Lessons from the English smoking cessation services

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 Nu
rses 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
Smokers
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
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
82
83
154
45

0.32
1.05
0.48


0.8
2.65 stop smoking

Prof Robert West, robert.west_at_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 lt10ppm
• 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