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CHAPTER 3: PATH IN CONTEXT

Summary

Tobacco use in Scotland

3.1 Smoking has been described as "Scotland's greatest public health challenge". ¹⁰ According to the recently-published Atlas of Tobacco Smoking in Scotland,¹¹ there were about 1,113,000 smokers aged 16 and over in Scotland in 2003/04. This information is taken from the 2003/04 Scottish Household Survey ( SHS); data from the most recent SHS (2005/06) show that 25% of Scotland's adults smoke cigarettes. When combined with the latest population data for Scotland ¹², this indicates that there were about 1,049,000 adult smokers in Scotland in 2005/06. The Atlas states that almost a quarter (24%, or 13,473) of deaths in 2004 were attributable to smoking - this is an average of 37 deaths per day. Almost 90% of all lung cancer deaths were attributable to smoking.

3.2 Data on smoking rates in Scotland have been derived from a number of sources in recent years, including annual Scottish Household Surveys, Scottish Health Surveys conducted in 1995, 1998 and 2003, and the long-established Office of National Statistics General Household Survey (which covers Great Britain). As surveys vary in their methodology, sample size and age ranges covered, their results may not be directly comparable.

3.3 Recent estimates for Scotland ¹³ show that:

• 27.2% of those aged 16 years plus smoked in 2003/04 - giving approximately 1.1 million adult smokers in Scotland;
• Prevalence is slightly higher amongst male adults (28.1%) than female adults (26.5%). However, there are more female than male smokers (570,000 compared with 542,000) because the female population is larger than the male population;
• Almost a quarter (22.7%) of pregnant women smoke during the first trimester;
• Amongst Scottish 15-year olds, 18% of girls and 12% of boys smoked regularly in 2006;
• The equivalent figures for 13-year olds are 5% for girls and 3% for boys;
• Amongst the 35-69 age group, an average of 22 years of life are lost per death from smoking.

3.4 When considered by regional NHS Health Board, smoking prevalence amongst adults ranges between 20% and 30%:

• The highest rates are in Greater Glasgow & Clyde (29.8%), Lanarkshire (29.3%) and Ayrshire & Arran (28.9%);
• The lowest rates are in Orkney (21.7%) and Shetland (22.5%).

3.5 However, these figures mask considerable variation within some areas:

• NHS Greater Glasgow and Clyde comprised 10 Community Health Partnerships ( CHPs) in 2003/04:
• • Overall adult smoking rates ranged from 37.5% in East Glasgow CHP and in North Glasgow CHP to 18.6% in East Dunbartonshire CHP;
  • When considered at intermediate zone ¹⁴ level:
  • • Rates within East Glasgow CHP ranged from 21.5% (Garrowhill West) to 52.4% (North Barlanark and Easterhouse South);
    • In North Glasgow CHP they ranged from 16.0% (Kelvindale) to 50.0% (Roystonhill, Blochairn and Provanmill);
    • The range in East Dunbartonshire CHP was 10.5% (Kilmardinny West) to 35.2% (Twechar and Harestanes East);
• Much less variation was observed at intermediate zone level in NHS Orkney and NHS Shetland:
• • In NHS Orkney, the range was 20.8% (West Mainland) to 23.5% (East Kirkwall);
  • In NHS Shetland, it was 18.0% (North and East Isles) to 27.7% (Lerwick North).

3.6 Rates of death attributable to smoking show similar variations at NHS Health Board level:

• In the NHS Greater Glasgow and Clyde area, 34% of all deaths in the 35 - 69 age group were attributed to smoking;
• NHS Lanarkshire has the second highest proportion at 26% overall (and with 31% of male deaths in the 35-69 age group due to smoking);
• In the Island Boards the equivalent rates of death were 15% in NHS Shetland and 16% in NHS Orkney and NHS Western Isles.

3.7 Although the data show a 5% drop in overall smoking rates amongst adults since 1999 (when 30.4% of persons aged 16 or more in Scotland were smokers ¹⁵), levels are still high, especially in the most deprived areas.

Tobacco use and smoking cessation in Scotland - some key national policy documents

3.8 Smoking Kills - A White Paper on Tobacco¹⁶ was presented to Parliament in 1998 by the Secretary of State for Health and the Secretaries of State for Scotland, Wales and Northern Ireland. It outlined a package of measures to help smokers quit and set targets for smoking reduction. It also outlined the following 'priority groups' for smoking reduction - pregnant women, young people and adults on low income. In Scotland, this led to setting up smoking cessation services in each Health Board area.

3.9 In the same year (1998), ASH Scotland and the (then) Health Education Board for Scotland ( HEBS) published A Smoking Cessation Policy for Scotland, ¹⁷ which contained evidence-based recommendations for a stepped care approach to smoking cessation in Scotland.

3.10 In 1999, Towards a Healthier Scotland: a White Paper on Health¹⁸ set out targets for reducing smoking rates in Scotland and outlined the initial resource allocation for smoking cessation services.

3.11 Another key publication by ASH Scotland and HEBS- Smoking Cessation Guidelines for Scotland - was published in 2000. ¹⁹ These guidelines were intended to give advice on how the NHS in Scotland and others can encourage and help people to stop smoking. They also aimed to make the case for dedicated funds to smoking cessation services and for integrating smoking cessation into routine clinical care.

3.12 Reducing Smoking and Tobacco-Related Harm - a key to transforming Scotland's health was published by NHS Health Scotland and ASH Scotland in 2003. ²⁰ Its three key recommendations were:

• We need to take a much more intensive approach to discouraging children and young people from ever smoking;
• A huge expansion in smoking cessation services is needed to help many more people to stop smoking;
• Further steps should be taken towards making all enclosed public places and workplaces smoke-free zones.

3.13 The following year (2004), A Breath of Fresh Air for Scotland (subtitled Improving Scotland's Health: The Challenge - Tobacco Control Action Plan) was published by the (then) Scottish Executive. ²¹ It was the first action plan on tobacco specifically for Scotland and covered areas of prevention and education, protection and control as well as an expansion of smoking cessation services.

3.14 In the same year (2004), NHS Health Scotland and ASH Scotland published Smoking Cessation Guidelines for Scotland: 2004 Update. ²² A supplementary update ²³ was published by these bodies in 2007.

3.15 On 26 March 2006 Scotland was the first part of the UK to go smoke free in enclosed public places.

3.16 In November 2006, the (then) Scottish Executive published Towards a Future without Tobacco - The Report of the Smoking Prevention Working Group. ²⁴ This report makes a comprehensive series of recommendations intended to protect and dissuade all young people in Scotland from starting to smoke and to deter adults, individually and collectively, from encouraging or enabling them to smoke. This document marks a shift in thinking towards smoking prevention to complement smoking cessation activities.

3.17 Another significant piece of Scottish legislation was passed in September 2007, when the legal age at which tobacco products can be purchased was raised from 16 to 18 years of age.

Targets for smoking rates

3.18 The Scottish Public Health White Paper of 1999 (see paragraph 3.10 above) published the Scottish Government's initial targets for smoking reduction in target groups. These were:

• Headline targets:
• • Reduce smoking among young people (aged 12-15) from 14% to 12% between 1995 and 2005 and to 11% by 2010;
  • Reduce the proportion of women who smoke in pregnancy from 29% to 23% between 1995 and 2005 and to 20% by 2010;
• Second rank target:
• • Reduce smoking among adults (16-64) from an average of 35% to 33% between 1995 and 2005 and to 31% by 2010.

3.19 These were reviewed and in some cases further reduced in the Scottish Government's 2004 Tobacco Control Action Plan (see paragraph 3.13 above). This document:

• Stated that the Scottish Executive would increase its existing target for smoking rates amongst adults (16-64) to 29% by 2010;
• Confirmed the commitment to reducing smoking amongst young people (aged 13-15) ²⁵ to 12% in 2005 and 11% by 2010;
• Confirmed the commitment to reducing the proportion of women who smoke in pregnancy to 23% in 2005 and 20% in 2010.

3.20 In 2004, the Scottish Executive set targets "to improve the health and the quality of life of the people of Scotland and to deliver integrated health and community care services making sure there is support and protection for those members of society who are in greatest need". ²⁶ National inequalities targets were set to reduce health inequalities by increasing the rate of improvement across a range of indicators for the most deprived communities by 15% by 2008. The selected indicators were:

• Adult (aged 16+) smoking rates;
• Smoking during pregnancy;
• <75 coronary heart disease ( CHD) mortality;
• Teenage pregnancy (aged 13-15 years);
• Suicide amongst young people (aged 10-24 years);
• <75 cancer mortality.

3.21 The Technical Notes that accompanied the 2004 Spending Review ²⁷ stated that the target for adult smoking rates (16-64 year olds) was to reduce this rate by 11% between 2003 and 2008 for the most deprived communities. This target was changed in December 2005 to reducing the rate of adult smoking (16+ year olds) for the most deprived communities by 10.9% between 2004 and 2008, giving a 2008 target level of 33.2%. The target level was based on a 15% increase in the improvement observed between 1999 and 2004 (when smoking prevalence in the most deprived communities fell by 11.6%, from 42.2% to 37.3%). In 2006 the prevalence of adult smoking in the most deprived areas was 34.9%, a reduction of 6.4% since 2004. ²⁸

3.22 These Technical Notes also stated that the target for smoking during pregnancy was to reduce this rate by 10% between 2003 and 2008. There had been a 15.2% reduction between 1994 and 2003, when rates fell from 42.2% to 35.8%. The target set for 2008 was 32.2%. In 2005 the prevalence of smoking during pregnancy in the most deprived areas was 31.8%, a reduction of 11.1% since 2003. ²⁹

3.23 A press release in December 2005 on the Scottish Executive's Clearing the Air website ³⁰ stated that the new target for adult smokers aged 16 and over was to reduce the rate from 26.5% in 2004 to 22% by 2010. This was because the original target of 29% by 2010 had "virtually been achieved five years early". This release also reiterated that the target for the most deprived areas remained unchanged at 33.2% in 2008.

3.24 This rate of 22% for adults aged 16+ is reiterated in the Technical Notes for the 2007 Spending Review. ³¹ These Notes only include this one national indicator/target relating to smoking rates (Indicator 22) and do not state any specific new national targets for smoking rates in deprived communities, by women during pregnancy, or by children. However, the Notes do suggest that the policy focus is likely to shift to young people in the next 5 years, with a revised target for 13-15 year olds and a new target for 16-24 year olds being developed by Spring 2008.

3.25 The Scottish Government also sets annual HEAT targets for health improvement, efficiency and governance, access, and treatment, measured over a three-year period. ³² One of the seven health improvement targets for 2008/09 - 2010/11 relates to smoking cessation ³³:

"Through smoking cessation services, support 8% of each Health Board's smoking population in successfully quitting (at one month post quit) over the period 2008/09 - 2010/11."

3.26 The HEAT targets for 2006/07 and 2007/08 were for each Health Board to reduce rates of adult (16+) smoking by 17% between 2004 and 2008. This 17% reduction came from the national target to reduce rates of adult smoking from 26.5% in 2004 to 22.0% in 2008. ³⁴

Tackling teen smoking

3.27 Recent years have seen a shift in emphasis towards tackling teen smoking (see, for example, paragraph 3.15 above). In September 2007 (when the minimum age for tobacco sales was raised from 16 to 18) British Medical Association ( BMA) Scotland published a five-point action plan aimed at tackling teen smoking. ³⁵ These points include banning tobacco vending machines and prohibiting the sale of ten packs of cigarettes to reduce the availability of cigarettes to young people.

3.28 The final recommendation is for "long term investment in comprehensive and targeted smoking prevention and cessation services". BMA Scotland believes that their other recommendations will not solve the problem of teen smoking if implemented in isolation. These measures must be "supported by continual investment in smoking prevention and cessation services in order to tackle the attitudes of young people towards smoking".

Levels of funding

3.29 Smoking cessation services have received additional allocations of funds from the Scottish Government in recent years. In 2008/09 Health Boards will receive £11 million to help smokers quit. ³⁶ Table 3.1 shows the distribution of a total of £9 million across the Health Boards, which includes £2 million allocated to the Keep Well projects in Greater Glasgow, Lanarkshire, Lothian and Tayside Health Boards. An additional £2 million is contained within NHS Boards' general funding allocations, giving a total of £11 million.

Table 3.1: Funding for smoking cessation services by Health Board: 2008/09

Source: Scottish Government News Release: Helping smokers kick the habit, 11 December 2007

3.30 Planned expenditure on health improvement set out in the Scottish Budget Spending Review 2007 document shows an annual amount of £13.8 million for tobacco control in 2008/09, 2009/10 and 2010/11. ³⁷

PATH's early achievements

3.31 PATH's first three-and-a-half years saw many significant achievements that laid the essential groundwork for offering long-term infrastructure support to underpin Scotland's rapidly expanding smoking cessation services and to help meet key objectives in the Tobacco Control Action Plan.

3.32 According to its Action Plan for its second tranche of funds, PATH's early achievements included:

• Successfully allocating the £1 million national support fund to a diverse range of innovative, evidence-gathering pilot cessation projects. Themes include Mental Health, Older Adults, Physical Activity, Black and Minority Ethnic Communities, Prisons, Secure Psychiatric Units and Pregnant Women. The first completed projects to have reported their findings have already attracted national and international attention;
• Commissioning a full and rigorous evaluation of the above projects to an independent research consortium;
• Completing an extensive needs assessment on smoking cessation training in Scotland and using this as the basis for the production of a National Training Strategy;
• Publication of Scotland's first ever national Training Standards for Smoking Cessation;
• Launch of a formal approval scheme for smoking cessation training courses, carrying the approval stamps of the Royal College of General Practitioners and NHS Education for Scotland alongside PATH's own award;
• Significant progress on the development of a system of, and resources for, formal accreditation for smoking cessation professionals and for health professionals seeking formal training in the field. This work is being conducted in conjunction with Glasgow Caledonian University;
• The finalisation, in 2004, of a Minimum Dataset ( MDS) for Smoking Cessation specifying national standards for data collection and monitoring of cessation services in Scotland;
• Significant steps towards a national Information Technology system which will allow quality-controlled capture, analysis and reporting of smoking cessation data and facilitate the monitoring and evaluation of service reach and effectiveness. This work is being conducted in conjunction with the Information Services Division ( ISD) of NHS Scotland. The system went live in June 2005.

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