Smoking Cessation Smoking Cessation Treatment Treatment

Services in the Services in the United KingdomUnited Kingdom

Hayden McRobbieHayden McRobbieBarts and The London School of Barts and The London School of

MedicineMedicineUniversity of LondonUniversity of London

The views expressed in the The views expressed in the presentation are that of the presentation are that of the presenter, and not of the University presenter, and not of the University of London, or the UK Department of of London, or the UK Department of HealthHealth

0

10

20

30

40

50

60

70

1948 1952 1956 1960 1964 1968 1972 1976 1980 1984 1988 1992 1996 1999 2001

Adult smoking Adult smoking prevalence, UKprevalence, UK

Men Women

%

National Health ServiceNational Health Service

Government funded through taxationGovernment funded through taxation Free for all ‘from the cradle to the grave’Free for all ‘from the cradle to the grave’ Hospital treatment, family doctors, Hospital treatment, family doctors,

community care, medicationcommunity care, medication Devolved to local level Devolved to local level

Initially 100 Health Authorities, now 300 Initially 100 Health Authorities, now 300 Primary Care Trusts (PCT)Primary Care Trusts (PCT)

Each PCT has its own smoking cessation Each PCT has its own smoking cessation serviceservice

New Government New Government StrategyStrategy

Smoking Smoking Kills Kills ((1998)1998)

Response to the White Response to the White PaperPaper

3 years of ring fenced funding for 3 years of ring fenced funding for Health Authorities: Health Authorities:

year 1 for Health Action Zones ($16 year 1 for Health Action Zones ($16 million)million)

years 2 and 3 nationwide ($32 million)years 2 and 3 nationwide ($32 million) Professionally Professionally

endorsed endorsed national smoking national smoking cessation cessation guidelinesguidelines

Structure of servicesStructure of services

Healthcare staff:

GPs

Hospital doctors

Dentists

Nurses

etc.

Core clinic

Community specialists

Co-ordinator

Referral

Training

Wide reach

Robust service

Expertise enhancedManagement

TrainingTraining Only short courses so farOnly short courses so far The longest established is the “Maudsley The longest established is the “Maudsley

Model” (SCTRP) course for specialists Model” (SCTRP) course for specialists (intensive 3 day evidence based training, with (intensive 3 day evidence based training, with annual updates)annual updates)

Other courses based on stages of change and Other courses based on stages of change and motivational interviewing for community motivational interviewing for community advisorsadvisors

‘‘In-House’ training – variable quality (0.5-1 In-House’ training – variable quality (0.5-1 day)day)

Heath Development Agency Training Heath Development Agency Training StandardsStandardswww.hda.nhs.uk/documents/smoking_cessation_treatments.pdfwww.hda.nhs.uk/documents/smoking_cessation_treatments.pdf

TreatmentTreatment Evidence based – following national Evidence based – following national

guidelinesguidelines Combination of behavioural support and Combination of behavioural support and

pharmacotherapypharmacotherapy Withdrawal oriented treatment used for Withdrawal oriented treatment used for

core clinics (Hajek 1989)core clinics (Hajek 1989) 6 or 7 weekly treatment sessions 6 or 7 weekly treatment sessions

(predominantly group setting, but individual (predominantly group setting, but individual sessions used where appropriate)sessions used where appropriate)

Assist smokers to avoid early relapseAssist smokers to avoid early relapse Emphasis on complete abstinence, Emphasis on complete abstinence,

supervision of medication use, motivational supervision of medication use, motivational supportsupport

EvaluationEvaluation

MonitoredMonitored Staffing and costsStaffing and costs ThroughputThroughput 4-week success rates4-week success rates

Targets Targets ThroughputThroughput Success ratesSuccess rates League tables publishedLeague tables published

Self-reported abstinence in the last 2 of 4 weeks after quitting, with CO validation (<10 ppm)

Not all community advisors are

measuring ECO

NHSNHS Smoking Cessation Smoking Cessation ServicesServices

THE THE RESULTSRESULTS

The GOOD: Success!The GOOD: Success!

234858

124082

83163

0

50000

100000

150000

200000

250000

Number setting aquit date

Number quit at 4weeks (self report)

Number quit at 4weeks (validated)

Performance of the Performance of the services services

Nationally, group treatment is a Nationally, group treatment is a positive predictor of 4-week positive predictor of 4-week abstinence (abstinence (Bauld, Chesterman, Judge et al. Tobacco Bauld, Chesterman, Judge et al. Tobacco Control 2003; 12: 296-301) Control 2003; 12: 296-301)

Within local services, where Within local services, where comparison is possible, the core clinic comparison is possible, the core clinic produces higher abstinence rates than produces higher abstinence rates than community advisors e.g. clinic 58% vs. community advisors e.g. clinic 58% vs. community 39%, community 39%, (Turbitt, Smoking Cessation Services (Turbitt, Smoking Cessation Services in East London, 2003)in East London, 2003)

The BAD: Problems The BAD: Problems

Demands on newly developed services Demands on newly developed services Many services moved away from evidence Many services moved away from evidence

basebase Medications: Limited NRT supply initially & Medications: Limited NRT supply initially &

most services unable to prescribemost services unable to prescribe Funding: drip-fed initially; no longer ring-Funding: drip-fed initially; no longer ring-

fencedfenced Staff: shortage & uncertain career Staff: shortage & uncertain career

developmentdevelopment NHS organisation changesNHS organisation changes

not sonot so^̂

The UGLY: TargetsThe UGLY: Targets

0

50,000

100,000

150,000

200,000

250,000

300,000

2001-02 2002-03 2003-04 2004-05 2005-06

No. of 4 No. of 4 Week Week QuittersQuitters

Targets for London!Targets for London!

57489174 9865

24635

41104

58216

0

10000

20000

30000

40000

50000

60000

2000-01 2001-02 2002-03 2003-04 2004-05 2005-06

ConclusionsConclusions Smoking cessation services are now Smoking cessation services are now

establishedestablished National guidelines, national training standards, National guidelines, national training standards,

and services offering evidence based treatmentand services offering evidence based treatment UK has a new group of professionals – UK has a new group of professionals –

approximately 1,000 full-time smoking approximately 1,000 full-time smoking cessation specialistscessation specialists

Short-term success rates in the region of 50%Short-term success rates in the region of 50% Lessons can be learnt from our experience so Lessons can be learnt from our experience so

far, e.g. pitfalls of mixing health promotion far, e.g. pitfalls of mixing health promotion and clinical treatmentand clinical treatment

Challenges for the future, but hopefully Challenges for the future, but hopefully services will continue to develop to meet the services will continue to develop to meet the needs of smokers who want to quitneeds of smokers who want to quit

Pohutukawa – New Zealand Christmas Tree