6: Influencing Tobacco Control Policy and Practice
Submitting InstitutionUniversity of Edinburgh
Unit of AssessmentSocial Work and Social Policy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
Smoking is the single most important preventable cause of mortality and
inequalities in health in the UK. Tobacco use causes over 100,000 deaths
each year in the UK, with around 10,000 of these due to non-smokers'
exposure to secondhand smoke. The total cost of smoking to society is
estimated to be over £13 billion. The UoE Tobacco Control Research Group's
(TCRG) research and knowledge exchange activities have significantly
influenced tobacco control policy and practice in the UK (http://www.cphs.mvm.ed.ac.uk/groups/tcrg
More specifically, their research on smoking and non-smoking by young
people has influenced smoking prevention and cessation policy at the
national level in Scotland and England and at regional/local levels. Their
evaluation studies of the national smoke-free legislation in Scotland and
England provided important evidence on the legislation's positive public
health impact, thereby undermining the case for repealing or diluting the
legislation. Their research on reducing smoking in the home has influenced
national policy and practice on this issue in Scotland including national
mass media campaigns.
TCRG members (listed below) have undertaken a range of research projects
focusing on improving understanding of the processes involved in smoking
uptake and cessation, and exposure to secondhand smoke in children and
disadvantaged smokers. These studies, which mostly take a
multi-disciplinary mixed methods approach, have advanced understanding of
determinants of smoking uptake, barriers to cessation, reducing exposure
to secondhand smoke and the effectiveness of innovative new approaches to
tackling these issues.
Amanda Amos, Professor of Health Promotion (1985 - present), Stephen
Platt, Professor of Health Policy Research (2005 - present), Sarah
Cunningham-Burley, Professor of Medical and Family Sociology (1990 -
present), Dr Deborah Ritchie, Senior Lecturer in Health Promotion and
Mental Health (1999 - present), Dr Catriona Rooke, Research Fellow (2011-
present), Dr Heide Weishaar, Research Fellow (2013 - present), Dr Gill
Highet, Research Fellow (2007-09), Dr Wendy Gnich, Research Fellow
(2002-06), Dr Richard Phillips, Research Fellow (2006-07).
Young people and smoking
Very few UK studies have assessed the effectiveness of smoking cessation
services or support for young people. TCRG members undertook the first
national study of innovative cessation approaches for young people
(2002-06) (Gnich et al 2008). Qualitative and quantitative methods were
used to evaluate a national programme of eight innovative pilot smoking
cessation projects in Scotland. The evaluation concluded that, while some
approaches had developed constructive ways of engaging with young smokers,
none had been effective in increasing quit rates.
TCRG members subsequently undertook several studies, mostly using
qualitative methods, which have made important contributions to
understanding the determinants of youth smoking. Amos was commissioned by
the Department of Health in 2008 to lead a review on young people and
smoking in England, which was to inform the development of the
Government's tobacco control white paper. This review developed a model
which summarised key determinants of smoking uptake and made
evidence-based recommendations on the most effective policy and practice
interventions in smoking prevention (Amos et al 2009).
Smokefree public places and homes (2002-12)
Scotland introduced comprehensive smokefree legislation banning smoking
in public places in 2006; the following year a similar ban was introduced
in England. These initiatives were described by Ministers as the most
important public health legislation in a generation. TCRG members
undertook three studies as part of the separate national evaluation
programmes in Scotland and England. These evaluations were internationally
unique in using qualitative longitudinal designs to explore the
legislation's impact on disadvantaged groups and in affluent compared to
deprived communities. As part of the Scottish evaluation programme
(CLEAN), they also undertook a qualitative study of the legislation's
impact on smoking in the home. These studies showed that the smokefree
legislation had an important influence on smokers' attitudes and behaviour
within and outside the home. TCRG members are involved in the REFRESH
study which comprises several components, including testing a novel
intervention to help disadvantaged mothers who smoke reduce their child's
exposure to secondhand smoke in the home. 2700 `How to Guides' based upon
the REFRESH findings have been distributed to Health Boards across
References to the research
Gnich W, Sheehy C, Amos A, Bitel M, Platt S (2008) A Scotland-wide pilot
programme of smoking cessation services for young people: process and
outcome evaluation. Addiction 103: 1866-74, DOI:
Phillips R, Amos A, Ritchie D, Cunningham-Burley S, Martin C (2007)
Smoking in the Home After the Smoke-Free Legislation in Scotland:
Qualitative Study. BMJ 335: 553, DOI: 10.1136/bmj.39301.497593.55.
Hargreaves K, Platt S, Amos A, Highet G, Martin C, Ritchie D, White M
(2010) The social context of change in tobacco consumption following the
introduction of 'smokefree' England legislation: a qualitative,
longitudinal study. Social Science and Medicine 71: 459-66, DOI:
Wilson IS, Semple SE, Mills LM, Ritchie D, Shaw A, O'Donnell R, Bonella
P, Turner SW, Amos A (2012) REFRESH: reducing families' exposure to
secondhand smoke in the home — a feasibility study. Tobacco Control,
Amos A, `A Review of Young People and Smoking in England'. Department of
Health (England). 2008-09, £45k.
Platt S, Amos A, et al, `Evaluation of HEBS Young People's Smoking
Cessation Pilots'. Health Education Board for Scotland. 2002-06, £250k.
Amos A, Martin C, Ritchie D, `Qualitative Study of Changes in Smoking
(and Drinking) Behaviour following Implementation of the Prohibition of
Smoking in Enclosed Public Places'. NHS Health Scotland. 2002-08, £145k.
Amos A, Martin C, Ritchie D, Cunningham-Burley S, `Qualitative Study of
Smoking in the Home'. NHS Health Scotland. 2006-07, £100k.
Platt S, Amos A, Ritchie D et al., `Impact of Smokefree Legislation in
England on Individuals and Communities'. Dept of Health (England) through
Public Health Research Consortium. 2007-09, £355k.
ASH Scotland, Semple SE, Ritchie D, Amos A, Turner SW, `Reducing
Children's Exposure to Secondhand Smoke in the Home (REFRESH)'. Big
Lottery Research Fund. 2010-13, £490k.
Details of the impact
With the introduction of bans on smoking in public places in Scotland
(2006) and England (2007), the REF period has seen intensive activity in
the field of smoking prevention and cessation, where the underpinning
research of the Group and its ongoing policy evaluation activities have
had an intensive impact on changing policies and practices.
Young people and smoking
The Department of Health (DH) commissioned Amos to lead a review on young
people and smoking in England to inform the development of the
Government's tobacco control strategy white paper. The DH Review was
quoted and referenced in the UK Government's 2010 white paper `A Smokefree
Future — a Comprehensive Tobacco Strategy for England' [5.1] and included
a key diagram from the report (p. 26). This diagram also appears in the
Scottish Government's 2013 `Tobacco Control Strategy for Scotland' [5.2,
p. 12]. The UK Government's 2011 white paper `Healthy Lives, Healthy
People: a Tobacco Control Plan for England' also referenced the Review
[5.3]. The model developed in the Review underpinned the UK Government's
adoption of a broad policy approach. The Review's findings also influenced
smoking prevention policy and practice at regional/local levels. Amos
presented the findings at several regional/local tobacco control seminars
and has received feedback that this directly impacted on local plans and
priorities. This can be confirmed by regional tobacco control leads [5.4].
The Review's findings form part of the teaching on the only national CPD
course on tobacco control
Several of Amos's research publications on young people were referenced
in the Scottish Smoking Prevention Working Group's report `Towards a
Future Without Tobacco' [5.5]. This report had a major influence on the
Scottish Government's Smoking Prevention Action Plan `Scotland's Future is
Smoke Free' (2008) [5.6]. In the Foreword, the Minister for Public Health
states that the Action Plan "builds upon and responds to the excellent
report, `Towards a Future without Tobacco',... the Expert Group's
recommendations also provide a clear mandate for the action proposed".
This is highlighted throughout the Action Plan. Amos was a member of the
expert Prevention Working Group and played an active role, including
making presentations to the Group on her research.
Young people and smoking cessation
In Scotland the evaluation of the young people's cessation pilots led to
the recommendation in the Scottish Government's 2008 Smoking Prevention
Action Plan that youth smoking cessation services should not be
established; rather, young people should be supported through standard NHS
cessation services. The Action Plan states that "in the light of the
recent poor outcome of the pilot smoking cessation services for young
people we recommend active consideration is given to developing other
approaches" [5.6, p. 37]. This is reiterated in the national guidelines
for smoking cessation [5.7], with the study cited as the evidence base.
The DH Review (see above) is also cited in these guidelines.
Legislation banning smoking in enclosed public spaces
TCRG members were involved in the national evaluations of the English and
Scottish smokefree legislation. In Scotland, in response to a
Parliamentary Question on 12/11/08, the Public Health Minister referred to
the evidence from the national evaluation programme, which included two
TCRG studies, which showed that Scotland was benefiting from the ban
[5.8]. The Minister also stated "importantly, there is evidence of a
change in the cultural acceptability of smoking", which related to the
TCRG qualitative studies' findings. The English evaluation programme was
mentioned in the 2010 white paper `Healthy Lives, Healthy People: Our
Strategy for Public Health in England' [5.3]. `Healthy Lives, Healthy
People: a Tobacco Control Plan for England' [5.3, pp. 37- 8], drawing on
an independent academic review of the evidence from the evaluation
programme [5.9], concluded that "the Government believes that the aims of
the legislation continue to be effectively achieved." This evidence review
cites the Final Report and a paper from our English study (Hargreaves et
al 2010) and the Final Report of our Scottish study (Martin et al 2008).
The REFRESH project piloted an innovative intervention which successfully
used personal home air quality feedback with motivational interviews to
help smoking mothers reduce their children's exposure to secondhand smoke.
REFRESH has influenced policy and practice. REFRESH is mentioned four
times in the Scottish Tobacco Control Strategy [5.2, p. 24], including in
Action Point 28. Recommendations from REFRESH influenced the inclusion in
the Strategy of a commitment to set a target to reduce children's exposure
to secondhand smoke. Scotland was the first country in the world to make
such a commitment. TCRG members with ASH Scotland used REFRESH findings to
develop a `How to' guide for practitioners working with parents. 2700 hard
copies have been distributed to 2700 practitioners and it is also
available on the study website (http://www.refreshproject.org.uk).
It is cited as a recommended resource by the NHS Health Scotland's
Maternal and Early Years website and led to a question on smoking in the
home being included in the new 24-30 month infant review delivered by
public health nurses [5.10]. The Scottish Government's Second Hand Smoke-
Social Marketing Steering Group has explicitly drawn on the findings of
REFRESH in the commissioning of a national public health campaign to be
launched in Spring 2014 (5.10).
Sources to corroborate the impact
PDFs of all web links are available at www.wiki.ed.ac.uk/display/REF2014REF3B/UoA+22
5.1 A Smokefree Future — a Comprehensive Tobacco Strategy for England.
2010. Department of Health, London.
5.2. Creating a Tobacco-Free Generation- A Tobacco Control Strategy for
Scotland. 2013. Scottish Government, Edinburgh. http://www.scotland.gov.uk/Resource/0041/00417331.pdf
5.3 Healthy Lives, Healthy People: a Tobacco Control Plan for England.
2011. Department of Health, London. https://www.gov.uk/government/publications/the-tobacco-control-plan-for-england
5.4 The following NHS Regional Tobacco Control leads can corroborate that
the DH review on young people and smoking, and Professor Amos's
presentations on the review at several regional/local tobacco control
seminars and conferences, influenced smoking prevention policy and
practice at regional/local levels: Director, Fresh- Smoke Free North East;
Director, Tobacco Free Futures; Director, Smoke Free South West.
5.5 Towards a Future Without Tobacco: the Report of the Smoking
Prevention Working Group. 2006. Scottish Executive, Edinburgh.
5.6 Scotland's Future is Smoke Free: A Smoking Prevention Action Plan.
2008. Scottish Government, Edinburgh. http://www.scotland.gov.uk/Resource/Doc/223415/0060163.pdf
5.7 A Guide to Smoking Cessation in Scotland 2010- Planning and Providing
Specialist Smoking Cessation Services. 2010. NHS Health Scotland,
5.8 The Public Health Minister's response to a Parliamentary Question on
12/11/08 in the Scottish Parliament, which referred to the evidence from
the national evaluation programme of the smokefree legislation, which
included two TCRG studies, and showed that Scotland was benefiting from
the ban can be found on the ASH Scotland website http://www.ashscotland.org.uk
5.9 Bauld L `The Impact of Smokefree Legislation in England: Evidence
Review'. University of Bath, 2010. https://www.gov.uk/government/publications/impact-of-smokefree-legislation-evidence-review-march-2011
5.10 NHS Health Scotland Maternal and Early Years website: http://www.maternal-and-early-years.org.uk/topic/0-3-years/smoking-in-the-home.
Official at Tobacco Policy, Public Health Division, Scottish Government
can corroborate that the REFRESH findings are being used in commissioning
the national public health campaign.