Smokefree England: Covid-19 and PHE Abolition

Baroness Laing of Elderslie Excerpts

Thursday 12th November 2020 Commons Chamber

[Liz Twist]

Sorry, Madam Deputy Speaker. I am getting carried away.

I will be asking the Minister what he will be doing to ensure that vital maternity safety programmes, such as the saving babies’ lives care bundle, can get back on track. I will be asking him what he will do to develop a national strategy for reducing rates of smoking in pregnancy among women from disadvantaged communities, learning the lessons from the areas where the greatest declines have been seen in smoking in pregnancy. I will be asking him how he will ensure that mental health trusts are required to implement National Institute for Health and Care Excellence guidance and that the Care Quality Commission is directed to assess that when it carries out its inspections. Finally, I will be asking him what steps he will take to ensure that smokers with mental health conditions receive evidence-based advice about switching from smoking to vaping.

I want to elaborate a little further on those issues. As a result of comprehensive action at national, regional and local levels, significant progress has been made over the years on bringing down smoking rates in England. The 2019 prevention Green Paper’s commitment to make England smokefree by 2030 was an appropriately ambitious and welcome commitment to continuing this important mission. However, a year on from the end of the Green Paper consultation, we have yet to see the Government’s response or their promised and much-needed further proposals, which would enable us to meet the 2030 ambition.

Despite our national progress, smoking remains the leading cause of preventable illness and death in England. Each year, smoking kills more people than obesity, alcohol, drug misuse, HIV and traffic accidents combined. Smoking is a particular challenge in my constituency of Blaydon, where 17.4% of adults smoke, compared with 15.3% across the north-east and 13.9% nationally. Smoking costs Blaydon £1.8 million every year, largely as a result of NHS treatment costs, lost productivity due to ill health and premature death caused by smoking. For communities such as Blaydon, achieving the smokefree 2030 ambition will be tough, but it remains essential for the health and wellbeing of our community. However, analysis by Cancer Research UK finds that on current trends, disadvantaged communities such as my own will not become smokefree until the mid-2040s. This rate of progress is not acceptable and not affordable for our most deprived communities.

The last tobacco control plan was two years late, as we have heard. It should have been published in 2015, and it was delivered in the summer of 2017 only because of the commitment of the then Health Minister, the hon. Member for Winchester (Steve Brine), who I am pleased to say has just joined us. The tobacco control plan that he introduced included the ambition for a smokefree generation, and now that the Government have committed to deliver this by 2030, the pressure is on. Our current tobacco control plan is set to run out in 2022, leaving an eight-year gap in which, according to Cancer Research UK, the rate of smoking prevalence decline must be 40% faster than our current trajectory if our nation is to meet the 2030 tobacco control plan commensurate with the scale of the ambition to be smokefree by 2030.

I shall turn now to the NHS long-term plan. The successful delivery of the plan is essential to the achievement of the smokefree 2030 ambition. The plan published in January last year sets out welcome commitments to tackle smoking in the NHS. By 2023-24, NHS-funded tobacco dependence treatment will be offered to all hospital in-patients who smoke; all pregnant smokers and their partners, too, if they smoke; and all long-term users of specialist mental health and learning disability services who smoke.

The evidence is clear of the benefits this will bring, both to smokers and to the NHS. Smokers are 36% more likely to be admitted to hospital and smoking is responsible for almost 500,000 admissions each year in England. One hospital patient in four is estimated to smoke. The increased demand that smoking places on NHS treatment capacity translates into an enormous financial burden. Each year, smoking costs the NHS around £2.6 billion, including avoidable secondary care costs estimated at £890 million a year. The cost in the north-east to the NHS is around £132.3 million a year, with smoking in Blaydon alone responsible for around £300,000 of that. Across the north-east, it is estimated that implementing the long-term plan commitments at just 40% coverage, as is aimed for by the end of 2021-22, would deliver net savings of nearly £12 million to the NHS in the north-east.

In the north-east, progress towards implementation of the long-term plan’s commitments on smoking is well under way. Treating tobacco dependency is one of two key priorities for the north-east and north Cumbria integrated care system population health and prevention work stream. To focus efforts across the region, a dedicated north-east Smokefree NHS/Treating Tobacco Dependency Task Force was established in 2017. The taskforce has provided strategic direction, developing regional resources and facilitating partnership working with all stakeholders, including NHS trusts, local authority tobacco commissioners, Public Health England and primary care.

As of April 2020, all NHS trusts in the north-east had achieved smokefree NHS status by implementing updated smokefree NHS policies and pathways to identify and treat smokers from admission, in line with national guidance. Across the north-east, trusts have established good links between hospitals and community stop-smoking services funded by local authorities to ensure treatment started in hospital is continued after patients leave hospital. Trusts are training staff to build capacity. They have also signed the NHS smokefree pledge as a clear and visible way to show commitment to helping smokers to quit and to providing smokefree environments.

Elsewhere, progress has not been so heartening, and it is clear that the funding and focus promised by the long-term plan are much needed. An audit of smoking cessation advice and services in NHS acute hospitals, published earlier this year by the British Thoracic Society, concluded that there is poor adherence to national standards and slow progress in identifying and treating smokers. In fact, in many cases the situation is worse than at the time of the last audit in 2016. One smoker in two is not asked whether they would like help to quit. Only one hospital in three has a hospital-funded smoking cessation practitioner, compared to one in two in 2016. Referral to hospital smoking cessation services is available in only four out of 10 hospitals. In 2016, the figure was more than half.

Progress on the long-term plan’s commitments has also not been immune from the impact of the covid-19 pandemic. Early implementation sites chosen to stress test the new tobacco dependency treatment pathways set out in the long-term plan were due to start in April, but this had to be delayed until last month. With winter approaching, and the risk of co-circulation of covid-19 and seasonal flu looming, there is a real risk that work to deliver the long-term plan’s commitments on smoking could be derailed. If we are to achieve the smokefree 2030 ambition, addressing smoking where contact with smokers is greatest is an opportunity that must not be missed

Let me turn to smoking in pregnancy. The Minister is as concerned as I am about this issue, on which there is too little progress. This needs to be a major focus of the next tobacco control plan. Ensuring that more pregnancies are smokefree not only protects the baby as it grows and reduces the risks of complications such as stillbirth and miscarriage; it also gives children the best start in life. NHS England has included addressing smoking as a key part of the initiative to reduce stillbirth and neonatal deaths through its saving babies’ lives care bundle, which is designed to encourage trusts to implement evidence-based measures to improve the safety of pregnancies. However, as with other aspects of NHS activity, this work has been undermined by the impact of covid-19, with a key aspect—carbon monoxide breath tests for all women—currently suspended. I understand that there are also reports from local authorities’ stop-smoking services that fewer pregnant women are being referred for them for support by maternity services. What will the Minister do to ensure that those vital maternity services get back on track as a matter of urgency?

Despite work in the NHS, progress has not been made anywhere near swiftly enough. There are big variations in the performance of different parts of the country. In a soon-to-be published analysis, Action on Smoking and Health finds that rates of smoking in pregnancy have increased in the past five years in a third of clinical commissioning groups, while declines have been seen in less than half, or 44%. It is therefore hardly surprising that the Government seem so unlikely to achieve their ambition of reducing rates to 6% by 2022. In the north-east, we continue to have some of the highest rates of smoking in pregnancy in the country. These are driven by high levels of disadvantage in the region, but, unlike in some regions where rates have even increased, rates in the north-east have fallen in the past five years, from 17% in 2016 to 15% in 2020. Progress has been driven by the regional tobacco programme in the north-east and by the work of NHS England, Public Health England and local government.

The Minister might be interested to hear that a recent analysis by The Times found that areas of the country that were likely to have seen big drops in rates of smoking in pregnancy were also more likely to have implemented financial incentive schemes to support pregnant women to quit. Evidence on the effectiveness of these schemes has been accumulating for many years; they have been shown to increase quit rates when implemented alongside evidence-based quit support. Such incentive schemes are in place in Greater Manchester and South Tyneside. Madam Deputy Speaker, I can see you looking at the clock, so I shall press on.

[Madam Deputy Speaker (Dame Eleanor Laing)]

For the sake of clarification, there are very few people present and the hon. Lady is making important points, so, just for once, I am not putting her under any time pressure.

[Liz Twist]

As you say, Madam Deputy Speaker, this is an important issue.

I return to my point about developing a national strategy for reducing rates of smoking in pregnancy among women and the disadvantaged communities they come from. What does the Minister plan to do to ensure that those reductions are seen and that there is a continued decline in smoking in pregnancy?

Let me turn to smoking and mental health. The last tobacco control plan for England was widely welcomed for including a specific focus on smoking and mental health. With such high rates of smoking in the community and such little progress in reducing rates, this focus was long overdue. Progress has been made since the plan was published, with mental health trusts being set a target: to implement smokefree settings, in line with NICE guidance on smoking, by 2018.

However, despite that, an ASH survey commissioned by Public Health England to look at trust implementation found the following:

“Staff behaviour often enables smoking, with staff accompanying patients on smoking breaks every day in 57% of trusts.

In 55% of trusts, patients were not always asked if they smoked on admission.

Only 47% of trusts offered the choice”

of stop smoking medications

“in line with NICE best practice”.

The impact of covid-19 is likely to have further hindered the implementation of NICE guidance. The Mental Health and Smoking Partnership, a coalition of leading mental health and physical health charities, has raised concerns that some trusts have been rolling back what smokefree policies they had put in place. There are concerns that the Care Quality Commission is not assessing the implementation of NICE guidance on smoking in a consistent way, with trusts receiving conflicting messages on implementation from different parts of the system. Another question I ask the Minister is whether he will ensure that mental health trusts are required to implement NICE guidance PH48 and that the CQC is directed to address this when it carries out inspections.

Action in mental health in-patient settings is only the tip of the iceberg; most smokers with a mental health condition will never have an in-patient stay. The NHS long-term plan has committed to implement a universal smoking cessation service in mental health settings. A promising area for support in the community, and via primary care, is improving access to psychological therapies services, which were established in 2008 with the ambition of scaling up access to talking therapies. About 1 million people with depression and anxiety access IAPT services each year. It is estimated that about 28% of people with depression and anxiety smoke. Quitting smoking has also been found to improve depression, with the same effect as taking antidepressants, so there is a major opportunity to improve both mental and physical health by integrating smoking cessation support into IAPT services. Research by the University of Bristol is under way to explore the integration of support for smokers with these talking therapies, and the early findings are positive. Individual local services, such as Talkworks in Devon, have also started to explore the potential of integration. However, smaller-scale pilots, although important, miss the big opportunity to reach many thousands each year with additional support.

E-cigarettes are a major opportunity to help more smokers to quit, particularly those with high levels of dependency, common among smokers with a mental health condition. E-cigarettes have been shown to help smokers successfully quit at greater rates than traditional nicotine replacement therapies and to be popular quitting aids. Despite the need among smokers with mental health conditions and the potential for e-cigarettes to save many lives, the attitude towards e-cigarettes within mental health services remains varied. Two excellent examples of good practice in mental health trusts can be found in my region, where the Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and the Tees, Esk and Wear Valleys NHS Foundation Trust both offer e-cigarettes to their patients as a treatment option, alongside the provision of nicotine replacement therapies. Those trusts have shown not only leadership in treating tobacco dependency and implementing national guidance, but real pragmatism on vaping, which could save the lives of many smokers with mental health problems who may not otherwise be able to quit smoking.

Unfortunately, that pragmatism is not found nationwide, and in many trusts the restrictions placed on vaping are not dissimilar to those placed on smoking. Such inconsistency is also seen in staff attitudes towards e-cigarettes. New unpublished data gathered by ASH found that 46% of mental health nurses and 66% of psychiatrists had received no training on e-cigarettes. As a result, many are uncertain about the role of e-cigarettes in supporting smokers in their care. So I reiterate the last of my questions: what steps will the Minister take to ensure that smokers with mental health conditions receive evidence-based advice about switching to vaping? This is an important issue that requires persistence and detailed attention. I look forward to the Minister’s positive responses to these proposals.

--- Later in debate ---

[Jim Shannon (Strangford) (DUP)]

For the second time today, it is a pleasure to follow the hon. Member for Winchester (Steve Brine), given the knowledge he has of all the subjects we have covered in this debate and the last one. I thank him for his contribution when he was Minister, too. It is always good to see him in his place.

I congratulate the hon. Member for City of Durham (Mary Kelly Foy) on what I think may be the first debate she has led in the Chamber. If it is, I say to her, “Well done and congratulations.” We look forward to many more contributions from her in this place. I was glad to add my name to the request to the Backbench Business Committee for this debate, and to work alongside the hon. Lady to highlight some of these issues.

I believe that freeing smokers from the tyranny caused by their addiction, and the damage it causes to their health and wellbeing, is an issue not just of health but of human rights. I am my party’s spokesperson for health and human rights, and this debate covers both those issues.

This issue is close to my heart, as I know it is for speakers on both sides of the House. Public health policies, which are the responsibility of the devolved nations, have a key role to play in tackling smoking, but so do the Government in Westminster and this debate. I am pleased to see the Minister in his place. He and I have been good friends for a long time, and I look forward to his response because I know it will be positive.

I want to refer quickly, if I may, to the Northern Ireland Department of Health tobacco control strategy, which was implemented in 2012. It was clear that the Northern Ireland Assembly was trying to direct its action at children and young people, disadvantaged people, and pregnant women and their partners who smoked. A review of that strategy undertaken earlier this year found that Northern Ireland has met its target of ensuring that a minimum of 5% of the smoking population accesses smoking cessation services annually, but there is still a group of people who continue to smoke. I am conscious that people have freedom of choice, but we hope that they take note when we present them with the health issues.

That target was achieved, but we are not hitting our targets at population level. There was a target to reduce the smoking rate among manual groups from 31% to 20% by 2020. That rate still lingers around 27%, so that target has not been met. There was also a target to reduce smoking during pregnancy from 15% in 2010 to 9% by 2020. To date, however, that rate has barely declined, so we have hit problems in Northern Ireland. At the time of speaking, the rate is 14%, so we have reduced it by only one percentage point. Let us be very clear: smoking when pregnant puts babies at risk of avoidable harm, including stillbirth, premature birth and birth defects.

We seem to have done better on the target for 11 to 16-year-olds. I am really quite encouraged by that. There has been a reduction from 8% in 2010 to 4%. The target was 3%, so we are one percentage point shy of it, but what we have done there has been quite dramatic. Children who live with smokers are almost three times more likely to take up smoking than children from non-smoking households, which creates a generational cycle of inequality, with smoking locked into disadvantaged communities.

Will the Minister make contact—he probably has—with the Northern Ireland Assembly, and particularly the Health Minister, Robin Swann, to see what has happened there? I feel that we can feed off each other regionally in Administrations, to our advantage. If something is being done right in England, we want to know about it in Northern Ireland, and the same applies in Scotland and Wales.

The disadvantaged communities worst affected by smoking have also been hit hardest by the coronavirus pandemic. Smoking is a leading risk factor for all sorts of things, such as cardiovascular disease and chronic obstructive pulmonary disease, which have been identified by Public Health England as being associated with worse outcomes from coronavirus. When households stop spending money on tobacco, it can lift them out of poverty, and it increases the disposable income available to spend in local communities rather than lining the pockets of the transnational tobacco firms.

Those inequalities are a problem not just for Northern Ireland but in every part of the United Kingdom. The answer is more action at population level through Government interventions that support people, particularly in disadvantaged communities. I believe that the time is right for the Department of Health and Social Care to publish a new tobacco control plan that addresses UK-wide issues as well as those relating just to England—I believe that we should be doing this across the four regions—and provides solutions to the threats posed by Brexit as well as delivering on the opportunities.

Smoking on screen is an issue close to my heart; we have to find some way of addressing it. Smoking is rarely portrayed in an unattractive manner, or associated with negative consequences. Guidelines on smoking have been established by the communications regulator, Ofcom, but they are often not rigorously applied. The UK Government and Ofcom have committed to working with the British Board of Film Classification to ensure a consistent approach across the piece. On the tobacco control plan, I said in 2018:

“A clear causal link has been established between smoking initiation among young people and smoking on screen in the entertainment media. The impact is down to the amount of smoking that young people see, not whether it is glamorised or not.”

Young people may feel, sometimes unconsciously, that smoking is normal, and that we should all be doing it. However, its depiction is linked to greater risk of smoking uptake. In that earlier debate, I asked:

“Will the Minister ask his colleagues who are responsible for the regulation of film and TV in the Department for Digital, Culture, Media and Sport to work with the Department of Health and Social Care, and press Ofcom and the British Board of Film Classification to ensure that their codes effectively tackle the portrayal of smoking in films and television programmes that are likely to be seen by children?”—[Official Report, 19 July 2018; Vol. 645, c. 685.]

At the time, the Minister briefed that Ofcom and the BBFC were dealing with the issue; quite clearly, Minister, that has not happened to the extent that we would like.

[Madam Deputy Speaker (Dame Eleanor Laing)]

Order. The hon. Gentleman promised me that he would no longer address the Minister, but would take to addressing the Chair, in the way one is supposed to in this place. He speaks in this Chamber more than any other Member, and he knows that he must not address the Minister. I cannot understand why he persists in doing it.

[Jim Shannon]

Thank you, Madam Deputy Speaker. I will certainly endeavour to get that right.

In 2018, there was an explosion of new video on demand services, such as Netflix and Amazon Prime, which are particularly popular among young people. Ofcom’s on demand programme service rules, governing video on demand services such as Netflix, have no rules at all on smoking. The use of video on demand continues to grow, so this problem will only get worse. Is the Minister prepared to look at that issue and address it?

The licensing of tobacco retailers is another issue that I spoke about in 2018 that bears raising again. In Northern Ireland, since 6 April 2016, retailers have been obliged to register with the tobacco register of Northern Ireland; the deadline for doing so was 1 July 2016. It built on similar schemes in Scotland and Wales. In 2018, we implemented a track-and-trace scheme that required every retailer to have an economic operator identifier code. That system was required by the EU tobacco products directive, but the Government have confirmed that it will continue after we leave the EU. Can the Minister confirm that all nations in the UK will continue to implement a retail register scheme? Will he ensure that officials at Her Majesty’s Revenue and Customs talk to their opposite numbers in Northern Ireland, Scotland and Wales about their experience of the retail register scheme, and the lessons to be learned about it from the devolved Administrations?

Are the tobacco control regulations on e-cigarettes delivering on the twin goals of helping smokers to quit and protecting children from taking up smoking—objectives supported by all parties and all nations of the United Kingdom of Great Britain and Northern Ireland?

There is a concerning loophole in our regulations: while it is illegal for e-cigarettes to be sold to children under 18, according to advice from trading standards, it is not illegal to give them out as free samples to anyone of any age. Could the Minister give us direction on that? How can we ensure that things are done correctly? I hope the Minister is aware of the article in The Observer in October that highlighted that a supplier working on behalf of British American Tobacco was caught handing out samples from BAT’s popular e-cigarette brand to a 17-year-old without carrying out any kind of age check. That contravenes the spirit, if not the letter, of the regulations. Given the importance of balancing the needs of smokers against any impact on young people, it is vital that a review of these regulations is undertaken. Will the Minister set a timeline for just that?