Plain packaging kicked into the not very long grass?

I chanced on a tweet that sported this link, and the relevant paragraph is here, embedded in Amendments to the Children and Families Bill:

(1)   The Secretary of State may, if satisfied that doing so is in the interests of preventing harm to the health of children under the age of 18 or of promoting the health of children under the age of 18, make regulations specifying retail tobacco packaging requirements.

The relevant legislation, if this amendment is passed and the bill becomes law, will enable the Secretary of State to write up the regulations just like that. Another amendment to the Bill is to make it an offence to 'fail to prevent smoking in a private vehicle when children are present'.

It seems that there is something more than a little underhand to prepare for the legislation to be brought in without further parliamentary debate, as part of a bill that will be full of glowing language about how life is being made much better for children.

This is clearly the solution that junior health minister Anna Soubry was working to enable but I didn't expect to see it in writing quite so soon as this!

Confused believer in liberties hails ban

Former smoker PM David Cameron applauded the smoking ban in bars while suggesting that actually smoking bans in cars were going too far and he is nervous about it.


I've been trying to work out all day what he meant. He is a strong believer in civil liberties but the ban has worked. What does that actually mean?

Government and non-governmental agencies right up to international level have colluded to ensure that two people can't share a smoke convivially in comfortable surroundings anywhere in public – even in private clubs. That has to be an infringement of liberty. As liberties go, it's pretty basic. There is no other way to describe it. It means that an authority gets to dictate the terms on which people associate with each other, and blocks what has been an accepted part of public social intercourse for many decades. Somewhere between a fifth and a third of the population smokes – varying from district to district. So how does a liberty lover get to believe that this 'works'?

The mind boggles, but I can only assume that the Prime Minister finds the outcome of the legislation pleases him, as a non-smoker who might be trying to avoid lapses in the style of Clegg and Obama – and it has been successful insofar as the people haven't taken to the streets yet. Something that doesn't restrict his personal freedom doesn't enter the picture in his understanding of liberties. Prime Minister – real liberty lovers enjoy the concept of liberties. They don't sacrifice the liberties of others – other people's liberties are as precious as their own.

Sad to say, Labour MP Alex Cunningham (who is trying to criminalise smoking in cars with children present) might also find the Prime Minister amenable on the subject of motor car bans, if he tries hard enough to persuade him.

And on Scotland, more on smoking in cars

I don't know why this topic has generated so much interest in the Scotsman. Today we have 1) a letter; 2) a report on the British Lung Foundation's call to ban smoking in cars in Scotland; 3) an exchange of views between Tom Miers of the Free Society Website and Dr James Cant, Head of the British Lung Foundation in Scotland.

Says the British Lung Foundation,  'smoking just one cigarette in a vehicle, even with the window open, creates a greater concentration of second-hand smoke than a whole evening's smoking in a pub'. Really? one cigarette in a vehicle? A people carrier? a Mini? Small pub, big pub? Pub with or without open windows? This surely epitomises the vagueness of the whole threat of passive smoke. How can one cigarette (especially in a car with an open window) produce the same level of emissions as a few hundred? 


And if this is the case, why did they ban smoking in pubs at all? Children of course are the people in our society without choice. Adults can choose to go into a pub, or remain elsewhere. 


There's also a poll – but not very much interest in it.


An MSP's tweet about smokers outdoors at the Edinburgh Festival firework display generated a little more interest. 

Scots urged to ban smoking in cars

Apparently Welsh parents are being given a period of grace to see whether a public education programme will change people's behaviour. The British Lung Foundation wants Scotland to follow the example of Wales.

Since there is (we are told) no safe level of secondary smoke, a delay in implementing the most severe restrictions is somewhat strange. The emphasis is on children after all. Not legislating immediately is endangering millions of children's respiratory systems forever, isn't it?

A delay suggests that the government recognises the sensitivity of legislating activities in private space. Many people who feel the government is pushing its luck defining pubs and restaurants as public spaces would be pushing their luck by extending rulings into a private car.

This could be a recognition that banning smoking in cars would be more a political gesture than an effective measure to protect respiratory health. There are unquestionably threats to children's respiratory health in this country, but it is very doubtful whether banning smoking in cars would be more than tinkering at the edges.

Ten-minute rule motion passed to ban smoking in cars: let's get some perspective

At Westminster today a Bill was approved that would ban smoking in cars carrying children. As a backbencher's  Bill it collected less than 150 votes, but it got media attention because of its subject matter including mainstream attention from the BBC and ITV (among others) and the blogosphere, where it attracted the attention of Big Brother Watch.

The argument goes that having protected adults from secondary smoke, we must now protect children. But legislation banning smoking in enclosed public places has existed in the Republic of Ireland since 2004. At this time they were beginning to think of introducing it to Scotland and legislation to do this was passed in 2005, around six years ago. In other words it has taken the great and the good over six years to come to the conclusion that what might hurt adults in areas they need not go, might also hurt children in areas where they have no choice about going.

The real issue is of course that they could almost get off with designating private businesses as 'public places', but public opinion had not caught up with the idea that you can interfere with the smoking habits in the undeniably private areas of the home and car. Having established the right of interference in quasi-public places, their courage (if you can call it that) is growing. It has nothing to do with the level of risk involved, or the vulnerability of those affected, and everything to do with a steady process of invading autonomy in businesses, then in family cars, then in family homes.

How can you say in July 2005: 'the risk of exposure is unacceptable. We'll ban it with effect from next March'? There are other ways of handling bans of risky commodities, that leave you in little doubt that the government actually believes there is a risk and isn't just trying to mess you about.

The risk itself? The UK has a poor record on clean air quality, and it is to be expected that the government will concentrate its 'air quality' efforts on the smoking issue. This typifies the focus on lifestyle issues now being taken by global bodies, including the World Health Organisation, which has recently been trying to ratchet up interest in non-communicable diseases. This effort is reflected in the media by stories such as Unhealthy lifestyles to kill 52 million yearly by 2030. Such stories may not reflect the intention of the World Health Organisation (who knows?), but this one says that 'most' chronic diseases are caused by 'unhealthy and ethically wanting lifestyles'.

It looks as if they intend to blame the poor for getting ill needlessly. But they still want to treat those conditions that the poor would not be getting if only they behaved themselves. Is someone making money out of this?

The framework confirms the industry’s crucial role in continued investment in R&D programmes to develop drugs for the prevention and treatment of non-communicable disease, with over 1,500 products in the pipeline currently. It also commits the industry to target its innovation towards the specific needs of the developing world. To this end, in addition to the framework, there will be a programme of research, to improve understanding of the specific needs of developing world populations. [emphasis added]

Yes, there might be some very lucrative contracts here ... prevention and treatment of conditions that are killing off people in vast quantities (conditions that the patients bring on themselves, let's not forget!). The paragraph quoted above reads almost like a business plan for pharmaceutical companies.

The truth of course is that while lifestyle factors may contribute to ill health and many non-communicable diseases, there is no certainty about how much. It is not known to what environmental and other hazards workers, urban dwellers or other groups are exposed ('developing countries' include most of the world's population and a vast variety of working and living conditions), and while it might sound catchy to say that lifestyle factors are a common cause in their sicknesses, it is also profoundly lazy. Public policy will become limited to warnings about lifestyle issues, rather than awareness training about environmental issues and hazards at the workplace, for example.  I hasten to add that I am guessing, but it looks like the World Health Organisation is taking a moralistic, judgemental and simplified approach to the issue of non-communicable diseases, rather than a scientific, measured one. And as we have already established, non-communicable diseases kill older people and people in wealthier parts of the world, more often than infants and young adult breadwinners. The 'paradigm shift' in the focus of pharmaceutical companies might be good for their balance sheets – will it result in improved conditions for people, or neglect for their most basic needs?

Counting the costs of tobacco control

Let's go back to last October, and a reported entitled 'Government lobbying government', reported here. It gave the Scottish Government's grant to ASH Scotland as over £921,000 in 2008–2009.

This is a tabloid trick perhaps but one might ask how this situation arises, when ASH Scotland is guaranteed an income that would pay for the treatment discussed here for four people.

In the real world, of course, this is about rationing treatment. I have no idea what factors are built into decisions that allow some people funding for this kind of condition and not others. It is quite clear that the pot paying for drugs is not bottomless and hard decisions have to be made. The drug in question has not been approved by the Scottish Medical Council, but arrangements have been made successfully for at least one patient in Scotland to receive it.

SMC refused to approve eculizumab for use on the NHS last November. Professor Peter Hillmen is a consultant haematologist and expert on PNH, who leads the only Scottish clinic for patients with the condition as well as heading up a key treatment base for the illness in Leeds. He said: “I have two to three patients in Glasgow who are not funded. They are the only patients in the UK who do not have treatment.”

Negotiations are ongoing.

In the face of such stories it is hard to see how ASH Scotland's income is guaranteed, at a considerably higher rate than the London-based Action on Smoking and Health (see first link above), even though the population is only one-tenth the size of England's population. It has 27 staff to push its agenda (as I've pointed out before, when I was on a casual contract with the Scottish Government in a division of the Health Department dealing with illegal drug use there were just half a dozen of us plus secretarial backup shared with other divisions). 

Here's another waste of money: 620 delegates at c. £350 a pop (conference fee) plus accommodation expenses, attending a two-day conference on pushing smoking cessation drugs. Even the BMJ's Tobacco Control blog acknowledges that most people giving up successfully don't need the drugs, so why does so much money need to be thrown at this national obsession?

Incidentally I heard that the SNP have overtaken Labour in the polls –  perhaps the popularity of this story helps to account for it. Having discovered that enforcing a smoking ban in the grounds of several hundred hospitals is next to impossible they now want to try it in the grounds of a few million motor cars

Hobson's choice at the Scottish polls

For a minority government, the scale of the vote in favour of the Tobacco and Primary Medical Services Bill on its final reading on 27 January last year was impressive (108 members voted in favour and 15 against). A similar landslide vote brought in the smoking ban itself on 30 June 2005 (97 in favour, 17 against). In both cases the Scottish Conservatives provided the only opposition. 

It's no secret that the Westminster Conservatives have been disappointing on the issue of the smoking ban (and related issues) since gaining power with the Liberal Democrats in Westminster last year. It is hard to imagine the Scottish Conservatives having the upper hand in any coalition emerging from the Scottish elections (not that being the stronger partner at Westminster has helped any!) 

Scotland's elected representatives are voted using the party list system (additional member system). This means that each person votes for a constituency MSP and for a regional MSP. Although meant to favour minority parties, the plan here shows that Holyrood is as dominated by major parties as Westminster. Since the Scottish media views the election as a two-horse race, major parties naturally respond by urging their supporters to vote for them on both lists. The result is dismally predictable. 

Further: I have never been sure what the list members are meant to represent. Constituency MSPs represent their constituents – in theory anyway. Are you meant to vote for the policies that they represent, rather than for their personal effectiveness as political representatives? Do they feel any sense of responsibility for their voters, or does most of their loyalty go to whatever party selected them to fight regional seats on its behalf?

Both Labour and the SNP want further powers for the Scottish Parliament. One wants Scotland to be its own country and the other doesn't. Personally I feel that Scotland has too many people trying to run it in too many different places (Edinburgh, London and Strasbourg) and that matters should be made simpler by chopping the devolved assemblies and allowing their function to be filled by regional Westminster MPs, who would meet in the regions (including London of course: no more West Lothian question!). (For reserved issues they could all meet together at Westminster. Much less travelling would be needed.) It would bring legislators closer to the voters on certain issues, whether in Cardiff, Edinburgh or Stormont. 

What of smoking issues in the election manifestos of the two front horses? Well, here is what the Scottish National Party had to offer in 2009 (current manifesto not yet released), under the heading 'Creating a smoke free Europe':

Preventing smoking in public places is an important step to creating a smoke free, healthier Scotland and the SNP is working in partnership with our European neighbours in the fight against tobacco. In addition to the Scottish Government’s smoking prevention action plan, a number of initiatives have been taken at a European-wide level and the SNP will continue to work with the EU to make sure that future initiatives are powerful tools in creating a smoke free Europe.

At least it's clear. Labour's message isn't quite so blunt, but the direction of travel is similar.

Scottish Labour led the UK in banning smoking in enclosed public spaces. We remain determined to do even more to tackle Scotland’s high smoking rates. We will introduce a revised Tobacco Control Strategy that will tighten up the loopholes in legislation to prevent tobacco advertising on merchandise. We will consult on the desirability of a ban on smoking in cars that are carrying child-passengers.

That's your choice.

Smoking in cars declared out of order by Greater Glasgow Health Board

Last week, many articles in the Scottish news media warned the public off smoking in cars, because the dangers to children were said to be phenomenally high: concentrates were higher, we were told, than in Scottish pubs before the ban. Don't bother opening your window, we were also told, because it won't make any difference (or enough difference).

Mr Gray in Glasgow is persuaded.

... I am certain most of the public will feel the same and condemn those who continue to puff away when they have kids in the car.

The law should be changed to deal with this, as serously as being caught, say, using a mobile phone while driving.

The Executive Summary of the NHSGGC report that kicked this off leaves much unanswered. The report shows an alarming picture of particulates in a smoky car at 14 times what they are in a car where no smoking was taking place, and peak concentrates at shocking levels:

The arithmetic mean PM2.5 concentration during journeys where smoking took place was 95 µg/m³, approximately 14 times higher than the mean figure of 6.8 µg/m³ measured during non-smoking journeys. Peak levels across the 26 smoking journeys averaged 410 µg/m³ compared to 12 µg/m³during nonsmoking journeys. The highest peak PM2.5 concentration of 886 µg/m³ occurred during a smoking journey.

At no point in any of the non-smoking journeys did PM2.5 concentrations exceed the 35 µg/m³ US EPA outdoor air guidance concentration for unhealthy air. All smoking journeys exceeded this threshold at some stage of the journey with the percentage of the time when concentrations rose above 35 µg/m³ ranging from16 to 100% (mean 49%).

Here's a useful analysis:

As a preface it is important to note just what [the Scottish Centre for Indoor Air] has chosen to measure and report on in compiling the report, something called “FPM 2.5.”  FPM 2.5 is the designation given to any particulate matter in the air that is 2.5 micrometers (microns) in diameter or smaller.  Normal people call it smoke or smog.  If you allow smoking in a place most people will realize that you will probably have smoke (FPM 2.5) in that place. If you go outside on particularly smoggy day you’ll be able to see FPM 2.5 in the outdoor air as well.

But there’s something very fundamental and important to remember when speaking of FPM 2.5: it is simply a measurement of a certain size range of particles.  It says nothing about what those particles consist of or how dangerous they are.  To pretend that the particles produced by the quiet burning of a few leaves in a scrap of paper is the same as the particles produced by the high temperatures and/or pressures of internal combustion engines, industrial processes, commercial incinerators, or even a roaring fireplace is simply false.  It’s like pretending that a teaspoon of sugar crystals is just as deadly as a teaspoon of arsenic crystals simply because both happen to have crystals of the same size.

And yet it is this false premise that lies at the very base of the SCIA Report.  Are the FPM 2.5 levels produced by cigarette smoke dangerous in the same way as the chemical air pollution produced in the air of our cities?  It could be argued that it is possible but it certainly can not be argued that it is known. It could very well be that it is indeed like comparing arsenic crystals and sugar crystals, and it could also be that just as concentrated amounts of sugar can be unhealthy for certain small populations (e.g. diabetics) that concentrated amounts of FPM 2.5 from tobacco smoke could be unhealthy for certain small and sensitive populations (e.g. those with impaired breathing, those with severe cardiovascular disease, those who are very old or very young.) 

Note however the importance of the word “concentrated.”  If two chain smokers are driving for hours in a car with such a  sensitive person and keep the windows rolled up tightly all during their trip, then yes, it could well be rationally argued that a real problem might exist.  To argue that the same problem exists when moderate smokers roll a window or two down a few inches while driving at normal speeds and smoking is something else entirely: the all-important “air changes per hour” that ventilation engineers concern themselves with is probably about 2 or 3 with the windows closed tightly, but more like 200 or 300 when the windows are opened.  To equate the two situations is simply a lie.

And there is more:

In addition to the above problems the SCIA report seems to deliberately make another very fundamental error, one that it would be difficult for the authors to plead innocent of.  While it is true that according to agencies such as the US EPA that urban, automotive, and industrial air pollution has been shown to be unhealthy or even dangerous when it reaches higher levels for periods of 24 hours or more, it is also true that the EPA doesn’t set standards for FPM 2.5 for shorter periods because there is no sound medical reason to believe that shorter episodes of such exposures actually pose a threat to health.  When the SCIA takes readings during car journeys that typically last less than several hours and tries to apply the EPA’s 24 hour standards to those readings, it is explicitly violating the very guidelines of the EPA itself.

Explicitly?  Deliberately?  Am I being unfair?  I don’t think so.  Here is the relevant passage from page 42 of the EPA’s own GUIDELINE ON DATA HANDLING CONVENTIONS FOR THE PM NAAQS for the use of its calculations:

If measurements are available for less than 75 percent (17 or less) of the hours during the 24-hour period, you must treat the 24-hour average as invalid, unless the concentrations are too high to be ignored, as determined by the following calculation:

A. Compute the lower bound. Substitute zero for each missing hour and compute the average over all 24 hours.

B. Round the lower bound. Round the lower bound to the nearest 1 µg/m³ for PM concentrations (round up decimals 0.5 or greater). Round the lower 2.5 bound to the nearest 10 µg/m³ for PM concentrations (round up integers 10 of 5 or greater).

C. Compare the rounded lower bound to the standard. If the rounded lower bound exceeds the level of the 24-hour standard, use the unrounded lower bound as the valid 24-hour average. Otherwise, treat the 24-hour average as invalid. 

Michael J. McFadden

What measurements do we have to go on? 

• the EPA safe level for healthy air is given as 35 µg/m³
• peak levels of particulates in the non-smoking car were about 12 µg/m³
• peak concentrations in the smoking car averaged 410 µg/m³ in the smoking journeys (while what they call the mean average was about 95 µg/m³).

The report (so far we only have access to the summary) doesn't define the lower bound but surely in a range with peak average of 410 µg/m³, an absolute maximum of 886 and an overall average of 95 µg/m³, the lower end of the range must have been very very low. Nor does it tell us how long the journeys were, but it's hard to see why journeys of this experimental nature should exceed two or three hours. We do know however from the Executive Summary that for up to 15 per cent of the smoking journeys the meter read <35 µg/m³, and it therefore seems clear that the pollution described in this report is insignificant in the terms defined by the Environmental Protection Agency (who set the 35 µg/m³ safe level), indeed that the SCIA has violated the EPA standard by its use of the figures.

So ... in the first place, we don't even know for sure that the particulates from smoke do any damage, just because of their size. In the second place, since the EPA levels are designed to apply to prolonged exposure, the pollution levels actually fall comfortably within the safe ranges defined.

In the Evening Times article, further misconceptions come to light. For example:

Dr Sean Semple, of the Scottish Centre For Indoor Air, was part of the research team. He said: “The air quality during smoking car journeys is much worse than normal outdoor air pollution levels.” 

This seems to miss most basic toxicity lessons. A car journey is often quite short, and even when it is long, smoking might occupy a very short part of it. Outdoor air pollution in busy cities will vary with the time of day and the weather but in general is much more constant than what you will find in a car. (Even in the non-smoking car, particulates didn't measure zero.) Furthermore particulates are only part of the story of outdoor air pollution – particulate measurements won't pick up noxious gases. 

MJM concludes:

The final paragraph of the Summary consists of three sentences, each of which is important enough to be examined on its own:

1)    PM2.5 concentrations in cars where smoking takes place are high and greatly exceed levels that are deemed to be unhealthy in outdoor air.

 The above statement was dealt with in the opening paragraphs of this Critique.  The comparison with EPA type 24 hour standards violates the very conditions of the guide and as such it should never have been permitted in such an official document as this Summary.  Not only are the FPM 2.5 measurements measuring something chemically and probably clinically quite different from the EPA measurements setting “unhealthy” level guidelines, but the EPA itself forbids usage of its guidelines while disregarding the 24 hour exposures for which they were set.

2)    Smoking in cars leads to exposure to SHS that is likely to be damaging to health. 

This statement is not in any sense supported by the data in the Report.  The Report does not show any data, at least not as indicated in its Summary, that would support such a claim for brief exposures at the levels measured.  This statement should also be stricken from the Summary.

3)   Measures to restrict the exposure of children to SHS should be considered at both an individual and a societal level.

This final statement is reasonable, but it should be more open about what it is urging: it is calling for the government to enact legal measures and remedies to “restrict the exposure of children” to SHS by their parents, not just in public places, but in the confines of vehicles and private homes.  It would have been a more honest concluding statement if it had said:

 “Measures to enact laws to restrict smoking in private homes and vehicles where minors are present should be considered even if the minors in question are themselves smokers.  Such measures obviously will also require the consideration of proper penalties and the removal of such children in the face of persistent parental smoking. Since the eyes of the government cannot be in every home, children should be empowered and encouraged to report on their parents if such exposure occurs with the parents being duly dealt with through fines and imprisonment.”

ASH Scotland has not yet nailed its colours to the mast and demanded a smoking ban in cars.

ASH Scotland calls for new anti-smoking laws

Or does it? I have to say I am a little confused.

A writer in The Scotsman says ASH Scotland wants further legislation.

Sheila Duffy says it doesn't.

ASH Scotland's paper on the issue is pretty non-committal.

ASH Scotland's recent CRUK-funded paper Beyond Smoke-free backs up Sheila's position to an extent. It talks about interventions, consultations, social marketing projects. It does not refer to further legislation, but does  wish to remove current exemptions from smoking bans in the short term. In the long term, says the paper:

There is public support for more comprehensive tobacco control policies and a strong ethical justification for additional measures aimed at reducing exposure to second-hand smoke. In order to make advances and substantially reduce exposure to second-hand smoke in Scotland, new approaches are required to tackle this complex issue.

But just what does public support mean? 'Support' for removing the mental health exemption is claimed to be found in this paper (which has 'demonstrated support for this move') The paper includes strong criticisms of the consultation paper on removing the mental health exemption and also says (page 12):

Just over one-third (35%) of those who responded to this question recommended that the existing exemption which permits smoking in designated rooms be removed by amending the existing legislation.  [...]

The vast majority (81%) of patient representative groups advocated the retention of the status quo, as did 6 out of 10 of respondents who identified themselves as current service users

It also says: 'Around one in ten (12%) of respondents advocated producing detailed guidance material without amending the legislation.' This was the option the government has taken, and the guidance will appear early next year.

From ASH Scotland's contacts with smoking cessation practitioners at local level in Scotland, we know that services are awaiting government leadership on this issue. The Scottish Government plans to produce guidance to support psychiatric units to close their smoking rooms – we await publication with interest.

Thus ASH Scotland says there is 'support' for a policy that 81 per cent of patient respondents have opposed and only one-third of all respondents supported.

Based on their assessment of the facts, I conclude that The Scotsman's version of events is correct and that Sheila Duffy does want legislation that will ban smoking in cars and even in the home.

Sheila Duffy, smoking ban on cars and social marketing

This letter appeared almost a week ago. Sheila Duffy remarks that, of all the proposals presented in Beyond Smoke-Free, people were interested only in the proposal of a smoking ban on cars.

But she doesn't want a smoking ban on cars.* She wants a debate and a public consultation on a smoking ban in cars (on a proposal that she claims not to want to be brought into law – doesn't she know we're all tightening our belts now?), and a social marketing campaign on smoking in cars.

Social marketing again. Has she got shares in it?

She might as well advocate a brainwashing campaign, or re-education. What's wrong with a good old-fashioned educational campaign? Not persuasive enough?

* Unlike Dame Helena Shovelton (British Lung Foundation).