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Health in Scotland 2003

CHAPTER 2 SMOKING

The toll of tobacco: the real cost of tobacco in Scotland

Smoking is the single biggest cause of preventable premature death and ill-health in Scotland. It is estimated that thirteen thousand Scots die every year from smoking-related illness and it accounts for 35,000 hospital admissions, costing NHSScotland an estimated 200 million. Smoking is linked to diseases of the heart and blood vessels, the lungs, stomach, kidneys and other organs. Avoidance of smoking would eliminate one-third of cancer deaths and one-sixth of deaths from other causes, including chronic respiratory diseases, heart disease and strokes. Many of these are premature deaths: the average male smoker aged 35 loses seven years of life expectancy and one in two smokers will die of a smoking-related disease.

There are an estimated 1.2 million smokers in Scotland. Although there has been a slight decrease in smoking prevalence in Scotland in recent years (with 33% of men and 29% of women smoking cigarettes) smoking rates are still well above the UK average of 26%.

There is a strong social class gradient in the prevalence of cigarette smoking, with those in the unskilled and manual social groups being much more likely to smoke than those in professional groups. Men and women living in the most deprived areas are more than twice as likely to smoke compared with those in the most affluent areas. Unskilled or manual class groups also smoke more cigarettes a day than those in higher socio-economic groups. Worryingly, smoking rates are highest amongst single mothers, with over 60% beginning their pregnancies as smokers.

Passive smoking

There is increasing evidence of the health risks associated with second-hand tobacco smoke, which is also known as environmental tobacco smoke (ETS) or passive smoking. Some of the immediate effects of second-hand tobacco smoke include eye irritation, headache, cough, sore throat, dizziness and nausea. Adults with asthma can experience significant decline in lung function when exposed, while new cases of asthma may be induced in children whose parents smoke. Short-term exposure to tobacco smoke also has a measurable effect on the heart of non-smokers: just 30 minutes' exposure is enough to reduce coronary blood flow.

In the longer-term, passive smokers suffer an increased risk of a range of smoking-related diseases. Those exposed to second-hand tobacco smoke in the home have a 25% increased risk of heart disease and lung cancer. A major review by the UK Scientific Committee on Tobacco and Health (SCOTH) concluded that second-hand tobacco smoke is a cause of lung cancer and ischaemic heart disease in adult non-smokers.

Risks to children

Almost half the children living in the UK are exposed to tobacco smoke at home. Second-hand smoking increases the risk of lower respiratory tract infections such as bronchitis, pneumonia and bronchiolitis in children. One study found that, in homes where both parents smoke, young children have a 72% increased risk of respiratory illness. Passive smoking causes a reduction in lung function, increases the severity of the symptoms of asthma in children and is a risk factor for new cases of asthma in children. Passive smoking is also associated with middle ear infection as well as possible cardiovascular impairment and behavioural problems.

Despite the recognised toll of tobacco-related disease and disability, it is relatively unusual for doctors to mention smoking as a contributory cause of death when completing death certificates. For example, over the period 2000 to 2002 smoking was mentioned on only 800 Scottish death certificates. In 187 of these cases the underlying cause of death was lung cancer but over the same period there were almost 12,000 deaths from lung cancer. As it is generally accepted that at least 80% of lung cancer deaths are smoking-related, it is clear that counting the number of references to smoking on death certificates is of limited value.

Various researchers in different countries have attempted to get over this problem by applying 'aetiological fractions' to the numbers dying from a range of causes of death, e.g. 80% of lung cancer deaths, 20% of coronary heart disease etc., to arrive at a total of smoking-related deaths. However, there is no standard methodology for such an approach and it is certain that the fractions will differ by age and gender and will change over time.

In answer to parliamentary questions on this subject, the General Register Office for Scotland (GROS) have usually provided information on the total number of deaths from a limited range of diseases known to be associated with smoking. Table 2.1 shows the numbers of deaths and the death rates per 100,000 population from these diseases over the period 1980 to 2002.

Table 2.1: Deaths from selected causes, Scotland

Some points to note include:

• the significant fall for both sexes in mortality from Coronary Heart Disease. However, as the numbers are still high, a smoking fraction of, say, 20% would still give rise to a large number of smoking-related deaths

• the falling male rates for cancer of the trachea, bronchus and lung and for respiratory diseases, contrasting with the rising female rates for the same causes

• the rising rates for male cancer of the larynx, lip, oral cavity, pharynx and oesophagus.

Figures 2.1 and 2.2 show age specific rates for cancer of the trachea, bronchus and lung for males and females respectively. For men the rates have generally been decreasing for the age groups shown. However, while the rates for women under 65 have been relatively stable, those for women aged 65 to 74 have increased significantly, almost to the same level as for men.

Figure 2.1: Deaths from malignant neoplasm of trachea, bronchus and lung, Scotland, 1980-2002. Age specific mortality rates per 100,000 population, Males

Figure 2.2: Deaths from malignant neoplasm of trachea, bronchus and lung, Scotland, 1980-2002. Age specific mortality rates per 100,000 population, Females

Figures 2.3 and 2.4 show similar patterns for bronchitis, emphysema and other chronic obstructive pulmonary disease. It is believed that these patterns reflect the later uptake of smoking by women during the 20th century.

Figure 2.3: Deaths from bronchitis, emphysema and other chronic obstructive pulmonary disease, Scotland, 1980-2002. Age specific mortality rates per 100,000 population, Males

Figure 2.4: Deaths from bronchitis, emphysema and other chronic obstructive pulmonary disease, Scotland, 1980-2002. Age specific mortality rates per 100,000 population, Females

Since the publication of the White Paper Smoking Kills in 1998, there has been a major expansion in smoking cessation services. All Scottish NHS Boards now provide smoking cessation services. Nicotine replacement therapy and bupropion are available on prescription. Although most adult smokers (70%) say that they would like to give up smoking, each year only 2% of smokers who try succeed by will-power alone.

There are several interventions which can increase quit rates. These range from low intensity support, such as telephone helplines and self-help materials, to more intensive interventions including individual and group counselling. In general the more intensive the intervention, the greater the increase in quit rate over will-power alone. In recognition of the clear health benefits of giving up smoking, Scottish Ministers announced an additional 1 million for this year and the following year and an additional 4 million in 2005/06 in order to enable NHS Boards to expand the provision of smoking cessation services.

However, the expansion of cessation services should not be seen as a matter of numbers alone. The Executive aims to ensure that the services on offer are of a high quality and produce long-term results. Consequently, the Executive's Partnership on Tobacco and Health (PATH), launched in June 2002, was specifically set up to support smoking cessation activity through gathering and disseminating evidence of best practice and through development of training standards. This work includes the management of a 900,000 fund over three years to support 11 innovative projects aimed at improving understanding about how to help different types of people to quit.

Tobacco action plan

One of the commitments in Improving Health in Scotland: the Challenge was to review tobacco control policies, in conjunction with key interests. The Executive invited NHS Health Scotland and ASH Scotland to undertake a detailed review of tobacco control policy which would build on the progress made to date. The resultant report, Reducing Smoking and Tobacco-Related Harm: a key to transforming Scotland's Health, provided a platform for the Executive's Tobacco Action Plan, launched early in 2004, A Breath of Fresh Air for Scotland, Improving Scotland's Health: The Challenge-Tobacco Control Action Plan. This is the first specific tobacco strategy for Scotland. It sets out a list of future actions on smoking prevention, provision of cessation services, protection from second-hand smoke and legislative controls on tobacco.

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