Evidence base, treatment policy and coverage in England

1. Evidence base, treatment policy and coverage in England Ann McNeill ann.mcneill@nottingham.ac.uk

2. Smoking cessation support: 2008/9 • 43% of smokers sought help in quitting • 671,259 smokers (~ 7%) set a quit date with the NHS Stop Smoking Services • 33% of these had validated quit rates at 4 weeks

3. Summary • England’s smoking cessation strategy • Evidence base • Development • Implementation • Impact • Throughput and effectiveness • Reaching disadvantaged smokers • National quitting behaviour

4. Evidence base to policy 1970 - Mike Russell started cessation research 1998 - First national evidence-based, professionally endorsed guidelines and cost-effectiveness guidance produced 1998 - Government White Paper, Smoking Kills 2000 - Smoking treatment services established nationally 2009 - National Smoking Cessation and Training Centre established 09/10 - New Government Smoking Strategy?

5. Professor Michael Russell (1932-2009) • Effectiveness of brief advice from GPs • Developed a model district wide smoking cessation service • “Maudsley Model” of treatment • “Russell Standard” for criteria for evaluating effectiveness (West et al, 2005)

6. Smoking cessation guidelines & cost-effectiveness guidance • Brought an evidence based approach to a ‘lifestyle’ as addiction to tobacco not universally accepted • Wide endorsement by experts, professional and voluntary bodies • Evidence from Cochrane tobacco addiction reviews supplemented by more recent studies

7. Brief opportunistic advice 1 The difference in >6 month abstinence rate between intervention and control/placebo in studies reported West R, McNeill A and Raw M. Thorax 2000; 55: 987-999. Lancaster T, Stead L. Physician advice for smoking cessation. Cochrane Database Syst Rev 2004; 4.

8. NRT products Bupropion –Atypical antidepressant Vareniclineα4beta2 nicotine receptor partial agonist

9. DH Service monitoring guidance 2008

10. DH Service monitoring guidance 2008

11. Cost effectiveness guidance Parrott et al, Thorax, 1998

12. Smoking recognised as an addiction Combination of approaches: Wide reach, lower effectiveness – all health professionals encouraged to give brief advice Smaller reach, higher effectiveness – a network of smoking cessation specialist services Increase accessibility of smoking cessation medications National cessation strategy

13. Referral patterns

14. Referral patterns

16. Services • Largely followed ‘Maudsley Model’ • 6 – 8 weekly sessions (group or individual) of withdrawal-oriented behavioural therapy combined with pharmacotherapy: • Nicotine replacement therapies • Bupropion • Varenicline • Combination therapies • 1 week NRT free  2001 NHS prescriptions

17. Broadening indications

19. Monitoring and Evaluation:Targets set for 4 week quitters SHORT – TERM SUCCESS Smoker quits for 4 weeks

20. PROS Targets raise profile within health service Monitoring encouraged feedback and improvement CONS Cause a focus on throughput rather than targeting those most in need Focused on short term successes (4 weeks) rather than long term Negative attention and fraud Targets? Targets moving to “treat 5% of local population of smokers over a year”

21. Monitoring and Evaluation • Government commissioned a wide ranging evaluation of the cessation services • Enabled implementation to be more aligned with the evidence base

22. REACH Smoker sets quit date SHORT – TERM SUCCESS Smoker quits for 4 weeks 15% one year CO validated continuous abstinence LONG-TERM SUCCESS Smoker quits for 1 year

24. Very little reduction in smoking in the most deprived groups compared with higher income smokers over the last few decades Lower cessation rates among low income smokers Smoking & disadvantage Jarvis & Wardle, 2006

25. Clear evidence that those in lower income groups have higher nicotine exposure Smoking & disadvantage Jarvis & Wardle, 2006

26. Services & disadvantaged smokers • Disadvantaged smokers were to be priority for the services: • 1st year Health Action Zones only  Spearhead Trusts • 1 week’s free NRT given to those most in need • No guidance given

27. REACH Smoker sets quit date SHORT – TERM SUCCESS Smoker quits for 4 weeks LONG-TERM SUCCESS Smoker quits for 1 year

28. Disadvantaged smokers: Reach of services • 4 evaluations of NHS SSS looked specifically at effectiveness in accessing disadvantaged groups: • Lowey et al 2002 • Chesterman et al 2005 • NEPHO 2005 • Baker et al 2006 Bell et al, 2007 NICE review

29. Conclusions on reach • “These studies provide a body of evidence that the NHS SSS have been effective overall in reachingroutine and manual groups. However, one of these studies reports that there is variation within regional services, and some SHAs have been less successful in deprived smokers than other authorities” Bell et al, 2007 NICE review

30. Disadvantaged smokers: Success of services • 12 sources • Lowey et al 2002 • Bauld et al 2003 • NEPHO 2005 • Watt et al 2005 • S Gloucestershire PCT, 2005 • Baker et al 2006 • 6 annual DH bulletins on quit rates Bell et al, 2007 NICE review

31. Bell et al, 2007 NICE review

32. 1 year CO validated quit rate by deprivation Increasing disadvantage Source: Data from Ferguson et al, 2005

33. Conclusions on success • Studies provided a consistent body of evidence that people from routine and manual groups are less successful in quitting successfully at 4 weeks than other smokers (Bell et al, 2007) • Dependence and socioeconomic group both independent predictors of success in 2005 evaluation of surveys (Judge et al, 2005; Ferguson et al, 2005)

34. Are services helping to reduce inequalities in health caused by smoking? • Bauld et al, 2007: • DH monitoring data 2003 - 6 • Compared no. of smokers treated and 4 week outcomes between spearhead and non-spearhead trusts • Because there were more smokers being treated, the overall result was that a higher proportion of smokers in the more disadvantaged areas reported success (8.8%) than in the more advantaged areas (7.8%)

35. Conclusions on reducing inequalities • This one study found that NHS Stop Smoking Services were making a modest contribution to reducing smoking-related inequalities in health in England Bell et al, 2007 NICE review

36. Smoker aware of service Proactive case finding Smoker contacts service Accessibility REACH Smoker sets quit date SUCCESS Retention (Effectiveness) Smoker quits for 4 weeks SUCCESS Smoker quits for 1 year

37. Reaching disadvantaged smokers? • Proactive identification through: primary care (case records) QOF, combining smoking with other interventions eg screening, cold calling, direct mail • Social marketing approaches & tailoring • Flexibility of delivery eg drop in or rolling clinics, out of hours services • Flexible location (workplace) • Pharmacy based smoking cessation services • Dental services • Lay people as stop smoking advisors • Incentives Bauld, McNeill, Hackshaw & Murray 2007

38. Gibson et al, paper submitted for publication

39. Gibson et al, paper submitted for publication

40. Gibson et al, paper submitted for publication

41. Evidence based treatment and universal coverage?

43. Recall of cessation interventions in the last year by current smokers UK 1999-2006 ONS Omnibus surveys

44. British GP attitudes to smoking interventionsVogt et al, Addiction 2005;100:1423-31

45. Service managers: provision of relapse prevention interventions 96 managers responded- 52% response rate Of these, 58% reported providing relapse prevention interventions

46. Evidence based treatment and universal coverage? • 671,259 smokers (~ 7%) set a quit date with the NHS Stop Smoking Services in 2008/9 • 33% of these had validated quit rates at 4 weeks Services ~ £74m annually • Services cost ~ £74m annually • Medication cost ~ £60m annually

49. THANK YOU ann.mcneill@nottingham.ac.uk