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Tobacco PSA
Delivery Plan Strategy
DRAFT
15/10/08
Version 2.8
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The challenge
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Current performance
Following the publication of Smoking Kills in 1998, government action has
reduced smoking prevalence from 26% in 1998 to 22% in 2006.
The Department of Health is on target to reach the Public Service Agreement
(PSA) objective of reducing adult smoking rates to 21% or less by 2010, but at
current trajectory the routine and manual PSA target will be missed. The focus
for the second half of PSA delivery should therefore be on achieving the routine
and manual group target.
Reduce smoking among manual workers from
32% (1998) to 26% by 2010
35 33 31 32 31 31
29
30 33
31 32 31 31
25 30 29 28
20
GHS - R&M
15
Trend - R&M
10
GHS - manual
5
Trend - manual
0
Target
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19
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Smoking related deaths and disease
Smoking remains the main cause of preventable morbidity and premature death,
accounting for 87,000 deaths a year in England alone.
A number equivalent to a city the size of Durham and more than the sum total of
the next six biggest causes of preventable death.
Causes of preventable deaths
100
Thousands
90
80
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10
0
Sm
Su
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s
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Scale of the PSA Challenge
With natural demographic changes, and existing policy levers, prevalence is
projected to fall to 28.2% by 2010. 319k additional RM quitters are required to
meet target.
This will
deliver all-
adult target
200k quitters from
existing policy
measures
519k RM smokers
need to quit by
2010
GAP
319k
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Routine & manual smokers in England
Routine and manual smokers represent the single biggest group of smokers –
approximately half of all smokers belong to the routine and manual group.
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Routine & manual smokers in North West
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Current delivery practice
Figures to be ALL SMOKERS
updated with
45% attempt to quit
latest data
23% use treatment 22% go ‘cold turkey’
15% buy NRT OTC 3% use prescription 5% use services
Quit for at
8% 8% 15% 4%
least 12mths
1.2% + 0.16% + 0.75% + 0.88%
= 2.99% Stop Smoking
40% 5% 25% 29%
Ratio of contribution of quitting methods to delivering the target
on current delivery
based DRAFT – RESTRICTED practice
Trajectory for delivery – key objectives
What will deliver the RM 2010 target? We need to both increase the no. of quit attempts
and the efficacy of those quit attempts to increase the rate of decline in smoking
prevalence between now and 2010. On average a smoker will need 12-14 quit attempts
before giving up for good. To hit the target we must reduce that number of quit attempts.
To reduce
All successful quitters – current delivery practice deaths &
disease caused
Increase no. by smoking
of quitters / Prescription
Clinic
5%
attempts 25%
Increase no. in
most effective
treatment
NRT OTC
40%
Cold Turkey Increase
30% availability /
Increase no. using
effectiveness treatment
of each
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Barriers to delivery
To increase quitting attempts and the incidence of successful quit
attempts we need to understand the barriers to achieving our
objectives and how they can be overcome
What’s the
How can we trajectory for
reduce the appeal delivery?
How do we & supply of
motivate RM tobacco How do we make
group? treatment more
ALL SMOKERS
ALL SMOKERS accessible?
How do we 45% attempt to quit
45% attempt to quit
improve entry into 23% use treatment
23% use treatment 22% go ‘cold turkey’
22% go ‘cold turkey’
the services? 15% buy NRT OTC
15% buy NRT OTC 2% use prescription
2% use prescription 5% use clinic
5% use clinic
Quit for at
Quit for at 8% 8% 15% 4%
least 12mths
least 12mths
1.2%
1.2% + 0.16%
0.16% + 0.75%
0.75% + 0.88%
0.88%
How can treatment
effectiveness be = 2.99% Stop Smoking
2.99% Stop Smoking
improved? 40%
40% 5%
5% 25%
25% 29%
29%
Ratio of contribution of quitting methods to delivering the target
Ratio of contribution of quitting methods to delivering the target
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based on current delivery practice
based on current delivery practice
Key issues & barriers to
delivery
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Targeting the group: the smoking / quitting cycle
The majority of quit attempts end About 9 in 10 adult smokers start
in failure. Factors to be as children or older teenagers.
considered to improve this are: The motivation for taking-up
smoking are down to a wide range
Demographics – who is most
of complex social, cultural and
likely to quit?
economic factors.
No. of quit attempts – what can
What will denormalise smoking
be done to increase
and minimise the motivations
motivation?
Relapse
Take-up for taking the habit up?
Quality of quit attempts – how smoking
can this be improved?
Only 5% of smokers make a quit Over 7 out of 10 smokers say they
attempt with specialist NHS support. want to give up, but only 45% will
Quitting Decision
About half of all quitters use other self- attempt to quit actually make a quit attempt. The
bought support –evidence suggests motivations around making a quit
that often NRT is used incorrectly. The attempt differ from person to
remainder quit cold turkey – without person, but health is cited as the
support. Only a small faction of most important reason for quitting.
quitters succeed in quitting. On What triggers a quit attempt
average smokers make 8 to 10 quit and what national and local
attempts before quitting for good. interventions will influence the
How can access to the most RM group?
effective treatment and the
effectiveness of all treatments be DRAFT – RESTRICTED
improved?
Health inequalities
Smoking is the primary reason for the gap in health expectancy between the rich
and the poor. Successful quit attempts are correlated with income.
Environmental factors within lower income groups, such as community mores
and prevailing culture, further compound the difficulties in making quit attempts
by reinforcing the negative influences on quit attempts.
Success rate in quitting by socio-economic class (smoking toolkit)
Success rate
E
D
Quit in past year C2
C1
AB
Tried to quit in
past year
0 20 40 60 80 100
Percent
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All-age all-cause mortality
One particular area of priority for the Government is to reduce the proportion of women who
smoke during pregnancy. 19% of women smoke when pregnant. Smoking remains one of the
few modifiable risk factors in pregnancy, and it can cause a range of serious health problems.
Smoking during pregnancy is estimated to contribute to c40% of all infant deaths. Babies of
smoking mothers are, on average, 200g lighter at birth – birth weight is a key indicator of a
newborn’s overall health. More than a quarter of the risk of sudden unexpected death in infancy
is attributable to smoking.
Pregnant women who smoke are most likely to be in the key high smoking prevalence groups –
smoking rates in pregnancy are almost double the national average among women in the
routine and manual group. Success in this area would have an added benefit of contributing to
a reduction in the number of families who smoke and the number of children who smoke.
It has also been reported abroad that the introduction of Smokefree has led to a decrease in
heart attack rates – evidence for England is not yet available on this.
35
30
25
Percentage of mothers who smoked
throughout pregnancy in England, by socio- 20
Percentage
economic group (2005)
15
10
5
0
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professional
Intermediate
occupations
Routine and manual Never worked Unclassified All mothers
NS-SEC
Going smokefree ~ Older People
20 Minutes
Your blood pressure & pulse return to normal. Circulation improves –
especially in your hands and feet.
8 Hours
Your blood oxygen levels return to normal and your chance of having
a heart attack falls
24 Hours
Carbon monoxide leaves your body. Your lungs start to clear out
mucus and debris.
2-12 Weeks
Circulation is now improved throughout your body. It’s easier to
exercise.
3-9 Months
Lung efficiency is up by 5-10%. Breathing problems are gone.
5 Years
You have half the chance of getting a heart attack than a smoker.
Studies have shown that the incidence of heart attack admissions significantly
control initiative such as Smokefree.
falls following a major tobacco DRAFT – RESTRICTED
Denormalising smoking – young people
The tobacco industry must recruit around 200k additional smokers each year to maintain
customer base within a difficult market to replace smokers who die or give-up. Smoking
prevalence in children below 16 has been reduced from 13% in 1996 to 9% in 2007.
However, it has remained at 9% since 2003. Children who live in smoking families are 3
times more likely to smoke. Around 9 out of 10 adult smokers began as older children or
teenagers and those who start smoking young are three times more likely to die of a
smoking related disease. Girls are more likely to smoke than boys and smokers in routine
and manual groups are more likely to have started smoking before 16 than other socio-
economic classes.
Smoking among children aged 11-15, by number of smokers they live with, England 2006*
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Supply of tobacco – illicit tobacco
Tobacco smuggling is not a victimless crime: it harms the health of our
communities, it damages business, fuels criminality and costs the taxpayer as
much as £3bn a year. Illicit tobacco has a major impact on health inequalities:
those on lower incomes are fours times as likely to smoke cheaper illicit tobacco
as those on the highest incomes.
Recent evidence from Smoking Toolkit: Lower social grades more likely to buy
from illicit source, higher social grades more likely to bring back from abroad
Social classes & illicit tobacco consumed (Smoking Toolkit)
30 Figures to be
25 updated with
22
latest data
20
15
15
%
12
10
7
5
0
AB to C1 DRAFT – RESTRICTED C2 to E
Illicit sources Abroad
Service delivery ~ improving access & treatment effectiveness
To deliver the RM target we need to improve access to the stop smoking clinics by
removing barriers to entry including treatment effectiveness and understanding the group
and targeting marketing appropriately. Treatment services need to be as accessible as
possible to less advantaged smokers, as a way of limiting the burden that high-cost
tobacco imposes on those with limited disposable incomes.
Currently, some 5% of all smokers report that they use the Stop Smoking Service each
year. Working with large employers is a good way of bringing appropriate treatment
services to RM employees and denormalise smoking at work.
Barriers to entry?
Lack of referrals / cooperation across agencies
RM attitudes & perception of service
Settings & opening hours
Method of treatment
Awareness of service
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Performance management & programme assurance
• ‘4-week quitters’ is a good proxy for NHS service delivery but a poor proxy for
reductions in smoking prevalence since quitters through the NHS only
contribute 25% of all quitters annually
• ‘4-week quitters’ as a metric puts the onus on NHS delivery in the LAA
process
• GHS data is not detailed enough to provide local smoking prevalence
segmented by socio-economic class – ONS will publish the Integrated
Household Data on local smoking prevalence in Dec 2010 (too late to
influence planning)
• Synthetic estimates of local smoking prevalence aren’t robust enough for
planning purposes
• It’s possible to assure delivery at national level, but difficult at regional and
local level
• Focus on ‘4-week quitters’ does ensure NHS investment
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Treatment effectiveness – improving NRT products & their use
Smoking is the most inefficient method of delivering nicotine – it is the tar and CO which
kills, not nicotine. By improving treatment effectiveness and providing safer alternatives to
smoking, we can reduce smoking prevalence within Routine and Manual groups and
reduce health inequalities.
Working with the pharma industry we need to ensure users buying NRT OTC are
provided with the right information and product to optimise the success of RM quit
attempts. Increased awareness of the available support will be fostered through
marketing campaigns and health messages. The pharma industry will look to the govt.
regulations to signal go ahead to develop more effective products.
Social gradient and nicotine dependence (Smoking Toolkit)
The Fagerstrom Test for
Nicotine Dependence
(FTNDF), is a validated E
measure of nicotine D
dependence. FTND C2
FTND scores are 70% C1
higher in the lowest social AB
grade (E) than social
grades A/B (ref. Smoking
Toolkit).
0 1 2 3 4 5 6 7
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Mean score
Key messages
“At current trajectory, we will hit the all-adult target but not the RM target – our efforts for the next
period must focus on RM smoking prevalence”
“Smoking is the single biggest preventable cause of health inequalities”
“Smoking in pregnancy is responsible for 40% of all infant deaths”
“Smokers generally make one quit attempt a year; we need to influence smokers at that point and
make the most of their attempt”
“To hit the target we need to increase number of quit attempts and the quality of those quit attempts”
“To do this, we need to motivate the RM group to quit and increase the effectiveness of all treatments
through population-level initiatives supported by local and regional action”
“Focusing on NHS delivery alone will not deliver the target”
“Population-level initiatives are instrumental in achieving the target”
“Action on affordability is the most effective means of reducing prevalence: the availability of cheap
illicit tobacco undermines price levers”
“A big risk to delivery is the lack of a local measure of prevalence; the focus on 4-week quitters
emphasises NHS service delivery at the expense of the other local tobacco control actions needed”
“Significant central funding for marketing is required to assure delivery of the target”
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