Summary of the impact

Research, policy development, evaluation and advocacy work at The University of Nottingham has achieved significant impact in helping to prevent the harm to health caused by smoking, which is the largest avoidable cause of death and disability, and of social inequalities in health, in the UK. This impact has been achieved through contributions in two areas of prevention: (1) conventional population- and individual-level interventions to prevent smoking uptake and promote smoking cessation; and (2) novel population-level measures to encourage substitution of smoked tobacco with alternative, low hazard nicotine products as a harm reduction strategy.

Underpinning research

Original research, evidence synthesis and policy advocacy has been carried out collaboratively through the UK Centre for Tobacco Control Studies (UKCTCS), one of five UK Clinical Research Collaboration (UKCRC) Public Health Research Centres of Excellence established in 2008 and led by John Britton (Professor of Epidemiology since 2000, Director of UKCTCS 2008-present) with Ann McNeill (Professor of Health Policy and Promotion 2005-12, now at Kings College London), Sarah Lewis (Professor of Medical Statistics), Tim Coleman (Professor of Primary Care) and Jo Leonardi-Bee (Associate Professor of Medical Statistics) and other Nottingham staff, named below. Centre funding was renewed for a further five years to 2018. The UKCTCS works closely with the Tobacco Advisory Group of the Royal College of Physicians (RCP), chaired by Britton since 1996 with substantial input from McNeill, Coleman and Leonardi-Bee, and with Action on Smoking and Health (Britton a Board member) in advocacy. The team has played major roles in producing evidence to support legislation prohibiting point of sale tobacco displays in England (now being implemented in stages from April 2012), plain tobacco packaging, development of more effective models of cessation service provision, and most importantly by establishing the UK as a world leader in tobacco harm reduction. The work includes:

Passive smoking in children: 2010 RCP Report including systematic reviews of health effects, attributable fractions and economic consequences of passive smoking in children, led and edited by Britton with contributors including McNeill, Leonardi-Bee, Hubbard (Professor of Respiratory Epidemiology), Szatkowski (Lecturer in Statistics) and 11 other Nottingham staff and students [1].

Plain tobacco packaging: While in Nottingham, McNeill developed and co-authored the first UK study of plain packaging and first international study involving children, and co-authored the 2012 systematic review supporting the 2012 consultation on plain tobacco packaging [2].

Point of sale legislation: McNeill and Lewis from Nottingham led an evaluation of the impact of the 2010 point of sale legislation in Ireland on children's perceptions of cigarette availability [3] and an economic evaluation of the effect of the legislation on tobacco sales [4].

Smoking cessation: Our work includes a definitive trial of nicotine therapy in pregnancy (led by Coleman [5]) and Cochrane review of cessation pharmacotherapy in pregnancy (Coleman and Leonardi-Bee) [6], work on service delivery in mental health settings and other hard-to-reach groups (by Elena Ratschen, Lecturer in Epidemiology) [7] and hospital inpatient settings (by Rachael Murray, Lecturer Health Policy and Promotion) [8].

Harm reduction: Our harm reduction work was initiated by Britton and driven through a range of outputs including the evidence and policy reviews summarised in the 2007 RCP report Harm reduction in Nicotine Addiction [9], which has fed into various aspects of government policy development and implementation, and resulted in a NICE Programme Development Group (PDG) on tobacco harm reduction (Britton and McNeill members; reported June 2013) and the MHRA decision to introduce permissive nicotine licensing (June 2013).

Policy evaluation: Lewis, Szatkowski, Hubbard, Langley (Lecturer in Economics) and Huang (Data Manager) have pioneered the use of routine electronic health databases in the evaluation of impacts of policy on smoking behaviour, clinical practice and safety of smoking cessation interventions which underpin the above work. Examples of use of large databases are available through the Nottingham Tobacco Control Database (http://www.ukctcs.org/ukctcs/research/featuredprojects/ntcd.aspx).

References to the research

The above work was supported by the UKCRC (Core UKCTCS funding as UK Public Health Research Centre of Excellence), along with the following peer-review grants:

• Cancer Research UK. `Passive smoking and children: a report by the Tobacco Advisory Group of the Royal College of Physicians'. Principal applicant: J Britton. April 2009-March 2010. £39,943. [Reference 1 above]

• Department of Health. `Systematic review of plain packaging'. Applicants: C Moodie, M Stead, G Hastings, L Bauld, A McNeill. May-Sept 2011. £126,613. [Reference 2]

• Cancer Research UK /OTC Ireland/ASH New Zealand/Irish Cancer Society. `Evaluation of the impact of point of sale removal in Ireland'. Principal applicant: A McNeill. 2009-2011. £55,000. [References 3 & 4]

• NIHR Health Technology Assessment programme. `Smoking, Nicotine and Pregnancy (SNAP) Trial'. Principal applicant: T Coleman. 2006-2011. £1,280,667. [Reference 5]

• Department of Health. `Tobacco Control Health Inequalities Pilots programme'. Principal applicant: A McNeill. April 2010-March 2012. £1,837,775. [Reference 7]

• NIHR (Programme grant). `Smoking: new approaches to cessation service delivery, prevention of passive smoke exposure in children, and healthcare cost estimation'. Principal applicant: J Britton. March 2010-February 2015. £2,002,012. [Reference 8].

Details of the impact

The primary beneficiaries of our work are the millions of smokers in the UK whose risks of death and disease are dramatically reduced by stopping smoking; their families and dependents, who avoid the suffering and economic cost of loss of a family member; employers, who enjoy higher productivity from non-smokers; and wider society, which avoids the estimated £14 billion that smoking costs society. The prevalence of adult smoking in the UK has fallen by about 7 percentage points (≈3 million smokers) in the last decade, and by about a third in adolescents aged <16. Our work has contributed to these falls, thus helping to prevent thousands of cases of lifelong addiction to, and premature death from, smoking. Examples of impact include:

Smoke-free policy and passive smoking: Our report on passive smoking and children generated widespread media coverage and calls by NGOs (including British Medical Association, British Lung Foundation, Action Cancer (Northern Ireland)) for wider restrictions on smoking in the presence of children, particularly in cars; a 2011 All Party Parliamentary Group hearing on smoking in private vehicles chaired by Steven Williams MP [5.1]); a private member's bill calling for legislation to prohibit smoking in cars in Northern Ireland (http://www.niassembly.gov.uk/Assembly-Business/Official-Report/Reports-11-12/14-November-2011/#4) and the Smoke-free Private Vehicles Bill [HL] 2012-13 in the House of Lords. Britton briefed the Secretary of State for Health (Hunt) and Public Health Minister (Soubry) personally on passive smoking and plain packaging on 21.11.12.

Point of sale legislation: McNeill's work on point of sale legislation in Ireland, presented in the House of Commons and followed by a personal telephone conversation with the Secretary of State for Health (Lansley), proved crucial to the retention of 2010 Health Act point of sale legislation in the 2011 Coalition Government's Tobacco Control Plan for England [5.2].

Plain packaging: Our advocacy, with others, was crucial to the inclusion of a commitment to consider plain packaging in the Tobacco Control Plan for England [5.2], and the systematic evidence review (AM) a key driver of the formal consultation in 2012.

Smoking cessation and prevention: Our research in hospital patients, adolescents, pregnant women and people with mental disorders has fed directly into several NICE guidelines over the past decade. Britton was a member of the NICE PDG which produced guidance on smoking cessation in community settings in 2008 (www.nice.org.uk/PH010). Coleman provided expert evidence reviews for 2010 NICE guidance on smoking cessation in pregnancy and after childbirth (http://guidance.nice.org.uk/PH26). Britton chaired the PDG (Ratschen and Murray members) producing guidance on smoking cessation in all NHS acute, maternity and mental health secondary care settings (consultation draft published 5.4.13 [5.3]; final guidance due 27.11.13), with Ratschen, Murray, Leonardi-Bee and Szatkowski providing expert reviews, and in which our work in acute and mental health hospital cessation service models, and clinical trials, were pivotal. Szatkowski was part of the NICE Advisory Group which produced the 2013 Evidence Update on school-based interventions to prevent the uptake of smoking among children and young people (http://guidance.nice.org.uk/PH23).

Harm reduction: Our work, particularly the RCP harm reduction report, has led to the inclusion of harm reduction strategies in a number of government policies, including the 2010 and 2011 Department of Health tobacco control strategies [5.2, 5.4], and encouraged major industries to enter the alternative nicotine market. Representations by Britton and others to the Medicines and Healthcare Products Regulatory Agency (MHRA) led to the establishment of and our involvement in an Expert Committee on Nicotine Containing Products [5.5], leading to a substantive review of MHRA licensing policy on nicotine products and an announcement of permissive licensing for nicotine-containing products in June 2013 [5.6]. The key change, a switch from using placebo as the safety comparator for nicotine products to the pragmatic likelihood of continued smoking, has opened the door to the development and use of alternative nicotine products (e.g. electronic cigarettes) as long-term substitutes for smoking. In 2008 Britton met with the Director of NICE to make the case for harm reduction as a public health strategy. This initiated a NICE Citizens Council on harm reduction in 2009 [5.7], and a NICE PDG on tobacco harm reduction (Britton and McNeill members) which produced guidance (June 2013) integrating harm reduction into NHS practice [5.8]. Britton also met with the Cabinet Office Behavioural Insight Team (BIT) in 2011, advocating harm reduction as a means to promote healthy choices, leading to the inclusion of harm reduction as a BIT policy [5.9]. Britton has since met twice with the Prime Minister's senior policy advisor on Health and Adult Care (Paul Bate) at 10 Downing St (in 2011 and 2012) to discuss harm reduction and other prevention strategy. These policy changes have established the UK as world leader in harm reduction approaches to nicotine addiction. Our influence and leadership was directly acknowledged in a speech by the Secretary of State for Health on 6.3.12 [5.10]. The RCP harm reduction report was also used by Britton to brief (meeting 2.3.13) Linda McAvan, rapporteur on the 2013 EU Tobacco Products Directive for the Environment, Public Health and Food Safety (ENVI) committee, to support permissive regulation of nicotine-containing products at EU level (and 75% health warnings on tobacco packs) in the EU Directive: http://www.europarl.europa.eu/pdfs/news/expert/infopress/20130708IPR16824/20130708IPR16824_en.pdf.

Sources to corroborate the impact

1. All Party Parliamentary Group on Smoking and Health Inquiry into smoking in private vehicles London: Action on Smoking and Health; 2011.
   http://www.ash.org.uk/files/documents/ASH_820.pdf (Call for consultation on options to protect children from passive smoking in private vehicles; JB gave evidence based on RCP 2010 report and other UKCTCS research)
2. Department of Health. Healthy lives, healthy people. A tobacco control plan for England. London: Department of Health; 2011.
   https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213757/dh_124960.pdf (Includes commitments to point of sale legislation, plain packaging consultation, and harm reduction; cites our work as source of evidence)
3. National Institute for Clinical Excellence. Smoking cessation in secondary care: acute, maternity and mental health services. NICE: 2013.
   http://www.nice.org.uk/nicemedia/live/13017/63459/63459.pdf (Programme group chaired by Britton with input from multiple individuals from Division, particularly on service designs for acute and mental health services)
4. Department of Health. A Smokefree Future. A comprehensive tobacco control strategy for England. London: Department of Health; 2010.
   http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_111789.pdf (Includes commitments to point of sale legislation and harm reduction, and cites our work as source of research evidence)
5. MHRA Public Assessment Report: The use of nicotine replacement therapy to reduce harm in smokers. London: MHRA; 2010
   http://www.mhra.gov.uk/home/idcplg?IdcService=GET_FILE&dDocName=CON068571&RevisionSelectionMethod=LatestReleased (Addresses use of nicotine in harm reduction as a viable strategy to provide a low hazard alternative to smoking for smokers who cannot or will not quit)
6. Medicines and Healthcare products Regulatory Agency. The Regulation of Nicotine Containing Products (NCPs). London: MHRA; 2013
   http://www.mhra.gov.uk/home/groups/comms-ic/documents/websiteresources/con286834.pdf
7. Report on NICE Citizens Council meeting: Smoking and harm reduction London: National Institute for Health and Clinical Excellence; 2010
   http://www.nice.org.uk/media/4EB/13/CCReportOnHarmReductionUpdated300410.pdf (Citizens Council held as a consequence or our advocacy for adoption of harm reduction as health policy; driven by RCP report (above) and other work)
8. National Institute for Health and Care Excellence. Tobacco — harm reduction. London: NICE; 2013 http://guidance.nice.org.uk/PH45/Guidance/pdf/English (Public health guidance on adoption of tobacco harm reduction strategies into clinical practice and policy. Britton and McNeill members of programme development group)
9. Behavioural Insights Team. Annual Update 2010-11. London: Cabinet Office;2011
   http://www.cabinetoffice.gov.uk/sites/default/files/resources/Behaviour-Change-Insight-Team-Annual-Update_acc.pdf (Includes harm reduction strategies, as direct consequence of our interactions with the BIT)
10. Speech: 6 March 2012, Andrew Lansley, Smoking and Health
    http://mediacentre.dh.gov.uk/2012/03/07/speech-6-march-2012-andrew-lansley-smoking-and-health/ (Speech by Secretary of State for Health at Royal College of Physicians, acknowledging RCP/UKCTCS leadership of development of UK harm reduction policy)