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Tobacco control (Adults)



Smoking is still the single largest cause of preventable morbidity and health inequalities in England. Every day in England more than 200 people die from smoking related illnesses (Smoking Still Kills: Protecting Children, Reducing inequalities).  In 2013 approximately 1 in 6 of all deaths among people aged 35 and over were attributable to smoking (HSCIC, 2014). There is no safe level of tobacco use. Smoking causes more deaths every year than obesity, alcohol, road traffic accidents, illegal drugs and HIV combined (ASH, 2014)


Tobacco addiction is a complex combination of factors; chemical addiction to Nicotine and behavioural dependence, which cause and sustain regular use. It is the toxins and carcinogens in tobacco, not the nicotine, that cause illness and death.  The risk of disease is closely related to continued smoking and the cumulative number of packs smoked.  Stopping smoking has both immediate and long term benefits, but for people who continue to smoke after the age of 30, on average three months of life is lost for every year of continued smoking.


Comprehensive tobacco control interventions at a local level developed as part of a strategic partnership approach with the specialist Bedford Borough Stop Smoking Service, aim to reduce smoking prevalence and the use of tobacco in Bedford Borough. Effective tobacco control measures, including helping people to stop smoking, save more money than they cost. 


Reducing smoking rates will impact on:

  • Reducing inequalities; beyond the well-recognised effects on health, tobacco also plays a role in perpetuating poverty, deprivation and disparity in health. Smoking is a major factor in the mortality divide between the most and least deprived areas and is responsible for around 50% of the difference in life expectancy between the richest and poorest (HM Government, 2011).
  • Cutting costs to local services; It is estimated that in England each year, smoking costs the public £13.1bn from lost output. This encompasses early deaths, smoking breaks, NHS care, social care, sick days, the impact of passive smoking, household fires and smoking litter (ASH, 2014).
  • Protecting Children; two thirds of smokers say they began smoking before the legal smoking age of 18 and 9 out of 10 began before the age of 19 (Office for National Statistics, 2013). Children exposed to tobacco smoke are at a higher risk of cot death, meningitis, respiratory infections and ear disease


The Bedford Borough Stop Smoking Service provides effective, tailored support packages, combining behavioural and pharmacological interventions to support clients to stop smoking. It is imperative that work is continued to make smoking less desirable, less attractive, less accessible and less affordable.


National & Local Strategies (Current best practices)


In March 2011, following the publication of the Public Health White Paper, the Government published a Tobacco Control Plan for England. Through the plan the Government demonstrated its support of comprehensive tobacco control through three national ambitions:


  • To reduce the adult (aged 18 or over) smoking prevalence in England to 18.5% or less by end of 2015.
  • To reduce rates of regular smoking among 15 year olds in England to 12% or less by end of 2015.
  • To reduce rates of smoking throughout pregnancy to 11% or less by the end of 2015 (measured at time of giving birth).


Tobacco Control

Research shows that no single approach to tackling smoking will be successful in isolation. This means that, tackling smoking is everyone’s business. Tobacco Control is internationally recognised, evidence- based approach to tackling the harm caused by tobacco. In England, tobacco control activity is guided by the Departments of health six strand approach, based on international evidence that a co-ordinated and multi – faceted response to the tobacco epidemic is required to effectively tackle tobacco use:.


  • support smokers  to quit;
  • reduce exposure to secondhand smoke;
  • run effective communications and educational campaigns;
  • reduce tobacco advertising, marketing and promotion;
  • regulate tobacco products;
  • reduce the availability and supply of tobacco products;


With 50 years of pioneering work behind them, it is quite legitimate to look to the US for a description of what works.  


“The mission of comprehensive tobacco control programmes is to reduce disease, disability and death related to tobacco use. A comprehensive approach – one that optimises synergy from applying a mix of educational, clinical, regulatory, economic and social strategies – has been established as the guiding principle for eliminating the health and economic burden of tobacco use.”

Report of the Surgeon General 2000.    


Tobacco control in Bedford Borough is coordinated by Bedfordshire Tobacco Control Alliance – Smokefree Bedfordshire. This group is a multi-agency group that is chaired by Bedford Borough. The Alliance works to an annual action plan that is developed using the six internationally recognised approach.      


Bedford Borough Specialist Stop Smoking Service – Overview


The Specialist Service; provides complex behavioural support and pharmacotherapy (at a prescription charge) for clients wishing to quit tobacco. Support is offered via 1:1 or group sessions based in a variety of community settings and at a range of times to suit the client’s needs. Telephone support is also provided. Specialist advisors develop tailored plans for each client and use a variety of behavioural, motivational and coaching techniques in order to empower them and maximise their success.


The evidence based, abrupt, cessation model i.e. stopping in one step, used by the Stop Smoking Service is proven to increase the likelihood of a client quitting by 4 times compared to smokers who quit without support. This involves assisting smokers to commit to a quit date and for them to stop smoking immediately from that date.


The standard support programme lasts 12 weeks However National Institute for Health and Care Excellence (NICE) has recently published Harm Reduction Guidance to support and extend the reach of the stop smoking services whilst increasing impact within targeted groups.


In June 2013, NICE published PH45 Tobacco: harm- reduction approaches to smoking. This guidance is about helping people, particularly those who are highly dependent on nicotine, who


  • May not be able (or do not want) to stop smoking
  • May want to stop smoking without necessarily giving up nicotine
  • May not be ready to stop smoking, but want to reduce the amount they smoke


In general stopping in one step offers the best chance of lasting success. Existing evidence is not conclusive about the health benefits of reducing the use of cigarettes or ‘cutting down,’ but what has been shown is that those individuals who do reduce their use of cigarettes are more likely to quit altogether (NICE, 2013).


It can take on average 8 attempts for an individual to quit for good.  In order to support the complexity of needs and ‘hard to reach’ clients, from 1st September 2015 the Bedford Borough Council Stop Smoking Service began piloting harm reduction programmes to support people with:


1.    Mental health Conditions

2.    Chronic obstructive pulmonary disease (COPD).


The extended treatment pathways provide support for up to 12 months, with a flexible quit date, cut down period, key milestones, tailored resources and up to 24 weeks of pharmacotherapy.


The second harm reduction programme is a ‘cut down to quit’ programme which is open to all service users that have struggled to quit in the past.  It offers a more flexible quit date and 16 week extended course of pharmacotherapy, plus behavioural support.


The Service also:


  • Facilitates and supports the implementation of new projects and services
  • Coordinates delivery and performance management of other local providers
  • Provides training and professional support to ensure a high quality fully integrated Stop Smoking Service


Other Providers: Health and social care services play an important role in reducing smoking in the population. Delivery options include referral into the Specialist Service and/or delivering an in-house, intermediate 12 week support programme.


Other providers include:


  • GP practice staff
  • Bedford Hospital
  • Beds and Luton Mind
  • The Stroke Association
  • HMP Prison Bedford
  • Schools
  • Pharmacies
  • Workplaces   


Cost of the Service:

The Department of Health has estimated that each quitter would save the NHS £658.22 per year. Based on that figure it is estimated the Public Health Stop Smoking Service in Bedford saved the NHS £538,588 in 2014/15 (excluding savings in social care).


Stop Smoking Services are highly cost effective (Shahab, 2015) and are a vital element of tobacco control. The cost per quitter 2015/16 equates to £348 (including pharmacotherapy) for Bedford Borough which is lower than the national average of £553 for those services that submitted data (HSCIC Health and Social Care Information Centre).


Monitoring;In line with NICE PH 10 guidance recommendations, the service aims to treat at least 5% of the local smoking population.


Current Activity

In 2014/15, the Bedford Borough Stop Smoking Service supported 1,560 to set a quit date and of these 843 quit at 4 weeks which equates to a 54% quit rate. This is above the national average quit rate of 51% (Health and Social Care Information Centre HSCIC). 


Nationally, the HSCIC reported that the number of people that set a quit date through NHS Stop Smoking Services in 2014/15, declined by 23%. This could be attributed to varying factors including increasing numbers of smokers with complex needs and the rising popularity of e-cigarettes.  Footfall into the Bedford Borough Stop Smoking Service also fell (see figure 8).


Figure 1: Bedford Borough Activity


Source: Public Health Core Team - QuitManager.

Local Views

Stop Smoking Service users are requested to complete a feedback questionnaire prior to discharge and relevant feedback is subsequently used to further inform future service delivery (see below).







Smoking in Pregnancy

Babies born to women who smoke during pregnancy are around 40% more likely to die within the first four weeks if life than babies born to non-smokers (Gardosi et al, 2005).


For many children the harm of tobacco smoke begins while still in their mother’s womb. Smoking during pregnancy increases the risks of miscarriage, premature birth, still birth and low birth weight babies. Exposure to smoking during pregnancy also has a detrimental effect on the development of the child after birth. Mothers who smoked during pregnancy are at greater risk of their babies dying early and suffering from respiratory illnesses, diabetes, obesity and cognitive development problems such as attention deficit and hyperactivity disorder. (PH26. 2010)


Smoking has been associated with:

  • 5-8% of premature births
  • 3-19% of cases of low birth weight in babies carried to full term
  • 5-7% of preterm-related deaths
  • 23-34% of deaths caused by sudden infant death syndrome (cot death).

(Dietz et al, 2010

In the UK, smoking in pregnancy causes up to 5,000 miscarriages, 300 peri-natal deaths and around 2,200 premature births each year. (Tobacco Advisory Group, 2010). The prevalence of women smoking at time of delivery in England is 12% which is equivalent to 83,000 infants born to smoking mothers each year (HSCIC).


Smoking at time of delivery is related to significant demographic differences and factors relating to inequalities and deprivation.  Pregnant mothers under the age of 20 are more than three times as likely to smoke as mothers over the age of 30. Those in routine and manual occupations are four times more likely to smoke through pregnancy than those in managerial occupations (29% and 7% respectively). Children born to smokers are more likely to become smokers themselves, which further perpetuates health inequalities (HSCIC).


Treating mothers and their babies (0-12 months) with smoking related problems during pregnancy is estimated to cost the NHS between £20m and £87.5 each yearSmoking during pregnancy poses a high risk of harm to both mother and foetus and it is therefore important that pregnant women are supported to stop for the duration of the pregnancy and postpartum. More women quit smoking when they are pregnant than at any other time during their lives (Murin et al, 2011).  Pregnant smokers are twice as likely to attempt to quit smoking as non-pregnant women, but only about half of pregnant women actually stop smoking during pregnancy (Chen at al, 2006). Support should be offered to other family members that also smoke.


A 2009 report found that interventions from health professionals reduced the proportion of women smoking in late pregnancy by about 6% overall (Lumley et al, 2009). The most effective intervention, particularly among low income women, appeared to be providing incentives (Higgins et al, 2012),


National & Local Strategies (Best Practices)

Public Health Guidance (PH26. 2010)

Local Data


Figure 2: Smoking at time of delivery 2014/15 comparison


Source:  Health & Social Care Information Centre - Statistics on Women's Smoking Status at Time of Delivery England


Local data is based on returns from the Bedfordshire Clinical Commissioning Group; for that reason is represented as Bedfordshire data. Current trends show that Smoking at time of delivery is lower in Bedfordshire 11.1% than regional and national averages.


Figure 2: Smoking at time of delivery comparison across years


Source:  Health & Social Care Information Centre - Statistics on Women's Smoking Status at Time of Delivery England                                                                            


The above graph confirms that Smoking at time of delivery is declining in Bedfordshire.


Current Activity

The Stop Smoking Service has well established links to the Maternity Department at Bedford Hospital Trust and SEPT community services. All midwifery teams have been trained to deliver brief smoking interventions, take carbon monoxide readings and refer onwards to the specialist Stop Smoking Service. Robust ‘opt out’ pathways are in place which means all pregnant women that smoke will be referred into the Stop Smoking Service for support unless they decline the invite.


The Specialist Service delivers a tailored, incentivised programme which supports pregnant ladies with 12 weeks of pharmacotherapy and behavioural support for up to one month, post-delivery.


What are the unmet needs/ service gaps?

Due to local demographics, niche tobacco training needs to be delivered to the maternity departments in order to ensure that mothers who chew tobacco are also supported.


Passive Smoking


What do we know?

There are over 4,000 chemicals in tobacco smoke (United States Environment Protection Agency, 1992). Exposure to other people’s cigarette smoke is called passive, involuntary or secondhand smoking. This is a combination of ‘sidestream’ smoke from the burning tip of the cigarette and ‘mainstream’ smoke that has been inhaled and then exhaled by the smoker. The toxic gases found in sidestream smoke are in higher concentrations than mainstream smoke and sidestream smoke accounts for almost 85% of the smoke in a room. There are more than 50 cancer-causing chemicals in secondhand smoke and the properties of the other gases include irritants (ASH, 2014).


Exposure to secondhand smoke has immediate and long term health effects.  In the long term it can increase the risk of a range of smoking-related diseases including lung diseases and cancers. Children are particularly susceptible with risks that include glue ear, asthma, meningitis and cot death. There is no safe level of exposure to tobacco smoke.


Local Data

ASH estimates that treating the effects of passive smoking in non-smokers costs the NHS £485,414.


Current activity

Bedford Borough encourages parents and other adults living with children to make their homes smokefree. Training has been provided to Health Visitors, Social Workers, and Children Centre staff, enabling frontline staff to positively discuss the harm passive smoking causes. Parents can sign up to a locally developed pledge scheme.


The new legislation on Smokefree Cars came into force from 1st Oct 2015 making it an offence to smoke in a private vehicle with someone under 18 years old present, and for a driver to fail to prevent smoking in a private vehicle with someone under 18 years old present. People who fail to comply could be issued with a £50 fixed penalty notice.


What are the unmet needs/ service gaps?

  • Review and rebranded local programme ‘Smokefree homes’.
  • Regular promotions coinciding with Smokefree Car Legislation from 1st October 2015.


Children and Young People


What do we know?

It is estimated that each year around 207,000 children in the UK start smoking (Hopkinson, NS et al 2013). The 2011 General Lifestyle Survey of adult smokers revealed that almost two-fifths (40%) had started smoking regularly before the age of 16 and 80% of all adult smokers started before they were 20 years old (Robinson et al 2010).


Smoking prevalence is dropping among children. The prevalence of regular smoking increases with age, from less than 0.5% of 11 year olds to 8% of 15-year olds; girls are more likely to smoke than boys (ICHSC, 2014). Children with at least one parent who smokes are 72% more likely to smoke in adolescence. If both parents smoke, children are four times more likely to start smoking than if neither parent smokes (Passive smoke and children, 2010).


Efforts to stop children taking up smoking are much less effective for children when smoking is seen as a norm. The best way to stop children from smoking is to get those around them, particularly their parents, to quit.


National & Local Strategies (Best Practices)

The national ambition for 15 year olds is to reduce rates of regular smoking among 15 year olds in England to 12% or less by end of 2015( HM Government, 2011).


The Department of Health recommends that an effective tobacco control approach to smoking in young people should incorporate education methods that de-normalise smoking as a habit, young people specific treatment services and enforcement of regulations.


Local Data

5-19 year olds represent 25% of the total estimated Bedford Borough population (ONS, 2014).

Stop Smoking support is available across Bedford Borough for young people in:

  • GP Practices
  • Schools
  • Community venues


Numbers of under 18’s accessing the local service through any of the above are low and have declined on the previous year.  In 2014/15, 12 clients attended for their first appointment, 11 set a quit date and 6 quit. Currently there is no available data to indicate Bedford Borough prevalence in under 16s.


Current Activity – Prevention

Kick Ash

The Kick Ash Smokefree Programme is implemented by schools to reduce the smoking prevalence in young people.  Kick Ash takes a 3 Tier approach including:


Tier 1:  Kick Ash Smoke free Policy Agreement – offered to all schools.

Tier 2:  Kick Ash Operation Smoke Storm web-based training, offered to middle schools.

Tier 3:  Kick Ash Training and Delivery to Upper School Year 10 Student – to also work with feeder middle schools.


Current activity relates to Tier 1. A Kick Ash Smoke free Policy has been developed and Bedford schools are currently being invited to sign up. Once schools have committed to the policy they will be offered 6 monthly follow up support.


The Kick Ash Smoke Free Policy aligns to The Health Act 2006 which was developed “to make provision for the prohibition of smoking in premises, places and vehicles. Smoking incorporates lit tobacco, or anything which contains tobacco, or being in possession of any other lit substance in a form in which it could be smoked.”  Premises must be smoke-free if they are open to the public and/or are used as a place of work. The school premises include all buildings, sports fields and areas around schools. Smoking is also prohibited in vehicles hired by the school or in any vehicle on the school premises.


Nicotine replacement therapy (NRT) is available to young people aged 12 and above. Any child that presents with a tobacco addiction can access the Specialist Service and will be supported accordingly. School Nurses have been trained to deliver intermediate interventions to children who want to quit.


What are the unmet needs/ service gaps?

Within some schools there is a lack of understanding of the importance of their role in supporting young people to stop smoking, how to raise the issue and make the most of every contact.  


Adult Smoking

Figure 3: Smoking prevalence – persons age 18+



Data source: Tobacco Profiles - Smoking Prevalence Integrated Household Survey

Adult (16 years +) smoking prevalence in Bedford Borough is currently 14.2%; this has increased by 0.5% in the past year although overall there has been a general downward trend over the last 5 years (Local Tobacco Control Profiles, 2014). Bedford Borough’s smoking prevalence is lower than the East of England average of 17.9% and the England average of 18%.



Smoking prevalence in England and Bedford Borough is higher in lower socio-economic groups and disadvantaged groups. ASH estimates that in Bedford Borough, 27% of households with at least one smoker present fall below the poverty line. Source: ash.org.uk/localtoolkit/docs/Reckoner.xls


Figure 4 below shows the smoking prevalence of those living in the most deprived deciles in Bedford Borough, and those living in the least deprived.


Figure 4: Smoking Prevalence Inequalities Gap


Source: Public Health Outcomes Framework 2015:  http://www.phoutcomes.info/

There are pockets of the population from deprived communities that are harder to reach, for various reasons which are likely to include:


  • More dependant smokers
  • Greater levels of nicotine addiction
  • Entrenched behaviour
  • Long term conditions


Priority group:Whilst progress is being made to reduce prevalence in the general population the priority groups with complex needs, higher levels of deprivation and higher smoking prevalence rates have not seen such declines. These include:


  • Routine and manual workers
  • People with long term conditions, for example poor mental health and COPD
  • Some black and minority ethnic groups


Routine and Manual Workers


What do we know?

Routine and manual (R&M) workers in England make up the largest group of smokers in the general population and also have higher smoking prevalence compared to other occupational groups


Workers in routine and manual occupations are twice more likely to smoke than those in managerial and professional roles. Lower income smokers spend five times as much of their weekly household budget on smoking than higher income smokers.


Smoking has an indirect impact on employers. Tobacco smokers generally have poorer health and on average take 4.4 days more time off sick than non-smokers. An estimated 34 million days a year are lost in England and Wales through sickness absence resulting from smoking related illness. The average total cost to businesses for smoking breaks and sick leave for an employee earning £20,000 is £2,500 a year (ASH, 2014).


National & Local Strategies (Best Practices)

Nice Guidelines PH10

Local Data


Figure 5:  Smoking prevalence by occupational group


Source: Source: General Lifestyle Survey and Opinions and Lifestyle Survey, Office for National Statistics


In 2014, smoking prevalence for routine and manual groups in Bedford Borough was 28.2%; this is higher than any other occupational group and reflects national trends. The prevalence in Bedford Borough has declined from the previous year and is also below the East of England average at 29.3%.


Figure 6: Smoking prevalence among routine and manual workers aged 18 years and over


Source: Tobacco Profiles - Smoking Prevalence Integrated Household Survey


Figure 7: Activity – Routine and Manual


Source: Public Health Core Team - QuitManager.


Figure 7 illustrates the steady decrease in activity with routine and manual workers over the last 3 years; this is reflected nationally.


It is estimated by ASH that in Bedford Borough:


Smoking breaks cost businesses £15.9 million annually

Smoking related sick days cost £2 million annually, equating to 26,082 days of lost productivity


Current Activity

One of the most effective ways of reaching the routine and manual smoking population is to go to their place of work. The Bedford Stop Smoking Service continues to work alongside a range of employers to provide educational stands, employer information booklets and stop smoking quit groups.


The service has also increased access to the 1:1 clinics based in the community by increasing the number of out of hours appointments and piloting a Saturday morning clinic.


What are the unmet needs/ service gaps?

Sustained communication channels with big employers and ‘buy in’ from the organisations to support the facilitation of workplace groups.


Mental Health & Addictions


What do we know?

Mental health disorders are the most significant risk factor in the uptake of smoking in children and adolescents (ONS, 2004). Smoking is, on average, twice as common among people with mental health diagnoses and there is a direct trend with smoking prevalence and addiction increasing with severity of mental health condition (Royal College of Physicians et al, 2013). Empowering individuals to make positive decisions about their health by quitting smoking will indirectly and directly promote good mental and physical health.


Smoking continues to be the leading cause of ill health and mortality in people with mental health disorders (Campion J et al 2008). Smokers with mental health conditions are just as likely to want to quit as those without but are inclined to smoke more frequently, smoke a higher quantity and are more likely to be heavily addicted. These factors combined with the complexity of their needs, make this group less likely to succeed in their attempts to quit smoking (ASH, 2013). However the chances of successful quit attempts within this group are greatly increased if given specialist evidence based support. 


Smoking prevalence for this group varies:


  • 32% for those with a common mental disorder
  • 40% for those with probable psychosis and
  • 69% for those with illicit drug dependence,
  • Within psychiatric inpatient setting up to 70% are smokers
  • Just over 16% of people in England had a common mental disorder, such as anxiety or depression, when interviewed - an overall rate that has not changed since 2000. 

(The Adult Psychiatric Morbidity Survey, 2007)

National & Local Strategies (Best Practices)

Nice Guidance PH48

Local data


The Bedford Borough Stop Smoking Service records the number of clients they support who report they have a mental health illness.  .


There is a decrease of smokers in 2014/15 who indicated that they have a mental health illness, accessing the service, setting a quit date and successfully quitting. In 2014/15, 49 smokers that indicated they had a mental health condition and attended their first appointment and of these, 44 set a quit date and 25 successfully quit. This warrants further work in this area to boost numbers through the service.  


Current Activity


The Bedford Borough Stop Smoking Service is working closely with the new Bedfordshire mental health provider, East London Foundation Trust (ELFT), to develop and implement the smoke-free (NICE PH48) and to develop care pathways to specialist support within in patient and community settings.


From the 1st September 2015, as part of the harm reduction guidance, the Bedford Borough Stop Smoking Service began piloting an enhanced and extended treatment package for this group. This involves 24 weeks of pharmacotherapy and/or Champix (if suitable) and an enhanced tailored support plan with specialist resources, over a 12 month period. The pilot will be reviewed and evaluated for effectiveness. The service also provides a clinic within the integrated substance misuse service i.e. P2R (Pathway to Recovery).


Beds and Luton Mind are also an intermediate stop smoking provider and offer support to clients attending Woburn Road Centre.


What are the unmet needs/ service gaps?


Continued work with ELFT to ensure that Stop Smoking Services are offered for inpatients and outpatients. This will involve mass training of staff to provide effective support and embedding pathways to the service.


Black and Minority Ethnic Groups (BME)


What do we know?

BME groups have high smoking prevalence rates compared to the general population; rates are highest among the Bangladeshi, Irish and Pakistani males (Health Survey for England, 2004).


National & Local Strategies (Best Practices)

Nice Guidance PH39


Local View


Figure 8: Ethnic Composition Accessing Service, Bedford Borough 2013-2014


Sources: ONS, 2011Census: Ethnic group (detailed) by local authority. Table QS211EW

The 2011 Census identified that 28.5% of the Borough's population are from Black and Minority Ethnic (BME) groups (defined as all ethnic groups other than White British). The number of BME groups (33.9%) attending their first appointments with the Bedford Borough Stop Smoking Service during 2014/15 are lower compared to the White British population (66%). It is evident that more needs to be done to increase access to the service for these groups.


The BME population is concentrated in the urban area of Bedford and Kempston wher  37.2% of the population is non-White British, compared to 12.7% in the rural area. Several wards in Bedford town have very high BME populations, particularly Queens Park (74.8%) and Cauldwell (59%).


Current Activity

The Stop Smoking Service has various access points within the community e.g. GP’s and Pharmacies as well as Level 3 services within Bedford Town and Kempston. The service offers a variety of appointments in the day time and evenings and the service is also piloting a weekend clinic.


The service is working closely with communities to develop local links and encourage Level 2 delivery in-house. This includes a more focused approach to specifically target key groups, for example the service supported Ramadan with a targeted campaign in 2015 and had a presence at the 2015 Polish Festival.


What are the unmet needs/ service gaps?

Community engagement needs to be strengthened in order to support BME groups and better understand how the service can be more culturally acceptable within its own limitations.


Offender Health


What do we know?


The “health inequalities experienced by people in contact with the criminal justice system are well above the average experienced by the general population” (Revolving Doors Agency, 2012). The report goes on to add that of those in custody one in three are suspected of suffering from anxiety or depression and one in ten from psychosis.


It has been estimated that around 80% of prisoners smoke (Smoking in Prisons, 2014). The offender population is associated with high smoking rates due to greater levels of poor mental health, substance misuse and disadvantaged backgrounds (Singleton N et al, 1999).


Local Data

Until recently, HMP Bedford was a remand prison with a transient clientele which made it difficult to achieve 4 week quits.  However it is now a resettlement prison which will enable the service to provide longer term support to clients. 


Figure 9: HMP Bedford – 4 week quits


Source: Public Health Intelligence – Quit Manager.

Current Activity


Over the last three years HMP Bedford has delivered behind target.  Reasons for this are varied but include;

Staff capacity, including number of prison guards available to escort clients

Prisoner turnover


HMP Bedford is scheduled to be completely smoke free from 2016 and as a result, the service will need to respond accordingly, in line with national guidance.

During 2014, probation staff working with offenders in the community setting were trained to deliver Level 2 Stop Smoking support.  Unfortunately due to national restructuring of the Probation Service, the development of this service has been delayed.


‘Sick Smokers’ – Bedford Hospital Trust


What do we know?


Many health problems are directly linked to smoking, these include cancers, cardiovascular disease and lung diseases, the exacerbation of which often results in a period of hospitalisation. People, who are in hospital for smoking-related illness, are likely to be more receptive to help to give up smoking, as are those waiting surgery.


Stopping smoking at any time has vast health benefits for the individuals themselves and to those around them. There are additional advantages for those using secondary care services which include shorter hospital stays, lower drug doses, fewer complications, higher survival rates, increased wound healing, decreased infections and fewer re-admissions after surgery (British Thoracic Society, 2013).

Local View


In 2012/13 there were 1,230 per 100,000 population smoking attributable hospital admissions in Bedford Borough, this increased slightly in 2013/14 to 1,276 (Tobacco Profile, 2013/14).  This is lower than the regional average at 1,598 per 100,000 and the England average at 1,645 per 100,000 population.


Current Activity


Bedford Hospital staff continue to identify smokers and refer out-patients into the specialist service.  A need was identified for inpatient smoking cessation support on the wards. Since identification a pilot involving a Specialist Advisor providing ward support for two half days a week has been in place. Further discussions are taking place to establish a longer term model of inpatient delivery and support.


What are the unmet needs/ service gaps?


There is a need for continuous provision on the wards so further work is ongoing to set up a model of long term collaborative support and delivery.


Long Term Conditions – COPD


What do we know?


An estimated 3 million people have COPD in the UK and of those, 2 million remain undiagnosed. Smoking is the main cause of COPD which is the fifth largest cause of death in the UK and the second most common cause of emergency admissions to hospital. As a result it is one of the most costly in-patient conditions and the impact on social care is also great.


This client group has complex needs and often present with other long term conditions, including mental health issues such as depression and/or anxiety. Smoking cessation is a treatment for COPD and can ultimately help to reduce the need for hospital admission and improve the outcomes and quality of life for patients.


Local Data


Current prevalence of COPD for 2014/15 in Bedford Borough is 1.4% which equates to 2,375 people however if the equivalent undiagnosed cases are accounted for, the true prevalence would be much greater.


Current Activity


Extended treatment pathways


Since 1st September 2015, in line with harm reduction guidance (NICE 45), the Bedford Borough Stop Smoking Service has been piloting an enhanced and extended treatment package for those diagnosed with COPD. This will entail 24 weeks of pharmacotherapy and/or Champix (if suitable) and an enhanced tailored support plan with specialist resources over a 12 month period.


From the 1st October 2015 a COPD ‘case finding’ initiative has been implemented by the specialist service to help address the high volume of undiagnosed COPD cases in Bedford Borough.  The initiative has received support from Bedfordshire Respiratory Implementation Groups and the local Clinical Commissioning Group. Expert advice has been sought from various professionals in the specific fields and links have been harnessed with a range of key organisations/stakeholders.


What are the unmet needs/ service gaps?


Evaluation of the pilot initiatives will reveal any needs/gaps.


Smoking related mortality


What do we know?


Areas with the highest smoking prevalence experience the highest rates of death from smoking. ‘Smoking related deaths rates are two to three times higher in low-income groups than wealthier social groups ’(Mental Health of Children and Young People in Great Britain, 2004)


Local Data


Bedford Borough has lower rates of smoking related mortality than the England average, with smoking accounting for the deaths of 199 people per year. This equates to 238 per 100,000 population aged 35+.  The graphs below demonstrate that Bedford Borough is below the national average for smoking related and attributable mortality.


Figure 10: Smoking related mortality


Source: Bedford Borough Health Profiles 2009, 2010, 2011, 2012, 2013, 2014 and 2015.

Figure 11:  Smoking Attributable mortality




The ASH Ready Reckoner tool estimates that in Bedford Borough there are 17,114 smokers, which cost society £32.7 million each year.


The total annual cost to the NHS in Bedford Borough is estimated at £4.3 million; £3.9 million as a direct result of treating smoking-related ill health and £485,414 due to treating the effects of passive smoking in non-smokers.


Current and ex-smokers who require care in later life as a result of smoking-related illnesses cost society an additional estimated £2.3 million across Bedford Borough. This equates to £1.3 million in costs to the local authority and £997.3 thousand in costs to individuals who self-fund their care.


Figure 12: costs of smoking


Source: ash.org.uk/localtoolkit/docs/Reckoner.xls


Smokeless Tobacco


What do we know?


Smokeless tobacco is consumed without burning the product, and can be used orally or nasally. It is generally used by some ethnic minority groups, most commonly those from South Asia. Chewing tobacco is more widely used in the Bangladeshi community; with 9% of men and 19% of women reporting that they use chewing tobacco (Sproston et al, 2004). The study has acknowledged that the figures may reflect a degree of under-reporting by some respondents. A separate report found that 15% of Bangladeshi women under-reported their personal tobacco use (Roth et al, 2009).


Chewing tobacco is embedded in many aspects of South Asian culture with symbolic implications at religious and cultural ceremonies. There are also many misconceptions regarding the health benefits of chewing tobacco which are promoted by misleading, false claims from manufacturers, such as chewing tobacco aids digestion and betel quid has curative effects for dental pain. Chewing tobacco is in fact associated with a range of diseases including an increased risk of cardiovascular disease and oral cancer. Smokeless tobacco contains carcinogens, which contribute to cancers of the oral cavity and the risk of other head and neck cancers conditions and can lead to nicotine addiction similar to that produced by cigarette smoking (Niche Tobacco Products Directory- http://www.ntpd.org.uk/).


National & Local Strategies (Best Practices)


Public Health Guidance PH39

Local Data


2011 Census data indicated that there are a significantly higher number of BME groups living in Bedford Borough (28.5%) when compared to the rest of England and East of England. The largest BME groups in Bedford Borough are white other and Indian, with substantial Black Caribbean, Black African, Pakistani, and Bangladeshi populations.


During Oral Cancer month in November 2013, 6 awareness sessions took place involving 37 members of the public. Although small numbers, this initial contact has produced anecdotal evidence that indicates that a large proportion of people, particularly from the Bangladeshi community, use smokeless tobacco and are unaware of the related health implications. Questionnaires have been developed for distribution to members of the community as a means of gathering local, quantifiable data.


As part of the aforementioned awareness sessions members of the public were advised where to seek support if they wished to stop using smokeless tobacco. However, access to the service shows less than 10% uptake from Bangladeshi and Pakistani communities. Further sessions will be delivered to further encourage individuals to quit using these products.


As recommended in the national guidance, niche tobacco training was delivered to a number of health professionals, including community dental services and health visiting. Feedback from these sessions was very positive.

Current Activity


The Specialist Stop Smoking Service offers the same level of support to chewers of tobacco and niche products.


During Ramadan in 2015, the Stop Smoking Service put together key messages to the Bangladeshi community which were broadcast during Friday prayers through the Imam and community radio. There was also a message about chewing tobacco on the Ramadan calendars delivered to Bangladeshi households. The Stop Smoking Service is preparing specific niche tobacco resources and is working closely on a wider project engaging with local communities and religious leaders.


What are the unmet needs/ service gaps?


Community engagement needs to be strengthened in order to better support BME groups and understand how the service can be more culturally acceptable within its own limitations. A ‘Niche Steering Group’ will direct the project and identify influential community members to represent the service as Champions. Further niche tobacco training sessions with local GP Practice staff and midwives will be planned in 2016/17 and specific resources developed.

Illicit Tobacco


What do we know?


The market for illicit tobacco is reducing but it is still prevalent in some areas and communities. Illicit tobacco undermines tobacco control measures, for example taxation and age restrictions to purchasing however its biggest impact is on those that are more vulnerable. Illicit tobacco is linked to criminal activity and because it is cheap it particularly attracts children and adults on low income, thereby further perpetuating health inequalities. (Tackling Illicit Tobacco for Better Health Partnership www.illegal-tobacco.co.uk)

 Poorer smokers are much more likely to smoke cheap illicit tobacco, and nearly half of all hand rolled tobacco is illicit. To address health inequalities and reduce tobacco use, especially in children, the illicit sale of tobacco must be tackled.

Illicit tobacco costs the taxpayer approximately £2 billion per year in lost revenue. It also involves organised crime networks that are likely to be engaged in other criminal activity such as drugs.


Tackling illicit tobacco is cost-effective. The National Anti-smuggling Strategy introduced in 2000, cost around £100 million in 2010 but generated £1.3 billion additional revenue from the reduction in the illicit market.


Current Activity

In order make this work more effective, by covering a wider geographically area, a steering group has been established across Bedford Borough, Central Bedfordshire and Luton, The group has members from Trading Standards and Public health.


Work, funded by the Department for Health, has been undertaken in Bedford Borough . Operation Henry is the first large scale coordinated action by Trading Standards to tackle the local supply of illicit tobacco products across England.


The Operation was developed and managed by the Trading Standards Institute on behalf of the Department of Health. Tobacco detection dogs search teams were provided by Wagtail UK Ltd, Illicit tobacco products were available in every English region.


81 local authority Trading Standards Services took part in Operation Henry; seizures occurred in 67 of those authorities including Bedford Borough.

The majority of seizures were made at small retailers, independent newsagents and off license premises; this was reflected in Bedford Borough.


What are the current unmet needs/service gaps?


In order to continue to reduce Illicit tobacco and smuggling there is a need to ensure that work is funded and local resources are in place to undertake the work.     

With the imminent change in law around e cigarettes work should be undertaken to ensure that e cigarettes that are sold in Bedford Borough comply with the required standards. This applies to both age of sale and packaging information.


From 2016 the Medicines and Healthcare Regulatory Authority has stated that manufacturers of e-cigarettes will be able to apply for a licence to have their products regulated as medicines in the UK. When this happens the Stop Smoking Service will be able to supply e-cigarettes as smoking cessation aids. The stop smoking service needs to develop to become e-cigarette friendly.




Tobacco Control


  • Continue to address tobacco control through the Bedfordshire Tobacco Free Alliance, ensuring that it is a strategic multi agency partnership with senior level accountability and a dedicated, well-funded and coordinated resource.
  • Continue implementation of the local tobacco control plan using local data and intelligence to ensure appropriate targeting and measurable outcomes.
  • Continue to promote compliance with tobacco legislation, for example by funding activities to stop under age sales of tobacco, promote Smokefree legislation and reduce the availability of illicit tobacco.
  • Encourage local people to make their homes Smokefree
  • Promote Smokefree Cars legislation


The Stop Smoking Service


  • Continue to provide training and refresher sessions on Brief Interventions, particularly to frontline staff, ensuring that ‘every contact counts’.
  • Continue to provide local stop smoking services in ways that maximise accessibility and outreach
  • Further develop interventions for identified groups with high rates of smoking prevalence, capitalising on ‘teachable moments’ such as referral for surgery and unplanned admissions.
  • Ensure there is adequate access in the 20% most deprived MSOAs in order to reduce the inequalities gap.
  • Ensure there is robust data collection and monitoring of Stop Smoking Service users, including mental health service users and COPD.
  • Accurate collection of data, including ethnicity, in order to better identify BME communities and implement smokeless tobacco programmes.
  • Further increase access of support to BME groups encouraging smokers and niche tobacco users.
  • Community engagement needs to be strengthened in order to support BME groups and better understand how the service can be more culturally acceptable within its own limitations.
  • Continue to work in partnership with key external organisations and internal departments to maximise opportunities to increase referrals to the service and subsequent quits.
  • Further develop and sustain links with local businesses to support the facilitation of workplace groups.
  • Evaluation of the pilot initiatives
  • E-cigarette friendly service


This chapter links to the following chapter in the JSNA:


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