reduce levels of heart disease. What particularly impresses us though is how well the ban was organised and implemented," he says. "A good awareness campaign prepared the general public and was supported by investment and information on smoking cessation services. Small businesses also had plenty of time and material to help them effectively enforce the ban on the ground. Compliance is high, enforcement low and [being] 'smoke free' has been normalised."
Some critics of the ban argued the risks from passive smoking were small and difficult to measure, that legislation covering all public places was like using a sledgehammer to crack a walnut and that it could drive people to smoking at home in front of children.
"The risks are small but certainly measurable and with a high enough degree of scientific credibility to survive a number of legal test cases in which people injured through breathing other people's smoke have successfully fought cases against the tobacco industry," says Association of Directors of Public Health president Tim Crayford.
He adds that this places a legal imperative on employers to protect workers by not putting them in a situation they know could be injurious - precisely the argument for introducing the ban and why it was a good public health measure.
While, like others, Dr Crayford reserves judgement on some of the associations being made between implementing "smoke free" and reductions in heart attacks, he applauds Harry Burns, the chief medical officer for Scotland and his desire for a Caledonia free of lung cancer.
"If we want to deal with the major health problems of the day, we need the vision of people like Dr Burns," he says. "To return to the days before cigarettes when lung cancer was a rarity, how great that would be."
As the prevalence of smoking decreases, it is likely to become increasingly socially unacceptable. California is an example of the long-term benefits for health when tobacco use becomes less common. Although it was the US state's 1988 introduction of higher taxes rather than a public smoking ban that prompted large numbers of people to quit, between then and 1997, lung cancer rates fell by 14 per cent - a drop roughly five times bigger than that seen in other cities undergoing similar epidemiological surveillance.
"In some ways, because of the chronic nature of lung cancer and coronary heart disease, we won't really be finding out about the health impact of the English ban for 20 or 30 years," says Andy McEwen, programme director for the 2008 UK National Smoking Cessation Conference.
"The public has been willing to accept it, however, and there have been no problems with compliance. The effect is that smoking becomes less acceptable and harder to do. As such a high-profile public policy event, it also creates an environment in which it is easier to bring in further tobacco control measures, such as those being considered in the [ongoing] Department of Health consultation paper [on tobacco control]."
The measures Mr McEwen refers to include controlling the display of tobacco in retail environments and putting it in plain packaging, limiting young people's access to tobacco and putting a stop to tobacco and cigarette smuggling. The moves could stop the sale of packs of 10 (often known as "kiddie packs") and introduce a ban on vending machines.
Support for such measures is thought to be strong. An ASH survey, Nor Shall My Sword Sleep In My Hand, conducted when the English ban was implemented and published in April, showed not only that there was a strong degree of support across Wales, Scotland and England for smoke-free workplace legislation, but that three out of four respondents supported further measures.
Moves that met with approval included graphic pictures of the effects of smoking on packaging, a crackdown on the illicit trade in tobacco and easier access to smoking cessation tools such as nicotine gums and patches.
"The government was very nervous about appearing to be too paternalistic," says ASH director Deborah Arnott.
"But what the big campaign for smoke-free legislation told us is the public are willing to get behind public health measures that actually support people. The large majority of adults, smokers and non-smokers alike, will support those new measures."
Stop smoking timeline
1998 The role of secondhand smoke in the death of hundreds of people a year from lung cancer is acknowledged in the white paper Smoking Kills, which introduces smoking cessation services and a ban on tobacco advertising but opts for a voluntary approach to smoking regulations in the hospitality sector.
2002-03 The chief medical officer, the British Medical Association and the Royal Colleges of Medicine call for a ban on smoking in public places. A hospitality industry report shows more than half of all pubs do not comply with the voluntary smoking controls code.
2004-05 Government consultation on health includes action to tackle secondhand smoke. An ASH survey shows 80 per cent support smoke-free enclosed workplace legislation. A study published in the BMJ shows one hospitality worker dies each week from workplace smoke. Italy goes workplace smoke free.
2006-07 Labour allows free vote on smoke-free legislation. Public give support to dropping of exemption for private clubs and pubs serving food. Smoke-free legislation passed and introduced in England. Within two weeks of implementation, 97 per cent of premises are compliant. More smokers support law than are against it.
Smoking and health inequalities
The North West of England is only the second region in England after the North East where primary care trusts have agreed to support a collaboratively funded programme to reduce tobacco-related health inequalities. Investment for the programme in 2008-09 will be£1.8m.
"This is very significant in helping us to tackle our number one health priority in terms of its impact on preventable morbidity and reduced life expectancy," says Smokefree North West regional tobacco policy manager Andrea Crossfield. "It is a real recognition that legislation is not job done, but a launch pad for a bolder long-term vision. Lots of people have been coming into stop-smoking services but the PCTs have recognised the need to move further and faster to reduce the inequalities."
The programme sets out to challenge the social norms that accompany smoking in the North West and lead many children and young people who are exposed to tobacco addiction to become smokers themselves.
While smoking rates are around 25 per cent across the whole of England, in many of the region's deprived communities they are much higher.
But in Knowsley, a borough with some of England's starkest health inequalities, more adult smokers quit in one ward between April and December 2007 than anywhere else in the country. Workplace compliance across the region, at 97.8 per cent, is also high.
At the launch of the region's consultation on tobacco control, NHS and local authority leaders committed themselves to a Make Smoking History for our Children campaign.
"We are putting out postcards with the slogan on to promote the campaign and are aiming for 50,000 public responses," says Ms Crossfield.