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Summary

Smoking is the UK's single greatest cause of preventable illness and early death. Adults who smoke lose on average 13 to 14 years of their lives and more than 86,000 people in the UK die from smoking each year. There is evidence that smoking causes various cancers (particularly lung cancer), heart and blood vessel disease (including high blood pressure, stroke and heart attacks), respiratory disease (e.g. chronic obstructive pulmonary disease) and many other conditions.

Since there is no definitive measure of how many people smoke, national modelled estimates of smoking were developed from national survey data. In Merton, it is estimated that 16.48% of the population smoke compared with 20% in London, this is the fifth lowest prevalence of all London boroughs. However, this masks a variation across the borough where smoking rates vary from 9% to 24%.

The higher rates are in line with the areas that have greater deprivation. These estimates are also supported by a survey of healthy living carried out in 2010 within Sutton and Merton, where people living in more deprived areas reported a smoking rate of about 24%. It has also been estimated that smoking prevalence among routine and manual workers is 23.5% in Merton.

Key commissioning recommendations

Merton has low overall smoking prevalence. However, there are clear inequalities in the levels of smoking across the borough and lower prevalence of quit rates compared with London and England. These factors, combined with plateauing mortality in circulatory disease, mean that tobacco control and tackling smoking should remain a high priority.

Recent figures on people stopping smoking have fallen short of local targets, however the integration with the LiveWell health improvement service will provide additional exposure to the programme. The stop smoking service also links into the NHS Health Check programme (a national initiative of regular vascular risk assessments) to provide support to help people reduce their risk of vascular disease caused by making changes to their lifestyle e.g. stopping smoking.

Since April 2013, Merton Council has been responsible for commissioning the Stop Smoking Service, rather than it being directly delivered by an in-house team in the NHS. The new provider, Hounslow and Richmond Community Healthcare NHS Trust, is focused on increasing the rate of residents accessing the programme and the number of smoking quitters, and will:

  • continue to focus on access for ethnic groups, particularly minority ethnic males
  • support younger people, particularly those most vulnerable
  • focus on routine and manual workers, unemployed people and those on a low income
  • support pregnant women to give up smoking early in pregnancy
  • increase the outreach of the programme, branded under the LiveWell banner, to include workplaces e.g. staff working in council buildings
  • link closely to Stoptober, the national campaign that encourages people not to smoke for the entire month. People who stop smoking for this length of time are less likely to start again.

Merton Council has worked to deliver effective comprehensive tobacco control in the borough, and at times nationally, with action leading to the banning of tobacco supplies from vending machines. With its partner agencies and organisations Merton Council should continue to make tobacco control a priority in order to reduce the level of tobacco usage, as well as work towards normalising smoke-free environments beyond current legislation.

Key facts on smoking

Smoking is the UK's single greatest cause of preventable illness and early death. Adults who smoke lose on average 13 to 14 years of their lives and more than 86,000 people in the UK die from smoking each year. There is evidence that smoking causes various cancers (particularly lung cancer), heart and blood vessel disease (including high blood pressure, stroke and heart attacks), respiratory disease (e.g. chronic obstructive pulmonary disease) and many other conditions. Smoking also affects child health increasing the likelihood of low birth weight and child mortality. Nationally the number of people who smoke is quoted as about 21%. However, this is not uniform and people are more likely to smoke if they are in manual or routine jobs, live in deprived areas or belong to specific groups such as lesbian, gay and bisexual groups who have higher reported rates of smoking than the general population.1

Since there is no definitive measure of how many people smoke, national  modelled estimates of smoking were developed from national survey data. In Merton, it is estimated that 16.48% of the population smoke compared with 20% in London; this is the fifth lowest prevalence of all London boroughs.

Additional indicators, such as smoking-related deaths and illness (as measured by hospital admissions), suggest that overall in Merton there is on average less smoking-related harm compared with London or England.

Additional indicators available from the London Health Observatory tobacco profiles

Smoking prevalence, Merton compared with statistical neighbours and London boroughs, April 2011- March 2012.

However, this masks variation across the borough where smoking rates vary from 9% to 24%. The higher rates are in line with the areas that have greater deprivation. These estimates are also supported by a survey of healthy living carried out in 2010 within Sutton and Merton, where people living in more deprived areas reported a smoking rate of about 24%. It has also been estimated that smoking prevalence among routine and manual workers is 23.5% in Merton. See map below.

Map of smoking prevalence by area estimates of the proportion of adults who are current smokers by middle super output area (MSOA) (2006-08).

 

Source: Association of Public Health Observatories

Estimates of Adults' Health and Lifestyles, Percentage of the adult population who are current smokers, 2006-08, by MSOA (modelled estimate)

©Crown copyright 2012. All rights reserved. ©1994-2012 ACTIVE Solutions Europe Ltd.


Services - what works and best practice

Helping people to stop smoking

A major factor in reducing smoking prevalence is to ensure ready access to the Stop Smoking Service and support. Due to changes due to the implementation of the Health and Social Care Act 2012, the Stop Smoking Service was externalised as part of a competitive procurement exercise and is now delivered by Hounslow and Richmond Community Healthcare NHS Trust. This procurement exercise also gave commissioners the opportunity to integrate the service with the LiveWell health improvement programme, resulting in a service that can support smokers to stop and also provide support around other health behaviours e.g. increasing physical activity levels to reduce potential weight gain that is sometimes experienced by those who stop smoking.

In the most recent Health Equity Audit (2009) of the service, the effect of age on service access was more prominent for males than females. Females were shown to have significantly higher rates of service access than males. A significantly higher proportion of white males were accessing services than [males] from ethnic minorities. However, the gap in the rate has narrowed indicating the effects of targeted action by the service since the first audit. Geographic variation in access rates had been shown with certain wards displaying markedly lower rates. There was also evidence of some of the most deprived wards having proportionally higher access rates due to targeted action. More recently, those in routine and manual employment have been entering services at a greater rate, particularly males, due to the efforts to target this demographic group by the Stop Smoking Service.

Smoking in pregnancy may not only affect the health of the mother but also the long-term health of the baby. Babies born to mothers who smoke are often of a much lower weight and prone to more ill health. In Merton, the levels of smoking recorded at time of delivery are around the average for London.

Overall there has been a reduction in the rate of people accessing the Stop Smoking Service, with 987 Merton residents accessing the service in 2012-13 compared with 1,600 in 2009-10. This could be in part explained by the reduction in the level of stop smoking marketing activity conducted nationally, and the previous success of the local Stop Smoking Service, leaving the hardened smokers who are not ready to consider stopping smoking.

The success rate of the service has dipped slightly to 45% (from 50%) of service users quitting at four weeks, which is lower than England and London levels. Targeted action is taking place to promote the integrated LiveWell stop smoking and health improvement service to increase both service users entering the service and the success rate.

Tobacco control

The effective enforcement of tobacco control legislation is a key element of any comprehensive approach to tobacco control. Laws are already in place regulating the way that tobacco products are presented for sale, to ensure that tobacco is not sold to people under the age of 18, and to reduce the exposure and effects of second-hand smoke. Local Trading Standards and Environmental Health Services have a recognised and essential role to play in wider efforts to reduce smoking rates and the Tobacco Control Plan for England (2011) places both services at the heart of its plan to reduce smoking as both have a growing contribution to public health.

In Merton, Trading Standards and Environmental Health Services take a proportionate, risk-based approach to enforcement and continue to build compliance with tobacco legislation, including through provision of advice and information to businesses, with enforcement action taken only where the law is deliberately flouted. The enforcement of tobacco legislation, which will contribute to the efforts to drive down the rates of tobacco use in the community, remains a priority with both services making a significant contribution through core activities such as:

  • age-restricted sales test purchasing, including a related programme for 'proxy' sales
  • tackling the supply of illicit products i.e. counterfeit and unsafe tobacco products
  • tobacco advertising and promotion
  • product labelling
  • point-of-sale display requirements
  • ensuring compliance with smoke-free legislation.

The majority of these activities have remained at the heart of tobacco control for the past 10 years following the publication of the 'Smoking Kills' White Paper, but they have been supplemented with the additional enforcement responsibilities around tobacco advertising, labelling, illicit products and smoke-free requirements in recent years.

Reducing smoking among children and pregnant women

National Institute for Health and Care Excellence (NICE) has produced evidence-based guidance on smoking in children and pregnant mothers.

The guidance on children recommends school-based interventions to prevent the uptake of smoking, including:

  • whole-school approaches, such as smoke-free policy
  • adult-led and peer-led interventions
  • training and development
  • coordinated approach as part of a local tobacco control strategy and embedded in the curriculum.

For relevant information on the NICE guidance see School-based interventions to prevent smoking (NICE website)

The guidance on helping pregnant women quit smoking during pregnancy and following childbirth recommends:

  • identifying pregnant women who smoke, referring to NHS Stop Smoking Services, and providing ongoing support
  • Using nicotine replacement therapy (NRT) and other pharmacological support
  • engaging with partners and others in the household who smoke
  • ensuring NHS Stop Smoking Services meet the needs of disadvantaged pregnant women who smoke
  • Providing training for all professionals involved in the delivery of interventions.

For relevant information on the NICE guidance see Quitting smoking during pregnancy and following childbirth (NICE website)

Use of smokeless tobacco in South Asian communities

National guidance on smokeless tobacco cessation in South Asian communities has also been produced. This has not been identified as a major issue locally in Merton. However, awareness and using local community information to assess changes in tobacco use is important.

For relevant information on the NICE guidance see Smokeless tobacco cessation: South Asian communities (NICE website)

Tobacco: harm-reduction approaches to smoking

National guidance has been developed on how to support people, particularly those that are highly dependent on nicotine, to reduce the harm that they face from smoking. Stopping smoking in one step (sometimes called 'abrupt quitting') offers the best chance of lasting success and is currently the approach that is supported in Merton.

For relevant information on the NICE guidance see Tobacco: harm-reduction approaches to smoking (NICE website)

 

References

1.^ Department of Health (2007)