Smoking

Smoking prevalence in Kent is 24.9%, however there is a significant amount of variation across Kent and it is a major reason for our health inequalities. Helping people to stop smoking is a key part of the business of NHS services across Kent and 4-week quitting remains a challenging vital signs target.

 

Motivating people to stop smoking

• Currently there is no local data concerning the prevalence of smoking and a reliance on national synthetic estimates and this needs to be addressed through either local surveys or through an augmentation of the Health Survey for England.
• Increased focus on primary and secondary care and frontline Council services is required, particularly in ensuring sufficient and appropriate staff are trained in Brief Intervention, good quality Brief Advice/Intervention is given, and that referrals to stop smoking services are made proactively.
• The Health Trainer resources in West Kent are limited. A consideration of how health improvement and health promotion resources are deployed across Kent to ensure that inequities are addressed needs to be undertaken.

 

Stop smoking services

• Stop smoking services are currently making contact with approximately 2.2% of the local smoking population, however these services should aim to treat at least 5% each year. In Kent, this equates to at least 14,000 smokers.

 

Protection from tobacco-related harm

• There is a need to raise awareness of tobacco control beyond health and highlight the impact of other agencies and departments, including: fire and rescue; housing; social care; and human resources.
• Continued focus by midwifery services and Stop Smoking Services of Kent Community Health is required to help motivate women to give up smoking prior to or early in pregnancy. 

 

Stopping Young People from starting to smoke

• The control of illicit tobacco and supply of tobacco to under-18s needs to be investigated further, with action taken to reduce access.
• Test purchasing and education of retailers to reduce underage sales is required.
• There is a lack of young people involvement in the development of local smoke-free campaigns.

 

Improving evidence base

• There is a lack of reliable local data around smoking prevalence in children and young people.

Motivating people to stop smoking

• Currently there is no local data concerning the prevalence of smoking and a reliance on national synthetic estimates and this needs to be addressed through either local surveys or through an augmentation of the Annual Health Survey for England.
• Train staff and upscale brief interventions in primary and secondary healthcare settings, and frontline Kent County Council settings (e.g. social care).

   

Smoking cessation services

• Revise the number of smokers Stop Smoking services should aim to treat to meet at least 5% of the local smoking population.
• Focus on/target: smoking in pregnancy; geographical areas of high prevalence; and routine and manual workers; families who smoke; prisoners and offenders in the community; and mental health in-patients.
• Explore the use of innovative approaches to offer the stop smoking services to clients, reduce barriers to service access and prevent relapse.

    

Protection from tobacco-related harm

• Upscale the Smoke Free Homes project to reach more homes across the Kent, but with a continued focus on the areas with the highest smoking prevalence.
• Review or develop and implement workplace smoking policies for NHS organisations, the Kent County Council, partner organisations and other Kent employers.

               

Stopping Young People from starting to smoke

• Focussed work to support children and young people to be smoke free in line with best practice: de-normalising smoking; targeting interventions; lobbying to gain political support for legislative proposals; and offering stop smoking support.
• Engage young people in developing stop smoking and smoke-free social marketing messages for young people.
• Increase the proportion of Kent schools which comply with the tobacco control/smoking element of the Healthy Schools criteria.
• Trading Standards to gather and act on intelligence around illicit tobacco and underage sales and to continue test purchasing and retailer education.

   

Improving evidence base

There has been little done to elucidate why more girls than boys smoke and what methods can be used to address smoking with young people.

Smoking prevalence rates are highest in the poorest areas of England and Wales, demonstrating the strong link between smoking and deprivation. There are also differences in prevalence between genders, socio-economic groups, ethnicities and age groups                          (ASH, 2005; ASH, 2008; ONS, 2010; Department of Health, 2010; The NHS Information Centre, 2009).

 

Socio-Economic Status

• Smoking is higher than average in lower socio-economic status
• Smoking prevalence in routine and manual workers continues to be higher at 29% than for those in the managerial and professional socio-economic group at 14%                                    (General Lifestyle Survey 2008).
• Smokers in lower socio-economic groups are less likely to succeed when trying to quit smoking, due in part to a stronger addiction to nicotine.
• At least 75% of lone parents in receipt of social security benefits smoke.
• People on low incomes (the bottom 15% in terms of material deprivation) have a significantly higher rate of smoking – 45% of men and 40% of women were current smokers                       (Low Income Diet and Nutrition Survey, 2007).

 

Gender

• Smoking in England is higher in men (22%) than women (19%), contributing to the life expectancy gap between the sexes (2007 data).
• However, among children and young people in the South East more girls (8%) than boys (6%) smoke (2009 data).

 

Ethnicity

• Irish and Bangladeshi men have higher smoking levels than the general population, with Black Caribbean, Black African, Chinese, Pakistani and Indian men having similar levels; Black Caribbean and Irish women have similar smoking levels to the general population; Black African, Chinese, Pakistani, Indian and Bangladeshi women have significantly lower levels of smoking (The Information Centre, 2008).

 

Age

• Those aged 20 to 34 reported the highest prevalence of cigarette smoking (32% among 20-24 year olds and 26% among 25-34 year olds) while those aged 60 and over reported the lowest (12%).
• Low Income Diet and Nutrition Survey 2007 found that older adults were much less likely to be current smokers than younger adults. Among men, the prevalence of current smokers was 54% for men aged 19-34, 58% for those aged 35-49, 52% for men 50-64 and 22% for men aged 65 and over. It is a similar pattern for women.

 

Young people and children

• Almost two thirds (65%) of current and ex-smokers who had smoked regularly at some point in their lives started smoking before they were 18.
• Across the South East Coast, 36% of girls and 33% of boys aged 11-15 will have smoked at least once. 8% of girls and 6% of boys aged 11-15 will be classed as regular smokers, defined as smoking at least once per week (The Information Centre, 2010). This is slightly higher than the national average.
• Nationally, 32% of pupils aged 11-15 have ever smoked, with a large variation by age: 55% of 15-year-olds have smoked at least once. The prevalence of regular smoking (at least once per week) also increases with age.
• The odds of being a regular smoker are higher if pupils live with other people who smoke, and also increase with the number of smokers in the household; children who live with two adult smokers are four times more likely to be regular smokers themselves than children who live with non-smokers.
• Smoking increases the risk of asthma in young people and aggravates asthma symptoms in those already diagnosed. It can also lead to impaired lung growth in children and young adults. (The Information Centre, 2009).

 

Other groups

Pregnant women

Prevalence of smoking in pregnancy across England is approximately 14% (Department of Health, 2010). In Kent it is higher at 17%.

 

Younger mothers are more likely to smoke throughout pregnancy than older mothers; 45% of mothers aged under 20 smoked throughout pregnancy compared with 9% of mothers aged 30 and over.

 

Mothers classed as having ‘never worked’ are significantly more likely to smoke throughout pregnancy than mothers in managerial and professional occupations.

 

Prisoners

Smoking prevalence among prisoners is estimated to be approximately 80%, with the 1997 psychiatric morbidity survey of prisoners in England and Wales reporting 82% of male prisoners and 81% of female prisoners being current smokers (ONS, 1999).

• Smoking status should be routinely recorded in primary care records

• Mental Health Trust staff, for example Wellbeing nurses, Occupational Therapists and Physical Activity co-ordinators should be trained to level 2 in Smoking Cessation.

• Patients who smoke should be offered referral to appropriate trained smoking cessation specialists on admission: or, if they do not wish to access this help at that time, a programme to promote readiness to quit should be agreed as soon as possible, and referral continue to be offered.

 

The Kent Community Health Stop Smoking Service, the Mental Health Care provider and KCC Social Services should work together to develop plans to bring the Forensic and Secure Units, and eventually the Residential Care home environment for this patient population towards completely smoke free status. The GPCCs will be expected to actively support these plans. Commissioners of Forensic Secure Unit providers should use contract review as an opportunity to instigate change following consultation with staff, clinicians and patients/service users.

 

Mental health

Approximately 70% of people on mental health inpatient units are current smokers and 50% smoke heavily (more than 20-a-day). 

 

People with mental illness who are living in the community and who are less ill, smoke less, with up to 40% smoking and close to 30% smoking heavily (Kings Fund, 2006).

Smoking prevalence

Nationally, the prevalence of smoking among adults dropped from 24% in 2005 to 21% in 2008 (ONS, 2010).  Smoking prevalence in Kent was higher than the national figure at 24.9%. The variation in prevalence is significant and varies between 16% in Sevenoaks and 26.3% in Dartford (see health and social care maps)

 

There were approximately 281,300 smokers in Kent in 2009 - at least 276,300 adults and approximately 5,000 children and young people between the ages of 11 and 16.

 

 Figure 1: Synthetic estimates of smoking prevalence among over 18s in Kent

Deaths and hospital admissions attributable to smoking in Kent

Of the 11,250 deaths of Kent residents aged 35 and over in 2008, approximately 2,250 (20%) can be attributed to smoking. The majority of these are due to lung cancer, chronic airway obstruction and ischaemic (coronary) heart disease.

 

Approximately 10,300 hospital admissions of Kent residents aged 35 and over in 2008 can be attributed to smoking (5% of the total 205,932 admissions). The majority of these are due to chronic airway obstruction, lung cancer and ischaemic heart disease                                                 (The Information Centre, 2009). 

 

Smoking prevalence is strongly linked to deprivation.  45% of men and 40% of women in the most deprived 15% of households are current smokers                                                                         (Low Income Diet and Nutrition Survey, 2007). Routine and manual smokers are defined by their occupations and most do not fall into the lowest quintile in terms of deprivation levels. 

 

Age

Those under 34 years are setting the most quit dates, but this age group are less likely to be successful at quitting. Those that are most successful in quitting are the older population.

 

Figure 2: Numbers of Kent residents quitting smoking by age group in 2009/10

Source: The Information Centre 2009/10 data

 

Gender

Males are more successful at quitting than females. Eastern and coastal Kent services have been more successful at getting both men and women to quit and are better than the England average. West Kent has had a lower success rate and the percentage of people quitting is lower than the England average.

Figure 3: Percentages of eastern and coastal, and west Kent residents quitting smoking by gender in 2009/10 compared with south east coast and England

Source: The Information Centre 2009/10 data

 

Young people

In recent years the proportions of young people smoking has declined. In 2006, the proportion of 11 to 15 year olds who said that they had smoked at least once in their lives was 39%; this fell to 33% in 2007 and 32% in 2008 (The Information Centre, 2010). The survey defines regular smoking for this age group as usually smoking at least once a week. The proportion of this age group who were regular smokers was 9%in 2006, and 6%in both 2007 and 2008. Girls are more likely to smoke than boys and there is an increase in the prevalence of regular smoking with age.

 

In the south east 7% of young people between 11 and 15 years old smoke with more girls smoking than boys (The Information Centre, 2010). This is despite the increase in age at which it is legal to buy tobacco to 18.

 

Three in ten (29%) of pupils have tried smoking at least once. This proportion is the lowest measured since the survey began in 1982, when more than half of pupils (53%) had tried smoking. In the south east 35% of young people self-report ever smoking a cigarette, compared to 29% nationally. More girls have tried smoking at least once (36%) than boys (33%).

 

There are approximately 37% homes within England in which dependent children are living with smokers and potentially exposed to second-hand smoke (ASH, 2011).

 

Smoking in Pregnancy

The number of maternities has been fairly steady in Kent and is currently around 16,000 per year (Department of Health, 2010). 

 

The prevalence of smoking during pregnancy is low among Kent residents compared to the England Average; it was 25.5% in 2003/4 but had decreased to 17% in the first three quarters of 2009/10, although the rate of this fall appears to be decreasing. 

          

This level equates to approximately 1,500 Kent-resident mothers still smoking at the time of delivery each year. It also indicates that around half the women who smoke are stopping smoking during pregnancy.

 

Prisoners

In the west Kent Forensic Secure Units, smoking status is not routinely recorded in primary care patient records (Prickett, 2011), and exact prevalence figures are therefore unknown. Anecdotally prevalence is estimated at 80%. Knowledge of a patient's smoking behaviour is important to the psychiatrist at an individual level because it may complicate assessment and treatment.

 

Notable changes in need since JSNA April 09

The vulnerable groups identified as a priority to target with interventions and services remain the same. Stop smoking services are providing Brief Intervention training to midwives in the acute trust which incorporates ensuring smoking status is recorded. This should also help to improve the quality of local data about the prevalence of smoking in pregnancy.

The Stop Smoking Service in eastern and coastal Kent

The service has a range of support options across NHS Eastern and Coastal Kent, including group, one to one, drop in and telephone support as well as specialist pregnancy support. They also offer specialist support whilst you are in hospital. They can provide these services in a wide range of venues including health centres, pharmacies, GP surgeries, community centres, libraries, hospitals and many more. Nicotine replacement therapy (NRT) is available for a one off prescription charge (exemptions apply) and prescription medication is also available via your local GP (prescription charges apply). 

All of the services recommend are provided by friendly trained stop smoking advisors, who offer a non-judgemental and supportive service. They will provide practical and expert advice on the most suitable treatment for you and give a wide range of coping strategies to help you be successful.

There is a website which is designed to be a further source of support for NHS Eastern and Coastal Kent residents who are either interested in quitting themselves, or helping a friend or family member to quit successfully. Registering for the website is free and those who register will not be contacted by any of our team unless requested to.

Registering as a member provides people with access to a wealth of information on how to quit smoking and the opportunity to join an online stop smoking group, so that they can receive specialist support from the comfort of their own home.

 

The Stop Smoking Service in west Kent

NHS Stop Smoking Services in west Kent are designed to meet the needs of all smokers. They are available in a range of formats and settings and options in 2009/10 included:

 

• Stop Smoking drop-in clinics, open and closed groups provided by the core stop smoking team.
• Workplace stop smoking groups for routine and manual groups and clinics provided within targeted workplaces by the core stop smoking team – many of these clients are males who are not registered with GPs or have not been to a GP for a considerable length of time
• 1-2-1 services provided in primary care by GP surgeries and community pharmacies (via LES).
• 1-2-1 services provided within the three prisons in west Kent (via LES).
• 1-2-1 services provided within military barracks and dental practices (via LES).
• 1-2-1 sessions for pregnant women and their families within Children’s Centres across west Kent and midwifery clinic at Darent Valley.
• Special services for young smokers tailored to need e.g. within school or youth setting.
• BME pilot undertaken by the communities team and the planning of a Ramadan event in conjunction with London stop smoking services
• Telephone support provided by external contractor ‘Help Stop Smoking’ following active recruitment of smokers from street campaigns.

 

2009/10 was a successful year for NHS Stop Smoking services in west Kent. There was a greater range of options available for smokers than ever before and the vital signs target was exceeded. The service was also extremely cost-effective as only £246.49 was spent per quitter. The service as been highlighted as a centre of excellence for their workplace scheme.

We expect the current trend in prevalence in Kent to continue to follow England’s downward trend.

 

However, the prevalence and rate of reduction varies widely across Kent and between groups within Kent, for example there is a far lower prevalence in managerial and professional groups than routine and manual groups. The reduction in routine and manual groups therefore needs to be greater if the gap is to be narrowed. 

 

Services will therefore need to be concentrated in areas that are most accessible for those groups that will continue to have a higher than average smoking prevalence, including routine and manual groups, geographical areas of high deprivation, offenders and mental health in-patients.

 

The Department of Health estimates nationally that 67% of smokers want to quit. As smoking is denormalised in Kent, more people are likely to want to quit and there is therefore likely to be an increase in smoking cessation service need over the next 10 years.

 

As noted earlier, while the smoking cessation service is a highly cost-effective intervention, it is clear that this can only be one part of a comprehensive programme. A Smokefree Future: A Comprehensive Tobacco Control Strategy for England (Department of Health, 2010), describes the other two objectives as ‘stopping the inflow of young people recruited as smokers’ and ‘protecting families and communities from tobacco-related harm’.

 

Nationally, as the number of smokers reduces and there is less smoking-related morbidity, the average associated health care costs will fall. Smoking prevalence in Kent continues to reduce, and there is likely to be a continued reduction in overall healthcare service use and costs associated with smoking if this continues. The cost to the NHS of smoking-related illnesses in the UK has been estimated at between £2.7 billion and £5.2 billion (ASH, 2008; Allender, 2009).

Kent evidence

Smoking Health Equity Audits for NHS West Kent , and  NHS Eastern and Coastal Kent have recently been produced.

 

Primary Care staff are expected to encourage patients to quit smoking and refer them to specialist help. Patients who have been risk assessed can access these programmes in the community. Stop smoking programmes have been delivered in west Kent prisons by Prison Healthcare staff and Physical Education Instructors, supported by training from the NHS West Kent Stop Smoking service. This has achieved even greater quit success rates than is achieved in the community; for example in HMP Blantyre House, prevalence has reduced to 59%, which is above the estimated local 24%, but better than the general estimated prison 78% (Prickett, 2011).

 

Also see Smoking in Kent: deaths, disease and economic loss attributable to tobacco smoking, published in May 2009.

 

The Kent 2005 Survey of Health and Lifestyle carried out by the University of Kent for KCC found lower prevalence rates and different trends in smoking. This was a sample of 2% of the over 16 population with a response rate of 25% and responses may have been skewed towards people with healthier lifestyles and in less deprived areas (University of Kent, 2007).

 

National Evidence

• The Centre for Disease Control Best Practices for Comprehensive Tobacco Control programme states: “A comprehensive state wide tobacco control programme is a co-ordinated effort to establish smoke free policies and social norms, to promote and assist tobacco users to quit and to prevent initiation of tobacco use.”
• The Health Inequalities National Support Team have published what works to improve uptake of SSS through their tobacco control visits Learning from National Support Team Visits Tobacco Control.

• Ten High Impact Changes to achieve tobacco control (Department of Health, 2008) should be used to plan the development and delivery of best practice tobacco control interventions. These recommendations and identified gaps from the benchmarking exercise have been translated into 6 priority actions within the Tobacco Control Strategy and Action Plans.

• The Health Act 2009 requires tobacco products to be removed from display in shops. This new law will be implemented for large retailers in October 2011 and small retailers in October 2013. The Act also enables the prohibition of tobacco sales from vending machines, although this still subject to Parliamentary consideration of regulations.
• Beyond Smoking Kills (ASH, 2008) details a number of tobacco control priorities and contains new and useful research to support local priority setting.
• A Smokefree Future: A comprehensive tobacco control strategy for England (Department of Health, 2010) details the rationale and evidence-based policies for future tobacco control work under three objectives:
  • To stop the inflow of young people recruited as smokers.
  • To motivate and assist every smoker to quit.
  • To protect families and communities from tobacco-related harm.

 

NICE public health 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), public health guidance 23 (School-based interventions to prevent smoking) and public health intervention guidance 1 (Brief interventions and referral for smoking cessation in primary care and other settings) details the guidance and recommendations for preventing uptake of smoking, engaging people and successful smoking cessation.

Desire to give up smoking

67% of smokers say they would like to give up smoking, with 75% having tried to give up smoking in the past (The Information Centre, 2009). There is no information regarding the desire to give up smoking amongst young people who regularly smoke in the report on smoking, drinking and drug use undertaken in 2009.

Motivating people to stop smoking

• Currently there is no local data concerning the prevalence of smoking and a reliance on national synthetic estimates and this needs to be addressed through either local surveys or through an augmentation of the Annual Health Survey for England.
• Train staff and upscale brief interventions in primary and secondary healthcare settings, and frontline Kent County Council settings (e.g. social care).

Smoking cessation services

• Revise the number of smokers Stop Smoking services should aim to treat to meet at least 5% of the local smoking population.
• Focus on/target: smoking in pregnancy; geographical areas of high prevalence; and routine and manual workers; families who smoke; prisoners and offenders in the community; and mental health in-patients.
• Explore the use of innovative approaches to offer the stop smoking services to clients, reduce barriers to service access and prevent relapse.

         
Protection from tobacco-related harm

• Upscale the Smoke Free Homes project to reach more homes across the Kent, but with a continued focus on the areas with the highest smoking prevalence.
• Review or develop and implement workplace smoking policies for NHS organisations, the Kent County Council, partner organisations and other Kent employers.

Stopping young people from starting to smoke

• Focussed work to support children and young people to be smoke free in line with best practice: de-normalising smoking; targeting interventions; lobbying to gain political support for legislative proposals; and offering stop smoking support.
• Engage young people in developing stop smoking and smoke-free social marketing messages for young people.
• Increase the proportion of Kent schools which comply with the tobacco control/smoking element of the Healthy Schools criteria.
• Trading Standards to gather and act on intelligence around illicit tobacco and underage sales and to continue test purchasing and retailer education.

        

Improving evidence base

There has been little done to elucidate why more girls than boys smoke and what methods can be used to address smoking with young people. 

• Gain intelligence on local counterfeit and smuggled tobacco; establish local data collection recording and monitoring methods.
• Consider need for reviewing health and well-being human resource allocation across Kent and possibly additional health improvement capacity.
• Investigate GP-recorded smoking status.
• Determine smoking prevalence levels across Kent.
• Identify the level of smoking among children and young people across Kent and ascertain levels of desire to give up smoking amongst those who regularly smoke

• Meradin Peachey - Director of Public Health, Kent County Council

• Allan Gregory – Tobacco Control Lead, Kent County Council

• – Trading Standards Manager, Kent County Council

• Marion Gibbon – Public Health Consultant, NHS West Kent

• Graham Thomas – Eastern and Coastal Kent Stop Smoking Service Manager, NHS Kent Community Health Trust

• Laura Bush –  West Kent Stop Smoking Service Manager, NHS Kent Community Health Trust

1. Allender, S, Balakrishnan, R, Scarborough, P, Webster, P and Rayner, M (2009) The burden of smoking-related ill health in the UK, Tob Control 2009;18:262-267

2. ASH (2011) Secondhand Smoke 

3. ASH (2005) Smoking and Peripheral Arterial Disease 

4. ASH (2008) Beyond Smoking Kills

5. ASH (2008) The cost of smoking to the NHS

6. Centre for Disease Control (2007) Best Practices for Comprehensive Tobacco Control 

7. Department of Health (2011) Learning from National Support Team Visits Tobacco Control Part 2 

8. Department of Health (2010) Local Data on Smoking in Pregnancy 

9. Department of Health (2010) A Smokefree Future: a Comprehensive Tobacco Control Strategy for England  

10. Department of Health (2008) Ten High Impact Changes to achieve tobacco control 

11. General Lifestyle Survey 2008 

12. Kent and Medway PHO (2009) Smoking in Kent: deaths, disease and economic loss attributable to tobacco smoking 

13. Kings Fund (2006) Clearing the Air 

14. Nelson, M, Erens, B, Bates, B, Church, S and Boshier, T (2007) Low  Income Diet and Nutrition Survey 

15. NICE Public Health Guidance 10 

16. NICE Public Health Guidance 23 

17. NICE Public Health Intervention Guidance 1

18. ONS (1999) Substance Misuse amongst Prisoners in England and Wales

19. Prickett, Linda (2011) Needs Assessment for West Kent Forensic Mental Health Secure Units

20. The Information Centre (2010) Smoking, Drinking and Drug Use among Young People in England in 2009 

21. The Information Centre, (2009). Statistics on Smoking in England 2009 

22. University of Kent (2007) Kent 2005 Survey of Health and Lifestyles  

23. Wanless, Derek (2004) Securing Good Health for the Whole Population