Norwich Medical School Faculty of Medicine and Health Science Longer-Term Smoking Abstinence after treatment by specialist or non-specialist advisors: secondary analysis of data from a trial Song F 1 Maskrey V 1 Blyth A 1 Brown TJ 1 Barton GR 1 Aveyard P 2 Notley C 1 Holland R 1 Bachmann MO 1 Sutton S 3 Brandon TH 4 1.Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK 2.Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK 3.Institute of Public Health, University of Cambridge, Cambridge, UK 4.Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa FL, USA

Introduction Behavioural and pharmacological interventions are cost-effective for smoking cessation. In English stop smoking services, smokers motivated to quit may receive support in specialist clinics (33%), primary care (39%), pharmacy (21%), or other settings (7%). [Data in 2012/13] Previous studies found that smokers treated in specialist centres tend to have a higher short-term quit rate, compared with those in non-specialist settings (by professionals for whom smoking cessation is only a part of their work).

Objectives To investigate differences in longer-term abstinence between short-term quitters who received smoking cessation treatment in specialist or other settings A secondary analysis using data from a relapse prevention trial

SHARPISH: randomised controlled trial of self-help booklets for smoking relapse prevention Funded by NIHR/HTA programme (09/91/36), to investigate the effect of self-help materials for the prevention of smoking relapse in 4-wk quitters who have used NHS Stop Smoking Services. Experimental: 8 Forever Free booklets (version for the UK patients) Control: Learning to Stay Stopped leaflet Main findings: No difference between the intervention groups in smoking abstinence from 4 to 12 months (37% vs. 39%; P=0.51 )

Methods Data from SHAPRISH trial: 1088 short-term quitters from specialist centres, 220 from general practice, 57 from health trainers, and 39 from pharmacy. Primary outcome: prolonged abstinence from months 4 to 12, with ≤5 cigarettes in total, and confirmed by CO<10ppm at 12 month. Participants who declined CO test were classified as relapse. The difference in longer-term smoking abstinence between specialist and non-specialist services was compared, using multivariable logistic regression analysis, adjusted for possible confounding factors.

Comparability of main characteristics at baseline between services

Use of smoking cessation medications during 2-3 months after the quit date

Prolonged abstinence from months 4-12 in short-term quitters by type of advisors

Results of multivariable logistic regression analysis for prolonged smoking abstinence from 4-12 month

Discussion Possible reasons for varying longer-term abstinence in short-term quitters by different types of advisors: -Training and supervision received -Adherence to evidence-based practice -Group-based vs. individual sessions -Intensity of support -Confounding factors

Implications Assuming the same quit rate (37%) at 4 weeks after the quit date, the prolonged abstinence rate from 4-12 months in people who set a quit date will be 14.4% and 11.8% respectively, with a difference of 2.6% between specialist and non-specialist services. The total number of people who set a quit date in non-specialist services was 485,245 in 2012/13 in England 3. If the rate of prolonged abstinence was increased by 2.6%, there would be 12,616 more people who were abstinent at 12 months.

Main limitations A secondary analysis of data from a trial (not randomised) More short-term quitters from specialist services, and fewer from non-specialist settings A comparison between different non-specialist settings was not conducted due to inadequate sample size

Conclusions Although smoking cessation support in any setting is cost-effective, specialist counselling, as an intervention that improves longer-term outcomes, should be emphasised. Health care professionals who provide smoking cessation counselling in non-specialist settings should receive more training and supervision. Further research is needed to investigate reasons for the difference in longer term outcomes, and whether enhancing training and skills in non-specialist advisors can reduce longer term relapse.

Main references Blyth A, Maskrey V, Notley C, et al. Self-help educational materials for the prevention of smoking relapse: randomised controlled trial (SHARPISH). Health Technology Assessment (Forthcoming). McDermott MS, Beard E, Brose LS, West R, McEwen A. Factors associated with differences in quit rates between "specialist" and "community" stop-smoking practitioners in the English stop-smoking services. Nicotine Tob Res. 2013; 15: McEwen A, West R, McRobbie H. Effectiveness of specialist group treatment for smoking cessation vs. one-to-one treatment in primary care. Addictive behaviors. 2006; 31: McDermott MS, West R, Brose LS, McEwen A. Self-reported practices, attitudes and levels of training of practitioners in the English NHS Stop Smoking Services. Addictive behaviors. 2012; 37: Brose LS, West R, Michie S, McEwen A. Changes in success rates of smoking cessation treatment associated with take up of a national evidence based training programme. Prev Med. 2014; 69C:1-4. Bauld L, Boyd KA, Briggs AH, et al. One-year outcomes and a cost-effectiveness analysis for smokers accessing group-based and pharmacy-led cessation services. Nicotine Tob Res. 2011; 13:

Acknowledgements This project was funded by the NIHR HTA programme (Project 09/91/36). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Department of Health. We thank stop smoking advisors from NHS stop smoking services in Norfolk, Lincolnshire, Suffolk, Hertfordshire, Great Yarmouth and Waveney for recruiting quitters to the study. The trial was conducted in collaboration with the Norwich Clinical Trials Unit whose staff provided input into the design, conduct and analysis (Tony Dyer – randomisation and data management). We thank Laura Vincent for providing administrative support, data entering and data checking. Declaration of interest: PA has done ad hoc consultancy and research for the pharmaceutical industry on smoking cessation. THB has received research funding and study medication from Pfizer, Inc. No other competing interest declared; no other relationships or activities that could appear to have influenced the submitted work.