An interview with Professor Donald Singer, Warwick Medical School

Published March 2012

According to statistics from Cancer Research UK 104,000 people died in the UK in 2009 from smoking-related diseases. About a fifth of adults in the UK are smokers and in general this is a downward trend.

Professor Donald Singer at Warwick Medical School is a leading expert in cardiovascular diseases. Here he explains how current research is shedding light on the efficacy of anti-smoking campaigns and in the war against smoking-related illnesses.

In your experience, how have anti-smoking campaigns affected the levels and presence of cardiovascular diseases in the general population?

Smoking is the leading preventable cause of death in developed societies, causing around one in five deaths, and killing one in two lifetime smokers. Smoking causes increased risk of serious illness and of premature death from heart and lung disease and a wide range of cancers. These risks are also transferred by passive smoking to other adults, children and babies.

This should provide plenty of ammunition for anti-smoking campaigns, including health warnings on packets. However anti-smoking warnings presented as health risks alone tend to be ignored by many smokers. A key risk for those running campaigns is to recognise that for some, portraying cigarettes as forbidden fruit makes them irresistible.

Public health agencies have therefore turned to advice from successful commercial companies and advertising agencies. For example Adidas, Levi-Straus, and Proctor and Gamble helped the US Center for Disease Control division with advice that more was needed than education on the harm of smoking. From this emerged the idea of a non-smoking ‘brand’ as counter-marketing against the tobacco industry’s efforts to portray smoking as glamorous and ‘cool’; smoking in the US ‘Truth Campaign’ was shown as an expensive, dirty, smelly habit.

A series of US campaigns with this approach running from the late 1990s onwards was estimated to reduce the number of adolescents smoking by 450,000; this was cost-effective with every $1 spent on the counter-marketing effort resulting in a savings of $6 of future medical costs averted – at least a 1:3 saving allowing for US national health costs being around twice those in the UK.

A British Heart Foundation-funded campaign in 2004 with a similar strategy, showing fat oozing out of a young smoker's artery, had a major public impact at the time. However a recent study from Australia suggests that campaigns warning of harm from smoking only appear to be effective for approximately a few months – thus recurrent investment in fresh anti-smoking campaigns is needed to ensure a sustained impact on smokers.

What difference has the ban on smoking in enclosed public spaces made?

Apart from making time spent in a pub or restaurant more enjoyable, smoking bans in public places have had a major and surprisingly early reduction in the serious complications of smoking. The most striking results were reported from Scotland: in the first ten months after the smoking ban in public places in Scotland, there were one in seven fewer admissions to hospital for acute coronary disease among smokers, and a one-in-five reduction among former smokers, and among persons who had never smoked.

In the first three years after the smoking ban in Ireland, there was a 25 per cent decrease in hospital admissions with acute coronary disease. Plus a recently-published report from Glasgow has revealed a large decrease in the number of premature births and the number underweight babies.

What else would you recommend the government does to encourage people not to smoke and reduce the effect of smoke on the general population?

Run frequent campaigns, each with a fresh message to avoid message fatigue. Be positive about smoking cessation and highlight years of health gain, looking younger for longer and keeping friends and children healthier by stopping their passive smoking.

There should be further training of GPs in strategies for stopping smoking. A recent study in Germany showed that a large improvement in the numbers of smokers who stopped was achieved by giving GPs more training, combined with financial incentives for longer sustained success.

A large increase in the price of tobacco would be particularly effective in deterring the young from smoking. There should also be effective systems for preventing advertising/product placement of smoking linked to glamour and apparent sophistication. Campaigns should use positive role models from the world of sport, media and entertainment, to illustrate the gains from stopping smoking, or from not starting in the first place.

Smoking should be banned on NHS premises – it is still too common to see in-patients, out-patients and visitors smoking near the doors of hospitals and clinics.

Do you think the NHS Stop Smoking support service is working well?

The current service appears most likely to help smokers who are already motivated to stop. Support can range from text messages, to helpline support, emails and advice on nicotine replacement and other drug treatments. It is important that support is available for as long as possible - many smokers who stop for four weeks - the current NHS-monitored target - and have no further support will resume smoking by 12 months. Research suggests that drugs alone, such as nicotine replacement, are not very effective. Relapse prevention interventions provided by NHS local Stop Smoking services appear to have an important role in providing people from returning to smoking: around 15 per cent of smokers remain smoke-free at 52 weeks.

Which smoking-related disease is your main concern?

As a cardiovascular pharmacologist, I am very worried about the risk of premature heart disease and stroke in smokers. Women as young as 24 have been treated at our University Hospital for smoking-related heart attack. The risks are compounded by our national epidemic of obesity and diabetes, which, when combined with smoking, enormously increases the risk of heart disease at a young age.

In addition, as a consultant looking after patients in the Emergency Department, I am also very concerned about other serious medical problems resulting from smoking, such as lung disease [exacerbations of asthma, chronic obstructive lung disease ('chronic bronchitis') and emphysema], and a wide range of cancers affecting the lungs and other organs.

There is work going on by clinicians at the University Hospital Campus in Coventry in partnership with experts in Birmingham to develop local programmes to encourage people to stop smoking.

What are you researching at the moment?

We already know that even smoking a single cigarette can cause severe narrowing of heart arteries. In my previous lab research we have shown that one of the consequences of smoking, oxidant stress, can interfere with the switch for allowing healthy small blood vessels to form. That may help to explain the reduced number of smaller blood vessels available to nourish the tissues in smokers – eventually a contributory factor in disease severity and potential for good recovery.

Currently I am working with a team of clinical scientists in France, Spain and Wales on new personalised ways to help smokers to be more successful at stopping. We are especially keen to find out what tailored approaches may be needed in different countries to maximise the chance of success in working with smokers to help them to stop.

Further reading:

• The New England Journal report on the early benefits of the smoking ban in Scotland
• British Heart Foundation: information on smoking
• WeQuit
• NHS Local Stop Smoking Services
• My Last Cigarette smartphone app

Donald Singer is Professor of Clinical Pharmacology and Therapeutics at Warwick Medical School. He leads the Clinical Pharmacology Centre at the University Trust Walsgrave Hospital. He trained in Aberdeen and London, and before moving to Warwick in February 2003, ran research programmes at St George's Hospital Medical School, London and at Imperial College, London.

His main research interests are in causes of vascular disease, better management of blood pressure and new systems to promote safety in prescribing, including applying pharmacogenetics to predicting risk of adverse drugs reactions. His initial major clinical aims at Warwick are establishing a Regional Hypertension Service and developing Adverse Drug Reaction Networks. He has an interest in Action Management as a way to bring together leadership and management skills from Public and Private Sectors.