Leicester tobacco control strategy 2024-2026

Foreword

Smoking is a leading cause of preventable ill health and premature death and, with around 56,000 smokers in Leicester, the need to make smoke-free the norm is as great as ever. Whilst the negative impacts of smoking on our health and wellbeing are well known, and the reasons why people take up smoking and continue to smoke are complex, tobacco use continues to be a fundamental factor of the deep-rooted health inequalities that we want to tackle.

The inequalities gap continues to be a cause for concern, as we know that those living in areas of deprivation, or routine and manual workers, are more likely to smoke than those living in our wealthier communities. Leicester has highlighted the importance of bridging the inequalities gap, along with improving health outcomes for all residents, with a renewed urgency.

That’s why I am pleased to introduce our new Tobacco control strategy and action plan, which will continue to build on our ambitions to work towards a smoke-free city by 2030 and eliminating tobacco-related harm in our city. At the heart of the strategy is the health and wellbeing of our residents. Reducing smoking prevalence will reduce health inequalities, help boost the local economy, build resilience in health and social care systems, reduce strain on the NHS and lift people out of poverty.

To achieve the vision of a smoke-free Leicester by 2030, we know we will need to be innovative and ambitious in our approach to ensure we deliver meaningful change. However, we are not starting from the beginning; we have made significant progress that has seen our smoking prevalence drop year on year. It is now about how we can continue to build on the strong foundations we already have in place.

There is plenty to be proud of and, since our previous strategy, smoking rates have significantly dropped below the regional average. We have launched our in-patient tobacco dependency service across three priority areas. We continue to excel in the field of smoking cessation through our integrated lifestyle service, Live Well, and recognise the importance of providing remote support as a response to COVID-19.

But we know that to make smoke-free the norm we need to reinforce our messages and work together with our partners. We will look beyond simply helping smokers to quit and consider how we will support people to live longer and healthier lives and support our young people to grow up in environments where smoking is unusual.

We recognise the work we need to do to dispel misinformation around the harms of smoking and address the wider determinants of tobacco related inequalities, such as reducing exposure to secondhand smoke and access to illicit tobacco. There is also more work needed to dispel misinformation associated to e-cigarettes.

The strategy recognises the importance of providing people with freedom of choice over their lifestyle choices, whilst also acknowledging that tobacco use is an addiction which requires specialist support and encouragement to inform and overcome. It also aims to protect those who are adversely affected by second hand smoke, such as young children, by offering guidance and support to those caring for them to bring them up in a smoke-free environment.

We will continue to work collaboratively with our partner agencies to achieve great outcomes and I look forward to taking great strides together to address the harms caused by smoking to achieve a smoke-free Leicester.

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Introduction

Tobacco is the single most important, entirely preventable cause of ill health, disability and death in this country¹. Although smoking related mortality and hospital admissions attributable to smoking have decreased in recent years, smoking is responsible for 64,000 deaths in England a year² and is responsible for over half a million hospital admissions per year³.

The harmful effects of tobacco on the health of an individual and to those around them are widely acknowledged, as smoking is a major risk factor for many diseases such as cancer, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease (COPD)⁴, and adversely affects fertility and maternal health.

However, there is reduced awareness of the role tobacco plays in perpetuating poverty, deprivation, health inequality and its impact on the economy. In 2022 smoking cost the economy a staggering £173 billion, including lost productivity and premature death⁵.

Whilst tobacco use is declining both nationally and locally, the proportion of the adult population using e-cigarettes has increased. Smoking is increasingly confined to the poorest communities, thus widening health inequalities. The difference in life expectancy between smokers and non-smokers (irrespective of wealth) is approximately 10 years. The poorest in our society, and therefore the least able to afford to smoke, represent the greatest proportion of the smoking population.

In 2019 the government set a bold ambition for England to be smoke free by 2030. Unfortunately, current modelling suggests that the smoke-free 2030 target is likely to be missed by nine years. Furthermore, pressures on local authority budgets have resulted in a significant reduction in spending on tobacco control and stop smoking services. The 2022 Khan review highlighted a need for further action and provided 15 recommendations that would help accelerate the reduction in smoking prevalence to achieve a smoke-free England by 2030.

Recommendations included urgent investment of £125 million per year and to abolish all duty-free entry of tobacco products at our borders. Unfortunately, the majority of these recommendations haven’t been adopted yet, however recent government plans have highlighted an ambition to increase the age of sale of tobacco by one year, every year, alongside a commitment to significantly increase funding to local authorities until 2028.

The new funding allocations will provide a substantial increase into our smoking cessation and tobacco control services, allowing us the opportunity to enhance our support to help residents quit smoking.

The national tobacco control plan expired last year and, whilst we are left without a national strategy and any targets for reducing smoking rates amongst the most disadvantaged groups, the government has released a command paper. Stopping the start: our new plan to create a smoke-free generation sets out a route to prevent addiction to smoking before it starts, to support smokers to quit and to stop vapes being marketed to children.

This strategy seeks to build on the local progress from the previous 2020-2022 strategy by continuing to identify the need for ongoing tobacco control within Leicester. Leicester City Council is committed to using the increased funding in a cost-effective way that delivers impact. We will implement innovative approaches to reducing smoking prevalence, such as creating system change through increasing workforce capability and collaborative communication campaigns.

The strategy will highlight local aims and ambitions, defining how we will seek to act in an evidence- and needs-based way across the next two years in the form of a tobacco control action plan. The tobacco control action plan will act as a dynamic document, in that it will be reviewed and amended as appropriate on a quarterly basis.

Why tobacco control is important

Tobacco control is one of the 16 essential health services monitored by the World Health Organization (WHO) to achieve universal health coverage (UHC). It is an internationally recognised, evidence-based approach to tackling the harm caused by tobacco and aims to reduce serious health risks and mortality it causes, through policies, laws, education and targeted intervention.

As smoking is the single most preventable cause of death, it is vital that we work jointly with local and national partners to implement the mandates of the tobacco control plan for England to protect our residents from tobacco, educate them about the dangers associated with its use and work towards a smoke-free generation.

Vision

‘Advancing our health: Prevention in the 2020s, the government green paper published in July 2019, outlines an ambitious goal for eliminating smoking in England by 2030. Although this is an ambitious target, smoking rates have declined year on year and a smoke-free generation now feels within reach. Since our previous strategy, smoking prevalence in Leicester has decreased by 2.3%. If we can reduce our prevalence by 1.2% each year then becoming a smoke-free Leicester by 2030 could be possible.

Leicester’s tobacco control strategy sets out a robust plan to raise more awareness of the harms of smoking, improve the capability of our workforce to hold conversations about smoking and encourage more smokers in the local population to attempt to quit year on year. There will be particular focus on high prevalence groups who are most at risk of tobacco-related harm, dispelling misinformation relating to smoking tobacco and reducing the sale of e-cigarettes and elicit tobacco.

If we connect with our partners to deliver a consistent and collaborative approach, then we can begin to mutually understand each other and build on the strengths of each partner, because the system wants to achieve a smoke-free Leicester by 2030.

The need for action

There are approximately 368,500 residents in Leicester⁶ with data from the annual population survey revealing an adult smoking prevalence estimate of 13.1% for Leicester⁷. Whilst Leicester has seen a year-on-year decline in smoking prevalence, it continues to place a major burden on the day-to-day business of the NHS, impairs population health outcomes and exacerbates inequalities⁸.

Although smoking prevalence has dropped below the regional average (14%) and remains just above the national average (12.7%) in recent years⁹, smoking attributable hospital admissions and mortality both continue to be significantly higher than the regional and national averages.

Local data estimates that there are approximately 56,000 adult smokers in the city and that approximately 346 lives are lost each year through smoking related illness¹⁰. Alongside this, pregnant smokers are at higher risk of many poor birth outcomes, including perinatal mortality (still birth and neonatal death) and miscarriage¹¹, and smoking accounts for a large portion of the 10-20 year gap in life expectancy between those with and without mental health condition¹².

National drives to reduce smoking prevalence, combined with local initiatives, has supported a reduction in the prevalence of smoking in Leicester from 15.4% in 2019/20 to 13.1% in 2022. Whilst smoking prevalence has reduced, there remains an imbalance depending on ward. This is linked to factors including social deprivation and ethnicity, which are both sources of health inequalities.

Also, smoking continues to be the main avoidable risk factor for oral cancer and is linked to 65% of oral cancer cases¹³. However, national estimates for local smoking prevalence are thought to underestimate the true smoking prevalence in the city when compared with local estimates.

Data for different population characteristics is not published at local authority level, but Leicester survey data provides greater insight. The last Leicester health and wellbeing survey 2018 estimated 19.6% of the Leicester 16+ population were smokers. This is higher than nationally produced estimates for Leicester relating to 2018 at 17.3%. Therefore, when we receive data from the Leicester health and wellbeing survey 2024, we anticipate the smoking prevalence to be higher than the annual population survey suggests.

Children and young people

It is estimated that each year around 207,000 children in the UK start smoking¹⁴ with 83% of smokers starting before the age of 20. People who start smoking under the age of 18 have higher levels of nicotine dependence compared to those starting over 21 and are less likely to make a quit attempt and successfully quit¹⁵.

Evidence suggests that children are four times more likely to take up smoking if they grow up in households where people smoke¹⁶ and in Leicester one in three children have a parent or carer who smokes¹⁷. Young people are heavily influenced by their adult role models, therefore supporting adult smokers to quit is one of the most effective ways to prevent young people from taking up smoking¹⁸.

Children are particularly susceptible to the effects of second hand smoke and are more likely to suffer second hand smoke related ill health, such as respiratory infections, asthma, severe ear infections and sudden infant death syndrome¹⁹. Smoking among young people is twice as common among those from disadvantaged backgrounds²⁰, transferring inequalities in smoking rates from generation to generation.

3.5% of young people in Leicester currently identify as regular smokers, however the smoking rate is much higher amongst children in care, with approximately 12% of Leicester’s children in care reporting regular smoking²¹.

Whilst smoking amongst children and young people remains a priority, the increase in children and young people vaping is also an area we will monitor. Although local data around youth vaping is currently limited, it is estimated that 12% of those aged 10-15 have tried e-cigarettes²². National data states the prevalence of 11- to 18-year-olds smoking is 6% compared to 8.6% for the prevalence of vaping²³.

Health inequalities

Health inequalities are preventable differences in health outcomes between population groups, with tobacco use firmly established as a major cause, accounting for 50% of the difference between the least deprived and most deprived communities²⁴.

Smoking significantly contributes to health inequalities in Leicester, which is ranked the 32^nd most deprived local authority with 35% of the population residing in the most deprived 20% of areas nationally²⁵. Smoking rates are disproportionately higher in low-income groups and in Leicester smoking amongst people in routine and manual occupations is 20.3%, which is significantly higher than the city average²⁶.

In addition, those who were defined as unemployed had a higher proportion of current smokers (25.7%), compared with those who were in paid employment (13.3%). The impact of this is stark: one in two smokers will die from smoking related illness, and half will die before the age of 70, losing an average of 10 years’ life expectancy²⁷.

Often groups who are most vulnerable to health inequalities experience poorer access to healthcare services²⁸, and it is vital that local services which support smokers to quit are accessible to those who are most at risk of being affected by health inequality.

Illicit tobacco/shisha

Counterfeit, cheap and illicit tobacco has not been subjected to the same stringent testing for quality control and regulation that governs tobacco generally and therefore may contain even more harmful chemicals and toxins than are permitted by these tests. Taxation on tobacco has increased, year on year, in an effort to make smoking less affordable and, therefore, less desirable.

This has supported a reduction in smoking rates, however the continued trade of illicit tobacco weakens the impact of taxation, damages legitimate businesses, undermines public health and facilitates the supply of tobacco to young people. Alongside the illicit sale of tobacco, there are growing concerns surrounding the illicit sale of e-cigarettes and its correlation to rises in vaping amongst young people.

Tobacco and e-cigarettes can be purchased illegally at a more affordable price, therefore perpetuating the cycle of addiction and smoking related poverty. Purchase and use of illicit tobacco in Leicester is of concern, particularly amongst low-income groups who are more likely to access it and who are more at risk of experiencing smoking related ill health.

Cheap tobacco and e-cigarette availability also increases the likelihood of young people taking up smoking or vaping who would otherwise be unable to afford it. There is also evidence that the illicit tobacco trade is part of wider criminal activity and even that it is used to fund terrorism²⁹.

The number of shisha premises in the city has decreased from 17 in 2020 to 14 in 2023, indicating the scale of shisha use in the city is on the decline.

Mental health

Smoking rates are higher in those with mental health illnesses and they increase with the severity of the mental health issues³⁰. People with diagnosed mental health conditions are at greater risk of health inequalities, dying an average of 10-20 years earlier than those who do not suffer with mental ill health and smoking contributes significantly to this. As well as being far more likely to smoke than the general population, those with mental ill health also tend to smoke much more heavily than other smokers.

The number of Leicester residents who have a poor mental health and wellbeing score has increased since 2015³¹. The 25.4% of adults with a long-term mental health condition report being a smoker³².  Quitting smoking has been associated with many benefits to both physical and mental health in those with mental ill health, including reduced depression, anxiety and stress, and improved positive mood and quality of life³³.

Pregnancy

Smoking in pregnancy has well known detrimental effects for the growth and development of the baby and health of the mother and remains a major concern in Leicester, with University Hospitals Leicester (UHL) data indicating that 27% of women currently smoke or recently stopped at the time of maternity booking (SATOB)³⁴ and 10% of women were still recorded as smoking at the time of delivery (SATOD) in 2021/22³⁵.

However, it is important to highlight that Leicester is a very ethnically diverse city and that the SATOB rate amongst white British women (53%) is significantly higher than the SATOB rate amongst some ethnic minority groups (Asian British 6.9%).

Pregnant women living in areas of deprivation have higher rates of SATOB with the 5% most deprived areas such as Braunstone West and Eyres Monsell having rates of 47%-55.9%, compared to the Leicester average of 27%³⁶.

Alongside increased SATOB rates in areas of deprivation, current data indicates that SATOB rates of women under the age of 25 (41%) are significantly higher than the Leicester average 27%³⁷.

There is a wealth of evidence to suggest that being exposed to tobacco smoke in the womb is responsible for a range of serious health and behavioural issues, and the still birth rate in Leicester is significantly above the national average at 5.9 per 100 births. The overall SATOD rate between 2015/16 and 2021/22 has remained largely unchanged, despite fluctuations during that time.

Whilst nationally we have made progress towards the national tobacco control plan target of 6% SATOD prevalence by 2022, we haven’t seen any progress statistically in Leicester. However, with the implementation of the NHS long term plan and an increased contribution to support people in contact with NHS services, we hope to see a reduction in the SATOD rate as we continue to work towards a target of 6%.

Smokeless tobacco

Smokeless tobacco is a leading cause of head and neck cancers globally³⁸ and the negative impact on oral health in Leicester is mounting. Smoking, however, is still the main avoidable risk factor for oral cancer and is linked to 65% of oral cancer cases³⁹.

Leicester has significantly higher incidence and mortality rates for oral cancer compared to England in general. The most recent local authority data reports Leicester with the highest local authority mortality rate from oral cancer in the country. Smokers have a seven times increased risk of developing oral cancer, while regular smokeless tobacco users are at an 11 times increased risk⁴⁰.

In addition, smokeless tobacco contains twice as much nicotine as a normal cigarette making it more addictive than cigarettes and can be linked to other health problems such as type 2 diabetes, premature births, dementia and respiratory diseases⁴¹.

Globally, a smaller proportion of smokeless tobacco users are advised to quit the use of smokeless tobacco products compared to smokers. Leicester follows these trends with only six referrals made to ‘stop smoking’ services for smokeless tobacco during 2021-22. Smokeless tobacco is a risk factor for oral cancer, particularly in Leicester due to its population demographic profile, however further data is needed to fully understand this issue.

Social housing

Housing tenure is a particularly strong predictor of smoking status, with those living in social housing being significantly more likely to smoke than those who own their own home, leading to greater smoking related inequalities amongst this group⁴².

This increases the likelihood of social tenants suffering the effects of smoking-related ill health, or second hand smoke exposure. Children are particularly vulnerable if they live in a home where smoking is permitted indoors.

Financially, social tenants are more likely to suffer from smoking related poverty, with one in seven living in poverty because of the impact of smoking costs on their disposable income⁴³. A cost calculator tool produced by Action for Smoking and Health (ASH) in 2019 estimates that 20% of social renters in Leicester are living in smoking households, spending on average £39.31 per week on tobacco, and that 32.9% are living in poverty as a result.

Non-smoking tenants living in other properties can be exposed to smoke drift from smoking properties, for example in blocks of flats where housing is in close proximity, or from communal areas.

There is also a significant workforce who are required to carry out works in social tenancies who are at risk of second hand smoke exposure and the associated health impacts, and employers have a responsibility to ensure that employees are protected from this.

Vaping

Leicester’s stop smoking service is nationally recognised as a leader in the field, having become the first stop smoking service nationally to become ‘e-cig friendly’. A recent evidence review published by the Office for Health Improvement and Disparities (OHID) indicates that, in the short and medium term, vaping poses a small fraction of the risks of smoking.

However, vaping is not risk-free, particularly for those who have never smoked. Vaping prevalence amongst adults in Leicester remains lower at over 4% locally compared to between 7.7% nationally⁴⁴.

Those aged 25-34 are most likely to have used an e-cigarette (13.8%) with over 65-year-olds being the least likely (2.9%)⁴⁵. White British adults have a significantly higher rate of vaping compared to the Leicester average and the highest use of e-cigarettes is amongst those employed or unemployed but looking for work⁴⁶. There has been a dramatic increase in the use of disposal vaping products from 2.2% in 2021 to 15.2% in 2022⁴⁷.

Messaging and understanding around the risks of vaping compared to smoking remains a complex landscape where inaccurate perceptions need to be addressed. Only 34% of adults who smoked accurately believed that vaping was less harmful than smoking⁴⁸.

Whilst vaping is becoming more and more recognised as one of the most effective quit aids for smokers, vaping amongst children and young people is a growing concern, both nationally and locally. Local data indicates that 12% of children and young people have tried e-cigarettes/vaping⁴⁹.

There remains a demand to increase the evidence around the long-term effects of vaping alongside increasing the communication around accurate information and it is our responsibility to support this at a hyper local level. We have started this by adopting a regional vaping statement developed and endorsed by the East Midlands Regional Tobacco Control Community of Improvement.

Governance

The tobacco control strategy for Leicester will be scrutinised by the joint city/county tobacco control alliance to ensure that no opportunity to reduce tobacco-related harm in Leicester is missed. The tobacco control alliance will also oversee performance and regularly monitor progress.  

The strategy will be delivered to the regional East Midlands tobacco control group to ensure local ambitions align with the regional vision and opportunities for joint working are explored. The strategy will be reviewed fully in 2026 where we hope to have received an update regarding the national tobacco control plan for England.

There will be an additional yearly interim review to ensure the plan still meets local priorities, which will be corroborated by quarterly updates to the supporting tobacco control action plan for Leicester. The Tobacco Control Alliance, comprised of public health, Trading Standards, the public safety team, Live Well, housing, social care and the NHS, supports the delivery of the aims.

System wide collaboration

To achieve our vision of a smoke-free Leicester we must work in collaboration with key partners. This requires accelerating efforts to eliminate smoking in Leicester through a multiple agency approach, working across organisational divides, together with a correct balance between clinical and social policies/interventions.

Through increasing the confidence, knowledge and capability of our workforce to use the millions of day-to-day interactions they have with other people to support them in making positive changes to their physical and mental health and wellbeing, we are enabling the system to build trusted relationships and support residents to take action. The implementation of programmes such as CURE and incentive schemes will further support target audiences to quit and promote systematic change across Leicester.

This will involve working with a range of key partners including but not limited to: Leicester City Council, Leicestershire County Council, University Hospitals Leicester (UHL), Leicestershire Partnership NHS Trust (LPT), Leicestershire Fire and Rescue Service, Leicestershire Police, Office of Health Improvement and Disparities (OHID), Trading Standards, public safety team, housing departments, corporate parenting partnerships, the University of Leicester, De Montfort University, children, young people and family centres, family hubs, the voluntary sector, local businesses, schools, and local media.

Key priorities for Leicester

Whilst many positive achievements have contributed to year-on-year reductions in prevalence, there is still a long journey ahead to achieve national ambitions. To reach a smoke-free Leicester by 2030, Leicester will need to be ambitious, innovative and unified in its approach. The key priorities locally will therefore be:

• Partnership working to address tobacco control within Leicester
• Achieving a smoke-free generation – when the number of smokers in the population reaches 5% or less
• Smoke-free pregnancy for all
• Reducing the inequality gap for those with mental ill health
• Deliver consistent messaging on the harms of tobacco across the system
• Continue to improve the quality of our services and understand impact through data collection

Based on the World Health Organization’s framework convention on tobacco control

(WHO FCTC), Leicester will use the MPOWER model (see below) to underpin its strategy priorities to reduce demand for tobacco and achieve a smoke-free Leicester. The measures align well with our priorities and are intended to assist the implementation of effective interventions.

Monitoring tobacco use and prevention

Across the UK, tobacco use and quit attempts are regularly monitored to inform policymaking and enhance tobacco control strategies. Monitoring tobacco use and prevention in Leicester will help us to achieve a smoke-free generation by identifying which groups are most vulnerable to the detrimental effects of smoking and ensuring that additional resource is dedicated to supporting these groups eg, those with mental health illness, children and young people, or those with a learning disability. This includes considering the practical needs of these groups, for example providing information in a format which is accessible.

Where possible, Leicester invests in and supports national research surveys to ensure insight is robust and informative at a local level. The Leicester health and wellbeing survey provides robust local data on a range of public health issues, including smokeless tobacco use, smoking and vaping rates. The last survey was undertaken pre-COVID in 2018, with the next survey due to be undertaken in 2024. This will help to provide the most relevant and up to date data.

 Our CURE and Live Well services also collect a variety of data that includes the number of quit dates set, quit rates at four weeks, 12 weeks and one year and how rates vary dependent on deprivation, gender and ethnicity. In addition, partnership working is of paramount importance if we are to continually monitor tobacco use within Leicester. Leicester City Council, Leicestershire County Council and Rutland County Council have developed a Tobacco Control Alliance to monitor and evaluate the effectiveness of locally delivered programmes and initiatives.

Further to this, Leicester forms part of a wider East Midlands regional tobacco control community of improvement to create a regional vision and align messages at a regional local level to ensure a consistent and collaborative approach to tackling tobacco control is achieved.

Leicester is committed to the continually improving the quality of our services. This will be achieved through increasing the collection of data to understand the local landscape, understanding impact and benchmarking against regional and national services.

Tobacco Control Alliance

The Tobacco Control Alliance provides the strategic lead for tobacco control in Leicester, Leicestershire and Rutland. This will include oversight of research and development activity, focus on evidence available and ensuring adequate and appropriate support mechanisms are in place. The current ambitions of the alliance replicate that of the England Tobacco Control Plan for England. Smoking prevalence amongst adults in Leicester has reduced significantly from 15.5% to 13.1%. This is just above the national target of 12% by 2022 and demonstrates a significant positive impact of the reduction of smoking prevalence across the city.

East Midlands regional tobacco control community of improvement

Many recommendations in the Khan review can be delivered through a collective approach at integrated care system (ICS) or wider regional level. This collective action provides an opportunity for areas to make progress towards a smokefree 2030 beyond that achievable at a local level. The East Midlands tobacco control community of improvement is a network of professionals who aim to reduce smoking prevalence across the East Midlands through regional collaboration. Tobacco control representatives from the East Midland’s public health teams, Trading Standards and OHID come together in response to rapidly changing evidence.

Protecting people from smoke

Smoke at any level of exposure is unsafe and can cause harm. Even smoking outdoors can lead to the exposure of secondhand smoke. To achieve our priority of a smoke-free generation we aim to support smoke-free workplaces, mental health units, hospital sites and prisons, as well as encouraging smoke-free homes. The effective implementation of smoke-free spaces can protect people from exposure to secondhand smoke and help smokers to reduce their tobacco use.

There are also environmental benefits such as the reduction of cigarette litter. Making smoking less visible also decreases the exposure children and young people have to smoking and is more likely to encourage healthier behaviours. Leicester’s smoke-free agenda seeks to reduce the level of smoke exposure to target audiences through effective partnership working, better connecting systems and uniting residents through the ‘step right out’ programme to make public and private spaces smokefree.

Children in care

The vision for this programme of work is for children in care to enjoy smoke-free lives in parity with young people in the general population. A children in care smoke free strategy and action plan is being developed to support strategic leadership on the prevention and use of tobacco amongst children in care. The programme addresses a number of key areas, including provision of training and support to staff and carers who work with children in care to support preventing the uptake of smoking and maintaining smoke free environments, along with development of a bespoke model of support for children in care who already smoke.

Social housing

Leicester’s public health team and housing department have been working in collaboration to support tenants by raising awareness of the impact of smoking and secondhand smoke and signposting tenants who smoke to smoking cessation services. This supports housing staff to manage tenancy issues which may have links with smoking.

Increasing the knowledge, confidence and capability of workforces outside of public health allows staff to use the many interactions they have with the population to support them to make healthy life choices for their mental and physical health.

The unique approach works across organisational divides and is an effective way to use already established relationships between officers and residents, empowering them to take control of their own lifestyle choices, preventing people from starting smoking and encouraging smokers to quit.

Alongside encouraging smokers to quit, we are hoping to explore opportunities regarding smoking policy amongst social housing in an ambition to help further protect people from smoke.

Step right out

Step right out is a campaign that provides conversational tools for frontline workers to gain the capability and knowledge to open conversations about how to maintain a smoke-free home. A pledge to maintain smoke-free homes raises awareness of the harms of second hand smoke and builds trust in a city-wide intervention.

Smoke-free sites

LPT sites are working hard to empower and motivate people being admitted to mental health wards to access smoke-free support and changes to policy will help to enforce these messages. Whilst we recognise the importance of smoke-free hospitals, prisons and mental health units, more work across Leicester is needed to enforce policy and make these sites smoke-free.

Offering to help quit tobacco use

Research suggests that it takes an average of 30 attempts before someone successfully quits smoking⁵⁰. Although most smokers may state that they want to quit, the likelihood of success first time is slim and it is even more difficult to quit without support. Understanding what support is available, how to access it and identifying what methods do and don’t work for you goes a long to creating a successful quitting journey.

Leicester’s approach is to raise awareness of how to quit and increase opportunities that make it easier to access support. Leicester now has more access to free, personalised stop smoking support than ever before. To help meet our priorities of a smoke-free pregnancy for all and to reduce the inequality gaps for those with mental ill health, we deliver targeted interventions that provide direct support to pregnant women and inpatients in mental health wards.

Workforce development framework

The Leicester tobacco control workforce development framework aims to provide a scalable and adaptable approach to increasing the confidence, knowledge and capability for frontline staff to initiate difficult conversations related to smoking and the harm it causes. The framework will seek to incorporate and build on the ‘making every contact count’ (MECC) approach. MECC enables the opportunistic delivery of consistent and concise healthy lifestyle information and enables individuals to engage in conversations about their health – at scale – across organisations and populations.
                   

Turning Point

Turning Point provides treatment for drug and alcohol users. Whilst smoking prevalence has declined in recent years across most groups, it has remained much higher in some groups, of which drug and alcohol users are one.

This programme builds on a pilot scheme whereby Turning Point staff, with whom clients already have established relationships, provide a smoking cessation service from within their premises, using a delivery model aimed at matching client need. The eligibility criteria will include clients who misuse substances with an aim to increase engagement with smoking cessation support from a high-risk group who may not otherwise engage with a smoking cessation service.

Live Well

Leicester’s stop smoking service forms part of the Live Well integrated lifestyle service. Having become the first stop smoking service nationally to become ‘e-cig friendly’ Live Well continues to excel in its field and was able to adapt operationally during the COVID-19 pandemic to ensure residents continued to receive support and had the opportunity to quit. The service responded to COVID-19 by introducing new forms of remote support, which have subsequently been retained to offer maximum flexibility. This is evident with 59.2% of referrals who set a quit date successfully quitting during 2020-21⁵¹.

Despite a national decline in use of stop smoking services, Leicester has continued to engage smokers and has maintained a high success rate. During 2020/21, 82% of clients who accessed the stop smoking service were from high prevalence groups, demonstrating that services are targeted appropriately and are meeting local need.

Due to the stop smoking service forming part of the integrated lifestyle services and the collaborative approach taken in Leicester, additional opportunities are available to access other lifestyle support services with Live Well or be signposted to additional support, such as debt management or housing support, demonstrating a system wide approach to reducing health inequalities. Live Well supports ambitions set out in the NHS long term plan through supporting the transfer of care from inpatient to community services.

NHS long term plan tobacco dependency programme

Smoking puts significant pressure on the NHS – almost every minute of every day someone is admitted to hospital because of smoking⁵². Conversation, Understand, Replace, Experts and Evidence-based treatments (CURE) is based on the Ottawa model for smoking cessation (OMSC), which aims “to change healthcare practices so that tobacco dependency treatment is provided as part of routine care to all patients who are tobacco users”.

The implementation of CURE in Leicester was launched in response to the NHS long term plan (2019) which states the NHS will make a significant new contribution to making England a smoke-free society, by supporting people in contact with NHS services to quit based on a proven model implemented in Canada and Manchester. By 2023/24, all people admitted to hospital who smoke will be offered NHS-funded tobacco treatment services⁵³.

Implementation in Leicester, Leicestershire and Rutland started in 2021 and has led to the delivery of three tobacco dependency service models in LPT and UHL to support acute inpatients, mental health inpatient and pregnant women by 2023.

Acute CURE tobacco dependency service

Leicester's acute CURE inpatient service delivers an in-reach model of care that is based in Leicester hospitals and includes patients from across Leicester, Leicestershire and Rutland. An in-reach model is defined as a service where a transfer of care takes place from one organisation to another.

Tobacco dependency advisors (TDAs) are employed by Leicester City Council and patients are referred to community services for their ongoing care, after discharge. Before a transfer of care takes place, tobacco dependency advisors screen inpatients for their smoking status through making every contact count for nursing (MECC) assessment. They also provide very brief advice and prescribe nicotine replacement therapy.

University Hospitals Leicester has an in-reach service. Acute CURE has fully launched across all three UHL hospital sites as of 2023. An evaluation of CURE and snapshot of data shows that, since implementation in 2021, over 8,500 smokers have been referred to the acute impatient service.

From October 2022 to February 2023, demographic data showed 83% of referrals received were of White British ethnicity; 36% of referrals were over the age of 60; 57% were male; and 28% of referrals were from the areas of most deprivation.

As well as patient care, the CURE team supports and educates staff on the importance of treating tobacco addiction as a disease, how to deliver effective very brief advice and prescribing nicotine replacement therapy (NRT) to patients. 2,597 clinical staff have received CURE training.

Smoke-free service for directorate of mental health at Leicestershire Partnership Trust

Smoking is significantly more prevalent in people with mental health conditions, with 40% of people with schizophrenia smoking over 20 cigarettes a day and over one-third of cigarettes smoked in England being smoked by people with severe mental illness⁵⁴. The severity of the statistics identifies the disparity that takes place in the current population and how there is a pressing need to provide smoke-free support that is specialist and person centred on mental health wards.

Smoking on mental health wards has historically been used as a way of managing stress and anxiety. The LPT smoke-free sites policy has helped greatly to move away from this culture to empower and motivate people being admitted to mental health wards to access smoke-free support and to greatly improve their mental and physical health.

The aim of the smoke-free service for directorate of mental health at Leicestershire Partnership Trust is to provide specialist behavioural support, nicotine replacement therapy and e-cigarettes throughout the person’s stay on the ward and provide transfer of care throughout the person’s stay on and discharge from the ward.

NHS saving babies lives care bundle

The saving babies’ lives care bundle (SBLCB) provides evidence-based best practice for providers and commissioners of maternity care across England to reduce perinatal mortality. Version three of the care bundle (SBLCBv3) builds on the achievements of previous iterations, drawing on national guidance such as from the National Institute for Health and Care Excellence (NICE) or the Royal College of Obstetricians and Gynaecologists (RCOG) green top guidelines, and frontline learning.

Element one of the bundle focuses on reducing smoking in pregnancy by implementing NHS-funded tobacco dependence treatment services within maternity settings, in line with the NHS long term plan and NICE guidance. This includes carbon monoxide testing and asking women about their smoking status at the antenatal booking appointment, as appropriate, throughout pregnancy.

Women who smoke should receive an opt-out referral for support from a trained tobacco dependence adviser who will offer a personalised care plan and support throughout pregnancy. We are working in partnership with University of Hospitals Leicester and Leicestershire County Council to:

1. Implement carbon monoxide monitoring at every antenatal appointment to enable testing throughout the pregnancy
2. Increasing the opt-out referral rate and engagement rate into support services, by providing increased training to maternity staff and enhanced packages of smoking cessation care for pregnant women and their partners
3. Providing smoking cessation support to the pregnant woman throughout the whole pregnancy, to promote smoke-free pregnancies and increase the number of babies going to smoke-free homes.
4. Increasing communication between maternity staff and smoking cessation services to ensure continued care.

Maternity CURE impatient tobacco dependency service

With the smoking at time of delivery (SATOD) rate largely unchanged in Leicester for over five years, the maternity inpatient tobacco dependency service aims to help reduce this rate by providing bedside smoking cessation support for both pregnant women and household members.

Empowering maternity staff through training to improve the confidence, capability and knowledge to talk about smoking cessation enables the provision of behavioural support that is designed to support pregnant mothers to stop smoking, to reduce the risk of harm to both the mother and baby.

Collaboration between public health and the hospitals has enabled us to provide greater opportunities to support and help reduce the prevalence of smoking in pregnant women. Support for pregnant mothers continues beyond the hospitals to ensure continued support is available for the duration of the pregnancy.

Pregnant women incentive scheme

In an ambition to reduce rates of smoking during pregnancy, NICE guidance now recommends tobacco dependency services offer financial incentives for pregnant women. Evidence suggests the NHS can save £4 for every £1 spent⁵⁵. We will be launching a two-year incentive scheme with an aim to increase acceptance rates into smoking cessation services and increase quit rates and smoke-free pregnancies in smoking cessation services.

NHS staff support service

The democratisation and personalisation of data and digital tools has created a population that both expects and is able to use digital tools and data to support their health and manage their care and treatment⁵⁶.

In an effort to support people to become active and engaged partners in their own health, wellbeing and care, the smoke-free app provides NHS staff across UHL and LPT hospitals free access to digital support and nicotine replacement therapy.

Targeted digital marketing and the innovative use of QR codes enables staff to directly download the digital app and access specialised support tailored to individual needs within 48 hours. If NHS staff don't want to use the digital app they can still be referred/self-refer into community stop smoking services and receive phone based or face to face support.

Warning about the dangers of tobacco

Communication is key and tailoring messages to grab the attention of your audience is imperative when warning people about the dangers of tobacco. Leicester’s previous approach has been sporadic and non-recurrent, which can lack impact. In an aim to deliver consistent messaging on the harms of tobacco across the system, a multi-channel approach will go a long way to encouraging smokers to quit and discouraging people from ever starting to smoke.

Leicester’s tobacco control communication toolkit utilises national campaigns to provide a localised approach, alongside developing a tone of voice and vision which all partners can use to ensure a consistent and united message is delivered throughout the city.

Tobacco control communications toolkit

The communications toolkit will help organisations create consistent evidence-based messaging relating to tobacco control. Communications campaigns can be a highly effective behaviour change interventions and a useful tool to inform and communicate tobacco control messages.

A consistent tone of voice and building consistent messaging across the system to dispel the misinformation on the harms of smoking will help to reduce confusion around newer treatments, such as e-cigarettes, and build a foundation of trust. It will also empower partners to openly discuss tobacco related topics and create a wider reach of public health messages.

The toolkit is accessible to a wide range of partners and can be used to improve confidence and capability of having smoking related conversations.

Oral health

With the highest local authority mortality rate from oral cancer in the country (2017-19)⁵⁷, Leicester will be increasing the awareness on the harms of smoking on oral health through targeted campaigns. Tobacco control, oral health and city wardens will be working in partnership to deliver the campaigns, which will include information on the harms of smoking and smokeless tobacco and the negative effect it will have on your oral health.

Enforcing bans on tobacco advertising, promotion and sponsorship

The advertising of tobacco has a long standing relationship with encouraging consumption and is largely blamed for driving the global tobacco epidemic. The reduction in promotion will support the decrease of consumption and there is a call to action from hyper-local to national level to support this. Enforcing regulation will help us to achieve a smoke-free generation and Leicester will work together with local Trading Standards team and Leicestershire Police to enforce regulation that reduces tobacco harm.

Trading Standards

Tackling illicit tobacco is delivered by Leicester City Council’s business regulation department. This activity restricts availability of cheap and illegal tobacco, which often undermines the effect of price rises and health warnings. Activities include surveillance of local markets in illicit sales and sharing of intelligence on supply chains, in collaboration with HM Revenue and Customs (HMRC) and police. Regulation of tobacco products is intelligence-led and involves underage test purchasing and enforcement of the health warning requirements on retail sales and supplies.

Raising tobacco taxes

Increasing tobacco taxes and prices is the most effective and cost-effective measure for reducing tobacco use. An increase in price makes smoking less affordable meaning people are less likely to use it. This is particularly effective with low-income groups and young people, as well as a prevention tool for youth initiation.

However, this is undermined by the sale of illicit tobacco and e-cigarettes, giving consumers, in particular young people, access to cheap and unregulated products. Alongside undermining national tobacco regulation, illicit sales can often be linked to organised crime.

To assist in achieving a smoke-free generation and help to reduce the inequality gap amongst deprived communities, Leicester’s Illicit tobacco programme aims to increase its focus on reducing the supply of illicit tobacco and e-cigarettes.

Local progress against national ambitions, and visions for the future

The first smoke-free generation

National ambitions

• Reduce the prevalence of 15 year olds who regularly smoke from 8% to 3%, or less by the end of 2022
• Reduce smoking prevalence amongst adults in England from 15.5% to 12%, or less, by the end of 2022
• Reduce the inequality gap in smoking prevalence between those in routine and manual occupations and the general population.

Our 2020 status

• 3.5% of young people in Leicester City are regular smokers (PHE fingertips, WAY survey 2015)
• 15.4% of adults in Leicester are current smokers, above the national average of 13.9% (PHE fingertips)
• Smoking prevalence amongst routine and manual workers in Leicester is 24.2%. 85% of homes in Leicester City are smoke-free, i.e smoking is not allowed inside. (Leicester health and wellbeing survey 2018).

Our current status

• Whilst there is no up to date data in Leicester for young people who smoke regularly, the children health and wellbeing survey 2021/22 states 3.8% of young people have tried cigarettes and 12% have tried e-cigarettes/vaping
• Smoking prevalence amongst adults in Leicester has decreased by 2.3% since 2019 with 13.1% of adults in Leicester current smokers, slightly above the national average of 12.7% (PHE fingertips, Local Tobacco Control Profiles 2021)
• Smoking prevalence amongst routine and manual workers in Leicester is 22.6%. A 1.6% decrease since 2020. 85% of homes in Leicester are smoke free, ie smoking is not allowed inside. (Leicester health and wellbeing survey 2018).

Our ambitions 

• To work towards a smoking prevalence amongst young of less than 3%
• Encouragement of the ‘annual quit attempt’ as per guidance in ‘The End of Smoking’ 14. Reduce smoking prevalence amongst adults to 11% or less by the end of 2026
• To reduce the supply of, and demand for, illicit tobacco and e-cigarettes in the city, and to ensure public premises in the city adhere to smoke-free legislation by working closely with partners in Trading Standards and the public safety team. To increase the percentage of smoke free homes in the city to 95% or more
• To embed tobacco control communications across all relevant systems so that tobacco control becomes ‘everyone’s business’
• To work in partnership with the public health oral health team to raise awareness of the harms of tobacco on oral health.

A smoke-free pregnancy for all

National ambitions

• Reduce the prevalence of smoking in pregnancy from 10.7% to 6% or less by the end of 2022

Our 2020 status

• Overall SATOD has remained almost static over the last 3 years (10.2% 2016/17 compared to 10% 2019/20).

Our current status

• Overall SATOD has remained static from 2019/20 (10%) to 2021/22 (10%). However, we have seen a decrease from 2021/22 (10%) to 2022/23 (9%).

Our ambitions

• To reduce prevalence of smoking in pregnancy to 7% or less in Leicester by the end of 2026.
• To deliver a robust pathway of support for pregnant smokers which runs throughout antenatal care and extends to postnatal care, including inpatient support.
• To support all families to live in smoke-free environments and prevent pregnant women from being exposed to harmful second hand smoke risks.

Parity of esteem for those with mental health conditions

National ambitions

• Improve data collected on smoking and mental health to help us to support people with mental health conditions to quit smoking
• Make all mental health inpatient services sites smoke free by 2018.

Our 2020 status

• 17% of Leicester residents have poor mental health – an increase from 14% in 2015. Adults with a serious mental health issue are significantly more likely to smoke – more than double the likelihood than the general population. 31.5% of adults in Leicester with a mental health condition are current smokers, double the city average
• Mental health sites at LPT are all smoke free since 2018.

Our current status

• It is believed that COVID-19 had a negative impact on mental health, however there is no up to date data to demonstrate its impact on poor mental health. Adults with a serious mental health issue are significantly more likely to smoke – more than double the likelihood than the general population 25.4% of adults in Leicester with a mental health condition are current smokers, this has reduced by 6.1% since 2020
• Mental health sites at LPT were no longer smoke free during Covid-19 but returned to being smoke free since 2022.

Our ambitions

• To reduce the prevalence of smoking in those with mental ill health
• To develop pathways to ensure people with mental ill health receive continuity of care throughout their journey to be smoke free
• To support Leicestershire Partnership Trust to maintain smoke-free mental health sites.

Backing evidence-based innovations to support quitting

National ambitions

• Help people to quit smoking by permitting innovative technologies that minimise the risk of harm
• Maximise the availability of safer alternatives to smoking.

Our 2020 status

• Live Well is an ‘e-cig friendly’ stop smoking service – a report published by Public Health England in 2015, which was corroborated by an independent expert evidence review in 2018, identified that e-cigarettes are at least 95% less harmful than tobacco smoking
• Leicester has a stop smoking service which provides licensed nicotine replacements therapies and prescription stop smoking medications to people for a 12 week period.

Our current status

• Live Well is an ‘e-cig friendly’ stop smoking service
• Leicester has a stop smoking service which provides licensed nicotine replacements therapies, e-cigarettes and prescription stop smoking medications to people for a 12 week period.
• CURE provides an inpatient bedside smoking cessation service for acute, maternity and mental health patients. CURE provides a digital app for NHS staff to access and support them along a quit journey.
• Launching incentive scheme for pregnant women and their partners to support quits during pregnancy.

Our ambitions

• Continue to provide people with up to date evidence-based advice on, and promote, less harmful quitting aids.