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Greater Manchester
Health and Social Care Partnership
Making Smoking History
A Tobacco Free Greater Manchester
2017-2021
2
Contents
1. Our Greater Manchester Ambition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2. The smoking context in Greater Manchester. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3. Benefits of a comprehensive evidenced based programme for a Tobacco Free Greater Manchester . . . . . 19
4. The GMPOWER model – an evidence based framework for delivering a Tobacco
Free Greater Manchester. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.1 Growing a social movement for a Tobacco Free Greater Manchester . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
4.2 Monitor tobacco use and prevention policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.3 Protect people from tobacco smoke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4.4 Offer help to quit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4.5 Warn about the dangers of tobacco. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
4.6 Enforce tobacco regulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.7 Raise the real price of tobacco. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
6. Next steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 2021
3
1. Our Greater Manchester Ambition
Greater Manchester is leading the way Infographic 1. Number of quits needed to
for tobacco control in the UK, by setting achieve 13% prevalence
an unprecedented ambition to reduce
Current adult
smoking prevalence levels at a pace and
smokers in Greater
scale greater than any other major global
Manchester
city. If we can reduce smoking by a third
by the end of 2020, overall adult smoking 393,000
prevalence will be 13%.
This is a key part of delivering our Taking
Adult smokers who
Charge commitment to achieving the must quit by 2020
greatest and fastest improvement to the to achieve 13%
health, wealth and wellbeing of the 2.8
million people who live here. Achieving this
115,000
in Greater Manchester would mean 115,000
Greater Manchester amongst those aged
fewer smokers by the end of 2020 as shown
over 351. That’s almost 13 people dying early
in infographic 1 right.
every day, around half in middle age. And
There has been some excellent local delivery while smoking uptake amongst the young
in recent years within the boroughs across has fallen markedly, it is estimated that
our city region where overall prevalence every hour in Greater Manchester another
rates have fallen significantly. In spite of child starts to smoke, equating to another
this, many localities and Greater Manchester classroom of smokers per day2. It is time
as a whole, still has much higher smoking we turned off the tap of new young smokers
rates than the England average. There are once and for all.
4,500 smoking attributable deaths a year in
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 2021
4
1.1 Our single greatest Currently, 18.4% of the adult population relationship with the public, use community
in Greater Manchester smokes compared assets, engage both commercial and
opportunity to close the gap in
to 15.5% nationally.3 VCSE (voluntary, community and social
health outcomes enterprise) sector partners and to combine
Significantly reducing smoking prevalence at
The Greater Manchester Population Health our investment and commissioning capability
a far faster rate than at present will: improve
Plan, published in January 2017, set out our creates a basis for fresh thinking and new
health outcomes, support poverty reduction,
approach to delivering a radical upgrade in ways of tackling complex entrenched health
deliver higher productivity, give babies and
the health and wellbeing of our communities. and social problems. Setting an ambitious
children a better start in life, reduce health
It includes a focus on developing local and target makes sense and provides extra
and social care costs and cut crime by
Greater Manchester-wide whole system focus and stretch for our evidence-
dealing with the illegal tobacco trade.
and innovative approaches to major health based approach across a wide range of
For many people smoking is a chronic and partners who have been involved in the
risks such as smoking, and in ways that fully
relapsing addiction, which generally begins development of this strategy.
harness the talents and assets of our citizens,
of local government, the NHS, public, private in childhood, and is not a lifestyle choice.
Reducing smoking rates will not only
We have an opportunity to break an inter-
and voluntary sector partners and employers. reduce the rates of cancer in our
generational cycle of tobacco harm in our
population4 (as illustrated in the Cancer
Smoking is still by far the greatest cause poorest communities in every borough of
Research UK Infographic 2 opposite),
of ill-health and early death in Greater Greater Manchester and deliver a tobacco
free generation. it will reduce cardiovascular disease,
Manchester. Despite good progress made
respiratory disease and dementia too.
in recent years there are still 393,000 adult
Devolution has provided a unique and There is also evidence to show that
smokers amongst the city region’s 2.8m
extraordinary chance to deliver sustainable quitting smoking can improve mental
population.3 This equates to 62,500 more
change. The ability to reform our public health. This is critical given the very high
smokers than if Greater Manchester
services, create a new sustainable health rates of smoking in those with mental health
prevalence was at England average.
and social care system, to broker a new conditions. Our Tobacco Free Greater
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 2021
5
Infographic 2: Cancer Research UK. Lifestyle changes to reduce cancer risks4 Manchester Strategy links to a wide range of
local and region-wide strategic programmes
of work, with which it will be fully integrated
at delivery level.
Tackling tobacco harm works. It is a cost
effective evidenced based approach which
will reduce smoking rates and saves local
lives. This strategy describes our vision, and
sets new compelling targets, and challenges
all stakeholders in tobacco control to
increase their efforts and accelerate the rate
of decline of smoking prevalence within the
next four years and over the longer term.
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 2021
6
Our Greater Manchester vision is for a tobacco free future where together
we make smoking history for all our children. Our transformation programme
delivered in collaboration with all partners will include a range of innovative and
evidence based interventions delivered at scale:
A public conversation with the whole population Local insight to drive
on smoking and health and measures that targeted campaigns
will bring about this change with the Greater and communications
Manchester Mayor and Local Authority Leaders at community level
and region-wide
Advancing a fully Smokefree NHS including
standardised primary and secondary care stop A new Smokefree Pregnancy
smoking journeys for all smokers programme that transforms whole
system support for interventions to
support quitting and keeps mums
Extending Smokefree Spaces across the city- and babies smokefree, including
region to create family friendly spaces to help those women identified as most
make everyone healthier vulnerable to relapse to smoking
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 2021
7
A crackdown on illegal tobacco will tackle
demand and supply safeguarding children and
tackling crime
State of the art stop smoking support for every smoker to quit
including a new local digital offer and telephone support
Innovative E-cigarette friendly policies, services and offers
Partnerships with social housing providers and their tenants for support to
quit innovations, smokefree homes and tenancies
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 2021
8
1.2 New ambitions for a tobacco manual workers to 21% by 2020 (now pleasant places for us to come together
free Greater Manchester 27.5%). for better health.
We hold and believe in our target of bringing ●● Reducing smoking rates in pregnancy
to 6% by 2021 (now 12.8%).
1.3 Achieving the ambitions
down adult smoking prevalence by around
Reducing smoking prevalence at this pace
a third, from the current 18.4% to 13% by ●● Reducing regular and occasional
and scale is unprecedented in the UK but
the end of 2020, and to 5% by 2035. These smoking in 15 year olds to 3% by 2021
expert analysis demonstrates that it is
are in line with targets set out both in the (now 8%).
achievable with sufficient focus, resource
national ‘Achieving World Class Cancer ●● Increasing stop smoking attempts to
and funding. It requires a tripling of the
Outcomes’5 strategy and the Action on 40% (now 30%).
longer term trend reduction of 0.5% a
Smoking and Health ‘Smoking Still Kills’6 ●● Sustaining short-term quit success at year – in other words smoking in Greater
report. Achieving this in Greater Manchester 20%. Manchester needs to fall by at least 1.5
would mean 115,000 fewer smokers by the
●● The Greater Manchester Combined percentage points every year to stay
end of 2020 as noted above. On current
Authority’s (GMCA) leadership, including on track towards the 13% overarching
trajectories achieving this level of quits
the Mayor, considering actions to prevalence target.
would close the gap in prevalence between
work towards a ‘Tobacco Free Greater
Greater Manchester and the England More recently, some localities appear
Manchester’, including options for
average by the end of 2020, and lead to to have been reducing smoking at a
extending smokefree proposals to
fundamental improvements to the health and greater rate than the longer term Greater
make parks and other family friendly
wellbeing of some of the poorest residents. Manchester average according to Annual
public spaces smoke-free and banning
Population Survey data trends. The four year
Other Greater Manchester proposed targets smoking around public building
trend indicated by the overall percentage
to contribute to achieving a Tobacco Free entrances; supporting quitting by
change between 2012 and 2016 in the data
Greater Manchester will include: providing fewer opportunities for people
set in Table 1 below demonstrates that the
●● Reducing smoking rates in routine and to smoke; less litter; greener and more
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 2021
9
vast majority of localities have more recently change and we will learn from what has legislation, widespread consultation and
accelerated the pace of smoking prevalence worked well in reducing smoking prevalence engagement on standardised packaging
reduction, with some correlation with levels in these localities. This period also saw and renewed health harms mass media
of investment. Bolton, Oldham, Salford, intense national tobacco control policy and campaigns.
Trafford and Wigan saw the greatest overall regulatory activity. This included display
Table 1: Adult Population Survey Smoking prevalence by locality 2012 - 20161
Percentage Overall Percentage
Point Change Change (2012 - 2016)
Locality 2012 2013 2014 2015 2016 (%) (%)
Bolton 22.8 22.7 21.6 18.5 17.9 -4.9 21.5
Bury 20.8 18.6 19 19.5 19.1 -1.7 8.2
Manchester 24.4 23.8 25.5 22.7 21.7 -2.7 11.1
Oldham 24.2 21 19.3 22.2 18.8 -5.4 22.3
Rochdale 24.4 21.6 22.5 22 19.4 -5 20.5
Salford 27.5 24 24.5 22.3 20.3 -7.2 26.2
Stockport 15.9 14.5 15.9 15.1 12.2 -3.7 23.3
Tameside 25.7 24 22.8 21.7 22.1 -3.6 14.0
Trafford 19.2 19.2 15.8 16.4 12.6 -6.6 34.4
Wigan 22.7 20.1 20.7 18.7 17.7 -5 22.0
North West 21.1 20 19.6 18.6 16.8 -4.3 20.4
England 19.3 18.4 17.8 16.9 15.5 -3.8 19.7
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 2021
10
However Figure 1 opposite which compares Figure 1: Smoking Prevalence (%) in Adults 2012-16 (APS) and projection to 2024 for the
the APS data for England and Greater general population of England and Greater Manchester
Manchester as a whole and projects the
current trends forward demonstrates that at
25
the current rate of decline we will not close England (General)
Percentage of adult population who smoke
the gap with England until beyond 2036. Our Greater Manchester (General)
GM Tobacco Target
new strategy should allow us to close the
gap by 2021. 20 Trend Greater Manchester (General)
Trend England (General)
We will learn from what’s working well in
these boroughs and other areas in Greater
Manchester, the UK and globally to bring 15
the very best evidence and innovation to our
delivery challenge.
10
5
0
2012 2014 2016 2018 2020 2022 2024
Year
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202111
Case Study
Making Smoking History through our Tameside Tobacco Alliance
Tameside has seen a decline in smoking in wants to ensure that services are accessible
adults and in pregnant women. Whilst smoking and acceptable to our LGBT population and
rates remain higher than the England average, have an even greater focus on prevention in
the Borough has a proactive and collaborative young people.
partnership that is working to reduce the biggest
An ethos of continuous improvement and
cause of ill health and early death in Tameside.
self-challenge has the Alliance to identify
The Tameside Tobacco Alliance is led by areas for development through self and peer-
public health and its diverse membership assessment processes. Members recognise
includes Be Well Tameside, local NHS partners, the synergy between different programmes and
regulatory services, New Charter Homes, organisations that the partnership brings, and
Greater Manchester Fire and Rescue Service, value that ‘the whole is greater than the sum of
and HealthWatch. Members’ work includes its parts’.
supporting adults, pregnant women and
By working collaboratively with partners and
young people to quit, tackling illegal tobacco,
communities, the Alliance, together with senior
promoting Stoptober, championing smokefree
level support from the Health and Wellbeing
events, supporting workplaces on tobacco
Board, is looking forward to seeing further
policies and interventions and encouraging
health gains for local residents by working
residents to sign up to a ‘7 Steps Out’
towards a Tobacco Free Tameside and making
smokefree homes pledge. This year the Alliance
smoking history for children.
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202112
Smoking kills 1 in 2 Local goals will be agreed to reflect Modelling by Professor Robert West from
long term smokers. contributions to be made by every locality University College London, a world-expert
to reducing smoking related health in stopping smoking, plots the projected
Around 4,500 people inequalities. The improvement journey progress using the Smoking Toolkit Study7
are currently dying will be evaluated and assessed in real North West data as a proxy for Greater
each year in Greater time to ensure that actions are delivering Manchester (Figure 2 below). A monthly
Manchester from against targets and amended if necessary boosted Greater Manchester sample for
smoking related during implementation. the Smoking Toolkit will support tracking
of actual progress
illnesses. Stopping Figure 2: estimated reduction in smoking prevalence alongside other data
smoking is the single (from smoking toolkit survey data) to 2025
sets including the
best thing a smoker can Annual Population
Projected smoking prevalence to 2025 at
do for their health. target prevalence reduction rate 1 Survey (APS).
GM target
25%
North West
20%
England
13.45%
15%
10%
11.05%
7.57%
5% 5.49%
0%
2016 2018 2020 2022 2024
Percentage of those people aged 16+ who are currently smoking cigarettes
1
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202113
Analysis by Professor West from many years Table 2: Key actions needed to achieve faster reduction in prevalence
of studying smoking behaviour sets out key
Increasing quitting and reducing uptake
actions that will drive prevalence reduction
detailed in in Table 2 right. Potential
constribution
to prevelence
Policy reduction1 Comment
Increase real cost of tobacco 0.2 Amplify tax increases via targeted localised
communications, tackle illicit supply and
demand
Run regional mass media 0.2% Amplify national campaigns and run
campaigns campaigns at Greater Manchester and
targeted borough level.
Implement Very Brief Advice in 0.2% Offer support to 50% of smokers
Primary Care
Introduce Stop-Smoking+ 0.2% Ensure that all smokers have access to
model of support, and extend appropriate support to stop smoking
Secondary care provision
Reduce access to tobacco 0.1 Restricting outlets, extending smoke-free, age
of sale
1
Over and above the existing 0.5%pa prevalence reduction
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202114
2. The smoking context in Greater Manchester
2.1 The impact of smoking on as a whole so R&M groups need particular for instance, health and social inclusion
our people and our city focus. However, as we target these groups policies. In Salford the local authority policy
we need to take great care not to stigmatise states that building and planning control
region
people who smoke and recognise that should ‘avoid possible adverse impacts
There is a downward trend in smoking
smoking is an addiction and not a lifestyle on health’ including ‘facilities that could
prevalence across most of Greater
choice. encourage smoking’.
Manchester. The difference of nearly 8%
between the borough with the highest We understand the drivers of smoking Digital support as part of a new Greater
prevalence (Manchester: 21.7%) and are complex and need multi-faceted Manchester-wide stop smoking offer to
lowest smoking rate (Stockport: 12.2%) approaches, including recognition in and empower people to quit will sit as part
masks the fact that smoking related cross-references to strategies to reduce of a locality health and wellbeing offer
inequalities impact every borough. poverty and worklessness and improve which recognises the complexity of
Smoking is the biggest single driver of mental health. Focus, though still needs people’s lives and their wider needs within
health inequalities and disproportionately to be maintained on tobacco control and local communities. These could be, for
affects poorer communities8. Those on low smoking cessation as stated in a recent instance, advice around debt management or
income, with mental health conditions, in Action on Smoking and Health briefing on accessing mental health services or housing
social isolation, in the criminal justice system, the relationship with health inequalities8: support.
looked after children and LGBT groups are ‘Improving social conditions is not a sufficient
Youth smoking rates are now at national
far more likely to smoke than the general strategy to reduce smoking prevalence in
average prevalence for Greater Manchester
population so efforts to reduce smoking need more disadvantaged groups. The specific
as a whole reflecting changing social norms
to be targeted. drivers of smoking uptake and tobacco
driven by tobacco policy and legislation.
addiction must also be addressed’.
In Greater Manchester, for example, 27.5% of Over the last decade a range of measures
routine and manual (R&M) workers currently There is scope to include measures to have reduced youth smoking rates nationally
smoke compared to 26.5%3 in the country tackle tobacco harms in locality work on, and in Greater Manchester. These include
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202115
a raised age of sale, graphic health warnings, Table 3: Number and % of smokers by borough (Annual Population Survey 2016 data)
proxy purchase regulations, and bans on
cigarette vending machines and displays, Estimated numbers % of smokers % of Routine & Manual
Local authority of smokers (age 18+) (age 18+) smokers (age 18+)
smoking in public places and cars with
children. The introduction of standardised Bolton 38,699 17.9 25.3
packaging in May this year which was Bury 27,846 19.1 29.9
championed by Greater Manchester Combined
Manchester 91,452 21.7 28.7
Authority and local communities will further
drive down rates over time. Oldham 32,697 18.8 27.4
Beyond such measures, sustained Rochdale 31,952 19.4 32.1
reductions in youth smoking will be Salford 39,351 20.3 31.0
delivered by tackling adult smoking Stockport 27,839 12.2 22.4
because children who live with smokers are
between three to four times more likely to Tameside 38,419 22.1 35.6
become smokers themselves than children Trafford 22,645 12.6 28.0
of non-smoking households9. Opportunities Wigan 45,175 17.7 26.3
also exist to work with local schools and
colleges to engage young people as part of an Greater Manchester 396,127 18.4 27.5
integrated school and community approach. Sources: Annual Population Survey 2016 and ONS Single Year Mid Year Population Estimates 2016
The estimated numbers and percentages of
To address the health of the poorest and Stockport 22.4% R&M smoking rates,
smokers across the 10 Greater Manchester
fastest routine and manual groups will however all localities face wide local
conurbations are highlighted right. (NB: minor
need greater focus. There is wide variation gradients in smoking rates across social
variations with other data sets reflect sample
in the city-region with Tameside at 35.6% class.
sizes, confidence intervals, roundings etc.)3
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202116
2.2 Tackling inequality Infographic 3: Smoking and poverty Demonstrating the economic benefits of
stopping smoking at an individual and family
Cutting smoking rates also has the
level needs to be connected to broader
potential to financially aid some of
work to reduce poverty and the burdens of
Greater Manchester’s poorest families.
debt throughout Greater Manchester. This
The Institute of Fiscal Studies has
could be through third sector activity
estimated that people in the lowest
such as that being undertaken by the
income group spend almost twice as
Citizens Advice organisations or asset
much of their income on tobacco and
based community development initiatives
alcohol than those in the richest.10 The
such as those led through social housing
Institute of Economic Affairs estimates
providers to help tenants with issues like
that the average smoker from the poorest
food poverty that impact family health
fifth of households spends between
and wellbeing.
18 and 22 per cent of their disposable
income on cigarettes.11
2.3 Costs to the Greater
Research by ASH indicates that there are Manchester economy
87,782 Greater Manchester households which Smoking costs the Greater Manchester
include a smoker that fall below the poverty economy an estimated £760m - £785m
line. If these smokers were empowered to quit, (equating to £1,800 every year for each
34,131 households and 62,133 people, could person who smokes).13 This includes
be lifted out of poverty if the costs of smoking increased costs of health and social care,
were taken out of the household budget as lost productivity, and house fires caused by
shown in infographic 3. Importantly this cigarettes, as illustrated in infographic 4.
would include 21,110 children.12
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202117
Infographic 4: Estimated system costs of 2.4 An opportunity to save lives cost saving benefits in Greater Manchester
smoking in GM as shown below.13
and money
More than half of smokers (54%) in Greater Based on the current smoking trends
Manchester want to quit their addiction Greater Manchester will fail to close the
and only 5% say they don’t want to stop gap with the England average until 2036 if
smoking.14 Swift action to support far more significant and sustained investment into
of those who would like to stop would not an ambitious and comprehensive tobacco
only close the gap with England prevalence control programme is not implemented. A
but also result in significant system wide radical new approach to tobacco control,
Table 4: Estimated systems cost savings by reducing prevalence
Estimated Cost
Estimated prevalence System cost*
number smokers difference
Current Greater Manchester
c393,000 £703,000,000
prevalence (18.4%) #
England prevalence (15.5%) # c331,000 £592,000,000 £111,000,000
13% c277,000 £496,000,000 £206,000,000
5% c107,000 £191,000,000 £512,000,000
# based on APS estimates
* based on estimated £1,789 system cost per smoker (ASH Ready Reckoner)
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202118
with commensurate levels of funding, cancers, vascular dementia and stroke, the risks of cardiovascular and respiratory disease and
will have the greatest impact on health levels of stillbirth. Infographic 5 below, produced by ASH, is a stark reminder of the health impacts.
inequalities, saving lives and reducing
systems costs. Infographic 5: Mortality impacts of smoking
An estimated 4,500 people in Greater
Manchester die from a smoking-related
illness each year. That equates to nearly 13
deaths every single day. Many, many more
are living with debilitating ill-health caused
by their addiction. Improving quit rates and
encouraging people not to start smoking has
a major impact on keeping people healthy,
and improving the health of current ‘sick
smokers’ such as those with some long term
conditions (LTCs). A focussed approach
to known smokers with LTCs through
primary care would significantly reduce
demand for primary care appointments,
medications, home visits and secondary
care interventions.
Reducing smoking also contributes greatly
to achieving health improvements such as
reducing the incidence of a wide range of
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202119
3. Benefits of a comprehensive evidenced based
programme for a Tobacco Free Greater Manchester
A coordinated and comprehensive approach ●● Boost the disposable income of the Multi-sector and focussed support for
to tobacco control locally and across poorest in Greater Manchester and delivery of a new strategy would make
Greater Manchester will make smoking return investment into local economies possible the significant increase needed
less accessible, acceptable and desirable, from the current c0.5% p.a. long-term
●● Drive a radical upgrade in population
empowering successful quitting and prevalence reduction rate.
health prevention as set out in the
stopping young people starting to smoke.
Greater Manchester Population Health
Reaching 13% prevalence by the end
This will: Plan
of 2020 can be achieved by:
●● Cut costs to local businesses, healthcare The delivery of a broad package of ●● Increasing the quit attempt rate from
and public services, delivering a measures will require the involvement 30% to 40%
significant return on investment of multiple stakeholders including local ●● Sustaining short-term quit success
authorities, the NHS, housing, voluntary, rates at 20%
●● Support the delivery of the 10 Locality
community, social enterprise sectors and
Plans as part of the wider Taking Charge ●● Reducing uptake of cigarette
others. A commitment from stakeholders
plan to transform our health and social smoking from 0.4% to 0.3%
to take ownership of different elements
care systems
of the programme to support and engage
This would achieve a year on year 1.47%
●● Assist diverse public service reform those who smoke to quit, stop young people
prevalence reduction. The actions needed
agendas such as employment and adults starting and change social
by partners are outlined in the next section.
and economic growth and service norms around smoking is paramount to the
reconfiguration success of achieving a smoking prevalence
of 13% by the end of 2020.
●● Protect children and young people from
multiple harms giving them the best start
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202120
4. The GMPOWER model – an evidence based framework
for delivering a Tobacco Free Greater Manchester
Our Tobacco Free Greater Manchester This will build on local and Greater Manchester wide work engaging young people, families
Strategy sets out a vision that is grounded and communities to make smoking history for children and take a stand against the tobacco
in an innovative international evidence industry whose products kill at least 1 in 2 long term smokers. The seven components of our
based framework, our GMPOWER GMPOWER model are:
model. This is based on the World Health
Organisation (WHO) multi component G row a social movement for a Tobacco Free Greater Manchester
MPOWER model introduced globally
M onitor tobacco use and prevention policies
in 2008, endorsed by the World Bank
and UK Government15. This approach P rotect people from tobacco smoke
advocates a comprehensive, multi
component approach to tackling tobacco. O ffer help to quit
Our Greater Manchester communities
W arn about the dangers of tobacco
offer us a unique opportunity to add a
seventh component to the original model E nforce tobacco regulation
to capitalise on coproduction and citizen
engagement. R aise the real price of tobacco
The following section examines the elements of the GMPOWER model, which will deliver the pace and
scale of change needed in Greater Manchester. A more detailed delivery plan will be published. In the
meantime this strategy outlines key actions to be delivered against each component in the first two
years of the strategy’s delivery.
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202121
4.1 Growing a social movement for a Tobacco Free Greater Manchester
Our approach to tobacco control will Plan work has been launched. This involves
What and when
be badged G-MPOWER, with the G close working with the Voluntary Community
standing for Growing a social movement and Social Enterprise (VCSE) sector In 2017 and 2018 we will:
for a Tobacco Free Greater Manchester. and a key aim is to enrol 20,000 ‘cancer
Build links with the Cancer
Achieving a reduction in smoking in Greater champions’ who will ‘use their experience,
Champions social movement to enlist
Manchester at the pace and scale set out knowledge and passion to support those at
their support
in this strategy will require a wide range of risk of developing cancer and those recently
actions, not least widespread public support diagnosed with the disease’16. The Greater Develop a public conversation led
and engagement and the mobilisation of a Manchester Cancer Board has a VCSE by Greater Manchester Leaders and
social movement for change. As the Greater reference group with wide representation the Greater Manchester Mayor. Early
Manchester Population Health Plan states: and this, along with other VCSE networks activity will utilise an effective digital
‘Social movements happen when people and partners such as Cancer Research UK, and local social engagement strategy
come together to fight for their rights, solve ASH and Macmillan Cancer Support could to consider people’s views on issues
problems, shift how people think, support play a vital part in designing, promoting such as smokefree spaces, licensing
each other and demand what they need’. and facilitating engagement and advocacy of tobacco retailers, raising the age
activities to help to grow social engagement. of sale of tobacco and a crackdown
In Greater Manchester we already have
on illegal tobacco
some good examples of harnessing
community engagement and involvement
in change programmes including ‘The
Wigan Deal’ and ‘People Powered Health’
in Stockport. More recently an NHS
exemplar social movement programme
linked to the Greater Manchester Cancer
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202122
4.2 Monitor tobacco use and prevention policies
Strategic intelligence and performance data A monthly boost to the Smoking Toolkit
are necessary to implement and evaluate Study will be commissioned from University
effective tobacco control policies. Regular College London. As we develop our digital
monitoring and evaluation at local and wellness offer for Greater Manchester there
city region levels, as appropriate, will be a is an opportunity to significantly improve
critical factor that influences the success data collection and collation about smoking
of the other GMPOWER measures and quits. It has the potential to revolutionise
support the ambitions of the tobacco the way we engage and connect with
control strategy and its links to wider communities and provide a new ‘front
public service reform agendas. door’ to health and well-being services as
people increasingly use their smart phones,
Proposed measures include: prevalence
wearable technology and other digital
(including within specific groups); quitting
devices to keep themselves on track.
behaviours; e-cigarette use; Shisha (water
pipes) and other niche tobacco; low What and when
birthweight for gestational age babies;
In 2017 and 2018 we will:
deaths and disease caused by smoking;
household spend on tobacco; stop smoking Develop and maintain a robust data
medication prescribing. set on smoking prevalence, attitudes
and behaviours
Commission a boosted sample
for the Smoking Toolkit Study to
track Greater Manchester smoking
prevalence and quitting behaviours
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202123
4.3 Protect people from tobacco smoke
There is no safe level of exposure to In the UK it is not illegal to use e-cigarettes voluntary smokefree places in parks and
secondhand smoke. Effectively enforced in enclosed public spaces and Public playgrounds.
smokefree legislation has been shown to Health England evidence reviews indicate
Local Authority leadership, including the
reduce the prevalence of smoking amongst that using an e-cigarette is around 95%
new Greater Manchester Mayor, could
young people and increase the probability of safer than smoking17 PHE guidance advises
lead the way on smokefree public spaces
quit attempts among adults. The successful making a clear distinction between smoking
through new byelaws for smokefree parks,
introduction of smokefree legislation in and vaping, protecting young people
entrances to public buildings, and family
2007 led to immediate improvements while supporting smokers to stop smoking
friendly spaces to create a healthier city
in population health. National evidence completely. We believe that e-cigarettes
region. Survey work in Greater Manchester in
subsequently demonstrated a 2.4% have the potential to make a significant
2015 by Healthier Futures showed there was
reduction in hospital admissions due to contribution to the achievement of our
good public support for such changes, as
heart attacks. Going smokefree saves lives ambitious smoking prevalence target.
shown in Table 7 on the next page.
and reduces smoking rates. Compliance Realising this potential depends on
with the legislation has been high and public fostering an environment in which The NHS should be an exemplar of
support increased from 72% of adults in e-cigarettes can provide a route out of smokefree policy yet many hospitals
2007 to 83% in 2014. Crucially, there is smoking without providing a route into continue to see smoking within their
now majority support for smokefree among smoking for children or non-smokers. grounds. NICE guidance on smoking
people who smoke6. Moreover, there is cessation in secondary care recommends
Given the popularity of the 2007 laws
emerging evidence that smokefree laws ‘strong leadership and management to
there is now scope to extend smokefree
lead to reductions of smoking in homes, ensure secondary care premises remain
environments further with many local
including homes with children.6 smokefree – to help to promote non-
authorities, including some in Greater
smoking as the norm for people using these
Manchester, having already introduced
services’. Creating social and environmental
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202124
Table 7: Levels of support in Greater Manchester for extending smokefree spaces motivations to go smokefree and, as
100%
9%
experience shows, this will increase the
11% 11% 10% 13%
90%
33%
chances of more successful quits.
33% 34%
80%
30% 29% 28%
70% 42% Involving young people, schools and
43%
60% colleges in messaging around the benefits
50%
28% 27%
27%
44%
of smokefree environments, not starting to
52%
40% 18% 50%
22% smoke and quitting brings opportunities to
30%
contribute to the achievement of the 13%
20% 25% 26% 28% 29%
10% 11% 20% 8%
9%
prevalence target. Smoking at age 15 in
12%
0%
5% 6% 5% 5% 7% 2%
6%
1% 1% Greater Manchester has fallen to c8%, and
I support no
smoking at
I support no
smoking at
I support no
smoking at the
I support no
smoking at the
I support no I find that people Smoking outdoors I find that people
smoking at the smoking outdoors in front of smoking outdoors
young people can be powerful ambassadors
general outdoor
public events
outdoor events
which are
following outdoor following outdoor following outdoor near to me in a
public spaces public spaces public spaces crowd to be a
children and near to me is
young people sets annoying when
if they are equipped with the confidence
specifically for
children and
where children where children where children
and families may and families may and families may
concern a bad example eating
to address smoking in their families and
families visit: Parks visit: Beaches visit: Town
centres
social circles. Healthy schools programmes
and the work of the newly created Greater
Strongly disagree Disagree Indifferent Agree Strongly agree
Manchester Children’s Health and Wellbeing
Board could help to bring a more unified
smokefree spaces reduce the chances of in the social housing sector there is
approach involving young people across the
young people viewing smoking as a normal also scope to explore opportunities with
10 localities.
thing to do and taking it up and protects providers to increase the number of
people from tobacco smoke. smokefree homes and spaces through Helping people to stop smoking also
the Housing and Health workstream of protects them from fire risk in their
Given that between 20% and 25% of
‘Taking Charge’. Work needs to happen homes. Greater Manchester Fire and
households in Greater Manchester are
in partnership with tenants to understand Rescue Service (GMFRS) estimates that
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202125
Case Study
Smokefree Sports in Bury
A pilot campaign at Manchester Maccabi Sport and Community
Club in Bury in late 2016 aimed to denormalise smoking around
children and young people, break any association of smoking with
sport and support the club to move towards becoming completely
smokefree.
It was able to galvanise parental and club support for smokefree
sporting spaces and touchlines by building on existing momentum
for a wider social movement of denormalising smoking in public
places.
Clear Smokefree Sports signage, a policy and guidance created
for sports club to adopt supported a successful campaign.
Signage was highly effective in deterring people from smoking.
Sports staff were engaged and felt confident to approach parents
and adult spectators smoking to remind them that the club is
smoke free. Parents responded very positively.
As the programme is rolled out, consideration is being given to
delivering Very Brief Advice (VBA) training for key sports club staff
to equip them with the skills, confidence and knowledge to deliver
brief smoking interventions. Further engagement work with local
and regional media will galvanise support and coverage.
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202126
carelessly discarded
What and when
smoking materials
cause almost 40% of In 2017 and 2018 we will: to ensure high levels of compliance with
accidental fire deaths. smokefree legislation, including cars
NHS Provider leaders across all Greater
GMFRS staff have a key Scope extension of smokefree spaces as
Manchester Trusts will fully mobilise delivering a
role in promoting positive potential action for GMCA and the new Greater
truly ‘smokefree NHS’ including the integration
quit messages during Manchester Mayor
of primary and secondary care support for
home and workplace
quitting as set out in NICE Guidance PH48 Work with Transport for Greater Manchester
safety checks, and
(Smoking: acute, maternity and mental health (TFGM) to launch a campaign on smokefree
signposting people to
services)18 spaces as part of a public engagement process
stop smoking support.
Reducing fire risks Social housing providers will work with Continue to work with Greater Manchester
also brings significant residents to identify opportunities to make Fire and Rescue Service (GMFRS) to promote
economic benefits, more of their estates smokefree, including smokefree homes and quit support
with smoking-related schemes for smokefree homes, supporting and
incentivising quitting and smokefree outdoor Develop guidance for GMHSC Partnership
fires estimated to cost
spaces for children member organisations to promote the use of
c£20m p.a. in Greater
e-cigarettes and other vaping devices
Manchester (see Scope a smokefree homes campaign to protect
infographic 3 on p16). children and families Work with the new Greater Manchester
Children’s Health and Wellbeing Board to
Support prisoners and prison staff to quit as part scope a more uniform approach to involving
of a move towards a smokefree prison estate young people across all localities in smokefree
Ensure local authority regulatory and other initiatives
enforcement agencies have sufficient resource
Making Smoking History - A Tobacco Free Greater Manchester 2017Tobacco
– 2021 Control Strategy - Greater Manchester 2017 – 202127
4.4 Offer help to quit
For the NHS and wider public services self-support channels with the option patients with mental health conditions,
the lifetime value of a person stopping to self-refer into more specialist brief or pregnant women, smokers with long
smoking is huge so across Greater intensive support if required. term conditions and others receive stop
Manchester we will to continue to invest smoking interventions as a routine part of
A re-designed wider range of support
in and support stop smoking services. treatment pathways.
available 24/7 would allow people to receive
They are proven to be a cost effective
help appropriate to their needs. A Greater Evidence to date indicates e-cigarettes
and key component of tobacco control
Manchester standardised specification are far safer than tobacco given that
strategies because they offer smokers
for local specialist stop smoking support tobacco is associated with more than one
their best chance of quitting.6 Most
will be agreed as part of wider work in four cancer deaths in the UK19. There is
tobacco users want to quit, however 90%
on common standards across Greater also growing evidence to suggest that
do so without specialist help or support.
Manchester. Sufficient capacity needs e-cigarettes can work successfully as
Good quality evidenced based stop to be commissioned locally to support an aid to smoking cessation. Recent
smoking services accessible to all smokers, targeted priority groups as part of the new analysis suggested that e-cigarettes may
particularly those from lower socio stop smoking service offer. This will include have contributed to an additional 18,000
economic and priority groups, are essential a digital and telephone support Greater long-term ex-smokers in England in 201520.
because people are much more likely to Manchester wide to empower and equip There is therefore scope to pilot some bold
quit long term with the right information and people with information on how to quit. All approaches to the use of e-cigarettes for
advice. A new support offer is needed to stop smoking support will be e-cigarette those smokers who have tried other quitting
help the great majority of smokers who friendly. methods unsuccessfully.
want to quit but do not want to access
Programmes to treat tobacco addiction Nationally it is estimated that 25% of
a specialist face to face service. Many
including advice and medication will be patients in acute hospitals are smokers –
people would benefit from information
incorporated into primary and secondary a far higher rate than national average.21
and guidance through digital and other
care healthcare services so that For people accessing secondary
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202128
care services there are additional improve how smoking cessation is woven based smokefree pregnancy programme
advantages of quitting, including shorter into patient pathways and these millions of including babyClear and an incentivisation
hospital stays, lower drug doses, conversations in Greater Manchester. As scheme for those pregnant women most
fewer complications, higher survival well as non-routine and routine (e.g. health vulnerable to relapse to smoking. This area
rates, decreased infections and fewer checks) appointments, known smokers with of activity is already under development as
readmissions after surgery. Addressing long term conditions and a diverse range of part of an early years workstream.
patients’ smoking needs to be a routine priority groups with high smoking rates will
There are also opportunities to scope what
part of their treatment plan. be targeted with offers of quit support.
other incentive schemes could be amplified
In secondary care, therefore, there are Many primary care clinicians show patients or rolled out in Greater Manchester. Work
opportunities to contribute to achieving the how their risk of cardiovascular risk can be is already planned to test out the role of
overall 13% target including: reduced by showing them the calculation incentives in behaviour change as part
●● The introduction systematic identification produced. Similar risk profiling systems of the emerging Greater Manchester
and support for all smokers attending for cancer could be used to explain how Lifestyle and Wellness Hub. In addition
secondary care and throughout the patients can reduce their risk by quitting there is also opportunity to work with social
patient journey smoking.23 housing providers to explore learnings from
incentive schemes which have reduced
●● Smoking cessation training included Smoking in pregnancy has major health
rent arrears or encouraged other mutually
within mandatory training impacts on two people - the mother and
beneficial behaviour changes,
●● A ‘zero tolerance’ approach to create a the baby. The present practice of assessing
truly ‘smokefree NHS estate’ smoking status by measuring the CO of all Work also needs to take place with the GM
women attending ante-natal care and having drugs and alcohol commissioners through
Primary care providers are responsible
an opt-out approach to referral for smoking the refresh of the GM Substance Misuse
for around 90% of people’s contacts with
cessation will be augmented by Greater Strategy to ensure that drug and alcohol
the NHS22 so there is scope to review and
Manchester wide adoption of an evidence services are aware that quitting smoking
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202129
Case Study
Empowering Smokefree Pregnancy in Stockport
In Stockport we have been an opportunity to be referred into
delivering babyClear, an evidence an incentive scheme which brings
based intervention to help self-empowerment, access to
professionals to deliver a whole additional information and support
system programme for smokefree and improves women’s chances
pregnancy since January 2016. of a safer delivery with minimal
complications.
At the booking visit every woman
is carbon monoxide (CO) verified, As this work has embedded into
and if the CO reading is high and practice, we promote quitting and
associated with smoking, a referral minimise the risks associated with
into the specialist service for smoking, to mums and their unborn
smoking cessation is made. The baby... for pregnancy, birth and life.
programme also gives opportunities
Once baby has been born you can
at every antenatal intervention for
see how proud mums are and there
CO verification and re-referral which
is a sense of self achievement.
becomes part of routine care.
We also offer those mums we
identify as most at risk of relapse
to smoking during their pregnancy
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202130
does not reduce the chance of recovery
What and when
from drug and alcohol misuse and may
improve it24. Contracts with drug and alcohol During 2017 and 2018 we will: Work with NHS Providers to carry out
services should include the provision of a cost-benefit analysis for hospital-
Implement a Greater Manchester
smoking cessation support. based stop smoking services, to
wide evidenced based stop smoking
inform an investment proposal
There is potential to better promote the framework and standards which
benefits of stopping smoking to workplaces provides brief and self-support Work with specialists such as National
and the development of organisational and options, including a digital platform Centre for Smoking Cessation
employee incentives such as additional as part of a wider well-being offer, Training to scope and implement
leave to reward reduced sickness absence. accessible to all smokers, particularly improvements to Very Brief Advice
This needs to be aligned to Greater those from routine and manual delivery across Greater Manchester
Manchester’s emerging work and health groups and other priority groups.
Explore opportunities to better
programme and workforce strategy. The self-support offer will also
promote to employers the benefits of
signpost access to a standardised
encouraging their workforce to stop
locality stop smoking support offer
smoking
to be delivered in a range of settings
building on existing local good Explore what measures could be
practice and making best use of local included in provider contracts to
assets. Services need to include incentivise contributions towards
harm reduction approaches and be achieving the prevalence reduction
e-cigarette friendly targets
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202132
! 4.5 Warn about the dangers of tobacco
In Greater Manchester we plan to pioneer Tailored communications need to be with a higher demographic of Asian, mixed
our own localised tailored and region- developed to reach groups of smokers with and black ethnicities.25
wide communications using integrated specific social or life-stage circumstances
In addition to the approaches that
mass media alongside the latest digital or cultural needs. This includes pregnant
work in adults there are measures that
developments and social engagement women (a separate workstream covering
reduce smoking in young people such as
innovations. smoking in pregnancy is in development),
peer education and appearance based
LGBT groups and BME communities.
Mass media and social marketing messages. Secondary schools, sixth
campaigns are known to be a cost effective In some areas campaigns need to be form colleges and further education
way of reaching large population groups developed to address particular harm establishments could be given access to
about the harms of smoking, changing issues. For instance, evidence suggests more resources to support work in reducing
attitudes and beliefs, increasing quit the use of shisha (waterpipes) is relatively the uptake of smoking, as well as being
attempts, and reducing both adult and low among adults and appears to be more encouraged to use existing materials.
youth smoking prevalence. They should be popular among young people and localities
targeted on lower socio economic groups
and disadvantaged populations, and
provide adequate resources to ensure that
reach, duration and frequency are in line
with best practice. They can also signpost
stop smoking support and promote the
benefits of enlisting help as smokers are far
more likely to succeed armed with the right
information and support.
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202133
What and when
In 2017 and 2018 we will: Scope needs of specific groups and building on existing local community
communities e.g. learning from the assets
Implement multi-channel mass media
recent ‘Proud2BSmokefree’ research
and social marketing campaigns Secure partner sign-up to a new
carried out on smoking amongst LGBT
to drive quits and denormalise Greater Manchester Declaration on
in Greater Manchester
tobacco, with a focus on lower socio tobacco control
economic and other priority groups, Tackle shisha (waterpipes) and niche
Support education establishments
and amplify national PHE campaigns products in localities to educate and
to reduce the uptake of smoking and
e.g. Stoptober / New Year Health inform smokers and businesses
support existing young smokers to
Harms / No Smoking Day to increase
Engage advocates and champions quit
penetration
amongst residents and cross sector
Develop proactive year round PR and professionals to build support for
social media activity ‘Smokefree Greater Manchester’,
Making Smoking History - A Tobacco Free Greater Manchester 2017 – 202134
4.6 Enforce tobacco regulation
Despite killing 1 in 2 consumers, tobacco Each year, the tobacco industry videos and video games also suggests
products can be sold by anyone in England. internationally spends £ billions to market a clear dose response relationship: the
Local authorities have powers, known its products using sophisticated and covert more exposure young people have to
as ‘negative licensing’, to shut down a forms of tobacco advertising, promotion smoking on screen, the more likely
tobacco retailer. However this requires the and sponsorship (TAPS). In May 2017 they are to smoke.27,28 Despite numerous
local authority to take legal action against standardised packaging legislation was efforts to engage the British Board of Film
the retailer, which is time consuming and fully-implemented, preventing tobacco Classification and Ofcom there is little
resource intensive. A positive licensing companies from aggressively marketing their evidence that the issue is taken seriously
scheme would enable local authorities tobacco products to children and young and public awareness of the impact on the
across Greater Manchester to build more people using graphics and clever gimmicks behaviour of young people is low. Anti-
proactive relationships with retailers, to initiate and maintain addiction. tobacco campaigners in the US have been
promoting good practice and making it particularly proactive on the issue for several
Whilst most other forms of UK tobacco
much easier for local authorities to stop years yet the film industry remains largely
advertising are banned tobacco is still more
retailers from selling tobacco if they find unaffected.29 In order to develop effective
subtly promoted across the entertainment
evidence of underage or illicit tobacco sales policy measures in this area, we need a
media sector - TV, films, music videos,
on the premises. There is public support clear strategy around how this exposure can
video games, the internet, music videos
for a new tobacco licensing scheme with be reduced or mitigated.
and sporting events – with glamourous
84% of adults, including 71% of smokers,
and provocative tobacco imagery. There Greater Manchester could also take a
agreeing that businesses should have a
is a growing body of evidence that lead on banning smoking on stage in
valid license to sell tobacco which can be
the representation of smoking in films theatres. This is currently allowed as an
removed if they are caught more than once
contributes to smoking uptake among exemption in England under the 2007
selling to underage smokers.6
young people.26 Evidence for music smokefree legislation if it is considered to
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