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Improving Public Health: the role of local authorities in reducing smoking

Prof Jim McManus, Cpsychol, Csci, FFPH, FRSB,FRSPH, FCIEH, AFBPsS

Director of Public Health for HertfordshireMembership Secretary, ADPH UKJim.mcmanus@hertfordshire.gov.uk

July 12th, 2016, Public Policy Exchange

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What I intend to cover

1. Background2. Why Smoking remains an issue for local

authorities3. What can be done4. What good might look like5. The developing importance of vaping

(ecigarettes) and why we should welcome it

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Some context• Public Health role of Local Authorities – historic

and future• Significant Reductions in Finance• Mortality and Morbidity from Smoking still

alarmingly high• Cost to society remains• Smoking prevalence reducing unequally –

highest in poorer areas and people with mental health problems

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But Continued loss of healthy life

References:1. ASH Factsheet, Smoking Statistics: illness & death, October 2011 (http://ash.org.uk/files/documents/ASH_107.pdf) NB area represents value

Obesity: 34,100

Smoking: 81,400

Alcohol: 6,541

Suicide:5,377

Drug misuse: 1,738

HIV: 529

Traffic:2,502

Each year smoking causes the greatest number of preventable deaths

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Why is smoking a local authority issue?• Early and avoidable disability and disease• Early avoidable death• Smoking prevalence uneven• Clustering of lifestyle risks• Overlay of inequalities• Burden of smoking falls on those least able to

pay for it• Safety issues• Cost to litter, cleaning etc functions

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Strategic Challenges1. Delivering core public health must dos for less2. Preventing cost and adverse outcome (Falls going up

in some areas)3. Levering whole system redesign and prevention using

everyone’s resources to save money and improve outcomes

4. Using PH skills within this to best advantage for the system

5. Using PH budget within this to best advantage for the system

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People are still quitting smoking• Demand steady in many areas including ours• In 14/15  3,306 smokers (over 16 years) per

100,000 smokers quit smoking in Herts compared to 2,999 for the east of England and 2,829 for England as a whole

• Herts Specialist stop smoking services have helped over 1,088 smokers to quit smoking in 15/16 compared with 934 in 14/15

• In 14/15 55% of smokers attempting to quit smoking were successful compared with 51% for England

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Our targeted work is showing results

• Smoking prevalence in pregnancy has declined from 10.1% in 2010/11 to 7.0% in 15/16 compared to 11.0%  for the east of England and 11.4% for England as a whole (2014/15 data)

• In 15/16 25% of smokers who quit smoking came from the 20% most deprived MSOAs, indicating that services are reaching and helping more deprived communities to quit smoking

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BUT• This doesn’t count those using e-cigarettes

who quit without our help! We are now helping people to quit using e cigarettes too locally

• E cigs seem to be a game changer even if only because of the number of people using them

• This forces us to look again• New research quantifies quitters in the millions

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Changing World for tobacco control• Footfall Changing• Segmentation of the population – a long tail

market? – E cigs - Roll ups– Shisha - Illicit tobacco– Young people still initiating smoking

• National campaigns• Legislation, Regulation and Licensing changes

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Where we are• A crowded and confused market of products

and users which is becoming increasingly differentiated and fragmented while the prevalence of tobacco use and burden of disease, disability and death is still highest in

– Routine and manual workers– Pregnant women – People with long term

conditions including HIV– People with mental health problems– Some BME communities

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Upshot• Local Authority approaches to smoking must not

be a black cab in an Uber World• E cigarettes/Vaping presents opportunities.• Traditional methods are not going to be enough

in the new social circumstances• Tobacco control has showed itself to be

innovative. It’s time to do that again

What does that mean in 2016?

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“The Big 4” issues going forward

1. Continue to control tobacco and its effects2. Keep going with nuanced strategy – segment

populations3. Getting people into quitting by targeting and

segmentating audiences1. Harm reduction2. Ecigs3. Stoptober, Our Services.....

4. New technologies, new solutions, new markets, and new allies?

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What does good look like?• Comprehensive approach to tobacco control

– Partnerships and Leadership– Controlling illicit and illegal availability– The end game for tobacco

• Segmentation of services• Working out how to include harm reduction• Working proactively and respectively with

vaping and vapers as a movement for public health

• Difference between tobacco and vaping

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The fundamental question....• What form do e-cigarettes play in a

comprehensive local tobacco control framework?

• Aims:– Less tobacco, fewer deaths, less disability– Stop people from taking up tobacco

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My contention....After more debate and reading bad and good science than I care to remember

• E cigarettes have a fundamental part to play in a coherent whole system approach to tobacco control

• We need to become friendly to their use and their distribution

• The science supports this• Much, much, safer than tobacco• No convincing evidence of gateway or

renormalisation

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Accumulation of evidence and guidance on vaping...for starters

• PHE evidence review 2015• CIEH guidance on public vaping 2015• RCP London Review 2016• NCSCT Guidance 2016• Consensus Statement 6 July • PHE guidance document on workplace vaping• Parliamentary Office for Science and

Technology Briefing July 2016

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The Big Wins• E cigarettes as part of the tobacco control repertoire • Reduce deaths, disease and disabillity• An acceptable route for people with mental health issues• Normalising e-cigarette use does NOT mean

renormalising smoking• Save some money in austerity climate• Help people to help themselves

1

Am J Public Health. 2015 Oct;105(10):1967-72. doi: 10.2105/AJPH.2015.302764. Epub 2015 Aug 13.Smoking Norms and the Regulation of E-Cigarettes.

1

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How.....• Working with ecig users in our services taking

their choice of tool (an ecig) seriously • Publicity about ecigs as a valid option for

quitting• Looking at how and whether we can give ecig

starter kits especially in MH facilities• Accrediting safe and knowledgeable retailers• Helping review vaping policies in workplaces

and elsewhere

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The common worries on e cigs• Renormalization – no evidence

• The Gateway – no evidence of any gateway other than out of smoking

• Young People – evidence suggests worries unfounded

• Long Term effects – still needs study

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Hertfordshire Approach to Vaping• Clinical guidelines changed 2015• New policy for workplace coming 2016• New overall policy on vaping coming 2016• Actively promoting it as a harm reduction tool

while watching the evidence as it develops• Our desire is to develop somehow a kitemark

scheme for safe and responsible retailers

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Could we go even further, what if..??• In Hertfordshire trusted e cig vendors operated

under explicit endorsement from us? “come here and quit tobacco” – directing would be quitters to knowledgeable and helpful vape vendors? Even a badge or quality mark?

Endorsed by Hertfordshire Public Health Service

Give up Tobacco Here!

Vaping – helping people quit tobaco in Herts

Benefits to Taxpayers?Benefits to Quitters?Benefits to Vendors?

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Post Brexit : EU Law and TPD (20 May)

• Article 50 not yet invoked so EU policy and law still binding

• Laws still binding unless and until we decide to abrogate

• UK has largely driven Tobacco Control policy so my guess is we wont lose anything

• TPD stays probably unless we decide to amend or abrogate

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Thank you

Jim.mcmanus@hertfordshire.gov.uk

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Winners 2015