Smoke-free Scotland - Guidance on smoking policies for the NHS, local authorities and care service providers

Appendix 2 The health and economic case for becoming smoke-free

The risks to health associated with smoking and tobacco smoke are clear and irrefutable. The Scottish smoke-free legislation addresses these risks in a direct and beneficial way. There is also, however, a strong economic case for going smoke-free, particularly for those involved in the care and treatment of those who are affected by tobacco-related diseases.

This section provides an overview of the health and economic case for going smoke-free.

What is passive smoking?

Passive smoking means breathing in other people's tobacco smoke. This smoke is often called environmental tobacco smoke ( ETS) or second-hand smoke ( SHS). It is made up of 'sidestream' and 'mainstream' smoke. Sidestream smoke comes from the burning tip of the cigarette and is the major component of SHS. Mainstream smoke is the smoke that is exhaled by the smoker.

What's in tobacco smoke?

Tobacco smoke contains over 4000 chemicals either in the form of particles or gases. Particles include tar, nicotine, benzene and benzo(a)pyrene. Some of these chemicals have marked irritant properties and 60 of them are known or suspected carcinogens (cancer causing substances). The gases include carbon monoxide, ammonia, dimethylnitrosamine, formaldehyde, hydrogen cyanide and acrolein ²⁸.

There is no safe level of exposure to second-hand smoke.

Health risks from passive smoking

SHS has been labelled 'carcinogenic to humans' by the World Health Organisation's International Agency for Research on Cancer ¹⁵. It has also been labelled a 'class A human carcinogen' by the US Environmental Protection Agency, along with asbestos, arsenic, benzene and radon gas ²⁹. The Scientific Committee on Tobacco and Health ( SCOTH) reviewed the evidence on passive smoking in 2004 and confirmed that second-hand smoke represents a substantial public health hazard and that no infant, child or adult should be exposed to it ¹⁶.

Every year up to 1,000 lifelong non-smokers die in Scotland, as a result of exposure to second-hand smoke. Taking ex-smokers into account, it is estimated that this figure rises to between 1,500 and 2,000 deaths and represents a significant public health hazard ¹⁷.

SCOTH also reported that exposure to second-hand smoke is a cause of lung cancer and, in those non-smokers facing long-term exposure, there is an increased risk of 20-30% and that exposure to second-hand smoke is a cause of heart disease, with an increased risk for non-smokers of about 25% ³⁰⁾⁽¹⁶.

Exposure can also reduce lung function and coronary blood flow, irritate eyes, and cause headaches, coughs, sore throats, dizziness and nausea, as well as many other illnesses. It can trigger asthma attacks and cause serious respiratory illnesses, asthma and ear infections in children ¹⁴.

Exposure to second-hand smoke in pregnancy can lead to poor gestational growth, and low birth weight. Low birth weight is linked to neonatal mortality and complications in the health and future development of the child ^31)(32)(33.

The health and economic impact of going smoke-free

The major reference for this section is the International Review of the Health and Economic Impact of the Regulation of Smoking in Public Places, which was carried out by the Health Economic Research Unit ( HERU), Department of Public Health, University of Aberdeen, in 2004 ²⁰.

This Scottish Executive funded study was commissioned by NHS Health Scotland to provide a review of the latest evidence of the impact of smoke-free legislation and restrictions. The study combined a literature review with a modelling exercise to determine the likely impacts of regulation on smoking in public places in a Scottish context. As the study was not intended to be a full cost-benefit analysis, it did not look at implementation costs, compliance costs or the costs of any legislative process.

Based on the available literature, the study considered a range of impacts from restrictions on smoking:

• Reduced exposure to SHS in the workplace
• Reduction in smoking/increase in quit attempts by active smokers
• Reduction in number of deaths from major disease types
• Reduced costs of treating smoking related diseases
• Economic impacts on the hospitality sector.

The HERU study found strong evidence that exposure to SHS increases mortality and morbidity from lung cancer and coronary heart disease. There is also weaker evidence of an effect in relation to stroke and respiratory diseases. These results were found to hold true even after taking account of possible confounding factors and other potential sources of bias.

The HERU study reported on a US review that identified 17 studies of the effect of smoking restrictions / bans on exposure to SHS. These studies showed a reduction in exposure to SHS from both restrictions and bans, but an important distinction could be made, namely that the greatest reductions in exposure resulted from complete bans rather than partial restrictions. Though the studies covered a narrow range of workplaces, this was not expected to bias the results.

The study reviewed a large number of studies on the impact of smoking restrictions on cigarette consumption and smoking prevalence. Studies of the impact on smoking prevalence provided a wide range of estimates. This range may in part be due to the fact that smoking restrictions studied were in many cases accompanied by other smoking cessation interventions. The HERU study used a conservative central estimate (2% reduction) of the impact on smoking prevalence of smoke-free policies.

As with reduction in exposure, the HERU study found that while bans and restrictions were associated with reductions in smoking and increases in quit attempts by smokers, greater reductions in active smoking were associated with smoke-free policies than with partial restrictions. The study concluded that health gains in Scotland from reductions in active smoking may be at least as great as those from reduced passive smoking.

On the basis of available estimates, the HERU study forecast that a complete ban in Scotland would result in 219 deaths per year being averted from reduced incidence of lung cancer and CHD associated with exposure to SHS. Based on 13,000 deaths from smoking related diseases in Scotland per annum, reductions in active smoking were estimated to lead to a further 260 deaths per year being averted due to reduced incidence of lung cancer and CHD. These figures represent the best central estimate of lives saved after 20 years, with lives saved increasing in a straight line from zero to 219/260 over this period. Over the 30 year forecast period chosen by HERU, 4,490 lives would be saved from reduced exposure to SHS and 5,330 lives would be saved through reductions in active smoking. Furthermore, these figures represent a conservative estimate, as only reduced deaths from lung cancer and CHD were included, and not reduced deaths from a variety of other disease types.

The HERU study converted lives saved into an economic impact based on studies of the value of life produced by the Department of Transport. The latest estimate provided by the Department of Transport for the value of a life is £1,249,150 (2002 prices). HERU adjusted this figure to account for the fact that deaths from smoking-related illnesses typically occur at a later age than road traffic accident fatalities. This gave a value per life saved of between £300k and £500k depending on disease type.

The economic impacts of restrictions on smoking in public places were considered. The literature considered by the HERU study suggested that overall there would be productivity gains from reduced smoking breaks, though whether any individual business gained or lost from the introduction of a complete ban would depend on the extant smoking policy for those premises. The study also derived estimated cost savings from reduced absenteeism due to reduced passive and active smoking, reduced fire hazards associated with a ban on smoking and reduced cleaning and decorating costs.

The HERU study gave separate consideration to the effect of smoking restrictions on the hospitality sector. Hospitality sector impacts were considered in terms of the impact on trade and split into impacts on restaurants, bars and hotels/tourism. Evidence from studies on the impact on hospitality sector was not as robust as the evidence available on health effects. In general it was found that studies had failed to find any statistically significant results. However, where evidence was available the results of the studies were reasonably consistent. The impact on the hospitality sector was calculated with reference to these studies and this figure was adjusted to account for expected offsetting expenditure elsewhere in the economy. This gave a net annual impact on the hospitality sector which was used in estimating the overall economic impact of a smoking ban.

As part of the HERU study, a model of the overall economic impact of a smoking ban in Scotland was constructed. The model was based on the evidence obtained on the various types of impact resulting from the smoking ban, as set out above. For each type of impact, for which a monetary value could be established the study projected the future value of costs and benefits in each year over a 30 year appraisal period. Future values of costs or benefits were then discounted to give net present values ( NPVs).

An economic value was placed on the following impacts of the smoking bill ( NPV (£m) of central estimate in brackets):

1. Health Benefits

• The Economic Value of Lives Saved: a) as a result of reduced exposure to ETS (1024) and; b) as a result of reduced levels of active smoking (1216)
• Savings in the human cost of ill health (morbidity savings) as a result of reduced exposure to ETS (144). (Savings in the human cost of ill health, aka morbidity savings, as a result of reduced levels of active smoking were not valued)

2. Resource Savings

• Reduced NHS Treatment Costs: a) as a result of reduced exposure to ETS (60) and; b) as a result of reduced levels of active smoking (31)
• Reduced Sickness Absence Savings: a) as a result of reduced exposure to ETS (46) and; b) as a result of reduced levels of active smoking (9)
• Productivity gains as a result of reduced smoking breaks (1403)
• Cost savings from reduced fire hazards (94)
• Reduced cleaning and decorating costs (222)

3. Hospitality Sector Impacts

• Impact on the hospitality sector (369)

The robustness of the study results was extensively tested by HERU. In addition to the central estimate, 'low' and 'high' scenarios were tested based on much less, and much more, advantageous outcomes of a smoking ban.

The total NPV for the central estimate is +£4,620m. This suggests that the introduction of the smoking ban might be expected to have a significant positive impact in Scotland over a 30 year period. The total NPV for the 'low' and 'high' scenarios were +£55m and +£7,395m.

The HERU report concluded that a negative NPV would only be found "under an unlikely combination of circumstances" and that "under reasonable assumptions the NPV will be positive."

All evidence reports referred to in this section can be accessed at www.clearingtheairscotland.com