Sefton-Wide Lung Cancer Equity Audit

Transcription

1 Sefton-Wide Lung Cancer Equity Audit Section 1: Risk Factors and Prevention Final Report July 2005 i

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3 Acknowledgements The following people contributed to this project or report: Katharine Abba Zara Anderson Chris Birt Nigel Bellamy Aniela Bylinski Gwyn Holland Gary Mahoney Simon Pearce Lorraine Shack Alison Shead Sue Summerfield Sandra Sumner Linda Turner Cathy Warlow Lyn Williams South Sefton/ Southport and Formby PCTs South Sefton/ Southport and Formby PCTs South Sefton/ Southport and Formby PCTs Sefton Council for Voluntary Service Sefton Metropolitan Borough Council South Sefton/ Southport and Formby PCTs Sefton Metropolitan Borough Council Cheshire and Merseyside Cancer Network Cheshire and Merseyside Cancer Registry South Sefton PCT Southport and Ormskirk Hospital NHS Trust South Sefton/ Southport and Formby NHS Trust South Sefton/ Southport and Formby NHS Trust Sefton Health Improvement Support Service (SHISS) Cheshire and Merseyside Cancer Registry 3

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5 Summary of Findings and Recommendations Findings Inequalities The South Sefton PCT area has a death rate from lung cancer over 50% higher than England as a whole. The Southport and Formby area has a death rate similar to that of England as a whole. People living in the most deprived areas of Sefton have over twice the death rate from lung cancer as those living in the least deprived areas (indicated using the Index of Multiple Deprivation (IMD) 2004). People living in the most deprived areas of Sefton also have around three times the smoking rate as those living in the least deprived areas. Smoking rates vary by age and sex, with young women having a particularly high smoking rate. There is a high rate of smoking among young people of school age, particularly young women. In a recent survey of Sefton school children, 17% of boys and 29% of girls aged reported smoking regularly or occasionally. Only 15% of the population in Sefton reported eating at least five portions of fruit and vegetables a day in a recent survey. The percentage was even lower in men, young people and those living in deprived areas. The areas with the highest levels of air pollution are concentrated around the Port of Liverpool in the south of the borough and are also those which are most deprived. Inequities Levels of nicotine replacement therapy prescribing by GP practices do not appear to be related to their different population needs, assessed by level of deprivation. Smokers living in deprived areas may therefore have less access to this service. Level of access also appears to vary randomly by GP practice. Effective access to specialist Stop Smoking services is lower in men than in women, despite similar smoking rates in men. Pharmacy-based Stop Smoking services, although generally sited in areas of the greatest need (indicated by level of deprivation), may not yet be accessible to those living in some of the deprived areas on the outskirts of Southport. 5

6 Equity The specialist Stop Smoking service in Sefton (SUPPORT) is equally as effective at four weeks for people living in deprived and less deprived areas. Effective access of smokers to specialist Stop Smoking services is not affected by level of deprivation. Approximately the same proportion of smokers from areas with different deprivation levels successfully accessed the specialist service SUPPORT. Specialist Stop Smoking clinics are located in areas with the highest needs, as indicated by level of deprivation. Extra prevention activities are already targeted towards schools in the most deprived areas, and work to reduce passive smoking among young children is targeted towards more deprived areas. 6

7 Recommendations Out of these findings, the following recommendations arose. They are presented in order of importance. 1. Work should be undertaken to continue the implementation of the Smokefree Sefton strategy and action plan, covering the seven key areas: Strong mass-media-led information campaigns A ban on tobacco advertising and promotion Price policy and control of smuggling Smoke-free public place, especially workplaces NHS Stop Smoking services Community-based initiatives Harm-reduction strategies This should include the development of smoke-free public places by: Arranging a conference on the objectives, policies and practicalities of smoke-free to which all employers based in Sefton would be invited. Preparing draft implementation policies, to assist managers, for different categories of premises, e.g. for offices, shop-floor production areas, schools, colleges, health service premises of all types, theatres and concert halls, restaurants, pubs., etc. This might best be done in collaboration with Heart of Mersey. Employing within Health Improvement of an officer who could work full time on implementation of smoke-free policies in premises of all kinds, also identifying models of good practice in this field. Providing information/ education on policy and smoking policy, including how to access support to stop smoking, to new employees on induction programmes. Collaborating with Sefton MBC and all other Merseyside City and MBCs to promote a private bill to enforce smoke-free policies across Merseyside. Ensuring that service-level agreements oblige sub-contractors to be smoke-free. Working with local partners to lobby national Government to implement a comprehensive smoke-free Bill across England as implemented in Ireland, Italy, Norway and Sweden, and planned in several other EU member states. Otherwise, current proposed legislation will widen the health inequalities between the deprived areas of Sefton and other areas. 2. Work should be undertaken to encourage primary care staff, especially those working in deprived areas, to support their patients to quit smoking; including prescribing nicotine replacement therapy where appropriate. 3. Additional effort should be made to make smoking less acceptable among young people and girls in particular. This should include encouraging all schools to become smoke-free for pupils, staff and visitors. 7

8 4. SUPPORT should continue with current practices which enable them to provide an equitable service for smokers who live in deprived and less deprived areas. 5. SUPPORT should continue develop services which are more accessible to men, for example, workplace-based groups or evening sessions. 6. SUPPORT should also extend work targeting young women aged The PCT should work with local employers to include tobacco education and introduction to Stop Smoking services in all introductory courses for new employees. 8. Pharmacy-based Stop Smoking services should continue to expand to cover all - areas of Sefton, including some deprived areas on the outskirts of Southport. This should be accompanied by public awareness-raising work to ensure that residents are aware of the service. 9. The Air Quality and Respiratory Health group should be re-formed. The group should continue the work begun in this report identifying the sources of key air pollutants of concern with regard to respiratory illness, regularly review air quality and respiratory health trends and lobby the government to include tobacco smoke in guidelines on indoor pollution. 10. Efforts should be made to facilitate increased consumption of fruit and vegetables among Sefton residents, particularly those with low incomes or living in deprived areas. 11. Local transport plans should include efforts to increase the use of public transport and active transport (walking and cycling) as a means of reducing pollution levels across the borough. In all these actions, resources should be targeted towards the most deprived areas, where smoking and other risk factors for lung cancer have the highest prevalence. Implementation of these recommendations needs to be supported with useful and timely data to enable their monitoring. This includes: A baseline audit is to ascertain access to public places that are smoke-free, have partial smoking or allow smoking throughout across Sefton. The audit should include workplaces, NHS premises, local authority premises, educational premises, childcare services, voluntary sector premises and recreational facilities. Ideally a validated questionnaire would be used to allow comparisons across other districts. The questions should cover staff and clients, including the provision and implementation of no smoking policies and exposure to tobacco smoke. Data on smoking cessation work in general practice, including NRT prescribing, referral to SUPPORT or pharmacy-based Stop Smoking services, and practicebased interventions. Trends in smoking rates and fruit and vegetable intake should continue to be monitored using local lifestyle surveys, preferably at five-year intervals, the next being

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11 Contents Page Introduction 1 Methods 2 Background 4 Geography of the Sefton area 4 Demographics of the Sefton area 5 Deprivation within Sefton 7 Incidence of lung cancer 9 Years of life lost 15 Survival 17 Risk factors 18 Smoking 18 Environmental tobacco smoke 23 Diet 24 Air pollution 25 Radon gas 28 Occupational factors 28 Prevention Activities 31 Strong mass-media led campaigns 31 A ban on tobacco advertising and promotion 31 Price policy and control of smuggling 31 Smoke-free public places, especially workplaces 32 NHS Stop Smoking Services Support provided within Primary Care NHS Stop Smoking service SUPPORT Stop smoking support in pharmacies 41 Community based initiatives 43 Harm reduction strategy 44 Equity-related issues identified 45 Recommendations 47 Tables Table 1: Table 2: Table 3: Percentage of the total population of Sefton living in lower level super output areas with different levels of deprivation as measured by quintiles of IMD Lung cancer statistics for the UK, Merseyside and Cheshire SHA, South Sefton PCT and Southport and Formby PCT 9 Occupational exposure agents identified as probable causes of lung cancer 28 Figures Figure 1: The cycle of health equity audit 1 Figure 2: Equity grid for Sefton lung cancer equity profile 2 Figure 3: Map of Sefton showing PCT and ward boundaries and urban areas and the names these areas are known by 4 11

12 Figure 4: Population pyramid comparing population age/sex structure of Sefton with England as a whole 5 Figure 5: Population pyramid comparing population age/sex structure of South Sefton PCT with England as a whole 6 Figure 6: Population pyramid comparing population age/sex structure of Southport and Formby PCT with England as a whole 6 Figure 7: Thematic Map showing overall Index of Multiple Deprivation 2004 for lower level super output areas in Sefton, by quintile within England 8 Figure 8: Standardized registration ratio for cancers of the trachea, bronchus and lung (with 95% CI) for men resident in PCTs in Merseyside and Cheshire Figure 9: Standardized registration ratio for cancers of the trachea, bronchus and lung (with 95% CI) for women resident in PCTs in Merseyside and Cheshire Figure10: All age male and female age-standardized lung cancer mortality rates per 100,000 population for Sefton wards over the period Figure 11: Thematic map showing age-standardized lung cancer mortality rates for Sefton Wards, Figure 12: Age-standardized mortality rates for lung cancer in Sefton, by levels of deprivation of lower level super output area of residence 14 Figure 13: Age-standardized years of life lost rates from lung cancer per 10,000 population for Sefton wards, Figure 14: Thematic map showing age-standardized years of life lost under the age of 75 rate for Sefton wards, Figure 15: Scatter plot of 5-year survival from lung cancer for patients diagnosed against aggregate deprivation score for 17 Merseyside and Cheshire PCTs Figure 16: Pyramid of risk factors for lung cancer with Sefton MBC area 18 Figure 17: Self-reported smoking rates in Sefton by level of deprivation 20 Figure 18: Self-reported smoking rates in Sefton by age and sex 21 Figure 19: Self-reported smoking rates in Sefton by gender and deprivation 21 Figure 20: Self-reported daily fruit and vegetable consumption in Sefton by level of deprivation 24 Figure 21: Map showing estimated daily average air concentrations of PM10 in Sefton for Figure 22: Map showing estimated daily average air concentrations of NO2 in Sefton for Figure 23: Responses in the Sefton Citizen s Panel to a question about preferred smoking policies in places they might visit 32 Figure 24: Prescribing costs per patient over the age of 15 for nicotine replacement therapy by LISI score for general practices in Sefton in Figure 25: Four-week quit rate for SUPPORT clients with a known outcome by level of deprivation of SOA of residence 36 Figure 26: Percentage of SUPPORT clients with a known outcome who successfully quit after 4 weeks, by age and sex 37 12

13 Figure 27: Comparisons of the percentage of smokers living in SOAs with different deprivation levels, and 4-week quitters through SUPPORT living in the same areas 38 Figure 28: Number of clients who successfully quit smoking after 4 weeks through SUPPORT in Sefton, by age and sex 39 Figure 29: Map of SUPPORT clinic locations in Sefton, with Index of Index of Multiple Deprivation Figure 30: Map of pharmacy-based Stop Smoking services led by SUPPORT in Sefton, with Index of Multiple Deprivation

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15 Introduction Health equity audit is a process by which local partners 1 : Systematically review inequities in the causes of ill-health, and in access to effective services and their outcomes, for a defined population Ensure that action is agreed and incorporated into local plans, services and practice Evaluate the impact of the actions in reducing inequity Health inequity describes differences in opportunity for different population groups, according to socio-economic status, geographical area, age, disability, gender or ethnic group. These groupings are known as equity dimensions. Health equity audit focuses on how fairly resources are distributed in relation to the needs of these different groups. The overall aim is to distribute resources according to need. There are six main stages in a health equity audit, which are shown in Figure 1. Figure 1: The cycle of health equity audit 1. Agree priorities and partners 6. Review progress and impacts against targets 2. Do an equity profile 5. Secure changes in investment and service delivery 3. Identify effective local action to tackle inequalities 4. Agree local targets with partners 1

16 Methods Lung cancer was identified by the Sefton Health Inequalities group as a priority for health equity audit. Stages two and three of the cycle (equity profiling and identifying local action to reduce inequalities) were delegated to a multi-agency and multi-professional group led by Public Health. This group included representatives from the two Primary Care Trusts (South Sefton PCT and Southport and Formby PCT), Sefton Metropolitan Borough Council (environmental protection section), Merseyside and Cheshire Cancer Network, Sefton Council for Voluntary Services (CVS) and Southport and Ormskirk NHS Hospital Trust. The health equity profile used an equity grid framework for deciding on potential indicators and analysis of the data (Figure 2). On one axis are the dimensions by which inequity can be measured: age, gender, socio-economic factors, geography, occupation and ethnicity. It was agreed that all these were relevant for the distribution of and access to services for lung cancer. The other axis focuses on risk factors for the population and access across the spectrum from prevention, diagnosis, treatment and care. Figure 2: Equity grid for Sefton lung cancer equity profile Risk factors Access to prevention Access to diagnosis / investigation Age Access to treatment and care (including palliative care) Gender Socioeconomic Geography Occupation Ethnicity Indicators were identified to measure equity within each of the boxes of the grid. The following principles were used in choosing the indicators used in the profile: Routinely available data, where possible Feasibility of repeating the indicators at regular intervals to produce trends and complete the audit cycle Data available at a level that allows for comparisons within one of the equity dimensions Meaningful measures that can represent broad change, rather than simply changing the indicator result, and be used for policy planning and monitoring 2

17 There is a gradient in the complexity of the type of indicators that can be used to measure equality and equity. At its most simplistic, the indicator describes the health experience of various groups and tests equality, i.e. whether the population groups experience the same death rates or utilization of services. A more sophisticated type of indicator is a use-need ratio that assesses both service provision (proxy for supply) and health inequalities (using need proxies) simultaneously. Characteristics of use-need ratios are: They measure the relationship between service use (or supply) to need They direct attention to the inequalities and actions that can be taken to decrease the extent of the inequalities in a single measure (i.e. equitable provision of services and/or facilitation of access for those with greatest need) By using two sources of numerator data from the same population base they remove many problems with defining denominators and age standardization issues. For example, if it is accepted that a population with twice the prevalence of smoking should be accessing stop smoking services twice as much, then there is less need to consider population differences such as age structure. This report describes the methods and results of the initial equity profiling exercise for lung cancer risk factors and prevention work in Sefton. Further reports will describe diagnosis and treatment, and supportive and palliative care. For the purposes of this audit, lung cancer is defined as primary cancer of lung (not including mesothelomia). 3

18 Background Geography of the Sefton area Sefton is geographically diverse borough, with the coastal resort of Southport and small town of Formby to the north, some rural areas also in the north, and a more densely populated area to the South, including the industrial area and seaport around Bootle and the towns of Crosby and Maghull. Figure 3 below shows a map of Sefton, including the PCT and ward boundaries, urban areas (shaded) and the known names of the urban areas (or towns), which are often not the same as the ward names. Figure 3: Map of Sefton showing PCT and ward boundaries and urban areas and the names these areas are known by. 4

19 Demographics of the Sefton area At the 2001 census, the total population of Sefton was recorded as 282, Figure 4 shows a population pyramid for Sefton, comparing the age/ sex structure of the population with that of England as a whole. Compared with England as a whole, Sefton has a greater proportion of adults over the age of 60 and lower proportion of adults aged residing in the area. Figure 4: Population pyramid comparing population age/ sex structure in Sefton with England as a whole at the 2001 census. Sefton MBC Percentage of total population by age band compared to England (Census Resident Population 2001) Source: Census 2001 Standard Tables for Wards Table Crown Copyright material is reproduced with the permission of the Controller of Her Majesty's Stationery Office (HMSO) Excess Sefton MALES Excess England % 10% 8% 6% 4% 2% 0% 2% 4% 6% 8% 10% 12% Percentage of total population FEMALES There is a significant difference in age structure of the population between the two PCTs within the Sefton area. In particular, there is an excess compared with England of people over the age of 75 living in the Southport and Formby area, whereas the South Sefton area does not have an excess of people within this age group. This is shown in Figures 5 and 6. 5

20 Figure 5: Population pyramid comparing population age/ sex structure in South Sefton PCT with England as a whole at the 2001 census. South Sefton Primary Care Trust Percentage of total population by age band compared to England (Census Resident Population 2001) Source: Census 2001 Standard Tables for Wards Table Crown Copyright material is reproduced with the permission of the Controller of Her Majesty's Stationery Office (HMSO) Excess South Sefton Excess England MALES % 10% 8% 6% 4% 2% 0% 2% 4% 6% 8% 10% 12% Percentage of total population FEMALES Figure 6: Population pyramid comparing population age/ sex structure in Southport and Formby PCT with England as a whole at the 2001 census. Southport and Formby Primary Care Trust Percentage of total population by age band compared to England (Census Resident Population 2001) Source: Census 2001 Standard Tables for Wards Table Crown Copyright material is reproduced with the permission of the Controller of Her Majesty's Stationery Office (HMSO) Excess Southport and Formby Excess England MALES % 10% 8% 6% 4% 2% 0% 2% 4% 6% 8% 10% 12% Percentage of total population FEMALES 6

21 Deprivation within Sefton Within Sefton, there are areas of extreme socio-economic deprivation and other areas of relative affluence. The latest and most detailed and comprehensive measure of deprivation available is the Index of Multiple Deprivation 2004 (IMD 2004), published online by the Office of the Deputy Prime Minister 3. This is available at Lower Level Super Output Area (SOA) level. Each SOA contains a population of approximately 5,000 individuals. Figure 7 shows the SOAs of Sefton thematically mapped by quintile (within England) of IMD 2004 rank, and also shows the ward boundaries. The most deprived areas, shown in red to indicate that they fall within the 20% most deprived in England, are concentrated in the south of the borough and within the centre of Southport. When viewing this map it should be borne in mind that the areas of highest population density also tend to correspond to areas of highest deprivation; therefore the proportion of the population who are living in deprived areas is greater than appears from the space taken by these areas. The percentage of the population of Sefton living in areas with different levels of deprivation as measured by the IMD 2004 is shown in Table 1. Table 1: Percentage of the total population of Sefton living in lower level super output areas with different levels of deprivation as measured by quintile of IMD 2004 Quintile within England of IMD 2004 Percentage of Sefton population living in these areas 1 (20% most deprived) 26% 2 20% 3 28% 4 15% 5 (20% least deprived) 10% 7

22 Figure 7: Thematic map showing overall Index of Multiple Deprivation 2004 for lower level super output areas in Sefton, by quintile within England 8

23 Incidence of lung cancer Lung cancer is the second most common cancer occurring in the UK (excluding nonmelanoma skin cancer), causing 14% of call cancers diagnosed. Non-melanoma skin cancer (NMSC) is excluded by convention because registration data for this cancer is known to be incomplete and, although NMSC is the most common cancer, it is rarely fatal. Table 2 shows some statistics on lung cancer in the UK, Merseyside and Cheshire Strategic Health Authority area (M&C), South Sefton Primary Care Trust (SSPCT) and Southport and Formby Primary Care Trust (S&FPCT). All the ranks stated exclude NMSC. Table 2: Lung cancer statistics for the UK, Merseyside and Cheshire SHA, South Sefton PCT and Southport and Formby PCT. UK M&C SSPCT S&FPCT Cumulative risk Men 8% (lifetime) 14% (0-84) 16.2% (0-84) 10.5% (0-84) Women 4.3% (lifetime) 7.5% (0-84) 7.9% (0-84) 4.4% (0-84) % of all cancers diagnosed Men 17% (2000) Rank 2 nd 16.9% ( ) Rank - 1 st 19.1% ( ) Women 11% (2000) 12.1% Rank 3 rd ( ) Rank 3 rd % of all cancer deaths Men 25% (2002) 30.5% Rank 1 st ( ) Rank 1 st Rank 1 st 13.1% ( ) Rank 3 rd 34.6% ( ) Rank 1 st 13.1% ( ) Rank 1 st 7.2% ( ) Rank 3 rd 26.0% ( ) Rank 1 st 22.3% Women 18% (2002) 23.6% 14.3% Rank 1 st ( ) Rank 1 st ( ) Rank 1 st ( ) Rank 2 nd Standardized Mortality Ratio (SMR) Men Women /- Significantly higher or lower mortality rate compared with UK as a whole. The risks of being diagnosed with lung cancer and of dying from lung cancer are particularly high in the South Sefton PCT area, where 16.2% of men are diagnosed with the disease before their death or 85 th birthday. The death rate from the disease is over 9

24 50% higher than the national rate, as indicated by SMRs of for men and for women. Figure 8 shows the standardized registration ratio for cancers of the trachea, bronchus and lung diagnosed in men living in Merseyside and Cheshire PCTs between 1996 and The red arrows point to the South Sefton and Southport and Formby areas. Figure 8: Standardized registration ratio for cancers of the trachea, bronchus and lung (with 95% CI) for men resident in PCTs in Merseyside and Cheshire Standardised registration ratio, % Eden Valley PCT Fylde PCT Cheshire West PCT Eastern Cheshire PCT Morecambe Bay PCT Trafford South PCT West Cumbria PCT Southport & Formby PCT Central Cheshire PCT Bebington & West Wirral PCT Stockport PCT Wyre PCT Hyndburn & Ribble Valley PCT Cumbria & Lancashire SHA Burnley, Pendle & Rossendale PCT Lancashire & South Cumbria CN West Lancashire PCT Preston PCT Chorley & South Ribble PCT Bury PCT Rochdale PCT Carlisle & District PCT Warrington PCT Trafford North PCT Bolton PCT St Helens PCT North West Greater Manchester & Cheshire CN Blackpool PCT Ellesmere Port & Neston PCT Oldham PCT Cheshire & Merseyside SHA Ashton, Leigh & Wigan PCT Tameside & Glossop PCT Greater Manchester SHA Halton PCT Merseyside & Cheshire CN South Liverpool PCT Blackburn with Darwen PCT Central Manchester PCT Salford PCT Birkenhead & Wallasey PCT South Sefton PCT Heywood & Middleton PCT Central Liverpool PCT Knowsley PCT South Manchester PCT North Liverpool PCT North Manchester PCT Source: Merseyside and Cheshire Cancer Registry Data: Merseyside and Cheshire Cancer Registry / North Western Cancer Registry / Northern and Yorkshire Cancer Registry and Information Service / Office for National Statistics Figure 9 shows the standardized registration ratio for cancers of the trachea, bronchus and lung diagnosed in women living in Merseyside and Cheshire PCTs between 1996 and The red arrows point to the South Sefton and Southport and Formby areas. 10

25 Figure 9: Standardized registration ratio for cancers of the trachea, bronchus and lung (with 95% CI) for women resident in PCTs in Merseyside and Cheshire Standardised registration ratio, % Fylde PCT Southport & Formby PCT Eastern Cheshire PCT Central Cheshire PCT Eden Valley PCT Cheshire West PCT Stockport PCT Morecambe Bay PCT Rochdale PCT Bebington & West Wirral PCT Chorley & South Ribble PCT Trafford South PCT Wyre PCT West Cumbria PCT Hyndburn & Ribble Valley PCT Lancashire & South Cumbria CN Cumbria & Lancashire SHA Warrington PCT Bolton PCT Blackburn with Darwen PCT Ashton, Leigh & Wigan PCT Bury PCT Tameside & Glossop PCT Preston PCT Burnley, Pendle & Rossendale PCT Blackpool PCT Greater Manchester & Cheshire CN Carlisle & District PCT West Lancashire PCT North West St Helens PCT Ellesmere Port & Neston PCT Oldham PCT Greater Manchester SHA Cheshire & Merseyside SHA Trafford North PCT Merseyside & Cheshire CN Central Manchester PCT South Sefton PCT South Manchester PCT Halton PCT Birkenhead & Wallasey PCT Salford PCT South Liverpool PCT Heywood & Middleton PCT Knowsley PCT Central Liverpool PCT North Liverpool PCT North Manchester PCT Source: Merseyside and Cheshire Cancer Registry Data: Merseyside and Cheshire Cancer Registry / North Western Cancer Registry / Northern and Yorkshire Cancer Registry and Information Service / Office for National Statistics Lung cancer rates also vary considerably by electoral ward. Figure 10 shows the agestandardized mortality rate per 100,000 population for Sefton wards over the six-year period The wards are shown in order of increasing deprivation left to right. Southport and Formby wards are shown in blue and South Sefton wards in dark red. A gradient is apparent, with mortality rate in the most deprived wards being higher than those in less deprived wards. All of the seven most deprived wards, with the highest mortality rate from lung cancer, are found within the South Sefton PCT boundary. Please note that the calculated rates are not exact, due to changes in ward boundaries over the time periods and also possible changes in ward population denominators, which were assumed to be identical to the 2001 census count for all years. 11

26 Figure 10: All age male and female age-standardized lung cancer mortality rates per 100,000 population for Sefton wards over the period Age standardised rate per 100, Harington Ravenmeols Meols Birkdale Sudell Blundellsands Park Ainsdale Victoria Molyneux Norwood Manor Kew Cambridge Dukes Church Netherton & Orrell Ford St Oswald Litherland Derby Linacre Increasing Deprivation Sources: ONS Registered Death Extracts for relevant years. Census 2001 Population Ward Tables. Mortality rates over the same time period are also illustrated by geographic area within Sefton in Figure 11. It is apparent that high lung cancer mortality rates are concentrated in the south of the borough, which also corresponds to areas of highest deprivation. 12

27 Figure 11: Thematic map showing age-standardized lung cancer mortality rates for Sefton wards,

28 Figure 12 shows the age-standardized death rate for people of all ages living in Lower Level Super Output areas within Sefton that fall within different quintiles within England of Index of Multiple Deprivation People living in areas with the highest deprivation had over twice the death rate from lung cancer of those living in the two quintiles with the lowest deprivation levels. Figure 12: Age standardized mortality rates for lung cancer in Sefton, by levels of deprivation of lower level super output area of residence (quintiles of IMD 2004) Age Standardised Mortality Rate for Lung Cancer by Quintile of IMD within Sefton SOAs, all ages R 2 = Rate per 100, Deaths Linear (Deaths) IMD 5 IMD 4 IMD 3 IMD 2 IMD 1 Quintile Increasing Deprivation 14

29 Years of Life Lost Figure 13 shows the age-standardized rate of years of life under the age of 75 1 lost due to lung cancer for Sefton wards, in order of level of deprivation of the wards. The calculation assumes that all those dying of lung cancer under the age of 75 would have lived to 75 if they had not died of lung cancer. It shows a similar pattern to that seen for all-age death rates. Figure 13: Age-standardized years of life lost rates from lung cancer per 10,000 population for Sefton wards over the period Years of Life Lost per 10, Harington Ravenmeols Meols Birkdale Sudell Blundellsands Park Ainsdale Victoria Molyneux Norwood Manor Kew Cambridge Dukes Church Netherton & Orrell Ford St Oswald Litherland Derby Linacre Increasing Deprivation Figure 14 shows rate per 10,000 people of years of life lost due to lung cancer under the age of 75, mapped for Sefton wards. It follows a very similar pattern to the lung cancer mortality rate. 1 For methodology see Compendium of Clinical and Health Indicators at nww.nchod.nhs.uk 15

30 Figure 14: Thematic map showing age-standardized years of life lost under the age of 75 rates for Sefton Wards,

31 Survival Lung cancer has one of the lowest survival outcomes of any cancer. In the Merseyside and Cheshire Strategic Health Authority Area, of people diagnosed with lung cancer during , only 8.4% (CI ) were alive five years after diagnosis. This has improved slightly from 6.0% (CI ) for those diagnosed between 1981 and Survival is so poor because most patients with lung cancer are diagnosed at an advanced stage of their disease and lung cancer is also difficult to treat. However, for a minority of patients, there is the possibility of radical treatment leading to cure or greatly extended survival. For Primary Care Trusts in Merseyside and Cheshire, there is a weak association between five-year survival rates and deprivation. This is shown in Figure 15. The r 2 value indicates that 5% of the variation in five-year survival rates between PCTs can be explained by deprivation. Figure 15: Scatter plot of 5-year survival from lung cancer for patients diagnosed against aggregate deprivation score for Merseyside and Cheshire PCTs 12 Scatterplot of 5-year survival rate from lung cancer for patients diagnosed against aggregate deprivation score for Merseyside and Cheshire PCTs 11 Five Year Survival Rate (%) R 2 = Deprivation Score 17

32 Risk Factors The main risk factor for lung cancer is smoking, although there are other risk factors. These, as relevant to Sefton, are shown in Figure 16 below: Figure 16: Pyramid of risk factors for lung cancer within Sefton MBC area Smoking (85-90% lung cancers) Passive smoking Diet, Air Pollution and Occupational Factors Each of these is discussed below, in relation to the population of Sefton. Smoking No other risk factor is as strongly associated with the development of lung cancer as smoking. Eighty percent of lung cancers in women and 90% in men are attributable to smoking and are therefore entirely preventable 4. Because it takes at least 20 years of smoking before lung cancer develops, the incidence and death rates in one period are related to past rather than current smoking patterns. There is no safe level of tobacco smoking. The overall risk is dependent on several factors including age at start of smoking (those who start smoking at a young age being most at risk), average consumption, duration, time since quitting, type of tobacco product and inhalation pattern. Duration of smoking is the most important factor. The excess risk sharply decreases in ex-smokers approximately five years after quitting but a small excess risk persists throughout life. Smoking is positively correlated with deprivation and with manual occupational group. In the ONS General Household Survey 2002/3, 31% of people from routine and manual occupational groups were smokers, compared with 26% in the general population. 18

33 The prevalence of smoking in the two PCTs within Sefton has recently been estimated by the Health Development Agency (HDA) 4, using multi-level synthetic estimation techniques applied to four runs of the Health Survey for England ( ). The estimated prevalence obtained in this way was 31% for South Sefton and 22% for Southport and Formby. This compares with an estimated prevalence of 27% for England and 29% in Cheshire and Merseyside Strategic Health Authority (SHA) area. In Sefton s closest statistical neighbour, Wirral, smoking prevalence was estimated at 31% in Birkenhead and Wallasey PCT and 21% in Bebington and West Wirral PCT, illustrating that these areas with similar demographics also have similar smoking rates. A recent population lifestyle survey, undertaken in Sefton and Liverpool during 2002 and 2003, asked people about their smoking habits. The Lifestyle Survey was not fully representative of the population, due to the poor response rates from some groups, particularly young people and those living in deprived areas. However, the survey did manage to capture samples of all ages living throughout the area, and with 7,922 respondents from the Sefton area answering questions about their smoking habits, it provides a good guide. The analyses presented below relate to those who said that they were current smokers of cigarettes, cigars or pipe tobacco. The majority of these were smokers of cigarettes. Overall, 21% of respondents from Sefton said that they were current smokers. This is low compared with the 26% nationally who reported being current smokers in the ONS General Household Survey 2002/3, and also compared with the HDA estimates. It probably reflects the over-representation of older people in the Lifestyle Survey rather than a genuinely lower smoking rate than expected. The rate of reported current smoking was higher in the South Sefton PCT area (23%) than in the Southport and Formby PCT area (19%), and was slightly higher in males (21%) than females (20%). Figure 17 shows the percentage of Lifestyle Survey respondents living in Sefton SOAs within each quintile within England of IMD 2004 who reported being current smokers. Quintile one represents the fifth of SOAs that are the most deprived in England, quintile two the second most deprived fifth etc. There is a clear gradient, with those living in the most deprived areas being the most likely to report being a smoker. Those living within the most deprived SOAs were around three times more likely to smoke than those living in the least deprived SOAs. This gradient in smoking prevalence mirrors that of lung cancer mortality rates, although it is steeper. 19

34 Figure 17: Self-reported smoking rates in Sefton by level of deprivation 40 Percentage of Respondents who Reported being a Current Smoker R 2 = One Two Three Four Five Most deprived Least deprived Quintile within England of Index of Multiple Deprivation 2004 of SOA of Residence Source: Liverpool and Sefton Lifestyle Survey Smoking status is also known to vary by age and sex. Younger age groups tend to have a higher proportion of current smokers and older age groups to have a higher proportion of ex-smokers. This is due to the numbers of people in older age groups who have given up smoking, and also the numbers who do not live to reach older ages as they have previously died of a smoking-related illness. In addition, older men are more likely to be current or former smokers than older women, and young women more likely to smoke than young men. Figure 18 shows the percentage of Lifestyle Survey respondents living in Sefton who reported being current smokers by age and sex. The age/sex pattern is similar to that expected according to nationally observed patterns. 20

35 Figure 18: Self-reported smoking rates in Sefton by age and sex Percentage current smokers Males Females Age group Source: Liverpool and Sefton Lifestyle Survey In addition, an analysis was undertaken to look at smoking rates by gender within quintiles of IMD. This is shown in Figure 19. The gradient in smoking prevalence by level of deprivation is apparent in both males and females. Figure 19: Self-reported smoking rates in Sefton by gender and deprivation 35% Percentage of respondents who were current smokers 30% 25% 20% 15% 10% 5% 0% % female smoker % Male smoker Quintile within England of Index of Multiple Deprivation 2004 of SOA of residence Most deprived Least deprived Source: Liverpool and Sefton Lifestyle Survey 21

36 Smoking status is also associated with ethnic group. However, the population of Sefton is predominantly White British, with few people from ethnic minorities, making analysis by ethnic group impractical. In addition to the Lifestyle Survey, a health-related behaviour survey was undertaken within Sefton schools in Year 10 (aged 14-15) pupils (sample size 991) were asked about their smoking behaviour. Seventeen percent of boys and 29% of girls reported smoking regularly or occasionally. Rates of regular smoking appear to have decreased slightly from 1997, when 25% of boys and 32% of girls of the same age in the same survey reported being regular smokers. Of the regular smokers in 2002, 78% expressed a wish to give up smoking. 22

37 Environmental tobacco smoke An association between exposure to passive smoking and lung cancer risk has been shown in many epidemiological studies, mainly involving environmental tobacco smoke in the workplace or home or both. One review estimated the increased risk of lung cancer of non-smokers who lived with smokers was around 24% 6. About a quarter of all lung cancers in non-smokers may be attributable to passive smoking. In 1998, the Scientific Committee on Tobacco and Health (SCOTH) of the Department of Health published a major review and concluded that passive smoking can cause lung cancer 7. Passive smoking is also a factor in continuing the family circle of smoking. The Acheson report 8 highlights the fact that one third of children live in the UK live with at least one adult smoker - among low income families the figure is 57%. Unfortunately, there is no reliable data on exposure to environmental tobacco smoke in Sefton. However, it is likely that those living in deprived areas are most at risk, as the prevalence of smoking is higher and people are more likely to be undertaking low paid work such bar work, in environments where people smoke. In the 2002 survey of health related behaviour among year 10 (aged 14-15) pupils in Sefton, 60% of pupils reported that at least one person smoked at home. It is not known whether these people smoked in the same room as the pupil or not. 23

38 Diet There is evidence that smokers with a diet low in fruit and vegetables, and beta carotene in particular, may be more likely to develop lung cancer than those with a better diet 9. Current guidelines recommend that people eat five portions of fruit and vegetables per day. In the Liverpool and Sefton Lifestyle Survey, only 15% of respondents from Sefton reported eating at least five portions of fruit and vegetables per day. This was higher in females (18%) than in males (12%), and was lowest in young people aged (8%) followed by those aged (13%). Figure 20 shows reported consumption of fruit and vegetables of respondents living in Sefton lower level super output areas with different levels of deprivation as measured by the English Index of Multiple Deprivation The is a clear gradient, with those in the most deprived areas eating the most fruit and vegetables and those in the least deprived areas eating the most. However, even in the least deprived areas, only 22% of people reported eating fruit and vegetables at the recommended levels. Figure 20: Self-reported daily fruit and vegetable consumption in Sefton by level of deprivation Percentage of Respondents to Quintile within England of Index of Multiple Deprivation 2004 of Area of Residence Increasing deprivation Source: Liverpool and Sefton Lifestyle Survey 24

39 Air pollution Long-term exposure to urban air pollution, particularly PM10 (small particulate matter with a diameter of 10 micrometers or less) and NO2 (nitrogen dioxide), is also a risk factor for lung cancer, although the risk is very small compared with that of smoking 10. Exposure to air pollution is also often associated with deprivation, as polluted areas, for example those near heavy industry or busy roads, tend to be seen as less desirable and are hence more affordable for those on low incomes. Figures 21 and 22 show patterns of air pollution for PM10 and NO2 in Sefton, also showing the main urban areas. The concentrations shown represent a daily average and were estimated from models using readings at selected points, prevailing wind speeds/ directions etc. 25

40 Figure 21: Map showing estimated daily average air concentrations of PM10 (micrograms per meter 3 ) in Sefton for

41 Figure 22: Map showing estimated daily average air concentrations of NO2 (micrograms per meter3) in Sefton for 2004 The areas with the highest pollution levels are concentrated in the south of the borough, around the Port of Liverpool. These areas are also amongst the most deprived in Sefton (Figure 7). 27

42 Radon gas The presence of radon gas depends on the type of underlying rock on which homes are built, and is therefore very geographically variable. Fortunately, the Sefton area is not affected by radon gas. Occupational factors Occupational exposures have been associated with an increased risk of lung cancer. It has been estimated that up to 15% of lung cancer cases in men and 5% in women may be attributable to occupational factors in conjunction with smoking 11. Table 3 lists occupational exposure agents which have been identified as probable causes of lung cancer 12. Table 3: Occupational exposure agents identified as probable causes of lung cancer Substance or Mixture Ionizing radiation Silica, crystalline Talc containing asbestiform fibres Arsenic and arsenic compounds Beryllium Cadmium and cadmium compounds Chromium compounds, hexavalent Selected nickel compounds, including combinations of nickel oxides and sulfides in the nickel refining industry Occupation or Industry in which the substance is found Radiologists, Technologists, Nuclear workers, radium-dial painters, underground miners, plutonium workers, cleanup workers following nuclear accidents, aircraft crew Granite and stone industries, ceramics, glass and related industries, foundries and metallurgical industries Manufacture of pottery, paper, paint and cosmetics Nonferrous metal smelting, production, packaging and use of arsenic-containing pesticides, sheep dip manufacture, wool fibre production, mining of ores containing arsenic. Beryllium extraction and processing, aircraft and aerospace industries, electronic and nuclear industries, jewellers Cadmium-smelter workers, battery production workers, cadmium-copper alloy worker, dyes and pigments production, electroplating processes Chromate production plants, dyes and pigments, plating and engraving, chromium ferro-alloy production, stainless steel welding, in wood preservatives, leather tanning, water treatment, inks, photography, lithography, drilling muds, synthetic perfumes, pyrotechnics, corrosion resistance Nickel refining and smelting, welding 28

43 Coal tars and pitches Mineral oils, untreated and mildly treated Soots 2,3,7,8 Tetrachlorodibenzo-paradioxin (TCDD) Involuntary (passive) smoking Mustard Gas Strong inorganic-acid mists containing sulphuric acid Polyaromatic hydrocarbons Benz(a)anthracene Benzo(a)pyrene Dibenz(a,h)anthracene Wood and fossil fuels and their byproducts Creosotes, Diesel engine exhaust Chlorinated hydrocarbons a-chlorinated toluenes Epichlorohydrin Nonarsenical insecticides Production of refined chemicals and coal tar products (patent-fuel), coke production, coal gasification, aluminium production, foundries, road paving and construction (roofers and slaters) Production; used as lubricant by metal workers, machinists, engineers, printing industry (Ink formulation), used in cosmetics, medicinal and pharmaceutical preparations. Chimney sweeps, heating-unit service personnel, brick masons and helpers, building demolition workers, insulators, firefighters, metallurgical workers, work involving burning of organic materials Production; use of chlorophenols and chlorophenoxy herbicides; waste incineration; PC8 production, pulp and paper bleaching. Workers in bars and restaurants, office workers Production; used in research laboratories, military personnel Pickling operations; steel industry, petrochemical industry; phosphate acid fertilizer manufacturing Work involving combustion of organic matter, foundries, steel mills, firefighters, vehicle mechanics Work involving combustion of organic matter, foundries, steels mills, firefighters, vehicle mechanics Work involving combustion of organic matter; foundries; steel mills; firefighters vehicle mechanics Brickmaking, wood preserving, Railroad workers, professional drivers, dock workers, mechanics Production; dye and pesticide manufacture Production and use of resins, glycerine and propylene-based rubbers, used as a solvent. Production, pest control and agricultural workers, flour and grain mill workers Asbestos is the most common occupation-related cause of cancer. Smoking acts synergistically with asbestos exposure to greatly increase the risk of lung cancer. Deaths from asbestos-related cancers are expected to rise until about 2020, before falling due to the introduction of legislative controls on exposure to asbestos in the 1970s. Mesothelioma, a cancer of the pleura surrounding the lung, is almost always caused by exposure to asbestos. The Health and Safety Executive (HSE) estimate that for every case of mesothelioma, there are one or two cases of lung cancer caused by asbestos. During the period , the SMR for mesothelioma in Sefton was 110 (95% CI 90-29

44 133) 13. This means that the death rate from mesothelioma is not significantly different to that of England as a whole, and therefore the death rate from asbestos related lungcancer is also unlikely to be significantly different from England as a whole. 30

45 Prevention Activities As the major risk factors for lung cancer are smoking and exposure to environmental tobacco smoke, prevention activities for lung cancer centre around tobacco control. Sefton s tobacco control strategy, Towards a Smokefree Sefton, lists the following as key element of tobacco control: 1. Strong mass media-led information campaigns 2. A ban on tobacco advertising and promotion 3. Price policy and control of smuggling 4. Smoke-free public places, especially workplaces 5. NHS Stop Smoking services 6. Community-based initiatives 7. Harm-reduction strategies Work undertaken in Sefton in each of these areas is described below, with an equity analysis where possible. Strong mass media-led information campaigns People from Sefton have participated in national media campaigns, including a man from Bootle with lung cancer who appeared in a television campaign. There have also been a number of local campaigns, many of which were targeted towards disadvantaged areas. For example, posters with the Smoke Free Sefton logo have been placed on the sides of bus shelters, mainly in the Neighbourhood Renewal Fund areas, and the items with the logo on (pens, car stickers etc.) have also been distributed in NRF areas. Another poster campaign Kiss a smokers and taste the difference is aimed at young people and also uses advertising space at bus stops, so as to be seen by those using public transport. Another campaign used dentists to raise the issue of smoking and distribute awareness raising material. This was found to be a very successful way of raising awareness. Sefton Health Improvement Support Service (SHISS) have recently obtained the funding for a communication post in public health and health improvement. One of the communication officer s roles will be to raise the profile of Smoke Free Sefton and local initiatives to reduce smoking, including local newspaper coverage. A ban on tobacco advertising and promotion This area is mostly under the control of national and European government. There has been legislation within the last two years to increase the size and visibility of health warnings on cigarette packets. Since December 2004 there has also been a ban on cigarette advertising outside shops (e.g. newsagents), which the local authority are enforcing locally. Price policy and control of smuggling Price control is under the control of national government. Prices are steadily increasing as the amount of tax on a packet of cigarettes increases. Smuggling controls are also national. It is known that locally there are issues with counterfeit cigarettes (which are even less healthy than legally manufactured cigarettes!) and that these are sold mainly in the more deprived areas. Local enforcement agencies are working to prevent this. 31

46 Smoke-free public places, especially workplaces Control of smoking at work and in public places reduces the opportunity for and perceived acceptability of smoking. In 2002, the Sefton Citizen s panel survey asked respondents about their views on smoke-free public places. This showed overwhelming support for smoke-free and restricted smoking policies and places, which was used for lobbying etc and led to the implementation of Smoke Free Sefton. The 2004 Sefton Citizen s Panel survey also had a module on smoking in public places. Respondents were asked whether they would prefer to visit the following entertainment/ catering venues if they were totally non-smoking, if smoking was restricted to certain areas, or if there were no smoking restrictions. Pubs and bars Nightclubs Restaurants Cinemas Cafés With the exception of bars and nightclubs, the majority said they would prefer venues to be totally non-smoking. In the case of bars and nightclubs, the largest proportion would prefer restricted smoking, closely followed by those who would prefer totally nonsmoking venues. This is shown in Figure 23. Figure 23: Responses in the Sefton Citizens Panel to a question about preferred smoking policies in places they would visit Preferred smoking policies for different venues Percentage of respondents Totally non-smoking Restricted smoking No smoking restrictions Not applicable/ w ould not visit 0 Bar Nightclub Restaurant Cinema Café Type of establishment In addition, almost one third (32%) said that a smoky atmosphere has stopped them doing something that they would like to do in the previous 12 months. 32

47 Sefton Health Improvement Support Service (SHISS) facilitate take-up of the National Clean Air Award scheme for workplaces in Sefton. This is a Roy Castle Lung Cancer Foundation initiative to encourage workplaces to implement no-smoking policies, and comprises a gold award for completely smoke-free premises and a silver award where smoking is only allowed in fully enclosed indoor smoking areas or designated outdoor areas. At March 2005 there were 7 Gold Award and 9 Silver Award holders in Sefton. These were based mainly in the South of the Borough. However, there are likely to many other workplaces which are smoke-free but have not chosen to apply for the award. Smoke Free Sefton awards were launched last March on National No-Smoking day On that day, the Strand shopping centre in Bootle became smoke-free, following months of preparation involving consultation with traders and shoppers, developing signage and training of security staff. There were also events at Southport and he Feelgood Factory in Netherton where awards were presented to various local smokefree workplaces. All Sefton PCT premises are already smoke-free, although some allow smoking in designated outdoor spaces. Aintree University Hospitals Trust went smoking-free in 9 th May 2005, and this will be followed by all Local Authority buildings in Sefton from 1 st September

48 NHS Stop Smoking services Smokers may receive encouragement and support to quit from the NHS in various ways including: 1. Advice and possible prescribing of Nicotine Replacement Therapy (NRT) in primary care. 2. More intensive advice, support and prescribing services offered by the NHS Stop Smoking service, SUPPORT. 3. Less intensive Stop Smoking services provided by some pharmacies, working under the guidance of SUPPORT. 1. Support provided in primary care Figure 24 shows the prescribing of nicotine replacement therapy, expressed as cost per patient over the age of 15, for GP practices in Sefton, by LISI score during the financial year 2003/4. LISI score is based on the percentage of adult patients who are eligible for free prescriptions on the basis of low income, and is therefore a proxy for level of deprivation among practice patients. It shows no apparent difference between practices with different LISI scores. This may indicate some inequity in provision of NRT prescribing in primary care, as deprivation is associated with smoking and hence with need for support to quit, including prescribing. In addition, it is evident that some GP practices have much higher prescribing rates than others, which indicates a level of inequity in access to NRT prescribing dependent upon which practice a patient is registered with. Figure 24: Prescribing costs per patient over the age of 15 for nicotine replacement therapy by LISI score for General Practices in Sefton in Costs per Patient aged 15 or over of Prescribing Nicotine Replacement Therapy LISI Score (deprivation indicator) Source: epact 34

49 2. NHS Stop Smoking service - SUPPORT SUPPORT provides the following services to people in Sefton: Smoking cessation clinics, located throughout South Sefton and Southport and Formby Satellite services seeing patients at Southport and Aintree hospitals. These link particularly with cardiology services. Smoking cessation midwives service, with links to Sure Start. Providing training to pharmacy workers to provide NRT vouchers, advice etc. Some pharmacies have been provided with vouchers and carbon monoxide meters. A support worker who attends events, including work in schools. Providing smoking cessation services in workplace, usually to support the implementation of a smoke-free workplace policy. Currently working with coronary care consultants to agree guidelines of prescribing of NRT. The main SUPPORT services are accessed in the following ways: Clients can be referred by a doctor or can self-refer. There are links with national and local help lines (National Quitline, Fag Ends) for self-referrals. People are allocated to a clinic near where they work or near where they live, depending on their preference. There are evening sessions available at some locations. There is an average waiting time of two weeks for a first appointment, but it varies by location, with longer waiting times for town centre locations. There are slightly longer waiting times for evening appointments. The service can obtain information for clients in Urdu and Bengali (from national helpline) and have been able to download some information from the internet in Turkish. Information is also available in Braille and on audiotapes. SUPPORT has access to the local interpreting service and has links with the asylum seeker support service. Extra time is allocated to clients with hearing difficulties. SUPPORT routinely collect data on patients using the services, including: Personal details including age, sex, address and postcode Dates and place of attendance Details of interventions received Quit date set Quit status at four weeks Quit status after one year For the period April 2003 to June 2004, a sub-set of this data was collated for the purposes of the audit. This included age, sex, postcode and quit status at four weeks. Quit status at one year was not available for a large proportion of clients as this has only recently been collected and relies of former clients voluntary responses to questionnaires sent out in the post. 35

50 Figure 25 shows the four-week quit rate (a measure of service effectiveness) among those who had set a quit date and whose outcome was known, by quintile of IMD 2004 of SOA of residence. The quit rate was similar in all groups, suggesting no inequity in effective use of SUPPORT by deprivation of area of residence. Figure 25: Four-week quit rate for SUPPORT clients with a known outcome by level of deprivation of SOA of residence 80% 70% 60% R 2 = Four-week quit rate 50% 40% 30% 20% 10% 0% One Two Three Four Five Quintile of IMD A similar analysis was undertaken comparing four-week quit rates by age and sex. This is shown in Figure 26. The quit rate is fairly similar in each age group, with the exception of the youngest group (15-24) who appear to be less likely to quit than clients in older age groupings. The difference was significant for females but not for males. Males aged 75+ were significantly more likely to successfully quit than males of all ages. There was no significant difference between males and females at any age. The differences between the youngest and oldest age groups and the middle age-groups are not necessarily due to inequities of service, but may relate to the characteristics of these groups. 36

51 Figure 26: Percentage of SUPPORT clients with a known outcome who successfully quit after 4 weeks, by age and sex 100% 90% 80% R 2 = Percentage of Clients 70% 60% 50% 40% 30% Males Females 20% 10% 0% Age group (years) These data only apply to patients whose quit status was known. To check whether there were any differences by level of deprivation in the proportion with a known quit state, which could have biased analyses, proportion with a known quit state was mapped against quintile of IMD of area of residence. There was an association, with quit state more often known for people living in deprived areas, r Percentages with known quit state ranged from 45.8% in quintile 1 (most deprived) to 57% in quintile 4. A similar analysis was undertaken to look at the percentage of clients who were lost to follow-up by quintile of IMD There was a definite trend by deprivation, with patients from more deprived areas being more likely to be lost to follow-up (r 2 = 0.89). However, the total lost to follow up was less than 11% even in the most deprived areas, which tend to have the most mobile populations. The analyses presented so far relate to the effectiveness of the service for different groups. Further analyses were undertaken to assess access rates by difference groups. Figure 27 shows the percentage of patients quitting at four weeks through SUPPORT who lived in areas with different IMD 2004 ranks by quintile within England, and compares this with the percentage of smokers estimated to be living in areas within each deprivation quintile, as identified through the Lifestyle Survey in Sefton. This estimate was obtained using data on population over the age of 15 by SOA and percentage of respondents to the Lifestyle Survey who reported being current smokers, by SOA. The percentage of successful 4-week quitters living in areas within different quintiles of IMD 2004 closely mirrors the estimated percentage of Sefton s current smokers living in these areas. This suggests that there is no inequity by level of deprivation. 37

52 Figure 27: Comparison of the percentage of smokers living in SOAs with different deprivation levels, and 4-week quitters through SUPPORT living in the same areas. 45% 40% Percentage of Respondents/ 4-week Quitters 35% 30% 25% 20% 15% 10% Percentage of current smokers living in areas within quintile of IMD Percentage of quitters through SUPPORT living in areas within quintile of IMD 5% 0% One Two Three Four Five Quintile within England of Index of Multiple Deprivation 2004 Figure 28 shows the number of clients who set a quit date and were known to have quit at four weeks by age and sex. There were 508 successful male quitters and 753 females, 33% more females than males. This suggest that women are more likely than men to make effective use of SUPPORT Stop Smoking services in Sefton, despite having similar smoking rates (Figure 18). This suggests a possible inequity of access to SUPPORT by sex, which disadvantages men. 38

53 Figure 28: Number of clients who successfully quit smoking after 4 Weeks through SUPPORT in Sefton, by age and sex 200 Number of people sucessfully quitting smoking after 4 weeks through SUPPORT in Sefton Males Females Age Group (Years) Figure 28 shows the location of SUPPORT clinics overlaid onto a map of deprivation, indicated by quintile within England of IMD 2004, in Sefton. The clinics are located within Sefton s major urban centres and are concentrated in areas of high deprivation. These are locations where need would be highest, and where access by public transport and/ or location near to client s workplaces would be maximised. This suggests that SUPPORT clinics are located in an equitable way. 39

54 Figure 29: Map of SUPPORT clinic locations in Sefton, with Index of Multiple Deprivation

55 3. Stop Smoking support in pharmacies SUPPORT also oversees Stop Smoking services provided by pharmacies in Sefton. This is a recent innovation and hence there has not yet been enough data collected to assess equity of access etc. to these services. However, it is possible to map the location of these pharmacies in relation to areas of highest deprivation, where the need for Stop Smoking services is greatest. This is shown in Figure 30. The darker areas represent the areas of highest deprivation. The majority of people living in the most deprived areas have access to a Stop Smoking support services at a pharmacy within 1km of their home. However, there is a small deprived area on the outskirts of Southport which does not have a local pharmacy providing Stop Smoking services. 41

56 Figure 30: Map of pharmacy-based Stop Smoking services led by SUPPORT in Sefton, with Index of Multiple Deprivation