for Directors of Public Health NORTH West Version 12.0 5 th October 2012

1. THE CASE FOR ACTIONon TOBACCO USE & SMOKINGHarms caused by tobacco use & an overview of local tobacco policies to aid commissioning for Directors of Public Health NORTH West Version 12.0 5th October 2012

2. 1. Scale of the challenge

3. Each year smoking causes the greatest number of preventable deaths HIV: 529 Traffic: 2,502 Alcohol: 6,541 Drug misuse: 1,738 Suicide: 5,377 Smoking: 81,400 Obesity: 34,100 References:1. ASH Factsheet, Smoking Statistics: illness & death, June 2011 (http://www.ash.org.uk/files/documents/ASH_107.pdf) NB area represents value References:1. ASH Factsheet, Smoking Statistics: illness & death, June 2011 (http://ash.org.uk/files/documents/ASH_107.pdf) NB area represents value

4. The decline in smoking rates has stalled Note to customise this chart: Save this presentation to your computer Double click the chart to enter values for your region and your locality Local data can be found at http://www.lho.org.uk/viewResource.aspx?id=16649 Delete these instructions Save the revised presentation. References:1. Integrated Household Survey 2010 (mid-point estimate for locality given small sample size and large confidence interval)

5. National children’s rates of smoking (age 11 – 15) References:1. Smoking, drinking and drug use among young people in England in 2009. National Centre for Social Research, 2010: NHS Information Centre for Health and Social Care.

6. The majority of smokers are from manual and routine occupations Number of smokers by occupation (millions, 2010) References:1. Smoking, drinking and drug use among young people in England in 2009. National Centre for Social Research, 2010: NHS Information Centre for Health and Social Care.

7. Smoking-related diseases Smoking attributable deaths from major diseases (2009) References:1. NHS Information Centre (2009), Statistics on smoking: England 2009 available at www.ic.nhs.uk/webfiles/publications/smoking09/statistics_on_smoking_england_2009.pdf

8. The annual cost of smoking to smokers(compared to additional costs to our community) Note to customise this chart: Double click on the chart to open the data sheet to input values for your locality. The example of Blackpool is used in this illustration. Open the Local Costs of Smoking spreadsheet to calculate the costs in your locality – instructions on how to use the spreadsheet' are contained within it. Paste the chart from the spreadsheet into this presentation. The spreadsheet also allows you to print off a handout to use with this presentation. Annual estimated costs of smoking to the individual and society References:1. Cough Up, Policy Exchange, 2010, 2. HMRC, 3. 'Reckoner' spreadsheet for calculated estimated local costs (ASH, 2011)

9. Smoking costs the local economy millions every year The annual cost of smoking in this local area (£millions) Note to customise this chart: Save this presentation on your computer Delete the sample chart Open the Local Costs of Smoking spreadsheet to calculate the costs in your locality – instructions on how to use the spreadsheet are contained within it Select a chart and paste it into this document The spreadsheet also allows you to print off a handout to use with this presentation. References:1. Cough Up, Policy Exchange, 2010 2. 'Reckoner' spreadsheet

10. If we do nothing… Evidence and experience show that when anti-smoking campaigns cease: Fewer adults are prompted to quit, more children start smoking, the effect is heaviest on the poorest Following Ireland’s smokefree legislation (2004) smoking rates declined sharply. When smoking was allowed to become more affordable and support for smokers to quit diminished smoking rates began to rise again.   The decline in smoking resumed following above inflation tax increases in 2008 References:1.Monthly survey for smoking rate in England, Smoking Toolkit, UCL 2011l’, smokinginengland.co.uk

11. 22 22 23 19 19 22 18 22 19 Local smoking rates differ greatly All across England there is more room for progress... … and international experience shows more can be achieved: in Smoking rates in New York City has fallen from 21% in 2001 to a historic low of 14% within a decade References:1. Smoking & drinking among adults, 2009. General Lifestyle Survey, ONS, 2011. 2. http://www.cdph.ca.gov/Pages/NR11-031.aspx

12. 2. Smoking attitudes & behaviours

13. Actions to break the ‘cycle of smoking’ Protect families & communities Reduce the appeal and supply of tobacco Encourage more quit attempts each year Support quit attempts

14. Children not adults start smoking Age smokers start smoking: 90% of smokers started before the age of 19 18 is the age at which you can legally buy tobacco References:1. Smoking Attitudes & Behaviours, ONS 2011

15. Children are three times as likely to start smoking if their parents smoke1 99% of 16 year old regular smokers live in a household with at least one other smoker1 Smoking prevalence in 11-15 year olds by number of smokers they live with1 References:1. Smoking, drinking and drug use among young people in England in 2010, ONS

16. Women in low-paid work are 3 times more likely to smoke during pregnancy Socio-economic group: % who smoked before or during pregnancy References:1. Infant Feeding Survey, ONS 2011

17. Teenagers are almost 4 times more likely to smoke whilst pregnant compared with those over 35 References:1. Infant Feeding Survey, ONS 2011

18. Each year nearly 10,000 children are treated in hospital for exposure to second-hand smoke References:1. Passive smoking and children, A report by the Tobacco Advisory Group of the Royal College of Physicians, March 2010

19. The poorer you are the more likely you are to smoke References:1. General Lifestyle Survey, ONS, 2010

20. Smoking not social status is the greatest cause of health inequalities Smokers from the highest social class have a lower life expectancy than non-smokers in the lowest social class 3.50 3.00 2.50 The life expectancy between rich and poor smokers is similar 2.00 Relative mortality Richer smokers have a lower life expectancy than poorer non-smokers 1.50 1.00 0.50 0.00 I+II IV+V Social Class Highest Lowest Male non-smokers Male smokers References:1. Gruer L et al. BMJ 2009;338;bmj.b480 (Relative mortality assessed at 2nd 14 year follow-up between male smokers & non-smokers of highest & lowest social class)

21. Certain minority groups & ethnic groups smoke at higher than average rates References:1. Passive smoking and children, A report by the Tobacco Advisory Group of the Royal College of Physicians, March 2010

22. Quitting is the best way for smokers to improve their life expectancy Years of life gained by stopping smoking at different ages, 30 to 60 References:1. Doll R, Mortality in relation to smoking, BMJ 2004

23. Benefits of quitting bring improvements in wellbeing regardless of age 20 Minutes Your blood pressure & pulse return to normal. Circulation improves – especially in your hands and feet. 8 Hours Your blood oxygen levels return to normal and your chance of having a heart attack falls 24 Hours Carbon monoxide leaves your body. Your lungs start to clear out mucus and debris. 2-12 Weeks Circulation is now improved throughout your body. It’s easier to exercise. 3-9 Months Lung efficiency is up by 5-10%. Breathing problems are gone. 5 Years You have half the chance of getting a heart attack than a smoker. References:1. West R. Shiffman S. S Fast Facts, 2nd Ed. Oxford Health Press, 2007

24. The tobacco industry uses pseudo economic arguments to divert attention from health issues Claims on the economic impact of policies to reduce smoking: Small businesses and workers’ jobs are lost Criminal gangs profit from increases in smuggled tobacco Tobacco control measures don’t work and are a waste of public money

25. Packs are ‘silent salesmen’ for tobacco brands • By the end of the year the Government will consult on requiring plain packaging for tobacco products. Research shows that that plain packs are • Less attractive to young people • Less likely to mislead smokers into thinking “mild” brands are safer • Give greater impact to health warnings This is the suggested ‘plain pack’ the Australian national government is considering.

26. The majority of children who smoke get their cigarettes from a ‘friend’ Usual sources of cigarettes for 11-15 year olds in England References:1. Smoking, drinking and drug use among young people in England in 2006

27. Smokers from lower social classes are more likely to provide an immediate and tangible reason for making a quit attempt References:1. E Vangeli, R West, Sociodemographic differences in triggers to quit smoking: findings from a national survey, Tobacco Control 2008

28. Using NHS support is nearly 4 times more successful than going ‘cold turkey’ References:1. West R, Smoking Toolkit, UCL www.smokinginengland.org

29. Smoking & public opinion (YouGov 2011) NB You can replace this chart with regional data produced with this toolkit. References:1. YouGov Survey 2011

30. Poorer smokers are as likely to want to quit and try to quit but half as likely to succeed Success rate in quitting by socio-economic class References:1. West R, Smoking Toolkit, UCL www.smokinginengland.org

31. 3. Tobacco policies

32. The World Bank has developed a ‘6 strand’ strategy for reducing tobacco use • stopping the promotion of tobacco; • making tobacco less affordable; • effective regulation of tobacco products; • helping tobacco users to quit; • reducing exposure to secondhand smoke; and • effective communications for tobacco control. References:1. World Bank, ‘6-Strand’ Tobacco Control Strategy (found at http://web.worldbank.org)

33. Local action: councils enforce tobacco laws

34. Local action: Councils will commission stop smoking services NHS Stop Smoking Services are the most successful route to quit and the most cost effective NHS treatment there is Data from www.smokinginengland.info; based on smokers who tried to stop in the past year who report still not smoking at the survey adjusting for other predictors of success (age, dependence, time since quit attempt, social grade, recent prior quit attempts, abrupt vs gradual cessation): N=7,939

35. Working together councils can mount effective local campaigns

36. Smokefree environments enjoy increasing public support Percentage of adults reporting that their homes are smokefree

37. Effective communications will direct smokers to the most effective route of quitting 37

38. Helping poorer smokers to quit is the most effective way of reducing health inequalities Poorer smokers are much more likely to buy illicit tobacco Social classes & illicit tobacco consumed (Smoking Toolkit) References:1. West R, Smoking Toolkit, www.smokinginengland.org.uk

39. 4. Delivery

40. Significant & growing role for Local Authorities LA responsibilities include enforcement on: Age-of-sale 'Smokefree' places Smuggled & counterfeit tobacco Advertising ban From 2013, Local Authorities will take on responsibility to commission services to motivate & support smokers to quit their habit.

41. Health cost of smoking in your area Note to customise this chart: Values for your locality are calculated in the 'Local Tobacco Profiles' Copy from the ‘pdf’ as this provides the clearest image. Due to the amount of detail on this slide, a printed “handout” will probably be necessary for your audience.

42. Working together for better health • Local Government, inc. Police & Fire Brigade • Local Health Services • Organisations that work across neighbouring localities within a region • Employers • Voluntary sector organisations • Smokers (particularly, groups with high rates of smoking e.g. routine & manual smokers)

43. Benefits of working across local boundaries • Marketing & mass media – to ensure ‘health messages’ are supportive, clear & do not conflict • Tackling smuggling – criminal gangs don’t pay heed to local government boundaries • Surveys, research & data collection – cost savings can be had from collectively commissioning research & surveys, & sharing the results

44. Make Smoking History for our children’ a collaborative approach Tobacco Free Futures has worked since 2008 as a collaborative specialised programme to tackle tobacco harm NW Primary Care Organisations commission Tobacco Free Futures to provide multiple components of work, delivered in partnership with localities and key sub-regional groups (e.g. public health networks) and national agencies (e.g. Smokefree Action Coalition) Small dedicated office; NW wide strategy; long term campaign ‘make smoking history for children’

45. Role of Tobacco Free Futures Providing strategic leadership, expertise, guidance, training and development to all localities and their alliances around effective tobacco control delivery Developing, delivering and evaluating integrated mass media campaigns, including ongoing public relations (over £4m earned media to date) and public engagement (inc. 60,000 NW responses to national consultation on future tobacco control) Tailored support to commissioners and providers of stop smoking services Advocacy around the evidence base and making sure that the North West can influence key legislative and policy decision making

46. North West and pan-regional programmes

47. Good progress in North West Beginning to make smoking history for children… Smoking rates at age 14 halved from 2009 to 2011 –down from 18% to 9% (Trading Standards NW young people surveys) Adult prevalence held at 23% (General Household Survey 2009) despite recession and highest levels in England of routine & manual groups in NW NW had highest numbers nationally setting quit date & successful quitters in 2009/10 (1,038 per 100,000 compared to England average of 895)

48. Key messages • Local Authorities have a key & important role to play; the NHS alone cannot reduce smoking rates • Smoking is the single biggest preventable cause of health inequalities; reducing rates will bring general improvements in health & cost savings in other areas • To reduce smoking we need to increase the number of quit attempts & the success of each attempt; we should target the poorest smokers to narrow the gap in life expectancy between the richest & poorest and improve the health of the poorest, fastest