southampton jsna taking responsibility for … 4 taking...that stopping smoking at age 60, 50, 40,...

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Taking Responsibility for Health: Smoking

Public Health Intelligence Team, Public Health Southampton,

Southampton City Council, Lower Ground Floor,

Municipal Block – East, Civic Centre, Southampton, SO14 7LT

Tel: 02380 833871 E-mail: [email protected]

Website: www.publichealth.southampton.gov.uk

Southampton JSNA Taking Responsibility for Health:

Smoking

Ginny Cranshaw May 2014

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Overview The World Health Organisation (WHO) acknowledges that smoking is the single largest preventable cause of death and disability in the developed world

1. Smoking continues to pose one of the biggest

risks to public health worldwide, killing almost six million people each year, five million of whom are smokers, and over 600 thousand non smokers who are killed by exposure to second-hand smoke.

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Smoking harms nearly every organ of the body and dramatically reduces both quality of life and life expectancy. Smoking causes lung cancer, respiratory disease and heart disease as well as numerous cancers in other organs including lip, mouth, throat, bladder, kidney, stomach, liver and cervix. The US Surgeon General’s report in 2010 concluded that “there is no risk-free level of exposure to tobacco smoke, and there is no safe tobacco product”.”

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Major causes of death in England 2011

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Despite the knowledge of the dangers of smoking, an estimated one in six people still smoke in England. In 2010 the Chief Medical Officer identified tobacco use as the single biggest behavioural risk factor for premature death in England.

5 As the diagram shows smoking was responsible for the

highest burden of death in England in 2011, a situation that remains unchanged. There are about 10 million adults who smoke cigarettes in Great Britain, including 21% of adult men and 19% of adult women. Smoking prevalence is highest among 20-24 year olds: 30% of men and 28% of women in this age group smoke. In 1974, 51% of men and 41% of women smoked cigarettes - nearly half the adult population. Smoking rates are also markedly higher among poorer people. In 2011, 13% of adults in managerial and professional occupations smoked compared with 28% in routine and manual occupations.

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Who is at risk and why? Along with the known health risks to smokers themselves, the health impacts of second hand smoke (SHS) exposure are well documented and people who are exposed to SHS face an increased risk of cancer and heart disease. It is a particular risk to infants and children, resulting in increased incidence of upper respiratory tract infections, glue ear and an increased risk of sudden infant death. Exposure to SHS is higher among disadvantaged communities where rates of smoking are higher and also in children whose mothers smoke. There are 9,500 hospital admissions and 40 sudden deaths each year in England directly attributed to SHS

7. There is a significant body of UK and international

evidence which demonstrates that smokefree laws are effective in reducing exposure to SHS. Whilst legislation exists making all enclosed environments smoke free, this law does not relate to peoples homes and many people, especially children, are still exposed to SHS. It is a priority therefore to undertake work to encourage families to protect children from SHS through smoke free homes and cars. Smoking is the biggest cause of health inequalities and the impact of smoking falls mostly on the poorest and most vulnerable people in society. Tobacco control was identified in the Marmot Review as a central platform in any strategy to tackle health inequalities, since half of the difference in life expectancy between the highest and lowest income groups can be attributed directly to smoking, and smoking-related death rates are two to three times higher in more disadvantaged social groups than in wealthier social groups

8.

The table shows the difference in life expectancy and mortality between the most deprived and the least deprived areas in the city. Whilst mortality rates in the most deprived areas from Chronic Obstructive Pulmonary Disease (COPD) have improved by 12%, they are still 203.9% higher than deaths from COPD in the least deprived areas. In Southampton more people in routine and manual classes smoke than in other social classes (30.3% compared to the national average of 29.7%). Within the city smoking prevalence rates are significantly higher in those areas with the greatest deprivation.

Life Expectancy and Mortality Indicators in Southampton City

Are the most deprived areas improving?

Is the gap narrowing?

Change between 2006-08 and 2009-11

Difference between most deprived and least deprived areas

Measure 2006-08 2009-11 Life Expectancy for males Increase of 1.0 years 6.5 years 6.4 years Life Expectancy for females

Increase of 0.2 years 1.1 years 2.6 years

Mortality – all cause, all age

Decreased 3.9% 40.6% higher 53.25% higher

Premature mortality (under 75) – all cause


Circulatory disease mortality – all ages


Circulatory disease mortality – under 75s


Cancer mortality – all ages Increased 2.7% 61.2% higher 94.1% higher Cancer mortality – under 75s

Increased 10.1% 71.9% higher 119.2% higher

COPD mortality – all ages Increased 12.0% 298.9% higher 203.9% higher

Survey data indicate that currently in the UK around 207,000 children aged 11-15 start smoking every year

9. Smoking is an even bigger problem for smokers who start at a young age because lung

development is affected meaning that subsequent decline in lung function starts from a lower base and the risk of COPD later in life is increased. Also, people who start to smoke before the age of 15 have a higher risk of lung a cancer than those who start later even after the amount smoked is taken into account.

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Two major longitudinal studies have demonstrated the benefits of stopping smoking at an early age. The 50 year follow up of the British doctors’ study revealed that if smokers quit before the age of 30 they can avoid more than 90% of the smoking-attributable risk of lung cancer. The authors concluded that stopping smoking at age 60, 50, 40, or 30 gains, respectively, about 3, 6, 9, or 10 years of life expectancy

10. A similar study of British women also found that stopping smoking before the age of 40

avoids more than 90% of the increased risk of dying caused by continuing to smoke, while stopping before the age of 30 avoids over 97% of the increased risk.

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There are immediate health gains to stopping smoking as shown below. Health benefits after stopping smoking

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Time since quitting Health benefit to quitting

20 minutes Pulse return to normal.

8 hours Nicotine is reduced by 90% and carbon monoxide levels in blood reduce by 75%. Circulation improves.

24 hours Carbon monoxide and nicotine almost eliminated from the body. Lungs start to clear out smoking debris.

48 hours All traces of nicotine are removed from the body. The ability to taste and smell improves.

72 hours Breathing is easier. Bronchial tubes begin to relax and energy levels increase.

2-12 weeks Circulation improves.

1 month Physical appearance improves – skin loses its grey pallor and becomes less wrinkled.

3-9 months Coughing and wheezing declines.

1 year Excess risk of a heart attack reduces by half.

10 years Risk of lung cancer falls to about half that of a continuing smoker.

15 years Risk of a heart attack falls to the same as someone who has never smoked.

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Level of Population Need Although smoking prevalence has decreased nationally, a wide disparity still exists across regions and Southampton compares less favourably both to the region and the country as a whole, making smoking a public health priority. The table below shows the latest Tobacco Control Profile for Southampton City, from Public Health England. This demonstrates the significant impact of smoking on the health of residents in the city, and how Southampton is performing against the rest of the region, and the national average. The prevalence of smoking in the city is 22.5% compared to the national average of 19.5%. 16.6% of pregnant women in the city smoke at the time of delivery compared to the national average of 13.2%, putting both their own health, and the health of their baby, at risk. In addition smoking rates are higher among the city’s routine and manual workers with rates of 30.3% in Southampton compared to 29.7% nationally. Tobacco Control Profile for Southampton City 2013

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Southampton Region England Count Value Value Value Worst Best

Smoking attributable mortality 1018 236 181.7 210.6 371.8 125.2

Smoking attributable deaths from heart disease 115 30 24.4 30.3 58.4 14.6

Smoking attributable deaths from stroke 39 9.6 8 9.8 19.2 4.8

Deaths from lung cancer 364 47.1 31.1 37.2 70.3 20.9 Deaths from chronic obstructive pulmonary disease 310 32.3 21.8 25.3 51.6 12.1

Lung cancer registrations 446 58.1 37.9 46.6 86.2 25.1

Oral cancer registrations 72 10.3 8.5 9.5 16.6 3.4

Smoking attributable hospital admissions 2113 1746 1114 1420 2536 726

Cost per capita of smoking attributable hospital admissions 4484057 40.9 32.2 36.9 61.7 14.5

Smoking prevalence - routine & manual - 30.3% 29.5% 29.7% 44.3% 14.2%

Smoking Prevalence (IHS) - 22.5% 18.0% 19.5% 29.8% 12.1%

Smoking status at time of delivery 574 16.6% 11.4% 13.2% 29.7%

Men living in Southampton have significantly lower healthy life expectancy than the national average (61.1 years compared with 63.2 years)

14, and smoking is one of the main causes for this. The table

shows that more people die from smoking related deaths in Southampton than the national average (236 per 100 000, compared to 210.6 in England). Deaths from lung cancer and chronic obstructive pulmonary disease are also higher than the national average, and more people are admitted to our hospitals with smoking related illnesses. Smoking brings a very high cost to the city in both health and financial terms. Along with the significant personal cost to individuals and their family from poor health and financial burden, there is a considerable economic cost to the city in terms of ill health and costs to local employers. Action on Smoking and Health (ASH) estimate that annually smoking in Southampton costs our population £70.9m, based on data from national research and surveys.

15 The city council spends £1.9 million

annually clearing up smoking litter, and £2.8 million on domestic fires caused by smoking. An estimated £81.1m is lost to the local economy in money that goes up in smoke spent on cigarettes and tobacco rather than being spent and recycled through our local shops and businesses. Details of

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the breakdown of the wider costs of smoking are shown in the table below and demonstrate a very high financial burden to the city directly attributed to smoking. The estimated cost of smoking to Southampton City

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Smoking causes a significant cost to both the national and local economy in terms of lost productivity from time off sick and smoking breaks. There are significant potential financial benefits for employers in implementing and complying with Smokefree legislation. Smokers take more sickness leave than non smokers, costing £13.7 million annually to the city, and cigarette breaks taken by smoking employees cost Southampton employers £15.9m each year. Employers should encourage and support staff with addiction to tobacco to contact NHS Stop Smoking services. Smoking causes a considerable burden for our health services, impacting on primary care and also increasing the number of hospital admissions, especially in the winter months. 1746 per 100 000 admissions to hospital in 2010-2011 were directly attributable to smoking. The cost to the local Health economy is estimated by ASH to be £1.48m. The cost of treating children who are affected by smoking within the home is estimated to be £10 million, while hospital admissions cost a further £13.6 million

17. To try to reduce the significant economic burden of smoking on local NHS services, there is

local investment in the Improving Fitness for surgery programme, which is an initiative that provides help to people to stop smoking for 4 weeks before having non-urgent (elective) surgery. There is also a need to ensure that smoking cessation is integrated into clinical pathways. A high level commitment is required within acute and mental health trusts to support the tobacco cessation agenda in order to realise the potential of the Fitness for Surgery Initiative to reduce bed days and post-operative complications.

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Current services Southampton City Council is committed to tackling the harm done by tobacco. It is a member of the Smokefree Action Coalition which works at a national level to influence government policy on smoking, which forms an important part of tobacco control, and in November 2013 the Council signed the Local Government Declaration on Tobacco Control. In Southampton there are many partners and stakeholders involved in smoking cessation and tobacco control. These include the regulatory services to reduce the supply of tobacco, children and family services, schools and early years, fire services, pharmacies, primary and secondary care, as well as the Smoking Cessation Service, provided through Solent Quitters. NHS Stop Smoking Services provide a resource for information on quitting support and provide expert advice to organisations that want to integrate a stop smoking approach for their workforce. This is also vitally important for the focus on routine and manual smokers. The NHS Stop Smoking Services in England and Wales were established in 2000 and since then the number of people using them has grown year on year, rising to over 800,000 in 2011-12. An evaluation of the effectiveness of the services found four-week validated quit rates of 53% and 15% at one year. By comparison the 12-month quit rate among people who attempt to quit unaided is estimated to be about 4%. A review of the English stop smoking services found that over the first ten years of operation they helped an estimated 20,000 people to achieve long term abstinence.

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In 2011/12 46% of those people setting a quit date had successfully quit at four weeks. The chart shows that this quit rate has fallen over time both nationally and locally but the Southampton rate is now lower than the England average. However, the rate of quitters is actually higher in Southampton than nationally (1,122 per 100,000 population in 2011/12 compared with 944 per 100,000).

Primary care Primary care staff have a huge role to play in helping their patients to quit smoking. NICE guidelines (Smoking cessation services PH10, partially updated by PH48)

19 recommend that everyone who

smokes should be encourage to quit, unless there are exceptional circumstances, and all staff working in primary care should be asking their patients whether they smoke. They should be trained

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to provide very brief advice to encourage patients to quit and encouraging them to attend the specialist service for support with quitting. They should also provide evidence based approaches to support quit attempts for those people who do not want to access specialist services.. Primary care also plays a significant role in risk reduction by helping patients to prepare for surgery as part of the “Fitness for Surgery” Initiative. Evidence shows patients who quit smoking prior to surgery have improved wound healing, reduced circulatory complications and less wound infections. Pharmacy-based services There is a strong evidence base to demonstrate the significant role of pharmacy-led stop smoking programmes in helping people to quit. Staff in community pharmacies who have been trained in behaviour change methods are effective at helping clients to stop smoking and these stop smoking services are cost effective. Evidence shows that quit rates provided by community pharmacists are similar to those of primary care nurses. However, there is concern about the impact from the sales of electronic cigarettes within pharmacies, and other settings, and the impact of these devices on people’s motivation to quit. Regulatory Services Regulatory Services have an important role to play in Tobacco Control and Trading Standards carries out work in the following areas relating to tobacco:

Ensuring tobacco advertising complies with the restrictions on displays and advertising in shops/pubs by responding to complaints, advice to relevant businesses and inspections of businesses.

Ensuring tobacco products bear the required health warnings

Preventing sales of tobacco and related products to persons under the age of 18 by the provision of advice to businesses, test purchasing using volunteers and carrying out enforcement action when required.

Preventing the sale of non duty paid/counterfeit tobacco products by means of inspections, responding to complaints, advice to businesses and seizing illegal products. These are often much cheaper than duty paid/genuine cigarettes.

Environmental Health enforces the Smokefree legislation, which restricts smoking in many public places and workplaces (including public transport and work vehicles). The legislation was introduced in July 2007 following a national and local campaign to raise awareness of the health risks associated with smoking and educating people in control of premises about the new law. ‘No smoking’ signs must be displayed in premises which are required to be Smokefree and enforcement action can be taken against individuals smoking in Smokefree premises or people who permit smoking in Smokefree premises under their control. Compliance with the law has been extremely high in Southampton and smoking is no longer permitted in workplaces, including pubs, bars and restaurants which reduces exposure to environmental tobacco smoke. This has a positive impact on public health and supports those people who wish to stop smoking. Tobacco Control Strategy As part of the Council’s statutory responsibility for improving health a city wide Tobacco Control Strategy has been developed to coordinate local efforts for effective tobacco control. The strategy will be presented to the Council’s Health and Wellbeing Board in March 2014 for approval. This includes work to implement effective tobacco controls to reduce the impact of smoking in Southampton through: 1. Motivating and assisting every smoker to stop

a) Commissioning specialist services to support all smokers wanting to quit ensuring open access, targeting those in the city’s most deprived neighbourhoods.

b) Ensuring effective communications for tobacco to ensure a robust approach to working with the Media, communications and public education about smoking by harnessing local authority communications and delivering local Support for key National Campaigns: Stop Smoking Day in March, Stoptober, Smokefree homes.

2. Protecting families and communities from tobacco related harm

a) Ensuring that local Maternity services actively work alongside other partners to reduce smoking rates among pregnant women.

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b) Reducing exposure to second hand smoke, especially children by promoting smoke free environments and raising awareness of the harm cause by tobacco.

3. Stopping the inflow of young people recruited as smokers a) Building on existing work to deliver targeted evidence-based interventions to ensure all

schools and colleges in the city comply with legislation and have smoke free policies in place. b) Delivering educational programmes to raise awareness of Young People and smoking.

All of the above work is underpinned by effective regulation of tobacco products through: a) Supporting the work of Trading Standards and Environmental Health, in partnership with the

local business community, to ensure compliance with legislation in local businesses. b) Partnership work with Trading standards, Police and HMRC to improve local intelligence on

illicit tobacco to control smuggled and counterfeit tobacco. c) Local authority support for the Local Government Declaration on Tobacco Control, and the

campaign for plain standardised tobacco packaging through the Smoke Free Action Coalition. d) Effective communications

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Future projections Male lung cancer incidence rates peaked in the early 1970s, reflecting the peak in smoking prevalence 20-30 years earlier. Rates in women have stabilised, after increasing throughout the 1970s and 1980s. Forecasting suggests that female lung cancer mortality rates will reach current male levels within the next ten years and then fall, while deaths will continue to fall in men

20.

Use of electronic cigarettes/e-cigarettes has grown in recent years; according to a survey by ASH 3% of smokers reported using them in 2010 and this had grown to 11% by 2013. A further 24% of smokers reported that they have tried e-cigarettes but do not use them any more.

21 This growth in use

is anticipated to increase at least over the next couple of years. As yet the safety of e-cigarettes has not been fully established.

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Stakeholder Views View of someone who stopped smoking through the Stoptober campaign: “My family had nagged me to give up for a long time and my daughter had me on a ‘reduction’ programme earlier this year, so the next step for me was definitely Stoptober. I went to Quitters for advise and nicotine replacement therapy before the big day..Throughout October I also attended the weekly Quitters session for SCC staff. I made it through Stoptober and have now gone for nearly 2 months without a cigarette ......I highly recommend it!! It’s not been easy but I now have more money and can run further, I’ve stopped coughing and generally feel fitter. I still can’t believe I’ve quit - it feels great. Thanks to Stoptober and everyone else who supported me.”

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Evidence of What Works There are many interventions required at a number of different levels in order to break the cycle of smoking. The commissioning of local NHS Stop Smoking Services is an essential part of tobacco control, as the most evidence-based support system available. However in order to change the view of smoking as a desirable, everyday activity, helping smokers to stop needs to become integrated into the work of every organisation. The diagram below shows the different opportunities where actions can be targeted including interventions to help people to quit, to protect families and communities and to reduce the supply of illegal tobacco. Partnership work is essential for tobacco controls to be effective, and these partners are drawn from a number of areas. At a local level there are many partners and stakeholders including the regulatory services to reduce the supply of tobacco, children and family services, schools and early years, fire services, pharmacies, primary and secondary care. Southampton City Council is now a member of the Smokefree Action Coalition which works at a national level to influence government policy on smoking, which forms an important part of tobacco control. Breaking the cycle of smoking

Actions to break the ‘cycle of smoking’

Take-up

smoking

Quitting

attempt

Relapse

Decision

to quit

Take-up

smoking

Quitting

attempt

Relapse

Decision

to quit

Take-up

smoking

Quitting

attempt

Relapse

Decision

to quit

Reduce the

appeal and

supply of

tobacco

Protect

families &

communities

Encourage

more quit

attempts each

year

Support quit

attempts

A Smokefree Future: A comprehensive tobacco control strategy for England (Department of Health, 2010) details the rationale and evidence-based policies for future tobacco control work under three objectives:

o To stop the inflow of young people recruited as smokers. o To motivate and assist every smoker to quit. o To protect families and communities from tobacco-related harm.

NICE public health guidance 10 (Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities), public health guidance 23 (School-based interventions to prevent smoking) and public health intervention guidance 1 (Brief interventions and referral for smoking cessation in primary care and other settings) details the guidance and recommendations for preventing uptake of smoking, engaging people and successful smoking cessation.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111749

http://www.nice.org.uk/nicemedia/pdf/PH010guidance.pdf

http://guidance.nice.org.uk/PH23/Guidance/pdf/English

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Recommendations In order to reduce the number of deaths and illness attributable to smoking there is a need to:

Sustain the availability and access to smoking cessation support across the City through the Quitters Service, primary care and community pharmacies

Target smoking cessation support to those neighbourhoods with highest prevalence

Work with Trading Standards and other enforcement agencies to reduce under age sales and to reduce the availability of illicit tobacco

Work together across health and social care to promote smoke free homes and cars as the norm by raising the dangers of second-hand smoke and the need to protect children

Provide training to all practitioners working with children, young people and their families to deliver basic tobacco education and information to signpost to cessation support

Further develop joint working between Health and Education to provide more school-based interventions around smoking prevention, in line with effectiveness evidence (NICE Guidance on School-based interventions to prevent the uptake of smoking among children -2010)

Develop policy stand with other colleagues across the network on harm reduction and e-cigarettes in line with the MHRA

Develop a joint approach to harm reduction in relation to NICE guidance 2013

Work with colleagues at UHS to implement the latest NICE guidance PH48 on smoking cessation in secondary care, in making UHS a Smoke free Site.

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Resources Data Compendium

Indicator Period

Smoking prevalence amongst adults (18+): Southampton and ONS Comparators

2011/12

Smoking prevalence amongst adults (18+): Southampton by socio-economic group

2011/12

Percentage of smokers setting a quit date that go on to successfully quit: Southampton and ONS Comparators

2011/12

Smoking quitters: Southampton wards & localities 2012/13

Smoking quitters: Southampton & England time trend 2006/07 to 2011/12

Smoking quitters rate per 100,000 population: Southampton & England Trend

2006/07 to 2011/12

Mortality attributable to smoking (ages 35 and Over): Southampton and ONS Comparators

2009 to 2011 (pooled)

Mortality attributable to smoking (ages 35 and Over): Southampton & England Trend

2005-07 to 2009-11 (pooled)

Smoking-related hospital admissions: Southampton & England Trend 2009/10 to 2010/11

1

World Health Organisation (2013). Available at: www.who.int/mediacentre/factsheets/fs339/en/index.html 2 World Health Organisation (2013). Available at:

http://www.who.int/mediacentre/factsheets/fs339/en/index.html 3 How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable

Disease: A Report of the Surgeon General. (2010). U.S. Department of Health and Human Services Atlanta, GA. National Centre for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 4 ASH Fact sheet: Illness and Disease Action on Smoking and Health (2011). Available at:

http://www.ash.org.uk/files/documents/ASH_107.pdf 5 Annual Report of the Chief Medical Officer. (2010) Department of Health.

6 Action for Smoking and Health (2013) Available at: http://www.ash.org.uk/information/facts-and-

stats/fact-sheets 7 Passive Smoking and Children (2010).Royal College of Physicians.

8 The Marmot Review, Fair Society, Healthy Lives: The Marmot Review of health inequalities in

England (2010). Available at: www.ucl.ac.uk/marmotreview 9 Hopkinson, N. et al (2013) Child Uptake of smoking by area across the UK. Thorax

http://m.thorax.bmj.com/content/early/2013/11/25/thoraxjnl-2013-204379.full 10

Doll, R., Peto, R., Boreham, J. and Sutherland, I. Mortality in relation to smoking: 50 years’

observations on male British doctors. BMJ 2004;328:1519–33 11

Pirie K, Peto R, Reeves G et al. The 21st century hazards of smoking and the benefits of stopping: a prospective study of one million women in the UK. The Lancet, 2012, 6736(12) 61720-6. 12

NHS Smokefree website http://smokefree.nhs.uk/why-quit/timeline/ 13

Tobacco Control Profiles (2013) London Public Health Observatory. http://www.tobaccoprofiles.info/ 14

Public Health Outcomes framework tool (2013). Available at: http://www.phoutcomes.info 15

http://www.ash.org.uk/localtoolkit/R8-SE.html 16

http://www.ash.org.uk/localtoolkit/R8-SE.html 18

ASH http://www.ash.org.uk/files/documents/ASH_116.pdf 19

http://www.nice.org.uk/PH010 20

Cancer Research UK http://www.cancerresearchuk.org/cancer-info/cancerstats/causes/lifestyle/tobacco/ 21

ASH (2013) http://www.ash.org.uk/files/documents/ASH_891.pdf

http://www.who.int/mediacentre/factsheets/fs339/en/index.html

http://www.who.int/mediacentre/factsheets/fs339/en/index.html

http://www.ash.org.uk/information/facts-and-stats/fact-sheets

http://www.ash.org.uk/information/facts-and-stats/fact-sheets

http://www.ucl.ac.uk/marmotreview

http://m.thorax.bmj.com/content/early/2013/11/25/thoraxjnl-2013-204379.full

http://smokefree.nhs.uk/why-quit/timeline/

http://www.tobaccoprofiles.info/

http://www.phoutcomes.info/

http://www.ash.org.uk/localtoolkit/R8-SE.html

http://www.ash.org.uk/localtoolkit/R8-SE.html

http://www.ash.org.uk/files/documents/ASH_116.pdf

http://www.nice.org.uk/PH010

http://www.cancerresearchuk.org/cancer-info/cancerstats/causes/lifestyle/tobacco/

http://www.cancerresearchuk.org/cancer-info/cancerstats/causes/lifestyle/tobacco/

http://www.ash.org.uk/files/documents/ASH_891.pdf

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