Health and Adult Social Care Policy and Scrutiny Committee	19^th March 2020
Report of the Assistant Director – Public Health

Smoking Cessation and Tobacco Control in York

Summary

1. Smoking is still the leading preventable cause of death and illness in York, with 11.4% of the York adult population currently smoking.

2. Since 2013 and the transfer of Public Health services from the NHS to Local Government, the Council have had responsibility for the provision of smoking cessation services in York.

3. In July 2019, the York Tobacco Control Alliance was formed, bringing partners together with the aim to reduce the prevalence of tobacco use in the city of York to below 5% of the adult population, through the actions of each individual organisation represented to prevent the uptake of smoking and through support for cessation services.

4. This report summarises the current work of both the council smoking cessation service and the wider partnership tobacco control work.

Background

5. Smoking is the leading cause of preventable death worldwide, killing half of all lifetime users. Currently, 11.4% of the York adult population smoke (nearly 20,000 smokers), which resulted in over 700 deaths in the city (2015-17), nearly 2000 hospital admissions a year, and costs the economy (through healthcare costs and lost productivity) nearly £40m a year.

6. Whilst levels of smoking have fallen faster in York than nationally over the last decade (the prevalence of smoking in England is 14.4%), it still ranks as one of the major public health issues facing our population, and one of the key modifiable factors in improving the health and wellbeing of the people of York across the life course.

7. In addition, there are large inequalities in smoking rates in York. 18.6% of people in routine and manual occupations smoke in the city, compared to 8.4% in managerial work. 19.8% of inpatients at York Teaching Hospitals Foundation Trust smoke, as do 36.8% of people with a severe mental illness in the city. 10.6% of pregnant women are recorded as smoking at the time of their baby’s delivery, a statistic which has not reduced in line with general smoking rates in the last 6 years.

8. Smoking is linked to countless pathogenic mechanisms in the human body, and decades of research has proved that amongst other things it

· hugely increases the risk of developing cardiovascular disease e.g. stroke or heart attack

· causes 16 types of cancer including 9 in 10 lung cancers

· is responsible for over 10% of incident Type II diabetes cases

· is the cause of most Chronic Obstructive Pulmonary Disorders

· exacerbates asthma and makes acute life threatening attacks more likely

· contributes to both common mental health problems such as depression and anxiety and severe mental illness such as psychoses

In addition, these risks are significant not just to the user but also – through second hand smoke – to those who live, work and socialise around them.

9. Smoking is not a lifestyle choice. Nicotine has been shown to be a more powerful and addictive a substance than heroin, and most tobacco users start the habit in their late teens before developing a lifelong use of tobacco. Smoking is thus more rightly framed as a chronic relapsing long term condition starting in childhood, but treatable through behavioural support and nicotine replacement therapy.

10. Over the last decade, the number of smokers in York has halved, which gives enormous hope for a continuing reduction in rates. One aspect of this is a slowing of uptake (prevention), whilst another is the increasing number of people attempting to quit (cessation).

11. There is very robust and clear evidence about what works to improve the chances of smoking cessation, and – although no quit is guaranteed and some relapse – people are 3 times more likely to succeed in quitting smoking if they use a combination of behavioural support by a qualified advisor and nicotine replacement therapy (NRT).

12. Alongside deployment of cessation support, smoking rates can be reduced through public policy measures, known as ‘tobacco control’. These approaches are laid out in the World Health Organisation Framework Convention on Tobacco Control, signed by 181 countries including the UK in 2005. They are:

Monitor tobacco use and prevention policies

Protect people from tobacco smoke

Offer help to quit tobacco use

Warn about the dangers of tobacco

Enforce bans on tobacco advertising, promotion and sponsorship

Raise taxes on tobacco

13. The York Tobacco Control Alliance was founded in July 2019, and aims to reduce the prevalence of tobacco use in the city of York to below 5% of the adult population, through partner actions, tackling the determinants of smoking, and supporting cessation services. This is in line with all other Local Authorities in the Yorkshire and the Humber who have endorsed the Breathe2025 initiative of the Yorkshire and Humber Association of the Directors of Public Health based on reducing rates to under 5% by 2025.

14. The benefits of work on smoking cessation and tobacco control go far beyond health and healthcare. Reducing smoking to 5% in York has the potential to:

· Lift thousands out of poverty

· Increase local productivity

· Protect children from harm

· Reduce inequalities

· Improve quality of life in local neighbourhoods

· Save thousands of lives

Smoking Cessation Services in York

15. Community smoking cessation support in York is delivered by the York Health Trainer service, part of the council’s Public Health team. This team of Health Trainers are trained to deliver three services: the national 40-74 year old Healthchecks; smoking cessation interventions; and a health trainer intervention covering stop smoking advice, alcohol awareness, weight management, physical activity and social isolation.

16. The Health Trainer service is responsible for providing support to residents that wish to stop smoking.  This is provided in accordance with NICE Guidance and staff are trained to deliver the service as set out by the National Centre for Smoking Cessation and Training (NCSCT Level 2), as well as supply Nicotine Replacement Therapy (NRT).

17. The service model developed in York prioritises as follows:

· Pregnant smokers and their family: 12 weeks of NRT and behavioural support from a Health Trainer.

· Adult smokers: 4 weeks of NRT and support for up to 12 weeks whilst self funding NRT from a Health Trainer

· Smokers aged 12-18: NRT can be provided to young people over the age of 12 as part of a family intervention

18. Since 2019 a licensed stop smoking medication (Varenicline, known as Champix) has been added to this offer in conjunction with community pharmacy for those who advisors judge would benefit. The recommended treatment from NICE is 12 weeks of NRT or 12 weeks of Varenicline; historic budgetary decisions mean the council funds 4 weeks of NRT and 6 weeks of Varenicline.

19. In 2018/19 the Health Trainer service received 331 referrals or self-referrals for smoking cessation support, and 28% of clients who were seen by an advisor had successfully quit for four weeks. As a proportion of York’s smoking population, the number of referrals was low. The service has recently created extra capacity to see more smokers per year in an increased number of community venues, and by raising awareness of the service and through multi-agency work with the recently established York Tobacco Control Alliance, referrals were expected to rise.

20. In the first three quarters of 2019-20 there have been an improvement in referral and quit rates.  Referrals increased from 94 in 2019-20 Q2 to 133 in 2019-20 Q3.  There have been 420 referrals in the year to date, already significantly higher than in 2018-19 before the year has ended. The percentage of clients that were seen by an advisor who successfully quit at four weeks has risen to 48%. In the first three quarters of 2019-20, a total of 95 smokers set a quit date and 56 of those (59%) had quit smoking at the four week follow up. Of the smokers who set a quit date, 22 were pregnant and 10 of these (46%) had quit smoking at the four week follow up.

21. In addition to community run cessation services, other partners in the city have a key role to play in promoting cessation, primarily through promoting Very Brief Advice on smoking for patients and signpost into Health Trainers. Pharmacists are heavily involved in promoting the Stoptober campaign, and supply Varenicline. GP practices have referred 63 patients to stop smoking services so far this year, a relatively small proportion of their smoking patients. Currently, with midwifery and respiratory medicine as notable exceptions, referrals from the rest of York Teaching Hospitals Trust are also low. There is the potential for further work to strengthen the treatment of tobacco dependency within acute care in the city in a similar manner to the CURE project in Greater Manchester or the QUIT programme in South Yorkshire.

22. One local model of good practice is the work of Tees, Esk and Wear Valley (TEWV) NHS Foundation Trust, who provide community and inpatient mental health services in York. TEWV have been a ‘smokefree’ organisation since 2016, an initiative which includes robust clinical, HR and estates policy around smoking but is underpinned by a high quality cessation offer (including two York-based clinics), which builds on their experience that people with a mental health condition generally want to quit smoking. The TEWV Healthy Living team ensure that inpatient services and community services provide a supportive environment for quitting smoking, and give people an alternatives through bespoke interventions delivered by mental health practitioners and easy access to nicotine replacement therapy and e-cigarettes. Since 2015, the percentage of adult inpatients who are smokers has declined from 62% to 48%. TEWV are an active member of the York Tobacco Alliance.

York Tobacco Control Alliance

23. The York Tobacco Control Alliance was launched in July 2019, and aims to reduce the prevalence of tobacco use in the city of York to below 5% of the adult population, through partner actions and support for cessation services.

24. Current membership of the Alliance includes several CYC departments, North Yorkshire Police, Vale of York CCG, York Teaching Hospital, North Yorkshire Community Pharmacy, North Yorkshire Fire and Rescue, York Against Cancer, Tees Esk and Wear Valley Mental Health Trust, and a GP representative.

25. The Tobacco Alliance is a partnership with no formal resourcing, working as a galvanising and coordinating group for efforts on this agenda. The range of activity which could be undertaken is large, with Tobacco Alliances in other Local Authority areas working on projects around:

· Education on smoking in the school curriculum

· Policy and public health messages on the use of e-cigarettes

· Point of sale enforcement

· Under age sale enforcement

· Work to support Smokefree Homes

· The designation of Smokefree outside zones

· Tackling illicit/counterfeit tobacco

· Enforcing advertising restrictions e.g. plain packaging

· Mass media campaigns

· Improving access to smoking cessation services

· Targeted Cessation (maternity, mental health settings)

· Very Brief Advice

· Supporting organisations with workplace policies on smoking

26. The Alliance is currently building relationships, prioritising which projects are achievable within the capacity of partners, mapping the good work already going on by different agencies, and planning a programme of work which will result in a Tobacco Control Plan for the City of York.

Council Plan

27. Smoking cessation and tobacco control work is in line with the Council’s Plan 2019-23, to ensure Good Health and Wellbeing through a broad range of opportunities to support healthy lifestyles. The York Health and Wellbeing Strategy 2017-2022 specifically commits to ‘make sustained progress towards a smoke-free generation in York’. Tobacco Control work in York aligns with the Council’s Health in All Policies approach whereby public health encompasses not just a set of services or work done by a single team, but runs through all city policies and practice and aims to improve the wider determinants of health.

Implications

· Financial

Smoking cessation services are funded through the Public Health grant. Nationally, the size of this grant reduced by £700m in real terms between 2015/16 and 2019/20 (LGA).

· Human Resources (HR)

There are no HR implication of this report

· Equalities

People in routine and manual occupations in York are twice as likely to smoke as those in other occupational groups. This is one of the major causes in the life expectancy and healthy life expectancy gap between the poorest and most affluent member of society. Supporting and enabling people to quit and protecting children from the harms of smoking with disproportionally benefit people from lower socioeconomic backgrounds, and decrease health inequalities.

· Legal

There are no Legal implication of this report

· Crime and Disorder

There are no Crime and Disorder implication of this report

· Information Technology (IT)

There are no IT implication of this report

· Property

There are no Property implication of this report

Risk Management

28. The major risk within smoking cessation and tobacco control in the city is the potential missed opportunity if this work is deprioritised to tackle the largest and most avoidable cause of early illness and death in our area.

Recommendations

29. Members of Scrutiny are asked:

· to note this report and comment on progress to prevent uptake of cigarette smoking and support people to quit smoking in the city

· to comment on the ambitions and work of the Tobacco Alliance and the resourcing and capacity required to make it successful

· to make recommendations for partners e.g. GPs and York Teaching Hospitals Trust to increase efforts to refer patients to stop smoking services

Reason: To assist the council smoking cessation service and the wider partnership tobacco control work

Contact Details

Author: Peter Roderick Specialty Registrar in Public Health Tel: 01904 551470 peter.roderick@york.gov.uk	Chief Officer Responsible for the report: Fiona Philips Assistant Director of Public Health
	Report Approved	√	Date 6/03/2020
Wards Affected:				All	√
For further information please contact the author of the report