December 2002, pages 360-362 Three years on, and serious questions are being raised on the success of the public places charter. Sue Blakeley reports on Birmingham's 'Smoke-free project'

In December 2001, Birmingham City Council's environmental and consumer services department was approached by the former Birmingham Health Authority to consider the formation of a tobacco control alliance and to begin greater collaborative work to address tobacco-related issues that impact upon the health of the Birmingham community.

The former health authority recognised the key role that environmental health officers and trading standards officers have towards the wellbeing and health agenda in the areas of smoking in the workplace, underage sales of tobacco and the promotion of smoke-free eating and drinking establishments. It was also important to consider the potential effects upon commerce and law enforcers resulting from the forthcoming approved code of practice (ACoP) "Passive smoking in the workplace". At the strategic level, the potential value of a city developing a tobacco control strategy was recognised.

Government and smoking

The worked carried out in Birmingham was done so within the context of the white paper on tobacco - Smoking kills - published in 1998. This document set out the Government's commitment to reducing the number of people starting to smoke, helping smokers to stop and protecting people from exposure to environmental tobacco smoke. It identified the valuable contribution that local authorities can make to achieve these goals.

Smoking kills 120,000 people in the UK each year and is a major cause of cancer and heart disease. Research has shown that the vast majority of smokers take up the habit as teenagers. Those who smoke regularly reduce their life expectancy by an average of 16 years. Chewing tobacco used by ethnic groups also causes cancer and leads to increased rates of premature death.

Undoubtedly, passive smoking - breathing in other people's tobacco smoke - also kills and several hundred people die from lung cancer brought about by passive smoking in the UK each year.¹ Also, children whose parents smoke are more likely to develop lung illness, including asthma, than those from non-smoking parents.

The white paper refers to the close link between health inequalities and smoking. There has been a relatively stable rate of smoking in the least advantaged groups (those in unskilled jobs and the unemployed) while there has been a reduction in smoking among those in professional jobs. Smoking is estimated to cost the NHS up to £1.7bn every year.

While there have been gradual improvements in the provision of non-smoking facilities in Birmingham, there is great potential for improvement. The greatest development and implementation of smoking policies has been carried out in education and health establishments. The health risks associated with passive smoking are clear. It is generally accepted that a non-smoker, living or working in a very smoky environment over a prolonged period, is 20 - 30 per cent more likely to get cancer than a non-smoker who does not.

If and when the proposed ACoP comes into force, it will improve protection of the welfare of all employees by defining the kind of smoking policies employers need to operate to comply with existing health and safety legislation by following the practical advice given. Employers who follow the code will be able to demonstrate compliance with the health and safety law relating to this issue. Health and safety, trading standards and environmental health officers who already visit food businesses, offices, warehouses and shops to fulfil existing statutory requirements and are best placed to educate employers about the new code.

Public places charter

In 1999, the hospitality industry's "charter group" launched the public places charter (PPC) on smoking. The charter is based on an agreement between the key hospitality associations and the Government, as set out in the white paper on tobacco control. The charter, a voluntary agreement between the Government and the industry, sets out measures to ensure that customers can make informed choices about the environment they want to eat and drink in. It was anticipated that customer choice would drive progress in the provision of smoke-free areas in public places.

However, within Birmingham a preliminary survey has shown there to be a very low level of compliance with this charter and that Birmingham citizens and visitors have limited access to information on smoke-free public places in the city. While the PPC promotes the interests of the customer, the benefits to employees are also important. Workers spend more time in hospitality venues than individual customers and are therefore more greatly exposed to the health risks associated with passive smoking. The comfort, health and welfare of staff are often overlooked.

Smoke-free Birmingham project

The primary focus of the work carried out in Birmingham was to increase public awareness about customer choice and access to smoke-free environments when eating or drinking outside the home, and to look at the effectiveness of face-to-face promotion of the PPC on smoking to bring this about.

Restaurants, cafes, hotels, public houses and places of public entertainment within four of the 39 wards within the city were initially assessed for compliance with the charter. This provided a baseline position from which progress could be objectively measured.

This was followed by an advisory visit to each venue to promote the PPC and provide information about the forthcoming ACoP. The commercial and health benefits of adopting a smoking policy were fully explained at the time of the visit. The areas for focused action were selected to include one of the city's premier hospitality districts, a ward with one of the highest proportions of smokers, a ward with one of the lowest proportion of smokers, and a ward with average incidence of smoking.

Between January and March 2002, officers visited 505 venues promoting the charter and urging proprietors to consider the health and safety implications of their staff working in smoky conditions. An initial assessment showed that only 3 per cent of venues displayed recognised PPC signage on the outside of the premises to advise of the smoking policy. Having determined this baseline, all premises were visited to promote the charter and to discuss the health and safety implications for employees exposed to passive smoke in the workplace. Of these, 31 per cent of proprietors said that they were aware of the charter and 14 per cent claimed that they fully complied. The most common information sources for those who knew about the charter were company head offices or through the trade press.

Being unaware of the charter did not necessarily mean that proprietors did not subscribe to a smoking policy; 304 proprietors (60 per cent) stated that they had a smoking policy operating in their premises. The most common means of reducing passive smoke was by the provision of ventilation systems, often combined with the provision of separate smoking and non-smoking areas. Methods of segregation ranged from signage, walkways and open windows to separate rooms and floor levels. A total of 64 premises (12 per cent) had a complete ban on smoking. Corporate adoption of smoking policies, particularly in high street branded chains of restaurants and pubs contributed significantly to the overall number of premises promoting smoke-free dining and drinking - 60 per cent of premises visited said that they would be interested in complying with and displaying PPC signage.

When questioned about health and safety issues relating to smoking, 120 premises (24 per cent) were aware of the forthcoming ACoP. As with knowledge of the charter, this arose largely through company policy or information in the trade press. Of those interviewed, 28 per cent viewed the ACoP as good and 28 per cent thought it would create difficulties and affect trade. The project enabled a booklet to be produced to inform customers about smoking policies at hospitality venues in the wards covered by the project, and for the development of an information website.²

Birmingham tobacco control policy

Work has also been undertaken to consider how the adoption of a city council tobacco control policy could seek to influence the 40,000 council employees and the wider community they serve. Given the large workforce, it is reasonable to assume that a significant number of working days will be lost as a result of smoking-related illness, but wider than this, is the recognition that the council has a vast potential to influence a population of over one million residents, visitors and workers.

It is estimated that in the city, 2,000 people die each year and that 12,500 adults are admitted to hospital as a result of smoking. In a year, up to 10 babies die from breathing in smoke from their parents and 35 to 65 babies are born with low birth weight as a result of smoking in pregnancy. There are 150 to 400 aggravated attacks of asthma as a result of passive smoking and, in a single year, 240 people will die through smoking-related disease.

Smoking prevalence varies by ward in Birmingham. The lowest incidence of smoking is recorded in Sutton Four Oaks, where 18 per cent of adults smoke. In Longbridge, 43 per cent of all adults smoke. It is estimated that one in every four children living in Birmingham becomes a regular smoker by the age of 15; 17 per cent of children begin smoking by the age of 12; and 73 per cent of smokers will have become addicted to tobacco by the age of 17.

Many council departments can contribute to tobacco-control work:

• trading standards officers enforce legislation on underage sales of tobacco and assist Customs and Excise in anti-smuggling initiatives;
• EHOs enforce legislation that prohibits smoking by food handlers while engaged in preparing or serving food;
• licensing officers prohibit smoking in all hackney carriages in Birmingham;
• the education department assists Birmingham schools in educating young people about the health effects of tobacco use and passive smoking; and
• social services cares for young people and people with special learning needs in residential and day care.

The Government's white paper on tobacco reports that there is a particularly high incidence of smoking-related death among adults with learning difficulties. The childcare team inspects and registers childminders who are responsible for the care of under fives as pre-school children are susceptible to harm from passive smoking. The city also works in partnership with government initiatives including Sure Start, Children's Fund and Connexions. All these initiatives seek to reduce the harmful effects of smoking on children and young persons.

Like many cities, Birmingham's leisure and culture department helps its customers to stop smoking or to recover from tobacco-related illness, including coronary heart disease. Fitness on prescription schemes and walking on prescription schemes have been successful in encouraging smoking cessation. Leisure facilities play an important role in engaging young people aged between 12 and 17 years in sport at the critical time that they are most likely to become tobacco dependant.

Benefits of a tobacco control policy

The advantages to a local authority in adopting a tobacco-control policy are that it:

• communicates a commitment to reducing tobacco-related deaths;
• identifies achievable measures that can be taken to reduce smoking within its own organisation;
• sets out how support is targeted through the services provided to customers in an effort to reduce smoking-related deaths;
• defines a code of conduct for employees and subcontractors that deals with passive smoking issues to the satisfaction of smokers and non-smokers; and
• explains how tobacco control legislation will be enforced by the organisation. The tobacco-control policy at Birmingham is currently in draft while full consultation takes place.

Tobacco control alliance

In 1995, the Health Education Authority developed the national alliance scheme in recognition of the requirement for multi-agency working in tobacco control. This was a network of local alliances designed to link national and local actions on tobacco control. Since April 2000, the Department of Health (DoH) has been responsible for the alliance network and has issued a draft framework for the consultation about the future development of the network (Department of Health Tobacco Policy Unit 2001). This consultation document indicates that the DoH wishes to move towards the alliance set-up being funded locally. The benefits of forming a tobacco alliance include:

• bringing together all organisations that have a tobacco control remit;
• ensuring a local profile;
• assisting in securing external funding;
• ensuring clarity of vision between the local authority, the primary care trusts and other organisations;
• enabling networking, sharing of resources and activity planning;
• communicating a common purpose to reduce smoking-related deaths in an area;
• has the potential to influence and enhance the work of local strategic partnerships; and
• the ability to target areas worst affected by smoking-related disease. Birmingham currently lacks such an alliance, but it is hoped that the local strategic partnership will recognise the value of adopting this approach.

Role of EHOs

The PPC on smoking affords consumers the opportunity to choose to eat and drink in a smoke-free environment. While the survey demonstrated a commitment by traders to provide smoke-free areas and easily accessible information about smoking policies, adoption of the PPC was limited by lack of quality information about the commercial benefits of providing a smoke-free environment.

Despite the charter being established for four years, the Birmingham study suggests that its impact had been minimal. Intensive promotion of the PPC resulted in a significant increase in its adoption locally, but this intensive proactive approach is not sustainable given the current pressures on EHOs.

EHOs are well placed to disseminate information and explain the potential ill health effects of passive smoking to traders, but their role needs to be strengthened by legislation. If customers are to be given real health choices, they must understand the potential harm that they are exposed to and the hospitality industry should be required to clearly identify to customers their policies on smoking.

While the charter continues as a voluntary agreement, it must be recognised that significant and intensive marketing is required to increase its adoption by the industry but more importantly, customers must be persuaded to vote with their feet and spend their money in smoke-free places. Local authorities should consider the valuable role that a tobacco control alliances provide in co-ordinating multi-agency tobacco control and the benefits of publishing a local authority tobacco-control policy to clearly communicate the organisations commitment to the tobacco control agenda.

Sue Blakeley is head of district services at Birmingham City Council. For more information e-mail: Sue_Blakeley@birmingham.gov.uk

References

1. Hackshaw AK, Law M, Wald NJ. The accumulated evidence on lung cancer and environmental tobacco smoke. BMJ 1997; 315:980-8.
2. www.birmingham.gov.uk/tobaccocontrol