:
HERTFORDSHIRE COUNTY COUNCIL
PUBLIC HEALTH AND LOCALISM CABINET PANEL
THURSDAY 19 MARCH AT 10.00 A.M
Agenda Item
No.
8
STOP SMOKING SERVICES IN HERTFORDSHIRE APRIL 2013 – MARCH
2014
Report of the Director of Public Health
Author: Liz Fisher, Head of Provider Services, Tobacco Control Lead
01442 453633
Executive Member: Teresa Heritage, Public Health and Localism
1.
Purpose of Report
1.1 The purpose of this report is to ask the Cabinet Panel to consider and
comment upon the performance of local stop smoking services in
Hertfordshire, in particular noting:
I.
II.
III.
The overall performance and cost of local stop smoking services
across the county.
The review of stop smoking service provision within Hertfordshire
and within specific groups and the areas identified for
development.
To consider and approve revised smoking cessation quit targets for
2015-2016.
2.2 This is in light of:
a) The County Council’s statutory responsibilities for Public Health
b) The Health and Wellbeing Board’s strategic priority to reduce the harm
from tobacco across the county
c) Hertfordshire’s Tobacco Control Strategic Plan 2013-2016
d) Hertfordshire’s Tobacco Harm Reduction Guidance, which was
approved by Cabinet Panel on 5 February 2015
2.0 Summary
2.1 This report highlights the performance of all local stop smoking services in
the county for the year 2013-2014.
2.2 Smoking prevalence is continuing to decline in Hertfordshire. It is estimated
that 15.5% of the adult population now smoke (approximately 135,300
smokers) compared with 20% in 2011 which were the latest data available
when the current quit targets were set.
Liz Fisher, Head of Provider Services, Tobacco Control Lead
Director of Public Health: Jim McManus
Page 1 of 10
:
2.3 The quit target for 2013-2014 and for 2014-2015 is 7672 smokers to have
quit smoking for at least 4 weeks.
2.4 During 2013-2014, 11,720 people attended a stop smoking service in
Hertfordshire and set a quit date to stop smoking; 6,788 went on to quit for
at least 4 weeks. This is a success rate of 58 percent compared with 51
percent for England.
2.5
In 2013-2014, there were 14 percent fewer quitters than in 2012-2013
which was 88.5 percent of the planned target for the year. By comparison in
England, there was a 20 percent reduction in people stopping smoking
through local stop smoking services over the same period.
2.6 Current smoking cessation targets may no longer be appropriate as
prevalence has declined and smokers are using alternative routes to
quitting, including harm reduction approaches. Current targets may disincentivise local providers as no local area currently is on trajectory to meet
their local smoking cessation targets for 2014-2015.
2.7 Providers may also be less inclined to invite more hard-to-reach groups into
services as they require more intensive support and are generally less
successful at quitting, even though they want to quit as much as other
smokers.
2.8
We propose recalculating the smoking cessation target, maintaining the
ambition to treat 5% of the smoking population to stop smoking each year,
but taking into account the decline in smoking prevalence:
Current target 2014/2015
Proposed target 2015/2016
Target of 7672 quits is based on:
Target of 6767 quits is based on:
 estimated smoking prevalence of  updated estimated prevalence of
19.4% (2011 data)
15.5% (2013 data) - 135,331 adult
smokers
 5% of adult smokers
 5% of adult smokers
3.0 Recommendations
3.1 The Panel is asked to:

Consider and comment upon the stop smoking services report for
2013-2014 in light of the County Council’s responsibilities for public
health.

Endorse the recommendations of the report including the revised
smoking cessation quit targets for 2015-2016.
Liz Fisher, Head of Provider Services, Tobacco Control Lead
Director of Public Health: Jim McManus
Page 2 of 10
:
4.0 Smoking Cessation Performance April 2013 - March 2014
4.1 Stop smoking services in Hertfordshire are available to anyone who lives or
works in the county for help and support to quit smoking. In Hertfordshire,
services are mainly provided by GP practices, Community Pharmacies and
by Stop Smoking Specialists employed by Hertfordshire Stop Smoking
Service (HSSS). Stop smoking services offer smokers a significantly greater
chance of stopping smoking compared with trying to quit without support.
4.2
There are over 300 local stop smoking services in Hertfordshire. Smokers
are up to 4 times more likely to stop smoking using a stop smoking service
than without support. Specialist stop smoking services also offer group,
work-place support and home visits for those unable to attend a local
service.
4.3
Stop smoking service delivery consists of behavioural support in one-one or
group settings provided over 6-8 weeks and medication supplied for up to
12 weeks. The overall quality of services in Hertfordshire is very good with a
success rate of 58% of those attending a service going onto quit compared
to 52% for England in 2013-2014.
4.4 The number of smokers accessing these services and quitting has been
increasing year on year; however, data for the last three years have shown
a significant downturn in the number of smokers using local stop smoking
services nationally and in Hertfordshire.
4.5 The use of appropriate medication increases the likelihood of quitting and in
line with best practice all licensed medications are available to smokers
planning to quit smoking. Just over 50 percent of smokers attending
services in Hertfordshire received free prescriptions in 2013-2014.
4.6
In 2013-2014, slightly more females (3542) than males (3246) attended a
stop smoking service in Hertfordshire and quit smoking. Males were slightly
more successful at quitting (59%) compared with females (57%). The
success rate of quitting smoking generally increases with age and more
smokers aged between 45-59 years used a stop smoking service in
Hertfordshire and quit smoking than any other age group .
4.7 GP practices see the greatest number of smokers, however in 2013-2014
just over 50 percent of smokers who quit smoking attended a stop smoking
service at their GP practice compared with 60 percent the previous year.
Smokers seen and outcome by intervention setting April 2013- March 2014
Liz Fisher, Head of Provider Services, Tobacco Control Lead
Director of Public Health: Jim McManus
Page 3 of 10
:
Service setting
Primary Care
Pharmacy Setting
Specialist Stop Smoking Service
Prison Medical Service
Other settings
All Settings
Number
who
set a quit date
6,003
3,678
1,909
88
42
11,720
Number who
successfully quit
3,486
1,977
1,254
39**
32
6,788
Success rate
58 %
54%
67%
44%
76%
58%
5.0 Performance in Specific Population Groups
5.1 Smoking and gender
Although equal numbers of men and women now smoke, smoking
prevalence is highest in 20-24 year old females and 25-30 year old males.
In 2013-2014, slightly more females (3542) than males (3246) attended a
local stop smoking service and quit smoking. Males were slightly more
successful at quitting (59%) compared with females (57%). Smokers in
LGBT groups have much higher levels of smoking than the general
population.
5.2 Smoking and age
Fewer young people are starting to smoke than ever before and smoking
prevalence in 15 year olds in Hertfordshire was estimated to be was 9.5
percent in 2012.i In adults, smoking prevalence decreases with age. For
every year a smoker continues to smoke beyond the age of 30, three
months of life are lost. More smokers in the 45-59 year age range
accessed services and quit smoking than any other age group.
5.3 Smoking and Ethnicity
5.31 Smoking varies considerably between ethnic minority groups and varies by
gender and correlates with socio-economic status and smoking prevalence
in the country of origin.
5.32 There are no local data on smoking prevalence and ethnicity. Data for
England as a whole indicates smoking prevalence is higher in Black
Caribbean men (37 percent) Bangladeshi men (36 percent) Pakistani men
(24 percent) and Irish men (26 percent).ii Bangladeshi and Pakistani men in
particular have higher rates of diabetes and heart disease than other BME
groups and therefore helping them to quit is a priority.
5.33 The Polish community comprises the largest BME group in Hertfordshire
with an estimated population of 10,000 in 2011, which is a significant
increase since the previous census in 2001. The estimated smoking
prevalence for Polish males is 46 percent and for Polish females, 30.9
percent.iii A project with Polish community leaders is currently underway to
identify and provide appropriate stop smoking support within the local Polish
community
Liz Fisher, Head of Provider Services, Tobacco Control Lead
Director of Public Health: Jim McManus
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:
Stopping smoking in Hertfordshire - outcome by ethnicity April 2013- March 2014
Ethnicity of service
user
White British
Irish
White other
Bangladeshi
Pakistani
Black Caribbean
Black African
Chinese
Indian
All other ethnic groups
TOTAL
Number
successfully quit
5816
109
368
19
44
33
35
4
60
300
6788
Percentage of
Total Quits
86%
1.6%
5.4%
0.3%
0.6%
0.5%
0.5%
0.06%
0.9%
4.4%
100%
Percentage of Ethnic
Group within Herts
80.8%
1.5%
5.1%
0.5%
1.1%
0.8%
1.8%
0.8%
2.6%
5.0%
100%
5.4 Smoking and socio-economic group
5.41 Smoking impacts more heavily on lower socio-economic groups and at least
40 percent of smokers are found in routine and manual occupations. iv
Children of routine and manual workers are up to three times more likely to
start smoking themselves than children of non-smokers and to have an
impact on reducing smoking prevalence, this group should be prioritised.v
5.42 Specialist stop smoking services, including one-one and group sessions
were held with a range of employers in 2013-2014 including local authority
staff. More staff from NHS organisations will be offered support to quit
smoking during 2014-2015.
5.5 Smoking in Pregnancy
5.51 The impact of smoking in pregnancy is significant in terms of morbidity,
mortality and costs to the NHS. Babies who are born to smokers are 40
percent more likely to die within the first 4 weeks of life.vi Reducing smoking
in pregnancy therefore remains a key Health and Wellbeing Board and
Public Health priority.
5.52 Smoking during pregnancy is continuing to decline. During 2013-2014, 1022
Hertfordshire women were known to have smoked throughout their
pregnancy (7.3 percent). This compares with 9.0 percent in 2012-2013.
5.53 In Hertfordshire in 2013-2014, 179 pregnant women set a quit date, with 72
successfully quitting for at least 4 weeks (40 percent success rate). This
compares with a success rate for pregnant women in England of 47
percent.vii
Liz Fisher, Head of Provider Services, Tobacco Control Lead
Director of Public Health: Jim McManus
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:
5.54 In 2014-2015, more work is being prioritised to increase midwives’
confidence in raising the issue of smoking and to be able to perform carbon
monoxide monitoring. A smoking in pregnancy social marketing campaign
was launched in February 2015.
5.55 Service quality will be monitored to ensure that stop smoking services for
pregnant women in Hertfordshire are at least as good as the average for
England in 2014-2015.
Percentage of mothers smoking at the time of delivery 2010-2014
% of Mothers smoking at time of delivery: Hertfordshire
Smoking Prevalence
Hertfordshire target by 2016
England Target 2015
12%
10%
8%
6%
1402 Women
1293 Women
1022 Women
2%
1529 Women
4%
2010/11
2011/12
2012/13
2013/14
0%
Hertfordshire Average
5.6 Smoking and mental health
5.61 Smoking prevalence in people with mental health conditions can be as high
as 70 percent and smokers with mental health conditions experience the
greatest difference in life expectancy.viii Smokers with mental health
conditions want to quit smoking as much as other smokers, but
misconceptions exist that stopping smoking will impact adversely on their
mental health condition.ix A more targeted approach for smokers with
mental health conditions needs to be prioritised in order to identify more
smokers and offer more intensive support over longer periods of time.
5.62 Hertfordshire Partnership NHS Foundation Trust (HPfT) was incentivised
through a CQUIN1 in 2013-2014. Over 700 HPfT staff were trained to give
brief intervention advice and 353 service users were referred to HSSS for
support. Service user involvement, including the views of MIND,
Healthwatch and Viewpoint will be sought in the development of future
services.
1
CQUIN – ‘Commissioning for Quality and Innovation’ is a tool for NHS commissioners (CCGs) to
set local quality improvement goals and reward excellence.
Liz Fisher, Head of Provider Services, Tobacco Control Lead
Director of Public Health: Jim McManus
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:
5.7 Smoking and offender health
5.71 Smoking prevalence is higher in the prison population and probation system
than in the general population.x In HMP the Mount, there is capacity for 770
inmates and smoking prevalence is estimated to be as high as 80 percent.xi
The provision of stop smoking services at the Mount is shared between the
Prison Medical Service as part of their core contract and HSSS specialist
services.
5.72 Prisoners are generally highly motivated to quit smoking. Of the 259
prisoners who set a date to stop smoking in 2013-2014, 105 successfully
quit (41 percent).
6.0
Key areas for development
I.
Due to the declining numbers of smokers accessing services since 2012,
more smokers need to be identified and routinely offered a referral into
evidence-based local stop smoking services.
II.
More front-line health and social care staff should trained to deliver
opportunistic brief intervention advice such as ‘Make Every Contact
Count’.
III.
As well as ensuring that there is a range of accessible and good quality
stop smoking services across the county, a more focused approach to
promoting and providing intensive specialist stop smoking services to more
vulnerable and disadvantaged groups needs to be a priority. These groups
include routine and manual workers; the unemployed; the homeless;
prisoners and offenders; people with mental health conditions; some black
and minority ethnic (BME) groups, pregnant and women and their partners
who smoke, and LGBT groups.
IV.
Disadvantaged and more addicted smokers, including those who have
failed to quit through commissioned (level 2) stop smoking services,
should be seen by specialist stop smoking services whenever possible to
increase their chances of success.
V.
To revise the current smoking cessation quit target in light of the decline in
smoking prevalence across the county and reduced demand for stop
smoking services:
We propose recalculating the smoking cessation target, maintaining the
ambition to treat 5% of the smoking population to stop smoking each year,
but taking into account the decline in smoking prevalence:
Current target 2014/2015
Target of 7672 quits is based on:
Proposed target 2015/2016
Target of 6767 quits is based on:
Liz Fisher, Head of Provider Services, Tobacco Control Lead
Director of Public Health: Jim McManus
Page 7 of 10
:


estimated smoking prevalence of 
19.4% (2011 data)
5% of adult smokers

updated estimated prevalence of
15.5% (2013 data) - 135,331 adult
smokers
5% of adult smokers
7.0 Background
7.1
Tobacco is extremely addictive and one half of long-term smokers will be
killed by their addiction, losing on average 10 years of productive life and
although smoking prevalence is declining (see figure 1 below), smoking still
kills almost 80,000 people in England and 1,500 people die prematurely in
Hertfordshire every year due to a smoking-related disease.xii
7.2
Nearly 70 percent of smokers indicate that they want to stop smoking and
50 percent say that they intend to do so within the next year. Stopping
smoking at any age will improve health, and life expectancy, however, the
younger a person stops smoking, the more years of life will be gained.
7.3 Although smokers are motivated to stop smoking, their ability to do so is
undermined by their addiction to nicotine, therefore evidence-based stop
smoking services in line with NICE guidance, are recommended by the
Department of Health and Public Health England to enable more smokers to
quit successfully and contribute to the reduction of smoking prevalence.
7.4 As well as ensuring fewer children start smoking and are protected from the
effects of second-hand smoke and ensuring fewer pregnant women smoke
during pregnancy, we need to identify and support adult smokers to quit
smoking whenever possible.
7.5
In line with other stop smoking services, regionally and nationally, there has
been a continuing decline in the number of smokers attending stop smoking
services and quitting smoking.
7.6
For the year to date for which there are complete data (April-December
2014 inclusive) 3294 smokers quit smoking through a local stop smoking
service compared with 4719 for the same period last year. This is 1425
fewer quits and a decline of 30 percent.
7.7 Helping smokers to quit smoking remains an important part of our tobacco
control strategic plan to reduce adult smoking prevalence as smokers are
up to four times more likely to quit smoking with support than trying to quit
on their own.xiii
8.0 Financial Implications
Liz Fisher, Head of Provider Services, Tobacco Control Lead
Director of Public Health: Jim McManus
Page 8 of 10
:
8.1 The total estimated cost of smoking to Hertfordshire in 2012 was nearly
£280 million, costing the NHS alone £54.9 million.
8.2
Smoking doubles the risk of developing care needs, and the estimated care
costs of smoking to Hertfordshire in 2014 is nearly £20 million.
8.3 Stop smoking services delivered in line with NICE Guidance is one of the
most cost-effective health interventions, and provides a good return on
investment: On average, £2.21 is saved for every £1.00 spent on service
delivery. The economic and health costs of smoking are so great, that even
modest reductions produce substantial gains.
8.4
In 2012-2013 (the latest data available) the ‘cost per quit’ for Hertfordshire
(including the core functions of HSSS) was £169, compared with England
average ‘cost per quit’ of £235.
8.5 The total public health allocation for Stop Smoking Services in Hertfordshire
for 2013-2014 was £1.805 million and total expenditure was £1.546 million.
The underspend was due to staff vacancies within the Hertfordshire Stop
Smoking Service core team and fewer payments to GP and community
pharmacy providers as 2,400 fewer smokers attended local stop smoking
services and 1100 fewer smokers quit smoking than in 2012-2013.
8.6 There are no additional financial implications beyond existing public health
commitment to tobacco control and smoking cessation activity.
9.0
Equalities Implications
9.1 When considering proposals placed before Members it is important that
they are fully aware of, and have themselves rigorously considered the
Equality implications of the decision that they are making.
9.2 This report does not have a negative impact on anyone with protected
characteristics and as individuals with protected characteristics are
recognised as priority groups within the report, the likelihood is that they will
benefit from the recommendations of the report.
9.3 The impact of the recommendations will be monitored and actions taken if
any negative impact is identified.
10.0 Appendices
Report on stop smoking services in Hertfordshire April 2013-March 2014
11.0 References
Liz Fisher, Head of Provider Services, Tobacco Control Lead
Director of Public Health: Jim McManus
Page 9 of 10
:
i
Hertfordshire Health Related Behaviour Survey (2012) Available at:
http://atlas.hertslis.org/IAS/hwb/priorities/HRBSDashboard.html
ii
Action on Smoking and Health (2011) Tobacco and Ethnic Minorities. Available at:
http://ash.org.uk/files/documents/ASH_131.pdf
iii
Zatronski, W. (2012) Smoking prevalence in the European community. Ann Agric
Environ Med. 19(2) p.p.181-92. Available at: www.ncbi.nlm.nih.gov/pubmed/22742786
iv
Action on Smoking and Health (2013) Smoking statistics: who smokes and how much.
Available at: http://ash.org.uk/files/documents/ASH_106.pdf
v
Marmot (2010) Fair Society, Healthy Lives, Strategic Review of Health Inequalities in
England. Available at: http://www.instituteofhealthequity.org/projects/fair-society-healthylives-the-marmot-review
vi
Royal College of Physicians (2010) Passive Smoking and Children. London: Royal
College of Physicians. Available at:
https://www.rcplondon.ac.uk/sites/default/files/documents/passive-smoking-andchildren.pdf
vii
Health and Social Care Information Centre (2014) Statistics on NHS Stop Smoking
Services in England: 1 April 2013 to 31 March 2014. Available at:
http://www.hscic.gov.uk/catalogue/PUB14610/stat-stop-smok-serv-eng-2014-q4-rep.pdf
viii
Royal College of Physicians and the Royal College of Psychiatrists (2013) Smoking
and mental health. Available at:
https://www.rcplondon.ac.uk/sites/default/files/smoking_and_mental_health__full_report_web.pdf
ix
Royal College of Physicians and the Royal College of Psychiatrists (2013) Smoking
and mental health. Available at:
https://www.rcplondon.ac.uk/sites/default/files/smoking_and_mental_health__full_report_web.pdf
x
Action on Smoking and Health (2014) Smokefree Prisons. Available at:
http://ash.org.uk/files/documents/ASH_740.pdf
xi
Action on Smoking and Health (2014) Smokefree Prisons. Available at:
http://ash.org.uk/files/documents/ASH_740.pdf
xii
Make Every Contact Count. Available at: http://www.makingeverycontactcount.co.uk
xiii
Hertfordshire County Council (2013) Hertfordshire Tobacco Control Strategic Plan
2014-2016
Liz Fisher, Head of Provider Services, Tobacco Control Lead
Director of Public Health: Jim McManus
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