Lessons from English Smoking Cessation Services: Development and Implementation

1. Lessons from the English smoking cessation services Robert West University College London Logroño, October 2006 www.rjwest.co.uk

2. Outline • Principles underpinning development of the English stop-smoking services • The development of the English services in practice • Evaluation of the English services

3. Principles underpinning the NHS services • Smoking cessation is vital primary and secondary prevention for a range of life-threatening and disabling conditions • Most smokers want to stop but need help to achieve this • Smoking cessation treatment costs approximately £200 per episode including behavioural support and medication; this saves lives at less than £1000 per life year gained • It would be unethical not to offer this treatment as a core service within the National Health Service to those that want it

4. Initial ideas for implementation • Treatment should be carried out by a cadre of trained specialists employed for the purpose • The system should be organised as a national network • There should be a common protocol and national system for monitoring and evaluation • Treatment should follow the ‘Maudsley model’ with groups as the preferred option where possible • All health professionals should be made aware of the treatment service and encourage their smoking patients to use it • There should be a major national publicity campaign advertising the service and the benefits of attending

5. What happened in practice: good points • Funding was generous and initially ring-fenced • There was a broad commitment to an evidence-based approach to treatment • A large national evaluation project was commissioned • A national monitoring system was set up • The treatment services were seen as just one part of a comprehensive tobacco control programme that included price increases, increasing smoking restrictions and other measures

6. What happened in practice: problems • Funding was provided on a short-term basis with uncertainty from year to year about continuation • Monitoring was carried out locally with inadequate specification of criteria for ‘success quitter’ • There was inadequate specification of what constituted an adequate level and type of service • There was strong pressure to treat as many smokers as possible with little regard to true success rates • The government did not pursue other important elements of tobacco control such as price rises

7. Typical structure of services in each locality Co-ordinator Healthcare staff: GPs Hospital doctors Dentists Nurses etc. Core clinic Community specialists Wide reach Robust service Expertise enhanced Referral Training Management

8. Trends in treatment usage 2000-2004 • No major change in NRT bought over the counter (OTC) but … • Progressive increase in medication prescribed and in use of NHS clinics Data extracted from ONS surveys for the year in question

9. Smoking cessation in the UK: 2004 Sources: 1 Derived from ONS October/November 2004 2 Hughes et al, Tob Con 2003, 12, 21-27 3. Shiffman et al, 2002, Addiction, 97, 505-512 4. Addiction supplement March 2005 5. Hughes et al, 2004, Addiction, 99, 29-38 OTC means from shop or pharmacist Smokers 33% Attempt to quit1 21% use treatment1 12% go ‘cold turkey’ 10% buy NRT OTC1 4% use prescription only1 7% use a smokers’ clinic1 Quit for at least 12 months 8%2 8%3 15%4 4%5 + 0.32% + 1.05% + 0.48% 0.8% = 2.65% stop smoking Prof Robert West, robert.west@ucl.ac.uk

10. Trends in patients seeking help from doctor 2000-2004 • Steady increase in proportion of patients seeking help from their doctor for stopping smoking • Tendency for more help-seeking from women than men Data extracted from ONS surveys for the year in question

11. Use of services in 19 areas by more deprived smokers • National evaluation of stop smoking services (Addiction (2005, supplement) • Proportion of service users residing in the 40% most deprived localities exceeded the proportion of smokers in those localities in almost all of 19 regions studied • Services are reaching more deprived smokers Taken from Chesterman et al, Addiction (2005)

12. Success rates from clinics • National evaluation of stop smoking services (Addiction (2005, supplement) • 29.8% of smokers in sample were quit at 4-week follow-up verified by CO <10ppm • 14.6% of smokers reported being abstinent for 52 weeks verified at follow-up by CO Taken from Ferguson et al, Addiction (2005)

13. Group versus individual treatment in one of the services • 1502 smokers in a London-based stop smoking service • Opportunity to compare success rates within the same type of service • CO-verified smoking cessation rates during 4 weeks of treatment • Controlling for confounding factors group treatment was more effective • Move away from group treatment may harm genuine treatment effectiveness

14. Possible improvements • Use of a more rigorous standard for assessing success rates (Russell Standard) • Improved training, assessment and supervision of smoking cessation counsellors • Coordination with national mass media campaigns to ‘market’ the services • A focus on providing a high quality service to smokers who want help with stopping rather than giving brief counselling to as many smokers as possible

15. Conclusions • The English stop smoking services were set up in recognition of: • the vital role of smoking cessation in primary and secondary prevention • the proven effectiveness and cost-effectiveness of treatments to help cessation • The initial goals were achieved and the services have proved very popular • Initial evaluations showed success rates in line with expectations from clinical trials • Political and financial pressures are currently causing an unwelcome drive to maximise throughput at the expense of quality of service • This can be averted by setting appropriate targets that recognise true success rates, more rigorous monitoring and setting more stringent standards for training, assessment and supervision of counsellors