Smoking cessation: stubbing it out

If you see an adult smoker, you are probably looking at someone who has tried to quit at least once. These attempts may have been prompted by health concerns; the advice of clinicians and loved ones; or even the nudge of the ever-increasing cost or the striking pictures on cigarette packets of the effects of smoking. Whatever the reason, many will have tried to give up without help and support.

Although smoking is the single biggest preventable cause of all cancers, accounts for 16% of all deaths, and treatment for current smokers costs £1.6bn a year in secondary care, NHS support for quitters is uneven. It is believed that around 95% of smokers try to give up without support – only about 1% of them succeed – because they are unaware of the support available or it is not offered during routine contacts with the NHS. About 50% of quitters succeed if they are given behavioural support and pharmacotherapy via a stop smoking service.

The inconsistent nature of NHS support may be partly due to the commissioning of smoking cessation services moving from the NHS to local authorities in 2013. Currently, on admission, hospitals check whether a patient smokes or not and collect the data, but they generally do not provide treatment such as pharmacotherapy – a range of drugs and nicotine replacement therapies that have been shown to double rates of smoking cessation.

To receive treatment to help them quit, patients are referred to smoking cessation services commissioned by local authorities. These can be provided by the NHS – community trusts, for example – local authorities and voluntary sector and commercial organisations.

The services are funded by the public health grant and councils have considerable flexibility in how to use it. However, the grant has been cut since 2015.

Overall, local authority smoking cessation budgets fell from £128m in 2013/14 to £89m in 2017/18, according to the Royal
College of Physicians (RCP). It says all smokers could access specialist help when the NHS handed over control of the services to local authorities in 2013/14. But in 2017, this specialist offer was only available in 61% of local authorities.

Hospital admissions attributable to smoking have been creeping up steadily. The Office for National Statistics says these admissions rose by 9% between 2006/07 and 2016/17. Yet smoking prevalence has fallen – from around 20% of adults in England in 2011 to just under 15% in 2017. Attempts to give up by attending specialist services have also declined since 2011/12.

Hospitals have some incentives to refer patients to stop smoking services – between 2017 and 2019 there is a tobacco-related CQUIN. To receive it, hospitals must identify smokers, deliver brief advice and refer patients for treatment. Other incentives include elements of best practice tariffs for specific conditions. And smoking cessation referrals have been included in GP quality and outcome framework (QOF) schemes. However, some areas have no smoking cessation services or have eligibility rules – prioritising, for example, smokers who are pregnant.

There is evidence that helping smokers to quit is not a priority in hospital. A British Thoracic Society survey in 2016 spoke to 15,000 hospital patients – 73% had been asked if they smoked. Of those who were asked, less than a third were asked if they would like to give up and 27% were given a referral.

Proactive role

Clearly, the system is not working, and many doctors, royal colleges and senior NHS leaders feel it is now time for hospitals to play a proactive role in helping their patients give up smoking for good.

A new tariff is central to these ambitions. NHS Improvement and NHS England announced in their recent tariff proposal document that they are working on advice and guidance for smoking cessation services in hospital.

The introduction of bedside intervention on smoking – and a tariff to support it – was advocated in a recent report from the Royal College of Physicians. The HFMA contributed to the report, Hiding in plain sight, which said the current opt-in system, where hospital patients are referred to stop smoking services, is not working.

‘The problem is that smokers access the NHS with a health-related tobacco problem, but they don’t get treatment at the point of care,’ says Sanjay Agrawal, a consultant respiratory intensivist who contributed to the RCP report. ‘Lots of local government services have disappeared entirely or have been cut back. Essentially, patients are not treated in hospital and they find it difficult to access local government-commissioned services. In local government it can be seen as a “nice to have”, but not absolutely necessary.’

He believes – as the report outlines – that NHS trusts should offer stop smoking services to their patients, complementing existing local authority-commissioned services. Treatment should be given on an opt-out basis, rather than the current opt-in.

‘If you have a heart attack, we don’t say, “Would you like us to treat you for a heart attack?”. We just treat you. So why should this be any different? People think it’s a lifestyle choice to smoke when it’s an addiction,’ he adds.

There is evidence of the value of supporting the introduction of a hospital-based stop smoking service. In Ottawa, Canada, a study identified and recruited smokers when they were admitted to hospital. They were given bedside counselling by a specialist nurse to help them quit, together with appropriate nicotine replacement therapy. Staff were given training in smoking cessation and, upon discharge, patients received follow-up phone calls and outpatient appointments.

The reported one-year quit rate of patients receiving the hospital-based support was 28.5%, compared with around 18% for those who just received a leaflet on stopping smoking.

There were significant reductions in all-cause readmissions (down 12%), smoking-related readmissions (9%), all-cause A&E visits (3%) and GP appointments (1% reduction) in the intervention group. The model has now been adopted in more than 350 primary and secondary care sites across Canada.

The RCP report estimates that a similar hospital-based service in the NHS would cost £24m, but produce savings of £85m within a year, based on a patient take-up rate of 27%. In the longer term, even with a more conservative take-up rate of 13.5%, the lifetime cost saving was estimated at £129m.

Dr Agrawal says the NHS could base its service on the Ottawa model, which has also caught the eye of health secretary Matt Hancock. In a speech launching his overall vision for a public health-led NHS, Mr Hancock said he ‘liked the look of’ the Ottawa model. ‘I want to see bedside interventions in our hospitals so smokers who are patients are offered medication, behavioural support and follow-up checks when they go home,’ he added.

At least one part of the NHS is already using the Ottawa model (see box overleaf).

A tariff to encourage the development of hospital smoking cessation services is being developed with support from senior members of the NHS England board.

Though yet to be finalised, this could mean a non-mandatory tariff with estimated costs in the first year. Following a familiar model, it is likely that a number of pilot sites would return cost data from the first year, with wider take-up of the tariff in the subsequent years, including mental health trusts, outpatients and possibly primary care.

Local authority services would remain – Dr Agrawal insists that the objective is not to replace these but to complement them.

A tariff, rather than new CQUIN or QOF payments, is needed to encourage hospitals to develop the new service. Dr Agrawal argues that most CQUINs do not lead to culture change.

‘This is for a variety of reasons,’ he continues. ‘It’s too easy to tick the box and say you’ve met your CQUIN, but long-term culture change and quality improvement is built on investment and transformation.’

The QOF scheme is not dissimilar, he adds. ‘GPs are rewarded for recording smoking status and offering support through a referral, but that’s meaningless. We should be initiating treatment in primary care and measuring and rewarding actual uptake of treatment, not a poor surrogate. This is why we have suggested a mandatory tariff and rewarding treatment uptake. The great thing about the proposed tariff is that it will be an enabler for hospitals to do it.’

He acknowledges a tariff alone will not ensure hospitals develop their own bedside stop smoking service. NHS England will have to work out how best to mainstream the service.

Dr Agrawal says data is key and figures on the number of smokers attending hospital should be routinely gathered, just as the prevalence of C difficile or MRSA is collected and reported.

‘If we are going to improve the treatment of tobacco addiction, we need to look at how we collect data. Smoking status is collected in hospital as part of routine coding and this is potentially a brilliant source of information. We need hospitals to use that information to drive improvement and actual treatment, but currently prevalence data is not being used by the NHS.’

Smoke-free estates

Moving to truly smoke-free estates will also help, he says. In England, there is no legislation outlawing smoking on hospital grounds, though the NHS as a whole and individual hospitals express a desire to be smoke free.

The British Thoracic Society survey found that only 6% of NHS institutions completely enforce smoke-free grounds. There is legislation in Scotland to enforce smoke-free estates: Nothern Ireland will go smoke-free from March; and Wales has consulted on such a move.

There is a new focus on hospital-based smoking cessation services and a tariff is in the pipeline. It is consistent with the likely emphasis on ill-health prevention in the long-term plan for England and, it appears, hospital smoking cessation will be strongly backed by the centre. It has a number of benefits. As Dr Agrawal concludes: ‘We have got to reduce demand by focusing on prevention of ill health. By introducing this service we can reduce demand – that’s why it’s important for hospitals. It will save lives and money with immediate benefit.’

Disease focus

Hospital-based intervention to help smokers quit should not be directed solely on patients who are admitted for smoking-related reasons, consultant Sanjay Agrawal says.

‘For every single doctor and specialty, it doesn’t matter where you work in the hospital, you will see smoking influencing the disease outcomes in every patient. Intervention will produce recurrent savings and avoid costs in secondary care.’

Smoking has wide-ranging effects on the body. The Royal College of Physicians (RCP) has come up with around 100 diseases or conditions associated with smoking, including back pain, rheumatism and still birth. The list is wider than that used by Public Health England in the past, which is around 30 years old and was originally developed by the US surgeon general.

The RCP report estimates that the financial burden on the NHS in England caused by smoking is £890m a year or around £1bn for the UK as a whole. This is based on a basket of 52 diseases and calculated using coding data.

Smoking prevalence among inpatients is 25%, compared with around 15% in the general population. In England almost 78,000 deaths in 2016 were attributable to smoking.

Addiction CURE

A hospital smoking cessation service based on the Ottawa model has been up and running at Wythenshawe Hospital for a little over two months.

The programme, known as CURE, sets out to provide a tobacco addiction service in hospital, bringing it into core NHS activity, according to Matt Evison (pictured), CURE’s clinical lead and a consultant in respiratory medicine at Manchester University NHS Foundation Trust. The service is scheduled to be rolled out across Greater Manchester in 2019.

The idea is to make treatment of tobacco addiction part of medical teams’ everyday practice. ‘Every clinician is responsible, and we aim to train the entire workforce to know about tobacco addiction and treatment. All non-clinical staff will be given brief training in a mandatory training module.’

The service has four steps, with each related to the CURE acronym – conversation, understanding, replacement therapy and evidence. The initial conversation helps clinicians gain an understanding of the level of a patient’s addiction, says Mr Evison. ‘We use the admission documents lodged in the electronic patient record to identify smokers, which triggers protocols and pathways leading quickly to replacement therapy.’

The service is delivered by frontline staff from the moment patients walk through the hospital doors. A team of six specialist nurses sees every smoker who is admitted to the hospital and develop an evidence-based treatment plan. The specialist team will follow up in face-to-face sessions with the patient at two, four and 12 weeks before handing them back to primary care.

The programme was launched at Wythenshawe on 1 October – the hospital was the obvious choice as it is the regional cardiothoracic centre. Though Dr Evison admits it will take a little time for it to be fully implemented – staff training, for example,
will take time – he is confident that it will make a difference.

It uses an opt-out model. ‘Every smoker is referred to the specialist team and offered an appointment. This is the point where they could opt out, but all will have received a brief intervention from the admission team and offered nicotine-replacement therapy immediately.’

Dr Evison says the experience in Canada and the evidence it produced have helped bring the service from concept to implementation. ‘It means we have won the argument over evidence. But we did need the support of the executive team – this is a big culture change for the whole hospital and the pharmacy has to be ready for the upsurge in demand for the medication.’

In Greater Manchester, he estimates the scheme could save 3,000 lives, 30,000 bed days and £10m in avoided demand in the first year. ‘In general terms, the prevention steps being talked about mean benefits years into the future, but this is a solution for the problems now.’

The scheme took 18 months to two years from first concept to launch and received more than £2m in transformation funding from the devolved health budget controlled by the Greater Manchester Health and Social Care Partnership.

Mr Evison says: ‘The initial pump-priming helped to get the service off the ground, but commissioners need to make this a commissioned service. A dedicated tariff for tobacco addiction treatment will help as it will show that it’s the right thing to do.’