New JSNA: This is the test site for the new Joint Strategic Needs Assessment

Smoking

Introduction

Smoking is the single biggest cause of preventable morbidity and mortality in England, and the most significant thing that a smoker can do to improve their health is to quit smoking. Smoking is particularly significant because of the complications that it causes to those that suffer non-smoking related ill health, as well as those who have a smoking-related illness. In both the short and long term, this has significant implications for the individual, their family and Carers and also, for health and social care services.

What do we know?

Smoking rates in adult men and women have more than halved in the last 30 years. Despite this, it is estimated that there are still 10 million adults who smoke in Great Britain today, and about half of the regular smokers will die prematurely as a result of their smoking (ASH, 2014).

Smoking kills almost 80,000 people in England each year and is the number one cause of preventable death in the country. Smoking continues to be one of the biggest health challenges and contributes significantly to health inequalities in our communities (PHE, 2015).

There are more than 4,000 compounds found in tobacco smoke and whilst many have a toxic, mutagenic or carcinogenic effect, nicotine is one of the most important chemical compounds that make tobacco products addictive. Whilst addiction is a complex combination of pharmacology, learned behaviour, genetics, and social and environmental factors, cigarettes are a highly efficient system by which nicotine is delivered to the body (ASH 1998; DHHS, 1989; RCP, 2000;). When smoke is drawn in, the large surface area of the lungs helps the nicotine rapidly cross the membrane into the bloodstream, delivering it to the brain within 10 - 19 seconds. It then increases the heart rate, blood pressure and overall metabolic rate, decreases appetite, blood flow to the skin and the amount of oxygen the blood can carry to vital organs, causing vasoconstrictions or narrowing of the coronary arteries. It also alters brain waves and functions of the endocrine system, and causes skeletal muscle relaxation (ASH 1998; DHHS 1988; DHHS, 1989; DHHS, 2010; RCP, 2000).

Nicotine levels within the body rapidly increase immediately after the cigarette. It has a half-life of 6-8 hours, meaning that levels of the compound will gradually fall in the body as a result, it will decrease slowly overnight. A common measure for nicotine addiction is how soon a person requires a cigarette after waking up (Heatherton et al, 1991). In large quantities, nicotine is extremely toxic, but acute poisoning is rare (often occurring through accidental swallowing or skin contact with pesticides that contain nicotine) (Higa de Landoni, 1991).Whilst nicotine is the not the substance strongly associated with the smoking-related illness, it is the important compound for addictions and therefore exposure to the thousands of agents which are harmful (RCP, 2000).

Surveys show that over half of smokers would like to stop smoking and just over a third of these (between 30 - 40%) will make an annual attempt to quit. Every cigarette damages the lungs of the smoker and, after the age of 35-40 years, for every year of continued smoking, a person loses about 3 months of life expectancy (Doll et al., 1994)

The benefits of stopping smoking occur within the first hour and, for long term quitters, risks can continue to decline for up to 15 years after they quit. For example, after 20 minutes, pulse returns to normal; after 48 hours, all traces of nicotine is removed from the body and the ability to taste and smell improves; at 2-12 weeks, circulation improves; after 1 year excess risk of a heart attack is reduced by half; after 10 years risk of lung cancer reduces to half that of a continuing smoker and, finally after 15 years, the risk of heart attack falls to the same as someone who has never smoked (NHS, 2015).

Facts, Figures and Trends

Lifestyle behaviours are difficult to measure and data is reliant on national surveys from which the results have been applied to local populations to give a local estimate. The Health Survey for England is used to produce estimates of the percentage of the adult population who smoke.

Estimated smoking prevalence in 2014 in Reading was 17.0% of the population - a figure which, as shown in Figure 1, remains very similar to the national average. This equates to just over 21,000 adults in Reading.

Figure 1. Prevalence of smoking among person aged 18 years, Reading and England, 2010 - 2014.

image1

Source: Integrated Household Survey. Analysed by Public Health England.

Certain health outcomes have been strongly linked with smoking, although the risk for each varies depending on personal characteristics like gender and age. A calculation of the risk is referred to as a 'relative risk factor' and can be applied to hospital admission data to estimate the number of admissions that are attributable to smoking. This information is presented as a rate per 100,000.

Figure 2. Smoking attributable hospital admission, Reading and England, 2009-10 - 2014-15.

image2

Source: Local Tobacco Control Profiles (May 2016)

Relative risk factors can also be applied to mortality data to estimate the number of deaths that are due to smoking. Figure 3 shows that while the rate of deaths attributable to smoking per 100,000 population has decreased since 2007-09, the rate has remained similar to the England average. Between 2012-14, the most recent figures available, 265 deaths per 100,000 population were attributed to smoking.

Figure 3. Smoking attributable mortality, Reading and England, 2008-10 to 2012-14.

image3

Source: Local Tobacco Control Profiles (May 2016)

As well as rates of all deaths estimated to be caused by smoking, risk calculations can be further analysed by specific causes of death which are attributable to smoking. The following sections will look at the mortality rates per 100,000 population in Reading and England for lung cancer, chronic obstructive pulmonary disease (COPD), heart disease and stroke. (As the number of deaths from some causes in a relatively small area may be quite low, some of these analyses may lack statistical power and should be interpreted with caution).

As shown in Figure 4, the rate of deaths from lung cancer in Reading have been fairly consistent and remained similar to the England average since 2001-03. The rate appears to have fallen slightly between 2007-09 and 2011-13, but returned to similar to the England average. Around 50-60 deaths per 100,000 a year in Reading are caused by lung cancer.

Figure 4. Deaths from lung cancer all ages, Reading and England, 2001-03 to 2012-14.

image4

Source: Public Health England (based on ONS source data)

Chronic obstructive pulmonary disease (COPD) is the fifth biggest cause of death in the United Kingdom (UK), accounting for 5% of deaths each year. Evidence shows that almost 86% of deaths from COPD could be prevented by quitting smoking, including in non-smokers who are exposed to second-hand smoke (WHO, 2016) Furthermore, those living with COPD have difficulties with breathing, primarily due to the narrowing of their airways and destruction of lung tissue and, in 2013 and 2014, there were over 110,000 emergency hospital admission led by COPD (DH, 2015).

Figure 5 suggests an inconsistent trend in deaths from COPD in Reading in comparison to England estimates. As the number of deaths in a relatively small area like Reading Borough is likely to be quite small, this may reflect a lack of statistical power and the rate may be disproportionately affected by some unknown factor. Further analysis of COPD evidence is therefore required, but these figures do suggest that the rate of deaths from COPD since 2009-11 has been consistently similar or higher than the England average.

Figure 5. Deaths from chronic obstructive pulmonary disease all ages, Reading and England, 2001-03 to 2012-14.

image5

Source: Public Health England (based on ONS source data)

Figures 6 and 7 also show consistent trends in deaths from heart disease and stroke attributable to smoking for both Reading and England population. Whilst Reading is similar to the England average, for heart disease, between 2010-12 and 2011-13, we saw the first increase in rates recorded since 2007-09. Neither of these is as high as the rates shown earlier for lung cancer and COPD, but these deaths should be considered preventable.

Figure 6. Smoking attributable deaths from heart disease all ages, Reading and England, 2007-09 to 2011-13.

image6

Source: ONS mortality file, ONS LSOA single year of age population estimates and smoking status from Integrated Household Survey, reality risk from The Information Centre for Health and Social Care, Statistics on Smoking, England 2010.

Figure 7. Smoking attributable deaths from stroke all ages, Reading and England, 2007-09 to 2011-13.

image7

Source: ONS mortality file, ONS LSOA single year of age population estimates and smoking status from Integrated Household Survey, reality risk from The Information Centre for Health and Social Care, Statistics on Smoking, England 2010.

Cost of Smoking

In addition to the significant cost to life and health individuals, family and carers, there are wider implications relating to smoking, particularly in relation to cost.

Action on Smoking and Health [ASH] , a not for profit public health charity established by the Royal College of Physicians, have produced a tool which estimates the total cost to society (in England) is approximately £13.9bn a year. This includes the cost of treating smoking-related disease caused by smoking in England which is approximately £1.88bn a year.

Figure 8 outlines the estimated cost of smoking to society for the Reading area. Each year in Reading, it is estimated that smoking costs society £36m, which equates to approximately £1,700 per smoker. The total annual cost to NHS trusts in Reading as result of smoking-related ill health (including passive smoking) is approximately £4.4m. In addition, current and ex-smokers who require care later in life as a result of smoking-related illness, are estimated to cost £2m per year. £1.2m of this is expected to be a direct cost to the local authority and over £850k to individuals who self-fund (DHHS, 1988).

Figure 8. Estimated cost of smoking in Reading (£millions)

image8

Source: ASH Ready Reckoner Tool, July 2016.

National and local context

Probably the most authoritative guidance on reducing harms from smoking and, smoking cessation is published by the National Institute for Health and Care Excellence (NICE). Updated guidance from NICE can be found on NICE's website.

In addition to this, there are a there are a number of national strategies, policy and legislation, as well as local strategies and policies which smoking directly impacts on. These include:

National Strategy, policy & legislation

  • Healthy Lives, Healthy People: A Tobacco Control Plan for England, (2011)
  • National Health Service Act (2006) and Health & Social Care Act (2012) - mandates local authorities to improve life expectancy and reduce health inequalities.
  • The Department for Health (2007) Implementation Plan for Reducing Inequalities in Infant Mortality
  • A Smokefree Future (2010)

Reading's Health & Wellbeing Strategy

Reading's Health & Wellbeing Strategy has a number of key targets which smoking cessation and tobacco control work contributes to. These include:

  • To promote and protect the health of all communities, particularly those disadvantaged
  • To reduce the impact of long term conditions with approaches focused on specific groups
  • To promote health-enabling behaviours & lifestyles tailored to the differing needs of communities.
  • Production of a Joint Strategic Needs Assessment - contributing to a number of health outcomes in the local population

The Berkshire Tobacco Control Action Plan 2014 - 2016 also outlined key areas of work in Reading and across Berkshire which aim to prevent the uptake of smoking, particularly in younger people. Areas of work involve regulatory work (such as ensuring that legal restrictions on the sale and promotion of tobacco are enforced) intelligence gathering and sharing, targeting cultural awareness/education and tackling normalization.

In addition to this, local smoking cessation services are commissioned by Reading Borough Council. Smokefreelife Berkshire services are provided by Solutions 4 Health. Smoking cessation services aim to help people to quit smoking by working with them, either on a one to one basis or in small groups, to provide smoking cessation advice and support, and direct supply of nicotine replacement. In addition to online, telephone and text support, the one to one or face to face services are available in many community settings (for example, GP surgeries, pharmacy's, local shopping centres and antenatal clinics). A mobile unit is also available which can respond to the specific needs of the community, providing smokers with the direct access to experts who can support them to quit. In 2014/15 the 'cost per quitter' in Reading decreased to £367.54 from £426.51 in the previous year. This compares favourably with the England average cost of £419.63, which increased from £283.43 in the previous year.

What is this telling us?

Smoking-attributable morbidity and mortality is preventable and a significant number of lives could be saved each year if we are able to prevent uptake and reduce prevalence both nationally and locally. Long term smoking causes conditions that significantly affect people's everyday lives, putting them at increased risk of serious illness and early death. In addition to personal cost to health and wellbeing, smoking also leads to increased costs for health and social care services.

Surveys show that over half of smokers would like to stop smoking with over a third of these (between 30 - 40%) will make an annual attempt to quit, and the first benefits of quitting are realized within 20 minutes. Smoking cessation services in Reading appears to provide good value and are likely to contribute to reducing long-term costs of providing health and social care.

Nationally and locally we are still navigating the emerging presence of e-cigarettes, their use as a replacement mechanism for the delivery of nicotine, their use in public places and their use in smoking cessation services. Ongoing monitoring of national guidance and policies will continue to ensure that locally we are up to date with best practice and guidance.

What are the key health inequalities?

The most significant differences in life expectancy and health inequalities between the richest and poorest people in the UK are attributable to smoking (Marmot, 2010). Quitting smoking can allow people to leap the health gap, with the poorest non-smoker having a substantially longer life than the richest smoker and, rich and poor smokers having similar life expectancies. On average, smokers lose 10 years of life in comparison to non-smokers.

Smoking in disadvantaged communities is more socially acceptable, possibly because of higher prevalence. Poorer smokers are more likely to smoke more each day, making them more addicted to nicotine. In addition, richer smokers who attempt to quite are more likely to succeed than poorer smokers (NHS, 2015).

Smoking is twice as common among routine and manual workers in England in comparison to those in managerial and professional roles. People with mental health disorders are also twice as likely to smoke, and ever more so for those with more severe mental health disorders. People from lesbian, gay and transgender communities are also significantly more likely to smoke as well as people who are unemployed and some black, minority ethnic groups (NHS, 2015).

References

Action on Smoking and Health [ASH] (2014). ASH Ready Reckoner and LeLan Solutions, September 2014 [Online]. Available at: http://www.ash.org.uk/information/ash-local-toolkit. [Accessed: 29/12/15].

Department of Health (2007). Implementation Plan for Reducing Health Inequalities in Infant Mortality. London: HMSO. Available at: http://www.sepho.org.uk/Download/Public/11120/1/DH_081336.pdf [Accessed: 29/12/15].

Department of Health (2011). Healthy Lives, Healthy People: A Tobacco Control Plan for England. London: HMSO. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213757/dh_124960.pdf. [Accessed: 29/12/15].

Department of Health [DH] (2015). Chronic smoking related lung disease blights over 1 million lives in England. Press release published 29 December 2015. Available at: https://www.gov.uk/government/news/chronic-smoking-related-lung-disease-blights-over-1-million-lives-in-england. [Accessed: 02/01/16].

Doll, R., Peto, R., Wheatley, K. et al. (1994). 'Mortality in relation to smoking: 40 years' observations on male British doctors'. British Medical Journal, 309, pp.901-911.

Heatherton, T., Kozlowski, L., Frecker, R. and Fagerström, K. (1991). 'The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire'. British Journal of Addiction; 86(9):1119-27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1932883

Higa de Landoni, J. (1991). Nicotine. Poisons Information Monographs. Ottawa: International Programme on Chemical Safety. Available from: http://www.inchem.org/documents/pims/chemical/nicotine.htm

HM Government (2006). National Health Service Act 2006. London: HMSO. Available at: http://www.legislation.gov.uk/ukpga/2006/41/contents. [Accessed: 22/3/16]

HM Government (2010). A smokefree future: a comprehensive tobacco control strategy for England. London: HMSO. Available from: http://webarchive.nationalarchives.gov.uk/20100509080731/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111749. [Accessed:22/3/16]

HM Government (2012). Health and Social Care Act 2012. Available at: http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted.

Marmot, M. et al. (2010). Fair Society, Healthy Lives. London: HMSO. Available at: http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review.

NHS (2015). Smokefree NHS. [Online]. Available at: http://www.nhs.uk/smokefree. [Accessed: 24/12/16].

Reading Borough Council, North and West Reading CCG and South Reading CCG. (2013). Reading's Health and Wellbeing Strategy. [Online]. Available at: http://www.southreadingccg.nhs.uk/images/publications/PDFs/ReadingHealthandWellbeingStrategy.pdf

Public Health England [PHE] (2015). Tobacco Control: JSNA Support Pack 2016-17.London: HMSO.

Royal College of Physicians [RCP] (2000). Nicotine addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. London: Royal College of Physicians.

U.S. Department of Health and Human Services [DHHS] (2010). How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease. A report of the Surgeon General. U.S Department of Health and Human Services, Centre for Disease Control and Prevention, Coordinating Centre for Health Promotion, National Centre for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

U.S. Department of Health and Human Services [DHHS] (1988). The health consequences of smoking: nicotine addiction. Rockville, Maryland: US Department of Health and Human Services.

U.S. Department of Health and Human Services [DHHS] (1988). The health consequences of smoking: nicotine addiction. Rockville, Maryland: US Department of Health and Human Services. Available from:

U.S. Department of Health and Human Services [DHHS] (1989). Reducing the health consequences of smoking: 25 years of progress. A report of the US Surgeon General. Rockville, Maryland: US Department of Health and Human Services.

World Health Organisation [WHO] (2016). Chronic respiratory diseases: Causes of COPD. [Online]. Available at: http://www.who.int/respiratory/copd/causes/en/ [Accessed: 22/3/16]

Switch To High Contrast Mode