Feature / Tackling tobacco dependency

Nobody disagrees about the damage that is caused by smoking. It continues to be one of the biggest killers – with 64,000 people dying from smoking-related illnesses in England every year.

And for everyone who dies, another 30 will suffer from serious smoking-related diseases. It is not just lung cancer – smoking can also cause 15 other cancers and more than 100 diseases. There are few activities that people undertake that have such a bad risk profile – according to NHS England, two out of every three smokers will die due to a smoking-related disease.

It is also closely associated with health inequalities, with the likelihood of smoking four times higher in England’s most deprived areas than its least deprived. So, for systems wanting to address health inequalities, reducing smoking dependency is a good place to start.

The patient benefits of stopping smoking are inarguable. But Joanna Feeney, tobacco clinical delivery manager for the North East and Yorkshire region, hosted by the NHS North of England Commissioning Support Unit, says that funding smoking cessation activities is also about the sustainability of the NHS.

‘If it is going to be sustainable for another 75 years, then we need to have prevention at the core. Treating tobacco dependency – as well as being one of the most tangible things you can do to tackle health inequalities – is also a capacity management tool,’ she says.

‘The moment you treat somebody for their tobacco dependency, they’re less likely to need further intervention or to be readmitted.’

The NHS long-term plan launched a programme on treating tobacco dependency, with the aim of offering all hospital inpatients NHS-funded tobacco dependency treatment services.

Ms Feeney (pictured) has been supporting the programme’s introduction in the North East and Yorkshire. The idea is to ascertain all patients’ smoking status when they are admitted to hospital and then offer advice, therapy and access to services in the community post-discharge. There are parallel schemes for maternity and mental health services.

It is based on a model piloted in Ottawa, which improved long-term quit rates by 11%. This scheme also demonstrated the impact of the new service on readmission rates and lengths of stay.

To support integrated care boards and trusts, Ms Feeney has produced infographics demonstrating the potential for the scheme in different areas and organisations by applying the results demonstrated in Ottawa to local admission levels.

On the acute side, it starts with the number of 16-plus admissions with a length of stay of more than one day and assumes that 20% are smokers – based on figures from the British Thoracic Society’s 2021 national smoking cessation audit. It then applies the Ottawa results and assumptions to these numbers. So, for example, the North East and Yorkshire region could expect a reduction of 4,251 all-cause 30-day readmissions in just one year. In addition, it would expect to see more than 8,000 fewer readmissions and 3,085 fewer presentations at A&E within 30 days of the inpatient episode.

Savings figures

To further emphasise what this could mean for the region, Ms Feeney has calculated that the savings from the reduction in all-cause one-year readmissions could be £12.8m and free up 110 beds per day.

These are powerful figures and Ms Feeney hopes they help to underline the case for continued support of the programme. Current funding arrangements are not without their challenges.

The long-term plan commitment came with dedicated new funding, starting in 2021/22 and delivered initially through the service development fund (SDF). The SDF funding was initially to cover the three-year phased implementation period, with allocations increasing year-on-year in line with the NHS long-term plan expectations. The original expectation was for this funding to move into system baselines from April 2024, as services become embedded.

However, there are pros and cons to this. Although the SDF funding wasn’t actually ringfenced, if it goes into the baseline, it is not so visibly connected to tobacco dependency treatment services.

‘But in some areas, because the funding has come through the SDF funding, trusts have been reluctant to appoint on a permanent basis,’ says Ms Feeney. ‘So they have appointed on fixed-term contracts, which can be both difficult to recruit to and have a high turnover of staff. And that means services can struggle to get embedded.’

There are 51 different tobacco dependency treatment services operating across the region, spread across four ICBs and delivering services for acute inpatients, mental health inpatients and maternity.

There are different approaches taken in different areas and key differences between the inpatient and maternity services. The jobs are different – for inpatients, the job is primarily about the assessments, support during a brief stay, and arranging continued help for the patient post-discharge.

The scale is different for maternity services, especially for the smaller services. So rather than have a separate dedicated maternity tobacco adviser working in the community, in some areas maternity support workers have added an element of tobacco dependency to their roles.

The maternity services have shown they can increase engagement with pregnant women compared with local authority services. But this has helped free up capacity for increased referrals to council-run services from the inpatient services.

In addition, the introduction of the community pharmacy smoking cessation service last year for patients discharged from hospital will also help spread the load and increase the overall capacity across the system.

Embedding the approach

Ms Feeney says the impact will build up as services become more established and embedded. Moving services to a recurrently funded model would help – the services that have moved beyond fixed-term contracts tend to be more mature.

Some real data based on the impact in the UK of the NHS tobacco dependency treatment services would perhaps help to make the case – data from the new NHS tobacco dependency data collection alongside actual tracked reductions in readmissions or A&E attendances, rather than theoretical ones based on the Ottawa pilot. But Ms Feeney says this would be something for academics to take forward.

She is convinced the programme makes sense. Getting a single person to stop smoking is a great outcome for them. It is also a major way of tackling health inequalities.

But there is also a big financial case for the programme – potentially swapping the much more invasive and expensive treatment for lung and other cancers, cardiovascular disease and strokes downstream for the much more modest costs of nicotine replacement therapy now.

And being able to reduce readmissions and A&E attendances is likely to have an almost immediate impact on existing services’ capacity – creating space to address the elective backlog and ensuring a more sustainable health service.