Facts and Figures

Smoking prevalence

The 2006 General Household Survey suggests a drop of four percentage points in smoking prevalence in the North East from 29% in 2005 to 25% in 2006.  Whilst it is likely that a downward trend may also be occurring in Newcastle, synthetic estimates suggest that smoking prevalence in adults (aged 16+) is 31.7%,  which is significantly higher than the national prevalence of  24.1% . (Table 1)  The North East Public Health Observatory estimates a slightly lower smoking prevalence of 26.8% in Newcastle. (NEPHO, 2004).  In any case, based on these figures, the regional targets for 2010 and 2015 may not be met without additional efforts to reduce smoking prevalence.

Through out this document, data for North Tyneside and Northumberland are also given to aid comparison. It is also important to note that Newcastle Primary Care Trust provides a joint NHS Stop Smoking Service to both Newcastle and North Tyneside.

Within Newcastle, there are considerable variations in estimated smoking prevalence across the city with up to 51% of the adult population smoking in the former Monkchester ward (contained parts of Walker, Walkergate and Byker wards) and 49% in Walker compared to only 17% in the former South Gosforth. In general, smoking prevalence tends to be higher in areas of deprivation.

Smoking prevalence in 11-15 year olds

Data on smoking prevalence for 11-15 year olds taken from the 2006 annual survey of secondary schools in England show that the that the percentage reporting that they are a regular smoker has fallen faster than required to meet the Smoking Kills target.

Smoking during pregnancy

A particular priority for the Government is to reduce the proportion of women who smoke during pregnancy.  Smoking remains one of the few modifiable risk factors in pregnancy, and it can cause a range of serious health problems, including lower birth weight, pre-term birth, and infant mortality. 

Smoking attributable mortality

Newcastle has rates of smoking attributable mortality that are statistically significantly higher than the England rate. The Newcastle Community Health Profile (NHS, 2008) indicates that the death rate from smoking is higher than the regional and national average and on average smoking kills about 566 people each year in Newcastle-upon-Tyne, this equates to 304.50 per 100,000 population aged 35+, (312.10 in 2007) . Areas with the highest smoking prevalence also experience the highest rates of death from smoking. Death rates from tobacco are two to three times higher among disadvantaged social groups than among the better off. 

Self reported four week smoking quitters

The Department of Health's preferred indicator is the rate of self-reported 4-week smoking quitters per 100,000 population aged 16 or over.  An equity audit of the North of Tyne NHS Stop Smoking Services[2] undertaken in 2006 showed that in Newcastle, the proportion of people accessing the service (that is setting quit dates) and successfully stopping smoking at 4 weeks remained similar across socioeconomic quintiles. That is, data do not show selective targeting of the more deprived smokers. This is in contrast to the picture in North Tyneside and Northumberland as illustrated in the graphs below. (Figures 1 - 3)   Quintile 1 includes the most deprived 20% of the population and Quintile 1, the least deprived.

Figures 1 – 3:  Inequalities in smoking:  Estimated smoking prevalence and percentage of smokers quitting at 4  weeks

[2] Corris. V, Ruta D.  Measuring Progress in Reducing Health and Health Care Inequalities in the North of Tyne Area.  Stop Smoking Services.  NHS North of Tyne Commissioning Consortium.  2006.

Trends

Smoking During Pregnancy

Newcastle has made significant progress on this issue over the last five years. The current prevalence is 18%.  (Table 2). However, in general, higher percentages of women smoke throughout pregnancy in areas with higher levels of deprivation.

National Indicator NI 123: Smoking quitters per 100,000 population aged 16 and over.

In 2008/09, the Local Area Agreement and the Primary Care Trust's Annual Operating Plans have agreed to the same target - 2,500 self reported smoking quitters at 4 weeks. This corresponds to a rate of 1,161 quitters/ 100,000 population. (Table 3)

It is important to note that this indicator specifically measures the number of people who stop smoking using the NHS Stop Smoking Services only. (Those who quit on their own or through other sources are not included in the indicator)  

Targets

There are regional, national and local targets related to smoking which include the following: 

National targets

• To reduce adult (16+) smoking rates to 21% or less by 2010, with a reduction in prevalence among routine and manual groups to 26% or less (PSA Target)
• To reduce smoking among 11-15 year olds from 13% (1996) to 11% by 2005 and 9% by 2010
• To reduce smoking among pregnant women from 23% (1995) to 18% by 2005 and 15% by 2010

Regional targets

• To achieve a regional smoking prevalence for the North East of no more than 23% by the end of 2010 To achieve a regional smoking prevalence rate of 20%, or a level below the national average, by 2015.
• To achieve an absolute regional smoking prevalence level of only 10% by 2032.

Local target

Indicator: (LAA 2 & the PCT's Vital Signs indicator)

National Indicator NI 123: Smoking quitters per 100,000 population aged 16 and over.

In 2008/09, the Local Area Agreement and the Primary Care Trust's Annual Operating Plans have agreed to the same target - 2,500 self reported smoking quitters at 4 weeks. This corresponds to a rate of 1,161 quitters/ 100,000 population. (Table 3)

It is important to note that this indicator specifically measures the number of people who stop smoking using the NHS Stop Smoking Services only. (Those who quit on their own or through other sources are not included in the indicator)  

Performance

Health Care Commission report

In 2006, the Healthcare Commission review of tobacco control in Newcastle gave a rating of excellent.

PCT Performance Monitoring

Between April 2007 and end March 2008, a total of 5,134 smokers set a quit date with the NHS Stop Smoking Service in Newcastle, of whom 2,369 people had stopped smoking at 4 weeks

This corresponds to a 46% quit rate. Nationally, the expected success rate range is 35% to 70%.

In Newcastle, and other PCOs in the North of Tyne, the number of people stopping smoking using the NHS Stop Smoking Services has been falling. The reasons for this are not fully understood.  In June 08 the number of smokers successfully quitting at 4 weeks using the NHS Stop Smoking Services was below the trajectory required to meet the vital signs/LAA2  target. A  draft North of Tyne Action plan has been developed to improve performance on this indicator; this process is being facilitated by the North of Tyne  Performance unit

Feedback from the National Support Team on Health Inequalities on Tobacco control activity in Newcastle following a visit from the NST in June 2008 was generally positive. The team made the following points:

• Both Newcastle and North Tyneside have strong committed and accountable tobacco control alliances
• The Health Gain and Health and Wellbeing strategies developed in North Tyneside are exemplars of good practice
• Supported by FRESH North East, both areas are able to address often neglected areas of tobacco control - including smuggling and illicit sales and training for metal health workers
• The Stop Smoking Service (SSS) is operating a 'hub and spoke' model and use of partners ensures diversity of delivery methods to reach the areas where smoking is most prevalent and embedded. Examples include Drop in to Quit, Smoke Free Project Office and BME community workers.
• Good examples of the use of evaluation and surveys to inform development of Tobacco Control

Recommendations from the NST include:

• Developing a Health Gain Schedule used to support a systematic delivery of key stop smoking messages through front line staff;
• Communications planning is integral to delivering on the stop smoking agenda; to enable broader ownership and partnership with all stake holders including the public
• The Stop Smoking Service specification should ensure a systematic approach in meeting the needs of prioritised groups of smokers.

Local Views

A range of methods of public engagement have been employed on the tobacco control agenda, as follows:

• The Newcastle and North Tyneside Stop Smoking Service routinely collects user feedback on its services.
• Community Action on Health carried out consultation exercises with people living within disadvantaged areas of inner West and Outer West of Newcastle and with a group of Community workers to ascertain their knowledge about the NHS Stop Smoking Services.

Findings include the following:

• Participants felt that a 10-20 minute consultation (in Intermediate level services, mostly in General Practices) was not long enough to be effective.

• With regard to stop smoking services in pharmacies, some felt that this may not work because of privacy issues in an enclosed environment; others thought that pharmacists were more approachable than doctors.

• In terms of information leaflets, there is a need to make these more relevant and available in a variety of languages and on video.
• There was general support for specialist stop smoking services but it was felt that they should be community-based rather than in a clinic or hospital; and that they should not be called 'clinics'.
• For BME communities, the need for the service to be culturally aware was mentioned; for e.g. having the same sex advisers and interpreters.
• There was a feeling that people should be able to access support without having to commit to giving up smoking completely.
• Support groups and drop-ins based in the community were seen as a more informal and relaxed set up. It was suggested that smoking advice should be incorporated into 'well person clinics' which could include 'stress relief' therapy, acupuncture, weight management.
• It was suggested that Nicotine Replacement Therapy (NRT) should be free to all.

Read the full report

Community Action on Health (CAOH). Smoking Cessation - what do communities know about the services available?.A report to establish people's awareness and use of accessing NHS Stop Smoking Services in the Inner West and Outer West of Newcastle upon Tyne . June 2008

National and Local Strategies

National policy drivers

• On July 1st 2007, a landmark piece of legislation, 'The Health Bill' came into effect in England making smoking illegal in virtually all enclosed public places and work places. This legislation provided the national and local tobacco control programmes with the potential to make 'not smoking' the norm in England.
• In England, tobacco control activity is guided by the Department of Health's six strand approach, based on international evidence that a co-ordinated and multi-faceted response to the tobacco epidemic is required to effectively tackle tobacco use. These six strands are:
  • Support smokers to quit;
  • Reduce exposure to second hand smoke;
  • Run effective communications and education campaigns;
  • Reduce tobacco advertising, marketing and promotion;
  • Regulate tobacco products; and
  • Reduce the availability and supply of tobacco products

Other key documents include

• Smoking Kills: the Department of Health's (DH) 1998 white paper which set out for the first time in the UK, a comprehensive tobacco control strategy and announced the introduction of a new NHS smoking cessation service. The focus of the service would be to help all smokers quit smoking, whilst specifically targeting young people, pregnant women and socio-economically disadvantaged smokers.
• The 2003-2006 the DH's Priorities and Planning Framework and the subsequent PSA 2005-2008 set smoking cessation targets for Primary care Trusts towards reducing health inequalities by 10% as measured by infant mortality and life expectancy at birth. The revised target was to reduce adult smoking rates from 26% in 2002 to 21% or less by 2010, with reduction in prevalence among routine and manual groups from 31% in 2002 to 26% or less. An additional target was to reduce smoking by 1 percentage point per year in women who continued to smoke during pregnancy.
• Choosing Health: making healthy choices easier (2004),
• The Wanless report; securing our future health. Taking a Long Term view (2002)
• NHS Cancer Plan (2000),
• The National Service Framework (NSF) for Coronary Heart Disease (2000)
• The Acheson report: an Independent enquiry into Inequalities in Health (1998)

Regional policy drivers

• The vision for tobacco control is of a smoke free North East with year on year reductions in smoking prevalence coupled with a comprehensive range of stop smoking support services provided in accessible venues, specifically targeting the more deprived areas North of Tyne. Regional policy documents include
• The 2007 regional public health strategy which highlighted tobacco control as a key area for action.  "The North East will reduce its overall smoking prevalence to the lowest in the country and will narrow the gap in smoking prevalence between social groups." The strategy also aims to "establish regional standards for quantity and quality levels of Stop Smoking Service provision that require the less well performing areas to increase their activity to match those achieved by the best, and to continue improvement in all services to ensure that those in the North East continue to be the most effective in the country

Local policy context

• The Newcastle Partnerships Local Area Agreement (2008 - 2021) contains a target to reduce the number of people who smoke.
• The Newcastle Health improvement strategy (2007 - 2017) sets out to make Newcastle a smoke-free city, by reducing the prevalence of smoking in the population of Newcastle and increasing the number of smokers who quit smoking. 
• Smoke Free Newcastle, the city's tobacco control alliance was established in 2004. In 2005 it produced a comprehensive 3 year tobacco control action plan which acted as the local delivery plan for the regional tobacco control strategy; the Newcastle action plan has been recently updated for 2008/09. 

Current Activity and Services

Tobacco Control and Stop Smoking Services

FRESH - the regional office for a Smoke Free North East is commissioned by Newcastle PCT and the other Primary Care Organizations (PCOs) in the region, to implement a comprehensive business plan to reduce smoking prevalence and increase the smoke free initiative

Smoke Free Newcastle is a multi disciplinary and cross agency alliance, co-ordinated by Newcastle PCT (lead agency) and Newcastle City Council which oversees tobacco control issues across the city.  The alliance is accountable to the Well-being and Health Partnership of the Newcastle Local Strategic Partnership.  Smoke Free Newcastle had a three year action plan covering the period 2005-08.  It has recently developed a one year action plan covering 2008/09 whilst the forthcoming National Tobacco Control Strategy is produced.  Once the national strategy is produced a new Regional Tobacco Control Strategy will be written, out of which a local action plan for delivery will emerge.

Current plans for Newcastle focus on the following key areas of tobacco control:

• Build the infrastructure, skills and capacity for local tobacco control across partner organisations in Newcastle.
• Reduce exposure to second hand smoke by supporting all workplaces and public places to effectively enforce the smoke free law and lead the introduction of programmes to reduce second hand smoke exposure in the home and in cars.
• Continue to provide free NHS stop smoking support to people wishing to quit through the Newcastle and North Tyneside Stop Smoking Service, focusing particularly on routine and manual workers and other 'hard to reach' groups.
• Support and develop public education and media campaigns which aim to give the public more information on the dangers of second hand smoke, stop smoking support and to prevent the uptake of smoking among young people.
• Reduce the availability and supply of tobacco products and address the supply of tobacco to children, working with FRESH and the HM Customs and Revenue Service to implement a regional strategy on counterfeit and smuggled cigarettes. Smoke Free Newcastle will continue to take action to reduce illegal tobacco sales to minors by carrying out regular test purchasing of cigarettes.
• Monitor tobacco regulation to ensure that relevant laws relating to tobacco are effectively enforced. This includes legislation on tobacco advertising.
• Reduce the promotion of tobacco by collecting evidence on how cigarettes are legally promoted at the point of sale, which can be fed into to national consultation.
• Undertake research, monitoring and evaluation of the plan to ensure that Smoke Fee Newcastle delivers an effective programme of action which is based on sound evidence.

The Newcastle and North Tyneside Stop Smoking Service has a separate delivery plan for 2008/09.  During this year the service will focus on:

• Targeting marketing to harder to reach groups to address the recent drop in referrals of motivated quitters; and
• Reviewing the less well performing parts of the service (e.g., drop in centres).
• Improving stop smoking quit rates at 4 weeks, by renegotiating Service Level Agreements with General Practices and Pharmacies.

Between 2006/07 and 2007/2008 Neighbourhood Renewal funding was secured for a project focused on Newcastle's NRF areas.  This comprised two main strands:

• Intensive smoke free support to businesses in NR areas to support them to prepare for the smoke free legislation in July 2007; and
• Stop smoking support from a Stop Smoking Advisor who used evidence based community development methods to encourage smokers, at community level, to access stop smoking services.

A Health Gain Schedule (HGS) has been drawn up between  Public Health and the PCT's provider unit,describing measurable ways in which appropriate front line health care professionals can help deliver the '4 week smoking quitter'. and other health improvement targets.  The effectiveness of the HGS will need to be monitored and reviewed at agreed intervals (annual?)

Resources and investment

Newcastle makes the following financial contributions to tobacco control:

• £86k to the FRESH Smoke Free North East Office;
• £230k core funding to local NHS Stop Smoking Services;
• An additional £144k for other stop smoking or tobacco control activity, for example from Choosing Health allocations.

Between 2006/07 and 2007/08 Newcastle through their local authority partners managed to secure time-limited Neighbourhood Renewal Fund grants to support tobacco control activity.  In addition, there is investment in staff time for tobacco control (the costs of which are not captured here).

Partnership arrangements

Smokefree Newcastle is a multi-disciplinary, cross agency alliance run in partnership between the PCT and Newcastle City Council.  The alliance is accountable to the Well-being and Health Partnership of the local strategic partnership.  Tobacco Control is an integral part of:

• The city's local area agreement, with clear links to programmes aimed at reducing inequalities in all age all cause and cardiovascular disease mortality; and
• The Newcastle Health Improvement Strategy.

Barriers and risks

In the section below, barriers and risks are reported for general tobacco control activity and for the NHS Stop Smoking Service.

Tobacco Control

The biggest risk to on-going support and delivery within tobacco control is the view that, with the introduction of the Smokefree legislation on 1st July 2007, we have done everything there is to do.  The on-going support for the tobacco control agenda is evident within the Newcastle Health Strategy and the Local Area Agreement.

Newcastle PCT makes a financial contribution to FRESH Smoke Free North East, but there needs to be a robust service level agreement that ensures this provides good value for money.

Newcastle does not have an identified budget to support the work of a tobacco alliance.  Small grants are available from FRESH or other sources for particular projects; in-kind resources are associated with staff working on the tobacco control agenda.

The current consultation on a new national strategy for Tobacco Control and the recent publication of the ten high impact changes will be taken as an opportunity to review local plans for tobacco control activity.

Stop Smoking Services

The recent Department of Health guidance to NHS Stop Smoking Services recommends that primary care staff should not be paid for stop smoking activity or for the return of data monitoring forms to the stop smoking service, unless the work is being carried out outside normal working hours or by 'bank staff'.  Newcastle PCT is supporting payments to GPs for returning data and is not currently planning to terminate them.  Nevertheless, the service is reporting a reduction in activity through primary care and will be working with both practices and commissioners to address this issue in the coming year.

National policy emphasises the need to target routine and manual workers rather than focusing on area based approaches to tackling inequalities.  This particular focus may be in conflict with local programmes, such as neighbourhood renewal.

Recent NICE guidance in relation to smoking cessation makes clear that all drug therapy treatments including Zyban should be offered as a first level treatment to clients. Currently the PCT offers Zyban only as a second line treatment.

The availability of cheap illicit and counterfeit cigarettes is seriously undermining efforts to reduce smoking prevalance particularly among disadvantaged communities. Fresh is currently consulting on a North of England Action Plan on this subject. It will be essential that the PCT and local tobacco alliance implements the plan locally.

What are the key inequalities?

• The number of people accessing stop smoking services living in disadvantaged areas of the city needs to be increased in order to impact on reducing health inequalities.
• The DH target group for stop smoking services is routine and manual workers where smoking rates remain high and targets for 2010 may not be met.
• Smoking prevalence in pregnancy is higher in the more deprived areas of Newcastle.
• The use of cheap and illicit tobacco by residents living in disadvantaged circumstances is high. This could potentially undermine the tobacco control work undertaken and increase health inequalities further.

What are the key gaps in knowledge / services?

• There are gaps in our knowledge and understanding of why smoking prevalence is higher in deprived communities. Though one in 7 smokers wants to quit, the success rate of quitting at 4 weeks in  the more deprived areas tend to be lower than in the more affluent areas.
• There are gaps in our understanding and information in relation to  smokers using cheap and illicit tobacco and about what would help them to quit. This information could help to inform a social marketing approach to tackle the issue. Fresh is has initiated some work on this.
• It is not clear how routine and manual workers can be most effectively targeted to quit. Smoking is a social norm for a number of communities in Newcastle so interventions need to segment target groups to ensure that messages are most effective.
• Engagement with services involving young people (excluding schools) such as the youth sector needs to be increased to ensure that education/prevention/advocacy programmes better meet the needs of young people and the next generation of teenagers remains smoke free. Key opinion formers in this setting need to be targeted to increase the profile of tobacco control with them.

What are the risks of not delivering our targets?

• Smoking prevalence will not show a significant decline in Newcastle.  As smoking is the single most important preventable cause of ill health and early deaths, this is likely to increase the health inequality gap between Newcastle and England as a whole. In addition, as smoking prevalence is known to be higher among lower socio economic groups health inequalities within Newcastle will increase.
• Young people may continue to take up smoking if the cultural norm in Newcastle does not shift towards 'not smoking'

Is what we are doing working?

• Compliance with smoke free legislation in Newcastle has been above the national average of over 99% both for signage and management response to prevent smoking in a smoke free area.
• The recent fall in smoking prevalence among the whole population in the UK would suggest that the stranded approach to tobacco control, which has clear measures in place at a local, regional and national level is effective. Indeed international evidence supports the approach being taken. The prevalence rate in the NE has fallen faster than in any other region.
• However, with regard to achieving the set LAA / Vital signs target, the number of people successfully quitting at 4 weeks via NHS Stop Smoking Services is showing a gradual decline.  The exact reasons for this is not well understood, but hypotheses include that some motivated smokers may be stopping on their own, without support from the services, that they may be using NRT which is now readily available in supermarkets and other outlets, that the current smokers are the more entrenched smokers who may not want to stop or who find it harder to give up. More research is necessary to get a picture

In relation to the dropping rates.

The PCT needs to monitor smoking prevalence effectively, particularly aiming to increase QOF data returns on smoking to a level of at least 70% in order to ensure the data are accurate as possible. Whilst data on 4 week quitters is used as a proxy for smoking prevalence, this indicator only captures a very specific part of the tobacco control programme; in addition research suggests that only around 10-15% of those who stop smoking at 4 weeks remain non-smokers at 52 weeks.

What is coming on the horizon?

• A public consultation by the Department of Health on a comprehensive 25 year strategy for tobacco control was completed in September. The proposed strategy set out a wide range of measures to effectively tackle tobacco, including new measures on harm reduction and legislation relating to reduce the marketing of tobacco products to young people. The new tobacco control strategy is awaited.
• Smoke Free Newcastle has a clear action plan for delivery in place for 2008-9 which uses the 8 strand approach to tobacco control shown to be effective. In 2009 once the National Tobacco strategy is in place a new regional tobacco strategy will be produced by Fresh from which an action plan for Smoke Free Newcastle will evolve. This is likely to cover a 3 year period 2009-2012.

What should we be doing next?

1. It is important that the PCT continues to invest in the Stop Smoking Service to ensure that stop smoking support is offered to those who have most to gain from stopping. This will impact on reducing health inequalities. Elements of the action plan that are likely to increase the number of smoking quitters should be strengthened in the short term. These include increasing access to stop smoking services particularly in the more deprived areas, through General Practices, Pharmacies and other key community venues.

2. Investment in the communication strategy for tobacco control, including the use of Social Marketing tools is essential to facilitate target groups of smokers (e.g. routine and manual workers; smokers from deprived areas) to stop smoking. Newcastle will be participating in the North of Tyne and regional communication strategies.

3. The funding of the regional office for tobacco control - Fresh, is important and must be continued. Fresh provides a comprehensive strategic direction for effective tobacco control at a regional and local level which is now being modelled elsewhere in England.

4. The PCT also needs to continue to support the community services directorate through the Health Improvement Team, to take a lead role in delivering the tobacco control agenda in Newcastle.