Appendix C
Smokefree Hertfordshire
A Tobacco Control Public Health
Report: 2013-2016
Contents
Page
Foreword
Councillor Teresa Heritage, Cabinet Member Public Health and Localism
3
Executive Summary
4
1.0 Introduction
4
2.0 Our Vision for 2016
12
Health and Wellbeing Board Strategic Priorities for Tobacco Control:
3.0 Strategic Priority 1:
To reduce adult smoking in every district to 18.5% or less by 2016
14
4.0 Strategic Priority 2:
To reduce smoking in young people so that less than 9% of 15 year olds
report to be smoking by the end of 2016
18
5.0 Strategic Priority 3:
To reduce smoking in pregnancy so that less than 7% of pregnant women
smoke throughout their pregnancy by the end of 2016
20
6.0 Strategic Priority 4:
To protect young people from second-hand smoke by rolling out
a comprehensive Smokefree homes and cars scheme
22
7.0 Strategic Priority 5:
All pubic sector workplaces to be completely Smokefree by 2016
23
8.0 Communication and Marketing Plan
24
9.0 Examples of Good Practice
25
10.0 Alternative forms of Tobacco and Nicotine Containing Products
27
11.0 Delivering the Tobacco Control Strategic Plan
30
12.0 References
32
Figures and Tables
Figure 1 Smoking prevalence by socio-economic group
Figure 2 Trends in smoking over time
Figure 3 Estimated annual cost of smoking in Hertfordshire
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9
10
Table 1 Smoking prevalence within District and Borough Councils 2011/12
14
Foreword
Good health is what we aspire to for ourselves, our families and our communities. The Health
and Social Care Act 2012 gave local authorities the responsibility for public health, giving us
the opportunity to realise this ambition. Hertfordshire County Council has outlined
Hertfordshire’s strategic priorities to improve and protect the health of its residents and to
reduce health inequalities between the best and the least well-off. These priorities are
published in Hertfordshire’s Public Health Strategy 2013-2017.1 Along with Public Health,
Hertfordshire’s NHS Clinical Commissioning Groups and local NHS Commissioning Board
also have a statutory duty to reduce inequalities in Hertfordshire.2 Hertfordshire County
Council’s Tobacco Policy was approved by Cabinet on 25 November 2013; this policy
established the Council‘s position on tobacco; and its commitment to reducing tobacco use
and smoking prevalence.3
The Health and Wellbeing Strategy for Hertfordshire 2013-2016 outlined the shared priorities
to improve health and well-being, three of which include measures to reduce preventable illhealth and premature death (reducing the harm from tobacco, obesity and alcohol).
With one in two adults dying prematurely because of smoking, killing almost 1500
Hertfordshire residents every year, tobacco remains the biggest threat to the health of our
residents and the 170,000 adults in Hertfordshire addicted to tobacco.4,5 Tobacco use
remains our biggest preventable killer as well as being a significant cause of long-term
disability and poor quality of life. Whilst overall smoking prevalence in Hertfordshire is
comparable with England, there are local areas and particular groups of people where levels
of smoking are much higher. It is within these priority localities and groups that we must
target our actions and services to reduce the harm to our citizens from tobacco, as well as to
reduce the costs of smoking to the individual and their family and the burden on health and
social care services and the wider economic community. We also need to do more to ensure
our children have a healthy start in life, grow up healthy and are protected from both the
effects of second-hand smoke and the influence of adults and peers who continue to smoke.
There is a significant number of people where harm reduction approaches to tobacco need to
be considered until smokers are ready and able to quit, and this includes an appropriate
response to the use of e-cigarettes as a means of harm reduction.
Effective tobacco control measures, including helping people to stop smoking, save more
than they cost. This tobacco control report and associated tobacco control strategic plan
2014-2016, draw together Hertfordshire’s ambitions to reduce avoidable smoking-related
death and disability to ensure effective, coordinated action across the county.
These documents have been developed by using the best available evidence in tobacco
control and by consulting with a range of partners who have already contributed to the work
of Hertfordshire’s Tobacco Control Alliance; we commend this report to you and we look
forward to reviewing the progress that needs to be made to protect our communities from
tobacco and to reduce the number of people who smoke.
Councillor Teresa Heritage
Executive Member, Public Health and Localism
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Executive Summary
This tobacco control public health report outlines the key priorities for Hertfordshire to
reduce the harm from tobacco and informs the accompanying Tobacco Control
Strategic Plan 2014-2016. Tobacco control requires collaborative work across a
range of organisations; in Hertfordshire this is coordinated by Hertfordshire’s
Tobacco Control Strategy Group and delivered through Smokefree Hertfordshire,
Hertfordshire’s multi-agency tobacco control alliance.
The work of Smokefree Hertfordshire includes:
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Advocacy for tobacco control at local, regional and national levels
Prevention, including reducing access to tobacco and preventing young
people from starting to smoke
Enforcement of tobacco legislation through Regulatory Services
Reducing the supply of illegal tobacco
Protection from second-hand smoke, including pregnant women, babies and
children
Helping smokers to quit or adopt harm reduction approaches to tobacco,
prioritising those most at risk of smoking-related health inequalities
To develop, coordinate and deliver annual action plans which support
Hertfordshire’s Tobacco Control Strategic Plan 2014-2016
To ensure tobacco control in Hertfordshire aligns with national, regional and
local public health policy and evidence
Tobacco control in Hertfordshire is informed by Hertfordshire’s Joint Strategic
Needs Assessment (JSNA)6 and underpinned by The National Institute for Health
and Clinical Excellence (NICE) public health guidance and quality standards, and
‘Healthy Lives, Healthy People: A tobacco control plan for England’. 7
Sub-groups of Smokefree Hertfordshire will consist of defined leads and
partnership members to implement the actions required to deliver Hertfordshire’s
Tobacco Control Strategic Plan 2014-2016.
1. Introduction
‘Healthy Lives, Healthy People: A tobacco control plan for England’ identified the
actions that the Government is taking to drive down the prevalence of smoking and to
support tobacco control in local areas.8 The most effective tobacco control strategies
demonstrate a comprehensive approach both at a national and local level and in
Hertfordshire, some of the local actions required to tackle tobacco use in our
communities are already being implemented (see page 25).
Deaths from smoking are greater than the next six most common causes of
preventable death combined (obesity, drug use, road accidents, other accidents and
falls, diabetes, suicide and alcohol abuse).9 Many smokers under-estimate the
health risks of smoking, but the following are directly attributable to smoking and
tobacco use:
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more than one in four of all cancers (nine out of ten lung cancers)
one in four circulatory disease deaths (including heart attacks and strokes)
more than one in three respiratory deaths
For every smoking-related death, 20 people are suffering a smoking-related
disease.10
1.1 Why people continue to smoke despite wanting to stop
Tobacco is highly addictive; nearly 70 percent of smokers say that they want to quit
smoking and 50 percent of smokers say that they intend to quit in the next 12
months.11 Without help and support only 2-3 percent of those who attempt to stop
smoking will be successful at the end of a year.
Nicotine addiction keeps tobacco users physically dependent, however, there is a
complex combination of factors which causes and sustains regular use and usually
begins in childhood and adolescence. Young people under-estimate the risk of
addiction to tobacco. Once addicted, smokers find it difficult to quit even in pregnancy
when there is strong motivation and strong social pressure to quit.
As well as addiction to nicotine, social and behavioural factors maintain dependence
on tobacco and encourage young people to take up smoking. The reshaping of social
norms, making smoking less desirable, less attractive, less accessible and less
affordable is vital to reduce the inter-generational effects of tobacco use which make
smoking levels higher in some families and communities.
Hertfordshire’s Health and Wellbeing Board strategic ambitions demonstrate a
lifecourse approach to reducing the harm from tobacco:

Reduce smoking among adults in every district to 18.5 per cent or less by
2016.

Reduce smoking in young people, so that less than 9 per cent of 15 year
olds smoke by 2016.

Reduce smoking in pregnancy so that less than 7 per cent of pregnant
women smoke throughout their pregnancy by the end of 2016.

Roll out a county-wide smoke free cars and homes scheme.

All public sector workplaces are completely smoke free including grounds
by 2016.
1.2 Smoking Prevalence and Inequalities
Although the number of smokers has declined over the last 40 years, over 10 million
adults continue to smoke in the UK of whom 100,000 smokers die each year.
Smoking accounts for 50 percent of inequalities in health between the better and
worse off and smoking prevalence correlates highly with indices of deprivation; with a
linear increase in smoking with increasing disadvantage. In Hertfordshire, smoking
prevalence ranges from 13.9 percent in East Hertfordshire to 26.7 percent in
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Stevenage, with seven out of ten localities currently having a smoking prevalence
above the 2016 ambition.12
As well as geographical differences in smoking patterns, heavier and more addicted
smokers are also disproportionally found within some population groups and they
experience even greater differences in ill health and life expectancy. These groups
include routine and manual workers and the unemployed, some black and minority
ethnic groups, people with mental health conditions, homeless people, prisoners,
offenders and young pregnant women.
Smoking prevalence has declined more slowly in lower socioeconomic groups than in
the general population, and as a result the health inequalities gap has widened. The
greatest number of smokers is to be found within the routine and manual workforce;
over 29% of smokers in routine and manual occupations continue to smoke in
Hertfordshire. They are more likely to be parents, to live in communities where levels
of smoking are higher, find long term quitting difficult and to have children who are
more likely to be affected by second-hand smoke.13,14 Smoking is also age-related,
with prevalence greatest in the 20-24 year old age group, followed by those aged 2529 years. The variation between men and women smoking has narrowed, so that a
similar number of men and women now smoke. 15,16
Within black and minority ethnic groups, smoking prevalence is higher in Pakistani
and Bangladeshi men and eastern Europeans than other groups and targeted
workplace and community focused work is required to reduce smoking in these
groups. The use of smokeless tobacco, a significant cause of dental disease and oral
cancer as well as heart disease and stroke, is also more prevalent in South Asian
Communities.17
People with serious mental health conditions are more likely to be extremely heavy
smokers and suffer greater levels of smoking-related disability. Forty percent of UK
tobacco consumption is by people with mental health conditions. Seventy percent of
people with schizophrenia are likely to be smokers and smoking is both a cause and
consequence of anxiety and depression. There is a long history of smoking within
mental health institutions and service users and professionals often fear that stopping
smoking will be detrimental to mental health. Recent guidelines published by the
National Institute for Health and Care Excellence (NICE) has highlighted the
smoking-related inequalities faced by people with mental ill-health and the 20 year
difference in life expectancy due to smoking related disease.18
Pregnant women who smoke throughout pregnancy are of particular concern. They
are likely to be younger, living in more disadvantaged circumstances and have
partners who also smoke, which make stopping smoking extremely difficult. Although
fewer than 1 in 10 women smoke throughout pregnancy, the effects on the
developing baby can be devastating, including a 40 percent increase in the chance of
the baby dying during the first year of life.19
Smoking is disproportionately represented in the offender population and those who
come into contact with the criminal justice system. National figures show that 77% of
male and 83% of female sentenced prisoners smoke.20 This is replicated in
Hertfordshire with 77% of offenders smoking. Higher levels of smoking-related
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disease is found in the offender population; with more asthma, chronic obstructive
pulmonary disease (COPD) and other long term conditions than in the general
population. Complex health needs including substance misuse and mental ill-health
are also high with 28% of offenders having a diagnosed mental health condition.21
Hertfordshire has a single category C prison and during 2012/2013 stop smoking
services at the prison helped 128 prisoners at HMP the Mount became successful
non-smokers.
At least 70% of homeless people smoke and homeless smokers are faced with
unique social and environmental barriers that make quitting more difficult despite
wanting to do so, including other lifestyle behaviours such as alcohol and illicit drug
use as well high levels of boredom and stress. Some of the smoking practices of
homeless people such as sharing cigarettes and rolling cigarettes from discarded
butts put them at particular risk.
The Marmot Review of health inequalities indicated that focusing on only the most
disadvantaged and least healthy does not reduce health inequalities overall. 22 This is
particularly relevant for reducing the harm from tobacco. Actions to reduce tobaccorelated inequalities must be universal, but with a scale and intensity that is
proportionate to the level of disadvantage and prevalence of smoking. This is the
principle of ‘proportional universalism’ adopted by both the Public Health and the
Health and Wellbeing Strategies. Applied to tobacco control this means that our
strategy has to increase our actions according to the level of smoking prevalence and
according to the level of risk associated with smoking in particular groups.
Health inequalities are not only due to smoking; Hertfordshire’s Public Health
Strategy 2013-2017, highlights the complex inter-relationship between our
environment and where we live and work, our genetic disposition, our parents’ health
before conception and during pregnancy and the importance of a healthy start in life
as well as the lifestyle choices we make (such as smoking, alcohol use and what we
choose to eat and how physically active we are).23 Hertfordshire’s Tobacco Control
Strategic Plan 2014-2016 has to be considered within the context of the wider
determinants of health which account for the 11 year difference in life expectancy
experienced between the healthiest and least healthy in Hertfordshire.
The figure below illustrates how smoking has become more concentrated in the
routine and manual working population and that the gap between manual and nonmanual smokers has widened over time.
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Figure 1
Figure 1
Trend in cigarette smoking prevalence among adults by socio-economic classification
1992-2011
Year
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1998
1996
1994
1992
0
5
10
15
20
25
30
35
Smoking Prevalence (%)
Manual
Non-Manual
Notes: Data from 1998 is based on a new weighted formula; socio-economic grouping taken from
head of household before the year 2000; results from 2006 include longitudinal data; adults are aged
16 years and over.
Source: General Lifestyle Survey 2011. Office for National Statistics
1.3 Risks and Impacts of Smoking
Tobacco smoke contains over 4,000 chemicals, including over 70 known
carcinogens.24 Smoking is the primary cause of preventable death and disability,
accounting for 81,400 deaths in England in 2009 and almost 1,500 deaths every year
in Hertfordshire. 18.5% of all deaths in adults over the age of 35 are caused by
smoking.25 There is no safe level of smoking and cigars and rolling tobacco are as
harmful as manufactured cigarettes.
The risks of disease are closely related to continued smoking and the cumulative
number of packs smoked; the effects of which impact more seriously on heavier and
more addicted smokers. Stopping smoking has both immediate and long term
benefits, but for people who continue to smoke after the age of 30, on average 3
months of life is lost for every year of continued smoking.
1.4 Quitting Smoking
Hertfordshire has an excellent track record of providing good quality local stop
smoking services. There are over 300 local stop smoking services with trained
advisors who provide intensive support to help people to stop smoking;
approximately 8,000 smokers quit smoking every year using one of these services.
Behavioural support and effective medication such as a nicotine containing product,
or a prescription only medication can increase the chances of quitting fourfold when
compared to going ‘cold turkey’.
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Figure 2
Figure 2
Adult Smoking Prevalence in Hertfordshire and England 2000-2012
30.0
Smoking Prevalence (%)
25.0
20.0
15.0
10.0
5.0
0.0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Year
Hertfordshire
England
Notes
Data from 2009 is for calendar years and for adults aged over 18 years. Data prior to 2009 is for financial year
and for adults aged over 16 years. Although not strictly comparable, the data back to 2000 does provide a general
sense of the trend in England and Hertfordshire over this period.
Source: Integrated Household Survey (Public Health Outcome Framework) and Health Survey for England
(Health Profiles)
1.5 The costs of smoking and the return on investment of tobacco
control measures
Each year it is estimated that tobacco use costs Hertfordshire nearly £280 million; of
this, nearly £55m is a cost to the NHS. By contrast, the Treasury revenue is around
£229million. Therefore, smoking costs us more than it collects in tax revenue. The
figure below breaks this down further.26 Investing in tobacco control and stop
smoking services, like other effective public health measures, reduces expenditure
from the public purse both in the short and long term. Health economic modelling
from the National Institute for Health and Care Excellence (NICE) has demonstrated
that helping a smoker to quit smoking is one of the most effective and cost-effective
interventions to improve health.27
Nash and Featherstone in 2010 calculated that the taxation of tobacco contributes
£10 billion annually to the Treasury, but that the costs to society from smoking are
much greater at £13.74 billion and represents the best estimate we currently have of
the wider costs of smoking to the whole economy.28
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Figure 3
1.6 The return on investment of Hertfordshire Stop Smoking Service
The total cost of the NHS Stop Smoking Services in England in 2012/13 was £87.7
million with an average cost per quitter of £235.29 Hertfordshire’s Stop Smoking
Services in 2012/13 cost £1.33 million with a cost per quitter of £169, which is below
the national average cost. 30 The average gross cost per smoker to the wider
economy is £1,374 per year. The net cost per smoker (i.e. taking account of the £10
billion tax paid on cigarettes) to the wider economy is approximately £374 per year.
In Hertfordshire, the cost per quitter of £169 gives a gross saving of £1,205 per
quitter and a net positive return on investment of £2.21 for every £1 spent on stop
smoking services.
1.7 The Public Health Outcomes Framework
The Public Health Outcomes Framework supports health improvement and
protection at all stages and across the lifecourse, especially in the early years and
aims to improve the health of the poorest fastest. The Framework contains a national
set of indicators which are aligned with the NHS and Adult Social Care Outcome
Frameworks, against which Hertfordshire can measure its progress towards
improving and protecting the health of its citizens.31
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Public Health Indicators
Our tobacco control strategic plan 2014-2016 will impact on a number of public
health indicators:
1. Children in poverty
2. Sickness absence rate
3. Low birth weight of term babies
4. Smoking status at the time of delivery
5. Smoking prevalence – 15 year olds
6. Smoking prevalence – adults (over 18)
7. Infant mortality
8. Mortality rate from causes considered preventable
9. Mortality from all cardiovascular diseases (including heart disease and stroke)
10. Mortality from cancer
11. Mortality from respiratory diseases
12. Excess under 75 mortality in adults with serious mental illness
13. Preventable sight loss
14. Health-related quality of life for older people
Our tobacco control strategic plan will improve the health and wellbeing of its citizens
by contributing to the improvement of the above indicators when compared against
regional and national trends and counties that are statistically similar to Hertfordshire.
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2.0 Our Vision for Hertfordshire
‘Healthy Lives, Healthy People: A tobacco control plan for England’ contains three
national ambitions to focus tobacco control work .32



Reduce smoking prevalence among adults in England to 18.5 percent or less
by the end of 2015.
Reduce smoking prevalence among young people in England so that less
than 12 percent of 15 year olds smoke by the end of 2015 (from a baseline of
15% in 2009).
Reduce smoking during pregnancy in England to 11 percent or less by the end
of 2015 (measured at the time of delivery)
The assessment of the agencies and partners working with us was that these
ambitions were not stretching for Hertfordshire as a whole to make a difference to
individuals and communities most affected by tobacco use. Consequently our vision
is to achieve greater improvements in Hertfordshire than the national ambitions. We
want to:
1) Reduce smoking among adults in every district to 18.5 per cent or less by
2016
2) Reduce smoking in young people, so that less than 9 per cent of 15 year
olds smoke by 2016
3) Reduce smoking in pregnancy so that less than 7 per cent of pregnant
women smoke throughout their pregnancy by the end of 2016
4) Roll out a county-wide smoke free cars and homes scheme
5) All public sector workplaces are completely smoke free including grounds
by 2016
In working to achieve this, we are committed to delivering an effective and integrated
strategic plan with every relevant stakeholder involved, taking local action to create a
Smokefree environment for everyone. In particular:
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
Young people do not want to start smoking and young people under 18 cannot
gain access to tobacco.
Young people are given early and age-appropriate help to stop smoking.
There are fewer adult smokers who act as role models for younger people.
Fewer babies are born to parents who smoke and smoking at time of delivery
prevalence continues to decline to reach less than 7% by 2016.
There are fewer people dying and suffering from smoking-related long term
conditions.
Stop smoking services are available and amenable to meet the needs of
different communities and populations, particularly those from disadvantaged
areas and vulnerable groups.
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Access to illegal and counterfeit tobacco is minimized through the work of
Trading Standards and Her Majesty’s Revenue and Customs (HMRC).
Increasing numbers of smokers are aware of local stop smoking services and
different routes to quitting or reducing smoking if they are unable to quit.
There is no exposure to second hand smoke in the home, car, work place or in
public places.
The public sector, local businesses, educational establishments and voluntary
organisations are exemplars in tobacco control and have comprehensive
Smokefree policies in place by 2016.
The health inequalities gap between the better and worse off in Hertfordshire
is narrowed so that areas with the highest smoking prevalence see the
steepest decline.
We are advocates of and support evidence-based tobacco-control measures
at regional and national levels
All partners are committed to reducing the harm from tobacco and understand
the association between smoking and health inequalities.
Our partners are skilled and have the capacity to deliver the tobacco control
strategic plan using a public health approach to tackle inequalities and
influence change through advocacy.
We have good quality data to inform our tobacco control strategic plan and we
can measure success against reliable and accurate information.
We have a communication and marketing plan and resources to deliver
consistent, coherent and co-ordinated communication on tobacco control
throughout the county that reaches all our partners and communities
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3.0 Strategic Priority 1:
Our ambition is to reduce smoking in every district to 18.5% or less
by 2016
Figure 4
Smoking Prevalence within District and Borough Councils 2011/12
(Adults over the age of 18)
Area
EAST & NORTH
HERTS
Stevenage
Welwyn Hatfield
Broxbourne
East Herts
North Herts
Smoking
Prevalence (%)
2011/2012
27.6
23.6
21.5
13.9
16.7
WEST HERTS
Watford
Dacorum
Three Rivers
Hertsmere
St Albans District
16.6
18.7
22.3
19.4
19.0
Hertfordshire
England
19.4
20.0
Source: Local Tobacco Control Profiles 2013 for England33
3.1 Responsibilities
The tobacco control profiles are updated annually and are the main source of data
which informs the Joint Strategic Needs Assessment (JSNA) against which to
measure our success.34
Nationally smoking is declining at approximately 0.5% per year and there is no ‘quick
win’ to reducing prevalence at a local level; tobacco control is ‘everybody’s business’;
all organisations and not just the public sector, should go beyond their legal duty to
comply with Smokefree legislation and to become exemplars of good tobacco control
practice. Hertfordshire’s Tobacco Control Strategy Group and the wider multi-agency
Tobacco Control Alliance, Smokefree Hertfordshire are the key agents to drive this
strategic plan forward at a local level.
Progress towards our ambitions will be reported to Hertfordshire’s Public Health
Board, Hertfordshire’s Health and Wellbeing Board and Hertfordshire County
Council’s Public Health and Localism Cabinet Panel.
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Hertfordshire County Council’s Tobacco Policy was approved by Cabinet on 25
November 2013. This policy established the Council‘s position on tobacco; its
commitment to reducing tobacco use and smoking prevalence.35 Hertfordshire’s
Tobacco Policy and the Local Government Declaration on Tobacco Control have
been shared with district council representatives other stakeholders as examples of
good practice for district councils to use within their own organisations or to sign up
and commit to36.
3.2 Local Smokefree Alliances
Our ambition is to establish local tobacco control (Smokefree) alliances within
these localities to identify local need and work with the range of local partners
to deliver all five priorities within this strategic plan at a local level.
Key Partners
 Hertfordshire County Council, including Public Health and Health and
Community Services, Community Protection and Young People’s Services.
 Local District and Borough Councils
 Local Officer tobacco control champions
 Public Health Tobacco Control Manager
 Education Establishments (School and College PHSE leads; University of
Hertfordshire)
 Clinical Commissioning Groups
 Children’s Centres
 Hertfordshire Stop Smoking Service and Locality Stop Smoking Specialists
 East and North Herts and West Herts NHS Trusts (including maternity
services)
 Hertfordshire Partnership foundation Trust
 Hertfordshire Community NHS Trust
 Health and Community Services (commissioners and providers)
 Primary Care/GPs
 The Local Pharmacy Committee and Community Pharmacies.
 Local voluntary and community organisations
 Housing Associations
 Leisure facilities and sports teams
 Work places and local businesses
 Trading Standards and Her Majesty’s Revenue and Customs (HMRC)
 Drug and Alcohol Services
3.4 Tobacco Control Enforcement
Our ambition is to have Her Majesty’s Revenue and Customs (HMRC)
integrated within our tobacco control alliance and to inform and use local
intelligence to drive down the availability of illegal tobacco.
Many actions to implement tobacco control are outside of local action and require
national legislative action and advocacy to have an impact, such as raising the legal
age to purchase tobacco, the removal of cigarette vending machines, the removal of
cigarette displays in large retailers (which were a key in-store marketing activity) and
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all shops by 2015 and the incremental tax increases which raise the price of
cigarettes and rolling tobacco, all of which have an impact on the uptake of smoking
and increase motivation to quit. Local action includes the work of Hertfordshire
Trading Standards to ensure compliance with the legislation including:




Regulation of the age of sales (including test purchasing)
Regulation of tobacco trading and counterfeit/non duty paid products
Point of sale restrictions on tobacco
Regulation of advertising and sponsorship
It is the work of Her Majesty’s Revenue and Customs to ensure that counterfeit and
smuggled tobacco is not available to smokers both nationally and locally. Illegal
tobacco brings crime into our community, is more readily available to young people
and undermines the price deterrent of legally purchased tobacco. Areas of
deprivation which correlate significantly with smoking prevalence are more prone to
the influences of illegal tobacco.
Tobacco displays and cigarette branding are designed to maximise the visual impact
in shop displays to attract new young smokers who are likely to make unplanned
purchases. Most adult smokers are brand loyal, with approximately 86% of smokers
always buying the same brand.37 An independent review of public health evidence for
standardised tobacco packaging, published in April 2014, reported that standardised
packaging is likely to reduce the uptake of smoking by children and recommended
that standardised packaging should be a part of a comprehensive tobacco control
policy.38 39
3.5 Smoking Cessation: Hertfordshire Stop Smoking Service
Our ambition is to ensure that stop smoking services are accessible to
everyone but are prioritized to ensure target populations identified above are
helped to quit smoking.
The provision of high quality stop smoking services is a priority for public health. In
Hertfordshire, there are over 300 local stop smoking services, including 135
pregnancy stop smoking services; these services are predominantly provided by
trained advisors in individual 1-1 settings in GP Practices and Community
Pharmacies. There are also specialist stop smoking services available across the
county. Stop smoking providers are commissioned by Hertfordshire’s Public Health
Service; they are trained to nationally agreed standards and are supported by
Hertfordshire Stop Smoking Service.40 There are also prison, work place and some
hospital based stop smoking services.
Stop smoking services provide behavioural support for at least 6-8 weeks and access
to nicotine containing products and prescription-only medication to help smokers
overcome withdrawal symptoms. In 2012/13, over 15,000 smokers attended a local
stop smoking service and nearly 8,000 smokers successfully quit.
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related inequalities, stop smoking services are prioritized to ensure a
disproportionate number of smokers from the routine and manual workforce and from
the 30 most deprived communities in Hertfordshire are helped to quit smoking.
For local stop smoking services to be successful, smokers need to be identified,
motivated and referred to Hertfordshire Stop Smoking Service. This is in addition to
the self-motivated smokers who quit smoking using online tools available through
national campaigns such as ‘Stoptober’ and National No Smoking Day initiatives.
GPs are incentivised through the Quality Outcomes Framework (QoF) to identify,
advise and refer smokers and our NHS Trust partners are incentivised through
Clinical Commissioning Groups’ contracting mechanisms to identify and refer
smokers, but particularly those most at risk.
Hertfordshire Stop Smoking Service offers tailored training packages and support to
all its partners to improve the reach and access to stop smoking services.
3.6 Drugs and Alcohol
Our ambition is that joint planning, training and referral pathways are
developed between statutory and voluntary agencies so that service users are
offered support to deal with a range of addictive behaviours and that smoking
cessation or tobacco harm reduction is seen as an integral part of an
individual’s package of care.
Smoking is often one of many risk-taking behaviours which impact on an individual’s
health. Our tobacco control strategic plan recognises the need for integrated referral
pathways between smoking cessation and drug and alcohol teams.
4.0 Strategic Priority 2:
To reduce smoking in young people so that less than 9% of
15 year olds report to be smoking by the end of 2016
4.1 Access to tobacco
Preventing young people from taking up smoking is part of Hertfordshire’s
approach to early intervention and prevention, which runs through its strategic
approach to supporting children and young people.
About two thirds of adult smokers say they started before the age of 18 and 90% by
the age of 19. Every year 205,000 young people in the UK take up the habit. In 2012
in the UK, 23% of 11 -15 year olds had smoked at least once and similar levels of
boys and girls start smoking and continue to smoke. Regular smoking increases with
age, from less than 0.5% of 11 year olds, increasing to 10% of 15 year olds.41
However, by age 20-24, more than one in four young adults have become smokers.
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4.2 Smoking and Young People
We recognise that although nicotine keeps smokers physically addicted to tobacco,
there is a wide range of social and behavioural factors that encourage young people
to take up smoking and make quitting difficult.
Living in a household where a parent or sibling smokes is strongly associated with
the uptake of smoking in young people. People who start smoking at a young age are
more likely to:




Continue smoking
Smoke more heavily than those who start later
Be more vulnerable to smoking-related disease
Find it more difficult to give up.
4.3 Helping young people to stop smoking
Young people who smoke and want help to quit should be able to access services
which are sensitive to their needs and committed to the ‘You’re Welcome’ quality
standard for young people’s services.42 Hertfordshire Stop Smoking Service is
committed to reducing smoking prevalence in young people and contributes to this by
supporting parents to quit smoking and training partners such as Children’s Centres
and Health Visitors to promote Smokefree lifestyles.
Young people who are found to be smoking should be encouraged to quit using peer
support and local stop smoking services. The ‘Yeah Butt’ booklet and resources and
materials specifically for young people are available through Hertfordshire’s Health
Promotion website. These should be used to help motivate young people to consider
stopping smoking.43
4.4 Young people and smoking in Hertfordshire
The latest (2012) Health Related Behaviour Survey of 7222 school age young people
across Hertfordshire demonstrated the need to continue to support parents make
changes in their smoking habits to reduce the harm of second hand smoke to babies
and children, as well as activities to de-normalise smoking and reduce parents as
smoking role models for their children.
The survey revealed that 43% had been exposed to second-hand smoke in their own
homes, 30% in someone else’s car and 26% in their family’s car; about a third (32%)
reported that one or both of their parents smoked. Almost all smokers knew at least
one person who smoked compared with about half of non-smokers.44
Smoking in young people should not be considered in isolation, as it is often linked to
other unhealthy or risk taking behaviours; factors strongly associated with smoking in
young people include being older, other risky behaviours (drinking alcohol, substance
misuse and truancy), and having friends and family who smoke.
Nationally, the number of young people who report that they have tried smoking or
are regular smokers continues to decline.45
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4.5 Preventing the uptake of smoking in young people
Hertfordshire runs a wide range of prevention programmes through its youth service,
Youth Connexions, and through providing small grants to voluntary organisations to
trial innovative ways of working with vulnerable young people. Many of these projects
involve physical activities such as football or other sports, which promote healthy and
Smokefree lifestyles. It’s important to remember that most young people in
Hertfordshire do not smoke, and publicising this fact to young people is an effective
way to promote Smokefree lifestyles as young people over-estimate the number of
their peers who smoke.
Alongside universal education around smoking and healthy lifestyles in schools,
targeted interventions for particularly vulnerable young people and parents and in
geographical areas where smoking is high are required. More work needs to be
developed in youth settings including schools, colleges and the university to prevent
the uptake and consolidation of smoking in young people during this transition phase
when smoking becomes a more regular pattern.
4.6 Mentoring Programmes
The Health Champions programme has just launched in Hertfordshire, and provides
training for young people to become Public Health Champions within their schools to
develop and implement their own interventions for their peers around health issues,
including smoking. Health messages tailored for young people are also regularly
promoted via Hertfordshire's youth website Channel Mogo, and its associated email
newsletter which goes to over 12,000 young people.
Hertfordshire already runs several successful mentoring schemes for young people
in schools and other youth settings, which could be developed to incorporate an
enhanced focus on smoking and other substance misuse issues. An evaluation of the
impact of these programmes and recommendations for their development is planned
for 2014-15. Peer mentoring programmes such as the ‘ASSIST’ (A Stop Smoking in
Schools Trial) programme are recommended by the National Institute for Health and
Care Excellence (NICE) and legislative enforcement play a key part in making
smoking less attractive to young people.[6]
4.7 Targeted Support
Hertfordshire already delivers high quality targeted support to its most vulnerable
young people through the Targeted Youth Support service. Vulnerable young people
are allocated personal advisors who identify any health issues, including smoking
addiction, and provide personalised support and referral to specialist services such
as Hertfordshire Stop Smoking Service. Youth offenders, young people in care, and
young people leaving care are particularly targeted for this sort of support.
More work needs to be developed in youth settings including colleges and the
university to prevent the uptake and consolidation of smoking in young people during
this transition phase when smoking becomes a more regular pattern.
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4.8 De-normalising tobacco
Reducing uptake is achieved by de-normalising tobacco use so that smoking is the
exception rather than the norm. This is done in a number of ways including making it
more difficult for young people to access tobacco and creating Smokefree
environments, and having adult and peer role models who don’t smoke.
Peer mentoring programmes such as the ‘ASSIST’ (A Stop Smoking in Schools Trial)
programme are recommended by the National Institute for Health and Care
Excellence (NICE) and legislative enforcement play a key part in making smoking
less attractive to young people.46
Hertfordshire Trading Standards has a regulatory duty to conduct test purchasing
and investigate where it thinks there are breaches to the legislation relating to the
sale of tobacco to minors. Decreasing access to tobacco and illegally accessed
tobacco is a vital part of this strategy.
5.0 Strategic Priority 3:
To reduce smoking in pregnancy so that less than 7% of pregnant
women throughout their pregnancy by the end of 2016
5.1 Risks and impacts of smoking during pregnancy
Smoking during pregnancy increases the risk of adverse pregnancy outcomes and
has a lifetime effect on the unborn baby. Smoking in pregnancy and exposure to
second-hand smoke is associated with increased risk of miscarriage, stillbirth, preterm birth, low birth weight, placental and labour complications and neonatal mortality
and Sudden Unexplained Infant Death (cot death).47
5.2 Hertfordshire Smoking at time of Delivery data (SATOD)
Each year there are approximately 14,500 deliveries to Hertfordshire mothers and on
average in 2011-2012, 9.8% of pregnant women smoked throughout their pregnancy;
this compared with 12.7% nationally. Smoking during pregnancy as measured at the
time of delivery (giving birth) has steadily declined in Hertfordshire. The figure was
11.0% in 2009 and 10.1% in 2010.48 However, smoking prevalence can be as high
as 29 percent in lower socio-economic groups and 45 percent in mothers under the
age of 20.49
The latest data for 2013/14 show that smoking in pregnancy continues to decline with
between 6.6% (West Herts) and 8.4% (East and North Herts) of mothers recorded as
smoking at the time of delivery in Hertfordshire between September and December
2013.50
Tackling smoking during pregnancy and reducing infants’ exposure to second-hand
smoke will reduce stillbirths and infant deaths by as much as 30-40 percent.
Pregnant smokers who continue to smoke throughout pregnancy are often heavier
and more addicted smokers, have partners who smoke and have wider social
influences which impact on their ability to quit successfully and they are more likely to
be depressed than non-smokers. Reducing smoking during pregnancy therefore
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requires a whole family approach and not treating the pregnant woman in isolation.
5.3 Pregnancy Stop Smoking Services
Intensive interventions from the point of referral are required as pregnant smokers
who fail to stop smoking early in pregnancy are hard to reach and support through to
quitting. Using the best available evidence, only between 3 and 6% of these pregnant
smokers are likely to be successfully quit at the time of giving birth.51
Pregnancy Stop Smoking Services in Hertfordshire are managed and delivered by
Hertfordshire Stop Smoking Service and a Smoking in Pregnancy Stop Smoking
Specialist. In 2012-2013, 84 pregnant women successful stopped smoking using a
local stop smoking service in Hertfordshire.
To ensure services are accessible to pregnant smokers across the county, local
service providers (GP and Community Pharmacy) are also trained and supported to
deliver these services. Nicotine replacement therapy is available to pregnant women
who are unable to stop without it, as this is significantly less harmful than continuing
to smoke.
5.5 Maternity Services
Maternity services have a key role in identifying and referring pregnant smokers and
their partners to Hertfordshire Stop Smoking Service at the earliest opportunity. We
have established training and support mechanisms for our maternity services and
during 2014, all our community midwives will be implementing Carbon Monoxide
testing which helps to identify more smokers and to facilitate discussions about the
risks of toxins to the baby. Clinical Commissioning Groups use their contracting
mechanisms to ensure that this remains a continuing priority with all NHS
organisations that work with pregnant women. Hertfordshire Stop Smoking Service
will continue working with NHS partners to implement National Institute for Health
and Clinical Excellence (NICE) Guidance on Smoking in Pregnancy (PH26) and
Secondary Care (PH48) which includes maternity services).
Our ambition is to make year on year reductions in the number of women who smoke
throughout pregnancy. This ambition not only requires good pregnancy stop smoking
services with highly intensive support and good midwifery referral pathways, but the
combined efforts of partners to prevent the uptake of smoking in children and young
people and programmes to help young adults to quit smoking prior to parenthood.
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6.0 Strategic Priority 4:
To protect young people from second-hand smoke by
rolling out a comprehensive Smokefree homes and cars
scheme
Our ambition is to protect greater numbers babies and children by working
with a range of partners to roll out a county wide scheme where organisations,
individuals and families acknowledge the dangers of second-hand smoke and
pledge to promote and maintain Smokefree environments for our children.
6.1 The Legislation
Second-hand smoke (previously known as passive smoking) is a significant cause of
harm to others. Although legislation protects others from the effects of second-hand
smoke in the work place and in enclosed public places, the majority of deaths from
exposure to second-hand smoke occur in the home.52
6.2 The Impact of second-hand smoke
Although smoking in the home has reduced, approximately two million children in the
UK are exposed to second-hand smoke this way.53 Children are more sensitive to
environmental tobacco smoke and measures of nicotine metabolism from inhaled
smoke are about 70% higher than in adults exposed to similar levels. Children
exposed to second-hand smoke are at greater risk of dying in the first year of life,
including neonatal mortality and Sudden Unexplained Infant Death (cot death), as
well as longer terms effects such as asthma, lower respiratory infections, middle ear
disease, pneumonia, bacterial meningitis, coughs and wheezes and childhood
cancer and adult heart disease. Children exposed to second-hand smoke on a daily
basis more than triple their risk of lung cancer than children who grow up in smoke
free environments.54 Exposure to second-hand smoke is also associated with
neurological impairment and behavioural problems in children. Second-hand smoke
within the car concentrates the toxins and carcinogens of tobacco smoke even more
highly in the confined space.
6.3 Smokefree homes and cars campaign
As well as the national Smokefree homes and cars campaign, there is already local
action in Stevenage to promote Smokefree homes and cars (Smokebusters). This
project is well underway and being coordinated with a range of partners to ensure
high visibility and impact. The Smokefree homes and cars campaign is included
within the Clinical Commissioning Group’s contracts with NHS organisations to
implement during 2014-2015 and will also be promoted with our alliance partners.
Smoking within the home is also a significant fire risk. We will continue to work with
Hertfordshire’s Community Protection Fire and Rescue Service to promote
smokefree homes and to provide support for our most vulnerable citizens to help
them quit smoking or to use alternative forms of nicotine.
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7.0 Strategic Priority 5:
All pubic sector workplaces to be completely Smokefree by
2016
7.1 Smokefree Workplaces
Our ambition is for all public sector organisations, and those who have an
influential role on children, young people, and young adults to adopt
Smokefree policies so that young people do not have adult role models who
smoke, and adults who do smoke are deterred from smoking during working
hours so that quitting smoking becomes easier.
In July 2007, legislation to create smoke free enclosed work and public places was
implemented to protect people from the harms of second-hand smoke. There is a
high compliance rate and overwhelming public support. A year after implementation,
76% of people supported the law for work and public places and 70% thought it had
a positive impact on people’s health.
A key aspect of this strategy is normalising Smokefree lifestyles. The Smokefree
legislation protects people’s health at work, but we need to capitalise on large routine
and manual employers and the opportunity they present as supportive environments
for their employees who want to quit, as well as developing a Smokefree workplace
culture. Public sector organisations should act as exemplars in tobacco control;
challenging the conditions which normalise tobacco use is part of our vision.
Employers across Hertfordshire are being encouraged to improve the health of their
employees – it improves both morale and productivity in the work place and is a key
aspect of the Public Health Responsibility Deal.55
7.2 Stop Smoking in the Work Place
Employers are supported to develop campaigns and referral pathways for their
employees who want to stop smoking and work with Community Pharmacies,
Hertfordshire’s Local Pharmacy Committee and Hertfordshire Stop Smoking Service
is increasing the capacity to offer workplace support.
7.3 Tobacco Policy
Hertfordshire County Council’s tobacco policy which outlines its own position on
tobacco control and its ambitions to become a Smokefree organisation can be found
here:
http://www.hertsdirect.org/yourcouncil/civic_calendar/publichealthlocalismcp/17941266/
Our NHS partners are also keen to develop their Smokefree policies and have plans
to implement the National Institute for Health and Clinical Excellence (NICE)
Guidance PH48: Smoking cessation in secondary care, acute, maternity and mental
health services during 2014-2016.56
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8.0 Communication and Marketing Strategy
8.1 Communications and Social Marketing
To maximise our chance of achieving our aims, communications will remain an
important aspect of tobacco control advocacy in Hertfordshire. Effective
communication in tobacco control involves raising awareness, shifting attitudes and
ultimately changing behaviour of professionals and the public.
We will develop a specific communications approach to ensure coordinated and
consistent messaging across all partner organisations.
Where possible, we will coordinate marketing activity with other agencies to
maximise our impact. Any local work will take into account regional and national
events, campaigns and branding so that there is a coordinated approach to
communications. We will capitalise on national events such as National No Smoking
Day and Stoptober to increase the impact of local activity, as well support regional
campaigns such as the east of England illegal tobacco campaign (2012).
We will ensure that we make best use of existing communication pathways to reach
professionals, voluntary organisations and the public so that everyone is aware of the
importance of promoting Smokefree lifestyles, the availability of training and
development opportunities for tobacco control and the support that is available to
help smokers quit across the county.
8.2 Stoptober 2013 Update
Over 5,200 Hertfordshire residents planned to quit smoking during October 2013.
Hertfordshire was one of the most successful local authorities to reach its smokers by
capitalising on a national campaign and promoting it locally though alliance
partnerships and media activity.57
8.3 Social Marketing and Motivation
Our approach locally will use insight and social marketing techniques to reduce
tobacco-related harm in Hertfordshire. Our support of local tobacco control action
plans and training and resources will be tailored to specific audiences to help support
organisations and give them the right tools for the job.
Training in brief intervention advice and motivational interviewing skills will be offered
to alliance partners to support the delivery of tobacco control.
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9.0 Examples of Good Practice in Hertfordshire
There are many positive examples of effective tobacco control measures being
implemented across Hertfordshire

Hertfordshire’s Tobacco Control Alliance will be conducting peer reviewed
assessment of tobacco control (CLeaR) in 2014 and will be sharing the results
with key stakeholders (the results will help to inform local tobacco control
action plans)

Hertfordshire County Council is committed to leading the way on tobacco
control and funded a county-wide tobacco control workshop in January 2014
to increase the knowledge, skills and capabilities of a wide range of range of
stakeholders and to inform this strategic plan and associated action plans.

Hertfordshire County Council has approved its own tobacco policy, ensuring
that the ambitions of Hertfordshire’s Health and Wellbeing Strategy are
endorsed and supported by elected County Council members and senior
officers.

Each of the 10 District or Borough Councils has elected member tobacco
control advocates and council officer champions who have adopted local
tobacco control action plans to address tobacco control within their
communities.

A yearly review of young people’s smoking beliefs and behaviour will be
conducted across Hertfordshire as part of the Health Related Behaviour
Survey to measure numbers of young people who report smoking at ages 12
and 15.

A commitment to provide training, support, resources and communication
expertise to key partners to rollout a county-wide Smokefree homes and cars
scheme so that babies and young children are protected from second-hand
smoke.

We are already working with Hertfordshire Fire and Rescue services to reduce
smoking-related house fires.

Multi-agency work in deprived areas of Watford to promote the uptake of
services including stop smoking support and fire prevention activities has had
promising results.

Work is underway with key partners to reduce the number of young adults who
smoke and pregnant women who smoke throughout their pregnancy.

Ensuring that young people under 18 cannot gain access to tobacco though
underage sales through the work of Trading Standards.
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
Ensure compliance with point of sale display restrictions is work already in
progress.

We are working with Her Majesty’s Revenue and Customs (HMRC) to ensure
that Hertfordshire residents are not exposed to the illegal tobacco trade.

Support for national smoking cessation campaigns such as ‘Stoptober’ and
‘National No Smoking Day’.

Stop smoking services in Hertfordshire continue to provide excellent, equitable
and accessible services to smokers who want to quit and as well as ensuring
that people who do not want to quit are provided with advice on how to reduce
their levels of smoking.

‘Stop before the Op’ initiative to promote smoking cessation prior to elective
surgery.

The Public Health Healthy Work place offer means employers and workplaces
are supported in improving the health of employees, including help to stop
smoking.

Work with NHS partners to identify and refer smokers and those at risk of
other lifestyle diseases by implementing ‘Making Every Contact Count.’

Innovative work with drama and film to prevent the uptake of smoking in young
people is being developed.

Smokefree playgrounds in North Herts, Hertsmere and Three Rivers District
Councils are already in place.
Hertfordshire Tobacco Control Strategy Group received ‘Reducing Health Inequalities
through Tobacco Control’ funding from the Department of Health in 2011. The
funding was allocated to trading standards and bids were received though Local
Strategic Partnerships (LSPs) and was used to fund tobacco control projects across
Hertfordshire which included:





Piloting a Smokefree homes and cars scheme (Stevenage Smokebusters).
Introducing a lung-age testing programme in community pharmacies.
A smoking and young people service development project.
Fair Trading Award seminars “Do you pass?”
North Hertfordshire District Council engagement with local businesses.
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10.0 Alternative forms of Tobacco and Nicotine Containing
Products
10.1 Niche Tobacco Products
There are a wide range of niche tobacco products available in the UK such as snuff,
smoking tobacco (Indian bidis), shisha and chewing tobacco (paan masala and
gutkha) predominantly used by South Asian communities. Use of these products is
culturally accepted and they often do not come with adequate health warning labels.
Smoking, oral tobacco use and excessive alcohol use all increase the risk of mouth
and stomach cancers as well as causing heart disease and stroke. Changing
attitudes around the use of niche products will take much effort and time. Local
intelligence regarding the extent of niche product use in Hertfordshire is required to
take appropriate action to protect communities from this form of tobacco-related
harm.
10.2 Harm Reduction
Harm reduction is appropriate in tobacco control and smoking cessation. Harm
reduction is about decreasing the burden of death and disease caused by tobacco
use, without completely eliminating nicotine and may include substituting the nicotine
in tobacco with less harmful nicotine containing products.
This approach seeks to help people who are highly dependent on nicotine who:










May not be ready or able to stop smoking in one step
May want to stop smoking but do not want to give up nicotine
May want to reduce the amount they smoke
May want or need to stop smoking on a temporary basis
May be at significant risk of tobacco-related harm (such as a long term
condition caused or exacerbated by smoking)
May be at risk of a smoking-related house-fire
May want to protect others from second-hand smoke
Are in custody or a closed institution (or working in them)
Are working in Smokefree environments
Are in hospital settings where smoking is not permitted in the grounds
Stopping smoking in one step remains the best chance of success and should
always be recommended as a first-line approach. Harm reduction is for smokers who
may have:






Many previous failed attempts
High dependency on nicotine
High exposure to smoking stimuli and cues to smoke
Craving and withdrawal symptoms
Insufficient support
Lack of confidence in quitting
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Mental health service users, routine and manual workers and people with
smoking-related long-term conditions are most likely to benefit from this
approach.
We will integrate harm reduction into our tobacco control plans where possible
and appropriate. A harm reduction policy will be developed along side this
strategic plan, which highlights the importance of raising awareness of harm
reduction, training staff in behavioural techniques to reduce smoking and to be
able to provide advice on nicotine containing products that can be used to reduce
smoking in the short, medium and long term.
NHS partners will be supported to implement NICE PH 45 Guidance ‘Tobacco:
harm-reduction approaches to smoking58.
10.3 Electronic Cigarettes
Electronic cigarettes are devices which vaporise a liquid solution into an aerosol mist,
simulating the act of tobacco smoking. They are often designed to look and feel like
cigarettes and have been marketed as cheaper and healthier alternatives to
cigarettes and for use in places where smoking is not permitted since they do not
produce smoke.
E-cigarettes are now commonplace in our communities and easily accessible on the
internet and in supermarkets. They are used by smokers for one or more of the
following reasons:
1. substituting for cigarettes
2. substituting for cigarettes with the intention of cutting down to quit
completely
3. complying with smoking legislation and policies as they can legally be used
in enclosed public places
4. reducing the costs of smoking tobacco.
Action on Smoking and Health (ASH) has estimated that there are 1.3 million current
users of electronic cigarettes in the UK. This number is almost entirely made of
current and ex-smokers; with perhaps as many as 400,000 people having replaced
smoking with electronic cigarette use. The number of users is increasing, 3% of
smokers reported using electronic cigarettes in 2010, increasing to 7% in 2012 and
11% in 2013.59
Electronic cigarettes are not covered by any UK food or medicines standards
legislation although the European Directive will make a number of changes to this.
Devices are of variable quality and effectiveness and safety of the devices remains a
concern. The intention is that they will become licensed by the Medicines and
Healthcare Products Regulatory Authority (MHRA) as nicotine-containing products by
2015.60
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Our review of the evidence indicates that we need to work with e-cigarettes as part of
a balanced approach to tobacco control. There are potentially significant benefits to
this approach, as well as some risks.
On balance, using them is significantly less harmful than smoking and smokers
should be offered support to quit as well as offered alternative forms of licensed
nicotine containing products to quit or reduce smoking. In the move to harm
reduction, e-cigarettes should be seen as a tool we can use sensibly, with ongoing
monitoring of evidence on harms and benefits.
Potential benefits


Supporting people who cannot quit or do not want to quit get the benefits of
tobacco-free products
Helping smokers to quit who do not want to use a conventional nicotine
replacement therapy
Potential risks

Nicotine is harmful to a developing child and pregnant women who use ecigarettes still risk potential harm. But on a harm reduction basis we prescribe
Nicotine Replacement Therapy and the nicotine levels in e-cigarettes are
similar. This is not a risk free solution.
Uncertainties



We do not know about the long term risks of nicotine addiction in and of itself
for most populations
We do not know about the safety of the delivery solutions
One concern is that they may be seen as a gateway for young non-smokers to
start smoking. But there is no evidence for this. Current evidence suggests
that they are almost exclusively used by current smokers and recent exsmokers and that young people are not using them as a precursor to smoking.
How e-cigarettes are marketed to the public has been the subject of
consultation and recommendations have been made to ensure e-cigarette
manufacturers do not market them to under18s.
We will develop a specific policy on e-cigarettes which treats them as nicotine
containing products and not as tobacco, and which seeks to develop a sensible,
evidence-based approach to including e-cigarettes as a help in the work towards
controlling and reducing harm from tobacco.
In the mean time, smokers should be advised of the variable standards and levels of
nicotine found in these products, as some contain no nicotine at all and nicotine
levels can vary considerably from the labelled content.61
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11.0 Delivering the Tobacco Control Strategic Plan
Hertfordshire’s Tobacco Control Strategic Plan 2014-2016 which
accompanies this report has been developed with input from key stakeholders
and following a tobacco control workshop held in January 2014. It will be
supported by an annual, multi-agency tobacco control action plan, to be
produced by Smokefree Hertfordshire, the local Tobacco Control Alliance and
following an annual tobacco control workshop.
Local Smokefree tobacco control action plans will also be developed jointly
with each district and borough council to reflect the strategic priorities but with
local smoking prevalence, priorities and insights taken into account. Local
Smokefree Alliances may be convened to address particular issues; these will
report individually to their local Health Partnerships which cover the ten
District and Borough Councils.
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At a glance Smokefree Hertfordshire’s Tobacco Control Strategic Plan 2014-2016
Reducing
smoking in
each district
to 18.5%
(Ambition 1)
Smokefree
Children and
Families
group
(Ambition 2)
Smokefree
in
Pregnancy
Group
(Ambition 3)
Smokefree
Cars and
Homes
Group
(Ambition 4)
Smokefree
Workplaces &
Communities
Group
(Ambition 5)
Programme Co-ordination: Local Action Groups
Communications and Marketing Plan
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Smokefree Hertfordshire:
Hertfordshire’s Tobacco
Control Alliance
Hertfordshire Stop
Smoking Service
Hertfordshire Tobacco Control Strategy Group
12 References
1
Hertfordshire County Council (2013) Healthier Herts: A Public Health Strategy for Hertfordshire 2013- 2017 Available at:
http://www.hertspublichealth.co.uk/files/Healthier%20Herts%20Public%20Health%20Strategy%202013-2017.pdf
2
NHS Commissioning Board: The functions of clinical commissioning groups (2013). Available at: http://www.england.nhs.uk/wp-content/uploads/2013/03/afunctions-ccgs.pdf
3
Hertfordshire County Council Cabinet Panel. Tobacco Control Report of the Director of Public Health (November 2013). Available at:
http://www.hertsdirect.org/your-council/civic_calendar/cabinet/17873330/
4Department
of Health (2013) Public Health Outcomes Framework 2013-2016. Available at: https://www.gov.uk/government/publications/healthy-lives-healthypeople-improving-outcomes-and-supporting-transparency
5
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30
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33
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