Smoking

Health and Social Behaviour: The Effects on Health of Smoking and Combating the Issue

Introduction

Smoking can range in amount of use – from daily smoking to non-daily to occasional use. In assessment of prevalence, all levels of use are included.

Tobacco use also includes the use of pipes, cigars, chewing tobacco and other smokefree tobacco products such as paan (Betel leaf combined with the areca nut, traditional in South and South East Asia), and snus (used frequently in Sweden).

Epidemiology

Smoking rates have been declining significantly in England since the 1960s.  Prevalence peaked in the 30s and has been declining since.  Scotland has higher rates than England.

More males smoke than females, except for in teenagers, where females have a higher prevalence of smoking.  There is a higher prevalence of smoking in lower socio-economic groups; social class V has the highest smoking rate.

Smoking is rare in Muslim communities, and among Chinese women.  There is a high proportion of smoking in some occupations e.g. publicans, soldiers.  There is a high prevalence in manual workers.

There is also a strong association with smoking and high alcohol intake.

Health Effects of Smoking

Smoking is known to be the principal avoidable cause of premature deaths in the UK. 106,000 deaths in the UK are caused by smoking every year (87,000 in England). Over 9 million adults in England still smoke.

The Department's tobacco control programme is split into six 'strands', which each contribute to the overall reduction in smoking. Since 1998 adult smoking rates in England have fallen from 28% to 22% in 2006. These are the lowest smoking rates in England on record.

There are many effects of smoking on health, and these include:

Coronary heart disease

Smokers under the age of 40 have five times greater risk of heart attack than non-smokers.  Smoking causes about 17% of deaths from heart disease.

Cerebrovascular disease

Smoking doubles the risk of stroke

Chronic Obstructive Pulmonary Disease (COPD)

COPD affects the lungs and respiratory system. Amongst other symptoms, breathing normally is made extremely difficult.  A person with COPD will gradually experience a decline in the function of their lungs.  Smoking is the main cause of
COPD.  Between 80 - 90% of all deaths from COPD are due to smoking.

Cancer

About one third of cancer deaths can be attributable to smoking. People who smoke between 1 to 14 cigarettes a day have eight times the risk of dying from lung cancer compared to non-smokers.  Lung cancer is particularly associated with
smoking, but also linked are cancers of oesophagus, larynx, bladder, kidney, pancreas, cervix and stomach. 

Emphysema

Emphysema is a severe lung disease.  Alveoli in the lungs become damaged due to tobacco smoke.

Psychological effects of addiction

Through addiction to nicotine, a person can develop a psychological, uncontrollable dependence on tobacco.  Stopping smoking would cause emotional and/or physical reactions.

Smoking in pregnancy and after birth

Smoking while pregnant causes increased risk of miscarriage, low birth weight, and inhibited child development.  Smoking by parents following the birth is linked to sudden infant death syndrome, and higher rates of infant respiratory illness.

Secondhand smoke

Secondhand smoke is a mixture of side stream smoke from the burning tip of a cigarette, and mainstream smoke exhaled by a smoker. There is evidence that secondhand smoke has negative health effects, particularly COPD and increased risk of lung
cancer.

Thirdhand smoke

There has been recent evidence that babies whose parents smoke are exposed to ‘third hand smoke’ by touching furniture and other objects in the home.  However there is no evidence yet of the health risk this might pose.

Levels of tobacco use are determined by cotinine levels in saliva.

Combating Smoking Using a Wide Range of Approaches (including health service interventions and broader cultural interventions)

Government policy and recommendations

The Department of Health published in 1998 the paper Smoking Kills, which highlighted the impact of smoking on the nation’s public health.

In 2004 the Department of Health White Paper Choosing Health: Making healthier choices easier emphasised the importance of tobacco control, and the huge impact smoking has on health and health inequalities.

The DH recently published a document entitled Excellence in Tobacco Control: 10 high impact changes to achieve tobacco control.  This document looks at local initiatives and implementation, to highlight what is working well and
encourage good practice.

From May to September 2008 the Department of Health carried out a consultation on the Future of Tobacco Control.  This aimed to start a debate around further measures to stop people smoking and preventing young people from starting.  The
document includes 4 main themes.  These are: protecting children and young people from smoking; further reducing smoking rates and health inequalities caused by smoking; helping smokers quit; helping those who can’t quit.  This
consultation is the first step in developing a new national tobacco control strategy.

Also important is the Framework Convention on Tobacco Control. The WHO FCTC is the world’s first global public health treaty.  The FCTC requires parties to adopt a range of measures designed to reduce the health and economic impacts of
tobacco. The Framework Convention Alliance (FCA) was founded in 1999 and is now made up of more than 350 organisations from more than 100 countries.

The Healthcare Commission document No Ifs No Buts summarises areas where tobacco control activity is working at a local level and areas where there should be improvements.

The National Institute for Health and Clinical Excellence (NICE) has published guidelines on smoking cessation services.

Interventions

The Department of Health’s tobacco control strategy covers 6 strands.  These are:

  • Reducing exposure to second hand smoke
  • Smoking cessation
  • Media and education campaigns
  • Reducing availability of tobacco products
  • Reducing tobacco advertising and legislation
  • Tobacco regulation

These can be implemented at a local as well as national level.  All tobacco control activity in the UK comes into one of these 6 areas of work.

National legislation:

Since July 2007, virtually all enclosed public places and workplaces in England became smokefree by law, including all pubs, clubs, membership clubs, cafes and restaurants.  This has the effect of denormalising smoking and helping create a
non-smoking culture, as well as preventing the health impacts of secondhand smoke.  This will have impacts on both a national and local level.

Increasing the price of cigarettes and tobacco is one method at policy level of decreasing tobacco use, and is a way of reducing the availability of tobacco products.  The UK has the most expensive cigarettes in the EU and among the most
expensive cigarettes in the world. This is, in large part, to deter people from smoking.  However, smuggling leads to the availability of cheap cigarettes and so helps to maintain high rates of smoking among disadvantaged groups.

The UK has a ban on tobacco advertising.  Evidence links a ban on tobacco advertising with a decrease in smoking levels. It is estimated that in the long term, the UK advertising ban will lead to a 2.5% decrease in smoking levels.

In addition, in the UK there are regulations on the labeling of packs.  Health warnings are printed on tobacco packs and these were introduced in 2003.  Misleading terms such as low-tar, mild and light are also prohibited from tobacco
packs. Picture warnings will start appearing on cigarette packs from the autumn of 2008, and on other tobacco products from the end of 2009. The UK is the first country in the EU to require picture warnings on all tobacco products.  Research
from Canada, where picture warnings have been required for several years, demonstrates that they are highly effective in encouraging people to quit smoking.

Ideas for further tobacco control developed in the recent Department of Health consultation include removing all branding and logos from packaging, having minimum pack size of 20, restricting access to vending machines, restricting display in
shops, and banning advertising of paraphernalia, e.g. papers.

Point-of-sales interventions take place at the point where tobacco could be sold and aim primarily to deter shopkeepers from making illegal sales.

Preventing uptake in young people:

In October 2007, the age of legal sale of tobacco products was increased from 16 to 18, with the aim of deterring young people from starting to smoke.  NICE have produced guidance on preventing the uptake of smoking by children and young
people.  This guidance focuses on mass-media and point-of-sales measures to prevent the uptake of smoking by children and young people under 18.

Campaigns and media:

Mass-media interventions use a range of methods to communicate a message at a local or national level. This can include television, radio and newspapers, and leaflets and booklets.

The NHS has had a recent smokefree advertising campaign which highlighted to parents who smoke that children with smoking parents are 3 times more likely to become smokers than those with parents who are non-smokers.

As routine and manual workers have a particularly high prevalence of smoking, which contributes to health inequalities, the Department of Health has a marketing strategy targeting smokers in these occupations.  Three overarching marketing
objectives have been defined by the Department of Health:

  • To trigger action
  • To make quitting easier
  • To reinforce motivation

All marketing communications activities will support one or more of these, and can be applied at a local and national level.  The Public Service Agreement (PSA) target relating to this group is to reduce prevalence to 26% or less by
2010.  This group is particularly hard to engage in stop-smoking services or to educate not to start smoking.

The ‘World No Tobacco Day’ is on the 31st May each year.  It highlights the widespread use of tobacco and its health effects and is a method of encouraging people to stop or not start smoking.  In England ‘No Smoking Day’
is on 12th March each year, and is an important time for campaigners and health promotion workers to encourage people not to smoke.

Local interventions:

The Healthcare Commission document No Ifs, No Buts, makes a number of recommendations for PCTs to implement on a local level to improve their tobacco control services.  Key to these recommendations is:

  • Ensuring data collection on people who use smoking cessation services and smoking outcomes is consistent.  This data should be in turn incorporated in the DH’s central return to develop measures of improvement
  • The Department of Health should ensure that the NICE guidance for PCTs is clear and effective, while PCTs should ensure that tobacco control services adhere to this guidance.
  • Tobacco control including smoking cessation services should be prioritised across the sector and with partners, including ensuring sufficient resources and capacity are available.

The NICE guidance on how to help employees stop smoking recommends a variety of approaches.  Employees comprise a large proportion of the population, therefore helping employees quit smoking could have a large impact on the prevalence of
smoking in the population.  Interventions recommended in the NICE guidelines include:

  • Brief interventions: including opportunistic advice, discussion, and encouragement by primary and community care professionals.
  • Individual behavioural counselling: face-to-face between a smoker and a counsellor.
  • Group behaviour therapy: scheduled meetings where people who smoke get information advice and encouragement and some form of behavioural intervention. 
  • Pharmacotherapies: including nicotine replacement therapy or bupropion prescribed by stop smoking advisors and healthcare professionals as an aid to help people quit smoking.
  • Self-help materials.
  • Telephone counselling or quit lines.

Pharmacotherapies are regularly prescribed through NHS stop-smoking services as a way of helping people quit smoking.

References

  • Department of Health Tobacco pages: http://www.dh.gov.uk/en/Publichealth Accessed August 2008
  • The Healthcare Commission.  No ifs, no buts: Improving services for tobacco control.  January 2007. http://www.healthcarecommission.org.uk
    Accessed August 2008
  • The National Institute of Health and Clinical Excellence.  Smoking Cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach
    communities.  February 2008.  http://www.nice.org.uk Accessed August 2008.
  • The National Institute of Health and Clinical Excellence.  Working health promotion: How to help employees to stop smoking.  April 2007. http://www.nice.org.uk
    Accessed august 2008.
  • The National Institute of Health and Clinical Excellence.  Preventing the uptake of smoking by children and young people.  July 2008.  http://www.nice.org.uk
    Accessed August 2008.
  • Action on Smoking and Health (ASH). Facts at a glance: Smoking statistics. August 2008. http://www.ash.org.uk Accessed August 2008
  • Action on Smoking and Health (ASH). Facts at a glance: Smoking and disease. November 2007  http://www.ash.org.uk Accessed August 2008.
  • The Framework Convention for Tobacco Control website: http://www.fctc.org Accessed August 2008.

© Sally Cartwright 2008