CASE STUDY

BACKGROUND

Every year, over 8 million people die as a result of tobacco use globally, of which 1.2 million are from second-hand smoke exposure. Tobacco is also significantly detrimental to the economy and the environment. Reducing smoking and tobacco-related harms are global health priorities that resulted in the adoption of the WHO Framework Convention on Tobacco Control (WHO FCTC).

England has responded to the WHO FCTC through national policy and action, including a vision to create a smoke- free generation (1–4). Its response is a result of how the United Kingdom of Great Britain and Northern Ireland has implemented the WHO FCTC, including its MPOWER measures (5). The National Health Service (NHS) Long-Term Plan, published in 2019, reinforces this by committing to more

action on prevention and health inequalities and to funding tobacco treatment services for smokers in hospital, pregnant women and mental health service users (6).

Despite the fact that the prevalence of smoking has been in decline since 2011, 5.9 million people still smoked in England in 2018 (14.4% of adults), accounting for 77 800 deaths (7).

Tobacco use continues to drive inequalities, compounded by a recent history of austerity and local government spending cuts (8). This highlights challenges in implementing the WHO FCTC and national plans within local settings, where diverse sociocultural barriers to smoking cessation exist.

However, opportunities are emerging. Recent changes in England promote population health through local health care, working in closer partnership across sectors (6).

Across the course of 2020 approximately 42 Integrated Care

CASE STUDY

Make smoking invisible: tailoring a global health priority to a former mining town in England

Ceryl Harwood,¹ Kaye Mann,² Anne Smith,³ Elizaveta Lebedeva,⁴ Kristina Mauer-Stender,⁴ Richard Jenkins,³ Julia Burrows², Andrew Snell³

1 Yorkshire and the Humber School of Public Health, Leeds, England.

2 Barnsley Metropolitan Borough Council, Barnsley, England.

3 Barnsley Hospital NHS Foundation Trust, Barnsley, England.

4 World Health Organization Regional Office for Europe, Copenhagen, Denmark.

Corresponding author: Andrew Snell (andrewsnell@ nhs .net)

ABSTRACT

Tobacco use is one of the leading preventable causes of illness and premature death globally, accounting for 8 million deaths a year. In England, approximately 5.9 million people still smoke.

England has strong national tobacco control, with many of the requirements of the WHO Framework Convention on Tobacco Control in place, including the MPOWER measures. However, tobacco remains a burden both to health and on the economy in England, and is also a driver of inequality. Addressing this burden effectively requires localized implementation to reinforce national action.

Barnsley is a former coal mining and now market town in England that has experienced high rates of tobacco use and the related health problems. In

response, Barnsley has taken innovative cross-sectoral action. Since 2012 the adult smoking prevalence in the town has fallen by 7%, compared to a 4.9% decrease nationally. The smoking prevalence in routine and manual occupations in Barnsley fell by 6.3% from 2016 to 2017.

This paper shares the lessons learned from Barnsley and describes the whole system approach that has targeted inequalities and achieved a greater reduction in local tobacco use than nationally. The paper focuses on three local interventions: the social norms campaign Make Smoking Invisible, and supporting smokers to quit through both maternity care and hospital services.

Keywords: TOBACCO CONTROL, CROSS-SECTORAL, SOCIAL NORMS, HOSPITAL, LOCAL

Systems (ICSs) will be established across England, facilitating local collaboration to manage resources, remove barriers and improve population health.

Over the last three years, Barnsley has exemplified cross- sectoral tobacco control shaped by local knowledge. Barnsley is a former coal-mining town in England and one of five towns and cities within the South Yorkshire and Bassetlaw ICS.

Barnsley has a growing and ageing population of 243 341, with areas of high deprivation and a strong cultural identity rooted in its industrial heritage (9, 10).

In 2012 Barnsley had an adult smoking prevalence of 24.4%, over 5% above the concurrent national average of 19.3% (11).

Particularly high rates of smoking were evident in routine and manual occupations (32.7%) and adults with mental health disorders (33% in 2013). According to nationally reported data, 23.3% of pregnant women in Barnsley smoked in 2011/12 compared to 13.3% nationally.

This paper describes how localized, cross-sectoral and synergistic tobacco control in Barnsley during subsequent years helped to achieve a rate of reduction both in overall smoking prevalence and in inequalities relating to smoking prevalence that exceeded that of England (11). Efforts particularly focused on changing social norms, hospital activity, support during pregnancy and addressing local influences on smoking behaviour, some of which had strong cultural roots.

PROGRAMME DEVELOPMENT

CROSS-SECTORAL PARTNERSHIPS

Since 2013 public health teams have been positioned within local government in England, their responsibilities include tobacco control, and in 2013 Barnsley’s public health team undertook a review of local tobacco control (12). Areas for improvement were identified as strengthening leadership, partnerships, innovation and communications, and also included the relaunch of Barnsley’s cross-sectoral Tobacco Control Alliance (TCA), which took place in 2014. TCA members include those from public health, children’s services, fire and rescue, education, local health-care providers and members of local government, with accountability to Barnsley’s health-care leaders. Supported by local intelligence, the review also prompted Barnsley to sign the Local Government Declaration on Tobacco Control, a national declaration to guide local commitments, in 2014 (13).

Barnsley’s TCA was tasked with developing an action plan.

The resultant Barnsley Tobacco Action Plan for 2016–2018 (14) included the vision, “to see the next generation of children in Barnsley born and raised in a place free from tobacco, where smoking is unusual,” and ambitions to:

• promote smoke-free workplaces and health care;

• reduce accessibility, visibility, affordability and acceptability of tobacco, especially for children;

• improve knowledge of tobacco harm;

• reduce second-hand smoke;

• support smoking cessation.

A new local stop smoking service contract specified a universal offer, which included behavioural change and pharmacotherapy support open to all Barnsley residents who smoke, alongside targeted support to reduce inequalities for people in routine and manual occupations (through workplace promotions and clinics) and with mental health disorders (by training mental health staff, encouraging smoke-free services and delivering co-located clinics) (15).

MAKING SMOKING INVISIBLE IN BARNSLEY

Evidence that children are less likely to smoke if it is not viewed as normal motivated Barnsley’s Make Smoking Invisible programme, part of the Tobacco Action Plan.

Building on the national ban on smoking in indoor public areas, Barnsley aimed to decrease smoking visibility for children by introducing outdoor smoke-free areas. A survey on smoking beliefs and attitudes in high street shoppers in Barnsley found general support for these smoke-free outdoor public areas (16). Respondents also overestimated smoking prevalence in Barnsley, supporting actions to reshape social norms. Public consultations were undertaken before each stage of the programme, which confirmed support for smoke- free areas including play parks, schools and high streets, and helped guide its implementation.

REDUCING SMOKING IN PREGNANCY

Barnsley had high rates of maternal smoking at time of delivery compared to the national average (23.3% versus 13.3% in 2011/12) (11). This, alongside a 2008 NHS quality review, prompted the innovative appointment of a public health midwife by Barnsley Hospital. Three models of support

for smokers were developed based on expert guidance and sequential testing (17):

1. awareness raising within existing hospital maternity services with referrals to external stop smoking services;

2. a maternity stop smoking service provided collaboratively with community partners and addressing coexisting social issues such as isolation and poverty;

3. a dedicated maternity stop smoking service delivered by trained midwives and support staff as part of routine antenatal care.

The models were tailored using local intelligence and engagement with service users and health-care partners to understand sociocultural influences on behaviour. Key motivators for pregnant women included the health and financial costs of smoking and simultaneous support of household members to quit. The service optimized contact with the women through one-on-one support and continuity with flexible access and location. A set of routine interventions was introduced for all pregnant women, including exhaled carbon monoxide screening, very brief advice and opt-out referrals for specialized support.

TOBACCO CONTROL IN THE HOSPITAL

Successes in Barnsley’s tobacco control programme, recognition of the attributable local disease burden and a new appreciation for the efficiency of a whole system response strengthened the partnership between Barnsley Hospital and the local authority. Aligned with best practice regarding the implementation of prevention in health-care settings, a novel joint hospital and local authority public health consultant post was created to support Barnsley’s tobacco control work through hospital activity.

Despite the presence of a pre-existing community-based stop smoking service in the hospital, most patients admitted into hospital were not routinely offered smoking cessation support, and this is consistent with findings from a national audit of hospitals (18). In response to this, the growing evidence for in-hospital support and advocacy by the Royal College of Physicians (19), Barnsley Hospital prioritized tobacco control.

This was reinforced by the ICS adopting the QUIT programme to systematically identify, advise and treat patients who smoke, reframing tobacco dependency as a clinical condition, not a lifestyle choice (20). Interventions include measuring exhaled carbon monoxide, documenting all patients’ smoking status and providing early brief advice, pharmacotherapy

and specialist support referrals, all on an opt-out basis. The programme also promotes smoke-free hospitals and supports staff who smoke, validating staff as role models and reaching over 3000 of the local workforce at Barnsley Hospital.

IMPLEMENTATION

MAKING SMOKING INVISIBLE ACROSS BARNSLEY

Implementation in all settings has been complex, reflecting the challenges of changing culturally engrained behaviour, navigating across sectors and reducing inequalities. Smoke- free areas were incrementally introduced. Initially children were targeted through smoke-free play parks, with signage designed by local school children (Fig. 1). High impact areas followed, including Barnsley’s Town Hall square and market areas. A tobacco-related sales ban was also introduced within Barnsley’s markets, making them England’s first smoke-free market areas. All 80 primary schools now have smoke-free school gates and promote a whole school approach, including parental support. Other local leisure and education partners are now helping sustain this rollout by proactively becoming smoke-free.

Smoke-free areas operate a voluntary code without enforcement. Signage asks people politely not to smoke and promotes social norm messages, such as “9 out of 10 users of this park would like it to be smoke-free.” Prominent local stakeholders and media have attended the launch events for each smoke-free area.

INVESTMENT SUPPORTS BETTER PREGNANCY OUTCOMES

Engaging pregnant women in maternity care and identifying psychosocial issues affecting many pregnant women who smoke helped improve the effectiveness of the models.

Alongside strong leadership and partnerships, this shaped a successful business case for a holistic stop smoking model delivered collaboratively by specialist trained midwives and community services.

However, despite successfully reducing smoking prevalence over two years, funding was substantially reduced in 2016 as a cost-saving exercise, with a 75% loss of the dedicated workforce. A subsequent audit demonstrated that, compared to non-smokers, pregnant women who smoke experienced more health-care contacts, labour complications and neonatal admissions, lower breastfeeding rates and were more likely to live in deprived communities. Supported by the TCA, these

findings and observed rises in smoking prevalence at delivery, the reinstatement and expansion of the service were secured by 2018.

SMOKE-FREE HOSPITAL

To drive tobacco control in Barnsley Hospital, a cross-sectoral group, coined the QUIT Steering Group and chaired by the hospital’s Chief Executive, was established. The smoke-free hospital was launched on World No Tobacco Day 2019, with a “Proud to be Smokefree” logo and new hospital signage displaying powerful messages from patients, staff and children asking people not to smoke (Fig. 2). To engage staff, QUIT was presented to hospital leaders and clinical staff in business and educational meetings. Communication materials, including posters and clinical guidance, have since been developed to challenge false beliefs regarding smoking prevalence, raise awareness of stop smoking support and encourage staff to routinely identify and treat people with tobacco addiction.

QUIT implementation has been coordinated by public health professionals in close collaboration with clinical staff. Local tailoring of the high-level standardized ICS model helped engage patients and staff and align it with clinical priorities.

The rollout will be incremental, working initially with priority wards and will use a quality improvement approach to develop pathways that integrate smoking cessation into routine clinical practice.

The demands of clinical work and the need to engage thousands of staff have shaped a pragmatic pathway within existing practice. Staff engagement and training helps to reshape beliefs and practice (for example, to consider an admission as a teachable moment and providing support using an opt-out rather than an opt-in approach), and to determine how QUIT is best delivered in clinical practice (for example simplifying pharmacotherapy options and referrals).

Highlighting continuity and accessibility of the hospital and community services helped dispel staff concerns that patients will return to smoking once discharged. Clinical leadership, programme visibility, consistent messages and alignment with FIG. 1. EXAMPLE OF SMOKE-FREE AREA SIGNAGE

DESIGNED BY SCHOOL CHILDREN IN BARNSLEY

Source: Barnsley Metropolitan Borough Council.

FIG. 2. EXAMPLE OF SMOKE-FREE HOSPITAL SIGNAGE CO-DESIGNED BY LOCAL PARTNERS AND MEMBERS OF THE BARNSLEY HOSPITAL QUIT STEERING GROUP

Source: Barnsley Hospital NHS Foundation Trust.

the Barnsley-wide approach have all been vital. A combination of committing dedicated public health workforce capacity and ensuring QUIT implementation was perceived as everyone’s business has helped to achieve programme delivery.

OUTCOMES

Significant progress has been made in Barnsley. Since 2012 smoking prevalence in adults has fallen by 7% to 17.4% in 2018, compared to the England average reduction of 4.9% and regional reduction of 5.2% (Fig.  3). Smoking prevalence in routine and manual occupations in Barnsley has fallen from 32.7% in 2012 to 27.5% in 2018 (Fig. 4). The greatest progress was seen in 2016, following the launch of Make Smoking Invisible, when the overall prevalence of smoking fell by 2.4%

compared to 0.6% for England, and the prevalence in routine and manual occupations fell by 6.3% compared to 0.8% for England (Fig. 4).

In a 2019 survey, when Barnsley residents were asked how many people out of ten they thought smoked in Barnsley, the average response was 5.27 out of 10, compared to 7.3 prior to the implementation of the smoke-free areas. This may have contributed to the lower actual smoking prevalence through associations between perceptions, social norms and behaviours. Ongoing public consultation confirms growing support of smoke-free areas and greater awareness of the detrimental effects of smoking.

In 2012, three years after the public health midwife was appointed in 2009, almost 3% less women were smoking at time of delivery in Barnsley, compared to a fall of less than 2%

over the same period nationally. From 2013/14, a considerable

decline in smoking rates occurred, closing the gap between the overall rates of maternal smoking in Barnsley and England as a whole (Fig. 5). A subsequent rise in 2017/18 followed service decommissioning, although once reinstated, a continuing reduction in smoking rates occurred. From July to October 2019, 14.1% of Barnsley women were smoking at time of delivery, nearly 2% less than the previous year, with a national reduction of only 0.2% observed.

The monitoring of QUIT implementation in Barnsley Hospital uses routinely collected data to identify changes to process, such as specialist referrals and pharmacotherapy prescriptions. Baseline activity showed approximately two thirds of patients admitted to the medical admission unit had a documented smoking status, but less than 5% who smoked FIG. 3. TRENDS IN SELF-REPORTED PREVALENCE OF

SMOKING IN ADULTS FOR BARNSLEY, THE YORKSHIRE REGION AND ENGLAND

0%

5%

10%

15%

20%

25%

30%

2011 2012 2013 2014 2015 2016 2017 2018

% of adults self-reporting as smokers

Year

Barnsley Yorkshire region England Data from the Annual Population Survey, conducted by the Office for National Statistics (11).

FIG. 4. TRENDS IN SELF-REPORTED PREVALENCE OF SMOKING IN ADULTS WORKING IN ROUTINE AND MANUAL OCCUPATIONS FOR BARNSLEY, THE YORKSHIRE REGION AND ENGLAND

0%

5%

10%

15%

20%

25%

30%

35%

40%

2011 2012 2013 2014 2015 2016 2017 2018

% of adults working in routine and manual occupations self-reporting as smokers

Barnsley Yorkshire region England Year

Data from the Annual Population Survey, conducted by the Office for National Statistics (11).

FIG. 5. TRENDS IN THE PERCENTAGE OF PREGNANT WOMEN KNOWN TO BE SMOKERS AT THE TIME OF DELIVERY FOR BARNSLEY, THE YORKSHIRE REGION AND ENGLAND

0%

5%

10%

15%

20%

25%

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19

% of pregnant women known to be smokers at time of delivery

Year

Barnsley Yorkshire region England Data calculated by Public Health England from the National Health Service Digital return on Smoking Status At Time of delivery (SATOD) (11).

received a specialist referral or pharmacotherapy. Since QUIT implementation, smoking status has been documented in the notes of 75% of admitted patients and inpatient referrals have increased from less than five a month to over 40 (Fig. 6).

SHARING LEARNING AND CHALLENGES

WHOLE SYSTEM WORKING

The NHS is committed to strengthening its support for tobacco control and treating addiction. Local authorities have ongoing responsibility for smoking cessation and tobacco control. With this shared interest and the nature of tobacco control, cross- sector collaboration is essential. Agreeing a shared vision helped to unite organizations in Barnsley and implement a more integrated programme delivery. Improving the health of local people resonated with all partners. However, short-term cost-saving efforts can distract from this. Ensuring all actions align with the shared vision and recognizing the health and financial benefits of a whole system approach were enablers to getting the right things done.

Specific activities have helped maintain engagement. Visible multi-agency senior leadership validates the agenda, engages partners and facilitates shared accountability. The TCA and QUIT steering group provide open forums to share challenges and opportunities. Cross-partner branding of programmes reinforces this. For example, hospital QUIT promotions include the Make Smoking Invisible brand.

Practical issues, such as data sharing, contracts and performance management, have challenged coordination.

However, the shared commitment has strengthened relationships and helped address these. As the work progresses, ongoing community engagement remains a priority, so that what matters to people living in Barnsley and at-risk groups shapes local tobacco control.

CHANGING CULTURALLY DEFINED BEHAVIOUR

The false belief that most people in Barnsley smoke is apparent through conversations with hospital staff and the public.

Community engagement in Barnsley helped understand the foundations of local beliefs and tailor factual counter- messages. Recognizing the deep-seated culture that drives these false beliefs and delivering coherent, iterative messages framed to different audiences will continue. Committing resources, applying behaviour change theory and creating system alignment have generated resilience.

EMBEDDING PREVENTION IN PRESSURIZED SYSTEMS

Health accounts for the biggest public service expenditure in England, but health and care systems are operating at capacity.

In the last decade, central government funding for local authorities has declined and annual NHS funding growth has been low, despite growing demand. In addition, Barnsley experiences higher emergency hospital admissions than nationally. Introducing new priorities is therefore difficult.

The case for change for Barnsley used local data to describe short- and long-term impact. For local authorities, communicating the benefits of reducing smoking on communities was important, including the lives saved, economic gains and the impact on waste. Promoting Barnsley as proactive and innovative through its novel alignment with national policy also appealed. Community experiences provided powerful narratives that helped engage elected members, who have responsibility for people living within their constituencies.

Within the hospital and local NHS organizations, emphasizing clinical relevance was crucial. Understanding the reduction in hospital readmission rates and overall health-care costs helped engage partners. NHS England and Royal Colleges (Physicians and Nursing) endorsement of tobacco control activity helped to validate the professional responsibility of clinical staff.

Framing tobacco addiction as a medical condition has helped create a paradigm shift in health-care staff and change daily practice. This is reinforced by clear messages of how rapid nicotine withdrawal treatment can reduce ward disruption.

Flexibility and persistence have been key. The initial targeting of priority clinical areas before a wider rollout has enabled the development of tailored information and training, while building collaboration with clinical leaders.

FIG. 6. TRENDS IN THE NUMBER OF INPATIENT REFERRALS MADE TO BARNSLEY HOSPITAL STOP SMOKING SERVICE FROM JANUARY TO NOVEMBER 2019

0 5 10 15 20 25 30 35 40 45

1 2 3 4 5 6 7 8 9 10 11

Number of referrals

Month

ENSURING INEQUALITIES ARE REDUCED, NOT WIDENED

A universal approach to smoking cessation risks engaging mainly those who are already motivated and able to make a change for themselves, and excluding those at greatest need.

Communities where smoking prevalence is high, health literacy is low and social motivators to smoke are strong are particularly vulnerable; these communities are often the most deprived with the poorest health outcomes.

Appreciating contextual issues that promote smoking is vital.

Local intelligence helped to target inequalities alongside a universal offer. Community stop smoking services are delivered within and tailored to all six Barnsley neighbourhoods (each of around 40 000 people). Maternity services use patient groups to identify issues pertinent to pregnant women, including psychosocial influences on smoking. Communicating free provision of pharmacotherapy and specialist services helps reduce financial barriers to engagement.

LOCALIZING A STANDARDIZED APPROACH

Delivering national and regional tobacco control commitments within local settings requires a balance of standardization delivered at scale and localization. There are unique opportunities that national programmes bring; however, aligning these with local priorities and mechanisms sharpens implementation and increases impact.

ICS ownership of the QUIT programme has supported collaboration, investment, programme design and accountability. A standardized approach across the ICS to certain components has improved efficiency. Barnsley’s experience from the maternity stop smoking services and the first stages of hospital QUIT implementation has helped demonstrate the value and sustainability of fitting the programme to local ways of working and aligning with local authority tobacco control activities.

CONCLUSIONS

Strong national policy must be supplemented by local leadership and tailored implementation if tobacco control is to make sustainable change and address inequalities. While tobacco use in Barnsley has historically been higher than the national average, and some of the observed reduction is likely to be related to national action, local progress has outstripped that of England overall. This achievement is strongly associated with whole system local working, facilitated by

strong partnerships within Barnsley’s TCA. The shared vision of a smoke-free generation motivates, focuses and sustains collaborative action in Barnsley, tailored to local needs and targeting priority groups. This has laid solid foundations for the effective maternity service and hospital-based QUIT campaign. QUIT implementation across the hospital is now being rolled out. The Barnsley Tobacco Action Plan has been refreshed to cover 2018–2021 and smoke-free high schools are planned. Success from this model is now being used to drive similar approaches for other local public health issues, including alcohol.

Acknowledgements

The authors acknowledge three invaluable and committed tobacco control champions: Diane Lee is the mastermind behind Make Smoking Invisible, she has built bridges within Barnsley’s Tobacco Control Alliance and celebrates success in a way that energizes all partners; Gilly Brenner tirelessly assessed the need for and benefits of more proactive tobacco control across Barnsley; Lisa Wilkins made the detailed and comprehensive case for sustainable investment in tobacco control from the Integrated Care System.

Disclaimer:

The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the World Health Organization.

Sources of funding:

None declared.

Conflict of interests:

None declared.

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