Raising Scotland's tobacco-free generation: our tobacco control action plan 2018

Chapter 2: Action Plan

A – Informing and Empowering through raising awareness

34. The World Health Organization has set out requirements for nations to help tackle the harms of tobacco in its Framework Convention on Tobacco Control ( FCTC). Article 12 of the framework requires governments to continue to raise public awareness of the consequences of smoking.

35. Over the next five years we will be taking action to raise awareness on: the harms and impacts of smoking; the benefits of stopping smoking; the availability of free, local services which increase chances of successful quit attempts; new legislation which restricts the type of place where smoking is allowed; illicit and illegal tobacco trading; proxy purchasing for underage smokers; and the relative risks of vaping compared to smoking.

36. We will be raising awareness through: support for national marketing campaigns; local advertising and promotion; improved training for care givers across a range of sectors; providing better guidance for traders and enforcers; supporting specific research; and regular evaluation of relevant research from Scotland and elsewhere.

National Campaign Action

37. Table 1 sets out the national campaign activity that we have already planned. The aim is to have at least one truly national campaign each year throughout the life of the plan. However, we will seek every opportunity over the next five years to maximise any other opportunities to raise awareness further.

Table 1: National Campaign Action

Action	Campaign	Timing	Purpose
RA1	“Getting Through 72”	Summer 2018	Encourage more smokers to try to quit. Four-month national and local TV, radio, community action and social media campaign to motivate smokers who are ready to quit – focused on areas where smoking rates are highest and linking to NHS services.
RA2	“Green Curtain”	Autumn 2018	Make smoking less acceptable and protect people in and around hospitals. National and local radio and social media campaign to inform smokers of a new offence – smoking around hospital buildings.
RA3	Smoking in school grounds, near school gates and in play parks	2019 - 2023	Make smoking less acceptable and reduce the visibility of smoking in areas where children learn and play. To borrow the phrasing from the ASH Scotland Charter – every child has the right to health and to grow up in environments where tobacco is mainly out of sight and out of mind. A campaign on this is needed and will be scheduled in the lifetime of this action plan.
RA4	Smoking in communal stairwells	2019 - 2023	Make smoking less acceptable and protect people in communal stairwells – which are not presently covered by smoke-free legislation. A campaign on this is needed and will be scheduled in the lifetime of this action plan.
RA5	Pharmacy window poster campaign	January	Raise awareness of free, local support to quit through community pharmacies. We will organise this poster campaign each January. 70% of smokers access stop-smoking services through their pharmacy.
RA6	No Smoking Day	March	Encourage smokers to make attempts to stop. On the second Wednesday of March in Scotland we annually mark No Smoking Day with a campaign. In 2018 we supported the campaign - #tellusyourway This campaign is linked with the rebranding of our NHS stop-smoking services and will run continuously.
RA7	World No Tobacco Day	May	Highlight the health and other risks associated with tobacco use and policies to reduce tobacco consumption. Every year, on 31 May, the World Health Organization and partners mark World No Tobacco Day. We will ensure this international campaign is marked in Scotland. The focus of World No Tobacco Day 2018 was “Tobacco and heart disease.” The campaign aimed to increase awareness of the link between tobacco and heart and other cardiovascular diseases ( CVD), including stroke, which combined are the world’s leading causes of death.
RA8	Proxy purchase	On-going	Help prevent young people taking up smoking. We continue to support ASH Scotland and local authorities to raise awareness of the dangers of buying cigarettes or tobacco for anyone under 18 through the SCOTSS [10] / ASH campaign - #notafavour
RA9	Illicit cigarettes	2018	Help prevent young people taking up smoking. We are working with governments across the UK on a national campaign to raise awareness on the harms to communities from the trade in illicit cigarettes.

Prevention/Protection Information and Training

38. One of the most effective means of raising public awareness is to make sure that service providers have the most up-to date information and training. ASH Scotland and Cancer Research UK are two organisations, among many, who have provided resources and information to professionals as well as to the public. We will continue to support this.

We will continue to co-fund ASH Scotland to provide important information, advice and training on smoking and health ( RA10).

39. The areas where we will aim to increase understanding in particular are in mental health, looked-after children, and smoking in pregnancy.

In mental health we will support ASH Scotland in rolling out its effective IMPACT ^[11] advice and training on the relationship between smoking and mental health care ( RA11).

40. One third of all cigarettes sold in Scotland are bought by people with mental health problems and smoking rates amongst this group are significantly higher than the national average. Therefore we need to increase efforts to raise awareness of the physical harm that tobacco is doing to people who already could be suffering mentally. Current evidence suggests that smoking reduces effectiveness of mental health medication by up to 50%. That impact cannot be ignored and requires greater awareness of this across health and care staff. We will also help ensure that awareness of this relationship is part of professional health and social care training. Another often overlooked impact of smoking is its link with dementia. A heavy smoker increases their risk of dementia by 70%.

We will continue to support NHS Health Scotland in its research, guidance, training and advice on smoking prevention, protection, cessation, electronic cigarettes and related health equalities ( RA12)

41. Health Scotland provides health boards and other service delivery partners with guidance, training and advice. Its role will develop during the course of this action plan as new public health priorities are agreed for Scotland and a new coordination body emerges. The new body will bring together local government and health body activity on public health. It’s priorities will include tackling the harms caused by smoking. It will have a significant role in prevention. One of Health Scotland’s main points of focus is on supporting healthcare workers address smoking in pregnancy.

42. The proportion of women smoking during pregnancy has fallen slightly but still remains too high. We know that mid-wives and other care providers need to be armed with information and protocols for dealing with smoking in the context of many different issues while there is more pressure to deliver a wide range of prospective brief interventions.

43. To help them provide the most effective interventions on smoking we will ensure midwives and other carers are involved in the further development of I Quit in Pregnancy and the forthcoming advice to parents and practitioners in Ready Steady Baby! – which will be published by NHS Health Scotland in early 2019. ( RA13)

44. The importance of giving up smoking during and after pregnancy is reflected in the prominent inclusion of smoking advice in the Baby Box resources for families with new babies.

Research, evaluation and monitoring

45. We will continue to raise awareness based on monitoring and evaluation of research, and through supporting and commissioning research. For this action plan we have commissioned specific evidence reviews on:

• Availability - What is the causal link between the tobacco outlet density and smoking prevalence?
• Price – Strengths and limitations of tobacco taxation and pricing strategies

46. Links to these evidence reviews and other material can be found in the Publications section of this action plan. The evidence reviews on availability and price were published on 17 May 2018 on the NHS Health Scotland website. These evidence reviews may now lead to further research to help develop policies on price and availability.

We will ensure the action plan is monitored by the Ministerial Working Group on Tobacco Control and is robustly evaluated. ( RA14)

47. NHS Health Scotland co-ordinated an independent review of the tobacco control strategy and published the review ^[12] in November 2017. It also published a qualitative study of expert views ^[13] . These publications provided assurance that the strategy action points had been implemented and the press coverage acknowledged the successes from the strategy.

48. The Ministerial Working Group’s sub-group on Research and Evaluation will see an evaluation framework for this action plan developed and ensure that new and emerging evidence is summarised and made publicly available. ( RA15)

Enforcement and Compliance

49. Regulations which have recently been brought into effect since 2016 and those currently being prepared all require guidance to be made available for enforcement officers, care providers and industry (including retailers). To make sure the guidance takes account of the needs and understanding of everyone, and that it is well distributed, we have relied on people and organisations who represent the views and interests of others. For example, for recent guidance to tobacco and nicotine vapour product retailers on some of the restrictions introduced by the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016, we were grateful for the assistance of the Scottish Grocers’ Federation for the development of guidance. We were also very grateful to the Society of Chief Officers of Trading Standards in Scotland ( SCOTSS) for distributing the guidance to retailers across Scotland.

50. For the introduction of the ban on smoking in a vehicle with someone under 18 in 2016, we were grateful for the help of the Society of Chief Officers of Environmental Health in Scotland in preparing enforcement guidance. We will ensure that all guidance published for enforcement of or compliance with regulations is developed with representatives of the non-tobacco-industry ^[14] groups affected. ( RA16)

51. Another important area in which guidance for retailers and other parts of the tobacco industry is needed is around the complex area of sponsorship. Research has suggested that there may still be some retailers unwittingly entering into agreements with the tobacco industry to promote particular tobacco products - for which the retailers benefit in some way. In law, such an agreement can be interpreted as sponsorship. We will work with trading standards officers in Scotland and with retailers’ organisations to make sure retailers are aware of the circumstances under which sponsorship activity is illegal. ( RA17)

Charter for a Tobacco-free generation

52. We will continue to support ASH Scotland in promoting Scotland’s Charter for a Tobacco-free Generation. ( RA18) The aim of the ASH Scotland charter is to:

• Inspire organisations to take action to reduce the harm caused by tobacco;
• Raise awareness of the goal of creating a tobacco-free generation of Scots by 2034 and;
• Support organisations whose work impacts on children, young people and families to address tobacco issues.

53. The Charter has six key principles that encourage discussion and enable organisations to examine how their own policy and practice can best contribute to the tobacco-free goal:

• Every baby should be born free from the harmful effects of tobacco;
• Children have a particular need for a smoke-free environment;
• All children should play, learn and socialize in places that are free from tobacco;
• Every child has the right to effective education that equips them to make informed positive choices on tobacco and health;
• All young people should be protected from commercial interests which profit from recruiting new smokers;
• Any young person who smokes should be offered accessible support to help them to become tobacco-free.

B– Encouraging Healthier Behaviours

Education

54. We have ensured that the harms of smoking and the benefits of making healthier choices have been included in the Health and Wellbeing strand of Curriculum for Excellence. This is for helping children in schools make better choices instead of smoking. In addition, there is some evidence that the numbers of children reporting they have tried e-cigarettes is increasing. We want to make sure that clear messages are given to children about the impacts of vaping, such as nicotine addiction, as well as the relative risks of harm comparing smoking, vaping and neither so that they can make better-informed choices.

We will support the inclusion of more up-to-date advice on electronic cigarettes into the Health and Wellbeing strand of education in schools in Scotland through the Curriculum for Excellence. ( EB1)

55. We support ASH Scotland in its promotion of Tobacco-free Schools. Our aim is to have all schools tobacco-free. There is a clear difference seen in the proportion of children who begin smoking when comparing their socio-economic backgrounds. So we need to see more action in communities with higher levels of up-take. We will continue to support the call for schools to become Tobacco-free Schools, and look for opportunities to encourage more to take part, especially in areas where there is high smoking prevalence and where teenagers are under most pressure to smoke.( EB2)

56. We already fund the National Union of Students ( NUS Scotland) to work with Scottish Student Sport and ASH Scotland to deliver the Healthy Body Healthy Mind awards project. This funding is used to support universities and colleges across Scotland - to look at the link between smoking, sport, physical activity and mental wellbeing. NUS Scotland works collaboratively with students’ associations, to increase awareness of each institution’s involvement in the awards, to highlight the particular issues they face and to introduce practical changes on campus. The project continues to extend its influence and has increased involvement and registration to now have 27 institutions taking part.

We will continue to support NUS Scotland to promote awareness and help with changes to make more campuses smoke-free. ( EB3)

Informal education and other settings

57. It is more challenging to reach the 16-24 age group outside educational settings. Smoking rates increase significantly in this age group. This uptake remains one of our most significant challenge in prevention activity.

58. Much effort goes into reaching this group through youth work, youth clubs and employability (including through apprenticeship schemes) settings. NHS Lothian has had probably the most success amongst Health Boards in reaching this group. ASH Scotland and NHS Greater Glasgow and Clyde Smokefree Services have developed a tobacco-free policy support guide for organisations, groups and youth workers that work with young people in community settings.

59. However, success through these activities has proven hard to achieve. There is a real need to share experience across health boards of where things have gone well and what sort of barriers to greater success have been difficult to overcome.

We will facilitate a conference in 2019 to consider what more can be done to reach 16-24 year olds more effectively either through youth engagement or employment. ( EB4)

Workplace health improvement

60. NHS Health Scotland publishes advice to employers for the Health Improvement strand of Healthy Working Lives’ programme and awards. This advice covers smoking, healthy eating, drugs, alcohol and physical activity. In the course of aligning our strategies and action plans for our policies, it has become clear that more information is needed about the financial cost of poor employee health. Better information on this would help more employers decide to devote more attention to initiatives such as the Healthy Working Lives programme. For tobacco control, if more employers actively supported employees to give up smoking or supported them to not take up smoking in the first place, the number of smokers overall could be reduced.

We will review the evidence on the impact of smoking and consequent employee health on business costs to help encourage employers to embrace initiatives such as the Health Working Lives programme. ( EB5)

Incentives

61. In Scotland we currently have research and pilots in place which aim to determine whether incentives for giving up smoking in pregnancy or giving up smoking while living in our most disadvantaged communities can be successful. We will analyse the evaluations of incentive pilot studies by NHS Greater Glasgow and Clyde, NHS Lanarkshire and NHS Tayside to consider whether incentives schemes could be extended to other territories. ( EB6)

Discouraging smoking in specific places

62. Following on from the success of the 2006 smoke-free enclosed public spaces legislation in Scotland, there have been calls for this type of restriction to be extended to other public spaces. Banning smoking in cars with children present in 2016 was part of that extension. The next public space within which we plan to make it an offence to smoke is around hospital buildings. The aim of this new restriction is to remove the visibility of smoking from environments in which people are facing health challenges. But the restriction will also help protect people – patients, visitors and staff – from the health risks associated with second hand smoke. We plan to ban smoking around hospital buildings in 2018 – making it an offence to smoke within 15 metres of hospital buildings. ( EB7)

63. Many local authorities in Scotland operate no-smoking policies in school grounds and children’s play areas and play parks. This is another setting where removing the visibility of smoking around children may be considered a positive step. Legislation on this is being taken forward in Wales on that basis. COSLA and Health Scotland have produced guidance for local authorities on creating smoke-free areas which includes school grounds and children’s play parks. We will monitor the implementation of smoking bans in Wales and monitor the implementation of guidance in Scotland to assess whether legislation is warranted in Scotland.

64. One of the most common concerns raised with local authorities about tobacco control is what can be done to stop people smoking in communal stairwells including landings and lifts in high rise or tenement properties. These stairways and landings are not included in the current law as they are usually not public spaces. In high rise and tenement settings these areas are in shared ownership of the flats or properties and are therefore generally, private spaces. Introducing legislation for private spaces would be complex and need to be considered with great care and evidence.

65. However, in the rented sector there may be scope for widening the coverage of tobacco-free clauses in tenancy agreements. Most private tenancy agreements and some social housing tenancies prevent tenants smoking inside. This can drive tenants to smoke in communal areas. Landlords could be encouraged to extend the no-smoking tenancy to cover the area directly outside the properties through additional clauses in the agreement. These clauses could discourage people from smoking in common areas in flatted accommodation such as in stairwells and landings.

66. This idea could be extended to consulting on and exploring with agencies whether new applicants for social housing or relocation could be offered a choice of accommodation in smoke-free housing units – i.e. blocks or tenements in which there was no smoking allowed anywhere, reflecting residents’ choices.

We will explore with local authorities and housing associations the idea of tobacco-free clauses in tenancy agreements and smoke-free housing alternatives being offered in social housing. ( EB8)

67. In five years’ time the tobacco-free generation Scotland is raising will be 10. So we need to make sure that there are smoking prevention activities, education, initiatives and programmes in place to help steer them through the next stage of their lives. Over the next five years we need to establish standards and agreed programmes for education and ensure efforts are being properly and consistently focused. We must give all children equal access to support and information no matter their background. Prevention messaging is often more successful in better-off communities. We must ensure that messaging in future is accessible, available and realistic for all parts of our society.

The Prevention sub group of the Ministerial Working Group will take work forward with practical help from NHS Health Scotland to provide support and guidance to boards and partnerships to ensure prevention initiatives are there for all children and young people. ( EB9)

C – Improving Services

Consistent services and identity

68. Stop-smoking services are provided with guidelines for services through A guide to smoking cessation in Scotland published by NHS Health Scotland in July 2017. However, this is only a guideline and not all health boards or health and social care partnerships adhere to everything in the guide. This is because responsibility for delivering prevention, protection and cessation services is mainly local. A review of cessation services by Health Scotland identified specific improvements to raise awareness amongst smokers of the free, local services which they can access to help them quit smoking. A key recommendation was that stop-smoking services should have a unified national identity.

69. We are now establishing that national identity under the banner of Quit Your Way. All local services will now be identified as Quit Your Way and the Smokeline service is now identified as Quit Your Way Scotland. The aim is to provide a single, identifiable and higher-profile service delivering more consistent services and outcomes across Scotland. The national stop-smoking campaign – Getting Through 72 encourages smokers to try the service, or try it again, and as part of the identity change, services have been revitalised to focus more on the various ways that smokers choose to quit, including with electronic cigarettes.

We will ensure this national Quit Your Way identify is embedded locally and nationally to help smokers know that there are free, local and effective stop-smoking services available to them. ( IS1)

70. Embedding the national identity is an important step but we will now be building on consistent messaging as a Scotland-wide and recognised approach to cessation. Over the life of this action plan we will build on the brand to provide a national Quit Your Way appointment booking system and further rebranding of national and local initiatives on smoking in pregnancy or for mental health initiatives. That could also help increase inclusivity amongst these priority groups. There should be no stigma implied for priority groups by having completely separate service branding.

We will build on the Quit Your Way brand for specific stop–smoking initiatives and services such as for smoking in pregnancy and for smoking and mental health to build inclusivity and help overcome barriers to access for priority groups ( IS2)

Continued integration of services

71. Integration or joining-up of services will be a theme for public health and for tobacco control services over the next five years. In Scotland we have already made strides on this, notably through Health and Social Care partnerships. In many areas it is the partnership rather than the NHS which has responsibility for delivering stop-smoking services. The new public health priorities build on this integration theme, bringing local government activity and health activity together. There will be opportunities for further integration as a result of this.

72. We need to reach out from tobacco control services to primary care to ensure GPs, dentists, mid wives and other professionals are informed and connected. For example, many health professionals will not yet be familiar with the benefits of newer pharmacological products which could be more effective than traditional NRT for most smokers. In acute services, there is still progress to make in ensuring that all smokers admitted to hospital or attending out-patient appointments are provided with timely advice and support to tackle their nicotine addiction. This is even if their reason for attending is not itself smoking-related. Over the life of this action plan we will look for every opportunity to improve the sharing of information with health professionals and improve the provision of stop-smoking advice to patients in hospitals.

73. With the integration of health and social care there are also a large group of specialists and professionals such as social workers and youth workers and other care givers who we need to reach out to. The integration of health and social care should help increase the number of smokers who can be directed to support through these professionals.

74. Boards and Partnerships already work well with Community Pharmacies to deliver stop-smoking services for the NHS. More than two-thirds of supported quit attempts are made through our Community Pharmacies rather than through specialist services provided directly by health boards. Some boards or partnerships have now adopted a shared-care approach where the pharmacological component of the specialist support is provided through community pharmacy. This sort of move will help integrate the support being made available. Integration such as this may help narrow the gap in terms of likely successful quitting between specialist services and pharmacy-only quit attempts. Currently a smoker is around twice as likely to succeed in a quit attempt through a specialist service than through pharmacy-only support. We will continue to work to close that outcome gap.

75. The pharmacological support given to smokers can vary from board to board depending on the approved medicines and medicinal products each board individually agrees as being a part of its “formulary”. In smoking cessation the recent change in status of the drug varenicline, which has been shown to be a more helpful means of quitting than using traditional nicotine replacement therapies ( NRT), is giving hope for helping a larger proportion of smokers to quit. Each board has considered whether or not to switch its first line of treatment from traditional NRT to this newer, more effective product. The Scottish Government is working with boards at the moment to develop a national formulary which will help ensure consistent access to products like this across all board areas.

Priority groups

76. In the previous sections of this action plan we have committed to raising awareness and encouraging healthier choices among some of our priority groups in the context of reducing levels of smoking. These commitments in respect of mental health and smoking in pregnancy must be accompanied by improvements in access to stop-smoking services and in delivery of these services.

77. Another of the groups we already consider a priority for action on tackling smoking is prisoners. With the removal of tobacco from prisons in December 2018, the provision of stop-smoking services in prison is being stepped up. There will be more support and advice made available to smokers while they are in prison and there will be improved through care from prison services out to community services on their release. Improvements in through care will also be reflected in the links between patients making a quit attempt in hospitals and the services available to them when they are discharged back to their communities.

We will ensure the smoker’s journey from cessation services provided for them in hospitals and prisons is as integrated as possible with the services they can expect in their own communities on their return. ( IS3)

78. In particular, NHS Health Scotland will continue to work with health boards and Scotland’s prisons. The shared ambition of that work is to have improved consistency in the availability of behavioural group support, increased consistency in prescribing stop-smoking products across the prison estate and to have improved follow-on support for people leaving prison while still receiving support. The support needs to follow the individual to their local services.

Electronic cigarettes and stop-smoking services

79. Some evidence suggests that successful quit rates for people who get specialist support for their stop-smoking attempt and who use e-cigarettes instead of NRT are at least as likely to succeed as those who get support and use NRT. In Scotland the numbers of smokers using e-cigarettes as part of an attempt to stop smoking is growing. In recognition of this change in smokers’ behaviour our Consensus statement on e-cigarettes ^[15] from 2017 includes advice to health professionals, especially those working in stop-smoking services. The advice is: “Do not turn anybody away because they choose to use e-cigarettes.”

80. On the basis of current evidence vaping e-cigarettes is definitely less harmful than smoking cigarettes. So, e-cigarette use as a means to quit should be seen by health professionals as a tool which some smokers will want to use. To help those smokers, professionals should recognise where advice about using e-cigarettes fits into their overall cessation and harm-reduction advice and be confident about giving this advice.

81. To help professionals we now need to take account of the Consensus statement and other advice such as the 2018 NICE tobacco harm reduction guidance. We need to update training and guidance for health professionals in Scotland. Going forward, we need to make sure health professionals and other carers have a basic understanding of e-cigarettes and how to advise smokers about them.

82. Updated guidance for professionals will be published by NHS Health Scotland. It would be important to set that guidance in context to show that use of e-cigarettes is not what health professionals are recommending for all smokers. Advice on electronic cigarettes should be provided as just one aspect of stop-smoking service support. The strongest evidence from recognised studies is that smokers have the best chances of stopping by combining the behaviour support that stop-smoking services provide with the use of licensed products (i.e. varenicline and traditional NRT).

83. Smokers who wish to make an attempt with support from NHS services through the use of electronic cigarettes should not be turned away. But e-cigarettes not licensed as medicinal products cannot currently be “prescribed” or made available free from the NHS. This is because a medicinally licensed e-cigarette is not available in Scotland, the UK or indeed any other country at this time. This may change in future in which case guidance and training would be updated. Many community pharmacies sell those e-cigarettes to smokers seeking NHS support. Guidance for pharmacists about e-cigarettes would also be helpful.

We will work with health professionals, academics, representative groups and others to develop guidance for health professionals and other relevant service providers so that they can offer basic advice on e-cigarette use as part of their support for smokers who choose to make quit attempts using e-cigarettes. ( IS4)

84. One of the best ways to demonstrate consistency across NHS Scotland on the place of electronic cigarettes in public health would be to settle on a consistent, national approach to whether or not vaping will be allowed by visitors and patients on hospital grounds. Some boards allow vaping and other boards do not allow it. The expectations of boards are set out in their local action plans or smoking policies. Not least because some patients are transferred to other boards and relatives and visitors could often visit patients in different board areas, it would be better to have a consistent approach to whether vaping is allowed or not.

85. The introduction of new offences for smoking within a no-smoking area around hospital buildings will be an opportunity to settle on a national position on vaping. Smoking policies will be updated in 2018 anyway to reflect the new no-smoking area arrangements.

So during the summer of 2018 we will work with health boards and integration boards to try to reach a consensus on whether vaping should or should not be allowed on hospital grounds through a consistent, national approach. ( IS5)

Refining stop-smoking data collection

86. This action plan and a range of other activities rely on the data provided in surveys and through on-going monitoring of progress. This is particularly important in monitoring the success of our stop-smoking services and tobacco control work. Data for these services are recorded by health boards, in specialist services, pharmacies and in prisons. The data is tracked based on recording how many quit attempts have been recorded and then whether the attempts have led to successful quits at 12 weeks. A review of a pilot to centralise follow-up monitoring at 12 months on from a recorded quit attempt has revealed that there is a need to improve the accuracy of data recording. Health boards and pharmacies in particular are actively looking to improve systems and training for pharmacy staff to help ensure data is well recorded. The Scottish Government has also supported pharmacies to make improvements and increase the number of devices per pharmacy on which data can be entered.

87. Smoking status information amongst people engaging with mental health services is one particular area where better data recording would be very useful. As part of our commitment to address the unequal harms of smoking associated with this patient group we will encourage better data collection and reporting.

88. There is scope to improve the sort of data we report on for stop-smoking services. We currently focus on the numbers of quit attempts smokers make and then which of those attempts have led to a successful quit. This method of recording activity does not take account of the fact that most smokers will need multiple attempts to be successful. Data would be more representative of the smoker’s journey if it were tracked and reported by person rather than by quit attempt. We will consider a move to this more person-centred approach.

We will ensure the data-recording process in stop-smoking services is fit-for-purpose. ( IS6)

D – Providing Protection through regulation

89. There are some aspects of tobacco control which require restrictions to be put in place or regulations made. These are intended to ensure people are protected from tobacco smoke or even prevented from smoking or buying and selling cigarettes, tobacco products or e-cigarettes. Scotland has a wide range of restrictions and regulations already in place. Many of the restrictions made here inspire similar action elsewhere. Over the past two years we have seen an almost unprecedented volume of new regulations being introduced and this has meant significant efforts have had to be devoted to implementing these and managing change.

90. The planned regulatory actions in this plan are that we will:

Table 2

Action	Purpose	Timing
PR1	Implement the ban on possession of tobacco in prisons	December 2018
PR2	Regulate to allow use of e-cigarettes in prisons	July 2018
PR3	Consult on the detail of restricting domestic advertising and promotion of e-cigarettes in law	Autumn 2018

91. There have been significant and recent legislative and regulatory changes related to smoking.

92. This requires some space to monitor its impact and to consider where future focus should be.

93. During our engagement over the past two years with representative bodies, health bodies, local authorities, third sector campaign groups, academics and the public we have been told that restrictions would be most useful for limiting demand and supply. From the suggestions which have been made we believe there is merit in exploring the following candidates for regulations. None of these would be considered in detail without full formal consultation.

94. Our action plan is to gather evidence, assess the potential impacts of, and potentially legislate where appropriate, over the next 5 years on, the suggestions in Tables 3 and 4.

Table 3 - Restricting Demand

Action	Topic	Details	Justification
PR4	Smoke-free communal landings	Communal landings and stairwells such as in tenements are, in law, not public places, as these are commonly owned by the owners of the properties served. Extending the smoking ban to these areas could require legislation to be approved by the Scottish Parliament.	Since the implementation of the smoke-free legislation in 2006 many people have expressed frustration that smoking is still allowed in communal stairwells and landings, such as in tenements and high-rise buildings. This is considered by many to be a nuisance and there is evidence to suggest that the levels of risk from second hand smoke in these places warrants an extension of the existing law to cover these areas.
PR5	Making cigarettes less attractive	For the same reasoning which led to the introduction of standardised cigarette packaging, legislation could be made to make cigarettes less attractive. This could be done through changes to colour, composition and/or warning messages on each stick.	There is some evidence that dissuasive colour or dissuasive messages on cigarettes could reduce the attractiveness of, and therefore the potential demand for, cigarettes. Other studies have considered composition – reducing the nicotine level or flavours that mask the true taste.
PR6	Ban the use of Heated Tobacco Products ( HTP) from public places	Using HTP is so similar to smoking that it may warrant inclusion alongside “lit cigarettes” in the smoking ban legislation.	Because they are not “lit”, heated tobacco products are not covered by the ban on smoking in public places. Some people have called for action to extend the current smoking ban to include HTP.
PR7	Ban on attractive flavourings in HTP	HTP companies may capitalise on the forthcoming ban on flavourings from cigarettes by offering those flavourings in HTP	With attractive flavourings such as menthol being banned from cigarettes, some people have asked that we impose the same restriction on HTP
PR8	Introduce standardised packaging for HTP	Amend the legislation on standardised packaging to include HTP	HTP are not covered by legislation which makes packaging indistinctive or unattractive.

Table 4 - Restricting Supply

Action	Topic	Details	Justification
PR9	Further restrict availability of tobacco products	Restricting the number and the clustering density of tobacco retailers could make tobacco products less available, and therefore could reduce smoking rates.	We have reviewed evidence on the link between tobacco availability through retail outlets and local smoking rates. This suggests that restricting the number of outlets, particularly where smoking rates are highest (such as in more deprived communities) could have a positive effect on reducing smoking rates.
PR10	Consider additional price interventions for tobacco products	Assessing what further pricing measures could impact on consumption and the purchase of tobacco products could point to further innovative actions to reduce smoking rates.	Increasing the price of tobacco has been shown by research to be the most effective way of reducing demand for it. The UK already has restrictive tax measures in place and has introduced a minimum excise duty for cigarettes.
PR11	Conditional registration or licencing of retail or changes to planning guidance	One mechanism for introducing any new measures on the availability or the price of tobacco would be to introduce compliance conditions into our retail registration scheme or to introduce a form of licensing.	If there are any more creative or effective measures we could introduce on availability or price one way of implementing these could be through conditional registration. This is likely to be the option which creates least disruption to business. This would need to be considered very carefully around compliance and enforcement to avoid increasing the regulatory burden. Amending national planning priorities guidance could also be considered as an option.

Enforcement

95. The effect of existing restrictions as well as any new restrictions or regulations that may be introduced as a result of this action plan relies on good, proportionate enforcement. This is the good work done particularly by trading standards, environmental health and other local authority officers in Scotland. Enforcement is more than just inspection and taking legal action where offences have been committed. It also involves monitoring activity and record keeping. It involves a great deal of giving advice and giving informal and formal warnings where appropriate.

96. We will continue to rely on our enforcement authorities to help deliver change and improvement in tobacco control and in other public health policies and strategies. Scotland’s achievements in discouraging under-age sales of tobacco, removing the visibility of cigarettes in shops and supporting businesses and organisations to become and remain smoke-free owes much to enforcement colleagues.

97. Existing enforcement activity – inspection, test purchasing and advice visits - on under-age sales, proxy purchasing and illicit tobacco trading help restrict the supply of tobacco to young people in particular. This will have helped drive down the numbers of children and young people who take up smoking in Scotland. On tackling illicit sales, the support given to local councils by the Society of Chief Officers for Trading Standards in Scotland ( SCOTSS) – who provide funding for Scotland’s detection dog – have been vital in adding value at a local level. We are grateful to SCOTSS for providing and distributing guidance on test purchasing for tobacco and Nicotine Vapour Products ( NVP) including e-cigarettes. SCOTSS has also provided new guidance for enforcement officers for the new regulations from the Health Act 2016.

98. As mentioned earlier in this plan, the Society of Chief Officers for Environmental Health in Scotland ( SCOEHS) has also provided guidance for enforcement officers. SCOEHS is also helping NHS hospital prepare for the new smoking offences that will be introduced this year in respect of smoking near hospital buildings. Under the forthcoming hospital building smoking regime it will be for NHS managers to ensure that all steps are taken to stop individuals smoking near buildings. Local authority officers can provide advice and assist with targeted initiatives to raise advice. For significant or persistent offences local authority officers now have powers to give offenders fixed penalties or where appropriate refer cases to a procurator fiscal for prosecution.

99. Over the course of this action plan it is likely that the markets for e-cigarettes and novel heated tobacco products will develop further. This could mean that the current focus of tobacco control enforcement changes over time to take account of these newer markets. For example if there were changes to the law on restricting the sales of non-nicotine-containing e-liquid for e-cigarettes this would have implications for enforcement. There may also need to be programmed initiatives on ensuring e-liquids are authorised products and perhaps even on whether these age-restricted products are being marketed in a way which primarily appeals to young people.