Public Services Inquiry: Public services: lessons from coronavirus



About ASH

  1. Action on Smoking and Health (ASH) is a public health charity set up by the Royal College of Physicians in 1971 to advocate for policy measures to reduce the harm caused by tobacco. ASH receives funding for its full programme of work from the British Heart Foundation and Cancer Research UK. It has also received project funding from the Department of Health and Social Care to support delivery of the Tobacco Control Plan for England. ASH does not have any direct or indirect links to, or receive funding from, the tobacco industry or any other commercial interest.




  1. Smoking is the leading cause of preventable death in the UK, responsible for nearly 100,000 preventable deaths a year.[1]


  1. Smoking is a modifiable risk factor for many of the comorbidities that Public Health England has identified as leading to worse outcomes from Covid-19 including chronic obstructive pulmonary disease (COPD), diabetes, cardiovascular disease, hypertensive diseases and dementia. [2] [3]


  1. Difference in smoking prevalence between socioeconomic groups are the leading cause of the gap in life expectancy between rich and poor in the UK.[4] Adult smoking prevalence in England is 14.4%,[5] but this increases to 25.4%5 among smokers in routine and manual occupations, up to 40.5%[6] among smokers with serious mental illness and is nearly 80%[7] [8] among smokers who are experiencing homelessness.


  1. Smokers are approximately three times as likely to quit successfully with the support a specialist stop smoking service compared to quitting unaided. Local authority commissioned stop smoking services have adapted well to the pause on delivering face-to-face behavioural support during lockdown, with 96% reporting to be providing advisor-led support for smokers remotely and 88% providing access to nicotine replacement therapy and medications.[9]


  1. However, services’ capacity to meet local need has varied depending on their commissioning model, with primary care based services (in pharmacy and general practice) reporting to be less able to meet need than specialist services operating in other community settings.9


  1. There is an opportunity to build on the partnerships and service models established to support smokers in disadvantaged populations, such as rough sleepers, to quit smoking during Covid-19 to create sustainability and share best practice nationally.


  1. The NHS should be taking a more proactive role in motivating smokers to quit and directing to specialist support. There are positive examples of collaboration between local authorities and health services to promote smoking cessation in light of Covid-19. However, this collaboration should be happening on a much larger scale and NHS England should review what powers it has to promote this.


  1. Supporting smokers to quit now, will help build resilience in the health service and economy supporting the recovery from Covid-19. Smoking cessation is one of the most effective and cost-effective healthcare interventions available.2 Smoking cessation delivers health benefits for everyone from pregnant women to people diagnosed with lung cancer[10] and there is a need to scale up the delivery of advice and support to quit if we are to achieve the ambition to make England smokefree by 2030.[11] To support this, the Government must urgently publish its response to the Prevention Green Paper and take forward actions including introducing a charge on tobacco companies to provide sustainable funding for tobacco control.


Question 6: Has the delivery of public services changed as a result of coronavirus? For example, have any services adopted new methods of meeting people’s needs in response to the outbreak? What lessons can be learnt from innovation during coronavirus?


Stop smoking services were advised to pause delivery of face-to-face support for smokers on 18th March 2020.[12] Since when, services have rapidly adapted to the changing circumstances to provide remote consultations and behavioural support for smokers.


A survey undertaken by ASH from 21st April – 7th May 2020 show that a majority (96%) of responding local authorities had established a method of providing advisor-based stop smoking support remotely with 88% having established a method of providing access to nicotine replacement therapy and stop smoking medications.9


All authorities providing remote support were delivering telephone consultations. Other methods of providing remote support included via video conferencing, apps, text messages, emails and webchat. The speed at which local authority public health teams and stop smoking services adapted to ensure continued provision of support has been impressive. At the time of ASH’s survey, a range of localities highlighted that they were looking to establish video conferencing consultations and app based support in addition to what they were already delivering.9


Five respondents to ASH’s survey stated that they were not providing advisor based support for smokers, with 10 local authorities responding that they were not providing access to nicotine replacement therapy or stop smoking medications.9 This highlights inequalities in access to effective stop smoking support. All local authorities should be supported to ensure there is some advisor-led support for smokers, and in contingency planning for a second wave of Covid-19 infections, localities should consider how to maintain capacity in their stop smoking services.


Further, it is clear in the responses to ASH’s survey that some services were better able to adapt to meet local need. Local authorities that commissioned primary care providers to deliver the local stop smoking service, reported being less well able to meet the needs of smokers, given the pressures on primary care services early in lockdown.


“Most of our advisors are based in GP parties and community pharmacies. They are mostly trying to maintain provision but their ability to do so varies and changes almost daily.”

-          Local Authority, Public Health Programme Lead


In the 2019/20 commissioning cycle 57% of local authorities commissioned stop smoking support in primary care, including 9% that only commissioned primary care based support.[13] Variation in commissioning of stop smoking services has increased in the context of shrinking budgets and cuts to the centrally funded public health grant. This has led to variation in how well local authorities were able to respond to the Covid-19 pandemic and ensure support has remained available to all local smokers.


Given the acute pressure on the NHS during the Covid-19 outbreak it is unsurprising that those services based in primary care (in pharmacies and general practice) have been less able to maintain delivery of stop smoking services. Specialist stop smoking services are estimated to cost £8.29 more per smoking resident than primary care based models.[14]14 For all local authorities to provide this specialist standalone services, the Government must reverse cuts to the public health grant and provide sustainable funding for tobacco control.


In some cases, these local authorities have been able to establish alternative provision to ensure that smokers have still be able to access support. For example, the Programme Lead above went on to say:

“We have established a dedicated telephone support service for pregnant women and others referred from secondary care. This is also open for self referrals where local providers are unable to provide support.”

-          Local Authority, Public Health Programme Lead


This demonstrates the new approaches local authorities are taking to support smokers to quit during the Covid-19 pandemic, and the need for sustainable funding to help ensure smokers are not faced with a postcode lottery in the support available.


Question 11: Are there lessons to be learnt for reducing inequalities from the new approaches adopted by services during the Covid-19 outbreak?


Local authority public health teams which have established effective relationships with services supporting disadvantaged residents during the Covid-19 outbreak should look to build sustainability into these relationships to ensure provision of stop smoking support for disadvantaged groups long-term.


For example, smoking rates among people experiencing homelessness are nearly 80%.7 8 Further, smoking behaviours which are more prevalent among particularly disadvantaged smokers, such as smoking dog ends or sharing cigarettes, pose a particular risk around the spread Covid-19.[15]


In identifying this, some local authorities have established relationships with homeless services to provide e-cigarettes as a harm reduction option for smokers:

“We are identifying very vulnerable people via our local Complex Needs Alliance and making a stand alone offer of e-cigarette starter kits to all homeless and hostel dwellers in the city. 270 provided to date [27 April] with positive initial reports of reduced risk of infection.”

-          Local Authority, Advanced Public Health Practitioner


Other local authorities have taken steps such as putting stickers with local stop smoking service contact information on food parcels or teamed up with local shielding hubs to provide stop smoking advice and nicotine replacement therapy to vulnerable residents.


Such interventions have the potential to make a lasting impact on the health of disadvantaged individuals and local authorities which have innovated in this way should be encouraged to consider how to maintain such collaborations longer-term.  However, the additional needs of disadvantaged populations make this work costly for local authorities. For the Government’s ambition to achieve a smokefree England by 203011 to be realised for all population groups and not just the most advantaged, sustainable funding for tobacco control must be available.


Question 14: Are there any examples of services collaborating in new and effective ways as a result of Covid-19? Are there lessons to be learnt for central Government and national regulators in supporting the integration of services?


Smokers see their GPs over a third more regularly than non-smokers[16] and GPs are well placed to direct smokers to specialist stop smoking services. While there are examples of good collaboration during the Covid-19 pandemic, too many practices are unwilling to engage without additional payment incentives. NHS England should exercise its additional Covid-19 powers to promote better collaboration at a local level but longer-term must consider ways to strengthen the incentives for primary care to collaborate with public health teams to deliver simple interventions which benefit population health.


Local public health teams that have been able to collaborate with local GP surgeries to contact smokers and encourage them to seek support to quit during the Covid-19 outbreak have seen positive results. For example, Hertfordshire stop smoking service provided local GPs a template text to send to all smokers in their records, directing smokers to the local service for support to quit. This text message alone generated 500 new referrals into the service which increased its clinic hours from approximately 70 to over 180 a week to meet the additional need.9


This demonstrates the impact that GPs could have if they consistently directed smokers to support to quit in line with the principles of Very Brief Advice; an evidence based intervention which involves asking about smoking status, advising on the best ways to quit smoking and acting, usually by providing a prescription or referral to local stop smoking service.


Delivery of Very Brief Advice should be part of standard GP care with Quality and Outcomes Framework (QoF) funding available to practices for asking and recording smoking status. However, research has found that only around half (53%) of primary care practitioners frequently complete Very Brief Advice,[17] and other local authorities have highlighted that without an existing relationship with local clinical commissioning groups (CCGs) this kind of productive collaboration has not been possible during the Covid-19 outbreak.


NHS England must recognise the crucial role that primary and secondary care providers have to play in treating tobacco dependence and ensure that evidence-based best practice is implemented across the NHS. Until 31st December 2020 NHS England has powers to exercise the functions of CCGs “for the purposes of directly or indirectly supporting the provision of services by NHS bodies to address coronavirus and coronavirus disease”.[18] Short-term it should exercise these powers to ensure enhanced action to tackle smoking, but long-term there is a need to consider how to ensure better collaboration with public health teams, including strengthening incentives.


Question 19: Would local communities benefit from public services focusing on prevention, as opposed to prioritising harm mitigation? Were some local areas able to reduce harm during coronavirus by having prevention-focused public health strategies in place, for example on obesity, substance abuse or mental health?


Public Health England’s review of the disparities in the risk and outcomes of Covid-19 states that: “Among deaths with COVID-19 mentioned on the death certificate, a higher percentage mentioned diabetes, hypertensive diseases, chronic kidney disease, chronic obstructive pulmonary disease and dementia than all cause death certificates.”3


The level of underlying poor health in the population as we entered the pandemic has undoubtedly impact its severity, and makes the case for further investing in preventative public health services.  Public Health England estimates that infection and death rates in deprived areas are twice that of the least deprived areas, and notes that the rate of comorbidities in deprived groups warrants additional investigation.3


Smoking is a modifiable risk factor of all the conditions Public Health England has listed. For example, excluding London Boroughs, the 10 local authorities with the highest death rate from Covid-19[19] all have rates of emergency hospital admission for COPD well above the national average.[20] COPD is associated with worse outcomes from Covid-19 and over 80% of COPD cases are caused by smoking.[21]


Smokers admitted to hospital with Covid-19 have worse outcomes than non-smokers. Stopping smoking leads to immediate improvements in respiratory and cardiovascular health.  Current smokers are:2


The preventative activity being undertaken to reduce smoking prevalence is significant not only for treating Covid-19, but for reducing pressure on the NHS from other diseases while it responds to the Covid-19 pandemic and any future increases in the infection rate. Reducing smoking rates will help to build resilience in the health service and economy which will be essential as we head towards winter and the risk of a disastrous co-circulation of Covid-19 and flu.


Examples of good practice actions such as introducing a charge on tobacco companies to provide sustainable funding for evidence based tobacco control interventions at a local and national level11 that the Government should take forward to provide sustainable funding for prevention, helping to remove the postcode lottery in delivery of public health services., such as collaboration between local authorities and the NHS must be expanded in the short term, while the Government must consider the evidence for the impact of comorbidities on Covid-19 in its urgently needed response to the Prevention Green Paper.11 The Green Paper set out


June 2020


[1] ONS. Adult smoking habits in the UK: 2018. 2019.

[2] Royal College of Physicians. Hiding in plain sight: treating tobacco dependency in the NHS. London: RCP. 2018.

[3] Public Health England. Disparities in the risks and outcomes of Covid-19. 2020.

[4] Marmot M. Fair society healthy lives. 2010.

[5] NHS Digital. Statistics on Smoking England. 2019.

[6] NHS Digital. 1.23 Smoking rates in people with serious mental illness (SMI). 2016.

[7] Homeless Link. The unhealthy state of homelessness. Health audit results. 2014.

[8] Groundswell. Room to Breathe. 2016.

[9] ASH. Local authority stop smoking support response to Covid-19. 2020.

Survey work undertaken between 21st April and 7th May 2020 with responses from 74% of upper tier local authorities with public health responsibility.

[10] NIHR. Cancer survivors who quit smoking sooner can live longer. 2017. [Online]. Accessed June 2020.

[11] Department of Health and Social Care. Advancing our health: prevention in the 2020s. 2019

[12] NCSCT.

[13] ASH. Many ways forward: stop smoking services and tobacco control work in English local authorities 2019. 2020.

[14] ASH. A changing landscape: stop smoking services and tobacco control in England. 2019.

[15] Cox S. The Last Pleasure? [Online] Accessed June 2020.

[16] Department of Health and Social Care. Towards a Smokefree Generation: A tobacco control plan for England. 2017.

[17] Cancer Research UK. Smoking cessation in primary care.2019.

[18] National Health Service England. The Exercise of Commissioning Functions by the National Health Service Commissioning Board (Coronavirus) Directions 2020. 2020.

[19] ONS. Deaths involving COVID-19 by local area and socioeconomic deprivation: deaths occurring between 1 March and 31 May 2020. June 2020.

[20] Public Health England. Local Tobacco Control Profiles: Emergency hospital admissions for COPD. Online. Accessed June 2020.

[21] US Department of Health and Human Service. The Health Consequences of Smoking-50 years of progress: A report of the Surgeon General. 2014.