Preliminary Results from the BTS Survey of Quit Smoking Services in Secondary Care August-September 2011

1. Preliminary Results from the BTS Survey of Quit Smoking Services in Secondary Care August-September 2011 Dr Myra Stern Project Lead, BTS Stop Smoking Champions BTS Stop Smoking Champions First Annual Meeting 11th October 2011, QE2 Conference Centre, London

3. 2011 1492 1600 1 BC 1BC: Native Americans using tobacco for medicinal & ceremonial purposes 1492: Columbus discovers tobacco in the New World “ he was offered certain dried leaves which gave off a distinct fragrance” 1600: Sir Walter Raleigh persuaded Queen Elizabeth to try smoking

4. 2011 1603 1 BC 1603: Physicians upset that tobacco was being used without a prescription and protested to the new king –James 1st.  ‘Counterblaste’ to Tobacco: “ smoking is a custom ‘loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs and in the black and stinking fume, nearest resembling the horrible stygian smoke of the pit that is bottomless’  RCP Debate on Smoking – King’s views dismissed!

5. 1912 1930 1962 2011 1912 1 BC 2011 1912: first strong connection between smoking & lung cancer ( Dr I Adler) 1930: England has the highest reported lung cancer rate in the world 1962: RCP publishes its first report “Smoking and Health” – restrictions on sales and advertising – fall in sales

6. 1912 1932 1976 2004 2011 2001 2011 1962 1976: Doll & Peto Study - 1 in 3 smokers dies from the habit 2004: 50th anniversary of that study - risks for persistent cigarette smoking are even higher than previously estimated !

7. 2001 S 1 2003 S 2 2008 S 3 2004 1999 White Paper ‘Smoking Kills’ 2005 Hospitals Smoke-Free 2007 UK Smoke-Free 2010 2011 S 4 2001: DoH announce that NRT available on Rx 2002-2011: Mounting evidence and NICE guidelines for NRT, Bupropion and Varenicline

8. Survey 1 - 2001 • 220 Questionnaires sent out • 126 responses (57%) • Issues covered: - Smoking Policies (buildings, grounds, shelters) - Smoking Cessation offered to Staff - Departments/Disciplines offering SS within the hospital - Who provided the service

9. Survey 1 - 2001 Minutes of the subsequent Tobacco committee on 2nd March 2001 concludes • 50% of hospitals have cessation officers or counsellors • Services were excellent in some areas and very poor in others • The BTS should run training days where people involved in hospital cessation could share experience and compare models and that there was to be a 2-day meeting for those involved in hospital based cessation services. • The committee would limit their activity to hospital ss services rather than primary care.

10. Survey 4 – 2011 • Sent to 247 hospitals (Respiratory lead if no Champion) • Provision (or not) of 2o care service and regional variations • Hospital Smoke free policies and adherence • Education around quit smoking Baseline practice against which we can measure improvements in smoking cessation provision to hospital patients New considerations

11. Survey 4 – 2011New Considerations • Increasing evidence regarding standard quit smoking strategies over past 10 years • More aware of the challenges of helping sick smokers to quit • Incentives for evidence-based strategy • CQUINs

12. Survey 4 – 2011New Considerations - Evidence - Quit smoking interventions (brief advice, NRT and/or Champix & counselling) improves quit rates - Quit smoking as a TREATMENT for COPD is the most cost effective intervention • Quit smoking interventions with patients • who smoke improves quit rates • Is NRT/Varenicline/counselling • available? • Are there guidelines?

13. Survey 4 – 2011New Considerations - Challenges • Sick smokers find it very difficult to quit • Find it difficult to set a quit date • Require longer periods of counselling • Require more phamacotherapy for a longer period of time • Who delivers the service and how skilled? • How are quits verified? • How long is abstinence recorded (DoH target 4/52)

14. Survey 4 – 2011New Considerations - Incentives • CQUINs – Care Quality Indicators Incentivises cost effective interventions that can be used in hospitals and in the community to reduce mortality improve health & prevent admissions across general medicine & surgery • How many hospitals have Quit Smoking CQUINs

15. Survey 4 - Survey • Electronic • 19 questions • Free text for other information/comments on the service and how best can BTS Stop Smoking Champions help you

16. Survey 4 – ResultsReturn and Regional Variation • 65/247 (26%) return • 53/65 (82%) Stop Smoking Champions 12/65 (18%) Respiratory Leads • 37/65 (57%) teaching hospitals

17. 25 % of Champions in UK Survey 4 – ResultsReturn and Regional Variation

18. Survey 4 – ResultsReturns Over Time

19. n=64 n=64 Access To Community Services n=37 Survey 4 – ResultsQuit Smoking Specialists (QSS) Full Time 13/37 (35%) 9/37 1WTE 3/37 2WTE 1/37 3WTE

20. Survey 4 – ResultsQSS Over Time

21. Survey 4 – ResultsQSS Follow-up n=40

22. Survey 4 – ResultsQSS Duration of Follow-up

23. Survey 4 – ResultsQuit Validation: Exhaled CO n=53

24. Survey 4 – ResultsPharmacotherapy: NRT (100%)

25. Survey 4 – ResultsPharmacotherapy: Varenicline

26. Survey 4 – ResultsPharmacotherapy: Varenicline n=65

27. Survey 4 – ResultsPharmacotherapy: Rx Guidelines n=63

28. n=65 Survey 4 – ResultsHospital Smoke Free Policies 100% have policies

29. Survey 4 – ResultsHospital Smoke Free Policies Over Time

30. Survey 4 – ResultsSmoke Free Policies: Adherence n=65

31. Survey 4 – ResultsBrief Intervention as Part of Induction A key element in embedding a Health Promoting Culture ? n=62

32. n = 61 Survey 4 – ResultsStop Smoking CQUINs

33. Extracts from Free Text Suggestions and Comments • Robust referral systems: electronic referrals • ‘Cuts’ – Either service or application for dedicated service pulled in favour of primary care service • Brief Intervention – common theme for work in progress • - Induction • - Streamlined by seconded QSS from 10 care • Difficulties of Recruiting a QS Champion – clinical pressures! • BTS Champions as national backing to get people working together • Enforcement of Smoke Free Hospital – very trying!

34. Extracts from Free Text Suggestions and Comments • Controversies Too: • “We have deliberately not appointed a dedicated quit-smoking cessation nurse within the acute trust. It is our belief that this expertise is best provided as part of the extensive community team with an ‘in-reach for hospital patients and staff. This is working well”. • “I would not favour a push to link recording of smoking status with a CQUIN . The mechanism is clumsy and may not be the most effective way to achieve what we want with regard to smoking”

35. Key Findings • Poor return (26%)– the worst in ten years • Quit Smoking Specialists • Very few hospital have a dedicated (f/t) QSS • No change since 2001! • Half are QSS; the rest do it as part of other job • Phamacotherapy • All have NRT; <20% have all types • <60% have Varenicline on formulary • ~60% have guidelines for prescribing

36. Key Findings • Hospital No Smoking Policies • Made to be broken – on a daily basis! • Shelters not yet relegated to history! • QS Education • <1/3 have Level 1 training as part of induction for all frontline health care professionals • QS CQUINs • Only 1/3 have put one in place

37. What’s to be Done • Returns – WE NEED MORE CHAMPIONS • QSS – need to be dedicated and fulltime pro rata the size of the hospital A lobbying job for Champions? • Pharmacotherapy – need to have all + guidelines A lobbying job for Champions?

38. What’s to be Done • No-Smoking Policies – policing needs to be formulated and agreed with security A lobbying job for Champions? • QS Education/Induction – HR needs to be lobbied for space on the ‘busy induction schedules’ A lobbying job for Champions? • QS CQUINS A lobbying job for Champions?

39. 2011 1 BC 10/2000 yrs – 0.5 % of the whole By the end of today (+ 0.0002% of 10yrs) Many of the solutions will be found?

40. Acknowledgements • Elin Roddy • Keir Lewis • Sheila Edwards • Sally Welham • Cathryn Stokes • BTS Tobacco SAG