Project: Joint Strategic Needs Assessment
Profile Title: Tobacco
Author/Priority Lead: Julie Parker-Walton
Date of Submission:
Document Reference no: 6
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Introduction
Tobacco control is a complex issue and no single approach will be successful in
isolation, therefore it requires commitment and contributions from a range of partners
across the City. Smoking is the primary cause of preventable illness and premature
death, accounting for an estimated 79,100 deaths (17% of all deaths) in England 2013,
resulting in more deaths than the next six causes combined. Over the past 5 years,
smoking prevalence has been falling nationally and locally, but smoking remains the
greatest contributor to premature death and disease across Sunderland, killing 1 in
every 2 long term smokers. It is estimated that up to half the difference in life
expectancy between the most and least affluent groups is associated with smoking.
In March 2011, the Government published, Healthy Lives, Health People: a Tobacco
Control Plan for England. The plan has three ambitious goals to be delivered locally,
these include:
 To reduce adult (aged 18 or over) smoking prevalence in England to 18.5 per
cent or less by the end of 2015 (from 21.2 per cent), meaning around 210,000
fewer smokers a year.
 To reduce rates of regular smoking among 15 year olds in England to 12 per cent
or less (from 15 per cent) by the end of 2015.
 To reduce rates of smoking throughout pregnancy to 11 per cent or less (from 14
per cent) by the end of 2015 (measured at time of giving birth).
The transfer of public health responsibilities to local authorities in 1st April 2013 included
the function of commissioning stop smoking services. Local authorities now have
responsibility to deliver against two overarching aims set out in Healthy Lives, Healthy
People; to improve health and to reduce inequalities.
The Public Health Framework (April 2013) sets out the context of the public health
system and the broad range of opportunities to improve and protect health across the life
course and reduce inequalities in health. Tobacco has three indicators within the
framework all of which are red:
 Reduce smoking at time of delivery
 Reduce smoking prevalence amongst 15 year old

Reduce smoking prevalence of adults (over 18s)
Impact on society - Each year in Sunderland it is estimated that smoking costs society
approximately £78.1 million. This is made up of £16 million from lost output due to
premature death, £39.6 million loss of productivity; and cost to the NHS is £13.9 million
as well wider costs from passive smoking, smoking related fires and littering.
The Sunderland Health and Wellbeing Strategy defines a new approach to improving
health outcomes across the City, taking an asset-based approach and building the
resilience of individuals, families and communities. Reducing tobacco prevalence is one
of the key eight priorities for the Sunderland Health and Wellbeing Board, with an agreed
HWB aspiration to work towards reducing adult smoked tobacco in Sunderland to below
5% by 2025.
Sunderland’s Tobacco Alliance is a multi-agency group, leading on the strategic
overview of reducing smoking locally. The alliance brings together key partners and
agencies including Public Health, City Services, Children’s Services, Housing, Adult
Services, Sunderland Stop Smoking Service, Gentoo, Fire Brigade, Sunderland
University and Sunderland City Hospitals, who support the delivery of the Tobacco
Action Plan for Sunderland. Tobacco control is a complex issue and no single approach
will be successful in isolation; therefore it requires commitment and contributions from a
range of organisations. Sunderland Tobacco Alliance successfully completed a peer
review in CLeaR - Excellence in local tobacco control, and was found to be CLeaR
compliant.
Regionally, Fresh – Smoke Free North East (FRESH) brings together a wide range of
partners to deliver a coordinated approach to making tobacco less attractive, less
accessible and less affordable. The programme runs across eight key strands of
activity, which is collectively delivered via a yearly action plan.
Key issues and gaps
Each year a Sunderland Tobacco Profile is published. Sunderland is in the worst 10% of
152 upper tier local authority populations for:
 Smoking prevalence in adults
 Smoking prevalence in adults in routine and manual occupations
 Smoking status at time of delivery
 Smoking prevalence of young people 15 and over
 Smoking attributable mortality
 Smoking attributable deaths from smoking
 Smoking attributable hospital admissions
 Deaths from lung cancer
 Deaths from COPD
Adult smoking rates - The proportion of adults that smoke in Sunderland fell between
2010 and 2014 from 24.6% to 22.8%, this compares to 18% nationally.
Routine and manual workers – Over the past 3 years smoking prevalence in routine
and manual occupations has increased from 30.6% to 35.3%, this compares to 28%
nationally.
Young people – 11.6% of 15 years olds in Sunderland say that they smoke compared
to 8.7% nationally. Among 16 to 17 years olds this rises to 18.7% in Sunderland and
14.7% across England
Smoking at time of delivery - Smoking during pregnancy remains high. In the 2014/15
figures, 531 women in Sunderland were recorded as smoking at the time they gave birth;
this equates to 19.4% compared to the England average of 11.4%.
Household poverty – In Sunderland 23% of households are classified as in poverty
compared to the official Households Below Average Income Figures. When the cost of
smoking are considered 34% of households fall below the poverty threshold which
shows tobacco imposes a real and substantial cost on many low-incomes households.
Inequalities of smoking prevalence at ward level - the highest smoking prevalence
are within the wards of Redhill, Castle, Sandhill, Pallion, Southwick, Washington North,
St. Anne’s, Hendon, Hetton and Silksworth. These wards are 10 highest in Sunderland
and above the Sunderland average of 22.8%.
Recommendations for Commissioning
1. A holistic approach to tobacco control is continued throughout Sunderland,
recognising that Stop Smoking Services and stop smoking interventions in isolation
should not be regarded as the main drivers for reducing smoking prevalence.
Therefore a comprehensive tobacco control plan involving a range of partners has to
be in place, and the Sunderland Tobacco Alliance is proactively supported through
partnership working.
2. Continue the commissioning of a holistic approach to tobacco control through the
Live Life Well model, and the Live Life Well Service. The Live Life Well service target
the areas of high prevalence by increasing the service provision in these areas which
traditionally have low rates of access, thus reducing the levels of smoking in routine
and manual workers by engaging them in accessible services which they want to
use.
3. To ensure that young people don’t start smoking in their teenage years, continue the
work with secondary schools across the City, and ensure that the health harm
messages are appropriate to the needs of young people. Increase provision of Stop
Smoking Services within youth organisations and schools
4. Improve the current stop smoking pathway for pregnant women, and ensure they are
offered appropriate support and advice. Health harm messages to be delivered that
are appropriate to their needs. Increase provision of Stop Smoking Services within
Children Centres.
5. Ensure that smoking is no longer accepted as the norm, and make parks in
Sunderland free from tobacco smoke.
6. To ensure services meet the needs of priority groups such as BME, LGBT, routine
and manual occupations, pregnant women within Sunderland by engaging the
community and delivering services appropriate to need.
7. To improve the current stop smoking pathway and ensure community tier 2 stop
smoking services can receive referrals from Northumberland, Tyne and Wear Mental
Health Trust and City Hospitals Sunderland via a robust electronic method.
8. Consider the use of e-cigarette to support smokers to quit and e-cig friendly stop
smoking services in Sunderland.
1) Who is at risk and why?
Tobacco control is a complex issue and no single approach will be successful in
isolation, therefore it requires commitment and contributions from a range of partners
across the City. Smoking is the primary cause of preventable illness and premature
death, accounting for an estimated 79,100 deaths (17% of all deaths) in England
2013, resulting in more deaths than the next six causes combined. Over the past 5
years, smoking prevalence has been falling nationally, regionally and locally, but
smoking remains the greatest contributor to premature death and disease across
Sunderland, killing 1 in every 2 long term users. It is estimated that up to half the
difference in life expectancy between the most and least affluent groups is
associated with smoking.
According to the Sunderland Tobacco Profile, Sunderland is in the top worst 10% of
152 upper tier local authority populations for:
 Smoking prevalence in adults
 Smoking prevalence in adults in routine and manual occupations
 Smoking status at time of delivery
 Smoking prevalence of young people 15 and over
 Smoking attributable mortality
 Smoking attributable deaths from smoking
 Smoking attributable hospital admissions
 Deaths from lung cancer
 Deaths from COPD
Smoking is the biggest cause of health inequalities in England accounting for half the
difference in life expectancy between richest and poorest. On average a smoker
loses 10 years of life. More people from disadvantaged communities smoke, where
smoking is more socially acceptable.
Impact on society - Each year in Sunderland it is estimated that smoking costs
society approximately £78.1 million. This is made up of £16 million from lost output
due to premature death, £39.6 million loss of productivity; and cost to the NHS is
£13.9 million as well wider costs from passive smoking, smoking related fires and
littering.
Household poverty – In Sunderland 23% of households are classified as in poverty
compared to the official Households Below Average Income Figures. A recent ASH
Fact Sheet found that when the cost of smoking are considered 34% of households
fall below the poverty threshold which shows tobacco imposes a real and substantial
cost on many low-incomes households. If these smokers were to quit 3,810
households would be elevated out of poverty.
Illicit tobacco is a major threat facing our communities and has serious
consequences for health, crime and community cohesion. The independent Illicit
Tobacco North East Study 2015 by NEMS market research found that nine out of ten
adults believe illegal tobacco is a danger to children, helping get teenagers hooked
on a lethal addiction, and nearly seven out of ten believes it brings crime into local
communities, lining the pockets of local crooks. More illegal tobacco buyers have
also switched to hand rolling tobacco which now makes up half of the regional illicit
market, with increasing numbers of women now smoking roll ups. Although hand
rolled tobacco contains the same poisonous chemicals like arsenic and carbon
monoxide, 44% of men and 29% of women in the survey wrongly believed roll ups
contain fewer chemicals than manufactured cigarettes. In the North East 9% of all
tobacco smoked is illegal, with Sunderland slightly higher than the regional average
at 11%.
2) The level of need in the population
The national rates of smoking have continued to fall over the past decade to the
current rate which is 18% (2014). The proportion of adults that smoke in Sunderland
fell between 2010 and 2014 from 24.6% to 22.8%. There is an estimated 51,457
smokers aged 16 + in Sunderland. In 2014/ 15, 8% of people who smoked set a date
to quit with Sunderland Stop Smoking Service and of them 46% went on to quit. This
is a reduction of 31% on 2013/ 14 figures. However this is in line with a national
decline in accessing stop smoking service. There are two probable reasons for this
decline. E-cigarettes, more people are likely to attempt to quit smoking on their own.
E-cigarette use has increased to 2.1 million users in 2014 but has since started to
decline. Increase in harm reduction approaches, some smokers may want to reduce
the amount they smoke or want to abstain from smoking for a set period of time.
Ward Level Differences
The top 10 wards with the highest smoking prevalence over the Sunderland average
are Redhill, Castle, Sandhill, Pallion, Southwick, Washington North, St. Anne’s,
Hendon, Hetton and Silksworth.
Routine and manual occupations
In Sunderland there is a strong correlation between smoking prevalence and the
level of deprivation. The more deprived the area, the higher the smoking prevalence.
Over the past 3 years smoking prevalence in routine and manual occupations has
increased between 2011 and 2014 from 30.6% to 35.3%, this compares to 28%
nationally.
Unemployed
People who are long termed unemployed are more likely to smoke.
Smoking at time of delivery
Smoking during pregnancy remains high. In 2014-15 figures, 531 women in
Sunderland were recorded as smoking at the time they gave birth; this equates to
19.4% of pregnant women compared to the England average of 11.4%.
Children
Children from low income families are more likely to be exposed to secondhand
smoke in the home. Children who have a parent who smokes are up to three times
more likely to go on to smoke. Secondhand or "passive" smoking is a killer and a
cause of serious and fatal illness. Children are especially vulnerable to becoming ill
from secondhand smoke because their lungs and respiratory organs are still
developing. A child exposed to secondhand smoke has an increased risk of sudden
infant death (‘cot death’), asthma, wheeze, lower respiratory infection, middle ear
disease and meningitis.
Young people
Current smokers in 15 years olds are at 11.6%, this compares to 8.7% nationally.
This increases to 18.7% in 16-17 years olds to 18.7% this compares 14.7%
nationally.
The Health Related Behaviour Survey carried out in 2012 showed the self-reported
rates of tobacco use in young people across Sunderland. The survey showed that:
Primary school children (8 to 11 years)
98% of pupils said they had never smoked
1% of pupils had smoked during the last seven days
87% of pupils think they won’t smoke when they are older, 13% said maybe
or yes they will
Secondary school children (12 to 15 years)
72% of secondary aged pupils said they had never smoked
24% from those who reported never smoking in primary school.
Boys: 3% of year 8 boys and 9% of year 10 boys reported they smoke
occasionally or regularly
Girls: 3% of year 8 girls and 13% of year 10 girls reported that they smoke
occasionally or regularly
BME Groups
According to the ASH Fact Sheet Smoking rates vary considerably between ethnic
groups. In men, compared to the general population, rates are particularly high in the
Black Caribbean (37%) and Bangladeshi (36%) populations but these differences are
explained by socioeconomic differences between the groups. Among women,
smoking rates are low (at 8% or below) with the exception of Black Caribbean (22%)
and Irish (24%) compared with the general population. Overall, smoking rates among
ethnic minority groups are lower than the UK population as a whole. Self-reported
smoking prevalence in Sunderland of all BME groupings is 18%.
Mental Health
There is a strong association between smoking and mental health conditions.
Smoking is the main cause of reduced life expectancy in those with a mental health
condition. A recent ASH Fact Sheet found those with a long standing mental health
condition are three times more likely to smoke as those without.
Lesbian, gay, bisexual and transgender (LGBT)
LGBT people are more likely to have higher rates of smoking. Data from the
Integrated Household Survey 2014 (HIS) shows that 25.3% of gay/ lesbian people
smoked compared to 18.3% of heterosexual people. Young LGB people are more
likely to smoke, to start smoking at a younger age and smoke more heavily. A recent
ASH Fact Sheet found that there is a lack of research on smoking amongst trans
people, but surveys do show that trans people are more likely to smoke.
Illicit tobacco is a major threat facing our communities and has serious
consequences for health, crime and community cohesion. The independent Illicit
Tobacco North East Study 2015 by NEMS market research found that:
 9% of all tobacco smoked in the North East is illegal, with Sunderland slightly
higher than the regional average at 11%
 21% of smokers buy illegal tobacco - slightly higher than the regional average
of 18%. Just over a third (38%) of smokers have tried illegal tobacco at some
point.
 7 out of 10 people who do buy illegal tobacco get it from one single source.
 39% of illegal tobacco buyers in Sunderland buy it from fag houses, 15% buy
it from a shop and 5% from a pub or club
 12% of current smokers in Sunderland say they are often offered illicit
tobacco.
3) Current services in relation to need
Live Life Well (Sunderland Stop Smoking Service)
Due to a decrease in the use of stop smoking services and engagement with local
people, a new model for the delivery of stop smoking support has been designed and
implemented in Sunderland with the aim of increasing smokers’ access to services.
Our new model will deliver an approach that takes into account the health needs of
the whole population while also being personalised to individual need. The model is
outlined in figure 1. Much of the feedback we received was that many people do not
want or need services but rather need to embed healthier choices into the way they
live their lives, with minimal additional cost.
Central Hub/ Gateway to Healthy Opportunities (incorporating the Stop Smoking
Hub) - To overcome the difficulties that many people have in finding opportunities to
improve their health we have commissioned a central hub that will be accessible and
available to all. The hub will enable people to improve their own health with
information and signposting available through a range of media. It will be a single
(but not exclusive) point of contact. It will also ensure that people continue to be
supported in making changes to their health by supporting self-monitoring and
following up those who want to make a change to offer further encouragement.
Smokers wanting to quit can access support in a number of ways; by referring
themselves directly to an approved level 2 Active Intervention (AI) providers, calling a
free phone number at the Stop Smoking Service Hub (which is open 7-days per
week) or finding details of their three nearest service providers via the text or webbased service locator.
Figure 1: Delivering Live Life Well model
Health champions/ Personal information and Advice - Whilst the hub will provide the
support that people need who have decided to make a change, we recognise that
some people need more encouragement to take that first step and so we will build on
our successful Sunderland Health Champions programme. Level 1 tobacco brief
intervention training has been incorporated in the Sunderland health champion
programme as one of the core elements of training. Previous to the health champion
programme, very few people were accessing the level 1 training each year. Since
November 2011 we have had over 1,100 people attend the level 1 training many of
which have then gone on to train as level 2 AI advisers.
Outreach - We will strengthen our proactive approach when we identify health issues
arising in specific neighbourhoods or communities in the city and work with local
people in a focused way to address the particular issues e.g. stop smoking services
for young pregnant women, disadvantaged neighbourhoods, routine and manual
occupations etc.
Support for Healthy Living - Recognising that some people need extra support to
make the necessary changes to improve their mental or physical health; we will have
Live Life Well coordinators who will help people to build a plan for themselves and/or
their families using the opportunities available that best suit their daily lives. They will
also support them in accessing the necessary opportunities such as stop smoking
services, but with the aim of people accessing opportunities independently as quickly
as possible.
Further opportunities - Finally, there will be a range of commissioned and noncommissioned direct delivery such as level 2 AI Stop Smoking Services. In addition,
there will be signposting and support into a range of opportunities for improved
mental and physical wellness offered by other sectors in the city as well as further
development of peer support. Stop smoking support is delivered by competent and
motivated Level 2 AI providers in GP, pharmacy and community settings. A team of
dedicated mentors provide intensive support and training to advisors to enable them
to deliver the service to anyone wanting to quit, including priority groups such as
pregnant smokers, BME communities and people with mental health issues.
Role of City Hospitals Sunderland
City Hospitals Sunderland will want to ensure that we maximise opportunities for
smokers to quit, offering brief intervention and support at opportunist moments within
patients care. Nicotine management care plans should be supported whilst in
hospital and proactive signposting to local services on discharge.
A comprehensive offer of support should be given to all pregnant women who smoke
via the community midwife with continued follow up at each appointment. All
pregnant women who smoke should be offered a home visit via a maternity health
care assistant or support via the Live Life Well Service who will signpost them to their
local GP Practices or local Pharmacy.
Role of Clinical Commissioning Groups
CCGs will want to ensure that we maximise opportunities for support to smokers via
local contracts and adopt the ‘make every contract count’ approach for example
maternity services are effective in reducing the prevalence of smoking in pregnancy
and this reduces the risks associated with premature births and perinatal mortality
caused by smoking. Further partnership working across agencies including CCGs
can maximise opportunities for further quitters and awareness of support for
smokers.
Role of Community Pharmacies
Currently community pharmacies are responsible for nearly half of all quits in
Sunderland. There is wide variation on number of quit dates set and rates of
successful quitters. Further engagement and partnership working with the Live Life
Well service mentors will help to address some of the variations in service delivery.
Role of GP Practices
Currently GP Practices are responsible for nearly half of all quits in Sunderland.
There is wide variation on number of quit dates set in each practice and rates of
successful quitters. Further engagement and partnership working with the Live Life
Well service mentors will help to address some of the variations in service delivery
4) Projected service use and outcomes in 3-5 years and 5-10 years
Smoking rates have continued to decline slowly over the past decade, but
Sunderland has a persistent high rate of smoking in routine and manual occupations
and pregnant women. Therefore continued support of the tobacco control agenda
and commissioned services will be essential in ensuring that the number of people in
these groups is reduced in Sunderland.
Over the next five years the estimated number of smokers projected to stop smoking
will increase, but with the continued growth in the use of e-cigarettes this has
decrease the number of people accessing local stop smoking services. Many people
are turning to e-cigarettes to help them quit, and e-cigarettes now the most popular
quitting aid with emerging evidence suggesting they can be effective for this purpose.
Regular e-cigarette use is confined almost entirely to smokers and ex-smokers.
The NICE tobacco Return on Investment tool has been developed to help decision
making in tobacco control. In Sunderland the potential saving from investing in
tobacco control is, for every £1 spent, it equals to £2.07 by five years, £3.92 by ten
years and £11.98 over the lifetime of a smoker who quits.
5) Evidence of what works
Regionally, Fresh – Smoke Free North East (FRESH) is based on an internationally
established evidence base for tobacco control as advocated by the World Health
Organisation.
Evidence of effective practice can be found in many guidance documents
produced by the national institute for health and care excellence (NICE). Such
documents include:
 A Smokefree Future – a Comprehensive Tobacco Control Strategy for
England (DH, February 2011)
 Healthy Lives, Healthy People: A new Tobacco Control Plan for England (DH,
March 2011)
 Stop Smoking Service Delivery and Monitoring Guidance 2011/12 (DH, March
2011)
 Excellence in Tobacco Control: 10 High Impact Changes (May 2008)
 NICE public health intervention guidance 10: Smoking cessation services in
primary care, pharmacies, local authorities and workplaces, particularly for
manual working groups, pregnant women and hard to reach communities
(2008)
 NICE public health intervention guidance 1: Brief Interventions and referral for
smoking cessation in primary care and other settings (March 2006)
 NICE public health intervention guidance 5: Workplace interventions to
promote smoking cessation :how to help employees stop smoking (2007)
 NICE public health guidance 6: Behaviour change (Oct 2007) (covers
individual level, community level and population level programmes, planning,
delivery and evaluation)
 NICE public health guidance 9: Community engagement (2008)
 NICE public health guidance 14: Preventing the uptake of smoking by children
and young people (2008)
 NICE public health guidance 23: School based interventions to prevent
smoking (2010)
 NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth (2010)
 NICE public health guidance 39: Smokeless tobacco cessation - South Asian
communities (2012)
 NICE public health guidance 45: Tobacco harm reduction (2013)
A number of other NICE guidelines relating to tobacco control can be found at:
http://pathways.nice.org.uk/pathways/smoking
6) User Views
Public Knowledge Engagement - In March 2013 the Sunderland tPCT Public
Health team commissioned a social marketing exercise in the form of qualitative
research from an independent organisation to deliver a detailed understanding of
levels of awareness, barriers to accessing services and motivational factors in
reference to making healthy lifestyle changes. They found that:
Integrated Approach & Communications
Many respondents raised the issue of being offered wellness services in isolation, as
a reactive response to an individual problem, rather than as a holistic approach to
their total wellbeing. They recognised that many wellness issues are interrelated and
would welcome being provided with information about nutrition and weight
management when accessing a stop smoking service, for example. There was an
overall feeling that there is a lack of communication between different service
providers and a lack of awareness from some health professions and health care
providers about other services that service users could benefit from.
There was also a general feeling that health professionals and health service
providers were detached from community organisations, a sentiment that was shared
by some of the community support workers interviewed. While not the case for
everyone, a high proportion of respondents were interested in attending community
groups, particularly those which were inclusive of the whole family and which support
multiple lifestyle changes such as offering nutritional information alongside exercise
classes.
Key recommendations:
 Wellness services ought to take a more integrated approach, with each
providing information that may cut across other services in order to address
individual needs (e.g. offering weight management advice to those accessing
a stop smoking service)
 NHS services and community organisations should take a more united
approach in offering support for lifestyle changes, although community
activities and sessions must be better advertised in order for this to be
successful
 To target those who are not accessing services, a wide variety of
communication channels should be utilised and a central directory of local
services should be compiled. To target those who have accessed services in
the past, gentle reminders and follow-ups could promote re-engagement
 Information needs to be advisory in tone, rather than dictatorial, be suitable
for all educational abilities and address any questions and issues that people
might have
In the case of smoking, excessive alcohol consumption and drug abuse, there was a
worrying sense that many people won’t change their behaviours until they are
personally affected by the consequences. For that reason, a CAT scan or other
method to show internal damage was suggested by some as the most effective way
of encouraging people to change their behaviour.
For those who had already quit smoking, reduced their alcohol consumption or
stopped using drugs, the support and encouragement of friends and family proved
critical. For many, just having children or committing to a new relationship was
enough to initiate a change. There was an overall consensus between those who
were still engaging in these behaviours, those who had already made changes and
those who offered community support that it is particularly important for smoking,
alcohol and drug services to be delivered by ‘normal’ laid-back people who have had
their own personal experience of overcoming an addiction.
While some suggested that the cost of buying tools to support them through the
quitting process was the reason for continuing to smoke (including one lady who said
she’d rather buy a sleeve of cigarettes for the price of an electronic cigarette), there
was a sense that these were just excuses to cover either not having the motivation or
the support to quit.
Key recommendations:
 Family, friends and people who have been through the same experiences
need to be encouraged to take a more active role in supporting a person to
overcome an addiction as this type of support is pivotal to success
 As many still won’t make changes until they are personally affected by the
consequences of their actions, there is need for the NHS to think of an
inventive,
 new method of showing the risks of alcohol, cigarettes and drugs
 There is a requirement for more advice and education around ‘binge drinking’
as many do not think the term applies to them despite their reported
behaviours suggesting otherwise
Smokefree Play Areas Engagement - During August 2013 the locality public health
team in Sunderland carried out a survey of 347 local people in various parks across
the borough to seek local views on whether ‘Smoking should be banned in outdoor
children’s play areas in Sunderland’. 98% said that they agreed or strongly agreed
with this statement indicating the very strong support for this position to be
considered in Sunderland, (37% of those completing the survey were smokers or exsmokers).
Health Related Behaviour Survey carried out in 2012 it showed that most students
aged 12 to 15 had never smoked and year ten girls were more likely to smoke than
boys. When these rates are compared to a Health Related Behaviour research
carried out by Sunderland College which found that 20% of students reported starting
smoking after they had started college, meaning 7% of smokers start between year
10 and starting college.
Illicit Tobacco – In 2015 an independent Illicit Tobacco North East Study was
commissioned. NEMS market research, they found that 9% of all tobacco smoked in
the North East is illegal, with Sunderland slightly higher than the regional average at
11%, 21% of smokers buy illegal tobacco - slightly higher than the regional average
of 18%. Just over a third (38%) of smokers have tried illegal tobacco at some point.
7 out of 10 people who do buy illegal tobacco get it from one single source with 39%
of illegal tobacco buyers in Sunderland buy it from fag houses, 15% buy it from a
shop and 5% from a pub or club. 12% of current smokers in Sunderland say they are
often offered illicit tobacco.
7) Equality Impact Assessments
Age
Children growing up with parents or siblings who smoke are 90% more likely to
become smokers themselves than those who do not. In England smoking
prevalence is highest among young adults: 23% of those aged 16-24 and 25%
among the 25-34 age group. Smoking continues to be lowest among people aged 60
and over. Although they are more likely than younger people to have been smokers,
they are more likely to have stopped smoking. However, there has been a significant
decline in smoking among young adults aged 16-19, reflecting the decline in uptake
of smoking among children.
Disability
At the time of writing we found limited published data on smoking and disability
on an England wide basis.
Mental Health
A recent ASH Fact Sheet found that there is a strong association between smoking
and mental health conditions. Smoking is the main cause of reduced life expectancy
in those with a mental health condition. Those with a long standing mental health
condition are three times more likely to smoke as those without.
Gender/Sex
In 2012 nationally the prevalence of smoking was 22% in men and 19% in
women. Nationally smoking prevalence among men is highest in the 25-34 age
group at 32%. Smoking is highest among women at 29% in the 20-24 year old
age group.
Nationally, of those who smoke, more men (40%) smoke hand-rolled cigarettes
than women (23%).
Marriage and Civil Partnership
At the time of writing we found little published evidence regarding the presence of
inequalities and tobacco use among individuals in a same sex marriage or civil
partnership. Nationally the prevalence of cigarette smoking varies according to
marital status. Smoking prevalence was lower among individuals who are in an
opposite sex marriage (13%) than among those who were single (27%);
cohabiting (29%); widowed, divorced or separated (21%). There is no current
evidence relating to tobacco usage and civil partnership.
Pregnancy and maternity
Smoking in pregnancy is more common in disadvantaged groups and younger
mothers.
Race/Ethnicity
Smoking rates vary considerably between ethnic groups but are generally lower
among people from ethnic minorities, although there are gender differences.
While smoking rates have decreased in the general population, this pattern is not
reflected among black and minority ethnic communities. Nationally, smoking rates
among men are particularly high in Black Caribbean (37%), Bangladeshi (36%)
and Chinese men (31%) The rate for White English men is 27%. Indian men have
lower smoking rates (15%). Nationally among women, smoking rates among
minority ethnic groups are low compared to the general population (at 8% or
below) with the exception of Black Caribbean (24%) and Irish (26%).
Religion/belief
Religion and cultural beliefs may have an influence on some communities’
attitudes towards tobacco use. The use of smokeless tobacco is embedded in
many aspects of South Asian culture and cultural beliefs, in particular chewing
tobacco which is either chewed alone or with betel quid/ paan. It has symbolic
implications at religious and cultural ceremonies. Chewing tobacco is most
commonly used by the Bangladeshi community with 9% of men and 19% of
women reporting that they use chewing tobacco. However these figures may
reflect a degree of under-reporting by some respondents.
Cancer Research UK cites chewing tobacco as a risk factor for cancer, and
furthermore one systematic review of health effects associated with smokeless
tobacco concluded that evidence (in India) showed an association between
chewing betel quid and tobacco with a risk of oral cancers.
Sexual Orientation
A recent ASH Fact Sheet showed lesbian, gay and bisexual (LGB) people are more
likely to experience health inequalities and have higher rates of smoking. Data from
the Integrated Household Survey 2014 (HIS) shows that 25.3% of gay/ lesbian
people smoke compared to 18.3% of heterosexual people. Young LGB people are
more likely to smoke, to start smoking at a younger age and smoke more heavily.
Trans-gender/gender identity
A recent ASH Fact Sheet found that there is a lack of research on smoking amongst
trans people, but surveys do show that trans people are more likely to smoke.
8) Unmet needs and service gaps
Many pregnant women continue to smoke thus the needs of these women are not
being met. Sunderland City Council, Live Life Well Service, City Hospitals
Sunderland and Sunderland Clinical Commissioning Group commissioners need to
ensure services are commissioned to meet their needs. Health professionals need to
be trained to give appropriate support on stopping smoking.
Smoking rates are highest in the most disadvantage wards, thus the needs of these
people are not being met. Live Life Well Service and Sunderland City Council need
to ensure that services are commissioned to meet the needs of the people who live in
these wards.
Smoking rates are continuing to rise in routine and manual occupations, thus the
needs of these people are not being met. Live Life Well Service and Sunderland City
Council need to ensure that stop smoking services are commissioned to meet the
needs of these occupational groups.
Some young people continue to take up smoking, therefore we need to ensure that
we continue to educate young people on the harms of smoking, and ensure services
are appropriate to the needs of young people. Live Life Well Service and Sunderland
City Council need to ensure that services are commissioned to meet the needs of
young people.
There is currently no referral pathway from Northumberland Tyne and Wear Trust to
community stop smoking services if a person has stopped smoking within the NTW
setting. This is a gap in the current pathway, and needs to be addressed.
There is currently no referral pathway from City Hospitals Sunderland to community
stop smoking services if a person has stopped smoking within the CHS setting. This
is a gap in the current pathway, and needs to be addressed.
There is currently no a pathway in place in the local stop smoking services to support
people using of e-cigarette to quit. This is a gap in the current pathway, and needs to
be addressed.
9) Recommendations for Commissioning
1. A holistic approach to tobacco control is continued throughout Sunderland,
recognising that Stop Smoking Services and stop smoking interventions in
isolation should not be regarded as the main drivers for reducing smoking
prevalence. Therefore a comprehensive tobacco control plan involving a range
of partners has to be in place, and the Sunderland Tobacco Alliance is
proactively supported through partnership working.
2. Continue the commissioning of a holistic approach to tobacco control through the
Live Life Well model, and the Live Life Well Service. The Live Life Well service
target the areas of high prevalence by increasing the service provision in these
areas which traditionally have low rates of access, thus reducing the levels of
smoking in routine and manual workers by engaging them in accessible services
which they want to use.
3. To ensure that young people don’t start smoking in their teenage years, continue
the work with secondary schools across the City, and ensure that the health harm
messages are appropriate to the needs of young people. Increase provision of
Stop Smoking Services within youth organisations and schools
4. Improve the current stop smoking pathway for pregnant women, and ensure they
are offered appropriate support and advice. Health harm messages to be
delivered that are appropriate to their needs. Increase provision of Stop Smoking
Services within Children Centres.
5. Ensure that smoking is no longer accepted as the norm, and make parks in
Sunderland free from tobacco smoke.
6. To ensure services meet the needs of priority groups such as BME, LGBT,
routine and manual occupations, pregnant women within Sunderland by
engaging the community and delivering services appropriate to need.
7. To improve the current stop smoking pathway and ensure community tier 2 stop
smoking services can receive referrals from Northumberland, Tyne and Wear
Mental Health Trust and City Hospitals Sunderland via a robust electronic
method.
8. Consider the use of e-cigarette to support smokers to quit and e-cig friendly stop
smoking services in Sunderland.
10) Recommendations for needs assessment work
Health Equity Audit of the Live Life Well Service to ensure that it is targeting the
population in most need of stop smoking support especially the risk groups identified
in the JSNA.
Key contacts
Julie Parker-Walton, Public Health Lead, [email protected]
0191 561 7819