The aim of this essay is to analyse the public health issue of smoking, which has major effects on the health of society and individuals within the adult population in England and Wales. Using evidence from a variety of sources including seminal texts, it will look at the cost to the NHS (National Health Service) and the policies that have been put in place by the government to address the issues surrounding tobacco use. It will also examine how the role of the nurse can promote healthy lifestyles in order to improve the health of individuals and the community.
Tobacco use is seen as the leading cause of preventable mortalities in adults aged thirty-five and over worldwide. In the UK (United Kingdom), as of 2017, there were over 7.4 million adult smokers (Office for National Statistics, 2017), 16.1% of the population in Wales smoke with 1 in 5 mortalities attributed to smoking (Welsh Government, 2012) and 14.9% of the population in England with tobacco use causing around 17% of the mortalities (Public Health England, 2015). The cost to the NHS for smoking-related illnesses in England was £2.6 billion in 2015 (Public Health England, 2017), in Wales it was £386 million in 2012/13 (Public Health Wales, 2013).
Public Health is described as the science of protecting and promoting healthy lifestyles and the well-being of individuals and their communities, to change their behaviours. This is achieved through the efficiency and organised efforts of the governments and local communities, working with individuals to make informed choices in order to minimise the risk of disease, ill health and to prolong life. (Naidoo & Wills, 2016; Scriven, 2017).
This is attained through health promotion, to work with communities and individuals to have more control in promoting and improving aspects of their health. Health promotion focuses not only on the individual but also on the social and environmental factors that affect the health and well-being of individuals to enable them to have a quality of life (World Health Organization (WHO), 1986).
Health promotion has an important role in public health. Its function is to support, empower and enable individuals and their communities to become more aware of lifestyle behaviours, in order to improve health and well-being (Scriven, 2017). This is achieved by educating communities and targeting individuals, who are considered at high risk of developing conditions that could affect their health (Naidoo & Wills, 2016). Nurses have an important role in public health and have a duty of care to prevent illness and protect the health of communities through health promotion. It is a fundamental skill of an adult nurse, in the healthcare setting to use their knowledge and skills to promote well-being, providing choice, while working in conjunction with the population, and other healthcare professionals to educate individuals on how to maintain their health, therefore prolonging life (Royal College of Nursing (RCN), 2016).
In accordance with the Nursing and Midwifery Council (NMC) The Code (2015), all names and locations have been changed in order to ensure patient confidentiality.
Smoking tobacco has been deemed as one of the leading health concerns in the world. It is believed to be the primary cause of many illnesses and the highest cause of preventable mortalities in the UK (Grant, 2017).
Tobacco use has accounted for almost 78 thousand preventable mortalities that occurred in England in 2016 and over five thousand five hundred mortalities in Wales every year (Office for National Statistics, 2017).
It is thought there are over four thousand different chemicals found in tobacco smoke, including tar, nicotine, benzene and ammonia. Of these four thousand chemicals, more than fifty are said to cause cancer (ASH, 2014).
That being said, the Centre of Disease Control and Prevention (CDC) agree that smoking is linked to a number of serious health issues such as lung cancer, chronic obstructive pulmonary disorder (COPD) and illnesses concerned with the cardiovascular system. Along with other organs in the body that could prematurely cause the death of half of the lifelong smokers (Centres for Disease Control and Prevention, 2018). The WHO concur with this information, confirming that people who smoke at least a packet of cigarettes a day are reducing their lives by at least seven years compared to those who don’t smoke (Da Costa e Silva, 2003).
As of 2017, there is around 15.1% of the population, that’s 7.4 million people who smoke in the UK, with Wales having 16.1% of smokers, this is equivalent to 386 thousand people. England currently has the lowest percentage of smokers with 14.9%, equivalent to 6.1 million people (Office for National Statistics, 2017). In 2010 both England and Wales had 25% of their population smoking, when the information is compared to 2017 it shows the prevalence of tobacco use has decreased by 8.9% in Wales and 10.1% in England (Public Health Wales Observatory & Welsh Government, 2012 & Office for National Statistics, 2017).
Studies have also shown that men are still more likely to smoke than women (National Institute on Drug Abuse, 2018). This could be due to the fact that more men among the unskilled manual workers, use tobacco to obtain the effects of the nicotine, by activating the reward pathway when they smoke (Graham, Jefferis, Manor, Power, 2004). Whereas women are less likely to do manual labour and more likely to do office work, where smoking is seen as a social disapproval (Fong & Hitchman, 2011), however, Women are given a false belief that smoking assists them to lose weight and with increasing numbers of women working in male-dominated occupations, receiving pressure from the job causes them to suffer from mental health conditions (Gardiner & Tiggemann, 2010), and smoke as a way to relieve stress and regulate mood (National Institute on Drug Abuse, 2018). In some countries, however, women are being empowered to smoke, thus closing the smoking rates between men and women (Fong & Hitchman, 2011).
In 2010 in the UK it can be seen the smoking population was made up of 21% of men and 20% of women who smoked, when this is compared to 2016 it shows the prevalence of smokers has decreased to 17.7% of men and 14.1% of women, ASH, 2017).
Since the smoking ban came into force in 2007, the cost of a packet of cigarettes has increased from £5.33 to a staggering £9.91, making the annual cost to the individual who smokes 20 a day, over £3500 (Statista, 2018). With the cost of cigarettes increasing, the prevalence of tobacco use has declined, with people more willing to quit and choose a healthier lifestyle. However, despite the downward trend of smokers, 39% of children are still being exposed to second-hand smoke (Welsh Government, 2012).
Even with the decline in smokers, the cost to NHS England in 2015 was £2.6 billion, with over 520 thousand admissions into a hospital from smoking-related illnesses in 2015/16 in adults over 35 years old (Public Health England, 2015). However, while the NHS cost is high for tobacco-related illnesses, it can be argued that the government in the 2017/18 financial year made over £8,827 million from the duty paid on cigarettes, profiting from people who smoke, therefore if the UK was to become smoke free, the country would be worse off financially (Dickson & O’Kane, 2018).
While across the border in Wales the cost to the Welsh NHS was £302 million in 2017. This is a result of 26489 smoking-attributable admissions into hospital, placing a significant burden on the Welsh NHS services (Public Health Wales Observatory, 2017). This does not include the cost to the Welsh government. Their cost is a staggering £790 million every year as a consequence of smoking-related fires, in homes and businesses, clearing up cigarette ends from the streets and also absences from work which have resulted in an estimated 1 million days that are lost. (Grant, 2017).
This also costs businesses approximately £8.7 billion a year, due to lost productivity, as a result of the number of smoking breaks and absences taken due to smoking-related illnesses (Centre for Economics and Business Research, 2014). To reduce the amount of days that are lost due to absences and improve productivity, the employer could support the employee to quit smoking (Healthy Working Wales, 2018), by encouraging them to attend smoking cessation support sessions without the loss of pay and also promote the employees to participate in no smoking days (Healthy Working Wales, 2018). This could save a company up to four thousand pounds a year as a result of less sickness and employees having shorter breaks (Healthy Working Wales, 2018).
Looking at the local health board area, tobacco use has decreased in the ABMU (Abertawe Bro Morgannwg University Health Board ) area from 23% in 2013/14 to 19% in 2015. This result is a promising start showing the prevalence of tobacco use is falling and ABMU is on target to reach 16% of smokers by 2020 (Newbury Davies, 2017). It is also said 22% of the population in Swansea are currently smoking with the lowest rate in Cardiff with 14%.
Even though the prevalence has fallen, it is believed that smoking has risen in the unemployed by 2%, (ASH Wales, 2018) possibly as a result of psychosocial factors. Suggesting those who smoke are affected by the stress, low self-esteem, and financial issues of being unemployed (Santinello & Vogli,2005). This epidemiology data does not provide an accurate account of current smokers but it does allow us to identify important information in the health of the population. However, it only provides part of a picture and consideration needs to be given to the socio-economic and environmental factors that affect the health of the individual and communities (Scriven, 2017).
Socio-economic and environmental factors known as determinants of health such as education, employment, housing and social status are said to have an influence on the health of both the community and individual (Matthews, 2015). With tobacco use is said to be linked to the different socio-economic groups, being at least four times higher in the most deprived areas in the UK than the most affluent areas. It is also said that the social and economic inequality in social classes is one factor that determines the increasing variation of life expectancy between classes (Amos, Bauld, Hiscock, & Platt, 2012).
It can be argued that people in the lower social groups living in the deprived areas of the UK, where they may have insecurities from low income, mental health or even homelessness are more at risk of smoking as a way of dealing with their concerns (Matthews, 2015). Therefore, being at higher risk of stroke or heart disease which will have a detrimental effect on their health and well-being (Kozier et al., 2012).
Tobacco use in 2017 was found to be higher in the unemployed with 29% compared to 15.5% of employed people (Office for National Statistics, 2017). However, this could be due to a decline in the employed people smoking, whereas the unemployed there is only a slight decline (Amos et al., 2012). It also found that the people from the lower class who were employed in routine and manual occupations such as lorry drivers, care workers and bar staff, accounted for 25.9% of the smokers in the UK. This, however, could be as a result of the lower class smoking habit, having the opportunity to smoke and peer pressure (Coleman & Sherriff, 2012) While those in the higher classes working in managerial and professional occupations such as teachers, lawyers and nurses have accounted for 10.2% of smokers. This shows that there is a significant difference between the higher and lower echelons of the working class, with the lower echelons twice as likely to smoke (Office of National Statistics, 2017).
Social inequality in health can also be explained further by other risk factors in the lifestyle and behaviours of individuals. These include the lack of physical exercise and the number of unhealthy foods that are eaten. Even though these are considered to be common lifestyle choices in the socio-economically worse off and can be attributed to serious health issues such as cardiovascular disease, (Marchman Anderson, Oksbjerg Dalton , Lynch , Johansen , & Holtug , 2013). It can be argued that it is a result of the level of income they receive, with the more money they receive the better their health and well-being as they less likely to eat unhealthily, so will feel better in themselves and more likely to exercise (Rowlingson, 2011).
Social factors that could influence an individual to start smoking may exert from different routes, such as pressure from peers or groups of friends, where they all smoke, showing 19.7% of smokers are between the age of 25 to 34 years’ old (Office for National Statistics, 2017). Family members who may see smoking as part of a normal lifestyle, or even people exposed to misuse of drugs, alcohol and also stress therefore increasing the likelihood of the individual to start smoking (mental health Foundation, ND).
One of the main psychological factors that may account for individuals to choose to smoke as a lifestyle choice, maybe down to the individual having stress or even having mental health issues (Mental Health Foundation, ND). Once the individual has had that first hit of nicotine, it is said to improve their mood and concentration, especially if they are stressed. It is also said to decrease anger and suppress appetite (Mental Health Foundation, ND). The nicotine does, however, cause an addiction in the body, with regular smoking the dose of nicotine the body receives leads to changes in the brain. To function normally, the brain begins to rely on the nicotine, when individuals smoke they are exposed to the other chemicals, which can cause smoking-related conditions (Benowitz, 2017). When the individual attempts to quit smoking, the body doesn’t get the nicotine it’s come to rely on and the individual begins to experience withdrawal symptoms such as irritability, anxiety and increased appetite (Mental Health Foundation, ND). These factors can impact health inequalities, especially in the lower socio-economic group
In 2008, the WHO introduced a framework on the convention of tobacco control in the global population. It provided the world with six evidence-based control measures, aimed at reducing the use of tobacco in each country. These guidelines were known as (MPOWER), referring to (M) monitoring the use of tobacco and prevention policies, (P) protecting populations from tobacco smoke, (O) offering people programmes that help them to quit. (W) Warn the population of the risks, (E) enforce bans on advertising, sponsorship and promotion of tobacco use and (R) raise the taxes on tobacco products (WHO, 2015).
In 2013, the World Health Organisation (WHO) then put together a world tobacco target, with aims to reduce the number of smokers worldwide by 30%, in order to protect the next generation of people. This is a consequence of tobacco being the only legal drug that prematurely causes the mortality of at least 6 million smokers and non-smokers worldwide (WHO, 2015).
In light of this, the British government continue to aim for a tobacco-free country and following the guidelines from the WHO, the British government to date has banned television and tabloid advertising of tobacco products. They have also banned smoking in enclosed spaces, in an attempt to protect non-smokers from second-hand smoke (Department of Health and Social Care, 2015). In 2016 the government made it law for all tobacco products to be sold in plain packets with pictures of the effects smoking has on the body and a strongly worded health warning, they also set high taxes on tobacco products in the hope to reduce the number of young adults and those on low incomes from smoking (Department of Health and Social Care, 2015).
The Welsh government is also wanting to improve the health of the communities and have taken some major steps to lower the number of Welsh smokers. They are striving to achieve this by setting laws to protect people. Since the smoking ban in 2007, where it was made illegal to smoke in enclosed spaces, air quality has improved and the exposure of second-hand smoke in adults has reduced (Malam, 2015).
In 2015 the Welsh government made it law for all shops to cover their displays of tobacco products and made it an offence to sell e-cigarettes to under eighteen, in the hope that by reducing the advertising of tobacco products, adults would be less likely to start smoking. It was also made illegal for adults to smoke in their cars whilst a child is present, reducing the risk of children being exposed to second-hand smoke (Welsh Government, 2017). This can be argued that the new policy is an invasion of privacy and infringed the rights of people’s freedom (Bain et al., 2014).
The Welsh government have produced a review of services aiming to achieve a smoke-free Wales and improve the health and well-being of the population. Working with seven local health boards, local governments and private sectors, all with the aim of improving the health and quality of life of individuals and communities, by providing services in areas that are deemed to be in most need (Public Health Wales Observatory, 2015).
Wales has goals to protect the well-being of future generations by providing a national framework that allows Wales to improve and grow as a nation and reduce the smoking population by 5% in the next four years, through the services currently available. Currently, the policies that are in place, aim to improve the quality of life and health of individuals in Wales (George, Griffiths, Tomlinson, Scholey & Williams, 2018). However, these policies are designed to enable individuals who are at greater risk of health issues to choose and live healthy lifestyles. Our healthy future focuses on preventing ill-health by having a strategic plan which addresses issues such as social and environmental determinants, including housing, transport, education and exercise. To achieve this, commitment is needed from the public, private and third sectors (Public Health Wales Observatory, 2015).
To reduce health inequalities, it is imperative to target community areas that are most deprived, with smoking being a single factor that causes ill-health. It is important to reduce the number of individuals who use tobacco, this can be achieved through health promotion (Public Health Wales Observatory, 2015).
There are four behaviour change models in health promotion, that aim to change the behaviour of patients. These are the cognition model; focusing on the individual and how they think. Social cognition model; focuses on the influence others have on the individual’s behaviour. Empowerment; takes into account the difficulties individuals have to change their behaviour. However, these models are unlikely to work on their own, so Prochaska and DiClemente (1982) devised the trans-theoretical stages of change model, which incorporates the three other theories. (Evans, Coutsaftiki & Patricia Fathers, 2017). It is believed individuals go through each stage when improving their lifestyles and can relapse at any time. These techniques enable health professionals to improve the success rate of individuals who quit smoking (Davies, 2011).
There are five stages to the model. Pre-contemplation; contemplation; preparation; action and maintenance. The task of the health professionals is to determine the readiness of the patient to change and assist them to move from one stage to another. It aims to educate and support people, hoping lifestyle choices and behaviours can be changed in order for them to lead a normal healthy life (Evans et al., 2017).
With six in ten people wanting to quit each year and some attempting to quit with no help, the Welsh government produced a number of initiatives that have been tailored to assist and motivate smokers to quit. These services have to be readily available to the public (Evans, 2017).
To provide these services, healthcare providers need to have good professional values, knowledge of various roles, responsibilities and also good patient-centred communication. This is fundamental if the patient is going to attempt behaviour change (Davies, 2011).
Utilising the skills in the framework developed by the public health and health and social care, which is based on Prochaska and DiClemente’s stages of change and also incorporating evidence-based practice to stop smoking, produced by NICE guidelines. Which has made recommendations that include providing behaviour support that is delivered by trained staff, nicotine replacement therapy and advice (National Institute for Health and Care Excellence, 2018). Which involves assessing the smoking behaviour of the patient past and present, provide information on the effects of smoking and not smoking, options for additional support and advice on medications (National Centre for Smoking Cessation and Training, 2018).
MECC (Making every contact count) aims to educate all NHS organisations in improving the health and well-being of the population (Making Every Contact Count, 2018). To bring together service and education providers along with individuals to change the systems and improve healthcare responsibilities, promoting all areas that affect the health and well-being such as psychological, socio-economic and environmental factors (Evans, 2017).
By adopting a systematic approach, working effectively in partnership with other organisations in the different sectors, focusing on individuals who are ill to improve their health and protect the population against potential ill-health, with the aim of improving the quality of health and reducing the life expectancies between classes (Department of Health, 2013).
Nurses have a major role in promoting healthy lifestyles, using day to day interactions that involve the local people to provide positive changes in their physical and mental well-being. They have the opportunity to improve nurse-patient interactions and engage with individuals and the communities, to change health behaviours and following the guidelines produced by MECC, they will be able to communicate in a way that encourages individuals to be open, acknowledging the individual’s rights to make their own decisions about their health. Nurses will also gain the confidence and competence to provide advice that encourages behaviour change and direct patients to the appropriate services (Making Every Contact Count, 2018).
Services that are currently available in Wales are Stop Smoking Wales, currently supported by public health Wales. ABMU Health board have; Help Me Quit, this service provides one to one support over the phone and face to face. There are also eighty-four community pharmacies that have been trained to level 3, which allows them to support smokers in the most deprived areas (Newbury Davies, 2017). However, even though lower economic classes will use the stop smoking sessions, they may not completely stop, this could be due to the lack of motivation or having a stressful lifestyle, being nervous and depressed or have a lack of support outside the services, leading to smokers relapsing (George et al., 2018).
This essay has looked at the public health issue surrounding the use of tobacco, which is currently the leading cause of preventable mortalities in the UK and has had major effects on the health of society and also the individual. Having used evidence from a variety of sources, looking at costs to the NHS and local governments, the policies that are in place and what the nurse’s role is to promote healthy lifestyles.
This evidence showed that there is still 7.4 million people who use tobacco in the UK. Life expectancy is reduced by seven years for every packet of cigarettes smoked a day and over 50 cancer-causing chemicals found in the smoke of cigarettes. Individuals in the lower classes continue to smoke more than the affluent, being more common in men of the 25 to 34-year age group. This could be a result of social-economic and environmental factors, as smoking is seen to be linked to the unemployed, homeless and those who are socio-economically worse off, it can often be an attribute to other health conditions such as stroke and heart disease.
Smoking-related illnesses are currently costing the Welsh NHS £302 million a year with over 26 thousand admissions to hospital. However, it is also said that while costs for the NHS are high, the government is profiting from the sale of cigarettes.
Since the smoking ban in 2007 the prevalence of smokers has declined, with the government wanting to eradicate smoking, policies have been put in place to help smokers to quit and reduce the numbers of people starting to smoke. This is done with the hope that by reducing the number of smokers will reduce some of the inequalities and the life expectancy between classes will be minimised.
Services currently in place, like Help Me Quit and the 84 pharmacies are to aid the individual to become a non-smoker. By using a framework designed to assist in changing behaviour, nurses can support individuals in all areas, but mainly in the most deprived to provide motivation and support to change their lifestyle and improve their well-being.
Amos, A., Bauld, L., Hiscock, R., & Platt, S. (2012). Smoking and socioeconomic status in England: The rise of the never smoker and the disadvantaged smoker. Journal of Public Health (United Kingdom), 34(3), 390-396. DOI: 10.1093/pubmed/fds012. Retrieved from University of Bristol: https://academic.oup.com/jpubhealth/article/34/3/390/1560637
ASH. (2014). Secondhand Smoke. Retrieved from ASH; Action on Smoking and Health: http://ash.org.uk/information-and-resources/secondhand-smoke/secondhand-smoke/
Ash. (2017, November). Factsheet, Smoking Statistics. Retrieved from ASH- Action on Smoking and Health: http://www.who.int/tobacco/resources/publications/tobacco_dependence/en/
ASH Wales Cymru. (2018). Wales’ Headline Statistics . Retrieved from ASH Wales Cymru: https://ash.wales/wales-headline-statistics/
Bain, J., Duffy, S., Hilton, S., Patterson, C., Semple, S., & Wood, K. (2014). Newsprint coverage of smoking in cars carrying children: a case study of public and scientific opinion driving the policy debate. Retrieved from BMC Public Health: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1116
Benowitz, N. (2017). Nicotine Addiction. Retrieved from US National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928221/
Centers for Disease Control and Prevention. (2018). Health Effects of Cigarette Smoking. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm
Centre for Economics and Business Research. (2014). Smoking costs UK businesses £8.7bn. Retrieved from Centre for Economics and Business Research: https://cebr.com/reports/smoking-costs-uk-businesses-8-7bn/
Coleman, L., & Sherriff, N. (2012). Understanding the needs of smokers who work as routine. Retrieved from Academia: http://www.academia.edu/3319861/Understanding_the_needs_of_smokers_who_work_as_routine_and_manual_workers_on_building_sites_Results_from_a_qualitative_study_on_workplace_smoking_cessation
Da Costa e Silva, v. (2003). Policy Recommendations for Smoking Cessation and Treatment of Tobacco Dependence. Retrieved from World Health Organization: http://www.who.int/tobacco/resources/publications/tobacco_dependence/en/
Davies, N. (2011). Healthier lifestyles: behaviour change. Nursing Times; Vol 107 No 23. Retrieved from Nursing Times: https://www.nursingtimes.net/Journals/2012/03/30/a/m/d/110614Lifestyle.pdf
Department of Health. (2013). Improving outcomes and supporting transparency Part 1A: A public health outcomes framework for England, 2013-2016. Retrieved from Department of Health: http://makingeverycontactcount.co.uk/media/1018/017_ph-outcomes-framework.pdf
Department of Health and Social Care. (2015). Policy paper 2010 to 2015 government policy: smoking. Retrieved from Department of Health and Social Care: https://www.gov.uk/government/publications/2010-to-2015-government-policy-smoking/2010-to-2015-government-policy-smoking
Dickson, M., & O’Kane, C. (2018). HM Revenue and Customs. Retrieved from Tax & Duty Bulletins; Tobacco Duties: https://www.uktradeinfo.com/Statistics/Pages/TaxAndDutybulletins.aspx
Evans, D., Coutsaftiki, D., & Patricia Fathers, C. (2017). Health Promotion and Public Health For Nursing Students 3rd ed. London: Learning Matters.
Evans, R. (2017). Tobacco Control Delivery Plan For Wales 2017-2020. Retrieved from Welsh Government: https://gov.wales/docs/dhss/publications/170915tobaccoplanen.pdf
Fong, G., & Hitchman, S. (2011). Gender empowerment and female-to-male smoking prevalence ratios. Retrieved from World Health Organization: http://www.who.int/bulletin/volumes/89/3/10-079905/en/
Gardiner, M., & Tiggemann, M. (2010). Gender differences in leadership style, job stress and mental health in male ‐ and female ‐ dominated industries. Retrieved from The British Psychological Society: https://psychsource.bps.org.uk/details/journalArticle/3334261/Gender-differences-in-leadership-style-job-stress-and-mental-health-in-male–and.html
George, E., Griffiths, J., Scholey, V., Tomlinson, A., & Williams, J. (2018). An Independant Review of the Provision of Smoking Cessation Services in Wales. Retrieved from Welsh Government: https://gov.wales/docs/caecd/research/2018/180612-independent-review-provision-smoking-cessation-services-en.pdf
Graham, H., Jefferis, B., Manor, O., & Power, C. (2004). Changing social gradients in cigarette smoking and cessation over two decades of adult follow‐up in a British birth cohor. Journal of Public Health, Volume 26, Issue 1,, Pages 13–18. Retrieved from https://academic.oup.com/jpubhealth/article/26/1/13/1532126
Grant, A. (2017). ASH Wales; The economic cost of smoking to Wales: a review of existing evidence. Retrieved from Online Research @ Cardiff: http://orca.cf.ac.uk/89325/
Healthy Working Wales. (2018). Smoking . Retrieved from Healthy Working Wales: http://www.healthyworkingwales.wales.nhs.uk/smoking
Kozier, B., Erb, G., Berman, A., Snyder, S., Harvey, S., & Morgan-Samuel, H. (2012). Fundamentals of Care: Concepts, process and practice. Harlow: Pearson Education Ltd.
Making Every Contact Count. (2018). National Resources. Retrieved from Making Every Contact Count: http://makingeverycontactcount.co.uk/national-resources/
Malam, S. (2015). Ban on smoking in public places . Retrieved from Welsh Government: https://gov.wales/docs/phhs/publications/150203smokingquantitativereporten.pdf
Marchman Anderson, M., Oksbjerg Dalton , S., Lynch , L., Johansen , C., & Holtug , N. (2013). Social inequality in health, responsibility and egalitarian justice. Retrieved from Journal of Public Health: https://academic.oup.com/jpubhealth/article/35/1/4/1593748
Matthews, D. (2015). Sociology in Nursing 2: Social Class and its Influence on Health. Retrieved from Nursing Times: https://www.nursingtimes.net/clinical-archive/public-health/sociology-in-nursing-2-social-class-and-its-influence-on-health/5091017.article
Mental Health Foundation. (ND). Smoking and Mental Health. Retrieved from Mental Health Foundation: https://www.mentalhealth.org.uk/a-to-z/s/smoking-and-mental-health
Naidoo, J., & Wills, J. (2016). Foundations for Health Promotion (4th Ed). London: Elsevier Ltd.
National Centre for Smoking Cessation and Training. (2018). Very Brief Advice (VBA) on Smoking: the evidence. Retrieved from National Centre for Smoking Cessation and Training: http://www.ncsct.co.uk/publication_very-brief-advice.php
National Institute for Health and Care Excellence . (2018). Stop smoking interventions and services. Retrieved from National Institute for Health and Care Excellence : https://www.nice.org.uk/guidance/ng92/chapter/Recommendations#evidence-based-stop-smoking-interventions
National Institute on Drug Abuse (NIDA). (2018). National Institute on Drug Abuse (NIDA) Tobacco, Nicotine, and E-Cigarettes. Retrieved from National Institute on Drug Abuse (NIDA): https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/1344-tobacco-nicotine-and-e-cigarettes_0.pdf
Newbury Davies, L. (2017). ABM University Health Board Smoking Cessation Recovery and Delivery Plan 2016 – 2020. Retrieved from NHS Wales: http://www.wales.nhs.uk/sitesplus/documents/863/2%20%28ii%29%20Smoking%20Cessation%20and%20Delivery%20Plan%202016-2020.pdf
Office for National Statistics. (2017). Adult smoking habits in the UK: 2017. Retrieved from Office for National Statistics: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2017#the-proportion-who-are-current-smokers-in-the-uk-its-constituent-countries-and-local-areas-2011-to-2017
Public Health England. (2015). Health matters: smoking and quitting in England . Retrieved from Gov.uk: https://www.gov.uk/government/publications/health-matters-smoking-and-quitting-in-england/smoking-and-quitting-in-england
Public Health England. (2015). Research and analysis . Retrieved from Gov.UK: https://www.gov.uk/government/publications/cost-of-smoking-to-the-nhs-in-england-2015/cost-of-smoking-to-the-nhs-in-england-2015
Public Health England. (2017). Cost of smoking to the NHS in England: 2015 . Retrieved from Gov.uk: https://www.gov.uk/government/publications/cost-of-smoking-to-the-nhs-in-england-2015/cost-of-smoking-to-the-nhs-in-england-2015
Public Health Wales. (2013). Annual report reveals positive results for Stop Smoking Wales. Retrieved from Health in Wales: http://www.wales.nhs.uk/news/30584
Public Health Wales Observatory and Welsh Government,. (2012). Tobacco and health in Wales . Retrieved from Public Health Wales Observatory: http://www2.nphs.wales.nhs.uk:8080/PubHObservatoryProjDocs.nsf/85c50756737f79ac80256f2700534ea3/509486bfd300fdef80257a29003c3c67/$FILE/Eng%20Smoking%20Report%20LowRes.pdf
Public Health Wales Observatory. (2015). Our Healthy Future Indicators . Retrieved from NHS Wales: http://www.publichealthwalesobservatory.wales.nhs.uk/ohf-2015
Public Health Wales Observatory. (2017). Smoking data: mortality, hospital admissions & prevalence projection tool. Retrieved from Public Health Wales Observatory: http://www.publichealthwalesobservatory.wales.nhs.uk/smoking2017
Rowlingson, K. (2011). Does income inequality cause health and social problems? Retrieved from Joseph Rowntree Foundation: https://www.jrf.org.uk/sites/default/files/jrf/migrated/files/inequality-income-social-problems-full.pdf
Royal Collage of Nursing. (2016). The role of nursing staff in public health . Retrieved from Royal Collage of Nursing: https://www.rcn.org.uk/clinical-topics/public-health/the-role-of-nursing-staff-in-public-health
Santinello, R., & Vogli, M. (2005). Tobacco Control; Unemployment and smoking: does psychosocial stress matter? Retrieved from BMJ Journals: https://tobaccocontrol.bmj.com/content/14/6/389
Scriven, A. (2017). Promoting Health; A Practical Guide (7th ed). London: Elsevier Ltd.
Statista. (2018). Recommended retail price of a typical pack of 20 cigarettes in the United Kingdom (UK) from 2005 to 2017 (in GBP). Retrieved from The Statistics Portal: https://www.statista.com/statistics/414973/cigarette-prices-in-the-united-kingdom/
Welsh Government. (2012). Tobacco and health. Retrieved from Welsh Government: https://gov.wales/statistics-and-research/tobacco-health-wales/?lang=en
Welsh Government. (2017). Smoking. Retrieved from Welsh Government: https://gov.wales/topics/health/improvement/smoking/?lang=en
World Health Organisation. (1986). The Ottawa Charter for Health Promotion. Retrieved from World Health Organisation: http://www.who.int/healthpromotion/conferences/previous/ottawa/en/
World Health Organization. (2015). WHO global report on trends in prevalence of tobacco smoking 2015 . Retrieved from World Health Organization: http://apps.who.int/iris/bitstream/handle/10665/156262/9789241564922_eng.pdf?sequence=1