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

2. 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. 3 Principles underpinning the NHS services 1.Smoking cessation is vital primary and secondary prevention for a range of life-threatening and disabling conditions 2.Most smokers want to stop but need help to achieve this 3.Smoking cessation treatment costs approximately £200 per episode including behavioural support and medication; this saves lives at less than £1000 per life year gained 4.It would be unethical not to offer this treatment as a core service within the National Health Service to those that want it

4. 4 Initial ideas for implementation 1.Treatment should be carried out by a cadre of trained specialists employed for the purpose 2.The system should be organised as a national network 3.There should be a common protocol and national system for monitoring and evaluation 4.Treatment should follow the ‘Maudsley model’ with groups as the preferred option where possible 5.All health professionals should be made aware of the treatment service and encourage their smoking patients to use it 6.There should be a major national publicity campaign advertising the service and the benefits of attending

5. 5 What happened in practice: good points 1.Funding was generous and initially ring-fenced 2.There was a broad commitment to an evidence- based approach to treatment 3.A large national evaluation project was commissioned 4.A national monitoring system was set up 5.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. 6 What happened in practice: problems 1.Funding was provided on a short-term basis with uncertainty from year to year about continuation 2.Monitoring was carried out locally with inadequate specification of criteria for ‘success quitter’ 3.There was inadequate specification of what constituted an adequate level and type of service 4.There was strong pressure to treat as many smokers as possible with little regard to true success rates 5.The government did not pursue other important elements of tobacco control such as price rises

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

8. 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. 9 Smokers 33% Attempt to quit 1 21% use treatment 1 12% go ‘cold turkey’ 10% buy NRT OTC 1 4% use prescription only 1 7% use a smokers’ clinic 1 0.32%1.05%0.48% 8% 2 8% 3 15% 4 4% 5 0.8% 2.65% stop smoking + ++ = Quit for at least 12 months 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 Prof Robert West, robert.west@ucl.ac.uk

10. 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. 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. 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. 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. 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. 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