Transcript Tobacco Control HWBB presentation 20110930

A Fresh Analysis of Tobacco Control in Norfolk
Dr Jenny Harries, Joint Director of Public Health
Creative Change for
Tobacco Control
Why?
• HWBB last met on 24th May 2011
• Defer structures
• Learn by doing – live health issue
• Tobacco Control:
• Key public health issue
• No organisational boundaries
• Needs whole systems approach
• Test out what the HWB would do
• Form follows function
What?
• Public health project group
• Collate and analyse routine data,
existing reports and other intelligence
• Involve wide range of agencies &
organisations
• Used Tobacco Control Framework
• Tobacco Control Needs Assessment
Where?
• Shortly on Norfolk Insight
at www.norfolkinsight.org.uk
• Living document: updated not fixed
• Read and react
• Today’s focus:
1. What would the HWBB do?
2. How would it use reports to
change outcomes?
3. How should we change reports
to help the HWBB?
Tobacco Control
in Norfolk
A Report for the
Shadow Health and
Wellbeing Board
September 2011
Shortly available on
Norfolk Insight
www.norfolkinsight.
org.uk
Tobacco and ill health
“Smoking is the primary cause of preventable
morbidity and premature death, accounting for
81,400 deaths in England in 2009....
..deaths from smoking are more numerous than
the next six most common causes of preventable
death combined”
Andrew Lansley
Health Inequalities
Tobacco control is central to
any strategy to tackle health
inequalities as smoking
accounts for approximately
half of the difference in life
expectancy between the lowest
and highest income groups.
Smoking-related death rates
are two to three times higher in
low-income groups than in
1. Prevalence
wealthier social groups.
2. Young people
[Fair Society, Health Lives Marmot Review, 2010]
3. Pregnancy
What is a Needs Assessment?
[After Stevens & Raftery]
Three key areas: Epidemiological, corporate
and comparative
Information: sources & use
What is Tobacco Control?
Effective
Communications
for Tobacco
Control
Stopping the
Promotion of
Tobacco
Making Tobacco
Less Affordable
Multi-Agency
Partnership
Working
Reducing
Exposure to
Secondhand
Smoke
Helping
Tobacco Users
to Quit
Effective
Regulation of
Tobacco
Products
Tobacco control is an
evidence-based approach
to tackling the harm
caused by tobacco. It
includes strategies that
reduce the demand for
and supply of tobacco in
communities.
Tobacco Control includes
Enforcing the minimum price of tobacco
• Ensuring non-price measures, such as
advertising restrictions, smokefree laws
and health warnings are in place
• Providing information and advocacy
• Providing effective stop smoking
programmes
• Restricting underage sales
• Controlling the illicit trade.
•
Do we know the
size of the
problem?
Smoking prevalence in Norfolk
35
% Prevalence of cigarette smoking
30
25
Integrated Household Survey
18+ (April 2009 - March 2010)
20
30.2
15
26.6
25.5
25.7
23.6
22.9
22.0
10
Modelled smoking estimate
Health Survey for England 16+,
2006-08
20.0
19.7
20.2
18.9
22.7
20.4
20.9
19.9
22.2
21.2
17.1
15.3
13.7
5
0
Breckland Broadland
Great
Yarmouth
King's
Lynn and
West
Norfolk
North
Norfolk
Norwich
South
Norfolk
Norfolk
East of
England
Area
Source: Integrated Household Survey, April 2009 to March 2010; and Health Survey for England, 2006-08
England
Stop Smoking Service use based on uptake of Stop Smoking Services in 2010/11
Estimated smoking prevalence and
smoking cessation service uptake.
Estimated smoking prevalence % aged 16+ 2006-08
Prevalence of smoking among persons aged 18 years and
Prevalence of smoking among persons aged 18 years and over18+ - routine & manual
over - routine & manual groups,
April
2009 - March 2010
April 2009 - March
2010
45
40
Prevalence (%) of smoking
35
30
25
20
33.9
15
31.6
29.4
26.1
28.5
29.7
Norfolk
EoE
England
23.8
22.7
10
27.4
18.2
5
0
Breckland
Broadland
Great
Yarmouth
Source: Integrated Household Lifestyle Survey
King's Lynn
and West
Norfolk
North Norfolk
Area
Norwich
South Norfolk
Ethnic minorities: smoking
prevalence
Smoking prevalence by ethnic minority group
45
40
40
35
Prevalence (%)
25
25
30
29
30
26
24
24
21
23
21
20
Women
20
15
10
10
8
5
5
5
2
0
Black
Caribbean
Black African
Men
Indian
Pakistani
Bangladeshi
Ethnic minority
Chinese
Irish
General
population
Estimated number of smokers among men
aged 16+ by BME community and district
Black or
Black
British:
Black
Caribbean
Black or
Black
British:
Black
African
Asian or
Asian
British:
Pakistani
Asian or
Asian
British:
Bangla
-deshi
Chinese
or Other
Ethnic
Group:
Chinese
Asian or
Asian
British:
Indian
White:
Irish
All
Groups
Breckland
56
43
75
35
23
206
117
12,552
Broadland
23
33
61
32
18
70
77
11,826
Great
Yarmouth
KLWN
33
39
59
47
133
174
59
49
20
21
21
87
80
115
9,183
13,613
N Norfolk
27
30
37
69
20
22
80
9,874
Norwich
56
94
338
235
61
163
125
13,830
S Norfolk
Norfolk
24
257
35
341
59
878
31
511
18
180
38
606
78
672
11,234
82,113
16+ population
Mental health & smoking
Significantly higher smoking rates than in the
general population
Depression – more likely to smoke, more
difficulty giving up
Psychotic disorders reported 70%
Schizophrenia – as high as 80%
Mental health disease prevalence UK norm
No local health data available for this cohort
– in primary care.
Key points
Prevalence of smoking and smoking attributable
mortality rates are higher in King’s Lynn & West
Norfolk, Norwich, Great Yarmouth and Breckland
districts.
Smoking at the time of delivery is higher in NHS Great
Yarmouth & Waveney.
Among ethnic minority groups, prevalence of smoking is
higher in Asian and Black African men compared with
other groups.
Smokers who begin at a young age are less likely to
give up than those who start smoking later.
Multi-agency
partnership working
•local
Who is in?
•local councils
•Local businesses
•schools and colleges
•children’s and youth groups
•local councillors and MPs
•NHS services, including coronary care, respiratory &
mental health services
•Trading Standards Officers
•Environmental Health Practitioners
•HM Revenue & Customs
•police
•fire services; and civil society groups with an
interest in tobacco control
• & public health
Key points
• Norfolk Tobacco Control Alliance is the central hub
for tobacco control work in the county - support for and
engagement in Norfolk Tobacco Control Alliance needs to
be prioritised to ensure that effective multi-agency
interventions are put in place.
• The planned, regional campaign to reduce the supply
of illicit tobacco provides a number of opportunities to
improve the health and wellbeing of people in Norfolk,
particularly some of the more vulnerable groups, whilst
also crime and disorder.
•The work of the Norfolk Tobacco Control Alliance is
informed by data and intelligence from partner agencies
and local communities. Information flows need to be
expanded.
Stopping the
promotion
of tobacco
Key points
Community intelligence plays an important role in determining
the levels of compliance with the regulations around tobacco
promotion.
Multi-agency compliance checks on premises and/or business
support packs with advice and information from a range of
agencies can be effective. This can include: Trading Standards;
HMRC; Work and Pensions; Fire and Rescue; and Norfolk
Constabulary.
Whilst the legislation and regulations are determined by central
government, there is a role for local input into the development
of national policy on Tobacco Control.
Helping tobacco
users to quit
RAF, 128
Prisons, 435
Unknown, 139
GP Surgeries
Pharmacy
Hospitals, 977
Community & Resource Centres
Hospitals
Community &
Resource Centres,
553
Prisons
RAF
Unknown
Pharmacy, 978
GP Surgeries ,
6028
Norfolk
Children's Centres,
18
Pharmacy, 16
Pathology, 61
Community &
Resource Centres,
500
GP Surgeries
Community & Resource Centres
Pathology
Children's Centres
Pharmacy
GP Surgeries, 1276
Stop Smoking Service
uptake by location for
Norwich (above)
and
Great Yarmouth (below)
2010/11
Total number of ‘Routine & Manual’
occupations using Stop Smoking
Services 2010/11
Smoking in pregnancy
When a pregnant mother smokes, the presence
of carbon monoxide means her baby’s blood
also contains less oxygen than normal.
This can cause the foetal heart rate to raise as
the baby struggles to get enough oxygen
Smoking at
time of
delivery
Norfolk
GYW
England
average
14%
25.2%
14%
Smoking
again after
giving up
(within 1
year)
At 6-8 weeks
all delivered
30%
?
19%
?
Percentage of users of Stop Smoking
Services 2010/11 who are pregnant women
Source: NHS Stop Smoking Services 2010/11
Status of Stop Smoking Service users
in Norfolk 2010/11
District
Breckland
Broadland
Great Yarmouth
King's Lynn & West Norfolk
North Norfolk
Norwich
South Norfolk
Quit
(Proportion)
Failed Quit
(Proportion)
Lost to Followup
(Proportion)
1,158
(53%)
422
(19%)
608
(28%)
2,188
721
(59%)
270
(22%)
230
(19%)
1,221
1,031
(54%)
587
(31%)
300
(16%)
1,918
980
(50%)
520
(27%)
453
(23%)
1,953
594
(54%)
220
(20%)
294
(27%)
1,108
929
(50%)
487
(26%)
449
(24%)
1,865
520
(51%)
239
(23%)
266
(26%)
1,025
Total
Stop Smoking Service uptake and quit
rate by intervention 2010/11
NHS Norfolk
Intervention
Great Yarmouth
Uptake
Quitters
%
Uptake
Quitter
s
%
8,352 (87%)
4,308
51.6%
1,859
(97%)
999
53.7%
713 (7%)
408
57.2%
20 (1%)
Couple / family
282 (2.9%)
159
56.4%
33 (1.7%)
17
51.5%
Open (rolling)
group
182 (1.9%)
108
59.3%
1 (<1%)
1
100%
One-to-one
support
Closed group
Note: Table shows proportion of service users utilising intervention.
Source: NHS Stop Smoking Services 2010/11
60.0%
Workplace tobacco control
•Chief Executives to ‘champion’ the organisation
being a smokefree workplace.
•Ensure 100% compliance with smokefree law in
buildings and vehicles.
•Extend smokefree policy to site boundaries.
•Do not permit smoking during work time.
•Promote quit support via all organisational
communication channels e.g. notice boards, staff
newsletters, pay slips, electronic bulletin boards.
•Train a member of staff in brief intervention and
signposting to the Stop Smoking Service (Smokefree
Norfolk training is free).
•Invite Smokefree Norfolk to provide on-site support.
Workplace data
On site clinics at Bernard
Matthews, Homebase & Bennetts
Electrical:
Uptake 18 Quit 11
Jobcentre Plus, Norwich
Uptake 8
Quit 4
Key points
• The uptake of stop smoking services does
not seem to match the need for stop smoking
services.
• The need is high in King’s Lynn & West
Norfolk, Norwich, Breckland and Great
Yarmouth districts; uptake is poor in Norwich
and King’s Lynn & West Norfolk.
• All districts are achieving the regional quit
targets of 50% and above, however, between
19% and 28% of service users were lost to
follow-up.
•The number of pregnant women who access
the stop smoking service is higher in Great
Yarmouth compared with other districts.
Effective regulation
of tobacco products
Enforcement
• Norfolk Trading Standards undertakes intelligence-led
and programmed compliance checks on vendors of
tobacco products in the county.
• Majority relate to general compliance and
enforcement activity around age-restricted products,
such as alcohol, fireworks and knives under the ‘Minor
Sales, Major Consequences’ scheme.
• During 2010/11 Norfolk Trading Standards conducted
68 business education visits and 90 test purchase
visits. Twenty-five of the 90, or 27.8%, test
purchase visits resulted in illegal sales to
young volunteers.
Effective regulation of tobacco
products
Community intelligence plays an important role in
determining the levels of compliance with the regulations
around tobacco sales.
Multi-agency compliance checks on premises and/or
business support packs with advice and information from a
range of agencies can be effective. This can include:
Trading Standards; HMRC; Work and Pensions; Fire and
Rescue; Norfolk Constabulary.
At present, there is no legislation in place that prohibits the
proxy sale of tobacco products, unlike that for alcohol.
Reducing exposure
to second
hand
smoke
Key points
• As children do not choose exposure to secondhand
smoke, we have to protect them and reducing exposure
to secondhand smoke in children should become a
priority area.
• Increase the number of organisations that are
committed to establishing a smokefree policy on their
sites.
• Based on national evidence, there is a need for
exploring the implementation of smoke free cars (at
least cars carrying children to begin with) and smoke
free homes (the local authority could be an early adopter
Making tobacco
less affordable
Key points
Tackling the demand for illicit tobacco is, in part, an issue
of cultural change, raising awareness of the links with
organised crime and challenging social norms.
Illicit tobacco sales are strongly linked with the enticement
of new smokers, particularly children and young people.
Success in reducing the illicit tobacco trade in Norfolk will
help to reduce consumption, reduce organised crime in
local communities, reduce potential revenue loss to the
Treasury and support legitimate retailers who can then be
regulated.
%
There is growing interest in incentives
as motivators of behaviour change
Consumer survey of factors which would
lead consumers to change their behaviour
Incentives are increasingly being used by healthcare
stakeholders worldwide
Payors and health insurers
Being diagnosed with health condition
79
Rewards and incentives for
improving health
55
Close friend/family member
being diagnosed with health condition
46
Employers
Change in current financial situation
Change in family circumstances
Public health campaigns
41
33
Academia
22
SOURCE: PruHealth Vitality Index based on a survey of 3,005 UK respondents aged 18 and over in January 2009;
43
Ethnography was used to identify five segments of
smokers based on their beliefs and motivations
Segment
characteristics
Depressed
victims of life
Hedonists
Default smoker
Aspiration
Stubborn deniers
▪
Smoking is the
least of their
problems
Need it to cope
with the day
Their only treat,
comforting
Doubtful about
being able to quit
▪
See smoking as an
expression of
choice and
freedom
Smoking is
pleasure oriented smoking often
related to positive
me-time
▪
Have smoked for
a very long time
Attempted and
failed to quit and
have low
confidence
Strong tendency
to relapse
triggered by
boredom and
stress
▪
Smoking initiated
by a need to
belong to peer
group
Represents a rite
of passage associated with
growing up and
independence
▪
Incapable of
responding to
information on
smoking in
isolation
▪
Smoking is an
important part of
their identity
▪
Low confidence
in their ability
given past failures
▪
Only concerned of
short term effects
and perceive
smoking as cool
▪
▪
▪
▪
Barriers to
intervention
effectiveness
▪
44
SOURCE: McKinsey & Co.
▪
▪
▪
▪
▪
▪
Committed not
to quit
Shut out any
information that
suggests that
smoking is
harmful
Frequently use
denial and
rationalization
to justify their
smoking
Use denial and
rationalization
when given
information
The segments differ significantly in
their readiness to change
High
Relatively
easier to
influence
Intention to change
Default smokers
Aspirationals
Victims of life
Hedonists
Stubborn deniers
Relatively
more
difficult to
influence
Low
Rational information
barrier
Deeper emotional
barriers
Barriers to change
45
Addictive/compulsive
behaviour
Provider staff research identified distinct attitudin
segments which could be influenced by
Use of hard-wiring
different interventions
Relatively
interventions
High
easier to
influence
Ease of change
1 Throughput-focused
GPs, Pharmacists
2 Impact sceptics
Acute nurses, Midwives,
GPs
6 Needing coaching
confidence
Pharmacy staff Midwives,
Physios
4 Tried and discouraged
Acute nurses, Midwives,
GPs, Consultants
3 Fixers
Acute staff, GPs Physios
4 Embarrassed by own
health status
Relatively
more
difficult to
influence
5 Alienated
from patients
Low
Rational
Common enablers of change
▪ Mandate
▪ Improve access to knowledge
▪ Remove practical obstacles
46
Emotional
Psychological
Barriers to change
Use of soft-wiring
interventions
Helping providers better support patients
with smoking cessation
Approach
Analyse data and interview staff to
understand why current referral and
conversion rates for stop smoking
service are low
Conduct ethnographic research to
segment smokers based on
motivations and barriers to change
Health
Potential impact – increase in smoking quitters per year
+ 102%
390
125
328
1.098
278
2.221
Use insights to develop high-impact
capability-building programme for
front-line staff
Support efforts through contracting,
performance management and
communications
Today
4 weeks
quitters
GPs
1 Includes midwifes, staff on in-patient wards and self referrals to local stop smoking service
47
SOURCE: McKinsey & Co.
Pharmacies
Increase Volume
of interventions
Hospitals1
Increase
Quality of
Interven
-tions
Potential
4 weeks
quitters
The programme is being supported by a
communications campaign
48
SOURCE: McKinsey; Bell Pottinger Group
No single organisation currently provides a broadILLUSTRATIVE
and
complex range of services – smoking cessation example
Potential focus
patient segments
Proposed initiative
1▪
Pharmacy support
▪
All segments
Execution
Identify and contract with best in
class providers to support PCTs
Boots/other pharmacies
Pharmaceutical firms
2▪
GP incentive
▪
All – esp. high-risk patients
3▪
Employer campaign
▪
Employees in top 50 local
organisations
Pharmaceutical companies
High risk/all patients
Broadsystems/Telemarketing firm
4▪
5▪
Telemarketing
Acute trusts campaign
▪
▪
PBC clusters and PCT (x9)
Boots/ other pharmacies
Staff, patients families and friends
Acute trust
PCT and acute
Trust
Cardio Wellness/Roy Castle
6▪
PR campaign
▪
All segments
PR firm
7▪
Hard-to-reach
populations
▪
▪
Mental health patients
Prisoners reached through social
marketing/ neighbourhood
approach
Cardio Wellness/Roy Castle
Cardio
Wellness
PBC clusters and
PCTs (x9)
Cardio Wellness/ Roy Castle
Pharmaceutical companies
8▪
Strategy/ Soc.
marketing plan
49
SOURCE: McKinsey & Co.
▪
All segments
SHA and PCTs
The Economics of tobacco in Norfolk
Fire risk – data example
Last 5 years in Norfolk:
• 24 tobacco related fire deaths, primary fires and dwelling
fires
• 11 of these caused by smoking materials
• 2.2 deaths per year smoking related
• 7,768 primary fires with 234 caused by smoking materials
(3%)
•Year on year increase in percentage of primary fires
caused by smoking materials (2.5% - 4%)
•2308 dwelling fires – 128 of these casued by smoking
materials (5.5%)
•485 hours professional attendance
The cost of tobacco at District level
District
Estimated
Estimated
Estimated
Total
cost of lost
cost of lost
Total
output
cost to productivity
productivity
from
Smoking lost from
the NHS
from
smokingCosts
early
of
smoking
deaths
smoking related sick
breaks
days
Estimated cost
of passive
smoking (from Cost of
Cost of
lost
Smoking cleaning
productivity
related smoking
due to early
fires in material
death, not
homes
litter
including NHS
costs and
absenteeism)
£ millions
Breckland
Broadland
Great
Yarmouth
King’s Lynn
& West
Norfolk
North
Norfolk
Norwich
South
Norfolk
Norfolk
41
25.1
12.6
7.7
8.9
5.4
8.3
5.1
7.7
4.7
2.1
1.3
1.6
0.8
1
0.6
31.5
9.6
6.8
6.3
5.9
1.6
1.2
0.8
32.8
10
7.1
6.6
6.1
1.7
1.2
0.8
22.6
41.8
6.9
12.8
4.9
9
4.6
8.4
4.2
7.8
1.2
2.2
0.9
1.6
0.6
1.1
25.7
220.5
7.9
67.5
5.6
47.7
5.2
44.5
4.8
41.2
1.3
11.4
0
7.3
0.7
5.6
The deficit from tobacco at District level
District
Smokers spend
on Tobacco
Products
Subsequent
Contribution to
the Exchequer
Annual Funding
Shortfall in this
District
£ millions
Breckland
47.7
36.4
4.7
Broadland
29.2
22.2
2.9
Great Yarmouth
36.6
27.9
3.6
Kings Lynn & West Norfolk
38.2
29.1
3.7
North Norfolk
26.3
20.1
2.6
Norwich
48.6
37
4.8
South Norfolk
29.9
22.8
2.9
Norfolk
256.5
195.5
25.2
Conclusions 1
• Most effective way to health inequalities
• Makes strong economic sense
• Cost = £226.2m pa
• Tax Revenue = £195.6m pa
• Prevalence highest in Great Yarmouth, Kings’
Lynn, Norwich, Thetford (deprivation link)
• High risk groups: Routine Manual; Pregnant
women; Children and young people; BME;
Prisoners; Mental Health Service users
Conclusions 2
• Age at which people start smoking is significant –
2800 children smoking this week
• Key role of community intelligence - Tobacco
Control Alliance
• Influence national policy
• Plain packaging
• Proxy sales
• Smoking in cars
• Expenditure on Tobacco Control est. £2.3m pa
(maj. NHS)
Conclusions 3
• NHS Stop Smoking Services busy but is it
targeted effectively?
• Key role of workplace health
• Illicit trade (smuggling/counterfeit) undermines
other tobacco control interventions
• Vendor regulatory compliance good
• Communications – speak with one voice.
Fundamental issues
emerging?
• Right balance between prevention and
stopping smoking?
• Targeting – areas, people and places?
• Children
• Targets leading interventions?
• Prevalence data not precise – implications
for other areas of public health?
• Role of social marketing?
• User/citizen views – we don’t have any
What we learned
• Lots of data – need analysis
• Everyone plays a role - not always easy to
see
• Risk of dis-engagement if people do not see
a clear role
• Asset analysis to balance needs
assessment
• Lots of activity in Norfolk
• Qualitative evidence valuable
• Approach takes time and resource.