Lewisham JSNA: Tobacco Control 2011
Key Messages
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Smoking is the primary cause of premature mortality and preventable
illness1.
Smoking kills half of all life long users; an average 20 years prematurely2
People on low incomes are twice as likely to smoke as the more affluent,3
to have started younger and to be more heavily addicted
People on the lowest incomes who smoke, spend up to 15% of their total
weekly income on tobacco
Lewisham has the fifth highest rate of smoking attributable deaths in
London4
More than 40% of total tobacco consumption is by those with mental
illness5
Passive (secondhand) smoking in the home is a major hazard to the
health of millions of children in the UK who live with smokers6
Children with a mother or both parents who smoke are 2-3 times as likely
to take up smoking themselves7
Only 8% of smokers access a stop smoking service when they try to quit8
1
Healthy Lives, Healthy People: A Tobacco Control Plan for England. HM Government 2011.
Doll R, Peto, R, Boreham J & Sutherland I. Mortality in relation to smoking: 50 years' observations on
male British doctors. BMJ 2004; 328: 1519 http://www.bmj.com/content/328/7455/1519.long
3
ONS General Lifestyle Survey 2009
4
London Health Observatory 2010: local tobacco control profiles for England
5
Stop Smoking Interventions in Mental Health Settings: A Systems Approach 2010
6
Passive Smoking and Children: A Report by the Tobacco Advisory Group of the Royal College of
Physicians March 2010
7
As in 6 above
8Office for National Statistics (2010) Smoking and drinking among adults, 2008. ONS
2
1
WHAT DO WE KNOW?
1.
Facts and figures
Tobacco is the only legally available consumer product that kills people when it is
used entirely as intended9.
1.1
Smoking burden
Smoking is the single greatest cause of preventable illness and premature death
in the UK, and is one of the main determinants of health inequalities. It is the
major contributing factor to the mortality divide between the most deprived areas
in England and England as a whole. It is estimated to cost the NHS in the UK
£5.2 billion a year.
It is a major contributor to ill health, including circulatory disease, cancer and
chronic obstructive pulmonary disease (COPD). Worldwide approximately 1.3
billion people currently smoke cigarettes or other tobacco products, and the
annual death toll from tobacco could rise to more than eight million by 203010.
Nearly two thirds of the world’s smokers live in just ten countries, the largest
proportion being in China, then India. In the EU, there is wide variation on
smoking prevalence, with 18% smoking in Sweden and up to 42% in Greece11.
The average for the twenty five countries of the EU was 32%. The global tobacco
epidemic threatens more lives than any infectious disease.12
Nationally, one fifth of all UK deaths, 112,000 per year, are caused by smoking.
One in two regular smokers is killed by tobacco, half dying before the age of 70
losing an average of 21 years of life. Around 84% of deaths from chronic
obstructive pulmonary disease, and 90% of all deaths from lung cancer are
caused by smoking. It is estimated that around 5% of all hospital admissions in
2008/09 were attributable to smoking.
There are a number of different sources of information about smoking
prevalence. The key sources are the General Lifestyle Survey, the Integrated
Household Survey, the Health Survey for England, and the ‘Smoking Epidemic in
England’ paper produced by the Institute for the Geography of Health at The
University of Portsmouth in 2004 and the GP Quality and Outcomes Framework
data13.
9
Oxford Medical Companion 1994
Cancer Research UK webpage, smoking statistics
11 European Commission, S.E., Attitudes of Europeans towards Tobacco, 2007.
12 WHO report on global tobacco epidemic 2008
10
13
See appendix for different measures of smoking prevalence
2
1.2
Smoking prevalence
Smoking prevalence for England was estimated to be 21% from the Integrated
Household Survey for the period October 2009 to September 2010. This is the
same as the 2009 General Lifestyle Survey, which estimated that 21 % of the
adult population were cigarette smokers, in Great Britain, in 2009,
1.3
Young people and smoking
Child and adolescent smoking causes serious risks to respiratory health and
increases the risk of chronic obstructive pulmonary disease later in life. The
earlier children become regular smokers and continue as adults, the greater the
risk of developing lung cancer or heart disease.14
Most long term smokers start smoking in their teens. Experimentation is an
important predictor of future use. Children who experiment with cigarettes can
quickly become addicted to the nicotine in tobacco. Children may show signs of
addiction within four weeks of starting to smoke and before they commence daily
smoking.15
Children who live with parents or siblings who smoke are 2 – 3 times more likely
to become smokers themselves than children of non-smoking households.
There is a strong association between smoking, other substance use, alcohol
consumption and truanting or school exclusion.
Every year, around 200,000 children and young people start smoking in England.
In 2009, 6% of school pupils said that they smoked at least once a week 6. In
2009, 29% of pupils aged 11-15 said they had tried smoking at least once. This is
lower than at any time since the young people’s smoking survey began in 1982.
The proportion of pupils who had tried smoking at least once represents a long
term decline since 1982, when 53% had tried smoking. Girls are more likely than
boys to have ever smoked or be regular smokers. The prevalence of regular
smoking increases with age, from less than 0.5% of 11 year olds to 15% of 15year olds. The 2009 survey found that those who describe their ethnicity as
mixed or black are less likely to smoke than white pupils.
In 2010, the Schools Health Education Survey of 3000 Lewisham pupils found a
decrease in the number of pupils who said they had ever smoked or expected to
14
15
ASH Young People and Smoking 2011
Di Franza JR et al. Initial symptoms of nicotine addiction in adolescents. Tobacco Control 2000
3
smoke when they were older in comparison with 2008. Seventy four percent said
they had never smoked at all. Seventy four percent of primary pupils said they
will not smoke when they are older. Four percent of Year 8 boys and 4% of Year
10 boys said they smoked ‘regularly’ or ‘occasionally’. Five percent of Year 8
girls and 5% of Year 10 girls said they smoked ‘regularly’ or ‘occasionally’.
However, 48% of pupils said that someone in their family smoked. Twenty
percent of pupils said that their mother smoked on most days, 30% of pupils said
that their father did. Twenty one percent said that they had a close friend that
smoked on most days. It is likely that pupils have under-reported smoking as
they may not wish to divulge their smoking status.
1.4
Mental health and smoking
Those with severe mental illness die on average 25 years earlier than the
general population and are 10 times more likely to die from respiratory disease.
Most of this increased mortality can be attributed to higher rates and levels of
smoking. Doses of many psychiatric medications can be reduced by up to 50% if
a mental health service user stops smoking, with a reduction in side effects.
Smoking rates are much higher among people with mental illness. Over 70% of
psychiatric inpatients smoke; 50% of them heavily, and 76% of people with first
episode psychosis are smokers. More than 40% of total tobacco consumption is
by those with mental illness.
Over 50% of smokers with mental illness say they would like to stop, but are less
likely to be offered help to do so.
1.5
Pregnancy and Smoking
Maternal smoking is a major risk factor for low birth weight. Babies born to
women who smoke are on average 200-250 grams lighter than babies born to
non-smoking mothers. Furthermore, the more cigarettes a woman smokes during
pregnancy, the less well the foetus grows and develops. It is estimated that one
third of all peri-natal deaths are caused by maternal smoking. More than one
quarter of the risk of Sudden Infant Death Syndrome is attributable to smoking.
Women who smoke in pregnancy are more likely to be younger, single, of lower
educational achievement and in unskilled occupations.
The 2005 Infant Feeding Survey found that almost half (49%) of women who
smoked before pregnancy managed to stop once they became pregnant but 17%
of mothers-to-be continued to smoke throughout their pregnancy. In 2010, the
percentage of mothers reported to be smoking at delivery in England had
4
dropped to 13.6% in 2010/11 (Quarter 1 figures). However it is widely felt that
these self reported figures are likely to be inaccurate16.
1.6 Ethnicity and Smoking
The main source of information about ethnicity and smoking is The Heath Survey
for England (HSE) in 2004 17, which looked in particular at the health of ethnic
minority groups.
Self-reported cigarette smoking prevalence was 40% among Bangladeshi, 30%
Irish, 29% Pakistani, 25% of Black Caribbean, 21% Black African and Chinese,
and 20% in Indian men, compared with 24% among men in the general
population. After adjustment for age, Bangladeshi and Irish men were more and
Indian men less, likely to report smoking cigarettes than men in the general
population.
Self-reported smoking prevalence was higher among women in the general
population (23%) than most minority ethnic groups, except Irish (26%) and Black
Caribbean women (24%). The figures for the other groups were 10% Black
African, 8% Chinese, 5% Indian and Pakistani, and 2% in Bangladeshi women.
Figure 1
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Men
n
la
tio
e
n
Ethnic group
pu
G
en
er
al
Po
C
hi
n
es
ia
an
In
d
Af
ric
Iri
sh
Ca
rib
be
an
k
Pa
Bl
ac
Ba
ng
l
ad
es
h
Women
kis
ta
n
Percentage
Percentage of smokers in minority ethnic groups,
2004
Source: HSE 2004, summary of key findings
1.7
Deprivation and smoking
Smoking is responsible for more than half the difference in premature death rates
between people on high incomes and those on low incomes.
16
Action on Smoking and Health Fact Sheet 2011
The Heath Survey for England (HSE) is an annual survey, designed to monitor the health of the
population of England. Each survey consists of core questions and measurements, plus modules of
questions on specific issues that change periodically.
17
5
Smoking rates are markedly higher among poorer people. The General Lifestyle
Survey has consistently shown striking differences in the prevalence of cigarette
smoking in relation to socio-economic status, with smoking being much more
prevalent among those in manual groups than among those in non-manual
groups. Smoking prevalence is higher in lower socio economic groups and the
number of cigarettes smoked per day is also high in this group. Cigarette
smoking is higher among households classified as routine and manual (26%),
than those classified as professional and managerial (15%)18. Smoking
prevalence among low income groups is declining at a slower rate than the
general population of smokers. People in deprived circumstances are not only
more likely to take up smoking but generally start younger, smoke more heavily
and are less likely to quit smoking, each of which increases the risk of smokingrelated disease.
In poorer families, parents’ addiction to tobacco can sometimes divert scarce
funds away from meeting basic needs. The UK government’s independent
inquiry on inequalities in health reported that parents smoked in more than 70%
of two-parent households on income support, spending about 15% of their
disposable income on cigarettes. Children in these families were more likely to
lack basic amenities such as food, shoes and coats. Interviews with smokers in
low socioeconomic groups support the idea that the majority will find the money
or use other strategies to obtain cigarettes, even when circumstances are
difficult.
1.8
Second Hand smoking
Breathing in other people’s cigarette smoke is called passive smoking, or
secondhand smoking. The US Environmental Protection Agency classifies
environmental or secondhand tobacco smoke as a Class A carcinogen. The
British Medical Association says that there is no safe level of exposure to
secondhand smoke. Exposure to other people's smoke increases the risk of lung
cancer by 20-30% and coronary heart disease by 25-35%. In babies and children
it can cause respiratory disease, cot death, middle ear infections and asthma
attacks.
Table 1 Main health risks of Second Hand Smoking
Main health
risks of Second
Hand Smoking
Adults
18
There is conclusive evidence
that exposure to SHS causes:
Lung cancer
Coronary heart disease
There is substantial
evidence that exposure to
SHS causes:
Stroke
Chronic obstructive
ONS Smoking and drinking among adults, 2009 General Lifestyle Survey 2009
6
Children
and pregnancy
Asthma attacks in those
already affected
Onset of symptoms of heart
disease
Worsening of symptoms of
bronchitis
Cot death
Middle-ear disease (ear
infections)
Respiratory infections
Asthma attacks in those
already affected
Reduced lung function
pulmonary disease
Reduced lung function
Onset of asthma
Reduced fetal growth
Premature birth
Development of asthma in
those previously unaffected
1.9
Smoking in Lewisham
Tobacco use is the biggest single factor in the gap in healthy life expectancy
between Lewisham and England.
Lewisham performed significantly worse on 9 out of 15 smoking indicators in the
local tobacco control profiles from the London Health Observatory 2010. In
2006-08, there was a rate of 267 per 100,000 smoking attributable deaths
compared with a 206.8 average in England as a whole19. Some of the other
indicators for which Lewisham performed worse than England included deaths
from lung cancer, numbers of hospital admissions, adult smoking prevalence,
and numbers of successful quitters. Lewisham had the sixth highest estimated
smoking prevalence in London, using the Integrated Household Survey (IHS)
data.
There is no precise measure of smoking prevalence in Lewisham. Using IHS
data for Lewisham there was an estimated 19.9% (17.7% to 22.6%) smoking rate
in Lewisham for the period September 2009 to October 2010 from a survey
sample of 875 responders. The difference from England at 21% was not
statistically significant.
However the estimated prevalence data that is available from Local Tobacco
Control Profiles,20 states a smoking prevalence of 27.1% for the three year period
2006/2008, higher than the England prevalence of 22.2% and London
prevalence of 20.8%.
19
20
Association of Public Health Observatories: Local Tobacco Control profiles 2010
ibid
7
Smoking prevalence from the ‘GP recorded smoking prevalence’ data in 2009
ranged from 17% in some Lewisham practice populations to 24% in others for
patients aged 16 and above. It is unlikely that the range between practices
would be as large as 7%. Despite the fact that it provides a measure of smoking
prevalence, it does not give an accurate picture due to incomplete data in some
practices and some smokers being reluctant to inform their GPs if they continue
to smoke.
The number of smokers in Lewisham is estimated to lie somewhere between
45,000 and 50,000 (with 58,253 at 27.1% and 37,325 at 17%).
With the exception of pregnant women and practice populations there is no data
available on smoking prevalence in different population groups in Lewisham,
therefore prevalence data for different population groups has to be extrapolated
from national data (as described above).
Data is available on the numbers of pregnant women smoking at the time of
delivery in Lewisham. The 2009/10 data estimates that 7.15% of pregnant
women were still smoking throughout pregnancy in Lewisham. This is taken from
data collected by hospitals in Lambeth, Southwark and Lewisham, however, this
is below the England smoking in pregnancy prevalence and the target for
pregnant smokers and will need to be validated.
Using the GP smoking prevalence data, it is possible to plot smoking prevalence
for each practice, which can then be considered in terms of deprivation. As would
be expected, a high Index of Multiple Deprivation (IMD) score correlates with
high smoking prevalence.
Table 2 looks at the ratio of smoking indicators for the most and least deprived
practices compared with Lewisham. A ratio of 1.00 indicates a similar profile to
Lewisham, above 1 is higher than Lewisham and below one is lower than the
Lewisham average.
8
Table 2: Ratio of smoking indicators comparing most deprived practices with least
deprived by IMD score
Practice Name
Lee Road
Torridon Road
Brockley
MacDonagh
Hilly Fields
Lewisham
Amersham Vale
Batra (Waldon)
Jamil (Waldron)
Boundfield Road
Bellingham Green
IMD Ratio
0.66
0.75
0.76
0.78
0.81
1
1.19
1.17
1.17
1.26
1.31
% 0-24 yrs
ratio
0.74
1.00
0.97
0.81
0.95
% 75 +
ratio
1.05
0.71
0.66
1.42
0.58
1.14
1.12
1.07
1.24
1.17
0.3
0.33
0.49
0.5
0.57
Smoking Prevalence
ratio
0.84
0.90
0.87
0.91
0.91
1
1.01
1.01
1.01
1.11
1.24
Smoking recorded
in last 15 months ratio
1.02
1.00
1.03
0.98
0.98
1
1.03
1.00
1.03
1.04
1.02
Source: Lewisham PCT Public Health Department, Annual Public Health Report 2009
2.
Trends
The overall prevalence of smoking in England has been around 21% since 2007.
The prevalence of cigarette smoking fell substantially in the 1970s and the early
1980s, from 45% in 1974 to 35% in 1982. The rate of decline then slowed, with
prevalence falling by only about one percentage point every two years until 1994,
after which it leveled out at about 27% before resuming a slow decline in the
2000s6.
2.1
Gender
The smoking prevalence difference between men and women has substantially
dropped to 22 per cent (men) and 20 per cent (women) in 2009, from the 1974
level of 51 per cent (men) and 41 per cent (women). 21
21
Smoking and drinking among adults, 2009, Office for National Statistics as part of the General Lifestyle Survey
9
Figure 2 - The Percentage of adults who smoke cigarettes by gender:
Great Britain 1974 to 2005
Source: General Household Survey 2005
Throughout the period in which the General Lifestyle Survey has been monitoring
cigarette smoking, prevalence has been higher among men than women and this
continues to be the case, with 22% men and 20% women smoking in 2009. In
1974, 51% of men smoked cigarettes, compared with 41% of women. Since the
early 1990s there has been an increase in the proportion of women taking up
smoking before the age of 16. In 1992, 28% of women who had ever smoked
started before the age of 16. In 2009 the corresponding figure was 37%. There
has been little change since 1992 in the proportion of men who had started
smoking regularly before the age of 16.
2.2
Age
Since the early 1990s, the prevalence of cigarette smoking has been higher
among those aged 20 to 34 than among those in other age groups. In 2009, 25%
16 – 24 year olds and 29% of 25 - 34 year olds were current smokers. Smoking
prevalence continues to be lowest in those aged over 60 years at 14%.
Since the survey began, it has shown considerable fluctuation in prevalence
rates among those aged 16 to 19 years. However, this is mainly due to the small
sample size in this age group and has occurred within a pattern of overall decline
in smoking prevalence in this age group from 31% in 1998 to 25% in 2009.
2.3
Socio–economic status
In the 1970s, 1980s and 1990s, the prevalence of cigarette smoking fell more
sharply among those in non-manual than in manual groups, so that differences
between the groups became proportionately greater8.
10
2.4
Ethnicity
The proportion of cigarette smokers in the general population fell to 24% of men
and 23% of women in 2004, from 27% for both in 1999. Among Black Caribbean
men and Irish men and women, cigarette smoking was also less prevalent in
2004 than in 1999. The prevalence in Black Caribbean men fell to 25% in 2004
from 35% in 1999, in Irish men to 30% in 2004 from 39% in 1999, and in Irish
women to 26% in 2004 from 33% in 1999. For all other minority ethnic groups no
differences were observed.
Questions about use of chewing tobacco were asked of South Asian (Pakistani,
Indian, Bangladeshi) informants. Use of chewing tobacco was most prevalent
among the Bangladeshi group, with 9% of men and 16% of women reporting
using chewing tobacco. Among Bangladeshi women, use of chewing tobacco
was greatest among those aged 35 and over (26%). Among men, there was no
difference in use of chewing tobacco by age.
2.5
Smoking in Lewisham
It is not possible to document the trend in smoking prevalence in Lewisham,
however it is likely that smoking prevalence has decreased in Lewisham as it has
in England. The research produced by the University of Portsmouth, linking
deprivation with smoking levels gave an estimated smoking prevalence for
Lewisham of 33% for current smokers in 2006. More recent different sources, as
stated above estimate smoking prevalence to be lower, ranging from 17% to
24%.
2.6
Stopping smoking
Nearly two thirds of smokers said they would like to give up in 2009. The
proportion wanting to give up has decreased from 72 per cent in 2000 to 63 per
cent in 2009.22
3.
Targets
There are two targets, one which is set out nationally for smoking prevalence and
one which is set locally for stop smoking services.
The Tobacco Control for England strategy 2011 sets out clear goals to decrease
smoking prevalence from 21% to 18.5% by 2015, to decrease smoking amongst
15yr olds from 15% to 12%, and in pregnant women from 14% to 11% by 2015.
22
ibid
11
Local targets are set for achieving four week quits set by the Department of
Health. A quit is defined as someone who has stopped smoking for four weeks
from an agreed quit date, with not a single puff in weeks three and four of the quit
attempt. This should be confirmed by carbon monoxide testing. The quit is
supported by a stop smoking advisor trained to the standard set by the National
Centre for Smoking Cessation and Training. The Client’s data is entered onto a
database, and the date they wish to stop is recorded. The outcome measure is
the smoking status at four week follow up. Clients are followed up for longer than
this, but data is not always recorded. The target for Lewisham Stop Smoking
Service for 2011/12 is 1728 quits or 815 per 100,000 of the adult population.
4.
Performance
The main measurable method for tobacco control is the number of smoking
quitters at 4 weeks (expressed as a percentage per 100,000 of the adult
population) through the Lewisham Stop Smoking Service. The latest full year
analysed data at the time of writing was that for 2010/11.
4.1
Overview
In 2009/10: Lewisham recorded 1724 quits; 36% over target.
 Lewisham’s performance on quits was 819 per 100,000 population; 15th of
31 PCTs in London. Greenwich achieved 903 and Islington achieved
nearly double Lewisham’s rate at 1506.
 Only 7% of Lewisham’s estimated smokers aged set a quit date with the
service
 44% of those setting a date to quit were successful at 4 weeks
 52 pregnant women quit.
 Lewisham’s poorest wards recorded the highest no of smoking quits, a
correlation which doubled in 2009/2010.
 15% of those setting a date to quit were of black Caribbean or black
African background; 65% were white.
In 2010/11: Lewisham recorded 1671 quits; 30% over target
 3,600 people set a date to quit. This is 6-10% of Lewisham’s smokers.
 88 pregnant women set a date to quit and 43 quit: 49% success rate.
 46% of all those who set a quit date had quit at 4 weeks
 29% of those who quit were from ethnic minorities; 8.4% black Caribbean,
2.6% black African, 1.3% other black groups, 3% all Asian groups, 5.2%
mixed parentage, 4.3% Chinese and other groups, 3.9% not stated.
12
Whilst Lewisham’s Stop Smoking Service has exceeded its target for the past
two years it is important to note that its level of performance was lower than
other similar boroughs, in and outside London in the first 9 months of
2010/11. See figures 3 & 4.
Figure 3
Smoking quit rate at 4 weeks per 100,000 population of
age 16 and over: Lewisham compared to its South East
London PCTs, London and England, April to December
2010
Lambeth
652
Greenwich
639
Bexley
596
England
583
London SHA
523
Lewisham
503
Bromley
398
Southwark
337
0
100
200
300
400
500
600
700
Quit rate/100,000
Source: Lewisham Public Health Performance Dashboard 2011
13
Figure 4
Smoking quit rate at 4 weeks per 100,000 population of
age 16 and over: Lewisham compared to its ONS London
Metropolitan Cluster, April to December 2010
Heart of Birmingham
855
Brent
783
Newham
763
Haringey
722
City & Hackney
696
Lambeth
652
Lewisham
503
Southwark
337
0
100
200
300
400
500
600
700
800
900
Quit rate/100,000
Source: Lewisham Public Health Performance Dashboard 2011
4.2
Deprivation and quitting
There is a correlation between dates set to quit smoking and the Index of Multiple
Deprivation (IMD), this correlation has become stronger in 2009/10 compared
with 2008/09. It shows there has been an increase in the numbers of people
setting a date to quit smoking in the most deprived wards of Lewisham (figure 5).
Figure 6 shows the breakdown of those setting a date to quit by ward, in
descending order of IMD.
14
Figure 5
Correlation between Index of Multiple
Deprivation scores by ward and number of
successful quitters by ward. Annual period,
2009/10
140
140
120
120
2
Number of quitters
Number of quitters
Correlation between Index of Multiple
Deprivation scores by ward and number of
successful quitters by ward. Annual period,
2008/09
R = 0.228
100
80
60
40
20
R2 = 0.464
100
80
60
40
20
0
0
0
10
20
30
40
50
0
10
Ward IMD Score
20
30
Ward IMD Score
Figure 6
Number of smokers aged 16 and over who had quit at 4 week follow-up (self
report) by Lewisham ward in order of Index of Multiple Deprivation (IMD) score
descending, 2009/10
400
335
350
285
250
213
207
210
217
216
200
193
220
183
146
178
170
150
116
135
125
134
64
53
67
77
100
50
83
120
125
91
90
104
116
81
76
90
89
42
90
52
77
Ev
el
yn
el
lin
gh
am
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ow
nh
am
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ew
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w
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fo
rd
So
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h
0
B
Number
300
Number who had quit at 4 wk follow-up (self-report)
Number lost to follow-up
Number who had not quit
Total number setting a quit date
15
40
50
4.3
Pregnant Women quits
In 2008, there was a change in the referral system for pregnant women to the
stop smoking service. Midwives and health visitors now refer every pregnant
woman, partner or parent of a child aged 0-5yrs, who smokes. The number of
pregnant women recorded quitting increased from 9 in 2006/7 to 24 in 2007/8, 61
in 2008/9 then dropped a little to 52 in 2009/10 and 43 in 2010/11. The
systematic approach to referring pregnant women increased dramatically the
number of pregnant women and their partners who use the stop smoking service
to quit smoking.
4.4
Quits by age
Table 3 shows the distribution of quitters by age for 2008/09 and 2009/10. It
shows that there were very few people under the age of 18 who set a quit date.
However, the number of young people accessing the service is increasing and
doubled between 2008 and 2010. Fewer people over the age of 60 set a date to
quit.
The rate of successful quitting increases with age. There is a clear gradient in the
percentage of successful quitters from 21% in those under 18 to 55% in those
over 60 years (2009/10). This has not changed much over the two year period.
Table 3: Those setting a date to quit and the proportions that are successful, by age
group, in Lewisham 2008/9 – 2009/10
2008/09
under 18
18-34
35-44
45-59
over 60
Quit Date Set
61
1019
871
948
453
2009/10
Successfully
Quit
12 (20%)
415 (41%)
413 (47%)
494 (52%)
250 (55%)
Quit Date Set
122
1293
949
1081
461
Successfully
Quit
26 (21%)
490 (38%)
444 (47%)
511 (47%)
253 (55%)
Source: Lewisham Stop Smoking Service
4.5
Ethnic Minorities who Quit Smoking
In Lewisham, 11% of the general population are black African and 13% are black
Caribbean and around 15% of the total number of people setting a quit date were
black Caribbean or black African (Fig 7). Those from Asian backgrounds make
up 6% of the population of Lewisham, 2% of those accessing the Lewisham stop
smoking service were from an Asian background.
16
Figure 7
Ethnic origin of those setting a quit date
10%
15%
White
Mixed
Asian
2%
Black
8%
5.
Other/unknow n
65%
Local Views
The stop smoking service in Lewisham gathers views on the service from those
who have used it. The service makes follow up calls to clients recorded in the
database. The social marketing project in Evelyn ward consulted individuals and
focus groups of smokers, people who wanted to quit and people who had used
the service. Those who attend stop smoking groups complete an evaluation at
the end of the programme. Outreach work gathers views from smokers and the
general public.
There is a good level of satisfaction overall from people who use the service.
Suggestions for improvement include: being more accessible, offering more time
within each session, dedicated sessions in primary care, support for a longer
period and more peer support. How to cope with stress without smoking is cited
by smokers as the main reason for smoking, relapsing and lack of confidence in
being able to quit for good.
6.
National and Local Strategies
The Government’s 1998 White Paper ‘Smoking Kills’ was a landmark public
health strategy. Since then progress has been made to reduce the harm from
tobacco use, by implementing the following:
17





Stop Smoking Services were set up in 1999 to help people to stop
Most forms of advertising and sponsorship were banned in 2003/4
In 2007 a landmark piece of legislation made all enclosed public spaces
and workplaces smoke-free to protect people from exposure to
secondhand smoke
The legal age for buying tobacco was raised to 18 in 2007
Pictorial health warnings on cigarette packets started in 2008
The national strategy for A Smoke Free Future: 2010 – 2020, aimed
 To stop the inflow of young people recruited as smokers
 To motivate and assist every smoker to quit
 To protect families and communities from tobacco related harm
The ‘Tobacco Control Plan for England’, March 2011 sets out three national
ambitions to:



Reduce smoking prevalence among adults in England
Reduce smoking prevalence among young people in England
Reduce smoking during pregnancy in England
Lewisham’s Smokefree Future Delivery Group is implementing this strategy in
Lewisham.
A new national strategy was introduced in March 2011; this is called the Tobacco
Control Plan for England. At the time of writing implementation has not yet been
developed.
7.
Current Activity and Services
7.1
Stopping the inflow of young people recruited as smokers
Lewisham Council’s Trading Standards, with the assistance of young volunteers,
periodically carries out supervised test purchase attempts at premises selling
tobacco to ensure that the over 18yrs requirements are complied with. Premises
are also monitored to ensure that the relevant tobacco warning signs are
displayed. The service provides signs to retailers along with other informative
material on age restricted goods, including tobacco. There were three sessions
of underage test purchases in 2009/10 resulting in 32 attempts with 1 sale made.
A warning was issued to this trader.
A survey of tobacco vending machines was carried out across the borough. A
total of 50 premises were visited. Some had stopped using vending machines
18
and those that still used them only had minor problems. The traders were
advised of the warning signage required, and most importantly the position of the
machine within the premises, so that there is a clear view of the purchaser in
order to challenge any attempts made by children.
7.2
Motivating and assisting every smoker to quit
Lewisham’s Stop Smoking Service (see 4. Performance for more detail)
is provided by Lewisham Healthcare Trust and commissioned by Lewisham
Public Health. It offers NHS evidence based interventions: a combination of
behavioural support and medication for up to 12 weeks, in line with NICE
guidance, which states that all smokers who wish to stop smoking should be
offered intensive support usually at an NHS Stop Smoking Service. The service
is provided in a variety of ways, including:
-
30 GP practices through a local enhanced service
30 pharmacies through a local enhanced service
100+ trained nurses, pharmacists, health care assistants and
pharmacy staff provide a service in primary care
Many pharmacists are trained to issue Champix, previously a
prescription only medication, to increase access
A 7 week evening group programme at Lewisham Hospital
Community advisors run drop in sessions in the most deprived
wards in leisure and health centres
Specialist advisors contact everyone who smokes in pregnancy and
parents of children under five
There is regular outreach to increase the number of people
encouraged to use the service
There is a dedicated freefone, text, e-mail and website
Referrals come from all health staff: midwives, GPs, health visitors, acute trust
staff and from individuals. People who want to quit are offered support and
motivational counseling, together with medication. The outcome measure is
smoking status at 4 week follow up, as defined by the Department of Health.
However, an additional 12 week quit status check is likely to be introduced in
future. This should increase the quality of the service provided, and ensure more
long term health gain.
Advice on smokefree homes is also given to people in pregnancy and to parents
of under 5s.
19
It is estimated that 25% of smokers who quit for four weeks are still quit at one
year. In 2009/10, 430 people who quit with the stop smoking service in Lewisham
will still be non smokers a year later. This is 0.8% of 56,000 smokers.
The London region suggested a minimum budget of £500k excluding medication
costs for London services to deliver a service complying with the standards set
by DoH monitoring and NICE guidance.
£544k was allocated by the PCT to the stop smoking service for 2010/11. But
£100k was transferred in June 2010 to the prescribing budget to pay for stop
smoking medication. PCT investment in the service was £444k for 2010/11. In
2011/12 the total budget was £529,868 which takes into account the extra
investment needed for mental health and hospital advisors.
7.3
Protecting families and communities from harm
7.3.1 Reducing the attraction of tobacco products.
Trading Standards is responsible for ensuring compliance with the restrictions on
tobacco advertising at the point of retail sale, for example the size and content of
signage. A recent Department of Health funded project performed 26 visits for
advertising compliance and 65 visits to ensure counterfeit tobacco was not on
sale at shops or tobacconists. Only minor advertising advice was required and
dealt with during the visit. No counterfeits were identified during this project.
7.3.2 Taking action on illicit tobacco
The government’s pricing policy has had an impact on the number of young
people taking up smoking. Easy access to cheap illicit cigarettes is a particular
risk to people on lower incomes including most young people. Lewisham
Council’s work combating illicit and counterfeit cigarettes is an important aspect
of protecting children from tobacco harm.
7.3.3 Counterfeit Tobacco Seizures
All the counterfeit tobacco seizures of the last year have been made at the same
time as seizures of illegal DVDs. There has been a rise in the number of tobacco
pouches seized in such circumstances. Last year over 300 pouches of hand
rolling tobacco branded as Golden Virginia were seized. In the previous year
approximately 70 pouches of the same items were seized.
Lewisham Council advises residents to be wary about buying cheap hand rolling
tobacco from unregulated sources. Officers from the council seized significant
amounts of counterfeit Golden Virginia hand rolling tobacco from itinerant sellers
who target customers of pubs and betting shops, as well as approaching people
20
on the street. The tobacco does not meet the standards set by the UK
Government for levels of tar, nicotine and carbon monoxide and may contain
harmful chemicals and other substances that are hazardous to peoples' health.
WHAT IS THIS TELLING US?
8.
What are the key inequalities?
Smoking in itself contributes to health inequalities; anyone who smokes is
increasing their likelihood of numerous health and social problems. There are
four broad population groups amongst whom smoking is likely to have a greater
effect, and there is therefore a need to focus efforts on reducing smoking among
these groups of people. The groups amongst whom there is the greatest need
are pregnant women, young people, those with mental health problems and
those from a low socio economic group.
Pregnant women are an important group to focus on due to the potential
consequences for their unborn child. It is also known that children with parents
who smoke are more likely to become smokers themselves, therefore parents
need to be encouraged to stop smoking in order to break this cycle.
The emphasis for young people should be to stop them from coming into contact
with smoking or accessing cigarettes in order to reduce the likelihood of them
starting to smoke. Young people are in particular danger from the effects of
smoking and therefore targeting this group before they start is essential.
Due to the fact that those with mental health issues are more likely to smoke, but
are less likely to be offered help to stop; this group of people needs an increased
input from services in order to reduce this inequality.
Those living in poorer communities are more likely to smoke, which in itself
exacerbates the inequalities experienced by people in this group. If those who
are in lower socio economic groups can be helped to reduce smoking, this will
reduce both health and economic inequalities. From (Figure 5) it is clear that the
Stop Smoking Service is successful in reaching those people living in areas of
high deprivation and that the proportion of smokers who quit are higher in these
areas and that also increasing. This trend should be continued.
It is encouraging to see that overall more people set a date to quit smoking in
2009/10 compared with 2008/09, through the stop smoking service. Although the
proportion of those achieving a four week quit date was lower in 2009/10, the
overall numbers of those managing to give up for four weeks is increasing. The
21
numbers using the service, although increasing, are small and represent only
around 7% of the smoking population of Lewisham.
9. What are the key gaps in knowledge or services?
It is difficult to know how much local prevalence has reduced with the
implementation of the various strategies on tobacco control. There are gaps in
local knowledge about how much people smoke, and who is smoking.
In terms of assisting people to stop smoking, there are gaps in the Lewisham
stop smoking service provision for those who are most heavily addicted, in
specialist services for people with poor mental health, for minority ethnic groups
with high tobacco use for example Polish, Vietnamese, and Somali people. The
stop smoking service will need to work more closely with people who want to
stop and have additional difficulties in achieving this. Referral systems will need
to be improved across all care pathways.
The need to integrate physical activity, stress management and weight
management into treatment programmes, which involve behavioral change has
been identified both through the healthy lifestyle pathway development of the
NHS Health Check programme and the Evelyn Stop Smoking Social Marketing
project.
Most importantly there is a gap in between the capacity of the stop smoking
service and the number of smokers.
10.
What is coming on the horizon?
A more strategic approach to implementing smoke free policies and raising
awareness will be needed to help protect children and young people from
tobacco harm through secondhand smoke and reduce the number of young
people who take up smoking.
Reorganisation of the NHS and reductions in local authority funding will
challenge partnership working, and investment in initiatives to prevent premature
mortality. The Lewisham ‘smoke free future delivery group’ will continue to work
towards their current goals and aim to adapt to the forthcoming challenges they
will encounter.
22
11. What should we be doing next?
There is a need to scale up the provision of Stop Smoking Services so that they
are able to reach more smokers. This is particularly important as those people
who are still smoking are likely to be more heavily addicted than those who have
already quit smoking.
A key priority must be to prevent as many young people as possible taking up
smoking in the first place through the de-normalising of tobacco.
Plans for the future include delivering Lewisham’s Smoke Free Future Action
Plan, and adapting to changes from the new government. The Action plan
focuses on ‘de-normalising’ smoking to reduce uptake by young people, on
implementing policies to protect children from the harm of secondhand smoke,
and increasing the contribution to prevalence reduction. The Stop Smoking
Service aims to improve outreach recruitment, referral systems from GP
practices and hospitals; to integrate physical activity, stress management and
weight management, and develop expertise and effectiveness in supporting
people to stop smoking. It will focus on helping parents and pregnant women,
those most heavily addicted, those with mental health problems, as well as those
in poorer communities and in some minority ethnic groups.
Planned development in 2011/12
 Increase the number of people who use the Lewisham Stop Smoking
Service, to meet the more challenging target set for 2011/12.
 Improve quality of service so that there is health gain from long term quits
 Apply learning from the social marketing project in developing the service
 Develop expertise of the team to enhance the quality of the advisory
network.
 A specialist mental health adviser has recently been appointed who will
develop referral systems, respond to referrals, increase expertise in
working directly with people with mental ill health and advise on managing
nicotine withdrawal for in-patients.
 A specialist advisor for the acute trust has been appointed to develop
referral systems, services for staff, patients and visitors and support the
implementation of smoke free grounds. They will also inform a hospital
policy for inpatients to use medication to manage nicotine withdrawal.
23
Appendix 1
A description of the different indicators for measuring smoking prevalence
The General Lifestyle Survey (GLF, formerly the General Household Survey), is
a large multi-purpose survey carried out by the Office for National Statistics. It
collects information on a range of topics from people living in private households
in Great Britain. The survey has run since 1971, and is a module of the
Integrated Health Survey. It consists of a household questionnaire, to be
answered by the Household Reference Person, and an individual questionnaire
to be completed by all adults aged 16 and over, resident in the responding
household. Demographic and health information is also collected about children
in the household. The average sample size is around 9,000 households. This
data is very useful for looking at trends, as the same data is collected annually.
The Integrated Household Survey (IHS) is a composite household survey
combining the answers from a number of surveys from the Office for National
Statistics. These household surveys are combined to produce an experimental
dataset of core variables. This survey has a sample size of around 223,000
individuals from the interviews undertaken named above. Due to the fact that the
IHS is a combination of different surveys it has a large sample size and this is
likely to lead to increased accuracy. This data is useful for looking at trends, as
the same data is collected annually and at is presented at regional and borough
level and comparisons can be made.
The Health Survey for England comprises a series of annual surveys beginning
in 1991. This survey is now commissioned and published by The NHS
Information Centre. It is designed to provide regular information on various
aspects of the nation's health. Every survey has included the adult population
aged 16 and over living in private households in England. Children were included
in every year since 1995, and every year a different aspect is looked at in more
depth, for example ethnicity, obesity and older people. The HSE has an average
sample size of 7,800 adults and 1,800 children. This is a useful set of data as it
looks in depth at different groups of the population. It is also useful to look at
trend data given that it is an annual survey and has been running for over ten
years.
The ‘Smoking Epidemic in England’ summarises research commissioned by the
Health Development Agency and undertaken by the Institute for the Geography
of Health, University of Portsmouth. The main objective of this study was to
estimate levels of smoking attributable mortality across two target geographies:
primary care trusts (PCTs) and strategic health authorities (SHAs) in England.
24
Identifying the prevalence of current smoking and the proportion of ex-smokers in
SHAs and PCTs required synthetic statistical estimation. Synthetic estimation
allows identification of the numbers of people in each SHA or PCT who, given
certain assumptions, might be expected to be current or ex-smokers. Robust
procedures were then used to generate high quality synthetic estimates. This
data represents a reasoned, ‘best guess’ as to smoking prevalence, and not a
definitive prevalence.
GP Quality and Outcomes Framework (QOF) data is taken from GP patient
records and is used primarily as a method of monitoring GP performance. The
indicator provides information about the percentage of smokers amongst GP
patients aged 16 years or over with a recorded smoking status. It gives an idea
of local prevalence; however it currently does not provide an accurate picture due
to incomplete data and some smokers being reluctant to inform their GPs if they
continue to smoke. It should not be used alone due to issues around data
completeness. Rather the indicator should be used against other smoking
estimates to understand to what extent GP practices are identifying smokers.
25
Additional references of key tobacco reports
Smoking Kills: A White Paper 1998
Healthy Lives, Healthy People: A Tobacco Control Plan for England. HM
Government 2011.
Statistics on Smoking, England 2010. The NHS Information Centre for Health
and Social Care 2010.
London Health Observatory: Local Tobacco Control Profiles 2010
Smoking, drinking and drug use among young people in England in 2009. The
Information Centre for Health and Social Care, 2010
Passive smoking and children. Royal College of Physicians, London, 2010
Breaking the cycle of children’s exposure to tobacco smoke: British Medical
Association 2007
School-based interventions to prevent the uptake of smoking among children.
NICE 2010
NICE Guidance on preventing the uptake of smoking by children and young
people
Cancer Research UK. Cancer Stats Key Facts: Lung Cancer and Smoking.
November 2010
Stop Smoking Interventions in Mental Health A Systems Approach NHS 2010
Smoking & mental health. Mental Health Foundation, London, 2007.
ASH – Action on Smoking and Health. Research reports, briefings and
factsheets.
Reducing Health Inequalities through tobacco control: a guide for councils. Local
Government Group
'Fair Society, Healthy Lives' – Marmot Report 2010
Supporting the Health of Young People in Lewisham 2010
26
A
Cough up: Balancing tobacco income & costs in society. Policy Exchange 2010
of the Health
27