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									      The Smoking, Health and Social Care (Scotland) Bill

        Supplementary Evidence to the Health Committee
                     from ASH Scotland

Contents                                                                    Page

1. ASH Scotland’s Recommendations for Research to Evaluate
the Impacts of Smoke-Free Legislation in Scotland

a. Health Outcome Measures                                                       3

b. Economic Outcome Measures                                                     3

c. Public Opinion Measures                                                       4

d. Implementation Issues                                                         4

2. The Tobacco Industry: Further Insights

a. Imperial Tobacco                                                              4

b. Tobacco Document Depositories                                                 5

 -The Guildford Depository, England                                              5

 -The Minnesota Depository, U.S.                                                 5

- The Master Settlement Agreement                                                5

c. What Have the Collections Revealed to Date?

 -Tobacco Industry Efforts to Undermine the World Health Organisation            5

 -Tobacco Industry Research Strategies                                           6

 -Tobacco Industry Evidence that Second-hand Smoke May be More
  Dangerous than Directly Inhaled Tobacco Smoke                                  6

- Tobacco Industry Efforts to Prevent Legislation on Smoke-Free Public Places    7

- Tobacco Industry Evidence that Second-hand Smoke Exposure Increases
  the Risk of Sudden Infant Death Syndrome (Cot Death)                           7


3. Additional Research Evidence Published Since our Written

a. Adult Health Risks                                          8

b. Benefits of Going Smoke-Free                                8

c. Ventilation                                                 8

d. Voluntary Agreements                                       10

e. Economic Impacts                                           10

References                                                    11

1. Recommendations for baseline and post legislation research to
measure success of legislation, and on implementation issues.

a. Health Outcome Measures

        We recommend measuring cotinine levels in non-smoking bar staff
         (before and after implementation) as a proxy for exposure to SHS.
         Cotinine can be measured by urine or salivary tests.

        In order to measure air quality in pubs – taking into account
         methodological issues around air quality measurements – we
         recommend assessing levels of respirable suspended particles (RSP), an
         accepted marker for levels that are known to increase risk of respiratory
         disease, cancer, heart disease and stroke. Measurements would need to
         be taken before and after implementation.

        We recommend assessing exposure of young (i.e. preschool) children
         to second-hand smoke. It may be possible to base research around
         routine health visitor annual checks of 1-3 year olds, possibly using
         salivary cotinine measures as a proxy for second-hand smoke exposure.
         Extent of exposure may also be measured using hair samples – this
         provides an accurate depiction of average exposure over a long period,
         as each 1cm of hair accumulates a reading over a whole month. The
         study numbers could be contained by a geographical selection –
         including several areas where smoking rates are known to be high.

        We recommend that hospital admission rates for asthma,
         bronchiolitis and other respiratory conditions in children are
         recorded pre-and post implementation.

b. Economic Outcome Measures

        We recommend that economic trends in the hospitality sector are
         validated by business tax receipts – ideally for 3 years before legislation
         is implemented. Should cover a range of areas especially rural.

        We recommend data is collected regarding the numbers of bars closing
         and opening, at least a year before, and possibly drink sales figures.

        We recommend collecting cigarette           sales data (pre-and post
         implementation) and bar sales data.

        We recommend measurement of employment rates in the hospitality
         sector, pre-and post legislation implementation.

        We recommend data be collected on tourism and travel as an indicator
         of number of visitors in Scotland pre-and post legislation implementation.

c. Public Opinion Measures

          We recommend revisiting some of the consultation questions one year
           after implementation

          We     recommend    measuring   increased    interest/update   of
           Smokeline/Smoking cessation services, and the number of
           individuals successfully quitting through smoking cessation
           services. This data should include information on specific health
           inequalities target groups (pregnant women, young people,
           disadvantaged communities)

          We recommend that surveys be conducted to measure levels of
           knowledge and awareness of the dangers of tobacco and second-
           hand smoke (pre-and post implementation). Data should be collected to
           show differences across region, age, gender, ethnicity and social class.
           Implementation will succeed through targeted communications. Surveys
           such as these will show where and how those communications need to
           be targeted.

d. Implementation Issues

          We recommend that data be collected on smoking cessation service
           waiting lists and throughput (pre-and post implementation).

          We recommend that data be collected on compliance with legislation – to
           include data from EHO‟s, data on prosecutions etc, and calls to report

          Intensive and strategic media campaigns are required pre-legislation to
           increase adults‟ awareness of the dangers of secondhand smoke. These
           campaigns will ensure maximum effect in protecting young people from
           the adverse health effects of secondhand smoke exposure.

2. The Tobacco Industry: Further Insights

a. Imperial Tobacco

The ongoing (McTear vs Imperial) court case in Scotland has not produced public
access tobacco documents. Imperial's Chief Executive, Gareth Davis, testified during
hearings for the McTear case that Imperial did not know whether smoking causes
lung cancer, citing doubts about the basis of scientific methodology.

Imperial Tobacco was previously singled out for criticism by members of the House
of Commons Select Committee on Public Accounts in 2002. Gareth Davis was
accused of being 'positively parsimonious with the truth as far as this Committee is
concerned' by Rt Hon Alan Williams MP (Labour, Swansea West), and all three
witnesses for Imperial Tobacco were overtly accused of lying to the committee by Mr
George Osborne MP (Conservative, Tatton) and by Mr Barry Gardiner MP (Labour,
Brent North) - who added ' I believe you are the least credible witnesses that I have
ever seen come before the Committee of Public Accounts'.1

b. Tobacco Document Depositories

The 1998 Minnesota Consent Judgement 2 was the outcome of legal action by the
State of Minnesota and Blue Cross and Blue Shield of Minnesota against Philip
Morris and several other tobacco companies, seeking to recover smoking related-
health care costs. Under the terms of the judgement several tobacco companies
were ordered to make public internal documents produced during the discovery
process. These were deposited at two sites, in Guildford and Minnesota.

The Guildford Depository, England3, holds an estimated 6-7 million internal
corporate documents from the British American Tobacco Company (BAT) produced
during the discovery process. It opened in February 1999 and will remain open until
2009. In contrast to the Minnesota archive (see below), the depository at Guildford is
managed by BAT itself. From the outset, the efforts of researchers to investigate the
contents of the documents housed there have been severely hampered. Recently
published reports describe how some industry documents held here have been
altered, how database searches conducted by visitors are tracked internally, and that
BAT refuse to supply some documents requested. These reports suggest minimal
compliance with the letter of the Minnesota agreement.4

The British American Tobacco Documents Archive is a joint undertaking by the
London School of Hygiene & Tropical Medicine University of California, San
Francisco (UCSF) and Mayo Clinic. It aims to expand access to the BAT documents
held in the Guildford Depository by scanning the entire collection and hosting them
on a website. 5 It is anticipated that all documents will be available on the website in

The Minnesota Depository, United States6, holds approximately 26 million pages
of tobacco industry documents produced in the discovery process from Philip Morris
Incorporated, Brown and Williamson Tobacco Corporation, Lorillard Tobacco
Company, American Tobacco Company, RJ Reynolds Tobacco Company, The
Council for Tobacco Research and The Tobacco Institute. It opened in 1998 and will
remain open until 2008. It is operated by an independent paralegal firm Smart Legal
Assistance. The collection is continually growing as the depository receives
documents produced in other litigation cases as a result of the 1998 Master
Settlement Agreement.

The Master Settlement Agreement was made on 23rd November 1998 between
the five largest US tobacco companies (Brown & Williamson Tobacco corporation,
Lorillard Tobacco Company, Philip Morris Incorporated, R.J. Reynolds Tobacco
Company, Commonwealth Tobacco, and Liggett & Myers) and 46 states' attorney
generals. Among other provisions it stipulated that the tobacco industry is to make
public all documents produced in US lawsuits, at their own expense set up and
maintain, until 30th June 2010, a website to include all these documents and to add
all documents produced in all future US lawsuits.7 The Master Settlement Agreement
does not apply to the UK based BAT.

c. What have the Collections Revealed to Date?

- Tobacco Industry Efforts to Undermine the World Health Organisation
A key finding from the Guildford documents has been the extent to which the tobacco
industry has engaged in efforts to undermine tobacco control worldwide. In 2000,
the World Health Organisation (WHO) published a detailed report of the industry‟s
efforts to infiltrate and undermine their organisation, for example by placing industry-
paid staff within the organisation. 8

- Tobacco Industry Research Strategies
In the late 1980s, the international tobacco industry assisted in the establishment of
the International Society of the Built Environment, which published the journal Indoor
and Built Environment. A research article recently published in the Lancet examines
the industry associations of the Society's executive, the journal's editor and board,
and the extent to which the journal published papers on environmental tobacco
smoke that would be deemed favourable to the tobacco industry. It concludes that
the tobacco industry's aim was to dominate the organisation and the content of its
academic journal, pushing the view that SHS posed little risk to those exposed to it.
In fact, some 90% of articles which were published in this journal that were positive to
the tobacco industry were written by people with a history of association with them.
When article quality, peer review status, article topic, and year of publication were
statistically controlled for, the only factor associated with the conclusion that passive
smoking was not harmful was whether an author was affiliated with the tobacco

Documents have also revealed how the industry built up networks of scientists
sympathetic to its position that SHS is an insignificant health risk. The industry
funded independent organisations to produce research that appeared separate from
the industry and would boost its credibility. Unfavourable research conducted or
proposed by industry was prevented from becoming public. 10

- Tobacco Industry Evidence that Second-hand Smoke may be more
Dangerous than Directly Inhaled Tobacco Smoke
A extremely significant example of such activity was highlighted in recently
discovered tobacco industry documents demonstrating that second–hand smoke
may be even more harmful than directly inhaled tobacco smoke. As stated in our
main submission to the Health Committee (Feb 2005):

“Recently discovered tobacco industry documents demonstrate that second-hand
smoke may be even more harmful, volume for volume, than directly inhaled cigarette
smoke.11 Yet the tobacco industry continues to place the highest priority on
preventing the introduction of restrictions on smoking in public places, and remain
equally active in spreading misinformation about the effects of legislation that has
already been introduced successfully in other countries.”

The tobacco industry maintained, for many years, that is was unaware of research
about the toxic effects of smoking. However, a recent report in the Lancet 12
documents the way in which one company, Philip Morris, acquired a research facility,
INBIFO, in Germany, in order to privately determine for themselves whether smoking
had hazardous health impacts. INBIFO appears to have published only a small
amount of its research and what has been published appears to differ considerably
from what has not. In particular, the unpublished reports provide evidence of the
greater toxicity of sidestream smoke compared to mainstream smoke. By contrast,
much of its published work comprises papers that cast doubt on methods used to
assess the effects of second-hand smoke.

In the 1980‟s INFIBO conducted a large number of animal experiments on
sidestream smoke. One INFIBO report 13 sent to Philip Morris in 1982 describes in
great details the results of exposure of rats to sidestream smoke. The report states
that secondhand smoke exposure was more irritating than mainstream smoke, and
most particularly to the upper airways (nasal cavities and olfactory membranes).
Sidestream exposure induced more frequent and more severe lesions in the nasal
cavity than mainstream of equal concentration. An accompanying letter to the report
concludes that the extent of cornification observed in these animals had “never been
seen before”. 12 14

These internal documents clearly demonstrate that Philip Morris was, contrary to its
contemporary public statements, aware of the greater health risks posed by second-
hand smoke from the early 1980s. However, as recently as April 2002, Philip Morris,
in an American court, rejected the statement that second-hand smoke causes
disease.12 This public statement is clearly at odds with its own research findings
concerning the consequences of exposure to second-hand smoke, and highlights the
extremely selective nature of what is eventually published by some scientists with
links to the industry.

- Tobacco Industry Efforts to Prevent Legislation on Smoking in Public Places
Documents have also revealed further insights into the tobacco industry‟s efforts to
prevent legislation on smoking in public places across a number of countries and
regions. In a recently published internal document from the Tobacco Institute, vice-
president Peter Sparber states, “the tobacco industry has faced more than 1,000
public smoking bills, and has defeated more than 90% of them… By in large,
these bills have attempted to restrict smoking in public places.” Those they have
defeated are more typically reintroduced year after year, often redrafted to
accommodate legislators‟ objections.” Sparber continues: “We cannot say that
ambient smoke doesn‟t harm non-smokers…and in fact the best we can say is that it
is not proven that cigarette smoke in the air harms normal, healthy non-smokers”. 15

- Tobacco Industry Evidence that Second-hand Smoke Exposure Increases the
Risk of Sudden Infant Death Syndrome (Cot Death)
A recently published report 16 reveals that in 1997, Phillip Morris commissioned a
review article on Sudden Infant Death Syndrome (SIDS), in response to company
concerns about the possible adverse effects of SHS on maternal and child health.
The draft review concluded that prenatal and postnatal smoking exposures are both
independent risk factors for SIDS. However, the final draft was modified following
exchanges with Phillip Morris and tobacco company scientists, to conclude that
postnatal SHS effects were “less well established” than those associated with
prenatal maternal smoking. The review paper was published in 2001 in the UK
journal Paediatric and Perinatal Epidemiology 17, stating that the relationship between
SIDS and exposure to SHS was „difficult to quantify'. The tobacco industry has long
fought to counteract scientific evidence that SHS is dangerous to health. By Philip
Morris‟ own admission, ‟there is perhaps no other issue as powerful facing the
industry‟ as SHS and maternal and child health issues.18 Three years after its
publication, the SIDS review had been cited at least 19 times in the medical
literature. This suggests that Phillip Morris succeeded in manipulating the content
and presentation of scientific results, to create a review that, until now, has been
seen as authoritative and credible.

3. Additional research published since our written submission to the
Health Committee

a. Adult Health Risks

A recent study published in the British Medical Journal 19 highlights that exposure to
second-hand smoke kills more than 11, 000 people a year in the UK – a much higher
figure than previously thought. This study also gives the first available figure for
people dying from second-hand smoke in the workplace – 600 lives are year are lost
because of exposure to SHS at work. The study found 2,700 deaths among people
aged 20 to 64 could be attributed to second-hand smoke and 8,000 in 65-year-olds
and over. A further 617 deaths are thought to be caused by workplace passive
smoking, including 54 in the hospitality industry. This is in line with recent research
that suggests around 1000 Scots die as a result of exposure to second-hand smoke
every year. 20

b. Benefits of Going Smoke-Free

The SLTA21 continue to argue that the evidence shows that there is little or no effec t
on smoking incidence among regular users following the introduction of smoke-free
legislation. They argue that, in Ireland, according to research Agency Millward
Brown, the incidence of smoking 5-plus cigarettes a day, among adults aged 18-64
has increased for both men (by 4%) and for women (by 2%). This is not in
accordance with any other estimates of incidence that have been drawn from Ireland
(see our main submission). On Tuesday 29th March 2005, the Republic of Ireland
celebrated one year of smoke-free success. According to the Irish Finance Minister,
cigarette sales have declined by 18%, and it is reported that an estimated 7000
smokers have quit smoking since legislation was introduced one year ago. 22 A team
of researchers from the Royal College of Surgeons in Ireland have reported that
smoking is on the decline among older people in Ireland; with prevalence rates falling
between 2-3% over the past 4 years; from 20% to 18% in the east, and from 21% to
17% in the west. By comparison, smoking rates among older people in Northern
Ireland have remained stable, at around 19% both in 2000 and 2004. 23

In a recent independently conducted poll, an overwhelming 98% of the Irish public
responded that workplaces are healthier since the introduction of the smoke-free law,
including 94% of smokers. 93% of respondents think the law was a good idea, and
96% of respondents feel that the law is successful.24 A recent survey by the trade
union Mandate has found that people working in public houses across the Republic
of Ireland believe that smoke-free legislation has yielded huge benefits for their
health. 87% of respondents believed that the law had already had a positive impact
on their health, with 82% stating that they now found it easier to breathe at work, and
68% reporting that they coughed less.25 A study by the Office of Tobacco Control
has found that since the introduction of smoke-free legislation, carbon monoxide
levels in non-smoking bar workers have fallen by 45%, and levels in ex-smokers
have fallen by 36%. Average levels of the smaller airbourne particles in SHS, which
are known to be particularly harmful to health, have been reduced by 87.6% 24

c. Ventilation

ASH Scotland‟s evidence-based research briefing on ventilation is available online at:


This briefing contains further details of the evidence submitted to the Health
Committee, and additional research that clearly demonstrates that ventilation
systems are not able to remove the hazardous gases that are present in SHS.

The SLTA21 recently stated that ETS contamination is subject to exponential decay,
and use a chart prepared by Building Services Research and Information Association
(BSRIA) to illustrate this point. They argue that most pubs have a natural leakage
rate of 1 or more air changes per hour, with air seeping through the fabric of the
building. This means that the equivalent of all the air in the room is replaced once
each hour with fresh outside air. At even a low rate of ventilation such as 5 air
changes per hour, the contamination would reduce by about 85% in about 30
minutes, and effectively to zero within an hour.

BSRIA are far from independent. They have in the past conducted testing on
ventilation equipment performance sponsored by Honeywell and other air cleaner
manufacturers, under the umbrella of the AIR (Atmosphere Improves Results)
initiative. Interestingly, at the time AIR published the results of this testing, relatively
few manufacturers agreed that their test results could be published. 26

BSRIA has also worked with the Air Cleaner Manufacturers Association (ACMA),
which was set up specifically to counter arguments regarding the inadequacy of
ventilation systems, and to prove the effectiveness of its members‟ equipment to
potential purchasers and Regulators. This led to the launch of BSRIA‟s certified
rating scheme “to clearly show the real performance, rather than the claimed
performance of an air cleaning product.”26 BSRIA are also a member of the AOB
group, the same group that is dedicated to opposing the Smoking, Health and Social
Care Bill and in partnership with companies such as Imperial Tobacco. 26

The SLTA2 1 continue to refer to the published “Black Dog study”, 27 which they state
clearly demonstrates that well-managed ventilation airflow can prevent ETS drifting
from a smoking area to a non-smoking area. The researchers conclude that
ventilation techniques for restaurants/pubs with separate smoking and non-smoking
areas are capable of achieving non-smoking areas ETS concentrations that are
comparable to those of similar facilities that prohibit smoking outright.

The SLTA fail to mention that this piece of research was led by Roger Jenkins, of the
Oakridge National Laboratory of Tennessee. Although part of the U.S Department of
Energy‟s often highly-classified research establishment, Oakridge National
Laboratory researchers are also for rent to private companies. Roger Jenkins has
conducted several other pieces of research that have been commissioned by the
tobacco industry, that typically attempt to show that exposure to SHS is not a health
hazard.28 Jenkin‟s findings, and Jenkins himself, frequently appear in hearings to
oppose local smoke-free measures. As an expert witness for the defence in a lawsuit
bought by flight attendants against the tobacco industry over the lung cancer and
other diseases they contracted at work, Jenkin‟s evidence was excluded by the judge
because of his pro-tobacco industry bias.29

It is also noteworthy that the research was published in the Journal of Regulatory
Toxicology and Pharmacology, which is sponsored by the International Society for
Regulatory Toxicology and Pharmacology (ISRTP). In turn, ISPRT are part
sponsored by RJ Reynolds Tobacco Company.30

d. Voluntary Agreements

A recently published European multi-centre study has demonstrated that introducing
non-smoking and smoking areas in public places fails to create a completely smoke-
free environment. The researchers measured SHS exposure in a range of public
places, including transport, educational settings, and bars and restaurants. The
researchers measured levels of environmental tobacco smoke in Vienna, Paris,
Athens, Florence, Oporto in Portugal, Barcelona and Orebro in Sweden. Whilst there
was some variability among cities, the study demonstrates that co-existing smoking
and non-smoking areas are not an effective means of controlling the health hazards
associated with SHS. Nicotine levels in many of the areas tested that had smoking
restrictions were not dissimilar in concentrations to areas where smoking was
permitted. The highest nicotine concentrations were found in bars and discos,
followed by restaurants. The researchers state that “A person dancing for four hours
in a disco with the median concentration found in cities like Vienna or Barcelona is
exposed to a similar amount of tobacco smoke as someone living with a smoker for a
month.” 31

Recent reports32 outline that the city council in Paris have now acknowledged that a
voluntary scheme launched three months ago has failed. The scheme aimed at
encouraging Paris's 12,452 cafes, bistros and brasseries to declare themselves
smoke-free zones had been adopted by barely thirty. Here is another example of
voluntary smoke-free plans failing to work.

e. Economic Impacts

There have been several attempts by the SLTA, TMA and AOB to undermine the
International Review of the Health and Economic Impact of the Regulation of
Smoking in Public Places that was recently undertaken by Aberdeen University. The
Scottish Beer and Pub Association33 state that the study makes no attempt to analyse
the macroeconomic impact of smoke-free legislation on the Scottish economy, that
the study is not robust, and that it relies on analyses of incomplete and non-
transferable studies.

Firstly, the author of the study acknowledges that the model for Scotland was
estimated on the basis of the best available evidence and using expert judgement
where the evidence does not exist. The majority of studies that have been
undertaken cover both bars and restaurants, as very few existing studies separate
out the economic effects for these two sectors.

Secondly, to acknowledge the limited number of existing studies available, the
authors combined a literature review with the modelling exercise to place the likely
impacts of restrictions on smoking in public places in a Scottish context. The
literature review covered a number of distinct areas, including economic impacts of
restrictions on the hospitality sector, costs of workplace smoking, and the costs of
smoking related diseases.

The model was based upon evidence relating to smoke-free public places, which
include workplaces and the leisure and hospitality sector. Smoke-free legislation was
modelled, rather than lesser restrictions, because the nature of health effects relating
to partial smoke-free restrictions remain unclear. In order to provide as complete an
overview of the impacts of smoke-free legislation as possible, some impacts have
been modelled on the basis of only limited information. Therefore, to reflect this
uncertainty, a range of estimates has been produced; central, low and high.
There are a number of challenges inherent in research of this kind. Some of the
problems in research design are unavoidable given that the impact of restrictions can
only be evaluated where they have been implemented.

Looking at the hard evidence from New York, Ireland, and California, there is not a
negative impact on business. The only studies that suggest that there is are funded
by the tobacco industry and are of poor quality.

Going smoke-free can offer many business opportunities – around 70% of the
Scottish population don‟t smoke; smoke-free is popular (especially after it‟s been
legislated for) and smoky pubs are unpopular. The only industry we know will be hurt
by progress on this issue is the tobacco industry.

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                                                                                   April 2005


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