An Endgame Strategy for Scotland

Professor Amanda Amos

Tobacco endgames

Chess- towards the end

of the game when fewer

pieces are on the board,

need to change tactics to win

Seeking to end the tobacco epidemic not control it

Countries setting tobacco-free targets

Goes beyond ‘business as usual’- requires

thinking outside the box

But not neglecting current action that is effective

Scottish adult smoking trends (NHS Health Scotland 2017)

Conclusions (1)

The current strategy has been effective in

reducing smoking but the current rate of

decline will not achieve the 2034 target

Endgame strategy- need to be more effective

in reducing smoking in lower socio-economic

groups

Focus- Prevention? Cessation? Both?

Prevention and/or cessation? (ASH Scotland 2017)

ASH Scotland (2017)

Conclusions (2)

Need to sustain declines in youth smoking

But 2034 target will only be achieved through

increased adult cessation rates

What further action is needed and/or likely to

achieve this?

CRUK Endgame Thinking Report (2014)

Synopsis of Endgame Strategies

Tobacco Control paper (2015)

Framework:

Product

Users

Market/supply

Structural/regulation

Integrated- all four approaches

9

Focus Proposal Current examples

(considering)

Product 1. Make cigarettes less addictive (e.g. mandate nicotine

reductions)

(US FDA)

2. Redesign cigarettes to make them less appealing (e.g.

remove filters)

Flavours ban-TPD

3. Popularise e-cigarettes as an alternative to cigarettes English Tobacco Control

Plan 2017

Users 4. Introduce a smoker’s licence

5. Require prescriptions for purchasing tobacco

6. Incrementally increase age of purchase, creating

‘tobacco free generations’ never able to legally

purchase tobacco.

Five US states (21 yrs)

(Tasmania)

Market 7. Restrict retail availability (e.g. retail licensing) Sales near schools-

Hungary

8. Ban combustible tobacco products Bhutan

9. Make cleaner nicotine products easier to purchase

(e.g. via price or availability) than combustibles

10. Gradually restrict tobacco products manufactured and

imported into country, reducing over time (‘sinking lid’)

11. Use price caps to reduce tobacco manufacturers’

profits

Minimum price- 24 US

States (Scotland)

(Polluter pays- ASH London)

Structural 12. Create a new tobacco control agency

13. Create a regulated market

14. State takeover of tobacco companies

15. Introduce a performance-based regulation system

Integrated endgame strategies (e.g. mix some of above proposals)

Summary of proposals identified in 2015 review and current examples

Dissuasive cigarettes

(Moodie 2017)

Focus Proposal Current examples

(considering)

Product 1. Make cigarettes less addictive (e.g. mandate nicotine

reductions)

(US FDA)

2. Redesign cigarettes to make them less appealing (e.g.

remove filters)

Flavours ban-TPD

3. Popularise e-cigarettes as an alternative to cigarettes English Tobacco Control

Plan 2017

Users 4. Introduce a smoker’s licence

5. Require prescriptions for purchasing tobacco

6. Incrementally increase age of purchase, creating

‘tobacco free generations’ never able to legally

purchase tobacco.

Five US states (21 yrs)

(Tasmania)

Market 7. Restrict retail availability (e.g. retail licensing) Sales near schools-

Hungary

8. Ban combustible tobacco products Bhutan

9. Make cleaner nicotine products easier to purchase

(e.g. via price or availability) than combustibles

10. Gradually restrict tobacco products manufactured and

imported into country, reducing over time (‘sinking lid’)

11. Use price caps to reduce tobacco manufacturers’

profits

Minimum price- 24 US

States (Scotland)

(Polluter pays- ASH London)

Structural 12. Create a new tobacco control agency

13. Create a regulated market

14. State takeover of tobacco companies

15. Introduce a performance-based regulation system

Integrated endgame strategies (e.g. mix some of above proposals)

Summary of proposals identified in 2015 review and current examples

Strategic approach Evidence on and modelling of the potential impact of

different strategies-

whole population

disadvantaged groups

Identify near term and longer term goals/strategies

UK and/or Scottish Government

Feasibility :

Political will and support for different strategies

Public support for different strategies

Tobacco control community consensus and support for

different strategies

Ethical approach- engagement with people and

communities most affected, unintended consequences

Evidence on potential impact of different

strategies- New Zealand 2025 (van der Deen et al TC 2017)

Five endgame strategies:

Annual tobacco increases (10%)

Tobacco Free Generation (TGF) strategy- all born after

1993 not allowed to buy tobacco ie uptake 0% from 2011

Sinking lid on tobacco supply- annual reductions in

imports until zero in 2025

Tobacco outlet reduction strategy- licencing and reducing

outlets over time, starting in most populated areas

Combined endgame strategy- tax + TGF+ outlet reduction

Projections of adult daily smoking for Māori (a) and non-Māori (b) under BAU and five endgame strategies.

Conclusions

Selected endgame strategies could accelerate

progress towards reducing smoking to minimum

level and further reduce absolute inequalities in

ethnic smoking

But none apart from sinking lid could achieve

goal by 2025

All achieved health gains and costs savings to

the health system, particularly for Maori

Did not model anything on e-cigarettes as

currently illegal to sell in New Zealand

Tobacco Control for England (2017)- an

endgame approach?

‘Our vision is nothing less than to create a

smokefree generation. To do this we need to

shift emphasis from action at the national level

– legislation and mandation of services to

focused, local action, supporting smokers,

particularly in disadvantaged groups, to quit.’

Tobacco Control for England (2017)- an

endgame approach?

Government/national- review under-age sale

sanctions, tax (high duty rates), PHE mass media

(Stoptober e-cig safety), illicit, 5.3

NHS- cessation training, pregnancy, mental health

patients, acute services, smokefree NHS by 2020

Local/local authority- cessation, pregnancy,

inequalities, local TC strategies

Harm reduction- evidence on nicotine delivery

products, possible de-regulatory measures (eg TPD

and e-cigs) post Brexit

Can Scotland create a more ambitious

endgame strategy in 2018? Product-

Dissuasive cigarettes

Alternative ‘clean’ nicotine products/reduce nicotine

Users-

Increase age of sale to 21

Mass media/social marketing campaigns- cessation, policy support

Incentives to stop smoking

Inclusive engagement (cf Youth Commission)

Market/supply –

Reduce retail outlets- start around schools (cf alcohol)

Make selling tobacco less profitable - licence including minimum

price, polluter pays

Hypothecated tax for health promotion- eg Scottish public health levy

Structural/regulation

But also…..

Maintain current tobacco control activities

Build and sustain alliances

Action on wider social determinants and

inequalities

Research to build evidence, monitor and

evaluate

Never forget the tobacco industry!!

Philip Morris Pledges $1 Billion

to Fight Smoking

(September 2018)

Acknowledgements

GRIT

ASH Scotland

Garth Reid

Crawford Moodie

CRUK

Over to you!