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A Smokefree Future:
A Tobacco Control Strategic Plan for Hertfordshire 2016-2018
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A Smokefree Future: A Tobacco Control Strategic Plan for Hertfordshire: 2016-2018
A Smokefree Future:
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CONTENTS PAGE Executive Summary………………………...………………………………………………….….4 Background…………………………………………………………………………………………4 Progress on the 2014-2016 Tobacco Control Priorities…..……………………………..… 6 A Vision for Hertfordshire……….………………………………………………………………..9 Priority 1. STARTING WELL: Reducing smoking-related morbidity and mortality in babies and children under 5……………………………………………………………..…………………10 Priority 2. DEVELOPING WELL: Preventing the uptake of smoking in young people and protecting children from secondhand smoke…………………………………………………….11 Priority 3. WORKING WELL: Reducing smoking in the adult population with a focus on reducing the health inequalites gap........................................................................................12 Priority 4. AGEING WELL: reducing smoking in older people with a focus on people with reducing smoking-related long-term conditions…………………………………………………13 Priority 5. DELIVERY OF THE ABOVE PRIORITIES: Tobacco control action plans (Appendix 3) are delivered by ‘Smokefree Hertfordshire’ (Hertfordshire’s Tobacco Control Alliance)…………………………….…………………..……………………………………………14
REFERENCES…………………………………………………………………………………...…15
FIGURES
Figure 1
Percentage of adults who smoke, England and Hertfordshire, 2010-2013…………………….6 Figure 2 Young people who smoke regularly in Hertfordshire 2008-2014………..………………………7 Figure 3 Percentage of pregnant women who smoke throughout pregnancy, England and Hertfordshire 13/14 – 14/15…………………………………………………………………………8 APPENDICES Appendix 1 Smokefree Hertfordshire (Hertfordshire Tobacco Control Alliance) membership
Appendix 2 NICE Public Health Guidance and Standards
Appendix 3 A Smokefree Future: Tobacco Control Action Plans for Hertfordshire 2016-2018
Appendix 4 Equality Impact Assessment
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Executive Summary Hertfordshire has made steady progress towards reaching the ambitions of the Health and Wellbeing Board’s Strategy to reduce the harm from tobacco and achieving the priorities outlined within Hertfordshire’s Tobacco Control Strategic Plan 2014-20161. In line with the refresh of the Health and Wellbeing Board Strategy for 2016-2018, this draft Tobacco Control Strategic Plan describes what we have achieved since the transfer of public health to Local Government in 2013 and sets new priorities to reduce the harm from tobacco even further. Smoking is the main cause of preventable illness and premature death in England and in Hertfordshire and has a greater impact on lower socio-economic groups, causing a widening gap in health inequalities between the better and the least well off, with some groups dying 16-20 years earlier than the general population. As well as the impact on individuals and families, smoking has a significant financial cost to Hertfordshire. Our focus is therefore not only to reduce smoking prevalence overall, but to reduce smoking in groups with higher prevalence even faster: routine and manual workers; people with mental health conditions; pregnant smokers; young people; some BME groups and lesbian, gay, bi-sexual and trans-gender (LGBT) groups as well as the homeless and unemployed and people with long term medical conditions (LTCs) as well as to protect babies and children from second-hand smoke. Providing evidence-based help to stop smoking is effective, improving success rates at 4 weeks by up to 4 times compared to no intervention and effective tobacco control measures save more than they cost. This draft strategic plan draws on the best available evidence, local insights and intelligence, following a review of tobacco control in Hertfordshire and in consultation with a wide range of members from Hertfordshire’s Tobacco Control Alliance. The Tobacco Control Action Plan (Appendix 3) describes in detail how we intend to deliver our priorities, ensuring a county-wide collaborative approach to reducing the unnecessary harm caused by tobacco.
Background ‘Healthy Lives, Healthy People, the national tobacco control plan for England’ (2011) contained three national ambitions to focus tobacco control work.2 Hertfordshire’s tobacco control ambitions 2013-2016 were based on this national plan, on data within Hertfordshire’s Joint Strategic Needs Assessment (JSNA) and following multi-agency consultation which identified that the national ambitions were not stretching enough for Hertfordshire.3
Since public health became the statutory responsibility of Local Government in 20134, tobacco control has been a high priority in Hertfordshire and steady progress has been made on our local tobacco control ambitions to reduce smoking prevalence in the adult population, to reduce the uptake of smoking in young people, to reduce smoking in pregnancy and to protect babies and children from second-hand smoke. These priorities are published in Hertfordshire’s Health and Wellbeing Strategy 2013 -20165, Hertfordshire’s Public Health Strategy 2013-20176 and subsequently Hertfordshire’s Tobacco Control Strategic Plan (2014-2016).7
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The collective efforts of ‘Smokefree Hertfordshire’, Hertfordshire’s Tobacco Control Alliance (see Appendix 1) sought to deliver these priorities for Hertfordshire to:
1. Reduce (adult) smoking in every district to 18.5 per cent or less by 2016 2. Reduce smoking in young people, so that less than 9 per cent of 15 year olds
smoke by 2016 3. Reduce smoking in pregnancy so that less than 7 per cent of pregnant women
smoke throughout their pregnancy by 2016 4. Roll out a county-wide Smokefree homes and cars scheme 5. Ensure all public sector workplaces (including grounds) are completely smoke
free by 2016 Hertfordshire’s Health and Wellbeing Board (HWbB) Strategy comes to an end in 2016 and public health has revised the tobacco control ambitions for 2016-2018 to align closely with the planned refresh of the HWbB strategy. This is also in recognition of the progress made in tobacco control to date and the need to reduce the widening gap in health between the better off and the worse off in our communities caused by tobacco use. Smoking is the main cause of preventable illness and premature death in England and in Hertfordshire and has a greater impact on lower socio-economic groups. There is a widening gap in health inequalities between socio-economic groups due to smoking, with some groups dying 16-20 years earlier than the general population from diseases such as cancer, respiratory disease, cardio-vascular disease, and gastro-intestinal disease.8 Smoking also causes debilitating conditions such as infertility, erectile dysfunction, osteoporosis, cataracts, oral disease and dementia as well as complications in pregnancy, labour and following childbirth.9 Children exposed to smoking and tobacco smoke are not only more likely to be admitted to hospital for conditions such as asthma and bronchitis, but they are more likely to start smoking themselves and smoke throughout adulthood.
Tobacco remains our biggest preventable killer, killing more people than the next six most common causes of preventable death and is a significant drain on the public purse in terms of cost to the NHS, Social Care and the wider economy.10 11 Effective and coordinated tobacco control measures save more than they cost (approximately £9.00 saved for every £1.00 spent) and this revised strategic plan pulls together actions for all stakeholders in Hertfordshire to continue to drive down smoking prevalence especially in our least well-off communities who face inequalities in health caused by smoking and second-hand smoke, which start before birth and continue throughout the lifecourse into older adulthood.12 13 Hertfordshire County Council’s Tobacco Policy was approved by Cabinet in November 2013. This policy established the Council‘s position on tobacco and its commitment to reducing tobacco use and smoking prevalence14 and the Council’s Tobacco Harm Reduction Guidance was approved in February 2015. This guidance sets out recommendations to enable smokers who are not able or not yet ready, to quit smoking to reduce the harm from tobacco without necessarily giving up nicotine use.15 16
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The NHS priority to reduce premature morbidity and mortality is outlined in the NHS 5 Year Forward View.17 All the NHS organisations in Hertfordshire are committed to delivering this and have signed the NHS Statement of Support for Tobacco Control and agreed actions to reduce smoking in pregnancy and in people with mental health conditions as well as in primary and secondary care services.18 Tobacco control in Hertfordshire was subjected to a review by Action on Smoking and Health (ASH) and Public Health England (PHE) in July 2014. The review commended Hertfordshire for its tobacco control work, resulting in winning the national CLeaR© award in July 2015. The priorities in this strategic plan come out of the recommendations of the CLeaR© report for Hertfordshire 2014,19 the revised national ambitions outlined in Smoking Still Kills, 20 and consultation with members of Smokefree Hertfordshire (Hertfordshire’s Tobacco Control Alliance) and with reference to NICE guidance (see Appendix 2).
Progress on the 2014-2016 Tobacco Control Priorities Hertfordshire’s Tobacco Control Strategic Plan 2014-2016 was approved by Hertfordshire County Council’s Public Health and Localism Panel on 6th March 2014 which provides the details on how the tobacco control priorities in the Health and Wellbeing Board (HWbB) Strategy 2013-2016 are being delivered in Hertfordshire.21 The following data and commentary show the progress that has been made to date. Priority 1: Reduce smoking in every district to 18.5% or less by 2015
Figure 1 Percentage of adults who smoke, England and Hertfordshire, 2010-2013
Overall, estimated smoking prevalence in Hertfordshire has reduced from 20.1% in 2011 to 17.8% in 2014, with a low of 15.5% in 2013.22
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It is important to note that small sample sizes at District level lead to wide confidence intervals around these prevalence estimates. This means that the actual population prevalence lies within a range of values, with the best estimate given in the above bar chart. In addition, these prevalence estimates are based on the Integrated Household Survey which is in an experimental phase, so potential changes in this indicator over time should be interpreted with caution. Despite the appearance of large potential changes between 2013 and 2014, estimated prevalence was statistically similar across all the Districts between these two years. Smoking prevalence in routine and manual groups is higher than in the general population with current estimates at 33.1%23. These prevalence estimates should also be viewed with care, for the same reasons outlined above. Priority 2: Reduce smoking in young people, so that less than 9 per cent of 15 year olds smoke by 2015
Figure 2 Young People who smoke regularly in Hertfordshire 2008-2014 Smoking prevalence in 15 year olds (based on Hertfordshire Schools Health Related Behaviour Survey (HRBS)) has declined from around 10.5% in 2010 to around 9.5% in 2012 and approximately 5% in 2014. Nationally, regular smoking in 15 year olds in England is at an all-time low of 8%. Regular AND occasional smoking in 15 year olds in Hertfordshire is estimated to be 10%.24 Data at district level need to be interpreted with caution as not all schools participate and therefore data from participating schools may cause wide variations in the results. There is more confidence in Hertfordshire data as a whole.
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Priority 3: Reduce smoking in pregnancy so that less than 7% of pregnant women smoke throughout their pregnancy by 2015
Figure 3 Percentage of pregnant women who smoke throughout pregnancy, England and Hertfordshire 13/14 – 14/15 Data for the whole year 2014/2015 showed that 9.2% of pregnant women registered with ENHCCG were recorded as smoking at the time of delivery, compared to 6.6% of pregnant women registered with HVCCG, and 7.8% of pregnant women across Hertfordshire. Demographic differences between the two CCG populations contribute to these differences.25 The percentage of women smoking at the time of delivery has broadly reduced across Hertfordshire since 2010/11, but an important number of pregnant women (987) were still recorded as smokers in 2014/15. The proportion smoking was also higher than the previous year. Priority 4: Roll out a Smokefree Homes and Cars Scheme in Hertfordshire A project lead was appointed in 2013 and resources were developed to support this priority. This scheme has been promoted with all Hertfordshire Tobacco Control Alliance members and has been promoted in communication and marketing activity alongside national campaigns. Protecting babies and children from second-hand smoke is included (along with safer sleeping messages to reduce cot death) in all relevant smoking cessation brief intervention training delivered by Hertfordshire Stop Smoking Service. Promoting Smokefree homes and cars is embedded within NHS Trust and Children Centre contracts and Hertfordshire Fire and Rescue Service have been encouraging
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Smokefree homes through home fire safety checks. Hertfordshire Stop Smoking Service has promoted the scheme through external events and over 500 parents have pledged to keep their home and car Smokefree since the launch of the campaign. Priority 5: All public sector organisations to become Smokefree by 2015 Progress has been made on this priority since the launch of NICE Guidance (PH48) Smoking cessation in secondary care, acute, maternity and mental health services.26 Hertfordshire Community NHS Trust became Smokefree in 2014 and East and North Herts Hospital Trust and Hertfordshire Partnership NHS Foundation Trust have approved board plans and implementation groups established to be Smokefree by the end of 2015. All NHS Trusts have agreed to sign the NHS Statement of Support for Tobacco Control and implement action plans to reduce smoking in pregnancy, smoking in mental health service users and smoking in primary and secondary care services.27 All district and borough councils have tobacco control action plans to reduce smoking in their localities and contribute to the work of Hertfordshire’s Tobacco Control Alliance. Hertfordshire County Council’s Smokefree policy and Smokefree policies of Alliance members have been updated to include guidance on the use of electronic cigarettes in the workforce and by service users.28
A Vision for Hertfordshire In line with the refresh of Hertfordshire’s Health and Wellbeing Board Strategy 2016-2018, we want to ensure that reducing the harm from tobacco aligns more closely to the proposed priority areas within the strategy which reflect health needs throughout the lifecourse:
1. STARTING WELL: Reducing smoking-related morbidity and mortality in
babies and children under 5
2. DEVELOPING WELL: Children up to the age of 18 are prevented from taking up smoking and are protected from second-hand smoke
3. WORKING WELL: Smoking prevalence in working age adults in
Hertfordshire decreases at a greater pace than England as a whole with a focus on reducing smoking-related health inequalities
4. AGEING WELL: Older adults are encouraged to quit smoking and there is
a reduction in people with, or at risk of, smoking-related long-term conditions
5. DELIVERY OF THE ABOVE PRIORITIES: Tobacco control action plans
(Appendix 3) are delivered by ‘Smokefree Hertfordshire’ (Hertfordshire’s Tobacco Control Alliance)
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PRIORITY 1 - STARTING WELL Reducing smoking-related morbidity and mortality in babies and children under 5 Our priorities are to:
Reduce smoking in pregnancy so that smoking prevalence at the time of delivery (SATOD) reduces to: o 5% for women registered with HVCCG (from a baseline of 6.6% in
2014-2015) o 7% for women registered with ENHCCG (from a baseline of 9.2% in
2014-2015)
Reduce the number of babies and children exposed to second-hand smoke.
Reduce the number of stillbirths, neonatal deaths, Sudden Unexpected Infant Deaths (cot deaths) and number of hospital admissions from asthma and bronchitis and otitis media and meningitis where smoking is a known contributory factor.
In particular we want to make sure that:
o Fewer babies are born to parents who smoke and smoking at time of delivery prevalence continues to decline by at least 1% per year across the county
o All stakeholders, but particularly maternity services, GPs, Community Pharmacies, Health Visitors and Children’s Centres are trained to identify and refer pregnant smokers, their partners and families at the earliest point of contact and throughout pregnancy and following childbirth
o The quality of stop smoking services for pregnant smokers is better than the England average and partners and families of pregnant smokers are encouraged and supported to quit smoking using the best available services
o Parents are informed of the dangers of smoking in the home and in the car and commit to protecting their babies and children from second-hand smoke
o There are fewer hospital admissions in pregnant women and babies and children from conditions related to exposure to tobacco smoke
o Smokefree (private vehicles) legislation is implemented uniformly across Hertfordshire to protect babies and children under 18 from second-hand smoke in the car.29
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PRIORITY 2 - DEVELOPING WELL Preventing the uptake of smoking in young people and protecting children from second-hand smoke Our priorities are to:
Reduce regular AND occasional smoking in 15 year olds to 5% by 2018 from a baseline of 10% in 2014
Reduce the number of parents of 12-15 year olds who smoke to 24% from a baseline of 29% in 2014
Reduce the number of children (12-15 year olds) who are exposed to second-hand smoke in the home from a baseline of 9% in 2014 to less than 5% by 2018 and in the car from 14% in 2014 to zero by 201830
In particular we want to make sure that:
o Tobacco control legislation is implemented effectively across Hertfordshire o Young people under the age of 18 cannot gain access to tobacco or electronic
cigarettes
o Parents, guardians and carers are provided with good quality information on tobacco use and encouraged to quit smoking by all relevant agencies
o There are fewer hospital admissions in children from conditions related to
exposure to second-hand smoke
o There are fewer adult smokers who act as role models for younger people and smoking in places where children are present becomes history
o Young people have access to good quality information on the role of the
tobacco industry and influences to start smoking
o Young people do not want to start smoking and young people who do smoke are given early and age-appropriate help to stop smoking
o Children under 18 years are protected from second-hand smoke in the home
and in the car
o Child poverty is reduced as families spend less on tobacco
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PRIORITY 3 - WORKING WELL Our priorities are to reducing smoking in adults at a greater pace than England as a whole with a focus on reducing the inequalities by reducing smoking prevalence in:
The general population by 1% per year (from a baseline of 17.8% in 2014)31
Routine and manual workers by 2% per year (from a baseline of 33.1% in 2014)32
People with mental health conditions33
Prisoners and offenders34 35 36
The homeless and unemployed37
Black and Minority Ethnic (BME) groups with high smoking prevalence38
Lesbian, Gay, Bisexual and Transgender (LGBT) groups39
In particular we want to make sure that:
o Increasing numbers of smokers are aware of local stop smoking services and different routes to quitting through initiatives such as ‘Making Every Contact Count’ (MECC)40
o The health inequalities gap between the better and worse off in Hertfordshire is narrowed so that groups and communities with the highest smoking prevalence see the steepest decline
o There are good quality stop smoking services throughout Hertfordshire and providers are trained and skilled to meet the needs of different population groups and communities, especially those with higher smoking prevalence and at greatest risk of harm.
o Harm reduction approaches to reducing tobacco use are promoted with smokers not yet ready to quit smoking or unable to quit smoking in one step, including the use of nicotine containing products to reduce tobacco use
o There is good quality information available on all products that aid smoking cessation or tobacco harm reduction and that smokers who use electronic-cigarettes as a means of quitting are provided with behavioural support to do so
o Tobacco control communication and marketing campaigns reach working age adults
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o Workplace Smokefree policies promote smoking cessation and tobacco harm reduction
PRIORITY 4 - AGEING WELL Our priorities are to: Improve the quality of life and reduce premature morbidity and mortality in older people by helping older people quit smoking with a focus on people with, or at risk of developing, smoking-related long-term conditions (LTCs) or complications arising from these conditions such as:
cardiac disease
stroke
dementia
lung disease
diabetes
cancer
In particular we want to make sure that:
o All partner agencies working with older adults are aware of the benefits of quitting smoking at any age
o Older adults have good quality information on the benefits of quitting smoking
o Routine NHS Health Checks (for people age 40-74) identify and refer all smokers to Hertfordshire Stop Smoking Service
o Smokers at risk of, or already suffering from, long-term conditions are identified and offered support to quit smoking at every opportunity through initiatives such as ‘Making Every Contact Count’
o There are fewer people dying and suffering from smoking-related long term conditions
o There are fewer adults requiring health and social care as a consequence of a smoking-related condition
o Carers of people with long-term conditions, mental ill health and other disabilities are provided with accessible help to quit smoking or provided with advice and support on how to reduce the harm from smoking and second-hand smoke
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PRIORITY 5 – DELIVERY OF THE ABOVE PRIORITIES: The tobacco control action plans (Appendix 3) are delivered by ‘Smokefree Hertfordshire’ (Hertfordshire’s Tobacco Control Alliance)
Smokefree Hertfordshire, Hertfordshire’s Tobacco Control Alliance will work collaboratively with all stakeholders to ensure the delivery of these priorities and that:
o All partners are committed to reducing the harm from tobacco and understand the association between smoking and health inequalities
o Our partners have the knowledge, skills, capacity and commitment to deliver Hertfordshire’s Tobacco Control Strategic Plan 2016-2018
o Hertfordshire’s Tobacco Control Strategic Plan is consistent with national strategy and is evidence based, effective and cost saving
o Tobacco legislation is implemented effectively in Hertfordshire though the work of the Police and Local Government Enforcement Agencies and Trading Standards
o Access to illegal and counterfeit tobacco is minimized through the work of Trading Standards and Her Majesty’s Revenue and Customs (HMRC)
o The public sector, local businesses, educational establishments and voluntary organisations are exemplars in tobacco control and have comprehensive Smokefree policies in place
o We are advocates of and support evidence-based tobacco-control measures at regional and national levels and influence change through advocacy
o We have good quality data within our JSNA to inform our tobacco control strategic plan and we can measure success against reliable and accurate information
o We have a communication and marketing plan and resources to deliver consistent, coherent and co-ordinated communication on tobacco control throughout the county using social marketing techniques to reach all our partners and communities
The draft tobacco control action plans (Appendix 3) reflect national strategy and local priorities based local insights and intelligence and evidence of effectiveness in tobacco control and identify the roles and responsibilities of key stakeholders and Tobacco Control Alliance members to achieve these priorities.
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REFERENCES
1 Hertfordshire County Council (2014) Smokefree Hertfordshire: A Tobacco Control Strategic Plan for
Hertfordshire. Available at: http://www.hertsdirect.org/services/healthsoc/healthherts/smoking/ 2 Department of Health (2011) Healthy Lives, Healthy people: A tobacco control plan for England. Available at: https://www.gov.uk/government/publications/the-tobacco-control-plan-for-england 3 Hertfordshire Joint Strategic Needs Assessment (JSNA). Available at: http://jsna.hertslis.org/ 4 Health and Social Care Act (2012) Available at: http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted 5 Hertfordshire County Council (2013) Healthier Herts: A Public Health Strategy for Hertfordshire 2013- 2017. Available at: http://www.hertspublichealth.co.uk/files/Healthier%20Herts%20Public%20Health%20Strategy%202013-2017.pdf 6 Hertfordshire County Council (2013) Healthier Herts: A Public Health Strategy for Hertfordshire 2013- 2017. Available at: http://www.hertspublichealth.co.uk/files/Healthier%20Herts%20Public%20Health%20Strategy%202013-2017.pdf 7 Hertfordshire County Council (2014) Smokefree Hertfordshire: A Tobacco Control Strategic Plan for Hertfordshire 2014-2016. Available at: http://www.hertsdirect.org/services/healthsoc/healthherts/smoking/ 8 Royal College of Physicians and Royal College of Psychiatrists (2013) Smoking and Mental Health. Available at: https://www.rcplondon.ac.uk/publications/smoking-and-mental-health 9 Action on Smoking and Health (2015) Smoking Still Kills, Available at: http://www.ash.org.uk/current-policy-issues/smoking-still-kills 10 Policy Exchange (2010) Cough up: balancing tobacco income and the costs to society. Available at: http://www.policyexchange.org.uk/publications/category/item/cough-up-balancing-tobacco-income-and-costs-in-society 11 Action on Smoking and Health (2015) Smoking Still Kills, Available at: http://www.ash.org.uk/current-policy-issues/smoking-still-kills 12 Policy Exchange (2010) Cough up: balancing tobacco income and the costs to society. Available at: http://www.policyexchange.org.uk/publications/category/item/cough-up-balancing-tobacco-income-and-costs-in-society 13 All Party Political Group (2010) Smoking and Health. Available here: http://www.ash.org.uk/APPGoct2010 14 Hertfordshire County Council Cabinet Panel. Tobacco Control Report of the Director of Public Health (November 2013). Available at: http://www.hertsdirect.org/your-council/civic_calendar/cabinet/17873330/
15 Hertfordshire County Council (2015) Hertfordshire Guidance on Tobacco Harm Reduction. Available here: http://www.hertsdirect.org/services/healthsoc/healthherts/smoking/ 16 National Institute for Health and Care Excellence (NICE) (2013) Tobacco: harm reduction approaches to smoking NICE guidelines (PH45). Available at: https://www.nice.org.uk/guidance/ph45
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17 NHS Commissioning Board: The functions of clinical commissioning groups (2013). Available at: http://www.england.nhs.uk/wp-content/uploads/2013/03/a-functions-ccgs.pdf 18 Smokefree Actions Coalition (2014) NHS Statement of Support for Tobacco Control. Available at: http://www.smokefreeaction.org.uk/declaration/NHSstatement.html 19 Public Health England and ASH (2014) Hertfordshire County Council CLeaR© Thinking in Tobacco Control. CLeaR© Model Assessment for Excellence in Tobacco Control Available at: http://www.hertsdirect.org/services/healthsoc/healthherts/smoking/ 20 Action on Smoking and Health (2015) Smoking Still Kills, Available at: http://www.ash.org.uk/current-policy-issues/smoking-still-kills 21 Hertfordshire County Council (2014) Smokefree Hertfordshire: A Tobacco Control Strategic Plan for Hertfordshire. Available at: http://www.hertsdirect.org/services/healthsoc/healthherts/smoking/ 22 Public Health England (2015) Tobacco Profiles. Available here: http://www.tobaccoprofiles.info/ 23 Public Health England (2015) Tobacco Profiles. Available here: http://www.tobaccoprofiles.info/ 24 Hertfordshire County Council (2014) Hertfordshire Schools Health Related Behaviour Survey: Supporting the Health and Wellbeing of Young People in Hertfordshire. Available at http://atlas.hertslis.org/IAS/hwb/priorities/HRBSDashboard.html 25 Hertfordshire Joint Strategic Needs Assessment (JSNA) Local Areas. Available at: http://jsna.hertslis.org/localareas/hertsval/ 26 National Institute for Health and Care Excellence (2013) Smoking cessation in secondary care: acute, maternity and mental health services. Available at: https://www.nice.org.uk/guidance/ph48 27 Smokefree Actions Coalition (2014) NHS Statement of Support for Tobacco Control. Available at: http://www.smokefreeaction.org.uk/declaration/NHSstatement.html 28 Hertfordshire County Council (2013) Reducing the harm from Tobacco in Hertfordshire: A policy statement. Available at: http://www.hertsdirect.org/docs/pdf/t/tobredharpo.pdf 29 Department of Health (2015) Explanatory memorandum to the smoke-free (private vehicles) regulations 2015. Available at: http://www.legislation.gov.uk/ukdsi/2015/9780111126004/pdfs/ukdsiem_9780111126004_en.pdf 30 Hertfordshire County Council (2014) Hertfordshire Schools Health Related Behaviour Survey: Supporting the Health and Wellbeing of Young People in Hertfordshire. Available at http://atlas.hertslis.org/IAS/hwb/priorities/HRBSDashboard.html 31 Public Health England (2015) Tobacco Profiles. Available at: http://www.tobaccoprofiles.info/ 32 Public Health England (2015) Tobacco Profiles. Available at: http://www.tobaccoprofiles.info/ 33 Royal College of Physicians and Royal College of Psychiatrists (2013) Smoking and Mental Health. Available at: https://www.rcplondon.ac.uk/publications/smoking-and-mental-health 34 Public Health England and Kings College London (2015) Reducing smoking in Prisons. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/412567/Reducing_smoking_in_prisons.pdf
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35 Action on Smoking and Health (ASH) (2014) Smokefree Prisons. Available at: http://ash.org.uk/files/documents/ASH_740.pdf 36 Morrish, D. (2011) A Health Needs Assessment of the Hertfordshire Probation Caseload 37 Office for National Statistics (2013) Adult Smoking Habits in Great Britain. Available at: http://www.ons.gov.uk/ons/rel/ghs/opinions-and-lifestyle-survey/adult-smoking-habits-in-great-britain--2013/stb-opn-smoking-2013.html 38 Action on Smoking and Health (2011) Tobacco and Ethnic Minorities. Available at: http://ash.org.uk/files/documents/ASH_131.pdf 39 Action on Smoking and Health Scotland (2012) Tobacco Use and LGBT communities. http://www.ashscotland.org.uk/media/3858/LGBT.pdf 40 Local Government Association (2014) Making Every Contact Count. Available at: http://www.local.gov.uk/documents/10180/5854661/Making+every+contact+count+-+taking+every+opportunity+to+improve+health+and+wellbeing/c23149f0-e2d9-4967-b45c-fc69c86b5424