Making Smoking History:
Tobacco control strategy for Surrey 2010-2015
1
Contents
Foreword
Executive Summary
The Vision for 2015
_______________________________________________________________
Aims, Objectives and Targets
Strategic Priority 1: Children and Young People
Strategic Priority 2: Health Inequalities and Helping Smokers to Quit
Strategic Priority 3: Secondhand Smoke
Strategic Priority 4: Combating Illicit Tobacco
References
Cover photograph by George Margetts
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Foreword
I am very pleased to be writing this foreword for the Tobacco Control Strategy for
Surrey. Evidence has shown that strategies designed to tackle tobacco need to be
comprehensive and can only be delivered by multiple partners. In Surrey, a number of
agencies work on tobacco control through statutory and contractual requirements (the
NHS, Trading Standards, Environmental Health and Education).
We all know the devastating effect of tobacco on health. Tobacco remains the single
greatest cause of health inequalities in the UK. Here, in Surrey, smoking remains the
leading cause of preventable death, killing over 1400 residents every year. While overall
smoking prevalence is low, there are pockets where levels of smoking are far higher
than the national average. It is in these priority places that we must target our actions
and services.
This strategy has been developed to pull all the strategic aims and objectives together
into one document to ensure effective, coordinated action across Surrey. A new
national tobacco control strategy has been launched this year which will help drive the
work locally.
We hope you find this strategy informative and look forward to working with you to
implement an effective approach to reducing the harm caused by tobacco across
Surrey.
Chris Butler
Chief Executive
NHS Surrey
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Executive summary
This Tobacco Control Strategy sets out why we need to target tobacco and how we can
work together to reduce its harmful effects in Surrey.
Tobacco is an extremely harmful consumer product, responsible for the premature
death of half of all life-long smokers. Over 80,000 people die from smoking-related
disease in England every year. It is responsible for 29% of cancer deaths, 13% of
cardiovascular deaths and 30% of deaths from respiratory disease. In Surrey, there are
over 1400 smoking related deaths each year, that’s nearly 30 deaths a week, almost
four a day.1
Tobacco is a unique consumer product. It is the only widely available product, which
when used as the manufacturers intend, kills. There is no easy answer to addressing
the problem. Banning tobacco, while appealing to most, is not practical.
In this context, the best that the government and we as a community can do is to reduce
the harm caused by smoking. This includes the harm to smokers, the harm to smokers’
children, families, friends and colleagues and the harm to society as a whole.
Strategies designed to tackle tobacco need to be comprehensive and can only be
delivered by multiple partners. In Surrey, a number of agencies work on tobacco control
through statutory and contractual requirements. This strategy has been developed to
pull all those strands together into one document to ensure effective, coordinated action
across the county to tackle its biggest cause of premature death and health inequalities.
It is helpful to view tobacco control as those strategies that:
• Reduce demand for tobacco with:
Price measures, including high rates of tax
Non price measures such as advertising restrictions, smokefree
legislation, health warnings on products, information and advocacy,
and stop smoking support.
• Reduce supply of tobacco by:
Controlling illicit trade (smuggled and counterfeit tobacco)
Restricting access to minors.
The strategy has four strategic priorities:
Strategic Priority 1 - Reducing uptake of smoking in children and young people
We will aim to reduce uptake of smoking in young people by:
• Ensuring our schools and youth projects work with young people to develop innovative
ways to make smoking less attractive
• Training a range of staff, working with young people, to support those most at risk of
starting smoking and to help young smokers to quit
• Reducing access to cigarettes by enforcing the legislation to prevent the illegal sale of
tobacco to under 18s.
Strategic Priority 2 - Tackling health inequalities and helping smokers to stop
We will increase the numbers of smokers accessing the Stop Smoking Service and the
numbers successfully quitting by:
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• Continuing to improve access to effective treatments to support quitters
• Training staff to offer brief interventions in a variety of community settings, such as
Children’s Centres
• Tackle inequalities in the county by targeting
• People living with mental illness
• Pregnant smokers, including teenage mothers
• Routine and manual workers (R&M smokers)
• Prisoners
• Surrey’s Priority Places using Health Trainers.
Strategic Priority 3 - Reducing exposure to secondhand smoke
We will reduce exposure to secondhand smoke in private and work places by:
• Continuing to strengthen the countywide Smokefree Homes and vehicles project
• Continuing to enforce the Smokefree legislation around the county, ensuring
compliance in “at risk” establishments and areas.
Strategic Priority 4 - Combating illicit tobacco
We will raise awareness of counterfeit and smuggled tobacco and take action by:
• Participating in regional discussions and contribute to the South East action plan to
tackle illicit tobacco
• Convening a working group of key agencies to draw up an action plan to target
counterfeit and smuggled tobacco in the county
• Devise a communications campaign to inform the public of Surrey about the issue.
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The Vision for 2015
Surrey will have the lowest smoking prevalence in the UK.
We will achieve this by ensuring:
•
•
•
•
•
•
•
Fewer young people in Surrey will start smoking
All smokers will know where to get appropriate support and more will access the
local service for help quitting
The support offered to smokers in Surrey will be accessible to all who want to
quit, including black and ethnic minority communities, young and old, the
housebound and those with learning disabilities, physical disabilities or mental
health problems
A range of partner organisations will have a full understanding of the extent of the
impact of smoking on health and health inequalities in Surrey, and be committed
to making a contribution to reducing its impact
Compliance with the smokefree legislation will be high and well supported
Residents across Surrey will understand the importance of keeping their own
homes and cars smoke free, and that this will be seen as a social norm
More people will be aware of illicit tobacco and its detrimental effects; agencies
will be taking active steps to reduce the accessibility of illicit tobacco.
Aims, objectives and targets
The overall aim of this strategy is to improve health and reduce health inequalities in
Surrey by reducing the prevalence of smokers in the county from 18.4% to 14% by
2015. We will achieve this by bringing together a range of stakeholders to strengthen
collaboration and improve action on tobacco control.
The objectives are:
• to reduce the numbers of young people starting to smoke
• to reduce the number of adults smoking, particularly among routine and manual
groups
• to reduce exposure to second hand smoke in workplaces, homes, vehicles, and
public places
• to promote local tobacco control advocacy
• to develop a framework for action to tackle illicit tobacco in the county.
The development of this strategy is timely as on 1st February 2010 the Government
launched its new national comprehensive tobacco control strategy for England, A
Smokefree Future.2
Governance of the strategy
NHS Surrey is charged with improving health and reducing health inequalities in Surrey.
Surrey County Council is committed to helping the people and communities of Surrey
improve their quality of life. These two objectives are inextricably linked under the
leadership of the Director of Public Health, a joint appointment between NHS Surrey and
Surrey County Council. This strategy will feed into the Health & Wellbeing Partnership
Board, the thematic board of Surrey Strategic Partnership. It is responsible for
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overseeing the delivery of health and social care targets. Partnerships and
organisations, who deliver Local Area Agreement (LAA) indicators, e.g. NI 123 smoking prevalence, report their progress to the board.
Smokefree Surrey Alliance
The Smokefree Surrey Alliance was set up in 2004 in response to the Government’s
white papers on tobacco, Smoking Kills, and public health, Choosing Health. It is a multi
agency partnership, the membership of which includes the borough and district councils,
the county council, the NHS and voluntary sector. It is hosted by NHS Surrey. The
alliance facilitates the work carried out between public, private and voluntary
organisations in the county to tackle tobacco use. It has led successfully a number of
countywide campaigns, in particular around second hand smoke.
Smokefree Surrey is a multi-agency strategic group which manages several action
groups, which will coordinate the action plans in the strategy. The action groups bring
together key staff from the range of agencies working in relevant fields to address
prevention and stop smoking work with young people (Children and Young Peoples’
subgroup), reduce exposure to secondhand smoke (Secondhand Smoke subgroup),
tackle smuggled and counterfeit tobacco (Illicit Tobacco subgroup*) and communication
of the above by representation on the Surrey Communications group.
* To be created
Health & Wellbeing
Board
Surrey Strategic
Partnership
Smokefree Surrey
Alliance
Smokefree Steering
Group
Illicit Tobacco
Subgroup
To be convened
Children & Young
People Subgroup
Links with Surrey
Communications Group
Surrey Environmental
Health Managers’
Group
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National targets and aspirations
The new national strategy, A Smokefree Future 2 launched in February 2010, sets out a
vision for a society in which health and social harms from tobacco use are eventually
rendered negligible and people lead healthier and longer lives. Three overarching
objectives are established to deliver the vision:
• To stop the inflow of young people recruited as smokers
• To motivate and assist every smoker to quit
• To protect our families and communities from tobacco related harm.
The strategy also sets aspirations of what could be achieved by 2020 if all partners
across the public, private and voluntary sectors prioritise tobacco control and implement
the policies in the strategy.
They include:
• Stopping the inflow of young people recruited as smokers: aspiring to reduce the
11–15-year-old smoking rate to 1% or less, and the rate among 16 and 17-yearolds to 8% by 2020.
• Motivating and assisting every smoker to quit: aspiring to reduce adult smoking
rates to 10% or less, and halve smoking rates for routine and manual workers,
among pregnant women and within the most disadvantaged areas by 2020.
• Protecting our families and communities from tobacco-related harm: aspiring to
increase to two-thirds the proportion of homes where parents smoke but that are
entirely smokefree indoors by 2020.
The Government is looking to develop a local smoking prevalence indicator to monitor
performance against the aspirations in the strategy. It is likely to be used from 2011.
Current national PSA targets
•
•
•
•
To reduce prevalence among the general population to 21% or less by 2010
To reduce smoking prevalence in the routine and manual (R&M) group to 26% or
less by 2010
To reduce smoking among 11-15 year olds from 13% in 1996 to 9% in 2010
To reduce smoking among pregnant smokers to 15% by 2010 and a 1%
reduction year on year.
In addition the Government has pledged to reduce health inequalities by tackling the
wider determinants of health, such as poverty, poor housing and educational outcomes.
This is supported by a PSA target:
To reduce inequalities in health outcomes by 10% as measured by infant mortality and
life expectancy at birth.
Local targets
Surrey Local Area Agreement 2009-2011
In order to promote healthy lifestyles, smoking is included in the National Indicator target
123 (NI123), which looks at the current smoking prevalence rate for those over 16
8
years. In Surrey, the target is 408 smoking quitters per 100,000 of the population aged
16 and over. The lead partners involved in achieving this target are NHS Surrey, Surrey
local and county authorities.
JAR Action Plan 2008
The Joint Area Review (JAR) is an inspection of all children’s services within a local
area. It is carried out by a team of inspectors from various central government agencies
including the Office for Standards in Education (OfSTED) and the Healthcare
Commission (HCC), now the Care Quality Commission. The aim of the JAR inspection
was to see how well partners are improving outcomes in the area and whether they are
providing joined-up services for children, young people, their parents and carers. In
2008 when Surrey was inspected, teenage mothers who smoke were identified as an
area which needed more focus to identify and effectively treat.
Current policy drivers
There are four key policy frameworks, which influence this strategy:
A Smokefree Future (2010 – 2020 Government strategy)
The ambitious new strategy aims to halve the number of smokers, from 21% to 10% by
2020 with three overarching strategic goals:
1 Stopping the inflow of young people recruited as smokers:
•
Reduce tobacco affordability by continuing to crack down on illicit tobacco and
consider increases in tobacco duty.
•
Restrict tobacco availability by continuing to tackle the supply of tobacco to
children.
2 Motivating and assisting every smoker to quit:
•
Introduce a radical approach to quitting smoking, producing more ways of quitting
that will help thousands more smokers - particularly those in disadvantaged
communities and the routine and manual group - to quit successfully. Although
always encouraging smokers to break their nicotine dependence entirely,
smokers will be supported to:
o cut down their levels of smoking before completely quitting;
o manage their nicotine addiction, using a safer alternative product, when
they are unable to smoke;
o dramatically reduce their health harms, and the harms to those around
them, by using a safer alternative to smoking.
•
Motivate more smokers to quit by developing a new tobacco control marketing
strategy and investigating new and innovative ways to quit.
3 Protecting families and communities from tobacco related harm:
•
Promote smokefree environments by reviewing the smokefree law later in 2010
and through working with the public sector, business and the public to
communicate the dangers of smoking in the home and in the car.
•
Identify and target high smoking rates in vulnerable, disadvantaged and minority
communities by supporting PCTs to develop public health interventions that
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consider lifestyle factors as a whole and help tackle the social, economic and
cultural factors that influence smoking rates through local partnerships.
•
Reduce smoking in pregnancy by improving methods of identifying and reporting
on smoking in pregnancy and developing care pathways to treat and support
cessation activities in pregnancy.
A delivery plan will be produced during 2010 for all of the key elements within the
strategy and how existing partnerships, frameworks, strategies and local delivery
mechanisms will contribute.
Smoking Kills (1998 Government White Paper)
In 1998, the Government produced the first comprehensive strategy to reduce smoking
in England, formally recognising smoking as an addiction. For the first time in the history
of the NHS substantial resources were invested in smoking cessation treatment
services. Treatment became recognised as an important and complementary approach
to tobacco control, taking its place alongside other actions, such as increases in the
price of tobacco and advertising bans.
The WHO Framework Convention on Tobacco Control 2003
This has been developed in response to the globalisation of the tobacco epidemic and in
recognition of the impact of global marketing, trade liberalisation, transnational
advertising and sponsorship, plus the effect of international smuggling. The aim is to
protect present and future generations from the consequences of tobacco consumption.
The framework for tobacco control measures covering the reduction of supply and the
demand for tobacco is to be implemented at national level. The United Kingdom
Government is a signatory to this framework.
Choosing Health (2004 Government White Paper on Public Health)
Following a national consultation the Government reiterated the importance of action
being undertaken under its Smoking Kills strategy. More proposals were outlined on
supporting smokers to stop, restricting tobacco advertising in shops, and tough action
on retailers who repeatedly flout the law on sales to minors. The largest single issue
raised in the whole of the national consultation was a national ban on smoking in public
places and workplaces. In preparing the White Paper, the Government took account of
the latest evidence on the risks to health from exposure to second-hand smoke.
Consequently, the Government introduced comprehensive smokefree legislation in
2007, to protect people from these risks.
Best practice guidance:
10 High Impact Changes to Achieve Tobacco Control
This document was published by the Department of Health in 2008 and provides an
evidence based guide to show how smoking prevalence can be effectively reduced in
communities. It recommends a systematic, comprehensive approach to tackling
tobacco and it stresses the fact that tackling smoking is everyone’s business, not just
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the job of those in the NHS. It states that there are three key principles that underpin
efforts to tackle tobacco use – a genuinely strategic approach to tobacco control,
effective partnership working and a focus on denormalising smoking.
National perspective
The most recent estimates show that around 82,800 people in England are killed by
smoking every year, accounting for one fifth of all UK deaths.3 This is more than three
times the number of deaths from obesity, the second major cause of ill-health and
premature death.4 Most die from one of three main diseases associated with cigarette
smoking: lung cancer, chronic obstructive pulmonary disease (COPD, bronchitis and
emphysema) and coronary heart disease.
Deaths caused by smoking are five times higher than the 22,833 deaths arising from:
traffic accidents (3,439); poisoning and overdose (881); alcoholic liver disease (5,121);
other accidental deaths (8,579); murder and manslaughter (513); suicide (4,066); and
HIV infection (234) in the UK during 2002.5
Health inequalities
Smoking has been identified as the single greatest cause of inequality in death rates
between the advantaged and the disadvantaged in the UK. Smoking accounts for over
half of the difference in risk of premature death between social classes. Death rates
from tobacco are two to three times higher among disadvantaged social groups than
among the more affluent.
Long-term smokers bear the heaviest burden of death and disease related to their
smoking. Long term smokers are disproportionately drawn from lower socio-economic
groups. People in poorer social groups who smoke, started smoking at an earlier age.
Of those in managerial and professional households, 31% started smoking before they
were 16, compared with 45% of those in routine and manual households.
One of the key reasons for lower quitting rates within poorer socio-economic groups
may be differences in nicotine addiction. National research shows that poorer groups
generally smoke more cigarettes, and smoke more intensely than other socio-economic
groups. Nationally there are a greater proportion of heavy smokers (20 cigarettes or
more a day) in manual groups, whereas light smokers (0–9 cigarettes) are more
prevalent in non-manual groups. As well as the number of cigarettes smoked, variation
in the type of cigarettes smoked may also help to explain why less affluent groups have
lower quitting rates.
In 2008 the King’s Fund published the final report of its Kicking Bad Habits programme6.
This report aimed to help those within health, local government and the voluntary sector
who are tasked with finding solutions to the problems caused by unhealthy lifestyles and
behaviour. It argued that if action is not taken, the financial cost to the NHS will grow
and, according to Sir Derek Wanless (2004)7, could make the NHS itself unsustainable.
This is why investing in effective behaviour change interventions is more important than
ever. The report focused on behaviour change among the general population, and it
emphasised the need for those diagnosed with a chronic illness to be supported to
change their behaviours where these have a direct impact on their condition. Behaviour
change should be promoted as an important component of self-management. For
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example, COPD sufferers need to give up smoking and targeted interventions should be
in place to support them in doing so.
The Surrey picture
Surrey is one of the largest counties in England, with a population of 1.2 million. It is
made up of diverse rural and urban communities with minority ethnic communities
making up 10.7% of the population according to the 2001 census. Surrey is
predominantly an affluent county where people experience better health, less crime and
disorder and a higher standard of living than others across the country. However, there
are marked pockets of significant inequalities.
Table 1: Expected smoking prevalence (and 95% CI) of adults (16 years and over).
England and Surrey local authorities (2003 – 2005)
30
Percentage
25
20
15
10
5
England
Surrey
Epsom and
Ewell
Elmbridge
Mole Valley
Waverley
Guildford
Tandridge
Surrey
Heath
Woking
Runnymede
Reigate and
Banstead
Spelthorne
0
Synthetic Estimate of healthy lifestyle behaviours, 2003-2005 (ONS)
Smoking prevalence for the county is 18.4%8 however research at parliamentary ward
level has suggested that some areas have prevalence levels as high as 40 %9. There
are over 1400 smoking related deaths each year in Surrey.1 In Surrey, circulatory
disease and cancers, of which smoking is the primary contributor, are the main causes
of death in line with national trends.
•
•
•
Spelthorne, Reigate and Banstead, and Runnymede have the highest
estimated number of smokers
Runnymede and Spelthorne have the highest rates of deaths attributable to
smoking
Figure 1 shows the spread of heavy smokers across Surrey. This correlates
with the areas of highest deprivation.
12
Table 2: Rates of deaths attributable to smoking - per 100,000 population age 35+, directly
age standardised rate, 2005-2007
250
200
150
100
50
En
gl
an
d
Ru
nn
ym
ed
e
Sp
el
Ep
th
so
or
ne
m
an
d
Ew
el
Re
l
ig
W
at
ok
e
an
in
g
d
Ba
ns
te
Su
ad
rr e
y
He
at
h
Ta
nd
rid
ge
M
ol
e
Va
l le
y
G
ui
ld
fo
rd
W
av
er
le
y
El
m
br
id
ge
Su
rr e
y
CC
0
Source: APHO. Community Health Profiles 2009
The costs of smoking
Smoking related ill health costs the NHS an estimated £1.5 billion per year. This figure
does not account for the cost of sickness and invalidity benefits, nor does it include the
cost to industry of lost productivity.10 Recent research has shown that smokers are
costing employers up to £2.1 billion every year. The report, by the London School of
Economics (LSE) on behalf of NHS Smokefree, estimated that the staggering costs are
dominated by illness absences for smokers (calculated at 1.77 excess sickness days
per smoker per year, or £1.1 billion) and by smokers taking cigarette breaks (£1 billion a
year).11 For Surrey, this would mean: 1/60th of this or slightly less.
Chart 1: Hospital admissions estimated to be caused by smoking by disease, for Surrey,
2008/2009 financial year, Hospital Episodes data (HES)
Hospital admissions from smoking related diseases
14%
24%
2%
Cancer
Respiratory
Circulatory
Digestive
33%
Other - Hip Fracture
27%
13
Figure 1. Percentages of heavy smokers (greater than 20 cigarettes per day) in Surrey
Source: ONS mid-year population estimates, October 2007 and Experian Mosaic Public Sector Grand Index Nov 2007
14
Figure 2 Percentages of light smokers (fewer than 10 cigarettes per day) in Surrey Source: ONS mid-year population estimates, October 2007 and Experian Mosaic Public Sector Grand
Index Nov
2007
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CHILDREN & YOUNG PEOPLE
Strategic Priority 1. Reducing uptake of smoking in children and young people
We will aim to reduce uptake of smoking in young people by:
• Ensuring our schools and youth projects work with young people to develop innovative
ways to make smoking less attractive
• Training a range of staff, working with young people, to support those most at risk of
starting smoking and helping young smokers to quit
• Reducing access to cigarettes by enforcing the legislation to prevent the illegal sale of
tobacco to under 18s.
Whilst smoking is harmful at any age, smoking during childhood has serious short and
long term health impacts. The latest research shows that two thirds of smokers who
start when a child, die prematurely if they do not quit.12 Children and young people who
smoke experience more respiratory symptoms than those who do not smoke and are
two to six times more susceptible to coughs, increased phlegm and wheezing.13
Smoking has been established as a cause of impaired lung growth in children and
young people and is also the cause of asthma-related symptoms in childhood and
adolescence.14
The earlier children become regular smokers and then persist in the habit as adults, the
greater the risk of developing lung cancer and heart disease. 15 Someone who starts
smoking at age 15 is three times more likely to die of cancer due to smoking than
someone who starts in their mid-20s. Female smokers who start to smoke as children
are much more likely to develop bronchitis or emphysema than those who begin to
smoke as adults.
The new national strategy aspires to reduce the numbers of 11-15 year olds smoking to
one percent or less by 2020.2
Addiction
According to the Royal College of Physicians, nicotine is as addictive as heroin and
cocaine, and cigarettes should be regarded as nicotine-delivery systems comparable to
a needle and syringe.16 It is therefore no surprise that children who smoke can become
addicted to nicotine very quickly. Research has suggested that experimental smoking in
childhood, even if this amounts to a single cigarette, is highly predictive of regular
smoking in adolescence. One study of London school children suggested that smoking
a single cigarette is a risk indicator for children to become regular smokers up to three
years later.17
Children may show signs of addiction within four weeks of starting to smoke and before
they commence daily smoking.18 Around two-thirds of people who have smoked took up
the habit before the age of 18 (The Information Centre 2006). Smokers who begin to
smoke at a young age are less likely to give up than those who start smoking in later
life. They are also likely to smoke more heavily than those who begin to smoke later.19
In the 2004 survey of school-children in England, 66% of smokers aged 11-15 reported
that they would find it difficult to go without smoking for a week while 79% thought they
would find it difficult to give up altogether.20 During periods of abstinence, young people
experience withdrawal symptoms similar to the kind experienced by adult smokers.21
16
What factors influence children starting to smoke?
Children are more likely to smoke if one or both of their parents smoke and parents’
approval or disapproval of the habit is also a critical factor22. A Dutch study revealed
that adolescents with both parents smoking were four times more likely to smoke than
peers whose parents had never smoked.23 The same study also showed that parental
cessation when the children were young reduced the likelihood of adolescent smoking.
There have been many studies which have shown the influence of peer and older sibling
smoking habits.11 There is a growing body of evidence that suggests that young people
may be influenced by watching smoking in films.24
Risk factors associated with youth smoking:
• parental smoking
• peer influence from older siblings and friends
• low socioeconomic status
• female sex
• low parental education
• living in a single parent household
• poor academic performance
• participation in risk taking activities
• exposure to tobacco marketing activities
• television and films
• mental illness
The annual Government survey of smoking among secondary school pupils defines
regular smoking as smoking at least one cigarette a week. However in 2008 pupils
classified as regular smokers smoked a mean (average) of 39.3 cigarettes a week,
approximately six a day. Occasional smokers smoked a mean of 3.9 cigarettes a week.
These averages have remained at similar levels since 2004.25
Children become aware of cigarettes at an early age. Three out of four children are
aware of cigarettes before they reach the age of five, whether their parents smoke or
not.26 In 2008, 68% of pupils said they had never tried smoking. This is higher than at
any time since the pupils’ smoking survey was begun in 1982. The proportion of pupils
who had tried smoking at least once (32%) represents a long term decline since 1982,
when 53% had tried smoking.
Education and prevention
The traditional approach to tackling young smokers has been education about the health
effects of smoking, yet adolescents continue to smoke, suggesting that traditional
approaches may educate, but they do not influence. Research suggests that
interventions do not prevent the uptake, but delay the onset of smoking. Nevertheless,
this delay can be considered to be beneficial, as the evidence also suggests that
individuals starting to smoke later in life are more likely to stop smoking subsequently.
Currently, NICE, (National Institute for Clinical Excellence) is reviewing school based
interventions to prevent smoking. The final report is due in February 2010.27
Nationally, education regarding smoking forms part of the drug and alcohol component
of the Personal, Social and Health Education (PSHE) curriculum in both primary and
17
high schools. The curriculum focuses on educating children on the health effects of
smoking. At Key Stage 2 (age 7–11) pupils are taught that tobacco, as a drug, has
harmful effects. At Key Stage 3 (11-14) pupils are taught that tobacco will affect health
including lung structure. At Key Stage 4 (14-16) pupils are taught the effects of smoking
on the body’s functions. Education regarding skills development, e.g. in resisting the
pressure to smoke, can also form part of the Personal, Social and Health Education
(PSHE) programme. PHSE Education is becoming a statutory requirement for schools
to deliver.
Alongside the national curriculum requirements, additional health promotion work
around smoking may take place in schools in Surrey. This is patchy and
uncoordinated. In the Tell Us 2 survey, nearly a quarter of the children (in years 8 & 10)
sampled said that they needed better/more information and advice on smoking.
The majority of schools in Surrey are working towards Healthy Schools Status. To
receive a Healthy School award, schools are required to promote a smoke-free
environment and provide smoking education. Schools must be smokefree in compliance
with the national legislation. From September 2009, to be re-accredited as a healthy
school, as well as schools fulfilling the current healthy schools criteria, schools will be
expected to undertake a healthy schools initiative based on local and school health
data/needs (eg smoking prevalence rates).
In Surrey, a model of enhanced status has been launched. Through the enhanced
model, schools will be encouraged to undertake projects on smoking. In 2009 Surrey
Healthy Schools completed an evaluation of PSHE in 20 secondary schools. This led to
the development of a PSHE education toolkit for Secondary schools which gives
guidance on programmes of work, information on supporting agencies and guidance on
assessment. The toolkit was officially launched at the SRE conference in November
2009 and has been further disseminated to secondary schools at network & training
events and individual consultation. The Healthy Schools team will use the guidance to
support schools in achieving effective and consistent PSHE education delivery in
schools. Tobacco will be included within this.
Health improvement, including education about smoking and helping young people to
quit, is part of the remit of school nurses. The new contracts for the 0-19 public health
nursing services will ensure that school nursing teams deliver focused smoking
education and advice in schools where the need is greatest.
Smoking can disrupt education. It was the stated cause of 155 fixed term exclusions
from Surrey schools in 2005/6 and 71 in 2006/07. 28 Surrey County Council is working
on reducing permanent exclusions and is just starting to look at fixed term exclusions. It
will begin by analysing the data of the reasons for fixed term exclusions and may look at
commissioning work in the area of prevention, depending on available funding.
Youth advocacy
Tackling youth smoking as a stand alone intervention will probably have little impact.
There is some emerging evidence, largely from America, regarding the impact of
educating young people regarding the techniques used by the tobacco industry to
manipulate the evidence regarding health and promote smoking as ‘cool’ within the
media. This is known as youth advocacy and organisations in the North West of
England are championing this approach in the UK.
18
Youth prevention has to be part of a comprehensive tobacco control programme based
on denormalising smoking as a habit. Thus, efforts to enforce smokefree regulations
have a bearing, as do action on the illicit trade and enforcing the age of sale of tobacco.
Access to cigarettes
Children and young people usually get cigarettes from friends, family and shops,
especially small corner shops. However, they also buy from adults who sell them from
home and from people involved in organised criminal activities.
In October 2007, the legal age for the purchase of tobacco in England and Wales was
raised from 16 to 18 years of age. The amendment was designed to make it more
difficult for teenagers to obtain cigarettes. This was because despite there being
legislation in place, children were still finding it easy to buy tobacco from shops and
vending machines. New restrictions came into force in April 2009 to penalise retailers
who are caught persistently selling to children and young people. The Criminal Justice
and Immigration Act includes prohibition orders for retailers who persistently sell
cigarettes to young people under the age of 18.
In 2006, 65% of 11-15 year olds smokers reported that they bought their cigarettes from
a shop, with older teenagers being much more likely to obtain their cigarettes from
shops than younger children: 78% of 15 year olds compared with 28% of those aged 1112. The same survey found that 17% of 11-15 year olds reported that vending
machines were their usual source of cigarettes.29 In Surrey, in 2008/09, the data from
trading standards shows that of 16 test purchases from vending machines, there were 9
sales of cigarettes. Trading Standards has a target for 2009/2010 to undertake 80 test
purchases (TP) from retailers and 20 test purchases from vending machines. The
targets are reviewed annually.
Surrey Trading Standards also participates in Department of Health funded work across
the Trading Standards South East region and all retailers have been sent a high quality
advice leaflet covering all age restricted goods. Tobacco has previously been neglected
in favour of alcohol but Surrey is aiming to continue with test purchase levels of around
100 per year (subject to any cutbacks in service). Test purchases are intelligence led
and trading standards would like to see more information coming from the general public
and schools.
It is important to note that there is no statutory obligation on local authorities to carry out
an enforcement campaign. However, the Local Government Association, Local
Authorities’ Coordinators of Regulatory Services (LACORS) and the government all
agree that local authorities should assess the need for such a campaign.
The Health Act 2009 includes clauses which will ban tobacco sales from vending
machines and remove point of sale advertising of tobacco from retail establishments.
The regulations to remove point of sale advertising will be phased in and be
implemented by 2011 in large retailers and 2013 in smaller shops.
19
Agencies involved in
Surrey
Lead Agency in bold
Surrey County
Council/Healthy Schools
via schools’ PHSE
coordinators
NHS Surrey
Surrey County
Council/4S – healthy
schools
Surrey County
Council/4s – healthy
schools
Surrey County
Council/4s – healthy
schools
Surrey County
Council/4s
Timescale
SCC/4S – healthy
schools /NHS Surrey
(SSS)
TBC
Ensuring that children and young people have easy access to cessation support
NHS Surrey via Surrey
Stop Smoking Service
Surrey County
Council/schools &
colleges
TBC
Targeting tobacco test purchases in areas of high smoking prevalence in Surrey (around
SCC Trading Standards
TBC
Tobacco Control Strategic Priority 1
ACTION PLAN
Ensuring education in schools and colleges on tobacco is robust and relevant
Promote PSHE CPD course for teachers and community nurses, especially tobacco,
drug & alcohol component.
Run the PSHE CPD course, ensuring tobacco is included, for participants who are
responsible for delivering a planned programme of PSHE in schools (e.g. community
liaison officers, HLTAs, youth workers etc.)
Arrange regular Healthy Schools twilight training session on Drug Education, including
tobacco
Use the findings from local evaluations and the National SRE review, to review
curriculum guidance for schools and help schools develop comprehensive programmes
of PSHE including tobacco in line with the new secondary national curriculum guidance
for PSHE Education and SEAL (Social and Emotional Aspects of Learning)
Target multi-level interventions with schools where pupil exclusions due to smoking are
high
Ongoing
Ongoing
TBC
TBC
TBC
20
100 test purchases per year)
In preparation for the introduction of the new legislation around the removal of point of
sale advertising and of vending machines, Trading Standards will work with local
businesses.
Countywide public awareness campaign around illegal sales to under 18s
SCC Trading Standards
2010-2013
SCC Trading
TBC
Standards/Schools/NHS
Surrey/local
magistrates/Alliance
Education campaign with retailers around illegal sales – promote good practice with local SCC Trading
award
Standards/Alliance
Investigate repeat offenders who sell tobacco to under 18s with a view to formal action.
SCC Trading Standards
In association with the existing informal ‘Eyes & Ears’ approach to enforcement between Environmental Health
Surrey Trading Standards and Surrey Environmental Health services for other
Inspecting
legislation, such as Animal By – Products, Inspecting Officers will share intelligence from officers/Surrey Trading
observations of underage sale of tobacco in the course of visits made to retail premises
Standards
for other enforcement purposes.
Ensure tobacco prevention is included in new contracts for 0-19 Public Health Nursing
Services
NHS Surrey
TBC
TBC
Ongoing
TBC
21
Strategic priority 2 Tackling health inequalities and helping smokers to stop
We will increase the numbers accessing the Stop Smoking Service and the numbers
successfully quitting by:
• Continuing to improve access to effective treatments to support quitters
• Training staff to offer brief interventions in a variety of community settings
• Tackle inequalities in the county by targeting
• People living with mental illness
• Pregnant smokers, including teenage mothers
• Routine and manual workers
• Prisoners
• Surrey’s Priority Places using Health Trainers.
Stopping smoking significantly reduces the risk of serious illness and premature death.
For example, people who stop smoking at 50 or 60 years of age avoid most of their
subsequent risk of developing lung cancer, and that those who stop at 30 years of age
avoid more than 90% of the risk attributable to tobacco of those who never quit (Peto et
al., 2000).
All major international guidance on tobacco control strategies considers helping
smokers to stop as a key part of the multi-strand approach to tackling tobacco use.
However, all too often the Stop Smoking Service is seen as the sole agency to deliver
tobacco control at a local level. It is a mistake to believe that the stop smoking service
equates to tobacco control or that it can in isolation deliver prevalence reduction on a
scale that is required. Instead the service must be viewed as one vital element of an
overall strategic and comprehensive tobacco control programme.
The primary role of the NHS Stop Smoking Service is to provide a high quality clinical
smoking cessation service to its local population. Evidence based NHS stop smoking
support is highly effective both in cost and clinical terms. In line with National Institute
for Health and Clinical Excellence (NICE) best practice recommendations, service
providers should aim to treat a minimum of 5% of their local population of smokers in the
course of a year.30
To work most effectively it is necessary to focus on specific segments of the population
– in particular, increasing access for smokers from routine and manual (R/M) groups.
Quit rates are lower for these groups than for those in higher socio-economic groups.
Services also need to increase access for black and minority ethnic (BME) groups with
high smoking rates (e.g. Bangladeshi men). Prisoners and those with mental illness also
have very high levels of smoking and it is important that appropriate services are made
available to these groups as well as pregnant smokers.
Primary and secondary care as well as mental health and prison care play key roles in
referring people to NHS Stop Smoking Services, and referral opportunities need to be
maximised. The roles of Surrey’s local authorities have an important responsibility in
encouraging their service users and residents to seek support in quitting smoking,
Surrey NHS Stop Smoking Service
Local Stop Smoking Services are well established across the NHS and remain a key
element of the Government’s overall tobacco control strategy. In Surrey, the stop
22
smoking service is part of NHS Surrey and provides an accessible and effective stop
smoking service. The treatment choices offered are a combination of weekly
behavioural support sessions supplemented by the provision of pharmacotherapy (e.g. –
nicotine replacement therapy). The support is delivered either individually, in a groupbased format (enabling quitters to get support from others trying to kick the habit) or by
telephone support. Stop Smoking Support can be accessed in local healthcare settings
such as General Practices or Community Pharmacies and local community venues,
including pubs.
There are currently three main categories of pharmacotherapy approved for use by the
Surrey NHS Stop Smoking Service, all of which are considered ‘first-line’ treatments.
The most widely used is Nicotine Replacement Therapy (NRT), which aims to replace
some of the nicotine previously gained from cigarettes and thereby reduce cravings and
other withdrawal symptoms. The other pharmacotherapies utilised are varenicline
(Champix) and bupropion (Zyban), both of which are taken in tablet form. All of these
pharmacotherapy products are available on prescription to clients using the Surrey Stop
Smoking Service following the appropriate medical checks. In order to be given the
optimum chance of success in any given quit attempt, nicotine replacement therapy
(NRT), Champix (varenicline) and Zyban (bupropion) should all be made widely
available in combination with intensive behavioural support as first-line treatments
(where clinically appropriate).
The new NHS Centre for Smoking Cessation and Training will be producing best
practice models, illustrating the optimum mix of treatment delivery methods and settings.
Surrey Stop Smoking Service will adhere to this, and other (i.e. NICE), best practice
guidance.
Targeting services
The key to ensuring that services are aligned with the needs of the local population is
data profiling. The Surrey Stop Smoking Service has carried out extensive research
using Mosaic modelling to analyse the county by both heavy and light smokers. These
data are available at ward, district and county level to optimise the targeting. Mosaic is
based on analysis of high quality, comprehensive data sources, which divide areas by
their socioeconomic make-up and lifestyles. The information is used to target social
marketing initiatives as well as service promotion and local service provision.
Targeting priority groups
The Public Service Agreement SR07 states ‘Tackle the underlying determinants of ill
health and health inequalities by: reducing adult smoking rates to 21% or less by 2010,
with a reduction in prevalence among routine and manual groups to 26% or less.’
Routine and manual (R/M) smokers make up 44% of the overall smoking population, so
targeting this group will need to be a priority for the NHS Stop Smoking Service. In
addition to ensuring that overall throughput and success rates are maximised, the
Service should be aiming for a minimum throughput of around 50% of local R/M
smokers and that quits are sustained by using the most effective and well-evidenced
approaches.
23
Other groups that require proportionate targeting include black and minority ethnic
(BME) communities and pregnant women, as well as people with mental health
problems and prisoners.
Targeting priority places in Surrey
The areas with the highest prevalence of smoking (table 1), and the largest percentage
of heavy smokers (Figure 1) are mostly found in the areas of highest deprivation in
Surrey. These are also the areas identified as priority places by Surrey Strategic
Partnership. The priority places include: Westborough, Merstham, Maybury and
Sheerwater and Stanwell North and Ashford North. By targeting these areas NHS
Surrey is ensuring those most at risk from inequalities in health and life expectancy are
supported to make behaviour changes. Mapping of black and ethnic minority
communities living in the priority places is planned to identify the health needs and
trends in these communities. The Stop Smoking Service is working alongside the local
community to maximise service throughput and ensure appropriate interventions are
available in these communities.
Balancing reach and efficacy
Ideally, NHS Stop Smoking Services should combine interventions that are appropriate
to the needs, preferences and diversity of their local smoking population, while being
mindful of the need to reach the more deprived in our communities.
In recent years, the majority of NHS Stop Smoking Services have modified their
treatment protocols, dramatically increasing the proportion of treatment delivered in
healthcare settings such as primary care and in pharmacies. There has also been a
sharp rise in the proportion of one-to-one interventions and a corresponding decline in
the provision of closed group treatment (the model recommended in national guidance
when the services were first set up 10 years ago).
However, the results show that closed group provision is significantly more effective,
with an average success rate of 63% compared with 48% for one-to-one treatment.31
Therefore, there needs to be a balance between the need for widely accessible services
against the need for high efficacy rates. Some interventions, such as online or telephone
support, reach high volumes of smokers, but may be less intensive and therefore less
effective. Interventions such as closed groups are highly effective and should form part
of the overall service delivery, but will need sustained, effective local promotion to
ensure throughput. NHS Surrey Stop Smoking Service is committed to maintaining
quality service provision.
24
Efficacy and choice
Table (3): Effectiveness of pharmacotherapy and support options
Source: Cochrane Database of Systematic Reviews32
The NICE programme guidance on smoking cessation recommends the following stop
smoking interventions as being cost-effective:
• Brief interventions
• Individual behaviour counselling
• Group behaviour therapy
• Pharmacotherapies – NRT, bupropion and varenicline
• Self help materials
• Telephone counselling and helplines.
25
Table (4): Intervention success rates
Working with other service providers to increase stop smoking referrals:
Primary care services
Primary care is a key setting for stop smoking interventions and an important source of
referrals to the NHS Stop Smoking Service. Service leads need to ensure that all local
GPs and other healthcare professionals (HCPs) (e.g. practice nurses, district nurses,
midwives and health visitors) are aware of the AAA model (Ask, Advise and Act) for the
provision of brief advice and referral of smokers to local NHS Stop Smoking Services.
COPD clinics/secondary care services
Chronic obstructive pulmonary disease (COPD) is a term used to describe a number of
conditions including chronic bronchitis, chronic airways obstruction and emphysema.
COPD leads to inflammation and damaged airways in the lungs, causing them to
become narrower and making it harder for air to get in and out of the lungs.
The most common cause of COPD is smoking. If people do smoke then stopping is the
single most effective, and cost-effective, way of reducing the risk of getting COPD.
Stopping smoking can prevent or delay the development of airflow limitation, or reduce
its progression, and can have a substantial effect on subsequent mortality.33
Good signposting and support between the stop smoking service and primary and
secondary care should be developed and maintained. The new national strategy
recommends the development of integrated care pathways for those with long term
conditions and lifestyle diseases, with robust systems for the identification and referral of
at-risk patients who smoke.
26
Hospitals and pre-operative patients
Stopping smoking before an operation decreases the risk of delayed wound healing,
wound infection, and post-operative pulmonary and cardiac complications. It can mean
a shorter stay in hospital. This is therefore a good opportunity for a successful
intervention.
A recent Cochrane review reported that delivering stop smoking services to in-patients
has a positive impact. A “Stop Before Your Op” Programme is being developed in
Surrey which will focus on helping those smokers scheduled for elective surgical
procedures to quit before their operation. The program is being implemented to link to
the CQUIN Contract in the Surrey Acute Hospital Trusts.
Pharmacies
Pharmacies have a good track record of providing stop smoking services to the general
public. They are ideally placed to provide this service, in the heart of communities and
are easily reached by people who may not access GPs. Hospital-based pharmacies can
also play an important role in developing and delivering stop smoking services in acute
settings.
Dentists
Almost 60% of the adult UK population visit a dentist for regular check-ups, including a
high proportion of people aged 25–35. Dentists also have regular contact with pregnant
women and teenagers, who are important groups for referral. Dental teams are
therefore well placed to offer brief advice and refer smokers to their local NHS Stop
Smoking Service. Where appropriate they can provide in-house intensive stop smoking
support.34
Mental health services
Given that up to 70% of people in mental health units smoke,35 mental health services
are an important source of referrals to stop smoking services. Smoking is associated
with an increased prevalence of all major psychiatric disorders36 as well as higher
suicide rates37. Smoking also increases the lifetime risk of developing a mental health
problem38. In contradiction to popular belief, smoking also exacerbates stress, and state
anxiety39. All of these are detrimental to most mental health conditions.
Smokers with a mental health problem can spend a large percentage of their, often low,
income on tobacco and cigarettes. This money is therefore not available to be spent on
food, heating, socialising or other things such as leisure activities which could help to
improve quality of life. As a consequence, the physical and mental health might suffer
for smokers with a mental health problem.
Smoking is responsible for most of the increased mortality of people with schizophrenia40,
whose life expectancy is 20% shorter compared to the general population41. Therefore
many premature deaths are preventable with appropriate smoking cessation support.
Smoking cessation for those with mental illness significantly improves mental and
physical health, while also reducing the risk of premature death42. After cessation
depressive or anxiety symptoms reduce, as the amount of tobacco smoked is related to
27
the number of depressive or anxiety symptoms 43. Anxiety levels fall significantly after
successfully giving up smoking for one week 44.
Currently, in Surrey, smoking cessation services specifically for people with mental
health conditions include one to one support by telephone and face to face in a
community venue (eg GP surgery), as well as cessation groups at Surrey and Borders
Partnership NHS Mental Health Trust premises (when there are sufficient numbers to
run a group).There is a need for smoking cessation services to ensure good access for
people with mental health conditions (including those using inpatient, outpatient and
voluntary sector services); to be appropriate to their needs – seeking their views on how
this should be done; and to monitor their access of smoking cessation services.
Prisons
It is estimated that 80% of the prison population smoke.45 There is considerable
evidence of a wish to quit and demand for support among smoking prisoners. As in the
general public, at least two thirds of smokers express a desire to quit and three quarters
indicate that they would accept support to quit if it was available.
Therefore prisons are an important source for stop smoking referrals. There are five
prisons in Surrey with a population of around 2700, and a throughput of more than 5000.
These figures indicate that there are between 2160 and 4000 smokers in Surrey prisons
over a year. In a health needs assessment for HMP High Down, a large male remand
prison in Surrey, 75% of prisoners reported that they smoked and 45% of these wanted
to give up. However, prisoners are waiting 4-10 weeks to access support, so further
work is needed to improve access to services.
Tackling smoking rates in prisoners, and ex-offenders in the community, offers a
valuable opportunity to influence health inequalities in this vulnerable and socially
excluded population.
Smoking and pregnancy
Smoking in pregnancy is harmful to the mother and baby. It is singularly the greatest
cause of preventable infant mortality and morbidity46. It can cause serious problems
including complications during labour, increased risk of miscarriage, ectopic pregnancy,
premature birth and even stillbirth. In addition it can cause significant health risks to the
baby, including low birth weight, slower growth, higher chance of cot death, foetal
abnormalities middle ear disease and damage to the airways. Long term problems for
the offspring include lower IQ, behaviour problems including hyperactivity and shorter
attention spans47.
The new national strategy, A Smokefree Future, aspires to halve smoking rates among
pregnant women by 2020.2 NICE is currently reviewing the evidence on smoking
cessation interventions for women who are pregnant or have recently given birth and
who smoke.48
The Government White Paper ‘Smoking Kills (DoH 1998) set a target to reduce the
percentage of women who smoke during pregnancy from 23% in 1995 to 18% by 2005
and 15% by 2010. The NHS Priorities and Planning Framework (2003/04 – 2005/06 set
a target to achieve a one percent point reduction per year in the numbers of women who
continue to smoke throughout pregnancy (PSA6a), specifically focusing on
disadvantaged women to tackle health inequalities in infant mortality. The Stop
28
Smoking Service has met this 1% point reduction each year since 2004. Reducing
smoking in pregnancy is also a health objective for Sure Start Children’s Centres.
24-50% of pregnant women do not disclose their smoking and a higher percentage
under report the number of cigarettes they smoke49. Pregnant women who smoke may
be pressurised to reduce smoking and the incentive to misreport may be greater than in
the past due to the greater public knowledge of the risks of smoking in pregnancy. CO
monitoring has been introduced as part of routine antenatal care in a number of
hospitals (Glasgow Breathe Project). There is a discrepancy across the country in this
regard and it would advantageous if routine CO monitoring for all pregnant women be
included in NICE Guidance.
In Surrey all pregnant smokers, including teenage pregnant smokers, are automatically
offered stop smoking support as part of their routine maternity care at booking and at
delivery. A variety of support options are available to pregnant smokers and they
include:
•
•
•
•
telephone support
1:1 support at a local community venue
public group clinic
access to a community based health professional e.g practice nurse, pharmacy.
If the client chooses 1:1 in the community there is the option that other family members,
who smoke and wish to quit, can be included in that support. The support consists
initially of 6/8 sessions and if the client successfully quits she will receive monthly
telephone/text messages to encourage continued abstinence. Clients are contacted via
telephone (can be seen if required) at 4 weeks and 2 weeks pre birth and again at 4
weeks and 4 months post birth. If the client chooses any of the other options then
support is provided for 6 sessions.
Women who have spontaneously quit (when they find out they are pregnant) are also
offered support by the service. The Smoking in Pregnancy Service is available to
women up until the child is 4 months old. If at any point during the pregnancy or after
the birth the woman relapses she would be offered support. For those mothers unable to
quit the Service engaged in a programme for creating a smokefree home and a
certificate was presented if successful. Training of midwives on how to refer to the
service is carried out by the Stop Smoking Service on an adhoc basis for the five acute
hospitals covered by the NHS Surrey.
Local authority partners
The Surrey LAA Target is being split by borough to facilitate joint working and leadership
in reducing the prevalence of smoking at a local level. This is to ensure that the service
is reaching all areas of Surrey, specifically those with the highest deprivation and
population of heavy smokers. Local authority level quit targets will help identify areas in
which partners can target work together to optimise smoking cessation. Examples of
effective partnership work include shared communications and media work, smokefree
workplace initiatives, smokefree homes projects. Training can be offered to Inspecting
Environmental Health Officers (and other Local Authority personnel) to provide brief
interventions in a variety of community settings, such as when Officers are advising
employers on achieving smokefree workplaces, linking the possibility of intervening to
29
promote smoking cessation in the workplace and the benefits of financial savings from
the associated reduced illness absence due to smoking-related illness.
These local authority level draft targets have been derived according to the estimated
smoking population in each area and reflect a ‘share’ of the overall county target (see
table below).
LOCAL AUTHORITY
Elmbridge
Epsom and Ewell
Guildford
Mole Valley
Reigate and Banstead
Runnymede
Spelthorne
Surrey Heath
Tandridge
Waverley
Woking
DRAFT QUIT TARGET
(2009/10)
380
204
457
250
485
313
364
282
275
378
312
Engagement with providers of community services
The harmful effects of smoking can be reduced through partnership working the
community. Linking with Borough targets allows the Stop Smoking Service to focus
work on areas of deprivation through a tailored approach that meets the needs of the
community.
Through partnership working with the Children’s Centre Development Officers, the Stop
Smoking Service has initiated a project to ensure Family Outreach Workers and centre
staff are trained in brief interventions to enable them to raise the issue of smoking within
the community. Identifying a ‘champion’ for each centre will enable them to work with
the Service to coordinate onsite stop smoking clinics/drop ins to address the needs of
the local population. Through the partnership links a reporting system can be put in
place to share quit targets and achievements unique to each specific area.
Services also being put into place include stop smoking clinics for parents/carers within
schools, which, alongside the Children’s Centres, remove barriers to services for
specific client groups that may struggle to attend mainstream clinics.
Cessation and Young People
There is little published evidence of the effects of interventions that focus on cessation
activity in adolescence.50 Data from English NHS Stop Smoking Services show a 22%
CO-verified quit rate in the under-18 age group against 33% in all ages.51
Only 3% of service users who set a quit date were aged 18 or under and this should be
reflected in service provision. Services should be available for young people who want
to stop smoking and local NHS Stop Smoking Services should link with other
programmes to ensure they reach as many children and young people as possible (e.g.
30
through healthy school programmes, health services on secondary school sites and
other youth settings).
31
Tobacco Control Strategic Priority 2
ACTION PLAN
Target multi-level interventions with schools where pupil exclusions due to smoking are
high
Ensuring that children and young people have easy access to cessation support (the 4S
survey will help shape remit as well as location of services)
To improve data collection and analysis within the stop smoking service
The service will deliver four street-based promotional campaigns per year. Each
campaign will last three weeks and cover the whole of the county.
To expand and develop further the telephone support offered to smokers to achieve a
target of 300 quitters a quarter
To develop a Stop before the Op programme
Expand the one-to-one service offered to mental health service users and incorporate
regular promotional events on-site at local mental healthcare settings.
To increase the capacity of the stop smoking service to deliver interventions with mental
health service users by recruiting mental health professionals as stop smoking advisors.
Undertake a review of services in each of the prisons in Surrey in order to reduce waiting
lists and ensure appropriate services
Identify quit targets for each borough to improve joint working and leadership in reducing
the prevalence of smoking at a local level
To develop and maintain links between the stop smoking service and primary care/others
to address COPD
To identify teenage mothers who smoke by working directly with the teenage pregnancy
strategy lead and midwifery services
To provide direct stop smoking support to assist teenage mothers in stopping smoking,
including staff training
To routinely collect data on the prevalence of smoking amongst teenage mothers in
Agencies involved in
Surrey
Lead Agency in bold
SCC/NHS Surrey (SSS)/4S
Timescale
NHS Surrey via Surrey Stop
Smoking Service
Surrey County
Council/schools & colleges
NHS Surrey Stop Smoking
Service
NHS Surrey/Surrey Stop
Smoking Service
NHS Surrey via Surrey Stop
Smoking Service
NHS Surrey, Commissioners,
Stop Smoking Service, GPs
NHS Surrey Stop Smoking
Service/ SABP
NHS Surrey Stop Smoking
Service/ SABP
NHS Surrey Stop Smoking
Service/HMPs
NHS Surrey/SSS/LAs
TBC
TBC
Ongoing
TBC
Ongoing
TBC
TBC
TBC
TBC
TBC
NHS SSS/ primary
care/COPD clinics/ etc
NHS Surrey/SSS/primary
care/SCC
NHS Surrey/SSS/Primary
care/midwifery leads
TBC
NHS Surrey/SSS
TBC
TBC
TBC
32
Tobacco Control Strategic Priority 2
ACTION PLAN
Surrey
To provide cessation training and support for personal advisers in Connexions
To ensure brief intervention training is commissioned for front line youth workers
To ensure Inspecting EH Officers and other LA frontline staff are offered free brief
intervention training.
Agencies involved in
Surrey
Lead Agency in bold
Timescale
SCC/NHS Surrey/Connexions TBC
SCC/NHS Surrey
TBC
Local Authorities
TBC
Environmental Health
Departments/NHS Surrey
Stop Smoking Service
33
Strategic Priority 3 Reducing exposure to secondhand smoke
We will reduce exposure to secondhand smoke in private and work places by:
• Continuing to strengthen the countywide Smokefree Homes and vehicles project
• Continuing to enforce the Smokefree legislation around the county, ensuring
compliance in “at risk” establishments and areas.
Smokefree legislation was introduced in July 2007, providing protection from exposure
to secondhand smoke (SHS) in virtually all enclosed work and public places in the UK,
including public transport.
Exposure to secondhand smoke is a serious health hazard, and there is no safe level of
exposure. Among others, the World Health Organisation and the US Surgeon General
have concluded that there is no risk-free level of exposure to SHS.52 53 This conclusion
adds to the weight of scientific evidence including a review by the Scientific Committee
on Tobacco and Health (SCOTH) in the UK, published in 2004, which stated that “no
infant, child or adult should be exposed to secondhand smoke” and that SHS is a
substantial health hazard. Every time someone breathes in secondhand smoke, they
breathe in over 4,000 chemicals. Many are highly toxic. More than 50 are known to
cause cancer.54 The International Agency for Research on Cancer (IARC) and the World
Health Organization (WHO) have classified SHS as a known (class A) human
carcinogen. Other class A carcinogens include asbestos, arsenic, benzene and radon
gas.55
General health effects
Exposure to SHS has immediate health effects. It can reduce lung function; exacerbate
respiratory problems; trigger asthma attacks; reduce coronary blood flow; irritate eyes;
and cause headaches, coughs, sort throats, dizziness and nausea. As well as the
immediate health effects there are also long-term health effects, especially with
continued exposure over time. Exposure can increase the risk of sudden infant death
syndrome and evidence also shows that babies born to mothers who come into contact
with secondhand smoke have lower birth weights.56
In 2004 the International Agency for Research on Cancer (IARC) concluded that a non
smoker, living with a smoker, has a significantly increased risk of lung cancer,
(approximately 24% for women and 37% for men). It, also, estimated that SHS exposure
increases the risk of an acute coronary heart disease event by 25-35%.55
Studies have consistently shown that exposure to SHS increases the risk of coronary
heart disease (CHD) in non smokers. Exposure to SHS increases blood platelet activity,
causing the blood to thicken and become more likely to clot. The tobacco smoke also
affects cells lining the coronary arteries, contributing towards the narrowing of the
arteries. This reduction in blood flow may lead to a heart attack. A small study in 2001
concluded that even half an hour of exposure to SHS can reduce coronary blood flow.57
Since the introduction of the smokefree legislation, studies have suggested a reduction
in the total number of hospital admissions for acute coronary syndrome. Recent
research from Scotland looked at whether the reduction in admissions involved non
smokers, smokers, or both. It concluded that the number of admissions for acute
coronary syndrome decreased after the implementation of smoke-free legislation. A total
34
of 67% of the decrease involved non smokers. However, fewer admissions among
smokers also contributed to the overall reduction.58
Children’s exposure to secondhand tobacco smoke is commonplace and has clear,
measurable effects. Prior to the implementation of smokefree legislation in 2007, 80%
of children under ten years old from the most affluent backgrounds were found to have
biological markers of exposure to smoke, rising to 95% of children from the least affluent
back grounds.59
Children may no longer breathe tobacco smoke in enclosed public places but the
primary site of exposure remains the home. Research from Ireland60 and Scotland 61
shows no evidence of smoking shifting from public places to the home after the
implementation of smokefree legislation. In fact some research has indicated that
smokefree legislation can reduce smoking in the home because of greater awareness of
the risks of secondhand smoke.62
Although it is possible to reduce smoke levels by opening windows, smoking less or
smoking away from children, these strategies still leave children exposed to dangerous
levels of secondhand smoke, as there is no safe level of exposure. Smokefree homes
offer the only sure protection63.
When the smokefree legislation came into force in 2007, a comprehensive public
relations campaign was implemented in Surrey, supported by all 11 districts and
boroughs, the PCT and the county council. Compliance is high. Recent research shows
that compliance with the legislation is 99.3% for the south east region.64 However, this
strategy is designed to ensure there is no complacency. Regular inspections are to be
encouraged in a cost effective way, i.e. included in other routine environmental health
inspections.
Problems do exist in specific areas and this strategic priority will look at targeting work in
these areas. Local authorities in Surrey have identified small pockets of non
compliance, for example in work and public vehicles and in schools. Partnership
working in this area is strong: the Alliance’s Smokefree Steering Group, led by the
Environmental Health Manager of Elmbridge Borough Council, with close accountability
to the Environmental Health Managers’ Group, has continued to promote the concept of
going smokefree with campaigns. In addition, Surrey Fire and Rescue Service was a
lead partner in targeting smoking in the home (July 2008) and smokefree vehicles
(March 2009).
There needs to be additional support for the boroughs and districts on promoting
smokefree, with the NHS and County Council presenting exemplary smokefree policies
and practices to the community as a whole.
Smokefree homes
Many local partnerships in England have implemented Smokefree Homes projects. The
Alliance launched a Smokefree Homes campaign in July 2008 with the vital support of
Surrey Fire and Rescue Service. On average Surrey Fire and Rescue Service responds
to 30 accidental dwelling fires each year caused by smoking. Smoking materials are
also found to be the source of ignition in 40% of the county's fire fatalities, making it the
major cause of accidental fire deaths. All of these fires were a consequence of
accidentally dropped lighted cigarettes or matches, or careless disposal of the same.65
35
Of those people that died, 64% suffered from a form of mental health illness and the Fire
Service would like to see more done to educate health workers and their clients about
the safety risks.
A campaign pack was produced to target smokers and encourage them to make their
homes smokefree, not only to reduce the exposure of their families to secondhand
smoke but to reduce the risk of house fires. The pack was distributed by fire officers
making house visits.
The campaign needs to be extended with other organisations promoting the message.
For example, hospitals can educate relatives and friends to create a smokefree
environment, for when patients go home post operatively, to facilitate their recovery.
This initiative could be useful in supporting the “Stop Before the Op” programme.
It is important that the messages get through to families and 0-19 nurses have a vital
role. Training should be provided so that they can offer encouragement to parents to
stop or not smoke in their children’s presence and make their homes smokefree.
Children’s Centres can promote the concept of smokefree homes.
Surrey Family Placement Service has a policy in place which acknowledges the proven
skills and abilities of many of its carers who smoke but believes that children’s health
must be their primary consideration. It recognises that a smoking environment should
be avoided in the best interest of children who are to be placed away from home and is
therefore working towards a position where no looked after child will be living in a
smoking household. Existing foster carers who smoke are encouraged to create a
smoke-free home. There may be the opportunity for the Stop Smoking Service to
support these carers, should they wish to quit.
Like most Adoption Agencies, Surrey County Council follow the guidelines issued by the
British Association for Fostering and Adoption which state that no child under five should
be placed in a smoking household. If a child suffers from a respiratory condition the
Council would not be placing them in a smoking household at all.
36
Smokefree vehicles
Children and young people are also regularly exposed to secondhand smoke in cars
where levels of toxins can get extremely high, even when windows are opened66,67.
Effective measures to protect people from the harmful effects of tobacco smoke in cars
should be investigated. We believe serious consideration should be given to the option
of prohibiting smoking in cars, especially where children are present, a step that has
already been taken in South Africa and in various jurisdictions in America, Canada and
Australia. Indeed in July 2009, New South Wales in Australia banned smoking in cars
where young people under the age of 16 are passengers. The Alliance will lobby for a
proper evaluation of the costs and benefits of this option to be undertaken for England.
The Government have committed to review the Smokefree legislation in 2010. The
provision exists in Clause 4 of the Act for further extensions of the smokefree law.
The Alliance’s Smokefree Steering Group in March 2009 launched a PR campaign to
raise awareness of smoking in vehicles. The campaign reminded drivers that work
vehicles are included in the Smokefree legislation and should be smokefree. It also
raised the issue of smoking in private vehicles, which are not covered by the law,
especially where children and vulnerable people are present.
A recent opinion poll in the UK showed that 67% of motorists would like smoking
completely banned in cars.68
37
Tobacco Control Strategic Priority 3
ACTION PLAN
Agencies involved in
Surrey
Lead Agency in bold
Enforcing smokefree legislation and ensuring workplaces, public places and 11 Boroughs and District
vehicles are smokefree (10% target inspection for all business visited each year councils
Timescale
Ongoing
would be checked for smokefree compliance)
Promoting smokefree homes and cars and raising awareness about second NHS Surrey & Surrey
hand smoke
County Council via Stop
Smoking Service, frontline
primary care workers, HVs,
Children Centres,
Surrey Fire and Rescue,
Family Placement service,
Local borough and
districts
Promoting smokefree environments to relatives/friends of patients to aid
post operative recovery
Campaigning for further smokefree protection
Raising awareness about smoking in the home and the risk of fires,
particularly with vulnerable groups
Ensure tobacco prevention, including awareness raising about second hand
smoke, is included in new contracts for 0-19 public health nursing services
RSCH, ASPH, etc
Acute trusts
Smokefree Surrey
Surrey Fire and Rescue
Service/?other partners
NHS Surrey
TBC
TBC
TBC
TBC
TBC
38
Strategic Priority 4. Combating illicit tobacco
We will raise awareness of the county's problem with counterfeit and smuggled tobacco
and take action by:
• Participate in the regional discussions and contribute to the south east plan to tackle
illicit tobacco
• Convening a working group of key agencies to draw up an action plan to target
counterfeit and smuggled tobacco in the county
• Devise a communications campaign to inform the public in Surrey of the issue.
Price is known to be one of the most effective ways of influencing smoking prevalence.
Tobacco price elasticity is estimated by the World Bank to be around -0.4 for developed
countries, which means that a 10% rise in price leads to a 4% decline in consumption.69
Research has shown price elasticity to be even higher among lower-income and
younger smokers.70 In the UK the current long run estimate is that price elasticity is
around 0.72, taking into account the smuggled market.71 Governments use tax to
ensure that the price to the customer is and remains high. The UK tax on tobacco
products (cigarettes, hand rolled tobacco (HRT), cigars, chewing tobacco, and other
smoking tobacco) is one of the highest in the European Union. The tax income is a
benefit as it can be used to fund government services, not least the NHS itself, but is not
the principal driver of the policy. A reduction in smoking would reduce the burden of
disease and premature death that it causes. Tax evasion undermines this policy, and
encourages smokers, in particular the most disadvantaged and vulnerable parts of
society including children and young people, to develop and maintain a smoking habit.
Evidence of the effect of the raising taxation on increasing supply of illicit tobacco can
be found in a recent French study.72 Action to curb the availability of cheap and illicit
tobacco must therefore accompany the taxation policy to ensure that it is effective. This
action is a recognised part of the Department of Health’s current six-strand approach to
tobacco control and is expected to be part of the new long-term tobacco strategy. The
consultation document on the new strategy proposes continued action to tackle the illicit
trade in tobacco as a major part of the theme of reducing health inequalities caused by
smoking. It is known that many responses strongly supported this.
Reducing smoking prevalence through taxation supported by action to stem tax
avoidance is a regressive measure, bearing more heavily on the more disadvantaged.
However, the aim is to encourage people to quit smoking altogether which is known to
be of such proven benefit to smokers and their families as to be acceptable. The
availability of NHS support including local NHS Stop Smoking Services in providing top
quality, easily accessible support for those wishing to quit is an essential
accompaniment to the pricing strategy.
Tackling criminal tobacco trading
Tackling the availability of cheap and illicit tobacco successfully must be
comprehensive, looking at both supply and demand, and covering all forms of tobacco
(sticks and Hand Rolled Tobacco (HRT)). Brief definitions of some commonly used
terms concerning illicit supply are:
o
Smuggling – is part of large scale organised crime, involving the illegal
transportation, distribution and sale of tobacco products. It occurs where
legitimately manufactured tobacco products are diverted, usually when in the
wholesale distribution chain, evading payment of the tax. The products are
cheap to the consumer and the profits are made throughout the supply chain,
39
from manufacturer to final supplier. Bootlegging is a variant of smuggling:
tobacco products are purchased in a country with a low level of taxation and
illegally brought into countries with higher rates of taxation.73
o
Counterfeiting – involves the illegal manufacture of tobacco products, often
abroad but sometimes in the UK. The product is then transported, distributed
and sold, avoiding tax. With counterfeiting, the product is made to look genuine.
Counterfeit tobacco products are sold cheaply to the customer and vast profits
are made throughout the supply chain. Like smuggling, it is part of large scale
organised crime.
Smuggling and counterfeiting are criminal activities. This crime phenomenon is not just
located in the ‘underworld’ but has many connections to the legitimate and legal world,
resulting in a blurring of the line between criminality and non-criminality.74 This adds to
the perception that all forms of non duty-paid cigarettes are acceptable.
The illicit tobacco trade produces cheap cigarettes and hand-rolled tobacco (HRT) which
encourage smokers to continue their habit. This illicit trade can undermine other
strategic measures introduced over recent years such as the raising of the age of sale to
18 and health warnings on tobacco packaging (including pictorial ones from 1 October
2008).
This strategy uses the terms ‘cheap and illicit tobacco’ to focus on these. It covers
smuggled, bootlegged and counterfeit tobacco, which are not, in any case, terms used
by consumers. Recent UK research from NE England has shown that users do not use
these terms and some are unaware that the products are illicit, referring to them as
‘duty-frees’.75 ‘Dodgy’ and ‘snidey’ are other terms used.
The table below illustrates the prices of cigarettes and HRT as at June 2008
Cigarette Sticks – pack of 20
Highest cost premium brand e.g. Marlboro
Lowest cost budget brand e.g. Ronson KS
Hand Rolled Tobacco (HRT)
Popular range 25g (pouch)
Price
inclusive of tax
£5.85
£4.10
£5.46
The range of cigarette prices indicates the scope for ‘trading down’ by switching to
cheaper legitimate products. Trading down can also mean changing from cigarettes
(stick tobacco) to hand-rolled tobacco (HRT). The proportion of smokers using mainly
hand-rolled cigarettes has steadily increased over past decades and was estimated at
25% in the 2006 General Household Survey.76 Moving to illicit sources of supply of the
product, sometimes without realising it75, achieves the lowest costs of all to the smoker:
in parts of the North of England such as Easington in County Durham or Halton in
Merseyside, dodgy, snidey or ‘duty free’ tabs are routinely bought for £2.50.77
Usage and users of illicit tobacco
The latest HMRC estimate is that across the country as a whole, 1 in 6 stick cigarettes
smoked is illicit. A survey of 391 smokers in January by BMRB found 68 reporting
buying from illicit sources.78 There was a strong socio-economic gradient and the two
40
youngest age groups, 16-24 and 25-34 bought most from these sources, as the two
tables below show:
Table 5 By social group
Table 6 By age
Other research indicates that the figures for the purchase of illicit cigarettes in deprived
communities are particularly high with purchasing of cheap illicit tobacco (sticks and
HRT) viewed as the norm.75 It also acknowledged the particular threat to vulnerable
groups of smokers, particularly the young. Buying cheap or ‘trading down’ is well
evidenced as helping to start and maintaining the smoking habit. In terms of starting or
encouraging early smoking there is evidence from many parts of the country of young
people obtaining tobacco from ‘tab houses’.
In Halton, Trading Standards conducted a tobacco survey in November 2006 of all Year
9 students in the borough which revealed that 22% were regular smokers and 18% of
these obtained their tobacco from a neighbour who was selling from home.79 Across the
North West a survey of 3,000 11-17 year olds found that 56% regularly bought
cigarettes with health warnings in another language and 28% had knowingly bought
‘fake’ cigarettes. Qualitative research in East Durham with young people aged 13 to 18
sheds further light on cultures in which the supply of cheap and illicit tobacco through
‘tab houses’ is a routine part of life.80
41
The agencies involved in tackling the supply of illicit tobacco are the UK Border Agency,
HMRC, Trading Standards, and the Police. A tobacco protocol, understood to be almost
complete, is being developed at present and will make the arrangements for the sharing
of information between HMRC and Trading Standards easier and clearer.
Tobacco Control
Strategic Priority 4
ACTION PLAN
Participate in the regional
discussions and contribute
to the south east regional
plan to tackle illicit tobacco
Convene a working group
of key agencies to draw up
an action plan to target
counterfeit and smuggled
tobacco in the county
Devise a communications
campaign to inform the
public in Surrey of the
issue
Agencies involved in Surrey
Lead Agency in bold
Timescale
Trading Standards/Surrey
Police/HMRC
TBC
Trading Standards/Surrey
Police/HMRC/Smokefree
Surrey Alliance
TBC
Trading Standards/Surrey
Police/HMRC/Smokefree
Surrey Alliance
TBC
Encourage the public to
report the illicit trade of
tobacco
Trading Standards/ Surrey
Police/HMRC/Smokefree
Surrey Alliance
TBC
42
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45