The decline in numbers accessing stop smoking services: challenges and opportunities Martyn Willmore – Fresh Ailsa Rutter – Fresh Dave Jones – Public Health England

Overview of workshop What we hope to achieve from this session... -A re-affirmation of the vital role of Stop Smoking Services within Tobacco Control -A shared understanding of recent changes in SSS activity levels -Discussion of potential factors behind this fall in throughput -Discussion of potential SSS provision in the future

Context Since 1999, we have seen over 7.7 million smokers accessing Stop Smoking Services across England alone Nearly half have been recorded as successfully quit by week 4 We know the case for effectiveness and cost effectiveness of our SSS Robert West article estimated that by end of 2010/11, over 145,000 long term quits were directly attributable to SSS* *West, R. et al. Performance of English stop smoking services in first 10 years: analysis of service monitoring data. BMJ 2013;347:f4921 doi: /bmj.f4921

Number of smokers using English SSS ( )

Number of smokers using English SSS ( )

Group discussion 1 From your experience, what factors are contributing to the recent decline in footfall through Stop Smoking Services? 10 minutes. Each group to feedback 2 headline issues

Factors impacting on throughput Electronic cigarettes Public Health reorganisation? Primary Care disengagement? Fewer smokers to engage? Less overt marketing of SSS? More challenging smokers to recruit? Less motivated to quit?

Electronic cigarettes Huge growth in market coincides with drop in SSS throughput Limited relationship between SSS and electronic cigarettes and their users?? Awaiting MHRA process of medicinal regulation. Game-changing?? Mixed opinions from Tobacco Control community. Can SSS sit on the fence?? In relation to SSS, are e-cigs any more than a distraction?

Prevalence of nicotine products in recent ex-smokers N=702 adults who stopped in the past year; increase p<0.001 for e-cigs; decrease p<0.001 for NRT Increase in use of e-cigarettes has offset a reduction in NRT use that began earlier

Public Health reorganisation How many localities have seen a major review of their SSS provider over the last two years? What does your SSS look like? Has it changed? Who hosts it? New PH commissioners from April Time spent re- making the case for SSS/Tobacco Control? Competing topics for funding. Ring-fencing of budgets Increasing focus on more joined-up “lifestyle services”?

Primary Care disengagement? What proportion of your quit attempts come from Primary Care settings? Has this changed recently? Are referral pathways from Primary Care working? Competing GP interests? Proportion of quit dates set by setting Primary CareStop Smoking ServicePharmacy 2009/1044.8%29.9%18.4% 2010/1143.1%31.4%18.5% 2011/1240.7%31.4%20.0% 2012/1339.2%32.6%20.6%

Primary Care disengagement? Number of quit dates set by setting ( )

Fewer smokers? More options for quitting? Prevalence continuing to fall But adult population growing (+3 million between ). 8 million smokers across England More Apps/online tools to help smokers quit National TV campaigns promote quitting, but not necessarily SSS

More challenging smokers to engage? Motivation levels? Anecdotal feedback from NE SSS that majority of remaining smokers have complex issues. E.g. Chaotic lifestyles Multiple public health challenges (drugs, alcohol) Mental health issues Learning difficulties Perception that “low-hanging fruit” are now quit Yet data suggests increasing numbers trying to quit….

Quit attempts 15 N=14,024 adults who smoke or who stopped in the past 3 months; increase p=0.005 There has been a small increase in quit attempts

Does the decline in the number of smokers accessing SSS necessarily matter? YESNO Local 4-week quitter targetsLess national focus on 4-week quits now they`re not nationally mandated Continued justification of service to commissioners/HWB boards The intervention is proven to be cost effective Payment by resultsPotential to re-frame any payments around most disadvantaged smokers Impact on prevalenceSSS not a prevalence reduction service. But can contribute to reducing health inequalities

What is the purpose of a SSS? “Smoking Kills” White Paper in 1998 set out intention to set up national smoking cessation services. Specifically, it highlighted, “Our priority will be the need to help the least well off smokers. Smoking is disproportionately high among the more disadvantaged. If we are to reduce smoking overall, and reduce health inequalities, we must start with the groups who smoke the most”.

What is the purpose of a SSS? “In Britain today, more than 120,000 people are going to die over the next year from illnesses directly related to smoking. And the year after that, and the year after that. Unless we all do something.” The Rt Hon Tony Blair MP Prime Minister, Smoking Kills, 1998

What different approaches to SSS are emerging? Rotherham & Doncaster - Triaging clients More generic lifestyles approach Leicester – more e-cigarette friendly SoTW – non-specialist model

Group discussion 2 Looking ahead 2-3 years, what are the key factors that you think would make a successful SSS? o What would the SSS look like? o What support would it be offering? o Who would be the key target groups? o How would it be delivering support? o What outcomes would it be measured on?

Future of SSS…?? Does the fall in activity offer a unique opportunity to look again at what the SSS can offer, to whom, and how? -More focus on those smokers with “greatest need” -Triaging clients based on expected level of support needed -SSS quality assurance hub, but with many outlets? -Better integration with clinical care pathways -General lifestyle services Vs. “specialist” advisors? -Role around harm reduction? -Online support? Telephone support? -Less focus on overall target, and more on the added value

Final thoughts….. We need to continue making the case for effective SSS within a broader tobacco control structure But as smokers have more options on ways to quit, does this mean that SSS can re-position themselves in the market? Is this a discussion we`d like to see taken forward? How, and who needs to be involved?

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