Smoking is the single greatest cause of preventable deaths in the UK, killing 80,000 people a year: more than obesity, road traffic accidents, illegal drugs, alcohol and HIV combined (Department of Health, 2011).
Smoking kills half of all regular smokers (Doll, R.R., 2004) and causes and exacerbates a range of diseases, reducing quality of life (as well as the length) for many individuals and their families. Following surgery, smoking contributes to lower survival rates, delayed wound healing and postoperative respiratory complications (NICE, 2013).
Smoking has been identified as the primary reason for the gap in life expectancy between the rich and the poor, with tobacco control therefore a vital part of strategies to tackle health inequalities (Marmot, 2010).
The smoking prevalence rates in York are lower than the national and regional averages. This is based on Public Health England’s Tobacco Control Profiles.
- In 2012 the adult smoking prevalence rate is 17.6%, lower than the national and regional rates (19.5% & 22.7%).
- The rate for persons in routine and manual occupations is 26.2%, lower than the national and regional rates (29.7% & 33.2%).
- The smoking prevalence rate for patients with a long term condition (LTC) is 14.9%, lower than the national and regional rates (19.3% & 17.5%).
- Across York Local Authority area, the smoking rate for pregnant women at the time of delivery is 13.7%, slightly higher than the national rate (12.7%), but lower than the regional rate (16.5%).
Local research provides information on smoking patterns in certain groups of people.
- In a cohort of 165 drug users in York, 73% said they had smoked tobacco in the last year.
- Informal feedback from front-line staff as part of a health needs assessment suggests high smoking prevalence rates in the gypsy and traveller community in York.
There are some gaps in the data for York e.g. smoking rates are not available at ward or LSOA level and rates for certain groups such as young people, BME residents and persons with a mental health problem are unknown.
The cost of smoking
The ASH model (updated 2013) uses local prevalence data to calculate the cost to society of smoking. In York the estimated cost is £45.7M per year including £13.6M in output lost from early deaths, £9.6M in 'smoking breaks' at work and £2.4M on NHS care.
Link between smoking and deprivation
Smoking rates for patients who have a long-term health condition are collected at GP practice level and can be analysed against the deprivation index for the practice (Health & Social Care Information Centre, 2012). It can be seen from the chart below that there is a significant correlation (correlation co-efficient = 0.8) between deprivation and smoking levels in patients who have long-term health conditions in the Vale of York Clinical Commissioning Group practices.
Smoking rate in the practice with the lowest deprivation score was 9%. In the practice with the highest deprivation score, it was 24%. GP practices in York that have greater levels of deprivation also have higher levels of patients who smoke.
Smoking Long-term Condition (LTC) rate: GP prevalence by deprivation score
Source: Quality & Outcomes Framework
Smoking related illness and mortality
In York, the following rates are significantly lower than the national average:
- smoking attributable mortality rates
- death rates from lung cancer
- smoking attributable hospital admissions
- lung cancer registrations
Other rates are not significantly different from the national average i.e. smoking attributable death rates from heart disease and strokes, death rates from Chronic Obstructive Pulmonary Disorder (COPD) and oral cancer registrations (Public Health England, Local Tobacco Profiles, 2013).
Smoking cessation services in York
Smoking cessation support in York is provided by the specialist service, North Yorkshire Stop Smoking Services (NYSSS) and the Local Enhanced Services (LESs) for GP practices and pharmacies. Cessation support is also carried out in prison and military settings and although this activity is not commissioned by CYC the data is reported to us and is captured in statutory returns.
The data on smoking cessation activity in York for 2012/13 shows high 4 week quit rates for those in treatment but low overall activity (Health & Social Care Information Centre, 2013).
The expectation is that the stop smoking services will treat between 5% and 10% of the local smoking population in a year (ASH, 2006).
York was just under this expectation and supported 4.9% of the local smoking population. The national rate has been between 9 and 10% for the last three years.
In York, the overall quit rate was 54% which is higher than the national average of 50%.
The quit rate for pregnant smokers (38%) was lower than the national average (46%).
The percentage of clients lost to follow up (those that did not complete their appointments with the smoking cessation service) was 27% in York. This was higher than the national average of 24%.
What are the recent trends?
Smoking prevalence rates are falling in York
- The adult prevalence rate in York has been falling at a quicker rate than the national average (see chart below)
- Rates for smoking at the time of delivery have remained in line with national averages
- Rates for patients with long-term conditions in York had fallen between 2008-2009 and 2010-2011 but there was a slight rise in 2011-2012.
Trend in adult smoking prevalence rates
The recent trends in smoking cessation activity in York are as follows:
- Quit rates are improving and are above national rates
- Treatment rates fell in 2012/13 and have been below national rates for the last three years
- Pregnancy quit rates have fallen in the last two years and are below national rates
- Lost to follow up rates have improved in the last two years but are above national rates
How well are needs being met in York?
A needs assessment was written in 2012 prior to the transfer of responsibility for tobacco control from NHS North Yorkshire and York to CYC. Key recommendations included developing a CYC specific tobacco control strategy, improving services for pregnant smokers and moving the focus away from 4 week quits towards sustained long term quits and reduced prevalence
The progress made in York towards meeting the national targets for smoking prevalence rates is shown below:
- York is already meeting the target for adult smoking prevalence (18.5% or less by the end of 2015).
- York is not currently meeting the target for smoking at the time of delivery (11% or less by the end of 2015) but at the current rate of reduction is on course to do so (see chart below).
Data are not currently available to measure progress against the target for smoking amongst 15 year olds (12% or less by the end of 2015).
York trend for the percentage of women known to have been smokers at time of delivery. 2010 to 2015 (projected)
Detailed analysis of 2013-14 activity to date shows that the impact of smoking cessation services in York varies between different groups.
Successful smoking quit rates varied between socio economic groups and ranged from 30% for students to 71% for sick or disabled clients
Successful smoking quit rates for pregnant women were low (25%) although the numbers treated were low (8 people).
The tendency was for successful smoking quit rates to increase with age e.g. 49% of 18-34s successfully quit compared with 67% of clients aged 60+.
Males were more likely to be lost to follow up (29%) than females (21%). Lost to follow up means people who did not have a follow up appointment and for whom the outcome of the smoking cessation intervention is unknown.
Younger clients were more likely to be lost to follow up e.g. 32% of 18-34s compared with 10% of clients aged 60+
Lost to follow up rates were highest in young males (34%) and lowest in older females (7%)
A ‘Stop Before Your Op’ programme has been established by NHS Vale of York Clinical Commissioning Group. This recommendation has been put forward in York for a pre-elective surgery smoking cessation programme. Key components of the programme are as follows:
- GP's would identify which of the patients requiring non urgent surgery are current smokers
- The patient’s referral for surgery would normally be delayed for up to 12 weeks whilst smoking cessation interventions take place.
- Patients would not have a delay if the clinical need for surgery is judged to be greater than the benefits of delaying surgery through smoking cessation treatment
Patients that smoke and have surgery are at the greatest risk of complications during or after an operation. These include potentially serious complications that can affect the lungs or heart as well as problems related to the general anaesthetic which is vital in the majority of surgical procedures.
Fighting infection is also more difficult for a smoker; whilst the risk of breathing problems increases too. There is also an increased chance of a longer stay in hospital. The wounds and bones in smokers also take longer to heal because of the reduced blood flow and lower oxygen levels in the blood.
Smoking reduces the benefits from treatment and the effects of recovery. There is a 1 in 3 risk of smokers experiencing breathing problems after an operation, but by stopping smoking at least eight weeks before the operation, the risk drops dramatically to 1 in 10 (NHS Vale of York Clinical Commissioning Group).
The anticipated benefits of such a programme would be:
- increasing the number of people who stop smoking for their operation and maintain their smoke-free status postoperatively
- improving postoperative recovery and reducing hospital length of stay
- improving clinical outcomes by reducing smoking-related ailments and postoperative complications, for example in wound healing
- reducing inequalities by increasing opportunities to access stop smoking support, particularly for hard-to-reach groups
The National Centre for Smoking Cessation and Training (NCSCT) is a social enterprise committed to support the delivery of effective evidence-based tobacco control programmes and smoking cessation interventions provided by local stop smoking services.
The NCSCT works with and for the field to deliver training and assessment programmes, support services for local and national providers and conducts research into behavioural support for smoking cessation.
A range of training programmes that can be completed on-line are available to practitioners. These include:
Public Health England (2011) the tobacco control plan for England
Tobacco Control Plan
Doll, R.R., (2004) Mortality in relation to smoking: 50 years’ observations on male British doctors
Mortality in relation to smoking: 50 years’ observations on male British doctors
National Institute for Health and Care Excellence (2013) PH10 Smoking Cessation Service: Guidance
PH10 Smoking Cessation Service: Guidance
Institute of Health Equality (2010) Fair Society, Healthy Lives
Fair Society, Healthy Lives
Public Health England (2014) Local Tobacco Control Profiles
Local Tobacco Control Profiles
Action on Smoking and Health (2012) Local cost of smoking
Local cost of smoking
Health and Social Care Information Centre (2013) Quality and Outcomes Framework
Quality and Outcomes Framework
Department of Health (2011) Healthy Lives, Healthy People: A Tobacco Control Plan for England
Healthy Lives, Healthy People: A Tobacco Control Plan for England
Health and Social Care Information Centre (2013) Statistics on NHS Stop Smoking Services England
Statistics on NHS Stop Smoking Services, England