Smoking

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

Cancer

Poverty

Alcohol misuse

Illicit drug use

Last updated: 2015-06-02 12:01:57
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1. What are the key issues?

The estimated smoking prevalence in Redcar & Cleveland (24.7%) is higher than the national average (18.4%).

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

The number of deaths in Redcar & Cleveland (362 per 100,000) that are attributable to smoking is significantly higher than the national average (289 per 100,000).

In Redcar & Cleveland, 5.5% of children aged 11-15 years old smoke.

In Redcar & Cleveland, around 357 children need GP or hospital treatment every year from breathing in other peoples smoke.

Smoking costs the Redcar & Cleveland NHS £6.5 million per year.

Smoking costs social care in Redcar & Cleveland £1.9 million per year.

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

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 Redcar & Cleveland.

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?

2015/01

Increase the number of tier 2 stop smoking service providers offering a service to maternal smokers and young people

2015/02

Improve the data collection of SSS information and improve referrals from acute to community settings

2015/03

Pilot a stop smoking service within a mental health trust

2015/04

Review the current Secondary Care Stop Smoking Service and re-commission with a focus on building a robust onsite stop smoking service facility that is fully-integrated with community stop smoking providers. Integration would be facilitated through the electronic referral system commissioned by the Authorities (i.e. Quit Manager) and a contract currency model that linked variable volume payments to the successful handover of service-users.

2015/05

Increase local information on the smoking habits and tobacco use of young people across Redcar & Cleveland

2015/06

Enhance capacity to conduct more focused work on illicit tobacco to increase local intelligence

2015/07

Review maternity tariff to mainstream the Baby CleaR pathway

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.

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

Age
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.

Ethnicity
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.

Prisoners
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

24.7% of adults smoke in Redcar & Cleveland, representing approximately 27,000 people, compared with an England average of 18.4%.

In Redcar & Cleveland, 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 Redcar & Cleveland for the years 2003-05, indicating prevalence by ward.

Stop smoking service

The chart below states that 5.7% of the smokers in Redcar & Cleveland accessed the Stop Smoking Service in 2014/15.

The chart below states that approximately 1.8% of the smokers in Redcar & Cleveland 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 E, J, K & O make up 61% of the population of Redcar & Cleveland (the largest four groups in Redcar & Cleveland). Groups K and O have much higher than average smoking rates. According to Mosaic, on average, 40.48% of group O and 32.35% of group K 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 Redcar & Cleveland. 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 0.3% from the previous year.

Source: Tobacco Control Profiles

Young people

In Redcar & Cleveland, 4% (2009-12) of 11-15 year olds are regular smokers.

In Redcar & Cleveland, 1.5% (2009-12) of 11-15 year olds are occasional smokers.

Mortality

Deaths in Redcar & Cleveland attributed to smoking (362 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

Benchmarking is the process of comparing one district with another.

Redcar & Cleveland v St. Helens

The chart below shows that Redcar & Cleveland is worse than St. Helens for the following indicators used in the Tobacco Control Profiles: deaths from/registrations of lung cancer, smoking attributable hospital admissions (incl costs per capita) and smoking in pregnancy.

 The cost of tobacco control

The estimated cost of smoking in Redcar & Cleveland is almost £50 million.

 

Last updated: 30/07/15

5. What services are currently provided?

Smoking cessation

South of Tees Stop Smoking Service working through Middlesbrough and Redcar & Cleveland NHS Foundation Trust, provide 6 stop smoking clinics per geographical area in a variety of community locations with easy access and at varied times.  Services include:

  • Support and advice to clients and staff
  • Pharmacotherapies – Nicotine Replace Therapy (NRT), (offered on prescription or via a voucher system in specific settings); Bupropion (Zyban); Varenicline (Champix)  
  • Carbon Monoxide monitoring and calibration
  • Telephone helpline support
  • Workplace stop smoking support
  • An enhanced support to quit programme for clients who need more dedicated support
  • Training a wide range of professionals in brief interventions

An element of the stop smoking service contract includes training up other service providers to increase the choice and access of service provision.  The current service model enables a competitive market structure encompassing a range of providers including 19 GP surgeries and 14 Pharmacies, predominantly remunerated on a Payment by Results basis, with South Specialist Stop Smoking Service accountable for 40% of the ISOP targets for both Middlesbrough and Redcar and Cleveland.

During 2010/11, Redcar and Cleveland NHS Stop Smoking Service has seen 3,470 smokers set a quit date with their support. This represents 13.3% of the estimated smoking population. 1,388 people have reached the 4-week quit benchmark successfully, which is 5.3% 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

Through Smokefree Redcar & Cleveland, funding has been provided to the tobacco control agenda through the following objectives:

  • To develop, manage and deliver an overall strategy aimed at reducing the sales of tobacco/alcohol to children within the authority – including update of current procedures / practices – in conjunction with the Senior Trading Standards Officer.
  • To enforce current legislation through Test Purchase (TP) exercises of alcohol and tobacco products together with the potential for expanding direct enforcement of illegal sales of fireworks and abusable solvents.
  • To work with communities raising awareness of the penalties of purchasing age restricted products for children and young people
  • To carry out targeted test purchases on individual problem traders based on available intelligence.
  • To inspect retailers of tobacco products each year checking for illicit tobacco, compliance with signage.
  • To work with primary/secondary schools, businesses, other council colleagues and community groups in the provision of advice, guidance, support and development of effective intelligence collection practices.
  • To inspect vehicles under smoke-free legislation.
  • To promote the use and acceptance of an appropriate proof of age card that complies with the PASS scheme standards.
  • To work with local partners to facilitate local answers to local problems.
  • To remain abreast of changes to best practice procedures and legislation.
  • To maintain appropriate records and compile reports as required for internal and external purposes.
  • To reduce the availability of tobacco/tobacco products and alcohol from unlicensed premises through raising awareness within local communities and by promoting the use of the crime stoppers number in local communities.
  • To provide support to the Smoke-Free R&C Alliance by promoting their targeted campaigns.
  • Develop strong partnership working with Neighbourhood Managers and Officers to engage with local communities

Secondhand Smoke

Smoke-free families

As part of the stop smoking service contract in 2008, Middlesbrough and Redcar & Cleveland Community Services (Now Community Division STHFT) launched the Smokefree Families Project. The aim of the project is to raise awareness of the dangers of second-hand smoke, to train key professionals and to support people to identify how they can reduce their family’s exposure to second-hand smoke in their homes and cars.

Redcar and Cleveland currently have 9 trained members of staff who are able to provide training. To date the training provided has delivered to workplaces, community groups and children’s centres. Resources and information on the project are available in a range of locations across Redcar & Cleveland including key public buildings.

Smoke-Free Redcar and Cleveland 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

Redcar and Cleveland are committed to “Turning off the tap” of young smokers and hosted an event in November 2011 to raise awareness of the issues.  NHS Redcar and Cleveland 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;
  • CIGS (Cigarette informing girls a youth health media group) have been formed now for 1 year and have worked with Time out of the Box to produce a resource.  The girls have produced a thought provoking film and accompanying resource to be used mainly in youth settings but it can also be used to complement a planned scheme of work.
  • A key stage 2 resource for primary education; and
  • E-learning brief intervention training available for all staff working with children and young people.

Redcar and Cleveland “Our Plan” and the Smoke-free Redcar & Cleveland Alliance action plans also contain key actions for reducing the uptake of ysmoking by young people.

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.  The pharmacies in Redcar & Cleveland 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 Redcar & Cleveland 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.

Payment by results

Currently only GPs and Pharmacies provide a stop smoking service through a tariff system.  The development of a non-clinical stop smoking service delivered via a voucher scheme would offer greater choice of services in local communities whilst stimulating the marker.

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 Middlesbrough and Redcar & Cleveland 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 also no formal shared care agreement between GPs in Redcar & Cleveland and the Stop Smoking Service which means that they have to rely on relationships which have been developed.  Without a formal shared care agreement being developed and adopted the ability of specialist advisors prescribing verenicline could lessen.

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

Smoking as an addiction

56% of smokers in Teesside admit they are dependent on cigarettes

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

47% of smokers state that health and expense associated with smoking are the most influential factors on deciding to quit

Illegal tobacco

71% of smokers in Redcar & Cleveland say they do not buy illegal tobacco

88% of smokers who buy illegal tobacco in Redcar & Cleveland agree it enables them to smoke when they could not afford to do so otherwise

86% of people in Redcar & Cleveland say illegal cigarettes are a danger to children as they can buy them easily and cheaply

College students

92% prefer their boyfriend or girlfriend to be a non-smoker

75% find smoking unattractive

Smoking Cessation Services

96% of clients stated they were “very satisfied” or ”satisfied” with the support they had received in order to stop smoking

99% of clients stated that they would recommend the service to others who want to stop smoking

95% of clients stated they would return to the service to help them stop smoking if they started again

Last updated: 02/06/15

10. What additional needs assessment is required?

There is a strong evidence base for effective intervention. However, there is a need to understand whether the currently stop smoking service model is suitable to meet the local needs and how this link to the increasing use of non-licensed nicotine containing products such as e-cigarettes

Last updated: 02/06/15

Key Contact

Name: Rebecca Laidler

Job Title: Health Improvement Commissioning Lead

e-mail: rebecca.laidler@redcar-cleveland.gov.uk

phone: 01642 77 1604