Lincolnshire JSNA: Compliance with smoke-free legislation, e.g. public smoke free places remains high in Lincolnshire.

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1 What do we know? Summary Smoking remains the biggest killer for premature mortality in England. There are stark health inequalities between people who smoke and those who don't smoke. The prevalence of smoking in adults in Lincolnshire is gradually reducing and continues to mirror what is happening across England. However, there are geographical differences in prevalence locally and diseases / deaths attributable to smoking which mirror health inequalities and deprivation. Compliance with smoke-free legislation, e.g. public smoke free places remains high in Lincolnshire. Lincolnshire's smoking cessation services, currently commissioned through the NHS are not meeting the 4 week quit targets set for them. This underperformance is a national phenomenon and it has been suggested (although not proved) that the development of electronic cigarettes (e-cigs) and their popularity amongst smokers has played a significant part in this reduction in numbers quitting with NHS stop smoking services. Research undertaken through the Smoking Toolkit Study 1 shows a steady decline in smokers accessing stop smoking services whilst the use of e-cigarettes has increased significantly over the same period. Smokers appear to be choosing to make a quit attempt using these products rather than accessing the support of the stop smoking service or they are swapping over to e-cigarettes as a potentially safer alternative to smoking. Compared to 2012/13 the Lincolnshire service was 19.3% off target in 2013/14, against a national reduction of 20% in smoking quits for the year Health and Social Care Information Centre (2014): Statistics on NHS Stop Smoking Services in England, April 2013 to March 2014Final report 1 of 10 April 2015 (v2.0)

2 Facts and figures The latest Integrated Household Survey (2013) 3 estimates that 19.1% of adults in Lincolnshire currently smoke, slightly higher than the England average of 18.4%. The estimate, as identified in the local Tobacco Control Profile for Lincolnshire, varies across the local authority areas from 24.1% in Boston to 14.6% in South Kesteven (Table 1). The profiles also suggest that diseases and deaths attributable to smoking are parallel with the England average and representative of the health inequalities historically and currently within the county, e.g. Lincoln has the highest disease and deaths rates attributable to smoking. During , 3,968 people died in Lincolnshire as a result of smoking. 4 Table 1: Local Tobacco Control Profiles - Lincolnshire Prevalence (percentage 18+ smoker) IHS, 2013 Smoking related mortality (value per 100,000) Lung cancer registrations (value per 100,000) Oral cancer registrations (value per 100,000) Boston BC East Lindsey Lincoln City North Kesteven South Holland South Kesteven West Lindsey Lincolnshire England Smoking during pregnancy can lead to serious risks and harms to both mother and baby. It can lead to an increased risk of miscarriage, complications during labour, still births, low birth weight babies and sudden infant death syndrome. Exposure to smoke whilst in the womb can also leave children more susceptible to conditions such as asthma, glue ear and even behavioural problems. Giving up smoking is one of the best things a pregnant woman can do to reduce the risks to both herself and baby, however quitting during of 10 April 2015 (v2.0)

3 pregnancy can be very difficult. The pressure not to smoke whilst pregnant can be so intense that some woman won't admit to it and therefore miss out on the help they need. 5 An assessment should be taken at the time of delivery of every pregnant woman; this Smoking at Time of Delivery (SATOD) measure is consistently higher for Lincolnshire (14.9 %) than the national average of (12.0 %, 2013/14). 6 The SATOD highlights an east / west divide across the county, with the east coast having a substantially higher rate of smoking during pregnancy and at delivery (Quarter 4: 2013/14): Lincs East CCG 20.8% Lincs South CCG 14.6% Lincs South West CCG 12.6% Lincs West CCG 10.7% NHS stop smoking services aim to support smokers who want to quit by offering a combination of behavioural support and access to stop smoking medicines. During the period 2012/13 the NHS stop smoking service in Lincolnshire supported 5,591 people to achieve the 4 week quit target; representing a 55% quit rate, a 1% rate increase on the previous years' quit rate. Nearly three quarters of these quits were validated by carbon monoxide measurements, however the national standard is to have 85% of quits validated by this measure. Over 1,000 pregnant smokers were referred to the services for support; 431 were confident enough to set a quit date and try and stop smoking. 264 achieved a 4- week quit target, representing a 61% quit rate. 48% of all clients achieving a 4-week quit represent one or more of the local health inequalities audiences. Trends Smoking in adults has continually declined over the decades; in 1974 (Great Britain) 45% of adults (aged 16+) smoked compared with 20% in This decline can be attributed to increased awareness of the harms of smoking as well as initiatives aimed at reducing smoking, protecting non- smokers and de-normalising smoking. For example, legislation was introduced in England that banned smoking in enclosed public places; between April and December 2007 the period leading up to and immediately after the introduction of the ban stop smoking services reported a 22% increase in successful 4 week quitters. 8 This decline has slowed in recent years and more significantly so in more deprived groups; the gap in health inequalities (the difference in health between different population groups) 5 NICE: Quitting smoking in pregnancy and following childbirth, June General Lifestyle Survey, 2001 release, March Office for National Statistics 8 Bauld, L (2011) I mpact of Smokefree Legislation in England: Evidence Review, University of Bath 3 of 10 April 2015 (v2.0)

4 is widening in measures such as life expectancy. 9 For example smoking prevalence is particularly high among people with mental health problems and has changed little in this group in the past 20 years. 10 Targets The prevalence target both locally and nationally is to reduce the prevalence of adult smokers (aged 18 or over) to 18.5% by the end of The current target for the local NHS stop smoking service for 2014/15 is 5,833 4 week quits, the delivery of which is to be split between the core service and the wider network of providers. There are also dedicated targets for pregnancy, acute, young people and the telephone service (Table 2). Table 2: Stop Smoking Service targets 2014/15 Subsets Set Quits 4-Week Quits Network 6,730 3,365 Core 4,487 2,468 Pregnancy Acute Telephone Young People Performance Previously there has been a year on year increase in the number of 4 week quitters in Lincolnshire from 5,229 in 2007/08 to 6,485 in 2011/12, and represented a 1.3% increase in people supported to stop smoking year on year by NHS commissioned services. However, in 2012/13, for the first time in six years the service failed to reach the 4 week quit target by 14.8%, and this continued in 2013/14 with the service missing the target by 19.3%. This is mirrored by a 19% reduction in people accessing stop smoking services nationally during 2013/14 when compared with 2012/ Hiscock and Bauld (2013) Stop Smoking Services and Health Inequalities, 2013, NCSCT 10 Royal College of Physicians, Royal College of Psychiatrists. Smoking and mental health.london: RCP, Local Stop Smoking Services: Service and delivery Guidance of 10 April 2015 (v2.0)

5 What is this telling us? Summary Smoking remains the largest single cause of premature death and is a fundamental component to health inequalities. The success of tackling tobacco control is heavily reliant on partnership working with joined up solutions, which doesn't only focus on quitting but also on the regulation of supply and demand, legislation, campaigns, media work, harm minimisation e.g. smoke free homes, as well as personalised interventions, e.g. smoking cessation. Local views The local tobacco control team and smoking cessation service engage the local population in surveys and user feedback regularly; for example the tobacco control team engaged with the public to establish the level of local support for legislation to prohibit smoking in cars with children, this then fed into a national consultation. National and local strategies Healthy Lives, Healthy People: A Tobacco Control Plan for England supports comprehensive tobacco control across six internationally recognised strands: Helping tobacco users to quit Reducing exposure to second-hand smoke Effective communications for tobacco control Stopping the promotion of tobacco Effective regulation of tobacco products Making tobacco less affordable. Source: Lincolnshire s Tobacco Control Strategy , aligned to the six strands, was launched in Source: 5 of 10 April 2015 (v2.0)

6 Current activity and services There is a smoke free alliance for tobacco control in Lincolnshire (Smokefree Lincolnshire), who collaborates with partners on the Co-ordination of tobacco control regulations e.g. smoke free public places. This activity is monitored/enforced by district council environmental health officers. Following the co-ordinated implementation of the legislation 100% of businesses in Lincolnshire were compliant. During 2013/14 there were only five incidents of noncompliance, two of which were smoking in a work vehicle. Co-ordination of activity to tackle smuggling and the illicit supply of tobacco. During operations by Trading Standards, Lincolnshire Police and HMRC in 2013/14, 14 premises were visited, leading to the seizure of 134,100 cigarettes and 38,810 grams of hand rolled tobacco; resulting in 3 written warnings, 3 licensing reviews and 9 criminal prosecutions. Smoke Free Homes & Cars programme: over 24,800 homes in Lincolnshire have pledged to apply smoking restrictions within their homes and cars, protecting 25,400 children from second hand smoke. Campaigns and media work e.g. national no smoking day and Stoptober. Developing education and awareness programmes to reduce the number of young people taking up smoking. During 2013/14, 265 young people took part in the 'BIIAB Level 1 Award in Smoking Awareness'. The award aims to provide candidates with a basic knowledge of the negative effects smoking has on young people and adults. Currently a comprehensive community based network of local stop smoking services is managed by the county's Phoenix NHS Stop Smoking Service. Phoenix operate a tiered, co-ordinated and managed model of smoking cessation through a series of core and specialist services and partnership networks applying motivational, educational and behavioural interventions. 12 Over 100+ local providers across primary care, pharmacies and military bases contribute towards 60 per cent of the annual quit rates. The service has specific targets to engage with pregnant smokers, smokers within routine and manual occupations and smokers in acute services (Stop B4 Your Op). 12 Garner P, Model for Delivery A Stop Smoking Service Commissioners Perspective, of 10 April 2015 (v2.0)

7 Key inequalities Smoking is the single biggest cause of inequalities in death between the richest and poorest in our communities. Smoking accounts for a significant proportion of inequalities in life expectancy at birth in the UK. 13 The London Health Inequalities Forecast (2006) identified that 37% of the differences in life expectancy for men and 30% for women was attributable to smoking. 14 Smoking rates are much higher in low income groups 15, smoking is around twice as common among people with mental disorders and more so in those with more severe disease 16, and more men than women still smoke, although the gender gap is reducing. 17 The independent review into health inequalities in England undertaken by Professor Sir Michael Marmot culminated in the publication in 2010 of 'Fair Society, Healthy Lives'. The review identified the most effective evidence-based strategies for reducing health inequalities in England and made the following recommendation: "Tobacco control is central to any strategy to tackle health inequalities as smoking accounts for approximately half of the difference in life expectancy between the lowest and highest income groups. Smoking-related death rates are two to three times higher in low-income groups than in wealthier social groups. "At local levels, greater emphasis in smoking cessation initiatives on the psychosocial reasons for smoking and prioritising deprived and marginalised groups is required, focused particularly on routine and manual socioeconomic groups, and people with mental health problems" Marmott (2010) 18 Key gaps in knowledge and services Whilst the nicotine in tobacco is highly addictive it is primarily the toxins and carcinogens in tobacco smoke that cause most of the disease and deaths 19. Harm reduction strategies help to reduce the harms of smoking by providing alternative forms of nicotine for those smokers who cannot or do not want to quit. NICE has developed the "Tobacco: harmreduction approaches to smoking" guidance that provides recommendations for commissioners and Stop Smoking Services on how to incorporate harm reduction in to the core service, which is something that could be taken forward in Lincolnshire General Lifestyle Survey, 2011 release, March Office for National Statistics 16 Royal College of Physicians, Royal College of Psychiatrists. Smoking and mental health.london: RCP, Do smoking rates vary between more and less advantaged areas?, 2012 release, March Office for National Statistics 18 Marmet M, (2010), `Fair Society, Healthy Lives 19 NICE, Tobacco: harm-reduction approaches to smoking, June of 10 April 2015 (v2.0)

8 The use of electronic cigarettes has grown dramatically in recent years with research from the Smoking Toolkit Study (2014) identifying use of e-cigarettes exceeding that of other nicotine replacement products. 20 Currently these products are un-licenced however manufactures are now able to apply for a medicines licence from the Medicines and Healthcare products Regulatory Agency (MHRA) which could allow them to be prescribed as part of the Stop Smoking Service. As products become licenced the service will need to consider changes that will encompass this. We would also like to focus more on young peoples' services, preventing young people from starting smoking and supporting young people to quit. It is also important for us to explore young people's use of electronic cigarettes by undertaking local research. Risks of not doing something It is estimated that treating tobacco related illnesses cost the NHS 5.2 billion in 2005/06 or 100 million every week. The latest estimates from the ASH "Ready Reckoner" (Chart 1) suggest that each year in Lincolnshire smoking costs society approx m and that in 2013/14, Lincolnshire smokers paid approx m in duty on tobacco products which leave a shortfall of around 54m each year in this area alone. 21 Doing nothing could lead to an increase in people smoking which in turn would result in a rise in morbidity and premature mortality, and widening the health inequalities gap. Chart 1: ASH "Ready Reckoner": estimated cost of smoking in Lincolnshire of 10 April 2015 (v2.0)

9 What is coming on the horizon? Continued work on the implementation of legislation relating to the ban of point of sales display of tobacco products in smaller retail establishments, which is due to be implemented on 1 st April 2015 and follows the ban imposed on larger retailers in April Continue to monitor the development and introduction of licensed e-cigarettes; as identified in the EU Tobacco Products Directive (TPD) any e-cigarettes that contains more than 20 mg/ml of nicotine or makes claims about helping smokers to quit must apply for a medicines license from the Medicines and Healthcare products Regulatory Agency. All other products will be covered by the TPD which comes in to force in May Source: Continued work to support the introduction of legislation on the Plain Packaging of tobacco products; this legislation will lead to all cigarettes being sold in standardised packaging, with all trademarks, logos, colour schemes and promotional graphics prohibited. This legislation will come in to force in May Source: Continued work to support the implementation of legislation on Smoking in Cars with Children l makes it an offence to smoke in an enclosed private vehicle, with someone under the age of 18 present. This legislation will come in to force on 1 st October Source: Budget reviews within the public sector are having an impact on the capacity of local partner organisations; priorities have changed and the pressure to provide more for less has increased however despite this the commitment to tackle smoking continues. 9 of 10 April 2015 (v2.0)

10 What should we be doing next? Use the Smokefree Lincolnshire Alliance Action Plan to deliver on Lincolnshire s Tobacco Control Strategy 2013 to 2018 and to feed in to Lincolnshire's joint Health and Wellbeing Strategy Following a service review undertaken in 2013 Lincolnshire's Stop Smoking Service is to be re-commissioned, in doing so it is hoped that this will broaden the scope for new providers such as voluntary and community groups and will re-invigorate the service at a time when nationally services are seeing a reduction in the number of people seeking support to stop smoking. 10 of 10 April 2015 (v2.0)