Tackling Tobacco Use

The Global Burden of Disease (GBD) study identifies smoking as one of the top 5 risk factors of premature deaths in England. Smoking remains the leading cause of preventable death, killing over 7 million people annually worldwide with almost 64,000 in England.  Smoking is responsible for the death of half of long-term smokers and leaves thousands more with long-term health conditions. Nicotine is highly addictive and demand for nicotine products remains, whilst smoking rates have fallen significantly. There are still around 6.1 million people in England that smoke (Source: ONS).  

There are stark health inequalities between people who smoke and those who do not, with smoking being a fundamental contributor, accounting for half the difference in life expectancy between the richest and poorest (Source: DHSC).  On average, smokers die 10 years earlier than non-smokers (Source: US Dept of Health & Human Services) and smokers who live in the most deprived areas of the county tend to smoke more. The earlier a smoker quits the greater potential for more life years saved. 

There are geographical differences across Lincolnshire in terms of smoking prevalence, disease, and deaths, along with inequalities relating to mental health issues and pregnancy.  More people in routine and manual occupations smoke, where it is culturally and socially more acceptable (Source: ONS). 

Smoking remains the single biggest modifiable risk factor for poor birth outcomes. Both smoking, and exposure to second-hand smoke during pregnancy, increase the risk of infant mortality and often causes serious pregnancy-related health problems including low birth weight, still birth, miscarriage, preterm birth, heart defects and sudden infant death (RCP, 2018). 

Children who are exposed to second-hand smoke are at much greater risk of respiratory conditions, infections, and wheezy illnesses (such as bronchitis, pneumonia and asthma), ear, nose and throat problems (including glue ear), obesity and diabetes. Smoking by a parent or carer has also been highlighted as the number one most frequent modifiable factor in child deaths. This included smoking during pregnancy and smoking by anyone in the child’s household (NCMB, 2021). 

Research has shown children whose parents smoke are four times more likely to become smokers themselves. Breaking this cycle would have huge benefits to parents and children both now, and in later life (DHSC, 2021). 

Tobacco use imposes a significant economic burden on society. In addition to the costs of treating tobacco-induced illnesses, other costs include, loss of productivity, fire damage and environmental harm from cigarette litter and destructive farming practices during production. The total burden caused by tobacco products outweighs any economic benefit from their manufacture and sale. 

• Core20PLUS5 is a national NHS England and NHS Improvement approach to support the reduction of health inequalities (HI) at both the National and System level. The framework will help to focus targeted support and action on specific population cohorts (the 20% most deprived communities as identified by Indices of Multiple Deprivation and ICS plus population group who experience poorer-than-average access to health care/ treatment, experience and or/ outcomes which would benefit from a tailored health care approach).  The approach defines and identifies ‘5’ focus clinical areas requiring accelerated improvement (Maternity, SMI, Chronic Respiratory Disease, Early Cancer Diagnosis, Hypertension).  Smoking is independently associated with every indicator of disadvantage.  We all have a role to play in tackling Health Inequalities and we are aiming to go beyond Core20PLUS5 in Lincolnshire to reduce HI in all areas of our system.  
• The Department of Health and Social Care Tobacco Control Plan for England 2017–2022 – Towards a Smokefree Generation outlines the government’s ambition to reduce smoking prevalence amongst 15 year olds, adults, pregnant women and those in routine and manual occupations. By May 2022, the release of the revised Tobacco Control Plan for England is awaited. 
• The NHS Long Term Plan – Smoking, sets out the intention that by 2023/24, all people admitted to hospital who smoke will be offered NHS-funded tobacco treatment services. This follows the Ottawa Model for smoking cessation developed in Canada and tested in Greater Manchester.  This will include Mental Health and Maternity settings. 
• The ‘Better Births’ report sets out a five-year plan for transforming maternity services implemented by Local Maternity Systems supported by NHS resource packs. 
• NHS England, Saving Babies’ Lives A care bundle for reducing stillbirth, and the follow up in 2019, Saving Babies’ Lives Version Two, looks to reduce the number of women smoking during pregnancy.  Smoking is a key factor linked to pre-term birth, low birth weight, still birth and sudden infant death syndrome (SIDS). 
• The World Health Organisation (WHO) Framework Convention on Tobacco Control aims to reduce tobacco use and the morbidity and mortality smoking causes.  Success in achieving tobacco control is heavily reliant on partnership working, using joined up solutions such as, regulation of supply and demand, legislation, education campaigns, media work and harm minimisation interventions. 
• Action on Smoking and Health (ASH) have published factsheets relating to Use of e-cigarettes among young people in Great Britain.  
• NICE has reviewed and published guidance, Preventing uptake, promoting quitting and treating dependence (NG209), which includes information on harm reduction opportunities 

Public Health data shows that whilst Lincolnshire’s smoking prevalence average continues to fall, the rate of decline is slower than in other parts of the country. Young people’s uptake of smoking remains stable and on a par with the national average however there are groups where smoking prevalence remains static or has begun to rise again. Smoking in pregnancy and smokers with mental ill health are of particular concern.  

A large proportion of people admitted into hospital are smokers currently not receiving help to stop smoking and yet, referrals from acute settings to community stop smoking services are minimal. 

Pregnancy

Lincolnshire has one of the highest “smoking at time of delivery” (SATOD) rates, above the national and regional average and much higher than the national ambition. Nationally, SATOD rates have reduced over the years but, in Lincolnshire, rates remain high with little reduction over time. 

As smoking prevalence has declined nationally, rates of smoking have become increasingly concentrated among disadvantaged communities and groups. Rates of smoking in pregnancy have a strong social and age gradient with poorer and younger women much more likely to smoke in pregnancy. Women who have mental health or substance misuse problems are more also likely to smoke during pregnancy and are less likely to quit. Women in routine and manual occupations are more likely to smoke throughout pregnancy, compared to women in managerial and professional occupations. Pregnant women are also more likely to smoke if they have less educational achievements, live in rented accommodation, are single, or have a partner who smokes (Source: ASH) 

In Lincolnshire, women in the highest decile of deprivation have a higher prevalence of smoking in early pregnancy compared to those women living in the least deprived area. Younger women are also more likely to smoke. Disparities in smoking rates in early pregnancy are also seen in some migrant communities within Lincolnshire. For example, migrants from countries in Eastern Europe, such as Bulgaria and Romania, where ‘background’ rates of smoking are higher than the UK. 

Mental Health 

A decrease in smoking rates has been seen among adults with a long-term mental health condition, but prevalence remains substantially higher than the general population. This is true for Lincolnshire. Prevalence is associated with the severity of mental ill health, with the highest levels of smoking found amongst psychiatric in-patients. It is estimated around 30% of smokers in the UK have a mental health condition. More than 40% of adults with a serious mental illness smoke (Source: ASH) 

In addition, people with mental health conditions smoke significantly more, have increased levels of nicotine dependency, and therefore are at even greater risk of smoking-related harm (Source: ASH). A joint study by the Royal College of Physicians and Royal College of Psychiatrists found that a third of cigarettes smoked in England are smoked by people with a mental health condition. Despite consuming a large proportion of tobacco in the UK and being heavier smokers, only a minority of people with mental disorders receive effective smoking cessation interventions. 

Partly a result of high smoking rates, people with a mental health condition have high mortality rates compared to the general population. Therefore, quitting smoking is particularly important for this group because smoking is the single largest contributor to their 10-20 year reduced life expectancy (Source: ASH). 

LGBT 

Lesbian, gay and bisexual people are more likely to smoke than heterosexual people. Rates are particularly high for LGB women and bisexual men, with the inequality particularly pronounced compared with heterosexual women and men (Source: ASH) 

Ethnic minorities 

Tobacco causes health problems across all ethnicities, but the way people from different ethnic backgrounds use tobacco varies considerably, leading to health disparities. Some ethnic minorities are more likely to use smokeless tobacco and shisha pipes. However, smoking remains the most common form of tobacco use in all communities (Source: ASH)   

Homeless 

In 2014, around 77% of people experiencing homelessness smoked compared to 17% in the general population (Source: Homeless Link). The quantity of cigarettes smoked by people experiencing homelessness is particularly high, smoking more than 20 cigarettes per day compared to an average of 11 cigarettes per day in the general population (Source: Groundswell and ONS). They have a three times higher chance of dying from chronic lower respiratory diseases (Source: Crisis) and 80% of homeless people have an increased risk of lung cancer (Source: Groundswell). The average age of death of a single person experiencing homelessness is 30 years lower than that of the general population (Source: PHE). 

Young People 

Smoking prevalence data for young people in Lincolnshire is unavailable, however the smoking rate of 15-year-olds nationally is around 5%, which is the lowest it has been since the earliest records.  The young persons’ smoking cessation specialist reports that around 50% of young people that they support live with adults who smokes. In a typical group, one or two will report having tried vaping, though many do not smoke or have never tried smoking. Schools have made requests for vaping interventions for the young people learning at their institutions. Although the lower legal age for purchasing vapes is 18 years in the UK, reports of sales of vaping devices to under 18s have been received by the licencing team, so vaping amongst young people is an ongoing concern.  

• One You Lincolnshire provides the countywide Integrated Lifestyle Service (ILS) including a stop smoking service, delivered by a core team of specialist advisors allied to sub-contractors based in GPs and Pharmacies across the county.  The programme comprises a 12-week program of behavioural support and medication direct to clients.  Due to the Covid pandemic much of the service has been adapted to be delivered on-line or via telephone. Feedback from clients has been very positive, therefore, this service will continue to be offered post pandemic. 
• The Long Term Plan outlines the ICS Board’s commitment to provide in-house tobacco treatment services across all hospital trusts, funded by Health Inequalities funding from central government. 
• United Lincolnshire Hospital Trust (ULHT) Maternity Services are:
  • Implementing the NHS Long Term Plan, alongside the Saving Babies’ Lives care bundle element, to provide a new model of enhanced support for expectant mothers, and their partners, to become smokefree.
  • Utilising the Local Maternity and Neonatal Equity and Equality strategy to understand the smoking population and associated inequalities as part of the wider Maternity and Neonatal Equity and Equality action plan. 
  • Utilising the Maternity Voice Partnership to engage smoking women and their families in the co-production and long-term development of the NHS Tobacco Dependency Treatment Service.
• The Mental Health Trust in Lincolnshire (Lincolnshire Partnership Foundation NHS Trust – LPFT) has prohibited smoking after implementing a Smoke Free Premises Policy. Smoking is prohibited on all Trust sites and extends to all vehicles being used for Trust business. The aim is to support service users who smoke to either, make a quit attempt or, temporarily abstain from smoking whilst receiving care on Trust premises. A Smoke Free steering group is in place to monitor smoking related issues and support staff and patients/service users to meet policy requirements. 

Service users receiving inpatient care should be offered Nicotine Replacement Therapy within 30 minutes of admission. E-cigarettes can also be offered to patients on acute inpatient wards for a limited period to support a quit attempt, as a means of harm reduction, or to support temporary abstinence in those who are not yet ready to make a full quit attempt. 

Staff caring for people in the community are asked and encouraged to ensure that service users and their support networks are provided with information regarding the Trust’s smoke free premises prior to admission. Where practicable, staff will support people to make arrangements enabling them to comply with the policy. 

Staff are encouraged to refer service users into behavioural support for smoking cessation or offer support to service users to self-refer. 

Online training is available for LPFT staff to support patients identified as smokers utilising Very Brief Advice (VBA) methods. 

• There is a Smokefree Policy across all ULHT sites and a commitment to retain mandatory VBA training for all staff.  
• Tobacco Control activity is co-ordinated by Safer Communities with representatives from fire service, public health, police, trading standards and LCC’s commissioned stop smoking service.  NHS members are yet to be included. Trading Standards officers lead the enforcement activities for combatting illegal and unsafe tobacco from retail premises in Lincolnshire, using an intelligence lead approach. Enforcement activities include: multi agency raids, closure orders, prosecution, and business advice. 

Lincolnshire police’s ‘Operation Vigilance’ combats hotspots of criminal and anti-social behaviour in the community. Police intelligence shows that, in certain locations within Lincolnshire, there is a direct correlation between crimes involving the supply of illegal cigarettes and tobacco, the supply of drugs, offences against the person, people trafficking, sex trafficking, modern day slavery, and anti-social behaviour. 

Trading Standards delivers a programme to combat sales of tobacco products to children including underage test purchasing, business advice and market surveillance.   

National and local tobacco control activities are delivered by many agencies. For example, ‘Operation June’, which highlighted the fire risks of cigarette smoking and the increased risks of unsafe, illegal cigarettes. 

• A young person’s tobacco control specialist delivers a level 1 educational course in smoking awareness, targeting people aged 13 to 18. Standalone workshops, lessons, and a resource library are offered freely to groups and cover a range of smoking themes such as health and environmental impact. Partnership working aids teams to target groups effectively. For instance, pupil re-integration teams provide tobacco exclusion reports, enabling targeted promotion of interventions to schools.  The team have provided opportunities to promote tobacco control work at regional CHIPS (Collaborative Headteacher Inclusion Panel) meetings. 

Harm reduction 

In terms of harm reduction, it would be ideal for all smokers to quit completely. However, for those who currently do not want to or are unable to stop smoking, measures to reduce illness and death caused by smoking tobacco are essential.  People can reduce personal harms by smoking less or temporarily abstaining from smoking, such as when being admitted into hospital. Whilst the benefits of harm reduction are uncertain, it may lead to people being more likely to completely stop smoking in the future.  For those addicted to nicotine, delivery mechanisms that are safer than smoking are encouraged (e.g. patches). Specialist stop smoking services should be offered whenever possible so people can receive advice to help them stop smoking. 

In 2005, the UK medicines regulator (MHRA) liberalised the licensing of Nicotine Replacement Therapy (NRT) on the basis that, “there are no circumstances in which it is safer to smoke than to use NRT”. The nicotine-containing products used for NRT deliver nicotine without the harmful toxins found in tobacco. These therapies include patches, lozenges, gum and nicotine-containing e-cigarettes.  Nicotine-containing e‑cigarettes on general sale are regulated under the Tobacco and Related Products Regulations (2016) by the MHRA.  

This JSNA review includes stakeholder input from the ICS, Lincolnshire CCG, Maternity Services, Safer Communities, 0–19 Service and Early Years. 

• Local intelligence relating to LGBT, Travellers, migrant, and homeless communities is currently unavailable  
• Patient/Service-user voice. Smokers are seldom heard, particularly in relation to pregnancy and mental health.  
• Gaps in local data relating to smoking, smoking cessation, and long-term outcomes. 
• Socio-economic status of those quitting, versus those who continue to smoke. 

• Successfully tackling issues of smoking will require multiorganisational strategic approaches to develop a Tobacco Control Plan for the next 3-5 years. 
• Local accountability for improving smoking rates. 
• A shared approach to tackling the issues of smoking, facilitated by the Tobacco Control Board.  This would ensure a relevant governance structure is in place to provide clear, system-wide oversight and strategic decision making in relation to tobacco and tobacco related harms.