Learning from 25 years of preventative interventions in Scotland

14. Smokefree Legislation

Smokefree Legislation: Protection from second hand smoke

Scotland was the first part of the UK to introduce smokefree legislation in 2006. The law prohibits smoking in wholly or substantially enclosed public spaces to protect people from the health harms of second-hand smoke (SHS). The law was evaluated in a series of studies that described its implementation and outcomes, including reductions in SHS exposure, health improvements and cost savings.

Introduction

Smokefree legislation (a ‘smoking ban’) involves the primary prevention of non-communicable diseases (NCDs) caused by SHS exposure. The comprehensive nature of the legislation, the ease with which it was implemented, and the demonstrable positive outcomes mean that this policy is still widely regarded as having been one of the notable successes of Scottish devolution.

Context

Smoking is the single biggest cause of preventable premature death and poor health in the world. In Scotland in 2004 before the legislation was introduced, there were around 1.2 million smokers, an estimated 13,000 people died per year from smoking-related illnesses and within that number around 1,000 deaths could be attributed to SHS.^[318] Smoking is also a leading contributor to health inequalities with rates in poorer communities being double those in more affluent ones, exacerbating the difference between life and healthy life expectancy between socio-economic groups.^[319] Even as smoking rates have declined overall in recent years, these inequalities have remained.

In the early 2000s, progress was slowly being made to address smoking-related NCDs. This included the three major causes of premature deaths in Scotland – heart disease, stroke, and cancer – but Scotland was still behind similar nations. Free at the point of use smoking cessation services had been introduced from the early 2000s, there were mass media campaigns relating to the health harms of smoking and other tobacco control policies were in place. However, the risks that SHS exposure caused, and especially its effects on workers and those in more deprived communities, needed much greater attention.

Response

The introduction of smokefree legislation was the culmination of many years of work including government action to reduce smoking rates, decades of lobbying from health interests for more radical action, the shifting of debate and public opinion as a result of scientific evidence, opinions being aired publicly by influential individuals at different points, as well as the immediate political context in Scotland at the time.^{[320],[321],[322]} Ireland had been the first country in the world to introduce a smoking ban, in 2004. Implementation had gone relatively smoothly there with high levels of compliance, which provided reassurance for policymakers that having worked in Ireland (with its social and cultural similarities), it could also work in Scotland.

Intervention

The Smoking, Health and Social Care (Scotland) Act 2005 made it an offence to smoke or to allow smoking in virtually all enclosed public areas and workplaces, including pubs and restaurants.^[323] The Bill was originally introduced to Parliament on December 17, 2004, and was approved by MSPs on June 30, 2005, by a majority of 97 to 17 with one abstention. It received Royal Assent on August 5, 2005, and came into force on March 26, 2006.

Dedicated funding was provided to support local authorities to recruit additional environmental health officers (EHOs) who were responsible for monitoring and enforcement, accompanied by additional funds to NHS Boards for cessation programmes. The Scottish Executive (SE, the predecessor to the Scottish Government) developed an enforcement protocol for local authorities and their EHOs building on learning from the Irish experience.

Communication was also key. A cross-sector communication team was established with marketing and comms colleagues within the SE and in major charities (including ASH Scotland, Cancer Research UK, Macmillan Cancer Research, British Heart Foundation, and Chest, Heart and Stroke Scotland) and organisations (like the British Medical Association). A wide-ranging suite of communications campaigns and media was developed. A dedicated website and telephone helpline was set up to answer questions from the public and organisations. FAQs were also developed and information packs in various formats. A flyer to raise awareness of the legislation was sent to every household in Scotland, and a pack was also developed for MSPs to use in engaging with constituents which helped sustain political co-operation.

Achieving a broad consensus was central to the policy. In the lead up to the Act and in its implementation, powerful alliances were built involving the charities and organisations mentioned above, the Scottish Tobacco Control Alliance and the Parliament via the Cross-Party group on Tobacco Control. Within the SE, a new Tobacco Control Division was formed, bringing an existing policy team together with a Bill Team and an implementation team. In addition to political leadership, regular communication between the branch head of the substance misuse division in SE (where the Tobacco Control Division was based) and the Chief Executive of ASH Scotland was an important factor.

Prior to the legislation a detailed public consultation had been conducted, with around 600,000 questionnaires distributed. Research was commissioned to support the consultation. This included a study estimating the number of deaths from second hand smoke in Scotland, a review of workplace smoking policies and an international evidence review of the health and economic impact of regulating smoking in public places.^[324] This evidence helped inform the public and stakeholders about key issues relevant to the proposed legislation. Twelve public forum meetings were also held in different cities as part of the consultation, and an international conference was hosted by the SE. These activities likely helped build public understanding of the issues the legislation was intended to address, and opinion polls in the period leading up to the passage of the law demonstrated a steady increase in public support.⁵

Monitoring and Evaluation

The SE with NHS Health Scotland funded an extensive national evaluation^[325] of smoke-free legislation that involved researchers from several organisations and Universities. This covered the period between 2005 and 2011 and focused on a range of key indicators, including smoking-related morbidity and mortality, exposure to SHS, and economic impacts. The methods used in the evaluation varied from the secondary analysis of routine data to primary research including air quality measurements, observations, surveys and qualitative research. More recent research has also examined the longer-term effects on outcomes such as reductions in hospital admissions for stroke, and pregnancy complications.

Key Findings

a) Improved outcomes

Compliance with the legislation was very high among individuals and premises from the date of introduction, over 90%. In terms of the evaluation, in 2010 a summary was published^[326] that outlined the key findings up to that point. These included:

• An 86% improvement in air quality in bars, with air quality in most bars post-legislation equivalent to outdoor air
• An 89% reduction in SHS exposure in bar workers
• A 39% reduction in SHS exposure in adults and 11-year-old children
• Improvements in the respiratory health of bar workers
• A substantial (17%) reduction in hospital admissions for acute coronary syndrome
• An increase in support for the legislation post-implementation among both smokers and non-smokers but evidence of less support in more deprived communities
• An increase in awareness of the risks associated with SHS and some evidence of changing social norms around exposing others to SHS
• Some evidence of more stringent home smoking restrictions post-legislation (for example residents only smoking outside and asking visitors to do the same)
• Some evidence that smokers, particularly women, experienced feelings of stigma associated with more visible smoking
• Some evidence of social isolation among older male smokers who no longer frequented pubs following the smoking ban.

Not covered in the 2010 summary was a study^[327] published just after it, that found a mean reduction in childhood hospital admissions for asthma of 18.2% per year up to 2009, reversing a rise in admissions that had been observed from 2000 to 2006. Subsequent studies identified reductions in pregnancy complications related to smoking and SHS exposure^[328].

There had been concerns about displacement of smoking into the home prior to the legislation. The evaluation could not find any evidence of this. It was also expected that more smokers would quit as a direct result, with the hypothesis that not being permitted to smoke in indoor public places would prompt quit attempts. The evaluation did not find consistent evidence to support this, although there was a rise in over-the-counter purchases of Nicotine Replacement Therapy (a stop smoking medication).^[329] Studies following the smoking ban in England did find a relationship with smoking cessation^[330] and the implementation of the legislation contributed to the denormalisation of smoking in Scotland.

b) Cost savings

Prior to the legislation, NHS Health Scotland commissioned the health economics unit at the University of Aberdeen (on behalf of SE) to estimate potential costs and cost savings, including effects on the hospitality sector and the NHS.^[331]

The research team used international evidence to model the health and economic impacts, under a range of scenarios. The net present value of benefits and costs over 30 years was demonstrated to be positive under all the scenarios examined. There was a central estimate of +£4.6 billion (ranging from +£0.056 billion to +£7.4 billion).

This evidence regarding cost savings was influential in the passage of the Act. The results of the research were submitted to the Scottish Cabinet in early November 2004 and the main finding — a net economic benefit to Scotland from banning smoking in public places — was cited in the First Minister's speech to the Scottish Parliament on 10^th November 2004 announcing the proposal to introduce the legislation. The research underpinned the Regulatory Impact Assessment produced by SE for the Committee stages of the Bill.

Following the introduction of the legislation there were studies^9,10,[332] that demonstrated reduced use of health services from smoking-related conditions, providing an economic benefit. However, a recent ten year follow up study^[333] of the reductions in hospital admissions for acute myocardial infarction (heart attacks) found these benefits had been sustained for older people (those aged 60+) but not younger people. Unfortunately, the most likely explanation for no sustained decrease of the benefits of smokefree legislation in younger groups is that other risk factors for heart disease – specifically overweight and obesity – have overtaken smoking as the main cause of these trends in younger people.

c) Addressing inequalities

Findings regarding inequalities across the population were mixed. A study^[334] that compared results from Scotland and the rest of the UK (prior to Smokefree being introduced there in 2007) did not find significant differences by socio-economic status (SES) when examining observed declines in smoking in public places, smoking in the home, support for smokefree policies and reported frequency of going to pubs and restaurants.

Studies examining children’s exposure to SHS^[335],[336] following the introduction of the legislation found that SHS exposure was still highest and private smoking restrictions (i.e. smokefree homes) least frequently reported among lower SES children. This was despite overall reductions in SHS exposure among all children. In other words, the law did not remove or narrow the gap in such exposure between those children living in the most deprived compared to least deprived areas. Other subsequent policies and interventions did contribute to continued reductions in SHS exposure in the home, however, with a national target to reduce this to 6% overall achieved five years early, by 2015.^[337]

Learning and Next Steps

Smokefree legislation remains in force today and has been extended since. Some of the settings that were originally not included in the policy have subsequently become smokefree, including private vehicles where children are present, prisons and the introduction of legislation to enforce a ban on smoking within 15 meters of NHS hospital buildings. The Tobacco and Vapes Bill that was introduced into the UK Parliament in November 2024 includes powers to extend smokefree places to specific outdoor public places. These powers are devolved to each UK nation and will require further regulations in Scotland following consultation. The use of products other than combustible tobacco in these outdoor public places could be included, such as heated tobacco and e-cigarettes.

Part of the legacy of smokefree legislation was that it gave government the confidence and a model for ambitious public health policies in a devolved Scotland. It was a ‘game-changer’ for the acceptable and effective use of legislation to improve population health. It paved the way for subsequent tobacco control policies and minimum pricing on alcohol. The lessons from the development of the legislation, its implementation and its robust evaluation continue to provide a model for public health policy today. There is a need to apply them to address current challenges for prevention and public health that now threaten hard won progress from years past.