Published: 16/12/2004, Volume II4, No. 5936 Page 15

Why are we still arguing about if and how we should get tough on smoking?

Locally, we struggle to persuade people to give up this deadly habit and we have certainly had more than our fair share of publicity around the issue.

The memory of the BBC camera crew in my lounge on a Sunday morning is still vivid (toys carefully stashed behind the sofa).

I still can't believe they were there because we were being harangued for paying health professionals to take on more responsibility for tackling our most pressing public health issue.

Yes, we could all argue that measuring the number of four-week quitters is not the most appropriate measure of long-term benefit.

But can we please stop arguing in public about how to judge whether or not people have stopped and just get on with trying to provide decent services and a clear message?

Let's face it, there are very few things that we have so much evidence about. Smoking is bad for you. It impacts on all ages and its physical effects are not confined to the smoker.

In London it causes 10,500 deaths a year, or just over 200 deaths a week. One hospitality worker dies every week from disease caused by passive smoking.

In 2001, smoking-related diseases accounted for 46,000 admissions, so tackling this problem effectively in active partnership with our local acute trusts will also help us meet shortterm national targets.

Given the evidence, shouldn't it be easy to get this simple message across to the general public?

Depressingly, no.

Turning on the radio on the day the white paper was published, I heard a debate about the plans to ban smoking in places where 'prepared food' was served.

Pre-packaged sandwiches did not constitute 'prepared food', toasted ones did. Pickled eggs in a jar only counted as prepared food if somebody served them to you on plate.

So if you wanted to smoke, you had to serve yourself your own pickled eggs (urgh - imagine the breath! ).

Chatting in the local village pub, I got challenged by non-smokers and smokers who had heard about the proposals in the white paper and could not understand why the government appeared to be mainly concerned about the potential deaths of people working in the food hospitality industry rather than the impact smoking was having on the non-smoking customers and staff in 'drink only' pubs.

Were they second-class citizens?

Why had the government lost the opportunity to do something meaningful? Was the evidence about smoking weaker than we were letting on?

We know that numerous surveys have shown repeatedly that the majority of the public support a ban on smoking in public places. In London last year participants in the Big Smoke debate voted 78 per cent in favour of public places becoming completely smoke-free.

In the white paper, it is clear that the public gave the government the mandate for action to be taken in certain areas to prevent people from doing things that put others at risk.

Smoking fits the bill. But as we know, the white paper backs away from a total ban on smoking in public places and allows exemptions.

Politicians are, of course, very concerned about accusations of running a 'nanny state'.

However, it would be interesting to compare the level of support for a total ban on smoking in public places to the number who want to see the end of hunting with hounds.

Speaking as a supporter of the hunting ban, even I have to ask myself, 'have we really got our priorities right?'

is not the partial smoking ban a clear sign of the power and influence of the major players working to support the smoking lobby?

If we are to deliver the 'fully engaged' public health agenda of government adviser Derek Wanless, then we have to tackle these issues head on.

In both of his reports, Mr Wanless recognised that we have to make radical changes to the way we approach the major public health threats.

Perhaps we should learn about the approach in Australia, California or, closer to home, Scotland, which all have, or will have, more stringent passive smoking measures?

Why did they feel galvanised into taking drastic action? I can't imagine the Australians tolerating a nanny state.

Perhaps it is about bravery, political timing, how you deliver the message and how often you deliver it.

Successful no-smoking cities, working incrementally, have successfully convinced the general public that smoking is not acceptable in public. If the people are with you, then the power of the lobbyists is reduced.

So how do we move on? Even if the politicians have not delivered a total ban on smoking in public in the white paper, please can we have messages in plain English that smoking is bad for you from all.

No one wants a lecture, but we do need to be consistent and clear. No matter how hard it is to give up - smoking kills.

Lise Llewellyn is chief executive of Brent primary care trust and a new regular columnist for HSJ. Her next column will be published on 3 February.

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