Suffolk Health and Wellbeing Board · Fires 27. Smoking materials are the third highest cause of non-fatal casualties in dwelling fires (after cooking materials and other electrical

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Agenda Item 10

Suffolk Health and Wellbeing Board

A committee of Suffolk County Council

Report Title: Aspiring to a tobacco free Suffolk : Moving towards a tobacco free generation

Meeting Date: 15 January 2015

Chairman: Councillor Alan Murray

Board Member Lead(s): Tessa Lindfield, Director of Public Health

Author: Dan Chapelle, Health Improvement Manager, Public Health Suffolk T. 01473 260064

Brief summary of report

1. This report describes a new approach to drive down the numbers of people smoking in Suffolk

Action recommended

2. For Board members to discuss their ability to actively support the implementation of the report recommendations:

Prevention: Creating an environment where young people choose not to smoke

RECOMMENDATION 1: Develop a smoking prevention programme for schools and youth organisations (lead agencies Public Health, Children & Young People, SCC).

RECOMMENDATION 2: Confirm that there are organisational smoke-free policies in place that ensure staff do not smoke around children and vulnerable adults. (All members of the H&W Board)

RECOMMENDATION 3: The focus on illicit tobacco should be maintained, including intelligence gathering for HMRC and underage sales. (All members of H&W Board)

RECOMMENDATION 4: Sponsor a strategic Tobacco Control Group with clear reporting structure and appropriate senior leadership (All members of the H&W Board)

Protection: Protecting people from second-hand smoke and supporting Tobacco Control interventions

RECOMMENDATION 5: Develop a smoke free homes initiative within Suffolk. Such an intervention could also be linked up with the Fire Service for provision of free fire safety checks, or could be extended to include smoke free cars (Suffolk Fire & Rescue, Public Health, SCC).

RECOMMENDATION 6: Establish smoke free terms within Local Authority tenancy agreements (All Local Authorities).

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RECOMMENDATION 7: Continue to use political and economic influence to support legalisation to strengthen Tobacco Control initiatives. This could include:

Prohibiting smoking in and within close range of children’s play areas

Supporting legalisation and campaigns that denormalises tobacco use.

(Local Authorities)

Cessation: Supporting and enabling people to quit smoking

RECOMMENDATION 8: Ensure robust evaluation of the service changes agreed with the stop smoking service which aim to deliver a more comprehensive system based on population need (Public Health Suffolk)

RECOMMENDATION 9: NHS facilities should implement the NICE recommendations on smoke-free building and grounds and routinely offer Nicotine Replacement Therapy to those admitted to hospital. (All NHS members of the H&W Board and their service providers).

RECOMMENDATION 10: Ensure front line staff are trained across the public sector to deliver MECC (Make Every Contact Count). There should be a particular emphasis on referrals from our most vulnerable communities (All members of the H&W board).

RECOMMENDATION 11: Place greater contractual emphasis on supporting prisoners to stop smoking and work with Prison Governors to gain support.

Reason for recommendation

3. Decreasing the numbers of smokers is essential to improve healthy life expectancy and tackle inequalities in health.

4. Continuing the current approach is unlikely to deliver at the scale required.

5. Commitment and action across the HWB partner organisations is needed for success.

Alternative options

6. The Board could choose to continue with the current approach, or request an alternative plan.

Who will be affected by this decision?

7. The population of Suffolk.

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Main body of report

Aspiring to a tobacco-free Suffolk: Moving towards a tobacco-free generation

January 2015

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Background

8. This report suggests that Suffolk takes a step change in the way we approach tobacco. If we proceed as we are now we cannot aspire to be smoke-free.

9. Tobacco use is the single most preventable cause of ill health in the UK. Smoking-related illnesses cause over 1,100 deaths every year in Suffolk - 3 people every day. Smoking is associated with 6,881 hospital admissions and costs the Suffolk economy an estimated £165.9 million each year through NHS costs, social care, lost productivity, smoking related fires, and smoking related litter. In Suffolk, around £208 million is spent on tobacco products2 annually.

10. One in five (19.6%) of the Suffolk population smokes1. In deprived communities it is almost 1 in 3 (30%). Smoking accounts for about half of the difference in life expectancy seen between our lowest and highest income groups2. Further reducing the use and impact of tobacco will help to:

Protect children and young people from harm;

Improve healthy life expectancy and reduce health inequalities;

Cut avoidable costs to local public services;

Boost the disposable income of the poorest people in our local area.

11. The provision of smoking cessation services and government measures such as taxation, the ban on advertising, smoke free legislation and mass-media campaigns, have seen smoking rates drop significantly over the last 40 years. But this reduction in smoking prevalence has begun to stagnate.

12. Smoking behaviour is primarily driven by addiction to nicotine but a wide range of personal, social and environmental factors influence who starts smoking, who continues to smoke and who gives up. We need a comprehensive approach with a range of interventions at different levels to challenge individual, social and cultural influences on smoking behaviour.

13. A reinvigorated strategy to reduce smoking will deliver additional protection to non-smokers, deter new smokers and enable existing smokers to stop smoking. It will focus on three themes:

Prevention - creating an environment where people choose not to

smoke.

Protection – protecting people from second-hand smoke and

supporting tobacco control interventions

Cessation –supporting and enabling people to stop smoking.

14. To succeed Suffolk needs a multi-agency and multi-stranded approach with local measures that complement and reinforce national actions in the next step towards a future “tobacco - free generation”

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The current situation

People

15. Almost 1 in 5 adults smoke (19.6%) and it is estimated that there are currently 114,000 smokers in Suffolk3.

16. The proportion of children who have ever smoked has declined to 22% in 20134 but this still equates to 33,000 young people in Suffolk. Young people who played truant or been excluded from school in the previous 12 months are almost twice as likely to smoke regularly compared to those who had not been truant or excluded4.

17. Smoking in pregnancy is harmful to the mother and baby. In Suffolk, 1 in 8 (12.5%) mothers smoke at the time of delivery which is higher than the England average5. Smoking rates in pregnancy vary by age and social group: pregnant women from unskilled occupation groups are five times more likely to smoke than professionals and teenagers who are pregnant are six times more likely to smoke than older mothers6.

18. Smoking rates in deprived communities are higher than in those living in more affluent areas. Men in the 20% most deprived areas are more than twice as likely to smoke (32.9%) compared with men in the least deprived areas (14.3%). Smoking rates amongst women are lower than those for men but still highest in the most deprived areas (26.1%) compared to the least deprived areas (10.2%)3.

19. Smoking rates in some black and minority ethnic (BME) communities are also higher, for example 37% of black Caribbean people smoke. Some communities have higher use of tobacco in other forms such as chewable tobacco or shisha pipes7.

Place

20. Smoking prevalence is similar in all the districts and boroughs of Suffolk except Babergh where the rate is lower (9.8%)5. Across all districts and boroughs there will be deprived communities that have a high proportion of smokers.

21. Smoking prevalence in prisons is as high as 80% - four times the national rate. Furthermore, prisons are exempt from the legislation that applies to indoor public places and workplaces. Prisoners are known to have poorer health than those of similar age in the community and smoking is one of the most important underlying causes.

Time

22. There has been a dramatic decrease in smoking since the early 1970s when 70% of men and 50% of women smoked8. This had decreased to 36% of men and 28% of women by the late 1990’s and in 2010 20% of men and 19% of women smoked. In 2012 19.6%, of Suffolk adults smoked, similar to the England average of 19.5%9.

Deaths

23. In 2012 there were 1,124 deaths in Suffolk due to smoking – 15% of all deaths3. Smoking is a major underlying cause to death from a variety of cancers, cardiovascular disease and respiratory disease. As the prevalence of smoking has decreased so have death rates due to smoking9.

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Poor health

24. Smoking not only shortens life, it reduces the quality of life. For every death caused by smoking there are approximately 20 people with a smoking-related disease10. These illnesses cost the NHS about £27 million annually11 due to the 6,881 Suffolk residents5 admitted to hospital each year, outpatient services and primary care

Social care

25. The total spending on social care for adults aged 50 and over during 2012-13 in Suffolk caused by tobacco related conditions is estimated at £17 million – for the estimated 14,117 individuals requiring social care. Using national averages this will be split between Suffolk County Council’s social care (£10 million) and self-funding (£7 million)11.

Productivity

26. Current smokers have significantly greater absenteeism than those who have never smoked. The cost of smoking to Suffolk employers is estimated to be around £130 million per annum based on the cost of sick leave; output lost from early deaths and cigarette breaks taken by smoking employees14. Quitting smoking significantly reduces absenteeism13.

Fires

27. Smoking materials are the third highest cause of non-fatal casualties in dwelling fires (after cooking materials and other electrical appliances). The total annual cost in Suffolk of smoking related fires is estimated at £2.5 million14. Due to preventative strategies the number of fires in Suffolk has decreased and fires triggered by cigarettes have fallen by 17% (142 to 118) over a ten year period.


Engaging young people to prevent new smokers

28. Two-thirds (66%) of current and previous regular adult smokers started before they were 18 years old and two-fifths (40%) before they were 16 years of age. People who start smoking at an early age are more likely than other smokers to smoke for a longer period of time and more likely to die from a smoking-related disease15. This highlights the importance of interventions that target the young and decrease the numbers who start smoking.

29. Smoking initiation is associated with social and environmental factors including: parental and sibling smoking; cigarette availability and price; smoking by friends and peer group members. Other major influences are exposure to tobacco marketing, depictions of smoking by role models in the media and individual factors such as the knowledge, self-esteem and self-image of the young people themselves.

30. There is evidence that long term programmes based on a holistic social competence approach are effective in decreasing uptake of smoking16. Peer-led interventions can be effective for example where young people act as Tobacco-Free advocates and assist trading standards in test purchasing. Schools and youth organisations are an important partner in developing the self-esteem of young people and delivering consistent messages.

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31. The personnel of all organisations working with young people need to model acceptable behaviour with regard to smoking. These workers are often role models for children and young people. Workers who smoke should refrain from smoking in the presence of and within sight of the young people in their care. This should form part of an organisation’s smoke free policy.


Illicit tobacco, Intelligence and Underage Sales

32. Illicit tobacco, some of which enters the UK through Felixstowe Port, undermines the effectiveness of high tobacco prices as a prevention measure. It has an estimated market share of 9% in 2013 with revenue losses of £1.1 billion17.

33. Continuing downward pressure on illegal tobacco requires regional level programmes which provide the optimum scale for expertise and resources to enforce regulation. Suffolk Trading Standards, the Police and HMRC work together and despite pressure on resources should continue to do so.

34. Directors of Public Health in parts of the East of England are working collaboratively to identify tobacco control measures which would benefit from a multi-county approach. A tobacco control office is planned which, having a broader geographical footprint, will improve working with HMRC and national partnerships on illicit tobacco.


Tobacco Control Group

35. A mechanism is required with the authority to drive the tobacco control agenda and hold organisations to account. It needs a strategic oversight group with accountability to the H&WB Board and a working group of core partners. The Tobacco Alliance focused on some of these areas but has been in abeyance since it worked on the implementation of the legislation regarding smoke-free public places. The purpose of the new group would be

... To generate momentum from all agencies into an agenda

... To flexibly draw on a wide range of partners and expertise

... To hold organisations to account for delivery streams.

36. Additionally, through this group, member organisations can be alerted to when and how co-ordinated action will deliver greater impact for example in response to local or national triggers. The Regional Tobacco Control Office could offer support to this group in developing regional campaigns on reducing illicit tobacco, smoking in pregnancy programmes, mass media communications and coordinated PR and news on tobacco to shift social norms.

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Children and Young People

37. The ban on smoking in public places has reduced the harm caused by second-hand smoke but children may still be harmed if there is smoking in cars and their homes. It is estimated that 3,402 additional incidents of childhood disease each year in Suffolk are directly attributable to the effects of second hand smoke18. The concentration of second-hand smoke in cars increases very quickly due to the confined space even if windows are open or air conditioners are used. Draft regulation has been formulated to protect children from tobacco smoke when travelling in private cars. The outcome of a consultation on legislation is imminent.

38. Based on the evidence of harm, Suffolk should establish a programme to increase the number of smoke-free homes within the county. This will reduce harm to the smoker and other members of the household, including children. It will also reduce the risks of residential fires and the cost this incurs. Local authorities can support this by considering smoke-free as a condition of tenancy.

RECOMMENDATION 5: Develop a smoke free homes initiative within Suffolk. Such an intervention could also be linked up with the Fire Service for provision of free fire safety checks and be extended to include smoke free cars (Suffolk Fire & Rescue, Public Health, SCC).


Supporting Tobacco Control Interventions

39. The Tobacco Control Group has the potential to be a powerful voice highlighting opportunities for political or economic influence on the tobacco control agenda. The UK is a signatory to the WHO Framework Convention on Tobacco Control (FCTC) we have a responsibility to protect population health policies from commercial and other vested interests of the tobacco industry (Article 5.3). Suffolk County Council has made a clear statement that it wishes to reduce the harm caused by smoking by supporting disinvestment in tobacco stock within its pension fund.

40. Decisions cannot always be made at a local level, for example the case for enforcing plain packaging of cigarette boxes which has been shown to decrease prevalence in other countries19 20. However Suffolk could take further action, for example by protecting children out of doors when they play in specific areas.

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RECOMMENDATION 7: Continue to use political and economic influence to support and strengthen Tobacco Control initiatives. This could include:

Prohibiting smoking in and within close range of children’s play

areas

Supporting legalisation and campaigns that denormalises

tobacco use. (Local Authorities)


What stop smoking services can offer

41. Many people successfully stop smoking on their own. Methods to support otherwise unaided attempts therefore have the potential to help a high proportion of the smoking population. In trials in which smokers were mailed materials to help them quit, the quit rate increased by 20% compared to a control no intervention group21.

42. The relatively new option of switching from tobacco to e-cigarettes as a much safer source of nicotine has the potential to reach smokers not able to quit on their own or with the help of stop smoking services. However the longer term harms related to e-cigarettes, which deliver a highly addictive substance, are not yet known22.

43. The Suffolk stop smoking service has concentrated on supporting smokers to quit by combining behavioural support with free stop smoking medication. The model is evidence based and has been in place over 12 years. At least 50% of those in Suffolk who use the service give up for at least 4 weeks. Information is limited about the proportion who stop long term.

44. There are a number of reasons to believe that the stop smoking service model needs updating:

As smoking levels have dropped, a greater proportion of remaining

smokers are those who find quitting more difficult, including

smokers with mental health conditions and chronic long-term

conditions.

Many current smokers have tried.to stop using the current service

model and not succeeded.

Some people are using e-cigarettes to try to stop smoking tobacco.

Recent NICE guidance on tobacco harm reduction24 has updated

the evidence around methods to quit smoking and suggested

additional intervention models.

The number of “4 week quits” in stop smoking services in England

fell by 19% in the past year23, and this drop is mirrored across

Suffolk and the East of England.

45. A revised model for Suffolk has been planned to refocus our smoking services to ensure they take account of the most recent evidence and also address the emerging issues.

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46. The new model will include:

Self-help materials to support those who want to stop smoking on their

own. These may include mobile apps, written materials or skype support.

Harm reduction approaches including cutting down prior to stopping

smoking, reduction in the amount smoked and temporary abstinence. The

aim of all harm reduction approaches will be total abstinence from

tobacco, but offering harm reduction approaches should increase

engagement by those who have previously found the 4 week quit model

doesn’t work for them.

Youth Prevention this has already been highlighted as a priority and the

Stop Smoking service will increase their focus in this area.

Quit programmes the current “quit” programme will be maintained as it has

a strong evidence base. It will continue to focus on communities with

higher rates of smoking and particular groups for example pregnant

women and people with poor mental health.

47. The change in focus for stop smoking services should increase the total number of clients starting an intervention, increase the number of youth focused prevention interventions leading to fewer smokers under 18years of age, more effectively target particular population groups like pregnant women, people with poor mental health and people in BME communities and increase the number of people quitting on their own.

48. This new model has been agreed with the current stop smoking service as a pilot over five months which will be evaluated. The evaluation will include the use of the CLeaR self-assessment tool and Suffolk County Council Public Health have applied to be part of the national Public Health England peer assessment pilot.


Opportunities for the NHS and LAs to further contribute to a decrease in smoking

49. Recent NICE guidance25 made 16 recommendations on making hospitals and other facilities smoke-free, including the grounds of NHS premises. Local hospitals have responded with varying degrees of success.


50. Local Authorities and health organisations within Suffolk have a wide sphere of influence both through the services they provide and commission. The Make Every Contact Count (MECC) programme trains staff to give evidence based brief interventions (relating to stop smoking, diet, physical activity and alcohol) and refer for additional support where necessary. The training and referral pathways are available through Livewell Suffolk and ECCH, but currently uptake by front line staff is limited.

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Smoking in Prisons

51. Smoke-free laws apply to indoor public places and workplaces but prisons in the UK are exempt. As stated earlier the smoking rate among prisoners is four times as high as the rate for the UK as a whole.

52. Smoking cessation within Suffolk prisons has been incentivised and Public Health have a contract with a 3rd party provider which pays them for each smoking quit they can deliver. However there are few successful quits within prisons – in 2013/14 only 163 prisoners quit. There is more scope to work with Prison Governors to develop a model of service that would be more effective for prisoners within the limitations of the setting.


SUMMARY OF RECOMMENDATIONS

53. The following recommendations are made to the Board for approval:







RECOMMENDATION 5: Develop a smoke free homes initiative within Suffolk. Such an intervention could also be linked up with the Fire Service for provision of free fire safety checks, or could be extended to include smoke free cars (Suffolk Fire & Rescue, Public Health, SCC).


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RECOMMENDATION 7: Continue to use political and economic influence to support legalisation to strengthen Tobacco Control initiatives. This could include:

Prohibiting smoking in and within close range of children’s play areas

Supporting legalisation and campaigns that denormalises tobacco use.

(Local Authorities)






Daniel Chappelle Amanda Jones Public Health Suffolk County Council January 2015

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Sources of Further Information

No other documents have been relied on to a material extent in preparing this report.

http://www.ncsct.co.uk/usr/pub/self-help-interventions.pdf

http://webarchive.nationalarchives.gov.uk/20140109155918/http:/www.hmrc.gov.uk/statistics/tax-gaps/ttg-2013.pdf

http://webarchive.nationalarchives.gov.uk/20140109155918/http:/www.hmrc.gov.uk/statistics/tax-gaps/ttg-2013.pdf

http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=3327

http://www.ncsct.co.uk/usr/pub/self-help-interventions.pdf

https://www.gov.uk/government/publications/electronic-cigarettes-reports-commissioned-by-phe

https://www.gov.uk/government/publications/electronic-cigarettes-reports-commissioned-by-phe

http://www.nice.org.uk/guidance/ph45

https://www.nice.org.uk/guidance/PH48

Documents

Suffolk Health and Wellbeing Board · Fires 27. Smoking materials are the third highest cause of non-fatal casualties in dwelling fires (after cooking materials and other electrical