DATE: 9 APRIL 2015 TITLE OF REPORT: A Tobacco-Free Future for Northumberland

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1 B COMMITTEE: HEALTH & WELLBEING BOARD DATE: 9 APRIL 2015 TITLE OF REPORT: A Tobacco-Free Future for Northumberland Report of Director of Public Health, Penny Spring Policy Board Member: Cllr Susan Dungworth, Policy Board Member for Adult Social Care and Public Health Purpose of report: The purpose of this report is to update the board on tobacco control strategy, make suggestions for further improvement, seek endorsement of the aspirational vision of 5% or fewer people smoking by 2025 and to consider signing up to the Local Government Declaration on Tobacco Control. Recommendations: 1. That the Board acknowledges the work of the public health team and partners and supports further strategic development of tobacco control work in Northumberland. 2. That the Board endorses the regional vision of 5% smoking prevalence, or less, by That the Board authorises the NCC and HWBB sign-up to the Local Government Declaration on Tobacco Control. 4. That Board members take the Declaration to their own organisations for consideration and sign-up. Link to Corporate Plan This report is relevant to the Health and Wellbeing priority included in the NCC Corporate Plan Key issues Smoking remains the single largest cause of preventable illness and early death in the world. It causes more deaths in England than anything else nearly 80,000 in 2011 as well as impacting on smokers families with UK hospitals seeing around 9,500 hospital admissions of children with illnesses caused by second-hand smoke i. Smoking is a major risk factor for many diseases such as cancers, heart disease and chronic lung disease. Smoking related deaths are declining in our county, following the same rate of decline as England overall (Table 1), but our number of deaths per 100,000

2 population is greater than the England average and represents 624 deaths per year in Northumberland. Excellent progress has been made locally over recent years, with adult smoking prevalence declining steadily for more than a decade and from 26.6% in 2009 to 17.6% in 2012, a remarkable change in such a short space of time. Latest data in the Integrated Household Survey (IHS 2013) however indicates that smoking has increased slightly in Northumberland to 19.7% (Table 2) but it is too soon to understand why this is or to anticipate a change in trend. We can estimate that we still have approximately 45,000 smokers in our population. Each year this smoking costs society approximately 71.9m ii. Table 1: Number of smoking related deaths per 100,000 population over 35 years old Table 2: Smoking prevalence in adults It is children who start smoking, not adults. We all want a safe and happy future for our children and we can achieve this by taking smoking seriously. Our vision is to create a Northumberland where all babies are born healthy and prosper; where children grow up without harm; where young people have aspirations to do well and where adults lead long and healthy lives

3 In spite of the considerable success in reducing smoking prevalence over the last 20 years, smoking still remains the leading cause of preventable illness and death. There are still over 45,000 people smoking in Northumberland, 90% of whom say they regret ever having started. In addition 9000 young people in the north east take up smoking every year and 15 people in our region die every day from smoking-related conditions. Action to support smokers to stop and to prevent young people starting needs to continue at a scale and pace which will realise the ambition of a 5% vision and the associated improvements in health and wellbeing outcomes and reduction in health inequalities. Smoking in Pregnancy Tobacco is the single most modifiable cause of poor pregnancy outcomes. Smoking during pregnancy increases the risk of, complications during labour, miscarriage, premature birth, still-birth, low birth weight and sudden unexpected death in infancy. Smoking during pregnancy also increases the risk of infant mortality by an estimated 40%. iii Northumberland s smoking at time of delivery (SATOD) rate is significantly worse than the England average at 16.2%. England s rate is 12%. Local discussions on maternal smoking have led to the development and implementation of BabyClear, a project commissioned by Fresh, backed by Foundation Trust Chief Executives, and with the Tobacco Control Collaborating Centre delivering various components of behalf of Fresh. There are four aspects to BabyClear. A simple overview is: Skills training has been delivered to around 400 midwives and midwifery staff in North East maternity units, and to over 100 advisers from all six NHS Stop Smoking Services (SSS), and to Stop Smoking Service admin teams on how best to contact and engage with women referred into the NHS SSS. A systematic approach to carbon monoxide (CO) monitoring has been implemented so that every woman in every Trust is tested at first booking appointment (around 8 weeks), and all readings over 3 parts of carbon monoxide per million are referred to the NHS Stop Smoking Service within 48 hours. Every midwife/health care professional undertaking these bookings has a new simple monitor and has been assigned a unique number for performance monitoring of activity internally by each Trust. For those smokers receiving this initial booking intervention who do not quit or engage with the Stop Smoking Service, a harder-hitting Risk Perception intervention is delivered by a specially trained midwife at the dating scan (approximately week 12). This is using new software and resources to ensure that the risks of continued smoking are fully understood by the pregnant woman, and to offer a referral into the NHS SSS. Systems for monitoring and evaluation of the project, including an in-depth evaluation led by Newcastle University which is tracking 30,000 pregnancies in the North East. The comprehensive training programme for midwives was implemented in 2013 resulting in all pregnant women receiving a carbon monoxide reading and referral to stop smoking support as part of their routine care by late 2013/early The BabyClear programme may be contributing to an improvement locally. The SATOD rate in Northumberland has declined rapidly from 20.9% in 2009/10 to 16.2% in 2013/14 which is encouraging although it s a little early to attribute this to BabyClear. Evidence - 3 -

4 indicates that around two-thirds of mothers who quit during pregnancy relapse within one year of giving birth. The O-5 public health contract for has included an indicator to increase the number of mothers who stopped smoking pre-conceptually or during pregnancy and who are still smoke free at their baby s first birthday. Health visitors have a key public health opportunity to support women and families to stop smoking and to remain stopped. The BabyClear scheme needs to remain a high priority within maternity services as a routine part of antenatal care, working with the specialist Stop Smoking Service to support pregnant women and their partners/significant others to stop smoking and maintain their smoke free status. Children and young people It is children who start smoking, not adults. 90% of smokers start before the age of 19 and children are three times more likely to start smoking if their parents smoke. iv If smoking is seen by young people as a normal part of everyday life, they are much more likely to become smokers themselves. 99% of 16-year old regular smokers live in a household with at least one other smoker. In order to create a society where smoking is not the norm, the adult world in which children grow up needs to change with adults quitting, tobacco becoming unattractive to young people and difficult to acquire and environments including cars and homes, being smoke free. We have made some progress with these approaches including policy support to schools from the Wellbeing and Health team and encouragement to schools to take part in the Fresh Smoke Free Quality Standard. The national drive toward standardised packaging is welcomed. However, our potential increase in adult prevalence is a cause for concern and warrants a return to a greater emphasis on young people s prevention work and educational approaches to complement the wider tobacco control measures. This needs to be done in the wider context of changing adult smoking through comprehensive action. The biggest influence on children smoking is adult smoking. Smoking and long-term conditions Smoking is a major contributory factor to some of the most debilitating and life-limiting illhealth conditions. Not only does smoking kill half of its long-term consumers prematurely, it also burdens its victims with chronic disease such as chronic obstructive pulmonary disease (COPD). People with COPD have difficulties breathing, primarily due to the narrowing of their airways, and experience symptoms including: increasing breathlessness when active a persistent cough with phlegm frequent chest infections A successful comprehensive strategy on tobacco control will ultimately contribute to the prevention of such conditions. Once people are diagnosed with a smoking-related disease it is crucial that support to stop smoking is a routine part of their clinical care. Northumbria Healthcare NHS Trust has commenced the implementation of the NICE guidance on - 4 -

5 smoking cessation in the acute setting. Consideration needs to be given to the formalisation of commissioning pathways to support this work. Clinical pathways can be strengthened to support all patients to stop smoking. GP practices, pharmacies and our acute trust all have some excellent good practice in place, however more needs to be done to support patients with the greatest needs. Further work needs to be undertaken to commission and implement robust pathways for all patients and clients, integrated between settings. Smoking and mental health Smoking is around twice as common among people with mental health disorders and even higher among those with more severe mental health disease. v People suffering from mental health problems who also smoke generally display patterns of heavy smoking and severe nicotine dependence. In contrast to the marked decline in smoking prevalence in the general population, smoking among those with mental disorders has changed little, if at all, over the past 20 years. These smokers are just as likely to want to quit, but are more likely to be heavily addicted to smoking and to anticipate difficulty quitting smoking, and historically less likely to succeed in any attempt to quit. vi The Northumberland Tyne and Wear Mental Health Trust is planning a programme of work to address the recommendations set out in the NICE guidance on smoking cessation in this setting. This can be further supported by commissioners of mental health services and the public health commissioned stop smoking and tobacco control support. The cost of smoking Smoking costs billions of pounds each year. The Action on Smoking and Health (ASH) ready reckoner tool has been developed to estimate the local costs of smoking to society. Using best available data and representative synthetic estimates, the tool takes into account costs relating to; Lost productivity due to early smoking-related deaths due to smoking breaks due to smoking-related sick days Costs to NHS Direct costs of treating smoking-related illnesses Costs of healthcare events caused by passive smoking Social care costs Costs of smoking-attributable fires Extent of smoking-related litter (cigarette butts) Tobacco duty contributions Lost productivity - With our estimated smoking population of 45,022, the ASH tool estimates our overall cost due to smoking to be 71.9m. Every year smoking-related early deaths in Northumberland result in 902 years of lost productivity. This costs the local economy approximately 16m. It is estimated that smoking breaks cost businesses in Northumberland a further 31m annually. Local businesses lose approximately 45,697 days of productivity every year due to smoking-related sick days. This costs about 4m. Costs to NHS - The total annual cost to the Northumberland NHS Trusts as a direct result of smoking-related ill health is approximately 12m. Passive smoking impacts on the - 5 -

6 health of non-smokers in Northumberland, costing the local healthcare system a further 1m every year. Social care costs - Current and ex-smokers who require care in later life as a result of smoking-related illnesses cost society an additional 3.5m each year. This represents 2m in costs to the local authority and 1.5m in costs to individuals who self-fund their care. Costs of smoking attributable fires Smoking materials are a major contributor to accidental fires in Northumberland. Each year there are around 33 smoking-related fires resulting in approximately 3 deaths. This impacts on the local economy to the sum of approximately 4m every year. This represents about 2.9m due to deaths, 217,000 due to injuries and 605,000 due to the non-human cost of smoking related fires. Smoking-related litter The majority of cigarette filters are non-biodegradable and must be disposed of in landfill sites. In Northumberland around 213m filtered cigarettes are smoked each year, resulting in approximately 36 tonnes of waste annually. Of this, more than 8 tonnes of cigarette waste is discarded as street litter that must be collected by local government street cleaning services. Background What is Tobacco Control? Tobacco control is an evidence-based multi-disciplinary approach to tackling the burden of tobacco and smoking on our society and reducing the morbidity and mortality it causes. It has long been recognised (WHO, 1979) that tackling smoking requires an over-arching and comprehensive tobacco control strategy. This work is not just the domain of the NHS - 6 -

7 and needs to address the three main elements of tobacco control Prevention, Protection and Cessation. It includes activities that strive to reduce the demand for, and supply of, tobacco in communities. Nationally, six strategy strands have been devised and at a local level these have been added to, to make an 8-strand action plan. The 8 strands in the Northumberland action plan are: 1. Developing infrastructure, skills and capacity for effective tobacco control and influencing action 2. Reducing exposure to second-hand smoke 3. Supporting smokers to stop 4. Media, communications, social marketing and effective education 5. Reducing the availability and supply of tobacco products- licit and illicit-and addressing the supply of tobacco to children 6. Tobacco regulation 7. Reducing tobacco promotion 8. Research, monitoring and evaluation Locally the plan is held and managed by the partnership group, Smoke Free Northumberland, and informed by Fresh, the regional office for tobacco control and the North East Tobacco Control Partnership (formerly called the Regional Advisory Group). The key issues in this report, if agreed as priorities by the Board, will strengthen the local action plan. Local impact The Smoke Free Northumberland partnership has been guided by public health to address all 8 strands of the local strategy. Public Health has commissioned the coordination of this work from the Northumbria Healthcare NHS Trust Health Improvement Team. Northumbria Healthcare is also commissioned to provide the specialist NHS Stop Smoking Service which has enjoyed great success over a period of more than 10 years. In addition, Public Health commissions GP practices and pharmacies to deliver stop smoking services, creating an NHS whole system for support and treatment. Out of an estimated smoking population of 45,000, the Stop Smoking Service (including primary care) supported approximately 7% of smokers last year, but the volume of smokers accessing these services is declining. This picture is reflected regionally and nationally. Other elements of the plan, such as illicit tobacco and tobacco regulation are led by the Public Protection team at Northumberland County Council. Other partners on the Smoke Free Northumberland alliance include children s centres, education, maternity services, fire and rescue and Northumbria Healthcare NHS Trust health improvement and stop smoking services

8 Beyond tobacco control The partnership approach in Northumberland, the commissioning of a regional office and the provision of a whole-system evidence-based support and treatment service for smokers has combined to deliver real improvements in the prevalence of smoking. However, latest figures show a slight increase in smoking prevalence in Northumberland and the recently conducted Northumberland Lifestyle Survey confirms that people living in our more disadvantaged communities continue to smoke. Working toward a tobacco-free future for our children, stating that all partners on the Board endorse the 5% or less regional vision, will give much needed renewed emphasis to tobacco control work in our county. The 5% vision is extremely challenging and will not be achieved by local activities alone, but our aspiration will galvanise local efforts and combine with regional and national initiatives. Why sign a declaration? There are two related declarations one for local government and one for NHS organisations. Their purpose is to encourage these organisations and their partners to commit to taking action, to protect their local communities from the harms caused by smoking and demonstrate local leadership and acknowledge best practice. It is a statement of a council s commitment to ensure tobacco control is part of mainstream public health work and commits councils to taking comprehensive action to address the harm from smoking. Since it was launched in May 2013, over 80 councils across the country have signed the Declaration. In August 2014, a sister document to the Declaration, the NHS Statement of Support was launched to allow NHS organisations to show their support for tobacco control. The Declaration commits councils to: Reduce smoking prevalence and health inequalities Develop plans with partners and local communities Participate in local and regional networks Support Government action at national level Protect tobacco control work from the commercial and vested interests of the tobacco industry Monitor the progress of our plans Join the Smokefree Action Coalition The Declaration has also been widely endorsed by leading figures and organisations in the public health community and mirrors much of the work being undertaken by Northumberland County Council and its partners. The Health and Wellbeing Board is asked to sign the local government declaration under its own auspices and that of Northumberland County Council. NHS organisations are being approached to sign the NHS declaration which also asks for support from the council - 8 -

9 via the Director of Public Health. Both statements provide a visible opportunity for organisations, boards and partners to publicly acknowledge the role that addressing smoking can play in protecting local communities from tobacco-related harm, and in improving clinical outcomes and preventing ill health. Implications Policy Agreement to the recommendations in this report will set the priorities for improving the health and wellbeing of Northumberland residents through targeted action on tobacco control. Finance and value for money Agreeing to the signing of the declaration on tobacco control will assist partners in achieving the vision and targets set out in the Smoke Free Northumberland tobacco control plan. HWBB endorsement will influence the prioritisation of resource for its successful development and implementation. There are no costs or specific initiatives that we commit ourselves to by signing the declaration. Legal Procurement Human Resources Property Equalities (Impact Assessment attached) Yes No N/A Risk Assessment Crime & Disorder Customer Consideration Carbon reduction Wards The signing of the Local Government Declaration on Tobacco Control commits the authority to the specified strategic aims. The vision and declaration relate to strategic commitment rather than specific procurement of services. There are no specific implications for human resources but adopting the shared vision and signing the declaration will lead to greater collaboration and joint working across organisations. None Implementation of the recommendations will improve the health and wellbeing of people in many of the groups with protected characteristics under the equalities legislation. Appropriate specific actions arising from the tobacco control work will be subject to the NCC EIA process. Agreeing to the recommendations will assist in the mitigation of the risk that the council does not meet its obligations and aspirations set out in the NCC Corporate Plan and the Health and Wellbeing Strategy. Action arising will contribute to the council s work addressing the tobacco indicators in the Public Health Outcomes Framework. None The fundamental aim of the vision and declaration is to commit to improving the health and wellbeing of Northumberland residents. None All but with appropriately targeted work in wards with greater numbers of smokers or tobacco-related burden

10 Background papers: Report sign off. Finance Officer Monitoring Officer/Legal Human Resources Procurement I.T. Executive Director Portfolio Holder(s) initials JB LH PG TP NA DL SD Author and Contact Details Kerry Lynch, Public Health Specialist, Northumberland County Council. tel:

11 References i ii iii Department of Health. Healthy Lives Healthy People. A tobacco control plan for England. DH (2011) ASH (Action on Smoking and Health) The Local Cost of Tobacco. ASH Ready Reckoner (2014) National Institute for Health and Clinical Excellence. Quitting smoking in pregnancy and following childbirth: Guidance. NICE (2010) iv Smoking attitudes and behaviours. ONS (2011) v Royal College of Physicians, Royal College of Psychiatrists. Smoking and mental health. RCP (2013), RCoP Council Report CR178 vi Action on Smoking and Health. Smoking and mental health, ASH (2013)