Tobacco Dependency Needs Assessment

Tobacco Dependence Needs Assessment January 2019 Produced by Claire Mulrenan, Public Health Registrar, Kent County Council Andrew Scott-Clark, Director of Public Health, Kent County Council Contents Executive Summary Background and Introduction ............................................................................................ 3 Epidemiology .................................................................................................................... 3 Smoking Cessation Services ............................................................................................... 4 1 Background ................................................................................ 6 2 Introduction ............................................................................... 6 Summary – Part 1 ................................................................................................................ 17 3 Epidemiology ............................................................................ 18 Summary – Part 2 ................................................................................................................ 31 4 Smoking Cessation Services ...................................................... 32 Summary and Recommendations – Part 3 ........................................................................... 41 Appendix 1 – Global Burden of disease ................................................................................ 43 Appendix 2- Cigarettes vs e-cigarettes ................................................................................. 45 Appendix 3 – Kent and Medway STP Position statement on e-cigarettes ............................. 47 Appendix 4: Achieving the 2022 targets- Smoking prevalence projections ........................... 50 Appendix 5: Achieving the 2022 targets- SATOD projections................................................ 53 Appendix 6: The Ashford smoking plus pilot ........................................................................ 56 Appendix 7: Literature Search.............................................................................................. 56 Appendix 8: Equality Impact Assessment ............................................................................. 56 2 Tobacco Dependence Needs Assessment, January 2019 Executive Summary Background and Introduction Despite a steady decline in Kent smoking prevalence over the past decade, smoking remains the single most modifiable risk factor for cancer and the leading cause of preventable illness and premature death. In Kent alone, there were an estimated 7,381 deaths attributable to smoking in the period of 2014-16 and an estimated 12,444 smoking attributable hospital admissions in 2016/17. In addition, tobacco is a significant driver of health inequalities. Smoking accounts for approximately half of the difference in life expectancy seen between the richest and poorest groups in society. Lower socioeconomic groups are typically more dependent, smoke more each day and find it harder to successfully quit. Smoking in pregnancy further entrenches inequalities, with greater likelihood of complications in pregnancy and children of smokers exposed to greater levels of harmful secondhand smoke. Beyond health, tobacco also results in significant costs to both society and the individual. In the South East alone, this cost has been estimated at £2.04 billion. Illicit tobacco and organised crime further compound these issues. The government has set out a long-term ambition to create a ‘smoke-free generation’ and has outlined several key targets for 2022. These include a reduction in overall smoking prevalence in adults to 12% or less, a reduction in smoking in pregnancy rates to 6% or less and reducing the inequality gap in smoking prevalence. Achievement of these targets would have a significant positive impact on health outcomes for the Kent population, including a reduction in lung cancer, COPD, coronary heart disease, acute myocardial infarction events and stroke. The smoking landscape has changed. A decline in the rates of referral to traditional stop smoking services has occurred alongside a concurrent increase in the use of e- cigarettes. There is a need to review current smoking cessation provision to ensure it is offering the best chance of quit success for smokers and is setting Kent on a trajectory towards attainment of the 2022 targets. Epidemiology There are inherent challenges in measuring smoking prevalence due to a reliance on self-reported smoking status and the fact that the Kent population is constantly in flux. Triangulation of the different measures available can produce a ‘range of precision’ and enable more effective monitoring of trends over time. Despite an estimated reduction in smoking prevalence of 4.4% in Kent over the past five years, 16.3% of Kent residents continue to smoke and the gap in smoking behaviour between the richest and poorest appears to be widening. Those in routine and manual occupations are nearly 3.5 times more likely to smoke than their counterparts in other occupations, and smoking prevalence in this group now stands at 32.4% (the highest in the South East). 3 Tobacco Dependence Needs Assessment, January 2019 Significant variation in prevalence also exists between districts, with estimated prevalence in Thanet (23.7%) significantly greater than national estimated prevalence of 14.9%. Smoking in pregnancy remains a priority with an estimated 14.4% of women smoking at time of delivery. It is believed attainment of smoking status in pregnancy has improved in the last few years due to the work of smoking in pregnancy midwives and CO monitoring at booking. However, concerns remain and there is a need to ensure a single effective measurement is in place for Kent. Current smoking prevalence projections suggest Kent is on course to achieve the overall target of 12% by 2022. These projections equate to a prevalence reduction of 0.89% per year and an estimated total of 58,500 additional quits by 2022 in Kent (average of 11,700 per year). That said, if Kent is to achieve the target of reducing health inequalities, rates of decline will need to be accelerated in certain districts (particularly Ashford, Dover, Gravesham, Maidstone, Swale and Thanet) and among certain groups in Kent. Given this, and the decline seen in smokers accessing cessation support, there is a need to consider innovative solutions to ensure achievement of the 2022 goals. Current SATOD (smoking at time of delivery) trends suggest a need to accelerate quits among smoking pregnant women to achieve 6% prevalence by 2022. Projections estimate reductions of 2.1% will need to be achieved each year. There are currently an estimated 2,372 women smoking in pregnancy in Kent; this will need to be reduced to 971 by 2022 to achieve the 6% target. Per year, this translates to an average target reduction of 350 women. Smoking Cessation Services Despite significant declines in smoking prevalence over the last decade, smoking rates remain too high and there is a need to look for new, flexible and innovative models of support to maximise Kent’s chances of achieving the ambitious 2022 targets. Smoking cessation remains highly cost effective. With a ‘number needed to treat’ (NNT) value of 20 to prevent a premature death, it compares extremely favourably with other routine medical interventions. Traditional smoking cessation services continue to offer the best chance of successful quits and Kent services perform well. However, the numbers accessing these services have continued to decline. An estimated two-thirds of smokers report a desire to quit, yet just over 3% of the Kent smoking population currently access existing cessation services. There is a need to broaden support services to appeal to a wider audience. Research has shown GPs have a particularly important role to play in encouraging and supporting quit attempts. Smokers are more likely to visit their GP than non-smokers, and data shows quit attempts are more likely if advice or support on smoking cessation is offered by a GP. Guidance also emphasises the need for patient choice. Allowing a smoker to choose the quit method they prefer, provided it is not a pharmacotherapy that is unsuitable for them, is likely to increase chances of success. Given this, Smoking+, an evidence-based Stop Smoking model developed by UCL Professor Robert West, appears to offer the best chance of success. 4 Tobacco Dependence Needs Assessment, January 2019 This model combines traditional smoking cessation services (tier 1) alongside GP brief advice and prescribing of NRT/varenicline (tier 2). Tier 3 would offer comprehensive online support and information. To achieve the desired population outcome, this model will require consistent intervention delivered at scale. Plans are currently underway for a smoking+ pilot in Ashford. This offers an opportunity for testing and costing the model locally before wider roll out. To maximise impact, wider implementation will require close collaboration between the Local Authority, the STP, CCGs and GP Practices across Kent. As with all interventions, there is a need to be mindful of widening existing health inequalities. Universal action is appropriate but should be delivered with a scale and intensity that is proportionate to level of need. Interventions will need to target the most vulnerable groups. Smoking+ would not replace specialist services that target pregnant women. Kent must continue to offer specialist smoking

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