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

Chapter 3: Outcomes and targets

What impact will this action plan have on Equalities in Scotland?

100. Smoking is an inequalities issue: health inequalities and socio-economic inequalities tend individuals toward smoking; smoking is a principle driver for health inequality and a contributor to socio-economic inequality. In terms of health inequalities, we still have significant variance in smoking rates when comparing our least well off areas (32%) and our better-off areas (12%).

101. Everything in this action plan is intended to reduce the level of smoking in Scotland. By reducing its levels of smoking, Scotland is likely to be reducing levels of health inequality - when comparing health outcomes between smokers and no-smokers there is a significant inequality relationship. Turning smokers into non-smokers will help balance the health inequalities between those groups.

102. But the ways in which we propose to further reduce levels of smoking must be chosen to ensure that they themselves are not creating other inequalities. Adopting policies which will more likely benefit certain sections of society such as those with better educational attainment levels could introduce inequality of outcomes. The physical and mental health costs as well as the financial costs of smoking are fairly well understood, but evidence suggests that this understanding is greater amongst better-off individuals and communities.

103. To mitigate for that potential inequality of outcomes we must adopt policies and interventions which can equalise that difference in understanding. These will include targeting advice and improving access to, and visibility of, prevention initiatives and support services to individuals and communities that are not so well-off. For this reason we have given our health boards and IJBs targets for successful stop-smoking attempts by people with postcodes in our less well-off communities. We believe this is having the desired effect. In recent years smoking rates in Scotland’s most disadvantaged communities have fallen more steeply than in any other types of community. This can be shown in the table on Smoking prevalence among adults in the Annex to this plan. That table shows the progress towards the 2034 target showing progress in each of the SIMD quintiles we use for our strategy.

104. This is a trend we wish to see continue.

105. Everything possible must be done to improve health literacy universally. We already have in Scotland a health literacy action plan – Making it Easy – and we need to ensure the principles of health literacy in that resource are taken into account in all of our communications and guidance on tobacco control.

106. We have evidence on what sort of interventions and activities are most likely to have a positive impact on inequalities. For interventions intended to reduce youth smoking we refer to the Equity Impact systematic review by Tamara Brown, Stephen Platt and Amanda Amos from 2014. ^[16] The systematic review on adult smoking interventions by the same authors is also a good source of evidence for us to consider. ^[17] These reviews identified studies which showed equity impact as across a range of policy interventions. From the reviews we can see that the interventions most likely to have a positive or at least a neutral impact on inequalities in terms of initiatives targeting adult smoking will likely be: increases in price; focused mass-media campaigns (focussing on NRT for example); controls on advertising; population-level cessation support; settings-based interventions (community, workplace, hospital etc). For initiatives targeted at youth smoking the policies likely to be most impactive on inequalities would also include schools-based prevention.

107. This action plan includes actions on most of these “positive” or “neutral” interventions. So we can with some confidence conclude that these actions in themselves are unlikely to lead to an increase in inequalities.

What will this action plan mean for priority groups?

108. We have tried to include some actions which aim to improve situations for each of our priority groups, over and above the improvements we hope the action plan will have at population level. Our greatest hope for improvement will be for smokers in mental health settings. Raising awareness of the need to take a new approach in these settings and particularly about the possibilities which e-cigarettes being made available in appropriate non- NHS prescribed ways could have a big impact on the physical health of these patients. We hope to learn lessons from the prison environment, where e-cigarettes are likely to become the most commonly used aid for smokers who no longer have access to tobacco. The experience of smokers in prisons are likely to be of great interest to smokers in many other settings.

109. In pregnancy we hope that two new sets of guidance as well as advice in baby boxes on the harms of smoking to unborn babies and children as well as to mothers will have a greater impact on mothers, children and wider families.

110. In acute services, we hope the introduction of offenses for smoking near hospital buildings and more consistent smoking policies potentially at national level –allowing patients and visitors to vape around hospitals - will have a positive impact on patients’ attitudes and behaviours in respect of smoking and accessing stop-smoking services through the new national brand – Quit Your Way.

111. In prisons, we are planning for the introduction of smoke-free prisons and with good quality and consistent through-care when people return to communities we hope there will be a knock-on effect in some of our more disadvantaged communities as a result of the prison tobacco laws.

Targets

112. The aspirations of this action plan must be matched by some meaningful medium and longer term targets. It is not easy to match up a whole plan of actions with specific outcome targets, especially in topics such as smoking where other social and economic determinants such as poverty, adequate housing, meaningful employment and access to high quality education are likely to be key factors alongside or over and above tobacco control or even public health initiatives alone.

113. However, it is important to have some things to aim for. There are a number of population-level measures where we would like to see change, and change which may be at least partly attributable to this action plan. These include the following changes we hope to see by 2023.

Action	Topic
Reducing levels proportionately of tobacco-related mortality/morbidity	ScotPHO [18] reports
Smoking prevalence declining, especially in priority groups (which may require better data collection to be in place)	Scottish Health Survey/Annual Population Survey/ Scottish Survey Core Questions
Continued reporting of low levels of exposure to second hand smoke (especially among young people and children)	Scottish Health Survey (Salcot sampling)
Year-on-year growth in smoker numbers using NHS Scotland stop-smoking services Quit Your Way	NHS National Services Scotland
Year-on-year growth in proportions of successful quits through services	NHS National Services Scotland
Year-on-year drop in the average number of cigarettes smoked	Scottish Health Survey
Year-on-year drop in the number of young people taking up smoking	SALSUS

114. But alongside these general trends, we would like to meet the following specific targets.

By 2034 – smoking prevalence should be at 5% or lower

By 2021 – smoking prevalence for SIMD 1 and SIMD 2 combined should be 20% or lower

By 2022 – the proportion of reported regular smokers among 13-15 years old combined should be 3% or less

By 2023 – smoking prevalence among smokers in the 20-24 years old age group should be 20% or less.

Evaluation

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

116. This review process was very helpful. The 2013 strategy was structured in a way which made evaluation of its impact difficult, so a review of its implementation was more appropriate. However, for this action plan our intention is to set some high-level targets and provide a selection of more detailed indicators for progress across the next five years. We also intend to develop an evaluation framework for the actions, targets and indicators in this plan. NHS Health Scotland will carry out an “evaluability assessment” of the action plan. For those actions most readily evaluable health Scotland will then develop a robust evaluation framework. That will allow for meaningful evaluation of progress during and after the life of the action plan. Oversight for this could be through the Research and Evaluation sub-group of the Ministerial Working Group on Tobacco Control.

117. We will schedule bi-annual evaluation – to be published in 2020, 2022 and 2024. These evaluations of progress will allow Ministers to plan in more detail for the following two years.

118. The tobacco control environment is constantly changing. So to keep this action plan relevant we need to continue to monitor changes and developments. There are some changes we already anticipate which will have an impact on how this plan is implemented. For example, the creation of new public health priorities and a new oversight body for public health will likely mean some change in tobacco control services and initiatives. We will continue to consider how changes such as these will require updates to this plan.

119. We will also continue to monitor how the market for alternatives to cigarettes continues to develop. We will ensure evidence of the potential harms and benefits of electronic cigarettes is constantly monitored. We will also support the monitoring of any growth in the heated tobacco products ( HTP) market, of other technological developments and any evaluation of evidence on HTP links to smoking. If this market grows there may be a need to consider regulating to bring the use of these products into line with existing laws on smoking in public places and the display of tobacco-related products.

120. We will continue to work with partners such as ASH Scotland’s information service to ensure a wide range of evidence summaries are available.

121. 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.