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Secondary care and smoking services in Wales

Secondary care and smoking services in Wales. Dr Keir E Lewis Reader in Respiratory Medicine & Consultant Chest Physician. Declaration of interests. Research grants: Pfizer (£135,000), Glaxo-Smith Kline (£9,000), Cardiff University (£2000)

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Secondary care and smoking services in Wales

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  1. Secondary care and smoking services in Wales Dr Keir E Lewis Reader in Respiratory Medicine & Consultant Chest Physician

  2. Declaration of interests • Research grants: Pfizer (£135,000), Glaxo-Smith Kline (£9,000), Cardiff University (£2000) • Conference attendance and honoraria for lectures and advisory boards: GSK, Pfizer • Smoking cessation specialist HDd HB: Pfizer (£5900) • (Honorary) Trustee for ASH Wales

  3. It is the imperative of every lover of mankind, to unite in suitable • efforts to remove this rapidly increasing evil . . . and its enslaving power on the habits . . .and also, by seeking to deter others, especially the young, from acquiring this unnecessary, offensive and injurious practice. • 6th Principle British Anti-Tobacco Society, 1853.

  4. Identifying the need - Political • ‘ . . smoking is the greatest single cause of preventable illness and premature death in the UK . .’GovtWhite Paper 1988 • NHS Smoke Free 2007 • Wales Tobacco Action Plan 2012- • Presentation to Health Minister • Health Board’s Smoking Policy

  5. Triggers for most recent quit attempt Data from 1237 smokers who tried to quit in past year, surveyed May 2009 onwards; smokers could select more than one item 5

  6. Percentage of smokers using different routes to quit N=7,808 6

  7. South Wales Echo, 6 January 2003

  8. Not all smokers are created equal! • Hospitalised smokers often: • -Older • -More addicted (e.g. higher Fagerstrom scores) • -Are already unwell • -Have multiple illnesses • -Are on multiple drugs (potential for interactions) Rigotti NA et al. ( 2007 ). Interventions for smoking cessation in hospitalised patients . CochraneDatabase of Systematic Reviews , 3 , CD001837

  9. but hospitalised patients… • More open to help at a time of perceived vulnerability • Teachable moments • Place where smoking is restricted anyway • Pharmacological aids (should be) readily available • At least 33 well-designed trials Cochrane Review updated 2008

  10. Identifying the need - Patients • A secondary care service is VERY cost effective • £426 per LYG1 • 26% adults in Hywel Dda smoke • 246 COPD admissions (current smokers 63% more likely > 3 adms/yr2) • < 10% smokers in chest clinic prefer a community service3 • Surgical benefits (complications, repeat surgery, LOS 2 days longer) • Cardiac procedures etc . . 1JR Soc Health 1998; 118(6), 2. Garcia-Aymerich2003 3. Thorax 2005; 60 (ii): 37)

  11. Where do patients prefer a stop smoking service to be located? • Inpatients: • 80 % of smokers attending MAU would like to receive some counselling during admission4 • Outpatients: • 65% of smokers attending Chest Clinics would prefer their SSS to based wholly or partly in Secondary Care5 4. Murphy J, Williams A [Unpublished] 5. Thorax 2005; 60(s) ii37: S105

  12. NICE Technical Appraisal No. 38, 7.3, 2003 • ‘‘ Arrangements should be made to ensure that smoking cessation advice and support is available to patients at both community and hospital locations. ’’ www.nice.org

  13. Only 4 from 17 Welsh hospitals have a dedicated smoking cessation specialist

  14. Costs of a secondary care service • Staff: 2 part-time specialists (Band 6) (£31,800) • NRT: (£12000) see later • Consumables: room, telephone, photocopying (£1000) (eCO monitors -free) • Publicity (£7000 WAG monies) TOTAL: £45, 000

  15. Publicity:

  16. Who refers to the HSSS? (n=513 between 2007-2008)

  17. Results (0-3 years) • Patients: n=1033,SVQR 28%. Referral rate was increasing • Staff: • -84 attended, 32 sustained quitters (saving approx £32K) • Research / publicity /teaching: • -2 papers, 1 book, 12 abstracts, invited talks (worldwide!) • -medical student elective placement • -1 portfolio, 1 pharmaceutical study • - Core Competency in FP1 and FP2, ST training week

  18. Risks of not meeting the secondary care need • Patients: Breaking NICE Guidance, more ill health, more costs, despite highest level of medical evidence and local validation / business cases • Staff: more sickness, extra breaks, fire insurance • Teaching: none • Political: difficult to implement national and HB Policies

  19. http://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspxhttp://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspx

  20. Secondary care and community services – joined up?? Hospital More motivated to quit because of acute symptoms Smoking is prohibited Less triggers Pharmacotherapy readily available Medical support for drug interactions, illnesses Community Closer to home Flexibility No parking fees! Less of an illness Longer-term relationships

  21. 450 PATIENTS randomised 150 PATIENTS 150 PATIENTS 150 PATIENTS Counsellor 1 week 2 weeks 3 weeks 4 weeks Counsellor 1 week 2 weeks 3 weeks 4 weeks Advice / NRT Tel no. / Leaflet Phone / fax DIRECT referral Tel no. / Leaflet Validated CO -3 months -6 months -12 months Validated CO -3 months -6 months -12 months Validated CO -3 months -6 months -12 months

  22. J Tob NicotineRes 2009; 11: 756-64

  23. Joined up working? • Hospitalised smokers don’t switch to a community service • Hospitals merely referring to a Community Service are not helping their patients • Having a Community Specialist doing 1-2 sessions per week is probably not enough

  24. Only 4 from 17 Welsh hospitals have a dedicated smoking cessation specialist

  25. Key Challenges / Vision for the future • Increase provision in secondary care • Standardise service in secondary care • Standardise data sets in secondary care • Increase referrals to / awareness of SCS in secondary care • Research

  26. Aged 33 Bryan Curtis aged 34 from St Petersburg Times 1999 (www.whyquit.com)

  27. Summary • Smoking cessation within secondary care is needed • Smoking cessation within secondary care is clinically effective • and extremely cost-effective • Smoking cessation provision within secondary care in Wales is very low (<25%) and is the lowest the UK

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