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Health Related Behaviour and Lifestyle (Public Health, State of the South West 2011)

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8.8.1 Smoking

8.8.1.1 Smoking is the largest single cause of preventable death in Great Britain. The National Centre for Social Research (NatCen) estimates the mortality rate from smoking-related diseases in the South West to be more than 170 deaths per 100,000 population (2006-08). According to population estimates for that period, this equates to 8,892 deaths in the South West or approximately 17% of all mortality. This compares with an England average of 22.5% (source: ONS).

8.8.1.2 Smoking is the single most important avoidable risk factor for cancers (especially lung cancer), heart disease and many other diseases. It is estimated that smoking causes around 87% of lung cancer deaths, 57% of all cancer deaths and 17% of deaths due to circulatory disease (source: Health Development Agency 2004).

8.8.1.3 Approximately 5.5% of the NHS budget is spent on smoking-related healthcare. In 2008/09, smoking-attributable hospital admissions in the South West cost in excess of £96m (source: Local Tobacco Control Profiles
for England). 8.8.1.4 The adult (age 16+) smoking prevalence in England for 2009 is estimated to be 21%. Between 1998 and 2009, the number of adult men (aged 16+) who smoke reduced from 30% to 22%, while the number of women smokers reduced from 26% to 20% (source: Smoking and drinking among adults, 2009).(More information).

8.8.1.5 The General Lifestyle Survey 2009 also estimates that in the South West fewer than one in five (18%) adults is a smoker (Figure 8.8.1.1). This represents a three percentage point drop from 21% in 2008, and compares very favourably with the 21% figure for England as a whole. The proportion of smokers is slightly
higher in men than in women, but both groups have seen considerable reductions in prevalence since 2008, with men dropping from 21% to 19% in 2009 and women from 22% to 17%.

Figure 8.8.1.1 Proportion of adults aged 16+ who smoke in England and the South West
(persons, 1998 - 2009)

[ Zoom ]
Proportion of adults aged 16+ who smoke in England and the South West (1998-2009) (Fig 8.8.1.1)
Proportion of adults aged 16+ who smoke in England and the South West (1998-2009) (Fig 8.8.1.1). General Lifestyle Survey 2009.
8.8.1.6 In Great Britain in 2009, the prevalence of smoking in people with routine or manual occupations is estimated to have been 28%, almost double the 15% prevalence of those in managerial and professional roles. Although reliable data for the South West are not currently available, these percentages are likely to be reflected in the smoking population in the South West.
8.8.2 Alcohol Consumption
8.8.2.1 Studies have shown that the regular use of alcohol above sensible daily limits (more than two to three units for women, and three to four units for men) is associated with an increased risk of certain types of cancers, haemorrhagic stroke, hypertension, and accidents (source: Smoking and drinking among adults, 2009, p.46).

8.8.2.2 Alcohol consumption accounts for 10% of disease burden, surpassed only by tobacco and blood pressure (source: Alcohol Needs Assessment Research Project 2004). Patterns of drinking, as well as volume consumed, determine the harm caused by alcohol.

8.8.2.3 The NHS recommends that men should not exceed three to four units per day. For women, the recommended daily maximum is two to three units. One unit is the amount of pure alcohol in a 25ml single measure of spirits (40% alcohol by volume (ABV)), a third of a pint of beer (5 to 6% ABV) or half a 175ml ‘standard’ glass of red wine (12% ABV). With respect to wine it is now assumed that a small glass (125ml) contains 1.5 units, a standard glass (175ml) contains 2 units and a large glass (250ml, or approximately one-third of a normal size bottle of wine) contains 3 units.

8.8.2.4 In 2009, 24% of women in the South West drank above recommended sensible daily limits (maximum of three units for women and four for men) on at least one day in the week prior to the survey (source: Smoking and drinking among adults, 2009, p.80), lower than the 29% for England. 34% of males in the South West drank above current recommended sensible daily limits on at least one day in the week prior to the survey, slightly lower than the 37% figure for England. Approximately one in eleven women (9%) and one in six men (17%), in the South West, drank more than six or eight units respectively on at least one day during a week period, more than twice the recommended sensible daily limit (source: Smoking and drinking among adults, 2009, p.80).

8.8.2.5 Deaths from chronic liver disease and cirrhosis of the liver (Figure 8.8.2.1) have unfortunately continued to increase since the early 1990s. While the rates of death are lower in the South West than England as a whole, the disease nonetheless costs many lives in the South West every year. Increasing rates highlight this as an important and continuing public health issue.

Figure 8.8.2.1 Directly age-standardised mortality rates (using European standard) from
chronic liver disease including cirrhosis, 2008 males and females, all ages, South West and
England, 1993 - 2008

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Directly age-standardised mortality rates (using European standard) from chronic liver disease including cirrhosis, 2008 males and females, all ages, South West and England, 1993 - 2008 (Fig 8.8.2.1)
Directly age-standardised mortality rates (using European standard) from chronic liver disease including cirrhosis, 2008 males and females, all ages, South West and England, 1993 - 2008 (Fig 8.8.2.1). Source: NCHOD).
8.8.2.6 In the years 2006–08, over a thousand males in the South West died from chronic liver disease (including cirrhosis of the liver), nearly double the number in 1995–97 (1,031 deaths compared to 564). A much smaller increase can be seen in females in the South West with 597 deaths in 2006–08, compared to 415 in 1995–97 (source: NCHOD).

8.8.2.7 Residents of the most deprived areas (Quintile 5) in the South West account for 40% of alcohol-specific admissions to hospital and are four times more likely to be admitted for those conditions than residents of the least deprived areas (Figure 8.8.2.2). Examples of alcohol-specific conditions include alcoholic liver disease, chronic pancreatitis (alcohol-induced), degeneration of the nervous system due to alcohol. More detailed information on Figure 8.8.2.2 and on hospitalisations due to alcohol in general may be found in the publication ‘Alcohol attributable hospital admissions (NI39) in the South West’ (SWPHO, 2011).

Figure 8.8.2.2 Percentage of alcohol specific hospital admissions by IMD quintile, South West, 2008/09

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Percentage of alcohol specific hospital admissions by IMD quintile, South West, 2008/09 (fig 8.8.2.2)
Percentage of alcohol specific hospital admissions by IMD quintile, South West, 2008/09 (fig 8.8.2.2). Source: HES, DfH and IMD 2007.
8.8.2.8 Alcohol is estimated to play a part in half of all violent crimes and impacts on physical, mental and sexual health. The Centre for Public Health, Liverpool John Moores University, and the North West Public Health Observatory have produced online profiles of alcohol related harm for every Local Authority in England. The South West, on average, is estimated to have one of the lowest violent crime rates attributable to alcohol of the English regions: 5.1 per 1,000 population in 2009/10 compared to 5.8 per 1,000 population for England as a whole. However, a number of areas in the South West have rates above the England average. Bournemouth, and the City of Bristol, for example, have the highest rates at 9.3 and 10 alcohol-attributable violent crimes per 1,000 population respectively, which are almost double the rate (5.1 per 1,000 population) for the South West as a whole (source: Local Health Profiles). As these rates suggest, the level of alcohol-attributable violent crime varies significantly within the South West, as indeed it does throughout England.
8.8.3 Drug Misuse
8.8.3.1 Drug misuse is associated with a number of health issues. People with drug problems are more likely to have mental health problems, self harm and overdose with suicidal intent. Drug misuse can also result in premature mortality, with fatal overdoses (leading to cardiac arrest or respiratory failure) the most common causes of death. Increased disease and mortality may also occur as a consequence of sharing injecting equipment.

8.8.3.2 The British Crime Survey (2008/09) shows that across Britain overall drug misuse among 16–59 year olds (defined by the use of ‘any illicit drug’ in the last year) was 10.1%. It has remained relatively stable since the previous year, when the proportion was 9.6%. Between 2007/08 and 2008/09 the proportion of 16–59 year olds who had used Class A drugs in the preceding year increased from 3% to 3.7%. As with any survey, care needs to be taken in interpreting results for any one year, due to sample size considerations.

8.8.3.3 On 30 April 2010 there were 19,376 clients in drug treatment in the South West, of which 70.7% were male and 15.2% were aged under 25 years (source: National Drug Treatment Monitoring System). Around 50.7% were referred through adult services (which includes social services, community drugs or alcohol team, sex worker projects, outreach services, Job Centre Plus, employment services and probation services).

8.8.3.4 In the 12 months up to the end of April 2010, the age-group with the most people in treatment in the South West was the 30–34 year old age-group (21.7%). The main drugs of misuse were heroin (71.2% of those in treatment), cannabis (10.1%), cocaine freebase (3.8%) and amphetamines (2.6%).
8.8.4.1 Obesity is associated with an increased risk of premature death and a wide range of health problems, including heart disease, stroke, Type II diabetes (non-insulin dependent) and complications in pregnancy and surgery.

8.8.4.2 Estimates of obesity are derived using the Body Mass Index (BMI), which estimates an individual’s body fat based on their height and weight. A BMI of 30 kg/m2 or more suggests an individual is obese.

8.8.4.3 Results from the Health Survey for England 2008 suggest that just over a quarter (27%) of men in the South West are obese. Obesity in men is estimated to have doubled in prevalence since 1993, when the proportion was 13%. Nearly a quarter (23%) of women in the South West are estimated to be obese, an increase from 16% in 1993. These figures are broadly similar to England as a whole, where an estimated 24% of men and 25% of women were obese in 2008.

8.8.4.4 Regular exercise is an important factor in reducing obesity. In the South West, the proportion of people who reported taking part in 30 minutes moderate exercise five or more times a week was 44% for men and 32% for women (source: Health Survey for England 2008).

8.8.4.5 A healthy, balanced diet is also essential for good health. The Health Survey for England 2008 found that people in the South West have similar eating habits to those in England as a whole. This is a change from the 2001 survey which suggested that adults aged 16 and over in the South West were more likely to have healthy eating habits. However, care should be taken when comparing years or areas, as natural variation is expected from the relatively small sample size involved in the survey. Figure 8.8.4.1 illustrates that in the South West in 2008, 25% of men and 31% of women consumed the recommended five portions of fruit and vegetables a day (compared to 25% and 29% for men and women respectively in England).

8.8.4.6 Whilst results from the Health Survey for England 2009 are not available at a sub-regional level, the survey shows that consumption of fruit and vegetables varies considerably by income level and deprivation.

Figure 8.8.4.1 Percentage of the population aged 16+, by sex, consuming 5 or more portions
of fruit and vegetables per day in the South West and England, 2008

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Percentage of the population aged 16+, by sex, consuming 5 or more portions of fruit and vegetables per day in the South West and England, 2008 (Fig 8.8.4.1)
Percentage of the population aged 16+, by sex, consuming 5 or more portions of fruit and vegetables per day in the South West and England, 2008 (Fig 8.8.4.1). Source: Health Survey for England 2008.
8.8.5 Travel, Transport & Health
8.8.5.1 There are aspects of road transport that are beneficial to health: transport allows people to access employment, education, social networks, healthy food choices and services such as the NHS, all of which can be said to improve health. However, transport also has a negative impact on many determinants of health. Injuries and air pollution are often thought of as the major direct impacts but the indirect effects on physical activity, social cohesion and health inequalities all have an influence on the health of individuals, communities and the environment.

8.8.5.2 Road traffic collisions are an important cause of premature death in the South West and account for a greater number of years of life lost than stroke (source: A Heavy Toll, SWPHO 2007).

8.8.5.3 Between 2005 and 2009 police records (source: Stats 19) show 869 transport related fatalities, with over half of these involving those aged between 15 and 39. Overall, the South West has relatively low rates of serious injury and death from road transport incidents, with 46 deaths per 100,000 residents compared to England’s 52 (source: Health Profiles 2010). However, this still equates to nearly 2,400 people being seriously injured or losing their life on the South West’s roads each year.

8.8.5.4 Variation in serious injuries and deaths on the South West's roads shows distinct patterns relating to urban–rural classification. Age-specific rates of serious injury and death for road transport incidents involving cars and motorcycles are significantly higher in rural areas than town and fringe or urban areas. Conversely, rates of pedestrian casualties and fatalities are significantly higher in urban areas. Differences exist when looking at rates by a casualty's or fatality's place of residence, with a relative reduction in the rate of rural deaths and serious injuries compared with analysis by incident location. This suggests many incidents that occur in rural locations involve people who live outside the local area.

8.8.5.5 The majority, 73%, of admissions to hospital for cycling related injuries are not related to road transport collisions per se, but are classified as non-collision incidents. Analysis of these hospital admissions by age shows that these non-collision incidents account for a greater proportion of all cycling related admissions for those aged under 19 compared to those aged between 20 and 64. This suggests that road or environmental conditions and/or insufficient skill levels may be the root cause of these injuries. A recent survey by Better by Bike, the project behind the Cycle City scheme in Greater Bristol, reports that slipping on ice is the leading cause of non-collision cycling incidents, followed by slipping on wet surfaces, and slipping on mud/gravel (source: Avon Public Health Network).

8.8.5.6 A persistent concern is the association between socioeconomic deprivation and road transport injuries, particularly among pedestrians and cyclists in urban areas. A forthcoming report on transport and health shows that the rates of incidents resulting in death or serious injury to pedestrians and cyclists are three times higher in the most, compared to the least, deprived urban areas. Comparing data from hospital episodes to that of police records shows that there is a greater degree of inequality in terms of where an incident occurs, as recorded by the police, compared to the deprivation status of where someone lives, as recorded by Hospital Episode Statistics.

8.8.5.7 People in the South West are currently extremely dependent on private transport, particularly in rural areas, and 83% of households in the region own one or more cars (source: National Travel Survey: 2009). Data from the last Census (2001) show that pensioner households, particularly single pensioner households, are less likely to own a car than other household types. As the South West has the highest proportion of those aged 64–84 and over 85, the relatively low car ownership in these older age-groups, along with increased demand for services is a concern, especially in relation to planning for an ageing population. Proposed cuts in public transport subsidies may disproportionately disadvantage those without access to a car.

8.8.5.8 It is also important to view road safety in the wider context. Local transport should encourage the use of and make provision for modes of transport that are accessible, environmentally friendly and encourage physical
activity. Road danger is a strong disincentive to using active modes of transport such as walking and cycling, especially in relation to parents’ perception of their children’s safety, and can indirectly contribute to rising levels of obesity.

8.8.5.9 The amount of social interaction among residents living on busy streets is inversely correlated with traffic levels in residential streets (Appleyard, D. 1981, Livable streets. University of California Press, Berkeley). Communities can become physically separated where roads have high levels of motor traffic. This limits or disrupts
interpersonal networks, reduces social contact and limits children’s ability to play freely in their immediate neighbourhood. Reductions in social contacts are associated with higher mortality and morbidity in the elderly and possibly poorer mental health.

8.8.5.10 A decrease in motor traffic has the potential to reduce danger from road death or injury, reduce pollution and allow neighbourhoods and communities to reclaim the streets for social interaction and active modes of travel such as walking and cycling. Evidence for safety in numbers suggests that risk declines for each cyclist and pedestrian the more cyclists and pedestrians there are (Jacobsen, P. Safety in numbers: more walkers and bicyclists, safer walking and bicycling. Inj Prev 2003;9:205-209 doi:10.1136/ip.9.3.205). Overall, policies to increase the acceptability, appeal, and safety of active travel and discourage travel in private motor vehicles would provide greater public health benefits than would policies that focus solely on lower emission motor vehicles. An increase in the safety, convenience and comfort of walking and cycling and a reduction in the attractiveness of the private motorcar (speed, convenience and cost) are essential to achieve the changes necessary to improve health.