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Tobacco use is harmful to health whether via cigarettes or shisha inhalation and increases the risk of developing a range of health problems including cancer, heart disease and respiratory disease. Tobacco can range from chewing paan or betel nuts which have been associated with causing oral cancer and can significantly impact health (Bonnie and Kwan, 2015).
Cigarette smoking is known to cause both chronic and acute illness, including lung cancer and asthma attacks. Both conditions can lead to suboptimal health conditions and lead to death. Cigarettes are known to contain more than 7,000 chemicals and the inhalation of smoke exposes individuals to a range of toxins and free radicals, which increase oxidative stress and depletion of bioavailable antioxidants micronutrients, increases inflammation, impairs immune status and alters lipid profiles, all of which lead to a range of respiratory symptoms, leading to cancer, heart disease, and stroke (Thomas et al. 2008).
Six million people die annually from tobacco use every year, and this is expected to rise to eight million by 2030 unless successful intervention strategies are employed to halt this projection (Hollis et al. 2000). It is estimated up to 80% of the deaths are expected to occur in low-income and middle-income countries, and areas where tobacco use is highly concentrated, which usually are in the poorest and most vulnerable social groups. The burden of tobacco also affects national and global economies, and globally costs the economy more than one trillion USD annually in ill-health related expenditures.
Smoking is the biggest cause of preventable deaths and related illness in the UK. It is estimated around 120,000 deaths are associated with tobacco related diseases per year. One in three cancer deaths and one in five coronary heart deaths are caused by smoking (Hollis et al. 2000). Over 80% of smokers start as teenagers. Up to 30% of children by the age of 11 and 65% by the age of 16 has experimented with cigarettes; therefore, cessation of smoking should be targeted to all age groups (Hollis et al. 2000). The prevention of smoking in children and adults is an important public health issue to avoid serious long term health complications and death.
Nicotine is an addictive drug found in tobacco. In the UK, the addictive nature of nicotine is recognised and a nicotine replacement therapy (NRT) is recommended as part of smoking cessation management. As part of prevention of the use of tobacco, smoking cessation programmes are recommended including the use of NRT (Bonnie and Kwan, 2015). It is recognised that tobacco related products, including cigarettes, contain toxicity with 7000 chemicals within it, of which many are unknown and unregulated.
In addition, low-tar cigarettes, which are advertised as having a reduced tar and nicotine content to give the impression of a ‘healthier’ product, are being sold. The tobacco in low-tar cigarettes is similar to standard cigarettes, with the only difference being in the filter used (Bonnie and Kwan, 2015). The filter of low tar cigarettes retains a larger quantity of tar and nicotine as smoke is drawn through it, and the air mixture, as it is drawn, reduces the tar and nicotine content of the smoke.
A low tar cigarette is possibly less carcinogenic; however, this is not fully the case. A smoker may use a low tar product; however, a smoker may compensate on the low delivery of smoke by inhaling larger or deeper quantities (Bonnie and Kwan, 2015). Therefore, the exposure to the carcinogenic products is relatively high including to agents such as M-nitosamines, which is likely to increase certain types of cancer, such as lung cancer. Other observations have shown these lighter cigarettes are less likely to be used by the young and more in those individuals in the latter part of their careers as they become more aware the risks, but these are seen as a substitute rather than a cessation.
Tobacco related illness are mainly managed through reduction policies and programmes to curtail tobacco products, including bans on tobacco industry marketing activities, implementation of smoke-free policies, strong graphic health warning labels, and tobacco cessation programmes, all of which are all highly effective and cost-effective in reducing tobacco use (Bonnie and Kwan, 2015). However, out of all the interventions, the monograph reaffirms that substantial tax and price increases are the most effective tobacco control measures. Higher prices reduce consumption, and tax generates significant revenues for the government, but only a small percentage of this profit is used for tobacco control or invested in other health programmes. For instance, approximately 269 billion GBP in government revenue was generated from global tobacco taxes, but globally, governments spent less than $1 billion on tobacco control activities (Hollis et al. 2000). The monograph does not dispel the economic arguments that tobacco companies maintain control measures against tobacco. For instances, a large increase in taxes does not increase the illicit trade in tobacco products nor do they harm economies. On the contrary, tobacco control, especially tax increases, reduces the disproportionate burden that tobacco use imposes on the poor.
Taxation is crucial if the WHO’s goals to cut worldwide tobacco consumption by 25% by 2025 and reduce premature deaths from non-communicable diseases by a third by 2030 are to be met (Hollis et al. 2000). These targets will only be met with large tax hikes. Only 33 countries are using strategies that include substantial tax increases. In countries such as China and India, tax increases are too small to reduce the overall tobacco burden.
Smoking is a serious public health concern and it is also economically detrimental. This report provides a strategy to help the Borough of Tower Hamlets to tackle tobacco related ill-health.
Area presentation: Tower Hamlets; the borough’s population is 301,900 (2016) and is one of the 20% most deprived boroughs in England. The average life expectancy for both men and women is less than the national average by 9.8 years in men and 6.6 years in women. The rate of smoking related death is 356 per 100,000 population and is worse than the average for England (Ipsos, 2016).
Figure 1. Life expectancy in Tower Hamlets Residents
Smoking is a major cause of morbidity and mortality in the UK, and is a major reason for inequalities in death rates between the rich and the poor. Tower Hamlets has a high level of deprivation and a disproportionate high disease burden compared to England as a whole (PHE, 2017).
Figure 2. Health inequalities
The charts compare the changes in death rates in those under the age of 75 years comparing Tower Hamlets to England (PHE, 2017).
In Tower Hamlets, 27% of the adult population smoke, in comparison to London’s average of 21%, with 22% of deaths in Tower Hamlets related to smoking, whereas the death rate related to smoking for London is 18% (Ipsos, 2016). The rate of smoke or tobacco related deaths is higher in Tower Hamlets compared to the whole of London, and poses a significant public health concern. A significant proportion of young children between the ages of 11 – 15 years in England who experiment with smoking become regular smokers. Children from poorer households are more likely to smoke and are exposed to second-hand tobacco smoke (PHE, 2017). It is estimated that one third of children live with at least one adult who smokes, increasing the health concern.
In London,31% of boys and 30% of girls smoke, which is similar to the national average for England. In relation to ethnicity, white pupils are more likely to smoke than Black or those of a mixed ethnicity, and more likely in those receiving free school meals, which reflects the lower income group. In Tower Hamlets, the ethnicity of the local population is considerably different from the general population with higher levels of diversity, mostly from Asian ethnicity. As a result, men are more likely to be smokers than women in contrast to the national smoking population. The reason for this is in the motivation and influence related to cultural norms (PHE, 2017).
Smoking is significantly associated with social inequalities in mortality and is the single greatest contributor to preventable illness and premature death in the UK (Hollis et al. 2000). The important interventions to reduce the association of smoking with the disadvantaged is well recognised and reflects, for instance, the target set by the Department of Health to reduce the prevalence of smoking in the manual working group from 32% to 26% by 2015. Smokers from lower socioeconomic groups may be less likely than those from higher socioeconomic groups to quit as a result of participating in individually targeted approaches such as smoking cessation services, although this social gradient in quit rates may be an offset by a greater penetration of smoking cessation services in the disadvantaged areas (Hollis et al. 2000). The potential contribution to reducing social inequalities in smoking of population-level interventions, such as restrictions on tobacco advertising and on smoking in public places, is less well researched.
Single studies on smoking restrictions in schools have shown to be more effective in girls and in younger school children, but lack evidence about other differential effects (PHE, 2017). There is no strong evidence to suggest restrictions in workplaces and public places are more effective in reducing smoking in more advantaged groups, although smoking behaviour and attitudes may be more acceptable amongst higher occupational grades.
The effect of health warnings does not appear to have a substantial effective on smoking. The increase in tobacco prices appears to be effective in reducing smoking in lower-income adults and those in manual occupations (Abrams, 2010). There is also some evidence to suggest that smokers with higher levels of education may be more responsive to price, although this evidence was limited to somewhat specific study populations.
Quitting smoking has significant health benefits and interventions that aid smoking cessations at a population level saves lives (PHE, 2017). The current work to help smoking cessation in Tower Hamlets includes:
• Illicit tobacco and underage sales; trading standards are increasing training for retailers about tobacco sales.
• Smoke free schools, an activity by which 37 schools have been made smoke free and eight schools have won smoke free awards.
• Bright Sparks offers 1:2 counselling, group work, and satellite clinical and football sessions to incorporate healthy messages.
• The Healthy School Programme provides support to schools to develop and implement policies and programmes about drug and tobacco use, ensuring evidence based practice is in place.
Pharmacotherapies, including nicotine patches, are useful in smoke cessations and are widely used by clinicians. The antidepressant bupropion is a proven cessation agent, as is Varenicline, a nicotine receptor partial agonist (Bonnie and Kwan, 2015). Data from the UK indicate the use of prescription medication has increased since the patches were first made available, and the rate for attempting to quit using prescriptions rose from 27% in 1999 to 61% in 2002, partly owing to the expansion in national policy concerning coverage of cessation medications (Thomas et al. 2008).
This was an evidence-based treatment as a means to provide a counselling service for behavioural management. Quit line helps to influence those who wish to quit smoking including having quit line telephone numbers printed on cigarette packages. However, most quit lines are components of larger tobacco control programmes rather than standalone clinical services (Thomas et al. 2008).
The use of internet and other media platforms allows smokers to seek cessations assistance. For instance, in the US 80% of all Americans seek health-related information on the internet and 9% of all internet users have searched for information on how to quit smoking. However, the evidence of the effectiveness of this method is less known and researched (Thomas et al. 2008). This is partly owed to the difficulty in methodological challenges; it is difficult to ensure a control group in which participants do no use other cessation websites.
Healthcare professionals play a major role in helping smokers to quit. This includes giving brief advice, prescribing medications and offering behavioural counselling (Thomas et al. 2008). Doctors can increase cessation rates among patients who smoke, and with follow-ups the effects can be greater. In the US, the rate of smokers who report receiving advice to quit smoking increased from 27% in 1974 to 50% in 1986, and has slowly increased since to 60%.
Workplace polices can promote healthier lifestyles including offering smoking cessations. This can be achieved by having policies in workplaces to inhibit smoking and to offer incentives with counselling (Thomas et al. 2008).
Advertisements and media have the potential to reach a large number of people in the population and can influence tobacco cessations (Thomas et al. 2008). Emotional or personal adverts have shown to be more effective than humorous adverts in encouraging quitting. Messages about the dangers of second-hand smoking to non-smokers can motivate smokers to quit as much as those that focus on the risk to smokers themselves.
The Ottawa Model for Smoking Cessation is a recognised approach to tackle tobacco use and help smokers quit. It had been developed in a hospital setting and can be adapted for primary care use (University of Ottawa, 2017). Smoking cessation is the most significant preventative method available in reducing the burden from tobacco use. It is thought that up to 60% or more of smokers want to quit smoking and 40% will attempt to quit per year, with only 5% being successful (University of Ottawa, 2017). The reason for not being able to quit is due to not using the best tools and support available. The majority of smokers who look to quit using counselling and cessation medication are more likely to be successful than those who do not.
Clinics also need to continue intervening to support high rates of cessation, and those health professionals who are continuously advising and supporting are more likely to help smokers quit (University of Ottawa, 2017).
The Ottawa model uses an interdisciplinary collaboration approach using range of healthcare and service providers to achieve this:
1) The first step requires questioning and documenting tobacco use. This can be done in either primary or secondary care. Healthcare professionals should identify and document the tobacco status of every patient during admission to hospital or clinics, and alert clinicians when they have a smoker or a recent quitter. Clinicians are encouraged to issue advice about tobacco cessation as a simple and effective method to prevent ill-health. The message is to give clear, tailored advice to the patient’s specific symptoms and risk factors (University of Ottawa, 2017).
2) A second step is to advise and refer. This provides strong and personalised advice to individuals on how to quit with support mechanisms (University of Ottawa, 2017).
3) Act, the third step, is for the patient who is prepared to quit, and provides a strategic counselling, pharmacotherapy and follow-up helpline (University of Ottawa, 2017). Those individuals who are not ready to quit are offered helpline and follow-ups. This step is g designed to provide the patient with the motivation and confidence to take the necessary steps to stop smoking. Follow-up support is regularly provided to ensure a caring and supportive method is available and a counsellor can use the opportunity to encourage the setting of a new cessation date.
In the UK, the use of smoking cessation medication has reduced the level of tobacco smoking, partly due to policy changes, but there is still a long way to go before the set target is reached. The lack of improvement in the cessation rate in the population means that the treatment approach is not the main approach to tackling this issue. This could also be due to a change in taxation or to the second-hand smoking campaign (Stead, 2008). Therefore, improving smoking cessation is not simply about increasing the intervention programmes.
Most interventions are proven to be effective with rigorous experimental designs, but one may suspect that they lose their effectiveness when translated into real world applications. There are many reasons why treatments tested in controlled settings might lose their effectiveness when they are implemented in the real world. Studies have shown that NRT continued to outperform placebos when they became available “over the counter” (Stead, 2008). Thus, smokers who have used these medications have not benefited from them. Therefore, the question as to why there isn’t a significant increase in pharmacotherapy use is not associated with an increase in population cessation, as was projected.
The loss of effectiveness argument does not apply to some interventions. For instance, taxes on cessation are studies that take place in the context of implementation where there is no additional step of translation. It is possible to have tax increases with different effects on smoking cessation and smoking uptake. Tax increases may have an initial effect by encouraging some smokers to quit, although they may not have any effect on those who continue to smoke after the tax increase (Schroeder, 2005).
The Ottawa model, which incorporates pharmacology and healthcare professional interventions, thereby creating a more sustained approached to helping smoker quit, is recommended.
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University of Ottawa Heart Institute (2017) An Evidence-Based, systematic approach to addressing Tobacco use in primary care clinics. University of Ottawa. [Online] Available at: https://ottawamodel.ottawaheart.ca/ [Accessed 05 November 2017].
Bonnie RJ, Stratton K, Kwan LY, eds. (2015). Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington (DC): National Academies Press (US); 2015 Jul 23. Available from: https://www.ncbi.nlm.nih.gov/books/NBK310412/ doi: 10.17226/18997
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Ipsos Mori Social Research Institute (2016) Tower Hamlets and Lifestyle Survey.
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