A Smokefree Generation:A Tobacco Control Strategic Plan for

Hertfordshire: 2019-2022VERSION TWO

A Smokefree Generation:A Tobacco Control Strategic Plan for Hertfordshire: 2019-2022

APPENDIX A

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CONTENTS PAGE

Executive Summary.............................................................................................................4

Background…………………………………………………………………………………………5

Progress on the 2016-2018 Tobacco Control Priorities…………………………………….7

Smokefree Hertfordshire Tobacco Control Priorities 2019-2022…………….................18

REFERENCES……………………………………………………………………………….……21

FIGURES

Figure 1: Percentage of women smoking at time of delivery (SATOD) NHS East and North Hertfordshire CCG, NHS Herts Valleys CCG, by year, 2013/14 to 2017/18………………………………………………………………………………………………7

Figure 2: Regular and occasional (current) smokers in 15 year olds in England, Hertfordshire and statistical neighbour counties ……………………………………………....10

Figure 3: Use of e-cigarettes at age 15: England, Hertfordshire and statistical neighbour counties (2014/15)…………………………………………………………………………………11

Figure 4: Smoking prevalence in adults (18+ years): England, Hertfordshire and individual districts (2013-2017)……………………………………………………………………………....13

Figure 5: Hertfordshire adult smoking prevalence in relation to its statistical neighbour counties……………………………………………………………………………………………..13

Figure 6: Smoking prevalence in routine and manual workers: England, East of England and Hertfordshire (2012 to 2017)………………………………………………………………….14

Figure 7: Smoking prevalence in adults with serious mental illness: England, Hertfordshire and statistical neighbours (2014/15)…………………………………………………………….15

TABLES

Table 1: Training delivered by HHIS to midwives in West Herts Hospital Trust (WHHT) and East and North Herts Hospital Trust (ENHHT) between 2016- 2019……….……………8

Table 2: Number of stillbirths and neonatal mortalities in Hertfordshire between 2014-17………………………………………….……………………..8

Table 3: Results of Hertfordshire Schools Health Related Behaviour Surveyfor Year 10 pupils when asked about smoking by parents/carersin the home and in the car ……………………………………………………………………….10 Table 4: Breakdown of age groups accessing Hertfordshire Health Improvement Service – Stop Smoking Services (2016/18)………………………..………………………….16

Table 5: Smoking related mortality and morbidity rates (2015-2017): Hertfordshire, England and Hertfordshire’s 3 closest CIPFA statistical neighbours….……17

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APPENDICES

Appendix 1Smokefree Hertfordshire (Hertfordshire Tobacco Control Alliance) membership

Appendix 2NICE Public Health Guidance and Standards

Appendix 3A Smokefree Generation: A Tobacco Control Action Plan for Hertfordshire 2019-2022

Appendix 4Equality Impact Assessment

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Executive Summary

Progress has been made in Hertfordshire to reach the ambitions of Hertfordshire Health and Wellbeing Strategy to tackle health inequalities and their underlying causes especially in the most vulnerable groups. This was outlined in Hertfordshire’s Tobacco Control Strategic Plan 2016-2018.i The strategy highlighted the role of Hertfordshire’s multi-agency Tobacco Control Alliance and the priority areas to reduce smoking prevalence and reduce health inequalities in: pregnant smokers and their families, routine and manual groups, people with mental health conditions as well as other groups where smoking rates are higher and tobacco addiction is greatest.

Smoking is the main cause of preventable illness and premature death in England and in Hertfordshire and has a greater impact on lower socio-economic groups, causing a widening gap in health inequalities between the better and the least well off, with some groups dying 16-20 years earlier than the general population.

As well as the impact on individuals and families, smoking has a significant financial cost to Hertfordshire. Providing evidence-based help to stop smoking is effective, improving success rates at 4 weeks by up to 4 times compared to no intervention and effective tobacco control measures save more than they cost.

Smoking causes more premature deaths than the next 5 most common causes of premature death combined and 79,000 people die annually in England from diseases caused by smoking. For every death caused by smoking, there are approximately 20 times more people living with a smoking-related long term condition. Stopping smoking reduces the risk of developing many of these fatal diseases. In 2014, there were 146,978 adult smokers in Hertfordshire. By 2017, this had dropped to 115,500 adult smokers.

During the period 2014/15 – 2017/18, 28,702 smokers attended a local stop smoking service and 15,757 quit smoking for at least 4 weeks.ii

This strategic plan draws on the best available evidence, local insights and intelligence and in consultation with a wide range of members from Hertfordshire’s Tobacco Control Alliance as well as the recommendations in the national strategy, A Smokefree Generation: A tobacco Control Plan for Englandiii and the NHS Long Term Plan.iv It also reports on the progress made on implementing the previous tobacco control strategic plan for Hertfordshire 2016-2018, and is written with reference to NICE guidance (see Appendix 2).

It includes targeting tobacco control interventions and supporting smokers in the routine and manual workforce, women who smoke in pregnancy, people who have mental health conditions and smokers who already have conditions that are caused by, or made worse by, smoking and those most addicted to tobacco and who have previously failed to quit.

The vision of Hertfordshire Health and Wellbeing Strategy 2016-2020v is ‘with all partners working together we aim to reduce health inequalities and improve the health and wellbeing of the people in Hertfordshire’. In relation to tobacco control, the two main areas are:

To reduce the proportion of women who smoke during pregnancy To reduce the harm caused to health by smoking, alcohol and drug use among

working age adults.

This refreshed Tobacco Control Strategic Plan is in recognition of the progress made to date and the need to focus on narrowing the gap between the better off and the worse off in our communities caused by tobacco use.

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The NHS priority to reduce premature mortality and morbidity is outlined in the NHS 5 year Forward Viewvi and in the NHS Long Term Planvii. All NHS organisations in Hertfordshire are committed to this and signed the NHS Statement of Support for Tobacco Control in January 2016.

The priorities in this strategic plan come out of the recommendations in the national strategy A Smokefree Generation: A tobacco Control Plan for Englandviii the progress made on implementing the previous tobacco control strategic plan for Hertfordshire 2016-2018, the NHS Long Term Planix and in consultation with members of Hertfordshire’s Tobacco Control Alliance and in reference to NICE guidance (see Appendix 2).

Background

The Tobacco Control Plan for England, ‘Towards a Smokefree Generation: A tobacco control plan for England’ (July 2017)x recognised that smoking prevalence has substantially reduced overall, but the burden of smoking remains much higher in more disadvantaged communities: In England in 2017:

8% of 15 yearxi olds still smoke, risking a lifetime of ill health Over 10% of pregnant women still smoke Smoking rates have remained stubbornly higher amongst those in our society who

already suffer from poor health and other disadvantages Smoking rates are almost three times higher amongst the lowest earners,

compared to the highest earners Prevalence remains even higher in people with mental health conditions, where

more than 40% of adults with a serious mental illness smoke

Adult smoking prevalence for England was 14.9% in 2017 compared with 17.8% in 2014xii. This decline has been largely achieved through legislation which banned advertising and the promotion of tobacco products at sporting events; created Smokefree public places; stopped retail displays of tobacco; increased cigarette pack sizes to make them less affordable; prohibited cigarette vending machines and increased the age of sale to 18; prevented proxy purchasing of tobacco as well as ensuring greater protection for children whilst traveling in cars. Legislation which brought in standardised (plain) packaging and more graphic health warnings also deter young people from taking up smoking and encourage established smokers to quit.

Adult smoking prevalence in Hertfordshire was approximately 12.7% in 2017. This is the lowest on record and the lowest in the East of England region. However, smoking prevalence in routine and manual workers in Hertfordshire in 2017 was 24.6%. Although this is declining, it remains significantly higher than in the adult population as a whole. Smoking at the time of delivery at 7.1% in 2017/18 is lower than for England at 10.8%. In 2016, 3% of 15 year olds smoked regularly in Hertfordshire, compared with 8% for England. Electronic cigarettes are a popular aid to quitting smoking and have contributed to the decline in smoking prevalence.

Hertfordshire Health Improvement Service (HHIS) formerly Hertfordshire Stop Smoking Service (HSSS) provides specialist stop smoking services across the county and Public Health commissions stop smoking services from 108 GP practices and 79 community pharmacies. HHIS trains providers and other stakeholders to help people who are addicted to nicotine to reduce or stop smoking and HHIS supports and performance manages the commissioned stop smoking services across the county. HHIS directly provides 29 specialist stop smoking clinics each week in a variety of locations across Hertfordshire

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The smoking rate amongst people with a mental health condition has barely changed over the last 20 years. People with a mental health condition are just as likely to want to quit smoking, but face more barriers to quitting. Reducing smoking prevalence in people with a mental health condition therefore requires action from many different stakeholders across the whole health and social care system.

Smokers who are admitted to hospital and use NHS services should be offered advice and information to quit smoking and provided support to quit smoking whilst in hospital, this can be done by supporting NHS providers in delivering the prevention agenda/promoting healthy lifestyles as outlined in the NHS Long Term Plan.xiii

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Progress on the 2016-2018 Tobacco Control Strategic Plan

The 2016-2018 Tobacco Control Strategic Plan was approved by Hertfordshire County Council’s Public Health and Localism Panel on 25 September 2015. It focused on reducing the harm from tobacco throughout the lifecourse. The following data and commentary show the progress that has been made to date:

PRIORITY 1

Reducing smoking-related morbidity and mortality in babies and children under 5

Reduce smoking in pregnancy so that smoking prevalence at the time of delivery (SATOD) reduces to:

5% for women registered with HVCCG (from a baseline of 6.6% in 2014-2015)

7% for women registered with ENHCCG (from a baseline of 9.2% in 2014-2015)

Reduce the number of babies and children exposed to second-hand smoke.

Reduce the number of stillbirths, neonatal deaths, Sudden Unexpected Infant Deaths (cot deaths) and number of hospital admissions from asthma and bronchitis and otitis media and meningitis where smoking is a known contributory factor.

Babies and children exposed to tobacco smoke are more likely to be admitted to hospital for conditions such as asthma and bronchitis and face inequalities in health related to tobacco throughout life.

Figure 1 shows that smoking levels at the end of pregnancy were significantly lower in Hertfordshire CCGs (7.1%) than in England (10.8%) as a whole in 2017/18, but remain higher in women registered with East and North Herts Clinical Commissioning Group (ENHCCG). Work continues to improve the identification of pregnant smokers, ensure all pregnant smokers and their partners are referred to Hertfordshire Health Improvement Service (HHIS) and that more pregnant smokers take up the offer of specialist stop smoking services. The engagement and commitment of both maternity units in Hertfordshire to achieve this is encouraging.

Figure 1: Percentage of women smoking at time of delivery (SATOD)NHS East and North Hertfordshire CCG, NHS Herts Valleys CCG, by year, 2013/14 to 2017/18

12.0

%

7.4%

7.8%

6.8%

11.4

%

7.8%

9.2%

6.6%

10.6

%

7.0%

7.9%

6.4%

10.5

%

6.7%

8.1%

5.8%

10.8

%

7.1%

8.7%

5.8%

England Herts CCGs ENHCCG HVCCG0%

2%

4%

6%

8%

10%

12%

14%

2013/14 2014/15 2015/16Source: NHS Digital, Local CCGs ph.ntelligence@hertfordshire.gov.uk

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Hertfordshire Health Improvement Service (HHIS) also reviewed how woman who smoked during pregnancy were supported to quit smoking. It was recognised that specialist stop smoking services had greater capacity and flexibility to meet the needs of pregnant smokers and achieved higher quit rates than commissioned stop smoking services. All pregnant smokers are now referred directly to HHIS and the specialist team has responsibility for supporting pregnant smokers and their families throughout pregnancy and beyond.

Midwives in both maternity trusts receive update training each year delivered by HHIS, as well as mandatory update training by their own maternity stop smoking leads. Training includes the risks of smoking and benefits of quitting, performing Carbon Monoxide monitoring and having ‘difficult conversations’ with pregnant women who smoke. The breakdown of training delivered by HHIS is shown in table 1. Additionally, training was undertaken each year with all student midwives, student nurses and student health visitors at the University of Hertfordshire,

Table 1: Training delivered by HHIS to midwives in West Herts Hospital Trust (WHHT) and East and North Herts Hospital Trust (ENHHT) between 2016- 2019 (this excludes training delivered by their own in-house midwifery training leads).

AREA/YEAR 2016/17 2017/18 2018/19 TOTAL

WHHT 174 180 177 531

ENHHT 122 145 24 291

TOTAL 296 325 201 822

In 2016, the ‘Love your Bump’ campaign was launched in Hertfordshire. This is an award winning social marketing campaign which encourages woman and their families to quit smoking for the sake of ‘the bump’. The campaign engaged with a larger number of pregnant woman and referrals to the service increased by 128% during the year of its launch.

With reference to reducing the number of babies and children exposed to second-hand smoke, there are no current data. Smokefree car legislation came into effect in 2015. This was widely promoted in Hertfordshire with a Smokefree Homes and Cars campaign and with the requirement that all partner agencies discussed the risks of second hand smoke with their service users. Compliance with this legislation is high and exposure to second-hand smoke both in the home and in the car is expected to be reduced. However, with families that experience health inequalities and are more dependent on tobacco, the reduction may be less.

Whilst we have data for number of stillbirths and neonatal deaths, where smoking can be contributory factor, we cannot give exact figures (see table 2).

Table 2: Number of stillbirths and neonatal mortalities in Hertfordshire between 2014-17

AREA/YEAR 2014-16 2015-17Stillbirths 161 166

Neonatal deaths 83 89

The rates of hospital admissions for asthma (under 19 years) in Hertfordshire has fallen from 361 in 2014/15 to 328 in 2017/18.xiv

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PRIORITY 2

Preventing the uptake of smoking in young people and protecting children from second-hand smoke

Priorities were to:

• Reduce regular AND occasional smoking in 15 year olds to 5% by 2018 from a baseline of 10% in 2014

• Reduce the number of parents of 12-15 year olds who smoke to 24% from a baseline of 29% in 2014

• Reduce the number of children (12-15 year olds) who are exposed to second-hand smoke in the home from a baseline of 9% in 2014 to less than 5% by 2018 and in the car from 14% in 2014 to zero by 2018

Children born into households where adults or siblings smoke may face years of exposure to secondhand smoke. Early exposure to secondhand smoke contributes to many adverse health outcomes including lower respiratory tract infections, asthma, wheezing, middle ear infections and invasive meningococcal disease and is associated with impaired mental health and with increased school absenteeismxv. A UK wide poll of young people in 2016 found that 86% of children reported no exposure to smoking in cars compared to 83% in 2015.xvi Reducing exposure to second-hand smoke and preventing the uptake of smoking by young people has been successfully addressed through legislation and regulation, including the sale and display of tobacco products. Exposure in cars has changed following implementation of the Families and Children’s Act (2015) which prohibited smoking in cars when under 18s were present.xvii

Amongst adult smokers, about two-thirds report that they took up smoking before the age of 18 and over 80% before the age of 20.xviii Regular smoking is also associated with other risky behaviours, namely drinking alcohol, taking drugs and truancy. The uptake of smoking is associated with a wide range of risk factors including: parental and sibling smoking, the ease of obtaining cigarettes, smoking by friends and peer group members, socioeconomic status, exposure to tobacco marketing, and depictions of smoking in films, television and other media.xix Children who live with parents or siblings who smoke are up to 3 times more likely to become smokers themselves than children of non-smoking households.

Smoking is a significant financial burden on low income families. Approximately 1.2 million children in the UK are living in poverty in households where adults smoke. If these adults quit and the costs of smoking were returned to household budgets, 365,000 of these children would be lifted out of poverty.xx

It is estimated that around 207,000 children in the UK start smoking every year. On average, 1 percent of 11 and 12 year olds smoke, but this rises with age. Regular smoking in 15 year olds in England is at an all-time low of 7%. In Hertfordshire in 2018, 14% of secondary pupils said they had tried smoking or were smoking now, compared with 16% in 2016, 21% in 2014 and 31% in 2012.xxi

The prevalence of children who have ever smoked continues to decline and smoking prevalence since 2010 has fallen most in younger age groups.

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Figure 2: Regular and occasional (current) smokers in 15 year olds in England, Hertfordshire and statistical neighbour counties

The national data for numbers of parents who smoke and children exposed to second hand smoke have not been updated since 2014. However, the Hertfordshire Schools Health Related Behaviour Surveyxxii which is conducted with secondary schools pupils (Year 10) showed that in 2018 (table 3), 19% of pupils in year 10 stated that their parent or carer smoked. Additionally 6% of year 10 pupils stated someone smoked at home in the same room and 5.5% pupils had someone smoke in the car they travelled in. The survey also showed that in 2018 only 2% of boys and girls smoked regularly. Please note: these data have to be interpreted with caution as the sample size was only representative of 12 secondary schools.

Table 3: Results of Hertfordshire Schools Health Related Behaviour Survey for Year 10 pupils when asked about smoking by parents/carers in the home and in the car

Figure 3 shows data from a national survey about the use of e-cigarettes among people aged 15 years. Use of e-cigarettes in young people is generally confined to those who are already smoking and there is no evidence to date that e-cigarettes are a gateway into smoking for young peoplexxiii

Year 10 male Year 10 femaleNo Yes No Yes

Do your parents/carers smoke?

81% 19% 81% 19%

Does anyone smoke indoors at home in rooms that you use?

95% 5% 93% 7%

Does anyone smoke in a car when you are in it?

95% 5% 92% 6%

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Figure 3: Use of e-cigarettes at age 15: England, Hertfordshire and statistical neighbour counties (2014/15)xxiv

To support the prevention of uptake of smoking in young people priority, a delivery group was set up with membership from Hertfordshire’s Vulnerable Young People Policy Team, Hertfordshire Health Improvement Service, and representation from schools, Youth Connexions (now YC Hertfordshire) and district councils.

The 3 main areas of work that were undertaken to support priority 2 were as follows:

ASSIST (A Stop Smoking in Schools Trial)ASSISTxxv is a peer mentoring programme for year 8 students, which aims to reduce adolescent smoking prevalence. The programme was delivered in four secondary schools in Stevenage over 3 academic school years (2015-2017). The programme is recognised by National Institute for Health and Care Excellence (NICE) as one of the few effective schools-based interventions. Peer supporters were trained and supported to have structured, but informal conversations with other year 8 students about the risks of smoking and the benefits of being Smokefree. By the end of 2017, HHIS had trained 226 peer supporters in Stevenage schools. Evaluation of the programme showed that peer supporters had increased confidence in their skills to talk about smoking with their peers from 68% at the beginning of the programme to 95% when programme was completed. Peer supporters also increased in confidence in their ability to talk to their peers about not starting smoking from 70% to 85%.

The feedback from the schools was that the programme not only gave the peer supporters confidence to talk about smoking, but improved their overall confidence.

Smokefree School Toolkit The toolkit was developed by the young people’s delivery group to promote and support schools in becoming Smokefree and enabled schools to support pupils who were found to be smoking. The toolkit included Smokefree policy templates for the school to adopt, template letters for pupils and parents, and advice and information for supporting students and staff who smoked. The toolkit also comprised referral forms, and information on Smokefree campaigns and resources. The toolkit was implemented in 17 schools in Hertfordshire (11 secondary schools and 6 primary schools). The toolkit is now promoted by school nurses and YC Hertfordshire whilst delivering health improvement programmes within schools.

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You’re Welcome Accreditation In 2016, Hertfordshire Health Improvement Service was awarded ‘You’re Welcome’ accreditation. The scheme sets out a clear set of quality criteria for youth-friendly health services. The quality criteria provide a framework to deliver better health outcomes for young people, ensuring that health workers respond to adolescents effectively, appropriately and with sensitivity, improving young people’s ability to be actively involved in their own care. Young people friendly services aim to give young people a voice in the care they receive and contribute to improving the quality and coverage of health services provided for young people.

Between 2015/16 and 2017/18, 171 young people under the age of 18 accessed stop smoking services in Hertfordshire and 53 successfully quit smoking.

PRIORITY 3

Priorities were to reducing smoking in adults at a greater pace than England as a whole with a focus on reducing the inequalities by reducing smoking prevalence in:

• The general population by 1% per year (from a baseline of 17.8% in 2014)

• Routine and manual workers by 2% per year (from a baseline of 33.1% in 2014)

• People with mental health conditions

• Prisoners and offenders

• The homeless and unemployed

• Black and Minority Ethnic (BME) groups with high smoking prevalence

• Lesbian, Gay, Bisexual and Transgender (LGBT) groups

All adultsThe latest smoking data for adults are taken from the 2017 Annual Population Survey (APS) in England, so the rates given are based on a representative sample of the population. Figure 1 indicates that the adult smoking prevalence in Hertfordshire in 2017 was 12.7%. This is a little lower than England as a whole (14.9%) and the East of England region (14.2%). Nationally, there have been sustained and significant reductions in adult smoking rates between 2012 and 2017. Smoking prevalence in Hertfordshire has fluctuated during the same time period, although this may, in part, be explained by the imprecision from the smaller sample size. Figure 4 shows there is some variation in smoking prevalence between the ten districts in Hertfordshire, although the smaller sample sizes make the estimates considerably less reliable at this level. In 2017, St Albans and North Hertfordshire had a statistically significant lower smoking prevalence and Stevenage had a statistically significant higher smoking prevalence than the Hertfordshire average.

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Figure 4: Smoking prevalence in adults (18+ years): England, Hertfordshire and individual districts (2013-2017)

Figure 5 Hertfordshire’s adult smoking prevalence in relation to its statistical neighbour counties shows that Hertfordshire’s prevalence has declined since 2013, though not significantly, and that it is significantly lower than the England rate. There doesn’t look to be any statistically significant differences between Hertfordshire and its CIPFA neighbours

Figure 5: Hertfordshire adult smoking prevalence in relation to its statistical neighbour counties

Routine and Manual workersFigure 6 indicates that the smoking rate in 2017 in routine and manual workers in Hertfordshire had decreased to 24.6% in comparison to 25.7% in England, and this is statistically similar to the statistical neighbour counties. This may, in part, be explained

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by the smaller sample size for this estimate. The prevalence rate in routine and manual workers may also be as a consequence of demographic changes to the population. There has been a significant increase in Hertfordshire residents born outside of the UK, from 90,785 in 2001 to 149,683 in 2011. Smoking prevalence in some BME groups is higher than the UK born population including the Polish community which is the largest white non-British community in Hertfordshire. Smoking prevalence in this group is estimated to be 31% for women and 46% in men, based on rates for their country of origin.xxvi

Figure 6: Smoking prevalence for routine and manual workers: England, East of England and Hertfordshire (2012 to 2017)

Smoking rates amongst people with a serious mental illness (SMI) in England and in Hertfordshire (40.5% and 35.7% respectively) are significantly higher than in the general population (14.9% and 12.7% respectively) and there is some evidence that smoking may actually be a trigger for mental ill health. The 2014 Adult Psychiatric Morbidity Survey found a strong association between smoking and having a common mental health disorder (CMD), with those smoking 15 or more cigarettes a day more likely to have a CMD than those smoking fewer cigarettes or non- smokers.xxvii The association between smoking and mental ill health becomes stronger relative to the severity of the condition, with the highest levels of smoking found in psychiatric in-patients. People with mental health conditions smoke significantly more and have increased levels of nicotine dependency than the general population and are therefore at even greater risk of smoking-related harm. Smoking is the single largest contributor to the 10-20 year reduced life expectancy in people with mental health conditions.

Data for smoking prevalence in adults with serious mental illness has not been updated since 2015 and shown in figure 7. Hertfordshire smoking prevalence in adults with serious mental illness (35.7%) is significantly lower than the level for England as a whole (40.5%) and similar to levels in other local authorities, although it is indicated that there is an issue with the quality of the data. This figure could be much higher, as 2009/10 data in primary care records reported smoking prevalence in people with serious mental illness such as bi-polar disorder or schizophrenia to be high at 37% and 45% respectively. Smokers with mental disorders can lose 10 or more years of life due to disease caused by smoking.xxviii

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Figure 7: Smoking prevalence in adults with serious mental illness: England, Hertfordshire and statistical neighbours (2014/15)

*indicates there is an issue with the quality of the data (Source: Health and Social Care Information Centre)

Hertfordshire Partnership NHS Foundation Trust (HPfT) became Smokefree on 1st January 2016. This included all grounds and buildings, staff, contractors, visitors and service users. Face to face training, was delivered to over 300 frontline staff and an e-learning package was developed for HPfT. It is a mandatory requirement for all staff to complete as part of their recruitment to HPfT and as a refresher on an annual basis.

No local authority level data are available on smoking prevalence in prison populations. However, in England and Wales, smoking rates among prisoners are more than four times higher than in the general population at approximately 80%. This is comparable with other countries.xxix In 2016/18 292 prisoners from HMP the Mount accessed stop smoking services with 129 quitting at 4 weeks.xxx Hertfordshire Health Improvement Service delivers a weekly stop smoking service within the prison, in partnership with the prison’s health care service.

The smoking rate in the unemployed is estimated to be 35% compared to 19% of those in employment and is also higher in Lesbian, Gay, Bisexual & Transgender (LGBT) groups than the general population (ASH, 2016).

Between 2015 and 2018, 5,834 smokers in routine and manual occupations attended a stop smoking service and 3,294 quit smoking at 4 weeks. The service promoted the ‘Wise Up to Roll Up’ campaign within workplaces that had a large routine and manual workforce throughout 2015/16. This raised awareness of the dangers of hand rolled tobacco, which is more widely used in lower socio-economic groups.

Tobacco control campaigns promoted in workplaces were ‘Health Harms’, ‘National No Smoking Day’ and ‘Stoptober’. Resources were ordered and HHIS produced materials to promote the campaigns and encourage smokers to get support to quit smoking. The campaigns were promoted through Hertfordshire’s Tobacco Control Alliance, press releases, communications in local council newsletters and waiting area TV screens. A number of the councils undertook targeted work with their depot staff as they have a higher prevalence of smoking.

PRIORITY 4

Improve the quality of life and reduce premature morbidity and mortality in older people by helping older people quit smoking with a focus on people with, or at risk of developing, smoking-related long-term conditions (LTCs) or complications arising from these conditions (e.g. cardio-vascular disease, stroke, dementia, lung disease, diabetes and cancer).

Smoking is the main cause of preventable illness and premature death in England and in Hertfordshire and has a greater impact on lower socio-economic groups. There is a widening gap in health inequalities between socio-economic groups due to smoking and about half of all regular cigarette smokers will be killed prematurely by their addiction, with some groups dying 16-20 years prematurely. For every year of smoking after the age of 35-40, 3 months of life are lost.xxxi Smoking causes heart and circulatory diseases, respiratory diseases such as chronic obstructive pulmonary disease (COPD) and is associated with nearly all forms of cancer (not just lung cancer) and every year

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approximately 79,000 people in England die from diseases caused by smoking.xxxii

Smoking accounts for over one-third of respiratory deaths, over one-quarter of cancer deaths, and about one-seventh of cardiovascular disease deaths.xxxiii Every day more than 200 people die in England from smoking-related disease, and more than 1,500 people die every year in Hertfordshire.xxxiv Smoking also causes debilitating conditions such as infertility, erectile dysfunction, osteoporosis, cataracts, oral disease and dementia as well as complications in pregnancy, childbirth and following childhood.

Table 4: Breakdown of age groups accessing Hertfordshire Health Improvement Service – Stop Smoking Services (2016/18)

Age group*

Number setting a quit date

Number who had quit at 4

weeks

Number who had quit at 4 weeks

Under18 109 30 32.7%

18-34years 2886 1343 46.5%

35-44years 2731 1454 53%

45-59years 4393 2417 55%

60+years 2677 1597 59.6%

Total 12796 6841 53.5%

*Note age groups are of different sizesxxxv

Age groups accessing the service can be seen in table 4 by the recording of four week quit rates by age group (Source: HHIS data Q4 data return for 2016/18 submitted to NHS Digital). The success rate of stopping smoking gradually increases with age for both men and women. The main age group that attends the service is aged 45-49. The quit rate increases with age, with the 60+ age group having the highest quit rate at nearly 60%.

Stop smoking support is a highly cost effective measure to improve health. In the UK, stopping smoking has been the single biggest factor in reducing deaths from heart disease, preventing nearly 30,000 heart disease deaths between 1981 and 2000.xxxvi

Table 5 shows that whilst a high number of deaths, cancers and hospital admissions in Hertfordshire are attributed to smoking, levels are lower than for England as a whole.

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Table 5: Smoking related mortality and morbidity rates (2015-2017): Hertfordshire, England and 3 closest CIPFA statistical neighbours

Smoking related mortality and morbidity rates: Hertfordshire and England

PRIORITY 5

The tobacco control action plan for 2016-18 to achieve the above priorities was delivered by members of ‘Smokefree Hertfordshire’ (Hertfordshire’s Tobacco Control Alliance). Actions included:

All partners are committed to reducing the harm from tobacco and understand the association between smoking and health inequalities

Our partners have the knowledge, skills, capacity and commitment to deliver Hertfordshire’s Tobacco Control Strategic Plan 2016-2018

Hertfordshire’s Tobacco Control Strategic Plan is consistent with national strategy and is evidence based, effective and cost saving

Tobacco legislation is implemented effectively in Hertfordshire though the work of the Police and Local Government Enforcement Agencies and Trading Standards

Access to illegal and counterfeit tobacco is minimized through the work ofHertfordshire Trading Standards and Her Majesty’s Revenue and Customs (HMRC)

The public sector, local businesses, educational establishments and voluntary organisations are exemplars in tobacco control and have comprehensive Smokefree policies in place

We are advocates of and support evidence-based tobacco-control measures at regional and national levels and influence change through advocacy

We have good quality data within our JSNA to inform our tobacco control strategic plan and we can measure success against reliable and accurate information

We have a communication and marketing plan and resources to deliver consistent, coherent and coordinated communication on tobacco control throughout the county using social marketing techniques to reach all our partners and communities

Highlights of achievements

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Since the last tobacco control strategy the achievement in Hertfordshire around Smokefree environments is that East and North Herts Trust (ENHT), West Herts Hospital Trust (WHHT) Hertfordshire Partnership foundation NHS Trust (HPfT), and HMP, the Mount became Smokefree. However, the ongoing implementation of these polices requires collaborative and sustained efforts to encourage and support patients, visitors and staff to adhere to the policy

All 10 district and borough councils support Smokefree playgrounds and play areas. They have implemented policies and signage to raise awareness of the importance of protecting children from tobacco smoke and creating safe places for children to play

The ‘Love your Bump’ social marketing campaign to raise awareness of the dangers of smoking in pregnancy targeted at smokers and their families won 2 national awards see below for the comments that the award panels made:

o Comms 2Point0 UnAwards - Excellent campaign with really creative and effective use of insight and social marketing techniques to deliver fantastic results that make a real difference in people’s lives.

o LGC Awards - This was a campaign plan rooted in science and art which successfully worked across a range of partners to ultimately change lives. A template for others to follow.

A Hertfordshire County Council e-cigarette policy was developed with a range of national and local experts in the field. This has helped to encourage organisations and businesses to adopt an evidence-based approach to developing their own e-cigarette policies.

Hertfordshire Health Improvement Service became ‘e-cigarette friendly’, ensuring that smokers who would otherwise not get support to quit were encouraged to do so. Service providers were also encouraged to see smokers who wanted to use e-cigarettes to quit smoking.

NHS leaders and Hertfordshire County Council signed the NHS Declaration on Tobacco Control to reduce the harm caused by tobacco across all our organisations.

The National CQUIN for Risky Behaviours (tobacco and alcohol) was implemented from 2017/18 in HPfT and Hertfordshire Community NHS Trust, ensuring more smokers and more individuals at risk from higher levels of drinking were advised about the risks and offered treatment and support.

Smokefree Hertfordshire Tobacco Control Priorities 2019-2022

This strategic plan draws on the best available evidence, local insights and intelligence and in consultation with a wide range of members from Hertfordshire’s Tobacco Control Alliance as well as the recommendations in the national strategy, A Smokefree Generation: A tobacco Control Plan for Englandxxxvii and the NHS Long Term Plan.xxxviii It also reports on the progress made on implementing the previous tobacco control strategic plan for Hertfordshire 2016-2018, and is written with reference to NICE guidance (see Appendix 2).

It includes targeting tobacco control interventions and supporting smokers in the routine and manual workforce, women who smoke in pregnancy, people who have mental health conditions and smokers who already have conditions that are caused by, or made worse by, smoking and those most addicted to tobacco and who have previously failed to quit.

We recognise that tobacco use is concentrated almost entirely in our more disadvantaged

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communities and that we have reduced smoking prevalence in the general population to 12.7%. Our sustained efforts to reduce the harm from tobacco must address the continuing health inequalities gap between the better and worst off in our communities.

Our tobacco control strategic plan reflects the Governments ambition to ‘improve and protect the nation’s health and wellbeing and to improve the health of the poorest fastest’ by reducing smoking, and the harm from tobacco, which is a Health and Wellbeing Boardxxxix and STP prevention priority. xl The national tobacco control plan for England states “We need to shift emphasis from action at the national level and legislation and mandation of services to focused, local action, supporting smokers particularly in disadvantaged groups, to quit”.xli

The priorities in this strategic plan come out of the recommendations in the national strategy A Smokefree Generation: A tobacco Control Plan for Englandxlii the progress made on implementing the previous tobacco control strategic plan for Hertfordshire 2016-2018, the NHS Long Term Planxliii and in consultation with members of Hertfordshire’s Tobacco Control Alliance and in reference to NICE guidance (see Appendix 2).

Tobacco Control Ambitions for Hertfordshire:

1. Ensure that all partner organisations are committed to improving the health of their workforce and the people they serve.

2. All front line staff to have the skills, knowledge and confidence to raise the issue of healthy lifestyles and encourage and support positive behaviour change (Make Every Contact Count).xliv

3. Reduce the smoking prevalence of smoking in routine and manual occupations from a baseline of 24.6% in 2017 to less than 20% by 2021:

Work in areas with higher levels of health inequalities and deprivation (focus on the 20% most deprived MSOAs in Hertfordshire)

Reduce smoking in the working age population (focus on organisations with higher numbers of R&M occupations and BME groups)

Promotion of tobacco harm reduction – including swapping to electronic cigarettes Effective campaign delivery with all partners including ‘Stoptober’, ‘One You’, and

other related campaigns that promote healthy lifestyles Promote Smokefree homes and cars Promote Smokefree environments with all partner organisations Ensure that unemployed and homeless people have access to behavioural support

to improve their health including stop smoking services Support carers, and people that they care for, to stop smoking or reduce the harm

from tobacco

4. Mental Health:Ensure that people with mental health conditions are offered the same opportunities to improve their physical health as people without a mental health condition.Reduce smoking prevalence in people with a mental health condition from a baseline of 35.7% in 2017 to less than 30% by 2021 (16% reduction).

Ensure that there is parity of esteem in delivering MECC and offering healthy lifestyle advice, and referral and support to all mental health service users

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Work with HPfT, community/voluntary organisations and primary care to identify, advise and support mental health clients to quit smoking

Ensure that prisoners and offenders (who have a high incidence of mental health problems) are offered help to quit smoking

Ensure that drug and alcohol service users are offered advice and support to quit smoking or reduce the harm from tobacco

Deliver bespoke training to organisations that work with mental health service users Provide more intensive support as required to support mental health service users

to improve their physical health Ensure that there are robust referral pathways into lifestyle services and that

outcomes can be measured Ensure that there are continuous improvements in the quantity and quality of stop

smoking services provided to mental health service users.

3. Smoking in Pregnancy: Reduce the prevalence of women who are known to be smoking at the time of delivery (SATOD) from 7.1% in 2017/18 to 6.4% by 2020/21 (10% reduction)

Ensure that maternity services and other partners are fully engaged with the above ambition to reduce smoking prevalence in pregnancy

Ensure that all partners and organisations that work with families and pregnant women are engaged with the Saving Babies’ Lives Care Bundlexlv (reducing smoking in pregnancy)

Deliver bespoke training to all midwives, ensuring that they have the skills, knowledge and confidence to identify all pregnant women who smoke through carbon monoxide (CO) testing at booking and throughout the care pathway for known smokers

Ensure that maternity services have the resources to deliver CO testing and promote stop smoking services (e.g. Love Your Bump)

Ensure that there are continuous improvements in the quality of stop smoking services available to pregnant smokers and their families.

4. Reduce Risky Behaviours in Secondary Care

Work with the CCGs and commissioners to ensure that there are Public Health metrics (healthy lifestyles) in place with all secondary care providers (WHHT, ENHT, HCT, CLCH and HPfT)

Support NHS providers in delivering the prevention agenda/promoting healthy lifestyles as outlined in the NHS Long Term Planxlvi (Smokefree hospitals, access to treatment and support to quit smoking, delivering MECC)

Deliver intensive stop smoking support to smokers with long term conditions (e.g. people with cardiovascular disease, dementia, kidney disease, respiratory conditions, cancer, diabetes) and people prior to planned admission to hospital)

5. Prevent access to illegal and illicit tobacco Prevent sales of electronic cigarettes and tobacco to young people under the age of

18 Support the work of Hertfordshire Trading Standards in identifying sources of illegal

tobacco and dealing with offenders.

The tobacco control action plan to deliver the above priorities can be found at Appendix 3.

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Referencesi Hertfordshire Tobacco Control Strategic Plan 2016-2018. Available at https://www.hertfordshire.gov.uk/media-library/documents/public-health/professionals/a-tobacco-control-strategic-plan-for-hertfordshire-2016-2018.pdf

ii NHS Digital (2017a) Statistics on Smoking. Available at: http://www.content.digital.nhs.uk/catalogue/PUB24228

iii Department of Health (2017) Towards a Smokefree Generation. A Tobacco Control Plan for England. Available at: Towards a smoke-free generation: tobacco control plan for England - GOV.UK

iv The NHS Long Term Plan (2019) Available at: https://www.longtermplan.nhs.uk/

v Hertfordshire Health and Wellbeing Strategy 2016-2020 https://www.hertfordshire.gov.uk/media-library/documents/about-the-council/partnerships/hertfordshire-health-and-wellbeing-strategy-2016-–-2020.pdf

vi NHS 5 year Forward View https://www.kingsfund.org.uk/publications/implementing-nhs-five-year-forward-view?gclid=EAIaIQobChMIkImrl93I4QIVr7_tCh15hg9AEAAYASAAEgK8ZPD_BwE

vii The NHS Long Term Plan (2019) Available at: https://www.longtermplan.nhs.uk/

viii Department of Health (2017) Towards a Smokefree Generation. A Tobacco Control Plan for England. Available at: Towards a smoke-free generation: tobacco control plan for England - GOV.UK

ix The NHS Long Term Plan (2019) Available at: https://www.longtermplan.nhs.uk/

x Department of Health (2017) Towards a Smokefree Generation. A Tobacco Control Plan for England. Available at: Towards a smoke-free generation: tobacco control plan for England - GOV.UK

xi NHS Digital. 'Smoking, drinking and drug use among young people in England'. 2014. Table 2.3b

xii Office for National Statistics. 'Annual Population Survey 2017'. Available at Public Health England Tobacco Control Profiles: http://www.tobaccoprofiles.info/tobacco-control xiii NHS Long Term Plan https://www.england.nhs.uk/long-term-plan

xiv Public Health England (2017) Tobacco Profiles, Available at https://fingertips.phe.org.uk/profile/public-health-outcomes-framework/data xv ASH (2014) Research report: Secondhand smoke, the impact on children cited in ASH (2015) Smoking still kills: protecting children, reducing inequalities. Available at: http://ash.org.uk/information-and-resources/reports-submissions/reports/smoking-still-kills/

xvi YouGov and ASH. Smokefree Youth Great Britain Survey, 2016.

xvii Smoke-free (Private Vehicles) Regulations (2015). Available here: http://www.legislation.gov.uk/ukdsi/2015/9780111126004/contents

xviii Robinson S & Bugler C (2010) Smoking and drinking among adults, 2008. General Lifestyle Survey 2008.. Office for National Statistics (ONS) cited in ASH (2015) Smoking

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still kills: protecting children, reducing inequalities. Available at: http://ash.org.uk/information-and-resources/reports- submissions/reports/smoking-still-kills/

xix Health and Social Care Information Centre (2014) Smoking, drinking and drug use in young people in England in 2014. Available at: http://content.digital.nhs.uk/catalogue/PUB17879

xx Health and Social Care Information Centre (2014) Smoking, drinking and drug use in young people in England in 2014. Available at: http://content.digital.nhs.uk/catalogue/PUB17879

xxi Hertfordshire Health Related Behaviour Survey. Available at https://www.hertshealthevidence.org/documents/thematic/hrbshealthylifestyles-hertfordshire-briefing-2018.pdf

xxii Hertfordshire Health Related Behaviour Survey. Available at https://www.hertshealthevidence.org/documents/thematic/hrbshealthylifestyles-hertfordshire-briefing-2018.pdf

xxiii UK Centre for Tobacco and Alcohol Studies, Public Health England, Action on Smoking and Health, and the DECIPHer Centre at the University of Cardiff http://home.bt.com/news/uk-news/e-cigarette-use-by-teenagers-doesnt-lead-to-smoking-experts-state-11364207855061

xxiv https://digital.nhs.uk/data-and-information/publications/statistical/health-and-wellbeing-of-15-year-olds-in-england/main-findings---2014

xxv ASSIST-Decipher http://decipher.uk.net/research-page/assist/

xxvi Zatonski, W. et al. (2012) Tobacco smoking in counties of the European Union. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22742786

xxvii ASH (2016 c) Smoking and Mental Health. Available at: http://ash.org.uk/category/information-and-resources/fact-sheets/

xxviii Royal College of Physicians, and Royal College of Psychiatrists.(2013) Smoking and mental health. London: RCP, Royal College of Psychiatrists Council Report CR178. Available at: http://shop.rcplondon.ac.uk/products/smoking-and-mental-health?variant=6638049733

xxix (Heidari et al, 2014 and Eadie et al., 2012). The smoking rate among juvenile prisoners is higher (than adult prisoners) with 89% stating that they smoked before coming to prison (Heidari et al, 2014).

xxx NHS Digital (2017a) Statistics on Smoking. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-smoking

xxxi ASH (September 2014) Factsheet: Stopping smoking and the benefits and aides to quitting. Available at: http://ash.org.uk/category/information-and-resources/fact-sheets/xxxii NHS Digital (2017a) Statistics on Smoking.

Available at: https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-smoking

xxxiii ASH (2017). Available at: http://ash.org.uk/category/information-and-resources/fact-sheets/

xxxiv Public Health England (2017) Tobacco Profiles, Available at

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https://fingertips.phe.org.uk/profile/public-health-outcomes-framework/data xxxv NHS Digital (2016, 2017) Statistics on Smoking. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-smoking

xxxvi ASH Smoking Cessation & Treatment. Available at: http://ash.org.uk/category/information-and-resources/fact-sheets/ xxxvii Department of Health (2017) Towards a Smokefree Generation. A Tobacco Control Plan for England. Available at: Towards a smoke-free generation: tobacco control plan for England - GOV.UK

xxxviii The NHS Long Term Plan (2019) Available at: https://www.longtermplan.nhs.uk/

xxxix Hertfordshire Health and Wellbeing Strategy 2016-2020 https://www.hertfordshire.gov.uk/media-library/documents/about-the-council/partnerships/hertfordshire-health-and-wellbeing-strategy-2016-–-2020.pdf

xl http://www.hertsdirect.org/your-council/hcc/partnerwork/hwb/

xli Department of Health (2017) Towards a Smokefree Generation. A Tobacco Control Plan for England. Available at: Towards a smoke-free generation: tobacco control plan for England - GOV.UK

xlii Department of Health (2017) Towards a Smokefree Generation. A Tobacco Control Plan for England. Available at: Towards a smoke-free generation: tobacco control plan for England - GOV.UK

xliii The NHS Long Term Plan (2019) Available at: https://www.longtermplan.nhs.uk/

xliv Make Every Contact Count https://www.makingeverycontactcount.co.uk/

xlv Saving Babies’ Lives Care Bundle https://www.england.nhs.uk/mat-transformation/saving-babies/

xlvi NHS Long Term Plan https://www.england.nhs.uk/long-term-plan/