Smoking is the single largest cause of preventable mortality in England. This is recognised in the Government’s Public Health White Paper ‘Healthy lives, healthy people', which states that ‘reducing smoking rates represents a huge opportunity for public health.'

Approximately 8.5 million people in England smoke and about half of all long-term smokers will die from smoking with half of those in middle age.

Tobacco use is one of the Government’s most significant public health challenges and causes over 80,000 premature deaths in England each year.

The health risks from tobacco smoking are well established. In 2006-7 there were approximately 1.4 million hospital admissions with a primary diagnosis of a disease that can be attributable to smoking.

Smoking is estimated to cost the NHS in England £2.7 billion a year and £13.7 billion in wider costs to society through sickness, absenteeism, the cost to the economy, social care, environmental pollution and smoking-related fires.  This burden impacts on every GP surgery and hospital, every local authority and every family whether they smoke or not. 

As a drug medically proven to be every bit as addictive as heroin, most tobacco users start as children.  The majority wish they could stop and are overwhelmingly in favour of helping stop the next generation becoming addicted to smoking.

About one-third of all cancer deaths can be attributed to smoking.   These include cancer of the lung, mouth, lip, throat, bladder, kidney, stomach and liver.

Chronic obstructive pulmonary disease (COPD) is the second most common cause of emergency admission to hospital and one of the most costly diseases in terms of acute hospital care (DH, 2010).  This is primarily a ‘smokers’ disease.

Provision of effective local NHS Stop Smoking Services is just one of a range of local tobacco control measures that need to be in place to reduce smoking prevalence.   Fresh North East has developed an evidence-based multi-component tobacco control programme based on an eight key strands approach that local alliances are encouraged to follow.

Smoking is linked most closely to the following JSNA topics:

Respiratory diseases

Circulatory diseases



Alcohol misuse

Illicit drug use

Last updated: 2015-06-02 11:50:47
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1. What are the key issues?

The estimated smoking prevalence in Middlesbrough (25.5%) is significantly higher than the national average (18.4%).

There is a high rate of smoking during pregnancy in Middlesbrough (23.9%). This is significantly higher than the national average (12.0%). 

The number of deaths in Middlesbrough (438 per 100,000) that are attributable to smoking is significantly higher than the national average (289 per 100,000).

In Middlesbrough, 5% of children aged 11-15 years old smoke.

In Middlesbrough, around 396 children need GP or hospital treatment every year from breathing in other peoples smoke.

Smoking costs the Middlesbrough NHS £6.3 million per year.

Smoking costs social care in Middlesbrough £1.9 million per year.

Stop Smoking Services (SSS) have seen a decrease in the numbers of people accessing services both nationally and in Middlesbrough.

The most likely reason for the decrease in people accessing an SSS is the emergence of electronic cigarettes and the likely arrival of other nicotine-containing devices currently in development provide an alternative to tobacco. However, these have not been appropriately regulated and the risks of using these alternative methods remain unknown.

People from the most disadvantaged areas (the areas with the highest smoking prevalence) have the least success in 4-week quit rates. This widens the gap in health inequalities nationally and within Middlesbrough.

Research shows that effective smoking cessation treatment is not routinely offered to people with mental health problems. On average, people with mental illness die five to ten years younger than the general population. 

Last updated: 08/06/15

2. What commissioning priorities are recommended?

Smoking cessation


Review the current stop smoking service model and decide on a service model for Tees Stop Smoking Services (SSS) to go out to tender.


Reduce smoking variability across localities by commissioning local service delivery appropriate to need.


Commission services to increase access and reduce smoking rates for specific populations such as:

  • pregnant smokers and their families;
  • BME communities;
  • Mental Health Service Users;


Ensure a whole system approach to tackling smoking across Middlesbrough including:

  • Primary & Secondary Care health professionals;
  • Local Authorities;
  • Voluntary Sector & Communities;


Incorporate brief interventions and lifestyle referral into relevant care pathways.


Tobacco control

  • Ensure Trading Standards, Environment Health and Public Health  Departments have the capacity to contribute to the tobacco control agenda
  • Tackle cheap and illicit tobacco in Middlesbrough
  • Ensure retailers comply with under-age sales legislation
  • Helping young people not to smoke
  • Maintain and promote smoke-free environments
  • Ensure alliance partners sign up to the plain packaging campaign
  • Ensure retailers comply with the Point of Sale regulations
Last updated: 02/06/15

3. Who is at risk and why?

Socioeconomic status

The prevalence of smoking amongst people in the “routine and manual” socio-economic group is higher than amongst those in the “managerial and professional” group.

Smokers from the most affluent areas are more likely to die earlier than none smokers from the most deprived areas.

The prevalence of cigarette smoking is higher for men than women.

For women, smoking is highest amongst 20 to 24-year-olds; for men the highest rate is amongst 16 to 19-year-olds, 20 to 34-year-olds and 35 to 49-year-olds.

Approximately two-thirds of current and ex-smokers who had smoked regularly at some point in their lives started smoking before they were aged 18 years old.

More than a quarter of 11 to 15-year-old children have tried smoking at least once and approximately 5% of children are regular smokers (smoking at least one cigarette a week). Girls are more likely to smoke than boys; 9% of girls are likely to have smoked in the last week compared to 6% of boys.

Bangladeshi and Irish men were more (Indian men less) likely to report smoking cigarettes than men in the general population.  Self-reported smoking prevalence is higher among women in the general population than most minority ethnic groups, except Irish (26%) and Black Caribbean women (24%).

Smoking in pregnancy
Women who smoke in pregnancy are more likely to be younger, single, of lower educational attainment and in unskilled occupations.

Mental health

There is a strong association between smoking and mental health problems.  The highest levels of smoking occur among inpatients in mental health units where up to 70% of people smoke, often heavily.  People with mental health problems are therefore at even greater risk of smoking-related harm than the general population.

Evidence suggests that people with mental health problems show the same level of motivation to quit smoking as the general population and are able to quit when offered evidence-based support.

Rates of smoking in prisons are extremely high.  Approximately 80% of prisoners smoke, compared with 22% of the UK population as a whole.

Last updated: 02/06/15

4. What is the level of need in the population?

Smoking prevalence

25.5% of adults smoke in Middlesbrough, representing approximately 27,000 people, compared with an England average of 18.4%.

In Middlesbrough, there is a strong correlation between smoking prevalence and the level of deprivation.  The more deprived the area, the higher the smoking prevalence.  Smoking rates in the most affluent wards (Quintile 5) are less than half of those in the more deprived wards (Quintile 1).  The table below shows the estimated smoking prevalence in Middlesbrough for the years 2003-05, indicating prevalence by ward.


Stop smoking service

The chart below states that 6% of the smokers in Middlesbrough accessed the Stop Smoking Service in 2014/15.

The chart below states that approximately 1.7% of the smokers in Middlesbrough have quit smoking in 2014/15.

The chart below shows the % of smokers setting a quit date and quitting at 4-weeks over a nine year period (04/05 – 12/13). Since 2004/05, the success rate has reduced both locally and nationally.

Social segmentation

Mosiac groups N & O make up 29.26% of the population of Middlesbrough (the largest two groups in Middlesbrough). These two groups have much higher than average smoking rates. According to Mosaic, on average, 40.48% of group O and 39.12% of group N are smokers.

Smoking during pregnancy

Smoking during pregnancy poses a significant health risk to both the mother and the unborn child. There are high rates of smoking during pregnancy in Middlesbrough. The current target is to ensure a 1% reduction per year in women smoking during pregnancy, with a view to reaching the target of 15% by 2015. The 2013/14 level was 23.9% - a decrease of 2.3% from the previous year.

Source: Tobacco Control Profiles

Young people

In Middlesbrough, 3.8% (2009-12) of 11-15 year olds are regular smokers.

In Middlesbrough, 1.2% (2009-12) of 11-15 year olds are occasional smokers.


Deaths in Middlesbrough attributed to smoking (438 per 100,000) are lower than the North East (373 per 100,000) but higher than the national average (289 per 100,000). The rate is decreasing year-on-year.

Source: Tobacco Control Profiles


Benchmarking is the process of comparing one district with another.

Middlesbrough v Kingston-upon-Hull

The chart below shows that Middlesbrough is worse than St. Helens for the following indicators used in the Tobacco Control Profiles: deaths from lung cancer, oral cancer registrations and smoking in pregnancy.


Last updated: 30/07/15

5. What services are currently provided?

Smoking Cessation
NHS Middlesbrough currently commissions a South Tees Specialist Stop Smoking service which includes a hub and spoke delivery model.

Hub Functions include: delivery of a range of training, generic provider support and governance, data management and reporting, financial reports and marketing coordination.

Specialist (Tier 3) Functions include: targeted and generalised cessation support. Targeted ‘specialist’ provision includes: cautionary groups (maternal smokers, under-18, and patients with contra-indications) and those requiring more intensive support (including, provision of Varenicline). 

Commissioned services include:

6 drop-in clinics within Middlesbrough delivering:

  • Support and advice
  • Workplace stop smoking support
  • Pharmacotherapies – Nicotine Replace Therapy (NRT), (offered on     prescription or via a voucher system in specific settings); Bupropion (Zyban); Varenicline (Champix)
  • CO monitoring
  • Telephone helpline support
  • Active case finding for lung health

An enhanced support to quit programme for clients who need more dedicated support. An element of the SSS contract includes training other service providers to increase capacity, choice and access of service provision.  The current service model enables a competitive market structure encompassing a range of providers, predominantly remunerated on a Payment by Results basis, with South Tees Specialist SSS accountable for 40% of the ISOP targets for both Middlesbrough and Redcar and Cleveland (please note that targets are being amended).

During 2010/11, Middlesbrough NHS SSS has seen 3,727 smokers set a quit date with their support. This represents 12.4% of the estimated smoking population. 1,410 people have reached the 4-week quit benchmark successfully, which is 4.7% of the estimated smoking population.  However, it has to be recognised that Stop Smoking Services alone cannot reduce smoking prevalence.   A comprehensive tobacco control plan involving a range of partners has to be in place.

Tobacco control

Trading standards

Trading standards contribute to the tobacco control agenda through:

  • Undertaking regular test purchasing, particularly in relation to under-age sales.
  • Identification of traders selling counterfeit, imported cigarettes.
  • Ensuring retailers comply with relevant legislation – not selling single cigarettes, age display notices, point of sale advertising, niche tobacco etc.
  • Identifying and taking enforcement action against traders selling counterfeit, imported cigarettes from retail premises and/or private dwellings.
  • Participation in regional and local campaigns to raise awareness of illegal sales, smuggling, counterfeiting and tobacco advertising and promotion through partnership working with NETSA (North East Trading Standards Authorities), FRESH, HMRC and Police.
  • To reduce the availability of tobacco/tobacco products from unlicensed premises through regularly raising awareness with other agencies and by promoting the use of the crime stoppers number in local communities.
  • Trading Standards Officers ensure current legislation is enforced and monitor any breaches through investigation of complaints, inspection, surveillance, special operations, search warrants, seizure of goods and enforcement sanctions, including prosecutions. Regular trader advice is also provided.

Environmental Health Officers

Environmental Health Officers contribute to the tobacco control agenda by:

  • Ensuring current legislation is enforced and monitor any breaches through general compliance work by inspection and routine visits.
  • Undertaking targeted education and awareness raising amongst sectors which are identified as being high risk for contravening smokefree legislation.
  • Promote the Better Health at Work Award to workplaces as part of their regulatory function which provides a supporting framework for employees wishing to quit smoking.

Second-hand smoke

In 2008 Middlesbrough Council, in conjunction with the PCT, developed a framework to raise awareness about the risk of exposure to second-hand smoke in the home or in vehicles. The Smokefree Families Project was launched and delivered jointly to raise awareness of the dangers of second-hand smoke, to train key front line health professionals and to support people to identify how they can reduce their family’s exposure to second-hand smoke in their home and car environments. The initiative was adopted on a regional scale for the North East by FRESH Smoke free North East.

Middlesbrough has a range of LA and NHS trained staff to disseminate the smoke-free message and provide ongoing training. To date the training provided has been delivered to workplaces, community groups and children’s centres, however this has been scaled down due to staffing reductions within the local authority. Resources and information on the project are available in a range of locations in Middlesbrough including key public buildings.

Smoke-Free Middlesbrough Alliance
There is an active local Alliance made up of a wide range of partners with a remit to raise the profile of tobacco control and champion local implementation of a smoke-free future. The Alliance develops, delivers and monitors an annual action plan based on regional and national guidance.

Smoking education for young people
Middlesbrough is committed to “Turning off the tap” of young smokers and hosted an event in November 2011 to raise awareness of the issues.  NHS Middlesbrough have also commissioned the production of a variety of educational prevention and support packages for young people including:

  • To Hell with the Butt – A prevention tool which can be used as part of a PSHE programme and also a 6-week support package for young smokers;
  • A key stage 2 resource for primary education; and
  • E-learning brief intervention training available for all staff working with children and young people.

Smoking education is also delivered as part of a Risk Taking Behaviour Programme in secondary schools.

Last updated: 02/06/15

6. What is the projected level of need?

No projections at present.

Last updated: 02/06/15

7. What needs might be unmet?

Education and support of young people

Young people continue to take up smoking.  There is a continuing need to educate young people on the harms of cigarettes and the benefits of not smoking.  Training needs to be given to youth/community workers in smoking awareness and brief interventions and also to identify positive role models to emphasise the 'no smoking being the social norm' message.

As very few young people access current Stop Smoking Service provision there is also a need to set up a dedicated Stop Smoking Service for those young people who are addicted to smoking and wish to quit.  There are a number of pharmacies in Middlesbrough operating under the Community Pharmacy Stop Smoking Enhanced Service scheme but currently they are only able to offer stop smoking support to young people aged 16 and over.  However, the intention stated in the Service Level Agreement is that suitably experienced and trained pharmacy staff will be able to offer a service to young people aged 12 and over, adhering to Fraser Guidelines for young people aged between 12 and 16.

It is recommended that suitable training to support this young age group is developed and delivered as soon as possible to meet the Government target ambition 'To reduce rates of regular smoking among 15 year olds in England to 12% or less by the end of 2015'.

Young people under the age of 18 still have illegal access to cigarettes.

Smoking during pregnancy

Many pregnant women continue to smoke, thus failing to give their child the best start in life.

Second hand smoke

Many non-smokers continue to suffer the effects of second-hand smoke, particularly at home and in private cars.

Mental health patients

The physical health needs of mental health patients are not being fully met by difficulties in engaging staff in undertaking the relevant brief/intermediate intervention training.  A top down approach is required.

Use of information

More information on general lifestyle issues (such as weight gain) should be available in community clinics.

More social marketing is needed to identify barriers to accessing Stop Smoking Services and quitting and also use of MOSAIC to target messages appropriately.

Stop Smoking Services

The development of a model of working in the SSS that offers more flexible support to reach more smokers as it is evident from the numbers accessing services that not all smokers feel they can, or want to, stop smoking in the way currently available.

The SSS needs to develop new ways of working such as the New Routes to Quit options currently being piloted in the Region. 

Pharmacies and prescribing

A number of pharmacies are funded to provide a stop smoking service through a tariff system.  This was commissioned primarily to improve access in terms of extended opening hours and increased convenience and choice of stop smoking services.   Community pharmacies must apply to join the Scheme by completing a self-assessment document to demonstrate that they can comply with the scheme requirements.  Selected pharmacies must agree to adhere to a service level agreement involving appropriate governance procedures; providing an appropriate level of trained staff; and collecting the full gold standard dataset in a timely manner, reimbursed under a tariff payment system.

Other pharmacies in Middlesbrough have expressed an interest in providing this service.  There is currently not sufficient resource to extend this work to enable pharmacies to provide an enhanced service particularly for clients who are routine and manual workers, pregnant women and young people, thereby contributing to a reduction in health inequalities.

From Statistics on NHS Stop Smoking Services;  England 2009/10 experimental statistics from SSS indicate that varenicline was the most successful smoking cessation aid between April 2009 and March 2010.  Of those who used varenicline 60% successfully quit, compared with 50% who received bupropion only and 47% who received NRT.   Clinical Governance requirements for the Stockton & Hartlepool SSS stipulate that if clients wish to be prescribed Varenicline, medical records must first be verified by their own GP to ensure there are no underlying medical conditions that would prevent its use.  When medical records are confirmed clients are then asked to attend for a specific appointment at a designated community clinic with an appropriately trained nurse prescriber.  Delays for clients are often experienced through waiting for confirmations from GPs, leading to frustrations for clients and SSS staff. There is continued pressure on the SSS to reduce prescribing costs.

Last updated: 02/06/15

8. What evidence is there for effective intervention?

NICE Guidance

  • Smoking cessation services (PH10) This guidance recommends that for the first time, all health professionals, including GPs seeing patients at a consultation, nurses in primary and community care, hospital clinicians, pharmacists and dentists, should advise everyone who smokes to stop and refer them to an intensive support service (for example, NHS Stop Smoking Services).
  • Brief interventions and referral for smoking cessation (PH1) This guidance recommends that all smokers should be advised to quit and referred to NHS Stop Smoking Service in primary, secondary and community care settings. For those who do not accept the offer, pharmacotherapy should be offered to them. Brief interventions for smoking could include opportunistic advice to stop, assessment of patents’ commitment to quit, offer of pharmacotherapy and/or behavioural support and provision of self-help material as well as referral to more intensive support e.g. NHS Stop Smoking Service. 
  • Quitting smoking in pregnancy and following childbirth (PH26) The recommendations mainly cover interventions to help pregnant women who smoke to quit and their partners and others in the household who smoke to quit. It also includes training for midwives to deliver interventions as well as a referral pathway from maternity services to NHS Stop Smoking Services. 
  • School-based interventions to prevent smoking (PH23) This guidance is for all those responsible for preventing the uptake of smoking by children and young people aged under 19. Information on smoking should be integrated into the curriculum and anti-smoking activities should aim to develop decision-making skills and include strategies for enhancing self-esteem.
  • Workplace interventions to promote smoking cessation (PH5) This guidance recommends employers to provide support to employees with help to stop smoking, including development of smoking cessation policy, promoting the Stop Smoking Services and allowing time off to attend smoking cessation services.
  • Preventing the uptake of smoking by children and young people (PH14) The recommendations focus on communication methods (mass media) and point-of-sales measures. These should be combined with regulation, education, cessation support and other activities as part of a comprehensive strategy.
  • Smoking cessation - varenicline (TA123) The guidance recommends varenicline as an option for smokers who have expressed a desire to quit smoking and it should be prescribed only as part of a programme of behavioural support.  
  • 2002/021 NICE recommends use of smoking cessation therapies The guidance recommends the use of pharmacotherapy such as Nicotine Replacement Therapies (NRT) in conjunction with advice and encouragement to help smokers who wish to quite.
  • Smokeless tobacco cessation – South Asian communities (PH39) - This guidance aims to help people of South Asian origin who are living in England to stop using traditional South Asian varieties of smokeless tobacco.
  • Smoking cessation: supporting people to stop smoking (QS43) This quality standard covers smoking cessation, which includes support for people to stop smoking and for people accessing smoking cessation services.
  • Tobacco: Harm Reduction Approaches to Smoking (PH45)
  • Smoking cessation in secondary care - acute, maternity and mental health services. (PH48) - This guidance aims to support smoking cessation, temporary abstinence from smoking and smokefree policies in all secondary care settings.
  • Smoking cessation in secure mental health settings - Guidance for commissioners. The guidance for commissioners provides: evidence on the effects of smoking on mental health the benefits of smoking cessation case studies where providers have successfully implemented NICE guidance PH48.
  • Introducing self-assessment for NICE guidance smoking cessation in secondary care: mental health settings (PH48) A practical guide to using the self-assessment mode- The self-assessment model offers a:
    • free-to-access model for self-assessment that can assist in evaluating the effectiveness of action to address harm from tobacco
    • suite of videos that set the scene and explain the benefits of action
    • replicable workshop format that can be delivered at a local level to support local action to reduce the harm of tobacco
Last updated: 15/06/15

9. What do people say?

Fresh has published some Middlesbrough specific public opinions surveyed in 2011 ranging from how to tackle smoking, quitting, protecting children and illegal tobacco:

Tackling smoking

  • Only 8% of people in the North East say they trust the tobacco industry to tell them the truth
  • 56% of people in the North East agree with removing tobacco display in shops, with just 11% strongly opposing
  • 57% of people in the North East support increasing tax on tobacco faster than the rate of inflation
  • 71% of the people in the North East think the government health policy should be protected fro the influence of the tobacco industry and its representatives

Help Quitting

  • 78% of smokers in Teesside say they regret they ever started smoking
  • 66% of smokers in Teesside say they would prefer not to smoke
  • 53% of smokers in Teesside say they smoke less now than they used to


Protecting children

  • 75% of people in the North East think smoking should be banned in outdoor children’s play areas
  • 78% of smokers in Teesside say the North East needs to do more to prevent children from starting smoking
  • Smoking is a childhood addiction long before it becomes an adult choice. The average age current smokers started in Teesside was just 15
  • Cancer Research UK estimates that children are three times more likely to become a smoker if parents smoke

Smoking around others

  • 82% of people in the North East say they agree that smoke free law is good for the health of the general public, with only 11% disagreeing
  • 78% of people in the North East say they support laws to ban smoking in cars carrying children
  • 93% of smokers in Teesside say they worry about smoking around children

Illegal Tobacco 

  • 56% of smokers who buy illegal tobacco in Middlesbrough agree it enables them to smoke when they could not afford to do so otherwise
  • 90% of people in Middlesbrough say illegal cigarettes are a danger to children as they can buy them cheaply and easily
Last updated: 09/05/12

10. What additional needs assessment is required?

No further needs assessment is required at this stage. There is a strong evidence base for effective intervention.

Some identified needs are unmet and these should be addressed particularly access to services for BME groups, young smokers and individuals with mental health issues.

Last updated: 09/05/12

Key contact: Rachel McIlvenna

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Local strategies and plans

  • Middlesbrough Tobacco Alliance Action Plan, 2011/12
  • Fresh North East Regional Delivery Plan, 2011/12

National strategies and plans

  • Stop smoking service delivery and monitoring guidance, 2011/12
  • A smoke free future: a comprehensive tobacco control strategy for England, February 2010

Other references

  • Ash -
  • Cancer Research -
  • Health Profiles -
  • Statistics on NHS Stop Smoking Services;  England, April 2009 to March 2010 NHS.IC –
  • Statistics on Smoking:  England, 2011, NHS Information Centre –
  • Healthy Lives, Healthy People: A Tobacco Control Plan for England, HM Government 2011
  • Doll R, Peto R, Boreham J, Sutherland I, (2004) Mortality in relation to smoking: 50 years observations on male british doctors BMJ 328, 1519.
  • Office for National Statistics (2009) General Lifestyle Survey
  • Stop Smoking Interventions in Mental Health Settings (2010) : A Systems Approach.
  • Passive Smoking and Children (2010) A Report by the Tobacco Advisory Group of the Royal College of Physicians.
  • Office for National Statistics (2010) Smoking and Drinking among adults
  • Integrated Household Survey - all adult prevalence data (October 2009-September 2010)
  • NHS Information Centre, Statistics on Smoking England, 2010
  • Directly standardized rate of smoking-related deaths from Local Tobacco Profiles
  • Sproston K and Mindell J. (eds) Health Survey for England 2004. The health of minority ethnic groups. Leeds, The Information Centre, 2004