TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL

TOWARDS A SMOKE FREE AGENDAFOR LIVERPOOL

Report of the scoping exercise for the SmokeFree Liverpool Group

Jon Dawson

November 2003

Jon Dawson and Associates

CONTENTS

Executive Summary i

1 Background 1

1.1 Introduction 11.2 The Brief 11.3 The Research Methodology 21.4 The Report 3

2 The Health Risks and Impacts of Smoking 4

2.1 Risks 42.2 Impacts of Smoking 5

3 Smoking Prevalence and Inequalities 7

4 The Policy and Legal Context 9

4.1 Introduction 94.2 National Policy and Statutory Context 104.3 Implications of Court and Tribunal Cases 134.4 The Local Context 14

5 Current Service Provision in Liverpool 17

5.1 Introduction 175.2 Smoking Cessation Services: Support/Fagends 175.3 Smoking Prevention and Education 185.4 Workplace Award Schemes 195.5 Research 215.6 Policy Development 22

6 Public Attitudes to Second-Hand Smoke and Smokingin Public Places 23

6.1 Introduction 236.2 ONS Nation-wide Survey 236.3 Nation-wide Survey of Attitudes to Smoking Bans 246.4 Survey Evidence from Ireland 24

7 The Financial Implications for Employers of SmokeFree Workplaces 26

7.1 Introduction 267.2 The Financial Costs of Smoking for Employers 267.3 A Model for Individual Employers 317.4 The Economic Implications of Smoke Free Workplaces for

the Hospitality Sector 32

8 Approaches to Smoke Free Agendas: the Picture fromElsewhere 35

8.1 A Global Trend towards Smoke Free Places 358.2 Key Lessons 37

9 Making Liverpool Smoke Free: Stakeholders Viewpoints 38

10 Summary of Findings 42

10.1 Reviewing the Study 4210.2 Main Findings 42

11 Conclusions and Recommendations 47

11.1 Introduction 4711.2 Developing the Smoke Free Agenda 4711.3 Implementing the Smoke Free Agenda 4811.4 Supporting the Smoke Free Agenda 53

Appendices

Jon Dawson and Associates 1

1 BACKGROUND________________________________________________

1.1 Introduction

1.1.1 A Smoke Free Liverpool Group1 was established in mid-2003 to take forwardthe objective of the Liverpool First for Health Strategic Partnership to makeLiverpool a Smoke Free City by 2008 – the year that the city celebrates itsstatus as European Capital of Culture – and to reduce smoking prevalence. Theinitial focus of the Group is to develop and oversee the implementation of astrategic agenda that will achieve these goals.

1.1.2 The timing of this initiative is propitious. Nationally and internationally,efforts to address the health impacts of tobacco smoking and, in particular,second-hand smoke2 are gathering pace. In May 2003, The World HealthOrganisation (WHO) adopted the Framework Convention on Tobacco Control– the first international treaty negotiated under the auspices of the WHO. InSeptember 2003, the European Commission announced its intention to worktowards making smoke free workplaces compulsory throughout the EuropeanUnion. In 2004, new legislation in Ireland and Norway will bring about smokefree workplaces, including premises – such as, restaurants, pubs, nightclubsand cafes - where customers, in the past, have been able to smoke.

1.1.3 In the UK, although national legislation may not be imminent, a series ofevents and initiatives are coalescing to raise the public profile of theimportance of reducing smoking prevalence and exposure to second-handsmoke. These include the Chief Medical Officer highlighting the need toaddress exposure to second-hand smoke as a priority in his 2002 annualreport3, hard-hitting national advertising campaigns about the dangers ofsecond-hand smoke, publicity about parts of the United States – such asBoston, New York and California – that have introduced comprehensivesmoking bans in public places and announcements by companies that theirpremises are becoming smoke free.

1.2 The Brief

1.2.1 The Smoke Free Liverpool Group commissioned this study to identify how asmoke free agenda could most effectively be taken forward in Liverpool. Theprimary aim was to generate a series of recommendations and establish a

1 The Smoke Free Liverpool Group brings together a wide range of partners including the City Council(Environmental Health and Trading Standards), Central, North and South Primary Care Trusts(including the Tobacco Lead for the PCTs), Health @ Work, Roy Castle Lung Cancer Foundation, theChamber of Commerce and the North West TUC.2 When non-smokers share a space with someone who is smoking they are being exposed to ambienttobacco smoke. This ambient tobacco smoke is called second-hand smoke, passive smoke orenvironmental tobacco smoke.3 Getting serious about second-hand smoke, Annual Report of the Chief Medical Officer 2002,Department of Health

Towards a Smoke Free Agenda for Liverpool__________________________________________________________________________


framework action plan. To achieve this, the study involved a scoping exercisedesigned to:

• analyse the national and local policy and legal context for makingLiverpool smoke free;

• identify existing smoking-related activities in the city;• assess the impact of the smoke free agenda on smoking cessation services;• compile local data on employment levels and within the hospitality and

SME sector;• assess the economic impact of smoking at work;• explore the potential for using local licensing or by-laws to further smoke

free objectives;• provide an analysis for employers of the potential benefits from

introducing smoking policies and smoking bans in workplaces and thecosts of not doing so;

• explore how to integrate a health inequalities dimension into the smokefree agenda;

• examine good practice and lessons from the implementation of smoke-freepolicies elsewhere;

• identify potential methods for making Liverpool a Smoke Free City by2008 and reducing smoking prevalence.

1.3 The Research Methodology

1.3.1 To address the research agenda, a range of research methods and activitieswere employed. Specifically, they involved conducting semi-structuredinterviews with stakeholders and key informants and compiling and assessingdata, key documents, reports and other publications related to smoke freeissues.

1.3.2 Engaging stakeholders in the research and in defining an Action Plan thatwould drive the Smoke Free agenda was central to the approach taken. As partof this approach, a workshop session of the Smoke Free Liverpool Group –drawing on preliminary recommendations - contributed to the development ofthe Action Plan.

1.3.3 Parallel to this study, a survey of second-hand tobacco smoke in Liverpoolworkplaces has been launched. It is being administered by the City Council’sEnvironmental Health Service. The findings from the survey will add value tothis study. They will provide local evidence and information that can be usedto inform the implementation of the Smoke Free agenda and enhance theeffectiveness of service delivery.

1.3.4 The survey has been designed to:

• build a profile of the extent and type of smoking policies within Liverpoolworkplaces;

• provide evidence of the actual and perceived economic impact of smokefree workplaces;



• explore employers’ perceptions of and attitudes to second-hand tobaccosmoke in the workplace;

• provide evidence of demand for smoking cessation services;• explore interest in participating in an Awards scheme and a Smoke Free

campaign.

1.4 The Report

1.4.1 The rest of this report is in three main parts. The first part (sections 2 to 10)sets out the findings from the scoping exercise. These examine:

• the health risks associated with smoking and second-hand smoke and theirimpacts;

• the challenge of smoking-related health inequalities;• smoking prevalence and inequalities;• the policy and legal context for introducing a smoke free agenda in

Liverpool;• public attitudes to second-hand smoke and smoking in public places;• the financial implications for employers of smoke free workplaces;• approaches to smoke free agendas in other countries;• the views of Liverpool stakeholders.

1.4.2 The second part (section 11) highlights the key recommendations that flowfrom these findings. The recommendations primarily relate to general policydirections and actions to take forward the Smoke Free Liverpool agenda.Finally, the appendices present a framework action plan that incorporates keyactions and their timing, provisional targets and resource implications.



2. THE HEALTH RISKS AND IMPACTS OF SMOKING________________________________________________

2.1 Risks

2.1.1 The links between smoking and cancer, heart disease and stroke are well-established. For instance, during the 1950s and 1960s, numerous studiesdemonstrated that smoking was acause of cancer.4 Equally,government health warnings andpublic health campaigns overmany years have meant thatsmokers in the UK are, for themost part, aware that smoking isharmful to health.

2.1.2 The health risks of exposure tosecond-hand tobacco smokehave, however, become a focusfor studies more recently (see box 2.1). Much of this research is based onepidemiological research that has examined the health of non-smokers wholive with smokers (see box 2.2). An analysis of 37 studies of lung cancer from

passive smoking foundthat the “excess risk oflung cancer was 24 percent in non-smokers wholived with a smoker”.Evidence from suchresearch has led toestimates that workingwith smoking co-workers increases therisk of lung cancer bybetween 20-30 per centi n n o n - s m o k e r s5.Equally, US and UKstudies in the 1990s havesuggested that non-smokers living withsmokers had an

increased risk of heart disease of between 20 and 30 per cent.6

4 Doll R, Tobacco: a medical history, Journal of Urban Health, Bulleting of the New York Academy ofMedicine, Vol 76, Issue 3, 19975 Working Group of Health and Safety Authority and Office of Tobacco Control, Ireland (2002) Reporton the health effects of environmental tobacco smoke in the workplace.6 (1) Glantz SA, Parmlev WW, Passive smoking and heart disease: mechanisms and risks, JAMA, 1955,273 (13): 1047-1053. (2) Law MR et al, Enviromental tobacco smoke exposure and ischaemic heartdisease: an evaluation of the evidence, BMJ, 1997, 315: 973-980 (3) Sheenland K et al, Environmental

Box 2.1: Evidence that second-hand smoke iscarcinogenic to humans

Two influential assessments have recentlydefinitively declared that second-hand smoke iscarcinogenic to people. These were:

• the 9th report on Carcinigens published in2000 by the US National Institute of HealthNational Toxicology Program;

• the new monograph on second-hand smoke(2002) from the IARC (a branch of WHO).

•

Box 2.2: Evidence linking second-hand smokewith heart disease

Most evidence linking heart disease with second-hand smoke comes form studies of spousalsmoking. There are few studies of the relationshipbetween exposure to second-hand smoke in theworkplace and cardiovascular disease.

However, scientific rationale suggests that “thereis no biologically plausible reason to believe thatthe hazards of exposure to second-hand smokethat have been demonstrated in the home shouldnot also apply in the workplace” (Working Groupof health and Safety Authority and Office ofTobacco Control, Ireland, 2002)

Moreover, the IARC Summary monograph statesthat evidence indicates that being exposed tosecond-hand tobacco smoke increases the risk ofan acute coronary heart disease event by 25 to 30per cent.



2.1.3 Moreover, it is widely accepted that exposure of pregnant women to second-hand tobacco smoke causes lower birth weight in babies and that childrenexposed to second-hand smoke are at increased risk of respiratory disease andsudden infant death syndrome (cot death). This has clear implications forpregnant working mothers and for children spending time in an adult’sworkplace.

2.1.4 Within the workplace context, bar staff and other hospitality workers are ahigh risk group as their workplaces often have high exposure to second-handsmoke. There is a growing body of evidence that provides objective data onthe extent of exposure of hospitality workers to second-hand smoke and itsimpact on them.

2.1.5 There is also evidence that the risks to staff of being exposed to carcinogenspersists even when ventilation systems are in place. A study by ManchesterMetropolitan University of public houses in Manchester indicated thatventilation did not appear to reduce the environmental tobacco smokecompounds measured. A new study to be carried out by Liverpool JohnMoores University, in co-operation with the Environmental Health Service, tomeasure carbon monoxide in the atmosphere should shed further light on thisissue.

2.2 Impacts of smoking

2.2.1 Department of Health statistics indicate that smoking kills 120,000 peopleeach year in the UK. On a proportional population basis, this implies thatabout 900 people in Liverpool die each year from smoking.

2.2.2 In addition, research in California developed estimates of rates of death and illhealth experienced by non-smokers as a result of exposure to second-handcigarette smoke.7 Applying the conclusions of this research to Liverpoolimplies that between 61 and 105 people die in Liverpool each year fromcancer or ischaemic heart disease because of exposure to second-hand smoke.

2.2.3 However, because SMRs for lung cancer and for coronary heart disease inLiverpool are significantly higher than national averages, it could be arguedthat these figures under-estimate actual numbers of deaths.

2.2.4 In terms of the financial costs of smoking, the White Paper Smoking Killsestimated that treating illness and disease caused by smoking costs the NHSabout £1.7 billion each year in terms of GP visits, prescriptions, treatments andoperations. On a proportional population basis, this would imply that smokingcosts the NHS in Liverpool about £12.7 million per annum. Again, however,

tobacco smoke and coronary heart disease in the American Cancer Society CP5-11 Cohort, ….., 1996,94, 622-628.7 Health effects of exposure to environmental tobacco smoke by Californian Environmental ProtectionAgency’s Office of Environmental Health Hazard Assessment.



given the higher incidence of smoking-related diseases in Liverpool -compared to the rest of the country - this figure is likely to be an under-estimate of the actual cost.

2.2.5 The implication is that reducing smoking prevalence and exposure to second-hand smoke could lead to economic benefits for society arising from healthcare cost savings. However, these benefits have to be weighed against longerlife expectancies that may consume more health care resources in later life andrevenue generated by taxation on cigarettes and other tobacco products.

2.2.6 Smoking also imposes financial costs on employers and on the city’seconomy. Estimates for this study suggest that the annual economic cost toemployers of smoking amongst the Liverpool workforce is approximately£28.5 million. Details of this estimate, how it is calculated and theassumptions underpinning it are set out in section 7.



3 SMOKING PREVALENCE AND INEQUALITIES________________________________________________

3.1 National data indicates that 27 per cent of adults in England smoke – 28 percent of men and 25 per cent of women.8 The prevalence of cigarette smokinghas dropped substantially since 1978 – from 40 per cent – although the rate ofdecline has levelled off in the 1990s. Indeed, there has been little change insmoking prevalence rates since 1994.

3.2 This overall rate disguises significant differences between specific groups.These highlight the health inequalities linked to smoking. There areparticularly pronounced differences between socio-economic classes andminority ethnic groups. Smoking prevalence rates also vary between differentparts of the country.

3.3 Smoking prevalence rates for different socio-economic classes show that 32per cent of manual workers smoke compared with just 21 per cent of thosewho have non-manual occupations.

3.4 National data also highlights that men from some minority ethnic groups havesmoking rates higher than the national average.9 In 1999, Bangladeshi menhad the highest smoking prevalence rates – 44 per cent were smokers. Thiswas followed by Irish men (37 per cent) and Black Caribbean men (35 percent). In contrast, data suggests that Chinese men are the least likely to smoke(17 per cent). Pakistani (26 per cent) and Indian (23 per cent) men hadsmoking prevalence rates similar to the general population.

3.5 Amongst women, however, the pattern is broadly reversed. Only Irish women(35 per cent) had higher smoking prevalence rates than the national average.Women in all other minority ethnic groups were less likely to smoke thanwomen in the general population. Moreover, women from minority ethnicgroups were much less likely to smoke than men with the same ethnicbackground. This difference was particularly marked within the Bangladeshicommunity. Survey data indicated that very few women smoke cigarettes –although about one-quarter of Bangladeshi women chewed tobacco.

3.6 Regionally, the North West has amongst the highest smoking prevalence ratesin England. It has a rate of 29 per cent compared to 24 per cent for the SouthEast and South West.

3.7 Up-to-date and reliable local data that could sketch an accurate picture ofsmoking prevalence rates and inequalities in Liverpool, however, is currentlylacking. Previous data in the mid-1990s indicates that smoking amongst

8 Estimates of the prevalence of smoking among adults age 16 and over are obtained from the GeneralHousehold survey conducted by the Office for National Statistics9 The Health of minority ethnic groups, Health Survey for England, 1999.



women in Liverpool was above the national average with a rate of between 32and 36 per cent.10 And, although recent research carried out by HACCRUsought to shed light on the incidence of smoking in Liverpool, the resultsappear to suggest that smoking prevalence is lower in Liverpool than in theUK as a whole. However, the methodology adopted – a postal questionnaire –resulted in a low response rate that raises obvious concerns about the validityof the findings. It is hoped that surveys being carried out by the Citizen’sPanel in Liverpool and for Smoke Free Liverpool will provide more reliabledata.

10 Arden K, Health needs of local people in North Mersey, 2003.



4 THE POLICY AND LEGAL CONTEXT________________________________________________

4.1 Introduction

4.1.1 As we have already observed, global and European policy initiatives areincreasingly promoting measures to address the health impacts of smoking andsecond-hand smoke. Equally, an increasing number of countries and cities areintroducing smoke free legislation that aims to ban smoking and preventexposure to second-hand smoke in indoor public places (see section 8). Suchlegislative changes tend to provide much greater clarity for the introduction ofsmoke free policies – they often compel employers and businesses to ensurethat their premises are effectively smoke free.

4.1.2 The policy context in the UK does emphasise the need to reduce smokingprevalence rates and recognises the dangers of exposure to second-handsmoke. UK legislation relates to prohibiting smoking where it can affect foodhygiene or poses a serious fire hazard. The Government has also passed a lawto ban tobacco advertising and restrict promotional opportunities.11 But, theabsence of all-embracing legislation relating to smoking in public placesmeans that identifying the responsibilities and requirements of employersrelating to smoking policies is more complex. Although legal experts havespelt out the likely interpretation of statutory legislation and legaldevelopments, there inevitably remains some “grey areas” and uncertainty.

4.1.3 Employers have to take account of precedents set by court cases and tribunalsand interpretations of health and safety legislation that does not – except forspecific types of business - explicitly address smoking in the workplace.Equally, it means that initiatives to take forward smoke free agendas – likeSmoke Free Liverpool – have to explore and develop creative approaches toachieve their objectives.

4.1.4 This section attempts to piece together the policy and legal framework relatingto smoking and second-hand tobacco smoke that will influence and informhow Smoke Free Liverpool will choose to take forward its Smoke Freeagenda. Specifically, it examines:

• the national policy and statutory context including the Smoking Kills WhitePaper, National Service Frameworks the Public Places Charter and Healthand Safety legislation;

• the implications of court and tribunal cases on the rights of smokers andnon-smokers and on the factors that employers need to consider tominimise risks of litigation;

• the regional and local context, including the potential of using locallicensing powers or by-laws to address smoking in the workplace,

11 The Tobacco Advertising and Promotion Act 2002.



approaches adopted by smoking alliances and initiatives in other parts ofMerseyside.

4.2 National Policy and Statutory Context

Smoking Kills White Paper

4.2.1 The Government’s 1998 White Paper “Smoking Kills” was instrumental inproviding a focus on tobacco control in the UK. The Smoking Kills WhitePaper set out the government’s aim to establish a downward trend in adultsmoking rates in all social classes. It set a specific target to reduce the overallrate from 28 to 24 per cent or less by 2010. It also set an interim target toreduce smoking rates to 26 per cent by 2005.

4.2.2 The White Paper indicated that key elements of a comprehensive policyshould include:

• strong mass media led information campaigns• a ban on tobacco advertising and promotion• price policy and control of smuggling• smoke-free public places, especially workplaces• NHS cessation services• community based initiatives

4.2.3 A raft of major initiatives aimed at reducing the incidence of smokingfollowed its publication. These have included a comprehensive ban on tobaccopromotion and advertising, the development of new smoking cessationservices – including a free helpline for smokers - more prominent healthwarnings on cigarette packets and anti-smoking advertising campaigns.Although an advertising campaign focused on passive smoking was recentlylaunched, measures to reduce people’s exposure to second-hand smoke havebeen more limited.

National Service Frameworks (NSFs)

4.2.4 The NSFs set national standards, identify key interventions and put in placestrategies to support implementation. The National Cancer Plan and the NSFfor Coronary Heart Disease both have an explicit focus on reducing theprevalence of smoking in the population. To address health inequalities, theCancer Plan sets an additional target to the Smoking Kills target for reducingsmoking. It sets a specific target to reduce smoking among manual workersfrom 32 per cent in 1998 to 26 per cent by 2010.

4.2.5 Both strategic documents place an emphasis on smoking cessationinterventions to address these targets. They also recognise that more broad-based local strategies have a role to play. The NSF for CHD states that localstrategies should, inter alia, be developed to reduce the illegal sale ofcigarettes, reduce smoking in public places, support national media campaigns



and develop smoking cessation services. The National Cancer Plan restates theSmoking Kills tobacco control strategy and supports local alliances to takeactions on smoking.

Priorities and Planning Framework (PPF)

4.2.6 The Department of Health published the PPF in 2002. It set out key targets forthe NHS up to 2005/6. It included a national target of 800,000 smokers - over3 years - successfully quitting at the four week follow-up with the help ofsmoking cessation services. The PPF also included a target to reduce by onepercentage point each year the proportion of women who continue to smokethroughout pregnancy.

The Public Places Charter

4.2.7 The Public Places Charter was agreed between the Charter Group – whorepresent various pub and restaurant trade associations – and the Departmentof Health following the Smoking Kills White Paper. Its objectives include:

• producing written smoking policies, available to customers and staff;• implementing good practice through non-smoking areas, air cleaning and

ventilation;• using external and internal signs to communicate smoking policies to

customers.

4.2.8 The Charter Group agreed to hit a series of targets for pubs by January 2003.By then, it was intended that:

• 50 per cent of public houses would have written smoking policies• 50 per cent of pubs would display external and internal signs on smoking• 35 per cent of pubs would have designated smoking and non-smoking

areas and/or be ventilated to the minimum standards.

4.2.9 The Charter provides standardised national signage for pubs and restaurants toshow what kind of arrangements they have for smoking and non-smokingcustomers. It varies from smoking allowed throughout, to separate smokingand non-smoking areas with ventilation. It essentially relies on voluntary co-operation from pubs and restaurants to achieve its targets.

4.2.10 However, the charter has been widely criticised. Broadly, criticism is two-fold.First, it is argued that it has low standards embodied within it and, second, thatthere are low levels of compliance. There is specific criticism that the Charterrelies heavily on providing ventilation to clear the air of tobacco smokedespite evidence that casts doubt on the effectiveness of such systems. Studiesof the effectiveness of ventilation systems have suggested that they do not



appear to reduce levels of second-hand smoke compounds.12 The Public PlacesCharter is currently being evaluated and the findings of the report will becrucial to its future and policy development in this area.

4.2.11 In Merseyside, Liverpool John Moores University also conducted researchamongst public houses, restaurants and cafes to explore awareness of thePublic Places Charter. Because the response rate was low – 11 per cent ofestablishments – results need to be treated with caution. However, the researchfound that of 88 establishments that responded, 63 per cent had not heard ofthe Charter. Public awareness appears even lower. For the study, 50 membersof the public were asked if they knew about the Charter but only one personstated that they did.

Health and Safety Legislation

4.2.12 As already observed, there is no explicit European or British legislation thatbans or restricts smoking in public places other than for specific reasons ofsafety or hygiene. However, in broad terms, employers in the UK are requiredto protect their employees in the workplace under the Health and Safety atWork Act 1974. Specifically,employers must “provide andmaintain a safe workingenvironment which is, so far asreasonably practicable, safe,without risks to health andadequate as regards facilities andarrangements for their welfare atwork”. The Act does notspecifically address issues ofexposure to second-hand smoke,but it has been argued13 that itsp rov i s ions embrace aresponsibility on employers to protect their workers from exposure to second-hand smoke (see also box 4.1). However, there have not been any casesbrought by the HSE or local authority inspectors to test this interpretation.

4.2.13 Whilst the 1974 Act is the most important legislation affecting health andsafety at work issues, subsequent regulations also have implications forsmoking at work. Employers have a responsibility under the Management ofHealth and Safety at Work Regulations 1992, to identify people particularlyat risk from workplace hazards. The HSC has stated that this covers peoplewhose health might be particularly badly affected by second-hand smoke.14

12 Working Group of Health and Safety Authority and Office of Tobacco Control, Ireland (2002)Report on the health effects of environmental tobacco smoke in the workplace. (The working groupconcluded that ventilation is not a viable control option for second-hand smoke.13 Getting serious about second-hand smoke, Annual Report of the Chief Medical Officer, 200214 HSC Consultative Document (1999): Proposal for an Approved Code of Practice on passive smokingat work

Box 4.1: expanding the scope of the 1974 Act

The HSE has recently served an improvementnotice on a Hospital Trust in Dorset to address aperceived threat to the workforce arising fromstress at work. The action illustrates thepotential of health and safety law to be appliedto wider areas of health protection.

It has led to suggestions that the HSE or localauthority inspectors may be able to take actionto ensure that employers comply with a generalduty to keep workplaces free from second-handsmoke.



4.2.14 The Workplace (Health, Safety and Welfare) Regulations 1992 implementthe European Workplace Directive. The regulations do not prohibit smokingat work but require that workplaces make effective provision to ensure thatworkplaces are “ventilated by sufficient quantity of fresh or purified air”15

They also require employers to make suitable arrangements to protect non-smokers from “discomfort caused by tobacco smoke” in rest rooms and restareas.16

4.2.15 A draft Approved Code of Practice which could translate the broadrequirements of the 1974 Act into specific guidance on tackling exposure tosecond-hand smoke was brought forward by the Health and SafetyCommission in Autumn 2000. However, it has not progressed further and nowseems unlikely to be adopted.

4.3 Implications of Court and Tribunal Cases

4.3.1 Despite the absence of cases to test the potential for the 1974 Health andSafety at Work Act to address smoking at work, a series of court cases andtribunals have clarified some issues concerning smoking in the workplace.They provide some clarification of the rights of non-smokers at work and ofthe duties of employers regarding exposure of the workforce to second-handsmoke.

4.3.2 Specifically, a series of court and tribunal cases indicate that:

• employers must consider the presence of smoke in the workplace and takeaccount of its effect on those exposed to second-hand smoke;

• employees are entitled to a rest room or area that is free from smoke;• smokers are not entitled to smoke at work unless their contract of

employment suggests otherwise.

4.3.3 The case of Waltons and Morse v Dorrington (1997) indicates that employersmust consider the presence of smoke and its effect on the passive smoker inthe working environment17. The case held that the 1974 Act creates an impliedterm in the contract of employment for the employer to “provide and monitorfor his employees, so far as is reasonably practicable, a working environmentwhich is reasonably suitable for the performance by them of their contractualduties”. The case also determined that the employee is entitled to a rest roomor rest area free from smoke.

4.3.4 Employment Tribunals have considered issues such as whether an employee isentitled to smoke at work and the rights of the second-hand smoker. The caseof Dryden v Greater Glasgow Health Board in 1992 held that the introductionof a no smoking policy was not a breach of the employee’s contract ofemployment. The implication being that so long as a contract of employment

15 Regulation 6(1)16 Regulation 2517 Smoking policy for the workplace – an update, Health Education Authority, 1999



does not specify that smoking is allowed in the workplace, the smokingemployee does not have the implied right to smoke at work.

4.3.5 There are several further implications for employers and employees arisingfrom these cases. First, employers should be wary of hastily introducing a nosmoking policy without consultation with all employees. Failure to consult anemployee may mean the employee is justified in resigning and claimingconstructive dismissal. On the other hand, failure by an employer to take stepsto minimise second-hand smoke may be regarded as a “repudiatory breach ofcontract” by the employee sufficient to allow the non-smoker to leave theworkplace and claim constructive dismissal.

4.3.6 Finally, employers whocontinue to allow smoking inthe workplace risk futureclaims for damages fromemployees exposed to second-hand smoke. Outside the UK,an increasing number of courtcases have resulted inemployers being ordered to pay substantial compensation to employeesharmed by second-hand smoke. Box 4.2 highlights some examples.

4.3.7 Within the UK, a few people have started legal proceedings against theiremployers for damages relating to ill health caused by second-hand smoke.However, such cases have, to date, been settled out of court. Nevertheless,they flag up the potential costs to an employer that can flow from employeesbeing exposed to second-hand smoke. For example:

• an information officer employed by Stockport Metropolitan BoroughCouncil received damages of £15,000 after claiming that she sufferedchronic bronchitis as a result of exposure to second-hand smoke;

• a casino worker, who claimed he developed asthma through inhalingtobacco smoke at work, was paid a reported £50,000 by his employers inan out-of-court settlement.

4.4 The Local Context

Liverpool First for Health and Smoke Free Liverpool Stakeholders

4.4.1 Liverpool First for Health has established implementing a smoke free policyagenda as central plank of its strategic objectives. This provides a supportivepolicy environment for efforts to reduce smoking prevalence and exposure tosecond-hand smoke. Support from the Liverpool Primary Care Trustsunderpins the smoke free agenda and has provided financial and humanresources to ensure its implementation.

Box 4.2: Court cases and compensation

• In 1997, US flight attendants won a $300million settlement in a class action lawsuit onbehalf of flight attendants harmed by second-hand smoke.

• In 2001, a non-smoking bar maid in Australiawas awarded US$235 k for cancer caused byworking for 11 years in a smoky bar.



4.4.2 The Smoke Free Liverpool Steering Group has been established to takeforward the smoke free agenda. Its make-up includes representatives fromLiverpool City Council, the PCTs, Roy Castle Lung Cancer Foundation, theChamber of Commerce, North West TUC and Health @ Work.

Licensing Regulations and By-Laws

4.4.3 The City Council’s Environmental Health and Trading Standards Departmentis playing a leading role in progressing the Smoke Free agenda. An importantaspect of its work is exploring the potential of using the City Council’slicensing powers and by-laws to address smoking in the workplace and otherpublic places. A new Licensing Act 2003 will bestow new liquor licensingpowers on local authorities. Premises that need such licences include publichouses, nightclubs and restaurants – the type of workplace where workers faceamongst the highest risks to their health from second-hand smoke. Althoughfinal legal guidance is still awaited, initial indications suggest that the newLicensing Act is unlikely to be amenable to addressing smoking in theworkplace.

4.4.4 The scope for employing by-laws is also being investigated. Any such movewould require approval from Parliament. Other cities – such as Manchester -are likewise exploring the possibility of using by-laws to further smoke freeobjectives. There is, therefore, potential for Liverpool to collaborate with othercities to draft workable by-laws and to campaign to secure Parliamentaryassent.

Merseyside-wide

4.4.5 Smoke Free Merseyside is part of the national network of tobacco alliancesfunded by the Department of Health and has a special focus on reducingsmoking prevalence amongst manual workers and tackling second-handsmoke. It is one of five alliances that link into Smoke Free North West. Itprovides a forum for sharing knowledge and awareness of activities and hasfacilitated Merseyside-wide activities (see 4.4.7).

4.4.6 Heart of Mersey is a coronary heart disease prevention programme thatoperates across Merseyside. It focuses on addressing the lifestyle behaviours -unhealthy diets, lack of physical activity and smoking - that are related to heartdisease. Heart of Mersey has run Merseyside-wide promotional campaignsfocused on these lifestyle issues. It operates a free phoneline and website thatincludes promoting anti-smoking interventions and services that Liverpool andother Merseyside residents can access.

4.4.7 Across Merseyside, a range of initiatives has been launched to reduce smokingprevalence rates and contribute to national goals. Like Liverpool (see section5), each local authority area has a smoking cessation service run in partnershipwith Fagends. In addition, each is developing a range of approaches to takeforward smoking-related agendas. These include action plans, recruitment ofproject officers to take forward smoke free agendas – such as raising



awareness of smoke free issues and encouraging the development of smokingpolicies in workplaces.

4.4.8 The five local authority areas have also combined their actions to workcollaboratively across Merseyside. An example is the Smoke FreeMerseyside Passive Smoking Campaign. Organised by Smoke FreeMerseyside in partnership with Sure Start and Liverpool Health PromotionService, the initiative combined a media campaign with training. TheMerseyside-wide media campaign consisted of radio, adshell, poster andleaflet promotion to raise awareness about passive smoking and to changepublic behaviour. There was also a series of “passive smoking” awarenesssessions with parents, health visitors, midwives and community nurses. Thesessions aimed to highlight the dangers of second-hand smoke and equiphealth professionals with the knowledge to relay key messages to parents moreeffectively. The campaign is now entering a second phase.



5 CURRENT SERVICE PROVISION IN LIVERPOOL________________________________________________

5.1 Introduction

5.1.1 In developing the approach to be taken by Smoke Free Liverpool, it isimportant for stakeholders to take account of existing service provision linkedto reducing the prevalence of smoking in the city. This will help to integratecurrent provision with potential new activity, to avoid duplication and tomaximise synergy between actions. This section presents smoking-relatedservices and initiatives within Liverpool within the following categories:

• smoking cessation services;• smoking prevention and education;• workplace award schemes;• research;• policy development.

5.2 Smoking Cessation Services: Support / Fagends

5.2.1 The smoking cessation service in Liverpool is delivered by a range of smokingcessation advisers. Many “intermediate advisers” such as practice nurses,school nurses, health visitors and pharmacists have been trained to deliver awidespread smoking cessation service. Liverpool Support also deliversspecialist services to pregnant women. There is also a worker who delivers,part-time, a smoking cessation in the workplace service. Future plans includeworking with senior schools to train students to deliver smoking cessationservices in collaboration with Roy Castle Foundation and the School NursingService.

5.2.2 The service works in partnershipwith Roy Castle Fagends, whichprovides a free and confidentialtelephone helpline. AcrossLiverpool there are over 40 stopsmoking courses. The serviceoffers intensive help and supportto smokers wishing to quit. Oneto one and group support areavailable.

5.2.3 Access to the service is throughhealth professional referrals –many GP practices have “in-house” advisers - and self-referral via the Roy Castle Fag Ends helpline. Drop-in smoking cessationsessions are held at a range of venues in Liverpool. Box 5.1 highlightsexpenditure to deliver smoking cessation services in the last financial year.

Box 5.1: Budget for smoking cessation.

In 2002/3, the smoking cessation budget forLiverpool was £570 k. Expenditure totalled£568,347. This breaks down into the followingcategories:

£

Roy Castle: 336,192Central PCT recharges: 60,250Pharmacy: 42,569Publicity: 60,161 Training: 8,517NRT recharges: 38,000Miscellaneous: 22,658

This implies that the cost per person quitting at“the 4-week follow-up” was £195.



5.2.4 Liverpool has consistently met its smoking cessation targets set by theDepartment of Health. For instance, targets for the smoking cessation servicein 2002/3 were surpassed for each of the three PCT areas. For Liverpooloverall, the target was for 1500 people to have quit smoking at “the 4-weekfollow up”. In 2002/3 the outcome for Liverpool overall was 2915 peoplehaving successfully quit at the four week follow-up – almost double the target.

5.2.5 To date, the smoking cessation in the workplace scheme has delivered supportto 32 workplaces whose staff wished to quit smoking. Overall, there were 407referrals into the service with 278 people setting a quit date and 169successfully quitting.

5.2.6 Following its success, table 5.1 illustrates the challenging targets that havenow been set.

Table 5.1: 4 week quit targets for Liverpool PCT areas 2003/4 to 2004/5

Year Central PCT North PCT South PCT Total

03 / 04 1673 708 543 2924

04 / 05 1840 779 597 3216

05 / 06 2063 873 668 3604

Total 5576 2360 1808 9744

5.3 Smoking Prevention and Education

Liverpool Health Promotion Service

5.3.1 Liverpool Health Promotion Service employs a Smoking Prevention Officer.Her agenda involves work around the tobacco control priorities to developsmoke free public places and workplace smoking policies and to engage withsecond hand tobacco smoke issues. The Officer played a leading role in thedevelopment of the Merseyside Passive Smoking campaign (see section 4.4.8).

Healthy Schools Award

5.3.2 Smoking prevention and education is an integral part of Liverpool’s HealthySchools Awards. The awards scheme has engaged with all primary andsecondary schools in the city and ensured that smoking prevention andeducation work reaches all pupils. It has also been a catalyst for ensuring thatall schools have smoke free policies for their premises and grounds. Schoolsfound to be in violation of the policy can have their healthy schools awardrevoked.



5.3.3 Liverpool City Council’s School Effectiveness unit has provided educationaland promotional materials to support the healthy schools programme. Itcontinues to deliver school-based training to teachers to implement it. Ifneeded, the trainers can also deliver the programme directly to pupils withinschools.

Kids Against Tobacco Campaign (KATS)

5.3.4 KATS is part of the Roy Castle Lung Cancer Foundation. It operates aninteractive web-site and provides smoking prevention materials. The websiteprovides access to information about the Liverpool School Children'sLongitudinal Study on Smoking (see section 5.5.1) and to the “World ofTobacco” training that has been developed from its findings. The latterpackage targets 5 to 11 year olds and looks at issues including the tobaccoindustry, the environment and human bodies.

5.4 Workplace Award Schemes

5.4.1 Although there are currently no workplace award schemes operating inLiverpool. Roy Castle Foundation is developing a scheme with the provisionaltitle of Clean Air Award. The City Council has also been considering re-launching its Heart of Liverpool Millennium Award scheme that embracedsmoking in the workplace.

Clean Air Award

5.4.2 The Clean Air Award Scheme would be a national award scheme to recogniseemployers who implement smoking policies and would provide support forimplementing smoking policies in the workplace.

5.4.3 The consultation process to finesse the award scheme and its criteria iscontinuing. However, the final scheme is likely to comprise a range of awards– currently they are categorised as bronze, silver, gold and platinum (see box5.2 for details of current criteria). The level of ward would relate to the extentthat employers restrict smoking at work. For instance, as it currently stands, toachieve the platinum award, employers would need to have a comprehensivesmoke free policy that covered premises, grounds and vehicles. Whilst thebronze award would only require the provision of a smoke free area.

5.4.4 The consultation process for the Clean Air Award has generated debate aboutwhether employers should receive an award for relatively modest levels ofaction to tackle smoking in the workplace. Some argue that such an awardscheme implicitly condones smoking at work. But, most involved in theconsultation process have favoured the view that engaging employers whomight otherwise be reluctant to take part outweighed the disadvantages.

5.4.5 Moreover, to counter concerns about condoning relatively limited restrictionson smoking, the Roy Castle Foundation is considering including a “statementof intention” within the bronze award. This would require employers to



satisfy the criteria for the silver award by a specified date. Failure to do sowould invoke withdrawal of bronze award status. The length of time allowedto reach the silver standard has yet to be finalised.

5.4.6 It is intended that the award scheme will operate on a franchise basis.Organisations wanting to reduce smoking in the workplace will be able to holdthe franchise for a fee of £600 – or £500 for each PCT that they represent. Inreturn, the franchise owner will receive training for a Clean Air Award Co-ordinator and access to resources to implement the scheme. The costs toemployers would be nominal and relate to the purchase of initial certificationand update certification every two years.

Heart of Liverpool Millennium Award

Box 5.2 Clean Air Award Criteria

The following criteria are still being considered.

Platinum:• completely smoke free premises, grounds and vehicles• written policy, prominently displayed• regular review process established• no smoking signage throughout premises• in house cessation service or referral to local cessation service with paid time off, for

smokers, to attend• inform all suppliers and subsidiary organisations of existence of the award requesting

that they consider implementing an effective smoking policy• promotion and publication of benefits of being a smoke free employer

Gold:• completely smoke free premises and smoking not tolerated at entrances or exits• grounds (include) – designated exterior smoking areas permitted so long as ensure

no exposure to second-hand smoke• vehicles, company vehicles smoke free (excluding lease vehicles used by only one

person for journeys to and from work)• written policy, prominently displayed• regular review process established• no smoking signage throughout premises• in house cessation service or referral to local cessation service with paid time off, for

smokers, to attend

Silver:• smoke free premises with separate, fully enclosed smoking area• smoking not tolerated at entrances or exits but designated exterior smoking areas

permitted• written policy, prominently displayed• smoking not allowed when smoking staff share vehicle with non-smokers• smoking cessation advice available for staff, may consist of in-house advice, referral

to local services or information only

Bronze:• provision of smoke free area• written policy prominently displayed



5.4.6 The City Council’s Environmental Health and Trading Standards Departmentran the Heart of Liverpool award. The award criteria relate to food hygiene,nutrition and smoking. Each element is assessed and weighted scoresdetermine the level of award that an employer can receive. From a smokingpolicy perspective, it is seen as a way to encourage food businesses to offer asmoke free environment. The award has three levels – gold, silver and bronze.The award was first run in 2001 and targeted food businesses in the city.

5.4.7 Feedback from the 40 businesses that have received an award indicated thatsuggestions from businesses to improve the scheme included training for staff,information packs and a higher profile for the award.

5.5 Research

Liverpool Longitudinal Study on Smoking

5.5.1 The Liverpool Longitudinal Study on Smoking began in 1994. Funded by theRoy Castle Lung Cancer Foundation, Liverpool John Moores University usesa variety of research tools to identify the attitudes, beliefs, intentions,knowledge and smoking behaviour of school children and their parents fromsix primary schools in Liverpool. The tools are administered each year to thesame group of children. This enables researchers to track how theirperspectives on smoking change as they move through primary and secondaryschool.

Second-hand tobacco smoke in Liverpool workplaces

5.5.2 As observed in section 1.3, a survey of second-hand tobacco smoke inLiverpool workplaces is being conducted in parallel to this scoping exercise.The survey has been designed to:

• build a profile of the extent and type of smoking policies within Liverpoolworkplaces;

• provide evidence of the actual and perceived economic impact of smokefree workplaces;

• explore employers’ perceptions of and attitudes to second-hand tobaccosmoke in the workplace;

• provide evidence of demand for smoking cessation services;• explore interest in participating in an Awards scheme and a Smoke Free

campaign.

Citizens’ Panel

5.5.2 Liverpool’s Citizens’ Panel is to conduct shortly a survey focusing on smokefree public places. At the time of writing, the details of the questionnaire areuncertain but it clearly has the potential to test:

• local views about smoke free workplaces – including restaurants, bars andnight-clubs;



• the proportion of Liverpool’s workforce who work in smoke free premises• smoking prevalence rates in the city;• whether making pubs, restaurants and nightclubs smoke free would

influence respondents’ behaviour as customers - i.e. whether it wouldchange frequency of visits, length of stay etc.

Carbon monoxide levels in pubs and clubs

5.5.3 Liverpool City Council’s Environmental Health Department and LiverpoolJohn Moores University are collaborating on research to test ambient levels ofcarbon monoxide in a sample of Liverpool’s clubs and pubs. The project is atan early stage and the research design is currently being developed.

5.6 Policy Development

5.6.1 Liverpool Health Promotion Service is working with Smoke Free Merseysideand the Strategic Health Authority to develop smoking policies for NHS staffand sites. It is proposed to develop a campaign to support this intervention.



6 PUBLIC ATTITUDES TO SECOND-HAND SMOKE ANDSMOKING IN PUBLIC PLACES________________________________________________

6.1 Introduction

6.1.1 There is currently limited up-to-date information about public attitudes tosmoke free work and public places in the UK. Whilst attitudes to second-handsmoke and smoking in the workplace have been explored by national studies,these have tended to focus on exploring attitudes to restrictions on smoking.They have not generally tapped attitudes to making workplaces or specificpublic places such as restaurants, cafes and pubs smoke free.18 This is animportant distinction.

6.1.2 Moreover, data relevant to public attitudes in Liverpool has not, so far, beencollated. Hence, whilst attitudes in Liverpool could be implied to becomparable with national views, there are no independent surveys to supportthis. The survey with the Citizens’ Panel (see section 5.5.2) could help tobridge this gap.

6.1.3 This section highlights the results of several key surveys that have focused onpublic attitudes to second-hand smoke and smoking in public places. Ithighlights the:

• 2002 ONS nation-wide survey data about smoking restrictions andattitudes to “passive smoking;

• 1998 Guardian ICM nation-wide survey data which did explore publicattitudes to smoking bans;

• August 2003 ICM survey data about public attitudes in Ireland to smokingbans and its effect on behaviour.

6.1.4 Perceptions of the hospitality industry about the likely economic impact ofsmoke free workplaces are examined in section 7.

6.2 ONS Nation-wide Survey

6.2.1 The ONS survey on smoking behaviour and attitudes carried out in 200219

indicates considerable public support for restrictions on smoking at work and,albeit to a lesser degree, within pubs. The survey was designed to exploreviews on second-hand smoking, smoking restrictions and giving up smoking.Key findings included:

• 86 per cent of people thought that there should be restrictions on smokingat work;

• 88 per cent wanted restrictions on smoking in restaurants;

18 The 1998 ICM poll highlighted in this section is an exception.19 Smoking related behaviour and attitudes, 2002 Office of National Statistics



• 87 per cent thought there should be restrictions in other public places suchas banks and post offices;

• 54 per cent thought smoking should be restricted in pubs.

6.2.2 Importantly, the survey also revealed that people had a high level ofknowledge about the effect of “passive smoking”. 90 per cent of respondentsthought that passive smoking increased a child’s risk of getting chestinfections and over 80 per cent thought that it would increase a non-smokingadult’s risk of lung cancer, bronchitis and asthma.

6.2.3 Other findings relevant to the economic impact of smoke free policies and therights of the non-smoker included:

• 55 per cent of non-smokers minded if other people smoked near them;• 66 per cent of smokers said that they do not smoke when they are in a

room with a child and a further 21 per cent stated that they would smokefewer cigarettes when with a child;

• 43 per cent of respondents considered whether or not a place had a non-smoking area was an important factor when deciding to go for a meal and19 per cent when choosing where to go for a drink.

6.3 Nation-wide Surveys of Attitudes to Smoking Bans

6.3.1 In January 1998, the Guardian commissioned an ICM poll that indicated thatthere is widespread public support in the UK for a ban on smoking in publicplaces, including bars and restaurants. Support was apparent across all agegroups and social classes. Support was slightly stronger amongst women thanmen. The results showed that:

• 73 per cent of respondents were in favour of smoking bans at work (59 percent stated that they “strongly approved” of bans at work);

• 64 per cent of respondents were in favour of smoking bans in restaurantsand bars (50 per cent “strongly approved”);

• 80 per cent of respondents were in favour of smoking bans on publictransport (67 per cent “strongly approved”);

• 54 per cent of respondents were in favour of smoking bans in all publicplaces – which could be taken to include smoking in the street (40 per cent“strongly approved”).

6.3.2 A more recent Telegraph YouGov poll (December 2003) suggested thatsupport for a law banning smoking has broadly strengthened. Its resultsshowed that:

• 94 per cent, 87 per cent and 80 per cent of respondents supported smokingbans in shops, offices and factories respectively.

• 83 per cent supported bans in restaurants;• 49 per cent of respondents supported a smoking ban in pubs compared to

41 per cent who opposed one.



6.4 Survey Evidence from Ireland

6.4.1 A recent survey in Ireland was carried out in the light of government proposalsto ban smoking in all public places in January 2004 (see section 8). The surveyexplored whether respondents supported or opposed the proposed ban in arange of premises. The survey found that:

• 58 per cent of respondents supported a total ban on smoking in pubscompared to 37 per cent who opposed it;

• 81 per cent of respondents supported a total ban on smoking in restaurantscompared to 17 per cent who opposed it;

• 60 per cent of respondents supported a total ban on smoking in hotelscompared to 36 per cent who opposed it;

• 55 per cent of respondents supported a total ban on smoking in night-clubscompared to 36 per cent who opposed it;

• 74 per cent of respondents supported a total ban on smoking in places ofwork compared to 23 per cent who opposed it;

6.4.2 The survey also asked whether respondents would be more or less likely to“go to the pub” if the smoking ban was in place. 37 per cent stated that theywould be more likely to go to the pub compared to 25 per cent who said thatthey would be less likely to go.



7 THE FINANCIAL IMPLICATIONS FOR EMPLOYERS OFSMOKE FREE WORKPLACES________________________________________________

7.1 Introduction

7.1.1 An increase in smoke free workplaces in Liverpool would have financialimplications for the city’s economy and for individual employers. This sectionattempts to estimate the cost implications associated with smoking for the cityas a whole and to establish how employers can assess the likely impact it hason their own workplaces. This section also includes a special focus on thefinancial implications for the hospitality sector - as it has particular concernsabout the financial impact of introducing smoke free policies. There arewidespread perceptions from the industry that smoke-free policies will have anegative effect on the trade and turnover of hospitality businesses.

7.2 The Financial Costs of Smoking for Employers

7.2.1 There is mounting evidence that employee smoking imposes costs onemployers. In particular, there is evidence that workers who smoke are absentfrom work more often than their non-smoking colleagues. And time is also lostwhen workers who smoke take “smoke breaks” in working hours. Otherpotential costs relate to costs for cleaning smoke-damaged fabrics anddecorations and higher fire risks with potentially higher insurance premiums.As section 4.3 highlighted, smoking at work also opens up employers to therisk of expensive claims for damages from employees exposed to second-handsmoke.

7.2.2 As a corollary, several advantages of smoke-free workplaces to the employerstand out. These can be summarised as:

• improved employee health and higher productivity;• avoidance of the expected future increase in worker compensation claims

related to second-hand smoke;• lower insurance premiums due to reduced fire risk;• lower cleaning costs.

7.2.3 However, there is limited research to quantify the costs of workplace smoking.Most studies tend to reflect circumstances in the United States and haveadopted diverse methodologies. However, a study by Parrott et al20 to quantifythe costs of employee smoking in Scotland reflects comparable economicfactors to Liverpool. Crucially, its methodology is amenable to establishing an

20 Parrott S, Godfrey C and Raw M, Costs of employee smoking in the workplace in Scotland, TobaccoControl, 2000, 9, 187-192.



estimate of the costs to the economy of employee smoking amongstLiverpool’s workforce.

7.2.4 The Scottish study drew on a baseline survey that explored the different typesof smoking policies within workplaces across Scotland. The ongoing survey ofemployers in Liverpool21 should provide similar evidence and enablecalculations to be finessed to establish a more accurate picture. Importantly,the Scottish study drew on other studies to inform estimates of the effects ofsmoking in the workplace and to develop assumptions about the likely costsand benefits of different restrictive policies.

7.2.5 Evidence from the Scottish survey identified different types of costs andbenefits for employers depending on the type of smoking policy introduced.For example, where employers allowed smokers to take smoking breaks it wasfound that:

• there was a loss of productivity due to smokers taking smoking breaks;• being able to take smoking breaks was perceived to be unfair by non-

smokers – especially when unlimited breaks were permitted;• there was concern about the adverse public image created by smokers

congregating at entrances to buildings.

7.2.6 In financial terms, two major costs can be identified that relate to employeesmoking. These are:

• absence caused by smoking related disease;• productivity losses caused by workplace smoking.

7.2.7 Following the methodology employed by Parrot et al, to calculate theseelements and their impact in Liverpool, it is first necessary to calculate:

• the prevalence of smoking among employees in Liverpool• the productivity of labour• excess absence from work among smokers.

Smoking prevalence

7.2.8 There is no reliable up-to-date picture of smoking prevalence rates inLiverpool. Figures for the Lifestyle survey conducted by HACCRU indicatedthat smoking prevalence rates were below national averages. However,significantly higher SMRs for lung cancer combined with a low response ratefor the survey means that these findings are questionable. National averagesindicate a smoking prevalence rate of 27 per cent ( 28 per cent for males and25 per cent for females).

7.2.9 Whilst public opinion surveys to be carried out in Liverpool should clarifysmoking prevalence rates – and, hence, provide a more accurate figure ofcosts- the calculations at this stage impute national figures also apply at the

21 See section 5.5



local level. Despite the HACCRU findings, these figures are likely to be anunder-estimate.

Labour productivity

7.2.10 As for the Scottish study, these calculations employ the human capitalapproach to calculating lost productivity by assuming that the value ofproductivity lost is equal to the wage rate. Average wage rates are thereforeused to approximate labour productivity. New earnings survey data fromNOMIS indicate that gross average hourly wage rates in Liverpool for allindustries were £12.05 (£13.27 including employers National Insurancecontributions) and £9.02 (£9.85) for men and women respectively.

Cost of absence from work

7.2.11 Following the approach adopted for the Scottish study, estimates of the cost ofexcess absence from work among smokers are based on the results of the DuPont study in the United States.22 This was a study with a large population(over 45,000) and a diversified workforce. the Du Pont study estimates anexcess absence from work among smokers of 0.9 days per year (7.2 hours peryear).

7.2.12 However, as Parrott et al point out, the basis for the calculation needs to betreated with some caution. There are clearly differences in institutionalstructure between the US and UK, and in the penalties faced by employees asa consequence of absenteeism in the two countries.

Cost of absence caused by smoking related- disease

7.2.13 Using the above figures, table 7.1 sets out the calculations to estimate the costof absenteeism caused by smoking in Liverpool. Assumptions underpinningthe calculations are set out in box 7.1.

22 Bertera RL The effects of behavioural risks on absenteeism and health-care costs in the workplace, Jof Occupational Medicine, 1991, 33, 1119-1124.

Box 7.1: Assumptions for cost of absence calculation

This calculation is based on the following assumptions:

1. Liverpool workforce figures based on local area labour force survey (ONS, 2001) – thisis not the same as numbers of people working within Liverpool, which is likely to behigher.

2. Full-time and part-time employment distribution for men and women are based onnational ratios.

3. Part-time workers included as working an average of 15.2 hours per week (LabourMarket Trends)

4. Smoking prevalence rates, wage rates and excess sickness based on sections 7.2.8 to7.2.12.



Table 7.1: Calculation to estimate the cost of absenteeism caused by smokingin Liverpool

Maleworkers

Femaleworkers

Total

Employment:Full timePart time

861129888

4248433516

12859643404

Smoking prevalence rate 28 % 25 % 27 %

Estimated number of smokers:Full timePart time

241112768

106218379

3473211147

Smokers in employment (FTE) 25312 14527 39569

Excess sickness absence perannum (hours) 182246 102650 284896

Wage per hour (including NICs) £13.27 £9.85

Cost of absenteeism £2,418,404 £1,011,102 £3,429,506

7.2.14 Clearly several key variables will affect the magnitude of absenteeism costestimates. Most obviously, the assumptions about the amount of absenteeismthat is due to smoking. In this context, the figures presented above may well beconservative estimates. For example, in contrast to the Du Pont study, a studyusing social security statistics in Northern Ireland23 estimated sickness absenceto be 7.3 days per annum. These estimates derived from applying smokingattributable proportions to the total days absent from work due to ischaemicheart disease, bronchitis, and other respiratory diseases. Applying theseassumptions to the Liverpool case would lead to a seven-fold increase in theestimates of costs to employers because of smoking-related absenteeism.

Productivity losses caused by workplace smoking

7.2.15 Table 7.2 sets out the calculations to estimate the cost to employers ofproductivity losses caused by workplace smoking. The assumptionsunderlying the estimate are detailed below.

23 Nelson H The economic consequences of smoking in Northern Ireland, Belfast: Ulster CancerFoundation, 1986)



Table 7.2: Calculation to estimate the daily productivity loss caused byemployee smoking

Proportionofworkplaces

Employ-ees whosmoke

Time lost(minutesper day)

Wage(hourlyrate)

Cost oftime perday

Total cost

MEN

Smokeroom

0.266 6732 30 £13.27 £6.63 £44,633

Somefree

0.17 4303 30 £13.27 £6.63 £28,528

No policy 0.066 1670 10 £13.27 £2.21 £3,690

Total £76,851

WOMEN

Smokeroom

0.266 3792 30 £9.85 £4.92 £18,656

Smokefree

0.17 2423 30 £9.85 £4.92 £11,921

NoPolicy

.066 941 10 £9.85 £1.64 £1,543

Total £32,120

Box 7.1: Assumptions for productivity losses calculation

This calculation is based on the following assumptions:

1. In the Scottish study, 53 per cent of firms restricted smoking to a “smoking room” and 34per cent of employers operated a smoke free building policy. This figure was comparableto the Department of Health finding that 40 per cent of the UK workforce works in asmoke free environment. However, more recent data now indicates that half of people inwork are not allowed to smoke at all on the premises where they work. Nevertheless,this study for Liverpool assumes that smoking policies in Liverpool are similar to thosefound in Scotland. The ongoing workplace survey should provide reliable local data thatwill enable more accurate calculations to be made.

2. The Scottish study assumed, in the absence of accurate data, that smokers could takeunrestricted smoke breaks in half of smoke free buildings and buildings with smokingrooms – and that in both cases smoke breaks totalled 30 minutes per day. Estimatesfrom a range of studies indicate that a time of loss of 30 minutes per day because ofsmoking is a reasonable estimate. This is equivalent to 5 cigarettes per day at anaverage of 6 minutes per cigarette. This study makes the same assumption.

3. Productivity lost is calculated by valuing the time spent smoking at the average wagerate.



7.2.16 Table 7.2 sets out the daily cost of smoking at work. On the basis of a five-day week and a 46-week year, productivity losses total £25,063,330.

7.2.17 As already observed, other costs are also likely to be imposed on the economybecause of smoking at work. Costs identified have included:

• cleaning and redecoration costs;• damage to equipment and buildings;• damage to an organisation’s image from people smoking;• fire damage and potentially higher insurance premiums.

7.2.18 However, these costs are difficult to generalise, tend to be specific to particularemployers or types of employer and are difficult to quantify.

7.2.19 Of the quantifiable costs, therefore, applying the above methodologies andassumptions to calculating the economic costs of smoking amongst theLiverpool workforce indicates direct economic costs to employers ofapproximately £28.5 million per annum. This comprises £25.1 million fromlost productivity and £3.4 million from higher rates of absenteeism amongstsmokers. These cost estimates exclude other potential costs such as cleaning,decoration and higher insurance premiums. Importantly, they also do not takeaccount of the increasing risk for employers that they may face legal costs andcompensation claims from failing to protect non-smokers at work.

7.3 A Model for Individual Employers

Formula

7.3.1 The above section has focussed on identifying economic costs for employersgenerally from smoking at work and from employees who smoke. However, itcould be useful for individual employers to be able to estimate costs for theirown organisations. This could also be a useful tool for influencing employersabout the type of smoking policy that they implement.

Box 7.3: Calculating the cost of smoking for individual employers

Number of FTE smokers nAverage hourly wage of smokers £yProductivity loss per smoker per day* x minutes

Cost of productivity loss per day = (x / 60) x £y x n

Multiply daily cost by number of annual days for full-timeworker to calculate Cost of productivity loss per annum = £z

Average cost of absence per annum** (£b) = n x £y x 7.2

Total cost of absence per annum = £b + £z

* smoking breaks in addition to normally allowed breaks** applying figure from Du Pont study



7.3.2 Box 7.3 highlights a simple formula that would enable employers to estimatethe costs to their own company or organisation arising from smoking at workand from employees who smoke. An example is set out in box 7.4..

Example

Box 7.3: Example

A firm with 30 employees has 9 full-time workers who smoke. The firm has a smoking room.Smokers take an average of 5 breaks per day more than non-smokers that take about 6minutes each. The estimated cost of smoking to this company using the above formula is: £13,747 per annum. This equates to £1,527 per smoker. NB. This calculation does not include thecost to the employer of making a smoking room available.

Calculation

Number of FTE smokers = 9

Average hourly wage of smokers = £12.50

Productivity loss per smoker per day = 30 minutes

Cost of productivity loss per day = 30/60 x £12.50 x 9 = £56.25

Cost of productivity loss per annum = £56.25 x 230 = £12,937

Average cost of absence per annum = 9 x £12.50 x 7.2 = £810

Total cost of absence per annum = £12,937 + £810 = £13,747

or £1,527 per smoker

Maximising benefits

7.3.3 From a managerial and economic perspective, the simplest policies are likelyto maximise benefits for employers. For instance, a total ban on smoking inthe premises combined with smoking only allowed during official break timeswould generate net financial benefits for employers. Evidence suggests thatsuch policies are not expensive to design and introduce – and, given goodcommunication – staff generally comply24. Equally, successfully encouragingemployees to give up smoking would be likely to generate additional benefitsthrough further reducing absenteeism.

7.4 The Economic Implications of Smoke Free Workplacesfor the Hospitality Sector

7.4.1 Much of the debate about the economic impact of smoke free public places hasfocussed on the implications for the hospitality industry. Broadly, the industry

24 Smoking Policy for the workplace, Health Education Authority, 1999



has been concerned about the impact that making premises smoke free wouldhave on trade. It is generally feared that pubs, restaurants, cafes and nightclubs would lose custom if their premises became smoke free. Businesses fearthat smokers - together with their friends or relations - will go elsewhere or notvisit their premises as much. This section explores those perceptions andexamines the potential implications of such premises introducing smoke freepolicies and practices.

7.4.2 The impact of smoke free policies in hospitality venues is likely to have adifferent dynamic when an area-wide smoking ban is introduced than in thecase where some venues become smoke free and others do not. Equally, thesocio-economic composition of an area or of a venue’s customer base is likelyto affect the economic impact flowing from a change in smoking policies.

7.4.3 This context is particularly important to bear in mind because much of theevidence relating to the economic impact of smoke free hospitality venues hasrelated to legislation banning smoking within all premises. This is animportant difference to the current situation in the UK where there is no suchlegislative framework.

7.4.4 Much of the research into the impact of making restaurants or bars smoke freecomes from the United States, where States and cities have required bars,restaurants and public places to be made smoke free. A range of studies hasindicated neutral or positive impacts on revenues for restaurants or bars wherecities have introduced smoke free regulations25. Scollo and Lal (2002) haveanalysed a comprehensive array of studies26. These studies have assessed theimpact of smoke free policies after they have been introduced and have usedobjective measures such as taxable sales receipts where data points severalyears before and after the introduction of smoke free policies were examinedand where economic conditions are controlled for.

7.4.5 There is also an array of studies that suggest the introduction of smoke-freepolicies is likely to lead to a reduction in business turnover in the hospitalitysector. However, these studies are based on subjective perceptions and manyreflect concerns before the policy is introduced. Significantly, these studiesalso tended to be funded by the tobacco industry.

7.4.6 Similar conclusions can be gleaned from the relatively few studies looking atthe impact of smoke free policies in the UK. Two studies of perceptions of theeconomic impact of smoke free policies indicate proprietors’ broadly negativeexpectations of the likely impact on trade. A survey of proprietors about thepotential impact of making public houses smoke free found that the proprietorsbelieved that, on average, a ban on smoking would lead to them losing about

25 for example Scollo et al (2003) Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry, Tobacco Control, 12, 13-20. Glantz and Smith (1997) Theeffect of ordinances requiring smoke-free restaurants and bars on revenues: a follow up, J of PublicHealth, 87, 1687-1693; Goldstein (1998) Environmental tobacco smoke regulations have not hurtrestaurant sales in North Carolina, Univ, of North Carolina School of Medicine; Glantz (2000) Effectof smoke free bar law on bar revenues in California, Tobacco Control, 9, 111-11226 Scollo and Lal (2002) Summary of studies assessing the economic impact of smoke free policies inthe hospitality sector, VicHealth Centre for Tobacco Control, Melbourne, Australia.



41 per cent of their custom27. Equally, a survey of restaurant proprietors forthe Restaurant Association of Great Britain found that over half ofrestaurateurs believed that a smoking ban would reduce their turnover. 24 percent indicated that it would be likely to reduce their turnover by more than 20per cent. 39 per cent thought it would make no difference but only 1 per centexpected it to increase turnover.

7.4.7 In contrast, perception studies of public house and restaurant proprietors in theNorth East,28 Staffordshire29 and Yorkshire30 that had voluntarily introducedsmoke free areas broadly suggest a neutral effect or an increase in turnoverfollowing introduction of the policy.

7.4.8 Relatively few restaurants or public houses are completely smoke free in theUK. Equally, there are no systematic studies of the impact on their trade.However, anecdotal evidence from individual restaurants or pubs that havegone smoke free suggests that their turnover has increased. However, it isimportant to take into account that, generally, those businesses that havevoluntarily introduced complete smoking bans have judged that their targetclientele would, predominantly, welcome such a move. Typically, thecustomer profile for such venues has a high proportion of families withchildren or from higher socio-economic categories.

7.4.9 A consistent pattern emerges from studies about smoke free hospitalityvenues. They show that prior to smoking bans being introduced, proprietorsare broadly pessimistic about their impact on their businesses. However,objective studies based on analysis of actual turnover suggest that the realityhas tended to be different with the impact on business turnover being eitherneutral or positive.

27 The Publican (2001), Reading the smoke signals, Market Report 2001, Smoking 2001, 2228 Edwards R (200), New study: 76 % of the North East hospitality trade backs smoke free areas andover 90 per cent of publicans recommend other pubs try one. URL:http://www.ash.org.uk/html/press/00720.html29 Parry et al (2001) An evaluation of the introduction of “no smoking areas” on trade and customersatisfaction in 11 public houses in Staffordshire, Tobacco Control, June 2001, 199-20030 Yorkshire ASH (2001) Popularity and impact on trade of smoke-free accommodation in thehospitality trade in Yorkshire, 2001.

Box 7.4: the hospitality sector in Liverpool

Data from Environmental Health records indicates that Liverpool has:

410 unlicensed cafes/restaurants294 licensed restaurants738 public houses171 social clubs

Box 7.5: the SME sector in Liverpool

Data from the Liverpool Business Centre Business Directory indicates that Liverpool has:

6743 organisations with less than 50 employees342 organisations with 51 – 250 employees



8 APPROACHES TO SMOKE FREE AGENDAS: THEPICTURE FROM ELSEWHERE________________________________________________

8.1 A Global Trend Towards Smoke Free Places

8.1.1 Initiatives to create smoke free public environments and workplaces have beendeveloped and are continuing to emerge in many other countries and cities.Globally, more than 60 countries - including the UK - has signed theFramework Convention on Tobacco Control. The next step is to ratify thetreaty, which will become legally binding once 40 countries proceed to ratifyit. However, ratification may prove to be a long and drawn out process.Nevertheless, the treaty is a significant development and highlights theinternational importance placed on tackling tobacco issues. Indeed, it is thefirst global health treaty of any kind. Under the framework convention, the keyobligations of signatories include protecting non-smokers from tobacco smokein workplaces and public places.

8.1.2 At European level, the EU Council of Ministers for Health adopted aresolution31, in 1989, that invited member states to:

• ban smoking in enclosed premises open to the public that provide services;• extend the ban to all forms of public transport• provide, where necessary, for clearly defined areas to be reserved for

smokers• ensure that in the event of conflict – except in areas reserved for smokers –

the right of non-smokers has precedence over the right to smoke.

8.1.3 More recently, the EU’s Health Commissioner has gone on record in callingfor an EU directive to ban smoking in public places. Commission officials aredeveloping a policy that could lead to the drafting of legislation.

8.1.4 Currently, across the EU (excepting the new member states) only the UK andGermany have no specific legislation on smoking in public places. However,although most European countries have some legislation, disregard forsmoking restrictions and a failure to enforce them is widespread. For instance,legislation in Belgium and France is widely perceived to be ineffective, as itdoes not fit with the climate of public opinion that broadly finds smokingacceptable. Equally, there is little political will to enforce the law.

8.1.5 Around the world, many countries have introduced legislation to ban smokingin a variety of settings – such as public transport, schools, hospitals,government buildings and workplaces. Whilst public acceptance, effectivenessand enforcement of legislation varies widely, there are an increasing number

31 EC Resolution 89/C189/01



of examples of smoke free initiatives that are reducing people’s exposure tosecond-hand smoke and cutting smoking prevalence rates. Examples include:

• Finland• Norway• Ireland• United States• Canada• Australia

Finland

8.1.6 Smoking restrictions at workplaces were voluntary until March 1995 whenreform of the Tobacco Control Act prohibited smoking in all common andpublic premises. However, legislation gave employers two options: a total banon smoking or to allow smoking in designated smoking rooms with separateventilation systems.

8.1.7 Research provided evidence that the legislation reduced smoking prevalencefrom 29.6 per cent to 25 per cent. Equally, the average number of cigarettesconsumed daily by smokers fell from 19 to 16.32 Legislation on smoking inrestaurants has also been tightened recently and resulted in significant falls inexposure to second-hand smoke for people working in the catering industry.

Norway

8.1.8 The Norwegian Parliament recently passed an anti-smoking law that will banall smoking in restaurants, bars, pubs and other public places that serve food ordrinks. The primary aim of the legislation is to protect the health of employeesworking in bars and restaurants. The legislation will come into effect early in2004.

8.1.9 This legislation builds on Norway’s long-standing track record ofimplementing tobacco control measures. Three decades ago, Norway was thefirst country to ban tobacco advertising. In 1988 and 1995 the governmentpassed laws banning smoking in many public places – including publictransport, schools and hospitals. And its taxation policy means that Norwayhas the highest cigarette prices in the world.

Ireland

8.1.10 Legislation banning smoking in public places including pubs and restaurants isdue to come into force throughout Ireland in January 2004. Like otherEuropean countries that have introduced smoking bans in public places, theemphasis and rationale for the legislation is to protect the workforce formexposure to second-hand smoke. Given many cultural similarities, the way thatthe legislation is implemented and enforced, the issues it raises and the impactit will have is particularly relevant for Liverpool.

32 Heloma et al (2001) “The short term impact of national smoke-free workplace legislation on passivesmoking and tobacco use”, American Journal of Public Health



United States

8.1.11 Legislation has been introduced at State and City levels in many parts of theUnited States. Bans on smoking in public places have, amongst other places,been introduced in California, New York and Boston. Moreover, much of theresearch into the impact of smoke free policies and practice reflect the USexperience. As highlighted in section 7, objective studies tend to indicate thatthe economic impact for businesses has been neutral or positive. Equally,surveys of public opinion are generally approving of smoking bans at workand in hospitality venues such as bars and restaurants.

Canada

8.1.12 Federal legislation in Canada includes government legislation passed in 1997and 1998 that restrict smoking in the workplace and on public transport.Individual states – such as Manitoba and British Columbia - have passedstricter legislation that prohibits smoking in public places.

Australia

8.1.13 In Australia, like the US, sub-federal government levels have been the drivingforce for the implementation of tobacco control legislation. For instance, allstates in Australia prohibit smoking on government operated urban buses,trams and trains. Equally, in recent years, several states have implementedsmoking bans in many public places – including restaurants.

8.2 Key Lessons

8.2.1 Several aspects of the experience from these various initiatives stand out.These include:

• the use of legislation to bring about effective change;• a focus on the protecting the health of the workforce as the rationale for

banning smoking – especially within bars and restaurants;• testing public support for smoke free initiatives through surveys;• campaigns to generate extensive support for smoke free agendas prior to

the introduction of legislation;• support for people wanting to give up smoking;• effective enforcement measures and sanctions for those who do not

comply;• research to demonstrate the impact of smoke free policies and laws.



9 MAKING LIVERPOOL SMOKE FREE:STAKEHOLDERS VIEWPOINTS________________________________________________

9.1 An integral part of the consultation and smoke free development process wasto provide opportunities for stakeholders to contribute to the development ofthe Smoke Free Liverpool agenda. This was done through face to face andtelephone interviews with a wide range of stakeholders, discussions in theSmoke Free Liverpool Group meetings and collaborative working in an ActionPlan Development Workshop.

9.2 This section highlights the key comments and suggestions highlighted bystakeholders. Comments emphasised issues relating to:

• adopting a comprehensive approach to taking forward the Smoke FreeLiverpool agenda;

• consulting with employers;• working with employers to enhance effectiveness;• tackling inequalities;• the shape of an award scheme for Smoke Free Liverpool;• promotional tactics for a Smoke Free Liverpool launch and publicity

campaign;• ensuring “joined-up” working between different strands of the Smoke Free

Liverpool agenda.

The following highlights key stakeholder observations:

9.3 Comprehensive approach

• The focus on tackling smoking in public and work places is the “next bigstep” in moves to reduce smoking prevalence and exposure to second-handsmoke. But it is crucial that existing and effective smoking cessation,prevention and education work should be maintained and integrated withnew Smoke Free Liverpool interventions.

• A focus on workplace actions should be additional to existing actions. Itshould add value to, not dilute, existing cessation, prevention andeducational activities.

• Unlocking demand within workplaces for smoking cessation serviceswould contribute to achieving the new challenging cessation targets.

9.4 Employer consultation

• There is a need for thorough consultation with the hospitality industry toaddress concerns and avoid misunderstandings about the Smoke Free



Liverpool approach – especially if licensing or the use of by-laws is to betaken forward.

• Consultation with the wider business community should focus onidentifying the most appropriate methods of implementing the Smoke FreeLiverpool agenda.

9.5 Working with employers

• Employers should be engaged in a way that attracts their support andspreads understanding of the smoke free agenda.

• Employers need clarity about the resources available to support them inimplementing smoke free policies.

• Smoke Free dimensions should be built into existing events that alreadyengage effectively with businesses – such as “good practice” or trainingevents around workplace management themes.

• Health and other public sector employers should be visibly seen to be“setting a good example” or, at least, “not setting a bad example”.Although many places are already smoke free, clear guidance should bedeveloped about staff smoking when wearing IDs, uniforms or when inpubic sector vehicles.

9.6 Tackling inequalities

• Targeting SMEs and manufacturing industry could prove an effectivemeans of reaching manual workers who have high smoking prevalencerates.

• Engage with local networks of business associations that aregeographically-based – especially in areas with poor health profiles.

• A workplace focus will not reach many of the most disadvantaged groupsor directly tackle smoking in home environments – this will require newand innovative measures.

• Initiatives to address high smoking prevalence rates amongst black andminority ethnic groups are likely to need a range of approaches that takeaccount of their distinctive characteristics and tobacco-related behaviour.

• More accurate information is needed about smoking prevalence rates andbehaviour amongst black and minority ethnic groups in Liverpool.

• Smoking cessation services should monitor impact on health inequalitiesby including ethnicity and post-code details within its monitoring process.



9.7 An award scheme for Smoke Free Liverpool

• The primary purpose of the award scheme should be to increase thenumber of smoke free workplaces and reduce exposure to second-handtobacco smoke in public places.

• There should be clarity for employers, employees and the public about thefocus and meaning of the award.

• Employers should have an interest in the scheme and recognise its benefitsto them.

• An award scheme – even if it was a pilot scheme – should be ready by thetime of the Smoke Free Liverpool launch.

• The award scheme should be clearly recognisable as being part of theSmoke Free Liverpool campaign.

9.8 Promotional tactics

• High profile smoke free “champions” should be integral to publicity andpromotional work to highlight the Smoke Free Liverpool initiative andcontribute to its objectives.

• Large employers, high profile venues (such as football clubs and theatres)and city gateways (such as Liverpool John Lennon Airport, Lime StreetStation and bus stations) should be encouraged to become smoke free at anearly stage. High profile, early “wins” for Smoke Free Liverpool would, itwas felt, establish its credibility and give it added momentum.

• Smoke Free Liverpool should aim to change the culture around theacceptability of smoking – strategies should aim to shift public perceptionsto “expect” places to be smoke free.

• The potential to exploit a link between developing a “smoke free culture”and the city’s cultural image should be explored.

• Publicity campaigns should be carefully co-ordinated with national andMerseyside campaigns.

9.9 Joined-up working

• There needs to be effective co-ordination between local initiatives to tacklesmoking prevalence and exposure to second-hand smoke.

• It is important for firms implementing smoke free policies to have accessto advice about how to implement policies.



• When employers introduce restrictive smoking policies, employees shouldhave access to support services for those wishing to give up smoking.



10 SUMMARY OF FINDINGS________________________________________________

10.1 Reviewing the Study

10.1.1 This study set out to provide a range of evidence and information that wouldinform how a smoke free agenda could be best taken forward in Liverpool. Ithas identified the policy and legal context which will affect how a smoke freeagenda will be put into action. And it has highlighted the range of currentinitiatives in Liverpool to reduce smoking prevalence and exposure to second-hand smoke that Smoke Free Liverpool should build on. The research haspulled together a wide range of research - related to health risks and impacts,smoking prevalence and inequalities, public opinion and the economic impactof smoking and smoke free policies – whilst identifying gaps that should befilled. It has examined the scope of smoke free initiatives elsewhere and pulledout key lessons. Finally, it has drawn on the considerable expertise of localstakeholders to identify key elements that the Smoke Free Liverpool agendaneeds to take on board.

10.2 Main Findings

Health Risks

10.2.1 The study identified evidence of the health risks from smoking and ofexposure to second-hand smoke. It highlighted:

• the established links between smoking and cancer, heart disease andstroke;

• evidence that working or living with smoking co-workers can increase therisk of lung cancer and heart disease by between 20 and 30 per cent;

• within the workplace context, bar staff and hospitality workers are a highrisk group as their workplaces often have high exposure to second-handsmoke.

Impacts of smoking

10.2.2 By applying population figures for Liverpool to UK statistics and to researchestimates of impacts, the study generated a series of estimates of the healthimpacts of smoking in the city. Specifically, it estimated that:

• 900 people in Liverpool die each year from smoking;• between 61 to 105 people in Liverpool die each year from cancer or

ischaemic heart disease because of exposure to second-hand smoke;• smoking costs the NHS in Liverpool about £12.7 million per annum;• the economic cost to employers of smoking amongst the Liverpool

workforce is approximately £28.5 million per annum.



10.2.3 Because SMRs for lung cancer and coronary heart disease are well abovenational averages, it could be argued that all these figures are under-estimates.

Smoking prevalence and inequalities

10.2.4 Up-to-date and reliable data of smoking prevalence for Liverpool is lacking.Data from the mid-1990s indicates smoking amongst women was above thenational average at 32 to 36 per cent. The North West has a smokingprevalence rate of 29 per cent. Apart from this, the study highlighted nationaldata. This showed:

• 27 per cent of adults in England smoke (28 per cent of men and 25 per centof women);

• 32 per cent of manual workers smoke compared to 21 per cent of non-manual workers;

• a high proportion of Bangladeshi (44 per cent), Irish (37 per cent) andBlack Caribbean (35 per cent) men smoke.

National policy and statutory context

10.2.5 The Smoking Kills White Paper set a target to reduce smoking prevalencerates to 26 per cent by 2005 and 24 per cent by 2010. It led to a ban on tobaccoadvertising, the development of smoking cessation services and anti-smokingcampaigns.

10.2.6 The National Cancer Plan and the NSF for Coronary Heart Disease focus onreducing smoking. The former set a target to reduce smoking among manualworkers to 26 per cent by 2010.

10.2.7 The Public Places Charter which relies on voluntary co-operation to establishsmoking policies in pubs and restaurants has failed to reach its targets and iswidely criticised for the low standards embodied within it.

10.2.8 Health and Safety legislation does not specifically address issues of exposureto second-hand smoke. However, it has been argued that its provisions placea responsibility on employers to protect their workers from second-handsmoke. This interpretation is yet to be tested in the courts.

Implications of court and tribunal cases

10.2.9 Despite the absence of cases to test health and safety legislation, a series ofcourt and tribunal cases indicate that:

• employers must consider the presence of smoke in the workplace and theeffect of exposure to second-hand smoke;

• employees are entitled to a rest room or area that is free from smoke;• smokers are not entitled to smoke at work unless specified in their

contract;



• employers should consult with employees before introducing no smokingpolicies;

• failure by an employer to minimise second-hand smoke could allow anon-smoker to leave the workplace and claim constructive dismissal.

10.2.10 Employers who continue to allow smoking in the workplace risk futureclaims for damages from employees exposed to second-hand smoke.

Local context

10.2.11 Liverpool First for Health and the Smoke Free Liverpool Group partnersprovide a supportive policy context and have prioritised efforts to reducesmoking prevalence and exposure to second-hand smoke.

10.2.12 The City Council is exploring the potential to use licensing powers and by-laws to further smoke free objectives. At this stage, the former seemsunlikely to be possible.

10.2.13 Smoke Free Merseyside and Heart of Mersey are engaging in tobacco controlissues on a Merseyside-wide basis.

Current service provision

10.2.14 The study highlighted the range of smoking-related services and initiativeswithin Liverpool. It demonstrated the importance of maintaining smokingcessation, prevention and education services. It also highlighted thechallenging targets that have been set for the smoking cessation service overthe next three years.

10.2.15 It also flagged up ongoing and planned research and illustrated the potentialof the research to support the delivery and implementation of the Smoke FreeLiverpool agenda.

Public attitudes

10.2.16 Data demonstrating public attitude to second-hand smoke and smoking inpublic places in Liverpool has not, so far, been collated – it is part of theplanned research in the city. However, national studies have indicatedconsiderable support for restrictions on smoking and smoke free publicplaces.

10.2.17 An ONS survey in 2002 found that:

• Over 80 per cent think that there should be restrictions on smoking atwork, in restaurants and most other public places;

• 54 per cent think that smoking should be restricted in pubs.

10.2.18 An ICM poll in 1998 found that:



• 73 per cent were in favour of smoking bans at work;• 64 per cent approved of smoking bans in restaurants;• 54 per cent supported bans in all public places.

Financial implications for employers

10.2.19 There is growing evidence of the costs that employee smoking imposes onemployers. In particular, there is evidence that:

• workers who smoke are absent from work more often than their non-smoking colleagues;

• time is lost when workers who smoke take “smoke breaks” in workinghours.

10.2.20 The study highlighted advantages for employers from smoke freeworkplaces. These include:

• improved employee health and higher productivity• avoidance of expected future increase in worker compensation claims

related to second-hand smoke;• the potential for lower insurance premiums;• lower cleaning costs.

10.2.21 Adopting the methodology employed in a Scottish study to quantify the costsof workplace smoking, the study estimated that the direct economic costs toemployers of smoking amongst the Liverpool workforce is about £28.5million per annum. This comprises £25.1 million from lost productivity dueto smoking breaks and £3.4 million from higher rates of absenteeismamongst smokers.

10.2.22 The study placed a special focus on the hospitality sector. This is partlybecause the industry is perceived as being particularly resistant to theintroduction of smoke free public places and because bar and otherhospitality staff often have high exposure to second-hand smoke.

10.2.23 A consistent pattern emerges from studies. Prior to smoking bans beingintroduced, proprietors are broadly pessimistic about the impact on theirbusinesses. But the reality tends to demonstrate that the actual impact isneutral or positive.

Experience elsewhere

10.2.24 Initiatives to bring about smoke free public places are continuing to emergein many countries and cities – such as Finland, Norway, Ireland, Californiaand New York. Globally, more than 60 countries – including the UK – hassigned the Framework Convention on Tobacco Control. The EU’s HealthCommissioner has recently called for an EU directive to ban smoking inpublic places.



10.2.25 Several aspects of the experience from these various initiatives stand out.These include:

• the use of legislation to bring about effective change;• a focus on the protecting the health of the workforce as the rationale for

banning smoking – especially within bars and restaurants;• testing public support for smoke free initiatives through surveys;• campaigns to generate extensive support for smoke free agendas prior to

the introduction of legislation;• support for people wanting to give up smoking;• effective enforcement measures and sanctions for those who do not

comply;• research to demonstrate the impact of smoke free policies and laws.

Stakeholders Viewpoints

10.2.25 Involvement of stakeholders in the study process generated valuablecomments and suggestions. Comments emphasised:

• adopting a comprehensive approach to taking forward the Smoke FreeLiverpool agenda that integrates existing and effective smoking cessation,prevention and education work with new Smoke Free Liverpoolinterventions;

• consulting with employers – including the hospitality sector – to addressconcerns, avoid misunderstanding and raise awareness;

• working with employers to achieve Smoke Free objectives and and deliverservices in an appropriate way;

• tackling inequalities by targeting manual workers, hard to reach groupsand black and minority ethnic communities;

• developing an award scheme for Smoke Free Liverpool that will increasethe number of smoke free workplaces, reduce exposure to second-handsmoke and be attractive to employers;

• employing a range of promotional tactics for a Smoke Free Liverpoollaunch and publicity campaign including high profile smoke free“champions” and early “wins” by encouraging large employers, highprofile venues and city gateways to become smoke free;

• ensuring “joined-up” working between different strands of the SmokeFree Liverpool agenda.

11 CONCLUSIONS AND RECOMMENDATIONS________________________________________________

11.1 Introduction



11.1.1 This final section sets out a series of recommendations that draw on thefindings of this scoping exercise and which relate to policy directions andactions for next steps. Key themes that a Smoke Free Liverpool agendashould address have emerged from the research. They relate to:

Developing the smoke free agenda

• policy development.

Implementing the smoke free agenda

• licensing and the hospitality industry;• workplace actions;• award scheme;• smoking cessation;• smoke free issues beyond the workplace: smoking prevention / tobacco

smuggling;• promotion and marketing;• influencing national policies.

Supporting the smoke free agenda

• co-ordination and organisational arrangements• financial and fund-raising plan;• monitoring and evaluation.

11.2 Developing the Smoke Free Agenda

Policy development

11.2.1 The scoping exercise demonstrates the potential for ongoing and further workto inform the design and implementation of a smoke free agenda in Liverpooland to enhance its quality and effectiveness. In particular, it highlights that thepolicy development process can be enhanced by taking account of :

• the ongoing survey of employers - being carried out by Inspectors fromthe Environmental Health and Trading Standards Service – that willprovide evidence of local circumstances and the views of local employersabout second-hand smoke;

• the way in which other cities and states developed a clear understandingof local public opinion as a critical part of their process to introduce smokefree initiatives;

• learning from the experience of others about how smoke free agendas haveworked out in practice.

Box 11.1: Recommendations for policy development

It is recommended that to inform and enhance the policy development process –“to get things right” – the Smoke Free Liverpool Group should:

Re Employers survey

• continue the survey of employers and expand it, in partnership with the localHealth and Safety Executive, to factories;

• conduct statistical analysis of the survey data, interpret results and produce,



11.3 Implementing the Smoke Free Agenda

11.3.1 The research has underlined the importance of Smoke Free Liverpool placinga strategic focus on increasing the number of smoke free public places andworkplaces in the city. There is evidence that such a new emphasis is likely tobe the most effective means of reducing exposure to second-hand smoke andcutting smoking prevalence rates. At the same time, the study has highlightedthe importance of maintaining and supporting the city’s well-regardedsmoking cessation, prevention and education initiatives. Indeed, it highlightsopportunities for potential synergies between new and existing interventions.

11.3.2 From a workplace perspective, legislation to ban smoking in the workplacewould have to come from national government – as is the case in Ireland andsome other countries. However, such legislation seems unlikely to beintroduced in the immediate future. This means that local policy makers needto identify other means of achieving the objectives to reduce smoking



prevalence and exposure to second-hand smoke. This section highlights therange of actions that Smoke Free Liverpool could employ to implement acomprehensive smoke free agenda.

Licensing, by-laws and the hospitality sector

11.3.3 It was hoped that the City Council’s new liquor licensing powers couldprovide the opportunity to address smoking in the workplace for premises –like pubs, clubs and restaurants - that require licenses to operate. However,although final legal guidance is awaited, at this stage it seems likely that thelicensing powers will not be able to be used to address smoking in licensedpremises. The scope for utilising by-laws seems to have more potential andcould be applied to all public places.

11.3.4 Experience elsewhere and the views of stakeholders emphasise the importanceof involving the hospitality industry in the development and implementation ofnew regulations. New regulations being introduced in a draconian way or “outof the blue” risk alienating many employers and generating entrenchedopposition.

Workplace actions

11.3.5 In the absence of by-laws, introducing smoke free policies in workplaces willneed to be encouraged through other means. Essentially it means stimulatingemployers to voluntarily adopt smoke free policies. A range of approachescould be adopted including promotional work and advice and guidance.

Box 11.2: Recommendations for pursuing the potential of licensing or by-laws to further Smoke Free objectives

It is recommended that :

• the City Council should obtain a legal judgement of the potential of usinglicensing laws.

• the Smoke Free Liverpool Group should work in partnership with other citiesto draft meaningful and workable by-laws and campaign collectively toachieve Parliamentary approval.

• work towards the implementation of a smoke free dimension to licensingrequirements or by-laws should fully engage the hospitality industry (andother employers in the case of by-laws) in a consultation process to raiseawareness of issues and address concerns. Important factors to exploreinclude timing issues, incentives for businesses, raising awareness of costs,benefits and available support for introducing smoke free policies.

Box 11.3: Recommendations for Actions in the Workplace

In the current policy context, it is recommended that Smoke Free Liverpoolshould:

• introduce a programme of publicity within the workplace to encourageemployers to voluntarily adopt smoke free policies. This should highlighteconomic and health benefits for firms and the threat from future litigationfrom employees who were exposed to second-hand smoke. (Specialattention should be given to ensuring high profile and strategically importantworkplaces – such as hospitals, large employers, high profile venues andcity gateways – adopt comprehensive smoke free agendas).

• develop an advice and guidance service to assist employers to implementsmoke free policies;



Award scheme

11.3.6 The Roy Castle Foundation is developing a smoking policy award scheme (theClean Air Awards) that will have national recognition. At the same time,Liverpool City Council has considered reinventing its Heart of LiverpoolMillennium Award scheme. However, interviews for the scoping exerciseindicated a series of advantages for a national scheme. Specifically, because:

• it is likely to be more attractive to employers – especially firms withworkplaces across the country;

• it provides an opportunity for Liverpool to excel and “to beat” other cities.

However, Smoke Free Liverpool also needs to consider the most appropriatetiming for the implementation of its award scheme and how this fits withdeveloping a city-wide scheme or adopting a proposed national scheme. Thereare also potential advantages from the award scheme being clearly identifiedwith the Smoke Free Liverpool campaign. Compatible branding could raisethe profile of the award and the scheme.

Box 11.4: Recommendations for an award scheme

It is recommended that Smoke Free Liverpool should:

• adopt an award scheme – focused on smoke free environments – that willbe attractive to businesses and which has standards comparable withnational schemes;

• agree the terms, conditions and format of the award in Liverpool and whoshould administer it;

• develop a system to administer the award scheme that dovetails with othersmoke free initiatives and objectives.



Smoking cessation

11.3.7 Liverpool has a successful, highly regarded and extensive smoking cessationservice. It has, year on year, achieved ever increasing targets. Its currenttargets are challenging – particularly taking account of the way in which theservice has dealt with the backlog of demand that the service unlocked in itsfirst few years. The service effectively operates at capacity during peakperiods but there is some spare capacity at other times. There is a more limitedservice that specifically focuses on smoking cessation in the workplace.Currently, one person delivers a part-time smoking cessation service in theworkplace – 32 workplaces have had support for their staff. Clearly, asignificant focus on increasing the number of smoke free workplaces wouldgenerate additional demands on this service.

11.3.8 Linking smoking cessation services to initiatives to increase the number ofworkplaces that are smoke free could generate additional benefits foremployers and employees. It would have economic and health benefits foremployers and employees. It would also contribute to the smoking cessationservice’s targets and Liverpool’s aim to reduce the prevalence of smoking andcontribute to national targets.

Smoke free issues beyond the workplace: smoking prevention andtobacco smuggling

11.3.9 It is important that the emerging emphasis to tackle smoking in the workplacedoes not dilute ongoing work on smoking prevention. In particular, it isimportant that support for school-based initiatives should continue. Equally,

Box 11.5: Recommendations for smoking cessation services

It is recommended that: Liverpool Health Promotion Service and Fagends should:

• expand the smoking cessation in the workplace service and ensure that it iseffectively co-ordinated with the actions outlined above;

• develop a flexible service that is acceptable to employers and employees alike.For instance, in some firms it may be necessary to provide services duringbreaks or outside working hours. Equally, some employees will prefer to accessalternative non-workplace based smoking cessation services. In this context, itwill be necessary to take account of travel to work areas for the Liverpoolworkforce



work with Customs and Excise to tackle cigarette smuggling and counterfeitproducts should be supported.

Promotion and marketing

11.3.10 Maximising the impact and effectiveness of the range of Smoke FreeLiverpool activities outlined above will require an integrated approach tomarketing and promotion. The survey work outlined in the policydevelopment section above is likely to provide valuable information toinform marketing and promotional strategies. Marketing objectives shouldinclude:

• raising public awareness and influencing public opinion about smoke freeworkplaces including, importantly, about making pubs, clubs andrestaurants smoke free;

• raising awareness about and encouraging employers to implement smokefree policies – taking account of the specific circumstances of thehospitality industry, factory workplaces and other private sectoremployers,

• providing support for the key actions outlined above – licensing in thehospitality sector, workplace actions, awards and smoking cessationservices;

• raising the profile and highlighting the achievements of Liverpool theSmoke Free City.

Box 11.6: recommendations for smoking prevention and tobacco smuggling

It is recommended that: the Smoke Free Liverpool Group should ensure that:

• opportunities for synergy between such actions and other activities under thesmoke free agenda are identified and maximised.

• the Healthy Schools Programme remains fully funded to deliver its smokingand wider health messages to primary and secondary school children.

Box 11.7: Recommendations for promotion and marketing

It is recommended that:

• an integrated Smoke Free Liverpool Marketing Plan should be developed thattargets public opinion and employers and supports the key actions. The planshould identify:• the market segments that will require different promotional approaches;• methods of marketing communication (the promotional tools or tactics) to be

used for the different market segments;• a media strategy;• a timetable for promotional activity.

• the overall strategy should take account of the overall emphasis that Smoke



Influencing national policy

11.3.12 Smoke Free Liverpool has the opportunity to take a lead in the UK inimplementing a radical and comprehensive smoke free agenda. It has theopportunity to become an exemplar of good practice and to influencenational debates and agendas. The heightened profile of the city from itsEuropean Capital of Culture status adds to this potential.

11.4 Supporting the Smoke Free Agenda

11.4.1 The study has underlined the importance of developing new interventions tobring about smoke free public places and to reduce smoking prevalence. It isalso apparent that there is a need to co-ordinate new actions with each otherand with existing services and initiatives. Some Free Liverpool, in takingforward a comprehensive tobacco control policy will need to co-ordinateprevention, cessation and workplace actions. It will need to ensure that thereare links between strategic approaches, service delivery, research andpromotional activities. Failure to do this could lead to duplication, missedopportunities for synergy and confused service delivery.

Box 11.8: Recommendations for influencing national policy

It is recommended that Smoke Free Liverpool should:

• devise a strategy for influencing and engaging with key national players andbodies and reaching out to a national audience.



11.4.2 This section considers the organisational and management arrangementsneeded to support an integrated, cohesive and dynamic initiative. It reviewsthe funding position for delivering the recommendations in this report. Finally,it highlights monitoring and evaluation principles that can support and addvalue to the smoke free agenda.

Co-ordination and organisational arrangements

11.4.3 The organisational arrangements for Smoke Free Liverpool need to identifyclear responsibility for distinct roles. These include:

• setting and amending the strategic direction;• co-ordinating actions across all themes;• co-ordinating activities in the workplace;• co-ordinating marketing and promotional work.

11.4.4 The Smoke Free Liverpool Group comprises key stakeholders that have theexperience, knowledge and institutional support to drive the Smoke FreeLiverpool agenda. Its members have:

• good knowledge of local, regional and national smoke free agendas;• detailed and up-to-date knowledge of city and regional affairs and strategic

priorities;• a track record of partnership working• direct links to other key organisations on Merseyside.

11.4.5 The group is well-placed to maintain overall responsibility for theachievement of Smoke Free Liverpool’s strategic objectives, to set policy andto ensure that the initiative overall – and its constituent parts – are functioningeffectively.

11.4.6 As the Smoke Free Liverpool agenda progresses, it is likely that specificaspects of its agenda will require more detailed attention. The Group hasestablished a Communications sub-group and others are likely to be requiredfrom time to time.

11.4.7 HAZ resources have been ear-marked for the appointment of a Smoke FreeLiverpool Programme Co-ordinator. The Co-ordinator should haveresponsibility for ensuring integration of all Smoke Free Liverpool actions.Equally, HAZ resources have been secured for a workplace co-ordinator whowill have primary responsibility for developing and co-ordinating workplaceinterventions.



Financial planning

11.4.8 Taking forward a comprehensive Smoke Free Liverpool agenda andimplementing a raft of new and extended activities clearly requires additionalresources. Financial support for the Smoke Free Liverpool agenda from thecity’s Primary Care Trusts means that the city has been able to take forward itssmoke free agenda promptly. However, the scope and scale of actions mayalter as the Smoke Free Programme gains momentum. This may requirefurther resources.

Monitoring and evaluation

11.4.9 Monitoring and evaluation should be an integral part of the Smoke FreeLiverpool agenda. They should be used to:

Box 11.9: Recommendations for co-ordination and organisationalarrangements

It is recommended that::

• the Smoke Free Liverpool Group should continue to steer the Smoke Freeagenda and ensure that the initiative keeps on track to achieve its goals.

• a central role of the Smoke Free Liverpool Programme Co-ordinator shouldbe to ensure that the various Smoke Free activities work in a co-ordinatedway. The aim should be to maximise the benefits of the human and financialresources devoted to achieving the smoke free objectives.

It is also recommended that the primary tasks of the Co-ordinator should be to:

- act as a central point of contact for Smoke Free Liverpool- drive forward the Smoke Free Liverpool agenda- develop partnership links- oversee the launch of Smoke Free Liverpool- oversee development and implementation of communication,- marketing and promotional agendas- ensure integration of all Smoke Free Liverpool actions- facilitate synergy between workplace actions, smoking prevention- work and tobacco smuggling initiatives- facilitate sharing of mutual experience with other Merseyside Smoke Free

initiatives to identify opportunities for synergy- manage policy development actions- oversee monitoring and evaluation activities- oversee implementation of financial plan- report to Smoke Free Liverpool Group

Box 11.10: Recommendations for financial planning

It is recommended that::

• funding opportunities to add value to existing resources, and as contingency incase of failed bids, are identified - including in-kind support from stakeholders;

• a financial plan for Smoke Free Liverpool is developed and budgets monitoredby the Smoke Free Liverpool Group.



• provide an important management tool and be part of the quality controlprocess;

• identify what is working well and what is less effective;• identify how delivery could be improved in future• contribute to dissemination agendas.

11.4.10 Monitoring and evaluation systems should be used, inter alia to assessprogress in:

• take up of the award scheme;• workplaces becoming smoke free and employees being able to work in

smoke free environments;• reducing smoking prevalence rates;• measurable economic benefits.

11.4.11 In addition, process evaluation should assess how effectively the Smoke FreeLiverpool agenda is being delivered and managed. Issues to focus on shouldinclude:

• the quality of service provision;• the effectiveness of management and organisational arrangements;• how partners and stakeholders are engaged.

11.5 Taking the Smoke Free Liverpool Agenda Forward

11.5.1 Financial support for the Smoke Free Liverpool agenda from the city’sPrimary Care Trusts means that the city has been able to take forward itssmoke free agenda promptly. For this reason, the appendix to this report setsout an Action Plan that incorporates key actions and their timing, provisionaltargets and resource implications. The Action plan flows from theserecommendations and pulls together the series of proposals for funding thathave been submitted to HAZ and to the Department of Health’s section 64grant scheme.

Box 11.12: Recommendations for monitoring and evaluation

It is recommended that: the Smoke Free Liverpool Group:

• uses ongoing research to establish Smoke Free Liverpool baselines;• develops a monitoring framework for tracking progress;• develops an evaluation framework for assessing progress and impact of

specific activities and for the Smoke Free Liverpool agenda as a whole.

Documents

TOWARDS A SMOKE FREE AGENDA FOR LIVERPOOL