Joint strategic needs assessment

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Smoking and Tobacco Control (2015)

Topic titleSmoking and tobacco control
Topic ownerTobacco Control Strategic Group
Topic author(s)John Wilcox, Insight Specialist - Public Health
Topic quality reviewedJune 2015
Topic endorsed byTobacco Control Strategic Group
Topic approved byTobacco Control Strategic Group
Current versionJuly 2015
Replaces versionSmoking (2012)
Linked JSNA topicsCancer, cardiovascular disease, chronic obstructive pulmonary disease, Adult mental health, maternities and pregnancy.
Insight Document ID87638

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Executive summary

Introduction

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Smoking causes 80,000 deaths in England each year, more than any other preventable cause. Nottingham has significantly higher rates of lung cancer, COPD and heart disease and other conditions compared to England due to smoking. It is estimated that each year smoking costs ‘society’ in Nottingham approximately £88m. This includes £3m per year to Nottingham City Council for additional social care costs and £11.0m to the NHS for treating smoking related illness.

Adult smoking prevalence has decreased in the city over the last decade. But according to the local Citizen’s Survey 27.4% smoked in 2014, which is the similar to the prevalence in England in the early 1990’s, and significantly higher than the current national prevalence of 18%. The represent a significant heath inequality which is indicative of the positive correlation between smoking prevalence and deprivation. There is also a positive correlation between smoking prevalence and deprivation within the city. Aspley, St Anns, Bulwell and Clifton wards have a smoking prevalence significantly higher than the city average and almost double the England average.

The high smoking rates during pregnancy in the city (18.5%), compared to England (12.5%), are of particular concern. Smoking in pregnancy increases risk of complications, which affect mothers and babies health, and increase risk of miscarriage and maternal death.  Children who grow up in families and communities with a high proportion of smokers are more likely to become smokers themselves. Over 80% of adult smokers took up the habit before the age of 20. Second-hand smoke continues to be a significant cause of morbidity and mortality in children and 22.3% of households in the city still allow smoking in the home. Smoking prevalence amongst young people in England has decreased significantly over the last decade with only 8% of 15 year olds smoking regularly. Model based estimates, local survey data, and the strong correlation between child and adult smoking, suggests that smoking prevalence amongst young people in Nottingham, particularly in the most deprived areas, is likely to be higher than the national average.

High rates of smoking are a significant cause of people with mental health problems dying younger than the general population. Smoking rates are reported to be as high as 80% amongst local mental health inpatients and 57% amongst patients with enduring serious mental illness smoke.  Research suggests smoking may contribute to stress and anxiety and stopping smoking is associated with an improvement in symptoms.  Other groups with particularly high rates of smoking include adults who are unemployed, adults with alcohol and drug misuse problems, adults from Eastern European Countries and adults from certain LGBT groups.

The majority of smokes use manufactured or hand rolled cigarettes of which a proportion is illicit or counterfeit. Illicit or counterfeit tobacco brings crime into our communities and makes smoking more affordable and accessible to everyone including children and young people, ensuring people start young and continue the habit into adulthood.  Shisha smoking is also an issue of concern due to the increase in businesses selling shisha tobacco to be smoked in bars, restaurants and at home. Local research and intelligence suggests this tends to be smoked more by young Asian people as a social activity, and awareness and knowledge of the health effects appears to be low.

Usage of e-cigarettes has increased significantly in recent years so that 22.9% of smokers and recent ex-smokers use e-cigarettes and 14.9% use them daily. Available evidence suggests that smoking e-cigarettes is likely to be less harmful than smoking tobacco, and that they may help people to cut down the amount they smoke and potentially help with quitting smoking. However they are currently unregulated products, of variable quality, with safety concerns and are not recommended as a smoking cessation aid by NICE.

Action to reduce smoking is coordinated through the city’s Tobacco Control Strategic Group which brings together partners from the NHS and city council to identify and oversees the city’s priorities for action which will be set out in a new strategy from September 2016. The chapter describes the current range of interventions to reduce smoking from across the partnership. It is estimated that through current tobacco control interventions there will be a return of £2.90, £6.95, £13.23 and £41.95 per smoker across all services over 2 years, 5 years, 10 years and Lifetime respectively, for each pound spent on the current programme.

Unmet needs and gaps

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  • Smoking in pregnancy is significantly higher in the city than the England average and the gap is widening.
  • Other than the information provided through the Healthy Child Programme 0-5 (delivered by midwifery, health visiting and FNP), it appears that Early Help services and Early Years providers do not focus on reducing smoking in the home or exposure to second hand smoke amongst children.
  • Although various services seek to reduce smoking initiation amongst children and young people as part of their overall offer, this is not the primary aim of any one service and there is a lack of a coordinated approach across the City.
  • Over a 5th of households with children in the city allow smoking in the home increasing risk of exposure to secondhand smoke and initiation of smoking in children and young people.
  • Approximately 15% of schools in Nottingham City do not currently have Healthy Schools Status.  These schools may need additional support in encouraging and supporting to develop smoke-free policies and practices in line with the relevant Healthy Schools criteria on smoking. 
  • There is evidence that the prevalence of smoking amongst 16 & 17 year olds in the city is higher than the England average and model based estimated.The proportion of adults who smoke in the city is at a similar level to the England prevalence 20 years ago.
  • There continues to be significantly higher rates of smoking in routine and manual groups and in certain areas of the city particularly Aspley, St Anns, Bulwell and Clifton and there is a risk that this inequity gap may increase as the overall smoking prevalence decreased.
  • Smoking rates continue to be particularly high amongst routine and manual groups in the city.
  • Smoking prevalence in particularly high amongst adults from Eastern European countries who have settled in the UK including Nottingham City.
  • Smoking prevalence is significantly higher amongst adults with poor mental wellbeing and amongst adults with mental health problems.
  • Available national and local evidence suggests that smoking prevalence is higher amongst gay and lesbian adults than other groups.
  • Adults who drink at levels which harm their health and adults with substance misuse problems have very high rates of smoking.
  • Illicit and counterfeit tobacco is a significant source of the tobacco smoked in the city, making tobacco more readily available and contributing to crime in communities.
  • Smoking of Shisha, in dedicated bars, restaurants and delivered to the home is an issue as in the low awareness of health harms amongst users.

Recommendations for consideration by commissioners

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  • Develop a multi-agency smoking in pregnancy pathway and enhance interventions to reduce smoking in pregnancy and support women who want to quit based on the latest evidence in the Healthy Child Programme Rapid Review.
  • Complete the Smoking in Pregnancy Assessment Tool (based on the CLeaR model) which aims to help areas to reduce smoking rates in pregnancy using a whole systems approach. The tool brings together existing resources to help support areas to identify areas where they could positively impact rates of smoking in pregnancy.
  • Develop interventions to reduce the exposure of children to second-hand smoke in different setting including in the home and outdoor areas and assist with reducing the number of children that start smoking as a result of living in a smoking home and family.
  • Ensure that providing information around smoking (including risks of exposure to second hand smoke amongst babies and children), brief intervention and referral to smoking cessation services is prioritised in the service specifications for all maternal and early years services.
  • Provide a coordinated approach to reducing smoking initiation and smoking prevalence amongst children and young people across agencies/services.
  • Ensure services who work with young people provide evidenced based support/brief intervention around smoking and particularly target  those at greatest risk including pupils who have truanted or been excluded from school and pupils who receive free school meals. 
  • Develop specific pathways and treatment models for people with different levels of mental health problems. 
  • Fully implement NICE guidance PH45 (Smoking cessation in secondary care: acute, maternity and mental health services).
  • Ensure services are impacting upon smoking rates in more deprived areas and amongst routine and manual groups.
  • Ensure pathways and appropriate service models exist for people with drug and alcohol problems who wish to stop smoking.
  • Allocate resources to tackling illicit and counterfeit tobacco.
  • Develop and promote smoke free environments, and support new tobacco control legislation with communication in the city.
  • Ensure establishment selling shisha are properly regulated and the risk to users.
  • Engage with other groups with high smoking prevalence including Eastern European communities, people of Mixed/dual heritage backgrounds, and gay and lesbian smokers.
  • Monitor the evidence and guidance relating to the use of e-cigarettes in harm reduction and smoking cessation.

What do we know?

1. Who is at risk and why?

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Health and Social Impact

Tobacco use remains one of the most significant public health challenges.  Smoking causes 80,000 deaths in England each year, more than any other preventable cause (Health & Social Care Information Centre, 2014).   Smoking causes 80% of deaths from lung cancer, 80% of deaths from bronchitis and emphysema, 80% of deaths from lung cancer, and 17% of deaths from heart disease. Smoking increases the risk of lung cancer amongst people who live in radon affected areas by up to 25 times compared to exposure to the gas alone (Darby, 2005).

Up to two thirds of life-long smokers will be killed by smoking, but importantly stopping smoking, can add years to life (Doll, Peto, Boreham, & Sutherland, 2014). The earlier an individual stops smoking the longer their life expectancy is likely to be. Smokers have an increased risk of heart disease, stroke, asthma, chronic obstructive pulmonary (lung) disease (COPD), lung cancer, cervical cancer, sperm abnormalities, disease of blood vessels, starting the menopause up to 2 years earlier, and developing osteoporosis. Also, several eye disorders including the risk of age related macular degeneration, cataracts, glaucoma and diabetic retinopathy and dry eye syndrome (Action on Smoking and Health, 2014)

Table 1 Health Impacts of smoking (Health & Social Care Information Centre, 2014); (Jamrozik, 2005) (Action on Smoking and Health, 2014); (Royal College of Physicians, 2010)

 

Smoking causes:

Secondhand smoke causes:

17% of deaths from heart disease

  • Children to be born underweight,
  • Cot death
  • Upper and lower respiratory tract illness

An increased risk of heart attack-5 times greater for those under 40 than non-smokers

  • Babies and children to be twice as likely to have asthma and chest infections

Teenagers to have;

  • more asthma and respiratory symptoms
  • poorer health,
  • more school absences
  • lower fitness levels

10,000 children to be treated in hospital for exposure to secondhand smoke

80% of deaths from bronchitis and emphysema

An increased risk of lung cancer in non-smokers by 20-30%

80% of deaths from lung cancer

An increased risk of coronary heart disease by 25-35%

Acknowledgement: Table taken from the Nottinghamshire County JSNA chapter on Smoking (2014)

It is estimated that the total smoking cost to society amounts to approximately £12.9bn compared with £9.5bn of income from taxation on tobacco products (Action on Smoking and Health, 2014). This includes significant costs to the NHS and Local Authorities:  Smokers take more sick leave than non-smokers and more breaks during the day. Cutting the level of smoking can improve productivity for small businesses (Featherstone, 2014).  Cigarettes and other smoking materials are the primary cause of fatal accidental fires in the home. In 2012-13, smokers’ materials accounted for 82 deaths in Great Britain - over a third of all accidental dwelling fire deaths (Action on Smoking and Health, 2014).

With cigarettes costing £8-9 for a pack of 20, an average smoker spends approximately £1300 per year on cigarettes which would be saved upon quitting (Shahan, 2013). This could increase to £6,000-£7,000 a year for a family with two parents smoking a premium cigarette brand. This can be a significant proportion of the income of a family earning e.g. £21,000 a year meaning they are more likely to require services like food banks (All-Party Parliamentary Inquiry into Hunger in the United Kingdom, 2014).  Stopping smoking can make a significant difference to household incomes, supporting people to budget in difficult times. There is also evidence to show that money saved when people quit is spent locally thus supporting the local economy (Public Health England, 2014).

Other short-term benefits of stopping smoking are improved appearance, mental wellbeing and mental health symptoms (Shahan, 2013).  Also improved symptoms in people mild and moderate lung disease and a 50% reduction in the risk of having a fatal and non-fatal heart attack in the first year amongst people aged 35 years and over.

Trend and prevalence in adult smoking

One in five adults continue to smoke increasing their risk of disease and premature death as described above. However, there has been a significant decrease in smoking amongst adults in England (people aged 16 and over) over the last 40 years (Health & Social Care Information Centre, 2014). This has reduced from over 50% of men and 40% of women to 22% of men and 17% of women in 2013 to an overall prevalence of 18.4% of adults smoking (figure 1).

Figure 1 Trend in smoking in England 1974 to 2013 (Health & Social Care Information Centre, 2014)

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Exposure to secondhand smoke in adults

Exposure to secondhand smoke can increase risk of lung cancer in non-smokers by 20-30% and increase risk of coronary heart disease by 25-35% (Action on Smoking and Health, 2014). The Health Survey for England has found that amongst adults exposure to secondhand smoke was highest amongst men, and 16 to 24 year olds and decreased with age (Royal College of Physicians, 2010). The most reported areas for exposure were outdoor areas outside pubs/restaurants and cafes, followed by other people’s homes and people’s own homes

Usage of manufactured and hand rolled cigarettes

Cigarettes in packets are the most popular type of cigarette smoked (52% of men and 66% of women) by current smokers. A higher proportion of men than women smoke hand-rolled cigarettes (38% of men and 24% of women) and they are most popular amongst men aged 50 to 59 years (Health & Social Care Information Centre, 2014).

Illicit and counterfeit tobacco

Illicit and counterfeit tobacco products are cigarettes, hand-rolling tobacco or niche products (such as bidis and shisha) that have been smuggled or are counterfeit or illicit. A high proportion of illicit and counterfeit cigarettes coming into England are mass produced and factory-made at known locations, mainly outside the EU (Tackling Illict Tobacco for Better Health partnership, 2014). HMRC ‘tax gap’ estimates published in 2014 give an indicative market share of 10% for cigarettes and a tax gap of £1.1 billion and 39% for hand rolling tobacco with a tax gap of £1 billion (HM Revenue & Customs, 2014).

There is no evidence that smoking illicit and counterfeit tobacco is any more harmful to health than smoking legal, duty-paid tobacco. Smoking kills at least half of all life-long users, whether it is illicit and counterfeit or duty-paid tobacco. However, illicit and counterfeit tobacco particularly impacts on our communities in the following ways:

  • Funds and supports serious and organised crime - there is evidence that illicit and counterfeit tobacco funds organisations such as the international criminal and terrorist organisations (Wilson, 2009) (Chen, 2009) and (Sharrock, 2006).
  • At significantly less than half the price of legitimate tobacco, it makes tobacco affordable and accessible to everyone including children and young people, ensuring people start young and continue the habit into adulthood.
  • Has a negative impact on legitimate retailers.
  • Creates a huge loss of revenue for the Government
  • More likely to cause fires as often illicit and counterfeit tobacco products are not self-extinguishing (under UK and EU law, tobacco must have a reduced ignition propensity (RIP) i.e. self-extinguishing).
  • Undermining the effectiveness of taxation and therefore making it harder for people to quit smoking.[1]

The UK has experienced high levels of illicit and counterfeit tobacco in the past. In recent years a lot of progress has been made nationally. Action by HM Revenue & Customs (formerly Customs & Excise) since 2000 has helped reduce the proportion of smuggled cigarettes from 21% to about 9% (midpoint estimate, 2012-13) (HM Revenue & Customs, 2013). Public opinion is largely in favour of increased taxation, according to various opinion polls (Action on Smoking and Health, 2013).  High levels of illicit and counterfeit tobacco means there is a significant loss of revenue to the government.

Waterpipes and Shisha

Waterpipes are also known as shisha, hookahs, narghiles, or hubble-bubble pipes. Research has found that waterpipe smoke contains many of the similar toxins and carcinogens to cigarette smoke and that smokers have more than double the risk of lung cancer, respiratory illness, low birthweight and periodontal disease (Action on Smoking and Health, 2013) . However shisha users can inhale significantly more smoke in a session (e.g. 45 minutes) with significant increased carbon monoxide blood levels. A UK cross sectional study in 2012/13 found that 1% of the adult population used shisha regularly (at least once or twice a month) and that use was more common amongst adults of Asian (7%), Mixed (5%), and Black (4%) ethnicity than amongst white adults (0.5%) (Grant, 2014). Factors which increased usage were being male, being from a higher social grade and being younger.

Smokeless tobacco

Smokeless tobacco increases the risk of oral, oesophagael and other cancers and cardiovascular disease (Action on Smoking and Health, 2012). In England, smokeless tobacco is combined with other ingredients in traditional South Asian products including Betel quid or paan, gutkha and zarda. Although products should contain health warnings, many chewing tobacco products on sale in the UK do not (Action on Smoking and Health, 2011). Data from the 2004 Health Survey for England indicated  that prevalence of smokeless tobacco use were highest in  Bangladeshi women (19%), followed by Bangladeshi men (9%), Indian men (4%) and Pakistani men (2%) (Millward & Karlsen, 2011). Research in the UK has particularly (but not exclusively) focused on the Bangladeshi community. Research has found that people use the products for reasons relating to tradition and cultural heritage, as well as using smokeless tobacco as part of a habitual practice that has a deeply rooted social component.  It is used to relieve stress, boredom or relax, and there are some beliefs about health negative and positive health effects (Messina, et al., 2012).

Electronic cigarette

E-cigarettes are not currently recommended by the National Institute for Health and Care Excellence (NICE) as a stop smoking aid as there is still limited research on their safety and effectiveness in helping people reduce or stop smoking,  and they are not licensed products (National Institute for Health and Care Excellence., 2013). From 2016, e-cigarettes will be regulated as medicinal products, similar to other nicotine delivery products, following the EU Tobacco Products Directive passed by the European Parliament in February 2014. There is an ongoing debate in the public health community with regard to the present and future utility of e-cigarettes in reducing tobacco related harm and contribution to tobacco supply and control (World Health Organisation, 2014) (Britton, 2014). Multinational tobacco companies are involved in the development of products and brands and buying out of existing brands (Bauld, Angus, & de Andrade, 2014).

The Health Survey for England 2013 (Health and Social Care Information Centre, 2014) found that 3% of all adults use e-cigarettes. Monitoring of e-cigarette usage by ASH shows that there was a rapid increase in usage amongst smokers from 3% in 2010 to 18% in 2014 ( Action on Smoking and Health, 2014). More recent and in depth analysis through the Smoking Tool kit study (West, 2015) has found than use amongst never smokers is extremely rare, that 85% of e-cigarette users also smoke, that 22.9% of smokers and recent ex-smokers use e-cigarettes and 14.9% use them daily, with the prevalence of usage plateauing since 2014, and is higher than nicotine replacement therapy. The study has estimated that 20,000 smokers stopped smoking last year who would not have stopped smoking otherwise. 

Smoking and age and gender in adults

During 2013, A higher proportion of men (22%) smoked cigarettes than women (17%), particularly in the younger age groups (figure 2). Smoking prevalence peaks in the 25-34 years age group (30% of men and 20% of women) and decreases with age.

Figure 2- Prevalence of smoking among adults (16+) in England, by age and sex, 2013 (Health & Social Care Information Centre, 2014)

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Smoking and socio-economic classification

Smoking prevalence differs by occupation as a marker of socioeconomic group. Nearly 30% of adults in ‘routine and manual’ occupations are smokers. Routine and Manual smokers are defined by their occupation (according to the Standard Occupational Classification, or SOC, codes). The SOC codes in terms of R&M groups include occupations such as lower supervisory and technical or routine and semi-routine occupations. This compares to 14% of adults in ‘managerial and professional’ occupations (Figure 3) (Health & Social Care Information Centre, 2014).  Prevalence of smoking in routine and manual groups has been steadily declining from 33% in 1998.

Figure 3 Smoking Prevalence by Socioeconomic group in England (Health & Social Care Information Centre, 2014)

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Whilst smoking has decreased across the deprivation gradient, higher rates of smoking continue to be correlated with increasing deprivation as they were in 1973. Smoking relates in the most deprived fifth of England are the same as the England average in 1990 (figure 4).

 Figure 4 Adult Smoking trend in England by Deprivation quintile

Whilst smoking has decreased across the deprivation gradient, higher rates of smoking continue to be correlated with increasing deprivation as they were in 1973. Smoking relates in the most deprived fifth of England are the same as the England average in 1990 (figure 4).

 Figure 4 Adult Smoking trend in England by Deprivation quintile

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Smoking and ethnicity

Analysis of smoking prevalence by ethnicity published by the Race Equality Foundation (Millward & Karlsen, 2011), highlights variation across ethnic groups in the levels of smoking by sex (figure 5). Amongst men, over a third of Black Caribbean and Bangladeshi men smoked, which was much higher than general population at the period (no statistical comparison is published). Smoking rates are highest amongst women from Black Caribbean and White Groups, which are similar to the average level of smoking amongst women.

Figure 5 Prevalence of smoking by ethnic group and sex, (2006-2008)

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Aspinal and Mitton analysed adult smoking rates from the 2009/10–2011/12 Integrated Household Survey (2014) by country of birth and found that smoking prevalence was substantially higher amongst migrants from East European countries (table 2) and from Turkey and Greece.

Table 2 Smoking prevalence (2009/10- to 2011/12) amongst immigrants from EU Accession countries which were greatest source of immigration in Nottingham (2013/14)

 

Country of birth

Smoking prevalence (males)

Smoking prevalence (females)

Poland

39.4%

30.0%

Romania

36.1%

22.9%

Hungary

32.6%

17.8%

Lithuania

53.5%

33.2%

Slovak Republic

50.7%

35.9%

Bulgaria

37.6%

29.6%

Nino National Insurance Registrations (Nottingham City Council 2014)

The same study also analysed data from the GP patient survey and found that amongst UK born ethnic groups, smoking prevalence was highest in the Gypsy or Irish Traveller Group (49% of males and 46% of females.

Smoking and sexual orientation

There is some evidence that people from lesbian, gay, bisexual and trans (LGBT) groups smoke at higher rates than the general population (National Centre for Smoking Cessation and Training, 2014). Analysis of data from the 2014 Integrated Household survey supports this, in particular in relation to gay and lesbian people (figure 6).  The reasons behind this are not well known, but there are suggestions from U.S. research that gay and lesbian social spaces (such as bars), violence, stress, and discrimination, as well as barriers to healthcare access and treatment services, contribute to the higher rates of smoking (Lee, 2009).

Figure 6 Smoking and sexual orientation in England 2013 (Public Health England, unpublished analysis)

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Smoking and mental health and substance misuse

People with serious mental health problems have a significantly lower life expectancy than the general population. Men living with schizophrenia in the community in the UK have a 20.5 year reduced life expectancy while women with schizophrenia have a 16.4 year reduced life expectancy than the general population, which is mainly due to cardiovascular disease caused by smoking (Brown, 2010).

In analysis of the 2007 Psychiatric Morbidity Survey, McManus (2010) found that 32% of adults with any mental health problems smoked. In the 2010 Health Survey for England, 37% of participants reporting a longstanding anxiety, depression or another mental health issue were smokers, and that people with these conditions were more than twice as likely to be smokers than those without (Royal College of Physicians, 2013). The significantly higher smoking prevalence amongst people with a longstanding mental health problem has persisted since the data was collected in the early 1990s. People with mental health problems tend to be more addicted to tobacco and smoke more cigarettes a day than smokers without a mental health problem (Royal College of Physicians, 2013.

McManus (2010) found that smoking prevalence was particularly high for people with illicit drug dependence (69%), alcohol dependence (46%) and people who had attempted suicide (57%). The report also referenced other research which has found smoking prevalence as high as 64% amongst people diagnosed with probable psychosis and rates of 70-80% have been found amongst mental health in patients. McManus et al estimated that 42% of all cigarettes smoked in the UK are smoked by somebody with a mental health problem (McManus, 2010).

A systematic review (Taylor, 2014) found significant improvements in anxiety, depression, and stress following smoking cessation. The size of the effect was as large amongst patients with mental health problems as with those without, and similar or larger than those of antidepressant treatment for mood and anxiety disorders. This supports the view that smoking cessation is positive for mental health, and that it is the withdrawal symptoms from smoking that cause worsening of mental health symptoms rather than smoking improving them.

Smoking and pregnancy

Women who smoke are at increased risk of miscarriage, premature birth, still birth, low birth-weight and sudden unexpected death in infancy. Smoking during pregnancy also increases the risk of infant mortality by an estimated 40%. Children exposed to smoking in the womb are more likely to be wheezy, be asthmatic, have problems with their ear, nose and throat and have behavioural issues (National Institute of Clinical Excellence, 2010).

Smoking prevalence is measured by Smoking at Time of Delivery (SATOD) rates, recorded at the time of giving birth. In England, SATOD rates have steadily been declining from 17% in 2005 to 12% in 2013/14 (Health & Social Care Information Centre, 2014). 

SATOD rates vary amongst certain groups.  Women who smoke in pregnancy are more likely to be under 20 years old (57%) and from the routine and manual occupational group (40%). Mothers aged under 20 are the least likely to give up smoking at some point before or during pregnancy

Smoking and secondhand exposure in children

It is important to recognise that it is children who start smoking, not adults. Almost two thirds (65%) of smokers start before they are aged 18 (Health & Social Care Information Centre, 2014).

Children who grow up in households where those around them smoke are 3 times more likely to become an adult smoker. Exposure to household smoking (role models) generates about 20,000 new smokers by the age of 16 each year (Leonardi-Bee, 2011).

Children and adolescents with behavioural disorders are at significant increased risk initiating smoking compared with those without (Royal College of Physicians, 2013).

In 2013, 22% of young people in England aged 11 to 15 years said they had tried smoking at least once-the lowest level recorded since the smoking Drinking and Drug Use Survey began in 1982. 3% were regular smokers (9% in 2003). Older pupils were more likely to be regular smokers than younger pupils (8% of 15 year olds compared to less than 0.5% of 11 and 12 year olds

The 2010-2015 Government’s Tobacco Plan (Department of Health , 2011) set an ambition to reduce the proportion of 15 year olds who smoke regularly to 12% or less by 2015. This target has been achieved (figure 7). Public Health England are seeking to build upon this strategy with their ambition for England to have a tobacco-free generation by 2025 (Fenton, 2015). This is defined as a smoking prevalence of 5% amongst 15 year olds.

Figure 7 Percentage of 15 year olds who smoke regularly (1998-2013) (Health & Social Care Information Centre, 2014)

 

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The Royal College of Physicians identified that exposure to secondhand smoke is a significant cause of morbidity and mortality to babies and children in the UK (Royal College of Physicians, 2010). In the report, following multivariate analysis on the impacts of passive smoking, the authors conclude that children from poorer backgrounds have higher exposure to secondhand smoke even allowing for higher parental smoking rates. Also that modifiable risk factors have the greatest impact on exposure to secondhand smoke (whether the child lives in a home where smoking occurs regularly, whether the parents smoke, and whether the child is looked after by carers). Other similar predictors for smoking in adolescents were found in a longitudinal study, including spending time in smoky places, IMD school score, and household smoking rules (Smith, Smith, Woods, & Springett, 2009).

Cigarettes are also used as a currency in child grooming and sexual exploitation where young people receive something such as cigarettes as a result of performing, and/or others performing on them, sexual activities (Local Government Association, 2013).

There are concerns that marketing of e-cigarettes could be particularly appealing to children and young people resulting in increased used of these products in this age range (Bauld, Angus, & de Andrade, 2014). There are also potential poisoning risks with children experimenting with e-cigarette liquids (Child Accident Prevention Trust, 2014).  However the proportion of children who have tried these products has been found by one survey to be low. There is a debate as to how this potential risk of exposure should be considered in relation to the potential for e-cigarettes to reduce tobacco related harm in the population (Britton, 2014). It is proposed that the marketing of e-cigarettes in relation to under 18s in more controlled in in the UK (Bauld, Angus, & de Andrade, 2014)

 

 

 

 

 

 


[1] Acknowledgement to Nottinghamshire County JSNA for the section on harms related to Illicit and counterfeit tobacco.

 

2. Size of the issue locally

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Impact of smoking in Nottingham

It is estimated that in Nottingham City around 268,000,000 filtered cigarettes (including filtered roll-ups) are smoked each year results in 46 tonnes of waste annually (Action on Smoking and Health, 2014). The total household expenditure on tobacco in Nottingham is estimated at £119M per year (Public Health England, 2015) and it is estimated that citizens contribute £69.1m to the tobacco duty through the purchase of tobacco products (Action on Smoking and Health, 2014).

Nottingham has significantly higher rates of lung cancer, COPD and heart disease and other conditions due to smoking than England (Public Health England, 2015). When rates are compared with areas with a similar demographic profile (ONS City’s with Industry group B), Nottingham has the second highest rates of smoking attributable hospital admissions and attributable deaths from heart disease (table 3).

Table 3 Smoking related health outcomes in Nottingham City and comparator areas (ONS City’s with Industry group B) and England (Source: Local Tobacco Control profiles, 2015)

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It is estimated that each year smoking costs ‘society’ in Nottingham approximately £88m (Action on Smoking and Health, 2014).  Current and ex-smokers who require care in later life as a result of smoking – related illnesses cost Nottingham City Council an additional estimated £3m per year and £2.2m in costs to individuals who self-fund their care. The total annual costs to the local NHS Clinical Commissioning Group and NHS Trusts and Providers due to smoking related ill health is approximately £11.0m (figure 8).

It is estimated that the cost per capita of smoking attributable hospital admissions in people aged 35 years and over (2010/2011) is significantly higher  (£43.5) in the city than the England average (£36.9) (Public Health England, 2015).

 

Figure 8 Estimated costs of smoking (£millions) in Nottingham City

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Adult Smoking prevalence

Prevalence of adult smoking has been measured locally through the annual Nottingham City Residents/Citizen Survey since 2006 (Nottingham City Council, 2015). The survey has shown an overall downward trend in smoking prevalence for citizens aged 18 years and over during this time period to the current 2014 level, where 27.4% of survey respondents were found to smoke (figure 9).

Local smoking prevalence is also measured through the Integrated Household survey (sometimes called the General Lifestyle survey) and reported in the Public Health Outcomes Framework. This survey uses a different methodology to the local Citizen Survey, both in terms of the size of the survey and how it is conducted, as well as how participants are asked about their smoking behaviour. Through this survey the city’s smoking prevalence was found to be 24.4% in 2013, still significantly higher than the England prevalence (figure 9).

Using the results from the 2013 Integrated Household Survey and the 2014 Citizen Survey and the latest population estimates, it is estimated that there are around 64,000 (59,000 to 67,000) smokers aged over 18 years in the city.

Figure 9 Trend in smoking in adults (aged 18 years and over) in Nottingham City (2006-2014)

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In the 2014 Citizen survey smoking was higher amongst males aged 16 years and over than females (31.1% and 23.7%, respectively) (Nottingham City Council, 2015). This is consistent with the higher prevalence of smoking amongst men than women from the national data. There has been a greater reduction in smoking prevalence amongst women than men between 2008 and 2014, although the gap in the linear trend remains similar (figure 10).

Figure 10 Trend in smoking prevalence between males and females  in Nottingham city 2008 and 2014 (Citizen Survey)

All local authorities in the cities of industry group, except Birmingham have a higher overall smoking prevalence than the England average using the Integrated Lifestyle Survey prevalence (figure 11). Nottingham City has the highest smoking prevalence within the group, although this is not statistically different to that in the 5 areas with lower prevalence

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All local authorities in the cities of industry group, except Birmingham have a higher overall smoking prevalence than the England average using the Integrated Lifestyle Survey prevalence (figure 11). Nottingham City has the highest smoking prevalence within the group, although this is not statistically different to that in the 5 areas with lower prevalence.

Figure 11 Adult smoking prevalence in Nottingham and Comparator areas (ONS Cities with Industry group B) compared with England (2013))

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The distribution of smoking across the life course follows a similar pattern to the national prevalence (above) with smoking prevalence peaking in the 25-34 years age band.  However there is no statistically significant peak in prevalence in this age band and smoking rates are statistically similar across all ages. This distribution has been similar since the year 2010 (figure 12).

 

Figure 12 Distribution of smoking across age bands in Nottingham City (Citizen Survey 2014)

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Analysis of smoking by ethnicity shows that citizens of mixed heritage, White (not British) and White British have the highest smoking prevalence, with the latter two groups having a smoking prevalence statistically higher than the city average (figure 13).

 

Figure 13 Percentage of smokers by ethnic group (Citizen Survey 2012-2014)

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National data (above) suggests that this higher smoking prevalence amongst the White (not British group) may in part be due to the high smoking prevalence amongst people from Eastern European countries (table 2). Polish are the main significant group living in Nottingham followed Romanians (table 4).

 

Table 4 National Insurance registrations in Nottingham from Eastern European Countries (2013-2014) 

Country of birth

National insurance number registrations in Nottingham (2013/2014)

Poland

64.9%

Romania

12.0%

Hungary

7.1%

Lithuania

4.5%

Slovak Republic

3.4%

Bulgaria

3.0%

 

Analysis of smoking by sexual identify follows a similar pattern to the national data with smoking prevalence being significantly higher amongst gay and lesbian groups than the heterosexual group and the city average (figure 14).

 

Figure 14 Smoking prevalence by sexual orientation (Citizen Survey 2012-2014)

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Usage of tobacco products and e-cigarettes

In 2013 and 2014 the Citizen Survey has asked what products participants use. The proportion of smokers who smoke manufactured cigarettes and roll-ups (figure 15) is very similar to the proportion reported in the Health Survey for England 2013.

 2.2% of all adults reported using e-cigarettes in the 2014 Citizen survey which was similar to that reported in England (3%). Reported usage of e-cigarettes amongst smokers is much lower in Nottingham than the national prevalence (18%). The reason for this is not clear, but it may be due to underreporting.

Figure 15 Tobacco products and e-cigarettes used by adults who smoke(Citizen Survey 2014) Capture-(24).JPG

Waterpipes and Shisha usage

The prevalence of shisha smoking and usage in the city is not known. However, the number of public establishments where people can smoke shisha is monitored through City Council Environmental Health. In 2014, 8 establishments were known to offer shisha smoking, these which were located in the city centre, Sneinton and Radford areas. However, this is unlikely to be the complete picture and it is known that shisha is also smoked in homes and there are businesses which can provide home delivery of shisha tobacco and pipes. Establishments should comply with the smoke-free legislation which does not permit smoking inside in enclosed or partially enclosed public places or workplaces

Research conducted in Nottingham in 2013 in shisha establishments found that the majority of users smoked shisha at least once a week, 50% were unaware they were smoking shisha containing tobacco and almost half thought shisha was less harmful to health than cigarettes. Participants (n=65) recruited from the establishments were 76% British Asian with a median age of 23 years (Loi, 2013). Intelligence from New Leaf indicates that users of shisha bars are predominantly young British Asian adults who frequent the establishments for socialising. There are concerns about shisha “binges” where participants feel dizzy after consumption which is a symptom of high blood levels of carbon monoxide (Action on Smoking and Health, 2013).

 Smokeless tobacco

Intelligence from New Leaf indicates that smokeless tobacco products are sold in Asian supermarkets and shops in Nottingham. Whilst these products are used within the Pakistani community which is the largest Asian community in the city, their use is more prevalent within the Bangladeshi community (Millward & Karlsen, 2011). There are around 700 Bangladeshi adults living in Nottingham which suggests there are around 100 people using these products in the city assuming a prevalence of 14%[1].  

 Geographical and socioeconomic differences in smoking

The prevalence of smoking varies across the city which may be caused by a range of socio-demographic factors outlined in this chapter. Smoking prevalence is also particularly high amongst people living in homes rented from the council or housing associations (38.7%), and amongst those who are unemployed (49.4%), and amongst people with a disability or long term illness (31.8%) ( Nottingham City Council, 2015).

Maps showing prevalence of smoking by local area committee and care delivery group boundaries are published for as part of the Citizen Survey reports on Nottingham Insight.  This map from the 2014 survey (figure 16) shows that the majority of the city has a smoking prevalence much higher than the England prevalence of 19%. In particular areas 3 and 6 have smoking prevalence’s above 30%.

 Figure 16 Differences in smoking prevalence by Local Area Committee and Care Delivery Group Boundary (Citizen Survey, 2014)

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Due to the Citizen survey sample size, it is not possible to calculate smoking prevalence within each of the city’s wards using data from one survey. However using pooled analysis of 3 years of survey data, we can see that 17 of the city’s wards have smoking prevalence significantly higher than the England average and 3 wards significantly higher than the city average (figure 17). This is also important as certain areas of the city have a raised risk of radon exposure (Public Health England, 2015) which when combined with smoking, significantly increases the risk of lung cancer than radon or smoking alone (Darby, 2005).

 Figure 17 Prevalence of smoking in Nottingham City ward (2013-2016 pooled Citizen Survey data)Capture-(30).JPG

Despite 76% of citizens living in areas within the most deprived two fifths of England which have a higher smoking prevalence (see above), there is still a positive correlation between IMD deprivation and smoking in the city (figure 18). Prevalence of smoking in the most deprived fifth of the city is significantly higher than the prevalence in the least deprived two fifths and the city average.

Figure 18 Nottingham City adult  smoking prevalence (aged 16 years and over) by IMD Deprivation quintile Capture-(33).JPG

Smoking rates amongst the routine and manual group in the city (33.3%) are also significantly higher than the city prevalence using the Integrated Lifestyle Survey measure (24.4%). The prevalence in the routine and manual group in the city is also higher than the national prevalence (28.6%) for this group (Public Health England, 2014) which suggests that other local factors contribute to higher smoking rates in this group.

Smoking, mental health, learning disability and substance misuse in adults

The mental wellbeing of citizens is collected through the annual Citizen Survey. In 2014, 17.0% of the population had above average mental wellbeing, 70.0% average wellbeing and 12.2% below average wellbeing ( Nottingham City Council, 2015). This distribution has remained similar over the last 5 years.  Analysis of the pooled 2012-2014 data shows that the proportion of adults who smoke who have poor mental wellbeing (41.8%) is significantly higher than amongst those with average (25.2%) and above average mental wellbeing (24.5%).

It is estimated that 51,000 adults in the city experience mental health problems (Nottingham City Clinical Commissioning Group; Nottingham City Council, 2014). It is estimated that there could be at least 16,000 adults with mental health problems who smoke in the city which suggests 25% of adult smokers in the city could have a mental health problem (table 6). This proportion could be higher if adjusted for deprivation.  If we assume this group consumes 42% (McManus, 2010) of the cigarettes smoked in the city, this equates to 112,560,000 cigarettes per year (using the ASH ready reckoner figure).

Table 5 Estimated number of adults with a Mental Health problem who smoke in Nottingham City

 

Mental Health problem

Number of adults with mental health problem1

Percentage who smoke2

Number who smoke

Common mental health problem (depression or anxiety)

41000

29%

11890

Post traumatic stress disorder

7000

37%

2590

Severe mental health problem (psychosis, personality disorder)

3000

64%

1920

1 Wellness in Mind. Nottingham’s Mental Health Strategy; 2 McManus (2007).

Smoking rates are reported to be even higher amongst inpatients of Nottinghamshire Healthcare Trust, the NHS secondary mental health service provider, where it is reported 80% of inpatients smoke and that 57% of patients with enduring serious mental illness smoke (Nottinghamshire Healthcare Trust unpublished data).

Using the Citizen Survey 2012-2014 data, smoking prevalence was 64.4% amongst participants who drank alcohol at higher risk levels[1], compared to 34.4% of increasing risk drinkers[2] and 26.6% of lower risk drinkers[3], showing the association with smoking and alcohol consumption.

Smoking is estimated to be high amongst dependent drinkers (46%) and illicit drug users (69%) (McManus, 2010). Using population estimates for these groups in the city, it is estimated that there are around 4,900 and 4300 smokers in these groups, respectively.

People with learning disabilities (LD) are reported to have lower levels of smoking than the general population (Emerson & Baines, 2010), however this is reported to be variable depending on level of LD. In Nottingham City, local analysis of an audit of primary care data in 2014 showed that people with LD were more likely to have smoking status recorded in the previous year than the general population. The proportion of smokers was similar to the general population, but the proportion of ex-smokers was significantly less. All services, including lifestyle services and smoking cessation services are required to make reasonable adjustments to their services for people with LD so that they are accessible.

Smoking and Pregnancy

Smoking rates during pregnancy are significantly higher in the city than the East Midlands and the England average and this gap has been growing since 2010/2011 (figure 20). 18.5% or 799 women smoked during pregnancy in 2013/14.

Figure 19 smoking prevalence during pregnancy in Nottingham, East Midlands and England

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The percentage of women who smoke at the time of delivery is also signficantly higher than comparator areas in the Cities with industry group with the exception of Wolverhampton (figure 21).

 Figure 20 Smoking prevalence during pregnancy in Nottingham and Comparator areas (ONS City’s with Industry group B) compared with England (2013))

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Smoking amongst children and young people and exposure to secondhand smoke

Smoking prevalence in the 2014 Citizen Survey was significantly higher amongst adult participants with one or more children living in their home than participants with no children in their home (table 8). Participants with children living in their home had a younger age profile indicative of the younger age profile of smokers in the city.  In the 2013 Citizen survey it was found that 22.3% of smokers and non smokers allowed smoking in the home. This increases to 37% amongst people in council houses and 47% of households where people were unemployed.

 Table 6 Smoking and children living in the home (Citizen Survey, 2014) 

Household with children living in the home

Smoking prevalence

Percentage of adults aged 25-44 years in group

Yes

30% (95% CI 26.5% to 33.6%)

55.2%

No

24% (95% CI 21.5% to 25.8%)

17.7%

 

Reliable local authority level smoking prevalence among children has not been readily available and the PHOF indicator (2.9) to monitor smoking prevalence in 15 year olds is not currently reported  (Public Health England, 2015). However, Public Health England have produced local area model based estimates of occasional and regular smokers aged 11-15, 15 and 16-17 years (table 7). These estimates should be used with caution as they have very large margins of error (confidence intervals) and therefore are not able to demonstrate statistical differences.

Table 7 Model based estimates of smoking in children and young people in Nottingham (Public Health England, 2015) 

Age group

Occasional smokers

Regular smokers

11-15 years

1.1%

3.1%

15 years

3.1%

9.4%

16-17 years

4.7%

14.6%

Primary and secondary schools in Nottingham have been invited to participate in a Child Health and Wellbeing survey for years 4 to 13 which is organised by the Public Health team at Nottingham City Council. By March 2015, 9 primary and 10 secondary schools had participated in the survey.  Only 3.5% (n=12) of children in years 4-8[1]  had tried cigarette smoking, compared to 22.7% (n=111) of children in years 9-13[2], suggesting that trying smoking increases significantly after aged 13 years. Less than 1.0% of children in years 4-8 were current smokers and 7.3% children in years 9-13 were current smokers. Amongst current smokers, friends and shops were the most common sources of cigarettes.

In the Citizen Survey (2012 to 2014) smoking prevalence amongst 16-17 year olds was 21.6% (95% CI 13.6-29.6%), which is higher than the model based estimate of 14.6% for Nottingham and increases to 25.8% (95% CI 23.2-28.4%)  amongst those aged 18 to 24 years. Smoking prevalence was lower amongst those 18-24 years in full time education at school, college or university (18.7% (95% CI 15.8-21.6%), suggesting that University students have a lower smoking prevalence than the general population in the city of similar age.



[1] Years 4 to 8: (aged 8-9 years to aged 12-13 years)

[2] Years 9 to 13: (aged 13-14 years to 17-18 years)

 



[1] Higher risk :(>35 and >50 units a week for women and men, respectively)

[2] Increasing risk: (>15-35 and >22-50 units a week for women and men, respectively)

[3] Lower risk (<15 and <22 units a week for women and men, respectively)

 


[1] Median of prevalence in Bangladeshi men (9%) and women (19%) (Millward & Karlsen, 2011).

 

3. Targets and performance

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The Nottingham Plan (Nottingham City Council, 2015) has a target to reduce smoking prevalence amongst citizens aged 18 years and over to 20% by the year 2020. The smoking prevalence in England was 20% in 2010 when the target was set and 39% in the city as measured by the Residents (now - Citizens) Survey.

Trajectory from the Citizen’s Survey suggests that if smoking prevalence continues to reduce at the current rate, the 2020 target may be met (figure 22).

Figure 21 Nottingham Plan Smoking Prevalence trajectory (Residents & Citizens Survey 2006-2014)Capture-(40).JPG

Nottingham Children’s and Young People’s Plan (CYPP) (2015.16)

Promoting the health and wellbeing of babies, children and young people is one of the priorities of the CYPP. The following indicator is included

• % of women reporting smoking at the time of delivery

Public Health Outcomes Framework 2013-2016

The Public Health Outcomes Framework (PHOF) had 3 indicators in the health improvement domain which Nottingham City is rated to be significantly worse than the England average (Public Health England, 2014):

  • 2.03 – Smoking Status at the time of delivery
  • 2.14 Smoking prevalence – routine and manual groups
  • 2.14 Smoking Prevalence  (adults)
  • 2.15 Smoking Prevalence  - 15 year olds (Placeholder-  the methodology for this has not been agreed)

It also contains indicators relating to reducing premature mortality from smoking related diseases including cardiovascular disease, respiratory disease and cancer.

NHS Outcomes Framework 2015/16

The NHS Outcomes does not contain any indicators relating to smoking. It does contain indicators relating to reducing premature mortality from smoking related diseases including cardiovascular disease, respiratory disease and cancer (Department of Health, 2015)

 

CCG Outcomes Framework 2014/15

The outcomes framework for CCGs had 2 indicators relating to smoking in 2014/15 (NHS England, 2015):

  • Reducing premature death in people with severe mental illness - severe mental illness: smoking rates.
  • Reducing deaths in babies and young children – Maternal smoking at delivery

Social Care Outcomes Framework

The social care outcomes framework does not contain any indicators relating to smoking (Department of Health, 2015).

4. Current activity, service provision and assets

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Strategic Leadership

Tobacco Control Strategic Group

Nottingham City has a Tobacco Control Strategic Group. The group is comprised of representatives from:

  • Health and Wellbeing Board Chair and Councillor Portfolio Holder for Adults, Commissioning and Health.
  • City Council (Public Health, Early Intervention, Environmental Health & Trading Standards)
  • Nottingham City CCG
  • Nottinghamshire Healthcare Trust
  • Nottingham University (Division of Epidemiology and Public Health)
  • Nottingham CityCare Partnership

The Groups Strategic Priorities are:

  1. Protecting children from the harmful effects of smoking
  2. Motivate and assist all smokers to quit
  3. Strategic leadership
  4. Protecting communities from tobacco related harm

The group is refreshing the city’s tobacco control strategy which will be published in 2015. The group also coordinates the city’s strategic action plan which includes actions across the partnership.

CLeaR Assessment

CLeaR is an evidence based improvement model designed to help local areas develop local action to reduce smoking prevalence and the use of tobacco. It was developed by ASH and partners and is now led by Public Health England (Public Health England, 2014). The Nottingham City Tobacco Control Strategic Group under took the self-assessment aspect of the tool with partners in 2014. The self-assessment particularly found that areas that scored lower (below 40%) were vision and leadership, prevention of smoking, planning and commissioning, use of smoking cessation service data. Actions for development have been identified.

Smoking in Pregnancy Steering Group

New Leaf, Nottingham City CCG, public health colleagues and the Nottinghamshire Children’s Integrated Commissioning Hub have established a multi-agency steering group aimed at reducing the prevalence of smoking in pregnancy across Nottingham City and Nottinghamshire South.  Members of the steering group will be responsible for driving implementation of a range of actions aimed at reducing smoking in pregnancy and early years.

Nottingham City Council

Local Authority Declaration on Tobacco Control

In September 2014, Nottingham City Council signed the Local Government Declaration on Tobacco Control (Nottingham City Council, 2015). In addition, the Council agreed a motion on tobacco control which included agreement that the council will:

  • Endorse and support the principles set out in the Local Government Declaration on Tobacco Control.
  • Call on partners and other relevant organisations in the city to sign up to the Declaration
  • Maximise the powers held by the Council to tackle illicit and counterfeit cigarettes
  • Work with local traders to explore a way to ensure under-age sales are prevented – such as implementing a Challenge 25 scheme.
  • Continue to work in partnership with colleagues and citizens to reduce smoking prevalence and prevent the uptake of smoking amongst children and young people.
  • Build on the successful prohibition of smoking at playgrounds, and, where local people want it, use new legislation to designate further smoke-free public places.

Environmental Health

The service hosts the councils’ Smokefree Nottingham Coordinator who is the lead officer working on tobacco control in the city.   Working with partners to develop and implement the tobacco control strategy and develop specific initiatives and policies across the partnership and within the city council. This includes influencing national policy and working with regional partnerships. The Tobacco Control Health Promotion Officer is also based in this service. The post supports the implementation of the strategy through working in partnership to develop and implement initiatives and training that across prevention, services which support smokers to quit or reduce, and tackling the demand and supply of illicit and counterfeit tobacco.

Environmental Health Officers lead on the monitoring and enforcement of the smokefree public spaces legislation. This includes visiting new establishments reported to the service, establishments where changes to their licence or planning permission may indicate change of usage with regard to smoking practice, or where other council officers or other citizens have raised an issue with a premises.

Trading Standards

Trading Standards works to reduce the supply of counterfeit and illicit tobacco across the City.  The service works in partnership with Nottinghamshire police, to stop the sale and distribution of these goods by seizing any illicit and counterfeit product sold from any premises, including retail shops and private addresses.  The Service also ensures the safety of consumer products, including the various electrical components and the associated liquids of e-cigarettes.  House fires have been caused by e-cigarettes, and there have been some serious health issues caused by the ingestion of the liquids. For the past 3 years, Trading Standards have had external funding to support a dedicated Tobacco Enforcement Officer, which is no longer funded.   The impact of this is that intelligence may not be acted upon in a timely manner, due to other priorities; criminal offences may not be detected as quickly as they would normally be, and the Service will not have an officer with an expertise in tobacco enforcement.

Public Health and Early Intervention

Public Health Consultants and Insight Specialists lead on aspects of tobacco control including strategic leadership, developing strategic partnership across partner organisations, the Health and Wellbeing Board and across the council. Also, leading on the development of the JSNA, and informing the development of the tobacco control strategy. Different members of the teams are involved in developing initiatives through partnership working to reduce smoking in pregnancy, amongst people with mental health problems and within acute NHS trusts and smokefree areas. In addition, the team leads on commissioning of the New Leaf Stop Smoking Service.

Healthy Schools - DrugAware Quality Standard Programme

All primary schools implement the city council smokefree policy as part of achieving local Healthy School Status. Approximately 85% of schools have achieved and maintained this in 2015. Smoking prevention, policy and treatment is covered through the DrugAware Quality Standard Programme in schools.  Schools meeting the DrugAware standard (currently 90% of Secondary Schools, 100% PRUs, 85% Primaries in the city) have more detailed sections in their policies regarding how they will deal with drugs (including nicotine) incidents, what support will be offered and the content of the curriculum to deliver preventative, developmental education at each year and key stage across all phases.

Nottingham City Clinical Commissioning Group

Cancer and long term conditions (including COPD, Diabetes, CHD) are two of the CCGs 6 Strategic Objectives due to high incidence, high mortality, poor survival and significant impact on years of life lost of patients. Therefore the CCG is a very active partner in the City’s tobacco control group. This includes providing funding for stop smoking campaigns, New Leaf team being based within NUH and Healthcare Trust, supporting both hospitals in becoming smoke free sites, piloting healthy lung checks within the North of the City (including Lung Cancer screening).

The CCG is proactively participating in partnership working to reduce smoking in pregnancy through its responsibility for commissioning maternity services. The CCG coordinates the Smoking in Pregnancy steering group. The CCG also works with the Healthcare Trust and Public Health to reduce smoking in patients with mental health problems.

Nottingham University Hospital

The Trust is developing its smokefree policy in line with the NICE guidance on smoking cessation in secondary care (PH48). This includes implementing smokefree campuses at the QMC and City Hospital sites, and working with the New Leaf stop smoking service to develop processes for treating smoking and offering stop smoking support to patients, staff and visitors.

Midwifery service

Midwives assess smoking status of all pregnant mothers and provide information on risks of smoking in pregnancy, risks of exposure to second hand smoke/smoke free homes and provide brief intervention as required. Carbon monoxide testing is conducted on all pregnant women at 8-12 weeks gestation (booking), 16-18 weeks and 31 weeks with opt-out referral to New Leaf for any woman with a CO reading of 4 and above.

Nottinghamshire Healthcare Trust

The Trust Board has agreed in 2015 to implement the NICE guidance on smoking cessation in secondary care (PH48) with a target date of 1st April 2016 for full implementation. The implementation plan includes no staff smoking on trust premises, including grounds; and supporting all patients to abstain/stop smoking on Trust premises. The Healthcare Trust services works with the New Leaf Stop Smoking Service to develop the programme.

University of Nottingham Division of Epidemiology and Public Health

The Universities’ Division is a leading centre for research on tobacco control and is part of the UK Centre for Tobacco and Alcohol Studies (UKCTCS) which is one of five Centres of Excellence in Public Health Research funded through the UK Clinical Research Collaboration (UKCRC).  The Centre does clinical trials of methods to support smoking cessation in a range of clinical and domestic settings, and have played leading roles in the development of policy on electronic cigarettes and NICE smoking cessation guideline development.  The Division is represented on the Tobacco Control Strategic group and collaborates to conduct primary research in the local area.

Citycare

School Nursing service and Health Improvement Facilitators

Specialist Public Health Nurses (school nurses) deliver public health interventions to school-aged children and young people. Together with their team, they lead and deliver the Healthy Child Programme (5-19). As such, the service plays a crucial role in ensuring that children, young people and families get joined-up support and access to available services at the earliest point, from a child’s transition into school and continuing through their school-aged years. The school nursing service provides advice and information to children and young people regarding smoking, brief intervention and signpost to smoking cessation services. A health improvement facilitator within school nursing coordinates health promotion activity for school aged children and this includes smoking.  The service distributes campaign material and resources for schools to use during No Smoking Day. The service is currently developing a stop smoking pathway to ensure all members of the school health team are offering consistent and evidenced based information and interventions.

Health Visiting

Health visitors discuss smoking with all new mothers including the risks of second hand smoke exposure and sudden infant death syndrome. New Leaf referral data indicates that referrals from Health Visitors are low.

Family Nurse Partnership

Evidence shows that FNP can reduce smoking prevalence among teenage mothers.  Smoking is prioritised in the local FNP service delivery model in terms of offering targeted information, brief intervention and referral to smoking cessation services. Performance data for 2013/14, indicates that there is a reduction in smoking prevalence amongst FNP clients from starting the FNP programme (41.8% had smoked in last 48 hours) to prevalence at 36 weeks gestation (36%). Despite this reduction, smoking prevalence amongst FNP clients is still a cause for concern.

New Leaf Stop Smoking service

The New Leaf Stop Smoking Service is part of, Nottingham CityCare, and was first developed in the year 2000. It is the sole provider of stop smoking support for Nottingham City.  New Leaf works in partnership with a wide range of stakeholders including CCG’s, G.P’s, Local Authority, Nottingham University Hospital Trust, Nottinghamshire Healthcare Trust, Community Pharmacists, voluntary and third sector and workplaces to promote and increase access to the service.

The service offers a comprehensive package of support including intensive behaviour change support delivered by specialist NCSCT level 2 accredited advisors including community pharmacies. It provides direct supply of Nicotine Replacement Therapy and facilitation of Varenicline/Zyban. New Leaf does not provide e-cigarettes but can support clients if they choose to continue using e-cigarettes as part of the quit attempt to help stop smoking tobacco. Service delivery has been developed and expanded overtime to provide support in more than 50 local sessions across Nottingham City including Evening and week-end provision and dedicated telephone support to improve equitable access.

During 2015/16 the service and commissioners agreed targets to build on existing work prioritising hospital patients, people with mental health problems, pregnant women and routine and manual groups.

New Leaf supported 2083 people to successfully stop smoking in 2013/14.  Numbers accessing and setting a quit date through NHS Stop Smoking services has declined nationally by 19% and locally over the last two years, with New Leaf seeing a reduction of 27% accessing the service in 2013/14 (figure 23).  Reasons for this may be a reduced number of smokers overall and increased use of electronic cigarettes to support a quit attempt and to reduce the amount smoked. Of the total of those setting a quit date in 13/14 across Nottingham City 61% were either unemployed for over a year, unable to work through illness, a home carer (unpaid) or in a Routine and Manual occupation.

However the service’s quit rate has increased positively during this period to 63.6% in 2013/14, compared to the national average of 51%. The quit rate for Nottingham City remains one of the highest across the county higher than the England and East Midlands rate (figure 24) (Health and Social Care Information Centre, 2015). Data from 20 12/13 shows that 36% of quitters remain smokefree at 52 weeks, an increase from 20% in 2011/12.

Figure 22 Number of citizens accessing Stop Smoking services in England and the Nottingham New Leaf Service (2007/08-2013/14) (Health and Social Care Information Centre, 2015)

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Figure 23 Stop smoking service quit rates in England, the East Midlands and Nottingham New Leaf Service (2007/08-2013/14) (Health and Social Care Information Centre, 2015)

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National guidance (National Institute of Clinical Excellence, 2008) indicates that services should aim to treat at least 5% of the local population who smoke. Therefore based on an estimated local prevalence of 64,000, the service should aim for a minimum of 3200 people per year accessing the service which it is currently close to.

Comparison of some headline published indicators for stop smoking services for Nottingham and ONS comparator areas shows that the Nottingham service performs favourably in relation to the population quit rate, the proportion of routine and manual groups who quit, and pregnant women who quit.  The percentage of people who quit using pharmacotherapy (which is an evidenced based approach) is the highest in the group (table 9).

Table 8 Headline stop Smoking Service Indicators in Nottingham and Comparator areas (ONS City’s with Industry group B) compared with England (April-Dec 2014 (Health and Social Care Information Centre, 2015))

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A health equity audit comparing services across Nottinghamshire and Nottingham City in 2011—2013 (Nottinghamshire and Nottingham City Public Health, 2013) found that in Nottingham City access to the service was equitable to need for women but not men but outcomes (4 week quit) rate were equitable for men and women, all broad ethnic groups and the least and most deprived deprivation quintiles. A separate analysis of geographical equity of access using Mosaic groups as the measure of need in 2010-2013, found that access to the service varied across the city with areas of lower access in Mapperley and Lenton Abbey areas (figure 25) These analyses were conducted prior to the recent decline in uptake of the service and therefore may not be representative of current issues.

Figure 24 Access to New Leaf (2010-2011) vs need (areas with highest density of Mosaic groups with high smoking prevalence (red dots)

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The number of referrals to the service varies by referral source. Table 10 shows that the proportion of referrals from Nottinghamshire Healthcare Trust has been particularly low and there were only 2 referrals from City Council services during this period (other category). There were only 121 referrals from within Citycare which includes community services such as Health Visiting and Family Nurse Partnership which come into contact with families who smoke.

 

Table 9 New Leaf referrals, access and quit rates from different sources Q1-Q3 2014/15

 

Referral Source

Percentage of all referrals (n=2601)

Percentage of referrals from this source accessing service

Percentage of clients from this source who quit at 4 weeks

 GP Practice

16.6%

37.2%

33.5%

Self Referral

29.0%

76.3%

43.4%

Healthy Change referral hub

4.3%

51.3%

25.9%

 NHS national helpline or website

0.1%

33.3%

100.0%

CityCare

5.8%

45.0%

26.5%

Dental surgeries

0.4%

30.0%

33.3%

Nottingham University Hospital Trust

5.0%

41.1%

50.9%

Nottinghamshire Healthcare Trust

0.3%

57.1%

0.0%

Other Stop smoking services

1.6%

73.2%

43.3%

Midwives

27.6%

53.3%

71.0%

Other

9.3%

57.7%

41.7%

Return on investment of tobacco control interventions

The return on investment of the current tobacco control interventions was analysed using the NICE Return on Investment Tool for Tobacco Control, version 3.00 (Pokhrel, et al., 2014). This analysis includes the limitations of the tool.

The following non standard assumptions were included in the analysis; 27.4% adult smoking prevalence; 28.64% adult ex-smoking prevalence; 18.5% pregnant smoking,; 5.52% of smokers accessing  the stop smoking service; 41% of pregnant smokers accessing the stop smoking service. Interventions included were stop smoking services, cessation interventions for pregnant women, and GP-led cessation interventions, a sub-national (regional) package of key strands advocated by the World Health Organisation's MOPWER model of tobacco control,  - to  describe our local wider tobacco control activity.

Using the above assumptions, the tool found the following:

Within 2 years

  • >£960,000 cost saving to the NHS due to fewer consultations, hospital visits and prescriptions amongst smokers.
  • £52,000 further cost savings to the NHS due to fewer children and adults being exposed to secondhand smoke.
  • A small saving of around £300 to local authorities caring for stroke survivors.
  • Give a saving of £31.40, £98.62, £202.63 and £678.33 across all services per smoker over 2 years, 5 years, 10 years and Lifetime respectively, net of the current intervention mix implementation costs, if both quasi-societal savings and the value of health gains are considered.
  • Give a return of £2.90, £6.95, £13.23 and £41.95 per smoker across all services over 2 years, 5 years, 10 years and Lifetime respectively, for each pound spent on implementing the current intervention mix, if both quasi-societal savings and the value of health gains are considered.

Notable changes since JSNA 2012

  • The Fresh Futures peer mentoring and smoke free action group for young people  was decommissioned.

The Smokefree Homes project has been decommissioned.

 

 

 

 

 

 

 

 

 

 

 

 

5. Evidence of what works (what we should be doing)

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There is a wealth of evidence supporting tobacco control interventions.  The National Institute for Health and Care Excellence (NICE) guidance predominantly focuses on smoking cessation interventions. Other government guidance and research addresses both smoking cessation and wider tobacco control.  Further detail on the NICE and other recommendations can be found at: https://smokefreenotts.co.uk/local-resources-and-documents/

Healthy Lives, Healthy People; A Tobacco Control Plan for England set out six internationally recognised strands for comprehensive tobacco control (figure 26).

Tobacco control is an evidence-based approach to tackling the harm caused by tobacco use and smoking. The hexagon diagram below highlights the holistic model of tobacco control with multi-agency partnership working at its heart.

Even though there are several elements to tobacco control the majority of interventions are achieved through partnership working and are reliant on national policy legislation. Each petal, with examples of effective tobacco control interventions are highlighted below with links to the evidence and/or further information.

Figure 25 Elements of tobacco control (Excellence in Tobacco Control: 10 high impact changes to achieve tobacco control, 2008)

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Stopping the promotion of tobacco

Helping shape perceptions of tobacco use by adults and young people, by ensuring that non-price measures are in place, such as;

Making tobacco less affordable

Price is the single most effective lever helping people to stop smoking. The health gain from high-priced tobacco, however, can be undermined if the illicit market in tobacco products is allowed to thrive at the expense of legal, duty-paid products.

Effectively regulate tobacco products

Effectively communicate for tobacco control

  • Educating the public & colleagues about the risks of smoking
  • Motivating smokers to quit, including pregnant smokers
  • De-normalising smoking amongst our communities – Be there tomorrow
  • Encouraging children & young people not to take up smoking – Public Health England Marketing Strategy

Help tobacco users to quit

Exposure to secondhand smoke is hazardous to health especially vulnerable adults & children. We can minimise this burden by;

Effectiveness and cost effectiveness

The All Party Parliamentary Group on Smoking and Health (2010) reported on the effectiveness and cost-effectiveness of tobacco control and found that there is a very strong evidence base for tobacco control interventions and that comprehensive tobacco control provides economic value and a positive return on investment. For example, there is strong evidence which demonstrates that Stop Smoking Services are highly effective both clinically and in terms of cost. Department of Health (2011) guidance recommends that all smokers should be routinely offered advice to quit and a referral to the Stop Smoking Service

 

 

6. What is on the horizon?

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Projected service use and outcomes in 3-5 years and 5-10 years

Adult smoking prevalence

Adult smoking prevalence in the city is decreasing as indicated by the Citizen Survey data. However, prevalence continues to be at a higher rate than the England average. Extrapolation of the Citizen Survey trend to 2025 using the scenarios in figure 27, indicates that theoretically the city prevalence could decrease below 20% after 2020 and further in the following years with a narrowing of the gap in prevalence between the city and England. However, the rate of decrease may be more realistically represented by the extrapolation of the Nottingham City Integrated survey results.

Future national policy decisions such as the introduction of standard packaging and the licensing of electronic cigarettes may alter this scenario further as well as local policy decisions.

Figure 26 Extrapolation of adult smoking prevalence trends In Nottingham City and England to 2025

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Young People’s smoking prevalence

Extrapolation of the proportion of regular smokers aged 15 years in England indicates that there is potential for the prevalence to fall below 5% before the year 2020. No local prevalence data is available to model this trend locally, however the model based estimates indicate that the city’s prevalence may be in the region of the national data and be following the national decrease (figure 28).

Figure 27 Extrapolation of young person smoking trends in England to 2025  (regular smokers aged 15 years, Drinking and Drug Use among Young People in England)

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Stop smoking Services

It is difficult to estimate how the uptake of the city’s stop smoking services will change in the future. As described above, the uptake of the city’s New Leaf service has decreased over recent years in line with the national trend but the quit rate has improved. However the service is performing well in terms of it’s quit rate. It is likely that prevalence will not drop as quick in group such as people living in more deprived areas, routine and manual groups and people with mental health problems as in the general population. Therefore as these groups become a greater proportion of the smoking population in the city there will be a need for a service to adapt to the needs of these groups as well as target groups with additional smoking related health harms such as pregnant women.

 

7. Local views

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Young People
Responses to the DVibe survey between March 2012 and July 2014 showed that 40% of young people felt the advice they got about smoking was good enough and 30% felt it needed to be better (30% responded ‘don’t know’).

Putting Health at the Heart of Nottingham and full Council debate
In February 2010, a full Council debate was held on smoking and healthy weight, with morning workshops attended by local community members and partnership organisations from each of the nine City neighbourhood areas, as well as a group of young people.  There were a wide range of issues raised; the key points and proposed actions from each of the areas are detailed below:

 

Area 1

Target Young People

  • Peer pressure – need teenage champions and sport role models, particularly for young males.

Target Adults

  • Educate parents on the impact of smoking on children’s health.

Area 2

Positive Education including

  • visual images of damage and related diseases
  • family sessions

Communication campaign

  • educate all
  • develop aspirations for people to want to look after their health
  • more incentives for young people

Area 3

West Area want a zap enforcer squad to address fag houses, shop vans, and smoking at school gates and bus stops.  This will be supported by more activities (for kids) and flexible support from NHS groups to help give up.

Area 4

Target a specific area with a range of approaches and different groups e.g. younger people and older people

  • Talk to smokers – see what they want
  • Use ‘Kid Power’ – Schools, Art and Drama

Area 5

Look at how effective work in relation to the reduction of tobacco usage is in the following areas:

  • control and enforcement
  • education and communication
  • health, wellbeing and stopping smoking
  • reducing deprivation

Area 6

  • Get mandates from local people.
  • Council staff to drive a plan engaging with local people to find local solutions.
  • Find local buddies to support people.
  • Use ex-smokers to drive this forward as role models.

Area 7

Education of all areas of the community.
Area 7 is often overlooked because it is not seen as a ‘deprived’ area.

Area 8

De-normalise the smoking culture in areas

  • Tackling illicit supplies
  • Look at specific areas to identify similarities for the way forward.

Area 9

Target – No smoking outside school gates

  • Area assessment of what has and has not worked.
  • Action day on ‘No smoking day’ in March
  • Targeting a group who want to give up but need help, particularly parents to help children break the intergenerational cycle.

Young People

Snatcha Patch is a campaign to make free nicotine patches available in shops and other public places where tobacco is on sale as an easy to find alternative to cigarettes.

 

Aspley Action Research on Smoking
The Action Research on smoking in Aspley project shared the findings from its research in November 2011.  Some of the key messages include:

  • In deprived communities such as those in the Aspley ward, there is no real concept of what it means to be ‘healthy’ given all the other difficulties and problems in their lives; for some, smoking is seen as the one luxury, as a badge of identity and inclusion.
  • Children particularly are seen as a powerful vehicle for reaching adults.
  • Reducing smoking is seen by many stakeholders as a challenging but essential task.  There is considerable willingness to support tackling smoking.
  • Access to cigarettes is easy and stopping smoking, whilst an aspiration among many, is deferred, seemingly indefinitely until the time or mental state is perceived to be right.
  • ‘Word of mouth’ is the most common form of advice in the area, so any negative experiences, for example with cessation support, are quickly transmitted around the neighbourhood. Negative perceptions are therefore often difficult to change.
  • Some report that the ‘abrupt quit’ method offered by New Leaf is too inflexible, and that sessions are not easily available in locations that are appropriate to them (e.g. SureStart centres may put off people who are not parents, or who are older).

Smokefree outdoor areas

In Summer 2010, 392 Nottingham City residents representative of the city population attending the Rivera/Beach installation in the Market Square were asked about their opinion of making the event smokefree as part of a survey (Nottingham City Public Health, unpublished report). Results showed that there was strong support overall for extending the smokefree area at the beach event, with 85% of all respondents and 79% of Nottingham City respondents stating they would agree or agree strongly and only 7% stating they would disagree or disagree strongly.  Of the 257 comments regarding making other events smokefree, 82 specifically mentioned that events aimed at children or where children are present should be made smokefree, or as the reason why events in general should be made smokefree.  46 comments specifically mentioned the impact on health.  Other reasons included dislike of the smell and concerns about risk of burns.

What does this tell us?

8. Unmet needs and service gaps

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  • Smoking in pregnancy is significantly higher in the city than the England average and the gap is widening.
  • Other than the information provided through the Healthy Child Programme 0-5 (delivered by midwifery, health visiting and FNP), it appears that Early Help services and Early Years providers do not focus on reducing smoking in the home or exposure to second hand smoke amongst children.
  • Although various services seek to reduce smoking initiation amongst children and young people as part of their overall offer, this is not the primary aim of any one service and there is a lack of a coordinated approach across the City.
  • Over a 5th of households with children in the city allow smoking in the home increasing risk of exposure to secondhand smoke and initiation of smoking in children and young people.
  • Approximately 15% of schools in Nottingham City do not currently have Healthy Schools Status.  These schools may need additional support in encouraging and supporting to develop smoke-free policies and practices in line with the relevant Healthy Schools criteria on smoking. 
  • There is evidence that the prevalence of smoking amongst 16 & 17 year olds in the city is higher than the England average and model based estimated.
  • The proportion of adults who smoke in the city is at a similar level to the England prevalence 20 years ago.
  • There continues to be significantly higher rates of smoking in routine and manual groups and in certain areas of the city particularly Aspley, St Anns, Bulwell and Clifton and there is a risk that this inequity gap may increase as the overall smoking prevalence decreased.
  • Smoking rates continue to be particularly high amongst routine and manual groups in the city.
  • Smoking prevalence in particularly high amongst adults from Eastern European countries who have settled in the UK including Nottingham City.
  • Smoking prevalence is significantly higher amongst adults with poor mental wellbeing and amongst adults with mental health problems.
  • Available national and local evidence suggests that smoking prevalence is higher amongst gay and lesbian adults than other groups.
  • Adults who drink at levels which harm their health and adults with substance misuse problems have very high rates of smoking.
  • Illicit and counterfeit tobacco is a significant source of the tobacco smoked in the city, making tobacco more readily available and contributing to crime in communities.
  • Smoking of Shisha, in dedicated bars, restaurants and delivered to the home is an issue as in the low awareness of health harms amongst users.

9. Knowledge gaps

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  • To determine smoking prevalence amongst adults from Eastern European countries and effective support to help stop smoking.
  • A Health Equity audit should be conducted to determine which groups of pregnant women are not accessing smoking cessation services, which are least likely to stop smoking and to determine effective interventions.
  • Although we have some information on smoking prevalence amongst young people it is not precise. Further work is needed to improve the quality of this information.
  • There is a poor understanding locally about the attitudes of different groups of smokers to various intervention options.
  • Understanding smoking prevalence amongst people living with long term conditions in the city.

What should we do next?

10. Recommendations for consideration by commissioners

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  • Develop a multi-agency smoking in pregnancy pathway and enhance interventions to reduce smoking in pregnancy and support women who want to quit based on the latest evidence in the Healthy Child Programme Rapid Review.
  • Complete the Smoking in Pregnancy Assessment Tool (based on the CLeaR model) which aims to help areas to reduce smoking rates in pregnancy using a whole systems approach. The tool brings together existing resources to help support areas to identify areas where they could positively impact rates of smoking in pregnancy.
  • Develop interventions to reduce the exposure of children to second-hand smoke in different setting including in the home and outdoor areas and assist with reducing the number of children that start smoking as a result of living in a smoking home and family.
  • Ensure that providing information around smoking (including risks of exposure to second hand smoke amongst babies and children), brief intervention and referral to smoking cessation services is prioritised in the service specifications for all maternal and early years services.
  • Provide a coordinated approach to reducing smoking initiation and smoking prevalence amongst children and young people across agencies/services.
  • Ensure services who work with young people provide evidenced based support/brief intervention around smoking and particularly target  those at greatest risk including pupils who have truanted or been excluded from school and pupils who receive free school meals. 
  • Develop specific pathways and treatment models for people with different levels of mental health problems. 
  • Fully implement NICE guidance PH45 (Smoking cessation in secondary care: acute, maternity and mental health services).
  • Ensure services are impacting upon smoking rates in more deprived areas and amongst routine and manual groups.
  • Ensure pathways and appropriate service models exist for people with drug and alcohol problems who wish to stop smoking.
  • Allocate resources to tackling illicit and counterfeit tobacco.
  • Develop and promote smoke free environments, and support new tobacco control legislation with communication in the city.
  • Ensure establishment selling shisha are properly regulated and the risk to users.
  • Engage with other groups with high smoking prevalence including Eastern European communities, people of Mixed/dual heritage backgrounds, and gay and lesbian smokers.
  • Monitor the evidence and guidance relating to the use of e-cigarettes in harm reduction and smoking cessation.

Key contacts

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Kate Thompson, Smokefree Coordinator, Environmental Health, Nottingham City Council. Kate.thompson@nottinghamcity.gov.uk

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Glossary