Tobacco Control Northern

‘ has been identified as the single greatest cause of preventable illness and premature death in .’

Gilmore G. Wilmot E. Northern Ireland. 2015 Public Health Agency: Belfast, 2015.

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Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8 Contents

The impact of smoking in NI ...... 5

Deaths attributable to smoking ...... 5

Inequality and smoking related mortality ...... 5

The costs of smoking ...... 6

The extent of smoking in Northern Ireland ...... 7

Disadvantaged adults who smoke ...... 7

Pregnant smokers ...... 9

Children and young people (11-16 year olds) ...... 9

Prevalence of E-cigarette use ...... 10

Second hand smoke exposure ...... 10

Tobacco control vs the ...... 11

Key advertising strategies ...... 11

Point of sale advertising ...... 13

Packaging as advertising ...... 13

Taxation/illicit tobacco ...... 13

Stop Smoking Services ...... 14

Conclusion ...... 15

References ...... 16

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Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8

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Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8 The impact of smoking Nevertheless, the ‘standardised death rate due to smoking related causes in ii Deaths attributable to smoking the most deprived areas was 54% Smoking has been identified as the higher than the overall regional rate single greatest cause of preventable and 129% higher than the standardised death rate in the least illness and premature death in 5iii Northern Ireland with 2014 data deprived areas’ . revealing approximately 16% or 1 in 6 of all deaths in Northern Ireland (NI) Furthermore, over the past decade, were attributable to smoking.1,2 there is now a widening inequality gap between the standardized death rate in the most deprived and the least deprived areas of NI (see Figure 1).5

Figure 1: Inequality gap in the Indeed smoking has been shown to standardized death rate due to contribute to deaths from a wide smoking in NI (2004/08-2009/13) 5 variety of causes and is thought to

2i 140 127 129 account for: 117 120 119

120 110

 86% of all deaths from lung cancer; 100  85% of all deaths from Chronic Obstructive Lung Disease; 80 52 53 54  Over half the deaths from 60 47 48 51 Stomach/Duodenum ulcers; causes related 40

 1 in 4 of all cancer deaths and; smoking to due (SDR) rate % gap in standardised death death standardised in gap %  1 in 10 of all circulatory disease 20 deaths. 0

During the past decade the number of Year deaths attributable to smoking has been estimated to be between 2,300- % gap in the SDR from smoking related 2,400 per year, equating to causes between the most deprived areas 1 and NI average approximately 6 deaths a day. % gap in the SDR from smoking related causes between the most deprived areas and least deprived areas. Moreover, research has shown a smoker’s life span is shortened by about five minutes for each cigarette Smoking related mortality among smoked and on average, those killed males is twice that of females (244 vs. by smoking have lost 10-15 years of 115 deaths per 100,000 population) life.3

Inequality and smoking related ii Deprivation level is assessed in Northern Ireland by the use of the Northern Ireland Multiple Deprivation Measure mortality (NIMDM) 2010. This measure examines 7 areas of The regional standardised death rate deprivation which are given individual weights to produce an overall combined measure of deprivation. The small due to smoking related causes in NI geographical area used for the NIMDM is the super output was 168 per 100,000 in the period area (SOA). Northern Ireland consists of 890 SOA areas, each with an average population of 2,000 people. These 2009-13, a decline from previous 890 areas are divided into 5 equal quintiles representing a years.4,5 measure of the diversity of deprivation in the population. iii Smoking related death rate in most deprived areas: 258 per 100,000, regional average 168 per 100,000 and in i Deaths relate to deaths registered in the 2012 year. least deprived areas 113 per 100,000. 5

Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8 (see Figure 2). Moreover, the care, premature death, excess inequality divide is strongly evident sickness absence, smoke breaks, within the genders. The standardised second hand smoke (early deaths), smoking related litter and fire in the death rate due to smoking related business place or home. The costs of causes is highest among males in the smoking have been estimated to be 20% most deprived areas, more than £790m per year in Wales, £1.1 billion twice that of males in the 20% least in Scotland and £12.9 billion in deprived areas and almost five times England with an additional one billion that of females in the 20% least pounds required for social care costs 9,10,11,12 deprived areas.6 in England alone.

Based on the economic studies above, Figure 2: Standardised death rate per (and accounting for the number of 100,000 (2009-13) from smoking smokers within the Northern Ireland related causes by gender and population) it is estimated that smoking deprivation6 costs the Northern Ireland economy around £450 million per year.

Given the economic costs outlined above, it is estimated the total cost of smoking to the UK as a whole could substantially outweigh the tax generated through cigarettes by an excess of £5 billion a year.13iv Moreover, nationally it has been Smoking not only causes death but reported a 1% decrease in the reduced quality of life through illness. prevalence of smoking could be While it is difficult to quantify the extent estimated to produce a net revenue and impact of these illnesses, it has gain of £240 million pounds per year in been estimated 17,889 people were the UK.14 admitted to in NI due to 7 smoking related causes in 2013. Asides from the societal costs of tobacco, the financial burden to The costs of smoking individual smokers is considerable. In 2014, a 20-a-day smoker would spend In Northern Ireland it has been on average, over £3,000 a year on estimated the costs of treating cigarettes with lower income groups in smoking related illness in NI hospitals the UK spending twice as much of alone is around £164m a year.8 their total income on cigarettes compared to the more affluent groups However, costs are only one (4% vs 2%).15,16 of the many financial outlays associated with smoking. Several studies conducted within the UK have examined the overarching costs of iv Total costs exclude any social care costs in Northern smoking to society. These studies Ireland, Scotland and Wales. £5 billion is calculated as the have accounted for a wide range of total costs of tobacco throughout the UK (minus tax revenue) plus an additional one billion lost through illicit smoking related costs including health tobacco. Note: additional pension costs or costs of quitter’s health care gained through extra life years are not included in the calculation. 6

Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8 The extent of smoking in The Northern Ireland Ten Year Tobacco Control Strategy for Northern Northern Ireland Ireland identifies a number of priority groups for targeted action owing to the Population prevalence high prevalence of smoking or the Twenty two percent of the NI particularly detrimental health impact population currently smoke, a figure smoking can cause within these which has declined from 24% in 2012 groups. These priority groups have but still remains the highest prevalence been identified as: disadvantaged rate (equal to Scotland, 22%), within adults who smoke, pregnant women the UK and (ROI), 17,18,19,20,21 who smoke and children and young (Figure 3). 23 people (11-16 years old).

Figure 3: Smoking prevalence Disadvantaged adults who smoke throughout the UK and ROI Smoking prevalence analysis by 29 deprivation quintile (see page 5,

27 footnote ii for further information on 25 deprivation quintiles) shows a strong 23 gradient exists. The most recent NI 21 data for 2014/15 shows three times as 19

(non zero axis) axis) zero (non many smokers living within the most 17 deprived quintile (36%) compared to Smoking prevalence (%) prevalence Smoking 15 2008 2009 2010 2011 2012 2013 2014 the least deprived quintile (12%), 5 Year (Figure 5).

England Scotland Wales N.Ireland ROI Figure 5: Smoking prevalence by deprivation quintile 2011/12-2014/15

It is now estimated around 320,000 50 36 adults aged 16 and over smoke in 40 11/12 Northern Ireland with the prevalence of 26 30 12/13 smoking among males being 23% and 21 17 17 females 21%. 20 13/14

Prevalence (%) Prevalence 12 10 14/15 Smoking prevalence differs 0 substantially by local government 1 2 3 4 5 district (LGD). Belfast (25.1%) and Deprivation quintile (1 most deprived Londonderry/Strabane (23.3%) LGD’s - 5 least deprived have the highest estimated smoking prevalence compared to the LGD areas of Lisburn and Castlereagh with Likewise, the smoking prevalence a prevalence of only 16.5% and North among routine and manual workers Down and Ards with a prevalence of remains around one third higher than 17.4% v (see Figure 4, overleaf).22 the general population average at around 30% and substantially higher v than that observed in professional Smoking prevalence by LGD is calculated from Quality 24,25 outcomes framework (QOF) data.22 Raw QOF data is occupations (9%). available to download from: http://www.dhsspsni.gov.uk/index/statistics/qof/qof- achievement/qof-practice-13-14.htm. Data analysis indicates an overall smoking prevalence of 21% as opposed to the 22% estimate derived from the Health has been recorded for 85% of all patients aged 16+ who Survey for Northern Ireland data17 Smoking information have registered with a General Practitioner (GP) in NI. 7

Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8 Figure 4: Smoking prevalence by Local Government District (LGD)22

Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8 Pregnant smokers Children and young people: 11-16 Fifteen percent of pregnant women year olds self-reported being a smoker at the Smoking prevalence among 11-16 time of their first antenatal appointment year olds has declined over the last during 2014/15, a fall from the 16% seven years from 8.7 % in 2007 to level observed in 2013/14.26 8.4% in 2010 and then to 5% in 2013 (see Figure 7).27,28,29 Pregnant women who smoke are more likely to have a baby of low birth Figure 7: Smoking habits of 11-16 weight (under 2,500g), a factor which years old 2007-2013 can result in future health problems for 100 the child. NI data shows over twice as 86.1 many mothers who smoke had a low 80 birth weight baby 11.1%, compared to 60 only 4.5% of mothers who do not smoke.26 40

20 5 8.3

The extent of the relationship between (%) prevalence Smoking 0 smoking in pregnancy and deprivation Smoke at all Do not smoke Never is shown in Figure 6. 27% of pregnant now smoked women in the most deprived areas of Smoking status NI smoke compared to only 6% of 2007 2010 2013 pregnant women in the least deprived quintile who smoke.26

Further analysis of 11-16 years olds Figure 6: Prevalence of smoking in smoking prevalence (2013) has shown pregnancy by deprivation quintile for the first time no deprivation 2014/15 difference is now evident among

children who smoke (see Table 1).30

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27 Table 1: Smoking status of 11-16

25 years old by deprivation quintile (2013)

20 (Deprivation quintiles: 1 most deprived 16 -5 least deprived). 15 11 10 10 Deprivation 1 2 3 4 5 All 6 pregnant women (%) (%) pregnantwomen quintile 5 Smoking prevalence among Smokingprevalence Current 5 5 5 4 6 5 0 smoker (%) 1 2 3 4 5 Deprivation quintile (1 most deprived- 5 least deprived)

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Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8 Prevalence of E-cigarette behaviour is therefore a concern for public health given its potential to use displace the current downward trend in smoking prevalence among young E-cigarettes are designed to look and people. feel like cigarettes; however, E- cigarettes are not licensed nicotine replacement products. These products Second hand smoke are not regulated in terms of their exposure safety and therefore the level of risk 31 associated with their use is unknown. Exposure to second hand smoke Trend data from England has shown (SHS) is a major health concern owing E-cigarette use among adults has to its association with smoking related taken a downturn, due to a reduction in illnesses such as lung cancer, heart use by people who continue to smoke; disease and stroke.35 Second hand nevertheless use for quitting continues 32 smoke is also a threat to the health of to increase somewhat. Currently data children and babies due to the from England shows the prevalence of established links between SHS and any E-cigarette use among smokers respiratory disease, cot death, middle and ex- smokers to be 24%, (around ear disease and asthma.36 5% of the overall population) while the prevalence of daily use is Information from the infant feeding approximately 15% and use for quitting 32 survey (UK including NI) has shown purposes is 38%. almost one fifth of mothers (19%) lived in a household in which someone NI data has shown that around 14% of other than the mother herself smoked. the overall population have ever used 37 an E-cigarette, with 5% of the population currently using these vi Beyond the physical damage caused products. Similar to the prevalence of by SHS, exposure to SHS has been smoking, this use is focused within the shown to have an impact on the more deprived areas (8%) compared 5,33 uptake of smoking and nicotine to the least deprived areas (4%). dependence symptoms in young people. Becklake et al., (2005) showed Data from England has shown that the that the proportion of nicotine majority of 11-15 year olds are aware absorbed from that available in SHS of E-cigarettes (88%), with over a fifth during childhood was associated with of children and young people having subsequent smoking in adolescence. reported ‘ever’ to have had an E- This was after adjustment for a cigarette (22%). Indeed young number of factors such as sex, socio- people’s experimentation with E- economic group and number of adult cigarettes has now overtaken that of 38 34 smokers at home. the traditional cigarette (18%). This finding coupled with the close linkages Indeed, it has been shown that between E-cigarette use and smoking children who live with parents or siblings who smoke are up to 3 times vi E-cigarette use in NI is reported from the overall more likely to become smokers population, in contrast to England which reports on themselves than children living in non- prevalence among smokers and ex-smokers only. 39 Nevertheless equivalent overall rates of E-cigarette use smoking households. Additionally within the overall population of around 5% are evident in local data (2008) indicates both countries. 10

Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8 approximately 45% of primary seven advertising, (ie above and below the children reported having at least one line advertising bans). This, thereby parent who smokes, with 14% from allows the tobacco industry to simply homes in which both parents smoke.40 divert its resources to fill market gaps, thus maintaining visibility and hence Furthermore, a multi–country study tobacco consumption. carried out in NI, Wales and Scotland While the tobacco industry in the UK pre and post smoke free legislation has traditionally carried out ‘above the showed SHS exposure was highest, line’ advertising this is now prohibited and private smoking restrictions least through the UK Tobacco advertising frequently reported, among children and promotion Act 2002.43 This ban from lower socio-economic groups.41 was then supplemented in 2005 with the European union (EU) Directive Research has shown the home and which regulates tobacco advertising car to be the major sources of and sponsorship with cross-border children’s smoking exposure, however implications in the media other than the most recent results from the television. 44 2014/15 Health Survey Northern Ireland found that 8 in 10 respondents Owing to these bans, the industry has did not allow smoking in the home and shifted its advertising strategies to just over 8 in 10 respondents (85%) ‘below the line’ activities including who had a family car did not allow point of sale displays and product smoking in their car at all.17 placement in various guises from alibivii branding of tobacco companies in Nevertheless, a 2013 omnibus survey, formula one to more mainstream which also examined smoking in the tobacco imageryviii in the media.ix car found rules on smoking in the car While evidence has shown the extent varied significantly depending on of this type of advertising within the whether the individual was a smoker or film industry has somewhat declined it not. 81% of those who never smoked continues to occur in films deemed by reported not allowing smoking in the the British Board of Film Classification car compared to only 24% of current as suitable for children and young smokers.42 people.45

Tobacco control vs Indeed more recent research has revealed this tobacco imagery extends tobacco industry beyond the film industry into mainstream television broadcasts. Key advertising strategies 34% of programmes shown on free to One key mechanism by which tobacco air prime time (18:00-22:00) United has emerged as a social norm within Kingdom (UK) TV contained some our society is the extensive advertising tobacco imagery with 12% of these carried out by the tobacco industry. programmes showing actual tobacco

Advertising may be defined as ‘above vii Alibi branding refers to the use of colours and branding the line’ (ie TV, radio or billboards) or representative of that of a product but omitting the product ‘below the line’ (sales promotion, point name. viii Tobacco imagery refers to actual tobacco use, implied of sale etc), however few jurisdictions tobacco use, the appearance of tobacco paraphernalia, across the globe have introduced tobacco brands and other references to tobacco. ix Tobacco imagery in television programmes for artistic or comprehensive bans on smoking editorial purposes is exempt from the Tobacco Advertising and Promotion Act. 11

Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8 use. Indeed, over 60% of these America, the tobacco industry is incidences of tobacco use occurred investing 97% of expenditure in ‘below before the 21:00 watershed thereby the line’ marketing despite ‘above the exploiting a potential source of young line’ advertising still being allowed in people’s tobacco exposure.46 the USA.48 Further analysis showed tobacco use on mainstream TV to be highly The value of anti-tobacco advertising variable depending on the programme is an important component in tobacco genre with over half of feature films control. The United States National (59%) and reality TV shows (56%) Cancer Institute released a shown during the peak viewing times comprehensive scientific review of of 18:00-22:00 showing actual tobacco international evidence concerning the use (see Figure 8). Nevertheless, 8% impact of media on smoking attitudes of soap operas also showed tobacco and behavior. The Institute concluded use, while 49% of soap operas on balance that well-funded anti- showed any tobacco imagery.46 tobacco campaigns can reduce smoking prevalence, with the extent of reductions highly related to levels of Figure 8: The proportion of each media expenditure.49 programme genre that contained any tobacco use on prime time (18:00- While the amount spent by the tobacco 22:00) UK free to air television, 2010x industry in the UK is unknown, in the US figures released by the Federal Trade commission in 2012, report over Sci-fi/ fantasy 0 9 billion dollars was spent on Game show 0 advertising by the tobacco industry xi 50 News 4 (around $285 per second). This is in stark contrast to the approximately Soap opera 8 £11.7m spent on mass media anti- Sport 12 tobacco advertising in England Chat show 12 (approx. 37p per second) and the

Programmegenre £440,000 in NI in 2013/14 (approx. 1p Drama 26 a second).51,52 Comedy 41 Reality Tv 56 The key value of local anti-tobacco Feature films 59 advertising has been observed with the 2012/13 NI anti-tobacco campaign 0 20 40 60 80 estimated to have reached 72% of NI Proportion of each genre that smokers and aided 6.8% smokers to showed actual use of tobacco (%) make a quit attempt.53 Nevertheless, media spend restrictions in NI on In addition, tobacco imagery appears public sector advertising may impinge in 22% of YouTube music videos while 47 on the frequency and sustainability of e-cigarette imagery appears in 2%. anti-tobacco advertising and the resultant impact on smoking The impact of this ‘below the line’ prevalence. marketing has clearly proved lucrative for the tobacco industry with data showing that in the United States of

xi For comparison purposes the prevalence of smoking in x Figure 8: reproduced from Lyons et al, 2014.46 USA was 21.3%% in 2012-13. 12

Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8 While above the line advertising, such standardised packaging. The value of as TV advertising is no-longer this strategy has been observed with permitted for tobacco products, this is the daily smoking rate falling pre plain not the case for E-cigarettes. The packaging from 15.9% (2010) to a evolution of E-cigarettes has led to level of 13.3% post plain packaging ‘above the line’ advertising of these (2013) in those aged 18 and over.56 devices in the UK, an issue of concern Furthermore, emerging evidence has for tobacco control given the shown the introduction of standardised increasing number of 11-18 year old packaging in Australia has increased users observed in the UK.34 the effectiveness of health warnings, reduced the ability of packaging to Point of sale advertising mislead about smoking harms and Point of sale is a key mechanism in reduced the appeal of cigarettes to below the line advertising. A strong adults and adolescents.57,58 positive relationship has been shown Furthermore, larger graphic health between point of sale (POS) warnings on the new standardised advertising and increased tobacco packets have been associated with consumption with POS displays increasing rates of thoughts of quitting 59 reportedly increasing young people’s among adult cigarette smokers. susceptibility to smoke, stifling ex- smokers ability to remain quit or More recently the Republic of Ireland detracting smokers from making a quit and the UK have followed in the attempt.54 As a result point of sale footsteps of Australia and have taken display bans have come into force in steps towards the introduction of large retailers since 31 October 2012 standardised packaging. in NI and in small retailers from 6 April 2015 as a key mechanism to reduce One counter-argument provided by the public exposure to cigarettes. industry for plain packaging is that this will increase illicit tobacco, however, Packaging as advertising the Chantler review has strongly 60 One key strategy the tobacco industry refuted this argument. Moreover, still utilizes to sell tobacco is branding. recent evidence from the While the industry implies this is to implementation of standardised influence brand choice, plain packaging in Australia has shown no packaging has been found to reduce evidence of increased use of two the appeal of cigarettes and smoking categories of manufactured cigarettes while enhancing the salience of health likely to be contraband, no increase in warnings on packs.55 Visibility of purchase from informal sellers and no cigarettes is an important advertising increased use of unbranded illicit 61 strategy for the tobacco industry with tobacco. some companies having increased the range of tobacco products displaying Taxation/illicit tobacco their branding to maximize the visibility Increased taxes placed on tobacco in of their products.54 recent years have played a significant role in the increased costs of the Nonetheless, Australia has led the way products. Price increases are globally in instigating a comprehensive considered to be the most effective advertising ban on tobacco products mechanism for decreasing including the introduction of consumption; yet, these increases are still not substantive enough to cover

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Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8 the economic costs of smoking within above the 5% reach of Stop Smoking society.62 While, the tobacco industry Services recommended within the NI claims price rises simply result in Ten Year Tobacco Strategy.66 increased smuggling and illicit tobacco, this argument is contradicted Cross country comparisons have by the downward trends displayed in shown the reach and effectiveness of the illicit market share for cigarettes NI Stop Smoking services compare from 15% in 2005/06 to 10 per cent in favorably with elsewhere in the UK 2013-14.13 (see Table 2 and Figure 9). 66,67,68,69

Stop Smoking Services Table 2: Uptake and reach of services Current evidence shows combined across the UK 2014/15 pharmacotherapy and behavioral Uptake Reach interventions to be the most effective mechanism to aid smokers to quit.63 In (n) (%) line with this evidence, the Public Scotland 73,338 7.0 Health Agency (PHA) commission Northern Ireland 21,779 6.8 specialist quality assured Stop England 450,582 5.4 Smoking Services as recommended by the National Institute for Health and

Clinical Excellence.64,65

The four week quit rate of smokers These services are designed registered with the NI Stop Smoking specifically for those smokers who are Services was 59% in 2014/15, thereby motivated, ready to quit and prepared maintaining the highest rate since the to set a quit date. The services are launch of the services in 2001/02. offered in a range of local settings Indeed, this quit rate exceeded that including GP practices, pharmacies, observed throughout the UK (Figure hospitals and community/voluntary 9).66, 67, 68 settings across Northern Ireland.

Figure 9: 4 week quit rates within The Stop Smoking Services are the Stop Smoking services, across delivered by specialist providers who the UK, 2014/15 have received specific training for this role. The services offer intensive treatment, over the course of 6-12 weeks, with structured support being available for at least four weeks after the clients quit date. To date, the provision of specialist Stop Smoking Services in NI has supported over 200,000 people to stop smoking since 2001/02, and over 50% of these clients remain quit at 4 weeks.

In 2014/15, 21,779 smokers registered NI services collect and collate 52 week with the NI Stop Smoking Services, quit rates for all smokers who quit at thereby reaching approximately 6.8% four weeks. For those smokers of all smokers in Northern Ireland, and registering with the Stop Smoking services in 2014/15, a 52 week quit

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Tobacco Control Northern Ireland, produced by Health Intelligence, Public Health Agency, 2015. 8 rate of 24.4% was observed, a figure smoking to the individual and to considerably higher than the 5% 52 society as a whole are immense. week quit rate observed in Scotland. The impact of tobacco is greatest 66,67 among the poorest in our society impacting on their income, health and Furthermore, the observed 52 week the health and social norms their quit rate in NI was the highest rate children are inadvertently exposed to. since the services began and equated It is evident the tobacco industry to the Stop Smoking services aiding continually utilizes a plethora of 2.0% of all smokers to remain mechanisms to promote tobacco abstinent from smoking for at least one products and encourage tobacco use year. within the population, thereby comprehensive tobacco control Despite the demonstrated policies are a necessity. effectiveness of the Stop Smoking Services, these services alone cannot The 2010 inquiry into the cost and cost eliminate tobacco as a public health effectiveness of tobacco control in the issue in NI. Recently, observed UK estimated overall costs of tobacco unexplained declines in the number of control to be around £300 million a smokers using Stop Smoking Services year, money which is primarily spent have been noted throughout the UK, a on the anti-smuggling strategy, Stop fact which limits the reach and Smoking Services and mass media. effectiveness of a key evidenced The inquiry reported the net annual based service. 66,67,68 Estimates revenue benefits to government given suggest, if the number of clients the decline in smoking prevalence utilizing the Stop Smoking Services in since 1998 stood at £1.7 billion per NI continue to decline at the current year and that Government expenditure ratexii, it would take a minimum of 32 on tobacco control ‘provides years for the services alone to aid NI substantial economic value and a approach the target 15% smoking positive return on investment. Cutting prevalence level depicted within the back on expenditure in this area would current Ten Year Tobacco Control almost certainly result in net revenue Strategy for Northern Ireland, and 102 losses rather than gains to the years to eliminate smoking from Exchequer’14 society.xiii While this briefing paper summarizes Conclusion some but not all of the key mechanisms of tobacco control in NI Tobacco remains a key public health (advertising, taxation and Stop issue in society with over a fifth of the Smoking Services) it is clear NI population still smoking. Moreover, comprehensive, sustained and the health effects and financial costs of adaptive evidenced based tobacco control measures are required to counteract and overcome the influence xii Approx. 18% yearly decline in service use has been of the tobacco industry in NI. observed between 2012/13-2014/15. Future declines are calculated at -18% until a limit whereby the services reach the 5% of smokers recommended by NICE guidance and the ten year Tobacco control strategy for Northern Ireland. xiii Estimates only account for quitting activity and do not take into account uptake of smoking. Predictions are therefore likely to vastly underestimate the necessary timelines for a smoke free society. 15

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