PHIAC took account of a number of factors and issues in making the recommendations.
3.1 Smoking is dangerous at any age, but the earlier someone starts, the more likely they are to smoke for longer and to die earlier from a related condition or disease. As the risk of disease is related to the overall length of time someone has smoked, PHIAC considers that delaying the onset of smoking is a worthwhile goal. Indeed, it may help stop some people taking up smoking at all. However, it is not known if mass-media campaigns or access restrictions delay (rather than prevent) someone from taking up smoking (that is, no studies were identified that addressed these issues).
3.2 Different elements of a broad, multi-faceted approach to prevent and reduce smoking may work synergistically. For example, mass-media campaigns targeted at children and young people may also have a positive effect on adults. Similarly, campaigns aimed at adults may influence children and young people. In this context, some types of intervention will have a greater or more immediate effect than others (for example, price increases compared with education). PHIAC stresses that it is not a question of choosing one type of intervention over another but, rather, employing a range of interventions and ensuring they are carried out in the most effective way.
3.3 This guidance does not cover: policies on tobacco pricing and smuggled cigarettes; family-, community- and school-based interventions; measures to help children and young people quit smoking; and measures to discourage or reduce the uptake of tobacco chewing and smokeless tobacco.
3.4 Most of the effectiveness studies reviewed were conducted in the US. However, PHIAC judged that some of the evidence was sufficiently applicable to England to inform the recommendations.
3.5 There was a paucity of evidence on how socioeconomic status (and other measures of inequality) might affect children and young people's response to mass-media interventions discouraging tobacco use or the effectiveness of tobacco access restrictions.
3.6 There is clear evidence that advertisements which evoke strong negative emotions (such as fear) are effective. PHIAC believes such advertisements should include (or be linked to) messages reassuring participants that they can avert health problems and giving them clear advice on what to do.
3.7 The assumptions made in the economic modelling were conservative. Any reasonable change to the variables would probably mean both mass-media campaigns and point-of-sales measures would be even more cost effective.
3.8 Local authorities do not have a duty to undertake test purchases to detect breaches in the law on under-age tobacco sales. While most local authority trading standards (LATS) departments do carry out tobacco test purchases, they often take second place to alcohol tests. PHIAC would like tobacco test purchases to be given greater priority and more resources made available to achieve this.
3.9 Smuggled tobacco is cheap. As a result, it erodes efforts to discourage people from taking up smoking (or to encourage them to stop), particularly those from deprived communities. PHIAC is also concerned about the ease with which children and young people can purchase smuggled cigarettes and tobacco. In addition, there is evidence that a large number of smuggled cigarettes are counterfeit. PHIAC believes the sale of smuggled cigarettes could be tackled (in part) through collaborative working between HMRC and other local enforcement agencies, including trading standards officers and the police.
3.10 PHIAC recognises the need to enforce the law on under-age tobacco sales. However, it is concerned that children and young people may, as a result, turn to illicit sources. Controlling their access to illicit cigarettes is crucial – particularly as it may also expose them to other drugs and illegal activities. PHIAC would like DH, HMRC and the Home Office to consider measures to control their access to all sources. These control measures could include tobacco gained by proxy (a proxy purchase involves an adult buying a product for a young person) and from adults selling cigarettes from home. Other measures could include an increase in the penalty for selling cigarettes to young people under 18 and the introduction of hand-held devices to check the origin and license for sale of cigarettes.
3.11 PHIAC supports sanctions that can help to reduce or eliminate illegal tobacco sales, including the introduction of fixed-penalty, on-the-spot fines for under-age tobacco sales. (This is one of a number of administrative sanctions in the Regulatory Enforcement and Sanctions Bill [Royal Assent is expected in late 2008].)
3.12 Clause 143 of the Criminal Justice and Immigration Act 2008 deals with persistent offenders who sell tobacco to children. It allows local authorities to apply for premises to be closed down if there are three incidents of under-age sales. Offenders can be fined up to £20,000. This approach is commonly referred to as 'negative licensing'. PHIAC was advised that other approaches, such as 'positive licensing' or mandatory registration (with penalties for non-registration) could offer significantly more advantages. For example, they could be easier to enforce and, in the case of registration, require fewer resources. When the licensing scheme is reviewed, PHIAC would encourage DH to consider which scheme would most effectively tackle illegal sales.
3.13 PHIAC welcomes the inclusion of point-of-sale displays, as part of the DH consultation on the future of tobacco control (see 'Policy and legal background' in section 2). During expert consultation, the committee was advised that tobacco products are, in effect, being promoted via point-of-sale displays. Options to overcome such promotions include: moving all tobacco products out of sight (for example, by storing them in cabinets under the counter); restricting the amount of product that can be seen; or placing limits on how near they can be placed to shop exits. In addition, plain packaging might be considered to reduce the attractiveness of cigarettes to young people.
3.14 Vending machines remain a popular source of cigarettes for young people under 18, despite legislation relating to under-age sales. (In 2004, one in five of those aged 11–15 who smoked said they bought cigarettes from a vending machine – see section 2.) PHIAC is concerned that vending machines may become a more important source of cigarettes for children and young people, as other options become more restricted. Tobacco sales via vending machines are part of the DH consultation mentioned above. The committee welcomes consultation on the full range of options, which includes making them token- or electronic card-operated or prohibiting them altogether. [At the time of writing, vending machines were legal. Since October 2011 they have been banned in England.]
3.15 On the basis of the evidence and other considerations, PHIAC took the view that government should consider new legislation. This was communicated to the DH in the form of a letter from NICE's Chief Executive, Andrew Dillon.
3.16 PHIAC notes that only national organisations are likely to run mass-media campaigns involving TV advertising, because the cost for local or regional organisations is likely to be prohibitive.
3.17 PHIAC considers that national, anti-tobacco mass-media campaigns, supported by local activities, can play an important role in changing society's attitude towards tobacco use.
3.18 New media options such as mobile phone texting and the use of social networking sites offer potential benefits as part of a mass-media campaign. PHIAC notes that these benefits need to be evaluated – and that the methods used for delivering messages may need to change over time to reflect changing technology.