Monitoring the impact of the English smokefree legislation using routine data

1
Monitoring the impact of the English smokefree
legislation using routine data

• Dr. Bobbie Jacobson OBE
• Vice Chair APHO
• Director LHO

2
Background

• Smokefree legislation came into force 1st July
  2007 in England
• Protecting against passive smoking is becoming
  more common place in policy globally
• Creates a supportive environment for those that
  want to quit
• Provides us with a unique opportunity to monitor
  the more local impacts of the legislation on a
  range of tobacco -related indicators
• For England as a whole, there were 234 smoking
  attributable deaths per 100,000 of the population
  aged 35 and over in 2003-05

3
Lessons learned from UK countries

• There is a need for early impact intelligence in
  addition to longer-term research projects
• Positive impact on acute coronary events could be
  a very early impact
• Smoking cessation increased before the
  legislation comes into force too early to tell
  for England
• Smokefree Legislation on its own- in the absence
  of other comprehensive tobacco control policies -
  is not enough to ensure prevalence continues
  falling (e.g. Ireland)
• APHO well placed to do national and regional
  analyses using routine secondary data analysis

4
What is the role of the Public Health
Observatories?

• Monitoring not research
• Providing intelligence to support local public
  health delivery using a range of routine data
  sources
• Providing early feedback to regional and local
  practitioners to help focus the wider efforts on
  tobacco control
• Working alongside researchers in National
  programmes
• Signposting important research findings and good
  practice as it emerges

5
Monitoring using routine data

• Short-term The smokefree scorecard approach
• Impact on smoking cessation services
• Compliance with the legislation
• Impact on (smoking cessation) prescribing
• Qualitative/contextual information (not routine)
• Medium/Longer-term analysis
• Hospital Admissions data
• Mortality data
• Smoking prevalence
• Primary care data from the quality and outcomes
  framework of the GP contract

6
The English Health and Health Care Delivery System
Government Departments
NATIONAL
NHS London
Government Office (London)
Mayor GLA Family
REGIONAL
London Public Health Team
London Health Commission
Third Sector
Primary Care
Police
Education
NHS Trusts
Local Authorities
LOCAL
Communities
7
Smoking Cessation Indicators

• Routine PCT returns to Strategic Health
  Authority
• 4 week quit rates per 100,000 population
• Considerations
• All PCTs in England submit these data
• Comparisons can be made by age and gender,
  pregnant women
• No information for ethnicity and prescribing -
  the central returns only show those that set a
  quit date and not those that quit
• Potential for more detailed analyses by ethnicity
  and SEG if data collected directly from PCTs

8
Short-term indicators smoking cessation

• Problems
• Indicator definition and population at risk
• Most cessation activity is outside the NHS
  service
• Timescales of data availability
• Interpretation of outputs. Legislation directed
  at protecting workers rather than at stopping
  smoking.
• PHOs responsibility to demonstrate both direct
  and indirect impacts

9
Short-term indicators - compliance

• Local authorities (LAs) will record information
  directly themselves
• Freephone national compliance line for the public
• DH Compliance data collection form for Local
  authorities (LAs)
• data published on the smokefree England website
  (www.smokefreeengland.co.uk)
• Regional level and national data only reported.
• Data fields include
• Number of compliant premises
• Enforcement action
• Number of complaints/queries received

10
Compliance

• Problems
• Interpretation and presentation LAs will have
  different approaches to breaches
• Can we add anything to current national analysis?
• Approaching LAs individually for data is a
  time-consuming option . Access will be variable.

11
Short term indicators - prescribing

• Data can be obtained from Electronic prescribing
  dataset (EPACT)
• Number of Nicotine Replacement Therapy (NRT)
  items prescribed and Zyban or Varenicline per
  quarter.
• Comparison with similar time periods in previous
  years and uptake of NRT in the months prior to
  the legislation .
• Potential additional work looking at spend on
  smoking cessation services held by PCTs and
  Hospitals

12
Short term indicators prescribing

• Problems
• Time consuming
• Only picks up GP data
• Misses data from smoking cessation services,
  hospitals and over- the- counter purchases.
• Drug sales data is not routinely available and
  may be difficult to obtain

13
Contextual/qualitative

• Show an evidence base from other countries
• Show real life accounts of monitoring legislation
  locally PCTs and Local authority partners
• Identified through regional tobacco leads
• Considerations
• Not routinely collected
• Inconsistencies

14
Medium/Long-term analyses admission data

• To fit with DH commissioned longer term projects
• PHO expertise in secondary analysis using HES,
  mortality and primary care data
• Ability to provide analyses at a
  regional/sub-regional level
• Work will benefit from collaboration with
  research colleagues who already have access to
  other non-routine data
• Areas for analysis could include
• Myocardial infarction
• Stroke/respiratory tract infection
• Smoking attributable admissions
• Smoking attributable bed use costs
• Consistent methodology needed in work across the
  country (e.g. use of ICD-10 codes)

15
Medium/Long-term analyses

• Mortality
• PHOs have access to mortality files
• Already produce smoking attributable mortality
  for community health profiles
• GP Contract Quality and Outcomes Framework (QOF)
• GPs record information for QOF as part of payment
  incentives
• Analysis of QOF smoking status for Local Delivery
  Plans (LDP) - how many of your practice
  population has a recorded smoking status
• Problems
• This is not now a requirement in QOF to record
  no incentives for GPs smoking status only
  included under disease groups such as CHD
  patients not all patients.

16
Medium/Long-term analyses

• Smoking prevalence
• Lacking good national consistent smoking
  prevalence figures for local populations to
  monitor tobacco control
• Will differ across areas with local surveys etc
• For example the London Boost of the HSfE aims to
  create a pre-legislation smoking prevalence
  figure
• Synthetic estimates from ONS new release due
  soon- are all we have currently

17
Recent progress - pre-legislation

• Public attitudes
• An ONS survey showed
• 77 of people agreed with the legislation in 2006
  and
• 8 would visit pubs less often but 15 would
  visit more often
• Recent DH surveys carried out by ICM from
  Feb-June 07 showed
• 78 of adults supporting the legislation,
  including 90 non-smokers and 47 smokers.

18
Current progress post legislation

• Early days - anecdotal evidence from
  consumer/market research
• Research by Ciao Surveys (market research
  company) of 1,000 people in August 07
• over 50 of smokers are smoking fewer cigarettes
  than before the legislation
• 34.1 said they now smoke less when they are out
  in bars and clubs.
• 89.3 of non-smokers and 61 of smokers believe
  bars and pubs to be more pleasant since the ban.

19
Current progress post legislation

• Cigarette Sales
• The consumer group AC Nielsen (who provide
  marketing research information services) found
• Cigarette sales fell by 6.9 in the four weeks to
  28th July
• Similar results found in Ireland when they
  introduced their legislation in 2004
• 2002 1.2 drop in cigarette sales
• 2003 3.4 drop
• 2004 8.7 drop

20
Current progress post legislation
Source Smokefree England July 2007
21
Current progress post legislation
Source Smokefree England July 2007
22
(No Transcript)
23
APHO resources on Tobacco and smoke free
legislation

• Smoke free England website resources e.g.
  compliance data and surveys
• ASH Briefings and Reports http//www.newash.org.
  uk/
• Summary of work undertaken by PHOs on tobacco and
  health (http//www.lho.org.uk/events/lhoevents.asp
  x)
• Report of APHO workshop Feb seminar Monitoring
  the impact of new Smoke-Free Workplace
  Legislation The role of the PHOs
  (http//www.lho.org.uk/events/lhoevents.aspx)
• Useful links
• APHO website http//www.apho.org.uk/apho/
• LHO website http//www.lho.org.uk/