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Politics of Health in the UK

Policy Paper

The purpose of this policy analysis assignment is to analyze the health policy document, Healthy Lives, Healthy People: Our strategy for public health in England published by the British Government. Smokers will be used as a client group for this analysis. The policy analysis will identify health-related challenges among smokers and show how the policy document strives to address them. In addition, the analysis will also draw from available studies, statistics, experts’ opinions, and other supporting materials. Finally, the analysis will highlight policy implications and their impacts on smokers.

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Governments come and go, but major public health problems have always persisted. The lifestyle of the contemporary and health outcomes alongside other new communicable diseases, as well as past diseases, have created challenges that require effective public health policy. Moreover, climate change outcomes have also affected public health. Any government, therefore, must focus on improving public health or face poor outcomes.

The Coalition Government published the White Paper, Healthy Lives, Healthy People on November 30th, 2010. The policy paper provides a framework for public health by identifying three key domains namely, protection, health improvement, and the quality of health services provision (Department of Health 2010).

While Healthy Lives, Healthy People was based on the ideology of individual responsibility for health, it also recognized the role of socioeconomic and environmental factors. The Coalition Government developed the policy based on the findings from the Marmot Review on social determinants of health (Marmot 2010). This implies that the Government implemented recommendations covered in the review on health inequalities. Based on the individual responsibility covered in Healthy Lives, Healthy People, it remains to be seen whether the Government will realize its vision for public health, address health inequalities, and influence health outcomes.

Healthy Lives, Healthy People policy focuses on several principles to address public health challenges. First, it identifies strong leadership to ensure the effective promotion of health care services. Second, the policy paper emphasizes the use of evidence, particularly during the implementation of the policy into practice. Third, the policy paper identifies the most effective interventions at a given stage of life. It shows that earlier years are critical and therefore, investments in health care should start from early childhood to adolescence to provide better health during adulthood. The Coalition Government has shown a different example from some of the previous Conservative Governments by focusing on reducing health inequalities in the UK. Fourth, Healthy Lives, Healthy People has recognized the importance of all stakeholders in the provision of health care services to the public. The Coalition Government highlights the role of the local government in promoting public health. Finally, the policy paper emphasizes the use of minimum intervention to achieve maximum desired outcomes, such as the use of regulation to combat poor health outcomes. At the same time, it also recognizes the use of appropriate interventions in various situations.

The Problem

Healthy Lives, Healthy People will result in significantly improved health outcomes for several client groups. The client groups chosen for this analysis are smokers. According to available literature, cigarette smoking is the principal single cause of preventable illnesses and premature deaths in the UK (Kenny 2012; NHS Confederation 2013). Smoking, therefore, is so harmful to the public. Nearly 100,000 people die every year because of smoking in the UK. Most deaths related to smoking result from cancers, heart diseases, and chronic obstructive pulmonary disease (COPD). In addition, there are also other health-related complications related to smoking. These include circulation, sexual problems, rheumatoid arthritis, fertility, aging, and menopause.

Still smoking is also could also worsen other health conditions such as “asthma, colds, flu, chest infections, tuberculosis, chronic rhinitis, diabetic retinopathy, hyperthyroidism, multiple sclerosis, optic neuritis, and Crohn’s disease, as well as increase the risks of developing dementia, optic neuropathy, cataracts, macular degeneration, pulmonary fibrosis, psoriasis, gum disease, tooth loss, osteoporosis, and Raynaud’s phenomenon” (Kenny 2012). More than half of the smokers succumb to smoking-related health problems. Moreover, smoking reduces life expectancy by 10 years. In other words, nearly half of long-term smokers do not live for more than 70 years. People who start to smoke earlier in life are likely to smoke for long and die early. Smoking-related deaths take a long to occur i.e., smokers will experience illness and distressing conditions for many years before death. People who have mental conditions and smoke are likely to live 16 to 25 years less relative to the public (NHS Confederation 2013).

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Healthy Lives, Healthy People aims to improve health outcomes among smokers and focuses on a comprehensive range of interventions to be initiated at the national and local levels to reduce smoking rates and smoking-related deaths (Locker & Chambers 2011). The policy recognizes that nicotine is the major element that leads to addiction. At the same time, it also accounts for other related behavioral and social factors that encourage individuals to smoke and inhibit them from quitting.

Healthy Lives, Healthy People covers six key issues to combat smoking prevalence among young people, adults, and pregnant women. It aims to reduce the smoking rate among adults aged 18 years and over in England from 21.2 percent to 18.5 percent or less by the year 2015 based on the measurement obtained from the Integrated Household Survey. Healthy Lives, Healthy People focuses on reducing the smoking rate among people aged 15 years old in England from the current 15 percent to 12 percent by the end of the year 2015. The rate will be based on the Smoking Drinking and Drug Use Among Young People in England Survey. Finally, it strives to reduce smoking prevalence among pregnant women in England from 14 percent to 11 percent by the end of the year 2015 based on the Smoking Status at Time of Delivery. These are major ambitions, which will reflect the outcomes from combined efforts on both national and local broad tobacco control interventions. Based on Healthy Lives, Healthy People initiatives on the Tobacco Control Plan, comprehensive tobacco control efforts should go beyond just providing smoke-free laws and local stop smoking services. Instead, it should include approaches, which account for a wide range of measures that complement and reinforce each other. In this regard, local communities should promote the health and well-being of the community by ensuring that “tobacco is less desirable, less acceptable and less accessible” (Locker & Chambers 2011). The White Paper provides an opportunity for the local authorities to take an active part in maximizing tobacco control and establishing stronger alliances with other stakeholders in a given area to ensure efficiency and effectiveness. In short, Healthy Lives, Healthy People aims to create an environment in which a smoke-free world is a norm.

Underpinning factors of the problem

Several key factors contribute to smoking among people in the UK. Many studies have indicated that individual factors determine and influence tobacco smoking. Faucher (2003) shows that individual factors such as self-concept, self-image, perception, and peer influences among others contribute to smoking among young people, particularly girls. Social factors associated with societal norms also contribute to tobacco use. There are also environmental factors, such as advertisement and economics that influence tobacco smoking. Cultural factors are also responsible for tobacco use in different communities in England. From these factors, individuals who smoke develop behaviors and patterns of smoking. In addition, all these key factors have a complex interplay in influencing and determining tobacco use, which is difficult to understand. Kerr, Knussen, and Hunter (2010) observed that people with severe mental illness are likely to smoke two to three times more relative to other people, whereas people who suffer from schizophrenia have high rates (70%) of smoking.

Factors associated with certain actions or inactions have affected attempts to combat tobacco use among the public. For instance, Kerr et al. (2010) noted that the UK had recognized the need to develop and test specific smoking cessation services for individuals with mental health challenges. There was however limited evidence to support the content and provision of the necessary services to people with mental problems who smoke. Still, numerous research findings have shown a strong relationship among tobacco advertisement campaigns, young people initiations to tobacco use, and succession to regular smoking of tobacco. Specifically, such studies have shown that tobacco advertisement led to increased consumption of tobacco. Faucher (2003) studied smoking habits in girls and noted that the influences of relationships and internal self-concept influenced tobacco use and they were more important for girls than boys. However, there were no direct studies to determine their influences on smoking (Faucher 2003). A study by Gilmore, Tavakoly, Taylor, and Reed (2013) found out that the tobacco industry has been able to keep the prices of its cheapest cigarettes “virtually static despite annual increases in tobacco taxes, circumventing the United Kingdom’s public health policy to reduce smoking through higher prices” (p. 1317). These cases highlight missed opportunities by academics, health care providers, and other stakeholders to combat tobacco consumption in England.

Evidence

Many studies have identified tobacco use in the UK and its related impacts (Lifestyle Statistics, Health and Social Care Information Centre 2013; Cancer Research UK 2014). Cancer Research UK provides comprehensive statistics on tobacco use in the UK. In 2012, out of five adults, one was a smoker in the UK (presenting 10.2 million adult smokers) (Cancer Research UK 2014).

Cancer Research UK shows that Scotland has the highest number of cigarette smokers in the UK.

Table 1: Cigarette Smoking Prevalence, Adults Aged 18 and Over, Countries of the UK, 2012.

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England Wales Scotland Northern Ireland United Kingdom
Males 22.1 22.1 24.8 20.6 22.3
Females 17.1 19.4 20.3 16.7 17.4
Persons 19.5 20.7 22.5 18.6 19.8

Cigarette smoking in the UK decreases as age increases i.e., there are more young people who smoke than seniors.

Cigarette Smoking Prevalence, by Age, UK
Figure 1: Cigarette Smoking Prevalence, by Age, UK, 2012.

The number of cigarette smokers in the UK has declined from the 1970s to the present. In addition, the difference between male and female smokers has also narrowed in the past few years (Cancer Research UK 2014).

Cigarette Smoking Prevalence, Adults aged 16 and Over, Great Britain
Figure 2: Cigarette Smoking Prevalence, Adults aged 16 and Over, Great Britain, 1974-2012.

Cancer Research UK shows that socioeconomic factors have significant influences on smoking patterns and behaviors. For instance, there are many smokers in deprived households relative to less deprived ones in the UK. Moreover, people in manual and routine occupations were most likely to start smoking earlier relative to others in managerial and professional jobs (Cancer Research UK 2014). It is imperative to note that socioeconomic variation among smokers has continued to widen over time.

Cigarette Smoking Prevalence, by Area Deprivation, Adults Aged 18 and Over, England
Figure 3: Cigarette Smoking Prevalence, by Area Deprivation, Adults Aged 18 and Over, England, 2012.

Cancer Research UK has estimated that secondhand smoke is responsible for nearly 11,000 or more deaths in the UK every year. Most deaths result from secondhand smoke at home while other deaths occur at work. Smoke-free legislation aims to curb the harmful effects of secondhand smoke on the public and children (Archer 2014). The rates of smoking cessation in the UK are generally low and differ across various regions.

Table 2: NHS Stop Smoking Service Users Successfully Quit, All Ages, Countries of the UK, 2012/13.

England Wales Scotland Northern Ireland
Percentage of self-reported successful quitters at 4 weeks after the agreed quit date 52 58 38 57

Interventions

Healthy Lives, Healthy People focuses on six key areas to reduce tobacco consumption among young people, adults, and pregnant women in the UK. First, it aims to limit tobacco promotion and display for large retailers and other small retailers by the year 2015. The tobacco promotion approach focuses on the use of plain packaging for tobacco products and the effects of tobacco accessories. In addition, it also incorporates other stakeholders at the local levels such as media and entertainment firms to encourage a positive portrayal of cigarettes. The White Paper strives to ensure that tobacco use and exposure among young people do not become normal behavior.

The second approach is to make tobacco less affordable (Department of Health 2010). One major approach has been to use tax proposals to ensure that tobacco prices remain high. However, Gilmore et al. (2013) established that tax increment on cigarettes was no longer effective because the tobacco industry has found ways of circumventing it. The policy also explores ways of working with local authorities to tackle illicit trade, developing a framework for tobacco conventions, and supporting local campaigns to reduce the use of illicit tobacco. In addition, the White Paper has been evaluating the feasibility and effects of restricting tobacco import.

Third, Healthy Lives, Healthy People has proposed effective control of tobacco products (Department of Health 2010). The method includes local enforcement of tobacco laws, identifying local tobacco manufacturers to their products meet the required British National Standards and the new EU standards. In addition, there is also increased focus on scientific and market research on nicotine use to facilitate decision-making on regulations.

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Fourth, the policy paper has focused on helping smokers to quit (Department of Health 2010). Marketing campaigns and communications will encourage smokers to quit and use available rehabilitation facilities. It recognizes the role of local authorities and other stakeholders to develop specific programs for smokers. Such programs must take into account the needs of local communities. The policy paper highlights the role of training and clinical guidance for service providers who assist smokers to quit. In addition, there would be a range of interventions to help them to quit. The approach will ensure that the number of people who seek advice on quitting increases steadily and assist users of smokeless tobacco to quit. It recognizes that some smokers may not be able to quit and therefore, they would be offered alternative sources of nicotine.

Fifth, Healthy Lives, Healthy People focuses on reducing exposure to secondhand smoke (Department of Health 2010). It would work with other stakeholders such as media, local authorities, academics, and individuals to raise awareness of the harmful effects of secondhand smoke. For instance, a study by Linda Bauld showed that smoke-free regulations were effective in reducing exposure to secondhand smoke (Bauld 2011). Specifically, the policy paper aims to encourage smokers to change their behaviors and smoking patterns.

Finally, Healthy Lives, Healthy People emphasizes the use of effective communication to control tobacco use (Department of Health 2010). The policy proposes the publication of a three-year marketing strategy for tobacco control and working with young people to assist them in making healthier life choices. Education will be a continuous process that would encourage people to understand the risks associated with smoking and the benefits of quitting. Communities will understand that tobacco smoking should not be a norm. Specifically, the policy will communicate to the client group on tobacco use, harmful effects of secondhand smoking and ensure that homes, work environments, and cars remain smoke-free zones. Communication strategies should be cost-effective but yield maximum outcomes. At the same time, health care providers must engage smokers and provide support and referral services.

Policy implications

Some studies have identified little evidence in specific issues about smoking, particularly on factors that influence girls to smoke (Faucher 2003). Healthy Lives, Healthy People should promote the use of evidence-based decision-making. In this regard, data on smoking prevalence should be available at all levels and from different sources. This would support intervention strategies and decision-making.

Healthy Lives, Healthy People has identified the need to protect tobacco control from vested interests. The policy paper understands the role of various stakeholders on tobacco control. However, it has failed to account for the role of the tobacco industry in the approach. It is therefore important for the Coalition Government to include the industry inputs into the control plane.

Healthy Lives, Healthy People certainly provides a stronger foundation and improved opportunities for better health in the UK. Most importantly, the White Paper acknowledges the role of social determinants in the provision of health care services. The Government has shown this strategy by creating a “special Cabinet Sub-Committee, which is looking at the contribution across all Departments of State” (Department of Health 2010). The strategy to use local stakeholders to promote health strategies in the UK will be effective. This approach will allow health care providers to identify priorities and ensure democratic accountability through various public and private bodies in the UK.

One major concern has been whether the commissioning arrangements for health care providers will work for both local and national levels. At the same time, the role of the tobacco industry in the tobacco control plan could be difficult to understand and achieve. Should these local approaches fail, however, the Coalition Government should utilize all various elements under the policy such as regulations, legislation, incentives, and financial penalties to push the policy? While Healthy Lives, Healthy People offers a better, integrated approach to national health care service, it is imperative to understand that the transfer of services to local levels could affect health care providers and other independent agencies.

Healthy Lives, Healthy People shows the high potential of transforming health care services among smokers in the UK. Nevertheless, the implementation process could present significant challenges. It would be important to understand whether GP commissioners can handle the NHS budget and meet various health needs of the public. Although data indicate that smoking patterns and behaviors in the UK have continued to decline, there is a widening gap in socioeconomic variations between smokers from deprived households and less deprived ones. This presents new forms of challenges for the tobacco control plan, and they may affect decision-making processes to improve health outcomes among smokers.

Conclusion

The Coalition Government has expressed its willingness to provide the best health care services for the public. Nevertheless, it must overcome certain impediments. First, the current public health care providers have limited capacities to meet the diverse needs of smokers. At the same time, there is a need to ensure that the system accounts for all interventions on tobacco control. This could be difficult at both the local and national levels because of the intended approach. Second, while local authorities will have increased roles to ensure effective implementation of the tobacco control plan, the leadership roles of NHS remain unclear and therefore, leaders must ensure that there are no contradictions between these organizations. Third, Healthy Lives, Healthy People recognizes the importance of inputs from private sectors, the tobacco industry, and academics. In this regard, it encourages equal participation of all stakeholders to promote and protect the health of tobacco smokers.

Healthy Lives, Healthy People is based on political will and rhetoric to promote health care among the public. The UK needs evidence-based approaches based on effective approaches to prevent tobacco use and related deaths. Public health is critical and cannot be simply left for Conservatives and Liberals to dictate. Graeme Archer’s article on the smoking ban has shown that such attempts could be detrimental (Archer 2014).

Reference List

Archer, G 2014, ‘A ban for this law, a law for that: When did Tories stop defending freedom?’, The Telegraph, Web.

Bauld, L 2011, The impact of smokefree legislation in England: Evidence Review, Web.

Cancer Research UK 2014, Tobacco statistics, Web.

Department of Health 2010, Healthy Lives, Health People: Our strategy for public health in England, Crown, London.

Faucher, M A 2003, ‘Factors That Influence Smoking in Adolescent Girls’, Journal of Midwifery & Women’s Health, vol. 48, no. 3, pp. 1-6.

Gilmore, A, Tavakoly, B, Taylor, G & Reed, H 2013, ‘Understanding tobacco industry pricing strategy and whether it undermines tobacco tax policy: the example of the UK cigarette market’, Addiction, vol. 108, no. 7, pp. 1317–1326. Web.

Kenny, T 2012, Smoking – The Facts, Web.

Kerr, S, Knussen, C & Hunter, R 2010, An exploration of the complex interplay of factors influencing the use of tobacco in people with mental health problems, Web.

Lifestyle Statistics, Health and Social Care Information Centre 2013, Statistics on Smoking: England, 2013, Health and Social Care Information Centre, London.

Locker, J & Chambers, M 2011, Healthy Lives, Healthy People: A Tobacco Control Plan for England, Web.

Marmot, M 2010, Fair Society, Health Lives: Strategic Review of Health Inequalities in England, University College London, London.

NHS Confederation 2013, Smoking and mental health, Web.

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