Ayrshire and Arran Tobacco Control Strategy Volume 2 (Fact File)
2012 - 2021
“Moving Towards a Smoke Free Ayrshire and Arran” Contents Page 1. Introduction 3 2. Demography of Ayrshire & Arran 4 - 10 3. National Policy Drivers 11 - 15 4. Local Policy Drivers 16 - 20 5. Tobacco Related Data 21 - 38 6. Prevention and Education 39 - 43 7. Provision of Smoking Cessation Services 44 - 50 8. Health Protection 50 - 57 9. Stakeholder Involvement 58 10. Performance Management 59 11. Conclusion 60 12. Appendix 1 61 – 65 13. Appendix 2 66
1. Introduction
Facilitating a reduction in the proportion of the population who smoke has been a priority for a number of years, at both a national and local level. The benefits of achieving this reduction are well established, with smoking being described as the number one cause of preventable death in Scotland (Beyond Smoke Free, 2010). In the current financial climate, the incentives and benefits of reducing the number of people who smoke could not be more apparent, with smoking related illnesses costing the NHS around £400 million a year (Scottish Government, 2010). While the financial implications of tobacco make the benefits of reducing smoking rates extremely advantageous, the number of deaths due to smoking related illnesses (13,500 Scots per year, Scottish Government, 2010) and the number of hospital admissions caused by smoking (33,500 admissions per year, Scottish Government, 2010) makes a reduction in tobacco consumption an imperative.
This document, aims to provide an overview of the evidence which supports the production and need for the actions outlined in Volume I of the Ayrshire and Arran Tobacco Strategy. This will be achieved by highlighting information on the following key areas:
- The demography of Ayrshire and Arran - The national tobacco policy drivers - The local tobacco policy drivers - Tobacco related data - The main approaches to tobacco control - Second Hand Smoke (passive smoking) - Protection and Controls - Stakeholder Involvement - Performance Management.
This report will form a crucial part of an evidence base which will be used to inform and drive the work of a multi-agency Tobacco Strategy Group.
2. The Demography and Epidemiology of Ayrshire and Arran
2.1 Ayrshire and Arran is located in mid south central Scotland and is surrounded by Inverclyde and East Renfrewshire in the North, by Lanarkshire in the East and Dumfries and Galloway in the South.
Figure 1: Map of NHS Ayrshire and Arran
Source: http://www.scotland.gov.uk/Publications/2007/03/07153942/4
NHS Ayrshire & Arran covers an area of 750,464 square hectares in the south west of Scotland, from Skelmorlie in the north to Ballantrae in the south and Muirkirk in the east. The area covers a mix of rural and urban development with an overall population density of 0.56 people per square hectare, slightly below the national average. Out of the total population of 367,510 people1, around 80% live in community settlements of over 500 people.
1 2008 VPS survey
2.2 Population profile for Ayrshire and Arran Ayrshire and Arran is comprised of three locality areas: North, East and South Ayrshire, which all vary in population size (Figure 2). The mid-year population estimates for 2009 indicate that North Ayrshire has the largest population of 135,510, compared to 120,210 in East Ayrshire and 111,440 in South Ayrshire. Within each of the three areas, there are more females than males.
Figure 2: Overview of estimated mid year population for East, North and South Ayrshire and for Scotland, 2009 East North South Scotland Population size - All 120,210 135,510 111,440 5,194,000 Females 62,065 71,229 57,995 2,678,712 Males 58,145 64,281 53,445 2,515,288 Source: General Register Office of Scotland (GROS) 2010
Based on the mid-2008 population estimates2, the key settlements within Ayrshire and Arran are:
Irvine (North Ayrshire) 32,920 Kilmarnock (East Ayrshire) 44,390 Ayr (South Ayrshire) 46,070
The age profile for each area in Ayrshire and Arran are similar (Figure 3) with North Ayrshire having the highest number of individuals in each age group apart from the over 75 age group where the number of people in South Ayrshire is greater. In 2009, there is a noticeable difference in the population age profiles that can be seen in the oldest age group (75+), where the number of people in South Ayrshire is greater than that found in East and North Ayrshire. In all other groups the number of people within East Ayrshire is greater than South Ayrshire apart from the 55-64 age group where they are both similar.
Figure 3: The number of people within each age group in East, North and South Ayrshire, mid-year estimates 2009
2 http://www.gro-scotland.gov.uk/files2/stats/population-estimates/08mye-localities-table1.xls 30,000
25,000
20,000
15,000
10,000 Number of Persons
5,000
0 Under 16 16-24 25-34 35-44 45-54 55-64 65-74 75+ Age Group
East Ayrshire North Ayrshire South Ayrshire
Source: General Register Office of Scotland (GROS) 2010
Other settlements with a population of over 10,000 include: Kilwinning, Prestwick, Troon, Saltcoats, Largs and Ardrossan. Cumnock in the east has a population of just over 9,000 people. There are also eight settlements with under 1,000 residents. NHS Ayrshire & Arran boundaries are coterminous with those of the three local authorities, North, South and East Ayrshire Councils.
2.2 Demography of Ayrshire and Arran Comparison between the census results of 2001 with that of 1991 indicated a reduction in the Ayrshire and Arran population of 1.03%, compared to an increase in the national average of 1.27%. The Voluntary Population Survey (VPS) in 2008 indicated a further fall of 0.2%. The population in North Ayrshire has declined by under 0.7% between 1991 and 2008, while in South Ayrshire, the reduction was 0.9%. Over the same period however, the population of East Ayrshire has decreased by 2.1%. Within settlements the changes are even more significant: Comparisons between 1991 and 2001 indicate changes ranging from a 20% reduction in population in Bellsbank and New Cumnock to a 26% increase in Coylton and a 58% increase in population in Loans3.
3 http://www.scrol.gov.uk/scrol/analyser/analyser?topicId=1&tableId=&tableName=Usual+resident+population&selectedTopicId=&aggregated=fa
2.3 Minority Ethnic population The 2001 Census4 indicated that the proportion of the population in ethnic minority groups in Scotland was 2% in comparison to 1.3% in 1991. For Ayrshire and Arran, the corresponding figures were 0.68% in 2001 in comparison to 0.49% in 1991. Nevertheless, NHS Ayrshire & Arran has the fifth lowest non European population in Scotland, with East, South, and North Ayrshire Council areas having the 5-7th lowest rates among the 32 local authorities. The largest ethnic groups in Ayrshire and Arran are fairly similar throughout Ayrshire and Arran’s localities: Chinese (0.18%) and Indian (0.16%). However, there is slight variation in East Ayrshire compared to the other council areas with an Indian population of 0.07% compared to a Pakistani cultural population of 0.14%.
NHS Ayrshire & Arran provides documentation and translation in any language, and interpreters, when required.
2.4 Religious affiliation in Ayrshire and Arran In the 2001 census, 53% of the population described themselves as being allied to the Church of Scotland. This level is the third highest of any Health Board area in Scotland. The proportion of people allied to the Church of Scotland is another confirmation of the cultural homogeneity of the Ayrshire and Arran population. Slightly over 24% of the population described themselves as having no religion, the fifth lowest in Scotland.
2.5 Socioeconomics of Ayrshire and Arran Scottish Index of Multiple Deprivation (SIMD) data, indicates that there are significant differences in socio-economic status and deprivation levels throughout Ayrshire; with areas of significantly high poverty close to areas of very low poverty. It is recognised, furthermore, that most people who are dependent on income related benefits or who are otherwise socially excluded live out with recognised areas of poverty.
lse&subject=&tableNumber=&selectedLevelId=&postcode=&areaText=&RADIOLAYER=&actionName=view- results&clearAreas=&stateData1=&stateData2=&stateData3=&stateData4=&debug=&tempData1=&tempData2=&tempData3=&tempData4=&a reaId=052&areaId=031&areaId=055&areaId=085&areaId=045&areaId=032&areaId=042&areaId=086&areaId=044&areaId=120&areaId=096& areaId=082&areaId=081&areaId=077&areaId=094&areaId=050&areaId=057&areaId=058&areaId=040&areaId=051&areaId=036&areaId=103 &levelId=9
4 http://www.gro-scotland.gov.uk/files1/stats/key_stats_chareas.pdf From the 2009 SIMD data5, there are 480 recognised data zones in Ayrshire and Arran (out of a Scottish total of 6505). Of these, a total of 28 are in the 5% most deprived areas of Scotland and another 28 in the 10% most deprived areas. In contrast, there are three areas in Ayrshire and Arran that are among the 5% least deprived in Scotland and another 18 in the 10% least deprived6. Figure 4 displays the significant inequalities between the most deprived areas in Ayrshire and Arran and the least deprived.
Figure 4: Percentage Population by data zone (%) Local Authority Area East North South Ayrshire and Arran Rate Ayrshire Ayrshire Ayrshire total 5% most deprived 7% 6% 4% 6% 5-10% most deprived 6% 7% 3% 5% 10-5% most affluent 2% 1% 8% 4% 5% most affluent 1% 0% 1% 1% Grand Total 100% 100% 100% 100%
Breaking down the proportion of the Ayrshire and Arran population living within quintiles 1-5 of employment deprivation (using SIMD 2009) (Figure 5).
Figure 5: Ayrshire and Arran total (%) residing in quintiles 1-5 of employment deprivation 1- least 5- most Total 2 3 4 deprived deprived population Total population 17% 15% 27% 19% 22% 100% Working age population 17% 15% 27% 19% 22% 100% The employment status domain7 gives an indication of the level of deprivation of people of working age and shows that a total of 29 zones are in the 5% most deprived areas of Scotland and another 26 in the 10% most deprived areas (Figure 6). In contrast there are five zones in Ayrshire and Arran that are among the 5% most affluent in Scotland and another 18 in the 10% most affluent.
Figure 6: People of economic deprivation by data zone
5 Scottish Index of Multiple Deprivation http://www.scotland.gov.uk/Resource/Doc/289599/0088642.pdf 6 Scottish Index of Multiple Deprivation http://www.scotland.gov.uk/Resource/Doc/933/0090601.xls 7 http://www.scotland.gov.uk/Topics/Statistics/SIMD/background4employment2009 SIMD Local Authority Area Employment East North South Ayrshire and Domain Rank Ayrshire Ayrshire Ayrshire Arran total 5% most deprived 10 13 6 29 5-10% most deprived 7 16 3 26 10-5% most affluent 4 5 9 18 5% most affluent 1 2 2 5 Grand Total 154 179 147 480
In total, 15% of the population of North Ayrshire, 14% of the population of East Ayrshire and 12% of the population of South Ayrshire are employment deprived (Figure 7). The highest levels being within the most deprived data zones in Ardrossan, Irvine, Kilmarnock (Altonhill South, Longpark and Hillhead), and Ayr (Lochside, Braehead and Whitletts). The areas with the lowest level of employment deprivation were in the most affluent data zones in Stewarton East, Largs and Ayr (Alloway and Doonfoot).
Figure 7: Percentage of working age population who are employment deprived within identified data zones
SIMD Local Authority Area Employment East North South Ayrshire and Arran Domain Rank Ayrshire Ayrshire Ayrshire total 5% most deprived 32% 34% 32% 33% 5-10% most deprived 26% 74% 26% 41% 10-5% most affluent 3% 3% 3% 3% 5% most affluent 2% 3% 2% 2% Grand Total 14% 15% 12% 14%
21% of East Ayrshire, 22% of North Ayrshire and 16% of South Ayrshire are defined as Income Deprived. The level of income deprivation range from 70% (Kilmarnock) and 66% (Ayr) – the most deprived, to 1% (Kilmarnock) and 2% (Ayr) - the least deprived8. This information on the demographics of Ayrshire and Arran highlights the significant levels of economic and multiple deprivation. The inequalities between the most affluent and most deprived are striking, demonstrating the need to continue targeting those living in the most deprived areas in the attempt to reduce health inequalities.
8 http://www.scotland.gov.uk/Resource/Doc/933/0090944.xls For additional information on the socioeconomics of Ayrshire 7 Arran, please see appendix 1.
3. National Tobacco Policy Drivers
The drive for a reduction in the consumption of tobacco has been widely supported across the political landscape of Scotland since devolution. Successive governments have recognised the economic and health related benefits that can be reaped from a reduction in Scotland’s high smoking rates.
3.1. ‘A Breath of Fresh Air for Scotland’ (Scottish Executive, 2004) was the first tobacco strategy introduced to Scotland. This outlined Scotland’s ambitions and commitments for the reduction in tobacco consumption, providing an action plan which covered prevention and education, protection and controls and the expansion of smoking cessation services. This document committed ring fenced monies for smoking cessation services up to 2008, which was subsequently extended to 2011. ‘A Breath of Fresh Air for Scotland’ also addressed passive smoking, highlighting the impact that smoking in public places has on the publics’ health. This document paved the way for the ‘Smoking, Health and Social Care (Scotland) Act’, by actioning a public consultation on the impacts of a ban on smoking in public places, an act that was passed in 2005.
3.2. The Smoking, Health and Social Care (Scotland) Act (2005) prohibits smoking in enclosed spaces with a few exemptions. These include designated rooms in residential accommodation, adult hospices or designated laboratory rooms. An extensive evaluation measured the outcomes of the smoking ban in terms of; compliance with the legislation; secondhand smoke exposure; smoking prevalence and tobacco consumption; tobacco-related morbidity and mortality; knowledge and attitudes; socio- cultural adaptation; economic impacts on the hospitality sector; and health inequalities (Haw, 2010). This evaluation outlined the benefits of this legislation and showed that as a result, there had been;
a 17 per cent reduction in heart attack admissions to nine Scottish hospitals. This compares with an annual reduction in Scottish admissions for heart attack of 3 per cent per year in the decade before the ban a 39 per cent reduction in second hand smoke exposure in 11-year-olds and in adult non-smokers an 86 per cent reduction in secondhand smoke in bars an increase in the proportion of homes with smoking restrictions no evidence of smoking shifting from public places into the home high public support for the legislation even among smokers, whose support increased once the legislation was in place.
This act has clearly benefited the health of the nation and acts as support for continued investment in smoking prevention and control measures.
3.3. In 2006, ‘Towards a Future Without Tobacco: The Report of the Smoking Prevention Working Group’ was published by the Scottish Executive. This report provided key recommendations which aimed to protect and dissuade all young people in Scotland from starting to smoke and to deter adults from encouraging or enabling them to smoke. The report makes 31 separate recommendations - summarised within the report on pages seven to ten - to protect or dissuade young people from starting to smoke and to deter adults from encouraging or enabling them to smoke. These recommendations are grouped under the broad headings of targets, research, reducing availability, discouraging young people from smoking, encouraging and enabling young regular smokers to stop, and making it happen. The working group conducted a thorough investigation of smoking related issues and provided a strong evidence base for action. The recommendations from this working group formed the basis for Scotland’s smoking prevention action plan, described below.
3.4 Scotland’s Future is Smoke-Free: A Smoking Prevention Action Plan (2008) Highlights the Scottish Governments strategic objective for a healthier Scotland which states that, ‘We will help people to sustain and improve health, especially in disadvantaged communities, ensuring better, local access to health care’ (Scottish Government, 2008). The actions being taken to discourage young people from smoking as recommended by the Smoking Prevention Working Group tie in closely with this objective. The actions are compiled under five headings – Health Education and Promotion, Reducing the Attractiveness of Tobacco Products, Reducing the Availability of Tobacco Products and Reducing the Affordability of Tobacco Products. - Health Education and Promotion – This section describes the actions currently underway that aim to raise awareness of the dangers of smoking, including smoking education within schools, national media campaigns and activities undertaken by NHS boards as part of their tobacco control programmes. Health education and promotion also includes Schools (Health Promotion and Nutrition) Scotland Act 2007 which ensures that health promotion has a central and continuing focus in education. Actions included in this section include developing advice, guidance and proposals aimed at helping schools and authorities to achieve the benefits sought through Curriculum for Excellence, Scotland’s curriculum for 3-18 year olds. - Reducing the Attractiveness of Tobacco Products – This section highlights and addresses the influence that marketing and promotion of tobacco products has on consumers. It outlines the restrictions on tobacco marketing that had already been introduced, including televisual, press and billboard advertising along with the introduction of hard hitting health warnings on all cigarette packs. This section then highlights further action includes the restriction of displaying tobacco products at the point of sale, the desirable move to plain packaged tobacco products and recommends to all agencies in contact with children to enforce a no smoking policy in all areas frequented by children e.g. playgrounds. - Reducing the Availability of Tobacco Products – The Scottish Government plans to work closely with the Convention of Scottish Local Authorities (COSLA) and Local Authorities to ensure a stricter enforcement of tobacco control laws. Along with this, a system of licensing is proposed to make tobacco enforcement procedures more robust. - Reducing the affordability of tobacco products – It is well established that reducing the affordability of tobacco products results in a marked decrease in tobacco consumption. It is made clear that the Scottish Government will continue to encourage the UK Government to continue using taxation of tobacco products as a tool to lower tobacco consumption. It is explained that the Scottish Government will also work closely with Her Majesties Revenue and Customs to reduce illicit sales of tobacco products in Scottish communities.
The smoking prevention action plan goes on to explain how these actions will be implemented. The Scottish Ministerial Working Group on Tobacco Control oversees the implementation of this action plan and an additional £1.5m was allocated to NHS Health Boards to support the implementation of this action plan. The evaluation of this action plan is included in the wider tobacco control research and evaluation programme for ‘A Breath of Fresh Air for Scotland’.
3.5. In 2010, A guide to smoking cessation in Scotland was produced by Action on Smoking & Health Scotland (ASH Scotland), NHS Health Scotland, The Royal College of General Practitioner and the Scottish Government. The purpose of this guide is to inform NHS policy and practice in smoking cessation by bringing together up-to-date, evidence-informed, advice on helping people to stop smoking. This guide is split into two components. The first component acts as a guide for health and health related practitioners, providing an outline of the importance of brief interventions in helping people in Scotland to stop smoking as well as highlighting the pathway for smokers quitting. The second component acts as a guide for strategic approaches to smoking cessation and is more applicable to tobacco policy makers. This follows on from the smoking cessation guidelines and the smoking cessation update.
3.6. The Curriculum for Excellence aims to achieve a transformation in education in Scotland by providing a coherent, more flexible and enriched curriculum from 3 to 18 years old. The curriculum includes the totality of experiences which are planned for children and young people through their education, wherever they are being educated. Curriculum for Excellence explains that the health and wellbeing framework are the responsibility of all adults, working together to support the learning and development of children and young people. The health and wellbeing framework included in Curriculum for Excellence begins with describing features of the environment that will nurture and support the health and wellbeing of children and young people. It stresses the importance of delivering health information early in life because these lessons are applicable throughout life. The need for positive and productive partnership working in developing effective tobacco prevention measures is made explicit.
3.7. The competencies required to give brief advice and in providing specialist support were outlined in the Scottish National Training Standards: Stop-Smoking Support, 2003, updated in 2004, 2007 and 2009. The Smoking Cessation Training Standards were produced to ‘enhance the consistency and quality of all smoking cessation work across Scotland’, and these were reflected in the local competency requirements of Ayrshire and Arran’s smoking prevention and cessation team (Fresh Air-Shire). The training standards outline the skills and knowledge that would be gained by participants on completion of courses.
These were specified at different levels:
A training for brief advice B training for an introduction to stop smoking support C part one training for specialist stop smoking support D part two for specialist stop smoking support
3.8. State of the Nation: measuring progress towards a tobacco free Scotland (2010) – This document, produced by ASH Scotland, reviews key targets set by the Scottish Government in working towards a tobacco free society. Using the same format as the government’s ‘Scotland Performs’1 assessments, it shows what we have achieved, and what more there is to do.
3.9. A HEAT (Health Improvement, Efficiency, Access and treatment) health improvement target was set for smoking cessation which required that each NHS Board should,’ through smoking cessation services, support 8% of each Board’s smoking population to successfully quit (at one month post quit) over the period 2008 - 11.
Nationally, targets for tobacco were set within ‘Towards a future without tobacco’, these targets are: Reduce the prevalence of smoking among adults (16+) in Scotland from 26.5% (2004 baseline) to 22% by 2010-11-15. Reduce the percentage of women who smoke during pregnancy from 29 % (1995 baseline) to 20% by 2010. Reduce the prevalence of regular smoking among 13 year old girls (defined as smoking one or more cigarettes per week) form 5% (2006 baseline) to 3% in 2014 and among 13 year old boys from 3% to 2%. Reduce the prevalence of regular smoking among 15 year old girls (defined as smoking one or more cigarettes per week) from 18% in 2006 to 14% in 2014, and among 15 year old boys from 12% to 9%. Reduce the prevalence of smoking among 16 to 24 year olds from 26% ( 2006 baseline) to 22.9% in 2012.
3.10. In England, the National Institute for Clinical Excellence (NICE) produced a guideline for smoking cessation services in primary care, pharmacies, local authorities and workplaces. The guidance is for NHS and other professionals who have a direct or indirect role in – and responsibility for – smoking cessation services. The document lists four recommendations that have been identified as key priorities for implementation, on the basis of: impact on health inequalities, impact on health of the target population, cost effectiveness, balance of risks and benefits, ease of implementation, speed of impact. Other NICE guidelines relating to tobacco include ‘Brief interventions and referrals for smoking cessation’ and the soon to be published ‘Smoking cessation services for people using smokeless tobacco’.
4. Local Policy Drivers
Key Strategy Documents
The ultimate aim of NHS Ayrshire & Arran’s Tobacco Strategy and Local Tobacco Control Action Plan 2006- 20109 was that ‘Ayrshire and Arran can live smoke-free and have access to support to realise this ambition’. It aimed to achieve this through:
Working in partnership with an holistic approach to ensure that an integrated approach is adopted to address tobacco prevention, control and cessation issues
Sustaining the continuing downward trend in smoking rates through targeted action in communities and nationally identified target groups to reduce the impact that smoking has in contributing to health inequalities Reducing the impact of passive smoking by supporting the introduction of the ban on smoking in enclosed public spaces and through raising awareness of its harm and reducing contact of non-smokers to smoke in private spaces Supporting the continued implementation of tobacco control measures.
The key publications underpinning the direction and targets of the action plan were ‘A Breath of Fresh Air for Scotland’10, Reducing Smoking and Tobacco Related Harm: A Key to Transforming Scotland’s Health11 and Towards a Healthier Scotland12 (4). These papers highlighted four fundamental areas that were essential for an effective tobacco strategy to focus on:
1) Prevention and Education (particularly aimed at young adults) 2) Provision of Smoking Cessation Services (aimed at adults including pregnant mothers) 3) Passive Smoking (raising awareness) 4) Protection and Control (particularly around educating and preparing for the ban on smoking in public places)
NHS Ayrshire & Arran’s Tobacco Strategy and Local Tobacco Control Action Plan 2006- 2010 developed actions in each of these key areas aiming to ‘develop a clear and concise, phased local plan of action which is outcome focused, evidence based and robustly monitored and evaluated’ (NHS Ayrshire & Arran , 2006). A new national action plan to guide local tobacco work is due to be released by the Scottish Government in 2011. This will build on the previous action plan and aims to provide a comprehensive tobacco prevention action plan to tie in with local strategies such as the
9 Tobacco Strategy and Local Tobacco Control Action Plan 2006-2010 (2006) NHS Ayrshire and Arran
10 A Breath of Fresh Air for Scotland- Improving Scotland’s Health: The Challenge Tobacco Control Action Plan (2004) The Scottish Government: Edinburgh. 11 Reducing Smoking and Tobacco Related Harm: A key to transforming Scotland’s Health (2003). NHS Scotland and ASH Scotland, Edinburgh 12 Towards a Healthier Scotland: A White Paper on Health (1999) Great Britain. Scottish Office. Dept. of Health NHS Ayrshire & Arran Tobacco Strategy. In anticipation of this Tobacco Control Strategy, Action on Smoking and Health (ASH) has produced recommendations for what should be included13. The recommendations maintain the four key themes previously used and break down the objectives into short, medium and long term ones. In Spring 2011 the Scottish Government is also due to release guidelines for mental health service providers to assist them in achieving smoke-free mental health services14 and this is likely to for a key objective for the new strategy in Ayrshire and Arran.
HEAT Targets
The HEAT target for Ayrshire and Arran requires that 6201 smokers should have achieved a four week quit over the period April 2008 to March 2011. At September 2010, Ayrshire and Arran had achieved 76% (4713) of the 4 week quits required to meet the target.
A new HEAT target has been set for the three year period following the end of March 2011. This target will have a greater emphasis on achieving 60% of 4 week quits from the most deprived areas. This target has been balanced by a lower overall target of 7.5% of the smoking population to have a 4 week quit. For Ayrshire and Arran this will require 5907 quits to be achieved over this period, of which 3544 should be from the 40% most deprived areas.
Business Plans
NHS Ayrshire & Arran’s Public Health Department delivers action in response to an annual business plan15 and the organisations Health Improvement Work Programme16. This is an organisation wide plan. Actions in relation to tobacco is contained in both plans. These plans are key drivers for this tobacco strategy and all of the actions within the strategy must compliment these plans.
Some of the main actions relating to tobacco in the Health Improvement Work Programme are: - Targeting interventions at specific groups (young women, pregnant women, looked after and accommodated young people, people with mental health problems, people with sensory impairment and/ or learning disability, deprived communities, homeless, prisoners) - Prevention Programmes targeting the most vulnerable groups
13Beyond Smoke free: Recommendations for a Scottish Tobacco Control Strategy (2010) ASH Scotland, Edinburgh 14 http://www.scotland.gov.uk/Topics/Health/health/Tobacco 15Public Health Department Business Plan: 1st April 2010- 31st March 2011 (2010) Public Health Department, NHS Ayrshire and Arran
16 14 NHS Ayrshire and Arran Population Health Work Programme 2009-2012 Version6.0 (2010) Public Health Department, NHS Ayrshire and Arran
- Delivering training programmes to build capacity within NHS communities and other organisations to deliver smoking cessation support and prevention approaches - Provide cessation support in a range of settings (NHS, communities, prison, homeless accommodation, educational establishments and workplaces)
The annual business plan breaks the actions into what is expected to be achieved in the year to come in line with current HEAT targets as well as focusing on policy and strategy development as well.
SOAs and Partnership working
Ayrshire and Arran’s public health work relies on effective partnership working with the three local authorities and other agencies. It is crucial that the aims and objectives of the local authorities parallel those of the tobacco strategy. Figure 9, below shows each Community Planning Partnership’s targets in relation to health and how smoking levels will be monitored to ensure local work is in line with the National Objective.
Figure 9 – SOA outcomes/indicators associated with tobacco Relevant Locality Relevant Local Relevant Data Source National Outcome Indicator(s) Outcome ‘We live North Health and well- - Percentage of - North Ayrshire longer, Ayrshire being smokers aged People’s Panel healthier throughout life 16 years and Survey Report lives’ have improved over - Scottish Schools Adolescent - Percentage of Lifestyle and 15 year olds Substance Use who are regular Survey smokers - Smoking at Booking - Percentage of women smoking during pregnancy
East Health and well - Percentage of - East Ayrshire Ayrshire being of the adults smoking Community local population Planning Residents’ improved Survey South People in South - Smoking - East Ayrshire Ayrshire Ayrshire enjoy Prevalence in Community the best Adults Planning Residents’ possible health Survey throughout their lives
(Sources: http://www.north- ayrshire.gov.uk/Documents/CorporateServices/ChiefExecutive/CommunityPlanning/SOA%20-%20Part%202%20- OutcomesandIndicators.pdf, http://www.eastayrshirecommunityplan.org/portal.asp?P_ID=32&URL=/cats/Single%20Outcome%20Agreement/SOA %20Archive%20Documents/Final%20SOA%20Appendix%201.pdf and http://www.south- ayrshire.gov.uk/documents/SingleOutcomeAgreement2009-12.pdf)
As can be seen each local authority includes lowering the level of smoking in their area as a target within their SOAs to achieve the national outcome relating to health.
Test Purchasing
Each Local Authority’s Trading Standards Department in Ayrshire and Arran now adopts test purchasing to establish if local retailers are selling tobacco products to under-age customers in order to reduce the accessibility of tobacco products to young people17,18,19. East Ayrshire council found their test purchasing programme was very successful and out of the 39 retailers tested under 8% resulted in illegal sales in 2008- 09. This percentage was amongst the lowest of any council in Scotland carrying out test purchasing23. South Ayrshire council used test purchasing and advisory visits and carried out 42 test purchases resulting in 12 illegal sales in 2008-0924. The success of the programmes has encouraged both councils to continue test purchasing for tobacco products and to use this technique for testing illegal sales of fireworks.
Smoking Policies
As described in section 3.2, in March 2006, the Smoking, Health and Social Care (Scotland) Act 2005 came into effect banning smoking in public places and guidance for businesses was published in 2005 to assist them with planning for this change20. NHS Ayrshire & Arran has developed have developed smoking policies in line with this legislation, as have the three of Ayrshire and Arran’s Local Authorities. Guidance in developing these policies was provided from a national level in the document ‘Smoke- free Scotland: Guidance on smoking policies for the NHS, local authorities and care service providers’.
The Healthy Working Lives Award Scheme is a national programme that assists and encourages employers to ‘implement a smoking policy and provide access to smoking cessation support’ as part of their most basic award criteria. It also encourages employers to develop the policy through consultation with employees. The Scottish
17 http://www.north-ayrshire.gov.uk/BusinessAndTrade/TradingStandards/TradingStandards- InspectionTestingAndEnforcement/TradingStandards-UnderAgeSales.aspx 18 http://www.east-ayrshire.gov.uk/corpres/ppr/ppr2008-09.pdf 19 www.south-ayrshire.gov.uk/documents/?file=Trading%20Standards%20Activity%20Report%202008-09.pdf 20 Helping to get your business or organisation ready for the new law on smoking: A guide for employers, managers and those in control of premises, published by the Scottish Executive(2005) Public Pensions Agency and British Gas are two examples of businesses who hold this award21.
More information on smoking policies can be found in section 7.2.
Local Strategies
NHS Ayrshire and Arran’s Draft Maternity Strategy 2010-2015 sets out the actions of the maternity service, along with key outputs22. One of these outputs is ‘the maternity service will ensure that mothers, partners and babies are supported to adopt healthy lifestyles’ and in order to achieve this one of the actions in place for maternity services is to make onward referrals to smoking cessation services for pregnant women who smoke so this action crosses over with the aims of the tobacco strategy for NHS Ayrshire and Arran.
Other local strategies that include tobacco actions are the Child Health Strategy, Health and Homelessness Strategy and Towards a Mentally flourishing Ayrshire and Arran.
NHS Ayrshire & Arran Strategic Objectives -
The Strategic Objectives of NHS Ayrshire and Arran are the key drivers for developing and improving the organisation. These should be considered throughout the development and implementation of the Ayrshire and Arran Tobacco Strategy. The strategic objectives of NHS Ayrshire & Arran can be seen in appendix 2.
21 http://www.healthyworkinglives.com/award/criteria.aspx#checklist 22http://www.nhsayrshireandarran.com/uploads/7295/Paper02app1.pdf
5. Tobacco Related Data
5.1 Epidemiology of Smoking in Scotland
The data presented in this section are taken from the Scottish Household Survey. This survey is designed to provide accurate, up-to-date information about the characteristics, attitudes and behaviour of Scottish households and individuals on a range of issues. The Scottish Health Survey uses a large data pool, when compared to the local profiles provided earlier in this document. Local profiles are still useful for providing data at a postcode level.
Data from the Scottish Household Survey show a downward trend in Scottish smoking rates. At present, 24.3% of adults over the age of 16 years in Scotland are smokers (Figure 10), and there are slightly more men (26%) than women that smoke (23%)23. There appears to be a gradual decrease in the number of adults reporting that they smoke between 1999 and 2009 in Scotland (Figure 10).
23 Scottish Government. Scotland’s People – Annual Report: results from 2009 Scottish Household Survey. 2010. Figure 10: Percentage of adults in Scotland that smoke by year
120
100
80
69.3 70.7 71.2 71.6 71.9 73.1 73.3 74.6 74.3 74.8
60 75.7 % of adults 40
20 30.7 29.3 28.8 28.4 28.1 26.9 26.7 25.4 25.7 25.2 24.3
0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year
Yes No
Source: Scottish Government. Scotland’s People – Annual Report: results from 2009 Scottish Household Survey. 2010.
Younger people are more likely to smoke than those over 60, and there are more young men that are smokers than young women. Smoking prevalence is highest in males in the age group 16-59. There is a reduced smoking prevalence in people aged between 60 – 74 years of age, where the proportion of smokers is down to 1 in 5. This is further reduced to slightly over 1 in 10 in the 75 and over age group15 (Figure 11).
Figure 11: Percentage of adults in Scotland that smoke by age group 35 33 32
30 28 27 27 26 26 25 25 23 23
20 20 17
15
11 10
10 % of adults that smoke that adults of %
5
0 16 to 24 25 to 34 35 to 44 45 to 59 60 to 74 75 plus All Age group
Male Female
Source: Scottish Government. Scotland’s People – Annual Report: results from 2009 Scottish Household Survey. 2010.
If the Scottish data are compared to the figures for Ayrshire and Arran (Figure 12), this decrease is also observed in the East and South Ayrshire figures; however, both noticed a rise in the 2003/2004 reporting period. During this period (2003/4), East Ayrshire had the third highest smoking rate of any other council area in Scotland24. The number of adults that smoke in North Ayrshire decreased from 1999 – 2004; however, from 2005 – 2008 the numbers have increased.
24 NHS Health Scotland, ISD Scotland and ASH Scotland. An atlas of tobacco smoking in Scotland (2007). Edinburgh: NHS Health Scotland. Figure 12: Percentage of adults that smoke in Scotland and the localities of Ayrshire and Arran, 1999-2008
% of adult % of adult % of adult % of adult population population population population Year smoking in smoking in smoking in smoking in Scotland East Ayrshire North Ayrshire South Ayrshire 1999/2000 30 33 32 26 2001/2002 28 28 25 22 2003/2004 27 35 25 29 2005/2006 26 26 27 26 2007/2008 25 25 31 21 Source: Scottish Government. Scotland’s People – Annual Reports: results from the Scottish Household Surveys (1999-2008). http://www.scotland.gov.uk/Publications
The local smoking data extracted from the GP data system (GPASS) from 1999 to 2009 show that East and North Ayrshire have higher adult smoking rates than South Ayrshire (Figure 13). These data are based on those being recorded as a smoker by their General Practitioner. A limitation of these data is that it depends on self reporting from patients and will not account for populations who are not registered with a GP. It is also apparent that in the year 2007/8, South Ayrshire has a lower smoking prevalence than the national average, East Ayrshire has the same smoking prevalence as the Scottish average and North Ayrshire has a higher smoking prevalence.
Figure 13: Percentages, at 1 Jan 1999, 2004 and 2009 of patients in Ayrshire and Arran who are smokers among all patients with smoking status recorded by their GPs, by CHP area (51 of 59 local practices) Sourc 40.0% e: GP surgeri 35.0% es in Ayrshi re and 30.0% Arran utilisin 25.0% g GPAS 20.0% S (51 out of 59 15.0% surgeri es) 10.0%
5.0% Toba 0.0% cco Percentage of patients recorded by GPs by as smokers recorded patients of Percentage 1999 2004 2009 use East Ayrshire 35.6% 31.8% 27.6% has North Ayrshire 34.8% 32.7% 28.2% been 30.8% 28.5% 24.9% South Ayrshire incre asingly associated with social disadvantage. In lower socio-economic and disadvantaged groups, smoking is recognised as a major contributor to health inequalities. The percentage of adults that smoke by economic status is shown in Figure 14. The adults that are unable to work due to short term ill-health (59%) most commonly smoke; this is followed by adults that are unemployed and seeking work (51%), and those that are permanently sick or disabled (48%). The group that least commonly smoke are those at school (3%), followed by those permanently retired from work (16%) and those in higher/further education (16%).
Figure 14: Percentage of adults in Scotland that smoke by economic status
70
59 60
51 50 48
40 36
30 24 24 24 22
% of adults that smoke that adults of % 20 16 16
10 3 0
0
All
Other
At At school
Fulltime
Parttime
education
employment employment
home/family
ill-health
Lookingafter
Higher/further
or disabled or
Selfemployed
Permanently
seekingwork
Unablework to
retired from work from retired
Unemployedand
due to short term short to due Permanentlysick
Source: Scottish Government. Scotland’s People – Annual Reports: results from the Scottish Household Surveys (1999-2008). http://www.scotland.gov.uk/Publications
Despite the downward trend in Scottish smoking rates, data show that smoking rates are highest in areas of deprivation. There is a link between deprivation and smoking rates from the 10% most deprived to the 10% least deprived with more adults in the most deprived areas reporting that they smoke (Figure 15).
Compared to the rest of Scotland, adults in the 15% most deprived areas (41%) are more likely to report that they are current smokers, compared to 21% in the rest of Scotland. It is important to highlight that this can increase health inequalities and suggests a focus of resources in these deprived communities.
Figure 15: Percentage of adults in Scotland that smoke by Scottish Index of Multiple Deprivation centile
50
45 43 41 40 36 35 31 30 28 25 25 24 22 21 20 20 17
% of adults that smoke that % adults of 15 13
10 9
5
0 15% Rest of 10% 2 3 4 5 6 7 8 9 10% All most Scotland most least deprived deprived deprived Source: Scottish Government. Scotland’s People – Annual Reports: results from the Scottish Household Surveys (1999-2008). http://www.scotland.gov.uk/Publications
5.2 Local smoking prevalence
Service user demographics In 2009, a total of 3090 clients living in Ayrshire and Arran were in contact with local smoking cessation services. This section presents a demographic analysis of these clients.
Area of residence Analysis by Community Health Partnership (CHP) area shows that the majority of clients were from East and North Ayrshire (Figure 16).
Figure 16: Percentage of smoking cessation clients by CHP area, 2009
22.9%
32.1%
East Ayrshire North Ayrshire South Ayrshire
44.0%
Gender In 2009, 61.7% of clients were women and 38.3% were men.
Age The peak age of clients in 2009 was 35 to 44 years (Figure 17). This age group accounted for approximately 1 in 4 clients. The next two groups that were well represented was the 45 to 54 years age group with slightly under 1 in 5 clients, followed by the 25 to 34 years age group (over 1 in 5 clients). The under 16 and 75 years and over age groups were less well represented.
Figure 17: Age of clients using local smoking cessation services in Ayrshire and Arran, 2009
800 752
700 654
600 572
500 454
400
310 300
254 Number of clients of Number
200
100 34 39
0 Under 16 16 – 24 25 – 34 35 – 44 45 – 54 55 – 64 65 – 74 75 + Age group of clients
Ethnicity In 2009, 91.4% of clients were white; the vast majority of these (83.9%) were ‘White: Scottish’. Two clients (0.06%) reported their ethnicity as ‘Asian: Pakistani’, one client (0.03%) as ‘Asian: Indian’, one client (0.03%) as ‘Other ethnic group: Arab’, 253 (8.2%) clients as ‘unknown’ and two clients (0.06%) as ‘other’. Eight clients (0.3%) did not disclose their ethnicity.
Employment status Almost one fifth (19.9%) of smoking cessation service clients in 2009 were unemployed (n=615), while 44% were in paid employment (n=1360).
Of the unemployed clients, nearly half (47.6%) were from North Ayrshire, almost a third (31.5%) were from East Ayrshire, and 20.2% were from South Ayrshire25.
25 The CHP area status of two unemployed clients (0.3% of total sample) was unknown and two clients were from outside Ayrshire and Arran. The employment status of the other clients was as follows:
Full time student (n=113) Homemaker/full time parent or carer (n=127) Permanently sick or disabled (n=127) Retired (n=408) Other (n=97) Unknown (n=238) Not given (n=5)
Service Utilisation
In 2009, 79% of smoking cessation clients used pharmacies, while the remaining 21% used specialist smoking cessation services.
Among all clients utilising pharmacies (n=2,440), 1,114 (45.7%) used services in North Ayrshire, 784 (32.1%) used services in East Ayrshire, and 530 (21.7%) used services in South Ayrshire. This reflects where people live (see Figure 16 above).
Among specialist services utilised, those with more than 10 clients were as follows: - North Ayrshire CHP (n=240) - East Ayrshire CHP (n=243) - South Ayrshire CHP (n=87) - Crosshouse Hospital (n=15) - Toll Pharmacy Pilot (n=30) - Workplace – NHS (n=10) - Unspecified (n=15).
Specialist services with under 10 clients each, included Ailsa Hospital (n=2), Ayr Hospital (n=4), Ayrshire Central Hospital (n=1), Biggart Hospital (n=1) and a specialist group from mental health service MHNA (Mental Health Needs Assessment) (n=2).
There are higher numbers of clients aged 34 to 64 years using the specialist services compared to younger clients (under 34 years) and older clients (65 years and over) (Figure 18). There are more females (59.7%) using the specialist services than males (40.3%). Figure 18: Percentage of clients using specialist services by age group, 2009
180 164 159 160 150
140
120
100 84 80
58
Number of clients of Number 60
40 24 20 11 0 0 Under 16 16 -24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 + Age group of clients (years)
Daily cigarette consumption
Overall daily smoking pattern In 2009, the majority (46.8%) of clients in contact with smoking cessation services smoked between 11 and 20 cigarettes per day, and 30.4% of clients smoked between 21 – 30 cigarettes per day. The percentage of heavy smokers (>30 cigarettes per day) was 12.3% and light smokers (10 or less cigarettes per day) was 10.5%. The numbers are given in Figure 19.
Figure 19: Percentage of clients by number of cigarettes smoked, 2009
Number of cigarettes Number of clients Valid percent smoked in a day 10 or less 321 10.5% 11 – 20 1436 46.8% 21 – 30 931 30.4% More than 30 378 12.3% Total 3066 100% Unknown or missing 24 Total 3090
5.3 Tobacco related mortality and morbidity
Tobacco is known to cause a wide range of diseases, most commonly those affecting the heart and lungs, and to be responsible for around 24% of all deaths in Scotland. Smoking is a major independent risk factor for coronary heart disease, including heart attacks, cerebrovascular disease (stroke), chronic obstructive pulmonary disease and cancer (notably those of the lung, mouth, larynx and pancreas). The effects depend on how much someone smokes, for how long and what type of tobacco product –with high tar content and unfiltered cigarettes causing disease most frequently. The World Health Organisation estimated that tobacco caused 5.4 million deaths worldwide in 2004.
In Ayrshire and Arran in 2000-04, smoking accounted for 25% of male deaths and 22% of female deaths in people aged 35 and over, and it was estimated that people aged 35- 69 years were dying 21 years earlier through smoking related illnesses.26 However the life expectancy gap between smokers and never-smokers is greater than the gap between the higher and lower social classes27
Non-smokers can also be affected by passive smoking, which is associated with lung cancer, asthma, and chronic pulmonary and heart disease.
Stopping smoking completely at any age reduces the risk of premature death.
5.3.1 Coronary heart disease Data for coronary heart disease and lung cancer are presented here as the highlighted causes of morbidity and mortality from tobacco.
Coronary heart disease (CHD) and lung cancer cause the largest number of deaths, with around 20% of CHD deaths in people aged less than 75 years attributed to smoking28.
Figure 20 shows the trend in coronary heart disease mortality, with the decline due in large part to reductions in smoking prevalence.
From 1995 to 2010 the overall percentage decrease is 62.7% whilst the gender differences are marked and reflect the national picture, with men experiencing higher mortality rates from CHD. The reduction in the mortality rate for women over the period is 70.8% and for men 59.9%.
26 NHS Health Scotland, ISD Scotland and ASH Scotland. An atlas of tobacco smoking in Scotland (2007). Edinburgh: NHS Health Scotland. 27 Tobacco smoking in Scotland: an epidemiological briefing (2008) NHS Health Scotland 28 Smoking and tobacco statistics factsheet (2007). ASH Scotland Figure 20 Coronary heart disease mortality rates in people aged under 75 years, NHS Ayrshire & Arran, 1995-2010
200.0
180.0
160.0
140.0
120.0
100.0
80.0
60.0 Rate per 100,000 per100,000 Rate Population 40.0
20.0
0.0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Male European Age Standardised Rate of Mortality Female European Age Standardised Rate of Mortality
Source: www.isdscotland.org/Health-Topics/Heart-Disease/Topic-Areas/Mortality/
There has been a 30% decline in incidence rate of coronary heart disease over the past decade (Figure 21). The incidence rate is the number of new cases (hospital admissions or deaths with no previous hospital admission for CHD in the previous decade) per 100,000 population.
Figure 21 New cases of coronary heart disease in people aged under 75 years, NHS Ayrshire and Arran and Scotland, 2001-2010
450
400
350
300
250
200
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100 Standardised rate per 100,000 pop'n 100,000 per rate Standardised 50
0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Males Females Both Sexes Scotland both sexes
Source: www.isdscotland.org/Health-Topics/Stroke/Topic-Areas/Incidence/
Figure 22 shows estimated prevalence of CHD in males by geographic locality within Ayrshire and Arran. East Ayrshire has the highest prevalence of CHD for males aged 45-64 years at 6.3% and for males aged 65-74 years at 18.0%. The rate per 100 for males aged 45-64 in North and South Ayrshire is 5.7 and 5.4 respectively however Scotland has a lower rate at 5.3. The pattern for 65 -74 year old males in North and South Ayrshire and Scotland is similar to the 45-64 year olds with North Ayrshire slightly higher.
Figure 23 shows that East Ayrshire has the highest prevalence of CHD for females aged 45-64 at 2.9% and for females aged 65-74 at 9.6%. The lowest rates for females aged 45-64 are the Scotland and South Ayrshire rates at 2.3% with the North Ayrshire rate at 2.6%. North Ayrshire has the lowest CHD prevalence rate for women aged 65 - 74 years old at 8.1%, the Scotland rate is 8.3% and the rate for females in South Ayrshire in this age group is 8.6%.
Coronary heart disease remains a major cause of illness and death for the population of Ayrshire and Arran.
Figure 22 Coronary heart disease estimated prevalence for males by CHP locality, 2007
20
18
16
14
12
10
8
Crude prevalent rate per 100 pop'n 100 per rate prevalent Crude 6
4
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0 Males aged 45-64 Males aged 65-74
East Ayrshire CHP North Ayrshire CHP South Ayrshire CHP Scotland
Source: www.isdscotland.org/Health-Topics/Heart-Disease/Topic-Areas/Prevalence/
Figure 23 Coronary heart disease estimated prevalence for females by CHP locality, 2007
12
10
8
6
4
Crude prevalent rate per100 pop'n per100 rate prevalent Crude 2
0 Females aged 45-64 Females aged 65-74 East Ayrshire CHP North Ayrshire CHP South Ayrshire CHP Scotland 5.3.2 Lung cancer In people over the age of 35 years, smoking is responsible for 90% of lung cancer deaths. The risk of developing lung cancer is higher, and the probability of surviving lung cancer is lower, among people living in areas of socioeconomic deprivation29.
Figure 24 shows that Ayrshire and Arran is highest in Scotland in the number of deaths from lung cancer for both males and females, and sits at second out of the 14 health boards for the incidence of lung cancer. More than 4,000 deaths a year are attributed to lung cancer and whilst the rates are declining in men – by almost 15% in the past decade – rates in women continue to rise, reflecting more recent smoking behavioural trends.
In the period 1985 to 2010, the mortality trend for lung cancer in Scotland reduced by 31.7% and by 27.1 % in Ayrshire and Arran. The rates however for Scotland as a whole are higher than for Ayrshire and Arran and this is shown in Figure 24.
Figure 24 Mortality rates for lung cancer, Scotland and NHS Ayrshire & Arran, 1985- 2010
90.0
80.0
70.0
60.0
50.0
40.0 risk 30.0
20.0 standardised rate per 100,000 person years at at yearsperson 100,000 per rate standardised - 10.0
- European age European
Scotland Trend NHS A&A Trend
Source: www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Lung-Cancer-and-Mesothelioma/
29 Tobacco smoking in Scotland: an epidemiological briefing (2008) NHS Health Scotland
Whilst the overall trend is declining (Figure 25), in Ayrshire and Arran the trend in male lung cancer rates has shown a reduction of 51% between 1985 and 2009, whereas the rate in females has shown an increase of 34.6%, and is now close to that for males. This gender difference is reflected nationally for lung cancer. However, the male rate in Ayrshire and Arran has decreased more than the male rate for Scotland by 4% and the female rate for Scotland has increased more than that for Ayrshire and Arran by 4.2%.
Figure 25 Trends in lung cancer mortality in Ayrshire and Arran, 1985-2010
140
120
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60
40
standardised rate per 100,000 person years at risk at person per100,000 rate years standardised - 20
0 European age European
A&A Males A&A Females
Source: www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Lung-Cancer-and-Mesothelioma/ 5.3 Prevention and Education
The primary approach to tobacco control within Ayrshire and Arran is through NHS Ayrshire and Arran’s Fresh Air-shire Service. This service aims to provide a range of smoking prevention and cessation services in a flexible and non-judgemental manner. The service is provided by a team which includes Specialist Smoking Cessation Advisors in smoking cessation and prevention and Support Officers and offers a specialist service to support those smokers who find it hardest to quit and who have tried to quit previously, often on several occasions. The service is targeted at areas of high smoking prevalence and operates across a range of settings. Community Pharmacy Advisors are aligned to the Fresh Air-shire team and work with community pharmacists to support their smoking cessation services and provide a link between both services. This facilitates greater joint working and development of complementary roles.
Based on the national objectives, the following local objectives were included in the last strategy: Develop innovative prevention initiatives for young people which reflect differing circumstances and social mores and which contribute to the evidence base. Build on the school based smoking prevention programme within South Ayrshire and roll out across Ayrshire and Arran, ensuring that the work is fully integrated within the health promoting school framework and becomes part of a wider programme that addresses alcohol, drug and tobacco use and the tobacco industry within the school and community. Develop and research gender specific smoking prevention programmes, particularly focusing on teenage girls and those in circumstances of vulnerability and disadvantage and teenage boys who use cannabis.
6. Outline of Activities/ Practices
6.1 Development of innovative prevention initiatives These initiatives represent a range of theory and evidence-led projects and services promoting prevention or cessation work with young people, developed in accordance with needs identified for these specific groups, as described below.
6.1.1 „Accessory to murder‟ drama production ‘Accessory to Murder’ was a tobacco prevention drama production created and developed by young people from North Ayrshire exploring the tobacco industry. The production took place in October 2006, with a DVD subsequently produced for use with tobacco prevention sessions, carried out by Fresh Air-shire smoking prevention and cessation service in schools and community youth groups across Ayrshire.
6.1.2 East Ayrshire Community planning smoking and fire safety survey Fresh Air-shire worked in partnership with East Ayrshire community planning residents’ panel in 2006 to develop a questionnaire to produce baseline data on smoking patterns in the home, the perception of risk of fire caused by smoking, and the knowledge and understanding of Home Fire Safety Visits. This information also revealed a low level of awareness of passive smoking and the health risks associated with second hand smoke, data which lead to the development of a smoke free homes campaign for Ayrshire and Arran. This is described further in section 6.1.1.7.
6.1.3 East Ayrshire Learning Partnership Tobacco Initiative Three pilot projects were implemented in East Ayrshire during 2007/2008, with the aim of reducing the number of 12-18 year olds smoking within the East Ayrshire Learning Partnership catchment areas. Three different approaches were piloted; two of these being group based smoking cessation support for pupils in S3 to S6, and the third being a Smoke- free Class Competition for younger pupils. All approaches offered incentives for participation and successful cessation. Evaluation of these pilots revealed that pupils had found these initiatives to be both enjoyable and worthwhile, but with little role for the incentives in encouraging participation.
6.1.4 Peer education The Peer Education Against Tobacco (PEAT) pilot project used a peer education model whereby trained S2 pupils delivered tobacco education sessions with P5/6 primary pupils from the associated cluster schools. Commencing in January 2008, eighteen young people received 12 weeks training in the knowledge and skills required to deliver this tobacco education over a five week period to the P5/P6 pupils from the cluster primary schools between April and June 2008. Evaluation of this pilot has provided evidence of significant learning and growth in self confidence and self esteem for the peer educators involved, as well as being of benefit to the primary school pupils in terms of their enjoyment and engagement with the materials and learning. The use of peer educators to deliver these teaching materials seems to have been particularly successful in motivating the learning of these primary school pupils.
Feedback from the schools involved further highlighted the effectiveness of the teaching methods and activities used with their pupils, and of the project’s fit with their existing teaching curriculum and with the expectations of the Curriculum for Excellence directives.
The learning from the PEAT projects has subsequently been used to develop a Peer Education pack for use with senior secondary pupils in schools and youth work settings. Working in partnership with the school or youth work setting, the Prevention and Education services now assists in the delivery of seven short training sessions to these pupils who then deliver this peer-based tobacco education to younger pupils or peers.
6.1.5 Tobacco education and awareness training for staff The service provides frequent delivery of two hour training to groups of staff across Ayrshire and Arran as and when requested.
6.1.6 Work in prison Health events relating to prevention and education aimed at young offenders aged 16- 18 years are delivered within Bowhouse prison.
6.1.7 Smoke Free Homes and Cars This first phase of the Smoke Free Homes and Cars campaign (launched in November 2009) was aimed at pre-school children and their parents and carers in South Ayrshire to raise awareness of second hand smoke, and motivate behaviour change in encouraging people to adopt a smoke free policy in their homes and cars. A partnership approach to working with primary schools was adopted, resulting in the production of a pupil-produced DVD to be used as a resource for the campaign.
Following an evaluation of this phase of the campaign which demonstrated successful outcomes in relation to numbers signing up for the gold pledge (going smoke free in both the home and car), as well as giving feedback on the processes used, the campaign was modified and second phase launched in East and North Ayrshire in October 2010. This phase has adopted a more community development approach in order to encourage increased participation and ownership from within those communities where smoking rates are likely to be higher. Additional information on this project can be found on page 45.
6.1.8 Youth smoking cessation services The Prevention and Education services also holds primary responsibility for the specialised cessation help for young people who recognise their dependence on smoking and wish support with quitting. Smoking cessation support is provided to any child or young person on a one to one or group basis. Whilst young people can approach the service directly for help and advice, referrals are also received from schools, youth work settings, training units, residential establishments and social work departments (for Looked After and Accommodated young people).
In line with NHS Ayrshire & Arran guidelines, nicotine replacement therapy (NRT) can be provided to young people aged 12 years and over which can increase their chance of successfully quitting. Whilst the service encourages young people to talk to their parents/carers and family about their smoking and inform them that they are attending stop smoking sessions , Fresh Airshire is required to respect young peoples wishes and will not inform parents or carers if they do not consent to this (‘Age of Legal Capacity (Scotland) Act’ 1991).
6.1.9 Smoking cessation training Training for school nurse and youth workers in smoking cessation was provided by the Prevention and Education Service between 2007 and 2009 in order to enable these individuals to encourage cessation amongst the young people with whom they worked. Responsibility for this training has now however transferred to the Training group within Fresh Airshire which provides monthly courses in brief interventions for all teaching, youth work, nursing and other professional staff groups across Ayrshire and Arran.
6.2 School based smoking prevention programmes Teaching resources have been developed by the Prevention and Education service with the aim of ensuring a consistent tobacco prevention message across all schools and nurseries in Ayrshire and Arran, and to support these establishments to become autonomous in their delivery of this education.
Whilst schools were initially provided with tobacco resources boxes of teaching models and displays, teaching resource packs were subsequently developed in line with current curricula requirements containing both factual information for teachers, together with a range of tobacco awareness activities for pupils appropriate to their age and stage of education.
6.2.1 Tobacco Awareness Resource Boxes Tobacco awareness resource boxes (containing visual and hands-on models) were distributed to every secondary school cluster in South, East and North Ayrshire in 2006, to support the delivery of tobacco awareness sessions by school nurses and teachers within classroom time.
6.2.2 P6/P7 resource pack The Primary 6 and 7 resource pack was produced in 2007 in line with the Health Education 5-14 National Guidelines covering physical, emotional and social health, and has since been updated according to the Curriculum for Excellence for schools requirements. An initial evaluation of the schools’ use of these packs showed that about half of the schools who were sent these packs were positive about the role they played in supporting their teaching of this topic area.
6.2.3 S1 resource pack The S1 resources pack was completed in 2010, and is currently in the final stages of production prior to its distribution to all secondary schools. It has been piloted with teachers and pupils in conjunction with a Smoke Free class competition held in 2009, with feedback from this evaluation used to inform changes to its content. These resources complement the messages highlighted within the P6/P7 pack, although offers more information about the short term effects of smoking, it effects on appearance, smoking and fitness, smoking and pregnancy and tobacco and cannabis use.
6.2.4 Early years (age 3-5) resource pack The Prevention and Education service is currently providing awareness training to all staff in local authority, private and independent nurseries, as well as conducting an analysis within these organisations in relation to appropriate tobacco education materials for this younger age group.
Initial work has been undertaken in the production of tobacco related stories that can be read aloud to nursery children, and will be further developed once the analysis has been completed.
6.3 Gender specific smoking prevention programmes A social marketing approach has been adopted to the research and development of a gender specific smoking prevention programme for young adults aged 16 to 25 years of age. Evidence from the Scottish Health Survey 2008 indicates that the number of young women who smoke at this age is 30%, which exceeds smoking prevalence of 28% amongst young males. However smoking rates amongst young men have been shown to overtake those for young women at the age of 21, rising to a rate of 36% in those aged 25 to 34 years
The target population for the project is young people living in East Ayrshire, as this area represents one of the highest for smoking prevalence (32.1%), when compared to the Scottish average of 27.2% (Tobacco Atlas, 2007).
The overall aim of this project is to find out what interventions the target group would respond positively to, based on an analysis of focus group data carried out with this group of young men and women. The fundamental aim of the focus groups will be to understand the needs of this group, exploring issues which have emerged from the literature including the need for different approaches for male and females, issues relating to life transitions, and body image and healthy eating. This will subsequently be used to inform and design effective interventions, utilising a mix of social marketing approaches, which considers the four elements of ‘Price, Product, Place and Promotion’.
7. Provision of Smoking Cessation Services
Smoking cessation services are delivered in Ayrshire and Arran through two main providers; Fresh Air-shire Smoking Cessation and Prevention Service and Community Pharmacies. The Fresh Air-shire service was set up in 2006 and was funded by ring fenced monies and core health promotion funding. The Pharmacy service was also established in 2006 funded through the tobacco monies and was subsequently funded through a national contract for pharmacy smoking cessation from 2008. Previous to 2006, smoking cessation and prevention had been delivered through a number of pilot programmes.
The aim in setting up the services in 2006 was to provide integrated services which were accessible and which met the different support needs of people wishing to stop smoking.
The specialist service provides support in various settings including community, hospital, prison, workplace and offer individual and group work, telephone support (particularly for those newly discharged from hospital and those unable to attend community based sessions).
From April 2008 to December 2010, the specialist service has received 3485 referrals which resulted 1943 smokers setting a quit date. The rate of success at 4 weeks has been consistently high within the specialist service, in comparison with similar services nationally. In 2008, 73% of smokers had successfully quit at the four week follow up, with 82% giving up at the four week follow up in 2009 and 65% in 2010.
When first set up the FreshAirshire service was organised in the community setting with both prevention and cessation officers. Other settings had cessation officers only. In practice, however, the delineation between Officers in respect of prevention and cessation was not very clear cut with prevention officers delivering cessation and cessation officers delivering some areas of prevention.
The team structure was realigned in 2010 to reflect this practice and prevention and cessation became integrated within posts as well as within the team. In addition, to address the needs of priority groups and settings a programme based approach was introduced.
The key actions to deliver the smoking cessation targets are as follows:
7.1 Access to treatments All smokers making an attempt to stop are given access to pharmacological treatments to support them. Nicotine replacement therapy (NRT) is supplied by pharmacists supporting smokers as part of the pharmacy scheme or supported by the specialist smoking cessation advisors. NRT is the first line support treatment and is available in different strengths and products. Advisors will assess the client’s motivation and past experience to determine the appropriate form of NRT support for them. Alternatives to NRT such as Bupropion or Varenicline are available on prescription and are normally suggested for those who have had a failed quit using NRT. Care pathways developed by the specialist smoking cessation service ensure that motivational support is available when these treatments are prescribed.
7.2 Patient Pathways There are a number of routes into the service: Self-referral: People can phone the helpline to talk to a advisor who can either direct them to their nearest local group, direct them to a pharmacy or provide them with one-to-one support. Alternatively, people are able to access group support without referral. GP referral: GPs are encouraged to refer patients who they identify as requiring additional support than they are able to provide to the service. Hospital referral: Clients can be referred following an assessment by nursing staff and/or following discharge from hospital. The service supports the clients quit effort by assisting the client to identify the most appropriate cessation support for them. It is recognised however, that some in-patients have no intention of giving up smoking when admitted and in such cases arranges for NRT to be provided for the duration of their stay to alleviate any distress caused by not being allowed to smoke whilst in hospital. This helps to avoid incidents where patients leave their ward on a regular basis to smoke which can hamper their recovery. Prison referral: Officers within the prison have been trained to raise the issue of smoking cessation with prisoners and refer them to the prison smoking cessation group. Prisoners also receive smoking cessation information at induction.
In assessing the appropriate form of support for clients, the motivation of clients is assessed through determining the clients confidence to quit and the level of importance the client believes quitting to be, was used. Since, May 2010, the Faggerstom assessment of level of addiction has been used as an initial means of determining the most appropriate support with the assessment of motivation used once the client attends the service most suitable to their needs. Through this process those who have the highest level of addiction should be referred to the specialist service and those with the less addiction referred to the Pharmacy service.
7.3 Pharmacy Service As part of Fresh Air-shire, a network of community pharmacies across Ayrshire and Arran offer an easily accessible, cost-effective smoking cessation service. The objectives of the service are:
to provide a structured programme of information, advice and support to patients supplied with NRT on a weekly basis up to a maximum of 12 weeks to involve both the pharmacist and counter assistant staff in promoting compliance and maximising the effectiveness of treatment to collect appropriate data to facilitate evaluation of service.
The service started in January 2006 and targets adults who smoke more than 10 cigarettes a day and are highly motivated to stop smoking. Pharmacists and their support staff across Ayrshire and Arran have been trained to provide this service and identify people suitable for inclusion through:
requests from people presenting within pharmacy setting (no appointment required) pharmacists proactively approaching people referral from specialist smoking cessation services referral from hospital pharmacists referral from general practice staff referral from dental practitioners.
The pharmacy service offers a 12 week programme of support, advice and supply of NRT. The pharmacist sees the patient at week 1, whenever the NRT product strength or formulation is changed and when the patient reports possible adverse effects from NRT. Otherwise a trained pharmacy assistant may assess the patient. Carbon monoxide (CO) levels are monitored using a Smokerlyzer on a weekly basis to determine if the patient has stopped smoking and the results of this are recorded at weeks 1, 5 and 12. From April 2008 to December 7664 smokers set a quit date with the community pharmacy service, with 2659 smokers achieving a 4 week quit. The level of successful 4 week quits has improved during that time with a self reported quit rate in 2008 of 29% ; 42% in 2009 and a self reported quit rate in 2010 to December of 42%. .
7.4 Varenicline Pilot Varenicline is a pharmacological therapy available through prescription by GP’s. The guidelines for this product are that this should be only be prescribed if support is available to the patient whilst using this product. In 2007, a pilot programme was developed within a pharmacy in Largs, using the prescribing pharmacist to prescribe varenicline with support provided by Fresh Air-shire. Following the success of this pilot, this approach was rolled out to other Pharmacies with a prescribing pharmacist. The criteria for varenicline were that the client should have previously used NRT in unsuccessful quit attempts and have no contraindications. Therefore the clients where those for whom giving up smoking was hard. The results from the pilot and the roll out showed a marked improvement in 4 week quit rates for this group of smokers, which ranged from 33% to 68%. This joint working initiative between GP’s, the Prescribing Pharmacist and the Smoking Cessation Advisor demonstrated positive outcomes for clients who found stopping smoking difficult.
7.5 Group Support Initially when the specialist service was started, the Maudsley model of group cessation support was adopted by the service. This evidence based model provides specialist, intensive support within a group. However, it was felt that for those who struggle to give up smoking and who have low confidence in their ability to quit, that this method had its limitations, as it was limited in length of support (7 sessions). It also created waiting lists because of its closed group and fixed time approach, which meant that sometimes the value of opportunistic events was lost. This situation was a particular problem in the prison where movement of prisoners created attrition in groups and the increase in no smoking areas created increased demand and therefore high waiting lists.
Fresh Airshire adopted a rolling programme model of delivery which was more flexible in its approach in that clients could join the group at any time rather than at the start of a set programme. It was found that the advantages of this model were that:
. It provides individuals who want support to stop smoking timely access to group support (for example, when people are motivated to stop smoking, they want immediate support- not in a number of weeks) . It utilises a person-centred approach that is flexible and meets the needs of clients (for example, the format for the group is based upon the clients previous week/forthcoming weeks etc- the Advisor does not work to a set agenda for the group and group support operates with a bottom-up approach) . It provides a form of support that supports clients through lapse and relapse (for example, rather than discount clients who lapse, they are encouraged to stay within the service and identify coping strategies to prevent lapse and relapse) . It works with clients to prepare for a quit attempt (for example, a large number of clients require more intensive support to prepare them for a quit attempt) . It enables a harm reduction approach to be used (for example, whilst total abstinence is always promoted, harm reduction methods such as ‘cut down to quit’ are used for certain clients- a number of whom do then go on to quit)
Whilst the rolling programme model has been effective, it is felt that the Maudsley model should still be used with clients who are confident and well motivated to stop. Time limited groups of 12 weeks are also used in smaller areas which cannot maintain viable group numbers for a longer period of time. Workplaces have also used time limited groups to deliver smoking cessation.
7.6 One to One Support Individual support is available to smokers who cannot access group support or where venues cannot accommodate group support such as GP surgeries and pharmacies. Access to group support is restrictive for those who have been discharged from hospital and for those in rural areas.
7.7 Telephone Helpline A freephone telephone helpline is available for information, advice and referral for smoking cessation. The helpline also offers cessation support to client who are unable to attend a venue for group or one to one support. This helpline support is mainly used by frail elderly/ housebound clients and for those who have been recently discharged from hospital and are not recovered sufficiently to attend a venue in which cessation support is delivered. The local helpline works in conjunction with the National helpline – Smokeline, and receives referrals from this source.
7.8 Voucher Scheme A voucher scheme was developed by Fresh Air-shire to enable NRT to be accessed easily by people supported by the specialist smoking cessation advisors. The advisor is able to indicate to the dispensing pharmacist the type of strength of NRT recommended for each person attempting to quit smoking, and the pharmacist supports this with appropriate advice. The requirement to attend a General Practitioner to obtain a prescription is removed, making it easier for the quitter to move through the service.
7.9 Information and advice Information on Fresh Air-shire is available on the NHS Ayrshire & Arran website and AthenA (the NHS Ayrshire 7 Arran intranet). The content is reviewed and updated regularly. It is also provided thorough delivery of local campaigns and events.
7.10 Training Smoking cessation services have a high level of 4 week quit rate success in comparison with other areas nationally. Key to meeting the HEAT targets set are the numbers of referrals to the service and to ensure that those referrals are guided to the service best suited to their needs. To maintain and increase the number of referrals, a training programme is delivered. The focus of the training programme has been on training to support brief interventions and is now beginning to develop the training further to enable a range of professionals to offer longer term support. The national training standard is used to guide the development and delivery of training.
7.11 Volunteers To support marketing of the Fresh Air-shire service, a volunteer programme has been developed and was implemented in December 2010. Volunteers on the programme are trained to assist the Fresh Air-shire service at marketing and campaign events. The future development of the programme will be determined following an evaluation of the initial roll out of the programme.
7.12 Data Input and Monitoring All data in respect of referrals, quit dates set and length of quits are inputted into an ISD (Information and Statistics Division, Scotland) national database. Information for both the pharmacy service and the specialist service is inputted into this system by the Fresh Air-shire service. Reports can be generated from this database at any time to monitor progress and to identify areas for improvement or difficulty. A local database has also been devised recently to monitor referrals and to track their outcomes. Activity logs are used by advisors to monitor numbers within groups and individual progress of clients.
7.13 Smoking Cessation Priority Groups
Mental Health A mental health needs assessment was carried out in 2008 and identified that people with severe mental health issues wanted to stop smoking. As a result of this pilot programmes have been introduced to support the cessation needs of this priority group. In the mental health acute hospital setting, mental health staff have formed a network of smoking cessation champions. These champions have been trained in brief interventions, offer on going support to patients, provide information and give support to campaigns. Through training of mental health staff, stereotypical views and attitudes have been addressed which has contributed to a positive approach to smoking cessation within the wards.
Young People Pilot smoking cessation projects were carried out with secondary school pupils. Monitoring of these pilots indicated that the pupils require flexible and longer term support with different types of support and also indicated that the setting of a school may not be suitable for smoking cessation. For additional information on smoking services for young people, please see section 6.1.
Smoking and Pregnancy The numbers of pregnant women who smoke although falling, remains high particularly in areas of socio and economic deprivation. To further the service’s understanding of this target group, an investigation was carried out with young women aged 16-20 years. This aimed to identify the factors which contribute to continue smoking during pregnancy, with a view to looking at effective interventions, to prevent young women smoking at this time and to continue not to smoke once their baby is born.
A pilot programme to support community midwives to carry out brief interventions was implemented in May 2010 in response to some of these changes. This programme was designed as a joint approach to address smoking and alcohol issues and employed three specialist midwives to train community midwives in brief interventions and to provide specialist support in these areas. The specialist cessation support is provided either at clinics or in the client’s home. This specialist midwife approach has resulted in a marked increase in the number of 4 week quits in this priority group.
From April 2008 to March 2010 there were 110 pregnant women who set a quit date (Specialist service 8; Pharmacy 102). This resulted in 7 quits at 4 weeks. The specialist service accounted for 4 of these quits (with 4 lost to follow up); the pharmacy service accounted for 3 of these quits (with 81 lost to follow up). The specialist midwife service was set up in April 2010 and from that time to December 2010 there were 76 pregnant women who set a quit date with the specialist service achieving 42 quits at 4 weeks. During the same period 26 women set a quit date in the Pharmacy service resulting in 8 quits at 4 weeks. These results show a vast improvement on previous figures and demonstrate that better outcomes are achieved if women use the specialist service and are encouraged to do so. However, some women will prefer to use the Pharmacy service and although the rate of success is lower there is a greater measure of success than had been previously.
Men and women from low socio economic areas The specialist service targets areas of high deprivation to deliver this service and all venues are located in these areas. A mapping exercise was carried out to determine the level of referral within these areas and the four week quits achieved within local data zones. This allows further refinement of the service to meet the smoking cessation support needs of clients.
8. Health Protection
The adverse health effects of Secondhand or ‘passive’ smoking have been documented as early as 192830 (Schönherr, 1928). Evidence that demonstrates the detrimental effects of second hand smoke has since accumulated, with an estimated 1,200 deaths associated with the effects of passive smoking.
The British Medical Association identified, within the "Breaking the Cycle of Exposure to Tobacco Smoke" (2007) report, that 80% of under 10s are exposed to passive smoke, with 95% of those children in the least affluent group. Four in 10 children are exposed to Environmental Tobacco Smoke (ETS) which equates to 5 million children across Britain. Smoker's awareness of the dangers of passive smoking is much lower than non-smokers. Children's views also indicated that eight in 10 children thought that passive smoking is bad.
The Healthy Environments Partnership (HEP) Survey (2005) also reported that 50.8% of non-smokers applied a complete ban to smoking within their home, whilst only 14.8% of smokers applied a complete ban. 39.7% of smokers did not apply any restrictions on smoking within their homes. The survey identified that children and grandchildren were important influences in increasing existing normal everyday restrictions and new events such as the birth of a baby were key motivators. Barriers to implementing restrictions on smoking within the home and car were identified as lack of understanding and knowledge of the risks of second hand smoke and beliefs about being able to manage/remove smoke via ventilation was possible.
Children and babies who live in a home with someone who smokes are more susceptible to the effects of passive smoking than adults, with an increased risk of developing asthma and ear, nose and chest infections31. As adults, these children are more likely to smoke themselves and are susceptible to chronic obstructive pulmonary disease, stroke, heart disease, and cancer. Adults who are exposed to other people smoking for long periods of time have an increased risk of developing heart disease, lung cancer, asthma and other smoking related illnesses.
8.1 National Measures
As well as the Smoking, Health and Social Care (Scotland) Act (2005) being introduced, as described in section 3, the NHS and its partners have adopted further measures to reduce individuals’ exposure to second hand smoke. Nationally there has been guidance produced to assist in the development of smoking policies for NHS, local authorities and care service providers. This document supported these organisations to comply with the smoke free provisions of the smoking, health and social care (Scotland) act 2005 and to advise on the development of an approach to tobacco which will
30 Schönherr E. Contribution to the statistical and clinical features of lung tumours (in German). Z Krebsforsch 1928; 27: 436–50.
31 http://www.emro.who.int/Publications/EMHJ/0903/pdf/25%20effects%20of%20passive%20smoking.pdf maximise the benefits of becoming smoke free. This document outlines that there is no requirement to provide external smoking areas to comply with the legislation and highlights the strong evidence that’s suggests that smoking shelters undermine the potential health benefits. The guidance goes on to highlight that the health and safety of staff and patients needs to be a major concern when considering the nearest smoking point. The national guidance explains that smoking cessation services and pharmacological support should be offered to patients as an alternative to leaving a site to smoke.
In England, the National Institute for Clinical Excellence (NICE) produced Smokefree hospital guidance. This provides a five step process, demonstrating how to introduce an effective smokefree policy.
8.2 Local Smoking Policies and Activity
Local smoking policies are developed by individual employers to protect the health of staff, volunteers and service users from the impact of smoking.
The NHS Ayrshire & Arran Policy states that smoking is not permitted inside NHS Ayrshire and Arran premises (including vehicles used for NHS business) other than areas exempted by the legislation under the terms of the Mental Health (Care and Treatment) Scotland Act 2003. This document is currently being reviewed.
NHS Ayrshire & Arran offer support to businesses to develop their own tobacco policy. This is conducted through the Healthy Working Lives team who offer support to all businesses, regardless of whether or not they are working towards the Healthy Working Lives award. Development of a smoking policy is necessary for companies working towards any level of the award. The company must have a no smoking policy which meets the assessment criteria.
Smoke Free Cars and Homes Project –
During the NHS Ayrshire & Arran Tobacco Strategy and Local Tobacco Control Action Plan consultation process, 602 responses from a wide range of partner organisations, service users, young people and members of the public were received. Feedback from the consultation identified concern within communities about the possible increase of smoking within the home as a result of the smoking ban and the need to work more closely with grandparents as carers of young children. An East Ayrshire Residents Panel Survey was completed by 322 residents in June 2006 and demonstrated that 61% of residents would support a smoke free homes and zones campaign. Although there was good awareness of Home Fire Safety Visits, only 5% of respondents had taken up this form of support. Findings from the survey highlighted the need for a multi- stranded approach in partnership with the Fire Service.
Fresh Air-shire smoking prevention and cessation service aims to address these issues through the introduction of a ‘smoke free homes and zones’ project. In partnership with Strathclyde Fire and Rescue Service a two strand prevention and education campaign would be implemented within targeted pre-five establishments within specific postcode areas of highest smoking prevalence and deprivation. Parents of young children, carers and grandparents would be targeted by raising awareness of the dangers of passive smoking and risk of fires associated with smoking with the aim of influencing and changing attitudes, beliefs and behaviours towards smoking and encouraging adoption of smoke free living and restricting smoking within the home. It would be anticipated that as a result of the implementation of the campaign, referrals to the smoking cessation service would increase. The campaign would follow a phased approach to implementation with a roll out firstly in South Ayrshire followed by East and North.
Smoke free homes and zones projects have been successfully carried out in Glasgow, Manchester and West Yorkshire and have been implemented in countries such as Australia and America. Following evaluation these campaigns have proven to be popular with high numbers of compliance and an overall increased knowledge of the health effects of ETS. Such campaigns have reported significant numbers of smokers making changes to their smoking habits and successful quit rates. Additionally, smoke free home initiatives have been highlighted as a vehicle to encourage smoking cessation among pre-natal women, pregnant women and post natal women. To demonstrate this outcome, numbers entering the Fresh Air-shire smoking cessation service as a direct result of the smoke free homes campaign will be recorded in the ISD national minimum database, a national smoking cessation system to capture information on people presenting to services for help to stop smoking. ISD is Scotland's national organisation for health information, statistics and IT services.
For additional information on smoking prevention services within Ayrshire and Arran, please refer to section 6.1.
8.3 Smoking Protection and Controls
8.3.1 National Picture
Over the past decade the Scottish Government has brought in number of measures to try to reduce the attractiveness, affordability and availability of cigarettes to the general population, with a particular focus on teenagers.
In 2000, the Scottish Age-restricted Sales Enforcement Working Group was established, whose aim is to ensure laws regarding tobacco sales (and subsequently sales of all age-restricted products) are being complied with by retailers.
The Tobacco Advertising and Promotion Act 2002 restricted the advertising and marketing of tobacco products within the UK, with exemptions for specialist tobacconists and displays at the 'point of sale' in retail outlets and vending machines. This act aimed to reduce the attractiveness of cigarettes and other tobacco products by limiting the power of tobacco companies in advertising their products.
In February 2005 prosecution policy was revised to allow test purchasing of cigarettes by teenagers, enabling Trading Standards officials to catch retailers in the act of illegally selling cigarettes to under 16’s. In March 2006, the Smoking, Health and Social Care (Scotland) Act 2005 came into effect. It banned smoking in the majority of public places enabling non smokers to benefit from smoke free environments and reducing the overall attractiveness of smoking in Scotland. It also included a clause enabling Scottish Ministers to modify section 18 of the Children and Young Persons (Scotland) Act 1937, allowing the substitution of a higher age for that specified (aged 16) at a future date. This came into force in October 2007 when the minimum age for tobacco sales was raised from 16 to 18 years.
Subsequently, the Enhanced Tobacco Sales Enforcement Programme was established which aims to intensify enforcement of tobacco sales law and decrease the availability of smuggled and counterfeit cigarettes within communities through test purchasing and providing tobacco retailers with advice and guidance (see Figure 26, which details the outcomes and targets of the Programme). The achievement of these goals relies on Local Authority Trading Standards Services working in partnership with Her Majesty’s Revenue and Customs.
Figure 26 Outcomes and targets of the Enhanced Tobacco Sales Enforcement Programme Outcome Target Methodology
Reduce the % of 15 year Reduce to 50% by 2010 From SALSUS (The Scottish old regular smokers who [2006 baseline: individual Schools Adolescent Lifestyle buy cigarettes from local authority SALSUS and Substance Use Survey) shops figures ] data,
Reduce the % of 15 year Existing government targets Reduce to 10.5% by 2010 old boys who regularly [2006 baseline: 12%] smoke From SALSUS data
Reduce the % of 15 year Existing government targets Reduce to 16% by 2010 old girls who regularly [2006 baseline: 18%] smoke From SALSUS data
(Source: http://www.scotland.gov.uk/Topics/Health/health/Tobacco/Protection)
In January of 2010, the Tobacco and Primary Medical Services (Scotland) Act was passed which will come into affect in 2011. The act bans tobacco displays in shops and cigarettes being sold in vending machines. Both of these measures aim to reduce the attractiveness of tobacco products and their accessibility for young people and furthered the aims of the Tobacco Advertising and Promotion Act 2002. The act also introduces a tobacco sales registration scheme and makes it an offence for under 18s to purchase tobacco (or for older adults to do so on their behalf). The onus for ensuring these standards are enforced is on the Trading Standards department of each Local Authority. In Spring 2011 the Scottish Government is also due to publish guidance to assist mental health service providers in achieving smoke free mental health services.
8.3.2 Local Picture
Within Ayrshire and Arran each of the Local Authority Trading Standards Departments is responsible for achieving the targets of the Enhanced Tobacco Sales Enforcement Programme (see Figure 27).
Figure 27 – Process Measures – Enhanced Tobacco Sales Enforcement Programme Outcome Target Methodology
Each local authority to consider the extent to which it is appropriate for At least once in Annual return compiled by them to carry out in their area a every period of National Co-coordinator for programme of enforcement action twelve months, Scottish Government relating to sale of tobacco to young persons
Simple output based on Minimum 10% per agreed number of tobacco Increase targeted enforcement annum of tobacco retailers in each area for activity at retail level retailers subject to which funding has been test purchase allocated.
Reduce sales by 50% by 2011 Simple measure to show Reduce percentage of retailers [2007 baseline increased compliance willing to sell cigarettes to persons 26%] following increased under 18 23% by 2009 enforcement activity. 19% by 2010 13% by 2011
Minimum 20% per Simple output to show annum of tobacco Increase advice and support to increased effort into retailers visited to tobacco retailers helping retailers prevent provide advice and sales by their own staff. support
Simple measure of joint 5 operations 08-09 operations on illegal Increase joint working with HMRC 6 operations 09-10 tobacco at local and 7 operations 10-11 national level. Quantities of seizures to be recorded.
(Source: http://www.scotland.gov.uk/Topics/Health/health/Tobacco/Protection)
The Trading Standards Departments will also be responsible for ensuring that the Tobacco and Primary Medical Services (Scotland) Act is implemented correctly by ensuring that retailers are aware of the act and that the ban on cigarette displays and vending machines selling cigarettes is enforced. The displays ban will come into effect in 2011 for larger retailers and 2013 for small retailers.
Each of the Local Authorities now distributes the Young Scot Card to all Secondary School children in Ayrshire and Arran. This allows tobacco retailers to request proof of age from any teenagers who wishes to buy cigarettes and allows them to be confident that they are not unintentionally breaking the law.
As described above, in 2006 the smoking ban came into place throughout Scotland. NHS Ayrshire & Arran’s Public Health Department facilitated this change by working in partnership with Environmental Health Officers to support compliance with the smoking ban. They offered support to local businesses by providing local seminars to assist them in understanding the new legislation and developing smoking policies. NHS Ayrshire & Arran also revised its smoking policy bringing it in line with the new legislation.
9. Stakeholder Involvement
Throughout the development and implementation of the Ayrshire & Arran Tobacco Strategy, partnership working is essential. This process begins with a stakeholder event being held to discuss and draft the short/medium/long term outcomes for the strategy. Stakeholders involved at this stage include NHS, Local Authorities, Scottish Health Council, trade unions, local academic institutions and a range of other partners. Following production of a draft tobacco strategy, a three month consultation period will take place where partners and members of the public can provide input to the strategy. This consultation will aim to investigate the publics’ perception of the strategy, including opinion on: the overall impression of the strategy, the vision, key areas for action, objectives, actions and any additional priorities that should be included.
10. Performance management
Performance management of the key performance indicators within the Tobacco strategy will be in line with the NHS Ayrshire & Arran Performs framework as agreed by the NHS Board.
Key performance indicators related to the delivery of the four key components of Scotland’s tobacco control strategy will be identified based on an outcomes modeling approach.
These are:
1. Smoking Prevention and Education 2. Protection and Controls 3. Smoking Cessation 4. Second hand smoke
Existing indicators reflected within the HEAT suite of targets or other indicators published nationally will be considered for inclusion within the NHS Ayrshire & Arran Tobacco strategy.
Outcomes modelling is already underway to identify the complex causal pathways that link the activities and inputs in relation to delivering agreed national outcomes. This work will be reflected within logic models and an outcomes triangle for Tobacco Control. In addition, an indicator set will be identified that provides evidence of delivery of key intermediate and long term outcomes.
Scrutiny and governance arrangements will require to be put in place for the lifetime of the strategy in order to ensure targets and outcomes are delivered and that remedial action is taken when performance is not on track.
11. Conclusion
The case for facilitating a reduction in smoking rates is strong, with the health and financial implications of tobacco affecting not just smokers, but the population as a whole. Previous national and local work has made a marked improvement in the nation’s tobacco habits; however smoking is still the number one cause of preventable death in Scotland. This document highlights the need for a continued tobacco prevention agenda and suggests areas where a new strategy should focus.
Evidence of the link between deprivation and smoking status is in abundance. This suggests that to have the biggest impact, strategically there should be a continued focus on providing tobacco related services for those in the more deprived areas of Ayrshire and Arran. The key areas for focus include the continued development of smoking prevention and cessation services, along with support for a reduction in second hand smoking through strong tobacco control policies along with effective enforcement and monitoring of these controls.
An important aspect of tackling the tobacco issue is how performance is measured. Without a solid performance management system, it is difficult to evidence the benefits reaped from any strategy. The performance management approach outlined above presents a logical and rational method of assessing progress against predetermined outcomes. To be successful, implementation of this outcome focused approach requires commitment from all partners.
Smoking is a complex challenge; one which requires commitment, expertise, effective practice and strong leadership. These qualities are apparent throughout the partnership agencies. The Ayrshire and Arran Tobacco Strategy aims to utilise these qualities and build upon the previous strategy in striving towards a smoke free Ayrshire and Arran.
Appendix 1
Additional Socioeconomic Information for Ayrshire & Arran
From 2001 census data32, the number of single parents by local authority area was identified. Overall, 7% of total households in Ayrshire and Arran were occupied by lone parents ranging from 6% in South Ayrshire to 9% in North Ayrshire (Table 1). 49% of male single parents and 42% of female lone parents were in some employment, although for 7% of males and 25% of females, this was part time. In total, 19% of single parents in East Ayrshire, 20% in North Ayrshire and 25% in South Ayrshire were in full time employment.
The individual localities with the highest proportion of lone parent households in Ayrshire and Arran were: Bellsbank (East Ayrshire) 14%, Stevenston (North Ayrshire) 12%, Ardrossan (North Ayrshire) 12%, Logan (East Ayrshire) and Saltcoats (North Ayrshire) both 11%. The localities with the lowest proportions of lone parents were Lamlash (North Ayrshire), Fenwick (East Ayrshire) and Dunlop (East Ayrshire) all 3%.
Table 1: Households with dependent children33
All lone All parent Percentage Percentage Percentage House households Council area of all in part time in full time holds with households employment employment total dependent children
East Ayrshire 50,346 3,400 7% 24% 19%
North Ayrshire 58,726 5,045 9% 23% 20%
South Ayrshire 48,748 2,788 6% 26% 25%
Ayrshire & Arran 157,820 11,233 7% 24% 21%
The 2009 SIMD data also measure the level of deprivation based on health factors alone34. Of the 480 data zones in Ayrshire and Arran, the most deprived area in terms of health is 43rd (in Irvine). The least deprived is 6388th (Troon). In total, measuring health deprivation the ranking of data zones in Ayrshire and Arran are shown in Table 2.
32 http://www.gro-scotland.gov.uk/files/setloc-ks01.xls 33 ibid 34 http://www.scotland.gov.uk/Resource/Doc/933/0088625.xls Table 2: SIMD data zones in most deprived / affluent - Number of data zones
Local Authority Area
SIMD Health East North South Ayrshire and Arran Domain Rank Ayrshire Ayrshire Ayrshire total
5% most deprived 13 9 7 29 5-10% most deprived 12 14 7 33 10-5% most affluent 3 4 7 14
5% most affluent 2 0 3 5
Grand Total 154 179 147 480
Table 8: Population by data zone (%) Local Authority Area
SIMD Health East North South Ayrshire and Arran Domain Rank Ayrshire Ayrshire Ayrshire total
5% most 8% 5% 5% 6% deprived
5-10% most 7% 7% 4% 6% deprived 2% 2% 4% 3% 5-10% most affluent
5% most affluent 1% 0% 2% 1%
Grand Total 100% 100% 100% 100%
The range of health deprivation across the three Community Planning Partnerships can be seen in Figure 1. This confirms that there is a significant range of health inequality across Ayrshire with a major weighting of poor health in both North and East Ayrshire. 50% of Scotland will be below 0 and 50% above 0 being higher deprivation.
Figure 1: Health Domain Score by Local Authority
3.00 2.80 2.60 2.40 2.20 2.00 Health poorer than Scottish average 1.80 1.60 1.40 1.20 1.00 0.80 0.60 0.40 0.20 Scottish average 0.00 -0.20 -0.40 -0.60 -0.80 Health better than Scottish average -1.00 -1.20 -1.40 -1.60 -1.80 -2.00 -2.20 -2.40 -2.60 South Ayrshire East Ayrshire North Ayrshire
Source: SIMD 2009
A negative score indicates a lower level of deprivation. This shows that the majority of data zones have a higher deprivation than the national average (59% of the data zones in South Ayrshire, 69% of East Ayrshire and 66% in North Ayrshire). The highest level of deprivation is found in North Ayrshire, and South Ayrshire has a lower deprivation overall. However, there are clear pockets of severe health deprivation in South Ayrshire and three of the six most health deprived data zones in Ayrshire are located in South Ayrshire (all in Ayr).
Figure 2: Health deprivation % of total data zones
0.12
0.1
0.08
0.06 percentageof total 0.04
0.02
0 0-5% 10-15% 20-25% 30-35% 40-45% 50-55% 60-65% 70-75% 80-85% 90-95% most deprived level of deprivation
number of datzones by local authority East Ayrshire number of datzones by local authority North Ayrshire number of datzones by local authority South Ayrshire
Source: SIMD 2009
The 2001 census35 asked for the first time a number of questions in relation to the health of people in Scotland including people with long standing illness, perception of own health and the number of carers.
The proportion of the working age population who reported having a limiting long-term illness in Ayrshire and Arran was 16.6%, the third highest for a Health Board area in Scotland. The proportion within each of the local authorities is shown in Table 3.
35 http://www.gro-scotland.gov.uk/files1/stats/key_stats_chareas.pdf Table 3: Limiting Long-term Illness - Census 2001
% people of working age Position among 32 local Local authority reporting a limiting long authorities term illness
East Ayrshire 17.2% 7th
North Ayrshire 17.3% 6th
South Ayrshire 15.3% 13th
Seven of the 10 localities in Ayrshire and Arran that report the highest proportions of working age people with long standing ill health are in East Ayrshire, with the top three being Bellsbank (35%), Patna (28%) and Muirkirk (27.6%). The localities with the least reported long standing illness were Fenwick (11.4%), Troon (11.8%) and Coylton (11.9%)36.
The proportion that reported that their general health was not good in Ayrshire and Arran was 10.7% - again the third highest in Scotland. The percentage of people reporting that their health is not good within each local authority area is shown in Table 10.
Table 14: Health Not Good Census 2001
% reporting that health Position among 32 local Local authority not good authorities
East Ayrshire 10.8% 10th
North Ayrshire 10.9% 7th
South Ayrshire 9.8% 12th
36 http://www.gro-scotland.gov.uk/files/setloc-ks08.xls Appendix 2 – NHS Ayrshire & Arran‟s Strategic Objectives
The objectives fall into three main themes: - Meeting the health needs of our population - Creating an environment in which staff flourish - Effectively managing resources.
Meeting the health needs of our population
- We will continue to drive continual clinical improvement, with a clear focus on patient safety
- We will achieve the best possible health for individual, families and communities by developing services which promote well-being and good health; prevent ill- health; provide equal and appropriate care and treatment for all; and ensure we plan for future health needs
- We will provide clear information about the services people seek from their surgery and other community services, community pharmacist, dentists, optometrists, their local hospitals and how patients can get the right help in an emergency.
An environment in which staff flourish
- We will ensure our staff have the appropriate skills and equipment - We will strive to be an exemplar employer on matters of equality and diversity - We will promote staff health and well-being - We will focus on workforce re-design to achieve optimal support across the patient journey - We will ensure effective staff development
Effectively managing resources
- We will address challenges in maintaining financial balance through effective use of resources - We will maintain essential services
With regards to the tobacco strategy the strategic objective that is particularly relevant is ‘We will achieve the best possible health for individual, families and communities by developing services which promote well-being and good health; prevent ill-health; provide equal and appropriate care and treatment for all; and ensure we plan for future health needs.’ The other objectives contribute to the success of this both directly and indirectly.