According to the Oxford Medical Companion (1994) cited in the WHO report on the global tobacco epidemic 2008, “tobacco is the only legally available consumer product which kills people when it is used entirely as intended”. Tobacco is the leading preventable cause of death in the World which causes one in ten deaths among adults worldwide and in 2005, tobacco caused about 5.4million deaths, an average of one death every six seconds. At the current rate, the death toll was projected to reach more than eight million annually by 2030 (over 175 million deaths by then as shown in figure 1) and a total of up to one billion deaths in the 21st century (WHO 2007).Certain behaviours have been labelled as risky behaviours associated with negative health outcomes among which smoking is and which has been the subject of UK national health strategies (Naidoo & Wills 2005). Smoking causes about one fifth of all deaths in the UK, most of which are premature and has hugely significant impacts on the wider environment and community through causing air pollution, fires, litter and environmental damage (Ewles 2005). This essay will look into why smoking is an important public health issue in England by defining it from various perspectives and will analyse why people smoke. Also, it will examine various demographical and epidemiological data related to smoking and in addition, it will examine how smoking is addressed in International, National and Local policy. It will also analyse various measures adopted at various geographical levels to address inequalities in health on promoting anti-smoking. In addition, it will look into various values, norms and ethical principles that influence anti-smoking policy development. From the gaps identified, recommendations and conclusions will be made.
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According to Ewles (2005), smoking in the UK can be defined from three different perspectives in terms of; the activity, the product and the market. In terms of the activity, it is the largely use of tobacco in manufactured and hand-rolled cigarettes which is the most common form of tobacco use since the early twentieth century. In terms of the product, the manufactured cigarette consists of
chopped tobacco that has been cured and mixed with a variety of additives to add flavour, increase nicotine availability from smoke and improve shelf life all rolled up in a paper tube with a filter at one end. In terms of the market, UK is home to several Worlds’ major tobacco companies such as the Imperial Tobacco, British American Tobacco, Gallagher and Rothmans UK who all together employ 9000 people in the UK and have more than 90% of UK cigarette market. The principal constituents of cigarette smoke are tar, carbon monoxide and nicotine and the paper used for manufacturing cigarettes is treated with chemicals to prevent self-extinguishing whenever the cigarette is lit. The filter usually consists of cellulose acetate which traps some solid particles in smoke and cools it (Ewles 2005). The principal constituents of cigarette smoke are carbon monoxide, tar and nicotine which is highly addictive (Cancer Research UK 2009).
FIGURE 1: Cumulative tobacco- related deaths, 2005- 2030.
Source: http://www.who.int/tobacco/mpower/mpower_report_tobacco_crisis_2008.pdf
The impact of tobacco smoking on public health extends beyond the direct effects on the individual smoker and personal health being to economic, environmental and social effects (Ewles 2005). Tobacco smoking is an important public health issue because the smoke is very toxic to every human tissue it touches on its way into, through and out of the smoker’s body (Ewles 2005). Smoking harms nearly every organ of the body thereby causing many diseases, reducing quality of life and life expectancy. Also it has been estimated that in England, 364,000 patients are admitted to NHS hospitals each year due to smoking related diseases which translates into about 7,000 hospital admission per week and 1,000 admissions per day (ASH 2006). In the UK, smoking causes about a fifth of all deaths, approximately 114,000 each year, most of which are premature with an average of 21 years early (Ewles 2005). According to Peto et. al. (2003) cited in Ewles (2005), most premature deaths caused by smoking are Lung and coronary cancer, chronic obstructive heart diseases and coronary heart diseases with 42800, 29100 and 30600 deaths respectively every year. In addition, smoking is known to also bring increased risk of many debilitating conditions like impotence, infertility, gum disease, asthma and psoriasis (Ewles 2005). Research has also shown that non-smokers are put at risk by exposure to other people’s smoke which is known as passive or involuntary smoking and is also referred to as second-hand smoke (SHS) or environmental tobacco smoke (ETS) (Cancer Research 2009).
Tobacco was first introduced to Britain way back in the sixteenth century when it was commonly smoked in pipes by men. Later snuff and cigar smoking became popular among men but as a result of the invention of the cigarette making machines in the latter part of the nineteenth century, mass consumption of tobacco was made possible and in 1919, more tobacco was sold as cigarettes than in any other form (Wald & Nicolaides- Bouman 1991). According to Wald& Nicolaides- Bouman (1991) cited in Cancer Research UK (2009), smoking was firstly common among men and the consumption rose steadily until 1945 when it peaked at 12 manufactured cigarettes per adult male per day. After the Second World War, there was a slight dip in consumption but thereafter it remained at around 10 manufactured cigarettes per day until 1974 which marked the beginning of a steady and continuous decrease to about 4.6 manufactured cigarettes per adult male per day in 1992. On the other hand, women began to smoke cigarettes in the 1920s but not in large numbers until after the Second World War when they were smoking 2.4 cigarettes per adult female per day. Later, consumption among women continued to increase until it reached 7.0 cigarettes per day in 1974 after which it declined to 3.9 cigarettes per day in 1992 (Cancer Research UK 2009).
HISTORY
The link between smoking and life threatening diseases began in the early 1950’s when Dr Richard Doll and Prof Austin Bradford conducted the first ever large scale study between smoking and lung cancer which was later published in 1954. In 1957, the British Medical research Council announced that, there is a direct causal connection between smoking and lung cancer. Later in 1962, the Royal College of Physicians concluded that smoking causes lung cancer, bronchitis and coronary heart diseases and recommended tougher laws on cigarette sales, advertising including smoking in the public places. In 1965, the British Government banned cigarette advertising on television and in 1971, there was an agreement between the Government and the tobacco industry that, Government health warnings must be carried out on all cigarettes packet sold in the UK. In 1973, the first tar/nicotine tables was published in UK which was later upgraded and divided cigarettes into five categories of tar content in 1974. In 1975, the Imperial Tobacco agreed to drop brand names and logos from racing cars in UK races as control of tobacco advertising switched from the Industry to the Independent advertising Standards Authority. In 1976, Prof Sir Richard Doll and Richard Peto published the results of 20 years study of smokers and concluded that, one out of three people died from the habit. In 1983, the Latest Royal College of Physicians report featured passive smoking for the first time and asserted that more than 100,000 people died every year in the UK from smoking -related illness which later resulted in the banning of smoking on London Underground trains in 1984. In 1985, the smoking ban was extended to stations that were wholly or partly underground and in 1986, new advertising and promotion guidelines agreed on including banning tobacco advertising in cinemas. In 1987, the London Underground smoking ban was extended to entire network following the King’s Cross station fire outbreak in which 31 people died. The Independent Scientific Committee on Smoking and Health report in 1988 concluded that, non-smokers have a 10-30% higher risk of developing lung cancer if exposed to other people’s smoke and in June 1988, a UK court ruled that injury caused by passive smoking can be an industrial accident. The first nicotine skin patch became available for prescription in the UK in 1992 and in 1993, Sir Richard Doll’s study results suggested that smokers were three times more likely to die in middle-age than non-smokers and up to half of all smokers may eventually die from the habit. In May 1997, the New Labour Government pledges to ban tobacco advertising and in the same year, the Government called for Formula One to be exempted from proposed EU directive on tobacco advertising and sponsorship but later backed down in the face of widespread criticism that was threatening the entire directive. In 1998, a White Paper named Smoking Kills was published after the Government -appointed Scientific Committee on Tobacco and Health announced that, passive smoking was responsible for causing lung cancer and heart disease in adults. In 2001, their was a new EU directive requiring larger and more prominent health warnings on tobacco packaging and in 2002, the British parliament passed legislation that began as a Private Member’s Bill, banning tobacco advertising named the Tobacco advertising and promotion Act. In December 2002, the British Medical Association called for the banning of smoking in the public places because of threat to non-smokers and young children. The Cancer Research UK launched an advertising campaign in 2003 and was funded by the Department of Health which target smokers of mild brand of cigarette, warning on the risk associated with the habit. In January 2004, the British Heart Foundation used graphic images to reinforce the Government -sponsored anti-smoking campaign. In March 2004, the Irish Republic introduced the toughest anti-smoking laws in Europe described as the landmark legislation with a complete ban on smoking at workplaces. In November 2004, a Public Health White Paper proposed to introduce smoking ban in workplaces in 2008 with the exemption of private members club and pubs that do not serve food. In, March 2005, the British Medical journal report produced data showing that smoking killed 11,000 a year in the UK and in April 2005, MSPs voted by 83 to 15 to introduce a ban on smoking in public places from April 2006 and any smoker who defy is liable to pay a £1,000 fine. In October 2005, the discussions over the England smoking ban broke down at the cabinet level causing severe delays. In December 2006, the Government announced the smoking ban in public spaces in England known as Smoke free England, which began on the 1st of July 2007 (BBC NEWS 2007). On the 1st of October 2007, the law for selling tobacco changed and became illegal to sell tobacco products to anyone under the age of 18 (an increase from 16) (Smoke free England 2007). In May 2008, the Health Bill then called the National Health Service Reform Bill was contained in the Draft Legislative Programme published and it was announced in the Queen’s speech during the state opening of Parliament on 3rd December 2008. The Bill was later introduced into the House of Lords on 15th January 2009 and was published on the 16th January 2009 which proposes measures to improve the quality of NHS care, the performance of NHS services and to improve public health (DOH 2009).
DEMOGRAPHY & EPIDEMIOLOGY
The United Kingdom of Great Britain and Northern Ireland (UK) is located in Northern and or Western Europe and it comprises the Island of Great Britain (England, Scotland and Wales) and the Island of Ireland (Northern Ireland) (Wikipedia 2009). According to the 2001 census, the population of the United Kingdom was 58,789,194 and has increased to 60,587,300 according to mid -2006 estimates by the Office for National Statistics.
EPIDEMIOLOGY
The prevalence of smoking varies widely around the World and has been observed to be on the increase in many developing countries thereby creating huge health problems for the future. Approximately 1.3 billion people smoke cigarettes or other tobacco products Worldwide (WHO 2003) and Figure 2 shows the worldwide tobacco epidemic model which describes the rise and decline of smoking prevalence followed by similar trends for smoking. The first stage is characterized by a low smoking prevalence of less than 20%, which is commonly observed among the males with no increase in lung cancer and other chronic diseases caused by smoking. Countries in this stage includes those in the Sub-Saharan Africa that have not yet been drawn into the global economy but are vulnerable to growth and changing strategic initiatives of transnational tobacco companies (WHO 2003). Stage two of the model is characterized by increase in smoking prevalence to above 50% in men with early increase in cigarettes smoking among women and a shift towards smoking initiation at younger age with an increasing burden of lung cancer and other tobacco-attributable diseases. These are characteristics of countries in the Asia, Latin America and North Africa continents. In these regions, tobacco control activities have been observed to be poorly developed and the health risks associated with tobacco smoking are not well understood. There are very low public and political supports for the effective implementation of tobacco control policies (WHO 2003). The third stage is characterized by a decline in smoking prevalence in men and gradual decline among women. Here, there is a convergence of male and female smoking prevalence at 45% and the burden of smoking attributable diseases is on the increase. Also, smoking-attributable deaths comprises of 10%to 30% of all deaths within the region which is about three quarters of men. Countries within this stage are those in the Eastern and Southern Europe where health education about the diseases caused by smoking decreases with the public acceptance of smoking, most especially among the educated ones (WHO 2003). The fourth stage is characterized by a decline in smoking prevalence among men and women with deaths attributable to smoking peaked at 30% to 35% of all deaths most of which are middle aged men. Among the women, smoking attributable deaths rose to about 20% to 25%. Examples of countries within this stage are the United States and United Kingdom where England falls.
FIGURE 2: Four stages of the Worldwide Tobacco Epidemic. (Source: WHO 2003).
According to the Cancer Research UK (2009), the survey of smoking in Britain began in 1948. Then, smoking was extremely prevalent among men and the survey showed that 82% smoked some form of tobacco while 65% smoked cigarette. Later on, smoking prevalence fell rapidly through the 1980s until the mid 1990s when the overall smoking rates stabilizes just below 30% among the population as shown in figure 3. The sharp fall in smoking prevalence during this period is as a result of several interventions put in place by the Government then such as banning of tobacco advertisement on TV in the 1960s and others. Since the mid 1990s, the rate of fall has been very slow and in 2007 it was observed that 22% of men aged 16years and over smoke cigarette. The percentage of female smokers on the other hand has remained constant between 1948 and 1970 as shown in Figure 2. Between 1970 and 2007, the % of women who smoked dropped from around 43% to 20 % still due to certain measures developed in the late 1960s.
FIGURE 3. % of person aged 16+ who smoke cigarettes in Great Britain from 1948 to 2007.
Source: General household survey, ONS.
Available from:
http://publications.cancerresearchuk.org/WebRoot/crukstoredb/CRUK_PDFs/lung/cs_lu_f6.1.xls
FIGURE 4: Prevalence of Cigarette smoking by sex, England and Govt. Office Regions 2005.
Source: Cancer Research UK.
Figure 4 shows the cigarette distribution of cigarette smoking prevalence in England and it can be observed that, the overall smoking prevalence in England is about 25% among men and around 22% among the women. Within the various regions in England, smoking prevalence is higher among men and women in the North East because the region is economically active and home to 588 overseas companies from 32 different countries employing over 27,000 people (UK Trade& Investment 2009). There has been a link between socio economic class and high prevalence of smoking as demonstrated in Figure 5 which buttresses the reason why the prevalence is high in Northeast England. Regions with high manual employee, occupation and high numbers of Industrial factories are characterised by high smoking prevalence.
FIGURE 5: Prevalence of cigarette smoking by sex and socio-economic groups in England in 1992, 1998 and 2002.
Source: Cancer Research UK.
As shown in figure 5, smoking prevalence is observed to be higher among manual workers than non-manual workers. From 1992 to 2002, smoking prevalence reduced as a result of some interventions introduced within these years especially the White Paper on Smoking Kills introduced in 1998 making the prevalence to reduce from 33% in 1998 among the manual workers to 28% in 2002.
FIGURE 6: Prevalence of cigarette smoking by age, persons aged 16+ in Great Britain, 1974-2005.
Source: Cancer Research UK.
FIGURE 7: Self reported cigarette smoking percentages by sex and minority ethnic group persons aged 16+ in England 2004.
Source: Cancer Research UK.
Smoking is more prevalent among the younger age groups of 16-19, 20-24 and 25-34 as shown in figure 6, where highest rate was observed among the 20-24 age group. Between 1974 and 2005, smoking prevalence among the 20-24 age groups fell from 48% to 32 %. On the other hand, among the 60+ age group, smoking prevalence halved between the same year intervals from 32% to 14%. Therefore, smoking prevalence has been observed to reduce with age as smokers tend to give up in middle age or die of smoking-related illnesses. (ONS 2002).
Smoking prevalence has been observed to vary among different ethnic minority groups in England as shown in figure 7. Smoking prevalence is higher among the Bangladeshi men of about 41% but rare among the women with about 3%. Although this rate is alarming but there has been a decrease as to what was observed in 2001, when cigarette smoking and tobacco use was around 44% among the men with a relatively small percentage among the women (ONS 2001).
FIGURE 8: Prevalence of cigarette smoking and use of tobacco products among ethnic minorities in England 2001.
Source: DOH 2001.
SOCIO-ECONOMIC FACTORS
Smoking in the UK has been observed to be closely associated with social class and deprivation. The prevalence of smoking among the low paid groups has been observed to be twice those of the affluent groups because of the great difficulty people in the less affluent groups experience in stopping smoking (Ewles 2005). Tobacco smoking is also widely recognised as a cause of health inequality in the UK because it is common among the deprived groups and also compromises the already poorer health of deprived population such as those that fall within the marginalized groups. Examples are people with mental problems and prisoners, who are more likely to smoke and less likely to have access to mainstream smoking cessation services (Ewles 2005). The Index of multiple deprivation ranks areas from the most deprived to the least deprived and the odds of smoking increases as deprivation in the area increases (The NHS Information centre 2008).
Children smoke for all sorts of reasons. Some smoke to show their independence, others because their friends do while some smoke because adults tell them not to and others do smoke to follow the example of role models. There is no single cause. Parents, brothers and sisters who smoke are a powerful influence. Also is the way it is been advertised and the tobacco companies sponsor sport which makes children want to try it (DOH 1998). The problems of smoking during pregnancy are closely related to health inequalities between those in need and the most advantaged. Women with partners in manual groups are more likely to smoke during pregnancy than those with partners in non-manual groups: 26 per cent of women with partners in manual groups smoke during pregnancy, compared with 12 per cent with partners doing non-manual work (DOH 1998).
Education is also another social determinant of health for smoking. Education empowers individuals to make healthy choices and provides practical, social and emotional knowledge needed to achieve a full and healthy life (The Annual Report of the Director of Public Health for Newham 2007). The relationship between education and smoking has been extensively examined in developed countries and in the1989 US Surgeon General report analyzed by Bao-ping et al.(1996), it was stated after reviewing the literature of smoking that, education is the best socio demographic predictor for cigarette smoking pattern. The general agreement was that, the fewer the year of education one has, the more likely the person smokes and this again accounts for why there is high smoking prevalence among the ethnic minority groups in England.
Another factor is the social norms whereby, in environments where smoking is freely permitted, it becomes a normal thing and becomes more difficult for individuals to opt out from (Ewles 2005).Other factors that prompt people to start smoking includes, the price and availability of cigarette, colourful advertisement and accessibility to treatment facilities for those that want to stop, the more available the facilities, the more people will be willing to use the facilities and stop smoking (Ewles 2005).
In response to the global tobacco epidemic, May 31st of every year was declared as the World No Tobacco day, so as to globally address the danger associated with smoking tobacco. Also, the World Health Organization developed a WHO Framework Convention on Tobacco Control in May 2003 (WHO 2003), which later came into force on the 27th o February 2005 (WHO 2009). This was the first global treaty for public health negotiated under the auspices of the WHO and requires participating countries to implement a range of legislative and other measures to control smoking by taking appropriate action on passive smoking, banning tobacco promotion, providing services to smokers , monitoring smoking prevalence and international cooperation to control smuggling (Ewles 2005).In order to expand the fight against tobacco epidemic, the WHO introduced the MPOWER package of six proven policies namely:
Monitor tobacco use and prevention policies,
Protect people from tobacco smoke,
Offer help to quit tobacco use,
Warn about the dangers of tobacco use,
Enforce bans on tobacco advertising promotion and sponsorship, and
Raise taxes on tobacco. (WHO 2008)
Smoking has been addressed at Government level in the UK since the publication of the White Paper Smoking Kills in 1998 which takes a comprehensive approach and prioritises people who want to give up, pregnant women, children and young people (DOH 1998). Between 1998 and 2009, various policies have been developed as stated earlier in this essay under the historical perspective of smoking in England which includes;
1998: Smoking Kills
↓
2002: Tobacco Advertising and Promotion Act
↓
2006: Health Act
↓
2007: Smoke Free England.
↓
2008: National Health Service Reform Bill
↓
2009: Health Bill.
GOVERNMENT MEASURES TO TACKLE SMOKING
In line with the WHO directive to address tobacco epidemic, the UK signed into the International WHO framework Convention on Tobacco Control in 2003 and has implemented a range of legislative measures to control smoking at different geographical levels and between various population groups. The overall measures were broadly classified into three sets of overlapping effects namely;
Changing social norms,
Influencing attitudes, and
Supporting individual behavioural change (Ewles 2005).
Measures classified under the changing social norms and influencing attitudes includes; educational programmes such as the Government-funded mass media education campaigns aimed to educate the public on the danger associated with smoking, bans on tobacco promotion with health warnings covering 30% of the front and 40% of the back of tobacco packaging while terms such as ‘low-tar’ and ‘light’ have been prohibited on cigarette packet (DOH 2003). Also education on the benefit of quitting smoking was also part of the measure and explaining why people get fat after quitting as a result of increased eating unbalanced by increase activity because smoking has slight appetite suppressant effect (Ewles 2005).
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In addition, picture warnings started appearing on tobacco products in autumn 2008 and by October 1st 2009, all cigarette packs will have to carry picture warnings including other tobacco products by 1st October 2010 (DOH 2003). Also, another measure employed was prohibiting sales of tobacco products to people under the age of 18 by directing tobacco retailers to ask for form of identification from buyers who are teenagers. Taxation has also been used frequently to increase the price of smoking with rises in duty imposed in each year’s budget by the Government (Ewles 2005). On average, a price increase of 10% on a packet of cigarette reduced consumption by about 4% in developed countries, however, price control is undermined by tobacco smuggling which currently accounts for 16% of the UK market (Cancer Research 2009). Another measure is ensuring a smoke free environment which has been introduced in 2007 as smoke free England whereby smoking in enclosed public places is illegal.
Under the supporting individual behavioural change is the cessation treatment programme, examples of which includes; a national telephone help lines and NHS specialist services for smokers who want to stop (Ewles 2005). To help smokers quit, the NHS Stop Smoking Services was set up between 1999 and 2000 following the recommendations of the White Paper Smoking Kills in 1998(DOH 1998). It was later observed that between April and September 2006, approximately a quarter of a million people (246,254) in England set a quit date through this NHS Stop Smoking Services and majority of these people receiving Nicotine replacement therapy (The Information Centre 2007).
CHALENGES OF PUBLIC HEALTH POLICY FORMULATION AND PRACTISE
The formulation of anti-smoking policy in England has always been big issue in most developed countries. In the UK, the Government needs people to smoke because the economy largely depends on it. The Government obtains £8billion per year from excise duty on tobacco products which is approximately 2% of its annual revenue (Ewles 2005).
Both in the policy formulation and in the implementation phase conflicts of commercial and health interests have been strongest on three issues: the ban on advertisement and sales promotion, the setting of upper limits for harmful substances in tobacco products, and proposals for an efprice policy. In the political process Parliament has been much more sensitive to the public health interest and to public opinion than to the lobbying power of the tobacco industry and trade, which has been more clearly visible in many Government decisions
MEASURES TO REDUCE INEQUALITY IN SMOKING/ POLICY CRITIQUING
After thorough review of the various policies aimed towards reducing cigarette smoking at the International, National and Local level, various gaps have been identified. Firstly, banning of smoking in public places is not enough to reduce the effect of smoking on health because be it passive or active smoking, it still endangers the life of the smoker. Therefore, abstinence should be the only message since smoking is a major cause of litter. In the UK, 200million cigarette ends are discarded each day and each takes 18months or more to biodegrade (Ewles 2005). Also, smoking in bus stops tends to serve as passive smoking to others waiting to join buses and therefore smoking in areas like this also needs to be banned. Another lapse in the smoking in the public places law is that, when people are not allowed to smoke in public places, they tend to do so when they get into their private cars and homes and these could be dangerous to young children living in the same house.
Another area worth reviewing is the use of taxation to increase the price of tobacco products. High price has helped dissuade people especially young children from smoking and prompted many smokers to stop; however, smoking is concentrated among the lowest paid sector of the society and common among the addicted population who continue smoking despite prices, therefore such measures by the Government is not fair because the poor people pay disproportionately more as a consequences of their acquired addiction caused by the Government originally (Ewles 2005).
Another misconception of tackling smoking is the youth smoking prevention programme which has always assumed to be the best way to tackle smoking among children and youths. The Youth-oriented media campaigns has a poor record of credibility among the target group (youths) and is often difficult to differentiate between those created by the health organizations and those created by the tobacco manufacturing companies. Therefore, discrediting smoking among the adult population will lessen the attraction for the youths because they tend to smoke in aspiration to be more adult (Ewles 2005). In addition, the law prohibiting sales to under -18s tend to add to the allure of smoking as an adult activity and thus creating challenges to children on finding a way around it buy getting the cigarette through adult friends, older siblings or black market routes(Ewles 2005).
Also people who stop smoking through the nicotine replacement therapy gets addicted to the cessation programme and use the product beyond the recommended period. Since the nicotine delivery rate in the content is slow, it mostly prompts a relapse making people return to smoking (Ewles 2005).
Reducing inequality in smoking has always been an issue the UK Government have been addressing and in response to this, a specific inequality target on smoking was set up in The NHS Cancer plan and the Public Service Agreement (PSA) 2004 aimed to reduce smoking rates among manual groups from 32% in 1998 to 26% by 2010 in order to reduce the health gap between the two groups. (DOH 2000).
RECOMMENDATION/ CONCLUSION
Evaluation of smoking patterns indicates that there has been an historic reversal of trends in total consumption, but distributional data show a widening social gradient in smoking. Two developments are needed for further improvement: a price policy that would support health policy and not contradict it, and better understanding of the socio-cultural dynamics of smoking which would be required for new innovative approaches in health education.
REFRENCES
Action on Smoking and Health (2006). Smoking Statistics; Illness and death. [Online]. Available from:
http://old.ash.org.uk/html/factsheets/html/fact02.html (Accessed 25/04/2009).
Bao-ping, Z., Giovino, G., Mowery, P. & Eriksen, M. (1996). The Relationship between Cigarette Smoking and Education Revisited: Implications for Categorising persons educational status. American Journal of Public Health.1996. Vol.86, No 11.
British Broadcasting Corporation (2007). Timeline: Smoking and Disease. [Online] Available from
http://news.bbc.co.uk/1/hi/health/4377928.stm (Accessed 28/09/2009).
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