- Email: [email protected]
In defence of helping people to stop smoking
Comment
be divided by four—producing an overall reduction of 0·13% per year or around 1% (from 26% to 25%) by 2010 for England.” Australia, by contrast, has negligible cessation services and since 1997 has run large scare-based15 campaigns to motivate quit attempts. Daily smoking prevalence in those aged 14 years and older has fallen by 30·2% from 23·8% in 1995 to 16·6% in 2007,16 with only 3·6% of adult smokers having ever even called the quitline.17 While pharmaceutical advertisers coattail the governmental campaign, the latter has never given centre stage to messages implying smokers need help. We need to restore smokers’ confidence in their ability to do what literally millions of smokers have done for many decades without having to rely on help. Simon Chapman School of Public Health, University of Sydney, Sydney, NSW 2006, Australia [email protected] I declare that I have no conflict of interest. 1 2 3
Chapman S. Stop-smoking clinics: a case for their abandonment. Lancet 1985; 1: 918–20. Milne E. NHS smoking cessation services and smoking prevalence: observational study. BMJ 2005; 330: 760. Bauld L, Judge K, Platt S. Assessing the impact of smoking cessation services on reducing health inequalities in England: observational study. Tob Control 2007; 16: 400–04.
4
5
6
7 8 9
10
11 12
13 14
15 16
17
Wakefield MA, Durkin S, Spittal MJ, et al. Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence. Am J Public Health 2008; 98: 1443–50. Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2006; 1: CD000146. Walsh R. Over-the-counter nicotine replacement therapy: a methodological review of the evidence supporting its effectiveness. Drug Alcohol Rev 2008; 27: 529–47. Illich I. Disabling professions. London: Marion Boyars 1977. Hatsukami DK, Stead LF, Gupta PC. Tobacco addiction. Lancet 2008; 371: 2027–38. Biener L, Reimer RL, Wakefield M, Szczypka G, Rigotti NA, Connolly G. Impact of smoking cessation aids and mass media among recent quitters. Am J Prev Med 2006; 30: 217–24. Doran CM, Valenti L, Robinson M, Britt H, Mattick RP. Smoking status of Australian general practice patients and their attempts to quit. Addict Behav 2006; 31: 758–66. Hart J. The inverse care law. Lancet 1971; 1: 405–12. Zhu S, Melcer T, Sun J, Rosbrook B, Pierce JP. Smoking cessation with and without assistance: a population-based analysis. Am J Prev Med 2000; 18: 305–11. Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004; 99: 29–38. Tocque K, Barker A, Fullard B. Are stop smoking services helping to reduce smoking prevalence? New analysis based on estimated number of smokers. Tob Control Res Bull (SmokeFree North West) 2005; March: 1–13. Hill D, Chapman S, Donovan R. The return of scare tactics. Tob Control 1998; 7: 5–8. Australian Institute of Health and Welfare. 2007 national drug strategy household survey: first results. April, 2008. http://www.aihw.gov.au/ publications/phe/ndshs07-fr/ndshs07-fr-no-questionnaire.pdf (accessed Oct 29, 2008). Miller CL, Wakefield M, Roberts L. Uptake and effectiveness of the Australian telephone Quitline service in the context of a mass media campaign. Tob Control 2003; 12 (suppl 2): ii53–58.
In defence of helping people to stop smoking Smoking is the largest avoidable cause of death and disability in the developed world, and preventing smoking is one of the highest public health priorities. Effective prevention strategies fall into two broad categories: price increases, mass-media campaigns, health warnings on cigarette packs, advertising and promotion bans, smoke-free policies, and purchase restrictions,1 all of which operate predominantly at the population level by discouraging smoking uptake and encouraging existing smokers to quit; and cessation services, which operate at the individual level, and increase the likelihood of quitting in individual attempts by up to three-fold.2–4 In an accompanying Comment, Simon Chapman5 argues that investment in cessation services is counter-productive to prevention, because the resources they devour could be better used in mass-media campaigns, because cessation clinics send out a message that smokers need help and are unlikely to quit alone, www.thelancet.com Vol 373 February 28, 2009
because medicalisation of cessation purposefully erodes smokers’ confidence in quitting, and because large numbers of smokers who quit do so without help. He singles out the English cessation approach for special criticism, for focusing tobacco control expenditure on dedicated smoking cessation services. While few would argue that population measures have the greater potential to reduce smoking prevalence, Chapman’s inference that health services should not support individual smokers who want to quit is misguided, for the following reasons. First, smoking is powerfully addictive. It is also most prevalent among the most disadvantaged in society. Governments that take tax from cigarettes, or indeed even permit their sale, have a moral duty to support smokers who want to quit, especially if price rises (which, however well intentioned, represent a regressive tax) or scare-based media campaigns are used to promote
See Comment page 701
703
Comment
cessation. Current best cessation practice combines behavioural support with pharmacotherapy.2–4 Second, clinicians need to be able to provide cessation support to individual smokers they treat. Many of these patients are desperate to quit, having repeatedly tried cold turkey and failed; some feel so trapped by their habit they do not even try. In this context the individual need is the imperative. If Chapman is unfortunate enough to suffer a coronary artery occlusion, I suspect he will accept life-saving acute therapy, despite knowing that his disease might have been prevented by more effective population strategies.6 The same argument applies to smoking. Third, when cessation services are provided and promoted to smokers, they are widely used. Last year over 680 000 smokers used the English cessation services, up 13% on the previous year and 500% on 2001–02.7 100 000 of those who used the services last year, 1% of the UK smoking population, will achieve validated long-term cessation.8 That most smokers do not use a service that is unavailable is not, as Chapman argues, evidence that they would not benefit from it if it were. In the days before tuberculosis chemotherapy, all who survived tuberculosis did so without it. Would Chapman argue that investing in tuberculosis therapy is also misguided? Fourth, cessation services are highly cost effective,9 much more so than most clinical or other general life-saving interventions,10 and better than most interventions that are approved by the UK’s National Institute for Health and Clinical Excellence for the
National Health Service (NHS).11 The cost of NHS cessation services last year, excluding drug therapy, was £61 million; about £80 per smoker who will quit for a year or more.7 This is excellent value for money. Chapman’s argument that resources invested in smoking cessation services in the UK could be used to better value in other tobacco-control activities ignores the fact that in the past 10 years the UK Government has introduced a comprehensive range of tobacco-control measures, putting the UK at the top of an objective ranking of policy implementation in Europe.12 Cessation services provide crucial underpinning to these policies. The practitioners who deliver them do not communicate to smokers that they are unlikely to succeed alone. Neither they, nor any other health professional who actually treats smokers, purposefully erodes confidence to quit. If there is a major failing in the UK approach, it is not that it has medicalised smoking, but that it has not done so enough. All smokers should be advised to quit at all contacts with health professionals,2–4 yet only half of smokers in England recall receiving such advice in the past year;13 a figure that is increasing, but should be much higher. Only 32% of smokers in England used pharmacotherapy last year, and 9% a counselling service; again too few, but much improved over the 9 years since English cessation services were first established.13 The challenge now is to widen the coverage and uptake of these services further. One wonders how much lower the prevalence of smoking in Australia might now be, had the admirable media campaigns run there over past decades been supported by UK-style cessation services. John Britton UK Centre for Tobacco Control Studies, University of Nottingham, Nottingham NG5 1PB, UK [email protected] I have consulted and done research for companies producing smoking cessation therapies. 1
2
Science Photo Library
3
4
704
WHO. WHO Framework Convention on Tobacco Control. 2003. http:// www.who.int/fctc/text_download/en/index.html (accessed Jan 25, 2009). West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax 2000; 55: 987–99. National Institute for Health and Clinical Excellence. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. February, 2008. http://www.nice.org.uk/Guidance/ PH10 (accessed Jan 25, 2009). Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. May, 2005. http://www.surgeongeneral.gov/tobacco/ treating_tobacco_use08.pdf (accessed Jan 25, 2009).
www.thelancet.com Vol 373 February 28, 2009
Comment
5 6
7
8 9
Chapman S. The inverse impact law of smoking cessation. Lancet 2009: 373: 702–03. Unal B, Critchley JA, Capewell S. Modelling the decline in coronary heart disease deaths in England and Wales, 1981–2000: comparing contributions from primary prevention and secondary prevention. BMJ 2005; 331: 614. The Information Centre. Statistics on NHS Stop Smoking Services in England, April 2007 to March 2008. 2008. http://www.ic.nhs.uk/webfiles/ publications/Stop%20smoking%20ANNUAL%20bulletins/SSS0708/ SSS%202007-08%20final%20format%20v2.pdf (accessed Jan 25, 2009). Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one-year outcomes. Addiction 2005; 100 (suppl 2): 59–69. Parrott S, Godfrey C. Economics of smoking cessation. BMJ 2004; 328: 947–49.
10 11 12
13
Tengs TO, Adams ME, Pliskin JS, et al. Five hundred life-saving interventions and their cost-effectiveness. Risk Analysis 1995; 15: 369–90. Appleby J, Devlin N, Parkin D. NICE’s cost effectiveness threshold. BMJ 2007; 335: 358–59. Joossens L, Raw M. Progress in tobacco control in 30 European countries, 2005 to 2007. 2007. http://www.ensp.org/files/30_european_countries_ text_final.pdf (accessed Jan 25, 2009). Lader D. Smoking-related behaviour and attitudes, 2007: a report on research using the National Statistics Omnibus Survey produced on behalf of the NHS Information Centre for health and social care. 2008. http:// www.statistics.gov.uk/downloads/theme_health/smoking2007.pdf (accessed Jan 25, 2009).
The Montreal Protocol: getting over the finishing line?
www.thelancet.com Vol 373 February 28, 2009
to achieve agreement annually for the past 20 years. The annual production of such substances is now down to less than 5% of its peak, but due to the long half-life of some ozone-depleting substances, even on the current phase-out schedule the ozone layer will only recover by about 2060. The last 5% of ozone-depleting substances was always going to be the hardest to manage, and includes CFCs for metered-dose inhalers for asthma and chronic obstructive pulmonary disease. It has taken about US$2 billion and 20 years for the multinational drug industry to overcome the substantial challenges of inhaler reformulation, and to switch to hydrofluorocarbon propellants.6 Now almost all inhalers in the US and European Union are CFC-free, and any containing CFCs should have disappeared completely in developed countries by the end of 2010. But just as final CFC phase-out seemed imminent, a potential problem has emerged. About a dozen developing countries will require CFCs beyond the 2010 deadline to supply inhaler manufacturers that have not yet acquired technology to produce non-CFC alternatives. Crucially, they supply inhalers to patients at locally affordable prices (cheaper than those from multinationals). Some early Protocol-funded projects to transfer manufacturing technology for hydrofluorocarbons to local companies in developing countries are nearing completion (eg, Uruguay, Cuba), but others are only just starting. As a result, India may need CFCs until 2012, and China until 2014. However, continued manufacture of small volumes of pharmaceutical-grade CFCs after 2010 might not be economically viable. This potential shortfall of CFCs could lead to uncertainty in supply of affordable inhalers, and a potential health risk for the rapidly
Science Photo Library
On Jan 1, 2010, the manufacture of chlorofluorocarbons (CFCs) for all uses worldwide is due to stop. Are we still on schedule for final phase-out? Stratospheric ozone protects us from the damaging effects of ultraviolet B.1 In 1974, Molina and Rowland proposed the landmark hypothesis (much derided at the time by the chemical industry) that stratospheric ozone would be broken down by stable man-made CFCs.2 This prediction was of enormous environmental importance—for which they rightly shared the Nobel Prize. Some countries immediately banned CFC-containing cosmetic aerosols. It took until the early 1980s for the Antarctic ozone hole to become apparent.3 Inaction would have led to a 2–4 fold increase in skin cancers worldwide.4 In response, the international community came together to sign the Montreal Protocol in 1987.5 The Montreal Protocol is one of the few successful international environmental agreements. In annual negotiations, the stakeholders (governments, industry, technical experts, environmental pressure groups) have all contributed to a steady decline in the use of ozone-depleting substances, through a combination of technical developments, legal deadlines, and grants to the developing world to facilitate their phase-out. A key success factor has been the political independence of the Protocol’s technical panels, especially the Technology and Economic Assessment Panel, and its six subsidiary technical committees. They report annually (by contrast with 5 yearly for the Climate Change convention), and provide up–to-date technical and scientific information to inform the decisions of the Parties to the Protocol. Consensus has not always been easy, especially when individual national or commercial interests intrude. However, the overarching need to get rid of ozone-depleting substances has driven the Parties
705
be divided by four—producing an overall reduction of 0·13% per year or around 1% (from 26% to 25%) by 2010 for England.” Australia, by contrast, has negligible cessation services and since 1997 has run large scare-based15 campaigns to motivate quit attempts. Daily smoking prevalence in those aged 14 years and older has fallen by 30·2% from 23·8% in 1995 to 16·6% in 2007,16 with only 3·6% of adult smokers having ever even called the quitline.17 While pharmaceutical advertisers coattail the governmental campaign, the latter has never given centre stage to messages implying smokers need help. We need to restore smokers’ confidence in their ability to do what literally millions of smokers have done for many decades without having to rely on help. Simon Chapman School of Public Health, University of Sydney, Sydney, NSW 2006, Australia [email protected] I declare that I have no conflict of interest. 1 2 3
Chapman S. Stop-smoking clinics: a case for their abandonment. Lancet 1985; 1: 918–20. Milne E. NHS smoking cessation services and smoking prevalence: observational study. BMJ 2005; 330: 760. Bauld L, Judge K, Platt S. Assessing the impact of smoking cessation services on reducing health inequalities in England: observational study. Tob Control 2007; 16: 400–04.
4
5
6
7 8 9
10
11 12
13 14
15 16
17
Wakefield MA, Durkin S, Spittal MJ, et al. Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence. Am J Public Health 2008; 98: 1443–50. Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2006; 1: CD000146. Walsh R. Over-the-counter nicotine replacement therapy: a methodological review of the evidence supporting its effectiveness. Drug Alcohol Rev 2008; 27: 529–47. Illich I. Disabling professions. London: Marion Boyars 1977. Hatsukami DK, Stead LF, Gupta PC. Tobacco addiction. Lancet 2008; 371: 2027–38. Biener L, Reimer RL, Wakefield M, Szczypka G, Rigotti NA, Connolly G. Impact of smoking cessation aids and mass media among recent quitters. Am J Prev Med 2006; 30: 217–24. Doran CM, Valenti L, Robinson M, Britt H, Mattick RP. Smoking status of Australian general practice patients and their attempts to quit. Addict Behav 2006; 31: 758–66. Hart J. The inverse care law. Lancet 1971; 1: 405–12. Zhu S, Melcer T, Sun J, Rosbrook B, Pierce JP. Smoking cessation with and without assistance: a population-based analysis. Am J Prev Med 2000; 18: 305–11. Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004; 99: 29–38. Tocque K, Barker A, Fullard B. Are stop smoking services helping to reduce smoking prevalence? New analysis based on estimated number of smokers. Tob Control Res Bull (SmokeFree North West) 2005; March: 1–13. Hill D, Chapman S, Donovan R. The return of scare tactics. Tob Control 1998; 7: 5–8. Australian Institute of Health and Welfare. 2007 national drug strategy household survey: first results. April, 2008. http://www.aihw.gov.au/ publications/phe/ndshs07-fr/ndshs07-fr-no-questionnaire.pdf (accessed Oct 29, 2008). Miller CL, Wakefield M, Roberts L. Uptake and effectiveness of the Australian telephone Quitline service in the context of a mass media campaign. Tob Control 2003; 12 (suppl 2): ii53–58.
In defence of helping people to stop smoking Smoking is the largest avoidable cause of death and disability in the developed world, and preventing smoking is one of the highest public health priorities. Effective prevention strategies fall into two broad categories: price increases, mass-media campaigns, health warnings on cigarette packs, advertising and promotion bans, smoke-free policies, and purchase restrictions,1 all of which operate predominantly at the population level by discouraging smoking uptake and encouraging existing smokers to quit; and cessation services, which operate at the individual level, and increase the likelihood of quitting in individual attempts by up to three-fold.2–4 In an accompanying Comment, Simon Chapman5 argues that investment in cessation services is counter-productive to prevention, because the resources they devour could be better used in mass-media campaigns, because cessation clinics send out a message that smokers need help and are unlikely to quit alone, www.thelancet.com Vol 373 February 28, 2009
because medicalisation of cessation purposefully erodes smokers’ confidence in quitting, and because large numbers of smokers who quit do so without help. He singles out the English cessation approach for special criticism, for focusing tobacco control expenditure on dedicated smoking cessation services. While few would argue that population measures have the greater potential to reduce smoking prevalence, Chapman’s inference that health services should not support individual smokers who want to quit is misguided, for the following reasons. First, smoking is powerfully addictive. It is also most prevalent among the most disadvantaged in society. Governments that take tax from cigarettes, or indeed even permit their sale, have a moral duty to support smokers who want to quit, especially if price rises (which, however well intentioned, represent a regressive tax) or scare-based media campaigns are used to promote
See Comment page 701
703
Comment
cessation. Current best cessation practice combines behavioural support with pharmacotherapy.2–4 Second, clinicians need to be able to provide cessation support to individual smokers they treat. Many of these patients are desperate to quit, having repeatedly tried cold turkey and failed; some feel so trapped by their habit they do not even try. In this context the individual need is the imperative. If Chapman is unfortunate enough to suffer a coronary artery occlusion, I suspect he will accept life-saving acute therapy, despite knowing that his disease might have been prevented by more effective population strategies.6 The same argument applies to smoking. Third, when cessation services are provided and promoted to smokers, they are widely used. Last year over 680 000 smokers used the English cessation services, up 13% on the previous year and 500% on 2001–02.7 100 000 of those who used the services last year, 1% of the UK smoking population, will achieve validated long-term cessation.8 That most smokers do not use a service that is unavailable is not, as Chapman argues, evidence that they would not benefit from it if it were. In the days before tuberculosis chemotherapy, all who survived tuberculosis did so without it. Would Chapman argue that investing in tuberculosis therapy is also misguided? Fourth, cessation services are highly cost effective,9 much more so than most clinical or other general life-saving interventions,10 and better than most interventions that are approved by the UK’s National Institute for Health and Clinical Excellence for the
National Health Service (NHS).11 The cost of NHS cessation services last year, excluding drug therapy, was £61 million; about £80 per smoker who will quit for a year or more.7 This is excellent value for money. Chapman’s argument that resources invested in smoking cessation services in the UK could be used to better value in other tobacco-control activities ignores the fact that in the past 10 years the UK Government has introduced a comprehensive range of tobacco-control measures, putting the UK at the top of an objective ranking of policy implementation in Europe.12 Cessation services provide crucial underpinning to these policies. The practitioners who deliver them do not communicate to smokers that they are unlikely to succeed alone. Neither they, nor any other health professional who actually treats smokers, purposefully erodes confidence to quit. If there is a major failing in the UK approach, it is not that it has medicalised smoking, but that it has not done so enough. All smokers should be advised to quit at all contacts with health professionals,2–4 yet only half of smokers in England recall receiving such advice in the past year;13 a figure that is increasing, but should be much higher. Only 32% of smokers in England used pharmacotherapy last year, and 9% a counselling service; again too few, but much improved over the 9 years since English cessation services were first established.13 The challenge now is to widen the coverage and uptake of these services further. One wonders how much lower the prevalence of smoking in Australia might now be, had the admirable media campaigns run there over past decades been supported by UK-style cessation services. John Britton UK Centre for Tobacco Control Studies, University of Nottingham, Nottingham NG5 1PB, UK [email protected] I have consulted and done research for companies producing smoking cessation therapies. 1
2
Science Photo Library
3
4
704
WHO. WHO Framework Convention on Tobacco Control. 2003. http:// www.who.int/fctc/text_download/en/index.html (accessed Jan 25, 2009). West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax 2000; 55: 987–99. National Institute for Health and Clinical Excellence. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. February, 2008. http://www.nice.org.uk/Guidance/ PH10 (accessed Jan 25, 2009). Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. May, 2005. http://www.surgeongeneral.gov/tobacco/ treating_tobacco_use08.pdf (accessed Jan 25, 2009).
www.thelancet.com Vol 373 February 28, 2009
Comment
5 6
7
8 9
Chapman S. The inverse impact law of smoking cessation. Lancet 2009: 373: 702–03. Unal B, Critchley JA, Capewell S. Modelling the decline in coronary heart disease deaths in England and Wales, 1981–2000: comparing contributions from primary prevention and secondary prevention. BMJ 2005; 331: 614. The Information Centre. Statistics on NHS Stop Smoking Services in England, April 2007 to March 2008. 2008. http://www.ic.nhs.uk/webfiles/ publications/Stop%20smoking%20ANNUAL%20bulletins/SSS0708/ SSS%202007-08%20final%20format%20v2.pdf (accessed Jan 25, 2009). Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one-year outcomes. Addiction 2005; 100 (suppl 2): 59–69. Parrott S, Godfrey C. Economics of smoking cessation. BMJ 2004; 328: 947–49.
10 11 12
13
Tengs TO, Adams ME, Pliskin JS, et al. Five hundred life-saving interventions and their cost-effectiveness. Risk Analysis 1995; 15: 369–90. Appleby J, Devlin N, Parkin D. NICE’s cost effectiveness threshold. BMJ 2007; 335: 358–59. Joossens L, Raw M. Progress in tobacco control in 30 European countries, 2005 to 2007. 2007. http://www.ensp.org/files/30_european_countries_ text_final.pdf (accessed Jan 25, 2009). Lader D. Smoking-related behaviour and attitudes, 2007: a report on research using the National Statistics Omnibus Survey produced on behalf of the NHS Information Centre for health and social care. 2008. http:// www.statistics.gov.uk/downloads/theme_health/smoking2007.pdf (accessed Jan 25, 2009).
The Montreal Protocol: getting over the finishing line?
www.thelancet.com Vol 373 February 28, 2009
to achieve agreement annually for the past 20 years. The annual production of such substances is now down to less than 5% of its peak, but due to the long half-life of some ozone-depleting substances, even on the current phase-out schedule the ozone layer will only recover by about 2060. The last 5% of ozone-depleting substances was always going to be the hardest to manage, and includes CFCs for metered-dose inhalers for asthma and chronic obstructive pulmonary disease. It has taken about US$2 billion and 20 years for the multinational drug industry to overcome the substantial challenges of inhaler reformulation, and to switch to hydrofluorocarbon propellants.6 Now almost all inhalers in the US and European Union are CFC-free, and any containing CFCs should have disappeared completely in developed countries by the end of 2010. But just as final CFC phase-out seemed imminent, a potential problem has emerged. About a dozen developing countries will require CFCs beyond the 2010 deadline to supply inhaler manufacturers that have not yet acquired technology to produce non-CFC alternatives. Crucially, they supply inhalers to patients at locally affordable prices (cheaper than those from multinationals). Some early Protocol-funded projects to transfer manufacturing technology for hydrofluorocarbons to local companies in developing countries are nearing completion (eg, Uruguay, Cuba), but others are only just starting. As a result, India may need CFCs until 2012, and China until 2014. However, continued manufacture of small volumes of pharmaceutical-grade CFCs after 2010 might not be economically viable. This potential shortfall of CFCs could lead to uncertainty in supply of affordable inhalers, and a potential health risk for the rapidly
Science Photo Library
On Jan 1, 2010, the manufacture of chlorofluorocarbons (CFCs) for all uses worldwide is due to stop. Are we still on schedule for final phase-out? Stratospheric ozone protects us from the damaging effects of ultraviolet B.1 In 1974, Molina and Rowland proposed the landmark hypothesis (much derided at the time by the chemical industry) that stratospheric ozone would be broken down by stable man-made CFCs.2 This prediction was of enormous environmental importance—for which they rightly shared the Nobel Prize. Some countries immediately banned CFC-containing cosmetic aerosols. It took until the early 1980s for the Antarctic ozone hole to become apparent.3 Inaction would have led to a 2–4 fold increase in skin cancers worldwide.4 In response, the international community came together to sign the Montreal Protocol in 1987.5 The Montreal Protocol is one of the few successful international environmental agreements. In annual negotiations, the stakeholders (governments, industry, technical experts, environmental pressure groups) have all contributed to a steady decline in the use of ozone-depleting substances, through a combination of technical developments, legal deadlines, and grants to the developing world to facilitate their phase-out. A key success factor has been the political independence of the Protocol’s technical panels, especially the Technology and Economic Assessment Panel, and its six subsidiary technical committees. They report annually (by contrast with 5 yearly for the Climate Change convention), and provide up–to-date technical and scientific information to inform the decisions of the Parties to the Protocol. Consensus has not always been easy, especially when individual national or commercial interests intrude. However, the overarching need to get rid of ozone-depleting substances has driven the Parties
705