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Contents Foreword by Jan Hutchinson
Page 3
1. Introduction
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2. Acknowledgments
5
3. Executive summary
6
4. National picture
7
5. Local picture
10
6. Key target groups
13
7. Key settings
24
8. Bolton Tobacco Alliance
33
9. Marmot
34
10.Performance Management
35
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Foreword
By Jan Hutchinson, Director of Public Health, NHS Bolton.
I am very pleased to introduce the new tobacco control strategy for Bolton. Stopping people smoking is the most important thing we can do to improve people’s health. Ten people each week lose their lives in Bolton to smoking related diseases. Lots of excellent work has already gone on in Bolton to reduce smoking prevalence, but we need to drive down prevalence rates even further and save more lives.
This comprehensive strategy outlines how we can tackle tobacco together; it ranges from helping people to quit, to protecting children from second hand smoke, to educating people about the dangers of shisha pipes. We need to work together to change society so that smoking in no longer seen as the ‘norm’ and where young people make an informed choice to not start smoking. Our vision is for a Bolton free from tobacco smoke and free from the disease that it inflicts on families and communities. I am looking forward to seeing the fruition of all these actions in this strategy and the improved health of Bolton it will bring.
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1.Introduction ‘Making Smoking History’ in Bolton has been an aim of the Borough since the 2003-06 strategy was launched seven years ago. Although a massive amount of work has gone on since then in Bolton, resulting in a reduction in smoking prevalence from 30% in 2003 to 21% in 2010 and fewer women smoking in pregnancy, there is still a huge amount to be done in tackling this serious health problem. Smoking remains the most significant preventable cause of ill health, premature death and health inequalities in the Borough. Smoking perpetuates ill health in our poorest communities. As the Government launched its new strategy ‘Healthy Lives Healthy People: A tobacco control plan for England’ earlier this year, it is timely that Bolton once again takes stock of what has been done and what more can be achieved. It is important to build upon the momentum of the smoke free legislation and keep bringing smoking prevalence down for the sake of the health of our communities. The inequalities in health and in smoking prevalence in Bolton must be tackled through sustained and collaborative work. The vast majority of smokers start before the age of 18, by which time they are already heavily addicted to nicotine. Smoking is not an adult choice; it is a childhood addiction to which most adults try to quit on numerous occasions. Children must be prevented from starting, adults helped to quit effectively and the fight must go on against the tobacco industry who continue to try and recruit ‘replacement smokers’ through any methods possible. Each of these factors must be tackled together, as only a comprehensive programme of tobacco control that tackles the issue from every angle will be successful. All partners must be committed to making smoking history if Bolton is to achieve the ambitious target of 10% smoking prevalence by 2020 as detailed in the previous Governments strategy. These are exciting times in tobacco control, so much has been achieved in the past ten years, and with widespread public support for further action, it seems that now is the time to finally make smoking history in Bolton once and for all.
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2. Acknowledgments With thanks to all those who have been involved in the Bolton Tobacco Control Partnership and all those who have helped to make this strategy possible. Written by Liz Wigg – Health improvement specialist – Tobacco.
Adrian Butterworth
Mark Cook
Alf Barker
Matthew Bowman
Debbie Collinson
Nicki Lomax
Garry Herrity
Pete Tomkies
Gary Bickerstaffe
Philip Jones
Jan Hutchinson
Sarah Lever
Jayne Wood
Shane O’Neill
Leesa Hellings
Sharon Tonge
Lesley Hardman
Tracey Holliday
Lesley Jones Linda Duckworth Liz Pritchard Louise Mcdade Marion Nulty
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3.Executive Summary Smoking kills half of all long term users and is the biggest cause of inequalities in death rates between rich and poor in the UK. Our vision is for a future for Bolton where smoking rates are low and all children can reach their full potential by leading a life free from tobacco. A future free from tobacco will mean our children will not suffer from ill health and die early and unnecessarily from smokingrelated diseases and people will lead longer and healthier lives. The aim of this strategy is to meet the objectives laid out in the previous Governments National tobacco control strategy ‘A Smoke Free Future’ published in 2010 and to inform our own local action plan. This strategy details key target groups and key settings and then outlines actions being taken in each area. There also recommendations for each area which have then been used to formulate the action plan which accompanies this strategy and have been divided under the three objectives. The three objectives are: 1. Stopping the inflow of young people recruited as smokers: aspiring to reduce the 1115 year old smoking rate to 1% or less, and the rate among 16-17 year olds to 8% by 2020. 2. Motivating and assisting every smoker to quit – aspiring to reduce the adult smoking rates to 10% or less, and halve smoking rates for routine and manual workers, among pregnant women and within our most disadvantaged areas by 2020. 3. Protecting our families and communities from tobacco related harm – Inspiring to increase to two thirds the proportion of homes where parents smoke but that are entirely smoke free indoors by 2020. To achieve these objectives will require a comprehensive and rounded course of action, helping people to quit and stopping young people from starting. There is still important work to be done in Bolton to drive down prevalence rates to 10% by 2020 which will require a 1% prevalence rate drop every year. This will require sustained partnership work between the NHS, the Local Authority, The Royal Bolton hospital NHS foundation Trust, the voluntary and third sectors and in co-operation with local communities. The key target groups have been identified as routine and manual workers, pregnant women, people with mental health problems, BME communities and children and young people. The key settings are schools, workplaces, healthcare and neighbourhood renewal areas. Representatives through which these interventions will be delivered from these areas have been asked to have representation of the Bolton Tobacco Alliance to ensure that tobacco control work in all of these settings is consistent and identified in any actions plans for the future.
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4. National Picture Nationally, smoking has declined significantly over the past decade. In 1998, when the Department of Health’s ‘Smoking Kills’ tobacco control strategy was first published, smoking prevalence was 28% and that had fallen to 21% in 2008, thanks to the raft of tobacco control measures that the document introduced. In the space of a decade, the number of smokers has dropped by a fifth and there are 2.1 million fewer smokers today then there were ten years ago and the United Kingdom has been seen to be the leader in European tobacco control. There has also been significant decline in the smoking rate amongst young people aged 11-15 years old from 11% in 1996 to 6% in 2008. The past decade has seen significant milestones in tobacco control which have no doubt contributed to this decline in prevalence. Some of the most significant measures include: The formation of NHS Stop Smoking Services (1999). Tobacco advertising and sponsorship in print, on billboards and on the internet banned (2003/4). The age at which people could buy cigarettes was raised from 16 from 18 (2007). The Smoke Free legislation was introduced (2007). Pictorial warnings were introduced on cigarette packets (2008). Nationally, the targets set by the previous Government seem to be on target to being achieved. The Public Service Agreements (PSA) that were established in 2004, set targets for reducing smoking prevalence in different social groups by 2010 (see Table 1).
Table 1.PSA Targets Adults
Pregnant Women
Target To reduce adult smoking in all social classes to 21% or less by 2010
National Position Overall smoking prevalence is now 21% in England.
Local Position According to the 2010 Bolton Lifestyle survey, smoking prevalence in Bolton was 21%
To reduce the rate of smoking in routine and manual groups from 31% (1998) to 26% or less in 2010. To reduce the percentage of pregnant women smoking at the time
The rate of smoking in routine and manual groups is now 26% on average across England. This figure was nationally 14% in 2008.
Unknown at a local level.
In 2009/10 =20.5% In 2010/11 = 18.7%
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of delivery to 15% by 2010. Children
To reduce smoking among children (1115 year olds) from 13% to 9% or less by the year 2010.
The figure nationally In 2007, the is now prevalence rate from 6%. the Young people’s alcohol and tobacco survey was 23% for 14-17 year olds in Bolton. This was up 2% to 25% in 2009. No figure is available for 11 -15 year olds.
Although great progress has been made nationally, this is not the time to become complacent. Evidence from Ireland (1) has shown that although there was a temporary decline in smoking prevalence after the smoke free legislation was introduced, there is some evidence to suggest it has started to rise again. It would be therefore dangerous to assume that the smoke free legislation on its own will be enough to keep smoking prevalence on a downward decline. This was fully recognised in the previous Governments’ tobacco control strategy, ‘Smoke Free Futures’ and building on the momentum of the smoke free legislation and the strong public support for further measures will be vital if a smoking prevalence rate of 10% in 2020 is to be achieved. Further tobacco control measures detailed in the strategy included: Prohibiting the sale of cigarettes through vending machines (Comes into force October 2011) Prohibiting the display of tobacco in point of sale displays (Comes into force in April 2012 for large retailers like supermarkets and all other shops from 2015) A government review into the purchase for and supply of tobacco to young people and to assess what more can be done to limit these sources (academic review of the evidence in this area will be completed in late 2011) A Government review of current tobacco regulations governing the retail sale of tobacco, including current sanctions for breaking the law. Will review whether a registration scheme for the selling of tobacco is needed. (Action to be taken determined after the academic review is completed) The Government will carefully examine the evidence base for introducing plain packaging for cigarette boxes. (Consultation before the end of 2011 on plain packaging) The Government are launching a review of all products that deliver nicotine, including electronic cigarettes so that all products will be regulated. (Consultation published and clear support for more regulation of NRT products, MHRA is now coordinating a period of scientific and market research) A review of Smoke Free legislation in 2010, examining whether the legislation is working and how it can be improved and will enable assessment of what more can 8
be done to extend protection. It will also examine the case for smoke free prisons, extending smoke free requirements to doorways and smoke free requirements for children’s play areas. (Now been postponed by the coalition Government) A transition to a local smoking prevalence target set with measurement using the data from the Integrated Household Survey, rather than PCT’s just being measured on Stop Smoking Service 4 week quit targets. (It has been proposed that Local Authorities will have a target for reducing smoking prevalence however four week quit targets are still in place for now) Despite the possible introduction of these measures, eight million people in Britain still smoke and in 2011, 250,000 people will take up the habit, the vast majority of them being under the age of 18. Deaths from smoking are more numerous than the next six most common causes of preventable death combined: drug misuse, road accidents, other accidents and falls, preventable diabetes, suicide and alcohol abuse (2). Although exposure to second hand smoke has declined since the smoke free legislation in 2007, the home is the most common place for exposure and has harmful effects on children and adults who are exposed (3). The higher the smoking prevalence rates, the more children and young people are exposed to toxic second hand smoke and its harmful effects in the home environment. Smoking is also one of the few modifiable risk factors in pregnancy and is the largest preventable cause of neonatal and infant ill health and death in the UK (4). Children born to mothers who smoke have higher risk of sudden infant death, complications in pregnancy, asthma, impaired lung function in childhood and adulthood and are more likely to have a lower birth weight. There is also substantial evidence linking smoking in pregnancy to attention deficit/hyperactivity disorder (ADHD). A review in 2005 concluded that children exposed to maternal smoking in utero were more than twice as likely to develop ADHD (5). There is also the economic cost of smoking to the NHS, a recent study putting the estimated cost to just the NHS at £5.2 billion annually (6). An another study by the think tank Policy Exchange looked at the wider costs of smoking to society and concluded that the real cost of smoking was £13.74 billion. According to the think tank, the cost of smoking is made up of the cost of treating smokers on the NHS (£2.7 billion); loss in productivity due to smoking breaks (£2.9 billion); increased absenteeism (£2.9 billion); the cost of cleaning up cigarette butts (£342 million); the cost of smoking-related fires (£507 million); and the loss in economic output from the deaths of smokers and passive smokers (£4.1 billion and £713 million respectively)(7).
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5. Local Picture In Bolton, as nationally, there has been a decline in smoking prevalence over the past decade. In the Bolton Lifestyle survey of 2003, the smoking prevalence rate was 29.6%, compared with 21% in the 2010 survey. Although this shows a significant decline, that figure puts Bolton at the national average of 21% and the 2010 survey showed large variances in the smoking prevalence across Bolton (map 1). The results of the young people’s alcohol and tobacco survey show that the rate of young people smoking in Bolton is higher than the average across Greater Manchester (23%) at 25%. Smoking in pregnancy is also a real issue in Bolton, with the smoking at time of delivery figure for Bolton at 18.7% in 2010/11, significantly higher than the national average of 14%. The cost of treating smoking related disease in Bolton is something that is now also pertinent in the current financial climate. Approximately £5 million is spent on prescribed respiratory items each year by NHS Bolton alone and respiratory conditions accounted for 24,500 bed days in 2008/9. Substantial investment in tobacco control represents an opportunity to curb rapidly increasing healthcare costs in the short term. Recent studies demonstrate that investment in tobacco control not only save lives, reduces disease and helps young people not to start smoking but can also lead – by reducing healthcare expenditures – to a 50 fold return on investment. The benefits in reducing heart disease, cancer and lung disease start to appear within two years and the cost reductions grow overtime. No other public health expenditure provides the social and economic returns of the magnitude that result from investments in reducing smoking prevalence. (8) (9) (10) Map 1: Map of smoking prevalence across Bolton according to the 2010 Lifestyle Survey.
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Map 2 : Change in prevalence of smoking in Bolton between 2001 - 2010
Table 2 – Changes in smoking prevalence in Bolton from 2001-2010
Proportion of current smokers by deprivation quintile 2001 to 2010 50
2001 2007
45
0 -5
2010 40
% change 01 to 10
Percent (%)
-15
30 -20 25 -25 20 -30
15
-35
10
-40
5 0
-45 Most deprived
2
3
4
Least deprived
11
Percentage change 2001 to 2010
35
-10
As expected due to their deprivation, smoking prevalence is higher in all the neighbourhood renewal areas than it is in Bolton overall. Deprivation also affects the ability of a population to quit smoking. From the 2001 survey to the 2010 survey, there is a marked difference in percentage change of smokers between the most and least deprived areas of Bolton, as evident in the below chart.
Once the results of the 2010 Bolton lifestyle survey are collated in 2011, there is an opportunity to conduct a further analysis of the smoking population of Bolton by age and gender. NHS Bolton, in collaboration with the local authority, has recently purchased a new piece of software which includes two geodemographic segmentation tools, ACORN and Health ACORN. Using these tools in collaboration will help the NHS to gain a greater understanding of our local population of smokers and enable the use of social marketing techniques to target distinct population groups into stop smoking services.
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6. Key target groups Routine and manual workers With the commitment to reduce health inequalities, one of the key groups the previous Government was keen for Stop Smoking Services to engage with were routine and manual smokers. Routine and manual smokers, as defined by Standard Occupational Codes, account for 50% of the smokers in England or 4.25 million smokers. When trying to target routine and manual workers, one of then the best ways to engage them with services is to help them when they are in their workplace setting as workers who work shifts are often unable to access services available in the day time. By taking stop smoking services out to them, instead of expecting them to come to us it often enable them to access services in group setting with colleagues who can also provide ongoing support for each other. R and M workers are more likely to have started smoking by the time they are 16, they are also more likely to be heavily addicted to smoking, with 37% of R & M male smokers reporting have their first cigarette in the first five minutes of smoking, a sign of heavy addiction (11). Bolton has a high proportion of households that contain a routine and manual worker, 48.3% of households compared to the national average of 32%. Of the 32 postcode sectors in Bolton, there are 11 with an R&M penetration above 70%. Bolton was chosen to be a pilot area for a mapping project run by the Department of Health in 2009 because of its high penetration. The project mapped which postcode areas contained routine and manual workers and suggested advertising routes. This enables any advertising campaigns to be optimised by targeting specific areas in which it is known that routine and manual workers live and work. The national stop smoking advertising campaign ,‘Congratulations’ ,launched in Autumn 2009 specifically targeted routine and manual workers and NHS Bolton uplifted the campaign based on the mapping project with personalised posters, billboards, radio adverts and advertisements on buses.
Recommendations: Bolton Stop Smoking service continues to try and engage more routine and manual smokers into the service through marketing and advertising campaigns.
Continual monitoring of the uptake of the Stop Smoking Service by routine and manual workers. Action plan produced by Bolton Stop Smoking of how they are going to target R & M workers. Clock on 2 health to work with the Stop Smoking Service to target businesses that employ R&M workers.
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Pregnant women
Although many efforts have been made in Bolton to reduce the smoking at time of delivery prevalence, this figure remains stubbornly high. Although the figure has been reducing every year since 2004, see below, the figure is still significantly higher than the national average of 14%. A previous audit of the smoking at time of delivery data collection (SATOD) found that there were some inaccuracies it how it was being was being recorded at the hospital. Currently the question is asked when a lady is in delivery suite and it is felt that this data would be more accurate if the question was asked on discharge from the hospital. It is essential that this question is moved in order for the data to accurately record the SATOD percentage for Bolton, without which we cannot accurately measure the effectiveness of any interventions that are put into place.
Table 3 – Smoking at time of delivery figures for Bolton Year
Percentage of women smoking at time of delivery
2004/5
26.7%
2005/6
24.1%
2006/7
23.5%
2007/8
21.4%
2008/9
20.7%
2009/10
20.5%
2010/11
18.7%
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North West LA's: Smoking in pregnancy
BOLTON West Lancashire South Ribble
40 35
Rossendale
30
Ribble Valley
Bury
Manchester Oldham Rochdale
25
Preston
Salford
20 Pendle
Stockport
15 10
Hyndburn
Tameside
5 Chorley
Wigan
0
Smoking in pregnancy North West average
Burnley
Knowsley
Vale Royal
Liverpool
Macclesfield
St. Helens
Ellesmere Port & Neston
Sefton
Crewe and Nantwich
Wirral
Congleton Chester Blackpool
Halton Warrington Blackburn with Darwen Source: Health Profiler 2008
Table 4: Age and smoking prevalence of women who have given birth at the Royal Bolton hospital in 2009/10 who were smoking at time of delivery Age at delivery
Number of women smoking at time of delivery
Smoking at time of delivery prevalence of women in this age category
Under 20
120
44%
Ages 20-24
238
27%
Ages 25 -29
207
19%
Ages 30-34
104
12%
Over 35
78
15%
*Women included in results are Bolton residents or registered with Bolton GP’s, figures, does not include Bolton residents who gave birth in hospitals in other areas. Analysis of smoking status at time of delivery by age shows that there is a very high smoking at time of delivery rate for the under twenty age group, 44%, which is well above the average smoking prevalence rate of 21% and the national average for smoking at time of delivery which is currently 14%. Another striking feature of this data is that a majority of 15
women who are smoking at time of delivery are in the age group 20-29 years old, 58% of the total women fall into this bracket. It is therefore essential for the specialist pregnancy service provided by Bolton Stop Smoking Service and all providers of smoking cessation advice to ensure it is appropriate for this age group. It is also important to make sure that all health care providers and who come into contact with teenage pregnant mother are able to offer smoking cessation brief advice. There is also some scope to target smoking prevention work at this age group through partnership work with Bolton teenage pregnancy service who are also trying to target this age group. A research proposal will be put together to further analyse this data and make sure that all pregnant women are able to access smoking cessation services that are appropriate for their needs, through whichever service provider they chose. In June 2010, new National NICE guidelines were published, ‘Quitting smoking in pregnancy and following childbirth,’ which made eight recommendations on how best to help pregnant women stop smoking. An action group has now been established to implement these guidelines in Bolton, the most far reaching of them being the recommendation that all pregnant women take a carbon monoxide (CO) breath test at their booking in appointment with a midwife and at each subsequent appointment for women who smoke. This could lead to approximately 7500 CO tests being carried out each year in Bolton which would have training, cost and time implications. A pilot is currently being set up in one community midwifery team in Bolton so a protocol can be tested and the evaluation can be used in any roll out of the use of the CO monitors. Other recommendations such as brief intervention training for midwives are also being considered. Recommendations for the future: Smoking at the time of delivery question to be moved to the discharge section of the questionnaire at the Royal Bolton Hospital. Brief intervention training for all staff working at the maternity unit in Royal Bolton Hospital to be mandatory. Fully evaluate the pilot project of CO monitors being used by one community midwifery team and investigate the feasibility of a borough wide roll out of the system. Ensure that all health professionals who come into contact with teenage girls who are pregnant are trained to provide smoking cessation brief advice. Integrate smoking cessation work with interventions targeted at those who are at a high risk of teenage pregnancy. All interventions targeting mothers include their partners as well and mothers are much more likely to succeed if their partners are involved. Action group put together to accelerate work in this area as the public consultation found this to be the highest priority area.
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People with mental health problems The highest rates of smoking in any population group occur among inpatients in mental health units where up to 70% smoke, with 50% smoking heavily (12). It is estimated that smoking rates are as high as 80% for people with schizophrenia (13). People with mental health problems smoke significantly more, have increased levels of nicotine dependency and are therefore at an even greater risk of smoking-related harm than the general population. People with mental health problems can spend a large proportion of their income on smoking, many of them living on a low income so a higher proportion of their income would be spent on smoking than the general population. Despite evidence that people with mental health conditions are often as motivated to quit smoking as the general population (14), there can be reluctance on the part of the medical profession and staff who work in mental health to bring up the subject. They often wrongly believe that quitting smoking could make their symptoms worse, that smoking is a kind of self medication or that they won’t want to quit smoking (15).However, a recent study has shown that treatment for smoking dependence is as effective among people with severe mental illnesses as it is for the general population. Importantly, they also found that offering such treatments did not cause any deterioration in mental health (16). Although some progress has been made in Bolton in making sure that staff employed by Greater Manchester West Mental Health Trust (GMW) are trained in smoking cessation brief intervention training, there are still great strides to be made to ensure that all patients who smoke are asked about their smoking status and offered support to quit. Whilst some staff at GMW have had brief intervention training, it would be ideal that all their staff undertake brief intervention training considering the number of their clients that are smokers. Although an offer of smoking cessation can be made whilst a client is an inpatient, it is also important that this is then followed up and offered when the clients are transferred to the community mental health teams as outpatients. As the smoking population declines even further over the next decade, it will mean a greater proportion of clients who want to quit smoking are those with mental health problems. In preparation for this, the Bolton Stop Smoking Service needs to consider how it can best help clients who might have longer term needs and might not easily be turned into four week quitters. The service currently offers a ‘drop in’ style service which is very good in terms of flexibility and has a very high quit rate; it does not however always allow for long periods of time and support with each client. Clients who fail to quit and come back to the service are not offered any different type of service which people with mental health problems may need. They may require a more intensive and lengthier period of support from staff members as well as longer term pharmacotherapy. The ‘new routes to quitting’ section of the previous Governments’ tobacco control strategy highlighted how they were planning to offer people more choice when quitting smoking, including cutting down to quit and using safer forms of nicotine for a much longer periods of time (17). These new routes to quitting would be ideal for people with mental health problems as they can very rarely quit easily because of their high level 17
addiction to nicotine. It is now unclear what the coalition Governments’ strategy will be in the future in terms of what routes to quitting will be available to people but a longer term approach, rather than asking Stop Smoking Services to focus of four week quitters, would certainly aid services in helping people with mental health problems to quit smoking. Recommendations for the future: Mandatory brief intervention training for staff from GMMHW Foundation Trust. Staff from Bolton Stop Smoking Service to undertake training in motivational interviewing (MI) and cognitive behavioural therapy (CBT). Work to dispel myths with staff that mental health patients do not want to give up smoking and that it can be harmful to them by highlighting positive examples during training. Smoking cessation started whilst a patient is an inpatient is able to be followed up by the community mental health teams on discharge from hospital. The development of the Stop Smoking Service as a specialist service designed to offer comprehensive support including emotional support in response to identified need. The Stop Smoking Service to screen clients for emotional and mental health problems to ensure that clients receive the appropriate treatments.
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BME communities Approximately 11% of residents in Bolton are classed as being from black, minority or ethnic communities according to the 2000 census information. The table below shows the differences in smoking prevalence rates in different ethnic groups. Table 5: Smoking prevalence of different ethnic groups according to the Bolton lifestyle survey 2010
Ethnicity: Smoking prevalence % White British
21.8
White other
28
Asian Indian
7.1
Asian Pakistani
19.7
Black
7.9
Mixed/Asian Other/Other
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The white ethnic groups have the highest prevalence of smoking in Bolton, with the Asian Pakistani group having the highest prevalence of the BME groups. However, due to the low smoking prevalence of women in South Asian communities, male prevalence rates can be as high as 40% in Bangladeshi communities. South Asian communities also use chewing tobacco and smoke shisha pipes, otherwise known as ‘hubble bubble’ or ‘hookah’, which also pose a danger to health. In general there is a lack of awareness of the dangers of chewing tobacco which comes in brightly coloured sachets which look like sweets and cost pocket money to buy. It has become traditional for chewing tobacco to be offered out at family occasions such as wedding. There are two main types of chewing tobacco - ‘gutka’ - usually containing tobacco and ‘Pann Masala’ – usually not containing tobacco – however analysis of products has shown this is not always the case and ingredients are often not stated on the packets. There is also evidence that betal/acrea nut is also a carcinogenic on its own without the addition of tobacco (18). The areca nut is the seed of the Areca palm which grows in much of the tropical Pacific, Asia and part of East Africa. A few slices of the nut are wrapped in a betel leaf along with lime and spices to make Pann with sometimes users adding tobacco to the mix. Ready prepared packages of the betel nut, lime and tobacco are known as ‘Pan Masala’ and are widely available in areas with high Asian populations.
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The use of chewing tobacco makes the user more likely to get oral cancer and can cause the pre cancerous condition, submucous fibrosis which also causes the mouth to be unable to open (19). This is becoming a more and more common disease in India where the use of chewing tobacco is widespread. There are around 5,000 new cases of mouth cancer in the UK each year and it kills 2000 people annually. Early detection is vital in mouth cancer, with early diagnosis raising survival rates to 90% which is why it is important to raise awareness of the signs and symptoms of mouth cancer. Shisha pipe smoking is also an area where the health implications are poorly understood. Shisha is a water pipe, popular in many Arab countries, in which fruit scented tobacco is burnt using coal, passed through an ornate water vessel and inhaled through a hose. Often thought to be ‘pure’ and ‘clean’ by users because the smoke passes through water in the pipe, research is now showing that it can be as harmful as using cigarettes. A recent study by the Department of Health and the Tobacco control collaborating centre showed that one session of smoking shisha resulted in carbon monoxide levels at least four to five times higher than the amount produced by one cigarette. High levels of carbon monoxide can lead to brain damage and unconsciousness. A typical shisha smoking session can last between 20 – 80 minutes, during which time the smoker may inhale as much smoke during one session as a cigarette smoker would inhale consuming one hundred or more cigarettes (20). In the past few years, Manchester has seen an explosion of shisha cafes and Bolton also now has at least three shisha cafes which have become popular places for young people to gather. However, as with cigarettes, the legal age to purchase tobacco is 18 and there has been anecdotal evidence that younger people are accessing the cafes in Bolton to use shisha pipes. The cafes also have to comply with the Smoke Free legislation by not being more than 50% enclosed. This requires a joined up approach by the NHS, Trading Standards and the Environmental Health department and the police to ensure that all these laws are being adhered to and joint visits to these premises are already taking place in Bolton. NHS Bolton has recently teamed up with Bolton Community Network and the community engagement workers to raise awareness of the dangers of chewing tobacco and shisha pipe smoking. The engagements workers deliver a workshop designed to raise awareness of the signs and symptoms of mouth cancer in a project called ‘Open Wide’. The project has been promoted and delivered in a range of community venues, schools and mosques in Bolton targeting areas with a high number of Asian communities, including, Rumworth, Crompton and Halliwell. So far 838 people have taken part in the workshop and the response has been very positive with many participants expressing disbelief about the health hazards of shisha pipes and the dangers of chewing tobacco.
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Recommendations for the future: Work with retailers of niche tobacco products so that they understand the products they are selling, the age restricted sales and the labelling laws for tobacco products. Work with the Bolton Youth Council to develop work on raising the awareness of the dangers of shisha pipe smoking Continued joint visits by the police and environmental health department to local shisha bars to ensure they are complying with smoke free legislation and age restrictions for entry. Training for health professionals in Bolton on niche tobacco products. Further work by Bolton Stop Smoking Service to encourage more people from BME communities to access the service. Continued seizures by Trading standards of niche tobacco products incorrectly labelled and awareness raising. Trading standards to continue to feed into the Local Government Nice Tobacco Table.
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Children and Young People The World Health Organisation (WHO) estimates that half of the children worldwide live with at least one smoker. Directly and indirectly, children and young people are significantly affected by smoking. They are affected by their exposure to SHS in utero, then in the home environment and subsequently if they become childhood smokers themselves. The impacts of smoking are intergenerational; parental smoking affects their children, not least in that children of parents who smoke are between two to three times more likely to smoke than those who come from non-smoking homes (21). Indirectly, the disposable income of parents spent on cigarettes can then leave less money for basic amenities such as clothes, food and shoes. There is an increased risk of house fire in smoker’s homes and more than 1,500 children under 16 are injured annually in house fires and approximately 40 die each year. The earlier children become regular smokers, the greater their risk of developing lifethreatening conditions, such as lung cancer or heart disease, if they continue smoking into adulthood. Those who start smoking before the age of 16 are twice as likely to continue to smoke as those who begin later in life – and are more likely to be heavier smokers (22). Work with children and young people on stopping them starting smoking in the future is vital if prevalence rates are to decline significantly. In Bolton, lots of work has already been going on to achieve this. In 2006, NHS Bolton set up its own Smoke Free Homes project, a project which aims to raise awareness of the dangers of second hand smoke by getting people to make a promise to smoke outside of the house. This not only protects children and other adults in the house from the harmful effects of second hand smoke, but it also reduces the fire risk in that house and there is some evidence that people who make their homes smoke free are more likely to go on to quit smoking in the future. Studies in the United Kingdom suggest that around 40% of children (around five million) live in households where at least one person smokes inside the home (23). In the United States, it’s been estimated that 90% of children’s exposure to tobacco smoke comes from inside the home (24). In addition, the Royal College of physicians estimates that 17,000 children under the age of five years are admitted to hospital each year with illnesses resulting from exposure to exposure to second hand smoke (25). Nearly 2200 homes in Bolton have now signed up to the scheme, with 57% of those homes situated in neighbourhood renewal areas which the project set out to target. The project is currently being promoted by health visitors, Bolton fire and rescue teams, Bolton Community Network and the Bolton Stop Smoking Service. Community events are also attended by members of the public health team where members of the public are signed up. There are now other areas which the project could be expanded into such as schools, the Royal Bolton hospital and workplaces. It is important now to expand the scheme to cover other areas such as cars and the public will be consulted on their views about making children’s playground in Bolton smoke free. There are also issues with children and gaining access to cigarettes which were addressed through the Health Bill in 2009, in which MP’s voted to ban tobacco vending machines 22
completely and to end the display of tobacco at point of sale. It has now been confirmed that this legislation will become law on the 1st of October 2011. Bolton trading standards also undertake their own annual underage sales tests and all those who sell to underage children are reported for prosecution. Recommendations: All health visitors to raise the issue of second hand smoke and sign up families to smoke free homes at each visit. Continue with a bi annual survey of Year 5 and 6 children which will help build a picture of children’s smoking prevalence rates in Bolton and help us to better understand what age’s children in Bolton start smoking. Analyse the results from the 2010 survey and collate them into a report. Carry on with promotion of the smoke free homes and cars project in Bolton and expand into other areas. Consult with the Bolton community about the possibility of designating children’s play areas in Bolton as no smoking areas through Bolton Community Network. Annual underage sales tests by Bolton trading standards to continue and prosecutions publicised.
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7. Key settings Schools There are currently 110 schools (88%) in Bolton who have achieved Healthy Schools status which means each school has a current and up to date no smoking policy. On national ‘No Smoking day’ 2010, a new website was launched www.packetoffacts.co.uk which has been developed by the Bolton Healthy schools team and deals with facts and issues around smoking. On the site there are lesson plans available for teachers to develop and adapt for their classes as well as interactive activities for the students to use. The healthy schools programme has now moved to offering an ‘enhanced’ programme where each school chooses its own priority area to work on further. The schools that have chosen substance misuse will be setting local targets to work towards and some of these may be around tobacco. The public health department will work with the schools to help them develop targets and work towards them with a range of options available such as further work on illicit tobacco, smoke free homes or niche tobacco products. Also over the past couple of years, the public health team have developed the concept of ‘BKATS’, Bolton Kids Against Tobacco Smoke, a website aimed at young children in primary school. The idea was developed in conjunction with local primary school children through workshops and the idea was launched with a competition where children designed a mascot for the website. The children could also register as members, collect points by taking part in activities and build them up to get promotional goodies such as t shirts, pens or baseball caps. Funding is currently being a sought to develop the website. Funding has just been secured to develop this website and it should be online by September 2011. NHS Bolton has recently conducted a survey of Year 5 and 6 children in Bolton to find out their thoughts about smoking and try and ascertain what ages children in Bolton are first being offered and experimenting with cigarettes. This information will help to inform the BKATS website when it is developed and help the designers of the website to make sure that they are targeting the right age groups. It is hoped that this survey will now be done on a bi-annual basis to track any changes in the numbers of children reporting that they are smoking and also be available as an evaluation tool for the BKATS website. The results of the survey are to be analysed and presented in a report. In the previous Governments’ strategy, there is no mention of cessation services for young people, however anecdotal evidence tells us that there is a large demand for cessation services for young people in Bolton. Also a survey of high schools in Bolton took place to find out how much demand there is for cessation services in their school. All four of the schools that replied reported a significant demand for cessation services. Young people can access the Bolton Stop Smoking Service however they see relatively few young people and it is primarily designed as an adult service. There is access to stop smoking advice through the Parallel health centre for young people, however with a town centre location, this is not easily accessible to young people across the Borough. The school nurses have now received training in smoking cessation and are running drop in clinics at six High schools in Bolton. 24
Recommendations: Public health to work with schools that have chosen substance misuse as their priority issue to work towards their targets in tobacco. Development of the BKATS website and extend to all primary schools in Bolton. Schools ‘No Smoking’ policies to be updated to include no smoking by teachers or any staff in view of pupils, not just off the school premises. Monitor the availability of cessation services for children and young people in Bolton to make sure that all young people can access appropriate services in their local areas. Continued participation in the ‘Crucial Crew’ initiative run the GM Fire Service which is provided to all Year 6 pupils each year and provides alcohol and tobacco education.
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Workplaces The workplace is a key setting in tobacco control as one of the targets for the stop smoking services set by the Department of Health is that 50% of the people setting quit dates should be from routine and manual occupations. NHS Bolton has its own workplace health team called Clock on 2 Health which engages local businesses in a reward scheme to think about the well being of their staff and provides them with help and support to achieve it. The Bolton Stop Smoking Service already has a good relationship with Clock on 2 Health, often working jointly with companies who request stop smoking support for staff and also offering help and support for workplaces that want to make their workplaces and grounds smoke free. As well as problems with smoking at work, employers are also encouraged to offer employees time off from work to attend smoking cessation groups. Other issues that can affect workplaces are issues such as whether to allow smoking on the premises or whether employees can smoke on works time. Employers are encouraged to follow the lead of the NHS Bolton and Bolton Council by only allowing smoking during unpaid lunch breaks and not on any works premises. These issues are covered by workplace smoke free policies and Clock on 2 health helps businesses write policies and often more importantly, how to enforce these policies. Evidence suggests that places where people work may also be the very places where cheap and illicit tobacco is accessed. It is therefore important to incorporate information about the illegality of selling illicit tobacco in workplaces and that managers understand that they are at risk of prosecution if they allow people to sell illicit tobacco on their premises. Fact sheets on illicit tobacco and posters are available now to all workplaces as part of the ‘Get Some Answers’ campaign which launch in the summer of 2010. Workplaces are also a great setting to educate people about the dangers of second hand smoke and to sign up people to the smoke free homes scheme and information about the dangers of chewing tobacco and shisha pipe smoking. Although workplaces are covered by the Smoke Free legislation of 2007, it is still important for the environmental health department to be vigilant about any breaches of this policy. There are still reported breaches of the law, particularly in work vehicles and taxi’s and environmental health officers must still look for signs of the law being broken in business visits. As well as the health costs to employees, there is also the economic cost of smoking to employers, with a report in 2009 putting the total cost to employers in the North West due to smoking at £225.5 million pounds a year (26).
26
Table 6: An economic analysis of the cost of employee smoking borne by employers. (LSE May 2009)
Ranking 1 2
3 4 5 6 7 8 9
Region London SE NW W Midlands East SW Y&H E Midlands NE
Total cost to employers in the Region £326.7m £274.2m £225.5m £173.3m £166.4m £161.4m £160.1m £121.6m £70.3m
Absences attributable to smoking
Smoking breaks at work
£174.6m £149.3m £122.8m £94.2m £91m £90m £87.5m £66.3m £38.3m
£152.1m £124.9m £102.7m £79.1m £75.4m £71.5m £72.6m £55.3m £31.9m
Recommendations: The Bolton Stop Smoking Service and Clock on 2 Health workplace health team continue to work together to offer smoking cessation support in the workplace. Clock on to health to offer workplaces information on ethnic tobacco products such as shisha and chewing tobacco through the ‘Open wide workshops’ offered by Bolton Community Network where it is seen appropriate for the workforce. Information on illicit tobacco is included in any work with workplaces and managers actively reminded that they could be at risk of prosecution if illicit tobacco products are sold on their premises. Bolton environmental health officers to continue to enforce with the 2007 smoke free legislation and prosecute persistent offenders.
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Healthcare settings Another key setting for tobacco control, health care settings, such as GP’s, pharmacies and the Royal Bolton Hospital have an important role to play in referring people to the Stop Smoking Service or providing specialist support themselves. GP’s are well placed to advise their patients on stopping smoking as many of them have personal relationships with their patients and can identify patients who are suffering from smoking related diseases or from second hand smoke exposure. However recent research has shown that in primary care, more than half (57%) of smokers had received no advice to quit from their GP in the last 12 months (27). In Bolton GP’s are already engaged with the Stop Smoking Service and can provide patients with stop smoking medicines such as Nicotine Replacement Therapy and Champix. They must however offer a service which can provide regular motivational support and CO monitoring to give patients the best chance of having successful quit attempt. Bolton’s GPs are currently engaged with the Triple Aim in Primary Care Programme. This remit supports GPs and their staff in ensuring patients on practice registers - Diabetes, CHD, COPD and Primary Prevention – are provided with optimum care to enable them to live longer and have a better quality of life. The Triple Aim project team has developed a robust system of data collection to support these initiatives. The collection includes smoking related data, in particular looking at the numbers of smokers on each register, as well as the recording of overall smoking status for the 16+ practice population. The Triple Aim Programme encourages GPs and their staff to offer routine smoking cessation advice, as well as supporting the practice to organise in-house closed sessions for patients with long term conditions and also those at risk of ill health. These sessions are usually organised in conjunction with the Stop Smoking Service. In an attempt to address localised health inequalities, sessions are organised at times to suit differing patient needs e.g. evening and weekend. Pharmacies are also well placed in the community to offer stop smoking advice, opening for extended hours and selling a wide range of products, people can often feel more comfortable asking for advice from a pharmacist in surroundings that they are familiar with. They have the potential to reach and treat large numbers of people who use tobacco .They are ideally placed to provide clear and credible information to help people make informed choices, and provide a readily available network of trusted health professionals and their teams, based in the heart of the communities. They are accessible to young people and those who may be less likely to attend more formal healthcare settings – one third of men aged between 16 and 54 years old report visiting a pharmacy at least once a month (28). The majority of pharmacies in Bolton offer Stop Smoking support and they also participate in the pharmacy campaign scheme which the theme in March is ‘No Smoking Day’ which they then actively promote through posters and leaflets. The Royal Bolton Hospital sees around 438,000 patients each year and as a large focal point for the local community, it too plays an important role in tobacco control. Visits to hospital provide an opportunity to assess patients overall health and assess their lifestyle risk factors. These interventions are timely as people will already be thinking about their health and it may be an opportune time for people to try to quit smoking. The hospital already has a well 28
established route for referrals to the Stop Smoking Service and was one of the forerunners in embedding referral pathways to smoking cessation. Patients can access nicotine replacement therapy during their stay in hospital from level 2 trained staff but they cannot however currently receive Varenicline (Champix) in the hospital which is a NICE approved first line treatment for stopping smoking. Access to Varenicline could increase quit rates for patients in the hospital and give them the best possible chance of having a successful quit attempt. Through the healthy hospitals public health project, the Royal Bolton hospital is now increasingly becoming involved in public health, promoting health improvement and disease prevention to its patients, staff and visitors. As part of this, the hospital adopted a smoke free grounds policy on the 1st of July 2009, removing the smoking shelters that had previously been onsite. This sends out a very strong public health message that hospitals are a place where optimum good health should be encouraged and supported. This move has also encouraged other local hospitals to adopt a smoke free site policy with Bolton being held as an exemplar trust model which can be replicated. The Bolton Stop Smoking Service also offers onsite stop smoking support for staff who want to quit smoking. The hospital was recently the first hospital in the UK to be awarded membership of the Global Network for Tobacco free Healthcare for its continuing efforts in tobacco control.
Recommendations: All GP’s to offer a consistent service to patients who which to quit smoking which includes Carbon monoxide monitoring and regular motivational and behavioural support. GP’s who are not able to offer this should refer to the specialist Stop Smoking Service. All pharmacies in Bolton to offer access to Stop Smoking support and continue to play an active role in promoting ‘No Smoking Day’. Royal Bolton hospital to continue to enforce the smoke free site policy and continue to offer onsite access to stop smoking support for staff who want to quit smoking. Patients in Royal Bolton hospital to have access to Champix where appropriate. All staff who have patient contact to attend Level I Brief Advice training. All hospital departments with inpatients to have adequate staff trained to Level II ('adequate' = enough to provide daily patient assessment cover).
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Neighbourhood Renewal Areas In the North West local area deprivation is a greater predictor of smoking prevalence than either sex or age and the likelihood of smoking is 2.5 times higher in the most deprived communities (29). As such, the neighbourhood renewal areas in Bolton are key settings for tobacco control activities and stop smoking services. In 2006, Bolton Council introduced a revised neighbourhood renewal strategy that decided to target 10 particular areas where the most intensive activity to reduce deprivation needed to take place, these were: Crompton, Halliwell and Rumworth wards; Great Lever and Farnworth neighbourhood management areas; Hall I’ th’ Wood, Hulton Lane, Johnson Fold and Washacre estates, Breightmet and Tonge with the Haulgh. The following table showing smoking prevalence rates in the NRS areas in 2010. Table 6: Smoking prevalence from The Bolton Health & Lifestyle Survey 2010 by neighbourhood renewal area.
Smoking prevalence Percent Lower CL
Upper CL
Breightmet
31.1
25.6
36.7
Crompton
22.5
15.5
29.4
Farnworth
26.8
22.4
31.2
Great Lever
24.3
19.6
29.0
Hall ith Wood
34.8
20.9
48.7
Halliwell
26.8
21.4
32.2
Hulton Lane
27.1
15.1
39
Johnson Fold
28.5
14.3
42.6
Rumworth
17.2
13.1
21.3
Tonge with the Haulgh
36.7
28.3
45.1
Washacre
33
21.3
44..7
BOLTON
20.7
19.8
21.7
30
As can be seen from the table above, all the NRS areas except Rumworth have a higher smoking prevalence rate than the average for Bolton of 21%. They are a key target for the Stop Smoking Service and the figures for 2009/10 show that the service is doing well in attracting clients from these areas, with 44% of their clients living in NRS areas, even though only 32% of the population of Bolton live in NRS areas. However, some areas like Johnson Fold and Washacre areas have lower quit rates than 35%, which is the quit rate for smokers attempting to stop without any additional support so these low rates need to be investigated. This is in line with national evidence that shows that although the desire to quit is relatively stable across all socio-economic groups, the success of attempts to quit is not equal across the different groups. People from the most disadvantaged groups are less likely to quit (and stay off tobacco) than those from more advantaged groups. There is also evidence to show that poorer smokers are more physically addicted to nicotine, and are therefore less likely to succeed in their quit attempts. (30) (31)
Table 7: Stop Smoking Service – Quit dates set and quit rates for people from NRS areas in 2009/10 Stop smoking service
Number setting a quit date
Rate pple setting a quite date/1000 smokers (18+)
Number quitting smoking
% using the service who quit
Breightmet
233
88.9
104
44.6
Crompton
93
79.3
38
40.9
Farnworth
523
133.0
220
42.1
Great Lever
190
67.9
84
44.2
57
114.0
25
43.9
273
116.4
124
45.4
Hulton Lane
61
86.2
29
47.5
Johnson Fold
84
120.3
26
31.0
Rumworth
170
83.1
88
51.8
Tonge wt Haulgh
140
107.7
69
49.3
89
114.1
31
34.8
NRS
1913
NA
838
43.8
Non-NRS
2447
NA
1218
49.8
Bolton
4360
94.4
2056
47.2
Hall ith Wood Halliwell
Washacre
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Projects such as smoke free homes have also been targeted at NRS areas where the number of households containing smokers will be the highest. The prevalence of illicit tobacco will also be an issue in NRS areas with sellers targeting these areas where demand will be highest and the lower prices will be more attractive. It is therefore very important that these issues are promoted through neighbourhood management and through the health development workers. The health development workers are just about to undertake a health needs assessment which will include tobacco which will inform how they work and promote health services. Illicit tobacco is becoming a prominent issue in Greater Manchester with the ‘Get Some Answers’ campaign in the summer of 2010 highlighting that illicit tobacco is far from the victimless crime that some people might think it is. Cancer Research UK estimates that it is a scourge which kills four times more people than smuggled illegal drugs. Illicit tobacco creates a cheap source of tobacco for children and young people and encourages adults to continue smoking. It is also linked to organised crime and contributes to an underground economy worth hundreds of millions of pounds. Illicit tobacco enables children to have access to cigarettes, increases health inequalities and helps fund organised crime. Partnership work between the Police, the NHS, HMRC and local trading standards departments started this year through the ‘North of England illicit tobacco action plan’. Cheap and unrestricted supply of tobacco in neighbourhood renewal areas will negate all the work that is being done to restrict tobacco to children and the prevention work that is being done in schools. Keeping a focus on illicit tobacco is crucial in reducing prevalence in Bolton and in particular, reducing health inequalities in the Borough. Recommendations: Low quit rates in Johnson Fold and Washacre to be investigated. Stop Smoking Service to continue to target smokers who live in NRS areas to continue to close the gaps in smoking prevalence across Bolton. Promotion of tobacco control campaigns in NRS areas through neighbourhood management teams and community development workers. Continue to monitor uptake of the Stop Smoking Service by postcode and uptake of the Smoke Free Homes project in NRS areas. Continued partnership work and focus on illicit tobacco.
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8. Bolton Tobacco Alliance The Bolton Tobacco Alliance was reformed in 2009 after the appointment of a health improvement specialist in tobacco control. A tobacco alliance can be defined as collaboration between two or more multi-agency parties that pursue a set of agreed goals for tobacco control. Local tobacco alliances have been crucial in the delivery of tobacco control work throughout the country. The purpose of the alliance will be to oversee the implementation of this strategy and ensure that the action plan that will be detailed is put into place. It is also to emphasise that bringing down the smoking prevalence in Bolton is something that NHS Bolton cannot achieve on its own, partners need to work together to enable this to happen. Local tobacco alliances are integral to the success of tobacco control and their activity and expertise needs to be reviewed and sustained. So far the Alliance has members from NHS Bolton, Bolton Council Environmental Health and Trading Standards department, Bolton Stop Smoking Service, Bolton Police force, NHS Bolton workplace health manager, NHS Bolton healthy schools worker, Bolton Fire and rescue service, Bolton Council neighbourhood management and Bolton Community network. The Alliance meets on a quarterly basis and membership is open to anyone who wants to join. The chair of the Alliance represents the group at the Greater Manchester Tobacco Alliance. The alliance will also be key in helping to implement any legislative changes that are brought in, for example the point of sale display ban that was due to brought in over the next couple of years, could be co-ordinated by the alliance.
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9. Marmot – ‘Fair society, Healthy Lives’ In November 2008, Professor Michael Marmot was asked by the Secretary of State for Health to chair an independent review to propose the most effective evidence-based strategies for reducing health inequalities in England from 2010. The report highlighted that there is a social gradient in health and action should focus on reducing this gradient. It stressed that focusing solely on the most disadvantaged would not reduce health inequalities sufficiently; actions must to universal, but with a scale and intensity that is proportionate to the level of the disadvantage. This is called proportionate universalism. The report sets out six priorities: A: Give every child the best start in life B: Enable all children, young people and adults to maximise their capabilities and have control over their lives C: Create fair employment and good work for all D: Ensure a healthy standard of living for all E: Create and develop healthy and sustainable places and communities F: Strengthen the role and impact of ill health prevention In respect of tobacco control, the principles of Marmot are interwoven with the aims and objectives of this strategy. By reducing smoking in pregnancy and ensuring that children grow up in smoke free homes, travel in smoke free cars and play in smoke free playgrounds, that contributes to giving every child the best start in life. Preventing children from starting smoking at an early age through education in schools and through the BKATS club in Bolton will enable children to maximise their capabilities and have control over their lives. By lowering the smoking prevalence rate to 10% by 2020 that will help to achieve a healthy standard of living for all and reduce the health inequalities that are contributed to by the high smoking prevalence rates in our most deprived areas. Marmot also stresses that these changes cannot be achieved through health services alone, all the recommendations require the involvement of a range of stakeholders which is echoed throughout this strategy. There is a note of caution in Marmot for tobacco control; all of the NHS resources should not just focus on the most deprived communities alone but across the Borough with varying degrees of intensity. Many of our services are universal, such as the Stop Smoking Service and the Smoke Free Homes project and they will remain so. In the current economic climate, it is important not to focus all resources on some particular areas/sections of society. The most far reaching tobacco control measures, those enacted by the Government, such as the Smoke Free legislation, are universal.
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10. Performance management The action plan that accompanies this strategy will have targets for each of the areas detailed above and the progress made towards these targets will be monitored by the Bolton Tobacco Alliance. The chair of the group, the tobacco control lead, will report to the health representative on the Healthy communities steering group. Currently, the Stop Smoking Service target is a vital sign which has to be reported on quarterly to the Department of Health. It may be that the coalition Government introduces some other form of monitoring in the near future which will be adhered to.
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References
(1) Slán 2007 Survey of Lifestyle, attitudes and nutrition in Ireland, Department of health and children , 2008 (2) Department of health analysis of Office for National Statistics death registrations 2007. (3) BMA. Breaking the cycle of children’s exposure to tobacco smoke. April 2007. (4) Royal College of Physicians. Nicotine addiction in Britain. London 2000. (5) Langley K, Rice F and Van Den Bree MB et al (2005) Maternal smoking during pregnancy as an environmental risk factor for attention deficit hyperactivity disorder behaviour. A review. Minerva Pediatrica 57: 359 -71. (6) Allender, S. The burden of smoking-related ill health in the UK. Tobacco Control. 2009. 18: 262-267. (7) Policy Exchange. Cough up – balancing tobacco income and costs in society. March 2010. (8) Lee K. Tobacco control yields clear dividends for health and wealth. PLos Medicine 2008;5:(9)189 (9) Lightwood J, Dinno A, Glantz S. Effect of the California tobacco control programme on personal healthcare expenditure. PLos Medicine 29008;5 (8): 1214-1222 (10) Curbing the epidemic. The World Bank 1999 www.worldbank.org/tobacco (11) Department of Health. Tackling health inequalities – targeting routine and manual smokers in support of the public service agreement smoking prevalence and health inequality targets. June 2009.p4. (12) Jochelson, J, Majrowski, B. Clearing the air. Debating smoke-free policies in psychiatric units. Kings Fund. 2006. (13) McNeill, A. Smoking and mental health. A literature review. London. Action on Smoking and health.2001. (14) Siru R, Hulse G, Tait R: Assessing motivation to quit smoking in people with mental illness: a review. Addition.2009, 104:719-733. (15) Northwestern University. Doctors fear asking the mentally ill to quit. September 2009. (16) Banham, L; Gilbody, S. Smoking cessation in severe mental illness : What works? Addiction. Volume 105: July 2010. 36
(17) Department of Health. A Smoke free future. February 2010.p48. (18) Bhavana J et al. Role of areca nut consumption in the cause of oral cancers. A cytogenetic assessment. Cancer. Vol 70:5. P1017-1023 (19) Critchely, JA; Unal, B. Health effects associated with smokeless tobacco : a systematic review. Thorax. 2003. 58: 435 – 443. (20) World health organisation. Water pipe tobacco smoking: health effects, research needs and recommended actions by regulators. 2005. (21) Farkas, A.J, Gilpin, E.A, White, M.M and Pierce, J.P. (2000), ‘Association between household and workplace smoking restrictions and adolescent smoking’, Journal of American Medical Association, Vol.284 No.6, pp.717-22 (22) NICE guidance 23. School –based interventions to prevent the uptake of smoking among children and young people. Feb 2010. P13. (23) BMA. Breaking the cycle of children’s exposure to tobacco smoke. April 2007. (24) US Environmental Protection Agency. National survey on environmental management of asthma and children’s exposure to environmental tobacco smoke. 2004. (25) Royal college of physicians. Smoking and the young. 1992. (26) Mcguire, A. An economic analysis of the cost of employee smoking borne by employers. Enterprise LSE Ltd. 2009. (27) West R. Smoking toolkit study. London. University College London. 2010. (28) Continental Research and solutions research on behalf of the Department of Health. Community pharmacy use – quantitative and qualitative research: Market research report. 2008. (29) Tocque, K. Closing the smoking gap: estimates of smoking prevalence in North West local authorities. KT Intelligence. May 2010. (30) Jarvis MJ and Wardle J (2006). Social patterning of individual health behaviours: the case of cigarette smoking. In : Marmot M and Wilkinson GR (eds) Social Determinants of Health. Second edition. Oxford University press, pp.224-37. (31) Kotz D and West R (2009). Exploring the social gradient in smoking cessation: it’s not in the trying, but in the succeeding. Tobacco Control 18:43-6.
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