WHO smoke-free city case study. From city to national legislation: a case study of Liverpool s smoke-free intervention

Transcription

1 WHO smoke-free city case study From city to national legislation: a case study of Liverpool s smoke-free intervention.

2 World Health Organization 2011 All rights reserved. Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to the WHO Centre for Health Development, I.H.D. Centre Building, 9 th Floor, 5-1, 1-chome, Wakinohama-Kaigandori, Chuo-ku, Kobe City, Hyogo Prefecture, , Japan (fax: ; wkc@wkc.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

3 Abbreviations CHATs COPD GBP MP NGO SFAC UK USD WHO Community Health Ambassador Teams Chronic obstructive pulmonary disease Great Britain pound Member of Parliament Non-governmental organization SmokeFree Action Coalition United Kingdom United States dollar World Health Organization 1

4 Contents Acknowledgements... 3 Foreword Introduction The Context City Background Tobacco Use and Smoking Behaviour The Health Costs of Tobacco The Tobacco Control and Smoke-Free Policy Context The Smoke-Free Law Key Stages and Elements in Developing and Implementing the Smoke-Free Law Development Phase Preparing for the Legislation Enforcing the Legislation Impact Conclusions and Lessons References

5 Acknowledgements The WHO smoke-free city case study From city to national legislation: a case study of Liverpool s smoke-free intervention was developed for the WHO Centre for Health Development in Kobe, Japan, WHO Tobacco Free Initiative in Geneva, Switzerland and the Regional Office for Europe in Copenhagen, Denmark. It was written by Jon Dawson, Jon Dawson Associates in Chester, United Kingdom. 3

6 Foreword All people have a fundamental right to breathe clean air. There is no safe level of exposure to second-hand smoke (SHS), which causes heart disease, cancer and many other diseases. Even brief exposure can cause serious damage. Only a total ban on smoking in all indoor public places, including workplaces, protects people from the harms of SHS exposure, helps smokers quit and reduces youth smoking. Guidelines to Article 8 of the WHO Framework Convention on Tobacco Control (WHO FCTC) help countries know exactly what to do to protect their people from SHS. An increasing number of countries have adopted legislation to accomplish smoke-free environments. Smoke-free legislation is popular wherever it is enacted, and these laws do not harm business. Any country can implement effective smokefree legislation. However, only a small proportion of the world s population currently has meaningful protection from SHS. While a national law protecting all the people in a country is ideal, cities can often pass legislation sooner than countries. In many cases public sub-national legislation or local regulations can be effective ways to address the issue with measures beyond the legal or political scope of national governments, and even to anticipate or promote national interventions. A growing number of cities and counties across the globe have already taken action. Many cities have every authority to pass comprehensive smoke-free laws to eliminate SHS exposure. If comprehensive smoke-free legislation does not exist at another jurisdictional level, these cities should use their authority to adopt laws or other available legal instruments to prohibit tobacco smoke in these places. Some cities may not have adequate authority to pass strong, comprehensive legislation. However, this does not mean that they should not take action. Most cities will at least have the authority to prohibit tobacco smoke in certain types of workplaces, for example, local public transportation and municipal public buildings. They can adopt legislation prohibiting smoking indoors in whatever categories of establishments they have authority to regulate. In addition, all cities can advocate for action at other governmental levels. Mayors and other city leaders can directly advocate for national comprehensive smoke-free laws. In a joint project, WHO Centre for Health Development, Kobe (WKC) and the WHO Tobacco Free Initiative (TFI) aimed to facilitate local action by documenting the experiences of nine selected cities in becoming smoke-free. Their interventions and processes were examined by local experts, based on evidence from a wide range of local sources. These included documentation, archival records, direct observation, interviews and participant-observation. A case study database was created and the most relevant documents kept on file, including statements from key-informants. Some cities have banned smoking in enclosed public places including workplaces, educational facilities, transportation, shopping malls, restaurants, and bars. Other cities have implemented smoking bans as part of 4

7 comprehensive tobacco control regulations, while imposing other restrictions, for example on tobacco sales and advertisements. Cities use different mechanisms to introduce such regulations and their impact goes beyond the cities adopting the smoke-free policies. The present case is one in a series of nine case studies of cities that have engaged in the process of becoming smoke-free. Although not all of the cities have yet accomplished the goal of becoming a "smoke-free city", they provide lessons learnt in relation to political commitment for local action towards smoke-free air for their citizens and the role of civil society in urging city governments to take action, helping them to build effective partnerships and to conduct awareness campaigns that benefit enforcement and maximize compliance. We hope that these lessons can be used by municipalities to succeed with local smoke-free legislation or tobacco control programmes. Municipal success may trigger action in other cities and countries, and thus contribute to worldwide protection from exposure to SHS. 5

8 1 Introduction 1.1 The UK Parliament s vote in favour of comprehensive smoke-free legislation in February 2006 effectively realised the ambitions of SmokeFree Liverpool to make workplaces in the city smoke-free. Three years earlier, Liverpool First for Health had set a strategic target for Liverpool to become a smoke-free city by the year that the city would celebrate its status as European Capital of Culture. 1.2 In the UK, at that time, a series of events and initiatives were raising the public profile of the importance of reducing exposure to second-hand smoke. The Chief Medical Officer had highlighted the need to address exposure to second-hand smoke as a priority in his 2002 annual report 1 and there were hard-hitting national advertising campaigns about the dangers of second-hand smoke. However, it was widely believed that national legislation to address exposure to second-hand smoke in the UK was further away. 1.3 This case study tells how Liverpool developed and implemented its smoke-free agenda, discusses the impact of its campaigns and identifies lessons learned. 2 The Context 2.1 City Background Liverpool has a population of 435,000 and is at the centre of Merseyside - a wider metropolitan area of 816,000. Historically a port city, Liverpool has a mostly white population though, amongst its diverse community, are significant communities of Somali, Yemeni, Chinese and South Asian populations. The city has amongst the highest mortality rates and one of the lowest levels of life expectancy in the country. There are wide health inequalities between different parts of the city. 2.2 Tobacco Use and Smoking Behaviour Smoking prevalence in Liverpool - despite a decline in recent years is above national averages. Currently, 28% of the city s population over 16 years old are smokers 2. This compares to a nation-wide smoking prevalence of 22%. Smoking prevalence amongst men and women, in the city, is broadly the same. There is also considerable evidence of smoking-related inequalities. Within some areas of the city smoking prevalence is 40% or more, whilst in other, better-off neighbourhoods prevalence can fall below 10%. 2 6

9 2.3 The Health Costs of Tobacco Smoking kills about 109,000 people each year in the UK one in five of all deaths 3. 87% of all lung cancer deaths are attributable to smoking as are 86% of deaths from COPD. * Moreover, smoking causes about one-third of deaths from ischaemic heart disease Half of all lifelong smokers in the UK die prematurely and a quarter of life-long smokers die in middle-age, losing an average of 20 to 25 years of life. Smoking is also the biggest contributor to health inequalities half the difference in life expectancy between the highest and lowest socio-economic groups is attributable to smoking In Liverpool, on a proportional population basis, and extrapolating from a range of estimates of smoking attributable deaths in the UK, about 900 people die each year from smoking 4. Studies in 2003 also implied that between 61 and 105 people were dying in Liverpool each year from cancer or ischaemic heart disease because of exposure to second-hand smoke The Tobacco Control and Smoke-Free Policy Context National Context The Government s 1998 White Paper Smoking Kills was instrumental in providing a focus on tobacco control in the UK. A raft of major initiatives aimed at reducing the incidence of smoking followed its publication. These included a comprehensive ban on tobacco promotion and advertising, the development of new stop smoking services including a free helpline for smokers - more prominent health warnings on cigarette packets and anti-smoking advertising campaigns. However, whilst an advertising campaign focused on passive smoking was launched, measures to reduce people s exposure to second-hand smoke were more limited. Indeed, UK legislation directly related to prohibiting smoking was confined to where smoking affected food hygiene or posed a serious fire hazard In 2003, government initiatives to bring about smoke-free places within the hospitality sector relied on largely ineffective voluntary agreements to provide non-smoking areas and to improve ventilation. A Public Places Charter that was agreed between the Charter Group who represented various pub and restaurant trade associations and the Department of Health, was criticised inter alia for relying heavily on providing ventilation to clear the air of tobacco smoke despite evidence that cast doubt on the effectiveness of such systems The potential to use existing health and safety legislation to bring about smokefree workplaces was also being explored at the time and a body of case law, relating to smoking in the workplace, was starting to build up. Overall, however, * COPD is an umbrella term for a group of lung diseases which include chronic bronchitis, emphysema and small airways disease. 7

10 the absence of all-embracing legislation relating to smoking in public or work places meant that identifying the responsibilities and requirements of employers relating to smoking policies was complex. Although legal experts had spelt out the likely interpretation of statutory legislation and legal developments, there inevitably remained grey areas and uncertainty. Liverpool s Tobacco Control Agenda In 2003, health and local authority partners within Liverpool already had a track record of delivering services to help to prevent people starting smoking, to support them to give up and to tackle smoke-free issues. At that time, efforts to address the health impacts of smoking in the city focussed on the provision of smoking cessation services, health promotion activities to reduce the numbers taking up smoking and specific actions that were beginning to address secondhand smoke. 3. The Smoke-Free Law 3.1 Section 4 of this study describes the actions taken in Liverpool to pursue smokefree legislation. It highlights that Liverpool was working to progress city-wide legislation but its preferred objective was for national legislation. In the event, a national smoke-free law, for which SmokeFree Liverpool was actively campaigning, was introduced. On 14 February 2006, the UK Parliament voted in favour of national smoke-free legislation and the 2006 Health Act, of which the smoke-free legislation was part, was passed. Extent of Smoke-Free Spaces 3.2 The law is highly protective and in line with the Liverpool City Council (Prohibition of Smoking in Places of Work) bill that was progressing through Parliament. The law requires all enclosed public places and workplaces including public transport, company vehicles, restaurants and bars to be 100% smoke-free. Contrasting with an earlier draft of the legislation, and in line with the proposed SmokeFree Liverpool law, there was no exemption for smoking in private members clubs or in pubs that did not serve food. The law came into effect on 1 July Regulations for the law were laid down in a series of Statutory Instruments. 3.3 The law prohibits smoking in all public places and workplaces that are enclosed or substantially enclosed. The Smoke-free (Premises and Enforcement) Regulations 2006, define enclosed or substantially enclosed spaces. Enclosed premises are those that have a ceiling or roof (which includes moveable structures such as canvas awnings) and, except for doors, windows and passageways, are wholly enclosed. Premises are substantially enclosed if they have a ceiling or roof and 8

11 there are openings in walls that are less than half of the area of the walls. The Liverpool Bill, if it had progressed, would have been slightly stricter, permitting smoking only in spaces that are wholly uncovered by any roof, ceiling or canopy, whether fixed or movable. 3.4 The Health Act also made provision for some vehicles to be smoke-free. The Smoke-free (Exemptions and Vehicles) Regulations 2007 specifies that any enclosed vehicle used by members of the public and any vehicle used for work purposes by more than one person must be smoke-free. The Liverpool Bill would also have made vehicles used for work smoke-free. Exemptions 3.5 There are a few explicit exemptions in the national law that permit smoking indoors (the Liverpool Bill did not set out any workplace exemptions). The Smokefree (Exemptions and Vehicles) Regulations 2007, spells these out. Hotels and similar businesses can permit smoking in designated bedrooms. Smoking is also permitted in bedrooms or rooms used only for smoking within care homes, hospices, offshore installations (such as oil rigs) and prisons. For all these exemptions, the regulations set conditions that must be complied with. These include not having a ventilation system that ventilates into any other part of the premises (except other designated smoking rooms). Mental health units had an exemption for the first year, after which they had to be smoke-free. 3.6 There are also exemptions for actors during a performance where artistic integrity makes it appropriate to smoke and for people sampling cigars and pipe tobacco in specialist tobacconists. Other requirements 3.7 The national law requires the clear display of no smoking signs at entrances to smoke-free premises. The Smoke-free (Signs) Regulations 2007 state that signs have to be at least A5 size, display the no-smoking symbol and include the words - No smoking. It is against the law to smoke in these premises. No smoking signs must also be prominently displayed in vehicles where smoking is not allowed. Penalties 3.8 The Health Act states that individual smokers and those who control or manage premises or vehicles can incur penalties where smoking violations occur. The law provides a defence for a failure to prevent smoking if reasonable steps have been taken to stop the violation, if the person responsible did not know that smoking was taking place or if, for other reasons, it was reasonable not to comply with the duty to prevent the smoking. Fines can also be levied for failure to display nosmoking signs. 9

12 3.9 The actual amount of penalties that can be levied are set out in the Smoke-free (Penalties and Discounted Amounts) Regulations They stipulate that: the fixed penalty fine for failure to display required no-smoking signs is 200. If payment is made within 15 days, a discounted amount of 150 applies. the fixed penalty fine for an individual smoking in a smoke-free place is 50 - the discounted amount is Failure or refusal to pay fixed penalties can, on conviction for the offence, lead to maximum fines of 1000 for failure to display signage and 200 for smoking where it is not allowed. The Liverpool Bill, if it had become law, would have allowed the local council to set the level of fixed penalty notices for similar offences, subject to the approval of the Secretary of State Penalty notices are not issued for failure to prevent smoking in a smoke-free place but, if prosecuted and convicted, a maximum fine of 2500 can apply. Enforcement 3.12 Responsibility for the enforcement of the law is laid down in the Smoke-free (Premises and Enforcement) Regulations In Liverpool, responsibility was designated to Liverpool City Council. In practice, an Enforcement Team - including Environmental Health, Trading Standards and Licensing Enforcement Officers - within the City Council were charged with enforcing the law (see section 4.3). 4 Key Stages and Elements in Developing and Implementing the Smoke-Free Law 4.1 Defining the Smoke-Free Issue: Towards a Strategic Consensus In June 2003, Liverpool First - the city s local strategic partnership of public, private, voluntary and community-sector organisations - launched Liverpool First for Health and set the ambition to make Liverpool a smoke-free city by A new SmokeFree Liverpool Steering Group of partner agencies was set up, under the chairmanship of Andrew Hull, the Head of Environmental Health and Trading Standards, to take forward and implement Liverpool First for Health s aspirations. Box i: Steering Group membership Members of the initial Steering Group included representatives from: Central, North and South Liverpool Primary Care Trusts; Liverpool City Council; The Chamber of Commerce; Work; Roy Castle Lung Cancer Foundation The Scarman Trust. Approximately USD 330 at November 2009 exchange rates: GBP 1 : USD

13 4.1.2 SmokeFree Liverpool s approach was built on a sound knowledge base that was shaped by a scoping study, partnership involvement and a formative study visit to New York City At the outset, SmokeFree Liverpool commissioned a scoping study 5 that: provided an overview of the smoke-free debate and the issues and arguments surrounding it; identified good practice; provided evidence of the local situation in relation to the impact of exposure to second-hand smoke and identified where there was a need to acquire further local evidence; collated the views of Liverpool stakeholders about how best to pursue a smoke-free agenda for the city Following a scoping study recommendation, a SmokeFree Liverpool delegation took part in a study visit to New York City in April Joining the delegation were reporters from the local press, local radio and regional television. The aim of the study visit was to learn from New York s experience, to raise awareness of the benefits of pursuing a smoke-free agenda, to understand good practice and to flag up potential pitfalls The New York study visit was highly influential 6. It changed views and the mindset of key partnership personnel. It enabled partners to see explicitly how policy makers had made the smoke-free city happen in New York and there was a confidence that the approach adopted was broadly transferable. Key strategic and process aspects that became embedded in partners approaches related to: the need to frame the debate as a worker health issue; recognising that the hospitality sector needed a level-playing field with few, if any, exemptions; ensuring a high level of awareness of the risks of exposure to second-hand smoke; the value of robust research to provide baselines, refute inaccurate claims and measure progress; the public relations advantages of regular polling of public opinion; integrating smoke-free agendas with other tobacco control activities; the value of having local smoke-free champions and an effective campaign The New York study visit and, a subsequent fact-finding visit to Dublin that enabled knowledge to be gleaned from experience closer to home, also provided crucial, first-hand evidence of the relatively benign economic impact of smokefree legislation on the hospitality sector and allayed fears about the enforceability of the legislation Crucially, following the New York study visit, there was uniformity across the SmokeFree Liverpool partnership that Liverpool s smoke-free activities should 11

14 focus exclusively on workplaces and on workers health. This was a fundamental strategic alignment that was central to the messages that Liverpool put forward and influenced its entire lobbying and marketing strategy in campaigning for smoke-free legislation. 4.2 Development Phase A Comprehensive Programme Approach Building on the New York study visit and the scoping report, SmokeFree Liverpool s strategy adopted two complementary strands. First, the partnership aimed to achieve smoke-free legislation for the city. This strand adopted a twin strategy of pursuing local legislation whilst pushing for the preferred option of a national smoke-free law. At the same time, the partnership placed considerable efforts on encouraging workplaces to become smoke-free voluntarily These overall objectives were approached from several different but integrated directions - lobbying for legislation, working directly with workplaces, engaging with communities and young people and demonstrating leadership from the health sector. Supporting these agendas was a communications strategy and a pragmatic research agenda designed to support the SmokeFree Liverpool agenda and assess its progress. SmokeFree Liverpool had a total budget, for all its activities, of 2.78 million from 2003/4 to 2007/ To drive the smoke-free agenda forward, SmokeFree Liverpool appointed a Project Director, a Project Co-ordinator and established topic specific implementation groups. A new Stakeholder Group - comprising senior representatives of the key partner organisations - was also formed. Legislation and Lobbying At the outset, the Chair of the SmokeFree Liverpool Steering Committee, sought legal counsel to clarify the legislative options available to bring about smoke-free workplaces. Central Liverpool PCT, with the backing of its Director of Public Health, Paula Grey, committed resources to seek expert legal opinions about the potential for utilising existing health and safety legislation, licensing powers and local by-laws The considered judgement was that none of these avenues was likely to succeed. Rather, it was suggested that Liverpool City Council could attempt to pursue a Private Bill in Parliament to obtain a Local Act of Parliament to bring about enforceable smoke-free legislation within the city Whilst partners had varied views about whether there was a realistic chance of Liverpool acquiring its own city law, there was a consensus that pursuing it was a Approximately USD 4.7 million at November 2009 exchange rates: GBP 1 : USD

15 potentially effective means of pushing the Government towards adopting smokefree legislation at national level To deposit the Bill with Parliament, the City Council had, first, to vote formally in favour of pursuing the Local Act of Parliament to make Liverpool smoke-free. In the build up to the Council vote, leading players in the SmokeFree Liverpool partnership, including Gideon Ben Tovim, Chair of Central Liverpool PCT and Ron Gould, the Lord Mayor at the time, were actively involved in lobbying local councillors from across the Council s political spectrum to support the proposal. Partners utilised PR, media and local research evidence to enhance lobbying efforts and to construct a strong case for supporting SmokeFree Liverpool s approach Establishing a cross-party consensus was a key aim to avoid the risk of Liverpool s approach being viewed, locally and nationally, as party political. In the end, the vote in favour of pursuing a Local Act of Parliament was achieved with a substantial majority on October 20 th 2004 and did achieve cross-party support. In November 2004, the local authority s Parliamentary Agent deposited the Liverpool City Council (Prohibition of Smoking in Places of Work) Bill with Parliament. The Bill was sponsored by Lord Faulkner and Louise Ellman, Liverpool Riverside MP The vote in the Council, the local bill, and a subsequent smoke-free conference in the city, raised Liverpool s profile and, arguably, progressed the smoke-free agenda. It established a leading role and national profile for SmokeFree Liverpool and raised awareness of the campaign Parallel to these developments, the UK Government published, in November 2004, its Public Health White Paper Choosing Health. This set out the Government s position with regard to restrictions on smoking in workplaces and public places together with a proposed time-frame for implementation. It proposed that non-exempt licensed premises would need to be smoke-free by the end of Crucially, however, and distinctive from Liverpool s Private Bill, the White Paper proposed to exempt from smoke-free legislation pubs that did not prepare and serve food and private members clubs. These proposals were reinforced in the governing Labour Party s manifesto for the 2005 election SmokeFree Liverpool and others argued that the Government s proposals were flawed in several ways: they would not protect many of the hospitality sector workers most exposed to second-hand smoke at work; they would create an uneven playing field for businesses; they would be likely to exacerbate health inequalities as many of the exempt premises were located in the most disadvantaged areas; they would be problematic to enforce Each of these aspects provided fertile ground for SmokeFree Liverpool and other tobacco control advocates to argue for a more protective smoke-free law. Equally, 13

16 Liverpool s Private Bill took on greater national significance as it set out a clear and more protective alternative to the Government s proposals Throughout 2005 and early 2006, SmokeFree Liverpool, with support from political lobbyists, pursued an active, wide-ranging and innovative lobbying agenda to pursue the Liverpool Bill and to push for comprehensive legislation nationally. At different stages, it lobbied MPs, Peers, Ministers, the Department of Health, Trade Unions and the Hospitality Sector. Key actions included generating numerous responses from the city to the National Government s consultation on its White Paper. It also built alliances with the Smokefree Cities and Communities network and the SFAC, to provide a united front in pushing a smoke-free workplace agenda at national level After a wide-ranging debate within and outside Parliament, in February 2006, MPs voted overwhelmingly in favour of comprehensive smoke-free legislation and rejected the various compromises that would have allowed a series of exemptions for the hospitality sector. Because this would ensure nation-wide comprehensive smoke-free legislation, and achieve SmokeFree Liverpool s aims, the Liverpool Bill was not progressed further but was kept live until the Health Act gained Royal Assent. Workplaces SmokeFree Liverpool s focus on workers health placed the workplace at the centre of its strategy. Led by a Workplace Action Group (WAG), its activities focused on engaging with workplaces to encourage support for a comprehensive smoke-free law at both local and national level, whilst working with employers to encourage workplaces in Liverpool to become smoke-free. Once the Government indicated that pubs that did not serve food and private members clubs would be exempt from the legislation, the smoke-free debate firmly shifted to a focus on the hospitality sector. In turn, SmokeFree Liverpool placed more emphasis on working with hotels, pubs and restaurants. Specific activities included: the development of a package of smoking-related services for businesses such as support in developing smoking policies, providing access to stop smoking services (including a workplace-based service) and encouraging takeup of the National Clean Air Award; educating the local hospitality sector about the rationale for smoke-free legislation and how the law would be implemented - including a further study visit to Dublin, specifically for restaurateurs and pub landlords, to develop an understanding of smoke-free issues and to demonstrate how smoke-free legislation had worked in practice; engaging with Trade Unions to shift their policy position to support for comprehensive smoke-free legislation for workplaces. 14

17 National Health Service (NHS) Strategically, it was essential that the NHS was seen to be leading by example in taking forward a smoke-free workplace agenda. The Primary Care Trusts placed an early emphasis on introducing a smoke-free policy for all their premises. Acute trusts in the city, with support from SmokeFree Liverpool, also began the process of making hospitals smoke-free. Local Communities Local communities played a significant role in SmokeFree Liverpool s campaigning activities. CHATs worked with local people to develop and implement campaigning activities that responded to local priorities. The CHATs worked with local people in encouraging and persuading publicans to hold smoke-free nights in their premises. Holding smoke-free nights at these venues had a high impact as they were not pubs that would typically be expected to support a smoke-free agenda. The events were used to earn media exposure for the SmokeFree Liverpool campaign. Youth Agenda: D-MYST A group of local young people concerned about tobacco-related issues was set up with support from Central Liverpool PCT and integrated into the SmokeFree Liverpool structure. In December 2005, the group adopted the name D-MYST and the initiative was launched. D-MYST s activities have included: awareness raising campaigns targeted at young people - particularly around tobacco industry tactics; ensuring that major youth events in the city are smoke-free; the commissioning of tobacco-related plays that were performed in young persons venues across Liverpool. Communications To support the various actions outlined above, SmokeFree Liverpool adopted a substantial marketing and PR dimension to take forward its campaigns. Between 2003/4 and 2007/8 it allocated 600k to its communications agenda. Key elements included: producing and distributing promotional materials; the SmokeFree Liverpool web-site; a range of conventional and innovative approaches to advertise key messages, including posters, leaflets, taxis and cycle rickshaws; facilitating TV and radio appearances for the SmokeFree Liverpool campaign; maximising media coverage in the press, on radio and on television. Approximately USD 1 million at November 2009 exchange rates: GBP 1 : USD

18 Informants for this case study indicated that the communications programme was successful in involving the media, stimulating public participation, influencing decision-makers and positioning Liverpool as a smoke-free leader nationally. Research The SmokeFree Liverpool agenda benefited from investment in research. Initially, SmokeFree Liverpool partners drew on existing and emerging evidence of the health and economic implications of second-hand tobacco smoke and of the introduction of smoke-free laws elsewhere However, there was widespread recognition of the need to generate locally based evidence to support and inform the SmokeFree Liverpool agenda. Key studies included attitudinal and behaviour surveys of workplaces, residents, visitors to the city and licensed premises together with air quality monitoring studies. They provided: evidence of the need to tackle second-hand smoke in the workplace; evidence of support for smoke-free legislation and for making workplaces smoke-free; baseline information, findings to inform policies and interventions and evidence for monitoring and evaluating impacts; content for press releases and marketing materials. 4.3 Preparing for the Legislation SmokeFree Liverpool placed considerable emphasis on constructing an effective enforcement infrastructure. Ensuring businesses were aware of the law and its implications were central to its implementation strategy in the build up to the law. Key actions included: The training of an enforcement team A Why Wait campaign to encourage workplaces to become smoke-free in advance of the law coming into effect and to build compliance with the legislation. Businesses where difficulties or issues (such as the provision of smoking shelters) were expected to arise were prioritised. Actions included an intensive effort by a team of over 50 trained staff to visit thousands of businesses across the city on one day (100 days before the law came into effect) to disseminate guidance and information about the law. Formal letters, informing businesses of the forthcoming legislation were also mailed out to businesses across the city. 16

19 4.4 Enforcing the Legislation The introduction of the smoke-free legislation went smoothly in Liverpool, as elsewhere in the country, with high levels of compliance from the public and workplaces. SmokeFree Liverpool had decided to adopt a soft approach to enforcement during the first few months after the law came into effect. They intended to warn individuals or workplaces about their responsibilities under the law, rather than issue fines - though any overt attempt to challenge or undermine the law would have been dealt with robustly. Focusing on workplaces where it was anticipated that violations were most likely to occur - such as betting shops and pubs - enforcement officers made visits to these premises to check if the new law was being complied with. After a couple of weeks, earlier than anticipated, and as it became clear that there was very high smoke-free compliance, inspections were scaled back. Enforcement activities have continued through being integrated into the routine tasks of enforcement officers. A national smokefree compliance line was also established. This enables members of the public to report violations of the law. Reports are forwarded to the appropriate local authority for action. In practice, relatively few reports of violations in Liverpool have been made through this reporting line Since the law came into effect, there have been violations, though they have been sporadic and underline the broadly high level of compliance with the law. Most smoking violations have concerned taxis - with taxi drivers smoking in their own cabs. There have also been some instances of pubs permitting smoking to take place - sometimes after hours when the pub had closed its doors. In most cases, these breaches of the law have been dealt with by an enforcement officer visiting the premises to remind them of their obligations under the law. In some cases, official cautions have been issued and, in a few instances, recommendations for prosecution have been issued. Any breach of the legislation for non-display of no smoking signs, continues to be handled by enforcement officers providing new signs and ensuring that they are displayed fixed penalty notices have been issued since March Over 80 per cent of these have been for smoking in taxis. In Liverpool, the only instance, to date, of a successful prosecution under the law was the conviction and fining of three individuals for failure to pay a penalty notice for smoking in the communal areas of a housing association-run, sheltered housing complex. 17

20 5. Impact 5.1 This section considers the impact of the law in terms of: exposure to second-hand smoke; smoking prevalence; intentions to quit; public opinion; the influence that Smoke-free Liverpool exerted on national legislation. Exposure to second-hand smoke 5.2 There is considerable evidence that people s exposure to second-hand smoke in Liverpool has decreased significantly since the law came into effect. Compliance levels demonstrate that indoor smoking in work and public places is far less than it was before the legislation came into effect. The most pronounced difference, in terms of exposure, is likely to be found in pubs and clubs where smoking was widespread before the smoke-free law. 5.3 During the campaign to bring about smoke-free legislation, some opponents argued that a ban on smoking would lead to more smoking at home. As a consequence, it was argued, children and young people would suffer from more exposure to second-hand smoke. However, survey research in Liverpool refutes this claim. It indicates that the ban on smoking has been accompanied by a fall in smoking in the home. Surveys show that prior to the law coming into effect, smoking took place in 34% of homes, in Liverpool, where children live. The latest evidence from a 2009 survey shows that this has now dropped to 25%. 7** Smoking prevalence and smoker intentions 5.4 Research has indicated that smoke-free laws can encourage smokers to quit 8. It shows that: In early 2007, smoking prevalence was 30% and had fallen in the build-up to the legislation. It has continued to decline since. In 2009, smoking prevalence in Liverpool was 28%. 9 Public opinion 5.5 SmokeFree Liverpool s surveys have regularly assessed levels of support or opposition to smoke-free laws. In 2005, 69% of respondents supported smokefree legislation. In 2007, in the build-up to the legislation, 74% of respondents supported the proposed legislation. Following the enactment of the law support reached a new high of 78% in ** More recent survey work exploring the extent that smoking takes place in the home when children are present indicates that for households with children or young people under 18 years old living at home, smoking takes place when they are in the home in 13.2% of households. 18

21 Influence on national legislation 5.6 Although SmokeFree Liverpool played an extensive role in lobbying and pushing for comprehensive smoke-free legislation, it is difficult to identify definitively the precise impact that SmokeFree Liverpool had on the final Parliamentary vote. SmokeFree Liverpool, although widely seen as leading the way, was not alone in campaigning for smoke-free legislation. Other alliances - of which SmokeFree Liverpool was part - also campaigned actively for the smoke-free law. In particular, the SFAC (an alliance, primarily, of NGO and local NHS organisations) and the Core Cities Group (a network of England s major regional cities) extensively lobbied central government to bring forward a comprehensive smokefree law. Individual NGOs with a tobacco control remit, such as ASH and the British Heart Foundation, were also highly active in supporting and pushing smoke-free campaigns, influencing national politicians and providing written evidence to Parliament. 5.7 Nevertheless, SmokeFree Liverpool s range of actions were well-known to Health Ministers and amongst MPs. In particular, through: the Liverpool Bill; a high level of responses from the city to the consultation on the Government s White Paper; providing leadership in encouraging the Core Cities Group to actively campaign for a comprehensive smoke-free law; direct lobbying of MPs and Lords. 6 Conclusions and Lessons 6.1 The approach adopted in Liverpool to take forward its smoke-free agenda highlights important lessons for health professionals, policy-makers and proponents of smoke-free cities generally. Key lessons from the Liverpool experience relate to: 6.2 Focusing on workers health: a focus on protecting the health of the workforce as the rationale for smoke-free workplaces. As elsewhere, this circumvented arguments about the rights of customers to choose smoking or non-smoking venues. It was also an effective advocacy tool and provided a powerful argument for removing exemptions for pubs that did not serve food - as workers in these pubs would often be exposed to particularly high levels of second-hand smoke. 6.3 A clear, comprehensive law. Successful implementation and high levels of compliance were aided by having a law that prohibits smoking in all enclosed workplaces and public places, with very few exemptions. The Liverpool, and wider UK experience, confirms experience elsewhere that such laws are clearer, 19

22 simpler to draft, fairer and easier to enforce. The law also meets the criteria favoured by most of the hospitality sector for smoke-free laws that cover all premises, providing a level-playing field. 6.4 Building compliance and active enforcement. Although compliance was good from the outset, active enforcement demonstrates that the authorities are prepared to enforce the law if necessary. This makes it more likely that people will comply with the law, gives the law credibility and is likely to promote selfenforcement. SmokeFree Liverpool also helped to prepare the ground for the smoke-free legislation by actively raising awareness of the law with the general public and workplaces, and engaging with both to generate support for it. 6.5 A robust policy development process. SmokeFree Liverpool s actions were built on the creation of a sound knowledge base and thorough understanding of the state of the art. The PCTs paid for a scoping report and implemented rapidly its recommendations. Partners knowledge was significantly aided by the study visit to New York. This changed views, and led to a new consensus, not just of the objectives of the smoke-free agenda but about how it should be achieved. 6.6 Effective leadership and partnership. SmokeFree Liverpool benefited from effective and involved leaders and champions who demonstrated a strong drive to make things happen and a willingness to work together. A strong sense of urgency imbued the leadership approach and this maintained the momentum of the development and delivery of the SmokeFree agenda. Crucially, the leadership qualities were prominent at all levels of the partnership at both strategic, management and delivery levels. 6.7 Effective strategies. A hallmark of SmokeFree Liverpool s approach was its adoption of a clear, comprehensive and well-resourced strategy with clear aims and objectives. Partners worked together on many different fronts but with common objectives. Equally, there was flexibility in the pursuit of smoke-free legislation. Whilst SmokeFree Liverpool adopted the high profile approach of striving for a Local Act of Parliament, the partnership was always clear that its preference was for national legislation. 6.8 Programme support. The SmokeFree Liverpool agenda benefited from research capacity, communications and legal expertise and support from professional lobbyists. Building a local evidence base: Interviewees highlighted the value of generating local evidence related to smoke-free issues in Liverpool. Local research helped to root the smoke-free debate firmly in the local area. Given the tactics of pursuing a local Act of Parliament, local evidence was vital. Communications and campaigns. A strong communications and campaigning strand, that presented clear and consistent messages, enabled SmokeFree Liverpool to build a high profile and to raise awareness of its agenda. 20

23 Legal expertise. The involvement of Parliamentary Agents and barristers was vital in steering SmokeFree Liverpool through a complex parliamentary process. Final remarks 6.9 The SmokeFree Liverpool experience and its implementation of the smoke-free law has demonstrated: widespread public support for smoke-free policies; healthier workplace environments when they became smoke-free; widespread compliance with the law and relatively few enforcement difficulties; a significant decline in smoking prevalence rates There are, however, some aspects of SmokeFree Liverpool s approach that limit the direct applicability of its experience to other cities. The first is cost. SmokeFree Liverpool invested considerable resources ( 2.78 million over five years) in progressing its smoke-free agenda. In part, this was a consequence of not having unfettered powers to bring forward its own legislation. There were significant financial costs in progressing the local bill through Parliament. Many cities would struggle to invest funds at the same level as Liverpool did. That said, investment decisions resulted from explicitly prioritising the smoke-free agenda as a cost-effective way of improving public health. Certainly, the long-term payback, flowing from reductions in smoking prevalence and reduced exposure to second-hand smoke, should mean that, in financial terms alone, the benefits will significantly outweigh the costs. For instance, deriving from recent research, 10 estimates 11 have suggested that the reduction of smoking prevalence of 3 per cent in the city could, on a pro-rata basis, generate future savings to the NHS in Liverpool of approximately 4.4 million per annum The second aspect that limits the apparent transferability of Liverpool s experience is that, unlike many cities, it had to obtain national level approval for local action. This clearly influenced SmokeFree Liverpool s tactics and actions. Nevertheless, SmokeFree Liverpool s experience is instructive for other cities wishing to progress smoke-free agendas. In particular, its strategic model offers a convincing framework for progressing smoke-free objectives and, arguably, wider Approximately USD 4.7 million at November 2009 exchange rates: GBP 1 : USD 1.67 These financial benefits to the NHS have to be weighed against longer life expectancies that may consume more health care resources in later life and revenue generated by taxation on cigarettes and other tobacco products. Equally, it does not take account of future smoking-related health costs of smokers who have quit. It also needs to be understood that these savings may only appear in the longer term. For instance, if smokers had not quit, their health costs - and hence the savings if they do quit - would most likely have occurred in later life. 4.4 million is approximately USD 7.3 million at November 2009 exchange rates: GBP 1 : USD

24 tobacco control ambitions. Embodying lobbying and advocacy, working directly with workplaces, engaging with communities and young people and demonstrating leadership from the health sector, SmokeFree Liverpool adopted a comprehensive and integrated approach. Support from a communications strategy involving public relations, media work, campaigning and marketing activities and a pragmatic research agenda bolstered its capacity to ensure a successful outcome. Combined with a skilled, dedicated and dynamic team that was working to clear objectives and had well-defined roles, SmokeFree Liverpool had many of the elements vital to a successful policy outcome. References 1 Getting serious about second-hand smoke, Annual Report of the Chief Medical Officer 2002, Department of Health 2 S Christakopoulou and J Dawson (2009) The 2009 Liverpool Tobacco Control Survey: Smoking prevalence, exposure to second-hand smoke and attitudes to tobacco control interventions, 5 th annual tobacco control survey, a report for SmokeFree Liverpool, Jon Dawson Associates 3 Allender S, Balakrishnan R, Scarborough P, Webster P, Rayner M. The burden of smokingrelated health in the United Kingdom, Tobacco Control, 2009: 0; J Dawson (2003) Towards a Smoke-Free Agenda for Liverpool, Report of the Scoping Exercise for SmokeFree Liverpool, Jon Dawson Associates 5 J Dawson (2003) Towards a Smoke-Free Agenda for Liverpool, Report of the Scoping Exercise for SmokeFree Liverpool, Jon Dawson Associates 6 A case study set out the New York experience and its implications for Liverpool: Jon Dawson Associates (2004) New York: Smoke-free City - a case study for SmokeFree Liverpool 7 S Christakopoulou and J Dawson (2009) The 2009 Liverpool Tobacco Control Survey: Smoking prevalence, exposure to second-hand smoke and attitudes to tobacco control interventions, 5 th annual tobacco control survey, a report for SmokeFree Liverpool, Jon Dawson Associates. 8 Jon Dawson Associates (2004) New York: Smoke-free City - a case study for SmokeFree Liverpool 9 S Christakopoulou and J Dawson (2009) The 2009 Liverpool Tobacco Control Survey: Smoking prevalence, exposure to second-hand smoke and attitudes to tobacco control interventions, 5 th annual tobacco control survey, a report for SmokeFree Liverpool, Jon Dawson Associates 10 Allender et al (2009) The burden of smoking related health in the UK Tobacco Control - published on-line 9 June S Christakopoulou and J Dawson (2009) The 2009 Liverpool Tobacco Control Survey: Smoking prevalence, exposure to second-hand smoke and attitudes to tobacco control interventions, 5 th annual tobacco control survey, a report for SmokeFree Liverpool, Jon Dawson Associates. 22