Smoking and Tobacco Control

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Joint Strategic Needs Assessment (healthysomerset.co.uk/JSNA)

Why Tackle Smoking?

Nicotine inhaled from smoking tobacco is highly addictive. It is the main reason people continue to smoke.  But it is primarily the toxins and carcinogens in tobacco smoke – not the nicotine – that cause illness and death. The best way for society to reduce these illnesses and deaths is to reduce the level of smoking in society to as low as practicable, which we achieve through tobacco control measures.

Smoking and Tobacco Control in Somerset - Key Facts

• 12.3% of the adult population of Somerset currently (2016) smokes which equates to around 53,000 people, a major fall from around 20% (75,000) three years ago.
• Smoking remains the single largest cause of preventable premature mortality in Somerset, killing around 875 people a year, half of them in middle age.
• This represents a rate of 226 deaths per 100,000 people over 35 years of age (2014-16).
• Smoking prevalence is higher in so-called "routine and manual" workers (at 23.2%) and in people with mental health problems.
• 1,641 children are estimated to start smoking in the county each year; that's around 32 a week (BMJ/Thorax).
• Somerset people spend over £138 million on tobacco each year (including illegal tobacco), most of which leaves the local economy.  Only 6% of the retail price of cigarettes is profit for the retailer, compared to 24% average across all other products.
• Smoking in Somerset is estimated to add around £24 million to costs incurred by the NHS and Somerset County Council for care services. 
• In 2016/17, there were 5,700 hospital admissions in Somerset attributable to smoking. The rate of 1,497 per 100,000 people over the age of 35 is below the national average of 1,685 per 100,000. Smoking-related hospital admissions in Somerset cost around £9.4 million, or £26.50 per head of population (2016/17) and falling overall. 
• Due to the longer term impacts of smoking, some health conditions primarily caused by smoking continue to rise eg lung cancer in women. This is a time lag effect.
• A total of 1293 people in Somerset successfully quit smoking in 2016/17 through the Smokefreelife Somerset Stop Smoking Service, up from 1240 in 2015/16. This was from a total of 2,463 clients who set a 'quit date', giving an improved overall quit success rate of 52%.
• There are increasing numbers of pregnant women in Somerset setting a quit date with the Stop Smoking Service, with the service achieving overall the greatest reach and quit success in England. In 2016/17 292 pregnant women quit from 504 setting a quit date (58%).

Key Issues Nationally

• Across the UK, just over one in six adults smoke (15.5%), notably higher than in Somerset.
• Smoking is a major driver of cancer and chronic lung disease, and a substantial contributor to heart and circulatory diseases. Smoking kills about 200 people a day in England.
• Current smokers are less likely to report themselves to be in good health compared to those who have never smoked, especially amongst 50-64 year-olds (IHS 2013).
• Smoking is the single largest cause of health inequalities, accounting for up to half the difference in life expectancy between the most and least healthy wards (see Tobacco Control Plan for England).
• Smoking is a major driver of poverty, and child poverty. A couple smoking 20 a day each will spend over £5,000 a year on cigarettes.
• Smoking imposes substantial costs on the local economy, through sickness absence, smoking breaks, health and social services costs, litter, fires, and lost economic output through early death or ill health retirement, amounting to at least £13.8 billion a year for the UK.
• Tobacco control has a very strong evidence base, which demonstrates the need for sustained, multi-faceted work at international, national, regional and local levels. At a local level this requires adequate investment across the range of tobacco control interventions. 
• Return on Investment models show that investment in regional and local tobacco control, coupled with local stop smoking services, is highly cost-effective in the short, medium and long-term.
• Standardised plain packaging was introduced during 2016, together with a prohibition on smaller pack sizes of cigarettes and rolling tobacco. Together these are expected to further reduce uptake of smoking by young people.

What is working well in Somerset

• Somerset County Council and all five district councils have signed the Local Government Declaration on Tobacco Control
• The Smokefreelife Somerset stop smoking service provides high quality support to smokers who are ready to quit.
• Smoking in pregnancy work has been provided with additional resources and results are very positive, and recognised as one of the most successful programmes in England.
• Work to create smoke-free hospitals and embed stopping smoking in care pathways of the acute hospitals (Yeovil and Musgrove Park) has progressed, but there is still significant room for improvement. 
• Somerset Partnership NHS Trust went completely smokefree on its estate in January 2018.
• The Smokefree Somerset Alliance exists to bring together local partners to advance tobacco control work in the county and a new Tobacco Control Strategy for the County will be adopted in 2018.
• Smokefree play parks have been rolled out in 4 of the 5 districts.
• The Alliance has worked with the Somerset Community Foundation to run a successful smokefree Sports Clubs grants programme to provide smokefree sporting environments for children and young people.
• Work is in progress to expand smokefree areas to include the surrounds of schools and children’s centres.

Challenges

• Funding cuts in regulatory services (Trading Standards and Environmental Health) mean capacity and resources to address underage sales, illegal tobacco activity and detect breaches of smoke-free laws are very limited, despite increasing numbers of regulations to enforce. 
• Funding cuts to public health have led to a regional decision to cut regional mass media campaigns and bring to an end Smokefree Southwest, the regional office for tobacco control. The local budget for tobacco control has also been cut heavily.
• Recent NICE guidance has called for stop smoking services to be provided in hospitals at a much greater level than is currently the case, which has funding implications for commissioners. A business case for a hospital stop smoking service with post-discharge support on demand was well received but is not yet funded.
• Reducing uptake by young people is recognised as extremely challenging. Reducing adult prevalence is most effective, as it progressively ‘de-normalises’ smoking in society. Highlighting the role of the tobacco industry, as has been done in parts of the USA, is effective but politically sensitive. 
• Reducing smoking in higher prevalence groups, such as people living with mental illness and in pregnancy are priorities. These groups require significantly more resource per client to achieve a successful quit than the general population.
• Vaping (e-cigarettes) has grown in popularity in recent years to now be the single most popular way of quitting smoking. Many organisations and employers do not distinguish well between smoking and vaping. There is concern that although the evidence to date is that vaping is around 95% safer than smoking, public perceptions are trending in the wrong direction, with people, especially non-vapers,  thinking that the risks are much more similar.  There is a need to ensure policies are based on the evidence, rather than on concerns which are not borne out by the evidence, while keeping a careful eye on research findings.

Smokefreelife Somerset is the stop smoking service provider for the county. The service caters for the needs of the local population with out-of-hours support for people whose work means they cannot access regular sessions, and accessible clinics in local community settings including community centres, leisure centres, pharmacies and GP surgeries. Support is offered over a 12 week period with free Nicotine Replacement Therapy (NRT) to help smokers overcome their addiction, as well as access to prescription medications.  The service also provides behavioural support for people who want to quit using their own e-cig, a service that may be particularly suited to those people who are both vaping and smoking, but struggling to switch completely.

Smokers are offered support through quit clubs providing them with professional and peer support whilst they quit.

Smoking during pregnancy

Smoking in pregnancy is a major public health challenge for Somerset on which we are making good progress.  It remains one of the few modifiable risk factors in pregnancy. There are significantly increased risks for the pregnant woman and baby due to smoking as shown below.

Babies born to mothers who smoke:

• are more likely to be born prematurely and with a low birth weight (below 2.5kg or 5lb 8oz).
• have a birth weight on average 200g (7oz) less than those born to non-smokers. This effect increases proportionally - the more the mother smokes, the less the child weighs.
• have organs that are smaller on average than babies born to non-smokers.
• have poorer lung function.
• are twice as likely to die from cot death.
• are ill more frequently. Babies born to women who smoked 15 cigarettes or more a day during pregnancy are taken into hospital twice as often during the first eight months of life.
• get painful diseases such as inflammation of the middle ear and asthmatic bronchitis more frequently in early childhood.
• are more likely to become smokers themselves in later years.

In addition, pregnant women who smoke increase their risk of early miscarriage.

In later pregnancy, smoking mothers are at increased risk of the baby's placenta coming away from the womb before the baby is born (placental abruption). This may cause the baby to be born prematurely, starve of oxygen, or even to die in the womb (stillborn).

In Somerset:

• Smoking in pregnancy is now falling in Somerset much faster than nationally, reflecting the investment made in tackling this issue, and is now just above the national average.
• The proportion of mothers recorded as still smoking at time of giving birth has been reduced from 17.4% to 11.5% over the last five years to March 2018.
• In 2017/18, 399 pregnant women in Somerset set a quit date with the Stop Smoking Service (down from the peak of 504 in 2016/17), of whom 199 quit (50%) (provisional data at 5/18).

Nationally, figures demonstrate links between smoking and deprivation.  There appears to be slower declines among women in deprived areas who need the most help to give up smoking.  It is important that midwives and stop smoking services offer targeted support and services to these women, appropriate to the context of their lives and their socio-economic circumstances.  Babies from deprived backgrounds are also more likely to have much greater exposure to secondhand smoke in childhood. 

Stop smoking services for pregnant women in Somerset 

In Somerset there is a programme to reduce smoking in pregnancy, involving the Somerset Clinical Commissioning Group, The Heads of Midwifery at Musgrove Park and Yeovil District Hospitals, the Smokefreelife Somerset Stop Smoking Service, and Public Health.

Commissioners have invested additional funds to improve identification and referral of pregnant women who smoke to stop smoking services and to offer intensive support from dedicated Mums2Be quit coaches.

The coaches provide weekly support during the initial quit attempt, as with standard stop smoking services, but in the home or other venue convenient to the pregnant woman. At each contact a carbon monoxide breath test is conducted to check for evidence of smoking. For each satisfactory reading the woman is issued with a shopping voucher, the value of which increases over time.

Unlike the standard service, the advisers meet the pregnant woman at two and three months after quitting, and also for a period after the birth to address the common problem of relapse and to promote a smokefree home. In addition, the advisers will support other members of the household who wish to quit.

Outcomes

• In the Yeovil pilot four out of five women who engaged with the programme were able to quit and stay quit throughout the pregnancy.
• Far more women engaged with this pilot programme than women elsewhere in the county, and enjoyed smokefree pregnancies as a result.
• Most importantly there were significant differences in birth outcomes between the women who engaged, and those who did not.
• In those who did not there were three stillbirths, compared to none in the engaged group. There were twice as many low birthweight babies in the non-engaged group, and mean birthweight was slightly lighter in the non-engaged group.
• Mean birthweights were 3386g (7lb 7oz) in the engaged group and 3148g (6lb 15oz) in the non-engaged group.

While this programme is now well established there is still room for improvement by

• ensuring that all women are offered a carbon monoxide breath test at first booking; 
• making sure that smoking is raised at every contact; 
• making sure that smoking status at delivery is accurately obtained and recorded; 
• routine referral of women who smoke to the Mums2Be Smokefree service; 
• improved engagement with partners of pregnant women.

For more data and information on maternity and pregnancy issues, please see our Pregnancy and Maternity page.

E-cigarettes

The latest (2018) Public health England evidence review’s main findings are that:

• vaping poses only a small fraction of the risks of smoking and switching completely from smoking to vaping conveys substantial health benefits
• e-cigarettes could be contributing to at least 20,000 successful new quits per year and possibly many more
• e-cigarette use is associated with improved quit success rates over the last year and an accelerated drop in smoking rates across the country
• many thousands of smokers incorrectly believe that vaping is as harmful as smoking; around 40% of smokers have not even tried an e-cigarette
• there is much public misunderstanding about nicotine (less than 10% of adults understand that most of the harms to health from smoking are not caused by nicotine)
• the use of e-cigarettes in the UK has plateaued over the last few years at just under 3 million
• the evidence does not support the concern that e-cigarettes are a route into smoking among young people (youth smoking rates in the UK continue to decline, regular use is rare and is almost entirely confined to those who have smoked)

It’s of great concern that smokers still have such a poor understanding about what causes the harm from smoking. When people smoke tobacco cigarettes, they inhale a lethal mix of 7,000 smoke constituents, 70 of which are known to cause cancer.

People smoke for the nicotine, but contrary to what the vast majority believe, nicotine causes little if any of the harm. The toxic smoke is the culprit and is the overwhelming cause of all the tobacco-related disease and death. There are now a greater variety of alternative ways of getting nicotine than ever before, including nicotine gum, nasal spray, lozenges and e-cigarettes.

Growth in e-cigarette use has slowed and contrary to earlier indications appears fairly stable over the past 3 years.  Growth in electronic cigarette use has been accompanied by a reduction, albeit smaller, in use of licensed nicotine products and prescription medication but the trajectories are very different suggesting no causal connection.

The latest ONS survey of Adult Smoking Habits in Great Britain 2014, published February 2016, estimates that there are currently 2.2 million users of e-cigarettes, and 3.9 million former users. 

Use of e-cigarettes by people who have never smoked remains rare and similar to use of licensed nicotine products. E-cigarettes may have helped approximately 20,000 smokers to stop in 2014 who would not have stopped otherwise. (Smoking toolkit study). The aforementioned ONS survey revealed that 53% of the 2.2 million current vapers relied on the product to try to quit their nicotine addiction.

In another recent national survey, young people who were current smokers or regular smokers were much more likely than non-smokers to have ever used e-cigarettes (76%, 84% and 13% respectively). This pattern was found for both girls and boys: among boys 87 per cent of regular smokers had ever used e-cigarettes compared with 14 per cent among non-smokers. Among girls, 82 per cent of regular smokers and 12 per cent of non-smokers had ever used e-cigarettes. 1 per cent of non-smokers currently used e-cigarettes (among both boys and girls) but among regular smokers, 29 per cent of boys and 21 per cent of girls currently used e-cigarettes. 

The Somerset Children and Young People Survey 2016 showed that trial usage of e-cigarettes has risen amongst Year 8 and Year 10 pupils from 11% in 2014 to 20% in 2016. Amongst Year 10 pupils, 30% have ever tried e-cigs, but most no longer use them.

1 in 8 of Year 10s who've never smoked has tried e-cigarettes, but none use them regularly. The table below shows the group most likely to use e-cigarettes regularly are those who want to give up smoking cigarettes.

Source: Somerset Children & Young People Survey 2016/SHEU

Smoking amongst children and young people

National survey data has shown continuing falls in smoking amongst school age young people, to the lowest levels ever recorded.  A new national survey of 15 year olds in 2014 found that 24% had ever smoked, with 8% (10% female, 7% male) being current smokers. 

This was also reflected in the 2016 Somerset Children and Young People Survey: less than 1% of Year 6 pupils and 4% of secondary pupils reported smoking in the last 7 days. Smoking among college students was higher at 22%, of whom nearly half expressed a wish to quit.  This suggests that the combined effects of tobacco control measures, for example age of sale and tax increases raising retail prices, has led to a delay in uptake of regular smoking amongst young people.  It also suggests a need to address uptake in the transition from school to college or workplace.

Smoking among Young People local prevalence estimates

Figures published by Public Health England (PHE) in January 2015 estimate smoking rates among young people in local areas for the first time. The figures are modelled estimates of youth smoking rates for every local authority, ward and local NHS, based on factors known to predict smoking in young people. In Somerset, the wards with the highest estimated prevalence are in Bridgwater (Westover, Eastover, Victoria and Hamp) and Taunton (Halcon and Eastgate). Further details are available here. 

For more information:-

Please update following links with latest version links

• Local Tobacco Control Profile for Somerset contains many more facts and figures.
• Opinion & Lifestyle Survey Adult Smoking Habits 2016 
• Smokefreelife Somerset
• ASH toolkit 
• Tobacco Control Commissioning Support Pack
• JSNA Tobacco Control Data Pack

Author: Stewart Brock, Public Health Specialist