Smokefree Camden and Islington 2016-2021democracy.islington.gov.uk/documents/s6756/Smokefree... · 2016-01-12 · Smoking litter: Cleaning up cigarette-related litter is a significant

SmokefreeCamden and Islington2016-2021

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Contents

1 Foreword 3

2 Executive summary 4

4 Introduction 15

5 Smoking still matters in Camden and Islington 18

6 Closing the gateways in 25

7 Helping people out 28 7.1 Supporting those who help smokers quit 28 7.2 Smokers with long term conditions 31 7.3 Smokers with mental health conditions 33 7.4 SmokersinIslington’smaleandfemaleprisons 35 7.5 Smokinginpregnancyandtheearlyyears 37 7.6 Young people 39

8 Reducing related harm 43 8.1 Smokefreeenvironments 43 8.2 Smoking litter 46 8.3 Illicit tobacco 47 8.4 Shisha 488.5 Electroniccigarettes 50

9 Conclusion 54

3 Summary of recommendations 8

Project Team 55

Smokefree Camden and Islington Strategy 2016-2021 3

We welcome the Camden and Islington TobaccoControlStrategy2016-2021whichlaysoutourboldambitiontobecomesmokefreeby2030.Thestrategysetsouthow,overthenextfiveyears,wewillworktogether across Camden and Islington to reducethenumberofpeoplewhosmoke.Ouraimisthatthenumberofsmokersinthepopulationwillfallto13%inCamdenand16%in Islington.

Thestrategysetsouttheplanforkeepingourchildrenandyoungpeoplesafefromtheharmsoftobacco.Itlaysouthowweintendtoprovidesupportforthosewhoalreadysmokeand want to quit and how we intend to create a cleanandsafeenvironmentwhileencouraginglocal businesses to support our work. We welcome our two boroughs working together. Wewanttofocusonthosecommunitiesingreatest need and work with residents to raise awarenessoftheissuesandwhatcanbe

done.MembersofCamdenandIslington’sSmokefreeAlliancehaveproposedawidearrayofrecommendationstoachievethesestrategicobjectives.

Insummary,thisnewstrategyfocusesontheneedforagoodstartinlifeforourchildrenandyoungpeopletostopthemtakingupsmoking,oneffortstotackletheunequalharmsrelatedtosmokingsufferedbysomeofourmostdisadvantagedand,inparticularonworking with those partners who, through their everydayactivities,areoftenbestplacedtohelp smokers quit.

Wewouldencourageyoutosupportthisstrategy’swork,supportingCamdenandIslingtoninourjourneytobeingsmokefreeby2030.

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Foreword

Councillor Janet BurgessDeputyLeaderandExecutiveMemberHealthand WellbeingLondonBoroughofIslington

Councillor Sally GimsonCabinetMemberforAdultSocialforCareandHealthLondonBoroughofCamden

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VisionBy2030ourvisionisforanewgenerationgrowing up in Camden and Islington where virtuallyno-onesmokes.

By2021,ourvisionisthat:■■ Fewerthan16%ofpeopleinIslingtonand13%ofpeopleinCamdenwillsmoke.

■■ Fewerpeoplewillsufferearlypreventabledeathsorlong-termillnessanddisabilitydue to smoking.

■■ Young people will understand the harms oftobaccoandshishauseandmakethechoice not to start smoking or to quit.

■■ Familieswillchoosetobesmokefreeandgivethebeststartinlifefortheirchildren.

■■ Approximately19,000morepeoplewholive,work,studyoraccesshealthservicesinCamdenandIslingtonwillhavebeensupported to stop smoking tobacco.

■■ Communitieswillbeprotectedfromtheharmsofcriminalactivitylinkedtoillegaltobacco sales.

■■ Thecostandimpactoftobaccolitterontheenvironmentwillbeminimised.

■■ Smokefreeoutdoorenvironmentswillhavebecomethenormwherechildrenstudyandplayandwherepeopleaccesshealthandsocialcareservices.

Introduction TheCamdenandIslingtonSmokefreeAlliance(CISA)wasformedinSpring2014toaddresstobaccocontrolissuesjointlyinbothboroughs.TheAllianceisapartnershipofvariousorganisationsacrossCamdenandIslington.

Overarching priorities1. Close the gateways in: Educateyoung

peopleandfamiliesabouttheharmsoftobaccosmokingandtherisksofshishause,tohelpyoungpeoplechoosenottosmoke.

2. Help people out: Provideeffectivesupportforsmokerstoquitthatalsoreachesthosemostatriskofpoorhealthorhealthinequalitytochangetheirsmokingbehaviours.Looktothefuture,whichincludescautiouslyharnessingthepotentialofelectroniccigarettes.

3. Reduce related harm: Ensurethatfamiliesareawareofthedangersofexposuretosecond-handsmoke;achieveacleanerenvironment,disruptillegalsalesandenforcesmokefreelegislation.

Smoking still matters in Camden and IslingtonSmoking still matters to Camden and Islington because it remains the single biggest preventableriskfactorforpoorhealthandprematuredeath.ThenumberofpeoplewhosmokeinCamdenandparticularly,inIslington,

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Executive Summary


hasremainedstubbornlystablesince2010,eventhoughprevalencehasbeensteadilydecreasingnationally.

In2014therewerearound32,100adultsmokersinCamden(17%)and40,400adultsmokersinIslington(22%).Ratesofsmokingremain much higher in certain population groups,disproportionallyaffectingthosealreadydisadvantaged.Theseincludepeoplewhoarelessaffluent,certainblackandethnicminoritycommunities,LGBTcommunities,peoplelivingwithlong-termconditions,including mental health, and people in the criminaljusticesystem.Thechallengeinthecomingyearswillbetotackletheinequalitiescausedbysmokinginourcommunities.

Ourtargetistoreducetheproportionofadultsmokersto13%inCamdenand16%inIslingtonby2021.Thisisaround7,600lesssmokersinCamdenand11,300lesssmokersinIslingtoninfiveyears.Weaimtodrivereductionsinprevalencebyatleastaquarterspecificallyincommunitieswithhighersmoking rates.

Smokingisstillakiller;halfofalllong-termsmokersdieofasmoking-relatedillness.Smokingcannabiswithtobaccogreatlyincreases the harms to health. In Camden, therearearound217smoking-relateddeathseachyearand225deathsinIslington.

These are ambitious goals which will require boldaction.EveryonemustplaytheirparttoachievethevisionofasmokefreeCamdenand Islington and reduce the impacts oftobaccoamongstthemostaffectedcommunities.

Closing the gateways in Smokingusuallystartsatanearlyageand most smokers start in childhood and developalife-longhabit.Thatiswhyitisessentialtoclosethegatewaysintosmoking,forchildrenandyoungpeople,tocreateasmokefreegeneration.Long-termsmokingiscloselyassociatedwithinequalityandsocialexclusion,withchildrenfromlowincomebackgroundsmostlikelytobesmokersinadulthood.

Themaininfluenceforchildrenstartingtosmokeistheirimmediatefamily.Therefore,helpingadultsinthefamilytostopsmokingandcreatingsmokefreeenvironmentswherechildrenliveandplayareessentialpartsofthisstrategyandwillcontributetofewerchildrenstartingtosmokeandmaycontributetoanewgenerationofpeopleaddictedtonicotine.

PleaseseethefulllistofRecommendationsforthoserelatedto‘closingthegatewaysin’.

Helping people outSupporting those who help smokers quit: Stopsmokingservicesprovidepharmacotherapyandusebehaviourchangetechniques to help smokers quit in the most effectiveway.InthelasttwoyearsthenumberofpeopleaccessingNHSstopsmokingserviceshasdeclinednationallyforanumberofreasons,includingtheuseofe-cigarettes.LondonClinicalSenate’sproject,‘HelpingSmokersQuit’hasparticularlyhighlightedtheroleforclinicianstomoreroutinelyprovideadviceandsupport,includingappropriatepharmacotherapy,topatientswhosmoke.Thereisalsoaneedforawidervarietyof‘front-line’staffwhocanhelpidentifyresidents

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whosmokeandsignpostthemtorelevantadviceandsupport.Employersalsohavearoletoplayandbenefitfromhelpingstaffquit.

Smokers with long term conditions: Smokingcancontributetothedevelopmentandworseningofseveralhealthconditions.Stoppingsmokinggreatlyimprovesoutcomesforpeoplewiththeseconditions–itisalmostnevertoolatetoquit.Offeringverybriefadvicetosmokerswithlongtermconditions,attheappropriate‘teachablemoments’duringtheircarepathwayhasmanypotentialbenefitsandshouldbeanintegralpartofthemanagementoflongtermconditions,bothinprimaryandsecondarycare.

Smokers with mental health conditions: Smokingprevalenceistwiceascommonamong people with mental health problems, andmoresointhosewithmoresevereillness.People with mental health problems use 42%ofalltobaccoconsumedintheUK,duetoheaviernicotinedependency.However,smokerswithmentalillhealtharejustaslikelyto want to quit as smokers without mental illhealth,butaremorelikelytobeheavilyaddictedtosmokingand,historically,havebeenlesslikelytosucceedwhentheytrytoquit.Smokerswithmentalillhealthoftenneedsubstantiallymoresupporttoquit,includingNicotineReplacementTherapyprovidedoveralongertimeframeandmoreintensivebehaviouralsupport.

Smokers in Islington’s male and female prisons: Smoking rates among prisoners havechangedrelativelylittleinthelastfewdecades:theyareestimatedtobethreetofourtimeshigher(upto80%)thanthegeneralpopulation(18%inEngland).ThePrisonServiceisnowactivelyworkingtowards

prisonsbecomingcompletelysmokefreefollowingtheirexemptionfromthe2007Smokefreelegislation.Adequateprovisionofpharmacotherapywillneedtobeassuredbeforethesmokefreeagendacanberolledacross the whole establishment.

Smoking in pregnancy and the early years:Stoppingsmokingisoneofthemosteffectiveinterventionstoimprovethehealthofmotherandbabyandpreventavoidableinfantmortality.CamdenandIslingtonbothhaveahigherrateofsmokinginpregnancythantheLondonaverage(5.1%):5.5%inCamdenand7.7%inIslington.Stoppingsmokinginpregnancycanbechallenging.Onlyasmallnumberofpregnantwomentakeuptheofferofhelptostopsmoking.Manyofthosewhosuccessfullystopsmokingduringtheirpregnancygobacktosmokingwithinsixmonthsofgivingbirth.

Young people: Smoking is a childhood addiction.Abouttwo-thirdsofadultsmokersreporttheytookupsmokingbeforetheageof18.Theyoungerpeoplearewhentheystartsmokingthegreatertheharmislikelytobe.Earlyinitiationofsmokingisassociatedwithsubsequentheaviersmoking,higherlevelsofdependency,lowerchancesofquittingandhighermortality.Accesstostopsmokingservicesbyteenagesmokershasbeenhistoricallylow.Itisimportanttodevelopinnovativeapproacheswhichwillensureyoungsmokershavethebestpossiblechancestoquitsmoking,beforeitbecomesalife-longhabitandimpactsontheirhealth.

PleaseseethefulllistofRecommendationsforthoserelatedto‘helpingsmokersout’.


Reducing related harmSmokefree environments: Oneoftheaimsofthisstrategyistoprotectchildrenfromtheriskscausedbyexposuretosecondhandsmoke.Itisourambitiontode-normalisesmokingforchildren,bycreatingenvironmentswherechildrenarenotexposedtosmoking:notonlyinthehomebutalsooutsideschoolsandinplaygrounds.

Smoking litter: Cleaningupcigarette-relatedlitterisasignificantproblemintheUK,accountingfor70-90%ofstreetlitterinurban areas. Cigarette butts are the most commonitemoflitterinbothboroughswithanannualstreetcleaningbillbetween£7.5and£9millioninCamdenand£3.5millioninIslington.Thoseresponsiblefordamagingourenvironmentshouldberequiredtopayfortheclean-up,i.e.‘thepolluterpays’.

Illicit tobacco:In2015,itwasestimatedthataround10%ofallcigarettesand39%ofhand-rolledtobaccoconsumedintheUKin2013-14wereillicit.Thecostofbuyingillicittobaccofortheindividualcanbeaslittleashalfthecostoflegitimateproducts.However,theprofitsfromillicittradearepocketedbycriminalnetworks,suchasgangs,whichcausefurtherharmtosocietythroughothercriminalactivitiessuchasdrugsmugglingandhumantrafficking.Cross-borough,andideally,regionalmulti-agencycooperationisneededtotackleillicittobacco trade.

Shisha: In Camden and Islington there is widespreadcompliancewithsmokefreelawssincethelegislationwaswidelywelcomedbythepublicandmostbusinesses.However,recentproliferationofshishapremiseshasseen an increase in businesses allowing

smokinginenclosedspacesincontraventionofthesmokefreelaws.Theproblemisbestaddressedbyacombinationofusereducationastothehealtheffects,earlyadviceto businesses thinking about shisha as a businessmodel,closecommunityliaison,multi-agencyworkingand,wherenecessary,arobustapproachtoenforcementwherethereispersistentnon-compliancewithsmokefreeand other laws.

PleaseseethefulllistofRecommendationsforthoserelatedto‘reducingrelatedharm’.

ConclusionThethreeoverarchingprioritiesclosingthegatewaysin;helpingpeopleoutandreducingrelated harm, are essential and interlocking piecesoftheoverallstrategy.Workineachpriorityareainformsandadvancesworkinothers.Withoutthiscomprehensiveapproach,sustainedoverthelongterm,wecannotdeliverfurtherreductionsinprevalenceandreduce social and health inequalities caused bysmoking.

Workonseveraloftherecommendationsproposedhasalreadystarted.However,manyrecommendations are new and ambitious and willrequirestrongleadershipfromanumberofpartnersandmakingtobaccocontroleveryone’sbusiness.Goingforwardwewillstrengthen and renew partnerships with a clearerfocusonhealthinequalities.TheCISAwill work with the wider stakeholder groups todevelopadeliveryplan,tomoveideasintoactionandachieveresults.

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Summary ofrecommendations

■■ ReducesmokingintheadultpopulationinCamdento13%andIslingtonto16%orlessby2021,withtargetsagreedonanannualbasis.Thisisaround7,600lesssmokersinCamdenand11,300lesssmokersinIslington,infiveyears.

■■ Reducesmokingamongstpregnantwomento3%inCamdenand5%inIslingtonby2021.

■■ Reduceregularandoccasionalsmokingamong15yearoldsto5%inCamdenandto7%inIslingtonby2021.

■■ Reducehealthinequalitiesbyreducingsmokingprevalenceinallkeytargetgroupswithabove-averagesmokingprevalencebyatleast25%fromthe2015baselineby2021.Forexample,wewillreducesmokingintheroutineandmanualsocio-economicgroupto20%(from27%)inCamdenandto29%(from41%)inIslingtonby2021.

Smoking still matters in Camden and Islington

■■ ImplementthehealthrelatedbehaviourquestionnaireinCamdenandIslingtonschoolsandusedataonsmokingtoinformarangeoftargetedinterventions.

■■ Continuetoeducateprimaryandsecondaryschoolchildren,encouragingthemtoconsiderthesocialinfluencesofsmoking,highlightingthehealthrisksandcostsofsmoking,aswellasthesupportavailabletostop.Extendthisworktoincludeenvironmentalandpoliticalimpactsoftobaccouseandtobaccocompanies’tactics,toresonatefurtherwithyoungpeoples’concerns.

■■ Createasmokefreeenvironmentforyoungpeople,familiesandstaffusingtheHealthySettingsAwardsasoneofthedrivers.

■■ Continuetoworkwithteacherstoidentifyyoungsmokersorpupilsatriskofsmokingandimplementpeereducationprogrammes,suchasASSIST,to change attitudes to smoking tobacco and cannabis.

■■ Ensurethatparentsandchildrenareeducatedabouttheharmsofshishasmokingandunderstandtherisksofelectroniccigaretteuse.

Closing the gateways in


■■ WorkwiththeYouthCouncil,theYoungPeople’sHealthForum,YouthHubsandotherpartnerstoexplorewaysofreachingyoungpeopleandensurethesmokefreemessagesareprioritised.

■■ Developatargetedapproachforcomplex/troubledfamilies.■■ WorkwithallCommissionersofchildrenandyoungpeopleservices(includingChildrenandAdolescentMentalHealthServices(CAMHS))to:

� ‘Mainstream’stopsmoking-relatedactivityaspartoftheircommissioningofclinicalcareinlinewithNICEguidance � Ensureadequateresourceallocationforage-appropriatestopsmokingadviceprovision

■■ Workwithclinicalstaffandhospitalserviceprovidersseeinganychildrenandyoungpeopleto:

� RequiremandatorytrainingonatleastVeryBriefAdviceforSmokingCessation(Ask,Advise,Act)forallclinicalstaff

� Considerthewholefamilyforsmokingcessationreferralandsupport � Streamlineinternalreferralsystems(inconjunctionwithCommunityStopSmokingServiceprovision)

■■ Ensuregoodquality,evidence-basedstopsmokingserviceisintegratedintothewiderbehaviourchangeofferavailablewithinbothboroughswhichaimstoimprovethehealthandwellbeingofpeopleinCamdenandIslington.Theseservicesshouldbeaccessibletoallsmokersandparticularlythosefromlowersocio-economicgroupsanddisadvantagedpopulations.

■■ DeveloplocalcommunicationsinitiativesbasedonnationalcampaignslikeStoptoberandNoSmokingDay,topromoteconsistentandcoordinatedmessagesaboutstopsmokingsupportandreachhighprioritygroupsthrougheffective,targetedcommunications.

■■ EnsurethattrainingonprovidingverybriefadviceonsmokingcessationisrequiredofeveryclinicianseeingCamdenandIslingtonpatientsandthatthereisadequateclinicalleadershipineveryNHSorganisation,bothatseniorandward/cliniclevelstosupportthis.

■■ Ensureclinicianswhoprescribearetrainedandcompetenttoprescribesmoking cessation medication.

■■ Ensureaccurateandtimelyinformationaboute-cigaretteusetoreducepublicconfusionabouttherelativerisksofnicotineproductscomparedtotobaccoproductsandallowaninformedchoice.

■■ Increasethenumberofpublicsectorstaffaswellascommunityandvoluntarysectorvolunteersandstaffwhoaretrainedtoprovideverybriefadviceonsmokingcessation.

■■ UseHealthySettingsAwardsasoneofthedriverstoincreasestopsmokinginterventionsbystaffworkingwithyoungpeople.

■■ Supportworkplacehealthandwellbeing,initiallyfocusingonbothboroughs’largestpublicsectoremployers,toreducesmokingamongstemployees.

Helping people out

Support those who help smokers quit

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■■ EngageprimarycareleadssuchasClinicalCommissioningGroup(CCG)clinicalchampions,LocalMedicalCommittee(LMC)andLocalPharmaceuticalCommittee(LPC)representativestoexploreopportunitiesforbetterengagementwithsmokingcessationandsharingbestpracticeinprimarycaretoensurethatpeoplewithlongtermconditionsareroutinelybeingencouragedtoquitsmokingandreceivetheappropriatesupporttodosoinlinewithNICEtobaccoguidance.

■■ WorkwiththeclinicalchampionineverysecondarycaretrustinCamdenand Islington, to lead on helping smokers quit and to consider how the LondonClinicalSenaterecommendationsonverybriefadvicetrainingandCO testing can be implemented.

■■ PromoteadherencetoNICEguidanceontobaccoespeciallyaimedatsecondarycare(acute,maternityandmentalhealthservices),byworkingwithCCGcommissionersandsecondarycareproviders.

■■ Ensureclinicianswhoprescribearetrainedandcompetenttoprescribesmoking cessation medication.

■■ Encourageclinicianstoroutinelyaskaboutcannabisuseaspartoftheirsmoking cessation discussion with their patient.

Smokers with long term conditions

■■ Includestopsmokingsupportininitiativespromotingphysicalhealth(e.g.healthyeating,obesitysupport,physicalactivity)formentalhealthserviceusers,includingyoungpeople.

■■ Ensurespecialiststopsmokingservicestailoredtosmokerswithmentalillhealthareavailableinresidentialcare,in-patientsettingsandthoselivingindependentlythecommunity,acrossCamdenandIslington.

■■ Ensureanetworkoflevel2trainedstopsmokingadvisorsexistsacrossallmentalhealthsecondaryandcommunitycaresettings.

■■ Allstaffinmentalhealthservicesaretrainedinverybriefadviceandsecond-handsmoke.

■■ Workwiththefiredepartmenttoensurethatresidentialcarehomescomplywithfiresafetystandardstominimisetherisksforresidentswhocontinue to smoke

■■ Ensurethatinlongtermresidentialcarehomesallsmokingtakesplaceoutside.

■■ Ensureclinicianswhoprescribeinmentalhealthsettingsaretrainedandcompetent to prescribe smoking cessation medication.

Smokers with Mental Health conditions


■■ Reducesmokingamongstpregnantwomento3%inCamdenand5%inIslingtonby2021.

■■ PromoteadherencetoNICEguidanceontobaccoinallmaternityservicesinCamdenandIslingtoncaringforpregnantwomenandfollowingchildbirth.

■■ Ensurepregnantwomenaccessingmaternitycareareroutinelyscreenedwithacarbonmonoxide(CO)monitorbymidwiferystaffwhoareequipped,trained and with adequate time, and that pregnant women who smoke are referredtostopsmokingservices,aspartoftheircarepathway.

■■ Earlyyearsservicescommissioningshouldexploretheroleofhealthvisitorsandotherprofessionalsinsupportingpregnantwomenandfamilieswithyoungchildrentostopsmoking.

Smoking in pregnancy

■■ Developstrongerlinksbetweenprisonandin-patientpsychiatricservicesandthecommunity-basedstopsmokingservicetoensurecontinuityofcare,whenprisonersreturntothecommunity.

■■ Explorecommissioningan“inreach”service,sothatwhenthepersonisdischargedtheycancontinuetoreceivestopsmokingsupportviathesameservice.

■■ Establishlinksbetweenhomelessprojects,psychiatriccareandtheprisonservicetoensurecontinuityofcareforCamdenandIslingtonresidentswhocyclethroughthesethreeservices.

■■ Strengthenthestopsmokingprovisionacrossthewholecriminaljusticepathway,sothatthoseleavingprisonshaveaccesstosupport.

■■ EnsurethatprisonerswhoaretransferredtoHMPPentonvilleandHMPHolloway(untilJune2016)whilsttheyarequittingsmokingcontinuetoreceivestopsmokingsupportanddonothavetogoontoawaitinglist.

■■ Allpsychiatriccarestaffinallsettings,allprisonstaffandhomelesssupportworkersshouldbetrainedinverybriefadviceinsmokingcessationandapprisedofthedangersofsecondhandsmoke.AnyCQUINorequivalentqualityimprovementincentiveforpsychiatriccarestaffcouldensurethatthetrainingismandatory.

■■ Ensureevidence-basedtreatmentsandstafftrainingarecommissionedforHMPPentonville.

■■ SupportHMPPentonvilletobecomesmokefreeanddevelopanupdatedsmokefreestrategy.

Smokers in Islington’s female and male prisons

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■■ Raiseawarenessofthebanofsmokingincarswithchildren,withparents,childrenandstaff(trafficwardens,roadsafetyunits,sustainabletravelofficers).

■■ Continuetosupportnationalsmokefreehomesandcarsawarenesscampaigns.

■■ Continuetode-normalisesmokingbyreducingsmokingaroundchildren:smokingandcigarettelitterisoutofsightofschoolgatesandplaygroundsinCouncilparks,housingestatesandadventureplaygrounds.Thiswork,alreadyunderwayinIslingtonwillbedevelopedinCamden.Ifsuccessful,inbothboroughs,wewilllooktoexpandthenumberandnatureofpublicspacese.g.publicsquares,tofurtherde-normalisesmokinginpublicforall ages.

■■ WorkwithpartnersofIslington’s“First21Months”andCamden’s“AThousandandOneDays”programmeteams,toincreasetheuptakeofsmokefreehomes.

■■ UseHealthySettingsAwardsasoneofthedriverstocreatesmokefreeenvironmentsforyoungpeopleandtheirfamilies.

■■ WorkwithpartnerstoincreasesmokefreeoutdoorenvironmentsinCamdenandIslington,aspartoforganisationalsmokefreepolicies;suchasimplementingsmokefreehospitalgrounds.

■■ WorkwithemployerstosupportthesmokefreeelementoftheLondonHealthyWorkplaceCharterawards.

Reducing related harm

Smokefree environ-ments

■■ Understandtheneedsofstaffworkinginchildren’scentresandschoolswhentalkingtoparentsandchildrenwhosmokeandprovidetailor-madetrainingtoenablethoseconversations.

■■ Showcasesuccessesofstaffworkinginchallengingsettingswhereviewson smoking are entrenched and share good practice.

■■ Targetvulnerablechildrenwhosmoke,byworkingwithsocialservices,youthoffendingservice,pupilreferralunitsandlookedafterchildrennursesandenablestafftogiveappropriateadviceandsupport.

■■ Createinnovativepartnershipstoreachyoungpeople16orolder,suchaswithstudentunions,leisurecentresandprivatelyownedgyms.

■■ Conductinsightresearchtotargetresourceswhereyoungpeoplearelikelytogetadviceandsupportaboutstoppingsmoking.

■■ WorkwiththeyouthoffendingserviceinCamdenandIslingtontopromotesmokingcessationtoyoungoffenders.

■■ Encourageresponsibleretailerpractices,suchasnotsellingtobacconearschools.

■■ Ensuretobaccoretailersnearschoolsarefullycompliantwithnewlegislationontobaccodisplaysinshops,asapriority.

■■ Exploretheprovisionofspecialiststopsmokingservicesforchildren,youngpeopleandtheirfamilies.

Young people


£■■ CamdenandIslingtonTradingStandardsshouldcontinuetoplayaleadroleinthenewlyestablishedNorthEastNorthCentralLondonIllicitTobaccoClusterGrouptodevelopacross-boroughapproachtodealingwiththeproblemofillicittobaccosales.ThegroupincludesTradingStandardsrepresentativesfromCamden,Islington,Haringey,Enfield,Hackney,WalthamForestandTowerHamlets.

■■ FurtherdeveloplinkswiththeSouthEastLondonIllicitTobaccoGroupwiththelong-termaimofdevelopingapan-Londonapproachtodealingwiththesaleofillicittobacco,toworkmorecloselywithHMRCandBorderControl.

■■ Continuetobuildonsuccessesinreducingthenumberofunderagesalesandtheamountofillicittobaccoonsale,bycontinuingstrongenforcementandcontinuetoidentifypriorityareastotargetanddevelopamethodforlocalresidentstoprovideintelligence.

■■ Workinpartnershipwiththeschools’healthandwellbeingteamstoraiseawarenessaboutillicittobaccoamongstyoungpeople(andtheirparents)andtoremindyoungpeoplethatshishaistobacco–itisnotalwayslabelledthatwayandyoungpeopleinparticularareunawarethattheyareconsumingtobacco,oftenillegallyimported.

Illicit tobacco

■■ Continueworkingwithsmokersofallagestoreducesmoking-relatedlitterinCamdenandIslingtonwithacombinationofeducationandenforcementactivities.

■■ ContinuepartnershipworkbetweenCamdenEnvironmentservicesandlocalschoolstoraiseawarenessamongstouryoungerresidentsabouttheimpactoflitterintheboroughandshowthemthattobaccoalsodamagestheenvironment.

■■ Introduceaninnovativescheme,alreadyinoperationinotherLondonlocalauthorities,suchasEnfieldandHaringey:asmokerwhoisissuedafixedpenaltynoticeforlitteringsmokingmaterialcancompleteacoursewiththelocalStopSmokingServiceasanalternativetoafine.

■■ Workwithlocalbusinessestoensurethatstaffonsmokingbreaksdisposecigarettebuttsresponsiblyandcustomersdonotlitterwhensittinginoutdoorareas,suchaspubsandcafes.

Smoking litter

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■■ InlinewithPHEguidance,welcometheuseofECsbyexistingsmokerswhomakeaquitattemptandsupportsmokersfurthertoquittobaccoproductsusingourevidence-basedstopsmokingservices.

■■ Respondpro-activelytoemergingnewevidenceonECsandtofutureavailabilityoflicensedproductstobeusedasstopsmokingaids.

■■ EnsureourstopsmokingservicesandallprofessionalsinCamdenandIslingtonprovidingLevel2stopsmokingadviceareequippedtogiveup-to-dateinformationabouttherelativerisksofnicotineandallnicotine-containingproducts(includingECs),basedonnationalguidanceandregulation.

■■ ContinuetomonitorthesaleofECsandensurethatsellerscomplywithnewandexistinglegislation(forexampleunder-agesales)andwithsafetyregulations,inparticularregardingunsafechargers.ExplorepotentialforpartnershipworkwiththeFireService.

Electronic cigarettes

■■ CamdenandIslingtonshouldcontinuetohaveaproactiveandpreventivemulti-teamapproachtomonitorshishapremiseswithroutinevisits,untiltheycomplywithlegislationorelsestopsellingshisha.Theyshouldcontinue to take action when shisha premises are breaking the law, such asallowingsmokingshishaand/orcigarettesindoors,ornotprovidingtherequiredwarninglabelsassociatedwiththesaleoftobacco.Theyshouldcontinuetoidentifyshishacafeswhichroutinelyallowunderagecustomersandtakeenforcementaction.

■■ InCamden,mapthelocationofshishacafestoidentifytheirproximitytolocalschools.TradingStandardsandthehealthyschoolsteamshouldraise awareness with children and their parents that shisha tobacco is not alwayslabelledthatway,soyoungpeopleinparticularmaybeunawaretheyareconsumingtobacco.

Shisha


ThefirsteverjointCamdenandIslingtonTobacco Control Summit took place on 13 February2014.TheeventwashostedbytheLeadMembersforHealthandAdultSocialCare in both boroughs and brought together stafffromPublicHealth,Environment,PublicProtection,SchoolImprovementServicein both Camden and Islington Councils, as wellastheStopSmokingServiceproviders,ClinicalCommissioningGroup,FireServiceandPublicHealthEngland.Thekeypriorityareas to address the damage caused to the localcommunitybytobaccowereagreedintheTobaccoControlSummit:reducingthenumberofyoungpeopletakingupsmoking;supporting tobacco users to quit using the mosteffectivemeanspossible;andreducingthewiderharmscausedtothecommunityatlarge,suchassecond-handsmokeinthehome,cigarettelitterandfires.

TherewasstrongsupportforCamdenandIslington to work in partnership to address tobaccocontrolissuesinthefuture,includingdevelopingajointstrategy,governancearrangementsfortobaccocontrolandanAllianceoflocalstakeholderswhowilldeliverthegoalsofthisstrategy,calledtheCamdenandIslingtonSmokefreeAlliance(CISA).TheCISAwasformedinSpring2014andatwo-yeartobaccocontrolactionplanwasdeveloped.

BothCamdenandIslingtonCouncilssignedtheLocalGovernmentDeclarationonTobaccoControlinMarch2014,confirmingtheircommitment to act in order to reduce smoking in our communities, as well as protect tobacco controlworkfromthevestedinterestsofthetobaccoindustry.A

TheCISAisworkingtowardsrealisingasmokefreeBCamdenandIslingtonby2030;thatis,towardsagenerationofpeoplegrowingupwherevirtuallyno-onesmokes.

This Camden and Islington Tobacco Control strategyoutlinestheambitionsfortobaccocontrolinCamdenandIslingtonin2016-21. It will be updated in line with national policy,asnecessary.Ouraimisthatsmokingprevalenceintheadultpopulationisreducedto13%inCamdenand16%inIslingtonby2021,contributingtotheambitionforLondontohavethelowestsmokingrateglobally(amongallcitiesover5millioninhabitants).1

The Camden and Islington Tobacco Control strategysetsoutarangeofrecommendationsforthenextfiveyears,acrossthefollowingthreethemes:

4

Introduction

A.Thisisinaccordancewitharticle5.3oftheWHOframeworkconventionontobaccocontrol.B.Forthepurposesofthisstrategy,asmokefreesocietyisdefinedas5%orlessofthepopulationbeingcurrent

smokers.

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1. Closing the gateways in Educatingchildren,youngpeopleandfamiliesabouttheharmsoftobaccosmokingandtherisksofshishauseandsupporting them to consider the social influencesofsmoking,inordertohelpchildrenandyoungpeopletochoosenotto smoke.

2. Helping people out Providingeffectivesupportforsmokersto quit that also reaches those most at riskofpoorhealthorhealthinequalitytochangetheirsmokingbehaviours.Lookingtothefuture,thisincludescautiouslyharnessingthepotentialofelectroniccigarettes(e-cigarettes).

3. Reducing related harm Ensuringthatfamiliesareawareofthedangersofexposuretosecond-handsmoke;achievingacleanerenvironment,disruptingillegalsalesandenforcingsmokefreelegislation.

However,withinthesethemes,wehaveparticular priorities. We recognise that most people become addicted to smoking tobaccowhilsttheyareyoung.Therefore,weneedtofocusmuchofourenergyonpromotingasmoke-freestartinlifeandchildhood.Inaddition,smokingdoesnotaffectcommunitiesfairly–thosewhoarepoorerorcomefromcertainminoritygroupsaremorelikelytosmokeandthereforebeaffecteddisproportionatelybythenegativeeffectsofsmoking.Andfinally,ourhealthcarepartnersareoftenuniquelypositionedtoinfluenceandencouragesmokerstoquit;wemustsupportandinvigoratethesecliniciansforthischallenge.Butweareclear–whileweaspiretobesmokefreeandanti-smoking,wearenotanti-smokerandinfactwanttosupportsmokers to tackle their nicotine addiction. TheCISAwillrealiseasmokefreeCamdenandIslingtonthroughthefollowing:

Closing the gateways inEducating young

people

Reducingrelated harm

Achieving cleaner smokefreeenvironments and

disrupting illegal sales

Helping people outSupporting smokers

to quit


1. Evidence-based interventions and recommendations Intacklingacomplex,multifacetedissue such as smoking where multiple interventionsareneeded,itcanbeverydifficulttoteaseoutclearevidenceofimpact. We recognise this is a limitation whendealingwithsuchacomplex issue.Wewilllookattheavailableevidenceandrecommendationsdrawnfrombothlocalandnationalpublications.23456 When possible, we will work with partners to use evaluationtoolstoassesswhatworks.We will draw on tools such as the PublicHealthEnglandjointstrategicneedsassessment(JSNA)packontobaccocontroltosupporteffectiveimplementationofourplans.

2. Partnership working CamdenandIslingtonSmokefreeAlliancepartnerswillworktogethertoachievetheambitionsoutlinedinthisstrategyandwillengagenewpartnersfromrelevantCouncildepartments,statutorybodiesandthecommunitytofurthersupportthiswork.

3. Making best use of the resources available Byworkingwithpartnersinbothboroughs(andacrossLondonwhereappropriate)wewillaimtomakebestuseofourcombinedresources-reducingduplicationandtakingadvantageofeconomiesofscalewherepossible.

4. Helping those who need help the most Afocusoncommunitieswithhighlevelsofdeprivationwillaimtoreducehealthinequalities.

5. A communications strategy Council communications departments in both boroughs will coordinate and enhancesmokefreemessagesandsupportborough-widecommunicationcampaigns.

Toachievethis,CISApartnerswilldevelopadetaileddeliveryplaneachyeartoensureweareontracktoachievetherecommendationssetoutinthisstrategyacrossthethreekeystrategic areas.

References1. LondonHealthCommission.BetterHealth

forLondon.2014.Availablefrom:http://www.londonhealthcommission.org.uk/wp-content/uploads/London-Health-Commission_Better-Health-for-London.pdf

2. NationalInstituteforHealthandClinicalExcellence.Smoking.ReducingTobaccoUse.QS82;2015[Online].Availablefrom:http://www.nice.org.uk/guidance/qs82/resources/guidance-smoking-reducing-tobacco-use-pdf

3. NationalInstituteforHealthandClinicalExcellence.SmokingCessation:SupportingPeopletoStopSmoking.QS43;2015[Online].Availablefrom:http://www.nice.org.uk/guidance/qs43/resources/guidance-smoking-cessation-supporting-people-to-stop-smoking-pdf

4. NationalInstituteforHealthandClinicalExcellence.Smoking:HarmReduction.QS92;2015[Online].Availablefrom:http://www.nice.org.uk/guidance/qs92/resources/guidance-smoking-harm-reduction-pdf

5. ActionforSmokingandHealth.SmokingStillKills:ProtectingChildren,ReducingInequalities.2015.Availablefromhttp://www.ash.org.uk/smokingstillkills

6. DepartmentofHealth.HealthyLivesHealthyPeople:ATobaccoControlPlanforEngland.2011.Availablefrom:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213757/dh_124960.pdf

18

MoredetailedevidenceisavailableinChapters6-8.

ToindividualsStill the biggest single preventable risk factor DespiteasignificantdropinsmokingprevalenceinEnglandinthelasttenyears,smokingremainsthebiggestsinglepreventableriskfactorforpoorhealthandprematuredeath.TheLondonHealthCommissionreportoutlinedtheambitionsforasmokefreeLondontoreducetobacco-relatedavoidabledeaths,currentlyestimatedatmorethan8,000ayearinLondon.1

Smoking prevalence Eventhoughtheproportionofpeoplewhosmoke has declined in Camden and Islington comparedtotenyearsago(23.5%inCamdenand27.5%inIslingtonestimatedin2003-5),A datafrom2010to2014showthatprevalencehasstoppeddecreasingandmaystillbeabovetheLondonandEnglandaverages.

Since2010theestimatedsmokingprevalenceBhasgraduallydecreasedinLondonandEnglandonaverage.

InIslingtonsmokingprevalencehasremainedstablesince2010,wideningthegapwiththeregionalandnationalaverages.In2014theestimatedprevalencewassignificantlyhigherinIslington(22%)comparedtoLondon(17%)andEngland(18%)(Figure1.1).Therearearound40,400adultsmokersinIslington.

InCamdensmokingprevalencehasalsoremained stableC since2010.In2014theestimatedprevalenceforCamden(17%)wasnotsignificantlydifferenttoLondon(also17%)orEngland(18%)(Figure1.2).Thereareapproximately32,100adultsmokersinCamden.2

5

Smoking still mattersin Camden and Islington

A.Althoughdataavailablefor2003-5arefromdifferentsourcesthandatapost2010andcannotbecompareddirectly,itislogicaltoassumethatprevalencehasfallensignificantlyinCamdenandIslingtoninlinewithnational trends.

B.Thesmokingprevalencefor2010to2014isestimatedfiguresdrawnfromtheIntegratedHouseholdSurvey.C.TheestimatesforCamdenhavefluctuated,butthereisnostatisticallysignificantdifferenceinsmoking

prevalencecomparingfromyeartoyear,orcomparingthechangefrom2010(20%)to2014(17%).


Islington

Camden

Figure 1.1 Prevalance of smoking in adults aged 18 and overIslington, London and England: 2010-2014

Figure 1.2 Prevalance of smoking in adults aged 18 and over Camden, London and England: 2010-2014

Islington London England

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Addiction starts young Mostsmokers’addictiontotobaccosetsinbeforetheageof18,aschildrenstartsmokingduetopeerpressure,rolemodellingofadultsmokersintheirfamilyenvironmentandotherinfluences.InCamden3.9%of15yearoldsand4.5%inIslingtonareregularsmokersA andasmanyareoccasionalsmokers(3.2%inCamdenand4.9%inIslington).3Aneffectivewaytopreventyoungpeoplefromstartingtosmoke is to support adult smokers to stop.4

Smoking in pregnancy CamdenandIslingtonbothhaveahigherrateofsmokinginpregnancythantheLondonaverage(5.1%).InCamden,5.5%ofwomensmokeatthetimeofdelivery.5Afteranincreasein2011-12,inIslingtontherateofsmokinginpregnancyhasfalleninthefollowingyearto7.7%.6 Smoking increases theriskofharmtobothmotherandunbornchildparticularlyofprematuredeliveryandstill birth. We also know that a child whose mothersmokesistwiceaslikelytosmokethemselves.7

Still a killer Halfofalllongtermsmokerswilldieofasmoking-relatedillness.InCamden,therearearound217smoking-relateddeathseveryyear8and225deathsinIslington9. Foreverydeathcausedbysmoking,thereareapproximately20smokerssufferingfromasmoking-relateddisease,manyofwhichcausesubstantialdisability.Smokingcannabiswithtobaccoismuchworseforhealth,particularlyincreasingtheriskandacceleratingthedevelopmentoflungdisease.

To our communitiesUnequal effectsTacklingsmokingisalsoanissueofsocialjustice.Theimpactoftobaccouseaffectsdifferentcommunitiesdisproportionally.Smokingisstilltheleadingcauseofavoidabledeathsanddisability,butalsothebiggestcauseofhealthinequalities–thegapinhealthandwellbeingexperiencedbydifferentgroups.Smokingcontributestoincreasedpovertyforthelessaffluentsmokersinourcommunities,whopaythehighestpricefortheirtobaccouse:poorerphysicalhealth,disabilityandpoorerqualityoflifeforthemandtheirfamiliesandanearlierdeath.Smokingaccountsforapproximatelyhalfofthedifferenceinlifeexpectancybetweenthelowestandhighestincomegroups.Smoking-relateddeathratesaretwotothreetimeshigherinlow-incomegroups than in wealthier social groups.10

Smoking prevalence is highest amongst the most deprived communitiesItis26%inCamdenand28%inIslingtonincontrastto14%and21%respectivelyamongstthemostaffluent.11,12 Itisstronglyassociatedwithunemployment13 and lower education.14,15 In routine and manual groups smokingprevalenceis27%inCamdenand41%inIslington.16 Some ethnic groups also havemuchhigherratesofsmoking,suchasthemixedWhiteandBlackCaribbeanpopulation(32%)inCamden17andTurkish-speaking(33%)andIrish(29%)communitiesin Islington18.Smokingisalsomoreprevalentamonglesbian,gay,bisexualandtransgendercommunities(LGBT).Forpeoplewithmental

A.IntheHealthandWellbeingSurveyquestionnairefor15yearolds,a‘regular’smokerissomeonewhosmokesoneormorecigarettesaweek,whilean‘occasional’smokerissomeonewhodoesn’tsmokeasmanyasonecigarette a week.


healthconditions,smokingsignificantlycontributestotheburdenofillhealth.Athirdofadultswithamentalhealthconditionsmoke,whichis50%higherthanthegeneralpopulation.19 Ratesofsmokingamongstpeoplewithapsychoticdisordermaybeashighas80%.Thehighprevalenceofsmokingamongprisonerscanalsobepartlyattributedtohighratesofmentalhealthproblemsinthisgroup.2071%ofsentencedprisonershavetwoormorementaldisorders,whilst90%ofyoungprisonersaged15-21haveonementaldisorder.21

Ifwearetoreducehealthinequalitiesinthetwoboroughs,wemustdevelopnewwaystodrivedownsmokingprevalenceamongstthemostdisadvantagedgroups.22, 23

ToourwidersocietyThetotalannualcostofsmokingtosocietyinCamdenis£60million(Figure1.3),inIslingtonit’s£66.22million(Figure1.4).ThiscoversnotonlythecoststotheNHS,butalsocoststopublicservicesforsocialcare,tacklingfirescausedbysmoking,andcoststobusinessfromlostproductivity.24 In contrast taxrevenuefromtobaccosalesbysmokersinCamdenwas£35.4millionandinIslington£37.2million,creatingashortfallof£24.6millionand£29millionrespectively.

WewelcometheNHSFiveYearForwardViewanditsemphasisonprevention.25 Helpingpeoplequitsmoking(andpreventingthemfromevenstarting)haswell-documentedhealth,socialandfinancialbenefitsforindividualsandourwidersociety.

22

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Figure 1.3 Smoking costs vs taxation (£millions)

Figure 1.4 Smoking costs vs taxation (£millions)

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Unexpected harmsTobaccousedoesn’tjustdamagepeople’shealth. It damages business through the lossofproductivityrelatedtoboth‘smokebreaks’butalsoemployeesicknessabsence.Thetradeinillicitcigarettesfuelscrimeinourcommunities,whilecarelesslydiscardedcigarettesarealeadingcauseofhousefires.CigarettebuttsarethemostcommonlylitterediteminLondonandareestimatedtocostlocalauthoritiesbetween£7.5and£9millioninCamdenand£3.5inIslingtontoclearup.

Atanationallevel,therearecallsforaTobacco Companies Obligation, similar to the EnergyCompaniesObligationwhichrequiresthemtoreduceandpayforenvironmentalpollution.WhileCamdenandIslingtonmaynothavethisfinancialleveratourdisposal,wecanstillsavemoney‘acrossthesystem’ifwereducethenumberofpeoplewhosmoke.

Bold in our ambitionPublicHealthEngland’srecommendationisforasmokefreegenerationby2025,wherelessthan5%ofthepopulationaresmokers.For Camden and Islington, balancing pragmatism with aspiration, we are aiming tobesmokefreeby2030.Thisisstillanambitious target, which will require bold action. Itwillmeanreducingthenumberofsmokersbyapproximately23,000inCamdenand31,300inIslingtoninthenextfourteenyears.Thiswillrequireahugeamountofwork.Thisstrategyisanimportantstepalongthewaytoachieveourgoalofasmokefreegeneration.Itwilloutlinewhatwewilldolocallytoachieveour ambitions.

■ ReducesmokingintheadultpopulationinCamdento13%andIslingtonto16%orlessby2021,withtargetsagreedonanannualbasis.Thisisaround7,600lesssmokersinCamdenand11,300lesssmokersinIslington,infiveyears.

■ Reducesmokingamongstpregnantwomento3%inCamdenand5%inIslingtonby2021.

■ Reduceregularandoccasionalsmokingamong15yearoldsto5%inCamdenandto7%inIslingtonby2021.

■ Reducehealthinequalitiesbyreducingsmokingprevalenceinallkeytargetgroupswithabove-averagesmokingprevalencebyatleast25%fromthe2015baselineby2021.Forexample,wewillreducesmokingintheroutineandmanualsocio-economicgroupto20%(from27%)inCamdenandto29%(from41%)inIslingtonby2021.

Recommendations

24

References1. LondonHealthCommission.BetterHealthfor

London.2014.Availablefrom: http://www.londonhealthcommission.org.uk/ wp-content/uploads/London-Health-Commission_Better-Health-for-London.pdf

2. PublicHealthEngland.LocalTobaccoControlProfiles2014.Availablefrom http://www.tobaccoprofiles.info/profile/tobacco-control/data

3. HealthandSocialCareInformationCentre.HealthandWellbeingof15yearoldsinEngland:SmokingPrevalence-FindingsfromtheWhatAboutYOUth?Survey2014.2015Availablefrom: http://www.hscic.gov.uk/catalogue/PUB17984

4. NationalCentreforSmokingCessationandTrainingwithPublicHealthEngland2014.Localstopsmokingservices.Serviceanddeliveryguidance.Availablefromhttp://www.ncsct.co.uk/usr/pub/LSSS_service_delivery_guidance.pdf

5. PublicHealthEngland.CamdenHealthProfile2015.Availablefrom:www.apho.org.uk

6. CamdenandIslingtonPublicHealth.FocusonSmokingOctober2014.Availablefrom: http://evidencehub.islington.gov.uk

7. HofhuisW,deJonsteJC,MerkusPJFM.Adversehealtheffectsofprenatalandpostnataltobaccosmokeexposureonchildren.ArchDisChild2003;88:1086-90.


9. PublicHealthEngland.IslingtonHealthProfile2015.Availablefrom:www.apho.org.uk

10. MarmotM,AllenJ,GoldblattP,BoyceTetal.FairSociety,HealthyLives:StrategicReviewofHealthInequalitiesinEnglandpost2010.2010.Availablefrom:http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review

11. CamdenCouncilJointStrategicNeedsAssessment.[Online]2013.Availablefrom:https://www.camden.gov.uk/ccm/content/social-care-and-health/health-in-camden/joint-strategic-needs-assessment-2012/chapter-8-smoking/?page=4

12. CamdenandIslingtonPublicHealth.FocusonSmokingOctober2014.Availablefrom: http://evidencehub.islington.gov.uk

13. DeVogliR,SantinelloM.UnemploymentandSmoking:doespsychosocialstressmatter?TobaccoControl[Online]2005;14:389-395Availablefrom:doi:10.1136/tc.2004.010611

14. GilmanSE,MartinLT,AbrahamDB,KawachiIetal.Educationalattainmentandcigarettesmoking:acausalassociation.InternationalJournalofEpidemiology[Online]2008;37(3):615-624.Availablefrom:http://ije.oxfordjournals.org/content/37/3/615.short

15. WagenknectLE,PerkinsLL,CutterGR,SidneySetal.Cigarettesmokingbehaviourisstronglyrelatedtoeducationalstatus:thecardiastudy.PreventiveMedicine[Online]1990;19(2):158-169.Availablefrom:http://www.sciencedirect.com/science/article/pii/009174359090017E

16. PublicHealthEngland.LocalTobaccoControlProfiles2014.Availablefromhttp://www.tobaccoprofiles.info/profile/tobacco-control/data

17. CamdenCouncilJointStrategicNeedsAssessment.[Online]2013.Availablefrom:https://www.camden.gov.uk/ccm/content/social-care-and-health/health-in-camden/joint-strategic-needs-assessment-2012/chapter-8-smoking/?page=4

18. CamdenandIslingtonPublicHealth.FocusonSmokingOctober2014.Availablefrom:http://evidencehub.islington.gov.uk

19. WuQ,SzatkiwskiL,BrittonJetal.EconomiccostofsmokinginpeoplewithmentaldisordersintheUK.TobaccoControl2015;24(5):462-8.Availablefrom:doi:10.1136/tobaccocontrol-2013-051464.

20. RoyalCollegeofPhysiciansandtheRoyalCollegeofPsychiatrists.SmokingandMentalHealth.2013.Availablefrom:https://www.rcplondon.ac.uk/publications/smoking-and-mental-health

21. PublicHealthEngland.Reducingsmokinginprisons.Managementoftobaccouseandnicotinewithdrawal.2015.Availablefrom:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/412567/Reducing_smoking_in_prisons.pdf

22. WalnessD.SecuringGoodHealthfortheWholePopulation.DepartmentofHealth.2004.Availablefrom:http://webarchive.nationalarchives.gov.uk/+/http:/www.hm-treasury.gov.uk/media/D/3/Wanless04_summary.pdf

23. MarmotM,AllenJ,GoldblattP,BoyceTetal.FairSociety,HealthyLives:StrategicReviewofHealthInequalitiesinEnglandpost2010.2010.Availablefrom:http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review

24. ActionforSmokingandHealthReadyReckonerv.4.627August2015.Availablefrom:ash.org.uk/localtoolkit/docs/Reckoner.xls

25. NHSFiveYearForwardView.October2014.Availablefrom:https://www.england.nhs.uk/ wp-content/uploads/2014/10/5yfv-web.pdf


Smokingusuallystartsatanearlyageandmostsmokersstartinchildhoodanddevelopalife-longhabit.Thatiswhyitisessentialtoclosethegatewaysintosmoking,forchildrenandyoungpeople,tocreateasmokefreegeneration.

Thereisnosinglereasonwhychildrenstarttosmoke.Preventionneedstoaddressmultiplefactorsthatcontributetoayoungpersonchoosingtosmoke.Factorsincludehavingparentsorsiblingswhosmoke;availabilityofcigarettes,forexamplecheapillicitcigarettes;peerpressure;socioeconomicstatus;tobaccomarketing and smoking in popular culture such asinfilmsandtelevision.1

Smokingislinkedtosocialdeprivation.Long-termsmokingiscloselycorrelatedwithinequalityandsocialexclusion,withchildrenfromlowincomebackgroundsmostlikelytobesmokersinadulthood.Vulnerablechildren,suchaschildrenwhoarelookedafterbythestate,infostercareorininstitutionalsettings,havedisproportionatelyhighsmokingratesandbegintosmokeataveryyoungage(under10yearsold).2Indeed,manyofthesechildrenandyoungpeopleareatriskwithvariousproblems(e.g.unsafesex,alcoholandsubstancemisuse,schooltruancy),soa‘commonriskapproach’isrequiredtoaddresstheneedsoftheyoungpersonholistically.Forexample,concurrentcannabisandtobaccosmokingconsiderablyincreaseshealthrisks.

Evidenceshowsthatnationalpolicies,likethestandardisedpackaginglegislationfortobaccoproducts,comingintoeffectinMay2016,canhaveasignificanteffectindiscouragingchildrenandyoungpeoplefromstartingtosmoke.Unappealing,dull-colouredpackswithstrong and prominent health warnings, will replacethebranded,bright-colouredpackswhichappealtochildrenandfalselyleadthemtobelievethatsomebrandsare‘safer’thanothers.3

Themaininfluenceforchildrenstartingtosmokeistheirimmediatefamily.Childrenwithfamilymemberswhosmokeareuptothreetimesmorelikelytobecomesmokersthemselvesthanchildrenwhoseparentsarenon-smokers.4 Helpingadultstostopsmokingandcreatingsmokefreeenvironmentswherechildrenliveandplayareessentialpartsofthisstrategyandwillcontributetofewerchildren starting to smoke. These will be addressedinsections7and8ofthestrategy.

Shisha smoking and electronic cigarettes are relativelynewwaysofsmokingtobaccoorusing nicotine.5 Weknowthatyoungpeopleexperimentwithbothshishaande-cigarettes.OneinthirtyYear6primaryschoolpupilssurveyedin2015inIslingtonandoneinfiftyinCamdenhavetriedane-cigaretteandthisgoesuptooneineightinsecondaryschool(12%inIslingtonand13%inCamden).Manymorepupilstryshishasmoking:oneinfivehavetrieditinsecondaryschoolandinYear

6

Closing the gateways in

26

10almosthalfhavetriedit(46.5%inIslingtonand48%inCamden).6 Young people are easilyinfluencedbyfashionsandtrends,aswell as peer pressure. On the other hand,

accesstoaccurateinformationaboutthesenewproductsmaynotbeeasilyavailable.Ourrecommendations to reduce tobacco related harm are outlined in section 8.

■ ImplementthehealthrelatedbehaviourquestionnaireinCamdenandIslingtonschoolsandusedataonsmokingtoinformarangeoftargetedinterventions.

■ Continuetoeducateprimaryandsecondaryschoolchildren,encouragingthemtoconsiderthesocialinfluencesofsmoking,highlightingthehealthrisksandcostsofsmoking,aswellasthesupportavailabletostop.Extendthisworktoincludeenvironmentalandpoliticalimpactsoftobaccouseandtobaccocompanies’tactics,toresonatefurtherwithyoungpeoples’concerns.

■ Createasmokefreeenvironmentforyoungpeople,familiesandstaffusingtheHealthySettingsAwardsasoneofthedrivers.

■ Continuetoworkwithteacherstoidentifyyoungsmokersorpupilsatriskofsmokingandimplementpeereducationprogrammes,suchasASSIST,tochangeattitudestosmoking tobacco and cannabis.

■ Ensurethatparentsandchildrenareeducatedabouttheharmsofshishasmokingandunderstandtherisksofelectroniccigaretteuse.

■ WorkwiththeYouthCouncil,theYoungPeople’sHealthForum,YouthHubsandotherpartnerstoexplorewaysofreachingyoungpeopleandensurethesmokefreemessages are prioritised.

■ Developatargetedapproachforcomplex/troubledfamilies. ■ WorkwithallCommissionersofchildrenandyoungpeopleservices(includingChildrenandAdolescentMentalHealthServices(CAMHS))to:

� ‘Mainstream’stopsmoking-relatedactivityaspartoftheircommissioningofclinicalcareinlinewithNICEguidance � Ensureadequateresourceallocationforage-appropriatestopsmokingadviceprovision

■ Workwithclinicalstaffandhospitalserviceprovidersseeinganychildrenandyoungpeopleto:

� RequiremandatorytrainingonatleastVeryBriefAdviceforSmokingCessation(Ask,Advise,Act)forallclinicalstaff

� Considerthewholefamilyforsmokingcessationreferralandsupport � Streamlineinternalreferralsystems(inconjunctionwithCommunityStopSmokingServiceprovision)

Recommendations


References1. TheRoyalCollegeofPhysicians.Passive

smokingandchildren.AreportoftheTobaccoAdvisoryGroup.2010.Availablefrom:https://www.rcplondon.ac.uk/sites/default/files/documents/passive-smoking-and-children.pdf

2. MullerT.Breakingthecycleofchildren’sexposuretotobaccosmoke.BritishMedicalAssociation.2007.Availablefrom:http://bmaopac.hosted.exlibrisgroup.com/exlibris/aleph/a21_1/apache_media/GR3GIR2QERK36MDPMLKEJ7AFL6AD8A.pdf

3. BritishHeartFoundation.Standardisedpackagingfortobaccoproducts.RecentevidencefromAustraliaandUnitedKingdom.InternationalTobaccoControlPolicyEvaluationProjectandBritishHeartFoundation.2014.Availablefrom:https://www.bhf.org.uk/~/media/files/publications/campaigns/itc-british-heart-foundationa4-v8-web-final-18dec2014.pdf

4. Leonardi-BeeJ,JereML,BrittonJ.Exposuretoparentalandsiblingsmokingandtheriskofsmokinguptakeinchildhoodandadolescence:asystematicreviewandmeta-analysis.Thorax2011;66:847-855Availablefrom:doi:10.1136/thx.2010.153379.

5. HughesK,BellisMAetal.Associationsbetweene-cigaretteaccessandsmokinganddrinkingbehavioursinteenagers.BMCPublicHealth2015;15:244.Availablefrom:http://www.biomedcentral.com/1471-2458/15/244

6. DatafromtheHealthRelatedBehaviourQuestionnaire(HRBQ)survey2015,carriedoutinprimaryandsecondaryschoolsinCamdenandIslington.Formoreinformationcontact: GillMorris(CamdenCouncil): [email protected] HelenCameron(IslingtonCouncil): [email protected]

28

7.1 Supporting those who help smokers quit

7.2 Smokers with long term conditions

7.3 Smokers with mental health conditions

7.4 Smokers in Islington’s male and female prisons

7.5 Smoking in pregnancy and the early years

7.6 Young people

7.1 Supporting those who help smokers quit Role of stop smoking servicesComparedtotenyearsago,smokingprevalencehasfallensignificantlyinCamdenand Islington in line with the national trend. Stopsmokingservicesinbothboroughswereestablishedandhaveplayedakeyroleinhelpingsmokerstoquit,withevidence-basedbehaviouralsupportandtreatments.

Stopsmokingservicesprovidepharmacotherapyandusebehaviourchangetechniquesandactivitiestomaximisemotivationtoquit,minimisethedesiretosmokeanddevelopcopingstrategiestodealwithhigh-risksituations,stressand

otherfactorswhichmaycausearelapseintosmoking.PharmacotherapyincludesNicotineReplacementTherapy(NRT),VareniclineandBupropion.Abstinenceismeasuredbyexpired-aircarbonmonoxide(CO)testing.

Theevidenceshowsthatthecombinationofpharmacotherapyandstructuredbehaviouralsupportprovidedbytrainedstopsmokingadvisorsincreasesthechanceofquittingbyuptofourtimes,comparedtotryingtogiveupsmokingwithouthelp1andishighlyeffectiveinimprovinglongtermquitrates.Longtermabstinenceratesmorethantriplewhenquittingwiththestopsmokingservice,compared to quitting without support.2

InthelasttwoyearsthenumberofpeopleaccessingNHSstopsmokingserviceshasdeclinednationally.Anumberoffactorscouldhavehadanimpactonthis:theincreasinguseofe-cigarettes,NHSre-organisationin2013andreducedrevenueforadvertisinglocalstopsmokingservices.3Anecdotalevidencefromlocalcommunitystopsmokingserviceshighlightsthattherearenowfewersmokersinthepopulationasmany‘quickwins’,i.e.smokerswhoarereadyandabletoquit,weretargetedandquitinpreviousyears.Thesmokingpopulationis,therefore,nowmainlymadeupof‘hard-core’smokers,manyofwhomhavelongtermhealthconditionsanda reluctance to quit smoking. These smokers are harder to engage, and those that do engagewiththeprogrammearelesslikely

7

Helping people out


toquitwithinthenationallydefinedsuccesscriteriaofa4-weekquitperiod.Servicesreportthatmanypeoplearealsochoosingtoquitontheirownbyusinge-cigarettesoveraccessingprofessionalsupport,althoughNHSstopsmokingservicesarestillthemosteffectivewayforsmokerstoquit.

Sections 7.2 to 7.6 outline our strategic recommendationstoincreasethenumberofsmokers accessing the local stop smoking servicefromdifferentgroupsandinparticularcircumstances,whohavedistinctsupportneedstoquitsuccessfully.

Encouraging healthcare clinicians to help smokers quitSmoking related hospital admissions and prematurepreventabledeathsremainveryhigh in Camden and Islington. In Islington thereareapproximately225smoking-relateddeathseachyear,makingIslingtonthethirdhighestboroughforsmoking-relatedmortalityinLondon.InCamdentherearearound217smoking-relateddeathseachyear.

Thiscomesatgreatcosttoboththeindividualandtoservices.Islingtonhasthehighestrateofsmoking-attributablehospitaladmissionsinLondon(2,534per100,000populationinIslingtonversus1,606inLondon).InCamdenthereare1,774smoking-relatedhospitaladmissions.4

Thesehospitaladmissionsareessentiallyallpreventable.Itisestimatedthatannually,smokingcoststheNHSinIslington£7millionandinCamden£6million(andAdultSocialCareafurther£3millionineachborough).5

TheNHSFiveYearForwardViewemphasisedtheimportanceofpreventiontoensureamoresustainablehealthsystem.RecentworkoftheLondonClinicalSenate’sprogramme,‘Helping

SmokersQuit’hasparticularlyhighlightedtheroleforclinicianstosupportsmokerstoquitby:routinelyprovidingadviceandsupport,includingappropriatepharmacotherapy,andusingcarbonmonoxidetestingasamotivationaltool.

However,toprovidegoodsupportforpatientswhowanttoquit,staffneedclinicalleadership, recognising smoking cessation as astandardpartofclinicalcareforsmokersandadequatetraining(atleastverybriefadvicetrainingonsmokingcessation).Thisneeds to occur across all specialties and includementalhealthandmaternitysettingsin particular. Where this has worked best, it has been a collaboration between senior clinicalchampionsandlocalward/clinic-levelchampions.

Other front line staff and volunteersThedriveforbothintegratedhealthandsocialcareandanincreasedfocusonpreventionwithinthepublicsectorprovidesnewopportunitiestoincreasethenumberofstaffacrossboththepublicsectorandvoluntaryandcommunitysectortrainedinverybriefadviceonsmokingcessation.

Staffcomefromawiderarrayofprofessionalbackgrounds including housing, social care andthevoluntarysector.ProgrammesinCamdenandIslingtonsuchas‘MakingEveryContactCount’offerameansofprovidinggoodqualityonlineandface-to-facetraininginsmokingcessation(andotherhealthimprovingbehaviourchange)toreachawidervarietyof‘front-line’staff,whocanhelpidentifyresidentswhosmokeandsignpostthemtorelevantadviceandsupport.

Ultimately,anyonewhohastheopportunityandabilitytoinfluencethehealthandwellbeingofpeopleinCamdenandIslington,

30

canbeofferedstopsmokingtraininginverybriefadvice.Thisincludesemployeesintheprivatesectorwhocanchampionstopsmoking messages with their customers or clients.6

Employers and ‘Wellness at Work’Promoting wellness at work which includes offeringopportunitiesforstafftoreducesmoking,havealsobeenseentobecost-effective.Reducinglevelsofsmokingamongemployeeswillhelpreducesomeillnessesandconditions(suchascardiovasculardiseaseandrespiratorydiseases)thatare

importantcausesofsicknessabsence.Thiswillresultinimprovedproductivityandlesscostsforemployers.7 The workplace has severaladvantagesasasettingforsmokingcessationinterventions:

■■ Largenumbersofpeoplecanbereached(includinggroupswhomaynotnormallyconsulthealthprofessionals,suchasworkingagemen)

■■ Thereisthepotentialtoprovidepeergroup support

■■ Seeing colleagues who are quitting encourages people who smoke to quit

■ Ensuregoodquality,evidence-basedstopsmokingserviceisintegratedintothewiderbehaviourchangeofferavailablewithinbothboroughswhichaimstoimprovethehealthandwellbeingofpeopleinCamdenandIslington.Theseservicesshouldbeaccessibletoallsmokersandparticularlythosefromlowersocio-economicgroupsanddisadvantagedpopulations.

■ DeveloplocalcommunicationsinitiativesbasedonnationalcampaignslikeStoptoberandNoSmokingDay,topromoteconsistentandcoordinatedmessagesaboutstopsmokingsupportandreachhighprioritygroupsthrougheffective,targetedcommunications.

■ EnsurethattrainingonprovidingverybriefadviceonsmokingcessationisrequiredofeveryclinicianseeingCamdenandIslingtonpatientsandthatthereisadequateclinicalleadershipineveryNHSorganisation,bothatseniorandward/cliniclevelstosupport this.

■ Ensureclinicianswhoprescribearetrainedandcompetenttoprescribesmokingcessation medication.

■ Ensureaccurateandtimelyinformationaboute-cigaretteusetoreducepublicconfusionabouttherelativerisksofnicotineproductscomparedtotobaccoproductsandallowaninformedchoice.

■ Increasethenumberofpublicsectorstaffaswellascommunityandvoluntarysectorvolunteersandstaffwhoaretrainedtoprovideverybriefadviceonsmokingcessation.

■ UseHealthySettingsAwardsasoneofthedriverstoincreasestopsmokinginterventionsbystaffworkingwithyoungpeople.

■ Supportworkplacehealthandwellbeing,initiallyfocusingonbothboroughs’largestpublicsectoremployers,toreducesmokingamongstemployees.

Recommendations


7.2 Smokers with Long Term Conditions Smokingcancontributetothedevelopmentofseverallongtermconditions,andotherhealthproblemssuchascoronaryheartdisease(CHD)andchronicobstructivepulmonarydisease(COPD)A,aswellascauselifethreatening conditions such as lung cancer. Concurrent cannabis smoking increases the healthrisksofsmokingtobacco,particularlyforlungdisease.Continuedsmokingafteraperson is diagnosed worsens their outcomes, accelerates disease progression, increases mortalityandworsenscomplications.Stoppingsmokinggreatlyimprovesoutcomesforpeople with long term conditions, including CHD,COPD,type2diabetesandHIV8. For COPD,stoppingsmokingisavitalpartoftreatment,whichgreatlyreducestherisksofexacerbationofthecondition.9

Despitetheclearevidenceaboutthesignificantnegativeeffectsofsmokingonlongtermconditions,significantproportionsofpeople with one or more long term conditions

continuetosmoke–34%ofpeoplewithlungcancerand44%ofpeoplewithCOPD.(SeeTable7.2.1).

Peoplewithlong-termconditions,suchasdiabetes,asthma,CHD,aregenerallymorereceptivetosmokingcessationmessagesandhavehigherlevelsofmotivationtoquit10.Therefore,offeringverybriefadvicetosmokerswithlong-termconditions,attheappropriate‘teachablemoments’duringtheircarepathwayhasmanypotentialbenefits.TheNationalInstituteforHealthandClinicalExcellence(NICE)offersguidanceontobaccoand recommends that stopping smoking shouldbeanintegralpartofthemanagementoflongtermconditions,bothinprimaryandsecondarycare.11

TheLondonClinicalSenate‘HelpingSmokersQuit’programmeencouragesclinicianstouseanexhaledcarbonmonoxide(CO)breathtestasamotivationaltool,inadditiontoverybriefadvice.COtestingisaproventoolinspecialiststopsmokingsettings.Whenusedroutinelyinthecontextofasupportiveconversationaboutsmoking,itisalsoausefulmotivationaltoolineverydayclinicalsettings.12

Condition SmokerCamden

SmokerIslington

Ex smokerCamden

Ex-smoker

Islington

Non smokerCamden

Non smoker

IslingtonLungCancer(diagnosiswithinlast5years)

34% 34% 48% 51% 18% 15%

COPD 44% 44% 45% 48% 11% 7%

Diabetes 18% 19% 25% 28% 57% 52%

Hypertension 15% 17% 28% 29% 56% 53%

Table 7.2.1

A.Awiderangeofdiseasesandconditionsarecausedbysmoking,includingcancers,respiratorydiseases,coronaryheartandothercirculatorydiseases,stomachandduodenalulcers,erectiledysfunction,infertility,osteoporosis,cataracts,agerelatedmaculardegenerationandperiodontitis.(NICEQualityStandardQS43)

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Thereareexamplesofgoodpracticeacrosslocalhospital(secondarycare)serviceswhichinclude:■■ WhittingtonHealthinIslingtonoffersspecialiststopsmokingadviceand treatment, to all inpatients and outpatients,includingahousevisitingservicetopatientswithCOPD,aspartofacomprehensivesetofinterventionsintegratingthehospitalandcommunityteams.StopsmokingspecialistsofferadviceandCOtestingtoallsmokersonthe wards, as well as to outpatients and staff.Trainingforhealthprofessionalsenablesthemtoofferverybriefadvicetosmokers.Provisionismadefornicotinereplacementtherapytobeofferedtoinpatients,fortemporaryabstinenceduringtheirhospitalstay.

■■ InCamden,theRoyalFreeHospital(RFH)andUniversityCollegeLondonHospitals(UCLH)aredevelopinglocalbestpractice,suchasRFH’sin-housestopsmokingserviceandUCLH’spre-operativeassessmentpathway,whichscreensandreferssmokers. Itisnecessarytosharebestpracticeinembeddingstopsmokinginterventionsineveryclinicalcontactinsecondarycare,toenhanceclinicaloutcomesforpeoplewithlong term conditions.

■ EngageprimarycareleadssuchasClinicalCommissioningGroup(CCG)clinicalchampions,LocalMedicalCommittee(LMC)andLocalPharmaceuticalCommittee(LPC)representativestoexploreopportunitiesforbetterengagementwithsmokingcessationandsharingbestpracticeinprimarycaretoensurethatpeoplewithlongtermconditionsareroutinelybeingencouragedtoquitsmokingandreceivetheappropriatesupporttodosoinlinewithNICEtobaccoguidance.

■ WorkwiththeclinicalchampionineverysecondarycaretrustinCamdenandIslington,toleadonhelpingsmokersquitandtoconsiderhowtheLondonClinicalSenaterecommendationsonverybriefadvicetrainingandCOtestingcanbeimplemented.

■ PromoteadherencetoNICEguidanceontobaccoespeciallyaimedatsecondarycare(acute,maternityandmentalhealthservices),byworkingwithCCGcommissionersandsecondarycareproviders.

■ Ensureclinicianswhoprescribearetrainedandcompetenttoprescribesmokingcessation medication.

■ Encourageclinicianstoroutinelyaskaboutcannabisuseaspartoftheirsmokingcessation discussion with their patient.

Recommendations


7.3 Smokers with Mental Health conditions Whilesmokingrateshavebeensteadilyfallinginthegeneralcommunity,theyremainunacceptablyhighamongstpeoplewithmentalhealthproblems.Smokingprevalenceis twice as common among people with mental health problems, and more so in those with moresevereillness.13 People with mental healthproblemsuse42%ofalltobaccoconsumedintheUK14,duetoheaviernicotinedependency.

Contrarytotheassumptionthatsuicideistheleadingcauseofdeathinpeoplewithmentalillhealth,smokingisthebiggestcauseofreducedlifeexpectancyforpeoplewithmentalhealthproblems,comparedtotherestofthepopulation.15 People with mental ill health experiencesubstantialphysicalillhealthasaresultoftheirtobaccouse–relatedparticularlytocardiovascularandrespiratoryconsequences.Thelifeexpectancyofpeoplewithseriousmentalillness(SMI)isestimatedtobeupto20yearslessthanthegeneralpopulation.16 Infact,itisestimatedthatpeoplewithSMIhavethesamelifeexpectancyasthegeneralpopulationinthe1950s.17

Notonlydoessmokingaffectthephysicalhealthofpeoplewithmentalhealthconditionsbutitalsoimpactspeople’smentalhealthbyinteractingwithsomepsychiatricmedicationmakingitlesseffective,resultinginincreaseddosagesandmoresideeffectsassociatedwith these drugs.

Smokinghasbeenwidelyacceptedandevenfacilitatedinmanypsychiatriccaresettings,formanyyears.Staffattitudesneedtochange.Smokingshouldnotbeseenas‘normal’behaviour,norasaneffectivewayforapersontomanagetheirmentalhealth.Achangeinpsychiatriccaretoplacemoreemphasisonphysicalwellbeingisalsonecessary.Theseconversationsarehappeningatbothanationalandboroughlevel.Significantly,inApril2015,ourlocalmentalhealthprovider,the Camden and Islington Foundation Trust wentsmoke-free–oneofthefirsttodothisinLondon.

Smokerswithmentalillhealtharejustaslikelyto want to quit as smokers without mental illhealth,butaremorelikelytobeheavilyaddictedtosmokingand,historically,arelesslikelytosucceedwhentheytrytoquit.18 Thecurrentmodelofstopsmokingspecialistservicesoffers6-8weeksofsupport,providedduringweeklysessionswithatrainedadvisor.Smokerswithmentalillhealthoftenneedsubstantiallymoresupportthanthis,includingNicotineReplacementTherapyprovidedoveralongertimeframeandmoreintensivebehaviouralsupport.19

Youngersmokersareunder-representedinthestopsmokingservicesgenerallyandthisistrueofservicesforthosewithmentalillhealth:themajorityofthosecurrentlyaccessingspecialistservicesareovertheageof65andalreadyexperiencesmoking-relatedphysicalill health. More needs to be done to support mentallyillsmokerstoquitsmokingbeforetobaccouseimpactsontheirphysicalhealth.Earlyinterventionisparticularlyimportantforthosewithpsychosisorwithaseriousmentalillness,asthisgrouphasparticularlyhighsmoking rates.

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■ Includestopsmokingsupportininitiativespromotingphysicalhealth(e.g.healthyeating,obesitysupport,physicalactivity)formentalhealthserviceusers,includingyoungpeople.

■ Ensurespecialiststopsmokingservicestailoredtosmokerswithmentalillhealthareavailableinresidentialcare,in-patientsettingsandthoselivingindependentlythecommunity,acrossCamdenandIslington.

■ Ensureanetworkoflevel2trainedstopsmokingadvisorsexistsacrossallmentalhealthsecondaryandcommunitycaresettings.

■ Allstaffinmentalhealthservicesaretrainedinverybriefadviceandsecond-handsmoke.

■ Workwiththefiredepartmenttoensurethatresidentialcarehomescomplywithfiresafetystandardstominimisetherisksforresidentswhocontinuetosmoke

■ Ensurethatinlongtermresidentialcarehomesallsmokingtakesplaceoutside. ■ Ensureclinicianswhoprescribeinmentalhealthsettingsaretrainedandcompetentto

prescribe smoking cessation medication.

Recommendations


7.4 Smokers in Islington’s male and female prisons TherearetwoCategoryBprisonsinIslington,HMPPentonvilleformaleoffendersandHMPHollowayandYoungOffenderInstitutionforfemaleoffenders.HMPHollowayisplannedforclosureinJune2016.Therearenoprisonsin Camden.

Smokingratesamongprisonershavechangedrelativelylittleinthelastfewdecades:theyareestimatedtobethreetofourtimeshigher(upto80%)thanthegeneralpopulation(18%inEnglandin2014).20 There is no research availableontheprevalenceofsmokingamongprisonstaff,butitisanecdotallyreportedasbeingnear40%whichistwiceashighasthenationalaverageinthecommunity.

Athematicreport21whichanalysedtheinspectionreportsofthirtythreeCategoryBprisons,includingHMPsHollowayandPentonville,publishedbetween2009and2011,foundthat33%ofprisonersreportedmental health or emotional wellbeing issues, oneinfive(22%)reportedtheyhadproblemswithfeelingdepressedorsuicidalonarrivalatprisonandmanyreportedadrug(37%)and/oralcohol(28%)problemonarrival.Thereisahigherincidenceofsmokinginpeoplewith mental health and substance misuse problems.

BothIslingtonprisonsofferstopsmokingsupporttoprisonersandstaff.Allsmokingcessationactivityisrecordedontheprisondatabasesystem.Aspernationalpolicy,prisonersreceiveahealthcheckwithin24hoursofadmissionandthisincludesNicotineReplacementTherapy(NRT)iftheyareona stop smoking programme or want to be.

When a prisoner is released and still in need oftreatmentforstoppingsmoking,thisisrecordedandthereceivingprisonwillgetthisinformation.Smokerswhoarereturningtothecommunityareoffereddetailsoflocalstopsmokingservicesintheirdischargepack.

Twiceyearlyhealthandwellbeingpromotioneventsareprovidedinbothprisonsforstaffandprisoners.Communityservices,includingstopsmokingservices,provideadviceandreferinterestedsmokerstoclinicsforsupport.Staffhaveaccesstoin-housestopsmokingclinicsorcanchoosetovisitthelocalpharmaciesthatofferstopsmokingsupport,during breaks.

AtthesametimethatSmokefreelegislationwasintroducedin2007,thePrisonServiceappliedforexemptionstatingthatpeopleinprison should be allowed to smoke in their cellsasitistheirtemporary‘home’.ThePrisonServiceisnowactivelyworkingtowardsprisonsbecomingcompletelysmokefree.Internationalexperiencehasshownthatpeopleheldincustodyorinsecurehospitalwardswhoaretoldtheycannotsmokeusuallyadaptverywelltotheidea,oftenmakingthedecisiontostopsmokingbeforetheyareinstructedtodoso.AdequateNRTprovisionwillneedtobeassuredbeforethesmokefreeagendacanberolledacrossthewhole establishment. Trials are taking place ofelectroniccigarettes,toassessanyimpactonsecurityandwhetherthereistake-upandforhowlong.Todateexperiencehasshownthattheyareasourceofinterestbutonlyshortterm,astheyarestillbeingsoldalongsidetobacco.Oncetobaccoisnolongeravailable,theyarelikelytoformausefulpartofthestrategy.

36

■ Developstrongerlinksbetweenprisonandin-patientpsychiatricservicesandthecommunity-basedstopsmokingservicetoensurecontinuityofcare,whenprisonersreturntothecommunity.

■ Explorecommissioningan“inreach”service,sothatwhenthepersonisdischargedtheycancontinuetoreceivestopsmokingsupportviathesameservice.

■ Establishlinksbetweenhomelessprojects,psychiatriccareandtheprisonservicetoensurecontinuityofcareforCamdenandIslingtonresidentswhocyclethroughthesethreeservices.

■ Strengthenthestopsmokingprovisionacrossthewholecriminaljusticepathway,sothatthoseleavingprisonshaveaccesstosupport.

■ EnsurethatprisonerswhoaretransferredtoHMPPentonvilleandHMPHolloway(untilJune2016)whilsttheyarequittingsmokingcontinuetoreceivestopsmokingsupportanddonothavetogoontoawaitinglist.

■ Allpsychiatriccarestaffinallsettings,allprisonstaffandhomelesssupportworkersshouldbetrainedinverybriefadviceinsmokingcessationandapprisedofthedangersofsecondhandsmoke.AnyCQUINorequivalentqualityimprovementincentiveforpsychiatriccarestaffcouldensurethatthetrainingismandatory.

■ Ensureevidence-basedtreatmentsandstafftrainingarecommissionedforHMPPentonville.

■ SupportHMPPentonvilletobecomesmokefreeanddevelopanupdatedsmokefreestrategy.

Recommendations


7.5 Smoking in Pregnancy and the Early YearsStoppingsmokingisoneofthemosteffectiveinterventionstoimprovethehealthofmotherandbabyandpreventavoidableinfantmortality.Smokinginpregnancyisassociatedwithincreasedriskofmiscarriage,perinataldeath, premature birth, low birth weight and congenitalabnormalitiesinthebaby.22 It is estimatedthataboutonethirdofallperinataldeathsintheUKarecausedbymaternalsmoking,whichmeansapproximately300deathsperyear.Smokingduringandafterpregnancyalsoincreasestheriskofsuddeninfantdeathsyndrome(SIDS).23

CamdenandIslingtonbothhaveahigherrateofsmokinginpregnancythantheLondonaverage(5.1%):5.5%inCamden24and7.7%in Islington.25

Smokingduringpregnancycontributestohealthinequalitiesbecauseoftheincreasedsmokingprevalenceamongpeoplelivingindeprivedareas,womenwhoarelesseducatedor in routine and manual occupations.26Manyteenagewomensmokeinpregnancy.Womenaged20oryoungeraremorethanthreetimesaslikelythanthoseover35tosmokeduringtheirpregnancy.27 Those in routine and manual occupationsaremorethanfourtimesaslikelyasthoseinmanagerialandprofessionaloccupationstosmokeinpregnancy.

Stoppingsmokinginpregnancycanbechallenging.Onlyasmallnumberofpregnantwomentakeuptheofferofhelptostop

smoking.Manyofthosewhosuccessfullystopsmokingduringtheirpregnancygobacktosmokingwithinsixmonthsofgivingbirth.28Theattitudeofthefamily,includingthewoman’spartnertowardssmoking,canhaveaneffectonthemother’ssmokingbehaviorwhichwillimpactthehealthofthewholefamily. Healthcareprofessionals,suchashealthvisitorsandotherprofessionalsworkingwithpregnantwomenandfamiliesintheearlyyears,haveakeyroleinsupportingsmokefreeenvironmentsforfamilies.Thefocusshouldnotbeonlyonthemother.Partnersandotherfamilymembersshouldalsobeofferedinformationonsecondhandsmoke and support to stop smoking. Section 8.1outlinesourapproachtosmokefreehomes.

38

■ Reducesmokingamongstpregnantwomento3%inCamdenand5%inIslingtonby2021.

■ PromoteadherencetoNICEguidanceontobaccoinallmaternityservicesinCamdenandIslingtoncaringforpregnantwomenandfollowingchildbirth.

■ Ensurepregnantwomenaccessingmaternitycareareroutinelyscreenedwithacarbonmonoxide(CO)monitorbymidwiferystaffwhoareequipped,trainedandwithadequatetime,andthatpregnantwomenwhosmokearereferredtostopsmokingservices,aspartoftheircarepathway.

■ Earlyyearsservicescommissioningshouldexploretheroleofhealthvisitorsandotherprofessionalsinsupportingpregnantwomenandfamilieswithyoungchildrentostop smoking.

Recommendations


7.6 Young PeopleSmokingisachildhoodaddiction.Abouttwo-thirdsofadultsmokersreporttheytookupsmokingbeforetheageof18.29The2011GeneralLifestyleSurveyofadultsmokersshowedthatalmost40%weresmokingregularlybeforetheageof16.30

Nationally,theproportionofchildrenwhosmokecontinuestodecline.Among15yearolds,8%smokedin2014,comparedwith20%in2006.31InCamden7.1%of15yearoldssmokeand9.4%smokeinIslington.32

Theyoungerpeoplearewhentheystartsmokingthegreatertheharmislikelytobe.Earlyinitiationofsmokingisassociatedwithsubsequentheaviersmoking,higherlevelsofdependency,lowerchancesofquittingandhighermortality.33

Childhoodsmokersareathighriskofimmediate health problems, including respiratoryillnesssuchascoughing,wheezing and phlegm. Smoking can also lead to impaired lung growth in children and youngadults.34Smokingaggravatesasthmasymptomsinthosealreadydiagnosedandincreasestheriskofasthmainyoungpeoplewithnohistoryofthecondition.35 The earlier children become regular smokers the greater theriskofdevelopinglungcancerorheartdisease,iftheycontinuetosmokeasadults.36

People who start smoking in adolescence aremorelikelytobecomelife-longsmokersthanthosewhostartsmokingintheir20′sorlater.37 Young smokers can become addicted tonicotineveryquickly.Insomepeople,symptomsofnicotineaddictioncanappearwithindaysofoccasional(notdaily)smoking.38

Astudyofbrainreactivityinteenagerswhosmokefewerthanfivecigarettesadayshowedthattherearesignsofaddictionevenatthislowlevelofsmoking.39 During periods ofabstinence,youngpeopleexperiencewithdrawalsymptomssimilartothoseexperiencedbyadultsmokers.40

Accesstostopsmokingservicesbyteenagesmokershasbeenhistoricallylow.Itisimportanttodevelopinnovativeapproacheswhichwillensureyoungsmokershavethebestpossiblechancestoquitsmoking,beforeitbecomesalife-longhabitandimpactsontheir health.

40

■ Understandtheneedsofstaffworkinginchildren’scentresandschools when talking to parents and children who smoke and providetailor-madetrainingtoenablethoseconversations.

■ Showcasesuccessesofstaffworkinginchallengingsettingswhereviewsonsmokingareentrenchedandsharegoodpractice.

■ Targetvulnerablechildrenwhosmoke,byworkingwithsocialservices,youthoffendingservice,pupilreferralunitsandlookedafterchildrennursesandenablestafftogiveappropriateadviceandsupport.

■ Createinnovativepartnershipstoreachyoungpeople16orolder,suchaswithstudentunions,leisurecentresandprivatelyownedgyms.

■ Conductinsightresearchtotargetresourceswhereyoungpeoplearelikelytogetadviceandsupportaboutstoppingsmoking.

■ WorkwiththeyouthoffendingserviceinCamdenandIslingtontopromotesmokingcessationtoyoungoffenders.

■ Encourageresponsibleretailerpractices,suchasnotsellingtobacconearschools. ■ Ensuretobaccoretailersnearschoolsarefullycompliantwithnewlegislationontobaccodisplaysinshops,asapriority.

■ Exploretheprovisionofspecialiststopsmokingservicesforchildren,youngpeopleandtheirfamilies.

Recommendations


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32. HealthandSocialCareInformationCentre.HealthandWellbeingof15yearoldsinEngland:SmokingPrevalence-FindingsfromtheWhatAboutYOUth?Survey2014.[Online]2015Availablefrom:http://www.hscic.gov.uk/catalogue/PUB17984


34. MullerT.Breakingthecycleofchildren’sexposuretotobaccosmoke.BritishMedicalAssociation.2007.Availablefromhttp://bmaopac.hosted.exlibrisgroup.com/exlibris/aleph/a21_1/apache_media/GR3GIR2QERK36MDPMLKEJ7AFL6AD8A.pdf

35. ActiononSmokingandHealth.AsthmaandSmoking.ResearchReport595;2015.Availablefrom:http://ash.org.uk/files/documents/ASH_595.pdf


37. TaioliE,WynderEL.Effectoftheageatwhichsmokingbeginsonfrequencyofsmokinginadulthood.NewEnglandJournalofMedicine1991;325(13):968–969.

38. DiFranzaJR,RigottiNA,McNeillAD,OckeneJK,SavageauJA,StCyrD,ColemanM.Initialsymptomsofnicotinedependenceinadolescents.TobaccoControl2000;9:313-319.

39. RubinsteinML,LuksTL,MoscickiAB,DrydenW,RaitMA,SimpsonGV.Smoking-cueinducedbrainactivationinadolescentlightsmokers.JournalofAdolescentHealth2011;48(1):7-12.

40. McNeillADetal.Cigarettewithdrawalsymptomsinadolescentsmokers.Psychopharmacology1986;90:533-536.


Tobaccouseaffectsnotonlysmokersandtheirfamilies,buthasmultiplesimpactsacrossthewholesociety.ToreducethetobaccorelatedharmsforCamdenandIslingtoncommunitieswewillfocusonfiveareas:

8.1 Smokefree environments8.2 Smoking related litter8.3 Illicit tobacco8.4 Shisha8.5 Electronic cigarettes

8.1 Smokefree environmentsFocus on children

Oneoftheaimsofthisstrategyistoprotectchildrenfromtheriskscausedbyexposuretosecondhandsmoke.TheJointHealthandWellbeingStrategy2013-16,outlinedavisiontoensureeverychildhasthebeststartinlife.Growingupinanenvironmentfreeoftobaccosmokeisakeyaspectofthatambition,aschildren’shealthandlifecanbeputatriskfromsecondhandsmoke.

Existingsmokefreelegislationprotectschildrenfromtobaccosmokeinenclosedpublicspacesandfrom1stOctober2015,alsoinprivatevehicles.Theprincipalsourceofexposuretosecondhandsmokeforchildren

remains the home.1 In Camden, almost a thirdofschoolchildrensurveyedin2015saidtheyareexposedtosecondhandsmokeathome.Threeintwenty(15%)primaryschoolchildrenandoneinfivesecondaryschoolchildren(20%)areexposedtosmokingeverydayintheirhomes.Anotherthreeintwenty(14%)primaryschoolandoneineight(12%)secondaryschoolchildrenareexposedweeklyormonthly.InIslington,threeintwentyprimaryschoolpupils(16%)andoneinfivesecondaryschoolpupils(21%)surveyedin2015,saidtheyareexposedtosmokinginthehomeeveryday.Anotherthreeintwentyareexposedmoreinfrequently,weeklyormonthly(15%inprimaryschooland14%insecondaryschool).2

Most adult smokers are aware that second hand smoke is a danger to children and claimtodoeverythingtheycantominimisetheir smoking around children.3However,thechildrenofsmokerscontinuetoexperiencehighlevelsofexposuretosecondhandsmoke,4 so more must be done to encourage theseparentstorefrainfromsmokingaroundtheir children and, at best, stop smoking altogether.

Exposuretosecondhandsmokeintheearlyyearsnotonlyhasasignificantimpactonthehealthofachildbutcontinuestoimpacttheirhealth into adulthood.5Childrenexposedtosecondhandsmokeareatincreasedriskofasthma6,chestinfectionssuchasbronchitis7,

8

Reducing related harm

44

middle ear disease8,suddeninfantdeathsyndrome9 and meningitis.10 Childhood exposuretosecondhandsmokeisalsoresponsibleforimpairedmentaldevelopment11

andcanexacerbateexistingchronicconditions such as sickle cell anaemia.12 Thereisalsoevidencewhichsuggeststhatchildrenexposedtosecondhandsmokeareatincreasedriskofdevelopinglungcancerandemphysemainadulthood.13 14 15 Children who grow up with smokers are90%morelikelytotakeupsmokingthemselves.16 17

Sincesmokingisstronglylinkedtodeprivation,childrenlivinginsocialhousingaremuchmorelikelytolivewithsmokersthanchildreninhighersocio-economicgroupsandthereforemorelikelytobecomesmokersthemselves.

Itisourambitiontode-normalisesmokingforchildren,bycreatingenvironmentswherechildrenarenotexposedtosmoking;notonlyin the home but also outside schools and in playgrounds.IslingtonlaunchedsmokefreeplaygroundsinallCouncilparksin2014-15

withhugesupportfromthepublic.94%ofplaygrounduserssurveyed,40%ofwhichweresmokers,supportedthevoluntarybanofsmokingintheplaygroundandno-oneopposedit.Camden’sparkplaygroundsarealsosmokefree.

Thewiderenvironment HavingsmokefreegroundsinCouncilandNHS-ownedpremisesandotheremployerpremisesgivesastrongmessageaboutthedangersofsmokingandsecondhandsmoke.Italsopreventssmokefromdriftinginto open doors and windows, where it can causeharmandnuisance,andreducesfirerisks.Furthermore,non-smokingenvironmentsencourage people to stop smoking or can resultinmoresmokersvoluntarilymakingtheirhomessmokefree.18


■ Raiseawarenessofthebanofsmokingincarswithchildren,withparents,childrenandstaff(trafficwardens,roadsafetyunits,sustainabletravelofficers).

■ Continuetosupportnationalsmokefreehomesandcarsawareness campaigns.

■ Continuetode-normalisesmokingbyreducingsmokingaroundchildren:smokingandcigarettelitterisoutofsightofschoolgatesandplaygroundsinCouncilparks,housingestatesandadventureplaygrounds.Thiswork,alreadyunderwayinIslingtonwillbedevelopedinCamden.Ifsuccessful,inbothboroughs,wewilllooktoexpandthenumberandnatureofpublicspacese.g.publicsquares,tofurtherde-normalisesmokinginpublicforallages.

■ WorkwithpartnersofIslington’s“First21Months”andCamden’s“AThousandandOneDays”programmeteams,toincreasetheuptakeofsmokefreehomes.

■ UseHealthySettingsAwardsasoneofthedriverstocreatesmokefreeenvironmentsforyoungpeopleandtheirfamilies.

■ WorkwithpartnerstoincreasesmokefreeoutdoorenvironmentsinCamdenandIslington,aspartoforganisationalsmokefreepolicies;suchasimplementingsmokefreehospitalgrounds.

■ WorkwithemployerstosupportthesmokefreeelementoftheLondonHealthyWorkplace Charter awards.

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8.2 Smoking litterCleaningupcigarette-relatedlitterisasignificantproblemintheUK,accountingfor70-90%ofstreetlitterinurbanareas.19 Cigarettebuttsarethemostcommonitemoflitter in both boroughs with an annual street cleaningbillbetween£7.5and£9millioninCamdenand£3.5inIslington.2021 That ismoneywewouldratherspendimprovingservicesinthelocalcommunityandsoweareexploringnewwaysofencouragingsmokerstodisposeoftheirbuttsresponsibly.

IslingtonandCamdenCouncilsenforcelitteringlegislationusingfixedpenaltynotices.Bothcouncilshavesettheleveloffixedpenaltyfinesatthehighestpermittedlevel,withpenaltiesfordroppinglitter,including

cigarettebutts,setat£80or£50ifthefineispaidwithin10days.In2011-12,IslingtonCouncilissued2,348penaltynoticestosmokers who littered.

Theconceptof‘thepolluterpays’isgatheringmomentumintheUKwiththenationalgovernmentconsideringaproposaltointroducealevyonthetobaccoindustrytopayforthedamagetheycause.22 We support thisproposal.Themajorityofourresidentsdonotsmokeyetfootthebillforcleaningupafteroursmokingresidentsandvisitors.Thatisnotright.Thoseresponsiblefordamagingourenvironmentshouldberequiredtopayfortheclean-up.Thisdoesn’tjustmeanindividualsmokers.Businessesandorganisationsshould make sure that the areas around their premises,whichareusedforsmokingbytheircustomersandstaff,arekeptfreeoflitter.

■ Continueworkingwithsmokersofallagestoreducesmoking-relatedlitterinCamdenandIslingtonwithacombinationofeducationandenforcementactivities.

■ ContinuepartnershipworkbetweenCamdenEnvironmentservicesandlocalschoolstoraiseawarenessamongstouryoungerresidentsabouttheimpactoflitterintheboroughandshowthemthattobaccoalsodamagestheenvironment.

■ Introduceaninnovativescheme,alreadyinoperationinotherLondonlocalauthorities,suchasEnfieldandHaringey:asmokerwhoisissuedafixedpenaltynoticeforlitteringsmokingmaterialcancompleteacoursewiththelocalStopSmokingServiceasanalternativetoafine.

■ Workwithlocalbusinessestoensurethatstaffonsmokingbreaksdisposecigarettebuttsresponsiblyandcustomersdonotlitterwhensittinginoutdoorareas,suchaspubsandcafes.

Recommendations


8.3 Illicit TobaccoIn2015,itwasestimatedthataround10%ofallcigarettesand39%ofhand-rolledtobaccoconsumedintheUKin2013-14wereillicit.Nearlyhalfofthisiscounterfeittobaccoproducedfortheillicitmarket.Thecosttosocietyamountsnotonlytolosttaxrevenuebutalsotocrime.Theprofitsfromillicittradearepocketedbyorganisedcriminalgroups,suchasgangs,whichcausefurtherharmtosocietythroughothercriminalactivitiessuchasdrugsmugglingandhumantrafficking.23

Thecostofbuyingillicittobaccocanbeaslittleashalfthecostoflegitimateproducts.Smokingismuchmoreprevalentindeprivedcommunities. Where cheap illicit tobacco isavailableitislikelytoencouragepeopletostartandcontinuesmoking.Thisfurtherincreaseshealthinequalitiescausedbytobacco use in poorer communities.

Inasurveyconductedin2015insevenNorthEastandNorthCentralLondonboroughsincluding Camden and Islington, 627 respondents(52%)thoughtthatavailabilityofcheaptobaccomakesitmoredifficulttoquitand56%believedthatitmakesiteasierforchildrentostartsmoking.Fourinten respondents agreed that cheap tobacco makes it possible to smoke, when otherwise theycouldnotaffordto.24

IllegalcigarettesdonotmeetReducedPropensityCigarettesregulationsintroducedin2011andcauseasignificantnumberofdomesticfiresanddeaths.

TheLondonHealthCommissionreportrecommendedthattheMayorlaunchesacrackdownonthetraffickingandsellingofillegaltobacco.25 The research report commissionedfortheSouthEastLondonIllegal Tobacco Cluster recommended that across-boroughandideallyregionalmulti-agencycooperationisneededtotackleillicittrade.26

■ CamdenandIslingtonTradingStandardsshouldcontinuetoplayaleadroleinthenewlyestablishedNorthEastNorthCentralLondonIllicitTobaccoClusterGrouptodevelopacross-boroughapproachtodealingwiththeproblemofillicittobaccosales.ThegroupincludesTradingStandardsrepresentativesfromCamden,Islington,Haringey,Enfield,Hackney,WalthamForestandTowerHamlets.

■ FurtherdeveloplinkswiththeSouthEastLondonIllicitTobaccoGroupwiththelong-termaimofdevelopingapan-Londonapproachtodealingwiththesaleofillicittobacco,toworkmorecloselywithHMRCandBorderControl.

■ Continuetobuildonsuccessesinreducingthenumberofunderagesalesandtheamountofillicittobaccoonsale,bycontinuingstrongenforcementandcontinuetoidentifypriorityareastotargetanddevelopamethodforlocalresidentstoprovideintelligence.

■ Workinpartnershipwiththeschools’healthandwellbeingteamstoraiseawarenessaboutillicittobaccoamongstyoungpeople(andtheirparents)andtoremindyoungpeoplethatshishaistobacco–itisnotalwayslabelledthatwayandyoungpeopleinparticularareunawarethattheyareconsumingtobacco,oftenillegallyimported.

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8.4 ShishaIn Camden and Islington there is widespread compliancewithsmokefreelawssincethelegislationwaswidelywelcomedbythepublicandmostbusinesses.However,therecentproliferationofshishapremiseshasseenan increase in businesses allowing smoking inenclosedspacesincontraventionofthesmokefreelaws.

Shishahasbeentraditionallyusedwithinspecificcommunities,butinLondon,asinother large cities, shisha use appears to be increasinglypopularamongstallethnicgroupsandespeciallywithyoungpeople.RecentresearchinSouthLondonsuggestedthatshishasmokingisnowendemicinLondonanda public health issue.27

Shisha smoking can take place while socialising,forexampleinashishacaféandinthehome.Shishaproducessecond-handsmoke, so when it is used in public spaces, itiscoveredbythesmokefreelegislation,whether or not it contains tobacco.

Inthelastfewyears,thenumbersofshishacafesorbarsinCamdenhavebeenontheincrease.In2013,shishapremisesinCamden

hadincreasedfrom12to16intwoyears.However,inSeptember2015,12premiseswere known to be operating. In Islington, as aresultofproactivemonitoringofpremises,theydecreasedfrom27in2012to12in2013and6inSeptember2015.

InCamdenandIslington,wehaveforgedamulti-teamapproachwithTradingStandards,theEnvironmentalHealthteams,Licensingteams,FireBrigadeandthelocalPolice.Weareaddressingenforcementoflegislationrelatingtothesaleofshishaproductscontainingtobacco,eitherpre-packagedorpreparedforsmokinginshishapremises.We are also ensuring premises do not floutthelawsprohibitingshishasmokinginenclosed spaces and do not sell to underage customers.

Islington Council, which has seen a decrease inthenumberofshishapremises,haslargelyresolvedtheproblemofnon-compliantpremises,throughacombinationofusereducationastothehealtheffects,earlyadviceto businesses thinking about shisha as a businessmodel,closecommunityliaison,multi-agencyworkingand,wherenecessary,arobustapproachtoenforcementwherethereispersistentnon-compliancewithsmokefreeand other laws.


■ CamdenandIslingtonshouldcontinuetohaveaproactiveandpreventivemulti-teamapproachtomonitorshishapremiseswithroutinevisits,untiltheycomplywithlegislationorelsestopsellingshisha.Theyshouldcontinuetotakeactionwhenshishapremisesarebreakingthelaw,suchasallowingsmokingshishaand/ or cigarettesindoors,ornotprovidingtherequiredwarninglabelsassociatedwiththesaleoftobacco.Theyshouldcontinuetoidentifyshishacafeswhichroutinelyallowunderagecustomersandtakeenforcementaction.

■ InCamden,mapthelocationofshishacafestoidentifytheirproximitytolocalschools.TradingStandardsandthehealthyschoolsteamshouldraiseawarenesswithchildrenandtheirparentsthatshishatobaccoisnotalwayslabelledthatway,soyoungpeopleinparticularmaybeunawaretheyareconsumingtobacco.

Recommendations

50

8.5 Electronic cigarettesElectroniccigarettes(ECs),alsomarketedas‘e-shisha’or‘shishasticksorpens’arecurrentlythesubjectofnationalandinternational debate, regarding their regulation,effectivenessforsmokingcessationandpotentialtoattractnon-smokers,especiallyyoungpeople,totobacco,actingasa‘gateway’tosmoking.

TheuseofECs(or‘vaping’)hasgrownthreefoldinthelasttwoyearsintheUK;2.6millionadultsusethem,almostallofwhomaresmokersorex-smokersbutuseamongyoungpeopleisrare(2%monthlyand0.5%weeklyuse).28Ina2014nationalsurveyof15yearolds,18%hadtriede-cigarettes.Thisisnotsignificantlydifferentto2015surveyresultsforYear10pupilsinCamden(20%)orIslington(18%).29Thenationalsurveyindicatesthatmostyoungpeopleusethemonceortwiceandonly3%arecurrentlyusingone.30

TheincreasingpopularityofECsanduseinpublic spaces has caused concern because ofthepotentialtore-introducesmokingbehavioursinsmokefreeenvironments.However,thereisnocurrentevidenceinEnglandthatECsarere-normalisingsmokingor increasing smoking uptake.31ECshavebecomethemostpopularquittingaidusedbysmokers.32Thus,theyhavegreatpotentialtohelp people who want to quit but who cannot overcometheiraddictiontonicotinetoreduceor stop smoking cigarettes, and in doing so, reducetheburdenofsmoking-relateddiseaseand death.

ArecentindependentevidencereviewbyPublicHealthEngland(PHE)concludedthat

althoughECsarenotcompletelyriskfree,evidenceshowstheycarryjustafractionofthe harm compared to smoking. The current bestestimateisthatECuseisaround95%lessharmfultohealththansmoking.Thereisnoidentifiedrisktobystandersfromnicotinereleasedwhenvaping,astheamountsarenegligible.33

Underthecurrentregulatorysystem,individualECproductsvaryconsiderablyinqualityandspecification.34Theyarecurrentlysubjecttoregulationsrelatingtogeneralproductsafety,buttherehasbeencriticismofthequalityofdevices,someofwhichhaveleakedormalfunctioned,oftencausingfires.Inadditionlabellingissues(suchasnicotinelevels)havebeenidentifiedincartridgesande-liquids35, includingintheresearchcompletedbyCamdenTradingStandardsofproductssoldintheboroughofCamden.

Nicotine-containingECsarenotcurrentlylicensed as medicines and are sold without thesafeguardsbuiltintotheregulationofmedicinalproducts.From20thMay2016ECswillcomeundertherevisedEUTobaccoProductsDirective,exceptwheretherapeuticclaimsaremadeortheycontainover20mg/mlofnicotine,whentheywillrequiremedicines authorisation36.IntheUK,theMedicalHealthcareRegulatoryAgency(MHRA)canregulatenicotineproductsasmedicinesanditisexpectedthatsomeproductswillbeauthorisedin2015.FollowingtheintroductionoftheTobaccoProductsDirective,ECswhicharenotlicensedunderMHRAwillbemorestrictlyregulated,includingimprovedsafetyandqualityrequirements,suchaschild/tamperproofpackagingfore-liquids,andnewpackagingandlabellingrequirements.37Restrictionsontheirsaletoyoungpeopleunder18yearsofagecameintoeffecton1stOctober2015.


ThestopsmokingservicesinCamdenandIslingtonareactivelysupportingsmokerswhouseECsaspartoftheirquitattempt,withbehaviouralsupportandadviceonlicensedmedications.NHSstopsmokingadvisorscannotcurrentlyprescribeun-licensedECsasstop smoking aids.

CamdenandIslingtonPublicHealthissuedapositionstatementonECsinApril2014.ItwasreviewedinDecember2015,inlightofPHE’sevidenceupdate:

“Onbalance,havingreviewedtheevidence,wemustconsiderhowwecanexploitthepotentialbenefitsofECsinhelpingsmokersquitwhilebuildinginsafeguardstomonitorissuessuchasthesafetyandqualityoftheproductscurrentlyavailable,promotiontochildren(andanyrelatedpotentialuptakeintobaccosmoking)andtheireffectonsmokefreelegislation.”

■ InlinewithPHEguidance,welcometheuseofECsbyexistingsmokerswhomakeaquitattemptandsupportsmokersfurthertoquittobaccoproductsusingourevidence-basedstopsmokingservices.

■ Respondpro-activelytoemergingnewevidenceonECsandtofutureavailabilityoflicensed products to be used as stop smoking aids.

■ EnsureourstopsmokingservicesandallprofessionalsinCamdenandIslingtonprovidingLevel2stopsmokingadviceareequippedtogiveup-to-dateinformationabouttherelativerisksofnicotineandallnicotine-containingproducts(includingECs),based on national guidance and regulation.

■ ContinuetomonitorthesaleofECsandensurethatsellerscomplywithnewandexistinglegislation(forexampleunder-agesales)andwithsafetyregulations,inparticularregardingunsafechargers.ExplorepotentialforpartnershipworkwiththeFireService.

Recommendations

52

References1. TheRoyalCollegeofPhysicians.Passive

smokingandchildren.AreportoftheTobaccoAdvisoryGroup.2010.Availablefrom:https://www.rcplondon.ac.uk/sites/default/files/documents/passive-smoking-and-children.pdf

2. DatafromtheHealthRelatedBehaviourQuestionnaire(HRBQ)survey2015,carriedoutinprimaryandsecondaryschoolsinCamdenandIslington.Formoreinformationcontact: GillMorris(CamdenCouncil):[email protected];HelenCameron(IslingtonCouncil): [email protected]

3. OfficeforNationalStatistics.OpinionsSurveyReportNo.40.Smoking-relatedbehaviourandattitudes2008/2009.2009.Availablefrom:http://www.ons.gov.uk/ons/rel/lifestyles/smoking-related-behaviour-and-attitudes/2008-09/index.html

4. AkhtarPC,HawSJ,CurrieDB,ZacharyR,CurrieCE.SmokingrestrictionsinthehomeandsecondhandsmokeexposureamongprimaryschoolchildrenbeforeandafterintroductionoftheScottishsmoke-freelegislation.TobaccoControl[Online]2009;18(5):409-15.Availablefrom:doi:10.1136/tc.2009.030627.

5. LovasiGS,DiezRouxAV,HoffmanEA,etal.AssociationofEnvironmentalTobaccoSmokeExposureinChildhoodwithEarlyEmphysemainAdulthoodAmongNonsmokers.AmericanJournalofEpidemiology[Online]2010;171(1):54-62.Availablefrom:doi:10.1093/aje/kwp358.Epub2009Nov25.

6. CabanaM,BirkN,SlishK,etal.Exposuretotobaccosmokeandchronicasthmasymptoms.PediatricAsthmaAllergyandImmunology2005;18(4):180-188.

7. WorldHealthOrganisation.InternationalConsultationonEnvironmentalTobaccoSmoke(ETS)andChildHealth.ConsultationReport.[Online]January1999.Availablefrom:www.who.int/tobacco/research/en/ets_report.pdf




11. YoltonK,DietrichK,AuingerPetal.ExposuretoenvironmentaltobaccosmokeandcognitiveabilitiesamongUSchildrenandadolescents.EnvironmentalHealthPerspectives2005;113(1):98–103.

12. BestD.Secondhandandprenataltobaccosmokeexposure.Pediatrics2009;124;e1017-e1044;originallypublishedonlineOct19,2009.

13. InternationalAgencyforResearchonCancer.Personal habits and indoor combustions. Volume100E:Areviewofhumancarcinogens.SecondhandSmoke.WorldHealthOrganisation.2012.Availablefrom:http://monographs.iarc.fr/ENG/Monographs/vol100E/mono100E-7.pdf

14. HemminkiK,ChenB.Parentallungcanceraspredictorofcancerrisksofoffspring:cluesaboutmultipleroutesofharmfulinfluence?InternationalJournalofCancer2006;118(3):744-748.

15. LovasiGS,DiezRouxAV,HoffmanEA,etal.AssociationofEnvironmentalTobaccoSmokeExposureinChildhoodwithEarlyEmphysemainAdulthoodAmongNonsmokers.AmericanJournalofEpidemiology[Online]2010;171(1):54-62.Availablefrom:doi:10.1093/aje/kwp358.Epub2009Nov25.


17. CentersforDiseaseControlandPrevention.Exposuretosecond-handsmokeamongstudentsaged13–15years–worldwide,2000–2007.Morbity&MortalityWeeklyReport2007;56:497–500.Availablefrom:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5620a2.htm

18. ActionforSmokingandHealth.SmokingStillKills;ProtectingChildren,ReducingInequalities.ExecutiveSummary.[Online]2015Availablefrom:http://www.ash.org.uk/files/documents/ASH_963.pdf

19. DepartmentfortheEnvironment,FoodandRuralAffairs.PreventingcigarettelitterinEngland:guidelinesforlocalauthorities.[Online]2007.Availablefrom:http://www.keepbritaintidy.org/Documents/Products/Files/662358db_2aef_4319_9cdb_bc58350eea09.pdf

20. https://www.camden.gov.uk/ccm/content/transport-and-streets/clean-streets/clean-streets-in-camden.en?page=1


21. http://www.smokefreeislington.nhs.uk/about-smokefree-islington/cleaner-greener/

22. AGovernmentconsultationranfromDecember2014toFebruary2015.Availablefrom:https://www.gov.uk/government/consultations/tobacco-levy

23. HMRevenue&Customs.TacklingIllicitTobacco:fromleaftolight.TheHMRCandBorderForcestrategytotackletobaccosmuggling.2015.Availablefromhttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/418732/Tackling_illicit_tobacco_-_From_leaf_to_light__2015_.pdf

24. Stewart,G.Yoshizaki,M.IllicitandillegaltobaccoinNorthCentralandNorthEastLondon.Areportonsmokers’perceptions,supplyanddemand.[Online]2015.Availablefrom:http://www.tradingstandards.uk/policy/illegaltobacco.cfm

25. LondonHealthCommission.BetterHealthforLondon.2014.Availablefrom:http://www.londonhealthcommission.org.uk/wp-content/uploads/London-Health-Commission_Better-Health-for-London.pdf

26. PowerG.IllicitTobaccoinSouthEastLondon:ASurveyofSmokers.‘Tobacco,CrimeandHealthInequalitiesinSouthEastLondon’.[Online]2013.Availablefrom:https://www.lambeth.gov.uk/sites/default/files/ssh-illicit-tobacco-survey-report.pdf

27. PowerG.ShishaSmokinginSouthEastLondon.Across-populationsurveyofshishauseandawarenessinSouthEastLondon.[Online]2014.Availablefrom:http://www.lambeth.gov.uk/sites/default/files/ssh-shisha-smoking.pdf

28. McNeillAetal.E-cigarettes:Anevidenceupdate.PublicHealthEngland2015.Availablefrom:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf

29. DatafromtheHealthRelatedBehaviourQuestionnaire(HRBQ)survey2015,carriedoutinprimaryandsecondaryschoolsinCamdenandIslington.Formoreinformationcontact: GillMorris(CamdenCouncil):[email protected];HelenCameron(IslingtonCouncil): [email protected]

30. HealthandSocialCareInformationCentre.HealthandWellbeingof15yearoldsinEngland:SmokingPrevalence–FindingsfromtheWhatAboutYOUth?Survey2014.Availablefrom:http://www.hscic.gov.uk/catalogue/PUB17984/what-about-youth-eng-2014-smok-rep.pdf2.HRBQ


32. SmokingToolkitStudy[Online]www.smokinginengland.info



35. McRobbieH/McEwenA(ed).ElectronicCigarettes.NationalCentreforSmokingCessationandTraining.Briefing;2014.Availablefrom:http://www.ncsct.co.uk/usr/pub/e-cigarette_briefing.pdf

36. ActionforSmokingandHealth.RegulatingNicotineProducts[Online].Availablefrom:http://www.ash.org.uk/current-policy-issues/harm-reduction-product-regulation/regulating-nicotine-products

37. EuropeanCommissionMemo.QuestionsandAnswers:Newrulesfortobaccoproducts26February2014[Online].Availablefrom: http://europa.eu/rapid/press-release_MEMO-14-134_en.htm

54

This Camden and Islington Tobacco Control Strategy2016-2021aimstoaddresstheongoingpublichealthchallengeoftobaccouse,throughthreestrandsofwork:closingthegatewaysin,helpingpeopleoutandreducing related harm. Our aim is that the rate ofsmokersinthepopulationwillfallto13%inCamdenand16%inIslingtonby2021.

WhilstsmokingprevalencehasbeensteadilydecreasingnationallyandtosomeextentinCamden,ithasremainedstubbornlystableinIslingtoninparticularsince2010.Asustainedfocusontacklingtobaccoisessential.Wealsoneedtoincreaseourfocusonaddressinghealthinequalitiescausedbysmokingbytargetingthemostdisadvantagedareasandgroupsandpromotingasmokefreestartinlifeforyoungfamilies.

Successcannotbeachievedwithoutlookingat the bigger picture and ensuring that ourplanscomplementandreinforceeachother.LeadershipfromtheNHSandLocalAuthoritiesandmakingthebestuseofourresourcesarekeyingredientsinimplementingtherecommendationsofthisstrategyeffectively.However,itisalsoimportanttoengage communities with the right messages, inordertoshiftsocialattitudesamongstthegroups with higher smoking rates and make it the normal thing not to smoke.

Totranslatethisstrategyintoaction,adeliveryplanwillbedevelopedbyCamdenandIslingtonSmokefreeAlliancepartners,whowillmonitorandoverseethetobaccocontrolprogrammesoutlinedinthestrategyoverthenext5years.WorkingwithourHealthandWellbeingBoards,wewillstrengthenexistingpartnershipsandengagenewpartners–thepublicandvoluntarysectoraswellasstatutoryauthoritygroups,toensureweareontrack.

Wewouldthereforeencourageyoutosupportthisstrategy’swork,supportingCamdenandIslingtoninourjourneytobeingsmokefreeby2030.

9

Conclusion


Project TeamProject LeadMarinaChrysou CamdenandIslingtonPublicHealth/WhittingtonHealthThankyoutoVerenaThompsonwholedtheinitialphaseofdevelopmentofthiswork.

Chapter writing and data analysisKateAlley CamdenandIslingtonPublicHealthDrLizBrutus CamdenandIslingtonPublicHealthMinkyoungChoi CamdenandIslingtonPublicHealthMarinaChrysou CamdenandIslingtonPublicHealth/WhittingtonHealthVictoriaMakepeace-Warren CamdenandIslingtonPublicHealthLeaSiba CamdenandIslingtonPublicHealth

ContributorsThankyoutothefollowingCamden&IslingtonSmokefreeAlliance(CISA)partners,CliniciansHelpingCamden&IslingtonSmokersQuitgroupandstakeholders,fortheircontributionsindevelopingthisdocumentandcommentsonthefinaldraft:KevinBlenkinsopp LondonMetropolitanPoliceSimonBristow CamdenandIslingtonNHSFoundationTrustHelenCameron SchoolsImprovementHealthandWellbeing,IslingtonCouncilSandra Chakara CamdenandIslingtonNHSFoundationTrustSuzyDymond-White NationalOffenderManagementServiceStephanie Duckworth Porras IslingtonStopSmokingService,WhittingtonHealthFionaExley Trading Standards, Islington CouncilBelindaGreen UniversityCollegeLondonHospitalsDrNeilGupta CamdenClinicalCommissioningGroupMartinHarland Trading Standards, Camden CouncilDonnaHarrison SmokefreeLifeCamden,Solutions4HealthDavidHunt Consumer Protection, Camden CouncilVincentJames EnvironmentandRegeneration,IslingtonCouncilWinstonLabarr BusinessCompliance,CamdenCouncilRobertLoton IslingtonStopSmokingService,WhittingtonHealthDougLove Trading Standards, Islington CouncilBrianMcKenna IslingtonClinicalCommissioningGroupHelenMichael CultureandEnvironment,CamdenCouncilGillMorris SchoolsImprovementHealthandWellbeing,CamdenCouncilMike Mortlock SchoolsImprovementHealthandWellbeing,CamdenCouncilDrFionaNolan CamdenandIslingtonNHSFoundationTrust

56

Design and CommunicationsCherylWestmacott MiacisMediaConsultancyLtd

SophieHutchings CommunicationsAdultSocialCareandHealth,CamdenCouncil

KimWard CommunicationsStrategyandCommunityPartnerships,Islington Council

Acknowledgments ThankyoutothemanycolleaguesinCamdenandIslingtonCouncilsandinCamdenandIslingtonClinicalCommissioningGroups(CCGs)whocommentedonthedraftstrategyandputforwardsuggestionsaboutimplementation.ThankyoutocolleaguesfortheirhelpinpreparingaplainEnglishsummaryandquestionnaireonthedraftstrategyandinengagingwiththepublic.ThequestionnairewaspublishedonWeAreCamdenwebsiteandthroughSurveyMonkeyinIslingtoninDecember2015withhelpfromthefollowingcolleagues:MubasshirAjaz Qualitativeinformationofficer,CamdenandIslingtonPublicHealth

Felicitie Walls Participationofficer,ChildrenandYoungPeople’sservices,IslingtonCouncil

Fung-YeeLee Strategyofficer,CamdenCouncil

Contributors continuedYogendra Parmar CamdenandIslingtonLocalPharmaceuticalCommitteeDrLouiseRestrick WhittingtonHealthVickySmith IslingtonStopSmokingService,WhittingtonHealthJasonStrelitz CamdenandIslingtonPublicHealthGrahamTuck StreetEnvironmentServices,IslingtonCouncilLoganVanLessen WhittingtonHealthAndrewWalker EnvironmentalHealth,IslingtonCouncilPeter Wathen RoyalFreeLondonNHSFoundationTrust

Ourintentionistoengagewiththepublicagainin2016inordertodevelopthedeliveryplanforthisstrategy.

Further informationPleasecontactMarinaChrysou(CamdenandIslingtonPublicHealth/WhittingtonHealth)foranyfurtherinformation:[email protected] 7527 6706