Why is it an issue?
Cigarette smoking is the single most preventable cause of death in the UK. The health implications of smoking are far reaching. Tobacco smoke is linked to many diseases in nearly every part of the human body.
In Wakefield smoking prevalence is estimated to be 27%. Life expectancy, deaths from smoking, early deaths from heart disease and stroke and from cancer are all worse than the England average.
Community groups that have high rates of smoking are
- Polish migrants (estimated 48%) (John Dawson et. al, 2009 in HEA 2010);
- 66% of Gypsies and travellers in Wakefield at Heath Common Site are known to be smokers (Gypsies & travellers HNA 2009),
- Prisoners (61% in HMP and 87% in New Hall) (Prison HNA 2010)
- In BME communities the level of smoking is very high but there are very few numbers who access the local stop smoking service (HEA 2010)
The prevalence of regular smoking in children and young people increases with age: from under 0.5% of pupils aged 11 years old to 12% of 15 year olds (Smoking, drinking and drug use among young people in England in 2010).
Smoking during pregnancyOf all pregnant smokers in 2010/11, almost 16% of pregnant smokers were under the age of 20. Wakefield showed some signs of improvement in 2011/12 as the YTD report (Aug 2011) showed a reduction in prevalence, but this has not been sustained going forward.
Younger mothers are more likely to smoke and these risk factors are further compounded if the mother is a single parent and still in their teenage years. The highest rate of smoking in pregnancies are in Normanton, Castleford, Knottingley, Fitzwilliam, Kinsley, Wakefield rural, North & West wards and Crofton. (HEA 2010)
Healthcare CostsMost of our expenditures are dedicated to treating diseases that are already well established. Smoking cost the NHS in the UK £5.2 bn/year (2005). In 2010/11 Wakefield has 4014 of 75056 (5.3%) hospital admissions attributable to smoking costing NHSWD approx £7.2m or £19 per head of population and the latest reports show that 615 adults died in 2010 from diseases that can be caused by smoking.
Maternal smoking is estimated to contribute around 17% to 26% of low birth weight babies. Data from the Neonatal Research Network found that babies born before 26 weeks’ gestation spend at least 111 days in neonatal intensive care during infancy and incur intensive care costs of more than £100 000 (£114 000; £160 000).
While most cost containment strategies focus on using more cost effective care within the medical sector, advocates for population health rightly argue that tackling rising costs and improving our comparatively poor health outcomes will require more attention to preventing disease by targeting the wider determinants of health.
What’s the local picture and how do we compare?
How do we compare?
What do things look like locally?
- Determining an authoritative figure of smoking prevalance is hampered due to different methodologies.
- Smoking levels show very high levels in our priority neighbourhoods, however across most neighbourhoods, we are above the England average (HEA, 2010).
- Modelled estimates from 2006-2008 showed that smoking levels by adults in Wakefield were significantly worse than the England average (NatCen/Information Centre, 2007).
- Smoking prevalence as reported in the Integrated Household Survey for NHS Wakefield is 23.5%, which is higher than the regional average (COPD Dashboard YHPHO, 2011).
- Local survey data from 2009 showed quite marked differences in adult smoking rates across the district, ranging from 29% of adults surveyed in Wakefield East ward and 28% in Knottingley ward, to just 12% in Wakefield Rural and Wrenthorpe and Outwood West wards (Lifestyle Survey, 2009).
- More recent SystmOne analysis paints a more extreme picture of the disparaties within the district, with small pockets of deprivation having a current smoker prevalence as high as 40%. This needs to be interpreted with care as recording practices across GP surgeries will differ.
- In spite of these analytical reservations, rates in the eastern side of Wakefield City seem resistantly high.
- On the LHO’s smoking profiles, Wakefield is considered to be significantly worse in almost every metric – from smoking attributable deaths, lung cancer, COPD, smoking related hospital admissions and smoking in pregnancy (LHO Smoking Profiles, 2010).
- This is confirmed by our high levels of smoking attributable deaths, in heart disease, stroke, lung cancer and COPD – of which the latter three are considered to be significantly different to that of the rest of the country. (Tobacco Control Profiles, APHO, 2010).
Smoking in Pregnancy
- Smoking in pregnancy is also an area in which we are significantly outside the national picture (Tobacco Control Profiles, APHO, 2010), although as of 2010, there had been a slight decrease in maternal smoking over the previous three financial years (DPH Annual Report, 2010).
- Areas most affected by deprivation also have the highest levels of smoking in pregnancy (e.g. parts of Kinsley and Fitzwilliam, South Kirkby, Knottingley, Castleford, Featherstone, Sharleston, Pontefract, Normanton, Portobello, Eastmoor and Lupset). However, some more affluent areas do not follow this pattern with maternal smoking levels amongst the highest quintile, such as parts of Stanley and Hollingthorpe (DPH Annual Report, 2010).
Smoking in children & young peopleThe most recent report for children and young people was through the Health Related Behaviour Questionnaire (HRBQ 11) in Wakefield showed:
- 38.5% of pupils (ages 9, 10 13 and14) said that a parent or carer smokes.
- 19% (ages 9, 10 13 and14) said someone smokes at home in rooms that they use.
- 23.5% (ages 9, 10 13 and14) said that someone smokes in a car when they are in it too.
- 69% of pupils (ages 9-10) said that they are bothered or irritated by tobacco smoke when people smoke around them.
- 20% of pupils (ages 9-10) said that they ‘may’ or ‘will’ smoke when they are older.
- 95% of primary pupils said that they have ‘never smoked at all’. 69% of secondary pupils said the same.
- 2% of boys and 0% of girls in Year 5 said they smoked a cigarette in the week before the survey. 5% of boys and 9% of girls in Year 9 said they were regular smokers
- 3% of pupils responded that they usually smoke with an older brother or sister, while 7% said they do so with their parents (ages 13 and 14).
What’s the trend and what can we predict?
- National survey results show that smoking prevalence has been in gradual decline over the last 15 years although the reductions have slowed in the last few years (State of the District, 2010).
- At present, we struggle to accurately measure and monitor what is often a transient or unreported status.
- Smoking in pregnancy has reduced from since 2008/09 (EOY Trust Board Performance, 2011) and there is some suggestion that the gap between affluent and deprived quintiles has also reduced (HI Gap Analysis, 2010).
What are we doing and what can be done differently?
- Despite the high prevalence and health impacts that Wakefield suffers through smoking, our smoking cessation services have significantly higher rates of successful 4-week quitters (LHO, 2010).
- The number of people within NHS Wakefield who set a quit date with NHS Stop Smoking Services during 2009-10 was 7,320.
- In 2010/11 NHS Wakefield had 3238 successful 4 week quitters. The Department of Health has estimated that each quitter would save the NHS £658.22 / year (Tobacco control: payback and return on marketing investment, Department of Health/ COI 2009). Based on this figure, and incorporating a 25% annual relapse rate on 4 week quitters, NHS Wakefield District has saved £1,598,158 during 2010/11 on a spend of 547,222 (based on £169 cost per quitter x 3238 quitters)
- In a survey of people in the Yorkshire & Humber region, Wakefield had significantly more smokers (72.3% compared to 58.3%) who claimed to have not received any smoking cessation advice from any healthcare group (YHPHO Adult Oral Health Survey, 2008).
We need to move beyond our reliance on smoking 4 week quitters and address the change in “social norms” to promote health. Our challenge, is to help establish and sustain interventions that are most responsive to the real needs of the communities. Hence we are using life course approach (NHSWD 2011) to efficiently investigate complex associations and to review factors influencing behaviour and choices relating to tobacco/smoking. This will help us understand the social norms of different communities.
Currently we are doing several projects to bring our prevalence rates down by denormalising smoking.
- Social norms pathfinder study in the Featherstone area
- Social Norms interventions in primary schools (SNIPS) –A Feasibility (in partnership with Leeds University and PCT
- Children learning about second hand smoke (CLASS) Trial
- Developing an e-learning package on brief advice on smoking cessation enabling all front line workers and other professionals to get trained. This training will be available through the national learning management system (NLMS).
- We have introduced an Opt out scheme where all pregnant smokers will be referred to local stop smoking services unless they mention they do not want to stop smoking.
- All pregnant women will have their CO levels checked regardless they smoke or not. This will help us identify smokers, non smokers and those whose non smokers whose CO levels are high due to gas leakage either in home or car.
What can be done differently?
- To identify number of relapses within our district
- To promote a stop smoking marketing campaign on fathers
- To promote stopping smoking before operation (in secondary care)
- To encourage all staff across all sectors to train on brief advice in smoking cessation
- To actively refer all smokers to stop smoking service and proactively encourage talking to patients about smoking cessation.