public health and social care

Not the time to pass the buck on tackling smoking

Professor Eugene Milne, director of public health at Newcastle City Council and joint editor of the Journal of Public Health, on why we need a relationship between the NHS and public health provision that recognises the need for collaboration in tackling smoking.

Smoking is a blight on the lives of millions of people. It is the largest single cause of cancer and the main cause of the three top reasons for hospital admission in people under 75. It causes premature death and disease on an industrial scale and costs the NHS an estimated £2bn a year. It is a driver of poverty and drain on our economy, environment and social care system. Smoking disproportionately affects our poorest communities. Its harm is severe and wide-ranging. 

In 2003, with the worst smoking rates in the country, partners in the north east began looking at best evidence from around the world and by 2005 had combined to establish ‘Fresh’, a comprehensive tobacco control programme. In combination with NHS Stop Smoking Services (SSS), Fresh has exploited avenues of campaigning, research and sustained media profile to bring about a combination of individual, social and environmental change. 

And it has worked. Smoking rates have fallen from 29% in 2005 to just under 19% – the biggest fall in England, while smoking-related deaths have declined faster than the England average. As much as half of the huge fall in cardiovascular mortality of recent decades is a consequence of reduced smoking. The achievement of smoke-free workplace legislation – a big focus in the early years of Fresh – is already, correctly, seen as an historic public health landmark. 

Challenges of transferred responsibility 

Fast-forward to 2017, and we have a shift in structures and priorities. The transfer to local authorities of public health in England at a time of sweeping budget cuts has brought many challenges, including the lack of any mandate to sustain SSS or broader tobacco control measures despite their manifest effectiveness. 

The NHS has, meanwhile, been waking up to the centrality of smoking in escalating healthcare demands. The NHS Five Year Forward View acknowledges this, and financial incentives in the NHS are being extended to support action on quitting. In November 2016, the chief executive of Public Health England, Duncan Selbie, wrote to every NHS trust asking for support in achieving a truly smoke-free NHS – not simply one with a few rules about where you can or can’t smoke. 

Action in the NHS in primary and secondary care is gathering pace. This hinges upon professionals in hospitals and the community acting upon best evidence – as summarised in National Institute for Health and Care Excellence guidance. This approach was pioneered in Ottowa with striking impact – mortality rates halved in a year and hospital readmissions halved after just 30 days. Yet a major study by the British Thoracic Society last year found opportunities to reduce smoking in this country are being missed across the system. 

There are some real beacons of effective work. The London Clinical Senate has engaged clinicians in treating smoking and attracted nationwide attention. Part of that shift lies in understanding that smoking is not some casual lifestyle choice, but should be treated like other addictions or chronic, relapsing conditions. 

Here in the north east, every pregnant woman is now offered CO measurement when they first see a midwife. Those with high readings are referred to local SSS. Numbers still smoking at the time of delivery have fallen by nearly a third since 2010. A recent study by Newcastle University found this approach doubled quit rates and there have been calls for it to be rolled out nationwide. 

More recently, with appalling rates of smoking-related illness in people with mental health problems, our region’s two mental health trusts have also implemented smoke-free guidance, highlighting in the process how quitting can have a stronger effect on mood and anxiety disorders than antidepressants. 

The impact of such efforts could be enormous. Tens of thousands of smokers are seen in hospitals and clinics every day. Most would love to quit and have probably tried many times. But too often they leave hospital thinking ‘if it was a worry they’d have asked me to stop’ while doctors, nurses may just feel too busy or doubt they make a difference by raising the issue so briefly.  

In fact, the evidence – even with brief professional advice – is strong and could save the NHS millions. Interventions, including nicotine replacement and specific drugs, are among the most cost-effective of all treatments. It is essential that we help healthcare professionals to understand that while their advice will not always lead to a quit, it works often enough for the benefits to be much greater than many imagine. 

In all of this, we need a relationship between the NHS and public health provision that recognises the need for collaboration. Community-based cessation support needs to be maintained, but the NHS needs also to provide and prescribe support, with neither side passing the buck – or the bill. 

We need not to be diverted by arguments about mandation, cost or whose job it is to do this – smoking is simply too important not to be at the heart of wellbeing and health improvement. We have the tools, we know they work, and it is never too late to benefit from quitting smoking.