Nottingham Insight

Smoking and Tobacco Control (2015)

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Topic title Smoking and Tobacco Control (2015)
Topic owner Tobacco Control Strategic Group
Topic author(s) John Wilcox, Insight Specialist - Public Health
Topic quality reviewed June 2015
Topic endorsed by Tobacco Control Strategic Group
Topic approved by Tobacco Control Strategic Group
Current version July 2015
Replaces version Smoking (2012)
Linked JSNA topics
Insight Document ID 87638

Executive summary


Smoking causes 80,000 deaths in England each year, more than any other preventable cause. Nottingham has significantly higher rates of lung cancer, COPD and heart disease and other conditions compared to England due to smoking. It is estimated that each year smoking costs ‘society’ in Nottingham approximately £88m. This includes £3m per year to Nottingham City Council for additional social care costs and £11.0m to the NHS for treating smoking related illness.

Adult smoking prevalence has decreased in the city over the last decade. But according to the local Citizen’s Survey 27.4% smoked in 2014, which is the similar to the prevalence in England in the early 1990’s, and significantly higher than the current national prevalence of 18%. The represent a significant heath inequality which is indicative of the positive correlation between smoking prevalence and deprivation. There is also a positive correlation between smoking prevalence and deprivation within the city. Aspley, St Anns, Bulwell and Clifton wards have a smoking prevalence significantly higher than the city average and almost double the England average.

The high smoking rates during pregnancy in the city (18.5%), compared to England (12.5%), are of particular concern. Smoking in pregnancy increases risk of complications, which affect mothers and babies health, and increase risk of miscarriage and maternal death.  Children who grow up in families and communities with a high proportion of smokers are more likely to become smokers themselves. Over 80% of adult smokers took up the habit before the age of 20. Second-hand smoke continues to be a significant cause of morbidity and mortality in children and 22.3% of households in the city still allow smoking in the home. Smoking prevalence amongst young people in England has decreased significantly over the last decade with only 8% of 15 year olds smoking regularly. Model based estimates, local survey data, and the strong correlation between child and adult smoking, suggests that smoking prevalence amongst young people in Nottingham, particularly in the most deprived areas, is likely to be higher than the national average.

High rates of smoking are a significant cause of people with mental health problems dying younger than the general population. Smoking rates are reported to be as high as 80% amongst local mental health inpatients and 57% amongst patients with enduring serious mental illness smoke.  Research suggests smoking may contribute to stress and anxiety and stopping smoking is associated with an improvement in symptoms.  Other groups with particularly high rates of smoking include adults who are unemployed, adults with alcohol and drug misuse problems, adults from Eastern European Countries and adults from certain LGBT groups.

The majority of smokes use manufactured or hand rolled cigarettes of which a proportion is illicit or counterfeit. Illicit or counterfeit tobacco brings crime into our communities and makes smoking more affordable and accessible to everyone including children and young people, ensuring people start young and continue the habit into adulthood.  Shisha smoking is also an issue of concern due to the increase in businesses selling shisha tobacco to be smoked in bars, restaurants and at home. Local research and intelligence suggests this tends to be smoked more by young Asian people as a social activity, and awareness and knowledge of the health effects appears to be low.

Usage of e-cigarettes has increased significantly in recent years so that 22.9% of smokers and recent ex-smokers use e-cigarettes and 14.9% use them daily. Available evidence suggests that smoking e-cigarettes is likely to be less harmful than smoking tobacco, and that they may help people to cut down the amount they smoke and potentially help with quitting smoking. However they are currently unregulated products, of variable quality, with safety concerns and are not recommended as a smoking cessation aid by NICE.

Action to reduce smoking is coordinated through the city’s Tobacco Control Strategic Group which brings together partners from the NHS and city council to identify and oversees the city’s priorities for action which will be set out in a new strategy from September 2016. The chapter describes the current range of interventions to reduce smoking from across the partnership. It is estimated that through current tobacco control interventions there will be a return of £2.90, £6.95, £13.23 and £41.95 per smoker across all services over 2 years, 5 years, 10 years and Lifetime respectively, for each pound spent on the current programme.


Unmet needs and gaps

Smoking in pregnancy is significantly higher in the city than the England average and the gap is widening.

  • Other than the information provided through the Healthy Child Programme 0-5 (delivered by midwifery, health visiting and FNP), it appears that Early Help services and Early Years providers do not focus on reducing smoking in the home or exposure to second hand smoke amongst children.
  • Although various services seek to reduce smoking initiation amongst children and young people as part of their overall offer, this is not the primary aim of any one service and there is a lack of a coordinated approach across the City.
  • Over a 5th of households with children in the city allow smoking in the home increasing risk of exposure to secondhand smoke and initiation of smoking in children and young people.
  • Approximately 15% of schools in Nottingham City do not currently have Healthy Schools Status.  These schools may need additional support in encouraging and supporting to develop smoke-free policies and practices in line with the relevant Healthy Schools criteria on smoking. 
  • There is evidence that the prevalence of smoking amongst 16 & 17 year olds in the city is higher than the England average and model based estimated.The proportion of adults who smoke in the city is at a similar level to the England prevalence 20 years ago.
  • There continues to be significantly higher rates of smoking in routine and manual groups and in certain areas of the city particularly Aspley, St Anns, Bulwell and Clifton and there is a risk that this inequity gap may increase as the overall smoking prevalence decreased.
  • Smoking rates continue to be particularly high amongst routine and manual groups in the city.
  • Smoking prevalence in particularly high amongst adults from Eastern European countries who have settled in the UK including Nottingham City.
  • Smoking prevalence is significantly higher amongst adults with poor mental wellbeing and amongst adults with mental health problems.
  • Available national and local evidence suggests that smoking prevalence is higher amongst gay and lesbian adults than other groups.
  • Adults who drink at levels which harm their health and adults with substance misuse problems have very high rates of smoking.
  • Illicit and counterfeit tobacco is a significant source of the tobacco smoked in the city, making tobacco more readily available and contributing to crime in communities.
  • Smoking of Shisha, in dedicated bars, restaurants and delivered to the home is an issue as in the low awareness of health harms amongst users.

Recommendation for consideration by commissioners

Develop a multi-agency smoking in pregnancy pathway and enhance interventions to reduce smoking in pregnancy and support women who want to quit based on the latest evidence in the Healthy Child Programme Rapid Review.

  • Complete the Smoking in Pregnancy Assessment Tool (based on the CLeaR model) which aims to help areas to reduce smoking rates in pregnancy using a whole systems approach. The tool brings together existing resources to help support areas to identify areas where they could positively impact rates of smoking in pregnancy.
  • Develop interventions to reduce the exposure of children to second-hand smoke in different setting including in the home and outdoor areas and assist with reducing the number of children that start smoking as a result of living in a smoking home and family.
  • Ensure that providing information around smoking (including risks of exposure to second hand smoke amongst babies and children), brief intervention and referral to smoking cessation services is prioritised in the service specifications for all maternal and early years services.
  • Provide a coordinated approach to reducing smoking initiation and smoking prevalence amongst children and young people across agencies/services.
  • Ensure services who work with young people provide evidenced based support/brief intervention around smoking and particularly target  those at greatest risk including pupils who have truanted or been excluded from school and pupils who receive free school meals. 
  • Develop specific pathways and treatment models for people with different levels of mental health problems. 
  • Fully implement NICE guidance PH45 (Smoking cessation in secondary care: acute, maternity and mental health services).
  • Ensure services are impacting upon smoking rates in more deprived areas and amongst routine and manual groups.
  • Ensure pathways and appropriate service models exist for people with drug and alcohol problems who wish to stop smoking.
  • Allocate resources to tackling illicit and counterfeit tobacco.
  • Develop and promote smoke free environments, and support new tobacco control legislation with communication in the city.
  • Ensure establishment selling shisha are properly regulated and the risk to users.
  • Engage with other groups with high smoking prevalence including Eastern European communities, people of Mixed/dual heritage backgrounds, and gay and lesbian smokers.
  • Monitor the evidence and guidance relating to the use of e-cigarettes in harm reduction and smoking cessation.

Key contacts

Kate Thompson, Smokefree Coordinator, Environmental Health, Nottingham City Council.

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