Hull Public Health 

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Joint Strategic Needs Assessment 2018


Behaviour and Lifestyle Risk Factors

Whilst general socio-economic, cultural and environmental conditions as shown in the Context of Need section determine health and wellbeing, the way individuals choose to live their lives in terms of healthy or unhealthy lifestyles and behaviours can also have a dramatic effect on health and wellbeing.

This section focuses on the main lifestyle and behavioural risk factors for poor health: smoking, obesity, lack of physical activity, poor diet, alcohol consumption, and drug and substance misuse.

These factors are also discussed in some of the later topic areas within the section on adults dealing with specific diseases where there is a very strong association between the behavioural risk factor and a specific disease. For instance, smoking is discussed in the section on lung cancer and in the section on chronic obstructive pulmonary disease, and obesity is discussed in relation to the section on diabetes, and excessive alcohol consumption is discussed in relation to the section on liver disease.

The association between health and wellbeing, and these behavioural and lifestyle factors is complex. Whilst these behavioural and lifestyle factors influence health and wellbeing and increase the risk of numerous diseases and medical conditions, poor health and wellbeing can also increase the likelihood of having an unhealthy lifestyle. For example, it is well known that people with poor mental health are much more likely to smoke and have unhealthier lifestyles, which exacerbates their poor mental and physical health. Information on learning disabilities, severe mental ill health and suicide and underdetermined injury are given in the section on vulnerable groups.

Furthermore, mental health can also influence physical health, and physical health can also influence mental health. This can further influence behavioural and lifestyle factors as well as affecting other important areas of life such as employment, because of physical disabilities, stress, confidence, motivation, etc.

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Smoking

What’s the issue?

“Tobacco is a unique product. It is the only consumable that, when used in the intended way, kills half of its users” [130]. “This makes it one of the biggest causes of death and illness in the UK. Every year around 100,000 people die from smoking, with many more deaths caused by smoking-related illnesses. Smoking causes almost 90% of lung cancers, but can also cause cancer in many other parts of the body” [131]. “Smoking causes around 79,000 preventable deaths in England and estimated to cost our economy excess of £11 billion per year. In 2015/16, there were approximately 474,000 smoking related hospital admissions with smokers seeing their GP 35% more than non-smokers” [132]. “Smoking also increases the risk of developing heart and circulation problems such as coronary heart disease, stroke, peripheral vascular disease and cerebrovascular disease. It also damages the lungs increasing the risk of bronchitis, emphysema and pneumonia, and other chronic obstructive pulmonary disease” [131]. Smoking can also cause or exacerbate numerous other health problems, and there are further risks caused by smoking in pregnancy and breathing in second hand smoke. Smokers who die prematurely lose on average about 10 years of life [133, 134]. Health benefits are immediate after quitting smoking [135], within 2-13 weeks circulation improves and lung function increases [136], within 1-9 months coughing and shortness of breath decreases and people start to regain lung function [136], after one year excess risk of coronary heart disease is half that of a continuing smoker's [137], after 2-5 years stroke risk falls to that of a non-smoker's [137, 138], after five years the risk of cancer of the mouth, throat, oesophagus and bladder are cut in half, and cervical cancer risk falls to that of a non-smoker [137, 138], after 10 years the risk of dying from lung cancer is about half that of a person who is still smoking, and risk of cancer of the larynx and pancreas decreases [136, 137] and after 15 years the risk of coronary heart disease is that of a non-smoker's [138].

What’s our situation?

In 2016/17, 878 out of 3,834 women (22.9%) were known to be smokers at the time of delivery, compared with 10.5% for England [27, 117, 139]. Whilst the rate in Hull has fallen since 2005/06 when 29.6% of women were recorded as smokers, the rate has increased slightly (possibility due to the introduction of carbon monoxide testing).

From the local Young People Health and Lifestyle Survey 2016 [107], smoking rates had decreased slightly, although remained high. Among 15 year olds, an estimated 6.8% of boys and 12.9% of girls smoked (9.5% overall) having decreased since 2008 when 11.3% of boys and 26.1% of girls smoked [140] and from 2012 when 12.5% for boys and 18.0% for girls smoked [95]. Rates of smoking were lower in the younger age groups. National estimates for Hull were slightly lower at 8.6%, comparable to England (8.2%) for 2014/15 [27, 117]. From the local survey [107], just under half of young people lived with someone who smoked (including around one third who lived with a smoker who smoked in the house) although this differed by deprivation (57% and 19% respectively for those in the most deprived fifth versus 29% and 6% respectively for those living in the least deprived fifth of areas of Hull). More boys (7.9%) used e-cigarettes compared to girls (5.9%). E-cigarette usage among boys was higher than smoking / tobacco use.

The prevalence of smoking among adults in Hull is high [139]. From the local Prevalence Survey 2014 [86], 30.7% adults smoked (32.4% for men and 29.3% for women). Although the local prevalence had decreased from 34.0% in 2011-12, it still is nevertheless around 50% higher than England. It is estimated that there are 63,500 smokers in Hull, half of which live in the eight most deprived wards in Hull (which have a prevalence of 37.4% to 48.4% compared to 31.6% in the next highest ward and 14.3% in Beverley ward which had the lowest prevalence). National estimates of smoking prevalence in Hull are considerably lower at 24.2% (compared to England at 15.5%) for 2016 [27, 117, 139]. Local survey estimates are likely to be more accurate as the numbers of people surveyed are much higher and the sample is more representative of Hull's residents. Overall, 8.4% used e-cigarettes (3.7% every day) and virtually all were current or former smokers with the majority using e-cigarettes to quit or cut down their tobacco usage.

From the Local Tobacco Control Profiles [141], in 2015/16, there were 2,968 smoking-related hospital admissions per 100,000 residents aged 35+ years (72% higher than England), lung cancer registrations for 2013-15 were 135 per 100,000 population (75% higher than England), emergency hospital admissions for COPD for 2015/16 was 860 per 100,000 population (more than double that of England), and smoking-attributable mortality for 2013-15 was 485 per 100,000 population (71% higher than England). In 2013-15, it is estimated that one in five deaths in Hull was directly attributable to smoking (1,505 out of 7,384 over the three years) meaning that there were over 40 deaths every month directly attributable to smoking [98, 142]. This rises to 23.6% of premature deaths before the age of 75 years with a total of 643 premature deaths out of 2,730 over the three year period. The total cost of smoking each year in Hull is estimated to be £62 million (economic loss of productivity costs of £45 million, NHS costs of £10 million and additional social care costs of £7 million) [143, 144, 145]. This does not include the cost of tobacco purchased by residents who smoke which could be around £118 million per annum [141, 143, 145, 146].

The position in Hull is improving in all areas, but the rate of change is needs to be quicker. The results from the CLeaR tobacco control assessment undertaken in Hull in April 2017 (see the JSNA Glossary) show that the approach being taken in Hull is fundamentally sound and identifies a number of opportunities for development which the Hull Alliance on Tobacco (HALT) now needs to focus on.

Social marketing research completed in Hull during September 2009 to assess general public knowledge and perception of chronic obstructive pulmonary disease found a perceived health danger relating to quitting smoking – “quit and you'll die!” together with a denial “it's not related to me” attitude [10]. Further local qualitative work revealed an attitude with a lack of immediate consequences in relation to health and a lack of concern over the future: “It doesn't really affect you when you are young but it might catch up with you later” [147].

What are the strategic needs?

It is necessary to work together to ensure people understand the benefit of positive life choices and know how to access information and seek early support to change. In order to do this effectively, health care providers need to work together with different communities to use existing assets to realise the benefit of positive life changes. A holistic approach should be used as different people need different approaches and support. The aims of the stop smoking services are to actively promote a smoke-free Hull, harness the wider public health workforce to deliver very brief advice to those people with whom they have contact in their day-to-day work (“make every contact count”), and reduce the number of people who smoke. It can help if people know that stopping smoking has immediate health effects.

The 2017 National Action Plan for Tobacco states actions needs to be taken in the four areas: prevention first; supporting smokers to quit; eliminating variation in smoking rates; and effective enforcement [132]. The current adult Smokefree Hull Service has a priority focus on people living in the most deprived wards (where smoking prevalence is the highest), pregnant women, and people with chronic obstructive pulmonary disease, coronary heart disease and mental health illness. There is a separate smoking cessation service for young people. Helping users quit through the provision of a cost effective, targeted smoking cessation service is just one strand of Hull’s revised Tobacco Control Plan. The HALT Plan recognises the need to deal with other aspects of tobacco use if smoking prevalence rates are to be reduced. This broader approach is supported by national guidance such as the Tobacco Plan for England [132], CLeaR Local Tobacco Control Assessment, and through bodies such as the World Health Organisation, National Institute of Health and Care Excellence (NICE) and the Regional Tobacco Control Group. In practice this means that in addition to helping people quit, the availability of tobacco has to be controlled through effective regulation, making tobacco less affordable and limiting its promotion in communities. People also have to be protected from the harmful effects of second hand cigarette smoke which is proven to have a harmful effect on health. There needs to be effective communication across all of the different strands of the tobacco control plan. There is a need to support people to make healthy lifestyle choices, to educate young people about the risks of starting smoking, to motivate users to quit, and to promote compliance with tobacco control legislation. The key areas contained in the revised HALT plan include smoking in pregnancy, mental health (parity of esteem), Smokefree NHS, illicit tobacco, e-cigarettes, marketing, and children and young people (denormalising smoking). We want not smoking to be seen as the norm in all local communities.

This 2018 JSNA section on Smoking (4 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Smoking (217 pages)

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Overweight and Obesity

What’s the issue?

“Obesity can reduce life expectancy by between three and ten years, depending on the severity of the obesity" [148]. Excess weight increases the risk of numerous daily problems and health conditions, and is the leading cause of type 2 diabetes, heart disease and cancer, and alongside the ill health issues, it can reduce people's prospects in life, affecting their ability to get and hold down work, their self-esteem and their underlying mental health. There are also increased complications in pregnancy such as gestational diabetes and pre-eclampsia” [148].

Obese children and young people are more likely to become overweight and obese adults.

“It is estimated that obesity is responsible for more than 30,000 deaths each year. On average, obesity deprives an individual of an extra 9 years of life, preventing many individuals from reaching retirement age. In the future, obesity could overtake tobacco smoking as the biggest cause of preventable death” [149].

The cost of being overweight and obese to society and the economy is estimated to be £27 billion per year [149]. The cost could increase to just under £50 billion in 2050 if obesity rates continue to rise [150]. It is predicted that there will be 11 million more obese adults in the UK by 2030, with combined medical costs for treatment of associated diseases estimated to increase by up to £2 billion per year [151].

Overweight is defined as having a body mass index (BMI) between 25 and 30kg/m², and obesity is defined as having a BMI of 30kg/m² or more (morbidly obese as 40kg/m² or more).

What’s our situation?

In 2016/17, over one in eight (13.0%) of reception year children (aged 4-5 years) were obese and a further 14.9% overweight [27, 117, 152]. The prevalence of excess weight has decrease in Hull for most years between 2006/07 and 2012/13 from 26.8% to a low of 22.9%, but since then it has increased for three successive years although it remained the same for this last year. The latest prevalence at 27.9% is considerably higher than England (22.6%). Out of the 3,680 Hull resident reception year children measured, 549 were overweight and 479 were obese. Among Year 6 children (aged 10-11 years), 22.7% were obese and a further 13.4% were overweight. Whilst the prevalence of excess weight had decreased in the last year from 37.4% to 36.1%, it had increased the previous two years, and the latest rate is still higher than the national average at 34.2%. Out of the 2,974 Hull resident Year 6 children measured, 399 were overweight and 676 were obese.

In the local adult Prevalence Survey 2014 [86], 63.6% of the survey responders were overweight (37.1%) or obese (26.5%). Prevalence was higher amongst male and older survey responders (but falling slightly in the oldest 75+ year age group). It is estimated that 132,496 adults (16+) in Hull are overweight or obese, with 55,246 of them being obese. From local surveys, between 2003 and 2014 [83, 86, 153, 154, 155], the prevalence of overweight decreased by 0.39 percentages points per year, but the prevalence of obese, and overweight and obese combined increased by 0.59 and 0.20 percentage points per year respectively. If the current trend continues in Hull, then by 2020 the prevalence of obesity is projected to be 31.1% (and overweight and obesity to be 65.6%). National estimates of overweight and obesity for Hull are similar to the local estimates at 65.8% for 2015/16 (England 61.3%) [27, 117].

Local qualitative work revealed a difference between clinical definitions and perceptions of obesity: “You don't see loads of fat people wandering around” [147].

What are the strategic needs?

Obesity is a complex problem with many drivers including behaviour, the environment, genetics, and culture. It is necessary to provide a healthy food and drink environment, and to increase physical activity and decrease sedentary behaviour.

The Childhood Obesity Action Plan for England (August 2016) aims to have fewer obese children by 2026, fourteen priority actions priority are: (1) Introducing a soft drinks industry levy; (2) Taking 20% out of sugar in products; (3) Supporting innovations to help business to make their product healthier; (4) Developing a new framework by updating the nutrient profile model; (5) Making healthy options available in the public sector; (6) Continue to provide support with the cost of healthy food for those who need it most; (7) Helping all children to enjoy an hour of physical activity every day; (8) Improving the co-ordination of quality sport and physical activity programmes for schools; (9) Creating a new healthy rating scheme for primary schools; (10) Making school food healthier; (11) Clearer food labelling; (12) Supporting early years settings; (13) Harnessing the best new technology; and (14) Enabling health professional to support families.

Locally, an obesity life course whole systems approach is used which views actions and behaviours of individuals in the context of the continuum of their lives from pre-natal through to older ages, and the transition through various life stages and transition points. These life stages and transition points can make individuals more susceptible to negative health outcomes, and can also present opportunities for intervention, for example, pregnancy as a key trigger point and a new mum's approach to the diet and activity levels of herself and her new baby can have a lasting impact on the future diet and activity levels of the family overall. The case for intervening in the very early years is very strongly evidenced. However, the life course approach also recognises that there are other very significant transition points, such as attending school, young adults moving into higher education, employment, marriage and living with a partner, parenthood, etc., middle years possibly starting to develop disease or having friends and colleagues with adverse health events, independent children and possibly having more time to become physically active and cook healthy meals, and older people in retirement. This life course approach involves a comprehensive and integrated range of interventions and activities such as those around healthy cooking on a budget, early year’s physical activity and parenting programmes, treatment and support for people who are overweight or obese, and using national marketing campaigns such as Change 4 Life. Also action to tackle the ‘obesogenic’ environment such as restricting planning permissions for new takeaways near schools, and ensuring opens spaces and places to be active are accessible. Long term sustainable change will only be achieved through the active engagement of schools, communities, families and individuals.

The following reports are available to download:

This 2018 JSNA section on Overweight and Obesity (3 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Overweight and Obesity (199 pages)

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Physical Activity

What’s the issue?

“Whatever a person's age, there is good scientific evidence that being physically active can help them lead a healthier and happier life” [156]. Lack of physical activity may increase the risk of obesity and its associated health risks, but there is increasing evidence that lack of physical activity and inactivity is a major risk factor in its own right “increasing the risk of circulatory disease, diabetes, dementia, Alzheimer's disease, stroke, and some cancers. There is also strong evidence that physical activity promotes mental wellbeing, boosting self-esteem, mood, sleep quality, and energy, as well as easing stress and anxiety” [156].

“One in four woman and one in five men in England are classed as physically inactive-doing less than 30 mins of moderate physical activity per week. Many adults spend in excess of seven hours per day sedentary, and this typically increases with age” [157].

This lack of physical activity is costing the UK and estimated £7.4b a year, including £0.9 billion to the NHS alone [157].

What’s our situation?

From the local adult Prevalence Survey 2014 [86], 41.4% of people were physically active (fulfilled national physical activity guidelines of 150 minutes or more of moderate physical activity per week) but there was a considerable difference between men (47.2%) and women (36.5%). Furthermore, 43.5% were classified as physical inactive (fewer than 30 minutes of moderate physical activity per week). This means that around 122,100 people (aged 16+) across Hull are not fulfilling the national physical activity guidelines. From the Active Lives Survey 2015/16, 61.7% of Hull adults were physically active compared to 64.9% for England, and a further 24.7% of Hull adults were physically inactive (fewer than 30 minutes of moderate physical activity per week) compared to 22.3% for England [27, 117]. These estimates differ considerably from the local survey, and it is likely that these national estimates for Hull are biased as fewer than 500 people were surveyed in Hull. The local survey is much larger involving more than 5,000 survey responders with a more representative sample of Hull's adult population.

In the local Young People Health and Lifestyle Survey 2016 [107], 44% of male and 24% of female secondary school pupils in Hull engaged in sufficient physical activity to fulfil national guidelines (at least one hour daily).

What are the strategic needs?

Public Health England's national physical activity framework ‘Everybody Active, Every Day’ [158] identifies four areas of local and national action: (i) Active Society – change the social norm to make physical activity the expectation; (ii) Moving Professionals – develop expertise and leadership within professionals and volunteers; (iii) Active Environments – create environments to support active lives; and (iv) Healthy at Work – identify and upscale successful programs nationwide.

In order to do this, it is necessary to work together to create an environment that promotes physical activity and active transport in everyday settings for all ages, and ensure people understand the benefit of positive life choices and know how to access information and seek early support to change. It should be recognised that different approaches and support are required for different people, and any specific problems or changes that are required should not be dealt with in isolation, but by considering the needs of each individual separately. The life course whole systems approach (see the section on Overweight and Obesity) aims to make physical activity the norm with support across all ages but focusing on life’s transition points and the early years to promote physical activity and embed good habits. Hull’s local strategy “Active Hull” [159] has a number of priority themes: (i) children, young people and families; (ii) active travel; (iii) not just sport – active living; (iv) reaching communities; (v) places and spaces; and (vi) Hull as a sporting destination. “Active Hull” has four cross cutting themes: (a) working together; (b) skills and employability; (c) communications and marketing; and (d) research, quality assurance, monitoring and evaluation.

The way services are commissioned and delivered, and the way in which neighbourhoods are designed and change can influence health and wellbeing, as well as changing health inequalities. The impact on health should be considered as part of the process of commissioning and planning. For example, the provision of green spaces and parks, and increasing and improving cycle routes throughout the city.

The Social Prescribing Service (Connect Well Hull – see the JSNA Glossary) aims to help people feel more linked in with their local communities and provide advice and support on a range of issues including getting more active.

The following reports are available to download:

This 2018 JSNA section on Physical Activity (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Physical Activity (157 pages)

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Diet

What’s the issue?

“A poor diet high in saturated fat, salt and sugar, low in essential nutrients and too high in calories can raise cholesterol and blood pressure, cause dental decay, and increase the risk of obesity, heart disease, stroke, diabetes, and some cancers such as colorectal cancer” [160]. “Around one in three people admitted to hospital or care homes in the UK are found to be malnourished or at risk of malnourishment, which can be caused by an inadequate diet or a health problem because the body cannot absorb nutrients from the food. Reduced mobility, a long-term health condition and low income are also factors that can influence diet” [161]. Furthermore, in more deprived areas, access to good quality fruit and vegetables, reliance of public transport, cost issues and lack of cookery knowledge and skills are further barriers to eating a well-balanced diet.

What’s our situation?

From the local adult Prevalence Survey 2014 [86], 68.9% stated that they ate a healthy diet, 23.9% stated they did not and 7.2% reported lack of knowledge about what constituted a healthy diet. Fewer than one in five (19.2%) ate five or more portions of fruit/vegetables per day (15.7% among those living in the most deprived fifth of areas of Hull versus 22.7% in the least deprived fifth). National estimates are much higher for Hull at around 50% [27, 117]. In the local adult Prevalence Survey 2009 [155], 79.3% ate a healthy diet and 27.5% ate 5-A-DAY, so reported diets have become worse. From the local Young People Health and Lifestyle Survey 2016 [107], it was estimated that 50% of year 7 boys and 59% of girls (aged 11-12 years) in Hull ate five or more portions of fruit/vegetables daily, but the percentage fell with age to 26% for both boys and girls in year 11 (aged 15-16 years). National estimates for Hull for 15 year olds are considerably higher at 44% for 2014/15 compared to 52% for England [27, 117]. One in twenty year 7 children never had breakfast on a school day, but this increased to 15% for boys and 28% for girls by year 11 [107].

Within local qualitative projects, participants always mentioned the preponderance of takeaways in their local area. “I was terrible for it, takeaways everywhere. Temptation. I mean, I live across the road from a takeaway and it’s lovely and I wish it wasn’t there. I'm glad it's there, but I wish it wasn’t there. It’s a kebab, pizza, Turkish takeaway. And within ten minutes’ walk, there’s four of that type, a couple of chicken places, two Chinese, an Indian, three chip shops, these are all in less than ten minute walk and I live in a council estate near the University” [11].

What are the strategic needs?

It is necessary to work together as part of Hull Sustainable Food Cities to develop a Food Charter that will improve access to healthy and affordable food, and ensure people understand the benefit of positive life choices and know how to access information. Furthermore, the family or household environment can have a strong influence on poor diet, so approaches to improving diet involving the entire family is preferable. People need to have the knowledge and confidence to cook cheap, healthy meals, and further education or training may be necessary. There is also a need to support ‘Fuel, Food and Finance’ anti-poverty initiatives that help people minimise the health impact of welfare reform and cost of living rises. Improving diet should be tackled using a life course whole system approach (see the section on Overweight and Obesity) looking at a combination of strategies and settings. This includes giving nutritional advice to pregnant women, encouraging healthy weaning practices, making affordable food available, healthy cooking sessions on a budget for families, and changing the food culture approach to food and nutrition across a variety of settings such as schools, workplace canteens and hospitals, etc. The way services are commissioned and delivered, and the way in which neighbourhoods are designed and change can influence health and wellbeing, and health inequalities. The impact on health should be considered as part of the process of commissioning and planning. For example, the number and location of takeaways already in the area should be considered when there are new takeaway applications.

The following reports are available to download:

This 2018 JSNA section on Diet (3 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Diet (160 pages)

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Alcohol Consumption

What’s the issue?

“Drinking alcohol is a freedom that many enjoy, however this must be balanced with the need to avoid harm and improve health outcomes” [162]. ”Alcohol consumption is the world's third largest risk factor for disease and disability. Alcohol is a causal factor in 60 types of diseases and injuries, and a component cause in 200 others” [163]. “Liver problems, reduced fertility, high blood pressure, increased risk of various cancers and heart attack are some of the numerous harmful effects of regularly drinking more than the recommended levels. Excessive alcohol consumption can also lead to fatigue, depression, weight gain, poor sleep and sexual problems” [164]. Modelled estimates suggest that over one million admissions attributable to alcohol occurred in England during 2012/13 [165]. In 2013/14, the total annual cost to society of alcohol-related harm was estimated to be £21 billion (£3.5 billion for NHS) [166]. There are also significant effects on families and communities, with an increased risk of vandalism, violent crime, domestic abuse, road casualties and sickness absence from work. It is estimated that around 40% of all violent crimes are alcohol-related [63].

It was recommended that men and women do not exceed 21 and 14 alcohol units per week (1995 national guidelines in place until December 2015), or regularly drink 3-4 and 2-3 units in a single day respectively. Regular binge drinking is classified as drinking more than double the daily limits at least once a week (≥8 units for men and ≥6 units for women). In the new guidelines published January 2016, the fundamental change to the recommendations is that there is no safe level of drinking alcohol, and the weekly maximum for men has changed to 14 units [167].

See the JSNA Glossary for information on definitions relating to alcohol-related admissions to hospital.

What’s our situation?

From the local adult Prevalence Survey 2014 [86], whilst 24% never drank alcohol, 28% had exceeded the 1995 national alcohol guidelines the previous week and/or usually undertook binge drinking weekly (35% of men and 22% of women) having increased from 22% in 2011-12. Following the 2016 update to the national guidelines, the percentage who had exceeded the weekly limits and/or usually undertook binge drinking weekly increased to 30% (38% of men and 22% of women), and would have been 25% in 2011-12 [83]. The increase in prevalence was mainly due to changes in the middle and older age groups and among those living in the least deprived areas.

From the local Young People Health and Lifestyle Survey 2016 [107], 5.3% of boys and 3.4% of girls drank alcohol every week (11.2% of boys and 8.5% of girls in year 11 (aged 15-16 years)), and 2.9% of boys and 2.1% of girls in Hull had exceeded the weekly units of alcohol which apply to adults (more than 14 units), with 7.7% of boys and 5.0% of girls having done so in year 11 (compared to 11.0% and 14.0% respectively in 2012 [95]).

From the Alcohol Profiles [168], in 2015/16, there were 732 admissions specifically due to alcohol per 100,000 population which was much higher than England (583) as was the modelled number of admissions for alcohol-related admissions (2,922 versus 2,179 per 100,000 population). There were also 34.5 alcohol-specific admissions among under 18s per 100,000 population between 2013/14 and 2015/16 which was slightly lower than England (37.4).

From the Alcohol Profiles [168], for 2013-15, it was estimated that there 14.3 deaths per 100,000 population for alcohol-specific conditions compared to 11.5 for England. Overall, it was estimated that there were 54.1 deaths per 100,000 population for alcohol-related conditions compared to 46.1 for England with 685 years of life lost due to alcohol-related conditions in Hull compared to 552 for England.

During 2015, 181 of 499 alcohol users in treatment (36.3%) successfully completed their treatment and did not re-present within six months, which was slightly lower than England (38.4%) [27, 117].

Local qualitative work revealed lack of understanding over what constituted binge drinking among women “Binge drinking is when you open a second bottle”, but particularly among men “Binge drinking is an all day session” and “Drinking all day and night and not going home” [147]. There was also a general lack of understanding of alcohol units “I find the words unit very confusing” [11]. Government guidelines were seen as ‘made up’, and most agreed that they did not understand them: “I haven't got a clue” [11], although some did have an understanding.

What are the strategic needs?

Hull’s Alcohol Strategy 2016-2020 [169] has three priorities: (i) prevention, education and promoting a responsible drinking culture; (ii) early intervention, treatment and long-term health; and (iii) regulation, crime prevention and community safety. This includes work around increasing awareness and understanding of recommended drinking limits, reducing acceptability of harmful drinking and a reduction in alcohol-related harm, large scale delivery of alcohol screening and brief advice by professionals who come into contact with young people and adults as part of their daily work, diversion of people from emergency services including Ambulance, Accident and Emergency departments, Fire and Rescue, and the Police service and encourage them to access treatment where needed, more people in treatment and becoming alcohol-free and remaining so, reducing alcohol-related anti-social behaviour and crime supporting people who are vulnerable, challenging inappropriate sales and drinking behaviours, and reducing alcohol-related road incidents and casualties.

It is necessary that public health, health providers, schools and those working with young people and families, community workers, and communities and the police work together to ensure people understand the benefit of positive life choices and know how to access information, seek early support to change, and refer into treatment through effective integrated alcohol treatment pathways. There is a lack of knowledge in relation to alcohol units and the calorie content of alcoholic drinks, and there is a need to increase awareness.

Hull City Council’s Liquor Licensing Policy is being revised in 2018 and it is important to consider how to maximise the potential benefits from the involvement of public health as a responsible authority in the licensing process. This can have an impact both in terms of developing the Policy itself and also when considering the potential health effects of each individual licence application.

Social return on investment tools for drugs and alcohol make the case of investing in treatment programs to reduce overall crime and anti-social behaviour to reduce costs to society and the economy [63, 68]. It is estimated that over 1,500 crimes were committed by alcohol treatment clients before their entry to treatment, and with an estimated 37% reduction in the number of crimes, around 570 crimes were prevented after treatment [63]. The gross benefit of alcohol treatment in 2016/17 in Hull was estimated to be over £360,000 [63].

The following reports are available to download:

This 2018 JSNA section on Alcohol Consumption (3 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Alcohol Consumption (228 pages)

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Drug and Substance Abuse

What’s the issue?

Different illicit drugs have different effects on physical and mental health, and some are highly addictive. From NHS Choices [170], the health risks include “death from an overdose, lung disease from smoking drugs, HIV or viral hepatitis, serious infections in the body and bloodstream, fertility problems, damage to veins and body tissue through injecting drugs, overheating and dehydration, kidney problems, schizophrenia, hallucinatory states, insomnia, fits, agitation, aggression, confusion, paranoia, psychosis, memory problems, depression, anxiety and lack of concentration. It can also be dangerous to drive after taking drugs, increasing the risk of an accident.” Drug and substance misuse has a serious impact not just on the individual, but also their family and friends who may require considerable support. There also can be a detrimental effect on the entire community. Individuals dependent on opioids and/or crack cocaine are responsible for an estimated 45% of acquisitive crime (shoplifting, burglary, vehicle crime and robbery) [63].

What’s our situation?

Estimates give the number of opiate users in Hull aged 15-64 years as 2,855 for 2014/15, the number of crack cocaine users as 902 and the number of opiate and/or crack cocaine users as 3,309 [171, 172]. These give rates of 16.5, 5.2 and 19.1 per 1,000 population respectively, with the opiate user rate twice that of England (where the rates are 7.3, 5.2 and 8.6 per 1,000 population respectively). From the Police and Crime Commissioner support packs for drugs and alcohol [63], there were 1,642 opiate, 104 non-opiate, 267 opiate and alcohol, and 479 alcohol only adults in treatment in Hull in 2016/17 representing an estimated 66%, 4%, 11% and 19% of the total user population. The age profile of those in treatment differed by substance with almost half of opiate treatment clients aged 35-44 years whereas just over half of non-opiate treatment clients were aged 18-29 years, although the age of those being treated for non-opiate and alcohol were more evenly spread between the ages groups. In Hull, in 2016/17, almost half (48%) of referrals for drug and alcohol treatment were self-referrals and 28% were referred through the criminal justice system.

During 2015, 98 of the 1,723 opiate clients (5.7%) and 117 of the 388 non-opiate clients (30.2%) successfully completed and did not re-present for treatment within six months, which was lower than England (6.7% and 37.3% respectively) [27, 117].

From the local Young People Health and Lifestyle Survey 2016 [107], around one in 10 pupils reported they had been offered or encouraged to try drugs in the last three months over all school years (just over one in six among year 11 (aged 15-16 years) pupils). Similar percentages reported that they had ever used or tried drugs. The age-adjusted percentage of year 9 to 11 pupils using drugs was small (<2%) for most specific drugs except for new psychoactive substances (3.8% of boys and 3.0% of girls) and cannabis (10.4% of boys and 15.4% of girls).

From the Child Health Profiles [19], there were 60 hospital admissions due to substance misuse among those aged 15-24 years during 2012/13 to 2014/15, considerably higher than England (155 versus 95 per 100,000 population).

The age-standardised mortality rate from drug misuse increased from 5.5 deaths per 100,000 population for deaths registered during 2001-03 (with 49 deaths in total or 16 per year) to a peak of 7.9 per 100,000 population in 2005-07 (65 deaths), but the rate has since fallen to a low of 3.9 per 100,000 population (30 deaths) in 2013-15, although the rate in 2014-16 was higher at 5.6 per 100,000 population (43 deaths) [27, 117]. The number of drug related deaths in Hull saw a temporary spike in 2017 due to the introduction of a very toxic ingredient (carfentanyl/fentanyl) into the local drug supply (predominantly heroin). The National Crime Agency and law enforcement took swift action to identify and cut off supply lines, but the situation continues to be closely monitored by all agencies.

Priority Families in Hull have been identified which intended to change the repeating generational patterns of poor parenting, abuse, violence, drug use, anti-social behaviour and crime in the most troubled families. In phase 2 of the programme which commenced in April 2015, over 2,500 families have been identified in Hull and over 700 have achieved all outcomes (see the JSNA Glossary for more information on Priority Families Programme and on Early Help and Priority Families Strategy).

What are the strategic needs?

The Government‘s 2010 Drug Strategy [173] had two overarching aims to reduce illicit and other harmful drug use, and to increase the numbers recovering from their dependence, structured around three key themes of reducing demand, restricting supply and building recovery in communities. There is a fundamental shift from harm reduction toward recovery and prevention, and designing local services for local people. This recognises that each person should be treated as an individual, and that health care providers and the police need to work together with different communities to use existing assets to prevent people from starting to take drugs and help those recover from drug dependence and harmful use. There includes a need to identify the most vulnerable children, young people and families, helping and supporting them so that poor health choices do not lead to drug taking.

The Government’s 2017 Drug Strategy [67] builds on the 2010 strategy with an additional overarching aim around global action. The new strategy aims to reduce illicit and other harmful drug use, and to increase the numbers recovering from their dependence. There is a recognition that more needs to be done to address the complex and evolving challenges of drug misuse with changing patterns of use, a recent increase in drug related deaths, an aging cohort of entrenched drug dependence often with accompanying physical and mental health issues, and an increase in the proportion of young people using drugs. A smarter, coordinated partnership approach is needed with a balanced approach across the four core strands or reducing demand, restricting supply, building recovery and global action. There is a need to reduce illicit drug use and increase the numbers recovering from dependence by measuring frequency and type of drug use, and using recovery data to segment the treatment population to better personalise support and recovery ambitions. There is a need to develop a new set of measures to better capture the joint ownership required to drive action across local authorities, health, employment, housing and criminal justice. There is also a necessity to provide stronger governance for delivering the strategy, including a Home Secretary chaired Board and the introduction of a national Recovery Champion [67].

Hull’s Early Help and Priorities Family Strategy 2015-2020 (see the JSNA Glossary) aims to identify individuals and families with problems and brings together different services and agencies to collectively look at what support is needed and then work together to deliver the required support in an coordinated way [119]. Drug related deaths and substance misuse is a priority for the multi-agency Community Safety Partnership, and a substance misuse scorecard is currently being developed.

Social return on investment tools for drugs and alcohol make the case of investing in treatment programs to reduce overall crime and anti-social behaviour to reduce costs incurred by drug and alcohol issues to society and the economy [63, 68]. In Hull, it is estimated that over 150,000 crimes were committed by drug treatment clients before their entry to treatment, and with an estimated 10% reduction in the number of crimes, over 15,000 crimes were prevented after treatment [63]. The gross benefit of drug treatment in 2016/17 in Hull was estimated to be £5.2 million [63].

Harmful drug use is currently measured through the crime survey for England and Wales, and this will continue to be the case, but there is an intention to measure the frequency and type of drug use, and provide data at a national and local level. Recovering from dependence is measured by the proportion of clients leaving treatment free from dependence and sustaining this for six months, but there is an intention to supplement this with the proportions sustaining this at one year, and segment this data into different types of users, as well as providing local estimates for access and waiting times to treatment.

The following reports are available to download:

This 2018 JSNA section on Drug and Substance Abuse (3 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Drug and Substance Misuse (150 pages)

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Multiple and Behavioural and Lifestyle Risk Factors

What’s the issue?

The individual behavioural and lifestyle risk factors have been discussed earlier, but there can be additional risks from combining risk factors. For example, “smoking and drinking alcohol together greatly increases the risk of developing throat and mouth cancer than doing either on their own, because drinking alcohol makes it easier for the mouth and throat to absorb the chemicals in tobacco that cause cancer” [174]. Furthermore, people who have a specific behaviour or lifestyle risk factor may be more likely to have another specific risk factor. For example, in the local 2007 Attitudes to Health Survey, an association between risk factors was found, in particular a relationship between alcohol and smoking, and between lack of physical activity, diet and obesity. For all of these risk factors, gender, age and deprivation are confounders (see the JSNA Glossary for information on confounding).

What’s our situation?

From the local adult Prevalence Survey 2014 [86], the prevalence of the combination of five risk factors was examined. The risk factors considered were smoking, excessive alcohol consumption (either in a single day (binge drinking) or total units over the previous week based on 2016 national guidelines), insufficient physical activity (<2.5 hours of moderate activity based on 2012 national guidelines), obesity and not eating 5-A-DAY. In Hull, 1.1% had all five of these risk factors, 8.3% had four, 25.4% had three, 34.9% had two, 24.3% had one and 6.0% had none of these five risk factors. There were relatively small differences between men and women, although men were slightly more likely to have three or more risk factors (37.1% versus 32.7%). Examining the number of risk factors for each five year age band, people aged 45-64 years tended to have the most risk factors with 41-42% having three or more risk factors, followed by those aged 35-44 years (37%), people aged 65+ (31-36%) and people aged 16-34 years (25-31%). People living in the most deprived fifth of areas of Hull were more likely to have more risk factors with 45% having three or more risk factors compared to 26% among those living in the least deprived fifth of areas.

From the local Young People Health and Lifestyle Survey 2016 [107], the prevalence of multiple risk factors (smoker, exceeded 14 units of alcohol previous week, failed to undertake one hour of exercise daily previous week, did not eat 5-A-DAY previous day, and previously tried drugs) differed among different year groups. There was a gradual decrease in the percentage of boys and girls having none of the risk factors from 26% in year 7 (aged 11-12 years) to 7% in year 11 (aged 15-16 years), while the percentage having three or more of the five risk factors increased with school year from 0.6% in year 7 to 17.5% in year 11. There were relatively small differences between boys and girls, although girls were less likely to have none of the risk factors and more likely to have more of the risk factors, and none of the girls had all five risk factors whereas 0.4% of year 9 and year 10 boys and 1.2% of year 11 boys did (only four boys in total though over these three year groups).

What are the strategic needs?

It is necessary to work together to ensure people understand the benefit of positive life choices and know how to access information and seek early support to change. In order to do this effectively, all relevant service providers need to work together with different communities to use existing assets to realise the benefit of positive life changes. It should be recognised that different approaches and support are required for different people, and any specific problems or changes that are required should not be dealt with in isolation, but by considering the needs of each individual separately. It may also be necessary to 'prioritise problems&rlsquo; as dealing with or changing too many factors together may not be as successful as dealing with one problem or issue at a time. Alternatively, some people may prefer having a 'clean sweep' and dealing with a number of issues at the same time.

Hull’s Early Help and Priorities Family Strategy 2015-2020 (see the JSNA Glossary) aims to identify individuals and families with problems and brings together different services and agencies to collectively look at what support is needed and then work together to deliver the required support in an coordinated way [119].

The following reports are available to download:

This 2018 JSNA section on Multiple and Behavioural and Lifestyle Risk Factors (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Smoking (217 pages)
JSNA Toolkit: Overweight and Obesity (199 pages)
JSNA Toolkit: Physical Activity (157 pages)
JSNA Toolkit: Diet (160 pages)
JSNA Toolkit: Alcohol Consumption (228 pages)
JSNA Toolkit: Drug and Substance Misuse (150 pages)

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