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CHAPTER FIVE RESEARCH FINDINGS: TOBACCO CONTROL POLICY

Summary

ASH Scotland appears to have robust business and strategic planning processes in place. The organisation was involved and made a contribution across all the key action point areas of the Scottish Tobacco Action Plan "A Breath of Fresh Air for Scotland". It continues to work and campaign using a number of bodies, partnership and alliances. The stakeholder survey revealed some reservations about the smoking cessation training which should be explored and resolved.

Introduction

5.1 This chapter summarises ASH Scotland's approach to strategic planning and reviews ASH Scotland's contribution to the development of "A Breath of Fresh Air for Scotland" (Scottish Executive, 2004), the Scottish Tobacco Action Plan, and its implementation. This includes an analysis of stakeholder views on ASH Scotland's role in the passage of the SHSC (Scotland) Act, a focus on the shift in public opinion, the Scottish Parliament's Cross Party Group on Tobacco Control, stakeholder feedback on partnerships and alliances and training standards for smoking cessation training.

Strategic planning processes

5.2 ASH Scotland appears to have robust business and strategic planning processes. The development of the 2007-10 Strategic Plan involved a structured process with support from an external consultant. It included workshops with ASH Scotland staff and Board members. The Strategic Plans of ASH Scotland are wholly aligned to the mission of the organisation.

5.3 Measures of success are prepared by the Senior Management Team for each priority action and presented to the Board. The Board exercises scrutiny to ensure that these attempt to measure impact rather than activity ²⁰. The Board is periodically updated on progress according to these measures.

5.4 In anticipation of the outcome of the External Review of ASH Scotland commissioned by the Scottish Government, and because of the Chief Executive's announcement of her departure from the organisation, ASH Scotland had not yet finalised its Strategic Plan for 2007-10 at the point when this review was completed. This was an update and roll forward of the current strategic plan and the delay did not impede ASH Scotland's day to day operations.

ASH Scotland's contribution to the Tobacco Control Action Plan "A Breath of Fresh Air for Scotland" (Scottish Executive, 2004)

5.5 The Scottish Government in its brief for this review asked the review team to pay particular attention to ASH Scotland's contribution to the Tobacco Control Action Plan referred to above. It is important to note here, therefore, the key action points contained therein. These are taken directly from the plan and are contained in full in Annex 7.

5.6 In short, they cover the following areas:

• The approach - introducing the Ministerial Working Group
• Prevention and education - in particular in relation to young people
• Provision of smoking cessation services - funding made available and PATH highlighted to develop the evidence base for effective cessation & development of baseline measures and outcome measures
• Second-hand smoke (passive smoking) - introducing public debate in 2004, a national advertising campaign with partners, challenging employers, trade unions, voluntary groups etc to encourage and support the introduction of effective smoking policies by all employers; ASH Scotland to be involved in the development of guidance for NHS Boards and local authorities to review smoking policies
• Protection and controls - work on test purchasing arrangements, illegal sales, tobacco advertising and promotion, point of sale, distribution, pack design etc, and liaison with UK Government on tobacco control
• Measuring progress - NHS broad-based programme of tobacco control action, targets on smoking rate reduction and measurement of performance against these targets

5.7 The following table drawn up for the purposes of the review matches ASH Scotland activity against the Tobacco Action Plan's key actions.

Table 5-1 ASH Scotland and the Tobacco Action Plan

Achieving a shift in public opinion

5.8 ASH Scotland's Strategic Plan 2004-09 sets as an objective the achievement of "widespread public support for a ban on smoking in public places" ( ASH Scotland, 2004) ²¹.

5.9 To set a backdrop to this section, some of the facts in respect of public opinion are contained in Annex 8.

5.10 ASH Scotland's contribution to a shift in opinion is examined in following section.

ASH Scotland's contribution to shifting public opinion - findings from stakeholder survey

5.11 Whilst it is not possible to be definitive about the extent of ASH Scotland's role in shifting public opinion in favour of a ban, stakeholders had much to say about its role. Those interviewed held a spectrum of views, but the majority felt that ASH Scotland had made a contribution to taking public opinion in the direction of the need for legislation and away from voluntary options. Some felt that this was ASH Scotland's critical role, including stakeholders from Scottish Government, Public Health and the voluntary sector. ASH Scotland stakeholders themselves see this as one of the major contributions.

5.12 A public health stakeholder reflected "Their major success was maintaining themselves apart from Government but playing a significant role in changing public opinion".

5.13 One Scottish Government stakeholder stated: "We would have got the legislation without ASH Scotland, but their crucial role was in shifting public opinion".

5.14 Another, from the charitable sector, believed that: "[During the consultation period] ASH Scotland were a constant, providing … sensible information and advice when there was a lot of misinformation".

5.15 A further stakeholder from the public health sector added:

"The message ASH Scotland put across was simple and consistent and, importantly ensured that the range of people who could influence opinion were transmitting the same message. With their co-ordination and leadership, we were all singing from the same song sheet."

5.16 One stakeholder who had been in the public health sector for many years, highlighted ASH Scotland's impact on public opinion on smoking by comparing the shift in respect of smoking and health to that in relation to obesity and health. They were of the view that ASH Scotland had had a significant impact on the level of public acceptance of the harm caused by smoking and secondary smoking, an acceptance which has not yet been achieved about obesity in Scotland.

5.17 The implementation of the legislation means it is unlikely that this kind of extensive work on shifting public opinion will be so central to the future work of ASH Scotland. Nevertheless, many stakeholders have pointed out that the public work on tobacco has not yet come to an end and ASH Scotland should endeavour to maintain its profile and presence with the public, even if this is with a change of direction to meet new circumstances, especially addressing the hardest to reach groups. It was also noted by one stakeholder that figures for Ireland showed a drop in the numbers of people smoking in the early period after the ban but have started to rise again since. This clearly illustrates that there is work on tobacco control still to do after legislation.

Case Study - Smoking, Health and Social Care (Scotland) Act 2005

5.18 As a result of the significance of the potential health gain of the SHSC Act 2005 and the fact that Scotland was the first part of the UK to achieve a ban on smoking in enclosed public places, it was felt useful to analyse the views of stakeholders in the "political" category on the extent of ASH Scotland's contribution to the legislation reaching the statute book as part of this review of ASH Scotland's effectiveness. Elsewhere, the Review report considers the potential economic impact of the health gain impact of the legislation.

5.19 What we cannot do with any certainty is state what would have happened without ASH Scotland's interventions. It seems likely that some form of ban on smoking in some public places would have been taken forward and it may be that the current position would have been achieved eventually. A strong case can be made for the influence of the Scottish legislation on the scope of the Westminster legislation and this was cited by several stakeholders.

5.20 The Scottish legislation was produced by a complex interaction of different factors, including UK and international drivers as well as the part played by a range of domestic players. Some stakeholders expressed a view on the root cause of the achievement of the SHSC Act 2005, often reflecting their own professional or geographical setting, or particular experience. These explanations of "the key" were not consistent and it is not possible to draw a definitive conclusion on the ultimate responsibility.

5.21 We can however state that all stakeholders acknowledged that ASH Scotland played a significant role. Some singled ASH Scotland out for particular mention; others added riders about other players, on occasion citing them as more important. The detail of the case study is contained in the table below (Table 5-2).

Table 5-2 The contribution of ASH Scotland to the achievement of the Smoking, Health and Social Care (Scotland) Act 2005 - an analysis of views expressed by political stakeholders ^vi

Cross Party Group

5.22 One mechanism whereby ASH Scotland can engage with MSPs outwith normal parliamentary business is through the Cross Party Group ( CPG).

5.23 The CPG on Tobacco Control was set up in December 1999 upon the initiative of the Scottish Cancer Coalition on Tobacco. Its purpose was "to take forward an effective tobacco control agenda and monitor the implementation of the UK White Paper on tobacco, 'Smoking Kills', in Scotland" ²². It is the practice with the majority of CPGs that a voluntary organisation or charitable group provides the secretariat ²³ and ASH Scotland does this for the Tobacco Control CPG. It was very strongly praised by one political stakeholder for the standard of service it provides, which was described as "exemplary".

5.24 Those political stakeholders who commented, regarded ASH Scotland as making good and appropriate use of the CPG. ASH Scotland acknowledges that it is for the MSPs to

determine the direction of development of the CPG and its programme of activities and topics for discussion. The organisation regards it as a very useful route for highlighting issues to MSPs, or for MSPs to approach ASH Scotland for information e.g. to support the development of a Private Member's Bill. ^viii

Feedback from stakeholders regarding other partnerships/alliances

5.25 Feedback on ASH Scotland's partnership/alliance work was received from stakeholders interviewed as part of the stakeholder survey.

5.26 A stakeholder from the charity sector said the following of the Cross Party Group on Tobacco Control: " The intention to bring together a wide group of parties was very much based on the idea of creating consensus and drive and that we found very helpful".

5.27 Another charity stakeholder, who had been a participant in SCCOT, was of the view that:

"One of the major successes in my view is pulling together the coalition. All four [charities] were saying the same thing individually, but it was easier for people to hear the message when we said it together."

5.28 An academic stakeholder, with long experience of ASH Scotland's work, commented generally on their role in partnership working: "They are key: they are hugely influential in bringing people together".

5.29 One public health stakeholder was keen to highlight the importance of SCOT as an alliance.

"I belong to the SCOT - it brings together public health and the big charities, eg the British Heart Foundation and this is one group I hope would continue in ASH Scotland. It gets to a wider church. Every four years we produce a manifesto and the last one was just before the elections in 2007. It is clear and precise, especially for politicians and was very well received."

5.30 The feedback would suggest that ASH Scotland should maintain its partnership/alliance work as a priority and that it should continue to address the areas of weakness reported in the STCA survey. The future of the organisation may require refocusing that work but it is, undoubtedly, greatly appreciated.

Training standards for smoking cessation training

5.31 The training and development function of ASH Scotland work lies with PATH. PATH's training and development objectives are:

• to promote best practice through evidence-based training
• to increase the quality and consistency of tobacco-related training in Scotland
• to broaden the range and scope of tobacco-related training in order to increase the number of people trained in tobacco issues
• to ensure that everyone who needs tobacco-related training has equal opportunity to access it
• to enhance the professional standing of the smoking cessation specialism, through developing validation and accreditation systems

5.32 To deliver on those objectives PATH has:

• developed standards for smoking cessation training in Scotland
• developed a strategy for smoking cessation training in Scotland
• set up an approval scheme for training that is in line with the standards
• developed accredited training modules in smoking cessation in partnership with Glasgow Caledonian University

5.33 The stakeholders interviewed recognised the importance of the development of standards for smoking cessation training and gaining accreditation for that training, saying, for instance:

"There were no standards for training. Everyone was delivering cessation in a different way."

"The delivery needed to be consistent. It shouldn't matter where people are or what type of professional it is, you should get the same service."

5.34 Some key stakeholders had strong views about the training and these included strong reservations. A reflection of these views is as follows:

• it doesn't currently meet the needs of all health boards, some of which have been doing their own training for a considerable time and it is too complicated to get accreditation for prior learning
• it is too time-consuming - one stakeholder said it could take up to two years to complete the three modules
• the health boards are still sending staff to London for training because they can do the same course in two days or they are bringing London-based trainers to Scotland which is very costly
• communication between PATH trainers and the health boards has room for improvement

5.35 It was suggested by stakeholders that a short term training development group to look at the future could well resolve these issues in order that the training better meets the needs of all health boards and other deliverers of smoking cessation services. ASH Scotland reports that the above issues have been identified by the training team and actions are in place to resolve them.

Conclusion

5.36 The review team found evidence of ASH Scotland's activity and achievement across all the key action point areas of the Tobacco Action Plan. All political stakeholders surveyed credited ASH Scotland with an important role in the passing of the SHSC (Scotland) Act 2005.

5.37 There was considerable dissatisfaction voiced by some stakeholders about the smoking cessation training. ASH Scotland has remedial actions in place to deal with the issues which were raised.

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