Reducing the inequalities of life expectancy – targets for a new NHS/public compact in November.

1 Smoking

A few weeks ago I talked about the new evidence that between 2003 and 2010 the NHS successfully reduced the inequalities of life expectancy between the better-off and poorer local authorities. I say ‘the NHS’ because whilst local government was involved in the programme, the interventions were around medical issues.

This post drew the strongest response from readers than anything I have written for the new blog. I think the reasons are twofold. First the morality of the discrepancy between life expectancy for the rich and poor offends people. They think it is wrong that the years you live should be influenced so profoundly by your wealth and income. And they are right.

But in tandem with the moral drive there was I think something very motivating about the idea that we could actually do something about this today. Not in the distant future but right here, right now. If we keep people alive for another 15-20 years who would previously have died in their 50s and 60s they get to live those years now – not in some distant future after major social changes have taken place.

So building on this conflation of morality and practicality, today I want to go into more detail about two sets of interventions that I believe could be rolled out in every poorer local authority and start saving lives tomorrow (or in the case of the new compact between the NHS and the people from November).

These are working with people to give up smoking, the subject of today’s post, and intervening with measures to limit cardiovascular disease – which I will be discussing tomorrow.

Just to be clear. Whilst this post is about persuading people to stop smoking, this is simply a methodology for intervening quickly in the lives of people in poorer areas to keep them alive longer. (It’s also a good thing in itself but that is not the burden of todays post).

The 2017 Statistics on Smoking showed that numbers of smokers had dropped to 7.4 million people – 15.5% of adults aged 18+. Down 0.7% in a year. This is great news.

However as the national figures drop the difference between the number of better-off and poorer smokers has got worse. 25.9 % of those working in manual occupations smoke. For managerial or professional occupations, the figure is 10%.

And crucially for my argument the inequality between these groups has become significantly worse since 2012.

Given that there are 79,000 deaths attributable to smoking and given that manual workers are two and a half times more likely to smoke than professional workers then we have a much greater chance of reducing overall deaths if we target manual workers. And, given that our aim is to prolong the lives of those dying prematurely in poorer areas then working with the greater number of people who smoke will help reduce the inequalities of life expectancy.

There is something very important here. Inequality, like smoking, is not randomly distributed across society. Inequality and smoking are much more concentrated in some locations than others. If you go to the poorest areas of society, you are more likely to find people there who smoke. (This is of course not a direct correlation – some very rich people smoke – but the numbers are clear. If we are going to reduce smoking to 10% of the whole population in the near future we have to deal with inequalities now – in 2018).

Why is it that more people with qualifications and in professional jobs have given up smoking than those with none? The answer lies in the extent of an individual’s control over their world. Earning more money, owning your own house, having more qualifications – all of these attributes will give you more social capital than others. You are in charge of a little bit more of your world. That experience can help you find it a bit easier to give up smoking. (But as an ex-smoker myself I know it isn’t easy to give up smoking!).

So if we want to work with people who don’t control much of their lives to gain control of their smoking, we have to recognise that this is a much bigger task for them than for that facing those who have to decide in which Mediterranean country they will spend 3 weeks of their summer.

There are two secrets to doing this.

The first is finding an individual’s motivation – the very strong motivation – required to give up smoking, the second is to provide strong support during the difficult days and weeks of trying to give up.

It is important to recognise that 60% of those who smoke want to quit. So let’s start with them. Everyone has their own motivation. It may be their own health, it may be being with a loved one, or having a longer future their children. It may be to prove they can achieve something. Whatever it may be, the first task is to find it.

It is entirely wrong to see motivation as being the preserve of the better off. Friends of mine who work with the homeless talk about the three very strong motivations for life. Somewhere to live, something to do and someone to love. Even under the most difficult circumstances these motivations are there for us to work with. We just need to find them.

Second having found a motivation its important to be able to provide support for acting on that motivation. If you are not used to having much say over your life, then changing something that may be fundamental to it is very hard. You need support.

So how do we reduce the inequalities of life expectancy?

We find those people who smoke and who want to give up in the fifty poorest local authorities in the country. Smokers are generally in poorer health than the rest of us so they are almost certain to already be in contact with the NHS.

Find the smokers, ask who wants to give up and then have health trainers unlock their motivation. Then provide a support group – most of whom should be people also trying to give up. But there should be some that have succeeded.

Nearly 50% of people who ‘vape’ want to give up smoking. So for those that want it let’s use vaping, patches – everything we’ve got. But let’s not leave people to do ‘this on their own. People love the NHS so let’s use reciprocate with some tough love that will really help.

The NHS can do more. 1 in 4 people who go into a hospital bed smokes. ‘Smoke Free Ontario’ included the development of effective non-smoking policies in their hospitals that has resulted in a reduction of 1 in 6 in the mortality rate of smokers entering hospital and giving up. Those are significant numbers.

My argument is that we need to reverse what we normally do. We normally try to do the difficult things – like having hospitals help patients give up smoking – in the better off areas.

This time let’s not.

If every hospital that served the 50 poorest local authorities followed the Ottawa Model for Smoking Cessation it would play a significant role in reducing inequalities of life expectancy. More people in poorer areas would live longer.

We know how to reduce life expectancy inequality. It requires us to help less well-off people give up smoking. Let’s concentrate the practice that we know works through both primary and secondary care in the 50 poorest authorities and achieve just that.

All it needs is the courage, the will, and the targeting.