- Key issues and gaps
- Who is at risk and why
- The level of need in the population
- Current services in relation to need
- Service users and carers opinion
- Expert opinion and evidence base
- Projected service use in 3-5 years and 5-10 years
- Unmet needs and service gaps
- Recommendations for consideration by commissioners
- Recommendations for further needs assessments
- Print-friendly version of this section (PDF, 400KB)
Reducing smoking rates is a key priority for Outcome 2 of the Haringey Health and Wellbeing Strategy (HWS): a reduced life expectancy gap across Haringey (see JSNA life expectancy chapter). 50% of the gap in life expectancy is due to smoking. Smoking and tobacco consumption is the UK’s greatest cause of preventable illness, disability, early death and health inequalities. More health gains would be achieved by stopping all smoking than from an increase to the NHS budget of 50% (Mayhew report (2010): ‘Increasing longevity and the economic value of healthy ageing and working longer.’ London: Cass Business School, City University (PDF, 821KB).
Smoking increases the likelihood of a number of diseases including coronary heart disease, stroke, diabetes and most cancers. Approximately 9 out of 10 cases of lung cancer and of chronic obstructive lung disease are due to smoking (TC profile (external link)). Smoking increases the risk of young people getting asthma and can lead to impaired lung growth in children and young adults (NHS Information Centre: statistics on smoking - 2009 (external link)). For those who smoke, quitting is often the single most effective thing you can do to improve health and prevent illness.
Smoking is a key driver of health inequalities. Smoking rates (prevalence) are highest in deprived communities and yet reductions in smoking prevalence have been slower in these communities than other population groups (NICE, Quick reference guide for smoking cessation services - 2008 (external link)). Reducing the prevalence of smoking in low income groups, certain black and minority ethnic (BME) groups, and disadvantaged communities will help reduce health inequalities more than any other measure to improve the public's health.
- Smoking is the largest cause of preventable death and contributor to the life expectancy gap
- A reduction in smoking prevalence will lead to improved health outcomes and lower levels of healthcare utilisation
- One in five adults in Haringey smoke
- Haringey smoking rates may not be reducing as fast as nationally
- There are big inequities in smoking rates by socio-economic group, certain BME groups and vulnerable groups (eg mental health users)
- Rates of smoking may be increasing in Haringey “routine and manual” groups
- Haringey has high rates of smoking attributable to hospital admissions. This calls for better links and referral pathways with health and social care services
- Key national target groups are pregnant women, young people and adults at risk
- The Haringey stop smoking service needs to further target: men, low income groups, BME groups and younger adults who don’t access the service currently to maximise access and outcomes for these groups
- Wider tobacco measures need strengthening
- A communications plan and social marketing programme to target the above groups is recommended
- There are opportunities for change as the current stop smoking service contract is ending and the tobacco control delivery plan of the HWS is being refreshed
This section outlines key risk factors for smoking.
Nearly one in five adults in Haringey smoke. (Tobacco Profile PHE latest data accessed - external link).
Gender: Nationally more males (20.0%) than females (19.0%) smoke. ( HSCIC Statistics on smoking: England 2013 (PDF, 1MB)).
Age: Smoking Nationally, 29% of pupils aged 11-15 have never smoked (NHS Information centre: statistics on smoking - 2010, (external link)). Young people are more likely to smoke regularly if they live with other people who smoke and this increases the greater the number of smokers in the household. Smoking before the age of 18 is a key risk factor. Nationally, two thirds (66%) of the current smokers and ex-smokers who smoked regularly, started smoking before they were 18 (Office for National Statistics (ONS) General Lifestyle Survey 2008, (external link)). The highest prevalence of smoking in adults is in the 25-34 year age group and the lowest in those over 65 years (Haringey Health Equity Audit).
Deprivation and low socio-economic groups: Smoking prevalence rates are highest in the poorest areas of England and Wales, demonstrating the strong link between smoking and deprivation. People in low socio economic groups or on low incomes are much more likely to smoke. Nationally people in the lowest 15% in terms of material deprivation have higher smoking rates (45% for men and 40% of women currently smoking) than the general population (Food Standards Agency - Low Income Diet and Nutrition Survey, 2007 (external link).
Ethnicity: Certain ethnic groups have higher rates of smoking. Over 50% of current smokers across London come from a BME background (London Boost Health Survey for England 2006, (external link).
Pregnancy: Smoking in pregnancy presents risks to the mother and the unborn child. Younger mothers are more likely to smoke throughout pregnancy than older mothers. Mothers who have ‘never worked’ are more likely to smoke than mothers in managerial and professional occupations.
Mental health: Up to 30% of all 3 million smokers in the UK have evidence of a mental disorder (VW draft: Smoking and Mental health: A Joint report by the Royal College of Physicians and the Royal College of Psychiatrists - (PDF, 2MB)). Smoking is up to three times more common in those with severe mental health problems than the general population.
More information on smoking prevalence by population group can be found at the London Boost Health Survey for England (London Boost Health Survey for England 2006, (external link)), the Integrated Household Survey (Integrated Household Survey, 2012 - external link) and the Local Tobacco Control Profiles (PHE tobacco Control Profiles - external link).
Prevalence: One in five (20.6%) of adults in Haringey smoke. This is slightly higher, but not significantly higher than England (19.5%) and London (18.0%) (PHE Tobacco Control profile - external link).
Geographical variation: Smoking prevalence by ward (figure 1) shows stark differences between the east and the west of the borough. This is a similar picture to the maps of deprivation by ward (see population profile JSNA) and circulatory disease.
Figure 1: Haringey smoking prevalence by ward
Prevalence in risk groups: Key risk groups are outlined in the section above.
- Smoking rates are much higher in low income groups. In Haringey, estimates from different sources of the proportion in “routine and manual” groups who smoke vary from: 35.9% in 2006 (London Boost Health Survey for England 2006, (external link)) to 24.6% 2012 from Public Health England (PHE) - PHE recent Tobacco control profile (external link). The PHE estimate places Haringey rates in “routine and manual” as similar to London and England (25.7% and 29.7%). ( TC PROFILES)
- Reducing smoking in pregnancy is a local concern and national priority. PHE data suggests only 4.3% of Haringey mothers smoke at the time of delivery, compared to 5.7% in London and 12.7% in England ( 2012/13 data, latest TC profile). However there may be under-reporting.
The Haringey Health Equity Audit gives additional prevalence measures by risk group and compares this to access and outcomes from the service ( Health Equity Audit Haringey)
Smoking attributable hospital admissions: There were nearly 1500 smoking attributable hospital admissions in Haringey in 2010/11. The admission rate is higher than London and England - Tobacco Control profile (external link).
Smoking attributable mortality: 637 deaths were attributed to smoking in 2010-12. The smoking attributable mortality rate is similar to London and England - Tobacco Control profile (external link).
Trends: There has been a very slight decrease in smoking prevalence in recent years (2010-12) in London and England but it has remained steady in Haringey. PHE data suggest that in 2011 Haringey had a lower prevalence in our routine and manual groups than London and England but this difference has narrowed. It also suggests that the prevalence in routine and manual groups in Haringey in 2012 has increased compared to recent years, whereas regionally and nationally there has been some decline. These trends are concerning, though based upon limited data. (Tobacco Control profile (external link)).
The PHE Local Tobacco Control Profile shows Haringey data compared to London or England. For most indicators Haringey is similar to London and England (Tobacco Control profile (external link)).
This section gives a brief overview of the current services and programmes relating to reducing smoking prevalence. We divided it into tobacco control measures, the stop smoking service and awareness campaigns.
A reduction in smoking prevalence is Priority 5 of the Haringey Health and Wellbeing Strategy.
Tobacco control measures
National action since the landmark strategy in 1998 (1998 White Paper ‘Smoking Kills’ (external link)) has aimed to reduce smoking prevalence. Key national actions have been to: ban most forms of advertising and sponsorship (2003/4), introduce national legislation in 2007 'A Smoke Free England' and to make all enclosed public spaces and workplaces smoke-free to protect people from exposure to second hand smoke. In addition measures were taken to raise the legal age for buying tobacco to 18 and insert pictorial health warnings on cigarette packets and to introduce point of sale display for large shops such that cigarettes are kept below the counter.
Local tobacco control measures currently in place are: to encourage all children’s play areas in parks smoke-free (notices are put up but this is not enforceable) and implement a scheme whereby those issued with a fixed penalty notice for littering with cigarette butts can get a partial refund of their fine if they engage with the service and quit smoking. There is also a campaign to encourage smoke-free Homes and Vehicles. The Haringey Council enforcement team works with partners (eg customs and the police) in reducing illicit tobacco. Illicit tobacco is cheaper and thus more affordable to people with less money, including children. Smoking is raised as an issue by other regulatory officers during visits where possible. The trading standards team continue to operate a programme to enforce age restricted sales including “test purchasers”. Compliance by premises with the smoke-free legislation has been high. Shisha is an emerging problem and officers are sharing best practice across borough and supporting proprietors in handling this.
Stop Smoking Service
The mainstay of action to reduce smoking prevalence is through wider national and local tobacco control measures. In addition the Department of Health guidance states that at least 5% of smokers should access stop smoking services each year. Smokers using the NHS services are approximately 4 times more likely to stop smoking successfully than those trying to stop alone - NHS Choices - Smokefree (external link).
The current service, commissioned by the council public health department has been provided by Innovision Healthcare services since February 2011. The service supports about 2000 smokers per year in stopping smoking. The key performance indicators target: “routine and manual” groups, people with mental health problems, pregnant women, BME groups, media and advertising campaigns and partnership work to support the Tobacco Control plans. The service is based upon behavioural support and pharmacotherapy where appropriate with success assessed at 4 weeks. Support is provided by trained advisers through one to one advice or group work and there are specialist stop smoking advisers to support people with, for example, mental health problems. The service operates from primary care, pharmacies and community clinics.
In addition both acute hospital trusts and the mental health trust locally have Commissioning for Quality and Innovation targets (CQUINs) whereby they are incentivised to promote smoking cessation within the trust. A specialist role to drive smoking cessation within the mental health trust is also under development.
The model of service for October 2014 when the current contract ends is under consideration.
Raising awareness and campaigns
Key national and local campaigns run each year including: Stoptober in October, the national “No Smoking” campaign in March and annual campaigns to encourage people to stop smoking in the New Year. In addition we put regular messages in local newsletters and GP newsletters. The Haringey health champions and health champions raise awareness of the need to stop smoking and refer to services. We are currently training key frontline staff of the importance of stopping smoking and to have confidence and skills in discussing this with clients.
Feedback by service users on services and local unmet needs and priorities should inform policy.
The local stop smoking service undertakes patient satisfaction surveys that show a good level of satisfaction overall from people who use the service. The recent health equity audit shows that men are not fully accessing the service. A social marketing programme has identified key approaches to help engage men in preventative services.
This section lists key documents that provide evidence to inform local and national policy on what works to reduce smoking prevalence.
Best practice in tobacco control is mainly drawn from:
- 1998 White Paper ‘Smoking Kills’ (external link) - a landmark strategy
- 2008 – Excellence in tobacco control: 10 High Impact Changes to achieve tobacco control – an evidence-based resource for local Alliances, (PDF, 626KB)
- The national strategy for A Smoke Free Future: 2010-2020 (PDF, 206KB) - national strategy to stop the inflow of young people recruited as smokers, to motivate and assist every smoker to quit and to protect families and communities from tobacco related harm
- Healthy Lives, Healthy People: A Tobacco Control Plan for England’, March 2011, (PDF, 523KB) which sets out national ambitions to reduce smoking prevalence among adults and among young people and to reduce smoking in pregnancy
- NICE Tobacco ROI Tool - Estimating Return on Investment of Tobacco Control (external link):- a tool to estimate the return on investment of local and sub-national tobacco control programmes
- Tobacco Control Alliances (PDF, 2MB) - a Toolkit for London
- Smoking and Health Inequalities, ASH, 2005 (PDF, 224KB - external link);
- Beyond Smoking Kills: Protecting Children reducing inequalities. ASH, 2008, (PDF, 5.2MB - external link);
Best practice in smoking cessation is mainly drawn from:
- The National Institute for Clinical Excellence (NICE), “Public Health Guidance 10 - Smoking Cessation Services” (PDF, 283KB - external link) and
- The Department of Health’s publication “Stop Smoking Service and Monitoring Guidance 2010/11 (PDF 1.2MB external link)
Key local documents:
- Haringey Health and Wellbeing Strategy (PDF, 777KB)
- Enfield and Haringey Tobacco Control Strategy and Haringey Delivery Plan (PDF, 1MB)
- Health Equity Audit of the Stop Smoking Service, Haringey Council, 2013 (PDF, 1MB)
- Men’s Health Social Marketing report (PDF, 951)
- CLeaR report on Tobacco control in Haringey, 2014 (PDF, 300KB) ()
- Tackling the Life Expectancy Gap: briefing paper for the cross party working group. Haringey Council, 2011 (PDF, 1MB)
- Redoubling Efforts to achieve the 2010 National Health Inequalities Life Expectancy Target. Resource Pack. Department of Health, March 2010 (external link)
It is not clear what the projected number of smokers will be. The impact of the smokefree legislation in 2007 is expected to reduce smoking prevalence (“The Impact of Smokefree Legislation in England: Evidence Review March 2011”, Professor Linda Bauld). The impact of the economic recession and situation is unknown, but is likely to increase smoking rates (Institute of Health Equity impact of economic reforms). The impact of e-cigarettes is also unknown.
Local service developments and campaigns will aim to increase service use of the local stop smoking service by local smokers. These include: expansion of the NHS Health Checks Programme within the east, and ultimately the west of the borough, expansion of the health trainers and health champions service who will direct referrals to the stop smoking service, roll out of motivational interviewing training to front line staff and a social marketing programme aimed at men.
This section describes the unmet needs and service gaps based upon the sections above. We subdivide the unmet needs into the three national target areas: adults at risk, young people and pregnant women. Service gaps are outlined in relation to three areas of the Health Inequalities National Support Team triangle to systematically address health inequalities through approaches focused on:
a) population health/wider tobacco control approaches
b) personal health/ service model for stop smoking services ,and
c) community health/approaches eg raising awareness ( redoubling efforts for 2010 target)
Adults at risk: Haringey is a deprived and ethnically diverse borough. Local data is showing: overall prevalence is not decreasing, concern that prevalence may be rising in routine and manual groups, higher prevalence of smoking on the east of the borough and high smoking attributable admissions compared to London and England. Haringey also has a high prevalence of people with mental health problems, who are at risk of smoking.
Young people: There is limited data on smoking rates in young people. This in itself is an issue.
Pregnant women: The data suggest that the rates of smoking in pregnancy in Haringey are lower than London or England, but this data may not be robust. Haringey has high numbers of teenage parents who are more likely to smoke and high infant mortality rate for which smoking is a risk factor. Reducing smoking in pregnancy is therefore a local priority in Haringey.
Stop smoking service: The current stop smoking service model reaches 2000 people per annum. This is slightly lower than the 5% of smokers per annum recommended by the Department of Health. The Haringey Health Equity Audit suggests that whilst deprived areas have access to the service, the quit rates for people from these areas is lower than from affluent areas. Other concerns identified were: certain BME groups are not accessing the service and BME groups have lower quit rates and younger adults (25-34 years) with higher prevalence are not accessing the service as much as older adults. Men a target group for reducing the gap, don’t access the service as much as women and (Haringey Health Equity Audit). Therefore despite the performance targets for the current service we need to strengthen outcomes for our high risk groups. Recent NICE guidance on harm reduction promotes the need for smoking services to link with other lifestyle services eg. weight management to support smokers in giving up, particularly in relapse prevention. The evidence of the “clustering” – that low income groups are more likely to have multiple unhealthy lifestyle behaviours than more affluent groups supports the need for generic services (dealing with more than one behaviour) ( D buck Kings Fund). The high level of smoking attributable admissions (see above) suggests stronger links are required with patients who already have disease such as diabetics and people with heart or lung disease to improve or prevent worsening of their condition and reduce admissions. Our current stop smoking services do link with the generic health trainers service. We are also rolling out motivational interviewing training to frontline staff. However more may be needed to strengthen referral pathways and scale up brief intervention advice.
Wider Tobacco control/population approaches and community approaches:
Current tobacco control programmes include enforcement of under age sales, smoke free children’s areas in parks, tackling illicit tobacco, enforcement of smoke free legislation. Current community approaches include regular publicity campaigns and some work with schools. However Haringey’s steady level and persistent inequalities in smoking prevalence suggest we are not having sufficient impact.
The CLeaR peer review areas for improvement proposed a communications/media plan, social marketing programme for smoking, better measurement of the impact of interventions and stronger engagement with stakeholders such as midwifery and social care. Across the board we need to ensure our service, our tobacco control measures and our community approaches target and achieve outcomes for at risk adults (eg mental health, low income groups), pregnant women and young people.
1) To review the tobacco control delivery plan of the Health and Wellbeing Strategy with a view to strengthening:
- The 3 core areas of the Health Inequalities National Support Team triangle: population health/wider tobacco approaches, personal health/the current stop smoking service model and linked referral pathways and community health/approaches ( redoubling efforts)
- Setting SMART targets to improve smoking prevalence in target groups and to reduce inequalities in smoking prevalence
- Short, medium and long-term objectives
2) Refresh of the service model for stop smoking service to ensure:
- Increase target to 5% of smokers
- Access to the service for the three national target groups of pregnant women, young people, at risk adults
- Improved access to men and younger adults, outcomes for low income groups and access and outcomes for BME groups, based upon the findings of the health equity audit ( Health equity audit)
- Stronger links of the service with other lifestyle services for example physical activity and weight management scheme and the generic health trainer scheme
- Stronger links and referral pathways for health and social care clients with co-morbidities such as diabetes and for pregnant women. Examples of this would be improving performance of CQUINs and roll out of motivational interviewing training to staff
- Guidance on e-cigarettes and other forms of tobacco use
3) Strengthen population based/ tobacco control approaches. Again target:
- east of the borough/low income groups eg strengthen work with businesses and fire and rescue services
- young people eg. strengthen work with schools and parents, develop a peer mentoring scheme and continue enforcement of under-age sales
- pregnant women
4) Scale up community based approaches for target groups:
- media and publicity campaigns with various media and social networks pulled together in a communications plan
- a social marketing programme focusing specifically on smoking and identifying how to improve access for BME groups, pregnant women, men and younger adults
- community health champions to raise awareness and sign post to these key groups
5) Fully integrate mechanisms to raise awareness and to offer support to stop smoking into the care pathways of the management of long term conditions
This is key to early intervention and admission avoidance and would include:
- publicity of the importance of the issue
- training of staff eg in motivational interviewing
- integration into referral pathways
- implementation of CQUINs
6) Health Intelligence:
- further investigation of : high smoking attributable admissions, the possible rise in the prevalence of smoking in “routine and manual” groups, smoking rates in pregnancy, scale and nature of use of other tobacco forms and guidance on e- cigarettes
- Stronger evaluation of the impact of our interventions
- Needs assessment of smoking in young people (including baseline data and actions)
- Needs assessment of smoking in the mental health setting
- Repeat Health Equity Audit of the Stop Smoking Service in 2016
- The Impact of the Economic Downturn and Policy Changes on Health Inequalities in London. Institute of Health Equity, 2012
- Buck D, Frosini F. Clustering of unhealthy behaviours over time, The King's Fund, 2012
- Local Tobacco Control Profiles for England. Public Health England, 2014. Weblink accessed 20/5/2014
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