Written evidence submitted by Action on Smoking and Health (ASH) [SRF 033]
- Action on Smoking and Health (ASH) is a public health charity set up by the Royal College of Physicians in 1971 to advocate for policy measures to reduce the harm caused by tobacco. ASH receives funding for its full programme of work from the British Heart Foundation and Cancer Research UK. ASH has also received project funding from the Department of Health and Social Care to support delivery of the Tobacco Control Plan for England. ASH does not have any direct or indirect links to, or receive funding from, the tobacco industry, except for nominal shareholdings in Imperial Brands and BAT for research purposes.
- Smoking remains the leading cause of preventable death and disease in the UK, responsible for half the difference in life expectancy between rich and poor, killing nearly 100,000 people a year prematurely in the UK, with thirty times as many suffering serious smoking-related disease and disability. The impact of this on the UK economy is enormous, with smoking costing individuals across the UK £14.1bn in lost income each year as a result of unemployment and reduced earnings alone.
- Local authorities, who hold responsibility for public health since its transfer from the NHS in 2013, are key local actors in addressing smoking and reducing the wide range of harm it causes. However, their ability to address smoking has been continually undermined as a result of year-on-year cuts to the public health grant since 2015/16. Today, in the midst of a global public health crisis and a day after the Government’s Spending Review 2020, funding for the public health grant remains 22% lower on a real terms per capita basis than in 2015/16.
- Cuts to the public health grant have had a significant impact on local authorities’ ability to deliver effective, evidence-based services which improve their community’s health and the health of our nation. Budgets for local stop smoking services have been cut year-on-year, in line with cuts to the public health grant. Improving the population’s health not only reduces pressures and costs on the NHS and social care services, but helps tackle socioeconomic inequalities and is integral to delivering on interlocking Government ambitions to ‘level up’ society; significantly increase disability-free life years, reduce inequalities; improve mental health; reduce obesity and alcohol harm; end smoking; and build back better from the pandemic.
- Yesterday’s Spending Review (25th November 2020) did nothing to alleviate these issues, with the public health grant being maintained at current levels. Whilst a pledge was made that “the government will set out further significant action that it is taking to improve the population’s health in the coming months”,7 yesterday was a missed opportunity to start re-building the public health system by providing adequate, sustainable long-term funding, upon which the success of the system is ultimately dependent.
- To deliver on these ambitions and as part of its “significant action to improve the population’s health”,7 ASH urges the Government:
1) In line with the recommendation made by the Health Foundation, to provide an additional £0.9bn to the public health grant, in order to restore funding to 2015 levels and to provide a further £2.5bn by 2023/24 to ‘level-up’ funding across local areas. (para 16)
2) To establish a ‘polluter pays’ Smokefree 2030 Fund to leverage funding for the recurring costs of tobacco control at national, regional and local levels from the tobacco industry. Devolved nations should also be given the opportunity to opt-in to the Fund. (para 19)
The cost of smoking
- Smoking is the leading cause of preventable death and disease in the UK. Each year in England, smoking kills almost 80,000 people – more than more than obesity, alcohol, drug misuse, HIV and traffic accidents combined. For those who smoke, no other aspect of their life will impact their health as significantly. On average, people who smoke die 10 years earlier and for every person killed by smoking, another 30 live with a serious smoking-related illness (on average, people who smoke develop social care need 10 years earlier than never-smokers.
- These health costs translate into a significant financial burden. Across the UK each year, £6.2bn of income is lost as a result of economic inactivity among smokers, largely as a result of smoking-caused disability, whilst smokers in work collectively lose £7.2bn of income through reduced earnings as a direct result of smoking.1 Additionally, each year smoking in England alone costs a further:
- £3bn due to premature death during productive working life caused by smoking;
- £2.4bn in NHS costs for treating ill-health caused by smoking;
- £880m in social care costs from additional social care need resulting from smoking; and
- £325m for Fire and Rescue Services to respond to fires caused by smoking materials.
- If local authorities were to cover the costs of all social care demand related to smoking which is currently met informally (e.g. by family members or friends), or is completely unmet, this would cost them an additional £19.8bn each year.14
- The impact of smoking is not felt equally across society. Around 1 in 4 people in routine and manual occupations smoke, compared to 1 in 10 in managerial and professional occupations. Whilst rates in these groups has declined over time as a result of comprehensive action, the gap in smoking rates between them has grown over time.16
- In light of COVID-19, these pre-existing inequalities are extremely severe. Indeed, COVID-19 is understood by public health experts not as a pandemic, but as a syndemic - a co-occuring synergistic pandemic that is interacting with and increasing social and economic inequalities. This can be seen clearly in the case of smoking. Smoking-related diseases which increase a person’s risk of dying from COVID-19, such as diabetes, respiratory and cardiovascular diseases are disproportionately common among those living in the most deprived areas. ,, People living in these areas are more than twice as likely to die from COVID-19 as those living in the least deprived areas. A failure, therefore, to address these underlying inequalities is a failure to adequately address the full impact of COVID-19 and enable recovery from it. As the leading cause of health inequalities in the UK, smoking must, therefore, be a top priority for local authorities to improve the health and wealth of their communities and to reduce future costs.
Giving local authorities the support they need
- For every £1 invested in public health, £14 is delivered in savings through reduced healthcare costs and longer-term gains to society.6 However, funding to support local authorities deliver public health functions has been significantly reduced since 2015, undermining their ability to deliver these wider savings and support government ambitions to ‘level up’ society;4 significantly increase disability-free life years,5 reduce inequalities; improve mental health; reduce obesity and alcohol harm; end smoking;6 and build back better from the pandemic.
- Local authorities have faced severe reductions in funding for their public health functions since 2015/16. Accounting for the 2.6% increase in funding for the public health grant announced in March, analysis by the Health Foundation shows that the grant is still 22% lower on real term per capita basis than in 2015/16.2 Given no new money was announced for the public health grant at yesterday’s spending review, this stark truth remains the case.
- These cuts have not gone unnoticed by local authorities. Pressure across the public health sector is clear and there is also a clear consensus that government needs to provide immediate and long-term funding for public health. Local stop smoking services, commissioned by local authorities, provide a good illustration of this pressure. Between 2018/19 and 2019/20, 35% of local authorities that still had a budget for stop smoking services cut this budget.  This was the fifth successive year in which more than a third of local authorities had cut their stop smoking budgets and each year, the main reason provided for the decision was ongoing cuts to the public health grant.23
- The failure to use yesterday’s Spending Review to increase public health funding is very disappointing. Greater investment in public health is urgently needed by councils in order to deliver more resilient, productive populations and to reduce pressure on local NHS and social care services and to allow the UK to begin its recovery from COVID-19.
- However, the government did state in yesterday’s Spending Review that it “will set out further significant action that it is taking to improve the population’s health in the coming months.”7 As part of this significant action and in line with the recommendation made by the Health Foundation, ASH urges the government to provide an additional £0.9bn to the public health grant, in order to restore funding to 2015 levels and to provide a further £2.5bn by 2023/24 to ‘level-up’ funding across local areas, enabling them to support communities with the greatest need.8
- This significant action should also include looking at alternative mechanisms for raising funding for the public health grant. The government has committed to consider a ‘polluter pays’ approach to funding tobacco control,6 where a specific charge is placed on the tobacco industry to fund the recurring costs of tobacco control activity. Such an approach is already in place in France and the USA and should be implemented in the UK also.
- A ‘polluter pays’ approach to funding tobacco control is strongly supported by the public. A recent YouGov survey of over 10,000 adults in England found that 76% supported requiring tobacco manufacturers to pay a levy to Government for measures to help smokers quit and prevent young people from taking up smoking with just 6% opposing. Further, over 70 leading health organisations, including the British Medical Association, Royal College of Physicians, Association of Directors of Public Health and Faculty of Public Health, endorse the Smokefree Action Coalition’s Roadmap to a Smokefree 2030, which calls for the institution of a ‘polluter pays’ Smokefree 2030 Fund.
- As part of its significant action to improve the population’s health and in order to support local government finances, the government should therefore establish a polluter pays Smokefree 2030 Fund used to fund the recurring costs of tobacco control at national, regional and local levels. Devolved nations should also be given the opportunity to opt-into the Fund - (for full details on how the Smokefree 2030 Fund would work, see ASH’s briefing).
 ASH. Smoking, employability and earnings. September 2020.
 The Health Foundation. Today's public health grant announcement provides some certainty, but more investment is needed over the longer-term: Health Foundation response to the public health grant allocations. March 2020.
 ASH and Cancer Research UK. Many Ways Forward: Stop smoking services and tobacco control work in English local authorities. January 2020.
 HMT. Budget 2020: Delivering on our promises to the British people. March 2020.
 BEIS. The Grand Challenges: Ageing society. September 2019.
 DHSC and Cabinet Office. Advancing our health: Prevention in the 2020s. July 2019.
 HMT. Spending Review 2020. November 2020.
 The Health Foundation. Spending Review 2020. November 2020.
 Smokefree Action Coalition. Roadmap to a Smokefree 2030. January 2020.
 NHS Digital. Statistics on smoking, England – 2019. July 2019.
 ASH. Smoking: Making the case. November 2019.
 Jha P, Ramasundarahettige C, Landsman V, et al. 21st Century Hazards of Smoking and Benefits of Cessation in the United States. New England Journal of Medicine 2013;368:341–50.
 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. 2014.
 ASH. The costs of smoking to the social care system in England. September 2019.
 ASH. Ready Reckoner 2019 edition. November 2019.
 ONS. Adult smoking habits in the UK: 2019. July 2020.
 Bambra C, Riordan R, Ford J, et al. The COVID-19 pandemic and health inequalities. J Epidemiol Community Health 2020;74:964-968.
 NHS Digital. National Diabetes Audit - Report 1 Care Processes and Treatment Targets 2018-19, full report. July 2020.
 ONS. How does deprivation vary by leading cause of death? November 2017.
 PHE. Health Matters: NHS Health Check - A world leading CVD prevention programme. January 2018.
 ONS. Deaths involving COVID-19 by local area and socioeconomic deprivation: deaths occurring between 1 March and 31 July 2020. August 2020.
 Joint statement to the Government on public health reorganisation. September 2020.
 ASH and Cancer Research UK. Annual local authority tobacco control reports. Updated February 2019 [accessed September 2020]
 YouGov. Smokefree 2020. Total sample size was 10749 adults. Fieldwork was undertaken between 17th February - 11th March 2020. The survey was carried out online. The figures have been weighted and are representative of all English adults (aged 18+). Conducted by YouGov on behalf of ASH.
 Smokefree Action Coalition. Roadmap to a Smokefree 2030. January 2020.
 ASH. Briefing on the Smokefree 2030 Fund. January 2020.